The effect of pure mitral regurgitation on mitral annular geometry and three-dimensional saddle shape Tom C. Nguyen, MD, Akinobu Itoh, MD, Carl J. Carlhäll,

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The effect of pure mitral regurgitation on mitral annular geometry and three-dimensional saddle shape Tom C. Nguyen, MD, Akinobu Itoh, MD, Carl J. Carlhäll, MD, PhD, Wolfgang Bothe, MD, Tomasz A. Timek, MD, Daniel B. Ennis, PhD, Robert A. Oakes, MD, David Liang, MD, PhD, George T. Daughters, MS, Neil B. Ingels, PhD, D. Craig Miller, MD The Journal of Thoracic and Cardiovascular Surgery Volume 136, Issue 3, Pages 557-565 (September 2008) DOI: 10.1016/j.jtcvs.2007.12.087 Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 A, Locations of LV epicardial markers (shaded circles) surgically implanted to silhouette the LV chamber along 4 equally spaced longitudinal meridians. B, Schematic representation of the 8 marker array on the mitral annulus, as viewed from the left atrium. Marker numbers (1–8) are shown. The location of the hole in the middle scallop of the posterior mitral leaflet is shown as a shaded circle. C, Intraoperative photograph as viewed from the left atrium of mitral annular markers with a 4.8-mm hole in the middle scallop of the posterior mitral leaflet. The Journal of Thoracic and Cardiovascular Surgery 2008 136, 557-565DOI: (10.1016/j.jtcvs.2007.12.087) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 Comparison of MR grade between CTRL (■, closed black squares) and HOLE (○, open circles) as a function of time, weeks (mean ± 1 standard error of the mean). MR, Mitral regurgitation. The Journal of Thoracic and Cardiovascular Surgery 2008 136, 557-565DOI: (10.1016/j.jtcvs.2007.12.087) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 Comparison of mitral annular area, CC dimension, and SL dimension between CTRL (■, closed black squares) and HOLE (○, open circles) at both 1 week and 12 weeks throughout the cardiac cycle (mean ± 1 standard error of the mean). Data centered at ED (t = 0) in a 700-ms time window. CC, Commissure–commissure; SL, septal-lateral; MAA, mitral annular area. The Journal of Thoracic and Cardiovascular Surgery 2008 136, 557-565DOI: (10.1016/j.jtcvs.2007.12.087) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 Mitral annular height between CTRL (■, closed black squares) and HOLE (○, open circles) at both 1 week and 12 weeks throughout the cardiac cycle (mean ± 1 standard error of the mean). Data centered at ES (t = 0) in a 700-ms time window. AH, Annular height; ES, end systole. The Journal of Thoracic and Cardiovascular Surgery 2008 136, 557-565DOI: (10.1016/j.jtcvs.2007.12.087) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

Figure 5 Distance of individual annular markers (1–8) at ED (left) and ES (right) from the least-squares annular plane for CTRL (■, closed black squares) versus HOLE (○, open circles) at 12 weeks. ED, End diastole; ES, end systole. The Journal of Thoracic and Cardiovascular Surgery 2008 136, 557-565DOI: (10.1016/j.jtcvs.2007.12.087) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

Figure 6 Cross-section of a normal (A) and chronic IMR heart (B) with schematic of the mitral annulus magnified on the right. Note that the mitral annulus (red dotted line) in the normal heart resembles the shape of saddle (A). After a posterior infarction, remodeling results in lateral displacement of the papillary muscle and ventricular wall (dotted blue line). Against a relatively fixed aortic annulus, this may “drag” the mitral annulus in the lateral direction thereby flattening the mitral annulus (solid blue line). This is also consistent with the predominant SL dilation seen with chronic IMR. IMR, Ischemic mitral regurgitation. The Journal of Thoracic and Cardiovascular Surgery 2008 136, 557-565DOI: (10.1016/j.jtcvs.2007.12.087) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions