Search Results (190)

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. Full article

Background/Objectives: Cardiovascular involvement is among the most consequential sequelae of SARS-CoV-2 infection. Myocardial injury, arrhythmia, and thromboembolic disease have been characterized in depth, yet the relationship between COVID-19 and valvular heart disease (VHD), and its interplay with heart failure (HF), has received comparatively limited synthesis. This narrative review consolidates current evidence on the mechanisms, diagnosis, differential assessment, and clinical outcomes linking acute and post-acute COVID-19 to valvular dysfunction and to incident or worsening heart failure, with emphasis on practical implications for cardiologists and internists. Methods: We searched PubMed, Scopus, and Web of Science (January 2020–January 2026) for studies on valvular dysfunction, heart failure, myocardial injury, and endothelial pathology in SARS-CoV-2 infection, and synthesized findings narratively. Results: Convergent pathways—endothelial injury, systemic hyperinflammation, micro- and macrovascular thrombosis, and pressure–volume overload—contribute to functional and, less frequently, structural valvular changes. Available evidence suggests that clinically relevant post-COVID valvular abnormalities are more often secondary/functional (mitral and tricuspid regurgitation) than primary structural lesions, although dedicated prospective valvular studies remain scarce. Pre-existing severe VHD markedly worsens acute COVID-19 prognosis. Elevated NT-proBNP, troponin, and interleukin-6 consistently predict decompensation and mortality, and a substantial minority of survivors show persistent fibrotic pulmonary changes and restrictive ventilatory defects on follow-up (pulmonary rather than cardiac findings). Conclusions: Post-COVID valvular dysfunction appears, on currently available but largely indirect evidence, predominantly functional and inflammation-related, and may overlap with HFpEF phenotypes in selected patients when objective diagnostic criteria are fulfilled. Biomarker-guided, multimodality follow-up is reasonable in high-risk survivors, and prospective longitudinal studies with standardized valvular endpoints remain a priority. Dedicated longitudinal evidence on valvular outcomes specifically remains very limited. Full article

Mitral valve regurgitation is the second most common valvular heart disease in Europe, and an estimated 10% of individuals older than 75 years have severe mitral regurgitation. Mitral valve repair is the preferred strategy to treat mitral regurgitation and is associated with better outcomes than mitral valve replacement. Despite the proven efficacy of surgical repair, available data in functional aetiologies reported a non-negligible rate of echocardiographically detected severe mitral regurgitation within ten years of the index procedure, in some cases resulting in redo interventions. Data on the optimal management of patients with failed mitral repair remain limited. The aim of this review is to present the available approaches for treating failed mitral valve repair and to describe criteria for selecting the most appropriate strategy on the basis of the underlying mechanism of repair failure, with respect to possible surgical re-repair and novel transcatheter edge-to-edge repair techniques in the presence of favourable mitral valve anatomies. Full article

Background and Clinical Significance: Carcinoid heart disease (CHD) is an uncommon valvular manifestation of neuroendocrine tumours, usually affecting right-sided cardiac valves. Left-sided involvement is rare and is generally associated with bronchopulmonary carcinoid, right-to-left shunting, or markedly elevated circulating vasoactive substances. Therapeutic decision-making is particularly challenging in advanced disease when severe tricuspid regurgitation occurs in patients at prohibitive surgical risk. Case Presentation: We report the case of a 61-year-old male patient with progressive dyspnoea, abdominal distension, lower-limb oedema, facial flushing, and 15 kg of unintentional weight loss. Transthoracic and transoesophageal echocardiography demonstrated torrential tricuspid regurgitation caused by thickened, retracted, and immobile leaflets, with additional mitral and aortic valve involvement, raising strong suspicion of CHD. An agitated-saline contrast study demonstrated delayed right-to-left shunting without patent foramen ovale, suggesting an extracardiac, likely intrapulmonary, shunt. Somatostatin receptor PET/CT identified a pancreatic lesion with metastatic disease, and bone marrow biopsy confirmed neuroendocrine tumour infiltration. Owing to prohibitive surgical risk, as reflected by a Tricuspid Regurgitation Impact Score (TRI-SCORE) with an estimated in-hospital mortality of 65%, unfavourable tricuspid anatomy for repair, and refractory venous congestion, heterotopic bicaval valve implantation was performed (TricValve system -P&F). Discussion: This case highlights the role of echocardiography in recognising the characteristic phenotype of CHD, detecting occult right-to-left shunting, and supporting selection of a palliative transcatheter intervention. It also illustrates the value of a multimodality diagnostic strategy integrating echocardiography, functional oncological imaging, and histopathology in tumour-related cardiac disease. Conclusions: In selected inoperable patients with advanced carcinoid-related tricuspid regurgitation, heterotopic bicaval valve implantation may represent a feasible strategy for reducing venous congestion and improving functional status. Full article

