Left ventricular shape is the primary determinant of functional mitral regurgitation in heart failure

Henry Ford Heart and Vascular Institute, Division of Cardiovascular Medicine, Detroit, Michigan.

OBJECTIVES. The aim of this study was to examine the temporal association between the onset of functional mitral regurgitation and the development of changes in left ventricular shape, chamber enlargement, mitral anulus dilation and regional wall motion abnormalities during the course of evolving heart failure. BACKGROUND. Despite extensive characterization, the exact etiology of functional mitral regurgitation in patients with chronic heart failure remains unknown. METHODS. Heart failure was produced in seven dogs by multiple sequential intracoronary microembolizations. Serial changes in left ventricular chamber volume and shape were evaluated from ventriculograms. Changes in mitral anulus diameter and ventricular regional wall motion abnormalities were evaluated echocardiographically. The presence and severity of mitral regurgitation were determined with Doppler color flow mapping. Measurements were obtained at baseline and then biweekly until mitral regurgitation was first observed. RESULTS. No dog had mitral regurgitation at baseline but all developed mild to moderate regurgitation 12 +/- 1 weeks after the first embolization. The onset of mitral regurgitation was not associated with an increase in left ventricular end-diastolic volume relative to baseline (58 +/- 3 vs. 62 +/- 3 ml), mitral anulus diameter (2.4 +/- 0.1 vs. 2.4 +/- 0.1 cm) or wall motion abnormalities of left ventricular wall segments overlying the papillary muscles. In contrast, the onset of mitral regurgitation was accompanied by significant changes in global left ventricular shape evidenced by increased end-systolic chamber sphericity index (0.22 +/- 0.02 vs. 0.30 +/- 0.01) (p < 0.01) and decreased end-systolic major axis/minor axis ratio (1.71 +/- 0.05 vs. 1.43 +/- 0.04) (p < 0.001). CONCLUSIONS. These data indicate that transformation of left ventricular shape (increased chamber sphericity) is the most likely substrate for the development of functional mitral regurgitation.

This article has been cited by other articles:

				P. K. Smith, R. E. Michler, Y. J. Woo, J. H. Alexander, J. D. Puskas, M. K. Parides, R. T. Hahn, J. B. Williams, J. M. Dent, T. B. Ferguson Jr., et al. Design, rationale, and initiation of the Surgical Interventions for Moderate Ischemic Mitral Regurgitation Trial: A report from the Cardiothoracic Surgical Trials Network J. Thorac. Cardiovasc. Surg., January 1, 2012; 143(1): 111 - 117.e1. [Abstract] [Full Text] [PDF]

				C. Yosefy, R. Beeri, J. L. Guerrero, M. Vaturi, M. Scherrer-Crosbie, M. D. Handschumacher, and R. A. Levine Mitral Regurgitation After Anteroapical Myocardial Infarction: New Mechanistic Insights Circulation, April 12, 2011; 123(14): 1529 - 1536. [Abstract] [Full Text] [PDF]

				P. Unger, C. Dedobbeleer, G. Van Camp, D. Plein, B. Cosyns, and P. Lancellotti Republished review: Mitral regurgitation in patients with aortic stenosis undergoing valve replacement Postgrad. Med. J., February 1, 2011; 87(1024): 150 - 155. [Abstract] [Full Text] [PDF]

				K. Tatsumi, H. Kawai, D. Sugiyama, K. Norisada, T. Kataoka, T. Onishi, H. Tanaka, and K.-i. Hirata Dobutamine-Induced Improvement in Inferior Myocardial Contractile Function Predicts Reduction in Functional Mitral Regurgitation: A Study Using Tissue Doppler Strain Rate Imaging Circ Cardiovasc Imaging, November 1, 2010; 3(6): 638 - 646. [Abstract] [Full Text] [PDF]

