Mitral Annular Diameter Research Articles

Mitral annulus is dilated with preserved function in acromegaly regardless of its activity: Insights from the three-dimensional speckle-tracking echocardiographic MAGYAR-Path Study

Introduction and ObjectiveAcromegaly is a rare, chronic and slowly developing endocrine disorder caused by hypersecretion of human growth hormone and consequently of insulin-like growth factor-1 during adulthood. The present study was conducted to assess mitral annular (MA) size and function between acromegalic patients and age- and gender-matched healthy controls by three-dimensional speckle-tracking echocardiography (3D-STE). It also aimed to examine whether activity of the disease has any effect on MA parameters. MethodsThis study included 27 patients with acromegaly, three of whom were excluded due to inferior image quality. The mean age of the remaining 24 patients was 55.7±14.0 years and seven were male. Complete two-dimensional Doppler echocardiography and 3D-STE were performed in all cases. ResultsSignificantly increased end-diastolic and end-systolic MA diameter (2.81±0.36 cm vs. 2.44±0.34 cm and 2.00±0.32 cm vs. 1.65±0.37 cm, respectively), area (9.67±2.33 cm2 vs. 7.38±1.93 cm2 and 5.14±1.62 cm2 vs. 3.74±1.19 cm2, respectively) and perimeter (11.76±1.42 cm vs. 10.27±1.33 cm and 8.61±1.23 cm vs. 7.36±1.10 cm, respectively) were demonstrated in acromegalic patients compared with control subjects. MA functional parameters were not significantly altered compared to those of healthy individuals. ConclusionsMA dilation could be seen in acromegaly regardless of its activity. Acromegaly is not associated with MA functional impairment.

Utility of 3-dimensional transoesophageal echocardiography for mitral annular sizing in transcatheter mitral valve replacement procedures: a cardiac computed tomography comparative study

Abstract Funding Acknowledgements Type of funding sources: None. Background. 3-dimensional transoesophageal echocardiography (3D-TEE) is frequently used as an initial screening tool in the evaluation of patients who are candidates to Transcatheter Mitral Valve Replacement (TMVR). However, little is known about the imaging correlation with the gold-standard computed tomography (CT) imaging. We aimed at testing the quantitative differences between these two modalities and finding the best 3D-TEE parameters for TMVR screening. Methods. We included 57 patients referred to our Heart Valve Clinic for TMVR with prostheses specifically designed for the mitral valve. Mitral annulus (MA) analyses were performed using commercially available software in 3D-TEE and CT. Results. 3D-TEE was feasible in 52 patients (91%). Although 3D-TEE measurements were slightly lower than in CT, both measurements of projected MA area and perimeter showed excellent correlation with small differences between the two modalities (r = 0.88 and r = 0.92 respectively, p < 0.0001). Correlations were significant but lower for MA diameters (r = 0.68 to 0.72, p < 0.0001) and mitro-aortic angle (r = 0.53, p = 0.0001). ROC curve analyses showed that 3D-TEE had a good ability to predict TMVR screening success defined by constructors based on CT measurements with a range of 12.9 to 15cm² for MA area (AUC = 0.88-0.91, p < 0.0001), 128 to 139mm for MA perimeter (AUC = 0.85-0.91, p < 0.0001), 35 to 39mm for anteroposterior diameter (AUC = 0.79-0.84 p < 0.0001) and 37 to 42mm for posteromedial-anterolateral diameter (AUC = 0.81-0.89, p < 0.0001) (Figure 1). Conclusion. 3D-TEE measurements of MA dimensions display strong correlation with CT measurements in patients undergoing TMVR screening process. 3D-TEE should be proposed as a reasonable alternative to CT in this vulnerable population. Abstract Figure.

Changes in mitral valve geometry after percutaneous valve repair with the MitraClip® System.

The aim of our study was to assess the anatomical changes of the mitral valve apparatus after percutaneous repair with the MitraClip® system. We included consecutive patients who underwent MitraClip® implantation in our center. Patients were assessed by 2- and 3-dimensional transesophageal echocardiography, acquired before and immediately after MitraClip® implantation. Off-line images analysis was performed to assess mitral annular diameters (antero-posterior and inter-commisural), area and circumference. Mitral tenting distance, area and volume were evaluated for functional mitral regurgitation. Patients had a 2-dimensional transthoracic echocardiography at follow-up (8months). 38 patients with successful results (residual mitral regurgitation grade ≤ II) were included. The anteroposterior annulus diameter (ADP) decreased (from 35 ± 5 to 28 ± 5mm, p < 0.001) with smaller decreases in the annular area and circumference and in the inter-commissural diameter. Annular ellipticity improved. The reduction in APD and tenting distance was sustained at follow-up. Successful percutaneous mitral valve repair with the MitraClip® system induces a stable change in mitral valve geometry mainly at the ADP, suggesting a significant annuloplasty that contributes to the reduction of mitral regurgitation.

