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J Thorac Cardiovasc Surg 2005;130:1459-1461
© 2005 The American Association for Thoracic Surgery

Brief Communication

Geometric change of mitral valve leaflets and annulus after reconstructive surgery for ischemic mitral regurgitation: Real-time 3-dimensional echocardiographic study

Yasuko Yamaura, MD a , * , Nozomi Watanabe, MD a , Yasuo Ogasawara, PhD c , Nozomi Wada, MD a , Takahiro Kawamoto, MD a , Eiji Toyota, MD a , Takashi Akasaka, MD a , Kazuo Tanemoto b , Kiyoshi Yoshida, MD a

a Department of Cardiology, Kawasaki Medical School, Kurashiki, Japan
b Department of Thoracic and Cardiovascular Surgery, Kawasaki Medical School, Kurashiki, Japan
c Department of Medical Engineering and Systems of Cardiology, Kawasaki Medical School, Kurashiki, Japan

Received for publication June 3, 2005; revisions received June 10, 2005; accepted for publication June 30, 2005.

* Address for reprints: Yasuko Yamaura, MD, Division of Cardiology, Hyogo Health Service Association, 4-4-20, Mikage-Honmachi, Higashinada-ku, Kobe, 658-0046, Japan. (Email: yasuko-yamaura{at}mvj.biglobe.ne.jp).


Figure 2
Watanabe, Yamaura, Wada, Ogasawara (left to right)


Ischemic mitral regurgitation (IMR) is a functional regurgitation characterized by structurally normal leaflets and subvalvular apparatus and is an important complication after myocardial infarction that is associated with excess mortality. 1 Go Reconstructive surgery, which restores a more normal alignment between the mitral annulus and displaced papillary muscles, might be beneficial in patients with IMR. However, little is known about the 3-dimensional (3-D) geometric changes of mitral leaflets and annulus after such reconstructive surgery for patients with IMR. We developed novel software, named Anatomical Image Creation System (AICS), which allows 3-D visualization and quantitative analysis of the mitral leaflets and annulus by using transthoracic real-time 3-D echocardiography (RT3DE). 2 Go We already demonstrated the apparent tenting of the mitral leaflets with flattened annulus in patients with IMR using this system. 3 Go In the present study we evaluated the 3-D geometric changes of the mitral leaflets and annulus in patients after reconstructive surgery for IMR using AICS.

Methods

We studied 3 patients who underwent mitral ring annuloplasty and concomitant left ventricular (LV) restorative surgery for severe IMR and severe LV systolic dysfunction caused by coronary artery disease. All the RT3DE examination was performed 1 week before and 3 weeks after the operation. LV systolic function and degree of mitral regurgitation (MR) were quantified by using 2-dimensional echocardiography. Using the transthoracic volumetric image by the RT3DE system with AICS, we created 3-D images of the mitral leaflets and annulus in midsystole for the 3-D quantitative measurements. The mitral leaflets' tenting volume was calculated as a volume enclosed between the 3-D annular plane and the mitral leaflets. Mitral annular size was measured by using those 3-D data sets as well (surface area, circumference, commissure-commissure diameter, and anterior-posterior diameter). Details of the 3-D image creation and measurements are described in our previous reports. 2,3 Go All 3 patients provided written informed consent to the study protocol, which was approved by the Committee for the Protection of Human Subjects in Research at Kawasaki Medical School.

Results

All 3 patients had severe MR and severe LV systolic dysfunction before the operation. After the operation, MR disappeared and LV volume decreased in all 3 patients. The mitral leaflets' tenting volume and the size of the mitral annulus apparently reduced after the operation in all patients (Table 1). Preoperative 3-D images demonstrated the apparent tenting of the mitral leaflets, which showed mountain-shaped bulging with tethering into the left ventricle (Figure 1, left). After the operation, the mitral annulus visibly shrank, and the mitral leaflets' tenting volume was apparently smaller compared with that seen in preoperative images (Figure 1, right).


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  		TABLE 1. Clinical characteristics and 3-dimensional measurements of mitral annulus and leaflets
 

Figure 1
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  		Figure 1. Three-dimensional images of the mitral leaflets and annulus in midsystole obtained from patient 2: left, preoperative images; right, postoperative images. A, Anatomic 3-dimensional images. The anatomic 3-dimensional images shows the actual configuration of the annulus and leaflets with surface colorations. The preoperative image (left) shows an apparent tenting of the mitral leaflets, which were tethered into the left ventricle, showing mountain-shaped leaflet bulging. In the postoperative image (right) the mitral annulus visibly shrank, and the mitral leaflets' tenting volume is apparently small. B, Actual 3-dimensional tenting images in the vertical view from the left ventricle. The mitral leaflets' configuration was represented in contour to appreciate the degree of tenting in the vertical from the left ventricle. The mitral annulus is dilated in the preoperative image (left), and it is prominently small in the postoperative image (right). Black dots indicate the coaptation line. A, Anterior; P, posterior; L, lateral; M, medial; LV, left ventricle; LA, left atrium.

 
Discussion

In this study we demonstrated 3-D geometric changes of the mitral leaflets and annulus in patients undergoing reconstructive surgery for IMR using our novel AICS system with RT3DE.

Although annuloplasty is the current common surgical strategy for IMR, 4 Go MR often persists after annuloplasty. Recently, new surgical strategies, such as chordal cutting or papillary muscle repositioning with LV reshaping, have been expected to reduce persistent IMR after annuloplasty. 5 Go However, in the clinical setting it has been difficult to assess the geometric changes of the mitral leaflets and annulus after reconstructive surgery by using 2-dimensional echocardiography. Precise and comprehensive understanding of the 3-D geometric changes of the mitral leaflets and annulus should be needed for postoperative evaluation of valve repair. In this study, using novel AICS with RT3DE, we could visually and quantitatively compare the 3-D geometry of the mitral leaflets and annulus in patients with IMR before and after the operation. Hence this technique would be helpful for the surgeon to evaluate the effect of reconstructive surgery on the 3-D geometry of the mitral leaflets and annulus in patients with IMR and to make a proper decision for surgical strategy for each individual in the clinical setting.

References

  1. Grigioni F, Enriquez-Sarano M, Zehr KJ, Bailey KR, Tajik AJ. Ischemic mitral regurgitation. long-term outcome and prognostic implications with quantitative Doppler assessment. Circulation 2001;103:1759-1764.[Abstract/Free Full Text]
  2. Yamaura Y, Watanabe N, Ogasawara Y, Yamamoto K, Kawamoto T, Toyota E, et al. Geometric demonstration and three-dimensional quantitative analysis of the mitral valve with real-time three-dimensional echocardiography. novel anatomical image creation system. J Echocardiogr 2004;2:99-104.
  3. Watanabe N, Ogasawara Y, Yamaura Y, Kawamoto T, Toyota E, Akasaka T, et al. Quantitation of mitral valve tenting in ischemic mitral regurgitation by transthoracic real-time three-dimensional echocardiography. J Am Coll Cardiol 2005;45:763-769.[Abstract/Free Full Text]
  4. Gillinov AM, Cosgrove 3rd DM, Shiota T, Qin J, Tsujino H, Stewart WJ, et al. Cosgrove-Edwards Annuloplasty System. midterm results. Ann Thorac Surg 2000;69:717-721.[Abstract/Free Full Text]
  5. Messas E, Pouzet B, Touchot B, Guerrero JL, Vlahakes GJ, Desnos M, et al. Efficacy of chordal cutting to relieve chronic persistent ischemic mitral regurgitation. Circulation 2003;108(suppl):II111-II115.[Medline]



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