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Timing surgery in mitral regurgitation: defining risk and optimising intervention using stress echocardiography

Echo Research & Practice volume 3, pages R45–R55 (2016)Cite this article

Abstract

Mitral regurgitation (MR) is the second most common form of valvular disease requiring surgery. Correct identification of surgical candidates and optimising the timing of surgery are key in management. For primary MR, this relies upon a balance between the peri-operative risks and rates of successful repair in patients undergoing early surgery when asymptomatic with the potential risk of irreversible left ventricular dysfunction if intervention is performed too late. For secondary MR, recognition that this is a highly dynamic condition where MR severity may change is key, although data on outcomes in determining whether concomitant valve intervention is performed with revascularisation has raised questions regarding timing of surgery. There has been substantial interest in the use of stress echocardiography to risk stratify patients in mitral regurgitation. This article reviews the role of stress echocardiography in both primary and secondary mitral regurgitation and discusses how this can help clinicians tackle the challenges of this prevalent condition.

References

  1. Iung B, Baron G, Butchart EG, Delahaye F, Gohlke-Barwolf C, Levang OW, Tornos P, Vanoverschelde JL, Vermeer F, Boersma E et al. 2003 A prospective survey of patients with valvular heart disease in Europe: the euro heart survey on valvular heart disease. European Heart Journal 24 1231–1243. (doi:10.1016/S0195-668X(03)00201-X)

    Article  PubMed  Google Scholar 

  2. Nkomo VT, Gardin JM, Skelton TN, Gottdiener JS, Scott CG, Enriquez-Sarano M 2006 Burden of valvular heart diseases: a population-based study. Lancet 368 1005–1011. (doi:10.1016/S0140-6736(06)69208-8)

    Article  PubMed  Google Scholar 

  3. Tribouilloy CM, Enriquez-Sarano M, Schaff HV, Orszulak TA, Bailey KR, Tajik AJ, Frye RL 1999 Impact of preoperative symptoms on survival after surgical correction of organic mitral regurgitation: rationale for optimizing surgical indications. Circulation 99 400–405. (doi:10.1161/01.CIR.99.3.400)

    Article  CAS  PubMed  Google Scholar 

  4. Quintana E, Suri RM, Thalji NM, Daly RC, Dearani JA, Burkhart HM, Li Z, Enriquez-Sarano M, Schaff HV 2014 Left ventricular dysfunction after mitral valve repair-the fallacy of ‘normal’ preoperative myocardial function. Journal of Thoracic and Cardiovascular Surgery 148 2752–2760. (doi:10.1016/j.jtcvs.2014.07.029)

    Article  Google Scholar 

  5. Vahanian A, Alfieri O, Andreotti F, Antunes MJ, Baron-Esquivias G, Baumgartner H, Borger MA, Carrel TP, De Bonis M, Evangelista A et al. 2012 Guidelines on the management of valvular heart disease (version 2012). European Heart Journal 33 2451–2496. (doi:10.1093/eurheartj/ehs109)

    Article  PubMed  Google Scholar 

  6. Enriquez-Sarano M, Suri RM, Clavel MA, Mantovani F, Michelena HI, Pislaru S, Mahoney DW, Schaff HV 2015 Is there an outcome penalty linked to guideline-based indications for valvular surgery? Early and long-term analysis of patients with organic mitral regurgitation. Journal of Thoracic and Cardiovascular Surgery 150 50–58. (doi:10.1016/j.jtcvs.2015.04.009)

    Article  Google Scholar 

  7. David TE, Armstrong S, McCrindle BW, Manlhiot C 2013 Late outcomes of mitral valve repair for mitral regurgitation due to degenerative disease. Circulation 127 1485–1492. (doi:10.1161/CIRCULATIONAHA.112.000699)

    Article  PubMed  Google Scholar 

  8. Enriquez-Sarano M, Tajik AJ, Schaff HV, Orszulak TA, Bailey KR, Frye RL 1994 Echocardiographic prediction of survival after surgical correction of organic mitral regurgitation. Circulation 90 830–837. (doi:10.1161/01.CIR.90.2.830)

