Mitral Regurgitation and Mortality Risk in Medicare Beneficiaries With Heart Failure and Preserved Ejection Fraction

Heart failure with preserved ejection fraction in atrial functional mitral regurgitation - Insight from the REVEAL-AFMR

BACKGROUND

Atrial functional mitral regurgitation (AFMR) and heart failure with a preserved ejection fraction (HFpEF) often coexist. However, the clinical impact of HFpEF in patients with AFMR has not been well characterized. This study aimed to determine clinical outcomes and response to mitral valve (MV) intervention or rhythm control therapy in patients with HFpEF and moderate AFMR (HFpEF-AFMR).

METHODS

This was a post-hoc analysis of the REVEAL-AFMR, a retrospective observational study involving patients with ≥ moderate AFMR. After excluding patients with severe MR, the presence of HFpEF was defined by the Universal definition.

RESULTS

Of 438 patients with moderate AFMR, 352 met the criteria of HFpEF (prevalence: 80 %). Compared to non-HFpEF-AFMR (n = 86), patients with HFpEF-AFMR were older and had greater symptom burden and a higher prevalence of severe tricuspid regurgitation (19 %). During a median follow-up of 33.2 months, a composite outcome of all-cause mortality or HF hospitalization occurred in 130 patients. Patients with HFpEF-AFMR had a 3.6-fold increased risk of the composite outcome compared to non-HFpEF-AFMR. While MV intervention was not associated with outcomes in HFpEF-AFMR, concomitant tricuspid valve (TV) procedures were associated with a better outcome than isolated MV intervention (HR 0.15, 95 %CI 0.04-0.54, p = 0.009). Catheter or surgical rhythm control showed a favorable outcome in HFpEF-AFMR and atrial fibrillation (HR 0.38, 95 %CI 0.17-0.87, p = 0.008).

CONCLUSION

HFpEF was substantially common in moderate AFMR and was associated with worse clinical outcomes. Simultaneous MV and TV intervention procedures or rhythm control therapy were associated with better clinical outcomes in HFpEF-AFMR.

Prognostic value of mitral valve regurgitation in patients with heart failure with mildly reduced ejection fraction

BACKGROUND

Although mitral valve regurgitation (MR) is a common valvular heart disease in patients with heart failure (HF), there is a paucity of data on the characterization and outcomes of patients with HF with mildly reduced ejection fraction (HFmrEF) and concomitant MR.

METHODS

From 2016 to 2022, consecutive patients hospitalized with HFmrEF (i.e., left ventricular ejection fraction from 41% to 49% and signs and/or symptoms of HF) were retrospectively included at one institution. Patients with MR were compared with patients without MR. Further risk stratification was performed according to MR severity and etiology (i.e., primary vs. secondary MR). The primary end point was all-cause mortality at 30 months (median follow-up), and the key secondary end point was hospitalization for worsening HF.

RESULTS

Of 2181 patients hospitalized with HFmrEF, 59% presented with mild, 10% with moderate, and 2% with severe MR. MR was associated with increased all-cause mortality at 30 months (HR = 1.756; 95% CI 1.458-2.114; p = 0.001), with higher risk in more advanced stages. Furthermore, MR patients had higher risk of HF-related re-hospitalization at 30 months (HR = 1.560; 95% CI 1.172-2.076; p = 0.002). Even after multivariable adjustment, mild, moderate, and severe MR were still associated with all-cause mortality. Finally, the risk of all-cause mortality was lower in patients with secondary MR compared with patients with primary MR (HR = 0.592; 95% CI 0.366-0.956; p = 0.032).

CONCLUSION

MR is common in HFmrEF and independently associated with higher risk of all-cause mortality and HF hospitalization.