Mitral arcade: A rare case presenting with fatigue and cough

An 11‐year‐old girl was admitted to pediatric emergency unit with complaints of fatigue and cough. The patient had no previous complaints. There was no history of rheumatic heart disease. The height and duration of the P‐wave was 4 mm and 0.16 seconds, respectively (p mitrale). Echocardiography showed enlarged left atrium (51×61 mm in diameter). Both the anterolateral and posteromedial papillary muscles were directly attached to the anterior and posterior mitral valve leaflets without tendinous chords. The patient was diagnosed with mitral arcade, severe mitral stenosis, and mitral regurgitation. The patient was referred to surgery for replacement of mitral valve.     

A Serendipitous Identification of a Lead Extraction Complication

A 57‐year‐old male with a dual chamber pacemaker and symptomatic, persistent atrial fibrillation (AF) accompanying a febrile illness presented for elective transesophageal echocardiography (TEE)‐guided cardioversion. The patient was found to have a large 2.5 cm × 2.3 cm, mobile mass attached to the right atrial lead. Following device and lead extraction, he developed progressive shortness of breath which was attributed to his underlying arrhythmia. One month later, AF ablation was pursued and preablation TEE revealed a dilated main pulmonary artery with a 1.8 cm × 1.6 cm mass in the distal left pulmonary artery, which was corroborated by a 1.4 cm × 2.5 cm filling defect in the descending left pulmonary artery on magnetic resonance angiography (MRA). To our knowledge, this is the first case report to document the distal migration of vegetation material into the pulmonary artery with serial TEE and highlights the risk of pulmonary embolism (PE) in patients with large endocardial lead vegetations undergoing transvenous lead extraction.     

Images in Cardiovascular Medicine: Caseous Calcification of the Mitral Annulus

A 78‐year‐old woman was admitted to our emergency department for subarachnoid hemorrhage. Since a month ago, she was taking warfarin after diagnosis, on transthoracic echocardiogram (TTE), of a suspected large atrial thrombus. The patient, referred to our institution for further investigation, presented asymptomatic; electrocardiogram showed sinus rhythm. TTE revealed an echo dense spherical mass located in the mitral periannular posterior region with moderate mitral regurgitation. Transesophageal echocardiography and cardiac computed tomography confirmed a calcified round mass (2.0 × 2.9 cm) with central areas of echolucency‐like liquefaction surrounded by a hyperechogenic structure without systolic flow inside the cavity. The mass was diagnosed as caseous calcification of the mitral annulus (CCMA), a rare finding associated with a benign prognosis, requiring surgery only in the presence of mitral valve dysfunction. The diagnosis of CCMA is, often, misconstrued as thrombus, tumor, or abscess, leading to unnecessary investigations or interventions. Our patient was discharged after discontinuation of warfarin.     

Incidence and Predictors of Atrial Septal Defect after Percutaneous Transvenous Mitral Commissurotomy – A Transesophageal Echocardiographic Study of 209 Cases

Background: The incidence of atrial septal defect (ASD) after percutaneous transvenous mitral commissurotomy (PTMC) ranges from 15.2% to 92% in small studies. Aim: To estimate the incidence of atrial septal defect (ASD) following PTMC and to determine the factors contributing to its development. Methods: We studied 209 patients with mitral stenosis (MS) undergoing PTMC. Transesophageal echocardiography (TEE) with color Doppler examination was performed to detect ASD. Results: TEE demonstrated ASD in 139 (66.5%) of 209 patients. The mean diameter of the interatrial septal defect detected by TEE was 4.47 ± 1.7 mm. The most common site of septal puncture was the inferior vena caval side of the interatrial septum followed by fossa ovalis. Color flow imaging across the defect showed left to right shunting in all the patients (100%). We examined the relationship of age, Wilkins score, left atrial volumes, the mitral valve orifice area, mitral valve gradient, and the degree of mitral and tricuspid regurgitation between the group that developed ASD and the group without ASD and found that none of these factors predicted the development of ASD. A residual ASD was seen in 11 patients (8.7%) at 6‐month follow‐up. Conclusion: Incidence of residual atrial septal defect immediately following PTMC by TEE color flow Doppler imaging is 66.5%. Surrogate markers of elevated left atrial pressures do not determine the development of atrial septal defect after PTMC. The majority of the defects close spontaneously and a residual defect is observed in 8.7% patients at 6 months.     

