Correlation Between the Severity of Primary Mitral Regurgitation and Left Ventricular Ejection Fraction in Patients With Mitral Valve Prolapse Assessed by Cardiac Magnetic Resonance: A Cross-Sectional Study

Correlation Between the Severity of Primary Mitral Regurgitation and Left Ventricular Ejection Fraction in Patients With Mitral Valve Prolapse Assessed by Cardiac Magnetic Resonance: A Cross-Sectional Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Correlation Between the Severity of Primary Mitral Regurgitation and Left Ventricular Ejection Fraction in Patients With Mitral Valve Prolapse Assessed by Cardiac Magnetic Resonance: A Cross-Sectional Study Andreas Klemens, Hilman -, Dian Komala Dewi, Astri Astuti This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8594474/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The increasing systolic dysfunction and persistent left ventricular volume overload caused by primary mitral regurgitation (MR) are symptoms of this prevalent valvular heart disease. LVEF decreases and ventricular remodeling occurs in individuals with MVP as the severity of regurgitation increases. Examining LVEF as measured by CMR in relation to the degree of primary mitral regurgitation was the major objective of this research. Methods The research team at Dr. Hasan Sadikin General Hospital used a cross-sectional design and ran the study from October 2021 to October 2025. The data was collected from the medical records of individuals who were 18 years old or older and had a diagnosis of MVP and had a CMR scan. Regurgitant volume and regurgitant fraction were used to measure the severity of mitral regurgitation, while left ventricular function was determined using LVEF. In order to assess the relationship between the variables, we used Spearman rank correlation analysis. Results The results showed that there was a strong negative relationship (p < 0.05) between the severity of primary mitral regurgitation and LVEF, suggesting that lower LVEF was linked to more severe regurgitation. Conclusions In individuals with mitral valve prolapse, the severity of primary mitral regurgitation is significantly correlated with left ventricular ejection fraction as measured by CMR. Mitral regurgitation Mitral valve prolapse Left ventricular ejection fraction Cardiac magnetic resonance Background When the mitral valve develops a structural abnormality, such as a prolapse, flail leaflet, or myxomatous degeneration, it causes blood to flow backwards during systole from the left ventricle into the left atrium. This condition is known as primary mitral regurgitation (MR). 1 , 2 Primary MR represents one of the most clinically significant valvular disorders, as it imposes chronic volume overload on the heart, leading to progressive left ventricular remodeling and the development of heart failure. 3 , 4 More than 2-2.5 million Americans were affected with moderate-to-severe MR in 2000, and this number is expected to quadruple by 2030 as a result of longer life expectancy. 3 , 4 , 5 Importantly, primary MR often remains asymptomatic during its early stages, resulting in delayed diagnosis until the onset of heart failure symptoms or complications such as atrial fibrillation. 6 , 7 Clinically, patients with significant MR may present with dyspnea, fatigue, reduced exercise tolerance, or acute pulmonary edema during the decompensated phase. 3 , 5 Even in asymptomatic individuals with apparently maintained left ventricular ejection fraction (LVEF), the existence of substantial MR is linked to an elevated risk of long-term death. 3 , 4 , 5 Epidemiologically, MR is one of the most prevalent valvular heart diseases worldwide. Population-based data from the Framingham Heart Study reported that moderate-to-severe MR affects approximately 2% of the adult population, with a marked increase in prevalence with age. 6 In individuals aged ≥ 60 years, the prevalence of clinically significant MR may reach 9–10%, making it the second most common valvular disease after aortic stenosis. 7 , 8 The annual incidence of newly diagnosed significant MR has been estimated at 140–150 cases per 100,000 population, with the highest rates observed in older adults. 9 Chronic regurgitant flow into the left atrium is the pathophysiological driver of primary MR, leading to a gradual overload of the left atrial and ventricular volumes. 10 In the early stages, left ventricular systolic function may appear preserved or even supranormal due to compensatory mechanisms described by the Frank–Starling law. 11 However, sustained regurgitant volume eventually leads to eccentric ventricular dilation, increased wall stress, myocardial contractile dysfunction, and a progressive decline in LVEF, which is strongly associated with adverse clinical outcomes. 2 , 12 The severity of MR is a key determinant of hemodynamic burden and clinical decision-making. Quantitative assessment classifies MR into mild, moderate, and severe categories based on regurgitant volume (RVol) and regurgitant fraction (RF). 11 , 13 Mild MR is defined by RVol < 30 mL/beat and RF < 20%, moderate MR by RVol 31–60 mL/beat or RF 21–40%, and severe MR by RVol ≥ 60 mL/beat or RF ≥ 40%. 11,14 These quantitative parameters provide objective markers of regurgitant burden and ventricular remodeling risk. 11 , 15 When it comes to MR prognosis and treatment decisions, left ventricular ejection fraction is king. 15 Current international guidelines recommend consideration of mitral valve intervention in asymptomatic patients before LVEF declines below 60%, particularly in the presence of structural valve abnormalities. 16 Once LVEF decreases below 30%, the operative risk of mitral valve surgery may exceed its potential benefits, highlighting the importance of early and accurate functional assessment. 16 Transthoracic echocardiography remains the first-line imaging modality for evaluating MR severity and ventricular function; however, its accuracy may be limited in cases with eccentric or complex regurgitant jets and geometric assumptions. 2 , 16 Because of its precise volumetric quantification, great repeatability, and high spatial and temporal resolution, CMR has become the gold standard for complete MR evaluation. 11 , 12 , 14 For a more accurate assessment of regurgitant severity and its effects on left ventricular remodeling, including changes in end-diastolic volume, end-systolic volume, stroke volume, and LVEF, 11,12,17 CMR permits direct quantification of RVol and RF through volumetric analysis and phase-contrast velocity mapping to measure aortic forward flow. regurgitation, and the functional effects on the ventricles, CMR is the method of choice. 11 , 14 , 17 Previous studies have demonstrated strong associations between quantitatively assessed MR severity using CMR and adverse ventricular remodeling, systolic dysfunction, and clinical outcomes. 11 , 12 , 18 CMR-derived parameters such as RVol and RF have been shown to outperform echocardiographic measures in predicting the need for surgical intervention and long-term prognosis. 11 , 15 , 18 However, conflicting results regarding the correlation between MR severity and LVEF have been reported, particularly in patients with advanced ventricular dysfunction. 19 , 20 Notably, while several studies have reported a significant correlation between MR severity and LVEF decline, other investigations have suggested that MR severity may not independently predict outcomes in patients with severely reduced LVEF, indicating that ventricular function itself may be the dominant prognostic determinant. 