Interplay between imaging and electrophysiology: mitral valve remodeling in atrial fibrillation

Background There is a pathophysiological link between left atrial remodeling, atrial fibrillation (AF), and mitral valve adaptation without left ventricular (LV) dysfunction. It remains unclear whether AF directly drives MV remodeling and regurgitation. Purpose Assess annular size, leaflet morphology, and leaflet-to-annulus adaptation in patients with persistent and paroxysmal AF to determine whether prolonged exposure to arrhythmia-induced stress leads to maladaptive MV changes. Methods In this prospective, non-randomized, single-center cohort, 44 patients with AF were enrolled and stratified as paroxysmal (n = 15) or persistent (n = 29). Patients with LV dilatation or dysfunction and primary MV disease were excluded. All participants underwent comprehensive transthoracic echocardiographic, followed by three-dimensional (3D) transesophageal echocardiography. Image datasets were analyzed offline using multiplanar reconstruction (MPR) and a quantitative 3D modeling software. Quantified indices included anteroposterior (AP) and intercommissural (IC) diameters, annular area (AA), circumferential length (CL), anterior and posterior leaflet lengths and areas, total leaflet area (TLA), total leaflet-to-annulus area ratio (TLA/AA), anterior-to-posterior leaflet length ratio (ALL/PLL), and total leaflet length-to-AP ratio (TLL/AP). Statistical analyses included t-tests, χ² tests, and Pearson’s correlation coefficient (r), with p < 0.05 considered significant. Results Baseline characteristics were comparable between groups. Persistent AF was associated with greater left atrial volume (49.96 ± 21.54 vs 35.13 ± 12.66 mL/m²; p = 0.006). Both groups had mild MV regurgitation. The echocardiographic analysis revealed significantly larger AP (17.61 ± 3.54 vs 15.93 ± 1.90 mm/m²; p = 0.046), AA (578.43 ± 155.62 vs 460.92 ± 150.41 mm²/m²; p = 0.021), and anterior leaflet area (ALA) (375.80 ± 146.59 vs 276.26 ± 94.09 mm²/m²; p = 0.009) in the persistent AF group. TLA was also increased (630.36 ± 178.12 vs 497.28 ± 161.75 mm²/m²; p = 0.018). The TLL/AP ratio was reduced in persistent AF (0.98 ± 0.11 vs 1.05 ± 0.79; p = 0.02), and asymmetric remodeling was evident with a higher ALL/PLL ratio (2.30 ± 0.70 vs 1.79 ± 0.30; p = 0.002). The other measures were comparable across groups. There was a strong positive correlation in all patients between AA and ALA (Pearson’s r = 0.993; p < 0.01). Conclusions Persistent AF is associated with a more pronounced degree of mitral valve (MV) remodeling. Three-dimensional echocardiography allows quantitative assessment of these geometric alterations, revealing asymmetric anterior–posterior leaflet adaptation and a reduction in coaptation reserve as potential early markers of maladaptive changes. This approach may represent a useful tool for identifying AF patients at risk of atrial functional mitral regurgitation and for guiding timely rhythm-control therapy.Correlation between AA and ALA