Hypertrophic Cardiomyopathy with Intermittent Free Mitral Regurgitation–A Surgical Dilemma

We describe the case of a 52‐year‐old woman presenting with non‐ST elevation myocardial infarction, atrial fibrillation, and a new diagnosis of hypertrophic cardiomyopathy. Transesophageal echocardiography following hemodynamic deterioration revealed completely restricted mitral leaflet motion with free mitral regurgitation, and severe left ventricular outflow tract (LVOT) obstruction. Surgical intervention was considered; however, repeat imaging following a period of clinical stability revealed resolution of the findings suggesting a transient ischemic etiology. The case is supported by clinical and echocardiographic images with movie clips, and a discussion of the likely pathology in the context of the underlying condition.     

High Sensitivity CRP Levels Predict Atrial Tachyarrhythmias in Rheumatic Mitral Stenosis

Background: The different levels of inflammation in rheumatic mitral stenosis determine its clinical consequences. Atrial fibrillation is frequently encountered in mitral stenosis, though the independent role of chronic inflammation in determining atrial tachyarrhythmia occurrence in rheumatic heart disease has not been demonstrated previously. Methods: Measurements of C‐reactive protein (CRP) with a high sensitivity assay to detect chronic inflammation were performed in a homogenous group of 50 patients with rheumatic mitral stenosis, who were in sinus rhythm. Patients were questioned to exclude confounders of CRP elevation. The patients underwent a twenty‐four‐hour ambulatory ECG monitoring to check for asymptomatic atrial tachyarrhythmias and were in addition classified according to the presence of atrial tachyarrhythmias. Results: Forty‐four percent of patients showed a total of 100 episodes of atrial tachyarrhythmias where 63% of these episodes were paroxysmal atrial fibrillation. The CRP values in patients with tachyarrhythmias were significantly higher than in patients who remained in sinus rhythm (4.2 ± 0.55 mg/L vs 1.99 ± 0.36 mg/L, P < 0.001). A logistic regression analysis revealed only CRP levels and previous history of mitral valvuloplasty significantly determined tachyarrhythmia occurrence where age, left atrial volumes, mitral gradients had no statistically significant effect. Conclusions: Our data implicated that nearly half of the mitral stenosis patients who are in sinus rhythm develop asymptomatic tachyarrhythmias and the higher levels of CRP in these patients show the significant effect of persistent inflammation on arrhythmia occurrence.     

Transesophageal Echocardiography in Candidates for Percutaneous Balloon Mitral Valvuloplasty

Prior to percutaneous balloon mitral valvuloplasty (PBMV), mitral valve morphology and the presence of left atrial thrombi are usually evaluated by transthoracic two-dimensional and Doppler echocardiography (TTE). This study analyzes the impact of transesophageal echocardiography (TEE) in addition to TTE on the selection of candidates considered for PBMV for mitral stenosis. Seventy-five patients with severe mitral stenosis who were considered as appropriate candidates for PBMV based on TTE findings were studied. In 19 (25%) patients, TEE revealed findings that were essential for PBMV but were missed by TTE: left atrial thrombi (n = 14; including 13 in left atrial appendage), right atrial thrombus (n = 1), incomplete cor triatriatum (n = 1) and mitral valve vegetation (n = 1). In two other patients, a left atrial thrombus had been suspected by TTE but could be excluded by TEE. TEE and TTE revealed similar scores of thickening, calcification, and mobility of the mitral valve. Compared to TTE, thickening of the subvalvular apparatus was graded lower using horizontal plane TEE due to shadowing by the mitral valve (echo score 1.8 ± 0.8 vs 1.4 ± 0.7; P < 0.05) whereas results from longitudinal plane TEE were similar to TTE findings. The data show that due to the high prevalence of left atrial thrombi, TEE should be performed in addition to TTE in all patients prior to PBMV.     

Severe Mitral Regurgitation Caused by Perivalvular Abnormal Communication of the Mitral Valve Due to Blunt Chest Trauma

Perivalvular leaks are usually caused by suture interruption in prosthetic valves or infective endocarditis. Traumatic mitral annular dehiscence is a very uncommon event. We present a rare case of severe mitral regurgitation secondary to perivalvular abnormal communication in a 35‐year‐old man with a history of blunt chest trauma. He presented with symptoms of cough and chest tightness for 3 months. Preoperative two‐dimensional and real time three‐dimensional transesophageal echocardiography clearly showed the position and size of the perivalvular abnormal communication and the incident damage of the left ventricular wall. The patient finally underwent successful surgical repair.     