19 , 20 This variability underscores the need for further studies using accurate quantitative imaging techniques in diverse populations. To date, no studies in Indonesia have specifically evaluated the correlation between primary mitral regurgitation severity and left ventricular ejection fraction in patients with mitral valve prolapse using Cardiac Magnetic Resonance. Therefore, this study aims to assess the relationship between quantitative MR severity and left ventricular systolic function using CMR in an Indonesian population, providing region-specific evidence to support imaging-based risk stratification and clinical decision-making. Methods A cross-sectional analytic observational design was used in this investigation. From October 2021 through October 2025, researchers combined through the medical records of patients at Hasan Sadikin General Hospital in Bandung who had cardiac MRI exams for mitral valve prolapse. Patients having a confirmed diagnosis of MVP based on earlier echocardiographic examination and who underwent CMR for additional assessment were included in the study population. Patients had to be 18 years old or older. In order to assess the severity of mitral regurgitation and left ventricular systolic function, patients were included in the study if full CMR data were available. Incomplete CMR imaging data, congenital cardiac disease, ischemic cardiomyopathy, previous mitral valve surgery or intervention, secondary mitral regurgitation, or substantial concurrent valvular illness are all grounds for patient exclusion. Cine steady-state free precession (SSFP) sequences were used for ventricular volumetric evaluation and phase-contrast velocity mapping for flow measurement in all CMR exams, which were conducted on a clinical MRI scanner according to a standardized cardiac MRI procedure. The left ventricular ejection fraction (LVEF) was determined using the conventional volumetric technique, and the volumes of the left ventricle, including the end-diastolic volume (EDV) and end-systolic volume (ESV), were quantified from short-axis cine pictures. The difference between EDV and ESV was used to determine stroke volume (SV). Volumetric analysis and aortic forward flow measurements were used to quantify the regurgitant fraction (RF) and regurgitant volume (RVol), which in turn evaluated the severity of primary mitral regurgitation. Using previously published quantitative CMR criteria, mitral regurgitation was classified as mild, moderate, or severe. Cardiovascular radiologists with extensive expertise evaluated and interpreted all CMR pictures without knowing any of the patients' medical history. Descriptive variables including age, sex, history of hypertension, smoking status, and left ventricular functional parameters were summarized and presented in tabular form. Categorical variables were presented as frequencies and percentages. The Spearman rank correlation test was used to analyze the relationship between the severity of mitral regurgitation and the left ventricular ejection fraction. When the conditions for chi-square analysis were not satisfied, Fisher's exact test was used to compare categorical variables. A statistically significant result was defined as a p-value less than 0.05. Version 22.0 of the Statistical Package for the Social Sciences (SPSS) was used to conduct the statistical analysis. Ethical approval for this study was obtained from the Ethics Committee of Hasan Sadikin General Hospital, Bandung. This study did not involve direct patient contact, as all data were derived from medical records and imaging archives. The use of patient data was conducted after obtaining permission from the hospital’s Medical Records Department, and patient confidentiality was strictly maintained throughout the study. Results A total of patients with MVP who received a CMR examination at Hasan Sadikin General Hospital were screened throughout the research period, which spanned from October 2021 to October 2025. All participants who met the inclusion and exclusion criteria were considered for the study. In Table 1 we can see a summary of the research population's demographic and clinical details. The mean age of the study subjects was in the late middle-age group, with no marked age difference across categories of LVEF. Male subjects constituted a slightly higher proportion compared with female subjects. Comorbid conditions, including hypertension and smoking history, were variably distributed among the study population. The baseline characteristics of the subjects according to LVEF categories (severely reduced, moderately reduced, mildly reduced, and normal) are presented in Table 1. Regurgitant volume (RVol) and regurgitant fraction (RF) were used to objectively evaluate the main MR severity, which was shown by quantitative CMR analysis to span a broad range. Subjects were classified as having mild, moderate, or severe MR based on these factors, with the use of predetermined CMR cut-off values. A negative association between the severity of mitral regurgitation and left ventricular ejection fraction (LVEF) was found by correlation analysis, suggesting that a decrease in LVEF was related to higher degrees of mitral regurgitation (p < 0.05). Correlation analysis between primary mitral regurgitation severity and left ventricular ejection fraction was performed using the Spearman rank correlation test, as the variables were ordinal and not normally distributed. This correlation is summarized in Table 2. There was a notable variation in the distribution of LVEF between male and female patients (p < 0.05) when analyzing demographic data, which indicated a substantial link between sex and LVEF categories. Age was not shown to be the primary determinant of left ventricular systolic function changes in this research sample, as further investigation revealed no significant connection between age and LVEF categories (p > 0.05). With regard to clinical risk factors, no significant relationship was found between smoking history and LVEF categories (p > 0.05). Conversely, a significant association was observed between hypertension and LVEF categories, indicating that subjects with hypertension were more likely to have reduced LVEF compared with those without hypertension (p < 0.05). The relationship between sex, age, smoking, and hypertension with LVEF categories is presented in Table 3. Regardless of age or smoking status, our results show that left ventricular systolic function is substantially related to CMR-derived quantitative evaluation of primary mitral regurgitation severity; however, sex and hypertension seem to be relevant determinants. These findings provide credence to the use of cardiac CMR as a reliable and objective tool for assessing the hemodynamic effects of primary mitral regurgitation in individuals suffering from mitral valve prolapse. Discussion This research shows that in individuals with mitral valve prolapse (MVP), the left ventricular ejection fraction (LVEF) as measured by cardiac magnetic resonance (CMR) is negatively correlated with the severity of primary mitral regurgitation (MR). The severity of MR is increasing, as measured by the regurgitant fraction (RF) and the regurgitant volume (RVol), was associated with progressive impairment of left ventricular systolic function, supporting the concept that chronic volume overload plays a central role in ventricular remodeling and contractile dysfunction. These findings reinforce the hemodynamic relevance of quantitative MR assessment and highlight the value of CMR in evaluating the functional consequences of primary MR. The observed inverse relationship between MR severity and LVEF is consistent with established pathophysiological mechanisms. In the early stages of primary MR, increased preload resulting from regurgitant flow may preserve or even augment LVEF through the Frank–Starling mechanism. However, persistent volume overload leads to eccentric left ventricular remodeling, increased wall stress, and progressive deterioration of myocardial contractility, ultimately resulting in reduced LVEF. CMR enables accurate quantification of ventricular volumes and regurgitant flow, allowing detection of subclinical ventricular dysfunction that may not be apparent using conventional imaging modalities. Our findings are in agreement with previous studies demonstrating that quantitative CMR-derived MR parameters are closely linked to left ventricular remodeling and systolic dysfunction. There is an elevated risk of unfavorable ventricular remodeling and LVEF reduction during follow-up associated with greater RVol and RF values, according to previous findings. The risk of ventricular dysfunction and the need for intervention is increased when RVol is equal to or more than 60 mL or RF is equal to or greater than 40–50%. The present study extends these observations by confirming this relationship specifically in an MVP population and within an Indonesian clinical setting, where data on CMR-based MR assessment remain limited. The absence of a significant association between age and LVEF in this study suggests that systolic dysfunction in primary MR is driven more by the hemodynamic burden of regurgitation than by age-related myocardial changes alone. This finding underscores the importance of disease severity rather than chronological age in determining ventricular performance. In contrast, hypertension showed a significant association with reduced