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Loke YH, Yildiran IN, Capuano F, Balaras E, Olivieri L. Tetralogy of Fallot regurgitation energetics and kinetics: an intracardiac flow analysis of the right ventricle using computational fluid dynamics. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2024; 40:1135-1147. [PMID: 38668927 DOI: 10.1007/s10554-024-03084-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 03/11/2024] [Indexed: 06/05/2024]
Abstract
Repaired Tetralogy of Fallot (rTOF) patients suffer from pulmonary regurgitation and may require pulmonary valve replacement (PVR). Cardiac magnetic resonance imaging (cMRI) guides therapy, but conventional measurements do not quantify the intracardiac flow effects from pulmonary regurgitation or PVR. This study investigates intracardiac flow parameters of the right ventricle (RV) of rTOF by computational fluid dynamics (CFD). cMRI of rTOF patients and controls were retrospectively included. Feature-tracking captured RV endocardial contours from long-axis/short-axis cine. Ventricular motion was reconstructed via diffeomorphic mapping, serving as domain boundary for CFD simulations. Vorticity (1/s), viscous energy loss (ELoss, mJ/L) and turbulent kinetic energy (TKE, mJ/L) were quantified in RV outflow tract (RVOT) and RV inflow. These parameters were normalized against total RV kinetic energy (KE) and RV inflow vorticity to derive dimensionless metrics. Vorticity contours by Q-criterion were qualitatively compared. rTOF patients (n = 15) had mean regurgitant fraction 38 ± 12% and RV size 162 ± 35 mL/m2. Compared to controls (n = 12), rTOF had increased RVOT vorticity (142.6 ± 75.6/s vs. 40.4 ± 11.8/s, p < 0.0001), Eloss (55.6 ± 42.5 vs. 5.2 ± 4.4 mJ/L, p = 0.0004), and TKE (5.7 ± 5.9 vs. 0.84 ± 0.46 mJ/L, p = 0.0003). After PVR, there was decrease in normalized RVOT Eloss/TKE (p = 0.0009, p = 0.029) and increase in normalized tricuspid inflow vorticity/KE (p = 0.0136, p = 0.043), corresponding to reorganization of the "donut"-shaped tricuspid ring-vortex. The intracardiac flow in rTOF patients can be simulated to determine the impact of PVR and improve the clinical indications guided by cardiac imaging.
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Affiliation(s)
- Yue-Hin Loke
- Department of Cardiology, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA.
| | - Ibrahim N Yildiran
- Laboratory for Computational Physics and Fluid Mechanics, Department of Mechanical and Aerospace Engineering, School of Engineering and Applied Science, George Washington University, Washington, DC, USA
| | - Francesco Capuano
- Department of Fluid Mechanics, Universitat Politècnica de Catalunya . BarcelonaTech (UPC), Barcelona, Spain
| | - Elias Balaras
- Laboratory for Computational Physics and Fluid Mechanics, Department of Mechanical and Aerospace Engineering, School of Engineering and Applied Science, George Washington University, Washington, DC, USA
| | - Laura Olivieri
- The Heart and Vascular Institute, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Kollar S, Balaras E, Olivieri LJ, Loke YH, Capuano F. Statistical shape modeling reveals the link between right ventricular shape, hemodynamic force, and myocardial function in patients with repaired tetralogy of Fallot. Am J Physiol Heart Circ Physiol 2022; 323:H449-H460. [PMID: 35839154 PMCID: PMC9394773 DOI: 10.1152/ajpheart.00228.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 07/11/2022] [Accepted: 07/11/2022] [Indexed: 11/22/2022]
Abstract
Patients with repaired tetralogy of Fallot (rTOF) can develop chronic pulmonary insufficiency (PI) with right ventricular (RV) dilation, progressive RV dysfunction, and decreased exercise capacity. Pulmonary valve replacement (PVR) can help reduce the amount of PI and RV dilation; however, optimal timing remains controversial; a better understanding of rTOF pathophysiology is of fundamental importance to inform clinical management of patients with rTOF and optimal timing of PVR. In this study, we hypothesize a tight interplay between RV shape, intracardiac biomechanics, and ventricular function in patients with rTOF. To explore this hypothesis and derive quantitative measures, we combined statistical shape modeling with physics-based analysis of in vivo 4D flow data in 36 patients with rTOF. Our study demonstrated for the first time a correlation between regional RV shape variations, hemodynamic forces (HDF), and clinical dysfunction in patients with rTOF. The main findings of this work include 1) general increase in RV size, due to both volume overload and physiological growth, correlated with decrease in strain magnitude in the respective directions, and with increased QRS; 2) regional PI-induced remodeling accounted for ∼10% of the shape variability of the population, and was associated with increased diastolic HDF along the diaphragm-to-right ventricular outflow tract (RVOT) direction, resulting in a net RV deformation along the same direction and decreased tricuspid annular plane systolic excursion (TAPSE); and 3) three shape modes independently correlated with systolic HDF and exercise capacity. Identification of patients based on the shape variations described in this study could help identify those at risk for irreversible dysfunction and guide optimal timing of PVR.NEW & NOTEWORTHY We combine statistical shape modeling with physics-based analysis of 4D flow data to elucidate the interplay between RV shape, hemodynamic forces, and clinical dysfunction in repaired tetralogy of Fallot. We are the first to show that ventricular remodeling is related to hemodynamic force magnitude and direction, global and regional functional parameters, and exercise intolerance. Identification of patients based on the shape variations described in this study could help identify those at risk for irreversible dysfunction.
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Affiliation(s)
- Sarah Kollar
- Division of Cardiology, Children's National Medical Center, Washington, District of Columbia
| | - Elias Balaras
- Department of Mechanical and Aerospace Engineering, George Washington University, Washington, District of Columbia
| | - Laura J Olivieri
- Division of Cardiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Yue-Hin Loke
- Division of Cardiology, Children's National Medical Center, Washington, District of Columbia
| | - Francesco Capuano
- Department of Fluid Mechanics, Universitat Politècnica de Catalunya-BarcelonaTech, Barcelona, Spain
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Loke YH, Capuano F, Kollar S, Cibis M, Kitslaar P, Balaras E, Reiber JHC, Pedrizzetti G, Olivieri L. Abnormal Diastolic Hemodynamic Forces: A Link Between Right Ventricular Wall Motion, Intracardiac Flow, and Pulmonary Regurgitation in Repaired Tetralogy of Fallot. Front Cardiovasc Med 2022; 9:929470. [PMID: 35911535 PMCID: PMC9329698 DOI: 10.3389/fcvm.2022.929470] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 06/20/2022] [Indexed: 11/25/2022] Open
Abstract
Background and Objective The effect of chronic pulmonary regurgitation (PR) on right ventricular (RV) dysfunction in repaired Tetralogy of Fallot (RTOF) patients is well recognized by cardiac magnetic resonance (CMR). However, the link between RV wall motion, intracardiac flow and PR has not been established. Hemodynamic force (HDF) represents the global force exchanged between intracardiac blood volume and endocardium, measurable by 4D flow or by a novel mathematical model of wall motion. In our study, we used this novel methodology to derive HDF in a cohort of RTOF patients, exclusively using routine CMR imaging. Methods RTOF patients and controls with CMR imaging were retrospectively included. Three-dimensional (3D) models of RV were segmented, including RV outflow tract (RVOT). Feature-tracking software (QStrain 2.0, Medis Medical Imaging Systems, Leiden, Netherlands) captured endocardial contours from long/short-axis cine and used to reconstruct RV wall motion. A global HDF vector was computed from the moving surface, then decomposed into amplitude/impulse of three directional components based on reference (Apical-to-Basal, Septal-to-Free Wall and Diaphragm-to-RVOT direction). HDF were compared and correlated against CMR and exercise stress test parameters. A subset of RTOF patients had 4D flow that was used to derive vorticity (for correlation) and HDF (for comparison against cine method). Results 68 RTOF patients and 20 controls were included. RTOF patients had increased diastolic HDF amplitude in all three directions (p<0.05). PR% correlated with Diaphragm-RVOT HDF amplitude/impulse (r = 0.578, p<0.0001, r = 0.508, p < 0.0001, respectively). RV ejection fraction modestly correlated with global HDF amplitude (r = 0.2916, p = 0.031). VO2-max correlated with Septal-to-Free Wall HDF impulse (r = 0.536, p = 0.007). Diaphragm-to-RVOT HDF correlated with RVOT vorticity (r = 0.4997, p = 0.001). There was no significant measurement bias between Cine-derived HDF and 4D flow-derived HDF by Bland-Altman analysis. Conclusion RTOF patients have abnormal diastolic HDF that is correlated to PR, RV function, exercise capacity and vorticity. HDF can be derived from conventional cine, and is a potential link between RV wall motion and intracardiac flow from PR in RTOF patients.
