Biomechanical drawbacks of different techniques of mitral neochordal implantation: When an apparently optimal repair can fail Francesco Sturla, PhD,

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Presentation transcript:

Biomechanical drawbacks of different techniques of mitral neochordal implantation: When an apparently optimal repair can fail Francesco Sturla, PhD, Emiliano Votta, PhD, Francesco Onorati, MD, PhD, Konstantinos Pechlivanidis, MD, Omar A. Pappalardo, MSc, Leonardo Gottin, MD, Aldo D. Milano, MD, Giovanni Puppini, MD, Alberto Redaelli, PhD, Giuseppe Faggian, MD The Journal of Thoracic and Cardiovascular Surgery Volume 150, Issue 5, Pages 1303-1312.e4 (November 2015) DOI: 10.1016/j.jtcvs.2015.07.014 Copyright © 2015 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 Study workflow: MV numeric simulation of patient-specific IPP geometry in patient 2 (A) and mechanical stress redistribution on the prolapsing MV posterior leaflet. B, Simulated standard NCI techniques adopting an ideal setting of NCI tuning (SN, DN, and SL) and systolic mechanical stress in postoperative conditions on the posterior MV leaflet. C, Simulation of postoperative MV systolic function after MV repair using the same NCI techniques and taking a realistic tuning of neochordal length into account. MV, Mitral valve; NCI, neochordal implantation; ePTFE, expanded polytetrafluoroethylene; SN, single neochorda; IPP, isolated posterior prolapse; DN, double neochorda; SL, standard loop. The Journal of Thoracic and Cardiovascular Surgery 2015 150, 1303-1312.e4DOI: (10.1016/j.jtcvs.2015.07.014) Copyright © 2015 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 A, Sketch of the MV in its closed configuration depicting the region of coaptation (black arrow), the ruptured native chordae, and the ePTFE suture (red line). B, Representation of the CoA, identified by the region where mechanical interaction between the mitral leaflets (ie, contact pressure) was computed at peak systole. CoA was quantified as the sum of the areas of the triangular elements where positive contact pressure was obtained. C, Representation of the computed biomechanical variables. FePTFE and Fnc represent the tension (ie, the axial force) acting on the ePTFE suture and the adjacent native chordae, respectively. SI is the maximum principal stress over the mitral leaflets: At every point, an infinitesimal portion of tissue is considered, and the stresses acting on it are analyzed in a local reference frame where no shear stresses are present, and the maximum possible tension at that point (P) is SI. The peak value of SI over the leaflets (located in the red region) is SIMAX. MV, Mitral valve; CoA, coaptation area; SI, maximum principal stress; SIMAX, peak value of maximum principal stresses along the leaflet free margin; FePTFE, artificial suture tension; Fnc, native chordal tension; ePTFE, expanded polytetrafluoroethylene. The Journal of Thoracic and Cardiovascular Surgery 2015 150, 1303-1312.e4DOI: (10.1016/j.jtcvs.2015.07.014) Copyright © 2015 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 Percentage variation, with respect to the corresponding “ideal” SN, DN, and SL repair, of the computed CoA (red bars) and peak of mechanical principal stress (SIMAX, blue bars) for each tested “apparently correct” configuration. Absolute values of CoA and SIMAX are provided for each “ideal” SN, DN, and SL configuration (using a horizontal colored line); the percentage variation for each “apparently correct” configuration is reported with respect to the corresponding “ideal” MV repair. The range of variability between the preoperative condition (Pre-model, dotted vertical line) and the physiologic state (Phys-model, continuous vertical line) for each reported variable. All the reported “apparently correct” configurations are detailed in the section “Patient-Specific Mitral Valve Finite Element Modeling.” SN, Single neochorda; DN, double neochorda; SL, standard loop; CoA, coaptation area; SIMAX, peak value of maximum principal stresses along the leaflet free margin. The Journal of Thoracic and Cardiovascular Surgery 2015 150, 1303-1312.e4DOI: (10.1016/j.jtcvs.2015.07.014) Copyright © 2015 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 Percentage of variation, with respect to the corresponding “ideal” MV repair (ie, SN, DN, and SL, respectively), of the resultant force of native chordae (Fnc, violet bars on the left of each panel) and the computed neochordal force (FePTFE, on the right of each panel) for each tested “apparently correct” configuration. The range of variability is reported, for Fnc resultant force, between the preoperative condition (Pre-model, dotted vertical line) and the physiologic state (Phys-model, continued vertical line). For each tested NCI multiple configuration, the percentage of redistribution of FePTFE between implanted artificial sutures is reported with different colors on the bar (ie, orange, green, and light-blue colors are used when necessary). All the reported “apparently correct” configurations are detailed in the section “Patient-Specific Mitral Valve Finite Element Modeling.” SN, Single neochorda; Fnc, native chordal tension; FePTFE, artificial suture tension. The Journal of Thoracic and Cardiovascular Surgery 2015 150, 1303-1312.e4DOI: (10.1016/j.jtcvs.2015.07.014) Copyright © 2015 The American Association for Thoracic Surgery Terms and Conditions

Figure E1 CoA measured at peak systole as the total extent of the elements in the posterior leaflet characterized by positive contact pressure with the anterior leaflet and reported in green color for each simulated configuration of patient 2, using a septo-lateral cut-view. A, CoA measured at peak systole under preoperative conditions (IPP). Percentage variation of CoA, with respect to the corresponding “ideal” (B) MV repair (SN, DN, and SL, respectively), is reported for each “apparently correct” configuration (C). All the reported “apparently correct” configurations are detailed in the section “Patient-Specific Mitral Valve Finite Element Modeling.” MV, Mitral valve; NCI, neochordal implantation; ePTFE, expanded polytetrafluoroethylene; SH, saddle horn; IPP, isolated posterior leaflet; P2, mid-point along the free margin of the posterior scallop; DN, double neochorda; CoA, coaptation area; SL, standard loop. The Journal of Thoracic and Cardiovascular Surgery 2015 150, 1303-1312.e4DOI: (10.1016/j.jtcvs.2015.07.014) Copyright © 2015 The American Association for Thoracic Surgery Terms and Conditions

Figure E2 Radar charts of the computed MV biomechanical variables (CoA, SIMAX, FePTFE, and Fnc) at peak systole, under physiologic conditions (Phys-model, blue dotted circumference), in the preoperative IPP configuration (Pre-model, red dotted circumference), the “ideal” NCI simulations (SN, DN, and SL, respectively), and all the performed “apparently correct” NCI simulated configurations. All the reported “apparently correct” configurations are detailed in the section “Patient-Specific Mitral Valve Finite Element Modeling.” CoA, Coaptation area; SIMAX, peak value of leaflet maximum principal stress; FePTFE, artificial chordae tension; Fnc, sum of tensions exerted by the native chordae tendineae; Phys-model, physiologic model; SL, standard loop; SN, single neochorda; DN, double neochorda. The Journal of Thoracic and Cardiovascular Surgery 2015 150, 1303-1312.e4DOI: (10.1016/j.jtcvs.2015.07.014) Copyright © 2015 The American Association for Thoracic Surgery Terms and Conditions

Study workflow: simulations of mitral prolapse and ideal and suboptimal mitral repairs. The Journal of Thoracic and Cardiovascular Surgery 2015 150, 1303-1312.e4DOI: (10.1016/j.jtcvs.2015.07.014) Copyright © 2015 The American Association for Thoracic Surgery Terms and Conditions