				B. J. W. Chow, J. G. Abunassar, K. Ascah, R. deKemp, J. DaSilva, T. Mesana, R. S. Beanlands, and T. D. Ruddy Effects of Mitral Valve Surgery on Myocardial Energetics in Patients With Severe Mitral Regurgitation Circ Cardiovasc Imaging, May 1, 2010; 3(3): 308 - 313. [Abstract] [Full Text] [PDF]

				T. G. Di Salvo, M. A. Acker, G. W. Dec, and J. G. Byrne Mitral Valve Surgery in Advanced Heart Failure J. Am. Coll. Cardiol., January 26, 2010; 55(4): 271 - 282. [Abstract] [Full Text] [PDF]

				P Unger, C Dedobbeleer, G Van Camp, D Plein, B Cosyns, and P Lancellotti Mitral regurgitation in patients with aortic stenosis undergoing valve replacement Heart, January 1, 2010; 96(1): 9 - 14. [Abstract] [Full Text] [PDF]

				M. Penicka, H. Linkova, O. Lang, R. Fojt, V. Kocka, M. Vanderheyden, and J. Bartunek Predictors of Improvement of Unrepaired Moderate Ischemic Mitral Regurgitation in Patients Undergoing Elective Isolated Coronary Artery Bypass Graft Surgery Circulation, October 13, 2009; 120(15): 1474 - 1481. [Abstract] [Full Text] [PDF]

				A. S. Rubino, F. Onorati, G. Santarpino, E. Pasceri, G. Santarpia, L. Cristodoro, G. F. Serraino, and A. Renzulli Neurohormonal and Echocardiographic Results After CorCap and Mitral Annuloplasty for Dilated Cardiomyopathy Ann. Thorac. Surg., September 1, 2009; 88(3): 719 - 725. [Abstract] [Full Text] [PDF]

				B. A. Bart Treatment of Congestion in Congestive Heart Failure: Ultrafiltration Is the Only Rational Initial Treatment of Volume Overload in Decompensated Heart Failure Circ Heart Fail, September 1, 2009; 2(5): 499 - 504. [Full Text] [PDF]

				J. L. Quill, A. J. Hill, T. G. Laske, O. Alfieri, and P. A. Iaizzo Mitral leaflet anatomy revisited. J. Thorac. Cardiovasc. Surg., May 1, 2009; 137(5): 1077 - 1081. [Abstract] [Full Text] [PDF]

				M. Gheorghiade and P. S. Pang Acute Heart Failure Syndromes J. Am. Coll. Cardiol., February 17, 2009; 53(7): 557 - 573. [Abstract] [Full Text] [PDF]

				P. Sorajja, R. A. Nishimura, J. Thompson, and K. Zehr A Novel Method of Percutaneous Mitral Valve Repair for Ischemic Mitral Regurgitation J. Am. Coll. Cardiol. Intv., December 1, 2008; 1(6): 663 - 672. [Abstract] [Full Text] [PDF]

				S. Gelsomino, R. Lorusso, C. Rostagno, S. Caciolli, G. Bille, G. De Cicco, S. Romagnoli, C. Porciani, P. Stefano, and G. F. Gensini Prognostic value of Doppler-derived mitral deceleration time on left ventricular reverse remodelling after undersized mitral annuloplasty Eur Heart J Cardiovasc Imaging, September 1, 2008; 9(5): 631 - 640. [Abstract] [Full Text] [PDF]

				S. Gelsomino, R. Lorusso, I. Capecchi, C. Rostagno, S. Romagnoli, G. Bille, G. De Cicco, C. Tetta, P. Stefano, and G. F. Gensini Left Ventricular Reverse Remodeling After Undersized Mitral Ring Annuloplasty in Patients With Ischemic Regurgitation Ann. Thorac. Surg., April 1, 2008; 85(4): 1319 - 1330. [Abstract] [Full Text] [PDF]

				S. Gelsomino, R. Lorusso, G. De Cicco, I. Capecchi, C. Rostagno, S. Caciolli, S. Romagnoli, U. Da Broi, P. Stefano, and G. F. Gensini Five-year echocardiographic results of combined undersized mitral ring annuloplasty and coronary artery bypass grafting for chronic ischaemic mitral regurgitation Eur. Heart J., January 2, 2008; 29(2): 231 - 240. [Abstract] [Full Text] [PDF]

