Prognostic significance of residual functional mitral regurgitation in hospitalized heart failure patients with chronic atrial fibrillation and preserved ejection fraction after medical therapies

  • Kazato Ito
  • Yukio AbeEmail author
  • Hiroyuki Watanabe
  • Yoshihisa Shimada
  • Kentaro Shibayama
  • Hiroki Oe
  • Eiichi Hyodo
  • Chinami Miyazaki
  • Yosuke Takahashi
  • Toshihiko Shibata
  • Hiroshi Ito
Original Investigation



Functional mitral regurgitation (MR) can be seen in patients with atrial fibrillation (AF), even without left-ventricular (LV) systolic dysfunction, as a result of left atrial enlargement. The purpose of this study was to evaluate the prognostic significance of residual functional MR in hospitalized heart failure patients with chronic AF and preserved LV ejection fraction (pEF) after medical therapies.


In this retrospective multi-center study, the determinants of post-discharge prognosis (cardiac death and re-hospitalization for worsening heart failure) were examined in 54 hospitalized heart failure patients with chronic AF and pEF at discharge.


Of the 54 patients, 53 (98%) had mild or higher degrees of functional MR at hospitalization.At discharge, 47 (87%) still had functional MR, even after medical therapies [mild in 27 (50%), moderate in 16 (30%), and severe in 4 (7%)]. During the follow-up period (20 ± 16 months) after discharge, 16 (30%) patients met the composite end points. The grading of residual functional MR at discharge was the significant predictor of the end point (hazard ratio per one grade increase: 2.4, 95% confidence interval 1.1–5.5, p = 0.035). The greater the residual functional MR was, the lower the event-free rate from the end point was in the Kaplan–Meier curve analysis (p = 0.0069 for trend).


A substantial proportion of patients hospitalized due to heart failure with chronic AF have residual functional MR at discharge, even with pEF after medical therapies, and the MR is related to future heart failure events.


Atrial fibrillation Echocardiography Heart failure Mitral regurgitation 


Compliance with ethical standards

Conflict of interest

Kazato Ito, Yukio Abe, Hiroyuki Watanabe, Yoshihisa Shimada, Kentaro Shibayama, Hiroki Oe, Eiichi Hyodo, Chinami Miyazaki, Yosuke Takahashi, Toshihiko Shibata, and Hiroshi Ito declare that they have no conflict of interest.

Human rights statements

Human rights statements and informed consent: All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1964 and later revisions.

Informed consent

Informed consent was obtained from all patients for being included in the study.


