Analysis of Risk Factors for Acute Heart Failure in Patients with Dilated Cardiomyopathy and Persistent Severe Functional Mitral Regurgitation Despite Cardiac Resynchronization Therapy

DOI: https://doi.org/10.30702/ujcvs/20.4112/051035-039/9.73
Keywords: dilated cardiomyopathy, functional mitral regurgitation, cardiac resynchronization therapy

Abstract

Congestive heart failure resulting from non-ischemic dilated cardiomyopathy (DCM) with secondary functional mitral regurgitation (FMR) is associated with poor prognosis. Medical treatment results in a 1-year survival of 52% to 87% and a 5-year survival of 22% to 54%, with highest survivals observed in more recent years, probably reflecting improvements in medical therapy. Non-surgical interventions involve cardiac resynchronization therapy. In addition to medical treatment, cardiac resynchronization therapy (CRT) should be considered in patients with New York Heart Association (NYHA) class II– IV HF, left ventricular ejection fraction (LVEF) =35%, normal sinus rhythm and left bundle branch block with QRS >150 ms. In these patients, CRT can also facilitate left ventricular (LV) reverse remodeling and reduce associated FMR.

The aim of this study was to investigate the features of symptomatology and to analyze the risk factors for acute heart failure (AHF) in patients with DCM and persistent severe functional mitral regurgitation despite CRT and optimal guideline-directed medical therapy (GDMT).

Materials and methods. After providing informed consent, 144 patients with severe FMR were involved in the study. Concomitant tricuspid valve regurgitation was registered in 142 (98.6%) cases. The median LVEF was 27.0 (23.0-31.6)%. 40 (27.8%) patients had a permanent form of atrial fibrillation, and 24 (16.7%) patients had a first-degree atrioventricular node block. The median NT-proBNP was 2600 (2133-3200) pg/ml, indicating the presence of severe chronic heart failure.

Results. The median term after CRT device implantation was 36 (3.5-60) months. A comparative analysis between DCM patients with and without CRT revealed statistically significant differences between clinical characteristics, namely: age (p=0.020), lower heart rate (p=0.004), lower hemoglobin (p=0.017), higher erythrocyte sedimentation rate (ESR) (p=0.000) and more frequent AHF at the hospital stage (p=0.030). The incidence of AHF at the hospital stage was 13.8% in patients with CRT and 3.5% in those without CRT. The calculated odds ratio of AHF was 4.44 (95% confidence interval (CI) 1.039-18.971), and the relative risk of AHF was 3.966 (95% CI 1.054-14.915).

Discussion. FMR has been reported to persist in about 20% to 25% of CRT patients and, in an additional 10% to 15%, it may actually worsen after CRT. In this subset of CRT non-responders, reduced reverse remodeling, increased morbidity, and increased mortality have been reported compared with CRT patients in whom FMR was significantly reduced or abolished.

Conclusions. The results of our study demonstrate that severe functional mitral regurgitation despite cardiac resynchronization therapy in patients with dilated cardiomyopathy is a significant risk factor for AHF and subsequent hospitalizations for heart failure.

