Dynamic changes in the ischemic mitral annulus: Implications for ring sizing

Objectives: Contrary to the rest of the mitral annulus, inter-trigonal distance is known to be relatively less dynamic during the cardiac cycle. Therefore, intertrigonal distance is considered a suitable benchmark for annuloplasty ring sizing during mitral valve (MV) surgery. The entire mitral annulus dilates and flattens in patients with ischemic mitral regurgitation (IMR). It is assumed that the fibrous trigone of the heart and the intertrigonal distance does not dilate. In this study, we sought to demonstrate the changes in mitral annular geometry in patients with IMR and specifically analyze the changes in intertrigonal distance during the cardiac cycle. Methods: Intraoperative three-dimensional transesophageal echocardiographic data obtained from 26 patients with normal MVs undergoing nonvalvular cardiac surgery and 36 patients with IMR undergoing valve repair were dynamically analyzed using Philips Qlab (R) software. Results: Overall, regurgitant valves were larger in area and less dynamic than normal valves. Both normal and regurgitant groups displayed a significant change in annular area (AA) during the cardiac cycle (P < 0.01 and P < 0.05, respectively). Anteroposterior and anterolateral-posteromedial diameters and inter-trigonal distance increased through systole (P < 0.05 for all) in accordance with the AAs in both groups. However, inter-trigonal distance showed the least percentage change across the cardiac cycle and its reduced dynamism was validated in both cohorts (P > 0.05). Conclusions: Annular dimensions in regurgitant valves are dynamic and can be measured feasibly and accurately using echocardiography. The echocardiographically identified inter-trigonal distance does not change significantly during the cardiac cycle.