				N. D. Patel, L. U. Nwakanma, E. S. Weiss, J. A. Williams, and J. V. Conte Impact of Septal Myocardial Infarction on Outcomes After Surgical Ventricular Restoration Ann. Thorac. Surg., January 1, 2008; 85(1): 135 - 146. [Abstract] [Full Text] [PDF]

				M. T. Spoor and S. F. Bolling Nontransplant Surgical Options for Heart Failure Card. Surg. Adult, January 1, 2008; 3(2008): 1639 - 1648. [Full Text]

				P. Lancellotti, E. Donal, B. Cosyns, G. Van Camp, J.-L. Monin, E. Brochet, A. Berrebi, P. Pibarot, C. Chauvel, C. Hassager, et al. Effects of surgery on ischaemic mitral regurgitation: a prospective multicentre registry (SIMRAM registry) Eur Heart J Cardiovasc Imaging, January 1, 2008; 9(1): 26 - 30. [Abstract] [Full Text] [PDF]

				J. H. Hankiewicz, P. H. Goldspink, P. M. Buttrick, and E. D. Lewandowski Principal strain changes precede ventricular wall thinning during transition to heart failure in a mouse model of dilated cardiomyopathy Am J Physiol Heart Circ Physiol, January 1, 2008; 294(1): H330 - H336. [Abstract] [Full Text] [PDF]

				L. R. Croft, J. H. Jimenez, R. C. Gorman, J. H. Gorman III, and A. P. Yoganathan Efficacy of the Edge-to-Edge Repair in the Setting of a Dilated Ventricle: An In Vitro Study Ann. Thorac. Surg., November 1, 2007; 84(5): 1578 - 1584. [Abstract] [Full Text] [PDF]

				N. D. Patel, J. A. Williams, L. U. Nwakanma, E. S. Weiss, and J. V. Conte Impact of Lateral Wall Myocardial Infarction on Outcomes After Surgical Ventricular Restoration Ann. Thorac. Surg., June 1, 2007; 83(6): 2017 - 2028. [Abstract] [Full Text] [PDF]

				M. Amigoni, A. Meris, J. J. Thune, D. Mangalat, H. Skali, M. Bourgoun, J. W. Warnica, S. Barvik, J. M. O. Arnold, E. J. Velazquez, et al. Mitral regurgitation in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both: prognostic significance and relation to ventricular size and function Eur. Heart J., February 1, 2007; 28(3): 326 - 333. [Abstract] [Full Text] [PDF]

				M. A. Acker, S. Bolling, R. Shemin, J. Kirklin, J. K. Oh, D. L. Mann, M. Jessup, H. N. Sabbah, R. C. Starling, S. H. Kubo, et al. Mitral valve surgery in heart failure: Insights from the Acorn Clinical Trial. J. Thorac. Cardiovasc. Surg., September 1, 2006; 132(3): 568 - 577.e4. [Abstract] [Full Text] [PDF]

				C. C. Sucharov, P. D. Mariner, K. R. Nunley, C. Long, L. Leinwand, and M. R. Bristow A beta1-adrenergic receptor CaM kinase II-dependent pathway mediates cardiac myocyte fetal gene induction Am J Physiol Heart Circ Physiol, September 1, 2006; 291(3): H1299 - H1308. [Abstract] [Full Text] [PDF]

				H. Morita, S. Khanal, S. Rastogi, G. Suzuki, M. Imai, A. Todor, V. G. Sharov, S. Goldstein, T. P. O'Neill, and H. N. Sabbah Selective matrix metalloproteinase inhibition attenuates progression of left ventricular dysfunction and remodeling in dogs with chronic heart failure Am J Physiol Heart Circ Physiol, June 1, 2006; 290(6): H2522 - H2527. [Abstract] [Full Text] [PDF]

