Department of Internal Medicine, Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA.
Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA.
JACC Cardiovasc Imaging. 2021 Apr;14(4):797-808. doi: 10.1016/j.jcmg.2021.02.008.
This study was designed to compare the clinical and echocardiographic characteristics, management, and outcomes of severe atrial functional mitral regurgitation (AFMR) to primary mitral regurgitation (PMR).
AFMR remains poorly defined clinically.
Consecutive patients who underwent transesophageal echocardiography at our institution between 2011 and 2018 for severe mitral regurgitation with preserved left ventricular function were screened. We excluded patients with endocarditis, any form of cardiomyopathy, or prior mitral intervention. The absence of leaflet pathology defined AFMR. Outcomes included death and heart failure hospitalizations.
A total of 283 patients were included (AFMR = 14%, PMR = 86%). Compared to PMR, patients with AFMR had more comorbidities, including hypertension (94.9% vs. 76.2%; p = 0.015), diabetes mellitus (46.2% vs. 18.4%; p < 0.001), long-standing atrial fibrillation (28.2% vs. 13.1%; p = 0.015), prior nonmitral cardiac surgery (25.6% vs. 9.8%; p = 0.004), and pacemaker placement (33.3% vs. 13.5%; p = 0.002). They also had higher average E/e' (median [interquartile range]:16.04 [13.1 to 22.46] vs. 14.1 [10.89 to 19]; p = 0.036) and worse longitudinal left atrial strain peak positive value (16.86 ± 12.15% vs. 23.67 ± 14.09%; p = 0.002) compared to PMR. During follow-up (median: 22 months), patients with AFMR had worse survival (log-rank p = 0.009) and more heart failure hospitalizations (log-rank p = 0.002). They were also less likely to undergo mitral valve intervention (59.0% vs. 83.6%; p = 0.001), although surgery was associated with improved survival (log-rank p = 0.021). On multivariable regression analysis, AFMR was independently associated with mortality [adjusted odds ratio: 2.61, 95% confidence interval: 1.17 to 5.83; p = 0.02].
AFMR constitutes an under-recognized high-risk group, with significant comorbidities, limited therapeutic options, and poor outcomes.
本研究旨在比较严重心房功能性二尖瓣反流（AFMR）与原发性二尖瓣反流（PMR）的临床和超声心动图特征、处理方法和转归。
AFMR 在临床上的定义仍不明确。
连续入选 2011 年至 2018 年在我院行经食管超声心动图检查的严重二尖瓣反流合并左心室射血分数正常的患者。我们排除了患有心内膜炎、任何形式的心肌病或既往二尖瓣介入治疗的患者。无瓣叶病变定义为 AFMR。转归包括死亡和心力衰竭住院。
共纳入 283 例患者（AFMR 占 14%，PMR 占 86%）。与 PMR 相比，AFMR 患者合并症更多，包括高血压（94.9% vs. 76.2%；p=0.015）、糖尿病（46.2% vs. 18.4%；p<0.001）、长期持续性心房颤动（28.2% vs. 13.1%；p=0.015）、既往非二尖瓣心脏手术（25.6% vs. 9.8%；p=0.004）和心脏起搏器植入（33.3% vs. 13.5%；p=0.002）。AFMR 患者的平均 E/e'（中位数[四分位数范围]：16.04[13.1 至 22.46] vs. 14.1[10.89 至 19]；p=0.036）和左心房纵向应变峰值正值（16.86±12.15% vs. 23.67±14.09%；p=0.002）也更高。在随访期间（中位数：22 个月），AFMR 患者的生存率较差（对数秩检验 p=0.009），心力衰竭住院次数更多（对数秩检验 p=0.002）。AFMR 患者更不可能接受二尖瓣瓣膜干预（59.0% vs. 83.6%；p=0.001），尽管手术与生存率改善相关（对数秩检验 p=0.021）。多变量回归分析显示，AFMR 与死亡率独立相关（调整比值比：2.61，95%置信区间：1.17 至 5.83；p=0.02）。
AFMR 是一个被低估的高危人群，合并症多，治疗选择有限，转归不良。
