Semi-rigid Annuloplasty Ring Research Articles

Simple and Safe: Inverse Plication of the Posterior Mitral Leaflet in Everyday Mitral Valve Reconstruction with and without Concomitant Procedures.

Objective: Cardiosurgical mitral valve repair (MVR) cannot be easily replaced by other interventional procedures due to the complexity of mitral valve regurgitation as well as physiologic and anatomic repair techniques. A wide variety of techniques have been adopted for proper reconstruction of posterior leaflet prolapse. We investigated the long-term results of quadrangular resections and compared them with a simplified reconstruction maneuver, the inverse plication. Methods: We retrospectively collected data from 1977 patients after mitral valve repair between 2004 and 2022. After considering inclusion and exclusion criteria, we analyzed data from 180 patients after MVR with and without concomitant procedures such as CABG and/or aortic valve replacement (AVR). All MVRs were performed with a semi-rigid annuloplasty ring. A total of 180 patients received quadrangular resection (QuadRes, N = 120)) or inverse plication (InvPlic, N = 60) of the posterior leaflet, among other measures. Demographic data, risk factors, procedure times, hospitalization time, early and long-term mortality as well as Kaplan-Meier survival were analyzed. Results: Age (65.3 vs. 63.1 years) and sex (28.8% female vs. 337.5% female) did not differ significantly, and the EuroSCORE was significantly higher in the InvPlic group (6.46 ± 2.75) than in the QuadRes group (5.68 ± 3.1). Procedural times did not differ for cardiopulmonary bypass, and were as follows: InvPlic 136 ± 44 min; QuadRes 140 ± 48 min; X-Clamp: InvPlic 91 ± 31 min; QuadRes 90 ± 32 min. Hospitalization time was slightly but insignificantly lower in the InvPlic group (15.5 days) than in the QuadRes group (16.1 days). Early mortality (5.08% vs. 8.33%) and re-do procedures (1.69% InvPlic; 6.67% QuadRes) did not differ significantly. However, long-term mortality was significantly lower in the InvPlic group (15.25% vs. 32.32%, p = 0.029). Conclusions: Among the surgical measures for the posterior leaflet, inverse plication appears to be non-inferior to quadrangular resection in unselected all-comer patients. Long-term results and absence of re-do procedures indicate very good stability. Thus, inverse plication not only allows correction of PML, but is also completely safe in the long term and can replace quadrangular resection, especially in patients where a reduction in technical challenges and procedure duration is desired.

OUR EXPERIENCE OF MITRAL VALVE REPAIR IN A PREDOMINANT RHEUMATIC POPULATION USING A SEMIFLEXIBLE ANNULOPLASTY RING (CE PHYSIO 2 ANNULOPLASTY RING).

Background: Annular dilation is the most typical nding in Mitral regurgitation and annuloplasty with a prosthetic ring is common to various techniques described in literature Mitral valve repair in rheumatic heart disease possesses various technical difculties with no general consensus on the ideal annuloplasty ring. This study describes our experience and results with a semirigid annuloplasty ring (CE physio II ring) in a predominant rheumatic population. This is a retrospectiv Methods: e study using data including 23 patients who underwent mitral valve repair at Vardhman Mahavir Medical College and Safdarjung hospital, New Delhi, between July 2018 to April 2022. Patients were followed up to a mean of 19.3 10.6 months with a minimum follow-up period of 6 months. The mean age was Results: 30.5 15.3 years. The majority of patients, 78.3% (18) had rheumatic heart disease. 82.6% (19) of patients belonged to NYHA class I/II. The results in our study with CE physio II ring are excellent with 91.3% patients free from signicant MR (grade 2). 72% of the patients had improved or preserved Left ventricular function with a decrease in mean LVEF by 2.4% which was statistically insignicant(P>0.05). There was 0 operative or early mortality in our study. The semiexible CE physio II ring provides Conclusions: excellent results in both short and midterm outcomes in terms of freedom from recurrence of signicant MR with preservation of left ventricular function.

Leaflet plication with neochordae implantation: A novel technique for mitral valve repair.

Leaflet plication with neochordae implantation: A novel technique for mitral valve repair.

