Skip to main content
SpringerLink
Log in

Mechanical and Structural Evaluation of Tricuspid Bicuspidization in a Porcine Model

  • Original Article
  • Published:
Cardiovascular Engineering and Technology Aims and scope Submit manuscript

Abstract

Introduction

Tricuspid regurgitation (TR) affects approximately 1.6 million Americans and is associated with just a 63.9% 1-year survival rate in its moderate to severe forms due to its asymptomatic nature and late diagnosis and surgical referral. As a result, industrial fervor has begun to broach this topic, with several percutaneous treatment devices currently under development. As much remains unknown about the tricuspid apparatus, the mechanics of these procedures remain unquantified. In this study, a testing apparatus and technique for the evaluation of percutaneous tricuspid valve (TV) bicuspidization were developed for the evaluation of these parameters in twelve porcine hearts.

Methods

The passive relaxed myocardial state and the active contracted state were each induced in six porcine hearts and the bicuspidization experiment was run twice, the second time after induction of TR. TV annular area, cinching force, static leakage through the TV annulus, and annular ellipticity were quantified and compared among the groups.

Results

The use of phenol was effective to induce functional TR by increased annular area. Cinching force was not found to differ between any of the testing states, but the bicuspidization experiment was able to reduce the TR annular area to that of its healthy counterpart in addition to reducing static leakage through the TV annulus. Despite appropriately reducing the area, bicuspidization was found to induce a more circular TV annular shape.

Conclusion

Taken together, these results provide a first mechanical analysis of the TV bicuspidization mechanism and may serve as a point of reference for future clinical animal studies.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Figure 1
Figure 2
Figure 3
Figure 4
Figure 5
Figure 6
Figure 7

Similar content being viewed by others

References

  1. Adkins, A., et al. Force required to cinch the tricuspid annulus: an ex-vivo study. J. Heart Valve Dis. 24(5):644, 2015.

    Google Scholar 

  2. Aleman, J., et al. Effects of Cinching Force on the Tricuspid Annulus: A Species Comparison. J. Cardiovasc. Dis. Diagn. 5:4, 2017.

    Google Scholar 

  3. Amini Khoiy, K., et al. Surface strains of porcine tricuspid valve septal leaflets measured in ex vivo beating hearts. J. Biomech. Eng. 138(11):111006, 2016.

    Google Scholar 

  4. Besler, C., C. U. Meduri, and P. Lurz. Transcatheter treatment of functional tricuspid regurgitation using the trialign device. Interv. Cardiol. Rev. 13(1):8, 2018.

    Google Scholar 

  5. Bhattacharya, S., et al. Tension to passively cinch the mitral annulus through coronary sinus access: An ex vivo study in ovine model. J. Biomech. 47(6):1382–1388, 2014.

    Google Scholar 

  6. Cilingiroglu, M., and K. Marmagkiolis. Percutanous management of tricuspid regurgitation: The “Achilles tendon” of transcatheter valve interventions. Catheterization Cardiovasc. Interv. 88(2):294–295, 2016.

    Google Scholar 

  7. Colombo, T., et al. Tricuspid regurgitation secondary to mitral valve disease: tricuspid annulus function as guide to tricuspid valve repair. Cardiovasc. Surg. 9(4):369–377, 2001.

    Google Scholar 

  8. Correia, P., G. Coutinho, and M. Antunes. Tricuspid valve: a valve not to be forgotten. E-J. Cardol. Pract. 11:20, 2013.

    Google Scholar 

  9. Di Mauro, M., et al. Mitral valve surgery for functional mitral regurgitation: prognostic role of tricuspid regurgitation☆. Eur. J. Cardio-Thorac. Surg. 35(4):635–640, 2009.

    Google Scholar 

  10. Dreyfus, G. D., et al. Secondary tricuspid regurgitation or dilatation: which should be the criteria for surgical repair? Ann. Thorac. Surg. 79(1):127–132, 2005.

