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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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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
Abstract
The geometrical details and biomechanical relationships of the mitral valve-left ventricular apparatus are very complex and have posed as an area of research interest for decades. These characteristics play a major role in identifying and perfecting the optimal approaches to treat diseases of this system when the restoration of biomechanical and mechano-biological conditions becomes the main target. Over the years, engineering approaches have helped to revolutionize the field in this regard. Furthermore, advanced modelling modalities have contributed greatly to the development of novel devices and less invasive strategies. This article provides an overview and narrative of the evolution of mitral valve therapy with special focus on two diseases frequently encountered by cardiac surgeons and interventional cardiologists: ischemic and degenerative mitral regurgitation.
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Affiliation(s)
- Antonia van Kampen
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
- Leipzig Heart Centre, University Clinic of Cardiac Surgery, 02189 Leipzig, Germany
| | - Jordan E. Morningstar
- Department of Regenerative Medicine and Cell Biology, University of South Carolina, Charleston, SC 29425, USA
| | - Guillaume Goudot
- Cardiac Ultrasound Laboratory, Department of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Neil Ingels
- Department of Biomedical Engineering, University of Arkansas, Fayetteville, AR 72701, USA
| | - Jonathan F. Wenk
- Department of Mechanical Engineering, University of Kentucky, Lexington, KY 40508, USA;
| | - Yasufumi Nagata
- Cardiac Ultrasound Laboratory, Department of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Koushiar M. Yaghoubian
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Russell A. Norris
- Department of Regenerative Medicine and Cell Biology, University of South Carolina, Charleston, SC 29425, USA
| | - Michael A. Borger
- Leipzig Heart Centre, University Clinic of Cardiac Surgery, 02189 Leipzig, Germany
| | - Serguei Melnitchouk
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Robert A. Levine
- Cardiac Ultrasound Laboratory, Department of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Morten O. Jensen
- Department of Biomedical Engineering, University of Arkansas, Fayetteville, AR 72701, USA
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
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3
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Nam HH, Herz C, Lasso A, Cianciulli A, Flynn M, Huang J, Wang Z, Paniagua B, Vicory J, Kabir S, Simpson J, Harrild D, Marx G, Cohen MS, Glatz AC, Jolley MA. Visualization and Quantification of the Unrepaired Complete Atrioventricular Canal Valve Using Open-Source Software. J Am Soc Echocardiogr 2022; 35:985-996.e11. [PMID: 35537615 PMCID: PMC9452462 DOI: 10.1016/j.echo.2022.04.015] [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: 01/10/2022] [Revised: 04/20/2022] [Accepted: 04/24/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Repair of complete atrioventricular canal (CAVC) is often complicated by residual left atrioventricular valve regurgitation. The structure of the mitral and tricuspid valves in biventricular hearts has previously been shown to be associated with valve dysfunction. However, the three-dimensional (3D) structure of the entire unrepaired CAVC valve has not been quantified. Understanding the 3D structure of the CAVC may inform optimized repair. METHODS Novel open-source work flows were created in SlicerHeart for the modeling and quantification of CAVC valves on the basis of 3D echocardiographic images. These methods were applied to model the annulus, leaflets, and papillary muscle (PM) structure of 35 patients (29 with trisomy 21) with CAVC using transthoracic 3D echocardiography. The mean leaflet and annular shapes were calculated and visualized using shape analysis. Metrics of the complete native CAVC valve structure were compared with those of normal mitral valves using the Mann-Whitney U test. Associations between CAVC structure and atrioventricular valve regurgitation were analyzed. RESULTS CAVC leaflet metrics varied throughout systole. Compared with normal mitral valves, the left CAVC PMs were more acutely angled in relation to the annular plane (P < .001). In addition, the anterolateral PM was laterally and inferiorly rotated in CAVC, while the posteromedial PM was more superiorly and laterally rotated, relative to normal mitral valves (P < .001). Lower native CAVC atrioventricular valve annular height and annular height-to-valve width ratio before repair were both associated with moderate or greater left atrioventricular valve regurgitation after repair (P < .01). CONCLUSIONS It is feasible to model and quantify 3D CAVC structure using 3D echocardiographic images. The results demonstrate significant variation in CAVC structure across the cohort and differences in annular, leaflet, and PM structure compared with the mitral valve. These tools may be used in future studies to catalyze future research intended to identify structural associations of valve dysfunction and to optimize repair in this vulnerable and complex population.
