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Defining the left ventricular base in mitral valve prolapse: impact on systolic function and regurgitation
1Carnegie Hill Radiology, New York, NY, USA.
Insights
Defining the left ventricular (LV) base at the mitral valve annulus in bileaflet mitral valve prolapse (BMVP) improves accuracy for assessing mitral regurgitant severity and LV systolic function. This method provides more clinically relevant measurements than defining the LV base at the leaflets.
Area of Science:
- Cardiology
- Medical Imaging
- Biomedical Engineering
Background:
- Bileaflet mitral valve prolapse (BMVP) presents unique challenges in volumetric assessment.
- Systolic leaflet displacement in BMVP can exclude blood from LV end-systolic volume if the annulus is used as the LV base.
- Accurate assessment of mitral regurgitant severity and LV systolic function is crucial for patient management.
Purpose of the Study:
- To quantitatively evaluate the implications of defining the left ventricular (LV) base at different levels on mitral regurgitant severity and LV systolic function in patients with BMVP.
- To compare the "Functional" method (mitral valve annulus) versus the "Anatomic" method (mitral valve leaflets) for LV base definition.
Main Methods:
- Retrospective analysis of 30 BMVP patients using SSFP images.
- Defined LV base at end-systole using both the "Functional" (annulus) and "Anatomic" (leaflets) methods.
- Calculated regurgitant volume and LV ejection fraction (LVEF).
- Assessed LV myocardial strain from short-axis images.
Main Results:
- The "Functional" method yielded significantly higher regurgitant volumes (mean difference: 22 ml) and LVEF (mean difference: 9%).
- Better correlations were observed with the "Functional" method for LV end-diastolic volume and regurgitant volume (r=0.79) and for global myocardial radial strain and LVEF (r=0.86).
- Defining the LV base at the leaflets resulted in substantially lower, potentially misleading, volumetric and functional measurements.
Conclusions:
- For BMVP, defining the LV base at the mitral valve annulus is recommended for accurate assessment of mitral regurgitation and LV systolic function.
- The "Functional" method provides a more accurate reflection of the functional significance of mitral valve disease and global LV systolic performance.
- Incorrect LV base definition can lead to underestimation of regurgitant volumes and LVEF, with potential clinical consequences.
Abstract:
In bileaflet mitral valve prolapse (BMVP) systolic leaflet displacement creates a pocket of blood on the left ventricular (LV) side of the leaflets, but on the atrial side of the annulus. This blood is excluded from the LV end-systolic volume if the mitral valve annulus is used to determine the most basal extent of the LV. The purpose of this study is to describe the quantitative implications of defining the LV base on mitral regurgitant severity and LV systolic function in BMVP. In 30 consecutive patients (53% male, 58 ± 14 years) with BMVP, LV endocardial and epicardial borders were determined from SSFP images. The LV base at end-systole was defined by the "Functional" method (at the mitral valve annulus) or the "Anatomic" method (at the mitral valve leaflets). Regurgitant volume was the difference between the LV stroke volume and mean forward flow. LV myocardial strain measurements were determined from the short axis endocardial and epicardial borders. The "Functional" method resulted in higher regurgitant volumes (mean difference: 22 ml, range 0-40 ml) and higher ejection fractions (mean difference: 9%, range 0-21%). The correlation between LV end-diastolic volume and regurgitant volume was better with the "Functional" method (r = 0.79, p < 0.0001) than the "Anatomic" method (r = 0.67, p < 0.0001). The correlation between global myocardial radial strain and LV EF was better with the "Functional" method (r = 0.86, p < 0.0001) than the "Anatomic" method (r = 0.68, p < 0.0001). In BMVP, the base of the LV should be defined at the level of the mitral valve annulus so that regurgitant volume most accurately reflects the functional significance of the mitral valve disease and LVEF most accurately reflects global systolic LV function. Defining the basal extent of the LV at the mitral valve leaflets leads to substantially lower regurgitant volumes and lower ejection fractions that could have important clinical consequences.
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