title: Long-term mortality associated with left ventricular dysfunction in mitral regurgitation due to flail leaflets: a multicenter analysis.
abstract: BACKGROUND
  Ejection fraction (EF) as a marker of left ventricular (LV) dysfunction and the appropriate thresholds for diagnosing severe or mild/moderate LV dysfunction in mitral regurgitation are doubted and poorly followed in clinical practice. We aimed at assessing the role of EF in a large registry of organic mitral regurgitation to objectively establish thresholds for various degrees of LV dysfunction and to analyze whether mitral surgery remains beneficial in those subsets of patients.
  
  
  RESULTS
  We investigated the relation between EF and mortality in 1875 patients with mitral regurgitation due to flail leaflets in sinus rhythm (65±13 years; median EF, 66% [60%-71%]) enrolled in the Mitral Regurgitation International Database (MIDA) registry. With EF <60%, mortality after diagnosis increased precipitously under medical management (adjusted hazard ratio [HR], 1.59 [1.19-2.12]) and during the entire follow-up (adjusted HR, 1.51 [1.22-1.87]). Severe LV dysfunction, if defined by EF <30%, would affect a minuscule number of patients (0.3%). Conversely, EF <45% was more frequent (2.9%) and was associated with considerable mortality under medical management (adjusted HR, 2.43 [1.50-3.95]) and during the entire follow-up (adjusted HR, 2.46 [1.67-3.61]). The group with EF of 45% to 60% represented a large proportion of patients (23%), exhibited rarely overt symptoms, and had higher mortality compared with EF >60%. Above 60%, no EF threshold further determined survival. The benefit of surgery remained considerable in the groups with EF <45% (adjusted HR, 0.28 [0.17-0.56]) and with EF of 45% to 60% (adjusted HR, 0.34 [0.21-0.64]).
  
  
  CONCLUSIONS
  EF is valuable in defining presence and severity of LV dysfunction in organic mitral regurgitation. Patients with EF <45% have severe LV dysfunction, catastrophic outcome under medical management, and should not be denied surgery. Although there is no survival gain with EF ranges >60%, with EF dropping <60%, mortality increases precipitously and prompt surgical referral is critical to outcome.
authors.affiliation: Department of Cardiology, University Hospital Amiens, Amiens, France.
authors.forename: Christophe
authors.initials: C
authors.lastname: Tribouilloy
authors.forename: Dan
authors.initials: D
authors.lastname: Rusinaru
authors.forename: Francesco
authors.initials: F
authors.lastname: Grigioni
authors.forename: Hector I
authors.initials: HI
authors.lastname: Michelena
authors.forename: Jean-Louis
authors.initials: JL
authors.lastname: Vanoverschelde
authors.forename: Jean-François
authors.initials: JF
authors.lastname: Avierinos
authors.forename: Andrea
authors.initials: A
authors.lastname: Barbieri
authors.forename: Sorin V
authors.initials: SV
authors.lastname: Pislaru
authors.forename: Antonio
authors.initials: A
authors.lastname: Russo
authors.forename: Agnès
authors.initials: A
authors.lastname: Pasquet
authors.forename: Alexis
authors.initials: A
authors.lastname: Théron
authors.forename: Catherine
authors.initials: C
authors.lastname: Szymanski
authors.forename: Franck
authors.initials: F
authors.lastname: Lévy
authors.forename: Maurice
authors.initials: M
authors.lastname: Enriquez-Sarano
mesh_terms: D000368:Aged; D001530:Belgium / Q000453:epidemiology; D004452:Echocardiography; D005260:Female; D005500:Follow-Up Studies; D005602:France / Q000453:epidemiology; D006801:Humans; D007558:Italy / Q000453:epidemiology; D008297:Male; D008943:Mitral Valve / Q000000981:diagnostic imaging* / Q000503:physiopathology; D008944:Mitral Valve Insufficiency / Q000150:complications / Q000401:mortality* / Q000503:physiopathology; D011379:Prognosis; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods*; D012307:Risk Factors; D013318:Stroke Volume / Q000502:physiology*; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D014481:United States / Q000453:epidemiology; D018487:Ventricular Dysfunction, Left / Q000209:etiology / Q000401:mortality* / Q000503:physiopathology
keywords: mitral valve; mitral valve insufficiency; mortality; surgery; systole