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CLINICAL RESEARCH: INTERVENTIONAL CARDIOLOGY

Importance of mitral regurgitation inpatients undergoing percutaneous coronaryintervention for acute myocardial infarction

The Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) Trial

Gregory G. Pellizzon, MD^*, Cindy L. Grines, MD, FACC, David A. Cox, MD, FACC, Thomas Stuckey, MD, FACC, James E. Tcheng, MD, FACC^||, Eulogio Garcia, MD^¶, Giulio Guagliumi, MD^#, Mark Turco, MD, FACC^**, Alexandra J. Lansky, MD, FACC, John J. Griffin, MD, FACC, David J. Cohen, MD, FACC, Eve Aymong, MD, Roxana Mehran, MD, FACC, William W. O'Neill, MD, FACC and Gregg W. Stone, MD, FACC^,*

^* Mid-America Heart Institute, Saint Luke's Hospital, Kansas City, Missouri, USA
William Beaumont Hospital, Royal Oak, Michigan, USA
Mid Carolina Cardiology, Charlotte, North Carolina, USA
Moses Cone Memorial Hospital, Greensboro, North Carolina, USA
^|| Duke Clinical Research Institute, Durham, North Carolina, USA
^¶ Hospital Gregorio Maranon, Madrid, Spain
^# Ospedali Riuniti di Bergamo, Bergamo, Italy
^** Washington Adventist Hospital, Tacoma Park, Maryland, USA
Virginia Beach General Hospital, Virginia Beach, Virginia, USA
Beth Israel-Deaconess Medical Center, Boston, Massachusetts, USA
the Cardiovascular Research Foundation and Lenox Hill Heart and Vascular Institute, New York, New York, USA

Manuscript received August 18, 2003; revised manuscript received November 4, 2003, accepted November 13, 2003.

^* Reprint requests and correspondence: Dr. Gregg W. Stone, The Cardiovascular Research Foundation, 5 East 59th Street, 6th Floor, New York, New York 10022, USA.
gstone{at}crf.org

OBJECTIVES: We sought to determine the prognostic importance of mitral regurgitation (MR) in patients undergoing percutaneous coronary intervention for acute myocardial infarction (AMI).

BACKGROUND: Mitral regurgitation has been associated with a poor prognosis in patients treated with thrombolytic therapy for AMI. The prognostic significance of MR in patients undergoing mechanical reperfusion therapy for AMI is unknown.

METHODS: Left ventriculography was performed during the index procedure in 1,976 (95%) of 2,082 non-shock patients enrolled in a prospective, multicenter, randomized trial of mechanical reperfusion strategies in AMI. The severity of operator-assessed MR was divided into four strata: none (n = 1,726), mild (n = 192), and moderate/severe (n = 58).

RESULTS: Patients with progressively more severe MR were older (p < 0.0001), were more often women (p < 0.0001), and had higher Killip class (p = 0.0007). More severe grades of MR correlated with triple-vessel disease (p < 0.0001) and lower left ventricular ejection fraction (LVEF) as measured during the index procedure (p = 0.0004). Increasingly severe MR was strongly associated with a higher mortality at 30 days (1.4% vs. 3.7% vs. 8.6%, respectively; p < 0.0001) and at one year (2.9%, 8.5%, 20.8%, respectively; p < 0.0001). By multivariate analysis, the presence of even mild MR was an independent predictor of long-term mortality (mild MR, relative risk [RR] = 2.40, p = 0.005; moderate/severe MR, RR = 2.82, p = 0.006).

CONCLUSIONS: Mitral regurgitation of any degree present on the baseline left ventriculogram during the index procedure is a powerful, independent predictor of mortality in patients undergoing mechanical reperfusion therapy for AMI. The presence of MR identifies high-risk patients in whom close out-patient follow-up is warranted, and who may benefit from aggressive adjunctive medical or surgical therapies.

Abbreviations and Acronyms   AMI = acute myocardial infarction   CADILLAC = Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications   LV = left ventricle/ventricular   MR = mitral regurgitation   PCI = percutaneous coronary intervention   PVC = premature ventricular contraction   TIMI = Thrombolysis In Myocardial Infarction

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