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Iwasieczko A, Jazwiec T, Gaddam M, Gaweda B, Piekarska M, Solarewicz M, Rausch MK, Timek TA. Septal annular dilation in chronic ovine functional tricuspid regurgitation. J Thorac Cardiovasc Surg 2023; 166:e393-e403. [PMID: 37061178 PMCID: PMC11088945 DOI: 10.1016/j.jtcvs.2023.04.003] [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: 01/29/2023] [Revised: 03/19/2023] [Accepted: 04/05/2023] [Indexed: 04/17/2023]
Abstract
INTRODUCTION Annular reduction with prosthetic rings represents the current surgical treatment of functional tricuspid regurgitation (FTR). However, alterations of annular geometry and dynamics associated with FTR are not well characterized. METHODS FTR was induced in 29 adult sheep with either 8 weeks of pulmonary artery banding (PAB, n = 15) or 3 weeks of tachycardia-induced cardiomyopathy (TIC, n = 14). Eight healthy sheep served as controls (CTL). At the terminal procedure, all animals underwent sternotomy, epicardial echocardiography, and implantation of sonomicrometry crystals on the tricuspid annulus (TA) and right ventricular free wall while on cardiopulmonary bypass. Simultaneous hemodynamic, sonomicrometry, and echocardiographic data were acquired after weaning from cardiopulmonary bypass and stabilization. Annular geometry and dynamics were calculated from 3-dimensional crystal coordinates. RESULTS Mean FTR grade (0-4) was 3.2 ± 1.2 and 3.2 ± 0.5 for PAB and TIC, respectively, with both models of FTR associated with similar degree of right ventricular dysfunction (right ventricular fractional area contraction 38 ± 7% and 37 ± 9% for PAB and TIC, respectively). Left ventricular ejection fraction was significantly reduced in TIC versus baseline (33 ± 9%, vs 58 ± 4%, P = .0001). TA area was 651 ± 109 mm2, 881 ± 242 mm2, and 995 ± 232 mm2 for CTL, FTR, and TIC, respectively (P = .006) with TA area contraction of 16.6 ± 4.2%, 11.5 ± 8.0%, and 6.0 ± 4.0%, respectively (P = .003). Septal annulus increased from 33.8 ± 3.1 mm to 39.7 ± 6.4 mm and 43.1 ± 3.2 mm for CTL, PAB, and TIC, respectively (P < .0001). CONCLUSIONS Ovine FTR was associated with annular dilation and reduced annular area contraction. Significant dilation of septal annulus was observed in both models of FTR. As tricuspid rings do not completely stabilize the septal annulus, continued remodeling may contribute to recurrent FTR after repair.
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Affiliation(s)
- Artur Iwasieczko
- Division of Cardiothoracic Surgery, Corewell Health, Grand Rapids, Mich; Clinical Department of Cardiac Surgery, St Jadwiga Provincial Clinical Hospital, Rzeszow, Poland
| | - Tomasz Jazwiec
- Department of Cardiac Surgery, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Manikantam Gaddam
- Division of Cardiothoracic Surgery, Corewell Health, Grand Rapids, Mich
| | - Boguslaw Gaweda
- Division of Cardiothoracic Surgery, Corewell Health, Grand Rapids, Mich; Clinical Department of Cardiac Surgery, St Jadwiga Provincial Clinical Hospital, Rzeszow, Poland
| | | | - M Solarewicz
- Division of Cardiothoracic Surgery, Corewell Health, Grand Rapids, Mich
| | - Manuel K Rausch
- Departments of Aerospace Engineering & Engineering Mechanics, Biomedical Engineering, University of Texas at Austin, Austin, Tex
| | - Tomasz A Timek
- Division of Cardiothoracic Surgery, Corewell Health, Grand Rapids, Mich.
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Pettinari M, De Kerchove L, Van Dyck M, Pasquet A, Gerber B, El-Khoury G, Vanoverschelde JL. Tricuspid annular dynamics, not diameter, predicts tricuspid regurgitation after mitral valve surgery: Results from a prospective randomized trial. JTCVS OPEN 2023; 14:92-101. [PMID: 37425472 PMCID: PMC10328816 DOI: 10.1016/j.xjon.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
Objective Current guidelines advise using prophylactic tricuspid valve annuloplasty during mitral valve surgery, especially in the presence of annular diameter enlargement. However, several retrospective studies and a prospective randomized study from our department could not confirm that diameter enlargement is predictive of late regurgitation. We examined whether 2- and 3-dimensional echocardiographic and clinical characteristics could identify patients who will develop moderate or severe recurrent tricuspid regurgitation. Methods Patients with less than severe functional tricuspid regurgitation (FTR) were randomized not to receive tricuspid annuloplasty, and 11 of 53 of them were excluded from the study because 3-dimensional echocardiographic analysis was not possible. Cox regression was used to estimate the model-based probability of moderate or severe FTR (vena contracta ≥3 mm) or progression of TR and FTR regression using valve dimensions (annulus area, diameter perimeter, nonplanar angle, and sphericity index), dynamics (annulus contraction, annulus displacement, and displacement velocity), and clinical parameters as possible predictors. Results At a median follow-up of 3.8 years (range, 3-5.6 years), 17 patients had moderate or severe FTR or progression, and 13 had FTR regression. Our models identified annular displacement velocity as a significant predictor for FTR recurrence and nonplanar angle as a significant predictor for FTR regression. Conclusions Annular dynamics, not the dimension, predict recurrence and regression of FTR. Annular contraction should be systematically investigated as a possible surrogate of right ventricle function to prophylactically treat the tricuspid valve.
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Affiliation(s)
- Matteo Pettinari
- Cardiac Surgery Department, Ziekenhuis Oost Limburg, Genk, Belgium
| | - Laurent De Kerchove
- Division of Cardiovascular and Thoracic Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Universitè Catholique de Louvain, Brussels, Belgium
| | - Michel Van Dyck
- Division of Anesthesiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Agnes Pasquet
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Universitè Catholique de Louvain, Brussels, Belgium
- Division of Cardiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Bernhard Gerber
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Universitè Catholique de Louvain, Brussels, Belgium
- Division of Cardiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Gebrine El-Khoury
- Division of Cardiovascular and Thoracic Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Universitè Catholique de Louvain, Brussels, Belgium
| | - Jean-Louis Vanoverschelde
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Universitè Catholique de Louvain, Brussels, Belgium
- Division of Cardiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
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Iwasieczko A, Malinowski M, Solarewicz M, Bush J, MacDougall B, Rausch M, Timek TA. Impact of reductive tricuspid ring annuloplasty on right ventricular size, geometry and strain in an ovine model of functional tricuspid regurgitation. Interact Cardiovasc Thorac Surg 2022; 35:6628589. [PMID: 35781336 PMCID: PMC9270866 DOI: 10.1093/icvts/ivac187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 06/18/2022] [Accepted: 06/01/2022] [Indexed: 11/14/2022] Open
Abstract
Abstract
OBJECTIVES
Reductive ring annuloplasty of the tricuspid annulus represents the contemporary surgical approach to functional tricuspid regurgitation (FTR). We set out to investigate the influence of moderate reductive tricuspid ring annuloplasty on tricuspid regurgitation and right ventricular (RV) size, geometry and strain in an ovine model of chronic FTR.
