Mechanisms of recurrent functional mitral regurgitation after mitral valve repair in nonischemic dilated cardiomyopathy importance of distal anterior leaflet tethering

Alex Pui Wai Lee, Michael Acker, Spencer H. Kubo, Steven F. Boiling, Seung W. Park, Charles J Bruce, Jae Kuen Oh

Research output: Contribution to journalArticle

118 Citations (Scopus)

Abstract

Background - Recurrent functional mitral regurgitation (MR) has been reported after mitral valve repair with annuloplasty in patients with dilated cardiomyopathy, but the mechanism is not understood completely. The authors sought to identify abnormalities of the mitral valve and left ventricle that are associated with recurrent MR after mitral annuloplasty. Method and Results - In 104 patients with idiopathic dilated cardiomyopathy who underwent annuloplasty for functional MR, basal mitral anterior leaflet angle, distal mitral anterior leaflet angle (ALA tip), posterior leaflet angle, coaptation depth, tenting area, mitral annular dimensions, left ventricular volumes, and MR severity were quantified by echocardiography before surgery and at 6-month intervals after it. Compared with patients without MR recurrence (n=79), patients with recurrent MR (defined as ≥2+) (n=25) had greater ALA tip (P<0.001) and basal mitral anterior leaflet angle (P<0.001), greater coaptation depth and tenting area (P<0.001), larger left ventricular volumes (P<0.001), and worse left ventricular ejection fraction (P<0.05) but similar mitral annular dimensions and postoperative exaggeration in posterior leaflet angle. Multivariable analysis identified postoperative ALA tip as the major determinant of postoperative MR. Receiver operator characteristic curves identified preoperative ALA tip as the best predictor of MR recurrence (area under curve, 0.98). For ALA tip >25°, the sensitivity, specificity, and positive and negative predictive values in predicting recurrent MR were 88%, 94%, 82%, and 93%, respectively. Three distinct patterns of anterior leaflet tethering (minimal, basal, and distal) with an increasing risk of recurrent MR were identified. Conclusions - Posterior leaflet tethering is invariable after mitral annuloplasty, rendering postoperative mitral competence highly dependent on distal anterior leaflet mobility.

Original languageEnglish (US)
Pages (from-to)2606-2614
Number of pages9
JournalCirculation
Volume119
Issue number19
DOIs
StatePublished - May 19 2009

Fingerprint

Dilated Cardiomyopathy
Mitral Valve Insufficiency
Mitral Valve
Mitral Valve Annuloplasty
Mental Competency
Heart Ventricles
Echocardiography
Recurrence
Sensitivity and Specificity

Keywords

  • Cardiomyopathy
  • Mitral valve
  • Regurgitation
  • Surgery
  • Ventricles

ASJC Scopus subject areas

  • Physiology (medical)
  • Cardiology and Cardiovascular Medicine

Cite this

Mechanisms of recurrent functional mitral regurgitation after mitral valve repair in nonischemic dilated cardiomyopathy importance of distal anterior leaflet tethering. / Lee, Alex Pui Wai; Acker, Michael; Kubo, Spencer H.; Boiling, Steven F.; Park, Seung W.; Bruce, Charles J; Oh, Jae Kuen.

In: Circulation, Vol. 119, No. 19, 19.05.2009, p. 2606-2614.

Research output: Contribution to journalArticle

Lee, Alex Pui Wai ; Acker, Michael ; Kubo, Spencer H. ; Boiling, Steven F. ; Park, Seung W. ; Bruce, Charles J ; Oh, Jae Kuen. / Mechanisms of recurrent functional mitral regurgitation after mitral valve repair in nonischemic dilated cardiomyopathy importance of distal anterior leaflet tethering. In: Circulation. 2009 ; Vol. 119, No. 19. pp. 2606-2614.
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abstract = "Background - Recurrent functional mitral regurgitation (MR) has been reported after mitral valve repair with annuloplasty in patients with dilated cardiomyopathy, but the mechanism is not understood completely. The authors sought to identify abnormalities of the mitral valve and left ventricle that are associated with recurrent MR after mitral annuloplasty. Method and Results - In 104 patients with idiopathic dilated cardiomyopathy who underwent annuloplasty for functional MR, basal mitral anterior leaflet angle, distal mitral anterior leaflet angle (ALA tip), posterior leaflet angle, coaptation depth, tenting area, mitral annular dimensions, left ventricular volumes, and MR severity were quantified by echocardiography before surgery and at 6-month intervals after it. Compared with patients without MR recurrence (n=79), patients with recurrent MR (defined as ≥2+) (n=25) had greater ALA tip (P<0.001) and basal mitral anterior leaflet angle (P<0.001), greater coaptation depth and tenting area (P<0.001), larger left ventricular volumes (P<0.001), and worse left ventricular ejection fraction (P<0.05) but similar mitral annular dimensions and postoperative exaggeration in posterior leaflet angle. Multivariable analysis identified postoperative ALA tip as the major determinant of postoperative MR. Receiver operator characteristic curves identified preoperative ALA tip as the best predictor of MR recurrence (area under curve, 0.98). For ALA tip >25°, the sensitivity, specificity, and positive and negative predictive values in predicting recurrent MR were 88{\%}, 94{\%}, 82{\%}, and 93{\%}, respectively. Three distinct patterns of anterior leaflet tethering (minimal, basal, and distal) with an increasing risk of recurrent MR were identified. Conclusions - Posterior leaflet tethering is invariable after mitral annuloplasty, rendering postoperative mitral competence highly dependent on distal anterior leaflet mobility.",
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T1 - Mechanisms of recurrent functional mitral regurgitation after mitral valve repair in nonischemic dilated cardiomyopathy importance of distal anterior leaflet tethering

