Background: Annuloplasty ring sizing is critical for durable outcomes in surgical mitral valve repair (MVr). However, there is no clear consensus on optimal sizing strategies. Artificial intelligence (AI)-based imaging tools may help to reduce uncertainty in preoperative decision-making by providing objective, reproducible and reliable measurements. This study evaluated the predictive capability of a fully automated, computed tomography (CT)-based AI-driven tool for annuloplasty ring sizing in patients undergoing minimally invasive MVr (MI-MVr). Methods: A total of 71 consecutive patients undergoing MI-MVr for Carpentier type II mitral valve insufficiency during the study period were included. Preoperative CT scans were analyzed using a cloud-based, fully automated AI tool to quantify mitral valve geometric parameters. Correlations between AI-derived measurements and implanted ring sizes were assessed using the Pearson correlation test. Univariable and multivariable linear regression analyses were performed to identify independent predictors of ring size selection. Results: Several AI-derived parameters correlated significantly with implanted ring size, with the strongest correlations observed for commissural width (R = 0.693, p < 0.001) and mitral annular area (R = 0.693, p < 0.001). In multivariable regression analysis, these parameters were the strongest predictors of annuloplasty ring size (R² = 0.504, p < 0.001). Using this model, accurate annuloplasty ring sizing could be predicted in 78.8% of patients. There were no in-hospital mortality and residual mitral regurgitation at discharge. Conclusions: A fully automated, CT-based AI-driven tool demonstrated good accuracy for preoperative annuloplasty ring size prediction in MI-MVr and may have the potential to support surgical decision-making, reduce operator dependence, and improve reproducibility.

Objectives: New generations of annuloplasty rings are designed to combine structural support with enhanced flexibility, allowing for better adaptation to the dynamic nature of the mitral annulus. This study investigated the early clinical and echocardiographic outcomes of minimally invasive mitral valve repair (MI-MVr) with a new semi-rigid open ring (PhysioFlex, annuloplasty ring, Edwards Lifesciences, Irvine, CA, USA). Methods: A total of 150 consecutive patients who underwent MI-MVr for severe degenerative mitral regurgitation (DMR) using the PhysioFlex annuloplasty ring between June 2021 and April 2024 were included in the study. Preoperative, intraoperative, and postoperative data were collected for the entire population. A three-dimensional mitral valve reconstruction analysis was performed across the entire cohort using a semi-automated software package (4D Mitral Valve Analysis; Tomtec Imaging Systems, Munich, Germany). Results: The median age was 59 (50–67) years and 25.3% patients were female. The median Euroscore II and left ventricular ejection fraction were 0.72 (0.56–0.99) and 60% (55–65), respectively. The median implanted ring size was 34 mm (32–36). The entire cohort was discharged with no residual mitral regurgitation greater than mild and a median mean transmitral pressure gradient of 2.4 mmHg (2–3). The median hospitalization time was 7 days (6–11) and in-hospital mortality occurred in 1 (0.7%) patient. Conclusions: MI-MVr was safely performed using the novel semi-rigid partial PhysioFlex ring in the DMR patient cohort with favorable early results. The PhysioFlex annuloplasty ring may be used as an alternative to complete rings in MI-MVr. Further research is needed to conduct comparisons with other currently available annuloplasty rings.