Functional mitral regurgitation combined with increased early diastolic transmitral velocity to early mitral annulus diastolic velocity ratio is associated with a poor prognosis in patients with shock

Ran Zhou, Tongjuan Zou, Wanhong Yin, Xiaoting Wang, Yan Kang, Chinese Critical Ultrasound Study Group (CCUSG), Ran Zhou, Tongjuan Zou, Wanhong Yin, Xiaoting Wang, Yan Kang, Chinese Critical Ultrasound Study Group (CCUSG)

Abstract

Background: Functional mitral regurgitation (FMR) is common in critically ill patients and may cause left atrial (LA) pressure elevation. This study aims to explore the prognostic impact of synergistic LA pressure elevation and FMR in patients with shock.

Methods: We retrospectively screened 130 consecutive patients of 175 patients with shock from April 2016 to June 2017. The incidence and impact of FMR and early diastolic transmitral velocity to early mitral annulus diastolic velocity ratio (E/e') ≥ 4 within 6 h of shock on the prognosis of patients were evaluated. Finally, the synergistic effect of FMR and E/e' were assessed by combination, grouping, and trend analyses.

Results: Forty-four patients (33.8%) had FMR, and 15 patients (11.5%) had E/e' elevation. A multivariate analysis revealed FMR and E/e' as independent correlated factors for 28-day mortality (P = 0.043 and 0.028, respectively). The Kaplan-Meier survival analysis revealed a significant difference in survival between patients with and without FMR (χ2 = 7.672, P = 0.006) and between the E/e' ≥ 14 and E/e' < 14 groups (χ2 = 19.351, P < 0.010). Twenty-eight-day mortality was significantly different among the four groups (χ2 = 30.141, P < 0.010). The risk of 28-day mortality was significantly higher in group 4 (E/e' ≥ 14 with FMR) compared with groups 1 (E/e' < 14 without FMR) and 2 (E/e' < 14 with FMR) (P = 0.001 and 0.046, respectively).

Conclusions: Patients with shock can be identified by the presence of FMR. FMR and E/e' are independent risk factors for a poor prognosis in these patients, and prognosis is worst when FMR and E/e' ≥ 14 are present. It may be possible to improve prognosis by reducing LA pressure and E/e'.

Trial registration: ClinicalTrials.gov, NCT03082326.

Conflict of interest statement

None.

Copyright © 2021 The Chinese Medical Association, produced by Wolters Kluwer, Inc. under the CC-BY-NC-ND license.

Figures

Figure 1
Figure 1
Representative cases of FMR. (A, B) A 39-year-old patient with shock and FMR. LV A4CH view showing an enlarged left atrium and left ventricle (A). Color Doppler image showing severe FMR (B). A4CH: Apical four-chamber; FMR: Functional mitral regurgitation; LV: Left ventricular.
Figure 2
Figure 2
Disposition of study patients. The 130 hospitalized patients with shock were divided into four groups: 77 FMR− patients with E/e’

Figure 3

Kaplan-Meier survival curves for patients…

Figure 3

Kaplan-Meier survival curves for patients with shock with and without FMR. There were…

Figure 3
Kaplan-Meier survival curves for patients with shock with and without FMR. There were significant differences in survival between groups (χ2 = 7.672, P = 0.006). FMR: Functional mitral regurgitation; FMR−: Without FMR; FMR+: With FMR.

Figure 4

Kaplan-Meier survival curves for patients…

Figure 4

Kaplan-Meier survival curves for patients with shock with E/e’ 2 = 19.351, P…

Figure 4
Kaplan-Meier survival curves for patients with shock with E/e’ 2 = 19.351, P < 0.010). E/e’: Early diastolic transmitral velocity to early mitral annulus diastolic velocity ratio.

