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J Am Coll Cardiol, 1998; 32:398-404
© 1998 by the American College of Cardiology Foundation
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CLINICAL STUDIES

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

Yutaka Otsuji, MDa, Dan Gilon, MDa, Leng Jiang, MDa, Shengqiu He, MDa, Marcia Leavitt, BAa, Marc J. Roy, RDCSa, Mary Jane Birmingham, RDCSa and Robert A. Levine, MD, FACCa

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

Manuscript received November 20, 1997; revised manuscript received April 13, 1998, accepted April 27, 1998.

Address for correspondence: Dr. Robert A. Levine, Cardiac Ultrasound Laboratory, VBK 508, Massachusetts General Hospital, 32 Fruit Street, Boston, Massachusetts 02114-2698


   Abstract
Top
 Abstract
Methods
 Results
 Discussion
 References
 
Objectives. We tested the hypothesis that patients with incomplete systolic mitral leaflet closure (IMLC: apically displaced coaptation) also have restricted diastolic leaflet opening that is independent of mitral inflow volume and provides evidence supporting increased leaflet tethering.

Background. Competing hypotheses for functional mitral regurgitation (MR) with IMLC include global left ventricular (LV) dysfunction per se (reduced leaflet closing force) versus geometric distortion of the mitral apparatus by LV dilation (augmented leaflet tethering). These are inseparable in systole, but restricted leaflet motion has also been observed in diastole, and attributed to reduced mitral inflow.

Methods. Diastolic mitral leaflet excursion and orifice area were measured by two-dimensional echocardiography in 58 patients with global LV dysfunction, 36 with and 22 without IMLC, compared with 21 normal subjects. The biplane Simpson’s method was used to calculate LV ejection volume, which equals mitral inflow volume in the absence of aortic regurgitation.

Results. The diastolic mitral leaflet excursion angle was markedly reduced in patients with IMLC compared with those without IMLC, whose ventricles were smaller, and normal subjects (17 ± 10° vs. 58 ± 13° vs. 67 ± 8°, p < 0.0001). Excursion angle was dissociated from mitral inflow volume (r2 = 0.04); excursion was reduced in patients with IMLC despite a normal inflow volume in the larger ventricles with MR (60 ± 25 vs. 61 ± 12 ml in normal subjects, p = NS), and excursion was nearly normal in patients without IMLC despite reduced inflow volume (40 ± 10 ml, p < 0.001 vs. normal subjects). The anterior leaflet when maximally open coincided well with the line connecting its attachments to the anterior annulus and papillary muscle tip (angular difference = 3 ± 7° vs. 25 ± 9° vs. 32 ± 10° in patients with and without IMLC vs. normal subjects, p < 0.0001). In patients with IMLC, the leaflet tip orifice was smaller in an anteroposterior direction but wider than in the other groups, giving a normal total area (6.8 ± 1.8 vs. 7.1 ± 1.2 vs. 6.9 ± 0.8 cm2, p = NS).

Conclusions. Patients with LV dysfunction and systolic IMLC also have restricted diastolic leaflet excursion that is independent of inflow volume, coincides with the tethering line connecting the annulus and papillary muscle and reflects limitation of anterior motion relative to the posteriorly placed papillary muscles without a decrease in total orifice area. These observations are consistent with increased tethering by displaced mitral leaflet attachments in the dilated ventricles of patients with IMLC that can restrict both diastolic opening and systolic closure.

Abbreviations and Acronyms
  ANOVA = analysis of variance
  IMLC = incomplete mitral leaflet closure
  LV = left ventricular
  MR = mitral regurgitation
  PM = papillary muscle

Functional mitral regurgitation (MR) complicates and affects the prognosis of patients with coronary artery disease and congestive heart failure (1–12), and is usually associated with incomplete mitral leaflet closure (IMLC, defined as apically displaced coaptation with failure of the mitral leaflets to reach the level of the mitral annulus and without apparent intrinsic cusp abnormalities) (13–15). It is usually accompanied by global left ventricular (LV) dysfunction and associated LV dilation (16,17), which can potentially cause geometric changes in the mitral leaflet attachments. This results in competing hypotheses for MR associated with IMLC: global LV dysfunction per se, with reduced force to close the leaflets (17,18), versus associated geometric changes in the mitral leaflet attachments, causing augmented chordal tension and leaflet tethering (11–15,19–30). These two effects generally occur together and cannot readily be separated during systole, but tethering might potentially be evident in terms of restricted leaflet opening during diastole, when the question of systolic dysfunction is no longer present.

Decreased diastolic leaflet excursion has, in fact, been described by M-mode echocardiography in patients with LV dysfunction (31–35), and is widely attributed to decreased transmitral flow volume (31,32), although results vary (33). To date, however, this observation has not been explored by two-dimensional echocardiography to address, for example, whether total leaflet cross-sectional area is reduced or only asymmetrically distributed, with decreased anterior excursion but a wider leaflet orifice; and decreased excursion has most commonly been measured by increased mitral–septal separation, to which septal motion also contributes.

The purpose of this study was to address the hypothesis that patients with LV dysfunction and incomplete systolic mitral leaflet closure also have restricted diastolic leaflet opening that provides evidence supporting increased leaflet tethering (Fig. 1). Such evidence would include demonstration that leaflet excursion is independent of mitral inflow volume and velocity, and that the leaflets assume a characteristic configuration that would not be predicted by decreased inflow volume per se, including a relatively fixed relation of the maximally open mitral leaflet to the line connecting its tethering attachments at the annular and papillary muscle (PM) ends. We tested this hypothesis using quantitative two-dimensional and Doppler echocardiography in patients with LV dysfunction, both with and without IMLC, compared with normal controls.



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  		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.

 

   Methods
Top
 Abstract
 Methods
Results
 Discussion
 References
 
Study population.   IMLC is usually associated with global LV dysfunction and MR (13–17). Therefore, in order to select patients with IMLC, we searched the Cardiac Ultrasound Laboratory computer database of this institution for patients with 1) global LV dysfunction (LV ejection fraction ≤30%); 2) significant (moderate or severe) MR on Doppler color flow mapping; and 3) no apparent intrinsic cusp disease. After that, we excluded patients with a) more than trace aortic regurgitation, which can potentially affect diastolic mitral leaflet motion and configuration; b) atrial fibrillation, with its variability in stroke volume; and c) no IMLC; we confirmed that the IMLC area between the leaflets and the mitral annulus at the time of maximal systolic closure on the apical four-chamber view was ≥0.05 cm2, because this value exceeded the 95% confidence limit of 21 normal subjects. During a 6-month period between January and June 1994, we identified 48 consecutive patients for this group; of these, 12 were excluded because of image quality unsuitable for quantification.

We then searched the database for the far less common group of patients with global LV dysfunction but without IMLC, looking for patients with 1) LV ejection fraction ≤30%; 2) no or trace MR on Doppler color flow mapping; and 3) no apparent intrinsic cusp disease, and excluding patients with a) more than trace aortic regurgitation; b) atrial fibrillation; and c) IMLC (IMLC area ≤0.05 cm2, the upper limit in control subjects). During a 5-year period between January 1990 and December 1994, we identified 30 consecutive patients for this group; 8 were excluded because of image quality. The normal controls consisted of 21 consecutive subjects with normal echocardiograms and without known cardiovascular disease.

Consequently, the IMLC(+) group consisted of 36 patients with global LV dysfunction and IMLC, the IMLC(–) group of 22 patients with global LV dysfunction but without IMLC and the control group of 21 normal control subjects (mean age = 62 ± 14, 61 ± 17 and 41 ± 16 years; 67%, 59% and 43% male; IMLC area = 1.7 ± 0.7, –0.09 ± 0.09 and –0.13 ± 0.09 cm2). The IMLC(+) group included 23 patients with moderate and 13 with severe MR; the subjects in the other groups had no or trace MR.

Basic echocardiographic measurements and calculations.   Complete two-dimensional and Doppler examinations with Doppler color flow mapping were performed in all patients with the 2.5-MHz transducer of a Hewlett-Packard phased array sector scanner (Sonos 1000, 1500 and 2000). The LV end-diastolic and end-systolic cavity areas were traced in the apical four- and two-chamber views, and the corresponding volumes and ejection fraction were calculated using the modified biplane Simpson’s method (36). End-diastolic and end-systolic volumes were subtracted to obtain the LV ejection volume, which equals the mitral inflow volume in the absence of aortic regurgitation (37). MR was graded based on color Doppler jet area using the method of Helmcke et al. (38). The systolic configuration of the mitral leaflet was also evaluated in the apical four-chamber view; to integrate the apical displacement over the extent of the mitral leaflets, the area between the leaflets and the mitral annular line in this view was traced at the time of maximal systolic closure (39). In order to evaluate whether mitral leaflet opening related to the determinants of the early transmitral pressure gradient (convective and inertial components) (40), we measured the peak E-wave velocity of early mitral inflow and its rate of rise from apical pulsed Doppler tracings aligned to record maximal velocity at the leaflet tips. Measurements were averaged over three beats.

Diastolic mitral leaflet motion and configuration.   Diastolic leaflet opening motion was measured in the same apical four-chamber view used to evaluate its systolic configuration and IMLC; measurements were based on the predominant clinical observation of restricted anterior diastolic excursion of the anterior mitral leaflet (31–35). The excursion angle of the anterior leaflet was defined as the angle over which the base of the leaflet moves from systole to its fully open diastolic position, measured as the excursion of a tangent line through the base of the leaflet (Fig. 2A). The angle at maximal leaflet opening, or maximal opening angle (alpha2), was measured between the base of the leaflet and the line connecting the annular hinge points (annulus line) at maximal diastolic opening; {alpha}1 was the angle measured at end-systole, one frame before diastolic leaflet opening. The excursion angle {Delta}{alpha} was therefore equal to {alpha}2 – {alpha}1.



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  		Figure 2 A, Measurement of the leaflet excursion angle {Delta}{alpha} 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 {alpha}1 and at maximal diastolic opening is {alpha}2. The leaflet excursion angle . LV, left ventricle; LA, left atrium. B, Method of assessing the diastolic alignment. The angle of maximal leaflet opening ({alpha}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.

 
At maximal leaflet opening, the angle between the annulus and the anterior leaflet ({alpha}2) was compared to that between the annulus and the line connecting the mitral leaflet attachments: the anterior annulus and papillary muscle tip (PM angle; Fig. 2B). How well the leaflet was aligned with its papillary muscle attachments was assessed by the difference between these angles: alignment angle = maximal opening angle – PM angle. The patient was considered to have diastolic alignment, with the leaflet opening only as far as the line connecting the annulus and the papillary muscle tip, if this difference between angles was <5°.

Reduced mitral inflow volume might be expected to reduce leaflet opening symmetrically; augmented leaflet tethering could potentially limit leaflet opening nonuniformly, just as nonuniform restriction of motion has been proposed in systole (13). Therefore, the short-axis view at the level of the mitral leaflet tips was examined to measure the entire mitral leaflet orifice area as well as its anteroposterior or vertical dimension, V, and its side-to-side or horizontal dimension, H (Fig. 3).



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  		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.

 
Mitral inflow direction.   The general direction of mitral inflow in the apical four-chamber view was determined using Doppler color flow mapping at the time of maximal early diastolic rapid filling as the line connecting the center of the filling flow signal at the mitral annulus and chordal levels between the leaflets and papillary muscles (curved arrow in Fig. 4, right panel). The angle between this line and the annulus was measured as the mitral inflow direction angle {phi}.



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  		Figure 4 Color Doppler echocardiograms in the apical four-chamber view showing the method to determine the mitral inflow direction angle {phi} (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 {phi}. 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.

 
Statistical analysis.   Results were expressed as mean ± SD. Differences in the mean value among all groups were determined using analysis of variance (ANOVA); if significant, differences between groups were explored using unpaired two-way comparisons (Student t test) with Bonferroni correction (p < 0.017 for significance) (41). Comparisons of proportions between groups were made using a chi-square statistic. Because of the number of variables being studied, the significance of the overall ANOVA was assessed at the conservative value of p < 0.005 (42).


   Results
Top
 Abstract
 Methods
 Results
Discussion
 References
 
Basic echocardiographic measurements.   The patients with LV dysfunction and IMLC had severely dilated left ventricles (Table 1, top). Their LV ejection volume (mitral inflow volume) was not reduced despite severely reduced ejection fractions due to marked LV dilation and the associated MR (60 ± 25 vs. 61 ± 12 ml in normal subjects, p = NS). In contrast, the patients without IMLC, with comparably low ejection fractions, had smaller ventricles and significantly reduced mitral inflow volume compared with both normal subjects and patients with IMLC (40 ± 10 vs. 61 ± 12 ml in normal subjects, p = 0.00005). The peak early mitral inflow velocity and its rate of rise were highest in patients with IMLC and lowest in those with LV dysfunction and no IMLC or significant MR.


