Significance of Residual Mitral Regurgitation After Continuous Flow Left Ventricular Assist Device Implantation

• Published in: JACC. Heart failure Vol. 5; no. 2; pp. 81 - 88
• Main Authors: Kassis, Hayah, MD, Cherukuri, Krishna, MD, Agarwal, Richa, MD, Kanwar, Manreet, MD, Elapavaluru, Subbarao, MD, Sokos, George G., DO, Moraca, Robert J., MD, Bailey, Stephen H., MD, Murali, Srinivas, MD, Benza, Raymond L., MD, Raina, Amresh, MD
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.02.2017
• Subjects: Aged; Cardiovascular; death; Echocardiography; Female; Heart Failure - epidemiology; Heart Failure - physiopathology; Heart Failure - therapy; Heart Ventricles - pathology; Heart-Assist Devices; hospitalization; Humans; Hypertension, Pulmonary - epidemiology; Hypertension, Pulmonary - physiopathology; left ventricular assist device; Male; Middle Aged; mitral regurgitation; Mitral Valve Insufficiency - epidemiology; Mitral Valve Insufficiency - physiopathology; Organ Size; Pulmonary Artery - physiopathology; Retrospective Studies; right ventricular failure; Treatment Outcome; Ventricular Dysfunction, Right - epidemiology; Ventricular Dysfunction, Right - physiopathology; left ventricular assist device; pulmonary artery; death; RV; TTE; PCW; LV; pulmonary capillary wedge; LVAD; RVFAC; left atrial area; left ventricular; continuous flow; CF; hospitalization; mitral regurgitation; MR; RVEDD; TAPSE; LVEDD; LAA; PA; tricuspid annular plane systolic excursion; left ventricular end diastolic dimension; right ventricular fractional area change; color jet area; right ventricular, right ventricle; right ventricular end diastolic dimension; transthoracic echocardiogram; CJA; left ventricular assist device; right ventricular failure
• ISSN: 2213-1779; 2213-1787
• DOI: 10.1016/j.jchf.2016.09.014

Abstract Objectives This study hypothesized that the presence of residual mitral regurgitation (MR) post–continuous flow (CF) left ventricular assist device (LVAD) implantation based on quantitative assessment would be negatively associated with right ventricular (RV) size and function and clinical outcomes. Background MR is associated with elevated left atrial pressure, secondary pulmonary hypertension and RV dysfunction. Implantation of a LVAD leads to mechanical unloading of the left ventricle and generally improves MR. The clinical significance of residual MR in patients supported with CF LVADs is uncertain. Most studies evaluating the presence of MR in LVAD patients have utilized predominantly qualitative assessments of MR. Methods We retrospectively identified patients implanted with CF LVADs at our institution from 2007 to 2013 who had a pre-operative transthoracic echocardiogram (TTE) within 3 months of LVAD implant and who had a post-operative TTE at least 1 month post-LVAD. MR was assessed quantitatively using the ratio of MR color jet area (CJA)/left atrial area (LAA) in apical views. We also compared quantitative RV metrics, hospitalizations, and mortality in patients with and without significant residual MR (defined as MR CJA/LAA >0.2) on post-implantation TTE. Results Sixty-nine patients were included in this study. Post-LVAD implantation, 55 patients (80%) had mild or less MR (mean MR CJA/LAA 0.08) but 14 (20%) had significant residual MR (mean MR CJA/LAA 0.34). Patients with residual MR had significantly larger RV size (right ventricular end diastolic dimension 49 mm vs. 45 mm; p = 0.04) and worse RV function (tricuspid annular plane systolic excursion 10 mm vs. 12 mm; p = 0.02; and right ventricular fractional area change 29% vs. 34%; p = 0.02). Post-implantation pulmonary artery pressures were higher in patients with residual MR (pulmonary artery systolic 43 mm Hg vs. 35 mm Hg; p = 0.05). In patients with residual MR there was slightly greater posterior displacement of the mitral coaptation point on pre-operative TTE (28 mm vs. 26 mm; p = 0.16) but this difference was not significant. Time from LVAD implantation to first hospitalization was shorter in patients with residual MR (62 days vs. 103 days; p = 0.05) as was time from LVAD implantation to death (80 days vs. 421 days; p = 0.03). Conclusions Significant residual MR post-LVAD implantation assessed by a quantitative measure is associated with persistent pulmonary hypertension, worse RV function, and significantly shorter time to hospitalization and death. MR post-LVAD implantation may serve as a surrogate for adverse outcomes post-LVAD implantation.