Assessment of Functional Anatomy of the Mitral Valve and...
Transcript of Assessment of Functional Anatomy of the Mitral Valve and...
-
Assessment of Functional
Anatomy of the Mitral Valve
and Left Ventricle in Ischemic
Cardiomyopathy with
Multislice Computed
Tomography:
Characteristics Associated
with Mitral Regurgitation
Natalia Solowjowa, Berlin 30.03.2015
-
Why are detailed anatomical studies in functional mitral
regurgitation essential?
- Successful valve repair must target the mechanism of
dysfunction in the individual patient taking into account
specific changes in mitral and ventricular geometry
- Techniques that can be potentially used:
- restrictive annuloplasty
- cutting or translocation of secondary chordae
- papillary muscle approximation or relocation
- LV restoration
- Revealing the predictors for failure of MV repair is essential
for the choice of therapeutic alternatives (LVAD etc.)
DHZB | Assessment of Functional Anatomy of the MV and LV in Ischemic Cardiomyopathy with Multislice Computed Tomography | Berlin 30.03.2015
2
-
DHZB | Assessment of Functional Anatomy of the MV and LV in Ischemic Cardiomyopathy with Multislice Computed Tomography | Berlin 30.03.2015
3
-
Mitral valve remodeling:
postero-lateral + antero-apical scar, papillary muscle involvement
DHZB | Assessment of Functional Anatomy of the MV and LV in Ischemic Cardiomyopathy with Multislice Computed Tomography | Berlin 30.03.2015
4
-
DHZB | Assessment of Functional Anatomy of the MV and LV in Ischemic Cardiomyopathy with Multislice Computed Tomography | Berlin 30.03.2015
5
Mitral valve remodeling:
huge antero-apical scar, intact papillary muscles
-
MSCT is increasingly applied to study
MV and LV anatomy
▪ Advantages:
▪ Spatial resolution of up to 0.33 mm
▪ Only one scan necessary, scan time for full cardiac CTA
-
Study population : 121 consecutive patients with
ischemic cardiomyopathy ( 2010-2015 )
Baseline characteristics
DHZB | Assessment of Functional Anatomy of the MV and LV in Ischemic Cardiomyopathy with Multislice Computed Tomography | Berlin 30.03.2015
7
MR < 2.0 ( n=87 ) MR ≥ 2.0 ( n=34 ) P-value
Median age (range), years 66.0 (38.0-78.0) 64.8 (37.0-79.0)
Female gender, n (%) 16 (18.4) 4 (11.8) 0.277
Body surface area (sqm) 1.97 ± 0.2 1.98 ± 0.2 0.732
Diabetes mellitus, n (%) 11 (27.6) 11 (32.4) 0.379
Hypertension, n (%) 47 (54.0) 26 (76.5) 0.018
Hypercholesterolemia, n (%) 44 (50.6) 24 (70.6) 0.036
History of atrial fibrillation, n (%) 13 (14.9) 13 (38.2) 0.006
NYHA Class ≥ III, n (%) 68 (78.2) 27 (79.4) 0.856
LVEF (Echo), % 26.5 ± 8.0 24.8 ± 7.4 0.268
LV EDD (Echo), mm 61.4 ± 8.7 65.6 ± 8.6 0.022
Triple vessel disease, n (%) 51 (58.6) 26 (76.5) 0.001
-
Volumetric and geometric parameters of LV and LA
measured in CT scans
DHZB | Assessment of Functional Anatomy of the MV and LV in Ischemic Cardiomyopathy with Multislice Computed Tomography | Berlin 30.03.2015
8
MR < 2.0 ( n=87 ) MR ≥ 2.0 ( n=34 ) p value
LV-EDVI, ml/sqm 151.8 ± 46.2 159.6 ± 52.0 0.448
LV-ESVI, ml/sqm 108.6 ± 43.4 110.9 ± 51.2 0.812
SVI, ml/sqm 43.2 ± 12.2 44.5 ± 10.9 0.562
LV EF, % 29.9 ± 9.0 29.1 ± 8.0 0.616
LA-VI, ml/qm 56.3 ± 17.1 73.3 ± 24.8 0.001
SI vol diast. 0.42 ± 0.09 0.48 ± 0.1 0.009
SI vol syst. 0.34 ± 0.1 0.41 ± 0.14 0.014
LV-EDVI, LV-ESVI – LV end diastolic and end systolic volume index;
SVI – stroke volume index; LV EF – LV ejection fraction;
LA-VI – left atrium volume index;
SI vol - volumetric sphericity index, diastolic and systolic
( all values as mean ±SD ).
Volumetric sphericity index =
LV volume/ LV long axis3× 𝜋/ 6
-
Segmental geometric indices of mitral valve
by computed tomography
DHZB | Assessment of Functional Anatomy of the MV and LV in Ischemic Cardiomyopathy with Multislice Computed Tomography | Berlin 30.03.2015
9
MR < 2.0
( n=87 )
MR ≥ 2.0
( n=34 ) p value
ICD, mm 40.6 ± 3.6 42.8 ± 5.9 0.048
APD, mm 26.8 ± 9.0 29.9 ± 3.8 0.000
MVAA, sqcm 10.2 ± 2.2 13.83 ± 1.4 0.014
CD A1-P1, mm 7.2 ± 1.9 8.0 ± 2.2 0.09
CD A2-P2, mm 8.6 ± 2.0 10.4 ± 2.3 0.000
CD A3-P3, mm 7.6 ± 2.0 8.7 ± 2.3 0.011
CL A2-P2, mm 4.1 ± 1.7 3.4 ± 1.8 0.055
TA A2-P2, sqcm 1.64 ± 0.6 2.26 ± 0.9 0.001
ICD and APD – intercommissural and
anteroposterior MV annulus diameter;
MVAA – MV annulus area;
CD A1-3 - P1-3 – coaptation distance at the level
of mitral segments A1-P1, A2-P2, A3-P3;
CL and TA A2-P2 – coaptation length and
tenting area at the level of mitral segments A2-P2
( all values as mean ±SD )
-
Segmental angular indices of mitral valve
by computed tomography
DHZB | Assessment of Functional Anatomy of the MV and LV in Ischemic Cardiomyopathy with Multislice Computed Tomography | Berlin 30.03.2015
10
MR < 2.0
( n=87 )
MR ≥ 2.0
( n=34 ) p Value
AMAA, degree 122.6 ± 11.2° 120.5 ± 22.2° 0.585
ALA Aα1, degree 23.8 ± 6.3° 24.1 ± 5.8° 0.803
ALA Aα2, degree 26.9 ± 7.8° 27.9 ± 6.8° 0.930
ALA Aα3, degree 25.1 ± 7.1° 24.6 ± 5.9° 0.663
APA Pα1, degree 37.2 ± 11.2° 35.5 ± 12.0° 0.484
APA Pα2, degree 41.9 ± 12.3° 42.2 ± 10.9° 0.889
APA Pα3, degree 37.2 ± 10.8° 38.3 ± 9.3° 0.580
A1-P1
A2-P2
A3-P3
MVA
AMAA – aortic-mitral annular angle;
ALA Aα1-3 and APA Pα1-3 – anterior and posterior mitral leaflet
angle at the level of mitral segments A1-P1, A2-P2 and A3-P3
(all values as mean ±SD)
-
Indices of submitral apparatus
by computed tomography
DHZB | Assessment of Functional Anatomy of the MV and LV in Ischemic Cardiomyopathy with Multislice Computed Tomography | Berlin 30.03.2015
11
MR < 2.0
( n=87 )
MR ≥ 2.0
( n=34 ) p Value
IMD, mm 33.7 ± 7.3 35.7 ± 8.8 0.252
AnAPMD, mm 24.8 ± 4.5 24.3 ± 4.7 0.420
AnPPMD, mm 26.4 ± 4.3 28.4 ± 4.8 0.044
AnAPMA, degree 93.4 ± 11.3° 91.5 ± 9.4° 0.342
AnPPMA, degree 84.3 ± 9.7° 87.2 ± 14.4° 0.295
IMD – interpapillary muscle distance,
AnAPMD, AnPPMD – distance between MV annulus and
anterior and posterior papillary muscle head
(papillary muscle tethering length);
AnAPMA, AnPPMA – angle between MV annulus and
anterior and posterior papillary muscle head
(papillary muscle anterior and posterior angle) –
all values as mean ±SD
-
Distribution of regional wall motion abnormalities
12
50%
31%
10%
9%
antero-apical
antero-apical+postero-lateral
lateral+postero-lateral
global hypokinesis
18%
29% 41%
12%
antero-apical
antero-apical+postero-lateral
lateral+postero-lateral
global hypokinesis
DHZB | Assessment of Functional Anatomy of the MV and LV in Ischemic Cardiomyopathy with Multislice Computed Tomography | Berlin 30.03.2015
-
Motion abnormalities of papillary muscles
and load bearing LV wall
24,1%
47,1%
36,8%
51,7%
35,3%
70,6%
38,2%
82,8%
0,0%
10,0%
20,0%
30,0%
40,0%
50,0%
60,0%
70,0%
80,0%
90,0%
APM PPM ABW PBW
*
13 DHZB | Assessment of Functional Anatomy of the MV and LV in Ischemic Cardiomyopathy with Multislice Computed Tomography | Berlin 30.03.2015
*
-
Results
DHZB | Assessment of Functional Anatomy of the MV and LV in Ischemic Cardiomyopathy with Multislice Computed Tomography | Berlin 30.03.2015
14
▪ MSCT-based measurements demonstrate:
▪ significantly higher LV sphericity, larger left atrial volume and significantly
more advanced changes in segmental geometric indices of mitral valve
in severe FMR
▪ no significant differences in segmental angular indices of mitral valve
between our study groups with moderate and severe FMR
▪ essentially different distribution of regional wall motion abnormalities in study
groups with prevalence of lateral and postero-lateral localization in severe FMR
▪ significantly higher prevalence of motion abnormalities of posterior papillary
muscles and corresponding load bearing LV wall in severe FMR
-
Conclusions
DHZB | Assessment of Functional Anatomy of the MV and LV in Ischemic Cardiomyopathy with Multislice Computed Tomography | Berlin 30.03.2015
15
This study provides further evidence for the decisive role of adverse mitral
and ventricular geometry in the mechanism of ischemic mitral regurgitation
The MSCT imaging approach described here can be used for surgery for FMR
to target the individual mechanisms with:
- annuloplasty techniques
- chordae cutting or translocation
- papillary muscle repositioning
- different procedures of LV restoration or biventricular pacing
Further studies of unbalanced tethering and role of papillary muscles
can help to specify the mechanisms of FMR
-
Thank you for your attention
Deutsches Herzzentrum Berlin
Stiftung des bürgerlichen Rechts
Augustenburger Platz 1
13353 Berlin
Telefon: +49 30 4593-1000
Telefax: +49 30 4593-1003
E-Mail: [email protected]
www.dhzb.de
-
Improvement of MV Geometry after SVR
DHZB | Assessment of Functional Anatomy of the MV and LV in Ischemic Cardiomyopathy with Multislice Computed Tomography | Berlin 30.03.2015
17
-
Headline Arial Bold 28 pt Subheadline Arial Regular 22 pt lorem
DHZB | Titel der Präsentation | Berlin 15.01.2015 18