				J. H. Rogers, J. A. Macoviak, D. A. Rahdert, P. A. Takeda, I. F. Palacios, and R. I. Low Percutaneous Septal Sinus Shortening: A Novel Procedure for the Treatment of Functional Mitral Regurgitation Circulation, May 16, 2006; 113(19): 2329 - 2334. [Abstract] [Full Text] [PDF]

				E. Buffolo, J. N. R. Branco, R. Catani, and the RESTORE Group End-stage cardiomyopathy and secondary mitral insufficiency surgical alternative with prosthesis implant and left ventricular restoration Eur J Cardiothorac Surg, April 1, 2006; 29(Supplement_1): S266 - S271. [Abstract] [Full Text] [PDF]

				Is a good perioperative echocardiographic result predictive of durability in ischemic mitral valve repair? J. Thorac. Cardiovasc. Surg., March 1, 2006; 131(3): 565 - 573.e2.

				P. Ferrazzi, M. L.S. Matteucci, M. Merlo, A. Iacovoni, G. Rescigno, M. Bottai, P. Parrella, L. Lorini, M. Senni, and A. Gavazzi Surgical ventricular reverse remodeling in severe ischemic dilated cardiomyopathy: The relevance of the left ventricular equator as a prognostic factor J. Thorac. Cardiovasc. Surg., February 1, 2006; 131(2): 357 - 363. [Abstract] [Full Text] [PDF]

				V. Kohli, H. Wasir, S. Mittal, A. Karlekar, Y. Mehta, and N. Trehan Mitral Valve Repair for Ischemic Mitral Regurgitation in Dilated Cardiomyopathy Asian Cardiovasc Thorac Ann, September 1, 2005; 13(3): 267 - 270. [Abstract] [Full Text] [PDF]

				R. A. Levine and E. Schwammenthal Ischemic Mitral Regurgitation on the Threshold of a Solution: From Paradoxes to Unifying Concepts Circulation, August 2, 2005; 112(5): 745 - 758. [Full Text] [PDF]

				D. L. Mann and M. R. Bristow Mechanisms and Models in Heart Failure: The Biomechanical Model and Beyond Circulation, May 31, 2005; 111(21): 2837 - 2849. [Full Text] [PDF]

				A. H. Wu, K. D. Aaronson, S. F. Bolling, F. D. Pagani, K. Welch, and T. M. Koelling Impact of mitral valve annuloplasty on mortality risk in patients with mitral regurgitation and left ventricular systolic dysfunction J. Am. Coll. Cardiol., February 1, 2005; 45(3): 381 - 387. [Abstract] [Full Text] [PDF]

				M. J. Byrne, D. M. Kaye, M. Mathis, D. G. Reuter, C. A. Alferness, and J. M. Power Percutaneous Mitral Annular Reduction Provides Continued Benefit in an Ovine Model of Dilated Cardiomyopathy Circulation, November 9, 2004; 110(19): 3088 - 3092. [Abstract] [Full Text] [PDF]

				E. Agricola, M. Oppizzi, F. Maisano, M. De Bonis, A. F.L. Schinkel, L. Torracca, A. Margonato, G. Melisurgo, and O. Alfieri Echocardiographic classification of chronic ischemic mitral regurgitation caused by restricted motion according to tethering pattern Eur Heart J Cardiovasc Imaging, October 1, 2004; 5(5): 326 - 334. [Abstract] [Full Text] [PDF]

				J. Hung, L. Papakostas, S. A. Tahta, B. G. Hardy, B. A. Bollen, C. M. Duran, and R. A. Levine Mechanism of Recurrent Ischemic Mitral Regurgitation After Annuloplasty: Continued LV Remodeling as a Moving Target Circulation, September 14, 2004; 110(11_suppl_1): II-85 - II-90. [Abstract] [Full Text] [PDF]

