Physiological and prognostic differences between types of exercise stress echocardiography for functional mitral regurgitation

Abstract

Objective Secondary mitral regurgitation (MR) demonstrates dynamic change during exercise. This prospective observational study aimed to compare exercise stress echocardiography (ESE) where handgrip exercise (handgrip-ESE) or semisupine ergometer exercise was performed (ergometer-ESE) for patients with secondary MR.Methods Handgrip-ESE and symptom-limited ergometer-ESE were performed for 53 patients (median age (IQR): 68 (58–78) years; 70% male) on the same day. Baseline global longitudinal strain (GLS) was 9.2% (6.0%–14.0%) and MR volume was 20 (14–26) mL. All-cause death and cardiac hospitalisation were tracked for median 439 (101–507) days.Results Handgrip-ESE induced slightly but significantly greater degrees of MR increase (median one grade increase; p<0.001) than ergometer-ESE, although the changes in other parameters, including GLS (+1.1% vs −0.6%, p<0.001), were significantly smaller. Correlations between the two examinations with respect to the changes in the echocardiographic parameters were weak. Kaplan-Meier analyses revealed poor improvement in GLS during ergometer-ESE, but not the change in MR, was associated with adverse events (p=0.0065). No echocardiographic change observed during handgrip-ESE was prognostic. After adjusting for a clinical risk score, GLS changes during ergometer-ESE remained significant in predicting the adverse events (HR 0.39, p=0.03) A subgroup analysis in patients with moderate or greater MR at baseline (n=27) showed the same results as in the entire cohort.Conclusions The physiological and prognostic implications of handgrip-ESE and ergometer-ESE findings significantly differ in patients with left ventricular dysfunction and secondary MR. The type of exercise to be performed in ESE should be carefully selected.