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Fumagalli I, Polidori R, Renzi F, Fusini L, Quarteroni A, Pontone G, Vergara C. Fluid-structure interaction analysis of transcatheter aortic valve implantation. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2023; 39:e3704. [PMID: 36971047 DOI: 10.1002/cnm.3704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 03/19/2023] [Indexed: 06/07/2023]
Abstract
Transcatheter aortic valve implantation (TAVI) is a minimally invasive intervention for the treatment of severe aortic valve stenosis. The main cause of failure is the structural deterioration of the implanted prosthetic leaflets, possibly inducing a valvular re-stenosis 5-10 years after the implantation. Based solely on pre-implantation data, the aim of this work is to identify fluid-dynamics and structural indices that may predict the possible valvular deterioration, in order to assist the clinicians in the decision-making phase and in the intervention design. Patient-specific, pre-implantation geometries of the aortic root, the ascending aorta, and the native valvular calcifications were reconstructed from computed tomography images. The stent of the prosthesis was modeled as a hollow cylinder and virtually implanted in the reconstructed domain. The fluid-structure interaction between the blood flow, the stent, and the residual native tissue surrounding the prosthesis was simulated by a computational solver with suitable boundary conditions. Hemodynamical and structural indicators were analyzed for five different patients that underwent TAVI - three with prosthetic valve degeneration and two without degeneration - and the comparison of the results showed a correlation between the leaflets' structural degeneration and the wall shear stress distribution on the proximal aortic wall. This investigation represents a first step towards computational predictive analysis of TAVI degeneration, based on pre-implantation data and without requiring additional peri-operative or follow-up information. Indeed, being able to identify patients more likely to experience degeneration after TAVI may help to schedule a patient-specific timing of follow-up.
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Affiliation(s)
- Ivan Fumagalli
- MOX, Dipartimento di Matematica, Politecnico di Milano, Milan, Italy
| | - Rebecca Polidori
- LaBS, Dipartimento di Chimica, Materiali e Ingegneria Chimica, Politecnico di Milano, Milan, Italy
| | - Francesca Renzi
- LaBS, Dipartimento di Chimica, Materiali e Ingegneria Chimica, Politecnico di Milano, Milan, Italy
| | - Laura Fusini
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino IRCSS, Milan, Italy
- Department of Electronics, Information and Biomedical Engineering, Politecnico di Milano, Milan, Italy
| | - Alfio Quarteroni
- MOX, Dipartimento di Matematica, Politecnico di Milano, Milan, Italy
- Institute of Mathematics, École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - Gianluca Pontone
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino IRCSS, Milan, Italy
| | - Christian Vergara
- LaBS, Dipartimento di Chimica, Materiali e Ingegneria Chimica, Politecnico di Milano, Milan, Italy
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Zareian R, Tseng JC, Fraser R, Meganck J, Kilduff M, Sarraf M, Dvir D, Kheradvar A. Effect of stent crimping on calcification of transcatheter aortic valves. Interact Cardiovasc Thorac Surg 2019; 29:64-73. [PMID: 30793744 DOI: 10.1093/icvts/ivz024] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 12/26/2018] [Accepted: 12/27/2018] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Although many challenges related to the acute implantation of transcatheter aortic valves have been resolved, durability and early degeneration are currently the main concerns. Recent reports indicate the potential for early valve degeneration and calcification. However, only little is known about the underlying mechanisms behind the early degeneration of these valves. The goal of this study was to test whether stent crimping increases the risk for early calcification. METHODS Stented valves that were crimped at 18-Fr and 14-Fr catheter and uncrimped controls were exposed to a standard calcifying solution for 50 million cycles in an accelerated wear test system. Subsequently, the leaflets of the valves were imaged by microcomputed tomography (micro-CT) followed by histochemical staining and microscopic analyses to quantify calcification and other changes in the leaflets' characteristics. RESULTS Heavily calcified regions were found over the stent-crimped leaflets compared to uncrimped controls, particularly around the stent's struts. Micro-CT studies measured the total volume of calcification in the uncrimped valves as 77.31 ± 1.63 mm3 vs 95.32 ± 5.20 mm3 in 18-Fr and 110.01 ± 8.33 mm3 in 14-Fr stent-crimped valves, respectively. These results were congruent with the increase in leaflet thickness measured by CT scans (0.44 ± 0.07 mm in uncrimped valves vs 0.69 ± 0.15 mm and 0.75 ± 0.09 mm in 18-Fr and 14-Fr stent-crimped valves, respectively). Histological studies confirmed the micro-CT results, denoting that the percentage of calcification in uncrimped leaflets at the valve's posts was 5.34 ± 3.97 compared to 19.97 ± 6.18 and 27.64 ± 13.17 in the 18-Fr and 14-Fr stent-crimped leaflets, respectively. CONCLUSIONS This study concludes that stent-crimping damage is associated with a higher level of passive leaflet calcification, which may contribute to early valve degeneration.
