Scripties UMCG - Rijksuniversiteit Groningen
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Three-Dimensional Quantitative Mitral Valve Analysis After Undersized Annuloplasty For Ischemic Mitral Regurgitation

(2017) Meijerink, F. (Frank)

BACKGROUND Mitral Valve (MV) Repair for Ischemic Mitral Regurgitation (IMR)
is characterized by high recurrence rates, up to 30% after six months. Previous studies
have shown that the preoperative P3 tethering angle is a strong predictor for recurrent
IMR, 6 months after annuloplasty and that three-dimensional (3D) predictive models
are stronger than two-dimensional (2D) predictive models. The effect of reduction
annuloplasty has not been studied with 3D transesophageal echocardiography (TEE).
With this study we aim to (1) determine the effect of reduction annuloplasty on 3D
echocardiographic annular and leaflet tethering parameters and (2) to compare these
parameters between patients that do and do not develop recurrent IMR 6 months after
METHODS In this study 35 patients were included. All had severe IMR eligible for
MV repair. There was no echocardiographic evidence for structural (chordal or
leaflet) MV disease or papillary muscle (PM) rupture. All patients underwent MV
repair with an undersized annuloplasty ring. For all patients pre- and post-repair 3D
TEE images were obtained. Six months after repair IMR grade was assessed using 2D
transthoracic echocardiography to determine recurrent IMR (≥grade 2). All 3D
images were processed and analyzed in a specialized software workstation, resulting
in a 3D model of the MV in mid-systole. This model allowed for quantitative analysis
using MATLAB. This way annular and leaflet tethering variables were measured and
statistical analysis was performed.
RESULTS Nine patients (25.7%) showed recurrent IMR after 6 months. The A1, A2,
P1, P2 and P3 tethering angles were significantly higher post-repair. The posterior
tethering angles showed the highest increase (>20°). The pre-repair P2 and P3
tethering angles were significantly different between non-recurrent and recurrent
groups. Post-repair there was no difference in tethering angles between the two
CONCLUSION Three-dimensional MV analysis shows that undersized annuloplasty
exacerbates global leaflet tethering. Pre-repair the tethering pattern is different
between non-recurrent and recurrent IMR patients, post-repair it is not. Although prerepair
MV tethering predicts recurrent IMR after annuloplasty, post-repair MV
tethering does not. The results indicate that subvalvular mechanisms and geometry
play a pivotal role in the postoperative development of recurrent IMR after undersized

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