Reparación de válvula tricúspide con anillos protésicos

IntroductionRepairing is the most common surgical treatment for tricuspid regurgitation. We analyze the results of tricuspid valve repair using a prosthetic ring. MethodsRetrospective review in patients with tricuspid regurgitation (at least severe), isolated or concomitant with left-sided valve disease, undergoing repair using a semi-rigid annuloplasty ring. Results182 patients were analyzed, with a median postoperative follow-up of 61 months. 16.5% had massive tricuspid regurgitation and in 90% of the cases the etiology was functional. Age over 70 years, NYHA functional class≥III, hyponatremia, and concomitant mitroaortic surgery were identified as risk factors for mortality. The worst preoperative functional class and anemia were associated with postoperative right heart failure. During follow-up, patients with massive tricuspid regurgitation had significantly higher mortality and recurrent tricuspid regurgitation. Preoperative anemia, mild hyponatraemia, and higher preoperative tricuspid annulus diameter were risk factors related to right heart failure during follow-up. ConclussionsThe mortality of tricuspid repair with semi-rigid annuloplasty ring increased in elderly patients, with a worse functional class, concomitant mitroaortic disease and incipient right ventricular dysfunction. Correction of anemia could reduce the risk of postoperative right heart failure. In patients with massive tricuspid regurgitation, prosthetic valve replacement or complex tricuspid valve repairing will be chosen to avoid recurrence and improve survival and quality of life.

One Hundred Percent Reparability of Mitral Prolapse: Results of a Dynamic Nonresectional Technique

BackgroundWe studied the results of a dynamic mitral repair technique that preserves normal mitral valve function by avoiding leaflet resection and rigid and semirigid annuloplasty rings. MethodsIn previous reports we demonstrated that intraoperative simulation of mitral valve locking and isovolumic systole by rapid left ventricular inflation with pressurized saline accurately simulates mitral annular and leaflet shape and position, and left ventricular outflow tract dimensions. Length of polytetrafluoroethylene neochordae and size of fully flexible adjustable annuloplasty ring can be adjusted in three dimensions for accurate apposition of zones of leaflet coaptation, premarked with dots. We followed 1068 consecutive patients after repairs performed between 2001 and 2018. ResultsOf the 1068 patients, 674 were men (63.1%). Mean age was 62.25 ± 13 years. Leaflet repaired was anterior in 118 patients (11.05%), posterior in 564 (52.81%), both in 55 (5.15%), and neither in 123 (11.5%). Barlow's disease was present in 208 patients (19.48%). Repair was isolated in 82.5% (881 of 1068). Reparability was 100%. Perioperative mortality overall was 1.59% (17 of 1068): isolated repair, 1.14% (10 of 881); and isolated posterior leaflet, 0.85% (4 of 472). Leaflet systolic anterior motion occurred in 1.7% (18 of 1068), and was significant in 0.4% (4 of 1068). Survival at 10 years by Kaplan-Meier analysis was 74.65%, freedom from reoperation was 96.01%, and freedom from severe mitral regurgitation was 94%. The only predictor of reoperation (Cox analysis) was being male (P = .001). ConclusionsUse of intraoperative simulation of mitral dynamics led to 100% reparability for degenerative valves with minimal systolic anterior motion, despite no leaflet resection. Long-term durability has been good and similar for all leaflets.

A comparison of rigid and semi-rigid annuloplasty rings in mitral valve repair

A comparison of rigid and semi-rigid annuloplasty rings in mitral valve repair

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.

Transcatheter Annuloplasty for Mitral Regurgitation with an Adjustable Semi-Rigid Complete Ring: Initial Experience with the Millipede IRIS Device

ABSTRACTBackground: Complete, semi-rigid annuloplasty rings result in more durable reduction of mitral regurgitation (MR) over time than partial or flexible bands. We herein report the initial experience with the IRIS transcatheter adjustable semi-rigid complete annuloplasty ring.Methods: Seven patients were treated with the IRIS ring. Inclusion criteria included: 3–4+ functional MR, symptomatic New York Heart Association (NYHA) II–IV, and left ventricle (LV) end systolic dimension ≤ 65 mm. Exclusion criteria included: left ventricular ejection fraction (LVEF) < 20%, aortic valve disease, right-sided heart failure, and pulmonary artery systolic pressure (PASP) > 70 mmHg. Baseline and 30-day transthoracic echocardiography and computed tomography (CT) imaging was performed.Results: In Phase 1, four patients had surgical IRIS mitral ring implantation, and two had rings placed for associated functional tricuspid regurgitation (TR). In Phase 2, three patients had transfemoral, transseptal delivery of the IRIS mitral ring. There was no procedural death, stroke, or myocardial infarction (MI). One patient from Phase 1 expired 2 days post-procedure from chronic renal failure complications. The mitral septal-lateral (SL) diameter was reduced from 38.0 ± 4.1 mm to 25.9 ± 4.9 mm at 30 days (31.8% SL reduction, n = 7). MR was reduced from baseline 3–4+ to 0–1+ in all patients at 30 days. There were improvements in NYHA class, and there was a decrease in diastolic LV volumes from 182.4 ± 54.3mL to 115.3 ± 98.8 mL at 30 days (36.8% reduction). In the two patients with tricuspid annuloplasty, TR grade and tricuspid annular diameter reductions were baseline 4+ to 1+ at 30 days (37% annular reduction) and baseline 3+ to 0 at 30 days (36% annular reduction).Conclusion: This initial experience with the Millipede IRIS adjustable semi-rigid complete ring has demonstrated robust reductions in the mitral SL diameter, MR grade, and LV volumes.

