PMC:7239603 / 4613-12699 JSONTXT

{"target":"https://pubannotation.org/docs/sourcedb/PMC/sourceid/7239603","sourcedb":"PMC","sourceid":"7239603","source_url":"https://www.ncbi.nlm.nih.gov/pmc/7239603","text":"MATERIALS AND METHODS\nTen female 80 kg pigs (Mixed Duroc and Landrace–Yorkshire) comprised the study material. One could not be weaned from extracorporeal circulation (ECC), resulting in 9 datasets available for analysis. The following 2 surgical groups were compared: single subvalvular annuloplasty ring versus double sub- and supravalvular annuloplasty ring. To minimize biological heterogenicity, both procedures were tested on the same animal, thus each animal acted as their own control. The study complied with Danish guidelines for animal research and was approved by the Danish Inspectorate of Animal Experimentation, no. 2013-15-2934-00915.\n\nForce measurements\nTwo dedicated force transducers with 3 measuring arms were inserted; 1 in the aortic annulus and 1 at the STJ. At the aortic annulus, the force transducer was implanted intraluminally with each arm located upstream of the leaflet commissures in the interleaflet triangle, as previously described [13, 14]. At the STJ, the force transducer was implanted externally on the aortic root, with the arms located downstream of the STJ (Fig. 1A). The force transducers measured radial forces in 3 individual segments corresponding to the 3 interleaflet triangles at the aortic annulus and the STJ, i.e. the left/right-coronary (LR), right/non-coronary (RN) and left/non-coronary (LN) segment at each level. The transducer comprised a basal ring and 3 equidistantly placed vertical arms with a diameter of 20 and 19 mm, respectively. On each arm, 2 strain gauges formed a Wheatstone half-bridge. The force transducers measured strain corresponding to radial compression and distension at each level. Prior to each experiment, the force transducers were calibrated to convert strain into calibrated forces. These forces described the segmental radial stress distribution at each level.\nFigure 1: Schematic illustration of the implanted force transducers, sonomicrometry crystals and annuloplasty procedures. (A) The 2 force transducers with 3 measuring arms placed internally at the aortic annulus and externally at the sinotubular junction. (B) The aortic root with the positioning of the 12 sonomicrometry crystals. (C) Single subvalvular ring annuloplasty at the aortic annulus. (D) Double sub- and supravalvular ring annuloplasty at the aortic annulus and sinotubular junction. Modified from Benhassen et al. [15].\n\nGeometrical measurements\nFor geometrical assessment, we implanted 2-mm sonomicrometry crystals (Sonometrics Corp., London, ON, Canada): 6 at the aortic annulus and 6 at the STJ (Fig. 1B). The crystals were placed with 1 crystal at each nadir and 1 crystal at each commissure, at the respective level (Fig. 2). The sonomicrometry method has been validated and described in detail in earlier porcine studies [14–17].\nFigure 2: Schematic illustration of the position of the sonomicrometry crystals at the 2 levels of the aortic root. Left: aortic annulus; Right: sinotubular junction. LC: left coronary sinus; NC: non-coronary sinus; RC: right coronary sinus. Modified from Benhassen et al. [15].\n\nSurgical protocol\nTransportation, medication and handling of the animals have previously been described [15, 18]. After sternotomy, corporal circulation and cardioplegic arrest, the aortic valve was exposed through a transverse aortotomy 2 cm downstream of the STJ.\nThe annular annuloplasty was sized to obtain a mild to moderate downsizing of the aortic annulus diameter of 10–15% in systole, which corresponded to a 22-mm Dacron ring [15], and a 20-mm Dacron ring at the STJ was used to complete the double-ring procedure. A standardized approach was used for the 2 annuloplasty procedures (Fig. 1C and D). For the single-ring procedure, an open ring of Dacron tube graft with a height of 4 mm and a diameter of 22 mm was used. The Dacron ring was anchored with 6 U-stitches around the aortic annulus to fasten the ring in the subvalvular position as described by Lansac et al. [19]. Due to the close proximity of the left coronary artery to the myocardium in the pig, it was not possible to position the ring under the left main coronary artery. The ring was opened and anchored closely at each side of the left coronary artery with U-stitches. For the double-ring procedure, we used an additional Dacron ring at the STJ, with a height of 4 mm and a diameter of 20 mm [3]. The Dacron ring was secured with 3 U-stitches above each sinus, and was closed by one of the anchoring U-sutures, to ensure that the ring was circumferential. The aorta was closed using running 4–0 Prolene® sutures. Mikro-Tip pressure catheters (SPR-350, Millar Instruments, Houston, TX, USA) were placed in the left ventricle through the apex and the ascending aorta through the aortotomy. After reperfusion, weaning off ECC and haemodynamic stabilization, data collection was performed for 20 s, with the acquisition of simultaneous pressure, force and electrocardiogram (ECG) data for both groups. Hereafter, the force transducers were released and removed to acquire simultaneous pressure, geometrical and ECG data without influence from the transducers for both groups. See the flowchart of the experimental protocol in Fig. 3. Two-dimensional echocardiography (Vivid I, GE Vingmed Ultrasound AS, Horten, Norway) was performed to verify valve competence at baseline, and after single- and double-ring implantation. The animals were euthanized with an overdose of pentobarbital. The heart was excised and the position of the sonomicrometry crystals and annuloplasties were verified. All animals were operated under standardized conditions by the same surgeon.\nFigure 3: Flowchart of the surgical and experimental protocol with data recordings. STJ: sinotubular junction.\n\nData acquisition and data analysis\nThe time derivative of left ventricular pressure (LV dP/dt) was used for synchronization between the analogue and sonomicrometry signals. The time points were defined as follows:\nMid-systole (MS): time point between LV dP/dt maximum and minimum.\nMid-diastole (MD): time point between LV dP/dt minimum and maximum.\nMinimum (Min) and maximum (Max): amplitude minimum and maximum with respect to each single parameter reported.\nForce measurements were reported from MD to MS (MS–MD). Geometrical values were reported from minimum to maximum (Max–Min). Expansibility was calculated as the change in area from Min to Max divided by the Min area. Three segmental distances corresponding to the segmental force measurements were used for analysis, i.e. the length of the LN, the RN and the LR for both the annular level and the STJ level. For analysis of the shape of the aortic annulus and STJ, 3 anatomical cross-sectional diameters were calculated, that corresponded to the sinus-commissure diameter for each segment throughout the cardiac cycle, i.e. the distance from the non-coronary sinus to LR (NC–LR), right coronary sinus to LN and left coronary sinus to RN (Fig. 2). The difference between the smallest and largest cross-sectional diameter was calculated as a measure of the sphericity and reported at MS and MD. The definition by Tops et al. [20] was used, which defined the structure as oval if the difference between 2 cross-sectional diameters was \u003e3 mm.\n\nStatistical analysis\nAll data are presented as mean ± standard deviation from 10 consecutive heart cycles with a significance level of P-value \u003c0.05. The collected data were analysed by two-way repeated-measures analysis of variance (ANOVA) using group and repetitive heart cycles as factors. The model allowed for different residual variations in the groups. Residuals were inspected for normality by QQ-plots and residuals versus fitted values and no reason to refute was found. Groups were then compared using post hoc Wald z-tests. No corrections were performed for multiple testing. Heart rate was compared between groups using a paired t-test. The data were analysed using Stata 13.0 (StataCorp LLC, College Station, TX, USA), and the statistical models were performed with support from Biostatistical Advisory Service, University of Aarhus, 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