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Ann Thorac Surg 1995;59:658-662
© 1995 The Society of Thoracic Surgeons

Comparison of the Carpentier and Duran Prosthetic Rings Used in Mitral Reconstruction

Yukikatsu Okada, MD, Toyo Shomura, MD, Yasuko Yamaura, MD, Junichi Yoshikawa, MD

Departments of Thoracic and Cardiovascular Surgery, and Cardiology, Kobe General Hospital, Kobe, Japan

Accepted for publication November 14, 1994.


   Abstract
Top
 Footnotes
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
This clinical study was undertaken to evaluate the Duran flexible ring and the Carpentier rigid ring in terms of mitral annulus motion, transmitral flow and left ventricular function. Twenty-six patients (11 receiving rigid rings and 15, flexible rings) with normal sinus rhythm and with no or only trivial mitral valve regurgitation after surgical repair were selected. Angiograms demonstrated no significant differences in left ventricular systolic function between the two groups of patients. The area of the mitral annulus with the flexible ring significantly changed during the cardiac cycle. There were significant differences in the left ventricular fractional shortening (rigid ring, 35.8%; flexible ring, 43.4%) and in the peak velocity (rigid ring, 222 cm/s; flexible ring, 186 cm/s) at peak exercise. These data suggest that the flexible ring interferes less with the normal movements of the mitral annulus during the cardiac cycle, and that, under exercise conditions, it performs better than the rigid ring. We therefore conclude that mitral valve reconstruction using the Duran flexible ring is advantageous in patients with mitral regurgitation due to degenerative disease and sinus rhythm.


   Introduction
Top
 Footnotes
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 
See also page 662.

Prosthetic annuloplasty rings are currently used in mitral reconstruction. Although a variety of models are currently available, they all conform to two basic types: the rigid ring developed by Carpentier and associates [1], which restores the mitral annulus to its normal systolic size and shape, and the totally flexible ring described by Duran and Umbago [2, 3], which also reduces the annulus size but allows for it to continuously change during the cardiac cycle. In general the arguments for and against each type remain rather theoretical, and there is an obvious lack of objective data supporting either position. In an experimental study, van Rijk-Zwikker and co-workers [4] showed a larger effective mitral orifice with the Duran ring than with the Carpentier, but small differences in left ventricular pump function. David and associates [5], in a clinical study consisting of 25 patients with degenerative chronic mitral valve regurgitation undergoing repair with both types of rings, showed better systolic left ventricular function at 2 to 3 months after repair in those patients with a flexible ring. Doppler echocardiogram–based clinical comparisons [6, 7] have shown that both rings decrease the mitral valve area but without producing a clinically significant increase in the transvalvular gradients. In an attempt to further elucidate this issue, a clinical comparative study was undertaken to evaluate the possible differences between the two rings in terms of the mitral annulus size and motion, transmitral flow, and left ventricular function.


   Patients and Methods
Top
 Footnotes
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
Between June 1987 and December 1993, 107 patients underwent mitral valve repair at our institution. A Carpentier or Duran ring was implanted with interrupted sutures in 71% of them. For the purpose of this study, 26 patients were selected who met the following criteria: (1) they were operated on for chronic mitral regurgitation secondary to degenerative disease; (2) they had sinus rhythm postoperatively; (3) they had no or trivial residual regurgitation postoperatively; and (4) they underwent no other concomitant surgical procedure. Eleven patients received a Carpentier ring and 15, a Duran ring. The size of the rigid ring was selected according to the size of the anterior leaflet; the size of the flexible rings was based on the intertrigonal distance. The clinical and echocardiographic data for both groups of patients are given in Table 1Go. There were no significant differences between the groups, except in the size of the ring used.


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  		Table 1. . Clinical Characteristics of the 26 Patients Studieda
 
Postoperative contrast-enhanced left ventriculograms were obtained in all patients within 1 month of mitral valve repair. The left ventricular volumes were calculated using the standard area-to-length method (left ventricular end-diastolic and end-systolic volume index, both in milliliters per square meter). The left ventricular ejection fraction and stroke volume index (in milliliters per square meter) were also calculated. Left ventricular segmental wall motion was analyzed by the center-line method [8] using the Cardio 500 system (Kontron, Germany). Wall motion was measured along 100 chords constructed perpendicular to a center line drawn midway between the end-diastolic and end-systolic contours. The measured motion of the 100 chords was normalized for heart size by dividing it by the length of the end-diastolic perimeter. The left ventricular wall (right anterior oblique projection) was divided into ten segments and the segmental wall motion was expressed as the mean value of ten chords of normalized motion. Left ventricular segmental wall motion was then compared between the two groups of patients.

