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Zhu Y, Yajima S, Park MH, Venkatesh A, Stark CJ, Tran NA, Walsh SK, Ethiraj S, Wilkerson RJ, Lin LE, Lee SH, Gates KY, Arthur JD, Baker SW, Mullis DM, Wu CA, Harima S, Pokhrel B, Resuello D, Bergamasco H, Wu MA, Baccouche BM, Pandya PK, Elde S, Wang H, Woo YJ. Large Animal Translational Validation of 3 Mitral Valve Repair Operations for Mitral Regurgitation Using a Mitral Valve Prolapse Model: A Comprehensive In Vivo Biomechanical Engineering Analysis. Circ Cardiovasc Interv 2024; 17:e013196. [PMID: 38626077 DOI: 10.1161/circinterventions.123.013196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 01/19/2024] [Indexed: 04/18/2024]
Abstract
BACKGROUND Various mitral repair techniques have been described. Though these repair techniques can be highly effective when performed correctly in suitable patients, limited quantitative biomechanical data are available. Validation and thorough biomechanical evaluation of these repair techniques from translational large animal in vivo studies in a standardized, translatable fashion are lacking. We sought to evaluate and validate biomechanical differences among different mitral repair techniques and further optimize repair operations using a large animal mitral valve prolapse model. METHODS Male Dorset sheep (n=20) had P2 chordae severed to create the mitral valve prolapse model. Fiber Bragg grating force sensors were implanted to measure chordal forces. Ten sheep underwent 3 randomized, paired mitral valve repair operations: neochord repair, nonresectional leaflet remodeling, and triangular resection. The other 10 sheep underwent neochord repair with 2, 4, and 6 neochordae. Data were collected at baseline, mitral valve prolapse, and after each repair. RESULTS All mitral repair techniques successfully eliminated regurgitation. Compared with mitral valve prolapse (0.54±0.18 N), repair using neochord (0.37±0.20 N; P=0.02) and remodeling techniques (0.30±0.15 N; P=0.001) reduced secondary chordae peak force. Neochord repair further decreased primary chordae peak force (0.21±0.14 N) to baseline levels (0.20±0.17 N; P=0.83), and was associated with lower primary chordae peak force compared with the remodeling (0.34±0.18 N; P=0.02) and triangular resectional techniques (0.36±0.27 N; P=0.03). Specifically, repair using 2 neochordae resulted in higher peak primary chordal forces (0.28±0.21 N) compared with those using 4 (0.22±0.16 N; P=0.02) or 6 neochordae (0.19±0.16 N; P=0.002). No difference in peak primary chordal forces was observed between 4 and 6 neochordae (P=0.05). Peak forces on the neochordae were the lowest using 6 neochordae (0.09±0.11 N) compared with those of 4 neochordae (0.15±0.14 N; P=0.01) and 2 neochordae (0.29±0.18 N; P=0.001). CONCLUSIONS Significant biomechanical differences were observed underlying different mitral repair techniques in a translational large animal model. Neochord repair was associated with the lowest primary chordae peak force compared to the remodeling and triangular resectional techniques. Additionally, neochord repair using at least 4 neochordae was associated with lower chordal forces on the primary chordae and the neochordae. This study provided key insights about mitral valve repair optimization and may further improve repair durability.
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Affiliation(s)
- Yuanjia Zhu
- Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA
- Department of Bioengineering (Y.Z., Y.J.W.), Stanford University, CA
| | - Shin Yajima
- Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA
| | - Matthew H Park
- Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA
- Department of Mechanical Engineering (M.H.P., P.K.P.), Stanford University, CA
| | - Akshay Venkatesh
- Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA
| | - Charles J Stark
- Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA
| | - Nicholas A Tran
- Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA
| | - Sabrina K Walsh
- Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA
| | - Sidarth Ethiraj
- Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA
| | - Robert J Wilkerson
- Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA
| | - Luca E Lin
- Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA
| | - Seung Hyun Lee
- Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA
| | - Kate Y Gates
- Department of Comparative Medicine (K.Y.G., J.D.A., S.W.B.), Stanford University, CA
| | - Justin D Arthur
- Department of Comparative Medicine (K.Y.G., J.D.A., S.W.B.), Stanford University, CA
| | - Sam W Baker
- Department of Comparative Medicine (K.Y.G., J.D.A., S.W.B.), Stanford University, CA
| | - Danielle M Mullis
- Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA
| | - Catherine A Wu
- Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA
| | - Shun Harima
- Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA
| | - Bipul Pokhrel
- Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA
| | - Dominique Resuello
- Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA
| | - Hunter Bergamasco
- Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA
| | - Matthew A Wu
- Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA
| | - Basil M Baccouche
- Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA
| | - Pearly K Pandya
- Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA
- Department of Mechanical Engineering (M.H.P., P.K.P.), Stanford University, CA
| | - Stefan Elde
- Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA
| | - Hanjay Wang
- Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery (Y.Z., S.Y., M.H.P., A.V., C.J.S., N.A.T., S.K.W., S. Ethiraj, R.J.W., L.E.L., S.H.L., D.M.M., C.A.W., S.H., B.P., D.R., H.B., M.A.W., B.M.B., P.K.P., S. Elde, H.W., Y.J.W.), Stanford University, CA
- Department of Bioengineering (Y.Z., Y.J.W.), Stanford University, CA
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Park MH, Pandya PK, Zhu Y, Mullis DM, Wang H, Imbrie-Moore AM, Wilkerson R, Marin-Cuartas M, Woo YJ. A Novel Rheumatic Mitral Valve Disease Model with Ex Vivo Hemodynamic and Biomechanical Validation. Cardiovasc Eng Technol 2023; 14:129-140. [PMID: 35941509 PMCID: PMC9905378 DOI: 10.1007/s13239-022-00641-3] [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: 10/22/2021] [Accepted: 07/08/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE Rheumatic heart disease is a major cause of mitral valve (MV) dysfunction, particularly in disadvantaged areas and developing countries. There lacks a critical understanding of the disease biomechanics, and as such, the purpose of this study was to generate the first ex vivo porcine model of rheumatic MV disease by simulating the human pathophysiology and hemodynamics. METHODS Healthy porcine valves were altered with heat treatment, commissural suturing, and cyanoacrylate tissue coating, all of which approximate the pathology of leaflet stiffening and thickening as well as commissural fusion. Hemodynamic data, echocardiography, and high-speed videography were collected in a paired manner for control and model valves (n = 4) in an ex vivo left heart simulator. Valve leaflets were characterized in an Instron tensile testing machine to understand the mechanical changes of the model (n = 18). RESULTS The model showed significant differences indicative of rheumatic disease: increased regurgitant fractions (p < 0.001), reduced effective orifice areas (p < 0.001), augmented transmitral mean gradients (p < 0.001), and increased leaflet stiffness (p = 0.025). CONCLUSION This work represents the creation of the first ex vivo model of rheumatic MV disease, bearing close similarity to the human pathophysiology and hemodynamics, and it will be used to extensively study both established and new treatment techniques, benefitting the millions of affected victims.
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Affiliation(s)
- Matthew H Park
- Department of Cardiothoracic Surgery, Stanford University, Falk Cardiovascular Research Building CV-235, 300 Pasteur Drive, Stanford, CA, 94305-5407, USA
- Department of Mechanical Engineering, Stanford University, Stanford, CA, USA
| | - Pearly K Pandya
- Department of Cardiothoracic Surgery, Stanford University, Falk Cardiovascular Research Building CV-235, 300 Pasteur Drive, Stanford, CA, 94305-5407, USA
- Department of Mechanical Engineering, Stanford University, Stanford, CA, USA
| | - Yuanjia Zhu
- Department of Cardiothoracic Surgery, Stanford University, Falk Cardiovascular Research Building CV-235, 300 Pasteur Drive, Stanford, CA, 94305-5407, USA
- Department of Bioengineering, Stanford University, Stanford, CA, USA
| | - Danielle M Mullis
- Department of Cardiothoracic Surgery, Stanford University, Falk Cardiovascular Research Building CV-235, 300 Pasteur Drive, Stanford, CA, 94305-5407, USA
| | - Hanjay Wang
- Department of Cardiothoracic Surgery, Stanford University, Falk Cardiovascular Research Building CV-235, 300 Pasteur Drive, Stanford, CA, 94305-5407, USA
| | - Annabel M Imbrie-Moore
- Department of Cardiothoracic Surgery, Stanford University, Falk Cardiovascular Research Building CV-235, 300 Pasteur Drive, Stanford, CA, 94305-5407, USA
- Department of Mechanical Engineering, Stanford University, Stanford, CA, USA
| | - Robert Wilkerson
- Department of Cardiothoracic Surgery, Stanford University, Falk Cardiovascular Research Building CV-235, 300 Pasteur Drive, Stanford, CA, 94305-5407, USA
| | - Mateo Marin-Cuartas
- Department of Cardiothoracic Surgery, Stanford University, Falk Cardiovascular Research Building CV-235, 300 Pasteur Drive, Stanford, CA, 94305-5407, USA
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University, Falk Cardiovascular Research Building CV-235, 300 Pasteur Drive, Stanford, CA, 94305-5407, USA.
- Department of Bioengineering, Stanford University, Stanford, CA, USA.
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