Attached indigenous microalgal-bacterial consortium with greater stress-resistance facilitated recovery of integrated fixed-film system after experiencing short-term stagnation inhibition.

Stability of integrated fixed-film indigenous microalgal-bacterial consortium (IF-IMBC) requires further investigation. This study focused on the influence of short-term stagnation (STS), caused by influent variations or equipment maintenance, on IF-IMBC. Results showed that the IF-IMBC system experienced initial inhibition followed by subsequent recovery during STS treatment. Enhanced organics utilization was believed to contribute to system recovery. It is proposed that the attached IMBC possessed greater stress resistance. On the one hand, a higher increase in bacteria potentially participating in organic degradation was observed. Moreover, the dominant eukaryotic species significantly decreased in suspended IMBC while its abundance remained stable in the attached state. On the other hand, increased abundance for most functional enzymes was primarily observed in the attached bacteria. This fundamental research aims to bridge the knowledge gap regarding the response of IMBC to variations in operational conditions.

PEDV-spike-protein-expressing mRNA vaccine protects piglets against PEDV challenge.

Porcine epidemic diarrhea virus (PEDV), a swine enteropathogenic coronavirus, causes severe diarrhea in neonatal piglets, which is associated with a high mortality rate. Thus, developing effective and safe vaccines remains a top priority for controlling PEDV infection. Here, we designed two lipid nanoparticle (LNP)-encapsulated mRNA (mRNA-LNP) vaccines encoding either the full-length PEDV spike (S) protein or a multiepitope chimeric spike (Sm) protein. We found that the S mRNA-LNP vaccine was superior to the Sm mRNA-LNP vaccine at inducing antibody and cellular immune responses in mice. Evaluation of the immunogenicity and efficacy of the S mRNA vaccine in piglets confirmed that it induced robust PEDV-specific humoral and cellular immune responses in vivo. Importantly, the S mRNA-LNP vaccine not only protected actively immunized piglets against PEDV but also equipped neonatal piglets with effective passive anti-PEDV immunity in the form of colostrum-derived antibodies after the immunization of sows. Our findings suggest that the PEDV-S mRNA-LNP vaccine is a promising candidate for combating PEDV infection.IMPORTANCEPorcine epidemic diarrhea virus (PEDV) continues to harm the global swine industry. It is important to develop a highly effective vaccine to control PEDV infection. Here, we report a PEDV spike (S) mRNA vaccine that primes a potent antibody response and antigen-specific T-cell responses in immunized piglets. Active and passive immunization can protect piglets against PED following the virus challenge. This study highlights the efficiency of the PEDV-S mRNA vaccine and represents a viable approach for developing an efficient PEDV vaccine.

A High-Resolution Network with Strip Attention for Retinal Vessel Segmentation.

Accurate segmentation of retinal vessels is an essential prerequisite for the subsequent analysis of fundus images. Recently, a number of methods based on deep learning have been proposed and shown to demonstrate promising segmentation performance, especially U-Net and its variants. However, tiny vessels and low-contrast vessels are hard to detect due to the issues of a loss of spatial details caused by consecutive down-sample operations and inadequate fusion of multi-level features caused by vanilla skip connections. To address these issues and enhance the segmentation precision of retinal vessels, we propose a novel high-resolution network with strip attention. Instead of the U-Net-shaped architecture, the proposed network follows an HRNet-shaped architecture as the basic network, learning high-resolution representations throughout the training process. In addition, a strip attention module including a horizontal attention mechanism and a vertical attention mechanism is designed to obtain long-range dependencies in the horizontal and vertical directions by calculating the similarity between each pixel and all pixels in the same row and the same column, respectively. For effective multi-layer feature fusion, we incorporate the strip attention module into the basic network to dynamically guide adjacent hierarchical features. Experimental results on the DRIVE and STARE datasets show that the proposed method can extract more tiny vessels and low-contrast vessels compared with existing mainstream methods, achieving accuracies of 96.16% and 97.08% and sensitivities of 82.68% and 89.36%, respectively. The proposed method has the potential to aid in the analysis of fundus images.

Classification of Children's Heart Sounds With Noise Reduction Based on Variational Modal Decomposition.

