Memo 3D Research Articles

P47 MITRAL VALVE RE–REPAIR THROUGH A RIGHT MINITHORACOTOMY

Abstract Objective Recurrent mitral valve regurgitation after prior repair is usually treated with re–repair or replacement through a median sternotomy. We report our small initial experience with mitral valve re–repair through a repeated minimally invasive approach. Methods From July 2018 to November 2021, 10 patients (median age 52 years IQR 49–68; male 90%) underwent isolated mitral valve re–repair with a right mini–thoracotomy approach with peripheral arterial and venous cannulation. Median Euroscore II was 2.05 (IQR 2.03–2.54). Results The median time from the original operation to redo surgery was 4.7 (3.5–8.1) years. Median cardiopulmonary bypass and cross–clamp times were 128 (IQR 109–134) and 99.5 (IQR 81–112) minutes, respectively. Failure of previous mitral valve repair was mainly due to Gore–Tex chordal rupture (3 patients), annular detachment (3 patients), native chordal rupture (2 patients), and posterior leaflet prolapse (2 patients). Concerning the surgical terchnique, a complete mitral valve ring Corcym Memo 3D or 4D was used in 8 patients while additional repair techniques were needed 5 patients (PTFE neochords implantation, cleft or commissure closure). No conversion to full sternotomy and no reoperation for bleeding was necessary. Median ICU and hospital stay were 2.0 (IQR 2.0–2.0) and 7.5 (7.0–9.0) days respectively. Median follow up time was 3.5 (2.8–3.9) years. Neither deaths nor major postoperative complications occurred in the follow–up period. Conclusions In our experience, mitral valve re–repair can be an attractive option for patients with failure of previous mitral valve surgery and can be safely performed through a minimally invasive approach with good outcomes. Main advantages seem to be the avoidance of extensive surgical dissection, optimal valve exposure, and low risk of surgical complications.

Mitral valve repair with the use of the “Memo 3D ReChord” ring

BackgroundFrom a variety of ring types, semirigid ring is more preferred for mitral annuloplasty during mitral valve repair particularly in patients whose native mitral saddle shape annulus is well maintained. During mitral annuloplasty artificial chord implantation with the appropriate neochord length is surgically challenging. We present our experience of using the Memo 3D ReChord, a semirigid ring with additional chordal guiding system for mitral valve repair.Patients and methodsFrom September 2018 to February 2020, we successfully treated ten patients with severe (4+/4+) degenerative mitral valve regurgitation due to posterior leaflet prolapse with chordal rupture with the implantation Memo 3D ReChord and neo-chords.ResultsWe implanted from one to three neo-chords and always a ring in our patients. None of the patients had any residual mitral valve regurgitation at the end of the repair and on their discharge evaluated through transesophageal and transthoracic echocardiography respectively. There was no mortality at 30-days or on midterm follow-up. During the 3-month follow-up no regurgitation was noticed either. We included in our study only the patients successfully treated. We also used it in two patients, who underwent valve replacement during the same operation due to mild to moderate mitral valve regurgitation.ConclusionsThis, in our knowledge, is the first Greek series of the implantation of the Memo 3D Rechord. The initial excellent results give us the enthusiasm to continue while long-term results and the durability of this technique are necessary to establish this semirigid annuloplastic ring in our every-day practice.

P4491Noninvasive evaluation of force distribution in mitral annuloplasty rings: do rigid annuloplasty rings increase stress?

