title: Synergistic Utility of Brain Natriuretic Peptide and Left Ventricular Global Longitudinal Strain in Asymptomatic Patients With Significant Primary Mitral Regurgitation and Preserved Systolic Function Undergoing Mitral Valve Surgery.
abstract: BACKGROUND
  In asymptomatic patients with ≥3+ mitral regurgitation and preserved left ventricular (LV) ejection fraction who underwent mitral valve surgery, we sought to discover whether baseline LV global longitudinal strain (LV-GLS) and brain natriuretic peptide provided incremental prognostic utility.
  
  
  RESULTS
  Four hundred and forty-eight asymptomatic patients (61±12 years and 69% men) with ≥3+ primary mitral regurgitation and preserved left ventricular ejection fraction, who underwent mitral valve surgery (92% repair) at our center between 2005 and 2008, were studied. Baseline clinical and echocardiographic data (including LV-GLS using Velocity Vector Imaging, Siemens, PA) were recorded. The Society of Thoracic Surgeons score was calculated. The primary outcome was death. Mean Society of Thoracic Surgeons score, left ventricular ejection fraction, mitral effective regurgitant orifice, indexed LV end-diastolic volume, and right ventricular systolic pressure were 4±1%, 62±3%, 0.55±0.2 cm(2), 58±13 cc/m(2), and 37±15 mm Hg, respectively. Forty-five percent of patients had flail. Median log-transformed BNP and LV-GLS were 4.04 (absolute brain natriuretic peptide: 60 pg/dL) and -20.7%. At 7.7±2 years, death occurred in 41 patients (9%; 0% at 30 days). On Cox analysis, a higher Society of Thoracic Surgeons score (hazard ratio 1.55), higher baseline right ventricular systolic pressure (hazard ratio 1.11), more abnormal LV-GLS (hazard ratio 1.17), and higher median log-transformed BNP (hazard ratio 2.26) were associated with worse longer-term survival (all P<0.01). Addition of LV-GLS and median log-transformed BNP to a clinical model (Society of Thoracic Surgeons score and baseline right ventricular systolic pressure) provided incremental prognostic utility (χ(2) for longer-term mortality increased from 31-47 to 61; P<0.001).
  
  
  CONCLUSIONS
  In asymptomatic patients with significant primary mitral regurgitation and preserved left ventricular ejection fraction who underwent mitral valve surgery, brain natriuretic peptide and LV-GLS provided synergistic risk stratification, independent of established factors.
authors.affiliation: From the Department of Cardiovascular Medicine (A.A., A.M., K.P., Z.B.P., L.L.R., B.P.G., M.Y.D.) and Department of Cardiothoracic Surgery (A.M.G., J.F.S., T.M., R.M.S., L.G.S.), Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, OH.
authors.forename: Alaa
authors.initials: A
authors.lastname: Alashi
authors.affiliation: From the Department of Cardiovascular Medicine (A.A., A.M., K.P., Z.B.P., L.L.R., B.P.G., M.Y.D.) and Department of Cardiothoracic Surgery (A.M.G., J.F.S., T.M., R.M.S., L.G.S.), Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, OH.
authors.forename: Amgad
authors.initials: A
authors.lastname: Mentias
authors.affiliation: From the Department of Cardiovascular Medicine (A.A., A.M., K.P., Z.B.P., L.L.R., B.P.G., M.Y.D.) and Department of Cardiothoracic Surgery (A.M.G., J.F.S., T.M., R.M.S., L.G.S.), Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, OH.
authors.forename: Krishna
authors.initials: K
authors.lastname: Patel
authors.affiliation: From the Department of Cardiovascular Medicine (A.A., A.M., K.P., Z.B.P., L.L.R., B.P.G., M.Y.D.) and Department of Cardiothoracic Surgery (A.M.G., J.F.S., T.M., R.M.S., L.G.S.), Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, OH.
