Preoperative Three-Dimensional Valve Analysis Predicts Recurrent Ischemic Mitral Regurgitation After Mitral Annuloplasty

Bouma, Wobbe; Lai, Eugene; Levack, Melissa M.; Shang, Eric K.; Pouch, Alison M.; Eperjesi, Thomas J.; Plappert, Theodore; Yushkevich, Paul A.; Mariani, Massimo A.; Khabbaz, Kamal R.; Gleason, Thomas G.; Mahmood, Feroze; Acker, Michael A.; Woo, Y. Joseph; Cheung, Albert T.; Jackson, Benjamin M.; Gorman, Joseph H.; Gorman, Robert C.

doi:10.1016/j.athoracsur.2015.09.076

Cited by 52 publications

(70 citation statements)

References 22 publications

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“…10 Unlike 2DE, 3DE is not influenced by viewing plane selection, regional asymmetry, or localized annular distortions. In the current study, 2DE PTA (measured in the 2-chamber view) independently predicts IMR recurrence with an AUC of 0.81.…”

Section: Discussionmentioning

confidence: 99%

“…Techniques of annular segmentation and modeling and leaflet segmentation and modeling have been described. 10 Briefly, the Cartesian (x, y, z) coordinates of each data point were exported from TomTec to Matlab software (The Math-works, Natick, Mass) to perform quantitative reconstruction of the valve. Determinations of septolateral diameter; intercommissural width; mitral transverse diameter; mitral annular area; mitral annular circumference; mitral valve tethering area, volume, and index; (segmental) anterior tethering angles; and (segmental) PTAs are shown or described in Figure 2.…”

Section: Methodsmentioning

confidence: 99%

“…10 Current annuloplasty rings treat annular dilatation but do little to improve (and may potentiate) leaflet tethering. 11, 12 This may explain the limited repair durability after annuloplasty (especially in patients with advanced tethering) and suggests that a patient-specific approach based on preoperative imaging is required to optimize postoperative results.…”

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confidence: 99%

“…6, 13–34 To improve patient selection and postoperative outcome, we sought to determine the incremental value of preoperative 3DE and advanced mitral valve modeling over 2DE in predicting recurrent IMR after mitral annuloplasty. We recently published the 3DE results of 50 patients with IMR, 10 and to determine the incremental value of 3DE over 2DE, we performed additional 2DE analyses in this same group of 50 patients.…”

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confidence: 99%

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The value of preoperative 3-dimensional over 2-dimensional valve analysis in predicting recurrent ischemic mitral regurgitation after mitral annuloplasty

Hamer

Bouma

Lai

et al. 2016

The Journal of Thoracic and Cardiovascular Surgery

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Objectives Repair for ischemic mitral regurgitation with undersized annuloplasty is characterized by high recurrence rates. We sought to determine the value of pre-repair 3-dimensional echocardiography over 2-dimensional echocardiography in predicting recurrence at 6 months. Methods Intraoperative transesophageal 2-dimensional echocardiography and 3-dimensional echocardiography were performed in 50 patients undergoing undersized annuloplasty for ischemic mitral regurgitation. Two-dimensional echocardiography annular diameter and tethering parameters were measured in the apical 2- and 4-chamber views. A customized protocol was used to assess 3-dimensional annular geometry and regional leaflet tethering. Recurrence (grade ≥2) was assessed with 2-dimensional transthoracic echocardiography at 6 months. Results Preoperative 2- and 3-dimensional annular geometry were similar in all patients with ischemic mitral regurgitation. Preoperative 2- and 3-dimensional leaflet tethering were significantly higher in patients with recurrence (n = 13) when compared with patients without recurrence (n = 37). Multivariate logistic regression revealed preoperative 2-dimensional echocardiography posterior tethering angle as an independent predictor of recurrence with an optimal cutoff value of 32.0° (area under the curve, 0.81; 95% confidence interval, 0.68–0.95; P = .002) and preoperative 3-dimensional echocardiography P3 tethering angle as an independent predictor of recurrence with an optimal cutoff value of 29.9° (area under the curve, 0.92; 95% confidence interval, 0.84–1.00; P < .001). The predictive value of the 3-dimensional geometric multivariate model can be augmented by adding basal aneurysm/dyskinesis (area under the curve, 0.94; 95% confidence interval, 0.87–1.00; P < .001). Conclusions Preoperative 3-dimensional echocardiography P3 tethering angle is a stronger predictor of ischemic mitral regurgitation recurrence after annuloplasty than preoperative 2-dimensional echocardiography posterior tethering angle, which is highly influenced by viewing plane. In patients with a preoperative P3 tethering angle of 29.9° or larger (especially when combined with basal aneurysm/dyskinesis), chordal-sparing valve replacement should be strongly considered.

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Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

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confidence: 99%

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confidence: 99%

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The value of preoperative 3-dimensional over 2-dimensional valve analysis in predicting recurrent ischemic mitral regurgitation after mitral annuloplasty

Hamer

Bouma

Lai

et al. 2016

The Journal of Thoracic and Cardiovascular Surgery

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“…Given the high recurrence rate of moderate to severe IMR after valve repair surgery (33% in the first year [1]), there is a critical need to identify patients at elevated risk of recurrence, for whom alternative surgical approaches (complete valve replacement) may provide better long-term outcomes. Recently, 3D morphological features extracted from intra-operative rt-3DE of the diseased valve were shown to predict post-repair IMR recurrence [2]. Static features such as leaflet tethering angles demonstrate promising predictive value but only take advantage of rt-3DE data at a single frame in the cardiac cycle.…”

Section: Introductionmentioning

confidence: 99%

Spatiotemporal Segmentation and Modeling of the Mitral Valve in Real-Time 3D Echocardiographic Images

Pouch

Aly

Lai

et al. 2017

Medical Image Computing and Computer Assisted Intervention − MICCAI 2017

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Transesophageal echocardiography is the primary imaging modality for preoperative assessment of mitral valves with ischemic mitral regurgitation (IMR). While there are well known echocardiographic insights into the 3D morphology of mitral valves with IMR, such as annular dilation and leaflet tethering, less is understood about how quantification of valve dynamics can inform surgical treatment of IMR or predict short-term recurrence of the disease. As a step towards filling this knowledge gap, we present a novel framework for 4D segmentation and geometric modeling of the mitral valve in real-time 3D echocardiography (rt-3DE). The framework integrates multi-atlas label fusion and template-based medial modeling to generate quantitatively descriptive models of valve dynamics. The novelty of this work is that temporal consistency in the rt-3DE segmentations is enforced during both the segmentation and modeling stages with the use of groupwise label fusion and Kalman filtering. The algorithm is evaluated on rt-3DE data series from 10 patients: five with normal mitral valve morphology and five with severe IMR. In these 10 data series that total 207 individual 3DE images, each 3DE segmentation is validated against manual tracing and temporal consistency between segmentations is demonstrated. The ultimate goal is to generate accurate and consistent representations of valve dynamics that can both visually and quantitatively provide insight into normal and pathological valve function.

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A comprehensive pipeline for multi‐resolution modeling of the mitral valve: Validation, computational efficiency, and predictive capability

Drach

Khalighi

Sacks

2017

Numer Methods Biomed Eng

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Multiple studies have demonstrated that the pathological geometries unique to each patient can affect the durability of mitral valve (MV) repairs. While computational modeling of the MV is a promising approach to improve the surgical outcomes, the complex MV geometry precludes use of simplified models. Moreover, the lack of complete in-vivo geometric information presents significant challenges in the development of patient-specific computational models. There is thus a need to determine the level of detail necessary for predictive MV models. To address this issue, we have developed a novel pipeline for building attribute-rich computational models of MV with varying fidelity directly from the in-vitro imaging data. The approach combines high-resolution geometric information from loaded and unloaded states to achieve a high level of anatomic detail, followed by mapping and parametric embedding of tissue attributes to build a high resolution, attribute-rich computational models. Subsequent lower resolution models were then developed, and evaluated by comparing the displacements and surface strains to those extracted from the imaging data. We then identified the critical levels of fidelity for building predictive MV models in the dilated and repaired states. We demonstrated that a model with a feature size of ~5 mm and mesh size of ~1 mm was sufficient to predict the overall MV shape, stress, and strain distributions with high accuracy. However, we also noted that more detailed models were found to be needed to simulate microstructural events. We conclude that the developed pipeline enables sufficiently complex models for biomechanical simulations of MV in normal, dilated, repaired states.

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Preoperative Three-Dimensional Valve Analysis Predicts Recurrent Ischemic Mitral Regurgitation After Mitral Annuloplasty

Cited by 52 publications

References 22 publications

The value of preoperative 3-dimensional over 2-dimensional valve analysis in predicting recurrent ischemic mitral regurgitation after mitral annuloplasty

The value of preoperative 3-dimensional over 2-dimensional valve analysis in predicting recurrent ischemic mitral regurgitation after mitral annuloplasty

Spatiotemporal Segmentation and Modeling of the Mitral Valve in Real-Time 3D Echocardiographic Images

A comprehensive pipeline for multi‐resolution modeling of the mitral valve: Validation, computational efficiency, and predictive capability

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