Mitral Annular Elasticity Determines Severity of Regurgitation in Barlow’s Mitral Valve Disease

Highlights

• Holographic display enabled noninvasive analysis of mitral annulus dynamics.

• Barlow patients demonstrate paradoxical annular motion during systole.

• Blood pressure may modify severity of regurgitation in Barlow patients with MAD.

• A novel AEI may predict severity of mitral valve regurgitation.

• FE analysis corroborates the use of an annulus intervention to maintain coaptation.

Objectives

Barlow’s mitral valve disease with late systolic mitral regurgitation provides diagnostic and therapeutic challenges. The mechanisms of the regurgitation are still unclear. We hypothesized that the onset and the severity of late systolic regurgitation are determined by annulus dynamics and the mechanical stresses imposed by the left ventricle.

Methods

Ten patients with Barlow's mitral valve disease and mitral annulus disjunction (MAD) were compared with 10 healthy controls. Resting blood pressure was measured, and transthoracic three-dimensional echocardiography was analyzed using a holographic display that allows tracking and measurements of mitral annulus surface area (ASA) throughout the cardiac cycle. A novel annulus elastance index (dASA/dP) was calculated between aortic valve opening and onset of mitral regurgitation. Severity of MAD was quantified as the disjunction index (mm × degree). Leaflet coaptation area was calculated using a finite element model.

Results

Peak systolic ASAs in controls and patients were 9.3 ± 0.6 and 21.1 ± 3.1 cm², respectively (P < .001). In patients, the ASA increased rapidly during left ventricular ejection, and onset of mitral regurgitation coincided closely with peak upslope of annulus area change (dASA/dt). The finite element model showed a close association between rapid annulus displacement and coaptation area deficit in Barlow’s mitral valve disease. Systolic annulus elastance index (0.058 ± 0.036 cm²/mm Hg) correlated strongly with disjunction index (r = 0.91, P < .0001). Moreover, regurgitation volume showed a positive correlation with systolic blood pressure (r = 0.80, P < .01).

Conclusion

The present pilot study supports the hypothesis that annulus dilatation may accentuate mitral valve regurgitation in patients with Barlow’s mitral valve disease. A novel annulus elastance index may predict the severity of mitral valve regurgitation in selected patients.