Author + information
- Received March 8, 2019
- Revision received May 8, 2019
- Accepted June 3, 2019
- Published online August 12, 2019.
- Benjamin Essayagh, MDa,
- Clémence Antoine, MDa,
- Giovanni Benfari, MDa,
- David Messika-Zeitoun, MD, PhDb,
- Hector Michelena, MDa,
- Thierry Le Tourneau, MDc,
- Sunil Mankad, MDa,
- Christophe M. Tribouilloy, MD, PhDd,
- Prabin Thapa, BSca and
- Maurice Enriquez-Sarano, MDa,∗ (, )@sarano_maurice
- aDepartment of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
- bUniversity of Ottawa Heart Institute, Ottawa, Ontario, Canada
- cDepartment of Cardiology, University of Nantes, Nantes, France
- dDepartment of Cardiology, University of Amiens, Amiens, France
- ↵∗Address for correspondence:
Dr. Maurice Enriquez-Sarano, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, Minnesota 55905.
Background Left atrial enlargement is frequent in degenerative mitral regurgitation (DMR), but its link to outcomes remains unproven in routine clinical practice.
Objectives The purpose of this study was to assess whether left atrial volume index (LAVI) measured in routine clinical practice of multiple sonographers/cardiologists is associated independently with DMR survival.
Methods A cohort of 5,769 (63 ± 16 years, 47% women) consecutive patients with degenerative mitral valve disease, in whom LAVI was prospectively measured, was enrolled and the long-term survival was analyzed.
Results LAVI (43 ± 24 ml/m2) was widely distributed (<40 ml/m2 in 3,154 patients, 40 to 59 ml/m2 in 1,606, and ≥60 ml/m2 in 1,009). Overall survival throughout follow-up (10-year 66 ± 1%) was strongly associated with LAVI (79 ± 1% vs. 65 ± 2% and 54 ± 2% for LAVI <40, 40 to 59, and ≥60 ml/m2, respectively; p < 0.0001) even after comprehensive adjustment, including for DMR severity (adjusted hazard ratio [HR]: 1.05 [95% confidence interval (CI): 1.03 to 1.08] per 10 ml/m2; p < 0.0001). Mortality under medical management was profoundly affected by LAVI (adjusted HR: 1.07 [95% CI: 1.04 to 1.10] per 10 ml/mm2 and 1.55 [95% CI: 1.31 to 1.84] for LAVI ≥60 ml/m2 vs. <40 ml/m2; both p < 0.0001) incrementally to adjusting variables (p < 0.0001) and in all subgroups, particularly sinus rhythm (adjusted HR: 1.25 [95% CI: 1.21 to 1.28]) or atrial fibrillation (adjusted HR: 1.10 [95% CI: 1.06 to 1.13] per 10 ml/m2; both p < 0.0001). Thresholds of excess mortality in spline curve analysis were approximated at 40 ml/m2 in all subgroups. Survival markedly improved after mitral surgery (time-dependent adjusted HR: 0.43 [95% CI: 0.36 to 0.53]; p < 0.0001) but remained modestly linked to LAVI (10-year survival 85 ± 3% vs. 86 ± 2% and 75 ± 3% for LAVI <40, 40 to 59, and ≥60 ml/m2, respectively; p < 0.0001).
Conclusions The frequent left atrial enlargement of DMR as measured by LAVI in routine practice displays, overall and in all subsets, a powerful, incremental, and independent link to excess mortality, which is partially alleviated by mitral surgery. Hence, LAVI measurement should be part of routine DMR evaluation and the clinical decision-making process.
Funding for this work was provided by the Mayo Foundation. Dr. Messika-Zeitoun has served as a consultant for Edwards Lifesciences and Mardil. Dr. Enriquez-Sarano is the recipient of a research grant from Edwards LLC. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Listen to this manuscript's audio summary by Editor-in-Chief Dr. Valentin Fuster on JACC.org.
- Received March 8, 2019.
- Revision received May 8, 2019.
- Accepted June 3, 2019.
- 2019 American College of Cardiology Foundation
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