The value of preoperative 3-dimensional over 2-dimensional valve analysis in predicting recurrent ischemic mitral regurgitation after mitral annuloplasty

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The value of preoperative 3-dimensional over 2-dimensional valve analysis in predicting recurrent ischemic mitral regurgitation after mitral annuloplasty Inez J. Wijdh-den Hamer, MD, Wobbe Bouma, MD, PhD, Eric K. Lai, BS, Melissa M. Levack, MD, Eric K. Shang, MD, Alison M. Pouch, PhD, Thomas J. Eperjesi, BS, Theodore J. Plappert, CVT, Paul A. Yushkevich, PhD, Judy Hung, MD, Massimo A. Mariani, MD, PhD, Kamal R. Khabbaz, MD, Thomas G. Gleason, MD, Feroze Mahmood, MBBS, Michael A. Acker, MD, Y.Joseph Woo, MD, Albert T. Cheung, MD, Matthew J. Gillespie, MD, Benjamin M. Jackson, MD, Joseph H. Gorman, MD, Robert C. Gorman, MD The Journal of Thoracic and Cardiovascular Surgery Volume 152, Issue 3, Pages 847-859 (September 2016) DOI: 10.1016/j.jtcvs.2016.06.040 Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 2DE geometric analysis of the mitral valve. A, Preoperative midsystolic 4-chamber view. B, Preoperative midsystolic 2-chamber view. C and D, Cross-section through the base of the heart with an atrial view of the mitral valve with its 6 segments. The red line indicates the cross-sectional transesophageal 2DE plane through the mitral valve (segments) in the 4-chamber (C) and 2-chamber (D) views. E, Determination of annular diameter, tethering height, and tethering area in the 2-chamber view. F, Determination of anterior tethering angle and PTA in the 2-chamber view. LA, Left atrium; AML, anterior mitral valve leaflet; PML, posterior mitral valve leaflet; LV, left ventricle; 4CH, 4-chamber; 2CH, 2-chamber; AD, annular diameter; TH, tethering height; TA, tethering angle; PTA, posterior tethering angle; ATA, anterior tethering angle. The Journal of Thoracic and Cardiovascular Surgery 2016 152, 847-859DOI: (10.1016/j.jtcvs.2016.06.040) Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 3D annular (A-E) and leaflet (F-H) segmentation technique and geometric analysis. A, 3DE volume containing the mitral valve with cross-sectional planes at 10-degree increments. B, Representative 2-dimensional cross-section with green dots representing the selected annular points. Oblique (C), intercommissural (D), and transvalvular (E), annular views of a single real-time 3D-derived mitral annular model with annular landmarks and the 36 annular data points (circles). The least-squares plane has been superimposed on the annulus in each view. The least-squares plane is depicted by a horizontal line in C and D and by the check boxes in E. Determinations of septolateral diameter, intercommissural width, and mitral transverse diameter are shown in D and E. Mitral annular area (the area enclosed by the 2-dimensional projection of an annular data set onto its corresponding least-squares plane) and mitral annular circumference were also determined. F, Template of transverse cross-sections every 1 mm along intercommissural axis. G, One of the 2-dimensional cross-sections represented by the white dashed line in F; the white and red dashed lines are both within least-squares annular plane. Determinations of mitral valve tethering (MVT) area, anterior tethering angle, and posterior tethering angle are shown in G and H. The atrial surface of the mitral valve leaflets and the coaptation zone is interactively marked (green curves), resulting in a 500- to 1000-point data set for each valve. MVT area was defined as the area enclosed by the mitral annular plane (white dashed line) and the mitral leaflets for a given point along the intercommissural axis. MVT area was calculated at known intervals (0.1 mm), Δc, along the intercommissural axis. MVT volume was calculated as the sum of the incremental regional volumes (MVT area × Δcn). MVT index (MVT volume divided by mitral annular area) also was calculated for each data set. ATA and PTA were computed at known intervals (0.1 mm) along the entire length of the intercommissural axis by measuring the angle formed by the anterior or posterior leaflet tangent relative to the mitral annular plane (H). Segmental (mean) tethering angles were determined by dividing the valve into equal thirds along the intercommissural axis to conform to the standard 6 anatomic leaflet segments (A1, A2, A3; P1, P2, P3) and by calculating the mean segmental tethering angle for each specific segment on the basis of computed tethering angles at 0.1-mm intervals (along the intercommissural axis). I, Normal mitral valve. J, Tethered mitral valve. LA, Left atrium; AA, anterior mitral annulus; PA, posterior mitral annulus; AoV, aortic valve; MVO, mitral valve orifice; AML, anterior mitral leaflet; PML, posterior mitral leaflet; LVOT, left ventricular outflow tract; LV, left ventricle; S, septal aspect of the annulus; L, lateral aspect of the annulus; PC, posterior commissure; AC, anterior commissure; SL, septolateral diameter; PM, posteromedial annulus; CW, commissural width; MTD, mitral transverse diameter; MVT(a), mitral valve tethering (area); Coapt, coaptation; ATA, anterior tethering angle; PTA, posterior tethering angle. The Journal of Thoracic and Cardiovascular Surgery 2016 152, 847-859DOI: (10.1016/j.jtcvs.2016.06.040) Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 ROC curves. ROC curve for preoperative PTA (optimal cutoff value 32.0°, AUC 0.81), preoperative P3TA (optimal cutoff value 29.9°, AUC 0.92), and preoperative P3TA and basal aneurysm/dyskinesis (AUC 0.94) as predictors of IMR recurrence after undersized mitral ring annuloplasty. The incremental value of preoperative 3DE over 2DE (orange area) in predicting IMR recurrence after mitral annuloplasty becomes apparent immediately. 3D, 3-Dimensional; P3TA, P3 tethering angle; BA/D, basal aneurysm/dyskinesis; AUC, area under the curve; 2D, 2-dimensional; 2CH, 2-chamber; PTA, posterior tethering angle; ROC, receiver operating characteristic; IMR, ischemic mitral regurgitation. The Journal of Thoracic and Cardiovascular Surgery 2016 152, 847-859DOI: (10.1016/j.jtcvs.2016.06.040) Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions

Preoperative predictors of recurrent IMR 6 months after annuloplasty: 3DE versus 2DE. The Journal of Thoracic and Cardiovascular Surgery 2016 152, 847-859DOI: (10.1016/j.jtcvs.2016.06.040) Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions

Video 1 The value of preoperative 3-dimensional over 2-dimensional valve analysis in predicting recurrent IMR after mitral annuloplasty. Video available at http://www.jtcvsonline.org/article/S0022-5223(16)30670-5/addons. The Journal of Thoracic and Cardiovascular Surgery 2016 152, 847-859DOI: (10.1016/j.jtcvs.2016.06.040) Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions