Mechanism of Recurrent/Persistent Ischemic/Functional Mitral Regurgitation Following Surgical Annuloplasty : Importance of Augmented Posterior Leaflet Tethering

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Surgical annuloplasty can potentially hoist the posterior annulus anteriorly, exaggerate posterior leaflet (PML) tethering, and lead to recurrent ischemic/functional mitral regurgitation (MR). In 30 patients with surgical annuloplasty for ischemic MR and 20 controls, the anterior leaflet (AML) and PML tethering angles relative to the line connecting annuli, posterior and apical displacement of the coaptation, and the MR grade were measured by echocardiography before, early after, and late after surgery. Early after surgery, grade of MR and AML tethering generally decreased (p<0.01), while PML tethering significantly worsened (p<0.01). Nine of the 30 patients showed recurrent/persistent MR late after surgery. Compared to patients without late MR, those with the MR showed similar reduction in the annular area, significant re-increase in posterior displacement of the coaptation, and progressive worsening in PML tethering (p<0.05) late after surgery in comparison to the early phase. While apical displacement of the coaptation was the primary determinant of pre-operative MR (r^2=0.60, p<0.0001), increased PM., tethering was the primary determinant of late MR (r^2=0.75, p<0.0001). Both leaflets tethering but with predominant contribution from augmented and progressive PML tethering is related to recurrent/persistent ischemic/functional MR late after surgical annuloplasty.