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Recco DP, Kneier NE, Earley PD, Kizilski SB, Hammer PE, Hoganson DM. Fiberscope-Based Measurement of Coaptation Height for Intraoperative Assessment of Mitral Valve Repair. World J Pediatr Congenit Heart Surg 2024; 15:371-379. [PMID: 38327093 DOI: 10.1177/21501351231221459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
BACKGROUND Restoring adequate coaptation height is a key principle of mitral valve (MV) repair. This study aimed to evaluate the utility of fiberscope (FS) technology to assess MV coaptation height for intraoperative use. METHODS Ex-vivo testing was performed on five adult porcine hearts. The left atrium (LA) was resected, and the left ventricle (LV) was pressurized retrograde to 27 ± 1mm Hg. An endoscope was inserted into the LV apex, centered under the MV orifice. An FS system (Milliscope II camera, LED light source, and 0.7 mm diameter × 15 cm long) 90° semirigid scope with 1.2 mm focal length) was mounted above the MV annulus in a custom alignment and measuring fixture. Three blinded measurements were taken at two locations on each MV, A2 and P2 segment, from the top of coaptation to the leaflet edge identified by the FS. Accurate positioning was verified using the LV endoscope. A control (metal rod of similar thickness) was used for comparison, with coaptation height recorded when the control was seen via the endoscope. RESULTS Coaptation heights were similar for the control and FS methods across all hearts at A2 (11.6 ± 2.6 mm control vs 11.8 ± 2.2 mm FS) and P2 (13.3 ± 2.6 mm control vs 13.4 ± 2.9 mm FS) segments, with similar measurement variability (control SD 0.1-1.0 mm; FS SD 0.1-0.9 mm). One outlier was excluded from analysis (n = 19/20). The maximum absolute difference and percent error between measurement methods were less than 1.1 mm (median [IQR], 0.6 [0.3-0.9] mm) and less than 14% (4.1 [2.2-7.6]%). CONCLUSIONS Utilization of a miniaturized FS enabled precise and accurate quantification of MV coaptation. This technique is promising for evaluating post-repair valve competence and coaptation height.
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Affiliation(s)
- Dominic P Recco
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Nicholas E Kneier
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Patrick D Earley
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Shannen B Kizilski
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Peter E Hammer
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - David M Hoganson
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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de Oliveira DC, Espino DM, Deorsola L, Buchan K, Dawson D, Shepherd DET. A geometry-based finite element tool for evaluating mitral valve biomechanics. Med Eng Phys 2023; 121:104067. [PMID: 37985031 DOI: 10.1016/j.medengphy.2023.104067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 09/08/2023] [Accepted: 10/30/2023] [Indexed: 11/22/2023]
Abstract
Mitral valve function depends on its complex geometry and tissue health, with alterations in shape and tissue response affecting the long-term restorarion of function. Previous computational frameworks for biomechanical assessment are mostly based on patient-specific geometries; however, these are not flexible enough to yield a variety of models and assess mitral closure for individually tuned morphological parameters or material property representations. This study details the finite element approach implemented in our previously developed toolbox to assess mitral valve biomechanics and showcases its flexibility through the generation and biomechanical evaluation of different models. A healthy valve geometry was generated and its computational predictions for biomechanics validated against data in the literature. Moreover, two mitral valve models including geometric alterations associated with disease were generated and analysed. The healthy mitral valve model yielded biomechanical predictions in terms of valve closure dynamics, leaflet stresses and papillary muscle and chordae forces comparable to previous computational and experimental studies. Mitral valve function was compromised in geometries representing disease, expressed by the presence of regurgitating areas, elevated stress on the leaflets and unbalanced subvalvular apparatus forces. This showcases the flexibility of the toolbox concerning the generation of a range of mitral valve models with varying geometric definitions and material properties and the evaluation of their biomechanics.
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Affiliation(s)
- Diana C de Oliveira
- Department of Mechanical Engineering, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom; Current affiliation: Department of Mechanical Engineering, University College London, Torrington Place, London WC1E 7JE, United Kingdom.
| | - Daniel M Espino
- Department of Mechanical Engineering, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom
| | - Luca Deorsola
- Paedriatic Cardiac Surgery, Ospedale Infantile Regina Margherita Sant Anna, Turin 10126, Italy
| | - Keith Buchan
- Department of Cardiothoracic Surgery, Aberdeen Royal Infirmary, Aberdeen AB24 2ZN, Scotland, UK
| | - Dana Dawson
- School of Medicine, University of Aberdeen, Aberdeen AB25 2ZD, Scotland, UK; Cardiology Department, Aberdeen Royal Infirmary, Aberdeen AB25 2ZN, Scotland, UK
| | - Duncan E T Shepherd
- Department of Mechanical Engineering, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom
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Sharkey A, Mahmood F, Hai T, Khamooshian A, Gao Z, Amador Y, Khabbaz K. Regional geometric differences between regurgitant and non-regurgitant mitral valves in patients with coronary artery disease. Echocardiography 2023; 40:750-759. [PMID: 37002823 DOI: 10.1111/echo.15549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 02/03/2023] [Accepted: 02/13/2023] [Indexed: 04/04/2023] Open
Abstract
OBJECTIVE Demonstrate that regional geometric differences exist between regurgitant and non-regurgitant mitral valves (MV's) in patients with coronary artery disease and due to the heterogenous and regional nature of ischemic remodeling in patients with coronary artery disease (CAD), that the available anatomical reserve and likelihood of developing mitral regurgitation (MR) is variable in non-regurgitant MV's in patients with CAD. METHODS In this retrospective, observational study intraoperative three-dimensional transesophageal echocardiographic data was analyzed in patients undergoing coronary revascularization with MR (IMR group) and without MR (NMR group). Regional geometric differences between both groups were assessed and MV reserve which was defined as the increase in antero-posterior (AP) annular diameter from baseline that would lead to coaptation failure was calculated in three zones of the MV from antero-lateral (zone 1), middle (zone 2), and posteromedial (zone 3). MEASUREMENTS AND MAIN RESULTS There were 31 patients in the IMR group and 93 patients in the NMR group. Multiple regional geometric differences existed between both groups. Most significantly patients in the NMR group had significantly larger coaptation length and MV reserve than the IMR group in zones 1 (p-value = .005, .049) and 2 (p-value = .00, .00), comparable between the two groups in zone 3 (p-value = .436, .513). Depletion of the MV reserve was associated with posterior displacement of the coaptation point in zones 2 and 3. CONCLUSIONS There are significant regional geometric differences between regurgitant and non-regurgitant MV's in patients with coronary artery disease. Due to regional variations in available anatomical reserve and the risk of coaptation failure in patients with CAD, absence of MR is not synonymous with normal MV function.
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Affiliation(s)
- Aidan Sharkey
- Department of Anesthesia Critical Care and Pain Management, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Feroze Mahmood
- Department of Anesthesia Critical Care and Pain Management, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ting Hai
- Department of Anesthesiology, Peking University Peoples Hospital, Beijing, China
| | - Arash Khamooshian
- Department of Cardio-Thoracic Surgery, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Zhifeng Gao
- Department of Anesthesiology, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - Yannis Amador
- Department of Anesthesiology and Perioperative Medicine, Queens University, Kingston, Ontario, Canada
| | - Kamal Khabbaz
- Division of Cardiac Surgery, Roberta L Hines Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Mufarrih SH, Sharkey A, Mahmood F, Yunus RA, Qureshi NQ, Senthilnathan V, Chu L, Liu D, Khabbaz K. Geometric Indices for Predicting Ischemic Mitral Regurgitation: Correlation of Mitral Valve Coaptation Area With Tenting Height, Tenting Area and Tenting Volume. J Cardiothorac Vasc Anesth 2023; 37:8-15. [PMID: 36357306 DOI: 10.1053/j.jvca.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 09/20/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Ischemic remodeling of the left ventricle in patients with coronary artery disease (CAD) results in geometric changes of the mitral valve (MV) apparatus, leading to reduced MV leaflet coaptation. Although the calculation of the coaptation area has value in assessing the effects of left ventricular remodeling on the MV, it is difficult and time-consuming to measure. In this study the authors hypothesized that the tenting volume (TV) would have a greater association with coaptation area than tenting height (TH) or tenting area (TA). DESIGN A retrospective review. SETTING A single tertiary-care academic hospital. PARTICIPANTS There were 145 adult patients who underwent coronary artery bypass graft surgery between April 2018 and July 2020. MEASUREMENTS AND MAIN RESULTS Intraoperative 2- and 3-dimensional transesophageal echocardiographic studies were obtained in the precardiopulmonary bypass period. Offline analysis was used to obtain TH, TA, TV and coaptation area for each patient. Correlation between the coaptation area and the TH, TA, and TV was conducted using Pearson's correlation. The median age of the population was 68.0 years (61.0-73.3), the body mass index was 29.0 kg/m2 (25.7-33.5), and 17.8% were females. Increases in TV were the most reliable predictor of decreases in coaptation area (R2 = 0.75) followed by TA (R2 = 0.48) and TH (R2 = 0.47). CONCLUSION As a representative of the complete topography of the MV, the authors' study demonstrated that in patients with CAD, TV has a greater negative correlation with coaptation area as compared to TH or TA.
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Affiliation(s)
- Syed Hamza Mufarrih
- Department of Anesthesia, Critical Care & Pain Medicine Department, Beth Israel Deaconess Medical Center, Boston, MA.
| | - Aidan Sharkey
- Department of Anesthesia, Critical Care & Pain Medicine Department, Beth Israel Deaconess Medical Center, Boston, MA
| | - Feroze Mahmood
- Department of Anesthesia, Critical Care & Pain Medicine Department, Beth Israel Deaconess Medical Center, Boston, MA
| | - Rayaan Ahmed Yunus
- Department of Anesthesia, Critical Care & Pain Medicine Department, Beth Israel Deaconess Medical Center, Boston, MA
| | - Nada Qaisar Qureshi
- Department of Anesthesia, Critical Care & Pain Medicine Department, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Louis Chu
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - David Liu
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Kamal Khabbaz
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
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Calafiore AM, Prapas S, Totaro A, Guarracini S, Katsavrias K, Di Mauro M. A morphofunctional analysis of the regurgitant mitral valve as a guide to repair: Another point of view. J Card Surg 2022; 37:4064-4071. [PMID: 36116054 DOI: 10.1111/jocs.16924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/19/2022] [Accepted: 08/23/2022] [Indexed: 01/06/2023]
Abstract
Based on Carpentier's classification and principles, the techniques for mitral valve repair continue to evolve. We herein report our experience with the morphofunctional echocardiographic analysis of single mitral leaflets, as different anatomic features, even if conflicting, may coexist not only in the two leaflets but in the same leaflet as well. A classification is proposed, based on the length (normal, short, or long) and mobility (normal, restricted, or excessive) of mitral leaflets. The surgical techniques adopted for mitral valve repair are the direct consequence of this analysis.
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Affiliation(s)
| | - Sotirios Prapas
- Department of Cardiac Surgery, Henry Dunant Hospital, Athens, Greece
| | - Antonio Totaro
- Dipartimento di Malattie Cardiovascolari, Gemelli Molise, Campobasso, Italia
| | | | - Kostas Katsavrias
- Department of Cardiac Surgery, Henry Dunant Hospital, Athens, Greece
| | - Michele Di Mauro
- Department of Crdiothoracic Surgery, Cardio-Thoracic Surgery Unit, Heart and Vascular Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
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Jainandunsing JS, Massari D, Vos JJ, Wijdh-den Hamer IJ, van den Heuvel AF, Mariani MA, Mahmood F, Bouma W, Scheeren TWL. Mitral Valve Coaptation Reserve Index: A Model to Localize Individual Resistance to Mitral Regurgitation Caused by Annular Dilation. J Cardiothorac Vasc Anesth 2022; 37:690-697. [PMID: 36509635 DOI: 10.1053/j.jvca.2022.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 11/02/2022] [Accepted: 11/07/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The objective of this study was to develop a mathematical model for mitral annular dilatation simulation and determine its effects on the individualized mitral valve (MV) coaptation reserve index (CRI). DESIGN A retrospective analysis of intraoperative transesophageal 3-dimensionalechocardiographic MV datasets was performed. A mathematical model was created to assess the mitral CRI for each leaflet segment (A1-P1, A2-P2, A3-P3). Mitral CRI was defined as the ratio between the coaptation reserve (measured coaptation length along the closure line) and an individualized correction factor. Indexing was chosen to correct for MV sphericity and area of largest valve opening. Mathematical models were created to simulate progressive mitral annular dilatation and to predict the effect on the individual mitral CRI. SETTING At a single-center academic hospital. PARTICIPANTS Twenty-five patients with normally functioning MVs undergoing cardiac surgery. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Direct measurement of leaflet coaptation along the closure line showed the lowest amount of coaptation (reserve) near the commissures (A1-P1 0.21 ± 0.05 cm and A3-P3 0.22 ± 0.06 cm), and the highest amount of coaptation (reserve) at region A2 to P2 0.25 ± 0.06 cm. After indexing, the A2-to-P2 region was the area with the lowest CRI in the majority of patients, and also the area with the least resistance to mitral regurgitation (MR) occurrence after simulation of progressive annular dilation. CONCLUSIONS Quantification and indexing of mitral coaptation reserve along the closure line are feasible. Indexing and mathematical simulation of progressive annular dilatation consistently showed that indexed coaptation reserve was lowest in the A2-to-P2 region. These results may explain why this area is prone to lose coaptation and is often affected in MR.
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Affiliation(s)
- Jayant S Jainandunsing
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
| | - Dario Massari
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Jaap Jan Vos
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Inez J Wijdh-den Hamer
- Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Ad Fm van den Heuvel
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Massimo A Mariani
- Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Feroze Mahmood
- Department of Anesthesiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Wobbe Bouma
- Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Thomas W L Scheeren
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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Ceresa F, Micari A, Rubino AS, Mammana L, Pipitone V, Vizzari G, Costa F, Patanè F. Analysis of changes in "mitral valve reserve" after coronary artery bypass grafts in patients with functional mitral regurgitation. J Cardiothorac Surg 2022; 17:255. [PMID: 36199145 PMCID: PMC9536007 DOI: 10.1186/s13019-022-01993-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 09/18/2022] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION The treatment of moderate functionalmitral regurgitation (FMR) during coronary artery bypass grafting (CABG) is still debated. Our primary end point was to assess the improvement of "mitral valve reserve" (MVR) after CABG alone as a clinical demonstration of left ventricular (LV) recovery. MATERIALS AND METHODS Between June 2019 and June 2021, we prospectively enrolled 104 consecutive patients undergoing CABG with moderate FMR. Inclusion criteria were inferior-posterior-lateral wall hypokinesia and revascularization of the circumflex or right coronary artery. MVR was calculated as the ratio between anterior and posterior leaflets' straight length. All patients were followed for 1 year. The improvement of MVR has been considered as a reduction of the ratio between anterior and posterior leaflets straight length. RESULTS Compared to baseline, mean MVR was significantly reduced both at 6 (2.24 ± 0.95 vs. 1,91 ± 0.6; p = 0,047) and 12 months follow-up (2.24 ± 0.95 vs. 1,69 ± 0.49; p = 0,006). Left ventricular (LV) reverse remodeling, meant as improvement of LV ejection fraction and reduction of LV end-systolic volume index and mitral anulus diameter were evaluated at 6 months and 1 year. Mitral regurgitation grade were also significantly reduced at 6 months (p < .001). CONCLUSION The benefits of myocardial revascularization in term of improvement of mitral regurgitation's degree can be explained by the changes of MVR. The patients with FMR, who could have more advantages from CABG alone, should be the ones who have LVESVi just moderately increased.
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Affiliation(s)
- Fabrizio Ceresa
- Vascular and Thoracic Department, Papardo Hospital, Stagno d'Alcontress Street, 98121, Messina, Italy.
| | - Antonio Micari
- Division of Cardiology, G. Martino University Hospital, Messina, Italy
| | - Antonino Salvatore Rubino
- Vascular and Thoracic Department, Papardo Hospital, Stagno d'Alcontress Street, 98121, Messina, Italy
| | - Liborio Mammana
- Vascular and Thoracic Department, Papardo Hospital, Stagno d'Alcontress Street, 98121, Messina, Italy
| | - Vito Pipitone
- Division of Cardiology, Papardo Hospital, Messina, Italy
| | - Giampiero Vizzari
- Division of Cardiology, G. Martino University Hospital, Messina, Italy
| | - Francesco Costa
- Division of Cardiology, G. Martino University Hospital, Messina, Italy
| | - Francesco Patanè
- Vascular and Thoracic Department, Papardo Hospital, Stagno d'Alcontress Street, 98121, Messina, Italy
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Simonian NT, Liu H, Pouch AM, Gorman JH, Gorman RC, Sacks MS. Quantitative in vivo assessment of human mitral valve coaptation area after undersized ring annuloplasty repair for ischemic mitral regurgitation. JTCVS Tech 2022; 16:49-59. [PMID: 36510522 PMCID: PMC9735426 DOI: 10.1016/j.xjtc.2022.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 08/29/2022] [Accepted: 09/13/2022] [Indexed: 11/08/2022] Open
Abstract
Objectives Long-term outcomes of mitral valve repair procedures to correct ischemic mitral regurgitation remain unpredictable, due to an incomplete understanding of the disease process and the inability to reliably quantify the coaptation zone using echocardiography. Our objective was to quantify patient-specific mitral valve coaptation behavior from clinical echocardiographic images obtained before and after repair to assess coaptation restoration and its relationship with long-term repair durability. Methods To circumvent the limitations of clinical imaging, we applied a simulation-based shape-matching technique that allowed high-fidelity reconstructions of the complete mitral valve in the systolic configuration. We then applied this method to an extant database of human regurgitant mitral valves before and after undersized ring annuloplasty to quantify the effect of the repair on mitral valve coaptation geometry. Results Our method was able to successfully resolve the coaptation zone into distinct contacting and redundant regions. Results indicated that in patients whose regurgitation recurred 6 months postrepair, both the contacting and redundant regions were larger immediately postrepair compared with patients with no recurrence (P < .05), even when normalized to account for generally larger recurrent valves. Conclusions Although increasing leaflet coaptation area is an intuitively obvious way to improve long-term repair durability, this study has implied that this may not be a reliable target for mitral valve repair. This study underscores the importance of a rigorous understanding of the consequences of repair techniques on mitral valve behavior, as well as a patient-specific approach to ischemic mitral regurgitation treatment within the context of mitral valve and left ventricle function.
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Key Words
- CMF, chordal mimicking force
- ED, end-diastolic
- ES, end-systolic
- FE, finite element
- IMR, ischemic mitral regurgitation
- LV, left ventricle
- MR, mitral regurgitation
- MV, mitral valve
- MVTa, mitral valve tenting area
- URA, undersized ring annuloplasty
- mitral valve imaging
- mitral valve mechanics
- mitral valve regurgitation
- mitral valve repair
- myocardial infarction
- rt-3DE, real-time 3-dimensional echocardiography
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Affiliation(s)
- Natalie T. Simonian
- James T. Willerson Center for Cardiovascular Modeling and Simulation, The Oden Institute for Computational Engineering and Sciences and the Department of Biomedical Engineering, The University of Texas at Austin, Austin, Tex
| | - Hao Liu
- James T. Willerson Center for Cardiovascular Modeling and Simulation, The Oden Institute for Computational Engineering and Sciences and the Department of Biomedical Engineering, The University of Texas at Austin, Austin, Tex
| | - Alison M. Pouch
- Departments of Radiology and Bioengineering, University of Pennsylvania, Philadelphia, Pa
| | - Joseph H. Gorman
- Department of Surgery, Smilow Center for Translational Research, Gorman Cardiovascular Research Group, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Robert C. Gorman
- Department of Surgery, Smilow Center for Translational Research, Gorman Cardiovascular Research Group, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Michael S. Sacks
- James T. Willerson Center for Cardiovascular Modeling and Simulation, The Oden Institute for Computational Engineering and Sciences and the Department of Biomedical Engineering, The University of Texas at Austin, Austin, Tex,Address for reprints: Michael S. Sacks, PhD, Department of Biomedical Engineering, The Oden Institute for Computational Engineering and Sciences, The University of Texas at Austin, 201 East 24th St, Stop C0200, Austin, TX 78712-1229.
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Isaka M, Hisada S, Araki R, Ueno H. The leaflet-annulus index in canine myxomatous mitral valve disease. Res Vet Sci 2022; 152:245-247. [PMID: 36029573 DOI: 10.1016/j.rvsc.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 07/14/2022] [Accepted: 08/03/2022] [Indexed: 11/19/2022]
Abstract
Myxomatous mitral valve disease (MMVD) is the most common chronic heart valve disease, leading to the eccentric hypertrophy. Recently, the leaflet-annulus index (LAI), which focuses on the mitral valve apparatus, has been considered a prognostic factor for human mitral regurgitation (MR); however, it has not been reported in veterinary medicine. In the present study, we retrospectively evaluated the LAI in dogs with MMVD. Eight-three dogs with MMVD diagnosed using echocardiography were included in this study. The anteroposterior length, anterior and posterior cusp coaptation lengths, LAI, left ventricular end-diastolic internal diameter normalized to body weight (LVIDDN), and left atrium to aorta ratio (LA/Ao) were measured. A significant correlation between the LAI, LVIDDN, and LA/Ao of MR grading, and left ventricle dilation was observed. In conclusion, LAI could help determine annular widening, suggesting the decision of an appropriate for SVR in clinical settings.
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Affiliation(s)
- Mitsuhiro Isaka
- Division of Companion Animal Surgery, Department of Small Animal Clinical Sciences, School of Veterinary Medicine, Rakuno Gakuen University, 582 Bunkyodai Midorimachi, Ebetsu, Hokkaido 069-8501, Japan.
| | - Shinichi Hisada
- Division of Companion Animal Surgery, Department of Small Animal Clinical Sciences, School of Veterinary Medicine, Rakuno Gakuen University, 582 Bunkyodai Midorimachi, Ebetsu, Hokkaido 069-8501, Japan
| | - Ryuji Araki
- Division of Companion Animal Surgery, Department of Small Animal Clinical Sciences, School of Veterinary Medicine, Rakuno Gakuen University, 582 Bunkyodai Midorimachi, Ebetsu, Hokkaido 069-8501, Japan
| | - Hiroshi Ueno
- Division of Companion Animal Surgery, Department of Small Animal Clinical Sciences, School of Veterinary Medicine, Rakuno Gakuen University, 582 Bunkyodai Midorimachi, Ebetsu, Hokkaido 069-8501, Japan
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Henry MP, Cotella J, Mor-Avi V, Addetia K, Miyoshi T, Schreckenberg M, Blankenhagen M, Hitschrich N, Amuthan V, Citro R, Daimon M, Gutiérrez-Fajardo P, Kasliwal R, Kirkpatrick JN, Monaghan MJ, Muraru D, Ogunyankin KO, Park SW, Tude Rodrigues AC, Ronderos R, Sadeghpour A, Scalia G, Takeuchi M, Tsang W, Tucay ES, Zhang M, Lang RM, Asch FM. Three-Dimensional Transthoracic Static and Dynamic Normative Values of the Mitral Valve Apparatus: Results from the Multicenter World Alliance Societies of Echocardiography Study. J Am Soc Echocardiogr 2022; 35:738-751.e1. [PMID: 35245668 DOI: 10.1016/j.echo.2022.02.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 01/31/2022] [Accepted: 02/22/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Recent advances in mitral valve (MV) percutaneous interventions have escalated the need for a more quantitative and comprehensive assessment of the MV, which can be best achieved using three-dimensional echocardiography. Understanding normal valve size, structure, and function is essential for differentiation of healthy from disease states. The aims of this study were to establish normative values for MV apparatus size and morphology and to determine how they vary across age, sex, and race groups using data from the World Alliance Societies of Echocardiography Normal Values Study. METHODS Three-dimensional volumetric data sets obtained on transthoracic echocardiography in 748 normal subjects (51% men) were analyzed using commercial MV analysis software (TomTec Imaging Systems) to determine annular and leaflet dimensions and areas. The subjects were divided into groups by sex (378 men and 370 women) and age (18 to 40 years [n = 266], 41 to 65 years [n = 249], and >65 years [n = 233]) to identify sex- and age-related differences. In addition, differences among black, white, and Asian populations were studied. Inter- and intraobserver variability was assessed in a subset of 30 subjects and expressed as mean absolute difference between pairs of repeated measurements. RESULTS Compared with women, men had larger annular size measurements, larger tenting size parameters, and larger leaflet length and area. Compared with the black and white populations, the Asian population showed significantly smaller mitral annular size. Although many of the age, sex, and race differences in MV parameters were statistically significant, they were comparable with or smaller than the corresponding measurement variability. Indexing to body surface area and height did not eliminate these differences consistently, suggesting that parameters may need to be indexed according to their dimensionality. CONCLUSIONS This analysis of the World Alliance Societies of Echocardiography data provides normative values of mitral apparatus size and morphology. Although sex- and age-related differences were noted, they need to be interpreted with caution in view of the associated measurement variability.
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Affiliation(s)
| | | | | | | | - Tatsuya Miyoshi
- MedStar Health Research Institute, Washington, District of Columbia
| | | | | | | | | | | | | | | | | | | | | | - Denisa Muraru
- Instituto Auxologico Italiano, IRCCS, San Luca Hospital and University of Milano-Bicocca, Milan, Italy
| | | | | | | | - Ricardo Ronderos
- Instituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina
| | | | | | - Masaaki Takeuchi
- University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Wendy Tsang
- Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Mei Zhang
- Qilu Hospital of Shandong University, Jinan, China
| | | | - Federico M Asch
- MedStar Health Research Institute, Washington, District of Columbia
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11
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McCarthy PM, Malaisrie SC, Thomas JD. Ring Sizing and Coaptation Length: Creating the Goldilocks Mitral Repair. Eur J Cardiothorac Surg 2022; 62:6584010. [PMID: 35543474 DOI: 10.1093/ejcts/ezac282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- Patrick M McCarthy
- Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Bluhm Cardiovascular Institute, Chicago, IL, USA
| | - S Chris Malaisrie
- Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Bluhm Cardiovascular Institute, Chicago, IL, USA
| | - James D Thomas
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Bluhm Cardiovascular Institute, Chicago, IL, USA
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12
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Translocation of the Mitral Valve in an Acute Large Animal Model. J Cardiovasc Transl Res 2022; 15:1100-1107. [PMID: 35175554 DOI: 10.1007/s12265-022-10215-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 02/07/2022] [Indexed: 10/19/2022]
Abstract
Current repair options for functional mitral regurgitation (FMR) are not durable and do not adequately address underlying pathophysiology including leaflet tethering and insufficient coaptation. The feasibility of mitral valve translocation as a repair strategy for FMR was examined in normal swine. Seven pigs (median 62 kg, IQR 55-65 kg) with normal cardiac function were implanted with a 1-cm frustum-shaped pericardial patch inserted between the native mitral annulus and intact mitral leaflets. Operative survival was 100% with no post-procedure mitral stenosis, systolic anterior motion, or central mitral regurgitation observed on echocardiography. Post-translocation mean gradient was 3.5 mmHg (IQR 1.5-4 mmHg); trace or mild suture line leaks on the atrial suture line were noted in 5/7 pigs. Median leaflet coaptation increased from 2.4 (IQR 2.1-4.3 mm) to 12.4 mm (IQR 10.8-13.4 mm) after translocation (P = 0.016). Translocation dramatically increases leaflet coaptation without impairing diastolic function in animals with normal left ventricular function and is a promising technique for repair of FMR. Implantation of a 1.0-cm circumferential pericardial patch (mitral valve translocation) increases leaflet coaptation in a normal animal model.
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13
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Secondary Mitral Regurgitation Repair Techniques and Outcomes: Initial Clinical Experience with Mitral Valve Translocation. JTCVS Tech 2022; 13:53-57. [PMID: 35711194 PMCID: PMC9196134 DOI: 10.1016/j.xjtc.2022.01.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 01/12/2022] [Indexed: 11/23/2022] Open
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14
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Jedrzejczyk JH, Carlson Hanse L, Javadian S, Skov SN, Hasenkam JM, Thørnild MJ. Mitral Annular Forces and Their Potential Impact on Annuloplasty Ring Selection. Front Cardiovasc Med 2022; 8:799994. [PMID: 35059450 PMCID: PMC8765723 DOI: 10.3389/fcvm.2021.799994] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 12/10/2021] [Indexed: 01/01/2023] Open
Abstract
Objectives: To provide an overview that describes the characteristics of a mitral annuloplasty device when treating patients with a specific type of mitral regurgitation according to Carpentier's classification of mitral regurgitation.Methods: Starting with the key search term “mitral valve annuloplasty,” a literature search was performed utilising PubMed, Google Scholar, and Web of Science to identify relevant studies. A systematic approach was used to assess all publications.Results: Mitral annuloplasty rings are traditionally categorised by their mechanical compliance in rigid-, semi-rigid-, and flexible rings. There is a direct correlation between remodelling capabilities and rigidity. Thus, a rigid annuloplasty ring will have the highest remodelling capability, while a flexible ring will have the lowest. Rigid- and semi-rigid rings can furthermore be divided into flat and saddled-shaped rings. Saddle-shaped rings are generally preferred over flat rings since they decrease annular and leaflet stress accumulation and provide superior leaflet coaptation. Finally, mitral annuloplasty rings can either be complete or partial.Conclusions: A downsized rigid- or semi-rigid ring is advantageous when higher remodelling capabilities are required to correct dilation of the mitral annulus, as seen in type I, type IIIa, and type IIIb mitral regurgitation. In type II mitral regurgitation, a normosized flexible ring might be sufficient and allow for a more physiological repair since there is no annular dilatation, which diminishes the need for remodelling capabilities. However, mitral annuloplasty ring selection should always be based on the specific morphology in each patient.
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Affiliation(s)
- Johannes H. Jedrzejczyk
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
- *Correspondence: Johannes H. Jedrzejczyk
| | - Lisa Carlson Hanse
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Shadi Javadian
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Søren N. Skov
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - J. Michael Hasenkam
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
| | - Marcell J. Thørnild
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
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15
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6547516. [DOI: 10.1093/ejcts/ezac133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 01/26/2022] [Accepted: 02/14/2022] [Indexed: 11/14/2022] Open
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16
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Mitral Valve Translocation: Optimization of Patch Geometry in an Ex Vivo Model of Secondary Mitral Regurgitation. J Cardiovasc Transl Res 2021; 15:666-675. [PMID: 34782943 DOI: 10.1007/s12265-021-10182-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 10/26/2021] [Indexed: 10/19/2022]
Abstract
Optimal translocation patch width for functional mitral regurgitation (FMR) treatment was evaluated in an air-filled ex vivo system. FMR was created in 19 isolated swine hearts by annular dilation and papillary muscle displacement. Frustum-shaped pericardial patches of varying widths (Group 1 = 0.5 cm; Group 2 = 1.0 cm; Group 3 = 1.5 cm) were implanted and imaged via a 3D-structured light scanner. Median leaflet coaptation decreased (P < 0.001) from 5.5 ± 2.0 mm at baseline to 2.4 ± 1.3 mm following FMR creation. Translocation repair increased coaptation length over FMR levels by 2.2 mm in Group 1 (P < 0.001), 4.6 mm in Group 2 (P < 0.001), and 4.7 mm in Group 3 (P < 0.001). After repair, no significant differences were found between groups for annular height, circularity index, tenting height, tenting area, and non-coapting surface area. The supranormal coaptation and minimal valve geometric changes support using a 1.0- or 1.5-cm translocation patch for FMR treatment. Implantation of a 1.0-cm or 1.5-cm circumferential pericardial patch (mitral valve translocation) increases leaflet coaptation length without significantly altering valve geometry.
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17
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Pasrija C, Quinn R, Ghoreishi M, Eperjesi T, Lai E, Gorman RC, Gorman JH, Gorman RC, Pouch A, Cortez FV, D'Ambra MN, Gammie JS. A Novel Quantitative Ex Vivo Model of Functional Mitral Regurgitation. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2021; 15:329-337. [PMID: 32830572 DOI: 10.1177/1556984520930336] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Durability of mitral valve (MV) repair for functional mitral regurgitation (FMR) remains suboptimal. We sought to create a highly reproducible, quantitative ex vivo model of FMR that functions as a platform to test novel repair techniques. METHODS Fresh swine hearts (n = 10) were pressurized with air to a left ventricular pressure of 120 mmHg. The left atrium was excised and the altered geometry of FMR was created by radially dilating the annulus and displacing the papillary muscle tips apically and radially in a calibrated fashion. This was continued in a graduated fashion until coaptation was exhausted. Imaging of the MV was performed with a 3-dimensional (3D) structured-light scanner, which records 3D structure, texture, and color. The model was validated using transesophageal echocardiography in patients with normal MVs and severe FMR. RESULTS Compared to controls, the anteroposterior diameter in the FMR state increased 32% and the annular area increased 35% (P < 0.001). While the anterior annular circumference remained fixed, the posterior circumference increased by 20% (P = 0.026). The annulus became more planar and the tenting height increased 56% (9 to 14 mm, P < 0.001). The median coaptation depth significantly decreased (anterior leaflet: 5 vs 2 mm; posterior leaflet: 7 vs 3 mm, P < 0.001). The ex vivo normal and FMR models had similar characteristics as clinical controls and patients with severe FMR. CONCLUSIONS This novel quantitative ex vivo model provides a simple, reproducible, and inexpensive benchtop representation of FMR that mimics the systolic valvular changes of patients with FMR.
