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Observational Study
. 2024 Aug 1;7(8):e2428032.
doi: 10.1001/jamanetworkopen.2024.28032.

Clinical Outcomes of Mitral Valve Surgery in Atrial Functional Mitral Regurgitation in the REVEAL-AFMR Registry

Nobuyuki Kagiyama  1 , Tomohiro Kaneko  1 , Masashi Amano  2 , Yukio Sato  3 , Yohei Ohno  4 , Masaru Obokata  5 , Kimi Sato  6 , Taiji Okada  7 , Naoki Hoshino  8 , Kentaro Yamashita  9 , Yuko Katsuta  10 , Yuki Izumi  11 , Mitsuhiko Ota  12 , Yasuhide Mochizuki  13 , Kaoruko Sengoku  14 , Shunsuke Sasaki  15 , Fukuko Nagura  16 , Nanaka Nomura  17 , Ryo Nishikawa  18 , Nahoko Kato  19 , Takahiro Sakamoto  20 , Noriko Eguchi  21 , Maiko Senoo  22 , Mariko Kitano  23 , Yoichi Takaya  24 , Yoshihito Saijo  25 , Hidekazu Tanaka  9 , Kotaro Nochioka  10 , Nami Omori  2 , Minoru Tabata  26 , Tohru Minamino  1 , Naoki Hirose  27 , Kojiro Morita  28 , Tomoko Machino-Ohtsuka  6 , Victoria Delgado  29 , Yukio Abe  17
Affiliations
Observational Study

Clinical Outcomes of Mitral Valve Surgery in Atrial Functional Mitral Regurgitation in the REVEAL-AFMR Registry

Nobuyuki Kagiyama et al. JAMA Netw Open. .

Abstract

Importance: The characteristics and treatment strategies of atrial functional mitral regurgitation (AFMR) are poorly understood.

Objective: To investigate the prevalence, clinical characteristics, and outcomes of mitral valve (MV) surgery in AFMR.

Design, setting, and participants: This retrospective cohort study, called the Real-World Observational Study for Investigating the Prevalence and Therapeutic Options for Atrial Functional Mitral Regurgitation (REVEAL-AFMR), was conducted across 26 Japanese centers (17 university hospitals, 1 national center, 3 public hospitals, and 5 private hospitals). All transthoracic echocardiography procedures performed from January 1 to December 31, 2019, were reviewed to enroll adult patients (aged ≥20 years) with moderate or severe AFMR, defined by preserved left ventricular function, a dilated left atrium, and an absence of degenerative valvular changes. Data were analyzed from May 8, 2023, to May 16, 2024.

Exposures: Mitral valve surgery, with or without tricuspid valve intervention.

Main outcomes and measures: The primary composite outcome included heart failure hospitalization and all-cause mortality.

Results: In 177 235 patients who underwent echocardiography, 8867 had moderate or severe MR. Within this group, 1007 (11.4%) were diagnosed with AFMR (mean [SD] age, 77.8 [9.5] years; 55.7% female), of whom 807 (80.1%) had atrial fibrillation. Of these patients, 113 underwent MV surgery, with 92 (81.4%) receiving concurrent tricuspid valve surgery. Patients who underwent surgery were younger but had more severe MR (57.5% [n = 65] vs 9.4% [n = 84]; P < .001), a larger mean (SD) left atrial volume index (152.5 [97.8] mL/m2 vs 87.7 [53.1] mL/m2; P < .001), and a higher prevalence of heart failure (according to the New York Heart Association class III [marked limitation of physical activity] or class IV [symptoms of heart failure at rest], 26.5% [n = 30] vs 9.3% [n = 83]; P < .001) than those who remained under medical therapy. During a median follow-up of 1050 days (IQR, 741-1188 days), 286 patients (28.4%) experienced the primary outcome. Despite a more severe disease status, only the surgical group showed a decrease in natriuretic peptide levels at follow-up and had a significantly lower rate of the primary outcome (3-year event rates were 18.3% vs 33.3%; log-rank, P = .03). Statistical adjustments did not alter these findings.

Conclusions and relevance: The findings of this cohort study suggest that in patients with AFMR, who were typically older and predominantly had atrial fibrillation, MV surgery was associated with lower rates of adverse clinical outcomes. Future studies are warranted to investigate a possible causal relationship to better regulate cardiovascular medicine.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Kagiyama reported receiving research grants from AMI Inc and EchoNous Inc outside the submitted work. Dr Kaneko reported receiving grants from the Japan Society for the Promotion of Science (JSPS) Grant-in-Aid for Scientific Research (KAKENHI) during the conduct of the study. Dr Obokata reported receiving research grants from the Fukuda Foundation for Medical Technology, the Mochida Memorial Foundation for Medical and Pharmaceutical Research, Nippon Shinyaku, the Takeda Science Foundation, the Japanese Circulation Society, the Japanese College of Cardiology, and JSPS KAKENHI and receiving speakers honoraria from Novartis, Otsuka Pharmaceutical, and Boehringer-Ingelheim. Prof Delgado reported receiving personal fees for consulting and speaking from Edwards Lifesciences; for speaking from JenaValve, GE HealthCare, Novartis, Philips, and Medtronic; and for consulting from Novo Nordisk and Merck Sharp & Dohme outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Patient Flowchart
AFMR indicates atrial functional mitral regurgitation; LA, left atrium; MR, mitral regurgitation; MV, mitral valve; SAM, systolic anterior motion. aDefined as a left ventricular ejection fraction less than 50% and/or wall motion abnormality. bDefined as an LA volume index less than 38 mL/m2 for men and less than 41 mL/m2 for women (or an LA diameter <40 mm for men and <37 mm for women).
Figure 2.
Figure 2.. Changes in Mitral Regurgitation (MR) Severity by Treatment Group
Atrial functional MR was well managed by surgery with only 1.9% (n = 2) of patients with recurrent severe MR, whereas 80.4% (n = 450) of patients who were medically treated presented moderate or severe MR at the latest follow-up. MV indicates mitral valve. aA total of 334 patients were lost to follow-up (266 with moderate MR, 43 with moderate-to-severe MR, 25 with severe MR). bA total of 11 patients were lost to follow-up (3 with moderate MR, 3 with moderate-to-severe MR, 5 with severe MR).
Figure 3.
Figure 3.. Kaplan-Meier Curve Analyses for Heart Failure Hospitalization and All-Cause Mortality
A, Patients who underwent mitral valve (MV) surgery had a significantly lower event rate compared with those treated medically. B, Propensity score time 0 matching to minimize immortal time bias showed similar results. HR indicates hazard ratio.
Figure 4.
Figure 4.. Associations of Treatment Types With Outcomes in Subgroup Analyses in the Matched Cohort
Subgroups of age (≥75 years), sex, the severity of tricuspid regurgitation (TR), left atrium (LA) diameter (≥55 mm), and left ventricle (LV) diameter (end-diastolic; ≥55 mm) were not associated with outcomes. The treatment effect favored mitral valve (MV) surgery in patients with severe mitral regurgitation (MR) compared with those with nonsevere MR. Markers indicate hazard ratios (HRs); horizontal lines, 95% CIs.
See this image and copyright information in PMC

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