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. Author manuscript; available in PMC: 2017 Sep 1.
Published in final edited form as: J Thorac Cardiovasc Surg. 2016 Jun 29;152(3):847–859. doi: 10.1016/j.jtcvs.2016.06.040

TABLE 4.

Systematic review of the literature on preoperative 2- and 3-dimensional echocardiography predictors of ischemic mitral regurgitation recurrence after mitral ring annuloplasty

Reference, Year N =;
2/3DT(T)(E)E; IMR
grading; % IMR
recurrence* (grade)
(follow-up)		 Predictors View Independent predictors View Cutoff value AUC Sensitivity Specificity
Matsunaga and
colleagues, 13 2004		 Posterior PM depth
(indexed), mm/m2 		AP2CH —
48; 2D TTE; JA/LAA Posterior PM angle, ° AP2CH
31% (≥3±) (NR)
McGee and colleagues, 6
2004		 Degree of IMR - —
422; 2D TTE; JA/LAA Degree of LV dysfunction -
±28% (≥3±) (6 mo) Jet direction (central or
complex)		 -
Zhu and colleagues, 14 2005 LVEDV index and LVESV
index, mL/m2 		Tethering height (indexed),
mm/m2 		PLAX NR NR NR NR
31; 2D TTE; VC Systolic sphericity index AP4CH Coaptation length
(indexed), mm/m2 		PLAX NR NR NR NR
19% (≥2±) (2–8 wks) Annular area index, cm2/m2 AP2/4CH
Tethering distance
(indexed), mm/m2 		PLAX
Basal anterior tethering
angle, °		 PLAX
PTA, ° PLAX
Anterior bending angle, ° PLAX
Anterior and post leaflet
excursion angle, °		 PLAX
Coaptation length
(indexed), mm/m2 		PLAX
Ereminiene and
colleagues, 15 2005		 LVEDD index and LVESD
index, mm/m2 		PLAX Restrictive LV diastolic
filling		 AP4CH - - - -
53; 2D TTE; JA/LAA,
ERO		 Deceleration time, ms —
±57%(≥2±)(1y)
Kongsaerepong and
colleagues, 16 2006		 LVEDV, cm3 - Degree of IMR - ≥3.5 NR 42.0 81.0
365; 2D TEE; JA/LAA,
PISA		 LVESV, cm3 - Mitral annular diameter, cm 4CH ≥3.7 cm NR 84.0 76.0
19% (≥2+) (mean 269 d) Tethering height, cm 2/4CH, LAX Tethering area, cm LAX ≥1.6 cm NR 80.0 54.0
Serri and colleagues, 17
2006		 Anterior annulus-PPM
distance, mm		 AP2CH —
73; 2D TEE; JA/LAA, PISA
57% (≥2±) (28 ± 23 mo)
Roshanali and colleagues, 18
2007		 Tethering height, mm NR IPMD, mm PSAX ≥20 mm 0.99 95.7 97.2
95; 2D TTE; VC Concavity area anterior
leaflet, mm		 NR
24% (≥2±) (±1.5–2 y)
Magne and colleagues, 19
2007		 Tethering area, cm AP4CH/PLAX Tethering height, mm AP4CH/PLAX ≥1 cm 0.87 64.0 90.0
51; 2D TTE;
JA/LAA, VC		 Anterior leaflet angle, ° AP4CH/PLAX Posterior leaflet angle, ° AP4CH/PLAX ≥45° 0.98 100.0 95.0
22% (≥2±) (mean 9 d)
Ueno and colleagues, 20
2008		 LVEDD and LVESD, mm PLAX -
20; 2D TTE; NR LVEDV index and LVESV
index, mL/m2 		-
40%† (±1–2 wk)
Gelsomino and
colleagues, 21 2008		 Tethering area, cm2 PLAX LVESV, mL ≥145mL 0.87 90.0 90.0
220; 2D TTE; ERO, RV Tethering height, mm PLAX Systolic sphericity index AP4CH ≥0.7 1.00 100.0 100.0
33%(≥2+)(3y) LVEDD and LVESD, mm PLAX Myocardial performance
index		 - ≥0.9 0.94 85.0 84.0
72% (≥2+) (5 y)
(median follow-up 33 mo)		 LVEF, %
Diastolic sphericity index		 AP4CH WMSI - ≥1.5 0.81 80.0 82.0
APM lateral distance, cm PSAX
APM WMSI -
Gelsomino and
colleagues, 22 2008		 Jet direction (central or
anterior)		 PLAX Tethering height, mm PLAX ≥11 mm 0.89 81.0 84.0
230; 2D TTE; ERO, RV APM posterior and lateral
distance, cm		 PSAX Basal anterior tethering
angle, °		 PLAX ≥39.5° 0.99 98.0 97.0
23% (≥2+) (median
33 mo)		 IPMD, cm PSAX Basal ATA/PTA ratio PLAX ≥0.76 0.92 87.0 86.0
APM and PPM WMSI - Anterior leaflet excursion
angle, °		 PLAX <35° 0.87 85.0 83.0
Tethering area, cm2 PLAX
