Article Abstract

Exercise capacity in asymptomatic patients with significant primary mitral regurgitation: independent effect of global longitudinal left ventricular strain

Authors: Amgad Mentias, Alaa Alashi, Peyman Naji, A. Marc Gillinov, L. Leonardo Rodriguez, Tomislav Mihaljevic, Rakesh M. Suri, Richard A. Grimm, Lars G. Svensson, Brian P. Griffin, Milind Y. Desai


Background: Despite preserved left ventricular ejection fraction (LVEF), patients with significant primary mitral regurgitation (MR) often have reduced exercise capacity. In asymptomatic patients with ≥3+ primary MR undergoing rest-stress echocardiography (RSE), we sought to evaluate the incremental impact of left ventricular global longitudinal strain (LV-GLS) on exercise capacity.
Methods: A total of 660 asymptomatic patients with ≥3+ primary MR, non-dilated LV and LVEF ≥60% (mean age, 57±14 years, 66% men, body mass index or BMI 25±4 kg/m2) who underwent RSE at our center between 2001 and 2013 were included. Standard RSE data were obtained. Average resting LV-GLS was measured using Velocity Vector Imaging.
Results: Mean mitral effective regurgitant orifice, resting right ventricular systolic pressure (RVSP) and LV-GLS were 0.45±0.2 cm2, 31±12 mmHg and −21.7%±2%, respectively; 28% had flail mitral leaflet. Mean metabolic equivalents (METs) and post-stress RVSP were 9.9±3, and 46±17 mmHg; 28% achieved <100% age-gender predicted METs. No patient had ischemia or significant arrhythmias. On logistic regression, resting LV-GLS [odds ratio (OR), 1.40, 95% confidence interval (CI): 1.21–1.55, BMI (OR, 1.11, 95% CI: 1.06–1.17)] and resting RVSP 1.22 (1.02–1.49) were independent predictors of exercise capacity. Area under the curve for association between 100% age-gender predicted METs and various factors were as follows: (I) BMI (0.60, 95% CI: 0.55–0.65, P<0.001); (II) resting RVSP (0.57, 95% CI: 0.52–0.62, P=0.006) and LV-GLS (0.66, 95% CI: 0.61–0.70, P<0.001).
Conclusions: In asymptomatic patients with ≥3+ primary MR, non-dilated LV and preserved LVEF, LV-GLS is independently associated with exercise capacity, beyond known predictors.