mr and atrial fibrillation Κολπική μαρμαρή μ σνοό ανπάρκια ... · mr...

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Κολπική μαρμαρυγή με συνοδό ανεπάρκεια των κολποκοιλιακών βαλβίδων: υπάρχει διέξοδος από το φαύλο κύκλο; Γεωργιος Κουργιαννιδης

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Page 1: MR And Atrial Fibrillation Κολπική μαρμαρή μ σνοό ανπάρκια ... · MR begets MR AFIB begets MR. MR And Atrial Fibrillation Ad et al. J Thorac Cardiovasc

MR And Atrial Fibrillation

Κολπική μαρμαρυγή με συνοδό ανεπάρκεια των

κολποκοιλιακών βαλβίδων: υπάρχει διέξοδος από το

φαύλο κύκλο;Γεωργιος Κουργιαννιδης

Page 2: MR And Atrial Fibrillation Κολπική μαρμαρή μ σνοό ανπάρκια ... · MR begets MR AFIB begets MR. MR And Atrial Fibrillation Ad et al. J Thorac Cardiovasc

MR And Atrial Fibrillation

Morbidity and mortality

StrokeBleeding Risk Heart FailureSurgical Results

THE VICIOUS CYCLE

Afib is a turning point in the physical history of MR

MR begets AFIB AFIB begets AFIB

MR begets MR AFIB begets MR*

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MR And Atrial Fibrillation

ATRIAL FUNCTIONAL MR Saito et al. Journal of Cardiology , Vol 72 (4) , 292 - 299

Page 4: MR And Atrial Fibrillation Κολπική μαρμαρή μ σνοό ανπάρκια ... · MR begets MR AFIB begets MR. MR And Atrial Fibrillation Ad et al. J Thorac Cardiovasc

MR And Atrial Fibrillation

“In an AF patient with moderately severe MR, should we first fix the MR to

achieve atrial reverse remodeling and hopefully maintain sinus rhythm, OR

should we primarily address the AF (RFCA /AADs/CVs) and hope that it will

prevent annular/leaflet remodeling and hence decrease mitral regurgitation?”

Thomas Atrial Fibrillation Begets Mitral Regurgitation, or Is it Vice Versa?JACC: CARDIOVASCULAR IMAGINGhttps://doi.org/10.1016/j.jcmg.2017.11.008

MR begets AFIB AFIB begets AFIB

MR begets MR AFIB begets MR

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MR And Atrial Fibrillation

Ad et al. J Thorac Cardiovasc Surg. 2018 Mar;155(3):983-994

MV 217pts

92

82

70

86

7058

0

10

20

30

40

50

60

70

80

90

100

1 years 5 years 7 years

Mv repair+Cox-Maze

SR SR no AAD

..in PRIMARY MR

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MR And Atrial Fibrillation

MR TR

Overall 8,1% 15%

>10 y 28% 25%24+/-17 FU 12% SURGERY

Circ J 2018; 82: 1451 – 1458

cohort type: single center consecutive ECHO afib LV normal pts

aFUNCTIONAL MR

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MR And Atrial Fibrillation

MECHANISMS aFMR

• ANNULAR DILATATION

• LEAFLET ADAPTATION IN AF-MR: ENDOTHELIAL-MESENCHYMAL TRANSFORMATION

• ABNORMAL ANNULO PAPILLARY BALANCE DUE TO IMPAIRED LV LONG –AXIS FUNCTION

• REDUCED MA CONTRACTILITY DUE TO ABNORMAL LV CIRCUMFERENTIAL MECHANICS

• ATRIOGENIC LEAFLET TETHERING

• HAMSTRINGING OF THE PML DUE TO PARADOXICAL LV POSTERIOR WALL MOTION

Page 8: MR And Atrial Fibrillation Κολπική μαρμαρή μ σνοό ανπάρκια ... · MR begets MR AFIB begets MR. MR And Atrial Fibrillation Ad et al. J Thorac Cardiovasc

MR And Atrial Fibrillation

ATRIOGENIC LEAFLET TETHERINGHAMSTRINGING OF THE PML DUE TO PARADOXICAL LV POSTERIOR WALL MOTION

Page 9: MR And Atrial Fibrillation Κολπική μαρμαρή μ σνοό ανπάρκια ... · MR begets MR AFIB begets MR. MR And Atrial Fibrillation Ad et al. J Thorac Cardiovasc

