CLINICAL STUDIES
Sudden death in mitral regurgitation due to flail leaflet
Francesco Grigioni, MD*,
Maurice Enriquez-Sarano, MD, FACC*,
Lieng H. Ling, MD*,
Kent R. Bailey, PhD ,
James B. Seward, MD, FACC*,
A. Jamil Tajik, MD, FACC* and
Robert L. Frye, MD, FACC*
* Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA
Section of Biostatistics, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA
Manuscript received January 29, 1998;
revised manuscript received July 8, 1999,
accepted September 7, 1999.
Reprint requests and correspondence: Dr. Maurice Enriquez-Sarano, Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, Minnesota
sarano.maurice{at}mayo.edu
OBJECTIVES
We sought to assess the incidence and determinants of sudden death (SUD) in mitral regurgitation due to flail leaflet (MR-FL).
BACKGROUND
Sudden death is a catastrophic complication of MR-FL. Its incidence and predictability are undefined.
METHODS
The occurrence of SUD was analyzed in 348 patients (age 67 ± 12 years) with MR-FL diagnosed echocardiographically from 1980 through 1994.
RESULTS
During a mean follow-up of 48 ± 41 months, 99 deaths occurred under medical treatment. Sudden death occurred in 25 patients, three of whom were resuscitated. The sudden death rates at five and 10 years were 8.6 ± 2% and 18.8 ± 4%, respectively, and the linearized rate was 1.8% per year. By multivariate analysis, the independent baseline predictors of SUD were New York Heart Association (NYHA) functional class (p = 0.006), ejection fraction (p = 0.0001) and atrial fibrillation (p = 0.059). The yearly linearized rate of sudden death was 1% in patients in functional class I, 3.1% in class II and 7.8% in classes III and IV. However, of 25 patients who had SUD, at baseline, 10 (40%) were in functional class I, 9 (36%) were in class II and only 6 (24%) in class III or IV. In five patients (20%), no evidence of risk factors developed until SUD. In patients with an ejection fraction  60% and sinus rhythm, the linearized rate of SUD was not different in functional classes I and II (0.8% per year). Surgical correction of MR (n = 186) was independently associated with a reduced incidence of SUD (adjusted hazard ratio [95% confidence interval] 0.29 [0.11 to 0.72], p = 0.007).
CONCLUSIONS
Sudden death is relatively common in patients with MR-FL who are conservatively managed. Patients with severe symptoms, atrial fibrillation and reduced systolic function are at higher risk, but notable rates of SUD have been observed without these risk factors. Correction of MR appears to be associated with a reduced incidence of SUD, warranting early consideration of surgical repair.
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Abbreviations and Acronyms
| | CAD | = coronary artery disease | | CI | = confidence interval | | EF | = ejection fraction | | LA | = left atrium | | LV | = left ventricle, ventricular | | MR | = mitral regurgitation | | MR-FL | = mitral regurgitation due to flail leaflet | | NYHA | = New York Heart Association | | SUD | = sudden death |
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