title: Does preoperative tethering symmetry affect left ventricular reverse remodeling after restrictive annuloplasty?
abstract: 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.
authors.affiliation: Experimental Surgery Unit, Cardiac Surgery, Department of Heart and Vessels, Careggi Hospital, Florence, Italy. sandro.gelsomino@libero.it
authors.forename: Sandro
authors.initials: S
authors.lastname: Gelsomino
authors.forename: Roberto
authors.initials: R
authors.lastname: Lorusso
authors.forename: Giuseppe
authors.initials: G
authors.lastname: De Cicco
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Billè
authors.forename: Sabina
authors.initials: S
authors.lastname: Caciolli
authors.forename: Carlo
authors.initials: C
authors.lastname: Rostagno
authors.forename: Irene
authors.initials: I
authors.lastname: Capecchi
authors.forename: Marco
authors.initials: M
authors.lastname: Chioccioli
authors.forename: Pierluigi
authors.initials: P
authors.lastname: Stefàno
authors.forename: Gian Franco
authors.initials: GF
authors.lastname: Gensini
mesh_terms: 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