A clinical study of annular geometry and dynamics in patients with ischemic mitral regurgitation: new insights into asymmetrical ring annuloplasty.
OBJECTIVE
Recent studies in animals showed that regional annulus distortion is a major determinant of ischemic mitral regurgitation (IMR) and accordingly suggested new surgical approaches with asymmetrical annuloplasty rings. As accurate measurement of annulus in patients is still a challenge, we performed this study to analyze the changes in three-dimensional annular geometry in patients with IMR compared to primary valvular lesions.


METHODS
We studied 110 patients divided into three groups: (1) 30 with coronary artery disease without IMR, (2) 38 with chronic IMR, and (3) 42 with MR due to primary valvular lesions. Longitudinal and septal-lateral annulus diameters; global diastolic and systolic annular area and its percentual shortening, diastolic and systolic areas of six regions corresponding to the segmental Carpentier classification were measured by 3D-echocardiography. The degree of MR was assessed by three-dimensional color Doppler. Global and regional left ventricular geometry were assessed by sphericity index and by measuring anterior and posterior tethering of papillary muscles.


RESULTS
Patients with significant IMR (group 2) showed larger longitudinal (52.7+/-3.9 mm vs 41.8+/-2.9 mm; p<0.01) and antero-lateral (31.8+/-3.5mm vs 26.7+/-2.8mm; p<0.01) annular diameters than the patients with MR due to primary valvular lesions (group 3). Diastolic (997.8+/-64.9 mm(2) vs 700.7+/-46.8mm(2); p<0.01) and systolic (894.9+/-57.3mm(2) vs 547.3+/-35.0mm(2); p<0.01) annular areas were larger in group 2 than in group 3. Annular area change was significantly lower in the group with ischemic mitral regurgitation than in the group with primary valvular lesions (10.3+/-1.1% vs 21.9+/-1.6%; p<0.01). Regional annular areas of the six sectors were homogeneously larger in group 2 than in group 3. The sector P3 did not show larger area than the other ones. The degree of MR, as assessed by the volumes of regurgitant jets, was higher in the group with primary valvular lesions than in the patients with IMR (32.6+/-13.4 cm(3) vs 23.1+/-11.1cm(3); p<0.01).


CONCLUSIONS
This study showed that annular enlargement in patients with IMR affects the different annular regions to the same extent. An ideal surgical repair of IMR should be individually tailored after quantitative assessment measurement of geometry and function of each single component of the mitral valve complex.
De Simone
Raffaele
R
Department of Cardiac Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany. r.de.simone@urz.uni-heidelberg.de
Wolf
Ivo
I
Mottl-Link
Sibylle
S
Hoda
Raschid
R
Mikhail
Bassem
B
Sack
Falk-Udo
FU
Meinzer
Hans-Peter
HP
Hagl
Siegfried
S
D000368:Aged; D003327:Coronary Disease / Q000150:complications; D004108:Dilatation, Pathologic / Q000000981:diagnostic imaging; D018618:Echocardiography, Doppler, Color / Q000379:methods; D017548:Echocardiography, Transesophageal / Q000379:methods; D006352:Heart Ventricles / Q000473:pathology; D006801:Humans; D021621:Imaging, Three-Dimensional / Q000379:methods; D008875:Middle Aged; D008943:Mitral Valve / Q000000981:diagnostic imaging / Q000601:surgery*; D008944:Mitral Valve Insufficiency / Q000150:complications / Q000473:pathology* / Q000601:surgery