    Google Scholar 

  11. Fender, E. A., R. A. Nishimura, and D. R. Holmes. Percutaneous therapies for tricuspid regurgitation. Expert review of medical devices 14(1):37–48, 2017.

    Google Scholar 

  12. Fukuda, S., et al. Three-dimensional geometry of the tricuspid annulus in healthy subjects and in patients with functional tricuspid regurgitation: a real-time, 3-dimensional echocardiographic study. Circulation 114(1_supplement):I-492-I–498, 2006.

    Google Scholar 

  13. Ghanta, R. K., et al. Suture bicuspidization of the tricuspid valve versus ring annuloplasty for repair of functional tricuspid regurgitation: Midterm results of 237 consecutive patients. J Thorac. Cardiovasc. Surg. 133(1):117–126, 2007.

    Google Scholar 

  14. Giannini, F. and Latib, A. (2016) The Next Frontier of Percutaneous Tricuspid Valve Repair.

  15. Granegger, M., et al. A passive beating heart setup for interventional cardiology training. Curr. Dir. Biomed. Eng. 2(1):735–739, 2016.

    Google Scholar 

  16. Green, G. R., et al. Mitral annular dilatation and papillary muscle dislocation without mitral regurgitation in sheep. Circulation 100(2):II-95-II-102, 1999.

    MathSciNet  Google Scholar 

  17. Hahn, R. T., et al. Early feasibility study of a transcatheter tricuspid valve annuloplasty: SCOUT trial 30-day results. J. Am. Coll. Cardiol. 69(14):1795–1806, 2017.

    Google Scholar 

  18. Hahn, R. T., et al. Early feasibility study of a transcatheter tricuspid valve annuloplasty: SCOUT Trial 30-day results. J. Am. Coll. Cardiol. 69(14):1795–1806, 2017.

    Google Scholar 

  19. Hung, J. The pathogenesis of functional tricuspid regurgitation. Semin. Thorac. Cardiovasc. Surg. 22(1):76–78, 2010.

    Google Scholar 

  20. Huntington, A., et al. Anisotropy of the Passive and Active Rat Vagina Under Biaxial Loading. Ann. Biomed. Eng. 47(1):272–281, 2019.

    Google Scholar 

  21. Jaworek, M., et al. Long-arm Clip for Transcatheter Edge-to-Edge Treatment of Mitral and Tricuspid Regurgitation–Ex-Vivo Beating Heart Study. Struct. Heart 3(3):211–219, 2019.

    Google Scholar 

  22. Jeong, D. S., et al. Fate of functional tricuspid regurgitation in aortic stenosis after aortic valve replacement. J. Thorac. Cardiovasc. Surg. 148(4):1328–1333, 2014.

    Google Scholar 

  23. Kato, T., et al. Inhibitory effects and active constituents of Alisma rhizomes on vascular contraction induced by high concentration of KCl. Bull. Chem. Soc. Japan 67(5):1394–1398, 1994.

    Google Scholar 

  24. Kay, J. H., G. Maselli-Campagna, and H. K. Tsuji. Surgical treatment of tricuspid insufficiency. Ann. Surg. 162(1):53, 1965.

    Google Scholar 

  25. Khoiy, K. A., and R. Amini. On the biaxial mechanical response of porcine tricuspid valve leaflets. J. Biomech. Eng. 138(10):104504, 2016.

    Google Scholar 

  26. Kim, Y.-J., et al. Determinants of surgical outcome in patients with isolated tricuspid regurgitation. Circulation 120(17):1672–1678, 2009.

    Google Scholar 

  27. Kragsnaes, E. S., et al. In-plane tricuspid valve force measurements: development of a strain gauge instrumented annuloplasty ring. Cardiovas. Eng. Technol. 4(2):131–138, 2013.

    Google Scholar 

  28. Kuwaki, K., et al. Tricuspid valve surgery for functional tricuspid valve regurgitation associated with left-sided valvular disease. Eur. J. Cardio-Thorac. Surg. 20(3):577–582, 2001.

