Atrial Functional Mitral Regurgitation Research Articles

Qualitative and Quantitative Assessment of Atrial Functional Mitral Regurgitation: analysis from the REVEAL-AFMR registry.

The prevalence, characteristics, and prognosis of atrial functional mitral regurgitation (AFMR) based on severity remain unclear. No studies have systematically evaluated quantitative thresholds, such as effective regurgitant orifice area (EROA) or regurgitant volume, in relation to outcomes in AFMR. This multicenter study aimed to clarify the clinical implications of both qualitative and quantitative assessments of AFMR severity. In this first multicenter study across 26 centers, patients with at least moderate AFMR-defined by preserved left ventricular (LV) function, enlarged left atrium (LA), and absence of primary mitral valve changes-were retrospectively analyzed. AFMR severity was evaluated using a comprehensive approach, including EROA, regurgitant volume, and regurgitant fraction. Among 1,007 patients, 728 (72.3%) had moderate, 146 (14.5%) moderate-to-severe, and 133 (13.2%) severe AFMR. Age, sex, natriuretic peptide levels, and LV ejection fraction were similar across all groups. Patients with severe AFMR had longer atrial fibrillation history, worse heart failure symptoms, larger LV and LA, and more severe tricuspid regurgitation. AFMR severity was independently associated with a higher risk of death, heart failure hospitalization, and mitral valve intervention (HR 1.51, p=0.001 for moderate-to-severe, 2.80, p<0.001 for severe). Quantitative thresholds showed a significantly higher event risk with EROA ≥0.30, regurgitant volume ≥60 mL, and regurgitant fraction ≥50%. Severe AFMR was common and linked to greater atrial fibrillation burden, cardiac structural issues, and an increased risk of adverse clinical events. Quantitative thresholds offer valuable guidance for clinical decision-making and treatment planning.

Commentator Discussion: Durability of annuloplasty in patients with atrial functional mitral regurgitation associated with atrial fibrillation

Commentator Discussion: Durability of annuloplasty in patients with atrial functional mitral regurgitation associated with atrial fibrillation

Cutting-Edge Echocardiographic Tools for Enhanced Understanding and Management of Atrial Functional Mitral Regurgitation.

Cutting-Edge Echocardiographic Tools for Enhanced Understanding and Management of Atrial Functional Mitral Regurgitation.

Effect of severe tricuspid regurgitation on the prognosis of patients with atrial functional mitral regurgitation: the REVEAL-AFMR registry

Abstract Background Tricuspid regurgitation (TR) often coexists with atrial functional mitral regurgitation (AFMR), resulting from tricuspid annular dilatation by right atrial enlargement/dysfunction without balanced leaflet area enlargement. The clinical impact of TR coexisting with AFMR have not been well understood. Purpose We aimed to investigate the prevalence and prognostic value of TR coexisting with AFMR. Methods In 26 facilities in Japan, patients with AFMR defined with significant functional MR with dilated left atrium and preserved left ventricular ejection fraction were enrolled. The primary endpoint was all-cause death, and the secondary endpoints were the composite of all-cause death and re-hospitalization for HF readmission. Results We analyzed 829 cases (age 77±9 years, 55% male) with moderate or severe AFMR excluding moderate or greater valvular stenosis and severe valvular regurgitation. Of these, 14.5% (n=120) had severe TR. The prevalence of severe TR increased as the severity of AFMR worsened (Figure A). Patients with severe TR had a longer history of atrial fibrillation, elevated NT-proBNP levels, a higher rate of prior heart failure hospitalizations, and a higher rate of prescription of loop diuretics than those with non-severe TR. There were no significant differences in tricuspid annular plane systolic excursion (TAPSE) and right ventricular S′ between the groups. In a multivariate logistic regression analysis, existence of atrial fibrillation and its duration, and higher right atrial pressure were independent determinants of severe TR. Kaplan-Meier curves showed prognostic stratification by severe or non-severe TR for both all-cause mortality and the composite endpoints (p&amp;lt;0.001). Severe TR was significantly associated with both all-cause deaths and the composite endpoints after adjusted for covariates regardless of the severity of MR (adjusted hazard ratio (HR) 1.74 [95% confidence interval 1.05-2.87], p=0.031 for all-cause deaths and adjusted HR 1.54 [1.03-2.30], p=0.033 for the composite endpoints) (Figure B). Conclusion Severe TR was associated with increased adverse events in patients with AFMR, independently of the severity of MR.

