The Heart Valve Society

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Echocardiographic Markers of Secondary Mitral Regurgitation Recurrence After Combined Mitral Valve Repair and Papillary Muscle Approximation
Christos G. Mihos1, Francesco Nappi2, Romain Capoulade3, Massimo Chello4, Raffaele Barbato4, Orlando Santana1.
1Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA, 2Centre Cardiologique du Nord de Saint-Denis, Paris, France, 3Institut du Thorax, Inserm, CNRS, Université de Nantes, CHU Nantes, Nantes, France, 4University Campus Bio-Medico of Rome, Rome, Italy.

Background: Mitral valve repair and papillary muscle approximation (MVr+PMA) may improve valve repair durability in the surgical treatment of secondary mitral regurgitation (MR). We sought to identify pre-operative echocardiographic markers of recurrent MR after MVr+PMA, which to date have not been described.
Methods: We retrospectively analyzed 58 patients with ischemic or non-ischemic cardiomyopathy that underwent MVr+PMA for moderate or severe secondary MR, between March 2008 and May 2015. PMA was performed utilizing a 4-mm polytetrafluoroethylene graft (papillary muscle sling) (Figure). Univariate analyses and receiver operating characteristic curves were used to identify transthoracic echocardiographic variables and diagnostic models associated with ≥ moderate recurrent MR.
Results: The mean age and baseline left ventricular ejection fraction and end-systolic volume index were 64 ± 12 years, 27 ± 7%, and 65 ± 4 ml/m2, respectively. At a mean follow-up of 7 months (range 0.25-42 months), the recurrence rate of ≥ moderate MR was 13.8%. Univariable analysis revealed an association between baseline left ventricular end-systolic volume index (OR=1.06, 95% CI 1.02-1.11; p=0.003), MV tenting area (OR=3.27, 95% CI 1.29-8.23; p=0.01), and end-systolic interpapillary muscle distance (OR=1.12, 95% CI 1.0-1.26; p=0.05), with ≥ moderate recurrent MR. The optimal discriminative cutoff values were left-ventricular end-systolic volume index ≥ 80 ml/m2 (area under the curve [AUC] 0.878, p=0.001), MV tenting area ≥ 2.9 cm2 (AUC 0.85, p=0.002), and end-systolic interpapillary muscle distance ≥ 26 mm (AUC 0.72, p=0.05). The presence of both, an MV tenting area ≥ 2.9 cm2 and end-systolic interpapillary muscle distance ≥ 26 mm, was the strongest discriminative model for ≥ moderate MR recurrence (sensitivity=100%, specificity=86%, AUC 0.93, p<0.001).
Conclusions: In patients undergoing MVr+PMA for moderate or severe secondary MR, the extent of baseline alterations in mitral valve apparatus geometry may identify patients at higher risk of early post-operative recurrent MR, who may benefit from an alternative treatment strategy.


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