Regional annular geometry in patients with mitral regurgitation: implications for annuloplasty ring selection

Ann Thorac Surg. 2014 Jan;97(1):64-70. doi: 10.1016/j.athoracsur.2013.07.048. Epub 2013 Sep 23.


Background: The saddle shape of the normal mitral annulus has been quantitatively described by several groups. There is strong evidence that this shape is important to valve function. A more complete understanding of regional annular geometry in diseased valves may provide a more educated approach to annuloplasty ring selection and design. We hypothesized that mitral annular shape is markedly distorted in patients with diseased valves.

Methods: Real-time 3-dimensional echocardiography was performed in 20 patients with normal mitral valves, 10 with ischemic mitral regurgitation, and 20 with myxomatous mitral regurgitation (MMR). Thirty-six annular points were defined to generate a 3-dimensional model of the annulus. Regional annular parameters were measured from these renderings. Left ventricular inner diameter was obtained from 2-dimensional echocardiographic images.

Results: Annular geometry was significantly different among the three groups. The annuli were larger in the MMR and in the ischemic mitral regurgitation groups. The annular enlargement was greater and more pervasive in the MMR group. Both diseases were associated with annular flattening, although though the regional distribution of that flattening was different between groups. Left ventricular inner diameter was increased in both groups. However, relative to the Left ventricular inner diameter, the annulus was disproportionately dilated in the MMR group.

Conclusions: Patients with MMR and ischemic mitral regurgitation have enlarged and flattened annuli. In the case of MMR, annular distortions may be the driving factor leading to valve incompetence. These data suggest that the goal of annuloplasty should be the restoration of normal annular saddle shape and that the use of flexible, partial, and flat rings may be ill advised.

Keywords: 3-dimensional; 35; 3D; AA; AC; AH; AHCWR; AML; AoV; CW; IMR; L; LA; LAA; LPA; LV; LVIDd; LVOT; MAA; MMR; MR; MTD; MVO; PA; PC; PM; PML; S; SD; SL; annular height; annular height: commissural width ratio; anterior commissure; anterior mitral annulus; anterior mitral leaflet; aortic valve; commissural width; ischemic mitral regurgitation; lateral annulus; left atrium; left ventricle; left ventricle inner diameter (diastolic); left ventricular outflow tract; length of anterior annulus; length of posterior annulus; maximum transverse diameter; mitral annular area; mitral regurgitation; mitral valve orifice; myxomatous mitral regurgitation; posterior commissure; posterior mitral annulus; posterior mitral leaflet; posteromedial annulus; septolateral dimension; septum; standard deviation.

Publication types

  • Comparative Study
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Case-Control Studies
  • Cohort Studies
  • Echocardiography, Three-Dimensional / methods*
  • Echocardiography, Transesophageal / methods
  • Female
  • Follow-Up Studies
  • Humans
  • Male
  • Middle Aged
  • Mitral Valve / diagnostic imaging
  • Mitral Valve / pathology*
  • Mitral Valve Annuloplasty / adverse effects
  • Mitral Valve Annuloplasty / methods*
  • Mitral Valve Insufficiency / diagnostic imaging*
  • Mitral Valve Insufficiency / pathology
  • Mitral Valve Insufficiency / surgery*
  • Mitral Valve Prolapse / diagnostic imaging
  • Mitral Valve Prolapse / physiopathology
  • Monitoring, Intraoperative / methods
  • Myocardial Ischemia / diagnostic imaging
  • Myocardial Ischemia / physiopathology
  • Reference Values
  • Risk Assessment
  • Treatment Outcome

Supplementary concepts

  • Mitral Valve Prolapse, Myxomatous 1