The mechanism of volume-related mitral regurgitation from anatomy of mitral valve_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

REN Yan ¹ , BAI Wenjuan ³ , YAN Ling ³ , XIE lin ² , RUAN Weiqiang ² , XU Tiewei ² , GAN Changping ² ,  DIAN Ke ²

1. Department of Cardiovascular Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, 563000, Guizhou, P.R.China;
2. Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, 610041, P.R.China;
3. Department of Echocardiography, West China Hospital, Sichuan University, Chengdu, 610041, P.R.China;

Corresponding author：

DIAN Ke, Email: edidian@163.com

Keywords：

Volume related; mitral regurgitation; ventricular septal defect; mechanism; surgery

DOI：

10.7507/1007-4848.202009006

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Objective To explore the mechanism of volume-related mitral regurgitation (MR) from the anatomy of mitral valve.Methods A total of 32 patients with ventricular septal defect (VSD) combined MR meeting inclusion criteria in West China Hospital from September 2018 to November 2019 were enrolled in this study. The direction relative to the cardiac axis: the deviation of the MR bundle along the left atrial wall was eccentric, otherwises it was central. There were 23 patients of VSD and eccentric MR (EMR, a VSD-EMR group), including 10 males and 13 females aged 21 (10, 56) months, and 9 patients of VSD and central MR (CMR, a VSD-CMR group), including 4 males and 5 females aged 26 (12, 87) months. Besides, 9 healthy children were enrolled in a control group, including 4 males and 5 females aged 49 (15, 72) months. All patients underwent transthoracic echocardiography (TTE) examination at 2 weeks before surgery and 6 months after surgery, respectively, The MR degree, end-diastolic volume (EDV), end-systolic volume (ESV), stroke volume (SV), ejection fraction (EF), antero-posterior diameter (AP), annulus circumference (AC), commissural diameter (CD) were assessed.Results Before operation, EDV, ESV, SV, AP, AC and CD in the VSD-EMR and VSD-CMR groups were significantly larger or longer than those in the control group (P<0.05); after operation, EDV, ESV, SV, AP and CD decreased compared with those before operation (P<0.05), but there was no significant difference compared with the control group (P>0.05). Compared with the control group, AC was slightly decreased (P<0.05). There was no significant difference in EF between and within groups before and after operation (P>0.05). The improvement rate of MR was 78.9% (15/19) in the VSD-EMR group and 100.0% (9/9) in the VSD-CMR group.Conclusion After unloading of volume, the valve structure is back to normal except AC. The improvement rate of MR in the VSD-EMR group is lower than that in the VSD-CMR group, which may indicate that the mechanism of VSD-EMR is more complicated.

Citation： REN Yan, BAI Wenjuan, YAN Ling, XIE lin, RUAN Weiqiang, XU Tiewei, GAN Changping, DIAN Ke. The mechanism of volume-related mitral regurgitation from anatomy of mitral valve. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2021, 28(4): 416-420. doi: 10.7507/1007-4848.202009006 Copy

