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Di Giannuario, Giovanna (2016) Mitral valve posterior leaflet morphology revisited from pathological anatomy to three-dimensional echocardiography evaluation: implications in patients with myxomatous disease for surgical procedures. [Tesi di dottorato]

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Abstract (inglese)

The perfect function of the mitral valve is linked to the anatomical conformation and physiological interaction of all the component of the mitral valve complex (leaflets, annulus, chordae, papillary muscles, left ventricle). The most important component of the valve are the leaflets. The nomenclature and the number of the leaflets are divergent in different studies. Usually the clinical Carpentier’s Classification is used, which identifies three posterior leaflet scallops: from antero-lateral (P1) to central (P2) and postero-medial (P3). The terminology of mitral valve leaflet is a lot debated in the scientific literature. The aim of the study is to analyze the variability of the anatomy of posterior leaflet in normal subjects (Autoptic and cardiectomy specimens) and patients with myxomatous disease (three dimensional echocardiography) for assess possible difference and similarity. In patient with myxomatous disease we evaluate the clinical influence of the anatomy of the posterior leaflet on the planning of the mitral valve surgical repair strategy.
MATERIALS AND METHODS
Thirty normal heart specimens without mitral valve disease, were examined by three independent observers ( two pathologists and 1 cardiologist). The specimens which had been fixed in formalin following autopsy or cardiectomy, were selected in the anatomo-pathological heart collection of Padua University. The mitral valve was opened along the optus margin of the heart and evaluated. It was used a new terminology and call the normal physiological indentation, deep more than 50% of the leaflet high, “subcommisure” and the simple indentation ,deep less than 50% ,“incisure”. The subcommissure and incisure with relative chordae tendineae were studied in detail. Special attention was given to (1) the number of the scallops of posterior leaflet with (2) the characterization of the subcommisure and incisure, to (3) the high and the width of every single scallop, and to (4) to the high of the leaflet in correspondence of subcommisure, incisure and commisure; to (5) the morphology of the chordae tendineae at the sites of insertion in the commisure, subcommisure and incisure. In all specimens the total annular circumference was measured . From a large database of 706 patients (pts) consecutively admitted to the Cardiovascular Department of San Raffaele Hospital, from January 2008 to December 2012 with a diagnosis of severe mitral regurgitation, we analysed the first 238 consecutively enrolled. All the patients were studied with pre-operative two dimensional (2D) and three dimensional (3D) Trans-oesophageal echocardiography (TOE) and submitted to surgical repair of the mitral valve.
We analyzed also the 3D TOE imaging (zoom 3D acquisitions) in order to establish the presence of subcommisure and incisure in patients affected by myxomatous disease. All examinations were stored in TomTec system and analyzed retrospectively with 3D dedicated software. Eighty eight examination were excluded: 1) for low quality of imaging and/or absence of 3D acquisition, 2) left anterior prolapse with no good evaluation of posterior leaflet anatomy.
In 163 pts I reconstructed with Tomtec system the zoom 3D morphology of the mitral valve in order to study the leaflet’s characteristics and to establish a clinical correlation with the type of surgical repair. The total patients population was divided in two groups A and B according to the type of surgical repair technique used , respectively simple and complex.
RESULTS
“Anatomic results”
There were variability in the number of scallop of posterior leaflet (PL): only 1 sample has 1 scallop (mono-scallop, 3,3%) and another one has 5 scallop, 2 samples have 2 scallops (bi-scallop, 6,6%), the major number of posterior leaflets are three scallops (63%) and 7 samples have 4 scallops (23%).Mean total annulus circumference was 9,6 ±1,25 cm. We identified a subcommisure as an indentation between two leaflets deeper than 50% of the high of the leaflets with fun like chordae very similar to the commissures, an incisure as an indentation in a scallop with an high less than 50% of the leaflets high and with or without small marginal chordae. In all sample we found: 23 total number of incisure, 4 incisure with chordae fun like and 19 incisure without chordae. The major number of incisure were on the posterior leaflet (19) and less on anterior (4). In the PL they were present more frequently in the central scallop P2 ( 9, 47%) and less on P3 ad P1 ( 5 and 3, 26% and 16 %, respectively).
