Individual variations in the fibrinolytic response during and after cardiopulmonary bypass.

The purpose of this study was to determine whether individual patients show different patterns of fibrinolytic response to cardiopulmonary bypass (CPB) and whether preoperative or intraoperative parameters were predictive of these different patterns. Active t-PA, active PAI-1 and total t-PA antigen were measured in plasma samples obtained from 38 subjects, age 32 to 85 (median 69 years), before, during and after CPB. Four patterns of fibrinolytic response were noted: 1) 40% of patients showed the "typical" response, a rapid rise in active and total t-PA during CPB followed postoperatively by elevated PAI-1 and reduced t-PA, 2) 10% showed no change in t-PA or PAI-1 during or after CPB, 3) 24% showed no change in t-PA with an increase in PAI-1 postoperatively, and 4) 26% showed an increase in t-PA during CPB with no change in PAI-1 postoperatively. When present, the t-PA response was rapid, occurring within the first 30 min of CPB and was more common in patients undergoing valve surgery than in coronary artery bypass grafting (p < 0.005). Increased levels of PAI-1 postoperatively were associated with ischemic times greater than 70 min (p = 0.003) but not with the total length of CPB. Age, sex, CPB temperature, total CPB time and preoperative levels of t-PA and PAI-1 were not associated in the intra- or postoperative fibrinolytic response pattern. We conclude that the fibrinolytic response to CPB is heterogeneous. Further studies will be needed to determine whether different response patterns are clinically significant.

Mechanisms of aortic valve incompetence: finite-element modeling of Marfan syndrome.

OBJECTIVES: Progressive aortic root dilatation and an increased aortic root elastic modulus have been documented in persons with Marfan syndrome. To examine the effect of aortic root dilatation and increased elastic modulus on leaflet stress, strain, and coaptation, we used a finite-element model. METHODS: The normal model incorporated the geometry, tissue thickness, and anisotropic elastic moduli of normal human roots and valves. Four Marfan models were evaluated, in which the diameter of the aortic root was dilated by 5%, 15%, 30%, and 50%. Aortic root elastic modulus in the 4 Marfan models was doubled. Under diastolic pressure, regional stresses and strains were evaluated, and the percentage of leaflet coaptation was calculated. RESULTS: Root dilatation and stiffening significantly increased regional leaflet stress and strain compared with normal levels. Stress increases ranged from 80% to 360% and strain increases ranged from 60% to 200% in the 50% dilated Marfan model. Leaflet stresses and strains were disproportionately high at the attachment edge and coaptation area. Leaflet coaptation was decreased by approximately 20% in the 50% root dilatation model. CONCLUSIONS: Increasing root dilatation and root elastic modulus to simulate Marfan syndrome significantly increases leaflet stress and strain and reduces coaptation in an otherwise normal aortic valve. These alterations may influence the decision to use valve-sparing aortic root replacement procedures in patients with Marfan syndrome.

Modified conduit preparation creates a pseudosinus in an aortic valve-sparing procedure for aneurysm of the ascending aorta.

