Three-Dimensional Echocardiographic Assessment of Mitral Apparatus and Left Atrial Remodeling to Guide TEER in Eccentric versus Central Ischemic Mitral Regurgitation

Background Three-dimensional echocardiography combined with speckle-tracking imaging was employed to compare mitral valve geometry, dynamic deformation, and left atrial (LA) function derived from strain between eccentric-jet and central-jet ischemic mitral regurgitation (IMR). Integrated thresholds were derived to refine IMR phenotyping and inform planning for transcatheter edge-to-edge repair (TEER). Methods In this single-center cross-sectional study, 111 consecutive patients with moderate-to-severe IMR (54 eccentric, 57 central) and 60 frequency-matched controls were prospectively enrolled. Mitral valve geometry was quantified offline using full-volume, three-dimensional transesophageal datasets. LA strain was measured by high-frame-rate two-dimensional speckle-tracking imaging. Determinants of jet eccentricity were identified by multivariable logistic regression adjusted for clinical and echocardiographic covariates. Results Eccentric jets exhibited greater anterior–posterior annular diameter, larger posterior leaflet angle, and lower anterior-to-posterior coaptation-length ratio, whereas central jets displayed increased tenting volume and height (all P < 0.05). Both IMR groups demonstrated significantly reduced LA reservoir strain (eccentric: 9.40% vs. central: 10.35%, P < 0.001) and lower total emptying fractions (LATEF: eccentric 32.7% vs. central 36.8%, P < 0.001) compared to controls (LASr: 28.55%, LATEF: 66.95%). Notably, the eccentric group showed relatively preserved reservoir strain but more severely reduced active emptying fraction (LAAEF: 17.4% vs. 20.8%, P < 0.05) and increased LA stiffness index (all P < 0.05), suggesting differential atrial functional remodeling patterns between IMR phenotypes. Conclusions Eccentric IMR exhibits asymmetric mitral deformation and LA remodeling with relatively preserved but still impaired reservoir function. In contrast, central IMR reflects global left ventricular (LV) sphericalization with comparatively less impaired LA stiffness. Integrated three-dimensional echocardiography provides reproducible metrics for patient-specific TEER planning.