Correlation of Hemodynamic Events with Clinical and Pathological Observations

Integrating Computational and Biological Hemodynamic Approaches to Improve Modeling of Atherosclerotic Arteries

Atherosclerosis is the primary cause of cardiovascular disease, resulting in mortality, elevated healthcare costs, diminished productivity, and reduced quality of life for individuals and their communities. This is exacerbated by the limited understanding of its underlying causes and limitations in current therapeutic interventions, highlighting the need for sophisticated models of atherosclerosis. This review critically evaluates the computational and biological models of atherosclerosis, focusing on the study of hemodynamics in atherosclerotic coronary arteries. Computational models account for the geometrical complexities and hemodynamics of the blood vessels and stenoses, but they fail to capture the complex biological processes involved in atherosclerosis. Different in vitro and in vivo biological models can capture aspects of the biological complexity of healthy and stenosed vessels, but rarely mimic the human anatomy and physiological hemodynamics, and require significantly more time, cost, and resources. Therefore, emerging strategies are examined that integrate computational and biological models, and the potential of advances in imaging, biofabrication, and machine learning is explored in developing more effective models of atherosclerosis.

A review on non-Newtonian fluid models for multi-layered blood rheology in constricted arteries

Haemodynamics is a branch of fluid mechanics which investigates the features of blood when it flows not only via blood vessels of smaller/larger diameter, but also under normal as well as abnormal flow states, such as in the presence of stenosis, aneurysm, and thrombosis. This review aims to discuss the rheological properties of blood, geometry of constrictions, dilations and the emergence of single-layered fluid to four-layered fluid models. To discuss further the influence of the aforesaid parameters on the physiologically important flow quantities, the mathematical formulation and solution methodology of the two-layered and four layered arterial blood flow problems studied by the authors (Afiqah and Sankar in ARPN J Eng Appl Sci 15:1129--1143, 2020, Comput Methods Programs Biomed 199:105907, 2021. 10.1016/j.cmpb.2020.105907) are recalled. It should be pointed out that the increasing resistive impedance to flow in three distinct states encompassing healthy, anaemic, and diabetic demonstrates that the greater the restriction in the artery, very few blood is carried to the pathetic organs, leading to subjects' death. It is also discovered that the pulsatile nature of blood movement produces a dynamic environment that poses a slew of intriguing and unstable fluid mechanical state. It is hoped that the intriguing results gathered from this literature survey and review conducted may help the medical practitioners to forecast blood behaviour mobility in stenotic arteries. Furthermore, the physiological information gathered from the available clinical data from the literature on patients diagnosed with diabetes and anaemia may be beneficial to doctors in deciding the therapeutic procedure for treating some particular cardiovascular disease.

Long-term prognostic impact of paravalvular leakage on coronary artery disease requires patient-specific quantification of hemodynamics

Transcatheter aortic valve replacement (TAVR) is a frequently used minimally invasive intervention for patient with aortic stenosis across a broad risk spectrum. While coronary artery disease (CAD) is present in approximately half of TAVR candidates, correlation of post-TAVR complications such as paravalvular leakage (PVL) or misalignment with CAD are not fully understood. For this purpose, we developed a multiscale computational framework based on a patient-specific lumped-parameter algorithm and a 3-D strongly-coupled fluid-structure interaction model to quantify metrics of global circulatory function, metrics of global cardiac function and local cardiac fluid dynamics in 6 patients. Based on our findings, PVL limits the benefits of TAVR and restricts coronary perfusion due to the lack of sufficient coronary blood flow during diastole phase (e.g., maximum coronary flow rate reduced by 21.73%, 21.43% and 21.43% in the left anterior descending (LAD), left circumflex (LCX) and right coronary artery (RCA) respectively (N = 6)). Moreover, PVL may increase the LV load (e.g., LV load increased by 17.57% (N = 6)) and decrease the coronary wall shear stress (e.g., maximum wall shear stress reduced by 20.62%, 21.92%, 22.28% and 25.66% in the left main coronary artery (LMCA), left anterior descending (LAD), left circumflex (LCX) and right coronary artery (RCA) respectively (N = 6)), which could promote atherosclerosis development through loss of the physiological flow-oriented alignment of endothelial cells. This study demonstrated that a rigorously developed personalized image-based computational framework can provide vital insights into underlying mechanics of TAVR and CAD interactions and assist in treatment planning and patient risk stratification in patients.