Mechanical valved conduit replacement of the aortic root is a durable and appropriate procedure for many diseases of the ascending aorta, but may sacrifice an anatomically salvageable aortic valve. For young active patients and for patients with "systemic" arterial disease (atherosclerosis, Marfan's syndrome) who may require future operations, life-long anticoagulation with its attendant thromboembolic versus hemorrhagic risks is not ideal. Several techniques have been suggested as aortic valve-sparing options. Recently, a procedure was described that combines the freehand homograft techniques with the standard Bentall techniques (David procedure). This innovative technique replaces the ascending aorta with a Dacron cylinder, spares the aortic valve, and restores competence and thus offers an excellent alternative. The durability of this procedure that places the aortic valve inside a cylindrical conduit without sinuses of Valsalva is unknown. In selected patients, we have used this technique to spare the aortic valve. On the basis of experimental data and preliminary computer modeling, with the hope of improving the durability, we have modified the conduit to create a "pseudosinus" in our most recent nine patients. We have done the David procedure in 10 patients. The pseudosinus modification was done in the most recent nine patients. Patients' ages ranged from 37 to 71 years (mean 49.9 years). There were five female and five male patients. Five patients had Marfan's syndrome and five patients had annuloaortic ectasia. There has been no mortality and all patients have had both early and late follow-up echocardiography. Five patients have zero to trace aortic insufficiency, four patients have trace to mild aortic insufficiency, and one patient has mild or "1+" aortic insufficiency. Aortic insufficiency has not progressed in any patient during the 18 months of follow-up. The patient with 1+ aortic insufficiency has no activity limits, good ventricular function, and no evidence of congestive symptoms. One patient who had extensive thoracoabdominal aneurysmal disease has undergone subsequent replacement of the descending aorta to the level of the renal arteries and has done well. Aortic valve-sparing replacement of the aortic root is an excellent procedure for any patient with an ascending aortic aneurysm and an anatomically salvageable valve. We believe that by modifying the proximal conduit and creating a "pseudosinus" into which the leaflets can retract without contact of the cylindrical conduit we may increase the longevity of the native aortic valve in this procedure.

Aortic root and valve relationships. Impact on surgical repair.

A surgical procedure has recently been described for patients with aortic incompetence caused by annular dilation, but with normal aortic leaflets. The dilated aortic root is replaced with a Dacron graft, and the native aortic valve is resuspended within the graft. Matching the size and shape of the graft to the size of the leaflets may have significant effects on valve closure and leaflet stress and thus on the longevity of the repair. To define the relationship of native aortic root structure to leaflet size, we morphologically examined normal human aortic roots (n = 10) and valve leaflets and applied mathematic analyses to the results. Our data show that the root has a consistent shape with varying size and that there is a definable mathematic relationship between root diameter and clinically measurable leaflet dimensions. We derived an equation that allows calculation of the appropriate diameter of the root at the sinus of Valsalva level from leaflet heights and perimeters. The diameter of the graft at the sinotubular junction and base should follow the relationship of the normalized root dimensions, either by tailoring of the graft or by new graft design. The current data imply that the graft should incorporate sinuses for proper valve closure and for sharing stress with the leaflets. Application of these results will allow prosthetic graft design to more closely resemble the native aorta. These new grafts should improve physiologic function of the valve, reduce leaflet stress, and increase the durability of the repair.

Re-creation of sinuses is important for sparing the aortic valve: a finite element study.

OBJECTIVE: The treatment of choice for aortic valve insufficiency due to root dilatation has become root replacement with aortic valve sparing. However, root replacement with a synthetic graft may result in altered valve stresses. The purpose of this study was to compare the stress/strain patterns in the spared aortic valve in different root replacement procedures by means of finite element modeling. METHODS: Our finite element model of the normal human root and valve was modified to simulate and evaluate three surgical techniques: (1) "cylindrical" graft sutured below the valve at the anulus, (2) "tailored" graft sutured just above the valve, and (3) "pseudosinus" graft, tailored and sutured below the valve at the anulus. Simulated diastolic pressures were applied, and stresses and strains were calculated for the valve, root, and graft. Leaflet coaptation was also quantified. RESULTS: All three root replacement models demonstrated significantly altered leaflet stress patterns as compared with normal patterns. The cylindrical model showed the greatest increases in stress (16%-173%) and strain (10%-98%), followed by the tailored model (stress +10%-157%, strain +9%-36%). The pseudosinus model showed the smallest increase in stress (9%-28%) and strain (2%-31%), and leaflet coaptation was closest to normal. CONCLUSION: Valve-sparing techniques that allow the potential for sinus space formation (tailored, pseudosinus) result in simulated leaflet stresses that are closer to normal than the cylindrical technique. Normalized leaflet stresses in the clinical setting may result in improved longevity of the spared valve.

Effect of papillary muscle position on mitral valve function: relationship to homografts.