    Article  CAS  PubMed  Google Scholar 

  9. Tribouilloy C, Grigioni F, Avierinos JF, Barbieri A, Rusinaru D, Szymanski C, Ferlito M, Tafanelli L, Bursi F, Trojette F et al. 2009 Survival implication of left ventricular end-systolic diameter in mitral regurgitation due to flail leaflets a long-term follow-up multicenter study. Journal of the American College of Cardiology 54 1961–1968. (doi:10.1016/j.jacc.2009.06.047)

    Article  PubMed  Google Scholar 

  10. Detaint D, Sundt TM, Nkomo VT, Scott CG, Tajik AJ, Schaff HV, Enriquez-Sarano M 2006 Surgical correction of mitral regurgitation in the elderly–outcomes and recent improvements. Circulation 114 265–272. (doi:10.1161/CIRCULATIONAHA.106.619239)

    Article  PubMed  Google Scholar 

  11. Enriquez-Sarano M, Akins CW, Vahanian A 2009 Mitral regurgitation. Lancet 373 1382–1394. (doi:10.1016/S0140-6736(09)60692-9)

    Article  PubMed  Google Scholar 

  12. Kang DH, Park SJ, Sun BJ, Cho EJ, Kim DH, Yun SC, Song JM, Park SW, Chung CH, Song JK et al. 2014 Early surgery versus conventional treatment for asymptomatic severe mitral regurgitation. Journal of the American College of Cardiology 63 2398–2407. (doi:10.1016/j.jacc.2014.02.577)

    Article  PubMed  Google Scholar 

  13. Suri RM, Vanoverschelde JL, Grigioni F, Schaff HV, Tribouilloy C, Avierinos JF, Barbieri A, Pasquet A, Huebner M, Rusinaru D et al. 2013 Association between early surgical intervention vs watchful waiting and outcomes for mitral regurgitation due to flail mitral valve leaflets. JAMA 310 609–616. (doi:10.1001/jama.2013.8643)

    Article  CAS  PubMed  Google Scholar 

  14. Bolling SF, Li SA, O’Brien SM, Brennan JM, Prager RL, Gammie JS 2010 Predictors of mitral valve repair: clinical and surgeon factors. Annals of Thoracic Surgery 90 1904–1912. (doi:10.1016/j.athoracsur.2010.07.062)

    Article  Google Scholar 

  15. Gammie JS, O’Brien SM, Griffith BP, Ferguson TB, Peterson ED 2007 Influence of hospital procedural volume on care process and mortality for patients undergoing elective surgery for mitral regurgitation. Circulation 115 881–887. (doi:10.1161/CIRCULATIONAHA.106.634436)

    Article  PubMed  Google Scholar 

  16. UK Early Mitral Surgery Trial 2015 British Heart Foundation. (available at: https://www.bhf.org.uk/research-projects/uk-early-mitral-surgery-trial)

    Google Scholar 

  17. Braunberger E, Deloche A, Berrebi A, Abdallah F, Celestin JA, Meimoun P, Chatellier G, Chauvaud S, Fabiani JN, Carpentier A 2001 Very long-term results (more than 20 years) of valve repair with Carpentier’s techniques in nonrheumatic mitral valve insufficiency. Circulation 104 I8–I11. (doi:10.1161/01.CIR.104.suppl_1.I-8)

    Article  CAS  PubMed  Google Scholar 

  18. Rosenhek R, Rader F, Klaar U, Gabriel H, Krejc M, Kalbeck D, Schemper M, Maurer G, Baumgartner H 2006 Outcome of watchful waiting in asymptomatic severe mitral regurgitation. Circulation 113 2238–2244. (doi:10.1161/CIRCULATIONAHA.105.599175)

    Article  PubMed  Google Scholar 

  19. Biner S, Rafique A, Rafii F, Tolstrup K, Noorani O, Shiota T, Gurudevan S, Siegel RJ 2010 Reproducibility of proximal isovelocity surface area, vena contracta, and regurgitant jet area for assessment of mitral regurgitation severity. JACC: Cardiovascular Imaging 3 235–243. (doi:10.1016/j.jcmg.2009.09.029)