“Echocardiographic results”: at the first analysis there is a predominant incidence of posterior leaflet prolapse. In the total population analyzed I found 46 bileaflet prolapse (28%), 117 posterior leaflet prolapse (72% ), Ninety five pts with flail ( 58%). The Type of posterior prolapse was: P2 involvement 142 pts (87%), other than P2 21 pts (13%), monolobate P2 45 pts (31%), bilobate P2 48 (33%), biscallop P2 62 (44%), number of incisure 61 (on posterior and anterior leaflet), number of pts with 2 subcommisure 99 (60%), number of pts with >2 subcommisure 65 (40%), intercommissural extension of the prolapse lesion: 2D evaluation 18,4 mm (±5,5) and 3D evaluation 28,5 mm (±11,12). The patients were divided in two groups according to the presence of simple (group A 49 pts) and complex surgical repair (group B 114) In the Group A (49 pts) the type of lesion and morphology were: 15 bileaflet prolapse (30%), type of posterior prolapse P2 involvement 39 pts (79%), other than P2 10 pts (20%), monolobate P2 20 pts (41%), bilobate P2 13 (26%), biscallop P2 18 (36%), number of incisure 11( 18%, on posterior and anterior leaflet), number of pts with 2 subcommisure 36 ( 73%), number of pts with >2 subcommisure 13 (26%), intercommissural extension of the prolapse lesion: 3D evaluation 25,7 mm. In the Group B (114 pts): Type of lesion and morphology were: 31 bileaflet prolapse (27%) , type of posterior prolapse: P2 involvement 101 pts (89%), other than P2 13 pts (11%), monolobate P2 25 pts (22%), bilobate P2 35 (30%), biscallop P2 50 (44%), number of incisure: 50 (44%, on posterior and anterior leaflet), number of pts with 2 subcommisure 63 ( 55%), number of pts with >2 subcommisure 51 (45%), intercommissural extension of the prolapse lesion: 3D evaluation 29,5 mm. I found the same prevalence in normal valves and in the myxomatous mitral valve diseases of the of three scallop morphology (about 30%), the posterior scallops are more wide and long in the myxomatous valve than in normal valve examined, according to the past literature. Also the annulus has more high dimension in myxomatous pts vs normal subjects. In the group B submitted to a complex surgical repair of the mitral valve prolapse I have found a major incidence of incisure (50/61) and a major incidence of bilobate P2 lesion and biscallop P2 ( major incidence also of more than 2 commisure). I have found also a significative difference in the evaluation of intercommisural prolapse lesion extension with two-dimensional vs three-dimensional echocardiography, due to the different power of the two imaging technology (18,4 vs 28, 5 mm, mean values). In the group B submitted to a complex mitral valve surgery repair there is a major intercommissural extension of the prolapse lesion (29,8 vs 25,8 mm, mean values). In the group A there is a prevalence of three scallops with monolobate morphology of the posterior leaflet (with 2 subcommissure 73%).
CONCLUSIONS: This study analyzed deeply the anatomy of the normal leaflets in order to establish the incidence of the presence of subcommisure and incisure. In the field of very debated past literature, this study introduce a new terminology and call the normal physiological indentation, deep more than 50% of the leaflet high, “subcommisure” and the simple indentation ,deep less than 50% ,“incisure”. This nomenclature is supported by the insertion on the subcommissure of tendineae chordae funny like very similar to the commissure ones. The main results of my PhD thesis are: 1° the same prevalence in normal valves and in the myxomatous mitral valve diseases of the of three scallop morphology (about 30%); 2° the posterior scallops are more wide and long in the myxomatous valve than in normal valve examined, according to the past literature; 3° The annulus ‘ dimensions are major in the myxomatous disease vs normal mitral valve; 4° in the group B submitted to a complex surgical repair of the mitral valve prolapse I have found a major incidence of incisure (50/61) and a major incidence of bilobate P2 lesion and biscallop P2 ( major incidence also of more than 2 commissure); 5° I have found also a significative difference in the evaluation of intercommisural prolapse lesion extension with two dimensional vs three-dimensional echocardiography, due to the different power of the two imaging technology; 6° In the group B submitted to a complex mitral valve surgery repair there is a major intercommissural extension of the prolapse lesion (29,8 vs 25,8 mm, mean value); 7° in the group A there is a prevalence of three scallops with monolobate morphology of the posterior leaflet (with 2 subcommissure 73%).
This study assess that in the analysis of severe myxomatous mitral valve incompetence, is essential to establish with a pre-operative three-dimensional echocardiography the presence of the subcommissure and the incisure, and the intercommissural extension of the prolapse lesion, those elements are important determinants to guide an optimal surgical repair treatment.

Abstract (italiano)

La corretta funzione della valvola mitrale è legata alla conformazione anatomica e all'interazione di tutte le componenti del complesso valvolare mitralico (lembi, anello, corde tendinee, muscoli papillari, ventricolo sinistro). La componente più importante della valvola sono i lembi. La nomenclatura ed il numero dei lembi è diversa in studi presenti in letteratura. La classificazione piu' comunemente utilizzata è quella di Carpentier, che identifica nel lembo posteriore tre scallop: dall'antero-laterale (P1) al centrale (P2) e il postero-mediale (P3). La terminologia della morfologia descrittiva dei lembi mitralici è molto dibattuta nella letteratura scientifica. Lo scopo dello studio è analizzazre la variabilità anatomica del lembo posteriore nei soggetti normali ( campioni da cuori autoptici e donatori per trapianto) e in pazienti con malattia mixomatosa (ecocardiografia tridimensionale) per stabilire possibili differenza. Nei pazienti con malattia mixomatosa vogliamo valutare inoltre la possibile influenza dell'anatomia del lembo posteriore sulla pianificazione della strategia chirurgica riparativa.
Materiali e Metodi
Nello studio anatomo patologico sono stati selezionati ed esaminati da tre osservatori indipedenti ( 2 anatomopatologi ed un cardiologo) trenta campioni di cuori normali, senza patologia della valvola mitrale.
I campioni erano stati fissati in formalina dopo autopsia o donazione da espianto, e sono stati selezionati dalla collezione anatomopatologica della Università di Padova.
La valvola mitrale è stata aperta lungo il margine ottuso del cuore e valutata. E' stata usata una nuova terminologia che definisce le fisiologiche indentature con altezza maggiore del 50% rispetto al lembo adiacente “subcommissure” e le indentature con altezza inferiore al 50% “incisure”. Sono state studiate in dettaglio le subcommissure e le incisure con le relative corde tenidinee.
E' stata effettuata una attenta valutazione al (1) numero degli scallop del lembo posteriore con (2) la caratterizzazione delle subcommisure e delle incisure, (3) all'altezza e all'ampiezza di ogni singolo scallop e (4) all'altezza dei lembi in corrispondenza delle subcommissure , delle incisure e delle commissure; (5) alla mrofologia delle corde tendinee nel sito di inserzione a livello delle commissure, subcommissure ed incisure. In tutti I campioni è stata misurata la lunghezza della circonferenza dell'anello. Da un grande database di 706 pazienti consecutivamente ricoverati copn diagnosi di insufficienza mitralica severa, da gennaio 2008 a Dicembre 2009 nel dipartimento Cardiovascolare dell'ospedale San Raffaele, sono stati analizzati I primi 238 paziente arruolati consecutivamente. Tutti i pazienti sono stati valutati con ecocardiogramma transesofageo (TEE) bidimensionale (2D) e tridimensionale (3D) e sottoposti successivamente ad intervento cardiochirurgico di riparazione della valvola mitrale.
