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Background In acute heart failure (AHF) with moderate-range ejection fraction (HFmrEF) the effect of mitral regurgitation (MR) is uncertain. Methods 103/440 consecutive patients in AHF had HFmrEF. They underwent bedside echocardiography within 24 hours of recruitment, prior to offloading, and were followed up for 2 years. The endpoint was all-cause mortality at 2 years. A novel proportionality index - where the effective regurgitant orifice is divided by the left ventricular end-diastolic volume (ERO/LVEDV)) - identified HFmrEF patients with disproportionate MR. Results 103/440 (23.4%) patients had HFmrEF with an average EF of 44.6±2.6%. 54.4% were male, with an average age of 80.5±11.4. 47.6% had a previous diagnosis of hypertension, 28.2% diabetes and 10.7% cerebrovascular disease. Patients did not present in shock, with average systolic/diastolic blood pressures of 141.7±26.2mmHg/ 78.5±19.3mmHg, nor did they primarily present with severe infections with mean CRP of 23.2±31.7. BNP at presentation was 1179.8±1028.5ng/L. Every patient had MR, 78/103 (75.7%) had MR quantifiable by PISA. 54/78 (69.2%) had disproportionate MR, defined by an ERO/LVEDV &amp;gt;0.14mm2/ml. When compared to proportionate MR, disproportionate MR in HFmrEF was associated with: greater LVEDV (136.3±53.6ml vs. 103.3±39.7ml [p=0.018]), greater mitral regurgitant volumes (41.8±18.5ml vs. 21.5±12.5ml [p&amp;lt;0.001]) and systolic pulmonary artery pressures (60.2±21.0mmHg vs. 48.0±14.7mmHg [p=0.012]) but not left-atrial size (30.2±7.1mm2 vs. 30.2±7.8mm2 [p=0.915]). Disproportionate MR in HFmrEF was also associated with worse 2-year outcome than proportionate MR – 40.1% vs. 16.7% (HR 2.30; 95% CI 1.02–5.17 [p=0.045]. Conclusion This is the first assessment of the effect of disproportionate volume loading secondary to MR in patients presenting in AHF with HFmrEF. Disproportionate MR was associated with worse outcome at 2 years. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Abbott

Disproportionate mitral regurgitation is associated with survival in acute heart failure with moderate range ejection fraction