    PubMed  Google Scholar 

  20. Lapar DJ, Ailawadi G, Isbell JM, Crosby IK, Kern JA, Rich JB, Speir AM, Kron IL, Investigators Virginia C 2014 Mitral valve repair rates correlate with surgeon and institutional experience. Journal of Thoracic and Cardiovascular Surgery 148 995–1003. (doi:10.1016/j.jtcvs.2014.06.039)

    Article  Google Scholar 

  21. Blue Book Online 2013 The Society for Cardiothoracic Surgery in Great Britain and Ireland. Accessed 21/07/2016. (available at: http://bluebook.scts.org/)

    Google Scholar 

  22. Bonow RO, Adams DH 2016 The time has come to define centers of excellence in mitral valve repair. Journal of the American College of Cardiology 67 499–501. (doi:10.1016/j.jacc.2015.12.007)

    Article  PubMed  Google Scholar 

  23. Suri RM, Clavel M-A, Schaff HV, Michelena HI, Huebner M, Nishimura RA, Enriquez-Sarano M 2016 Effect of recurrent mitral regurgitation following degenerative mitral valve repair long-term analysis of competing outcomes. Journal of the American College of Cardiology 67 488–498. (doi:10.1016/j.jacc.2015.10.098)

    Article  PubMed  Google Scholar 

  24. Grigioni F, Avierinos JF, Ling LH, Scott CG, Bailey KR, Tajik AJ, Frye RL, Enriquez-Sarano M 2002 Atrial fibrillation complicating the course of degenerative mitral regurgitation: determinants and long-term outcome. Journal of the American College of Cardiology 40 84–92. (doi:10.1016/S0735-1097(02)01922-8)

    Article  PubMed  Google Scholar 

  25. Le Tourneau T, Messika-Zeitoun D, Russo A, Detaint D, Topilsky Y, Mahoney DW, Suri R, Enriquez-Sarano M 2010 Impact of left atrial volume on clinical outcome in organic mitral regurgitation. Journal of the American College of Cardiology 56 570–578. (doi:10.1016/j.jacc.2010.02.059)

    Article  PubMed  Google Scholar 

  26. Messika-Zeitoun D, Johnson BD, Nkomo V, Avierinos JF, Allison TG, Scott C, Tajik AJ, Enriquez-Sarano M 2006 Cardiopulmonary exercise testing determination of functional capacity in mitral regurgitation: physiologic and outcome implications. Journal of the American College of Cardiology 47 2521–2427. (doi:10.1016/j.jacc.2006.02.043)

    Article  PubMed  Google Scholar 

  27. Supino PG, Borer JS, Schuleri K, Gupta A, Hochreiter C, Kligfield P, Herrold EM, Preibisz JJ 2007 Prognostic value of exercise tolerance testing in asymptomatic chronic nonischemic mitral regurgitation. American Journal of Cardiology 100 1274–1281. (doi:10.1016/j.amjcard.2007.05.046)

    Article  Google Scholar 

  28. Naji P, Griffin BP, Asfahan F, Barr T, Rodriguez LL, Grimm R, Agarwal S, Stewart WJ, Mihaljevic T, Gillinov AM et al. 2014 Predictors of long-term outcomes in patients with significant myxomatous mitral regurgitation undergoing exercise echocardiography. Circulation 129 1310–1319. (doi:10.1161/CIRCULATIONAHA.113.005287)

    Article  PubMed  Google Scholar 

  29. Naji P, Griffin BP, Barr T, Asfahan F, Gillinov AM, Grimm RA, Rodriguez LL, Mihaljevic T, Stewart WJ, Desai MY 2014 Importance of exercise capacity in predicting outcomes and determining optimal timing of surgery in significant primary mitral regurgitation. Journal of the American Heart Association 3 e001010. (doi:10.1161/JAHA.114.001010)

    Article  PubMed  PubMed Central  Google Scholar 

  30. Magne J, Lancellotti P, Piérard LA 2010 Exercise-induced changes in degenerative mitral regurgitation. Journal of the American College of Cardiology 56 300–309. (doi:10.1016/j.jacc.2009.12.073)