				J. J. Bax, J. Braun, S. T. Somer, R. Klautz, E. R. Holman, M. I.M. Versteegh, E. Boersma, M. J. Schalij, E. E. van der Wall, and R. A. Dion Restrictive Annuloplasty and Coronary Revascularization in Ischemic Mitral Regurgitation Results in Reverse Left Ventricular Remodeling Circulation, September 14, 2004; 110(11_suppl_1): II-103 - II-108. [Abstract] [Full Text] [PDF]

				M. H. Yacoub and L. H. Cohn Novel Approaches to Cardiac Valve Repair: From Structure to Function: Part I Circulation, March 2, 2004; 109(8): 942 - 950. [Full Text] [PDF]

				P. Lancellotti, F. Lebrun, and L. A. Pierard Determinants of exercise-induced changes in mitral regurgitation in patients with coronary artery disease and left ventricular dysfunction J. Am. Coll. Cardiol., December 3, 2003; 42(11): 1921 - 1928. [Abstract] [Full Text] [PDF]

				M. C. Oz, W. F. Konertz, F. X. Kleber, F. W. Mohr, J. F. Gummert, J. Ostermeyer, M. Lass, J. Raman, M. A. Acker, and N. Smedira Global surgical experience with the Acorn cardiac support device J. Thorac. Cardiovasc. Surg., October 1, 2003; 126(4): 983 - 991. [Abstract] [Full Text] [PDF]

				S E Karagiannis, G T Karatasakis, N Koutsogiannis, G D Athanasopoulos, and D V Cokkinos Increased distance between mitral valve coaptation point and mitral annular plane: significance and correlations in patients with heart failure Heart, October 1, 2003; 89(10): 1174 - 1178. [Abstract] [Full Text] [PDF]

				H. N. Sabbah The cardiac support device and the Myosplint: treating heart failure by targeting left ventricular size and shape Ann. Thorac. Surg., June 1, 2003; 75(90060): S13 - 19. [Abstract] [Full Text] [PDF]

				J. Kwan, T. Shiota, D. A. Agler, Z. B. Popovic, J. X. Qin, M. A. Gillinov, W. J. Stewart, D. M. Cosgrove, P. M. McCarthy, and J. D. Thomas Geometric Differences of the Mitral Apparatus Between Ischemic and Dilated Cardiomyopathy With Significant Mitral Regurgitation: Real-Time Three-Dimensional Echocardiography Study Circulation, March 4, 2003; 107(8): 1135 - 1140. [Abstract] [Full Text] [PDF]

				T. Kumanohoso, Y. Otsuji, S. Yoshifuku, K. Matsukida, C. Koriyama, A. Kisanuki, S. Minagoe, R. A. Levine, and C. Tei Mechanism of higher incidence of ischemic mitral regurgitation in patients with inferior myocardial infarction: Quantitative analysis of left ventricular and mitral valve geometry in 103 patients with prior myocardial infarction J. Thorac. Cardiovasc. Surg., January 1, 2003; 125(1): 135 - 143. [Abstract] [Full Text] [PDF]

				V. Badhwar and S. F. Bolling Nontransplant Surgical Options for Heart Failure Card. Surg. Adult, January 1, 2003; 2(2003): 1515 - 1526. [Full Text]

				G. Suzuki, H. Morita, T. Mishima, V. G. Sharov, A. Todor, E. J. Tanhehco, A. E. Rudolph, E. G. McMahon, S. Goldstein, and H. N. Sabbah Effects of Long-Term Monotherapy With Eplerenone, a Novel Aldosterone Blocker, on Progression of Left Ventricular Dysfunction and Remodeling in Dogs With Heart Failure Circulation, December 3, 2002; 106(23): 2967 - 2972. [Abstract] [Full Text] [PDF]

				P. M. McCarthy Does the intertrigonal distance dilate? Never say never J. Thorac. Cardiovasc. Surg., December 1, 2002; 124(6): 1078 - 1079. [Full Text]

				A. C. Hueb, F. B. Jatene, L. F. P. Moreira, P. M. Pomerantzeff, E. Kallas, and S. A. de Oliveira Ventricular remodeling and mitral valve modifications in dilated cardiomyopathy: New insights from anatomic study J. Thorac. Cardiovasc. Surg., December 1, 2002; 124(6): 1216 - 1224. [Abstract] [Full Text]

