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La reparación de la válvula mitral patológica: una aventura multidisciplinar desde hace cien años. CIRUGIA CARDIOVASCULAR 2022. [DOI: 10.1016/j.circv.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Zhou Z, Gao B, Jing T, Wang S, Parameswaran S, He Z. How and where the mitral valve leaks in functional mitral regurgitation. MEDICINE IN NOVEL TECHNOLOGY AND DEVICES 2019. [DOI: 10.1016/j.medntd.2019.100017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Kimura T, Roger VL, Watanabe N, Barros-Gomes S, Topilsky Y, Nishino S, Shibata Y, Enriquez-Sarano M. The unique mechanism of functional mitral regurgitation in acute myocardial infarction: a prospective dynamic 4D quantitative echocardiographic study. Eur Heart J Cardiovasc Imaging 2019; 20:396-406. [PMID: 30517693 PMCID: PMC6429236 DOI: 10.1093/ehjci/jey177] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 09/27/2018] [Accepted: 10/31/2018] [Indexed: 02/06/2023] Open
Abstract
AIMS Mechanisms of chronic ischaemic mitral regurgitation (IMR) are well-characterized by apically tethered leaflet caused by papillary muscles (PMs) displacement and adynamic mitral apparatus. We investigated the unique geometry and dynamics of the mitral apparatus in first acute myocardial infarction (MI) by using quantified 3D echocardiography. METHODS AND RESULTS We prospectively performed 3D echocardiography 2.3 ± 1.8 days after first MI, in 174 matched patients with (n = 87) and without IMR (n = 87). 3D echocardiography of left ventricular (LV) volumes and of mitral apparatus dynamics throughout cardiac cycle was quantified. Similar mitral quantification was obtained at chronic post-MI stage (n = 44). Mechanistically, acute IMR was associated with larger and flatter annulus (area 9.29 ± 1.74 cm2 vs. 8.57 ± 1.94 cm2, P = 0.002, saddle shape 12.7 ± 4.5% vs. 15.0 ± 4.6%, P = 0.001), and larger tenting (length 6.36 ± 1.78 mm vs. 5.60 ± 1.55 mm, P = 0.003) but vs. chronic MI, mitral apparatus displayed smaller alterations (all P < 0.01) and annular size, PM movement remained dynamic (all P < 0.01). Specific to acute IMR, without PM apical displacement (P > 0.70), greater separation (21.7 ± 4.9 mm vs. 20.0 ± 3.4 mm, P = 0.01), and widest angulation of PM (38.4 ± 6.2° for moderate vs. 33.5 ± 7.3° for mild vs. 31.4 ± 6.3° for no-IMR, P = 0.0009) wider vs. chronic MI (P < 0.01). CONCLUSIONS 3D echocardiography of patients with first MI provides insights into unique 4D dynamics of the mitral apparatus in acute IMR. Mitral apparatus remained dynamic in acute MI and distinct IMR mechanism in acute MI is not PM displacement seen in chronic IMR but separation and excess angulation of PM deforming the mitral valve, probably because of sudden-onset regional wall motion abnormality without apparent global LV remodelling. This specific mechanism should be considered in novel therapeutic strategies for IMR complicating acute MI.