Left ventricular outflow obstruction occurs immediately after exercise in patients with non-obstructive hypertrophic cardiomyopathy

We evaluated the hemodynamic and geometric determinants of latent obstruction (LO, trans-left ventricular outflow tract (LVOT) gradient ≥30 mmHg with provocation) in patients with non-obstructive hypertrophic cardiomyopathy (HCMP). A total of 35 patients with non-obstructive HCMP underwent stepwise supine bicycle exercise echocardiography. Trans-LVOT pressure gradients, mitral geometric parameters, left ventricular ejection fractions (LVEF) and left ventricular end-systolic and diastolic dimensions (LVESD, LVEDD) were measured at each stage. The highest peak LVOT pressure gradient predominantly occurred immediately after exercise (n = 32, 91.3%) rather than during peak exercise (n = 3, 8.7%). Significant LO developed in nine patients (25%). No significant differences were found in resting echocardiographic parameters. Compared to the remaining patients, however, patients with LO had longer residual mitral leaflets (defined as residual portions of leaflets after coaptation; 4 ± 4 vs. 13 ± 4 mm, respectively; p = 0.001) and higher resting LVOT pressure gradients (7.4 ± 3.7 vs. 12.9 ± 5.8 mmHg, respectively; p = 0.001). Substantial decreases in mitral annular diameters from peak exercise to recovery after exercise were observed in the LO group, while mitral annular diameters increased after exercise in the non-LO group. In conclusion, the highest peak LVOT pressure gradient predominantly occurred immediately after exercise rather than during peak exercise, regardless of LO. Abrupt decrease of mitral annular diameter immediately after exercise, a longer residual mitral leaflet and a higher resting LVOT pressure gradient at rest might be related to LO.

Predicting clinical outcome by indexed mitral valve tenting in functional mitral valve regurgitation

ObjectivesMitral valve (MV) tenting parameters are indicators of left ventricular remodelling severity and may predict outcome in functional mitral regurgitation (FMR). We hypothesised that indexing of MV tenting area to...

Cardiovascular magnetic resonance reference values of mitral and tricuspid annular dimensions: the UK Biobank cohort

BackgroundMitral valve (MV) and tricuspid valve (TV) apparatus geometry are essential to define mechanisms and etiologies of regurgitation and to inform surgical or transcatheter interventions. Given the increasing use of cardiovascular magnetic resonance (CMR) for the evaluation of valvular heart disease, we aimed to establish CMR-derived age- and sex-specific reference values for mitral annular (MA) and tricuspid annular (TA) dimensions and tethering indices derived from truly healthy Caucasian adults.Methods5065 consecutive UK Biobank participants underwent CMR using cine balanced steady-state free precession imaging at 1.5 T. Participants with non-Caucasian ethnicity, prevalent cardiovascular disease and other conditions known to affect cardiac chamber size and function were excluded. Absolute and indexed reference ranges for MA and TA diameters and tethering indices were stratified by gender and age (45–54, 55–64, 65–74 years).ResultsOverall, 721 (14.2%) truly healthy participants aged 45–74 years (54% women) formed the reference cohort. Absolute MA and TA diameters, MV tenting length and MV tenting area, were significantly larger in men. Mean ± standard deviation (SD) end-diastolic and end-systolic MA diameters in the 3-chamber view (anteroposterior diameter) were 2.9 ± 0.4 cm (1.5 ± 0.2 cm/m2) and 3.3 ± 0.4 cm (1.7 ± 0.2 cm/m2) in men, and 2.6 ± 0.4 cm (1.6 ± 0.2 cm/m2) and 3.0 ± 0.4 cm (1.8 ± 0.2 cm/m2) in women, respectively. Mean ± SD end-diastolic and end-systolic TA diameters in the 4-chamber view were 3.2 ± 0.5 cm (1.6 ± 0.3 cm/m2) and 3.2 ± 0.5 cm (1.7 ± 0.3 cm/m2) in men, and 2.9 ± 0.4 cm (1.7 ± 0.2 cm/m2) and 2.8 ± 0.4 cm (1.7 ± 0.3 cm/m2) in women, respectively. With advancing age, end-diastolic TA diameter became larger and posterior MV leaflet angle smaller in both sexes. Reproducibility of measurements was good to excellent with an inter-rater intraclass correlation coefficient (ICC) between 0.92 and 0.98 and an intra-rater ICC between 0.90 and 0.97.ConclusionsWe described age- and sex-specific reference ranges of MA and TA dimensions and tethering indices in the largest validated healthy Caucasian population. Reference ranges presented in this study may help to improve the distinction between normal and pathological states, prompting the identification of subjects that may benefit from advanced cardiac imaging for annular sizing and planning of valvular interventions.