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Affiliation(s)
- Hannah H Nam
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Christian Herz
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Andras Lasso
- Laboratory for Percutaneous Surgery, Queen's University, Kingston, Ontario, Canada
| | - Alana Cianciulli
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Maura Flynn
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jing Huang
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Zi Wang
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | - Saleha Kabir
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, United Kingdom
| | - John Simpson
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, United Kingdom
| | - David Harrild
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Gerald Marx
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Meryl S Cohen
- Division of Pediatric Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Andrew C Glatz
- Division of Pediatric Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Matthew A Jolley
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Division of Pediatric Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
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Aly AH, Khandelwal P, Aly AH, Kawashima T, Mori K, Saito Y, Hung J, Gorman JH, Pouch AM, Gorman RC, Yushkevich PA. Fully Automated 3D Segmentation and Diffeomorphic Medial Modeling of the Left Ventricle Mitral Valve Complex in Ischemic Mitral Regurgitation. Med Image Anal 2022; 80:102513. [PMID: 35772323 DOI: 10.1016/j.media.2022.102513] [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: 03/30/2021] [Revised: 05/30/2022] [Accepted: 06/10/2022] [Indexed: 10/18/2022]
Abstract
There is an urgent unmet need to develop a fully-automated image-based left ventricle mitral valve analysis tool to support surgical decision making for ischemic mitral regurgitation patients. This requires an automated tool for segmentation and modeling of the left ventricle and mitral valve from immediate pre-operative 3D transesophageal echocardiography. Previous works have presented methods for semi-automatically segmenting and modeling the mitral valve, but do not include the left ventricle and do not avoid self-intersection of the mitral valve leaflets during shape modeling. In this study, we develop and validate a fully automated algorithm for segmentation and shape modeling of the left ventricular mitral valve complex from pre-operative 3D transesophageal echocardiography. We performed a 3-fold nested cross validation study on two datasets from separate institutions to evaluate automated segmentations generated by nnU-net with the expert manual segmentation which yielded average overall Dice scores of 0.82±0.03 (set A), 0.87±0.08 (set B) respectively. A deformable medial template was subsequently fitted to the segmentation to generate shape models. Comparison of shape models to the manual and automatically generated segmentations resulted in an average Dice score of 0.93-0.94 and 0.75-0.81 for the left ventricle and mitral valve, respectively. This is a substantial step towards automatically analyzing the left ventricle mitral valve complex in the operating room.
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Affiliation(s)
- Ahmed H Aly
- Division of Cardiothoracic Surgery, The Ohio State University, Columbus, OH, USA; Department of Bioengineering, School of Engineering and Applied Sciences, University of Pennsylvania, Philadelphia, PA, USA; Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA.
| | - Pulkit Khandelwal
- Department of Bioengineering, School of Engineering and Applied Sciences, University of Pennsylvania, Philadelphia, PA, USA
| | - Abdullah H Aly
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; The Ohio State College of Medicine, Columbus, OH, USA
| | - Takayuki Kawashima
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA
| | - Kazuki Mori
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA
| | - Yoshiaki Saito
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA
| | - Judy Hung
- Department of Cardiology at Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Joseph H Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA; Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Alison M Pouch
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert C Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA; Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Paul A Yushkevich
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Meucci MC, Delgado V. Preoperative assessment of mitral valve regurgitation with two- and three-dimensional transesophageal echocardiography. CIRUGIA CARDIOVASCULAR 2022. [DOI: 10.1016/j.circv.2022.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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6
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Herz C, Pace DF, Nam HH, Lasso A, Dinh P, Flynn M, Cianciulli A, Golland P, Jolley MA. Segmentation of Tricuspid Valve Leaflets From Transthoracic 3D Echocardiograms of Children With Hypoplastic Left Heart Syndrome Using Deep Learning. Front Cardiovasc Med 2021; 8:735587. [PMID: 34957233 PMCID: PMC8696083 DOI: 10.3389/fcvm.2021.735587] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 11/16/2021] [Indexed: 11/13/2022] Open
Abstract
Hypoplastic left heart syndrome (HLHS) is a severe congenital heart defect in which the right ventricle and associated tricuspid valve (TV) alone support the circulation. TV failure is thus associated with heart failure, and the outcome of TV valve repair are currently poor. 3D echocardiography (3DE) can generate high-quality images of the valve, but segmentation is necessary for precise modeling and quantification. There is currently no robust methodology for rapid TV segmentation, limiting the clinical application of these technologies to this challenging population. We utilized a Fully Convolutional Network (FCN) to segment tricuspid valves from transthoracic 3DE. We trained on 133 3DE image-segmentation pairs and validated on 28 images. We then assessed the effect of varying inputs to the FCN using Mean Boundary Distance (MBD) and Dice Similarity Coefficient (DSC). The FCN with the input of an annular curve achieved a median DSC of 0.86 [IQR: 0.81-0.88] and MBD of 0.35 [0.23-0.4] mm for the merged segmentation and an average DSC of 0.77 [0.73-0.81] and MBD of 0.6 [0.44-0.74] mm for individual TV leaflet segmentation. The addition of commissural landmarks improved individual leaflet segmentation accuracy to an MBD of 0.38 [0.3-0.46] mm. FCN-based segmentation of the tricuspid valve from transthoracic 3DE is feasible and accurate. The addition of an annular curve and commissural landmarks improved the quality of the segmentations with MBD and DSC within the range of human inter-user variability. Fast and accurate FCN-based segmentation of the tricuspid valve in HLHS may enable rapid modeling and quantification, which in the future may inform surgical planning. We are now working to deploy this network for public use.
