title: Mitral regurgitation in heart failure: insights from CPET combined with exercise echocardiography.
abstract: OBJECTIVE
  In heart failure patients with reduced ejection fraction (HFrEF), exercise-induced functional mitral regurgitation (MR) may affect functional capacity and outcome. We sought to study functional and cardiac phenotypes of HFrEF patients according to the MR degree.
  
  
  RESULTS
  We performed rest and exercise echocardiography (Ex-Echo), simultaneously combined with cardiopulmonary exercise test (CPET), in 102 HFrEF patients, identifying 3 groups: non-severe (ERO <20 mm2) MR (group A), exercise-induced severe (ERO ≥20 mm2) MR (group B), and rest severe MR (group C). Patients were tracked for the composite end point of death and heart failure hospitalization. Group B (ERO: rest= 14 ± 5 mm2, Ex= 28 ± 6 mm2; P = < 0.001) had a functional impairment (workload = 56 ± 21 vs. 50 ± 17 watts, P = 0.42; peak VO2 = 11.8 ± 3.2 vs. 11.5 ± 3.0 mL/Kg/min, P = 0.70) similar to Group C (ERO: rest = 29 ± 7 mm2, Ex = 42 ± 7 mm2, P = < 0.001), associated with comparable advanced left ventricle remodelling (end diastolic indexed volume = 107 ± 34 vs. 115 ± 30 mL/m2, P = 0.27), characterized by exercise-induced pulmonary hypertension (PH) (Ex systolic pulmonary pressures = 63 ± 16 mmHg). Group C showed the worse cardiac phenotype (right ventricle dilatation, dysfunction, and rest PH) with severe ventilatory impairment (VE/VCO2 = 41.2 ± 11) compared with Groups A and B. Moreover, Group C had the higher rate of death and HF hospitalization.
  
  
  CONCLUSIONS
  In HFrEF patients, severe dynamic MR produces functional limitation similar to rest severe MR, characterized by dynamic PH. Rest severe MR reflects the most advanced bi-ventricular remodelling associated with rest PH, the most unfavourable ventilatory profile, and the worst mid-term outcome.
authors.affiliation: University Cardiology Department, Cardiopulmonary Laboratory, IRCCS Policlinico San Donato, University of Milano, Milano, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Bandera
authors.affiliation: University Cardiology Department, Cardiopulmonary Laboratory, IRCCS Policlinico San Donato, University of Milano, Milano, Italy.
authors.forename: Greta
authors.initials: G
authors.lastname: Generati
authors.affiliation: University Cardiology Department, Cardiopulmonary Laboratory, IRCCS Policlinico San Donato, University of Milano, Milano, Italy.
authors.forename: Marta
authors.initials: M
authors.lastname: Pellegrino
authors.affiliation: Department of Cardiac Surgery, IRCCS Policlinico San Donato, Milano, Italy.
authors.forename: Andrea
authors.initials: A
authors.lastname: Garatti
authors.affiliation: University Cardiology Department, Cardiopulmonary Laboratory, IRCCS Policlinico San Donato, University of Milano, Milano, Italy.
authors.forename: Valentina
authors.initials: V
authors.lastname: Labate
authors.affiliation: University Cardiology Department, Cardiopulmonary Laboratory, IRCCS Policlinico San Donato, University of Milano, Milano, Italy.
authors.forename: Eleonora
authors.initials: E
authors.lastname: Alfonzetti
authors.affiliation: Unit of Biostatistics and Clinical Epidemiology, Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy.
authors.forename: Maddalena
authors.initials: M
authors.lastname: Gaeta
authors.affiliation: Department of Cardiac Surgery, IRCCS Policlinico San Donato, Milano, Italy.
authors.forename: Serenella
authors.initials: S
authors.lastname: Castelvecchio
authors.affiliation: Department of Cardiac Surgery, IRCCS Policlinico San Donato, Milano, Italy.
authors.forename: Lorenzo
authors.initials: L
authors.lastname: Menicanti
authors.affiliation: University Cardiology Department, Cardiopulmonary Laboratory, IRCCS Policlinico San Donato, University of Milano, Milano, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Guazzi
mesh_terms: D000368:Aged; D000704:Analysis of Variance; D015331:Cohort Studies; D015897:Comorbidity; D025401:Echocardiography, Stress / Q000379:methods*; D005080:Exercise Test / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000000981:diagnostic imaging* / Q000453:epidemiology* / Q000503:physiopathology; D019918:Heart Valve Prosthesis Implantation / Q000379:methods / Q000401:mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D008944:Mitral Valve Insufficiency / Q000000981:diagnostic imaging* / Q000453:epidemiology* / Q000601:surgery; D012189:Retrospective Studies; D012720:Severity of Illness Index; D018709:Statistics, Nonparametric; D013318:Stroke Volume / Q000502:physiology; D016019:Survival Analysis; D013997:Time Factors; D018487:Ventricular Dysfunction, Left / Q000000981:diagnostic imaging / Q000453:epidemiology
keywords: exercise echocardiography; functional mitral regurgitation; heart failure; pulmonary hypertension; right ventricle