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Atrial fibrillation complicating the course of degenerative mitral regurgitation: determinants and long-term outcome
Francesco Grigioni1, Jean-François Avierinos, Lieng H Ling
1Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA.
Objectives:
The study was done to define the incidence, determinants and prognostic implications of onset of atrial fibrillation (AF) during follow-up of mitral regurgitation (MR) initially in sinus rhythm.
Background:
The rates and clinical implications of AF in MR are undefined.
Methods:
We analyzed the occurrence of AF under conservative management in two populations of patients with degenerative MR in sinus rhythm at diagnosis: 1) 360 patients (65 +/- 13 years, 74% men) with MR due to flail leaflets; and 2) 89 residents of Olmsted County, Minnesota (67 +/- 17 years, 56% men) with grade 3 or 4 MR due to simple mitral valve prolapse (MVP) diagnosed echocardiographically.
Results:
In patients with MR due to flail leaflets, AF rates at 5 and 10 years were 18 +/- 3% and 48 +/- 6%, respectively, and the linearized rate was 5.0 +/- 0.7% per year. Development of AF during follow-up was independently associated with high risk of cardiac death or heart failure (adjusted risk ratio 2.23, p = 0.025). The AF rate at 10 years was higher in patients >or=65 years (75 +/- 10% vs. 24 +/- 6%, p < 0.0001) and in those with baseline left atrial (LA) dimension >or=50 mm (67 +/- 8% vs. 37 +/- 9%, p < 0.001). In multivariate analysis, independent baseline predictors of AF were age and LA diameter (both p < 0.01). In patients with MR due to MVP, similar rates of AF (41 +/- 7% vs. 44 +/- 6% at nine years, p > 0.50) and predictors of AF (age and LA dimension, both p < 0.006) were noted.
Conclusions:
In patients with degenerative MR in sinus rhythm at diagnosis, the incidence of AF occurring under conservative management is high and similar whether the cause of MR is flail leaflet or simple MVP. After onset of AF, an increased cardiac mortality and morbidity are both observed under conservative management. The risk of AF increases with advancing age and larger LA dimension. These data suggest that the clinical management of MR should take into account the high incidence, excess risk, and predictors of AF.
Insights
Atrial fibrillation (AF) develops frequently in patients with mitral regurgitation (MR) and is linked to increased cardiac death and heart failure. Age and left atrial size predict AF onset in MR patients.
Area of Science:
- Cardiology
- Valvular Heart Disease
- Electrophysiology
Background:
- The incidence and clinical significance of atrial fibrillation (AF) in patients with mitral regurgitation (MR) are not well-defined.
- Understanding AF development in MR is crucial for patient management.
Purpose of the Study:
- To determine the incidence, predictors, and prognostic impact of new-onset atrial fibrillation (AF) in patients with mitral regurgitation (MR) initially in sinus rhythm.
- To compare AF development in MR caused by flail leaflets versus mitral valve prolapse (MVP).
Main Methods:
- Analysis of two patient cohorts with degenerative MR in sinus rhythm: 360 with flail leaflets and 89 with MVP.
- Echocardiographic assessment of MR severity and left atrial (LA) dimensions.
- Long-term follow-up to ascertain AF occurrence and clinical outcomes under conservative management.
Main Results:
- High rates of AF observed: 5-year incidence 18% and 10-year incidence 48% in flail leaflet MR.
- AF onset was independently associated with increased risk of cardiac death or heart failure (aRR 2.23).
- Predictors of AF included advanced age and larger LA dimension (>50 mm). AF incidence was similar for flail leaflet and MVP causes of MR.
Conclusions:
- Degenerative MR patients in sinus rhythm have a high incidence of AF under conservative management, regardless of MR etiology (flail leaflet or MVP).
- Onset of AF in MR is associated with increased cardiac mortality and morbidity.
- Clinical management strategies for MR should consider the high risk and predictors of AF, including age and LA size.
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