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Comparative Study
. 2011 Feb;141(2):345-53.
doi: 10.1016/j.jtcvs.2010.10.015.

Effects of different annuloplasty ring types on mitral leaflet tenting area during acute myocardial ischemia

Wolfgang Bothe  1 , John-Peder Escobar Kvitting, Elizabeth H Stephens, Julia C Swanson, David H Liang, Neil B Ingels Jr, D Craig Miller
Affiliations
Comparative Study

Effects of different annuloplasty ring types on mitral leaflet tenting area during acute myocardial ischemia

Wolfgang Bothe et al. J Thorac Cardiovasc Surg. 2011 Feb.

Abstract

Objective: The study objective was to quantify the effects of different annuloplasty rings on mitral leaflet septal-lateral tenting areas during acute myocardial ischemia.

Methods: Radiopaque markers were implanted along the central septal-lateral meridian of the mitral valve in 30 sheep: 1 each to the septal and lateral aspects of the mitral annulus and 4 and 2 along the anterior and posterior mitral leaflets, respectively. Ten true-sized Carpentier-Edwards Physio, Edwards IMR ETLogix, and GeoForm annuloplasty rings (Edwards Lifesciences, Irvine, Calif) were inserted in a releasable fashion. Marker coordinates were obtained using biplane videofluoroscopy with ring inserted at baseline (RING_BL) and after 90 seconds of left circumflex artery occlusion (RING_ISCH). After ring release, another dataset was acquired before (No_Ring_BL) and after left circumflex artery occlusion (No_Ring_ISCH). Anterior and posterior mitral leaflet tenting areas were computed at mid-systole from sums of marker triangles with the midpoint between the annular markers being the vertex for all triangles.

Results: Compared with No_Ring_BL, mitral regurgitation grades and all tenting areas significantly increased with No_Ring_ISCH. Compared with No_Ring_ISCH, (1) all rings significantly prevented mitral regurgitation and reduced all tenting areas; (2) Edwards IMR ETLogix and GeoForm rings reduced posterior mitral leaflet area, but not anterior mitral leaflet tenting area, to a significantly greater extent than the Carpentier-Edwards Physio ring; and (3) Edwards IMR ETLogix and GeoForm rings affected tenting areas similarly.

Conclusions: In response to acute left ventricular ischemia, disease-specific functional/ischemic mitral regurgitation rings (Edwards IMR ETLogix, GeoForm) more effectively reduced posterior mitral leaflet area, but not anterior mitral leaflet tenting area, compared with true-sized physiologic rings (Carpentier-Edwards Physio). Despite its radical 3-dimensional shape and greater amount of mitral annular septal-lateral downsizing, the GeoForm ring did not reduce tenting areas more than the Edwards IMR ETLogix ring, suggesting that further reduction in tenting areas in patients with FMR/IMR may not be effectively achieved on an annular level.

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Figures

Figure 1
Figure 1
Schematics depicting the A: marker array used to delineate the septal-lateral (S-L) aspects of the mitral annulus (#22 and 18), anterior mitral leaflet (AML, #A1–4) and posterior mitral leaflet (PML, #P1 and 2); B: calculation of AML and PML tenting areas; C: experimental protocol timeline (see METHODS for details).
Figure 2
Figure 2
Total, anterior and posterior mitral leaflet (AML and PML, respectively) septal-lateral (S-L) tenting areas in animals from all three groups with no ring implanted under baseline conditions and during acute postero-lateral LV ischemia.
Figure 3
Figure 3
Total, anterior and posterior mitral leaflet (AML and PML, respectively) septal-lateral (S-L) tenting areas in animals from all three groups during acute postero-lateral LV ischemia with and without annuloplasty ring (A-C) and with annuloplasty rings implanted under baseline conditions and during ischemia (D-F).
Figure 4
Figure 4
Relative changes in tenting area (A) and mitral annular diameters (B) between the respective experimental conditions (see METHODS for details).
See this image and copyright information in PMC

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