Echocardiographic quantification of annular dilatation and papillary muscle separation in patients of functional mitral regurgitation: Role of anterior mitral leaflet length as reference

AbstractWe performed “Papillary muscle heads focalization” for three patients with severe functional mitral regurgitation with severe leaflet tethering (coaptation distance ≥1 cm and/or posterior leaflet angle ≥45 degrees). All separated papillary muscle heads were sutured together and both the anterolateral and posteromedial papillary muscles were reconstructed as single head papillary muscles. The stitches are positioned to adjust the levels of mitral leaflet tips, concerning the length of the marginal chordae connected to each head. A downsized annuloplasty is performed concomitantly. At discharge, no patient showed moderate/severe mitral regurgitation. Their coaptation lengths were 7.1, 8.5, and 8.3 mm.

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Does Left Atrial Enlargement Contribute to Mitral Leaflet Tethering in Patients with Functional Mitral Regurgitation? Proposed Role of Atriogenic Leaflet Tethering

Echocardiography ◽

10.1111/echo.12629 ◽

2014 ◽

Vol 31 (10) ◽

pp. 1310-1311 ◽

Cited By ~ 20

Author(s):

Jeffrey J. Silbiger

Keyword(s):

Mitral Regurgitation ◽

Left Atrial ◽

Functional Mitral Regurgitation ◽

Mitral Leaflet ◽

Left Atrial Enlargement ◽

Atrial Enlargement

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Mitral Annular Dilatation and Papillary Muscle Dislocation Without Mitral Regurgitation in Sheep

Circulation ◽

10.1161/circ.100.suppl_2.ii-95 ◽

1999 ◽

Vol 100 (suppl_2) ◽

Author(s):

G. Randall Green ◽

Paul Dagum ◽

Julie R. Glasson ◽

George T. Daughters ◽

Ann F. Bolger ◽

...

Keyword(s):

Left Ventricle ◽

Mitral Regurgitation ◽

Papillary Muscle ◽

Ex Vivo ◽

Mitral Annulus ◽

Functional Mitral Regurgitation ◽

3 Dimensional ◽

Annular Dilatation ◽

Muscle Geometry ◽

Anterior Papillary Muscle

Background —Asymmetrical mitral annular (MA) dilatation and papillary muscle dislocation are implicated in the pathogenesis of functional mitral regurgitation (MR). Methods and Results —To determine the mechanism by which annular and papillary muscle geometric alterations result in MR, we implanted radiopaque markers in the left ventricle, mitral annulus, anterior and posterior mitral leaflets, and papillary muscle tips and bases in 2 groups of sheep. One group served as controls (CTL, n=7); an experimental group (EXP, n=9) underwent topical phenol application to obliterate anterior annular and leaflet muscle (confirmed histologically ex vivo). After 1 week of recovery, markers were imaged with biplane videofluoroscopy, and hemodynamic data were recorded. MA area (computed from 3-dimensional marker coordinates) was 11% to 13% larger in the EXP group than in the CTL group ( P <0.05 by ANOVA). This area increase resulted exclusively from intercommissural axis increase except in 1 heart with large (>1 cm) increases in both the intercommissural and septolateral annular axes. The anterior papillary muscle tip in EXP was displaced from CTL by 2.9±0.23 mm toward the anterolateral left ventricle and 2.5±0.12 mm toward the mitral annulus at end systole; the posterior papillary muscle geometry was unchanged. Transthoracic echocardiography revealed MR only in the heart exhibiting biaxial annular enlargement. Conclusions —MA dilatation in the intercommissural dimension with anterior papillary muscle tip displacement toward the annulus is insufficient to produce MR in sheep. Functional MR may require MA dilatation in the septolateral axis, as observed with proximal circumflex coronary occlusion.

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Faculty Opinions recommendation of Mitral leaflet adaptation to ventricular remodeling: occurrence and adequacy in patients with functional mitral regurgitation.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.1119476.580295 ◽

2008 ◽

Author(s):

Jan Poelaert

Keyword(s):

Mitral Regurgitation ◽

Ventricular Remodeling ◽

Functional Mitral Regurgitation ◽

Mitral Leaflet

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Abstract 17145: Mitral Leaflet Growth and its Relationship with Functional Mitral Regurgitation in Non-ischemic Left Ventricular Systolic Dysfunction

Circulation ◽

10.1161/circ.130.suppl_2.17145 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Yu Kang ◽

Xiao-Jing Chen ◽

Qing Zhang ◽

Xiao-Ling Sun ◽

Yu-Chen Chen ◽

...

Keyword(s):

Mitral Regurgitation ◽

Left Ventricular Systolic Dysfunction ◽

Systolic Dysfunction ◽

Normal Subjects ◽

Left Ventricular ◽

Area Ratio ◽

Functional Mitral Regurgitation ◽

Mitral Leaflet ◽

Significant Difference ◽

Annular Dilation

Backgrounds: Recent studies evidenced growth of the mitral leaflet (ML) in patients with functional mitral regurgitation (FMR), casting doubt on the traditional understanding of FMR. The aim of this study was to explore whether growth of ML occurs in patients with non-ischemic left ventricular (LV) systolic dysfunction and to examine whether there was any relationship between the growth of ML and the development of FMR. Methods: Echocardiographic examination was performed in 3 groups of patients: patients with non-ischemic LV systolic dysfunction [LV ejection fraction (EF) <50%] and significant FMR (MR jet area ratio≥20%) (group1, n=40), patients with non-ischemic LV systolic dysfunction but no significant FMR (MR jet area ratio <20%) (group2, n=30), and normal subjects (group3, n=40). The lengths of the anterior (AML) and posterior (PML) mitral leaflets as well as the anterior-posterior mitral annular dimension (MAD) were measured to reflect the degree of ML growth and mitral annular dilation. The ratio of AML and PML to MAD (AML: MAD, PML: MAD) were calculated respectively to assess the adequacy of ML growth in the context of mitral annular dilation. Results: The AML, PML, and the MAD were all increased in patients with LV systolic dysfunction (group1 and group2) compared with normal subjects (group3). In patients with LV systolic dysfunction, both PML and MAD were further increased in group1 compared with group2. However, AML showed no significant difference between the 2 groups. As a result, PML:MAD showed no significant difference between group1 and group2, while AML:MAD was significantly decreased in group1 compared with group2 (Table 1). Conclusion: Mitral leaflet growth occurs in patients with non-ischemic LV systolic dysfunction. Insufficient growth of the anterior mitral leaflet relative to dilated mitral annulus is associated with the development of significant FMR.

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