Coaptation length, mm PLAX
Anterior leaflet bending
angle, °		 PLAX
PTA, ° PLAX
Anterior leaflet excursion,
mm		 PLAX
Gelsomino and
colleagues, 23 2009		 - - Deceleration time, ms‡ - <142 ms 0.94 87.0 80.0
234; 2D TTE; ERO, RV
23% (≥2+) (median
38 mo)
Onorati and colleagues, 24
2009		 Degree of IMR - LVEDD, mm NR ≥70 mm NR NR NR
82; 2D TTE; JA/LAA Systolic PAP, mm Hg -
26% (≥2+) (18 ± 15 mo) LVESD, mm NR
Ciarka and colleagues, 25
2010		 Basal anterior tethering
angle, °		 AP4CH Distal anterior tethering
angle, °		 AP4CH NR NR NR NR
109§; 2D TTE; VC, ERO,
RV		 Tethering area, cm2 PLAX PTA, ° AP4CH NR NR NR NR
19% (≥2+) (2.6 ± 1.6 y)
Tethering height, mm
Coaptation length, mm		 PLAX
PLAX
Systolic and diastolic
sphericity index		 -
Gelsomino and
colleagues, 26 2011		 - - Basal anterior tethering
angle, °		 PLAX ≥39.5° NR NR NR
362; 2D TTE; ERO, RV
19% (≥2+) (median
14 mo)
Troubil and colleagues, 27
2012		 LVEDD index, mm/m PLAX Anterior tethering angle, ° AP4CH ≥27° 0.72 67.0 76.0
87; 2D TTE;
JA/LAA, VC, ERO, RV		 LVEF, % -
32% (≥2+) (24 ± 2 mo) Jet direction (not central)
PTA, °		 NR
AP4CH
Lee and colleagues, 28 2012
250; 2D TTE; NR		 - - LVEDD index, cm/m2 PLAX ≥3.5 cm/m NR NR NR
13% (≥3+) (mean ± 2 y)
van Garsse and
colleagues, 29 2012		 Basal anterior tethering
angle, °		 PLAX ≥36.9 NR NR NR
435; 2D TTE; ERO, RV Basal ATA/PTA ratio PLAX NR NR NR NR
23% (≥2+) (median45 mo) Anterior leaflet excursion
angle, °		 PLAX <35° NR NR NR
van Garsse and
colleagues, 30 2012		 Papillary muscle
dyssynchrony, ms		 AP4CH/PLAX ≥58 ms 0.92 100.0 83.0
144; 2D TTE; ERO, RV Basal anterior tethering
angle, °		 PLAX ≥39.5° 0.86 95.0 80.0
68% (≥2+) (median
39 mo)║ 		Basal ATA/PTA ratio PLAX ≥0.75 0.82 88.0 79.0
van Garsse and
colleagues, 31 2013		 LVEDV index and LVESV
index, mL/m2 		- Left atrial peak global
strain, %		 AP2/4CH ≤25% 0.90 92.0 87.0
95; 2D TTE; ERO, RV WMSI - Peak systolic strain rate, s−1 AP2/4CH ≤1.50s−1 0.85 90.0 82.0
32% (≥2+) (median 42 mo) Systolic and diastolic
sphericity index		 - Peak early diastolic strain
rate, s−1 		AP2/4CH ≤1.11 s −1 0.79 86.0 80.0
Tethering area, cm2 PLAX
Coaptation length, mm PLAX
Tethering height, mm PLAX
Left atrial diameter, mm PLAX
Different left atrial volumes,
mL/m2 		AP2/4CH
Peak late diastolic strain
rate, s−1 		AP2/4CH
van Garsse and
colleagues, 32 2013		 LVESVand LVEDV, mL - Papillary muscle
dyssynchrony, ms		 AP4CH/PLAX ≥58 ms 0.97 98.0 90.0
524; 2D TTE; ERO, RV Diastolic sphericity index - Systolic sphericity index - ≥0.72 0.85 88.0 71.0
21% (≥2+) (median
45 mo)		 WMSI - Basal anterior tethering
angle, °		 PLAX ≥39° 0.93 90.0 86.0
Tethering area, cm2 PLAX Basal ATA/PTA ratio PLAX ≥0.76 0.89 93.0 83.0
Coaptation length, mm PLAX
Tethering height, mm PLAX
Kron and colleagues, 33
2015		 - - Basal aneurysm/dyskinesis - - - - -
110; 2D TTE;
JA/LAA, VC, ERO
60% (≥3+) (2 y)
Hajsadeghi and
colleagues, 34 2015		 LVEF, % - LVESV, cm3 - ≥3.85 cm3 0.69 83.0 57.0
126; 2D TTE; VC, ERO Basal-IPMD diastolic-
systolic ratio		 PSAX ≥1.25 0.95 100.0 95.0
46% (≥2+) (30 d)
Wijdh-den Hamer, 2016 Tethering height, mm 2CH PTA, ° 2CH ≥32.0 0.81 90.9 61.1
50; 2D TEE; JA/LAA Tethering area, cm2 2CH
26% (≥2+) (6 mo)
50; 3D TEE Annular circumference, mm 3D TEE P3TA, ° 3D TEE ≥29.9° 0.92 84.6 89.2
Mitral valve tethering
volume, mm		 3D TEE Basal aneurysm/dyskinesis 3D TEE - - - -
Mitral valve tethering index 3D TEE
A1, A2, A3, P1, P2
tethering angles, °		 3D TEE

