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Amin S, Dewey H, Lasso A, Sabin P, Han Y, Vicory J, Paniagua B, Herz C, Nam H, Cianciulli A, Flynn M, Laurence DW, Harrild D, Fichtinger G, Cohen MS, Jolley MA. Euclidean and Shape-Based Analysis of the Dynamic Mitral Annulus in Children using a Novel Open-Source Framework. J Am Soc Echocardiogr 2024; 37:259-267. [PMID: 37995938 PMCID: PMC10872766 DOI: 10.1016/j.echo.2023.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 11/08/2023] [Accepted: 11/08/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND The dynamic shape of the normal adult mitral annulus has been shown to be important to mitral valve function. However, annular dynamics of the healthy mitral valve in children have yet to be explored. The aim of this study was to model and quantify the shape and major modes of variation of pediatric mitral valve annuli in four phases of the cardiac cycle using transthoracic echocardiography. METHODS The mitral valve annuli of 100 children and young adults with normal findings on three-dimensional echocardiography were modeled in four different cardiac phases using the SlicerHeart extension for 3D Slicer. Annular metrics were quantified using SlicerHeart, and optimal normalization to body surface area was explored. Mean annular shapes and the principal components of variation were computed using custom code implemented in a new SlicerHeart module (Annulus Shape Analyzer). Shape was regressed over metrics of age and body surface area, and mean shapes for five age-stratified groups were generated. RESULTS The ratio of annular height to commissural width of the mitral valve ("saddle shape") changed significantly throughout age for systolic phases (P < .001) but within a narrow range (median range, 0.20-0.25). Annular metrics changed statistically significantly between the diastolic and systolic phases of the cardiac cycle. Visually, the annular shape was maintained with respect to age and body surface area. Principal-component analysis revealed that the pediatric mitral annulus varies primarily in size (mode 1), ratio of annular height to commissural width (mode 2), and sphericity (mode 3). CONCLUSIONS The saddle-shaped mitral annulus is maintained throughout childhood but varies significantly throughout the cardiac cycle. The major modes of variation in the pediatric mitral annulus are due to size, ratio of annular height to commissural width, and sphericity. The generation of age- and size-specific mitral annular shapes may inform the development of appropriately scaled absorbable or expandable mitral annuloplasty rings for children.
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Affiliation(s)
- Silvani Amin
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Hannah Dewey
- 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
| | - Patricia Sabin
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ye Han
- Kitware Inc., Clifton Park, New York
| | | | | | - Christian Herz
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Hannah Nam
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - 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
| | - Devin W Laurence
- Division of Pediatric Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - David Harrild
- Division of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Gabor Fichtinger
- Laboratory for Percutaneous Surgery, Queen's University, Kingston, Ontario, Canada
| | - Meryl S Cohen
- Department of Anesthesiology and Critical Care Medicine, 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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de Oliveira DC, Espino DM, Deorsola L, Buchan K, Dawson D, Shepherd DET. A geometry-based finite element tool for evaluating mitral valve biomechanics. Med Eng Phys 2023; 121:104067. [PMID: 37985031 DOI: 10.1016/j.medengphy.2023.104067] [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: 03/15/2023] [Revised: 09/08/2023] [Accepted: 10/30/2023] [Indexed: 11/22/2023]
Abstract
Mitral valve function depends on its complex geometry and tissue health, with alterations in shape and tissue response affecting the long-term restorarion of function. Previous computational frameworks for biomechanical assessment are mostly based on patient-specific geometries; however, these are not flexible enough to yield a variety of models and assess mitral closure for individually tuned morphological parameters or material property representations. This study details the finite element approach implemented in our previously developed toolbox to assess mitral valve biomechanics and showcases its flexibility through the generation and biomechanical evaluation of different models. A healthy valve geometry was generated and its computational predictions for biomechanics validated against data in the literature. Moreover, two mitral valve models including geometric alterations associated with disease were generated and analysed. The healthy mitral valve model yielded biomechanical predictions in terms of valve closure dynamics, leaflet stresses and papillary muscle and chordae forces comparable to previous computational and experimental studies. Mitral valve function was compromised in geometries representing disease, expressed by the presence of regurgitating areas, elevated stress on the leaflets and unbalanced subvalvular apparatus forces. This showcases the flexibility of the toolbox concerning the generation of a range of mitral valve models with varying geometric definitions and material properties and the evaluation of their biomechanics.
