ARTICLE IN PRESS

Journal of Biomechanics 38 (2005) 2460–2471

www.elsevier.com/locate/jbiomech
www.JBiomech.com

Structural effects of an innovative surgical technique to

repair heart valve defects
F. Dal Pana, G. Donzellaa,, C. Fuccib, M. Schreibera
a
Dipartimento di Ingegneria Meccanica– Università di Brescia,Via Branze 38, 25123, Brescia, Italy
b
Divisione di Cardiochirurgia– Ospedale Civile di Brescia, Brescia, Italy
Accepted 7 October 2004

Abstract

The structural and functional effects of the ‘‘edge-to-edge’’ technique on the human mitral valve have been investigated, paying
particular attention to the diastolic phase. An advanced finite element model of the valve has been developed, using a hyperelastic
material schematization, suitable geometry and constraint conditions, and an effective fluidodynamic analysis. The edge-to-edge
suture has been applied on this model and the diastolic phase has been simulated. The results of this calculation show that the
operation increases the transvalvular pressure and the maximum stress in the leaflets, which reaches a level similar to that of the
systolic phase. The influence of suture position and extension, and the mitral annulus dimension has also been investigated. The
results indicate that a lateral location of the stitch is better than a central one, both regarding valve functionality (pressure level and
mobility) and internal stresses level, that a longer suture worsens the valve functionality but reduces the stresses level, finally, that the
dilatation of the mitral annulus does not affect the valve functionality but increases the stresses level.
r 2004 Elsevier Ltd. All rights reserved.

Keywords: Heart valve; Heart valve suture; Finite elements; Hyperelasticity

1. Introduction composed by four principal elements: mitral annulus,

The human heart can be thought as a four-chamber
pump which propels blood throughout the body. The
left atrium and ventricle act to circulate blood toward all
the parts of the body to bring oxygen and steal carbonic
anhydride. The heart operates in a cyclic mode
alternating between periods of contraction (systole),
which produces the pumping action, and relaxation
(diastole), which allows for filling of the heart. Blood
flow within the heart is controlled by cardiac valves,
which prevent backflow within the heart chambers
(Fig. 1a).
The mitral valve (MV) is located between the left
atrium and the left ventricle. Its complex apparatus is
Corresponding author. Tel.: +39 030 3715553;
fax: +39 030 3702448.
E-mail address: donzella@ing.unibs.it (G. Donzella).
leaflets (anterior and posterior), chordae tendineae, and
papillary muscles (Fig. 1b). During the cardiac cycle,
when the intraventricular pressure rises (systole), the
free edges of the leaflets firmly close sealing the orifice,
while the annulus decreases its circumferential size. The
shortening of the ventricle is accompanied by the
contraction of the papillary muscles so that an appro-
priate force is applied to the chordae tendineae,
preventing the eversion of the leaflets toward the atrium.
In diastole the valve opens when the ventricular diastolic
pressure falls below the atrial pressure: the leaflets are
passively pushed in the ventricle allowing the blood
flow.
MV prolapse is a typical disease of the MV apparatus,
due to an abnormal elongation of the chordae tendineae
and responsible for mitral regurgitation.
Since 1991, Alfieri and co-workers developed an
innovative surgical procedure to correct MV prolapse,

0021-9290/$ - see front matter r 2004 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jbiomech.2004.10.005
 ARTICLE IN PRESS
F. Dal Pan et al. / Journal of Biomechanics 38 (2005) 2460–2471
Fig. 1. (a) Blood flow scheme through the left human heart and (b) Mitral apparatus.
the edge-to-edge (E-to-E) technique, which restores
valvular competence by anchoring the free edge of the
prolapsing leaflet to the corresponding free edge of the
opposing leaflet (Alfieri et al., 2001; Fucci et al., 1995).
When the prolapse is in the middle portion of a leaflet,
the correction creates a double orifice valve, while in
case of commissural lesions, the correction results in a
single orifice valve with a smaller area. This technique is
simpler than traditional surgical solutions, and it can be
carried out in a shorter period of time, with mid- and
early-term results comparable with those obtained by
other techniques (Fig. 2) (Maisano et al., 2000, 1998).
The effects of E-to-E on MV functionality and on the
stresses generated near the stitch is not, however, clear:
it is therefore very important to understand if they are
acceptable for every surgical configuration.
This is possible only with a detailed structural
analysis, able to simulate the behaviour of a MV
subjected to E-to-E. Several studies have been carried
out in the past to perform the structural analysis of the
MV, both by analytical and finite elements methods
(FEM).
Ghista and Rao (1972a, b) idealised the valve leaflets
as two semi-circular membranes, supposed of a linear-
elastic material, obtaining the following expression for
the maximum stress in the leaflets:
sffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
3 Eq20 a2 S n
s¼ ; (1)
p2 h2 ð1  nÞ
where E is the Young modulus, q0 the pressure applied
to the valve, a the leaflet radius, Sn a numerical series
getting the value of about 0.3279, h the thickness of the
membrane, n the Poisson ratio.
2461
Arts et al. (1983) schematised the leaflets as three-
dimensional (3-D) shells, supposing again a linear-
elastic material behaviour, thus obtaining the following
relationship for the membranal stress sustained by the
valve
 
