Severe Atrial Functional Mitral Regurgitation

Mesi, Oltion; Gad, Mohamed M.; Crane, Alejandro Duran; Ramchand, Jay; Puri, Rishi; Layoun, Habib; Miyasaka, Rhonda; Gillinov, Marc; Wierup, Per; Griffin, Brian P.; Kapadia, Samir; Harb, Serge C.

doi:10.1016/j.jcmg.2021.02.008

Cited by 62 publications

(28 citation statements)

References 36 publications

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“…4,36,37 Clinical Implications AFMR has been etiologically attributed to atrial and annular dilation, with later studies also demonstrating an additional role of incomplete leaflet remodeling and atriogenic posterior leaflet tethering. 25,[38][39][40] The role of abnormal atrial mechanical function has not been previously examined. Our study included patients with established moderate or greater AFMR so we could not address the initial cause of the regurgitation.…”

Section: Atrial Dysfunction and Outcome In Afmrmentioning

confidence: 99%

Atrial Dysfunction in Significant Atrial Functional Mitral Regurgitation: Phenotypes and Prognostic Implications

Cramariuc

Alfraidi

Nagata

et al. 2023

Circ: Cardiovascular Imaging

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BACKGROUND: Atrial functional mitral regurgitation (AFMR) is associated with increased morbidity and mortality. Left atrial (LA) size and function in AFMR are poorly characterized. We aimed to assess LA function by reservoir strain (LASr) and estimated reservoir work (LAWr) and their impact on outcome in AFMR. METHODS: Consecutive patients at our institution between 2001 and 2019 and with significant (moderate or greater) AFMR were examined. LAWr was estimated as LASr×LA reservoir volume, and patients were grouped by median LASr and LAWr. Outcomes were all-cause death or heart failure hospitalizations. RESULTS: Five hundred fifteen AFMR patients were followed up for 5 (1–17) years. Patients had previously documented atrial fibrillation (AF; 37%), heart failure with preserved ejection fraction (HFpEF) without AF (24%), or both (HFpEF+AF, 39%). LA volume was largest in AF, while LA function parameters were most impaired in the combined HFpEF+AF group. During follow-up, patients with low LASr or LAWr had higher risk of death ( P <0.001) and heart failure hospitalization ( P <0.05). In Cox regression analyses, low LASr and LAWr, but not LA volume or left ventricular function, were associated with a higher risk of death (LASr: hazard ratio, 2.3 [95% CI, 1.6–3.5]; LAWr: hazard ratio, 3.4 [95% CI, 2.4–4.9]; both P <0.001) after adjustment for clinical and echocardiographic confounders. Low LASr and LAWr were strongest associated with death in HFpEF and HFpEF+AF. CONCLUSIONS: LA reservoir function but not LA size is a robust predictor of outcome in significant AFMR. This provides mechanistic insights into the interplay of functional versus geometric LA changes in AFMR.

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Section: Atrial Dysfunction and Outcome In Afmrmentioning

confidence: 99%

Atrial Dysfunction in Significant Atrial Functional Mitral Regurgitation: Phenotypes and Prognostic Implications

Cramariuc

Alfraidi

Nagata

et al. 2023

Circ: Cardiovascular Imaging

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“…7 Some authors have described a subform of AFMR that occurs as the result of a posteriorly located dilatation of the mitral annulus leading to a herniation of the annulus beyond the circumference of the ventricular myocardium, and a particularly strong tethering of the posterior leaflet, with the consequence of a posteriorly directed regurgitant jet. 4,[8][9][10] Several terms, such as "hamstringing" or "atriogenic MR", have been used to describe this configuration.…”

Section: Definition and Mechanismmentioning

confidence: 99%

“…In the so far largest published cohort study of severe AFMR patients with follow-up, it has been shown that these patients had worse overall survival, more heart failure hospitalizations (and more diastolic dysfunction), and underwent valve surgery less often than similarly aged patients with severe primary MR and normal LV function. 10 Recently, the results of percutaneous edge-to-edge repair in 126 patients with AFMR were published, with good procedural success and symptomatic improvement 13 ; however, whether this translates into improved prognosis cannot be currently determined.…”

