Mitral valve and left ventricular reverse remodeling after surgical repair of submitral left ventricular aneurysms assessed with multi-slice computed tomography

Objectives: Surgical repair of submitral aneurysms may present a technical challenge especially if the mitral valve (MV) apparatus is involved. We present the single center surgical experience with the potential of multi-slice computed tomography (MSCT) in assessment of MV and LV geometry and aneurysm morphology.

Methods: Between 05/06 and 08/13, 24 patients (m:w = 20:4, ages 38-78, mean 62.3 years; mean NYHA class 2.91) with submitral LV aneurysm were operated upon. Echocardiography and MSCT were performed before and a short time after surgery. LV and aneurysm end-diastolic/end-systolic volume were measured and indexed to body surface area (LV-EDVI/LV-ESVI, A-EDVI/A-ESVI, respectively). LV ejection fraction (LVEF), cardiac output (CO) and cardiac index (CI) were calculated on the basis of MSCT data. MV geometry was characterized by intercommissural and anteroposterior MV annulus diameter (ICD and APD respectively), MV annulus area (MVAA), coaptation distance (CD), tenting area (TA), MV closure angle (MVCA), interpapillary muscle distance (IMD) and coaptation-to-septum distance (CSD).

Results: Thirty-day and 5-year survival was 91.3% and 78.3%, respectively.

Aneurysms were prevalently localized in myocardial segments 4/10/11. Preoperative A-EDVI showed a slight systolic increase, demonstrating adverse volume shift during systole (70.6 ± 20.9 to 75.5 ± 21.4 ml/sqm, p = 0.001). There were reductions of LV-EDVI (160.9 ± 21.6 to 86.5 ± 7.8 ml/sqm, p = 0.002) and LV-ESVI (121.4 ± 26.3 to 51.2 ± 6.4.9 ml/sqm, p = 0.006) and LVEF improvement (29.9 ± 4.2% to 42.5 ± 3.1%, p = 0.001) after surgical repair. Mitral repair and replacement was necessary in three patients in each case. Postoperative reduction of mitral regurgitation in the remaining 17 patients (1.26 ± 0.23° to 0.21 ± 0.08°, p = 0.000) corresponded with improvement of MV geometry (ICD 38.8 ± 1.4 mm to 35.0 ± 1.6, p = 003, APD 24.9 ± 1.3 to 23.0 ± 1.1 mm, p = 0.103, MVAA 8.8 ± 0.5 to 8.1 ± 0.5 sqcm, p = 0.011, CD 10.0 ± 0.5 to 7.9 ± 0.5, p = 0,006, TA 1.8 ± 0.1 to 1.5 ± 0.1 sqcm, p = 0.022, MVCA 104 ± 3.6° to 114.5 ± 2.2°, p = 0.015) and reduction in MV tethering (IMD 35.18 ± 1.88 to 28.23 ± 0.98, p = 0.000, CSD 31.9 ± 1.4 to 28.7 ± 1.7, p = 0.012).

Conclusions: Surgical reconstruction of submitral LV aneurysms can be performed with good mid-term results. Advantages of MSCT, with possibilities to analyze the coherence of ventricular remodeling and subtle geometrical changes in mitral valve apparatus, make it a useful tool for analysis and planning of surgical restoration approaches.