Simulation study of transcatheter heart valve implantation in patients with stenotic bicuspid aortic valve

Material modeling and recent findings in transcatheter aortic valve implantation simulations

BACKGROUND AND OBJECTIVE

Transcatheter aortic valve implantation (TAVI) has significantly transformed the management of aortic valve (AV) diseases, presenting a minimally invasive option compared to traditional surgical valve replacement. Computational simulations of TAVI become more popular and offer a detailed investigation by employing patient-specific models. On the other hand, employing accurate material modeling procedures and applying basic modeling steps are crucial to determining reliable numerical results. Therefore, this review aims to outline the basic modeling approaches for TAVI, focusing on material modeling and geometry extraction, as well as summarizing the important findings from recent computational studies to guide future research in the field.

METHODS

This paper explains the basic steps and important points in setting up and running TAVI simulations. The material properties of the leaflets, valves, stents, and tissues utilized in TAVI simulations are provided, along with a comprehensive explanation of the geometric extraction methods employed. The differences between the finite element analysis, computational fluid dynamics, and fluid-structure interaction approaches are pointed out and the important aspects of TAVI modeling are described by elucidating the recent computational studies.

RESULTS

The results of the recent findings on TAVI simulations are summarized to demonstrate its powerful potential. It is observed that the material properties of aortic tissues and components of implanted valves should be modeled realistically to determine accurate results. For patient-specific AV geometries, incorporating calcific deposits on the leaflets is essential for ensuring the accuracy of computational findings. The results of numerical TAVI simulations indicate the significance of the selection of optimal valves and precise deployment within the appropriate anatomical position. These factors collectively contribute to the effective functionality of the implanted valve.

CONCLUSIONS

Recent studies in the literature have revealed the critical importance of patient-specific modeling, the selection of accurate material models, and bio-prosthetic valve diameters. Additionally, these studies emphasize the necessity of precise positioning of bio-prosthetic valves to achieve optimal performance in TAVI, characterized by an increased effective orifice area and minimal paravalvular leakage.

Evolving capabilities of computed tomography imaging for transcatheter valvular heart interventions - new opportunities for precision medicine

The last decade has witnessed a substantial growth in percutaneous treatment options for heart valve disease. The development in these innovative therapies has been mirrored by advances in multi-detector computed tomography (MDCT). MDCT plays a central role in obtaining detailed pre-procedural anatomical information, helping to inform clinical decisions surrounding procedural planning, improve clinical outcomes and prevent potential complications. Improvements in MDCT image acquisition and processing techniques have led to increased application of advanced analytics in routine clinical care. Workflow implementation of patient-specific computational modeling, fluid dynamics, 3D printing, extended reality, extracellular volume mapping and artificial intelligence are shaping the landscape for delivering patient-specific care. This review will provide an insight of key innovations in the field of MDCT for planning transcatheter heart valve interventions.

Validation evidence with experimental and clinical data to establish credibility of TAVI patient-specific simulations

PURPOSE

The objective of this study is to validate a novel workflow for implementing patient-specific finite element (FE) simulations to virtually replicate the Transcatheter Aortic Valve Implantation (TAVI) procedure.

METHODS

Seven patients undergoing TAVI were enrolled. Patient-specific anatomical models were reconstructed from pre-operative computed tomography (CT) scans and subsequentially discretized, considering the native aortic leaflets and calcifications. Moreover, high-fidelity models of CoreValve Evolut R and Acurate Neo2 valves were built. To determine the most suitable material properties for the two stents, an accurate calibration process was undertaken. This involved conducting crimping simulations and fine-tuning Nitinol parameters to fit experimental force-diameter curves. Subsequently, FE simulations of TAVI procedures were conducted. To validate the reliability of the implemented implantation simulations, qualitative and quantitative comparisons with post-operative clinical data, such as angiographies and CT scans, were performed.

RESULTS

For both devices, the simulation curves closely matched the experimental data, indicating successful validation of the valves mechanical behaviour. An accurate qualitative superimposition with both angiographies and CTs was evident, proving the reliability of the simulated implantation. Furthermore, a mean percentage difference of 1,79 ± 0,93 % and 3,67 ± 2,73 % between the simulated and segmented final configurations of the stents was calculated in terms of orifice area and eccentricity, respectively.

CONCLUSION

This study shows the successful validation of TAVI simulations in patient-specific anatomies, offering a valuable tool to optimize patients care through personalized pre-operative planning. A systematic approach for the validation is presented, laying the groundwork for enhanced predictive modeling in clinical practice.

Fluid-structure interaction analysis of a healthy aortic valve and its surrounding haemodynamics

The opening and closing dynamics of the aortic valve (AV) has a strong influence on haemodynamics in the aortic root, and both play a pivotal role in maintaining normal physiological functions of the valve. The aim of this study was to establish a subject-specific fluid-structure interaction (FSI) workflow capable of simulating the motion of a tricuspid healthy valve and the surrounding haemodynamics under physiologically realistic conditions. A subject-specific aortic root was reconstructed from magnetic resonance (MR) images acquired from a healthy volunteer, whilst the valve leaflets were built using a parametric model fitted to the subject-specific aortic root geometry. The material behaviour of the leaflets was described using the isotropic hyperelastic Ogden model, and subject-specific boundary conditions were derived from 4D-flow MR imaging (4D-MRI). Strongly coupled FSI simulations were performed using a finite volume-based boundary conforming method implemented in FlowVision. Our FSI model was able to simulate the opening and closing of the AV throughout the entire cardiac cycle. Comparisons of simulation results with 4D-MRI showed a good agreement in key haemodynamic parameters, with stroke volume differing by 7.5% and the maximum jet velocity differing by less than 1%. Detailed analysis of wall shear stress (WSS) on the leaflets revealed much higher WSS on the ventricular side than the aortic side and different spatial patterns amongst the three leaflets.