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Affiliation(s)
- Toshiyuki Kimura
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
- Department of Cardiology, Miyazaki Medical Association Hospital, Funado, Shinbeppu-chou, Miyazaki city, Miyazaki, Japan
| | - Véronique L Roger
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
- Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Nozomi Watanabe
- Department of Cardiology, Miyazaki Medical Association Hospital, Funado, Shinbeppu-chou, Miyazaki city, Miyazaki, Japan
| | - Sergio Barros-Gomes
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Yan Topilsky
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
- Department of Cardiovascular Diseases, Tel Aviv Medical Center, 6 Weizmann Street, Tel Aviv, Israel
| | - Shun Nishino
- Department of Cardiology, Miyazaki Medical Association Hospital, Funado, Shinbeppu-chou, Miyazaki city, Miyazaki, Japan
| | - Yoshisato Shibata
- Department of Cardiology, Miyazaki Medical Association Hospital, Funado, Shinbeppu-chou, Miyazaki city, Miyazaki, Japan
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Abstract
At the beginning of the 20th century, Cutler and Levine performed the first successful surgical treatment of a stenotic mitral valve, which was the only treatable heart valve defect at that time. Mitral valve surgery has evolved significantly since then. The introduction of the heart-lung machine in 1954 not only reduced the surgical risk, but also allowed the treatment of different mitral valve pathologies. Nowadays, mitral valve insufficiency has become the most common underlying pathomechanism of mitral valve disease and can be classified into primary and secondary mitral insufficiency. Primary mitral valve insufficiency is mainly caused by alterations of the valve (leaflets and primary order chords) itself, whereas left ventricular dilatation leading to papillary muscle displacement and leaflet tethering via second order chords is the main underlying pathomechanism for secondary mitral valve regurgitation. Valve reconstruction using the "loop technique" plus annuloplasty is the surgical strategy of choice and normalizes life expectancy in patients with primary mitral regurgitation. In patients with secondary mitral regurgitation, implanting an annuloplasty is not superior to valve replacement and results in high rates of valve re-insufficiency (up to 30 % after 3 months) due to ongoing ventricular dilatation. In order to improve repair results in these patients, we add a novel subvalvular technique (ring-noose-string) to the annuloplasty that aims to prevent ongoing ventricular remodeling and re-insufficiency. In modern mitral surgery, a right lateral thoracotomy is the approach of choice with excellent repair and cosmetic results.
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Affiliation(s)
- W Bothe
- Klinik für Herz-und Gefäßchirurgie, Universitäts-Herzzentrum Freiburg - Bad Krozingen, Hugstetter Str. 55, 79106, Freiburg, Deutschland
| | - F Beyersdorf
- Klinik für Herz-und Gefäßchirurgie, Universitäts-Herzzentrum Freiburg - Bad Krozingen, Hugstetter Str. 55, 79106, Freiburg, Deutschland.
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Schneider RJ, Perrin DP, Vasilyev NV, Marx GR, del Nido PJ, Howe RD. Mitral annulus segmentation from four-dimensional ultrasound using a valve state predictor and constrained optical flow. Med Image Anal 2011; 16:497-504. [PMID: 22200622 DOI: 10.1016/j.media.2011.11.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Revised: 03/14/2011] [Accepted: 11/15/2011] [Indexed: 11/30/2022]
Abstract
Measurement of the shape and motion of the mitral valve annulus has proven useful in a number of applications, including pathology diagnosis and mitral valve modeling. Current methods to delineate the annulus from four-dimensional (4D) ultrasound, however, either require extensive overhead or user-interaction, become inaccurate as they accumulate tracking error, or they do not account for annular shape or motion. This paper presents a new 4D annulus segmentation method to account for these deficiencies. The method builds on a previously published three-dimensional (3D) annulus segmentation algorithm that accurately and robustly segments the mitral annulus in a frame with a closed valve. In the 4D method, a valve state predictor determines when the valve is closed. Subsequently, the 3D annulus segmentation algorithm finds the annulus in those frames. For frames with an open valve, a constrained optical flow algorithm is used to the track the annulus. The only inputs to the algorithm are the selection of one frame with a closed valve and one user-specified point near the valve, neither of which needs to be precise. The accuracy of the tracking method is shown by comparing the tracking results to manual segmentations made by a group of experts, where an average RMS difference of 1.67±0.63mm was found across 30 tracked frames.