LVEF, which may reflect the additive effect of increased afterload on an already volume-overloaded ventricle. Chronic hypertension can exacerbate myocardial stress, accelerate adverse remodeling, and contribute to earlier systolic dysfunction in patients with primary MR. Sex-related differences in LVEF categories were also observed, suggesting potential biological or clinical differences in disease progression between male and female patients. Previous studies have reported sex-specific variations in ventricular remodeling and outcomes in valvular heart disease, which may be related to differences in myocardial adaptation, hormonal influences, or referral patterns for advanced imaging and intervention. Smoking history, however, did not demonstrate a significant association with LVEF in this cohort, indicating that its impact on systolic function may be less pronounced than that of hemodynamic factors directly related to MR severity. Importantly, the use of CMR in this study provides a robust and objective assessment of MR severity and ventricular function. Unlike echocardiography, which may be limited by acoustic windows, jet eccentricity, and operator dependency, CMR offers high reproducibility and accurate volumetric measurements. The ability to directly quantify RVol and RF using volumetric and phase-contrast techniques allows for a comprehensive evaluation of both the severity of regurgitation and its impact on ventricular remodeling. This is particularly relevant in MVP patients, where regurgitant jets are often complex and eccentric. It is important to recognize a number of constraints. Because it is retrospective and cross-sectional, it cannot evaluate changes in ventricular function over time or draw any conclusions about causality. Because CMR is used selectively in clinical practice, the sample size was quite small, which might impact the generalizability of the results. In addition, other factors that could influence LVEF, such as duration of regurgitation, medical therapy, and additional comorbidities, were not fully evaluated. Nevertheless, the findings provide valuable insights into the relationship between quantitative MR severity and ventricular function in a real-world clinical setting. In conclusion, this study confirms that increasing severity of primary MR is significantly associated with reduced LVEF in patients with MVP when assessed using CMR. Quantitative CMR parameters offer a reliable means of evaluating the hemodynamic burden of MR and its impact on ventricular function. These results support the integration of CMR into the diagnostic and follow-up strategies for patients with primary MR, particularly for risk stratification and optimization of intervention timing. Conclusions There is a significant correlation between primary mitral regurgitation severity and left ventricular ejection fraction in patients with mitral valve prolapse as assessed by Cardiac Magnetic Resonance. CMR offers precise quantitative assessment and should be considered an essential imaging modality for comprehensive evaluation of mitral regurgitation. Declarations Ethics approval and consent to participate Ethical approval was obtained from the Ethics Committee of Dr. Hasan Sadikin General Hospital, Bandung (Approval No.: DP.04.03/D.XIV.6.5/617/2025). This study involved the use of anonymized secondary data obtained from medical records and did not involve direct interaction with human participants. The use of medical record data was permitted after obtaining authorization from the Head of the Medical Record Department. aThis study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Due to the retrospective and cross-sectional nature of the study using anonymized data, the requirement for informed consent to participate was waived by the Ethics Committee. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request and subject to institutional regulations. Funding The authors received no specific funding for this work. Authors’ contributions AKW conceived and designed the study, wrote the research proposal, and participated in data collection. AKW, H, DKD, and AA performed data analysis and interpretation. AKW drafted the initial manuscript. All authors critically revised the manuscript for important intellectual content, read, and approved the final version of the manuscript. Competing interests The authors declare that they have no competing interests. Acknowledgements The authors would like to express their sincere appreciation to Universitas Padjadjaran and Dr. Hasan Sadikin General Hospital for providing ethical clearance to conduct this study. We also acknowledge the Medical Record Department for their assistance in data access. References Topilsky Y. Mitral Regurgitation: Anatomy, Physiology, and Pathophysiology-Lessons Learned From Surgery and Cardiac Imaging. Front Cardiovasc Med. 2020 May 29;7:84. doi: 10.3389/fcvm.2020.00084. Zoghbi WA, Adams D, Bonow RO, Enriquez-Sarano M, Foster E, Grayburn PA, et al. 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Tables Table 1 Subject Characteristics, Mitral Regurgitation, and Left Ventricle Ejection Fraction Characteristics N (%) N = 34 n Gender Male 18 (52.9%) Female 16 (47.1%) Age 50 years old 22 (64.7%) Smoking Yes Not 19 (55.9%) 15 (44.1%) Hypertension Yes Not 15 (44.1%) 19 (55.9%) Mitral Regurgitation Severity Mild 12 (35.3%) Moderate 8 (23.5%) Severe 14 (41.2%) Left Ventricle Ejection Fraction (%) Normal 10 (29.4%) Mildly reduced 4 (11.8%) Moderately reduced 9 (26.5%) Severely reduced 11 (32.4%) Table 2 Correlation between Mitral Regurgitation and Left Ventricle Ejection Fraction Mitral Regurgitation Severity Left Ventricle Ejection Fraction Total (%) Normal Mildly reduced Moderately reduced Severely reduced N % N % N % N % Mild 6 50 3 25 3 25 0 0 12 (35.3%) Moderate 3 37.5 0 0 3 37.5 2 25 8 (23.5%) Severe 1 7.1 1 7.1 3 21.4 9 64.3 14 (41.2%) Total 10 29.4 4 11,8 9 26.5 11 32,4 34 (100%) Variable r Spearman p value MR Severity and LVEF 0.622 0.013 Table 3 Correlation beetwen sex, age, smoking and hypertension and left ventricle ejection fraction Variabl1 Left Ventricle Ejection Fraction P value Normal Mildly reduced Moderately reduced Severely reduced Total (%) Age 50 years old 4 (18.2%) 3 (13.6%) 5 (22.7%) 10 (45.5%) 22 (64.7) Total 10 (29.4%) 4 (11.8%) 9 (26.5%) 11 (32.4%) 34 (100%) Sex Male 4 (22.2%) 2 (11.1%) 2 (11.1%) 10 (55.6%) 18 (52.9%) 0.015 Female 6 (37.5%) 2 (12.5%) 7(43.8%) 1 (6.3%) 16 (47.1%) Total 10 (29.4%) 4 (11.8%) 9 (26.5%) 11 (32.4%) 34 (100%) Smoking Yes 5 (26.3%) 2 (105%) 3 (15.8%) 9 (47.4%) 19 (55.9%) 0.168 Not 5 (33.3%) 2 (13.3%) 6 (40%) 2 (13.3%) 15 (44.1%) Total 10 (29.4%) 4 (11.8%) 9 (26.5%) 11 (32.4%) 34 (100%) Hypertension Yes 3 (20%) 2 (13.3%) 1 (67%) 9 (60%) 15 (44.1%) 0.011 Not 7 (36.8%) 2 (10.5%) 8 (42.1%) 2 (10.5%) 19 (55.9%) Total 10 (29.4%) 4 (11.8%) 9 (26.5%) 11 (32.4%) 34 (100%) Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8594474","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":592707646,"identity":"fc133e4f-bd7c-47da-aec2-c24913959a55","order_by":0,"name":"Andreas Klemens","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFUlEQVRIiWNgGAWjYHACAzDBB+HY1PeDqIQCIrSwQThpjDMbQFoMiNdymHHDAbggdsA/u3nbhw81dcZs7N2Jjwv+MDMbn1+d+OGBAYM8v9gBrFok7hwrnjnj2GEzNp6zm41ntrGxmd14u1kC6DDDmbMTsFtzI8eYmYftgA2bRO42ad4GHh6zG2c3gLQkGNzGrkUepOXPvzobNvm323/z/JGQMJ5xdvMPfFoMQFoY25jN2CR4twGtMzAw4O/dhtcWwxtpxYy9fYeN2XhyN0vztiUkSNzg3WaRYCCB0y9yN5I3M/z4VmfYz35242eeP/8T+PvPbr75o8JGnl8ah/cxgQRYpQSxykGA/wApqkfBKBgFo2AEAABkAV0SC9Mn7AAAAABJRU5ErkJggg==","orcid":"","institution":"Padjadjaran University","correspondingAuthor":true,"prefix":"","firstName":"Andreas","middleName":"","lastName":"Klemens","suffix":""},{"id":592707647,"identity":"37eadeea-7e41-4c43-975f-518d5269a7ca","order_by":1,"name":"Hilman -","email":"","orcid":"","institution":"Padjadjaran University","correspondingAuthor":false,"prefix":"","firstName":"Hilman","middleName":"","lastName":"-","suffix":""},{"id":592707648,"identity":"d97357af-6050-491d-8429-f526410393ae","order_by":2,"name":"Dian Komala Dewi","email":"","orcid":"","institution":"Padjadjaran University","correspondingAuthor":false,"prefix":"","firstName":"Dian","middleName":"Komala","lastName":"Dewi","suffix":""},{"id":592707649,"identity":"a3b5d8e4-a71b-47cc-9f63-a7162eb43e79","order_by":3,"name":"Astri Astuti","email":"","orcid":"","institution":"Padjadjaran University","correspondingAuthor":false,"prefix":"","firstName":"Astri","middleName":"","lastName":"Astuti","suffix":""}],"badges":[],"createdAt":"2026-01-13 17:08:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8594474/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8594474/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106868572,"identity":"094a6032-6914-4b63-b34b-8e9d2d7154f6","added_by":"auto","created_at":"2026-04-14 09:29:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":673551,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8594474/v1/d37317da-4a57-44ef-bfea-3cbe4dedc590.