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Affiliation(s)
- Chetan Pasrija
- 12264 Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Rachael Quinn
- 12264 Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Mehrdad Ghoreishi
- 12264 Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Thomas Eperjesi
- 6572 Department of Surgery, University of Pennsylvania, PA, USA
| | - Eric Lai
- 6572 Department of Surgery, University of Pennsylvania, PA, USA
| | - Robert C Gorman
- 6572 Department of Surgery, University of Pennsylvania, PA, USA
| | - Joseph H Gorman
- 6572 Department of Surgery, University of Pennsylvania, PA, USA
| | - Robert C Gorman
- 6572 Department of Surgery, University of Pennsylvania, PA, USA
| | - Alison Pouch
- 6572 Department of Surgery, University of Pennsylvania, PA, USA
| | - Felino V Cortez
- 12264 Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Michael N D'Ambra
- 12264 Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - James S Gammie
- 12264 Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
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18
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Initial Clinical Experience With Mitral Valve Translocation for Secondary Mitral Regurgitation. Ann Thorac Surg 2021; 112:1946-1953. [PMID: 33440174 DOI: 10.1016/j.athoracsur.2020.12.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/05/2020] [Accepted: 12/21/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Functional (secondary) mitral regurgitation (FMR) results from altered geometry of the mitral valve apparatus. Repair with restrictive mitral annuloplasty is associated with high rates of recurrent mitral regurgitation (MR). We developed a novel operative repair for FMR that translocates the intact mitral valve towards the apex. METHODS The mitral valve was detached circumferentially and translocated into the ventricle with a frustum-shaped glutaraldehyde-treated autologous pericardial patch. Clinical and echocardiographic follow-up was performed. RESULTS Fifteen consecutive patients with FMR (mean age, 59 years; 67% female) had mitral valve translocation between 2018 and 2020. Preoperative mean ejection fraction, left ventricular end-diastolic dimension, and systolic pulmonary artery pressure were 40% ± 11%, 59 ± 8 mm, and 49 ± 21 mm Hg, respectively; 33% had atrial fibrillation. Cardiomyopathy was ischemic in 4 and nonischemic in 11. Concomitant procedures included tricuspid valve operation (n = 8), coronary artery bypass grafting (n = 4), and atrial fibrillation ablation (n = 5). Post bypass transesophageal echocardiogram demonstrated none/trace MR in all patients and mean gradient of 3 mm Hg (interquartile range, 2-4 mm Hg). Mean leaflet extent of coaptation was 14 ± 2 mm (range, 11-17 mm). There was no postoperative mortality, stroke, or renal failure. Predismissal echocardiography showed none/trace MR in 14 patients and mild MR in 1. One patient underwent successful late rerepair of a suture line leak. Twelve patients were alive at latest follow-up and MR at 1 and 6 months was mild or less in all patients with mean leaflet extent of coaptation of 14 ± 2 mm (range, 12-16 mm) at 6 months. CONCLUSIONS Mitral valve translocation creates a large surface of coaptation and effectively corrects FMR. Further study is needed to demonstrate the long-term durability and clinical utility of this operation.
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19
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Mihos CG, Yucel E, Upadhyay GA, Orencole MP, Singh JP, Picard MH. Left ventricle and mitral valve reverse remodeling in response to cardiac resynchronization therapy in nonischemic cardiomyopathy. Echocardiography 2020; 37:1557-1565. [PMID: 32914427 DOI: 10.1111/echo.14844] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 07/23/2020] [Accepted: 08/12/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) improves left heart geometry and function in nonischemic cardiomyopathy (NICMP). We aimed to detail the effects of CRT on left ventricular (LV) and mitral valve (MV) remodeling using 2-dimensional transthoracic echocardiography. METHODS Forty-five consecutive patients with NICMP who underwent CRT implantation between 2009 and 2012, and had pre-CRT and follow-up echocardiograms available, were included. Paired t test, linear and logistic regression, and Kaplan-Meier survival analyses were used for statistical assessment. RESULTS The mean age and QRS duration were 60 years and 157 ms, respectively, and 13 (28.9%) were female. At a mean follow-up of 3 years, there were 22 (48.9%) "CRT responders" (≥15% reduction in LV end-systolic volume index [LVESVi]). Significant improvements were observed in LV ejection fraction (26.3% vs 34.3%) and LVESVi (87.7 vs 71.1 mL/m2 ), as well as mitral regurgitation vena contracta width, MV tenting height and area, and end-systolic interpapillary muscle distance. Five-year actuarial survival was 87.5%. Multivariate regression analyses revealed the pre-CRT LVESVi (β = 0.52), and MV coaptation length (β = -0.34) and septolateral annular diameter (β = 0.25) as good correlates of follow-up LVESVi. Variables associated with CRT response were pre-CRT MV coaptation length (OR 1.75, 95% CI 1.0-3.1) and posterior leaflet tethering angle (OR 1.07, 95% CI 1.0-1.14), irrespective of baseline QRS morphology and duration (all P < .05). CONCLUSIONS Cardiac resynchronization therapy improves LV and MV geometry and function in half of patients with NICMP, which is paralleled by decreased mitral regurgitation severity. The extent of pre-CRT LV remodeling and MV tethering are associated with CRT response.
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Affiliation(s)
- Christos G Mihos
- Echocardiography Laboratory, Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, Florida, USA.,Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Evin Yucel
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Mary P Orencole
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jagmeet P Singh
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael H Picard
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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20
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Jaworek M, Mangini A, Maroncelli E, Lucherini F, Rosa R, Salurso E, Votta E, Antona C, Fiore GB, Vismara R. Ex Vivo Model of Functional Mitral Regurgitation Using Deer Hearts. J Cardiovasc Transl Res 2020; 14:513-524. [PMID: 32959169 PMCID: PMC8219575 DOI: 10.1007/s12265-020-10071-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 09/07/2020] [Indexed: 12/21/2022]
Abstract
Transcatheter therapies are emerging for functional mitral regurgitation (FMR) treatment, however there is lack of pathological models for their preclinical assessment. We investigated the applicability of deer hearts for this purpose. 8 whole deer hearts were housed in a pulsatile flow bench. At baseline, all mitral valves featured normal coaptation. The pathological state was induced by 60-minutes intraventricular constant pressurization. It caused mitral annulus dilation (antero-posterior diameter increase from 31.8 ± 5.6 mm to 39.5 ± 4.9 mm, p = 0.001), leaflets tethering (maximal tenting height increase from 7.3 ± 2.5 mm to 12.7 ± 3.4 mm, p < 0.001) and left ventricular diameter increase (from 67.8 ± 7.5 mm to 79.4 ± 6.5 mm, p = 0.004). These geometrical reconfigurations led to restricted mitral valve leaflets motion and leaflet coaptation loss. Preliminary feasibility assessment of two FMR treatments was performed in the developed model. Deer hearts showed ability to dilate under constant pressurization and have potential to be used for realistic preclinical research of novel FMR therapies. Graphical abstract figure legend: Deer heart mitral valve fiberscopic and echocardiographic images in peak systole at baseline and after inducing the pathological conditions representing functional mitral regurgitation. In the pathological conditions lack of coaptation between the leaflets, enlargement of the antero-posterior distance (red dashed line) and the left ventricular diameter (orange dashed line) were observed. ![]()
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Affiliation(s)
- Michal Jaworek
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Via Golgi 39, 20133, Milan, Italy. .,ForcardioLab - Fondazione per la Ricerca in Cardiochirurgia ONLUS, Milan, Italy.
| | - Andrea Mangini
- ForcardioLab - Fondazione per la Ricerca in Cardiochirurgia ONLUS, Milan, Italy.,Cardiovascular Surgery Department, ASST Fatebenefratelli Luigi Sacco University Hospital, Milan, Italy
| | - Edoardo Maroncelli
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Via Golgi 39, 20133, Milan, Italy
| | - Federico Lucherini
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Via Golgi 39, 20133, Milan, Italy.,ForcardioLab - Fondazione per la Ricerca in Cardiochirurgia ONLUS, Milan, Italy
| | - Rubina Rosa
- ForcardioLab - Fondazione per la Ricerca in Cardiochirurgia ONLUS, Milan, Italy.,Cardiovascular Surgery Department, ASST Fatebenefratelli Luigi Sacco University Hospital, Milan, Italy
| | - Eleonora Salurso
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Via Golgi 39, 20133, Milan, Italy
| | - Emiliano Votta
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Via Golgi 39, 20133, Milan, Italy.,3D and Computer Simulation Laboratory, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Carlo Antona
- ForcardioLab - Fondazione per la Ricerca in Cardiochirurgia ONLUS, Milan, Italy.,Cardiovascular Surgery Department, ASST Fatebenefratelli Luigi Sacco University Hospital, Milan, Italy.,Università degli Studi di Milano, Milan, Italy
| | - Gianfranco Beniamino Fiore
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Via Golgi 39, 20133, Milan, Italy.,ForcardioLab - Fondazione per la Ricerca in Cardiochirurgia ONLUS, Milan, Italy
| | - Riccardo Vismara
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Via Golgi 39, 20133, Milan, Italy.,ForcardioLab - Fondazione per la Ricerca in Cardiochirurgia ONLUS, Milan, Italy
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21
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Shim H, Harloff M, Percy E, Hirji S, Shah PB, Kaneko T. Prediction for residual regurgitation after MitraClip for functional mitral regurgitation using leaflet coaptation index. J Card Surg 2020; 35:3555-3559. [PMID: 32906188 DOI: 10.1111/jocs.15008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 08/10/2020] [Accepted: 08/27/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Given the recent growth in the number of MitraClip procedures in patients with functional mitral regurgitation (MR), there is interest in an echocardiographic index to predict technical success before intervention. We investigated the utility of a novel leaflet coaptation index (LCI) to predict outcomes after MitraClip in functional MR patients. METHODS Forty consecutive patients with functional MR who underwent MitraClip were included. The LCI was defined as the coapted leaflet length divided by the anteroposterior diameter of the mitral annulus. The coapted leaflet length was calculated by separately tracing the total length of the mitral valve leaflets at early and end systole on transesophageal echocardiography. The primary endpoint was defined as residual MR ≥ moderate after MitraClip. RESULTS The LCI was significantly associated with residual MR ≥ moderate (odds ratio, 0.827; 95% confidence interval, 0.696-0.982; p = .030) with the cut-off LCI value of 0.14 (sensitivity 70.4%, specificity 69.2%, c-statistic 0.815; p = .001). CONCLUSION This novel index may be a useful adjunct that can be incorporated into the armamentarium of contemporary clinical performance risk prediction tools for MitraClip success.
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Affiliation(s)
- Hunbo Shim
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Morgan Harloff
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Edward Percy
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Division of Cardiovascular Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Sameer Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Pinak B Shah
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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22
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Calafiore AM, Totaro A, De Amicis V, Pelini P, Pinna G, Testa N, Alfonso JJ, Mazzei V, Sacra C, Gaudino M, Di Mauro M. Surgical mitral plasticity for chronic ischemic mitral regurgitation. J Card Surg 2020; 35:772-778. [PMID: 32126160 DOI: 10.1111/jocs.14487] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND AIM OF THE STUDY The outcome of mitral valve (MV) repair for chronic ischemic mitral regurgitation (IMR) is suboptimal, due to the high recurrence rate of moderate or severe mitral regurgitation (MR) during follow-up. The MV adapts to new MR increasing its area to cover the enlarged annular area (mitral plasticity). As this process is often incomplete, we aimed to evaluate if augmenting the anterior leaflet (AL) and cutting the second-order chords (CC) together with restrictive mitral annuloplasty, a strategy we call "surgical mitral plasticity," could improve the midterm results of MV repair for IMR. MATERIALS AND METHODS From November 2017 to October 2019, 22 patients with chronic IMR underwent surgical mitral plasticity. Mean age was 73 ± 7 years and six were female. Mean ejection fraction was 32% ± 11%, IMR grade was moderate in 10 and severe in 12. Mean clinical and echocardiographic follow-up was 12 ± 6 months. RESULTS There was no early death, and one patient died 6 months after surgery. Ejection fraction improved from 32% ± 15% to 40% ± 6% (P = .031). IMR was absent or mild in all patients, and none showed recurrent moderate or more IMR. Tenting area decreased significantly from 2.5 ± 0.5 to 0.5 ± 0.3 cm² and coaptation length increased from 1.9 ± 0.7 to 7.8 ± 1.6 mm. All patients were in New York Heart Association class I or II. CONCLUSIONS Mitral plasticity, if uncomplete, is ineffective in preventing IMR to become significant. Surgical mitral plasticity, by completing incomplete process of MV adaptation, has a strong rationale, which however needs to be validated with longer follow-up.