A0
sX0:5 p ; (2)
c0 h tv
where s is the radial stress in the leaflets, A0 the orifice
area, c0 the orifice circumference, h the thickness of the
membrane, and ptv the transvalvular pressure.
Miller and Marcotte (1987) and Miller et al. (1981)
furnished a very simple model in which the leaflets are
idealised as thin cylindrical shells
T ¼ 666 ðTPÞ ðANLÞ=HL; (3)
where T (dyne/cm) is the circumferential tension in the
cylindrical leaflets, TP (mmHg) is the transvalvular
pressure, ANL (cm) the annulus diameter, and HL (cm)
is the leaflet thickness.
More complex analyses have been carried out by
using FEM models: they were in particular devoted to
solve some controversies such as the risk of late
degeneration and mitral stenosis.
Kunzelman et al. (1993) developed a 3-D finite
element model: they made a symmetry assumption in
order to analyse only an half of the apparatus, using a
linear-elastic material schematisation, defined by the
post-transition Young modulus. Only the systolic phase
of cardiac cycle was analised, observing peak stresses
near the fibrous trigone area and the leaflet mid-line.
Votta et al. (2002) used another FEM model to
simulate the systolic phase, the diastolic phase and the
E-to-E repair with central suture of 4 or 8 mm. Their
 ARTICLE IN PRESS
2462 F. Dal Pan et al. / Journal of Biomechanics 38 (2005) 2460–2471

Fig. 2. The E-to-E repair in its two typical configurations: (a) double orifice valve and (b) single orifice valve (para-commissural configuration).

assumptions were again a linear-elastic material beha-

viour, a circular annular shape and predetermined
systolic and diastolic pressure. The systolic results of
this model are consistent with Kunzelman’s work, while
diastolic stress were negligible in the native MV; after
E-to-E repair the stresses were lower, but comparable
with those observed at the systolic peak.
Because of the complexity of the problem, the
limitations of the above described models can result in
a poor simulation of the real behaviour of the working
valve and, in particular, in a too rough estimation of the
stress state induced by the E-to-E repair. It is therefore
very important to develop a more advanced model,
taking into account more precisely the actual valve in
terms of geometry and constraint conditions, fluidody-
namic response and, above all, hyperelastic behaviour of
the material. Fig. 3. Assumed mitral annulus shape and dimensions (mm).

2. FEM models of the MV tendineae. It is therefore useful to evaluate the

Three FEM MV models of increasing complexity
have been developed. They present the same geometry,
but differ in material properties and boundary condi-
tions, in order to appreciate the different precision levels
reached by removing some simplifying hypotheses.
effectiveness of the equivalent boundary conditions
introduced to simulate the chordae tendineae in the
first two models.
All the numerical analyses were carried out by means
of ABAQUS/Standard code, Version 6.3.

 The first model (E model, i.e. elastic model) considers
a linear-elastic material behaviour and it is therefore
useful to compare the present results with those
obtained from the pre-existent linear-elastic models.
The constraint introduced by the chordae tendineae is
obtained by an ‘‘equivalent’’ boundary condition
described in the following.
 The second model (H model, i.e. hyperelastic model)
considers a non-linear hyperelastic material behaviour
and presents the same boundary conditions used in
the E model to represent the effect of the chordae
tendineae.
 The third model (FH model, i.e. full hyperelastic
model) considers a non-linear hyperelastic material
behaviour together with a modelling of the chordae
2.1. Geometry and mesh
The mitral annulus geometry assumed for the
analyses is shown in Fig. 3. It has been taken as
representative for the human heart on the basis of
medical literature (Brock, 1952; Chiechi et al., 1956; du
Plessis and Marchand, 1964; Ormiston et al., 1981;
Roberts, 1983; Rusted et al., 1952; Silverman and Hurst,
1968) and direct observations. In particular, the annulus
perimeter is 81.6 mm and the enclosed area is 492 mm2.
In Fig. 4a the 3-D geometry and the mesh of the valve
model are shown. In the undeformed configuration the
valve is almost closed. Its height is 8.7 mm, the anterior
leaflet middle section length is 16.8 mm, while the
posterior is 10.0 mm. The mesh is composed of four
 ARTICLE IN PRESS
F. Dal Pan et al. / Journal of Biomechanics 38 (2005) 2460–2471 2463