METHODS
Eight healthy Dorsett male sheep (62.8 + 2kg) underwent a left thoracotomy for placement and tightening of pulmonary artery band to at least double proximal pulmonary artery blood pressure. After 8 weeks of recovery, animals underwent sternotomy, epicardial echocardiography and sonomicrometry crystal implantation. Six crystals were placed around tricuspid annulus and 13 on RV free wall epicardium along 3 parallels defining 3 wall regions (basal, mid and lower) and 1 on the RV apex. All animals underwent beating heart implantation of 26 mm MC3 annuloplasty ring during a second cardiopulmonary bypass run after baseline data acquisition. Simultaneous haemodynamic, sonomicrometry and echocardiography data were acquired at Baseline and after reductive tricuspid ring annuloplasty.
RESULTS
Implantation of reductive ring annuloplasty resulted in 47 ± 7% annular area reduction (996 ± 152 mm vs 516 ± 52 mm2, P = 0.0002) and significantly decreased RV end-diastolic volume (185 ± 27 vs 165 ± 30 ml, P = 0.02). Tricuspid ring annuloplasty effectively reduced FTR grade (3.75 ± 0.6 vs 0.3 ± 0.5, P = 0.00004) and had little influence on RV function, cross-sectional area, radius of curvature or free wall regional strains.
CONCLUSIONS
In adult sheep with 8 weeks of pulmonary artery banding and FTR, tricuspid annulus reduction of 47% with prosthetic ring annuloplasty effectively abolished FTR while maintaining regional RV function and strain patterns.
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Affiliation(s)
- Artur Iwasieczko
- Division of Cardiothoracic Surgery, Spectrum Health , Michigan State College of Human Medicine, Grand Rapids, MI, USA
- Clinical Department of Cardiac Surgery, District Hospital No. 2, University of Rzeszow , Rzeszow, Poland
| | - Marcin Malinowski
- Department of Cardiac Surgery, Medical University of Silesia, School of Medicine in Katowice , Katowice, Poland
| | - Monica Solarewicz
- Division of Cardiothoracic Surgery, Spectrum Health , Michigan State College of Human Medicine, Grand Rapids, MI, USA
| | - Jared Bush
- Division of Cardiothoracic Surgery, Spectrum Health , Michigan State College of Human Medicine, Grand Rapids, MI, USA
| | - Brian MacDougall
- Division of Cardiothoracic Surgery, Spectrum Health , Michigan State College of Human Medicine, Grand Rapids, MI, USA
| | - Manuel Rausch
- Department of Aerospace Engineering & Engineering Mechanics, Department of Biomedical Engineering, Institute of Computational Engineering and Science, University of Texas at Austin , Austin, TX, USA
| | - Tomasz A Timek
- Division of Cardiothoracic Surgery, Spectrum Health , Michigan State College of Human Medicine, Grand Rapids, MI, USA
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Teng P, Dai X, Zou Y, Yuan S, Chen Y, Ma L, Ni Y. Tricuspid Annulus Dilation in Patients With Combined Functional Tricuspid Regurgitation and Left-Heart Valvular Disease: Does Septal Annulus Not Dilate? Front Cardiovasc Med 2022; 9:889163. [PMID: 35557516 PMCID: PMC9086675 DOI: 10.3389/fcvm.2022.889163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 04/04/2022] [Indexed: 11/24/2022] Open
Abstract
Background This study aimed to investigate the course of tricuspid annulus dilation in functional tricuspid regurgitation with varied severities by direct intraoperative assessment. Methods A total of 317 patients who underwent left heart surgery and concomitant tricuspid repair were divided into three groups according to the severity of the functional tricuspid regurgitation (mild, moderate and severe). Demographic and echocardiographic data were collected. The length of each tricuspid annulus segment was measured intraoperatively. The risk factors for preoperative severe functional tricuspid regurgitation and its postoperative recurrence were identified, and the impact of each tricuspid annulus segment on postoperative recurrence was compared. Results In the course of tricuspid annulus dilation, the posterior annulus dilated 17% (group 1: 33.31 ± 6.94 mm vs. group 2: 35.56 ± 7.63 vs. group 3: 38.98 ± 8.70, p < 0.01), the anterior annulus dilated 13.4% (group 1: 36.71 ± 6.30 mm vs. group 2: 38.21 ± 8.35 vs. group 3: 41.63 ± 9.20, p < 0.01), and the septal annulus dilated 11.4% (group 1: 38.11 ± 5.28 mm vs. group 2: 39.76 ± 6.90 vs. group 3: 42.46 ± 7.50, p < 0.01). Tricuspid annulus circumference index (p < 0.01) independently correlated with preoperative severe tricuspid regurgitation and postoperative recurrence. When patients were grouped based on the length of each segment, the septal annulus demonstrated significantly higher sensitivity (p < 0.001) to postoperative recurrence than the anterior (p = 0.085) or posterior annulus (p = 0.262). Conclusions This study revealed that each segment of tricuspid annulus could dilate in functional tricuspid regurgitation and highlighted the potential benefits of septal annulus plication in tricuspid annuloplasty, which may aid in the development of a methodology for prosthetic ring annuloplasty.
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Affiliation(s)
- Peng Teng
- Department of Cardiovascular Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Xiaoyi Dai
- College of Medicine, Zhejiang University, Hangzhou, China
| | - Yu Zou
- Department of Cardiovascular Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Shuai Yuan
- Department of Echocardiography and Vascular Ultrasound Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yan Chen
- Department of Echocardiography and Vascular Ultrasound Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Liang Ma
- Department of Cardiovascular Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yiming Ni
- Department of Cardiovascular Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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Malinowski M, Jazwiec T, Ferguson H, Bush J, Rausch MK, Timek TA. Tricuspid leaflet kinematics after annular size reduction in ovine functional tricuspid regurgitation. J Thorac Cardiovasc Surg 2021; 164:e353-e366. [PMID: 33685738 DOI: 10.1016/j.jtcvs.2021.01.104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 01/24/2021] [Accepted: 01/25/2021] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Tricuspid annular size reduction with annuloplasty rings represents the foundation of surgical repair of functional tricuspid regurgitation. However, the precise effect of annular size reduction on leaflet motion and geometry remains unknown. METHODS Ten sheep underwent surgical implantation of a pacemaker with an epicardial lead and were paced 200-240 beats/min to achieve biventricular dysfunction and functional tricuspid regurgitation. Subsequently, sonomicrometry crystals were implanted on the right ventricle, the tricuspid annulus, and on the belly of anterior, posterior, and septal tricuspid leaflets. Double-layer polypropylene suture was placed around the tricuspid annulus and externalized to a tourniquet. Simultaneous echocardiographic, hemodynamic, and sonomicrometry data were acquired with functional tricuspid regurgitation and during 5 consecutive annular reduction steps. Annular area, tenting height, and volume, together with each leaflet strain, radial length, and angles, were calculated from crystal coordinates. RESULTS Rapid pacing reduced both left ventricle and right ventricle function and induced functional tricuspid regurgitation (0-3+) in all animals (from 0 ± 0 to 2.4 ± 0.7, P = .002), whereas tricuspid annulus diameter increased from 2.6 ± 0.3 cm to 3.3 ± 0.3 cm (P = .001). Tricuspid annular size reduction 1 to 5 resulted in 16% ± 7%, 37% ± 11%, 55% ± 11%, 66% ± 10%, and 76% ± 8% tricuspid annulus area reduction, respectively, and successively decreased tricuspid regurgitation. Tricuspid annular size reduction 2 to 5 induced anterior and posterior leaflet restricted motion and lower diastolic motion velocities. Tricuspid annular size reduction 5 perturbed septal leaflet range of motion but preserved its angle velocities. Tricuspid annular size reduction 3-5 generated compressive strains in all leaflets. CONCLUSIONS Tricuspid annular area reduction of 55% perturbed anterior and posterior leaflet motion while maintaining normal septal leaflet movement. More extreme reduction triggered profound changes in anterior and posterior leaflet motion, suggesting that aggressive undersizing impairs leaflet kinematics.
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Affiliation(s)
- Marcin Malinowski
- Division of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, Mich; Department of Cardiac Surgery, Medical University of Silesia School of Medicine in Katowice, Katowice, Poland
| | - Tomasz Jazwiec
- Division of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, Mich; Department of Cardiac, Vascular, and Endovascular Surgery and Transplantology, Medical University of Silesia School of Medicine in Katowice, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Haley Ferguson
- Division of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, Mich
| | - Jared Bush
- Division of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, Mich
| | - Manuel K Rausch
- Departments of Aerospace Engineering and Engineering Mechanics and Biomedical Engineering, Oden Institute for Computational Engineering and Sciences, University of Texas at Austin, Austin, Tex
| | - Tomasz A Timek
- Division of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, Mich.
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The influence of tricuspid annuloplasty prostheses on ovine annular geometry and kinematics. J Thorac Cardiovasc Surg 2021; 161:e191-e207. [DOI: 10.1016/j.jtcvs.2019.09.060] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 09/06/2019] [Accepted: 09/09/2019] [Indexed: 11/19/2022]
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Meador WD, Mathur M, Sugerman GP, Jazwiec T, Malinowski M, Bersi MR, Timek TA, Rausch MK. A detailed mechanical and microstructural analysis of ovine tricuspid valve leaflets. Acta Biomater 2020; 102:100-113. [PMID: 31760220 PMCID: PMC7325866 DOI: 10.1016/j.actbio.2019.11.039] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 11/14/2019] [Accepted: 11/19/2019] [Indexed: 12/26/2022]
Abstract
The tricuspid valve ensures unidirectional blood flow from the right atrium to the right ventricle. The three tricuspid leaflets operate within a dynamic stress environment of shear, bending, tensile, and compressive forces, which is cyclically repeated nearly three billion times in a lifetime. Ostensibly, the microstructural and mechanical properties of the tricuspid leaflets have mechanobiologically evolved to optimally support their function under those forces. Yet, how the tricuspid leaflet microstructure determines its mechanical properties and whether this relationship differs between the three leaflets is unknown. Here we perform a microstructural and mechanical analysis in matched ovine tricuspid leaflet samples. We found that the microstructure and mechanical properties vary among the three tricuspid leaflets in sheep. Specifically, we found that tricuspid leaflet composition, collagen orientation, and valve cell nuclear morphology are spatially heterogeneous and vary across leaflet type. Furthermore, under biaxial tension, the leaflets' mechanical behaviors exhibited unequal degrees of mechanical anisotropy. Most importantly, we found that the septal leaflet was stiffer in the radial direction and not the circumferential direction as with the other two leaflets. The differences we observed in leaflet microstructure coincide with the varying biaxial mechanics among leaflets. Our results demonstrate the structure-function relationship for each leaflet in the tricuspid valve. We anticipate our results to be vital toward developing more accurate, leaflet-specific tricuspid valve computational models. Furthermore, our results may be clinically important, informing differential surgical treatments of the tricuspid valve leaflets. Finally, the identified structure-function relationships may provide insight into the homeostatic and remodeling potential of valvular cells in altered mechanical environments, such as in diseased or repaired tricuspid valves. STATEMENT OF SIGNIFICANCE: Our work is significant as we investigated the structure-function relationship of ovine tricuspid valve leaflets. This is important as tricuspid valves fail frequently and our current approach to repairing them is suboptimal. Specifically, we related the distribution of structural and cellular elements, such as collagen, glycosaminoglycans, and cell nuclei, to each leaflet's mechanical properties. We found that leaflets have different structures and that their mechanics differ. This may, in the future, inform leaflet-specific treatment strategies and help optimize surgical outcomes.
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Affiliation(s)
- William D Meador
- Department of Biomedical Engineering, The University of Texas at Austin, Austin, TX 78705, USA
| | - Mrudang Mathur
- Department of Mechanical Engineering, The University of Texas at Austin, Austin, TX 78705, USA
| | - Gabriella P Sugerman
- Department of Biomedical Engineering, The University of Texas at Austin, Austin, TX 78705, USA
| | - Tomasz Jazwiec
- Cardiothoracic Surgery, Spectrum Health, Grand Rapids, MI 49503, USA; Department of Cardiac, Vascular, and Endovascular Surgery and Transplantology, Medical University of Silesia School of Medicine in Katowice, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Marcin Malinowski
- Cardiothoracic Surgery, Spectrum Health, Grand Rapids, MI 49503, USA; Department of Cardiac Surgery, Medical University of Silesia School of Medicine in Katowice, Katowice, Poland
| | - Matthew R Bersi
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN 37235, USA
| | - Tomasz A Timek
- Cardiothoracic Surgery, Spectrum Health, Grand Rapids, MI 49503, USA
| | - Manuel K Rausch
- Department of Biomedical Engineering, The University of Texas at Austin, Austin, TX 78705, USA; Department of Mechanical Engineering, The University of Texas at Austin, Austin, TX 78705, USA; Department of Aerospace Engineering and Engineering Mechanics, The University of Texas at Austin, Austin, TX 78705, USA.
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Rausch MK, Mathur M, Meador WD. Biomechanics of the Tricuspid Annulus: A Review of the Annulus' In Vivo Dynamics With Emphasis on Ovine Data. MITTEILUNGEN DER GESELLSCHAFT FUR ANGEWANDTE MATHEMATIK UND MECHANIK 2019; 42:e201900012. [PMID: 38690196 PMCID: PMC11058966 DOI: 10.1002/gamm.201900012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 01/28/2019] [Indexed: 05/02/2024]
Abstract
The tricuspid annulus forms the boundary between the tricuspid valve leaflets and their surrounding perivalvular tissue of the right atrioventricular junction. Its shape changes throughout the cardiac cycle in response to the forces from the contracting right heart myocardium and the blood-valve interaction. Alterations to annular shape and dynamics in disease lead to valvular dysfunctions such as tricuspid regurgitation from which millions of patients suffer. Successful treatment of such dysfunction requires an in-depth understanding of the normal shape and dynamics of the tricuspid annulus and of the changes following disease and subsequent repair. In this manuscript we review what we know about the shape and dynamics of the normal tricuspid annulus and about the effects of both disease and repair based on non-invasive imaging studies and invasive fiduciary marker-based studies. We further show, by means of ovine data, that detailed engineering analyses of the tricuspid annulus provide regionally-resolved insight into the kinematics of the annulus which would remain hidden if limiting analyses to simple geometric metrics.
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Affiliation(s)
- Manuel K. Rausch
- Aerospace Engineering & Engineering Mechanics, Biomedical Engineering, Institute for Computational Engineering and Sciences, University of Texas at Austin, TX, USA
| | - Mrudang Mathur
- Aerospace Engineering & Engineering Mechanics, Biomedical Engineering, Institute for Computational Engineering and Sciences, University of Texas at Austin, TX, USA
| | - William D. Meador
- Aerospace Engineering & Engineering Mechanics, Biomedical Engineering, Institute for Computational Engineering and Sciences, University of Texas at Austin, TX, USA
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Jazwiec T, Malinowski M, Bush J, Goehler M, Quay N, Parker J, Langholz DE, Timek TA. Right ventricular free wall stress after tricuspid valve annuloplasty in acute ovine right heart failure. J Thorac Cardiovasc Surg 2019; 158:759-768. [DOI: 10.1016/j.jtcvs.2018.11.092] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 11/20/2018] [Accepted: 11/26/2018] [Indexed: 12/27/2022]
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Lee CH, Laurence DW, Ross CJ, Kramer KE, Babu AR, Johnson EL, Hsu MC, Aggarwal A, Mir A, Burkhart HM, Towner RA, Baumwart R, Wu Y. Mechanics of the Tricuspid Valve-From Clinical Diagnosis/Treatment, In-Vivo and In-Vitro Investigations, to Patient-Specific Biomechanical Modeling. Bioengineering (Basel) 2019; 6:E47. [PMID: 31121881 PMCID: PMC6630695 DOI: 10.3390/bioengineering6020047] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 05/16/2019] [Accepted: 05/17/2019] [Indexed: 12/29/2022] Open
Abstract
Proper tricuspid valve (TV) function is essential to unidirectional blood flow through the right side of the heart. Alterations to the tricuspid valvular components, such as the TV annulus, may lead to functional tricuspid regurgitation (FTR), where the valve is unable to prevent undesired backflow of blood from the right ventricle into the right atrium during systole. Various treatment options are currently available for FTR; however, research for the tricuspid heart valve, functional tricuspid regurgitation, and the relevant treatment methodologies are limited due to the pervasive expectation among cardiac surgeons and cardiologists that FTR will naturally regress after repair of left-sided heart valve lesions. Recent studies have focused on (i) understanding the function of the TV and the initiation or progression of FTR using both in-vivo and in-vitro methods, (ii) quantifying the biomechanical properties of the tricuspid valve apparatus as well as its surrounding heart tissue, and (iii) performing computational modeling of the TV to provide new insight into its biomechanical and physiological function. This review paper focuses on these advances and summarizes recent research relevant to the TV within the scope of FTR. Moreover, this review also provides future perspectives and extensions critical to enhancing the current understanding of the functioning and remodeling tricuspid valve in both the healthy and pathophysiological states.
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Affiliation(s)
- Chung-Hao Lee
- Biomechanics and Biomaterials Design Laboratory, School of Aerospace and Mechanical Engineering, The University of Oklahoma, Norman, OK 73019, USA.
- Institute for Biomedical Engineering, Science and Technology (IBEST), The University of Oklahoma, Norman, OK 73019, USA.
| | - Devin W Laurence
- Biomechanics and Biomaterials Design Laboratory, School of Aerospace and Mechanical Engineering, The University of Oklahoma, Norman, OK 73019, USA.
| | - Colton J Ross
- Biomechanics and Biomaterials Design Laboratory, School of Aerospace and Mechanical Engineering, The University of Oklahoma, Norman, OK 73019, USA.
| | - Katherine E Kramer
- Biomechanics and Biomaterials Design Laboratory, School of Aerospace and Mechanical Engineering, The University of Oklahoma, Norman, OK 73019, USA.
| | - Anju R Babu
- Biomechanics and Biomaterials Design Laboratory, School of Aerospace and Mechanical Engineering, The University of Oklahoma, Norman, OK 73019, USA.
- Department of Biotechnology and Medical Engineering, National Institute of Technology Rourkela, Rourkela, Odisha 769008, India.
| | - Emily L Johnson
- Department of Mechanical Engineering, Iowa State University, Ames, IA 50011, USA.
| | - Ming-Chen Hsu
- Department of Mechanical Engineering, Iowa State University, Ames, IA 50011, USA.
| | - Ankush Aggarwal
- Glasgow Computational Engineering Centre, School of Engineering, University of Glasgow, Scotland G12 8LT, UK.
| | - Arshid Mir
- Division of Pediatric Cardiology, Department of Pediatrics, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA.
| | - Harold M Burkhart
- Division of Cardiothoracic Surgery, Department of Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA.
| | - Rheal A Towner
- Advance Magnetic Resonance Center, MS 60, Oklahoma Medical Research Foundation, Oklahoma City, OK 73104, USA.
| | - Ryan Baumwart
- Center for Veterinary Health Sciences, Oklahoma State University, Stillwater, OK 74078, USA.
| | - Yi Wu
- Biomechanics and Biomaterials Design Laboratory, School of Aerospace and Mechanical Engineering, The University of Oklahoma, Norman, OK 73019, USA.
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Mathur M, Jazwiec T, Meador WD, Malinowski M, Goehler M, Ferguson H, Timek TA, Rausch MK. Tricuspid valve leaflet strains in the beating ovine heart. Biomech Model Mechanobiol 2019; 18:1351-1361. [PMID: 30980211 DOI: 10.1007/s10237-019-01148-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 04/03/2019] [Indexed: 12/25/2022]
Abstract
The tricuspid leaflets coapt during systole to facilitate proper valve function and, thus, ensure efficient transport of deoxygenated blood to the lungs. Between their open state and closed state, the leaflets undergo large deformations. Quantification of these deformations is important for our basic scientific understanding of tricuspid valve function and for diagnostic or prognostic purposes. To date, tricuspid valve leaflet strains have never been directly quantified in vivo. To fill this gap in our knowledge, we implanted four sonomicrometry crystals per tricuspid leaflet and six crystals along the tricuspid annulus in a total of five sheep. In the beating ovine hearts, we recorded crystal coordinates alongside hemodynamic data. Once recorded, we used a finite strain kinematic framework to compute the temporal evolutions of area strain, radial strain, and circumferential strain for each leaflet. We found that leaflet strains were larger in the anterior leaflet than the posterior and septal leaflets. Additionally, we found that radial strains were larger than circumferential strains. Area strains were as large as 97% in the anterior leaflet, 31% in the posterior leaflet, and 31% in the septal leaflet. These data suggest that tricuspid valve leaflet strains are significantly larger than those in the mitral valve. Should our findings be confirmed they could suggest either that the mechanobiological equilibrium of tricuspid valve resident cells is different than that of mitral valve resident cells or that the mechanotransductive apparatus between the two varies. Either phenomenon may have important implications for the development of tricuspid valve-specific surgical techniques and medical devices.
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Affiliation(s)
- M Mathur
- Department of Mechanical Engineering, University of Texas at Austin, Austin, TX, USA
| | - T Jazwiec
- Division of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, MI, USA
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia in Katowice, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - W D Meador
- Department of Biomedical Engineering, University of Texas at Austin, 2501 Speedway, Room 7.620, Austin, TX, 78712, USA
| | - M Malinowski
- Division of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, MI, USA
- Department of Cardiac Surgery, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - M Goehler
- Division of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, MI, USA
| | - H Ferguson
- Division of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, MI, USA
| | - T A Timek
- Division of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, MI, USA
| | - M K Rausch
- Department of Biomedical Engineering, University of Texas at Austin, 2501 Speedway, Room 7.620, Austin, TX, 78712, USA.