Abstract Purpose To evaluate forces distribution, local stresses and deformation of mitral annuloplasty rings in response to annuloplasty. Methods Seguin (St. Jude Medical), Physio I (Edwards LifeScience), Memo 3D (Sorin) and Future SG (Medtronic) MAR of size 30 mm were included in the study. The study group included 4 males patients aged 52–68 years who underwent isolated mitral valve annuloplasty for ischemic mitral regurgitation. All surgeries were performed by the same experienced operator according to the standardized protocol. The mechanical properties of the similar set of MAR were evaluated under uniaxial compression by 15% in the longitudinal and transverse directions on the Testing Machines Z5.0 (Zwick/Roell). Biomechanics was assessed with MSCT. The MAR frame models at the initial state and at the ventricular ejection and atrial systole phases were obtained from DICOM-data using computer tomography Sensation Somatom 64 (Siemens). The models were compared using the innovative numerical algorithm in MatLab (Mathworks) by forming pairs for “systole – diastole”, “initial state – diastole” for all four types of MAR. We compared the mobility of the implanted devices and changes in the physiological saddle shape geometry of the mitral annulus in response to annuloplasty. We performed the quantitative analysis of the movement of each point of the reconstructed model between two states with the subsequent calculation of the required forces based on the finite element analysis. Results Future CG MAR has the greatest longitudinal and transverse stiffness (18.1N and 4.8N, respectively), whereas Memo 3D demonstrates the lowest values (2.3N and 1.5N). The rest two models show intermediate values of 4.2 - 11.3 N to 2.0 - 4.3N. The comparative analysis of MAR before and after implantation shows that Physio demonstrates the most pronounced deviations from normal physiological shape with significant annular compression along the intercommissural diameter by 1.36 mm resulted in a rounded annulus shape. None significant geometrical deformity among the other prosthetic rings. MEMO 3D demonstrates an average deformation by 0.18 mm across all zones, Seguin - 0.42 mm, Future CG - 0.34 mm. The force distribution analysis demonstrated the least forces of MEMO 3D, whereas the largest ones (up to 1.5N) are shown by Future SG, leading to the induction of locally elevated stress in surrounding tissues, potentially triggering the development of paravalvular fistulae. Conclusion Preliminary results demonstrate that the use of flexible rings with initially mobile structure allows preserving the native mitral annulus mobility after annuloplasty and reducing the stress (forces) acting on the surrounding tissues. The presented non-invasive method for estimating the stress of mitral annulus is crucial for advanced clinical practice as it allows further studying of the underlying pathologic mechanisms of developing paravalvular fistulae.

Comparison of the sustainability of mitral annular dynamics between two semi-rigid annuloplasty devices.

The choice of annuloplasty device is fundamental at the time of mitral valve repair, the goal being to optimally restore the physiological 3-dimensional (3D) structure and dynamics of the mitral annulus (MA). This study evaluated MA dynamics after annuloplasty with 2 different semi-rigid devices. Thirty-three patients eligible for mitral valve repair were selected for annuloplasty with the Physio II ring (Edwards Lifesciences, Irving, CA, USA) (n = 17) or the Memo 3D ring (LivaNova, Saluggia, Italy) (n = 16). MA dynamics were assessed with transoesophageal 3D echocardiography intraoperatively and 1 year after repair. The postoperative changes in the anteroposterior diameter {3.7% [standard deviation (SD) 2.7] vs 1.9% [SD 1.3]; P = 0.013} and in the annular height [27.7% (SD 8.7) vs 18.0% (SD 13.9); P = 0.003] were significantly larger with the Memo 3D ring during the cardiac cycle. The restoration of the saddle shape at baseline was superior with the Physio II ring, defined by a larger systolic annular height-to-commissural width ratio [15.1% (SD 2.3) vs 7.1% (SD 2.4); P < 0.001]. These observations of MA dynamics were sustained after 1 year, shown by a greater anteroposterior extension [5.1% (SD 1.0) vs 1.7% (SD 1.6); P = 0.002] and change in annular height-to-commissural width ratio [15.7% (SD 12.7) vs 3.1% (SD 3.0); P = 0.020] for the Memo 3D ring. There were no significant differences in mitral valve function between the 2 devices. The MA dynamics after annuloplasty with the Physio II and Memo 3D rings demonstrated a better systolic 3D restoration of the saddle shape with the Physio II ring, whereas the saddle-shaped geometry improved significantly with the Memo 3D ring, as a dynamic phenomenon. The Memo 3D ring also showed increased anteroposterior annular mobility and folding dynamics throughout the cardiac cycle. Moreover, the observed differences in MA dynamics between both devices appeared to be sustainable 1 year after ring implantation.

