Anatomic and Quantitative 3D Echocardiographic Predictors for Risk Stratification and Improved Management of Congenital Mitral Valve Disease

Background: Congenital mitral valve disease (CMVD) presents major challenges regarding medical and surgical management. Three dimensional echocardiography (3DE) allows precise delineation of area tracing from cross-sectional planes for obtaining more accurate measurements and improved outcome analysis. However, there are no available data to inform clinicians on how 3DE can help guide management. We hypothesized that anatomic descriptions and quantitative 3DE measurements can provide improved risk stratification and guide management of CMVD.

Method: Demographic, procedural, and outcome data were obtained for all 206 children who underwent MV reconstruction for CMVD from 2002 to 2018. A total of 105 patients had mitral stenosis (MS), 75 mitral regurgitation (MR), and 26 mixed disease (MD). Thirteen patients (6%) died. MD patients had higher rates of mortality, reoperation, and valve replacement. Preoperative anatomic variables were collected from surgical reports. Quantitative 3DE measurements of the effective orifice area (EOA) and vena contracta regurgitant area (VCRA) were determined preoperatively and before discharge.

Results: Multivariable Cox's regression confirmed that the risk of reoperation was higher in patients with at least moderate postoperative MR (hazard ratio = 4.26; 95% CI: 2.45, 7.4; p < 0.001) and the presence of tethered leaflets (hazard ratio = 2.02; 95% CI: 1.05; 3.89; p < 0.001). Changes from baseline in EOA and VCRA were significantly independent predictors of reoperation with excellent area under the curve (AUC) values (EOA:AUC = 0.888; VCRA:AUC = 0.962; both p < 0.001). Decision analysis revealed that an increase in EOA < 30% for patients with MS is associated with 76% risk of reoperation (HR = 11.4; 95% CI: 3.4–37.8; p < 0.001), whereas a decrease in VCRA < 40% for MR patients is associated with 93% risk of reoperation (HR = 18.1; 95% CI: 2.3–142; p = 0.006). Comparison of the AUCs indicated that the change in EOA is a significantly stronger predictor of reoperation than changes in mean gradients (p = 0.018; DeLong's test).

Conclusion: Reconstructive surgery for CMVD can be performed with good outcomes. At least moderate postoperative MR and tethered leaflets are significant multivariable predictors of reoperation. The 3DE EOA and VCRA aid in postoperative clinical decision-making. Further, 3DE is a better predictor of patient outcomes than 2DE measurements of mean gradients. Therefore, we now incorporate 3DE EOA and VCRA into clinical and surgical management planning.

Die Autoren geben an, dass kein Interessenkonflikt besteht.

Publikationsverlauf

Artikel online veröffentlicht:
12. Februar 2022