SpDmtmtnetpctlto

Upr

0d

Annular-to-Leaflet Mismatch and the Need for ReductiveAnnuloplasty in Patients Undergoing Mitral Repair for Chronic

Mitral Regurgitation Due to Mitral Valve Prolapse

Francesco Maisano, MDa, Giovanni La Canna, MDc,*, Antonio Grimaldi, MDc,Giorgio Viganò, MDa, Andrea Blasio, MDa, Andrea Mignattia, Antonio Colombo, MDd,

Attilio Maseri, MDb, and Ottavio Alfieri, MDa

Annular dilation is a common feature of chronic degenerative mitral regurgitation causedby leaflet prolapse. Accordingly, patients undergoing surgical repair usually undergoconcomitant reductive annuloplasty to restore a normal annular-to-leaflet relation. Withthe evolution of transcatheter valve repair technologies, patient selection criteria for thosewho do not require annuloplasty are needed. A series of patients undergoing mitral repairwas analyzed, and the role of annular-to-leaflet mismatch in identifying patients requiringreductive annuloplasty was explored. Preoperative data for 82 patients undergoing mitralrepair with annuloplasty for degenerative mitral regurgitation were prospectively collected,including annular intercommissural (IC) and septolateral (SL) dimensions and heights ofanterior (ALH) and posterior leaflets. An SL/ALH ratio >1.4 was used to define annular-to-leaflet mismatch. After mitral repair, the ratio between preoperative IC distance and thesize of the implanted annular prosthesis (Seguin ring [SR], IC/SR <1.2) was used toidentify patients for whom annuloplasty was nonreductive. All patients underwent suc-cessful mitral repair. Mean preoperative IC was 46 � 6 mm, SL was 42 � 5 mm, and ALHwas 31 � 5 mm. Mean SR was 34 � 3 mm, with a mean IC/SR ratio of 1.34 � 0.14. Sixteenpatients (19%) had an IC/SR ratio <1.2. IC/SR ratio <1.2 was predicted by a SL/ALH ratio<1.4 (p � 0.009). In conclusion, annular dilation is negligible in <20% of surgicalcandidates. In this subgroup, an isolated leaflet repair may be indicated. SL/ALH ratiois a good indicator of annular-to-leaflet mismatch and could be used as an adjunct toother methods of annular function assessment to select patients for ringless mitral

repair. © 2007 Elsevier Inc. All rights reserved. (Am J Cardiol 2007;99:1434 –1439)

M

FswdflpcstitTcwi

aeSdew

urgical valve repair of mitral regurgitation caused by valverolapse1 is routinely supplemented by ring annuloplasty.2

espite its widespread use, in some patients, annuloplastyay lead to reinforcement of valve repair without a reduc-

ive effect on the native annulus. Recently, transcatheteritral valve repair was proposed to correct mitral regurgi-

ation without annuloplasty.3 Lacking strict criteria to defineormal annular dimensions, selection of patients who ben-fit from ringless correction of mitral regurgitation is unde-ermined. The aim of our study is to identify the features ofatients undergoing “reductive annuloplasty” during surgi-al repair to restore mitral valve competence as opposed tohose undergoing “nonreductive annuloplasty.” In particu-ar, we compared absolute annular dimensions with annular-o-leaflet relations to predict the degree of annular reductionbtained by surgical annuloplasty.

Departments of aCardiac Surgery and bCardiology, cEchocardiographynit, and dInterventional Cardiology Unit, San Raffaele University Hos-ital, Milan, Italy. Manuscript received August 2, 2006; revised manuscripteceived and accepted December 28, 2006.

*Corresponding author: Tel: 39-022-643-7156; fax: �39-022-643-7125.

dE-mail address: giovanni.lacanna@hsr.it (G. La Canna).

002-9149/07/$ – see front matter © 2007 Elsevier Inc. All rights reserved.oi:10.1016/j.amjcard.2006.12.072

ethods

rom January 2004 to June 2004, a total of 175 patients withevere chronic degenerative mitral regurgitation presentingith a prolapse or flail leaflet underwent mitral repair at ourepartment. A ring prosthesis was used in all patients,exible in 84 patients (48%) and rigid or semi-rigid in 91atients (52%). From the latter group, only those who re-eived the Seguin (St Jude Medical Inc., St. Paul, Minne-ota) ring were selected as the study population (82 pa-ients). Seguin ring nominal size (SR) is defined by itsntercommissural (IC) distance, and according to manufac-urer specifications, corresponds to the model numbers.herefore, a ratio between preoperative echocardiographi-ally measured IC distance and size of the implanted SRas calculated to assess the extent of annular reduction

nduced by annuloplasty in each patient.

Echocardiography: All patients underwent transthoracicnd transesophageal echocardiography the day before the op-ration in our echocardiography laboratory using a Philipsonos 7500 echocardiographic machine (Philips Inc., An-over, Massachusetts). All examinations were performed by 2xperienced cardiologists (GLC, AG). Echocardiographic dataere stored at the time of examination in a dedicated echocar-

iographic database including clinical and surgical data.

www.AJConline.org

Csiaartt

tmmwr

hfiLae

mmmtaSbl

smmbvaa

AiiifmnTww

p

Fe(9a

FSssscpCst

1435Valvular Heart Disease/Annular Dilatation and Mitral Valve Repair

Regurgitation mechanisms were classified according toarpentier criteria.2 Degree of mitral regurgitation was con-

idered severe on the basis of a multiparameter approach,ncluding measurement of the effective regurgitant orificerea (�0.4 cm2), width of the vena contracta (�7 mm), andmount of left atrial surface occupied by the area of theegurgitant jet (�40%).4 Left ventricular and atrial diame-ers and volumes were determined using 2-dimensionalransthoracic echocardiography using a standard approach.5

Annular and leaflet dimensions were assessed usingransesophageal echocardiography. Annular dimensions were

easured in systole at the first recorded image showingitral valve closure. Septolateral (SL) and IC dimensionsere measured in the mid-esophageal view at 120° and 90°,

igure 1. Echocardiographic views used to determine systolic IC and SL dchocardiographic views to measure annular and leaflet dimensions are sA) the mid-esophageal 120° plane is used to measure SL (also known as0° plane is used to measure IC dimension of the annulus in systole; and (Cnnulus to free edge) in diastole.

igure 2. Efficient systolic configuration of the mitral valve withL/ALH � PLH ratio �0.7. The SL/ALH � PLH ratio is built usingystolic annular and diastolic leaflet dimensions. A model of efficientystolic configuration is shown. The anterior leaflet (AL) is composed of 2egments: S to C (the portion of the anterior leaflet not participating tooaptation) and C to P (the coapting surface). The same applies for theosterior leaflet (L to C is the segment nonparticipating to coaptation andto P is the coapting segment). When SL/ALH � PLH ratio is �0.7, the

um of ALH and PLH is 30% longer than SL: the excess tissue constituteshe coapting surface (SA and CP).

espectively. Anterior (ALH) and posterior leaflet (PLH) I

eights (from annulus to free edge) were calculated in therst diastolic image in the mid-esophageal at 120° view.eaflet height was determined as the distance from thennulus to the free edge of the leaflet. Figure 1 showschocardiographic images of such measurements.

Annular-to-leaflet relations and annular-to-leafletismatch: Based on measurement of the annular SL di-ension and leaflet heights, we calculated annular SL di-ension to the ALH ratio (SL/ALH), annular SL dimension

o the sum of ALH and PLH ratio (SL/ALH � PLH), andnnular-to-leaflet mismatch, defined as SL/ALH �1.4 andL/ALH � PLH �0.7 according to an ideal anatomic com-ination to obtain sufficient coaptation surface between theeaflets (Figure 2).

Surgical technique and method of annuloplasty ringizing: Mitral repair was carried out through a conventionalid-line sternotomy in all patients under normothermic orildly hypothermic cardiopulmonary bypass, using cold

lood cardioplegia for myocardial protection. The mitralalve was exposed through a left atriotomy, and valvenatomy was inspected thoroughly before repair to reviewnd confirm preoperative echocardiographic findings.

Mitral repair was performed as indicated by anatomy.fter leaflet reconstruction, a Seguin annuloplasty ring was

mplanted using interrupted sutures in all patients. This rings a complete semi-rigid annuloplasty prosthesis, availablen sizes from 24 to 40 mm. Annuloplasty ring implantationollowed well-established surgical rules, using the constantethod described next. A dedicated annuloplasty sizer with

otches was used to measure IC distance of the mitral valve.he closest sizer to the IC distance of the anterior leafletas selected. Additionally, the surface of the anterior leafletas matched to the sizer that reproduced its size and shape.