    Google Scholar 

  29. Latib, A., et al. Percutaneous bicuspidization of the tricuspid valve. JACC 10(4):488–489, 2017.

    Google Scholar 

  30. Leopaldi, A., et al. A novel passive left heart platform for device testing and research. Med. Eng. Phys. 37(4):361–366, 2015.

    Google Scholar 

  31. Li, R.-K., et al. Autologous porcine heart cell transplantation improved heart function after a myocardial infarction. J. Thorac. Cardiovasc. Surg. 119(1):62–68, 2000.

    Google Scholar 

  32. Lurz, P., et al. Early experience of the trialign system for catheter-based treatment of severe tricuspid regurgitation. Eur. Heart J. 37(47):3543–3543, 2016.

    Google Scholar 

  33. Madukauwa-David, I. D., et al. Suture dehiscence and collagen content in the human mitral and tricuspid annuli. Biomech. Model. Mechanobiol. 8(2):291–299, 2018.

    Google Scholar 

  34. Madukauwa-David, I. D., et al. Suture dehiscence and collagen content in the human mitral and tricuspid annuli. Biomech. Model. Mechanobiol. 18(2):291–299, 2019.

    Google Scholar 

  35. Malinowski, M., et al. Tricuspid annular geometry and strain after suture annuloplasty in acute ovine right Heart failure. Ann. Thorac. Surg. 106(6):1804–1811, 2018.

    Google Scholar 

  36. Malinowski, M., et al. Impact of tricuspid annular size reduction on right ventricular function, geometry and strain. Eur. J. Cardio-Thorac. Surg. 2019. https://doi.org/10.1093/ejcts/ezy484.

    Article  Google Scholar 

  37. Malinowski, M., et al. Sonomicrometry-derived 3-dimensional geometry of the human tricuspid annulus. J. Thorac. Cardiovasc. Surg. 157(4):1452–1461, 2019.

    Google Scholar 

  38. Marciniak, A., K. Glover, and R. Sharma. Cohort profile: prevalence of valvular heart disease in community patients with suspected heart failure in UK. BMJ open 7(1):e012240, 2017.

    Google Scholar 

  39. McCarthy, P. M., et al. Tricuspid valve repair: durability and risk factors for failure. The Journal of Thoracic and Cardiovascular Surgery 127(3):674–685, 2004.

    Google Scholar 

  40. Nath, J., E. Foster, and P. A. Heidenreich. Impact of tricuspid regurgitation on long-term survival. J. Am. Coll. Cardiol. 43(3):405–409, 2004.

    Google Scholar 

  41. Nijenhuis, V., et al. The last frontier: transcatheter devices for percutaneous or minimally invasive treatment of chronic heart failure. Netherlands Heart J. 25(10):536–544, 2017.

    Google Scholar 

  42. Nishimura, R. A., et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 129(23):e521–643, 2014.

    Google Scholar 

  43. Nkomo, V. T., et al. Burden of valvular heart diseases: a population-based study. Lancet 368(9540):1005–1011, 2006.

    Google Scholar 

  44. Paul, D. M., et al. Suture dehiscence in the tricuspid annulus: an ex vivo analysis of tissue strength and composition. Ann. Thorac. Surg. 104(3):820–826, 2017.

    Google Scholar 

  45. Pierce, E. L., et al. How local annular force and collagen density govern mitral annuloplasty ring dehiscence risk. Ann. Thorac. Surg. 102(2):518–526, 2016.

    Google Scholar 

  46. Pokutta-Paskaleva, A., et al. Comparative mechanical, morphological, and microstructural characterization of porcine mitral and tricuspid leaflets and chordae tendineae. Acta Biomater. 85:241–252, 2019.

    Google Scholar 

  47. Rausch, M. K., et al. Engineering analysis of tricuspid annular dynamics in the beating ovine heart. Ann. Biomed. Eng. 46(3):443–451, 2018.

