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Tadokoro N, Tonai K, Kainuma S, Kawamoto N, Suzuki K, Hirayama M, Fukushima S. Management of aortic valve insufficiency in patients with continuous-flow left ventricular assist device: a republication of the review published in Japanese Journal of Artificial Organs. J Artif Organs 2024; 27:177-181. [PMID: 38594483 DOI: 10.1007/s10047-024-01439-x] [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: 02/20/2024] [Accepted: 02/21/2024] [Indexed: 04/11/2024]
Abstract
Since 2011, implantable ventricular assist devices have been a standard treatment for severe heart failure alongside heart transplantation in Japan. However, the limited availability of donors has led to a prolonged wait for transplants, now averaging 1719 days, intensifying the issue of aortic insufficiency in patients with continuous flow ventricular assist devices. These devices limit the opening of the aortic valve, leading to sustained closure and increased shear stress, which accelerates valve degradation. Risk factors for aortic insufficiency include having a smaller body surface area, being of advanced age, and the presence of mild aortic insufficiency prior to device implantation. In patients presenting with mild or moderate aortic regurgitation at the time of ventricular assist device implantation, interventions such as aortic valve repair or bioprosthetic valve replacement are performed with the aim of halting its progression. The choice of surgical procedure should be tailored to each patient's individual condition. The management of de novo aortic insufficiency in patients with continuous flow ventricular assist devices remains challenging, with no clear consensus on when to intervene. Interventions for significant aortic insufficiency typically consider the patient's symptoms and aortic insufficiency severity. De novo aortic insufficiency progression in continuous flow ventricular assist devices patients necessitates careful monitoring and intervention based on individual patient assessments and valve condition. This review was created based on a translation of the Japanese review written in the Japanese Journal of Artificial Organs in 2023 (Vol. 52, No. 1, pp. 77-80), with some modifications.
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Affiliation(s)
- Naoki Tadokoro
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-7 Kishibeshinmachi, Suita, Osaka, 564-8565, Japan.
| | - Kohei Tonai
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-7 Kishibeshinmachi, Suita, Osaka, 564-8565, Japan
| | - Satoshi Kainuma
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-7 Kishibeshinmachi, Suita, Osaka, 564-8565, Japan
| | - Naonori Kawamoto
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-7 Kishibeshinmachi, Suita, Osaka, 564-8565, Japan
| | - Kota Suzuki
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-7 Kishibeshinmachi, Suita, Osaka, 564-8565, Japan
| | - Masaya Hirayama
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-7 Kishibeshinmachi, Suita, Osaka, 564-8565, Japan
| | - Satsuki Fukushima
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-7 Kishibeshinmachi, Suita, Osaka, 564-8565, Japan.
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Wang Y, He F, Hao P, Zhang X. A fluid-structure interaction simulation on the impact of transcatheter micro ventricular assist devices on aortic valves. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2024; 254:108270. [PMID: 38878358 DOI: 10.1016/j.cmpb.2024.108270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 05/20/2024] [Accepted: 06/02/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND AND OBJECTIVE The implantation of ventricular assist devices (VADs) has become an important treatment option for patients with heart failure. Aortic valve insufficiency is a common complication caused by VADs implantation. Currently, there is very little quantitative research on the effects of transcatheter micro VADs or the intervention pumps on the aortic valves. METHODS In this study, the multi-component arbitrary Lagrange-Eulerian method is used to perform fluid-structure interaction simulations of the aortic valve model with and without intervention pumps. The effects of intervention pumps implantation on the opening area of the aortic valves, the stress distribution, and the flow characteristics are quantitatively analyzed. Statistical results are consistent with clinical guidelines and experiments. RESULTS The implantation of intervention pumps leads to the valve insufficiency and causes weak valve regurgitation. In the short-term treatment, the valve regurgitation is within a controllable range. The distribution and variation of stress on the leaflets are also affected by intervention pumps. The whirling flow in the flow direction affects the closing speed of the aortic valves and optimizes the stress distribution of the valves. In the models with whirling flow, the effects of intervention pumps implantation on valve motion and stress distribution differ from those without whirling flow. However, the valve insufficiency and valve regurgitation caused by intervention pumps still exist in the models with whirling flow. Conventional artificial bioprosthetic valves have limited effectiveness in treating the valve diseases caused by intervention pumps implantation. CONCLUSIONS This study quantitatively investigates the impact of intervention pumps on the aortic valves, and investigates the effect of blood rotation on the valve behavior, which is a gap in previous research. We suggest that in the short-term treatment, the implantation of intervention pumps has limited impact on aortic valves, caution should be exercised against valve regurgitation issues caused by intervention pumps.