References

  1. Bakalakos A, Ritsatos K, Anastasakis A. Current perspectives on the diagnosis and management of dilated cardiomyopathy Beyond heart failure: a Cardiomyopathy Clinic Doctor’s point of view. Hellenic J Cardiol. 2018 Sep-Oct;59(5):254-61. https://doi.org/10.1016/j.hjc.2018.05.008
  2. Weintraub RG, Semsarian C, Macdonald P. Dilated cardiomyopathy. Lancet. 2017 Jul 22;390(10092):400-14. https://doi.org/10.1016/S0140-6736(16)31713-5
  3. Patel JB, Borgeson DD, Barnes ME, Rihal CS, Daly RC, Redfield MM. Mitral regurgitation in patients with advanced systolic heart failure. J Card Fail. 2004;10(4):285-91. https://doi.org/10.1016/j.cardfail.2003.12.006
  4. Shah N, Shah S, Sato K, Downey S, Flamm S, Tang HW, Cho L, Griffin B, Kwon D. Prognostic impact of functional mitral regurgitation in patients with non-ischemic cardiomyopathy: association of myocardial fibrosis and left ventricular remodeling. Journal of the American College of Cardiology. 2019;73(9 Suppl 1):1456. https://doi.org/10.1016/S0735-1097(19)32062-5
  5. Dietz MF, Prihadi EA, van der Bijl P, Ajmone Marsan N, Delgado V, Bax JJ. Prognostic implications of staging right heart failure in patients with significant secondary tricuspid regurgitation. J Am Coll Cardiol HF. 2020;8(8):627-36. https://doi.org/10.1016/j.jchf.2020.02.008
  6. Blondheim DS, Jacobs LE, Kotler MN, Costacurta GA, Parry WR. Dilated cardiomyopathy with mitral regurgitation: decreased survival despite a low frequency of left ventricular thrombus. Am Heart J. 1991;122(3 Pt 1):763-71. https://doi.org/10.1016/0002-8703(91)90523-K
  7. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP 3rd, Fleisher LA, et al. 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2017 Jul 11;70(2):252-89. https://doi.org/10.1016/j.jacc.2017.03.011
  8. Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Colvin MM, et al. 2016 ACC/AHA/HFSA focused update on new pharmacological therapy for heart failure: an update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. J Am Coll Cardiol. 2016 Sep 27;68(13):1476-88. https://doi.org/10.1016/j.jacc.2016.05.011
  9. Bartko PE, Arfsten H, Heitzinger G, Pavo N, Strunk G, Gwechenberger M, Hengstenberg C, Binder T, Hulsmann M, Goliasch G. Papillary Muscle Dyssynchrony-Mediated Functional Mitral Regurgitation: Mechanistic Insights and Modulation by Cardiac Resynchronization. JACC Cardiovasc Imaging. 2019 Sep;12(9):1728-37. https://doi.org/10.1016/j.jcmg.2018.06.013
  10. Ypenburg C, van Bommel RJ, Borleffs CJ, Bleeker GB, Boersma E, Schalij MJ, et al. Long-term prognosis after cardiac resynchronization therapy is related to the extent of left ventricular reverse remodeling at midterm follow-up. J Am Coll Cardiol. 2009 Feb 10;53(6):483-90. https://doi.org/10.1016/j.jacc.2008.10.032
  11. Di Biase L, Auricchio A, Mohanty P, Bai R, Kautzner J, Pieragnoli P, et al. Impact of cardiac resynchronization therapy on the severity of mitral regurgitation. Europace. 2011 Jun;13(6):829-38. https://doi.org/10.1093/europace/eur047
  12. Onishi T, Onishi T, Marek JJ, Ahmed M, Haberman SC, Oyenuga O, Adelstein E, Schwartzman D, Saba S, Gorcsan J. Mechanistic features associated with improvement in mitral regurgitation after cardiac resynchronization therapy and their relation to long-term patient outcome. Circ Heart Fail. 2013;6(4):685-93. https://doi.org/10.1161/CIRCHEARTFAILURE.112.000112
Published
2020-12-16
How to Cite
1.
Buriak RV, Rudenko KV, Krykunov OA. Analysis of Risk Factors for Acute Heart Failure in Patients with Dilated Cardiomyopathy and Persistent Severe Functional Mitral Regurgitation Despite Cardiac Resynchronization Therapy. ujcvs [Internet]. 2020Dec.16 [cited 2024Dec.22];(4 (41):35-9. Available from: http://cvs.org.ua/index.php/ujcvs/article/view/381
Issue
Ukrainian Journal of Cardiovascular Surgery No 4 (41) 2020
Section
ACQUIRED HEART DISEASES