Values for Mitral Valve Annulus Dimensions in Normals and Patients with Mitral Regurgitation

Objectives. The present study was designed to investigate the dimensions of mitral valve annulus in the presence of mitral regurgitation. Method. Fifty-four patients were examined. On transthoracic echocardiographic images, we performed linear measurements in the parasternal plane in order to define the size of the left ventricle, left atrium, and mitral valve annulus. We compared these findings with those obtained in 16 control subjects. Results. Twenty-one patients with mild or moderate mitral regurgitation demonstrated no significant change of the mitral valve annulus compared with the control group (P > 0.05). Seventeen patients with severe mitral regurgitation (grade of 4) had a significant increase of the dimensions of the mitral valve annulus, left ventricle, and left atrium (P < 0.05). The etiology of mitral regurgitation was degenerative in 32 patients, rheumatic in 2 patients, and mitral valve prolapse in 4 patients. All patients had normal left ventricular systolic function. Thirty-one patients were in normal sinus rhythm, and seven were in atrial fibrillation. Conclusions. The measurement of the diameter of the mitral valve annulus is feasible with transthoracic echo-cardiography. In addition to the evaluation of mitral valve leaflets and subvalvular apparatus, the measurement of the mitral valve annulus is important in the evaluation of mitral regurgitation, as its enlargement is indicative for severe mitral regurgitation .     

Short-Term Results of Transapical Transcatheter Mitral Valve Implantation for Mitral Regurgitation

Background

Mitral regurgitation (MR) is the most common valvular heart disease, and mitral valve surgery is the gold standard therapy for severe MR. Many patients with severe MR are not referred for surgery because of old age, comorbidities, or severe left ventricular dysfunction. Transcatheter mitral valve implantation may be a better therapeutic option for these high-risk patients with severe symptomatic MR.

Objectives

This study sought to describe the first-in-man series of transapical mitral valve implantation for mitral regurgitation with the TIARA device.

Methods

Extensive preclinical ex vivo and animal studies were conducted with the transapical mitral valve implantation of the Tiara system. The first 2 cases of human implantation were successfully performed in a 73-year-old man and a 61-year-old woman with severe functional MR. Both patients were in New York Heart Association class IV heart failure with depressed left ventricular ejection fraction, pulmonary hypertension, and additional comorbidities.

Results

The valve was implanted uneventfully in both patients. General anesthesia and transapical access were used. Patients were hemodynamically stable with no need for cardiopulmonary bypass. Immediately after implantation, systemic arterial pressure and stroke volume increased and pulmonary pressure decreased dramatically. There were no intraoperative complications, and both patients were extubated in the operating room. Post-procedural echocardiograms at 48 h, 1 month, and 2 months demonstrated excellent prosthetic valve function with a low transvalvular gradient and no left ventricular outflow tract obstruction. There was a trivial paravalvular leak in the first patient at 48 h, which was completely resolved at subsequent studies; no paravalvular leak occurred in the second patient.

Conclusions

Transapical transcatheter mitral valve implantation is technically feasible and can be performed safely. Early hemodynamic performance of the prosthesis was excellent. Transcatheter mitral valve implantation may become an important treatment option for patients with severe MR who are at high operative risk.     

Anomalous Mitral Arcade Variant with Accessory Mitral Leaflet and Chordae Presenting for the First Time with Acute Decompensated Heart Failure in an Adult

The anomalous mitral arcade is a rare congenital malformation of the mitral valve and its tensor apparatus. It is characterized by enlarged papillary muscles connected to each other and to the free edge of the anterior mitral leaflet by a bridge of fibrous tissue. We report a rare variant of anomalous mitral arcade that was associated with accessory mitral leaflet in subaortic area and accessory chordae. Our patient was asymptomatic till the age of 18 years, when he presented for the first time in acute decompensated heart failure secondary to severe mitral regurgitation and left ventricular dysfunction. The patient had rapid deterioration with fatal outcome.     

