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For: Paulsen MJ, Cuartas MM, Imbrie-Moore A, Wang H, Wilkerson R, Farry J, Zhu Y, Ma M, MacArthur JW, Woo YJ. Biomechanical engineering comparison of four leaflet repair techniques for mitral regurgitation using a novel 3-dimensional-printed left heart simulator. JTCVS Tech 2021;10:244-51. [PMID: 34977730 DOI: 10.1016/j.xjtc.2021.09.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 09/24/2021] [Indexed: 01/05/2023] Open

For:	Paulsen MJ, Cuartas MM, Imbrie-Moore A, Wang H, Wilkerson R, Farry J, Zhu Y, Ma M, MacArthur JW, Woo YJ. Biomechanical engineering comparison of four leaflet repair techniques for mitral regurgitation using a novel 3-dimensional-printed left heart simulator. JTCVS Tech 2021;10:244-51. [PMID: 34977730 DOI: 10.1016/j.xjtc.2021.09.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 09/24/2021] [Indexed: 01/05/2023] Open

Number

Cited by Other Article(s)

Zhu Y, Yajima S, Park MH, Venkatesh A, Stark CJ, Tran NA, Walsh SK, Ethiraj S, Wilkerson RJ, Lin LE, Lee SH, Gates KY, Arthur JD, Baker SW, Mullis DM, Wu CA, Harima S, Pokhrel B, Resuello D, Bergamasco H, Wu MA, Baccouche BM, Pandya PK, Elde S, Wang H, Woo YJ. Large Animal Translational Validation of 3 Mitral Valve Repair Operations for Mitral Regurgitation Using a Mitral Valve Prolapse Model: A Comprehensive In Vivo Biomechanical Engineering Analysis. Circ Cardiovasc Interv 2024;17:e013196. [PMID: 38626077 DOI: 10.1161/circinterventions.123.013196] [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: 04/22/2023] [Accepted: 01/19/2024] [Indexed: 04/18/2024]

Abstract

BACKGROUND

Various mitral repair techniques have been described. Though these repair techniques can be highly effective when performed correctly in suitable patients, limited quantitative biomechanical data are available. Validation and thorough biomechanical evaluation of these repair techniques from translational large animal in vivo studies in a standardized, translatable fashion are lacking. We sought to evaluate and validate biomechanical differences among different mitral repair techniques and further optimize repair operations using a large animal mitral valve prolapse model.

METHODS

Male Dorset sheep (n=20) had P2 chordae severed to create the mitral valve prolapse model. Fiber Bragg grating force sensors were implanted to measure chordal forces. Ten sheep underwent 3 randomized, paired mitral valve repair operations: neochord repair, nonresectional leaflet remodeling, and triangular resection. The other 10 sheep underwent neochord repair with 2, 4, and 6 neochordae. Data were collected at baseline, mitral valve prolapse, and after each repair.

RESULTS

All mitral repair techniques successfully eliminated regurgitation. Compared with mitral valve prolapse (0.54±0.18 N), repair using neochord (0.37±0.20 N; P=0.02) and remodeling techniques (0.30±0.15 N; P=0.001) reduced secondary chordae peak force. Neochord repair further decreased primary chordae peak force (0.21±0.14 N) to baseline levels (0.20±0.17 N; P=0.83), and was associated with lower primary chordae peak force compared with the remodeling (0.34±0.18 N; P=0.02) and triangular resectional techniques (0.36±0.27 N; P=0.03). Specifically, repair using 2 neochordae resulted in higher peak primary chordal forces (0.28±0.21 N) compared with those using 4 (0.22±0.16 N; P=0.02) or 6 neochordae (0.19±0.16 N; P=0.002). No difference in peak primary chordal forces was observed between 4 and 6 neochordae (P=0.05). Peak forces on the neochordae were the lowest using 6 neochordae (0.09±0.11 N) compared with those of 4 neochordae (0.15±0.14 N; P=0.01) and 2 neochordae (0.29±0.18 N; P=0.001).

CONCLUSIONS

Significant biomechanical differences were observed underlying different mitral repair techniques in a translational large animal model. Neochord repair was associated with the lowest primary chordae peak force compared to the remodeling and triangular resectional techniques. Additionally, neochord repair using at least 4 neochordae was associated with lower chordal forces on the primary chordae and the neochordae. This study provided key insights about mitral valve repair optimization and may further improve repair durability.