Fig. 4. Finite elements models of the MV: (a) FH model, with inextensible chordae tendineae and (b) E and H models, with boundary conditions
simulating the chordae tendineae: all the leaflets free-edge points are constrained to move on a plane inclined 26.51 with respect to the annulus plane.

nodes reduced-integration shell elements with hourglass 0.28

control and finite membranal strain. This ‘‘first-order’’ 0.24
element is recommended in presence of large strain
Nominal stress (MPa)

gradients and when contact problems are involved
(Abaqus technical note (2003)). In particular, 2478
elements were employed for the anterior leaflet, 1882 for
the posterior one. A convergence analysis was carried
out to choose this mesh density: several models with
different mesh densities were examined for this aim,
stopping the process when a difference less than 3% in
the maximum stress was found by a further mesh
refinement.
2.2. Material properties
The characterisation of MV material is very complex,
due to the difficulty in obtaining and testing samples of
regular shape. The data available in the literature are
therefore very poor, variable and sometimes referring to
specific pathologies.
Anyway, it has been verified (Barber et al., 2001;
Clark, 1973; Ghista and Rao, 1972a, b; Kunzelman and
Cochran, 1991; Lim and Boughner, 1974) that the
material of the MV presents a non-linear stress–strain
curve typical of many biological tissues, as reported with
cross symbols in Fig. 5. The initial part of the diagram
(pre-transition segment) is characterised by a small slope
(i.e. a low ‘‘tangent modulus’’), indicating a low material
rigidity. After an intermediate zone, in which the slope
begins to increase, the stress–strain curve appears very
steep in the final part of the diagram (post-transition
segment), thus indicating a high material rigidity.
Moreover, when the load is removed, the material
returns in the undeformed condition.
This kind of behaviour, also typical of rubbers, can be
well described by a hyperelastic schematisation, which
has been adopted in the H and FH models. Really, the
Experimental
0.2 Reduced-polynomial
0.16
0.12
0.08
0.04
0
0 0.04 0.08 0.12 0.16 0.2 0.24 0.28
Nominal strain
Fig. 5. Experimental leaflets material stress–strain curve and corre-
spondent reduced-polynomial strain energy potential schematisation
used in H and FH models.
experimental data shown in Fig. 5 refer to the loading
curve. Considering also the unloading, a very small
hysteresis is present, which has been neglected in the
hyperelastic schematisation.
For this aim, the most comprehensive experimental
data found in literature, those obtained by Barber
(Barber et al., 2001) by tensile tests on MV tissue, have
been at first elaborated in terms of nominal stress–strain
curve, as shown with cross symbols in Fig. 5.
The hyperelastic material behaviour has been then
described in terms of a strain energy potential U, which
defines the strain energy stored per unit of a reference
volume. Assuming isotropy, the strain energy potential
can be formulated as a function of the strain invariants
and, taking the derivative of U with respect to strain,
stress can be obtained. A number of different forms of
strain energy potentials have been developed in the past
and many of these are now available in most commercial
FEM codes. In the present work, the strain energy
 ARTICLE IN PRESS
2464 F. Dal Pan et al. / Journal of Biomechanics 38 (2005) 2460–2471
potential has been defined in the reduced polynomial
form
X
N XN
1 el
U¼ C i0 ðĪ 1  3Þi þ ðJ  1Þ2i ;
i¼1 i¼1
D i
where N; C i0 ; Di are material parameters, to be defined
on the basis of the test data, Ī 1 is the first deviatoric
strain invariant and Jel is the elastic volume ratio
(Abaqus Manuals, 2002). In our case, a fifth-order
reduced polynomial was employed to fit the experi-
mental data. The result is reported in Fig. 5 compared to
the experimental stress–strain curve, showing a very
good agreement.
The calculations carried out with the E model
consider on the contrary a simple linear-elastic material
schematisation defined by a Young modulus of about
4 MPa and a Poisson coefficient n ¼ 0:45: These values
are representative of the material post transition zone
and have been chosen just to compare the results of the
E model with those of the other FEM models available
in the literature, which also describe the material
behaviour in terms of linear-elastic schematisation
defined by the post-transition tangent modulus. It must
be remarked, however, that this assumption implicates
an excessive material rigidity in the first phases of
loading, which can lead to a not correct prediction of the
stress and strain distribution. This fact will be discussed
in the following.
2.3. Boundary conditions and interactions
The following boundary conditions were applied to
simulate physical constraints in the non-repaired valve:
 The nodes of the fibrosus annulus have been fixed (no
displacements).
 In the E and H models, the effect of the chordae
tendineae has been simulated by imposing the free-
edge nodes of the leaflets to move in a plane inclined
of 26.51 with respect to the annulus plane (Fig. 4b).
This assumption allowed to correctly reproduce the
leaflets movement during the cardiac cycle and was
verified by the authors, observing several ECG.
 In the FH model, the chordae tendineae have been
modelled by inextensible elements (being the elastic
modulus of their material much higher than that of
the leaflet material), fixed at one end (condition which
simulates the constraint induced by the papillary
muscles) and connected to the free edge nodes of the
leaflets on the other end (see Fig. 4a).
2.4. Loading
A uniform ventricular pressure up to 120 mmHg (the
same chosen by Kunzelman and Votta) has been applied
to the whole valve surface to simulate the systolic phase
of the cardiac cycle. Diastolic load was determined from
the fluid-dynamic FEM model proposed by Redaelli et
al. (2001). This model hypothesises a constant blood
(4)
flow rate across the valve Q (l/min), determining the
diastolic pressure drop (Dp, mmHg) as a function of the
effective orifice area (A, mm2 ). The relationship
