Three-Dimensional Echocardiographic Analysis of Mitral Annular Dynamics

Implication for Annuloplasty Selection

Melissa M. Levack, MD*; Arminder S. Jassar, MD; Eric K. Shang, MD; Mathieu Vergnat, MD; Y. Joseph Woo, MD; Michael A. Acker, MD;
Benjamin M. Jackson, MD; Joseph H. Gorman III, MD; Robert C. Gorman, MD

Circulation. 2012; 126: S183-S188

Abstract
Background—Proponents of flexible annuloplasty rings have hypothesized that such devices maintain annular dynamics. This hypothesis is based on the supposition that annular motion is relatively normal in patients undergoing mitral valve repair. We hypothesized that mitral annular dynamics are impaired in ischemic mitral regurgitation and myxomatous mitral regurgitation.

Methods and Results—A Philips iE33 echocardiographic module and X7–2t probe were used to acquire full-volume real-time 3-dimensional transesophageal echocardiography loops in 11 normal subjects, 11 patients with ischemic mitral regurgitation and 11 patients with myxomatous mitral regurgitation. Image analysis was performed using Tomtec Image Arena, 4D-MV Assessment, 2.1 (Munich, Germany). A midsystolic frame was selected for the initiation of annular tracking using the semiautomated program. Continuous parameters were normalized in time to provide for uniform systolic and diastolic periods. Both ischemic mitral regurgitation (9.98±155 cm2) and myxomatous mitral regurgitation annuli (13.29±3.05 cm2) were larger in area than normal annuli (7.95±1.40 cm2) at midsystole. In general, ischemic mitral regurgitation annuli were less dynamic than controls. In myxomatous mitral regurgitation, annular dynamics were also markedly abnormal with the mitral annulus dilating rapidly in early systole in response to rising ventricular pressure.

Conclusions—In both ischemic mitral regurgitation and myxomatous mitral regurgitation, annular dynamics and anatomy are abnormal. Flexible annuloplasty devices used in mitral valve repair are, therefore, unlikely to result in either normal annular dynamics or normal anatomy.