Inez J Wijdh-den Hamer1, Wobbe Bouma1, Eric K Lai2, Melissa M Levack2, Eric K Shang3, Alison M Pouch2, Thomas J Eperjesi2, Theodore J Plappert2, Paul A Yushkevich4, Judy Hung5, Massimo A Mariani6, Kamal R Khabbaz7, Thomas G Gleason8, Feroze Mahmood9, Michael A Acker3, Y Joseph Woo10, Albert T Cheung11, Matthew J Gillespie12, Benjamin M Jackson3, Joseph H Gorman13, Robert C Gorman14. 1. Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa; Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands. 2. Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa. 3. Department of Surgery, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa. 4. Department of Radiology, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa. 5. Department of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass. 6. Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands. 7. Department of Cardiothoracic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass. 8. Department of Surgery, University of Pittsburgh, Pittsburgh, Pa. 9. Department of Anesthesia, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass. 10. Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif. 11. Department of Anesthesia, Stanford University, Stanford, Calif. 12. Department of Cardiology, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa. 13. Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa; Department of Surgery, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa. 14. Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa; Department of Surgery, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa. Electronic address: gormanr@uphs.upenn.edu.
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.
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.
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