Annular dynamics of memo3D annuloplasty ring evaluated by 3D transesophageal echocardiography.

We assessed the mitral annular motion after mitral valve repair with the Sorin Memo 3D® (Sorin Group Italia S.r.L., Saluggia, Italy), which is a unique complete semirigid annuloplasty ring intended to restore the systolic profile of the mitral annulus while adapting to the physiologic dynamism of the annulus, using transesophageal real-time three-dimensional echocardiography. 17 patients (12 male; mean age 60.4 ± 14.9years) who underwent mitral annuloplasty using the Memo 3D ring were investigated. Mitral annular motion was assessed using QLAB®version8 allowing for a full evaluation of the mitral annulus dynamics. The mitral annular dimensions were measured throughout the cardiac cycle using 4D MV assessment2® while saddle shape was assessed through sequential measurements by RealView®. Saddle shape configuration of the mitral annulus and posterior and anterior leaflet motion could be observed during systole and diastole. The mitral annular area changed during the cardiac cycle by 5.7 ± 1.8%.The circumference length and diameter also changed throughout the cardiac cycle. The annular height was significantly higher in mid-systole than in mid-diastole (p < 0.05). The Memo 3D ring maintained a physiological saddle-shape configuration throughout the cardiac cycle. Real-time three-dimensional echocardiography analysis confirmed the motion and flexibility of the Memo 3D ring upon implantation.

3-Dimensional–Printed Model for Planning Transcatheter Mitral Valve Replacement

A 69-year-old man with a previous history of mitral valve repair plus aortic valve replacement subsequently developed prosthetic valve endocarditis and underwent aortomitral curtain reconstruction and mitral valve re-repair with a 38-mm Memo 3D (LivaNova, London, United Kingdom) ring and a Bentall

Mitral Valve Repair With Sorin Memo Three-dimensional Rechord Annuloplasty Ring: An Early New Zealand Single-centre Experience

Mitral valve repair—as opposed to replacement—has been regarded as the preferred treatment in mitral regurgitation. The purpose was to demonstrate an easily reproducible, mitral valve-sparing technique with functional and anatomical improvement of the diseased valve using the Sorin Memo 3D Rechord Annuloplasty Ring, which provides a guidance system for artificial chordae placement. Fourteen patients underwent mitral valve repair using the ring with neochord placement between the years 2016 and 2017. No patients required re-run bypass for further correction of repair. The mean age of our patients was 74 years, with 10 patients being male. Thirteen patients had isolated mitral valve repair with one patient having a combined procedure with bypass grafting. The postoperative complications included partial dehiscence of the ring (two patients), with one patient requiring redo mitral valve surgery. Mean follow-up time was 4 months, with the longest being about 10 months. Follow-up echocardiogram showed no chordal shortening in all patients and most had no significant mitral regurgitation with good anatomical and physiological valve function. There have been no mortalities in our series, with minor complications including pericarditis and postoperative arrhythmia. We are a relatively small centre with a low load of mitral valve surgeries. However, our preliminary experience with this device have shown promising signs with the ease in sizing the neochords. However, comparison studies and longer follow-up times are required to ascertain the effectiveness of the device.

Physiological mitral annular dynamics preserved after ring annuloplasty in mid-term period.