Continuous-wave Doppler and two-dimensional echocardiograms were obtained 6 months after repair to assess mitral diastolic flow and left ventricular function at rest and also during exercise on a bicycle ergometer with the patient in the supine position. Toshiba SSH 160A (Tokyo, Japan) and Aloka SSD870 (Tokyo, Japan) echo systems were used in these studies. Transmitral flow characteristics were defined in terms of the peak velocity and mean velocity, both rendered in centimeters per second. Fractional shortening was evaluated at rest and during exercise.

To evaluate the size and motion of the mitral annulus after ring implantation, the two-dimensional echocardiography [9] was performed in all patients at 9 months in those with the Duran ring and at 30 months in those with the Carpentier ring. The mitral annulus with the prosthetic ring was recorded from a view close to the standard apical four-chamber view. The transducer was rotated and recordings were made at 30-degree rotational intervals around the circumference of the mitral valve annulus. To reconstruct the annulus, diameters from each rotational interval were arranged around a reference point eight times during the cardiac cycle. The area of the mitral annulus with the prosthetic ring was then measured with a planimeter.

All data are presented as the mean ± standard deviation. Comparisons between the patients with a rigid ring and those with a flexible ring were done using the Mann-Whitney U test for grouped data. The difference was considered significant at a p level of less than 0.05.


   Results
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 Footnotes
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
As shown in Table 2Go, the left ventricular end-diastolic volume index was, on average, 7% less in the patients with the rigid ring, but this difference was not statistically significant. Although the stroke index and left ventricular ejection fraction in those with the flexible ring were greater than those in the patients with the rigid ring, these differences also were not statistically significant.


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  		Table 2. . Left Ventricular Function Using Area Length Methoda
 
There was no significant difference between the two groups in the length of the center line (rigid ring, 17.5 ± 1.6 cm; flexible ring, 17.8 ± 1.6 cm). Normalized motion with the flexible ring was greater from segments 5 to 10, but this difference was not statistically significant except for segment 10 (Fig 1Go).



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  		Fig 1. . Left ventriculograms in right anterior oblique projection were used for this analysis. Left ventricular wall was divided into ten segments, and each segmental wall motion is presented as normalized motion. There is a significant difference in segment 10. (NS = not significant.)

 
Two-dimensional echocardiography demonstrated that the area of the mitral annulus with the rigid ring did not change significantly during the cardiac cycle. By contrast, the area of the mitral annulus with the flexible ring did change during the cardiac cycle (Fig 2Go). The area reconstructed coincidental with the P wave was maximal, followed by presystolic and systolic narrowing to the minimal size at midsystole. The maximum area achieved with the size 29 flexible ring corresponded to the area achieved with the size 32 rigid ring. The minimal area of the size 29 flexible ring at midsystole was smaller than that of the size 30 rigid ring. In other words, the size 29 flexible ring functioned similarly to a size 32 rigid ring at diastole and a size 30 rigid ring at systole. The posterior mitral annulus with the flexible ring contracted and moved anteriorly (Fig 3Go). The percentage reduction in the area of the flexible ring during the cardiac cycle was 26% ± 4% (Fig 4Go). This change is similar to that noted for the annulus of normal subjects [9].



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  		Fig 2. . Area of the mitral annulus with the Carpentier rigid ring does not change during the cardiac cycle, but the area of the mitral annulus with the Duran flexible ring changes similar to that occurring in normal subjects.

 


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  		Fig 3. . Reconstructed mitral annulus with a Duran flexible ring. The solid line represents the minimum area and the dashed line demonstrates the maximum area.

 


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  		Fig 4. . Area of the mitral annulus with the flexible ring changes significantly during the cardiac cycle. Percentage reduction in the size of the mitral annulus area with the flexible ring is, on average, 26% ± 4% of the maximum area at P wave. (NS = not significant; T = time; *p < 0.05.)

