Asymmetric versus symmetric tethering patterns in ischemic mitral regurgitation: Geometric differences from three-dimensional transesophageal echocardiography

Xin Zeng, Maria Carmo P. Nunes, John Dent, Linda Gillam, Joseph P. Mathew, James S. Gammie, Deborah D. Ascheim, Ellen Moquete, Judy Hung

Research output: Contribution to journalArticle

23 Citations (Scopus)

Abstract

Background Ischemic mitral regurgitation (IMR) results from mitral leaflet tethering from left ventricular remodeling. Heterogeneity in local or global left ventricular remodeling can result in differential tethering patterns and affect mitral valve function and the degree of mitral regurgitation. The aims of this study were to compare mitral valve geometry in asymmetric and symmetric tethering patterns using three-dimensional transesophageal echocardiography and to examine the impact of tethering pattern on IMR severity. Methods Sixty-two patients with moderate or greater IMR underwent three-dimensional transesophageal echocardiography for the assessment of mitral valve geometry. Symmetric and asymmetric tethering patterns were determined by mitral regurgitation jet direction and coaptation of the mitral leaflets. The ratio of posterior to anterior leaflet tethering angle was a measure of tethering pattern (the higher the ratio, the more asymmetric the pattern). Overall tethering degree was assessed by tenting volume (TV). Results Compared with the symmetric group, the asymmetric group had less annular dilatation, greater annular heights (10.3 ± 1.9 vs 8.5 ± 1.9 mm, P <.01), greater ratios of posterior to anterior leaflet tethering angle (3.19 ± 0.88 vs 1.95 ± 0.46, P <.01), and smaller TVs with more posterior displacement of the coaptation line. Vena contracta normalized to TV was greater in the asymmetric group (0.38 ± 0.24 vs 0.19 ± 0.13 cm/mL, P <.01). Multivariate analysis showed that both ratio of posterior to anterior leaflet tethering angle (β = 0.46, P <.001) and TV (β = 0.41, P =.001) were predictors of IMR severity. Conclusions Differences in mitral valve geometry are observed between asymmetric and symmetric tethering patterns in IMR. IMR degree is affected by both the pattern of tethering and the total degree of tethering. For the same degree of tethering, an asymmetric pattern is associated with increased MR severity. The pattern of mitral leaflet tethering may be considered in therapeutic decision making.

Original languageEnglish (US)
Pages (from-to)367-375
Number of pages9
JournalJournal of the American Society of Echocardiography
Volume27
Issue number4
DOIs
StatePublished - Jan 1 2014
Externally publishedYes

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Three-Dimensional Echocardiography
Transesophageal Echocardiography
Mitral Valve Insufficiency
Mitral Valve
Ventricular Remodeling
Dilatation
Decision Making
Multivariate Analysis

All Science Journal Classification (ASJC) codes

  • Radiology Nuclear Medicine and imaging
  • Cardiology and Cardiovascular Medicine

Cite this

Zeng, Xin ; Nunes, Maria Carmo P. ; Dent, John ; Gillam, Linda ; Mathew, Joseph P. ; Gammie, James S. ; Ascheim, Deborah D. ; Moquete, Ellen ; Hung, Judy. / Asymmetric versus symmetric tethering patterns in ischemic mitral regurgitation : Geometric differences from three-dimensional transesophageal echocardiography. In: Journal of the American Society of Echocardiography. 2014 ; Vol. 27, No. 4. pp. 367-375.
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abstract = "Background Ischemic mitral regurgitation (IMR) results from mitral leaflet tethering from left ventricular remodeling. Heterogeneity in local or global left ventricular remodeling can result in differential tethering patterns and affect mitral valve function and the degree of mitral regurgitation. The aims of this study were to compare mitral valve geometry in asymmetric and symmetric tethering patterns using three-dimensional transesophageal echocardiography and to examine the impact of tethering pattern on IMR severity. Methods Sixty-two patients with moderate or greater IMR underwent three-dimensional transesophageal echocardiography for the assessment of mitral valve geometry. Symmetric and asymmetric tethering patterns were determined by mitral regurgitation jet direction and coaptation of the mitral leaflets. The ratio of posterior to anterior leaflet tethering angle was a measure of tethering pattern (the higher the ratio, the more asymmetric the pattern). Overall tethering degree was assessed by tenting volume (TV). Results Compared with the symmetric group, the asymmetric group had less annular dilatation, greater annular heights (10.3 ± 1.9 vs 8.5 ± 1.9 mm, P <.01), greater ratios of posterior to anterior leaflet tethering angle (3.19 ± 0.88 vs 1.95 ± 0.46, P <.01), and smaller TVs with more posterior displacement of the coaptation line. Vena contracta normalized to TV was greater in the asymmetric group (0.38 ± 0.24 vs 0.19 ± 0.13 cm/mL, P <.01). Multivariate analysis showed that both ratio of posterior to anterior leaflet tethering angle (β = 0.46, P <.001) and TV (β = 0.41, P =.001) were predictors of IMR severity. Conclusions Differences in mitral valve geometry are observed between asymmetric and symmetric tethering patterns in IMR. IMR degree is affected by both the pattern of tethering and the total degree of tethering. For the same degree of tethering, an asymmetric pattern is associated with increased MR severity. The pattern of mitral leaflet tethering may be considered in therapeutic decision making.",
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Asymmetric versus symmetric tethering patterns in ischemic mitral regurgitation : Geometric differences from three-dimensional transesophageal echocardiography. / Zeng, Xin; Nunes, Maria Carmo P.; Dent, John; Gillam, Linda; Mathew, Joseph P.; Gammie, James S.; Ascheim, Deborah D.; Moquete, Ellen; Hung, Judy.

