Ann Thorac Surg 2009;88:1202-1208. doi:10.1016/j.athoracsur.2009.04.112
© 2009 The Society of Thoracic Surgeons
Original Articles: Adult Cardiac
Is the Anterior Intertrigonal Distance Increased in Patients With Mitral Regurgitation Due to Leaflet Prolapse?
Rakesh M. Suri, MD, DPhil*,a,*,
Jasmine Grewal, MD*,b,
Sunil Mankad, MDb,
Maurice Enriquez-Sarano, MDb,
Fletcher A. Miller, Jr, MDb,
Hartzell V. Schaff, MDa
a Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
b Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
Accepted for publication April 24, 2009.
* Address correspondence to Dr Suri, Division of Cardiovascular Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (Email: suri.rakesh{at}mayo.edu).
Presented at the Poster Session of the Forty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Jan 26–28, 2009.
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Abstract
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Background: Severe mitral regurgitation (MR) leads to progressive enlargement of left ventricular dimensions and, consequently, the mitral valve (MV) annulus. Data from animal and cadaver studies suggest that the mitral annulus may dilate asymmetrically in certain conditions, which may influence the choice of valve repair technique. Although it is generally accepted that the posterior mitral annulus dilates in patients with severe MR due to leaflet prolapse, the stability of the anterior intertrigonal distance has not yet been demonstrated in humans.
Methods: We obtained real-time, three-dimensional (3D) transesophageal echocardiographic images of the MV in 44 patients: 29 patients scheduled to undergo MV repair for severe MR due to leaflet prolapse (MV disease group) and 15 normal outpatients undergoing evaluation for various reasons (control group). Mitral valve repair was performed by median sternotomy or minimally invasively using thoracoscopic or robotic assistance. All patients underwent implantation of a standard-length flexible 63-mm posterior annuloplasty band at the time of mitral repair and we obtained postoperative 3D images for 11 patients after separation from bypass. Mitral annular dimensions were measured throughout the cardiac cycle using reconstructive analysis software (QLAB MVQ Version 6.0; Phillips, Bothell, WA).
Results: The mean patient age was 60 years; 30 were men. The mean ejection fraction was 0.61 and was similar between the two groups (p = 0.16). In patients with MR due to leaflet prolapse, posterior annular length and total annular circumference were significantly larger than in control patients (p < 0.001). In contrast, there was no detectable difference in the anterior intertrigonal distance between patients with MR and normal controls. After mitral valve leaflet repair and posterior annuloplasty there was a significant decrease in both the total annular circumference and posterior annular length (p < 0.0001) while cyclic annular contraction was preserved.
Conclusions: Although the posterior mitral annulus is enlarged in patients with significant MR due to degenerative leaflet prolapse, there is no evidence that the intertrigonal distance is abnormal in these patients. Our data support the conclusion that posterior annular reduction with a flexible device at the time of mitral valve repair is important, and that altering the anterior intertrigonal portion of the mitral annulus is unnecessary.
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Introduction
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The mitral annulus is a complex dynamic structure important to normal mitral valve (MV) function. Early animal studies from our institution, conducted over 35 years ago, demonstrated that the normal mitral annulus undergoes presystolic narrowing of the posterior and lateral segments which is thought to contribute to MV competence [1]. Subsequent cadaveric and animal models demonstrated that normal cyclic variation in the size of the anterior mitral annulus exists and is linked dynamically to cardiac ejection [2–4]. In contrast, postinfarction left ventricular remodeling may lead to fixed pathologic enlargement of both the anterior and posterior portions of the mitral annulus, contributing to functional or ischemic mitral regurgitation (MR) [5]. It is unclear whether left ventricular enlargement resulting from severe MR caused by myxomatous MV disease, specifically degenerative leaflet prolapse, also leads to alteration in the length of the anterior intertrigonal distance in humans.
Characterization of mitral annular size and motion has been impeded largely by the technical limitations of classical two-dimensional (2D) echocardiography techniques. The prolonged acquisition and computation times historically necessary with early three-dimensional (3D) echocardiography led to respiratory artifacts in initial reports [2, 6–8]. The most-recent-generation 3D transesophageal echocardiography (TEE) probes offer real-time, full-volume acquisition of the entire mitral orifice over a full cardiac cycle. We sought to investigate the differences in mitral annular size between patients with significant MR due to degenerative leaflet prolapse (before and after surgical MV repair) and healthy normal controls.
