Rigid Annuloplasty Ring Research Articles

Comparison of flexible and rigid annuloplasty rings in isolated mitral regurgitation

Objectives: The aim of this study was to examine the early and midterm results of various annuloplasty rings in terms of residual mitral regurgitation (MR) in patients undergoing mitral valve repair. Patients and methods: In the retrospective study, 298 patients (157 males, 141 females; mean age: 58.8±14.3 years; range, 16 to 82 years) underwent repair between September 2009 and April 2012. Two hundred eleven were assigned to the flexible ring group (Group 1), whereas 87 were included in the rigid ring group (Group 2). Mitral pathologies were divided into three subgroups: ischemic, degenerative, and rheumatic. Results: The causes of mitral pathology were ischemic in 36.2%, degenerative in 54.4%, and rheumatic in 9.4%. Concomitant surgical procedures were present in 87%. The follow-up period ranged from 2 days to 33 months, with a mean of 15.8±7.5 months. The 30-day mortality rate was 9.2% and 10.4% in Groups 1 and 2, respectively. There was a high rate of successful repair in the rigid group with 88.5% and acceptable rate of repair in the flexible group with 72%. Mitral regurgitation was significantly reduced after intervention regardless of the ring type (p<0.01). Significant improvement in NYHA class was observed in both groups. Recurrent regurgitation was detected in 27.9% of patients in Group 1 and 11.5% in Group 2. Recurrence occurred within three to nine months following the surgery. Reoperation rates for residual MR were 3.3% (n=7) vs. 1.1% (n=1) in Groups 1 and 2, respectively (p=0.293). Conclusion: Saddle-shaped rings provide a mechanical benefit through a low and uniform force distribution and improve repair durability compared to flat rings. As a result, the rigid ring had a significant advantage, particularly in degenerative and rheumatic subgroups, but there was a loss of superiority in late ischemic MR due to left ventricle remodeling.

Impact of the Type of Annuloplasty Prosthesis on Hemodynamic Status after Mitral Valve Repair in Egyptian Patients

Abstract Objective The aim of this study is to evaluate mitral valve competency and gradient after mitral valve repair comparing rigid annuloplasty ring vs flat physio II ring. Methods Between October 2018 and October 2021, thirty-three (33) patients underwent mitral valve repair by flat physio ring and saddle shaped annuloplasty ring for degenerative and ischemic mitral valve disease respectively. Correlation between postoperative mitral hemodynamics was evaluated, the ischemic patients were fully revascularized. Additional Content An author video to accompany this abstract is available on https://academic.oup.com/eurheartjsupp. Please click on the arrow next to ‘More Content’ and then click on ‘Author videos’.

Surgical management of tricuspid regurgitation: a new algorithm to minimise recurrent tricuspid regurgitation

IntroductionRecurrent tricuspid regurgitation (TR) is frequently observed after cardiac surgery; however, the correct approach remains controversial. We developed an algorithm for action on the tricuspid valve (TV) and conducted a...

C14 A PROMISING SURGICAL TECHNIQUE IN PATIENTS WITH ATRIAL FUNCTIONAL MITRAL REGURGITATION: HYPER–DOWN–SIZING ANNULOPLASTY