Fluid-Solid Interaction Analysis for Developing In-Situ Strain and Flow Sensors for Prosthetic Valve Monitoring

Transcatheter aortic valve implantation (TAVI) was initially developed for adult patients, but there is a growing interest to expand this procedure to younger individuals with longer life expectancies. However, the gradual degradation of biological valve leaflets in transcatheter heart valves (THV) presents significant challenges for this extension. This study aimed to establish a multiphysics computational framework to analyze structural and flow measurements of TAVI and evaluate the integration of optical fiber and photoplethysmography (PPG) sensors for monitoring valve function. A two-way fluid-solid interaction (FSI) analysis was performed on an idealized aortic vessel before and after the virtual deployment of the SAPIEN 3 Ultra (S3) THV. Subsequently, an analytical analysis was conducted to estimate the PPG signal using computational flow predictions and to analyze the effect of different pressure gradients and distances between PPG sensors. Circumferential strain estimates from the embedded optical fiber in the FSI model were highest in the sinus of Valsalva; however, the optimal fiber positioning was found to be distal to the sino-tubular junction to minimize bending effects. The findings also demonstrated that positioning PPG sensors both upstream and downstream of the bioprosthesis can be used to effectively assess the pressure gradient across the valve. We concluded that computational modeling allows sensor design to quantify vessel wall strain and pressure gradients across valve leaflets, with the ultimate goal of developing low-cost monitoring systems for detecting valve deterioration.

A fast in silico model for preoperative risk assessment of paravalvular leakage

In silico simulations can be used to evaluate and optimize the safety, quality, efficacy and applicability of medical devices. Furthermore, in silico modeling is a powerful tool in therapy planning to optimally tailor treatment for each patient. For this purpose, a workflow to perform fast preoperative risk assessment of paravalvular leakage (PVL) after transcatheter aortic valve replacement (TAVR) is presented in this paper. To this end, a novel, efficient method is introduced to calculate the regurgitant volume in a simplified, but sufficiently accurate manner. A proof of concept of the method is obtained by comparison of the calculated results with results obtained from in vitro experiments. Furthermore, computational fluid dynamics (CFD) simulations are used to validate more complex stenosis scenarios. Comparing the simplified leakage model to CFD simulations reveals its potential for procedure planning and qualitative preoperative risk assessment of PVL. Finally, a 3D device deployment model and the efficient leakage model are combined to showcase the application of the presented leakage model, by studying the effect of stent size and the degree of stenosis on the regurgitant volume. The presented leakage model is also used to visualize the leakage path. To generalize the leakage model to a wide range of clinical applications, further validation on a large cohort of patients is needed to validate the accuracy of the model's prediction under various patient-specific conditions.

Mechanical behaviors of a new elliptical valve stent in bicuspid aortic valve

BACKGROUND AND OBJECTIVE

The conventional valve stents that are cylindrical in shape will become elliptical when implanted in bicuspid aortic valve, thereby reducing the durability of the artificial valve. In this study, a new design of valve stent is presented where valve stents have elliptical cross-section at the annulus and it is expected to have better expandability and circle shape during the interaction between the stent and bicuspid aortic valve, thereby extending the durability of artificial valve.

METHODS

Finite element method (FEM) is used to study the mechanical behavior of the novel valve stent in the bicuspid aortic valve. The effects of three matching relationship between the ellipticity of the stents and the ellipticity of the annulus (i.e., the ellipticity of the stent is greater than, equal to and less than the annulus ellipticity, respectively) on the mechanical behavior of stent expansion are studied. In addition, the expansion mechanical behavior of the novel valve stent at different implantation depths is also compared.

RESULTS

Results indicate that novel valve stent implantation with elliptical features is superior to conventional circular valve stent. When the novel valve stent ellipticity is less than the annulus ellipticity, the ellipticity of the novel valve stent after implantation is smaller than that of the conventional circular valve stent. This indicated that the novel valve stent has better expandability and post-expansion shape, making artificial valve to have better durability. The risk of paravalvular leak after implantation is lowest when the novel valve stent ellipticity is less than annulus ellipticity. When the novel valve stent ellipticity coincides with annulus ellipticity, the aortic wall is subjected to greatest stress. With the increase of implantation depth, the stress on the novel valve stent decrease.

CONCLUSIONS

This study might provide insights for improving stent design for bicuspid aortic valve.

On the Material Constitutive Behavior of the Aortic Root in Patients with Transcatheter Aortic Valve Implantation

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is a minimally invasive procedure used to treat patients with severe aortic valve stenosis. However, there is limited knowledge on the material properties of the aortic root in TAVI patients, and this can impact the credibility of computer simulations. This study aimed to develop a non-invasive inverse approach for estimating reliable material constituents for the aortic root and calcified valve leaflets in patients undergoing TAVI.

METHODS

The identification of material parameters is based on the simultaneous minimization of two cost functions, which define the difference between model predictions and cardiac-gated CT measurements of the aortic wall and valve orifice area. Validation of the inverse analysis output was performed comparing the numerical predictions with actual CT shapes and post-TAVI measures of implanted device diameter.

RESULTS

A good agreement of the peak systolic shape of the aortic wall was found between simulations and imaging, with similarity index in the range in the range of 83.7% to 91.5% for n.20 patients. Not any statistical difference was observed between predictions and CT measures of orifice area for the stenotic aortic valve. After TAVI simulations, the measurements of SAPIEN 3 Ultra (S3) device diameter were in agreement with those from post-TAVI angio-CT imaging. A sensitivity analysis demonstrated a modest impact on the S3 diameters when altering the elastic material property of the aortic wall in the range of inverse analysis solution.

CONCLUSIONS

Overall, this study demonstrates the feasibility and potential benefits of using non-invasive imaging techniques and computational modeling to estimate material properties in patients undergoing TAVI.

Differences in blood flow dynamics between balloon- and self-expandable valves in patients with aortic stenosis undergoing transcatheter aortic valve replacement

BACKGROUND

The differences in pre- and early post-procedural blood flow dynamics between the two major types of bioprosthetic valves, the balloon-expandable valve (BEV) and self-expandable valve (SEV), in patients with aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR), have not been investigated. We aimed to investigate the differences in blood flow dynamics between the BEV and SEV using four-dimensional flow cardiovascular magnetic resonance (4D flow CMR).

METHODS

We prospectively examined 98 consecutive patients with severe AS who underwent TAVR between May 2018 and November 2021 (58 BEV and 40 SEV) after excluding those without CMR because of a contraindication, inadequate imaging from the analyses, or patients' refusal. CMR was performed in all participants before (median interval, 22 [interquartile range (IQR) 4-39] days) and after (median interval, 6 [IQR 3-6] days) TAVR. We compared the changes in blood flow patterns, wall shear stress (WSS), and energy loss (EL) in the ascending aorta (AAo) between the BEV and SEV using 4D flow CMR.

