Does preoperative tethering symmetry affect left ventricular reverse remodeling after restrictive annuloplasty?
BACKGROUND
We hypothesized that a preoperative symmetric pattern with anterior mitral leaflet (AML) tethering predominance is related to lack of LVRR after restrictive annuloplasty.


METHODS
In 300 patients with surgical annuloplasty for chronic ischemic mitral regurgitation the AML and posterior mitral leaflet (PML) tethering angles were quantified and patients were divided on the basis of the preoperative anterior/posterior tethering angle ratio: there were 144 patients with symmetric (Group 1) and 156 with asymmetric (Group 2) preoperative tethering pattern patients underwent echocardiography preoperatively, at discharge and at follow-up appointments (6 months [IQR 5-8 months]; late, 48 months [15-63 months]). Reverse remodeling was defined as a reduction in left ventricular end systolic volume index >15%.


RESULTS
LVRR was higher in the asymmetric group at discharge (69.2% vs. 9.7%, p<0.001), early (70.55% vs. 10.45%, p<0.001 and late follow up (81.4% vs. 4.8%, p<0.001). At multivariable regression analysis corrected by significant key factors of LVRR, symmetric leaflet tethering (OR, 4.8 [95% CI 2.9-5.6], p<0.001), anterior tethering angle alpha'<39.5 degrees (OR, 5.0 [95% CI 2.0-6.6], p<0.001), coaptation height<11 mm (OR, 2.5 [95% CI 1.1-3.3], p=0.006) and coaptation length > or =8 mm at the end of procedure (OR, 2.0 [CI 0.8-3.0], p=0.01) were independent predictors of LVRR. Compared with patients with asymmetric pattern (adjusted OR 0.2 [95% CI 0.03-1.6), those with symmetric pattern had >4-fold odds for lack of LVRR.


CONCLUSIONS
The preoperative symmetric pattern with AML prevalence was strongly associated with lack of reverse remodeling after annuloplasty. An accurate echocardiographic evaluation of the tethering mechanisms should be incorporated into clinical risk assessment and prediction models.
Gelsomino
Sandro
S
Experimental Surgery Unit, Cardiac Surgery, Department of Heart and Vessels, Careggi Hospital, Florence, Italy. sandro.gelsomino@libero.it
Lorusso
Roberto
R
De Cicco
Giuseppe
G
Billè
Giuseppe
G
Caciolli
Sabina
S
Rostagno
Carlo
C
Capecchi
Irene
I
Chioccioli
Marco
M
Stefàno
Pierluigi
P
Gensini
Gian Franco
GF
D000368:Aged; D006348:Cardiac Surgical Procedures; D001026:Coronary Artery Bypass; D005260:Female; D006801:Humans; D008297:Male; D008943:Mitral Valve / Q000000981:diagnostic imaging*; D008944:Mitral Valve Insufficiency / Q000601:surgery*; D015999:Multivariate Analysis; D010210:Papillary Muscles / Q000000981:diagnostic imaging; D057234:Preoperative Period; D013599:Systole; D014463:Ultrasonography; D016277:Ventricular Function, Left; D020257:Ventricular Remodeling