BACKGROUND: We used a finite element model to determine the effect of papillary muscle position on the stress distribution in the mitral valve. METHODS: A normal model was modified to move the posteromedial papillary muscle outward by either 2.5 mm or 5.0 mm. Next, the thickness was increased by 20%, simulating diseased tissue. Physiologic loading pressures were applied, and leaflet stress, chordal stress, and coaptation results were analyzed. RESULTS: Displacement of the posteromedial papillary muscle increased the leaflet stresses and altered the normal stress patterns. The displacement also restricted the leaflets from closing completely, allowing regurgitation. Combining increased thickness with papillary displacement decreased the stresses slightly. However, the amount of leaflet coaptation was further decreased, creating larger gaps for regurgitation. In all models, the stresses in the chordae were increased in the marginal chordae and decreased in the basal chordae, demonstrating a transfer of stress. CONCLUSIONS: Papillary muscle displacement creates abnormal valve stresses, and the potential for significant regurgitation. Papillary-chordal-leaflet geometry must be maintained in partial or complete mitral homograft replacement.

Bovine pericardium: a source of pulmonary venous obstruction in the Mustard procedure.

Following Mustard's popularization of the intraatrial baffle procedure for transposition of the great arteries, debate has persisted regarding the ideal materials to use. Reports of xenograft (i.e., bovine pericardium) as a suitable prosthetic material made it an appealing choice. We report our recent experience with 2 patients in whom bovine pericardium was used for atrial augmentation, with subsequent pulmonary venous obstruction. For this reason, we have abandoned this material as an acceptable prosthetic in the Mustard procedure.

Altered collagen concentration in mitral valve leaflets: biochemical and finite element analysis.

BACKGROUND: Ischemic mitral regurgitation or ventricular wall motion abnormalities will alter the stress distribution in the mitral valve. We hypothesize that in response, the regional collagen concentration will be altered and will significantly impact the stress distribution in the mitral valve. METHODS: Two sheep served as normal (sham) controls. Two other sheep had coronary ligation resulting in abnormal ventricular wall motion. Four sheep underwent ligation to infarct the posteromedial papillary muscle, resulting in ischemic regurgitation. After 4 or 8 weeks, the mitral valves were excised, and the anterior leaflet sections were subjected to an assay for collagen concentration. Next, in a finite element model, to simulate changes in collagen concentration, the tissue stiffness was increased by 20%, and then decreased by 20%. In another model, the thickness of the tissue was increased by 20%, and then combined with decreased tissue stiffness. Physiologic loading pressures were applied, and leaflet stress, chordal stress, and coaptation results were analyzed. RESULTS: The average collagen concentration in the normal sheep leaflets was 59.2% (dry weight), 50.6% in the ischemic controls, and 45.8% in the papillary muscle infarct group. Collagen concentration was greatest at the midline and decreased toward the commissures. Increased tissue stiffness resulted in increased leaflet and chordal stresses, as well as reduced coaptation. Decreased stiffness resulted in the opposite. Increased tissue thickness reduced leaflet and chordal stresses, but also reduced coaptation. The combination of increased tissue thickness and decreased stiffness demonstrated the greatest reduction in leaflet and chordal stress, while maintaining normal leaflet coaptation. CONCLUSIONS: The observed changes may demonstrate an early effort to compensate for increased leaflet stress. Microstructural alterations may demonstrate an early effort to compensate for altered physiologic loading to reduce stress and maintain coaptation. It is crucial in repairing or partially replacing thickened tissue that normal geometry and physiology be restored.

Mechanisms of aortic valve incompetence: finite element modeling of aortic root dilatation.