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Affiliation(s)
- Christian Herz
- Children's Hospital of Philadelphia, Department of Anesthesia and Critical Care Medicine, Philadelphia, PA, United States
| | - Danielle F. Pace
- Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge, MA, United States
- Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Hannah H. Nam
- Children's Hospital of Philadelphia, Department of Anesthesia and Critical Care Medicine, Philadelphia, PA, United States
| | - Andras Lasso
- Laboratory for Percutaneous Surgery, Queen's University, Kingston, ON, Canada
| | - Patrick Dinh
- Children's Hospital of Philadelphia, Department of Anesthesia and Critical Care Medicine, Philadelphia, PA, United States
| | - Maura Flynn
- Children's Hospital of Philadelphia, Department of Anesthesia and Critical Care Medicine, Philadelphia, PA, United States
| | - Alana Cianciulli
- Children's Hospital of Philadelphia, Department of Anesthesia and Critical Care Medicine, Philadelphia, PA, United States
| | - Polina Golland
- Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge, MA, United States
| | - Matthew A. Jolley
- Children's Hospital of Philadelphia, Department of Anesthesia and Critical Care Medicine, Philadelphia, PA, United States
- Division of Pediatric Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
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7
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Huang K, Wang Y, Huang J, Chu X, Wang F, Pang L, Sun X. Nomogram Predicts Improvement of Ischemic Mitral Regurgitation after Coronary Artery Bypass Grafting. Ann Thorac Surg 2021; 114:1656-1663. [PMID: 34695405 DOI: 10.1016/j.athoracsur.2021.09.037] [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: 04/05/2021] [Revised: 08/08/2021] [Accepted: 09/04/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Developing a nomogram to predict improvement in moderate ischemic mitral regurgitation (IMR) after coronary artery bypass grafting (CABG) is in need. METHODS Between 2010 and 2018, data were retrospectively collected from 112 patients with prior myocardial infarction and moderate IMR undergoing CABG. Patients were divided into two groups based on IMR degree 1 year after CABG as follows: Improved Group with no or mild IMR (n=54) and Failure Group with moderate or severe IMR (n=58). To determine the predictors of postoperative IMR improvement, preoperative clinical and echocardiographic data were compared, and a nomogram was formulated based on all independent predictors. Discriminative ability, calibration, and clinical usefulness of the prediction model were assessed. RESULTS Independent predictors of IMR improvement after CABG constructing the nomogram included duration between infarction and operation, poster-inferior to left ventricular volume ratio, maximum difference of the time to reach minimum systolic volume of 16 segments, P3 leaflet tethering angle, and annular Non-planar angle. The nomogram exhibited well-fitted calibration curves and excellent discriminative ability. The area under receiver operating characteristic curve was 0.974. Patients with a score > 236 demonstrated a high probability of IMR improvement (sensitivity, 90.7%; specificity, 93.1%). Patients in the Improved Group demonstrated greater actuarial survival rates than those in the Failure Group. CONCLUSIONS The nomogram combining 5 preoperative clinical and echocardiographic predictors provides an accurate preoperative estimation of moderate IMR improvement after surgery, with excellent discriminative ability. Based on this nomogram, patients with a higher score predict higher probabilities of IMR improvement.
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Affiliation(s)
- Kai Huang
- From the Departments of Cardiothoracic Surgery, Huashan Hospital of Fudan University, Shanghai, China
| | - Yiqing Wang
- From the Departments of Cardiothoracic Surgery, Huashan Hospital of Fudan University, Shanghai, China
| | - Jiechun Huang
- From the Departments of Cardiothoracic Surgery, Huashan Hospital of Fudan University, Shanghai, China
| | - Xianglin Chu
- From the Departments of Cardiothoracic Surgery, Huashan Hospital of Fudan University, Shanghai, China
| | - Fangrui Wang
- From the Departments of Cardiothoracic Surgery, Huashan Hospital of Fudan University, Shanghai, China
| | - Liewen Pang
- From the Departments of Cardiothoracic Surgery, Huashan Hospital of Fudan University, Shanghai, China
| | - Xiaotian Sun
- From the Departments of Cardiothoracic Surgery, Huashan Hospital of Fudan University, Shanghai, China.
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8
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Park MH, Zhu Y, Imbrie-Moore AM, Wang H, Marin-Cuartas M, Paulsen MJ, Woo YJ. Heart Valve Biomechanics: The Frontiers of Modeling Modalities and the Expansive Capabilities of Ex Vivo Heart Simulation. Front Cardiovasc Med 2021; 8:673689. [PMID: 34307492 PMCID: PMC8295480 DOI: 10.3389/fcvm.2021.673689] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 05/17/2021] [Indexed: 01/05/2023] Open
Abstract
The field of heart valve biomechanics is a rapidly expanding, highly clinically relevant area of research. While most valvular pathologies are rooted in biomechanical changes, the technologies for studying these pathologies and identifying treatments have largely been limited. Nonetheless, significant advancements are underway to better understand the biomechanics of heart valves, pathologies, and interventional therapeutics, and these advancements have largely been driven by crucial in silico, ex vivo, and in vivo modeling technologies. These modalities represent cutting-edge abilities for generating novel insights regarding native, disease, and repair physiologies, and each has unique advantages and limitations for advancing study in this field. In particular, novel ex vivo modeling technologies represent an especially promising class of translatable research that leverages the advantages from both in silico and in vivo modeling to provide deep quantitative and qualitative insights on valvular biomechanics. The frontiers of this work are being discovered by innovative research groups that have used creative, interdisciplinary approaches toward recapitulating in vivo physiology, changing the landscape of clinical understanding and practice for cardiovascular surgery and medicine.