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Affiliation(s)
- Diana C de Oliveira
- Department of Mechanical Engineering, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom; Current affiliation: Department of Mechanical Engineering, University College London, Torrington Place, London WC1E 7JE, United Kingdom.
| | - Daniel M Espino
- Department of Mechanical Engineering, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom
| | - Luca Deorsola
- Paedriatic Cardiac Surgery, Ospedale Infantile Regina Margherita Sant Anna, Turin 10126, Italy
| | - Keith Buchan
- Department of Cardiothoracic Surgery, Aberdeen Royal Infirmary, Aberdeen AB24 2ZN, Scotland, UK
| | - Dana Dawson
- School of Medicine, University of Aberdeen, Aberdeen AB25 2ZD, Scotland, UK; Cardiology Department, Aberdeen Royal Infirmary, Aberdeen AB25 2ZN, Scotland, UK
| | - Duncan E T Shepherd
- Department of Mechanical Engineering, University of Birmingham, Edgbaston, Birmingham B15 2TT, United Kingdom
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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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Yang Y, Wang H, Song H, Hu Y, Gong Q, Xiong Y, Liu J, Ren W, Zhou Q. Morphological Evaluation of Mitral Valve Based on Three-dimensional Printing Models: Potential Implication for Mitral Valve Repair. BIO INTEGRATION 2021. [DOI: 10.15212/bioi-2021-0017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Abstract Objective: This study aimed to analyze the morphological characteristics of rheumatic (RMVD) and degenerative mitral valve diseases (DMVD) based on three-dimensional (3D) printing model before and after surgery and to explore the potential implication of the
3D printing model for mitral valve (MV) repair.Methods: 3D transesophageal echocardiography (TEE) data of the MV were acquired in 45 subjects (15 with RMVD, 15 with DMVD, and 15 with normal MV anatomy). 3D printing models of the MV were constructed by creating molds to be printed
with water-soluble polyvinyl alcohol, then filled with room temperature vulcanizing silicone. The parameters of the annulus and leaflet of the MV were acquired and analyzed using the 3D printing model. Mitral valve repair was simulated on 3D printing models of 10 subjects and compared with
the actual operation performed on patients. The effects of surgery were assessed by evaluating the changes in coaptation length (CL) and the annular height to commissural width ratio (AHCWR) before and after MV repairs. The correlations of the grade of mitral regurgitation with CL and AHCWR
were analyzed.Results: 3D silicone MV models were all successfully constructed based on 3D TEE data. Compared with the normal groups, the mitral annulus size in the RMVD groups showed no significant differences. In contrast, mitral annulus in DMVD groups was dilated and flattened
with diameters of anteroposterior, anterolateral-posteromedial, commissural width, annular circumferences, and area increased. Mitral repair was successfully simulated on 10 models with significant increase in leaflet coaptation area both in vivo and in vitro. Good agreement was observed in
CL and AHCWR after surgery in the 3D printing model compared with real surgery on the patient valve. The grade of mitral regurgitation correlated inversely with CL (r = ‐0.87, P < 0.01) and AHCWR (r = ‐0.79, P < 0.01). Mitral valve repair was performed twice
in one model to assess which provided a better outcome.Conclusions: 3D printing models of the MV based on 3D TEE data could be used in morphological analysis of the MV before and after surgery in RMVD and DMVD. Surgery simulation on 3D printing models could provide valuable information
concerning morphological changes after surgery, with are closely associated with clinical outcomes.
