Combined Atrial Functional Mitral and Tricuspid Regurgitation in Atrial Fibrillation: Prevalence, Associated Factors, and Three-Dimensional Valve Remodeling

Q: What are the key findings of this study?

Combined moderate/severe functional mitral and tricuspid regurgitation occurred in 22.4% of persistent AF patients and was independently associated with female sex (OR 4.60, p=0.015).

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Persistent atrial fibrillation without organic mitral regurgitation or moderate/severe aortic valve disease (n=125). Intervention: Combined moderate or severe functional mitral and tricuspid regurgitation (evaluated with 3D transesophageal echocardiography) vs. No clinically significant mitral or tricuspid regurgitation. Primary outcome: Combined moderate or severe functional mitral and tricuspid regurgitation (independent association with female sex) (OR 4.60, 95% CI 1.35-15.69, p=0.015).

Q: What does this research mean for the field?

Combined moderate-to-severe functional mitral and tricuspid regurgitation occurs in 22.4% of persistent atrial fibrillation patients without organic valve disease and is independently associated with female sex, lower left ventricular ejection fraction, and larger right atrial diameter. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Andrei-Alexandru Nour; Diana-Ruxandra Hădăreanu; Despina-Manuela Toader; Călin-Dinu Hădăreanu; Maria Iovănescu; Anca Mihu-Marinescu; Georgică-Costinel Târtea; Ionuţ Donoiu; Edme-Roxana Mustafa; Oana Munteanu-Mirea; Răzvan-Ilie Radu; Octavian Istrătoaie; Cristina Florescu

doi:10.3390/jcm15135198

July 2, 2026Journal of Clinical MedicineOpen Access

Combined Atrial Functional Mitral and Tricuspid Regurgitation in Atrial Fibrillation: Prevalence, Associated Factors, and Three-Dimensional Valve Remodeling

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Key result

Female sex is linked to ~4.6-fold higher odds of combined functional MR and TR in persistent AF.

OR 4.60
95% CI 1.35-15.69
P=0.015
n=125

Figures

Why the study?

The prevalence and structural characteristics of combined functional mitral and tricuspid regurgitation in atrial fibrillation were not well defined.

What is the prevalence, 3D mitral valve remodeling profile, and independent predictors of combined moderate or severe functional mitral and tricuspid regurgitation in patients with persistent atrial fibrillation?

Key Points

To determine the prevalence, clinical characteristics, and structural factors associated with combined clinically significant mitral and tricuspid regurgitation in patients with atrial fibrillation.
Prospective observational study (REMO-FIB) evaluating 175 consecutive persistent atrial fibrillation patients with transesophageal echocardiography and 3D mitral valve analysis.
Analyzed 125 patients after excluding organic mitral regurgitation and significant aortic valve disease, categorized by moderate/severe regurgitation status.
Multivariable logistic regression assessed clinical and echocardiographic factors independently associated with combined mitral and tricuspid regurgitation.
Among 125 analyzed patients, 53 (42.4%) had no significant regurgitation, 33 (26.4%) had isolated MR, 11 (8.8%) had isolated TR, and 28 (22.4%) had combined MR/TR.
Combined MR/TR was associated with higher heart failure prevalence (92.9% vs. 67.9%, p = 0.048), lower ejection fraction (47.5% vs. 55.0%, p = 0.006), larger mitral annular perimeter (129.0 vs. 121.0 mm, p = 0.009), and greater tenting area (2.1 vs. 1.4 cm2, p = 0.002) compared to no regurgitation.
Independent predictors of the combined phenotype were female sex (OR 4.60, p = 0.015), lower ejection fraction (OR 0.47 per SD, p = 0.005), and larger right atrial diameter (OR 1.85 per SD, p = 0.037), with good model discrimination (AUC 0.81).

Study Design

Type

Cohort (n=125)

Multicenter

No

Structured PICO

What is the prevalence, 3D mitral valve remodeling profile, and independent predictors of combined moderate or severe functional mitral and tricuspid regurgitation in patients with persistent atrial fibrillation?

P

Population

125 adults (median age 68.0 years, IQR 63.0-72.0) with persistent atrial fibrillation undergoing transesophageal echocardiography before electrical cardioversion, free of organic mitral or significant aortic valve disease, evaluated cross-sectionally.

