Functional mitral stenosis after surgical annuloplasty for ischemic mitral regurgitation: Importance of subvalvular tethering in the mechanism and dynamic.

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Functional mitral stenosis after surgical annuloplasty for ischemic mitral regurgitation: Importance of subvalvular tethering in the mechanism and dynamic deterioration during exertion Kayoko Kubota, MD, Yutaka Otsuji, MD, Tetsuya Ueno, MD, Chihaya Koriyama, MD, Robert A. Levine, MD, Ryuzo Sakata, MD, Chuwa Tei, MD The Journal of Thoracic and Cardiovascular Surgery Volume 140, Issue 3, Pages 617-623 (September 2010) DOI: 10.1016/j.jtcvs.2009.11.003 Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 A, Potential mechanism of functional MS after surgical annuloplasty for ischemic MR. Valve tethering in ischemic MR restricts leaflet mobility even in diastole, thereby reducing leaflet opening (middle). However, MVA is not usually small enough to cause significant MS. Surgical annuloplasty to reduce annular size might further limit valve opening, which could result in significant functional MS without organic leaflet disease (right). B, Methods to quantify diastolic mitral leaflet tethering in apical long-axis view. α1 and α2 express diastolic tethering of anterior and posterior leaflets, respectively. Mitral leaflet tip opening dimension (ℓ1), annular dimension (ℓ2), and their ratios (ℓ1/ℓ2) were also measured. C, Mitral leaflet opening and filling flow velocity before and after surgical annuloplasty for ischemic MR. Before surgery, leaflet opening angle α1 is restricted, leaflet opening dimension is mildly reduced, and filling flow velocity is mildly increased. After surgery, leaflet opening dimension is further reduced and increase in filling flow velocity is significant. Ao, Aorta, LA, left atrium; LV, left ventricle; MS, mitral stenosis; MR, mitral regurgitation; IMR, ischemic mitral regurgitation. The Journal of Thoracic and Cardiovascular Surgery 2010 140, 617-623DOI: (10.1016/j.jtcvs.2009.11.003) Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 A, B, Dynamic worsening of functional MS observed by exercise stress echocardiography in a patient who underwent surgical annuloplasty for ischemic MR. During exercise, the left ventricle tended to dilate, mitral leaflet opening dimension decreased, and mitral flow velocity increased. The Journal of Thoracic and Cardiovascular Surgery 2010 140, 617-623DOI: (10.1016/j.jtcvs.2009.11.003) Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions