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Eur J Cardiothorac Surg 2007;31:839-844. doi:10.1016/j.ejcts.2007.01.050
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved

Quantification and localization of mitral valve tenting in ischemic mitral regurgitation using real-time three-dimensional echocardiography

^a Harrison Department of Surgical Research, University of Pennsylvania School of Medicine, United States
^b Department of Medicine, University of Pennsylvania School of Medicine, United States

Received 30 October 2006; received in revised form 11 January 2007; accepted 22 January 2007.

^_* Corresponding author. Address: Department of Surgery, 313 Stemmler Hall, 36th and Hamilton Walk, University of Pennsylvania, Philadelphia, PA 19104-4283, United States. Tel.: +1 215 614 0364; fax: +1 215 615 4195. (Email: gormanr{at}uphs.upenn.edu).

Objective: Ischemic mitral regurgitation (IMR) results from a variable combination of annular dilatation and remodeling of the subvalvular apparatus. Current surgical techniques effectively treat annular dilatation, but methods for addressing subvalvular remodeling have not been standardized. An effective technique for determining the extent of subvalvular remodeling could improve surgical results by identifying patients who are unlikely to benefit from annuloplasty alone. Methods: A well-characterized ovine model of IMR was employed. Real-time three-dimensional echocardiography was performed on each animal at baseline, immediately after infarction and 8 weeks after infarction. Intercommissural width and mitral annular area were calculated for each subject at each time point. Mitral valve tenting area and height were calculated at discrete intervals along the entire intercommissural axis. The location at which maximal tenting area and height occurred was recorded. Mitral valve tenting volume was calculated by summation. Results: Both immediate and long-term increases were observed in mean intercommissural width and mean mitral annular area (from 33.2 to 36.3 to 39.7 mm and from 740 to 810 to 1020 mm², respectively). Both immediate and long-term increases were observed in maximum mitral valve tenting area and height (from 38.5 to 50.6 to 112.1 mm² and from 3.9 to 4.7 to 10.1 mm, respectively). Mitral valve tenting area and height at the mid-point of the intercommissural axis did not change significantly during the observation period. The position along the intercommissural axis at which maximal mitral valve tenting area and height occurred shifted progressively toward the anterior commissure (from 51.8% to 45.1% to 38.9% and from 52.9% to 45.1% to 37.8%). Both immediate and long-term increases were observed in mitral valve tenting volume (from 474.0 to 622.1 to 1483.5 mm³). Conclusions: We have described a technique that utilizes real-time three-dimensional echocardiography to perform a comprehensive assessment of leaflet tethering on the entire mitral valve. Our methodology is not influenced by viewing plane selection, regional tenting asymmetry, or annular dilatation and, therefore, represents a potentially useful surrogate measure of subvalvular remodeling.

Key Words: Mitral valve • Echocardiography • Surgery • Structure