Left Atrial Function Is Associated with Earlier Need for Cardiac Surgery in Moderate to Severe Mitral Regurgitation: Usefulness in Targeting for Early Surgery

Liam Ring; Yasir Abu-Omar; Nikki Kaye; Bushra S Rana; William Watson; David P Dutka; Vassilios S Vassiliou

doi:10.1016/j.echo.2018.03.011

Left Atrial Function Is Associated with Earlier Need for Cardiac Surgery in Moderate to Severe Mitral Regurgitation: Usefulness in Targeting for Early Surgery

J Am Soc Echocardiogr. 2018 Sep;31(9):983-991. doi: 10.1016/j.echo.2018.03.011. Epub 2018 May 24.

Authors

Liam Ring¹, Yasir Abu-Omar², Nikki Kaye³, Bushra S Rana², William Watson², David P Dutka³, Vassilios S Vassiliou⁴

Affiliations

¹ Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge; Cardiology Department, West Suffolk Hospital NHS Foundation Trust, Bury St. Edmunds. Electronic address: liamring@doctors.org.uk.
² Department of Cardiology, Papworth Hospital NHS Foundation, Cambridge University Health Partners, Papworth Everard.
³ Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge.
⁴ Department of Cardiology, Royal Brompton and Harefield NHS Trust and Imperial College London, London; Norwich Medical School, University of East Anglia, and Norfolk and Norwich University Hospital, Norwich, United Kingdom.

PMID: 29804897
DOI: 10.1016/j.echo.2018.03.011

Abstract

Background: The aim of this study was to determine whether assessment of left atrial (LA) function helps identify patients at risk for early deterioration during follow-up with mitral valve prolapse and mitral regurgitation.

Methods: Patients with moderate to severe mitral regurgitation but no guideline-based indications for surgery were retrospectively identified from a dedicated clinical database. Maximal and minimal LA volumes were used to derive total LA emptying fraction ([maximal LA volume - minimal LA volume]/maximal L volume × 100%). Average values of peak contractile, conduit, and reservoir strain were obtained using two-dimensional speckle-tracking imaging. The study outcome was time to mitral surgery.

Results: One hundred seventeen patients were included; median follow-up was 18 months. Sixty-eight patients underwent surgery. Receiver operating characteristic curves were used to derive optimal cutoffs for TLAEF (>50.7%) and strain (reservoir, >28.5%; contractile, >12.5%). Using Cox analysis, TLAEF and contractile, reservoir, and conduit strain were univariate predictors of time to event. After multivariate analysis, TLAEF (hazard ratio, 2.59; P = .001), reservoir strain (hazard ratio, 3.06; P < .001), and contractile strain (hazard ratio, 2.01; P = .022) remained independently associated with events, but conduit strain did not. Using Kaplan-Meier curves, event-free survival was considerably improved in patients with values above the derived thresholds (TLAEF: 1-year survival, 78 ± 5% vs 28 ± 8%; 3-year survival, 68 ± 6% vs 13 ± 5%; P < .001 for both; reservoir strain: 1-year survival, 79 ± 5% vs 29 ± 7%; 3-year survival, 67 ± 6% vs 15 ± 6%; P < .001 for both; contractile strain: 1-year survival, 80 ± 5% vs 41 ± 7%; 3-year survival, 69 ± 6% vs 24 ± 6%; P < .001 for both).

Conclusion: LA function is independently associated with surgery-free survival in patients with mitral valve prolapse and moderate to severe mitral regurgitation. Quantitative assessment of LA function may have clinical utility in guiding early surgical intervention in these patients.

Keywords: Atrial function; Mitral regurgitation; Mitral valve prolapse; Mitral valve surgery; Prognosis.

MeSH terms

Aged
Atrial Function, Left*
Echocardiography, Doppler / methods*
Female
Humans
Male
Middle Aged
Mitral Valve Insufficiency / diagnostic imaging*
Mitral Valve Insufficiency / physiopathology
Mitral Valve Insufficiency / surgery*
Prognosis
Retrospective Studies
Survival Analysis