Reappraisal of the Concept and Implications of Pulmonary Hypertension in Degenerative Mitral Regurgitation

IF 12.8 1区医学 Q1 CARDIAC & CARDIOVASCULAR SYSTEMS

JACC. Cardiovascular imaging Pub Date : 2024-10-01 DOI:10.1016/j.jcmg.2024.05.006

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Abstract

Background

European and U.S. clinical guidelines diverge regarding pulmonary hypertension (PHTN) in degenerative mitral regurgitation (DMR). Gaps in knowledge underpinning these divergences affect risk assessment and management recommendations attached to systolic pulmonary pressure (SPAP) in DMR.

Objectives

This study sought to define PHTN links to DMR severity, prognostic thresholds, and independent outcome impact in a large quantitative DMR registry.

Methods

This study gathered a large multicentric registry of consecutive patients with isolated moderate-to-severe DMR, with DMR and SPAP quantified prospectively at diagnosis.

Results

In 3,712 patients (age 67 ± 15 years, 36% women) with ≥ moderate-to-severe DMR, effective regurgitant orifice (ERO) was 0.42 ± 0.19 cm², regurgitant volume 66 ± 327 mL/beat and SPAP 41 ± 16 mm Hg. Spline-curve analysis showed excess mortality under medical management emerging around SPAP 35 mm Hg and doubling around SPAP 50 mm Hg. Accordingly, severe pulmonary hypertension (sPHTN) (SPAP ≥50 mm Hg) was detected in 916 patients, moderate pulmonary hypertension (mPHTN) (SPAP 35-49 mm Hg) in 1,128, and no-PHTN (SPAP <35 mm Hg) in 1,668. Whereas SPAP was strongly associated with DMR-ERO, nevertheless excess mortality with sPHTN (adjusted HR: 1.65; 95% CI: 1.24-2.20) and mPHTN (adjusted HR: 1.44; 95% CI: 1.11-1.85; both P ≤ 0.005) was observed independently of ERO and all baseline characteristics and in all patient subsets. Nested models demonstrated incremental prognostic value of mPHTN and sPHTN (all P < 0.0001). Despite higher operative risk with mPHTN and sPHTN, DMR surgical correction was followed by higher survival in all PHTN ranges with strong survival benefit of early surgery (<3 months). Postoperatively, excess mortality was abolished (P ≥ 0.30) in mPHTN, but only abated in sPHTN.

Conclusions

This large international registry, with prospectively quantified DMR and SPAP, demonstrates a Doppler-defined PHTN impact on mortality, independent of DMR severity. Crucially, it defines objectively the new and frequent mPHTN range, independently linked to excess mortality under medical management, which is abolished by DMR correction. Thus, at DMR diagnosis, Doppler-SPAP measurement defining these new PHTN ranges, is crucial to guiding DMR management.

Abstract Image

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重新评估退行性二尖瓣反流中肺动脉高压的概念和影响。

背景：欧洲和美国的临床指南在退行性二尖瓣反流（DMR）的肺动脉高压（PHTN）方面存在分歧。造成这些分歧的知识差距影响了对 DMR 收缩压（SPAP）的风险评估和管理建议：本研究旨在确定 PHTN 与 DMR 严重程度、预后阈值之间的联系，以及在大型定量 DMR 登记中对独立结果的影响：该研究收集了一个大型多中心登记，登记对象为连续的孤立性中度至重度 DMR 患者，诊断时对 DMR 和 SPAP 进行了前瞻性量化：在 3712 名中重度 DMR 患者（67 ± 15 岁，36% 为女性）中，有效反流孔 (ERO) 为 0.42 ± 0.19 平方厘米，反流容量为 66 ± 327 毫升/次，SPAP 为 41 ± 16 毫米汞柱。花键曲线分析表明，在接受药物治疗的情况下，超额死亡率在 SPAP 35 mm Hg 左右出现，在 SPAP 50 mm Hg 左右增加一倍。因此，916 名患者被诊断为重度肺动脉高压（sPHTN）（SPAP ≥ 50 mm Hg），1128 名患者被诊断为中度肺动脉高压（mPHTN）（SPAP 35-49 mm Hg），无肺动脉高压（SPAP 结论：SPAP ≥ 50 mm Hg）：这项大型国际登记研究对 DMR 和 SPAP 进行了前瞻性量化，证明了多普勒定义的 PHTN 对死亡率的影响与 DMR 严重程度无关。最重要的是，它客观地定义了新的和频繁出现的 mPHTN 范围，这与医疗管理下的超额死亡率无关，而 DMR 纠正则消除了这一影响。因此，在诊断 DMR 时，多普勒-SPAP 测量确定这些新的 PHTN 范围，对于指导 DMR 管理至关重要。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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来源期刊

JACC. Cardiovascular imaging CARDIAC & CARDIOVASCULAR SYSTEMS-RADIOLOGY, NUCLEAR MEDICINE & MEDICAL IMAGING

CiteScore

24.90

自引率

5.70%

发文量

330

审稿时长

4-8 weeks

期刊介绍： JACC: Cardiovascular Imaging, part of the prestigious Journal of the American College of Cardiology (JACC) family, offers readers a comprehensive perspective on all aspects of cardiovascular imaging. This specialist journal covers original clinical research on both non-invasive and invasive imaging techniques, including echocardiography, CT, CMR, nuclear, optical imaging, and cine-angiography. JACC. Cardiovascular imaging highlights advances in basic science and molecular imaging that are expected to significantly impact clinical practice in the next decade. This influence encompasses improvements in diagnostic performance, enhanced understanding of the pathogenetic basis of diseases, and advancements in therapy. In addition to cutting-edge research,the content of JACC: Cardiovascular Imaging emphasizes practical aspects for the practicing cardiologist, including advocacy and practice management.The journal also features state-of-the-art reviews, ensuring a well-rounded and insightful resource for professionals in the field of cardiovascular imaging.