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• W1993208052 abstract "Ischemic mitral regurgitation (IMR) is a functional regurgitation characterized by structurally normal leaflets and subvalvular apparatus and is an important complication after myocardial infarction that is associated with excess mortality.1Grigioni F. Enriquez-Sarano M. Zehr K.J. Bailey K.R. Tajik A.J. Ischemic mitral regurgitation long-term outcome and prognostic implications with quantitative Doppler assessment.Circulation. 2001; 103: 1759-1764Crossref PubMed Scopus (1119) Google Scholar Reconstructive surgery, which restores a more normal alignment between the mitral annulus and displaced papillary muscles, might be beneficial in patients with IMR. However, little is known about the 3-dimensional (3-D) geometric changes of mitral leaflets and annulus after such reconstructive surgery for patients with IMR. We developed novel software, named Anatomical Image Creation System (AICS), which allows 3-D visualization and quantitative analysis of the mitral leaflets and annulus by using transthoracic real-time 3-D echocardiography (RT3DE).2Yamaura Y. Watanabe N. Ogasawara Y. Yamamoto K. Kawamoto T. Toyota E. et al.Geometric demonstration and three-dimensional quantitative analysis of the mitral valve with real-time three-dimensional echocardiography novel anatomical image creation system.J Echocardiogr. 2004; 2: 99-104Crossref Scopus (15) Google Scholar We already demonstrated the apparent tenting of the mitral leaflets with flattened annulus in patients with IMR using this system.3Watanabe N. Ogasawara Y. Yamaura Y. Kawamoto T. Toyota E. Akasaka T. et al.Quantitation of mitral valve tenting in ischemic mitral regurgitation by transthoracic real-time three-dimensional echocardiography.J Am Coll Cardiol. 2005; 45: 763-769Abstract Full Text Full Text PDF PubMed Scopus (157) Google Scholar In the present study we evaluated the 3-D geometric changes of the mitral leaflets and annulus in patients after reconstructive surgery for IMR using AICS. We studied 3 patients who underwent mitral ring annuloplasty and concomitant left ventricular (LV) restorative surgery for severe IMR and severe LV systolic dysfunction caused by coronary artery disease. All the RT3DE examination was performed 1 week before and 3 weeks after the operation. LV systolic function and degree of mitral regurgitation (MR) were quantified by using 2-dimensional echocardiography. Using the transthoracic volumetric image by the RT3DE system with AICS, we created 3-D images of the mitral leaflets and annulus in midsystole for the 3-D quantitative measurements. The mitral leaflets’ tenting volume was calculated as a volume enclosed between the 3-D annular plane and the mitral leaflets. Mitral annular size was measured by using those 3-D data sets as well (surface area, circumference, commissure-commissure diameter, and anterior-posterior diameter). Details of the 3-D image creation and measurements are described in our previous reports.2Yamaura Y. Watanabe N. Ogasawara Y. Yamamoto K. Kawamoto T. Toyota E. et al.Geometric demonstration and three-dimensional quantitative analysis of the mitral valve with real-time three-dimensional echocardiography novel anatomical image creation system.J Echocardiogr. 2004; 2: 99-104Crossref Scopus (15) Google Scholar, 3Watanabe N. Ogasawara Y. Yamaura Y. Kawamoto T. Toyota E. Akasaka T. et al.Quantitation of mitral valve tenting in ischemic mitral regurgitation by transthoracic real-time three-dimensional echocardiography.J Am Coll Cardiol. 