RESULTS

The absolute reductions in helical flow and flow eccentricity were significantly higher in the SEV group compared in the BEV group after TAVR (BEV: - 0.22 ± 0.86 vs. SEV: - 0.85 ± 0.80, P < 0.001 and BEV: - 0.11 ± 0.79 vs. SEV: - 0.50 ± 0.88, P = 0.037, respectively); there were no significant differences in vortical flow between the groups. The absolute reduction of average WSS was significantly higher in the SEV group compared to the BEV group after TAVR (BEV: - 0.6 [- 2.1 to 0.5] Pa vs. SEV: - 1.8 [- 3.5 to - 0.8] Pa, P = 0.006). The systolic EL in the AAo significantly decreased after TAVR in both the groups, while the absolute reduction was comparable between the groups.

CONCLUSIONS

Helical flow, flow eccentricity, and average WSS in the AAo were significantly decreased after SEV implantation compared to BEV implantation, providing functional insights for valve selection in patients with AS undergoing TAVR. Our findings offer valuable insights into blood flow dynamics, aiding in the selection of valves for patients with AS undergoing TAVR. Further larger-scale studies are warranted to confirm the prognostic significance of hemodynamic changes in these patients.

A Systematic Review of Individualized Heart Surgery with a Personalized Prosthesis

Personalized surgery is not just a new trend but rather a patient-specific approach to therapy that makes it possible to adopt a targeted approach for a specific patient and closely mirrors the approach of personalized medicine. However, the application of tailored surgery in the context of cardiovascular replacement surgery has not been systematically reviewed. The ability to customize a device is highly dependent on the collection of radiological image data for precise prosthesis modeling. These facts are essential to "tailor-made" device design for precise prosthesis implantation. According to this study, computed tomography (CT) was the most prominent imaging modality; however, transesophageal echocardiography and echocardiography were also found to be helpful. Additionally, a dynamic finite element simulation was also found to be an attractive alternative to the finite element analysis for an in-silico experiment. Nonetheless, there is a paucity of relevant publications and only sporadic evidence. More clinical studies have been warranted, notwithstanding that the derived data and results from this insight into the use of therapeutic interventions may be evidence of multiple directives in clinical practices and beyond. This study may help the integration of personalized devices for better comprehension of predicted clinical outcomes, thus leading towards enhanced performance gains.

Parametric analysis of transcatheter aortic valve replacement in transcatheter aortic valve replacement: evaluation of coronary flow obstruction

Transcatheter aortic valve replacement (TAVR) is increasingly being considered for use in younger patients having longer life expectancy than those who were initially treated. The TAVR-in-TAVR procedure represents an appealing strategy to treat failed transcatheter heart valves (THV) likely occurring in young patients. However, the permanent displacement of first THV can potentially compromise the coronary access and ultimately inhibit the blood flow circulation. The objective of this study was to use finite-element analysis (FEA) to quantify coronary flow in a patient who underwent TAVR-in-TAVR. A parametric investigation was carried out to determine the impact of both the implantation depth and device size on coronary flow for several deployment configurations. The FEAs consisted of first delivering the SAPIEN 3 Ultra THV and then positioning the Evolut PRO device. Findings indicates that high implantation depth and device undersize of the second THV could significantly reduce coronary flow to 20% of its estimated level before TAVR. Additionally, a positive correlation was observed between coronary flow and the valve-to-coronary distance (R = 0.86 and p = 0.032 for the left coronary artery, and R = 0.93 and p = 0.014 for the right coronary artery). This study demonstrated that computational modeling can provide valuable insights to improve the pre-procedural planning of TAVR-in-TAVR.

Latest Developments in Adapting Deep Learning for Assessing TAVR Procedures and Outcomes

Aortic valve defects are among the most prevalent clinical conditions. A severely damaged or non-functioning aortic valve is commonly replaced with a bioprosthetic heart valve (BHV) via the transcatheter aortic valve replacement (TAVR) procedure. Accurate pre-operative planning is crucial for a successful TAVR outcome. Assessment of computational fluid dynamics (CFD), finite element analysis (FEA), and fluid-solid interaction (FSI) analysis offer a solution that has been increasingly utilized to evaluate BHV mechanics and dynamics. However, the high computational costs and the complex operation of computational modeling hinder its application. Recent advancements in the deep learning (DL) domain can offer a real-time surrogate that can render hemodynamic parameters in a few seconds, thus guiding clinicians to select the optimal treatment option. Herein, we provide a comprehensive review of classical computational modeling approaches, medical imaging, and DL approaches for planning and outcome assessment of TAVR. Particularly, we focus on DL approaches in previous studies, highlighting the utilized datasets, deployed DL models, and achieved results. We emphasize the critical challenges and recommend several future directions for innovative researchers to tackle. Finally, an end-to-end smart DL framework is outlined for real-time assessment and recommendation of the best BHV design for TAVR. Ultimately, deploying such a framework in future studies will support clinicians in minimizing risks during TAVR therapy planning and will help in improving patient care.

Effects of leaflet curvature and thickness on the crimping stresses in transcatheter heart valve

With the current advances and expertise in biomedical device technologies, transcatheter heart valves (THVs) have been drawing significant attention. Various studies have been carried out on their durability and damage by dynamic loading in operational conditions. However, very few numerical investigations have been conducted to understand the effects of leaflet curvature and thickness on the crimping stresses which arise during the surgical preparation processes. In order to contribute to the current state of the art, a full heart valve model was presented, the leaflet curvature and thickness of which were then parameterized so as to understand the stress generation as a result of the crimping procedure during the surgical preparations. The results show that the existence of stresses is inevitable during the crimping procedure, which is a reduction factor for valve durability. Especially, stresses on the leaflets at the suture sites connected with the skirt were deduced to be critical and may result in leaflet ruptures after THV implantation.

Fluid-structure interaction analysis of transcatheter aortic valve implantation

Transcatheter aortic valve implantation (TAVI) is a minimally invasive intervention for the treatment of severe aortic valve stenosis. The main cause of failure is the structural deterioration of the implanted prosthetic leaflets, possibly inducing a valvular re-stenosis 5-10 years after the implantation. Based solely on pre-implantation data, the aim of this work is to identify fluid-dynamics and structural indices that may predict the possible valvular deterioration, in order to assist the clinicians in the decision-making phase and in the intervention design. Patient-specific, pre-implantation geometries of the aortic root, the ascending aorta, and the native valvular calcifications were reconstructed from computed tomography images. The stent of the prosthesis was modeled as a hollow cylinder and virtually implanted in the reconstructed domain. The fluid-structure interaction between the blood flow, the stent, and the residual native tissue surrounding the prosthesis was simulated by a computational solver with suitable boundary conditions. Hemodynamical and structural indicators were analyzed for five different patients that underwent TAVI - three with prosthetic valve degeneration and two without degeneration - and the comparison of the results showed a correlation between the leaflets' structural degeneration and the wall shear stress distribution on the proximal aortic wall. This investigation represents a first step towards computational predictive analysis of TAVI degeneration, based on pre-implantation data and without requiring additional peri-operative or follow-up information. Indeed, being able to identify patients more likely to experience degeneration after TAVI may help to schedule a patient-specific timing of follow-up.