Mitral annular structure and dynamics after mitral ring annuloplasty using transesophageal echocardiography during the operation have been reported. We evaluated mitral annular structure and dynamics of three different rings in the mid-term period postoperatively. Thirty-one patients underwent mitral valve repair for degenerative mitral insufficiency. The MEMO 3D ring (semi-flexible), Carpentier-Edwards Physio II ring (semi-rigid), and St. Jude Medical Rigid Saddle Ring (rigid) were implanted in 15, 12, and eight patients, respectively, from September 2009 to February 2015. Electrocardiogram-gated three-dimensional computed tomography was performed in the mid-term period postoperatively. The postoperative antero-posterior rate of reduction in diameter from end-diastole to end-systole was slightly larger in the MEMO3D (0.57±0.69%) than in the Physio II (0.08±0.60%) and Rigid Saddle Ring (0.11±0.59%). There was no significant difference in the commissure-to-commissure rate of reduction in diameter among the groups. The postoperative end-systolic annular height to commissure width ratio was significantly larger in the Physio II (20.4±1.7%) and Rigid Saddle Ring (21.3±1.7%) than in the MEMO3D (10.8±3.1%, both p<0.0001). The rate of increase in the postoperative annular height to commissure width ratio from end-diastole to end-systole was significantly larger in the MEMO3D (2.1±1.7%) than in the Physio II (0.1±0.4%) and Rigid Saddle Ring (0.1±0.6%). The Physio II and Rigid Saddle Ring can restore the physiological and three-dimensional annular shape, and the MEMO3D can preserve physiological annular dynamics in mid-term period postoperatively.

Transapical transcatheter valve-in-ring implantation following mitral annuloplasty

Despite advances in surgical techniques for mitral valve repair, more than 20% of patients require reoperation within 10 years due to recurrence of severe mitral regurgitation. However, reoperations on the mitral valve are often associated with increased morbidity and mortality. We report a transapical mitral valve-in-ring implantation in a patient who had undergone mitral valve repair for ischemic mitral regurgitation using a complete semi-rigid Memo 3D mitral ring (LivaNova Group, Milan, Italy).

Mitral valve repair using a semirigid ring: patient selection and early outcomes.

Commonly used complete mitral annuloplastic rings include saddle-shaped and semirigid rings, with no clear indication for either type. A semirigid ring may be preferred in patients whose native mitral saddle shape is well maintained. We present our experience of using semirigid rings for mitral valve repair. We routinely measured the annular height-to-commissural width ratio by 3-dimensional transesophageal echocardiography prior to mitral repair. We generally chose a semirigid (Memo 3D) ring in patients whose annular height-to-commissural width ratio was normal (≥ 15%). The same semirigid ring with an additional chordal guiding system (Memo 3D ReChord) was selected for patients with anterior leaflet or bileaflet pathology. Over an 18-month period, 66 patients with severe degenerative (n = 60) or functional (n = 6) mitral regurgitation had Memo 3D (n = 32) or Memo 3D ReChord (n = 34) rings implanted. Postoperative 3-dimensional transesophageal echocardiography was completed in all patients (mean follow-up 7 ± 5 months). The majority of patients had no or mild residual mitral regurgitation; only two had moderate (2+) mitral regurgitation. There was no mortality at 30-days or on midterm follow-up. Our series represents the first Asian clinical experience using the Memo 3D ReChord ring. Although the long-term durability of mitral repair with this type of semirigid annuloplastic ring warrants further validation, our current clinical data are encouraging.

A Comparison of 2 Mitral Annuloplasty Rings for Severe Ischemic Mitral Regurgitation: Clinical and Echocardiographic Outcomes

Controversies regarding the choice of annuloplasty rings for treatment of ischemic mitral regurgitation still exist. Aim of the study is to compare early performance of 2 different rings in terms of rest and exercise echocardiographic parameters (transmitral gradient, systolic pulmonary artery pressure, and mitral valve area), clinical outcomes, and recurrence of mitral regurgitation. From January 2008 till December 2013, prospectively collected data of patients who underwent coronary artery bypass grafting and undersizing mitral valve annuloplasty for severe chronic ischemic mitral regurgitation at our Institution were reviewed. A total of 93 patients were identified; among them 44 had semirigid Memo 3D ring implanted (group A) whereas 49 had a rigid profile 3D ring (group B). At 6 months, recurrent ischemic mitral regurgitation, equal or more than moderate, was observed in 4 and 6 patients in the group A and B, respectively (P = 0.74). Group A showed certain improved valve geometric parameters such as posterior leaflet angle, tenting area, and coaptation depth. Transmitral gradient was significantly higher at rest in the group B (P < 0.0001). During exercise, significant increase of transmitral gradient and systolic pulmonary artery pressure was observed in group B (P < 0.0001). Mitral valve area was not statistically significantly smaller at rest in between groups (P = 0.09); however, it significantly decreased with exercise in group B (P = 0.01). At midterm follow-up, patients in group B were more symptomatic. In patients with chronic ischemic mitral regurgitation, use of semirigid Memo 3D ring when compared to the rigid Profile 3D may be associated with early improved mitral valve geometrical conformation and hemodynamic profile, particularly during exercise. No difference was observed between both groups in recurrent mitral regurgitation.

