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Objectives. To investigate the contributions of dynamic changes in the mitral valve geometry with papillary muscle (PM) alignment, to the reduction of functional mitral regurgitation (MR) after intensive treatment for heart failure. Background. Although alteration in the mitral complex geometry has been speculated as a major mechanism for the reduction in MR after heart failure treatment, it has been difficult to recognize the mechanistic changes of mitral apparatus because of their complex morphology and anatomical position. Methods. 2D/3D echocardiography was performed in 10 patients with decompensated heart failure and functional MR before and after intensive therapy. We used novel software to analyze the volumetric image recorded by real-time 3D echocardiography. Reconstructed 3D images show leaflets and annulus configuration with PM position. We measured maximum tenting length (max-Tent-L), mean tenting length (mean-Tent-L) and tenting volume (Tent-V), distances from anterior annulus to anterolateral PM (A-tethering length) and posteromedial PM (P-tethering length), distance between two PM (intrapapillary distance), and the angle made by anterolatel PM, anterior annulus and posteromedial PM (intrapapillary angle). Results. MR reduced after the intensive treatment in all patients (p<0.0001). Leaflet tenting decreased significantly after the therapy (max-Tent-L, 16.8±2.5 vs. 13.3±2.0mm, p=0.0002; mean-Tent-L, 9.5±2.1 vs. 7.3±1.3mm, p=0.0013; Tent-V, 10.3±2.8 vs. 6.2±1.6ml, p=0.0002). P-tethering length shortened (46.9±5.1 vs. 38.6±4.9mm, p=0.0004). Intrapapillary distance (25.8±5.6 vs. 17.2±4.0mm, p=0.0001) and Intrapapillary angle (32.0±7.3 vs. 23.8±7.5 degree, p=0.0006) decreased after treatment. Conclusions. Inward shift of PM after heart failure treatment resulted in the improvement of mitral valve tenting, which caused the reduction of functional MR.

Dynamics of Mitral Complex Geometry and Functional Mitral Regurgitation During Heart Failure Treatment