MR And Atrial Fibrillation

Silbiger Echocardiography. 2019;36:164–169

Page 10: MR And Atrial Fibrillation Κολπική μαρμαρή μ σνοό ανπάρκια ... · MR begets MR AFIB begets MR. MR And Atrial Fibrillation Ad et al. J Thorac Cardiovasc

MR And Atrial Fibrillation

Page 11: MR And Atrial Fibrillation Κολπική μαρμαρή μ σνοό ανπάρκια ... · MR begets MR AFIB begets MR. MR And Atrial Fibrillation Ad et al. J Thorac Cardiovasc

MR And Atrial Fibrillation

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MR And Atrial Fibrillation

828 pt ablation/53 FMR

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MR And Atrial Fibrillation

POSITIVE EFFECT OF RADIOFREQUENCY CATHETER ABLATION ON MITRAL REGURGITATION SECONDARY TO ATRIAL FIBRILLATION

81RFCA 6mo

76.5% kept sinus rhythm while 23.4% showed recurrent AF.

Sinus group showed significant reduction in MR and MAnnulus size in A-P direction

Recurrent group showed no significant changes

SUBCLINICALKuwahara et (poster) JACC April 5, 2016 Volume 67, Issue 13

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MR And Atrial Fibrillation

Vohra et al European Journal of Cardio-Thoracic Surgery 42 (2012) 634–637

20 pts

In all cases, AF preceded MR

mitral annuloplasty plus concomitant antiarrhythmic procedures

18.0 ± 12.5 months

AF a mean duration of 84.6 ± 92.0 months

Takahashi et alInteract CardioVascThorac Surg 2015;21:163–8.

10 AFMR pts with HF symptoms

mitral annuloplasty

FU 10-52 mo LAV improved

SURGICAL TREATMENT

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MR And Atrial Fibrillation

Zhou et alCirc J 2002; 66: 913– 916

Annular Dilatation in TV is more profound

31 consecutive patients with lone AF and 28 normal controls

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MR And Atrial Fibrillation

And can be Isolated….

9,2% FTR vs 45,3% LHTR

437 patients with moderate to severe TR underwent3-dimensional (3D) transesophageal echocardiography…

Utsunomiya et al Circ Cardiovasc Imaging 2017;10.

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MR And Atrial Fibrillation

• AF predicts recurrence of TR after left valves surgery

• Improvement in TR without performing surgical correction is not uncommon in patients with severe functional TR due to Left Valve Disease and AF (22.5%).

Cho eta al.Journal of Cardiology 68 (2016) 419–425

• Isolated TR associated with Afib may improve with conversion to Sinus Rhythm

Wang et al. Am Heart Assoc. 2016;5:e004213

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MR And Atrial Fibrillation

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MR And Atrial Fibrillation

Early rhythm control strategy in patients in mild MR to prevent LA /MA remodeling

Routine/Serial evaluation of MA dimensions?

TR as a marker of annular dilatation and to more strict rhythm control?

• 24% still MR in Gertz Study ( …All were Advanced MR)• Hypertension is a confounder not addressed substantially in studies

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MR And Atrial Fibrillation

• Based on the above findings an early rhythm control strategy may be justified to prevent Mitral valve remodeling

• Similarly an early mitral valve repair may also be considered for MR (plus Afib surgical or catheter ablation) to avoid further atrial and valvular remodelling

• Therapies regarding TR should always imply prior rhythm control (AADs/RFCA) because of its reversibility

OVERVIEW

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MR And Atrial Fibrillation

Seeing…. not looking

Fibrotic Atrial Cardiomyopathy

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MR And Atrial Fibrillation

Bonus Slides

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MR And Atrial Fibrillation

MECHANISMS aFMR

• ANNULAR DILATATION

• LEAFLET ADAPTATION IN AF-MR: ENDOTHELIAL-MESENCHYMAL TRANSFORMATION

• ABNORMAL ANNULO PAPILLARY BALANCE DUE TO IMPAIRED LV LONG –AXIS FUNCTION

• REDUCED MA CONTRACTILITY DUE TO ABNORMAL LV CIRCUMFERENTIAL MECHANICS

• ATRIOGENIC LEAFLET TETHERING

• HAMSTRINGING OF THE PML DUE TO PARADOXICAL LV POSTERIOR WALL MOTION

Page 24: MR And Atrial Fibrillation Κολπική μαρμαρή μ σνοό ανπάρκια ... · MR begets MR AFIB begets MR. MR And Atrial Fibrillation Ad et al. J Thorac Cardiovasc