    Article  PubMed  Google Scholar 

  31. Magne J, Donal E, Mahjoub H, Miltner B, Dulgheru R, Thebault C, Pierard LA, Pibarot P, Lancellotti P 2015 Impact of exercise pulmonary hypertension on postoperative outcome in primary mitral regurgitation. Heart 101 391–396. (doi:10.1136/heartjnl-2014-306296)

    Article  PubMed  Google Scholar 

  32. Agricola E, Galderisi M, Oppizzi M, Schinkel AF, Maisano F, De Bonis M, Margonato A, Maseri A, Alfieri O 2004 Pulsed tissue Doppler imaging detects early myocardial dysfunction in asymptomatic patients with severe mitral regurgitation. Heart 90 406–410. (doi:10.1136/hrt.2002.009621)

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  33. Magne J, Mahjoub H, Pierard LA, O’Connor K, Pirlet C, Pibarot P, Lancellotti P 2012 Prognostic importance of brain natriuretic peptide and left ventricular longitudinal function in asymptomatic degenerative mitral regurgitation. Heart 98 584–591. (doi:10.1136/heartjnl-2011-301128)

    Article  CAS  PubMed  Google Scholar 

  34. Lee R, Haluska B, Leung DY, Case C, Mundy J, Marwick TH 2005 Functional and prognostic implications of left ventricular contractile reserve in patients with asymptomatic severe mitral regurgitation. Heart 91 1407–1412. (doi:10.1136/hrt.2004.047613)

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  35. Donal E, Mascle S, Brunet A, Thebault C, Corbineau H, Laurent M, Leguerrier A, Mabo P 2012 Prediction of left ventricular ejection fraction 6 months after surgical correction of organic mitral regurgitation: the value of exercise echocardiography and deformation imaging. European Heart Journal: Cardiovascular Imaging 13 922–930. (doi:10.1093/ehjci/jes068)

    PubMed  Google Scholar 

  36. Flachskampf FA 2010 Mitral regurgitation is incompletely characterized at rest. Journal of the American College of Cardiology 56 310–313. (doi:10.1016/j.jacc.2010.02.052)

    Article  PubMed  Google Scholar 

  37. Lee T-M, Su S-F, Huang T-Y, Chen M-F, Liau C-S, Lee Y-T 1996 Excessive papillary muscle traction and dilated mitral annulus in mitral valve prolapse without mitral regurgitation. American Journal of Cardiology 78 482–485. (doi:10.1016/0002-9149(97)00002-7)

    Article  CAS  Google Scholar 

  38. Han Y, Peters DC, Salton CJ, Bzymek D, Nezafat R, Goddu B, Kissinger KV, Zimetbaum PJ, Manning WJ, Yeon SB 2008 Cardiovascular magnetic resonance characterization of mitral valve prolapse. JACC: Cardiovascular Imaging 1 294–303. (doi:10.1016/j.jcmg.2008.01.013)

    PubMed  Google Scholar 

  39. Han YC, Peters DC, Kissinger KV, Goddu B, Yeon SB, Manning WJ, Nezafat R 2010 Evaluation of papillary muscle function using cardiovascular magnetic resonance imaging in mitral valve prolapse. American Journal of Cardiology 106 243–248. (doi:10.1016/j.amjcard.2010.02.035)

    Article  Google Scholar 

  40. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP 3rd, Guyton RA, O’Gara PT, Ruiz CE, Skubas NJ, Sorajja P et al. 2014 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology 63 e57–e185. (doi:10.1016/j.jacc.2014.02.536)

    Article  PubMed  Google Scholar 

  41. Sharma V, Newby DE, Stewart RA, Lee M, Gabriel R, Van Pelt N, Kerr AJ 2015 Exercise stress echocardiography in patients with valvular heart disease. Echo Research and Practice 2 89–98. (doi:10.1530/ERP-15-0015)