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Affiliation(s)

Yuanjia Zhu Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA Department of Bioengineering (Y.Z., Y.J.W.), Stanford University, CA
Shin Yajima Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA
Matthew H Park Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA Department of Mechanical Engineering (M.H.P., P.K.P.), Stanford University, CA
Akshay Venkatesh Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA
Charles J Stark Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA
Nicholas A Tran Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA
Sabrina K Walsh Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA
Sidarth Ethiraj Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA
Robert J Wilkerson Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA
Luca E Lin Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA
Seung Hyun Lee Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA
Kate Y Gates Department of Comparative Medicine (K.Y.G., J.D.A., S.W.B.), Stanford University, CA
Justin D Arthur Department of Comparative Medicine (K.Y.G., J.D.A., S.W.B.), Stanford University, CA
Sam W Baker Department of Comparative Medicine (K.Y.G., J.D.A., S.W.B.), Stanford University, CA
Danielle M Mullis Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA
Catherine A Wu Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA
Shun Harima Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA
Bipul Pokhrel Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA
Dominique Resuello Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA
Hunter Bergamasco Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA
Matthew A Wu Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA
Basil M Baccouche Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA
Pearly K Pandya Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA Department of Mechanical Engineering (M.H.P., P.K.P.), Stanford University, CA
Stefan Elde Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA
Hanjay Wang Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA
Y Joseph Woo Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA Department of Bioengineering (Y.Z., Y.J.W.), Stanford University, CA

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Zhu Y, Lee SH, Venkatesh A, Wu CA, Stark CJ, Ethiraj S, Lee JJ, Park MH, Yajima S, Woo YJ. Biomechanical engineering analysis of neochordae length's impact on chordal forces in mitral repair. Eur J Cardiothorac Surg 2024;65:ezae008. [PMID: 38258541 DOI: 10.1093/ejcts/ezae008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 12/20/2023] [Accepted: 01/17/2024] [Indexed: 01/24/2024] Open

van Kampen A, Morningstar JE, Goudot G, Ingels N, Wenk JF, Nagata Y, Yaghoubian KM, Norris RA, Borger MA, Melnitchouk S, Levine RA, Jensen MO. Utilization of Engineering Advances for Detailed Biomechanical Characterization of the Mitral-Ventricular Relationship to Optimize Repair Strategies: A Comprehensive Review. Bioengineering (Basel) 2023;10:601. [PMID: 37237671 PMCID: PMC10215167 DOI: 10.3390/bioengineering10050601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/10/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023] Open

Zhu Y, Imbrie-Moore AM, Wilkerson RJ, Paulsen MJ, Park MH, Woo YJ. Ex vivo biomechanical analysis of flexible versus rigid annuloplasty rings in mitral valves using a novel annular dilation system. BMC Cardiovasc Disord 2022;22:73. [PMID: 35219298 PMCID: PMC8882272 DOI: 10.1186/s12872-022-02515-x] [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: 05/28/2021] [Accepted: 02/07/2022] [Indexed: 12/04/2022] Open

Abstract

Background

Mitral annuloplasty rings restore annular dimensions to increase leaflet coaptation, serving a fundamental component in mitral valve repair. However, biomechanical evaluations of annuloplasty rings are lacking. We aim to biomechanically analyze flexible and rigid annuloplasty rings using an ex vivo mitral annular dilation model.

Methods

Juvenile porcine mitral valves (n = 4) with intercommissural distance of 28 mm were dilated to intercommissural distances of 40 mm using a 3D-printed dilator and were sewn to an elastic mount. Fiber bragg grating sensors were anchored to native chordae to measure chordal forces. The valves were repaired using size 28 rigid and flexible annuloplasty rings in a random order. Hemodynamic data, echocardiography, and chordal force measurements were collected.

Results

Mitral annular dilation resulted in decreased leaflet coaptation height and increased mitral regurgitation fraction. Both the flexible and rigid annuloplasty rings effectively increased leaflet coaptation height compared to that post dilation. Rigid ring annuloplasty repair significantly decreased the mitral regurgitation fraction. Flexible annuloplasty ring repair reduced the chordal rate of change of force (7.1 ± 4.4 N/s versus 8.6 ± 5.9 N/s, p = 0.02) and peak force (0.6 ± 0.5 N versus 0.7 ± 0.6 N, p = 0.01) compared to that from post dilation. Rigid annuloplasty ring repair was associated with higher chordal rate of change of force (9.8 ± 5.8 N/s, p = 0.0001) and peak force (0.7 ± 0.5 N, p = 0.01) compared to that after flexible ring annuloplasty repair.

Conclusions

Both rigid and flexible annuloplasty rings are effective in increasing mitral leaflet coaptation height. Although the rigid annuloplasty ring was associated with slightly higher chordal stress compared to that of the flexible annuloplasty ring, it was more effective in mitral regurgitation reduction. This study may help direct the design of an optimal annuloplasty ring to further improve patient outcomes.

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