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Ito C, Kohno H, Matsuura K, Watanabe M, Inui T, Matsumiya G. Mid-term outcomes of right ventricular papillary muscle approximation for severe functional tricuspid regurgitation. Eur J Cardiothorac Surg 2024; 65:ezae151. [PMID: 38603618 DOI: 10.1093/ejcts/ezae151] [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: 09/19/2023] [Revised: 03/27/2024] [Accepted: 04/10/2024] [Indexed: 04/13/2024] Open
Abstract
OBJECTIVES Recurrence of tricuspid regurgitation (TR) after tricuspid annuloplasty can occur in cases where a dilated right ventricle exists and subsequent leaflet tethering follows. We previously reported a new technique of the right ventricular papillary muscle approximation (RV-PMA) for functional TR associated with leaflet tethering. The objective of this study is to elucidate the mid-term outcomes and evaluate the durability of RV-PMA. METHODS Between January 2014 and March 2023, we applied RV-PMA in 20 patients of advanced functional TR with severe leaflet tethering. The indication of the technique was severe TR with leaflet tethering height >8 mm, and/or a right ventricular end-diastolic diameter >45 mm. The patients were followed up with echocardiography before discharge and at annual interval thereafter. RESULTS There was no perioperative mortality. In the echocardiography performed before discharge, TR was decreased to mild or less in 85%, and a significant improvement in right ventricular end-diastolic diameter and tethering height were achieved (53-45 mm and 11.1-4.4 mm, respectively). Furthermore, during the median 3-year follow-up period, TR was kept controlled mild or less in 80% of the cases. CONCLUSIONS RV-PMA is considered to be a safe, effective and durable technique as an additional approach for tricuspid annuloplasty.
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Affiliation(s)
- Chihiro Ito
- Department of Cardiovascular Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Hiroki Kohno
- Department of Cardiovascular Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Kaoru Matsuura
- Department of Cardiovascular Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Michiko Watanabe
- Department of Cardiovascular Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Tomohiko Inui
- Department of Cardiovascular Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Goro Matsumiya
- Department of Cardiovascular Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
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Takada J, Morimura H, Hamada K, Okamoto Y, Mineta S, Tsuboko Y, Hattori K, Iwasaki K. A tissue-silicone integrated simulator for right ventricular pulsatile circulation with severe functional tricuspid regurgitation. Sci Rep 2024; 14:5120. [PMID: 38429438 PMCID: PMC10907752 DOI: 10.1038/s41598-024-55058-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 02/20/2024] [Indexed: 03/03/2024] Open
Abstract
There is a great demand for development of a functional tricuspid regurgitation (FTR) model for accelerating development and preclinical study of tricuspid interventional repair devices. This study aimed to develop a severe FTR model by creating a tissue-silicone integrated right ventricular pulsatile circulatory simulator. The simulator incorporates the porcine tricuspid annulus, valve leaflets, chordae tendineae, papillary muscles, and right ventricular wall as one continuous piece of tissue, thereby preserving essential anatomical relationships of the tricuspid valve (TV) complex. We dilated the TV annulus with collagenolytic enzymes under applying stepwise dilation, and successfully achieved a severe FTR model with a regurgitant volume of 45 ± 9 mL/beat and a flow jet area of 15.8 ± 2.3 cm2 (n = 6). Compared to a normal model, the severe FTR model exhibited a larger annular circumference (133.1 ± 8.2 mm vs. 115.7 ± 5.5 mm; p = 0.009) and lower coaptation height (6.6 ± 1.0 mm vs. 17.7 ± 1.3 mm; p = 0.003). Following the De-Vega annular augmentation procedure to the severe FTR model, a significant reduction in regurgitant volume and flow jet area were observed. This severe FTR model may open new avenues for the development and evaluation of transcatheter TV devices.