between the above-described parameters, obtained from
interpolations of FEM results, is
Dp ¼ 0:16 ðQ=AÞ2 : (5)
It is graphically shown in Fig. 17 and represents the
loci of all the possible working points of the valve.
Following the literature (Muntinga et al., 2000), a
typical value of Q ¼ 13 l=min has been assumed in the
present analyses, and the orifice area was computed
approximating it as elliptical.
The FEM models of the MV here presented could be
enhanced in the future, to take into account to actual
fluid-valve interaction, thus solving together the fluid-
dynamics and the structural problems. These enhanced
models would be probably more realistic, but also
significantly more complex and heavier from a compu-
tational point of view. In our opinion, however, they
would not give substantially different results in terms of
systolic and diastolic stresses in the MV with respect to
the present models, but only additional information on
the whole cardiac cycle and on the correspondent
instantaneous values of the stress cycle. Comparing the
structural effects of the E-to-E surgical parameters in
the MV, being the aim of the present work, an
assessment based on the systolic and diastolic stresses
seems to be valid and sufficient.
2.5. Comparison of models
In Table 1, the Von Mises maximum stresses in
systole obtained with the E model are compared with
those predicted by other FEM models, which refer to
very similar valve geometry and pressure levels, showing
Table 1
Comparison of linear-elastic model results
Maximum Von Mises stress (MPa) Systole
E model (FEM) anterior leaflet 0.336
posterior leaflet 0.225
Kunzelmann et al. (FEM) anterior leaflet 0.350
posterior leaflet 0.200
Votta et al. (FEM) anterior leaflet 0.396
posterior leaflet 0.194
Ghista (analytical) 0.054
Arts (analytical) X0.042
Miller (analytical) 0.227
 ARTICLE IN PRESS
F. Dal Pan et al. / Journal of Biomechanics 38 (2005) 2460–2471
Fig. 6. Deformed mesh and Von Mises stress contour in systole (1)
and diastole (2), obtained with E, H and FH models.
a good agreement with them. All these models produce
in effect also a very similar stress distribution, with the
maximum value in the centre of the leaflets and
singularities near the commissures (see Fig. 6, E-1).
Thus, it can be said that the E model is consistent with
the previous linear-elastic FEM models.
It is, however, remarkable that due to the excessive
material rigidity, the leaflets closure is not satisfactory
compared to the E model, as also happens for the
Kunzelman and Votta models. For the same reason, the
valve opening in diastole is difficult and limited,
appearing not realistic at all.
The correct choice of material schematisation and
parameters is therefore fundamental to develop a model
of the MV able to predict the effects of E-to-E repair: it
is thought in particular that a correct assessment of the
stress and strain distribution in the sutured valve can be
made only considering a hyperelastic material beha-
viour, which allows a realistic simulation of the leaflets
deformation in all the loading phases and, as a
consequence, of the valve fluidodynamics. Actually, as
will be shown in the following, the stress distribution
predicted by the linear-elastic models is strongly
different from that predicted by the hyperelastic models.
In the same Table 1, the stress values calculated by the
analytical approaches available in the literature are also
reported. They were obtained introducing in the
correspondent formulas the geometrical and material
parameters of the valve under investigation. Concerning
analytical approaches, only the Miller one gives a result
comparable to those of the FEM models, while Ghista
and Arts approaches strongly underestimate the stress
2465
Table 2
Comparison of hyperelastic model results
Maximum Von Mises stress (MPa) Systole Diastole
H model anterior leaflet 0.345 0.027
posterior leaflet 0.266 0.006
FH model anterior leaflet 0.330 0.027
posterior leaflet 0.252 0.006
level, probably due to the approximation in the valve
geometry.
In Table 2, the results obtained by the H and FH
models, in terms of maximum systole and diastole Von
Mises stresses, are shown. Even if the maximum stress
values are similar to those obtained by the E model, the
correspondent deformed shapes and stress distributions,
which can be seen in Fig. 6, are different: in particular,
in the hyperelastic models the maximum stress is not
located in the middle of the leaflets, while two symmetric
highly stressed zones appears in the anterior leaflet;
there are no more singular peaks in the commissures;
and the diastolic mobility is better.
Concerning the comparison between H and FH
models, their results are very similar, both qualitatively
and quantitatively, thus proving the effectiveness of the
boundary conditions used in the E and H models to
represent the effect of the chordae tendineae. Also
considering that the computational costs of H and FH
models are significantly different, being almost double
for the latter, the H model was chosen as the best
compromise (in terms of precision and complexity) to
study the MV and, in particular, to evaluate the E-to-E
effects.
3. Application to the E-to-E technique
As said before, the H model was employed to study
E-to-E effects on stress and strain distribution on the
valve. In particular, the suture has been simulated using
a link connector supported by a coupling constraint for
each of the two leaflets (Fig. 7), with the function of
distributing the transmitted load on an area correspond-
ing to the extension of the actual teflon pledgets, used by
surgeons just for this reason.
It is known that the force substained by an E-to-E
suture during systole is very low (see, for example,
Nielsen and Timek, 2001). So its effect on the leaflets
stress state can be considered negligible. Therefore, only
the diastolic phase was studied on the repaired valve,
assuming the systolic stresses unchanged with respect to
those of a non-sutured valve.
The calculation was divided into three steps: the first
step for leaflets approach, the second one for suture
 ARTICLE IN PRESS
2466 F. Dal Pan et al. / Journal of Biomechanics 38 (2005) 2460–2471

prolapse; on the other hand, the negative dilatation (i.e.

a contraction) is reproducing the common procedure to
implant an annuloplastic ring during E-to-E operation.
In particular, the following were considered:
 1 mm long suture having seven different locations,
from centred to lateral; the suture position is defined
by the curvilinear coordinate s, defined in Fig. 8a,
ranging from 0 to 18 mm with steps of 3 mm.
 A centred suture having six different lenghts e, from
1 mm to 6 mm, with steps of 1 mm, as indicated in Fig.
8b.
 A centred 1 mm long suture with seven different
annulus areas. For this aim, a preliminar step was
introduced in the calculation procedure, imposing an
uniform radial dilatation of the annulus, as shown in
Fig. 8c. In particular, six annulus area variations DA,
ranging from 16% to +32% of that assumed in
Fig. 3, with steps of 8%, were considered.

Fig. 7. The inextensible connector simulating the stitch, supplied with
two ‘‘coupling’’ constraints, one for each leaflet.
e
s not affected by the presence of the suture in the systolic
Suture position Suture extension
(a) (b)
∇
+ A
∇ Table 2). The immediate consequence is that during
- A
(c) Annulus dilatation
Fig. 8. The three surgical parameters under examination: (a) suture
position, (b) suture extension and (c) annulus area variation.
creation, at the end of which the approach load is
removed, and the final step for diastole, i.e. the
application of a differential pressure following for-
mula (5).
Three fundamental surgical parameters of the re-
paired valve were investigated (Fig. 8): suture position,
suture extension, and annulus area variation. This last
modification is consistent with the common presence of
strongly dilated annulus in patients affected by MV
3.1. Results and discussion
Fig. 9 shows the strong effect of the suture (centred,
1-mm-long) in the opening mechanism of MV: E-to-E
generate a double-orifice valve, with a reduced mobility
in comparison with normal MV. Consequently, the
stress distribution is greatly changed, with a critical zone
in proximity of the connector.
While the stress distribution has been supposed to be
phase, the diastolic Von Mises maximum stress, which
was negligible in the non-repaired valve (0.027 MPa,
see Table 2), resulted to a value of 0.245 MPa, be-
coming comparable to the systolic one (0.345 MPa, see
the cardiac cycle the leaflets are stressed twice with
respect to normal situation, as if the heart rate were
doubled and this fact had been observed by Votta
et al. (2002) too.
The load transmitted by the connector resulted in
0.264 N. This value is very close to that experimentally
measured during diastole by Nielsen (Nielsen and
Timek, 2001) in the suture of an ovine MV submitted
to E-to-E. Taking into account the anatomical and
physiological differences and variabilities of the two
investigations, we have to consider this agreement quite
fortuitous, anyway the same order of magnitude of the
experimental and numerical results confirms the effec-
tiveness of the H model in describing the behaviour of
the MV and in particular the effect of the E-to-E on the
stress and strain distribution.
3.1.1. Influence of suture position
The effect of the lateral shifting of the stitch
(increasing s) on the valve mobility is to allow a better
 ARTICLE IN PRESS
F. Dal Pan et al. / Journal of Biomechanics 38 (2005) 2460–2471 2467

Fig. 9. Deformed shape and Von Mises stress contour of the MV in the diastolic phase: (a) before and (b) after E-to-E repair (1 mm long centred
suture). A highly stressed zone is well visible near the suture.

opening of the valve with a consequent improvement of

