Abstract
BackgroundRing sizing for mitral valve annuloplasty is conventionally done intraoperatively using specific ‘sizer’ instruments, which are placed onto the valve tissue. This approach is barely reproducible since different sizing strategies have been established among surgeons. The goal of this study is to virtually apply different sizing methods on the basis of pre-repair echocardiography to find out basic differences between sizing strategies.MethodsIn three-dimensional echocardiographs of 43 patients, the mitral annulus and the contour of the anterior mitral leaflet were segmented using MITK Mitralyzer software. Similarly, three-dimensional virtual models of Carpentier-Edwards Physio II annuloplasty rings and their corresponding sizers were interactively generated from computer tomography images. For each patient, the matching annuloplasty ring was selected repeatedly according to popular sizing strategies, such as the height of anterior mitral leaflet, the intercommissural distance and the surface area of anterior mitral leaflet. The areas of the selected rings were considered as the neo-surface area of the mitral annulus after implantation.ResultsThe sizing of the mitral valve according to the height of anterior mitral leaflet (mean ring size = 29.9 ± 3.90), intercommissural distance (mean ring size = 37.5 ± 1.92) or surface area of anterior mitral leaflet (mean ring size = 32.7 ± 3.3) led to significantly different measurements (p ≤ 0.01). In contrary to intercommissural distance, height and surface area of the anterior mitral leaflet exhibited significant variations between the patients (p ≤ 0.01). The sizing according to the height of anterior mitral leaflet led to the maximal reduction of the mitral annulus surface area followed by the sizing according to the surface area of anterior mitral leaflet and finally by the intercommissural distance.ConclusionsThis novel comprehensive computer-based analysis reveals that the surveyed sizing methods led to the selection of significantly different annuloplasty rings and therefore underscore the ambiguity of routinely applied annuloplasty sizing strategies.
Highlights
Ring sizing for mitral valve annuloplasty is conventionally done intraoperatively using specific ‘sizer’ instruments, which are placed onto the valve tissue
Our goal was to study the effect of different sizing methods commonly used to implant a Carpentier-Edwards Physio II mitral ring (CE ring) with regard to ring size selection, i.e. to find out if various strategies lead to the same results
Eight patients (24%) of them needed an additional implantation of artificial polytetrafluoroethylene neochordae during mitral valve repair while sixteen patients (47%) received leaflet repair procedures and seven patients (21%) received both neochordae and leaflet repair
Summary
Ring sizing for mitral valve annuloplasty is conventionally done intraoperatively using specific ‘sizer’ instruments, which are placed onto the valve tissue. This approach is barely reproducible since different sizing strategies have been established among surgeons. The advent of real-time three-dimensional transesophageal echocardiography (3D TEE) has allowed impressive volume renderings of the mitral valve anatomy and dynamics, especially the annulus, the leaflets and the papillary muscles, thereby significantly improving diagnostic capabilities and therapy planning. A specific software plugin called “Mitralyzer” of the freely available Medical Imaging Interaction Toolkit (MITK), which is able to process medical images [22, 23], was developed by our group for interactive and semi-automatic 3dimensional mitral annulus modeling [24]. The MITK plugin is planned to be released as a freely available software package soon
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