Key result
Mitral valve surgery for primary MR linked to ~9-point postoperative drop in LVEF.
Why the study?
It was hypothesized that myocardial principal strain angles determine LV functional recovery following mitral valve repair in patients with primary mitral regurgitation.
Does corrective mitral valve surgery normalize principal strain angles and left ventricular ejection fraction in patients with primary mitral regurgitation?
Observational (n=161)
Yes
Does corrective mitral valve surgery normalize principal strain angles and left ventricular ejection fraction in patients with primary mitral regurgitation?
Persistent structural shifts in myocardial principal strain angles occur early in primary mitral regurgitation and may explain the lack of left ventricular functional recovery and sustained decrease in ejection fraction following corrective surgery.
Postoperative LVEF decline cautions against assuming full recovery after mitral valve surgery; leaves open whether strain normalization improves outcomes in primary MR.
BACKGROUND: The double helical direction of myocardial fibers allows for left ventricular (LV) twist. This led to the hypothesis that principal strain angles determine LV functional recovery after mitral valve repair in patients with primary mitral regurgitation (PMR). METHODS: Controls (n=52) and patients with PMR with regurgitant volume defined as mild (<30 mL, n=16), moderate (30-50 mL, n=38), and severe (50 mL, n=55) had cardiac magnetic resonance with tissue tagging and 3-dimensional analysis. Fifty-four patients with PMR had presurgery and 6 (n=46), 12 (n=44), and 24 (n=25) month studies. Longitudinal, circumferential, and maximal shortening were computed along with principal strain angles (circumferential, longitudinal, and radial directions) at base, mid, and distal LV levels. RESULTS: LV ejection fraction did not differ in mild, moderate, and severe PMR with similar increases in mid LV 3-dimensional radius-to-wall thickness and decrease in LV mass to volume and sphericity index versus controls. Radial longitudinal shear strain and LV mid and distal LV circumferential and longitudinal angles increased in all groups with PMR. Postsurgery LV end-diastolic volume, LV end-diastolic mass to volume and 3-dimensional radius-to-wall thickness returned to normal at 6, 12, and 24 months; however, mid LV circumferential, longitudinal, and maximal shortening decreased below normal. LV circumferential and longitudinal angles and LV sphericity index did not change from presurgery whereas LV ejection fraction post surgery correlated with decrease in LV twist at 6, 12, and 24 months. CONCLUSIONS: Changes in principle strain angles occur early in PMR. The extent to which they persist after surgery may underlie the decrease in LV ejection fraction.
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Dell’Italia et al. (2025) conducted an observational in Primary Mitral Regurgitation (n=161). Mitral valve surgery for primary mitral regurgitation vs. Healthy controls and presurgery baseline was evaluated on Left ventricular ejection fraction (LVEF) at 6, 12, and 24 months postsurgery compared to presurgery (p=<0.001). Following mitral valve surgery for primary mitral regurgitation, left ventricular ejection fraction significantly declined from 64% at baseline to 55%, 53%, and 57% at 6, 12, and 24 months, respectively (p<0.001).
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