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Affiliation(s)
| | - Antonio Totaro
- Department of Cardiovascular Diseases, Gemelli Molise, Campobasso, Italy
| | | | - Piero Pelini
- Division of Cardiac Surgery, D'Annunzio University, Chieti, Italy
| | - Giovanni Pinna
- Division of Cardiac Surgery, Federico II University, Naples, Italy
| | - Nicola Testa
- Department of Cardiovascular Diseases, Gemelli Molise, Campobasso, Italy
| | - Juan J Alfonso
- Department of Research, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Valerio Mazzei
- Department of Cardiovascular Diseases, Gemelli Molise, Campobasso, Italy
| | - Cosimo Sacra
- Department of Cardiovascular Diseases, Gemelli Molise, Campobasso, Italy
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Michele Di Mauro
- Division of Cardiac Surgery, D'Annunzio University, Chieti, Italy
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Eulzer P, Engelhardt S, Lichtenberg N, de Simone R, Lawonn K. Temporal Views of Flattened Mitral Valve Geometries. IEEE TRANSACTIONS ON VISUALIZATION AND COMPUTER GRAPHICS 2020; 26:971-980. [PMID: 31425104 DOI: 10.1109/tvcg.2019.2934337] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The mitral valve, one of the four valves in the human heart, controls the bloodflow between the left atrium and ventricle and may suffer from various pathologies. Malfunctioning valves can be treated by reconstructive surgeries, which have to be carefully planned and evaluated. While current research focuses on the modeling and segmentation of the valve, we base our work on existing segmentations of patient-specific mitral valves, that are also time-resolved ( 3D+t) over the cardiac cycle. The interpretation of the data can be ambiguous, due to the complex surface of the valve and multiple time steps. We therefore propose a software prototype to analyze such 3D+t data, by extracting pathophysiological parameters and presenting them via dimensionally reduced visualizations. For this, we rely on an existing algorithm to unroll the convoluted valve surface towards a flattened 2D representation. In this paper, we show that the 3D+t data can be transferred to 3D or 2D representations in a way that allows the domain expert to faithfully grasp important aspects of the cardiac cycle. In this course, we not only consider common pathophysiological parameters, but also introduce new observations that are derived from landmarks within the segmentation model. Our analysis techniques were developed in collaboration with domain experts and a survey showed that the insights have the potential to support mitral valve diagnosis and the comparison of the pre- and post-operative condition of a patient.
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Commentary: Mitral repair-Where it all comes together? J Thorac Cardiovasc Surg 2019; 159:e187. [PMID: 31597620 DOI: 10.1016/j.jtcvs.2019.08.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 08/05/2019] [Indexed: 11/22/2022]
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Calafiore AM, Totaro A, Sacra C, Foschi M, Tancredi F, Pelini P, Gaudino M, Di Mauro M. Unbalanced mitral valve remodeling in ischemic mitral regurgitation: Implications for a durable repair. J Card Surg 2019; 34:885-888. [DOI: 10.1111/jocs.14119] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 05/13/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Antonio M Calafiore
- Department of Cardiac Surgery and CardiologyFondazione “Papa Giovanni Paolo II” Campobasso Italy
| | - Antonio Totaro
- Department of Cardiac Surgery and CardiologyFondazione “Papa Giovanni Paolo II” Campobasso Italy
| | - Cosimo Sacra
- Department of Cardiac Surgery and CardiologyFondazione “Papa Giovanni Paolo II” Campobasso Italy
| | | | | | - Piero Pelini
- Department of Cardiac Surgery and CardiologyFondazione “Papa Giovanni Paolo II” Campobasso Italy
| | - Mario Gaudino
- Department of Cardiothoracic SurgeryWeill Cornell Medicine New York New York
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Ma W, Chen J, Zhang W, Wu W, Ye W, Shi W, Kong Y. Triangular resection versus neochordal replacement for posterior leaflet prolapse: a morphological assessment. Interact Cardiovasc Thorac Surg 2018; 26:54-59. [PMID: 29049793 DOI: 10.1093/icvts/ivx260] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 07/09/2017] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES To evaluate the morphological reconstruction as assessed by 3D transoesophageal echocardiography after triangular resection and neochordal replacement in the treatment of posterior leaflet prolapse. METHODS We retrospectively selected 46 patients with isolated posterior leaflet prolapse who were undergoing mitral valve repair using triangular resection (n = 20) and neochordal replacement (n = 26) techniques. Sixty patients without valvular heart disease were also included as the control group. Thorough 3D transoesophageal echocardiography inspections were performed for the entire cohort, and morphological parameters of mitral valve complex were measured and compared. Mid-term repair durability was followed up by transthoracic echocardiography. RESULTS The baseline parameters, including annular size, leaflet tenting, leaflet area, coaptation line lengths and aortomitral angle, were significantly larger in prolapsed valves. After repair, tenting volume, exposed posterior leaflet area and coaptation line lengths were restored to the normal range. Baseline clinical characteristics and 3D transoesophageal echocardiography parameters were comparable in patients treated with 2 techniques, and all parameters remained comparable between the resection and the non-resection groups after repair, except for exposed posterior leaflet area and posterior leaflet ratio. At 62.2 ± 18.5 months after surgery, degrees of residual regurgitation were similar between 2 techniques. CONCLUSIONS Triangular resection and neochordal replacement can achieve comparable restoration to structural normality and functional competency of mitral valves with posterior leaflet prolapse. Resection of prolapsed segment does not significantly affect coaptation geometry but instead may aid in achieving normal posterior leaflet ratio.
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Affiliation(s)
- Wenrui Ma
- Department of Cardiovascular Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jiafei Chen
- Department of Cardiovascular Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Wei Zhang
- Department of Cardiovascular Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Weihua Wu
- Department of Echocardiography, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Wei Ye
- Department of Cardiovascular Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Wei Shi
- Department of Cardiovascular Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Ye Kong
- Department of Cardiovascular Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
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Morbach C, Bellavia D, Störk S, Sugeng L. Systolic characteristics and dynamic changes of the mitral valve in different grades of ischemic mitral regurgitation - insights from 3D transesophageal echocardiography. BMC Cardiovasc Disord 2018; 18:93. [PMID: 29747569 PMCID: PMC5946441 DOI: 10.1186/s12872-018-0819-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 04/25/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Mitral regurgitation in ischemic heart disease (IMR) is a strong predictor of outcome but until now, pathophysiology is not sufficiently understood and treatment is not satisfying. We aimed to systematically evaluate structural and functional mitral valve leaflet and annular characteristics in patients with IMR to determine the differences in geometric and dynamic changes of the MV between significant and mild IMR. METHODS Thirty-seven patients with IMR (18 mild (m)MR, 19 significant (moderate+severe) (s)MR) and 33 controls underwent TEE. 3D volumes were analyzed using 3D feature-tracking software. RESULTS All IMR patients showed a loss of mitral annular motility and non-planarity, whereas mitral annulus dilation and leaflet enlargement occurred in sMR only. Active-posterior-leaflet-area decreased in early systole in all three groups accompanied by an increase in active-anterior-leaflet-area in early systole in controls and mMR but only in late systole in sMR. CONCLUSIONS In addition to a significant enlargement and loss in motility of the MV annulus, patients with significant IMR showed a spatio-temporal alteration of the mitral valve coaptation line due to a delayed increase in active-anterior-leaflet-area. This abnormality is likely to contribute to IMR severity and is worth the evaluation of becoming a parameter for clinical decision-making. Further, addressing the leaflets aiming to increase the active leaflet-area is a promising therapeutic approach for significant IMR. Additional studies with a larger sample size and post-operative assessment are warranted to further validate our findings and help understand the dynamics of the mitral valve.
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Affiliation(s)
- Caroline Morbach
- Yale School of Medicine, Section Cardiovascular Medicine, 330 Cedar Street, P.O Box 208017, New Haven, CT, 06511, USA.,Comprehensive Heart Failure Center and Department of Internal Medicine I, University of Würzburg, Würzburg, Germany
| | - Diego Bellavia
- Yale School of Medicine, Section Cardiovascular Medicine, 330 Cedar Street, P.O Box 208017, New Haven, CT, 06511, USA.,Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione (IRCCS-ISMETT), Palermo, Italy
| | - Stefan Störk
- Comprehensive Heart Failure Center and Department of Internal Medicine I, University of Würzburg, Würzburg, Germany
| | - Lissa Sugeng
- Yale School of Medicine, Section Cardiovascular Medicine, 330 Cedar Street, P.O Box 208017, New Haven, CT, 06511, USA.
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Guo Y, He Y, Zhang Y, Ge S, Sun L, Liu W, Han J, Gu X. Assessment of the mitral valve coaptation zone with 2D and 3D transesophageal echocardiography before and after mitral valve repair. J Thorac Dis 2018; 10:283-290. [PMID: 29600058 DOI: 10.21037/jtd.2017.12.62] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Mitral valve (MV) coaptation is very important in MV repair patients. But accurate quantitation of the degree of MV coaptation remains challenging. This study aimed to evaluate the utility of two-dimensional (2D) and three-dimensional (3D) transesophageal echocardiography (TEE) to assess MV coaptation before and after MV repair. Methods Forty-eight patients [(age: 52.23±13.31 years; 26 men (54.17%)] undergoing MV repair for mitral regurgitation (MR) were studied. We assessed the utility of 2D and 3D TEE to assess MV coaptation before and after MV repair. Complete conventional 2D and 3D TEE studies were performed, and the degree of the MV coaptation defect before and after surgery was assessed by measuring the MV coaptation length (CL) and length index (CLI) with 2D TEE, and the coaptation area (CA) and coaptation area index (CAI) with 3D TEE. Results CL and CLI were measured successfully in 46 (95.83%) patients and CA and CAI in 39 (81.25%). Compared with preoperatively, postoperative CL, CLI, CA, and CAI were significantly increased (CL: 4.99±0.79 to 9.66±1.09 mm, P<0.05; CLI: 9.30%±2.66% to 38.24%±3.82%, P<0.05; CA: 158.49±64.17 to 371.33±143.57 mm2, P<0.05; CAI: 9.71%±2.76% to 36.24%±7.26%, P<0.05). Spearman's rank correlation analysis revealed that the CLI and CAI had a significant negative correlation with the degree of MR (r=-0.97, P<0.01; r=-0.92, P<0.01, respectively). Furthermore, Pearson's correlation analysis revealed that the CLI was significantly correlated with the CAI both preoperatively (r=-0.66, P<0.01) and postoperatively (r=-0.67, P<0.01). Conclusions The coaptation variables increased significantly in patients undergoing MV repair. The CLI and CAI significantly correlated with MR severity. The CL and CLI determined with 2D TEE are more feasible than the CA and CAI determined with 3D TEE. Both 2D and 3D variables may complement each other for aiding MV repair. 2D CLI is an alternative to 3D CAI due to its simplicity.
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Affiliation(s)
- Yong Guo
- Department of Ultrasound, Beijing An Zhen Hospital, Capital Medical University, Beijing 100029, China
| | - Yihua He
- Department of Ultrasound, Beijing An Zhen Hospital, Capital Medical University, Beijing 100029, China
| | - Ye Zhang
- Department of Ultrasound, Beijing An Zhen Hospital, Capital Medical University, Beijing 100029, China
| | - Shuping Ge
- St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Lin Sun
- Department of Ultrasound, Beijing An Zhen Hospital, Capital Medical University, Beijing 100029, China
| | - Wenxu Liu
- Department of Ultrasound, Beijing An Zhen Hospital, Capital Medical University, Beijing 100029, China
| | - Jiancheng Han
- Department of Ultrasound, Beijing An Zhen Hospital, Capital Medical University, Beijing 100029, China
| | - Xiaoyan Gu
- Department of Ultrasound, Beijing An Zhen Hospital, Capital Medical University, Beijing 100029, China
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Deorsola L, Bellone A. Coaptation Triangle and Golden Proportion in mitral valve anatomy. Does nature play with geometry? Echocardiography 2017; 35:30-38. [DOI: 10.1111/echo.13727] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Luca Deorsola
- Pediatric Cardiac Surgery Department; Regina Margherita Children's Hospital; Turin Italy
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Pham T, Kong F, Martin C, Wang Q, Primiano C, McKay R, Elefteriades J, Sun W. Finite Element Analysis of Patient-Specific Mitral Valve with Mitral Regurgitation. Cardiovasc Eng Technol 2017; 8:3-16. [PMID: 28070866 DOI: 10.1007/s13239-016-0291-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 12/29/2016] [Indexed: 12/30/2022]
Abstract
Functional mitral regurgitation (FMR) is a significant complication of left ventricular dysfunction and strongly associated with a poor prognosis. In this study, we developed a patient-specific finite element (FE) model of the mitral apparatus in a FMR patient which included: both leaflets with thickness, annulus, chordae tendineae, and chordae insertions on the leaflets and origins on the papillary muscles. The FE model incorporated human age- and gender-matched anisotropic hyperelastic material properties, and MV closure at systole was simulated. The model was validated by comparing the FE results from valve closure simulation with the in vivo geometry of the MV at systole. It was found that the FE model could not replicate the in vivo MV geometry without the application of tethering pre-tension force in the chordae at diastole. Upon applying the pre-tension force and performing model optimization by adjusting the chordal length, position, and leaflet length, a good agreement between the FE model and the in vivo model was established. Not only were the chordal forces high at both diastole and systole, but the tethering force on the anterior papillary muscle was higher than that of the posterior papillary muscle, which resulted in an asymmetrical gap with a larger orifice area at the anterolateral commissure resulting in MR. The analyses further show that high peak stress and strain were found at the chordal insertions where large chordal tethering forces were found. This study shows that the pre-tension tethering force plays an important role in accurately simulating the MV dynamics in this FMR patient, particularly in quantifying the degree of leaflet coaptation and stress distribution. Due to the complexity of the disease, the patient-specific computational modeling procedure of FMR patients presented should be further evaluated using a large patient cohort. However, this study provides useful insights into the MV biomechanics of a FMR patient, and could serve as a tool to assist in pre-operative planning for MV repair or replacement surgical or interventional procedures.
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Affiliation(s)
- Thuy Pham
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Technology Enterprise Park, Room 206, 387 Technology Circle, Atlanta, GA, 30313-2412, USA
| | - Fanwei Kong
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Technology Enterprise Park, Room 206, 387 Technology Circle, Atlanta, GA, 30313-2412, USA
| | - Caitlin Martin
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Technology Enterprise Park, Room 206, 387 Technology Circle, Atlanta, GA, 30313-2412, USA
| | - Qian Wang
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Technology Enterprise Park, Room 206, 387 Technology Circle, Atlanta, GA, 30313-2412, USA
| | | | - Raymond McKay
- Cardiology Department of Hartford Hospital, Hartford, CT, USA
| | | | - Wei Sun
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Technology Enterprise Park, Room 206, 387 Technology Circle, Atlanta, GA, 30313-2412, USA.
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Abstract
We aimed to elucidate the relationship between severity of secondary mitral regurgitation and mitral valve geometry in children with dilated cardiomyopathy. The medical records of 16 children with dilated cardiomyopathy (median age, 1.2 years; range, 0.4-12.3 years) were reviewed. Mitral valve geometry was evaluated by measuring coaptation depth using echocardiographic apical four-chamber views at the initial presentation. Patients were dichotomised according to the mitral regurgitation severity: patients with moderate or severe secondary mitral regurgitation (n=6) and those with mild secondary mitral regurgitation (n=10). A total of 58 healthy children were considered as normal controls, and a regression equation to predict coaptation depth by body surface area was derived: coaptation depth [mm]=4.37+1.34×ln (body surface area [m2]) (residual standard error, 0.49; adjusted R2, 0.68; p<0.0001). Compared with patients with mild secondary mitral regurgitation, those with moderate or severe secondary mitral regurgitation had significantly larger coaptation depth z-scores (6.4±2.3 versus 1.9±1.4, p<0.005), larger mitral annulus diameter z-scores (3.6±2.6 versus 0.9±1.8, p<0.05), higher left ventricular sphericity index (0.89±0.07 versus 0.79±0.06, p<0.005), and greater left ventricular fraction shortening (0.15±0.05 versus 0.09±0.05, p<0.05). In conclusion, geometric alteration in the mitral valve and the left ventricle is associated with the severity of secondary mitral regurgitation in paediatric dilated cardiomyopathy, which would provide a theoretical background to surgical intervention for secondary mitral regurgitation in paediatric populations.
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Pierlot CM, Moeller AD, Lee JM, Wells SM. Pregnancy-induced remodeling of heart valves. Am J Physiol Heart Circ Physiol 2015; 309:H1565-78. [DOI: 10.1152/ajpheart.00816.2014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 09/06/2015] [Indexed: 01/13/2023]
Abstract
Recent studies have demonstrated remodeling of aortic and mitral valves leaflets under the volume loading and cardiac expansion of pregnancy. Those valves' leaflets enlarge with altered collagen fiber architecture, content, and cross-linking and biphasic changes (decreases, then increases) in extensibility during gestation. This study extends our analyses to right-sided valves, with additional compositional measurements for all valves. Valve leaflets were harvested from nonpregnant heifers and pregnant cows. Leaflet structure was characterized by leaflet dimensions, and ECM composition was determined using standard biochemical assays. Histological studies assessed changes in cellular and ECM components. Leaflet mechanical properties were assessed using equibiaxial mechanical testing. Collagen thermal stability and cross-linking were assessed using denaturation and hydrothermal isometric tension tests. Pulmonary and tricuspid leaflet areas increased during pregnancy by 35 and 55%, respectively. Leaflet thickness increased by 20% only in the pulmonary valve and largely in the fibrosa (30% thickening). Collagen crimp length was reduced in both the tricuspid (61%) and pulmonary (42%) valves, with loss of crimped area in the pulmonary valve. Thermomechanics showed decreased collagen thermal stability with surprisingly maintained cross-link maturity. The pulmonary leaflet exhibited the biphasic change in extensibility seen in left side valves, whereas the tricuspid leaflet mechanics remained largely unchanged throughout pregnancy. The tricuspid valve exhibits a remodeling response during pregnancy that is significantly diminished from the other three valves. All valves of the heart remodel in pregnancy in a manner distinct from cardiac pathology, with much similarity valve to valve, but with interesting valve-specific responses in the aortic and tricuspid valves.
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Affiliation(s)
- Caitlin M. Pierlot
- School of Biomedical Engineering, Dalhousie University, Halifax, Nova Scotia, Canada; and
| | - Andrew D. Moeller
- School of Biomedical Engineering, Dalhousie University, Halifax, Nova Scotia, Canada; and
| | - J. Michael Lee
- School of Biomedical Engineering, Dalhousie University, Halifax, Nova Scotia, Canada; and
- Department of Applied Oral Sciences, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Sarah M. Wells
- School of Biomedical Engineering, Dalhousie University, Halifax, Nova Scotia, Canada; and
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Bouma W, Aoki C, Vergnat M, Pouch AM, Sprinkle SR, Gillespie MJ, Mariani MA, Jackson BM, Gorman RC, Gorman JH. Saddle-Shaped Annuloplasty Improves Leaflet Coaptation in Repair for Ischemic Mitral Regurgitation. Ann Thorac Surg 2015; 100:1360-6. [PMID: 26184554 DOI: 10.1016/j.athoracsur.2015.03.096] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Revised: 03/26/2015] [Accepted: 03/30/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Current repair results for ischemic mitral regurgitation (IMR) with undersized annuloplasty rings are characterized by high IMR recurrence rates. Current annuloplasty rings treat annular dilatation, but they do little to improve (and may actually exacerbate) leaflet tethering. New saddle-shaped annuloplasty rings have been shown to maintain or restore a more physiologic annular and leaflet geometry and function. Using a porcine IMR model, we sought to demonstrate the influence of annuloplasty ring shape on leaflet coaptation. METHODS Eight weeks after posterolateral infarct, eight pigs with grade 2+ or higher IMR were randomized to undergo either a 28-mm flat ring annuloplasty (n = 4) or a 28-mm saddle-shaped ring annuloplasty (n = 4). Real-time three-dimensional echocardiography and a customized image analysis protocol allowed three-dimensional assessment of leaflet coaptation before and after annuloplasty. RESULTS Total leaflet coaptation area was significantly higher after saddle-shaped ring annuloplasty (109.6 ± 26.9 mm(2)) compared with flat ring annuloplasty (46.2 ± 7.7 mm(2), p <0.01). After annuloplasty, total coaptation area decreased by 87.5 mm(2) (or 65%) in the flat annuloplasty group (p = 0.01), whereas total coaptation area increased by 22.2 mm(2) (or 25%) in the saddle-shaped annuloplasty group (p = 0.28). CONCLUSIONS This study shows that the use of undersized saddle-shaped annuloplasty rings in mitral valve repair for IMR improves leaflet coaptation, whereas the use of undersized flat annuloplasty rings worsens leaflet coaptation. Because one of Carpentier's fundamental principles of mitral valve repair (durability) is to create a large surface of coaptation, saddle-shaped annuloplasty may increase repair durability.
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Affiliation(s)
- Wobbe Bouma
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania; University of Groningen, University Medical Center Groningen, Department of Cardiothoracic Surgery, Groningen, Netherlands
| | - Chikashi Aoki
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mathieu Vergnat
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alison M Pouch
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Shanna R Sprinkle
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew J Gillespie
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Massimo A Mariani
- University of Groningen, University Medical Center Groningen, Department of Cardiothoracic Surgery, Groningen, Netherlands
| | - Benjamin M Jackson
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert C Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph H Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania.
