(Circulation. 2000;102:1400.)
© 2000 American Heart Association, Inc.
Clinical Investigation and Reports |
Determinants of the Degree of Functional Mitral Regurgitation in Patients With Systolic Left Ventricular Dysfunction
A Quantitative Clinical Study
From the Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minn.
Background—Functional mitral regurgitation (FMR) occurs with a structurally normal valve as a complication of systolic left ventricular dysfunction (LVD). Determinants of degree of FMR are poorly defined; thus, mechanistic therapeutic approaches to FMR are hindered.
Methods and Results—In a prospective study of 21 control subjects and 128 patients with LVD (defined as ejection fraction <50%, mean 31±9%) in sinus rhythm, we quantified simultaneously by echocardiography the effective regurgitant orifice (ERO) of FMR by using 2 methods: mitral deformation (valve and annulus) and left ventricular (LV) global (volumes, stress, function, and sphericity) and local (papillary muscle displacements and regional wall motion index) remodeling. A wide range of ERO (15±14 mm2, 0 to 87 mm2) was observed, unrelated to ejection fraction (P=0.32). The major determinant of ERO was mitral deformation, ie, systolic valvular tenting and annular contraction in univariate (r=0.74 and r=-0.61, respectively; both P<0.0001) and multivariate (both P<0.0001) analyses, independent of global LV remodeling. Systolic valvular tenting was strongly determined by local LV alterations, particularly apical (r=0.75) and posterior (r=0.70) displacement of papillary muscle, with confirmation in multivariate analysis (both P<0.0001), independent of LV volumes, function, and sphericity.
Conclusions—The presence and degree of FMR complicating LVD are unrelated to the severity of LVD. Local LV remodeling (apical and posterior displacement of papillary muscles) leads to excess valvular tenting independent of global LV remodeling. In turn, excess tenting and loss of systolic annular contraction are associated with larger EROs. These determinants of FMR warrant consideration for specific approaches to the treatment of FMR complicating LVD.
Key Words: echocardiography • heart failure • ventricles • mitral valve • regurgitation
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R. A. Levine and E. Schwammenthal Ischemic Mitral Regurgitation on the Threshold of a Solution: From Paradoxes to Unifying Concepts Circulation, August 2, 2005; 112(5): 745 - 758. [Full Text] [PDF]
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M. B. Srichai, R. A. Grimm, A. E. Stillman, A. M. Gillinov, L. L. Rodriguez, M. L. Lieber, A. Lara, J. A. Weaver, P. M. McCarthy, and R. D. White Ischemic Mitral Regurgitation: Impact of the Left Ventricle and Mitral Valve in Patients with Left Ventricular Systolic Dysfunction Ann. Thorac. Surg., July 1, 2005; 80(1): 170 - 178. [Abstract] [Full Text] [PDF]
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F. A. Tibayan, F. Rodriguez, F. Langer, M. K. Zasio, L. Bailey, D. Liang, G. T. Daughters, N. B. Ingels Jr, and D. C. Miller Annular or subvalvular approach to chronic ischemic mitral regurgitation? J. Thorac. Cardiovasc. Surg., June 1, 2005; 129(6): 1266 - 1275. [Abstract] [Full Text] [PDF]
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M. Daimon, T. Shiota, A. M. Gillinov, M. Hayase, M. Ruel, W. E. Cohn, S. J. Blacker, and J. R. Liddicoat Percutaneous Mitral Valve Repair for Chronic Ischemic Mitral Regurgitation: A Real-Time Three-Dimensional Echocardiographic Study in an Ovine Model Circulation, May 3, 2005; 111(17): 2183 - 2189. [Abstract] [Full Text] [PDF]
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N. Watanabe, Y. Ogasawara, Y. Yamaura, T. Kawamoto, E. Toyota, T. Akasaka, and K. Yoshida Quantitation of mitral valve tenting in ischemic mitral regurgitation by transthoracic real-time three-dimensional echocardiography J. Am. Coll. Cardiol., March 1, 2005; 45(5): 763 - 769. [Abstract] [Full Text] [PDF]
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A. H. Wu, K. D. Aaronson, S. F. Bolling, F. D. Pagani, K. Welch, and T. M. Koelling Impact of mitral valve annuloplasty on mortality risk in patients with mitral regurgitation and left ventricular systolic dysfunction J. Am. Coll. Cardiol., February 1, 2005; 45(3): 381 - 387. [Abstract] [Full Text] [PDF]
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T. V. Salukhe, M. Y. Henein, and R. Sutton Ischemic Mitral Regurgitation and Its Related Risk After Myocardial Infarction Circulation, January 25, 2005; 111(3): 254 - 256. [Full Text] [PDF]
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F. Bursi, M. Enriquez-Sarano, V. T. Nkomo, S. J. Jacobsen, S. A. Weston, R. A. Meverden, and V. L. Roger Heart Failure and Death After Myocardial Infarction in the Community: The Emerging Role of Mitral Regurgitation Circulation, January 25, 2005; 111(3): 295 - 301. [Abstract] [Full Text] [PDF]
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F. Grigioni, D. Detaint, J.-F. Avierinos, C. Scott, J. Tajik, and M. Enriquez-Sarano Contribution of ischemic mitral regurgitation to congestive heart failure after myocardial infarction J. Am. Coll. Cardiol., January 18, 2005; 45(2): 260 - 267. [Abstract] [Full Text] [PDF]
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C. V. Maniu, J. B. Patel, D. G. Reuter, D. M. Meyer, W. D. Edwards, C. S. Rihal, and M. M. Redfield Acute and chronic reduction of functional mitral regurgitation in experimental heart failure by percutaneous mitral annuloplasty J. Am. Coll. Cardiol., October 19, 2004; 44(8): 1652 - 1661. [Abstract] [Full Text] [PDF]
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R. A. Levine, E. Messas, N. S. Nathan, and L. G. Rudski New understanding of ischemic mitral regurgitation: the marionette and its masters Eur J Echocardiogr, October 1, 2004; 5(5): 313 - 317. [Full Text] [PDF]
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T. A. Timek, D. T. Lai, D. Liang, F. Tibayan, F. Langer, F. Rodriguez, G. T. Daughters, N. B. Ingels Jr, and D. C. Miller Effects of Paracommissural Septal-Lateral Annular Cinching on Acute Ischemic Mitral Regurgitation Circulation, September 14, 2004; 110(11_suppl_1): II-79 - II-84. [Abstract] [Full Text] [PDF]
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F. Rodriguez, F. Langer, K. B. Harrington, F. A. Tibayan, M. K. Zasio, D. Liang, G. T. Daughters, N. B. Ingels, and D. C. Miller Cutting Second-Order Chords Does Not Prevent Acute Ischemic Mitral Regurgitation Circulation, September 14, 2004; 110(11_suppl_1): II-91 - II-97. [Abstract] [Full Text] [PDF]
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F. A. Tibayan, F. Rodriguez, F. Langer, M. K. Zasio, L. Bailey, D. Liang, G. T. Daughters, N. B. Ingels Jr, and D. C. Miller Does septal-lateral annular cinching work for chronic ischemic mitral regurgitation? J. Thorac. Cardiovasc. Surg., March 1, 2004; 127(3): 654 - 663. [Abstract] [Full Text] [PDF]
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