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- W2923200081 abstract "Authors have nothing to disclose with regard to commercial support. Authors have nothing to disclose with regard to commercial support. Ejiofor and colleagues1Ejiofor J.I. Hirji S.A. Ramirez-Del Val F. Norman A.V. McGurk S. Aranki S.F. et al.Outcomes of repeat mitral valve replacement in patients with prior mitral surgery: a benchmark for transcatheter approaches.J Thorac Cardiovasc Surg. 2018; 156: 619-627.e1Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar concluded that redo mitral valve replacement surgery can be performed with acceptable results despite the high operative risk. Mitral valve repair conferred better long-term survival than did replacement, making the repair cohort a benchmark for transcatheter intervention. This report highlights “teething” issues of the procedure before a wider application. Catheter-based interventions are the result of technological evolution of mechanical intervention in the field of transcatheter valve therapy.2Grover F.L. Vemulapalli S. Carroll J.D. Edwards F.H. Mack M.J. Thourani V.H. et al.STS/ACC TVT Registry2016 annual report of the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry.J Am Coll Cardiol. 2017; 69: 1215-1230Crossref PubMed Scopus (370) Google Scholar, 3Feldman T. Kar S. Elmariah S. Smart S.C. Trento A. Siegel R.J. et al.EVEREST II Investigators. Randomized comparison of percutaneous repair and surgery for mitral regurgitation: 5-year results of EVEREST II.J Am Coll Cardiol. 2015; 66: 2844-2854Crossref PubMed Scopus (508) Google Scholar, 4Muller D.W. Farivar R.S. Jansz P. Bae R. Walters D. Clarke A. et al.Tendyne Global Feasibility Trial Investigators. Transcatheter mitral valve replacement for patients with symptomatic mitral regurgitation: a global feasibility trial.J Am Coll Cardiol. 2017; 69: 381-391Crossref PubMed Scopus (208) Google Scholar The clinical trials have focused primarily on patients with primary severe mitral regurgitation, reasonable life expectancy, and prohibitive surgical risk because of comorbidities. Results of ongoing randomized trials of transcather mitral therapy (TMiT) edge-to-edge in patients with heart failure and secondary mitral regurgitation (COAPTNCT01626079, RESHAPE-HF-NCT01772108, MITRA-FR-NCT01920698) are imminent and may shed light on patient suitability. The last mentioned study (MITRA-FR-NCT01920698) is of particular interest from a biomechanics perspective, because mitral regurgitation recurrence occurred within 6 months after TMiT edge-to-edge. The wider application of transcather mitral valve therapy (TMVT) is limited by long-term durability concerns of new devices, thereby excluding younger patients with intermediate to low risk. Expansion to include these patients5Nishimura R.A. Otto C.M. Bonow R.O. Carabello B.A. Erwin 3rd, J.P. Fleisher L.A. et al.2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.J Am Coll Cardiol. 2017; 70: 252-289Crossref PubMed Scopus (1812) Google Scholar involves exposing them to the uncertainty of long-term effectiveness. TMVT results should not be inferior to surgical intervention for patients undergoing transmitral valve replacement, transmitral mitral valve-in-valve, and transmitral mitral valve-in-ring or TMiT edge-to-edge. Finite element analysis (FEA) biomodeling allows development of predictive models for short and long-term follow-up by means of computed biomodeling applied to TMVT. FEA involves calculating the stress and strain coefficients of the complex structures within a small geometric area, whereby its behavior can be mathematically anticipated (Videos 1 and 2). Its widespread use in cardiology and cardiac surgery is limited because of clinician hesitancy stemming from the lack of related clinical studies, thereby curtailing its potential effectiveness.6Kunzelman K.S. Cochran R.P. Chuong C. Ring W.S. Verrier E.D. Eberhart R.D. Finite element analysis of the mitral valve.J Heart Valve Dis. 1993; 2: 326-340PubMed Google Scholar Application of FEA biomodeling can be clinically validated through a comparative analysis with computed dynamic computed tomographic scan, magnetic resonance imaging, or 3-dimensional transesophageal echocardiographic reconstruction of the mitral valve.7Nappi F. Spadaccio C. Mihos C.G. Fraldi M. Euler's elastica–based biomechanical assessment for neochordal insertion in the treatment of degenerative mitral valve repair.J Thorac Cardiovasc Surg. 2018; 155: 603-605Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 8Nappi F. Spadaccio C. Biomechanics of failed ischemic mitral valve repair: discovering new frontiers.J Thorac Cardiovasc Surg. 2017; 154: 832-833Abstract Full Text Full Text PDF PubMed Scopus (15) Google ScholarVideo 2Biomechanical simulation of transcatheter valve therapy that show the main step of finite element analysis model: Stent crimping, catheter removing and stent self-expansion. Video available at: https://www.jtcvs.org/article/S0022-5223(18)32507-8/fulltext.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Transmitral valve replacement, transmitral mitral valve-in-valve, and TMViR therapies are subject to higher levels of stress and strain of valve leaflets and attachment of the stent in the trigonal area during the systole as the mitral valve bulges into the left atrium.9Prot V. Skallerud B. Sommer G. Holzapfel G.A. On modelling and analysis of healthy and pathological human mitral valves: two case studies.J Mech Behav Biomed Mater. 2010; 3: 167-177Crossref PubMed Scopus (99) Google Scholar FEA is able to foresee these biomechanical perturbations in quasistatic boundary conditions and during fatigued dynamic stress10Prot V. Skallerud B. Simulation of native, diseased, and prosthetic heart valve function. Contributions of prestrains, hyperelasticity, and muscle fiber activation on mitral valve systolic performance.Int J Numer Meth Biomed Eng. 2017; 33: e2806Google Scholar; both potentially are responsible for early risk of structural valve deterioration. This is likely accentuated during crimping movements in 14F dispensing systems, especially with the latest transcatheter valve therapy generations with thinner leaflets. In TMiT edge-to-edge, the mechanical behavior of the mitral valve differs between leaflets and connective scaffolding. The current trend of biomodelling mitral valve leaflets involves using anisotropic hyperelastic materials with a preferred anisotropic direction defined by a single collagen family within an isotropic matrix.10Prot V. Skallerud B. Simulation of native, diseased, and prosthetic heart valve function. Contributions of prestrains, hyperelasticity, and muscle fiber activation on mitral valve systolic performance.Int J Numer Meth Biomed Eng. 2017; 33: e2806Google Scholar Understanding the functioning mechanisms are essential for lasting results. For TMiT edge-to-edge, a scallop of the anterior leaflet is attached to its counterpart (Figure 1). In vitro studies of mechanical testing have raised concerns about the active components present in the mitral leaflets and the presence of prestrains contributing to physiologic deformations during peak systole of the mitral valve, highlighting insufficiency of biomodeling in numerical studies of the mitral apparatus. In vitro studies11Sacks M.S. He Z. Baijens L. Wanant S. Shah P. Sugimoto H. et al.Surface strains in the anterior leaflet of the functioning mitral valve.Ann Biomed Eng. 2002; 30: 1281-1290Crossref PubMed Scopus (137) Google Scholar, 12Jimenez J.H. Liou S.W. Padala M. He Z. Sacks M.S. Gorman R.C. et al.A saddle-shaped annulus reduces systolic strain on the central region of the mitral valve anterior leaflet.J Thorac Cardiovasc Surg. 2007; 134: 1562-1568Abstract Full Text Full Text PDF PubMed Scopus (100) Google Scholar performed on porcine anterior mitral leaflets in a simulator yielded measures of circumferential and radial strains ranging between 15% and 40% at peak systole. These strains were measured in vivo by Krishnamurthy and colleagues13Krishnamurthy G. Ennis D.B. Itoh A. Bothe W. Swanson J.C. Karlsson M. et al.Material properties of the ovine mitral valve anterior leaflet in vivo from inverse finite element analysis.Am J Physiol Heart Circ Physiol. 