Development and feasibility testing of a dynamic image-derived simulation framework for assessing left atrioventricular valve repair strategies

To establish a proof-of-concept for a dynamic, image-derived patient-specific physical simulation platform designed to aid in the assessment of left atrioventricular valve (LAVV) repair strategies in pediatric patients with repaired atrioventricular canal defects.

Three-dimensional transesophageal echocardiographic images of two patients with regurgitant LAVVs were processed using custom code in SlicerHeart to segment leaflets, define the annulus, and generate patient-specific valve molds. Silicone valve models were fabricated and tested in a pulse duplicator under simulated physiological conditions. Five unrepaired valves were analyzed for manufacturing consistency, and multiple surgical repair techniques were compared for two patient-specific models.

Manufacturing variability was low in annular metrics but higher in leaflet closure metrics. Simulated valves demonstrated altered leaflet closure geometry relative to clinical imaging due to the passive nature of the simulator and the increased stiffness of silicone–gauze composite leaflets. In Patient 1, cleft closure and an Alfieri stitch both eliminated the regurgitant orifice area, but the Alfieri stitch resulted in elevated mean pressure gradient (17 mmHg vs. 4–9 mmHg for other repairs) and deteriorated with repeated loading. In Patient 2, no simulated repair eliminated regurgitation entirely; however, combining leaflet patch augmentation with commissuroplasty reduced regurgitant area to 0.147 cm², the smallest observed among tested strategies.

This study demonstrates the feasibility of a dynamic physical simulation platform for preclinical LAVV repair evaluation. Although the absence of annular motion, papillary displacement, and physiologic contraction limits reproduction of in vivo leaflet dynamics, this proof-of-concept highlights the platform’s value for qualitative assessment of repair options in congenital heart disease.