title: Predictors and Prognostic Impact of Progressive Ischemic Mitral Regurgitation in Patients With Advanced Ischemic Cardiomyopathy: A Multimodality Study.
abstract: BACKGROUND
  Ischemic mitral regurgitation (IMR) is associated with poor outcomes. It is unknown what factors contribute to progression of IMR and how progressive IMR affects outcomes. We sought to determine imaging predictors of IMR progression and to determine if progressive IMR is an independent predictor of survival in patients with advanced ischemic cardiomyopathy.
  
  
  RESULTS
  Consecutive advanced ischemic cardiomyopathy patients who underwent cardiac magnetic resonance and echocardiograms at baseline with echocardiographic follow-up were studied. Cardiac magnetic resonance was used to assess left ventricular volumes, infarct size, and mitral valve geometry. The effective regurgitant orifice area (EROA) was calculated from the proximal isovelocity surface area by echocardiography. Repeated measures mixed effects and Cox proportional hazards regression models were built to identify predictors of IMR progression and survival. We evaluated 336 patients (age, 62±11 years) over a median follow-up time of 54 months: 154 patients were subsequently revascularized, and 182 patients were medically treated. Ninety-eight patients (29%) demonstrated an increase in EROA values of ≥0.1 cm(2). There were 87 adverse events (death or transplant). On multivariable analysis, infarct size (P<0.001), progression in IMR (P=0.008), age (P=0.003), and baseline EROA (P=0.010) were independently associated with adverse events. Independent predictors of IMR progression were as follows: baseline EROA (P<0.001), left ventricular end-systolic volume index (P=0.014), and total scar (P=0.036).
  
  
  CONCLUSIONS
  IMR frequently increases in severity, and progression is independently associated with adverse left ventricular remodeling and infarct size, as assessed by cardiac magnetic resonance. Furthermore, IMR progression is a powerful independent predictor of adverse events, even after controlling for the severity of IMR at baseline.
authors.affiliation: From the Department of Cardiology, Heart and Vascular Institute (D.H.K., K.K., Z.B.P., M.Y.D., S.D.F., B.P.G.), Imaging Institute (D.H.K., M.Y.D., S.D.F.), and Quantitative Health Sciences (N.A.O.), Cleveland Clinic, OH; Cardiovascular Medicine, Tokushima University Hospital, Japan (K.K.); Division of Cardiology, Department of Medicine, Heart and Vascular Institute, University of Pittsburgh/University of Pittsburgh Medical Center, PA (J.L.C.); Heart and Vascular Institute, Northwestern University Hospital, Chicago, IL (J.D.T.). kwond@ccf.org.
authors.forename: Deborah H
authors.initials: DH
authors.lastname: Kwon
authors.affiliation: From the Department of Cardiology, Heart and Vascular Institute (D.H.K., K.K., Z.B.P., M.Y.D., S.D.F., B.P.G.), Imaging Institute (D.H.K., M.Y.D., S.D.F.), and Quantitative Health Sciences (N.A.O.), Cleveland Clinic, OH; Cardiovascular Medicine, Tokushima University Hospital, Japan (K.K.); Division of Cardiology, Department of Medicine, Heart and Vascular Institute, University of Pittsburgh/University of Pittsburgh Medical Center, PA (J.L.C.); Heart and Vascular Institute, Northwestern University Hospital, Chicago, IL (J.D.T.).
authors.forename: Kenya
authors.initials: K
authors.lastname: Kusunose
authors.affiliation: From the Department of Cardiology, Heart and Vascular Institute (D.H.K., K.K., Z.B.P., M.Y.D., S.D.F., B.P.G.), Imaging Institute (D.H.K., M.Y.D., S.D.F.), and Quantitative Health Sciences (N.A.O.), Cleveland Clinic, OH; Cardiovascular Medicine, Tokushima University Hospital, Japan (K.K.); Division of Cardiology, Department of Medicine, Heart and Vascular Institute, University of Pittsburgh/University of Pittsburgh Medical Center, PA (J.L.C.); Heart and Vascular Institute, Northwestern University Hospital, Chicago, IL (J.D.T.).
authors.forename: Nancy A
authors.initials: NA
authors.lastname: Obuchowski
authors.affiliation: From the Department of Cardiology, Heart and Vascular Institute (D.H.K., K.K., Z.B.P., M.Y.D., S.D.F., B.P.G.), Imaging Institute (D.H.K., M.Y.D., S.D.F.), and Quantitative Health Sciences (N.A.O.), Cleveland Clinic, OH; Cardiovascular Medicine, Tokushima University Hospital, Japan (K.K.); Division of Cardiology, Department of Medicine, Heart and Vascular Institute, University of Pittsburgh/University of Pittsburgh Medical Center, PA (J.L.C.); Heart and Vascular Institute, Northwestern University Hospital, Chicago, IL (J.D.T.).
authors.forename: João L
authors.initials: JL
authors.lastname: Cavalcante
authors.affiliation: From the Department of Cardiology, Heart and Vascular Institute (D.H.K., K.K., Z.B.P., M.Y.D., S.D.F., B.P.G.), Imaging Institute (D.H.K., M.Y.D., S.D.F.), and Quantitative Health Sciences (N.A.O.), Cleveland Clinic, OH; Cardiovascular Medicine, Tokushima University Hospital, Japan (K.K.); Division of Cardiology, Department of Medicine, Heart and Vascular Institute, University of Pittsburgh/University of Pittsburgh Medical Center, PA (J.L.C.); Heart and Vascular Institute, Northwestern University Hospital, Chicago, IL (J.D.T.).
authors.forename: Zoran B
authors.initials: ZB
authors.lastname: Popovic
authors.affiliation: From the Department of Cardiology, Heart and Vascular Institute (D.H.K., K.K., Z.B.P., M.Y.D., S.D.F., B.P.G.), Imaging Institute (D.H.K., M.Y.D., S.D.F.), and Quantitative Health Sciences (N.A.O.), Cleveland Clinic, OH; Cardiovascular Medicine, Tokushima University Hospital, Japan (K.K.); Division of Cardiology, Department of Medicine, Heart and Vascular Institute, University of Pittsburgh/University of Pittsburgh Medical Center, PA (J.L.C.); Heart and Vascular Institute, Northwestern University Hospital, Chicago, IL (J.D.T.).
authors.forename: James D
authors.initials: JD
authors.lastname: Thomas
authors.affiliation: From the Department of Cardiology, Heart and Vascular Institute (D.H.K., K.K., Z.B.P., M.Y.D., S.D.F., B.P.G.), Imaging Institute (D.H.K., M.Y.D., S.D.F.), and Quantitative Health Sciences (N.A.O.), Cleveland Clinic, OH; Cardiovascular Medicine, Tokushima University Hospital, Japan (K.K.); Division of Cardiology, Department of Medicine, Heart and Vascular Institute, University of Pittsburgh/University of Pittsburgh Medical Center, PA (J.L.C.); Heart and Vascular Institute, Northwestern University Hospital, Chicago, IL (J.D.T.).
authors.forename: Milind Y
authors.initials: MY
authors.lastname: Desai
authors.affiliation: From the Department of Cardiology, Heart and Vascular Institute (D.H.K., K.K., Z.B.P., M.Y.D., S.D.F., B.P.G.), Imaging Institute (D.H.K., M.Y.D., S.D.F.), and Quantitative Health Sciences (N.A.O.), Cleveland Clinic, OH; Cardiovascular Medicine, Tokushima University Hospital, Japan (K.K.); Division of Cardiology, Department of Medicine, Heart and Vascular Institute, University of Pittsburgh/University of Pittsburgh Medical Center, PA (J.L.C.); Heart and Vascular Institute, Northwestern University Hospital, Chicago, IL (J.D.T.).
authors.forename: Scott D
authors.initials: SD
authors.lastname: Flamm
authors.affiliation: From the Department of Cardiology, Heart and Vascular Institute (D.H.K., K.K., Z.B.P., M.Y.D., S.D.F., B.P.G.), Imaging Institute (D.H.K., M.Y.D., S.D.F.), and Quantitative Health Sciences (N.A.O.), Cleveland Clinic, OH; Cardiovascular Medicine, Tokushima University Hospital, Japan (K.K.); Division of Cardiology, Department of Medicine, Heart and Vascular Institute, University of Pittsburgh/University of Pittsburgh Medical Center, PA (J.L.C.); Heart and Vascular Institute, Northwestern University Hospital, Chicago, IL (J.D.T.).
authors.forename: Brian P
authors.initials: BP
authors.lastname: Griffin
mesh_terms: D000368:Aged; D009202:Cardiomyopathies / Q000000981:diagnostic imaging / Q000209:etiology* / Q000401:mortality / Q000503:physiopathology; D016009:Chi-Square Distribution; D023921:Coronary Stenosis / Q000150:complications* / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology; D018450:Disease Progression; D004452:Echocardiography; D005260:Female; D006801:Humans; D007090:Image Interpretation, Computer-Assisted; D019028:Magnetic Resonance Imaging, Cine; D008297:Male; D008875:Middle Aged; D008944:Mitral Valve Insufficiency / Q000000981:diagnostic imaging* / Q000209:etiology / Q000401:mortality / Q000503:physiopathology; D064847:Multimodal Imaging / Q000379:methods*; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000000981:diagnostic imaging / Q000209:etiology* / Q000401:mortality / Q000503:physiopathology; D009206:Myocardium / Q000473:pathology; D015588:Observer Variation; D011237:Predictive Value of Tests; D011379:Prognosis; D016016:Proportional Hazards Models; D015203:Reproducibility of Results; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D013318:Stroke Volume; D013997:Time Factors; D016277:Ventricular Function, Left; D020257:Ventricular Remodeling
keywords: echocardiography; magnetic resonance imaging; mitral valve; myocardial infarction