(Circulation. 1997;96:1999-2008.)
© 1997 American Heart Association, Inc.
Articles |
Insights From Three-Dimensional Echocardiography Into the Mechanism of Functional Mitral Regurgitation
Direct In Vivo Demonstration of Altered Leaflet Tethering Geometry
From the Cardiac Ultrasound Laboratory and Cardiovascular Surgical Unit, Massachusetts General Hospital, Departments of Medicine and Surgery, Harvard Medical School, Boston, Mass.
Correspondence to Yutaka Otsuji, MD, Cardiac Ultrasound Laboratory, VBK508, Massachusetts General Hospital, 32 Fruit St, Boston, MA 02114.
Background Recent advances in three-dimensional (3D) echocardiography allow us to address uniquely 3D scientific questions, such as the mechanism of functional mitral regurgitation (MR) in patients with left ventricular (LV) dysfunction and its relation to the 3D geometry of mitral leaflet attachments. Competing hypotheses include global LV dysfunction with inadequate leaflet closing force versus geometric distortion of the mitral apparatus by LV dilatation, which increases leaflet tethering and restricts closure. Because geometric changes generally accompany dysfunction, these possibilities have been difficult to separate.
Methods and Results We created a model of global LV dysfunction by esmolol and phenylephrine infusion in six dogs, initially with LV expansion limited by increasing pericardial restraint and then with the pericardium opened. The mid-systolic 3D relations of the papillary muscle (PM) tips and mitral valve were reconstructed. Despite severe LV dysfunction (ejection fraction, 18±6%), only trace MR developed when pericardial restraint limited LV dilatation; with the pericardium opened, moderate MR accompanied LV dilatation (end-systolic volume, 44±5 mL versus 12±5 mL control, P<.001). Mitral regurgitant volume and orifice area did not correlate with LV ejection fraction and dP/dt (global function) but did correlate with changes in the tethering distance from the PMs to the anterior annulus derived from the 3D reconstructions, especially PM shifts in the posterior and mediolateral directions, as well as with annular area (P<.0005). By multiple regression, only changes in the PM-to-annulus distance independently predicted MR volume and orifice area (R2=.82 to .85, P=2x10-7 to 6x10-8).
Conclusions LV dysfunction without dilatation fails to produce important MR. Functional MR relates strongly to changes in the 3D geometry of the mitral valve attachments at the PM and annular levels, with practical implications for approaches that would restore a more favorable configuration.
Key Words: echocardiography • regurgitation • mitral valve
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M. J. Byrne, D. M. Kaye, M. Mathis, D. G. Reuter, C. A. Alferness, and J. M. Power Percutaneous Mitral Annular Reduction Provides Continued Benefit in an Ovine Model of Dilated Cardiomyopathy Circulation, November 9, 2004; 110(19): 3088 - 3092. [Abstract] [Full Text] [PDF]
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H. Kanzaki, R. Bazaz, D. Schwartzman, K. Dohi, L. E. Sade, and J. Gorcsan III A mechanism for immediate reduction in mitral regurgitation after cardiac resynchronization therapy: Insights from mechanical activation strain mapping J. Am. Coll. Cardiol., October 19, 2004; 44(8): 1619 - 1625. [Abstract] [Full Text] [PDF]
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R. A. Levine Dynamic Mitral Regurgitation -- More Than Meets the Eye N. Engl. J. Med., October 14, 2004; 351(16): 1681 - 1684. [Full Text] [PDF]
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H.-Y. Yu, M.-Y. Su, T.-Y. Liao, H.-H. Peng, F.-Y. Lin, and W.-Y. I. Tseng Functional mitral regurgitation in chronic ischemic coronary artery disease: Analysis of geometric alterations of mitral apparatus with magnetic resonance imaging J. Thorac. Cardiovasc. Surg., October 1, 2004; 128(4): 543 - 551. [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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E. Agricola, M. Oppizzi, F. Maisano, M. De Bonis, A. F.L. Schinkel, L. Torracca, A. Margonato, G. Melisurgo, and O. Alfieri Echocardiographic classification of chronic ischemic mitral regurgitation caused by restricted motion according to tethering pattern Eur J Echocardiogr, October 1, 2004; 5(5): 326 - 334. [Abstract] [Full Text] [PDF]