Purpose: Children's heart sounds were denoised to improve the performance of the intelligent diagnosis. Methods: A combined noise reduction method based on variational modal decomposition (VMD) and wavelet soft threshold algorithm (WST) was proposed, and used to denoise 103 phonocardiogram samples. Features were extracted after denoising and employed for an intelligent diagnosis model to verify the effect of the denoising method. Results: The noise in children's phonocardiograms, especially crying noise, was suppressed. The signal-to-noise ratio obtained by the method for normal heart sounds was 14.69 dB at 5 dB Gaussian noise, which was higher than that obtained by WST only and the other VMD denoising method. Intelligent classification showed that the accuracy, sensitivity and specificity of the classification system for congenital heart diseases were 92.23, 92.42, and 91.89%, respectively and better than those with WST only. Conclusion: The proposed noise reduction method effectively eliminates noise in children's phonocardiograms and improves the performance of intelligent screening for the children with congenital heart diseases.

A Single-opening&closing Valve Tester for Direct Measurement of Closing Volume of the Heart Valve.

PURPOSE: The objective of this study was to develop a novel single opening&closing pulsatile flow in-vitro valve tester for direct measurement of closing volume of the heart valve. METHODS: A single opening&closing valve tester was composed of a piston pump, valve mounting chamber, reservoir, measurement and control system. The piston pump was used to drive a valve to open and close with dictated flow which comprised three phases of accelerated, constant, and decelerated flow with six slopes. A high speed camera was used to record valve opening and closing images. Two pressure transducers across the tested valve were used to capture the ending time of valve closing which was verified by the high-speed photography. The closing time was measured and closing volume was calculated with a piston displacement volume during valve closing. A tilting disc valve and porcine mitral valve were tested. RESULTS: There was a big difference in flowrate between the Transonic flowmeter and piston pump. The heart valve opened and closed under the dictated flow driven by the piston pump. The transvalvular pressure was minor during valve opening and then increased sharply during valve closing. The closing time varied approximately linearly with the slope of the decelerated flow and was comparable between the two methods by the transvalvular pressure and high-speed photography. The closing volumes did not change much with the slope of the decelerated flow and were 7.0 ± 1.0 and 14.0 ± 1.5 mL for the tilting disc valve and mitral valve, respectively. CONCLUSION: Pulsatile flow is challenging to the flowmeter. A novel single opening&closing pulsatile flow in-vitro valve tester for the heart valve has successfully been developed and can be used to simulate and evaluate the opening and closing hemodynamics of the heart valve. The tester can be used to measure valve closing volume and time accurately with a standardized testing protocol free from effect of other components such as the resistance, compliance units and auxiliary valve in the continuous pulsatile flow valve tester.

Intelligent Diagnosis of Heart Murmurs in Children with Congenital Heart Disease.

Heart auscultation is a convenient tool for early diagnosis of heart diseases and is being developed to be an intelligent tool used in online medicine. Currently, there are few studies on intelligent diagnosis of pediatric murmurs due to congenital heart disease (CHD). The purpose of the study was to develop a method of intelligent diagnosis of pediatric CHD murmurs. Phonocardiogram (PCG) signals of 86 children were recorded with 24 children having normal heart sounds and 62 children having CHD murmurs. A segmentation method based on the discrete wavelet transform combined with Hadamard product was implemented to locate the first and the second heart sounds from the PCG signal. Ten features specific to CHD murmurs were extracted as the input of classifier after segmentation. Eighty-six artificial neural network classifiers were composed into a classification system to identify CHD murmurs. The accuracy, sensitivity, and specificity of diagnosis for heart murmurs were 93%, 93.5%, and 91.7%, respectively. In conclusion, a method of intelligent diagnosis of pediatric CHD murmurs is developed successfully and can be used for online screening of CHD in children.

Mechanical Properties and Composition of the Basal Leaflet-Annulus Region of the Tricuspid Valve.

The Tricuspid valve (TV) annulus is a transition structure from the leaflets to the myocardium, with 3 different annulus segments corresponding to the TV leaflets, which includes both basal leaflets and bordering myocardium. The objective of this study was to understand TV annulus mechanical properties and correlate it to the biological composition. The uniaxial testing of the annulus segments from ten porcine TVs was performed to measure Young's modulus (E) and extensibility (εT). Western blotting and histology were executed. The septal annulus E value (208.7 ± 67.2 kPa) was statistically greater (p < 0.01) than that of the anterior (92.0 ± 66.8 kPa) and the posterior annulus segment (136.8 ± 56.9 kPa) (p < 0.05), respectively. εT among the 3 segments were equivalent (p values < 0.05). Western blotting and histology indicated that collagen was greatest along the septal annulus segment, which is correlated to E values. Collagen fibers from the leaflets inserted into the myocardium and faded out. Collagen content explains greater E and suture strength in the surgical annulus repair and larger resistance to annulus dilation in the septal annulus as compared with other segments. This study elucidates new knowledge of mechanical properties of the basal leaflet-annulus region of the TV annulus, which can be useful for future TV repair techniques.

