title: In vivo measurement of mitral leaflet surface area and subvalvular geometry in patients with asymmetrical septal hypertrophy: insights into the mechanism of outflow tract obstruction.
abstract: BACKGROUND
  Analyzing the determinants of systolic anterior motion of the mitral valve and consequent left ventricular outflow tract (LVOT) obstruction in patients with asymmetrical septal hypertrophy requires a comprehensive 3-dimensional analysis of mitral leaflet (ML) area, papillary muscle (PM) geometry, and the distribution of left ventricular hypertrophy.
  
  
  RESULTS
  Real-time 3-dimensional echocardiography was performed in 47 patients with asymmetrical septal hypertrophy and 32 normal controls. Patients included 20 with resting LVOT obstruction (group I) and 27 without (group II). Customized software (Omni 4D) provided a validated measure of ML surface area, LVOT area, mitral annular area and nonplanarity, LVOT hypertrophy index by topography (percent area with wall thickness >16 mm), and 3-dimensional PM positions relative to annulus. ML area was more than twice as large in group I than normal and 1.4 times normal in group II (P<0.001). Group I patients were also characterized by higher LVOT hypertrophy index and medial and anterior displacements of both PMs, resulting in a shorter inter-PM distance. Independent determinants of LVOT obstruction were indexed total ML area (adjusted odds ratio, 5.651; 95% confidence interval, 1.573 to 20.304; P=0.008) and inter-PM distance (adjusted odds ratio, 0.416; 95% confidence interval, 0.203 to 0.854; P=0.0169). Minimal LVOT area during systole correlated well with peak LVOT pressure gradient (R(2)=0.83, P<0.001); its independent determinants were left ventricular end-systolic volume (P=0.0183), indexed total ML area (P=0.0108), inter-PM distance (P=0.0378), annular height (P=0.0047), and LVOT hypertrophy index (P=0.0098).
  
  
  CONCLUSIONS
  Myocardium is not the only tissue affected in patients with asymmetrical septal hypertrophy, and primary changes of the mitral apparatus, including ML area increase and PM displacement, are independent determinants of LVOT obstruction and provide a comprehensive mechanism that determines leaflet slack and anteriorly directed motion. Abnormal PM-mitral valve geometry assessed by real-time 3-dimensional echocardiography can provide reasonable new targets for individualized intervention.
authors.affiliation: Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1 Poongnap-dong Songpa-gu, Seoul 138-736, South Korea.
authors.forename: Dae-Hee
authors.initials: DH
authors.lastname: Kim
authors.forename: Mark D
authors.initials: MD
authors.lastname: Handschumacher
authors.forename: Robert A
authors.initials: RA
authors.lastname: Levine
authors.forename: Yun-Sil
authors.initials: YS
authors.lastname: Choi
authors.forename: Yun Jeong
authors.initials: YJ
authors.lastname: Kim
authors.forename: Sung-Cheol
authors.initials: SC
authors.lastname: Yun
authors.forename: Jong-Min
authors.initials: JM
authors.lastname: Song
authors.forename: Duk-Hyun
authors.initials: DH
authors.lastname: Kang
authors.forename: Jae-Kwan
authors.initials: JK
authors.lastname: Song
mesh_terms: D019560:Echocardiography, Three-Dimensional; D005260:Female; D006339:Heart Rate; D006346:Heart Septum / Q000000981:diagnostic imaging* / Q000473:pathology* / Q000503:physiopathology; D006352:Heart Ventricles / Q000002:abnormalities / Q000000981:diagnostic imaging / Q000503:physiopathology; D006801:Humans; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000002:abnormalities / Q000000981:diagnostic imaging*; D018487:Ventricular Dysfunction, Left / Q000000981:diagnostic imaging* / Q000503:physiopathology; D014694:Ventricular Outflow Obstruction / Q000000981:diagnostic imaging / Q000503:physiopathology*