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CLINICAL STUDY: ATRIAL FIBRILLATION

Isolated annular dilation does not usually cause important functional mitral regurgitation

Comparison between patients with lone atrial fibrillation and those with idiopathic or ischemic cardiomyopathy

Yutaka Otsuji, MD, FACC^*,*, Toshiro Kumanohoso, MD^*, Shiro Yoshifuku, MD^*, Keiko Matsukida, MD^*, Chihaya Koriyama, MD, Akira Kisanuki, MD^*, Shinichi Minagoe, MD^*, Robert A. Levine, MD, FACC and Chuwa Tei, MD, FACC^*

^* First Department of Internal Medicine, , Kagoshima, Japan
Department of Public Health, Kagoshima University School of Medicine, Kagoshima, Japan
Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Boston, Massachusetts, USA

Manuscript received September 25, 2000; revised manuscript received February 20, 2002, accepted February 25, 2002.

^* Reprint requests and correspondence: Dr. Yukata Otsuji, First Department of Internal Medicine, Kagoshima University School of Medicine, 8-35-1 Sakuragaoka, Kagoshima City, 890-8520, Japan.
yutaka{at}m.kufm.kagoshima-u.ac.jp

OBJECTIVES: We sought to test whether isolated mitral annular (MA) dilation can cause important functional mitral regurgitation (MR).

BACKGROUND: Mitral annular dilation has been considered a primary cause of functional MR. Patients with functional MR, however, usually have both MA dilation and left ventricular (LV) dilation and dysfunction. Lone atrial fibrillation (AF) can potentially cause isolated MA dilation, offering a unique opportunity to relate MA dilation to leaflet function.

METHODS: Mid-systolic MA area, MR fraction, LV volumes and papillary muscle (PM) leaflet tethering length were compared by echocardiography among 18 control subjects, 25 patients with lone AF and 24 patients with idiopathic or ischemic cardiomyopathy (ICM).

RESULTS: Patients with lone AF had a normal LV size and function, but MA dilation (isolated MA dilation) significant and comparable to that of patients with ICM (MA area: 8.0 ± 1.2 vs. 11.6 ± 2.3 vs. 12.5 ± 2.9 cm² [control vs. lone AF vs. ICM]; p < 0.001 for both lone AF and ICM). However, patients with lone AF had only modest MR, compared with that of patients with ICM (MR fraction: –3 ± 8% vs. 3 ± 9% vs. 36 ± 25%; p < 0.001 for patients with ICM). Multivariate analysis identified PM tethering length, not MA dilation, as an independent primary contributor to MR.

CONCLUSIONS: Isolated annular dilation does not usually cause moderate or severe MR. Important functional MR also depends on LV dilation and dysfunction, leading to an altered force balance on the leaflets, which impairs coaptation.

Abbreviations and Acronyms   AF   atrial fibrillation   EF   ejection fraction   ICM   idiopathic or ischemic cardiomyopathy   IMLC   incomplete mitral leaflet closure   LV   left ventricle or ventricular   MA   mitral annulus or annular   MR   mitral regurgitation   PM   papillary muscle

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