Predictors and prognostic impact of secondary mitral regurgitation in myocardial infarction with preserved ejection fraction

  • Maki Nogi
  • Hiroyuki OkuraEmail author
  • Toru Kataoka
  • Kiyoshi Yoshida
Original Investigation



Secondary or functional mitral regurgitation (FMR) has been reported associated with poor prognosis in patients with ischemic or non-ischemic cardiomyopathy. Prognostic impact of the FMR in myocardial infarction with preserved ejection fraction (MIpEF) is unknown. The aim of this study was to investigate predictors and prognostic impact of FMR in MIpEF.


A total of 556 patients with MIpEF were selected from the Bell Land General Hospital MI (BELAMI) registry (n = 953). Patients were grouped according to the presence or absence of severe FMR. Clinical endpoint was all-cause death.


Severe FMR was present in 26 patients (4.7%) (FMR group) and absent in 530 patients (control). FMR group was older (77.5 ± 7.2 vs. 67.3 ± 11.3 years, P < 0.01) and had more female gender (54% vs. 28%, P < 0.01). By echocardiography, FMR group had larger left atrial diameter and left ventricular end-systolic volume. E and E/e′ were significantly higher and deceleration time of E was significantly shorter in FMR group. By Kaplan–Meier analysis, survival was significantly lower in FMR group than in control (log-rank, P = 0.004).


Severe FMR is rare in MI patients with preserved EF but is associated with poor long-term prognosis.


Mitral regurgitation Myocardial infarction Prognosis Systolic function 


Compliance with ethical standards

Conflict of interest

Maki Nogi, Hiroyuki Okura, Toru Kataoka and Kiyoshi Yoshida declare that they have no conflict of interest.

Human rights statements and informed consent

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1964 and later revisions. Informed consent for echocardiographic examination was obtained from all patients. As described in the methods section, informed consent for being included in this specific study was not obtained because the ethical committee of the institution (Bell Land General Hospital) did not require either approval by the committee or informed consent from the patients for this retrospective observational analysis.

Supplementary material

Supple Figure A Comparison of cardiac event-free survival between FMR treated with and without renin–angiotensin inhibitors. Cardiac event-free survival was similar between FMR treated with and without RASI FMR = functional mitral regurgitation, RASI = renin–angiotensin system inhibitors. (TIFF 36 kb)


