Progression of mitral regurgitation: a prospective Doppler echocardiographic study.

OBJECTIVES This study was performed to define the rates and determinants of progression of organic mitral regurgitation (MR). BACKGROUND Severe MR has major clinical consequences, but the rates and determinants of progression of the degree of regurgitation are unknown. Quantitative Doppler echocardiographic methods allow the quantitation of regurgitant volume (RVol), regurgitant fraction (RF) and effective regurgitant orifice (ERO) to define progression of MR. METHODS In a prospective study of MR progression, 74 patients had two quantitative Doppler echocardiographic examinations of MR (with at least two methods) 561 +/- 423 days apart without an intervening event. RESULTS Progression of MR was observed, with increase in RVol (77 +/- 46 ml vs. 65 +/- 40 ml, p < 0.0001), RF (47 +/- 16% vs. 43% +/- 15%, p < 0.0001), and ERO (50 +/- 35 mm2 vs. 41 +/- 28 mm2, p < 0.0001). Annual rates (95% confidence interval) were, respectively, 7.4 ml/year (5.1, 9.7), 2.9%/year (1.9, 3.9) and 5.9 mm2/year (3.9, 7.8). However, wide individual variation was observed, and regression and progression of RVol >8 ml was found in 11% and 51%, respectively. In multivariate analysis, independent predictors of progression of RVol were progression of the lesions, particularly a new flail leaflet (p = 0.0003), and progression of mitral annulus diameter (p = 0.0001). Regression of MR was associated with marked changes in afterload, particularly decreased blood pressure (p = 0.008). No significant effect of treatment was detected. CONCLUSIONS Organic MR tends to progress over time with increase in volume overload (RVol) due to increase in ERO. Progression of MR is variable and determined by progression of lesions or mitral annulus size. These data should help plan follow up of patients with organic MR and future intervention trials.

[1]  J. Seward,et al.  Progression of aortic stenosis in adults: new appraisal using Doppler echocardiography. , 1990, American heart journal.

[2]  R G Gould,et al.  Left atrial volume determination by biplane two-dimensional echocardiography: validation by cine computed tomography. , 1991, American heart journal.

[3]  M. Enriquez-Sarano,et al.  Left Ventricular Volume Changes During Dobutamine Stress Echocardiography Identify Patients with More Extensive Coronary Artery Disease , 1994, Journal of the American College of Cardiology.

[4]  A. Bolger,et al.  Three-dimensional dynamics of the canine mitral annulus during ischemic mitral regurgitation. , 1996, Annals of Thoracic Surgery.

[5]  N. Reichek,et al.  Recommendations for quantitation of the left ventricle by two-dimensional echocardiography. American Society of Echocardiography Committee on Standards, Subcommittee on Quantitation of Two-Dimensional Echocardiograms. , 1989, Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography.

[6]  M. Quiñones,et al.  Determination of regurgitant fraction in isolated mitral or aortic regurgitation by pulsed Doppler two-dimensional echocardiography. , 1986, Journal of the American College of Cardiology.

[7]  M. Enriquez-Sarano,et al.  Echocardiographic Prediction of Survival After Surgical Correction of Organic Mitral Regurgitation , 1994, Circulation.

[8]  W. Parmley,et al.  Beneficial Effects of Vasodilator Agents in Severe Mitral Regurgitation Due to Dysfunction of Subvalvar Apparatus , 1973, Circulation.

[9]  A P Yoganathan,et al.  A new method for quantification of regurgitant flow rate using color Doppler flow imaging of the flow convergence region proximal to a discrete orifice. An in vitro study. , 1991, Circulation.

[10]  A Piwnica,et al.  A new reconstructive operation for correction of mitral and tricuspid insufficiency. , 1971, The Journal of thoracic and cardiovascular surgery.

[11]  W. Gaasch,et al.  Vasoactive drugs in chronic regurgitant lesions of the mitral and aortic valves. , 1996, Journal of the American College of Cardiology.

[12]  D. Mele,et al.  Application of color Doppler flow mapping to calculate effective regurgitant orifice area. An in vitro study and initial clinical observations. , 1993, Circulation.

[13]  B. Carabello,et al.  Valvular heart disease. , 1997, The New England journal of medicine.

[14]  R A Levine,et al.  Dynamics of Mitral Regurgitant Flow and Orifice Area: Physiologic Application of the Proximal Flow Convergence Method: Clinical Data and Experimental Testing , 1994, Circulation.

[15]  H. Hultgren,et al.  Progression of aortic stenosis in adult men. Detection by noninvasive methods. , 1987, Chest.

[16]  E. Sonnenblick,et al.  Dynamics of mitral regurgitation during nitroglycerin therapy: a Doppler echocardiographic study. , 1986, American heart journal.

[17]  L Hatle,et al.  DIAGNOSTIC METHODS , 2005 .

[18]  P. Kligfield,et al.  Natural history of the asymptomatic/minimally symptomatic patient with severe mitral regurgitation secondary to mitral valve prolapse and normal right and left ventricular performance. , 1994, The American journal of cardiology.

[19]  J B Seward,et al.  Clinical outcome of mitral regurgitation due to flail leaflet. , 1996, The New England journal of medicine.

