Mitral annular size predicts Alfieri stitch tension in mitral edge-to-edge repair

Tomasz A. Timek, Sten L. Nielsen, David T. Lai, Frederick (Fred) Tibayan, David Liang, George T. Daughters, Philip Beineke, Trevor Hastie, Neil B. Ingels, D. Craig Miller

Research output: Contribution to journalArticle

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Abstract

Background and aim of the study: Whilst increased 'Alfieri stitch' tension may reduce the durability of 'edge-to-edge' mitral repair, the factors affecting suture tension are unknown. In order to study hemodynamics and left ventricular (LV) and annular dynamics that determine suture tension, the central edge of the mitral leaflets was approximated with a miniature force transducer to measure leaflet tension (T) at the leaflet approximation point. Methods: Eight sheep were studied under open-chest conditions immediately after surgical placement of a force transducer and implantation of radiopaque markers on the left ventricle and mitral annulus (MA). Hemodynamic variables were altered by two caval occlusion steps (AVI and AV2) and dobutamine infusion. Three-dimensional marker coordinates were obtained by simultaneous biplane videofluoroscopy to measure LV volume, MA area (MAA) and septal-lateral (SL) annular dimension throughout the cardiac cycle. Results: At baseline, peak Alfieri stitch tension (0.30 ± 0.18 N) was observed 96 ± 61 ms prior to end-dias-tole coincident with peak annular SL diameter (98 ± 58 ms before end-diastole). Dobutamine infusion decreased suture tension (from 0.30 ± 0.18 N to 0.20 ± 0.12 N, p = 0.01), although peak systolic pressure increased significantly (138 ± 19 versus 115 ± 14 mmHg; p = 0.03). A regression model was fitted with the goal of interpreting the hemodynamic and geometric predictors of tension as their influence varied with time: Tt (N) = 0.1916 + 0.2115 x SL (cm) -0.1996 x MAA/SL (cm2/cm) + ft x LVP (mmHg), where Tt is tension at any time during the cardiac cycle and ft is the time-varying coefficient of LVR Conclusion: Tension on the leaflets in the edge-to-edge repair is determined primarily by MA SL size, and paradoxically is lower when the contractile state is enhanced. This indicates that annular and/or LV dilatation increase stitch tension and may adversely affect durability of the repair if concomitant ring annuloplasty is not performed.

Original languageEnglish (US)
Pages (from-to)165-173
Number of pages9
JournalJournal of Heart Valve Disease
Volume13
Issue number2
StatePublished - Mar 2004
Externally publishedYes

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Sutures
Septum of Brain
Dobutamine
Hemodynamics
Transducers
Venae Cavae
Diastole
Heart Ventricles
Dilatation
Sheep
Thorax
Blood Pressure

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

Timek, T. A., Nielsen, S. L., Lai, D. T., Tibayan, F. F., Liang, D., Daughters, G. T., ... Miller, D. C. (2004). Mitral annular size predicts Alfieri stitch tension in mitral edge-to-edge repair. Journal of Heart Valve Disease, 13(2), 165-173.

Mitral annular size predicts Alfieri stitch tension in mitral edge-to-edge repair. / Timek, Tomasz A.; Nielsen, Sten L.; Lai, David T.; Tibayan, Frederick (Fred); Liang, David; Daughters, George T.; Beineke, Philip; Hastie, Trevor; Ingels, Neil B.; Miller, D. Craig.

In: Journal of Heart Valve Disease, Vol. 13, No. 2, 03.2004, p. 165-173.

Research output: Contribution to journalArticle

Timek, TA, Nielsen, SL, Lai, DT, Tibayan, FF, Liang, D, Daughters, GT, Beineke, P, Hastie, T, Ingels, NB & Miller, DC 2004, 'Mitral annular size predicts Alfieri stitch tension in mitral edge-to-edge repair', Journal of Heart Valve Disease, vol. 13, no. 2, pp. 165-173.
Timek TA, Nielsen SL, Lai DT, Tibayan FF, Liang D, Daughters GT et al. Mitral annular size predicts Alfieri stitch tension in mitral edge-to-edge repair. Journal of Heart Valve Disease. 2004 Mar;13(2):165-173.
Timek, Tomasz A. ; Nielsen, Sten L. ; Lai, David T. ; Tibayan, Frederick (Fred) ; Liang, David ; Daughters, George T. ; Beineke, Philip ; Hastie, Trevor ; Ingels, Neil B. ; Miller, D. Craig. / Mitral annular size predicts Alfieri stitch tension in mitral edge-to-edge repair. In: Journal of Heart Valve Disease. 2004 ; Vol. 13, No. 2. pp. 165-173.
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abstract = "Background and aim of the study: Whilst increased 'Alfieri stitch' tension may reduce the durability of 'edge-to-edge' mitral repair, the factors affecting suture tension are unknown. In order to study hemodynamics and left ventricular (LV) and annular dynamics that determine suture tension, the central edge of the mitral leaflets was approximated with a miniature force transducer to measure leaflet tension (T) at the leaflet approximation point. Methods: Eight sheep were studied under open-chest conditions immediately after surgical placement of a force transducer and implantation of radiopaque markers on the left ventricle and mitral annulus (MA). Hemodynamic variables were altered by two caval occlusion steps (AVI and AV2) and dobutamine infusion. Three-dimensional marker coordinates were obtained by simultaneous biplane videofluoroscopy to measure LV volume, MA area (MAA) and septal-lateral (SL) annular dimension throughout the cardiac cycle. Results: At baseline, peak Alfieri stitch tension (0.30 ± 0.18 N) was observed 96 ± 61 ms prior to end-dias-tole coincident with peak annular SL diameter (98 ± 58 ms before end-diastole). Dobutamine infusion decreased suture tension (from 0.30 ± 0.18 N to 0.20 ± 0.12 N, p = 0.01), although peak systolic pressure increased significantly (138 ± 19 versus 115 ± 14 mmHg; p = 0.03). A regression model was fitted with the goal of interpreting the hemodynamic and geometric predictors of tension as their influence varied with time: Tt (N) = 0.1916 + 0.2115 x SL (cm) -0.1996 x MAA/SL (cm2/cm) + ft x LVP (mmHg), where Tt is tension at any time during the cardiac cycle and ft is the time-varying coefficient of LVR Conclusion: Tension on the leaflets in the edge-to-edge repair is determined primarily by MA SL size, and paradoxically is lower when the contractile state is enhanced. This indicates that annular and/or LV dilatation increase stitch tension and may adversely affect durability of the repair if concomitant ring annuloplasty is not performed.",
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T1 - Mitral annular size predicts Alfieri stitch tension in mitral edge-to-edge repair

