Retrospective Cohort Study
Copyright ©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Cardiol. May 26, 2023; 15(5): 253-261
Published online May 26, 2023. doi: 10.4330/wjc.v15.i5.253
Importance of concomitant functional mitral regurgitation on survival in severe aortic stenosis patients undergoing aortic valve replacement
Ramdas G Pai, Padmini Varadarajan
Ramdas G Pai, Department of Cardiology, University of California Riverside School of Medicine, Riverside/St. Bernardine Medical Center, San Bernardino, Riverside, CA 92521, United States
Padmini Varadarajan, Department of Cardiology, University of California Riverside School of Medicine, Riverside, CA 92521, United States
Author contributions: Pai RG and Varadarajan P designed the study, analyzed the data, wrote the manuscript and revised the final form.
Institutional review board statement: The research project was approved by the institutional review board of Loma Linda University, Loma Linda, California.
Informed consent statement: A need for an informed consent was waived because of its retrospective, observational study design without any intervention.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Ramdas G Pai, FACC, FRCP (Hon), MD, Doctor, Professor, Department of Cardiology, University of California Riverside School of Medicine, Riverside/St. Bernardine Medical Center, San Bernardino, Riverside, CA 92507, United States. ramdaspai@yahoo.com
Received: December 20, 2022
Peer-review started: December 20, 2022
First decision: February 20, 2023
Revised: March 20, 2023
Accepted: April 25, 2023
Article in press: April 25, 2023
Published online: May 26, 2023
Processing time: 150 Days and 0.1 Hours
Abstract
BACKGROUND

Mitral regurgitation (MR) is commonly seen in patients with severe aortic stenosis (AS) undergoing aortic valve replacement (AVR). But the long-term implications of MR in AS are unknown.

AIM

To investigate MR’s impact on survival of patients undergoing surgical AVR for severe AS.

METHODS

Of the 740 consecutive patients with severe AS evaluated between 1993 and 2003, 287 underwent AVR forming the study cohort. They were followed up to death or till the end of 2019. Chart reviews were performed for clinical, echocardiographic, and therapeutic data. MR was graded on a 1-4 scale. Mortality data was obtained from chart review and the Social Security Death Index. Survival was analyzed as a function of degree of MR.

RESULTS

The mean age of the severe AS patients who had AVR (n = 287) was 72 ± 13 years, 46% women. Over up to 26 years of follow up, there were 201 (70%) deaths, giving deep insights into the determinants of survival of severe AS who had AVR. The 5, 10 and 20 years survival rates were 75%, 45% and 25% respectively. Presence of MR was associated with higher mortality in a graded fashion (P = 0.0003). MR was significantly associated with lower left ventricular (LV) ejection fraction and larger LV size. Impact of MR on mortality was partially mediated through lower LV ejection fraction and larger LV size. By Cox regression, MR, lower ejection fraction (EF) and larger LV end-systolic dimension were independent predictors of higher mortality (χ2 = 33.2).

CONCLUSION

Presence of greater than 2+ MR in patients with severe AS is independently associated with reduced survival in surgically managed patients, an effect incremental to reduced EF and larger LV size. We suggest that aortic valve intervention should be considered in severe AS patients when > 2+ MR occurs irrespective of EF or symptoms.

Keywords: Aortic stenosis, Mitral regurgitation, Aortic valve replacement, Long term survival

Core Tip: This study is unique in several aspects: (1) Shows that mitral regurgitation negatively impacts survival in an independent fashion, an effect incremental to left ventricular size and ejection fraction; (2) Perhaps the longest follow up of severe aortic stenosis (AS) patients undergoing aortic valve replacement (AVR) (till death or 16-26 year follow up in survivors); (3) Gives insights into potential mitral regurgitation (MR) mechanisms; and (4) Validates echocardiographic MR severity against survival in patients with severe AS undergoing AVR.