A review of numerical simulation in transcatheter aortic valve replacement decision optimization

BACKGROUND

Recent trials indicated a further expansion of clinical indication of transcatheter aortic valve replacement to younger and low-risk patients. Factors related to longer-term complications are becoming more important for use in these patients. Accumulating evidence indicates that numerical simulation plays a significant role in improving the outcome of transcatheter aortic valve replacement. Understanding mechanical features' magnitude, pattern, and duration is a topic of ongoing relevance.

METHODS

We searched the PubMed database using keywords such as "transcatheter aortic valve replacement" and "numerical simulation" and reviewed and summarized relevant literature.

FINDINGS

This review integrated recently published evidence into three subtopics: 1) prediction of transcatheter aortic valve replacement outcomes through numerical simulation, 2) implications for surgeons, and 3) trends in transcatheter aortic valve replacement numerical simulation.

INTERPRETATIONS

Our study offers a comprehensive overview of the utilization of numerical simulation in the context of transcatheter aortic valve replacement, and highlights the advantages, potential challenges from a clinical standpoint. The convergence of medicine and engineering plays a pivotal role in enhancing the outcomes of transcatheter aortic valve replacement. Numerical simulation has provided evidence of potential utility for tailored treatments.

Biomechanical performance of the Bicaval Transcatheter System for the treatment of severe tricuspid regurgitation

Introduction: Tricuspid regurgitation (TR) is a relatively common valvular disease, which can result from structural abnormalities of any anatomic part of the tricuspid valve. Severe TR is linked to congestive heart failure and hemodynamic impairment, resulting in high mortality when repaired by elective surgery. This study was undertaken to quantify the structural and hemodynamic performance of the novel Transcatheter Bicaval Valves System (TricValve) percutaneously implanted in the superior vena cava (SVC) and inferior vena cava (IVC) of two patients with severe TR and venous congestion. Methods: After developing the SVC and IVC device models, the contact pressure exerted on the vena cava wall was obtained by computational analysis. Both smoothed-particle hydrodynamics (SPH) and computational fluid dynamics were carried out to quantify caval reflux in the right atrium and the pressure field of pre- and post-TricValve scenarios, respectively. Results: Analysis of contact pressure highlighted the main anchoring area of the SVC device occurring near the SVC device belly, while the IVC device exerted pronounced forces in the device's proximal and distal parts. SPH-related flow velocities revealed the absence of caval reflux, and a decrease in time-averaged pressure was observed near the SVC and IVC after TricValve implantation. Discussion: Findings demonstrated the potential of computational tools for enhancing our understanding of the biomechanical performance of structural tricuspid valve interventions and improving the way we design next-generation transcatheter therapies to treat the tricuspid valve with heterotopic caval valve implantation.

Risk evaluation of adverse aortic events in patients with non-circular aortic annulus after transcatheter aortic valve implantation: a numerical study

Transcatheter aortic valve implantation (TAVI) is a micro-invasive surgery used to treat patients with aortic stenosis (AS) efficiently. However, the uneven valve expansion can cause a non-circular annulus, which is one of the main factors leading to complications after TAVI. As a preliminary work, the main purpose of this study was to evaluate the risk of adverse aortic events in patients with a non-circular aortic annulus after TAVI. This study numerically investigated the distribution of four wall shear stress (WSS)-based indicators and three helicity-based indicators in eight patient-specific aortas with different annulus including circular, type I elliptical and type II elliptical shapes. Both elliptical annulus features can significantly enhance the intensity of the helicity (h2) in the ascending aorta (p < 0.001). However, for the type I elliptical annulus, the spiral flow structure was changed into low-velocity and disturbed flow pattern close to the inner side of the aortic arch. For the type II elliptical annulus, the spiral flow remained but became skewed in distribution. The elliptical annulus feature could increase the general level WSS-based indicators, especially in the ascending aorta. However, due to the disturbance of spiral flow or second helical flow in ascending aortas, areas with low TAWSS accompanied by high oscillatory shear index (OSI) and cross flow index (CFI) were observed in all the ascending aortas with non-circular annulus. The elliptical annulus feature can change the hemodynamic environment in the aortic arch, especially in the ascending aorta. Although both elliptical annulus features enhanced the strength of helicity, the uniform distribution of the helical flow was disturbed, especially in the ascending aorta, indicating the potential risk of adverse aortic events may increase. Therefore, for the patients without paravalvular leak but elliptical annulus shape after TAVI treatment, surgeons may be needed to consider further dilatation to make the non-circular annulus become circular.

Transcatheter Tricuspid Valve Replacement: Illustrative Case Reports and Review of State-of-Art

Tricuspid regurgitation (TR) is one of the most common heart valve diseases, associated a with poor prognosis since significant TR is associated with an increased mortality risk compared to no TR or mild regurgitation. Surgery is the standard treatment for TR, although it is associated with high morbidity, mortality, and prolonged hospitalization, particularly in tricuspid reoperation after left-sided surgery. Thus, several innovative percutaneous transcatheter approaches for repair and replacement of the tricuspid valve have gathered significant momentum and have undergone extensive clinical development in recent years, with favorable clinical outcomes in terms of mortality and rehospitalization during the first year of follow-up. We present three clinical cases of transcatheter tricuspid valve replacement in an orthotopic position with two different innovative systems along with a review of the state-of-the-art of this emergent topic.

Identification of Heart Arrhythmias by Utilizing a Deep Learning Approach of the ECG Signals on Edge Devices

Accurate and timely detection of cardiac arrhythmias is crucial in reducing treatment times and, ultimately, preventing serious life-threatening complications, such as the incidence of a stroke. This becomes of major importance, especially during the diagnostic process, where there is limited access to cardiologists, such as in hospital emergency departments. The proposed lightweight solution uses a novel classifier, consistently designed and implemented, based on a 2D convolutional neural network (CNN) and properly optimized in terms of storage and computational complexity, thus making it suitable for deployment on edge devices capable of operating in hospital emergency departments, providing privacy, portability, and constant operation. The experiments on the MIT-BIH arrhythmia database, show that the proposed 2D-CNN obtains an overall accuracy of 95.3%, mean sensitivity of 95.27%, mean specificity of 98.82%, and a One-vs-Rest ROC-AUC score of 0.9934. Moreover, the results and metrics based on the NVIDIA® Jetson Nano™ platform show that the proposed method achieved excellent performance and speed, and would be particularly useful in the clinical practice for continuous real-time (RT) monitoring scenarios.

