Mechanism of persistent ischemic mitral regurgitation after annuloplasty - Importance of augmented posterior mitral leaflet tethering

Background-We hypothesized that surgical annuloplasty for ischernic mitral regurgitation (MR) that displaces the posterior annulus anteriorly can potentially augment posterior leaflet (PML) tethering, leading to persistent MR. Relationships between leaflet configurations and persistent ischernic MR after the annuloplasty were investigated. Methods and Results-In 31 patients with surgical annuloplasty for ischernic MR and 20 controls, posterior and apical displacement of the leaflet coaptation, the anterior leaflet (AML) and PML tethering angles relative to the line connecting annuli, coaptation length (CL), and the MR grade were quantified before and early after surgery in echocardiographic left ventricular long-axis views. Six of the 31 patients showed persistent MR despite annuloplasty. Compared with patients without persistent MR, those with MR showed no improvement in the left ventricular ejection fraction and systolic volume, similar reduction in the annular area, significant increase in posterior displacement of the coaptation (P < 0.01), no improvement in AML tethering, greater worsening in PML tethering (P < 0.01), and no increase in the CL. All tethering variables were significantly correlated with both preoperative and postoperative MR in univariate analysis, and reduced CL was the primary independent determinant of both preoperative and postoperative MR. Although increased AML tethering was the primary determinant of the preoperative CL (r(2) = 0.46, P < 0.0001), increased PML tethering was the primary determinant afterward (r(2) = 0.60, P < 0.0001). Conclusion-Although tethering of both leaflets is the major determinant of ischernic MR before surgical annuloplasty, both leaflets tethering but with predominant and augmented PML tethering is related to persistent ischemic MR after the ammuloplasty.