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Affiliation(s)
- Yue-Hin Loke
- Department of Cardiology, Children’s National Hospital, Washington, DC, United States
- 3D Cardiac Visualization Laboratory, Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, Washington, DC, United States
| | - Francesco Capuano
- Department of Fluid Mechanics, Universitat Politècnica de Catalunya BarcelonaTech (UPC), Barcelona, Spain
| | - Sarah Kollar
- Department of Cardiology, Children’s National Hospital, Washington, DC, United States
| | - Merih Cibis
- Medis Medical Imaging Systems, Leiden, Netherlands
| | | | - Elias Balaras
- Laboratory for Computational Physics and Fluid Mechanics, Department of Mechanical and Aerospace Engineering, School of Engineering and Applied Science, George Washington University, Washington, DC, United States
| | | | - Gianni Pedrizzetti
- Department of Engineering and Architecture, University of Trieste, Trieste, Italy
- Department of Biomedical Engineering, University of California, Irvine, Irvine, CA, United States
| | - Laura Olivieri
- 3D Cardiac Visualization Laboratory, Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, Washington, DC, United States
- Department of Cardiology, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, United States
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Loke YH, Capuano F, Balaras E, Olivieri LJ. Computational Modeling of Right Ventricular Motion and Intracardiac Flow in Repaired Tetralogy of Fallot. Cardiovasc Eng Technol 2022; 13:41-54. [PMID: 34169460 PMCID: PMC8702579 DOI: 10.1007/s13239-021-00558-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 06/08/2021] [Indexed: 02/03/2023]
Abstract
PURPOSE Patients with repaired Tetralogy of Fallot (rTOF) will develop dilation of the right ventricle (RV) from chronic pulmonary insufficiency and require pulmonary valve replacement (PVR). Cardiac MRI (cMRI) is used to guide therapy but has limitations in studying novel intracardiac flow parameters. This pilot study aimed to demonstrate feasibility of reconstructing RV motion and simulating intracardiac flow in rTOF patients, exclusively using conventional cMRI and an immersed-boundary method computational fluid dynamic (CFD) solver. METHODS Four rTOF patients and three normal controls underwent cMRI including 4D flow. 3D RV models were segmented from cMRI images. Feature-tracking software captured RV endocardial contours from cMRI long-axis and short-axis cine stacks. RV motion was reconstructed via diffeomorphic mapping (Deformetrica, deformetrica.org), serving as the domain boundary for CFD. Fully-resolved direct numerical simulations were performed over several cardiac cycles. Intracardiac vorticity, kinetic energy (KE) and turbulent kinetic energy (TKE) was measured. For validation, RV motion was compared to manual tracings, results of KE were compared between CFD and 4D flow. RESULTS Diastolic vorticity and TKE in rTOF patients were 4.12 ± 2.42 mJ/L and 115 ± 27/s, compared to 2.96 ± 2.16 mJ/L and 78 ± 45/s in controls. There was good agreement between RV motion and manual tracings. The difference in diastolic KE between CFD and 4D flow by Bland-Altman analysis was - 0.89910 to 2 mJ/mL (95% limits of agreement: - 1.351 × 10-2 mJ/mL to 1.171 × 10-2 mJ/mL). CONCLUSION This CFD framework can produce intracardiac flow in rTOF patients. CFD has the potential for predicting the effects of PVR in rTOF patients and improve the clinical indications guided by cMRI.
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Affiliation(s)
- Yue-Hin Loke
- Division of Cardiology, Children's National Hospital, 111 Michigan Ave NW W3-200, Washington, DC, 20010, USA.
| | - Francesco Capuano
- Department of Industrial Engineering, Università degli Studi di Napoli "Federico II", 80125, Naples, Italy
- Department of Mechanics, Mathematics and Management, Politecnico di Bari, 70126, Bari, Italy
| | - Elias Balaras
- Department of Mechanical and Aerospace Engineering, George Washington University, Washington, DC, 20052, USA
| | - Laura J Olivieri
- Division of Cardiology, Children's National Hospital, 111 Michigan Ave NW W3-200, Washington, DC, 20010, USA
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA
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Loke YH, Capuano F, Cleveland V, Mandell JG, Balaras E, Olivieri LJ. Moving beyond size: vorticity and energy loss are correlated with right ventricular dysfunction and exercise intolerance in repaired Tetralogy of Fallot. J Cardiovasc Magn Reson 2021; 23:98. [PMID: 34412634 PMCID: PMC8377822 DOI: 10.1186/s12968-021-00789-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 06/28/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The global effect of chronic pulmonary regurgitation (PR) on right ventricular (RV) dilation and dysfunction in repaired Tetralogy of Fallot (rTOF) patients is well studied by cardiovascular magnetic resonance (CMR). However, the links between PR in the RV outflow tract (RVOT), RV dysfunction and exercise intolerance are not clarified by conventional measurements. Not all patients with RV dilation share the same intracardiac flow characteristics, now measurable by time resolved three-dimensional phase contrast imaging (4D flow). In our study, we quantified regional vorticity and energy loss in rTOF patients and correlated these parameters with RV dysfunction and exercise capacity. METHODS rTOF patients with 4D flow datasets were retrospectively analyzed, including those with transannular/infundibular repair and conduit repair. Normal controls and RV dilation patients with atrial-level shunts (Qp:Qs > 1.2:1) were included for comparison. 4D flow was post-processed using IT Flow (Cardioflow, Japan). Systolic/diastolic vorticity (ω, 1/s) and viscous energy loss (VEL, mW) in the RVOT and RV inflow were measured. To characterize the relative influence of diastolic vorticity in the two regions, an RV Diastolic Vorticity Quotient (ωRVOT-Diastole/ωRV Inflow-Diastole, RV-DVQ) was calculated. Additionally, RVOT Vorticity Quotient (ωRVOT-Diastole/ωRVOT-Systole, RVOT-VQ) and RVOT Energy Quotient (VELRVOT-Diastole/VELRVOT-Systole, RVOT-EQ) was calculated. In rTOF, measurements were correlated against conventional CMR and exercise stress test results. RESULTS 58 rTOF patients, 28 RV dilation patients and 12 controls were included. RV-DVQ, RVOT-VQ, and RVOT-EQ were highest in rTOF patients with severe PR compared to rTOF patients with non-severe PR, RV dilation and controls (p < 0.001). RV-DVQ positively correlated with RV end-diastolic volume (0.683, p < 0.001), PR fraction (0.774, p < 0.001) and negatively with RV ejection fraction (- 0.521, p = 0.003). Both RVOT-VQ, RVOT-EQ negatively correlated with VO2-max (- 0.587, p = 0.008 and - 0.617, p = 0.005) and % predicted VO2-max (- 0.678, p = 0.016 and - 0.690, p = 0.001). CONCLUSIONS In rTOF patients, vorticity and energy loss dominate the RVOT compared to tricuspid inflow, correlating with RV dysfunction and exercise intolerance. These 4D flow-based measurements may be sensitive biomarkers to guide surgical management of rTOF patients.
