title: Description of regional mitral annular nonplanarity in healthy human subjects: a novel methodology.
abstract: OBJECTIVE
  Finite-element analysis demonstrates that the nonplanar shape of the mitral annulus diminishes mitral leaflet stress. It has therefore been postulated that repair with annuloplasty rings that maintain the nonplanar shape of the annulus could increase repair durability. Although the global nonplanarity of the mitral annulus has been adequately characterized, design of such a ring requires a quantitative description of regional annular geometry. By using real-time 3-dimensional echocardiography in conjunction with available image processing software, we developed a methodology for describing regional annular geometry and applied it to the characterization of the normal human mitral annulus.
  
  
  METHODS
  Five healthy volunteers underwent mitral valve imaging with real-time 3-dimensional echocardiography. Regional annular height was calculated at 36 evenly spaced intervals.
  
  
  RESULTS
  Maximal annular height/commissural width ratio was found to occur at the midpoint of the anterior annulus in all cases. These values averaged 26% +/- 3.1%, whereas those for the midposterior annulus averaged 18% +/- 3.0%. The average commissural width was 35.2 +/- 6.0 mm. Although substantial spatial heterogeneity was observed, regional annular height at a given rotational position was highly conserved among subjects when normalized to commissural width.
  
  
  CONCLUSIONS
  These quantitative imaging and analytic techniques demonstrate that the normal human mitral annulus is regionally heterogeneous in its nonplanarity, and they establish a means of describing annular geometry at a regional level. With wider application, these techniques may be used both to characterize pathologic annular geometry and to optimize the design of mitral valve annuloplasty devices.
authors.affiliation: Harrison Department of Surgical Research, University of Pennsylvania School of Medicine, Philadelphia, Pa 19104-4283, USA.
authors.forename: Liam P
authors.initials: LP
authors.lastname: Ryan
authors.forename: Benjamin M
authors.initials: BM
authors.lastname: Jackson
authors.forename: Yoshiharu
authors.initials: Y
authors.lastname: Enomoto
authors.forename: Landi
authors.initials: L
authors.lastname: Parish
authors.forename: Theodore J
authors.initials: TJ
authors.lastname: Plappert
authors.forename: Martin G
authors.initials: MG
authors.lastname: St John-Sutton
authors.forename: Robert C
authors.initials: RC
authors.lastname: Gorman
authors.forename: Joseph H
authors.initials: JH
authors.lastname: Gorman
mesh_terms: D019560:Echocardiography, Three-Dimensional; D006801:Humans; D007091:Image Processing, Computer-Assisted; D008943:Mitral Valve / Q000033:anatomy & histology* / Q000601:surgery; D012016:Reference Values