Impact of left atrial size on outcomes in patients with atrial functional mitral regurgitation

Abstract Background Atrial functional mitral regurgitation (AFMR) is caused by mitral annular enlargement following left atrium (LA) enlargement because of atrial fibrillation and/or heart failure with preserved ejection fraction. However, the distribution and clinical impact of LA size are unknown. Purpose To assess the impact of LA volume index (LAVI) on clinical outcomes in patients with AFMR. Methods We investigated patients with ≥moderate AFMR from the REVEAL-AFMR registry. Patients with ≥moderate aortic valve diseases and/or missing LAVI were excluded. The primary endpoint was a composite of cardiovascular death and heart failure hospitalization. Results Of total 871 patients with AFMR (age 78 ± 9 years, men 45%, atrial fibrillation 80%, severe MR 28%), median LAVI was 75 [58-110] mL/m². LAVI &amp;lt;50, 50-99, 100-149, 150-199 and ≥200 mL/m² were present in 117 (13%), 48 (55%), 162 (19%), 61 (7%) and 48 (6%), respectively. In these subgroups, severe MR was present in 10%, 20%, 38%, 61%, and 69% (Figure A), and NYHA III or IV in 8%, 8%, 13%, 13% and 23%, respectively. During the median follow up of 2.9 [2.0-3.2] years, LAVI ≥200 and 150-199 mL/m² were associated with lower event-free survival compared with &amp;lt;50 mL/m² (Figure B) . In the multivariable analysis, LAVI ≥150 mL/m² was an independent risk factor of adverse events (adjusted hazard ratio [HR] 1.69; 95% CI 1.05-2.73, p=0.030), adjusted for age, sex, body mass index, severe symptoms, chronic kidney disease, anemia, severe MR and tricuspid regurgitation (TR). Variables associated with LAVI ≥150 mL/m² were atrial fibrillation (adjusted OR 5.95; 95% CI 1.79-19.8, p&amp;lt;0.01), severe MR (OR 3.99; 95% 2.49-6.39, p&amp;lt;0.01) , elevated PASP (OR 3.10; 95% 1.80-5.33, p&amp;lt;0.01) and TR (OR; 2.46 95% 1.43-4.21, p&amp;lt;0.01), left ventricular end-diastolic volume (adjusted OR 1.26 per 10mL; 95% 1.17-1.36, p&amp;lt;0.01). Conclusion LAVI was 50-99 mL/m² in nearly a half of patients with AFMR, but enlarged to ≥150 mL/m² in 13%. Patients with larger LAVI more frequently had severe symptoms. LAVI ≥150 mL/m² was associated with worse outcomes, independent of MR severity. Severe MR and left ventricular size were strongly associated with LA enlargement other than atrial fibrillation.Figure AFigure B

Clinical outcomes and impact of mitral valve surgery in atrial functional mitral regurgitation: the REVEAL-AFMR registry

