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Effect of local annular interventions on annular and left ventricular geometry

^a Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, United States
^b Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, United States
^c Laboratory of Cardiovascular Physiology and Biophysics, Research Institute of the Palo Alto Medical Foundation, Palo Alto, CA, United States

Received 9 December 2007; received in revised form 9 March 2008; accepted 13 March 2008.

^_* Corresponding author. Address: Department of Cardiothoracic Surgery, Falk Cardiovascular Research Center, Stanford University School of Medicine, Stanford, CA 94305-5247, United States. Tel.: +1 650 725 3826; fax: +1 650 725 3846. (Email: dcm{at}stanford.edu).

Objective: Etiology-specific annular interventions and annuloplasty rings are now commercially available for the treatment of different types of mitral regurgitation; however, knowledge concerning the effects of local annular alterations on annular and left ventricular (LV) geometry is limited. Methods: Seven adult sheep underwent implantation of eight radiopaque markers around the mitral annulus (MA) and eight markers on the LV (four each on two levels: basal and apical), and one on each papillary muscle tip. Trans-annular septal-lateral (SL) sutures were placed between the corresponding markers on the septal and lateral annulus at valve center (CENT) and near anterior (ACOM) and posterior (PCOM) commissures and externalized. Hemodynamic parameters and 4D marker coordinates were measured before and during SL annular cinching (‘SLAC’; suture tightening 3–5 mm for 20 s) at each suture location. Mitral annular SL diameter, annular area (MAA), and distance from the mid-septal annulus to the LV markers and papillary muscle tips were determined from marker coordinates every 17 ms. Results: End-systolic MAA decreased from 5.93 ± 1.27 to 5.23 ± 1.29^* cm², 5.98 ± 1.16 to 5.33 ± 1.31^* cm², and 6.30 ± 1.65 to 5.61 ± 1.37^* cm² for SLAC_ACOM, SLAC_CENT, and SLAC_PCOM, respectively (^* p < 0.05 vs pre-cinching). Each SLAC intervention reduced the SL diameter at all three locations, while both SLAC_ACOM and SLAC_CENT affected ventricular geometry, and SLAC_PCOM only slightly altered valvular–subvalvular distance. Only SLAC_CENT altered papillary muscle position. Conclusions: Local annular SL reduction influences remote annular SL dimensions and affects LV geometry. The effect of local annular interventions on global annular geometry and LV remodeling should be considered in surgical or interventional approaches to mitral regurgitation and the design of new annular prostheses as well as supra-annular and sub-annular catheter interventions.

Key Words: Mitral valve • Mitral valve repair • Mitral annulus