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CLINICAL STUDIES

Mechanism of dynamic regurgitant orifice area variation in functional mitral regurgitation

Physiologic insights from the proximal flow convergence technique

Judy Hung, MD^*, Yutaka Otsuji, MD^*, Mark D. Handschumacher, BS^*, Ehud Schwammenthal, MD, PhD and Robert A. Levine, MD, FACC^*

^* Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Boston, Massachusetts, USA
Heart Institute, Chaim Sheba Medical Center, Tel Hashomer, Israel

Manuscript received April 29, 1998; revised manuscript received August 27, 1998, accepted October 6, 1998.

Reprint requests and correspondence: Judy Hung, MD, Cardiac Ultrasound Laboratory-VBK 508, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114
jhung{at}partners.org

Objectives

We used the Doppler proximal flow convergence technique as a physiologic tool to explore the effects of the time courses of mitral annular area and transmitral pressure on dynamic changes in regurgitant orifice area.

Background

In functional mitral regurgitation (MR), regurgitant flow rate and orifice area display a unique pattern, with peaks in early and late systole and a midsystolic decrease. Phasic changes in both mitral annular area and the transmitral pressure acting to close the leaflets, which equals left ventricular-left atrial pressure, have been proposed to explain this dynamic pattern.

Methods

In 30 patients with functional MR, regurgitant orifice area was obtained as flow (from M-mode proximal flow convergence traces) divided by orifice velocity (v) from the continuous wave Doppler trace of MR, transmitral pressure as 4v², and mitral annular area from two apical diameters.

Results

All patients had midsystolic decreases in regurgitant orifice area that mirrored increases in transmitral pressure, while mitral annular area changed more gradually. By stepwise multiple regression analysis, both mitral annular area and transmitral pressure significantly affected regurgitant orifice area; however, transmitral pressure made a stronger contribution (r² = 0.441) than mitral annular area (added r² = 0.008). Similarly, the rate of change of regurgitant orifice area more strongly related to that of transmitral pressure (r² = 0.638) than to that of mitral annular area (added r² = 0.003). A similar regurgitant orifice area time course was observed in four patients with fixed mitral annuli due to Carpentier ring insertion.

Conclusions

In summary, the time course and rate of change of regurgitant orifice area in patients with functional MR are predominantly determined by dynamic changes in the transmitral pressure acting to close the valve. Thus, although mitral annular area helps determine the potential for MR, transmitral pressure appears important in driving the leaflets toward closure, and would be of value to consider in interventions aimed at reducing the severity of MR.

Abbreviations and Acronyms   LA = left atrium   LV = left ventricle   MAA = mitral annular area   MR = mitral regurgitation   PFC = proximal flow convergence   ROA = regurgitant orifice area   TMP = transmitral pressure

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