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Affiliation(s)
- Yitao Wang
- Department of Engineering Mechanics, School of Aerospace Engineering, Tsinghua University, Beijing 100084, China
| | - Feng He
- Department of Engineering Mechanics, School of Aerospace Engineering, Tsinghua University, Beijing 100084, China
| | - Pengfei Hao
- Department of Engineering Mechanics, School of Aerospace Engineering, Tsinghua University, Beijing 100084, China; Applied Mechanics Laboratory, Department of Engineering Mechanics, Tsinghua University, Beijing 100084, PR China
| | - Xiwen Zhang
- Department of Engineering Mechanics, School of Aerospace Engineering, Tsinghua University, Beijing 100084, China.
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Maeda S, Toda K, Shimamura K, Nakamoto K, Igeta M, Sakata Y, Sawa Y, Miyagawa S. Preoperative higher right ventricular stroke work index increases the risk of de novo aortic insufficiency after continuous-flow left ventricular assist device implantation. J Artif Organs 2024; 27:222-229. [PMID: 37468735 PMCID: PMC11345319 DOI: 10.1007/s10047-023-01411-1] [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: 03/15/2023] [Accepted: 06/11/2023] [Indexed: 07/21/2023]
Abstract
During continuous-flow left ventricular assist device (CF-LVAD) support, hemodynamic shear stress causes a burden on aortic valve (AV) leaflets, leading to de novo aortic insufficiency (AI). This study investigated the influence of preoperative hemodynamic parameters on de novo AI in CF-LVAD recipients. We reviewed 125 patients who underwent CF-LVAD implantation without concomitant AV surgery between 2005 and 2018. De novo AI was defined as moderate or severe AI in those with none or trivial preoperative AI. During mean 30 ± 16 months of CF-LVAD support, de novo AI-free rate was 86% and 67% at 1 and 2 years, respectively. Multivariable analysis showed that higher right ventricular stroke work index (RVSWI) (hazard ratio, 1.12 /g/m2/beat; 95% confidence interval, 1.00-1.20; p = 0.047) and trivial grade AI (hazard ratio, 2.8; 95% confidence interval, 1.2-6.4; p = 0.020) were independent preoperative risk factors for de novo AI. The longitudinal analysis using generalized mixed effects model showed that higher RVSWI was associated with continuous AV closure after LVAD implantation (Odd ratio, 1.20/g/m2/beat; 95% confidence interval, 1.00-1.43 /g/m2/beat; p = 0.047). Right heart catheterization revealed that preoperative RVSWI was positively correlated with postoperative pump flow index in patients with continuously closed AV (r = 0.44, p = 0.04, n = 22). Preoperative higher RVSWI was a significant risk factor for de novo AI following CF-LVAD implantation. In patients with preserved right ventricular function, postoperative higher pump flow may affect AI development via hemodynamic stress on the AV.
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Affiliation(s)
- Shusaku Maeda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Koichi Toda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Kazuo Shimamura
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Kei Nakamoto
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Masataka Igeta
- Department of Biostatistics, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Shigeru Miyagawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
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Lopez-Santana G, De Rosis A, Grant S, Venkateswaran R, Keshmiri A. Enhancing the implantation of mechanical circulatory support devices using computational simulations. Front Bioeng Biotechnol 2024; 12:1279268. [PMID: 38737533 PMCID: PMC11084291 DOI: 10.3389/fbioe.2024.1279268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 04/08/2024] [Indexed: 05/14/2024] Open
Abstract
Introduction: Patients with end-stage heart failure (HF) may need mechanical circulatory support such as a left ventricular assist device (LVAD). However, there are a range of complications associated with LVAD including aortic regurgitation (AR) and thrombus formation. This study assesses whether the risk of developing aortic conditions can be minimised by optimising LVAD implantation technique. Methods: In this work, we evaluate the aortic flow patterns produced under different geometrical parameters for the anastomosis of the outflow graft (OG) to the aorta using computational fluid dynamics (CFD). A three-dimensional aortic model is created and the HeartMate III OG positioning is simulated by modifying (i) the distance from the anatomic ventriculo-arterial junction (AVJ) to the OG, (ii) the cardinal position around the aorta, and (iii) the angle between the aorta and the OG. The continuous LVAD flow and the remnant native cardiac cycle are used as inlet boundaries and the three-element Windkessel model is applied at the pressure outlets. Results: The analysis quantifies the impact of OG positioning on different haemodynamic parameters, including velocity, wall shear stress (WSS), pressure, vorticity and turbulent kinetic energy (TKE). We find that WSS on the aortic root (AoR) is around two times lower when the OG is attached to the coronal side of the aorta using an angle of 45° ± 10° at a distance of 55 mm. Discussion: The results show that the OG placement may significantly influence the haemodynamic patterns, demonstrating the potential application of CFD for optimising OG positioning to minimise the risk of cardiovascular complications after LVAD implantation.
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Affiliation(s)
- Gabriela Lopez-Santana
- School of Engineering, The University of Manchester, Manchester, United Kingdom
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Wythenshawe Hospital, Manchester, United Kingdom
| | - Alessandro De Rosis
- School of Engineering, The University of Manchester, Manchester, United Kingdom
| | - Stuart Grant
- Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Rajamiyer Venkateswaran
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Wythenshawe Hospital, Manchester, United Kingdom
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Amir Keshmiri
- School of Engineering, The University of Manchester, Manchester, United Kingdom
- Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
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Zambrano BA, Wilson SI, Zook S, Vekaria B, Moreno MR, Kassi M. Computational investigation of outflow graft variation impact on hemocompatibility profile in LVADs. Artif Organs 2024; 48:375-385. [PMID: 37962282 DOI: 10.1111/aor.14679] [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: 04/24/2023] [Revised: 10/17/2023] [Accepted: 10/29/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Hemocompatibility-related adverse events (HRAE) occur commonly in patients with left ventricular assist devices (LVADs) and add to morbidity and mortality. It is unclear whether the outflow graft orientation can impact flow conditions leading to HRAE. This study presents a simulation-based approach using exact patient anatomy from medical images to investigate the influence of outflow cannula orientation in modulating flow conditions leading to HRAEs. METHODS A 3D model of a proximal aorta and outflow graft was reconstructed from a computed tomography (CT) scan of an LVAD patient and virtually modified to model multiple cannula orientations (n = 10) by varying polar (cranio-caudal) (n = 5) and off-set (anterior-posterior) (n = 2) angles. Time-dependent computational flow simulations were then performed for each anatomical orientation. Qualitative and quantitative hemodynamics metrics of thrombogenicity including time-averaged wall shear stress (TAWSS), oscillatory shear index (OSI), endothelial cell platelet activation potential (ECAP), particle residence time (PRT), and platelet activation potential (PLAP) were analyzed. RESULTS Within the simulations performed, endothelial cell activation potential (ECAP) and particle residence time (PRT) were found to be lowest with a polar angle of 85°, regardless of offset angle. However, polar angles that produced parameters at levels least associated with thrombosis varied when the offset angle was changed from 0° to 12°. For offset angles of 0° and 12° respectively, flow shear was lowest at 65° and 75°, time averaged wall shear stress (TAWSS) was highest at 85° and 35°, and platelet activation potential (PLAP) was lowest at 65° and 45°. CONCLUSION This study suggests that computational fluid dynamic modeling based on patient-specific anatomy can be a powerful analytical tool when identifying optimal positioning of an LVAD. Contrary to previous work, our findings suggest that there may be an "ideal" outflow cannula for each individual patient based on a CFD-based hemocompatibility profile.
