Ischemic Mitral Regurgitation: A Quantitative Three-Dimensional Echocardiographic Analysis

Background A comprehensive three-dimensional echocardiography based approach is applied to preoperative mitral valve (MV) analysis in patients with ischemic mitral regurgitation (IMR). This method is used to characterize the heterogeneous nature of the pathologic anatomy associated with IMR. Methods Intraoperative real-time three-dimensional transesophageal echocardiograms of 18 patients with IMR (10 with anterior, 8 with inferior infarcts) and 17 patients with normal MV were analyzed. A customized image analysis protocol was used to assess global and regional determinants of annular size and shape, leaflet tethering and curvature, relative papillary muscle anatomy, and anatomic regurgitant orifice area. Results Both mitral annular area and MV tenting volume were increased in the IMR group as compared with patients with normal MV (mitral annular area=1,065 ± 59 mm 2 versus 779 ± 44 mm 2 , p = 0.001; and MV tenting volume=3,413 ± 403 mm 3 versus 1,696 ± 200 mm 3 , p = 0.001, respectively). Within the IMR group, patients with anterior infarct had larger annuli (1,168 ± 99 mm 2 ) and greater tenting volumes (4,260 ± 779 mm 3 versus 2,735 ± 245 mm 3 , p = 0.06) than the inferior infarct subgroup. Papillary-annular distance was increased in the IMR group relative to normal; these distances were largest in patients with anterior infarcts. Whereas patients with normal MV had very consistent anatomic determinants, annular shape and leaflet tenting distribution in the IMR group were exceedingly variable. Mean anatomic regurgitant orifice area was 25.8 ± 3.0 mm 2 , and the number of discrete regurgitant orifices varied from 1 to 4. Conclusions Application of custom analysis techniques to three-dimensional echocardiography images allows a quantitative and systematic analysis of the MV, and demonstrates the extreme variability in pathologic anatomy that occurs in patients with severe IMR.