AU - Lee, Alex Pui Wai

AU - Acker, Michael

AU - Kubo, Spencer H.

AU - Boiling, Steven F.

AU - Park, Seung W.

AU - Bruce, Charles J

AU - Oh, Jae Kuen

PY - 2009/5/19

Y1 - 2009/5/19

N2 - Background - Recurrent functional mitral regurgitation (MR) has been reported after mitral valve repair with annuloplasty in patients with dilated cardiomyopathy, but the mechanism is not understood completely. The authors sought to identify abnormalities of the mitral valve and left ventricle that are associated with recurrent MR after mitral annuloplasty. Method and Results - In 104 patients with idiopathic dilated cardiomyopathy who underwent annuloplasty for functional MR, basal mitral anterior leaflet angle, distal mitral anterior leaflet angle (ALA tip), posterior leaflet angle, coaptation depth, tenting area, mitral annular dimensions, left ventricular volumes, and MR severity were quantified by echocardiography before surgery and at 6-month intervals after it. Compared with patients without MR recurrence (n=79), patients with recurrent MR (defined as ≥2+) (n=25) had greater ALA tip (P<0.001) and basal mitral anterior leaflet angle (P<0.001), greater coaptation depth and tenting area (P<0.001), larger left ventricular volumes (P<0.001), and worse left ventricular ejection fraction (P<0.05) but similar mitral annular dimensions and postoperative exaggeration in posterior leaflet angle. Multivariable analysis identified postoperative ALA tip as the major determinant of postoperative MR. Receiver operator characteristic curves identified preoperative ALA tip as the best predictor of MR recurrence (area under curve, 0.98). For ALA tip >25°, the sensitivity, specificity, and positive and negative predictive values in predicting recurrent MR were 88%, 94%, 82%, and 93%, respectively. Three distinct patterns of anterior leaflet tethering (minimal, basal, and distal) with an increasing risk of recurrent MR were identified. Conclusions - Posterior leaflet tethering is invariable after mitral annuloplasty, rendering postoperative mitral competence highly dependent on distal anterior leaflet mobility.

AB - Background - Recurrent functional mitral regurgitation (MR) has been reported after mitral valve repair with annuloplasty in patients with dilated cardiomyopathy, but the mechanism is not understood completely. The authors sought to identify abnormalities of the mitral valve and left ventricle that are associated with recurrent MR after mitral annuloplasty. Method and Results - In 104 patients with idiopathic dilated cardiomyopathy who underwent annuloplasty for functional MR, basal mitral anterior leaflet angle, distal mitral anterior leaflet angle (ALA tip), posterior leaflet angle, coaptation depth, tenting area, mitral annular dimensions, left ventricular volumes, and MR severity were quantified by echocardiography before surgery and at 6-month intervals after it. Compared with patients without MR recurrence (n=79), patients with recurrent MR (defined as ≥2+) (n=25) had greater ALA tip (P<0.001) and basal mitral anterior leaflet angle (P<0.001), greater coaptation depth and tenting area (P<0.001), larger left ventricular volumes (P<0.001), and worse left ventricular ejection fraction (P<0.05) but similar mitral annular dimensions and postoperative exaggeration in posterior leaflet angle. Multivariable analysis identified postoperative ALA tip as the major determinant of postoperative MR. Receiver operator characteristic curves identified preoperative ALA tip as the best predictor of MR recurrence (area under curve, 0.98). For ALA tip >25°, the sensitivity, specificity, and positive and negative predictive values in predicting recurrent MR were 88%, 94%, 82%, and 93%, respectively. Three distinct patterns of anterior leaflet tethering (minimal, basal, and distal) with an increasing risk of recurrent MR were identified. Conclusions - Posterior leaflet tethering is invariable after mitral annuloplasty, rendering postoperative mitral competence highly dependent on distal anterior leaflet mobility.

KW - Cardiomyopathy

KW - Mitral valve

KW - Regurgitation

KW - Surgery

KW - Ventricles

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