Mitral Annuloplasty Ring Fracture and Annular Injury During Transcatheter Mitral Valve-in-Ring Intervention

A 60-year-old man who underwent prior surgical repair of severe mitral regurgitation with a 28-mm Sorin 3-dimensional Memo complete semi-rigid annuloplasty ring (Sorin Group, Arvada, Colorado) developed symptomatic severe functional mitral stenosis (transmitral mean gradient: 10.7 mm Hg at a heart

Minimally invasive mitral valve repair using a semi-rigid annuloplasty ring with a new chordal sizing system: the Memo3D ReChord.

We present a 55-year-old male with severe mitral regurgitation who underwent cardiology investigation for palpitations and worsening dyspnea (NYHA functional class II) and subsequently a minimally invasive mitral valve (MIMV) repair through right minithoracotomy (RT). The patient’s height was 175 cm tall and weighed 76 kg. The patient’s cardiovascular risk factors were hypertension and history of smoking. The patient has previously undergone surgical bilateral correction of carpal tunnel syndrome. On examination, the patient was in sinus rhythm. Transthoracic echocardiography showed severe mitral valve regurgitation due to posterior prolapse and mild left atrial dilation. The left ventricular ejection fraction was 60% and the systolic pulmonary arterial pressure was 45 mmHg.

Improving mitral valve coaptation with adjustable rings: outcomes from a European multicentre feasibility study with a new-generation adjustable annuloplasty ring system†

To evaluate the performance and safety of an adjustable semi-rigid annuloplasty ring for mitral regurgitation (MR) in a multicentre study. Between March 2010 and December 2011, 30 subjects underwent mitral valve (MV) repair using the Cardinal adjustable annuloplasty ring. This device is a semi-rigid ring allowing postimplantation size adjustment, under beating-heart conditions, to optimize leaflet coaptation under echocardiographic guidance. Coaptation length was determined before and after adjustment by transoesophageal echocardiography. The study enrolled 21 (70%) male and 9 (30%) female subjects with a mean age of 64 years. The approach was conventional midline sternotomy or mini-invasive right thoracotomy. Leaflet resection was done in 17 subjects, and chordal repair was used in 13. Concomitant procedures included coronary artery bypass grafting in 2 (7%) subjects, atrial ablation in 4 (13%) and tricuspid repair in 4 (13%). There was 1 (3%) early death unrelated to the study device. Intraoperative ring adjustment was performed in 24 of the 30 subjects. Residual MR was detected prior to adjustment in 6 subjects (4 mild and 2 moderate MR). Following adjustment, 5 subjects had no MR and 1 had trace MR. After adjustment, mean coaptation length improved from 7 ± 3 to 10 ± 3 mm (P < 0.0001). All patients who completed 1-year follow-up had less-than-mild MR, with the exception of 1 patient with ring dehiscence (and resultant 2+ MR) and 1 functional MR patient who developed recurrent 2+ MR due to persistent leaflet tethering. MV repair with the Cardinal adjustable annuloplasty ring is a reliable technique that enables the adjustment of the ring diameter on a beating heart under echocardiographic control. Such technology allows the optimization of leaflet coaptation, providing minimal residual MR and durable repair.

Midterm Results of Mitral Valve Repair: Closed Versus Open Annuloplasty Ring

Closed and open annuloplasty rings are both used for mitral valve repair. This study compared the clinical and echocardiographic results in patients with degenerative mitral disease undergoing MV repair with closed semirigid rings vs open bands. Between 2004 and 2008, 377 patients (mean age, 59 + or - 12 years) underwent mitral valve repair. Valve pathology was degenerative in 273 (72%). Closed rings were used in 163 (60%) and open rings in 110 (40%). Patients had similar characteristics and comorbidities. In addition to annuloplasty, repair techniques included leaflet resection (48% and 77%, p < 0.01), artificial chordal (55% and 36%, p < 0.01), and edge-to-edge repair (4% and 4%, p = 0.79), in closed and open groups, respectively. One patient in each group died (0.7%). Mean follow-up was 19 + or - 14 (closed group) and 34 + or - 15 months (open group; p < 0.01). Freedom from reoperation was 97.5% (closed group) vs 96.5% (open group). At follow-up, New York Heart Association functional class was similar between groups, and 91% in the closed group and 84% in the open group were free from moderate or severe mitral regurgitation (p = 0.05). Closed group patients had a longer line of leaflet coaptation (9.1 + or - 2.7 mm) vs the open group (7.1 + or - 1.9 mm; p < 0.01). Patients with closed semirigid annuloplasty rings demonstrated significantly longer lines of leaflet coaptation and tendency toward better echocardiographic midterm results than patients with open bands and may, therefore, benefit from improved repair durability.

Structure, Function, And Dynamics Of The Mitral Annulus: Importance In Mitral Valve Repair For Myxomatous Mitral Valve Disease

The first successful open repair of a mitral valve for mitral insufficiency was performed by Dr. Dwight McGoon in 1958. He employed a triangular plication of the prolapsing portion of the posterior leaflet and no annuloplasty. Other surgeons subsequently introduced a variety of techniques. Of these, the repair techniques developed by Dr. Alain Carpentier, which incorporated both leaflet repair by a quadrangular resection and annuloplasty, soon proved to be the most effective and reproducible method at that time. Because of the limited knowledge of normal and pathological mitral valve function available in the late 1960s, this repair was based on anatomical and pathological studies obtained through autopsies as well as intraoperatively. While the Carpentier technique continues to be used widely, most centers have found it difficult to repair more than 50-60% of insufficient valves. Only a few centers have achieved higher early success rates. Most have done this by modifications of the classical techniques. Recent reports have documented high rates of recurrence of significant mitral regurgitation in the 5- to 10-year follow-up interval. Our own experience with the Carpentier technique began in 1983. By this time, a growing body of knowledge was accumulating that demonstrated the highly dynamic behavior and important interactions of the six elements of the mitral complex: the left atrium, leaflets, mitral annulus, chordae, papillary muscles, and left ventricle. Because the Carpentier technique uses leaflet resection and rigid or semi-rigid annuloplasty rings, it produces a substantial disruption of these important functions. The mitral annulus is flattened and fully immobilized, and the leaflets also are flattened at their annular attachment. The loss of surface area amd distortion of the subvalvular chordae and papillary muscles from the leaflet resection produces diminished or absent leaflet movement. The entire mitral valve is left in a highly stressed state. In order to overcome these problems, we developed a new technique called the American Correction (Figure 1). The mitral leaflets are never resected, regardless of size. Artificial polytetrafluoroethylene (PTFE) chordae are used to correct localized leaflets prolapse. A full, totally flexible annuloplasty ring is utilized. Most importantly, all adjustments of leaflet position and annular sizing are done during inflation of the heart, with pressurized normal saline delivered at 4 liters a minute into the cavity of the left ventricle. In a controllable fashion, the left ventricular intracavitary and aortic root pressure can be elevated to systolic levels. This produces a series of reproducible changes in the leaflets and annulus that can be correlated with the normally functioning mitral valve in the beating heart (Figures 2-5).

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.

Mitral annular hinge motion contribution to changes in mitral septal–lateral dimension and annular area

The mitral annulus is a dynamic, saddle-shaped structure consisting of fibrous and muscular regions. Normal physiologic mechanisms of annular motion are incompletely understood, and more complete characterization is needed to provide rational basis for annuloplasty ring design and to enhance clinical outcomes. Seventeen sheep had radiopaque markers implanted; 16 around the annulus and 2 on middle anterior and posterior leaflet edges. Four-dimensional marker coordinates were acquired with biplanar videofluoroscopy at 60 Hz. Hinge angle was quantified between fibrous and muscular annular planes, with 0 degrees defined at end diastole, to characterize its contribution to alterations in mitral septal-lateral dimension and 2-dimensional total annular area throughout the cardiac cycle. During isovolumic contraction (pre-ejection), hinge angle abruptly increased, reaching maximum (steepest saddle shape, change 18 degrees +/- 13 degrees ) at peak left ventricular pressure. During ejection, hinge angle did not change; it then decreased during early filling (change 2 degrees +/- 2 degrees ). Septal-lateral dimension and total area paralleled hinge angle dynamics and leaflet distance (anterior to posterior marker). Pre-ejection septal-lateral reduction was 13% +/- 7% (3.3 +/- 1.5 mm) from 9% muscular dimension fall and 18 degrees +/- 13 degrees hinge angle increase. Pre-ejection increase in hinge angle contributes substantially to septal-lateral and total area reduction, facilitating leaflet coaptation. Semirigid annuloplasty rings or partial bands may preserve hinge motion, but possible recurrent annular dilatation could result in recurrent mitral regurgitation. Long-term clinical studies are required to determine who might benefit most from preserving intrinsic hinge motion without compromising repair durability.

Valve repair in patients with ischemic mitral regurgitation using a new semi-rigid annuloplasty device

In patients with ischemic mitral regurgitation (MR) concomitant valve correction leads to improved long term outcome. In these patients repair may be technically difficult due to small atrial diameters. A new semi-rigid annuloplasty ring (Medtronic Future Band®, MFB) allows a simplified handling as a consequence of an innovative design.