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Affiliation(s)
- Ramin Zareian
- The Edwards Lifesciences Center for Advanced Cardiovascular Technology, University of California Irvine, Irvine, CA, USA
| | | | | | | | | | - Mohammad Sarraf
- Cardiovascular Division, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Danny Dvir
- Division of Cardiology, University of Washington Medical Center, Seattle, WA, USA
| | - Arash Kheradvar
- The Edwards Lifesciences Center for Advanced Cardiovascular Technology, University of California Irvine, Irvine, CA, USA
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van Broekhoven A, Krijnen PAJ, Fuijkschot WW, Morrison MC, Zethof IPA, van Wieringen WN, Smulders YM, Niessen HWM, Vonk ABA. Short-term LPS induces aortic valve thickening in ApoE*3Leiden mice. Eur J Clin Invest 2019; 49:e13121. [PMID: 31013351 DOI: 10.1111/eci.13121] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 04/16/2019] [Accepted: 04/19/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Recently, it was shown that 12 weeks of lipopolysaccharide (LPS) administration to nonatherosclerotic mice induced thickening of the aortic heart valve (AV). Whether such effects may also occur even earlier is unknown. As most patients with AV stenosis also have atherosclerosis, we studied the short-term effect of LPS on the AVs in an atherosclerotic mouse model. METHODS ApoE*3Leiden mice, on an atherogenic diet, were injected intraperitoneally with either LPS or phosphate buffered saline (PBS), and sacrificed 2 or 15 days later. AVs were assessed for size, fibrosis, glycosaminoglycans (GAGs), lipids, calcium deposits, iron deposits and inflammatory cells. RESULTS LPS injection caused an increase in maximal leaflet thickness at 2 days (128.4 µm) compared to PBS-injected mice (67.8 µm; P = 0.007), whereas at 15 days this was not significantly different. LPS injection did not significantly affect average AV thickness on day 2 (37.8 µm), but did significantly increase average AV thickness at day 15 (41.6 µm; P = 0.038) compared to PBS-injected mice (31.7 and 32.3 µm respectively). LPS injection did not affect AV fibrosis, GAGs and lipid content. Furthermore, no calcium deposits were found. Iron deposits, indicative for valve haemorrhage, were observed in one AV of the PBS-injected group (a day 2 mouse; 9.1%) and in five AVs of the LPS-injected group (both day 2- and 15 mice; 29.4%). No significant differences in inflammatory cell infiltration were observed upon LPS injection. CONCLUSION Short-term LPS apparently has the potential to increase AV thickening and haemorrhage. These results suggest that systemic inflammation can acutely compromise AV structure.
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Affiliation(s)
- Amber van Broekhoven
- Department of Pathology, Amsterdam UMC-Location VUmc, Amsterdam, The Netherlands.,Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.,Department of Cardiac Surgery, Amsterdam UMC-Location VUmc, Amsterdam, The Netherlands
| | - Paul A J Krijnen
- Department of Pathology, Amsterdam UMC-Location VUmc, Amsterdam, The Netherlands.,Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Wessel W Fuijkschot
- Department of Pathology, Amsterdam UMC-Location VUmc, Amsterdam, The Netherlands.,Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.,Department of Internal Medicine, Amsterdam UMC-Location VUmc, Amsterdam, The Netherlands
| | - Martine C Morrison
- Department of Metabolic Health Research, The Netherlands Organization for Applied Scientific Research (TNO), Leiden, The Netherlands
| | - Ilse P A Zethof
- Department of Pathology, Amsterdam UMC-Location VUmc, Amsterdam, The Netherlands.,Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Wessel N van Wieringen
- Department of Epidemiology and Biostatistics, Amsterdam UMC-Location VUmc, Amsterdam, The Netherlands.,Department of Mathematics, VU University, Amsterdam, The Netherlands
| | - Yvo M Smulders
- Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.,Department of Internal Medicine, Amsterdam UMC-Location VUmc, Amsterdam, The Netherlands
| | - Hans W M Niessen
- Department of Pathology, Amsterdam UMC-Location VUmc, Amsterdam, The Netherlands.,Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.,Department of Cardiac Surgery, Amsterdam UMC-Location VUmc, Amsterdam, The Netherlands
| | - Alexander B A Vonk
- Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.,Department of Cardiac Surgery, Amsterdam UMC-Location VUmc, Amsterdam, The Netherlands
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Development of calcific aortic valve disease: Do we know enough for new clinical trials? J Mol Cell Cardiol 2019; 132:189-209. [PMID: 31136747 DOI: 10.1016/j.yjmcc.2019.05.016] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 05/11/2019] [Accepted: 05/19/2019] [Indexed: 12/19/2022]
Abstract