Definition of reductive versus nonreductive annulo-lasty (IC/SR ratio): Patients were classified according the

of the mitral annulus and diastolic ALH and PLH. The 3 transesophagealelow each view, a schematic representation of the measure is reported:roposterior) dimension of the annulus in systole; (B) the mid-esophageald-esophageal 120° plane is used to measure the height of the leaflets (from

istanceshown. Bthe ante) the mi

C/SR ratio: patients with IC/SR ratio �1.2 were included

iuln

bgw

ls

dbtDpdfSaobpp

R

Pt77scT

ttapS

l

mpr

Fpclsp

TC

V

N

HSDDRM

C

lc

TE

LLLLSEFSPSAAAVAPASS

1436 The American Journal of Cardiology (www.AJConline.org)

n the reductive annuloplasty group (group A) because theynderwent �20% annular dimension reduction after annu-oplasty; patients with IC/SR �1.2 were included in theonreductive annuloplasty group (group B).

After repair and after weaning from cardiopulmonaryypass, all patients underwent intraoperative transesopha-eal echocardiography. Before discharge, all patients under-ent routine transthoracic Doppler echocardiography.

Data collection and statistical analysis: Data were col-ected using dedicated databases, and written informed con-

igure 3. Segmental distribution of type II lesions. The mitral valve isresented as seen by the surgeon. Segments are named according to thelassic Carpentier topographic classification. For each segment, the cumu-ative number of lesions encountered in the study group is reported. Theum of lesions is greater than the number of patients because of theresence of multiple lesions in several patients.

able 1linical characteristics of the study population (n � 82)

ariable

YHA functional classI 26/82 (32%)II 46/82 (56%)III 10/82 (12%)IV 0/82 (0%)ypertension 20/82 (24%)moker* 29/82 (24%)iabetes mellitus† 3/82 (4%)yslipidemia‡ 5/82 (6%)enal insufficiency 2/82 (2%)edical therapy

Angiotensin-enzyme inhibitors 42 (56%)Diuretics 32 (40%)� blockers 26 (32%)Digitalis 13 (16%)alcium antagonists 6 (7%)

* Either current or past.† Either insulin dependent or non–insulin dependent.‡ Defined as the presence of any of total cholesterol �240 mg/ml,

ow-density lipoprotein cholesterol �160 mg/ml, high-density lipoproteinholesterol �40 mg/ml, triglycerides �200 mg/ml.

NYHA � New York Heart Association.

ent was obtained from patients to retrieve and analyze the A

ata. The database and subsequent analysis was authorizedy the San Raffaele Institutional Ethics review board (in-ernal protocol MItral Valve Outcome Research Protocol).ata analysis was conducted using the JMP 5.1 statisticalackage (SAS Institute Inc., Cary, North Carolina). Stu-ent’s t test and chi-square analysis were used to test dif-erences between continuous and categorical variables.tandard least-squares regression analysis was used to an-lyze correlations between continuous variables. Receiver-perating characteristic curves were used to verify the ar-itrarily set cut-off SL/ALH and SL/ALH � PLH values forrediction of IC/SR �1.2. Statistical difference was set at�0.05.

esults

atient mean age was 55 � 12.6 years (range 26 to 78);here were 20 women (24%) and 62 men. Mean weight was5 � 11.2 kg (range 47 to 120) and mean height was 172 �.3 cm (range 154 to 185), for a calculated mean bodyurface area of 1.8 � 0.17 cm2 (range 1.4 to 2.3). Additionallinical characteristics of the study population are listed inable 1.

Mechanism of mitral regurgitation: There were 55 pa-ients with isolated posterior leaflet type II disease, 22 pa-ients with bileaflet disease, and 5 patients with isolatednterior leaflet disease. A flail lesion was detected in 27atients (26 posterior leaflet and 1 anterior leaflet flail lesions).egmental distribution of lesions is shown in Figure 3.

Echocardiographic features of the study population areisted in Table 2.