authors.forename: A Marc
authors.initials: AM
authors.lastname: Gillinov
authors.affiliation: From the Department of Cardiovascular Medicine (A.A., A.M., K.P., Z.B.P., L.L.R., B.P.G., M.Y.D.) and Department of Cardiothoracic Surgery (A.M.G., J.F.S., T.M., R.M.S., L.G.S.), Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, OH.
authors.forename: Joseph F
authors.initials: JF
authors.lastname: Sabik
authors.affiliation: From the Department of Cardiovascular Medicine (A.A., A.M., K.P., Z.B.P., L.L.R., B.P.G., M.Y.D.) and Department of Cardiothoracic Surgery (A.M.G., J.F.S., T.M., R.M.S., L.G.S.), Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, OH.
authors.forename: Zoran B
authors.initials: ZB
authors.lastname: Popović
authors.affiliation: From the Department of Cardiovascular Medicine (A.A., A.M., K.P., Z.B.P., L.L.R., B.P.G., M.Y.D.) and Department of Cardiothoracic Surgery (A.M.G., J.F.S., T.M., R.M.S., L.G.S.), Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, OH.
authors.forename: Tomislav
authors.initials: T
authors.lastname: Mihaljevic
authors.affiliation: From the Department of Cardiovascular Medicine (A.A., A.M., K.P., Z.B.P., L.L.R., B.P.G., M.Y.D.) and Department of Cardiothoracic Surgery (A.M.G., J.F.S., T.M., R.M.S., L.G.S.), Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, OH.
authors.forename: Rakesh M
authors.initials: RM
authors.lastname: Suri
authors.affiliation: From the Department of Cardiovascular Medicine (A.A., A.M., K.P., Z.B.P., L.L.R., B.P.G., M.Y.D.) and Department of Cardiothoracic Surgery (A.M.G., J.F.S., T.M., R.M.S., L.G.S.), Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, OH.
authors.forename: L Leonardo
authors.initials: LL
authors.lastname: Rodriguez
authors.affiliation: From the Department of Cardiovascular Medicine (A.A., A.M., K.P., Z.B.P., L.L.R., B.P.G., M.Y.D.) and Department of Cardiothoracic Surgery (A.M.G., J.F.S., T.M., R.M.S., L.G.S.), Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, OH.
authors.forename: Lars G
authors.initials: LG
authors.lastname: Svensson
authors.affiliation: From the Department of Cardiovascular Medicine (A.A., A.M., K.P., Z.B.P., L.L.R., B.P.G., M.Y.D.) and Department of Cardiothoracic Surgery (A.M.G., J.F.S., T.M., R.M.S., L.G.S.), Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, OH.
authors.forename: Brian P
authors.initials: BP
authors.lastname: Griffin
authors.affiliation: From the Department of Cardiovascular Medicine (A.A., A.M., K.P., Z.B.P., L.L.R., B.P.G., M.Y.D.) and Department of Cardiothoracic Surgery (A.M.G., J.F.S., T.M., R.M.S., L.G.S.), Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, OH. desaim2@ccf.org.
authors.forename: Milind Y
authors.initials: MY
authors.lastname: Desai
mesh_terms: D000368:Aged; D058070:Asymptomatic Diseases; D015415:Biomarkers / Q000097:blood; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000401:mortality; D016009:Chi-Square Distribution; D004452:Echocardiography; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D008944:Mitral Valve Insufficiency / Q000097:blood / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D015999:Multivariate Analysis; D009200:Myocardial Contraction; D020097:Natriuretic Peptide, Brain / Q000097:blood*; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013318:Stroke Volume; D013997:Time Factors; D016896:Treatment Outcome; D016277:Ventricular Function, Left; D016278:Ventricular Function, Right; D017725:Ventricular Pressure
chemical_list: D015415:Biomarkers; D020097:Natriuretic Peptide, Brain
keywords: echocardiography; hemodynamic; hypertension; mitral valve; sample size