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Correlation Between the Severity of Primary Mitral Regurgitation and Left Ventricular Ejection Fraction in Patients With Mitral Valve Prolapse Assessed by Cardiac Magnetic Resonance: A Cross-Sectional Study","fulltext":[{"header":"Background","content":"\u003cp\u003eWhen the mitral valve develops a structural abnormality, such as a prolapse, flail leaflet, or myxomatous degeneration, it causes blood to flow backwards during systole from the left ventricle into the left atrium. This condition is known as primary mitral regurgitation (MR).\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Primary MR represents one of the most clinically significant valvular disorders, as it imposes chronic volume overload on the heart, leading to progressive left ventricular remodeling and the development of heart failure.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eMore than 2-2.5\u0026nbsp;million Americans were affected with moderate-to-severe MR in 2000, and this number is expected to quadruple by 2030 as a result of longer life expectancy.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Importantly, primary MR often remains asymptomatic during its early stages, resulting in delayed diagnosis until the onset of heart failure symptoms or complications such as atrial fibrillation.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eClinically, patients with significant MR may present with dyspnea, fatigue, reduced exercise tolerance, or acute pulmonary edema during the decompensated phase.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Even in asymptomatic individuals with apparently maintained left ventricular ejection fraction (LVEF), the existence of substantial MR is linked to an elevated risk of long-term death.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eEpidemiologically, MR is one of the most prevalent valvular heart diseases worldwide. Population-based data from the Framingham Heart Study reported that moderate-to-severe MR affects approximately 2% of the adult population, with a marked increase in prevalence with age.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e In individuals aged\u0026thinsp;\u0026ge;\u0026thinsp;60 years, the prevalence of clinically significant MR may reach 9\u0026ndash;10%, making it the second most common valvular disease after aortic stenosis.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e The annual incidence of newly diagnosed significant MR has been estimated at 140\u0026ndash;150 cases per 100,000 population, with the highest rates observed in older adults.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eChronic regurgitant flow into the left atrium is the pathophysiological driver of primary MR, leading to a gradual overload of the left atrial and ventricular volumes.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e In the early stages, left ventricular systolic function may appear preserved or even supranormal due to compensatory mechanisms described by the Frank\u0026ndash;Starling law.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e However, sustained regurgitant volume eventually leads to eccentric ventricular dilation, increased wall stress, myocardial contractile dysfunction, and a progressive decline in LVEF, which is strongly associated with adverse clinical outcomes.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe severity of MR is a key determinant of hemodynamic burden and clinical decision-making. Quantitative assessment classifies MR into mild, moderate, and severe categories based on regurgitant volume (RVol) and regurgitant fraction (RF).\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Mild MR is defined by RVol\u0026thinsp;\u0026lt;\u0026thinsp;30 mL/beat and RF\u0026thinsp;\u0026lt;\u0026thinsp;20%, moderate MR by RVol 31\u0026ndash;60 mL/beat or RF 21\u0026ndash;40%, and severe MR by RVol\u0026thinsp;\u0026ge;\u0026thinsp;60 mL/beat or RF\u0026thinsp;\u0026ge;\u0026thinsp;40%.\u003csup\u003e11,14\u003c/sup\u003e These quantitative parameters provide objective markers of regurgitant burden and ventricular remodeling risk.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eWhen it comes to MR prognosis and treatment decisions, left ventricular ejection fraction is king.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Current international guidelines recommend consideration of mitral valve intervention in asymptomatic patients before LVEF declines below 60%, particularly in the presence of structural valve abnormalities.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e Once LVEF decreases below 30%, the operative risk of mitral valve surgery may exceed its potential benefits, highlighting the importance of early and accurate functional assessment.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eTransthoracic echocardiography remains the first-line imaging modality for evaluating MR severity and ventricular function; however, its accuracy may be limited in cases with eccentric or complex regurgitant jets and geometric assumptions.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e Because of its precise volumetric quantification, great repeatability, and high spatial and temporal resolution, CMR has become the gold standard for complete MR evaluation.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eFor a more accurate assessment of regurgitant severity and its effects on left ventricular remodeling, including changes in end-diastolic volume, end-systolic volume, stroke volume, and LVEF,\u003csup\u003e11,12,17\u003c/sup\u003e CMR permits direct quantification of RVol and RF through volumetric analysis and phase-contrast velocity mapping to measure aortic forward flow. regurgitation, and the functional effects on the ventricles, CMR is the method of choice.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003ePrevious studies have demonstrated strong associations between quantitatively assessed MR severity using CMR and adverse ventricular remodeling, systolic dysfunction, and clinical outcomes.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e CMR-derived parameters such as RVol and RF have been shown to outperform echocardiographic measures in predicting the need for surgical intervention and long-term prognosis.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e However, conflicting results regarding the correlation between MR severity and LVEF have been reported, particularly in patients with advanced ventricular dysfunction.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eNotably, while several studies have reported a significant correlation between MR severity and LVEF decline, other investigations have suggested that MR severity may not independently predict outcomes in patients with severely reduced LVEF, indicating that ventricular function itself may be the dominant prognostic determinant.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e This variability underscores the need for further studies using accurate quantitative imaging techniques in diverse populations.\u003c/p\u003e \u003cp\u003eTo date, no studies in Indonesia have specifically evaluated the correlation between primary mitral regurgitation severity and left ventricular ejection fraction in patients with mitral valve prolapse using Cardiac Magnetic Resonance. Therefore, this study aims to assess the relationship between quantitative MR severity and left ventricular systolic function using CMR in an Indonesian population, providing region-specific evidence to support imaging-based risk stratification and clinical decision-making.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eA cross-sectional analytic observational design was used in this investigation. From October 2021 through October 2025, researchers combined through the medical records of patients at Hasan Sadikin General Hospital in Bandung who had cardiac MRI exams for mitral valve prolapse.