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Affiliation(s)
- Yue-Hin Loke
- Division of Cardiology, Children's National Medical Center, 111 Michigan Ave NW, W3-200, Washington, DC, 20010, USA.
| | - Francesco Capuano
- Department of Mechanics, Mathematics and Management, Polytechnic University of Bari, Bari, Italy
| | - Vincent Cleveland
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Medical Center, 111 Michigan Ave NW, Washington, DC, 20010, USA
| | - Jason G Mandell
- Division of Cardiology, Children's National Medical Center, 111 Michigan Ave NW, W3-200, Washington, DC, 20010, USA
| | - Elias Balaras
- Department of Mechanical and Aerospace Engineering, George Washington University, Washington, DC, 20052, USA
| | - Laura J Olivieri
- Division of Cardiology, Children's National Medical Center, 111 Michigan Ave NW, W3-200, Washington, DC, 20010, USA
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Medical Center, 111 Michigan Ave NW, Washington, DC, 20010, USA
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Pedrizzetti G, Faganello G, Croatto E, Di Lenarda A. The hemodynamic power of the heart differentiates normal from diseased right ventricles. J Biomech 2021; 119:110312. [PMID: 33609983 DOI: 10.1016/j.jbiomech.2021.110312] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 01/31/2021] [Accepted: 02/03/2021] [Indexed: 12/15/2022]
Abstract
Cardiac mechanics is primarily described by the pressure-volume relationship. The ventricular pressure-volume loop displays the instantaneous relationship between intraventricular pressure and volume throughout the cardiac cycle; however, it does not consider the shape of the ventricles, their spatiotemporal deformation patterns, and how these balance with the flowing blood. Our study demonstrates that the pressure-volume relationship represents a first level of approximation for the mechanical power of the ventricles, while, at a further level of approximation, the importance of hemodynamic power emerges through the balance between deformation patterns and fluid dynamics. The analysis is preliminarily tested in a healthy subject's right ventricle and two patients. Moreover, patients' geometry was then rescaled to present a normal volumetric profile to verify whether results were affected by volume size or by the spatiotemporal pattern of how that volume profile was achieved. Results show that alterations of hemodynamic power were found in the abnormal ventricles and that they were not directly caused by the ventricular size but by changes in the ability of intraventricular pressure gradient to generate blood flow. Therefore, hemodynamic power represents a physics-based measure that takes into account the dynamics of the space-time shape changes in combination with blood flow. Hemodynamic power is assessed non-invasively using cardiac imaging techniques and can be an early indicator of cardiac dysfunction before changes occur in volumetric measurements. These preliminary results provide a physical ground to evaluate its diagnostic or prognostic significance in future clinical studies.
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Affiliation(s)
- Gianni Pedrizzetti
- Department of Engineering and Architecture, University of Trieste, Italy.
| | - Giorgio Faganello
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Elisa Croatto
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Andrea Di Lenarda
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
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Martiniello AR, Bianchi V, Tonti G, Cioppa C, Tavoletta V, D’Onofrio A, Caso VM, Pedrizzetti G, Caso P. Combined flow-based imaging assessment of optimal cardiac resynchronization therapy pacing vector: a case report. J Med Case Rep 2019; 13:161. [PMID: 31126329 PMCID: PMC6534894 DOI: 10.1186/s13256-019-2048-1] [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: 12/19/2018] [Accepted: 03/12/2019] [Indexed: 11/25/2022] Open
Abstract
Background There are still many pendent issues about the effective evaluation of cardiac resynchronization therapy impact on functional mitral regurgitation. In order to reduce the intrinsic difficulties of quantification of functional mitral regurgitation itself, an automatic quantification of real-time three-dimensional full-volume color Doppler transthoracic echocardiography was proposed as a new, rapid, and accurate method for the assessment of functional mitral regurgitation severity. Recent studies suggested that images of left ventricle flow by echo-particle imaging velocimetry could be a useful marker of synchrony. Echo-particle imaging velocimetry has shown that regional anomalies of synchrony/synergy of the left ventricle are related to the alteration, reduction, or suppression of the physiological intracavitary pressure gradients. Case summary We describe a case in which the two technologies are used in combination during acute echocardiographic optimization of left pacing vector in a 63-year-old man, Caucasian, who showed worsening heart failure symptoms a few days after an implant, and the effect of the device’s optimization at 6-month follow-up. Discussion The degree of realignment of hemodynamic forces, with quantitative analysis of the orientation of blood flow momentum (φ), can represent improvement of fluid dynamics synchrony of the left ventricle, and explain, with a new deterministic parameter, the effects of cardiac resynchronization therapy on functional mitral regurgitation. Real-time three-dimensional color flow Doppler quantification is feasible and accurate for measurement of mitral inflow, left ventricular outflow stroke volumes, and functional mitral regurgitation severity. Conclusion This clinical case offers an innovative and accurate approach for acute echocardiographic optimization of left pacing vector. It shows clinical utility of combined three-dimensional full-volume color Doppler transthoracic echocardiography/echo-particle imaging velocimetry assessment to increase response to cardiac resynchronization therapy, in terms of reduction of functional mitral regurgitation, improving fluid dynamics synchrony of the left ventricle. Electronic supplementary material The online version of this article (10.1186/s13256-019-2048-1) contains supplementary material, which is available to authorized users.
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Abstract
OBJECTIVE This study investigated the intraventricular flow dynamics in ischaemic heart disease patients. PATIENTS AND METHODS Fourteen patients with normal ejection fraction and 16 patients with reduced ejection fraction were compared with 20 healthy individuals. Phase-contrast MRI was used to assess intraventricular flow variables and speckle-tracking echocardiography to assess myocardial strain and left ventricular (LV) dyssynchrony. Infarct size was acquired using delayed-enhancement MRI. RESULTS The results obtained showed no significant differences in intraventricular flow variables between the healthy group and the patients with normal ejection fraction group, whereas considerable reductions in kinetic energy (KE) fluctuation index, E' (P<0.001) and vortex KE (P=0.003) were found in the patients with reduced ejection fraction group. In multivariate analysis, only vortex KE and infarct size were significantly related to LV ejection fraction (P<0.001); furthermore, vortex KE was correlated negatively with energy dissipation, energy dissipation index (r=-0.44, P=0.021). CONCLUSION This study highlights that flow energetic indices have limited applicability as early predictors of LV progressive dysfunction, whereas vortex KE could be an alternative to LV performance.