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Patients and Methods
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Patient Population
We prospectively enrolled 29 consecutive patients referred for MV repair to correct severe MR due to degenerative leaflet prolapse (cases). Fifteen patients referred for TEE and found to have no underlying structural cardiac disease or arrhythmias were included as control subjects. Patients with contraindications to TEE and those with mitral stenosis, aortic valve disease, tricuspid regurgitation considered more than mild, pericardial disease, or congenital heart defects were excluded. The Mayo Clinic Institutional Review Board approved the study. Written informed consent was obtained from all patients.
Transesophageal Echocardiography
Complete 2D and 3D TEE (Fig 1A) was performed intraoperatively, after endotracheal intubation and before cardiopulmonary bypass on mitral valve repair cases. The 3D examination was repeated (Fig 1B) after MV repair in a subset of patients (n = 11), as dictated by the availability of a 3D TEE operator (Sunil Mankad, Jasmine Grewal). Imaging was performed using the real-time 3D imaging probe (model X72t) and the iE33 echocardiography imaging platform, both from Philips Medical Systems (Bothell, WA). Imaging of the MV was performed in live 3D zoom mode, ensuring inclusion of the aortic valve and the entire annulus throughout the cardiac cycle. A direct intraoperative measurement of the anterior intertrigonal distance was taken by the operating surgeon (Hartzell V. Schaff, Rakesh M. Suri) using a flexible metric ruler. Care was taken to prevent distortion of the annulus during measurement by avoiding excessive retraction on the left atrium. Surgical measurements were subsequently compared with the corresponding 3D TEE measurement to allow validation. Similarly, 3D TEE was also performed in outpatients serving as controls. All control patients were imaged under deep sedation. Hemodynamic loading conditions were similar in both groups during imaging with a mean systolic blood pressure in surgical cases of 122 mm Hg versus 135 mm Hg in controls. The quantification of MR was performed using 2D transthoracic echocardiography (TTE) according to the American Society of Echocardiography task force consensus recommendations [9].
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Figure 1. Three-dimensional (3D) echocardiographic images. (A) Preoperative 3D echocardiogram images of a flail middle scallop of the posterior leaflet. Trigones are demarcated (star). (B) Postoperative 3D echocardiogram images after mitral valve repair with the annuloplasty band anchored at the fibrous trigones (star). (C) Atrial view of the mitral annulus at end diastole without (left panel) and with (right panel) measurement markers. Verification of correct position of measurement markers on the mitral annulus was obtained in three orthogonal planes. (A = anterior; AL = anterolateral; P = posterior; PM = posteromedial.)
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The full-volume 3D MV data sets were digitally stored on CDs and transferred to a workstation with Q-Lab mitral valve quantification software (Philips Medical Systems) for off-line analysis. Three standard 2D orthogonal images of the mitral annulus were automatically displayed and subsequently modified to optimize visualization of the annular structures. Four key reference points were initially marked on two of the three orthogonal 2D images of the annulus: anterolateral and posteromedial hinge points of leaflet insertion and anterior and posterior midpoints (Fig 1C, left panel). With three key orthogonal planes locked in, seven 2D rotational planes allowed the delineation of 14 markers around the annulus at the point of leaflet insertion, for 18 total discretely marked points (Fig 1C, right panel). With this completed, the short axis atrial view containing 3D information of the entire annulus was obtained. Confirmation of the accuracy of anatomic markings relied on simultaneous view of point positioning in all planes, irrespective of the plane marked. The anterior intertrigonal distance was measured in the short axis atrial view after marking of the entire annulus to ensure 3D (rather than 2D) measurement acquisition. The anterior intertrigonal distance was demarcated by the points at which the anterior leaflet attached to the fibrous skeleton of the heart between trigones (Fig 1A). The mitral annular measurements were performed four times during the cardiac cycle: early diastole, late diastole, early systole, and late systole. Early diastole was assigned to the frame preceding mitral valve opening, late diastole was assigned to the frame preceding aortic valve opening, early systole assigned to the frame preceding mitral valve closure, and late systole to the frame preceding aortic valve closure.
Statistical Analysis
Baseline characteristics are reported as mean (±SD) for continuous variables and number (percentage) for categoric variables. Mitral annular characteristics are presented as mean and standard deviation. Comparison of baseline characteristics between cases and controls was performed using standard t tests for continuous variables and 
2 test for dichotomous variables. Comparison of mitral annulus measures between groups was also performed using standard t tests. Intragroup comparisons of each annular measure between two points in the cardiac cycle used paired t tests. A p value less than 0.05 was considered significant. All computations were performed using JMP statistical software for Windows (version 6.0; SAS Institute Inc, Cary, NC).