- Department of Aerospace Engineering and Engineering Mechanics, University of Texas at Austin, Austin, TX, USA.
- The Institute for Computational Engineering and Sciences, University of Texas at Austin, Austin, TX, USA.
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12
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Malinowski M, Timek TA. Reply. Ann Thorac Surg 2019; 108:959. [PMID: 30951696 DOI: 10.1016/j.athoracsur.2019.02.068] [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: 02/25/2019] [Accepted: 02/25/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Marcin Malinowski
- Division of Cardiothoracic Surgery, Meijer Heart and Vascular Institute at Spectrum Health, 100 Michigan Ave SE, Grand Rapids, MI 49503.
| | - Tomasz A Timek
- Division of Cardiothoracic Surgery, Meijer Heart and Vascular Institute at Spectrum Health, 100 Michigan Ave SE, Grand Rapids, MI 49503
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Sonomicrometry-derived 3-dimensional geometry of the human tricuspid annulus. J Thorac Cardiovasc Surg 2019; 157:1452-1461.e1. [DOI: 10.1016/j.jtcvs.2018.08.110] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 08/23/2018] [Accepted: 08/23/2018] [Indexed: 12/17/2022]
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Singh-Gryzbon S, Siefert AW, Pierce EL, Yoganathan AP. Tricuspid Valve Annular Mechanics: Interactions with and Implications for Transcatheter Devices. Cardiovasc Eng Technol 2019; 10:193-204. [PMID: 30756336 DOI: 10.1007/s13239-019-00405-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 02/01/2019] [Indexed: 02/06/2023]
Abstract
In the interventional treatment of tricuspid valve regurgitation, the majority of prosthetic devices interact with or are implanted to the tricuspid valve annulus. For new transcatheter technologies, there exists a growing body of clinical experience, literature, and professional discourse related to the difficulties in delivering, securing, and sustaining the function of these devices within the dynamic tricuspid annulus. Many of the difficulties arise from circumstances not encountered in open-heart surgery, namely; a non-arrested heart, indirect visualization, and a reliance on non-suture-based methods. These challenges require the application of procedural techniques or system designs to account for tricuspid annular motion, forces, and underlying tissue strength. Improved knowledge in these interactions will support the goals of improving device systems, their procedures, and patient outcomes. This review aims to describe current concepts of tricuspid annular mechanics, key device and procedural implications, and highlight current knowledge gaps for future consideration.
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Affiliation(s)
- Shelly Singh-Gryzbon
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology & Emory University, Technology Enterprise Park, 387 Technology Circle NW, Atlanta, GA, 30313-2412, USA
| | - Andrew W Siefert
- Cardiac Implants LLC, 25 Lake Terrace, Tarrytown, NY, 10591, USA
| | - Eric L Pierce
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology & Emory University, Technology Enterprise Park, 387 Technology Circle NW, Atlanta, GA, 30313-2412, USA
| | - Ajit P Yoganathan
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology & Emory University, Technology Enterprise Park, 387 Technology Circle NW, Atlanta, GA, 30313-2412, USA.
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Malinowski M, Jazwiec T, Goehler M, Bush J, Quay N, Ferguson H, Rausch MK, Timek TA. Impact of tricuspid annular size reduction on right ventricular function, geometry and strain. Eur J Cardiothorac Surg 2019; 56:5303950. [PMID: 30698674 DOI: 10.1093/ejcts/ezy484] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 12/21/2018] [Indexed: 02/28/2024] Open
Abstract
OBJECTIVES Restrictive tricuspid annuloplasty is a clinically accepted approach to treat functional tricuspid regurgitation. We set out to investigate the effect of varying degrees of tricuspid annular reduction on the right ventricular (RV) function, geometry and strain. METHODS Eight, healthy sheep (45 ± 4 kg) had 6 sonomicrometry crystals implanted around the tricuspid annulus and 20 onto the epicardium of the right ventricle defining 3 free wall regions: basal, mid and lower. A polypropylene annuloplasty suture was placed around the tricuspid annulus and externalized to an epicardial tourniquet. Simultaneous echocardiographic, haemodynamic and sonomicrometry data were acquired at baseline and during 5 consecutive annular reduction steps (TAR 1-5) with successive (5-7 mm) suture cinching. RV free wall circumferential, longitudinal and areal cardiac and interventional strains, RV radius of curvature (ROC), cross-sectional area and tricuspid annular dimensions were calculated from 3-dimensional crystal coordinates. RESULTS TAR 1-5 resulted in 19 ± 15%, 35 ± 15%, 51 ± 15%, 60 ± 15% and 68 ± 13% tricuspid annular area reduction, respectively. TAR 1 and 2 had minimal influence on the RV function, RV-ROC and strains. TAR 4 and 5 decreased RV-ROC in basal and mid-regions, but reduced the RV cross-sectional area change (from 19 ± 4% at baseline to 14 ± 3% and 13 ± 2%, respectively, P < 0.001) and circumferential and areal strains. TAR 3 significantly decreased free wall RV-ROC from 44.0 ± 1.5 to 42.6 ± 2.4 mm P < 0.001 at the RV base but maintained the regional ventricular function and strains. CONCLUSIONS In healthy ovine hearts, a tricuspid annular area reduction of ∼50% provides optimal conditions for reducing RV-ROC while maintaining regional RV function and strain patterns.
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Affiliation(s)
- Marcin Malinowski
- Division of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, MI, USA
- Department of Cardiac Surgery, Medical University of Silesia, School of Medicine in Katowice, Katowice, Poland
| | - Tomasz Jazwiec
- Division of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, MI, USA
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia in Katowice, Silesian Centre for Heart Disease, Zabrze, Poland
| | - Matthew Goehler
- Division of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, MI, USA
| | - Jared Bush
- Division of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, MI, USA
| | - Nathan Quay
- Division of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, MI, USA
| | - Haley Ferguson
- Division of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, MI, USA
| | - Manuel K Rausch
- Department of Aerospace Engineering and Engineering Mechanics, Institute for Computational Engineering and Science, University of Texas at Austin, Austin, TX, USA
- Department of Biomedical Engineering, Institute for Computational Engineering and Science, University of Texas at Austin, Austin, TX, USA
| | - Tomasz A Timek
- Division of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, MI, USA
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16
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Malinowski M, Proudfoot AG, Eberhart L, Schubert H, Wodarek J, Langholz D, Rausch MK, Timek TA. Large animal model of acute right ventricular failure with functional tricuspid regurgitation. Int J Cardiol 2019; 264:124-129. [PMID: 29776560 DOI: 10.1016/j.ijcard.2018.02.072] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 02/12/2018] [Accepted: 02/19/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Functional tricuspid regurgitation (FTR) commonly arises secondary to conditions affecting the left heart and is associated with right ventricular dysfunction and tricuspid annular dilatation. We set out to establish an animal model of acute RV failure (RVF) with FTR resembling the clinical features. METHODS Ten adult sheep had pressure sensors placed in the LV, RV, and right atrium while sonomicrometry crystals were implanted around tricuspid annulus and on the RV. Animals were studied open-chest to assess for RV function and FTR after: (1) volume infusion, (2) pulmonary artery constriction, (3) 5 min posterior descending artery occlusion, and (4) combination of all interventions. Hemodynamic, echocardiographic, and sonomicrometry data were collected at baseline and after every intervention. RV dimensions, RV strain, and annular area, perimeter, and size were calculated from crystal coordinates. The model was validated in six additional sheep studied only before and after combined interventions. RESULTS Neither volume infusion, pulmonary hypertension, nor ischemia were associated with RVF or clinically significant TR when applied separately but combined resulted in RVF and greater than moderate FTR. In the validation group, maximal RV volume increased (62 ± 14 vs 70 ± 16 ml, p = 0.006), contractility decreased (20 ± 6 vs 12 ± 2%, p = 0.02), and strain increased. FTR increased from 0.4 ± 0.5 to 2.5 ± 0.8 (p < 0.001) and annular area from 652 ± 87 mm2 to 739 ± 87 mm2 (p = 0.005). CONCLUSIONS The developed ovine model of acute RVF was associated with significant annular and RV enlargement and FTR. This novel and clinically pertinent research platform offers insight into the acute RVF pathophysiology and can be utilized to evaluate treatment interventions.
