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Purpose: Significant mitral regurgitation (MR) may be holosystolic (HS) or mid-late systolic (MLS) in duration; with differences in volumetric impact on left ventricle. We sought to assess long-term outcomes of patients with myxomatous MR undergoing exercise echocardiography (execho), based on MLS vs HS MR.

Methods: We included 609 consecutive patients (59±14 years, 67% men) with ≥3+ myxomatous MR undergoing execho. MLS MR was defined as late MR in systole, relative to valve opening spikes (and/or QRS complex) on continuous-wave Doppler images, while HS MR occurred throughout systole. Clinical data was recorded. Composite events of death, myocardial infarction, stroke, & admission for heart failure were recorded.

Results: There were 51 primary events during 6±3 years of follow up (398 MV surgeries, 0% operative mortality). Comparative and outcome results are summarized in the table.

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Table 1

VariableComparison of patients with holosystolic vs mid-late systolic mitral regurgitationCox proportional hazards survival analysis of entire study population for composite outcomes
Holosystolic (n=487)Mid-late systolic (n=122)p-valueUnivariate Hazard Ratio [95% CI]Univariate p-valueMultivariate Hazard Ratio [95% CI]Multivariate p-value
Age (years)60±1453±12<0.0011.09 [1.05–1.2]0.001
Male Gender351 (72%)58 (53%)0.0011.13 [0.62–2.07]0.7
Hypertension241 (49%)45 (37%)0.030.91 [0.51–1.61]0.6
Coronary artery disease65 (14%)7 (5%)0.0040.94 [0.35–2.52]0.9
Atrial fibrillation/flutter77 (16%)9 (7%)0.0092.92 [1.46–5.86]0.0022.61 [1.32–5.15]0.007
LV ejection fraction (%)58±558±50.90.93 [0.89–1.04]0.2
Indexed LV end systolic diameter (cm/m2)1.62±0.51.72±0.40.040.83 [0.42–1.63]0.6
Left atrial area (cm2)27±725±70.051.03 [0.99–1.07]0.1
Peak exercise right ventricular systolic pressure (mmHg)48±1647±130.11.02 [0.96–1.06]0.2
Mid-late systolic vs holosystolic mitral regurgitation–––0.25 [0.07–0.98]0.020.21 [0.10–0.47]0.03
Flail mitral leaflet174 (36%)7 (6%)<0.0010.9 [0.5–1.64]0.6
% Age & gender predicted metabolic equivalents115±28121±280.020.98 [0.97–0.99]0.0040.98 [0.97–0.99]0.004
Mitral valve surgery None/Repair/Replacement164 (33%)/288 (59%)/35 (7%)47 (38%)/72 (59%)/3 (2%)0.10.70 [0.39–1.28]0.2
Time to surgery (years)0.8±1.51.5±2.30.0031.22 [0.96–1.54]0.12
VariableComparison of patients with holosystolic vs mid-late systolic mitral regurgitationCox proportional hazards survival analysis of entire study population for composite outcomes
Holosystolic (n=487)Mid-late systolic (n=122)p-valueUnivariate Hazard Ratio [95% CI]Univariate p-valueMultivariate Hazard Ratio [95% CI]Multivariate p-value
Age (years)60±1453±12<0.0011.09 [1.05–1.2]0.001
Male Gender351 (72%)58 (53%)0.0011.13 [0.62–2.07]0.7
Hypertension241 (49%)45 (37%)0.030.91 [0.51–1.61]0.6
Coronary artery disease65 (14%)7 (5%)0.0040.94 [0.35–2.52]0.9
Atrial fibrillation/flutter77 (16%)9 (7%)0.0092.92 [1.46–5.86]0.0022.61 [1.32–5.15]0.007
LV ejection fraction (%)58±558±50.90.93 [0.89–1.04]0.2
Indexed LV end systolic diameter (cm/m2)1.62±0.51.72±0.40.040.83 [0.42–1.63]0.6
Left atrial area (cm2)27±725±70.051.03 [0.99–1.07]0.1
Peak exercise right ventricular systolic pressure (mmHg)48±1647±130.11.02 [0.96–1.06]0.2
Mid-late systolic vs holosystolic mitral regurgitation–––0.25 [0.07–0.98]0.020.21 [0.10–0.47]0.03
Flail mitral leaflet174 (36%)7 (6%)<0.0010.9 [0.5–1.64]0.6
% Age & gender predicted metabolic equivalents115±28121±280.020.98 [0.97–0.99]0.0040.98 [0.97–0.99]0.004
Mitral valve surgery None/Repair/Replacement164 (33%)/288 (59%)/35 (7%)47 (38%)/72 (59%)/3 (2%)0.10.70 [0.39–1.28]0.2
Time to surgery (years)0.8±1.51.5±2.30.0031.22 [0.96–1.54]0.12

Age was incorporated in predicted metabolic equivalents and was not added to the multivariable model. LV, Left Ventricular; CI, Confidence Interval.

Conclusion: In patients with ≥3+ myxomatous MR undergoing execho, holosystolic MR (despite shorter time to surgery), atrial fibrillation/flutter and lower achieved % age & gender predicted metabolic equivalents were associated with worse outcomes.

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The European Society of Cardiology
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