Abstract Background The real-world impact and effective treatment strategies of atrial functional mitral regurgitation (AFMR) are poorly understood. The aim of this study was to investigate the prevalence, clinical characteristics, and the effectiveness of mitral valve surgery in AFMR. Methods The REal-world obserVational study for invEstigAting the prevaLence and therapeutic options for Atrial Functional Mitral Regurgitation (REVEAL-AFMR) was a retrospective cohort study conducted across 26 Japanese centers. All transthoracic echocardiography performed in 2019 were reviewed and patients with moderate or severe AFMR defined by preserved left ventricular function, dilated left atrium, and absence of degenerative valvular changes. The primary composite outcomes were heart failure hospitalization and all-cause mortality. Besides traditional multivariable regression analysis, propensity score-based time-zero matching was performed to account for immortal time bias. Results In 177,235 patients who underwent echocardiography, 8,867 had moderate or severe MR. Within this group, 1,007 were diagnosed with AFMR (mean age 78±10, 56% female, 80% atrial fibrillation). Of these, 113 underwent MV surgery, with 81% receiving concurrent tricuspid valve surgery. Patients who underwent surgery were younger but had more severe MR, larger left heart chambers, and a higher prevalence of heart failure than those who remained under medical therapy. During a median follow-up of 1050 days, 28% experienced the primary outcome, and 18% died. Despite a more severe disease status, only the surgical group showed a decrease in natriuretic peptide levels at follow-up and had significantly lower rate of the primary outcome (hazard ratio 0.43 [0.29-0.64], p&amp;lt;0.001 after adjustment for 25 covariates). Propensity score-based time-zero matching also indicated a lower risk of the primary outcome in the surgical group (hazard ratio 0.39 [0.20–0.78], p=0.007). Multiple sensitivity analyses yielded consistent results. Subgroup analysis suggested a significantly greater benefit of surgery for patients with severe MR than those with non-severe MR (p for interaction=0.044). Conclusions Our registry revealed that patients with AFMR are typically old with predominantly with atrial fibrillation, facing poor outcomes. MV surgery was associated with fewer adverse events, a finding that should be validated in future clinical trials.

DPdT &amp;gt;1200ms predicts greater and sustained drop in ejection fraction post mitral TEER

Abstract Background The maximum rate of left ventricular pressure rise (dP/dTmax) using a CW Doppler from a mitral regurgitation (MR) curve is a simple technique which can estimate myocardial contractility, with "normal" values &amp;gt;1200ms. This technique has not been applied to patients undergoing mitral transcatheter edge-to-edge repairs (M-TEER). Purpose Assess if dP/dT can predict post-procedural ejection fraction (EF). Methods A retrospective review of all M-TEER's performed from January 2011 – February 2023 at a single cardiac centre with an adequate MR CW Doppler to calculate the dP/dT as well as a subsequent TTE at the institution were included. An early TTE (performed day 1-50, average 34.9) and late TTE (goal 1 year, average 354 days) were recorded. Results A total of 155 M-TEER procedures were performed; 66 for degenerative MR (DMR), 11 for atrial functional MR (AFMR) and 78 for ventricular functional MR (VFMR). Baseline characteristics: overall EF 47.9% (DMR 61%, AFMR 52% and VFMR 32%). Age DMR 75.8y, AMFR 78.9y, VFMR 75.6y), overall 31.6% female (DMR 34.6%, AFMR 45.5%, VFMR 25.8%). Surprisingly the DMR cohort demonstrated a significant drop in EF post M-TEER of 5.1% (p&amp;lt;0.001, figure 1). This was most marked in the group with "normal" dP/dT of &amp;gt;1200ms (figure 2, DMR EF drop 7.8% p&amp;lt;0.001). This cohort remained at the new, lower value on follow up (figure 2). The EF in the VFMR remained severely impaired despite M-TEER (figure 1). There was no significant difference between EF pre or early post (p= 0.86). When divided into groups according to baseline dP/dT. The greatest drop in EF was again seen with an apparently normal dP/dT of &amp;gt;1200ms (figure 2). Conclusion "Normal" dP/dT of &amp;gt;1200ms in patients undergoing M-TEER is likely a marker of hyper-contractile LV function as a compensatory mechanism, and may predict a greater fall in EF post correction of MR.

Effect of radiofrequency ablation on improving cardiac structure and function in patients with atrial fibrillation and functional mitral regurgitation

Objective: Exploring the effect of radiofrequency ablation treatment to restore sinus rhythm on the improvement of functional mitral regurgitation (FMR) and cardiac structure in patients with atrial fibrillation combined with moderate or severe FMR, compared with drug therapy alone. Methods: This retrospective cohort study consecutively enrolled patients diagnosed with persistent atrial fibrillation and moderate or severe FMR who were admitted to the Third Affiliated Hospital of Sun Yat-sen University from January 2019 to December 2021. Forty-eight patients who were treated with radiofrequency ablation and maintained sinus rhythm were enrolled in the ablation group, and 63 patients who were treated with medication alone during the same period were in the medicine group. Patients in the ablation group and medicine group were matched in a 1∶1 ratio using a propensity score, and 41 patients were finally included in each of the 2 groups. All patients reexamined echocardiography after 3-month of treatment. The proportion of patients with FMR improvement and the differences in changes of cardiac structural and functional parameters were compared between groups. Results: After propensity score matching, the ablation group was aged (69.3±7.1) years with 21 males (51.2%) and the medicine group was aged (71.3±9.4) years with 21 males (51.2%). The echocardiography after 3-month of treatment showed the rate of FMR improvement was significantly higher in the ablation group than in the medicine group (19 (46.3%) vs. 33 (80.5%), P<0.001), and patients in the ablation group showed a significant decrease in FMR extent (Δmitral regurgitation area: (-1.30±2.64) cm2 vs. (-3.55±2.50) cm2, P<0.001), left atrial size (Δleft atrial diameter: (-0.17±3.78) mm vs. (-2.46±4.01) mm, P=0.009) and E/e' (ΔE/e':-2.54±7.34 vs.-6.34±7.08, P=0.021) compared with the medicine group. There was also a significant decrease in left ventricular size (Δleft ventricular end diastolic diameter: (-3.12±6.62) mm vs. (-0.73±3.62) mm, P=0.046) and significant increase in left ventricular ejection fraction (Δleft ventricular ejection fraction: (2.73±9.69) % vs. (-0.93±5.41) %, P=0.038) in ablation group. Conclusion: Performing radiofrequency ablation to restore sinus rhythm can effectively reduce the severity of mitral regurgitation and improve left atrial and left ventricular remodeling and cardiac function in patients with atrial fibrillation and FMR.

TCT-947 AltaValve Atrial Fixation System for Treatment of Severe Atrial Functional Mitral Regurgitation

TCT-947 AltaValve Atrial Fixation System for Treatment of Severe Atrial Functional Mitral Regurgitation

Additional left atrial plication improves postoperative cardiovascular events in atrial functional mitral regurgitation.

Left atrial (LA) plication is a procedure used to correct an LA that expands posteriorly due to remodeling. This study aimed to determine the efficacy of additional LA plication in reducing postoperative cardiovascular events (CVEs) after mitral valve (MV) repair in atrial functional mitral regurgitation (MR) patients. Between October 2008 and August 2023, MV repair with or without LA plication in 74 patients was studied. This study examined the efficacy of concomitant LA plication during MV repair. All patients underwent mitral annuloplasty. Of these, 26 underwent additional LA plication. In the mid-term periods, protruding posterior LA length in patients with LA plication was shorter than those without LA plication (2.8±0.49 vs. 3.3±0.72 cm, P=0.01). The percentage change in aortomitral angle from preoperative to mid-term periods in patients with LA plication was bigger than those without LA plication (1.04°±0.102° vs. 0.98°±0.084°, P=0.01). Posterior leaflet coaptation angle in patients with LA plication was smaller than those without LA plication (42°±15° vs. 76°±30°, P<0.001). A postoperative posterior leaflet coaptation angle of 101° had the maximum sum of sensitivity and specificity in predicting postoperative CVEs (96.9% and 76.9%, respectively). Patients with a postoperative posterior leaflet coaptation angle of 101° or higher had a poorer prognosis than those with an angle less than 101°, with an event-free rate of 18% vs. 80% at 7 years after surgery (P<0.0001). Additional LA plication might be useful in reducing postoperative CVEs in atrial functional MR patients.

Impact of residual mitral regurgitation after transcatheter edge-to-edge repair in atrial functional mitral regurgitation: Results from MITRA-PRO registry.

Transcatheter edge-to-edge repair (TEER) has emerged to address symptomatic atrial functional mitral regurgitation (aFMR) in patients who are at high operative risk. No clinical data is available on the impact of residual mitral regurgitation (MR) following TEER in aFMR compared to ventricular functional MR (vFMR). In the MITRA-PRO registry, 846 patients with FMR and MitraScore assessment for residual MR quantification were included (722 patients with vFMR and 124 patients with aFMR). Compared to vFMR similar procedural results in regard of residual MR following TEER were found in aFMR patients (MitraScore post TEER 2.5 ± 1.8 vs. 2.7 ± 1.9), while the amount of implanted TEER devices was increased in vFMR. 1-year survival was better in aFMR compared to vFMR regardless of relevant residual MR (MitraScore ≥ 4), while 1-year rehospitalization was comparable for both MR entities. Patients with aFMR and mild residual MR had a lower mortality rate (6.6% vs. 10.3%) and rehospitalization rate (29.1% vs. 46.2%) 1 year after mitral TEER. However, in contrast to vFMR a MitraScore ≥4 was no independent predictor of mortality in aFMR indicating a better tolerance toward residual MR. Residual MR is an independent predictor of 1-year mortality in vFMR patients, whereas in aFMR patients, a MitraScore of ≥4 is associated with higher mortality but is not an independent predictor in multivariate analysis. Therefore, minimizing MR through mitral TEER is crucial for survival in vFMR patients, while aFMR patients tolerate significant residual MR better 1 year after the procedure.

Adjuncts to annuloplasty in atrial functional mitral regurgitation.

Atrial fibrillation is the most common cardiac arrhythmia, leading to progressive dilation of cardiac chambers, abnormal contraction patterns of the atria and ventricles and, potentially, atrioventricular valvular insufficiency. Moreover, heart failure with preserved ejection fraction is often present and closely intertwined with disease initiation and progression. Surgical valve repair with a true-sized ring annuloplasty is a well-established treatment option in atrial functional mitral regurgitation. While early results are good, recent studies have brought the durability of this repair approach into question, highlighting the need for further refinement of the surgical strategy. In particular, repair strategies that simultaneously target the mitral valve as well as the left ventricle could provide improved repair durability.

Long-term Outcomes of Mitral Valve Repair for Atrial Functional Mitral Regurgitation

BackgroundAtrial functional mitral regurgitation (AFMR), defined by normal left ventricular function, enlarged left atrium, and a dilated mitral valve annulus, has been a concept discussed for >10 years. However, there are still no established guidelines for its treatment in the American College of Cardiology/American Heart Association recommendations. This study aimed to determine the long-term outcomes of mitral annuloplasty as a treatment for AFMR. MethodsWe analyzed 1435 patients who underwent mitral valve repair at our institution between 2005 and 2020, with 162 classified as having AFMR. Exclusion criteria for AFMR were established based on preoperative echocardiography and operative notes. The primary outcome was overall mortality, and the secondary outcome was MR recurrence, which was defined as moderate or greater mitral regurgitation observed on echocardiography during the follow-up period, analyzed using our hospital’s medical records and data from the National Statistical Office. ResultsThe median follow-up duration for the entire patient cohort was 6.1 years (interquartile range, 3.2-11.2 years). Patients had a 5-year survival rate of 86% and a 10-year survival rate of 73%, with freedom from MR recurrence rates of 89% and 80% at 5 and 10 years, respectively. Although all 162 patients had moderate or greater MR before surgery, most experienced trivial or mild MR after mitral valve repair throughout the follow-up period. ConclusionsIn summary, mitral valve repair effectively treats patients with AFMR, addressing survival and mitigating MR recurrence.

Atrial functional mitral regurgitation in cardiology and cardiac surgery.

Functional or secondary mitral regurgitation (MR) is a clear and present danger to cardiovascular health, with heightened morbidity and mortality rates. Secondary MR is caused by an imbalance between two sets of forces. There are two forces at play here. One keeps the mitral leaflets tethered, while the other closes them. The evidence clearly shows inadequate coaptation. Functional MR (FMR) is the typical form of MR. It is almost always caused by dysfunction and alterations of the left ventricle (LV) geometry. It occurs in both ischemic and non-ischemic disease states. Atrial FMR (AFMR) is a disease that has only recently come to be acknowledged. This phenomenon arises when mitral annular enlargement is caused by left atrial enlargement. This preserves the geometry and function of the LV. AFMR is most frequently encountered in individuals with chronic atrial fibrillation or heart failure, in whom a normal ejection fraction is present. Published studies and ongoing research vary in their definition of AFMR, but there is no doubt that AFMR exists. This review definitively explains the pathophysiology of AFMR and demonstrates the necessity of a common working standard for the definition of AFMR. This is essential to warrant cohesiveness in the data reported and to drive forward the much-needed research into the outcomes and treatment strategies in this critical field. A number of high-quality studies have demonstrated that restrictive mitral annuloplasty and transcatheter procedure based on edge-to-edge repair are effective in reducing MR and alleviating symptoms. The pathophysiology, echocardiographic diagnosis, and treatment of AFMR are thoroughly reviewed in this comprehensive review.

Atrial Functional Mitral Regurgitation: From Diagnosis to Current Interventional Therapies.

Mitral regurgitation (MR) is one of the most common valvular pathologies worldwide, contributing to the morbidity and mortality of several cardiovascular pathologies, including heart failure (HF). Novel transcatheter treatment for MR has given the opportunity for a safe and feasible alternative, to surgery, in order to repair the valve and improve patient outcomes. However, after the results of early transcatheter edge-to-edge repair (TEER) trials, it has become evident that subcategorizing the mitral regurgitation etiology and the left ventricular function, in patients due to undergo TEER, is of the essence, in order to predict responsiveness to treatment and select the most appropriate patient phenotype. Thus, a novel MR phenotype, atrial functional MR (AFMR), has been recently recognized as a distinct pathophysiological entity, where the etiology of the regurgitation is secondary to annular dilatation, in a diseased left atrium, with preserved left ventricular function. Recent studies have evaluated and compared the outcomes of TEER in AFMR with ventricular functional MR (VFMR), with the results favoring the AFMR. In specific, TEER in this patient substrate has better echocardiographic and long-term outcomes. Thus, our review will provide a comprehensive pathogenesis and mechanistic overview of AFMR, insights into the echocardiographic approach of such patients and pre-procedural planning, discuss the most recent clinical trials and their implications for future treatment directions, as well as highlight future frontiers of research in the setting of TEER and transcatheter mitral valve replacement (TMVR) in AFMR patients.

Clinical Outcomes of Mitral Valve Surgery in Atrial Functional Mitral Regurgitation in the REVEAL-AFMR Registry

The characteristics and treatment strategies of atrial functional mitral regurgitation (AFMR) are poorly understood. To investigate the prevalence, clinical characteristics, and outcomes of mitral valve (MV) surgery in AFMR. This retrospective cohort study, called the Real-World Observational Study for Investigating the Prevalence and Therapeutic Options for Atrial Functional Mitral Regurgitation (REVEAL-AFMR), was conducted across 26 Japanese centers (17 university hospitals, 1 national center, 3 public hospitals, and 5 private hospitals). All transthoracic echocardiography procedures performed from January 1 to December 31, 2019, were reviewed to enroll adult patients (aged ≥20 years) with moderate or severe AFMR, defined by preserved left ventricular function, a dilated left atrium, and an absence of degenerative valvular changes. Data were analyzed from May 8, 2023, to May 16, 2024. Mitral valve surgery, with or without tricuspid valve intervention. The primary composite outcome included heart failure hospitalization and all-cause mortality. In 177 235 patients who underwent echocardiography, 8867 had moderate or severe MR. Within this group, 1007 (11.4%) were diagnosed with AFMR (mean [SD] age, 77.8 [9.5] years; 55.7% female), of whom 807 (80.1%) had atrial fibrillation. Of these patients, 113 underwent MV surgery, with 92 (81.4%) receiving concurrent tricuspid valve surgery. Patients who underwent surgery were younger but had more severe MR (57.5% [n = 65] vs 9.4% [n = 84]; P < .001), a larger mean (SD) left atrial volume index (152.5 [97.8] mL/m2 vs 87.7 [53.1] mL/m2; P < .001), and a higher prevalence of heart failure (according to the New York Heart Association class III [marked limitation of physical activity] or class IV [symptoms of heart failure at rest], 26.5% [n = 30] vs 9.3% [n = 83]; P < .001) than those who remained under medical therapy. During a median follow-up of 1050 days (IQR, 741-1188 days), 286 patients (28.4%) experienced the primary outcome. Despite a more severe disease status, only the surgical group showed a decrease in natriuretic peptide levels at follow-up and had a significantly lower rate of the primary outcome (3-year event rates were 18.3% vs 33.3%; log-rank, P = .03). Statistical adjustments did not alter these findings. The findings of this cohort study suggest that in patients with AFMR, who were typically older and predominantly had atrial fibrillation, MV surgery was associated with lower rates of adverse clinical outcomes. Future studies are warranted to investigate a possible causal relationship to better regulate cardiovascular medicine.

