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Jiang X, Xiang G, Du G, Li X, Wu P, Du X. A hemodynamic analysis of fenestrated physician-modified endograft repair for complicated aortic dissections involving the visceral arteries. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2023; 242:107785. [PMID: 37678097 DOI: 10.1016/j.cmpb.2023.107785] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 08/12/2023] [Accepted: 08/29/2023] [Indexed: 09/09/2023]
Abstract
OBJECTIVE The aim of this study is to perform patient-specific hemodynamic simulations of the patients with complicated aortic dissection underwent Physician-modified endograft (PMEG) and evaluate the treatment outcome. METHOD 12 patient-specific models were reconstructed from computed tomography angiography (CTA) data of 6 patients with complicated aortic dissection before and after the PMEG. Hemodynamic simulations were conducted with the same time-varying volumetric flow rate extracted from the literature and 3-element Windkessel model (3 EWM) boundary conditions were applied at the aortic outlet. Hemodynamic indicators such as time-averaged wall shear stress (TAWSS), relative residence time (RRT) and endothelial cell activation potential (ECAP) were obtained to evaluate the postoperative effect of PMEG. RESULTS Comparing with the preoperative models, the flow rates of most visceral arteries were increased in the postoperative models (PSMA = 0.012, PRRA = 0.013, and PLRA = 0.005). Pressure and TAWSS in visceral regions were significantly reduced (PP = 0.003 and PTAWSS = 0.017). With the false lumens (FL) covered by the stent grafts, the average TAWSS level increased in the regions of postoperative abdominal aorta (P = 0.002), and the average RRT and ECAP values decreased significantly (PRRT = 0.02 and PECAP = 0.003). CONCLUSION This study shows that PMEG, as a new technique for the treatment of complicated aortic dissection involving the distal tears in the visceral region, can effectively restore the abnormal blood supply of the visceral arteries, reduce the risk of aortic rupture, the formation of aortic dissection aneurysm (ADA), and thrombosis. This corresponds well with clinical retrospective studies and 1-year follow-up outcomes. The findings of this study are of great significance for the development of PMEG.
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Affiliation(s)
- Xudong Jiang
- Department of Vascular Surgery, Nanjing Drum Tower Hospital Clinical College of Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, 321 Zhongshan Road, Nanjing, Jiangsu, China; Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, Jiangsu 210008, China
| | - Guangyuan Xiang
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, Jiangsu 210008, China
| | - Guanting Du
- Artificial Organ Technology Laboratory, School of Mechanical and Electrical Engineering, Soochow University, 8 Jixue Road, Suzhou, Jiangsu 21513, China
| | - Xiaoqiang Li
- Department of Vascular Surgery, Nanjing Drum Tower Hospital Clinical College of Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, 321 Zhongshan Road, Nanjing, Jiangsu, China; Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, Jiangsu 210008, China.
| | - Peng Wu
- Artificial Organ Technology Laboratory, School of Mechanical and Electrical Engineering, Soochow University, 8 Jixue Road, Suzhou, Jiangsu 21513, China.
| | - Xiaolong Du
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, Jiangsu 210008, China.
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Stokes C, Ahmed D, Lind N, Haupt F, Becker D, Hamilton J, Muthurangu V, von Tengg-Kobligk H, Papadakis G, Balabani S, Díaz-Zuccarini V. Aneurysmal growth in type-B aortic dissection: assessing the impact of patient-specific inlet conditions on key haemodynamic indices. J R Soc Interface 2023; 20:20230281. [PMID: 37727072 PMCID: PMC10509589 DOI: 10.1098/rsif.2023.0281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 08/29/2023] [Indexed: 09/21/2023] Open
Abstract
Type-B aortic dissection is a cardiovascular disease in which a tear develops in the intimal layer of the descending aorta, allowing pressurized blood to delaminate the layers of the vessel wall. In medically managed patients, long-term aneurysmal dilatation of the false lumen (FL) is considered virtually inevitable and is associated with poorer disease outcomes. While the pathophysiological mechanisms driving FL dilatation are not yet understood, haemodynamic factors are believed to play a key role. Computational fluid dynamics (CFD) and 4D-flow MRI (4DMR) analyses have revealed correlations between flow helicity, oscillatory wall shear stress and aneurysmal dilatation of the FL. In this study, we compare CFD simulations using a patient-specific, three-dimensional, three-component inlet velocity profile (4D IVP) extracted from 4DMR data against simulations with flow rate-matched uniform and axial velocity profiles that remain widely used in the absence of 4DMR. We also evaluate the influence of measurement errors in 4DMR data by scaling the 4D IVP to the degree of imaging error detected in prior studies. We observe that oscillatory shear and helicity are highly sensitive to inlet velocity distribution and flow volume throughout the FL and conclude that the choice of IVP may greatly affect the future clinical value of simulations.
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Affiliation(s)
- C. Stokes
- Department of Mechanical Engineering, University College London, London, UK
- Wellcome-EPSRC Centre for Interventional Surgical Sciences, London, UK
| | - D. Ahmed
- Department of Aeronautics, Imperial College London, London, UK
| | - N. Lind
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, University of Bern, Bern, Switzerland
| | - F. Haupt
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, University of Bern, Bern, Switzerland
| | - D. Becker
- Clinic of Vascular Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - J. Hamilton
- Department of Mechanical Engineering, University College London, London, UK
| | - V. Muthurangu
- Centre for Translational Cardiovascular Imaging, University College London, London, UK
| | - H. von Tengg-Kobligk
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, University of Bern, Bern, Switzerland
| | - G. Papadakis
- Department of Aeronautics, Imperial College London, London, UK
| | - S. Balabani
- Department of Mechanical Engineering, University College London, London, UK
- Wellcome-EPSRC Centre for Interventional Surgical Sciences, London, UK
| | - V. Díaz-Zuccarini
- Department of Mechanical Engineering, University College London, London, UK
- Wellcome-EPSRC Centre for Interventional Surgical Sciences, London, UK
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Zhu Y, Xu XY, Rosendahl U, Pepper J, Mirsadraee S. Advanced risk prediction for aortic dissection patients using imaging-based computational flow analysis. Clin Radiol 2023; 78:e155-e165. [PMID: 36610929 DOI: 10.1016/j.crad.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 11/28/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022]
Abstract
Patients with either a repaired or medically managed aortic dissection have varying degrees of risk of developing late complications. High-risk patients would benefit from earlier intervention to improve their long-term survival. Currently serial imaging is used for risk stratification, which is not always reliable. On the other hand, understanding aortic haemodynamics within a dissection is essential to fully evaluate the disease and predict how it may progress. In recent decades, computational fluid dynamics (CFD) has been extensively applied to simulate complex haemodynamics within aortic diseases, and more recently, four-dimensional (4D)-flow magnetic resonance imaging (MRI) techniques have been developed for in vivo haemodynamic measurement. This paper presents a comprehensive review on the application of image-based CFD simulations and 4D-flow MRI analysis for risk prediction in aortic dissection. The key steps involved in patient-specific CFD analyses are demonstrated. Finally, we propose a workflow incorporating computational modelling for personalised assessment to aid in risk stratification and treatment decision-making.
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Affiliation(s)
- Y Zhu
- Department of Chemical Engineering, Imperial College London, London, UK
| | - X Y Xu
- Department of Chemical Engineering, Imperial College London, London, UK
| | - U Rosendahl
- Department of Cardiac Surgery, Royal Brompton and Harefield Hospitals, London, UK; National Heart and Lung Institute, Imperial College London, London, UK
| | - J Pepper
- Department of Cardiac Surgery, Royal Brompton and Harefield Hospitals, London, UK; National Heart and Lung Institute, Imperial College London, London, UK
| | - S Mirsadraee
- National Heart and Lung Institute, Imperial College London, London, UK; Department of Radiology, Royal Brompton and Harefield Hospitals, London, UK.
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Kimura N, Nakamura M, Takagi R, Mieno MN, Yamaguchi A, Czerny M, Beyersdorf F, Kari FA, Rylski B. False lumen/true lumen wall pressure ratio is increased in acute non-A non-B aortic dissection. Interact Cardiovasc Thorac Surg 2022; 35:6585342. [PMID: 35552699 PMCID: PMC9486891 DOI: 10.1093/icvts/ivac138] [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: 04/11/2022] [Revised: 05/06/2022] [Accepted: 05/09/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
OBJECTIVES
We aimed to determine whether non-A non-B aortic dissection (AD) differs in morphologic and haemodynamic properties from type B AD.
METHODS
We simulated and compared haemodynamics of patients with acute type B or acute non-A non-B AD by means of computational fluid dynamics. Wall pressure and wall shear stress (WSS) in both the true lumen (TL) and false lumen (FL) at early, mid- and late systole were evaluated. Morphology, WSS and the FL/TL wall pressure ratio were compared between groups.
RESULTS
Nineteen patients (type B, n = 7; non-A non-B, n = 12) were included. The median age (51 [46, 67] vs 53 [50, 63] years; P = 0.71) and a complicated course (14% vs 33%; P = 0.6) did not differ between the type B group and the non-A non-B group. However, the median entry tear width was increased in the non-A non-B group (9.7 [7.3, 12.7] vs 16.3 [11.9, 24.9] mm; P = 0.010). Streamlines showed, in patients with non-A non-B AD, blood from the TL flowed into the FL via the entry tear. Prevalence of a FL/TL wall pressure ratio >1.0 (type B versus non-A non-B) at early, mid- and late systole was 57% vs 83% (P = 0.31), 43% vs 83% (P = 0.13) and 57% vs 75% (P = 0.62), respectively. WSS did not differ between the groups.
CONCLUSIONS
The increased FL/TL wall pressure ratio observed during systole in non-A non-B AD may beget a complicated presentation.
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Affiliation(s)
- Naoyuki Kimura
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University , Saitama, Japan
| | - Masanori Nakamura
- Department of Electrical and Mechanical Engineering, Nagoya Institute of Technology , Nagoya, Japan
| | - Reiya Takagi
- Department of Electrical and Mechanical Engineering, Nagoya Institute of Technology , Nagoya, Japan
| | - Makiko Naka Mieno
- Department of Medical Informatics, Center for Information, Jichi Medical University , Shimotsuke, Japan
| | - Atsushi Yamaguchi
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University , Saitama, Japan
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Centre Freiburg, University of Freiburg , Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Heart Centre Freiburg, University of Freiburg , Freiburg, Germany
| | - Fabian Alexander Kari
- Department of Cardiovascular Surgery, University Heart Centre Freiburg, University of Freiburg , Freiburg, Germany
| | - Bartosz Rylski
- Department of Cardiovascular Surgery, University Heart Centre Freiburg, University of Freiburg , Freiburg, Germany
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Fatma K, Carine GC, Marine G, Philippe P, Valérie D. Numerical modeling of residual type B aortic dissection: longitudinal analysis of favorable and unfavorable evolution. Med Biol Eng Comput 2022; 60:769-783. [PMID: 35076858 DOI: 10.1007/s11517-021-02480-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 11/24/2021] [Indexed: 11/26/2022]
Abstract
Residual type B aortic dissection was numerically investigated to highlight the contribution of biomechanical parameters to the pathology's evolution. Patient-specific geometries from cases involving both favorable and unfavorable evolution were modeled to assess their hemodynamic features. This original approach was supported by a longitudinal study confirming the association between morphological changes, hemodynamic features, adverse clinical outcomes, and CT-angioscan observations on the same patient. Comparing one patient with unfavorable evolution with one with favorable one, we identify potential biomechanical indicators predictive of unfavorable evolution: (i) a patent false lumen with a flow rate above 50% of inlet flow rate; (ii) high wall shear stress above 18 Pa at entry tears, and above 10 Pa at some regions of the false lumen wall; (iii) low time-averaged wall shear stress in distal false lumen below 0.5 Pa; (iv) vortical structure dynamics. Although these comparisons could only be conducted on 2 patients and need to be confirmed by a larger number of cases, our findings point to these hemodynamic markers as possible candidates for early evaluation of the pathology's evolution towards an unfavorable scenario. Graphical Abstract Correlation between hemodynamics index and thrombus initiation for unfavorable case. ET2 and ET3 are entry tear numbers 2 and 3 respectively. WSS is wall shear stress. TAWSS is time average shear stress.
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Affiliation(s)
- Khannous Fatma
- Aix Marseille Univ, CNRS, IRPHE-UMR7342, Ecole Centrale, Marseille, France
| | | | - Gaudry Marine
- Aix Marseille Univ, CNRS, IRPHE-UMR7342, Ecole Centrale, Marseille, France
- Aix Marseille Univ, APHM, Timone Hospital, Department of Vascular Surgery, Marseille, France
| | - Piquet Philippe
- Aix Marseille Univ, APHM, Timone Hospital, Department of Vascular Surgery, Marseille, France
| | - Deplano Valérie
- Aix Marseille Univ, CNRS, IRPHE-UMR7342, Ecole Centrale, Marseille, France.
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Numerical Investigation of Methodologies for Cavitation Suppression Inside Globe Valves. APPLIED SCIENCES-BASEL 2020. [DOI: 10.3390/app10165541] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Cavitation inside globe valves, which is a common phenomenon if there is a high-pressure drop, is numerically investigated in this study. Firstly, the cavitation phenomenon in globe valves with a different number of cages is compared. When there is no valve cage, cavitation mainly appears at the valve seat, the bottom of the valve core, and the downstream pipelines. By installing a valve cage, cavitation bubbles can be restricted around the valve cage protecting the valve body from being damaged. Secondly, the effects of the outlet pressure, the working temperature, and the installation angle of two valve cages in a two-cage globe valve are studied to find out the best method to suppress cavitation, and cavitation number is utilized to evaluate cavitation intensity. Results show that cavitation intensity inside globe valves can be reduced by increasing the valve outlet pressure, decreasing the working temperature, or increasing the installation angle. Results suggest that increasing the outlet pressure is the most efficient way to suppress cavitation intensity in a globe valve, and the working temperature has a minimal effect on cavitation intensity.
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7
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Wang R, Yu X, Zhang Y. Mechanical and structural contributions of elastin and collagen fibers to interlamellar bonding in the arterial wall. Biomech Model Mechanobiol 2020; 20:93-106. [PMID: 32705413 DOI: 10.1007/s10237-020-01370-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 07/15/2020] [Indexed: 12/25/2022]
Abstract
The artery relies on interlamellar structural components, mainly elastin and collagen fibers, for maintaining its integrity and resisting dissection propagation. In this study, the contribution of arterial elastin and collagen fibers to interlamellar bonding was studied through mechanical testing, multiphoton imaging and finite element modeling. Steady-state peeling experiments were performed on porcine aortic media and the purified elastin network in the circumferential (Circ) and longitudinal (Long) directions. The peeling force and energy release rate associated with mode-I failure are much higher for aortic media than for the elastin network. Also, longitudinal peeling exhibits a higher energy release rate and strength than circumferential peeling for both the aortic media and elastin. Multiphoton imaging shows the recruitment of both elastin and collagen fibers within the interlamellar space and points to in-plane anisotropy of fiber distributions as a potential mechanism for the direction-dependent phenomena of peeling tests. Three-dimensional finite element models based on cohesive zone model (CZM) of fracture were created to simulate the peeling tests with the interlamellar energy release rate and separation distance at damage initiation obtained directly from peeling test. Our experimental results show that the separation distance at damage initiation is 80 μm for aortic media and 40 μm for elastin. The damage initiation stress was estimated from the model for aortic media (Circ: 60 kPa; Long: 95 kPa) and elastin (Circ: 9 kPa; Long: 14 kPa). The interlamellar separation distance at complete failure was estimated to be 3 - 4 mm for both media and elastin. Furthermore, elastin and collagen fibers both play an important role in bonding of the arterial wall, while collagen has a higher contribution than elastin to interlamellar stiffness, strength and toughness. These results on microstructural interlamellar failure shed light on the pathological development and progression of aortic dissection.
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Affiliation(s)
- Ruizhi Wang
- Department of Mechanical Engineering, Boston University, 110 Cummington Mall, Boston, MA, 02215, USA
| | - Xunjie Yu
- Department of Mechanical Engineering, Boston University, 110 Cummington Mall, Boston, MA, 02215, USA
| | - Yanhang Zhang
- Department of Mechanical Engineering, Boston University, 110 Cummington Mall, Boston, MA, 02215, USA. .,Department of Biomedical Engineering, Boston University, 110 Cummington Mall, Boston, MA, 02215, USA. .,Divison of Materials Science & Engineering, Boston University, 110 Cummington Mall, Boston, MA, 02215, USA.
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Statistical Shape Analysis of Ascending Thoracic Aortic Aneurysm: Correlation between Shape and Biomechanical Descriptors. J Pers Med 2020; 10:jpm10020028. [PMID: 32331429 PMCID: PMC7354467 DOI: 10.3390/jpm10020028] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 04/14/2020] [Accepted: 04/17/2020] [Indexed: 12/21/2022] Open
Abstract
An ascending thoracic aortic aneurysm (ATAA) is a heterogeneous disease showing different patterns of aortic dilatation and valve morphologies, each with distinct clinical course. This study aimed to explore the aortic morphology and the associations between shape and function in a population of ATAA, while further assessing novel risk models of aortic surgery not based on aortic size. Shape variability of n = 106 patients with ATAA and different valve morphologies (i.e., bicuspid versus tricuspid aortic valve) was estimated by statistical shape analysis (SSA) to compute a mean aortic shape and its deformation. Once the computational atlas was built, principal component analysis (PCA) allowed to reduce the complex ATAA anatomy to a few shape modes, which were correlated to shear stress and aortic strain, as determined by computational analysis. Findings demonstrated that shape modes are associated to specific morphological features of aneurysmal aorta as the vessel tortuosity and local bulging of the ATAA. A predictive model, built with principal shape modes of the ATAA wall, achieved better performance in stratifying surgically operated ATAAs versus monitored ATAAs, with respect to a baseline model using the maximum aortic diameter. Using current imaging resources, this study demonstrated the potential of SSA to investigate the association between shape and function in ATAAs, with the goal of developing a personalized approach for the treatment of the severity of aneurysmal aorta.
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9
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Pasta S, Agnese V, Gallo A, Cosentino F, Di Giuseppe M, Gentile G, Raffa GM, Maalouf JF, Michelena HI, Bellavia D, Conaldi PG, Pilato M. Shear Stress and Aortic Strain Associations With Biomarkers of Ascending Thoracic Aortic Aneurysm. Ann Thorac Surg 2020; 110:1595-1604. [PMID: 32289298 DOI: 10.1016/j.athoracsur.2020.03.017] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 02/10/2020] [Accepted: 03/05/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND This study aims to investigate the association of wall shear stress (WSS) and aortic strain with circulating biomarkers including matrix metalloproteinases (MMP), tissue inhibitors of metalloproteinase (TIMP), and exosomal level of microRNA (miRNA) in ascending aortic aneurysms of patients with bicuspid or tricuspid aortic valve. METHODS A total of 76 variables from 125 patients with ascending aortic aneurysms were collected from (1) blood plasma to measure plasma levels of miRNAs and protein activity; (2) computational flow analysis to estimate peak systolic WSS and time-average WSS (TAWSS); and (3) imaging analysis of computed tomography angiography to determine aortic wall strain. Principal component analysis followed by logistic regression allowed the development of a predictive model of aortic surgery by combining biomechanical descriptors and biomarkers. RESULTS The protein activity of MMP-1, TIMP-1, and MMP-2 was positively correlated to the systolic WSS and TAWSS observed in the proximal ascending aorta (eg, R = 0.52, P < .001, for MMP-1 with TAWSS) where local maxima of WSS were found. For bicuspid patients, aortic wall strain was associated with miR-26a (R = 0.55, P = .041) and miR-320a (R = 0.69, P < .001), which shows a significant difference between bicuspid and tricuspid patients. Receiver-operating characteristics curves revealed that the combination of WSS, MMP-1, TIMP-1, and MMP-12 is predictive of aortic surgery (area under the curve 0.898). CONCLUSIONS Increased flow-based and structural descriptors of ascending aortic aneurysms are associated with high levels of circulating biomarkers, implicating adverse vascular remodeling in the dilated aorta by mechanotransduction. A combination of shear stress and circulating biomarkers has the potential to improve the decision-making process for ascending aortic aneurysms to a highly individualized level.
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Affiliation(s)
- Salvatore Pasta
- Bioengineering Division, Department of Engineering, University of Palermo, Palermo, Italy.
| | - Valentina Agnese
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy
| | - Alessia Gallo
- Department of Laboratory Medicine and Advanced Biotechnologies, IRCCS-ISMETT, Palermo, Italy
| | - Federica Cosentino
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Marzio Di Giuseppe
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Giovanni Gentile
- Department of Diagnostic and Therapeutic Services, Radiology Unit, IRCCS-ISMETT, Palermo, Italy
| | - Giuseppe M Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy
| | - Joseph F Maalouf
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, Rochester, Minnesota
| | - Hector I Michelena
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, Rochester, Minnesota
| | - Diego Bellavia
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy
| | - Pier Giulio Conaldi
- Department of Laboratory Medicine and Advanced Biotechnologies, IRCCS-ISMETT, Palermo, Italy
| | - Michele Pilato
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy
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10
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Pre-Operative Modeling of Transcatheter Mitral Valve Replacement in a Surgical Heart Valve Bioprosthesis. PROSTHESIS 2020. [DOI: 10.3390/prosthesis2010004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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11
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Pasta S, Cannata S, Gentile G, Di Giuseppe M, Cosentino F, Pasta F, Agnese V, Bellavia D, Raffa GM, Pilato M, Gandolfo C. Simulation study of transcatheter heart valve implantation in patients with stenotic bicuspid aortic valve. Med Biol Eng Comput 2020; 58:815-829. [DOI: 10.1007/s11517-020-02138-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 01/22/2020] [Indexed: 12/19/2022]
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Computational Fluid Dynamics Modeling of Hemodynamic Parameters in the Human Diseased Aorta: A Systematic Review. Ann Vasc Surg 2020; 63:336-381. [DOI: 10.1016/j.avsg.2019.04.032] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 03/09/2019] [Accepted: 04/18/2019] [Indexed: 02/07/2023]
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13
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Munshi B, Parker LP, Norman PE, Doyle BJ. The application of computational modeling for risk prediction in type B aortic dissection. J Vasc Surg 2019; 71:1789-1801.e3. [PMID: 31831314 DOI: 10.1016/j.jvs.2019.09.032] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 09/04/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE New tools are urgently needed to help with surgical decision-making in type B aortic dissection (TBAD) that is uncomplicated at the time of initial presentation. This narrative review aims to answer the clinical question, Can computational modeling be used to predict risk in acute and chronic Stanford TBAD? METHODS The review (PROSPERO 2018 CRD42018104472) focused on risk prediction in TBAD. A comprehensive search of the Ovid MEDLINE database, using terms related to computational modeling and aortic dissection, was conducted to find studies of any form published between 1998 and 2018. Cohort studies, case series, and case reports of adults (older than 18 years) with computed tomography or magnetic resonance imaging diagnosis of TBAD were included. Computational modeling was applied in all selected studies. RESULTS There were 37 studies about computational modeling of TBAD identified from the search, and the findings were synthesized into a narrative review. Computational modeling can produce numerically calculated values of stresses, pressures, and flow velocities that are difficult to measure in vivo. Hemodynamic parameters-high or low wall shear stress, high pressure gradient between lumens during the cardiac cycle, and high false lumen flow rate-have been linked to the pathogenesis of branch malperfusion and aneurysm formation by numerous studies. Considering the major outcomes of end-organ failure, aortic rupture, and stabilization and remodeling, hypotheses have been generated about inter-relationships of measurable parameters in computational models with observable anatomic and pathologic changes, resulting in specific clinical outcomes. CONCLUSIONS There is consistency in study findings about computational modeling in TBAD, although a limited number of patients have been analyzed using various techniques. The mechanistic patterns of association found in this narrative review should be investigated in larger cohort prospective studies to further refine our understanding. It highlights the importance of patient-specific computational hemodynamic parameters in clinical decision-making algorithms. The current challenge is to develop and to test a risk assessment method that can be used by clinicians for TBAD.
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Affiliation(s)
- Bijit Munshi
- Vascular Engineering Laboratory, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands, Australia; Centre for Medical Research, The University of Western Australia, Perth, Australia; Medical School, The University of Western Australia, Perth, Australia; Department of Vascular Surgery, Fiona Stanley Hospital, Perth, Australia
| | - Louis P Parker
- Vascular Engineering Laboratory, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands, Australia; Centre for Medical Research, The University of Western Australia, Perth, Australia; School of Engineering, The University of Western Australia, Perth, Australia
| | - Paul E Norman
- Vascular Engineering Laboratory, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands, Australia; Centre for Medical Research, The University of Western Australia, Perth, Australia; Medical School, The University of Western Australia, Perth, Australia; Department of Vascular Surgery, Fiona Stanley Hospital, Perth, Australia
| | - Barry J Doyle
- Vascular Engineering Laboratory, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands, Australia; Centre for Medical Research, The University of Western Australia, Perth, Australia; School of Engineering, The University of Western Australia, Perth, Australia.
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14
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Patient-specific haemodynamic simulations of complex aortic dissections informed by commonly available clinical datasets. Med Eng Phys 2019; 71:45-55. [DOI: 10.1016/j.medengphy.2019.06.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 05/22/2019] [Accepted: 06/09/2019] [Indexed: 12/26/2022]
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15
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Experimental Insight into the Hemodynamics and Perfusion of Radiological Contrast in Patent and Non-patent Aortic Dissection Models. Cardiovasc Eng Technol 2019; 10:314-328. [PMID: 30805874 DOI: 10.1007/s13239-019-00407-4] [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: 07/04/2018] [Accepted: 02/09/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE In a curved vessel such as the aortic arch, the velocity profile closer to the aortic root is normally skewed towards the inner curvature wall, while further downstream along the curve, the velocity profile becomes skewed towards the outer wall. In an aortic dissection (AD) disease, blood velocities in the true lumen (TL) and false lumen (FL) are hypothesized to depend on the proximity of the entry tear to the root of aortic arch. Faster velocity in the FL can lead to higher hemodynamic loading, and pose tearing risk. Furthermore, the luminal velocities control the perfusion rate of radiological contrast media during diagnostic imaging. The objective in this study is to investigate the effect of AD disease morphology and configuration on the blood velocity field in the TL and FL, and on the relative perfusion of radiological enhancement agents through the dissection. METHODS Eight in vitro models were studied, including patent and non-patent FL configurations. Particle image velocimetry (PIV) was used to quantify the AD velocity field, while laser-induced fluorescence (LIF) was implemented to visualize dynamical flow phenomena and to quantify the perfusion of injected dye, in mimicry of contrast-enhanced computed tomography (CT). RESULTS The location of the proximal entry tear along the aortic arch in a patent FL had a dramatic impact on whether the blood velocity was higher in the TL or FL. The luminal velocities were dependent on the entry/reentry tear size combination, with the smaller tear (whether distal or proximal) setting the upper limit on the maximal flow velocity in the FL. Upon merging near the distal reentry tear, the TL/FL velocity differential gave rise to the roll up and shedding of shear layer vortices that convected downstream in close proximity to the wall of the non-dissected aorta. In a non-patent FL, the flow velocity was practically null with all the blood passing through the TL. LIF imaging showed much slower perfusion of contrast dye in the FL compared to the TL. In a patent FL, however, dye had a comparable perfusion rate appearing around the same time as in the TL. CONCLUSIONS Blood velocities in the TL and FL were highly sensitive to the exact dissection configuration. Geometric case A1R, which had its proximal entry tear located further downstream along the aortic arch, and had its entry and reentry tears sufficiently sized, exhibited the highest FL flow velocity among the tested models, and it was also higher than in the TL, which suggest that this configuration had elevated hemodynamic loading and risk for tearing. In contrast-enhanced diagnostic imaging, a time-delayed acquisition protocol is recommended to improve the detection of suspected cases with a non-patent FL.
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Rikhtegar Nezami F, Athanasiou LS, Amrute JM, Edelman ER. Multilayer flow modulator enhances vital organ perfusion in patients with type B aortic dissection. Am J Physiol Heart Circ Physiol 2018; 315:H1182-H1193. [PMID: 30095992 DOI: 10.1152/ajpheart.00199.2018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Management of aortic dissections (AD) is still challenging, with no universally approved guideline among possible surgical, endovascular, or medical therapies. Approximately 25% of patients with AD suffer postintervention malperfusion syndrome or hemodynamic instability, with the risk of sudden death if left untreated. Part of the issue is that vascular implants may themselves induce flow disturbances that critically impact vital organs. A multilayer mesh construct might obviate the induced flow disturbances, and it is this concept we investigated. We used preintervention and post-multilayer flow modulator implantation (PM) geometries from clinical cases of type B AD. In-house semiautomatic segmentation routines were applied to computed tomography images to reconstruct the lumen. The device was numerically reconstructed and adapted to the PM geometry concentrically fit to the true lumen centerline. We also numerically designed a pseudohealthy case, where the geometry of the aorta was extracted interpolating geometric features of preintervention, postimplantation, and published representative healthy volunteers. Computational fluid dynamics methods were used to study the time-dependent flow patterns, shear stress metrics, and perfusion to vital organs. A three-element Windkessel lumped parameter module was coupled to a finite-volume solver to assign dynamic outlet boundary conditions. Multilayer flow modulator not only significantly reduced false lumen blood flow, eliminated local flow disturbances, and globally regulated wall shear stress distribution but also maintained physiological perfusion to peripheral vital organs. We propose further investigation to focus the management of AD on both modulation of blood flow and restoration of physiologic end-organ perfusion rather than mere restoration of vascular lamina morphology. NEW & NOTEWORTHY The majority of aortic dissection modeling efforts have focused on the maintenance of physiological flow using minimally invasive placed grafts. The multilayer flow modulator is a complex mesh construct of wires, designed to eliminate flow disruptions in the lumen, regulate the physiological wall stresses, and enhance endothelial function and offering the promise of improved perfusion of vital organs. This has never been fully proved or modeled, and these issues we confirmed using a dynamic framework of time-varying arterial waveforms.
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Affiliation(s)
- Farhad Rikhtegar Nezami
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology , Cambridge, Massachusetts
| | - Lambros S Athanasiou
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology , Cambridge, Massachusetts.,Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School , Boston, Massachusetts
| | - Junedh M Amrute
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology , Cambridge, Massachusetts.,Division of Biology and Biological Engineering, California Institute of Technology , Pasadena, California
| | - Elazer R Edelman
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology , Cambridge, Massachusetts.,Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School , Boston, Massachusetts
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17
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Luo J, Fu X, Zhou Y, Tang H, Song G, Tang T, Liao X, Zhou X. Aortic Remodeling Following Sun's Procedure for Acute Type A Aortic Dissection. Med Sci Monit 2017; 23:2143-2150. [PMID: 28475566 PMCID: PMC5431888 DOI: 10.12659/msm.900345] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Sun’s procedure is a surgical technique widely used in type A aortic dissection. The purpose of this study was to analyze clinical outcomes and morphologic changes in true and false lumen by computed tomography (CT) angiography after Sun’s procedure. Material/Methods We retrospectively reviewed 51 patients who underwent Sun’s procedure for acute Stanford type A aortic dissection extending down to iliac bifurcation between January 2013 and December 2014. The images of preoperative, one-month, three-month, and six-month follow-up were analyzed by CT angiography to measure the area and diameter of true and false lumen. Results Four patients died before surgical intervention and postoperative deaths occurred in five patients (in-hospital mortality rate 10.6%). Only 42 patients (36 male, 6 female; mean age, 45.9±9.8 years; range, 24–65 years) with acute type A aortic dissection were involved in our study. Thirty-five patients (83.3%) suffered from chest or abdominal pain and only one patient (2.4%) was asymptomatic. Thirty-seven patients (88.1%) had hypertension as the most common comorbidity. In the ascending aorta, false lumen was eliminated and the change of true lumen was not significant (p>0.05). In the descending aorta, complete and partial thrombosis of false lumen were observed in eight patients (19.0%) and 33 patients (78.6%) by one-month follow-up CT scan, respectively. After the six-month follow-up, the rate of complete thrombosis increased to 36.1% and partial thrombosis decreased to 61.9%. The area and maximal diameter of true lumen were increased significantly (p<0.05), whereas significant decreases were found in the area and maximal diameter of false lumen (p<0.05). In the abdominal aorta, thrombosis was found in 52.4% patients at one-month follow-up CT. Furthermore, there were no significant changes in both true and false lumen within three months (p>0.05). Nevertheless, the false luminal area and maximal diameter decreased significantly (p<0.05) after six months, while these changes of true lumen were not significant (p>0.05). Conclusions After Sun’s procedure, aortic remodeling was a continuous process and occurred in a predictable model, and the extent of aortic remodeling varied at different levels. Remodeling in descending thoracic aorta was earlier than it was in abdominal aorta.
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Affiliation(s)
- Jiawen Luo
- Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China (mainland)
| | - Xianming Fu
- Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China (mainland)
| | - Yangzhao Zhou
- Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China (mainland)
| | - Hao Tang
- Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China (mainland)
| | - Guobao Song
- Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China (mainland)
| | - Tao Tang
- Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China (mainland)
| | - Xiaobo Liao
- Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China (mainland)
| | - Xinmin Zhou
- Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China (mainland)
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18
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Raffa GM, Pasta S, Gentile G, Scardulla F, Wu B, D'Ancona G, Follis F, Pilato M. Early distal remodeling after elephant trunk repair of thoraco-abdominal aortic aneurysms. J Biomech 2016; 49:2398-404. [PMID: 26776928 DOI: 10.1016/j.jbiomech.2015.12.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 12/16/2015] [Indexed: 11/16/2022]
Abstract
Hemodynamic alterations occur when the elephant trunk (ET) technique is adopted to treat extensive aortic aneurysms. In planning the 2nd stage operation to complete ET repair, surgeons must weigh an adequate recovery time after initial surgery against the risk of postoperative ET-related complications. The purpose of this study was to understand the mechanistic link between the flow alteration caused by the ET graft and the development of premature aortic rupture before the 2nd stage operation. Specifically, fluid-structure interaction (FSI) analysis was performed using the CT imaging data of aorta at different stages of ET repair, and then computational variables were compared to those observed in patients who underwent a prophylactic 2nd stage operation to complete aortic repair. Results show that intramural stress exerted near the distal ET anastomosis (IMS=37.5kPa) at the time of urgent intervention was comparable to that of the extensive aortic aneurysm (IMS=47.4kPa) at initial in-hospital admission, but was considerably higher than that occurring after the 1st stage procedure (IMS=3.5kPa). Pressure index suggested higher peri-graft pressurization than aortic lumen pressure during diastole, imparting an apparent risk of aortic dilatation. These critical hemodynamic and structural parameters are related to the impending rupture of descending aorta observed clinically and can thus guide prophylactic intervention and optimal timing for the 2nd stage operation of a ET technique.
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Affiliation(s)
- Giuseppe M Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT-IRCCS), Palermo, Italy.
| | - Salvatore Pasta
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT-IRCCS), Palermo, Italy; Fondazione Ri.MED, Palermo, Italy.
| | - Giovanni Gentile
- Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT-IRCCS), Palermo, Italy
| | - Francesco Scardulla
- Department of Chemical, Management, Computer Science, Mechanical Engineering, University of Palermo, Palermo, Italy
| | - Bryan Wu
- School of Medicine, University of Pittsburgh, Pittsburgh, USA
| | - Giuseppe D'Ancona
- Cardiovascular Medicine Clinical and Research Unit, Vivantes Klinikum im Friedrichschein und Am Urban, Berlin, Germany
| | - Fabrizio Follis
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT-IRCCS), Palermo, Italy
| | - Michele Pilato
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT-IRCCS), Palermo, Italy
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D'Ancona G, Lee JJ, Pasta S, Pilato G, Rinaudo A, Follis F, Pilato M. Computational analysis to predict false-lumen perfusion and outcome of type B aortic dissection. J Thorac Cardiovasc Surg 2014; 148:1756-8. [DOI: 10.1016/j.jtcvs.2014.06.065] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Revised: 06/08/2014] [Accepted: 06/16/2014] [Indexed: 12/19/2022]
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20
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Lee JJ, D'Ancona G, Amaducci A, Follis F, Pilato M, Pasta S. Role of Computational Modeling in Thoracic Aortic Pathology:
A Review. J Card Surg 2014; 29:653-62. [DOI: 10.1111/jocs.12413] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Jake J. Lee
- School of Medicine; University of Pittsburgh; Pittsburgh Pennsylvania
| | - Giuseppe D'Ancona
- Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT); Palermo Italy
| | - Andrea Amaducci
- Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT); Palermo Italy
| | - Fabrizio Follis
- Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT); Palermo Italy
| | - Michele Pilato
- Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT); Palermo Italy
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