Wobbe Bouma, MD, Chikashi Aoki, MD, Mathieu Vergnat, MD, Alison M

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Saddle-Shaped Annuloplasty Improves Leaflet Coaptation in Repair for Ischemic Mitral Regurgitation Wobbe Bouma, MD, Chikashi Aoki, MD, Mathieu Vergnat, MD, Alison M. Pouch, PhD, Shanna R. Sprinkle, MD, Matthew J. Gillespie, MD, Massimo A. Mariani, MD, PhD, Benjamin M. Jackson, MD, Robert C. Gorman, MD, Joseph H. Gorman, MD The Annals of Thoracic Surgery Volume 100, Issue 4, Pages 1360-1366 (October 2015) DOI: 10.1016/j.athoracsur.2015.03.096 Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Mitral annuloplasty rings viewed from different orientations. (A) and (B) Carpentier-Edwards Physio (Edwards Lifesciences, Irvine, CA) flat mitral annuloplasty ring. (C) and (D) Medtronic Profile 3D (Medtronic, Minneapolis, MN) saddle-shaped mitral annuloplasty ring. Subtle differences in the shape of the flow orifice can be appreciated in the short-axis views (A and C), whereas dramatic differences in annular height and nonplanarity are evident in the oblique views (B and D). The Annals of Thoracic Surgery 2015 100, 1360-1366DOI: (10.1016/j.athoracsur.2015.03.096) Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Leaflet segmentation technique. (A) Template of transverse cross-sections every 1 mm along the intercommissural axis. (B) One of the two-dimensional cross-sections represented by the white dashed line in (A); the atrial surface of the mitral valve leaflets and the coaptation zone are interactively marked (green curves). The most atrial coaptation point is marked with the white dot, and the most ventricular coaptation point is marked with an X. (C) Schematic demonstrating how the atrial and ventricular coaptation points are then projected onto a viewing plane orthogonal to the least squares annular plane passing through the commissures to construct a two-dimensional representation of the coaptation zone. The white and red dashed lines are both within least squares annular plane in all three panels. (AC = anterior commissure; AML = anterior mitral leaflet; AoV = aortic valve; Coapt = coaptation; LA = left atrium; LV = left ventricle; LVOT = left ventricular outflow tract; PC = posterior commissure; PML = posterior mitral leaflet.) The Annals of Thoracic Surgery 2015 100, 1360-1366DOI: (10.1016/j.athoracsur.2015.03.096) Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Comparison of coaptation area and coaptation length. The black curve represents the two-dimensional projections of the averaged atrial and ventricular coaptation edges for the flat annuloplasty group. The area bounded by the two curves is the projected two-dimensional coaptation area. The distance between the two curves represents coaptation length at each intercommissural position. The dashed curve signifies similar parameters for the saddle-shaped annuloplasty group. The represented viewing plane is orthogonal to the averaged best-fit annular plane and passes through the line connecting the anterior commissure (AC) and the posterior commissure (PC). These composite images were created using interpolation of a normalized intercommissural sampling scale for each valve. The Annals of Thoracic Surgery 2015 100, 1360-1366DOI: (10.1016/j.athoracsur.2015.03.096) Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Comparison of postoperative change in coaptation length (and area). Shown here is net change in coaptation length (postrepair coaptation length compared with prerepair coaptation length) versus normalized intercommissural position for both the saddle-shaped (dashed) and flat (black) annuloplasty groups. Notice an increase in coaptation length (and area) across the entire intercommissural distance for the saddle group (especially toward the posterior commissure [PC]) and a decrease in coaptation length (and area) across the entire intercommissural distance for the flat group (especially toward the PC). (AC = anterior commissure.) The Annals of Thoracic Surgery 2015 100, 1360-1366DOI: (10.1016/j.athoracsur.2015.03.096) Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions