Document Detail

Mitral annular dynamics in myxomatous valve disease: new insights with real-time 3-dimensional echocardiography.
MedLine Citation:
PMID:  20231533     Owner:  NLM     Status:  MEDLINE    
BACKGROUND: Mitral annulus is a complex structure of poorly understood physiology. Full-volume real-time 3-dimensional transesophageal echocardiography offers a unique opportunity to completely image and quantify mitral annulus size and motion. METHODS AND RESULTS: Real-time 3-dimensional transesophageal echocardiography of the mitral valve was acquired in 32 patients with myxomatous valve disease (MVD) and moderate to severe regurgitation, 15 normal control subjects, and 10 patients with ischemic mitral regurgitation of identical body surface area. Mitral annular dimensions (circumference, area, anteroposterior and intercommissural diameters, height, and ratio of height to intercommissural diameter ratio, which appraises annular saddle-shape depth) were measured throughout the cardiac cycle with dedicated quantification software. Compared with direct surgical measurement, 3-dimensional anterior annular dimension provided reliable measurements (mean difference, 0.1+/-0.1 mm; P=0.73; 95% confidence interval, +/-4.4 mm). Annular dimensions were larger in MVD patients compared with control subjects in diastole (all P<0.05). Normal annulus displayed early-systolic anteroposterior (P<0.001) and area (P=0.04) contraction, increased height (P<0.001), and deeper saddle shape (ratio of height to intercommissural diameter, 15+/-1% to 21+/-1%; P<0.001), whereas intercommissural diameter was unchanged (P=0.30). In contrast, MVD showed early-systolic intercommissural dilatation (P=0.02) and no area contraction (P=0.99), height increase (P=0.11), or saddle-shape deepening (P=0.35). Late-systolic MVD annular saddle shape deepened but annular area excessively enlarged (P<0.04) as a result of persistent intercommissural widening (P<0.02). MVD annulus also contrasts with ischemic mitral regurgitation annulus, which, despite similar anteroposterior enlargement, is narrower and essentially adynamic. After MVD repair, the annulus remained dynamic without systolic saddle-shape accentuation (P=0.30). CONCLUSIONS: Real-time 3-dimensional transesophageal echocardiography provides insights into normal, dynamic mitral annulus function with early-systolic area contraction and saddle-shape deepening contributing to mitral competency. MVD annulus is also dynamic but considerably different with loss of early-systolic area contraction and saddle-shape deepening despite similar magnitude of ventricular contraction, suggestive of ventricular-annular decoupling. Subsequent area enlargement may contribute to mitral incompetence. After mitral repair, MVD annulus remains dynamic without systolic saddle-shape accentuation. Thus, real-time 3-dimensional transesophageal echocardiography provides new insights that allow the refining of mitral pathophysiology concepts and repair strategies.
Jasmine Grewal; Rakesh Suri; Sunil Mankad; Akiko Tanaka; Douglas W Mahoney; Hartzell V Schaff; Fletcher A Miller; Maurice Enriquez-Sarano
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Publication Detail:
Type:  Journal Article; Research Support, Non-U.S. Gov't     Date:  2010-03-15
Journal Detail:
Title:  Circulation     Volume:  121     ISSN:  1524-4539     ISO Abbreviation:  Circulation     Publication Date:  2010 Mar 
Date Detail:
Created Date:  2010-03-30     Completed Date:  2010-05-24     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  0147763     Medline TA:  Circulation     Country:  United States    
Other Details:
Languages:  eng     Pagination:  1423-31     Citation Subset:  AIM; IM    
Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minn 55905, USA.
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MeSH Terms
Case-Control Studies
Echocardiography, Three-Dimensional
Echocardiography, Transesophageal
Middle Aged
Mitral Valve / pathology*,  ultrasonography
Mitral Valve Insufficiency / pathology*,  ultrasonography

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