Preoperative Three-Dimensional Valve Analysis Predicts Recurrent Ischemic Mitral Regurgitation After Mitral Annuloplasty

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• 作者：Wobbe Bouma ; MD^a ; ^b ; Eric K. Lai ; BS^a ; Melissa M. Levack ; MD^a ; Eric K. Shang ; MD^c ; Alison M. Pouch ; PhD^a ; Thomas J. Eperjesi ; BS^a ; Theodore J. Plappert ; CVT^a ; Paul A. Yushkevich ; PhD^d ; Massimo A. Mariani ; MD ; PhD^b ; Kamal R. Khabbaz ; MD^e ; Thomas G. Gleason ; MD^f ; Feroze Mahmood ; MBBS^g ; Michael A. Acker ; MD^c ; Y. Joseph Woo ; MD^h ; Albert T. Cheung ; MDⁱ ; Benjamin M. Jackson ; MD^c ; Joseph H. Gorman III ; MD^a ; ^c ; Robert C. Gorman ; MD^a ; ^c ; ^{gormanr@uphs.upenn.edu" class="auth_mail" title="E-mail the corresponding author}
• 刊名：The Annals of Thoracic Surgery
• 出版年：2016
• 出版时间：February 2016
• 年：2016
• 卷：101
• 期：2
• 页码：567-575
• 全文大小：1306 K

文摘

Valve repair for ischemic mitral regurgitation (IMR) with undersized annuloplasty rings is characterized by high IMR recurrence rates. Patient-specific preoperative imaging-based risk stratification for recurrent IMR would optimize results. We sought to determine if prerepair three-dimensional (3D) echocardiography combined with a novel valve-modeling algorithm would be predictive of IMR recurrence 6 months after repair.

Methods

Intraoperative transesophageal real-time 3D echocardiography was performed in 50 patients undergoing undersized ring annuloplasty for IMR and in 21 patients with normal mitral valves. A customized image analysis protocol was used to assess 3D annular geometry and regional leaflet tethering. IMR recurrence (≥ grade 2) was assessed with two-dimensional transthoracic echocardiography 6 months after repair.

Results

Preoperative annular geometry was similar in all IMR patients, and preoperative leaflet tethering was significantly higher in patients with recurrent IMR (n=13) than in patients in whom IMR did not recur (n=37) (tethering index: 3.91 ± 1.01 vs 2.90 ± 1.17, p = 0.008; tethering angles of A3: 23.5° ± 8.9° vs 14.4° ± 11.4°, p = 0.012; P2: 44.4° ± 8.8° vs 28.2° ± 17.0°, p = 0.002; and P3: 35.2° ± 6.0° vs. 18.6° ± 12.7°, p < 0.001). Multivariate logistic regression analysis revealed the preoperative P3 tethering angle as an independent predictor of IMR recurrence with an optimal cutoff value of 29.9° (area under the curve, 0.92; 95% confidence interval, 0.84 to 1.00; p < 0.001).

Conclusions

3D echocardiography combined with valve modeling is predictive of recurrent IMR. Preoperative regional leaflet tethering of segment P3 is a strong independent predictor of IMR recurrence after undersized ring annuloplasty. In patients with a preoperative P3 tethering angle of 29.9° or larger, chordal-sparing valve replacement rather than valve repair should be strongly considered.