Mitral Valve Early Systolic Billowing Induces Following Annular Expansion and Leaflet Augmentation in Barlow's Disease: Sequential Analysis using Three-dimensional Echocardiography

Masashi Amano; Chisato Izumi; Misako Toki; Yoshiki Yanagi; Akihiro Hayashida; Takahiro Kawamoto; Arudo Hiraoka; Satsuki Fukushima; Taichi Sakaguchi; Nozomi Watanabe; Kiyoshi Yoshida

doi:10.1093/ehjci/jeae031

Mitral Valve Early Systolic Billowing Induces Following Annular Expansion and Leaflet Augmentation in Barlow's Disease: Sequential Analysis using Three-dimensional Echocardiography

Eur Heart J Cardiovasc Imaging. 2024 Jan 30:jeae031. doi: 10.1093/ehjci/jeae031. Online ahead of print.

Authors

Affiliations

¹ Department of Herat Failure and Transplantation, National Cerebral and Cardiovascular Center, Suita, Japan.
² Department of Clinical Laboratory, The Sakakibara Heart Institute of Okayama, Okayama, Japan.
³ Department of Clinical Laboratory, The National Hospital Organization Osaka National Hospital, Osaka, Japan.
⁴ Department of Cardiology, The Sakakibara Heart Institute of Okayama, Okayama, Japan.
⁵ Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, Okayama, Japan.
⁶ Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Japan.
⁷ Division of Cardiovascular Physiology, University of Miyazaki Faculty of Medicine, Miyazaki, Japan.

PMID: 38289248
DOI: 10.1093/ehjci/jeae031

Abstract

Aims: Although systolic expansion of the annulus has been recognized in Barlow's disease, the mechanisms of the unique pathological movement of the annulus and its relation to the leaflet augmentation has not yet been clarified. We aimed to investigate the detailed mechanisms of the characteristic mitral apparatus dynamics in Barlow's disease by frame-by-frame sequential geometric analysis using real-time three-dimensional transesophageal echocardiography.

Methods and results: Fifty-three patients with Barlow's disease and severe mitral regurgitation without torn chordae, as well as 10 controls, were included. We evaluated geometric changes in the mitral complex using three-dimensional transesophageal echocardiography at five points during systole. To identify early systolic billowing of leaflets, the annulo-leaflet angle was measured. We also performed a more detailed analysis in four consecutive frames just before and after leaflet free-edge prolapse above the annulus plane. The median annulo-leaflet angle of both leaflets in early systole was greater than 0° (above annulus plane) in patients with Barlow's disease, and billowing of the leaflet body were observed from early systole. The prolapse volume of both leaflets increased markedly from early to mid-systole (1.60 [0.85-2.80] to 4.00 [2.10-6.45] mL; analysis of variance, p < 0.001; post-hoc, p < 0.05). With frame-by-frame analysis, dynamic augmentation of the annulus and leaflets developed between frames just before and just after leaflet free-edge prolapse (analysis of variance, p < 0.01; post-hoc, p < 0.05).

Conclusions: In Barlow's disease, early systolic billowing of the mitral leaflet induces systolic annulus expansion followed by leaflet augmentation and leaflet free-edge prolapse.

Keywords: Barlow’s diseases; annulus expansion; billowing; leaflet augmentation; mitral regurgitation; prolapse.