    Article  PubMed  PubMed Central  Google Scholar 

  42. Lancellotti P, Lebrun F, Piérard LA 2003 Determinants of exercise-induced changes in mitral regurgitation in patients with coronary artery disease and left ventricular dysfunction. Journal of the American College of Cardiology 42 1921–1928. (doi:10.1016/j.jacc.2003.04.002)

    Article  PubMed  Google Scholar 

  43. Izumo M, Lancellotti P, Suzuki K, Kou S, Shimozato T, Hayashi A, Akashi YJ, Osada N, Omiya K, Nobuoka S et al. 2009 Three-dimensional echocardiographic assessments of exercise-induced changes in left ventricular shape and dyssynchrony in patients with dynamic functional mitral regurgitation. European Journal of Echocardiography 10 961–967. (doi:10.1093/ejechocard/jep114)

    Article  PubMed  Google Scholar 

  44. Giga V, Ostojic M, Vujisic-Tesic B, Djordjevic-Dikic A, Stepanovic J, Beleslin B, Petrovic M, Nedeljkovic M, Nedeljkovic I, Milic N 2005 Exercise-induced changes in mitral regurgitation in patients with prior myocardial infarction and left ventricular dysfunction: relation to mitral deformation and left ventricular function and shape. European Heart Journal 26 1860–1865. (doi:10.1093/eurheartj/ehi431)

    Article  PubMed  Google Scholar 

  45. Srichai MB, Grimm RA, Stillman AE, Gillinov AM, Rodriguez LL, Lieber ML, Lara A, Weaver JA, McCarthy PM, White RD 2005 Ischemic mitral regurgitation: impact of the left ventricle and mitral valve in patients with left ventricular systolic dysfunction. Annals of Thoracic Surgery 80 170–178. (doi:10.1016/j.athoracsur.2005.01.068)

    Article  Google Scholar 

  46. Lancellotti P, Gérard PL, Piérard LA 2005 Long-term outcome of patients with heart failure and dynamic functional mitral regurgitation. European Heart Journal 26 1528–1532. (doi:10.1093/eurheartj/ehi189)

    Article  PubMed  Google Scholar 

  47. Grigioni F, Enriquez-Sarano M, Zehr KJ, Bailey KR, Tajik AJ 2001 Ischemic mitral regurgitation - long-term outcome and prognostic implications with quantitative Doppler assessment. Circulation 103 1759–1764. (doi:10.1161/01.CIR.103.13.1759)

    Article  CAS  PubMed  Google Scholar 

  48. Michler RE, Smith PK, Parides MK, Ailawadi G, Thourani V, Moskowitz AJ, Acker MA, Hung JW, Chang HL, Perrault LP, et al. 2016 Two-year outcomes of surgical treatment of moderate ischemic mitral regurgitation. New England Journal of Medicine 374 1931–1940.

    Article  CAS  Google Scholar 

  49. Chan KMJ, Punjabi PP, Flather M, Wage R, Symmonds K, Roussin I, Rahman-Haley S, Pennell DJ, Kilner PJ, Dreyfus GD, et al. 2012 Coronary artery bypass surgery with or without mitral valve annuloplasty in moderate functional ischemic mitral regurgitation final results of the randomized ischemic mitral evaluation (RIME) trial. Circulation 126 2502–2510. (doi:10.1161/CIRCULATIONAHA.112.143818)

    Article  PubMed  Google Scholar 

  50. Fattouch K, Guccione F, Sampognaro R, Panzarella G, Corrado E, Navarra E, Calvaruso D, Ruvolo G 2009 POINT: efficacy of adding mitral valve restrictive annuloplasty to coronary artery bypass grafting in patients with moderate ischemic mitral valve regurgitation: a randomized trial. Journal of Thoracic and Cardiovascular Surgery 138 278–285. (doi:10.1016/j.jtcvs.2008.11.010)

    Article  Google Scholar 

  51. Smith PK, Puskas JD, Ascheim DD, Voisine P, Gelijns AC, Moskowitz AJ, Hung JW, Parides MK, Ailawadi G, Perrault LP, et al. 2014 Surgical treatment of moderate ischemic mitral regurgitation. New England Journal of Medicine 371 2178–2188. (doi:10.1056/NEJMoa1410490)

