Geometric differences of the mitral valve apparatus in atrial and ventricular functional mitral regurgitation |
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| Institution: | 1. Department of Medicine I, Klinikum der LMU München, Ludwig-Maximilians-Universität München, Marchioninistr. 15, Munich, Germany;2. German Centre for Cardiovascular Research (DZHK), Partner Site Munich, Germany;3. Department of Radiology, Klinikum der LMU München, Ludwig-Maximilians-Universität München, Marchioninistr. 15, Munich, Germany;4. Department of Heart Surgery, Klinikum der LMU München, Ludwig-Maximilians-Universität München, Marchioninistr. 15, Munich, Germany;1. Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK;2. Oxford University Hospitals NHS Foundation Trust, OX3 9DU, UK;3. Aviation Medicine Consultation Service, AMCS, RAF Henlow, SG16 6DN, UK;4. Faculty of School of Biomedical Engineering & Imaging Sciences, Kings College, London, WC2R 2LS, UK;1. Cardiovascular Center Aalst, OLV-Clinic, Aalst, Belgium;2. Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy;3. Department of Translational Medical Sciences, University of Campania ‘Luigi Vanvitelli’, Naples, Italy;4. Centro Cardiologico Monzino, IRCCS, Milan, Italy;5. Department of Biomedical and Clinical Sciences “Luigi Sacco”, University of Milan, Milan, Italy;6. Cardiology Clinic, “Alexandrovska” University Hospital, Medical University of Sofia, Sofia, Bulgaria;7. Department of Internal Medicine, Discipline of Cardiology, University of Campinas, Campinas, Brazil;8. Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland;1. Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA;2. School of Business Studies, Stralsund University of Applied Sciences, Stralsund, Germany;3. Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR, USA;4. Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA;5. Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA |
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| Abstract: | BackgroundFunctional mitral regurgitation (FMR) occurs in patients with annular dilation (atrial, aFMR) or patients with left ventricular (LV) disease (ventricular, vFMR). Meticulous understanding of the mechanisms underpinning regurgitation is crucial to optimize therapeutic strategies.MethodsPatients with moderate-severe FMR were identified from a registry of patients referred for transcatheter mitral valve intervention. In addition, controls without cardiovascular disease were identified. Differences in the geometry of the LV and mitral valve apparatus (including leaflet and tenting geometry, papillary muscle displacement and movement, annular dimensions, and dynamism) between atrial and ventricular FMR, and control subjects, were assessed using multiphasic cardiac CT.ResultsOf 183 FMR patients, 18 patients (10%) were found to have aFMR. The remaining patients had either ischemic or non-ischemic ventricular FMR. In aFMR, both increasing LV end-systolic volume (rho 0.701, p ?< ?0.01) and left atrial volume (rho 0.909, p ?< ?0.01) were associated with larger annular area. By contrast, in vFMR larger annular area was most strongly associated with larger left atrial volume (rho 0.63, p ?< ?0.01). In controls, increased annular area was associated with larger LVEDV (rho 0.78, p ?< ?0.01) and LVESV (rho 0.824, p ?< ?0.01), but not left atrial size (rho 0.16, p ?= ?0.45).Ventricular FMR comprised apicolaterally displaced, akinetic posteromedial papillary muscles, resulting in pronounced leaflet tethering, leaflet elongation compared to controls, and only modest relative LA dilatation. Compared to vFMR, aFMR was characterised by marked relative annular dilation, smaller but discernible mitral valve tenting, shorter leaflet lengths when related to annular size, but normal papillary geometry.ConclusionFMR is characterised by multiple changes within the mitral valve complex. Atrial and ventricular FMR differ significantly in terms of the drivers of annular size, and geometry and function of the subvalvular apparatus. This highlights the need to consider these as separate disease entities. |
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| Keywords: | Functional mitral regurgitation Atrial mitral regurgitation Mitral annulus Left ventricular geometry Transcatheter mitral valve implantation Cardiac computed tomography |
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