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Affiliation(s)
- Matthew H Park
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, United States.,Department of Mechanical Engineering, Stanford University, Stanford, CA, United States
| | - Yuanjia Zhu
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, United States.,Department of Bioengineering, Stanford University, Stanford, CA, United States
| | - Annabel M Imbrie-Moore
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, United States.,Department of Mechanical Engineering, Stanford University, Stanford, CA, United States
| | - Hanjay Wang
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, United States
| | - Mateo Marin-Cuartas
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, United States.,University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Michael J Paulsen
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, United States
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, United States.,Department of Bioengineering, Stanford University, Stanford, CA, United States
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9
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Mahmood F, Sharkey A, Maslow A, Mufarrih SH, Qureshi NQ, Matyal R, Khabbaz KR. Echocardiographic Assessment of the Mitral Valve for Suitability of Repair: An Intraoperative Approach From a Mitral Center. J Cardiothorac Vasc Anesth 2021; 36:2164-2176. [PMID: 34334319 DOI: 10.1053/j.jvca.2021.06.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 06/23/2021] [Accepted: 06/27/2021] [Indexed: 11/11/2022]
Abstract
Intraoperative echocardiography of the mitral valve in the precardiopulmonary bypass period is an integral part of the surgical decision-making process for assessment of suitability for repair. Although there are comprehensive reviews in the literature regarding echocardiographic examination of the mitral valve, the authors present a practical stepwise algorithmic workflow to make objective recommendations. Advances in echocardiography allow for quantitative geometric analyses of the mitral valve, along with precise assessment of the valvular apparatus with three-dimensional echocardiography. In the precardiopulmonary bypass period, echocardiographers are required to diagnose and quantify valvular dysfunction, assess suitability for repair, assist in annuloplasty ring sizing, and determine the success or failure of the surgical procedure. In this manuscript the authors outline an algorithmic approach to intraoperative echocardiography examination using two-dimensional and three-dimensional modalities to objectively analyze mitral valve function and assist in surgical decision-making.
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Affiliation(s)
- Feroze Mahmood
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
| | - Aidan Sharkey
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Andrew Maslow
- Department of Anesthesiology, Rhode Island Hospital, Providence, RI
| | - Syed Hamza Mufarrih
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Nada Qaisar Qureshi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Robina Matyal
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Kamal R Khabbaz
- Department of Surgery, Division of Cardiac Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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10
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Aly AH, Saito Y, Bouma W, Pilla JJ, Pouch AM, Yushkevich PA, Gillespie MJ, Gorman JH, Gorman RC. Multimodal image analysis and subvalvular dynamics in ischemic mitral regurgitation. JTCVS OPEN 2021; 5:48-60. [PMID: 36003177 PMCID: PMC9390375 DOI: 10.1016/j.xjon.2020.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 10/09/2020] [Indexed: 11/15/2022]
Affiliation(s)
- Ahmed H. Aly
- Gorman Cardiovascular Research Group, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
- Department of Bioengineering, University of Pennsylvania, Philadelphia, Pa
| | - Yoshiaki Saito
- Gorman Cardiovascular Research Group, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University, Aomori, Japan
| | - Wobbe Bouma
- Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - James J. Pilla
- Gorman Cardiovascular Research Group, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Alison M. Pouch
- Gorman Cardiovascular Research Group, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Paul A. Yushkevich
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Matthew J. Gillespie
- Gorman Cardiovascular Research Group, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
- Department of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Joseph H. Gorman
- Gorman Cardiovascular Research Group, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Robert C. Gorman
- Gorman Cardiovascular Research Group, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
- Address for reprints: Robert C. Gorman, MD, Gorman Cardiovascular Research Group, Smilow Center for Translational Research, 3400 Civic Center Blvd, Bldg 421, 11th Floor, Room 114, Philadelphia, PA, 19104-5156.
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11
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Drake DH, Zimmerman KG, Sidebotham DA. Past, current and future management of secondary mitral valve disease: the importance of anatomic staging. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:968. [PMID: 32953768 PMCID: PMC7475447 DOI: 10.21037/atm.2020.03.82] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Daniel H Drake
- Department of Surgery, Munson Medical Center, Traverse City, MI, USA
| | - Karen G Zimmerman
- Department of Cardiology, Henry Ford Health System, Detroit, MI, USA
| | - David A Sidebotham
- Department of Cardiothoracic Anesthesia and Cardiothoracic Intensive Care Unit, Auckland City Hospital, Grafton, Auckland, New Zealand
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12
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Meijerink F, Wijdh-den Hamer IJ, Bouma W, Pouch AM, Aly AH, Lai EK, Eperjesi TJ, Acker MA, Yushkevich PA, Hung J, Mariani MA, Khabbaz KR, Gleason TG, Mahmood F, Gorman JH, Gorman RC. Intraoperative post-annuloplasty three-dimensional valve analysis does not predict recurrent ischemic mitral regurgitation. J Cardiothorac Surg 2020; 15:161. [PMID: 32616001 PMCID: PMC7333337 DOI: 10.1186/s13019-020-01138-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 05/04/2020] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND High ischemic mitral regurgitation (IMR) recurrence rates continue to plague IMR repair with undersized ring annuloplasty. We have previously shown that pre-repair three-dimensional echocardiography (3DE) analysis is highly predictive of IMR recurrence. The objective of this study was to determine the quantitative change in 3DE annular and leaflet tethering parameters immediately after repair and to determine if intraoperative post-repair 3DE parameters would be able to predict IMR recurrence 6 months after repair. METHODS Intraoperative pre- and post-repair transesophageal real-time 3DE was performed in 35 patients undergoing undersized ring annuloplasty for IMR. An advanced modeling algorhythm was used to assess 3D annular geometry and regional leaflet tethering. IMR recurrence (≥ grade 2) was assessed with transthoracic echocardiography 6 months after repair. RESULTS Annuloplasty significantly reduced septolateral diameter, commissural width, annular area, and tethering volume and significantly increased all segmental tethering angles (except A2). Intraoperative post-repair annular geometry and leaflet tethering did not differ significantly between patients with recurrent IMR (n = 9) and patients with non-recurrent IMR (n = 26). No intraoperative post-repair predictors of IMR recurrence could be identified. CONCLUSIONS Undersized ring annuloplasty changes mitral geometry acutely, exacerbates leaflet tethering, and generally fixes IMR acutely, but it does not always fix the delicate underlying chronic problem of continued left ventricular dilatation and remodeling. This may explain why pre-repair 3D valve geometry (which reflects chronic left ventricular remodeling) is highly predictive of recurrent IMR, whereas immediate post-repair 3D valve geometry (which does not completely reflect chronic left ventricular remodeling anymore) is not.
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Affiliation(s)
- Frank Meijerink
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA.
- Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
| | - Inez J Wijdh-den Hamer
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA
- Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Wobbe Bouma
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA
- Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Alison M Pouch
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA
| | - Ahmed H Aly
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA
| | - Eric K Lai
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA
| | - Thomas J Eperjesi
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael A Acker
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Paul A Yushkevich
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Judy Hung
- Department of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Massimo A Mariani
- Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Kamal R Khabbaz
- Department of Cardiothoracic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Thomas G Gleason
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Feroze Mahmood
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Joseph H Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert C Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
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13
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Gimpel D, Cheung M, Bassin L, Jennings S, Weiss B, Akhunji Z, Grant P, Wolfenden H. Operative Results of Mitral Valve Repair and Replacement in Chronic Ischaemic Mitral Valve Regurgitation. Heart Lung Circ 2020; 29:1713-1724. [PMID: 32493579 DOI: 10.1016/j.hlc.2020.03.007] [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: 09/17/2019] [Revised: 01/10/2020] [Accepted: 03/10/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Ischaemic mitral regurgitation (IMR) carries significant morbidity and mortality. Surgical management includes coronary artery bypass surgery alone or concomitant with mitral valve repair or replacement. There is ongoing debate regarding the appropriate approach to the mitral valve in relation to long-term outcomes. This review examines our early and late follow-up, with operative and echocardiographic outcomes for mitral valve repair and mitral replacement for chronic IMR. METHODS A retrospective review was performed on prospectively collected data of 119 consecutive patients who either underwent mitral repair (n=101) or mitral replacement (n=18) for chronic IMR at Prince Henry and The Prince of Wales hospitals in Sydney between 1999-2016. All patients had pre and postoperative transthoracic echocardiograms. Follow-up echocardiographic data was obtained from the most recent clinical appointment. Follow-up mortality outcomes were obtained with ethics approval from the Australian National Death Index (NDI). RESULTS There was no statistical difference between cardiopulmonary bypass (CPB) time, cross-clamp time, time spent in intensive care unit (ICU) and time to discharge between cohorts. The replacement cohort was noted to have higher preoperative pulmonary artery (PA) pressures and a higher severity of IMR. Seven (7) deaths were in the mitral valve (MV) repair group within 30 days (6.9%) and three deaths in the MV replacement group within 30 days (16.7%). Echocardiographic follow-up was complete in 78% of the MV repair cohort at an average of 4.06±2.66 years, and 73% complete in the MV replacement cohort at an average of 6.09±4.3 years. Three (3) patients had prior MV repair before MV replacement early at days zero and 17, and late at 8 years respectively. Follow-up echocardiography showed mitral regurgitation (MR) in the mitral valve repair cohort as ≤ mild in 83.5% and ≤ trivial in 35.6%. In the MV replacement cohort MR ≤ mild in 100% and ≤ trivial in 82% with no moderate or severe MR. Preoperative tricuspid regurgitation (TR) and a flexible annuloplasty were predictive of an MR grade > mild in the repair cohort at discharge. Five-year (5-year) survival for the repair cohort was 85% with a mean follow-up time of 7.1±3.83 years. For the replacement cohort, five-year survival was 77.8% with a mean follow-up time of 5.35±1.54 years. CONCLUSIONS Mitral valve repair and replacement for chronic IMR has acceptable mortality, reintervention rates and excellent postoperative echocardiographic degrees of IMR in this cohort. Further evaluation is required into quality of life post intervention for IMR and of preoperative predictive factors of significant MR postoperatively to help guide the appropriate choice of treatment. The presence of preoperative tricuspid regurgitation of moderate grade or higher, and the use of a flexible annuloplasty may indicate patients more likely to have a higher grade of MR at follow-up following mitral valve repair in patients with IMR.
