Preoperative Three-Dimensional Valve Analysis Predicts Recurrent Ischemic Mitral Regurgitation After Mitral Annuloplasty.
Preoperative Three-Dimensional Valve Analysis Predicts Recurrent Ischemic Mitral Regurgitation After Mitral Annuloplasty.
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DOI：
10.1016/j.athoracsur.2015.09.076
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发表时间：
2016-02
期刊：
影响因子：
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通讯作者：
Gorman RC
中科院分区：
文献类型：
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作者：
Bouma W;Lai EK;Levack MM;Shang EK;Pouch AM;Eperjesi TJ;Plappert TJ;Yushkevich PA;Mariani MA;Khabbaz KR;Gleason TG;Mahmood F;Acker MA;Woo YJ;Cheung AT;Jackson BM;Gorman JH 3rd;Gorman RC
二尖瓣环过小的缺血性二尖瓣反流(IMR)瓣膜修补术的特点是IMR复发率高。根据患者特定的术前影像对复发的IMR进行风险分层将优化结果。我们试图确定修复前的三维(3D)超声心动图结合新的瓣膜建模算法是否可以预测修复后6个月的IMR复发。应用经食道实时三维超声心动图对50例IMR患者和21例正常二尖瓣患者进行了术中超声心动图检查。使用定制的图像分析方案来评估3D环状几何形状和区域叶系留。术后6个月行经胸二维超声心动图检查，评估≥分级2级。复发组(13例)术前叶系留角度明显高于未复发组(P=0.008)，A3(23.5±8.9°比14.4±11.4°，P=0.012)、P2(44.4±8.8°比28.2±17.0°，P=0.002)和P3(35.2±6.0°比18.6±12.7°，P<；0.001)。多因素Logistic回归分析显示，P3夹角是IMR复发的独立预测因素，其最佳切断值为29.9°(AUC0.92，95%CI0.84~1.00，P<；0.001)。三维超声心动图结合瓣膜模型预测IMR复发。术前P3节段的局部叶拴系是较小的环状成形术后IMR复发的独立预测因素。对于术前P3夹角≥为29.9°的患者，应优先考虑保留绳索的瓣膜置换术，而非瓣膜修补术。
Valve repair for ischemic mitral regurgitation (IMR) with undersized annuloplasty rings is characterized by high IMR recurrence rates. Patient-specific preoperative imaging-based risk stratification for recurrent IMR would optimize results. We sought to determine if pre-repair three-dimensional (3D) echocardiography combined with a novel valve modeling algorithm would be predictive of IMR recurrence 6 months after repair. Intraoperative transesophageal real-time 3D echocardiography was performed in 50 patients undergoing undersized ring annuloplasty for IMR (and in 21 patients with normal mitral valves). A customized image analysis protocol was used to assess 3D annular geometry and regional leaflet tethering. IMR recurrence (≥grade 2) was assessed with two-dimensional transthoracic echocardiography 6 months after repair. Preoperative annular geometry was similar in all IMR patients; and preoperative leaflet tethering was significantly higher in patients with recurrent IMR (n=13) as compared with patients in whom IMR did not recur IMR (n=37) (tethering index 3.91±1.01 vs. 2.90±1.17, P=0.008; tethering angles of A3 (23.5±8.9° vs. 14.4± 11.4°, P=0.012), P2 (44.4±8.8° vs. 28.2±17.0°, P=0.002), and P3 (35.2±6.0° vs. 18.6±12.7°, P<0.001)). Multivariate logistic regression analysis revealed preoperative P3 tethering angle as an independent predictor of IMR recurrence with an optimal cut-off value of 29.9° (AUC 0.92, 95%CI 0.84–1.00, P<0.001). 3D echocardiography combined with valve modeling is predictive of recurrent IMR. Preoperative regional leaflet tethering of segment P3 is a strong independent predictor of IMR recurrence after undersized ring annuloplasty. In patients with a preoperative P3 tethering angle ≥29.9° chordal-sparing valve replacement rather than valve repair should be strongly considered.