The prognostic value of exercise-induced pulmonary hypertension in asymptomatic patients with primary mitral regurgitation

Nikolaos P E Kadoglou; Constantinos H Papadopoulos; Argyris Krommydas

doi:10.1016/j.jjcc.2021.09.016

The prognostic value of exercise-induced pulmonary hypertension in asymptomatic patients with primary mitral regurgitation

J Cardiol. 2022 Feb;79(2):306-310. doi: 10.1016/j.jjcc.2021.09.016. Epub 2021 Oct 19.

Authors

Nikolaos P E Kadoglou¹, Constantinos H Papadopoulos², Argyris Krommydas³

Affiliations

¹ Medical School, University of Cyprus, 215/6 Old road Lefkosias-Lemesou, CY, Aglantzia, Nicosia 2029, Cyprus. Electronic address: kadoglou.nikolaos@ucy.ac.cy.
² 2nd Cardiology Department, Korgialenio-Benakio Red Cross Hospital, Athens, Greece.
³ Echocardiography Department, "Mitera" Hospital, Athens, Greece.

PMID: 34674917
DOI: 10.1016/j.jjcc.2021.09.016

Abstract

Background: We examined whether the early development of exercise-induced pulmonary hypertension (EIPH) and right ventricular dysfunction during exercise stress echocardiography (ESE) may predict clinical deterioration in so-called "asymptomatic" patients with primary, at least moderate mitral regurgitation (MR).

Methods: 79 consecutive patients underwent a symptom-limited, graded ESE protocol on semi-supine bicycle at the beginning of the study. During the test, we assessed symptom development, test duration, and the following echocardiographic parameters: MR severity, maximum velocity of the tricuspid regurgitation jet (TR Vmax), pulmonary artery systolic pressure (PASP), and tricuspid annulus systolic excursion (TAPSE). All patients were then followed-up for at least 12 months for clinical end-points (heart failure-related symptoms requiring pharmaceutical therapy, heart failure hospitalization, and/or mitral valve surgery in case of refractory symptoms).

Results: After 16 ± 4 months of follow-up, 75 patients completed the study; 26 of them achieved any clinical end-point and were classified as 'high-risk', while the rest (49 patients) were assigned to the 'low-risk' group. High-risk group showed significantly higher exercise-induced TR Vmax and PASP levels at maximum workload of ESE than low-risk counterparts (p<0.001). Based on receiver operating characteristic analysis, the early (within the first two stages of ESE or up to 50 W) steep rise of calculated PASP ≥51 mmHg (TR Vmax ≥3.4 m/s) had a 92.3% sensitivity and 100% specificity to predict clinical deterioration within the following year. That cut-off value seemed superior predictor than peak value of PASP at the end of ESE. TAPSE levels during ESE did not add prognostic value in our sample.

Conclusion: This is the first study demonstrating that the early development of EIPH has prognostic value in asymptomatic patients with primary at least moderate MR and may become a new valid determinant of mitral valve surgery. Additional larger prospective studies are needed to validate our findings.

Keywords: Exercise stress echocardiography; Mitral valve surgery; Primary mitral regurgitation; Pulmonary hypertension.

MeSH terms

Echocardiography
Echocardiography, Stress
Humans
Hypertension, Pulmonary* / diagnosis
Hypertension, Pulmonary* / etiology
Mitral Valve Insufficiency* / etiology
Prognosis