Section: Treatment and Outcomesmentioning

confidence: 99%

Atrial functional mitral regurgitation: Insufficiently understood and recognized

Flachskampf¹

2022

Adv Clin Exp Med

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Atrial functional mitral regurgitation (AFMR) is a form of functional mitral regurgitation that is still insufficiently recognized and characterized. The driving cause of AFMR is atrial, not ventricular dilatation, usually due to long-standing atrial fibrillation, and often in association with left ventricular diastolic dysfunction and heart failure with preserved ejection fraction (HFpEF). An increase in mitral annular area leads to a loss of central coaptation of the leaflets, often resulting in an "override" configuration and flattening of the annulus, as well as a loss of annular contraction. The left ventricle (LV) has a normal size; thus, there is usually only minor tenting of the leaflets. The regurgitant jet is mostly central, although posterior jet direction also occurs, frequently in a subform with posterior leaflet tethering and a marked localized dilatation of the posterior annulus. Because of the normal-sized and normally or nearly normally contracting LV, the amount of regurgitation is typically not more than moderate (or moderate-to-severe). Over time, functional mitral regurgitation may become mixed atrial and ventricular, with remodeling of the LV. However, the time course and the relation to symptoms have yet to be elucidated. This review presents current concepts and published insights into this form of mitral regurgitation.

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“…[3] This is termed atrial FMR, which is linked to a worse outcome. [4,5] With the rapid development of transcatheter solutions, there is a growing need to understand the mechanism underlying atrial mitral regurgitation (MR) in order to determine appropriate management solutions.…”

Section: Introductionmentioning

confidence: 99%

Assessment of mitral valve geometry in nonvalvular atrial fibrillation patients with or without ventricular dysfunction: insights from high volume rate three- dimensional transesophageal echocardiography

Bai

Chen

Zhong

et al. 2023

Preprint

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Aims Meticulous understanding of the mechanisms underpinning mitral regurgitation in atrial fibrillation (AF) patients is crucial to optimize therapeutic strategies. The morphologic characteristics of mitral valves in atrial functional mitral regurgitation (FMR) patients with and without left ventricular (LV) dysfunction were evaluated by high volume rate (HVR) three-dimensional transesophageal echocardiography (3D-TEE).Methods and results Of 265 AF patients who underwent 3D-TEE, 68 were retrospectively selected, including 36 patients with AF, FMR, and preserved LV function (AFMR group) and 32 patients with AF, FMR, and LV dysfunction (VFMR group). In addition, 36 fever patients without heart disease were included in the control group. The left atrium (LA) was enlarged in the AFMR and VFMR groups compared with the control group. The mitral annulus (MA) in the AFMR group was enlarged and flattened compared with the control group and was smaller than in the VFMR group. The annulus area fraction was significantly diminished in the AFMR and VFMR groups, indicative of reduced MA contractility. The posterior mitral leaflet (PML) angle was smallest in the AFMR group and largest in the control group, whereas the distal anterior mitral leaflet angle did not significantly differ among the three groups.Conclusion HVR 3D-TEE improves the 3D temporal resolution greatly. LA remodeling causes expansion of the MA and reduced MA contractility, disruption of the annular saddle shape, and atriogenic PML tethering. Finally, atrial FMR occurs. Comparison of atrial FMR patients with and without LV dysfunction indicates that atriogenic PML tethering is an important factor that aggravates FMR.

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Severe Atrial Functional Mitral Regurgitation

Cited by 62 publications

References 36 publications

Atrial Dysfunction in Significant Atrial Functional Mitral Regurgitation: Phenotypes and Prognostic Implications

Atrial Dysfunction in Significant Atrial Functional Mitral Regurgitation: Phenotypes and Prognostic Implications

Atrial functional mitral regurgitation: Insufficiently understood and recognized

Assessment of mitral valve geometry in nonvalvular atrial fibrillation patients with or without ventricular dysfunction: insights from high volume rate three- dimensional transesophageal echocardiography

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