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Pasipoularides A. Clinical-pathological correlations of BAV and the attendant thoracic aortopathies. Part 2: Pluridisciplinary perspective on their genetic and molecular origins. J Mol Cell Cardiol 2019; 133:233-246. [PMID: 31175858 DOI: 10.1016/j.yjmcc.2019.05.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 05/10/2019] [Accepted: 05/27/2019] [Indexed: 12/30/2022]
Abstract
Bicuspid aortic valve (BAV) arises during valvulogenesis when 2 leaflets/cusps of the aortic valve (AOV) are fused together. Its clinical manifestations pertain to faulty AOV function, the associated aortopathy, and other complications surveyed in Part 1 of the present bipartite-series. Part 2 examines mainly genetic and epigenetic causes of BAV and BAV-associated aortopathies (BAVAs) and disease syndromes (BAVD). Part 1 explored the heterogeneity among subsets of patients with BAV and BAVA/BAVD, and investigated abnormal fluid dynamic stress and strain patterns sustained by the cusps. Specific BAV morphologies engender systolic outflow asymmetries, associated with abnormal aortic regional wall-shear-stress distributions and the expression/localization of BAVAs. Understanding fluid dynamic factors besides the developmental mechanisms and underlying genetics governing these congenital anomalies is necessary to explain patient predisposition to aortopathy and phenotypic heterogeneity. BAV aortopathy entails complex/multifactorial pathophysiology, involving alterations in genetics, epigenetics, hemodynamics, and in cellular and molecular pathways. There is always an interdependence between organismic developmental signals and genes-no systemic signals, no gene-expression; no active gene, no next step. An apposite signal induces the expression of the next developmental gene, which needs be expressed to trigger the next signal, and so on. Hence, embryonic, then post-partum, AOV and thoracic aortic development comprise cascades of developmental genes and their regulation. Interdependencies between them arise, entailing reciprocal/cyclical mutual interactions and adaptive feedback loops, by which developmental morphogenetic processes self-correct responding to environmental inputs/reactions. This Survey can serve as a reference point and driver for further pluridisciplinary BAV/BAVD studies and their clinical translation.
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Affiliation(s)
- Ares Pasipoularides
- Duke/NSF Center for Emerging Cardiovascular Technologies, Emeritus Faculty of Surgery and of Biomedical Engineering, Duke University School of Medicine and Graduate School, Durham, NC, USA.
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Pasipoularides A. Clinical-pathological correlations of BAV and the attendant thoracic aortopathies. Part 1: Pluridisciplinary perspective on their hemodynamics and morphomechanics. J Mol Cell Cardiol 2019; 133:223-232. [PMID: 31150733 DOI: 10.1016/j.yjmcc.2019.05.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 05/10/2019] [Accepted: 05/23/2019] [Indexed: 12/12/2022]
Abstract
Clinical BAV manifestations pertain to faulty aortic valve (AOV) function, the associated aortopathy, and other complications such as endocarditis, thrombosis and thromboembolism. BAV arises during valvulogenesis when 2 of the 3 leaflets/cusps of the AOV are fused together. Ensuing asymmetric BAV morphologies alter downstream ejection jet flow-trajectories. Based on BAV morphologies, ejection-flows exhibit different wall-impingement and scouring patterns in the proximal aorta, with excessive hydrodynamic wall-shear that correlates closely with mural vascular smooth muscle cell and extracellular matrix disruptions, revealing hemodynamic participation in the pathogenesis of BAV-associated aortopathies. Since the embryologic regions implicated in both BAV and aortopathies derive from neural crest cells and second heart field cells, there may exist a common multifactorial/polygenic embryological basis linking the abnormalities. The use of Electronic Health Records - encompassing integrated NGS variant panels and phenotypic data - in clinical studies could speed-up comprehensive understanding of multifactorial genetic-phenotypic and environmental factor interactions. This Survey represents the first in a 2-article pluridisciplinary work. Taken in toto, the series covers hemodynamic/morphomechanical and environmental (milieu intérieur) aspects in Part 1, and molecular, genetic and associated epigenetic aspects in Part 2. Together, Parts 1-2 should serve as a reference-milestone and driver for further pluridisciplinary research and its urgent translations in the clinical setting.
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Affiliation(s)
- Ares Pasipoularides
- Duke/NSF Center for Emerging Cardiovascular Technologies, Emeritus Faculty of Surgery and of Biomedical Engineering, Duke University School of Medicine and Graduate School, Durham, NC, USA.
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Berlot B, Moya Mur JL, Jug B, Rodríguez Muñoz D, Megias A, Casas Rojo E, Fernández-Golfín C, Zamorano JL. Effect of diastolic dysfunction on intraventricular velocity behavior in early diastole by flow mapping. Int J Cardiovasc Imaging 2019; 35:1627-1636. [PMID: 31041633 DOI: 10.1007/s10554-019-01612-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 04/25/2019] [Indexed: 10/26/2022]
Abstract
Intraventricular velocity distribution reflects left ventricular (LV) diastolic function and can be measured non-invasively by flow mapping technologies. We designed our study to compare intraventricular velocities and gradients, obtained by vector flow mapping (VFM) technology during early diastole in consecutive patients diagnosed with mild and advanced diastolic dysfunction at echocardiography and a control group with a purpose to validate the hypothesis of relationship between new parameters and severity of diastolic dysfunction and conventional markers of elevated LV filling pressure. Two-dimensional streamline fields were obtained using VFM technology in 121 subjects (57 with normal diastolic function, 38 with mild diastolic dysfunction and 26 with advanced diastolic dysfunction). We measured several velocities and calculated a gradient along the selected streamline, which we compared between groups and correlated them with conventional echocardiographic parameters. Apical intraventricular velocity gradient (GrIV) was the lowest in control group, followed by mild and advanced diastolic dysfunction groups (5.3 ± 1.9 vs. 6.8 ± 2.5 vs. 13.6 ± 5.0/s, p < 0.001) and showed good correlation with E/e' (r = 0.751, p < 000.1). GrIV/e' ratio was the strongest single predictor of severity of diastolic dysfunction. Different degrees of diastolic dysfunction affect the Intraventricular velocity behavior during early diastole obtained by VFM. GrIV could discriminate between groups with different levels of diastolic dysfunction and was closely associated with classical echocardiographic indices of elevated LV filling pressure. GrIV/e' ratio has a potential to become a single parameter needed to assess left ventricular diastolic function.
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Affiliation(s)
- Bostjan Berlot
- Cardiology Department, Hospital Universitario Ramon y Cajal, de km. 9, 100, Ctra. Colmenar Viejo, 28034, Madrid, Spain. .,Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000, Ljubljana, Slovenia.