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Affiliation(s)
- Marcin Malinowski
- Meijer Heart and Vascular Institute at Spectrum Health, 100 Michigan Ave NE, Grand Rapids, MI 49503, USA; Department of Cardiac Surgery, Medical University of Silesia, School of Medicine in Katowice, Ziołowa 47, 40635 Katowice, Poland
| | - Alistair G Proudfoot
- Meijer Heart and Vascular Institute at Spectrum Health, 100 Michigan Ave NE, Grand Rapids, MI 49503, USA
| | - Lenora Eberhart
- Meijer Heart and Vascular Institute at Spectrum Health, 100 Michigan Ave NE, Grand Rapids, MI 49503, USA
| | - Hans Schubert
- Meijer Heart and Vascular Institute at Spectrum Health, 100 Michigan Ave NE, Grand Rapids, MI 49503, USA
| | - Jeremy Wodarek
- Meijer Heart and Vascular Institute at Spectrum Health, 100 Michigan Ave NE, Grand Rapids, MI 49503, USA
| | - David Langholz
- Meijer Heart and Vascular Institute at Spectrum Health, 100 Michigan Ave NE, Grand Rapids, MI 49503, USA
| | - Manuel K Rausch
- Department of Aerospace Engineering & Engineering Mechanics, Department of Biomedical Engineering, Institute for Computational Engineering and Science, University of Texas at Austin, 210 E 24th Street, Austin, TX 78703, USA
| | - Tomasz A Timek
- Meijer Heart and Vascular Institute at Spectrum Health, 100 Michigan Ave NE, Grand Rapids, MI 49503, USA.
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17
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Kondapalli SH, Alazzawi Y, Malinowski M, Timek T, Chakrabartty S. Feasibility of Self-Powering and Energy Harvesting Using Cardiac Valvular Perturbations. IEEE TRANSACTIONS ON BIOMEDICAL CIRCUITS AND SYSTEMS 2018; 12:1392-1400. [PMID: 30113900 DOI: 10.1109/tbcas.2018.2865405] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
In this paper, we investigate the feasibility of harvesting energy from cardiac valvular perturbations to self-power a wireless sonomicrometry sensor. Compared to the previous studies involving piezoelectric patches or encasings attached to the cardiac or aortic surface, the proposed study explores the use of piezoelectric sutures that can be implanted in proximity to the valvular regions, where non-linear valvular perturbations could be exploited for self-powering. Using an ovine animal model, the magnitude of valvular perturbations are first measured using an array of sonomicrometry crystals implanted around the tricuspid valve. These measurements were then used to estimate the levels of electrical energy that could be harvested using a simplified piezoelectric suture model. These results were revalidated across seven different animals, before and after valvular regurgitation was induced. Our study shows that power harvested from different annular planes of the tricuspid valve (before and after regurgitation) could range from nano-watts to milli-watts, with the maximum power harvested from the leaflet plane. We believe that these results could be useful for determining optimal surgical placement of wireless and self-powered sonomicrometry sensor, which in turn could be used for investigating the pathophysiology of ischemic regurgitation.
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18
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Tricuspid Annular Geometry and Strain After Suture Annuloplasty in Acute Ovine Right Heart Failure. Ann Thorac Surg 2018; 106:1804-1811. [DOI: 10.1016/j.athoracsur.2018.05.057] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 04/18/2018] [Accepted: 05/17/2018] [Indexed: 02/07/2023]
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19
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Tricuspid valvular dynamics and 3-dimensional geometry in awake and anesthetized sheep. J Thorac Cardiovasc Surg 2018; 156:1503-1511. [DOI: 10.1016/j.jtcvs.2018.04.065] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 04/04/2018] [Accepted: 04/13/2018] [Indexed: 11/17/2022]
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20
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Meador WD, Malinowski M, Jazwiec T, Goehler M, Quay N, Timek TA, Rausch MK. A fiduciary marker-based framework to assess heterogeneity and anisotropy of right ventricular epicardial strains in the beating ovine heart. J Biomech 2018; 80:179-185. [PMID: 30292534 DOI: 10.1016/j.jbiomech.2018.08.036] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 08/30/2018] [Accepted: 08/31/2018] [Indexed: 11/30/2022]
Abstract
Quantifying ventricular deformation in health and disease is critical to our understanding of normal heart function, heart disease mechanisms, and the effect of medical treatments. Imaging modalities have been developed that can measure ventricular deformation non-invasively. However, because of the small thickness, complex shape, and anatomic position of the right ventricle, using these technologies to determine its deformation remains challenging. Here we develop a first fiduciary marker-based method to assess heterogeneity and anisotropy of right ventricular epicardial strain across the entire free wall. To this end, we combine a high-density array of sonomicrometry crystals implanted across the entire right ventricular epicardial surface with a subdivision surface algorithm and a large deformation kinematics framework. We demonstrate our approach on four beating ovine hearts and present a preliminary regional analysis of circumferential, longitudinal, and areal strain. Moreover, we illustrate maps of the same strains across the entire right ventricular epicardial surface to highlight their spatial heterogeneity and anisotropy. We observe in these animals that RV epicardial strains vary throughout the cardiac cycle, are heterogeneous across the RV free wall, and are anisotropic with larger compressive strains, i.e., contraction, in the longitudinal direction than in the circumferential direction. Average peak compressive strains vary by region between -3.34% and -8.29% in circumferential direction, and -4.02% and -10.57% in longitudinal direction. In summary, we introduce an experimental framework that will allow us to study disease- and device-induced deformations, and long-term consequences of these deformations, including heterogeneous and anisotropic effects.
