Page 60 - Advanced echocardiography in characterization and management of patients with secondary mitral regurgitation
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Chapter three. Prognostic Value of Left Ventricular Global Longitudinal Strain
the indication of surgical mitral valve repair or replacement (3). Heart failure patients who remain symptomatic despite optimal medical therapy (including CRT) and who have a LVEF >30% may be considered for mitral valve surgery if the surgical risk is low (Class IIb) or percutaneous edge-to-edge repair if the surgical risk is high or there are contraindications (Class IIb) (3). The prognostic benefit of reducing secondary MR remains controversial due to a lack of convincing evidence showing improved survival with any intervention (14, 15, 16). Although it is well known that patients with secondary MR have a poor prognosis (17,18), it is less well known if secondary MR affects prognosis independently of LV systolic dysfunction (19). Recently, a long-term observational study demonstrated that secondary MR has an adverse prognostic impact in patients with heart failure and reduced LVEF, but it was only independently associated with all-cause mortality in those with a LVEF of 30% to 40% (20). This intriguing finding suggests that the benefit of mitral valve intervention may be limited to a certain range of LVEF.
Central Illustration. Asso- ciation of Left Ventricular Global Longitudinal Strain and All-Cause Mortality in Patients With Significant Secondary Mitral Regurgi- tation
(A) Example of a patient with severe secondary mi- tral regurgitation (MR) and a left ventricular ejection fraction (LVEF) of 21%. (B) Example of another patient with severe secondary MR and an LVEF of 20%. Despite having the same degree of MR and a comparable LVEF, it is shown that the LV glob-
al longitudinal strain (GLS) is highly different, indicating that patient in panel A had a better LV systolic function when compared with the patient in panel B. (C) Prediction of all-cause mortality across a range of LV GLS, plotted as a fitted spline model on a log-hazard scale with overlaid con- fidence intervals. Dashed lines represent 95% confidence intervals. (D) Kaplan-Meier curves for all-cause mortality according to baseline LV GLS: ≥7.0% (less impaired, green) and LV GLS <7.0% (more impaired, red). It is shown that patients with an impaired LV GLS have higher mortality rates.
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