				M. V. Pitzalis, M. Iacoviello, R. Romito, F. Massari, B. Rizzon, G. Luzzi, P. Guida, A. Andriani, F. Mastropasqua, and P. Rizzon Cardiac resynchronization therapy tailored by echocardiographic evaluation of ventricular asynchrony J. Am. Coll. Cardiol., November 6, 2002; 40(9): 1615 - 1622. [Abstract] [Full Text] [PDF]

				D. T. Lai, F. A. Tibayan, T. Myrmel, T. A. Timek, P. Dagum, G. T. Daughters, D. Liang, N. B. Ingels Jr, and D. C. Miller Mechanistic Insights Into Posterior Mitral Leaflet Inter-Scallop Malcoaptation During Acute Ischemic Mitral Regurgitation Circulation, September 24, 2002; 106(12_suppl_1): I-40 - I-45. [Abstract] [Full Text] [PDF]

				Y. Otsuji, T. Kumanohoso, S. Yoshifuku, K. Matsukida, C. Koriyama, A. Kisanuki, S. Minagoe, R. A. Levine, and C. Tei Isolated annular dilation does not usually cause important functional mitral regurgitation: Comparison between patients with lone atrial fibrillation and those with idiopathic or ischemic cardiomyopathy J. Am. Coll. Cardiol., May 15, 2002; 39(10): 1651 - 1656. [Abstract] [Full Text] [PDF]

				T. A. Timek, P. Dagum, D. T. Lai, D. Liang, G. T. Daughters, N. B. Ingels Jr, and D. C. Miller Pathogenesis of Mitral Regurgitation in Tachycardia-Induced Cardiomyopathy Circulation, September 18, 2001; 104(2009): I-47 - I-53. [Abstract] [Full Text] [PDF]

				Y. Etienne, J. Mansourati, A. Touiza, M. Gilard, V. Bertault-Valls, P. Guillo, J. Boschat, and J. J. Blanc Evaluation of left ventricular function and mitral regurgitation during left ventricular-based pacing in patients with heart failure Eur J Heart Fail, August 1, 2001; 3(4): 441 - 447. [Abstract] [Full Text] [PDF]

				A. M. Calafiore, S. Gallina, M. Di Mauro, F. Gaeta, A. L. Iaco, S. D'Alessandro, V. Mazzei, and G. Di Giammarco Mitral valve procedure in dilated cardiomyopathy: repair or replacement? Ann. Thorac. Surg., April 1, 2001; 71(4): 1146 - 1152. [Abstract] [Full Text] [PDF]

				Y. Otsuji, M. D. Handschumacher, N. Liel-Cohen, H. Tanabe, L. Jiang, E. Schwammenthal, J. L. Guerrero, L. A. Nicholls, G. J. Vlahakes, and R. A. Levine Mechanism of ischemic mitral regurgitation with segmental left ventricular dysfunction: three-dimensional echocardiographic studies in models of acute and chronic progressive regurgitation J. Am. Coll. Cardiol., February 1, 2001; 37(2): 641 - 648. [Abstract] [Full Text] [PDF]

				D. T. M. Lai, T. A. Timek, P. Dagum, G. R. Green, J. R. Glasson, G. T. Daughters, D. Liang, N. B. Ingels Jr, and D. C. Miller The effects of ring annuloplasty on mitral leaflet geometry during acute left ventricular ischemia J. Thorac. Cardiovasc. Surg., November 1, 2000; 120(5): 966 - 975. [Abstract] [Full Text] [PDF]

				P. A. Chaudhry, T. Mishima, V. G. Sharov, J. Hawkins, C. Alferness, G. Paone, and H. N. Sabbah Passive epicardial containment prevents ventricular remodeling in heart failure Ann. Thorac. Surg., October 1, 2000; 70(4): 1275 - 1280. [Abstract] [Full Text] [PDF]

