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Does left atrial deformation impact on symptoms and prognosis in functional mitral regurgitation patients with poor left ventricular function?

This article refers to ‘Quantified mitral regurgitation and left atrial function in heart failure with reduced ejection fraction: interplay and outcome implications’ by A. Malagoli et al. , published in this issue on pages 694–702. It is a long-standing accepted notion that the presence of some degree of mitral incompetence is going to impact negatively and significantly on symptoms and prognosis of patients with functional mitral regurgitation (FMR) associated with a poor left ventricular ejection fraction (EF) due to ischaemic heart disease. 1 The back-ground pathophysiological explanation would be that, in heart failure patients with reduced ejection fraction (HFrEF), even a minor degree of regurgitation will cause a considerable increase in pressure if the atrium is non-compliant. 2 Such reasoning fits the more recent acquisition that, when EF is severely depressed, the effective regurgitant orifice area (EROA) is skewed towards a smaller size, and that such smaller EROA, if routinely measured, appears as the strongest independent mitral incompetence determinant of survival after diagnosis. 3 Excess mortality, in fact, has been reported to increase exponentially above a certain threshold area (0. 1 0 cm 2 ), with a much steeper slope, for any EROA increment, than in degen-erative mitral insufficiency. 3 In this issue of the Journal, Malagoli and colleagues move further their investigation addressing the complex interaction between peak atrial longitudinal strain (PALS), taken as an estimate of