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Jedrzejczyk JH, Krog S, Skov SN, Poulsen KB, Sharghbin M, Benhassen LL, Nielsen SL, Hasenkam JM, Tjørnild MJ. Entire Mitral Valve Reconstruction Using Porcine Extracellular Matrix: Adding a Ring Annuloplasty. Cardiovasc Eng Technol 2024; 15:451-462. [PMID: 38504076 PMCID: PMC11319488 DOI: 10.1007/s13239-024-00727-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 03/10/2024] [Indexed: 03/21/2024]
Abstract
PURPOSE This study investigated the implications of inserting a flexible annuloplasty ring after reconstructing the entire mitral valve in a porcine model using a previously investigated tube graft design made of 2-ply small intestinal submucosa extracellular matrix (CorMatrix®). METHODS An acute model with eight 80-kg pigs, each acting as its own control, was used. The entire mitral valve was reconstructed with a 2-ply small intestinal submucosa extracellular matrix tube graft (CorMatrix®). Subsequently, a Simulus® flexible ring was inserted. The characterization was based on mitral annular geometry and valvular dynamics with sonomicrometry and echocardiography. RESULTS After adding the ring annuloplasty, the in-plane annular dynamics were more constant throughout the cardiac cycle compared to the reconstruction alone. However, the commissure-commissure distance was statistically significantly decreased [35.0 ± 3.4 mm vs. 27.4 ± 1.9 mm, P < 0.001, diff = - 7.6 mm, 95% CI, - 9.8 to (-5.4) mm] after ring insertion, changing the physiological annular D-shape into a circular shape which created folds at the coaptation zone resulting in a central regurgitant jet on color Doppler. CONCLUSION We successfully reconstructed the entire mitral valve using 2-ply small intestinal submucosal extracellular matrix (CorMatrix®) combined with a flexible annuloplasty. The annuloplasty reduced the unphysiological systolic widening previously found with this reconstructive technique. However, the Simulus flex ring changed the physiological annular D-shape into a circular shape and hindered a correct unfolding of the leaflets. Thus, we do not recommend a flexible ring in conjunction with this reconstructive technique; further investigations are needed to discover a more suitable remodelling annuloplasty.
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Affiliation(s)
- Johannes H Jedrzejczyk
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Århus, Denmark.
- Department of Clinical Medicine, Aarhus University Hospital, Århus, Denmark.
| | - Stine Krog
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Århus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Århus, Denmark
| | - Søren N Skov
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Århus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Århus, Denmark
| | - Karen B Poulsen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Århus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Århus, Denmark
| | - Mona Sharghbin
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Århus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Århus, Denmark
| | - Leila L Benhassen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Århus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Århus, Denmark
| | - Sten L Nielsen
- Department of Clinical Medicine, Aarhus University Hospital, Århus, Denmark
| | - J Michael Hasenkam
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Århus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Århus, Denmark
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
| | - Marcell J Tjørnild
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Århus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Århus, Denmark
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Salavitabar A, Armstrong AK, Carrillo SA. Hybrid Interventions in Congenital Heart Disease. Interv Cardiol Clin 2024; 13:399-408. [PMID: 38839172 DOI: 10.1016/j.iccl.2024.02.005] [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: 06/07/2024]
Abstract
Hybrid interventions in congenital heart disease (CHD) embody the inherent collaboration between congenital interventional cardiology and cardiothoracic surgery. Hybrid approaches to complex and common lesions provide the opportunity to circumvent the limitations of patient size, vascular access, severity of illness, and anatomy that would otherwise be prohibitive to surgical and percutaneous techniques alone. This review describes several important hybrid approaches to interventions in CHD.
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Affiliation(s)
- Arash Salavitabar
- The Heart Center, Nationwide Children's Hospital, The Ohio State University College of Medicine, 700 Children's Drive, Columbus, OH 43205, USA.
| | - Aimee K Armstrong
- The Heart Center, Nationwide Children's Hospital, The Ohio State University College of Medicine, 700 Children's Drive, Columbus, OH 43205, USA
| | - Sergio A Carrillo
- The Heart Center, Nationwide Children's Hospital, The Ohio State University College of Medicine, 700 Children's Drive, Columbus, OH 43205, USA
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Abdelghani E, Cua CL, Giver J, Rodriguez V. Thrombosis Prevention and Anticoagulation Management in the Pediatric Patient with Congenital Heart Disease. Cardiol Ther 2021; 10:325-348. [PMID: 34184214 PMCID: PMC8555036 DOI: 10.1007/s40119-021-00228-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Indexed: 01/19/2023] Open
Abstract
Thrombosis is one of the most frequent complications affecting children with congenital heart disease (CHD). Palliative and reparative cardiac surgeries are some of the main players contributing to the thrombosis risk in this patient population. Additional risk factors related to the CHD itself (e.g., cardiac dysfunction, arrhythmias, and polycythemia in cyanotic cardiac disorders) can contribute to thrombogenicity alone or combined with other factors. Thrombotic complications have been recognized as a significant cause of morbidity and mortality in this patient population. Here, we provide an overview of the pathophysiology and risk factors for thrombosis as well as the indications for and use of different anticoagulation, antiplatelet, and thrombolytic agents. In addition, we describe some of most common thrombotic complications and their management in the pediatric CHD population.
