title: Importance of anterior leaflet tethering in predicting recurrence of ischemic mitral regurgitation after restrictive annuloplasty.
abstract: OBJECTIVE
  We investigated the relationship between anterior mitral leaflet (AML) tethering and recurrent ischemic mitral regurgitation (MR) after restrictive annuloplasty. We also explored whether the effect of AML tethering was secondary to modifications in left ventricular size and geometry.
  
  
  METHODS
  The study population consisted of 435 consecutive patients with chronic ischemic MR who survived combined coronary artery bypass grafting and undersized mitral ring annuloplasty performed at 3 institutions (University Hospital, Maastricht, The Netherlands; Careggi Hospital, Florence, Italy; and Civic Hospital, Brescia, Italy) from 2001 to 2008. The median follow-up was 44.7 months (interquartile range 25.9-66.4). The patients were divided by the baseline measurements into quintiles of AML tethering angle α' as follows: group 1, normal/slight AML tethering; group 2, mild AML tethering; group 3, moderate AML tethering; group 4, moderate-to-severe AML tethering; and group 5, severe AML tethering.
  
  
  RESULTS
  Recurrence of MR was significantly greater in patients with moderate-to-severe (28.3%) and severe (39.4%) AML tethering (P < .001). A strong correlation was found between α' (r = 0.83, P < .001) and recurrent MR but a weak correlation with the posterior mitral angle β' (r = 0.12, P = .05). On logistic regression analysis corrected for other echocardiographic risk factors, moderate-severe AML tethering or worse (adjusted odds ratio, 3.6; 95% confidence interval, 3.0-4.1; P < .001) was a strong predictor of MR recurrence. Compared with patients with β' of 45 or greater, those with severe and moderate-severe AML tethering had more than 3.7 and 1.7 times greater odds of MR recurrence, respectively. No significant interactions were found between α' and the indexes of left ventricular function and geometry.
  
  
  CONCLUSIONS
  Preoperative moderate-severe AML tethering or worse was strongly associated with MR recurrence. Thus, assessment of leaflet tethering should be incorporated into clinical risk assessment and prediction models.
authors: Department of Cardiothoracic Surgery, University Hospital, Maastricht, The Netherlands.
authors: Leen
authors: L
authors: van Garsse
authors: Sandro
authors: S
authors: Gelsomino
authors: Fabiana
authors: F
authors: Lucà
authors: Roberto
authors: R
authors: Lorusso
authors: Carmelo Massimiliano
authors: CM
authors: Rao
authors: Pieluigi
authors: P
authors: Stefàno
authors: Jos
authors: J
authors: Maessen
mesh_terms: D000368:Aged; D016009:Chi-Square Distribution; D002908:Chronic Disease; D001026:Coronary Artery Bypass; D005060:Europe; D005260:Female; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects; D006801:Humans; D017379:Hypertrophy, Left Ventricular / Q000000981:diagnostic imaging / Q000209:etiology; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000000981:diagnostic imaging / Q000601:surgery*; D058386:Mitral Valve Annuloplasty / Q000009:adverse effects*; D008944:Mitral Valve Insufficiency / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery*; D015999:Multivariate Analysis; D017202:Myocardial Ischemia / Q000150:complications*; D016017:Odds Ratio; D012008:Recurrence; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014463:Ultrasonography