BACKGROUND: Idiopathic root dilatation often results in dysfunction of an otherwise normal aortic valve. To examine the effect of root dilatation on leaflet stress, strain, and coaptation, we utilized a finite element model. METHODS: The normal model incorporated the geometry, tissue thickness, stiffness, and collagen fiber alignment of normal human roots and valves. We evaluated four dilatation models in which diameters of the aortic root were dilated by 5%, 15%, 30%, and 50%. Regional stress and strain were evaluated and leaflet coaptation percent was calculated under diastolic pressure. RESULTS: Root dilatation significantly increased regional leaflet stress and strain beyond that found in the normal model. Stress increases ranged from 57% to 399% and strain increases ranged from 39% to 189% in the 50% dilatation model. Leaflet stress and strain were disproportionately high at the attachment edge and coaptation area. Leaflet coaptation was decreased by 18% in the 50% root dilatation model. CONCLUSIONS: Idiopathic root dilatation significantly increases leaflet stress and strain and reduces coaptation in an otherwise normal aortic valve. These alterations may affect valve-sparing aortic root replacement procedures.

Perfluorocarbon emulsion in the cardiopulmonary bypass prime reduces neurologic injury.

BACKGROUND: Perfluorocarbon emulsion has proved beneficial in the prevention and amelioration of experimental air embolism. We examined whether the addition of perfluorocarbon to the prime solution could lead to a reduction in the incidence and severity of neurologic injury after the formation of a massive air embolism during cardiopulmonary bypass. METHODS: Fourteen pigs underwent bypass in which either a crystalloid prime solution or a perfluorocarbon prime solution (10 mL/kg) was used. Ten minutes into bypass a bolus (5 mL/kg) of air or saline (control) was delivered via the carotid artery. The resulting cerebral infarcts were graded on the basis of the findings in triphenyltetrazolium chloride-stained cerebral sections. Colored microspheres were used to measure cerebral blood flow. Bitemporal electroencephalography was used to evaluate cerebral function. RESULTS: Cerebral infarction was not found in the perfluorocarbon-air group (0 to 5 animals), as compared with its occurrence in 3 of the 5 animals in the crystalloid-air group. Cerebral blood flow was also maintained or increased in the perfluorocarbon-air group (p < 0.05), and the electroencephalogram total power showed less of a decrease and recovered more completely (p < 0.05) than it did in the crystalloid-air group. CONCLUSIONS: The addition of perfluorocarbon emulsion to the cardiopulmonary bypass prime solution leads to a reduction in the incidence and severity of neurologic injury after the formation of a massive air embolism during bypass.

Schwannoma of the left atrium: diagnostic evaluation and surgical resection.

A case of primary benign schwannoma of the left atrium is reported. A 35-year-old man presented with new onset atrial fibrillation. Noninvasive evaluation revealed a 4 x 7-cm mediastinal mass either directly posterior to or involving the left atrium. The histologic diagnosis and specific location of the mass were established by incisional biopsy through a left thoracotomy. On cardiopulmonary bypass the tumor was resected by widely excising the posterior left atrium. The residual 20-cm2 left atrial defect was patched with pericardium. This unusual case illustrates that left atrial tumors originating near the pulmonary veins may be nonmyxomatous neoplasms of neural origin. Diagnosis may be difficult and require a surgical transthoracic approach.

Prospective trial of catheter irrigation and muscle flaps for sternal wound infection.

BACKGROUND: Sternal wound infection is a relatively rare but potentially devastating complication of open heart operations. The most common treatments after debridement are rewiring with antibiotic irrigation and muscle flaps. Here we present the results of a prospective trial to determine the appropriate roles of closed-chest catheter irrigation and muscle flap closure for sternotomy infection and to assess the effect of internal mammary artery bypass grafting on the outcome of each treatment modality. METHODS: Between 1990 and 1994, 5,658 sternotomies were performed at the University of Washington Medical Center. Sternal dehiscence occurred in 43 patients, 25 of whom had infection (overall incidence, 0.44%). Because of the infrequency of this complication, a prospective, randomized trial was developed in which the initial approach to sternal dehiscence was rewiring and catheter irrigation. Muscle flaps were used as the primary treatment if the sternum could not be restabilized or as secondary treatment if catheter irrigation failed. Wound resolution, length of hospital stay, and complications were evaluated. RESULTS: Sterile dehiscences were successfully closed with irrigation in 17 of 18 patients; the other patient required flap closure. Of the 25 patients with infection, 19 had irrigation and 6, closure with flaps primarily. In the group of infected patients, 17 of the 19 who received irrigation also had internal mammary artery bypass grafting. Irrigation failed in 15 (88.2%) of these 17 patients, and salvage was accomplished with muscle flap closure. All 6 patients with infection who were closed primarily with muscle flaps had a successful outcome. Hospitalization averaged 10.2 days when muscle flaps were used primarily and 14.3 additional days for unsuccessful irrigation. When irrigation was successful, the hospital stay averaged 11.2 days. CONCLUSIONS: Catheter irrigation should be reserved for patients without infection or patients with infection but without internal mammary artery bypass grafts in whom dehiscence occurs less than 1 month after sternotomy. All others should have closure with muscle flaps.

