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Background We evaluated a novel formula using preoperative transesophageal echocardiographic measurements to determine neochordae length for repair of degenerative mitral regurgitation (MR). Methods The formula is based on measuring the distance from the adjacent papillary head to the intended coaptation zone of the flail/prolapsing leaflet segment and subtracting the redundant leaflet length. Between 2008 and 2017, 264 consecutive patients underwent mitral valve repair (82.2% endoscopic, minimally invasive approach and 17.8% sternotomy) with neochordae loop reconstruction (68.6% posterior, 6.4% anterior, and 25% bileaflet repair). Mean patient age was 63 ± 13.6 years, 73.5% were men, and mean left ventricular ejection fraction was 63.1% ± 6.7%. Results Mitral valve repair was successful in 100% of patients, with no patient requiring conversion to replacement. Neochordae length measurement was accurate in 259 patients (98%), with 4 patients requiring conversion to resection and 1 patient requiring longer anterior leaflet neochordae. Median anterior and posterior neochordae lengths were 27 mm (range, 18-32) and 17 mm (range, 9-27), respectively. Intraoperative transesophageal echocardiography demonstrated no or trace residual MR in 254 patients and mild residual MR in 10 patients. In-hospital mortality occurred in 1 patient, and complications included respiratory failure (2.7%) and renal failure (1.8%). At the median follow-up of 12.6 months (interquartile range, 11.1), 98.9% of patients remained free from ≥2+ MR, whereas freedom from reoperation was 100%. Conclusions Preoperative transesophageal echocardiographic measurements can accurately and reproducibly predict the required length of neochordae loop reconstruction for degenerative mitral valve repair with good results. Longer-term follow-up is necessary.

This chapter focuses on the surgical reconstruction of the aortic arch and highlights surgical indications and techniques for aneurysmal disease as well as in the setting of aortic dissection. Surgical approaches for both conventional hemiarch and total arch reconstruction as well as hybrid arch and Frozen Elephant trunk procedures are discussed here. Additionally, we describe our approach to the management of the difficult left subclavian artery in aortic arch surgery, a topic that is infrequently discussed within the literature but can pose a major challenge. Lastly, this chapter highlights the excellent surgical results published in larger studies to give the reader an idea of the expected outcomes from these complex and technically challenging operations.

© 2020 SPIE. Physical replicas of patient specific heart valve pathologies may improve clinicians' ability to plan the optimal treatment for patients with complex valvular heart disease. Our previous work has demonstrated the ability to replicate patient pathology of the adult mitral valve (MV) in a dynamic environment [13]. Infant congenital heart defects present possibly the most challenging form of valvular disease, given the range of pathologies, the relative size of these valves compared to adult anatomy, and the rarity of congenital heart disease. Patient specific valve models could be particularly valuable for pediatric cardiologists and surgeons, as a means to both plan for and practice interventions. Our current goal is to assess our ability to apply our workflow to the more challenging case of the tricuspid valve (TV) presented in cases of hypoplastic left heart syndrome (HLHS). We explore the feasibility of adapting our previous workflow for creating dynamic silicone MV models for pre-surgical planning and simulation training, to developing 3D echocardiogram derived, patient specific TV models for use in a physical heart simulator. These models are intended for characterization of the TV, and exploration of the relationship between specific anatomical features and tricuspid regurgitation (TR) severity. The simulations may be relevant to pre-surgical planning of repair of the particularly complex and unique anatomical pathologies presented in children with HLHS.

Mitral valve regurgitation is the most common valvular disease, affecting 10% of the population over 75 years old. Left untreated, patients with mitral valve regurgitation can suffer declining cardiac health until cardiac failure and death. Mitral valve repair is generally preferred over valve replacement. However, there is a direct correlation between the volume of cases performed and surgical outcomes, therefore there is a demand for the ability of surgeons to practice repairs on patient specific models in advance of surgery. This work demonstrates a semi-automated segmentation method to enable fast and accurate modelling of the mitral valve that captures patient-specific valve geometry. This modelling approach utilizes 3D active contours in a user-in-the-loop system which segments first the atrial blood pool, then the mitral leaflets. In a group of 15 mitral valve repair patients, valve segmentation and modelling attains an overall accuracy (mean absolute surface distance) of 1.40+-0.26 mm, and an accuracy of 1.01+-0.13 mm when only comparing the extracted leaflet surface proximal to the ultrasound probe. Thus this image-based segmentation tool has the potential to improve the workflow for extracting patient-specific mitral valve geometry for 3D modelling of the valve., Accepted for publication in Lecture Notes in Computer Science, Functional Imaging and Modelling of the Heart 2019

Medical imaging has advanced enormously over the last few decades, revolutionizing patient diagnostics and care. At the same time, additive manufacturing has emerged as a means of reproducing physical shapes and models previously not possible. In combination, they have given rise to 3-dimensional (3D) modeling, an entirely new technology for physicians. In an era in which 3D imaging has become a standard for aiding in the diagnosis and treatment of cardiac disease, this visualization now can be taken further by bringing the patient's anatomy into physical reality as a model. The authors describe the generalized process of creating a model of cardiac anatomy from patient images and their experience creating patient-specific dynamic mitral valve models. This involves a combination of image processing software and 3D printing technology. In this article, the complexity of 3D modeling is described and the decision-making process for cardiac anesthesiologists is summarized. The management of cardiac disease has been altered with the emergence of 3D echocardiography, and 3D modeling represents the next paradigm shift.