Research progress on atrial functional mitral regurgitation_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

HUANG Huowang ,  LI Peng , HAN Shen , LIN Li , LONG Jinting , LIU Guihua , LI Yaxiong , LI Hai'ou

Department of Cardiovascular Surgery, Yan'an Affiliated Hospital of Kunming Medical University, Kunming, 650000, P. R. China;

Corresponding author：

LI Peng, Email: 2417629480@qq.com

Keywords：

Atrial functional mitral regurgitation; atrial fibrillation; mitral regurgitation; review

DOI：

10.7507/1007-4848.202211097

Video：

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Abstract Full text Figures/Tables Video References Cited by

Atrial functional mitral regurgitation (AFMR) is mitral regurgitation in patients with atrial fibrillation (AF), whose left atrium (LA) is enlarged, the left ventricle is not enlarged or only slightly enlarged, the left ventricular ejection fraction is preserved, and the mitral valve itself has no apparent lesion. At present, the etiology, pathophysiology and mechanism of this disease have not been completely clear yet. Existing studies have found that the causes of AFMR mainly include AF, enlargement of LA and mitral annulus, destruction of mitral annular shape, inability of mitral valve remodeling to compensate for mitral annular expansion, and hamstringing of the posterior mitral leaflet by atriogenic tethering. AFMR is demonstrated to be associated with an increased risk of mortality and readmission due to heart failure. Therefore, it serves as a primary therapeutic target for patients with heart failure and AF. However, the optimal treatment of AFMR still remains controversial. Therefore, this article will mainly expound the current definition, etiology, pathophysiological mechanism, treatment, and prognosis of AFMR.

Citation： HUANG Huowang, LI Peng, HAN Shen, LIN Li, LONG Jinting, LIU Guihua, LI Yaxiong, LI Hai'ou. Research progress on atrial functional mitral regurgitation. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2024, 31(9): 1369-1375. doi: 10.7507/1007-4848.202211097 Copy

