Saddle-Shape Annuloplasty Increases Mitral Leaflet Coaptation After Repair for Flail Posterior Leaflet

Abstract

Background The primary goal of mitral repair surgery is the re-establishment of normal leaflet coaptation. Surgical techniques which maintain or restore leaflet geometry promote leaflet coaptation. Recent three-dimensional (3D) echocardiographic studies have shown that saddle-shape annuloplasty has a salutary influence on leaflet geometry. Therefore, we hypothesized saddle-shaped annuloplasty would improve leaflet coaptation in repair cases for flail posterior leaflet segments. Methods Sixteen patients with a flail posterior segment and severe MR had valve repair using standard techniques. Eight patients received a saddle-shaped annuloplasty and eight received flat annuloplasty. Real-time 3D transesophageal echocardiography was performed before and after repair. Images were analyzed using a custom software to calculate mitral annular area (MAA), septolateral dimension (SL), Intercommissural width (CW), total leaflet area (TLA) and leaflet coaptation area (LCA). Results Post-repair mitral annular area (flat − 588.6 ± 26.5 mm2; saddle − 628.0 ± 35.3 mm2, p= 0.12) and total leaflet area (flat − 2198.5 ± 151.6 mm2; saddle − 2303.9 ± 183.8 mm2, p= 0.67) were similar in both groups. Post-repair leaflet coaptation area was significantly greater in the saddle group than in the flat group (226.8 ± 24.0 mm2 and 154.0 ± 13.0 mm2, respectively, p= 0.02). Conclusion Real-time 3D echocardiography and novel imaging software provides a powerful tool for analyzing mitral leaflet coaptation. When compared to flat annuloplasty saddle-shaped annuloplasty improves leaflet coaptation area after mitral valve repair for severe mitral regurgitation secondary to a flail posterior leaflet segment. Use of saddle-shaped annuloplasty devices may increase repair durability. (245 Words)

Is Physiologic Annular Dynamics Preserved After Mitral Valve Repair With Rigid or Semirigid Ring?

“…There are some reports regarding the advantages of a saddle-shaped ring compared with a flat annular ring [6,7,[9][10][11]. In an animal model, a saddle-shaped ring influenced the three-dimensional curvature of both the anterior and posterior leaflet, although a flat ring could affect only limited lesions of the posterior leaflet [7].…”

Measurement of Mitral Leaflet and Annular Geometry and Stress After Repair of Posterior Leaflet Prolapse: Virtual Repair Using a Patient-Specific Finite Element Simulation

“…A large variety of mitral annuloplasty systems are available with rings designed to recreate the normal valve saddle shape [18, 19], rings that significantly reduce the septolateral dimension of the annulus [20] and asymmetric ring shapes proposed for ischemic mitral regurgitation. [21] Stiffness ranges from flexible to semi-rigid to stiff, and in each case a range of sizes are available.…”

Saddle-Shaped Annuloplasty Improves Leaflet Coaptation in Repair for Ischemic Mitral Regurgitation

“…Techniques for mitral leaflet segmentation and modeling have been described previously [15]. Briefly, measurement planes were marked at 1-mm intervals along the entire length of the intercommissural axis (Fig 2A).…”

“…These atrial and ventricular edges of the coaptation zone (actual area of overlap) were then marked interactively (Fig 2B) [15]. …”

“…These new insights have led to the introduction of saddle-shaped annuloplasty rings to restore normal mitral annular 3D geometry. We have previously shown that saddle-shaped annuloplasty restores or maintains a more physiologic annular and leaflet geometry and function compared with flat annuloplasty [10, 14, 15] and that it reduces leaflet strain by increasing leaflet curvature [10, 14]. …”