Advertisement

Sizing the mitral annulus in healthy subjects and patients with mitral regurgitation: 2D versus 3D measurements from cardiac CT

  • Sonja Gordic
  • Thi Dan Linh Nguyen-Kim
  • Robert Manka
  • Simon Sündermann
  • Thomas Frauenfelder
  • Francesco Maisano
  • Volkmar Falk
  • Hatem Alkadhi
Original paper

Abstract

The purpose of our study was (1) to assess retrospectively, in healthy subjects and in patients with moderate and severe functional mitral regurgitation (FMR), the normal mitral annular dimensions, (2) to determine differences in mitral annular geometry between healthy subjects and patients with FMR, and (3) to evaluate potential errors in 2-dimensional (2D) measurements given the 3D nature of the mitral annulus. 15 patients with no cardiac abnormalities (referred to as normals), 13 with moderate and 15 with severe FMR as determined by echocardiography underwent contrast-enhanced cardiac 64-slice Computed tomography (CT) with prospective electrocardiography-gating for excluding coronary artery disease. With an advanced visualization, segmentation, and image analysis software, the area, intercommissural distance (CC), septolateral distance (SLD), and the anterior and posterior circumference of the MA were measured in diastole. We found significant (P < .001) differences between normals and patients with severe FMR for area, SLD and posterior circumference in 3D (P < .001) and 2D (P < .001). Similarly, the SLD and the posterior circumference in both 3D (P = .002) and 2D (P = .001) were significantly smaller in patients with moderate FMR as compared to those with severe FMR. In contrast, there were no significant differences between groups regarding the CC and the anterior circumference both in 3D and 2D (all, P > .05). Measurements in 3D differed significantly from those with 2D for all circumference measurements and groups (P < .01), with a systematic underestimation of the posterior circumference of 2.1 ± 1.5 mm in normals, 1.8 ± 1.3 mm in patients with moderate FMR, and 1.9 ± 1.9 mm in patients with severe FMR for 2D. Our study provides in vivo human CT data on MA dimensions in normals and patients with FMR, indicating differences in patients for the area, posterior circumference and SLD but not for the anterior circumference and CC. Systematic differences exist between 2D and 3D measurements for all circumferential measurements.

Keywords

Mitral annulus Circumference Mitral regurgitation Computed tomography 

Notes

Conflict of interest

Francesco Maisano and Volkmar Falk are consultants for Valtech Cardio Ltd.

References

  1. 1.
    Adams DH, Rosenhek R, Falk V (2010) Degenerative mitral valve regurgitation: best practice revolution. Eur Heart J 31:1958–1966PubMedCrossRefGoogle Scholar
  2. 2.
    De Bonis M, Maisano F, La Canna G, Alfieri O (2012) Treatment and management of mitral regurgitation. Nat Rev Cardiol 9:133–146CrossRefGoogle Scholar
  3. 3.
    Iung B, Vahanian A (2011) Epidemiology of valvular heart disease in the adult. Nat Rev Cardiol 8:162–172PubMedCrossRefGoogle Scholar
  4. 4.
    Hueb AC, Jatene FB, Moreira LF, Pomerantzeff PM, Kallas E, de Oliveira SA (2002) Ventricular remodeling and mitral valve modifications in dilated cardiomyopathy: new insights from anatomic study. J Thorac Cardiovasc Surg 124:1216–1224PubMedCrossRefGoogle Scholar
  5. 5.
    Fedak PW, McCarthy PM, Bonow RO (2008) Evolving concepts and technologies in mitral valve repair. Circulation 117:963–974PubMedCrossRefGoogle Scholar
  6. 6.
    Greelish JP, Cohn LH, Leacche M et al (2003) Minimally invasive mitral valve repair suggests earlier operations for mitral valve disease. J Thorac Cardiovasc Surg 126:365–371 (; discussion 371–373)PubMedCrossRefGoogle Scholar
  7. 7.
    Nifong LW, Chu VF, Bailey BM et al (2003) Robotic mitral valve repair: experience with the da Vinci system. Ann Thorac Surg 75:438–442 (; discussion 443)PubMedCrossRefGoogle Scholar
  8. 8.
    Ender J, Koncar-Zeh J, Mukherjee C et al (2008) Value of augmented reality-enhanced transesophageal echocardiography (TEE) for determining optimal annuloplasty ring size during mitral valve repair. Ann Thorac Surg 86:1473–1478PubMedCrossRefGoogle Scholar
  9. 9.
    Mirabel M, Iung B, Baron G et al (2007) What are the characteristics of patients with severe, symptomatic, mitral regurgitation who are denied surgery? Eur Heart J 28:1358–1365PubMedCrossRefGoogle Scholar
  10. 10.
    Chiam PT, Ruiz CE (2011) Percutaneous transcatheter mitral valve repair: a classification of the technology. JACC Cardiovasc Interv 4:1–13PubMedCrossRefGoogle Scholar
  11. 11.
    Banai S, Jolicoeur EM, Schwartz M et al (2012) Tiara: a novel catheter-based mitral valve bioprosthesis: initial experiments and short-term pre-clinical results. J Am Coll Cardiol 60:1430–1431PubMedCrossRefGoogle Scholar
  12. 12.
    von Ballmoos MW, Haring B, Juillerat P, Alkadhi H (2011) Meta-analysis: diagnostic performance of low-radiation-dose coronary computed tomography angiography. Ann Intern Med 154:413–420CrossRefGoogle Scholar
  13. 13.
    Ewe SH, Klautz RJ, Schalij MJ, Delgado V (2011) Role of computed tomography imaging for transcatheter valvular repair/insertion. Int J Cardiovasc Imaging 27:1179–1193PubMedCentralPubMedCrossRefGoogle Scholar
  14. 14.
    Wildermuth S, Leschka S, Duru F, Alkadhi H (2005) 3-D CT for cardiovascular treatment planning. Eur Radiol 15(Suppl 4):D110–D115PubMedCrossRefGoogle Scholar
  15. 15.
    Cremer J, Teebken OE, Simon A, Hutzelmann A, Heller M, Haverich A (1998) Thoracic computed tomography prior to redo coronary surgery. Eur J Cardiothorac Surg 13:650–654PubMedCrossRefGoogle Scholar
  16. 16.
    Delgado V, Tops LF, Schuijf JD et al (2009) Assessment of mitral valve anatomy and geometry with multislice computed tomography. JACC Cardiovasc Imaging 2:556–565PubMedCrossRefGoogle Scholar
  17. 17.
    Alkadhi H, Desbiolles L, Stolzmann P et al (2009) Mitral annular shape, size, and motion in normals and in patients with cardiomyopathy: evaluation with computed tomography. Invest Radiol 44:218–225PubMedCrossRefGoogle Scholar
  18. 18.
    Deng W, Yang ZG, Peng LQ, Dong ZH, Chu ZG, Wang QL (2010) Morphological and dynamic features of normal mitral valve evaluated by dual-source computed tomography. Int J Cardiol 145:633–636PubMedCrossRefGoogle Scholar
  19. 19.
    Wilson PWF, D’Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB (1998) Prediction of coronary heart disease using risk factor categories. Circulation 97:1837–1847PubMedCrossRefGoogle Scholar
  20. 20.
    Alkadhi H, Stolzmann P, Scheffel H et al (2008) Radiation dose of cardiac dual-source CT: the effect of tailoring the protocol to patient-specific parameters. Eur J Radiol 68:385–391PubMedCrossRefGoogle Scholar
  21. 21.
    Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33:159–174PubMedCrossRefGoogle Scholar
  22. 22.
    Mandinov L (2010) Mitralign Percutaneous Annuloplasty System for the Treatment of Functional Mitral Regurgitation. Eur Cardiol 6(2):67–70Google Scholar
  23. 23.
    Maisano F, Vanermen H, Seeburger J et al (2012) Direct access transcatheter mitral annuloplasty with a sutureless and adjustable device: preclinical experience. Eur J Cardiothorac Surg 42:524–529PubMedCrossRefGoogle Scholar
