Assessment of Functional Anatomy of the Mitral Valve and ...eposterscannes2015.avmediaproject.at/eposters/1290.pdf · specific changes in mitral and ventricular geometry - Techniques

Assessment of Functional

Anatomy of the Mitral Valve

and Left Ventricle in Ischemic

Cardiomyopathy with

Multislice Computed

Tomography:

Characteristics Associated

with Mitral Regurgitation

Natalia Solowjowa, Berlin 30.03.2015

Why are detailed anatomical studies in functional mitral

regurgitation essential?

- Successful valve repair must target the mechanism of

dysfunction in the individual patient taking into account

specific changes in mitral and ventricular geometry

- Techniques that can be potentially used:

- restrictive annuloplasty

- cutting or translocation of secondary chordae

- papillary muscle approximation or relocation

- LV restoration

- Revealing the predictors for failure of MV repair is essential

for the choice of therapeutic alternatives (LVAD etc.)

DHZB | Assessment of Functional Anatomy of the MV and LV in Ischemic Cardiomyopathy with Multislice Computed Tomography | Berlin 30.03.2015

2


3

Mitral valve remodeling:

postero-lateral + antero-apical scar, papillary muscle involvement


4


5

Mitral valve remodeling:

huge antero-apical scar, intact papillary muscles

MSCT is increasingly applied to study

MV and LV anatomy

▪ Advantages:

▪ Spatial resolution of up to 0.33 mm

▪ Only one scan necessary, scan time for full cardiac CTA

Study population : 121 consecutive patients with

ischemic cardiomyopathy ( 2010-2015 )

Baseline characteristics


7

MR < 2.0 ( n=87 ) MR ≥ 2.0 ( n=34 ) P-value

Median age (range), years 66.0 (38.0-78.0) 64.8 (37.0-79.0)

Female gender, n (%) 16 (18.4) 4 (11.8) 0.277

Body surface area (sqm) 1.97 ± 0.2 1.98 ± 0.2 0.732

Diabetes mellitus, n (%) 11 (27.6) 11 (32.4) 0.379

Hypertension, n (%) 47 (54.0) 26 (76.5) 0.018

Hypercholesterolemia, n (%) 44 (50.6) 24 (70.6) 0.036

History of atrial fibrillation, n (%) 13 (14.9) 13 (38.2) 0.006

NYHA Class ≥ III, n (%) 68 (78.2) 27 (79.4) 0.856

LVEF (Echo), % 26.5 ± 8.0 24.8 ± 7.4 0.268

LV EDD (Echo), mm 61.4 ± 8.7 65.6 ± 8.6 0.022

Triple vessel disease, n (%) 51 (58.6) 26 (76.5) 0.001

Volumetric and geometric parameters of LV and LA

measured in CT scans


8

MR < 2.0 ( n=87 ) MR ≥ 2.0 ( n=34 ) p value

LV-EDVI, ml/sqm 151.8 ± 46.2 159.6 ± 52.0 0.448

LV-ESVI, ml/sqm 108.6 ± 43.4 110.9 ± 51.2 0.812

SVI, ml/sqm 43.2 ± 12.2 44.5 ± 10.9 0.562

LV EF, % 29.9 ± 9.0 29.1 ± 8.0 0.616

LA-VI, ml/qm 56.3 ± 17.1 73.3 ± 24.8 0.001

SI vol diast. 0.42 ± 0.09 0.48 ± 0.1 0.009

SI vol syst. 0.34 ± 0.1 0.41 ± 0.14 0.014

LV-EDVI, LV-ESVI – LV end diastolic and end systolic volume index;

SVI – stroke volume index; LV EF – LV ejection fraction;

LA-VI – left atrium volume index;

SI vol - volumetric sphericity index, diastolic and systolic

( all values as mean ±SD ).

Volumetric sphericity index =

LV volume/ LV long axis3× 𝜋/ 6

Segmental geometric indices of mitral valve

by computed tomography


9

MR < 2.0

( n=87 )

MR ≥ 2.0

( n=34 ) p value

ICD, mm 40.6 ± 3.6 42.8 ± 5.9 0.048

APD, mm 26.8 ± 9.0 29.9 ± 3.8 0.000

MVAA, sqcm 10.2 ± 2.2 13.83 ± 1.4 0.014

CD A1-P1, mm 7.2 ± 1.9 8.0 ± 2.2 0.09

CD A2-P2, mm 8.6 ± 2.0 10.4 ± 2.3 0.000

CD A3-P3, mm 7.6 ± 2.0 8.7 ± 2.3 0.011

CL A2-P2, mm 4.1 ± 1.7 3.4 ± 1.8 0.055

TA A2-P2, sqcm 1.64 ± 0.6 2.26 ± 0.9 0.001

ICD and APD – intercommissural and

anteroposterior MV annulus diameter;

