title: Early and late effects of cardiac resynchronization therapy on exercise-induced mitral regurgitation: relationship with left ventricular dyssynchrony, remodelling and cardiopulmonary performance.
abstract: OBJECTIVE
  Exercise-induced mitral regurgitation (MR) bears a poor prognosis in patients with congestive heart failure (CHF). Cardiac resynchronization therapy (CRT) is associated with improved clinical outcome but its effects on exercise-induced MR remain undetermined. We investigated serial changes in functional MR in relation to left ventricular (LV) remodelling and cardiopulmonary performance after CRT.
  
  
  RESULTS
  Twenty-eight patients with CHF (LV ejection fraction 25 +/- 7%), broad QRS complex (171 +/- 27 ms), and at least mild MR [effective regurgitant orifice (ERO) 0.25 +/- 0.12 cm2] were studied with quantitative exercise echocardiography and cardiopulmonary exercise testing prior, within 1 week, and 3 months after CRT. Early after CRT, a decrease in LV dyssynchrony (from 54 +/- 21 to 19 +/- 7 ms, P < 0.001) and in MR at rest (ERO from 0.25 +/- 0.12 to 0.20 +/- 0.10 cm2, P = 0.047) was observed. However, no change in exercise-induced increase in MR was observed (ERO from 0.34 +/- 0.12 to 0.31 +/- 0.16 cm2, NS). Three months after CRT, a decrease in the mitral valve tenting area (from 3.3 +/- 1.2 to 2.0 +/- 0.6 cm2, P < 0.001) and an increase in LV sphericity index (from 1.5 +/- 0.3 to 1.8 +/- 0.5, P < 0.001) were paralleled by an attenuation of exercise-induced MR (ERO 0.19 +/- 0.06 cm(2), P = 0.001 vs. prior CRT). This was associated with an increase in LV ejection fraction (from 25 +/- 7 to 35 +/- 9%, P < 0.001), peak oxygen uptake (from 11.7 +/- 2.4 to 13.7 +/- 3.8 mL/kg/min, P = 0.001), and a decrease in Nt-pro-BNP (from 2777 +/- 1681 to 1963 +/- 1361 pg/mL, P = 0.067).
  
  
  CONCLUSIONS
  CRT is associated with acute decrease in resting MR but does not immediately attenuate exercise-induced MR. In contrast, only late, CRT-induced reversed LV remodelling and reduced mitral apparatus deformation are associated with a reduction in both resting and exercise-induced MR and with an improvement in cardiopulmonary performance.
authors.affiliation: Cardiovascular Center, OLV Ziekenhuis, Moorselbaan 164, BE-9300 Aalst, Belgium.
authors.forename: Juraj
authors.initials: J
authors.lastname: Madaric
authors.forename: Marc
authors.initials: M
authors.lastname: Vanderheyden
authors.forename: Christophe
authors.initials: C
authors.lastname: Van Laethem
authors.forename: Katia
authors.initials: K
authors.lastname: Verhamme
authors.forename: Ann
authors.initials: A
authors.lastname: Feys
authors.forename: Marc
authors.initials: M
authors.lastname: Goethals
authors.forename: Sofie
authors.initials: S
authors.lastname: Verstreken
authors.forename: Peter
authors.initials: P
authors.lastname: Geelen
authors.forename: Martin
authors.initials: M
authors.lastname: Penicka
authors.forename: Bernard
authors.initials: B
authors.lastname: De Bruyne
authors.forename: Jozef
authors.initials: J
authors.lastname: Bartunek
mesh_terms: D000368:Aged; D002304:Cardiac Pacing, Artificial / Q000379:methods*; D015150:Echocardiography, Doppler; D015444:Exercise / Q000502:physiology*; D005080:Exercise Test / Q000379:methods; D005260:Female; D006333:Heart Failure / Q000503:physiopathology / Q000628:therapy*; D006334:Heart Function Tests / Q000379:methods; D006801:Humans; D008297:Male; D008944:Mitral Valve Insufficiency / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control*; D010101:Oxygen Consumption / Q000502:physiology; D010138:Pacemaker, Artificial; D018487:Ventricular Dysfunction, Left / Q000503:physiopathology / Q000628:therapy*; D020257:Ventricular Remodeling / Q000502:physiology