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Page 4 of 11 Spieker et al. Vessel Plus 2020;4:29 I http://dx.doi.org/10.20517/2574-1209.2020.28

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Figure 1. Consort diagram. Two hundred twenty-one patients with complete echocardiographic and follow-up data were included
in retrospect. In 93 patients, handgrip echocardiography was performed prior to the procedure. Of those 93 patients, 44 patients
presented with moderate MR at rest and dynamic severe MR during handgrip. Thirty-nine patients had severe MR already at rest.
However, 10 patients showed moderate MR at rest and during exercise, but nevertheless underwent MitraClip implantation because
of persistent severe symptoms. In addition, 128 patients with severe MR at rest were included, who did not undergo handgrip
echocardiography. MR: mitral regurgitation

Demographic and clinical data of the cohort are summarized in Table 1. Mean age was 75 ± 10 years, 36%
were female. One hundred ninety-six patients (89%) presented with NYHA functional class III or IV. Eighty
patients (36%) had DMR, while 141 patients (64%) presented with FMR [Table 2]. One hundred sixty-seven
[4]
patients (76%) fulfilled criteria for severe MR at rest according to current recommendations [Figure 1] .
The remaining patients presented with moderate MR at rest (n = 54, 24%). As expected, patients with
severe MR at rest displayed more pronounced elevations in NT-proBNP (P = 0.015) and had a higher
logistic EuroSCORE (P = 0.037) compared to patients with moderate MR and dynamic severe MR [Table 1].
Regarding echocardiographic parameters, LA area was larger in patients with severe MR at rest compared
to patients with dynamic MR [Table 2]. In addition, LVEF tended to be lower in patients with severe MR at
rest compared to patients with dynamic MR (46% ± 12% vs. 42% ± 13%; P = 0.053). Furthermore, SPAP was
numerically increased in patients with severe MR at rest compared to patients with dynamic MR, however,
without reaching statistical significance (47 ± 15 vs. 42 ± 12 mmHg; P = 0.345).

Handgrip exercise testing
Handgrip exercise resulted in a meaningful hemodynamic response. Heart rate increased from 67 ±
12 beats/min (bpm) at rest to 78 ± 14 bpm with handgrip exercise (P < 0.001). Systolic blood pressure
increased from 123 ± 21 mmHg at rest to 138 ± 23 mmHg with exercise (P < 0.001), and diastolic blood
pressure increased as well from 66 ± 14 mmHg to 73 ± 20 mmHg (P = 0.005). Rate pressure product