Clinical outcome of mitral regurgitation due to flail leaflet.

BACKGROUND Mitral regurgitation due to flail leaflet is difficult to manage, because it is frequently asymptomatic yet carries a high risk of left ventricular dysfunction and because the natural history of the condition is poorly defined. METHODS We obtained clinical follow-up data through 1994-1995 in 229 patients with isolated mitral regurgitation due to flail leaflet; this condition was first diagnosed by echocardiography between 1980 and 1989. RESULTS The 86 patients who were treated medically had a mortality rate significantly higher than expected (6.3 percent yearly, P=0.016 for the comparison with the expected rate in the U.S. population according to the 1990 census). Independent determinants of mortality were an older age, the presence of symptoms, and a lower ejection fraction. Patients who were even transiently in New York Heart Association functional class III or IV had a high mortality rate (34 percent yearly), but the rate was also notable (4.1 percent yearly) among those in class I or II. At 10 years, the mean (+/- SE) rates of heart failure, atrial fibrillation, and death or surgery were 63 +/- 8, 30 +/- 12, and 90 +/- 3 percent, respectively. In a multivariate analysis, surgical correction of mitral regurgitation (performed in 143 patients) was associated with a reduced mortality rate (hazard ratio, 0.29; 95 percent confidence interval, 0.15 to 0.56; P<0.001). CONCLUSIONS When treated medically, mitral regurgitation due to flail leaflet is associated with excess mortality and high morbidity. Surgery is almost unavoidable within 10 years after the diagnosis and appears to be associated with an improved prognosis; this finding suggests that surgery should be considered early in the course of the disease.

[1]  M. Enriquez-Sarano,et al.  Valve repair improves the outcome of surgery for mitral regurgitation. A multivariate analysis. , 1995, Circulation.

[2]  M. Emond,et al.  Long‐term Survival of Medically Treated Patients in the Coronary Artery Surgery Study (CASS) Registry , 1994, Circulation.

[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]  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.

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

[6]  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.

[7]  S. Vaziri,et al.  Echocardiographic Predictors of Nonrheumatic Atrial Fibrillation: The Framingham Heart Study , 1994, Circulation.

[8]  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.

[9]  I. Burwash,et al.  Usefulness of left atrial and left ventricular chamber sizes as predictors of the severity of mitral regurgitation. , 1992, The American journal of cardiology.

[10]  P. Bruneval,et al.  Aetiology of surgically treated mitral regurgitation. , 1991, European heart journal.

[11]  J. Delahaye,et al.  Natural history of severe mitral regurgitation. , 1991, European heart journal.

[12]  A. Vahanian,et al.  Indications for surgery in mitral regurgitation. , 1991, European heart journal.

[13]  A. Labovitz,et al.  Color Doppler echocardiographic evaluation of patients with a flail mitral leaflet. , 1990, Journal of the American College of Cardiology.

[14]  A. Galloway,et al.  Current concepts of mitral valve reconstruction for mitral insufficiency. , 1988, Circulation.

[15]  A. Galloway,et al.  Long-term results of mitral valve reconstruction with Carpentier techniques in 148 patients with mitral insufficiency. , 1988, Circulation.

[16]  C. Mackenzie,et al.  A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. , 1987, Journal of chronic diseases.

[17]  W. Edwards,et al.  Surgical pathology of the mitral valve: a study of 712 cases spanning 21 years. , 1987, Mayo Clinic proceedings.

[18]  N. Nanda,et al.  Color Doppler assessment of mitral regurgitation with orthogonal planes. , 1987, Circulation.

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

[20]  G. Bergeron.  Minimally symptomatic patients with ruptured chordae tendineae due to myxomatous degeneration of the mitral valve. , 1986, The American journal of medicine.

[21]  P. Kligfield,et al.  Mitral regurgitation: relationship of noninvasive descriptors of right and left ventricular performance to clinical and hemodynamic findings and to prognosis in medically and surgically treated patients. , 1986, Circulation.

[22]  S. Goldberg,et al.  Ruptured mitral chordae tendineae may be a frequent and insignificant complication in the mitral valve prolapse syndrome. , 1985, European heart journal.