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  		Table 1 Echocardiographic Measurements and Calculations

 
Restricted opening of the mitral leaflet.   As shown in Figure 5 and Table 1 (bottom), the excursion angle ({Delta}{alpha}) of the anterior mitral leaflet from end-systole to maximal leaflet opening was markedly decreased in patients with IMLC compared with those without IMLC and normal subjects (17 ± 10 vs. 58 ± 13 vs. 67 ± 8, p < 0.0001). The end-systolic angle was higher, consistent with IMLC with apical leaflet displacement away from the annulus. Excursion angle was dissociated from mitral inflow volume; excursion was reduced in patients with IMLC despite a normal inflow volume in the larger ventricles with MR (60 ± 25 vs. 61 ± 12 ml in normal subjects, p = NS), and excursion was nearly normal in patients without IMLC despite reduced inflow volume (40 ± 10 ml, p < 0.001 vs. normal). Excursion angle, therefore, did not significantly correlate with mitral inflow volume among all these three patient groups (r2 = 0.04) or within those with IMLC (r2 = 0.06). The maximal leaflet opening angle relative to the annulus ({alpha}2) also did not significantly correlate with mitral inflow volume among all patients or those with IMLC (r2 = 0.02–0.03). There was also no significant correlation between these leaflet mobility angles and either the peak E-wave velocity or its rate of rise in the patients with IMLC (r2 = 0.001–0.07). In all three patient groups, there was a mildly significant (p generally = 0.02–0.03) but inverse relation between these angles and the velocity measures (lowest angles in IMLC despite highest velocities, r2 = 0.06–0.11). Finally, as shown in Figure 6, the excursion angle was inversely related to the IMLC area (r2 = 0.83 for an inverse or hyperbolic fit), with greater immobility corresponding to more IMLC.



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  		Figure 5 Bar graphs showing mitral inflow volume and leaflet excursion angle {Delta}{alpha} 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.

 


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  		Figure 6 Scattergram showing a significant inverse correlation between leaflet excursion angle {Delta}{alpha} and incomplete mitral leaflet closure area. SEE, standard error of estimate.

 
Diastolic configuration of the mitral leaflet.   In patients with IMLC, the maximally open anterior leaflet coincided well with the line connecting the anterior annulus and papillary muscle tip (angular difference = 3 ± 7° vs. 25 ± 9° vs. 32 ± 10° in patients with and without IMLC vs. normal subjects, p < 0.0001). Diastolic alignment of the leaflet within 5° of the line between its attachments occurred in 30/36 (83%) of patients with IMLC versus none of the others; even in the 6 without such tight alignment angular differences were generally small (≤10°; up to 24° in only 1 patient).

The leaflet orifice: excursion versus area.   The anteroposterior or vertical dimension of the orifice at the level of the leaflet tips, as seen in the short-axis view, was significantly decreased only in the patients with IMLC (Table 1), often with a distinctly abnormal flattened configuration of the anterior leaflet (Fig. 3). However, the horizontal dimension of the orifice was actually larger in the patients with IMLC, so that the total orifice area was not different among the three groups, either in absolute terms or normalized to body surface area.

Abnormal mitral inflow direction.   As shown by the apical four-chamber views in Figure 4, mitral inflow, like the anterior leaflet, was directed posterolaterally in patients with IMLC, with a reduced inflow direction angle relative to the other two groups (Table 1, bottom). In patients with LV dysfunction but without IMLC, inflow, like the anterior leaflet, was only slightly redirected. The mitral inflow direction angle correlated with the maximal leaflet opening angle ( , r2 = 0.67), both defined relative to the annulus.


   Discussion
Top
 Abstract
 Methods
 Results
 Discussion
References
 
Limited leaflet opening and mitral flow.   The results of this study show that, in patients with comparably low ejection fractions, averaging 24–27%, diastolic mitral leaflet opening is most restricted in the patients with dilated left ventricles who also have the systolic pattern of incomplete mitral leaflet closure. This reduced leaflet excursion is not dependent on transmitral flow; mitral leaflet excursion is reduced in patients with IMLC despite a normal mitral inflow volume, which is preserved in these patients with larger ventricles and MR; and, on the other hand, excursion is nearly normal in patients with smaller ventricles and no IMLC, despite a significantly lower inflow volume. Further, in patients with IMLC, excursion is reduced despite higher values for the velocity determinants of the early transmitral pressure gradient (40) that could contribute to leaflet opening. Finally, in patients with IMLC, the mitral valve also assumes a characteristic diastolic configuration that is difficult to explain based on decreased forward flow. If low flow limited excursion, it is not obvious why the anterior leaflet should so frequently stop moving when it reaches the line connecting its attachments, or why the total orifice area should remain normal rather than symmetrically reduced.

