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Prediction of the annuloplasty ring size in patients undergoing mitral valve repair using real-time three-dimensional transoesophageal echocardiography.

Ender J, Eibel S, Mukherjee C, Mathioudakis D, Borger MA, Jacobs S, Mohr FW, Falk V - Eur J Echocardiogr (2011)

Bottom Line: In 53 patients undergoing elective mitral valve repair, an RT 3D TOE was performed pre- and post-operatively.The correlation for measurement of the intercommissural distance was 0.55 and for measurement of the height of the anterior mitral leaflet 0.75.The post-operative correlation with the actual implanted ring size was 0.96 for mitral valve assessment, 0.92 for intercommissural distance, and 0.79 for the anterior mitral leaflet height.

View Article: PubMed Central - PubMed

Affiliation: Department of Anaesthesiology and Intensive Care Medicine II, Leipzig Heart Center, University of Leipzig, Struempellstrasse 39, 04289 Leipzig, Germany. joerg.ender@medizin.uni-leipzig.de

ABSTRACT

Aims: We sought to investigate the additional value of real-time three-dimensional transoesophageal echocardiography (RT 3D TOE)-guided sizing for predicting annuloplasty ring size during mitral valve repair.

Methods and results: In 53 patients undergoing elective mitral valve repair, an RT 3D TOE was performed pre- and post-operatively. The digitally stored loops were imported into a software for mitral valve assessment. The annuloplasty ring size was predicted by superimposing computer-aided design (CAD) models of annuloplasty rings onto Live 3D zoom loops, measurement of the intercommissural distance, or the height of the anterior mitral leaflet. The surgeon implanted the annuloplasty ring according to the usual surgical technique and was blinded to the echocardiographic measurement results. Pre-operative correlation between the selected ring size with mitral valve assessment and the actual implanted annuloplasty ring size was 0.91. The correlation for measurement of the intercommissural distance was 0.55 and for measurement of the height of the anterior mitral leaflet 0.75. The post-operative correlation with the actual implanted ring size was 0.96 for mitral valve assessment, 0.92 for intercommissural distance, and 0.79 for the anterior mitral leaflet height.

Conclusion: Superimposition of annuloplasty ring CAD models on the Live 3D zoom loops of the mitral valve using mitral valve assessment is superior to two-dimensional measurements of the intercommissural distance or the height of the anterior mitral leaflet in predicting correct annuloplasty ring size.

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Computer-assisted design model of an annuloplasty ring (yellow) superimposed on the three-dimensional loop of the native mitral valve.
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JER042F1: Computer-assisted design model of an annuloplasty ring (yellow) superimposed on the three-dimensional loop of the native mitral valve.

Mentions: After routine induction of anaesthesia and placement of the central venous lines, a 3D probe was inserted and connected to the TOE console (IE33, Philips; Netherlands). After completion of a comprehensive 2D TOE examination, a 3D assessment of the mitral valve was performed. Data were acquired in Live 3D zoom in all patients and additionally in full volume modes in 20 patients. We used the mid-oesophageal four-chamber view and adjusted the region of interest for the Live 3D zoom to cover the whole mitral valve. Two heartbeats were digitally recorded with optimal settings of gain and compression in order to visualize the mitral valve leaflets, as well as the commissures, with the best possible image quality using Live 3D zoom. Four consecutive heartbeats were used for the full volume mode. These 3D loops were reviewed off-line on a laptop with the use of a prototype of the 4D Valve Assessment® software called Ring Tool® (TomTec, Munich, Germany). The Ring Tool® software modification consisted of a digital database of CAD models of Carpentier–Edwards Physio® annuloplasty rings (Edwards Lifesciences, Irvine, CA, USA) ranging in size from 28 to 36. The creation of these CAD models, as well as the modified software, was described previously in detail by Ender et al.9 In short, the CAD models were generated using computed tomography imaging of annuloplasty rings. Geometries of the artificial rings were defined by triangular meshes stored in a polygon (PLY) file format. With the help of Ring Tool®, an automated ring adjustment algorithm, the CAD models could be superimposed on the 3D loops of the mitral valve. In the current study, all patients received a complete, rigid Carpentier–Edwards Physio® annuloplasty ring because it is the device of choice for MV repair at our institution. Ring Tool® enables the echocardiographer to use a CAD model out of the database and to overlay the CAD model with the 3D loop of the mitral valve (Figure 1). In addition, the software programme offers the possibility to move the selected ring into different possible directions (see Supplementary data online, Video S1). The ring can be adjusted upwards and downwards, rotated around its own axes, moved to the right or left, as well as backwards and forwards. If position adjustment results in an unsatisfactory location, however, the database can be used to return to the last ring location. It is also possible to change the selected ring size (see Supplementary data online, Video S2). Optimal ring sizing prior to mitral valve repair was determined using a combination of three techniques. First, the 3D loop was examined visually in order to determine the best fit of the virtual ring to the native mitral valve (i.e. ‘eyeballing'). Secondly, Ring Tool® was used to simultaneously view three 2D planes (coronal, sagittal, and transverse; Figure 2), resulting in a repeated measurement of the mitral valve intercommissural distance. Lastly, we measured the maximum height of the anterior leaflet in the 2D planes (Figure 3). The cardiac surgeon chose the appropriate annuloplasty ring size according to standard surgical techniques. These techniques consisted of assessment of the intertrigonal distance and the area of the anterior mitral valve leaflet using a commercial ring sizer (Figure 4), in addition to assessment of the height of the anterior mitral leaflet. The surgeon was blinded to the annuloplasty ring size selection based on the Ring Tool® software, as well as for the 2D measurement of the intercommissural distance.Figure 1


Prediction of the annuloplasty ring size in patients undergoing mitral valve repair using real-time three-dimensional transoesophageal echocardiography.

