Preoperative Three-Dimensional Valve Analysis Predicts Recurrent Ischemic Mitral Regurgitation After Mitral Annuloplasty Wobbe Bouma, MD, Eric K. Lai,

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Preoperative Three-Dimensional Valve Analysis Predicts Recurrent Ischemic Mitral Regurgitation After Mitral Annuloplasty Wobbe Bouma, MD, Eric K. Lai, BS, Melissa M. Levack, MD, Eric K. Shang, MD, Alison M. Pouch, PhD, Thomas J. Eperjesi, BS, Theodore J. Plappert, CVT, Paul A. Yushkevich, PhD, Massimo A. Mariani, MD, PhD, Kamal R. Khabbaz, MD, Thomas G. Gleason, MD, Feroze Mahmood, MBBS, Michael A. Acker, MD, Y. Joseph Woo, MD, Albert T. Cheung, MD, Benjamin M. Jackson, MD, Joseph H. Gorman, MD, Robert C. Gorman, MD The Annals of Thoracic Surgery Volume 101, Issue 2, Pages 567-575 (February 2016) DOI: 10.1016/j.athoracsur.2015.09.076 Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Annular segmentation technique. (A) Three-dimensional (3D) echocardiographic volume containing the mitral valve with cross-sectional planes at 10° increments. (B) Representative two-dimensional cross-section, with green dots representing the selected annular points. (C) Oblique, (D) intercommissural, and (E) transvalvular annular views of a single real-time 3D-derived mitral annular model with annular landmarks and the 36 annular data points (circles). The least-squares plane has been superimposed on the annulus in each view. The least-squares plane is depicted by a horizontal line in C and D and by the check boxes in E. (AA = anterior mitral annulus; AC = anterior commissure; AL = anterolateral annulus; AML = anterior mitral leaflet; AoV = aortic valve; CW = commissural width; L = lateral aspect of the annulus; LA = left atrium; LV = left ventricle; LVOT = left ventricular outflow tract; MTD = mitral transverse diameter; MVO = mitral valve orifice; PA = posterior mitral annulus; PC = posterior commissure; PM = posteromedial annulus; PML = posterior mitral leaflet; S = septal aspect of the annulus; SL = septolateral diameter.) The Annals of Thoracic Surgery 2016 101, 567-575DOI: (10.1016/j.athoracsur.2015.09.076) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Leaflet segmentation technique. (A) Template of transverse cross-sections every 1 mm along the intercommissural axis. (B) One of the two-dimensional cross-sections is represented by the white dashed line in A; the atrial surface of the mitral valve leaflets and the coaptation zone is interactively marked (green curves), resulting in a data set of 500 to 1,000 points for each valve. The white and red dashed lines are both within the least-squares annular plane. Determination of the (B) mitral valve tethering area (MVTa), (C) the anterior tethering angle (ATA), and the posterior tethering angle (PTA) is shown. (AC = anterior commissure; AML = anterior mitral leaflet; AoV = aortic valve; Coapt = coaptation; LA = left atrium; LV = left ventricle; LVOT = left ventricle outflow tract; PC = posterior commissure; PML = posterior mitral leaflet.) The Annals of Thoracic Surgery 2016 101, 567-575DOI: (10.1016/j.athoracsur.2015.09.076) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Preoperative regional mitral valve tethering. (A) Regional mitral valve tethering area (MVTa) distribution for patients with normal valves (light gray) and those with recurrent (medium gray) and nonrecurrent (black) ischemic mitral regurgitation (IMR). The MVTa is plotted as a function of intercommissural distance, expressed as a percentage of the distance traveled from the anterior commissure (AC). The positions of the AC and posterior commissure (PC) are, respectively, 0% and 100%. (B) Regional MVTa for patients with nonrecurrent and recurrent IMR. The dashed lines represent standard deviations. The shaded areas indicate regions where the MVTa differs significantly between groups. (C) Three-dimensional echocardiographic virtual models of a representative normal mitral valve and preoperative mitral valves that will and will not develop recurrent IMR after undersized ring annuloplasty: (top row) oblique commissure-to-commissure view, (middle row) oblique septolateral view, (bottom row) left ventricular view. The Annals of Thoracic Surgery 2016 101, 567-575DOI: (10.1016/j.athoracsur.2015.09.076) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Preoperative regional tethering angles. (A) Regional anterior tethering angle (ATA) distribution for patients with normal valves (light gray) and those with recurrent (medium gray) and nonrecurrent (black) ischemic mitral regurgitation (IMR). ATA is plotted as a function of intercommissural distance. (B) Regional ATA for patients with nonrecurrent and recurrent IMR. The dashed lines represent standard deviations. The shaded areas indicate regions where ATA differs significantly between the groups. (C) Regional posterior tethering angle (PTA) distribution for patients with normal valves and those with recurrent and nonrecurrent IMR. (D) Regional PTA for patients with nonrecurrent and recurrent IMR. The Annals of Thoracic Surgery 2016 101, 567-575DOI: (10.1016/j.athoracsur.2015.09.076) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Receiver operating characteristic (ROC) curve for the preoperative P3 tethering angle as a predictor of ischemic mitral regurgitation (IMR) recurrence after undersized mitral ring annuloplasty (optimal cutoff value: 29.9°). The Annals of Thoracic Surgery 2016 101, 567-575DOI: (10.1016/j.athoracsur.2015.09.076) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions