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Restricted diastolic opening of the mitral leaflets in patients with left ventricular dysfunction: evidence for increased valve tethering

^a Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA

View larger version (24K): [in a new window]   Figure 1 Potential effects of augmented leaflet tethering on the mitral leaflets in a dilated left ventricle (LV) with systolic dysfunction: incomplete systolic leaflet closure because the leaflets are restricted from closing at the annular level (left), and reduced diastolic opening, redirecting inflow toward the papillary muscles (right). LA, left atrium.

View larger version (39K): [in a new window]   Figure 2 A, Measurement of the leaflet excursion angle on the apical four-chamber view. The angle between the base of the anterior mitral leaflet (its tangent line) and the mitral annular line at end-systole is 1 and at maximal diastolic opening is 2. The leaflet excursion angle . LV, left ventricle; LA, left atrium. B, Method of assessing the diastolic alignment. The angle of maximal leaflet opening (2) is compared to that between the annular line and the line connecting the attachments of the anterior leaflet at the anterior annulus and lateral papillary muscle tip (PM angle). The patient is considered to have diastolic alignment if the difference between these angles is <5°. The upper panel shows a normal control, the lower, a patient with diastolic alignment in the IMLC group.

View larger version (55K): [in a new window]   Figure 3 Evaluation of asymmetric opening of the mitral leaflets in the short-axis view of their maximal opening at the level of the leaflet tips. The anteroposterior or vertical (V) and side-to-side or horizontal (H) dimensions are noted. The image on the right from a patient with IMLC shows the characteristic flattening of the normally round anterior leaflet in this configuration. LV, left ventricle; LA, left atrium.

View larger version (80K): [in a new window]   Figure 4 Color Doppler echocardiograms in the apical four-chamber view showing the method to determine the mitral inflow direction angle (right panel). Using Doppler color flow mapping at maximal early diastolic rapid filling, a line (straight arrow) is constructed to connect the center of the color Doppler inflow area at the mitral annular and chordal levels. The angle between this line and the mitral annular line (curved arrow) is the mitral inflow direction angle . The other two panels show markedly abnormal mitral inflow direction (directed posterolaterally) in an IMLC(+) patient and mildly abnormal direction in an IMLC(–) patient compared with normal direction in control subjects. LV, left ventricle; LA, left atrium; RV, right ventricle; RA, right atrium.

View larger version (46K): [in a new window]   Figure 5 Bar graphs showing mitral inflow volume and leaflet excursion angle in patients with global left ventricular (LV) dysfunction and IMLC, with global LV dysfunction but without IMLC, and normal control subjects. In the IMLC(+) patients, excursion angle is markedly reduced despite preserved inflow volume. In contrast, in the IMLC(–) patients, the excursion angle is only mildly reduced despite a prominent reduction in inflow volume.

View larger version (17K): [in a new window]   Figure 6 Scattergram showing a significant inverse correlation between leaflet excursion angle and incomplete mitral leaflet closure area. SEE, standard error of estimate.