Mitral annulus components in patients with metabolic syndrome and relapse after atrial fibrillation cardioversion
Authors: Toader D M , Tartea G , Munteanu O , Craciun-Mirescu A , Stanisor R , Chitu M , Bezna C M , Tudorascu P , Donoiu I , Istratoaie O , Militaru C 
Published: January 2025

Abstract

Background
Metabolic syndrome (MetS) is associated with recurrent episodes of atrial fibrillation (AF) due to atrial remodeling. Four-dimensional transesophageal echocardiography (4DTEE) is an ideal imaging technique to evaluate these patients' complex morphology of the mitral valve apparatus (MVA).

Purpose
The study aimed to find some features of MVA components in patients with MetS and persistent AF and if some of them could be indicative of relapse after cardioversion.

Methods
The study enrolled 101 patients with persistent AF and mild/moderate functional mitral regurgitation (FMR) before cardioversion. According to the latest guidelines, 46(45,54%) of the patients were diagnosed with MetS. After performing two-dimensional transthoracic echocardiography (2DTTE), the study included only mild/moderate FMR patients. 4D TEE permitted a detailed examination of the MVA components, using an E95 machine for acquisition and an ECHOPAC 204 for image postprocessing with mitral valve quantification (MVQ) software. The studied measured: annulus area (AA)3D, annulus perimeter (AP), antero-posterior diameter (APD), posteromedial-anterolateral diameter (PM-ALD), commissural diameter (CD), inter-trigonal distance (ITd), annular height (AH), non-planar angle (NPa), mitral-aortic angle (MAa), anterior leaflet area (ALA), posterior leaflet area (PLA), anterior leaflet length (ALL), posterior leaflet length (PLL), anterior leaflet angle (ALa), posterior leaflet angle (PLa), tenting height (TH), tenting area (TA), and tenting volume (TV).

Results
1. Relapse after cardioversion were 32,6% in MetS (+) patients and 17,85% in MetS (-) group. 2. Features of MA parameters in patients with or without MetS were: AA3D 13.09 vs. 12.18 (p= 0.02), AP 12.89 vs. 12.11 (P = 0.01), APD 3.75 vs. 3.6 (P = 0.07), PM-ALD 4.18 vs. 3.98 (P = 0.04), CD 4.2 vs. 4.04 (P = 0.08), and 2.91 vs. 2.88 (P = 0.7), AH 5.85 vs. 5.32 (P = 0.03), NPa 160.39 vs. 157.89 (P = 0.2), MAa 124 vs. 123.4 (P = 0.7), ALA 6.74 vs. 6.03 (P = 0.006), PLA 7.64 vs. 6.96 (P = 0.03), ALL 2.21 vs. 2.17 (P = 0.4), PLL 1.74 vs. 1.72 (P = 0.7), Ala 18.26 vs 17.56 (P = 0.6), Pla 23.41 vs 22.56 (P = 0.5), TH 1.43 vs 1.01 (P = 0.004), TA 1.85 vs 1.51 (P = 0.03), TV 2.76 vs 2.18 (P = 0.03). 3. Parameters that showed significant differences in patients with relapse with or without MetS were AA3D 15.25 vs. 13.45 (P = 0.03), AP 4.22 vs. 13.02 (p=0.04), PM-ALD 4.61 vs. 3.99 (P = 0.008), CD 4.75 vs. 4.02 (P &lt; 0.0001), AH 6.37 vs. 4.91 (P = 0.004), and for the leaflets ALA 8.25 vs. 7.18 (P = 0.02), PLA 9.31 vs 7.97 (P = 0.04), TA 2.66 vs 1.79 (P = 0.02), TV 4.03 vs 2.27 (P = 0.006).

Conclusions
1. Mitral annulus and mitral leaflet remodeling were more evident in patients with MetS with or without relapse. 2. The annular area, annular perimeter, posteromedial to anterolateral diameter, commissural diameter, leaflets area, and tenting parameters are most damaged in patients with MetS and relapse after the first cardioversion.
4DE reconstruction of the mitral valve
Mitral valve apparatus evaluation by MVQ