the diastolic function. In particular, the transvalvular
pressure decreases, as shown in Fig. 17, where all the
investigated effects are synthetised.
Fig. 10 shows the Von Mises stress contours for the
different suture positions. The value of the maximum
Von Mises stress, which is located in the anterior leaflet
near the stitch, is reported in Fig. 11. It decreases as
suture becomes more lateral, with a slight increment for
extreme positions, probably due to flexional effects: this
fact constitutes the first important indication for the
surgeon to reduce (when a choice is possible) the stresses
generated by the operation.

3.1.2. Influence of suture extension

As expected, a longer suture (increasing e) results in
decreasing the valve mobility and increasing the
transvalvular pressure (see Fig. 17), even if, for the
examined cases, it always remains within an acceptable
threshold.
The correspondent Von Mises stress contours
are reported in Fig. 12. The maximum stress is again
located in the anterior leaflet, near the suture; it has
been found to decrease with suture length (see Fig. 13).
This behaviour is due to the redistribution, along
the whole length of the suture, of the load trans-
mitted by the connector, as shown in Fig. 14. The
abscissa of this graph is the coordinate x along
the suture length, defined in Fig. 7. A significant
‘‘border effect’’ can be noticed from this graph, with
the most external stitches much more loaded than the
internal ones.
These results suggest that the choice of the suture
length should be based on the best compromise between
valve mobility and stress level. New solutions for the
suture setup can be also searched for in order to reduce Fig. 10. Deformed shape and Von Mises stress contour for the seven
the border effects, for example, by employing stitches different positions of the suture (top view on the left, perspective view
with variable stiffness. on the right).
 ARTICLE IN PRESS
2468 F. Dal Pan et al. / Journal of Biomechanics 38 (2005) 2460–2471
Fig. 11. Maximum Von Mises stress in the leaflets as a function of the
suture position.
Fig. 12. Deformed shape and Von Mises stress contour for the six
different extensions of the suture (top view on the left, magnification of
the critical zone on the right).
3.1.3. Influence of annulus area variation
The annular dimension does not affect substantially
the transvalvular pressure (see Fig. 17). However,
looking at the deformed shapes reported in Fig. 15, it
can be seen that as the valve is pressurised and the
annulus is stretched, the final elevation of the stitch is
Fig. 13. Maximum Von Mises stress in the leaflets as a function of the
suture extension.
Fig. 14. Von Mises stress along the suture in the anterior leaflet, for
each extension of the suture itself. A progressive stress redistribution as
the suture length increases can be noted.
higher for higher annulus dimensions, thus reducing the
leaflet mobility.
A significant maximum stress increment in anterior
leaflet as a consequence of annular dilatation can also be
noted (Fig. 16).
These results promote and justify the use of a
prosthetic ring (as Carpentier ring) to contain the
annulus dilatation (Fig. 17).
4. Conclusions
The structural analysis of the MV required the
development of an advanced finite elements model, able
to simulate realistically the behaviour of the valve, in
particular, in the diastolic phase. For this aim, it was
necessary to define and to model a representative valve
geometry, to introduce the hyperelastic behaviour of the
leaflets material, to correctly represent the boundary
 ARTICLE IN PRESS
F. Dal Pan et al. / Journal of Biomechanics 38 (2005) 2460–2471 2469

