Document Detail

Evidence of a vicious cycle in mitral regurgitation with prolapse: secondary tethering attributed to primary prolapse demonstrated by three-dimensional echocardiography exacerbates regurgitation.
MedLine Citation:
PMID:  22965986     Owner:  NLM     Status:  MEDLINE    
BACKGROUND: In patients with mitral valve prolapse, nonprolapsed leaflets are often apically tented. We hypothesized that secondary left ventricular dilatation attributed to primary mitral regurgitation (MR) causes papillary muscle (PM) displacement, resulting in this leaflet tenting/tethering, and that secondary tethering further exacerbates malcoaptation and contributes to MR severity.
METHODS AND RESULTS: Three-dimensional transesophageal echocardiography was performed in 25 patients with posterior mitral leaflet prolapse with an intact anterior mitral leaflet (AML) and 20 controls. From 3D zoom data sets, 11 equidistant antero-posterior cut planes of the mitral valve at midsystole were obtained. In each plane, tenting area of nonprolapsed leaflet and prolapse area of prolapsed leaflet were measured. Prolapse/tenting volume of each region was obtained as the product of interslice distance and the prolapse/tenting area. AML tenting volume and whole leaflet prolapse/tenting volume were then obtained. The PM tethering distance between PM tips and anterior mitral annulus was measured from 3D full-volume data sets. The severity of MR was quantified by vena contracta area extracted from color 3D transesophageal echocardiography data sets. AML tenting volume was significantly larger in patients with posterior mitral leaflet prolapse compared with that in controls (1.2 ± 0.5 versus 0.6 ± 0.2 mL/m(2); P<0.001). Multivariate regression analysis identified independent contribution to AML tenting volume from an increase in PM tethering distance. Multivariate regression analysis identified independent contributions to MR severity (vena contracta area) from both whole leaflet tenting volume (r=0.44; P<0.05) and prolapse volume (r=0.44; P<0.05). AML tenting volume decreased along with left ventricular volume and PM tethering distance postrepair (n=8; P<0.01).
CONCLUSIONS: These results suggest that primary mitral valve prolapse with MR causes secondary mitral leaflet tethering with PM displacement by left ventricular dilatation, which further exacerbates valve leakage, constituting a vicious cycle that would suggest a pathophysiologic rationale for early surgical repair.
Kyoko Otani; Masaaki Takeuchi; Kyoko Kaku; Nobuhiko Haruki; Hidetoshi Yoshitani; Masataka Eto; Masahito Tamura; Masahiro Okazaki; Haruhiko Abe; Yoshihisa Fujino; Yousuke Nishimura; Robert A Levine; Yutaka Otsuji
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Publication Detail:
Type:  Journal Article; Research Support, Non-U.S. Gov't    
Journal Detail:
Title:  Circulation     Volume:  126     ISSN:  1524-4539     ISO Abbreviation:  Circulation     Publication Date:  2012 Sep 
Date Detail:
Created Date:  2012-09-11     Completed Date:  2012-11-27     Revised Date:  2014-02-07    
Medline Journal Info:
Nlm Unique ID:  0147763     Medline TA:  Circulation     Country:  United States    
Other Details:
Languages:  eng     Pagination:  S214-21     Citation Subset:  AIM; IM    
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MeSH Terms
Dilatation, Pathologic / etiology,  physiopathology,  ultrasonography
Disease Progression
Echocardiography, Three-Dimensional*
Echocardiography, Transesophageal
Heart Ventricles / pathology
Middle Aged
Mitral Valve / ultrasonography*
Mitral Valve Insufficiency / physiopathology*,  ultrasonography
Mitral Valve Prolapse / complications*,  physiopathology,  ultrasonography
Models, Cardiovascular*
Ventricular Dysfunction, Left / etiology,  physiopathology,  ultrasonography
Grant Support

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

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