Response of Functional Mitral Regurgitation during Dobutamine Infusion in Relation to Changes in Left Ventricular Dyssynchrony and Mitral Valve Geometry

PURPOSE: Functional mitral regurgitation (FMR) and myocardial dyssynchrony commonly occur in patients with dilated cardiomyopathy (DCM). The aim of this study was to elucidate changes in FMR in relation to those in left ventricular (LV) dyssynchrony as well as geometric parameters of the mitral valve (MV) in DCM patients during dobutamine infusion. MATERIALS AND METHODS: Twenty-nine DCM patients (M:F=15:14; age: 62+/-15 yrs) with FMR underwent echocardiography at baseline and during peak dose (30 or 40 ug/min) of dobutamine infusion. Using 2D echocardiography, LV end-diastolic volume, end-systolic volume (LVESV), ejection fraction (EF), and effective regurgitant orifice area (ERO) were estimated. Dyssynchrony indices (DIs), defined as the standard deviation of time interval-to-peak myocardial systolic contraction of eight LV segments, were measured. Using the multi-planar reconstructive mode from commercially available 3D image analysis software, MV tenting area (MVTa) was measured. All geometrical measurements were corrected (c) by the height of each patient. RESULTS: During dobutamine infusion, EF (28+/-8% vs. 39+/-11%, p=0.001) improved along with significant decrease in cLVESV (80.1+/-35.2 mm3/m vs. 60.4+/-31.1 mm3/m, p=0.001); cMVTa (1.28+/-0.48 cm2/m vs. 0.79+/-0.33 cm2/m, p=0.001) was significantly reduced; and DI (1.31+/-0.51 vs. 1.58+/-0.68, p=0.025) showed significant increase. Despite significant deterioration of LV dyssynchrony during dobutamine infusion, ERO (0.16+/-0.09 cm2 vs. 0.09+/-0.08 cm2, p=0.001) significantly improved. On multivariate analysis, DeltacMVTa and DeltaEF were found to be the strongest independent determinants of DeltaERO (R2=0.443, p=0.001). CONCLUSION: Rather than LV dyssynchrony, MV geometry determined by LV geometry and systolic pressure, which represents the MV closing force, may be the primary determinant of MR severity.

Role of Dyssynchrony on Functional Mitral Regurgitation in Patients with Idiopathic Dilated Cardiomyopathy: A Comparison Study with Geometric Parameters of Mitral Apparatus

BACKGROUND: Functional mitral regurgitation (FMR) occurs commonly in patients with dilated cardiomyopathy (DCM). This study was conducted to explore the role of left ventricular (LV) dyssynchrony in developing FMR in patients with DCM in comparison with geometric parameters of the mitral apparatus. METHODS: Twenty patients without FMR and 33 patients with FMR [effective regurgitant orifice area (ERO) = 0.17 +/- 0.10 cm2] were enrolled. MR severity was estimated with ERO area. Dyssynchrony indices (DI) were measured using the standard deviations of time to peak myocardial systolic velocity between eight segments. Using real time 3D echocardiography, mitral valve tenting area (MVTa), anterior (APMD) and posterior papillary muscle distances (PPMD), LV sphericity, and tethering angle of anterior (Aalpha) and posterior leaflets (Palpha) were estimated. All geometrical measurements were corrected (c) by the height of each patient. RESULTS: The patient with FMR had significantly higher cDI, cMVTa, cAPMD and cPPMD, LV sphericity, Aalpha, and Palpha than the patients without FMR (all p < 0.05). With multiple logistic regression analysis, cMVTa (p = 0.017) found to be strongest predictor of FMR development. In patients with FMR, cMVTa (r = 0.868), cAPMD (r = 0.801), cPPMD (r = 0.742), Aalpha (r = 0.454), LV sphericity (r = 0.452), and DI (r = 0.410) showed significant correlation with ERO. On multivariate regression analysis, cMVTa and cAPMD (p < 0.001, p = 0.022, respectively) remained the strongest determinants of the degree of ERO and cAPMD (p < 0.001) remained the strongest determinant of the degree of cMVTa. CONCLUSION: Displacement of anterior papillary muscle and consequent mitral valve tenting seem to play a major role in developing FMR in DCM, while LV dyssynchrony seems to have no significant role.