In: Journal of the American Society of Echocardiography, Vol. 27, No. 4, 01.01.2014, p. 367-375.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Asymmetric versus symmetric tethering patterns in ischemic mitral regurgitation

T2 - Geometric differences from three-dimensional transesophageal echocardiography

AU - Zeng, Xin

AU - Nunes, Maria Carmo P.

AU - Dent, John

AU - Gillam, Linda

AU - Mathew, Joseph P.

AU - Gammie, James S.

AU - Ascheim, Deborah D.

AU - Moquete, Ellen

AU - Hung, Judy

PY - 2014/1/1

Y1 - 2014/1/1

N2 - Background Ischemic mitral regurgitation (IMR) results from mitral leaflet tethering from left ventricular remodeling. Heterogeneity in local or global left ventricular remodeling can result in differential tethering patterns and affect mitral valve function and the degree of mitral regurgitation. The aims of this study were to compare mitral valve geometry in asymmetric and symmetric tethering patterns using three-dimensional transesophageal echocardiography and to examine the impact of tethering pattern on IMR severity. Methods Sixty-two patients with moderate or greater IMR underwent three-dimensional transesophageal echocardiography for the assessment of mitral valve geometry. Symmetric and asymmetric tethering patterns were determined by mitral regurgitation jet direction and coaptation of the mitral leaflets. The ratio of posterior to anterior leaflet tethering angle was a measure of tethering pattern (the higher the ratio, the more asymmetric the pattern). Overall tethering degree was assessed by tenting volume (TV). Results Compared with the symmetric group, the asymmetric group had less annular dilatation, greater annular heights (10.3 ± 1.9 vs 8.5 ± 1.9 mm, P <.01), greater ratios of posterior to anterior leaflet tethering angle (3.19 ± 0.88 vs 1.95 ± 0.46, P <.01), and smaller TVs with more posterior displacement of the coaptation line. Vena contracta normalized to TV was greater in the asymmetric group (0.38 ± 0.24 vs 0.19 ± 0.13 cm/mL, P <.01). Multivariate analysis showed that both ratio of posterior to anterior leaflet tethering angle (β = 0.46, P <.001) and TV (β = 0.41, P =.001) were predictors of IMR severity. Conclusions Differences in mitral valve geometry are observed between asymmetric and symmetric tethering patterns in IMR. IMR degree is affected by both the pattern of tethering and the total degree of tethering. For the same degree of tethering, an asymmetric pattern is associated with increased MR severity. The pattern of mitral leaflet tethering may be considered in therapeutic decision making.

AB - Background Ischemic mitral regurgitation (IMR) results from mitral leaflet tethering from left ventricular remodeling. Heterogeneity in local or global left ventricular remodeling can result in differential tethering patterns and affect mitral valve function and the degree of mitral regurgitation. The aims of this study were to compare mitral valve geometry in asymmetric and symmetric tethering patterns using three-dimensional transesophageal echocardiography and to examine the impact of tethering pattern on IMR severity. Methods Sixty-two patients with moderate or greater IMR underwent three-dimensional transesophageal echocardiography for the assessment of mitral valve geometry. Symmetric and asymmetric tethering patterns were determined by mitral regurgitation jet direction and coaptation of the mitral leaflets. The ratio of posterior to anterior leaflet tethering angle was a measure of tethering pattern (the higher the ratio, the more asymmetric the pattern). Overall tethering degree was assessed by tenting volume (TV). Results Compared with the symmetric group, the asymmetric group had less annular dilatation, greater annular heights (10.3 ± 1.9 vs 8.5 ± 1.9 mm, P <.01), greater ratios of posterior to anterior leaflet tethering angle (3.19 ± 0.88 vs 1.95 ± 0.46, P <.01), and smaller TVs with more posterior displacement of the coaptation line. Vena contracta normalized to TV was greater in the asymmetric group (0.38 ± 0.24 vs 0.19 ± 0.13 cm/mL, P <.01). Multivariate analysis showed that both ratio of posterior to anterior leaflet tethering angle (β = 0.46, P <.001) and TV (β = 0.41, P =.001) were predictors of IMR severity. Conclusions Differences in mitral valve geometry are observed between asymmetric and symmetric tethering patterns in IMR. IMR degree is affected by both the pattern of tethering and the total degree of tethering. For the same degree of tethering, an asymmetric pattern is associated with increased MR severity. The pattern of mitral leaflet tethering may be considered in therapeutic decision making.

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