The value of preoperative 3-dimensional over 2-dimensional valve analysis in predicting recurrent ischemic mitral regurgitation after mitral annuloplasty

Abstract

Objectives Repair for ischemic mitral regurgitation with undersized annuloplasty is characterized by high recurrence rates. We sought to determine the value of pre-repair 3-dimensional echocardiography over 2-dimensional echocardiography in predicting recurrence at 6 months. Methods Intraoperative transesophageal 2-dimensional echocardiography and 3-dimensional echocardiography were performed in 50 patients undergoing undersized annuloplasty for ischemic mitral regurgitation. Two-dimensional echocardiography annular diameter and tethering parameters were measured in the apical 2- and 4-chamber views. A customized protocol was used to assess 3-dimensional annular geometry and regional leaflet tethering. Recurrence (grade ≥2) was assessed with 2-dimensional transthoracic echocardiography at 6 months. Results Preoperative 2- and 3-dimensional annular geometry were similar in all patients with ischemic mitral regurgitation. Preoperative 2- and 3-dimensional leaflet tethering were significantly higher in patients with recurrence (n = 13) when compared with patients without recurrence (n = 37). Multivariate logistic regression revealed preoperative 2-dimensional echocardiography posterior tethering angle as an independent predictor of recurrence with an optimal cutoff value of 32.0° (area under the curve, 0.81; 95% confidence interval, 0.68–0.95; P = .002) and preoperative 3-dimensional echocardiography P3 tethering angle as an independent predictor of recurrence with an optimal cutoff value of 29.9° (area under the curve, 0.92; 95% confidence interval, 0.84–1.00; P < .001). The predictive value of the 3-dimensional geometric multivariate model can be augmented by adding basal aneurysm/dyskinesis (area under the curve, 0.94; 95% confidence interval, 0.87–1.00; P < .001). Conclusions Preoperative 3-dimensional echocardiography P3 tethering angle is a stronger predictor of ischemic mitral regurgitation recurrence after annuloplasty than preoperative 2-dimensional echocardiography posterior tethering angle, which is highly influenced by viewing plane. In patients with a preoperative P3 tethering angle of 29.9° or larger (especially when combined with basal aneurysm/dyskinesis), chordal-sparing valve replacement should be strongly considered.

Commentary: Three-dimensional P3 tethering angle at the heart of future surgical decision making in ischemic mitral regurgitation

“…On a day-to-day basis, cardiac surgeons are faced with 2 important questions regarding IMR: Should we operate on this (moderately) regurgitant mitral valve and, Should we repair or replace this (severely) regurgitant mitral valve? As shown by Sun and colleagues 2 and by our group, 6,7 3DE P3TA may be the key to answering these questions. At this point, both questions are difficult to answer for an individual patient based on current guidelines.…”

“…5 Additional studies from our group with similar modeling algorithms have shown that preoperative 3DE P3TA is a strong (ie, independent) predictor of IMR recurrence after undersized ring annuloplasty for severe IMR 6 and that 3DE is superior over 2-dimensional echocardiography because it is not dependent on viewing plane selection. 7 Those studies and the study by Sun and colleagues 2 are, however, limited by the fact that IMR severity was measured semiquantitatively with jet area/left atrium area. Future IMR studies should include quantitative IMR severity assessment with effective regurgitant orifice area and regurgitant volume.…”

Intraoperative post-annuloplasty three-dimensional valve analysis does not predict recurrent ischemic mitral regurgitation

“…Using three-dimensional echocardiography (3DE) and advanced valve modeling algorithms, we showed that P3 preoperative segmental leaflet tethering is a strong predictor of recurrent IMR 6 months after undersized annuloplasty [5]. In a subsequent study we showed a much higher predictive value of 3DE over two-dimensional echocardiography (2DE) for recurrent IMR [6]. In addition to preoperative 3DE predictors we are also in need of intraoperative (immediate post-repair) 3DE predictors that can guide patientspecific intraoperative surgical decision-making.…”

Multimodality imaging assessment of mitral valve anatomy in planning for mitral valve repair in secondary mitral regurgitation

“…Degree of leaflets tethering, quantitated by the precise evaluation of the altered MV morphology in patients with secondary MR, has been associated with failure of MV repair (i.e., MV annuloplasty with significant recurrent MR). Specific echocardiographic indices derived from 2D TTE and TEE as well as 3D TEE modeling, have been identified in several retrospective studies performed in the last decade ( Figure 3, Table 2): the posterior and/or anterior leaflet angles, the mitral annulus dimensions and spatial conformation, the posterior displacement of the mitral leaflet coaptation, the tenting area and/or volume, the tethering length and height (43,(104)(105)(106)(107)(108)(109)(110)(111). The most commonly used cut-offs to determine high degree of MV tethering, and thus high risk of MV repair failure, are the following: posterior leaflet angle >45º, anterior leaflet angle >25º, tenting area ≥2.5 cm 2 , and the tenting height ≥11 mm (Figure 3, Table 2) (9,112).…”