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Affiliation(s)
- Damian Gimpel
- School of Medicine Sydney, University of Notre Dame Australia, Sydney, NSW, Australia; Department of Cardiothoracic Surgery, The Prince of Wales Hospital, Sydney, NSW, Australia.
| | - Michael Cheung
- School of Medicine Sydney, University of Notre Dame Australia, Sydney, NSW, Australia
| | - Levi Bassin
- Department of Cardiothoracic Surgery, The Prince of Wales Hospital, Sydney, NSW, Australia
| | - Scott Jennings
- Department of Cardiothoracic Surgery, The Prince of Wales Hospital, Sydney, NSW, Australia
| | - Beatrix Weiss
- School of Medicine Sydney, University of Notre Dame Australia, Sydney, NSW, Australia; Department of Cardiothoracic Surgery, The Prince of Wales Hospital, Sydney, NSW, Australia
| | - Zakir Akhunji
- Department of Cardiothoracic Surgery, The Prince of Wales Hospital, Sydney, NSW, Australia
| | - Peter Grant
- Department of Cardiothoracic Surgery, The Prince of Wales Hospital, Sydney, NSW, Australia
| | - Hugh Wolfenden
- Department of Cardiothoracic Surgery, The Prince of Wales Hospital, Sydney, NSW, Australia
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14
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Fatima H, Matyal R, Mahmood F, Baribeau Y, Khabbaz KR. Ischemic Mitral Regurgitation: To Fix or Not to Fix. J Cardiothorac Vasc Anesth 2020; 34:2532-2535. [PMID: 32540246 DOI: 10.1053/j.jvca.2020.04.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 04/10/2020] [Accepted: 04/20/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Huma Fatima
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA
| | - Robina Matyal
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA
| | - Feroze Mahmood
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA
| | - Yanick Baribeau
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA
| | - Kamal R Khabbaz
- Department of Surgery, Division of Cardiac Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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15
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Abstract
Functional mitral regurgitation (FMR) in the setting of left ventricular (LV) dysfunction and heart failure portends a poor prognosis. Guideline-directed medical therapy remains the cornerstone of initial treatment, with emphasis placed on treatment of the underlying LV dysfunction, as FMR is a secondary phenomenon and a disease due to LV remodeling. Surgical correction of FMR is controversial because it typically does not address the underlying mechanism and etiology of the condition. However, new, minimally invasive transcatheter therapies, in particular the MitraClip system, have shown promise in the treatment of FMR in selected patients. This review will summarize the pathophysiology underlying FMR, the prognosis of patients with heart failure and FMR, and the various medical and procedural treatment options currently available and under investigation.
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16
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Semi-automated Image Segmentation of the Midsystolic Left Ventricular Mitral Valve Complex in Ischemic Mitral Regurgitation. STATISTICAL ATLASES AND COMPUTATIONAL MODELS OF THE HEART. STACOM (WORKSHOP) 2019. [PMID: 31579311 DOI: 10.1007/978-3-030-12029-0_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register]
Abstract
Ischemic mitral regurgitation (IMR) is primarily a left ventricular disease in which the mitral valve is dysfunctional due to ventricular remodeling after myocardial infarction. Current automated methods have focused on analyzing the mitral valve and left ventricle independently. While these methods have allowed for valuable insights into mechanisms of IMR, they do not fully integrate pathological features of the left ventricle and mitral valve. Thus, there is an unmet need to develop an automated segmentation algorithm for the left ventricular mitral valve complex, in order to allow for a more comprehensive study of this disease. The objective of this study is to generate and evaluate segmentations of the left ventricular mitral valve complex in pre-operative 3D transesophageal echocardiography using multi-atlas label fusion. These patient-specific segmentations could enable future statistical shape analysis for clinical outcome prediction and surgical risk stratification. In this study, we demonstrate a preliminary segmentation pipeline that achieves an average Dice coefficient of 0.78 ± 0.06.
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Commentary: Three-dimensional P3 tethering angle at the heart of future surgical decision making in ischemic mitral regurgitation. J Thorac Cardiovasc Surg 2019; 157:1806-1807. [PMID: 31288359 DOI: 10.1016/j.jtcvs.2018.10.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 10/09/2018] [Indexed: 11/22/2022]
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18
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Sun X, Jiang Y, Huang G, Huang J, Shi M, Pang L, Wang Y. Three-dimensional mitral valve structure in predicting moderate ischemic mitral regurgitation improvement after coronary artery bypass grafting. J Thorac Cardiovasc Surg 2019; 157:1795-1803.e2. [DOI: 10.1016/j.jtcvs.2018.09.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 08/08/2018] [Accepted: 09/04/2018] [Indexed: 11/26/2022]
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19
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Sacks M, Drach A, Lee CH, Khalighi A, Rego B, Zhang W, Ayoub S, Yoganathan A, Gorman RC, Gorman Iii JH. On the simulation of mitral valve function in health, disease, and treatment. J Biomech Eng 2019; 141:2731932. [PMID: 31004145 PMCID: PMC6611349 DOI: 10.1115/1.4043552] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 03/26/2019] [Indexed: 12/19/2022]
Abstract
The mitral valve (MV) is the heart valve that regulates blood ?ow between the left atrium and left ventricle (LV). In situations where the MV fails to fully cover the left atrioventricular ori?ce during systole, the resulting regurgitation causes pulmonary congestion, leading to heart failure and/or stroke. The causes of MV insuf?ciency can be either primary (e.g. myxomatous degeneration) where the valvular tissue is organically diseased, or secondary (typically inducded by ischemic cardiomyopathy) termed ischemic mitral regurgitation (IMR), is brought on by adverse LV remodeling. IMR is present in up to 40% of patients and more than doubles the probability of cardiovascular morbidity after 3.5 years. There is now agreement that adjunctive procedures are required to treat IMR caused by lea?et tethering. However, there is no consensus regarding the best procedure. Multicenter registries and randomized trials would be necessary to prove which procedure is superior. Given the number of proposed procedures and the complexity and duration of such studies, it is highly unlikely that IMR procedure optimization will be achieved by prospective clinical trials. There is thus an urgent need for cell and tissue physiologically based quantitative assessments of MV function to better design surgical solutions and associated therapies. Novel computational approaches directed towards optimized surgical repair procedures can substantially reduce the need for such trial-and-error approaches. We present the details of our MV modeling techniques, with an emphasis on what is known and investigated at various length scales.