Annular-to-leaflet relations: Annular-to-leaflet mis-atch was absent in a minority of patients in this surgical

opulation. There were 17 patients (21%) with SL/ALHatio �1.4 and 21 (26%) with SL/ALH � PLH ratio �0.7.

able 2chocardiographic features

Mean � SD Range

V end-diastolic diameter (mm) 58 � 6.9 50–81V end-systolic diameter (mm) 36 � 5.8 18–48V end-diastolic volume (ml) 139 � 36.7 60–240V end-systolic diameter (ml) 51 � 19.1 20–144troke volume (ml) 89 � 26.8 36–153jection fraction (%) 63.9 � 8.9 30–77ractional shortening (%) 39 � 10 11–67ystolic pulmonary artery pressure (mm Hg) 39 � 10.1 25–70osterior wall thickness (mm) 10 � 1.2 8–13eptal thickness (mm) 12 � 1.5 8–15nteroposterior left atrial dimension (mm) 47 � 6.7 31–66nnular SL dimension (mm) 41 � 5.3 29–54nnular IC dimension (mm) 46 � 5.8 25–60alve area (cm2) 8 � 2.5 4–12LH (mm) 31 � 5.4 21–46LH (mm) 21 � 5.8 7–40LH � PLH (mm) 52 � 8.5 29–83L/ALH 1.67 � 0.35 1.05–2.62L/ALH � PLH 0.82 � 0.14 0.60–1.37

LV � left ventricular.

s listed in Table 3, absolute annular dimensions were not

slP

r

Fa

TA

I

S

rior lea

1437Valvular Heart Disease/Annular Dilatation and Mitral Valve Repair

ignificantly different in patients with normal and patho-ogic ratios, except for SL dimensions in the SL/ALH �

0.7

0.8

0.9

1

1.1

1.2

1.3

1.4

1.5

1.6

1.7

1.8

1 1.5

S

IC/S

R

0.7

0.8

0.9

1

1.1

1.2

1.3

1.4

1.5

1.6

1.7

1.8

IC/S

R

0.5 0.6 0.7 0.8

SL/igure 4. Linear correlations of (A) IC/SR ratio to SL/ALH ratio and (B) SLre represented by dashed lines.

able 3nnular dimensions and SL/ALH and SL/ALH � PLH ratios correlations

SL/ALH �1.4 SL/ALH �1.4

C (mm) 44 � 4.2 (38–50) 47 � 5.6 (36–6p � 0.07

L (mm) 39 � 5.7 (29–48) 43 � 4.3 (31–5p � 0.053

ALH � anterior leaflet height from annulus to free edge; PLH � poste

LH ratio. p

Surgical techniques and annuloplasty effects: Leafletepair included edge-to-edge repair in 45 patients (56%) and

2 2.5

LH A

r2= 0.11; p=0.01

1 1.1 1.2 1.3 1.4

+PLH B

r2= 0.12; p=0.008

PLH ratio are represented by solid lines. The 95% confidence limit curves

SL/ALH � PLH �0.7 SL/ALH � PLH �0.7

45 � 6.7 (36–60) 47 � 53 (35–58)p � 0.34

39 � 5.8 (29–48) 43 � 4.3 (31–54)p � 0.002

flet height from annulus to free edge.

L/A

0.9

ALH/ALH �

0)

4)

osterior quadrangular resection in the remaining 37 pa-

tMiad

rPpnIwstphtpaPr

v(ovct

m

grmdmaavtra(g

D

Tanrrtipcpl

cArrsata

clp

iIrTaswUIpo“

ncaubB

TE

LLLLSEFS

PSA

AAVAPASSS

p

1438 The American Journal of Cardiology (www.AJConline.org)

ients (34%). Mean SR was 33 � 3.3 mm (range 28 to 40).ean IC/SR ratio was 1.34 � 0.15 (range 0.78 to 1.75),

ndicating a 34% average decrease in IC dimension afternnuloplasty. In 16 of 82 patients (19%), the decrease in ICimension was �20% (IC/SR �1.2, group B).

There was a linear correlation of IC/SR with SL/ALHatio (r2 � 0.11, p � 0.01, Figure 4) and with SL/ALH �LH (r2 � 0.12, p � 0.008; Figure 4), suggesting thatatients with more balanced annular-to-leaflet surfaceseeded less annular reduction to restore competence. AnC/SR ratio �1.2 was observed more frequently in patientsith a SL/ALH ratio �1.4 (p � 0.009): SL/ALH ratio �1.4

howed 87% sensitivity, 50% specificity, 84% positive predic-ive value, and 55% negative predictive value to predict aostoperative IC/SR ratio �1.2. SL/ALH � PLH ratio �0.7ad 87% sensitivity, 55% specificity, 88% positive predic-ive value, and 57% negative predictive value for the samerediction. Using receiver-operating characteristic curvenalysis, areas under the curve for SL/ALH and SL/ALH �LH ratios were 0.78 (p � 0.007) and 0.77 (p � 0.005),espectively.

