Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2015 Feb 10;65(5):452-61.
doi: 10.1016/j.jacc.2014.11.037.

Mitral valve area during exercise after restrictive mitral valve annuloplasty: importance of diastolic anterior leaflet tethering

Philippe B Bertrand  1 , Frederik H Verbrugge  1 , David Verhaert  2 , Christophe J P Smeets  3 , Lars Grieten  1 , Wilfried Mullens  1 , Herbert Gutermann  4 , Robert A Dion  4 , Robert A Levine  5 , Pieter M Vandervoort  6
Affiliations
Free PMC article

Mitral valve area during exercise after restrictive mitral valve annuloplasty: importance of diastolic anterior leaflet tethering

Philippe B Bertrand et al. J Am Coll Cardiol. .
Free PMC article

Abstract

Background: Restrictive mitral valve annuloplasty (RMA) for secondary mitral regurgitation might cause functional mitral stenosis, yet its clinical impact and underlying pathophysiological mechanisms remain debated.

Objectives: The purpose of our study was to assess the hemodynamic and clinical impact of effective orifice area (EOA) after RMA and its relationship with diastolic anterior leaflet (AL) tethering at rest and during exercise.

Methods: Consecutive RMA patients (n = 39) underwent a symptom-limited supine bicycle exercise test with Doppler echocardiography and respiratory gas analysis. EOA, transmitral flow rate, mean transmitral gradient, and systolic pulmonary arterial pressure were assessed at different stages of exercise. AL opening angles were measured at rest and peak exercise. Mortality and heart failure readmission data were collected for at least 20 months after surgery.

Results: EOA and AL opening angle were 1.5 ± 0.4 cm(2) and 68 ± 10°, respectively, at rest (r = 0.4; p = 0.014). EOA increased significantly to 2.0 ± 0.5 cm(2) at peak exercise (p < 0.001), showing an improved correlation with AL opening angle (r = 0.6; p < 0.001). Indexed EOA (EOAi) at peak exercise was an independent predictor of exercise capacity (maximal oxygen uptake, p = 0.004) and was independently associated with freedom from all-cause mortality or hospital admission for heart failure (p = 0.034). Patients with exercise EOAi <0.9 cm(2)/m(2) (n = 14) compared with ≥0.9 cm(2)/m(2) (n = 25) had a significantly worse outcome (p = 0.048). In multivariate analysis, AL opening angle at peak exercise (p = 0.037) was the strongest predictor of exercise EOAi.

Conclusions: In RMA patients, EOA increases during exercise despite fixed annular size. Diastolic AL tethering plays a key role in this dynamic process, with increasing AL opening during exercise being associated with higher exercise EOA. EOAi at peak exercise is a strong and independent predictor of exercise capacity and is associated with clinical outcome. Our findings stress the importance of maximizing AL opening by targeting the subvalvular apparatus in future repair algorithms for secondary mitral regurgitation.

Keywords: exercise echocardiography; heart failure; mitral valve; valvuloplasty.

PubMed Disclaimer

Figures

FIGURE 1
FIGURE 1
Transmitral Pressure-Flow Relationship During Exercise
FIGURE 2
FIGURE 2
EOA as a Function of Transmitral Flow Rate
FIGURE 3
FIGURE 3
Diastolic Leaflet Tethering After RMA on Echocardiography
See this image and copyright information in PMC

Comment in

Similar articles

See all similar articles

Cited by

See all "Cited by" articles

References

    1. Lamas GA, Mitchell GF, Flaker GC, et al. for the Survival and Ventricular Enlargement Investigators. Clinical significance of mitral regurgitation after acute myocardial infarction. Circulation. 1997;96:827–33. - PubMed
    1. Grigioni F, Enriquez-Sarano M, Zehr KJ, Bailey KR, Tajik AJ. Ischemic mitral regurgitation: long-term outcome and prognostic implications with quantitative Doppler assessment. Circulation. 2001;103:1759–64. - PubMed
    1. Bax JJ, Braun J, Somer ST, et al. Restrictive annuloplasty and coronary revascularization in ischemic mitral regurgitation results in reverse left ventricular remodeling. Circulation. 2004;110(Suppl):II103–8. - PubMed
    1. Braun J, van de Veire NR, Klautz RJ, et al. Restrictive mitral annuloplasty cures ischemic mitral regurgitation and heart failure. Ann Thorac Surg. 2008;85:430–6. - PubMed
    1. Vahanian A, Alfieri O, Andreotti F, et al. Guidelines on the management of valvular heart disease (version 2012): the Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery. Eur Heart J. 2012;33:2451–96. - PubMed

Publication types

LinkOut - more resources