Reverse Cardiac Remodeling and Functional Regurgitation in Atrial Fibrillation
- In a prospective observational study of patients with AF, active restoration of sinus rhythm was associated with reverse cardiac remodeling compared with the group in whom sinus rhythm restoration was not attempted or unsuccessful.
- Improvement in cardiac remodeling resulted in the reduction of atrial functional mitral and tricuspid regurgitation.
What are the three-dimensional (3-D) echocardiographic variables of cardiac cavity remodeling, and what is the impact on functional regurgitation in patients with atrial fibrillation (AF) with and without sinus rhythm (SR) restoration at 12 months?
A total of 117 consecutive patients hospitalized for AF were examined using serial 3-D transthoracic echocardiography at admission, at 6 months, and at 12 months. 3-D echo parameters were analyzed within three categories: 1) active restoration of SR with cardioversion, antiarrhythmic medication and/or ablation, 2) absence or failure of restoration of SR, and 3) spontaneous restoration of SR and maintenance of SR for 12 months.
Patients with active restoration of SR (n = 47) experienced a decrease in all atrial indexed volumes (Vi), end-systolic (ES) right ventricular (RV) Vi, an increase in end-diastolic (ED) left ventricular Vi, and an improvement in four-chambers function (p < 0.05). Patients with absence/failure of restoration of SR (n = 39) had an increase in ED left atrial (LA) Vi and ED/ES RV Vi without modification of four-chambers function, except for a decrease in LA emptying fraction. Patients with spontaneous restoration of SR (n = 31) had no changes in Vi or function. There was an improvement in the severity of functional mitral regurgitation and tricuspid regurgitation in patients with active restoration of SR and in spontaneous restoration of SR (tricuspid regurgitation). In multivariable analysis, right atrial and/or LA reverse remodeling exclusively correlated with intervention (cardioversion and/or ablation) during 12-month follow-up.
The authors concluded that management of AF should focus on restoration of SR to induce anatomical (all atrial Vi, ES RV Vi) and/or functional (four chambers) cardiac cavity reverse remodeling and reduce severity of functional regurgitation.
Persistence of AF is known to promote anatomic, autonomic, and electrophysiological changes in the LA, which in turn contribute to the perpetuation of AF. Prior studies have focused on the LA size and function in this condition, while the current study extended observations to remodeling of other heart chambers and atrial functional mitral and tricuspid regurgitation. Using 3-D echocardiography, the authors of the present study show that successful restoration of SR with cardioversion, antiarrhythmic medication, and/or ablation results in reverse remodeling with decreases in all atrial Vi, ES RV Vi, an increase in ED left ventricular Vi, and an improvement in four-chambers function. In contradistinction, patients in whom SR restoration was either not attempted or unsuccessful experienced an increase in ED LA Vi and ED/ES RV Vi without modification of four-chambers function, except for a decrease in LA emptying fraction. Additionally, there was a reduction in the severity of mitral and tricuspid regurgitation after active restoration of SR, which was not observed in patients who remained in AF. This prospective observational study suggests that restoration of SR should be attempted to improve cavity reverse remodeling and severity of functional regurgitation. A randomized study will be necessary to confirm these findings.
Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Valvular Heart Disease, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Echocardiography/Ultrasound, Mitral Regurgitation
Keywords: Arrhythmias, Cardiac, Arrhythmia, Sinus, Atrial Fibrillation, Atrial Function, Left, Atrial Remodeling, Catheter Ablation, Diagnostic Imaging, Echocardiography, Echocardiography, Three-Dimensional, Electric Countershock, Heart Failure, Heart Valve Diseases, Mitral Valve Insufficiency, Tricuspid Valve Insufficiency, Ventricular Remodeling
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