Author + information
- Received April 23, 2020
- Revision received May 18, 2020
- Accepted May 19, 2020
- Published online July 13, 2020.
- Li-Tan Yang, MDa,b,
- Maurice Enriquez-Sarano, MDa,
- Christopher G. Scott, MSc,
- Ratnasari Padang, MBBS, PhDa,
- Joseph F. Maalouf, MDa,
- Patricia A. Pellikka, MDa and
- Hector I. Michelena, MDa,∗ (, )@michelenahector
- aDepartment of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
- bDivision of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- cDivision of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
- ↵∗Address for correspondence:
Dr. Hector I. Michelena, Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester Minnesota 55905.
Background Etiology, mechanisms, and survival of mitral regurgitation (MR) plus hemodynamically-significant chronic aortic regurgitation (AR) are mostly unknown.
Objectives The purpose of this study was to investigate the prevalence, mechanisms, etiologies, and survival impact of coexistent ≥ moderate MR in AR patients.
Methods Consecutive patients with ≥ moderate-severe AR were retrospectively identified between 2004 and 2019.
Results Of 1,239 eligible patients (61 ± 18 years, 80% men), 1,072 (86%) had pure AR, and 167 (14%) had AR + MR (9% functional mitral regurgitation [FMR] [84% nonischemic] and 5% organic mitral regurgitation [OMR] [62% degenerative]). At baseline transthoracic echocardiogram, pure AR versus AR + OMR versus AR + FMR exhibited differences in age (59 ± 18, 62 ± 16, and 73 ± 14 years, respectively), female sex (18%, 27%, and 39%, respectively), symptoms (36%, 41%, and 64%, respectively), atrial fibrillation (5%, 17%, and 36%, respectively), left ventricular (LV) ejection fraction (59%, 58%, and 46%, respectively), LV end-systolic dimension and volume index, ≥ moderate tricuspid regurgitation (TR) (7%, 35%, and 53%, respectively), and right ventricular systolic pressure (32 ± 11, 45 ± 15, and 50 ± 14 mm Hg, respectively), all p < 0.0001. After a median follow-up of 5.2 years (interquartile range: 2.2 to 10.0 years) and adjusting for demographics, New York Heart Association functional class, aortic valve surgery, LV ejection fraction, LV end-systolic dimension and volume index, presence of FMR was independently associated with all-cause mortality (p ≤ 0.004). Compared with pure AR, AR + MR + TR exhibited the highest adjusted risk of death (2.4-fold; p < 0.0001). When compared with expected population survival, excess mortality risks of pure AR, AR + OMR, and AR + FMR were 1.25-fold, 1.76-fold, and 2.34-fold, respectively (all p ≤ 0.02).
Conclusions In hemodynamically significant AR, coexistent MR is not uncommon (approximately 14%) and mostly comprises FMR and less commonly OMR. As compared with pure AR, AR + MR + TR exhibit the largest mortality risk. Both AR + OMR and AR + FMR carry a survival penalty compared with the general population, but AR + FMR is associated with the largest excess mortality and represents an advanced stage within the AR clinical spectrum.
This study was supported by a grant from the Mayo Clinic Department of Cardiovascular Medicine. Dr. Enriquez-Sarano has relationships with Mardil Inc. and Cryolife Inc. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC author instructions page.
- Received April 23, 2020.
- Revision received May 18, 2020.
- Accepted May 19, 2020.
- 2020 American College of Cardiology Foundation
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