Impact of preoperative anterior leaflet tethering on the recurrence of ischemic mitral regurgitation and the lack of left ventricular reverse remodeling after restrictive annuloplasty.
BACKGROUND
The aim of this multicenter study was to investigate the impact of the preoperative anterior mitral leaflet tethering angle, α', on the recurrence of mitral regurgitation (MR) and left ventricular (LV) reverse remodeling (LVRR) after undersized mitral ring annuloplasty.


METHODS
The study population consisted of 362 patients, who were divided into two groups by baseline α': group 1, α' < 39.5° (n = 196), and group 2, α' ≥ 39.5° (n = 166). End points were recurrent MR ≥ 2+; LVRR, defined as a reduction in end-systolic volume index > 15%; and LV geometric reverse remodeling, defined as a reduction in systolic sphericity index to a normal value of <0.72 in patients with altered baseline geometry.


RESULTS
MR occurred in 9.6% (n = 19) and 43.3% (n = 72) of the patients in groups 1 and 2, respectively (P < .001). LVRR (85.7% vs 22.2%) at follow-up was higher in group 1 (P < .001). On multivariate regression analysis, α' ≥ 39.5° was a strong predictor of MR recurrence, lack of LV reverse remodeling and lack of LV geometric reverse remodeling (all P values < .001). In contrast, the posterior mitral leaflet tethering angle, β', was not significant (all P values > .05). When we allowed for interactions between α' and other risk factors, this effect occurred also in low-risk subgroups, and it was equivalent or generally attenuated in higher risk patients. There were no significant interactions between α' and any of the covariates (all P values > .05).


CONCLUSIONS
Anterior mitral leaflet tethering is a powerful predictor of MR recurrence and lack of LVRR after undersized mitral ring annuloplasty. Evaluation of leaflet tethering should be incorporated into clinical risk assessment and prediction models.
Department of Heart and Vessels, Careggi Hospital, Florence, Italy. sandro.gelsomino@libero.it
Sandro
S
Gelsomino
Leen
L
van Garsse
Fabiana
F
Lucà
Roberto
R
Lorusso
Emile
E
Cheriex
Carmelo Massimiliano
CM
Rao
Sabina
S
Caciolli
Enrico
E
Vizzardi
Elena
E
Crudeli
Pierluigi
P
Stefàno
Gian Franco
GF
Gensini
Jos
J
Maessen
D000368:Aged; D015897:Comorbidity; D004452:Echocardiography / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D008943:Mitral Valve / Q000000981:diagnostic imaging* / Q000601:surgery; D008944:Mitral Valve Insufficiency / Q000000981:diagnostic imaging* / Q000453:epidemiology*; D017202:Myocardial Ischemia / Q000000981:diagnostic imaging* / Q000453:epidemiology*; D009426:Netherlands / Q000453:epidemiology; D011300:Preoperative Care / Q000706:statistics & numerical data; D011379:Prognosis; D015203:Reproducibility of Results; D018570:Risk Assessment; D012307:Risk Factors; D055502:Secondary Prevention; D012680:Sensitivity and Specificity; D016896:Treatment Outcome; D018754:Ventricular Dysfunction / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000517:prevention & control*; D020257:Ventricular Remodeling