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Maes L, Vervenne T, Hendrickx A, Estrada AC, Van Hoof L, Verbrugghe P, Rega F, Jones EAV, Humphrey JD, Famaey N. Cell signaling and tissue remodeling in the pulmonary autograft after the Ross procedure: A computational study. J Biomech 2024; 171:112180. [PMID: 38906711 DOI: 10.1016/j.jbiomech.2024.112180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 03/20/2024] [Accepted: 05/31/2024] [Indexed: 06/23/2024]
Abstract
In the Ross procedure, a patient's pulmonary valve is transplanted in the aortic position. Despite advantages of this surgery, reoperation is still needed in many cases due to excessive dilatation of the pulmonary autograft. To further understand the failure mechanisms, we propose a multiscale model predicting adaptive processes in the autograft at the cell and tissue scale. The cell-scale model consists of a network model, that includes important signaling pathways and relations between relevant transcription factors and their target genes. The resulting gene activity leads to changes in the mechanical properties of the tissue, modeled as a constrained mixture of collagen, elastin and smooth muscle. The multiscale model is calibrated with findings from experiments in which seven sheep underwent the Ross procedure. The model is then validated against a different set of sheep experiments, for which a qualitative agreement between model and experiment is found. Model outcomes at the cell scale, including the activity of genes and transcription factors, also match experimentally obtained transcriptomics data.
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Affiliation(s)
- Lauranne Maes
- BioMechanics, Department of Mechanical Engineering, KU Leuven, Leuven, Belgium.
| | - Thibault Vervenne
- BioMechanics, Department of Mechanical Engineering, KU Leuven, Leuven, Belgium
| | - Amber Hendrickx
- Cardiac Surgery, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Ana C Estrada
- Department of Biomedical Engineering, Yale University, New Haven CT, USA
| | - Lucas Van Hoof
- Cardiac Surgery, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Peter Verbrugghe
- Cardiac Surgery, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Filip Rega
- Cardiac Surgery, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Elizabeth A V Jones
- Centre for Molecular and Vascular Biology, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium; CARIM School for Cardiovascular Diseases, Department of Cardiology, Maastricht University, Maastricht, Netherlands
| | - Jay D Humphrey
- Department of Biomedical Engineering, Yale University, New Haven CT, USA
| | - Nele Famaey
- BioMechanics, Department of Mechanical Engineering, KU Leuven, Leuven, Belgium
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2
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Balasubramanya A, Maes L, Rega F, Mazzi V, Morbiducci U, Famaey N, Degroote J, Segers P. Hemodynamics and wall shear metrics in a pulmonary autograft: Comparing a fluid-structure interaction and computational fluid dynamics approach. Comput Biol Med 2024; 176:108604. [PMID: 38761502 DOI: 10.1016/j.compbiomed.2024.108604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 05/02/2024] [Accepted: 05/11/2024] [Indexed: 05/20/2024]
Abstract
OBJECTIVE In young patients, aortic valve disease is often treated by placement of a pulmonary autograft (PA) which adapts to its new environment through growth and remodeling. To better understand the hemodynamic forces acting on the highly distensible PA in the acute phase after surgery, we developed a fluid-structure interaction (FSI) framework and comprehensively compared hemodynamics and wall shear-stress (WSS) metrics with a computational fluid dynamic (CFD) simulation. METHODS The FSI framework couples a prestressed non-linear hyperelastic arterial tissue model with a fluid model using the in-house coupling code CoCoNuT. Geometry, material parameters and boundary conditions are based on in-vivo measurements. Hemodynamics, time-averaged WSS (TAWSS), oscillatory shear index (OSI) and topological shear variation index (TSVI) are evaluated qualitatively and quantitatively for 3 different sheeps. RESULTS Despite systolic-to-diastolic volumetric changes of the PA in the order of 20 %, the point-by-point correlation of TAWSS and OSI obtained through CFD and FSI remains high (r > 0.9, p < 0.01) for TAWSS and (r > 0.8, p < 0.01) for OSI). Instantaneous WSS divergence patterns qualitatively preserve similarities, but large deformations of the PA leads to a decrease of the correlation between FSI and CFD resolved TSVI (r < 0.7, p < 0.01). Moderate co-localization between FSI and CFD is observed for low thresholds of TAWSS and high thresholds of OSI and TSVI. CONCLUSION FSI might be warranted if we were to use the TSVI as a mechano-biological driver for growth and remodeling of PA due to varying intra-vascular flow structures and near wall hemodynamics because of the large expansion of the PA.
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Affiliation(s)
| | - Lauranne Maes
- Department of Mechanical Engineering, KU Leuven, Leuven, Belgium
| | - Filip Rega
- Cardiac Surgery, Department of Cardiovascular Sciences, KU Leuven, Belgium
| | - Valentina Mazzi
- PolitoBIOMed Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Turin, Italy
| | - Umberto Morbiducci
- PolitoBIOMed Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Turin, Italy
| | - Nele Famaey
- Department of Mechanical Engineering, KU Leuven, Leuven, Belgium
| | - Joris Degroote
- Department of Electromechanical Systems and Metal Engineering, Ghent University, Ghent, Belgium
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3
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Maes L, Vervenne T, Van Hoof L, Jones EAV, Rega F, Famaey N. Computational modeling reveals inflammation-driven dilatation of the pulmonary autograft in aortic position. Biomech Model Mechanobiol 2023; 22:1555-1568. [PMID: 36764979 DOI: 10.1007/s10237-023-01694-6] [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: 05/16/2022] [Accepted: 01/17/2023] [Indexed: 02/12/2023]
Abstract
The pulmonary autograft in the Ross procedure, where the aortic valve is replaced by the patient's own pulmonary valve, is prone to failure due to dilatation. This is likely caused by tissue degradation and maladaptation, triggered by the higher experienced mechanical loads in aortic position. In order to further grasp the causes of dilatation, this study presents a model for tissue growth and remodeling of the pulmonary autograft, using the homogenized constrained mixture theory and equations for immuno- and mechano-mediated mass turnover. The model outcomes, compared to experimental data from an animal model of the pulmonary autograft in aortic position, show that inflammation likely plays an important role in the mass turnover of the tissue constituents and therefore in the autograft dilatation over time. We show a better match and prediction of long-term outcomes assuming immuno-mediated mass turnover, and show that there is no linear correlation between the stress-state of the material and mass production. Therefore, not only mechanobiological homeostatic adaption should be taken into account in the development of growth and remodeling models for arterial tissue in similar applications, but also inflammatory processes.
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Affiliation(s)
- Lauranne Maes
- Biomechanics Section, Mechanical Engineering Department, KU Leuven, Celestijnenlaan 300 box 2419, 3001, Leuven, Belgium.
| | - Thibault Vervenne
- Biomechanics Section, Mechanical Engineering Department, KU Leuven, Celestijnenlaan 300 box 2419, 3001, Leuven, Belgium
| | - Lucas Van Hoof
- Cardiac Surgery, Department of Cardiovascular Sciences, KU Leuven, UZ Herestraat 49 box 276, 3000, Leuven, Belgium
| | - Elizabeth A V Jones
- Centre for Molecular and Vascular Biology, KU Leuven, UZ Herestraat 49 box 911, 3000, Leuven, Belgium
| | - Filip Rega
- Cardiac Surgery, Department of Cardiovascular Sciences, KU Leuven, UZ Herestraat 49 box 276, 3000, Leuven, Belgium
| | - Nele Famaey
- Biomechanics Section, Mechanical Engineering Department, KU Leuven, Celestijnenlaan 300 box 2419, 3001, Leuven, Belgium
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Laubrie JD, Bezmalinovic A, García-Herrera CM, Celentano DJ, Herrera EA, Avril S, Llanos AJ. Hyperelastic and damage properties of the hypoxic aorta treated with Cinaciguat. J Biomech 2023; 147:111457. [PMID: 36701962 DOI: 10.1016/j.jbiomech.2023.111457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 12/27/2022] [Accepted: 01/13/2023] [Indexed: 01/18/2023]
Abstract
Chronic hypoxia during gestation and postnatal period induces pulmonary hypertension, aorta stiffening and vascular remodeling. In this study, we hypothesized that a postnatal treatment with Cinaciguat, a guanylate cyclase activator, may improve the vascular function by enhancing NO-sGC pathways that induce vasodilation. To assess this, we collected aortas from six lambs gestated, born and raised at 3600 masl. Half of these lambs received a Cinaciguat postnatal treatment, while the other half was used as control (vehicle). Uniaxial tension was applied on samples of each group of aortas (control and Cinaciguat-treated) through cyclic loading. The obtained stress-stretch curves were used to identify constitutive parameters of a hyperelastic damage model. These material constants allowed us to assess the softening/dissipation behavior and to characterize the treatment effects. Results showed that Cinaciguat has an effect on the damage behavior at large strains, altering the damage onset under uniaxial tension. We conclude that Cinaciguat, as a vasodilator, can prevent the very early effects of vascular remodeling caused by perinatal hypoxia, and improve the aortic-tissue damage properties of hypoxic lambs.
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Affiliation(s)
- Joan D Laubrie
- Departamento de Ingeniería Mecánica, Facultad de Ingeniería, Universidad de Santiago de Chile, Santiago, Chile
| | - Alejandro Bezmalinovic
- Departamento de Ingeniería Mecánica, Facultad de Ingeniería, Universidad de Santiago de Chile, Santiago, Chile
| | - Claudio M García-Herrera
- Departamento de Ingeniería Mecánica, Facultad de Ingeniería, Universidad de Santiago de Chile, Santiago, Chile.
| | - Diego J Celentano
- Departamento de Ingeniería Mecánica y Metalúrgica, Instituto de Ingeniería Biológica y Médica, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Emilio A Herrera
- Programa de Fisiopatología, Facultad de Medicina, Instituto de Ciencias Biomédicas, Universidad de Chile, Santiago, Chile; International Center for Andean Studies (INCAS), Universidad de Chile, Putre, Chile
| | - Stéphane Avril
- Mines Saint-Etienne, Univ Jean Monnet, INSERM, U 1059 Sainbiose, F - 42023 Saint-Etienne, France
| | - Aníbal J Llanos
- Programa de Fisiopatología, Facultad de Medicina, Instituto de Ciencias Biomédicas, Universidad de Chile, Santiago, Chile; International Center for Andean Studies (INCAS), Universidad de Chile, Putre, Chile
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5
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Tanaka D, Mazine A, Ouzounian M, El-Hamamsy I. Supporting the Ross procedure: preserving root physiology while mitigating autograft dilatation. Curr Opin Cardiol 2022; 37:180-190. [PMID: 35081548 DOI: 10.1097/hco.0000000000000949] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The purpose of this article is to describe the optimized approach to nonrepairable aortic valve disease in young adults with a Ross procedure, while preserving the dynamic physiology of the aortic root. RECENT FINDINGS As the techniques for supporting pulmonary autografts continue to be refined, and the applicability of the Ross procedure continues to expand, an assessment of the various techniques based on aortic root physiology is warranted. Semi-resorbable scaffolds show promise in ovine models for improving the Ross procedure. Recent long-term outcomes for the Dacron inclusion technique in comparison to more physiologic methods of support emphasize the importance of balancing the prevention of early dilatation with the preservation of root haemodynamics. As this review will synthesize, the dynamic physiology of the root may be preserved even in patients at a higher risk of autograft dilatation. SUMMARY The favourable long-term outcomes of the Ross procedure can be partly attributed to the ability of the autograft to restore dynamism to the neoaortic root. Patient-specific modifications that respect root physiology can tailor the Ross procedure to address each patient's risk factors for early dilatation and late failure. As such, the Ross procedure should be recognized as an increasingly favourable solution for a wide spectrum of nonpreservable aortic valve disease in young adults.
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Affiliation(s)
| | | | - Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Ismail El-Hamamsy
- Department of Cardiovascular Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Van Hoof L, Verbrugghe P, Jones EAV, Humphrey JD, Janssens S, Famaey N, Rega F. Understanding Pulmonary Autograft Remodeling After the Ross Procedure: Stick to the Facts. Front Cardiovasc Med 2022; 9:829120. [PMID: 35224059 PMCID: PMC8865563 DOI: 10.3389/fcvm.2022.829120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 01/17/2022] [Indexed: 12/12/2022] Open
Abstract
The Ross, or pulmonary autograft, procedure presents a fascinating mechanobiological scenario. Due to the common embryological origin of the aortic and pulmonary root, the conotruncus, several authors have hypothesized that a pulmonary autograft has the innate potential to remodel into an aortic phenotype once exposed to systemic conditions. Most of our understanding of pulmonary autograft mechanobiology stems from the remodeling observed in the arterial wall, rather than the valve, simply because there have been many opportunities to study the walls of dilated autografts explanted at reoperation. While previous histological studies provided important clues on autograft adaptation, a comprehensive understanding of its determinants and underlying mechanisms is needed so that the Ross procedure can become a widely accepted aortic valve substitute in select patients. It is clear that protecting the autograft during the early adaptation phase is crucial to avoid initiating a sequence of pathological remodeling. External support in the freestanding Ross procedure should aim to prevent dilatation while simultaneously promoting remodeling, rather than preventing dilatation at the cost of vascular atrophy. To define the optimal mechanical properties and geometry for external support, the ideal conditions for autograft remodeling and the timeline of mechanical adaptation must be determined. We aimed to rigorously review pulmonary autograft remodeling after the Ross procedure. Starting from the developmental, microstructural and biomechanical differences between the pulmonary artery and aorta, we review autograft mechanobiology in relation to distinct clinical failure mechanisms while aiming to identify unmet clinical needs, gaps in current knowledge and areas for further research. By correlating clinical and experimental observations of autograft remodeling with established principles in cardiovascular mechanobiology, we aim to present an up-to-date overview of all factors involved in extracellular matrix remodeling, their interactions and potential underlying molecular mechanisms.
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Affiliation(s)
- Lucas Van Hoof
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Peter Verbrugghe
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | - Jay D. Humphrey
- Department of Biomedical Engineering, Yale University, New Haven, CT, United States
| | - Stefan Janssens
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Nele Famaey
- Biomechanics Section, KU Leuven, Leuven, Belgium
| | - Filip Rega
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
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7
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Van Hoof L, Claus P, Jones EAV, Meuris B, Famaey N, Verbrugghe P, Rega F. Back to the root: a large animal model of the Ross procedure. Ann Cardiothorac Surg 2021; 10:444-453. [PMID: 34422556 DOI: 10.21037/acs-2020-rp-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 03/29/2021] [Indexed: 12/16/2022]
Abstract
The excellent clinical outcomes of the Ross procedure and previous histological studies suggest that the pulmonary autograft has the potential to offer young patients a permanent solution to aortic valve disease. We aim to study the early mechanobiological adaptation of the autograft. To this end, we have reviewed relevant existing animal models, including the canine models which enabled Donald N Ross to perform the first Ross procedure in a patient in 1967. Two research groups recently evaluated the isolated effect of systemic pressures on pulmonary arterial tissue in an ovine model of a pulmonary artery interposition graft in the descending aorta. While this model is ideal to study the artery's biological response and the effect of external support, it does not recreate the complex environment of the aortic root. The freestanding Ross procedure has been performed in pigs and sheep before. These studies offered valuable insights into leaflet growth and histological remodeling, yet may be less relevant to adults undergoing the Ross procedure, as pronounced autograft dilatation was achieved by using small, rapidly growing animals. Therefore, a large animal model remains needed to determine the ideal conditions and surgical technique to ensure long-term autograft remodeling and valve function. We set out to develop an ovine model of the Ross procedure performed as a freestanding root replacement, acknowledging that the sheep's specific anatomy and the setting of an animal laboratory would mandate several modifications in surgical strategy. This article describes the development, surgical technique and early outcomes of our animal model while highlighting opportunities for further research.
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Affiliation(s)
- Lucas Van Hoof
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium.,Experimental Cardiac Surgery, KU Leuven, Leuven, Belgium
| | - Piet Claus
- Cardiovascular Imaging and Dynamics, KU Leuven, Leuven, Belgium
| | | | - Bart Meuris
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium.,Experimental Cardiac Surgery, KU Leuven, Leuven, Belgium
| | - Nele Famaey
- Biomechanics Section, KU Leuven, Leuven, Belgium
| | - Peter Verbrugghe
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium.,Experimental Cardiac Surgery, KU Leuven, Leuven, Belgium
| | - Filip Rega
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium.,Experimental Cardiac Surgery, KU Leuven, Leuven, Belgium
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8
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The Choice of Pulmonary Autograft in Aortic Valve Surgery: A State-of-the-Art Primer. BIOMED RESEARCH INTERNATIONAL 2021; 2021:5547342. [PMID: 33937396 PMCID: PMC8060091 DOI: 10.1155/2021/5547342] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 03/31/2021] [Accepted: 04/05/2021] [Indexed: 11/18/2022]
Abstract
The Ross procedure has long been seen as an optimal operation for a select few. The detractors of it highlight the issue of an additional harvesting of the pulmonary artery, subjecting the native PA to systemic pressures and the need for reintervention as reasons to avoid it. However, the PA is a living tissue and capable of adapting and remodeling to growth. We therefore review the current evidence available to discuss the indications, contraindications, harvesting techniques, and modifications in a state-of-the-art narrative review of the PA as an aortic conduit. Due to the lack of substantial well-designed randomized controlled trials (RCTs), we also highlight the areas of need to reiterate the importance of the Ross procedure as part of the surgical armamentarium.
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9
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Ramachandra AB, Latorre M, Szafron JM, Marsden AL, Humphrey JD. Vascular adaptation in the presence of external support - A modeling study. J Mech Behav Biomed Mater 2020; 110:103943. [PMID: 32957235 DOI: 10.1016/j.jmbbm.2020.103943] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 04/24/2020] [Accepted: 06/17/2020] [Indexed: 10/24/2022]
Abstract
Vascular grafts have long been used to replace damaged or diseased vessels with considerable success, but a new approach is emerging where native vessels are merely supported, not replaced. Although external supports have been evaluated in diverse situations - ranging from aneurysmal disease to vein grafts or the Ross operation - optimal supports and procedures remain wanting. In this paper, we present a novel application of a growth and remodeling model well suited for parametrically exploring multiple designs of external supports while accounting for mechanobiological and immunobiological responses of the supported native vessel. These results suggest that a load bearing external support can reduce vessel thickening in response to pressure elevation. Results also suggest that the final adaptive state of the vessel depends on the structural stiffness of the support via a mechano-driven adaptation, although luminal encroachment may be a complication in the presence of chronic inflammation. Finally, the supported vessel can stiffen (structurally and materially) along circumferential and axial directions, which could have implications on overall hemodynamics and thus subsequent vascular remodeling. The proposed framework can provide valuable insights into vascular adaptation in the presence of external support, accelerate rational design, and aid translation of this emerging approach.
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Affiliation(s)
| | - Marcos Latorre
- Department of Biomedical Engineering, Yale University, New Haven, CT, USA
| | - Jason M Szafron
- Department of Biomedical Engineering, Yale University, New Haven, CT, USA
| | - Alison L Marsden
- Departments of Bioengineering and Pediatrics, Institute of Computational and Mathematical Engineering, Stanford University, Stanford, CA, USA
| | - Jay D Humphrey
- Department of Biomedical Engineering, Yale University, New Haven, CT, USA; Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, CT, USA.
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10
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Fehervary H, Maes L, Vastmans J, Kloosterman G, Famaey N. How to implement user-defined fiber-reinforced hyperelastic materials in finite element software. J Mech Behav Biomed Mater 2020; 110:103737. [PMID: 32771879 DOI: 10.1016/j.jmbbm.2020.103737] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 12/20/2019] [Accepted: 03/05/2020] [Indexed: 10/24/2022]
Abstract
Finite element modeling is often used in biomechanical engineering to evaluate medical devices, treatments and diagnostic tools. Using an adequate material model that describes the mechanical behavior of biological tissues is essential for a reliable outcome of the simulation. Pre-programmed material models for biological tissues are available in many finite element software packages. However, since these pre-programmed models are presented to the user as a black box, without the possibility to modify the material description, many researchers turn to implementing their own material formulations. This is a complex undertaking, requiring extensive knowledge while documentation is limited. This paper provides a detailed description, at the level of the biomedical engineer, of the implementation of a nonlinear hyperelastic material model using user subroutines in Abaqus®, in casuUANISOHYPER_INV and UMAT. The Gasser-Ogden-Holzapfel material model is used as an example, resulting in four implementation variations: the built-in implementation, a UANISOHYPER_INV formulation, a UMAT with analytical tangent stiffness formulation and a UMAT with numerical tangent stiffness formulation. In addition, three different element formulations are used: a continuum compressible, a continuum incompressible and a plane stress incompressible. All cases are thoroughly verified by applying a series of deformations on a single cube element and by simulating an extension-inflation experiment with non-homogeneous deformations and multiple elements. In these test cases, stresses, displacements, reaction forces, the required number of iterations and the total CPU time were compared. The results show that the four implementation variations are very similar, with total relative errors between 10-3 and 10-15, number of iterations that varied by maximum one iteration, and a comparable CPU time. In addition to this detailed overview, the user subroutines are added as supplementary material to this tutorial, which can be used as the ideal starting point for biomechanical engineers to implement their own material models at different levels of complexity.