1.	Otto CM. Clinical practice. Evaluation and management of chronic mitral regurgitation. N Engl J Med, 2001, 345(10): 740-746.
2.	Yiu SF, Enriquez-Sarano M, Tribouilloy C, et al. Determinants of the degree of functional mitral regurgitation in patients with systolic left ventricular dysfunction: A quantitative clinical study. Circulation, 2000, 102(12): 1400-1406.
3.	Otsuji Y, Handschumacher MD, Schwammenthal E, et al. Insights from three-dimensional echocardiography into the mechanism of functional mitral regurgitation: direct in vivo demonstration of altered leaflet tethering geometry. Circulation, 1997, 96(6): 1999-2008.
4.	Cho YS, Park SE, Hong SK, et al. The natural history of fetal diagnosed isolated ventricular septal defect. Prenat Diagn, 2017, 37(9): 889-893.
5.	李梦思, 李东旭, 殷小容, 等. 先天性膜周型室间隔缺损经胸封堵有效性及安全性的系统评价与Meta分析. 中国胸心血管外科临床杂志, 2019, 26(3): 251-259.
6.	Kulyabin YY, Soynov IA, Zubritskiy AV, et al. Does mitral valve repair matter in infants with ventricular septal defect combined with mitral regurgitation? Interact Cardiovasc Thorac Surg, 2018, 26(1): 106-111.
7.	Mavroudis C, Backer CL. 小儿心脏外科学. 4版. 刘锦纷, 译. 北京: 世界图书出版公司, 2014. 356-357.
8.	Kleinman CS, Tabibian M, Starc TJ, et al. Spontaneous regression of left ventricular dilation in children with restrictive ventricular septal defects. J Pediatr, 2007, 150(6): 583-586.
9.	Papadimitriou JM, Hopkins BE, Taylor RR. Regression of left ventricular dilation and hypertrophy after removal of volume overload. Morphological and ultrastructural study. Circ Res, 1974, 35(1): 127-135.
10.	Bolling SF, Pagani FD, Deeb GM, et al. Intermediate-term outcome of mitral reconstruction in cardiomyopathy. J Thorac Cardiovasc Surg, 1998, 115(2): 381-386.
11.	Bouma W, van der Horst IC, Wijdh-den Hamer IJ, et al. Chronic ischemic mitral regurgitation. Current treatment results and new mechanism-based surgical approaches. Eur J Cardiothorac Surg, 2010, 37(1): 170-185.
12.	Silbiger JJ. Mechanistic insights into ischemic mitral regurgitation: echocardiographic and surgical implications. J Am Soc Echocardiogr, 2011, 24(7): 707-719.
13.	Hung J, Papakostas L, Tahta SA, et al. Mechanism of recurrent ischemic mitral regurgitation after annuloplasty: continued LV remodeling as a moving target. Circulation, 2004, 110(11 Suppl 1): Ⅱ85-Ⅱ90.
14.	Magne J, Pibarot P, Dumesnil JG, et al. Continued global left ventricular remodeling is not the sole mechanism responsible for the late recurrence of ischemic mitral regurgitation after restrictive annuloplasty. J Am Soc Echocardiogr, 2009, 22(11): 1256-1264.
15.	Gelsomino S, Lorusso R, De Cicco G, et al. Five-year echocardiographic results of combined undersized mitral ring annuloplasty and coronary artery bypass grafting for chronic ischaemic mitral regurgitation. Eur Heart J, 2008, 29(2): 231-240.
16.	Acker MA, Jessup M, Bolling SF, et al. Mitral valve repair in heart failure: five-year follow-up from the mitral valve replacement stratum of the Acorn randomized trial. J Thorac Cardiovasc Surg, 2011, 142(3): 569-574.
17.	Digiammarco G, Liberi R, Giancane M, et al. Recurrence of functional mitral regurgitation in patients with dilated cardiomyopathy undergoing mitral valve repair: how to predict it. Interact Cardiovasc Thorac Surg, 2007, 6(3): 340-344.
18.	Jang WS, Kim WH, Cho JY, et al. Surgical indications and results of mitral valve repair in pediatric patients with ventricular septal defects accompanied by mitral valve regurgitation. Ann Thorac Surg, 2015, 99(3): 891-897.
19.	Levine RA. Dynamic mitral regurgitation—more than meets the eye. N Engl J Med, 2004, 351(16): 1681-1684.