MVAA – MV annulus area;

CD A1-3 - P1-3 – coaptation distance at the level

of mitral segments A1-P1, A2-P2, A3-P3;

CL and TA A2-P2 – coaptation length and

tenting area at the level of mitral segments A2-P2

( all values as mean ±SD )

Segmental angular indices of mitral valve



10

MR < 2.0

( n=87 )

MR ≥ 2.0

( n=34 ) p Value

AMAA, degree 122.6 ± 11.2° 120.5 ± 22.2° 0.585

ALA Aα1, degree 23.8 ± 6.3° 24.1 ± 5.8° 0.803

ALA Aα2, degree 26.9 ± 7.8° 27.9 ± 6.8° 0.930

ALA Aα3, degree 25.1 ± 7.1° 24.6 ± 5.9° 0.663

APA Pα1, degree 37.2 ± 11.2° 35.5 ± 12.0° 0.484

APA Pα2, degree 41.9 ± 12.3° 42.2 ± 10.9° 0.889

APA Pα3, degree 37.2 ± 10.8° 38.3 ± 9.3° 0.580

A1-P1

A2-P2

A3-P3

MVA

AMAA – aortic-mitral annular angle;

ALA Aα1-3 and APA Pα1-3 – anterior and posterior mitral leaflet

angle at the level of mitral segments A1-P1, A2-P2 and A3-P3

(all values as mean ±SD)

Indices of submitral apparatus



11

MR < 2.0

( n=87 )

MR ≥ 2.0

( n=34 ) p Value

IMD, mm 33.7 ± 7.3 35.7 ± 8.8 0.252

AnAPMD, mm 24.8 ± 4.5 24.3 ± 4.7 0.420

AnPPMD, mm 26.4 ± 4.3 28.4 ± 4.8 0.044

AnAPMA, degree 93.4 ± 11.3° 91.5 ± 9.4° 0.342

AnPPMA, degree 84.3 ± 9.7° 87.2 ± 14.4° 0.295

IMD – interpapillary muscle distance,

AnAPMD, AnPPMD – distance between MV annulus and

anterior and posterior papillary muscle head

(papillary muscle tethering length);

AnAPMA, AnPPMA – angle between MV annulus and

anterior and posterior papillary muscle head

(papillary muscle anterior and posterior angle) –

all values as mean ±SD

Distribution of regional wall motion abnormalities

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50%

31%

10%

9%

antero-apical

antero-apical+postero-lateral

lateral+postero-lateral

global hypokinesis

18%

29% 41%

12%

antero-apical

antero-apical+postero-lateral

lateral+postero-lateral

global hypokinesis


Motion abnormalities of papillary muscles

and load bearing LV wall

24,1%

47,1%

36,8%

51,7%

35,3%

70,6%

38,2%

82,8%

0,0%

10,0%

20,0%

30,0%

40,0%

50,0%

60,0%

70,0%

80,0%

90,0%

APM PPM ABW PBW

*

13 DHZB | Assessment of Functional Anatomy of the MV and LV in Ischemic Cardiomyopathy with Multislice Computed Tomography | Berlin 30.03.2015

*

Results


14

▪ MSCT-based measurements demonstrate:

▪ significantly higher LV sphericity, larger left atrial volume and significantly

more advanced changes in segmental geometric indices of mitral valve

in severe FMR

▪ no significant differences in segmental angular indices of mitral valve

between our study groups with moderate and severe FMR

▪ essentially different distribution of regional wall motion abnormalities in study

groups with prevalence of lateral and postero-lateral localization in severe FMR

▪ significantly higher prevalence of motion abnormalities of posterior papillary

muscles and corresponding load bearing LV wall in severe FMR

Conclusions


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This study provides further evidence for the decisive role of adverse mitral

and ventricular geometry in the mechanism of ischemic mitral regurgitation

The MSCT imaging approach described here can be used for surgery for FMR

to target the individual mechanisms with:

- annuloplasty techniques

- chordae cutting or translocation

- papillary muscle repositioning

- different procedures of LV restoration or biventricular pacing

Further studies of unbalanced tethering and role of papillary muscles

can help to specify the mechanisms of FMR

Thank you for your attention

Deutsches Herzzentrum Berlin

Stiftung des bürgerlichen Rechts

Augustenburger Platz 1

13353 Berlin

Telefon: +49 30 4593-1000

Telefax: +49 30 4593-1003

E-Mail: [email protected]

www.dhzb.de

Improvement of MV Geometry after SVR


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Headline Arial Bold 28 pt Subheadline Arial Regular 22 pt lorem

DHZB | Titel der Präsentation | Berlin 15.01.2015 18

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Assessment of Functional Anatomy of the Mitral Valve and ...eposterscannes2015.avmediaproject.at/eposters/1290.pdf · specific changes in mitral and ventricular geometry - Techniques