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Affiliation(s)
- Heleen Fehervary
- Biomechanics Section, Mechanical Engineering Department, KU Leuven, Leuven, Belgium
| | - Lauranne Maes
- Biomechanics Section, Mechanical Engineering Department, KU Leuven, Leuven, Belgium
| | - Julie Vastmans
- Biomechanics Section, Mechanical Engineering Department, KU Leuven, Leuven, Belgium
| | - Gertjan Kloosterman
- Mechanical Engineering, Institute for Engineering and Design, University of Applied Sciences Utrecht, Utrecht, the Netherlands
| | - Nele Famaey
- Biomechanics Section, Mechanical Engineering Department, KU Leuven, Leuven, Belgium.
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Pepper J, Izgi C, Golesworthy TJ, Takkenberg JJM, Treasure T. Personalised external aortic root support (PEARS) to stabilise an aortic root aneurysm. THE BRITISH JOURNAL OF CARDIOLOGY 2020; 27:22. [PMID: 35747770 PMCID: PMC9205243 DOI: 10.5837/bjc.2020.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Patients with congenitally determined aortic root aneurysms are at risk of aortic valve regurgitation, aortic dissection, rupture and death. Personalised external aortic root support (PEARS) may provide an alternative to aortic root replacement. This was a multi-centre, prospective cohort of all consecutive patients who received ExoVasc mesh implants for a dilated aortic root between 2004 and 2017. Baseline and peri-operative characteristics, as well as early postoperative outcomes are described, and time-related survival and re-operation free survival are estimated using the Kaplan-Meier method. From 2004 through 2017, 117 consecutive patients have received ExoVasc mesh implants for aortic root aneurysm. The inclusion criteria were an aortic root/sinus of Valsalva and ascending aorta with asymptomatic dilatation of between 40 and 50 mm in diameter in patients aged 16 years or more. Patients with more than mild aortic regurgitation were excluded. There was one early death. The length of stay was within seven days in 75% of patients. In conclusion, the operation achieves the objectives of valve-sparing root replacement. PEARS may be seen as a low-risk conservative operation, which can be applied earlier on in the disease process, and which is complementary to more invasive procedures, such as valve-sparing root replacement or total root replacement.
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Affiliation(s)
- John Pepper
- Consultant Cardiac Surgeon, Royal Brompton and Harefield NHS Foundation Trust, Sydney Street, London, SW3 6NP
| | - Cemil Izgi
- Consultant Cardiac Radiologist, Royal Brompton and Harefield NHS Foundation Trust, Sydney Street, London, SW3 6NP
| | - Tal J Golesworthy
- Chartered Energy Engineer, Extent Ltd., Theocsbury House, 18-20 Barton Street, Tewkesbury Gloucestershire
| | - Johanna J M Takkenberg
- Cardiac Epidemiologist, Erasmus University Medical Centre, PO Box 2040, 3000 CA Rotterdam The Netherlands
| | - Tom Treasure
- Consultant Cardiothoracic Surgeon, Clinical Operational Research Unit, University College London, 4 Taviton Street, London WC1H 0BT
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12
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Nappi F, Spadaccio C, Acar C, El-Hamamsy I. Lights and Shadows on the Ross Procedure: Biological Solutions for Biological Problems. Semin Thorac Cardiovasc Surg 2020; 32:815-822. [PMID: 32439545 DOI: 10.1053/j.semtcvs.2020.04.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 04/20/2020] [Indexed: 11/11/2022]
Abstract
The Ross procedure represents a valid option for aortic valve replacement in young adults and was repeatedly shown to restore survival to that of the age- and sex-matched general population. However, its major drawback relies in the risk of pulmonary autograft (PA) dilation, negative histological remodeling and need for reoperation. Several techniques and materials to reinforce the PA have been proposed. They mainly include Dacron, personalized external aortic root support with a polyethylene terephthalate mesh system, autologous aortic tissue and bioresorbable materials. Synthetic materials, despite widely used in cardiac surgery, have significant biocompatibility issues with the PA and their interaction with this living structure translates into negative remodeling phenomena and disadvantageous biomechanical behaviors. Conversely, biomaterials with tailored degradable profiles might be able to reinforce while integrating with the PA and enhance its remodeling capabilities. The recent advancement in this field are here discussed.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery Center, Cardiologique du Nord de Saint-Denis, Paris, France.
| | - Cristiano Spadaccio
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, United Kingdom; Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Christophe Acar
- Department of Cardiovascular Surgery, Hopital de la Salpetriere, Paris, France
| | - Ismail El-Hamamsy
- Department of Cardiac Surgery, Montreal Heart Institute, Montreal, Canada
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Mechano-biological adaptation of the pulmonary artery exposed to systemic conditions. Sci Rep 2020; 10:2724. [PMID: 32066803 PMCID: PMC7026065 DOI: 10.1038/s41598-020-59554-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 01/29/2020] [Indexed: 12/30/2022] Open
Abstract
Cardiac surgeries may expose pulmonary arterial tissue to systemic conditions, potentially resulting in failure of that tissue. Our goal was to quantitatively assess pulmonary artery adaptation due to changes in mechanical environment. In 17 sheep, we placed a pulmonary autograft in aortic position, with or without macroporous mesh reinforcement. It was exposed to systemic conditions for 6 months. All sheep underwent 3 ECG-gated MRI’s. Explanted tissue was subjected to mechanical and histological analysis. Results showed progressive dilatation of the unreinforced autograft, while reinforced autografts stabilized after two months. Some unreinforced pulmonary autograft samples displayed more aorta-like mechanical behavior with increased collagen deposition. The mechanical behavior of reinforced autografts was dominated by the mesh. The decrease in media thickness and loss of vascular smooth muscle cells was more pronounced in reinforced than in unreinforced autografts. In conclusion, altering the mechanical environment of a pulmonary artery causes changes in its mechano-biological properties.
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Chauvette V, Chamberland MÈ, El-Hamamsy I. A review of pulmonary autograft external support in the Ross procedure. Expert Rev Med Devices 2019; 16:981-988. [PMID: 31663385 DOI: 10.1080/17434440.2019.1685380] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Although the Ross procedure offers several advantages over standard prosthetic AVR, its use remains limited. The risk of pulmonary autograft dilatation requiring reintervention remains one of the main concerns. Consequently, multiple techniques have been developed in attempt to mitigate this complication.Areas covered: This article reviews the incidence of pulmonary autograft dilatation, its risk factors and pathophysiology. The techniques of external pulmonary autograft support are discussed along with their respective advantages and limitations. Finally, future areas of research and developments are examined.Expert opinion: The risk of autograft dilatation is mainly prevalent in patients with aortic regurgitation and a dilated aortic annulus. In these selected patients, an external support may prevent dilatation of the autograft. However, any permanent support potentially restricts autograft root motion, mitigating some of the advantages associated with the Ross procedure. A bioresorbable matrix that could support the root during its initial adaptative phase could alleviate this problem. In our opinion, aggressive blood pressure control during the first postoperative year along with annular and sino-tubular junction support in selected patients provides optimal stability of autograft root dimensions while preserving root dynamics. Serial imaging and clinical follow-up are necessary to define the role of these various strategies.
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Affiliation(s)
- Vincent Chauvette
- Department of Cardiac Surgery, Montreal Heart Institute, Montreal, Canada
| | | | - Ismail El-Hamamsy
- Department of Cardiac Surgery, Montreal Heart Institute, Montreal, Canada
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Maes L, Fehervary H, Vastmans J, Mousavi SJ, Avril S, Famaey N. Constrained mixture modeling affects material parameter identification from planar biaxial tests. J Mech Behav Biomed Mater 2019; 95:124-135. [DOI: 10.1016/j.jmbbm.2019.03.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 03/07/2019] [Accepted: 03/29/2019] [Indexed: 12/11/2022]
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Vanderveken E, Vastmans J, Verbelen T, Verbrugghe P, Famaey N, Verbeken E, Treasure T, Rega F. Reinforcing the pulmonary artery autograft in the aortic position with a textile mesh: a histological evaluation. Interact Cardiovasc Thorac Surg 2019; 27:566-573. [PMID: 29912400 DOI: 10.1093/icvts/ivy134] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 03/25/2018] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The Ross procedure involves replacing a patient's diseased aortic valve with their own pulmonary valve. The most common failure mode is dilatation of the autograft. Various strategies to reinforce the autograft have been proposed. Personalized external aortic root support has been shown to be effective in stabilizing the aortic root in Marfan patients. In this study, the use of a similar external mesh to support a pulmonary artery autograft was evaluated. METHODS The pulmonary artery was translocated as an interposition autograft in the descending thoracic aortas of 10 sheep. The autograft was reinforced with a polyethylene terephthalate mesh (n = 7) or left unreinforced (n = 3). After 6 months, a computed tomography scan was taken, and the descending aorta was excised and histologically examined using the haematoxylin-eosin and Elastica van Gieson stains. RESULTS The autograft/aortic diameter ratio was 1.59 in the unreinforced group but much less in the reinforced group (1.11) (P < 0.05). A fibrotic sheet, variable in thickness and containing fibroblasts, neovessels and foreign body giant cells, was incorporated in the mesh. Histological examination of the reinforced autograft and the adjacent aorta revealed thinning of the vessel wall due to atrophy of the smooth muscle cells. Potential spaces between the vessel wall and the mesh were filled with oedema. CONCLUSIONS Reinforcing an interposition pulmonary autograft in the descending aorta with a macroporous mesh showed promising results in limiting autograft dilatation in this sheep model. Histological evaluation revealed atrophy of the smooth muscle cell and consequently thinning of the vessel wall within the mesh support.