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Affiliation(s)
- Michael Sacks
- aWillerson Center for Cardiovascular Modeling and Simulation, Institute for Computational Engineering and Sciences and the Department of Biomedical Engineering, The University of Texas at Austin, Austin, TX
| | - Andrew Drach
- Willerson Center for Cardiovascular Modeling and Simulation, Institute for Computational Engineering and Sciences and the Department of Biomedical Engineering, The University of Texas at Austin, Austin, TX
| | - Chung-Hao Lee
- Department of Mechanical and Aerospace Engineering, University of Oklahoma, Norman, OK
| | - Amir Khalighi
- Willerson Center for Cardiovascular Modeling and Simulation, Institute for Computational Engineering and Sciences and the Department of Biomedical Engineering, The University of Texas at Austin, Austin, TX
| | - Bruno Rego
- Willerson Center for Cardiovascular Modeling and Simulation, Institute for Computational Engineering and Sciences and the Department of Biomedical Engineering, The University of Texas at Austin, Austin, TX
| | - Will Zhang
- Willerson Center for Cardiovascular Modeling and Simulation, Institute for Computational Engineering and Sciences and the Department of Biomedical Engineering, The University of Texas at Austin, Austin, TX
| | - Salma Ayoub
- Willerson Center for Cardiovascular Modeling and Simulation, Institute for Computational Engineering and Sciences and the Department of Biomedical Engineering, The University of Texas at Austin, Austin, TX
| | - Ajit Yoganathan
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA
| | - Robert C Gorman
- Gorman Cardiovascular Research Group, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Joseph H Gorman Iii
- Gorman Cardiovascular Research Group, Department of Surgery, University of Pennsylvania, Philadelphia, PA
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20
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Application of polymer-mesh device to remodel left ventricular-mitral valve apparatus in ischemic mitral regurgitation. J Thorac Cardiovasc Surg 2017; 155:1485-1493. [PMID: 29249485 DOI: 10.1016/j.jtcvs.2017.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 10/14/2017] [Accepted: 11/05/2017] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Ischemic mitral regurgitation (IMR) results from ischemic left ventricular (LV) distortion and remodeling, which displaces the papillary muscles and tethers the mitral valve leaflets apically. The aim of this experimental study was to examine efficacy of an adjustable novel polymer filled mesh (poly-mesh) device to reverse LV remodeling and reduce IMR. METHODS Acute (N = 8) and chronic (8 weeks; N = 5) sheep models of IMR were studied. IMR was produced by ligation of circumflex branches to create myocardial infarction. An adjustable poly-mesh device was attached to infarcted myocardium in acute and chronic IMR models and compared with untreated sham sheep. Two- and 3-dimensional echocardiography and hemodynamic measurements were performed at baseline, post IMR, and post poly-mesh (humanely killed). RESULTS In acute models, moderate IMR developed in all sheep and decreased to trace/mild (vena contracta: 0.50 ± 0.09 cm to 0.26 ± 0.12 cm; P < .01) after poly-mesh. In chronic models, IMR decreased in all sheep after poly-mesh, and this reduction persisted over 8 weeks (vena contracta: 0.42 ± 0.09 cm to 0.08 ± 0.12 cm; P < .01) with significant increase in the slope of end-systolic pressure-volume relationship (1.1 ± 0.5 mm Hg/mL to 2.9 ± 0.7 mm Hg/mL; P < .05). There was a significant reduction in LV volumes from chronic IMR to euthanasia stage with poly-mesh compared with sham group (%end-diastolic volume change -20 ± 11 vs 15% ± 16%, P < .01; %end-systolic volume change -14% ± 19% vs 22% ± 22%, P < .05; poly-mesh vs sham group) consistent with reverse remodeling. CONCLUSIONS An adjustable polymer filled mesh device reduces IMR and prevents continued LV remodeling during chronic follow-up.