Validating In Silico and In Vitro Patient-Specific Structural and Flow Models with Transcatheter Bicuspid Aortic Valve Replacement Procedure

INTRODUCTION

Bicuspid aortic valve (BAV) is the most common congenital cardiac malformation, which had been treated off-label by transcatheter aortic valve replacement (TAVR) procedure for several years, until its recent approval by the Food and Drug Administration (FDA) and Conformité Européenne (CE) to treat BAVs. Post-TAVR complications tend to get exacerbated in BAV patients due to their inherent aortic root pathologies. Globally, due to the paucity of randomized clinical trials, clinicians still favor surgical AVR as the primary treatment option for BAV patients. While this warrants longer term studies of TAVR outcomes in BAV patient cohorts, in vitro experiments and in silico computational modeling can be used to guide the surgical community in assessing the feasibility of TAVR in BAV patients. Our goal is to combine these techniques in order to create a modeling framework for optimizing pre-procedural planning and minimize post-procedural complications.

MATERIALS AND METHODS

Patient-specific in silico models and 3D printed replicas of 3 BAV patients with different degrees of post-TAVR paravalvular leakage (PVL) were created. Patient-specific TAVR device deployment was modeled in silico and in vitro-following the clinical procedures performed in these patients. Computational fluid dynamics simulations and in vitro flow studies were performed in order to obtain the degrees of PVL in these models.

RESULTS

PVL degree and locations were consistent with the clinical data. Cross-validation comparing the stent deformation and the flow parameters between the in silico and the in vitro models demonstrated good agreement.

CONCLUSION

The current framework illustrates the potential of using simulations and 3D printed models for pre-TAVR planning and assessing post-TAVR complications in BAV patients.

Self-expandable stent for thrombus removal modeling: Solid or beam finite elements?

BACKGROUND

The performance of self-expandable stents is being increasingly studied by means of finite-element analysis. As for peripheral stents, transcatheter valves and stent-grafts, there are numerous computational studies for setting up a proper model, this information is missing for stent-retrievers used in the procedure of thrombus removal in cerebral arteries. It is well known that the selection of the appropriate finite-element dimensions (topology) and formulations (typology) is a fundamental step to set up accurate and reliable computational simulations. In this context, a thorough verification analysis is here proposed, aimed at investigating how the different element typologies and topologies - available to model a stent-retriever - affect simulation results.

METHOD

Hexahedral and beam element formulations were analyzed first individually by virtually replicating a crimping test on the device, and then by replicating the thrombectomy procedure aiming at removing a thrombus from a cerebral vessel. In particular, three discretization refinements for each element type and different element formulations including both full and reduced integration were investigated and compared in terms of the resultant radial force of the stent and the stress field generated in the thrombus.

RESULTS

The sensitivity analysis on the element formulation performed with the crimping simulations allowed the identification of the optimal setting for each element family. Both setting lead to similar results in terms of stent performance in the virtual thrombectomy and should be used in future studies simulating the mechanical thrombectomy with stent-retrievers.

CONCLUSIONS

The carried out virtual thrombectomy procedures confirmed that the beam element formulation results were sufficiently accurate to model the radial force and the performance of the stent-retriever during the procedure. For different self-expandable stents, hexahedral formulation could be essential in stress analysis.

Patient-specific multi-scale design optimization of transcatheter aortic valve stents

BACKGROUND AND OBJECTIVE

Transcatheter aortic valve implantation (TAVI) has become the standard treatment for a wide range of patients with aortic stenosis. Although some of the TAVI post-operative complications are addressed in newer designs, other complications and lack of long-term and durability data on the performance of these prostheses are limiting this procedure from becoming the standard for heart valve replacements. The design optimization of these devices with the finite element and optimization techniques can help increase their performance quality and reduce the risk of malfunctioning. Most performance metrics of these prostheses are morphology-dependent, and the design and the selection of the device before implantation should be planned for each individual patient.

METHODS

In this study, a patient-specific aortic root geometry was utilized for the crimping and implantation simulation of 50 stent samples. The results of simulations were then evaluated and used for developing regression models. The strut width and thickness, the number of cells and patterns, the size of stent cells, and the diameter profile of the stent were optimized with two sets of optimization processes. The objective functions included the maximum crimping strain, radial strength, anchorage area, and the eccentricity of the stent.

RESULTS

The optimization process was successful in finding optimal models with up to 40% decrease in the maximum crimping strain, 261% increase in the radial strength, 67% reduction in the eccentricity, and about an eightfold increase in the anchorage area compared to the reference device.

CONCLUSIONS

The stents with larger distal diameters perform better in the selected objective functions. They provide better anchorage in the aortic root resulting in a smaller gap between the device and the surrounding tissue and smaller contact pressure. This framework can be used in designing patient-specific stents and improving the performance of these devices and the outcome of the implantation process.

Fluid-Structure Interaction Analysis on the Influence of the Aortic Valve Stent Leaflet Structure in Hemodynamics

Transcatheter aortic valve replacement (TAVR) is a minimally invasive surgical treatment for heart valve disease. At present, personalized TAVR valves are not available for some patients. This study adopts the fluid-structure interaction (FSI) model of the research object that has a three-disc leaflet form and structural design in the valve leaflet area. The valve opening shape, orifice area, stress-strain, and distribution of hemodynamic flow and pressure were compared under the condition of equal contact area between valve and blood. The FSI method was used to simulate the complex three dimensional characteristics of the flow field more accurately around the valve after TAVR stent implantation. Three personalized stent systems were established to study the performance of the leaflet design based on computational fluid dynamics. By comparing the different leaflet geometries, the maximum stress on leaflets and stents of model B was relatively reduced, which effectively improved the reliability of the stent design. Such valve design also causes the opening area of the valve leaflet to increase and the low-velocity area of the flow field to decrease during the working process of the valve, thus reducing the possibility of thrombosis. These findings can underpin breakthroughs in product design, and provide important theoretical support and technical guidance for clinical research.

