Tethering Symmetry Reflects Advanced Left Ventricular Mechanical Dyssynchrony in Patients With Ischemic Mitral Regurgitation Undergoing Restrictive Mitral.

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Tethering Symmetry Reflects Advanced Left Ventricular Mechanical Dyssynchrony in Patients With Ischemic Mitral Regurgitation Undergoing Restrictive Mitral Valve Repair Leen van Garsse, MD, Sandro Gelsomino, MD, PhD, Emile Cheriex, MD, Fabiana Lucà, MD, Carmelo Massimiliano Rao, MD, Orlando Parise, MSc, Gian Franco Gensini, MD, Jos Maessen, MD, PhD The Annals of Thoracic Surgery Volume 94, Issue 5, Pages 1418-1428 (November 2012) DOI: 10.1016/j.athoracsur.2012.05.099 Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Patient selection. (CABG = coronary artery bypass grafting; MR = mitral regurgitation; MV = mitral valve.) The Annals of Thoracic Surgery 2012 94, 1418-1428DOI: (10.1016/j.athoracsur.2012.05.099) Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Measurement of tethering angles. (A) Tethering of the anterior mitral leaflet (AML) was assessed by measuring the angle α between the annular plane and AML. Tethering of the posterior mitral leaflet (PML) was assessed by measuring the angle β between the annular plane and the PML. (AO = aorta; LA = left atrium; LV = left ventricle.) (B) Patient belonging to the symmetric group with central regurgitant jet. (C) Patient belonging to the asymmetric group with eccentric regurgitant jet. The Annals of Thoracic Surgery 2012 94, 1418-1428DOI: (10.1016/j.athoracsur.2012.05.099) Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 (A) Representative example of measuring papillary global longitudinal strain (G-LS) and global longitudinal strain peak (G-LSpeak) in apical four-chamber view. (B) Representative example of measuring papillary muscle dyssynchrony as difference in time to peak (TTP) between anterolateral and posteromedial papillary muscles. (AVC = aortic valve closure.) The Annals of Thoracic Surgery 2012 94, 1418-1428DOI: (10.1016/j.athoracsur.2012.05.099) Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 (A) Preoperative papillary muscle dyssynchrony (DYS-PAP) in a patient with symmetrical tethering (60.3 ms). (B) Postoperative DYS-PAP in the same patient (95.2 ms). (C) Preoperative DYS-PAP in a patient with asymmetrical tethering (35.5 ms). (D) Postoperative DYS-PAP in the same patient (11.9 ms). (ALPM = anterolateral papillary muscle; AVC = aortic valve closure; PMPM = posteromedial papillary muscle.) The Annals of Thoracic Surgery 2012 94, 1418-1428DOI: (10.1016/j.athoracsur.2012.05.099) Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 (A) Papillary muscle dyssynchrony at baseline, discharge, and follow-up in the 2 groups (symmetric and asymmetric). (B) Anterolateral papillary muscle longitudinal strain at baseline, discharge, and follow-up in the 2 groups. (C) Global longitudinal strain at baseline, discharge, and follow-up in the 2 groups. (D) Posteromedial papillary muscle longitudinal strain at baseline, discharge, and follow-up in the 2 groups. (* = significance versus baseline; ** = significance versus discharge.) The Annals of Thoracic Surgery 2012 94, 1418-1428DOI: (10.1016/j.athoracsur.2012.05.099) Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions

Fig 6 Multivariable predictors of postoperative papillary muscle dyssynchrony. (α = anterior mitral leaflet tethering angle; β = posterior mitral leaflet tethering angle; CI = confidence interval; ESVI = end-systolic volume index; HR = hazard ratio; MPI = myocardial performance index; SIsys = systolic sphericity index.) The Annals of Thoracic Surgery 2012 94, 1418-1428DOI: (10.1016/j.athoracsur.2012.05.099) Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions