Koschatko Sophia, Heitzinger Gregor, Pavo Noemi, Spinka Georg, Prausmüller Suriya, Mascherbauer Katharina, Dannenberg Varius, Torrefranca Christoph, Koschutnik Matthias, Donà Carolina, Rosenhek Raphael, Jantsch Charlotte, Halavina Kseniya, Hauptmann Laurenz, Hemetsberger Rayyan, Nitsche Christian, Demirel Caglayan, Hengstenberg Christian, Hülsmann Martin, Goliasch Georg, Bartko Philipp E
Department of Internal Medicine II, Medical University of Vienna, Austria.
Circ Cardiovasc Imaging. 2025 Jul;18(7):e017872. doi: 10.1161/CIRCIMAGING.124.017872. Epub 2025 Jun 4.
Severe functional mitral regurgitation (fMR) is a heterogenous disease that exhibits different underlying pathophysiological mechanisms and represents independent entities. The aim of this study was to characterize remodeling patterns defined by the left atrial (LA) to left ventricular (LV) volume ratio in patients with severe fMR and heart failure, and to examine its prognostic implications.
A total of 13 052 patients with fMR were included. Based on the LA/LV volume ratio, patients with severe fMR were divided into 2 distinct groups: predominant LV remodeling (PLVR [ratio ≤0.56, n=581]) and predominant LA remodeling (PLAR [ratio >0.56, n=582]).
Patients with PLAR were more often female, with the peak age a decade later. PLAR was associated with lower leaflet tethering indices, as indicated by the leaflet tenting area (PLVR versus PLAR: 227 mm versus 181 mm, <0.001) and angles (PLVR versus PLAR: posterior leaflet: 42° versus 36°, <0.001; anterior leaflet: 28° versus 23°, <0.001). PLAR was the predominant subtype in heart failure with preserved (76%) and heart failure with mildly reduced ejection fraction (61%), but a significant proportion could be observed in heart failure with reduced ejection fraction (32%). The median follow-up time for severe fMR was 66 months (interquartile range, 60-85). After 4 years, 42.1% with PLAR and 34.1% with PLVR had died. At 8 years, 57.3% of patients with PLAR, and 49.6% of patients with PLVR had died. Compared with PLVR, PLAR showed excess mortality, with a hazard ratio of 1.37 ([95% CI, 1.13-1.65]; =0.001) in the univariate analysis. This effect remained after multivariable adjustment.
The LA/LV volume ratio indicates the prevailing remodeling pattern in severe fMR. It is associated with morphological features of valve apparatus distortion resulting from differential remodeling. A strong correlation is observed between the LA/LV volume ratio and mortality.
重度功能性二尖瓣反流（fMR）是一种异质性疾病，具有不同的潜在病理生理机制，代表独立的实体。本研究的目的是描述重度fMR和心力衰竭患者中由左心房（LA）与左心室（LV）容积比定义的重塑模式，并探讨其预后意义。
共纳入13052例fMR患者。根据LA/LV容积比，重度fMR患者被分为2个不同的组：以左心室为主的重塑（PLVR [比值≤0.56，n = 581]）和以左心房为主的重塑（PLAR [比值>0.56，n = 582]）。
PLAR组女性更为常见，发病高峰年龄晚10年。PLAR与较低的瓣叶牵拉指数相关，如瓣叶帐篷面积所示（PLVR与PLAR：227 mm对181 mm，<0.001）和角度（PLVR与PLAR：后叶：42°对36°，<0.001；前叶：28°对23°，<0.001）。PLAR是射血分数保留的心力衰竭（76%）和射血分数轻度降低的心力衰竭（61%）中的主要亚型，但在射血分数降低的心力衰竭中也可观察到相当比例（32%）。重度fMR的中位随访时间为66个月（四分位间距，60 - 85）。4年后，PLAR组42.1%的患者和PLVR组34.1%的患者死亡。8年后，PLAR组57.3%的患者和PLVR组49.6%的患者死亡。与PLVR相比，PLAR显示出更高的死亡率，单因素分析中的风险比为1.37（[95%CI，1.13 - 1.65]；P = 0.001）。多变量调整后这种效应仍然存在。
LA/LV容积比表明重度fMR中主要的重塑模式。它与不同重塑导致的瓣膜装置变形的形态学特征相关。LA/LV容积比与死亡率之间存在强烈相关性。
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