Dynamic changes in the ischemic mitral annulus: Implications for ring sizing.

Objectives: Contrary to the rest of the mitral annulus, inter‑trigonal distance is known to be relatively less dynamic during the cardiac cycle. Therefore, intertrigonal distance is considered a suitable benchmark for annuloplasty ring sizing during mitral valve (MV) surgery. The entire mitral annulus dilates and flattens in patients with ischemic mitral regurgitation (IMR). It is assumed that the fibrous trigone of the heart and the intertrigonal distance does not dilate. In this study, we sought to demonstrate the changes in mitral annular geometry in patients with IMR and specifically analyze the changes in intertrigonal distance during the cardiac cycle. Methods: Intraoperative three‑dimensional transesophageal echocardiographic data obtained from 26 patients with normal MVs undergoing nonvalvular cardiac surgery and 36 patients with IMR undergoing valve repair were dynamically analyzed using Philips Qlab® software. Results: Overall, regurgitant valves were larger in area and less dynamic than normal valves. Both normal and regurgitant groups displayed a significant change in annular area (AA) during the cardiac cycle (P < 0.01 and P < 0.05, respectively). Anteroposterior and anterolateral‑posteromedial diameters and inter‑trigonal distance increased through systole (P < 0.05 for all) in accordance with the AAs in both groups. However, inter‑trigonal distance showed the least percentage change across the cardiac cycle and its reduced dynamism was validated in both cohorts (P > 0.05). Conclusions: Annular dimensions in regurgitant valves are dynamic and can be measured feasibly and accurately using echocardiography. The echocardiographically identified inter‑trigonal distance does not change significantly during the cardiac cycle.

Echocardiography derived three-dimensional printing of normal and abnormal mitral annuli.

Aims and Objectives: The objective of this study was to assess the clinical feasibility of using echocardiographic data to generate three‑dimensional models of normal and pathologic mitral valve annuli before and after repair procedures. Materials and Methods: High‑resolution transesophageal echocardiographic data from five patients was analyzed to delineate and track the mitral annulus (MA) using Tom Tec Image‑Arena software. Coordinates representing the annulus were imported into Solidworks software for constructing solid models. These solid models were converted to stereolithographic (STL) file format and three‑dimensionally printed by a commercially available Maker Bot Replicator 2 three‑dimensional printer. Total time from image acquisition to printing was approximately 30 min. Results: Models created were highly reflective of known geometry, shape and size of normal and pathologic mitral annuli. Post‑repair models also closely resembled shapes of the rings they were implanted with. Compared to echocardiographic images of annuli seen on a computer screen, physical models were able to convey clinical information more comprehensively, making them helpful in appreciating pathology, as well as post‑repair changes. Conclusions: Three‑dimensional printing of the MA is possible and clinically feasible using routinely obtained echocardiographic images. Given the short turn‑around time and the lack of need for additional imaging, a technique we describe here has the potential for rapid integration into clinical practice to assist with surgical education, planning and decision‑making.