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CLINICAL RESEARCH: VALVULAR HEART DISEASE

Survival Implication of Left Ventricular End-Systolic Diameter in Mitral Regurgitation Due to Flail Leaflets

A Long-Term Follow-Up Multicenter Study

Christophe Tribouilloy, MD, PhD^_*,_*, Francesco Grigioni, MD, PhD, Jean François Avierinos, MD, Andrea Barbieri, MD, Dan Rusinaru, MD^_*, Catherine Szymanski, MD^_*, Marinella Ferlito, MD, Laurence Tafanelli, MD, Francesca Bursi, MD, Faouzi Trojette, MD^_*, Angelo Branzi, MD, Gilbert Habib, MD, Maria G. Modena, MD, Maurice Enriquez-Sarano, MD^|| on behalf of the MIDA Investigators

^_* Department of Cardiology, INSERM, ERI 12, and University Hospital, Amiens, France
Cardiovascular Department, University Hospital of Bologna, Bologna, Italy
Department of Cardiology, University Hospital of Marseille, Marseille, France
Department of Cardiology, University Hospital of Modena, Modena, Italy
^|| Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota

Manuscript received December 22, 2008; revised manuscript received June 3, 2009, accepted June 9, 2009.

^_* Reprint requests and correspondence: Prof. Christophe Tribouilloy, INSERM, ERI 12, and University Hospital, Department of Cardiology, Avenue René Laënnec, 80054 Amiens Cedex 1, France (Email: tribouilloy.christophe{at}chu-amiens.fr).

Objectives: This study analyzed the association of left ventricular end-systolic diameter (LVESD) with survival after diagnosis in organic mitral regurgitation (MR) due to flail leaflets.

Background: LVESD is a marker of left ventricular function in patients with organic MR but its association to survival after diagnosis is unknown.

Methods: The MIDA (Mitral Regurgitation International Database) registry is a multicenter registry of echocardiographically diagnosed organic MR due to flail leaflets. We enrolled 739 patients with MR due to flail leaflets (age 65 ± 12 years; ejection fraction: 65 ± 10%) in whom LVESD was measured (36 ± 7 mm).

Results: Under conservative management, 10-year survival and survival free of cardiac death were higher with LVESD <40 mm versus 40 mm (64 ± 5% vs. 48 ± 10%; p < 0.001, and 73 ± 5% vs. 63 ± 10%; p = 0.001). LVESD 40 mm independently predicted overall mortality (hazard ratio [HR]: 1.95, 95% confidence interval [CI]: 1.01 to 3.83) and cardiac mortality (HR: 3.09, 95% CI: 1.35 to 7.09) under conservative management. Mortality risk increased linearly with LVESD >40 mm (HR: 1.15, 95% CI: 1.04 to 1.27 per 1-mm increment). During the entire follow-up (including post-surgical), LVESD 40 mm independently predicted overall mortality (HR: 1.86, 95% CI: 1.24 to 2.80) and cardiac mortality (HR: 2.14, 95% CI: 1.29 to 3.56), due to persistence of excess mortality in patients with LVESD 40 mm after surgery (HR: 1.86, 95% CI: 1.11 to 3.15 for overall death, and HR: 1.81, 95% CI: 1.05 to 3.54 for cardiac death).

Conclusions: In MR due to flail leaflets, LVESD 40 mm is independently associated with increased mortality under medical management but also after mitral surgery. These findings support prompt surgical rescue in patients with LVESD 40 mm but also suggest that best preservation of survival is achieved in patients operated before LVESD reaches 40 mm.

Key Words: mitral regurgitation • left ventricular size • survival • surgery

Abbreviations and Acronyms   AF = atrial fibrillation   EF = ejection fraction   LV = left ventricle/left ventricular   MR = mitral regurgitation   LVESD = left ventricular end-systolic diameter

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