Eleven years before this admission, the second patient, a 65-year-old woman, underwent mitral valve repair with quadrangular resection and annuloplastic ring #30, without mitral regurgitation being observed postoperatively. It now presents with increasing shortness of breath, more peripheral edema and an echocardiogram that showed worsening of mitral regurgitation. The flexible ring and Simulus™ band are used for the repair of mitral or tricuspid valves. The reason for mitral annuloplasty is the correction of mitral valve insufficiency by restoring the physiological form and function of the healthy mitral valve apparatus [9]. The healthy mitral valve undergoes significant dynamic changes in shape and size during the cardiac cycle [36]. These changes are largely due to the dynamic movement of the mitral ring [39], a fibrous structure of collagen connective tissue that binds the mitral leaves and left atrium to the left ventricle and aortic root [24]. From diastole to systole, the ring undergoes a sphincteric movement that narrows the opening area to improve the coaptation of the two leaves [46]. The opening surface is further reduced by a pronounced three-dimensional configuration during systole, the characteristic shape of the saddle [23, 31]. These dynamic changes are thought to be important for satisfactory mitral valve function in terms of optimizing packaging coordination [22] and theoretical minimization of leaf tissue stresses [37, 44]. The Cleveland Clinic series (18) primarily used the flexible Cosgrove band, which was primarily developed to maintain mitral annular dynamics (19).

It has been suggested that the shape of the stool and the mechanism of the mitral valve sphincter can be preserved up to five years after implantation of this ligament (20). The Mayo Clinic group also reported good medium-term results for the systematic use of a flexible but `standard size` (unmeasured) posterior annuloplastic band (21). However, there is still a lack of real long-term data on the durability of the flexible belt. Open heart surgeryTo repair the mitral valve, your surgeon sews a ligament to the ring around your mitral valve. The tape is made of surgical mesh, plastic or metal; The group remains in place permanently. Once your surgeon has completed annuloplasty and any other required procedure, he or she uses stitches to close the incisions and cover the incision area with a bandage. Minimally invasive heart surgeryWith minimally invasive heart surgery, your surgeon may make several smaller incisions in your chest to access your mitral valve. Your surgeon inserts surgical tools into the incisions with a tiny camera at the end. The specialized vision camera looks into your body during the procedure. The tape is made of surgical mesh, plastic or metal; The group remains in place permanently.

Once your surgeon has completed annuloplasty and any other required procedure, he or she uses stitches to close the incisions and cover the incision area with a bandage. During annuloplasty, surgeons place a ring-shaped device around your heart valve. The ring can be made of mesh, metal or plastic. The ring mimics the natural movement and flexibility of your heart valve. It stays in place at all times and helps the valve open and close properly. After the marker and device were implanted, the animals were weaned off cardiopulmonary bypass surgery and taken to the catheter lab. Here we took biplane video fluoroscope images of the valves with devices implanted with a sampling rate of 60 Hz in an acute and open chest state. At the same time, we recorded blood pressure in the left ventricle, aorta and left atrium using catheter micromanometer pressure transmitters. After taking the first set of images, we published the devices, see Figure 3, and pulled them on the roof of the courtyard. In a second set of images, we captured the control data without the existing devices. Offline, we used semi-automatic image processing and scanning software [33] to obtain four-dimensional coordinates χn(t) for all n= 1, …, 16 markers for three consecutive heartbeats, using both implanted and implanted annuloplastic devices.

Figure 5 summarizes the clinical characteristics of annular dynamics without gray bars and with device, white bars, for flexible, incomplete, semi-rigid complete and rigid-complete devices. For all control data sets n = 34 without a device, the changes amounted to −14.4 ± 5.0% in the septal-lateral distance, − 5.7 ± 2.1% in the commissioner-station distance, +15.9 ± 6.4% in the eccentricity, −17.9 ± 6.2% in the mitral ring area, − 6.4 ± 2.1% in the ring-shaped circumference and +61.0 ± 38.4% in the height of the saddle. In general, all three devices showed a tendency to freeze annular dynamics and reduce dynamic changes throughout the cardiac cycle. In particular, the students` t-tests for the semi-rigid and rigid rings showed statistically significant differences for all clinical parameters between the non- and device-free groups, with p<0.0005 for septal-lateral and commissure-commissure distances, eccentricity, mitral ring-shaped surface and ring-shaped circumference for both groups, p<0.05 for saddle height for semi-rigid rings and p <0.005 for saddle height for rigid rings. The flexible band showed statistically significant changes in annular dynamics with p<0.0005 for septal-lateral distance, eccentricity, mitral annular area and ring-shaped circumference, and p<0.005 for commissure-commissure distance, but not for saddle height. This suggests that annuloplastic devices that maintain the native dynamics of the mitral valve complex could be beneficial. Here we show that flexible bands maintain annular dynamics to a greater extent than semi-rigid and rigid rings and can therefore be beneficial. Overall, of course, the choice of the annuloplasty device depends on several factors, of which the preservation of annular dynamics is only one. Conversely, for example, the very rigid and complete ring geoform is a disease-specific ring specifically designed to disproportionately reduce the septal-lateral distance dimension of the mitral ring in patients with congestive heart failure due to left ventricular dilation and systolic dysfunction, e.g.

functional mitral insufficiency (FMR) and ischemic mitral insufficiency (IMR) than the dimension of the commissure-commissure distance [13], 48]. Like many other groups, we have introduced various annuloplasty strategies over the past few decades, ranging from “no ring whenever possible” in the early stages of our valve repair program to the current practice of using a saddle-shaped complete ring almost exclusively. However, over the past decade, we have observed that the native mitral annular saddle form has often been well preserved in patients with relatively short mitral regurgitation. Such a phenomenon is especially true for young patients with acute infectious endocarditis. In our own experience, a semi-rigid ring instead of a saddle-shaped ring in this particular subset of patients can provide more reliable repair results. In fact, Carpentier`s statement remains inspiring even 30 years later: “The goal of valve reconstruction can be defined as the restoration of normal valve function and not the normal anatomy of the valve” (31). For permanent mitral valve repair, it remains controversial whether stool-shaped annuloplasty should be used in each patient. In fact, it has been suggested that mitral annular dynamic changes (i.e., “flexibility”) may be largely limited after saddle-shaped annuloplasty using a physio-II ring or rigid saddle ring (32). We characterized the dynamics of the mitral valve ring in the heart of the beating sheep, with and without three commonly used annuloplastic devices.