    Article  CAS  Google Scholar 

  52. Goldstein D, Moskowitz AJ, Gelijns AC, Ailawadi G, Parides MK, Perrault LP, Hung JW, Voisine P, Dagenais F, Gillinov AM, et al. 2016 Two-year outcomes of surgical treatment of severe ischemic mitral regurgitation. New England Journal of Medicine 374 344–353. (doi:10.1056/NEJMoa1512913)

    Article  CAS  Google Scholar 

  53. Lancellotti P, Zamorano JL, Vannan MA 2014 Imaging challenges in secondary mitral regurgitation unsolved issues and perspectives. Circulation: Cardiovascular Imaging 7 735–746. (doi:10.1161/circimaging.114.000992)

    Google Scholar 

  54. Szymanski C, Levine RA, Tribouilloy C, Zheng H, Handschumacher MD, Tawakol A, Hung J 2011 Impact of mitral regurgitation on exercise capacity and clinical outcomes in patients with ischemic left ventricular dysfunction. American Journal of Cardiology 108 1714–1720. (doi:10.1016/j.amjcard.2011.07.045)

    Article  Google Scholar 

  55. Lancellotti P, Magne J, Dulgheru R, Ancion A, Martinez C, Pierard LA 2015 Clinical significance of exercise pulmonary hypertension in secondary mitral regurgitation. American Journal of Cardiology 115 1454–1461. (doi:10.1016/j.amjcard.2015.02.028)

    Article  Google Scholar 

  56. Lancellotti P, Magne J 2013 Stress echocardiography in regurgitant valve disease. Circulation: Cardiovascular Imaging 6 840–849. (doi:10.1161/circimaging.113.000474)

    Google Scholar 

  57. Enriquez-Sarano M, Avierinos JF, Messika-Zeitoun D, Detaint D, Capps M, Nkomo V, Scott C, Schaff HV, Tajik AJ 2005 Quantitative determinants of the outcome of asymptomatic mitral regurgitation. New England Journal of Medicine 352 875–883. (doi:10.1056/NEJMoa041451)

    Article  CAS  Google Scholar 

  58. Barbieri A, Bursi F, Grigioni F, Tribouilloy C, Avierinos JF, Michelena HI, Rusinaru D, Szymansky C, Russo A, Suri R, et al. 2011 Prognostic and therapeutic implications of pulmonary hypertension complicating degenerative mitral regurgitation due to flail leaflet: a multicenter long-term international study. European Heart Journal 32 751–759. (doi:10.1093/eurheartj/ehq294)

    Article  PubMed  Google Scholar 

  59. Le Tourneau T, Messika-Zeitoun D, Russo A, Detaint D, Topilsky Y, Mahoney DW, Suri R, Enriquez-Sarano M 2010 Impact of left atrial volume on clinical outcome in organic mitral regurgitation. Journal of the American College of Cardiology 56 570–578. (doi:10.1016/j.jacc.2010.02.059)

    Article  PubMed  Google Scholar 

  60. Lancellotti P, Troisfontaines P, Toussaint AC, Pierard LA 2003 Prognostic importance of exercise-induced changes in mitral regurgitation in patients with chronic ischemic left ventricular dysfunction. Circulation 108 1713–1717. (doi:10.1161/01.CIR.0000087599.49332.05)

    Article  PubMed  Google Scholar 

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Funding from BHF (grant no: PG/14/74/31056).

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Authors and Affiliations

  1. University Hospital Birmingham NHS Foundation Trust & Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK

    Boyang Liu MA MRCP, Nicola C. Edwards PhD MRCP & Richard P. Steeds MA MD FRCP FESC

  2. University Hospital South Manchester, Manchester, UK

    Simon Ray BSc MD FRCP FACC FESC

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  1. Boyang Liu MA MRCP
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Liu, B., Edwards, N.C., Ray, S. et al. Timing surgery in mitral regurgitation: defining risk and optimising intervention using stress echocardiography. Echo Res Pract 3, R45–R55 (2016). https://doiorg.publicaciones.saludcastillayleon.es/10.1530/ERP-16-0019

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Echo Research & Practice

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