Page 121 - Advanced echocardiography in characterization and management of patients with secondary mitral regurgitation

Introduction
Patients with heart failure (HF) and reduced left ventricular (LV) ejection fraction (EF) may develop secondary mitral regurgitation (MR) which leads to chronic volume overload, further LV and left atrial (LA) remodelling, LV dysfunction, distortion of the mitral valve apparatus and eventually increasing MR volume which constitutes a self- perpetuating cycle (1, 2). The chronic volume overload, LV dysfunction and increasing LV filling pressures lead to pulmonary hypertension (PH) and right ventricular (RV) dysfunction with an increased risk of morbidity and mortality (1). The emergence of transcatheter therapies has influenced the management of patients with severe secondary MR. However, two major trials evaluating transcatheter edge-to-edge mitral valve repair in HF patients with secondary MR demonstrated different results in survival and symptomatic improvement (3, 4). These conflicting results demonstrate that patient selection of those who might benefit from transcatheter treatment of MR remains challenging. RV dysfunction, assessed by tricuspid annular plane systolic excursion (TAPSE), has been demonstrated to provide strong prognostic value in patients with HF (5) and to be a major predictor of outcome in patients with moderate to severe secondary MR (6). PH also appears to be associated with increased risk of mortality in patients with secondary MR undergoing transcatheter edge-to-edge repair (7). RV dysfunction and pulmonary pressures are commonly evaluated as separate components. However, RV function is highly dependent on its afterload (8) and evaluation of RV systolic function should be corrected for pulmonary pressures. The ratio between TAPSE and pulmonary arterial systolic pressure (PASP) has been proposed to predict patient prognosis in several diseases (9, 10). This ratio, a measure of RV to pulmonary artery (RV-PA) coupling, assesses RV systolic function adjusted for the degree of afterload (11, 12) and has prognostic value in patients with HF (9) and those undergoing transcatheter aortic valve replacement (10). However, the potential utility of TAPSE/PASP has not yet been evaluated in HF patients with secondary MR. Accordingly, our objective herein was to investigate the prognostic value of RV-PA coupling as assessed by the TAPSE/PASP ratio in patients with secondary MR.
Methods
Patient population
Through the departmental echocardiographic database (Imagevault EchoPAC, General Electric Vingmed Ultrasound, Norway) of Leiden University Medical Center, Leiden, The Netherlands, patients with HF and significant (moderate or severe) secondary MR
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