Abstract Objective Atrial functional mitral valve regurgitation is a less common form of functional mitral regurgitation with normal leaflet motion and morphology, preserved dimension and function of left ventricle, associated with atrial fibrillation ad/or left atrial dilatation. Several factors are involved into the etiology, such as mitral annular dilation and insufficient leaflet remodeling, atriogenic leaflet tethering, loss of annular saddle shape and contractility, changes in heart rate. Methods Eleven consecutive patients with atrial functional mitral regurgitation, mean age 65 ± 12 years, normal left ventricle dimension and ejection fraction greater than 50% underwent mitral valve repair via right mini–thoracotomy in case of isolated mitral and tricuspid valve surgery or via median sternotomy in case of combined procedures. Concomitant procedures include tricuspid valve repair in 1 patient and coronary artery bypass in 5 patients. All patients presented an increased dimension of left atrium (mean left atrial volume: 90 ± 23 ml); mitral annular dimension was investigated with trans–esophageal echocardiography before operation. In all patients was implanted a downsized complete rigid annuloplasty ring with asymmetrical design of two sizes smaller respect to measured intercommissural distance. Clinical outcomes of patients and echocardiographic findings related to mitral regurgitation recurrence and left ventricle function were followed in the time. Results At discharge, any patient present a residual mitral regurgitation greater than mild, mean trans–mitral gradient was 2.5 ±2.1 mmHg. During the follow–up period of 24 ± 5 months, the New York Heart Association functional class significantly improved from 2.5 ± 0.4 to 1.5 ± 2.1. In three patients occurred cardiac rhythm disturbances requiring hospital stay, only one patient developed a greater than mild mitral regurgitation, reoperation was not becessary in any case. Left atrial volume decreased from 90 ± 23 ml to 58 ± 30 ml. Conclusions Mitral annuloplasty with downsized ring is a safe and effective procedure in patient with atrial functional mitral regurgitation in the same way of patient with functional mitral regurgitation due to ventricular dilation and tethering. The comforting clinical and echocardiographic outcome in our small group of patient encourage future studies in this particular group of patients.

Ex vivo biomechanical analysis of flexible versus rigid annuloplasty rings in mitral valves using a novel annular dilation system

BackgroundMitral 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.MethodsJuvenile 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.ResultsMitral 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.ConclusionsBoth 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.

Mitral valve repair for mitral regurgitation in pediatrics and children: Initial experience

IntroductionMitral valve repair in pediatrics has been slow because of the great variety in congenital mitral valve malformations and the still unknown growing effect over the mitral valve. The aim of this study is to evaluate the early and mid-term results in surgical repair of mitral valve regurgitation in pediatrics and children.Patients and methodsA total of 16 patients had mitral valve repair for mitral regurgitation (MR) between November 2016 and December 2020 at the National Heart Institute. There were seven (43.75%) males and nine (56.25%) females. The mean age was 7.5 years (5 months and 14 years). The mean weight was 19.9 kg (5.5–40 kg). Concomitant procedures were done in 11 (68.75%) patients. The mean cardiopulmonary bypass time was 82 min (40–150 min), and the mean aortic cross-clamp time was 59 min (25–110 min).ResultsThere was only one (6.25%) early mortality after 3 months. The number of patients who had posterior patch annuloplasty was six (37.5%), rigid rings was four (25%), whereas suture annuloplasty was five (31.25%). The mean postoperative mitral valve gradient was 5 mmHg (3.5–8 mmHg). More than 50% of patients with suture annuloplasty had moderate MR, whereas posterior patch annuloplasty had trivial to mild MR and rigid ring annuloplasty had trivial MR. Aortic valve surgery was done in two (12.5%) cases. The mean hospital stay was 7.2 days (4–14 days) and ICU mean stay was 2.9 days (1–7 days), with a mean mechanical ventilation time of 6 h (2–15 h). Reoperation was done in four (26.6%) patients, with 81.25% freedom from reoperation for mitral valve prosthetic replacement.ConclusionMitral valve repair for mitral valve regurgitation in pediatrics and children improves symptoms, valve function, and myocardial performance and delays replacement. Posterior patch and ring annuloplasty have satisfactory early and mid-term results, low mortality, and a high freedom from reoperation.