Transcatheter edge-to-edge repair (TEER) is a recent minimally invasive method of managing mitral regurgitation (MR) in dogs with myxomatous mitral valve disease (MMVD). As the goal of intervention is to minimize MR severity, this study aimed to determine the association between reduced MR and changes in myocardial work indices after TEER in dogs. Ten client-owned dogs with moderate-to-severe MR were enrolled in the study, and all underwent TEER with multimodal imaging guidance. Myocardial work was analyzed before and after the procedure, and the MR severity, transmitral pressure gradients, left atrial and ventricular measurements, and index of myocardial work (GWI: the total myocardial work during systole; GCW: work contributing to LV ejection; GWW: ineffective work that contributes to no forward displacement; and GWE: ratio of constructive work to total work) were calculated. TEER significantly reduced MR severity in the majority of dogs, and this MR decrease was associated with a greater efficiency of myocardial work, more constructive work, and less wasted energy. No significant negative associations of moderate post-procedure gradients with short-term clinical outcomes emerged. TEER-mediated reduction in MR improves myocardial function in dogs. However, long-term studies are also needed to examine the effects of residual MR and transmitral gradients on cardiac function and clinical outcome. Full article

Background/Objectives: Sex differences in ST-elevation myocardial infarction (STEMI) outcomes persist despite advances in primary percutaneous coronary intervention (PCI), but whether female sex independently influences early mortality remains unclear. study aimed to assess sex-based differences in clinical characteristics, management, in-hospital outcomes and to determine whether female sex independently predicts in-hospital mortality. Methods: This retrospective observational study included 512 consecutive patients with STEMI presenting within 6 h of symptom onset and treated with primary PCI. Clinical, laboratory, echocardiographic and angiographic data were analyzed. The primary endpoint was in-hospital mortality. Multivariable logistic regression identified independent predictors of mortality. Results: Women comprised 32.0% of the cohort and were older than men (median 69 vs. 59 years, p < 0.001), with a higher prevalence of diabetes and hypertension, but lower rates of smoking (all p < 0.001). Women had lower hemoglobin levels and a higher prevalence of moderate-to-severe mitral regurgitation (17.1% vs. 8.0%, p = 0.004). Procedural characteristics, including door-to-balloon time and complete revascularization, were similar between sexes. Crude in-hospital mortality was higher in women (13.4% vs. 7.5%, p = 0.047); however, female sex was not independently associated with mortality after adjustment (adjusted OR 1.07, 95% CI 0.48–2.41; p = 0.864). Lower LVEF and reduced GFR were the strongest independent predictors of death. Conclusions: Higher mortality in women is primarily driven by a more adverse clinical profile rather than sex itself, emphasizing the importance of early risk stratification and management. Full article

