Design of a new surgical approach for ventricular remodeling to relieve ischemic mitral regurgitation: Insights from 3-dimensional echocardiography

Noah Liel-Cohen, J. Luis Guerrero, Yutaka Otsuji, Mark D. Handschumacher, Lawrence G. Rudski, Patrick R. Hunziker, Hiroaki Tanabe, Marielle Scherrer-Crosbie, Suzanne Sullivan, Robert A. Levine

Research output: Contribution to journalArticlepeer-review

201 Scopus citations


Background - Mechanistic insights from 3D echocardiography (echo) can guide therapy. In particular, ischemic mitral regurgitation (MR) is difficult to repair, often persisting despite annular reduction. We hypothesized that (1) in a chronic infarct model of progressive MR, regurgitation parallels 3D changes in the geometry of mitral leaflet attachments, causing increased leaflet tethering and restricting closure; therefore, (2) MR can be reduced by restoring tethering geometry toward normal, using a new ventricular remodeling approach based on 3D echo findings. Methods and Results - We studied 10 sheep by 3D echo just after circumflex marginal ligation and 8 weeks later. MR, at first absent, became moderate as the left ventricle (LV) dilated and the papillary muscles shifted posteriorly and mediolaterally, increasing the leaflet tethering distance from papillary muscle tips to the anterior mitral annulus (P < 0.0001). To counteract these shifts, the LV was remodeled by plication of the infarct region to reduce myocardial bulging, without muscle excision or cardiopulmonary bypass. Immediately and up to 2 months after plication, MR was reduced to trace-to-mild as tethering distance was decreased (P < 0.0001). LV ejection fraction, global LV end-systolic volume, and mitral annular area were relatively unchanged. By multiple regression, the only independent predictor of MR was tethering distance (r2 = 0.81). Conclusions - Ischemic MR in this model relates strongly to changes in 3D mitral leaflet attachment geometry. These insights from quantitative 3D echo allowed us to design an effective LV remodeling approach to reduce MR by relieving tethering.

Original languageEnglish
Pages (from-to)2756-2763
Number of pages8
Issue number23
StatePublished - 13 Jun 2000
Externally publishedYes


  • Echocardiography
  • Ischemia
  • Mitral valve
  • Regurgitation
  • Surgery


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