Impaired left ventricular contractile function in patients with long-term mitral regurgitation and normal ejection fraction

Department of Internal Medicine, University of Michigan, Ann Arbor.

OBJECTIVES. We tested the hypotheses that left ventricular chamber elastance would detect impaired contractile function in patients with long-term mitral regurgitation and a normal ejection fraction and that these patients would have unique temporal left ventricular size and ejection fraction responses to mitral valve surgery. BACKGROUND. Although it has been suggested that left ventricular contractile function may begin deteriorating in patients with long-term mitral regurgitation whereas ejection fraction remains normal, no data exist in humans. METHODS. We studied 11 control patients and 28 patients with long-term mitral regurgitation using micromanometer-measured pressures, biplane contrast cineventriculography and radionuclide angiography under control conditions and with alterations in load during right atrial pacing to calculate left ventricular chamber elastance and myocardial stiffness. RESULTS. The patients with mitral regurgitation were classified into subgroups: Group I, normal contractile function; Group II, impaired contractile function (reduced Emax) but normal ejection fraction, and Group III, impaired contractile function (reduced Emax) with reduced systolic myocardial stiffness. Twenty-two of the patients with mitral regurgitation underwent mitral valve surgery. In Group I, comparable decreases in left ventricular volume indexes (p < 0.01 and p = 0.05, respectively) were associated with no change in ejection fraction at 3 months and 1 year. In contrast, in Group II, reductions in volume indexes (p < 0.0001 and p < 0.001) were associated with a short-term decrease in ejection fraction (p < 0.001) that recovered at 1 year (p < 0.01 vs. short-term). Finally, in Group III, variable responses in volume indexes were associated with a consistent decrease in ejection fraction at 3 months and 1 year. CONCLUSIONS. An analysis of left ventricular chamber elastance provides data to support the concepts that 1) contractile function is impaired in some patients with long-term mitral regurgitation and a normal ejection fraction, 2) impaired contractile function may not be irreversible in all of these patients, and 3) an earlier consideration of mitral valve surgery may be warranted to preserve contractile function in these patients.

This article has been cited by other articles:

				C. Tribouilloy, D. Rusinaru, C. Szymanski, S. Mezghani, A. Fournier, F. Levy, M. Peltier, A. Ben Ammar, D. Carmi, J.-P. Remadi, et al. Predicting left ventricular dysfunction after valve repair for mitral regurgitation due to leaflet prolapse: additive value of left ventricular end-systolic dimension to ejection fraction Eur Heart J Cardiovasc Imaging, September 1, 2011; 12(9): 702 - 710. [Abstract] [Full Text] [PDF]

				M. Pu, Z. Gao, X. Zhang, D. Liao, D. K. Pu, T. Brennan, and W. R. Davidson Jr. Impact of mitral regurgitation on left ventricular anatomic and molecular remodeling and systolic function: implication for outcome Am J Physiol Heart Circ Physiol, June 1, 2009; 296(6): H1727 - H1732. [Abstract] [Full Text] [PDF]

				R. M. Suri, H. V. Schaff, J. A. Dearani, T. M. Sundt, R. C. Daly, C. J. Mullany, M. Enriquez-Sarano, and T. A. Orszulak Recovery of left ventricular function after surgical correction of mitral regurgitation caused by leaflet prolapse. J. Thorac. Cardiovasc. Surg., May 1, 2009; 137(5): 1071 - 1076. [Abstract] [Full Text] [PDF]

				D.-H. Kang, J. H. Kim, J. H. Rim, M.-J. Kim, S.-C. Yun, J.-M. Song, H. Song, K.-J. Choi, J.-K. Song, and J.-W. Lee Comparison of Early Surgery Versus Conventional Treatment in Asymptomatic Severe Mitral Regurgitation Circulation, February 17, 2009; 119(6): 797 - 804. [Abstract] [Full Text] [PDF]

				R. M. Suri, H. V. Schaff, J. A. Dearani, T. M. Sundt III, R. C. Daly, C. J. Mullany, M. E. Sarano, and T. A. Orszulak Determinants of early decline in ejection fraction after surgical correction of mitral regurgitation. J. Thorac. Cardiovasc. Surg., August 1, 2008; 136(2): 442 - 447. [Abstract] [Full Text] [PDF]

