Clinical Investigation
Ventricular Mechanics in Diverse Disorders
Assessment of Longitudinal Myocardial Mechanics in Patients with Degenerative Mitral Valve Regurgitation Predicts Postoperative Worsening of Left Ventricular Systolic Function

https://doi.org/10.1016/j.echo.2014.02.008Get rights and content

Background

The optimal timing of mitral valve repair (MVr) in patients with chronic severe degenerative mitral regurgitation (MR) remains controversial and is broadly based on either measurable loss of systolic function, as determined by left ventricular (LV) ejection fraction (LVEF) and/or LV chamber remodeling. The aim of this study was to test the hypothesis that the assessment of LV deformation by speckle-tracking echocardiography might uncover subclinical changes for predicting reduction of LVEF after MVr.

Methods

One hundred thirty patients (mean age, 57 ± 14 years; 85 men) who underwent MVr for chronic severe degenerative MR were retrospectively identified. Baseline and immediate postoperative transthoracic echocardiography was used to assess global longitudinal strain (GLS), global radial strain, and global circumferential strain before and after MVr.

Results

In comparison with baseline, MVr resulted in significant reductions in LVEF (P < .0001) and in GLS (P < .0001). Postoperative change in LVEF was related to the changes in GLS (r = −0.71, P < .0001) and global circumferential strain (r = −0.22, P = .01) but not global radial strain. For the entire group, the presence of a high preoperative GLS magnitude predicted a postoperative reduction in LVEF of >10% (odds ratio, 0.80; P < .001). Furthermore, GLS showed diagnostic value in predicting a reduction in LVEF of >10% with a resulting postoperative LVEF of <50% (area under the curve, 0.93; P < .001).

Conclusions

In chronic severe degenerative MR, disproportionately higher LV global longitudinal strain signifies a maladaptive preload-related change that is associated with substantial loss of LVEF immediately after MVr. Preoperative assessment of longitudinal strain may be potentially useful for optimizing the timing of MVr for degenerative MR.

Section snippets

Patient Selection

From January 2002 to December 2010, 744 patients underwent MVr for chronic severe degenerative MR; the data from these patients were analyzed retrospectively. Patients with occlusive coronary artery disease (n = 80 [10.8%]), connective tissue disorders (n = 3 [0.4%]), previous sternotomy (n = 44 [5.9%]), and additional valvulopathies (n = 37 [5%]), except for tricuspid regurgitation, were excluded. An additional 227 cases were excluded because they were not saved in Digital Imaging and

Results

Patients' baseline characteristics and values are presented in Table 1. Standard 2D transthoracic echocardiography was performed at baseline and 4 ± 3 days after MVr. MV reconstruction was successful in all patients. One patient (0.7%) required revisiting for residual moderate MR and underwent a successful repeat repair the following day. The underlying etiology of MR was fibroelastic deficiency (n = 54) and Barlow's disease (n = 76, including forme fruste Barlow's deformity). MV leaflet

Discussion

Our results show that LV GLS is an independent predictor of LV function reduction after MV reconstructive surgery, compared with 2D echocardiographic markers of chamber dimensions. Our principal findings were as follows: (1) Alterations in LVEF in patients with severe MR due to degenerative MV disease are primarily correlated with changes in long-axis LV mechanics, with minimal contribution from the circumferential or radial thickening components, and (2) hypercompensatory GLS in severe MR

Conclusions

In patients with chronic severe degenerative MR, disproportionately higher LV GLS signifies a maladaptive preload-related change that is associated with substantial loss of LVEF (>10%) immediately after MVr. Preoperative use of speckle-tracking echocardiography-derived longitudinal strain may be potentially useful for optimal timing of MVr for degenerative MR.

Acknowledgments

The authors thank Marissa Sansone (St George Medical School) and Janell Wright (Mount Holyoke College) for their help in preparing this report.

References (40)

  • Y. Topilsky et al.

    Quantitation of mitral regurgitation

    Semin Thorac Cardiovasc Surg

    (2011)
  • M. Enriquez-Sarano et al.

    Determinants of pulmonary venous flow reversal in mitral regurgitation and its usefulness in determining the severity of regurgitation

    Am J Cardiol

    (1999)
  • W.A. Zoghbi et al.

    Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography

    J Am Soc Echocardiogr

    (2003)
  • R.M. Lang et al.

    Recommendations for chamber quantification: a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a Branch of the European Society of Cardiology

    J Am Soc Echocardiogr

    (2005)
  • B. Pirat et al.

    A novel feature-tracking echocardiographic method for the quantitation of regional myocardial function: validation in an animal model of ischemia-reperfusion

    J Am Coll Cardiol

    (2008)
  • D.Y. Leung et al.

    Left ventricular function after valve repair for chronic mitral regurgitation: Predictive value of preoperative assessment of contractile reserve by exercise echocardiography

    J Am Coll Cardiol

    (1996)
  • R.M. Suri et al.

    Determinants of early decline in ejection fraction after surgical correction of mitral regurgitation

    J Thorac Cardiovasc Surg

    (2008)
  • M. Enriquez-Sarano et al.

    Echocardiographic prediction of left ventricular function after correction of mitral regurgitation: results and clinical implications

    J Am Coll Cardiol

    (1994)
  • H. Geyer et al.

    Assessment of myocardial mechanics using speckle tracking echocardiography: fundamentals and clinical applications

    J Am Soc Echocardiogr

    (2010)
  • M.R. Zile et al.

    Chronic mitral regurgitation: predictive value of preoperative echocardiographic indexes of left ventricular function and wall stress

    J Am Coll Cardiol

    (1984)

    • Cited by (0)

    The present study was funded in its entirety by the Mount Sinai School of Medicine (New York, NY). Dr Sengupta has received research grants and support from TomTec Imaging Systems (Munich, Germany) and Forest Laboratories (New York, NY) and is an advisor to Medical Intelligence (Las Vegas, NV), and Saffron Technologies (Cary, NC). He is an inventor with Royalty Agreement with Mayo Medical Ventures for “Method for Imaging Intracavitary Blood Flow Patterns.”

    Dr. Adams is an inventor with Royalty Agreements with Edwards Lifesciences and Medtronic for the Physio II Mitral Annuloplasty Ring, IMR ETlogix Mitral Annuloplasty Ring, and TriAd Tricuspid Annuloplasty Ring. National CO-PI: Core Valve-Medtronic US Pivotal Trial.

    Drs Pandis and Sengupta contributed equally to the preparation of this report.

    View full text
    Copyright © 2014 American Society of Echocardiography. Published by Mosby, Inc. All rights reserved.