title: Mitral valve tenting index for assessment of subvalvular remodeling.
abstract: BACKGROUND
  Ischemic mitral regurgitation results from a variable combination of annular dilatation and remodeling of the subvalvular apparatus. Current surgical techniques effectively treat annular dilatation, but methods for addressing subvalvular remodeling have not been standardized. An effective technique for determining the extent of subvalvular remodeling could improve surgical results by identifying patients who are unlikely to benefit from annuloplasty alone.
  
  
  METHODS
  A well-characterized ovine model of ischemic mitral regurgitation was used. Real-time three-dimensional echocardiography was performed on each animal at baseline and at 1 hour and 8 weeks after infarction. Multiple valvular geometric measurements were calculated at each time point.
  
  
  RESULTS
  Immediate and long-term changes in mitral valvular geometry were observed. Annular height-to-commissural width ratio decreased from 20.0% +/- 1.6% to 11.2% +/- 0.9% 1 hour after infarction (p < 0.001) and to 9.4% +/- 0.4% 8 weeks after infarction (p < 0.001), whereas mitral annular area increased from 8.1 +/- 0.3 cm2 to 9.2 +/- 0.4 cm2 (p < 0.05) and then to 10.5 +/- 0.6 cm2 (p < 0.05). Maximum mitral valve tenting area increased from 49.7 +/- 5.1 mm2 to 58.6 +/- 4.2 mm2 (p < 0.05) and then to 106.4 +/- 3.9 mm2 (p < 0.001), whereas mitral valve tenting volume increased from 679.0 +/- 75.5 mm3 to 828.6 +/- 102.4 mm3 (p = 0.050) and then to 1530.5 +/- 97.8 mm3 (p < 0.001). The mitral valve tenting index increased from 0.83 +/- 0.08 mm to 0.88 +/- 0.08 mm (p > 0.05) and then to 1.46 +/- 0.08 mm (p < 0.001).
  
  
  CONCLUSIONS
  We have described a technique that uses real-time three-dimensional echocardiography to perform a comprehensive assessment of leaflet tethering on the entire mitral valve. Our methodology is not influenced by viewing plane selection, regional tenting asymmetry, or annular dilatation and therefore represents a potentially useful, clinically relevant, and consistent measure of subvalvular remodeling.
authors: Harrison Department of Surgical Research, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA.
authors: Liam P
authors: LP
authors: Ryan
authors: Benjamin M
authors: BM
authors: Jackson
authors: Landi M
authors: LM
authors: Parish
authors: Hiroaki
authors: H
authors: Sakamoto
authors: Theodore J
authors: TJ
authors: Plappert
authors: Martin
authors: M
authors: St John-Sutton
authors: Joseph H
authors: JH
authors: Gorman
authors: Robert C
authors: RC
authors: Gorman
mesh_terms: D000818:Animals; D006348:Cardiac Surgical Procedures / Q000379:methods; D019560:Echocardiography, Three-Dimensional; D007091:Image Processing, Computer-Assisted; D008943:Mitral Valve / Q000000981:diagnostic imaging* / Q000601:surgery; D008944:Mitral Valve Insufficiency / Q000000981:diagnostic imaging / Q000601:surgery*; D008955:Models, Cardiovascular; D017202:Myocardial Ischemia / Q000000981:diagnostic imaging* / Q000601:surgery; D011336:Probability; D012680:Sensitivity and Specificity; D012756:Sheep; D018487:Ventricular Dysfunction, Left / Q000000981:diagnostic imaging; D020257:Ventricular Remodeling / Q000502:physiology*