Annular dynamics after mitral valve repair with different prosthetic rings: A real-time three-dimensional transesophageal echocardiography study.

We assessed the effects of different types of prosthetic rings on mitral annular dynamics using real-time three-dimensional echocardiography (RT3DE). RT3DE was performed in 44 patients, including patients undergoing mitral annuloplasty using the Cosgrove-Edwards flexible band (Group A, n=10), the semi-rigid Sorin Memo 3D ring (Group B, n=17), the semi-rigid Edwards Physio II ring (Group C, n=7) and ten control subjects. Various annular diameters were measured throughout the cardiac cycle. We observed flexible anterior annulus motion in all of the groups except Group C. A flexible posterior annulus was only observed in Group B and the Control group. The mitral annular area changed during the cardiac cycle by 8.4±3.2, 6.3±2.0, 3.2±1.3, and 11.6±5.0% in Group A, Group B, Group C, and the Control group, respectively. The dynamic diastolic to systolic change in mitral annular diameters was lost in Group C, while it was maintained in Group A, and to a good degree in Group B. In comparison to the Control group, the mitral annulus shape was more ellipsoid in Group B and Group C, and more circular in Group A. Although mitral regurgitation was well controlled by all of the types of rings that were utilized in the present study, we demonstrated that the annulus motion and annulus shape differed according to the type of prosthetic ring that was used, which might provide important information for the selection of an appropriate prosthetic ring.

First-in-man implantation of a Sorin Memo 3D ring: Mitral annular flexibility is still preserved at 5 years of follow-up!

First-in-man implantation of a Sorin Memo 3D ring: Mitral annular flexibility is still preserved at 5 years of follow-up!

Early Clinical Experience and Echocardiographic Results With a New Semirigid Mitral Annuloplasty Ring: The Sorin Memo 3D

The Sorin Memo 3D (Sorin Biomedica Cardio S.r.L., Saluggia, Italy) is a new, complete semirigid annuloplasty ring. Clinical use, outcomes, and echocardiographic results are reported as an evaluation of its safety and efficacy in the treatment of mitral valve regurgitation (MVR). This device was assessed in 63 patients (63.5% men; mean age, 70.2 +/- 10.3 years) who underwent MVR operations between January 2007 and June 2008. Functional classification was normal leaflet motion (type I; 1.6%), leaflet prolapse (type II; 66.7%), and restricted leaflet motion (type III; 31.7%). Valve disease was degenerative (68.25%), ischemic (25.4%), and nonischemic dilated cardiomyopathy (6.35%). Early mortality (< or = 30 days) was 3.3% (2 patients). Late mortality (11.2 +/- 5.1 months) was 4.9% (3 patients). No deaths were device-related. Thromboembolic stroke occurred in 3.3% and endocarditis in 1.6%. Freedom from reoperation was 98.4%. At 6 months, MVR was grade 0/1 in 93.7% and grade 2+ in 6.4%. Left end-diastolic ventricular diameters decreased significantly from 59.3 +/- 6.9 mm preoperatively to 50.6 +/- 12.2 mm at 6 months, pulmonary arterial pressure decreased from 44.8 +/- 7.1 mm Hg to 38.4 +/- 5.5 mm Hg, and left ventricular ejection fraction increased significantly from 0.469 +/- 0.129 to 0.582 +/- 0.106. New York Heart Association functional class was I in 81% and II in 13.8%. Early results indicate the Sorin Memo 3D ring safely and effectively minimizes secondary MVR resulting from all causes and preserves mitral annular flexibility and function at follow-up.