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21
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Jeganathan J, Knio Z, Amador Y, Hai T, Khamooshian A, Matyal R, Khabbaz KR, Mahmood F. Artificial intelligence in mitral valve analysis. Ann Card Anaesth 2017; 20:129-134. [PMID: 28393769 PMCID: PMC5408514 DOI: 10.4103/aca.aca_243_16] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Background: Echocardiographic analysis of mitral valve (MV) has become essential for diagnosis and management of patients with MV disease. Currently, the various software used for MV analysis require manual input and are prone to interobserver variability in the measurements. Aim: The aim of this study is to determine the interobserver variability in an automated software that uses artificial intelligence for MV analysis. Settings and Design: Retrospective analysis of intraoperative three-dimensional transesophageal echocardiography data acquired from four patients with normal MV undergoing coronary artery bypass graft surgery in a tertiary hospital. Materials and Methods: Echocardiographic data were analyzed using the eSie Valve Software (Siemens Healthcare, Mountain View, CA, USA). Three examiners analyzed three end-systolic (ES) frames from each of the four patients. A total of 36 ES frames were analyzed and included in the study. Statistical Analysis: A multiple mixed-effects ANOVA model was constructed to determine if the examiner, the patient, and the loop had a significant effect on the average value of each parameter. A Bonferroni correction was used to correct for multiple comparisons, and P = 0.0083 was considered to be significant. Results: Examiners did not have an effect on any of the six parameters tested. Patient and loop had an effect on the average parameter value for each of the six parameters as expected (P < 0.0083 for both). Conclusion: We were able to conclude that using automated analysis, it is possible to obtain results with good reproducibility, which only requires minimal user intervention.
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Affiliation(s)
- Jelliffe Jeganathan
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ziyad Knio
- Department of Surgery, Division of Cardiothoracic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Yannis Amador
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Department of Anesthesia, Hospital México, University of Costa Rica, San José, Costa Rica
| | - Ting Hai
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Department of Anesthesiology, Peking University People's Hospital, Beijing, China
| | - Arash Khamooshian
- Department of Cardio-Thoracic Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Robina Matyal
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Kamal R Khabbaz
- Department of Surgery, Division of Cardiothoracic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Feroze Mahmood
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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22
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Bouchard MA, Côté-Laroche C, Beaudoin J. Multi-Modality Imaging in the Evaluation and Treatment of Mitral Regurgitation. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2017; 19:91. [PMID: 29027633 DOI: 10.1007/s11936-017-0589-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OPINION STATEMENT Mitral regurgitation (MR) is frequent and associated with increased mortality and morbidity when severe. It may be caused by intrinsic valvular disease (primary MR) or ventricular deformation (secondary MR). Imaging has a critical role to document the severity, mechanism, and impact of MR on heart function as selected patients with MR may benefit from surgery whereas other will not. In patients planned for a surgical intervention, imaging is also important to select candidates for mitral valve (MV) repair over replacement and to predict surgical success. Although standard transthoracic echocardiography is the first-line modality to evaluate MR, newer imaging modalities like three-dimensional (3D) transesophageal echocardiography, stress echocardiography, cardiac magnetic resonance (CMR), and computed tomography (CT) are emerging and complementary tools for MR assessment. While some of these modalities can provide insight into MR severity, others will help to determine its mechanism. Understanding the advantages and limitations of each imaging modality is important to appreciate their respective role for MR assessment and help to resolve eventual discrepancies between different diagnostic methods. With the increasing use of transcatheter mitral procedures (repair or replacement) for high-surgical-risk patients, multimodality imaging has now become even more important to determine eligibility, preinterventional planning, and periprocedural guidance.
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Affiliation(s)
- Marc-André Bouchard
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart and Lung Institute), Department of Medicine, Laval University, Québec, QC, Canada
| | - Claudia Côté-Laroche
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart and Lung Institute), Department of Medicine, Laval University, Québec, QC, Canada
| | - Jonathan Beaudoin
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (Quebec Heart and Lung Institute), Department of Medicine, Laval University, Québec, QC, Canada.
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23
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Capoulade R, Piriou N, Serfaty JM, Le Tourneau T. Multimodality imaging assessment of mitral valve anatomy in planning for mitral valve repair in secondary mitral regurgitation. J Thorac Dis 2017; 9:S640-S660. [PMID: 28740719 PMCID: PMC5505945 DOI: 10.21037/jtd.2017.06.99] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Accepted: 06/13/2017] [Indexed: 12/23/2022]
Abstract
Secondary mitral regurgitation (MR) is frequent valvular heart disease and conveys worse prognostic. Therapeutic surgical or percutaneous options are available in the context of severe symptomatic secondary MR, but the best approach to treat these patients remains unclear, given the lack of clear clinical evidence of benefit. A comprehensive evaluation of the mitral valve apparatus and the left ventricle (LV) has the ability to clearly define and characterize the disease, and thus determine the best option for the patient to improve its clinical outcomes, as well as quality of life and symptoms. The current report reviews the mitral valve (MV) anatomy, the underlying mechanisms associated with secondary MR, the related therapeutic options available, and finally the usefulness of a multimodality imaging approach for the planning of surgical or percutaneous mitral valve intervention.
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Affiliation(s)
- Romain Capoulade
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Institut du Thorax, CHU Nantes, Nantes University, Nantes, France
| | - Nicolas Piriou
- Institut du Thorax, CHU Nantes, Nantes University, Nantes, France
- Department of Nuclear Medicine, CHU Nantes, Nantes University, Nantes, France
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24
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Yuh DD. Predicting recurrent ischemic mitral regurgitation: Through the 3-dimensional looking glass. J Thorac Cardiovasc Surg 2016; 152:860-1. [PMID: 27530640 DOI: 10.1016/j.jtcvs.2016.06.049] [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: 06/27/2016] [Accepted: 06/27/2016] [Indexed: 11/26/2022]
Affiliation(s)
- David D Yuh
- Section of Cardiac Surgery, Yale University School of Medicine, New Haven, Conn.
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