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Affiliation(s)
- Jumpei Takada
- Department of Modern Mechanical Engineering, School of Creative Science and Engineering, Waseda University, Tokyo, Japan
- Department of Integrative Bioscience and Biomedical Engineering, Graduate School of Advanced Science and Engineering, Waseda University, Tokyo, Japan
| | - Hayato Morimura
- Cooperative Major in Advanced Biomedical Sciences, Joint Graduate School of Tokyo Women's Medical University and Waseda University, Waseda University, Tokyo, Japan
- Waseda Research Institute for Science and Engineering, Waseda University, Tokyo, Japan
| | - Kohei Hamada
- Department of Integrative Bioscience and Biomedical Engineering, Graduate School of Advanced Science and Engineering, Waseda University, Tokyo, Japan
| | - Yusei Okamoto
- Department of Modern Mechanical Engineering, Graduate School of Creative Science and Engineering, Waseda University, Tokyo, Japan
| | - Shiho Mineta
- Department of Integrative Bioscience and Biomedical Engineering, Graduate School of Advanced Science and Engineering, Waseda University, Tokyo, Japan
| | - Yusuke Tsuboko
- Waseda Research Institute for Science and Engineering, Waseda University, Tokyo, Japan
| | - Kaoru Hattori
- Department of Integrative Bioscience and Biomedical Engineering, Graduate School of Advanced Science and Engineering, Waseda University, Tokyo, Japan
- Institute for Medical Regulatory Science, Waseda University, Tokyo, Japan
| | - Kiyotaka Iwasaki
- Department of Modern Mechanical Engineering, School of Creative Science and Engineering, Waseda University, Tokyo, Japan.
- Department of Integrative Bioscience and Biomedical Engineering, Graduate School of Advanced Science and Engineering, Waseda University, Tokyo, Japan.
- Cooperative Major in Advanced Biomedical Sciences, Joint Graduate School of Tokyo Women's Medical University and Waseda University, Waseda University, Tokyo, Japan.
- Waseda Research Institute for Science and Engineering, Waseda University, Tokyo, Japan.
- Department of Modern Mechanical Engineering, Graduate School of Creative Science and Engineering, Waseda University, Tokyo, Japan.
- Institute for Medical Regulatory Science, Waseda University, Tokyo, Japan.
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Salurso E, Jaworek M, Perico F, Frigelli M, Romagnoni C, Contino M, Gelpi G, Fiore GB, Vismara R. Morphometric Characterization of an Ex Vivo Porcine Model of Functional Tricuspid Regurgitation. Ann Biomed Eng 2023; 51:715-725. [PMID: 36151505 PMCID: PMC10023622 DOI: 10.1007/s10439-022-03080-2] [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: 04/12/2022] [Accepted: 09/07/2022] [Indexed: 11/01/2022]
Abstract
Emerging treatments for tricuspid valve (TV) regurgitation require realistic TV pathological models for preclinical testing. The aim of this work was to investigate structural features of fresh and defrosted porcine right-heart samples as models of mild and severe functional tricuspid regurgitation (FTR) condition in ex-vivo pulsatile flow platform. Ten fresh hearts were tested ex-vivo under steady and pulsatile flow in typical right-heart loading conditions. Hemodynamics and 3D echocardiographic imaging of TV and right ventricle (RV) were acquired. Hearts were then kept frozen for 14 days, defrosted, and tested again with the same protocol. Morphometric parameters of TV and RV were derived from 3D reconstructions based on echo data. Fresh samples showed a slightly dilated TV morphology, with coaptation gaps among the leaflets. Sample freezing induced worsening of TV insufficiency, with significant (p < 0.05) increases in annulus size (annulus area and perimeter 7.7-3.1% respectively) and dilation of RV (9.5%), which led to an increase in tenting volume (123.7%). These morphologic alterations reflected into a significant increment of regurgitation fraction (27%). Together, such results suggest that fresh porcine heart samples may be a reliable ex-vivo model of mild FTR condition, which can be enhanced through freezing/thawing treatment to model a severe pathological condition.
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Affiliation(s)
- Eleonora Salurso
- 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.