[20]  L Hatle,et al.  Non-invasive assessment of aortic stenosis by Doppler ultrasound. , 1980, British heart journal.

[21]  W. N. Lim,et al.  The Natural History of Rheumatic Heart Disease in the Third, Fourth, and Fifth Decades of Life: I. Prognosis with Special Reference to Survivorship , 1957, Circulation.

[22]  E. Yellin,et al.  Dynamic Changes in the Canine Mitral Regurgitant Orifice Area during Ventricular Ejection , 1979, Circulation research.

[23]  M. Enriquez-Sarano,et al.  Color flow imaging compared with quantitative Doppler assessment of severity of mitral regurgitation: influence of eccentricity of jet and mechanism of regurgitation. , 1993, Journal of the American College of Cardiology.

[24]  Progression of aortic stenosis in 394 patients: relation to changes in myocardial and mitral valve dysfunction. , 1995, Journal of the American College of Cardiology.

[25]  M. Enriquez-Sarano,et al.  Early surgery in patients with mitral regurgitation due to flail leaflets: a long-term outcome study. , 1997, Circulation.

[26]  J. Kilman,et al.  Evidence for progression from mild to severe mitral regurgitation in mitral valve prolapse. , 1986, The American journal of cardiology.

[27]  C. Otto,et al.  Hemodynamic progression of aortic stenosis in adults assessed by Doppler echocardiography. , 1989, Journal of the American College of Cardiology.

[28]  A. Pichard,et al.  Coronary arteriography 1984-1987: a report of the Registry of the Society for Cardiac Angiography and Interventions. II. An analysis of 218 deaths related to coronary arteriography. , 1989, Catheterization and cardiovascular diagnosis.

[29]  M. Enriquez-Sarano,et al.  Effective mitral regurgitant orifice area: clinical use and pitfalls of the proximal isovelocity surface area method. , 1995, Journal of the American College of Cardiology.

[30]  H. Goldberg,et al.  Clinical and hemodynamic features of advanced rheumatic mitral regurgitation , 1961 .

[31]  E. Sonnenblick,et al.  The Effects of Left Ventricular Load and Contractility on Mitral Regurgitant Orifice Size and Flow in the Dog , 1977, Circulation.

[32]  E. Yellin,et al.  Dynamic Aspects of Acute Mitral Regurgitation: Effects of Ventricular Volume, Pressure and Contractility on the Effective Regurgitant Orifice Area , 1979, Circulation.

[33]  A. Weyman,et al.  Impact of Impinging Wall Jet on Color Doppler Quantification of Mitral Regurgitation , 1991, Circulation.

[34]  J. Seward,et al.  Continuous-wave Doppler echocardiographic assessment of severity of calcific aortic stenosis: a simultaneous Doppler-catheter correlative study in 100 adult patients. , 1985, Circulation.

[35]  M. Zile,et al.  Mitral Valve Replacement With and Without Chordal Preservation in Patients With Chronic Mitral Regurgitation: Mechanisms for Differences in Postoperative Ejection Performance , 1992, Circulation.

[36]  Harold T. Dodge,et al.  Left Ventricular Tension and Stress in Man , 1963, Circulation research.

[37]  P. Tunick,et al.  Comparison of cardiac catheterization and Doppler echocardiography in the decision to operate in aortic and mitral valve disease. , 1991, Journal of the American College of Cardiology.

[38]  E. Braunwald.  Heart Disease: A Textbook of Cardiovascular Medicine , 1992, Annals of Internal Medicine.

[39]  E. Alderman,et al.  Ventriculographic and hemodynamic features of mitral regurgitation of cardiomyopathic, rheumatic and nonrheumatic etiology. , 1977, The American journal of cardiology.

[40]  K. Hammermeister,et al.  Clinical Investigation Determinants of Survival and Left Ventricular Performance After Mitral Valve Replacement , 2005 .

[41]  著者なし.  Heart Disease : A Textbook of Cardiovascular Medicine, 5th Ed. , 1997 .

[42]  M. Enriquez-Sarano,et al.  Grading of mitral regurgitation by quantitative Doppler echocardiography: calibration by left ventricular angiography in routine clinical practice. , 1997, Circulation.

[43]  M. Winniford,et al.  Limitations of qualitative angiographic grading in aortic or mitral regurgitation. , 1984, The American journal of cardiology.

[44]  M. Enriquez-Sarano,et al.  Changes in effective regurgitant orifice throughout systole in patients with mitral valve prolapse. A clinical study using the proximal isovelocity surface area method. , 1995, Circulation.

[45]  M. Enriquez-Sarano,et al.  Effective regurgitant orifice area: a noninvasive Doppler development of an old hemodynamic concept. , 1994, Journal of the American College of Cardiology.

[46]  E. Botvinick,et al.  Quantitation of mitral regurgitation by Doppler echocardiography. , 1986, Circulation.

[47]  J. Ross.  The timing of surgery for severe mitral regurgitation. , 1996, The New England journal of medicine.

[48]  James B. Seward,et al.  Quantitative Doppler Assessment of Valvular Regurgitation , 1993, Circulation.