Abstract 15253: Significant Discrepancies in Quantification of Regurgitant Volume in Primary Mitral Regurgitation Observed on Multimodality Imaging: Is It Time for Reappraisal?

Introduction: Mitral valve regurgitation volume (RV) can be quantified using proximal isovelocity surface area (PISA) or stroke volume (SV). SV method incorporates mitral annulus (MA) diameter (assumed circular) on 2D transthoracic echo (2D TTE). However, MA area (MAA) can be precisely measured using 3D transesophageal echocardiographic (3DTEE) or computed tomography (CT). Hypothesis: We sought to compare RV obtained using a) PISA b) standard SV using MA diameter on 2D echo and c) modified SV using MAA on 3D TEE and d) MAA on CT. Methods: 37 patients (63±9 years, 81 % men) with severe primary mitral regurgitation (MR) undergoing surgery were prospectively recruited. RV was calculated using a) PISA b) standard SV method using MA diameter on 2D echo (0.785*diameter 2 MV *VTI MV -0.785*d 2 LVOT *VTI LVOT ) c) &amp; d) modified SV methods where MAA (on 3D TEE and CT) were incorporated instead of MA diameter. Results: The mean MAA (cm 2 ) by 2DTTE, 3DTEE &amp; CT were 10.7±3, 10.9 ±3 &amp; 15.9 ±3. Mean RV (cc) by standard SV method, modified SV (3D TEE &amp; CT) &amp; PISA were 294±126, 276±82, 355±127 &amp; 91±51, respectively. Correlations &amp; agreements of SV-based RV are shown in Figure 1. RV was highest using CT-based MAA. The closest agreement was between 2D TTE &amp; CT with a mean error (ME) of -61 cc. There was a large discrepancy in RV derived from PISA vs all SV methods, with a systemic overestimation using SV methods with root mean square errors (RMSE) ranging from 156 to 293 cc Figure 2. Conclusions: In severe MR,calculating RV using SV vs PISA yields vastly different values. The differences are exaggerated using modified SV method incorporating more accurate MAA on 3D TEE or CT. These techniques should not be interchanged to quantify MR.

Patterns of left ventricular longitudinal myocardial dysfunction in mitral valve prolapse and effects of valve repair

Abstract Background Regional longitudinal left ventricular (LV) dysfunction in patients with mitral regurgitation (MR) due to valve prolapse (MVP) with normal ejection fraction has been recently described, with data pointing at dysfunction of the LV base related to dilatation of the mitral annulus. Purpose To investigate degree and extent of regional LV dysfunction and its mechanisms in patients with MVP and severe acute (MRa, n=27) or chronic (MRc, n=41) MR and no coronary disease, undergoing surgical valve repair with 3 months follow-up (FU); 20 normal subjects were used as controls (N). Methods Speckle-tracking echocardiography was performed pre- (Bas), 1 week (1w) and 4 months (4mo) post-operatively to measure longitudinal global (GLPSS, %), regional (RPSS, %) and segmental (SPSS) peak systolic strain. Maximum and minimum mitral annulus (MA) diameters were measured with 3D echo at Bas. We also evaluated: LV end-diastolic volume index (EDVi, ml/m2); ejection fraction (EF, %); left atrial end-systolic volume index (LAVi, ml/m2); non-invasive pulmonary systolic pressure (PSP, mmHg). Results Risk factors (hypertension, diabetes, atrial fibrillation, smoke and previous stroke) were similar in MRc and MRa. At Bas EDVi was larger by definition in MRc (MRc: 102±21, MRa: 67±10 ml/m2, p&amp;lt;0.001) as LAVi (101±46 vs 76±31 ml/m2, p=0.035). Both EF (65±8 vs 64±8 ml/m2) and GLPSS (−20±4 vs −21±5%) were normal, but RPSS was reduced, only at the base (−13±6 vs −13±6%, p= ns; N: −18±2, p&amp;lt;0.03 vs MRc and MRa) in MRc and MRa, with reduced SPSS localized at anterior, lateral and posterior – but not septal – segments. At 1w, EF decreased in both MRc (47±14%, p&amp;lt;0.001 vs Bas) and MRa (56±10%, p=0.014 vs Bas), together with GLPSS (MRc: −11±4%, p&amp;lt;0.001 vs Bas; MRa; −13±4, p&amp;lt;0.001 vs Bas) driven by a prevalent marked decrease in RPSS (MRc: −7±4%, p&amp;lt;0.001 vs Bas; MRa; −8±5, p&amp;lt;0.001 vs Bas) of the LV base. All patients were alive at 3 months with no MACEs, similar reduction of mean MR grade (MRc: 4±0 to 1.9±0.7, p&amp;lt;0.001; MRa: 3.9±0.3 to 0.9±0.9, p&amp;lt;0.001) and PSP (MRc: 50±23 to 29±5 mmHg, p&amp;lt;0.001; MRa: 42±22 to 32±6 mmHg, p=0.039), normal EDVi (MRc: 70±27, MRa: 49±10 ml/m2), dilated LAVi (MRc: 101±46, MRa: 54±13 ml/m2), and reduced GLPSS (MRc: −12±5%, p&amp;lt;0.001 vs Bas; MRa; −15±3, p=0.001 vs Bas) and base RPSS (MRc: −7±6%, p=0.004 vs Bas; MRa; −10±4, p= ns vs Bas). At multivariate analysis, regional dysfunction was not related to the prolapsing scallop, presence of flail, commissure involvement, dimension and geometry of the MA, EF or pulmonary pressures. Conclusions In patients with MVP and severe MR, there is a specific regional longitudinal dysfunction pattern prevalent at the LV base which may be related to the duration of MR but not to annular dilatation or morphology of the prolapsing leaflets. The dysfunction worsens greatly following acute reduction of preload after surgical repair and is still significant at 4mo FU. Funding Acknowledgement Type of funding source: None

