JACC: CARDIOVASCULAR IMAGING
3, 2016
ª 2016 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
PUBLISHED BY ELSEVIER
EDITORIAL COMMENT
Sizing the Mitral Annulus
Is CT the Future?*
Anita W. Asgar, MD
T he first surgical mitral annuloplasty using a
bioprosthesis was performed in 1968 (1).
Since that time, our understanding of mitral
valve anatomy has increased due to enhanced imag-
ing modalities, such as 2- and 3-dimensional (3D)
echocardiography, magnetic resonance imaging, and
computed tomography (CT). The mitral valve annulus
has a dynamic 3D saddle shape with the maximum
height of the saddle in the middle of the anterior
part of the annulus, another rise along the posterior
leaflet, and the deepest point at the commissures or
fibrous trigones (2).
Mitral regurgitation (MR) is the second most com-
mon valvular heart disease and is divided into pri-
mary (also known as degenerative) and secondary
(commonly referred to as functional). Primary MR is
associated with excessive motion of the mitral valve
leaflets, which are frequently myxomatous, chordal
elongation or rupture, and dilation of the mitral
annulus. Secondary MR may occur as a result of an
ischemic or dilated cardiomyopathy with tenting or
restriction of the mitral valve leaflets and annular
dilation (3). The traditional surgical approach to
either type of MR has been predominantly mitral
repair with annuloplasty. Sizing of the mitral annulus
is performed intraoperatively according to 3 measures
(intertrigonal distance, intercommissural distance,
and surface of the anterior leaflet) and confirmed with
the use of a sizer inserted into the annular space (4).
In this issue of iJACC, Naoum et al. (5) described CT
analysis of the mitral annulus in patients with mod-
erate to severe MR using a D-shaped segmentation
method. This technique has been previously pub-
lished by the researchers and involves imaging the
*Editorials published in JACC: Cardiovascular Imaging reflect the views of
the authors and do not necessarily represent the views of JACC:
Cardiovascular Imaging or the American College of Cardiology.
From the Montreal Heart Institute, Université de Montreal, Montreal,
Quebec, Canada. Dr. Asgar has served as a consultant to Abbott
Vascular, Medtronic, and Gore Medical.
VOL. 9, NO.
ISSN 1936-878X/$36.00
http://dx.doi.org/10.1016/j.jcmg.2015.10.019
mitral annulus and then excluding the anterior peak
to result in a more planar structure with reduced
annular height (6). The posterior peak remains the
same, as does the distance between the fibrous
trigones, resulting in a D shape.
SEE PAGE 269
The goal of such analysis would be to optimize sizing
for future transcatheter mitral valve implantation and
minimize left ventricular (LV) outflow tract obstruc-
tion. In the current retrospective study, the inves-
tigators compared patients with significant MR with
control subjects with no previous cardiac history. Using
this technique, the mitral annuli of patients with either
primary or secondary MR were larger than those of
controls. Patients with primary MR were found to have
larger mitral annuli than those with secondary MR
despite larger LV volumes in the latter group (5). These
findings are consistent with previous echocardio-
graphic data, which demonstrated larger annular di-
mensions in mitral valve prolapse/flail compared with
ischemic MR despite significantly greater LV dilation in
the ischemic group, illustrating that annular remodel-
ing can occur independently of LV remodeling (7).
Previous 3D echocardiographic studies have
demonstrated that although annular dimensions may
be similar in patients with dilated LV, even in the
absence of secondary MR, those with secondary MR
were more likely to have enlargement of the anterior-
to-posterior diameter (8,9). This was also demon-
strated in the current study; however, the differences
were not found to be statistically significant. Naoum
et al. (5) also suggested that secondary MR was more
likely to be associated with dilation of the left atrium.
These findings should be interpreted with some
caution, given the low numbers of patients with sec-
ondary MR (n ¼ 27), particularly those with non-
ischemic cardiomyopathy (n ¼ 8).
Evaluation of the mitral annulus using CT is not
new; in fact, a previous smaller study compared
mitral annular assessment of patients with secondary
282 Asgar JACC: CARDIOVASCULAR IMAGING, VOL. 9, NO. 3, 2016