False inferior pseudoaneurysm: two-dimensional and Doppler echocardiographic findings.

The noninvasive differentiation of true aneurysm from pseudoaneurysm is sensitively and specifically accomplished with two-dimensional echocardiography. Recent reports suggest that Doppler flow patterns may further enhance the specificity of the diagnosis of pseudoaneurysm. We present a patient with ventriculographic and two-dimensional echocardiographic features of an inferior pseudoaneurysm. Doppler examination, however, failed to show phasic flow characteristic of a small communicating orifice between two larger chambers. At surgery, a large posterolateral true aneurysm was found. Thus the addition of Doppler flow patterns to imaging information may help to distinguish pseudoaneurysms from true aneurysms.

Flexible versus rigid ring annuloplasty for mitral valve annular dilatation: a finite element model.

BACKGROUND AND AIMS OF THE STUDY: The study objective was to compare coaptation, and leaflet and chordal stresses in normal and dilated mitral valves (18% annular dilatation) versus valves with flexible (Duran) and rigid (Carpentier-Edwards classic) ring annuloplasty, using a computer model. We have developed a 3D finite element model which allows us to evaluate valvular function in terms of coaptation and stresses in both leaflets and individual chordae. METHODS: The mitral valve was simulated using ANSYS 4.4A software. Normal model geometry, collagen fiber orientation, tissue thickness and material properties were determined from fresh porcine valves. For annular dilatation, the annular circumference was increased by 18% versus normal. For annuloplasty, a simulated flexible ring was attached to the annulus, and a simulated rigid ring then attached. Valves were evaluated during systolic pressure loading, after which timing of coaptation and leaflet and chordal stresses were determined. RESULTS: In the normal valve, the anterior leaflet was subject to higher tensile stresses than the posterior leaflet which was under compression. With annular dilatation, all stresses were increased, particularly in the posterior leaflet. The flexible ring returned leaflet and chordal stresses closer to normal than did the rigid ring. Leaflet coaptation began at 5 ms in the normal state, was delayed by dilatation, and returned towards normal with both rings. The flexible ring returned coaptation and stresses closer to normal than did the rigid ring. CONCLUSIONS: Ring annuloplasty reduces the stresses and improves coaptation relative to annular dilatation. The success of mitral annuloplasty is likely due to the re-establishment of posterior leaflet compressive stresses and near-normal coaptation.

The effect of chordal replacement suture length on function and stresses in repaired mitral valves: a finite element study.

BACKGROUND AND AIMS OF THE STUDY: Replacement of ruptured mitral valve chordae using expanded polytetrafluoroethylene (ePTFE) sutures is becoming an increasingly utilized repair technique. However, setting the proper length of the replacement suture is technically challenging, and the effect of a non-optimal suture length is undefined. The purpose of this study was to assess how varying the length of replacement sutures affects mitral valve function and stresses. MATERIALS AND METHODS: We employed a finite element model of the mitral valve used extensively in our laboratory. Seven different valve conditions were simulated using this model: (i)normal valve, (ii) chordal rupture without repair, and (iii-iv) chordal replacement using ePTFE sutures that were equal in length to the replaced chordae (equal length), 10% longer (Long10), 3% longer (Long3), 3% shorter (Short3), and 10% shorter (Short10) than the replaced chordae. Each model was loaded to physiologic pressures. RESULTS: Both the Long10 and chordal rupture models achieved complete valve closure, but chordal stresses were nearly double normal values. The Long3 model also demonstrated complete valve closure, but chordal stresses were increased to only one-third more than normal. Using sutures equal to or shorter than the length of the replaced chordae prevented complete valve closure, and produced stress concentrations at the anterior leaflet free edge. The resulting gaps and stress concentrations were most significant in the Short10 model and least significant in the equal length model. CONCLUSIONS: These models demonstrate that replacement sutures equal to, or slightly longer than the replaced chordae optimize function and stresses in the repaired valve.