[23]  J. Ross,et al.  Flail mitral valve syndrome: comparison with chronic mitral regurgitation of other etiologies. , 1985, American heart journal.

[24]  D. Mirvis,et al.  Natural history of chronic mitral insufficiency: relation of peak systolic pressure/end-systolic volume ratio to morbidity and mortality. , 1984, Journal of the American College of Cardiology.

[25]  J. Ross,et al.  Natural history of the flail mitral leaflet syndrome: a serial 2-dimensional echocardiographic study. , 1983, American Journal of Cardiology.

[26]  K. Dawkins,et al.  Chordal rupture. I: aetiology and natural history. , 1983, British heart journal.

[27]  H. Trampisch,et al.  [Effect of prosthetic heart valve replacement on the natural course of isolated mitral and aortic as well as multivalvular diseases. Clinical results in 783 patients up to 8 years following implantation of the Björk-Shiley tilting disc prosthesis]. , 1983, Zeitschrift fur Kardiologie.

[28]  S. Rich,et al.  Determination of left ventricular ejection fraction by visual estimation during real-time two-dimensional echocardiography. , 1982, American heart journal.

[29]  N. Reichek,et al.  Noninvasive Determination of Left Ventricular End‐systolic Stress: Validation of the Method and Initial Application , 1982, Circulation.

[30]  G. Mintz,et al.  Left atrial volume overload in mitral regurgitation: a two dimensional echocardiographic study. , 1982, The American journal of cardiology.

[31]  W. Daggett,et al.  Mitral valve replacement for isolated mitral regurgitation: analysis of clinical course and late postoperative left ventricular ejection fraction. , 1981, The American journal of cardiology.

[32]  R R Miller,et al.  A New, Simplified and Accurate Method for Determining Ejection Fraction with Two‐dimensional Echocardiography , 1981, Circulation.

[33]  G. Mintz,et al.  Statistical comparison of M mode and two dimensional echocardiographic diagnosis of flail mitral leaflets. , 1980, The American journal of cardiology.

[34]  D. Decristofaro,et al.  Detection and Estimation of the Degree of Mitral Regurgitation by Range‐gated Pulsed Doppler Echocardiography , 1980, Circulation.

[35]  D J Hagler,et al.  Two-dimensional real-time ultrasonic imaging of the heart and great vessels. Technique, image orientation, structure identification, and validation. , 1978, Mayo Clinic proceedings.

[36]  G. Mintz,et al.  Two‐dimensional Echocardiographic Recognition of Ruptured Chordae Tendineae , 1978, Circulation.

[37]  K. Hammermeister,et al.  Prediction of Late Survival in Patients with Mitral Valve Disease from Clinical, Hemodynamic, and Quantitative Angiographic Variables , 1978, Circulation.

[38]  E. Rapaport.  Natural history of aortic and mitral valve disease. , 1975, The American journal of cardiology.

[39]  O. Medina,et al.  Influence of surgery on the natural history of rheumatic mitral and aortic valve disease. , 1975, The American journal of cardiology.

[40]  H. Dodge,et al.  Hemodynamics in Ruptured Chordae Tendineae and Chronic Rheumatic Mitral Regurgitation , 1973, Circulation.

[41]  A. Selzer,et al.  Mitral regurgitation: clinical patterns, pathophysiology and natural history. , 1972, Medicine.

[42]  L. B. Ellis,et al.  The clinical course of patients with severe "rheumatic" mitral insufficiency. , 1969, American heart journal.

[43]  R. Dinsmore,et al.  Diagnosis and surgical treatment of mitral regurgitation secondary to ruptured chordae tendineae. , 1967, The New England journal of medicine.

[44]  E. Braunwald,et al.  Acute Severe Mitral Regurgitation Secondary to Ruptured Chordae Tendineae: Clinical, Hemodynamic, and Pathologic Considerations , 1966, Circulation.

[45]  C. Sanders,et al.  Severe Mitral Regurgitation Secondary to Ruptured Chordae Tendineae , 1965, Circulation.

[46]  B. F. Massell,et al.  Relatively Benign “Pure” Mitral Regurgitation of Rheumatic Origin: A Study of Seventy‐Four Adult Patients , 1960, Circulation.

[47]  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.