1
|
Frishman S, Kight A, Pirozzi I, Maddineni S, Imbrie-Moore AM, Karachiwalla Z, Paulsen MJ, Kaiser AD, Woo YJ, Cutkosky MR. DynaRing: A Patient-Specific Mitral Annuloplasty Ring With Selective Stiffness Segments. J Med Device 2022; 16:031009. [PMID: 35646225 PMCID: PMC9125864 DOI: 10.1115/1.4054445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 02/23/2022] [Indexed: 09/03/2023] Open
Abstract
Annuloplasty ring choice and design are critical to the long-term efficacy of mitral valve (MV) repair. DynaRing is a selectively compliant annuloplasty ring composed of varying stiffness elastomer segments, a shape-set nitinol core, and a cross diameter filament. The ring provides sufficient stiffness to stabilize a diseased annulus while allowing physiological annular dynamics. Moreover, adjusting elastomer properties provides a mechanism for effectively tuning key MV metrics to specific patients. We evaluate the ring embedded in porcine valves with an ex-vivo left heart simulator and perform a 150 million cycle fatigue test via a custom oscillatory system. We present a patient-specific design approach for determining ring parameters using a finite element model optimization and patient MRI data. Ex-vivo experiment results demonstrate that motion of DynaRing closely matches literature values for healthy annuli. Findings from the patient-specific optimization establish DynaRing's ability to adjust the anterior-posterior and intercommissural diameters and saddle height by up to 8.8%, 5.6%, 19.8%, respectively, and match a wide range of patient data.
Collapse
Affiliation(s)
- Samuel Frishman
- Department of Mechanical Engineering, Stanford University, Stanford, CA 94305
| | - Ali Kight
- Department of Bioengineering, Stanford University, Stanford, CA 94305
| | - Ileana Pirozzi
- Department of Bioengineering, Stanford University, Stanford, CA 94305
| | | | | | | | - Michael J. Paulsen
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA 94305
| | | | - Y. Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA 94305
| | - Mark R. Cutkosky
- Department of Mechanical Engineering, Stanford University, Stanford, CA 94305
| |
Collapse
|
2
|
Zhu Y, Imbrie-Moore AM, Wilkerson RJ, Paulsen MJ, Park MH, Woo YJ. Ex vivo biomechanical analysis of flexible versus rigid annuloplasty rings in mitral valves using a novel annular dilation system. BMC Cardiovasc Disord 2022; 22:73. [PMID: 35219298 PMCID: PMC8882272 DOI: 10.1186/s12872-022-02515-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 02/07/2022] [Indexed: 12/04/2022] Open
Abstract
Background Mitral annuloplasty rings restore annular dimensions to increase leaflet coaptation, serving a fundamental component in mitral valve repair. However, biomechanical evaluations of annuloplasty rings are lacking. We aim to biomechanically analyze flexible and rigid annuloplasty rings using an ex vivo mitral annular dilation model. Methods Juvenile porcine mitral valves (n = 4) with intercommissural distance of 28 mm were dilated to intercommissural distances of 40 mm using a 3D-printed dilator and were sewn to an elastic mount. Fiber bragg grating sensors were anchored to native chordae to measure chordal forces. The valves were repaired using size 28 rigid and flexible annuloplasty rings in a random order. Hemodynamic data, echocardiography, and chordal force measurements were collected.
Results Mitral annular dilation resulted in decreased leaflet coaptation height and increased mitral regurgitation fraction. Both the flexible and rigid annuloplasty rings effectively increased leaflet coaptation height compared to that post dilation. Rigid ring annuloplasty repair significantly decreased the mitral regurgitation fraction. Flexible annuloplasty ring repair reduced the chordal rate of change of force (7.1 ± 4.4 N/s versus 8.6 ± 5.9 N/s, p = 0.02) and peak force (0.6 ± 0.5 N versus 0.7 ± 0.6 N, p = 0.01) compared to that from post dilation. Rigid annuloplasty ring repair was associated with higher chordal rate of change of force (9.8 ± 5.8 N/s, p = 0.0001) and peak force (0.7 ± 0.5 N, p = 0.01) compared to that after flexible ring annuloplasty repair. Conclusions Both rigid and flexible annuloplasty rings are effective in increasing mitral leaflet coaptation height. Although the rigid annuloplasty ring was associated with slightly higher chordal stress compared to that of the flexible annuloplasty ring, it was more effective in mitral regurgitation reduction. This study may help direct the design of an optimal annuloplasty ring to further improve patient outcomes.
Collapse
|
3
|
Tjørnild MJ, Carlson Hanse L, Skov SN, Poulsen KB, Sharghbin M, Benhassen LL, Røpcke DM, Nielsen SL, Hasenkam JM. Annular and subvalvular dynamics after extracellular matrix mitral tube graft implantation in pigs. Interact Cardiovasc Thorac Surg 2021; 32:978-987. [PMID: 33595082 DOI: 10.1093/icvts/ivab027] [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: 07/19/2020] [Revised: 11/24/2020] [Accepted: 12/20/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Entire mitral valve reconstruction with an extracellular matrix tube graft is a potential candidate to overcome the current limitations of mechanical and bioprosthetic valves. However, clinical data have raised concern with respect to patch failure. The aim of our study was to evaluate the impact of extracellular matrix mitral tube graft implantation on mitral annular and subvalvular regional dynamics in pigs. METHODS A modified tube graft design made of 2-ply extracellular matrix was used (CorMatrix®; Cardiovascular Inc., Alpharetta, GA, USA). The reconstructions were performed in an acute 80-kg porcine model (N = 8), where each pig acted as its own control. Haemodynamics were assessed with Mikro-Tip pressure catheters and mitral annular and subvalvular geometry and dynamics with sonomicrometry. RESULTS Catheter-based peak left atrial pressure and pressure difference across the mitral and aortic valves in the reconstructions were comparable to the values seen in the native mitral valves. Also comparable were maximum mitral annular area (755 ± 100 mm2), maximum septal-lateral distance (29.7 ± 1.7 mm), maximum commissure-commissure distance (35.0 ± 3.4 mm), end-systolic annular height-to-commissural width ratio (10.2 ± 1.0%) and end-diastolic interpapillary muscle distance (27.7 ± 3.3 mm). Systolic expansion of the mitral annulus was, however, observed after reconstruction. CONCLUSIONS The reconstructed mitral valves were fully functional without regurgitation, obstruction or stenosis. The reconstructed mitral annular and subvalvular geometry and subvalvular dynamics were found in the same range to those in the native mitral valve. A regional annular ballooning effect occurred that might predispose to patch failure. However, the greatest risk was found at the papillary muscle attachments.
Collapse
Affiliation(s)
- Marcell J Tjørnild
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Orthopaedic Surgery, Randers Regional Hospital, Denmark
| | - Lisa Carlson Hanse
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Søren N Skov
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Karen B Poulsen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Mona Sharghbin
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Leila L Benhassen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Diana M Røpcke
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Sten L Nielsen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - J Michael Hasenkam
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
| |
Collapse
|
4
|
Tjørnild MJ, Carlson Hanse L, Skov SN, Poulsen KB, Sharghbin M, Benhassen LL, Waziri F, Røpcke DM, Nielsen SL, Hasenkam JM. Entire mitral reconstruction with porcine extracellular matrix in an acute porcine model. J Thorac Cardiovasc Surg 2020; 160:102-112. [DOI: 10.1016/j.jtcvs.2019.07.085] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 06/03/2019] [Accepted: 07/04/2019] [Indexed: 01/20/2023]
|
5
|
Tjørnild MJ, Sørensen SW, Carlson Hanse L, Skov SN, Røpcke DM, Nielsen SL, Hasenkam JM. Mitral Valve Posterior Leaflet Reconstruction Using Extracellular Matrix: In Vitro Evaluation. Cardiovasc Eng Technol 2020; 11:405-415. [PMID: 32592143 DOI: 10.1007/s13239-020-00472-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 06/15/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE To investigate the anatomical and functional effects of complete surgical reconstruction of the posterior mitral leaflet and associated chordae tendineae with a patch made of 2-ply small intestinal submucosal extracellular matrix in vitro. METHODS Seven explanted mitral valves with intact subvalvular apparatus from 80-kg pigs were evaluated in a left heart simulator and served as their own controls. After testing the native valve, the mitral posterior leaflet and associated chordae tendineae were excised and reconstructed by using the 2-ply small intestinal submucosa extracellular matrix patch. The characterization of the reconstruction was based on geometric data from digital images, papillary muscle force, annular tethering force and leaflet pressure force. RESULTS The reconstructed valves were fully functional without regurgitation, tearing or rupture during incrementally increased pressure from 0 to 120 mmHg. The leaflet areas were preserved after reconstruction, with a normal configuration of the coaptation line. However, the coaptation midpoint moved posteriorly after reconstruction (A2: 15.8 ± 1.4 vs. 18.9 ± 1.5 mm, p = 0.002, diff = 3.1 mm, 95% CI 1.3 to 4.8 mm). The anterior papillary muscle force increased significantly (3.9 vs. 4.6 N, p = 0.029, diff = 0.7 N, 95% CI 0.1 to 1.4 N at 120mmHg) after reconstruction. The posterior papillary muscle force, leaflet pressure force and annular pressure force did not change significantly. CONCLUSIONS In this in vitro model, mitral valve anatomy and function were comparable between the native mitral valve and our new surgical technique for complete reconstruction of the posterior mitral leaflet and associated chordae tendineae. These promising results warrant further in vivo evaluation.
Collapse
Affiliation(s)
- Marcell J Tjørnild
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark.
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark.
- Department of Orthopaedic Surgery, Randers Regional Hospital, Randers, Denmark.
| | - Søren W Sørensen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Lisa Carlson Hanse
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Søren N Skov
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Diana M Røpcke
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Sten L Nielsen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - J Michael Hasenkam
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
| |
Collapse
|