LAUSR

Miller et al. present a single‐center retrospective analysis describing the prognostic value of atrial remodeling in patients undergoing mitral transcatheter edge‐to‐edge repair (TEER). The investigators hypothesized that downstream pathological changes of mitral valvular regurgitation such as atrial dilation would be prognostic. Their analysis supports this theory as right atrial volume index (RAVI) and the ratio of RAVI to left atrial volume index (LAVI) were found to be independent predictors of mortality among their small single‐ center cohort. These findings are consistent with a long history of pathophysiological forces manifesting as maladaptive chamber remodeling corresponding to attenuated survival. As mentioned in the article, atrial dilation results from unrelenting pressure/volume overload and authors compare this to HbA1c in diabetes care. Not surprisingly, there was an association between an elevated RAVI/LAVI ratio (RLR) with pulmonary hypertension. Naturally, being a retrospective study, confounding is present. In this case, the authors overlooked several covariates that may have been important. First, the multivariate analysis only included mitral regurgitation type (degenerative vs. functional) and Society of Thoracic Surgeon Score (STS) and they likely could not expand further due to the small sample size. With the luxury of a larger cohort, one could include more variables that are directly related to right atrial dilation such as tricuspid valve regurgitation,