Utility of Three-Dimensional Transesophageal Echocardiography for Mitral Annular Sizing in Transcatheter Mitral Valve Replacement Procedures: A Cardiac Computed Tomographic Comparative Study

Three-dimensional (3D) transesophageal echocardiographic (TEE) imaging is frequently used as an initial screening tool in the evaluation of patients who are candidates for transcatheter mitral valve replacement (TMVR). However, little is known about the imaging correlation with the gold standard, computed tomographic (CT) imaging. The aims of this study were to test the quantitative differences between these two modalities and to determine the best 3D TEE parameters for TMVR screening. Fifty-seven patients referred to the heart valve clinic for TMVR with prostheses specifically designed for the mitral valve were included. Mitral annular (MA) analyses were performed using commercially available software on 3D TEE and CT imaging. Three-dimensional TEE imaging was feasible in 52 patients (91%). Although 3D TEE measurements were slightly lower than those obtained on CT imaging, measurements of both projected MA area and perimeter showed excellent correlations, with small differences between the two modalities (r=0.88 and r=0.92, respectively, P<.0001). Correlations were significant but lower for MA diameters (r=0.68-0.72, P<.0001) and mitroaortic angle (r=0.53, P=.0001). Receiver operating characteristic curve analyses showed that 3D TEE imaging had a good ability to predict TMVR screening success, defined by constructors on the basis of CT measurements, with ranges of 12.9 to 15cm2 for MA area (area under the curve [AUC]=0.88-0.91, P<.0001), 128 to 139mm for MA perimeter (AUC=0.85-0.91, P<.0001), 35 to 39mm for anteroposterior diameter (AUC=0.79-0.84, P<.0001), and 37 to 42mm for posteromedial-anterolateral diameter (AUC=0.81-0.89, P<.0001). Three-dimensional TEE measurements of MA dimensions display strong correlations with CT measurements in patients undergoing TMVR screening. Three-dimensional TEE imaging should be proposed as a reasonable alternative to CT imaging in this vulnerable population.

Relation of Mitral Annulus and Left Atrial Dysfunction to the Severity of Functional Mitral Regurgitation in Patients with Dilated Cardiomyopathy.

Methods 56 patients (58 ± 17 years, 42 men) with DCM and FMR and 52 controls, prospectively enrolled, underwent 3DTTE dedicated for mitral valve (MV), LA, and left ventricle (LV) quantitative analysis. Results Patients with FMR vs. controls presented increased MA size and sphericity during the entire systole, whereas MA fractional area change (MAFAC) and MA displacement were decreased (15 ± 5 vs. 28 ± 5%; and 5 ± 3 vs. 10 ± 2 mm, p < 0.001). In patients with moderate/severe FMR, MA diameters correlated with PISA radius, EROA, and regurgitant volume (Rvol), as also did the MA area (with PISA radius, EROA, and Rvol: r = 0.48, r = 0.58, and r = 0.47, p < 0.05). MAFAC correlated inversely with EROA and Rvol (r = −0.32 and r = −0.35, p < 0.05), with both active and total LA emptying fractions and with LV ejection fraction as well. In a stepwise multivariate regression model, decreased MAFAC and increased LA volume independently predicted patients with severe FMR. Conclusions Patients with DCM and FMR have MA geometry remodeling and contractile dysfunction, correlated with the severity of FMR. MA contractile dysfunction correlated with both LA and left LV pumps dysfunctions and predicted patients with severe FMR. Our results provide new insights that might help with better selection of patients for MV transcatheter procedures.