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J. Hung, L. Papakostas, S. A. Tahta, B. G. Hardy, B. A. Bollen, C. M. Duran, and R. A. Levine Mechanism of Recurrent Ischemic Mitral Regurgitation After Annuloplasty: Continued LV Remodeling as a Moving Target Circulation, September 14, 2004; 110(11_suppl_1): II-85 - II-90. [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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A. Franke and H. P Kuehl Regurgitant mitral valve and 3D echocardiography--meant for each other? Eur J Echocardiogr, June 1, 2004; 5(3): 159 - 161. [Full Text] [PDF]
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G. G. Pellizzon, C. L. Grines, D. A. Cox, T. Stuckey, J. E. Tcheng, E. Garcia, G. Guagliumi, M. Turco, A. J. Lansky, J. J. Griffin, et al. Importance of mitral regurgitation inpatients undergoing percutaneous coronaryintervention for acute myocardial infarction: The Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) Trial J. Am. Coll. Cardiol., April 21, 2004; 43(8): 1368 - 1374. [Abstract] [Full Text] [PDF]
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M. Inoue, P. M. McCarthy, Z. B. Popovic, K. Doi, S. Schenk, H. Nemeh, Y. Ootaki, M. W. Kopcak Jr, R. Dessoffy, J. D. Thomas, et al. The Coapsys device to treat functional mitral regurgitation: In vivo long-term canine study J. Thorac. Cardiovasc. Surg., April 1, 2004; 127(4): 1068 - 1077. [Abstract] [Full Text] [PDF]
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M. H. Yacoub and L. H. Cohn Novel Approaches to Cardiac Valve Repair: From Structure to Function: Part I Circulation, March 2, 2004; 109(8): 942 - 950. [Full Text] [PDF]
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A. E. Weyman The year in echocardiography J. Am. Coll. Cardiol., January 7, 2004; 43(1): 140 - 148. [Full Text] [PDF]
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R. A. Levine and J. Hung Ischemic mitral regurgitation, the dynamic lesion: clues to the cure J. Am. Coll. Cardiol., December 3, 2003; 42(11): 1929 - 1932. [Full Text] [PDF]
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W. A. Zoghbi, M. Enriquez-Sarano, E. Foster, P. A. Grayburn, C. D. Kraft, R. A. Levine, P. Nihoyannopoulos, C. M. Otto, M. A. Quinones, H. Rakowski, et al. American Society of Echocardiography: recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography : A report from the American Society of Echocardiography's Nomenclature and Standards Committee and The Task Force on Valvular Regurgitation, developed in conjunction with the American College of Cardiology Echocardiography Committee, The Cardiac Imaging Committee, Council on Clinical Cardiology, The American Heart Association, and the European Society of Cardiology Working Group on Echocardiography, represented by: Eur J Echocardiogr, December 1, 2003; 4(4): 237 - 261. [Full Text] [PDF]
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J. H. Gorman III, R. C. Gorman, B. M. Jackson, Y. Enomoto, M. G. St. John-Sutton, and L. H. Edmunds Jr Annuloplasty ring selection for chronic ischemic mitral regurgitation: lessons from the ovine model Ann. Thorac. Surg., November 1, 2003; 76(5): 1556 - 1563. [Abstract] [Full Text] [PDF]
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E. Messas, B. Pouzet, B. Touchot, J. L. Guerrero, G. J. Vlahakes, M. Desnos, P. Menasche, A. Hagege, and R. A. Levine Efficacy of Chordal Cutting to Relieve Chronic Persistent Ischemic Mitral Regurgitation Circulation, September 9, 2003; 108(90101): II-111 - 115. [Abstract] [Full Text] [PDF]
