Influence of catheter ablation for atrial fibrillation on atrial and ventricular functional mitral regurgitation

Abstract

Aims The purpose of this study was to compare the impact of catheter ablation on cardiac structural reverse remodelling and atrial (AFMR) and ventricular (VFMR) functional mitral regurgitation (MR), and the long‐term prognosis of patients with AFMR and VFMR. Methods and results The retrospective study included persistent AF patients who had AFMR (n = 136, left atrial (LA) volume index >30 mL/m2 and left ventricular (LV) ejection fraction ≥40%) or VFMR (n = 31, LV ejection fraction <40% or LV regional asynergy) and had undergone the initial AF ablation from April 2015 to December 2019. Baseline and 6 month follow‐up echocardiography were performed to assess MR, LA, and LV sizes. MR improvement after ablation was comparable in the AFMR (64%) and VFMR groups (52%, P = 0.20). Patients with AFMR improvement showed a greater decrease in left atrial volume after ablation than those without (amount of change: −11.4 ± 15.1 vs. −2.3 ± 21.1 mL/m2, P = 0.01). Patients with VFMR improvement showed a greater increase in LV ejection fraction than those without (amount of change: 28.5 ± 13.6% vs. 9.0 ± 14.8%, P = 0.001). The composite endpoint of all‐cause death and heart failure hospitalization during the 2 year follow‐up period was more frequently observed in the VFMR than in the AFMR group (22.6% vs. 3.7%, P < 0.0001). Patients with MR improvement after catheter ablation less frequently demonstrated the composite endpoint than those without (1.9% vs. 15.6%, P < 0.0001). Conclusions Atrial functional mitral regurgitation and VFMR improvement after ablation were associated with atrial and ventricular reverse remodelling, respectively. It is possible that long‐term prognosis is better in patients with AFMR than with VFMR, and in those with MR improvement than in those without.

Prognostic Impact of Severe Atrial Functional Tricuspid Regurgitation in Atrial Fibrillation Patients

“…Similar findings were also reported regarding functional mitral regurgitation in AF patients [ 32 ]. These results confirm that the benefit of rhythm strategy in AF patients may surpass that of symptomatic relief and extend to the improvement in morbi-mortality.…”

Outcomes of transcatheter edge‐to‐edge repair for atrial functional mitral regurgitation: A meta‐analysis of observational studies

“…Studies have reported reductions in vena contracta and effective regurgitant orifice area as well as improvements in MR severity after conducting rhythm control in those with AFMR secondary to AF. [33][34][35] This is attributed to the restoration of sinus rhythm exhibiting atrial reverse remodeling, thereby reducing the degree of annular dilatation. 34,35 The 2020 Japanese Circulation Society heart valve disease management guideline gives an IIa recommendation to consider catheter ablation in symptomatic patients with AF and severe functional MR if maintenance of sinus rhythm can be expected, but nothing regarding this is mentioned in American and European guidelines.…”

“…Studies have reported reductions in vena contracta and effective regurgitant orifice area as well as improvements in MR severity after conducting rhythm control in those with AFMR secondary to AF 33–35 . This is attributed to the restoration of sinus rhythm exhibiting atrial reverse remodeling, thereby reducing the degree of annular dilatation 34,35 .…”

“…[33][34][35] This is attributed to the restoration of sinus rhythm exhibiting atrial reverse remodeling, thereby reducing the degree of annular dilatation. 34,35 The 2020 Japanese Circulation Society heart valve disease management guideline gives an IIa recommendation to consider catheter ablation in symptomatic patients with AF and severe functional MR if maintenance of sinus rhythm can be expected, but nothing regarding this is mentioned in American and European guidelines. 9 The results from our study showed that TEER might be a reasonable, less invasive option for AFMR patients with chronic longpersistent AF and a high degree of LA dilation and atrial fibrosis who may be unlikely to benefit from catheter ablation.…”

Atrial functional mitral regurgitation: Insufficiently understood and recognized

“…14 In a cohort of 136 AFMR individuals who underwent atrial fibrillation ablation, MR decreased in 64%, and only in those patients the LA volume also decreased. 15 Patients who had sinus rhythm restored had less MR and more reduction in LA volume than those who did not. The extent of low-voltage areas in the LA thought to reflect left atrial fibrosis and correlated with less reduction in MR and LA volume, suggesting that in the presence of extensive low-voltage areas AFMR may not be improved by ablation even if sinus rhythm is restored.…”