  1. 1.
    Okura H, Takada Y, Kubo T, et al. Functional mitral regurgitation predicts prognosis independent of left ventricular systolic and diastolic indices in patients with ischemic heart disease. J Am Soc Echocardiogr. 2008;21(4):355–60.CrossRefGoogle Scholar
  2. 2.
    Okura H, Kataoka T, Yoshida K. Renin–angiotensin system inhibitors in patients with myocardial infarction and secondary mitral regurgitation. Heart. 2016;102(9):694–700.CrossRefGoogle Scholar
  3. 3.
    Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the american college of cardiology/american heart association task force on practice guidelines. J Am Coll Cardiol. 2014;63(22):e57–185.CrossRefGoogle Scholar
  4. 4.
    Baumgartner H, Falk V, Bax JJ, et al. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2017;38(36):2739–91.CrossRefGoogle Scholar
  5. 5.
    Marechaux S, Pibarot P, Ennezat PV. Insights into functional mitral regurgitation despite preserved LVEF. Arch Cardiovasc Dis. 2011;104(2):131–3.CrossRefGoogle Scholar
  6. 6.
    Ennezat PV, Marechaux S, Pibarot P, et al. Secondary mitral regurgitation in heart failure with reduced or preserved left ventricular ejection fraction. Cardiology. 2013;125(2):110–7.CrossRefGoogle Scholar
  7. 7.
    Zoghbi WA, Enriquez-Sarano M, Foster E, et al. Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and doppler echocardiography. J Am Soc Echocardiogr. 2003;16(7):777–802.CrossRefGoogle Scholar
  8. 8.
    Otsuji Y, Handschumacher MD, Schwammenthal E, et al. Insights from three-dimensional echocardiography into the mechanism of functional mitral regurgitation: direct in vivo demonstration of altered leaflet tethering geometry. Circulation. 1997;96(6):1999–2008.CrossRefGoogle Scholar
  9. 9.
    Otsuji Y, Handschumacher MD, Liel-Cohen N, et al. Mechanism of ischemic mitral regurgitation with segmental left ventricular dysfunction: three-dimensional echocardiographic studies in models of acute and chronic progressive regurgitation. J Am Coll Cardiol. 2001;37(2):641–8.CrossRefGoogle Scholar
  10. 10.
    Saito K, Okura H, Watanabe N, et al. Influence of chronic tethering of the mitral valve on mitral leaflet size and coaptation in functional mitral regurgitation. JACC Cardiovasc Imaging. 2012;5(4):337–45.CrossRefGoogle Scholar
  11. 11.
    Pitt B, Zannad F, Remme WJ, et al. The effect of spironolactone on morbidity and mortality in patients with severe heart failure. randomized aldactone evaluation study investigators. N Engl J Med. 1999;341(10):709–17.CrossRefGoogle Scholar
  12. 12.
    Packer M, Poole-Wilson PA, Armstrong PW, et al. Comparative effects of low and high doses of the angiotensin-converting enzyme inhibitor, lisinopril, on morbidity and mortality in chronic heart failure. Circulation. 1999;100(23):2312–8.CrossRefGoogle Scholar
  13. 13.
    Zannad F, McMurray JJ, Krum H, et al. Eplerenone in patients with systolic heart failure and mild symptoms. N Engl J Med. 2011;364(1):11–21.CrossRefGoogle Scholar
  14. 14.
    Bhatia RS, Tu JV, Lee DS, et al. Outcome of heart failure with preserved ejection fraction in a population-based study. N Engl J Med. 2006;355(3):260–9.CrossRefGoogle Scholar
  15. 15.
    Cleland JG, Tendera M, Adamus J, et al. The perindopril in elderly people with chronic heart failure (PEP-CHF) study. Eur Heart J. 2006;27(19):2338–45.CrossRefGoogle Scholar
  16. 16.
    Massie BM, Carson PE, McMurray JJ, et al. Irbesartan in patients with heart failure and preserved ejection fraction. N Engl J Med. 2008;359(23):2456–67.CrossRefGoogle Scholar
  17. 17.
    Watanabe N, Ogasawara Y, Yamaura Y, et al. Quantitation of mitral valve tenting in ischemic mitral regurgitation by transthoracic real-time three-dimensional echocardiography. J Am Coll Cardiol. 2005;45(5):763–9.CrossRefGoogle Scholar
  18. 18.
    Yamada R, Watanabe N, Kume T, et al. Quantitative measurement of mitral valve coaptation in functional mitral regurgitation: in vivo experimental study by real-time three-dimensional echocardiography. J Cardiol. 2009;53(1):94–101.CrossRefGoogle Scholar
  19. 19.
    Saito K, Okura H, Watanabe N, et al. Quantification of mitral valve apparatus by three-dimensional transesophageal echocardiography: in vitro validation study comparing two different analysis systems. J Echocardiogr. 2011;9(4):130–6.CrossRefGoogle Scholar
  20. 20.
    Ito K, Abe Y, Takahashi Y, et al. Mechanism of atrial functional mitral regurgitation in patients with atrial fibrillation: a study using three-dimensional transesophageal echocardiography. J Cardiol. 2017;70(6):584–90.CrossRefGoogle Scholar
  21. 21.
    Abe Y, Akamatsu K, Ito K, et al. Prevalence and prognostic significance of functional mitral and tricuspid regurgitation despite preserved left ventricular ejection fraction in atrial fibrillation patients. Circ J. 2018;82(5):1451–8.CrossRefGoogle Scholar
  22. 22.
    Grigioni F, Enriquez-Sarano M, Zehr KJ, et al. Ischemic mitral regurgitation: long-term outcome and prognostic implications with quantitative Doppler assessment. Circulation. 2001;103(13):1759–64.CrossRefGoogle Scholar
  23. 23.
    Harris KM, Sundt TM 3rd, Aeppli D, et al. Can late survival of patients with moderate ischemic mitral regurgitation be impacted by intervention on the valve? Ann Thorac Surg. 2002;74(5):1468–75.CrossRefGoogle Scholar
  24. 24.
    Kim K, Kaji S, Kasamoto M, et al. Renin–angiotensin system inhibitors in patients with or without ischaemic mitral regurgitation after acute myocardial infarction. Open Heart. 2017;4(2):e000637.CrossRefGoogle Scholar
  25. 25.
    Baldus S, Schillinger W, Franzen O, et al. MitraClip therapy in daily clinical practice: initial results from the German transcatheter mitral valve interventions (TRAMI) registry. Eur J Heart Fail. 2012;14(9):1050–5.CrossRefGoogle Scholar

Copyright information

© Japanese Society of Echocardiography 2019

Authors and Affiliations

  • Maki Nogi
    • 1
  • Hiroyuki Okura
    • 2
    Email author
  • Toru Kataoka
    • 3
  • Kiyoshi Yoshida
    • 4
  1. 1.Department of Cardiovascular MedicineNara Medical UniversityKashiharaJapan
  2. 2.Department of CardiologyGifu University Graduate School of MedicineGifuJapan
  3. 3.Division of CardiologyBell Land General HospitalSakaiJapan
  4. 4.Division of CardiologyThe Sakakibara Heart Institute of OkayamaOkayamaJapan

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