Systolic Papillary Muscle Dyssynchrony Predicts Recurrence of Mitral Regurgitation in Patients with Ischemic Cardiomyopathy (ICM) Undergoing Mitral Valve Repair

Objective: We investigated the impact of papillary muscle dyssynchrony (DYS‐PAP) in predicting recurrent mitral regurgitation (MR) in patients with ischemic cardiomyopathy (ICM) undergoing undersized mitral ring annuloplasty (UMRA). Methods: One hundred forty‐four ICM patients (left ventricular ejection fraction <35%) in sinus rhythm undergoing UMRA between January 2001 and December 2010 at three Institutions (University Hospital, Maastricht, The Netherlands; Careggi Hospital, Florence, Italy; Civic Hospital, Brescia, Italy) were recruited. The primary endpoint was the recurrence of MR at the latest echocardiographic study defined as insufficiency ≥2+ in patients with no/trivial MR at discharge. The assessment of DYS‐PAP was performed by applying two‐dimensional (2D) speckle‐tracking imaging. Results: In patients with MR recurrence, DYS‐PAP significantly worsened (84.1 ± 8.8 msec vs.65.4 ± 8.8 msec at baseline, P < 0.001) whereas in patients with no MR recurrence, DYS‐PAP did not vary (22.3 ± 5.3 msec vs. 25.9 ± 7.2 msec at baseline, P = 0.8). Recurrent MR was positively correlated with preoperative DYS‐PAP (P < 0.001), baseline anterior mitral leaflet tethering angle α (P < 0.001) and tethering symmetry index α/β before surgery (P < 0.001). There was no significant correlation between MR recurrence and other echocardiographic parameters. Logistic regression analysis revealed that baseline values of DYS‐PAP (OR: 5.4 [95% CI: 3.1–7.7], P < 0.001), α (OR: 5.0 [2.6–6.7], P < 0.001), and α/β (OR: 3.9 [2.5–5.7], p < 0.001) were predictors of recurrent MR. A DYS‐PAP value ≥ 58 msec predicted recurrence of MR with 100% sensitivity and 83% specificity (area under the curve [AUC]: 0.92 [0.7–1], P < 0.001). Conclusions: A DYS‐PAP cutoff value of 58 msec is useful to identify patients in whom UMRA is likely to fail. That way decision making in ischemic functional MR might be facilitated.     

Mitral Valve Annular Bacterial Vegetative Mass Masquerading as a Left Atrial Myxoma

A 49‐year‐old male with chronic kidney disease and history of renal transplantation in 2006 on chronic immunosuppressant therapy presented with a 1‐week history of chills and generalized myalgia. He had a temperature of 101°F. One set of blood cultures grew methicillin‐sensitive Staphylococcus aureus. Transesophageal echo (TEE) revealed a mobile mass that was 2 cm in length attached by a thin stalk to the base of the anterior leaflet of the mitral valve. The surgical diagnosis was a left atrial myxoma. The echocardiographic as well as the surgical findings were consistent with an atrial myxoma. However, the histopathology of the specimen showed no evidence of myxoma as the characteristic stellate mesenchymal cells were absent. Instead the milieu of inflammatory cells, fibrin and multimicrobial colonization of both Gram‐positive and Gram‐negative cocci suggested a super infected vegetative mass. It is interesting that the mitral valve was intact as de novo vegetation being formed on a structurally normal native valve is rare. In some instances, the echocardiographic distinction between atrial masses such as vegetation, thrombus or an atrial myxoma may be ambiguous. Not only does surgical removal allow histological determination of the diagnosis that is critical for treatment, but in cases where an infected mass is mobile and greater than 15 mm, as in this case, there is high potential for embolization. Surgical removal significantly decreases the risk of an embolic event. (Echocardiography 2010;27:E62‐E64)     

Spontaneous left atrial echo contrast,mitral annular systolic velocity,and left atrial appendage late emptying velocity in predicting improvement of left atrial function after percutaneous balloon mitral valvuloplasty

Background

Thromboembolic events are the major cause of morbidity and mortality in patients with mitral stenosis (MS). This study aims to investigate left atrial spontaneous echo contrast (LA SEC), mitral annular systolic velocity (Sa‐wave), left atrial appendage (LAA) late emptying velocity (LAAEV), LAA filling velocity (LAAFV) pre‐ and postpercutaneous balloon mitral valvuloplasty (PBMV) for MS. This also aims to study the association of LA SEC with inflammatory marker, high‐sensitivity C‐reactive protein (hs‐CRP) in MS.