Mechanistic insights.   In contrast, these clinical observations can be understood if we consider that the ventricles of patients with IMLC are considerably larger than those without it. In the larger ventricles, with increased separation between the mitral valve attachments, increased tethering and abnormally tensed chordae may interrupt further valve opening, aligning the anterior leaflet with the line connecting its anterior annular end and its posterior papillary muscle connection. It is also reasonable, then, that leaflet motion is limited in an anterior direction away from the papillary muscles (Fig. 1), whereas the increased side-to-side separation of those muscles actually allows for a wider orifice, preserving a normal total orifice area. Measurable chordal tension has, in fact, been shown in vivo when the leaflets reach their diastolic tether (43); it is therefore reasonable that the leaflets can respond to altered tethering geometry by limited diastolic motion.

Relation to prior studies.   Early investigation of mitral leaflet excursion led to the concept that it is flow dependent (31,32). Those studies, however, assessed mitral inflow volume by thermodilution or Fick’s method, which will not provide mitral inflow volume in the presence of MR, commonly associated with LV dysfunction (44). In contrast, the E-point septal separation, which is related in part to mitral leaflet excursion and inversely correlates with ejection fraction (33–35), did not correlate with angiographic stroke volume, which equals mitral inflow volume even with MR (33). Further, leaflet excursion did not correlate with inflow volume measured directly by an electromagnetic flow meter attached to the mitral annulus in an animal experiment (45). The results of the present study are therefore consistent with these clinical and experimental findings. This study also goes beyond prior reports by exploring the question of diastolic excursion with the full spatial perspective of two-dimensional echocardiography, allowing us to appreciate the relation of the leaflet motion to the papillary muscle tip, and for the first time to measure the cross-sectional area at the leaflet tips and show that it is surprisingly normal despite reduced anterior excursion.

Practical implications for echocardiographic diagnosis and measurement.   In addition to providing insights into the fundamental mechanisms of mitral valve opening, these findings have several practical implications for cardiac imaging. First, it is important to note that decreased leaflet excursion in patients with LV dysfunction cannot be interpreted as necessarily diagnosing a state of low mitral inflow. Second, relatively preserved mitral leaflet excursion in patients with LV dysfunction cannot be interpreted as implying normal flow; other means for estimating flow and output are needed (46,47). Third, the differentiation of functional reduced excursion from mild rheumatic mitral stenosis, which can at times be difficult, can be made easier and with greater confidence by displaying increased width of the mitral leaflet opening in the short-axis view as a clue to the functional case as opposed to the commissural fusion and narrowing seen in the rheumatic case. Fourth, the results show posterolaterally redirected inflow in patients with IMLC, previously described but unexplained (48–50); this needs to be considered in measuring Doppler mitral inflow velocities (51–53).

Limitations.   Clinical observations suggest that restricted excursion of the anterior mitral leaflet can be seen relative to both papillary muscles in different views, consistent with the leaflet appearance in the short-axis view (Fig. 3). However, for purposes of this quantitative investigation, we only measured the relation between the leaflet and one of the PMs in order to demonstrate that diastolic leaflet tethering actually occurs. It should also be noted that the four-chamber view does not strictly speaking examine the excursion of the anterior mitral leaflet in an anteroposterior direction coinciding with the anteroposterior orifice dimension measured at the leaflet tips. Nevertheless, the direction of the apical four-chamber view does have a partially anteroposterior component, and measurements of both leaflet excursion in that view and anteroposterior orifice dimension at the leaflet tips demonstrated restricted diastolic leaflet motion consistent with tethering.

Conclusions.   Patients with LV dysfunction and incomplete systolic mitral leaflet closure also have restricted diastolic leaflet excursion that is independent of inflow volume and velocity, coincides with the line connecting the annulus and papillary muscle and reflects limitation of anterior motion relative to the posteriorly placed papillary muscles without a decrease in total orifice area. These observations are consistent with increased tethering by displaced mitral leaflet attachments in the dilated ventricles of patients with IMLC that have the potential to restrict both diastolic opening and systolic closure.


   Footnotes
 
Supported in part by grants HL 38176 and 53702 of the National Institutes of Health, Bethesda, MD (R.A.L.). Dr. Otsuji was supported in part by a fellowship of Kagoshima University, Kagoshima, Japan.


   References
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 Abstract
 Methods
 Results
 Discussion
 References
 

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