Editorial Comment MARCH 2016:281–2

MR and normal controls with similar findings, but
without truncation of the anterior peak (10). The
challenge with both of these reports is the lack of
comparison with 3D echocardiography, which has
been used both pre-operatively and intraoperatively
to evaluate mitral annular geometry (11–13). 3D trans-
esophageal echocardiography has been demonstrated
to be superior to 2-dimensional imaging of the mitral
valve in the assessment of MR severity and anatomic
evaluation and provides real-time imaging of the
mitral valve in systole and diastole and assessment
of annular dynamics without the use of ionizing
radiation (14,15). In addition, 3D transesophageal
echocardiography is recommended by the American
Society of Echocardiography for the guidance of
percutaneous procedures and is extensively used in
transcatheter mitral leaflet repair (16).
Changes in the mitral annulus in the setting of MR
are complex and include not only dilation but also
flattening, which may be more regional depending on
the underlying pathology (e.g., ischemic cardiomy-
opathy). The CT assessment described in the current
paper, although intended for future transcatheter
techniques, may represent an oversimplification of
the mitral annulus, but it is too early to know. Ideally,
comparisons with 3D echocardiography should be
made to further correlate the 2 assessments and
establish a gold standard. Ultimately, additional
evaluation of this technique is required to establish
normal ranges and understand the impact of MR from
various pathologies on these measures prior to
widespread use.
REPRINT REQUESTS AND CORRESPONDENCE: Dr.
Anita W. Asgar, Montreal Heart Institute, Université
de Montreal, 5000 rue Belanger, Montreal, Quebec
H1T 1C8, Canada. E-mail: anita.asgar@umontreal.ca.

REFERENCES

1. Carpentier A. Cardiac valve surgery—the “French
correction.” J Thorac Cardiovasc Surg 1983;86:
323–37.
2. Levine RA, Triulzi MO, Harrigan P, Weyman AE.
The relationship of mitral annular shape to the
diagnosis of mitral valve prolapse. Circulation
1987;75:756–67.
3. Asgar AW, Mack MJ, Stone GW. Secondary
mitral regurgitation in heart failure: pathophysi-
ology, prognosis, and therapeutic considerations.
J Am Coll Cardiol 2015;65:1231–48.
4. Maisano F, Skantharaja R, Denti P, Giacomini A,
Alfieri O. Mitral annuloplasty. Multimed Man Car-
diothorac Surg 2009;2009(918):mmcts.2008.
003640.
5. Naoum C, Leipsic J, Cheung A, et al. Mitral
annular dimensions and geometry in patients with
functional mitral regurgitation and mitral valve
prolapse: implications for transcatheter mitral
valve implantation. J Am Coll Cardiol Img 2016;9:
269–80.
6. Blanke P, Dvir D, Cheung A, et al. A simplified
D-shaped model of the mitral annulus to facilitate
CT-based sizing before transcatheter mitral valve
implantation. J Cardiovasc Comput Tomogr 2014;
8:459–67.
7. Mihalatos DG, Joseph S, Gopal A, et al. Mitral
annular remodeling with varying degrees and
mechanisms of chronic mitral regurgitation. J Am
Soc Echocardiogr 2007;20:397–404.
8. Topilsky Y, Vaturi O, Watanabe N, et al. Real-
time 3-dimensional dynamics of functional mitral
regurgitation: a prospective quantitative and
mechanistic study. J Am Heart Assoc 2013;2:
e000039.
9. Ahmad RM, Gillinov AM, McCarthy PM, et al.
Annular geometry and motion in human ischemic
mitral regurgitation: novel assessment with three-
dimensional echocardiography and computer
reconstruction. Ann Thorac Surg 2004;78:
2063–8.
10. Gordic S, Nguyen-Kim TD, Manka R, et al.
Sizing the mitral annulus in healthy subjects and
patients with mitral regurgitation: 2D versus 3D
measurements from cardiac CT. Int J Cardiovasc
Imaging 2014;30:389–98.
11. Jassar AS, Vergnat M, Jackson BM, et al.
Regional annular geometry in patients with mitral
regurgitation: implications for annuloplasty ring
selection. Ann Thorac Surg 2014;97:64–70.
12. Pouch AM, Vergnat M, McGarvey JR, et al.
Statistical assessment of normal mitral annular
geometry using automated three-dimensional
echocardiographic analysis. Ann Thorac Surg
2014;97:71–7.
13. Mahmood F, Shakil O, Mahmood B,
Chaudhry M, Matyal R, Khabbaz KR. Mitral
annulus: an intraoperative echocardiographic
perspective. J Cardiothorac Vasc Anesth 2013;27:
1355–63.
14. Tsang W, Lang RM. Three-dimensional echo-
cardiography is essential for intraoperative
assessment of mitral regurgitation. Circulation
2013;128:643–52.
15. Grewal J, Suri R, Mankad S, et al. Mitral annular
dynamics in myxomatous valve disease: new
insights with real-time 3-dimensional echocardi-
ography. Circulation 2010;121:1423–31.
16. Lang RM, Badano LP, Tsang W, et al. EAE/
ASE recommendations for image acquisition and
display using three-dimensional echocardiogra-
phy. Eur Heart J Cardiovasc Imaging 2012;13:
1–46.
KEY WORDS computed tomography, mitral
annulus, mitral regurgitation, TMVI/TMVR,
transcatheter mitral valve implantation