Long-term outcomes of rigid ring versus De Vega annuloplasty for functional tricuspid regurgitation: A propensity score-matching analysis

ObjectiveThis study was conducted to compare the outcomes of rigid ring versus De Vega annuloplasty for the treatment of functional tricuspid regurgitation (TR). MethodsFrom 2003 to 2017, De Vega annuloplasty (group D) was used in 231 patients, and rigid ring annuloplasty (group R) was used in 204 patients for the treatment of functional TR during left-sided valve surgery. A propensity score-matching analysis was used to pair group D (n = 109) with group R (n = 109). The primary outcomes were long-term overall survival and cardiac death, and the secondary outcomes were tricuspid valve-related events and TR recurrence (TR moderate or severe). The follow-up data were complete in 99.6% (447 out of 449) of the patients with a follow-up duration of 102 months. ResultsThere were no differences in the overall survival and cardiac death between the propensity score-matched groups (P = .793 and P = .175, respectively) up to 14 years after surgery. Tricuspid valve-related events, including cardiac death, permanent pacemaker implantation, thromboembolism, bleeding and tricuspid valve reoperation were also similar between the 2 matched groups during the follow-up (P > .999). However, cumulative incidence of TR recurrence was significantly higher in group R than in group D (P = .007). Multivariate analysis indicated the annuloplasty method (De Vega) and preoperative TR grade as risk factors for late TR recurrence. ConclusionsIn functional TR, annuloplasty methods did not influence long-term overall survival, cardiac mortality, and tricuspid valve-related events. However, rigid ring annuloplasty showed less late TR recurrence. Rigid ring annuloplasty can be considered for the treatment of functional TR in terms of its better durability.

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.

Outcomes after surgery for functional tricuspid regurgitation: a systematic review and meta-analysis.

This study aims to provide a contemporary overview of outcomes after tricuspid valve (TV) surgery for functional tricuspid regurgitation (TR). The literature was systematically searched for papers published between January 2005 and December 2017 reporting on clinical/echocardiographic outcomes after TV surgery for functional TR. A random effects meta-analysis was conducted for outcome variables, and late outcomes are visualized by pooled Kaplan-Meier curves. Subgroup analyses were performed for studies with a within-study comparison of suture vs. ring repair and flexible vs. rigid ring repair. Eighty-seven publications were included, encompassing 13184 patients (mean age: 62.1 ± 11.8 years, 55% females). A mitral valve procedure was performed in 92% of patients. Pooled mean follow-up was 4.0 ± 2.8 years. Pooled early mortality was 3.9% (95% CI: 3.2-4.6), and late mortality rate was 2.7%/year (95% CI: 2.0-3.5), of which approximately half was cardiac-related 1.2%/year (95% CI: 0.8-1.9). Pooled risk of early moderate-to-severe TR at discharge was 9.4% (95% CI: 7.0-12.1). Late moderate-to-severe TR rate after discharge was 1.9%/year (95% CI: 1.0-3.5). Late reintervention rate was 0.3%/year (95% CI: 0.2-0.4). Mortality and overall (early and late) TR rate were comparable between suture vs. ring annuloplasty (14 studies), whereas overall TR rate was higher after flexible ring vs. rigid ring annuloplasty (6 studies) (7.5%/year vs. 3.9%/year, P = 0.002). This study shows that patients undergoing surgery for functional tricuspid regurgitation (FTR) have an acceptable early and late mortality. However, TR remains prevalent after surgery. The results of this study can be used to inform patients and clinicians about the expected outcome after surgery for FTR and can results serve as a benchmark for the performance of emerging transcatheter TV interventions.

New insight into tricuspid valve anatomy from 100 hearts to reappraise annuloplasty methodology.

Prosthetic ring annuloplasty plays an important role in tricuspid valve repair. However, discussions regarding the appropriate suturing technique for rigid annuloplasty rings in patients with tricuspid valve anatomical variations are lacking. We aimed to clarify the diversity and pattern of tricuspid valve morphology. We analyzed tricuspid valve morphology and measured leaflet dimensions in 100 autopsy hearts, which were classified into three groups based on the number of posterior leaflet scallops: single scallop (PLS1) (n = 52), two scallops (PLS2) (n = 42), and three scallops (PLS3) (n = 5). One heart without posterior leaflet was excluded from the statistical analysis. Demographic characteristics were compared between PLS1, PLS2, and PLS3. The linear trends of proportions of each leaflet between PLS1, PLS2, and PLS3 were assessed using linear regression analysis. Median proportion (interquartile range) of the posterior annular length out of the entire annular perimeter in PLS1, PLS2, and PLS3 was 26% (22-31%), 37% (33-40%), and 45% (42-49%), respectively. Linear regression analysis showed a significant increasing trend (p for trend < 0.001) of the posterior leaflet annulus proportion from PLS1 to PLS3. Accordingly, the anterior and septal annulus proportions significantly decreased from PLS1 to PLS3. Approximately half of the tricuspid valve has multiple posterior leaflet scallops. The proportion of the posterior leaflet annular length to the tricuspid valve annulus perimeter increases as the number of posterior leaflet scallops increases. These morphologic variations will be fundamental for future discussion about the pathology of a dilated tricuspid valve and methodology of prosthetic ring annuloplasty.

Bicuspid aortic valve repair with “self-made” radio-opaque rigid annuloplasty ring implantation

Bicuspid aortic valve repair with “self-made” radio-opaque rigid annuloplasty ring implantation

Fifteen years' experience with the use of artificial chords for valve reconstruction in children.

To retrospectively review our experience with artificial chords in mitral and tricuspid reconstructive surgery in children. All consecutive paediatric (<18 years) patients who underwent mitral or tricuspid valve reconstruction with the use of artificial chords in our centre in the past 15 years were retrospectively analysed. Thirty-nine patients (age 3 days to 17 years) underwent reconstruction of the mitral (n = 27) or tricuspid (n = 12) valve using artificial chords. Mean number of chords was 3.5 ± 1.7. In 26 of 27 mitral valve patients, chords were placed on the anterior leaflet, in one on the posterior leaflet. In 10 of the 12 tricupid valve, patients chords were placed on the anterior leaflet and in 2 on the septal leaflet. All mitral patients underwent annuloplasty (10 bilateral Wooler-Kay and 17 rigid ring annuloplasty). Ten of the 12 tricuspid patients underwent annuloplasty (1 rigid ring and 9 commissural plication). Follow-up was after 8.7 ± 5.5 years. There was no early or late mortality. The actuarial freedom from reoperation rates at 1, 5 and 10 years were 95%, 91% and 81%, respectively. No reoperations occurred in the tricuspid group. In the mitral group, there were 2 early failures and 3 late reoperations due to mitral stenosis. Restricted leaflet motion probably caused by the artificial chords was seen in only 1 patient. Our data show that long-term durability of mitral and tricuspid valve reconstruction using artificial chords in children is good. Despite patient growth, restricted leaflet motion by the artificial chords does not seem to form a major problem.

Flexible band versus rigid ring annuloplasty for tricuspid regurgitation: a systematic review and meta-analysis.

Up to 20% of patients have pre-discharge residual moderate to severe tricuspid regurgitation (TR) after tricuspid repair. Reoperations for recurrent TR carry high mortality rates, which emphasizes the importance of identifying the optimal technique for the surgical management of TR. The present study is a systematic review and meta-analysis that aims to compare short and long term survival and freedom from TR of flexible band ring versus rigid ring for annuloplasty of TR. We conducted a systematic review and meta-analysis of comparative studies to evaluate these procedures. A systematic search of the literature was performed from six electronic databases. Pooled meta-analysis was conducted using odds ratio (OR) and weighted mean difference (WMD). The rates of in-hospital mortality were not different between the two groups, with cumulative rates of 6.9% for flexible band and 7.3% for rigid ring (OR: 0.92; 95% CI: 0.49-1.71). Rates of stroke were also similar with 1.7% of flexible band and 1.3% of rigid rings suffering a perioperative stroke (OR: 1.29; 95% CI: 0.74-2.23). Rigid ring had significantly better freedom from grade ≥2 TR at 5 years (OR: 0.44; 95% CI: 0.20-0.99) and overall (P=0.005). There was no significant difference in overall rates of reoperation (P=0.232) and survival (P=0.086) between flexible band and rigid ring. Both rigid ring and flexible band offer acceptable outcomes for the treatment of TR. Compared to flexible band, rates of TR are stable after rigid ring annuloplasty and long term freedom from TR are superior for rigid ring devices. Large prospective randomized trials are required in order to validate these findings and assess for improvements in patient survival.