Methods

The study population consisted of 100 patients with symptomatic MS with sinus rhythm who underwent PBMV. Transthoracic echo (TTE), tissue Doppler imaging (TDI), and transesophageal echo (TEE) examinations were carried out before and 14 days following PBMV. High‐sensitivity C‐reactive protein (hs‐CRP) was measured at the time of admission.

Results

The mean age was 33.2 ± 10.3 years with female preponderance (71%). There was a decrease in SEC grading, (pre‐PBMV 2.8 ± 0.9 and post‐PBMV 0.4 ± 0.1; P < .01), increase in LAAEV (pre‐PBMV 23.0 ± 7.9 cm/s and post‐PBMV 40.9 ± 8.4 cm/s; P < .01), and LAAFV (pre‐PBMV 31.8 ± 9.3 cm/s and post‐PBMV 51.2 ± 8.7 cm/s; P < .01).A significant positive correlation was present between LAAEV and Sa‐wave (r = .52, P < .01). Correlation between hs‐CRP and SEC was positive and significant (r = .33, P < .01). Optimal cutoff value of hs‐CRP for prediction of moderate to dense SEC was >2.3 mg/dL, the cutoff value of Sa‐wave was≤ 5.5 cm/s for prediction of the presence of inactive LAA (LAAEV < 25 cm/s).

Conclusion

Mitral annular systolic velocity (Sa‐wave) is an independent predictor of inactive LAA and a useful parameter in estimating inactive LAA in MS. Sa‐wave and hs‐CRP are independent predictors for SEC. PBMV improves LAA function in patients with MS.     

Isolated cleft of both the anterior and posterior mitral valve leaflets

A 37 year‐old female patient in whom the transthoracic echocardiography examination revealed dilatation of left heart chambers with left ventricular ejection fraction of 30% and moderate‐to‐severe mitral valve regurgitation was admitted to our hospital. On 2DTEE examination, mitral valve was normal; however, on 3D images, clefts of both anterior and posterior leaflets were revealed. Isolated cleft mitral valve without any other feature of atrioventricular septal defect is uncommon. 2D echocardiography has limited capability in defining the complex 3D anatomic characteristics of the cleft. 3DTEE allows to visualize the cleft position, morphology, and size, and it is important for surgical planning.     

Mitral valve hemodynamic effects of percutaneous edge-to-edge repair with the MitraClip device for mitral regurgitation.

INTRODUCTION: The Endovascular Valve Edge-to-Edge REpair STudies (EVEREST) are investigating a percutaneous technique for edge-to-edge mitral valve repair with a repositionable clip. The effects on the mitral valve gradient (MVG) and mitral valve area (MVA) are not known. METHODS: Twenty seven patients with moderate to severe or severe mitral regurgitation (MR) were enrolled. Echocardiography was performed preprocedure, at discharge, and at 1, 6, and 12 months. Mean MVG was measured by Doppler and MVA by planimetry and pressure half-time, and evaluated in a central core laboratory. Pre- and postclip deployment, simultaneous left atrial/pulmonary capillary wedge and left ventricular pressures were obtained in eight patients. RESULTS: Three patients did not receive a clip, six patients had their clip(s) explanted by 6 months (none for mitral stenosis), and four were repaired with two clips. Results are notable for a slight increase in mean MVG by Doppler postclip deployment (1.79 +/- 0.89 to 3.31 +/- 2.09 mm Hg, P < 0.01) and an expected decrease in MVA by planimetry (6.49 +/- 1.61 to 4.46 +/- 2.14 cm(2), P < 0.001) and by pressure half time (4.35 +/- 0.98 to 3.01 +/- 1.42 cm(2), P < 0.05). There were no significant changes in hemodynamic parameters postclip deployment by direct pressure measurements. There was no change in MVA by planimetry from discharge to 12 months (3.90 +/- 1.90 to 3.79 +/- 1.54 cm(2), P = 0.78). CONCLUSIONS: Echocardiographic and hemodynamic measurements after percutaneous mitral valve repair with the MitraClip show an expected decrease in mitral valve area with no evidence of clinically significant mitral stenosis either immediately after clip deployment or after 12 months of follow-up.     

Mitral valve prolapse causing severe mitral regurgitation in a patient with absent right pulmonary artery

A 33-year-old man was investigated for dyspnea on exertion and the presence of a pansystolic murmur. Physical examination revealed dextrocardia confirmed by chest radiograph, which also showed oligemic right lung field. Subsequent cardiac catheterization revealed secundum atrial septal defect, persistent left sided superior vena cava, and severe mitral valve prolapse causing severe mitral regurgitation with pulmonary hypertension. The right pulmonary artery was absent. It is the first report of the association between severe mitral valve prolapse and absent right pulmonary artery.     