AU - Timek, Tomasz A.

AU - Nielsen, Sten L.

AU - Lai, David T.

AU - Tibayan, Frederick (Fred)

AU - Liang, David

AU - Daughters, George T.

AU - Beineke, Philip

AU - Hastie, Trevor

AU - Ingels, Neil B.

AU - Miller, D. Craig

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N2 - Background and aim of the study: Whilst increased 'Alfieri stitch' tension may reduce the durability of 'edge-to-edge' mitral repair, the factors affecting suture tension are unknown. In order to study hemodynamics and left ventricular (LV) and annular dynamics that determine suture tension, the central edge of the mitral leaflets was approximated with a miniature force transducer to measure leaflet tension (T) at the leaflet approximation point. Methods: Eight sheep were studied under open-chest conditions immediately after surgical placement of a force transducer and implantation of radiopaque markers on the left ventricle and mitral annulus (MA). Hemodynamic variables were altered by two caval occlusion steps (AVI and AV2) and dobutamine infusion. Three-dimensional marker coordinates were obtained by simultaneous biplane videofluoroscopy to measure LV volume, MA area (MAA) and septal-lateral (SL) annular dimension throughout the cardiac cycle. Results: At baseline, peak Alfieri stitch tension (0.30 ± 0.18 N) was observed 96 ± 61 ms prior to end-dias-tole coincident with peak annular SL diameter (98 ± 58 ms before end-diastole). Dobutamine infusion decreased suture tension (from 0.30 ± 0.18 N to 0.20 ± 0.12 N, p = 0.01), although peak systolic pressure increased significantly (138 ± 19 versus 115 ± 14 mmHg; p = 0.03). A regression model was fitted with the goal of interpreting the hemodynamic and geometric predictors of tension as their influence varied with time: Tt (N) = 0.1916 + 0.2115 x SL (cm) -0.1996 x MAA/SL (cm2/cm) + ft x LVP (mmHg), where Tt is tension at any time during the cardiac cycle and ft is the time-varying coefficient of LVR Conclusion: Tension on the leaflets in the edge-to-edge repair is determined primarily by MA SL size, and paradoxically is lower when the contractile state is enhanced. This indicates that annular and/or LV dilatation increase stitch tension and may adversely affect durability of the repair if concomitant ring annuloplasty is not performed.

AB - Background and aim of the study: Whilst increased 'Alfieri stitch' tension may reduce the durability of 'edge-to-edge' mitral repair, the factors affecting suture tension are unknown. In order to study hemodynamics and left ventricular (LV) and annular dynamics that determine suture tension, the central edge of the mitral leaflets was approximated with a miniature force transducer to measure leaflet tension (T) at the leaflet approximation point. Methods: Eight sheep were studied under open-chest conditions immediately after surgical placement of a force transducer and implantation of radiopaque markers on the left ventricle and mitral annulus (MA). Hemodynamic variables were altered by two caval occlusion steps (AVI and AV2) and dobutamine infusion. Three-dimensional marker coordinates were obtained by simultaneous biplane videofluoroscopy to measure LV volume, MA area (MAA) and septal-lateral (SL) annular dimension throughout the cardiac cycle. Results: At baseline, peak Alfieri stitch tension (0.30 ± 0.18 N) was observed 96 ± 61 ms prior to end-dias-tole coincident with peak annular SL diameter (98 ± 58 ms before end-diastole). Dobutamine infusion decreased suture tension (from 0.30 ± 0.18 N to 0.20 ± 0.12 N, p = 0.01), although peak systolic pressure increased significantly (138 ± 19 versus 115 ± 14 mmHg; p = 0.03). A regression model was fitted with the goal of interpreting the hemodynamic and geometric predictors of tension as their influence varied with time: Tt (N) = 0.1916 + 0.2115 x SL (cm) -0.1996 x MAA/SL (cm2/cm) + ft x LVP (mmHg), where Tt is tension at any time during the cardiac cycle and ft is the time-varying coefficient of LVR Conclusion: Tension on the leaflets in the edge-to-edge repair is determined primarily by MA SL size, and paradoxically is lower when the contractile state is enhanced. This indicates that annular and/or LV dilatation increase stitch tension and may adversely affect durability of the repair if concomitant ring annuloplasty is not performed.

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