Comparison of Balloon-Expandable Valve and Self-Expandable Valve in Transcatheter Aortic Valve Replacement: A Patient-Specific Numerical Study

Transcatheter aortic valve replacement (TAVR) is a minimally invasive strategy for the treatment of aortic stenosis. The complex post-operative complications of TAVR were related to the type of implanted prosthetic valve, and the deep mechanism of this relationship may guide the clinical pre-operative planning. The purpose of this study was to develop a numerical method of TAVR to compare the outcome difference between balloon-expandable valve and self-expandable valve and predict the post-operative results. A complete patient-specific aortic model was reconstructed. Two prosthetic valves (balloon-expandable valve and self-expandable valve) were introduced to simulate the implantation procedure, and post-procedural function was studied with fluid-structure interaction method, respectively. Results showed similar stress distribution for two valves, but higher peak stress for balloon-expandable valve model. Compared with the self-expandable valve, the balloon-expandable valve was associated with a better circular cross-section and smaller paravalvular gaps area. Hemodynamic parameters like cardiac output, mean transvalvular pressure difference and effective orifice area (EOA) of the balloon-expandable valve model were better than those of the self-expandable valve model. Significant outcome difference was found for two prosthetic valves. Balloon-expandable valve may effectively decrease the risk and degree of post-operative paravalvular leak, while self-expandable valve was conducive to lower stroke risk due to lower aortic stress. The numerical TAVR simulation process may become an assistant tool for prosthesis selection in pre-operative planning and post-operative prediction.

On the Modeling of Transcatheter Therapies for the Aortic and Mitral Valves: A Review

Transcatheter aortic valve replacement (TAVR) has become a milestone for the management of aortic stenosis in a growing number of patients who are unfavorable candidates for surgery. With the new generation of transcatheter heart valves (THV), the feasibility of transcatheter mitral valve replacement (TMVR) for degenerated mitral bioprostheses and failed annuloplasty rings has been demonstrated. In this setting, computational simulations are modernizing the preoperative planning of transcatheter heart valve interventions by predicting the outcome of the bioprosthesis interaction with the human host in a patient-specific fashion. However, computational modeling needs to carry out increasingly challenging levels including the verification and validation to obtain accurate and realistic predictions. This review aims to provide an overall assessment of the recent advances in computational modeling for TAVR and TMVR as well as gaps in the knowledge limiting model credibility and reliability.

Computational Methods for Fluid-Structure Interaction Simulation of Heart Valves in Patient-Specific Left Heart Anatomies

Given the complexity of human left heart anatomy and valvular structures, the fluid–structure interaction (FSI) simulation of native and prosthetic valves poses a significant challenge for numerical methods. In this review, recent numerical advancements for both fluid and structural solvers for heart valves in patient-specific left hearts are systematically considered, emphasizing the numerical treatments of blood flow and valve surfaces, which are the most critical aspects for accurate simulations. Numerical methods for hemodynamics are considered under both the continuum and discrete (particle) approaches. The numerical treatments for the structural dynamics of aortic/mitral valves and FSI coupling methods between the solid Ωs and fluid domain Ωf are also reviewed. Future work toward more advanced patient-specific simulations is also discussed, including the fusion of high-fidelity simulation within vivo measurements and physics-based digital twining based on data analytics and machine learning techniques.

Virtual Reality in the Preoperative Planning of Adult Aortic Surgery: A Feasibility Study

Background: Complex aortic anatomy needs careful preoperative planning in which a patient-tailored approach with novel immersive techniques could serve as a valuable addition to current preoperative imaging. This pilot study aimed to investigate the technical feasibility of virtual reality (VR) as an additional imaging tool for preoperative planning in ascending aortic surgery. Methods: Ten cardiothoracic surgeons were presented with six patients who had each undergone a recent repair of the ascending aorta. Two-dimensional computed tomography images of each patient were assessed prior to the VR session. After three-dimensional (3D) VR rendering and 3D segmentation of the ascending aorta and aortic arch, the reconstructions were analyzed by each surgeon in VR via a head-mounted display. Each cardiothoracic surgeon completed a questionnaire after each planning procedure. The results of their assessments were compared to the performed operations. The primary endpoint of the present study was a change of surgical approach from open to clamped distal anastomosis, and vice versa. Results: Compared with conventional imaging, 80% of surgeons found that VR prepared them better for surgery. In 33% of cases (two out of six), the preoperative decision was adjusted due to the 3D VR-based evaluation of the anatomy. Surgeons rated CardioVR usefulness, user-friendliness, and satisfaction with median scores of 3.8 (IQR: 3.5-4.1), 4.2 (IQR: 3.8-4.6,) and 4.1 (IQR: 3.8-4.7) on a five-point Likert scale, respectively. Conclusions: Three-dimensional VR imaging was associated with improved anatomical understanding among surgeons and could be helpful in the future preoperative planning of ascending aortic surgery.

Atlas-Based Evaluation of Hemodynamic in Ascending Thoracic Aortic Aneurysms

Atlas-based analyses of patients with cardiovascular diseases have recently been explored to understand the mechanistic link between shape and pathophysiology. The construction of probabilistic atlases is based on statistical shape modeling (SSM) to assess key anatomic features for a given patient population. Such an approach is relevant to study the complex nature of the ascending thoracic aortic aneurysm (ATAA) as characterized by different patterns of aortic shapes and valve phenotypes. This study was carried out to develop an SSM of the dilated aorta with both bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV), and then assess the computational hemodynamic of virtual models obtained by the deformation of the mean template for specific shape boundaries (i.e., ±1.5 standard deviation, σ). Simulations demonstrated remarkable changes in the velocity streamlines, blood pressure, and fluid shear stress with the principal shape modes such as the aortic size (Mode 1), vessel tortuosity (Mode 2), and aortic valve morphologies (Mode 3). The atlas-based disease assessment can represent a powerful tool to reveal important insights on ATAA-derived hemodynamic, especially for aneurysms which are considered to have borderline anatomies, and thus challenging decision-making. The utilization of SSMs for creating probabilistic patient cohorts can facilitate the understanding of the heterogenous nature of the dilated ascending aorta.