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePatients having a confirmed diagnosis of MVP based on earlier echocardiographic examination and who underwent CMR for additional assessment were included in the study population. Patients had to be 18 years old or older. In order to assess the severity of mitral regurgitation and left ventricular systolic function, patients were included in the study if full CMR data were available. Incomplete CMR imaging data, congenital cardiac disease, ischemic cardiomyopathy, previous mitral valve surgery or intervention, secondary mitral regurgitation, or substantial concurrent valvular illness are all grounds for patient exclusion.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCine steady-state free precession (SSFP) sequences were used for ventricular volumetric evaluation and phase-contrast velocity mapping for flow measurement in all CMR exams, which were conducted on a clinical MRI scanner according to a standardized cardiac MRI procedure. The left ventricular ejection fraction (LVEF) was determined using the conventional volumetric technique, and the volumes of the left ventricle, including the end-diastolic volume (EDV) and end-systolic volume (ESV), were quantified from short-axis cine pictures. The difference between EDV and ESV was used to determine stroke volume (SV).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eVolumetric analysis and aortic forward flow measurements were used to quantify the regurgitant fraction (RF) and regurgitant volume (RVol), which in turn evaluated the severity of primary mitral regurgitation. Using previously published quantitative CMR criteria, mitral regurgitation was classified as mild, moderate, or severe. Cardiovascular radiologists with extensive expertise evaluated and interpreted all CMR pictures without knowing any of the patients\u0026apos; medical history.\u003c/p\u003e\n\u003cp\u003eDescriptive variables including age, sex, history of hypertension, smoking status, and left ventricular functional parameters were summarized and presented in tabular form. Categorical variables were presented as frequencies and percentages.\u003c/p\u003e\n\u003cp\u003eThe Spearman rank correlation test was used to analyze the relationship between the severity of mitral regurgitation and the left ventricular ejection fraction. When the conditions for chi-square analysis were not satisfied, Fisher\u0026apos;s exact test was used to compare categorical variables. A statistically significant result was defined as a p-value less than 0.05. Version 22.0 of the Statistical Package for the Social Sciences (SPSS) was used to conduct the statistical analysis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was obtained from the Ethics Committee of Hasan Sadikin General Hospital, Bandung. This study did not involve direct patient contact, as all data were derived from medical records and imaging archives. The use of patient data was conducted after obtaining permission from the hospital\u0026rsquo;s Medical Records Department, and patient confidentiality was strictly maintained throughout the study.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of patients with MVP who received a CMR examination at Hasan Sadikin General Hospital were screened throughout the research period, which spanned from October 2021 to October 2025. All participants who met the inclusion and exclusion criteria were considered for the study. In Table 1 we can see a summary of the research population\u0026apos;s demographic and clinical details. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe mean age of the study subjects was in the late middle-age group, with no marked age difference across categories of LVEF. Male subjects constituted a slightly higher proportion compared with female subjects. Comorbid conditions, including hypertension and smoking history, were variably distributed among the study population. The baseline characteristics of the subjects according to LVEF categories (severely reduced, moderately reduced, mildly reduced, and normal) are presented in Table 1.\u003c/p\u003e\n\u003cp\u003eRegurgitant volume (RVol) and regurgitant fraction (RF) were used to objectively evaluate the main MR severity, which was shown by quantitative CMR analysis to span a broad range. Subjects were classified as having mild, moderate, or severe MR based on these factors, with the use of predetermined CMR cut-off values. A negative association between the severity of mitral regurgitation and left ventricular ejection fraction (LVEF) was found by correlation analysis, suggesting that a decrease in LVEF was related to higher degrees of mitral regurgitation (p \u0026lt; 0.05). Correlation analysis between primary mitral regurgitation severity and left ventricular ejection fraction was performed using the Spearman rank correlation test, as the variables were ordinal and not normally distributed. This correlation is summarized in Table 2.\u003c/p\u003e\n\u003cp\u003eThere was a notable variation in the distribution of LVEF between male and female patients (p \u0026lt; 0.05) when analyzing demographic data, which indicated a substantial link between sex and LVEF categories. Age was not shown to be the primary determinant of left ventricular systolic function changes in this research sample, as further investigation revealed no significant connection between age and LVEF categories (p \u0026gt; 0.05). With regard to clinical risk factors, no significant relationship was found between smoking history and LVEF categories (p \u0026gt; 0.05). Conversely, a significant association was observed between hypertension and LVEF categories, indicating that subjects with hypertension were more likely to have reduced LVEF compared with those without hypertension (p \u0026lt; 0.05). The relationship between sex, age, smoking, and hypertension with LVEF categories is presented in Table 3.\u003c/p\u003e\n\u003cp\u003eRegardless of age or smoking status, our results show that left ventricular systolic function is substantially related to CMR-derived quantitative evaluation of primary mitral regurgitation severity; however, sex and hypertension seem to be relevant determinants. These findings provide credence to the use of cardiac CMR as a reliable and objective tool for assessing the hemodynamic effects of primary mitral regurgitation in individuals suffering from mitral valve prolapse.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis research shows that in individuals with mitral valve prolapse (MVP), the left ventricular ejection fraction (LVEF) as measured by cardiac magnetic resonance (CMR) is negatively correlated with the severity of primary mitral regurgitation (MR). The severity of MR is increasing, as measured by the regurgitant fraction (RF) and the regurgitant volume (RVol), was associated with progressive impairment of left ventricular systolic function, supporting the concept that chronic volume overload plays a central role in ventricular remodeling and contractile dysfunction. These findings reinforce the hemodynamic relevance of quantitative MR assessment and highlight the value of CMR in evaluating the functional consequences of primary MR.\u003c/p\u003e \u003cp\u003eThe observed inverse relationship between MR severity and LVEF is consistent with established pathophysiological mechanisms. In the early stages of primary MR, increased preload resulting from regurgitant flow may preserve or even augment LVEF through the Frank\u0026ndash;Starling mechanism. However, persistent volume overload leads to eccentric left ventricular remodeling, increased wall stress, and progressive deterioration of myocardial contractility, ultimately resulting in reduced LVEF. CMR enables accurate quantification of ventricular volumes and regurgitant flow, allowing detection of subclinical ventricular dysfunction that may not be apparent using conventional imaging modalities.\u003c/p\u003e \u003cp\u003eOur findings are in agreement with previous studies demonstrating that quantitative CMR-derived MR parameters are closely linked to left ventricular remodeling and systolic dysfunction. There is an elevated risk of unfavorable ventricular remodeling and LVEF reduction during follow-up associated with greater RVol and RF values, according to previous findings. The risk of ventricular dysfunction and the need for intervention is increased when RVol is equal to or more than 60 mL or RF is equal to or greater than 40\u0026ndash;50%. The present study extends these observations by confirming this relationship specifically in an MVP population and within an Indonesian clinical setting, where data on CMR-based MR assessment remain limited.