The right ventricular pulmonary circulation continuum in mitral valve disease study
File(s)
Author(s)
Afoke, Jonathan
Type
Thesis
Abstract
Background: Primary mitral regurgitation is one of the most common heart valvular pathologies. However, optimum timing of surgery remains controversial.
Methods: In a single centre prospective study, patients undergoing surgery under current guidelines for severe primary mitral regurgitation underwent additional assessment with cardiopulmonary exercise testing with pulmonary function tests, cardiac MRI and quality of life questionnaire pre-operatively and at six months after surgery in addition to transthoracic echocardiogram. The primary outcome was a per protocol analysis of impaired post-operative functional capacity (defined as post-operative LVEF on transthoracic echocardiogram <50% and/or post-operative percentage predicted peak VO2 ≤ 84%). The secondary outcomes were correlation between transthoracic echocardiogram and cardiac MRI for current trigger points for surgery and to compare changes in quality of life after surgery at six months between patients with class I versus class II guidelines for surgery.
Results: Forty three of the fifty patients (86%) recruited between February 2017 and October 2018 were included in the per protocol analysis. Thirty five patients (72.9%) had impaired post-operative functional capacity. In the multivariate analysis, pre-operative LVEF ≤ 60% (hazard ratio, 1.69; 95% confidence interval, 1.56 to 480.1, p=0.04) and pre-operative percentage predicted peak VO2 ≤ 84% (hazard ratio, 1.22; 95% confidence interval, 2.13 to 107.1, p<0.01) were independent predictors for impaired post-operative functional capacity. There was poor correlation between transthoracic echocardiogram and cardiac MRI for pre-operative measurements of LVEF (R2=0.31) and end systolic diameter/volume (R2=0.36). Quality of life at six months improves in patients with a class I indication for surgery, but returns to baseline in patients with a class II indication for surgery. However, quality of life at six months is superior in those with a class II indication for surgery compared to class I.
Conclusions: Pre-operative percentage predicted peak VO2 ≤ 84% may predict impaired post-operative functional capacity. There is poor correlation between transthoracic echocardiogram and cardiac MRI in the assessment of pre-operative left ventricular function and volumes. Surgery should be considered before patients meet the class I triggers for surgery for superior post-operative quality of life. (Funded by the Rosetrees Trust and Friends of Hammersmith Hospital, RIPCOM1 ClinicalTrials.gov number NCT03155373).
Methods: In a single centre prospective study, patients undergoing surgery under current guidelines for severe primary mitral regurgitation underwent additional assessment with cardiopulmonary exercise testing with pulmonary function tests, cardiac MRI and quality of life questionnaire pre-operatively and at six months after surgery in addition to transthoracic echocardiogram. The primary outcome was a per protocol analysis of impaired post-operative functional capacity (defined as post-operative LVEF on transthoracic echocardiogram <50% and/or post-operative percentage predicted peak VO2 ≤ 84%). The secondary outcomes were correlation between transthoracic echocardiogram and cardiac MRI for current trigger points for surgery and to compare changes in quality of life after surgery at six months between patients with class I versus class II guidelines for surgery.
Results: Forty three of the fifty patients (86%) recruited between February 2017 and October 2018 were included in the per protocol analysis. Thirty five patients (72.9%) had impaired post-operative functional capacity. In the multivariate analysis, pre-operative LVEF ≤ 60% (hazard ratio, 1.69; 95% confidence interval, 1.56 to 480.1, p=0.04) and pre-operative percentage predicted peak VO2 ≤ 84% (hazard ratio, 1.22; 95% confidence interval, 2.13 to 107.1, p<0.01) were independent predictors for impaired post-operative functional capacity. There was poor correlation between transthoracic echocardiogram and cardiac MRI for pre-operative measurements of LVEF (R2=0.31) and end systolic diameter/volume (R2=0.36). Quality of life at six months improves in patients with a class I indication for surgery, but returns to baseline in patients with a class II indication for surgery. However, quality of life at six months is superior in those with a class II indication for surgery compared to class I.
Conclusions: Pre-operative percentage predicted peak VO2 ≤ 84% may predict impaired post-operative functional capacity. There is poor correlation between transthoracic echocardiogram and cardiac MRI in the assessment of pre-operative left ventricular function and volumes. Surgery should be considered before patients meet the class I triggers for surgery for superior post-operative quality of life. (Funded by the Rosetrees Trust and Friends of Hammersmith Hospital, RIPCOM1 ClinicalTrials.gov number NCT03155373).
Version
Open Access
Date Issued
2020-01
Date Awarded
2022-01
Copyright Statement
Creative Commons Attribution NonCommercial Licence
License URL
Advisor
Punjabi, Prakash
Gibbs, John
Sponsor
Rosetrees Trust
Imperial College Healthcare NHS Trust
Grant Number
M647
Publisher Department
National Heart & Lung Institute
Publisher Institution
Imperial College London
Qualification Level
Doctoral
Qualification Name
Doctor of Medicine (Research) MD (Res)