title: Computer-based comparison of different methods for selecting mitral annuloplasty ring size.
abstract: BACKGROUND
  Ring sizing for mitral valve annuloplasty is conventionally done intraoperatively using specific 'sizer' instruments, which are placed onto the valve tissue. This approach is barely reproducible since different sizing strategies have been established among surgeons. The goal of this study is to virtually apply different sizing methods on the basis of pre-repair echocardiography to find out basic differences between sizing strategies.
  
  
  METHODS
  In three-dimensional echocardiographs of 43 patients, the mitral annulus and the contour of the anterior mitral leaflet were segmented using MITK Mitralyzer software. Similarly, three-dimensional virtual models of Carpentier-Edwards Physio II annuloplasty rings and their corresponding sizers were interactively generated from computer tomography images. For each patient, the matching annuloplasty ring was selected repeatedly according to popular sizing strategies, such as the height of anterior mitral leaflet, the intercommissural distance and the surface area of anterior mitral leaflet. The areas of the selected rings were considered as the neo-surface area of the mitral annulus after implantation.
  
  
  RESULTS
  The sizing of the mitral valve according to the height of anterior mitral leaflet (mean ring size = 29.9 ± 3.90), intercommissural distance (mean ring size = 37.5 ± 1.92) or surface area of anterior mitral leaflet (mean ring size = 32.7 ± 3.3) led to significantly different measurements (p ≤ 0.01). In contrary to intercommissural distance, height and surface area of the anterior mitral leaflet exhibited significant variations between the patients (p ≤ 0.01). The sizing according to the height of anterior mitral leaflet led to the maximal reduction of the mitral annulus surface area followed by the sizing according to the surface area of anterior mitral leaflet and finally by the intercommissural distance.
  
  
  CONCLUSIONS
  This novel comprehensive computer-based analysis reveals that the surveyed sizing methods led to the selection of significantly different annuloplasty rings and therefore underscore the ambiguity of routinely applied annuloplasty sizing strategies.
authors.affiliation: Department of Cardiac Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany. yemendoctor@yahoo.com.
authors.forename: Sameer
authors.identifier: http://orcid.org/0000-0001-8758-1722
authors.initials: S
authors.lastname: Al-Maisary
authors.affiliation: Department of Computer-Assisted Medical Intervention, German Cancer Research Center (DKFZ), Heidelberg, Germany.
authors.forename: Sandy
authors.initials: S
authors.lastname: Engelhardt
authors.affiliation: Department of Computer-Assisted Medical Intervention, German Cancer Research Center (DKFZ), Heidelberg, Germany.
authors.forename: Bastian
authors.initials: B
authors.lastname: Graser
authors.affiliation: Department of Computer Science, Mannheim University of Applied Science, Mannheim, Germany.
authors.forename: Ivo
authors.initials: I
authors.lastname: Wolf
authors.affiliation: Department of Cardiac Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
authors.forename: Matthias
authors.initials: M
authors.lastname: Karck
authors.affiliation: Department of Cardiac Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
authors.forename: Raffaele
authors.initials: R
authors.lastname: De Simone
mesh_terms: D000368:Aged; D003198:Computer Simulation; D019560:Echocardiography, Three-Dimensional; D005260:Female; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000295:instrumentation* / Q000379:methods; D006801:Humans; D007090:Image Interpretation, Computer-Assisted; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000000981:diagnostic imaging / Q000601:surgery*; D058386:Mitral Valve Annuloplasty / Q000295:instrumentation* / Q000379:methods; D008944:Mitral Valve Insufficiency / Q000000981:diagnostic imaging / Q000601:surgery*; D008953:Models, Anatomic; D016896:Treatment Outcome
keywords: Annuloplasty ring; Implant; Mitral valve; Sizing