Ender J, Eibel S, Mukherjee C, Mathioudakis D, Borger MA, Jacobs S, Mohr FW, Falk V - Eur J Echocardiogr (2011)

Computer-assisted design model of an annuloplasty ring (yellow) superimposed on the three-dimensional loop of the native mitral valve.
© Copyright Policy - creative-commons
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3117468&req=5

JER042F1: Computer-assisted design model of an annuloplasty ring (yellow) superimposed on the three-dimensional loop of the native mitral valve.
Mentions: After routine induction of anaesthesia and placement of the central venous lines, a 3D probe was inserted and connected to the TOE console (IE33, Philips; Netherlands). After completion of a comprehensive 2D TOE examination, a 3D assessment of the mitral valve was performed. Data were acquired in Live 3D zoom in all patients and additionally in full volume modes in 20 patients. We used the mid-oesophageal four-chamber view and adjusted the region of interest for the Live 3D zoom to cover the whole mitral valve. Two heartbeats were digitally recorded with optimal settings of gain and compression in order to visualize the mitral valve leaflets, as well as the commissures, with the best possible image quality using Live 3D zoom. Four consecutive heartbeats were used for the full volume mode. These 3D loops were reviewed off-line on a laptop with the use of a prototype of the 4D Valve Assessment® software called Ring Tool® (TomTec, Munich, Germany). The Ring Tool® software modification consisted of a digital database of CAD models of Carpentier–Edwards Physio® annuloplasty rings (Edwards Lifesciences, Irvine, CA, USA) ranging in size from 28 to 36. The creation of these CAD models, as well as the modified software, was described previously in detail by Ender et al.9 In short, the CAD models were generated using computed tomography imaging of annuloplasty rings. Geometries of the artificial rings were defined by triangular meshes stored in a polygon (PLY) file format. With the help of Ring Tool®, an automated ring adjustment algorithm, the CAD models could be superimposed on the 3D loops of the mitral valve. In the current study, all patients received a complete, rigid Carpentier–Edwards Physio® annuloplasty ring because it is the device of choice for MV repair at our institution. Ring Tool® enables the echocardiographer to use a CAD model out of the database and to overlay the CAD model with the 3D loop of the mitral valve (Figure 1). In addition, the software programme offers the possibility to move the selected ring into different possible directions (see Supplementary data online, Video S1). The ring can be adjusted upwards and downwards, rotated around its own axes, moved to the right or left, as well as backwards and forwards. If position adjustment results in an unsatisfactory location, however, the database can be used to return to the last ring location. It is also possible to change the selected ring size (see Supplementary data online, Video S2). Optimal ring sizing prior to mitral valve repair was determined using a combination of three techniques. First, the 3D loop was examined visually in order to determine the best fit of the virtual ring to the native mitral valve (i.e. ‘eyeballing'). Secondly, Ring Tool® was used to simultaneously view three 2D planes (coronal, sagittal, and transverse; Figure 2), resulting in a repeated measurement of the mitral valve intercommissural distance. Lastly, we measured the maximum height of the anterior leaflet in the 2D planes (Figure 3). The cardiac surgeon chose the appropriate annuloplasty ring size according to standard surgical techniques. These techniques consisted of assessment of the intertrigonal distance and the area of the anterior mitral valve leaflet using a commercial ring sizer (Figure 4), in addition to assessment of the height of the anterior mitral leaflet. The surgeon was blinded to the annuloplasty ring size selection based on the Ring Tool® software, as well as for the 2D measurement of the intercommissural distance.Figure 1

Bottom Line: In 53 patients undergoing elective mitral valve repair, an RT 3D TOE was performed pre- and post-operatively.The correlation for measurement of the intercommissural distance was 0.55 and for measurement of the height of the anterior mitral leaflet 0.75.The post-operative correlation with the actual implanted ring size was 0.96 for mitral valve assessment, 0.92 for intercommissural distance, and 0.79 for the anterior mitral leaflet height.

View Article: PubMed Central - PubMed

Affiliation: Department of Anaesthesiology and Intensive Care Medicine II, Leipzig Heart Center, University of Leipzig, Struempellstrasse 39, 04289 Leipzig, Germany. joerg.ender@medizin.uni-leipzig.de

ABSTRACT

Aims: We sought to investigate the additional value of real-time three-dimensional transoesophageal echocardiography (RT 3D TOE)-guided sizing for predicting annuloplasty ring size during mitral valve repair.

Methods and results: In 53 patients undergoing elective mitral valve repair, an RT 3D TOE was performed pre- and post-operatively. The digitally stored loops were imported into a software for mitral valve assessment. The annuloplasty ring size was predicted by superimposing computer-aided design (CAD) models of annuloplasty rings onto Live 3D zoom loops, measurement of the intercommissural distance, or the height of the anterior mitral leaflet. The surgeon implanted the annuloplasty ring according to the usual surgical technique and was blinded to the echocardiographic measurement results. Pre-operative correlation between the selected ring size with mitral valve assessment and the actual implanted annuloplasty ring size was 0.91. The correlation for measurement of the intercommissural distance was 0.55 and for measurement of the height of the anterior mitral leaflet 0.75. The post-operative correlation with the actual implanted ring size was 0.96 for mitral valve assessment, 0.92 for intercommissural distance, and 0.79 for the anterior mitral leaflet height.

Conclusion: Superimposition of annuloplasty ring CAD models on the Live 3D zoom loops of the mitral valve using mitral valve assessment is superior to two-dimensional measurements of the intercommissural distance or the height of the anterior mitral leaflet in predicting correct annuloplasty ring size.

Show MeSH