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Mitral regurgitation recovery and atrial reverse remodeling following pulmonary vein isolation procedure in patients with atrial fibrillation: a clinical observation proof-of-concept cardiac MRI study

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Abstract

Background

Reverse remodeling of the left atrium (LA) following successful pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF) has been well documented. However, mitral regurgitation (MR) recovery after successful PVI has never been demonstrated systematically. The objective of our study was to retrospectively analyze the effectiveness of PVI in patients with AF on recovery of MR using cardiac magnetic resonance (CMR) imaging.

Methods

Prior to PVI, patients underwent a clinically indicated CMR imaging. Post-PVI (6 ± 2 months), patients underwent a follow-up MRI and were classified into two groups—responders (R) and non-responders (NR) to PVI—as assessed by cessation of AF at the end of the prespecified 6-month (14-day “P” sensitive event monitor defined) follow-up period. Furthermore, CMR was used to evaluate the severity of MR (0 to 4+) and to relate changes in MR to LA volumes as well as mitral apparatus geometry. Patients who had mild and higher MR (2+) on baseline CMR and had a post-PVI CMR were selected for final analysis.

Results

Out of the consecutive 122 patients with AF who underwent PVI, 74 patients that had mitral regurgitation on initial CMR were included in the study. Of these74 patients with AF with MR, 52 (70 %) were classified as R and 22 (30 %) were classified as NR. Baseline demographics were similar between the groups. In the subgroup with mild to severe MR, pre vs. post in the R group MR severity significantly improved (mean = 2.3, median = 2.0 vs. mean = 1.0, median = 1.0, p < 0.0001) and was matched by favorable reverse remodeling of the mitral apparatus geometry (annulus = 35 ± 4 vs. 33 ± 3 mm, p < 0.002; tenting area = 175 ± 56 vs.137 ± 37 mm2, p < 0.003; tenting height = 8 ± 2 vs.7 ± 2 mm, p < 0.02; and tenting angle = 129 ± 10° vs. 131 ± 11°, p = 0.1). However, in the NR subgroup, MR failed to improve (mean = 2.2, median = 2.0 vs. mean = 1.5, median = 1.0, p = NS) and paralleled general failure of mitral geometry reverse remodeling (annulus = 35 ± 4 vs. 35 ± 4 mm, p = 0.2; tenting area = 153 ± 39 vs. 152 ± 34 mm2, p = NS; tenting height = 7 ± 1 vs. 7.0 ± 2, p = 0.1; and tenting angle = 131 ± 11° vs. 133 ± 10°, p = NS). In those with lesser degrees of MR, favorable remodeling was predicated on responder status to PVI. Similarly, other cardiac dimensions pre- to post-PVI favorably improved in the R group, but not in the NR group.

Conclusion

In those with durable maintenance of normal sinus rhythm (NSR), cardiac reverse remodeling demonstrated by 3D CMR occurs and is matched by marked improvements in MR and mitral apparatus, likely contributing to continued maintenance of NSR.

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Abbreviations

AF:

Atrial fibrillation

MR:

Mitral regurgitation

TR:

Tricuspid regurgitation

CMR:

Cardiac magnetic resonance

NSR:

Normal sinus rhythm

R:

Responders

NR:

Non-responders

PVI:

Pulmonary vein isolation

LA:

Left atrium

LAA:

Left atrial appendage

SSFP:

Steady-state free precession

VLA:

Vertical long axis

HLA:

Horizontal long axis

LVOT:

Left ventricular outflow tract

RVOT:

Right ventricular outflow tract

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Disclosures

All the authors have none to disclose, except off-label use of gadolinium.

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Authors and Affiliations

  1. Center of Cardiovascular Magnetic Resonance Imaging, The Gerald McGinnis Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA, USA

    Sahadev T. Reddy, William Belden, Mark Doyle, Diane V. Thompson, Ronald Williams, June Yamrozik, Moneal Shah & Robert W. W. Biederman

  2. Department of Cardiovascular MRI, Division of Cardiology, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA, 15212, USA

    Sahadev T. Reddy

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  1. Sahadev T. Reddy
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  2. William Belden
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Correspondence to Sahadev T. Reddy.

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Reddy, S.T., Belden, W., Doyle, M. et al. Mitral regurgitation recovery and atrial reverse remodeling following pulmonary vein isolation procedure in patients with atrial fibrillation: a clinical observation proof-of-concept cardiac MRI study. J Interv Card Electrophysiol 37, 307–315 (2013). https://doi.org/10.1007/s10840-013-9784-8

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