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Results
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Baseline characteristics of the 29 patients with MV disease and 15 normal patients are shown in Table 1. Those with MV disease were more often symptomatic and controls were more frequently diabetic. Although left ventricular ejection fraction was identical between groups, left ventricular dimensions were slightly greater in the MV disease group. All patients with MV disease had severe MR, with a mean effective regurgitant orifice area of 0.53 ± 0.22 cm2, and regurgitant volume of 80.0 ± 31.5 mL/beat. Trivial MR was documented in 5 normal patients. The predominant lesion in the MV disease group was a prolapse-flail of the posterior leaflet in 14 (48%) patients, whereas both leaflets (bileaflet) were involved in 11 (38%) and anterior the leaflet alone in 4 (14%). Mitral repair was performed by median sternotomy in 22 (75%), and minimally invasively using either robotic assistance in 6 (21%) or thoracoscopic port access in 1 (3%). Of the 15 control patients with structurally normal hearts, 12 (80%) were evaluated for cardioembolic source, 2 (13%) to rule out infective endocarditis and 1 (7%) to exclude aortitis.
Of the 29 MV disease patients, valve repair of the posterior leaflet involved resection in 15 patients (52%), plication in 6 (21%), and chordal transfer in 1 (3%). Anterior leaflet procedures included plication in 1 (3%) and placement of GORE-TEX (W. L. Gore & Associates, Flagstaff, AZ) neochordae in 5 (17%). An edge-to-edge stitch was placed in 1 (3%) patient. All patients had a standard-length, flexible 63-mm posterior annuloplasty band inserted, which was anchored between left and right fibrous trigones. Three patients (10%) received annuloplasty alone (Table 2).
A robust correlation was observed between 3D echocardiographic quantification and direct intraoperative measurement of the anterior mitral annulus length (Fig 2) (r = 0.97, p < 0.0001, surgical measurement = –3.888359 + 1.1248247 3D echo measurement). Total MV annular circumference and posterior annular length were both significantly enlarged in patients with MV disease compared with normal controls (Fig 3, both p < 0.001). In contrast, the anterior intertrigonal distance was statistically indistinguishable between MV disease and control groups (p = 0.13). These comparisons held true throughout the cardiac cycle. After mitral repair, all MV disease patients had trivial (insignificant) residual MR and total annular circumference was significantly reduced compared with preoperative dimensions (Fig 4). Importantly, the cyclic variation in annular circumference observed preoperatively in mitral prolapse patients was preserved after valve leaflet repair and insertion of a flexible posterior annuloplasty band (Fig 4).
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Fig 2. Measurement of the intertrigonal distance. The bar graph presents anterior intertrigonal distance measurements by the surgeon versus two repeat three-dimensional (3D) echocardiographic calculations. There was no significant difference in the distance obtained between the two techniques (p = 0.73) or between repeat echocardiogram measurements (p = 0.41).
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Fig 4. Mitral annular dynamics before and after mitral valve repair. The line plots present total mitral annular circumference of leaflet prolapse cases measured by three-dimensional echocardiography before (- - -) and after (—) mitral valve repair including a standard length flexible 63 mm posterior annuloplasty band. The total circumference is significantly smaller postrepair at all time points during the cardiac cycle (*, p < 0.001). Significant cyclic enlargement of the mitral annulus is noted between early diastole and late systole prerepair ( , p = 0.001) which is preserved after valve repair (+, p = 0.004).
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Comment
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Several publications have underlined the importance of MV annuloplasty during repair of degenerative mitral leaflet prolapse in order to optimize repair durability [10–12]. Debate persists regarding the superiority of partial band versus complete ring devices largely due to conflicting data derived from cadaveric studies reporting global annular enlargement in cardiac specimens from patients with dilated cardiomyopathy. In the current report, we confirm by live, real-time 3D echocardiography that the anterior intertrigonal distance is normal in patients with severe MR due to degenerative leaflet prolapse and that posterior annuloplasty alone is capable of decreasing the dilated posterior annular length. The dynamic nature of the mitral annulus is preserved after mitral repair with a flexible band, arguing against the use of fixed prosthetic annular devices in this patient population.
