Three-dimensional dynamic morphology of the mitral valve in different forms of mitral valve prolapse - potential implications for annuloplasty ring selection.

Astrid Apor,Attila Kovács,Péter Andrássy,Anikó Ilona Nagy,Aristomenis Manouras,Béla Merkely

doi:10.1186/s12947-016-0073-4

Abstract

BackgroundReal-time three-dimensional transesophageal echocardiography has increased our understanding of the distinct pathomechanisms underlying functional, ischaemic or degenerative mitral regurgitation. However, potential differences in dynamic morphology between the subtypes of degenerative mitral prolapse have scarcely been investigated.MethodsIn order to compare the dynamic behavior of the different phenotypes of degenerative mitral valve prolapse, real-time three-dimensional transesophageal echocardiography recordings of 77 subjects, 27 with Barlow disease (BD), 32 with Fibroelastic deficiency (FED) and 18 normal controls (NC) were analysed.ResultsGeometric annular and valvular parameters of the myxomatous patients were significantly larger compared to controls (BD vs. FED vs. NC 3D annular area: 15 ± 2.8 vs. 13.3 ± 2.4 vs. 10.6 ± 2.3cm2, all p < 0.01). Beside similar ellipticity, BD annuli were significantly flatter compared to FED. Myxomatous annuli appeared less dynamic than normals, with decreased overall 3D area change, however only the BD group differed from NC significantly (BD vs. FED vs. NC normalized 3D area change 4.40 vs. 6.81 vs. 9.69 %; BD vs. NC p = 0.000; FED vs. NC p = not significant, BD vs. FED p = 0.025).ConclusionBD and FED differ not only in terms of valve morphology, but also annular dynamics. Both pathologies are characterized by annular dilatation. However, in BD the annulus is remarkably flattened and hypodynamic, whereas in FED its saddle-shape and contractile function is relatively preserved. These features might influence the choice of repair technique and the selection of annuloplasty ring.

Highlights

Real-time three-dimensional transesophageal echocardiography has increased our understanding of the distinct pathomechanisms underlying functional, ischaemic or degenerative mitral regurgitation
BSA indicates body surface area, EF ejection fraction, LV EDV left ventricular end diastolic volume, LV ESV left ventricular end systolic volume, LAVi left atrial volume indexed to BSA, PAPs systolic pulmonary artery pressure, mitral regurgitation (MR)
Myxomatous annuli appeared less dynamic than normal, with decreased overall 3D area change, only the Barlow disease (BD) group differed from normal controls (NC) significantly (BD vs. Fibroelastic deficiency (FED) vs. NC relative 3D area change 4.40 vs. 6.81 vs. 9.69 %; BD vs. NC p = 0.001; FED vs. NC p = NS, BD vs. FED p = 0.025)

Summary

Introduction

Real-time three-dimensional transesophageal echocardiography has increased our understanding of the distinct pathomechanisms underlying functional, ischaemic or degenerative mitral regurgitation. Potential differences in dynamic morphology between the subtypes of degenerative mitral prolapse have scarcely been investigated. We hypothesized that BD and FED patients, who display remarkable phenotypic differences in valvular morphology, might represent discriminative cohorts with respect to the geometric and functional characteristics of the mitral annulus. The aim of the present study was to investigate the geometric properties and the dynamicity of the MA out of special consideration for the different subtypes of myxomatous mitral valve disease, i.e. BD and FED, compared to healthy individuals

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