Atrial functional mitral regurgitation – current concepts in mechanisms, imaging, and management

Atrial functional mitral regurgitation (AF-MR) has emerged as a distinct subtype of secondary mitral regurgitation (MR) in the context of heart failure with preserved ejection fraction (HFpEF) and atrial fi brillation, indicating advanced left atrial disease. This review outlines current knowledge in terms of pathophysiology, diagnosis, and therapy and highlights areas for further research. The differentiation between AF-MR and ventricular functional MR (VF-MR), primarily attributed to left ventricular (LV) remodeling, has important pathophysiological, diagnostic and treatment implications. Three-dimensional (3D) echocardiography and atrial function assessment have enabled detailed characterization of the underlying mechanism and guidance of treatment of AF-MR. Integrated therapeutic management ranges from optimal medical therapy for HFpEF, catheter ablation (CA), mitral valve annuloplasty or transcatheter edge-to-edge repair. AF-MR is a distinct disease with growing significance driven by left atrial cardiomyopathy. The combination of advanced imaging, optimal medical therapy, and interventional strategies may improve prognosis. More detailed research in patient selection and timing of intervention is required to facilitate clinical outcomes.