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Functional mitral regurgitation, updated: ventricular or atrial?

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Abstract

Lone atrial fibrillation (AF) can cause functional mitral regurgitation (MR), commonly referred to as “atrial functional MR (AFMR).” This type of MR has recently received much attention as an important cause of heart failure, and it represents a considerable therapeutic target in heart failure patients with AF. Mitral annular dilatation due to left atrial (LA) dilatation can be recognized as an original cause of AFMR, whereas the exact cascade of AFMR etiologies has not been established. AFMR is typically classified as Carpentier type I, and is likely to have a central jet. In contrast, a proportion of AFMR is classified as a combination of Carpentier type I for a flattened anterior mitral leaflet and Carpentier type IIIb for a tethered posterior mitral leaflet and is likely to have an eccentric jet directed toward the LA posterior wall. The traditional functional MR occurring in patients with left ventricular (LV) dilatation and/or systolic dysfunction, which is classified as Carpentier type IIIb, has since been designated “ventricular functional MR (VFMR)” to distinguish it from AFMR. Traditional VFMR, newly recognized AFMR, and their etiologic relations to LV/LA size and function are discussed in this review article.

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References

  1. Chugh SS, Havmoeller R, Narayanan K, et al. Worldwide epidemiology of atrial fibrillation: a Global Burden of Disease 2010 Study. Circulation. 2014;129:837–47.

    PubMed  Google Scholar 

  2. Krijthe BP, Kunst A, Benjamin EJ, et al. Projections on the number of individuals with atrial fibrillation in the European Union, from 2000 to 2060. Eur Heart J. 2013;34:2746–51.

    PubMed  PubMed Central  Google Scholar 

  3. Benjamin EJ, Blaha MJ, Chiuve SE, et al. Heart disease and stroke statistics—2017 update: a report from the American Heart Association. Circulation. 2017;135:e146–603.

    PubMed  PubMed Central  Google Scholar 

  4. Marijon E, Le Heuzey JY, Connolly S, et al. Causes of death and influencing factors in patients with atrial fibrillation: a competing-risk analysis from the randomized evaluation of long-term anticoagulant therapy study. Circulation. 2013;128:2192–201.

    CAS  PubMed  Google Scholar 

  5. Pokorney SD, Piccini JP, Stevens SR, et al. Cause of death and predictors of all-cause mortality in anticoagulated patients with nonvalvular atrial fibrillation: data from ROCKET AF. J Am Heart Assoc. 2016;5:e002197.

    PubMed  PubMed Central  Google Scholar 

  6. Gómez-Outes A, Lagunar-Ruíz J, Terleira-Fernández AI, et al. Causes of death in anticoagulated patients with atrial fibrillation. J Am Coll Cardiol. 2016;68:2508–21.

    PubMed  Google Scholar 

  7. Zakeri R, Chamberlain AM, Roger VL, et al. Temporal relationship and prognostic significance of atrial fibrillation in heart failure patients with preserved ejection fraction: a community-based study. Circulation. 2013;128:1085–93.

    PubMed  PubMed Central  Google Scholar 

  8. Ho JE, Gona P, Pencina MJ, et al. Discriminating clinical features of heart failure with preserved vs. reduced ejection fraction in the community. Eur Heart J. 2012;33:1734–41.

    PubMed  PubMed Central  Google Scholar 

  9. Wang TJ, Larson MG, Levy D, et al. Temporal relations of atrial fibrillation and congestive heart failure and their joint influence on mortality: the Framingham Heart Study. Circulation. 2003;107:2920–5.

    PubMed  Google Scholar 

  10. Kihara T, Gillinov AM, Takasaki K, et al. Mitral regurgitation associated with mitral annular dilation in patients with lone atrial fibrillation: an echocardiographic study. Echocardiography. 2009;26:885–9.

    PubMed  Google Scholar 

  11. 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;58:1474–81.

    PubMed  Google Scholar 

  12. 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;21:163–8.

    PubMed  Google Scholar 

  13. 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;70:584–90.

    PubMed  Google Scholar 

  14. 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;82:1451–8.

    PubMed  Google Scholar 

  15. Silbiger JJ. Mechanistic insights into atrial functional mitral regurgitation: far more complicated than just left atrial remodeling. Echocardiography. 2019;36:164–9.

    PubMed  Google Scholar 

  16. Ito K, Abe Y, Watanabe H, et al. Prognostic significance of residual functional mitral regurgitation in hospitalized heart failure patients with chronic atrial fibrillation and preserved ejection fraction after medical therapies. J Echocardiogr. 2018. https://doi.org/10.1007/s12574-018-0412-6.

    Article  PubMed  Google Scholar 

  17. 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;72:292–9.

    PubMed  Google Scholar 

  18. Trichon BH, Felker GM, Shaw LK, et al. Relation of frequency and severity of mitral regurgitation to survival among patients with left ventricular systolic dysfunction and heart failure. Am J Cardiol. 2003;91:538–43.

    PubMed  Google Scholar 

  19. Robbins JD, Maniar PB, Cotts W, et al. Prevalence and severity of mitral regurgitation in chronic systolic heart failure. Am J Cardiol. 2003;91:360–2.

    PubMed  Google Scholar 

  20. Grigioni F, Enriquez-Sarano M, Zehr KJ, et al. Ischemic mitral regurgitation: long-term outcome and prognostic implications with quantitative Doppler assessment. Circulation. 2001;103:1759–64.

    CAS  PubMed  Google Scholar 

  21. 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;39:1651–6.

    PubMed  Google Scholar 

  22. Park SM, Park SW, Casaclang-Verzosa G, et al. Diastolic dysfunction and left atrial enlargement as contributing factors to functional mitral regurgitation in dilated cardiomyopathy: data from the Acorn trial. Am Heart J. 2009;157(762):e3–10.