2D, 2-dimensional; 3D, 3-dimensional; IMR, ischemic mitral regurgitation; AUC, area under the curve; (A)PM, (anterior) papillary muscle; AP2CH, apical 2-chamber view; TTE, transthoracic echocardiography; JA/LAA,jet area/left atrial area; NR, not reported; LV, left ventricular; LVEDV, left ventricular end-diastolic volume; LVESV, left ventricular end-systolic volume; PLAX, parasternal long-axis view; VC, vena contracta; AP4CH, apical 4-chamber view; PTA, posterior tethering angle; LVEDD, left ventricular end-diastolic diameter; LVESD, left ventricular end-systolic diameter; ERO, effective regurgitant orifice; PISA, proximal isovelocity surface area; PPM, posterior papillary muscle; IPMD, interpapillary muscle distance; PSAX, parasternal short-axis view; RV, regurgitant volume; LVEF, left ventricular ejection fraction; WMSI, wall motion score index; ATA, anterior tethering angle; PAP, pulmonary artery pressure; TEE, transesophageal echocardiography.

*

Defined as postoperative persistence or recurrence (within 1–5 years) IMR grade ≥2+.

†

Any increase in MR compared with the immediate postoperative phase.

‡

Additional independent predictors from the same cohort were mentioned by Ueno and colleagues.20

§

A total of 53 patients with IMR and 56 patients with functional MR.

║

All patients had LV ejection fraction <35%.