Comparison of outcomes of tricuspid annuloplasty with 3D-rigid versus flexible prosthetic ring for functional tricuspid regurgitation secondary to rheumatic mitral valve disease.

Annuloplasty bands and rings are widely used for repairing functional tricuspid regurgitation (FTR). However, the question regarding which is the ideal annuloplasty device remains unclear. The aim of this study was to compare the efficacy and mid-term durability of tricuspid ring annuloplasty for FTR secondary to rheumatic mitral valve disease using flexible Cosgrove-Edwards band and the rigid Edwards MC3 ring (Edwards Lifesciences, LLC, Irvine, CA, USA). We retrospectively collected the clinical data of those who underwent mitral valve replacement (MVR) in concomitant with tricuspid ring annuloplasty from 2009 to 2013. The flexible band was used in 46 patients (flexible group), and the 3D rigid ring was used in 60 patients (rigid group). Echocardiographic evaluation of tricuspid function was performed preoperatively and postoperatively. The grade of TR was significantly improved compared to preoperative values in two groups. There was no significant difference regarding postoperative TR grade between the two groups at 1 week and 2-3 months but there was statistical significant difference at postoperative 6-12 months, and 2-3 years. During the follow up period, 25 of 46 patients (54.3%) in flexible group and 22 of 60 patients (30.3%) in rigid group developed recurrent TR. Freedom from recurrent TR in flexible group is significant lower than rigid group in each postoperative follow up period. These findings suggest that 3D rigid ring annuloplasty might be more effective for tricuspid ring annuloplasty in FTR in mid-term postoperative periods when compared to flexible band.

Undersized Mitral Annuloplasty Increases Strain in the Proximal Lateral Left Ventricular Wall

Recurrence of mitral regurgitation (MR) after undersized mitral annuloplasty (MA) for ischemic MR is as high as 60%, with the recurrence rate likely due to continued dilation of the left ventricle (LV). To better understand the causes of recurrent MR, we studied the effect of undersized MA on strain in the LV wall. We hypothesize that the acute change in ventricular shape induced by MA will cause increased strain in regions nearest the mitral valve. Finite element models were previously reported, based on cardiac magnetic resonance images of 5 sheep with mild to moderate ischemic MR. A 24-mm saddle-shaped rigid annuloplasty ring was modeled and used to simulate virtual MA. Longitudinal and myofiber strains were calculated at end-diastole and end-systole, with preoperative early diastolic geometry as the reference state. The undersized MA significantly increased longitudinal strain at end-diastole in the lateral LV wall. The effect was greatest in the proximal-lateral endocardial surface, where longitudinal strain after MA was approximately triple the preoperative strain (11.17% ± 2.15% vs 3.45% ± 0.92%, p= 0.0057). In contrast, postoperative end-diastolic fiber strain decreased in this same region (2.53% ± 2.14% vs 7.72% ± 1.79%, p= 0.0060). There were no significant changes in either strain type at end-systole. Undersized MA increased longitudinal strain in the proximal lateral LV wall at end-diastole. This procedure-related strain at the proximal-lateral LV wall may foster continued LV enlargement and subsequent recurrence of mitral regurgitation.