Blood Flow Modeling in Coronary Arteries: A Review

Atherosclerosis is one of the main causes of cardiovascular events, namely, myocardium infarction and cerebral stroke, responsible for a great number of deaths every year worldwide. This pathology is caused by the progressive accumulation of low-density lipoproteins, cholesterol, and other substances on the arterial wall, narrowing its lumen. To date, many hemodynamic studies have been conducted experimentally and/or numerically; however, this disease is not yet fully understood. For this reason, the research of this pathology is still ongoing, mainly, resorting to computational methods. These have been increasingly used in biomedical research of atherosclerosis because of their high-performance hardware and software. Taking into account the attempts that have been made in computational techniques to simulate realistic conditions of blood flow in both diseased and healthy arteries, the present review aims to give an overview of the most recent numerical studies focused on coronary arteries, by addressing the blood viscosity models, and applied physiological flow conditions. In general, regardless of the boundary conditions, numerical studies have been contributed to a better understanding of the development of this disease, its diagnosis, and its treatment.

In vitro Biomodels in Stenotic Arteries to Perform Blood Analogues Flow Visualizations and Measurements: A Review

Cardiovascular diseases are one of the leading causes of death globally and the most common pathological process is atherosclerosis. Over the years, these cardiovascular complications have been extensively studied by applying in vivo, in vitro and numerical methods (in silico). In vivo studies represent more accurately the physiological conditions and provide the most realistic data. Nevertheless, these approaches are expensive, and it is complex to control several physiological variables. Hence, the continuous effort to find reliable alternative methods has been growing. In the last decades, numerical simulations have been widely used to assess the blood flow behavior in stenotic arteries and, consequently, providing insights into the cardiovascular disease condition, its progression and therapeutic optimization. However, it is necessary to ensure its accuracy and reliability by comparing the numerical simulations with clinical and experimental data. For this reason, with the progress of the in vitro flow measurement techniques and rapid prototyping, experimental investigation of hemodynamics has gained widespread attention. The present work reviews state-of-the-art in vitro macro-scale arterial stenotic biomodels for flow measurements, summarizing the different fabrication methods, blood analogues and highlighting advantages and limitations of the most used techniques.

Quantification of internal carotid artery flow with digital subtraction angiography: validation of an optical flow approach with Doppler ultrasound

BACKGROUND AND PURPOSE

Digital subtraction angiography is the reference standard technique to evaluate intracranial vascular anatomy and used on the endovascular treatment of vascular diseases. A dedicated optical flow-based algorithm was applied to DSA to measure arterial flow. The first quantification results of internal carotid artery flow validated with Doppler sonography are reported.

MATERIALS AND METHODS

We included 22 consecutive patients who underwent endovascular procedures. To assess the sensitivity of the algorithm to contrast agent-blood mixing dynamics, we acquired high-frame DSA series (60 images/s) with different injection rates: 1.5 mL/s (n = 19), 2.0 mL/s (n = 18), and 3.0 mL/s (n = 13). 3D rotational angiography was used to extract the centerline of the vessel and the arterial section necessary for volume flow calculation. Optical flow was used to measure flow velocities in straight parts of the ICAs; these data were further compared with Doppler sonography data. DSA mean flow rates were linearly regressed on Doppler sonography measurements, and regression slope coefficient bias from value 1 was analyzed within the 95% confidence interval.

RESULTS

DSA mean flow rates measured with the optical flow approach significantly matched Doppler sonography measurements (slope regression coefficient, b = 0.83 ± 0.19, P = .05) for injection rate = 2.0 mL/s and circulating volumetric blood flow <6 mL/s. For injection rate = 1.5 mL/s, volumetric blood flow <3 mL/s correlated well with Doppler sonography (b = 0.67 ± 0.33, P = .05). Injection rate = 3.0 mL/s failed to provide DSA-optical flow measurements correlating with Doppler sonography because of the lack of measurable pulsatility.

CONCLUSIONS

A new model-free optical flow technique was tested reliably on the ICA. DSA-based blood flow velocity measurements were essentially validated with Doppler sonography whenever the conditions of measurable pulsatility were achieved (injection rates = 1.5 and 2.0 mL/s).