| | - 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
| | - Francesca Perico
- 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
| | - Matteo Frigelli
- 3D and Computer Simulation Laboratory, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Claudia Romagnoni
- ForcardioLab - Fondazione per la Ricerca in Cardiochirurgia ONLUS, Milan, Italy
- Cardiovascular Surgery Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Monica Contino
- ForcardioLab - Fondazione per la Ricerca in Cardiochirurgia ONLUS, Milan, Italy
- Cardiovascular Surgery Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Guido Gelpi
- ForcardioLab - Fondazione per la Ricerca in Cardiochirurgia ONLUS, Milan, Italy
- Cardiovascular Surgery Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico 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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Xu KW, Gao Q, Wan M, Zhang K. Mock circulatory loop applications for testing cardiovascular assist devices and in vitro studies. Front Physiol 2023; 14:1175919. [PMID: 37123281 PMCID: PMC10133581 DOI: 10.3389/fphys.2023.1175919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 04/03/2023] [Indexed: 05/02/2023] Open
Abstract
The mock circulatory loop (MCL) is an in vitro experimental system that can provide continuous pulsatile flows and simulate different physiological or pathological parameters of the human circulation system. It is of great significance for testing cardiovascular assist device (CAD), which is a type of clinical instrument used to treat cardiovascular disease and alleviate the dilemma of insufficient donor hearts. The MCL installed with different types of CADs can simulate specific conditions of clinical surgery for evaluating the effectiveness and reliability of those CADs under the repeated performance tests and reliability tests. Also, patient-specific cardiovascular models can be employed in the circulation of MCL for targeted pathological study associated with hemodynamics. Therefore, The MCL system has various combinations of different functional units according to its richful applications, which are comprehensively reviewed in the current work. Four types of CADs including prosthetic heart valve (PHV), ventricular assist device (VAD), total artificial heart (TAH) and intra-aortic balloon pump (IABP) applied in MCL experiments are documented and compared in detail. Moreover, MCLs with more complicated structures for achieving advanced functions are further introduced, such as MCL for the pediatric application, MCL with anatomical phantoms and MCL synchronizing multiple circulation systems. By reviewing the constructions and functions of available MCLs, the features of MCLs for different applications are summarized, and directions of developing the MCLs are suggested.
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Affiliation(s)
- Ke-Wei Xu
- Department of Engineering Mechanics, School of Aeronautics and Astronautics, Zhejiang University, Hangzhou, China
| | - Qi Gao
- Department of Engineering Mechanics, School of Aeronautics and Astronautics, Zhejiang University, Hangzhou, China
- *Correspondence: Qi Gao,
| | - Min Wan
- Shandong Institute of Medical Device and Pharmaceutical Packaging Inspection, Jinan, China
| | - Ke Zhang
- Shandong Institute of Medical Device and Pharmaceutical Packaging Inspection, Jinan, China
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Schiavone NK, Elkins CJ, McElhinney DB, Eaton JK, Marsden AL. In Vitro Assessment of Right Ventricular Outflow Tract Anatomy and Valve Orientation Effects on Bioprosthetic Pulmonary Valve Hemodynamics. Cardiovasc Eng Technol 2021; 12:215-231. [PMID: 33452649 DOI: 10.1007/s13239-020-00507-6] [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: 02/18/2020] [Accepted: 12/02/2020] [Indexed: 01/30/2023]
Abstract
PURPOSE The congenital heart defect Tetralogy of Fallot (ToF) affects 1 in 2500 newborns annually in the US and typically requires surgical repair of the right ventricular outflow tract (RVOT) early in life, with variations in surgical technique leading to large disparities in RVOT anatomy among patients. Subsequently, often in adolescence or early adulthood, patients usually require surgical placement of a xenograft or allograft pulmonary valve prosthesis. Valve longevity is highly variable for reasons that remain poorly understood. METHODS This work aims to assess the performance of bioprosthetic pulmonary valves in vitro using two 3D printed geometries: an idealized case based on healthy subjects aged 11 to 13 years and a diseased case with a 150% dilation in vessel diameter downstream of the valve. Each geometry was studied with two valve orientations: one with a valve leaflet opening posterior, which is the native pulmonary valve position, and one with a valve leaflet opening anterior. RESULTS Full three-dimensional, three-component, phase-averaged velocity fields were obtained in the physiological models using 4D flow MRI. Flow features, particularly vortex formation and reversed flow regions, differed significantly between the RVOT geometries and valve orientations. Pronounced asymmetry in streamwise velocity was present in all cases, while the diseased geometry produced additional asymmetry in radial flows. Quantitative integral metrics demonstrated increased secondary flow strength and recirculation in the rotated orientation for the diseased geometry. CONCLUSIONS The compound effects of geometry and orientation on bioprosthetic valve hemodynamics illustrated in this study could have a crucial impact on long-term valve performance.
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Affiliation(s)
| | | | | | - John K Eaton
- Mechanical Engineering, Stanford University, Stanford, CA, USA
| | - Alison L Marsden
- Pediatrics and Bioengineering, Stanford University, Stanford, CA, USA.