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Bothe W, Kvitting JPE, Stephens EH, Swanson JC, Liang DH, Ingels NB, Miller DC. Effects of different annuloplasty ring types on mitral leaflet tenting area during acute myocardial ischemia. J Thorac Cardiovasc Surg 2011; 141:345-53. [PMID: 21241857 DOI: 10.1016/j.jtcvs.2010.10.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2010] [Revised: 09/04/2010] [Accepted: 10/16/2010] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The study objective was to quantify the effects of different annuloplasty rings on mitral leaflet septal-lateral tenting areas during acute myocardial ischemia. METHODS Radiopaque markers were implanted along the central septal-lateral meridian of the mitral valve in 30 sheep: 1 each to the septal and lateral aspects of the mitral annulus and 4 and 2 along the anterior and posterior mitral leaflets, respectively. Ten true-sized Carpentier-Edwards Physio, Edwards IMR ETLogix, and GeoForm annuloplasty rings (Edwards Lifesciences, Irvine, Calif) were inserted in a releasable fashion. Marker coordinates were obtained using biplane videofluoroscopy with ring inserted at baseline (RING_BL) and after 90 seconds of left circumflex artery occlusion (RING_ISCH). After ring release, another dataset was acquired before (No_Ring_BL) and after left circumflex artery occlusion (No_Ring_ISCH). Anterior and posterior mitral leaflet tenting areas were computed at mid-systole from sums of marker triangles with the midpoint between the annular markers being the vertex for all triangles. RESULTS Compared with No_Ring_BL, mitral regurgitation grades and all tenting areas significantly increased with No_Ring_ISCH. Compared with No_Ring_ISCH, (1) all rings significantly prevented mitral regurgitation and reduced all tenting areas; (2) Edwards IMR ETLogix and GeoForm rings reduced posterior mitral leaflet area, but not anterior mitral leaflet tenting area, to a significantly greater extent than the Carpentier-Edwards Physio ring; and (3) Edwards IMR ETLogix and GeoForm rings affected tenting areas similarly. CONCLUSIONS In response to acute left ventricular ischemia, disease-specific functional/ischemic mitral regurgitation rings (Edwards IMR ETLogix, GeoForm) more effectively reduced posterior mitral leaflet area, but not anterior mitral leaflet tenting area, compared with true-sized physiologic rings (Carpentier-Edwards Physio). Despite its radical 3-dimensional shape and greater amount of mitral annular septal-lateral downsizing, the GeoForm ring did not reduce tenting areas more than the Edwards IMR ETLogix ring, suggesting that further reduction in tenting areas in patients with FMR/IMR may not be effectively achieved on an annular level.
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Affiliation(s)
- Wolfgang Bothe
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA 94305-5247, USA
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Schneider RJ, Perrin DP, Vasilyev NV, Marx GR, del Nido PJ, Howe RD. Mitral annulus segmentation from 3D ultrasound using graph cuts. IEEE TRANSACTIONS ON MEDICAL IMAGING 2010; 29:1676-1687. [PMID: 20562042 PMCID: PMC3122108 DOI: 10.1109/tmi.2010.2050595] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
The shape of the mitral valve annulus is used in diagnostic and modeling applications, yet methods to accurately and reproducibly delineate the annulus are limited. This paper presents a mitral annulus segmentation algorithm designed for closed mitral valves which locates the annulus in three-dimensional ultrasound using only a single user-specified point near the center of the valve. The algorithm first constructs a surface at the location of the thin leaflets, and then locates the annulus by finding where the thin leaflet tissue meets the thicker heart wall. The algorithm iterates until convergence metrics are satisfied, resulting in an operator-independent mitral annulus segmentation. The accuracy of the algorithm was assessed from both a diagnostic and surgical standpoint by comparing the algorithm's results to delineations made by a group of experts on clinical ultrasound images of the mitral valve, and to delineations made by an expert with a surgical view of the mitral annulus on excised porcine hearts using an electromagnetically tracked pointer. In the former study, the algorithm was statistically indistinguishable from the best performing expert (p=0.85) and had an average RMS difference of 1.81+/-0.78 mm to the expert average. In the latter, the average RMS difference between the algorithm's annulus and the electromagnetically tracked points across six hearts was 1.19+/-0.17 mm .
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Affiliation(s)
- Robert J Schneider
- Harvard School of Engineering and Applied Sciences, Cambridge, MA 02138, USA.
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Bothe W, Ennis DB, Carlhäll CJ, Nguyen TC, Timek TA, Lai DT, Itoh A, Ingels NB, Miller DC. Regional mitral leaflet opening during acute ischemic mitral regurgitation. THE JOURNAL OF HEART VALVE DISEASE 2009; 18:586-597. [PMID: 20099707 PMCID: PMC2863307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
BACKGROUND AND AIM OF THE STUDY Diastolic mitral valve (MV) opening characteristics during ischemic mitral regurgitation (IMR) are poorly characterized. The diastolic MV opening dynamics were quantified along the entire valvular coaptation line in an ovine model of acute IMR. METHODS Ten radiopaque markers were sutured in pairs on the anterior (A1-E1) and corresponding posterior (A2-E2) leaflet edges from the anterior (A1/A2) to the posterior (E1/E2) commissure in 11 adult sheep. Immediately after surgery, 4-D marker coordinates were obtained before and during occlusion of the proximal left circumflex coronary artery. Distances between marker pairs were calculated throughout the cardiac cycle every 16.7 ms. Leaflet opening was defined as the time after end-systole (ES) when the first derivative of the distance between marker pairs was greater than a threshold value of 3 cm/s. Valve opening velocity was defined as the maximum slope of marker pair tracings. RESULTS Hemodynamics were consistent with acute ischemia, as reflected by increased MR grade (0.5 +/- 0.3 versus 2.3 +/- 0.7, p < 0.05), decreased contractility (dP/dt(max): 1,948 +/- 598 versus 1,119 +/- 293 mmHg/s, p < 0.05), and slower left ventricular relaxation rate (dP/dt(min): -1,079 +/- 188 versus -538 +/- 147 mmHg/s, p < 0.05). During ischemia, valve opening occurred earlier (A1/A2: 112 +/- 28 versus 83 +/- 43 ms, B1/B2: 105 +/- 32 versus 68 +/- 35 ms, C1/C2: 126 +/- 25 versus 74 +/- 37 ms, D1/D2: 114 +/- 28 versus 71 +/- 34 ms, E1/E2: 125 +/- 29 versus 105 +/- 33 ms; all p < 0.05) and was slower (A1/A2: 16.8 +/- 9.6 versus 14.2 +/- 9.4 cm/s, B1/B2: 40.4 +/- 9.9 versus 32.2 +/- 10.0 cm/s, C1/C2: 59.0 +/- 14.9 versus 50.4 +/- 18.1 cm/s, D1/D2: 34.4 +/- 10.4 versus 25.5 +/- 10.9 cm/s; all p < 0.05), except at the posterior edge (E1/E2: 13.3 +/- 8.7 versus 10.6 +/- 7.2 cm/s). The sequence of regional mitral leaflet separation along the line of coaptation did not change with ischemia. CONCLUSION Acute posterolateral left ventricular ischemia causes earlier leaflet opening, probably due to a MR-related elevation in left-atrial pressure; reduces leaflet opening velocity, potentially reflecting an impaired left ventricular relaxation rate; and does not perturb the homogeneous temporal pattern of regional valve opening along the line of coaptation. Future studies will confirm whether these findings are apparent in patients with chronic IMR, and may help to refine the current strategies used to treat IMR.
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Affiliation(s)
- Wolfgang Bothe
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Daniel B. Ennis
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Carl Johan Carlhäll
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
- Laboratory of Cardiovascular Physiology and Biophysics, Research Institute of the Palo Alto Medical Foundation, Palo Alto, California, USA
| | - Tom C. Nguyen
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Tomasz A. Timek
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - David T. Lai
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Akinobu Itoh
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Neil B. Ingels
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
- Laboratory of Cardiovascular Physiology and Biophysics, Research Institute of the Palo Alto Medical Foundation, Palo Alto, California, USA
| | - D. Craig Miller
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
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