Association between AV valve regurgitation and rhythm stability following electrical cardioversion of persistent atrial fibrillation – a retrospective analysis

Background

Atrial fibrillation and atrioventricular (AV) valve regurgitation are frequent comorbidities, each promoting the other condition through various mechanisms. The coexistence of the two conditions limits the prognosis of patients and the treatment options at hand. Electrical cardioversion is the primary treatment for patients with persistent atrial fibrillation (AF), however, evidence is limited on its effectiveness and longevity in patients with relevant AV valve regurgitation. It is also controversial, whether rhythm control has the potential to improve AV valve regurgitation.

The aim of the present study is therefore to investigate the association between rhythm stability and AV valve regurgitation severity in patients with persistent AF following electrical cardioversion.

Methods

We conducted a retrospective observational study including patients with relevant AV valve regurgitation (moderate or severe mitral (MR) or tricuspid regurgitation (TR)) undergoing electrical cardioversion for persistent AF at the University Heart Center Freiburg-Bad Krozingen between Jan 2008 and Dec 2022. Patients were screened for outpatient or inpatient readmission to our clinic. Follow-up information on heart rhythm and severity of AV valve regurgitation was obtained.

Based on rhythm stability at follow-up, patients were stratified into a sinus rhythm group and a group with AF recurrence. The primary endpoint of the study was improvement in regurgitation severity, defined as a reduction in regurgitation severity grade 0-3 at follow-up compared to baseline. For secondary endpoint, we evaluated predictors for an improved valve function at follow-up.

Results

A total of 1283 patients with relevant MR and 1046 patients with relevant TR underwent electrical cardioversion. Of these, follow-up information was available for 484 patients with relevant MR on average 391 days (IQR 58–1907 days) after cardioversion and for 360 patients with relevant TR after 667 days (IQR 73-2405 days). At follow-up, stable sinus rhythm was present in 46% of patients with relevant baseline MR and 42% of patients with relevant baseline TR. In comparison to patients with AF recurrence, patients with stable sinus rhythm exhibited more often an improvement in MR severity at follow-up (63 vs 45%, p < .001). This effect was even more pronounced in patients with relevant TR (79 vs 45%, p < .001). Multivariate logistic regression identified sinus rhythm at follow-up as an independent predictor for an improved valve function in both mitral and tricuspid regurgitation (MR: OR: 1.93; 95%CI: 1.11-3.38; p = 0.019; TR: OR: 5.59, 95%CI: 2.46-13.65, p < .001), whereas left atrial diameter at baseline was predictive only for MR improvement (MR: OR = 1.07, 95%CI: 1.01-1.12, p =  0.014).

Conclusion

In patients with ≥ moderate AV valve regurgitation, rhythm stability following electrical cardioversion was associated with a significant improvement in MR and TR severity.