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Long-term prognostic impact of paravalvular leakage on coronary artery disease requires patient-specific quantification of hemodynamics. Sci Rep 2022; 12:21357. [PMID: 36494362 PMCID: PMC9734172 DOI: 10.1038/s41598-022-21104-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 09/22/2022] [Indexed: 12/13/2022] Open
Abstract
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.
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Weisskopf M, Glaus L, Trimmel NE, Hierweger MM, Leuthardt AS, Kukucka M, Stolte T, Stoeck CT, Falk V, Emmert MY, Kofler M, Cesarovic N. Dos and don'ts in large animal models of aortic insufficiency. Front Vet Sci 2022; 9:949410. [PMID: 36118338 PMCID: PMC9478759 DOI: 10.3389/fvets.2022.949410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 07/22/2022] [Indexed: 11/14/2022] Open
Abstract
Aortic insufficiency caused by paravalvular leakage (PVL) is one of the most feared complications following transcatheter aortic valve replacement (TAVI) in patients. Domestic pigs (Sus scrofa domestica) are a popular large animal model to study such conditions and develop novel diagnostic and therapeutic techniques. However, the models based on prosthetic valve implantation are time intensive, costly, and often hamper further hemodynamic measurements such as PV loop and 4D MRI flow by causing implantation-related wall motion abnormalities and degradation of MR image quality. This study describes in detail, the establishment of a minimally invasive porcine model suitable to study the effects of mild-to-moderate “paravalvular“ aortic regurgitation on left ventricular (LV) performance and blood flow patterns, particularly under the influence of altered afterload, preload, inotropic state, and heart rate. Six domestic pigs (Swiss large white, female, 60–70 kg of body weight) were used to establish this model. The defects on the hinge point of aortic leaflets and annulus were created percutaneously by the pierce-and-dilate technique either in the right coronary cusp (RCC) or in the non-coronary cusp (NCC). The hemodynamic changes as well as LV performance were recorded by PV loop measurements, while blood flow patterns were assessed by 4D MRI. LV performance was additionally challenged by pharmaceutically altering cardiac inotropy, chronotropy, and afterload. The presented work aims to elaborate the dos and don'ts in porcine models of aortic insufficiency and intends to steepen the learning curve for researchers planning to use this or similar models by giving valuable insights ranging from animal selection to vascular access choices, placement of PV Loop catheter, improvement of PV loop data acquisition and post-processing and finally the induction of paravalvular regurgitation of the aortic valve by a standardized and reproducible balloon induced defect in a precisely targeted region of the aortic valve.
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Affiliation(s)
- Miriam Weisskopf
- Center for Surgical Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Lukas Glaus
- Department of Health Sciences and Technology, Swiss Federal Institute of Technology, Zurich, Switzerland
| | - Nina E. Trimmel
- Center for Surgical Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Melanie M. Hierweger
- Center for Surgical Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Andrea S. Leuthardt
- Center for Surgical Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Marian Kukucka
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Thorald Stolte
- Department of Health Sciences and Technology, Swiss Federal Institute of Technology, Zurich, Switzerland
| | - Christian T. Stoeck
- Center for Surgical Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Institute for Biomedical Engineering, University and ETH Zurich, Zurich, Switzerland
| | - Volkmar Falk
- Department of Health Sciences and Technology, Swiss Federal Institute of Technology, Zurich, Switzerland
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
- Department of Cardiovascular Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Maximilian Y. Emmert
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
- Department of Cardiovascular Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Markus Kofler
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Nikola Cesarovic
- Department of Health Sciences and Technology, Swiss Federal Institute of Technology, Zurich, Switzerland
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
- *Correspondence: Nikola Cesarovic
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Kananathan S, Perera LA, Mohanarajan M, Sherif M, Harky A. The management of paravalvular leaks post aortic valve replacement. J Card Surg 2022; 37:2786-2798. [PMID: 35695718 DOI: 10.1111/jocs.16672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 04/04/2022] [Accepted: 04/08/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Paravalvular leak (PVL) is uncommon but can lead to severe complications after surgical or transcatheter aortic valve implantation. Conditions associated with PVLs such as heart failure, hemolysis, and infective endocarditis can lead to catastrophic results if not treated promptly; the therapeutic goals differ according to the presentation. It is vital that PVLs are diagnosed early using various imaging modalities. Different approaches have been studied in managing PVLs; there is an increased interest in the transcatheter aortic valve closure procedure as it is minimally invasive and decreases the occurrence of further reinterventions. AIM To discuss the classification of PVLs, diagnostic approaches, and available management options. METHOD A literature review was performed using 28 studies. RESULTS This review evaluated the relationship between the time of diagnosis, management of PVL and the resulting outcomes. DISCUSSION Patients with PVL should be assessed through a multidisciplinary team approach and a patient-selective plan should be in place. CONCLUSION Open surgical intervention is reserved for complex cases where minimally invasive techniques cannot be utilized.
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Affiliation(s)
- Shalini Kananathan
- Dnipro Medical Institute of Traditional and Non-Traditional Medicine, Dnipro, Ukraine
| | | | - Maneeshaa Mohanarajan
- Dnipro Medical Institute of Traditional and Non-Traditional Medicine, Dnipro, Ukraine
| | - Mohamed Sherif
- Department of Cardiothoracic Surgery, Northern General Hospital, Sheffield, UK
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
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Successful Treatment of Severe Paravalvular Leak by Repositioning a Self-Expandable Percutaneous Aortic Valve Bioprosthesis (Evolut PRO+) Using the “Double Snare” Technique. Case Rep Cardiol 2022; 2022:4458109. [PMID: 35425645 PMCID: PMC9005318 DOI: 10.1155/2022/4458109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 03/10/2022] [Indexed: 11/24/2022] Open
Abstract
Significant (moderate or severe) paravalvular leak (PVL) after transcatheter aortic valve replacement (TAVR) remains a common phenomenon and has been associated with decrease survival and quality of life. Transcatheter valve embolization and migration (TVEM) is a rare post-TAVR complication that can occur in 1% of cases and has been associated with worse patient outcomes. Valve embolization or migration into the left ventricle can result in significant PVL causing hemodynamic instability, shock, heart failure, and hemolytic anemia. Although this complication most commonly occurs in the acute setting (90%) within 4 hours of TAVR, it can also present late (4 hr-43 days later) in 10% of cases. There are no clear guidelines as to how this condition should be managed; however, several percutaneous bailout techniques exist that can ultimately spare the patient from emergent cardiovascular surgery. We present a rare case of late ventricular transcatheter aortic valve migration 3 days after TAVR causing severe PVL and heart failure symptoms that was successfully treated using the percutaneous “double snare” technique.
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Bansal M, Kasliwal R. Role of Echocardiography in Guiding Transcatheter Aortic and Mitral Valve Replacement. JOURNAL OF THE INDIAN ACADEMY OF ECHOCARDIOGRAPHY & CARDIOVASCULAR IMAGING 2022. [DOI: 10.4103/jiae.jiae_45_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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