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Effect of Mitral Annuloplasty Ring Shape and Size on Leaflet and Myofiber Stress Following Repair of Posterior Leaflet Prolapse: A Patient-Specific Finite-Element Simulation
William G. Morrel, IV1, Liang Ge1, Alison Ward2, Zhihong Zhang3, Joe Pantoja1, Sarthak Gulati4, Eugene A. Grossi2, Mark B. Ratcliffe1.
1University of California, San Francisco, San Francisco, CA, USA, 2NYU School of Medicine, New York, NY, USA, 3San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA, 4University of California, Los Angeles, Los Angeles, CA, USA.

OBJECTIVE: Calculate changes in leaflet coaptation and stresses on mitral valve (MV) and left ventricle (LV) resulting from MV repair in a patient with posterior leaflet (P2) prolapse degenerative mitral regurgitation (MR). Analyze three mitral annuloplasty (MA) devices, each in four sizes, to assess impact of ring shape and size on leaflet and LV stress.
METHODS: Magnetic resonance imaging (MRI) was performed before and intra-operative 3D trans-esophageal echocardiogram (TEE) was performed before and after repair of P2 prolapse in a single patient. Repair included triangular resection and placement of a CG Future partial annuloplasty band. MRI and TEE images were co-registered to create a 3D finite-element model. Elements of the P2 region were removed to model leaflet resection, and virtual sutures were used to repair the leaflet and attach the MA ring. The model was optimized to match leaflet coaptation, end-diastolic volume, and end-systolic volume from the imaging data. Two additional rings were digitized using microCT. Simulations were completed in four sizes for each ring. Anterior and posterior leaflet and LV myofiber stress were compared.

RESULTS: All three rings abolished regurgitation. Repair decreased stress in the anterior leaflet and LV wall during diastole and systole but increased posterior leaflet stress. Compared to a flat ring, saddle-shape increased anterior leaflet stress while decreasing posterior leaflet and myofiber stress at end-diastole. At end-systole, saddle-shape decreased leaflet and myofiber stress modestly. As ring size decreased, leaflet and myofiber stress and orifice area decreased regardless of ring shape. Undersizing the ring by two sizes decreased anterior leaflet stress by 12.4±5.8% and posterior leaflet stress by 14.1±3.0% (averaged across all ring shapes).
CONCLUSIONS: None of the studied ring shapes was superior in all categories. Undersizing was associated with decreased end-systolic anterior leaflet, posterior leaflet, and myofiber stress and also decreased orifice area. Creation of additional patient-specific models will allow broader clinical conclusions. This modeling method may allow calculation of optimal ring shape and creation of a virtual surgical training tool.

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