title: The value of preoperative 3-dimensional over 2-dimensional valve analysis in predicting recurrent ischemic mitral regurgitation after mitral annuloplasty.
abstract: Repair for ischemic mitral regurgitation with undersized annuloplasty is characterized by high recurrence rates. We sought to determine the value of pre-repair 3-dimensional echocardiography over 2-dimensional echocardiography in predicting recurrence at 6 months.
  
  
  
  Intraoperative transesophageal 2-dimensional echocardiography and 3-dimensional echocardiography were performed in 50 patients undergoing undersized annuloplasty for ischemic mitral regurgitation. Two-dimensional echocardiography annular diameter and tethering parameters were measured in the apical 2- and 4-chamber views. A customized protocol was used to assess 3-dimensional annular geometry and regional leaflet tethering. Recurrence (grade ≥2) was assessed with 2-dimensional transthoracic echocardiography at 6 months.
  
  
  
  Preoperative 2- and 3-dimensional annular geometry were similar in all patients with ischemic mitral regurgitation. Preoperative 2- and 3-dimensional leaflet tethering were significantly higher in patients with recurrence (n = 13) when compared with patients without recurrence (n = 37). Multivariate logistic regression revealed preoperative 2-dimensional echocardiography posterior tethering angle as an independent predictor of recurrence with an optimal cutoff value of 32.0° (area under the curve, 0.81; 95% confidence interval, 0.68-0.95; P = .002) and preoperative 3-dimensional echocardiography P3 tethering angle as an independent predictor of recurrence with an optimal cutoff value of 29.9° (area under the curve, 0.92; 95% confidence interval, 0.84-1.00; P < .001). The predictive value of the 3-dimensional geometric multivariate model can be augmented by adding basal aneurysm/dyskinesis (area under the curve, 0.94; 95% confidence interval, 0.87-1.00; P < .001).
  
  
  
  Preoperative 3-dimensional echocardiography P3 tethering angle is a stronger predictor of ischemic mitral regurgitation recurrence after annuloplasty than preoperative 2-dimensional echocardiography posterior tethering angle, which is highly influenced by viewing plane. In patients with a preoperative P3 tethering angle of 29.9° or larger (especially when combined with basal aneurysm/dyskinesis), chordal-sparing valve replacement should be strongly considered.
authors.affiliation: Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa; Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
authors.forename: Inez J
authors.initials: IJ
authors.lastname: Wijdh-den Hamer
authors.affiliation: Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa; 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, Pa.
authors.forename: Eric K
authors.initials: EK
authors.lastname: Lai
authors.affiliation: Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa.
authors.forename: Melissa M
authors.initials: MM
authors.lastname: Levack
authors.affiliation: Department of Surgery, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa.
authors.forename: Eric K
authors.initials: EK
authors.lastname: Shang
authors.affiliation: Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa.
authors.forename: Alison M
authors.initials: AM
authors.lastname: Pouch
authors.affiliation: Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa.
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Eperjesi
authors.affiliation: Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa.
authors.forename: Theodore J
authors.initials: TJ
authors.lastname: Plappert
authors.affiliation: Department of Radiology, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa.
authors.forename: Paul A
authors.initials: PA
authors.lastname: Yushkevich
authors.affiliation: Department of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
authors.forename: Judy
authors.initials: J
authors.lastname: Hung
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, Mass.
authors.forename: Kamal R
authors.initials: KR
authors.lastname: Khabbaz
authors.affiliation: Department of Surgery, University of Pittsburgh, Pittsburgh, Pa.
authors.forename: Thomas G
authors.initials: TG
authors.lastname: Gleason
authors.affiliation: Department of Anesthesia, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
authors.forename: Feroze
authors.initials: F
authors.lastname: Mahmood
authors.affiliation: Department of Surgery, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa.
authors.forename: Michael A
authors.initials: MA
authors.lastname: Acker
authors.affiliation: Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif.
authors.forename: Y Joseph
authors.initials: YJ
authors.lastname: Woo
authors.affiliation: Department of Anesthesia, Stanford University, Stanford, Calif.
authors.forename: Albert T
authors.initials: AT
authors.lastname: Cheung
authors.affiliation: Department of Cardiology, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Gillespie
authors.affiliation: Department of Surgery, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa.
authors.forename: Benjamin M
authors.initials: BM
authors.lastname: Jackson
authors.affiliation: Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa; Department of Surgery, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa.
authors.forename: Joseph H
authors.initials: JH
authors.lastname: Gorman
authors.affiliation: Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa; Department of Surgery, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa. Electronic address: gormanr@uphs.upenn.edu.
authors.forename: Robert C
authors.initials: RC
authors.lastname: Gorman
mesh_terms: D000368:Aged; D004452:Echocardiography; D019560:Echocardiography, Three-Dimensional; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D058386:Mitral Valve Annuloplasty; D008944:Mitral Valve Insufficiency / Q000000981:diagnostic imaging* / Q000601:surgery*; D011237:Predictive Value of Tests; D011300:Preoperative Care; D012008:Recurrence
keywords: echocardiography; ischemia; mitral regurgitation; mitral valve repair