1. Otto CM. Clinical practice. Evaluation and management of chronic mitral regurgitation. N Engl J Med, 2001, 345(10): 740-746.
2. Yiu SF, Enriquez-Sarano M, Tribouilloy C, et al. Determinants of the degree of functional mitral regurgitation in patients with systolic left ventricular dysfunction: A quantitative clinical study. Circulation, 2000, 102(12): 1400-1406.
3. Otsuji Y, Handschumacher MD, Schwammenthal E, et al. Insights from three-dimensional echocardiography into the mechanism of functional mitral regurgitation: direct in vivo demonstration of altered leaflet tethering geometry. Circulation, 1997, 96(6): 1999-2008.
4. Cho YS, Park SE, Hong SK, et al. The natural history of fetal diagnosed isolated ventricular septal defect. Prenat Diagn, 2017, 37(9): 889-893.
5. 李梦思, 李东旭, 殷小容, 等. 先天性膜周型室间隔缺损经胸封堵有效性及安全性的系统评价与Meta分析. 中国胸心血管外科临床杂志, 2019, 26(3): 251-259.
6. Kulyabin YY, Soynov IA, Zubritskiy AV, et al. Does mitral valve repair matter in infants with ventricular septal defect combined with mitral regurgitation? Interact Cardiovasc Thorac Surg, 2018, 26(1): 106-111.
7. Mavroudis C, Backer CL. 小儿心脏外科学. 4版. 刘锦纷, 译. 北京: 世界图书出版公司, 2014. 356-357.
8. Kleinman CS, Tabibian M, Starc TJ, et al. Spontaneous regression of left ventricular dilation in children with restrictive ventricular septal defects. J Pediatr, 2007, 150(6): 583-586.
9. Papadimitriou JM, Hopkins BE, Taylor RR. Regression of left ventricular dilation and hypertrophy after removal of volume overload. Morphological and ultrastructural study. Circ Res, 1974, 35(1): 127-135.
10. Bolling SF, Pagani FD, Deeb GM, et al. Intermediate-term outcome of mitral reconstruction in cardiomyopathy. J Thorac Cardiovasc Surg, 1998, 115(2): 381-386.
11. Bouma W, van der Horst IC, Wijdh-den Hamer IJ, et al. Chronic ischemic mitral regurgitation. Current treatment results and new mechanism-based surgical approaches. Eur J Cardiothorac Surg, 2010, 37(1): 170-185.
12. Silbiger JJ. Mechanistic insights into ischemic mitral regurgitation: echocardiographic and surgical implications. J Am Soc Echocardiogr, 2011, 24(7): 707-719.
13. Hung J, Papakostas L, Tahta SA, et al. Mechanism of recurrent ischemic mitral regurgitation after annuloplasty: continued LV remodeling as a moving target. Circulation, 2004, 110(11 Suppl 1): Ⅱ85-Ⅱ90.
14. Magne J, Pibarot P, Dumesnil JG, et al. Continued global left ventricular remodeling is not the sole mechanism responsible for the late recurrence of ischemic mitral regurgitation after restrictive annuloplasty. J Am Soc Echocardiogr, 2009, 22(11): 1256-1264.
15. Gelsomino S, Lorusso R, De Cicco G, et al. Five-year echocardiographic results of combined undersized mitral ring annuloplasty and coronary artery bypass grafting for chronic ischaemic mitral regurgitation. Eur Heart J, 2008, 29(2): 231-240.
16. Acker MA, Jessup M, Bolling SF, et al. Mitral valve repair in heart failure: five-year follow-up from the mitral valve replacement stratum of the Acorn randomized trial. J Thorac Cardiovasc Surg, 2011, 142(3): 569-574.
17. Digiammarco G, Liberi R, Giancane M, et al. Recurrence of functional mitral regurgitation in patients with dilated cardiomyopathy undergoing mitral valve repair: how to predict it. Interact Cardiovasc Thorac Surg, 2007, 6(3): 340-344.
18. Jang WS, Kim WH, Cho JY, et al. Surgical indications and results of mitral valve repair in pediatric patients with ventricular septal defects accompanied by mitral valve regurgitation. Ann Thorac Surg, 2015, 99(3): 891-897.
19. Levine RA. Dynamic mitral regurgitation—more than meets the eye. N Engl J Med, 2004, 351(16): 1681-1684.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

The mechanism of volume-related mitral regurgitation from anatomy of mitral valve

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