| | - Jose Luis Moya Mur
- Cardiology Department, Hospital Universitario Ramon y Cajal, de km. 9, 100, Ctra. Colmenar Viejo, 28034, Madrid, Spain
| | - Borut Jug
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000, Ljubljana, Slovenia
| | - Daniel Rodríguez Muñoz
- Cardiology Department, Hospital Universitario Ramon y Cajal, de km. 9, 100, Ctra. Colmenar Viejo, 28034, Madrid, Spain
| | - Alicia Megias
- Cardiology Department, Hospital Universitario Ramon y Cajal, de km. 9, 100, Ctra. Colmenar Viejo, 28034, Madrid, Spain
| | - Eduardo Casas Rojo
- Cardiology Department, Hospital Universitario Ramon y Cajal, de km. 9, 100, Ctra. Colmenar Viejo, 28034, Madrid, Spain
| | - Covadonga Fernández-Golfín
- Cardiology Department, Hospital Universitario Ramon y Cajal, de km. 9, 100, Ctra. Colmenar Viejo, 28034, Madrid, Spain
| | - Jose Luis Zamorano
- Cardiology Department, Hospital Universitario Ramon y Cajal, de km. 9, 100, Ctra. Colmenar Viejo, 28034, Madrid, Spain
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12
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Voorneveld J, Muralidharan A, Hope T, Vos HJ, Kruizinga P, van der Steen AFW, Gijsen FJH, Kenjeres S, de Jong N, Bosch JG. High Frame Rate Ultrasound Particle Image Velocimetry for Estimating High Velocity Flow Patterns in the Left Ventricle. IEEE TRANSACTIONS ON ULTRASONICS, FERROELECTRICS, AND FREQUENCY CONTROL 2018; 65:2222-2232. [PMID: 29990263 DOI: 10.1109/tuffc.2017.2786340] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Echocardiographic determination of multicomponent blood flow dynamics in the left ventricle remains a challenge. In this paper, we compare contrast enhanced, high frame rate (HFR) (1000 frames/s) echo-particle image velocimetry (ePIV) against optical particle image velocimetry (oPIV, gold standard), in a realistic left ventricular (LV) phantom. We find that ePIV compares well to oPIV, even for the high velocity inflow jet (normalized RMSE = 9% ± 1%). In addition, we perform the method of proper orthogonal decomposition, to better qualify and quantify the differences between the two modalities. We show that ePIV and oPIV resolve very similar flow structures, especially for the lowest order mode with a cosine similarity index of 86%. The coarser resolution of ePIV does result in increased variance and blurring of smaller flow structures when compared to oPIV. However, both modalities are in good agreement with each other for the modes that constitute the bulk of the kinetic energy. We conclude that HFR ePIV can accurately estimate the high velocity diastolic inflow jet and the high energy flow structures in an LV setting.
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13
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Pasipoularides A. Morphomechanic phenotypic variability of sarcomeric cardiomyopathies: A multifactorial polygenic perspective. J Mol Cell Cardiol 2018; 126:23-35. [PMID: 30423317 DOI: 10.1016/j.yjmcc.2018.10.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 10/11/2018] [Accepted: 10/31/2018] [Indexed: 01/01/2023]
Abstract
Morphology underlies subdivision of the primary/heritable sarcomeric cardiomyopathies (CMs) into hypertrophic (HCM) and dilated (DCM). Next-generation DNA-sequencing (NGS) has identified important disease-variants, improving CM diagnosis, management, genetic screening, and prognosis. Although monogenic (Mendelian) analyses directly point at downstream studies, they disregard coexisting genomic variations and gene-by-gene interactions molding detailed CM-phenotypes. In-place of polygenic models, in accounting for observed defective genotype-phenotype correlations, fuzzy concepts having gradations of significance and unsharp domain-boundaries are invoked, including pleiotropy, genetic-heterogeneity, incomplete penetrance, and variable expressivity. HCM and DCM undoubtedly entail cooperativity of unidentified/elusive causative genomic-variants. Modern genomics can exploit comprehensive electronic/digital health records, facilitating consideration of multifactorial variant-models. Genome-wide association studies entailing high-fidelity solid-state catheterization, multimodal-imaging, molecular cardiology, systems biology and bioinformatics, will decipher accurate genotype-phenotype correlations and identify novel therapeutic-targets, fostering personalized medicine/cardiology. This review surveys successes and challenges of genetic/genomic approaches to CMs, and their impact on current and future clinical care.
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Affiliation(s)
- Ares Pasipoularides
- Duke/NSF Center for Emerging Cardiovascular Technologies, Emeritus Faculty of Surgery and of Biomedical Engineering, Duke University School of Medicine and Graduate School, Durham, NC, USA.
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14
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Pasipoularides A. Know Me! Unraveling the Riddle of Calcific Aortic Valve Disease by Bioinformatics. TOHOKU J EXP MED 2018; 243:255-261. [PMID: 29212966 DOI: 10.1620/tjem.243.255] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Ares Pasipoularides
- Emeritus Faculty of Surgery and of Biomedical Engineering, Duke University School of Medicine and Graduate School
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15
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Pasipoularides A. The new era of whole-exome sequencing in congenital heart disease: brand-new insights into rare pathogenic variants. J Thorac Dis 2018; 10:S1923-S1929. [PMID: 30023082 PMCID: PMC6036033 DOI: 10.21037/jtd.2018.05.56] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 05/03/2018] [Indexed: 12/30/2022]
Affiliation(s)
- Ares Pasipoularides
- Department of Surgery, Emeritus Faculty of Surgery and of Biomedical Engineering, Duke University School of Medicine and Graduate School, Durham, NC, USA
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16
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Post-operative ventricular flow dynamics following atrioventricular valve surgical and device therapies: A review. Med Eng Phys 2018; 54:1-13. [DOI: 10.1016/j.medengphy.2018.01.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 12/17/2017] [Accepted: 01/28/2018] [Indexed: 01/26/2023]
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17
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Retos y controversias en miocardiopatía hipertrófica: visión integral desde la investigación básica, clínica y genética. Rev Esp Cardiol 2018. [DOI: 10.1016/j.recesp.2017.06.034] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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18
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Abstract
Cardiac function is about creating and sustaining blood in motion. This is achieved through a proper sequence of myocardial deformation whose final goal is that of creating flow. Deformation imaging provided valuable contributions to understanding cardiac mechanics; more recently, several studies evidenced the existence of an intimate relationship between cardiac function and intra-ventricular fluid dynamics. This paper summarizes the recent advances in cardiac flow evaluations, highlighting its relationship with heart wall mechanics assessed through the newest techniques of deformation imaging and finally providing an opinion of the most promising clinical perspectives of this emerging field. It will be shown how fluid dynamics can integrate volumetric and deformation assessments to provide a further level of knowledge of cardiac mechanics.
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19
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Pasipoularides A. Implementing genome-driven personalized cardiology in clinical practice. J Mol Cell Cardiol 2018; 115:142-157. [PMID: 29343412 PMCID: PMC5820118 DOI: 10.1016/j.yjmcc.2018.01.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 01/04/2018] [Accepted: 01/12/2018] [Indexed: 12/18/2022]
Abstract
Genomics designates the coordinated investigation of a large number of genes in the context of a biological process or disease. It may be long before we attain comprehensive understanding of the genomics of common complex cardiovascular diseases (CVDs) such as inherited cardiomyopathies, valvular diseases, primary arrhythmogenic conditions, congenital heart syndromes, hypercholesterolemia and atherosclerotic heart disease, hypertensive syndromes, and heart failure with preserved/reduced ejection fraction. Nonetheless, as genomics is evolving rapidly, it is constructive to survey now pertinent concepts and breakthroughs. Today, clinical multimodal electronic medical/health records (EMRs/EHRs) incorporating genomic information establish a continuously-learning, vast knowledge-network with seamless cycling between clinical application and research. It can inform insights into specific pathogenetic pathways, guide biomarker-assisted precise diagnoses and individualized treatments, and stratify prognoses. Complex CVDs blend multiple interacting genomic variants, epigenetics, and environmental risk-factors, engendering progressions of multifaceted disease-manifestations, including clinical symptoms and signs. There is no straight-line linkage between genetic cause(s) or causal gene-variant(s) and disease phenotype(s). Because of interactions involving modifier-gene influences, (micro)-environmental, and epigenetic effects, the same variant may actually produce dissimilar abnormalities in different individuals. Implementing genome-driven personalized cardiology in clinical practice reveals that the study of CVDs at the level of molecules and cells can yield crucial clinical benefits. Complementing evidence-based medicine guidelines from large ("one-size fits all") randomized controlled trials, genomics-based personalized or precision cardiology is a most-creditable paradigm: It provides customizable approaches to prevent, diagnose, and manage CVDs with treatments directly/precisely aimed at causal defects identified by high-throughput genomic technologies. They encompass stem cell and gene therapies exploiting CRISPR-Cas9-gene-editing, and metabolomic-pharmacogenomic therapeutic modalities, precisely fine-tuned for the individual patient. Following the Human Genome Project, many expected genomics technology to provide imminent solutions to intractable medical problems, including CVDs. This eagerness has reaped some disappointment that advances have not yet materialized to the degree anticipated. Undoubtedly, personalized genetic/genomics testing is an emergent technology that should not be applied without supplementary phenotypic/clinical information: Genotype≠Phenotype. However, forthcoming advances in genomics will naturally build on prior attainments and, combined with insights into relevant epigenetics and environmental factors, can plausibly eradicate intractable CVDs, improving human health and well-being.