    Google Scholar 

  48. Rausch, M. K., et al. The effect of acute pulmonary hypertension on tricuspid annular height, strain, and curvature in sheep. Cardiovasc. Eng. Technol. 9(3):365–376, 2018.

    Google Scholar 

  49. Rodés-Cabau, J., et al. Transcatheter therapies for treating tricuspid regurgitation. Journal of the American College of Cardiology 67(15):1829–1845, 2016.

    Google Scholar 

  50. Schofer, J., et al. First-in-human transcatheter tricuspid valve repair in a patient with severely regurgitant tricuspid valve. J. Am. Coll. Cardiol. 65(12):1190–1195, 2015.

    Google Scholar 

  51. Singh, J. P., et al. Prevalence and clinical determinants of mitral, tricuspid, and aortic regurgitation (the Framingham Heart Study). Am. J. Cardiol. 83(6):897–902, 1999.

    Google Scholar 

  52. Spinner, E. M., et al. In vitro characterization of the mechanisms responsible for functional tricuspid regurgitation. Circulation 124(8):920–929, 2011.

    Google Scholar 

  53. Stuge, O., and J. Liddicoat. Emerging opportunities for cardiac surgeons within structural heart disease. J. Thorac. Cardiovasc. Surg. 132(6):1258–1261, 2006.

    Google Scholar 

  54. Stuge, O. and J. Liddicoat, Emerging opportunities for cardiac surgeons within structural heart disease. 2006, Mosby.

  55. Taramasso, M., et al. Percutaneous tricuspid valve therapies: the new frontier. European heart journal 38(9):639–647, 2017.

    Google Scholar 

  56. Ton-Nu, T.-T., et al. CLINICAL PERSPECTIVE. Circulation 114(2):143–149, 2006.

    Google Scholar 

  57. Tricuspid Regurgitation Global Strategic Market Assessmen, D. Consulting, Editor. 2016.

  58. Tritthart, H., et al. Effects of Ca-free and EDTA-containing Tyrode solution on transmembrane electrical activity and contraction in guinea pig papillary muscle. Pflügers Archiv 338(4):361–376, 1973.

    Google Scholar 

  59. Van de Veire, N. R., et al. Tricuspid annuloplasty prevents right ventricular dilatation and progression of tricuspid regurgitation in patients with tricuspid annular dilatation undergoing mitral valve repair. J. Thorac. Cardiovasc. Surg. 141(6):1431–1439, 2011.

    Google Scholar 

  60. Vismara, R., et al. Transcatheter edge-to-edge treatment of functional tricuspid regurgitation in an ex vivo pulsatile heart model. J. Am. Coll. Cardiol. 68(10):1024–1033, 2016.

    Google Scholar 

Download references

Acknowledgments

Fatiesa Sulejmani is also supported by the Georgia Institute of Technology-Emory University-Peking University Global Biomedical Engineering Research and Education Fellowship, as well as the Friends of Bobby Jones Fund from Emory University’s Laney Graduate School.

Conflict of interest

Dr. Wei Sun is a co-founder and serves as the Chief Scientific Advisor of Dura Biotech. He has received compensation and owns equity in the company. Fatiesa Sulejmani and Joshua Pataky declare that they have no conflict of interest.

Author information

Authors and Affiliations

  1. Tissue Mechanics Laboratory, The Wallace H. Coulter, Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, 206 Technology Enterprise Park, 387 Technology Circle, Atlanta, GA, 30313-2412, USA

    Fatiesa Sulejmani, Joshua Pataky & Wei Sun

Authors
  1. Fatiesa Sulejmani
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Joshua Pataky
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Wei Sun
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Wei Sun.

Additional information

Associate Editor Changfu Wu oversaw the review of this article.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Sulejmani, F., Pataky, J. & Sun, W. Mechanical and Structural Evaluation of Tricuspid Bicuspidization in a Porcine Model. Cardiovasc Eng Tech 11, 522–531 (2020). https://doi.org/10.1007/s13239-020-00480-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s13239-020-00480-0

Keywords

Search

Navigation