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Affiliation(s)
- Eman Abdelghani
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University, Columbus, OH, USA
| | - Clifford L Cua
- Heart Center, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, USA. .,Department of Pediatrics, The Ohio State University, Columbus, OH, USA.
| | - Jean Giver
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University, Columbus, OH, USA
| | - Vilmarie Rodriguez
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University, Columbus, OH, USA
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Caldaroni F, Brizard CP, d'Udekem Y. Replacement of the Mitral Valve Under One Year of Age: Size Matters. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2021; 24:57-61. [PMID: 34116783 DOI: 10.1053/j.pcsu.2021.03.006] [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: 10/27/2020] [Revised: 03/17/2021] [Accepted: 03/19/2021] [Indexed: 11/11/2022]
Abstract
Surgical management of mitral valve disease in neonates and infants is challenging. When repair is no longer feasible, replacement may become inevitable, but should only be considered as an option of last resort due to the remarkably high rate of associated morbidity and mortality. Mechanical valves are the preferred choice in large annuli, while stented conduits seem promising in smaller ones. In patients with a preoperative mitral valve annulus equal or larger than 15-16 mm, an intra-annular placement of the smallest mechanical valve available should be attempted. In patients with smaller annuli, the placement of a stented valved conduit seems to display a lower mortality risk. Supra-annular implantation of prostheses should be reserved for exceptional cases and to those familiar with this technique because of the high rate of associated complications.
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Affiliation(s)
- Federica Caldaroni
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia
| | - Christian P Brizard
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia; Heart Research, Murdoch Children's Research Institute, Melbourne, Australia; Department of Paediatrics, The University of Melbourne, Melbourne, Australia
| | - Yves d'Udekem
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia; Heart Research, Murdoch Children's Research Institute, Melbourne, Australia; Department of Paediatrics, The University of Melbourne, Melbourne, Australia.
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Lehenbauer DG, Tweddell JS, Winlaw DS. Debate - Replacement of the Mitral Valve Under One Year of Age: Mechanical Valves Should Be Used. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2021; 24:44-56. [PMID: 34116782 DOI: 10.1053/j.pcsu.2021.03.005] [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: 10/08/2020] [Revised: 03/01/2021] [Accepted: 03/19/2021] [Indexed: 11/11/2022]
Abstract
This article reviews the literature, focusing on publications from the third millennium and the results of mitral valve replacement in children younger than 1 year of age. Special consideration has been given to neonatal and infant valve replacement to provide insights into valve choice and technique. Mitral valve replacement is an important topic because it carries the highest mortality and poorer long-term prognosis than any other valve replacement in children.
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Affiliation(s)
- David G Lehenbauer
- Heart Institute and Department of Surgery, and the Division of Cardiothoracic Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio.
| | - James S Tweddell
- Heart Institute and Department of Surgery, and the Division of Cardiothoracic Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David S Winlaw
- Heart Institute and Department of Surgery, and the Division of Cardiothoracic Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Chakraborty B, Wang H. Pathological Changes of Adult Mitral Valves after Failed CorMatrix ECM Repair. JOURNAL OF CLINICAL AND TRANSLATIONAL PATHOLOGY 2021; 1:9-15. [PMID: 34957472 PMCID: PMC8697744 DOI: 10.14218/jctp.2021.00009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND OBJECTIVES CorMatrix acts as a tissue scaffold and is intended to promote the proliferation of small vessels and tissue remodeling to replicate normal tissue function. METHODS At Temple University Hospital, Philadelphia, PA, USA from 2013 to 2016, CorMatrix material was utilized during mitral valve anterior leaflet augmentation repair in 25 adult patients, and four patients required repeat interventions at 4-12 months (8.25 ± 4.35 months) after the initial repair. This study evaluated the pathological changes in four patients. RESULTS Histological examination of the CorMatrix showed matrix degradation in all cases. At 4 months after repair, mixed acute and chronic inflammatory cells that included eosinophils were visible within the matrix, which was more severe around the suture material. Later, the extent of inflammation abated and became more chronic with macrophage dominance. Some macrophages and multinucleated cells were visible deep in the matrix. The neovascularization was limited to the tissue-matrix boundary at early time points; the more mature vessels with dilated lumens extended deeper into the matrix as time increased, combined with some elongated fibroblast-like cells. In addition, marked acute and chronic inflammation with neutrophil and eosinophil infiltrate was identified in the surrounding native tissue at 4 months, especially around the suture material. Marked granulomatous inflammation was identified in all cases, with prominent multinucleated giant cells present at later time points (50%). Immunohistochemical staining for CD68 and CD163 showed prominent M2 macrophages in the CorMatrix and surrounding tissue. CONCLUSIONS Our results demonstrated time-dependent changes in failed CorMatrix repaired valves after mitral valve repair, with macrophages and neovascularization in the matrix 12 months after the initial repair.
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Affiliation(s)
- Baidarbhi Chakraborty
- Department of Pathology and Laboratory Medicine, Temple University Hospital, Philadelphia, PA, USA
| | - He Wang
- Department of Pathology, Yale University School of Medicine, 310 Cedar Street, New Haven, CT, USA
- Correspondence to: He Wang, Department of Pathology, Yale University School of Medicine, 310 Cedar Street, New Haven, CT 06520, USA. Tel: +1-203-789-3707, Fax: +1-203-789-3710,
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