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Affiliation(s)
- Ares Pasipoularides
- Consulting Professor of Surgery, Emeritus Faculty of Surgery and of Biomedical Engineering, Duke University School of Medicine and Graduate School, Durham, NC 27710, USA.
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20
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Pasipoularides A. Challenges and Controversies in Hypertrophic Cardiomyopathy: Clinical, Genomic and Basic Science Perspectives. ACTA ACUST UNITED AC 2017; 71:132-138. [PMID: 28802532 DOI: 10.1016/j.rec.2017.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 07/05/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Ares Pasipoularides
- Department of Surgery, School of Medicine, Duke University, Durham, North Carolina, United States.
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21
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Pedrizzetti G, Arvidsson PM, Töger J, Borgquist R, Domenichini F, Arheden H, Heiberg E. On estimating intraventricular hemodynamic forces from endocardial dynamics: A comparative study with 4D flow MRI. J Biomech 2017; 60:203-210. [PMID: 28711164 DOI: 10.1016/j.jbiomech.2017.06.046] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 05/26/2017] [Accepted: 06/25/2017] [Indexed: 10/19/2022]
Abstract
Intraventricular pressure gradients or hemodynamic forces, which are their global measure integrated over the left ventricular volume, have a fundamental importance in ventricular function. They may help revealing a sub-optimal cardiac function that is not evident in terms of tissue motion, which is naturally heterogeneous and variable, and can influence cardiac adaptation. However, hemodynamic forces are not utilized in clinical cardiology due to the unavailability of simple non-invasive measurement tools. Hemodynamic forces depend on the intraventricular flow; nevertheless, most of them are imputable to the dynamics of the endocardial flow boundary and to the exchange of momentum across the mitral and aortic orifices. In this study, we introduce a simplified model based on first principles of fluid dynamics that allows estimating hemodynamic forces without knowing the velocity field inside the LV. The model is validated with 3D phase-contrast MRI (known as 4D flow MRI) in 15 subjects, (5 healthy and 10 patients) using the endocardial surface reconstructed from the three standard long-axis projections. Results demonstrate that the model provides consistent estimates for the base-apex component (mean correlation coefficient r=0.77 for instantaneous values and r=0.88 for root mean square) and good estimates of the inferolateral-anteroseptal component (r=0.50 and 0.84, respectively). The present method represents a potential integration to the existing ones quantifying endocardial deformation in MRI and echocardiography to add a physics-based estimation of the corresponding hemodynamic forces. These could help the clinician to early detect sub-clinical diseases and differentiate between different cardiac dysfunctional states.
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Affiliation(s)
- Gianni Pedrizzetti
- Department of Engineering and Architecture, University of Trieste, Trieste, Italy.
| | - Per M Arvidsson
- Lund University, Skane University Hospital, Department of Clinical Sciences, Clinical Physiology, Lund, Sweden
| | - Johannes Töger
- Lund University, Skane University Hospital, Department of Clinical Sciences, Clinical Physiology, Lund, Sweden
| | - Rasmus Borgquist
- Lund University, Skane University Hospital, Department of Arrhythmias, Lund, Sweden
| | - Federico Domenichini
- Department of Civil and Environmental Engineering, University of Firenze, Firenze, Italy
| | - Håkan Arheden
- Lund University, Skane University Hospital, Department of Clinical Sciences, Clinical Physiology, Lund, Sweden
| | - Einar Heiberg
- Lund University, Skane University Hospital, Department of Arrhythmias, Lund, Sweden; Department of Biomedical Engineering, Lund University, Lund, Sweden
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22
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Pasipoularides A. Genomic translational research: Paving the way to individualized cardiac functional analyses and personalized cardiology. Int J Cardiol 2016; 230:384-401. [PMID: 28057368 DOI: 10.1016/j.ijcard.2016.12.097] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 11/27/2016] [Accepted: 12/17/2016] [Indexed: 01/08/2023]
Abstract
For most of Medicine's past, the best that physicians could do to cope with disease prevention and treatment was based on the expected response of an average patient. Currently, however, a more personalized/precise approach to cardiology and medicine in general is becoming possible, as the cost of sequencing a human genome has declined substantially. As a result, we are witnessing an era of precipitous advances in biomedicine and bourgeoning understanding of the genetic basis of cardiovascular and other diseases, reminiscent of the resurgence of innovations in physico-mathematical sciences and biology-anatomy-cardiology in the Renaissance, a parallel time of radical change and reformation of medical knowledge, education and practice. Now on the horizon is an individualized, diverse patient-centered, approach to medical practice that encompasses the development of new, gene-based diagnostics and preventive medicine tactics, and offers the broadest range of personalized therapies based on pharmacogenetics. Over time, translation of genomic and high-tech approaches unquestionably will transform clinical practice in cardiology and medicine as a whole, with the adoption of new personalized medicine approaches and procedures. Clearly, future prospects far outweigh present accomplishments, which are best viewed as a promising start. It is now essential for pluridisciplinary health care providers to examine the drivers and barriers to the clinical adoption of this emerging revolutionary paradigm, in order to expedite the realization of its potential. So, we are not there yet, but we are definitely on our way.
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Affiliation(s)
- Ares Pasipoularides
- Department of Surgery, Duke University School of Medicine, Durham, NC, 27710, USA.
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23
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Pesce M, Messina E, Chimenti I, Beltrami AP. Cardiac Mechanoperception: A Life-Long Story from Early Beats to Aging and Failure. Stem Cells Dev 2016; 26:77-90. [PMID: 27736363 DOI: 10.1089/scd.2016.0206] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The life-long story of the heart starts concomitantly with primary differentiation events occurring in multipotent progenitors located in the so-called heart tube. This initially tubular structure starts a looping process, which leads to formation of the final four-chambered heart with a primary contribution of geometric and position-associated cell sensing. While this establishes the correct patterning of the final cardiac structure, it also provides feedbacks to fundamental cellular machineries controlling proliferation and differentiation, thus ensuring a coordinated restriction of cell growth and a myocyte terminal differentiation. Novel evidences provided by embryological and cell engineering studies have clarified the relevance of mechanics-supported position sensing for the correct recognition of cell fate inside developing embryos and multicellular aggregates. One of the main components of this pathway, the Hippo-dependent signal transduction machinery, is responsible for cell mechanics intracellular transduction with important consequences for gene transcription and cell growth control. Being the Hippo pathway also directly connected to stress responses and altered metabolism, it is tempting to speculate that permanent alterations of mechanosensing may account for modifying self-renewal control in tissue homeostasis. In the present contribution, we translate these concepts to the aging process and the failing of the human heart, two pathophysiologic conditions that are strongly affected by stress responses and altered metabolism.