Background: Ischemic cardiomyopathy (ICM) is characterized by heterogeneous structural remodeling that is not fully captured by conventional systolic metrics. How multidimensional structural echocardiographic information can improve pre-revascularization risk stratification remains unclear. Methods: In this retrospective study, 989 patients with ICM undergoing coronary angiography and revascularization were included in the derivation cohort, and 482 patients from an independent campus served as the validation cohort, with a median follow-up duration of 6.5 years. The primary endpoint was cardiovascular mortality. Eight routinely acquired pre-revascularization echocardiographic structural variables were analyzed. Unsupervised clustering identified structural clusters, and principal component analysis (PCA) was used to derive a structural risk score. Associations with cardiovascular mortality were assessed using the Cox proportional hazards model, and prognostic performance was evaluated by comparing individual echocardiographic predictors using Harrell’s C-index and time-dependent AUC analyses. Results: Three distinct structural clusters emerged, differing in chamber size, systolic function, pulmonary pressures, mitral regurgitation severity, and long-term cardiovascular mortality. The PCA-derived structural risk score, reflecting the dominant axis of remodeling and volume overload, showed association with cardiovascular mortality in the derivation cohort and remained independently predictive after multivariable adjustment. Compared with single echocardiographic parameters, both the structural clusters and the risk score demonstrated superior discriminative performance. In the validation cohort, the structural score again showed a consistent and independent association with cardiovascular mortality. Conclusions: Multidimensional structural echocardiographic assessment reveals clinically meaningful remodeling patterns and enables construction of a robust PCA-derived structural risk score. Both approaches provide prognostic information beyond individual echocardiographic measures and support more precise pre-revascularization risk stratification in patients with ICM. Full article

Background/Objectives: Atrial fibrillation (AF) is common in heart failure with preserved ejection fraction (HFpEF) and is associated with worse symptoms and prognosis. Emerging evidence suggests that sex modifies the AF–HFpEF relationship through differences in atrial remodeling, comorbidity burden, and hemodynamic vulnerability. This study aimed to evaluate how sex and AF jointly relate to differences in cardiac structure, clinical characteristics, and outcomes in HFpEF. Methods: We retrospectively analyzed 622 patients with HFpEF admitted between January 2019 and May 2023. Patients were categorized into four predefined clinical subgroups: women without AF, women with AF, men without AF, and men with AF. The primary endpoint was first rehospitalization for HF decompensation. Results: Over a mean follow-up of 48.6 ± 16.4 months, 181 patients (29.1%) were rehospitalized for worsening HF, with the highest event burden observed in men with AF. Sex and AF were each associated with distinct clinical and remodeling profiles, without significant sex-by-AF interaction effects. AF was independently associated with a higher risk of HF rehospitalization (HR 1.45, 95% CI 1.06–1.99, p = 0.021), whereas female sex was protective (HR 0.71, 95% CI 0.53–0.97, p = 0.032). Men with AF exhibited the most adverse remodeling profile, characterized by the largest unindexed left atrial and left ventricular dimensions, the highest prevalence of significant tricuspid regurgitation, and the lowest event-free survival (HR 1.92, 95% CI 1.23–2.99, p = 0.004). In contrast, women with AF more frequently displayed concentric remodeling and significant mitral regurgitation. Independent predictors of rehospitalization included higher NYHA functional class and lower left ventricular EF within the preserved EF range. Conclusions: Sex and AF were independently associated with substantial differences in cardiac structure, clinical characteristics and prognosis in HFpEF. Men with AF represent the highest-risk subgroup, driven by more advanced structural remodeling and valvular dysfunction. These findings suggest that simple sex- and rhythm-based classification may provide complementary information for risk stratification and management in HFpEF. Further validation in independent cohorts is warranted. Full article

Background: Mitral regurgitation due to Barlow’s disease remains surgically demanding. Despite widespread experience, consensus is lacking on whether the Alfieri repair can serve as a deliberate and durable rather than a rescue strategy in this complex pathology. Methods: We retrospectively analyzed patients undergoing mitral valve repair due to severe mitral regurgitation resulting from Barlow’s disease using either the Alfieri or Neochordae repair techniques. Patients received a uniform semi–rigid annuloplasty ring, while leaflet resection and concomitant coronary or aortic procedures were excluded. Results: Baseline demographics and echocardiography were broadly comparable. Perioperative mortality was 0% in both cohorts, with similarly low rates of major complications. Aortic cross–clamp time was significantly shorter with Alfieri repair (p < 0.001). No relevant postoperative transmitral gradient or systolic anterior motion occurred. At a mean follow–up of 4.2 years, more–than–moderate MR was observed in one patient per group (Alfieri 2.4% vs. Neochordae 1.2%). At 10 years, the cumulative incidence of more–than–moderate mitral regurgitation and redo mitral surgery was similarly low between techniques (p = 0.810 and p = 0.460). Most patients were NYHA class I–II at last follow–up, demonstrating improved functional status. Echocardiography showed left ventricular reverse remodeling without intergroup differences. Conclusions: These data indicate that the Alfieri approach provides durable competence and hemodynamic safety comparable to the Neochordae technique while reducing cross–clamp time, supporting its use as a deliberate strategy rather than a bailout in anatomically suitable valves. Full article