1.	Nkomo VT, Gardin JM, Skelton TN, et al. Burden of valvular heart diseases: A population-based study. Lancet, 2006, 368(9540): 1005-1011.
2.	Enriquez-Sarano M, Akins CW, Vahanian A. Mitral regurgitation. Lancet, 2009, 373(9672): 1382-1394.
3.	Gertz ZM, Raina A, Saghy L, et al. Evidence of atrial functional mitral regurgitation due to atrial fibrillation: Reversal with arrhythmia control. J Am Coll Cardiol, 2011, 58(14): 1474-1481.
4.	Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol, 2017, 70(2): 252-289.
5.	Abe Y, Akamatsu K, Ito K, et al. Prevalence and prognostic significance of functional mitral and tricuspid regurgitation despite preserved left ventricular ejection fraction in atrial fibrillation patients. Circ J, 2018, 82(5): 1451-1458.
6.	Takahashi Y, Abe Y, Sasaki Y, et al. Mitral valve repair for atrial functional mitral regurgitation in patients with chronic atrial fibrillation. Interact Cardiovasc Thorac Surg, 2015, 21(2): 163-168.
7.	Machino-Ohtsuka T, Seo Y, Ishizu T, et al. Novel mechanistic insights into atrial functional mitral regurgitation: 3-dimensional echocardiographic study. Circ J, 2016, 80(10): 2240-2248.
8.	Kagiyama N, Hayashida A, Toki M, et al. Insufficient leaflet remodeling in patients with atrial fibrillation: Association with the severity of mitral regurgitation. Circ Cardiovasc Imaging, 2017, 10(3): e005451.
9.	Liang JJ, Silvestry FE. Mechanistic insights into mitral regurgitation due to atrial fibrillation: "Atrial functional mitral regurgitation". Trends Cardiovasc Med, 2016, 26(8): 681-689.
10.	Silbiger JJ. Mechanistic insights into atrial functional mitral regurgitation: Far more complicated than just left atrial remodeling. Echocardiography, 2019, 36(1): 164-169.
11.	Otsuji Y, Kumanohoso T, Yoshifuku S, et al. Isolated annular dilation does not usually cause important functional mitral regurgitation: Comparison between patients with lone atrial fibrillation and those with idiopathic or ischemic cardiomyopathy. J Am Coll Cardiol, 2002, 39(10): 1651-1656.
12.	Vaziri SM, Larson MG, Lauer MS, et al. Influence of blood pressure on left atrial size. The Framingham heart study. Hypertension, 1995, 25(6): 1155-1160.
13.	Sanfilippo AJ, Abascal VM, Sheehan M, et al. Atrial enlargement as a consequence of atrial fibrillation. A prospective echocardiographic study. Circulation, 1990, 82(3): 792-797.
14.	Wozakowska-Kapłon B. Changes in left atrial size in patients with persistent atrial fibrillation: A prospective echocardiographic study with a 5-year follow-up period. Int J Cardiol, 2005, 101(1): 47-52.
15.	Tanimoto M, Pai RG. Effect of isolated left atrial enlargement on mitral annular size and valve competence. Am J Cardiol, 1996, 77(9): 769-774.
16.	Ho SY. Anatomy of the mitral valve. Heart, 2002, 88 Suppl 4(Suppl 4): iv5- iv10.
17.	Levy MJ, Edwards JE. Anatomy of mitral insufficiency. Prog Cardiovasc Dis, 1962, 5: 119-44.
18.	Angelini A, Ho SY, Anderson RH, et al. A histological study of the atrioventricular junction in hearts with normal and prolapsed leaflets of the mitral valve. Br Heart J, 1988, 59(6): 712-716.
19.	Chazan JA. The CIBA collection of medical illustrations. JAMA, 1974, 227(9):1065.
20.	Akamatsu K, Abe Y, Matsumura Y, et al. Etiology of atrial functional mitral regurgitation: Insights from transthoracic echocardiography in 159 consecutive patients with atrial fibrillation and preserved left ventricular ejection fraction. Cardiology, 2020, 145(8): 511-521.
21.	Ito K, Abe Y, Takahashi Y, et al. Mechanism of atrial functional mitral regurgitation in patients with atrial fibrillation: A study using three-dimensional transesophageal echocardiography. J Cardiol, 2017, 70(6): 584-590.