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Nguyen YN, Tay ELW, Kabinejadian F, Ong CW, Ismail M, Leo HL. Ventricular vortex loss analysis due to various tricuspid valve repair techniques: an ex vivo study. Am J Physiol Heart Circ Physiol 2019; 317:H1312-H1327. [PMID: 31603355 DOI: 10.1152/ajpheart.00150.2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The deteriorating nature of severe functional tricuspid regurgitation (FTR) has led to the heightened interest in this pathology. However, therapies are heterogeneous and an ideal technique is uncertain. The hemodynamic impact on the cardiac chamber following therapeutic repairs has not been well studied, while its analysis could be used to predict the treatment success. In this study, the hemodynamics of the right ventricle (RV) after 1) clover edge-to-edge tricuspid repair, and 2) double orifice tricuspid repair was evaluated in three right heart models using an ex vivo pulsatile platform emulating severe FTR with the aid of stereoscopic particle image velocimetry. Although all repairs substantially reduced tricuspid regurgitant area, they resulted in a more than 50% reduction in diastolic tricuspid valve (TV) opening area. Splitting the TV orifice into multiple smaller orifices by both repairs eliminated the ring-shaped vortical structure inside the RV observed in FTR cases. Postrepair RV domain was mostly occupied with irregular vortical features and isolated vortex residuals. Moreover, vortical features varied among repair samples, indicating enhanced sensitivity of RV flow to postrepair TV morphology. Compared with clover repair, double orifice subjected the RV to enhanced swirling motions and exposed more regions to vortical motions, potentially indicating better rinsing and lower risk of mural thrombus formation. Double orifice repair increased the levels of RV mean kinetic energy and viscous energy loss than those observed in clover repair, although the impact of these on the cardiac efficiency remains unclear. These preliminary insights could be used to improve future treatment design and planning.NEW & NOTEWORTHY While clover and double orifice tricuspid repairs markedly improved leaflet coaptation, they substantially reduced diastolic tricuspid opening area. Postrepair right ventricle (RV) exhibited specific hemodynamic traits, including the loss of ring-shaped vortical structure and the enhanced sensitivity of RV flow to postrepair tricuspid valve morphology. Compared with clover technique, double orifice repair led to higher swirling motions in the RV domain, which could indicate lower risk of mural thrombus formation.
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Affiliation(s)
- Yen Ngoc Nguyen
- Department of Biomedical Engineering, National University of Singapore, Singapore
| | - Edgar Lik Wui Tay
- Department of Cardiology, National University Heart Centre, Singapore
| | - Foad Kabinejadian
- Department of Biomedical Engineering, Tulane University, New Orleans, Louisiana
| | - Chi Wei Ong
- Department of Biomedical Engineering, National University of Singapore, Singapore
| | - Munirah Ismail
- School of Mechanical and Aerospace Engineering, Nanyang Technological University, Singapore
| | - Hwa Liang Leo
- Department of Biomedical Engineering, National University of Singapore, Singapore.,Graduate School for Integrative Sciences and Engineering, National University of Singapore, Singapore
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Ex vivo assessment of bicuspidization repair in treating severe functional tricuspid regurgitation: a stereo-scopic PIV study. Sci Rep 2019; 9:11504. [PMID: 31395907 PMCID: PMC6687742 DOI: 10.1038/s41598-019-47873-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 06/24/2019] [Indexed: 11/22/2022] Open
Abstract
There has been a resurgence of interest in the treatment of severe functional tricuspid regurgitation (FTR) due to the awareness of its poor outcomes and potential percutaneous therapies. Kay bicuspidization has been adapted in percutaneous therapies but its clinical outcome remains uncertain. The present study evaluates the efficacy of Kay repair in a novel ex vivo pulsatile system. Porcine tricuspid valve (TV) (n = 3) was extracted and incorporated into a patient-specific silicon right ventricle (RV) emulating severe FTR, on which Kay repair was subsequently performed. TV area metrics and RV hemodynamic assessment by means of stereo-scopic particle image velocimetry were quantified in both FTR and post-repair conditions. Bicuspidization led to significant increase in cardiac output although the overall increment due to this approach alone was generally small, possibly due to existence of residual TR and the large reduction in TV opening area. Kinetic energy and viscous loss levels were increased post-repair, especially during diastolic filling. Main vortex structures generally maintained post-procedural. However, there was enhanced swirling motion in larger RV domain. Although this might reduce mural-thrombus risk, the relatively more complex vortex phenomenon likely resulted in elevated viscous loss observed and may potentially impact long-term adaptation. The RV hemodynamic alteration after tricuspid repair could be used to predict the success of these future transcatheter solutions.
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