Measuring mitral regurgitation predicts clinical outcome of treatment
http://www.100md.com
《英国医生杂志》
Quantitative grading of mitral regurgitation, based on the effective regurgitant orifice of the valve and the regurgitated volume of blood, is a powerful predictor of the clinical outcome of medical management in asymptomatic patients. Patients with an effective regurgitant orifice of 40 mm2 or more should be considered for surgical repair.
The prognostic power of this quantitative classification superseded that of all other semiquantitative indexes, say the authors of the new study. They accurately determined the rates of death from any cause, death from cardiac causes, and cardiac events with the use of medical management based on this new classification (New England Journal of Medicine 2005;352:875-83).
The researchers, led by Dr Maurice Enriquez-Sarano of the divisions of cardiovascular diseases and internal medicine at the Mayo Clinic, Rochester, Minnesota, prospectively enrolled 456 patients with asymptomatic organic mitral regurgitation to determine independent predictors of outcomes from increasing severity of mitral regurgitation. The mean age of the patients was 63 (standard deviation 14) years and the mean ejection fraction was 70% (8%); 63% were men.
The study found that the predictive power of an increasing effective regurgitant orifice (adjusted risk ratio per increment of 10 mm2, 1.18; 95% confidence interval 1.06 to 1.30; P<0.01) superseded all other qualitative and quantitative measures of regurgitation. The other independent determinants of survival were increasing age and the presence of diabetes.
Five year survival in patients with an effective regurgitant orifice of 40 mm2 or more was lower than expected on the basis of US census data (58% v 78%, P=0.03). Compared with patients with a regurgitant orifice of less than 20 mm2, those with an orifice of 40 mm2 or more had an increased risk of death from any cause (adjusted risk ratio 2.90; 95% confidence interval 1.33 to 6.32; P<0.01), death from cardiac causes (5.21; 1.98 to 14.40; P<0.01), and cardiac events (5.66; 3.07 to 10.56; P<0.01).
Cardiac surgery was ultimately performed in 232 patients and was independently associated with improved survival (0.28; 0.14 to 0.55; P<0.01). Cardiac surgery, despite its associated increase in the risk of atrial fibrillation, markedly reduced the risk of heart failure and death and normalised the patients?life expectancy, said the authors.
In patients with an effective regurgitant orifice of 40 mm2 or more the five year probability of death or late cardiac surgery was 84%, suggesting that surgery is almost inevitable. Patients with an effective regurgitant orifice of 20-39 mm2 had complication rates that were initially low but subsequently rose over time.
In an editorial in the same journal (p 928) Drs Catherine Otto and Christopher Salerno of the division of cardiothoracic surgery at the University of Washington, Seattle, urged caution. They reasoned that precision is needed to measure regurgitation accurately and that quantitative grading can be difficult when regurgitation is present only in late systole, as often seen in patients with prolapse and with atrial fibrillation.(New York Scott Gottlieb)
The prognostic power of this quantitative classification superseded that of all other semiquantitative indexes, say the authors of the new study. They accurately determined the rates of death from any cause, death from cardiac causes, and cardiac events with the use of medical management based on this new classification (New England Journal of Medicine 2005;352:875-83).
The researchers, led by Dr Maurice Enriquez-Sarano of the divisions of cardiovascular diseases and internal medicine at the Mayo Clinic, Rochester, Minnesota, prospectively enrolled 456 patients with asymptomatic organic mitral regurgitation to determine independent predictors of outcomes from increasing severity of mitral regurgitation. The mean age of the patients was 63 (standard deviation 14) years and the mean ejection fraction was 70% (8%); 63% were men.
The study found that the predictive power of an increasing effective regurgitant orifice (adjusted risk ratio per increment of 10 mm2, 1.18; 95% confidence interval 1.06 to 1.30; P<0.01) superseded all other qualitative and quantitative measures of regurgitation. The other independent determinants of survival were increasing age and the presence of diabetes.
Five year survival in patients with an effective regurgitant orifice of 40 mm2 or more was lower than expected on the basis of US census data (58% v 78%, P=0.03). Compared with patients with a regurgitant orifice of less than 20 mm2, those with an orifice of 40 mm2 or more had an increased risk of death from any cause (adjusted risk ratio 2.90; 95% confidence interval 1.33 to 6.32; P<0.01), death from cardiac causes (5.21; 1.98 to 14.40; P<0.01), and cardiac events (5.66; 3.07 to 10.56; P<0.01).
Cardiac surgery was ultimately performed in 232 patients and was independently associated with improved survival (0.28; 0.14 to 0.55; P<0.01). Cardiac surgery, despite its associated increase in the risk of atrial fibrillation, markedly reduced the risk of heart failure and death and normalised the patients?life expectancy, said the authors.
In patients with an effective regurgitant orifice of 40 mm2 or more the five year probability of death or late cardiac surgery was 84%, suggesting that surgery is almost inevitable. Patients with an effective regurgitant orifice of 20-39 mm2 had complication rates that were initially low but subsequently rose over time.
In an editorial in the same journal (p 928) Drs Catherine Otto and Christopher Salerno of the division of cardiothoracic surgery at the University of Washington, Seattle, urged caution. They reasoned that precision is needed to measure regurgitation accurately and that quantitative grading can be difficult when regurgitation is present only in late systole, as often seen in patients with prolapse and with atrial fibrillation.(New York Scott Gottlieb)