Background: Papillary muscles (PMs) are important for mitral valve competence and left ventricular mechanics, but accurate evaluation is often limited by poor visualization in conventional echocardiographic views. We developed papillary muscle–targeted (PM-targeted) echocardiographic views to improve PM visualization and aimed to validate this approach and establish normative reference values in healthy adults. Methods: In protocol 1, posteromedial papillary muscle (PPM) length and maximum diameter measured using PM-targeted and standard views were compared with anatomic measurements in ten ex vivo porcine hearts. In protocol 2, measurements of the anterolateral papillary muscle (APM) and PPM were compared between PM-targeted and standard views in 100 healthy adults. In protocol 3, PM structural, spatial, and functional parameters were measured using PM-targeted views in 245 healthy adults. In protocol 4, PM measurements obtained from 2D PM-targeted views were compared with 3D echocardiographic measurements in 50 patients with ventricular functional mitral regurgitation (VFMR); PM parameters in VFMR were also compared with those in healthy adults. Results: In protocol 1, PM-targeted views showed stronger correlation with anatomic measurements for PPM length than standard views (0.966 vs. 0.752, p = 0.049), while standard views underestimated PPM length. In protocol 2, PM-targeted views enabled complete visualization of APM and PPM and yielded longer PM lengths and smaller maximum diameters than standard views. In protocol 3, males had larger PM maximum diameters and longer tip-to-annulus distances than females (all p < 0.05). With aging, interpapillary distance reduction (ΔIPMD), IPMD fractional shortening (IPMD-FS), and APM length decreased, whereas end-systolic IPMD increased (all p < 0.05). PM parameters correlated positively with body surface area (all p < 0.05). In protocol 4, PM measurements obtained from 2D PM-targeted views showed no differences from 3D echocardiographic measurements and demonstrated good correlation and agreement across assessed PM parameters against 3D echocardiographic measurement as a standard reference. Compared with healthy adults, patients with VFMR showed altered PM geometry/remodeling patterns. Conclusions: PM-targeted echocardiographic views improve visualization and measurement of papillary muscles and provide normative reference values, facilitating more accurate evaluation of PM-related abnormalities in clinical practice. Full article

Background: Risk stratification of patients with mitral regurgitation (MR), including both primary (degenerative) and secondary (functional) forms, remains challenging, particularly in asymptomatic or minimally symptomatic stages, as clinical assessment and resting echocardiography may underestimate disease severity and functional impairment. Exercise stress echocardiography (ESE) enables dynamic evaluation of regurgitation severity, ventricular performance, and cardiopulmonary response, potentially improving prognostic assessment. Methods: A systematic review was conducted according to PRISMA guidelines. PubMed, Scopus, and EMBASE were searched from inception to March 2026. Studies including adult patients with primary or secondary MR undergoing exercise-based stress echocardiography and reporting clinical outcomes were selected. Studies using exclusively pharmacological stress were excluded. Data were qualitatively synthesized, and continuous variables were summarized as weighted medians and interquartile ranges. In addition, emerging and non-conventional prognostic markers, including anatomical indices such as the modified Haller index (MHI), were explored to provide a more comprehensive risk stratification framework. Results: Nineteen studies were included, encompassing a heterogeneous population in terms of MR etiology, severity, and clinical presentation. During follow-up, a substantial proportion of patients experienced adverse events, including heart failure, mitral valve intervention, or death. Exercise-derived parameters consistently showed strong prognostic value. In particular, exercise-induced worsening of MR severity (increase in effective regurgitant orifice area and regurgitant volume), absence of contractile reserve, elevated filling pressures (E/e’), and exercise-induced pulmonary hypertension were associated with worse outcomes. Reduced functional capacity and impaired right ventricular–pulmonary arterial coupling provided additional prognostic information. Emerging markers, including chest wall configuration assessed by MHI, appeared to further refine risk stratification in selected patient subsets. In contrast, resting parameters were less consistently predictive. Conclusions: ESE provides incremental prognostic information in patients with MR by identifying dynamic abnormalities not evident at rest. Its integration into clinical evaluation, together with novel anatomical and functional markers, may improve risk stratification and support earlier identification of high-risk patients who could benefit from timely intervention. Further studies are needed to standardize methodologies and define clinically relevant thresholds. Full article

