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Functional Anatomy of the Mitral Valve-Left Ventricle Complex in Patients with Ischemic Cardiomyopathy as Assessed with Multislice Computed Tomography: Characteristics Associated with Mitral Regurgitation
Natalia Solowjowa1, Leyla Musayeva2, Yuriy Hrytsyna3, Christoph Knosalla1, Volkmar Falk1.
1Deutsches Herzzentrum Berlin, Berlin, Germany, 2N.Tusa Clinic, Baku, Azerbaijan, 3Charite-Universitätsmedizin, Berlin, Germany.

OBJECTIVE: Functional mitral regurgitation (FMR) remains an important prognostic determinant in patients with ischemic cardiomyopathy (ICMP). A differentiated surgical approach based on knowledge about impact of left ventricular (LV) and mitral valve (MV) remodeling is important for successful therapy. We evaluated volumetric and geometric parameters of the MV-LV complex with multislice computed tomography (MSCT) in patients with ICMP and their relation to moderate and severe FMR.
METHODS: Between 09/09 and 09/14, 78 patients (m:w=70:8, age 37-84, median 63.1 years; mean NYHA class 2.97) with echocardiographic LV ejection fraction (LVEF) <40% underwent cardiac MSCT for LV functional assessment. The following MSCT data were analyzed retrospectively: indexed left atrial and LV enddiastolic and endsystolic volumes (LAVI, LVEDVI, LVESVI) and LV volumetric sphericity index (SI). LVEF, cardiac output (CO) and cardiac index (CI) were also calculated on the basis of MSCT data. MV apparatus was characterized by intercommissural and anteroposterior MV annulus diameter (ICD, AMD), MV annulus area and posterior circumference (MVAA, MVAPC), coaptation distance, tenting area, anterior and posterior leaflet to annulus angle (CD, TA, ALA, PLA) in segments 1-3 and interpapillar muscle distance (IMD), measured in midsystole. These parameters were compared in patients (n=48) with moderate MR (<2.0) and patients (n=29) with severe (≥2.0) MR.
RESULTS: The differences in LVEDVI, LVESVI and LVEF between two groups were not significant, whereas LAVI and SI were significantly higher in patient with severe FMR (LAVI 74.7±22.5 vs. 58.3±16.9 ml/sqm, p=0.001; SI 0.48±0.1 vs. 0.43±0.1, p=0.018). Patients with severe FMR showed significantly longer CD (CD A2-P2 10.4±2.4 vs.8.8±2.1 mm, p=0.004; CD A3-P3 8.7±2.4 mm, p=0.017) and larger TA (TA A2-P2 2.2±0.9 vs. 1.7±0.6 sq cm, p=0.011), demonstrating more advanced MV remodeling. The differences in MV diameter, circumference and area, IMD and segmental leaflet to annulus angles did not reach statistical significance.
CONCLUSIONS: MSCT represents an appropriate diagnostic tool for evaluation of MV-LV remodeling in ICMP patients. Our data show more pronounced tethering of the mitral leaflets at the central and posteromedial segments and more advanced LA and LV remodeling in patients with severe FMR. Further studies may reveal more features relevant to surgical therapy.

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