Examination of Anterior Leaflet Pseudoprolapse Causing Severe Mitral Regurgitation and Its Ideal Surgical Procedure
DOI:
https://doi.org/10.1532/hsf.2895Keywords:
Pseudoprolapse, Annuloplasty, Mitral valve, Mitral repair, Atrial functional mitral regurgitationAbstract
Background: The aim of this study is to evaluate severe mitral regurgitation caused by so called atrial leaflet “pseudoprolapse” and verify the effect of simple
annular stabilization.
Methods: One-hundred-twenty-two patients underwent surgery for severe mitral regurgitation at our institute between January 2015 to July 2018. Of those, 32 cases diagnosed as anterior leaflet prolapse that underwent mitral repair were analyzed. Ten cases with pseudoprolapse, which is defined as anterior leaflet prolapse without dropping into the left atrium beyond the annular line causing eccentric regurgitation flow directed to the posterior atrium, were classified as the Pseudoprolapse Group. The other 22 cases had obvious anterior leaflet prolapse dropping into the left atrium; these cases were classified as the True Prolapse Group. We compared clinical findings between the 2 groups and reviewed pseudoprolapse cases.
Results: Patients in the Pseudoprolapse Group had lower ejection fraction and lower regurgitation volume than those in the True Prolapse Group. A2 lesion as main inflow of regurgitation was more included in the
Pseudoprolapse Group. All but one patient in the
Pseudoprolapse Group received only simple annuloplasty, and all patients in the True Prolapse Group received leaflet repair and annuloplasty. In both groups, mid-term regurgitation grade and the reoperation rate were satisfactory. In the Pseudoprolapse Group, 6 cases were clarified as atrial functional mitral regurgitation, and 4 cases were considered to have focal posterior leaflet tethering.
Conclusions: Pseudoprolapse cases could be characterized by low ejection fraction, low regurgitation volume, and A2 prolapse. For most cases with pseudoprolapse, simple annuloplasty may be enough, however further study
is needed.
References
Agricola E, Oppizzi M, Maisano F et al. 2004. Echocardiographic classification of chronic ischemic mitral regurgitation caused by restricted motion according to tethering pattern. Eur J Echocardiogr 5:326-34.
Berdejo J, Shiota M, Mihara H, Itabashi Y, Utsunomiya H, Shiota T. 2017. Vena contracta analysis by color Doppler three-dimensional transesophageal echocardiography shows geometrical differences between prolapse and pseudoprolapse in eccentric mitral regurgitation. Echocardiography 34:683-689.
Carpentier A, Chauvaud S, Fabiani JN et al. 1980. Reconstructive surgery of mitral valve incompetence: ten-year appraisal. J Thorac Cardiovasc Surg 79:338-48.
Cong T, Gu J, Lee AP et al. 2018. Quantitative analysis of mitral valve morphology in atrial functional mitral regurgitation using real-time 3-dimensional echocardiography atrial functional mitral regurgitation. Cardiovasc Ultrasound 16:13.
El Sabbagh A, Reddy YNV, Nishimura RA. 2018. Mitral Valve Regurgitation in the Contemporary Era: Insights Into Diagnosis, Management, and Future Directions. JACC Cardiovasc Imaging 11:628-643.
Gelsomino S, Lorusso R, Caciolli S et al. 2008. Insights on left ventricular and valvular mechanisms of recurrent ischemic mitral regurgitationafter restrictive annuloplasty and coronary artery bypass grafting. J Thorac Cardiovasc Surg 136:507-18.
Gertz ZM, Raina A, Saghy L et al. 2011. Evidence of atrial functional mitral regurgitation due to atrial fibrillation: reversal with arrhythmiacontrol. J Am Coll Cardiol 58:1474-81.
Hashim SW, Youssef SJ, Ayyash B et al. 2012. Pseudoprolapse of the anterior leaflet in chronic ischemic mitral regurgitation: identification and repair. J Thorac Cardiovasc Surg 143:S33-7.
Kawazoe K, Beppu S, Takahara Y et al. 1983. Surgical treatment of giant left atrium combined with mitral valvular disease. J Thorac Cardiovasc 85:885-892.
Levi GS, Bolling SF, Bach DS. 2001. Eccentric mitral regurgitation jets among patients having sustained inferior wall myocardial infarction. Echocardiography 18:97-103.
Liang JJ, Silvestry FE. 2016. Mechanistic insights into mitral regurgitation due to atrial fibrillation: "Atrial functional mitral regurgitation". Trends Cardiovasc Med 26:681-689.
Machino-Ohtsuka T, Seo Y, Ishizu T et al. 2016. Novel Mechanistic Insights Into Atrial Functional Mitral Regurgitation- 3-Dimensional Echocardiographic Study. Circ J 80:2240-8.
Otsuji Y, Handschumacher MD, Schwammenthal E et al. 1997. Insights from three-dimensional echocardiography into the mechanism of functional mitral regurgitation: direct in vivo demonstration of altered leaflet tethering geometry. Circulation 96:1999-2008.
Pecha S, Hakmi S, Subbotina I, Willems S, Reichenspurner H, Wagner FM. 2015. Concomitant surgical ablation for atrial fibrillation (AF) in patients with significant atrial dilation >55 mm. Worth the effort? J Cardiothorac Surg 10:165.
Ring L, Dutka DP, Wells FC, Fynn SP, Shapiro LM, Rana BS. 2014. Mechanisms of atrial mitral regurgitation: insights using 3D transoesophageal echo. Eur Heart J Cardiovasc Imaging 15:500-8.
Saito C, Minami Y, Arai K et al. 2018. Prevalence, clinical characteristics, and outcome of atrial functional mitral regurgitation in hospitalized heart failure patients with atrial fibrillation. J Cardiol 72:292-299.
Silbiger JJ. 2014. Does left atrial enlargement contribute to mitral leaflet tethering in patients with functional mitral regurgitation? Proposed role of atriogenic leaflet tethering. Echocardiography 31:1310-1.
Silbiger JJ. 2019. Mechanistic insights into atrial functional mitral regurgitation: Far more complicated than just left atrial remodeling. Echocardiography 36:164-169.
Takahashi Y, Abe Y, Sasaki Y et al. 2015. Mitral valve repair for atrial functional mitral regurgitation in patients with chronic atrial fibrillation. Interact Cardiovasc Thorac Surg 21:163-8.
Takahashi Y, Shibata T, Hattori K et al. 2014. Extended posterior leaflet extension for mitral regurgitation in giant left atrium. J Heart Valve Dis 23:88-90.
Yamano T, Furukawa K, Matoba S. 2016. "Hamstring Leaflet" Now Demonstrated to Be a Determinant of Functional Mitral Regurgitation in Patients With Atrial Fibrillation. Circ J 80:2098-9.
Zeng X, Nunes MC, Dent J et al. 2014. Asymmetric versus symmetric tethering patterns in ischemic mitral regurgitation: geometric differences from three-dimensional transesophageal echocardiography. J Am Soc Echocardiogr 27:367-75.
