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van Kampen A, Morningstar JE, Goudot G, Ingels N, Wenk JF, Nagata Y, Yaghoubian KM, Norris RA, Borger MA, Melnitchouk S, Levine RA, Jensen MO. Utilization of Engineering Advances for Detailed Biomechanical Characterization of the Mitral-Ventricular Relationship to Optimize Repair Strategies: A Comprehensive Review. Bioengineering (Basel) 2023; 10:601. [PMID: 37237671 PMCID: PMC10215167 DOI: 10.3390/bioengineering10050601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/10/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023] Open
Abstract
The geometrical details and biomechanical relationships of the mitral valve-left ventricular apparatus are very complex and have posed as an area of research interest for decades. These characteristics play a major role in identifying and perfecting the optimal approaches to treat diseases of this system when the restoration of biomechanical and mechano-biological conditions becomes the main target. Over the years, engineering approaches have helped to revolutionize the field in this regard. Furthermore, advanced modelling modalities have contributed greatly to the development of novel devices and less invasive strategies. This article provides an overview and narrative of the evolution of mitral valve therapy with special focus on two diseases frequently encountered by cardiac surgeons and interventional cardiologists: ischemic and degenerative mitral regurgitation.
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Affiliation(s)
- Antonia van Kampen
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
- Leipzig Heart Centre, University Clinic of Cardiac Surgery, 02189 Leipzig, Germany
| | - Jordan E. Morningstar
- Department of Regenerative Medicine and Cell Biology, University of South Carolina, Charleston, SC 29425, USA
| | - Guillaume Goudot
- Cardiac Ultrasound Laboratory, Department of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Neil Ingels
- Department of Biomedical Engineering, University of Arkansas, Fayetteville, AR 72701, USA
| | - Jonathan F. Wenk
- Department of Mechanical Engineering, University of Kentucky, Lexington, KY 40508, USA;
| | - Yasufumi Nagata
- Cardiac Ultrasound Laboratory, Department of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Koushiar M. Yaghoubian
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Russell A. Norris
- Department of Regenerative Medicine and Cell Biology, University of South Carolina, Charleston, SC 29425, USA
| | - Michael A. Borger
- Leipzig Heart Centre, University Clinic of Cardiac Surgery, 02189 Leipzig, Germany
| | - Serguei Melnitchouk
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Robert A. Levine
- Cardiac Ultrasound Laboratory, Department of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Morten O. Jensen
- Department of Biomedical Engineering, University of Arkansas, Fayetteville, AR 72701, USA
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
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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.
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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
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Park MH, Marin-Cuartas M, Imbrie-Moore AM, Wilkerson RJ, Pandya PK, Zhu Y, Wang H, Borger MA, Woo YJ. Biomechanical Analysis of Neochordal Repair Error from Diastolic Phase Inversion of Static Left Ventricular Pressurization. JTCVS Tech 2022; 12:54-64. [PMID: 35403058 PMCID: PMC8987390 DOI: 10.1016/j.xjtc.2022.01.009] [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: 07/27/2021] [Accepted: 01/12/2022] [Indexed: 11/30/2022] Open
Abstract
Objective Neochordal implantation is a common form of surgical mitral valve (MV) repair. However, neochord length is assessed using static left ventricular pressurization, leading surgeons to evaluate leaflet coaptation and valve competency when the left ventricle is dilating instead of contracting physiologically, referred to as diastolic phase inversion (DPI). We hypothesize that the difference in papillary muscle (PM) positioning between DPI and physiologic systole results in miscalculated neochord lengths, which might affect repair performance. Methods Porcine MVs (n = 6) were mounted in an ex vivo heart simulator and PMs were affixed to robots that accurately simulate PM motion. Baseline hemodynamic and chordal strain data were collected, after which P2 chordae were severed to simulate posterior leaflet prolapse from chordal rupture and subsequent mitral regurgitation. Neochord implantation was performed in the physiologic and DPI static configurations. Results Although both repairs successfully reduced mitral regurgitation, the DPI repair resulted in longer neochordae (2.19 ± 0.4 mm; P < .01). Furthermore, the hemodynamic performance was reduced for the DPI repair resulting in higher leakage volume (P = .01) and regurgitant fraction (P < .01). Peak chordal forces were reduced in the physiologic repair (0.57 ± 0.11 N) versus the DPI repair (0.68 ± 0.12 N; P < .01). Conclusions By leveraging advanced ex vivo technologies, we were able to quantify the effects of static pressurization on neochordal length determination. Our findings suggest that this post-repair assessment might slightly overestimate the neochordal length and that additional marginal shortening of neochordae might positively affect MV repair performance and durability by reducing load on surrounding native chordae.