Our findings extend prior data which established the dynamic nature of the mitral annulus using 3D reconstruction [6, 7, 13]. It has been previously reported that the normal mitral annulus undergoes a systolic reduction in annular area along with augmentation of the nonplanar saddle shape [2], and for this reason several authors [14–16] have recommended the avoidance of rigid preshaped annuloplasty devices during MV repair. In an elegant canine study utilizing radiopaque markers and biplane fluoroscopy, Glasson and colleagues [3] demonstrated that the anterior mitral annulus lengthens significantly during systole, prompting the authors to recommend that valvuloplasty techniques should respect the dynamic nature of the anterior mitral annulus. Additional putative benefits of flexible annuloplasty include facilitation of mitral annular contraction, maintenance of the normal nonplanar saddle shape, minimization of left ventricular outflow obstruction [4], and preservation of ejection fraction. A flexible posterior annuloplasty band contributes to the preservation of normal mitral annular contraction and physiologic function [17] and thus is an important component of the observed durability of MV repair in the current era [14, 18, 19].
If we accept that the maintenance of mitral annular flexibility is key, the next relevant question becomes the need for posterior versus total annular reduction, a debate that has been muddied by studies drawing conclusions from patient populations affected by a heterogeneous array of disease states. Hueb and colleagues [5] analyzed 68 fixed adult human hearts, of which 48 had dilated cardiomyopathy (ischemic or idiopathic), comparing them with 20 others that were free of pathologic diagnosis. The authors concluded that the mitral annulus in cardiomyopathy patients is globally enlarged, demonstrating a proportionate increase in both the fibrous and muscular portions. To further address the concern that cardiac dimensions might be artifactually altered in fixed cadaveric tissues, Okamoto and colleagues [20] studied the mitral annulus of 82 fresh cadaveric hearts. The authors found that even though normal hearts demonstrated varying degrees of posterior mitral annular dilation, the anterior intertrigonal distance was generally preserved. They also proposed that the anterior annulus beyond the left and right fibrous trigones was capable of lengthening; inferring that correct placement of an effective and durable annuloplasty band is predicated upon the ability to anchor the device at the fibrous trigones. An important recent study by Nguyen and colleagues [21] from Stanford University utilized radiopaque markers to study the effect of pure MR caused by posterior leaflet perforation while maintaining ventriculovalvar continuity by preserving the subvalvar apparatus. They discovered that even though isolated MR caused a slow and gradual increase in left ventricular volume leading to dilation of the intercommissural diameter, both annular saddle shape and septolateral (ie, anteroposterior) dimensions were preserved. The authors concluded that the mechanism and tempo of ventriculoannular dilation varies significantly among different pathologic processes, most specifically when comparing degenerative and ischemic MV disease. It is important therefore that pathologic disease state be carefully considered when discussing mitral annular changes in patients with MR.
Our study is the first to characterize the mitral annular dimensions of a homogeneous population of myxomatous valve disease patients with severe MR utilizing live 3D TEE, and further, in comparison with normal controls. As expected, the mitral annulus was larger in those with MR due to leaflet prolapse. Importantly, our data clearly demonstrate that the enlargement of mitral annular circumference spares the intertrigonal or fibrous component of the anterior mitral annulus. The remaining extratrigonal mitral annulus, encompassing the posterior annulus plus the portion of the anterior annulus (a) lateral to the left trigone towards the anterolateral commissure, and (b) medial to the right trigone toward the posteromedial commissure, was significantly elongated in those with myxomatous mitral disease. The ability of the extratrigonal annulus to dilate explains the poor durability of mitral repair when annuloplasty devices are not anchored within the fibrous skeleton of the heart at the trigones [18, 19]. Total annular circumference decreased significantly in our study after correction of leaflet prolapse and posterior annuloplasty band placement. We have previously reported that mitral valve repair supported by a flexible posterior annuloplasty band is a safe and durable procedure. The frequency of mitral reintervention after correction of posterior leaflet prolapse is approximately 0.5% per year, and rates of reoperation after repair of anterior or bileaflet prolapse are similarly low (1.6% and 0.9% per year, respectively; p = 0.13) [18].
