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Ann Thorac Surg. 2016 Feb;101(2):567-75; discussion 575. doi: 10.1016/j.athoracsur.2015.09.076. Epub 2015 Dec 12.

Preoperative Three-Dimensional Valve Analysis Predicts Recurrent Ischemic Mitral Regurgitation After Mitral Annuloplasty.

Author information

1
Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
2
Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania.
3
Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
4
Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania.
5
Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
6
Department of Cardiothoracic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
7
Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.
8
Department of Anesthesia, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
9
Department of Cardiothoracic Surgery, Stanford University, Stanford, California.
10
Department of Anesthesia, Stanford University, Stanford, California.
11
Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
12
Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address: gormanr@uphs.upenn.edu.

Abstract

BACKGROUND:

Valve repair for ischemic mitral regurgitation (IMR) with undersized annuloplasty rings is characterized by high IMR recurrence rates. Patient-specific preoperative imaging-based risk stratification for recurrent IMR would optimize results. We sought to determine if prerepair three-dimensional (3D) echocardiography combined with a novel valve-modeling algorithm would be predictive of IMR recurrence 6 months after repair.

METHODS:

Intraoperative transesophageal real-time 3D echocardiography was performed in 50 patients undergoing undersized ring annuloplasty for IMR and in 21 patients with normal mitral valves. A customized image analysis protocol was used to assess 3D annular geometry and regional leaflet tethering. IMR recurrence (≥ grade 2) was assessed with two-dimensional transthoracic echocardiography 6 months after repair.

RESULTS:

Preoperative annular geometry was similar in all IMR patients, and preoperative leaflet tethering was significantly higher in patients with recurrent IMR (n=13) than in patients in whom IMR did not recur (n=37) (tethering index: 3.91 ± 1.01 vs 2.90 ± 1.17, p = 0.008; tethering angles of A3: 23.5° ± 8.9° vs 14.4° ± 11.4°, p = 0.012; P2: 44.4° ± 8.8° vs 28.2° ± 17.0°, p = 0.002; and P3: 35.2° ± 6.0° vs. 18.6° ± 12.7°, p < 0.001). Multivariate logistic regression analysis revealed the preoperative P3 tethering angle as an independent predictor of IMR recurrence with an optimal cutoff value of 29.9° (area under the curve, 0.92; 95% confidence interval, 0.84 to 1.00; p < 0.001).

CONCLUSIONS:

3D echocardiography combined with valve modeling is predictive of recurrent IMR. Preoperative regional leaflet tethering of segment P3 is a strong independent predictor of IMR recurrence after undersized ring annuloplasty. In patients with a preoperative P3 tethering angle of 29.9° or larger, chordal-sparing valve replacement rather than valve repair should be strongly considered.

PMID:
26688087
PMCID:
PMC4718840
DOI:
10.1016/j.athoracsur.2015.09.076
[Indexed for MEDLINE]
Free PMC Article

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