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(Circulation. 2001;104:I-47.)
© 2001 American Heart Association, Inc.

Surgery for Valvular Heart Disease

Pathogenesis of Mitral Regurgitation in Tachycardia-Induced Cardiomyopathy

Tomasz A. Timek, MD; Paul Dagum, MD, PhD; David T. Lai, FRACS; David Liang, MD, PhD; George T. Daughters, MS; Neil B. Ingels, Jr, PhD; D. Craig Miller, MD

Department of Cardiovascular and Thoracic Surgery (T.A.T., P.D., D.T.L., G.T.D., N.B.I., D.C.M.), Division of Cardiovascular Medicine (D.L.), Stanford University School of Medicine, Stanford, and Laboratory of Cardiovascular Physiology and Biophysics, Research Institute of the Palo Alto Medical Foundation (G.T.D., N.B.I.), Palo Alto, Calif.

Correspondence to D. Craig Miller, MD, Department of Cardiovascular Surgery, Falk Cardiovascular Research Center, Stanford University School of Medicine, Stanford, CA 94305-5247. E-mail dcm{at}leland.stanford.edu

Background— Dilated cardiomyopathy is often associated with mitral regurgitation (MR), or so-called functional MR, the mechanism of which continues to be debated. We studied the valvular and ventricular 3D geometric perturbations associated with MR in an ovine model of tachycardia-induced cardiomyopathy (TIC).

Methods and Results— Nine sheep underwent myocardial marker implantation in the left ventricle (LV), mitral annulus, and mitral leaflets. After 5 to 8 days, the animals were studied with biplane videofluoroscopy (baseline), and mitral competence was assessed by transesophageal echocardiography. Rapid ventricular pacing (180 to 230 bpm) was subsequently initiated for 15±6 days until the development of TIC and MR, whereupon biplane videofluoroscopy and transesophageal echocardiography studies were repeated. LV volume was calculated from the epicardial marker array. Valve closure time was defined as the time after end diastole when the distance between leaflet edge markers reached its minimal plateau. TIC resulted in increased LV end-diastolic volume (P=0.001) and LV end-systolic volume (P=0.0001) and greater LV sphericity (P=0.02). MR increased significantly (grade 0.2±0.3 versus 2.2±0.9, P=0.0001), as did mitral annulus area (817±146 versus 1100±161 mm², P=0.0001) and mitral annulus septal-lateral diameter (28.2±3.5 versus 35.1±2.6 mm, P=0.0001). Time of valve closure (70±18 versus 87±14 ms, P=0.23) and angular displacement of both the anterior (29±5° versus 27±3°, P=0.3) and posterior (55±15° versus 44±11°, P=0.13) leaflet edges relative to the mitral annulus after valve closure did not change, but leaflet edge separation after closure increased (5.2±0.9 versus 6.8±1.2 mm, P=0.019).

Conclusions— MR in TIC resulted from decreased leaflet coaptation secondary to annular dilatation in the septal-lateral direction. These data support the use of annular reduction procedures, such as rigid, complete ring annuloplasty, to address functional MR in patients with dilated cardiomyopathy.

Key Words: mitral valve • regurgitation • cardiomyopathy • pacing