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• W3024422463 abstract "Central MessageSmall and complete mitral annuloplasty prostheses perturb physiologic cardiac flow patterns after repair of degenerative mitral regurgitation.See Article page 947. Small and complete mitral annuloplasty prostheses perturb physiologic cardiac flow patterns after repair of degenerative mitral regurgitation. See Article page 947. Modern magnetic resonance imaging (MRI) is providing a window to the hemodynamic intricacies of cardiac flow patterns and simultaneously elucidating previously unchartered physiologic territory. Ascending aortic flow imaging has been illuminating in exploring the link between bicuspid aortic valves and aneurysms of the ascending aorta,1Hope M.D. Hope T.A. Crook S.E. Ordovas K.G. Urbania T.H. Alley M.T. et al.4D flow CMR in assessment of valve-related ascending aortic disease.JACC Cardiovasc Imaging. 2011; 4: 781-787Crossref PubMed Scopus (201) Google Scholar and ventricular chamber flow characterization is adding to our understanding of normal2Fredriksson A.G. Zajac J. Eriksson J. Dyverfeldt P. Bolger A.F. Ebbers T. et al.4-D blood flow in the human right ventricle.Am J Physiol Heart Circ Physiol. 2011; 301: H2344-H2350Crossref PubMed Scopus (101) Google Scholar and pathologic3Eriksson J. Bolger A.F. Ebbers T. Carlhäll C.J. Assessment of left ventricular hemodynamic forces in healthy subjects and patients with dilated cardiomyopathy using 4D flow MRI.Physiol Rep. 2016; 4Crossref Scopus (41) Google Scholar cardiac function. In the current issue of the Journal, Morichi and colleagues4Morichi H. Itatani K. Yamazaki S. Numata S. Nakaji K. Tamaki N. et al.Influences of mitral annuloplasty on left ventricular flow dynamics assessed with 3-dimensional cine phase-contrast flow magnetic resonance imaging.J Thorac Cardiovasc Surg. 2022; 163: 947-959Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar go a step beyond and use 4-dimensional MRI to assess the influence of mitral annular prostheses on left ventricular flow patterns after mitral repair for degenerative disease. The authors report that mitral repair with smaller annuloplasty rings significantly altered left ventricular flow patterns with complete rings also perturbing aortic root flow. Although the influence of these differential flow characteristics on repair durability and clinical outcomes is yet unknown, preservation of physiologic cardiac flow ought to offer a hemodynamic advantage in the long term. The presented findings add new pieces to the complexity of the mitral puzzle and spur renewed interest in previous mechanistic studies. The flow patterns in healthy volunteers revealed formation of vertexes under the anterior and posterior leaflets in early diastole with subsequent enlargement of the anterior vortex displacing the anterior leaflet toward the valve. This flow-induced leaflet motion acts to pre-position the valve for competent and efficient closure before rise of ventricular pressure. The vivid images provided by the authors corroborate the findings of Tsakiris and colleagues,5Tsakiris A.G. Gordon D.A. Mathieu Y. Irving L. Motion of both mitral valve leaflets: a cineroentgenographic study in intact dogs.J Appl Physiol. 1975; 39: 359-366Crossref PubMed Scopus (20) Google Scholar who more than 4 decades ago postulated facilitated valve closure with “eddy currents” under the leaflets. In the current study, both partial and complete annular prostheses abolished the vortex-induced displacement of the anterior leaflet in mid-diastole and hence perturbed normal physiologic flow patterns. These findings from healthy volunteers also add clarity to the complex mechanisms of mitral valve closure. Diastolic vortexes and atrially mediated annular reduction6Timek T. Dagum P. Lai D.T. Green G.R. Glasson J.R. Daughters G.T. et al.The role of atrial contraction in mitral valve closure.J Heart Valve Dis. 2001; 10: 312-319PubMed Google Scholar work in tandem to approximate the valve leaflets in late diastole for subsequent sealing by rising systolic pressure to achieving timely and competent valve closure. The interaction between the aortic root and the mitral annulus also deserves renewed attention in light of the results at hand. Previous experimental work has shown that the mitral and aortic annuli change size during the cardiac cycle in reciprocal manner that is not strictly mediated by the aorto-mitral curtain.7Timek T.A. Green G.R. Tibayan F.A. Lai D.T. Rodriguez F. Liang D. et al.Aorto-mitral annular dynamics.Ann Thorac Surg. 2003; 76: 1944-1950Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar To this end, incomplete mitral annuloplasty prostheses have been shown to better preserve anterior annular flexion than complete rings,8Dagum P. Timek T. Green G.R. Daughters G.T. Liang D. Ingels Jr., N.B. et al.Three-dimensional geometric comparison of partial and complete flexible mitral annuloplasty rings.J Thorac Cardiovasc Surg. 2001; 122: 665-673Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar thus perhaps better facilitating normal aortic root dynamics. Demonstration of near-physiologic aortic flow patterns with mitral bands but not rings in the current study substantiates these suggestive data of the past. However, the results of this advanced imaging analysis should be viewed through a lens of important limitations, as it is difficult to separate whether leaflet or annular techniques were responsible for the altered flow patterns. Artificial chordae with differential tension and posterior leaflet resective techniques may perturb normal leaflet motion and disturb physiologic vortex formation irrespective of the annular prosthesis used. Perhaps patients with functional mitral regurgitation repaired with an annuloplasty prosthesis alone would have been a better substrate for this study. Indeed, in healthy sheep implanted with annuloplasty rings only,9Witschey W.R. Zhang D. Contijoch F. McGarvey J.R. Lee M. Takebayashi S. et al.The influence of mitral annuloplasty on left ventricular flow dynamics.Ann Thorac Surg. 2015; 100: 114-121Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar the MRI flow patterns were substantially different from those presented herein. The 4-dimensional MRI flow patterns reported in the presented patients offer a unique glimpse into the physiologic subtleties of degenerative mitral valve repair that goes beyond the usual gross assessment of valvular insufficiency. Other investigators10Ma W. Shi W. Wu W. Ye W. Kong Y. Zhu D. et al.Elevated gradient after mitral valve repair: the effect of surgical technique and relevance of postoperative atrial fibrillation.J Thorac Cardiovasc Surg. 2019; 157: 921-927.e3Abstract Full Text Full Text PDF PubMed Google Scholar have shown that even with successful restoration of valvular competence, the technical nuances of mitral repair may lead to distant morbidity. The current report adds impetus for further refinement of surgical technique. Advanced imaging techniques may be the new bellwether of not only competent but also physiologic mitral valve repair. Influences of mitral annuloplasty on left ventricular flow dynamics assessed with 3-dimensional cine phase-contrast flow magnetic resonance imagingThe Journal of Thoracic and Cardiovascular SurgeryVol. 163Issue 3PreviewWe assessed the influence of annuloplasty procedures in mitral repair on left ventricular (LV) vortex flow patterns and aortic outflow patterns, and flow energy loss (EL). Full-Text PDF" @default.
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• W3024422463 title "Commentary: The vortex and the ring" @default.
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