E

Exposure

Comprehensive transesophageal echocardiography (TEE) with three-dimensional (3D) mitral valve analysis; exposure to combined moderate or severe atrial functional mitral regurgitation (MR) and tricuspid regurgitation (TR)

C

Comparator

Patients without clinically significant MR or TR (n=53), isolated moderate/severe MR (n=33), or isolated moderate/severe TR (n=11)

O

Outcome

Prevalence of combined moderate or severe functional MR and TR, associated 3D mitral valve remodeling parameters, and independent clinical and echocardiographic predictors via multivariable logistic regressionsurrogate

Main Result

Odds Ratio: 4.6 (95% CI 1.35–15.69)

Absolute Event Rate: 53.6% vs 27.5%

p-value: p=0.015

Limitations

Relatively small sample size (n=125), particularly for the isolated TR subgroup (n=11), and limited events (n=28) for multivariable modeling
Cross-sectional design precludes evaluation of valvular disease progression over time or long-term clinical outcomes
Difficulty distinguishing atrial from ventricular functional regurgitation in cases with mixed features
Single-center study restricted to persistent AF patients referred for TEE prior to electrical cardioversion, limiting generalizability
Atrial remodeling was assessed using linear dimensions rather than volumetric parameters, and 3D valve analysis was restricted to the mitral valve
Relatively small sample size, particularly for the isolated TR subgroup (n=11), and limited events (n=28) in the combined MR+TR group affecting the events-per-variable ratio
Cross-sectional analysis does not allow evaluation of valvular disease progression over time or impact on long-term clinical outcomes
Potential difficulty distinguishing between atrial and ventricular functional regurgitation in cases with mixed features
Single-center study (REMO-FIB) of persistent AF patients referred for TEE before electrical cardioversion, limiting generalizability
Atrial remodeling was assessed using linear dimensions rather than volumetric parameters, and 3D analysis was performed only for the mitral valve

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Implication

Combined moderate or severe functional mitral and tricuspid regurgitation affects over one-fifth (22.4%) of persistent AF patients without organic valve disease and is characterized by advanced biatrial remodeling, insufficient mitral leaflet adaptation on 3D TEE, higher heart failure burden, and independent associations with female sex, right atrial enlargement, and lower LVEF.

Abstract

Background/Objectives: Atrial fibrillation (AF) may cause functional mitral regurgitation (MR) and tricuspid regurgitation (TR) through atrial remodeling and annular dilation. However, the prevalence and structural characteristics of combined MR/TR in AF are not well defined. We aimed to determine the prevalence, clinical profile, and factors associated with combined clinically significant MR and TR in AF patients. Methods: In this prospective observational study (REMO-FIB), 175 consecutive AF patients underwent comprehensive transesophageal echocardiography with three-dimensional mitral valve analysis. After excluding organic MR and significant aortic valve disease, 125 patients were analyzed. Patients were classified into four groups according to the presence of moderate/severe MR and/or TR. Multivariable logistic regression evaluated factors associated with the combined phenotype. Results: Among 125 patients, 53 (42.4%) had no significant MR/TR, 33 (26.4%) had isolated MR, 11 (8.8%) had isolated TR, and 28 (22.4%) had combined MR/TR. Compared with patients without regurgitation, those with combined MR/TR had higher symptom burden (EHRA class, p = 0.036), more heart failure (92.9% vs. 67.9%, p = 0.048), larger left (47.0 vs. 42.0 mm, p = 0.002) and right atria (42.0 vs. 38.0 mm, p < 0.001), higher pulmonary artery pressure (40.0 vs. 28.0 mmHg, p = 0.004), and lower left ventricular ejection fraction (47.5% vs. 55.0%, p = 0.006). Three-dimensional analysis showed larger mitral annular perimeter (129.0 vs. 121.0 mm, p = 0.009), greater annular area (12.7 vs. 11.1 cm2, p = 0.014), longer anterior leaflet length (26.5 vs. 24.0 mm, p < 0.001), and greater tenting area (2.1 vs. 1.4 cm2, p = 0.002). Factors independently associated with the combined phenotype were female sex (OR 4.60, p = 0.015), lower ejection fraction (OR 0.47 per SD, p = 0.005), and larger right atrial diameter (OR 1.85 per SD, p = 0.037). Model discrimination was good (AUC 0.81). Conclusions: Combined moderate/severe MR and TR affects over one-fifth of AF patients without organic valve disease and is associated with advanced biatrial remodeling, adverse symptoms, and heart failure. Comprehensive assessment of both atrioventricular valves should be considered in AF.

Discussion

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Cite This Study

Nour et al. (2026) conducted a cohort in Persistent atrial fibrillation without organic mitral regurgitation or moderate/severe aortic valve disease (n=125). Combined moderate or severe functional mitral and tricuspid regurgitation (evaluated with 3D transesophageal echocardiography) vs. No clinically significant mitral or tricuspid regurgitation was evaluated on Combined moderate or severe functional mitral and tricuspid regurgitation (independent association with female sex) (OR 4.60, 95% CI 1.35-15.69, p=0.015). Combined moderate/severe functional mitral and tricuspid regurgitation occurred in 22.4% of persistent AF patients and was independently associated with female sex (OR 4.60, p=0.015).

synapsesocial.com/papers/6a48a3cb89561a0c2d78d8c1 https://doi.org/10.3390/jcm15135198

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Combined Atrial Functional Mitral and Tricuspid Regurgitation in Atrial Fibrillation: Prevalence, Associated Factors, and Three-Dimensional Valve Remodeling

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Combined Atrial Functional Mitral and Tricuspid Regurgitation in Atrial Fibrillation: Prevalence, Associated Factors, and Three-Dimensional Valve Remodeling

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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