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Exercise-induced Significant Increase In Mitral Pressure Gradient After Surgical Repair For Degenerative Mitral Regurgitation
Kiyoshi Doi, Hitoshi Yaku, Kazunari Okawa, Sachiko Yamazaki, Tsunehisa Yamamoto, Suguru Ohira, Thetsuhiro Yamano.
Kyoto Prefectural University of Medicine, Kyoto, Japan.

Background We occasionally encounter patients with considerably high mitral pressure gradient (PG) after mitral valve plasty (MVP) for degenerative mitral regurgitation (MR). The objective of this study was to assess these patients at rest and during exercise using echocardiography.
Methods Between April 2004 and March 2013, 247 consecutive patients underwent MVP for degenerative MR at our institution. From this cohort, we enrolled patients who met the following criteria: (1) those who underwent annuloplasty using a semi-rigid ring, (2) those with sinus rhythm at postoperative echocardiography and (3) those with a <moderate residual MR. The final study group was composed of 67 patients. Of these patients, exercise stress echocardiography (ESE) was performed in 12 patients with good exercise tolerance. Mitral stenosis was defined as severe when the mean PG at rest and at peak exercise was >10 mmHg and >15 mmHg, respectively. The indexed ring orifice area (IROA) was calculated by dividing the geometric orifice area of the used prosthetic ring by body surface area (BSA).
Results The ring size used was 30.7 ± 3.3 mm (26-36 mm) and BSA was 1.67 ± 0.2 m2 (1.3-2.1 m2). IROA was 291.5 ± 69.2 mm2/m2. Resting mean mitral PG was 3.4 ± 1.6 mmHg (1.0-8.9 mmHg). Peak exercise capacity according to ESE ranged from 75 to 150 Watts (99.9 ± 23.3 Watts), which significantly increased mean mitral PG from 5.5 ± 2.4 mmHg (2.1-9.5 mmHg) at rest to 16.6 ± 6.9 mmHg (7.8-29.9 mmHg) at peak exercise. Although none of the 12 patients had severe mitral stenosis at rest, it became severe in 7 patients (mean mitral PG >15 mmHg) after exercise. Smaller IROA was well associated with higher mean mitral PG at peak exercise (R2 = -0.737; p = 0.006), and patients with higher mean mitral PG at peak exercise had lower exercise capacity (R2 = -0.620; p = 0.032).
Conclusions Even MVP using a true size ring may be associated with a high mitral PG when the ring size is relatively small for BSA, and this association becomes more prominent during exercise.

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