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

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.