Ann Thorac Surg 2008;86:1478-1479. doi:10.1016/j.athoracsur.2008.08.022
© 2008 The Society of Thoracic Surgeons
Original Articles: Adult Cardiac
Invited Commentary
James I. Fann, MD
Department of Cardiothoracic Surgery, Stanford University and VA Palo Alto HCS, Falk Cardiovascular Research Center, 300 Pasteur Dr, Stanford, CA 94305-5247
(Email: jfann{at}stanford.edu).
With advances in cardiac imaging modalities, such as multi-detector computed tomography, magnetic resonance with parallel imaging, and three-dimensional (3-D) transesophageal echocardiography (TEE), the possibility arises for more comprehensive understanding and insights regarding congenital and acquired heart diseases, surgical planning, and development and deployment of novel therapeutic technologies. Current echocardiography with Doppler accurately assesses valvular lesions, pressure gradients, intracardiac pressures, regurgitant volumes, and chamber volumes. In this study, Ender and colleagues demonstrated good correlation between annuloplasty sizing using virtual templates from augmented reality enhanced 3-D TEE superimposed on the preoperative reconstructions and sizing under direct vision in patients undergoing mitral valve repair [1].
Predicting annuloplasty sizing is predicated on numerous factors, one of which is the impact of the mechanism of mitral regurgitation on the underlying mathematical assumptions; for instance, in functional mitral regurgitation, as opposed to a degenerative cause, the surgeon may choose an undersized ring to optimize leaflet coaptation. Given the less quantifiable intraoperative assessment and judgment, it may be difficult to consistently correlate mathematical and visual approximation. Because of the dynamics and three-dimensional aspect of the annulus (ie, its saddle shape) and the two-dimensional aspect of many annuloplasty rings, certain geometrical assumptions need to be appropriately modified. Therefore, preoperative planning, including defining the type and extent of the proposed repair, will likely increase the predictive accuracy of virtual ring selection. Nonetheless, collaboration among the echocardiographers and surgeons in this study has resulted in the development of an important imaging modality with relevant mathematical constructs.
Although they focused on annular sizing, Ender and colleagues recognize the potential value of cardiac imaging in defining complex mitral valvular patho-anatomy and the surgical implications [1]. Current conventional and 3-D echocardiography provides the clinician with information regarding segmental valvular anatomy and likelihood of surgical repair, annular remodeling after annuloplasty, and efficacy of percutaneously implanted devices. In the future, advanced imaging can establish the basis for preoperative simulation of various repair techniques to better predict postoperative and long-term outcomes. With sophisticated software, one will be able to manipulate in a virtual fashion the valvular components to effect the optimal repair. In the arena of less invasive and percutaneous devices, the role of 3-D TEE has become more prominent in the design and development of new therapeutic technologies. In addition, clinically pertinent information generated from imaging provides an obvious and valuable educational opportunity for students, residents, and fellows.
Thus, Ender and colleagues [1] are to be congratulated for extending the diagnostic capabilities of 3-D TEE in the surgical realm and for assessing its impact in mitral annuloplasty sizing. Continued software development and multidisciplinary collaboration will result in greater understanding of and appreciation for the complexities of the mitral valve and improved treatment of its disorders.
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References
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- Ender J, Kon
ar-Zeh J, Mukherjee C, et al. Value of augmented reality-enhanced transesophageal echocardiography (TEE) for determining optimal annuloplasty ring size during mitral valve repair Ann Thorac Surg 2008;86:1473-1479.[Abstract/Free Full Text]
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Value of Augmented Reality-Enhanced Transesophageal Echocardiography (TEE) for Determining Optimal Annuloplasty Ring Size During Mitral Valve Repair
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Ann. Thorac. Surg. 2008 86: 1473-1478.
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