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Mitral Regurgitation: Anatomy, Physiology, and Pathophysiology-Lessons Learned From Surgery and Cardiac Imaging.

ABSTRACT: The normal mitral valve is a dynamic structure that permits blood to flow from the left atrial (LA) to left ventricle (LV) during diastole and sealing of the LA from the LV during systole. The main components of the mitral apparatus are the mitral annulus (MA), the mitral leaflets, the chordae tendineae, and the papillary muscles (PM) (Figure 1). Normal valve function is dependent on the integrity and normal interplay of these components. Abnormal function of any one of the components, or their interplay can result in mitral regurgitation (MR). Understanding the anatomy and physiology of all the component of the mitral valve is important for the diagnosis, and for optimal planning of repair procedures. In this review we will focus first on normal anatomy and physiology of the different parts of the mitral valve (MA, leaflets, chordae tendineae, and PM). In the second part we will focus on the pathologic anatomic and physiologic derangements associated with different types of MR.

SUBMITTER: Topilsky Y

PROVIDER: S-EPMC7272584 | biostudies-literature | 2020

REPOSITORIES: biostudies-literature

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Mitral Regurgitation: Anatomy, Physiology, and Pathophysiology-Lessons Learned From Surgery and Cardiac Imaging.

Topilsky Yan Y

Frontiers in cardiovascular medicine 20200529

The normal mitral valve is a dynamic structure that permits blood to flow from the left atrial (LA) to left ventricle (LV) during diastole and sealing of the LA from the LV during systole. The main components of the mitral apparatus are the mitral annulus (MA), the mitral leaflets, the chordae tendineae, and the papillary muscles (PM) (Figure 1). Normal valve function is dependent on the integrity and normal interplay of these components. Abnormal function of any one of the components, or their ...[more]

PMID: 32548127

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Project description:BackgroundInitial studies have suggested the familial clustering of mitral valve prolapse, but most of them were either community based among unselected individuals or applied non-specific diagnostic criteria. Therefore little is known about the familial distribution of mitral regurgitation in a referral-type population with a more severe mitral valve prolapse phenotype. The objective of this study was to evaluate the presence of familial mitral regurgitation in patients undergoing surgery for mitral valve prolapse, differentiating patients with Barlow's disease, Barlow forme fruste and fibro-elastic deficiency.MethodsA total of 385 patients (62 ± 12 years, 63% men) who underwent surgery for mitral valve prolapse were contacted to assess cardiac family history systematically. Only the documented presence of mitral regurgitation was considered to define 'familial mitral regurgitation'. In the probands, the aetiology of mitral valve prolapse was defined by surgical observations.ResultsA total of 107 (28%) probands were classified as having Barlow's disease, 85 (22%) as Barlow forme fruste and 193 (50%) patients as fibro-elastic deficiency. In total, 51 patients (13%) reported a clear family history for mitral regurgitation; these patients were significantly younger, more often diagnosed with Barlow's disease and also reported more sudden death in their family as compared with 'sporadic mitral regurgitation'. In particular, 'familial mitral regurgitation' was reported in 28 patients with Barlow's disease (26%), 15 patients (8%) with fibro-elastic deficiency and eight (9%) with Barlow forme fruste (P < 0.001).ConclusionsIn a large cohort of patients operated for mitral valve prolapse, the self-reported prevalence of familial mitral regurgitation was 26% in patients with Barlow's disease and still 8% in patients with fibro-elastic deficiency, highlighting the importance of familial anamnesis and echocardiographic screening in all mitral valve prolapse patients.

Project description:BackgroundAppropriate surgical management of moderate functional mitral regurgitation (MR) at the time of coronary artery bypass graft (CABG) surgery remains controversial. A recent study demonstrated no survival benefit from adding mitral repair to CABG for patients with moderate functional MR. Preoperative prediction of reverse remodelling is crucial in making the decision to add mitral valve repair to CABG. Late gadolinium-enhanced magnetic resonance imaging (LGE MRI) offers a reference method to assess myocardial viability.Case summaryA 60-year-old man with ischaemic cardiomyopathy was admitted to our hospital with exacerbation of heart failure symptoms. Left ventricular (LV) dilatation, severe impairment of LV systolic function, and moderate MR due to tethering were noted on transthoracic echocardiography. The mitral regurgitant jet was central. Intravenous administration of furosemide and human atrial natriuretic peptide was initiated. The patient experienced an episode of ventricular tachycardia, and coronary angiography demonstrated triple-vessel disease. On LGE MRI, subendocardial infarction with a transmural extent of 25-50% was revealed in the inferior, posterior, and lateral walls. Findings from LGE MRI suggested that myocardial viability had been preserved. After performing CABG and cardiac resynchronization therapy, LV volume was substantially decreased and moderate MR was significantly improved without surgical mitral repair. On speckle tracking echocardiography before surgery, a significant difference in the times to peak radial strain between the lateral wall (462 ms) and inferior wall (17 ms) indicated the presence of LV dyssynchrony. Left ventricular dyssynchrony was substantially improved after CABG and cardiac resynchronization therapy defibrillator implantation.DiscussionIn patients with ischaemic cardiomyopathy and moderate functional MR, acquisition of LGE MRI of the LV should be considered to evaluate the viability of LV myocardium. Findings from LGE MRI of the LV can potentially influence the surgical strategy. In patients with preserved viability of LV myocardium, functional MR could be improved after CABG without any surgical repair.

Project description:OBJECTIVES:The Cardiothoracic Surgical Trials Network recently reported no difference in the primary end point of left ventricular end-systolic volume index at 1 year postsurgery in patients randomized to repair (n = 126) or replacement (n = 125) for severe ischemic mitral regurgitation. However, patients undergoing repair experienced significantly more recurrent mitral regurgitation than patients undergoing replacement (32.6% vs 2.3%). We examined whether baseline echocardiographic and clinical characteristics could identify those who will develop moderate/severe recurrent mitral regurgitation or die. METHODS:Our analysis includes 116 patients who were randomized to and received mitral valve repair. Logistic regression was used to estimate a model-based probability of recurrence or death from baseline factors. Receiver operating characteristic curves were constructed from these estimated probabilities to determine classification cut-points maximizing accuracy of prediction based on sensitivity and specificity. RESULTS:Of the 116 patients, 6 received a replacement before leaving the operating room; all other patients had mild or less mitral regurgitation on intraoperative echocardiogram after repair. During the 2-year follow-up period, 76 patients developed moderate/severe mitral regurgitation or died (53 mitral regurgitation recurrences, 13 mitral regurgitation recurrences and death, and 10 deaths). The mechanism for recurrent mitral regurgitation was largely mitral valve leaflet tethering. Our model (including age, body mass index, sex, race, effective regurgitant orifice area, basal aneurysm/dyskinesis, New York Heart Association class, history of coronary artery bypass grafting, percutaneous coronary intervention, or ventricular arrhythmias) yielded an area under the receiver operating characteristic curve of 0.82. CONCLUSIONS:The model demonstrated good discrimination in identifying patients who will survive 2 years without recurrent mitral regurgitation after mitral valve repair. Although our results require validation, they offer a clinically relevant risk score for selection of surgical candidates for this procedure.

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Mitral Regurgitation: Anatomy, Physiology, and Pathophysiology-Lessons Learned From Surgery and Cardiac Imaging.

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Mitral Regurgitation: Anatomy, Physiology, and Pathophysiology-Lessons Learned From Surgery and Cardiac Imaging.

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