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Diagnostic and Therapeutic Decision-Making Problems Evoked by Mitral Regurgitation in Heart Failure With Preserved Left Ventricular Ejection Fraction

Published:November 03, 2022DOI:https://doi.org/10.1016/j.amjcard.2022.10.021
      Given that in the presence of mitral regurgitation (MR), the difference between the left ventricular (LV) end-diastolic and end-systolic volume is no longer the forward stroke volume (SVf) but becomes the sum of SVf and regurgitant volume, it is evident that MR can increase the volumetrically measured ejection fraction (EF) correspondingly with the increased blood volume leaving the LV during the systole.
      • Dandel M
      • Hetzer R.
      Ventricular systolic dysfunction with and without altered myocardial contractility: clinical value of echocardiography for diagnosis and therapeutic decision-making.
      • Maréchaux S
      • Terrade J
      • Biausque F
      • Lefetz Y
      • Deturck R
      • Asseman P
      • Le Jemtel TH
      • Ennezat PV
      Exercise-induced functional mitral regurgitation in heart failure and preserved ejection fraction: a new entity.
      • Hetzer R
      • Dandel M.
      Early detection of left ventricular dysfunction in patients with mitral regurgitation due to flail leaflet is still a challenge.
      With aggravation of MR, the regurgitant fraction increases to the detriment of SVf without reduction of the LVEF, even with further reduction of the SVf.
      • Dandel M
      • Hetzer R.
      Ventricular systolic dysfunction with and without altered myocardial contractility: clinical value of echocardiography for diagnosis and therapeutic decision-making.
      ,
      • Hetzer R
      • Dandel M.
      Early detection of left ventricular dysfunction in patients with mitral regurgitation due to flail leaflet is still a challenge.
      This leads to an overestimation of the EF and thereby also of the LV contractile function in both heart failure with reduced LVEF and heart failure with preserved LVEF (HFpEF).
      • Maréchaux S
      • Terrade J
      • Biausque F
      • Lefetz Y
      • Deturck R
      • Asseman P
      • Le Jemtel TH
      • Ennezat PV
      Exercise-induced functional mitral regurgitation in heart failure and preserved ejection fraction: a new entity.
      Nevertheless, the impact of MR on the course of HFpEF still receives little attention. At least in part, this might be due to the increasing overestimation of the LVEF with the progression of MR. In view of these aspects, the recent study by Jiang et al
      • Jiang GY
      • Xu J
      • Manning WJ
      • Markson LJ
      • Khabbaz KR
      • Garan AR
      • Sabe MA
      • Strom JB.
      Mitral regurgitation and mortality risk in Medicare beneficiaries with heart failure and preserved ejection fraction.
      is of particular importance. It proves that moderate-to-severe and severe secondary MR in patients with HFpEF is associated with an increased risk of all-cause mortality, which is in line with the expected consequences of a serious mitral incompetence for the whole cardiovascular system. In that study, the deleterious effects of MR on the heart and pulmonary circulation in HFpEF are also notably reflected by the left atrial volume, the peak tricuspid regurgitation velocity, and the prevalence of relevant tricuspid regurgitation, which were significantly higher in patients with advanced MR.
      • Jiang GY
      • Xu J
      • Manning WJ
      • Markson LJ
      • Khabbaz KR
      • Garan AR
      • Sabe MA
      • Strom JB.
      Mitral regurgitation and mortality risk in Medicare beneficiaries with heart failure and preserved ejection fraction.
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