{
  "abstract": "Chronic aortic regurgitation (AR) is a progressive disease that often remains asymptomatic until advanced stages. Retrograde flow of blood into the left ventricle (LV) during diastole results in persistent volume overload, elevating end-diastolic pressure and inducing eccentric hypertrophy.1 To preserve forward stroke volume, the LV compensates by expelling both regurgitant and effective volumes during systole. This compensation leads to systolic hypertension, which in turn promotes aortic root dilation and enlargement of the regurgitant orifice—creating a self-perpetuating cycle of worsening haemodynamics.2 As LV end-diastolic pressure rises, it is passively transmitted to the left atrium (LA), resulting in progressive LA dilatation and fibrotic remodelling. These structural changes impair atrial conduction and establish a substrate for atrial fibrillation (AF). Elevated LA pressure also triggers neurohormonal responses, particularly sympathetic activation, which further destabilises atrial electrophysiology.3 Once AF develops, the loss of atrial contraction reduces LV preload, compromises cardiac output, worsens heart failure symptoms and increases thromboembolic risk. Despite these pathophysiological links, current American and European guidelines base surgical aortic valve replacement (SAVR) decisions on symptomatic status and LV function, such as ejection fraction ≤50%, end-systolic diameter >50 mm or indexed LV end-systolic diameter >25 mm/m².4 Atrial parameters and the presence of AF are not currently included in these surgical criteria. However, recent findings suggest that AF may offer complementary prognostic information beyond conventional ventricular markers.",
  "authors": [
    {
      "affiliations": [
        "Department of Cardiovascular Medicine, Nephrology, and Neurology, University of the Ryukyus, Okinawa, Japan"
      ],
      "name": "Hiroyuki Tsurumi"
    },
    {
      "affiliations": [
        "Department of Cardiovascular Medicine, Nephrology, and Neurology, University of the Ryukyus, Okinawa, Japan"
      ],
      "name": "Kenya Kusunose"
    }
  ],
  "title": "Atrial fibrillation in chronic aortic regurgitation: the missing link in prognosis and surgical timing",
  "uid": "df5f691f-0c80-537d-9c73-10c5112b4785"
}