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Affiliation(s)
- Yuanting Yang
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Hao Wang
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Hongning Song
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Yugang Hu
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Qincheng Gong
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Ye Xiong
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Junbi Liu
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Wei Ren
- Department of Cardiovascular Surgery, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Qing Zhou
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan 430060, China
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de Oliveira DC, Espino DM, Deorsola L, Mynard JP, Rajagopal V, Buchan K, Dawson D, Shepherd DET. A toolbox for generating scalable mitral valve morphometric models. Comput Biol Med 2021; 135:104628. [PMID: 34246162 DOI: 10.1016/j.compbiomed.2021.104628] [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: 03/11/2021] [Revised: 06/25/2021] [Accepted: 07/02/2021] [Indexed: 11/26/2022]
Abstract
The mitral valve is a complex anatomical structure, whose shape is key to several traits of its function and disease, being crucial for the success of surgical repair and implantation of medical devices. The aim of this study was to develop a parametric, scalable, and clinically useful model of the mitral valve, enabling the biomechanical evaluation of mitral repair techniques through finite element simulations. MATLAB was used to parameterize the valve: the annular boundary was sampled from a porcine mitral valve mesh model and landmark points and relevant boundaries were selected for the parameterization of leaflets using polynomial fitting. Several geometric parameters describing the annulus, leaflet shape and papillary muscle position were implemented and used to scale the model according to patient dimensions. The developed model, available as a toolbox, allows for the generation of a population of models using patient-specific dimensions obtained from medical imaging or averaged dimensions evaluated from empirical equations based on the Golden Proportion. The average model developed using this framework accurately represents mitral valve shapes, associated with relative errors reaching less than 10% for annular and leaflet length dimensions, and less than 24% in comparison with clinical data. Moreover, model generation takes less than 5 min of computing time, and the toolbox can account for individual morphological variations and be employed to evaluate mitral valve biomechanics; following further development and validation, it will aid clinicians when choosing the best patient-specific clinical intervention and improve the design process of new medical devices.
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Affiliation(s)
- Diana C de Oliveira
- Department of Mechanical Engineering, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK.
| | - Daniel M Espino
- Department of Mechanical Engineering, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Luca Deorsola
- Paedriatic Cardiac Surgery, Ospedale Infantile Regina Margherita Sant Anna, Turin, 10126, Italy
| | - Jonathan P Mynard
- Department of Biomedical Engineering, The University of Melbourne, Melbourne, VIC, 3010, Australia; Heart Research, Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, VIC, 3052, Australia; Department of Paediatrics, The University of Melbourne, Melbourne, VIC, 3010, Australia; Department of Cardiology, Royal Children's Hospital, Melbourne, VIC, 3052, Australia
| | - Vijay Rajagopal
- Department of Biomedical Engineering, The University of Melbourne, Melbourne, VIC, 3010, Australia
| | - Keith Buchan
- Department of Cardiothoracic Surgery, Aberdeen Royal Infirmary, Aberdeen, AB24 2ZN, Scotland, UK
| | - Dana Dawson
- School of Medicine, University of Aberdeen, Aberdeen, AB25 2ZD, Scotland, UK; Cardiology Department, Aberdeen Royal Infirmary, Aberdeen, AB25 2ZN, Scotland, UK
| | - Duncan E T Shepherd
- Department of Mechanical Engineering, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
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Naser JA, Kucuk HO, Ciobanu AO, Jouni H, Oguz D, Thaden JJ, Pislaru C, Pellikka PA, Foley TA, Eleid MF, Muraru D, Nkomo VT, Pislaru SV. Atrial fibrillation is associated with large beat-to-beat variability in mitral and tricuspid annulus dimensions. Eur Heart J Cardiovasc Imaging 2021:jeab033. [PMID: 33724363 DOI: 10.1093/ehjci/jeab033] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Indexed: 11/13/2022] Open
Abstract
AIMS Beat-to-beat variability in cycle length is well-known in atrial fibrillation (Afib); whether this also translates to variability in annulus size remains unknown. Defining annulus maximal size in Afib is critical for accurate selection of percutaneous devices given the frequent association with mitral and tricuspid valve diseases. METHODS AND RESULTS Images were obtained from 170 patients undergoing 3D echocardiography [100 (50 sinus rhythm (SR) and 50 Afib) for mitral annulus (MA) and 70 (35 SR and 35 Afib) for tricuspid annulus (TA)]. Images were analysed for differences in annular dynamics with a commercially available software. Number of cardiac cycles analysed was 567 in mitral valve and 346 in tricuspid valve. Median absolute difference in maximal MA area over four to six cycles was 1.8 cm2 (range 0.5-5.2 cm2) in Afib vs. 0.8 cm2 (range 0.1-2.9 cm2) in SR, P < 0.001. Maximal MA area was observed within 30-70% of the R-R interval in 81% of cardiac cycles in SR and in 73% of cycles in Afib. Median absolute difference in maximal TA area over four to six cycles was 1.4 cm2 (range 0.5-3.6 cm2) in Afib vs. 0.7 cm2 (range 0.3-1.7 cm2) in SR, P < 0.001. Maximal TA area was observed within 60-100% of the R-R interval in 81% of cardiac cycles in SR, but only in 49% of cycles in Afib. CONCLUSION MA and TA reach maximal size within a broad time interval centred around end-systole and end-diastole, respectively, with significant beat-to-beat variability. Afib leads to a larger beat-to-beat variability in both timing of occurrence and values of annulus size than in SR.