 
Supine exercise significantly increased heart rate and systolic blood pressure in both groups (Fig 5Go). Exercise workloads were 41.7 ± 20.4 watts in the patients with the rigid ring and 52.9 ± 15.0 watts in the patients with the flexible ring (p = not significant). There were no significant differences in heart rate and systolic pressure between the two groups either at rest or during peak exercise. Figure 6Go demonstrates the changes in the fractional shortening, peak velocity, and mean velocity across the mitral valve at rest and during peak exercise. At rest, there were no significant differences between the two groups in the left ventricular fractional shortening (rigid ring, 36.2% ± 9.2%; flexible ring, 37.1% ± 9.4%), peak velocity (rigid ring, 131 ± 12 cm/s; flexible ring, 128 ± 12 cm/s), and mean velocity (rigid ring, 91 ± 23 cm/s; flexible ring, 70 ± 20 cm/s). During exercise, fractional shortening in the patients with the flexible ring increased significantly, whereas it did not change significantly in the patients with the rigid ring. Both the peak velocity and mean velocity of transmitral flow increased significantly with exercise. During exercise, there was a significant difference in the peak velocity between the two groups, as shown in Figure 6Go (p < 0.05).



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  		Fig 5. . Supine exercise significantly increased the heart rate and systolic blood pressure in both groups. There are no significant differences in either variable at rest or during peak exercise. (BPM = beats/min; NS = not significant.)

 


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  		Fig 6. . There is a significant difference in fractional shortening during peak exercise between the two groups (rigid ring, 35.8%; flexible ring, 43.4%). The peak velocity in the patients with the flexible ring is significantly slower than that in the patients with a rigid ring (rigid ring, 222 cm/s; flexible ring, 186 cm/s). (NS = not significant.)

 

   Comment
Top
 Footnotes
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
Our present data demonstrate that the Duran ring interferes less with the normal movements of the mitral annulus during the cardiac cycle. Based on the annular area, the size 29 flexible ring functions like a size 32 rigid ring at diastole and a size 30 rigid ring at systole. In our clinical cases, the mean systolic reduction rate of the mitral annulus area with the Duran ring was approximately 26%, but the actual area of the mitral annulus with the flexible ring was understandably smaller than that of normal subjects. Recently van Rijk-Zwikker and colleagues [4] demonstrated using cinefluoroscopy that the end-systolic area of the porcine mitral annulus with a Duran ring was, on average, 86.3% of the diastolic area. This ratio dropped to 66.7% after stimulation with inotropic agents. Using two-dimensional echocardiography, Ormiston and colleagues [9] found that the mean reduction in the mitral annulus area from diastole to systole in normal subjects was 26%; they also discovered that the motion pattern was similar to that noted in experimental studies on dogs. Because our echocardiographic studies were done within 30 months after operation, further clinical assessment is needed to confirm continued flexibility of the Duran ring at late follow-up, when intimal coverage may be more extensive.

The peak and mean velocity of diastolic flow across the mitral valve with the two types of ring are not different from those reported by Unger-Graeber and associates [6]. We demonstrated that there was a significant difference in peak velocity across the mitral valve between the two groups during exercise. Rassi and colleagues [10] noticed that the exercise-induced increase in mitral volume flow was mainly due to an increase in the maximum diastolic valve orifice. Our results suggest that a mitral valve repaired with a flexible ring has a larger effective orifice during exercise than does a mitral valve with a rigid ring.

The effect of rigid ring fixation of the mitral annulus on left ventricular function has been discussed for a long time. Findings from an experimental study conducted by Tsakiris and associates [11] suggested that rigid fixation of the mitral annulus does not have a harmful effect on the left ventricle. Spence and associates [12] compared the respective effects of rigid and flexible mitral rings in isolated porcine hearts, and found that fixation of the mitral annulus with a rigid prosthesis was detrimental to systolic function of the left ventricle. van Rijk-Zwikker and associates [4] demonstrated that the effect of rigid support of the annulus could be described as a reduction in pump function caused by impaired filling of the left ventricle, which limits stroke volume, particularly when cardiac output is high. Castro and associates [13] recently reported that annuloplasty with a flexible or rigid ring did not alter left ventricular systolic performance in conscious, closed-chest dogs. There are two clinical reports concerning the effect of the type of ring on left ventricular function. In 1976, Duran and Ubago [3] demonstrated that there was no statistically significant difference in left ventricular function between the two types of ring, although there was a significant difference in the systolic shortening of the basal segments of the left ventricle measured by angiography. David and associates [5] reported that the patients with a flexible annuloplasty ring had better left ventricular systolic function than did patients with a rigid annuloplasty ring 2 to 3 months after mitral valve reconstruction for chronic mitral regurgitation secondary to degenerative disease. Although there is no statistically significant difference in the left ventricular pump function, the present data show a larger end-diastolic volume, smaller end-systolic volume, and better left ventricular ejection fraction in the patients with the flexible ring. The diastolic filling across the mitral valve and left ventricular fractional shortening during exercise were significantly superior in the patients with the flexible ring. Left ventricular pump function with the rigid ring is affected not only by impairment of the stretching and shortening actions of the basal part of the left ventricle, but by the diastolic filling of the left ventricle.