Abbiamo analizzato le acquisizioni zoom 3D transesofagee per stabilire la presenza di subcommissure e incisure in pazienti affetti da malattia mixomatosa. Tutti gli esami sono stati salvati sul sistema di archivio e analisi Tomtec e analizzati retrospettivamente con programmi tridimensionali dedicati all'analisi valvolare. Ottantotto esami sono stati esclusi per : 1) bassa qualità delle immagini o assenza delle acquisizioni tridimensionali, 2) prolasso dominante del lembo anteriore con scadente visualizzazione dell'anatomia del lembo posteriore.
In 163 pazienti sono state ricostruite le immagini delle acquisizioni zoom 3D della valvola mitrale con il sistema Tomtec, per studiare le caratteristiche dei lembi e stabilire una correlazione clinica con il tipo di tecnica chirurgica riparativa usata. Il gruppo di pazienti della popolazione totale è stato diviso in due sottogruppi A e B in base alla tecnica riparativa usata, semplice (A) e complessa (B) rispettivamente.
Risultati
“Risultati Anatomici” :
Abbiamo troavto la seguente variabilità morfologica nel numero di scallop del lembo posteriore: solo 1 campione aveva uno scallop (mono-scallop, 3,3%) e un solo campione aveva 5 scallop (3,3%), 2 campioni avevano 2 scallop (6,6%), il numero maggiore di campioni (19) aveva 3 scallop (63%) e 7 campioni avevano 4 scallop (23%). La media della circonferenza totale dell’anello era 9,6 ±1,25 cm. Abbiamo identificato come subcommissura una indentatura profonda più del 50% dell’altezza del lembo con corde a festone molto simili alle corde commissurali, una incisura come un’indentatura in uno scallop con un’altezza inferiore al 50% dell’altezza del lembo con o senza piccole corde marginali. In tutti I campioni abbiamo trovato un totale di 23 incisure, 4 incisure con corde e 19 incisure senza corde. Il maggior numero delle incisure era sul lembo posteriore (19) e meno sull’anteriore (4). Nel lembo posteriore erano presenti più frequentemente nello scallop central P2 (9,47%) e meno sugli scallop P3 e P1 (5 e 3 , 26% e 16% rispettivamente).
“Risultati Ecocardiografici”: ad una prima analisi risulta una incidenza predominante del prolasso del lembo posteriore ed in particolare dello scallop central P2. Nella popolazione totale ho trovato 46 prolassi bilembo (28%), 117 prolassi del lembo posterior (72%), 95 pazienti con flail (58%). Il tipo di prolasso del lembo posteriore era: conivolgente lo scallop P2 142 pts (87%), altro che P2 21 pz (13%), con morfologia di P2 monolobato: 45 pts (31%), P2 bilobato 48 (33%), P2 biscallop 62 (44%) , un numero di incisure: 61 sui due lembi, numero di pz con 2 subcommissure: 99 (60%), numero di pz con più di 2 subcommissure : 65 (40%), l’estensione intercommissurale della lesion prolassante era: alla valutazione bidimensionale 18,4 mm (±5,5) e alla valutazione tridimensionale 28,5 mm (±11,12). I pazienti sono stati divisi in 2 gruppi in base alla presenza di chirurgia semplice (gruppo A 49 pz) e chirurgia complessa (Gruppo B 114 pz). Nel gruppo A (49 pz) il tipo di lesione e la morfologia erano: 15 pz con prolasso bi-lembo (30%), tipo di prolasso posteriore: coinvolgente P2 in 39 pz (79%), altro tipo non P2 10 pz (20%), P2 monolobato 20 pz (41%), P2 bilobato 13 pz (26%), P2 biscallop 18 pz (36%), numero si incisure : 11 (18% sui due lembi), numero di pz con 2 subcommissure 36 (73%), pz con più di 2 subcommissure 13 (26%), estensione intercommissurale del prolasso in 3D 25,7 mm. Nel gruppo B (114 pz) il tipo di lesione e la morfologia erano: coinvolgimento di P2 101 pz (89%), altro scallop non P2 13 pz (11%), P2 monolobato 25 pz (22%), P2 bilobato 35 (30%), P2 biscallop 50 pz (44%), numero di