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Affiliation(s)
- Emma Vanderveken
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Julie Vastmans
- Department of Mechanical Engineering, KU Leuven, Leuven, Belgium
| | - Tom Verbelen
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Peter Verbrugghe
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Nele Famaey
- Department of Mechanical Engineering, KU Leuven, Leuven, Belgium
| | - Eric Verbeken
- Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
| | - Tom Treasure
- Clinical Operational Research Unit, UCL, London, UK
| | - Filip Rega
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
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Nappi F, Nenna A, Larobina D, Carotenuto AR, Jarraya M, Spadaccio C, Fraldi M, Chello M, Acar C, Carrel T. Simulating the ideal geometrical and biomechanical parameters of the pulmonary autograft to prevent failure in the Ross operation. Interact Cardiovasc Thorac Surg 2019. [PMID: 29538653 DOI: 10.1093/icvts/ivy070] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Reinforcements for the pulmonary autograft (PA) in the Ross operation have been introduced to avoid the drawback of conduit expansion and failure. With the aid of an in silico simulation, the biomechanical boundaries applied to a healthy PA during the operation were studied to tailor the best implant technique to prevent reoperation. METHODS Follow-up echocardiograms of 66 Ross procedures were reviewed. Changes in the dimensions and geometry of reinforced and non-reinforced PAs were evaluated. Miniroot and subcoronary implantation techniques were used in this series. Mechanical stress tests were performed on 36 human pulmonary and aortic roots explanted from donor hearts. Finite element analysis was applied to obtain high-fidelity simulation under static and dynamic conditions of the biomechanical properties and applied stresses on the PA root and leaflet and the similar components of the native aorta. RESULTS The non-reinforced group showed increases in the percentages of the mean diameter that were significantly higher than those in the reinforced group at the level of the Valsalva sinuses (3.9%) and the annulus (12.1%). The mechanical simulation confirmed geometrical and dimensional changes detected by clinical imaging and demonstrated the non-linear biomechanical behaviour of the PA anastomosed to the aorta, a stiffer behaviour of the aortic root in relation to the PA and similar qualitative and quantitative behaviours of leaflets of the 2 tissues. The annulus was the most significant constraint to dilation and affected the distribution of stress and strain within the entire complex, with particular strain on the sutured regions. The PA was able to evenly absorb mechanical stresses but was less adaptable to circumferential stresses, potentially explaining its known dilatation tendency over time. CONCLUSIONS The absence of reinforcement leads to a more marked increase in the diameter of the PA. Preservation of the native geometry of the PA root is crucial; the miniroot technique with external reinforcement is the most suitable strategy in this context.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, Paris, France
| | - Antonio Nenna
- Department of Cardiovascular Surgery, University Campus Bio-Medico of Rome, Rome, Italy
| | - Domenico Larobina
- Institute for Polymers, Composites and Biomaterials, National Research Council of Italy, Rome, Italy
| | - Angelo Rosario Carotenuto
- Department of Structures for Engineering and Architecture and Interdisciplinary Research Center for Biomaterials, Università di Napoli 'Federico II', Naples, Italy
| | | | - Cristiano Spadaccio
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, UK.,Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Massimiliano Fraldi
- Department of Structures for Engineering and Architecture and Interdisciplinary Research Center for Biomaterials, Università di Napoli 'Federico II', Naples, Italy
| | - Massimo Chello
- Department of Cardiovascular Surgery, University Campus Bio-Medico of Rome, Rome, Italy
| | - Christophe Acar
- Banc de Tissus Humains Hopital Saint Louis, Paris, France.,Department of Cardiac Surgery, Hopital La Pitie Salpetriere, Paris, France
| | - Thierry Carrel
- Deptartment of cardiovascular surgery, University Hospital of Bern, Bern, Switzerland
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