22.	Chaput M, Handschumacher MD, Tournoux F, et al. Mitral leaflet adaptation to ventricular remodeling: Occurrence and adequacy in patients with functional mitral regurgitation. Circulation, 2008, 118(8): 845-852.
23.	Dal-Bianco JP, Aikawa E, Bischoff J, et al. Active adaptation of the tethered mitral valve: Insights into a compensatory mechanism for functional mitral regurgitation. Circulation, 2009, 120(4): 334-342.
24.	Saito C, Minami Y, Arai K, et al. Prevalence, clinical characteristics, and outcome of atrial functional mitral regurgitation in hospitalized heart failure patients with atrial fibrillation. J Cardiol, 2018, 72(4): 292-299.
25.	Dziadzko V, Dziadzko M, Medina-Inojosa JR, et al. Causes and mechanisms of isolated mitral regurgitation in the community: Clinical context and outcome. Eur Heart J, 2019, 40(27): 2194-2202.
26.	Kim K, Kitai T, Kaji S, et al. Outcomes and predictors of cardiac events in medically treated patients with atrial functional mitral regurgitation. Int J Cardiol, 2020, 316: 195-202.
27.	Vahanian A, Beyersdorf F, Praz F, et al. 2021 ESC/EACTS guidelines for the management of valvular heart disease: Developed by the Task Force for the Management of valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Rev Esp Cardiol (Engl Ed), 2022, 75(6): 524.
28.	Saito C, Minami Y, Hagiwara N. Treatment options for the management of atrial functional mitral regurgitation. Heart, 2021, 107(18): 1448-1449.
29.	Andrade JG, Wells GA, Deyell MW, et al. Cryoablation or drug therapy for initial treatment of atrial fibrillation. N Engl J Med, 2021, 384(4): 305-315.
30.	Deferm S, Bertrand PB, Verbrugge FH, et al. Atrial functional mitral regurgitation: JACC review topic of the week. J Am Coll Cardiol, 2019, 73(19): 2465-2476.
31.	Izumi C, Eishi K, Ashihara K, et al. JCS/JSCS/JATS/JSVS 2020 guidelines on the management of valvular heart disease. Circ J, 2020, 84(11): 2037-2119.
32.	Shibata T, Takahashi Y, Fujii H, et al. Surgical considerations for atrial functional regurgitation of the mitral and tricuspid valves based on the etiological mechanism. Gen Thorac Cardiovasc Surg, 2021, 69(7): 1041-1049.
33.	Kilic A, Schwartzman DS, Subramaniam K, et al. Severe functional mitral regurgitation arising from isolated annular dilatation. Ann Thorac Surg, 2010, 90(4): 1343-1345.
34.	Vohra HA, Whistance RN, Magan A, et al. Mitral valve repair for severe mitral regurgitation secondary to lone atrial fibrillation. Eur J Cardiothorac Surg, 2012, 42(4): 634-637.
35.	Sakaguchi T, Totsugawa T, Orihashi K, et al. Mitral annuloplasty for atrial functional mitral regurgitation in patients with chronic atrial fibrillation. J Card Surg, 2019, 34(9): 767-773.
36.	Balogh Z, Mizukami T, Bartunek J, et al. Mitral valve repair of atrial functional mitral regurgitation in heart failure with preserved ejection fraction. J Clin Med, 2020, 9(11): 3432.
37.	Sakon, Y, Takahashi, Y, Fujii, H, et al. Mitral valve repair with patch augmentation for atrial functional mitral regurgitation complicated with giant left atrium. Gen Thorac Cardiovas, 2022, 71(2): 104-112.
38.	Kaneyuki D, Nakajima H, Asakura T, et al. The change in the mitral-septal angle after surgery for atrial functional mitral regurgitation. Gen Thorac Cardiovasc Surg, 2021, 69(1): 1-7.
39.	Matsumori M, Kawashima M, Aihara T, et al. Efficacy of left atrial plication for atrial functional mitral regurgitation. Gen Thorac Cardiovasc Surg, 2021, 69(3): 458-465.
40.	Nagaura T, Hayashi A, Yoshida J, et al. Percutaneous edge-to-edge repair for atrial functional mitral regurgitation: A real-time 3-dimensional transesophageal echocardiography study. JACC Cardiovasc Imaging, 2019, 12(9): 1881-1883.

1. Nkomo VT, Gardin JM, Skelton TN, et al. Burden of valvular heart diseases: A population-based study. Lancet, 2006, 368(9540): 1005-1011.
2. Enriquez-Sarano M, Akins CW, Vahanian A. Mitral regurgitation. Lancet, 2009, 373(9672): 1382-1394.
3. Gertz ZM, Raina A, Saghy L, et al. Evidence of atrial functional mitral regurgitation due to atrial fibrillation: Reversal with arrhythmia control. J Am Coll Cardiol, 2011, 58(14): 1474-1481.
4. Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol, 2017, 70(2): 252-289.
5. Abe Y, Akamatsu K, Ito K, et al. Prevalence and prognostic significance of functional mitral and tricuspid regurgitation despite preserved left ventricular ejection fraction in atrial fibrillation patients. Circ J, 2018, 82(5): 1451-1458.
6. Takahashi Y, Abe Y, Sasaki Y, et al. Mitral valve repair for atrial functional mitral regurgitation in patients with chronic atrial fibrillation. Interact Cardiovasc Thorac Surg, 2015, 21(2): 163-168.
7. Machino-Ohtsuka T, Seo Y, Ishizu T, et al. Novel mechanistic insights into atrial functional mitral regurgitation: 3-dimensional echocardiographic study. Circ J, 2016, 80(10): 2240-2248.
8. Kagiyama N, Hayashida A, Toki M, et al. Insufficient leaflet remodeling in patients with atrial fibrillation: Association with the severity of mitral regurgitation. Circ Cardiovasc Imaging, 2017, 10(3): e005451.
9. Liang JJ, Silvestry FE. Mechanistic insights into mitral regurgitation due to atrial fibrillation: "Atrial functional mitral regurgitation". Trends Cardiovasc Med, 2016, 26(8): 681-689.
10. Silbiger JJ. Mechanistic insights into atrial functional mitral regurgitation: Far more complicated than just left atrial remodeling. Echocardiography, 2019, 36(1): 164-169.
11. Otsuji Y, Kumanohoso T, Yoshifuku S, et al. Isolated annular dilation does not usually cause important functional mitral regurgitation: Comparison between patients with lone atrial fibrillation and those with idiopathic or ischemic cardiomyopathy. J Am Coll Cardiol, 2002, 39(10): 1651-1656.
12. Vaziri SM, Larson MG, Lauer MS, et al. Influence of blood pressure on left atrial size. The Framingham heart study. Hypertension, 1995, 25(6): 1155-1160.
13. Sanfilippo AJ, Abascal VM, Sheehan M, et al. Atrial enlargement as a consequence of atrial fibrillation. A prospective echocardiographic study. Circulation, 1990, 82(3): 792-797.
14. Wozakowska-Kapłon B. Changes in left atrial size in patients with persistent atrial fibrillation: A prospective echocardiographic study with a 5-year follow-up period. Int J Cardiol, 2005, 101(1): 47-52.
15. Tanimoto M, Pai RG. Effect of isolated left atrial enlargement on mitral annular size and valve competence. Am J Cardiol, 1996, 77(9): 769-774.
16. Ho SY. Anatomy of the mitral valve. Heart, 2002, 88 Suppl 4(Suppl 4): iv5- iv10.
17. Levy MJ, Edwards JE. Anatomy of mitral insufficiency. Prog Cardiovasc Dis, 1962, 5: 119-44.
18. Angelini A, Ho SY, Anderson RH, et al. A histological study of the atrioventricular junction in hearts with normal and prolapsed leaflets of the mitral valve. Br Heart J, 1988, 59(6): 712-716.
19. Chazan JA. The CIBA collection of medical illustrations. JAMA, 1974, 227(9):1065.
20. Akamatsu K, Abe Y, Matsumura Y, et al. Etiology of atrial functional mitral regurgitation: Insights from transthoracic echocardiography in 159 consecutive patients with atrial fibrillation and preserved left ventricular ejection fraction. Cardiology, 2020, 145(8): 511-521.
21. Ito K, Abe Y, Takahashi Y, et al. Mechanism of atrial functional mitral regurgitation in patients with atrial fibrillation: A study using three-dimensional transesophageal echocardiography. J Cardiol, 2017, 70(6): 584-590.
22. Chaput M, Handschumacher MD, Tournoux F, et al. Mitral leaflet adaptation to ventricular remodeling: Occurrence and adequacy in patients with functional mitral regurgitation. Circulation, 2008, 118(8): 845-852.
23. Dal-Bianco JP, Aikawa E, Bischoff J, et al. Active adaptation of the tethered mitral valve: Insights into a compensatory mechanism for functional mitral regurgitation. Circulation, 2009, 120(4): 334-342.
24. Saito C, Minami Y, Arai K, et al. Prevalence, clinical characteristics, and outcome of atrial functional mitral regurgitation in hospitalized heart failure patients with atrial fibrillation. J Cardiol, 2018, 72(4): 292-299.
25. Dziadzko V, Dziadzko M, Medina-Inojosa JR, et al. Causes and mechanisms of isolated mitral regurgitation in the community: Clinical context and outcome. Eur Heart J, 2019, 40(27): 2194-2202.
26. Kim K, Kitai T, Kaji S, et al. Outcomes and predictors of cardiac events in medically treated patients with atrial functional mitral regurgitation. Int J Cardiol, 2020, 316: 195-202.
27. Vahanian A, Beyersdorf F, Praz F, et al. 2021 ESC/EACTS guidelines for the management of valvular heart disease: Developed by the Task Force for the Management of valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Rev Esp Cardiol (Engl Ed), 2022, 75(6): 524.
28. Saito C, Minami Y, Hagiwara N. Treatment options for the management of atrial functional mitral regurgitation. Heart, 2021, 107(18): 1448-1449.
29. Andrade JG, Wells GA, Deyell MW, et al. Cryoablation or drug therapy for initial treatment of atrial fibrillation. N Engl J Med, 2021, 384(4): 305-315.
30. Deferm S, Bertrand PB, Verbrugge FH, et al. Atrial functional mitral regurgitation: JACC review topic of the week. J Am Coll Cardiol, 2019, 73(19): 2465-2476.
31. Izumi C, Eishi K, Ashihara K, et al. JCS/JSCS/JATS/JSVS 2020 guidelines on the management of valvular heart disease. Circ J, 2020, 84(11): 2037-2119.
32. Shibata T, Takahashi Y, Fujii H, et al. Surgical considerations for atrial functional regurgitation of the mitral and tricuspid valves based on the etiological mechanism. Gen Thorac Cardiovasc Surg, 2021, 69(7): 1041-1049.
33. Kilic A, Schwartzman DS, Subramaniam K, et al. Severe functional mitral regurgitation arising from isolated annular dilatation. Ann Thorac Surg, 2010, 90(4): 1343-1345.
34. Vohra HA, Whistance RN, Magan A, et al. Mitral valve repair for severe mitral regurgitation secondary to lone atrial fibrillation. Eur J Cardiothorac Surg, 2012, 42(4): 634-637.
35. Sakaguchi T, Totsugawa T, Orihashi K, et al. Mitral annuloplasty for atrial functional mitral regurgitation in patients with chronic atrial fibrillation. J Card Surg, 2019, 34(9): 767-773.
36. Balogh Z, Mizukami T, Bartunek J, et al. Mitral valve repair of atrial functional mitral regurgitation in heart failure with preserved ejection fraction. J Clin Med, 2020, 9(11): 3432.
37. Sakon, Y, Takahashi, Y, Fujii, H, et al. Mitral valve repair with patch augmentation for atrial functional mitral regurgitation complicated with giant left atrium. Gen Thorac Cardiovas, 2022, 71(2): 104-112.
38. Kaneyuki D, Nakajima H, Asakura T, et al. The change in the mitral-septal angle after surgery for atrial functional mitral regurgitation. Gen Thorac Cardiovasc Surg, 2021, 69(1): 1-7.
39. Matsumori M, Kawashima M, Aihara T, et al. Efficacy of left atrial plication for atrial functional mitral regurgitation. Gen Thorac Cardiovasc Surg, 2021, 69(3): 458-465.
40. Nagaura T, Hayashi A, Yoshida J, et al. Percutaneous edge-to-edge repair for atrial functional mitral regurgitation: A real-time 3-dimensional transesophageal echocardiography study. JACC Cardiovasc Imaging, 2019, 12(9): 1881-1883.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Research progress on atrial functional mitral regurgitation

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