Prognostic Impact of Extra–Mitral Valve Cardiac Involvement in Patients With Primary Mitral Regurgitation

BackgroundIn patients with severe primary mitral regurgitation (MR), the indication for surgery is currently based on the presence of symptoms, left ventricular dilatation and dysfunction, atrial fibrillation, and pulmonary hypertension.ObjectivesThe aim of this study was to evaluate the prognostic impact of the presence of extra–mitral valve cardiac involvement (including known risk factors but also severe left atrial [LA] dilatation and right ventricular [RV] dysfunction) in a large multicenter study of patients with primary MR.MethodsPatients with severe primary MR undergoing surgery were included and categorized according to the extent (highest) of cardiac involvement: group 0, no cardiac involvement; group 1, left ventricular involvement; group 2, LA involvement; group 3, pulmonary vasculature or tricuspid valve involvement; or group 4, RV involvement. The outcome was all-cause mortality.ResultsA total of 1,106 patients were included (mean age 63 ± 12 years, 68% male). In total, 377 patients (34%) were classified in group 0, 239 (22%) in group 1, 213 (19%) in group 2, 180 (16%) in group 3, and 97 (9%) in group 4. Kaplan-Meier curve analysis revealed significantly worse survival (log-rank chi-square = 43.4; P < 0.001) with higher group. On multivariable analysis, age, male sex, chronic obstructive pulmonary disease, kidney function, and group of cardiac involvement were independently associated with all-cause mortality. For each increase in group, a 17% higher risk for all-cause mortality was observed (95% CI: 1.051-1.313; P = 0.005) during a median follow-up time of 88 months.ConclusionsIn patients with severe primary MR, a novel classification system based on extra–mitral valve cardiac involvement may help refine risk stratification and timing of surgery, particularly including severe LA dilatation and RV dysfunction in the assessment.     

Preoperative Right Ventricular Function in Patients with Organic Mitral Regurgitation

Aims: To assess the right ventricular (RV) function in patients with severe mitral regurgitation (MR); to find a relation between preoperative and postoperative parameters. Methods: RV function was echocardiographically assessed by determining the tricuspid annular plane systolic excursion (TAPSE) and the peak systolic velocity of the lateral tricuspid annulus (Sa) in 45 patients with severe organic MR (53.3% men, age 58 ± 10 years). Mean NYHA class was 2.6 ± 0.4, LVEF was 55.3 ± 12%, RV end‐diastolic diameter was 28.7 ± 4.7, left ventricular end‐systolic diameter (LVESD) was 44.6 ± 12.6 mm, and LV end‐diastolic volume (Simpson) was 160.6 ± 50.3 ml. All patients underwent mitral valve replacement with posterior chordal sparing. Results: Mean preoperative TAPSE and Sa were 19.4 ± 4.3 mm and 10.3 ± 3 cm/sec, respectively. RV dysfunction, defined as TAPSE < 22 mm, had 66.6% of the patients, and Sa < 11 cm/sec was found in 62.2% of the patients preoperatively. Preoperative TAPSE and Sa were significantly correlated (P < 0.00001, r = 0.61). Both TAPSE and Sa were correlated with the RV end‐diastolic diameter (P < 0.01), LVESD (P < 0.05) left ventricular dp/dt (P < 0.05), and LVEF (P < 0.0001). Postoperative LVEF was 50% (P < 0.001), Sa 5.3 ± 2 cm/sec (P < 0.001), and TAPSE 8.7 ± 3.2mm (P < 0.001). Twenty‐one patients (46.6%) reached the study end point of decrease of LVEF by more than 10%. Univariate predictors were age (P = 0.04), male gender (P = 0.01), TAPSE (P = 0.007), and Sa (P = 0.009), while a trend was found for regurgitation fraction (P = 0.058) and LV end‐diastolic volume index (P = 0.09). By multivariate analysis, TAPSE (P = 0.01) and Sa (P = 0.01) were predictive for the study end point. Conclusion: The assessment of the RV function by echocardiography is a simple tool that provides prognostic information in patients with MR. (Echocardiography 2010;27:282‐285)