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Affiliation(s)
- Matthew H. Park
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
- Department of Mechanical Engineering, Stanford University, Stanford, Calif
| | - Mateo Marin-Cuartas
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Annabel M. Imbrie-Moore
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
- Department of Mechanical Engineering, Stanford University, Stanford, Calif
| | | | - Pearly K. Pandya
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
- Department of Mechanical Engineering, Stanford University, Stanford, Calif
| | - Yuanjia Zhu
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
- Department of Bioengineering, Stanford University, Stanford, Calif
| | - Hanjay Wang
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
| | - Michael A. Borger
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Y. Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
- Department of Bioengineering, Stanford University, Stanford, Calif
- Address for reprints: Y. Joseph Woo, MD, Department of Cardiothoracic Surgery, Department of Bioengineering, Stanford University, Falk Cardiovascular Research Building CV-235, 300 Pasteur Drive, Stanford, CA 94305-5407.
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Park MH, Zhu Y, Imbrie-Moore AM, Wang H, Marin-Cuartas M, Paulsen MJ, Woo YJ. Heart Valve Biomechanics: The Frontiers of Modeling Modalities and the Expansive Capabilities of Ex Vivo Heart Simulation. Front Cardiovasc Med 2021; 8:673689. [PMID: 34307492 PMCID: PMC8295480 DOI: 10.3389/fcvm.2021.673689] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 05/17/2021] [Indexed: 01/05/2023] Open
Abstract
The field of heart valve biomechanics is a rapidly expanding, highly clinically relevant area of research. While most valvular pathologies are rooted in biomechanical changes, the technologies for studying these pathologies and identifying treatments have largely been limited. Nonetheless, significant advancements are underway to better understand the biomechanics of heart valves, pathologies, and interventional therapeutics, and these advancements have largely been driven by crucial in silico, ex vivo, and in vivo modeling technologies. These modalities represent cutting-edge abilities for generating novel insights regarding native, disease, and repair physiologies, and each has unique advantages and limitations for advancing study in this field. In particular, novel ex vivo modeling technologies represent an especially promising class of translatable research that leverages the advantages from both in silico and in vivo modeling to provide deep quantitative and qualitative insights on valvular biomechanics. The frontiers of this work are being discovered by innovative research groups that have used creative, interdisciplinary approaches toward recapitulating in vivo physiology, changing the landscape of clinical understanding and practice for cardiovascular surgery and medicine.
