Long-term mortality in patients with severe secondary mitral regurgitation and normal left ventricular ejection fraction: interventional perspective.

AIMS: Patients with severe secondary mitral regurgitation (MR) and normal ejection fraction are being excluded from clinical trials evaluating transcatheter mitral devices. We sought to evaluate the long-term mortality with medical management alone in this patient population. METHODS AND RESULTS: We retrospectively evaluated patients diagnosed with ≥3+ MR at our institution over 15 years. Only patients with an ejection fraction ≥60% were included in the study. Those with degenerative mitral valve disease, papillary muscle dysfunction, or hypertrophic cardiomyopathy, and those who underwent mitral valve intervention were excluded. The study included 400 patients (age 71.1±14.8, 25.1% male, ejection fraction 62.5±3.6%). Mechanism of secondary MR was restricted valve motion, annular dilation and apical tethering in 91.5, 4.5 and 4%, respectively. One-year and three-year mortality were 19.1 and 26.3%, respectively. On multivariable Cox proportional regression analysis, older age, New York Heart Association functional Class III or IV, >3+ MR and larger left atrium were independent predictors of mortality. CONCLUSIONS: Severe secondary MR with normal left ventricular systolic function has significant mortality with medical management alone. This initial observation needs to be confirmed in larger prospective studies. These patients should be included in future transcatheter clinical trials.

Two-Decade Trends in the Prevalence of Atherosclerotic Risk Factors, Coronary Plaque Morphology, and Outcomes in Adults Aged ≤45 Years Undergoing Percutaneous Coronary Intervention.

Data are limited about the prevalence trends of risk factors, lesion morphology, and clinical outcomes of coronary artery disease in patients, aged ≤45 years, undergoing percutaneous coronary intervention (PCI), between the bare-metal stent (BMS; 1994 to 2002) and drug-eluting stent (DES; 2003 to 2012) eras. From the PCI database at the Cleveland Clinic, we identified 1,640 patients aged ≤45 years and without a history of coronary artery bypass grafting who underwent PCI from 1994 to 2012. There were 883 patients in the BMS era cohort with a mean follow-up period of 13.15 years and 757 in the DES era cohort with a mean follow-up of 5.02 years. The DES era had more obese (51.8% vs 44.7%, p <0.001) and diabetes (23.0% vs 19.5%, p = 0.09) patients. DES era patients had more B2/C lesions (74.0% vs 32.5%, p <0.001), more severe preprocedural stenosis (86.1 ± 12.9 vs 72.2 ± 21.3, p <0.001), and longer lesions (15.5 ± 9.9 vs 9.6 ± 6.8, p <0.001). No difference was observed in the 30-day mortality between the DES and BMS eras. Irrespective of era, diabetics had worse long-term mortality (19.4% vs 9.3%, p <0.001) compared with nondiabetics. Obese patients had similar long-term outcomes compared with nonobese patients. In conclusion, patients aged ≤45 years, who underwent a PCI procedure in the DES era had worse risk factor profiles, including obesity, compared with patients in the BMS era. They also had more complex lesions. Procedural and long-term outcomes of these patients have not changed between the 2 eras. Young diabetic patients have worse long-term outcomes compared with nondiabetics.