IC/SR ratio �1.2 was also predicted by smaller leftentricular end-systolic volume and annular dimensionsTable 4). IC/SR ratio was not influenced by the mechanismf regurgitation or surgical technique used to repair thealve. The ratio was also not influenced by any patientlinical characteristic (listed in Table 1), including medicalherapy.

Mitral valve competence after repair: After repair,

able 4chocardiographic features in groups A versus B

Group AReductive

Annuloplasty

Group BNonreductiveAnnuloplasty

pValue

V end-diastolic diameter (mm) 58 � 6.9 59 � 5.1 0.28V end-systolic diameter (mm) 36 � 5.5 36 � 6.6 0.96V end-diastolic volume (ml) 135 � 32.6 148 � 40.6 0.29V end-systolic volume (ml) 47 � 11.6 56 � 16.8 0.01troke volume (ml) 89 � 25.4 92 � 28.0 0.72jection fraction (%) 65 � 6.0 62 � 6.5 0.05ractional shortening (%) 38 � 9.4 39 � 8.15 0.50ystolic pulmonary artery

pressure (mm Hg)38 � 9.7 40 � 10.7 0.66

osterior wall thickness (mm) 10 � 0.2 10 � 0.4 0.13eptal thickness (mm) 12 � 0.2 11 � 0.4 0.20nteroposterior left atrialdimension (mm)

47 � 6.1 49 � 7.5 0.28

nnular SL dimension (mm) 42 � 4.8 38 � 5.6 0.001nnular IC dimension (mm) 47 � 5.0 39 � 4.7 �0.0001alve area (cm2) 8 � 2.5 8 � 2.6 1.0LH (mm) 31 � 5.3 32 � 5.8 0.70LH (mm) 21 � 5.5 21 � 7.1 0.95LH � PLH (mm) 52 � 7.7 53 � 11.1 0.78L/ALH 1.75 � 0.34 1.42 � 0.23 0.003L/ALH � PLH 0.85 � 0.14 0.74 � 0.11 0.004R (ring size in mm) 34 � 3.4 34 � 2.7 0.70

ALH � anterior leaflet height from annulus to free edge; PLH �osterior leaflet height from annulus to free edge.Abbreviation as in Table 2.

ean residual mitral regurgitation did not differ between l

roups (0.24 � 0.47 and 0.20 � 0.41 for groups A and B,espectively, p � 0.74). No evidence of systolic anteriorotion of the mitral valve was detected. Doppler echocar-

iography before discharge showed no or trivial residualitral regurgitation in all except 2 patients who had 2� onscale of 4� residual mitral regurgitation, unrelated to

nnular dilation or systolic anterior motion of the mitralalve. The 2 patients who had 2� residual mitral regurgi-ation at discharge Doppler echocardiography had IC/SRatios of 1.37 and 1.65, respectively. Mean ejection fractiont discharge (mean 5 days after surgery) was 53 � 7.3%range 23% to 65%), with no difference (p � 0.6) betweenroups A (54.8 � 5.9%) and B (53.8 � 6.8%).

iscussion

he main finding of this study is that the ratio betweennnular SL dimension and leaflet height may predict theeed for reductive annuloplasty in the setting of surgicalepair of mitral regurgitation caused by prolapse. SL/ALHatio �1.4 and SL/ALH � PLH ratio �0.7 indicate annular-o-leaflet mismatch and could be used as cut-off values todentify patients requiring reductive annuloplasty. However,atients without evidence of annular-to-leaflet mismatchould undergo leaflet repair without concomitant annulo-lasty, particularly in the setting of endovascular mitraleaflet repair procedures.

Surgical mitral repair is currently indicated early in thelinical course of the disease before symptoms develop.6nnuloplasty has a central role to enhance early and late

esults of mitral reconstruction,7 possibly because of theeduction in structural stresses acting on the leaflets anduture lines.8 Most surgeons therefore routinely implantnnuloplasty rings at the end of mitral repair to “reinforce”he reconstruction regardless of the shape and size of thennulus.

