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Spieker M, Sidabras J, Lagarden H, Christian L, Angendohr S, Zweck E, Bejinariu A, Veulemanns V, Schulze C, Polzin A, Rana O, Westenfeld R, Kelm M, Horn P. Prevalence and prognostic impact of dynamic atrial functional mitral regurgitation assessed by isometric handgrip exercise. Eur Heart J Cardiovasc Imaging 2024; 25:589-598. [PMID: 38066677 DOI: 10.1093/ehjci/jead336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 11/17/2023] [Accepted: 12/02/2023] [Indexed: 01/10/2024] Open
Abstract
AIMS In atrial functional mitral regurgitation (aFMR), a considerable proportion of patients displays a discrepancy between symptoms and echocardiographic findings at rest. Exercise testing plays a substantial role in assessing the haemodynamic relevance of mitral regurgitation (MR) and is recommended by current guidelines. Here, we aimed to assess the prevalence, extent, and prognostic impact of exercise-induced changes in patients with aFMR. METHODS AND RESULTS Patients with at least mild MR who underwent handgrip exercise echocardiography at the University Hospital Duesseldorf between January 2019 and September 2021 were enrolled. Patients were followed up for 1 year to assess clinical outcomes. Eighty patients with aFMR were included [median age: 80 (77-83) years; 53.8% female]. The median N-terminal pro-brain natriuretic peptide level was 1756 (1034-3340) ng/L. At rest, half of the patients (53.8%) had mild MR, 20 patients (25.0%) had moderate MR, and 17 patients (21.2%) had severe MR. In approximately every fifth patient (17.5%) with non-severe MR at rest, the MR became severe during exercise. Handgrip exercise led to a reclassification of MR severity in 28 patients (35.0%). At 1-year follow-up, adverse events occurred more often in patients with severe MR at rest (76.5%) and exercise-induced dynamic severe MR (66.7%) than in those with non-severe MR (28.6%; P < 0.001). CONCLUSION Handgrip exercise during echocardiography revealed exercise-induced changes in aFMR in every third patient. These data may have implications for therapeutic decision-making in symptomatic patients with non-severe aFMR at rest.
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Affiliation(s)
- Maximilian Spieker
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Jonas Sidabras
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Hannah Lagarden
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Lucas Christian
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Stephan Angendohr
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Elric Zweck
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Alexandru Bejinariu
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Verena Veulemanns
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Christian Schulze
- Division of Cardiology, Intensive Care Medicine and Vascular Medicine, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Amin Polzin
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Obaida Rana
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Ralf Westenfeld
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Malte Kelm
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225 Duesseldorf, Germany
- Cardiovascular Research Institute Duesseldorf, Medical Faculty, Heinrich-Heine University, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Patrick Horn
- Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225 Duesseldorf, Germany
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Spieker M, Lagarden H, Sidabras J, Veulemans V, Christian L, Bejinariu A, Akhyari P, Rana O, Polzin A, Horn P, Kelm M, Westenfeld R. Prevalence, mechanisms, and prognostic impact of dynamic mitral regurgitation assessed by isometric handgrip exercise. Eur Heart J Cardiovasc Imaging 2024; 25:240-248. [PMID: 37740790 DOI: 10.1093/ehjci/jead230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/26/2023] [Accepted: 09/07/2023] [Indexed: 09/25/2023] Open
Abstract
AIMS The extent of mitral regurgitation (MR) may vary depending on the haemodynamic situation; thus, exercise testing plays an important role in assessing the haemodynamic relevance of MR. We aim to assess prevalence, mechanisms, and prognostic impact of exercise-induced changes in MR in patients with degenerative MR (DegMR) and functional MR (FMR). METHODS AND RESULTS We enrolled 367 patients with at least mild MR who underwent standardized echocardiography at rest and during handgrip exercise. Handgrip exercise led to an increase in MR by one grade or more in 19% of DegMR and 28% of FMR patients. In FMR, patients with exercise-induced increases in MR, handgrip exercise led to a reduction in left ventricular stroke volume index, being maintained in DegMR patients. Exercise-induced changes in systolic pulmonary artery pressure were linked to changes in effective regurgitant orifice area (DegMR: r = 0.456; P < 0.001; FMR: r = 0.326; P < 0.001). Thus, 26% of patients with DegMR and FMR developed pulmonary hypertension during exercise. In both cohorts, a significant proportion of patients with non-severe MR at rest and exercise-induced severe MR underwent mitral valve surgery/intervention during follow-up. In FMR patients (but not in DegMR patients), early mitral valve surgery/intervention was independently associated with lower event rates during follow-up [0.177 (0.027-0.643); P = 0.025]. CONCLUSIONS Handgrip exercise echocardiography provides important information regarding the dynamic nature of MR, exercise-induced changes in left ventricular function, and pulmonary circulation with subsequent consequences for further therapeutic decision making. Thus, it should be considered as a diagnostic tool in symptomatic patients with non-severe MR at rest.