\u003c/p\u003e \u003cp\u003eThe absence of a significant association between age and LVEF in this study suggests that systolic dysfunction in primary MR is driven more by the hemodynamic burden of regurgitation than by age-related myocardial changes alone. This finding underscores the importance of disease severity rather than chronological age in determining ventricular performance. In contrast, hypertension showed a significant association with reduced LVEF, which may reflect the additive effect of increased afterload on an already volume-overloaded ventricle. Chronic hypertension can exacerbate myocardial stress, accelerate adverse remodeling, and contribute to earlier systolic dysfunction in patients with primary MR.\u003c/p\u003e \u003cp\u003eSex-related differences in LVEF categories were also observed, suggesting potential biological or clinical differences in disease progression between male and female patients. Previous studies have reported sex-specific variations in ventricular remodeling and outcomes in valvular heart disease, which may be related to differences in myocardial adaptation, hormonal influences, or referral patterns for advanced imaging and intervention. Smoking history, however, did not demonstrate a significant association with LVEF in this cohort, indicating that its impact on systolic function may be less pronounced than that of hemodynamic factors directly related to MR severity.\u003c/p\u003e \u003cp\u003eImportantly, the use of CMR in this study provides a robust and objective assessment of MR severity and ventricular function. Unlike echocardiography, which may be limited by acoustic windows, jet eccentricity, and operator dependency, CMR offers high reproducibility and accurate volumetric measurements. The ability to directly quantify RVol and RF using volumetric and phase-contrast techniques allows for a comprehensive evaluation of both the severity of regurgitation and its impact on ventricular remodeling. This is particularly relevant in MVP patients, where regurgitant jets are often complex and eccentric.\u003c/p\u003e \u003cp\u003eIt is important to recognize a number of constraints. Because it is retrospective and cross-sectional, it cannot evaluate changes in ventricular function over time or draw any conclusions about causality. Because CMR is used selectively in clinical practice, the sample size was quite small, which might impact the generalizability of the results. In addition, other factors that could influence LVEF, such as duration of regurgitation, medical therapy, and additional comorbidities, were not fully evaluated. Nevertheless, the findings provide valuable insights into the relationship between quantitative MR severity and ventricular function in a real-world clinical setting.\u003c/p\u003e \u003cp\u003eIn conclusion, this study confirms that increasing severity of primary MR is significantly associated with reduced LVEF in patients with MVP when assessed using CMR. Quantitative CMR parameters offer a reliable means of evaluating the hemodynamic burden of MR and its impact on ventricular function. These results support the integration of CMR into the diagnostic and follow-up strategies for patients with primary MR, particularly for risk stratification and optimization of intervention timing.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThere is a significant correlation between primary mitral regurgitation severity and left ventricular ejection fraction in patients with mitral valve prolapse as assessed by Cardiac Magnetic Resonance. CMR offers precise quantitative assessment and should be considered an essential imaging modality for comprehensive evaluation of mitral regurgitation.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the Ethics Committee of Dr. Hasan Sadikin General Hospital, Bandung (Approval No.: DP.04.03/D.XIV.6.5/617/2025). This study involved the use of anonymized secondary data obtained from medical records and did not involve direct interaction with human participants. The use of medical record data was permitted after obtaining authorization from the Head of the Medical Record Department.\u003c/p\u003e\n\u003cp\u003eaThis study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Due to the retrospective and cross-sectional nature of the study using anonymized data, the requirement for informed consent to participate was waived by the Ethics Committee.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request and subject to institutional regulations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no specific funding for this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAKW conceived and designed the study, wrote the research proposal, and participated in data collection. AKW, H, DKD, and AA performed data analysis and interpretation. AKW drafted the initial manuscript. All authors critically revised the manuscript for important intellectual content, read, and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to express their sincere appreciation to Universitas Padjadjaran and Dr. Hasan Sadikin General Hospital for providing ethical clearance to conduct this study. We also acknowledge the Medical Record Department for their assistance in data access.\u003c/p\u003e"},{"header":"References","content":"\u003col start=\"1\" type=\"1\"\u003e\n\u003cli\u003eTopilsky Y. Mitral Regurgitation: Anatomy, Physiology, and Pathophysiology-Lessons Learned From Surgery and Cardiac Imaging. Front Cardiovasc Med. 2020 May 29;7:84. doi: 10.3389/fcvm.2020.00084.\u003c/li\u003e\n\u003cli\u003eZoghbi WA, Adams D, Bonow RO, Enriquez-Sarano M, Foster E, Grayburn PA, et al. Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation: A Report from the American Society of Echocardiography Developed in Collaboration with the Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr. 2017;30(4):303\u0026ndash;371. doi: 10.1016/j.echo.2017.01.007.\u003c/li\u003e\n\u003cli\u003eNkomo VT, Gardin JM, Skelton TN, Gottdiener JS, Scott CG, Enriquez-Sarano M. Burden of valvular heart diseases: a population-based study. Lancet. 2006;368(9540):1005\u0026ndash;1011. doi:10.1016/S0140-6736(06)69208-8.\u003c/li\u003e\n\u003cli\u003eFiglioli G, Sticchi A, Christodoulou MN, Hadjidemetriou A, Amorim Moreira Alves G, De Carlo M, Praz F, Caterina R, Nikolopoulos GK, Bonovas S, Piovani D. Global Prevalence of Mitral Regurgitation: A Systematic Review and Meta-Analysis of Population-Based Studies. J Clin Med. 2025 Apr 16;14(8):2749. doi: 10.3390/jcm14082749.\u003c/li\u003e\n\u003cli\u003eParcha V, Patel N, Kalra R, Arora G, Booker KS, Arora P. Mortality due to mitral regurgitation among adults in the United States: 1999\u0026ndash;2018. Clin Proc. 2020;95(12):2633\u0026ndash;2643. doi: 10.1016/j.mayocp.2020.08.039.\u003c/li\u003e\n\u003cli\u003eDziadzko V, Dziadzko M, Medina-Inojosa JR, Benfari G, Michelena HI, Crestanello JA, et al. Outcome and undertreatment of mitral regurgitation: a community cohort study. Lancet. 2018;391(10124):960\u0026ndash;969. doi: 10.1016/S0140-6736(18)30473-2.\u003c/li\u003e\n\u003cli\u003eDel Forno, B., De Bonis, M., Agricola, E. et al. Mitral valve regurgitation: a disease with a wide spectrum of therapeutic options. Nat Rev Cardiol 17, 807\u0026ndash;827 (2020). https://doi.org/10.1038/s41569-020-0395-7.\u003c/li\u003e\n\u003cli\u003eTusa M, Popolo Rubbio A, Sisinni A, Borin A, Barletta M, Grasso C, Adamo M, Denti P, Giordano A, De Marco F, Bartorelli AL, Montorfano M, Godino C, Citro R, De Felice F, Mongiardo A, Monteforte I, Villa E, Petronio AS, Giannini C, Munaf\u0026ograve; AR, Crimi G, Tarantini G, Testa L, Tamburino C, Bedogni F; GIOTTO Registry. Prognostic Significance of Flail Mitral Leaflet in Transcatheter Edge-to-Edge Repair for Primary Mitral Regurgitation. Am J Cardiol. 2023 Aug 1;200:178-187. doi: 10.1016/j.amjcard.2023.05.045.\u003c/li\u003e\n\u003cli\u003eWells F. Carpentier\u0026apos;s Reconstructive Valve Surgery. Ann R Coll Surg Engl. 2011 May;93(4):330. doi: 10.1308/147870811X571929b.\u003c/li\u003e\n\u003cli\u003eBenfari G, Antoine C, Miller WL, Thapa P, Topilsky Y, Rossi A, Michelena HI, Pislaru S, Enriquez-Sarano M. Excess Mortality Associated With Functional Regurgitation Complicating Heart Failure With Reduced Ejection Fraction. Circulation. 2019 Jul 16;140(3):196-206. doi: 10.1161/CIRCULATIONAHA.118.038946.