				T. G. Neilan, T.-T. Ton-Nu, Y. Kawase, R. Yoneyama, K. Hoshino, F. del Monte, R. J. Hajjar, M. H. Picard, R. A. Levine, and J. Hung Progressive nature of chronic mitral regurgitation and the role of tissue Doppler-derived indexes Am J Physiol Heart Circ Physiol, May 1, 2008; 294(5): H2106 - H2111. [Abstract] [Full Text] [PDF]

				J. I. Fann, N. B. Ingels Jr., and D. C. Miller Pathophysiology of Mitral Valve Disease Card. Surg. Adult, January 1, 2008; 3(2008): 973 - 1012. [Full Text]

				R. Lee and T. H. Marwick Assessment of subclinical left ventricular dysfunction in asymptomatic mitral regurgitation Eur Heart J Cardiovasc Imaging, June 1, 2007; 8(3): 175 - 184. [Abstract] [Full Text] [PDF]

				M. A. Yousefnia, M. H. Mandegar, F. Roshanali, F. Alaeddini, and F. Amouzadeh Papillary Muscle Repositioning in Mitral Valve Replacement in Patients With Left Ventricular Dysfunction Ann. Thorac. Surg., March 1, 2007; 83(3): 958 - 963. [Abstract] [Full Text] [PDF]

				S. Ray, J. Chambers, C. Gohlke-Baerwolf, and B. Bridgewater Mitral valve repair for severe mitral regurgitation: the way forward? Eur. Heart J., December 2, 2006; 27(24): 2925 - 2928. [Abstract] [Full Text] [PDF]

				B. P. Griffin Timing of Surgical Intervention in Chronic Mitral Regurgitation: Is Vigilance Enough? Circulation, May 9, 2006; 113(18): 2169 - 2172. [Full Text] [PDF]

				L. Hellgren, P. Kvidal, L.-G. Horte, U.-B. Krusemo, and E. Stahle Survival After Mitral Valve Replacement: Rationale for Surgery Before Occurrence of Severe Symptoms Ann. Thorac. Surg., October 1, 2004; 78(4): 1241 - 1247. [Abstract] [Full Text] [PDF]

				P. M. Grossman, O. A. Linares, M. A. Supiano, H. Oral, R. H. Mehta, and M. R. Starling Cardiac-specific norepinephrine mass transport and its relationship to left ventricular size and systolic performance Am J Physiol Heart Circ Physiol, August 1, 2004; 287(2): H878 - H888. [Abstract] [Full Text] [PDF]

				A. Macnab, N. P Jenkins, B. J.M Bridgewater, T. L Hooper, D. L Greenhalgh, M. R Patrick, and S. G Ray Three-dimensional echocardiography is superior to multiplane transoesophageal echo in the assessment of regurgitant mitral valve morphology Eur Heart J Cardiovasc Imaging, June 1, 2004; 5(3): 212 - 222. [Abstract] [Full Text] [PDF]

				T. Matsumura, E. Ohtaki, K. Tanaka, K. Misu, T. Tohbaru, R. Asano, M. Nagayama, K. Kitahara, J. Umemura, T. Sumiyoshi, et al. Predictors of left ventricular dysfunction following mitral valve repair for mitral regurgitation: Reply J. Am. Coll. Cardiol., May 19, 2004; 43(10): 1925 - 1926. [Full Text] [PDF]

				T. Matsumura, E. Ohtaki, K. Tanaka, K. Misu, T. Tobaru, R. Asano, M. Nagayama, K. Kitahara, J. Umemura, T. Sumiyoshi, et al. Echocardiographic prediction ofleft ventricular dysfunction aftermitral valve repair for mitral regurgitation as anindicator to decide the optimal timing of repair J. Am. Coll. Cardiol., August 6, 2003; 42(3): 458 - 463. [Abstract] [Full Text] [PDF]

				J. I. Fann, N. B. Ingels Jr., and D. C. Miller Pathophysiology of Mitral Valve Disease Card. Surg. Adult, January 1, 2003; 2(2003): 901 - 931. [Full Text]

				T. L. Gentles and S. D. Colan Wall stress misrepresents afterload in children and young adults with abnormal left ventricular geometry J Appl Physiol, March 1, 2002; 92(3): 1053 - 1057. [Abstract] [Full Text] [PDF]