Reproducibility of geometric and flow-based echocardiographic measurements used for quantification of left ventricular total and forward stroke volume in healthy dogs

BackgroundCardiac structure and function in dogs are commonly assessed using echocardiography. A variety of linear, area, and flow-based measurements can be used to calculate left ventricular (LV) total stroke volume (TSV) and forward stroke volume (FSV), but the reproducibility of many of these measurements has not been fully studied. We hypothesized that survey of echocardiographic variables would identify those with high reproducibility and inform future investigation of different methods to measure LV TSV and FSV. MethodsThe reproducibility of 25 geometric and flow-based echocardiographic measurements was prospectively evaluated in 23 healthy dogs by two experienced observers. Reproducibility (i.e., interobserver agreement) was described using intraclass correlation coefficients. The reproducibility of various methods to calculate LV TSV and FSV was explored. ResultsReproducibility was generally good to excellent. Variables of LV width, length, and area and aortic and sinotubular junction diameter and velocity time integral were among measures with the highest reproducibility. Measurements of mitral annular diameter and mitral inflow velocity time integral possessed lower reproducibility. Calculation of LV TSV using measurements involved in the cube and bullet formulas demonstrated higher reproducibility than the Simpson's method of disks or mitral inflow methods. Calculation of LV FSV using LV outflow tract and aortic diameters from the right parasternal view generally demonstrated higher reproducibility compared with the left-sided view. ConclusionsThe reproducibility of many simple geometric and flow-based echocardiographic measurements is high. Comparison of the reliability of different measurement informs future investigation of echocardiographic methods to determine LV TSV and FSV in dogs.

Normal reference values of three-dimensional speckle-tracking echocardiography-derived mitral annular dimensions and functional properties in healthy adults: Insights from the MAGYAR-Healthy Study.

There is a limited number of echocardiographic studies determining mitral annular (MA) dimensions in healthy subjects. The present study aimed to establish normal reference values of three-dimensional speckle-tracking echocardiography-derived MA dimensions and functional properties in healthy adults in relation with age and gender. The present study comprised 298 healthy adult subjects. From this population, 94 subjects were excluded due to inadequate image quality. Therefore the remaining group consisted of 204 subjects with the mean age of 33.88 ± 12.97 years (107 males). The population sample was further divided into age categories: 18-29 years (n = 105; mean age: 24.11 ± 2.98 years, 51 males), 30-39 years (n = 44; mean age: 33.80 ± 2.39 years, 31 males), 40-49 years (n = 19; mean age: 43.47 ± 3.18 years, 11 males) and ≥50 years of age (n = 36, mean age: 57.42 ± 6.11 years, 14 males). End-diastolic MA dimensions did not change significantly during the decades. End-systolic MA diameter, area, and perimeter were larger over the age of 50 years than in the 18-29 year-old group. MA fractional area change was found smaller over the age of 50 years than in 18-29-year-old group. While end-diastolic MA variables did not show gender-differences, end-systolic MA area and perimeter were lower in females in the 18-29-year-old group. End-systolic MA dimensions change over decades, resulting in a special pattern of MA functional properties with significant reduction over the age of 50 years.

Association Between Malignant Mitral Valve Prolapse and Sudden Cardiac Death

Importance Malignant arrhythmic mitral valve prolapse (MVP) phenotype poses a substantial risk of sudden cardiac death (SCD), and an estimated 26 000 individuals in the United States are at risk of SCD per year. Thus, identifying risk-stratification strategies for SCD is imperative. Observations Patients with MVP have a heterogenous clinical spectrum, ranging from a benign course to a devastating complication such as SCD. Some of the high-risk markers of MVP, which are identified electrocardiographically, include inverted or biphasic T waves, QT dispersion, QT prolongation, and premature ventricular contractions originating from the left ventricular outflow tract and papillary muscles. Morphofunctional characteristics of SCD are leaflet thickness of 5 mm or greater, mitral annulus disjunction, paradoxical systolic increase of the mitral annulus diameter, increased tissue Doppler velocity of the mitral annulus, and higher mechanical dispersion on echocardiography and fibrosis identified by late gadolinium enhancement on cardiac magnetic resonance imaging. Conclusions and Relevance Findings from this review suggest that SCD can occur earlier in the course of MVP from complex arrhythmias that are triggered by the repeated tugging and traction of the chordopapillary muscle unit and basal mid-myocardium, even before macrofibrosis can be identified in these regions by late gadolinium enhancement on cardiac magnetic resonance imaging. Some of the newer markers identified by speckle-tracking Doppler, such as mechanical dispersion, myocardial work index, and postsystolic shortening, need further validation in a larger population.