Calcific aortic valve disease (CAVD), previously thought to represent a passive degeneration of the valvular extracellular matrix (VECM), is now regarded as an intricate multistage disorder with sequential yet intertangled and interacting underlying processes. Endothelial dysfunction and injury, initiated by disturbed blood flow and metabolic disorders, lead to the deposition of low-density lipoprotein cholesterol in the VECM further provoking macrophage infiltration, oxidative stress, and release of pro-inflammatory cytokines. Such changes in the valvular homeostasis induce differentiation of normally quiescent valvular interstitial cells (VICs) into synthetically active myofibroblasts producing excessive quantities of the VECM and proteins responsible for its remodeling. As a result of constantly ongoing degradation and re-deposition, VECM becomes disorganised and rigid, additionally potentiating myofibroblastic differentiation of VICs and worsening adaptation of the valve to the blood flow. Moreover, disrupted and excessively vascularised VECM is susceptible to the dystrophic calcification caused by calcium and phosphate precipitating on damaged collagen fibers and concurrently accompanied by osteogenic differentiation of VICs. Being combined, passive calcification and biomineralisation synergistically induce ossification of the aortic valve ultimately resulting in its mechanical incompetence requiring surgical replacement. Unfortunately, multiple attempts have failed to find an efficient conservative treatment of CAVD; however, therapeutic regimens and clinical settings have also been far from the optimal. In this review, we focused on interactions and transitions between aforementioned mechanisms demarcating ascending stages of CAVD, suggesting a predisposing condition (bicuspid aortic valve) and drug combination (lipid-lowering drugs combined with angiotensin II antagonists and cytokine inhibitors) for the further testing in both preclinical and clinical trials.
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Chang HH, Cheng CL, Wang WC, Huang PJ, Lin SY. Assessment of Unicuspid Aortic Valve Stenosis Using Multimodality Imaging, X-ray Radiography and Raman Analysis. Int Heart J 2019; 60:482-488. [DOI: 10.1536/ihj.18-338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Hsiao-Huang Chang
- Division of Cardiovascular Surgery, Department of Surgery, Taipei Veterans General Hospital
| | - Ching-Li Cheng
- Department of Nursing, National Tainan Institute of Nursing
| | - Wei-Chen Wang
- Division of Cardiovascular Surgery, Department of Surgery, Taipei Veterans General Hospital
| | - Pei-Jung Huang
- Division of Cardiovascular Surgery, Department of Surgery, Taipei Veterans General Hospital
| | - Shan-Yang Lin
- Department of Biotechnology and Pharmaceutical Technology, Yuanpei University of Medical Technology
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Cheng CL, Chang HH, Huang PJ, Wang WC, Lin SY. Echocardiographic manifestations and chemical composition of stenotic bicuspid aortic valves. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2018; 29:80. [PMID: 29869720 DOI: 10.1007/s10856-018-6087-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 05/14/2018] [Indexed: 06/08/2023]
Abstract
Bicuspid aortic valve (BAV) is an inherited form of heart disease with only two aortic valve leaflets via a disorder of cardiac valvulogenesis. We investigated the in vivo echocardiographic features of cardiac morphology in patients with BAV and the ex vivo compositional components of all the excised BAV leaflets isolated from BAV patients. Three BAV patients were randomly selected. All patients underwent 2D transthoracic echocardiography (TTE) with a Doppler ultrasound tool. The compositional components of each respective BAV leaflet for all the excised BAVs were determined by a portable fiber-optic Raman spectroscopy. Preoperative TTE revealed the thickened and calcified BAV leaflets, and stenotic aortic flow for all BAV patients. These BAV patients exhibited severe aortic stenosis (AS) by the lower values of aortic valve area (AVA) index. One patient showed a more significant left ventricle hypertrophy, whereas two patients exhibited a significant aortic regurgitation (AR). In addition, three different Raman spectral patterns were summed up from 121 randomized Raman determinations for all the excised BAV leaflets. The main calcified deposition in each BAV leaflet was formed by large amounts of calcium hydroxyapatite and type-B carbonate apatite (Raman bands at 960 and 1070 cm-1). The calcified BAV leaflets were composed of different compositional components such as calcium hydroxyapatite, type-B carbonate apatite, lipids, proteins, cholesterol and β-carotene. The rare NL subtype of type 1 BAV morphotype was found in one patient, but two patients had the purely BAV morphotype with two equal-sized leaflets.
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Affiliation(s)
- Ching-Li Cheng
- Department of Nursing, National Tainan Institute of Nursing, Tainan, Taiwan
| | - Hsiao-Huang Chang
- Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Pei-Jung Huang
- Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wei-Chen Wang
- Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shan-Yang Lin
- Department of Biotechnology and Pharmaceutical Technology, Yuanpei University of Medical Technology, Hsin Chu, Taiwan.
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