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      Echocardiographic Assessment of Mitral Valve Regurgitation, Pattern and Prevalence, Expanding Clinical Awareness Through an Institutional Survey with the Perspective of a Quality Improvement Project

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          Abstract

          BACKGROUND

          Mitral regurgitation (MR) is frequently reported in everyday echocardiograms; accurate assessment is essential for appropriate management and decision making.

          OBJECTIVE

          We performed a self-audit in order to define the prevalence and pattern of MR and to evaluate methods of assessment with the perspective of developing a quality improvement project.

          METHODS AND SETTING

          This retrospective analytical study was conducted in a university hospital. Inclusion criteria: age more than 18 years and medical records available within the facility, including a “complete” medical history. Using the picture archiving and communication system, we reviewed 961 echocardiograms performed over a 6-month period. The methods of assessment of native mitral valve regurgitation were reported, and also relevant medical data were collected using an electronic archiving system.

          RESULTS AND DISCUSSION

          Among the 961 patients reviewed, 322 (33.50%) had MR, with variable grades. MR pattern (organic versus functional) was not specified in 49.68% of cases. “Eyeball” assessment and “color jet area” were the most frequently used methods for MR assessment (90.06% and 27.95%, respectively), while “vena contracta” and “flow convergence” methods were rarely implemented (1.55% and 2.17%, respectively). Discussion is made according to current guidelines, while showing the strengths and weaknesses of each method.

          CONCLUSION

          The prevalence of MR was 33.50%, and in nearly half of cases, the MR pattern was not specified. Qualitative and semi-quantitative methods of assessment were mostly used; quantitative assessment should be implemented more frequently, in accordance with current guidelines. Increasing clinical awareness by creating and implementing a quality improvement project is essential in this context.

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          Most cited references 28

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          A prospective survey of patients with valvular heart disease in Europe: The Euro Heart Survey on Valvular Heart Disease.

          To identify the characteristics, treatment, and outcomes of contemporary patients with valvular heart disease (VHD) in Europe, and to examine adherence to guidelines. The Euro Heart Survey on VHD was conducted from April to July 2001 in 92 centres from 25 countries; it included prospectively 5001 adults with moderate to severe native VHD, infective endocarditis, or previous valve intervention. VHD was native in 71.9% of patients and 28.1% had had a previous intervention. Mean age was 64+/-14 years. Degenerative aetiologies were the most frequent in aortic VHD and mitral regurgitation while most cases of mitral stenosis were of rheumatic origin. Coronary angiography was used in 85.2% of patients before intervention. Of the 1269 patients who underwent intervention, prosthetic replacement was performed in 99.0% of aortic VHD, percutaneous dilatation in 33.9% of mitral stenosis, and valve repair in 46.5% of mitral regurgitation; 31.7% of patients had > or =1 associated procedure. Of patients with severe, symptomatic, single VHD, 31.8% did not undergo intervention, most frequently because of comorbidities. In asymptomatic patients, accordance with guidelines ranged between 66.0 and 78.5%. Operative mortality was <5% for single VHD. This survey provides unique contemporary data on characteristics and management of patients with VHD. Adherence to guidelines is globally satisfying as regards investigations and interventions.
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            Prevalence and clinical outcome of mitral-valve prolapse.

            Mitral-valve prolapse has been described as a common disease with frequent complications. To determine the prevalence of mitral-valve prolapse in the general population, as diagnosed with the use of current two-dimensional echocardiographic criteria, we examined the echocardiograms of 1845 women and 1646 men (mean [+/-SD] age, 54.7+/-10.0 years) who participated in the fifth examination of the offspring cohort of the Framingham Heart Study. Classic mitral-valve prolapse was defined as superior displacement of the mitral leaflets of more than 2 mm during systole and as a maximal leaflet thickness of at least 5 mm during diastasis, and nonclassic prolapse was defined as displacement of more than 2 mm, with a maximal thickness of less than 5 mm. A total of 84 subjects (2.4 percent) had mitral-valve prolapse: 47 (1.3 percent) had classic prolapse, and 37 (1.1 percent) had nonclassic prolapse. Their age and sex distributions were similar to those of the subjects without prolapse. None of the subjects with prolapse had a history of heart failure, one (1.2 percent) had atrial fibrillation, one (1.2 percent) had cerebrovascular disease, and three (3.6 percent) had syncope, as compared with unadjusted prevalences of these findings in the subjects without prolapse of 0.7, 1.7, 1.5, and 3.0 percent, respectively. The frequencies of chest pain, dyspnea, and electrocardiographic abnormalities were similar among subjects with prolapse and those without prolapse. The subjects with prolapse were leaner (P<0.001) and had a greater degree of mitral regurgitation than those without prolapse, but on average the regurgitation was classified as trace or mild. In a community based sample of the population, the prevalence of mitral-valve prolapse was lower than previously reported. The prevalence of adverse sequelae commonly associated with mitral-valve prolapse in studies of patients referred for that diagnosis was also low.
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              Mitral-Valve Repair versus Replacement for Severe Ischemic Mitral Regurgitation

              Ischemic mitral regurgitation is associated with a substantial risk of death. Practice guidelines recommend surgery for patients with a severe form of this condition but acknowledge that the supporting evidence for repair or replacement is limited. We randomly assigned 251 patients with severe ischemic mitral regurgitation to undergo either mitral-valve repair or chordal-sparing replacement in order to evaluate efficacy and safety. The primary end point was the left ventricular end-systolic volume index (LVESVI) at 12 months, as assessed with the use of a Wilcoxon rank-sum test in which deaths were categorized below the lowest LVESVI rank. At 12 months, the mean LVESVI among surviving patients was 54.6±25.0 ml per square meter of body-surface area in the repair group and 60.7±31.5 ml per square meter in the replacement group (mean change from baseline, -6.6 and -6.8 ml per square meter, respectively). The rate of death was 14.3% in the repair group and 17.6% in the replacement group (hazard ratio with repair, 0.79; 95% confidence interval, 0.42 to 1.47; P=0.45 by the log-rank test). There was no significant between-group difference in LVESVI after adjustment for death (z score, 1.33; P=0.18). The rate of moderate or severe recurrence of mitral regurgitation at 12 months was higher in the repair group than in the replacement group (32.6% vs. 2.3%, P<0.001). There were no significant between-group differences in the rate of a composite of major adverse cardiac or cerebrovascular events, in functional status, or in quality of life at 12 months. We observed no significant difference in left ventricular reverse remodeling or survival at 12 months between patients who underwent mitral-valve repair and those who underwent mitral-valve replacement. Replacement provided a more durable correction of mitral regurgitation, but there was no significant between-group difference in clinical outcomes. (Funded by the National Institutes of Health and the Canadian Institutes of Health; ClinicalTrials.gov number, NCT00807040.).
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                Author and article information

                Journal
                Clin Med Insights Cardiol
                Clin Med Insights Cardiol
                Clinical Medicine Insights: Cardiology
                Clinical Medicine Insights. Cardiology
                Libertas Academica
                1179-5468
                2014
                25 August 2014
                : 8
                : 71-77
                Affiliations
                Echocardiography unit, Cardiology division, USEK-University Hospital Notre Dame de Secours, St Charbel Street, Byblos, Lebanon.
                Author notes
                Article
                cmc-8-2014-071
                10.4137/CMC.S17367
                4149403
                © 2014 the author(s), publisher and licensee Libertas Academica Ltd.

                This is an open access article published under the Creative Commons CC-BY-NC 3.0 License.

                Categories
                Original Research

                Cardiovascular Medicine

                improvement, quality, assessment, mitral regurgitation, echocardiography

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