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J Am Coll Cardiol, 2001; 37:641-648
© 2001 by the American College of Cardiology Foundation
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EXPERIMENTAL STUDY

Mechanism of ischemic mitral regurgitation with segmental left ventricular dysfunction: three-dimensional echocardiographic studies in models of acute and chronic progressive regurgitation

Yutaka Otsuji, MD, FACCa, Mark D. Handschumacher, BSa, Noah Liel-Cohen, MDa, Hiroaki Tanabe, MDa, Leng Jiang, MD, FACCa, Ehud Schwammenthal, MD, PhDa, J. Luis Guerrero, BSa, Lori A. Nicholls, BSa, Gus J. Vlahakes, MD, FACCa and Robert A. Levine, MD, FACCa

a Cardiac Ultrasound Laboratory and Cardiovascular Surgical Unit, Massachusetts General Hospital, Departments of Medicine and Surgery, Harvard Medical School, Boston, Massachusetts, USA

Manuscript received February 9, 2000; revised manuscript received August 31, 2000, accepted October 12, 2000.

Reprint requests and correspondence: Dr. Robert A. Levine, Cardiac Ultrasound Laboratory, Massachusetts General Hospital, VBK 508, 32 Fruit St., Boston, Massachusetts 02114-2698
rlevine{at}partners.org

OBJECTIVES

This study aimed to separate proposed mechanisms for segmental ischemic mitral regurgitation (MR), including left ventricular (LV) dysfunction versus geometric distortion by LV dilation, using models of acute and chronic segmental ischemic LV dysfunction evaluated by three-dimensional (3D) echocardiography.

BACKGROUND

Dysfunction and dilation—both mechanisms with practical therapeutic implications—are difficult to separate in patients.

METHODS

In seven dogs with acute left circumflex (LCX) coronary ligation, LV expansion was initially restricted and then permitted to occur. In seven sheep with LCX branch ligation, LV expansion was also initially limited but became prominent with remodeling over eight weeks. Three-dimensional echo reconstruction quantified mitral apparatus geometry and MR volume.

RESULTS

In the acute model, despite LV dysfunction with ejection fraction = 23 ± 8%, MR was initially trace with limited LV dilation, but it became moderate with subsequent prominent dilation. In the chronic model, MR was also initially trace, but it became moderate over eight weeks as the LV dilated and changed shape. In both models, the only independent predictor of MR volume was increased tethering distance from the papillary muscles (PMs) to the anterior annulus, especially medial and posterior shift of the ischemic medial PM, measured by 3D reconstruction (r2 = 0.75 and 0.86, respectively). Mitral regurgitation volume did not correlate with LV ejection fraction or dP/dt.

CONCLUSIONS

Segmental ischemic LV contractile dysfunction without dilation, even in the PM territory, fails to produce important MR. The development of MR relates strongly to changes in the 3D geometry of the mitral apparatus, with implications for approaches to restore a more favorable configuration.

Abbreviations and Acronyms
  ANOVA = analysis of variance
  EF = ejection fraction
  IMLC = incomplete mitral leaflet closure
  LA = left atrium
  LCX = left circumflex coronary artery
  LV = left ventricle
  MR = mitral regurgitation
  MROA = mitral regurgitant orifice area
  PM = papillary muscle
  3D = three-dimensional
  2D = two-dimensional




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 J. Thorac. Cardiovasc. Surg.Home page
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.
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 Card Surg AdultHome page
R. C. Gorman, J. H. Gorman III, and L. H. Edmunds Jr.
Ischemic Mitral Regurgitation
Card. Surg. Adult, January 1, 2003; 2(2003): 751 - 769.
[Full Text]

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 Card Surg AdultHome page
J. I. Fann, N. B. Ingels Jr., and D. C. Miller
Pathophysiology of Mitral Valve Disease
Card. Surg. Adult, January 1, 2003; 2(2003): 901 - 931.
[Full Text]

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 Eur. J. Cardiothorac. Surg.Home page
D. T. Lai, T. A. Timek, F. A. Tibayan, G. R. Green, G. T. Daughters, D. Liang, N. B. Ingels Jr, and D. C. Miller
The effects of mitral annuloplasty rings on mitral valve complex 3-D geometry during acute left ventricular ischemia
Eur. J. Cardiothorac. Surg., November 1, 2002; 22(5): 808 - 816.
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 CirculationHome page
T. A. Timek, D. T. Lai, F. Tibayan, D. Liang, F. Rodriguez, G. T. Daughters, P. Dagum, N. B. Ingels Jr, and C. Miller
Annular Versus Subvalvular Approaches to Acute Ischemic Mitral Regurgitation
Circulation, September 24, 2002; 106(12_suppl_1): I-27 - I-32.
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 J Am Coll CardiolHome page
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.
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 Eur Heart J SupplHome page
G Breithardt, H Kuhn, D Hammel, H.-H Scheld, L Seipel, and D. Bocker
Cardiac resynchronization therapy into the next decade: from the past to morbidity/mortality trials
Eur. Heart J. Suppl., April 1, 2002; 4(suppl_D): D102 - D110.
[Abstract] [PDF]

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 J. Thorac. Cardiovasc. Surg.Home page
D. C. Miller
Ischemic mitral regurgitation redux--To repair or to replace?
J. Thorac. Cardiovasc. Surg., December 1, 2001; 122(6): 1059 - 1062.
[Full Text] [PDF]


 
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