Mitral regurgitation in heart failure with preserved ejection fraction: The interplay of valve, ventricle, and atrium

Abstract

Mitral regurgitation (MR) is highly prevalent among patients with heart failure and preserved ejection fraction (HFpEF). Despite this combination being closely associated with unfavourable outcomes, it remains relatively understudied. This is partly due to the inherent heterogeneity of patients with HFpEF. To address this gap, dissecting HFpEF into mechanism-based phenotypes may offer a promising avenue for advancing our comprehension of these complex intertwined conditions. This review employs the validated CircAdapt model to explore the haemodynamic implications of moderate to severe MR across a well-defined spectrum of myocardial disease, characterized by impaired relaxation and reduced myocardial compliance. Both heart failure and mitral valve disease share overlapping symptomatology, primarily attributed to elevated pulmonary pressures. The intricate mechanisms contributing to these elevated pressures are multifaceted, potentially influenced by diastolic dysfunction, left atrial myopathy, and MR. Accurate evaluation of the haemodynamic and clinical impact of MR necessitates a comprehensive approach, taking into account the characteristics of both the left atrium and left ventricle, as well as their intricate interactions, which may currently be underemphasized in diagnostic practice. This holistic assessment is imperative for enhancing our understanding and refining therapeutic strategies within this patient cohort.

Keywords: Diastolic dysfunction; Heart failure with preserved ejection fraction; Mitral regurgitation; Pressure–volume loops.

Figure 1

Evaluating the clinical challenges of treating the mitral valve in symptomatic heart failure with preserved ejection fraction (HFpEF) with moderate to severe mitral regurgitation (MR). EROA, effective regurgitant area; eGFR, estimated glomerular filtration rate; LAVI, left atrial volume index; LV-EF, left ventricular ejection fraction; mPAP, mean pulmonary artery pressure; M-TEER, mitral transcatheter edge-to-edge repair; NTproBNP, N-terminal pro-B-type natriuretic peptide; NYHA, New York Heart Association; PAWP, pulmonary arterial wedge pressure; RV, regurgitant volume; TRV, tricuspid regurgitant jet velocity.

Figure 2

Stratifying heart failure with preserved ejection fraction into haemodynamic predominant phenotypes. LA, left atrial; L, left ventricular.

Figure 3

Normal left ventricular and left atrial pressure–volume loops using the CircAdapt model. (A) Wiggers diagram with pressure and volume tracing as a function of time during the cardiac cycle. (B) Left ventricular (top) and left atrial (bottom) pressure–volume loop. A-loop, atrial loop; AVC, aortic valve closure; AVO, aortic valve opening; EDPVR, end-diastolic pressure volume relationship; ESPVR, end-systolic pressure volume relationship; IVC, isovolumetric contraction; IVR, isovolumetric relaxation; LA, left atrium; LV, left ventricle; MVC, mitral valve closure; MVO, mitral valve opening; V-loop, ventricular loop.

Figure 4

Comparison of left ventricular and left atrial pressure–volume loops and tracings in normal hearts, left atrial and left ventricular phenotypes without and with mitral regurgitation (MR). A-loop, atrial loop; LA, left atrium; V-loop, ventricular loop.

Figure 5

Proposed treatment strategy of mitral regurgitation (MR) in heart failure with preserved ejection fraction (HFpEF). LA, left atrium; SGLT-2, sodium–glucose cotransporter 2; RAAS, renin–angiotensin–aldosterone system.