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Affiliation(s)
- Maurizio Pesce
- 1 Tissue Engineering Research Unit, Centro Cardiologico Monzino, IRCCS , Milan, Italy
| | - Elisa Messina
- 2 Department of Pediatric Cardiology, "Sapienza" University , Rome, Italy
| | - Isotta Chimenti
- 3 Department of Medical Surgical Science and Biotechnology, "Sapienza" University , Rome, Italy
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24
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Nehrhoff I, Bocancea D, Vaquero J, Vaquero JJ, Ripoll J, Desco M, Gómez-Gaviro MV. 3D imaging in CUBIC-cleared mouse heart tissue: going deeper. BIOMEDICAL OPTICS EXPRESS 2016; 7:3716-3720. [PMID: 27699132 PMCID: PMC5030044 DOI: 10.1364/boe.7.003716] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 08/12/2016] [Accepted: 08/23/2016] [Indexed: 06/06/2023]
Abstract
The ability to acquire high resolution 3D images of the heart enables to study heart diseases more in detail. In this work, the CUBIC (clear, unobstructed brain imaging cocktails and computational analysis) clearing protocol was optimized for thick mouse heart sections to enhance the penetration depth of the confocal microscope lasers into the tissue. In addition, the optimized CUBIC clearing of the heart enhances antibody penetration into the tissue by a factor of five. The present protocol enables deep 3D high-quality image acquisition in the heart allowing a much more accurate assessment of the cellular and structural changes that underlie heart diseases.
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Affiliation(s)
- Imke Nehrhoff
- Instituto de Investigación Sanitaria Gregorio Marañón. (IiSGM), Madrid, Spain
- These authors contributed equally to this work
| | - Diana Bocancea
- Instituto de Investigación Sanitaria Gregorio Marañón. (IiSGM), Madrid, Spain
- Departamento de Bioingeniería e Ingeniería Aeroespacial, Universidad Carlos III de Madrid, Spain
- These authors contributed equally to this work
| | - Javier Vaquero
- Instituto de Investigación Sanitaria Gregorio Marañón. (IiSGM), Madrid, Spain
- CIBER de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Juan José Vaquero
- Instituto de Investigación Sanitaria Gregorio Marañón. (IiSGM), Madrid, Spain
- Departamento de Bioingeniería e Ingeniería Aeroespacial, Universidad Carlos III de Madrid, Spain
| | - Jorge Ripoll
- Instituto de Investigación Sanitaria Gregorio Marañón. (IiSGM), Madrid, Spain
- Departamento de Bioingeniería e Ingeniería Aeroespacial, Universidad Carlos III de Madrid, Spain
| | - Manuel Desco
- Instituto de Investigación Sanitaria Gregorio Marañón. (IiSGM), Madrid, Spain
- Departamento de Bioingeniería e Ingeniería Aeroespacial, Universidad Carlos III de Madrid, Spain
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain
| | - María Victoria Gómez-Gaviro
- Instituto de Investigación Sanitaria Gregorio Marañón. (IiSGM), Madrid, Spain
- Departamento de Bioingeniería e Ingeniería Aeroespacial, Universidad Carlos III de Madrid, Spain
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25
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Pasipoularides A. Calcific Aortic Valve Disease: Part 2-Morphomechanical Abnormalities, Gene Reexpression, and Gender Effects on Ventricular Hypertrophy and Its Reversibility. J Cardiovasc Transl Res 2016; 9:374-99. [PMID: 27184804 PMCID: PMC4992466 DOI: 10.1007/s12265-016-9695-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 05/03/2016] [Indexed: 02/07/2023]
Abstract
In part 1, we considered cytomolecular mechanisms underlying calcific aortic valve disease (CAVD), hemodynamics, and adaptive feedbacks controlling pathological left ventricular hypertrophy provoked by ensuing aortic valvular stenosis (AVS). In part 2, we survey diverse signal transduction pathways that precede cellular/molecular mechanisms controlling hypertrophic gene expression by activation of specific transcription factors that induce sarcomere replication in-parallel. Such signaling pathways represent potential targets for therapeutic intervention and prevention of decompensation/failure. Hypertrophy provoking signals, in the form of dynamic stresses and ligand/effector molecules that bind to specific receptors to initiate the hypertrophy, are transcribed across the sarcolemma by several second messengers. They comprise intricate feedback mechanisms involving gene network cascades, specific signaling molecules encompassing G protein-coupled receptors and mechanotransducers, and myocardial stresses. Future multidisciplinary studies will characterize the adaptive/maladaptive nature of the AVS-induced hypertrophy, its gender- and individual patient-dependent peculiarities, and its response to surgical/medical interventions. They will herald more effective, precision medicine treatments.
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Affiliation(s)
- Ares Pasipoularides
- Duke University School of Medicine, Durham, NC, USA.
- Duke/NSF Research Center for Emerging Cardiovascular Technologies, Duke University, Durham, NC, 27710, USA.
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26
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Man HSJ, Yan MS, Lee JJ, Marsden PA. Epigenetic determinants of cardiovascular gene expression: vascular endothelium. Epigenomics 2016; 8:959-79. [PMID: 27381277 DOI: 10.2217/epi-2016-0012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The modern landscape of gene regulation involves interacting factors that ultimately lead to gene activation or repression. Epigenetic mechanisms provide a perspective of cellular phenotype as dynamically regulated and responsive to input. This perspective is supported by the generation of induced pluripotent stem cells from fully differentiated cell types. In vascular endothelial cells, evidence suggests that epigenetic mechanisms play a major role in the expression of endothelial cell-specific genes such as the endothelial nitric oxide synthase (NOS3/eNOS). These mechanisms are also important for eNOS expression in response to environmental stimuli such as hypoxia and shear stress. A newer paradigm in epigenetics, long noncoding RNAs offer a link between genetic variation, epigenetic regulation and disease. While the understanding of epigenetic mechanisms is early in its course, it is becoming clear that approaches to understanding the interaction of these factors and their inputs will be necessary to improve outcomes in cardiovascular disease.
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Affiliation(s)
- Hon-Sum Jeffrey Man
- Department of Medicine, Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada.,Departments of Respirology & Critical Care, University Health Network & Mt Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Matthew S Yan
- Department of Medicine, Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - John Jy Lee
- Department of Medicine, Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.,Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Philip A Marsden
- Department of Medicine, Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.,Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Department of Nephrology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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27
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Martiniello AR, Pedrizzetti G, Bianchi V, Tonti G, D'Onofrio A, Caso P. Left ventricular pacing vector selection by novel echo-particle imaging velocimetry analysis for optimization of quadripolar cardiac resynchronization device: a case report. J Med Case Rep 2016; 10:191. [PMID: 27387667 PMCID: PMC4937536 DOI: 10.1186/s13256-016-0965-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 06/01/2016] [Indexed: 11/21/2022] Open
Abstract
Background The availability of pacing configurations offered by quadripolar left ventricular leads could improve patients’ response to cardiac resynchronization therapy; however, the selection of an optimal setting remains a challenge. Echo-particle imaging velocimetry has shown that regional anomalies of synchrony/synergy of the left ventricle are related to the alteration, reduction, or suppression of the physiological intracavitary pressure gradients. These observations are also supported by several numerical models of the left ventricle that have shown the close relationship between wall motion abnormalities, change of intraventricular flow dynamics, and abnormal distribution of forces operating on the ventricular endocardium. Case presentation A 73-year-old white man in New York Heart Association III functional class with an ejection fraction of 27.5 % did not improve after 1 month of cardiac resynchronization therapy. Five configurations were tested and settings were defined by optimizing intraventricular flow. After 6 months, he became New York Heart Association II class with left ventricular ejection fraction of 53.2 %. Conclusions The abnormal dynamic of pressure gradients during the cardiac cycle, through biohumoral endocrine, autocrine, and paracrine transduction, may lead to structural changes of the myocardial walls with subsequent left ventricular remodeling. The echo-particle imaging velocimetry technique may be useful for elucidating the favorable effects of cardiac resynchronization therapy on intraventricular fluid dynamics and it could be used to identify appropriate pacing setting during acute echocardiographic optimization of left pacing vector. Electronic supplementary material The online version of this article (doi:10.1186/s13256-016-0965-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Gianni/G Pedrizzetti
- Department of Engineering and Architecture, University of Trieste, Trieste, Italy
| | - Valter/V Bianchi
- Department of Cardiology, Monaldi Hospital, AORN Ospedali dei Colli, Via Leonardo Bianchi, 80131, Naples, Italy
| | - Giovanni/G Tonti
- Institute of Cardiology and Center of Excellence on Aging, 'G. d'Annunzio' University , Chieti, Italyᅟ
| | - Antonio/A D'Onofrio
- Department of Cardiology, Monaldi Hospital, AORN Ospedali dei Colli, Via Leonardo Bianchi, 80131, Naples, Italy
| | - Pio/P Caso
- Department of Cardiology, Monaldi Hospital, AORN Ospedali dei Colli, Via Leonardo Bianchi, 80131, Naples, Italy
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28
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Chnafa C, Mendez S, Nicoud F. Image-Based Simulations Show Important Flow Fluctuations in a Normal Left Ventricle: What Could be the Implications? Ann Biomed Eng 2016; 44:3346-3358. [DOI: 10.1007/s10439-016-1614-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 04/06/2016] [Indexed: 10/22/2022]
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Calcific Aortic Valve Disease: Part 1--Molecular Pathogenetic Aspects, Hemodynamics, and Adaptive Feedbacks. J Cardiovasc Transl Res 2016; 9:102-18. [PMID: 26891845 DOI: 10.1007/s12265-016-9679-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Accepted: 01/27/2016] [Indexed: 01/01/2023]
Abstract
Aortic valvular stenosis (AVS), produced by calcific aortic valve disease (CAVD) causing reduced cusp opening, afflicts mostly older persons eventually requiring valve replacement. CAVD had been considered "degenerative," but newer investigations implicate active mechanisms similar to atherogenesis--genetic predisposition and signaling pathways, lipoprotein deposits, chronic inflammation, and calcification/osteogenesis. Consequently, CAVD may eventually be controlled/reversed by lifestyle and pharmacogenomics remedies. Its management should be comprehensive, embracing not only the valve but also the left ventricle and the arterial system with their interdependent morphomechanics/hemodynamics, which underlie the ensuing diastolic and systolic LV dysfunction. Compared to even a couple of decades ago, we now have an increased appreciation of genomic and cytomolecular pathogenetic mechanisms underlying CAVD. Future pluridisciplinary studies will characterize better and more completely its pathobiology, evolution, and overall dynamics, encompassing intricate feedback processes involving specific signaling molecules and gene network cascades. They will herald more effective, personalized medicine treatments of CAVD/AVS.
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Linking Genes to Cardiovascular Diseases: Gene Action and Gene-Environment Interactions. J Cardiovasc Transl Res 2015; 8:506-27. [PMID: 26545598 DOI: 10.1007/s12265-015-9658-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 10/08/2015] [Indexed: 01/22/2023]
Abstract
A unique myocardial characteristic is its ability to grow/remodel in order to adapt; this is determined partly by genes and partly by the environment and the milieu intérieur. In the "post-genomic" era, a need is emerging to elucidate the physiologic functions of myocardial genes, as well as potential adaptive and maladaptive modulations induced by environmental/epigenetic factors. Genome sequencing and analysis advances have become exponential lately, with escalation of our knowledge concerning sometimes controversial genetic underpinnings of cardiovascular diseases. Current technologies can identify candidate genes variously involved in diverse normal/abnormal morphomechanical phenotypes, and offer insights into multiple genetic factors implicated in complex cardiovascular syndromes. The expression profiles of thousands of genes are regularly ascertained under diverse conditions. Global analyses of gene expression levels are useful for cataloging genes and correlated phenotypes, and for elucidating the role of genes in maladies. Comparative expression of gene networks coupled to complex disorders can contribute insights as to how "modifier genes" influence the expressed phenotypes. Increasingly, a more comprehensive and detailed systematic understanding of genetic abnormalities underlying, for example, various genetic cardiomyopathies is emerging. Implementing genomic findings in cardiology practice may well lead directly to better diagnosing and therapeutics. There is currently evolving a strong appreciation for the value of studying gene anomalies, and doing so in a non-disjointed, cohesive manner. However, it is challenging for many-practitioners and investigators-to comprehend, interpret, and utilize the clinically increasingly accessible and affordable cardiovascular genomics studies. This survey addresses the need for fundamental understanding in this vital area.
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Pasipoularides A. Mechanotransduction Mechanisms for Intraventricular Diastolic Vortex Forces and Myocardial Deformations: Part 2. J Cardiovasc Transl Res 2015; 8:293-318. [PMID: 25971844 PMCID: PMC4519381 DOI: 10.1007/s12265-015-9630-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 04/27/2015] [Indexed: 01/10/2023]
Abstract
Epigenetic mechanisms are fundamental in cardiac adaptations, remodeling, reverse remodeling, and disease. A primary goal of translational cardiovascular research is recognizing whether disease-related changes in phenotype can be averted by eliminating or reducing the effects of environmental epigenetic risks. There may be significant medical benefits in using gene-by-environment interaction knowledge to prevent or reverse organ abnormalities and disease. This survey proposes that "environmental" forces associated with diastolic RV/LV rotatory flows exert important, albeit still unappreciated, epigenetic actions influencing functional and morphological cardiac adaptations. Mechanisms analogous to Murray's law of hydrodynamic shear-induced endothelial cell modulation of vascular geometry are likely to link diastolic vortex-associated shear, torque and "squeeze" forces to RV/LV adaptations. The time has come to explore a new paradigm in which such forces play a fundamental epigenetic role, and to work out how heart cells react to them. Findings from various imaging modalities, computational fluid dynamics, molecular cell biology and cytomechanics are considered. The following are examined, among others: structural dynamics of myocardial cells (endocardium, cardiomyocytes, and fibroblasts), cytoskeleton, nucleoskeleton, and extracellular matrix; mechanotransduction and signaling; and mechanical epigenetic influences on genetic expression. To help integrate and focus relevant pluridisciplinary research, rotatory RV/LV filling flow is placed within a working context that has a cytomechanics perspective. This new frontier in cardiac research should uncover versatile mechanistic insights linking filling vortex patterns and attendant forces to variable expressions of gene regulation in RV/LV myocardium. In due course, it should reveal intrinsic homeostatic arrangements that support ventricular myocardial function and adaptability.
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Affiliation(s)
- Ares Pasipoularides
- Department of Surgery, Duke University School of Medicine, Durham, NC, 27710, USA,
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Pasipoularides A. Fluid dynamics of ventricular filling in heart failure: overlooked problems of RV/LV chamber dilatation. Hellenic J Cardiol 2015; 56:85-95. [PMID: 25701976 PMCID: PMC4461873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023] Open
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