  24. 24.
    Gunnal SA, Farooqui MS, Wabale RN (2012) Study of mitral valve in human cadaveric hearts. Heart Views 13:132–135PubMedCentralPubMedCrossRefGoogle Scholar
  25. 25.
    Bulkley BH, Roberts WC (1975) Dilatation of the mitral anulus. A rare cause of mitral regurgitation. Am J Med 59:457–463PubMedCrossRefGoogle Scholar
  26. 26.
    Rusted IE, Scheifley CH, Edwards JE (1952) Studies of the mitral valve. I. Anatomic features of the normal mitral valve and associated structures. Circulation 6:825–831PubMedCrossRefGoogle Scholar
  27. 27.
    Chiechi MA, Lees WM, Thompson R (1956) Functional anatomy of the normal mitral valve. J Thorac Surg 32:378–398PubMedGoogle Scholar
  28. 28.
    Duplessis LA, Marchand P (1964) The Anatomy of the Mitral Valve and Its Associated Structures. Thorax 19:221–227PubMedCrossRefGoogle Scholar
  29. 29.
    McAlpine WA (1975) Heart and Coronary Arteries. Springer Verlag, New YorkCrossRefGoogle Scholar
  30. 30.
    Ormiston JA, Shah PM, Tei C, Wong M (1981) Size and motion of the mitral valve annulus in man. I. A 2-dimensional echocardiographic method and findings in normal subjects. Circulation 64:113–120PubMedCrossRefGoogle Scholar
  31. 31.
    Levine RA, Handschumacher MD, Sanfilippo AJ et al (1989) Three-dimensional echocardiographic reconstruction of the mitral valve, with implications for the diagnosis of mitral valve prolapse. Circulation 80:589–598PubMedCrossRefGoogle Scholar
  32. 32.
    Khabbaz KR, Mahmood F, Shakil O et al (2013) Dynamic 3-dimensional echocardiographic assessment of mitral annular geometry in patients with functional mitral regurgitation. Ann Thorac Surg 95:105–110PubMedCrossRefGoogle Scholar
  33. 33.
    Maffessanti F, Gripari P, Pontone G, et al. (2013) Three-dimensional dynamic assessment of tricuspid and mitral annuli using cardiovascular magnetic resonance. Eur Heart J Cardiovasc ImagingGoogle Scholar
  34. 34.
    Timek TA, Miller DC (2001) Experimental and clinical assessment of mitral annular area and dynamics: what are we actually measuring? Ann Thorac Surg 72:966–974PubMedCrossRefGoogle Scholar
  35. 35.
    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 96:1999–2008PubMedCrossRefGoogle Scholar
  36. 36.
    Carpentier A, Chauvaud S, Fabiani JN et al (1980) Reconstructive surgery of mitral valve incompetence: 10-year appraisal. J Thorac Cardiovasc Surg 79:338–348PubMedGoogle Scholar
  37. 37.
    Choo SJ, Olomon J, Bowles C et al (1998) An in vitro study of the correlation between aortic valve diameter and mitral intertrigonal distance: a simple method to select the correct mitral annuloplasty ring size. J Heart Valve Dis 7:593–597PubMedGoogle Scholar
  38. 38.
    Tibayan FA, Rodriguez F, Langer F et al (2003) Annular remodeling in chronic ischemic mitral regurgitation: ring selection implications. Ann Thorac Surg 76:1549–1554 (; discussion 1554–1555)PubMedCrossRefGoogle Scholar
  39. 39.
    Kaji S, Nasu M, Yamamuro A et al (2005) Annular geometry in patients with chronic ischemic mitral regurgitation: three-dimensional magnetic resonance imaging study. Circulation 112:I409–I414PubMedGoogle Scholar
  40. 40.
    Ender J, Eibel S, Mukherjee C et al (2011) Prediction of the annuloplasty ring size in patients undergoing mitral valve repair using real-time three-dimensional transoesophageal echocardiography. Eur J Echocardiogr 12:445–453PubMedCentralPubMedCrossRefGoogle Scholar
  41. 41.
    Bartel T (2013) Contemporary echocardiographic guiding tools for device closure of interatrial communications. Cardiovasc Diagn Ther 3(1):38–46PubMedCentralPubMedGoogle Scholar
  42. 42.
    Sundermann SH, Gessat M, Cesarovic N et al (2013) Implantation of personalized, biocompatible mitral annuloplasty rings: feasibility study in an animal model. Interact Cardiovasc Thorac Surg 16:417–422PubMedCrossRefGoogle Scholar
  43. 43.
    De Bonis M, Maisano F, La Canna G, Alfieri O (2012) Treatment and management of mitral regurgitation. Nat Rev Cardiol 9:133–146CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2013

Authors and Affiliations

  • Sonja Gordic
    • 1
  • Thi Dan Linh Nguyen-Kim
    • 1
  • Robert Manka
    • 1
    • 2
    • 4
  • Simon Sündermann
    • 3
  • Thomas Frauenfelder
    • 1
  • Francesco Maisano
    • 3
  • Volkmar Falk
    • 3
  • Hatem Alkadhi
    • 1
  1. 1.Institute of Diagnostic and Interventional RadiologyUniversity Hospital ZurichZurichSwitzerland
  2. 2.Clinic for CardiologyUniversity Hospital ZurichZurichSwitzerland
  3. 3.Clinic for Cardiovascular SurgeryUniversity Hospital ZurichZurichSwitzerland
  4. 4.Institute for Biomedical EngineeringUniversity and ETH ZurichZurichSwitzerland

Personalised recommendations