Transapical Coaptation Plate for Functional Mitral Regurgitation: An In Vitro Study.

A novel transapical coaptation plate (TCP) device was developed and anchored by sutures in the mitral valve to treat functional mitral regurgitation. The objective of this study was to test efficacy of the TCP in an in vitro model. Eight fresh porcine mitral valves were mounted in a left heart simulator to simulate functional mitral regurgitation by means of annular dilatation and asymmetrical or symmetrical papillary muscle (PM) displacement. Six polyurethane TCPs in thickness of 6.4(#1), 4.8(#2), 3.2(#3) mm and hardness of durometer 30 A (H) and 30 OO(S),were fabricated and labeled as H1, H2, H3 and S1, S2, S3, respectively. These TCPs were anchored by the sutures in the mitral annulus and left ventricle apex, and tested. Steady backward flow leakage in a hydrostatic condition and regurgitant volume in a pulsatile flow were measured before and after implantation of the TCPs. Mean regurgitant volume fractions in the asymmetric PM displacement were reduced significantly from 59.1 to 37.2% for H1, 43.2% for H2, 35.9% for S1 and 34.2% for S2 (p < 0.021), after implantation of the TCPs. No significant reduction in mitral regurgitation was seen for H3 and S3 (p > 0.067). Mitral regurgitation was mild in the symmetric PM displacement, and was not significantly reduced after implantation of the TCPs. In conclusion, the TCP anchored by the sutures in the mitral annulus and left ventricle apex functions successfully as a plug in the mitral valve leaflet gap. The TCP with thickness equal to or greater than 4.8 mm is effective to reduce functional mitral regurgitation. The TCP hardness has no effect on difference in reduction of functional mitral regurgitation.

Characterization of biomechanical properties of aged human and ovine mitral valve chordae tendineae.

The mitral valve (MV) is a highly complex cardiac valve consisting of an annulus, anterior and posterior leaflets, chordae tendineae (chords) and two papillary muscles. The chordae tendineae mechanics play a pivotal role in proper MV function: the chords help maintain proper leaflet coaptation and rupture of the chordae tendineae due to disease or aging can lead to mitral valve insufficiency. Therefore, the aim of this study was to characterize the mechanical properties of aged human and ovine mitral chordae tendineae. The human and ovine chordal specimens were categorized by insertion location (i.e., marginal, basal and strut) and leaflet type (i.e., anterior and posterior). The results show that human and ovine chords of differing types vary largely in size but do not have significantly different elastic and failure properties. The excess fibrous tissue layers surrounding the central core of human chords added thickness to the chords but did not contribute to the overall strength of the chords. In general, the thinner marginal chords were stiffer than the thicker basal and strut chords, and the anterior chords were stiffer and weaker than the posterior chords. The human chords of all types were significantly stiffer than the corresponding ovine chords and exhibited much lower failure strains. These findings can be explained by the diminished crimp pattern of collagen fibers of the human mitral chords observed histologically. Moreover, the mechanical testing data was modeled with the nonlinear hyperelastic Ogden strain energy function to facilitate accurate computational modeling of the human MV.

Annulus Tension on the Tricuspid Valve: An In-Vitro Study.

Annulus tension (AT) is defined as leaflet tension per unit length of the annulus circumference. AT was investigated to understand tricuspid valve (TV) annulus mechanics. Ten porcine TVs were mounted on a right ventricle rig with an annulus plate to simulate TV closure. The TVs were mounted on the annulus plate in a normal and dilated TV annulus sizes, and closed under transvalvular pressure of 40 mmHg with the annulus held peripherally by wires. Anterior papillary muscle (PM) and septal PM were displaced in the dilated annulus. Wire forces were measured, and ATs (N/m) were calculated. Clover repair was performed in the dilated TV state subsequently, and AT was calculated again. A one-way ANOVA and Tukey's HSD test were used to test significances between the different TV states along each annulus segment with p < 0.05. Average ATs for the normal annulus, dilated annulus, and clover repair were 10.75 ± 1.87, 28.81 ± 10.51, and 26.93 ± 11.44 N/m, respectively. Septal annulus segments had the highest ATs when compared to the other segments. For the clover repair, there were no significant changes in AT values. ATs and leaflet forces increased roughly 3-4 times with annulus dilation. AT decelerates annulus dilation as previously shown in the mitral valve. Clover repair does not prevent further annulus dilation by AT change and should be accompanied by annuloplasty. AT improves annulus contraction during a cardiac cycle and should be considered when designing annuloplasty in the future.

[Numerical Analysis of Two-stage Axial Blood Pump Based on Blood Damage].

The implantable miniaturized axial blood pump works at a high rotational speed,which increases the risk of blood damage.In this article,we aimed to reduce the possibility of hemolysis and thrombosis by designing a twostage axial blood pump.Under the operation conditions of flow rate 5L/min and outlet pressure of 100 mm Hg,we carried out the numerical simulation on the two-stage and single-stage blood pumps to compare the hemolysis and platelet activation state.The results turned out that the hemolysis index of two-stage axial blood pump was better while the platelet activation state was worse than those of single stage design.On the index of hemolysis level and platelet activation state,the design of the two-stage pump with the low and high-head impeller combination was better than the two-stage pump with the equal heads,or the high and low-head impeller combination.In terms of reducing the risk of blood damage for implantable miniaturized axial blood pump,the research result can provide some theoretical basis and new design ideas.

[Research on Control of the Cardiovascular System Based on a Left Ventricular Assist Device].

We propose a control model of the cardiovascular system coupled with a rotary blood pump in the present paper.A new mathematical model of the rotary heart pump is presented considering the hydraulic characteristics and the similarity principle of pumps.A seven-order nonlinear spatial state equation adopting lumped parameter is used to describe the combined cardiovascular-pump model.Pump speed is used as the control variable.To achieve sufficient perfusion and to avoid suction,a feedback strategy based on minimum(diastolic)pump flow is used in the control model.The results showed that left ventricular assist device(LVAD)could improve hemodynamics of the cardiovascular system of the patient with heart failure in open loop.When rotation speed was 9,000r/min,cardiac output reached 82mL/s while the initial cardiac output was only 34mL/s without the LVAD support.When the rotation speed was above 12 800r/min,suction was found because the high rotating speed resulted in insufficient venous return volume.Suction was avoided by adopting the feedback control.The model reveals the interaction of LVAD and the cardiovascular system,which provides theoretical basis for the therapy of heart failure in the left ventricular and for the design of a physiological control strategy.

Mechanics of mitral valve edge-to-edge-repair and MitraClip procedure.

The edge-to-edge repair (ETER) technique has been used as a stand-alone procedure, or as a secondary procedure with ring annuloplasty for degenerative, functional mitral regurgitation, or for mitral regurgitation of other kinds of valvular etiologies. The percutaneous MitraClip technique based on ETER has been used in patients who are inoperable or at high surgical risk. However, adverse events such as residual mitral regurgitation, and clip detachment or fracture indicate that the mechanics underlying these procedures is not well understood. Therefore, current studies on mitral valve functionality and mechanics related to the ETER and MitraClip procedures are reviewed to improve the efficacy and safety of both procedures. Extensive in vivo, in vitro, and in silico studies related to ETER and MitraClip procedures along with MitraClip clinical trial results are presented and discussed herein. The ETER suture force and the mitral valve tissue mechanics and hemodynamics of each procedure are discussed. A quantitative understanding of the interplay of mitral valve components and as to biological response to the procedures remains challenging. Based on mitral valve mechanics, ETER or MitraClip therapy can be optimized to enhance repair efficacy and durability.

A novel coaptation plate device for functional mitral regurgitation: an in vitro study.

A novel mitral valve repair device, coaptation plate (CP), was proposed to treat functional mitral regurgitation. The objective of this study was to test efficacy of the CP in an in vitro model of functional mitral regurgitation. Ten fresh porcine mitral valves were mounted in a left heart simulator, Mitral regurgitation was emulated by means of annular dilatation, and the asymmetrical or symmetrical papillary muscles (PM) displacement. A rigid and an elastic CPs were fabricated and mounted in the orifice of regurgitant mitral valves. Steady flow leakage in a hydrostatic condition and regurgitant volume in a pulsatile flow were measured before and after implantation of the CPs. The rigid and elastic CPs reduced mitral valve regurgitant volume fraction from 60.5 ± 11.4 to 35 ± 11.6 and 36.5 ± 9.9%, respectively, in the asymmetric PM displacement. Mitral regurgitation was much lower in the symmetric PM displacement than in the asymmetric PM displacement, and was not significantly reduced after implantation of either CP. In conclusion, both the rigid and elastic CPs are effective and have no difference in reduction of functional mitral regurgitation. The CP does not aggravate mitral valve coaptation and may be used as a preventive way.

Tension to passively cinch the mitral annulus through coronary sinus access: an ex vivo study in ovine model.

INTRODUCTION: The transcatheter mitral valve repair (TMVR) technique utilizes a stent to cinch a segment of the mitral annulus (MA) and reduces mitral regurgitation. The cinching mechanism results in reduction of the septal-lateral distance. However, the mechanism has not been characterized completely. In this study, a method was developed to quantify the relation between cinching tension and MA area in an ex vivo ovine model. METHOD: The cinching tension was measured from a suture inserted within the coronary sinus (CS) vessel with one end tied to the distal end of the vessel and the other end exited to the CS ostium where it was attached to a force transducer on a linear stage. The cinching tension, MA area, septal-lateral (S-L) and commissure-commissure (C-C) diameters and leakage was simultaneously measured in normal and dilated condition, under a hydrostatic left ventricular pressure of 90 mm Hg. RESULTS: The MA area was increased up to 22.8% after MA dilation. A mean tension of 2.1 ± 0.5 N reduced the MA area by 21.3 ± 5.6% and S-L diameter by 24.2 ± 5.3%. Thus, leakage was improved by 51.7 ± 16.2% following restoration of normal MA geometry. CONCLUSION: The cinching tension generated by the suture acts as a compensation force in MA reduction, implying the maximum tension needed to be generated by annuloplasty device to restore normal annular size. The relationship between cinching tension and the corresponding MA geometry will contribute to the development of future TMVR devices and understanding of myocardial contraction function.

Effects of suture position on left ventricular fluid mechanics under mitral valve edge-to-edge repair.

Mitral valve (MV) edge-to-edge repair (ETER) is a surgical procedure for the correction of mitral valve regurgitation by suturing the free edge of the leaflets. The leaflets are often sutured at three different positions: central, lateral and commissural portions. To study the effects of position of suture on left ventricular (LV) fluid mechanics under mitral valve ETER, a parametric model of MV-LV system during diastole was developed. The distribution and development of vortex and atrio-ventricular pressure under different suture position were investigated. Results show that the MV sutured at central and lateral in ETER creates two vortex rings around two jets, compared with single vortex ring around one jet of the MV sutured at commissure. Smaller total orifices lead to a higher pressure difference across the atrio-ventricular leaflets in diastole. The central suture generates smaller wall shear stresses than the lateral suture, while the commissural suture generated the minimum wall shear stresses in ETER.

An elongation model of left ventricle deformation in diastole.

A numerical method of the left ventricle (LV) deformation, an elongation model, was put forth for the study of LV fluid mechanics in diastole. The LV elongated only along the apical axis, and the motion was controlled by the intraventricular flow rate. Two other LV models, a fixed control volume model and a dilation model, were also used for model comparison and the study of LV fluid mechanics. For clinical sphere indices (SIs, between 1.0 and 2.0), the three models showed little difference in pressure and velocity distributions along the apical axis at E-peak. The energy dissipation was lower at a larger SI in that the jet and vortex development was less limited by the LV cavity in the apical direction. LV deformation of apical elongation may represent the primary feature of LV deformation in comparison with the secondary radial expansion. The elongation model of the LV deformation with an appropriate SI is a reasonable, simple method to study LV fluid mechanics in diastole.

Annulus tension of the prolapsed mitral valve corrected by edge-to-edge repair.

BACKGROUND: Mitral valve (MV) performance after edge-to-edge repair (ETER) without ring annuloplasty is suboptimal. ETER efficacy needs to be evaluated from annulus tension (AT) of a prolapsed MV corrected by ETER to understand annular dilatation. METHODS: Ten porcine MVs were harvested and mounted on a MV closure test rig. The MV annulus tissue rested on top of a saddle-shaped plastic ring on which the annulus could slide freely. The annulus was held by strings in the periphery during MV closure under a hydrostatic trans-mitral pressure. String tensions were measured and further divided by string spacing to obtain AT. The MVs were then prolapsed by shifting split papillary muscles to simulate mono-leaflet prolapse due to elongation of chords, which insert into a single leaflet. Last, MV prolapse was corrected by ETER applied in the central leaflet region and AT was measured. RESULTS: AT in both anterior and posterior leaflet prolapse corrected by ETER was less than that of normal MVs. AT in the anterior leaflet prolapse corrected by ETER was less than that in the posterior leaflet prolapse corrected by ETER. CONCLUSION: ETER does not restore the normal AT and therefore leads potential of annular dilatation. The anterior leaflet prolapse has a greater potential of annular dilatation than the posterior leaflet prolapse after ETER. Annuloplasty is recommended to maintain long-term ETER efficacy.

Mechanics of the mitral valve strut chordae insertion region.

Interest in developing durable mitral valve repair methods is growing, underscoring the need to better understand the native mitral valve mechanics. In this study, the authors investigate the dynamic deformation of the mitral valve strut chordae-to-anterior leaflet transition zone using a novel stretch mapping method and report the complex mechanics of this region for the first time. Eight structurally normal porcine mitral valves were studied in a pulsatile left heart simulator under physiological hemodynamic conditions -120 mm peak transvalvular pressure, 5 l/min cardiac output at 70 bpm. The chordal insertion region was marked with a structured array of 31 miniature markers, and their motions throughout the cardiac cycle were tracked using two high speed cameras. 3D marker coordinates were calculated using direct linear transformation, and a second order continuous surface was fit to the marker cloud at each time frame. Average areal stretch, principal stretch magnitudes and directions, and stretch rates were computed, and temporal changes in each parameter were mapped over the insertion region. Stretch distribution was heterogeneous over the entire strut chordae insertion region, with the highest magnitudes along the edges of the chordal insertion region and the least along the axis of the strut chordae. At early systole, radial stretch was predominant, but by mid systole, significant stretch was observed in both radial and circumferential directions. The compressive stretches measured during systole indicate a strong coupling between the two principal directions, explaining the small magnitude of the systolic areal stretch. This study for the first time provides the dynamic kinematics of the strut chordae insertion region in the functioning mitral valve. A heterogeneous stretch pattern was measured, with the mechanics of this region governed by the complex underlying collagen architecture. The insertion region seemed to be under stretch during both systole and diastole, indicating a transfer of forces from the leaflets to the chordae and vice versa throughout the cardiac cycle, and demonstrating its role in optimal valve function.

Mitral valve annulus tension and the mechanism of annular dilation: an in-vitro study.

BACKGROUND AND AIM OF THE STUDY: The mitral annulus mechanics associated with annular dilation in pathologies such as mitral valve (MV) prolapse, ischemic and dilative heart diseases remain unknown. The study aim was to investigate annulus tension (AT) in the dilated annulus and in the displaced papillary muscles due to these pathological conditions. METHODS: Ten porcine MVs were harvested and mounted on a MV closure test rig with the papillary muscles held in the slack, normal, and taut positions. The MV annulus tissue rested on top of a plastic ring on which it could slide freely. The annulus was held by strings in the periphery during valve closure under hydrostatic trans-mitral pressure. The string tensions were measured, and further divided by string spacing to obtain the AT. Three annuli of normal, 25% dilated and 50% dilated annulus sizes were used. RESULTS: The AT was lowest at the commissural segment of the annulus, but increased towards the anterior and posterior segments, with a greater increase towards the anterior segment than towards the posterior. The AT increased with the increase of the apical PM displacement from the slack to normal, and then taut position in the commissural segment of the annulus. Although the AT increased with annulus area, the increase was less pronounced in the commissural segment than in the anterior and posterior segments. CONCLUSION: There is a significant difference in AT values between a normal and prolapsed MV, and between a normal MV and a MV with displaced papillary muscles. This difference suggests that annular dilation is a consequence and MV counteraction of imbalanced annular mechanics between the AT and myocardial force.