Fiberscope-Based Measurement of Coaptation Height for Intraoperative Assessment of Mitral Valve Repair.

BACKGROUND: Restoring adequate coaptation height is a key principle of mitral valve (MV) repair. This study aimed to evaluate the utility of fiberscope (FS) technology to assess MV coaptation height for intraoperative use. METHODS: Ex-vivo testing was performed on five adult porcine hearts. The left atrium (LA) was resected, and the left ventricle (LV) was pressurized retrograde to 27 ± 1mm Hg. An endoscope was inserted into the LV apex, centered under the MV orifice. An FS system (Milliscope II camera, LED light source, and 0.7 mm diameter × 15 cm long) 90° semirigid scope with 1.2 mm focal length) was mounted above the MV annulus in a custom alignment and measuring fixture. Three blinded measurements were taken at two locations on each MV, A2 and P2 segment, from the top of coaptation to the leaflet edge identified by the FS. Accurate positioning was verified using the LV endoscope. A control (metal rod of similar thickness) was used for comparison, with coaptation height recorded when the control was seen via the endoscope. RESULTS: Coaptation heights were similar for the control and FS methods across all hearts at A2 (11.6 ± 2.6 mm control vs 11.8 ± 2.2 mm FS) and P2 (13.3 ± 2.6 mm control vs 13.4 ± 2.9 mm FS) segments, with similar measurement variability (control SD 0.1-1.0 mm; FS SD 0.1-0.9 mm). One outlier was excluded from analysis (n = 19/20). The maximum absolute difference and percent error between measurement methods were less than 1.1 mm (median [IQR], 0.6 [0.3-0.9] mm) and less than 14% (4.1 [2.2-7.6]%). CONCLUSIONS: Utilization of a miniaturized FS enabled precise and accurate quantification of MV coaptation. This technique is promising for evaluating post-repair valve competence and coaptation height.

Systematic Analysis of PTFE Monocusp Leaflet Design in a Patient-Based 3D in-Vitro Model of Tetralogy of Fallot.

PURPOSE: Pulmonary valve (PV) monocusp reconstruction in transannular patch (TAP) right ventricular outflow tract (RVOT) repair for Tetralogy of Fallot has variable clinical outcomes across different surgical approaches. The study purpose was to systematically evaluate how monocusp leaflet design parameters affect valve function in-vitro. METHODS: A 3D-printed, disease-specific RVOT model was tested under three infant physiological conditions. Monocusps were sewn into models with the native main pulmonary artery (MPA) forming backwalls that constituted 40% and 50% of the reconstructed circumference for z-score zero PV annulus and MPA diameters (native PV z-score - 3.52 and - 2.99 for BSA 0.32m2). Various leaflet free edge lengths (FEL) (relative to backwall), positions (relative to PV STJ), and scallop depths were investigated across both models. Pressure gradient, regurgitation, and coaptation were analyzed with descriptive statistics and regression models. RESULTS: Increasing FEL beyond 100% of the MPA backwall decreased gradient but mildly increased regurgitation to a peak of 25%. Positioning the free edge 2 mm past the STJ mildly increased gradient for each FEL without significantly changing regurgitation compared to STJ placement. Scalloping leaflets trivially affected performance. Pre-folding leaflets improved mobility and slightly reduced gradient. CONCLUSIONS: Balancing gradient, regurgitation, and oversizing for growth, a set of leaflet designs have been selected for pre-clinical evaluation. Designs with leaflet widths 140-160% in the 40% backwall model (110-120% in the 50% backwall), positioned at or 2 mm past the STJ, demonstrated the best results. The next stage of ex-vivo testing will additionally consider native RVOT distensibility, native leaflet interactions, and TAP characteristics.

Mechanical failure analysis of patch materials used in aortic arch reconstruction: implications for clinical practice.

OBJECTIVES: Thick-patch pulmonary homograft, autologous pericardium and CardioCel Neo are common patch materials for aortic arch reconstruction. Insufficient data exist on sutured patch strength and limits of use. We evaluated failure strength of these materials to develop a failure prediction model for clinical guidance. METHODS: Patch failure strength was evaluated via sutured uniaxial and burst pressure testing. In sutured uniaxial testing, patches were sutured to aortic or Dacron tabs and pulled to failure. In burst pressure testing, patches were sewn into porcine aortas or Dacron grafts and pressurized to failure. Failure membrane tension was calculated. A prediction model of membrane tension versus vessel diameter was generated to guide clinical patch selection. RESULTS: Combining sutured uniaxial and burst pressure test data, pulmonary homograft failure strength {0.61 [interquartile range (IQR): 0.44, 0.78] N/mm, n = 21} was less than half that of autologous pericardium [2.22 (IQR: 1.65, 2.78) N/mm, n = 15] and CardioCel Neo [1.31 (IQR: 1.20, 1.42) N/mm, n = 20]. Pulmonary homograft burst pressure [245 (IQR: 202, 343) mmHg, n = 7] was significantly lower than autologous pericardium [863 (IQR: 802, 919) mmHg, n = 6] and CardioCel Neo [766 (IQR: 721, 833) mmHg, n = 6]. Our model predicts failure limits for each patch material and outlines safety margins for combinations of aortic diameter and pressure. CONCLUSIONS: Sutured failure strength of thick-patch pulmonary homograft was significantly lower than autologous pericardium and CardioCel Neo. Patient selection (predicted postoperative arch diameter and haemodynamics) and blood pressure management must be considered when choosing patch material for arch reconstruction. In older children and adolescents, autologous or bovine pericardium may be more suitable materials for aortic patch augmentation to minimize the risk of postoperative patch failure.

An In Vitro Circulatory Loop Model of the Pediatric Right Ventricular Outflow Tract as a Platform for Valve Evaluation.

PURPOSE: Tetralogy of Fallot and other conditions affecting the right ventricular outflow tract (RVOT) are common in pediatric patients, but there is a lack of quantitative comparison among techniques for repairing or replacing the pulmonary valve. The aim of this study was to develop a robust in vitro system for quantifying flow conditions after various RVOT interventions. METHODS: An infant-sized mock circulatory loop that includes a 3D-printed RVOT anatomical model was developed to evaluate flow conditions after different simulated surgical repairs. Physiologically correct flow and pressure were achieved with custom compliant tubing and a tunable flow restrictor. Pressure gradient, flow regurgitation, and coaptation height were measured for two monocusp leaflet designs after tuning the system with a 12 mm Hancock valved conduit. RESULTS: Measurements were repeatable across multiple samples of two different monocusp designs, with the wider leaflet in the 50% backwall model consistently exhibiting lower pressure gradient but higher regurgitation compared to the leaflet in the 40% backwall model. Coaptation height was measured via direct visualization with endoscopic cameras, revealing a shorter area of contact for the wider leaflet (3.3-4.0 mm) compared to the narrower one (4.3 mm). CONCLUSION: The 3D-printed RVOT anatomical model and in vitro pulmonary circulatory loop developed in this work provide a platform for planning and evaluating surgical interventions in the pediatric population. Measurements of regurgitation, pressure gradient, and coaptation provide a quantitative basis for comparison among different valve designs and positions.