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Affiliation(s)
- Matthew H Park
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, United States.,Department of Mechanical Engineering, Stanford University, Stanford, CA, United States
| | - Yuanjia Zhu
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, United States.,Department of Bioengineering, Stanford University, Stanford, CA, United States
| | - Annabel M Imbrie-Moore
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, United States.,Department of Mechanical Engineering, Stanford University, Stanford, CA, United States
| | - Hanjay Wang
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, United States
| | - Mateo Marin-Cuartas
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, United States.,University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Michael J Paulsen
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, United States
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, United States.,Department of Bioengineering, Stanford University, Stanford, CA, United States
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Imbrie-Moore AM, Park MH, Paulsen MJ, Sellke M, Kulkami R, Wang H, Zhu Y, Farry JM, Bourdillon AT, Callinan C, Lucian HJ, Hironaka CE, Deschamps D, Joseph Woo Y. Biomimetic six-axis robots replicate human cardiac papillary muscle motion: pioneering the next generation of biomechanical heart simulator technology. J R Soc Interface 2020; 17:20200614. [PMID: 33259750 DOI: 10.1098/rsif.2020.0614] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Papillary muscles serve as attachment points for chordae tendineae which anchor and position mitral valve leaflets for proper coaptation. As the ventricle contracts, the papillary muscles translate and rotate, impacting chordae and leaflet kinematics; this motion can be significantly affected in a diseased heart. In ex vivo heart simulation, an explanted valve is subjected to physiologic conditions and can be adapted to mimic a disease state, thus providing a valuable tool to quantitatively analyse biomechanics and optimize surgical valve repair. However, without the inclusion of papillary muscle motion, current simulators are limited in their ability to accurately replicate cardiac biomechanics. We developed and implemented image-guided papillary muscle (IPM) robots to mimic the precise motion of papillary muscles. The IPM robotic system was designed with six degrees of freedom to fully capture the native motion. Mathematical analysis was used to avoid singularity conditions, and a supercomputing cluster enabled the calculation of the system's reachable workspace. The IPM robots were implemented in our heart simulator with motion prescribed by high-resolution human computed tomography images, revealing that papillary muscle motion significantly impacts the chordae force profile. Our IPM robotic system represents a significant advancement for ex vivo simulation, enabling more reliable cardiac simulations and repair optimizations.
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Affiliation(s)
- Annabel M Imbrie-Moore
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA.,Department of Mechanical Engineering, Stanford University, Stanford, CA, USA
| | - Matthew H Park
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA.,Department of Mechanical Engineering, Stanford University, Stanford, CA, USA
| | - Michael J Paulsen
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
| | - Mark Sellke
- Department of Mathematics, Stanford University, Stanford, CA, USA
| | - Rohun Kulkami
- Department of Mechanical Engineering, Stanford University, Stanford, CA, USA
| | - Hanjay Wang
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
| | - Yuanjia Zhu
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA.,Department of Bioengineering, Stanford University, Stanford, CA, USA
| | - Justin M Farry
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
| | | | - Christine Callinan
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA.,Department of Mechanical Engineering, Stanford University, Stanford, CA, USA
| | - Haley J Lucian
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
| | - Camille E Hironaka
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
| | - Daniela Deschamps
- Department of Mechanical Engineering, Stanford University, Stanford, CA, USA
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA.,Department of Bioengineering, Stanford University, Stanford, CA, USA
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Cohen JE, Goldstone AB, Wang H, Purcell BP, Shudo Y, MacArthur JW, Steele AN, Paulsen MJ, Edwards BB, Aribeana CN, Cheung NC, Burdick JA, Woo YJ. A Bioengineered Neuregulin-Hydrogel Therapy Reduces Scar Size and Enhances Post-Infarct Ventricular Contractility in an Ovine Large Animal Model. J Cardiovasc Dev Dis 2020; 7:jcdd7040053. [PMID: 33212844 PMCID: PMC7711763 DOI: 10.3390/jcdd7040053] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 09/26/2020] [Accepted: 10/26/2020] [Indexed: 12/11/2022] Open
Abstract
The clinical efficacy of neuregulin (NRG) in the treatment of heart failure is hindered by off-target exposure due to systemic delivery. We previously encapsulated neuregulin in a hydrogel (HG) for targeted and sustained myocardial delivery, demonstrating significant induction of cardiomyocyte proliferation and preservation of post-infarct cardiac function in a murine myocardial infarction (MI) model. Here, we performed a focused evaluation of our hydrogel-encapsulated neuregulin (NRG-HG) therapy’s potential to enhance cardiac function in an ovine large animal MI model. Adult male Dorset sheep (n = 21) underwent surgical induction of MI by coronary artery ligation. The sheep were randomized to receive an intramyocardial injection of saline, HG only, NRG only, or NRG-HG circumferentially around the infarct borderzone. Eight weeks after MI, closed-chest intracardiac pressure–volume hemodynamics were assessed, followed by heart explant for infarct size analysis. Compared to each of the control groups, NRG-HG significantly augmented left ventricular ejection fraction (p = 0.006) and contractility based on the slope of the end-systolic pressure–volume relationship (p = 0.006). NRG-HG also significantly reduced infarct scar size (p = 0.002). Overall, using a bioengineered hydrogel delivery system, a one-time dose of NRG delivered intramyocardially to the infarct borderzone at the time of MI in adult sheep significantly reduces scar size and enhances ventricular contractility at 8 weeks after MI.
