{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,23]],"date-time":"2026-09-23T06:21:39Z","timestamp":1790144499151,"version":"4.0.1"},"reference-count":72,"publisher":"MDPI AG","issue":"3","license":[{"start":{"date-parts":[[2026,3,11]],"date-time":"2026-03-11T00:00:00Z","timestamp":1773187200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medicina"],"abstract":"<jats:p>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.<\/jats:p>","DOI":"10.3390\/medicina62030520","type":"journal-article","created":{"date-parts":[[2026,3,11]],"date-time":"2026-03-11T10:43:27Z","timestamp":1773225807000},"page":"520","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":4,"title":["Atrial Secondary Mitral Regurgitation: Pathophysiology, Diagnosis, and Surgical Implications"],"prefix":"10.3390","volume":"62","author":[{"ORCID":"https:\/\/orcid.org\/0009-0000-0874-9735","authenticated-orcid":false,"given":"Damiano","family":"Venturiello","sequence":"first","affiliation":[{"name":"Department of Cardiac Surgery, San Carlo di Nancy Hospital, GVM Care & Research, 00165 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Giuseppe","family":"Campolongo","sequence":"additional","affiliation":[{"name":"Department of Cardiac Surgery, San Carlo di Nancy Hospital, GVM Care & Research, 00165 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Emiliano Marco","family":"Navarra","sequence":"additional","affiliation":[{"name":"Department of Cardiac Surgery, San Carlo di Nancy Hospital, GVM Care & Research, 00165 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Giuseppe","family":"Speziale","sequence":"additional","affiliation":[{"name":"Department of Cardiac Surgery, San Carlo di Nancy Hospital, GVM Care & Research, 00165 Rome, Italy"},{"name":"Department of Cardiac Surgery, Anthea Hospital and Santa Maria Hospital, GVM Care & Research, 70124 Bari, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,3,11]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"2465","DOI":"10.1016\/j.jacc.2019.02.061","article-title":"Atrial Functional Mitral Regurgitation: JACC Review Topic of the Week","volume":"73","author":"Deferm","year":"2019","journal-title":"J. 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