Tricuspid Regurgitation in Adults after Repair of Right Ventricular Outflow Obstructive Lesions

We determined the prevalence and factors associated with tricuspid regurgitation (TR) in adults with repair of right ventricular (RV) outflow obstruction. A total of 256 patients (128 males) were studied at 25.7 ± 7.2years after surgery, of whom 179 had repaired tetralogy of Fallot (TOF), 31 had pulmonary atresia with intact ventricular septum (PAIVS), and 46 had pulmonary stenosis (PS). The mitral and tricuspid annulus diameters, maximum right atrial (RA) area, RV end-systolic and end-diastolic areas, and tricuspid and pulmonary regurgitation were assessed using echocardiography. The prevalence of moderate-to-severe TR was 20.7%. Subgroup analysis revealed that prevalence was greater in patients with repaired TOF (20.7%) and PAIVS (35.5%) than PS patients (10.9%). As a group, severity of TR was found to be correlated with RA area (r = 0.35, p < 0.001), RV end-diastolic (r = 0.28, p < 0.001) and end-systolic (r = 0.22, p = 0.001) areas, and tricuspid valve annulus diameter (r = 0.15, p = 0.022). Moderate-to-severe TR was associated with development of cardiac arrhythmias with an odds ratio of 2.9 (95% CI 1.1 to 8.1, p = 0.031). Multivariate analysis revealed maximum RA area (β = 0.36, p = 0.016) as an independent determinant of severity of TR. Moderate-to-severe TR occurs in about one-fifth of adults with repaired TOF, PAVIS, and PS and is associated with RA dilation and risk of development of cardiac arrhythmias.

Change in Mitral Valve Geometry after Left Ventricular Assist Device Implantation in Patients with Functional Mitral Regurgitation

Previous studies have shown remarkable decrease in severity of functional mitral regurgitation (FMR) after left ventricular assist device (LVAD) implantation with mechanical unloading. This study aimed to identify the change of FMR and mitral geometry in LVAD patients. We retrospectively reviewed all patients who underwent LVAD implantation and had significant FMR without mitral valve procedure between January 2010 and December 2017. All patients underwent echocardiographic examination preoperatively and 1 month after LVAD implantation. We defined significant FMR as MR color jet area / left atrial area &gt; 0.2. We measured mitral annular diameter (MAD) and posterior (Dp) and apical (Da) displacement of the coaptation point of mitral leaflets on echocardiogram. Patients were divided into 2 groups, patients with and without AF. 106 patients were identified, 82 with no AF and 24 with AF. Mitral geometry significantly changed after LVAD insertion in both groups (table). Preoperative MAD was smaller in patients without AF (39.0 +/-4.5 vs. 41.2 +/-3.8mm; P=0.04) and reduced following LVAD in both postoperative (30.3+/-5.4 vs. 36.5 +/-4.1mm; P<0.0001), however, the changes of MAD before and after surgery were larger in patients with no AF (8.8 +/-5.0 vs. 4.7 +/-3.2 mm; P=0.0003). There were no significant differences in Da between groups. Patients with AF had a higher prevalence of significant FMR at 1 month after LVAD implantation than patients with no AF (4% vs. 17%; P =0.03). LVAD implantation significantly changed mitral geometry, however, the changes were less in patients with AF resulting in greater residual FMR.

Left ventricular apical rotation is associated with mitral annular function in healthy subjects. Results from the three-dimensional speckle-tracking echocardiographic MAGYAR-Healthy Study.

Left ventricular (LV) twist is considered an essential part of LV function due to oppositely directed LV basal and apical rotations. Several factors could play a role in determining LV rotational mechanics in normal circumstances. This study aimed to investigate the relationship between LV rotational mechanics and mitral annular (MA) size and function in healthy subjects. The study comprised 118 healthy adult volunteers (mean age: 31.5 ± 11.8 years, 50 males). All subjects had undergone complete two-dimensional (2D) Doppler echocardiography and three-dimensional speckle-tracking echocardiography (3DSTE) at the same time by the same echocardiography equipment. The normal mean LV apical and basal rotations proved to be 9.57 ± 3.33 and -3.75 ± 1.98°, respectively. LV apical rotation correlated with end-systolic MA diameter, area, perimeter, fractional area change, and fractional shortening, but did not correlate with any end-diastolic mitral annular morphologic parameters. The logistic regression model identified MA fractional area change as an independent predictor of ≤6° left ventricular apical rotation (P < 0.003). Correlations could be detected between apical LV rotation and end-systolic MA size and function, suggesting relationships between MA dimensions and function and LV rotational mechanics.

