Risk Stratification in Severe and Asymptomatic Mitral Valve Regurgitation: How Could Patients with Adverse Outcomes Be Identified?

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Abstract

Objective
To assess the usefulness a score which might identify adverse outcomes in asymptomatic patients with severe organic mitral valve regurgitation using clinical, echocardiographic and exercise variables.

Material and Methods
We assessed 375 asymptomatic patients with severe organic mitral valve regurgitation (61±10 years, left ventricular ejection fraction [LVEF] 67%±5%). The score performed included the presence of atrial fibrillation, end-diastolic diameter e”40 mm, effective regurgitant orifice 55 mm2, left atrium volume >120 cm3, age >60, and exercise time <7 minutes. The score ranged from 0 to 6.5. The primary endpoint was the development of symptoms and/or left ventricular dysfunction, defined as a decrease in LVEF >5% or LVEF <60%. The secondary endpoints included isolated symptoms, isolated left ventricular dysfunction, sudden death and valvular surgery.

Results
During a mean follow-up of 10±3.5 years, 145 patients (39%) presented the primary endpoint; 157 (42%) had symptoms, 99 (26%) ventricular dysfunction, 10 patients (2.6%) died (7 of cardiovascular causes) and 207 patients underwent surgery (55%). The incidence of the primary endpoint with a score < 2, between 2-3, and > 3 was 2.3%, 26% and 78%, respectively. Primary event rate with a score < 2, 2-3 and > 3 was 2.3%±0.1%, 28%±4% and 73%±9%, respectively. The area under the ROC curve was 0.87.

Conclusion
In asymptomatic patients with severe mitral valve regurgitation, a score using clinical, echocardiographic and exercise variables is useful to identify subgroups of patients at greater long-term risk.