Our present data suggest that mitral repair with a flexible ring produces results superior to those associated with use of a rigid ring in patients with degenerative mitral regurgitation who are in sinus rhythm.


   Footnotes
Top
 Footnotes
Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 
Address reprint requests to Dr Okada, Department of Thoracic and Cardiovascular Surgery, Kobe General Hospital, 4-6 Minatojimanakamachi Chuou-ku kobe, Japan, 650


   References
Top
 Footnotes
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

  1. Carpentier A, Deloche A, Dauptain J, et al. A new reconstructive operation for correction of mitral and tricuspid insufficiency. J Thorac Cardiovasc Surg 1971;61:1–13.[Medline]
  2. Duran CMG, Ubago JL. Clinical and hemodynamic performance of a totally flexible prosthetic ring for atrioventricular valve reconstruction. Ann Thorac Surg 1976;22:458–63.[Abstract]
  3. Duran CMG, Ubago JL. Conservative mitral valve surgery: problems and developments in the technique of prosthetic ring annuloplasty. In: Kalmanson D, ed. The mitral valve: a pluridisciplinary approach. Acton, MA: Publishing Science Group, 1976:549–77.
  4. Van Rijk-Zwikker GL, Mast F, Schipperheyn JJ, Huysmans HA, Bruschke AVG. Comparison of rigid and flexible rings for annuloplasty of the porcine mitral valve. Circulation 1990;82(suppl IV):58–64.
  5. David TE, Komeda M, Pollick C, Burns RJ. Mitral valve annuloplasty: the effect of the type on left ventricular function. Ann Thorac Surg 1989;47:524–8.[Abstract]
  6. Unger-Graeber B, Lee RT, Sutton MSJ, Plappert M, Collins JJ, Cohn LH. Doppler echocardiographic comparison of the Carpentier and Duran annuloplasty rings versus no ring after mitral valve repair for mitral regurgitation. Am J Cardiol 1991;67:517–9.[Medline]
  7. Kenny J, Cohn L, Shemin R, Collins JJ, Plappert M, Sutton MSJ. Doppler echocardiographic evaluation of ring mitral valvuloplasty for pure mitral regurgitation. Am J Cardiol 1987;59:341–5.[Medline]
  8. Sheehan FH, Bolson E, Dodge HT, Mathey DG, Schofer J, Woo HW. Advantages and applications of the centerline method for characterizing regional ventricular function. Circulation 1986;74:293–305.[Abstract/Free Full Text]
  9. Ormiston JA, Shah PM, Tei C, Wong M. Size and motion of the mitral valve annulus in man: I. A two-dimensional echocardiographic method and findings in normal subjects. Circulation 1981;64:113–20.[Abstract/Free Full Text]
  10. Rassi A Jr, Crawford MH, Richards KL, Miller JF. Differing mechanisms of exercise flow augmentation at the mitral and aortic valves. Circulation 1988;77:543–51.[Abstract/Free Full Text]
  11. Tsakiris AG, Rastelli GC, Banchero N, Wood EH, Kirklin JW. Fixation of the annulus of the mitral valve with a rigid ring: hemodynamic studies. Am J Cardiol 1967;20:812–9.[Medline]
  12. Spence PA, Peniston CM, David TE, et al. Toward a better understanding of the etiology of left ventricular dysfunction after mitral valve replacement: an experimental study with possible clinical implications. J Thorac Cardiovasc Surg 1986;41:363–71.
  13. Castro LJ, Moon MR, Rayhill SC, et al. Annuloplasty with flexible or rigid ring does not alter left ventricular systolic performance, energetics, or ventricular-arterial coupling in conscious, closed-chest dogs. J Thorac Cardiovasc Surg 1993;105:643–59.[Abstract]

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