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Adams J, O'Rourke MJ. In vitro measurement of the coaptation force distribution in normal and functional regurgitant porcine mitral valves. J Biomech Eng 2015; 137:2111008. [PMID: 25661678 DOI: 10.1115/1.4029746] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Indexed: 11/08/2022]
Abstract
Closure of the left atrioventricular orifice is achieved when the anterior and posterior leaflets of the mitral valve press together to form a coaptation zone along the free edge of the leaflets. This coaptation zone is critical to valve competency and is maintained by the support of the mitral annulus, chordae tendinae, and papillary muscles. Myocardial ischemia can lead to an altered performance of this mitral complex generating suboptimal mitral leaflet coaptation and a resultant regurgitant orifice. This paper reports on a two-part experiment undertaken to measure the dependence of coaptation force distribution on papillary muscle position in normal and functional regurgitant porcine mitral heart valves. Using a novel load sensor, the local coaptation force was measured in vitro at three locations (A1-P1, A2-P2, and A3-P3) along the coaptation zone. In part 1, the coaptation force was measured under static conditions in ten whole hearts. In part 2, the coaptation force was measured in four explanted mitral valves operating in a flow loop under physiological flow conditions. Here, two series of tests were undertaken corresponding to the normal and functional regurgitant state as determined by the position of the papillary muscles relative to the mitral valve annulus. The functional regurgitant state corresponded to grade 1. The static tests in part 1 revealed that the local force was directly proportional to the transmitral pressure and was nonuniformly distributed across the coaptation zone, been strongest at A1-P1. In part 2, tests of the valve in a normal state showed that the local force was again directly proportional to the transmitral pressure and was again nonuniform across the coaptation zone, been strongest at A1-P1 and weakest at A2-P2. Further tests performed on the same valves in a functional regurgitant state showed that the local force measured in the coaptation zone was directly proportional to the transmitral pressure. However, the force was now observed to be weakest at A1-P1 and strongest at A2-P2. Movement of the anterolateral papillary muscle (APM) away from both the annular and anterior-posterior (AP) planes was seen to contribute significantly to the altered force distribution in the coaptation zone. It was concluded that papillary muscle displacement typical of myocardial ischemia changes the coaptation force locally within the coaptation zone.
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Regeer MV, Al Amri I, Versteegh MI, Bax JJ, Marsan NA, Delgado V. Mitral Valve Geometry Changes in Patients with Aortic Regurgitation. J Am Soc Echocardiogr 2015; 28:455-62. [DOI: 10.1016/j.echo.2015.01.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Indexed: 11/30/2022]
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New method of posterior scallop augmentation for ischemic mitral regurgitation. Ann Thorac Surg 2015; 99:1087-9. [PMID: 25742844 DOI: 10.1016/j.athoracsur.2014.09.080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 09/03/2014] [Accepted: 09/29/2014] [Indexed: 11/22/2022]
Abstract
We report a new method of posterior middle scallop (P2) augmentation for ischemic mitral regurgitation to achieve deep coaptation. First, P2 was divided straight at the center and partially detached from the annulus in a reverse T shape. A narrow pentagon-shaped section of pericardium was sutured to the divided P2 and annular defect. The tip of the pentagon was attached directly to the papillary muscle, thus creating a very large P2 scallop. A standard-sized ring was placed. We adopted this technique in 2 patients with advanced ischemic cardiomyopathy, and no mitral regurgitation was observed during a 1-year follow-up.
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Engelhardt S, Lichtenberg N, Al-Maisary S, De Simone R, Rauch H, Roggenbach J, Müller S, Karck M, Meinzer HP, Wolf I. Towards Automatic Assessment of the Mitral Valve Coaptation Zone from 4D Ultrasound. FUNCTIONAL IMAGING AND MODELING OF THE HEART 2015. [DOI: 10.1007/978-3-319-20309-6_16] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Sturla F, Onorati F, Votta E, Pechlivanidis K, Stevanella M, Milano AD, Puppini G, Mazzucco A, Redaelli A, Faggian G. Is it possible to assess the best mitral valve repair in the individual patient? Preliminary results of a finite element study from magnetic resonance imaging data. J Thorac Cardiovasc Surg 2014; 148:1025-34; discussion 1034. [DOI: 10.1016/j.jtcvs.2014.05.071] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 05/21/2014] [Accepted: 05/27/2014] [Indexed: 11/30/2022]
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Cobey FC, Swaminathan M, Phillips-Bute B, Hyca M, Glower DD, Douglas PS, Shaw AD, Mathew JP, Mackensen GB. Quantitative assessment of mitral valve coaptation using three-dimensional transesophageal echocardiography. Ann Thorac Surg 2014; 97:1998-2004. [PMID: 24655467 DOI: 10.1016/j.athoracsur.2014.01.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 12/27/2013] [Accepted: 01/06/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Functional mitral regurgitation (FMR) occurs as a consequence of left ventricular remodeling and is an independent predictor of adverse outcome. FMR is assessed qualitatively with two-dimensional echocardiography, but accurate quantitation of the actual degree of mitral valve (MV) coaptation is not possible with this method. We evaluated a novel three-dimensional (3D) approach to quantify the MV coaptation zone in patients with FMR. We hypothesized that measuring the 3D MV coaptation zone is feasible and would correlate with FMR severity when indexed to MV area. METHODS Data were gathered on 25 patients with FMR undergoing cardiac operations, and included a comprehensive two-dimensional and 3D examination with intraoperative transesophageal echocardiography. Using available 3D MV quantification software, offline analysis of end-systolic MV coaptation zone and MV area was performed. A novel MV coaptation index was calculated by the following formula: [3D end-systolic MV coaptation zone/3D MV area]. FMR severity was described as trace, mild, moderate, and severe using the integrative approach recommended by official guidelines. RESULTS Analysis of variance demonstrated that the coaptation index was associated with the severity of FMR (F = 20.5, r(2) = 0.75, p < 0.0001). There was also a correlation between 2D vena contracta and the coaptation index (r = -0.74, p < 0.0003). CONCLUSIONS We describe a novel 3D approach to direct assessment of the MV coaptation zone. When indexed to the MV area, the 3D MV coaptation zone is closely associated with FMR severity. Assessment of the mitral coaptation may be a potentially powerful tool in the perioperative evaluation of the competency of the MV.
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Affiliation(s)
- Frederick C Cobey
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina; Department of Anesthesiology, Tufts Medical Center, Boston, Massachusetts
| | - Madhav Swaminathan
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Barbara Phillips-Bute
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Martin Hyca
- TomTec Imaging Systems, Unterschleissheim, Germany
| | - Donald D Glower
- Division of Cardiac Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Pamela S Douglas
- Division of Cardiovascular Medicine, Department of Medicine and the Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Andrew D Shaw
- Veteran's Affairs Anesthesiology Services, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Joseph P Mathew
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - G Burkhard Mackensen
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina; Division of Cardiothoracic Anesthesiology, Department of Anesthesiology & Pain Medicine University of Washington Medical Center, Seattle, Washington.
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Zeng X, Nunes MCP, Dent J, Gillam L, Mathew JP, Gammie JS, Ascheim DD, Moquete E, Hung J. Asymmetric versus symmetric tethering patterns in ischemic mitral regurgitation: geometric differences from three-dimensional transesophageal echocardiography. J Am Soc Echocardiogr 2014; 27:367-75. [PMID: 24513242 DOI: 10.1016/j.echo.2014.01.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Ischemic mitral regurgitation (IMR) results from mitral leaflet tethering from left ventricular remodeling. Heterogeneity in local or global left ventricular remodeling can result in differential tethering patterns and affect mitral valve function and the degree of mitral regurgitation. The aims of this study were to compare mitral valve geometry in asymmetric and symmetric tethering patterns using three-dimensional transesophageal echocardiography and to examine the impact of tethering pattern on IMR severity. METHODS Sixty-two patients with moderate or greater IMR underwent three-dimensional transesophageal echocardiography for the assessment of mitral valve geometry. Symmetric and asymmetric tethering patterns were determined by mitral regurgitation jet direction and coaptation of the mitral leaflets. The ratio of posterior to anterior leaflet tethering angle was a measure of tethering pattern (the higher the ratio, the more asymmetric the pattern). Overall tethering degree was assessed by tenting volume (TV). RESULTS Compared with the symmetric group, the asymmetric group had less annular dilatation, greater annular heights (10.3 ± 1.9 vs 8.5 ± 1.9 mm, P < .01), greater ratios of posterior to anterior leaflet tethering angle (3.19 ± 0.88 vs 1.95 ± 0.46, P < .01), and smaller TVs with more posterior displacement of the coaptation line. Vena contracta normalized to TV was greater in the asymmetric group (0.38 ± 0.24 vs 0.19 ± 0.13 cm/mL, P < .01). Multivariate analysis showed that both ratio of posterior to anterior leaflet tethering angle (β = 0.46, P < .001) and TV (β = 0.41, P = .001) were predictors of IMR severity. CONCLUSIONS Differences in mitral valve geometry are observed between asymmetric and symmetric tethering patterns in IMR. IMR degree is affected by both the pattern of tethering and the total degree of tethering. For the same degree of tethering, an asymmetric pattern is associated with increased MR severity. The pattern of mitral leaflet tethering may be considered in therapeutic decision making.
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Affiliation(s)
- Xin Zeng
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Boston, Massachusetts
| | - Maria Carmo P Nunes
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Boston, Massachusetts
| | - John Dent
- Cardiovascular Division, University of Virginia, Charlottesville, Virginia
| | - Linda Gillam
- Cardiovascular Medicine, Atlantic Health System, Morristown, New Jersey
| | - Joseph P Mathew
- Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - James S Gammie
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Deborah D Ascheim
- Department of Health Evidence and Policy, Mount Sinai School of Medicine, New York, New York; Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ellen Moquete
- Department of Health Evidence and Policy, Mount Sinai School of Medicine, New York, New York
| | - Judy Hung
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Boston, Massachusetts.
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Modified single-patch compared with two-patch repair of complete atrioventricular septal defect. Ann Thorac Surg 2013; 97:666-71. [PMID: 24266947 DOI: 10.1016/j.athoracsur.2013.09.084] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Revised: 09/17/2013] [Accepted: 09/23/2013] [Indexed: 11/24/2022]
Abstract
BACKGROUND We compared the outcomes of modified single-patch and two-patch surgical repair of complete atrioventricular septal defect (CAVSD) on left ventricular outflow tract (LVOT) diameter and on left atrioventricular valve (LAVV) coaptation. METHODS We reviewed retrospectively postoperative 2-dimensional echocardiograms of all CAVSD patients who underwent modified single-patch or two-patch repair between 2005 and 2011. We measured the leaflet coaptation length of the LAVV in the apical four-chamber view. The LVOT was measured in the long axis view. RESULTS Fifty-one patients underwent CAVSD repair at a median age of 4 months (range, 1 to 9 months) (single-patch, n=29; two-patch, n=22). The images from 46 echocardiograms were adequate for analysis. Modified single-patch repair required significantly shorter bypass time (102.0±33.6 vs 152.9±39.5 minutes, p<0.001) and ischemic time (69.0±21.7 vs 106.9±29.7 minutes, p<0.001) than did two-patch repair. The indexed coaptation length of the septal and lateral leaflets was not different between single-patch and two-patch (3.1±2.3 vs 4.1±3.1 mm/m2, p=0.25; 2.3±2.3 vs 3.3±3.0 mm/m2, p=0.21). Indexed LVOT diameter was not different in the two groups (26.1±5.2 vs 28.5±7.1 mm/m2, p=0.22). There was no hospital or late death during the median follow-up time of 35 months (range, 1 to 69 months). Five patients underwent reoperation after single-patch repair (3 with residual ventricular septal defect [VSD] and LAVV regurgitation, 1 with residual VSD, 1 with pacemaker implantation). After the two-patch repair, 1 patient required reoperation for a residual VSD and right atrioventricular valve regurgitation (p=0.22). CONCLUSIONS The modified single-patch repair was performed with significantly shorter bypass time and myocardial ischemic time. The postoperative LVOT diameter and LAVV leaflet coaptation length were not significantly different between techniques.