conditions generated by the surrounding parts and to

Fig. 15. Deformed shape and Von Mises stress contour for the seven
different annular dimensions (top view on the left, perspective view on
the right).
describe the applied loads with the support of an
adequate fluidodynamic model. The comparison of this
model with the simpler ones available in literature
showed the importance of taking into account the
above-described factors for a correct prediction of the
valve behaviour. It resulted in the fundamental assump-
tion of a hyperelastic material schematisation to obtain
realistic stress distribution and values.
The effects of the E-to-E repair on the valve was
studied with this FEM model. The suture has been
demonstrated to worsen the diastolic function in terms
of valve mobility and transvalvular. The maximum
diastolic stress considerably rises, becoming similar
(although lower) to the systolic one. As a consequence,
the valve is stressed two times a cycle.
The analysis of the effects of the three principal
surgical parameters (suture position, suture extension
and annulus dimension) was also carried out. It gave
suggestions useful for the technique improvement and
optimization. In particular, a lateral shifting of the stitch
gives both an improvement in valve functionality (in
terms of transvalvular pressure and mobility) and a
reduction in leaflets stress level; a larger extension of the
suture worsens the valve functionality but also reduces
the stresses; a dilatation of the mitral annulus does not
significantly affect the transvalvular pressure, but
reduces the valve mobility and increases remarkably
the stress level in the leaflets.
Anyway, for all the examined configurations, an
unavoidable structural worsening generated by the E-to-
E repair resulted within the ‘‘acceptability limits’’ from a
medical point of view, even if some long-term effects

Maximum stress near the suture

0.30

0.25
Von Mises stress (N/mm2)

0.20

0.15

0.10 Anterior leaflet

Posterior leaflet

0.05

0.00
-20 -10 0 10 20 30
Annulus area variation, ∆A (%)

Fig. 16. Maximum Von Mises stress in the leaflets as a function of the annular area variation.