\u003c/li\u003e\n\u003cli\u003eGarg P, Swift AJ, Zhong L, Carlh\u0026auml;ll CJ, Ebbers T, Westenberg J, et al. Assessment of mitral valve regurgitation by cardiovascular magnetic resonance imaging. 2020; \u003cem\u003eNat Rev Cardiol\u003c/em\u003e 17,298\u0026ndash;312. doi: https://doi.org/10.1038/s41569-019-0305-z. \u003c/li\u003e\n\u003cli\u003eMyerson SG, d\u0026rsquo;Arcy J, Christiansen JP, Dobson LE, Mohiaddin R, Francis JM, et al. Determination of clinical outcome in mitral regurgitation with cardiovascular magnetic resonance quantitation. Circulation. 2016;133(23):2287\u0026ndash;2296. doi: https://doi.org/10.1161/CIRCULATIONAHA.115.017888.\u003c/li\u003e\n\u003cli\u003eKrieger EV, Lee J, Branch KR, Hamilton-Craig C. Quantitation of mitral regurgitation with cardiac magnetic resonance imaging: a systematic review. Heart. 2016;102(24):1864\u0026ndash;1870. doi: 10.1136/heartjnl-2015-309054.\u003c/li\u003e\n\u003cli\u003eUretsky S, Argulian E, Narula J, Wolff SD. Use of cardiac magnetic resonance imaging in assessing mitral regurgitation: current evidence. J Am Coll Cardiol. 2018;71(5):547\u0026ndash;563. doi: 10.1016/j.jacc.2017.12.009.\u003c/li\u003e\n\u003cli\u003eFidock B, Archer G, Barker N, McCann GP, Squire IB, Singh A, et al. Standard and emerging CMR methods for mitral regurgitation quantification. Int J Cardiol. 2021;331:316\u0026ndash;321. doi: 10.1016/j.ijcard.2021.01.066.\u003c/li\u003e\n\u003cli\u003eUretsky S, Gillam LD, Lang RM, Chaudhry FA, Argulian E, Supariwala A, et al. A comparative assessment of echocardiographic parameters for primary mitral regurgitation using MRI reference Standard. J Am Soc Echocardiogr. 2018;31(9):992\u0026ndash;1002. doi: 10.1016/j.echo.2018.04.006.\u003c/li\u003e\n\u003cli\u003eGarg P, Kidambi A, Swift AJ, Brown LAE, Mangion K, Dobson LE, et al. Cardiovascular magnetic resonance imaging in mitral valve disease. 2025;606\u0026ndash;18. doi: 10.1093/eurheartj/ehae801.\u003c/li\u003e\n\u003cli\u003ePenicka M, Vecera J, Mirica DC, Kotrc M, Kockova R, Tousek F, et al. Prognostic power of quantitative assessment of functional mitral regurgitation by cardiac magnetic resonance. Circ Cardiovasc Imaging. 2023;16(8):e015134. doi: https://doi.org/10.1161/CIRCIMAGING.122.015134. \u003c/li\u003e\n\u003cli\u003ePecini R, M\u0026oslash;ller DV, Torp-Pedersen C, Hassager C, K\u0026oslash;ber L. Relationship between mitral regurgitation and left ventricular ejection fraction as predictors of prognosis in heart failure. Eur J Heart Fail. 2011;13:1121\u0026ndash;1125. doi:https://doi.org/10.1093/eurjhf/hfr114.\u003c/li\u003e\n\u003cli\u003eVermes E, Altes A, Iacuzio L, Levy F, Bohbot Y, Renard C, Grigioni F, Mar\u0026eacute;chaux S, Tribouilloy C. The evolving role of cardiovascular magnetic resonance in the assessment of mitral valve prolapse. Front Cardiovasc Med. 2023 Mar 3;10:1093060. doi: 10.3389/fcvm.2023.1093060.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 Subject Characteristics, Mitral Regurgitation, and Left Ventricle Ejection Fraction\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"282\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 52.2642%;\"\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 36.6824%;\"\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36.6824%;\"\u003e\n \u003cp\u003eN = 34 n\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 54.5366%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 36.6824%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 54.5366%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 36.6824%;\"\u003e\n \u003cp\u003e18 (52.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 54.5366%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 36.6824%;\"\u003e\n \u003cp\u003e16 (47.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 54.5366%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 36.6824%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 54.5366%;\"\u003e\n \u003cp\u003e\u0026lt;50 years old\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 36.6824%;\"\u003e\n \u003cp\u003e12 (35.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 54.5366%;\"\u003e\n \u003cp\u003e\u0026gt;50 years old\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 36.6824%;\"\u003e\n \u003cp\u003e22 (64.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 54.5366%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSmoking\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNot\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 36.6824%;\"\u003e\n \u003cp\u003e19 (55.9%)\u003c/p\u003e\n \u003cp\u003e15 (44.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 54.5366%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHypertension\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNot\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 36.6824%;\"\u003e\n \u003cp\u003e15 (44.1%)\u003c/p\u003e\n \u003cp\u003e19 (55.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 91.219%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMitral Regurgitation Severity\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 54.5366%;\"\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 36.6824%;\"\u003e\n \u003cp\u003e12 (35.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 54.5366%;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 36.6824%;\"\u003e\n \u003cp\u003e8 (23.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 54.5366%;\"\u003e\n \u003cp\u003eSevere\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 36.6824%;\"\u003e\n \u003cp\u003e14 (41.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 91.219%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLeft Ventricle Ejection Fraction (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 54.5366%;\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 36.6824%;\"\u003e\n \u003cp\u003e10 (29.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 54.5366%;\"\u003e\n \u003cp\u003e\u003cem\u003eMildly reduced\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 36.6824%;\"\u003e\n \u003cp\u003e4 (11.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 54.5366%;\"\u003e\n \u003cp\u003e\u003cem\u003eModerately reduced\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 36.6824%;\"\u003e\n \u003cp\u003e9 (26.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 54.5366%;\"\u003e\n \u003cp\u003e\u003cem\u003eSeverely reduced\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 36.6824%;\"\u003e\n \u003cp\u003e11 (32.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2 Correlation between Mitral Regurgitation and Left Ventricle Ejection Fraction\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"498\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMitral Regurgitation Severity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"8\" style=\"width: 309px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLeft Ventricle Ejection Fraction\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cem\u003eNormal\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cem\u003eMildly reduced\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 88px;\"\u003e\n \u003cp\u003e\u003cem\u003eModerately reduced\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cem\u003eSeverely reduced\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 44px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 42px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e12 (35.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e37.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e37.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e8 (23.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eSevere\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e7.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e7.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e21.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e64.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e14 (41.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e29.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e11,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e26.