https://doi.org/10.1007/s00392-025-02625-4
1Uniklinik RWTH Aachen Med. Klinik I - Kardiologie, Angiologie und Internistische Intensivmedizin Aachen, Deutschland; 2Universitätsklinikum Essen Klinik für Kardiologie und Angiologie Essen, Deutschland
Background: The pathophysiology of secondary or functional mitral regurgitation (MR) was considered to result of left ventricular (LV) abnormalities in LV function and remodeling (VSMR). But more recently the culprit being isolated mitral annular enlargement caused by left atrial dilatation was characterized and termed atrial secondary mitral regurgitation (ASMR) (Figure). Handgrip exercise has been recognized as a simple method for stress testing in the evaluation of patients with MR.
Aim: The effect of stress tests in patients with the newly defined group of ASMR has not yet been adequately studied. This study sought to evaluate the impact of handgrip exercise in patients with ASMR compared to patients with VSMR.
Methods: 573 consecutive patients with at least mild secondary MR were included. MR was quantified at rest and during dynamic handgrip exercise by transthoracic echocardiography. The response of handgrip in MR was defined as any increase of effective regurgitant orifice area (EROA). Possible associations of clinical variables and echocardiographic parameters on the response to handgrip were evaluated.
Results: 138 (24%) of all patients with secondary MR had ASMR and these patients were older, more female, had more often atrial fibrillation, better LV function and smaller LV diameters compared to the other 435 patients (76%) with VSMR. There was a comparable increase of absolute MR during handgrip (Δ EROA 4.3±5.8 mm² and 4.4±6.1 mm²; p=0.876) and relative increase from baseline EROA (27.8±40.8 % and 26.4±34.9 %; p=0.709) in ASMR and VSMR. Any increase of MR during handgrip was observed in a similar portion of patients in both groups (52 % and 55 %; p=0.539). Reclassification of MR grade due to the increase of regurgitation severity during handgrip was also not different between patients with ASMR and VSMR (24 % and 28 %; p=0.397) (Table 1).
In ASMR there was no association between clinical variables and baseline echocardiographic parameters to the response of dynamic handgrip, while in VSMR the presence of atrial fibrillation, baseline EORA and LV dimensions were associated with an increase of MR during handgrip (Table 2).
Conclusions: Although baseline characteristics were different, there was a similar response to dynamic handgrip in patients with ASMR and VSMR with any exercise induced increase of MR in about half of the patients and reclassification of MR grade in about one fourth of all patients. But only in VSMR several baseline variables and echocardiographic parameters were associated with an increase of MR during handgrip, while there were no predictors in patients with ASMR.