incisure 50 (44% sui due lembi), numero di pz con 2 subcommissure 63 (55%), numero di pz con più d 2 subcommissure 51 (45%), estensione intercommissurale della lesione prolassante alla valutazione tridimensionale 29,5 mm. È stata trovata la stessa prevalenza della mrofologia con 3 scallop (30% circa ) sia nella popolazione dei campioni normali che nei pz con malattia mitralica mixomatosa, gli scallop del lembo posterior sono più ampi e lunghi nella valvola mixomatosa rispetto alla valvola mitrale normale, in accorso con la letteratura esistente. Anche l’anello ha dimensioni maggiori nei pazienti mixomatosi. Nel gruppo B sottoposto a chirurgia riparativa complessa è stata trovata una maggiot incidenza di incisure (50/61) e una maggior incidenza di P2 bilobati e biscallop con più di 2 subcommissure, inoltre vi è anche una maggior estensione 3D intercommissurale della lesione prolassante (29,8 vs 25,8 mm). Nel gruppo generale è stata trovata una significative differenza nella valutazione ecocardiografica intercommissurale con 2D versus 3D (18,4 vs 28, 5 mm, mean values) legata al diverso potere delle due tecniche. Nel gruppo A vi è una prevalenza della morfologia monolobato di P2 con due subcommissure (73%).
Conclusioni: Lo studio analizza in dettaglio l’anatomia dei lembi mitralici in valvole normali per stabilire l’incidenza e la presenza di subcommissure ed incisure. In un campo molto dibattuto nella letteratura scientifica esistente , introduce una nuova terminologia chiamando “subcommissure” indentature con altezza maggiore del 50% ed “incisure” indentature con altezza inferiore al 50% dell’altezza del lembo. Questa nomenclatura è supportata dall’inserzione sulle subcommisure di corde a festone molto simili a quelle commissurali. I principali risultati della mia tesi sono: 1° la stessa prevalenza della morfologia a 3 scallop nelle valvole normali e mixomatouse (circa 30%); 2° ampiezza e lunghezza maggiore degli scallop del lembo posteriore nelle valvole mixomatose; 3° anello con dimensioni maggiori nelle valvole mixomatose, 4° nel gruppo B sottoposto a chirurgia riparativa complessa maggiore incidenza di incisure e di lesioni bilobate e biscallop con più di 2 subcommissure; 5° è stata trovata inoltre una significativa differenza nella valutazione ecocardiografica 2D vs 3D della estensione intercommissurale del prolasso; 6° inoltre nel gruppo B vi è una maggiore estensione intercommissurale del prolasso rispetto al gruppo A; 7° nel gruppo A vi è una prevalenza maggiore della morfologia monolobata con 2 subcommissure (73%). Questo studio afferma che nell’analisi pre-operatoria di una insufficienza mitralica severa mixomatosa è essenziale eseguire un ecocardiogramma tridimensionale transesofageo per stabilire la presenza di subcommissure ed incisure, e valutare la estensione intercommissurale della lesione prolassante, essi sono elementi determinanti per la scelta della complessità della tecnica chirurgica riparativa.

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Tipo di EPrint:Tesi di dottorato
Relatore:Angelini, Annalisa
Dottorato (corsi e scuole):Ciclo 27 > scuole 27 > SCIENZE MEDICHE, CLINICHE E SPERIMENTALI > SCIENZE CARDIOVASCOLARI
Data di deposito della tesi:31 Gennaio 2016
Anno di Pubblicazione:31 Gennaio 2016
Parole chiave (italiano / inglese):valvola mitrale/mitral valve, ecocardiografia/echocardiography, anatomia/anatomy
Settori scientifico-disciplinari MIUR:Area 06 - Scienze mediche > MED/11 Malattie dell'apparato cardiovascolare
Struttura di riferimento:Dipartimenti > Dipartimento di Medicina
Codice ID:9456
Depositato il:06 Ott 2016 16:04
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