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Affiliation(s)
- Jeffrey E. Cohen
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA 94305, USA; (J.E.C.); (A.B.G.); (H.W.); (Y.S.); (J.W.M.); (A.N.S.); (M.J.P.); (B.B.E.); (C.N.A.); (N.C.C.)
| | - Andrew B. Goldstone
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA 94305, USA; (J.E.C.); (A.B.G.); (H.W.); (Y.S.); (J.W.M.); (A.N.S.); (M.J.P.); (B.B.E.); (C.N.A.); (N.C.C.)
| | - Hanjay Wang
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA 94305, USA; (J.E.C.); (A.B.G.); (H.W.); (Y.S.); (J.W.M.); (A.N.S.); (M.J.P.); (B.B.E.); (C.N.A.); (N.C.C.)
| | - Brendan P. Purcell
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA 19104, USA; (B.P.P.); (J.A.B.)
| | - Yasuhiro Shudo
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA 94305, USA; (J.E.C.); (A.B.G.); (H.W.); (Y.S.); (J.W.M.); (A.N.S.); (M.J.P.); (B.B.E.); (C.N.A.); (N.C.C.)
| | - John W. MacArthur
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA 94305, USA; (J.E.C.); (A.B.G.); (H.W.); (Y.S.); (J.W.M.); (A.N.S.); (M.J.P.); (B.B.E.); (C.N.A.); (N.C.C.)
| | - Amanda N. Steele
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA 94305, USA; (J.E.C.); (A.B.G.); (H.W.); (Y.S.); (J.W.M.); (A.N.S.); (M.J.P.); (B.B.E.); (C.N.A.); (N.C.C.)
- Department of Bioengineering, Stanford University, Stanford, CA 94305, USA
| | - Michael J. Paulsen
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA 94305, USA; (J.E.C.); (A.B.G.); (H.W.); (Y.S.); (J.W.M.); (A.N.S.); (M.J.P.); (B.B.E.); (C.N.A.); (N.C.C.)
| | - Bryan B. Edwards
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA 94305, USA; (J.E.C.); (A.B.G.); (H.W.); (Y.S.); (J.W.M.); (A.N.S.); (M.J.P.); (B.B.E.); (C.N.A.); (N.C.C.)
| | - Chiaka N. Aribeana
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA 94305, USA; (J.E.C.); (A.B.G.); (H.W.); (Y.S.); (J.W.M.); (A.N.S.); (M.J.P.); (B.B.E.); (C.N.A.); (N.C.C.)
| | - Nicholas C. Cheung
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA 94305, USA; (J.E.C.); (A.B.G.); (H.W.); (Y.S.); (J.W.M.); (A.N.S.); (M.J.P.); (B.B.E.); (C.N.A.); (N.C.C.)
| | - Jason A. Burdick
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA 19104, USA; (B.P.P.); (J.A.B.)
| | - Y. Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA 94305, USA; (J.E.C.); (A.B.G.); (H.W.); (Y.S.); (J.W.M.); (A.N.S.); (M.J.P.); (B.B.E.); (C.N.A.); (N.C.C.)
- Department of Bioengineering, Stanford University, Stanford, CA 94305, USA
- Correspondence: ; Tel.: 1-650-725-3828
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