2008; 295: H1141-H1149Crossref PubMed Scopus (71) Google Scholar with a linear inverse FEA technique to estimate material stiffness of bovine anterior leaflets, suggesting the possible underestimation of leaflet stiffness. The tips of the papillary muscles should be fixed, varying by only a few millimeters in distance between the implantation base of the papillary muscles during end-diastole and end-systole. The relative distance between the plane of the annulus and the tips of the papillary muscles is almost constant in degenerative diseases but not in secondary mitral regurgitation resulting from tethering traction. Edge-to-edge without ring annuloplasty, which improves the malcoaptation of the leaflets by reducing the anteroposterior diameter, may be insufficient to reduce the stress load of the anterior leaflet. These findings were noted by De Bonis and coworkers.14De Bonis M. Lapenna E. Barili F. Nisi T. Calabrese M. Pappalardo F. et al.Long-term results of mitral repair in patients with severe left ventricular dysfunction and secondary mitral regurgitation: does the technique matter?.Eur J Cardiothorac Surg. 2016; 50: 882-889Crossref PubMed Scopus (27) Google Scholar A later study by the same group15De Bonis M. Taramasso M. Lapenna E. Denti P. La Canna G. Buzzatti N. et al.MitraClip therapy and surgical edge-to-edge repair in patients with severe left ventricular dysfunction and secondary mitral regurgitation: mid-term results of a single-centre experience†.Eur J Cardiothorac Surg. 2016; 49: 255-262Crossref PubMed Scopus (32) Google Scholar showed the MitraClip (Abbott Vascular, Santa Clara, Calif) device to be an independent predictor of mitral regurgitation recurrence in a similar patient cohort. It is hoped that further studies of subgroup analysis between conventional Mitral valve surgery versus TMiT edge-to-edge through FEA application may clarify TMVT limits. Three-dimensional transesophageal echocardiographic biomodeling through FEA can measure the stress and strain of the mitral apparatus and predict clinical evolution. Simultaneous predictive biomodeling through FEA and computed 3-dimensional imaging may be useful for predicting the success of the long-term implantation of TMVTs. https://www.jtcvs.org/cms/asset/db80fd90-c544-4529-8d8d-53d3ecbe805a/mmc1.mp4Loading ... Download .mp4 (1.11 MB) Help with .mp4 files Video 1Simulation of Von Mises average stress distribution after biomechanical simulation of transcatheter valve therapy. Video available at: https://www.jtcvs.org/article/S0022-5223(18)32507-8/fulltext.https://www.jtcvs.org/cms/asset/97ec32ce-548d-422c-8a4f-19333c95af01/mmc2.mp4Loading ... Download .mp4 (1.14 MB) Help with .mp4 files Video 2Biomechanical simulation of transcatheter valve therapy that show the main step of finite element analysis model: Stent crimping, catheter removing and stent self-expansion. Video available at: https://www.jtcvs.org/article/S0022-5223(18)32507-8/fulltext. Outcomes of repeat mitral valve replacement in patients with prior mitral surgery: A benchmark for transcatheter approachesThe Journal of Thoracic and Cardiovascular SurgeryVol. 156Issue 2PreviewWith the emergence of transcatheter mitral valve-in-valve/ring replacement for deteriorated bioprostheses or failed repair, comparative clinical benchmarks for surgical repeat mitral valve replacement (re-MVR) are needed. We present in-hospital and survival outcomes of a 24-year experience with re-MVR. Full-Text PDF Open Archive" @default.
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- W2923200081 title "Finite element analysis applied to the transcatheter mitral valve therapy: Studying the present, imagining the future" @default.
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