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Severity of Mitral Regurgitation and extent of systolic leaflet tethering govern mitral leaflet remodeling in Ischemic Mitral Regurgitation
Kanika Kalra, Robert Guyton, Vinod Thourani, Muralidhar Padala.
Emory University School of Medicine, Atlanta, GA, USA.

Background: Mitral valve leaflets undergo active remodeling and fibrosis in patients with ischemic mitral regurgitation (IMR). The role of severity of mitral regurgitation and the extent of leaflet tethering on this process has not been quantified. In this study we sought to investigate if the mitral regurgitant volume (MRV) and systolic leaflet tethering impact leaflet remodeling in IMR patients. Methods: Cardiac gated phase contrast MRI was performed in eighty-one human subjects with varying severity of IMR (Mild=47, Moderate=23, Severe=11) and ten subjects with aortic stenosis (N=10, control). Ventricular volumes, MRV, left atrial area, inter-papillary muscle distance (IPMD), and tenting area were measured from MRI. Leaflet remodeling was quantified as the diastolic unstressed length of anterior (ALL) and posterior leaflets (PLL, measured from long axis MRI images). All measurements were normalized to body surface area. Results: Ventricular volumes did not vary between the different patient groups. Anterior leaflet length increased by 23.7% from 12.6 ± 3.3 mm/m2 in mild MR to 15.5 ± 3.4 mm/m2 in severe MR (p=0.006). Posterior leaflet length increased by 39.8% from 8.7 ± 2.5 mm/m2 in mild MR to 12.2 ± 3.6 mm/m2 in severe MR. Patients with aortic stenosis however had shorter leaflets (ALL: 11.57 ± 3.28 mm/m2; PLL: 7.59 ± 2.42 mm/m2) as compared to moderate and severe MR (Fig 1E,F). In patients with IMR, leaflet lengths correlated significantly with MRV (ALL: r=0.36, P=0.001, PLL: r=0.42, P=0.0002) and left atrial area (ALL: r=0.38, P=0.01), which is considered a surrogate measure of duration of MR. Measures of valve tethering i.e. tenting area and IPMD correlated with leaflet lengths. Conclusion: Active remodeling of the mitral valve leaflets was evident in IMR, which could be a result of increased amounts of shear stress or stretch imposed on the tethered leaflets.

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