Effect of anterior strut chordal transection on the force distribution on the marginal chordae of the mitral valve Muralidhar Padala, PhD, Lazarina Gyoneva,

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Presentation transcript:

Effect of anterior strut chordal transection on the force distribution on the marginal chordae of the mitral valve Muralidhar Padala, PhD, Lazarina Gyoneva, BS, Ajit P. Yoganathan, PhD The Journal of Thoracic and Cardiovascular Surgery Volume 144, Issue 3, Pages 624-633.e2 (September 2012) DOI: 10.1016/j.jtcvs.2011.10.032 Copyright © 2012 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 A, Atrial surface of anterior leaflet with collagen fibers inserting from anterior strut chordae tendineae; B, ventricular surface of anterior leaflet with fibers from strut chordae; and C, different settings of anterior leaflet tethering for variety of papillary muscle positions. The Journal of Thoracic and Cardiovascular Surgery 2012 144, 624-633.e2DOI: (10.1016/j.jtcvs.2011.10.032) Copyright © 2012 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 A, Ex vivo pulsatile left heart simulator in which chordal forces on native mitral valve chordae tendineae can be measured. B, Mitral valve leaflet and annular sizing using a sizer. C, In vivo measurement of annular tip to papillary muscle tip distance before explanting mitral valve. D, Explanted mitral valve with all structures intact. The Journal of Thoracic and Cardiovascular Surgery 2012 144, 624-633.e2DOI: (10.1016/j.jtcvs.2011.10.032) Copyright © 2012 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 A, Extracted mitral valve sutured onto silicone annulus using sutures. B, Mitral valve mounted into left heart simulator. C, Annular size increase induced with silicone annulus to simulate mitral annular dilation. D, Miniature C-ring force transducers developed with strain gauge technology to mount on chordae tendineae to measure forces acting on them throughout cardiac cycle. The Journal of Thoracic and Cardiovascular Surgery 2012 144, 624-633.e2DOI: (10.1016/j.jtcvs.2011.10.032) Copyright © 2012 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 Top, Experimental protocol used in our study. Bottom, Representative images of mitral valve tethering obtained under different pathologic mitral valve papillary muscle positions, reconstructed from 3-dimensional echocardiograms. The Journal of Thoracic and Cardiovascular Surgery 2012 144, 624-633.e2DOI: (10.1016/j.jtcvs.2011.10.032) Copyright © 2012 The American Association for Thoracic Surgery Terms and Conditions

Figure 5 Top, Ventricular surface of mitral anterior leaflet depicting insertion sites of strut and marginal chordae. Bottom, Left, Posteromedial papillary muscle marginal chordal force at normal and different pathologic papillary muscle positions before chordal cutting. Bottom, Right, Anterolateral papillary muscle marginal chordal force at normal and different pathologic papillary muscle positions before chordal cutting. The Journal of Thoracic and Cardiovascular Surgery 2012 144, 624-633.e2DOI: (10.1016/j.jtcvs.2011.10.032) Copyright © 2012 The American Association for Thoracic Surgery Terms and Conditions

Figure 6 Changes in marginal chordal forces before and after chordal cutting in left and right marginal chordae under different papillary muscle positions. Row 1, Apical papillary muscle displacement depicting minimal changes in measured chordal forces before and after chordal cutting. Row 2, Apical lateral papillary muscle displacement depicting significant increase in chordal force before and after chordal cutting in both chordae. Row 3, Apical lateral posterior papillary muscle displacement depicting significant changes in chordal force before and after chordal cutting in both chordae. The Journal of Thoracic and Cardiovascular Surgery 2012 144, 624-633.e2DOI: (10.1016/j.jtcvs.2011.10.032) Copyright © 2012 The American Association for Thoracic Surgery Terms and Conditions

Figure 7 Changes in anterior marginal chordal force before and after chordal cutting with progressive change in papillary muscle positions. Slope of increase in marginal chordal force after chordal cutting was significantly greater than before chordal cutting in the case of progressive displacement of papillary muscles after chordal cutting. The Journal of Thoracic and Cardiovascular Surgery 2012 144, 624-633.e2DOI: (10.1016/j.jtcvs.2011.10.032) Copyright © 2012 The American Association for Thoracic Surgery Terms and Conditions

Figure E1 Photograph of a porcine mitral valve depicting the various chordae tendineae classified based on their insertion zone in the mitral leaflet. The red dotted lines depict the location of the strut chordal transection and the yellow dotted lines depict the location where the force transducers are mounted. The Journal of Thoracic and Cardiovascular Surgery 2012 144, 624-633.e2DOI: (10.1016/j.jtcvs.2011.10.032) Copyright © 2012 The American Association for Thoracic Surgery Terms and Conditions

Figure E2 Native porcine valve depicting increase in free edge tethering even under diastolic conditions, with lateral and posterior displacement of papillary muscles. Such tethering not evident with just apical displacement. A = Anterior; APM = apical papillary muscle; P = posterior; PPM = posterior papillary muscle. The Journal of Thoracic and Cardiovascular Surgery 2012 144, 624-633.e2DOI: (10.1016/j.jtcvs.2011.10.032) Copyright © 2012 The American Association for Thoracic Surgery Terms and Conditions

Figure E3 Left, Valve from experimental setup in which chordal cutting relieved leaflet tethering and restored normal leaflet coaptation with apical papillary muscle displacement only. Right, Regurgitant orifice persisted even after repair procedure with apical posterior and lateral displacement of muscles. The Journal of Thoracic and Cardiovascular Surgery 2012 144, 624-633.e2DOI: (10.1016/j.jtcvs.2011.10.032) Copyright © 2012 The American Association for Thoracic Surgery Terms and Conditions