Atrial fibrillation versus heart failure with preserved ejection fraction as drivers of atrial functional mitral and tricuspid regurgitation: clinical and echocardiographic profiles across phenotypes
H G Uzun, S EkinciAbstract
Background
Atrial functional mitral and tricuspid regurgitations (AFMR/AFTR) arise from atrial and annular dilatation rather than leaflet pathology. Both atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF) enlarge the atria, but their individual and combined contributions to atrial functional valvulopathy are unclear.
Purpose
We compared three phenotypes, HFpEF in sinus rhythm (Sinus-HFpEF), AF with HFpEF (AF-HFpEF) and AF without HFpEF (AF-non-HFpEF), to disentangle the relative impact of AF and HFpEF on bi-atrial remodeling and functional atrioventricular regurgitation.
Methods
In a prospective cross-sectional study, 2,877 consecutive patients referred for transthoracic echocardiography were screened; 94 fulfilled predefined criteria and were assigned to Sinus-HFpEF (n=31), AF-HFpEF (n=34) or AF-non-HFpEF (n=29). Clinical data, natriuretic peptides, H2FPEF scores, symptoms, and comprehensive echocardiography (atrial volumes, annular diameters, mitral/tricuspid regurgitation grades, tricuspid annular plane systolic excursion [TAPSE], tricuspid regurgitant velocity, left ventricular ejection fraction [LVEF]) were compared.
Results
AF-HFpEF patients were oldest (74±8 vs 71±10 and 67±11 years, p=0.02) and had the highest NT-proBNP (1,724 vs 1,170 and 771 pg/mL, p=0.004) and H2FPEF scores (6.5 vs 6 and 4, p<0.001). They showed the largest left- and right-atrial volume indexes (LAVi 60±16 vs 49(21) and 46±16 mL/m2; RAVi 46(21) vs 43(17) and 43(17) mL/m2, all p≤0.01) and the greatest AFMR/AFTR burden: tricuspid regurgitation severity followed AF-HFpEF > AF-non-HFpEF > Sinus-HFpEF (global p<0.001), in parallel with tricuspid-annular dilatation (4.1±0.5 vs 4.0(0.7) and 3.8±0.5 cm, p=0.03). TAPSE was reduced in both AF groups (19 mm) compared with Sinus-HFpEF (25 mm, p<0.001), whereas LVEF was similar (57–60%, p=0.10). A multivariable echocardiographic model combining LAVi, RAVi, H2FPEF score and TAPSE discriminated the AF-HFpEF phenotype with an AUC of 0.84.
Conclusion
AF is the main driver of bi-atrial and annular dilatation, while concomitant HFpEF amplifies right-sided remodeling and functional tricuspid regurgitation, defining a high-burden AF-HFpEF phenotype. Integrating atrial volumes, tricuspid annulus and right-ventricular longitudinal function may improve recognition and risk stratification of atrial functional valvulopathy in routine practice.TableROC Curve