P1796 Three dimensional echocardiograhy navigation of mitral valve in patients with left ventricular dysfunction and functional mitral regurgiation

Abstract OnBehalf cairo university Background Mitral valve MV apparatus is a dynamic three-dimensional system that allows a unidirectional heart pump function. Functional mitral regurgitation (FMR) is a common complication that adversely affects the prognosis in patients with congestive heart failure. Accurate assessment of the interaction of the LV and MV apparatus is crucial for surgical correction of FMR. Purpose Evaluation of MV deformity indices in patients with Left ventricle (LV) dysfunction and varying severity FMR using 3D transoesophageal echocardiography and MV navigation (MVN) software Methods 96 patients were selected with echocardiographic evidence of dilated LV dimensions, EF ≤ 45%,and at least mild MR . A standard comprehensive transthoracic echocardiographic assessment of : 1. LV diameters and volumes with calculation of LVEF , LV shape, sphericity index, 2. Mitral leaflets morphology including anterior mitral leaflet length ,Mitral annular (MA) diameter , mid-systolic mitral annular area (MAA) , The coaptation height (CH) or distance , MV tenting area, leaflet-tethering distance for anterolateral papillary muscle (Tethering-AL) and posteromedial papillary muscle (Tethering-PM), 3.Quantification of MR : MR jet area , vena contracta (VC) width, effective regurgitant orifice area (EROA), , regurgitant volume, 4. 2D speckle-tracking imaging for LV strain analysis,5.MV morphology and dynamics were analysed using MVN for assessment of : Annular geometry including diameters, circumference ,height , annular ellipticity . Results MV deformation (AML and PML tethering distance) was negatively correlated with GLS (r= -0.408, p = 0.009),and (r= -0.428, p = 0.006) as well as 2D and 3D MAA were negatively correlated with the GLS (r= -0.469, p = 0.002) and (r= -0.477, p = 0.002). MR severity parameters as MR volume and EROA were associated with increased MAA (r = 0.38, p = 0.015), (r = 0.469, p = 0.002) respectively. Severity of MR was strongly correlated with MVA indices including AP diameter, 3D MA circumference, MAA, MV tenting height and volume and annular ellipsicity. Conclusion Mitral annular enlargement appears to be more closely linked to occurrence of FMR in patients with LV dysfunction. 3D imaging modalities will help assessment of complicated, dynamic, three-dimensional and non-planar mitral annulus

1642 Mitral annulus disjunction, a rare form of focal arrhythmogenic cardiomyopathy

Abstract Funding Acknowledgements Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary The rate of sudden cardiac death in mitral valve prolapse (MVP) patients is roughly twice that observed in the general population. Arrhythmogenic bileaflet MVP syndrome has been recently described and mitral annulus disjunction (MAD) has been found associated with papillary muscle fibrosis and ventricular arrhythmias even without severe mitral regurgitation. An underlying primary structural myocardial disease might be expected and the non-invasive imaging techniques are playing an increasingly important role in the detection of myocardial fibrosis as a focal arrhythmogenic substrate. Standard 2D-, 3D- and speckle tracking echocardiography and cardiac MRI can help to differentiate between the benign and malignant forms of MVP. A 52-year-old man with a history of hypertension was referred for evaluation of frequent palpitations and presyncope. Ambulatory Holter monitoring showed paroxysmal atrial fibrillation and non-sustained ventricular tachycardias. Dilated left ventricle (LVEDD: 65mm, LVESD: 45 mm) and left atrium (LAVi: 52mL/m2), moderately reduced left ventricular (LV) systolic function (LVEF: 42%), and reduced LV global longitudinal strain (GLS: -13.5%) with severely decreased segmental longitudinal strain in the basal inferolateral segment were measured by transthoracic echocardiography. The diastolic function was preserved, however Pickelhaube sign was noticed in the lateral mitral annulus TDI curves. MAD (17 mm) and curling motion of the inferolateral basal segment of the left ventricle was observed. Transesophageal echocardiography showed bileaflet mitral valve prolapse with the involvement of all the six scallops (mitral valve prolapse volume: 10.2 mL). Severe mitral regurgitation (3D vena contracta area: 1cm2) and extremely dilated and dyskinetic mitral annulus (diameters: 55x72x12 mm, area: 34 cm2) was measured by 3D echocardiography. MRI showed transmural late gadolinium enhancement in the underlying myocardium of both papillary muscles and midmyocardial enhancement in the basal inferior, inferolateral and anteroseptal LV segments. During electrophysiology study ventricular fibrillation was easily induced and ICD was placed for primary prevention of sudden cardiac death. The patient was referred to the heart surgeon for mitral valve replacement. This case highlights the importance of early recognition of MAD and arrhythmogenic MVP syndrome using novel non-invasive imaging techniques. The presence of MAD, the curling motion of the inferolateral basal LV segment, the Pickelhaube sign, the decreased LVEF and GLS, the characteristic segmental longitudinal strain pattern and the presence of late enhancement in the papillary muscles and the surrounding myocardium could be warning signs of the malignant form of MVP. Abstract 1642 Figure. CMR images of arrhythmogenic MAD

P287 Assessment of mitral regurgitation and mitral geometry in patients after transcatheter aortic valve implantation

