The lack of a guideline consensus regarding the quantitative assessment of secondary mitral regurgitation (sMR) contributes to the uncertainty, inconsistency, and ongoing debate surrounding sMR. This can cloud medical judgement when weighing the risks of valvular intervention against the potential benefits.
In a five-year, observational, non-interventional study of 423 patients (median age 66 years) with chronic heart failure and reduced ejection fraction under guideline-directed medical therapy, sMR was assessed using a ‘unifying concept’ approach. This approach involved using a combination of conventional quantitative parameters (effective regurgitant orifice area [EROA], regurgitant volume [RegVol], and regurgitant fraction [RegFrac]) to stratify patients into low-risk (EROA <20 mm2 and RegVol <30 mL), intermediate-risk (EROA 20–29 mm2 and RegVol 30–44 mL), and high-risk (EROA ≥30 mm2 and RegVol ≥45 mL) groups.
The researchers found that while an assessment of ‘high risk’ patients showed a clear potential benefit to intervention, it is in the mid-spectrum patients that this ‘unifying concept’ approach could have the greatest impact. In this group, a combination of intermediate-range EROA (20–29 mm2) with higher-range RegFrac (≥50%) suggested hemodynamically severe sMR was associated with poor outcome (p=0.017), indicating that the patient should be stratified into the high-risk patient group.
The authors show that this more patient specific approach, based on combined assessment of parameters, shows significantly better discrimination when compared to the currently established algorithms, and may provide a unifying solution that could ultimately benefit all patients on the sMR spectrum.
Author: Daniel Guns, Cardiology Update
Original article: J Am Coll Cardiol. 2019;73:2506-17.