Recently, the dogma of annuloplasty in mitral repair washallenged by some investigators reporting excellent ring-ess repair results, although they did not address the issue ofatient selection.9,10

In the present study, we used the IC/SR ratio to discrim-nate patients undergoing reductive annuloplasty (group A,C/SR ratio �1.2) from patients who had nonreductive oreinforcement annuloplasty (group B, IC/SR ratio �1.2).he method of patient assignment to the groups was oper-tor independent: the size of the annuloplasty ring prosthe-is was determined using standard surgical procedure inhich the size of the ring is based on the size of the leaflets.sing this method, 19% of patients had �20% reduction in

C annular dimension after annuloplasty (group B). Theseatients were characterized preoperatively by lower degreesf annular-to-leaflet mismatch, suggesting the absence ofrelative” annular dilation.

Annular-to-leaflet mismatch is a novel definition of an-ular dilation based on the concept that effective leafletoaptation is impaired when leaflet size is smaller thannnular size. We used 2 different annular-to-leaflet ratios: 1sing anterior leaflet size only (SL/ALH ratio) and 1 com-ining the sizes of both leaflets (SL/ALH � PLH ratio).oth ratios effectively identified patients with annular-to-

eaflet mismatch who needed reductive annuloplasty. Other

mtrdBva

ucuaoah

vla

cdeht

fsw2c

rirce

gsocn

Ad

1

1

1

1

1

1

1

1

1

1

1439Valvular Heart Disease/Annular Dilatation and Mitral Valve Repair

easures (ventricular dimensions, mechanism of regurgita-ion, repair technique, and other clinical data) failed in thisespect. Noteworthy, absolute annular dimensions were notifferent in patients with and without mismatch (Table 3).ecause the SL/ALH ratio is simpler to achieve and pro-ides similar results, it is now the preferred method to detectnnular-to-leaflet mismatch at our institution.

The present study design is limited because all patientsnderwent annuloplasty. An ideal study should include aontrol group of patients with equivalent characteristicsndergoing ringless repair to prove that patients withoutnnular-to-leaflet mismatch can be effectively treated with-ut annuloplasty. However, because surgical annuloplasty isfactor improving repair durability, such a study would

ave relevant ethical limitations.Medical therapy was variable among patients. Because

ariations in diuretic or vasodilator therapy are able to affecteft ventricular function and shape, they potentially affectnnular dimensions.11

To create the SL/ALH ratio, annular diameter was cal-ulated in systole, whereas leaflet height was measured iniastole when the anterior leaflet is completely visualized bychocardiography. Because leaflets are plastic and theireight may vary between systole and diastole, the differentime of acquisition may induce measurement inaccuracy.

Regarding the model of annular geometry, the studyocused on 2 annular dimensions,12–17 the IC and SL dimen-ions. They were only recorded in systole. No dynamic dataere recorded, and annular dimensions were analyzed on a-dimensional basis as a simplification of the 3-dimensionalonfiguration of the mitral annulus.18

Although prosthetic ring sizing follows well-definedules, additional factors not included in data collection maynfluence the decision. For example, for valve anatomy atisk of SAM after repair, larger annuloplasty ring sizesould be selected. Conversely, for larger ventricles or lowerjection fraction, smaller rings could be selected.

In addition to these limitations, the present study sug-ests that calculation of the ratio between annular dimen-ions and leaflet size may be used to identify patients with-ut annular-to-leaflet mismatch (SL/ALH ratio �1.4) whoould benefit from isolated mitral valve repair without an-uloplasty, eventually using a transcatheter technique.19

cknowledgment: We thank Lorenzo Arcobasso, BS, forata management and retrieval assistance.

1. Braunberger E, Deloche A, Berrebi A, Abdallah F, Celestin JA, Mei-moun P, Chatellier G, Chauvaud S, Fabiani JN, Carpentier A. Verylong-term results (more than 20 years) of valve repair with Carpenti-er’s techniques in nonrheumatic mitral valve insufficiency. Circulation2001;104(suppl 1):I8–I11.

2. Carpentier A. Cardiac valve surgery—the “French correction.” J Tho-

rac Cardiovasc Surg 1983;86:323–337.

