title: Saddle-Shaped Annuloplasty Improves Leaflet Coaptation in Repair for Ischemic Mitral Regurgitation.
abstract: BACKGROUND
  Current repair results for ischemic mitral regurgitation (IMR) with undersized annuloplasty rings are characterized by high IMR recurrence rates. Current annuloplasty rings treat annular dilatation, but they do little to improve (and may actually exacerbate) leaflet tethering. New saddle-shaped annuloplasty rings have been shown to maintain or restore a more physiologic annular and leaflet geometry and function. Using a porcine IMR model, we sought to demonstrate the influence of annuloplasty ring shape on leaflet coaptation.
  
  
  METHODS
  Eight weeks after posterolateral infarct, eight pigs with grade 2+ or higher IMR were randomized to undergo either a 28-mm flat ring annuloplasty (n = 4) or a 28-mm saddle-shaped ring annuloplasty (n = 4). Real-time three-dimensional echocardiography and a customized image analysis protocol allowed three-dimensional assessment of leaflet coaptation before and after annuloplasty.
  
  
  RESULTS
  Total leaflet coaptation area was significantly higher after saddle-shaped ring annuloplasty (109.6 ± 26.9 mm(2)) compared with flat ring annuloplasty (46.2 ± 7.7 mm(2), p <0.01). After annuloplasty, total coaptation area decreased by 87.5 mm(2) (or 65%) in the flat annuloplasty group (p = 0.01), whereas total coaptation area increased by 22.2 mm(2) (or 25%) in the saddle-shaped annuloplasty group (p = 0.28).
  
  
  CONCLUSIONS
  This study shows that the use of undersized saddle-shaped annuloplasty rings in mitral valve repair for IMR improves leaflet coaptation, whereas the use of undersized flat annuloplasty rings worsens leaflet coaptation. Because one of Carpentier's fundamental principles of mitral valve repair (durability) is to create a large surface of coaptation, saddle-shaped annuloplasty may increase repair durability.
authors.affiliation: Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania; University of Groningen, University Medical Center Groningen, Department of Cardiothoracic Surgery, Groningen, Netherlands.
authors.forename: Wobbe
authors.initials: W
authors.lastname: Bouma
authors.affiliation: Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Chikashi
authors.initials: C
authors.lastname: Aoki
authors.affiliation: Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Mathieu
authors.initials: M
authors.lastname: Vergnat
authors.affiliation: Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Alison M
authors.initials: AM
authors.lastname: Pouch
authors.affiliation: Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Shanna R
authors.initials: SR
authors.lastname: Sprinkle
authors.affiliation: Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Gillespie
authors.affiliation: University of Groningen, University Medical Center Groningen, Department of Cardiothoracic Surgery, Groningen, Netherlands.
authors.forename: Massimo A
authors.initials: MA
authors.lastname: Mariani
authors.affiliation: Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Benjamin M
authors.initials: BM
authors.lastname: Jackson
authors.affiliation: Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Robert C
authors.initials: RC
authors.lastname: Gorman
authors.affiliation: Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address: gormanj@uphs.upenn.edu.
authors.forename: Joseph H
authors.initials: JH
authors.lastname: Gorman
mesh_terms: D000818:Animals; D006350:Heart Valve Prosthesis; D008297:Male; D058386:Mitral Valve Annuloplasty / Q000379:methods*; D008944:Mitral Valve Insufficiency / Q000601:surgery*; D011474:Prosthesis Design; D011897:Random Allocation; D013552:Swine