    Google Scholar 

  23. Furukawa A, Abe Y, Ito K, et al. Mechanisms of changes in functional mitral regurgitation by preload alterations. J Cardiol. 2018;71:570–6.

    PubMed  Google Scholar 

  24. Abe Y, Imai T, Ohue K, et al. Relation between reduction in ischaemic mitral regurgitation and improvement in regional left ventricular contractility during low dose dobutamine stress echocardiography. Heart. 2005;91:1092–3.

    CAS  PubMed  PubMed Central  Google Scholar 

  25. Zhou X, Otsuji Y, Yoshifuku S, et al. Impact of atrial fibrillation on tricuspid and mitral annula dilatation and valvular regurgitation. Circ J. 2002;66:913–6.

    PubMed  Google Scholar 

  26. Machino-Ohtsuka T, Seo Y, Ishizu T, et al. Novel mechanistic insights into atrial functional mitral regurgitation: 3-dimensional echocardiographic study. Circ J. 2016;80:2240–8.

    PubMed  Google Scholar 

  27. 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. https://doi.org/10.1161/circimaging.116.005451.

    Article  PubMed  Google Scholar 

  28. 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;40:2194–202.

    PubMed  Google Scholar 

  29. Ring L, Dutka DP, Wells FC, et al. Mechanisms of atrial mitral regurgitation: insights using 3D transoesophageal echo. Eur Heart J Cardiovasc Imaging. 2014;15:500–8.

    PubMed  Google Scholar 

  30. van Rosendael PJ, Katsanos S, Kamperidis V, et al. New insights on Carpentier I mitral regurgitation from multidetector row computed tomography. Am J Cardiol. 2014;114:763–8.

    PubMed  Google Scholar 

  31. Itabashi Y, Mihara H, Berdejo J, et al. Distant position of chordae from coaptation causes mitral regurgitation in patients with atrial fibrillation. J Heart Valve Dis. 2016;25:323–31.

    PubMed  Google Scholar 

  32. Cong T, Gu J, Lee AP, et al. Quantitative analysis of mitral valve morphology in atrial functional mitral regurgitation using real-time 3-dimensional echocardiography atrial functional mitral regurgitation. Cardiovasc Ultrasound. 2018;16:13.

    PubMed  PubMed Central  Google Scholar 

  33. Kim DH, Heo R, Handschumacher MD, et al. Mitral valve adaptation to isolated annular dilation: insights into the mechanism of atrial functional mitral regurgitation. JACC Cardiovasc Imaging. 2019;12:665–77.

    PubMed  Google Scholar 

  34. Tang Z, Fan YT, Wang Y, et al. Mitral annular and left ventricular dynamics in atrial functional mitral regurgitation: a three-dimensional and speckle-tracking echocardiographic study. J Am Soc Echocardiogr. 2019;32:503–13.

    PubMed  Google Scholar 

  35. 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;118:845–52.

    PubMed  PubMed Central  Google Scholar 

  36. 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;120:334–42.

    PubMed  PubMed Central  Google Scholar 

  37. Netter FH. The CIBA collection of medical illustrations volume 5: heart. Ardsley: CIBA; 1969.

    Google Scholar 

  38. Silbiger JJ. Novel pathogenetic mechanisms and structural adaptations in ischemic mitral regurgitation. J Am Soc Echocardiogr. 2013;26:1107–17.

    PubMed  Google Scholar 

  39. Kagiyama N, Mondillo S, Yoshida K, et al. Subtypes of atrial functional mitral regurgitation: imaging insights into their mechanisms and therapeutic implications. JACC Cardiovasc Imaging. 2019. https://doi.org/10.1016/j.jcmg.2019.01.040(Epub ahead of print).

    Article  PubMed  Google Scholar 

  40. Yoshida J, Nagaura T, Ikenaga H, et al. Difference in mitral valve morphology between eccentric and central atrial functional mitral regurgitation: its effect on percutaneous edge-to-edge repair. J Am Coll Cardiol. 2019;73:1523 (abstract).

    Google Scholar 

  41. 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. Circulation. 2017;135:e1159–95.

    PubMed  Google Scholar 

  42. Baumgartner H, Falk V, Bax JJ, et al. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2017;38:2739–91.

    PubMed  Google Scholar 

  43. 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;42:634–7.

    PubMed  Google Scholar 

  44. 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;34:767–73.

    PubMed  Google Scholar 

  45. Takahashi Y, Abe Y, Murakami T, et al. Mid-term results of valve repairs for atrial functional mitral and tricuspid regurgitations. Gen Thorac Cardiovasc Surg. 2019. https://doi.org/10.1007/s11748-019-01203-6.

    Article  PubMed  Google Scholar 

  46. Takahashi Y, Shibata T, Hattori K, et al. Extended posterior leaflet extension for mitral regurgitation in giant left atrium. J Heart Valve Dis. 2014;23:88–90.

    PubMed  Google Scholar 

  47. 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;12:1881–3.

    PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Cardiology, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka, 534-0021, Japan

    Yukio Abe

  2. Department of Cardiovascular Surgery, Osaka City University, Osaka, Japan

    Yosuke Takahashi & Toshihiko Shibata

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  1. Yukio Abe
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Correspondence to Yukio Abe.

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Yukio Abe, Yosuke Takahashi, and Toshihiko Shibata declare that they have no conflicts of interest.

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Abe, Y., Takahashi, Y. & Shibata, T. Functional mitral regurgitation, updated: ventricular or atrial?. J Echocardiogr 18, 1–8 (2020). https://doi.org/10.1007/s12574-019-00453-w

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  • DOI: https://doi.org/10.1007/s12574-019-00453-w

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