3. Alfieri O, Maisano F, Colombo A. Future of transcatheter repair of themitral valve. Am J Cardiol 2005;96:71L–75L.

4. Zoghbi WA, Enriquez-Sarano M, Foster E, Grayburn PA, Kraft CD,Levine RA, Nihoyannopoulos P, Otto CM, Quinones MA, RakowskiH, et al, for the American Society of Echocardiography. Recommen-dations for evaluation of the severity of native valvular regurgitationwith two-dimensional and Doppler echocardiography. J Am Soc Echo-cardiogr 2003;16:777–802.

5. Schiller NB, Shah PM, Crawford M, DeMaria A, Devereux R, Feigen-baum H, Gutgesell H, Reichek N, Sahn D, Schnittger I. Recommen-dations for quantitation of the left ventricle by two-dimensional echo-cardiography. J Am Soc Echocardiogr 1989;2:358–367.

6. David TE, Ivanov J, Armstrong S, Rakowski H. Late outcomes ofmitral valve repair for floppy valves: implications for asymptomaticpatients. J Thorac Cardiovasc Surg 2003;125:1143–1152.

7. Gillinov AM, Cosgrove DM, Blackstone EH, Diaz R, Arnold JH, LytleBW, Smedira NG, Sabik JF, McCarthy PM, Loop FD. Durability ofmitral valve repair for degenerative disease. J Thorac Cardiovasc Surg1998;116:734–743.

8. Kunzelman KS, Reimink MS, Cochran RP. Flexible versus rigid ringannuloplasty for mitral valve annular dilation: a finite element model.J Heart Valve Dis 1998;7:108–116.

9. Barlow CW, Ali ZA, Lim E, Barlow JB, Wells FC. Modified techniquefor mitral repair without ring annuloplasty. Ann Thorac Surg 2003;75:298–300.

0. Duebener LF, Wendler O, Nikoloudakis N, Georg T, Fries R, SchafersHJ. Mitral-valve repair without annuloplasty rings: results after repairof anterior leaflet versus posterior-leaflet defects using polytetrafluo-roethylene sutures for chordal replacement. Eur J Cardiothorac Surg2000;17:206–212.

1. Levine HJ, Gaasch WH. Vasoactive drugs in chronic regurgitant le-sions of the mitral and aortic valves. J Am Coll Cardiol 1996;28:1083–1091.

2. Chandraratna PAN, Aronow WS. Mitral valve ring in normal vsdilated left ventricle. Cross-sectional echocardiographic study. Chest1981;79:151–154.

3. Pini R, Devereux RB, Greppi B, Roman MJ, Hochreiter C, Kramer-Fox R, Niles NW, Kligfield P, Erlebacher JA, Borer JS. Comparison ofmitral valve dimensions and motion in mitral valve prolapse withsevere mitral regurgitation to uncomplicated mitral valve prolapse andto mitral regurgitation without mitral valve prolapse. Am J Cardiol1988;62:257–263.

4. Weissman NJ, Pini R, Roman MJ, Kramer-Fox R, Andersen HS,Devereux RB. In vivo mitral valve morphology and motion in mitralvalve prolapse. Am J Cardiol 1994;73:1080–1088.

5. Herregods MC, Tau A, Vandeplas A, Bijnens B, Van De Werf F.Values for mitral valve annulus dimensions in normals and patientswith mitral regurgitation. Echocardiography 1997;14:529–534.

6. King DH, Smith EO, Huhta JC, Gutgesell HP. Mitral and tricuspidvalve annular diameter in normal children determined by two-dimen-sional echocardiography. Am J Cardiol 1985;55:787–789.

7. Ormiston JA, Shah PM, Tei C, Wong M. Size and motion of the mitralvalve annulus in man. I. A two-dimensional echocardiographic methodand findings in normal subjects. Circulation 1981;64:113–120.

8. Kaplan SR, Bashein G, Sheehan FH, Legget ME, Munt B, Li XN,Sivarajan M, Bolson EL, Zeppa M, Arch MZ, Martin RW. Three-dimensional echocardiographic assessment of annular shape changesin the normal and regurgitant mitral valve. Am Heart J 2000;139:378–387.

9. Feldman T, Wasserman HS, Herrmann HC, Gray W, Block PC,Whitlow P, St Goar F, Rodriguez L, Silvestry F, Schwartz A, et al.Percutaneous mitral valve repair using the edge-to-edge technique:six-month results of the EVEREST Phase I Clinical Trial. J Am Coll

Cardiol 2005;46:2134–2140.