on April 14, 2009
Published online before print April 14, 2009, doi: 10.1161/CIRCHEARTFAILURE.108.822999
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Original Article |
Reduction in Mitral Regurgitation During Therapy Guided by Measured Filling Pressures in the ESCAPE Trial
1 Brigham and Women's Hospital, Boston, MA;
2 Duke Medical Center, Durham, NC;
3 UCLA Medical Center, Los Angeles, CA;
4 University of Alabama, Birmingham, AL;
5 Vanderbilt University Hospital, Nashville, TN;
6 University of Southern California, Los Angeles, CA;
7 University of Florida, Gainesville, FL;
8 UT Southwestern Medical Center, Dallas, TX
9 E-mail: lstevenson{at}partners.org
Background—Dynamic mitral regurgitation (MR) contributes to decompensation in chronic dilated heart failure. Reduction of MR was the primary physiologic endpoint in the ESCAPE trial, which compared acute therapy guided by JVP, edema, and weight (CLIN) to therapy guided additionally by pulmonary artery catheters (PAC) toward pulmonary wedge pressure 
15 and right atrial pressure 8 mmHg.
Methods and Results—Patients were randomized to PAC or CLIN during hospitalization with chronic HF and mean LVEF 20%, and at least 1 symptom and 1 sign of congestion. MR and mitral flow patterns, measured blinded to therapy and timepoint, were available at baseline and discharge in 133 patients, and at 3 months in 104 patients. Changes in MR and related transmitral flow patterns were compared between PAC and CLIN patients. Jugular venous pressure, edema, and weights decreased similarly during therapy in the hospital for both groups. In PAC but not in CLIN patients, MR jet area, MR/LAA ratio, and E velocity were each significantly reduced and deceleration time increased by discharge. By 3 months, patients had clinical evidence of increased JVP, edema, and weight since discharge, reaching significance in the PAC arm, and the change in MR was no longer different between the 2 groups, although the change in E velocity remained greater in PAC patients.
Conclusions—During hospitalization, therapy guided by PAC to reduce left-sided pressures improved MR and related filling patterns more than therapy guided clinically by evidence of systemic venous congestion. This early reduction did not translate into improved outcomes out of the hospital, where volume status reverted toward baseline.
Key Words: cardiomyopathy • heart failure • hemodynamics • mitral valve • regurgitation