Potential Applications of Computational Fluid Dynamics for Predicting Hemolysis in Mitral Paravalvular Leaks

Paravalvular leaks (PVLs) may lead to hemolysis. In vitro shear stress forces above 300 Pa cause erythrocyte destruction. PVL channel dimensions may determine magnitude of shear stress forces that affect erythrocytes; however, this has not been tested. It remains unclear how different properties of PVL channels contribute to presence of hemolysis. A model of a left ventricle was created based on data from computer tomography with Slicer software PVLs of various shapes and sizes were introduced. Blood flow was simulated using ANSYS Fluent software. The following variables were examined: wall shear stress, shear stress in fluid, volume of PVL channel with shear stress exceeding 300 Pa, and duration of exposure of erythrocytes to shear stress values above 300 Pa. In all models, shear stress forces exceeded 300 Pa. Shear stress increased with blood flow rates and cross-sectional areas of any PVL. There was no linear relationship between cross-sectional area of a PVL and volume of a PVL channel with shear stress > 300 Pa. Blood flow through mitral PVLs is associated with shear stress above 300 Pa. Cross-sectional area of a PVL does not correlate with volume of a PVL channel with shear stress > 300 Pa and duration of exposure of erythrocytes to shear stress > 300 Pa.

Assessment of Paravalvular Leak Severity and Thrombogenic Potential in Transcatheter Bicuspid Aortic Valve Replacements Using Patient-Specific Computational Modeling

Bicuspid aortic valve (BAV), the most common congenital valvular abnormality, generates asymmetric flow patterns and increased stresses on the leaflets that expedite valvular calcification and structural degeneration. Recently adapted for use in BAV patients, TAVR demonstrates promising performance, but post-TAVR complications tend to get exacerbated due to BAV anatomical complexities. Utilizing patient-specific computational modeling, we address some of these complications. The degree and location of post-TAVR PVL was assessed, and the risk of flow-induced thrombogenicity was analyzed in 3 BAV patients - using older generation TAVR devices that were implanted in these patients, and compared them to the performance of the newest generation TAVR devices using in silico patient models. Significant decrease in PVL and thrombogenic potential was observed after implantation of the newest generation device. The current work demonstrates the potential of using simulations in pre-procedural planning to assess post-TAVR complications, and compare the performance of different devices to achieve better clinical outcomes. Patient-specific computational framework to assess post-transcatheter bicuspid aortic valve replacement paravalvular leakage and flow-induced thrombogenic complications and compare device performances.

A computational optimization study of a self-expandable transcatheter aortic valve

Developing an efficient stent frame for transcatheter aortic valves (TAV) needs thorough investigation in different design and functional aspects. In recent years, most TAV studies have focused on their clinical performance, leaflet design, and durability. Although several optimization studies on peripheral stents exist, the TAV stents have different functional requirements and need to be explicitly studied. The aim of this study is to develop a cost-effective optimization framework to find the optimal TAV stent design made of Ni-Ti alloy. The proposed framework focuses on minimizing the maximum strain occurring in the stent during crimping, making use of a simplified model of the stent to reduce computational cost. The effect of the strut cross-section of the stent, i.e., width and thickness, and the number and geometry of the repeating units of the stent (both influencing the cell size) on the maximum strain is investigated. Three-dimensional simulations of the crimping process are used to verify the validity of the simplified representation of the stent, and the radial force has been calculated for further evaluation. The results suggest the key role of the number of cells (repeating units) and strut width on the maximum strain and, consequently, on the stent design. The difference in terms of the maximum strain between the simplified and the 3D model was less than 5%, confirming the validity of the adopted modeling strategy and the robustness of the framework to improve the TAV stent designs through a simple, cost-effective, and reliable procedure.

Transcatheter Heart Valve Implantation in Bicuspid Patients with Self-Expanding Device

Bicuspid aortic valve (BAV) patients are conventionally not treated by transcathether aortic valve implantation (TAVI) because of anatomic constraint with unfavorable outcome. Patient-specific numerical simulation of TAVI in BAV may predict important clinical insights to assess the conformability of the transcathether heart valves (THV) implanted on the aortic root of members of this challenging patient population. We aimed to develop a computational approach and virtually simulate TAVI in a group of n.6 stenotic BAV patients using the self-expanding Evolut Pro THV. Specifically, the structural mechanics were evaluated by a finite-element model to estimate the deformed THV configuration in the oval bicuspid anatomy. Then, a fluid–solid interaction analysis based on the smoothed-particle hydrodynamics (SPH) technique was adopted to quantify the blood-flow patterns as well as the regions at high risk of paravalvular leakage (PVL). Simulations demonstrated a slight asymmetric and elliptical expansion of the THV stent frame in the BAV anatomy. The contact pressure between the luminal aortic root surface and the THV stent frame was determined to quantify the device anchoring force at the level of the aortic annulus and mid-ascending aorta. At late diastole, PVL was found in the gap between the aortic wall and THV stent frame. Though the modeling framework was not validated by clinical data, this study could be considered a further step towards the use of numerical simulations for the assessment of TAVI in BAV, aiming at understanding patients not suitable for device implantation on an anatomic basis.

Understanding TAVR device expansion as it relates to morphology of the bicuspid aortic valve: A simulation study

The bicuspid aortic valve (BAV) is a common and heterogeneous congenital heart abnormality that is often complicated by aortic stenosis. Although initially developed for tricuspid aortic valves (TAV), transcatheter aortic valve replacement (TAVR) devices are increasingly applied to the treatment of BAV stenosis. It is known that patient-device relationship between TAVR and BAV are not equivalent to those observed in TAV but the nature of these differences are not well understood. We sought to better understand the patient-device relationships between TAVR devices and the two most common morphologies of BAV. We performed finite element simulation of TAVR deployment into three cases of idealized aortic anatomies (TAV, Sievers 0 BAV, Sievers 1 BAV), derived from patient-specific measurements. Valve leaflet von Mises stress at the aortic commissures differed by valve configuration over a ten-fold range (TAV: 0.55 MPa, Sievers 0: 6.64 MPa, and Sievers 1: 4.19 MPa). First principle stress on the aortic wall was greater in Sievers 1 (0.316 MPa) and Sievers 0 BAV (0.137 MPa) compared to TAV (0.056 MPa). TAVR placement in Sievers 1 BAV demonstrated significant device asymmetric alignment, with 1.09 mm of displacement between the center of the device measured at the annulus and at the leaflet free edge. This orifice displacement was marginal in TAV (0.33 mm) and even lower in Sievers 0 BAV (0.23 mm). BAV TAVR, depending on the subtype involved, may encounter disparate combinations of device under expansion and asymmetry compared to TAV deployment. Understanding the impacts of BAV morphology on patient-device relationships can help improve device selection, patient eligibility, and the overall safety of TAVR in BAV.

