Role of Vortices in Growth of Microbubbles at Mitral Mechanical Heart Valve Closure

Thrombogenic potential of transcatheter aortic valve implantation with trivial paravalvular leakage

BACKGROUND

Significant paravalvular leakage after transcatheter aortic valve implantation (TAVI) correlates with increased morbidity and mortality, but adverse consequences of trivial paravalvular leakage have stimulated few investigations. Using a unique method distinctly different from other diagnostic approaches, we previously reported elevated backflow velocities of short duration (transients) in mechanical valve closure. In this study, similar transients were found in a transcatheter valve paravalvular leakage avatar.

METHODS

Paravalvular leakage rate (zero to 58 mL/second) and aortic valve incompetence (volumetric back flow/forward flow; zero to 32%) were made adjustable using a mock transcatheter aortic valve device and tested in quasi-steady and pulsatile flow test systems. Projected dynamic valve area (PDVA) from the back illuminated mock transcatheter aortic valve device was measured and regional backflow velocities were derived by dividing volumetric flow rate by the PDVA over the open and closing valve phase and the total closed valve area derived from backflow leakage.

RESULTS

Aortic incompetence from 1-32% generated negative backflow transients from 8 to 267 meters/second, a range not dissimilar to that measured in mechanical valves with zero paravalvular leakage. Optimal paravalvular leakage was identified; not too small generating high backflow transients, not too large considering volume overload and cardiac energy loss caused by defective valve behavior and fluid motion.

CONCLUSIONS

Thrombogenic potential of transcatheter aortic valves with trivial aortic incompetence and high magnitude regional backflow velocity transients was comparable to mechanical valves. This may have relevance to stroke rate, asymptomatic microembolic episodes and indications for anticoagulation therapy after transcatheter valve insertion.

Relationship between exercise-induced heart rate increase and the formation of microbubbles and high-intensity transient signals in mechanical heart valve implanted patients

INTRODUCTION

The formation and collapse of vapor-filled bubbles near a mechanical heart valve is called cavitation. Microbubbles can be detected in vivo by doppler ultrasonography (USG) as HITS (high intensity transient signals) in cranial circulation. We investigated the relationship between exercise induced heart rate increase and HITS formation in cranial circulation.

MATERIAL AND METHODS

Thirty-nine mechanical heart valve implanted (8 aortic valve replacement (AVR) + mitral valve replacement (MVR), 9 AVR, 22 MVR) patients aged 18-80 years old were included in our study. Microbubbles were counted in the left ventricular cavity via transthoracic echocardiography at rest per cardiac cycle. Afterwards transcranial Doppler USG was performed and HITS were counted in each patient's middle cerebral artery at 5 min duration. Subsequently an exercise test according to the Bruce protocol was performed. After achieving maximal heart rate, microbubbles in the left ventricle and HITS were counted again.

RESULTS

Microbubbles in the left ventricle and transcranial HITS increased after exercise significantly compared to resting values (15.79 ±10.91 microbubbles/beat vs. 26.51 ±18.00 microbubbles/beat, p < 0.001; 6.13 ±8.07 HITS/5 min vs. 13.15 ±15.87 HITS/5 min, p = 0.001). There was a significant correlation between microbubbles and HITS counts after peak exercise (r = 0.55, p < 0.001).

CONCLUSIONS

In our study, we found that the microbubbles were increasing as the heart rate increased and more HITS were propelled to the cerebral circulation. As previously shown, HITS can alter cognitive functions. Therefore heart rate control is essential in mechanical heart valve patients to protect neurocognitive functions.

Effects of the driving condition of a pneumatic ventricular assist device on the cavitation intensity of the inlet and outlet mechanical heart valves

Our group is currently developing a pneumatic ventricular assist device (PVAD), and in previous studies, we reported the mechanical heart valve (MHV) cavitation intensity at the inlet valve in the PVAD only. In this study, we investigated the effect of the running conditions on the cavitation intensity both for the inlet and outlet valve in the PVAD using an acoustic signal. A 23-mm Medtronic Hall valve with an opening angle of 70 degrees was mounted in the inlet and outlet port of the PVAD after removing the sewing ring. A mini pressure sensor with high frequency was mounted 15 mm downstream from the inlet valve and downstream from the outlet valve. The pressure signal was band-pass filtered between 35 and 500 kHz using a digital filter. The band-pass filtered root mean squared (RMS) pressure was used as an index of the cavitation intensity. The RMS pressure of the inlet valve was higher than that of the outlet valve. Even if the outlet valve has a lower RMS pressure than the inlet valve, cavitation occurs. In case of a full-filling and full-ejection condition, the RMS pressure of the inlet valve was higher than that of the partial-filling and partial-ejection condition. This means that a partial-filling and partial-ejection condition is best to prevent the hemolysis caused by the cavitation phenomenon and the damage to the valve surface in our PVAD system.