MR And Atrial Fibrillation

ANNULAR DILATATION

Almost universal finding but controversial. Second hit

This study demonstrated that isolated MA dilation inpatients with lone AF does not usually cause moderate tosevere MR, even though they have MA dilation comparableto those with ICM and frequent, significant MR

Otsuji et al. J Am Coll Cardiol 2002;39:1651– 6)

Silbiger Echocardiography. 2019;36:164–169

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MR And Atrial Fibrillation

170 pts with CT

Each 1 mm/m2 increase in AP diameter of MA odds ratio of 1.8 (95% ,1.35–2.40)of having significant MR after correcting for age, type of AF,hypertension, LV function and dimensions, and LA dimensions.

Rosendael Am J Cardiol 2014;114:763e768Kagiyama et ai. Circ Cardiovasc Imaging. 2017;10:e005451.

LEAFLET ADAPTATION IN AF-MR: ENDOTHELIAL-MESENCHYMAL TRANSFORMATION

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MR And Atrial Fibrillation

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MR And Atrial Fibrillation

ABNORMAL ANNULO PAPILLARY BALANCE DUE TO IMPAIRED LV LONG –AXIS FUNCTION

Silbiger Echocardiography. 2019;36:164–169

Page 28: MR And Atrial Fibrillation Κολπική μαρμαρή μ σνοό ανπάρκια ... · MR begets MR AFIB begets MR. MR And Atrial Fibrillation Ad et al. J Thorac Cardiovasc

MR And Atrial Fibrillation

REDUCED MITRAL ANNULAR CONTRACTILITY DUE TO ABNORMAL LVCIRCUMFERENTIAL MECHANICS

• normal sinusrhythm coupled presystolic and systolic annular dynamics• AF absent presystolic butpreserved systolic annular dynamics,albeit with a delayed timing• AFMR is associated withdiminished presystolic and additionally systolic annular dynamics• such abnormal dynamics

are associated with impaired LV GLS. Tang et al J Am Soc Echocardiogr 2018

Page 29: MR And Atrial Fibrillation Κολπική μαρμαρή μ σνοό ανπάρκια ... · MR begets MR AFIB begets MR. MR And Atrial Fibrillation Ad et al. J Thorac Cardiovasc

MR And Atrial Fibrillation

ATRIOGENIC LEAFLET TETHERINGHAMSTRINGING OF THE PML DUE TO PARADOXICAL LV POSTERIOR WALL MOTION

Page 30: MR And Atrial Fibrillation Κολπική μαρμαρή μ σνοό ανπάρκια ... · MR begets MR AFIB begets MR. MR And Atrial Fibrillation Ad et al. J Thorac Cardiovasc

MR And Atrial Fibrillation

Silbiger Echocardiography. 2019;36:164–169

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MR And Atrial Fibrillation

Utsunomiya et al Circ Cardiovasc Imaging 2017;10.

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MR And Atrial Fibrillation

MR confers to poorer results of RFCA

95 pts with significant MR 1 year

Gertz et al. Europace (2011) 13, 1127–1132

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MR And Atrial Fibrillation

Zhao et al Europace (2014) 16, 848–854

216 RFCA pts

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MR And Atrial Fibrillation

Aggressive rhythm control on top of optimal medical treatment is obligatory to access the need for tricuspid correction if MV surgery is indicated

TR can serve as a marker of annular dilatation and lead to more stringent rhythm control

Can atrial fibrosis as assessed by electroanatomicalmapping or CMR be a stratifier for ORGANIC MVR?

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MR And Atrial Fibrillation

Prevalence

Evolving Physiology Longstanding afib vs paroxysmal

Sharma et alWJC May 26, 2012 Vo 4

Issue 5

57 consecutive patients with lone AF /TEE

66% MR>2/4

Saito et al.Journal of Cardiology , Volume 72 , Issue 4 , 292

189 hospitalized HF patients with AF

15.9% 83% longstanding

Gertz et alJ Am Coll Cardiol2011;58:1474–81

828 pt for ablation 6% (12%)

aFUNCTIONAL MR

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MR And Atrial Fibrillation

Gillinov et al. N Engl J Med 2015;372:1399-409

260 patients 21.5 vs.8.1 per 100 patient-years for Pacemaker in ablation

55.6% underwent mitral-valve repair