Abstract Introduction Mitral regurgitation is often found in conjunction with aortic stenosis and the prevalence of both valvular lesions increases with age. Purpose The aim of this study was to evaluate mitral regurgitation, left ventricle and left atrium in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI). Methods A total of 31 patients (29% males) with severe aortic stenosis and moderate or severe mitral regurgitation, who underwent TAVI were included in this study. Clinical and echocardiographic characteristics were performed at baseline and in 6, 12 months observation. Results After TAVI, decrease of vena contracta width of mitral regurgitation (p = 0.00002, p = 0.00004), aorto-mural mitral annulus diameter (p = 0.00008, p = 0.02), increase mitral annular plane systolic excursion (p = 0.0004, p = 0.0003), left ventricular stroke volume (p = 0.0003, p = 0.0004), ejection fraction (p = 0.0004, p = 0.01) and decrease major dimension of left ventricle in three chamber view (p = 0.05, p = 0.002) was observed in patient in both time points, respectively. Additionally, we observed decrease of distance between head of papillary muscles (p = 0.003) at 6 months and decrease of left atrium indexed volume (p = 0.01) and grade of tricuspid regurgitation (p = 0.03) at 12 months follow up. Conclusions Patients with moderate or severe mitral regurgitation after TAVI procedure achieved significant reductions of mitral regurgitation and improvement of some parameters assessing mitral annulus, left ventricle and left atrium geometry.

P1754 Regional left ventricular longitudinal myocardial dysfunction in mitral valve prolapse could be primary

Abstract Background Regional left ventricular dysfunction in patients with mitral valve prolapse (MVP) and normal ejection fraction has been described by different Authors, and recent data point to a dysfunction (prevalently longitudinal strain) of the myocardium of the LV base secondary to dilatation of the mitral annulus. Purpose To investigate degree and extent of regional LV dysfunction and its mechanisms in patients with MVP, severe regurgitation and normal global systolic function, compared to patients with equivalent degree of regurgitation but functional etiology (FMR). Methods Speckle-tracking echocardiography was performed in 30 controls (N), and in severe primary (MVP, n= 50) or functional (FMR, n= 20) mitral regurgitation, to measure global, regional and segmental longitudinal peak systolic strain (LPSS, %), and time delay of peak maximum strain (TTPd, ms, calculated as time to peak maximum strain - time of aortic valve closure). Maximum and minimum mitral annulus diameters and area were measured with 3D echo. We also evaluated as recommended: LV end-diastolic volume index (EDVi, ml/m2), ejection fraction (EF, %), and left atrial end-systolic volume index (LAESVi, ml/m2) with 2D echo; LV stroke volume index, and non-invasive pulmonary systolic (PSP, mmHg) and diastolic pressures (PDP), mmHg) with Doppler echo. Results Age, heart rate, BSA and systolic blood pressure were similar between groups. Atrial fibrillation was present in 34% of MVP and 71% of FMR patients. LV EF was normal in MVP and reduced in FMR (43 ± 14 % vs N, p&amp;lt;.001). LV EDVi (MVP: 77 ± 20 ml/m2; FMR: 107 ± 35, both p&amp;lt;.001 vs N) and LAESVi (MVP: 91 ± 26 ml/m2; FMR: 80 ± 30, both p&amp;lt;.001 vs N) were similarly increased (volume overload) in MVP and FMR, as were PSP (MVP: 42 ± 23 ml/m2; FMR: 52 ± 25, both p&amp;lt;.001 vs N) and PDP (MVP: 16 ± 6 ml/m2; MVP: 15 ± 5, both p&amp;lt;.001 vs N). In FMR, LPSS was reduced globally (-12.8 ± 3.3, p&amp;lt;.001 vs N and MVP) and similarly at LV base, papillary and apical levels. In contrast, in MVP global (-19.4 ± 3.7%) and apical (-23.4 ± 4.5%) LPSS were normal, whereas LV base (-12.3 ± 5.8%, p=.003 vs N) and papillary (-17.1 ± 4%, p=.024 vs N) LPSS were reduced; further, LPSS reduction was localized to the anterior (-16 ± 4, p=.028 vs N), lateral (-17 ± 5, p=.006 vs N) and posterior (-16 ± 6, p=.007 vs N) segments, and was associated with an increased TTPd in the same segments in MVP but not in FMR patients. At multivariate analysis, degree and localisation of regional myocardial dysfunction in patients with MVP was not related to the prolapsing scallop, dimension of the mitral annulus, degree of volume overload or pulmonary pressures, or stroke volume index. Conclusions In patients with MVP, severe regurgitation and normal EF, there is a specific dysfunction pattern of regional LV longitudinal function which appears to be primary and not dependent on the degree of preload increase, mitral annulus dilatation, or localization of the prolapsing scallop.