Anterior Pericardial Patch Augmentation Repair and Neochord Implantation for Rheumatic Mitral Valves

Q: What is the clinical evidence from this study?

Population: Ex vivo rheumatic mitral valve (RMV) model (n=4). Intervention: Anterior pericardial patch augmentation repair (APAR) with or without implantation of 2 neochordae vs. Unrepaired ex vivo rheumatic mitral valve model and healthy baseline control (each valve served as its own control). Primary outcome: Regurgitant fraction (RF) (p=0.05).

Q: What does this research mean for the field?

Anterior pericardial patch augmentation repair reduces regurgitant fraction and transvalvular gradient in an ex vivo rheumatic mitral valve model, with neochord implantation further improving coaptation and chordal force profiles. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Yuanjia Zhu; Shin Yajima; Robert J. Wilkerson; Matthew H. Park; Joo Young Kim; Pearly K. Pandya; Y. Joseph Woo

doi:10.1016/j.atssr.2023.02.006

February 21, 2023Annals of Thoracic Surgery Short ReportsOpen Access

Anterior Pericardial Patch Augmentation Repair and Neochord Implantation for Rheumatic Mitral Valves

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Key result

Anterior pericardial patch repair cuts regurgitant fraction by an absolute ~17% in ex vivo RMV.

P=0.05
n=4

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Why the study?

The study was designed to biomechanically evaluate anterior pericardial patch augmentation repair and a modified technique using neochord implantation in an ex vivo rheumatic mitral valve model.

Does anterior pericardial patch augmentation repair with or without neochord implantation improve valve hemodynamics, leaflet coaptation, and native chordal force profiles in an ex vivo rheumatic mitral valve model?

Key Points

To biomechanically evaluate anterior pericardial patch augmentation repair and a modified repair technique incorporating neochord implantation in an ex vivo model of rheumatic mitral valve disease.
Created an ex vivo rheumatic mitral valve model using 4 healthy porcine valves treated with 100 °C thermal exposure to leaflets and chordae plus commissure fusion.
Tested valves sequentially across baseline, rheumatic disease, anterior pericardial patch augmentation repair (APAR), and modified repair using 2 neochordae sutured to papillary muscles.
Assessed valvular hemodynamics, echocardiographic coaptation height, high-speed videography, and native primary and secondary chordal forces in a left heart simulator.
In the rheumatic model compared with baseline, regurgitant fraction increased from 1.1% ± 1.5% to 20.3% ± 9.4% (P = .03), coaptation height decreased from 1.6 ± 0.3 cm to 0.5 ± 0.3 cm (P = .004), and mean gradient rose from 2.8 ± 1.0 mm Hg to 14.3 ± 5.6 mm Hg (P = .02).
APAR reduced regurgitant fraction to 3.3% ± 1.7% (P = .05) and mean gradient to 6.0 ± 2.9 mm Hg (P = .008) while increasing coaptation height to 1.4 ± 0.3 cm (P = .003), but left mild patch prolapse.
The modified neochord technique eliminated patch prolapse, achieved baseline-comparable coaptation height (1.8 ± 0.3 cm; P = .09) and regurgitant fraction (3.4% ± 2.2%; P = .12), and reduced secondary chordal rate of force change compared to APAR (2.1 ± 1.3 N/s vs 3.1 ± 1.7 N/s; P = .05).

Structured PICO

Does anterior pericardial patch augmentation repair with or without neochord implantation improve valve hemodynamics, leaflet coaptation, and native chordal force profiles in an ex vivo rheumatic mitral valve model?

P

Population

4 healthy porcine mitral valves treated thermally and with commissure fusion to generate an ex vivo rheumatic mitral valve model.

I

Intervention

Commissural release and anterior pericardial patch augmentation repair (APAR) using an oval bovine pericardial patch sutured with 4-0 polypropylene sutures, followed by a modified technique adding 2 artificial CV-5 neochordae placed through each papillary muscle and the pericardial patch.

C

Comparator

Unrepaired ex vivo rheumatic mitral valve (RMV) condition and baseline healthy porcine valve condition (each sample served as its own sequential control).

O

Outcome

Valvular hemodynamics (regurgitant fraction, leaflet coaptation height, and mean transvalvular gradient) and native primary and secondary chordal force profiles (peak forces and rates of change of force).surrogate

Main Result

Absolute Event Rate: 3.3% vs 20.3%

p-value: p=0.05

This ex vivo biomechanical study demonstrates that anterior pericardial patch augmentation effectively restores coaptation and reduces transvalvular gradient in rheumatic mitral valves, while adding neochordae to the patch eliminates mild patch prolapse and further reduces stress on native chordae.

Limitations

Does not simulate long-term changes in rheumatic mitral valve with calcification and papillary muscle pathologic changes such as fusion and displacement
Requires removal of the mitral valve and reimplantation of chordal force sensors in the simulator
Ex vivo porcine model requiring large animal in vivo validation and human tissue verification
Does not simulate long-term changes in rheumatic mitral valve disease such as calcification and papillary muscle fusion or displacement
Requires removing the mitral valve and reimplanting chordal force sensors from the simulator
Ex vivo porcine study requiring large animal in vivo validation and verification experiments using human tissues

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Implication

Should not yet change surgical practice for rheumatic mitral disease; extends ex vivo evidence and warrants in vivo validation.

Abstract

Background: The objective of this study was to biomechanically evaluate anterior pericardial patch augmentation repair and the modified technique using neochord implantation in an ex vivo rheumatic mitral valve (RMV) model. Methods: Thermal treatment to the leaflets and chordae and commissure fusion were performed on 4 healthy porcine mitral valves to generate the ex vivo RMV model. Repair was performed by conducting commissural release and anterior pericardial patch augmentation, with or without implantation of 2 neochordae. Hemodynamic, echocardiography, native chordal forces, and high-speed videography data were collected. Conclusions: Anterior pericardial patch augmentation was effective in repairing RMV by re-establishing coaptation while reducing mean gradient. The modified technique further improved valve hemodynamics and native chordal forces. This study provides biomechanical evidence in favor of anterior pericardial patch augmentation repair and may direct further repair modifications to improve clinical outcomes.

Discussion

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Cite This Study

Zhu et al. (2023) studied Ex vivo rheumatic mitral valve (RMV) model (n=4). Anterior pericardial patch augmentation repair (APAR) with or without implantation of 2 neochordae vs. Unrepaired ex vivo rheumatic mitral valve model and healthy baseline control (each valve served as its own control) was evaluated on Regurgitant fraction (RF) (p=0.05). Anterior pericardial patch augmentation repair reduced regurgitant fraction from 20.3% to 3.3% (P=.05) and mean gradient from 14.3 to 6.0 mm Hg (P=.008) in an ex vivo rheumatic mitral valve model.

synapsesocial.com/papers/6a819da76494b7aed7bf65cc https://doi.org/10.1016/j.atssr.2023.02.006

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Anterior Pericardial Patch Augmentation Repair and Neochord Implantation for Rheumatic Mitral Valves

Figures

Key Points

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Anterior Pericardial Patch Augmentation Repair and Neochord Implantation for Rheumatic Mitral Valves

Figures

Key Points

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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