Figure 5

Kaplan-Meier survival curves for four…

Figure 5

Kaplan-Meier survival curves for four groups of patients with shock. There was a…

Figure 5
Kaplan-Meier survival curves for four groups of patients with shock. There was a significant difference in survival between the four groups (χ2 = 30.141, P < 0.010). E/e’: Early diastolic transmitral velocity to early mitral annulus diastolic velocity ratio; FMR: Functional mitral regurgitation; FMR−: Without FMR; FMR+: With FMR.

Figure 6

Endpoints. The rate of 28-day…

Figure 6

Endpoints. The rate of 28-day mortality in patients with shock in the four…

Figure 6
Endpoints. The rate of 28-day mortality in patients with shock in the four groups. E/e’: Early diastolic transmittal velocity to early mitral annulus diastolic velocity ratio; FMR: Functional mitral regurgitation; FMR−: Without FMR; FMR+: With FMR.
Figure 3
Figure 3
Kaplan-Meier survival curves for patients with shock with and without FMR. There were significant differences in survival between groups (χ2 = 7.672, P = 0.006). FMR: Functional mitral regurgitation; FMR−: Without FMR; FMR+: With FMR.
Figure 4
Figure 4
Kaplan-Meier survival curves for patients with shock with E/e’ 2 = 19.351, P < 0.010). E/e’: Early diastolic transmitral velocity to early mitral annulus diastolic velocity ratio.
Figure 5
Figure 5
Kaplan-Meier survival curves for four groups of patients with shock. There was a significant difference in survival between the four groups (χ2 = 30.141, P < 0.010). E/e’: Early diastolic transmitral velocity to early mitral annulus diastolic velocity ratio; FMR: Functional mitral regurgitation; FMR−: Without FMR; FMR+: With FMR.
Figure 6
Figure 6
Endpoints. The rate of 28-day mortality in patients with shock in the four groups. E/e’: Early diastolic transmittal velocity to early mitral annulus diastolic velocity ratio; FMR: Functional mitral regurgitation; FMR−: Without FMR; FMR+: With FMR.

References

    1. Schmitto JD, Lee LS, Mokashi SA, Bolman RM, 3rd, Cohn LH, Chen FY. Functional mitral regurgitation. Cardiol Rev 2010; 18:285–291. doi: 10.1097/CRD.0b013e3181e8e648.
    1. Enriquez-Sarano M, Akins CW, Vahanian A. Mitral regurgitation. Lancet 2009; 373:1382–1394. doi: 10.1016/S0140-6736(09)60692-9.
    1. Nkomo VT, Gardin JM, Skelton TN, Gottdiener JS, Scott CG, Enriquez-Sarano M. Burden of valvular heart diseases: a population-based study. Lancet 2006; 368:1005–1011. doi: 10.1016/S0140-6736(06)69208-8.
    1. Iung B, Baron G, Butchart EG, Delahaye F, Gohlke-Bärwolf C, Levang OW, et al. . A prospective survey of patients with valvular heart disease in Europe: the Euro Heart Survey on Valvular Heart Disease. Eur Heart J 2003; 24:1231–1243. doi: 10.1016/S0195-668X(03)00201-X.
    1. Ducas RA, White CW, Wassef AW, Farag A, Bhagirath KM, Freed DH, et al. . Functional mitral regurgitation: current understanding and approach to management. Can J Cardiol 2014; 30:173–180. doi: 10.1016/j.cjca.2013.11.022.
    1. Watanabe N, Maltais S, Nishino S, O’Donoghue TA, Hung J. Functional mitral regurgitation: imaging insights, clinical outcomes and surgical principles. Prog Cardiovasc Dis 2017; 60:351–360. doi: 10.1016/j.pcad.2017.11.006.
    1. Di Salvo TG, Acker MA, Dec GW, Byrne JG. Mitral valve surgery in advanced heart failure. J Am Coll Cardiol 2010; 55:271–282. doi: 10.1016/j.jacc.2009.08.059.
    1. Punnoose L, Burkhoff D, Cunningham L, Horn EM. Functional mitral regurgitation: therapeutic strategies for a ventricular disease. J Card Fail 2014; 20:252–267. doi: 10.1016/j.cardfail.2014.01.010.
    1. McCutcheon K, Manga P. Left ventricular remodelling in chronic primary mitral regurgitation: implications for medical therapy. Cardiovasc J Afr 2018; 29:51–65. doi: 10.5830/CVJA-2017-009.
    1. Nagueh SF, Smiseth OA, Appleton CP, Byrd BF, 3rd, Dokainish H, Edvardsen T, et al. . Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging 2016; 17:1321–1360. doi: 10.1093/ehjci/jew082.
    1. Vincent JL, De Backer D. Circulatory shock. N Engl J Med 2013; 369:1726–1734. doi: 10.1056/NEJMra1208943.
    1. Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R, et al. . Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016. Intensive Care Med 2017; 43:304–377. doi: 10.1007/s00134-017-4683-6.
    1. Vahanian A, Baumgartner H, Bax J, Butchart E, Dion R, Filippatos G, et al. . Guidelines on the management of valvular heart disease: the task force on the management of valvular heart disease of the European Society of Cardiology. Eur Heart J 2007; 28:230–268. doi: 10.1093/eurheartj/ehl428.
    1. Lancellotti P, Tribouilloy C, Hagendorff A, Moura L, Popescu BA, Agricola E, et al. . European Association of Echocardiography recommendations for the assessment of valvular regurgitation. Part 1: aortic and pulmonary regurgitation (native valve disease). Eur J Echocardiogr 2010; 11:223–244. doi: 10.1093/ejechocard/jeq030.
    1. Lancellotti P, Moura L, Pierard LA, Agricola E, Popescu BA, Tribouilloy C, et al. . European Association of Echocardiography recommendations for the assessment of valvular regurgitation. Part 2: mitral and tricuspid regurgitation (native valve disease). Eur J Echocardiogr 2010; 11:307–332. doi: 10.1093/ejechocard/jeq031.
    1. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, 3rd, Guyton RA, et al. . 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Thorac Cardiovasc Surg 2014; 148:e1–e132. doi: 10.1016/j.jtcvs.2014.05.014.
    1. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, 3rd, Fleisher LA, et al. . 2017 AHA/ACC focused update of the 2014 AHA/ACC Guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2017; 135:e1159–e1195. doi: 10.1161/CIR.0000000000000503.
    1. Nagueh SF, Appleton CP, Gillebert TC, Marino PN, Oh JK, Smiseth OA, et al. . Recommendations for the evaluation of left ventricular diastolic function by echocardiography. J Am Soc Echocardiogr 2009; 22:107–133. doi: 10.1016/j.echo.2008.11.023.
    1. Volpicelli G, Elbarbary M, Blaivas M, Lichtenstein DA, Mathis G, Kirkpatrick AW, et al. . International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med 2012; 38:577–591. doi: 10.1007/s00134-012-2513-4.
    1. Bouhemad B, Brisson H, Le-Guen M, Arbelot C, Lu Q, Rouby JJ. Bedside ultrasound assessment of positive end-expiratory pressure-induced lung recruitment. Am J Respir Crit Care Med 2011; 183:341–347. doi: 10.1164/rccm.201003-0369OC.
    1. Soummer A, Perbet S, Brisson H, Arbelot C, Constantin JM, Lu Q, et al. . Ultrasound assessment of lung aeration loss during a successful weaning trial predicts postextubation distress. Crit Care Med 2012; 40:2064–2072. doi: 10.1097/CCM.0b013e31824e68ae.
    1. Yin W, Li Y, Zeng X, Qin Y, Wang D, Zou T, et al. . The utilization of critical care ultrasound to assess hemodynamics and lung pathology on ICU admission and the potential for predicting outcome. PLoS One 2017; 12:e0182881.doi: 10.1371/journal.pone.0182881.

Source: PubMed

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