Patient-specific Computer Simulation: An Emerging Technology for Guiding the Transcatheter Treatment of Patients with Bicuspid Aortic Valve

Transcatheter aortic valve implantation (TAVI) is increasingly being used to treat younger, lower-risk patients, many of whom have bicuspid aortic valve (BAV). As TAVI begins to enter these younger patient cohorts, it is critical that clinical outcomes from TAVI in BAV are matched to those achieved by surgery. Therefore, the identification of patients who, on an anatomical basis, may not be suitable for TAVI, would be desirable. Furthermore, clinical outcomes of TAVI in BAV might be improved through improved transcatheter heart valve sizing and positioning. One potential solution to these challenges is patient-specific computer simulation. This review presents the methodology and clinical evidence surrounding patient-specific computer simulation of TAVI in BAV.

Predicting TAVI paravalvular regurgitation outcomes based on numerical simulation of the aortic annulus eccentricity and perivalvular areas

Trans-catheter aortic valve implantation (TAVI) is an increasingly adopted technique which provides a minimal invasive solution for patients who suffer from severe aortic stenosis. Some complications of the procedure could be annular rupture or paravalvular leakage, both related with adverse outcome. In TAVI with balloon expandable devices, a mismatch between those two factors leads to a conflict situation, where improving one worsens the other. The presented research proposes a methodology that uses numerical simulation to obtain certain TAVI outcomes related with aortic regurgitation due to paravalvular leakage, such as perivalvular area, aortic eccentricity or annular pressure. The application of the methodology for two patients shows the possibility of predicting those quantities. The highest stress values are distributed along the contact area. Results also show that a great deformation on the aortic annulus does not necessarily imply a higher stress; pressure can either be converted into root reshape or into root stretching. Validation of the results was done using scientific publications, clinical guidelines and clinical reports. Numerical simulation provides a suitable tool that could possibly contribute to optimize the planification procedure adjusting the mismatch between size and pressure.

In silico approaches for transcatheter aortic valve replacement inspection

Introduction: Increasing applications of transcatheter aortic valve replacement (TAVR) to treat high- or medium-risk patients with aortic diseases have been proposed in recent years. Despite its increasing use, many influential factors are still to be understood. Furthermore, innovative applications of TAVR such as in bicuspid aortic valves or in low-risk patients are emerging in clinical use. Numerical analyses are increasingly used to reproduce clinical treatments. The future trends in this area are foreseen for in silico trials and personalized medicine. Areas covered: This review paper analyzes the recent years (Jan 2018 - Aug 2020) of in silico studies simulating the behavior of transcatheter aortic valves with emphasis on the addressed clinical question and the used modeling strategies. The manuscripts are firstly classified based on their clinical hypothesis. A second classification is based on the adopted modeling approach in terms of patient domain, device modeling, and inclusion or exclusion of the fluid domain. Expert opinion: The TAVR can be virtually performed in numerous vessel geometries and with different devices. This versatility allows a rapid evaluation of the feasibility of different implantation approaches for specific patients, and patient populations, resulting in faster and safer introduction or optimization of new treatments or devices.

Pakistan Following Foot Prints of Developed World in Structural Interventions: Experience of Transcatheter Aortic Valve Implantation Reported First Time

Background

The aim of this study was to evaluate the safety and efficacy of transcatheter aortic valve implantation (TAVI) program in a Tertiary care hospital in Karachi, Pakistan.

Methodology

This study was conducted by interventional cardiology department of the National Institute of Cardiovascular Diseases (NICVD), Karachi from July 2015 to February 2020. All patients of severe aortic stenosis (AS) who underwent TAVI were included. Baseline characteristics, in-hospital course and one-month follow-up data were collected.

Results

This study included 100 consecutive patients with severe AS undergoing TAVI. Sixty-three (63.0%) patients were males and the mean age was 67.38 ± 10.73 years. Eighty-five (85%) patients were in the New York Heart Association (NYHA) class III-IV. Aortic valve mean gradient was 51.33±10.47 mmHg and 50% of patients had bicuspid aortic valves. Core valve was implanted in 86 (86%) and evolute-R aortic valve was implanted in 14 (14%) patients. TAVI was successfully done in 94% of patients. Post-deployment aortic valve mean gradient was 5.33±4.13 mmHg. Major vascular access site complications were noted in 14% and atrioventricular (AV) blocks were seen in 22% of cases. There was a significant difference in symptoms of patients before and after the procedure. Overall, eight (8%) patients expired during hospital stay. At one-month follow-up, 76% of patients were found to have no limitation of physical activities.

Conclusions

Results of this study showed that TAVI is a safe procedure in these high-risk patients and is an alternative to surgery for AS patients in the region.

The impact of calcification patterns in transcatheter aortic valve performance: a fluid-structure interaction analysis

Transcatheter aortic valve replacement (TAVR) strongly depends on the calcification patterns, which may lead to a malapposition of the stented valve and complication onsets in terms of structure kinematics and paravalvular leakage (PVL). From one anatomical-resembling model of the aortic root, six configurations with different calcific deposits were built. TAVR fluid-structure interaction simulations predicted different outcomes for the different calcifications patterns in terms of the final valve configuration in the implantation site and the PVL estimations. In particular models with deposits along the cups coaptation resulted in mild PVL, while those with deposits along the attachment line in moderate PVL.

Pre-Operative Modeling of Transcatheter Mitral Valve Replacement in a Surgical Heart Valve Bioprosthesis

Obstruction of the left ventricular outflow tract (LVOT) is a common complication of transcatheter mitral valve replacement (TMVR). This procedure can determine an elongation of an LVOT (namely, the neo-LVOT), ultimately portending hemodynamic impairment and patient death. This study aimed to understand the biomechanical implications of LVOT obstruction in a patient who underwent TMVR using a transcatheter heart valve (THV) to repair a failed bioprosthetic heart valve. We first reconstructed the heart anatomy and the bioprosthetic heart valve to virtually implant a computer-aided-design (CAD) model of THV and evaluate the neo-LVOT area. A numerical simulation of THV deployment was then developed to assess the anchorage of the THV to the bioprosthetic heart valve as well as the resulting Von Mises stress at the mitral annulus and the contract pressure among implanted bioprostheses. Quantification of neo-LVOT and THV deployment may facilitate more accurate predictions of the LVOT obstruction in TMVR and help clinicians in the optimal choice of the THV size.