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Affiliation(s)
- Maximilian Spieker
- Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Hannah Lagarden
- Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Jonas Sidabras
- Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Verena Veulemans
- Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Lucas Christian
- Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Alex Bejinariu
- Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Payam Akhyari
- Department of Cardiac Surgery, Medical Faculty, University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Obaida Rana
- Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Amin Polzin
- Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Patrick Horn
- Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Malte Kelm
- Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany
- Cardiovascular Research Institute Duesseldorf, Medical Faculty, Heinrich-Heine University, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Ralf Westenfeld
- Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany
- Abiomed Europe GmbH, Neuenhofer Weg 3, 52074 Aachen, Germany
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Hamatani Y, Iguchi M, Minami K, Ishigami K, Ikeda S, Doi K, Yoshizawa T, Ide Y, Fujino A, Ishii M, Ogawa H, Masunaga N, Abe M, Akao M. Isometric Handgrip Stress Test during Right Heart Catheterization in Patients with Mitral Regurgitation -A Case Series Study. Intern Med 2022; 61:1817-1822. [PMID: 34776492 PMCID: PMC9259811 DOI: 10.2169/internalmedicine.8505-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective The severity of mitral regurgitation (MR) dynamically changes during a stress test. Isometric handgrip is a readily-available stress test in daily practice; however, little is known regarding the response to isometric handgrip in MR patients during right heart catheterization. We aimed to evaluate this issue from our case-series study. Methods We retrospectively investigated consecutive MR patients using the isometric handgrip stress test during right heart catheterization at our institution between October 2019 and April 2021. After resting measurements were obtained, sustained maximum-effort hand dynamometer grasping was maintained for about 2-3 minutes. We investigated the differences in right heart catheterization data between at rest and during handgrip, and evaluated the individual response to the isometric handgrip stress test. Results We investigated a total of 15 patients (mean age: 75±6 years, moderate/severe MR: 7/8, primary/secondary MR: 8/7, mean left ventricular ejection fraction: 56±16%, exertional dyspnea: 10). During the handgrip test, the pulmonary capillary wedge pressure (PCWP) significantly increased [9 (8, 13) mmHg at rest to 20 (15, 27) mmHg during handgrip; p<0.001]. PCWP changes varied among individuals (range 2-22 mmHg) and were not correlated with patients' backgrounds including age, the natriuretic peptide levels, left ventricular ejection fraction, left atrial diameter or E/e' (all p>0.05). Patients with PCWP ≥25 mmHg during handgrip had a higher prevalence of exertional dyspnea than those without [6 (100%) vs. 4 (44%); p=0.04]. Conclusion We observed dynamic and varied hemodynamic changes during isometric handgrip in MR patients, suggesting that further research is needed to evaluate the clinical value of this maneuver.
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Affiliation(s)
- Yasuhiro Hamatani
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Japan
| | - Moritake Iguchi
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Japan
| | - Kimihito Minami
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Japan
| | - Kenjiro Ishigami
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Japan
| | - Syuhei Ikeda
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Japan
| | - Kosuke Doi
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Japan
| | - Takashi Yoshizawa
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Japan
| | - Yuya Ide
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Japan
| | - Akiko Fujino
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Japan
| | - Mitsuru Ishii
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Japan
| | - Hisashi Ogawa
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Japan
| | - Nobutoyo Masunaga
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Japan
| | - Mitsuru Abe
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Japan
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Japan
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Donal E, Panis V, Kosmala W. Exercise stress echocardiography: a great tool that can be adapted to the clinical question? Open Heart 2021; 8:openhrt-2021-001641. [PMID: 33888594 PMCID: PMC8070874 DOI: 10.1136/openhrt-2021-001641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2021] [Indexed: 11/17/2022] Open
Affiliation(s)
- Erwan Donal
- Cardiology, CHU de Rennes, Inserm, LTSI-UMR 1099, Rennes, Bretagne, France
| | - Vasileios Panis
- Cardiology, CHU de Rennes, Inserm, LTSI-UMR 1099, Rennes, Bretagne, France
| | - Wojciech Kosmala
- Cardiology, Wroclaw Medical University, Wroclaw, Dolnoslaskie, Poland
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