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Affiliation(s)
- Jwan A Naser
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
| | - Hilal Olgun Kucuk
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
| | - Andrea O Ciobanu
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
- University and Emergency Hospital Bucharest, Bucharest, Romania
| | - Hayan Jouni
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
| | - Didem Oguz
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
| | - Cristina Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
| | - Patricia A Pellikka
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
| | - Thomas A Foley
- Department of Radiology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
| | - Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
| | - Denisa Muraru
- IRCCS, Instituto Auxologico Italiano, S. Luca Hospital, University of Milano-Bicocca, Milan, Italy
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
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Arrhythmic Mitral Valve Prolapse: Introducing an Era of Multimodality Imaging-Based Diagnosis and Risk Stratification. Diagnostics (Basel) 2021; 11:diagnostics11030467. [PMID: 33800155 PMCID: PMC7999774 DOI: 10.3390/diagnostics11030467] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/04/2021] [Accepted: 03/05/2021] [Indexed: 01/13/2023] Open
Abstract
Mitral valve prolapse is a common cardiac condition, with an estimated prevalence between 1% and 3%. Most patients have a benign course, but ever since its initial description mitral valve prolapse has been associated to sudden cardiac death. Although the causal relationship between mitral valve prolapse and sudden cardiac death has never been clearly demonstrated, different factors have been implicated in arrhythmogenesis in patients with mitral valve prolapse. In this work, we offer a comprehensive overview of the etiology and the genetic background, epidemiology, pathophysiology, and we focus on the state-of-the-art imaging-based diagnosis of mitral valve prolapse. Going beyond the classical, well-described clinical factors, such as young age, female gender and auscultatory findings, we investigate multimodality imaging features, such as alterations of anatomy and function of the mitral valve and its leaflets, the structural and contractile anomalies of the myocardium, all of which have been associated to sudden cardiac death.
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Oliveira D, Srinivasan J, Espino D, Buchan K, Dawson D, Shepherd D. Geometric description for the anatomy of the mitral valve: A review. J Anat 2020; 237:209-224. [PMID: 32242929 DOI: 10.1111/joa.13196] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 03/06/2020] [Accepted: 03/09/2020] [Indexed: 12/16/2022] Open
Abstract
The mitral valve is a complex anatomical structure whose physiological functioning relies on the biomechanical properties and structural integrity of its components. Their compromise can lead to mitral valve dysfunction, associated with morbidity and mortality. Therefore, a review on the morphometry of the mitral valve is crucial, more specifically on the importance of valve dimensions and shape for its function. This review initially provides a brief background on the anatomy and physiology of the mitral valve, followed by an analysis of the morphological information available. A characterisation of mathematical descriptions of several parts of the valve is performed and the impact of different dimensions and shape changes in disease is then outlined. Finally, a section regarding future directions and recommendations for the use of morphometric information in clinical analysis of the mitral valve is presented.