Improved prediction of disturbed flow via hemodynamically-inspired geometric variables

Arterial geometry has long been considered as a pragmatic alternative for inferring arterial flow disturbances, and their impact on the natural history and treatment of vascular diseases. Traditionally, definition of geometric variables is based on convenient shape descriptors, with only superficial consideration of their influence on flow and wall shear stress patterns. In the present study we demonstrate that a more studied consideration of the actual (cf. nominal) local hemodynamics can lead to substantial improvements in the prediction of disturbed flow by geometry. Starting from a well-characterized computational fluid dynamics (CFD) dataset of 50 normal carotid bifurcations, we observed that disturbed flow tended to be confined proximal to the flow divider, whereas geometric variables previously shown to be significant predictors of disturbed flow included features distal to the flow divider in their definitions. Flaring of the bifurcation leading to flow separation was redefined as the maximum relative expansion of the common carotid artery (CCA), proximal to the flow divider. The beneficial effect of primary curvature on flow inertia, via suppression of flow separation, was characterized by the in-plane tortuosity of CCA as it enters the flare region. Multiple linear regressions of these redefined geometric variables against various metrics of disturbed flow revealed R(2) values approaching 0.6, better than the roughly 0.3 achieved using the conventional shape-based variables, while maintaining their demonstrated real-world reproducibility. Such a hemodynamically-inspired approach to the definition of geometric variables may reap benefits for other applications where geometry is used as a surrogate marker of local hemodynamics.

Theoretical models for coronary vascular biomechanics: progress & challenges

A key aim of the cardiac Physiome Project is to develop theoretical models to simulate the functional behaviour of the heart under physiological and pathophysiological conditions. Heart function is critically dependent on the delivery of an adequate blood supply to the myocardium via the coronary vasculature. Key to this critical function of the coronary vasculature is system dynamics that emerge via the interactions of the numerous constituent components at a range of spatial and temporal scales. Here, we focus on several components for which theoretical approaches can be applied, including vascular structure and mechanics, blood flow and mass transport, flow regulation, angiogenesis and vascular remodelling, and vascular cellular mechanics. For each component, we summarise the current state of the art in model development, and discuss areas requiring further research. We highlight the major challenges associated with integrating the component models to develop a computational tool that can ultimately be used to simulate the responses of the coronary vascular system to changing demands and to diseases and therapies.

Two-dimensional intraventricular flow mapping by digital processing conventional color-Doppler echocardiography images

Doppler echocardiography remains the most extended clinical modality for the evaluation of left ventricular (LV) function. Current Doppler ultrasound methods, however, are limited to the representation of a single flow velocity component. We thus developed a novel technique to construct 2D time-resolved (2D+t) LV velocity fields from conventional transthoracic clinical acquisitions. Combining color-Doppler velocities with LV wall positions, the cross-beam blood velocities were calculated using the continuity equation under a planar flow assumption. To validate the algorithm, 2D Doppler flow mapping and laser particle image velocimetry (PIV) measurements were carried out in an atrio-ventricular duplicator. Phase-contrast magnetic resonance (MR) acquisitions were used to measure in vivo the error due to the 2D flow assumption and to potential scan-plane misalignment. Finally, the applicability of the Doppler technique was tested in the clinical setting. In vitro experiments demonstrated that the new method yields an accurate quantitative description of the main vortex that forms during the cardiac cycle (mean error for vortex radius, position and circulation). MR image analysis evidenced that the error due to the planar flow assumption is close to 15% and does not preclude the characterization of major vortex properties neither in the normal nor in the dilated LV. These results are yet to be confirmed by a head-to-head clinical validation study. Clinical Doppler studies showed that the method is readily applicable and that a single large anterograde vortex develops in the healthy ventricle while supplementary retrograde swirling structures may appear in the diseased heart. The proposed echocardiographic method based on the continuity equation is fast, clinically-compliant and does not require complex training. This technique will potentially enable investigators to study of additional quantitative aspects of intraventricular flow dynamics in the clinical setting by high-throughput processing conventional color-Doppler images.

The role of biofluid mechanics in the assessment of clinical and pathological observations: sixth International Bio-Fluid Mechanics Symposium and Workshop, March 28-30, 2008 Pasadena, California

Biofluid mechanics is increasingly applied in support of diagnosis and decision-making for treatment of clinical pathologies. Exploring the relationship between blood flow phenomena and pathophysiological observations is enhanced by continuing advances in the imaging modalities, measurement techniques, and capabilities of computational models. When combined with underlying physiological models, a powerful set of tools becomes available to address unmet clinical needs, predominantly in the direction of enhanced diagnosis, as well as assessment and prediction of treatment outcomes. This position paper presents an overview of current approaches and future developments along this theme that were discussed at the 5th International Biofluid Symposium and Workshop held at the California Institute of Technology in 2008. The introduction of novel mechanical biomarkers in device design and optimization, and applications in the characterization of more specific and focal conditions such as aneurysms, are at the center of attention. Further advances in integrative modeling, incorporating multiscale and multiphysics techniques are also discussed.