2005; 45: 763-769Abstract Full Text Full Text PDF PubMed Scopus (157) Google Scholar All 3 patients provided written informed consent to the study protocol, which was approved by the Committee for the Protection of Human Subjects in Research at Kawasaki Medical School. All 3 patients had severe MR and severe LV systolic dysfunction before the operation. After the operation, MR disappeared and LV volume decreased in all 3 patients. The mitral leaflets’ tenting volume and the size of the mitral annulus apparently reduced after the operation in all patients (Table 1). Preoperative 3-D images demonstrated the apparent tenting of the mitral leaflets, which showed mountain-shaped bulging with tethering into the left ventricle (Figure 1, left). After the operation, the mitral annulus visibly shrank, and the mitral leaflets’ tenting volume was apparently smaller compared with that seen in preoperative images (Figure 1, right).TABLE 1Clinical characteristics and 3-dimensional measurements of mitral annulus and leafletsPatient 1Patient 2Patient 3Age (y)747373SexMaleMaleMaleInfarct territoryLADLAD, RCALADOperationDor, MAP, PM repositioningCABG, MAP, chordal cuttingSAVE, MAP, PM repositioningPreopPostopPreopPostopPreopPostopLV EDV (mL)25816013410710880 ESV (mL)21713175496858 EF (%)151844543728MR Regurgitant volume (mL)330460280 ROA (cm2)0.200.2400.20Mitral annulus Area (mm2)116550911513241488422 Circumference (mm)121080012036381367728 c-c Diameter (mm)40.625.734.920.740.122.0 a-p Diameter (mm)37.422.437.416.236.719.8Mitral leaflets Tenting volume (mm3)42192176387211643541320LAD, Left anterior descending coronary artery; RCA, right coronary artery; MAP, mitral annuloplasty; CABG, coronary artery bypass grafting; SAVE, septal anterior ventricular exclusion; PM, papillary muscle; Preop, preoperative; Postop, postoperative; LV, left ventricle; EDV, end-diastolic volume; ESV, end-systolic volume; EF, ejection fraction; MR, mitral regurgitation; ROA, regurgitant orifice area; c-c, commissure-commissure; a-p, anterior-posterior. Open table in a new tab LAD, Left anterior descending coronary artery; RCA, right coronary artery; MAP, mitral annuloplasty; CABG, coronary artery bypass grafting; SAVE, septal anterior ventricular exclusion; PM, papillary muscle; Preop, preoperative; Postop, postoperative; LV, left ventricle; EDV, end-diastolic volume; ESV, end-systolic volume; EF, ejection fraction; MR, mitral regurgitation; ROA, regurgitant orifice area; c-c, commissure-commissure; a-p, anterior-posterior. In this study we demonstrated 3-D geometric changes of the mitral leaflets and annulus in patients undergoing reconstructive surgery for IMR using our novel AICS system with RT3DE. Although annuloplasty is the current common surgical strategy for IMR,4Gillinov A.M. Cosgrove 3rd, D.M. Shiota T. Qin J. Tsujino H. Stewart W.J. et al.Cosgrove-Edwards Annuloplasty System midterm results.Ann Thorac Surg. 2000; 69: 717-721Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar MR often persists after annuloplasty. Recently, new surgical strategies, such as chordal cutting or papillary muscle repositioning with LV reshaping, have been expected to reduce persistent IMR after annuloplasty.5Messas E. Pouzet B. Touchot B. Guerrero J.L. Vlahakes G.J. Desnos M. et al.Efficacy of chordal cutting to relieve chronic persistent ischemic mitral regurgitation.Circulation. 2003; 108: II111-II115PubMed Google Scholar However, in the clinical setting it has been difficult to assess the geometric changes of the mitral leaflets and annulus after reconstructive surgery by using 2-dimensional echocardiography. Precise and comprehensive understanding of the 3-D geometric changes of the mitral leaflets and annulus should be needed for postoperative evaluation of valve repair. In this study, using novel AICS with RT3DE, we could visually and quantitatively compare the 3-D geometry of the mitral leaflets and annulus in patients with IMR before and after the operation. Hence this technique would be helpful for the surgeon to evaluate the effect of reconstructive surgery on the 3-D geometry of the mitral leaflets and annulus in patients with IMR and to make a proper decision for surgical strategy for each individual in the clinical setting. Yoshida and Tanemoto (left to right) Watanabe, Yamaura, Wada, Ogasawara (left to right)" @default.
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• W1993208052 title "Geometric change of mitral valve leaflets and annulus after reconstructive surgery for ischemic mitral regurgitation: Real-time 3-dimensional echocardiographic study" @default.
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