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Mathieu Vergnat, MD, Arminder S. Jassar, MBBS, Benjamin M

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1 Ischemic Mitral Regurgitation: A Quantitative Three-Dimensional Echocardiographic Analysis 
Mathieu Vergnat, MD, Arminder S. Jassar, MBBS, Benjamin M. Jackson, MD, Liam P. Ryan, MD, Thomas J. Eperjesi, BS, Alison M. Pouch, BS, Stuart J. Weiss, MD, PhD, Albert T. Cheung, MD, Michael A. Acker, MD, Joseph H. Gorman, MD, Robert C. Gorman, MD  The Annals of Thoracic Surgery  Volume 91, Issue 1, Pages (January 2011) DOI: /j.athoracsur Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions

2 Fig 1 Annular and leaflet segmentation. (A) Annular delineation using rotational cross-sections at 10-degree increments, centered on the geometric center of the mitral valve. (B) Leaflet segmentation using transverse cross-sections every 1 mm along intercommissural axis. (C) Regurgitant orifice delineation using rotational cross-sections at 5-degree increments, centered on the aortomitral junction. In each panel, the three-dimensionally rendered echocardiographic volume containing the mitral valve is displayed on the left, with cross-sectional planes; the two-dimensional resulting cross-section is displayed on the right. (AA = anterior annulus; AC = anterior commissure; AML = anterior mitral leaflet; AoV = aortic valve; Coapt = coaptation; LA = left atrium; LV = left ventricle; LVOT = left ventricular outflow tract; MVO = mitral valve orifice; PA = posterior annulus; PC = posterior commissure; PML = posterior mitral leaflet; RO = regurgitant orifice.) The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur ) Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions

3 Fig 2 Annular modeling. (A) Intercommissural and (B) transvalvular views of a real-time three-dimensional echocardiography derived mitral annular model are depicted. The least squares plane has been superimposed on the annulus in each view. (A) The manner in which the annular height (AH) and septolateral diameter (SL) are determined is illustrated. (B) The manner in which the intercommissural width (CW) and the mitral transverse diameter (MTD) are determined is illustrated. (AC = anterior commissure; AL = anterolateral annulus; L = lateral annulus; PC = posterior commissure; PM = posteromedial; S = septum; Zmax = maximum annular height corresponding to septum; Zmin = minimum annular height.) The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur ) Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions

4 Fig 3 Three-dimensional valve renderings. Mitral leaflet tethering for representative valves: (left) two-dimensional echocardiographic image with tenting area delineated; (right) three-dimensional rendering in an oblique view. (A) Normal valve, (B) ischemic mitral regurgitation (IMR) valve with limited tethering, and (C) IMR valve with severe leaflet tethering. (AA = anterior annulus; AML = anterior mitral leaflet; AoV = aortic valve; Coapt = coaptation; LA = left atrium; LV = left ventricle; LVOT = left ventricular outflow tract; PA = posterior annulus; PML = posterior mitral leaflet.) The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur ) Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions

5 Fig 4 Regional annular shape, presented as regional annular height (AH) plotted as a function of rotational position, averaged for (A) cohorts and for (B–E) selected ischemic mitral regurgitation patients. All patients' commissures were aligned in such a way that the posterior commissure (PC) was located at 0% and the anterior commissure (AC) at 33.3% of the rotational position along the annulus. Note the increased variability of AH in the posterior annular (PA) region. Also note the extremely variable annular shape, varying from normal (B) to flat (C), midposterior restriction (D), and bimodal posterior restriction (E). (AA = anterior annulus; PC = posterior commissure; black line = normal; dark gray line = inferior; light gray line = anterior.) The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur ) Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions

6 Fig 5 Regional mitral valve tenting area (MVTa [tenting distribution]) plotted as a function of intercommissural (IC) position, expressed as a percentage of the distance traveled from the anterior commissure (AC). The positions of the AC and posterior commissure (PC) are, respectively, 0% and 100%. (A) Mean data (with SEM) for the normal cohort and ischemic mitral regurgitation (IMR) cohorts with either inferior or anterior infarcts. Note the shifting of the maximum tenting area toward PC with anterior infarct location. (B–E) Data for selected individual IMR patients are displayed. Note the variability in the extent and location of leaflet tenting. (Black line = normal; dark gray line = inferior; light gray line = anterior.) The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur ) Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions

7 Fig 6 Three-dimensional renderings of leaflet curvature. Color contouring is determined by three-dimensional leaflet Gaussian curvature (K). Negative K values indicate saddle-shaped (hyperbolic) local surface curvature; positive K values indicate elliptic local surface curvature but may be concave toward the left ventricle or left atrium. Valves are rendered as if the viewer were looking down from the left atrium. The left-hand image in each panel is oriented to allow appreciation of the three-dimensional directionality of positive Gaussian curvature (see text); the right-hand image is a two-dimensional planar projection of the leaflets. (A) A valve with two areas of intensive positive curvature convex toward the left ventricle; this was the most common configuration in the ischemic mitral regurgitation group. (B) A unifocal area of intense positive curvature is demonstrated. (C) A lesser degree of positive curvature foci is illustrated. (D) A healthy person with normal leaflet redundancy is shown. (AA = anterior annulus; AC = anterior commissure; PA = posterior annulus; PC = posterior commissure.) The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur ) Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions

8 Fig 7 Regurgitant orifice geometry, presented as orifice width plotted as a function of location along coaptation line (expressed as a percentage of the distance traveled from the anterior commissure). The positions of the anterior commissure (AC) and posterior commissure (PC) and valve segments (A1-P1 to A3-P3) are labeled. To avoid curves overlapping, all patients have been overlaid. Each vertical graduation represents 1-mm regurgitant width. Note extension of regurgitant orifice along the entire coaptation region and also the variable size and number of orifices. The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur ) Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions

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