Anatomic basis for mitral valve modelling.

The increasing popularity of mitral valve repair and current interest in replacement with a mitral homograft or heterograft warrant a new look at the normal functional anatomy of the system. We conducted a detailed review of the anatomic structure of both the intact and excised mitral apparatus of porcine and human species. The following intact structural dimensions were measured: total annular length, anterior and posterior annular length. Excised measurements included: total annular length, anterior and posterior annular lengths, leaflet edge lengths, leaflet heights, and anterolateral and posteromedial commissural heights. Leaflet area was calculated from planimetric measurements. Chordal lengths were measured and distribution recorded. The majority of leaflet measurements were not statistically different between groups. For both groups, the measured annular length increased significantly upon valve excision. In both groups, the posterior leaflet area was significantly larger than the anterior leaflet area, and the area of each leaflet alone was significantly greater than the calculated orifice area. Chordal length was not significantly different between groups, however, distribution varied slightly with the ratio of origins to insertions being 8:1 (porcine) and 5:1 (human). The results are consistent with previous studies of the human mitral valve. This study showed little difference between human and porcine data, and the porcine valve was identified as an appropriate model for further investigation of the mitral valve system.(ABSTRACT TRUNCATED AT 250 WORDS)

Mechanisms of aortic valve incompetence in aging: a finite element model.

BACKGROUND AND AIM OF THE STUDY: The effect of aging on aortic valve and root function was examined using a three-dimensional finite element model of the aortic root and valve. METHODS: Three models representing normal (< 35 years), middle (35-55 years) and older (> 55 years) age groups, were created by assigning tissue thickness and stiffness that increased with age (using ANSYS software). Diastolic pressure was applied; stresses and strains were then evaluated for the valve and root, and percent leaflet coaptation was calculated. RESULTS: Leaflet stresses were increased with aging, whereas leaflet strain and coaptation were decreased with aging. Specifically, leaflet stresses were increased by 6-14% in the middle-age model, and by 2-11% in the older-age model, as compared with normal in specified leaflet regions. Conversely, leaflet strains were decreased by 27-41% and 42-50% in the middle-age and older-age models, respectively. This reduced strain resulted in markedly decreased coaptation (9% and 30% reduction for middle- and older-age models). In the root, stress remained fairly constant with age, but strain in the root was progressively reduced with age (11% and 35% reduction for the middle and older-age models, respectively). CONCLUSIONS: In these models, increased stiffness and thickness due to aging reduces leaflet deformation and restricts coaptation. Clinically, valvular regurgitation may result due to leaflet thickening and stiffening with normal aging. Our model can now be utilized to evaluate the root-valve relationship in the presence of bioprosthetic valves or root replacements.

Differential collagen distribution in the mitral valve and its influence on biomechanical behaviour.

Surgical repair of the mitral valve primarily involves endogenous valve tissue, however, the intrinsic mechanical behaviour of the tissue is not well described. To address this issue, porcine mitral valve leaflets were examined histologically and engineering concepts were applied to understand the mechanical behaviour of the layered tissue. Rectangular portions were excised from the anterior and posterior leaflets, either parallel or perpendicular to the annulus, and sections were stained for collagen (Masson's trichrome). The cross sectional layers of the valve (atrialis/spongiosa, fibrosa, and ventricularis) were identified by differences in cellularity and collagen density. The fibrosa is composed of dense collagen, while the atrialis/spongiosa and ventricularis are composed of loose collagen. Layer thicknesses were recorded digitally across the section. These values were averaged within tissue groups to determine changes in layer thickness over the length of the sample and average thickness of each layer. In all tissue groups, the fibrosa was the thickest layer, and the atrialis/spongiosa layer was thicker than the ventricularis layer. The total and fibrosa layer thicknesses of the anterior leaflet were significantly thicker than in the posterior leaflet. Mechanical engineering analysis of the layered structures under tension indicated that the anterior leaflet would be able to support greater tensile loads than the posterior leaflet. The layered arrangement was then examined as a beam in bending, and was shown to decrease the resistance of leaflets to bending, and decrease the overall bending stresses on the leaflet. This type of analysis may be extrapolated to gain insight into changes in function in diseased valves as well.(ABSTRACT TRUNCATED AT 250 WORDS)

Finite element analysis of the mitral valve.

A finite element model was developed to examine deformation and stress patterns in the mitral valve under systolic loading conditions. This is the first three-dimensional finite element model of the mitral valve, incorporating all essential anatomic components, regional tissue thickness, collagen fiber orientation and related anisotropic material properties. A non-linear, transient, dynamic analysis was performed which included time-dependent loading, leaflet and chordal mass inertial effects and chordal element bi-linearity. The model was first analyzed without either annular or papillary muscle contraction and then with either or both. The hypothesis was that the combination of annular and papillary muscle contraction would have a beneficial effect on valve function. In all models, the computed anterior leaflet principal stresses were tensile and of greater magnitude than those in the posterior leaflet. The principal stress directions were observed to correlate well with collagen fiber orientation. Earlier leaflet coaptation was demonstrated with annular contraction, promoting valve closure, while papillary muscle contraction increased the stress on the chordae tendineae and both leaflets, tending to pull the latter apart. The combination of the two combined these effects, and showed the most even stress distribution. The effects of annular and papillary muscle contraction on valve function were shown to be beneficial by this model, and they can be further elucidated by varying the extent and timing of the individual contractions. This model can be used to examine the effects of pathologic changes, surgical manipulations and proposed material replacements. It can thus aid both the surgeon and the biomedical engineer in improving the materials and techniques available for the repair and/or replacement of mitral valve system components.

Acute mitral valve regurgitation created in sheep using echocardiographic guidance.

BACKGROUND AND AIM OF STUDY: This study was designed to determine: (i) Whether acute mitral valve regurgitation (MVR) due to chordal rupture can be reproducibly created under echocardiographic guidance; (ii) what degree of MVR can be created; (iii) what degree of acute regurgitation is survivable; and (iv) whether acute MVR due to chordal rupture progresses over time. METHODS: In a pilot group of six juvenile farm-bred sheep, selected chordae tendineae were ruptured using either a biopsy needle or endoscopic scissors under echocardiographic guidance, without need for cardiopulmonary bypass. Sheep were sacrificed acutely (n = 2), and at six weeks (n = 2) or eight weeks (n = 2). When the technique was optimized, five sheep entered a study group in which chords were ruptured using endoscopic scissors; the sheep were sacrificed 16 weeks after surgery. RESULTS: In the pilot study, acute MVR (grade 2-4+) was produced in all sheep, normal ventricular wall motion was maintained, with minimal progression of regurgitation over time. In one pilot sheep which did not survive, grade 4+ MVR was created acutely. Use of endoscopic scissors was preferable to the biopsy needle. In the study group, acute MVR (grade 2-4+) was produced in all five sheep, and was still present at 16 weeks, with progression in only one animal. CONCLUSIONS: This pilot study demonstrated that controlled degrees of survivable acute MVR due to chordal rupture can be created under echocardiographic guidance, with minimal progression of MVR over time. This animal model can be applied to investigate the pathogenesis of clinical MVR, and to suggest appropriate medical or surgical intervention.