Undersized Rigid Nonplanar Annuloplasty: The Key to Effective and Durable Repair of Functional Tricuspid Regurgitation

Previous clinical experiences have demonstrated high early and late recurrence rates after repair of functional tricuspid regurgitation (TR). We investigated the results of functional TR repair with undersized rigid nonplanar annuloplasty rings. From January 2007 to December 2013, 216 consecutive patients with moderate or greater functional TR were treated with undersized (size 26 mm or 28 mm) rigid nonplanar annuloplasty rings. The mean age was 69 ± 13 years. There was a previous history of cardiac operation in 25% (54 of 216 patients). Tricuspid regurgitation was graded as severe in 47% (102 of 216) and moderate in 53% (114 of 216). Concomitant operations included mitral valve procedures in 92% (198 of 216), coronary artery bypass grafting in 21% (45 of 216), aortic valve procedures in 9% (20 of 216), and cryomaze procedures in 35% (76 of 216). Size 26 mm rings were used in 38% of patients (81 of 216), and size 28 mm in 62% (135 of 216). The perioperative mortality rate was 6% (14 of 216). On predischarge echocardiography, TR grade was none or mild in 94% (176 of 187 patients), moderate in 4% (7 of 187), and severe in 2% (4 of 187). At a mean follow-up of 33.0 ± 24.0 months, TR grade was none or mild in 81% of patients (130 of 160), moderate in 16% (26 of 160), and severe in 2% (4 of 160). There were no reoperations for recurrent TR, and no patients have had tricuspid stenosis or annuloplasty ring dehiscence. Treatment of functional TR with undersized (26 mm or 28 mm) nonplanar rigid annuloplasty rings is safe and highly effective, with a near absence of recurrent severe TR at midterm follow-up.

Surgical approach to functional tricuspid regurgitation

Functional tricuspid regurgitation (FTR) is an important clinical entity that is encountered frequently during the operative management of left-sided heart valve disease, particularly in the setting of mitral regurgitation. Failure to recognize the importance of FTR during mitral valve surgery may result in inferior early and late outcomes because of the progression of tricuspid regurgitation and right heart failure. In this review, attention is focused on recent literature, which increasingly supports the use of corrective tricuspid valve annuloplasty, and the growing consensus that FTR or tricuspid annular dilation should be more aggressively addressed at the time of cardiac surgery. The European Society of Cardiology and the European Association for Cardiothoracic Surgery (ESC/EACTS) 2012 guidelines recommend a more proactive approach to tricuspid regurgitation correction and highlight the shifting consensus toward more aggressive surgical therapy. Rigid annuloplasty rings should be used in favor of flexible bands or DeVega-style repairs. Preoperative determinants of clinical outcomes now include echocardiographic parameters of tricuspid valve tenting area, and associated right ventricular size and function. Despite data demonstrating inferior outcomes in the presence of residual tricuspid regurgitation after cardiac surgery, surgical repair for FTR appears to be underutilized. Increased recognition and correction of tricuspid regurgitation at the time of surgery is increasingly supported by published guidelines, although randomized prospective data are needed to bolster current recommendations.

Quantitative Evaluation of Annuloplasty on Mitral Valve Chordae Tendineae Forces to Supplement Surgical Planning Model Development

Computational models of the heart's mitral valve (MV) exhibit potential for preoperative surgical planning in ischemic mitral regurgitation (IMR). However challenges exist in defining boundary conditions to accurately model the function and response of the chordae tendineae to both IMR and surgical annuloplasty repair. Towards this goal, a ground-truth data set was generated by quantifying the isolated effects of IMR and mitral annuloplasty on leaflet coaptation, regurgitation, and tethering forces of the anterior strut and posterior intermediary chordae tendineae. MVs were excised from ovine hearts (N=15) and mounted in a pulsatile heart simulator which has been demonstrated to mimic the systolic MV geometry and coaptation of healthy and chronic IMR sheep. Strut and intermediary chordae from both MV leaflets (N=4) were instrumented with force transducers. Tested conditions included a healthy control, IMR, oversized annuloplasty, true-sized annuloplasty, and undersized mitral annuloplasty. A2-P2 leaflet coaptation length, regurgitation, and chordal tethering were quantified and statistically compared across experimental conditions. IMR was successfully simulated with significant increases in MR, tethering forces for each of the chordae, and decrease in leaflet coaptation (p<.05). Compared to the IMR condition, increasing levels of downsized annuloplasty significantly reduced regurgitation, increased coaptation, reduced posteromedial papillary muscle strut chordal forces, and reduced intermediary chordal forces from the anterolateral papillary muscle (p<.05). These results provide for the first time a novel comprehensive data set for refining the ability of computational MV models to simulate IMR and varying sizes of complete rigid ring annuloplasty.

