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Does preoperative tethering symmetry affect left ventricular reverse remodeling after restrictive annuloplasty?
Sandro Gelsomino1, Roberto Lorusso, Giuseppe De Cicco
1Experimental Surgery Unit, Cardiac Surgery, Department of Heart and Vessels, Careggi Hospital, Florence, Italy. sandro.gelsomino@libero.it
International Journal of Cardiology
|January 23, 2009
Summary
A symmetric mitral valve tethering pattern before surgery is linked to poor outcomes after restrictive annuloplasty. Echocardiography can help predict which patients may not experience reverse remodeling.
Area of Science:
- Cardiology
- Cardiac Surgery
- Echocardiography
Background:
- Chronic ischemic mitral regurgitation often requires surgical annuloplasty.
- Mitral leaflet tethering, particularly of the anterior mitral leaflet (AML), is a key factor in mitral regurgitation.
- Predicting reverse left ventricular remodeling (LVRR) after annuloplasty is crucial for patient outcomes.
Purpose of the Study:
- To investigate the association between preoperative mitral leaflet tethering patterns and LVRR after restrictive annuloplasty.
- To determine if a symmetric tethering pattern, especially with AML predominance, predicts lack of LVRR.
Main Methods:
- A cohort of 300 patients undergoing annuloplasty for ischemic mitral regurgitation was analyzed.
- Preoperative tethering angles of the AML and posterior mitral leaflet (PML) were quantified.
- Patients were categorized into symmetric and asymmetric tethering groups based on the AML/PML angle ratio.
- Echocardiography was performed preoperatively, at discharge, and during follow-up (6 and 48 months).
- LVRR was defined as a >15% reduction in left ventricular end-systolic volume index.
Main Results:
- The asymmetric tethering group showed significantly higher LVRR rates at discharge, early, and late follow-up compared to the symmetric group (p<0.001 for all).
- Multivariable analysis identified symmetric leaflet tethering, a specific anterior tethering angle (alpha'<39.5 degrees), and certain coaptation parameters as independent predictors of LVRR.
- Patients with a symmetric pattern had over four times higher odds of lacking LVRR compared to those with an asymmetric pattern.
Conclusions:
- A preoperative symmetric tethering pattern, particularly with AML prevalence, is strongly associated with a lack of reverse remodeling post-annuloplasty.
- Echocardiographic assessment of mitral valve tethering mechanisms should be integrated into clinical risk stratification and prediction models for patients undergoing mitral annuloplasty.