				S. F. Yiu, M. Enriquez-Sarano, C. Tribouilloy, J. B. Seward, and A. J. Tajik Determinants of the Degree of Functional Mitral Regurgitation in Patients With Systolic Left Ventricular Dysfunction : A Quantitative Clinical Study Circulation, September 19, 2000; 102(12): 1400 - 1406. [Abstract] [Full Text] [PDF]

				S. Goldstein Passive ventricular restaint Cardiovasc Res, December 1, 1999; 44(3): 468 - 469. [Full Text] [PDF]

				J.M Power, J Raman, A Dornom, S.J Farish, L.M Burrell, A.M Tonkin, B Buxton, and C.A Alferness Passive ventricular constraint amends the course of heart failure: a study in an ovine model of dilated cardiomyopathy Cardiovasc Res, December 1, 1999; 44(3): 549 - 555. [Abstract] [Full Text] [PDF]

				D. L. Mann Mechanisms and Models in Heart Failure : A Combinatorial Approach Circulation, August 31, 1999; 100(9): 999 - 1008. [Full Text] [PDF]

				S. L. Nielsen, H. Nygaard, A. A. Fontaine, J. M. Hasenkam, S. He, N. T. Andersen, and A. P. Yoganathan Chordal force distribution determines systolic mitral leaflet configuration and severity of functional mitral regurgitation J. Am. Coll. Cardiol., March 1, 1999; 33(3): 843 - 853. [Abstract] [Full Text] [PDF]

				J. Hung, Y. Otsuji, M. D. Handschumacher, E. Schwammenthal, and R. A. Levine Mechanism of dynamic regurgitant orifice area variation in functional mitral regurgitation: Physiologic insights from the proximal flow convergence technique J. Am. Coll. Cardiol., February 1, 1999; 33(2): 538 - 545. [Abstract] [Full Text] [PDF]

				Y. Otsuji, D. Gilon, L. Jiang, S. He, M. Leavitt, M. J. Roy, M. J. Birmingham, and R. A. Levine Restricted diastolic opening of the mitral leaflets in patients with left ventricular dysfunction: evidence for increased valve tethering J. Am. Coll. Cardiol., August 1, 1998; 32(2): 398 - 404. [Abstract] [Full Text] [PDF]

				S. F. Bolling, F. D. Pagani, G. M. Deeb, and D. S. Bach Intermediate-Term Outcome Of Mitral Reconstruction In Cardiomyopathy J. Thorac. Cardiovasc. Surg., February 1, 1998; 115(2): 381 - 388. [Abstract] [Full Text] [PDF]

				S. He, A. A. Fontaine, E. Schwammenthal, A. P. Yoganathan, and R. A. Levine Integrated Mechanism for Functional Mitral Regurgitation : Leaflet Restriction Versus Coapting Force: In Vitro Studies Circulation, September 16, 1997; 96(6): 1826 - 1834. [Abstract] [Full Text]

				Y. Otsuji, M. D. Handschumacher, E. Schwammenthal, L. Jiang, J.-K. Song, J. L. Guerrero, G. J. Vlahakes, and R. A. Levine Insights From Three-Dimensional Echocardiography Into the Mechanism of Functional Mitral Regurgitation : Direct In Vivo Demonstration of Altered Leaflet Tethering Geometry Circulation, September 16, 1997; 96(6): 1999 - 2008. [Abstract] [Full Text]

				E. J. Eichhorn and M. R. Bristow Medical Therapy Can Improve the Biological Properties of the Chronically Failing Heart: A New Era in the Treatment of Heart Failure Circulation, November 1, 1996; 94(9): 2285 - 2296. [Abstract] [Full Text]

				S. F. Bolling, G. M. Deeb, L. A. Brunsting, and D. S. Bach Early outcome of mitral valve reconstruction in patients with end-stage cardiomyopathy J. Thorac. Cardiovasc. Surg., April 1, 1995; 109(4): 676 - 683. [Abstract] [Full Text]