Durability of annuloplasty in patients with atrial functional mitral regurgitation associated with atrial fibrillation

ObjectiveTo determine the durability of mitral valve repair (MVr) with complete ring or flexible band annuloplasty in patients with atrial functional mitral regurgitation (AFMR) due to atrial fibrillation (AF) and identify risk factors associated with postoperative recurrence of mitral regurgitation. MethodsBetween January 1, 2000, and January 1, 2023, 194 adults with a history of AF underwent MVr with annuloplasty alone for moderate/severe AFMR. Exclusion criteria were prior cardiac surgery, additional repair techniques, ejection fraction <45%, ischemic heart disease, aortic valve disease, mitral annular calcification, and concomitant procedures other than surgical ablation or tricuspid repair/replacement. The durability of annuloplasty was assessed using longitudinal analysis of postoperative echocardiographic data. ResultsComplete ring annuloplasty was performed in 126 of 194 patients (65%); partial ring (posterior band) in the other 68 (35%). Concomitantly, 124 of the 194 patients underwent tricuspid valve surgery, and 173 (89%) had a procedure for AF, including biatrial Cox-Maze III/IV lesion set in 152 (88%) and pulmonary vein isolation in 21 (12%). All patients were discharged with no/trace MR. Freedom from moderate/severe MR after repair with annuloplasty alone was 89% at 10 years, and no significant differences were noted between complete and partial ring annuloplasty (early, P = .41; late, P = .92). Forty-eight percent of patients developed AF at 3 months or longer after surgery, and the presence of postoperative AF was not associated with a greater likelihood of recurrence of MR (P = .15). Freedom from mitral reintervention was 96% at 10 years. ConclusionsIn appropriate patients with AFMR, the long-term durability of annuloplasty is excellent with complete ring and posterior band annuloplasty techniques.

Atrial Functional Mitral Regurgitation Subtypes Undergoing Transcatheter Edge-to-Edge Repair: Suboptimal Outcomes in Atriogenic Hamstringing.

Two subtypes of atrial functional mitral regurgitation (AFMR) have been described, one is characterized by Carpentier type I and the other by Carpentier type IIIb leaflet motion. The authors sought to analyze echocardiographic characteristics and outcomes of AFMR subtypes undergoing mitral valve transcatheter edge-to-edge repair (M-TEER). Of 1,047 consecutive patients who underwent M-TEER, the authors identified those with isolated mitral annulus dilation (Carpentier I), termed AFMR-IAD, and those with atriogenic hamstringing characterized by restricted posterior mitral leaflet motion (Carpentier IIIb), termed AFMR-AH. Echocardiographic baseline characteristics and outcomes up to 1-year were analyzed. A total of 128 patients (12.2%) met AFMR criteria; 75 (58.6%) were identified as AFMR-IAD and 53 (41.4%) as AFMR-AH. AFMR-AH displayed greater left atrial and left ventricular volumes, greater mitral annulus, shorter and steeper posterior mitral leaflet, and more pronounced MR (all P< 0.05). Technical success was achieved in 98.7% (AFMR-IAD) and 86.8% (AFMR-AH) of patients (P = 0.009). At discharge, device detachments were exclusively observed in AFMR-AH (10.0%). MR≤II was achieved in 95.6% and 78.6% at 30days (P=0.009) and in 93.0% and 74.1% at 1 year (P = 0.038) in patients with AFMR-IAD and AFMR-AH, respectively. AFMR-AH was associated with procedural failure (OR: 1.17 [95%CI: 1.00-1.38]; P = 0.045) at 30days (43.4% vs 24.0%; P = 0.023) and all-cause mortality (HR: 2.54 [95%CI: 1.09-5.91]; P = 0.031) at 1 year (77% vs 92%, Kaplan-Meier estimated 1-year survival; P = 0.017). AFMR-AH shows worse procedural and clinical outcomes following M-TEER than AFMR-IAD. Thus, vigilance regarding this pathology is warranted and alternative mitral valve therapies might need to be considered.