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T. A. Timek, S. L. Nielsen, D. T. Lai, F. A Tibayan, D. Liang, F. Rodriguez, G. T. Daughters, N. B. Ingels Jr, and D. C. Miller Edge-to-Edge Mitral Valve Repair Without Ring Annuloplasty for Acute Ischemic Mitral Regurgitation Circulation, September 9, 2003; 108(90101): II-122 - 127. [Abstract] [Full Text] [PDF]
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O. A. Breithardt, A. M. Sinha, E. Schwammenthal, N. Bidaoui, K. U. Markus, A. Franke, and C. Stellbrink Acute effects of cardiac resynchronization therapy on functional mitral regurgitation in advanced systolic heart failure J. Am. Coll. Cardiol., March 5, 2003; 41(5): 765 - 770. [Abstract] [Full Text] [PDF]
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J. Kwan, T. Shiota, D. A. Agler, Z. B. Popovic, J. X. Qin, M. A. Gillinov, W. J. Stewart, D. M. Cosgrove, P. M. McCarthy, and J. D. Thomas Geometric Differences of the Mitral Apparatus Between Ischemic and Dilated Cardiomyopathy With Significant Mitral Regurgitation: Real-Time Three-Dimensional Echocardiography Study Circulation, March 4, 2003; 107(8): 1135 - 1140. [Abstract] [Full Text] [PDF]
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T. A. Timek, D. T. Lai, F. Tibayan, D. Liang, G. T. Daughters, P. Dagum, M. K. Zasio, S. Lo, T. Hastie, N. B. Ingels Jr, et al. Ischemia in three left ventricular regions: Insights into the pathogenesis of acute ischemic mitral regurgitation J. Thorac. Cardiovasc. Surg., March 1, 2003; 125(3): 559 - 569. [Abstract] [Full Text] [PDF]
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T. Kumanohoso, Y. Otsuji, S. Yoshifuku, K. Matsukida, C. Koriyama, A. Kisanuki, S. Minagoe, R. A. Levine, and C. Tei Mechanism of higher incidence of ischemic mitral regurgitation in patients with inferior myocardial infarction: Quantitative analysis of left ventricular and mitral valve geometry in 103 patients with prior myocardial infarction J. Thorac. Cardiovasc. Surg., January 1, 2003; 125(1): 135 - 143. [Abstract] [Full Text] [PDF]
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R. C. Gorman, J. H. Gorman III, and L. H. Edmunds Jr. Ischemic Mitral Regurgitation Card. Surg. Adult, January 1, 2003; 2(2003): 751 - 769. [Full Text]
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P. M. McCarthy Does the intertrigonal distance dilate? Never say never J. Thorac. Cardiovasc. Surg., December 1, 2002; 124(6): 1078 - 1079. [Full Text]
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A. C. Hueb, F. B. Jatene, L. F. P. Moreira, P. M. Pomerantzeff, E. Kallas, and S. A. de Oliveira Ventricular remodeling and mitral valve modifications in dilated cardiomyopathy: New insights from anatomic study J. Thorac. Cardiovasc. Surg., December 1, 2002; 124(6): 1216 - 1224. [Abstract] [Full Text]
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J. Hung, J. L. Guerrero, M. D. Handschumacher, G. Supple, S. Sullivan, and R. A. Levine Reverse Ventricular Remodeling Reduces Ischemic Mitral Regurgitation: Echo-Guided Device Application in the Beating Heart Circulation, November 12, 2002; 106(20): 2594 - 2600. [Abstract] [Full Text] [PDF]
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D. T. Lai, T. A. Timek, F. A. Tibayan, G. R. Green, G. T. Daughters, D. Liang, N. B. Ingels Jr, and D. C. Miller The effects of mitral annuloplasty rings on mitral valve complex 3-D geometry during acute left ventricular ischemia Eur. J. Cardiothorac. Surg., November 1, 2002; 22(5): 808 - 816. [Abstract] [Full Text] [PDF]
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Y. Otsuji, T. Kumanohoso, S. Yoshifuku, K. Matsukida, C. Koriyama, A. Kisanuki, S. Minagoe, R. A. Levine, and C. Tei Isolated annular dilation does not usually cause important functional mitral regurgitation: Comparison between patients with lone atrial fibrillation and those with idiopathic or ischemic cardiomyopathy J. Am. Coll. Cardiol., May 15, 2002; 39(10): 1651 - 1656. [Abstract] [Full Text] [PDF]
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