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Mitral annulus dynamics in myxomatous mitral valve disease

Maria-Magdalena Gurzun
Maria-Magdalena Gurzun
, 
Monica Rosca
Monica Rosca
, 
Andreea Calin
Andreea Calin
, 
Carmen Beladan
Carmen Beladan
, 
Marinela Serban
Marinela Serban
, 
Roxana Enache
Roxana Enache
, 
Ruxandra Jurcut
Ruxandra Jurcut
, 
Carmen Ginghina
Carmen Ginghina
 e 
Bogdan A. Popescu
Bogdan A. Popescu
   | 30 apr 2022
Romanian Journal of Cardiology's Cover Image
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Article Category: Original Article
Pubblicato online: 30 apr 2022
Pagine: 66 - 75
DOI: https://doi.org/10.47803/rjc.2021.31.1.66
Parole chiave
© 2021 Maria-Magdalena Gurzun et al., published by Sciendo
This work is licensed under the Creative Commons Attribution 4.0 International License.

Figure 1

Transesophageal echocardiographic views for analysing the morphology of mitral valve (mid-systole still images) in a patient with extensive mitral valve mixomatous disease: mid-oesophageal long axis view for A2-P2 visualisation and measurement of antero-posterior annulus (A), bi-commisural view for P1-A2-P3 scallop visualisation and measurement of commissural diameter (B), „en-face” 3D visualisation of mitral valve (C).
Transesophageal echocardiographic views for analysing the morphology of mitral valve (mid-systole still images) in a patient with extensive mitral valve mixomatous disease: mid-oesophageal long axis view for A2-P2 visualisation and measurement of antero-posterior annulus (A), bi-commisural view for P1-A2-P3 scallop visualisation and measurement of commissural diameter (B), „en-face” 3D visualisation of mitral valve (C).

Figure 2

Mitral annulus measurements performed using 3D reconstructed model (b,d): antero-posterior diameter (between red and blue dots- a and b), anterolateral-posteromedial diameter (between white dots- a and b), bi-commissural diameter (between yellow dots), non-planar angle (c and d).
Mitral annulus measurements performed using 3D reconstructed model (b,d): antero-posterior diameter (between red and blue dots- a and b), anterolateral-posteromedial diameter (between white dots- a and b), bi-commissural diameter (between yellow dots), non-planar angle (c and d).

Figure 3

The three groups analysed in our study (3D atrial view of mitral valve- a, b and c and mathematical model- e, f and g): normal (a and e), limited mitral valve disease (b and f) and extensive mitral valve disease (c and g).
The three groups analysed in our study (3D atrial view of mitral valve- a, b and c and mathematical model- e, f and g): normal (a and e), limited mitral valve disease (b and f) and extensive mitral valve disease (c and g).

Figure 4

Static MA parameters dynamics among five systolic moments (beginning of systole of proto-systole, early systole, mid-systole, late systole and end of systole or tele-systole): the MA antero-posterior diameter is larger in patients with limited MVD (green) comparing to normal (blue) and even larger in patients with extensive MVD (red) and increases along systole in all groups but the increasing rate is higher in patients with limited MVD (a); the MA anterolateral-posteromedial diameter (b) and MA area (c) has the same characteristics as MA antero-posterior diameter.
Static MA parameters dynamics among five systolic moments (beginning of systole of proto-systole, early systole, mid-systole, late systole and end of systole or tele-systole): the MA antero-posterior diameter is larger in patients with limited MVD (green) comparing to normal (blue) and even larger in patients with extensive MVD (red) and increases along systole in all groups but the increasing rate is higher in patients with limited MVD (a); the MA anterolateral-posteromedial diameter (b) and MA area (c) has the same characteristics as MA antero-posterior diameter.

Figure 5

The graphic representation of MA non-planar dynamic evolution during systole (a): ascendant–blue, descendent – green, U turn yellow and U shape- purple; in the group of normal the U turn pattern is predominant while in the group of patients with limited mitral valve disease the predominant pattern is ascendant and in the group of patients with extensive mitral valve disease the predominant pattern is descending. Therefore, the MA non-planar angle dynamics describe an ascendant-descendent shape in normal group (blue), an ascendant shape in limited MVD group (green) and descendent shape in extensive MVD group (red).
The graphic representation of MA non-planar dynamic evolution during systole (a): ascendant–blue, descendent – green, U turn yellow and U shape- purple; in the group of normal the U turn pattern is predominant while in the group of patients with limited mitral valve disease the predominant pattern is ascendant and in the group of patients with extensive mitral valve disease the predominant pattern is descending. Therefore, the MA non-planar angle dynamics describe an ascendant-descendent shape in normal group (blue), an ascendant shape in limited MVD group (green) and descendent shape in extensive MVD group (red).

Automatic mitral valve measurements (using 4D MV Assessment 2.0 TomTec imaging Systems)

Parameter Definition Unit
Antero-posterior diameter Distance between the anterior and posterior point of mitral annulus. cm
Anterolateral-posteromedial diameter Longest distance between two points on the annulus that are derived by intersecting the annulus and a line perpendicular to antero-posterior diameter. cm
Commissural diameter Distance between two points on the annulus. Both points are derived by intersecting the annulus spline with a plane that goes through both end points of the coaptation and is perpendicular to the best fitting plane. cm
Annulus circumference (3D) Real length of annulus spline cm
Annulus area (3D) Size of core area cm2
Annulus area (2D) Size of area derived by projecting the annulus spline onto the Best Fitting Plane. cm2
Non-planar Angle Angle between the plane formed by anterior point of MA and commissural diameter and the plane formed by posterior point of MA and commissural diameter. °

Parameters of mitral valve apparatus geometry

Normal Limited MVD Extensive MVD p p′
Patients (number) 38 58 41
Antero-posterior diameter2 (cm) 3+/−0.23 3.58+/−0.56 3,86+/−0.61 <0.001 0.008
Anterolateral-posteromedial diameter2 (cm) 3.35+/−.31 3.84+/−0.55 4.27+/−0.7 <0.001 <0.001
MA circumference2 (cm) 10,46+/−0,87 12,15+/−1,7 13.4+/−2.18 <0.001 <0.001
MA 2D area2 (cm2) 8,08+/−1,35 11,14+/−3,3 13.53+/−4.53 <0.001 0.001
MA 3D area2 (cm2) 8,3+/−1,38 11,33+/−3,36 13.66+/−4.2 <0.001 0.001
Intercommisural distance2 (cm) 3,31+/−0.31 3,75+/−0.52 4.14+/−0.68 <0.001 <0.001
Anterior mitral leaflet area2 (cm) 5,32+/−0,92 6,71+/−2,00 8.4+/−2.9 <0.001 <0.001
Posterior mitral leaflet area2 (cm2) 4,02+/−0,93 7,16+/−3,15 9.51+/−4.64 <0.001 0.001
Leaflets area reported to 3D MA area2 1.1+/−0.05 1.2+/−0.11 1.3+/−0.20 <0.001 0.005
Mitral-aortic angle2 (degree) 120,91+/−10,50 122,09+/−12,33 119.73+/−25.66 0,936 0.74
Nonplanar angle- beginning systole 150,23+/−8,73 154,45+/−11.97 162.83+/−13.29 <0.001 <0.001
Nonplanar angle- early-systole 146,81+/−8,87 150,91+/−12,36 160.19+/−11.92 <0.001 <0.001
Nonplanar angle- mid-systole 147,13+/−7,92 152,29+/−10,01 158.21+/−10.70 <0.001 0.006
Nonplanar angle- late- systole 149,93+/−7,07 155,21+/−10.01 158.21+/−10.7 0,001 0.124
Nonplanar angle- end-systole 153,64+/−7,51 157,54+/−10,18 158.10+/−11.23 0,09 0.7
Nonplanar angle- mean value 149,55+/−7,23 153.48+/−10.18 159.46+/−10.3 <0.001 0.003

Parameters of mitral annulus dynamics

Parameter Normal subjects Limited MVD Extensive MVD p p′
Annular displacement (mm) 8,01+/−2,66 8.83+/−2.88 6.42+/−2.76 0,000 <0.001
Annular velocity (mm/sec) 32,84+/−11,86 40.77+/−14.56 31.2+/−14.25 0,001 0.001
Antero-posterior diameter change (%) 15.03+/−1.6 13.9+/−6.5 9.8+/−0.05 0.004 0.007
Anterolateral-postero medial diameter change (%) 10.2+/−5.3 6.9+/−4.4 6.8+/−4.5 0.002 0.92
Fractional 3D MA area change (%) 21,59+/−12,36 16.06+/−8.41 11.89+/−7.3 0,000 0.033
Fractional non-planar MA angle change (%) 10,34+/−6,34 11.87+/−6.61 14.15+/−7.8 0,51 0.89

Demographic and clinical characteristics in normal subjects and patients with mitral regurgitation

Normal subjects Limited MVD Extensive MVD p*
Patients, n 38 58 41
Age, y 54.9+/−10.6 58.5+/−9.1 56.11+/−10.33 0.55
Men, % 57.9 58.6 56.1 0.96
BSA, m2 1.91+/−0.2 1.85+/−0.2 1.83+/−0.19 0.14
Symptoms
• No symptoms 38
• NYHA I 28 22
• NYHA II 14 13
• NYHA III 6 4
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