Background: The effective regurgitant orifice area to left ventricular end-diastolic volume (EROA/LVEDV) ratio has been proposed to distinguish proportionate from disproportionate functional mitral regurgitation and to guide patient selection for transcatheter edge-to-edge repair (TEER). Methods: We conducted a multicenter, retrospective cohort study of 221 patients undergoing TEER with the Mitraclip system. Preprocedural echocardiographic parameters, including EROA, LVEDV, diastolic indices, and chamber volumes, were systematically collected. The primary outcome indicative of symptom worsening was defined as Heart Failure Hospitalizations (HFH) requiring IV diuresis/death in the one year following clip placement. Association of the preprocedural EROA/LVEDV ratio and symptom worsening was assessed using multivariate regression models and ROC-AUC. Results: In the one-year follow-up, 87 patients (39.36%) had symptom worsening. In the multivariate regression analysis, preprocedural EROA/LVEDV ratio was associated with symptom worsening at one year (OR: 0.95 (0.92–0.97, p value < 0.01). In the ROC model, the pre-procedural EROA/LVEDV ratio had an AUC value of 0.74 (0.69–0.83), with a moderate value for predicting symptom worsening at one year. Conclusions: Results of the study proved that a lower pre-procedural EROA/LVEDV ratio had a significant association with symptom worsening, with the ratio proving to have a moderate value for predicting symptom worsening/death at one year. Full article

Introduction: Hypertrophic cardiomyopathy (HCM) is a common myocardial disease worldwide and is associated with heart failure symptoms and sudden cardiac death. In a subset of patients, it may produce dynamic left ventricular outflow tract obstruction (LVOTO) and systolic anterior motion (SAM)-related mitral valve dysfunction through drag forces and altered mitral–septal geometry. In contrast, subaortic stenosis caused by a subaortic membrane is an uncommon congenital lesion that may lead to fixed subvalvular LVOTO in adulthood. The coexistence of these entities is rare and can substantially complicate diagnosis and management. Case presentation: A 51-year-old woman with HCM, paroxysmal atrial fibrillation, and heart failure presented with acute decompensation and cardiogenic shock. After initial hemodynamic stabilization and cardioversion for atrial fibrillation with rapid ventricular response, multimodality imaging with transthoracic and transesophageal echocardiography, coronary computed tomography angiography, and cardiac magnetic resonance demonstrated dual LVOTO, with a dynamic component related to HCM/SAM physiology and a fixed component caused by an elongated subaortic membrane, accompanied by severe SAM-related mitral regurgitation. Echocardiography showed a resting peak LVOT gradient of 49 mmHg, increasing to 85 mmHg with the Valsalva maneuver. After exclusion of obstructive coronary artery disease and evaluation for selected phenocopies, the patient underwent septal myectomy, subaortic membrane resection, and adjunctive mitral valve plication. Early postoperative echocardiography showed reduction in the maximum provoked LVOT gradient to 38 mmHg and improvement of mitral regurgitation from severe to mild. At 3-month follow-up, she remained in sinus rhythm, improved to New York Heart Association functional class II, and had no documented readmissions for heart failure. Conclusions: Combined fixed and dynamic LVOTO due to concomitant subaortic membrane and HCM is exceedingly rare. Accurate diagnosis requires a high index of suspicion and a multimodality imaging strategy to define the obstructive mechanisms and support mechanism-based surgical management and avoid incomplete treatment when a coexisting fixed lesion is present. Full article

Background: Cardiovascular–kidney–metabolic (CKM) syndrome delineates the occurrence of clinical cardiovascular diseases alongside renal or metabolic complications. The prognostic implications of functional mitral regurgitation (FMR) in patients with CKM syndrome remain unclear. This study aimed to elucidate the association and independent impact of FMR regarding clinical outcomes in this population. Methods: In this retrospective cohort study, 1201 patients with CKM syndrome undergoing maintenance hemodialysis between January 2020 and November 2024 were analyzed. Participants were stratified according to the presence and severity of FMR/atrial functional mitral regurgitation (AFMR) into the non-FMR/AFMR, mild FMR/AFMR, and moderate-to-severe FMR/AFMR groups. The primary outcome measure was all-cause mortality. Survival analyses were performed using Kaplan–Meier estimates and multivariate Cox proportional hazard models. Results: FMR prevalence was higher (79.68%) in the CKM cohort. FMR was independently associated with increased all-cause mortality (hazard ratio [HR], 1.831; 95% confidence interval [CI], 1.320–2.541; p = 0.0019). Even mild FMR conferred a significantly elevated risk compared to patients without FMR (HR, 1.699; 95% CI, 1.200–2.405; p = 0.0078). Similarly, AFMR was an independent predictor of mortality (HR, 2.106; 95% CI, 1.349–3.289; p = 0.0046), with moderate-to-severe AFMR associated with a three-fold higher risk (HR, 3.294; 95% CI, 1.007–10.78; p = 0.0027) than non-AFMR. Conclusions: Both FMR and AFMR were found to be independently associated with elevated all-cause mortality in patients with CKM syndrome undergoing hemodialysis. These findings underscore the critical need for early detection and tailored management of mitral regurgitation in this high-risk population to potentially improve outcomes. Full article

Background and Objectives: Atrial secondary mitral regurgitation (A-SMR), also referred to as atrial functional mitral regurgitation, has emerged as a distinct clinical phenotype characterized by left atrial enlargement, mitral annular dilatation, and preserved left ventricular geometry and systolic function. Frequently associated with long-standing atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF), A-SMR challenges the traditional ventricular-centered classification of functional mitral regurgitation (MR) and is increasingly recognized as a clinically relevant condition. Materials and Methods: This narrative review provides an updated and critical overview of current evidence on A-SMR. We summarize available data on pathophysiology, diagnostic imaging, natural history, and therapeutic strategies, with particular emphasis on implications for cardiac surgery and clinical decision-making. Evidence was derived from observational studies, registry analyses, interventional reports, and contemporary guideline documents. Results: A-SMR is primarily driven by atrial remodeling and annular dilatation, with minimal contribution from ventricular distortion or leaflet tethering. Echocardiography and Magnetic Resonance Imaging (MRI) play a central role in diagnosis and phenotypic characterization, allowing differentiation from ventricular functional MR and identification of distinct A-SMR subtypes with potential therapeutic implications. A-SMR is a progressive condition associated with worsening symptoms and adverse clinical outcomes. Rhythm control strategies may reduce MR severity in selected patients by promoting atrial reverse remodeling. Transcatheter edge-to-edge repair (TEER) represents a treatment option for selected high-risk patients, although concerns regarding long-term durability remain in this predominantly annular disease. From a pathophysiological standpoint, surgical mitral valve repair based on annuloplasty directly targets the dominant mechanism of A-SMR and has been associated with favorable outcomes in appropriately selected patients. Conclusions: A-SMR is a distinct and increasingly recognized form of functional MR requiring a mechanism-oriented diagnostic and therapeutic approach. The 2025 ESC/EACTS Guidelines for the management of valvular heart disease have acknowledged A-SMR as a specific clinical phenotype, although dedicated phenotype-specific management recommendations remain limited. Surgical mitral valve repair, particularly when combined with AF ablation, represents a rational treatment strategy in selected patients and may improve long-term outcomes. Full article