A Novel Rigid Annuloplasty Ring for Aortic Valve Reconstruction: An In Vitro Investigation

Remodeling of the dilated valve annulus with a prosthetic ring for repair of valve insufficiency is a well-established concept in mitral and tricuspid valve surgery and may also be suitable for aortic valve reconstruction. A novel rigid aortic annuloplasty ring was tested in vitro. Ten fresh porcine aortic roots were investigated in a pulsatile flow simulator before surgery (group N), after patch dilatation of the annulus (group D), and after reconstruction using a rigid annuloplasty ring (group R). The ring was designed to (1) prevent contact with the leaflets, reducing the risk of contact injury, (2) be applicable to all valve phenotypes, (3) prevent injury to the conduction bundle, and (4) be implantable from inside the aortic root (subvalvular). For each group pressure gradient, leakage volume, and coaptation height were measured. With the annuloplasty ring, regurgitation volume decreased from -8.50 ± 1.91 mL (group D) to -4.75 ± 1.66 mL (group R; p < 0.0003), not different from group N. Coaptation height of the leaflets increased from 0.62 ± 0.08 mm (group D) to 0.77 ± 0.11 mm (group R; p < 0.005), similar to group N. Mean pressure gradient increased from 2.98 ± 0.38 mm Hg (group D) to 3.72 ± 0.40 mm Hg (group R; p < 0.0001). This novel aortic annuloplasty ring has the potential for supporting aortic valve reconstruction by remodeling the subvalvular area.

Three-dimensional valve repair—the better care? Midterm results of a saddle-shaped, rigid annuloplasty ring in patients with ischemic mitral regurgitation

Undersized ring annuloplasty is the treatment of choice for functional mitral regurgitation. However, recurrence of mitral regurgitation within the first years is frequent. The aim of this study was to analyze the functional and clinical outcome after mitral valve repair with the 3-dimensional saddle-shaped Edwards GeoForm (Edwards Lifesciences LLC, Irvine, Calif) annuloplasty ring in patients with ischemic mitral regurgitation. Between November 2006 and November 2012, 70 patients (mean age, 68 ± 10 years; mean left ventricular ejection fraction, 40% ± 15%) with functional mitral regurgitation due to ischemic cardiomyopathy underwent mitral valve repair with the Edwards GeoForm annuloplasty ring. Concomitant procedures, suchascoronary artery bypass grafting (75.7%), tricuspid valve repair (25.7%), aortic valve replacement (8.6%), and the Maze procedure (4.3%), were performed in 92.9% of patients. Follow-up is 97% complete (mean, 3.0 ± 1.7 years). Transthoracic echocardiography was obtained 2.4 ± 1.7 years postoperatively. Thirty-day mortality was 5.9%. Overall survival at 5 years was 71.3% ± 6.9%. At 4 years, overall freedom from recurrence of mitral regurgitation grade 3+ or greater was 92.5% ± 3.6%, and freedom from recurrence of mitral regurgitation grade 2+ or greater was 71.0% ± 8.7%. Three patients required a mitral valve-related reoperation for ring dehiscence. New York Heart Association functional class improved from 3.6 ± 0.6 to 1.6 ± 0.6 during follow-up (P<.05). Mean mitral valve pressure gradient was 3.3 ± 1.8 mm Hg across all ring sizes at the time of follow-up. Mitral valve repair with the 3-dimensional saddle-shaped Edwards GeoForm annuloplasty ring in case of ischemic mitral regurgitation shows a low rate of recurrent regurgitation at 4 years. Clinically relevant mitral stenosis was not detected. The importance of secure anchoring of the device in the mitral annulus has to be emphasized to prevent ring dehiscence.