  1. 1.
    Blondheim DS, Jacobs LE, Kotler MN, et al. Dilated cardiomyopathy with mitral regurgitation: decreased survival despite a low frequency of left ventricular thrombus. Am Heart J. 1991;122:763–71.CrossRefGoogle Scholar
  2. 2.
    Agricola E, Ielasi A, Oppizzi M, et al. Long-term prognosis of medically treated patients with functional mitral regurgitation and left ventricular dysfunction. Eur J Heart Fail. 2009;11:581–7.CrossRefGoogle Scholar
  3. 3.
    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.CrossRefGoogle Scholar
  4. 4.
    Gertz ZM, Raina A, Saghy L, et al. Evidence of atrial functional mitral regurgitation due to atrial fibrillation. J Am Coll Cardiol. 2011;58:1474–81.CrossRefGoogle Scholar
  5. 5.
    Kilic A, Schwartzman DS, Subramaniam K, et al. Severe functional mitral regurgitation arising from isolated annular dilation. Ann Thorac Surg. 2010;90:1343–5.CrossRefGoogle Scholar
  6. 6.
    Kajimoto K, Minami Y, Otsubo S, et al. Ischemic or non-ischemic functional mitral regurgitation and outcomes in patients with acute decompensated heart failure with preserved or reduced ejection fraction. Am J Cardiol. 2017;120:809–16.CrossRefGoogle Scholar
  7. 7.
    Vahanian A, Alfieri O, Andreotti F, et al. Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) Guidelines on the management of valvular heart disease (version 2012). Eur Heart J. 2012;33:2451–96.CrossRefGoogle Scholar
  8. 8.
    Nishimura RA, Otto CM, Bonow RO, American College of Cardiology, American Heart Association Task Force on Practice Guidelines, et al. 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 Practice Guidelines. J Am Coll Cardiol. 2014;2014(63):e57–185.CrossRefGoogle Scholar
  9. 9.
    Lang RM, Bierig M, Devereux RB, et al. Chamber Quantification Writing Group; American Society of Echocardiography’s Guidelines and Standards Committee; European Association of Echocardiography. Recommendations for chamber quantification: a report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr. 2005;18:1440–63.CrossRefGoogle Scholar
  10. 10.
    Gudmundsson P, Rydberg E, Winter R, et al. Visually estimated left ventricular ejection fraction by echocardiography is closely correlated with formal quantitative methods. Int J Cardiol. 2005;101:209–12.CrossRefGoogle Scholar
  11. 11.
    Zoghbi WA, Enriquez-Sarano M, Foster E, et al. American Society of Echocardiography. Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. J Am Soc Echocardiogr. 2003;16:777–802.CrossRefGoogle Scholar
  12. 12.
    Ommen SR, Nishimura RA, Appleton CP, et al. Clinical utility of Doppler echocardiography and tissue Doppler imaging in the estimation of left ventricular filling pressures: a comparative simultaneous Doppler-catheterization study. Circulation. 2000;102:1788–94.CrossRefGoogle Scholar
  13. 13.
    Sumida T, Tanabe K, Yagi T, et al. Single-beat determination of Doppler-derived aortic flow measurement in patients with atrial fibrillation. J Am Soc Echocardiogr. 2003;16:712–5.CrossRefGoogle Scholar
  14. 14.
    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.CrossRefGoogle Scholar
  15. 15.
    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.CrossRefGoogle Scholar
  16. 16.
    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.CrossRefGoogle Scholar
  17. 17.
    Abe Y, Akamatsu K, Ito K, et al. Prevalence and prognostic significance of functional Mitral and tricuspid regurgitations occurring despite preserved left ventricular ejection fraction in patients with atrial fibrillation. Circ J. 2018;82:1451–8.CrossRefGoogle Scholar
  18. 18.
    Abe Y, Akamatsu K, Furukawa A, et al. Pre-load-induced changes in forward LV stroke and functional mitral regurgitation: echocardiographic detection of the descending limb of Starling’s curve. JACC Cardiovasc Imaging. 2017;10:611–8.CrossRefGoogle Scholar
  19. 19.
    Palardy M, Stevenson LW, Tasissa G, et al. ESCAPE Investigators. Reduction in mitral regurgitation during therapy guided by measured filling pressures in the ESCAPE trial. Circ Heart Fail. 2009;2:181–8.CrossRefGoogle Scholar
  20. 20.
    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.CrossRefGoogle Scholar
  21. 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.CrossRefGoogle Scholar
  22. 22.
    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.CrossRefGoogle Scholar
  23. 23.
    Nagueh SF, Smiseth OA, Appleton CP, et al. Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2016;29:277–314.CrossRefGoogle Scholar

Copyright information

© Japanese Society of Echocardiography 2018

Authors and Affiliations

  • Kazato Ito
    • 1
  • Yukio Abe
    • 2
    Email author
  • Hiroyuki Watanabe
    • 3
  • Yoshihisa Shimada
    • 1
  • Kentaro Shibayama
    • 3
  • Hiroki Oe
    • 4
  • Eiichi Hyodo
    • 5
  • Chinami Miyazaki
    • 6
  • Yosuke Takahashi
    • 7
  • Toshihiko Shibata
    • 7
  • Hiroshi Ito
    • 4
  1. 1.Cardiovascular CenterShiroyama HospitalHabikinoJapan
  2. 2.Department of CardiologyOsaka City General HospitalOsaka CityJapan
  3. 3.Department of CardiologyTokyo Bay Urayasu/Ichikawa Medical CenterUrayasuJapan
  4. 4.Department of Cardiovascular MedicineOkayama UniversityOkayamaJapan
  5. 5.Department of CardiologyNishinomiya-Watanabe Cardiovascular CenterNishinomiyaJapan
  6. 6.Department of CardiologyHigashisumiyioshi Morimoto HospitalOsakaJapan
  7. 7.Department of Cardiovascular SurgeryOsaka City University Graduate School of MedicineOsakaJapan

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