title: Preoperative Three-Dimensional Valve Analysis Predicts Recurrent Ischemic Mitral Regurgitation After Mitral Annuloplasty.
abstract: BACKGROUND
  Valve repair for ischemic mitral regurgitation (IMR) with undersized annuloplasty rings is characterized by high IMR recurrence rates. Patient-specific preoperative imaging-based risk stratification for recurrent IMR would optimize results. We sought to determine if prerepair three-dimensional (3D) echocardiography combined with a novel valve-modeling algorithm would be predictive of IMR recurrence 6 months after repair.
  
  
  METHODS
  Intraoperative transesophageal real-time 3D echocardiography was performed in 50 patients undergoing undersized ring annuloplasty for IMR and in 21 patients with normal mitral valves. A customized image analysis protocol was used to assess 3D annular geometry and regional leaflet tethering. IMR recurrence (≥ grade 2) was assessed with two-dimensional transthoracic echocardiography 6 months after repair.
  
  
  RESULTS
  Preoperative annular geometry was similar in all IMR patients, and preoperative leaflet tethering was significantly higher in patients with recurrent IMR (n=13) than in patients in whom IMR did not recur (n=37) (tethering index: 3.91 ± 1.01 vs 2.90 ± 1.17, p = 0.008; tethering angles of A3: 23.5° ± 8.9° vs 14.4° ± 11.4°, p = 0.012; P2: 44.4° ± 8.8° vs 28.2° ± 17.0°, p = 0.002; and P3: 35.2° ± 6.0° vs. 18.6° ± 12.7°, p < 0.001). Multivariate logistic regression analysis revealed the preoperative P3 tethering angle as an independent predictor of IMR recurrence with an optimal cutoff value of 29.9° (area under the curve, 0.92; 95% confidence interval, 0.84 to 1.00; p < 0.001).
  
  
  CONCLUSIONS
  3D echocardiography combined with valve modeling is predictive of recurrent IMR. Preoperative regional leaflet tethering of segment P3 is a strong independent predictor of IMR recurrence after undersized ring annuloplasty. In patients with a preoperative P3 tethering angle of 29.9° or larger, chordal-sparing valve replacement rather than valve repair should be strongly considered.
authors.affiliation: Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
authors.forename: Wobbe
authors.initials: W
authors.lastname: Bouma
authors.affiliation: Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Eric K
authors.initials: EK
authors.lastname: Lai
authors.affiliation: Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Melissa M
authors.initials: MM
authors.lastname: Levack
authors.affiliation: Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Eric K
authors.initials: EK
authors.lastname: Shang
authors.affiliation: Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Alison M
authors.initials: AM
authors.lastname: Pouch
authors.affiliation: Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Eperjesi
authors.affiliation: Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Theodore J
authors.initials: TJ
authors.lastname: Plappert
authors.affiliation: Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Paul A
authors.initials: PA
authors.lastname: Yushkevich
authors.affiliation: Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
authors.forename: Massimo A
authors.initials: MA
authors.lastname: Mariani
authors.affiliation: Department of Cardiothoracic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
authors.forename: Kamal R
authors.initials: KR
authors.lastname: Khabbaz
authors.affiliation: Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.
authors.forename: Thomas G
authors.initials: TG
authors.lastname: Gleason
authors.affiliation: Department of Anesthesia, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
authors.forename: Feroze
authors.initials: F
authors.lastname: Mahmood
authors.affiliation: Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Michael A
authors.initials: MA
authors.lastname: Acker
authors.affiliation: Department of Cardiothoracic Surgery, Stanford University, Stanford, California.
authors.forename: Y Joseph
authors.initials: YJ
authors.lastname: Woo
authors.affiliation: Department of Anesthesia, Stanford University, Stanford, California.
authors.forename: Albert T
authors.initials: AT
authors.lastname: Cheung
authors.affiliation: Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Benjamin M
authors.initials: BM
authors.lastname: Jackson
authors.affiliation: Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Joseph H
authors.initials: JH
authors.lastname: Gorman
authors.affiliation: Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address: gormanr@uphs.upenn.edu.
authors.forename: Robert C
authors.initials: RC
authors.lastname: Gorman
mesh_terms: D000368:Aged; D019560:Echocardiography, Three-Dimensional / Q000379:methods*; D017548:Echocardiography, Transesophageal / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000000981:diagnostic imaging*; D058386:Mitral Valve Annuloplasty / Q000009:adverse effects*; D008944:Mitral Valve Insufficiency / Q000150:complications / Q000000981:diagnostic imaging / Q000601:surgery*; D017202:Myocardial Ischemia / Q000150:complications / Q000601:surgery*; D011237:Predictive Value of Tests; D011300:Preoperative Care / Q000379:methods*; D012008:Recurrence; D013997:Time Factors