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Ugaki S, Khoo NS, Ross DB, Rebeyka IM, Adatia I. Tricuspid valve repair improves early right ventricular and tricuspid valve remodeling in patients with hypoplastic left heart syndrome. J Thorac Cardiovasc Surg 2013; 145:446-50. [DOI: 10.1016/j.jtcvs.2012.10.040] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Revised: 09/07/2012] [Accepted: 10/22/2012] [Indexed: 10/27/2022]
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Baird CW, Myers PO, Marx G, Del Nido PJ. Mitral valve operations at a high-volume pediatric heart center: Evolving techniques and improved survival with mitral valve repair versus replacement. Ann Pediatr Cardiol 2012; 5:13-20. [PMID: 22529595 PMCID: PMC3327008 DOI: 10.4103/0974-2069.93704] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Mitral valve disease is quite variable and can occur as an isolated defect or in association with other complex left sided lesions. These lesions are often best described with detailed pre-operative imaging studies to define the valve anatomy and to access associated left heart disease. Depending on the type of mitral valve disease, various surgical repair techniques have led to improved survival in the recent era. We describe lesion specific approach to mitral valve repair and results.
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Affiliation(s)
- Christopher W Baird
- Department of Cardiac Surgery, Children's Hospital Boston and Harvard Medical School, Boston, USA
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Finite element modeling of mitral valve dynamic deformation using patient-specific multi-slices computed tomography scans. Ann Biomed Eng 2012; 41:142-53. [PMID: 22805982 DOI: 10.1007/s10439-012-0620-6] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Accepted: 07/05/2012] [Indexed: 10/28/2022]
Abstract
The objective of this study was to develop a patient-specific finite element (FE) model of a human mitral valve. The geometry of the mitral valve was reconstructed from multi-slice computed tomography (MSCT) scans at middle diastole with distinguishable mitral leaflet thickness, chordal origins, chordal insertion points, and papillary muscle locations. Mitral annulus and papillary muscle dynamic motions were also quantified from MSCT scans and prescribed as boundary conditions for the FE simulation. Material properties of the human mitral leaflet tissues were obtained from biaxial tests and characterized by an anisotropic hyperelastic material model. In vivo dynamic closing of the mitral valve was simulated. The closed shape of the mitral valve output from the simulation was similar to the mitral valve geometry reconstructed from MSCT images at middle systole. Forces from the anterolateral and posteromedial papillary muscle groups at middle systole were 4.51 N and 5.17 N, respectively. The average maximum principal stress of the midsection of the anterior mitral leaflet was approximately 160 kPa at the systolic peak. Results demonstrated that the developed FE model could closely replicate in vivo mitral valve dynamic motion during middle diastole and systole. This model may serve as a basis for utilizing computational simulations to obtain a better understanding of mitral valve mechanics, disease and surgical repair.
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Jassar AS, Minakawa M, Shuto T, Robb JD, Koomalsingh KJ, Levack MM, Vergnat M, Eperjesi TJ, Jackson BM, Gorman JH, Gorman RC. Posterior leaflet augmentation in ischemic mitral regurgitation increases leaflet coaptation and mobility. Ann Thorac Surg 2012; 94:1438-45. [PMID: 22795059 DOI: 10.1016/j.athoracsur.2012.05.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Revised: 05/02/2012] [Accepted: 05/03/2012] [Indexed: 01/09/2023]
Abstract
BACKGROUND Restoring leaflet coaptation is the primary objective in repair of ischemic mitral regurgitation (IMR). The common practice of placing an undersized annuloplasty ring partially achieves this goal by correcting annular dilation; however, annular reduction has been demonstrated to exacerbate posterior leaflet tethering. Using a sheep model of IMR, we tested the hypothesis that posterior leaflet augmentation (PLA) combined with standard annuloplasty sizing increases leaflet coaptation more effectively than undersized annuloplasty alone. METHODS Eight weeks after posterobasal myocardial infarction, 15 sheep with 2+ or greater IMR underwent annuloplasty with either a 24-mm annuloplasty ring (24-mm group, n = 5), 30-mm ring (30-mm group, n = 5), or 30-mm ring with concomitant augmentation of the posterior leaflet (PLA group, n = 5). Using three-dimensional echocardiography, postrepair coaptation zone and posterior leaflet mobility were assessed. RESULTS Leaflet coaptation length after repair was greater in the PLA group (4.1 ± 0.3 mm) and the 24-mm group (3.8 ± 0.5 mm) as compared with the 30-mm group (2.7 ± 0.6 mm, p < 0.01). Leaflet coaptation area was significantly greater in the PLA group (121.5 ± 6.6 mm(2)) as compared with the 30-mm group (77.5 ± 17.0 mm(2)) or the 24-mm group (92.5 ± 17.9 mm(2), p < 0.01). Posterior leaflet mobility was significantly greater in the PLA group as compared with the 30-mm group or the 24-mm group. CONCLUSIONS Posterior leaflet augmentation combined with standard-sized annuloplasty enhances leaflet coaptation more effectively than either standard-sized annuloplasty or undersized annuloplasty alone. Increased leaflet coaptation after PLA provides redundancy to IMR repair, and may decrease incidence of both recurrent IMR and mitral stenosis.
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Affiliation(s)
- Arminder S Jassar
- Department of Surgery, University of Pennsylvania, Philadelphia, PA 19036, USA
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Greenhouse DG, Dellis SL, Schwartz CF, Loulmet DF, Yaffee DW, Galloway AC, Grossi EA. Regional changes in coaptation geometry after reduction annuloplasty for functional mitral regurgitation. Ann Thorac Surg 2012; 93:1876-80. [PMID: 22542067 DOI: 10.1016/j.athoracsur.2012.02.066] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2011] [Revised: 02/16/2012] [Accepted: 02/20/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND While it is known that band annuloplasty for functional mitral regurgitation (FMR) improves leaflet coaptation, the effect on regional coaptation geometry has not previously been well defined. We used three-dimensional transesophageal echocardiography (3D-TEE) to analyze the regional effects of semirigid band annuloplasty on annular geometry and leaflet coaptation zones of patients with FMR. METHODS Sixteen patients with severe FMR underwent a semirigid band annuloplasty. Intraoperative full volume 3D-TEE datasets were acquired pre valve and post valve repair. Offline analysis assessed annular dimensions and regional coaptation zone geometry. The regions were defined as R1 (A1-P1), R2 (A2-P2), and R3 (A3-P3); coaptation distance, coaptation depth, and coaptation length were measured in each region. Differences were analyzed with repeated measures within a general linear model. RESULTS Band annuloplasty decreased mitral regurgitation grade from 3.7 to 0.1 (scale 0 to 4). Annular septolateral dimension (p<0.01) and coaptation distance (p<0.01) decreased significantly in all regions. Likewise, anterior and posterior leaflet coaptation lengths increased in all regions (p<0.01 and p=0.05, respectively), with region 2 showing the greatest increase (p=0.01). Changes in coaptation depth were not significant. CONCLUSIONS Semirigid band annuloplasty for FMR produces significant regional remodeling of leaflet coaptation zones, with region 2 showing the greatest increase in leaflet coaptation length. This regional analysis of annular geometry and leaflet coaptation creates a framework to better understand the mechanisms of surgical success or failure of annuloplasty for FMR.
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Affiliation(s)
- David G Greenhouse
- Department of Cardiothoracic Surgery, New York University School of Medicine, New York, New York 10016, USA
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Influence of Chronic Tethering of the Mitral Valve on Mitral Leaflet Size and Coaptation in Functional Mitral Regurgitation. JACC Cardiovasc Imaging 2012; 5:337-45. [DOI: 10.1016/j.jcmg.2011.10.004] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2011] [Revised: 09/28/2011] [Accepted: 10/11/2011] [Indexed: 11/18/2022]
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Grossi EA, Galloway AC. Impact of annuloplasty device aggressiveness on leaflet coaptation. Ann Thorac Surg 2012; 93:1020-1; author reply 1021. [PMID: 22365010 DOI: 10.1016/j.athoracsur.2011.10.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Revised: 10/11/2011] [Accepted: 10/18/2011] [Indexed: 11/19/2022]
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Vergnat M, Jackson BM, Cheung AT, Weiss SJ, Ratcliffe SJ, Gillespie MJ, Woo YJ, Bavaria JE, Acker MA, Gorman RC, Gorman JH. Saddle-shape annuloplasty increases mitral leaflet coaptation after repair for flail posterior leaflet. Ann Thorac Surg 2011; 92:797-803. [PMID: 21803330 DOI: 10.1016/j.athoracsur.2011.04.047] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2011] [Revised: 04/05/2011] [Accepted: 04/07/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND The primary goal of surgical mitral repair is the reestablishment of normal leaflet coaptation. Surgical techniques that maintain or restore leaflet geometry promote leaflet coaptation. Recent 3-dimensional (3D) echocardiographic studies have shown that saddle-shaped annuloplasty has a salutary influence on leaflet geometry. Therefore we hypothesized that saddle-shaped annuloplasty would improve leaflet coaptation in cases of repair for flail posterior leaflet segments. METHODS Sixteen patients with flail posterior segment and severe mitral regurgitation had valve repair using standard techniques. Eight patients received saddle-shaped annuloplasty and 8 patients received flat annuloplasty. Real-time 3D transesophageal echocardiography was performed before and after repair. Images were analyzed using custom software to calculate mitral annular area (MAA), septolateral dimension (SLD), intercommissural width (CW), total leaflet area (TLA), and leaflet coaptation area (LCA). RESULTS Postrepair MAA (flat, 588.6±26.5 mm2; saddle, 628.0±35.3 mm2; p=0.12) and TLA (flat, 2198.5±151.6 mm2; saddle, 2303.9±183.8 mm2; p=0.67) were similar in both groups. Postrepair LCA was significantly greater in the saddle group than in the flat group (226.8±24.0 mm2 and 154.0±13.0 mm2, respectively; p=0.02). CONCLUSIONS Real-time 3D echocardiography and novel imaging software provide a powerful tool for analyzing mitral leaflet coaptation. When compared with flat annuloplasty, saddle-shaped annuloplasty improves LCA after mitral valve repair for severe mitral regurgitation secondary to flail posterior leaflet segment. Use of saddle-shaped annuloplasty devices may increase repair durability.
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Affiliation(s)
- Mathieu Vergnat
- Gorman Cardiovascular Research Group, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Shin H, Mori M, Yamabe K, Iwanaga S. Reconstruction of the free margin of the anterior mitral leaflet with autologous pericardium in active infected endocarditis. Eur J Cardiothorac Surg 2011; 39:784-5. [PMID: 20932770 DOI: 10.1016/j.ejcts.2010.08.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2010] [Revised: 08/13/2010] [Accepted: 08/25/2010] [Indexed: 10/19/2022] Open
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