2470 F. Dal Pan et al. / Journal of Biomechanics 38 (2005) 2460–2471
18
16
e=6
Tranvalvular pressure (mmHg)
14
12
e=1
10
8
2
0
120 140
Fig. 17. Constant flow-rate curve (13 l/min) and working points representative of the examined E-to-E configurations.
have not been completely studied yet. This demonstrates
the goodness of this technique, whose effectiveness and
medical benefits have been already largely ascertained.
Acknowledgement
The authors wish to thank Prof. Franco Docchio,
whose efforts made possible the collaboration between
engineers and medicians in this work.
References
Abaqus Manuals, version 6.3, 2002. Abaqus, Inc.
Abaqus technical note, 2003. Modeling rubber and viscoelasticity with
Abaqus, Abaqus, Inc.
Alfieri, O., et al., 2001. The double-orifice technique in mitral valve
repair: a simple solution for complex problems. The Journal of
Thoracic and Cardiovascular Surgery 122, 674–681.
Arts, T., Meerbaum, S., Reneman, R., et al., 1983. Stresses in the
closed mitral valve: a model study. Journal of Biomechanics 16,
539–547.
Barber, J.E., Kasper, F.K., Ratliff, N.B., 2001. Mechanical properties
of myxomatous mitral valves. The Journal of Thoracic and
Cardiovascular Surgery 122 (5), 955–962.
Brock, R.C., 1952. The surgical and pathological anatomy of the
mitral valve. British Heart Journal 14 (4), 489–513.
Chiechi, M.A., Lees, W.M., Thompson, R., 1956. Functional anatomy
of the normal mitral valve. The Journal of Thoracic and
Cardiovascular Surgery 32 (3), 378–398.
Clark, R.E., 1973. Stress–strain characteristics of fresh and frozen
human aortic and mitral leaflets and chordae tendineae. The
Journal of Thoracic and Cardiovascular Surgery 66 (2), 202–208.
Du Plessis, L.A., Marchand, P., 1964. The anatomy of the mitral valve
and its associated structures. Thorax 19, 221–227.
ARTICLE IN PRESS
Constant flow rate curve (13 l/min)
Suture extension
e Annulus dilatation
Suture position
s=0 Constant flow rate curve
s
s =18
160 180 200 220 240 260 280 300
Total orifice area (mm2)
Fucci, C., Sandrelli, L., Pardini, A., et al., 1995. Improved results with
mitral valve repair using new surgical techniques. European
Journal of Cardio-Thoracic Surgery 9, 621–627.
Ghista, D.N., Rao, A.P., 1972a. Structural mechanics of the mitral
valve: stresses sustained by the valve, non-traumatic determination
of the stiffness of the in vivo valve. Journal of Biomechanics 5,
295–307.
Ghista, D.N., Rao, A.P., 1972b. Mitral-valve mechanics-stress/strain
characteristics of excised leaflets, analysis of its functional
mechanics and its medical application. Medical and Biological
Engineering November, 1973, 691–702.
Kunzelman, K.S., Cochran, R.P., 1991. Stress/strain characteristics of
porcine mitral valve tissue: parallel versus perpendicular collagen
orientation. Journal of Cardiac Surgery 7 and 1, 71–78.
Kunzelman, K.S., Cochran, R.P., Chuong, C., Ring, W.S., Verrier,
E.D., Eberhart, R.D., 1993. Finite element analysis of the mitral
valve. Journal of Heart Valve Disease 2, 326–340.
Lim, K.O., Boughner, D.R., 1974. Mechanical properties of human
mitral valve chordae tendineae: variation with size and strain rate.
Canadian Institute of Physiology and Pharmacology 53, 330–339.
Maisano, F., Torracca, L., Oppizzi, M., et al., 1998. The edge-to-edge
technique: a simplified method to correct mitral insufficiency.
European Journal of Cardio-Thoracic Surgery 13, 240–245.
Maisano, F., Schreuder, J.J., Oppizzi, M., et al., 2000. The double-
orifice technique as a standardized approach to treat mitral
regurgitation due to severe myxomatous disease: surgical techni-
que. European Journal of Cardio-Thoracic Surgery 17, 201–205.
Miller, G.E., Hunter, J.F., Lively, W.M., 1981. A note on mitral valve
mechanics: a pre-stressed leaflet concept. Journal of Biomechanics
14 (5), 373–375.
Miller, G.E., Marcotte, H., 1987. Computer simulation of human
mitral valve mechanics and motion. Computers in Biology and
Medicine 17 (5), 305–319.
Muntinga, H.J., et al., 2000. Normal values and reproducibility of left
ventricular filling parameters by radionuclide angiography. In:
Muntinga, H.J. (Ed.), Left ventricular diastolic function and
cardiac disease: a radionuclide angiography study. Proefshrift
Rijksuniversiteit, Groningen, pp. 30–40.
 ARTICLE IN PRESS
F. Dal Pan et al. / Journal of Biomechanics 38 (2005) 2460–2471 2471

Nielsen, S.L., Timek, T.A., 2001. Edge-to-Edge mitral repair: tension of
approximating suture and leaflet deformation during acute ischemic
mitral regurgitation in ovine heart. Circulation 104, I-29–I-35.
Ormiston, J.A., Shah, P.M., Tei, C., Wong, M., 1981. Size and motion
of the mitral valve annulus in man. I. A two-dimensional
echocardiographic method and findings in normal subjects.
Circulation 64 (1), 113–120.
Redaelli, A., Maisano, F., et al., 2001. A computational study of the
hemodynamics after ‘‘Edge-to-Edge’’ mitral valve repair. Journal
of Biomechanical Engineering 123, 565–570.
Roberts, W.C., 1983. Morphologic features of the normal and
abnormal mitral valve. American Journal of Cardiology 15, 51
(6), 1005–1028.
Rusted, I.E., Scheifley, C.H., Edwards, J.E., 1952. Studies of the mitral
valve. I. Anatomic features of the normal mitral valve and
associated structures. Circulation. 6 (6), 825–831.
Silverman, M.E., Hurst, J.W., 1968. The mitral complex, interaction of
the anatomy, physiology, and pathology of the mitral annulus,
mitral valve leaflets, chordae tendineae, and papillary muscles.
American Heart Journal 76 (3), 399–418.
Votta, E., Maisano, F., Soncini, M., et al., 2002. 3-D computational
analysis of the stress distribution on the leaflets after Edge-to-Edge
repair of mitral regurgitation. Journal of Heart Valve Disease 11,
810–822.