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e32,4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e34 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 35px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e\u003cstrong\u003er Spearman\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eMR Severity and LVEF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e0.622\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 3 Correlation beetwen sex, age, smoking and hypertension and left ventricle ejection fraction\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"636\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariabl1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"9\" style=\"width: 444px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLeft Ventricle Ejection Fraction\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cem\u003eNormal\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cem\u003eMildly reduced\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cem\u003eModerately reduced\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cem\u003eSeverely reduced\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 222px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026lt;50 years old\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e6 (50.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 84px;\"\u003e\n \u003cp\u003e1 (8.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e4 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e1 (8.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e12 (35.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"3\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.090\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026gt;50 years old\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e4 (18.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 84px;\"\u003e\n \u003cp\u003e3 (13.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e5 (22.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e10 (45.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e22 (64.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 132px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e10 (29.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 84px;\"\u003e\n \u003cp\u003e4 (11.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e9 (26.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e11 (32.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e34 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 222px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 96px;\"\u003e\n \u003cp\u003e4 (22.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 84px;\"\u003e\n \u003cp\u003e2 (11.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e2 (11.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e10 (55.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e18 (52.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"3\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.015\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 96px;\"\u003e\n \u003cp\u003e6 (37.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 84px;\"\u003e\n \u003cp\u003e2 (12.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e7(43.8%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e1 (6.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e16 (47.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 96px;\"\u003e\n \u003cp\u003e10 (29.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 84px;\"\u003e\n \u003cp\u003e4 (11.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e9 (26.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e11 (32.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e34 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSmoking\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 96px;\"\u003e\n \u003cp\u003e5 (26.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 84px;\"\u003e\n \u003cp\u003e2 (105%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e3 (15.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e9 (47.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e19 (55.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"3\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.168\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003eNot\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 96px;\"\u003e\n \u003cp\u003e5 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 84px;\"\u003e\n \u003cp\u003e2 (13.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e6 (40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e2 (13.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e15 (44.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 96px;\"\u003e\n \u003cp\u003e10 (29.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 84px;\"\u003e\n \u003cp\u003e4 (11.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e9 (26.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e11 (32.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e34 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHypertension\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 96px;\"\u003e\n \u003cp\u003e3 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 84px;\"\u003e\n \u003cp\u003e2 (13.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e1 (67%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e9 (60%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e15 (44.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.011\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003eNot\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 96px;\"\u003e\n \u003cp\u003e7 (36.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 84px;\"\u003e\n \u003cp\u003e2 (10.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e8 (42.1%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e2 (10.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e19 (55.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 126px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 96px;\"\u003e\n \u003cp\u003e10 (29.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 84px;\"\u003e\n \u003cp\u003e4 (11.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e9 (26.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e11 (32.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e34 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Mitral regurgitation, Mitral valve prolapse, Left ventricular ejection fraction, Cardiac magnetic resonance","lastPublishedDoi":"10.21203/rs.3.rs-8594474/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8594474/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe increasing systolic dysfunction and persistent left ventricular volume overload caused by primary mitral regurgitation (MR) are symptoms of this prevalent valvular heart disease. LVEF decreases and ventricular remodeling occurs in individuals with MVP as the severity of regurgitation increases. Examining LVEF as measured by CMR in relation to the degree of primary mitral regurgitation was the major objective of this research.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe research team at Dr. Hasan Sadikin General Hospital used a cross-sectional design and ran the study from October 2021 to October 2025. The data was collected from the medical records of individuals who were 18 years old or older and had a diagnosis of MVP and had a CMR scan. Regurgitant volume and regurgitant fraction were used to measure the severity of mitral regurgitation, while left ventricular function was determined using LVEF. In order to assess the relationship between the variables, we used Spearman rank correlation analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe results showed that there was a strong negative relationship (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) between the severity of primary mitral regurgitation and LVEF, suggesting that lower LVEF was linked to more severe regurgitation.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eIn individuals with mitral valve prolapse, the severity of primary mitral regurgitation is significantly correlated with left ventricular ejection fraction as measured by CMR.\u003c/p\u003e","manuscriptTitle":"Correlation Between the Severity of Primary Mitral Regurgitation and Left Ventricular Ejection Fraction in Patients With Mitral Valve Prolapse Assessed by Cardiac Magnetic Resonance: A Cross-Sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-18 14:14:54","doi":"10.21203/rs.3.rs-8594474/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fb6730b4-0ee3-42ae-9ab9-6b263c68839c","owner":[],"postedDate":"February 18th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-14T09:28:07+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-18 14:14:54","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8594474","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8594474","identity":"rs-8594474","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}