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Affiliation(s)
- William D Meador
- Department of Aerospace Engineering and Engineering Mechanics, University of Texas at Austin, TX, USA; Department of Biomedical Engineering, University of Texas at Austin, TX, USA
| | - Marcin Malinowski
- Meijer Heart and Vascular Institute at Spectrum Health, Michigan, MI, USA; Department of Cardiac Surgery, Medical University of Silesia, Katowice, Poland
| | - Tomasz Jazwiec
- Meijer Heart and Vascular Institute at Spectrum Health, Michigan, MI, USA
| | - Matthew Goehler
- Meijer Heart and Vascular Institute at Spectrum Health, Michigan, MI, USA
| | - Nathan Quay
- Meijer Heart and Vascular Institute at Spectrum Health, Michigan, MI, USA
| | - Tomasz A Timek
- Meijer Heart and Vascular Institute at Spectrum Health, Michigan, MI, USA
| | - Manuel K Rausch
- Department of Aerospace Engineering and Engineering Mechanics, University of Texas at Austin, TX, USA; Department of Biomedical Engineering, University of Texas at Austin, TX, USA; Institute for Computational Engineering and Sciences, University of Texas at Austin, TX, USA.
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Li Y, Wang Y, Yang Y, Liu M, Meng X, Shi Y, Zhu W, Lu X. Tricuspid annular displacement measured by 2-dimensional speckle tracking echocardiography for predicting right ventricular function in pulmonary hypertension: A new approach to evaluating right ventricle dysfunction. Medicine (Baltimore) 2018; 97:e11710. [PMID: 30045334 PMCID: PMC6078723 DOI: 10.1097/md.0000000000011710] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
This study aimed to determine the ability of tricuspid annular displacement measured by 2-dimensional speckle tracking echocardiography (STE) to predict right ventricular (RV) dysfunction in pulmonary hypertension (PH) patients. Here, we present a new method for assessing RV function that also employs STE and is based on measurement of tricuspid annular displacement.A total of 225 patients were divided into 2 groups according to the pulmonary artery systolic blood pressure (PASP), estimated by echocardiographic measurement of tricuspid regurgitation: group I (PASP ≥50 mm Hg) and group II (36 mm Hg ≤ PASP <50 mm Hg). The tricuspid annular plane systolic excursion (TAPSE), RV index of myocardial performance (RIMP), RV fractional area change (RVFAC), tissue Doppler-derived tricuspid lateral annular systolic velocity (s'), and the tricuspid annular longitudinal displacement (TMAD) parameters were measured. Thirty patients underwent cardiac magnetic resonance (CMR) examination, and right ventricular ejection fraction (RVEF) was calculated.The conventional parameters as well as the TMAD parameters differed significantly between the 2 groups (all P < .01). Good correlation was observed between the TMAD parameters and CMR-derived RVEF (all P < .01). The TMAD parameters had moderate predictive value for predicting RV dysfunction in PH patients (all P < .01). From receiver operating characteristic curves, we determined the optimal cut-off values for TMAD parameters for detecting RV dysfunction with good sensitivity and specificity.The TMAD parameters can predict the decline of RV function in patients with PH and thus provide new diagnostic indices for clinical management of these patients.
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Affiliation(s)
- Yidan Li
- Department of Echocardiography, Heart Center
| | - Yidan Wang
- Department of Echocardiography, Heart Center
| | - Yuanhua Yang
- Department of Respiratory and Critical Care Medicine
| | - Mingxi Liu
- Department of Radiology, Beijing Chao Yang Hospital, Capital Medical University, Beijing, China
| | | | - Yanping Shi
- Department of Echocardiography, Heart Center
| | - Weiwei Zhu
- Department of Echocardiography, Heart Center
| | - Xiuzhang Lu
- Department of Echocardiography, Heart Center
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Rausch MK, Malinowski M, Meador WD, Wilton P, Khaghani A, Timek TA. The Effect of Acute Pulmonary Hypertension on Tricuspid Annular Height, Strain, and Curvature in Sheep. Cardiovasc Eng Technol 2018; 9:365-376. [DOI: 10.1007/s13239-018-0367-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 05/24/2018] [Indexed: 12/16/2022]
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Engineering Analysis of Tricuspid Annular Dynamics in the Beating Ovine Heart. Ann Biomed Eng 2017; 46:443-451. [PMID: 29139013 DOI: 10.1007/s10439-017-1961-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 11/10/2017] [Indexed: 12/11/2022]
Abstract
Functional tricuspid regurgitation is a significant source of morbidity and mortality in the US. Furthermore, treatment of functional tricuspid regurgitation is suboptimal with significant recurrence rates, which may, at least in part, be due to our limited knowledge of the relationship between valvular shape and function. Here we study the dynamics of the healthy in vivo ovine tricuspid annulus to improve our understanding of normal annular deformations throughout the cardiac cycle. To this end, we determine both clinical as well as engineering metrics of in vivo annular dynamics based on sonomicrometry crystals surgically attached to the annulus. We confirm that the tricuspid annulus undergoes large dynamic changes in area, perimeter, height, and eccentricity throughout the cardiac cycle. This deformation may be described as asymmetric in-plane motion of the annulus with minor out-of-plane motion. In addition, we employ strain and curvature to provide mechanistic insight into the origin of this deformation. Specifically, we find that strain and curvature vary considerable across the annulus with highly localized minima and maxima resulting in aforementioned configurational changes throughout the cardiac cycle. It is our hope that these data provide valuable information for clinicians and engineers alike and ultimately help us improve treatment of functional tricuspid regurgitation.
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Malinowski M, Proudfoot AG, Langholz D, Eberhart L, Brown M, Schubert H, Wodarek J, Timek TA. Large animal model of functional tricuspid regurgitation in pacing induced end-stage heart failure. Interact Cardiovasc Thorac Surg 2017; 24:905-910. [PMID: 28329164 DOI: 10.1093/icvts/ivx012] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 01/03/2017] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Functional tricuspid regurgitation (FTR) is common in patients with advanced heart failure and frequently complicates left ventricular assist device implantation yet remains poorly understood. We set out to establish large animal model of FTR that could serve as a research platform to investigate the pathogenesis of FTR associated with end-stage heart failure. METHODS : Through right thoracotomy, ten adult sheep underwent implantation of pacemaker with epicardial LV lead, five sonomicrometry crystals on the right ventricle, and left and right ventricular telemetry pressure sensors during a beating heart off-pump procedure. After 5 ± 1 days of recovery, baseline haemodynamic, echocardiographic and sonomicrometry data were collected. Animals were paced thereafter at a rate of 220-240 beats/min until the development of heart failure and concomitant tricuspid regurgitation. RESULTS : Three animals died during early recovery period and one during the pacing phase. Six surviving animals were paced for a mean of 14 ± 5 days. Cardiac function was significantly depressed compared to baseline, with LV ejection fraction falling from 69 ± 2% to 22 ± 4% ( P < 0.001) and RV fractional area change from 52 ± 11% to 25 ± 9% ( P = 0.005). All animals developed significant enlargement of tricuspid annulus (from 29.5 ± 1.6 to 36.5 ± 4.5 mm; P = 0.01) and right ventricle (from 21.9 ± 0.2 to 30.3 ± 0.6 mm; P = 0.03). Sonomicrometry derived contractility of RV free wall was depressed and at least moderate tricuspid insufficiency developed in all animals. CONCLUSIONS : Biventricular dysfunction, tricuspid annular dilatation and significant FTR were observed in our model of ovine tachycardia induced cardiomyopathy. This animal model reflects the clinical situation of end-stage heart failure patients presenting for mechanical support.