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Affiliation(s)
- Diana Oliveira
- Department of Mechanical Engineering, University of Birmingham, Birmingham, UK
| | | | - Daniel Espino
- Department of Mechanical Engineering, University of Birmingham, Birmingham, UK
| | - Keith Buchan
- Department of Cardiothoracic Surgery, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Dana Dawson
- Cardiology Research Facility, University of Aberdeen and Aberdeen Royal Infirmary, Aberdeen, UK
| | - Duncan Shepherd
- Department of Mechanical Engineering, University of Birmingham, Birmingham, UK
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Aruta P, Muraru D, Guta AC, Mihaila S, Ruozi N, Palermo C, Elnagar B, Iliceto S, Badano LP. Comparison of mitral annulus geometry between patients with ischemic and non-ischemic functional mitral regurgitation: implications for transcatheter mitral valve implantation. Cardiovasc Ultrasound 2018; 16:27. [PMID: 30314517 PMCID: PMC6186037 DOI: 10.1186/s12947-018-0145-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 09/24/2018] [Indexed: 12/11/2022] Open
Abstract
Background Transcatheter mitral valve replacement (TMVR) is a new therapeutic option for high surgical risk patients with mitral regurgitation (MR). Mitral valve (MV) geometry quantification is of paramount importance for success of the procedure and transthoracic 3D echocardiography represents a useful screening tool. Accordingly, we sought to asses MV geometry in patients with functional MR (FMR) that would potentially benefit of TMVR, focusing on the comparison of mitral annulus (MA) geometry between patients with ischemic (IMR) and non ischemic mitral regurgitation (nIMR). Methods We retrospectively selected 94 patients with severe FMR: 41 (43,6%) with IMR and 53 (56,4%) with nIMR. 3D MA analysis was performed on dedicated transthoracic 3D data sets using a new, commercially-available software package in two moments of the cardiac cycle (early-diastole and mid-systole). We measured MA dimension and geometry parameters, left atrial and left ventricular volumes. Results Maximum (MA area 10.7 ± 2.5 cm2 vs 11.6 ± 2.7 cm2, p > 0.05) and the best fit plane MA area (9.9 ± 2.3 cm2 vs 10.7 ± 2.5 cm2, p > 0.05, respectively) were similar between IMR and nIMR. nIMR patients showed larger mid-systolic 3D area (9.8 ± 2.3 cm2 vs 10.8 ± 2.7 cm2, p < 0.05) and perimeter (11.2 ± 1.3 cm vs 11.8 ± 1.5 cm, p < 0.05) with longer and larger leaflets, and wider aorto-mitral angle (135 ± 10° vs 141 ± 11°, p < 0.05). Conversely, the area of MA at the best fit plane did not differ between IMR and nIMR patients (9 ± 1.1 cm2 vs 9.9 ± 1.5 cm2, p > 0.05). Conclusions Patients with ischemic and non-ischemic etiology of FMR have similar maximum dimension, yet systolic differences between the two groups should be taken into account to tailor prosthesis’s selection. Trial registration N.A.
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Affiliation(s)
- Patrizia Aruta
- Department of Cardiac, Thoracic and Vascular Science, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Denisa Muraru
- Department of Cardiac, Thoracic and Vascular Science, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Andrada Camelia Guta
- Department of Cardiac, Thoracic and Vascular Science, University of Padua, Via Giustiniani 2, 35128, Padua, Italy.,University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
| | - Sorina Mihaila
- University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
| | - Niccolò Ruozi
- Department of Cardiac, Thoracic and Vascular Science, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Chiara Palermo
- Department of Cardiac, Thoracic and Vascular Science, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | | | - Sabino Iliceto
- Department of Cardiac, Thoracic and Vascular Science, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Luigi P Badano
- Department of Cardiac, Thoracic and Vascular Science, University of Padua, Via Giustiniani 2, 35128, Padua, Italy.
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Jolley MA, Ghelani SJ, Adar A, Harrild DM. Three-Dimensional Mitral Valve Morphology and Age-Related Trends in Children and Young Adults with Structurally Normal Hearts Using Transthoracic Echocardiography. J Am Soc Echocardiogr 2017; 30:561-571. [PMID: 28391001 DOI: 10.1016/j.echo.2017.01.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Indexed: 10/19/2022]
Abstract
BACKGROUND The mitral valve has a complex three-dimensional (3D) morphology that is incompletely described by two-dimensional echocardiography (echo). Three-dimensional echo provides a more robust tool to analyze the mitral valve. The shape of the mitral annulus and leaflets, and differences with age, have not been described by 3D echo in normal children. Our objective was to characterize and quantify the 3D mitral valve morphology in children with normal transthoracic echocardiograms over a broad spectrum of age and to identify differences in valve shape with age. METHODS Three-dimensional midsystolic mitral valve models were constructed in 100 children and young adults with normal echocardiograms using 3D transthoracic images. Annular and leaflet metrics were quantified and regression equations were prepared. Interuser and intrauser variability was measured. RESULTS Two hundred fifty patients, from neonate to young adult, were retrospectively reviewed to obtain 100 evaluable patients (40% evaluable). The annular height to commissural width ratio of the mitral valve ("saddle shape") was preserved across age (median 24.3, IQR 21.8-28.1). Three-dimensional mitral valve area, length, and volume parameters were linearly related to body surface area (P < .001). The ratio of anterior to posterior leaflet length and posterior leaflet angle increased with body surface area (P = .0004 and .002, respectively) suggesting posterior movement of the coaptation line. Two-dimensional lateral annular diameter underestimated 3D lateral annular metrics (P < .001, mean difference 20-22%) but was highly correlated (R > 0.87, P < .001). Interuser and intrauser variability were acceptable. CONCLUSIONS Assessment of 3D mitral valve morphology in children is possible in a modern clinical pediatric echocardiography laboratory using transthoracic images, although further optimization of imaging is needed. The saddle shape of the mitral annulus was preserved across age and size. Most mitral valve parameters increased linearly with patient size. Further investigation is warranted to explore changes in valve morphology in the pediatric population in health and with disease.
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Affiliation(s)
- Matthew A Jolley
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatric Cardiac Anesthesia and Pediatric Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Sunil J Ghelani
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Adi Adar
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - David M Harrild
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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Owais K, Montealegre-Gallegos M, Jeganathan J, Matyal R, Khabbaz KR, Mahmood F. Dynamic changes in the ischemic mitral annulus: Implications for ring sizing. Ann Card Anaesth 2016; 19:15-9. [PMID: 26750668 PMCID: PMC4900374 DOI: 10.4103/0971-9784.173014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Contrary to the rest of the mitral annulus, inter-trigonal distance is known to be relatively less dynamic during the cardiac cycle. Therefore, intertrigonal distance is considered a suitable benchmark for annuloplasty ring sizing during mitral valve (MV) surgery. The entire mitral annulus dilates and flattens in patients with ischemic mitral regurgitation (IMR). It is assumed that the fibrous trigone of the heart and the intertrigonal distance does not dilate. In this study, we sought to demonstrate the changes in mitral annular geometry in patients with IMR and specifically analyze the changes in intertrigonal distance during the cardiac cycle. METHODS Intraoperative three-dimensional transesophageal echocardiographic data obtained from 26 patients with normal MVs undergoing nonvalvular cardiac surgery and 36 patients with IMR undergoing valve repair were dynamically analyzed using Philips Qlab ® software. RESULTS Overall, regurgitant valves were larger in area and less dynamic than normal valves. Both normal and regurgitant groups displayed a significant change in annular area (AA) during the cardiac cycle (P < 0.01 and P < 0.05, respectively). Anteroposterior and anterolateral-posteromedial diameters and inter-trigonal distance increased through systole (P < 0.05 for all) in accordance with the AAs in both groups. However, inter-trigonal distance showed the least percentage change across the cardiac cycle and its reduced dynamism was validated in both cohorts (P > 0.05). CONCLUSIONS Annular dimensions in regurgitant valves are dynamic and can be measured feasibly and accurately using echocardiography. The echocardiographically identified inter-trigonal distance does not change significantly during the cardiac cycle.
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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
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Cardiac Imaging-3-Dimensional Echocardiography. Int Anesthesiol Clin 2016; 54:39-53. [PMID: 26655508 DOI: 10.1097/aia.0000000000000082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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14
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Ramakrishna H, Gutsche JT, Evans AS, Patel PA, Weiner M, Morozowich ST, Gordon EK, Riha H, Shah R, Ghadimi K, Zhou E, Fernadno R, Yoon J, Wakim M, Atchley L, Weiss SJ, Stein E, Silvay G, Augoustides JGT. The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights From 2015. J Cardiothorac Vasc Anesth 2015; 30:1-9. [PMID: 26847747 DOI: 10.1053/j.jvca.2015.09.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Indexed: 12/14/2022]
Affiliation(s)
| | - Jacob T Gutsche
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Adam S Evans
- Icahn School of Medicine, Mount Sinai Hospital, New York, NY
| | - Prakash A Patel
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Menachem Weiner
- Icahn School of Medicine, Mount Sinai Hospital, New York, NY
| | | | - Emily K Gordon
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Hynek Riha
- Department of Anesthesiology and Intensive Care Medicine, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Ronak Shah
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Kamrouz Ghadimi
- Department of Anesthesiology and Critical Care, Duke University, Durham, NC
| | - Elizabeth Zhou
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Rohesh Fernadno
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jeongae Yoon
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Mathew Wakim
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lance Atchley
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Stuart J Weiss
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Erica Stein
- Department of Anesthesiology, Ohio State University, Columbus, OH
| | - George Silvay
- Icahn School of Medicine, Mount Sinai Hospital, New York, NY
| | - John G T Augoustides
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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A Quantitative Approach to the Intraoperative Echocardiographic Assessment of the Mitral Valve for Repair. Anesth Analg 2015; 121:34-58. [DOI: 10.1213/ane.0000000000000726] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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