				I. A. Smolens, F. D. Pagani, G. M. Deeb, R. L. Prager, S. S. Sonnad, and S. F. Bolling Prophylactic mitral reconstruction for mitral regurgitation Ann. Thorac. Surg., October 1, 2001; 72(4): 1210 - 1216. [Abstract] [Full Text] [PDF]

				T. Le Tourneau, D. Grandmougin, C. Foucher, E. P. McFadden, P. de Groote, A. Prat, H. Warembourg, and G. Deklunder Anterior Chordal Transection Impairs Not Only Regional Left Ventricular Function But Also Regional Right Ventricular Function in Mitral Regurgitation Circulation, September 18, 2001; 104(2009): I-41 - I-46. [Abstract] [Full Text] [PDF]

				T. L. Gentles, S. D. Colan, N. J. Wilson, R. Biosa, and J. M. Neutze Left ventricular mechanics during and after acute rheumatic fever: contractile dysfunction is closely related to valve regurgitation J. Am. Coll. Cardiol., January 1, 2001; 37(1): 201 - 207. [Abstract] [Full Text] [PDF]

				Y. Ishibashi, J. C. Rembert, B. A. Carabello, S. Nemoto, M. Hamawaki, M. R. Zile, J. C. Greenfield Jr., and G. Cooper IV Normal myocardial function in severe right ventricular volume overload hypertrophy Am J Physiol Heart Circ Physiol, January 1, 2001; 280(1): H11 - H16. [Abstract] [Full Text] [PDF]

				T. Le Tourneau, P. de Groote, A. Millaire, C. Foucher, C. Savoye, P. Pigny, A. Prat, H. Warembourg, and J. M. Lablanche Effect of mitral valve surgery on exercise capacity, ventricular ejection fraction and neurohormonal activation in patients with severe mitral regurgitation J. Am. Coll. Cardiol., December 1, 2000; 36(7): 2263 - 2269. [Abstract] [Full Text] [PDF]

				S. R. Kapadia, K. Yakoob, S. Nader, J. D. Thomas, D. L. Mann, and B. P. Griffin Elevated circulating levels of serum tumor necrosis factor-alpha in patients with hemodynamically significant pressure and volume overload J. Am. Coll. Cardiol., July 1, 2000; 36(1): 208 - 212. [Abstract] [Full Text] [PDF]

				T. A. Abd-El-Aziz, A.-E.-F. H. Frere, T. S. Khalil, K. S. Mansour, A. F. Abd-El-Hamid, and K. H. Abd-El-Barry Study of the Value of Corrected Ejection Fraction in the Evaluation of Left Ventricular Function in Patients with Mitral or Aortic Regurgitation Angiology, July 1, 2000; 51(7): 555 - 564. [Abstract] [PDF]

				W. H. Devlin, J. Petrusha, K. Briesmiester, D. Montgomery, and M. R. Starling Impact of Vascular Adaptation to Chronic Aortic Regurgitation on Left Ventricular Performance Circulation, March 2, 1999; 99(8): 1027 - 1033. [Abstract] [Full Text] [PDF]

				C. M. Tribouilloy, M. Enriquez-Sarano, H. V. Schaff, T. A. Orszulak, K. R. Bailey, A. J. Tajik, and R. L. Frye Impact of Preoperative Symptoms on Survival After Surgical Correction of Organic Mitral Regurgitation : Rationale for Optimizing Surgical Indications Circulation, January 26, 1999; 99(3): 400 - 405. [Abstract] [Full Text] [PDF]

				L. H. Ling, M. Enriquez-Sarano, J. B. Seward, T. A. Orszulak, H. V. Schaff, K. R. Bailey, A. J. Tajik, and R. L. Frye Early Surgery in Patients With Mitral Regurgitation Due to Flail Leaflets : A Long-term Outcome Study Circulation, September 16, 1997; 96(6): 1819 - 1825. [Abstract] [Full Text]

				M. R. Starling Effects of Valve Surgery on Left Ventricular Contractile Function in Patients With Long-term Mitral Regurgitation Circulation, August 15, 1995; 92(4): 811 - 818. [Abstract] [Full Text]