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Affiliation(s)
- Marcin Malinowski
- Meijer Heart and Vascular Institute at Spectrum Health, Grand Rapids, MI, USA.,Department of Cardiac Surgery, Medical University of Silesia, School of Medicine in Katowice, Katowice, Poland
| | | | - David Langholz
- Meijer Heart and Vascular Institute at Spectrum Health, Grand Rapids, MI, USA
| | - Lenora Eberhart
- Meijer Heart and Vascular Institute at Spectrum Health, Grand Rapids, MI, USA
| | - Michael Brown
- Meijer Heart and Vascular Institute at Spectrum Health, Grand Rapids, MI, USA
| | - Hans Schubert
- Meijer Heart and Vascular Institute at Spectrum Health, Grand Rapids, MI, USA
| | - Jeremy Wodarek
- Meijer Heart and Vascular Institute at Spectrum Health, Grand Rapids, MI, USA
| | - Tomasz A Timek
- Meijer Heart and Vascular Institute at Spectrum Health, Grand Rapids, MI, USA
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25
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Malinowski M, Wilton P, Khaghani A, Brown M, Langholz D, Hooker V, Eberhart L, Hooker RL, Timek TA. The effect of acute mechanical left ventricular unloading on ovine tricuspid annular size and geometry. Interact Cardiovasc Thorac Surg 2016; 23:391-6. [PMID: 27209530 DOI: 10.1093/icvts/ivw138] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 04/12/2016] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Left ventricular assist device (LVAD) implantation may alter right ventricular shape and function and lead to tricuspid regurgitation. This in turn has been reported to be a determinant of right ventricular (RV) failure after LVAD implantation, but the effect of mechanical left ventricular (LV) unloading on the tricuspid annulus is unknown. The aim of the study was to provide insight into the effect of LVAD support on tricuspid annular geometry and dynamics that may help to optimize LV unloading with the least deleterious effect on the right-sided geometry. METHODS In seven open-chest anaesthetized sheep, nine sonomicrometry crystals were implanted on the right ventricle. Additional nine crystals were implanted around the tricuspid annulus, with one crystal at each commissure defining three separate annular regions: anterior, posterior and septal. Left ventricular unloading was achieved by connecting a cannula in the left atrium and the aorta to a continuous-flow pump. The pump was used for 15 min at a full flow of 3.8 ± 0.3 l/min. Epicardial echocardiography was used to assess the degree of tricuspid insufficiency. Haemodynamic, echocardiographic and sonomicrometry data were collected before and during full unloading. Tricuspid annular area, and the regional and total perimeter were calculated from crystal coordinates, while 3D annular geometry was expressed as the orthogonal distance of each annular crystal to the least squares plane of all annular crystals. RESULTS There was no significant tricuspid regurgitation observed either before or during LV unloading. Right ventricular free wall to septum diameter increased significantly at end-diastole during unloading from 23.6 ± 5.8 to 26.3 ± 6.5 mm (P = 0.009), but the right ventricular volume, tricuspid annular area and total perimeter did not change from baseline. However, the septal part of the annulus significantly decreased its maximal length (38.6 ± 8.1 to 37.9 ± 8.2 mm, P = 0.03). Annular contraction was not altered. The tricuspid annulus had a complex 3D saddle-shaped geometry that was unaffected during experimental conditions. CONCLUSIONS In healthy sheep hearts, left ventricular unloading increased septal-free wall RV diameter and reduced the length of the septal annulus, without altering the motion or geometry of the tricuspid annulus. Acute left ventricular unloading alone in healthy sheep was not sufficient to significantly perturb tricuspid annular dynamics and result in tricuspid insufficiency.
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Affiliation(s)
- Marcin Malinowski
- Meijer Heart and Vascular Institute at Spectrum Health, Grand Rapids, MI, USA Department of Cardiac Surgery, Medical University of Silesia, School of Medicine in Katowice, Katowice, Poland
| | - Penny Wilton
- Meijer Heart and Vascular Institute at Spectrum Health, Grand Rapids, MI, USA
| | - Asghar Khaghani
- Meijer Heart and Vascular Institute at Spectrum Health, Grand Rapids, MI, USA
| | - Michael Brown
- Meijer Heart and Vascular Institute at Spectrum Health, Grand Rapids, MI, USA
| | - David Langholz
- Meijer Heart and Vascular Institute at Spectrum Health, Grand Rapids, MI, USA
| | - Victoria Hooker
- Meijer Heart and Vascular Institute at Spectrum Health, Grand Rapids, MI, USA
| | - Lenora Eberhart
- Meijer Heart and Vascular Institute at Spectrum Health, Grand Rapids, MI, USA
| | - Robert L Hooker
- Meijer Heart and Vascular Institute at Spectrum Health, Grand Rapids, MI, USA
| | - Tomasz A Timek
- Meijer Heart and Vascular Institute at Spectrum Health, Grand Rapids, MI, USA
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Adkins A, Aleman J, Boies L, Sako E, Bhattacharya S. Force Required to Cinch the Tricuspid Annulus: An Ex-Vivo Study. THE JOURNAL OF HEART VALVE DISEASE 2015; 24:644-652. [PMID: 26897846 PMCID: PMC5048676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND AND AIM OF THE STUDY Tricuspid annuloplasty is the most preferred technique for the treatment of functional tricuspid regurgitation (FTR). However, high incidences of recurrent regurgitation and risky reoperation demands a deeper insight into the technique. The cinching force required to bring a dilated annulus back to the original size is unknown. The study aim was to quantify the cinching force in the tricuspid annulus which can contribute to the long-term durability of tricuspid annuloplasty and percutaneous device design. METHODS In ten ovine hearts, a suture was anchored around the free wall of the tricuspid annulus with the free end attached to a force transducer. The force transducer was mounted on a slider system which pulled the suture at regular intervals. Closure of the tricuspid valve was achieved by pressurizing the right ventricle at 30 mmHg through the pulmonary valve. The suture was pulled to cinch the tricuspid annulus. The tricuspid annulus area was measured from images taken at each increment, and the corresponding force was recorded. The hearts were tested for three conditions: (i) non-pressurized (NP); (ii) pressurized (P; normal), and (iii) dilated-pressurized (DP; diseased). Leakage data were also collected for pressurized and dilated pressurized conditions. Annulus dilation was created by injecting phenol into the annulus. RESULTS The maximum annulus dilation obtained was 8.82%, and the maximum cinching force was 0.38 +/- 0.09 N. Leakage was increased by 81.73% from the pressurized to dilated condition. CONCLUSION The minimal force required to cinch a tricuspid annulus with severe FTR (23.98% dilation) can be approximated to 0.25 N. The required cinching force can play a major role in the long-term durability of the tricuspid annuloplasty.
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Affiliation(s)
- Amy Adkins
- School of Science, Engineering, and Technology, St. Mary’s University, San Antonio, Texas, USA
| | - Jesus Aleman
- School of Science, Engineering, and Technology, St. Mary’s University, San Antonio, Texas, USA
| | - Lori Boies
- School of Science, Engineering, and Technology, St. Mary’s University, San Antonio, Texas, USA
| | - Edward Sako
- Department of Cardiothoracic Surgery, University of Texas Health Science Center, San Antonio, Texas, USA
| | - Shamik Bhattacharya
- School of Science, Engineering, and Technology, St. Mary’s University, San Antonio, Texas, USA
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