Impact on Outcome of Different Mechanisms, Baseline Degree and Changes of Mitral Regurgitation in Patients With Aortic Stenosis Who Underwent Transcatheter Aortic Valve Replacement.

Mitral regurgitation (MR) is frequent in patients with aortic stenosis (AS). Although primary MR is an established negative prognostic factor, whether different mechanisms of MR have different effects on outcome is currently unknown. The aim of this study was to evaluate the impact of the MR mechanism in patients undergoing transcatheter aortic valve replacement (TAVR). This is a retrospective observational study of patients who underwent TAVR for severe aortic stenosis in a high-volume tertiary care center. Echocardiographic comprehensive MR assessment was performed at baseline and within 3 months post TAVR. The study population was divided into 4 groups according to MR mechanism: Group I: fibro-calcific leaflet degeneration; Group II: prolapse/flail; Group III: ventricular secondary MR (functional MR); and Group IV: atrial functional MR. The study end point was a combination of death from cardiovascular cause and heart failure-related hospitalization. The study population included 427 patients (mean age 81.7±6.5 years; 71% primary MR; 62% ≥moderate MR). At 3-year follow-up, survival free from the composite end point significantly differs according to MR mechanism: it was higher in group IV (atrial functional MR, 96.6%) compared with group I (80.4%, P=0.002) and group II patients (60.7%, P=0.001), and group III (84.8%, P=0.037); patients with MR due to leaflet prolapse showed poorer prognosis compared with patients with functional MR (group III, P=0.023 and group IV, P=0.001) and with group I (P=0.040). Overall, severe MR after TAVR identified patients with poorer prognosis and was significantly more frequent in group II (46.4%, P=0.001). In patients undergoing TAVR, preprocedural identification of MR mechanism and mechanism provides prognostic insights.

Outcomes of maze procedure and mitral valve surgery in atrial functional mitral regurgitation: a retrospective study

BackgroundAtrial functional mitral regurgitation (AFMR) is a newly discovered condition associated with longstanding atrial fibrillation. This retrospective study aimed to analyze the outcomes of the maze procedure and mitral regurgitation (MR) surgery in AFMR and atrial fibrillation in comparison with those in degenerative MR (DMR).MethodsPatients who underwent mitral valve repair/replacement with a maze procedure at a hospital (July 2012–August 2021) were included. We excluded patients aged below 18 years undergoing concomitant coronary artery bypass grafting or atrial septal defect repair and those with MR etiology other than ARMR or DMR.ResultsWe included 35 patients with AFMR and 50 patients with DMR. Patient characteristics and postoperative outcomes were not significantly different between the two groups. Long-term outcomes revealed no significant differences in the ratio of cardiac mortality, stroke, or hospital readmission. However, after the maze procedure, the sinus rhythm restoration rate was significantly lower (62% vs. 28.5%, p < 0.001), a junctional rhythm state (p < 0.001) and permanent pacemaker insertion for sick sinus syndrome (SSS) (p = 0.03) were significantly more common in AFMR than DMR. On postoperative transthoracic echocardiography (TTE), the pulmonary artery systolic pressure was significantly less decreased in the AFMR group than in the DMR group compared with that on preoperative TTE (p = 0.04).ConclusionsAFMR showed excellent mitral valve surgery outcomes, similar to DMR, but had a significantly higher risk of pacemaker insertion for SSS after the maze procedure.