Debate persists regarding the selection of the optimal annuloplasty band size for use during repair of degenerative leaflet prolapse. Many methods to select device size have been proposed, including calibration based on intertrigonal distance, intercommissural distance, anterior mitral leaflet area, and visual estimation [22–24]. Although it might appear seductively reassuring to rely upon the use of sizers to select annuloplasty length, the above noted techniques are likely not entirely objective as evidenced by the number of available methods utilized by surgeons worldwide. The ability to precisely determine leaflet and annular dimensions in a flaccid, empty, nonanimated heart is difficult at times. Instead of deriving true objective guidance from various calibration techniques, it is more likely that surgeons learn to rely upon empiric judgment. Moreover, the ability to accurately measure the intertrigonal distance can be difficult when exposure of the mitral valve is limited by body habitus or small left atrial dimensions. Recent studies have proposed that image-guided "virtual" sizing of the mitral annulus during the normal cardiac cycle may be a better method of annuloplasty selection prior to cardioplegic arrest of the heart [2, 7, 20, 22–27]. Ender and colleagues [22] from Leipzig found a strong correlation between the preoperative 3D TEE determination of Carpentier-Edwards Physio (Edwards Lifesciences, Irvine, CA) annuloplasty ring size and the actual dimension of the device implanted [23, 24]. However, the authors also observed that the discrepancy between imaged and implanted ring size was ± 2 mm in 38% of patients. A cadaveric study examining 712 excised mitral valves, from an era when more frequent MV replacement was performed, reported that the mean annular circumference of a purely regurgitant, floppy MV was 123 mm versus 98 mm in nondilated specimens [28]. Because the posterior annulus comprised nearly two-thirds of the total annular circumference, the best estimation of the normal posterior annulus length was approximately 66 mm. Since the 1980s we have routinely implanted a standard-length, flexible 63-mm posterior annuloplasty band during MV repair for degenerative leaflet prolapse at our Institution. The safety and long-term durability of mitral repair using this strategy have been reported previously [4, 18, 19, 29, 30].
Despite seemingly ubiquitous marketing efforts aimed at convincing surgeons of the superiority of proprietary shaped annuloplasty devices of varying sizes and rigidity, it is important to ask what substantiating clinical evidence exists to support an effect on repair outcome. Prior work established that the normal mitral annulus undergoes a systolic increase in circumference and augmentation in saddle shape [2, 7, 31]. Our current study demonstrates that the myxomatous mitral annulus is also capable of cyclic contraction which, importantly, is preserved after repair with a flexible posterior band. Attempts to statically fix the size and shape of the entire mitral annulus using rigid devices might theoretically impair this contraction, potentially altering normal systolic augmentation of annular saddle shape and increasing leaflet stress [17]. Concern regarding a speculated increase in the incidence of postsurgical systolic anterior motion (SAM) of the anterior mitral leaflet leading to left ventricular outflow tract obstruction or recurrent MR using a standard length flexible band has proven unfounded. A recently published report from our Institution demonstrated that among 2,076 patients undergoing mitral repair for leaflet prolapse, early SAM was demonstrated intraoperatively in 174 cases (8.4%) and only four required a related early reoperation [32, 33]. The use of a standard-length 63-mm flexible annuloplasty band anchored between right and left fibrous trigones is safe, and associated with a very low risk of late reoperation [18, 19, 34].
Limitations
Full-volume 3D echocardiography is a new technology that has not been extensively investigated to date. It is reassuring that direct intraoperative measurements of the intertrigonal distance, which were confirmed at the time of annuloplasty stitch insertion, were in close agreement with repeated 3D TEE values (Fig 2). Although the intracardiac measurements of controls were relatively normal, this group of patients underwent TEE for various indications and, therefore, do not strictly represent a random sample of the general population. Mitral annular dimensions would likely be different in individuals with chronic MR, including massively enlarged ventricular dimensions and ventricular dysfunction; however, the patients included in this study were representative of those with severe degenerative MR referred for early mitral valve repair in accordance with current guidelines. All patients undergoing TEE were deeply sedated and had similar systolic blood pressure to surgical cases at the time of imaging. Future studies will further examine how hemodynamic loading conditions affect mitral annular dynamics. Finally, we did not compare ischemic and degenerative mitral regurgitation in this study as changes in mitral annular geometry are likely quite different.
Conclusion
In patients with severe MR due to leaflet prolapse, live 3D TEE visualization of the myxomatous mitral annulus demonstrates that the anterior intertrigonal distance does not dilate and its length is comparable with that found in normal controls. These data suggest that reduction of the extra trigonal mitral annular length to near normal by anchoring a standard length flexible annuloplasty band at the fixed fibrous trigones is an important component of MV repair. The use of complete rings or those of fixed shape during correction of MR due to degenerative leaflet prolapse does not appear to be necessary or justified.
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Footnotes
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* These authors contributed equally. 
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Top
Abstract
Introduction
) versus myxomatous leaflet prolapse cases prior to mitral valve repair (
). The total circumference and posterior mitral annulus length are both significantly increased in leaflet prolapse cases (*: p < 0.001) while the intertrigonal distance is similar to normal controls (p = 0.13).