Yonsei Med J.  2014 May;55(3):592-598. 10.3349/ymj.2014.55.3.592.

Response of Functional Mitral Regurgitation during Dobutamine Infusion in Relation to Changes in Left Ventricular Dyssynchrony and Mitral Valve Geometry

• Choi WG
• Kim SH
• Kim SH
• Park SD
• Baek YS
• Shin SH
• Woo SI
• Kim DH
• Park KS
• Kwan J

• KMID: 2068667
• DOI: http://doi.org/10.3349/ymj.2014.55.3.592

Abstract

PURPOSE
Functional mitral regurgitation (FMR) and myocardial dyssynchrony commonly occur in patients with dilated cardiomyopathy (DCM). The aim of this study was to elucidate changes in FMR in relation to those in left ventricular (LV) dyssynchrony as well as geometric parameters of the mitral valve (MV) in DCM patients during dobutamine infusion.
MATERIALS AND METHODS
Twenty-nine DCM patients (M:F=15:14; age: 62+/-15 yrs) with FMR underwent echocardiography at baseline and during peak dose (30 or 40 ug/min) of dobutamine infusion. Using 2D echocardiography, LV end-diastolic volume, end-systolic volume (LVESV), ejection fraction (EF), and effective regurgitant orifice area (ERO) were estimated. Dyssynchrony indices (DIs), defined as the standard deviation of time interval-to-peak myocardial systolic contraction of eight LV segments, were measured. Using the multi-planar reconstructive mode from commercially available 3D image analysis software, MV tenting area (MVTa) was measured. All geometrical measurements were corrected (c) by the height of each patient.
RESULTS
During dobutamine infusion, EF (28+/-8% vs. 39+/-11%, p=0.001) improved along with significant decrease in cLVESV (80.1+/-35.2 mm3/m vs. 60.4+/-31.1 mm3/m, p=0.001); cMVTa (1.28+/-0.48 cm2/m vs. 0.79+/-0.33 cm2/m, p=0.001) was significantly reduced; and DI (1.31+/-0.51 vs. 1.58+/-0.68, p=0.025) showed significant increase. Despite significant deterioration of LV dyssynchrony during dobutamine infusion, ERO (0.16+/-0.09 cm2 vs. 0.09+/-0.08 cm2, p=0.001) significantly improved. On multivariate analysis, DeltacMVTa and DeltaEF were found to be the strongest independent determinants of DeltaERO (R2=0.443, p=0.001).
CONCLUSION
Rather than LV dyssynchrony, MV geometry determined by LV geometry and systolic pressure, which represents the MV closing force, may be the primary determinant of MR severity.

Keyword

Mitral regurgitation; dyssynchrony; dobutamine

MeSH Terms

Aged
Dobutamine/administration & dosage/*pharmacology
Echocardiography
Female
Humans
Male
Middle Aged
Mitral Valve/*anatomy & histology/drug effects/*physiopathology
Mitral Valve Insufficiency/*physiopathology
Ventricular Dysfunction, Left/*physiopathology
Dobutamine

Figure

• 

  Fig. 1 Illustrations explaining geometric measurements of the mitral tethering angle (A), mitral valve tenting area (B), cross-sectional volumetric image at the mitral valve level (C), and CC plane (D) connecting both commissures. CC, commissure-commissure; Pα, posterior tethering angle; Aα, anterior tethering angle; AP, anteroposterior; MVTa, mitral valve tenting area; AML, anterior mitral leaflet; PML, posterior mitral leaflet; PC, posterior commissure; AC, anterior commissure.

• 

  Fig. 2 Individual changes in effective regurgitant orifice, ejection fraction, mitral tenting area, dyssynchrony index between rest, and peak dobutamine infusion (red line: LBBB patients). LBBB, left bundle branch block.

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