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Affiliation(s)
- Byron A Zambrano
- J. Mike Walker '66 Department of Mechanical Engineering, Texas A&M University, College Station, Texas, USA
| | - Shannon I Wilson
- Department of Biomedical Engineering, Texas A&M University, College Station, Texas, USA
| | - Salma Zook
- Houston Methodist, Department of Cardiology, Houston Methodist Research Hospital, Houston, Texas, USA
| | - Bansi Vekaria
- Houston Methodist, Department of Cardiology, Houston Methodist Research Hospital, Houston, Texas, USA
| | - Michael R Moreno
- J. Mike Walker '66 Department of Mechanical Engineering, Texas A&M University, College Station, Texas, USA
| | - Mahwash Kassi
- Houston Methodist, Department of Cardiology, Houston Methodist Research Hospital, Houston, Texas, USA
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Chen Q, Wang C, Wang H, Xiao J, Zhou Y, Gu S, Xu W, Yang H. Strengthened Decellularized Porcine Valves via Polyvinyl Alcohol as a Template Improving Processability. Polymers (Basel) 2023; 16:16. [PMID: 38201681 PMCID: PMC10780456 DOI: 10.3390/polym16010016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 12/11/2023] [Accepted: 12/16/2023] [Indexed: 01/12/2024] Open
Abstract
The heart valve is crucial for the human body, which directly affects the efficiency of blood transport and the normal functioning of all organs. Generally, decellularization is one method of tissue-engineered heart valve (TEHV), which can deteriorate the mechanical properties and eliminate allograft immunogenicity. In this study, removable polyvinyl alcohol (PVA) is used to encapsulate decellularized porcine heart valves (DHVs) as a dynamic template to improve the processability of DHVs, such as suturing. Mechanical tests show that the strength and elastic modulus of DHVs treated with different concentrations of PVA significantly improve. Without the PVA layer, the valve would shift during suture puncture and not achieve the desired suture result. The in vitro results indicate that decellularized valves treated with PVA can sustain the adhesion and growth of human umbilical vein endothelial cells (HUVECs). All results above show that the DHVs treated with water-soluble PVA have good mechanical properties and cytocompatibility to ensure post-treatment. On this basis, the improved processability of DHV treated with PVA enables a new paradigm for the manufacturing of scaffolds, making it easy to apply.
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Affiliation(s)
- Qingqing Chen
- College of Materials Science and Engineering, Wuhan Textile University, Wuhan 430200, China; (Q.C.); (C.W.); (Y.Z.); (S.G.)
| | - Chaorong Wang
- College of Materials Science and Engineering, Wuhan Textile University, Wuhan 430200, China; (Q.C.); (C.W.); (Y.Z.); (S.G.)
| | - Han Wang
- Key Laboratory of Green Processing and Functional New Textile Materials of Ministry of Education, Wuhan Textile University, Wuhan 430200, China (J.X.); (W.X.)
- Institute for Frontier Materials, Deakin University, Geelong, VIC 3216, Australia
| | - Jinfeng Xiao
- Key Laboratory of Green Processing and Functional New Textile Materials of Ministry of Education, Wuhan Textile University, Wuhan 430200, China (J.X.); (W.X.)
| | - Yingshan Zhou
- College of Materials Science and Engineering, Wuhan Textile University, Wuhan 430200, China; (Q.C.); (C.W.); (Y.Z.); (S.G.)
| | - Shaojin Gu
- College of Materials Science and Engineering, Wuhan Textile University, Wuhan 430200, China; (Q.C.); (C.W.); (Y.Z.); (S.G.)
| | - Weilin Xu
- Key Laboratory of Green Processing and Functional New Textile Materials of Ministry of Education, Wuhan Textile University, Wuhan 430200, China (J.X.); (W.X.)
| | - Hongjun Yang
- College of Materials Science and Engineering, Wuhan Textile University, Wuhan 430200, China; (Q.C.); (C.W.); (Y.Z.); (S.G.)
- Key Laboratory of Green Processing and Functional New Textile Materials of Ministry of Education, Wuhan Textile University, Wuhan 430200, China (J.X.); (W.X.)
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Gu Z, Ong CW, Mi Y, Seetharaman A, Ling RR, Ramanathan K, Leo HL. The Impact of Left Ventricular Assist Device Outflow Graft Positioning on Aortic Hemodynamics: Improving Flow Dynamics to Mitigate Aortic Insufficiency. Biomimetics (Basel) 2023; 8:465. [PMID: 37887596 PMCID: PMC10604423 DOI: 10.3390/biomimetics8060465] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/27/2023] [Accepted: 09/20/2023] [Indexed: 10/28/2023] Open
Abstract
Heart failure is a global health concern with significant implications for healthcare systems. Left ventricular assist devices (LVADs) provide mechanical support for patients with severe heart failure. However, the placement of the LVAD outflow graft within the aorta has substantial implications for hemodynamics and can lead to aortic insufficiency during long-term support. This study employs computational fluid dynamics (CFD) simulations to investigate the impact of different LVAD outflow graft locations on aortic hemodynamics. The introduction of valve morphology within the aorta geometry allows for a more detailed analysis of hemodynamics at the aortic root. The results demonstrate that the formation of vortex rings and subsequent vortices during the high-velocity jet flow from the graft interacted with the aortic wall. Time-averaged wall shear stress (TAWSS) and oscillatory shear index (OSI) indicate that modification of the outflow graft location changes mechanical states within the aortic wall and aortic valve. Among the studied geometric factors, both the height and inclination angle of the LVAD outflow graft are important in controlling retrograde flow to the aortic root, while the azimuthal angle primarily determines the rotational direction of blood flow in the aortic arch. Thus, precise positioning of the LVAD outflow graft emerges as a critical factor in optimizing patient outcomes by improving the hemodynamic environment.
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Affiliation(s)
- Zhuohan Gu
- Department of Biomedical Engineering, National University of Singapore, Singapore 119077, Singapore; (Z.G.); (A.S.)
| | - Chi Wei Ong
- School of Chemistry, Chemical Engineering and Biotechnology, Nanyang Technological University, Singapore 639798, Singapore
| | - Yongzhen Mi
- Institute of High Performance Computing (IHPC), Agency for Science, Technology and Research (A*STAR), Singapore 138632, Singapore;
| | - Ashwin Seetharaman
- Department of Biomedical Engineering, National University of Singapore, Singapore 119077, Singapore; (Z.G.); (A.S.)
| | - Ryan Ruiyang Ling
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore (K.R.)
| | - Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore (K.R.)
- Cardiothoracic Intensive Care Unit, National University Heart Centre Singapore, National Univeristy Health System, Singapore 119228, Singapore
| | - Hwa Liang Leo
- Department of Biomedical Engineering, National University of Singapore, Singapore 119077, Singapore; (Z.G.); (A.S.)
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Wilson SI, Ingram KE, Oh A, Moreno MR, Kassi M. The role of innovative modeling and imaging techniques in improving outcomes in patients with LVAD. Front Cardiovasc Med 2023; 10:1248300. [PMID: 37692033 PMCID: PMC10484111 DOI: 10.3389/fcvm.2023.1248300] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 08/10/2023] [Indexed: 09/12/2023] Open
Abstract
Heart failure remains a significant cause of mortality in the United States and around the world. While organ transplantation is acknowledged as the gold standard treatment for end stage heart failure, supply is limited, and many patients are treated with left ventricular assist devices (LVADs). LVADs extend and improve patients' lives, but they are not without their own complications, particularly the hemocompatibility related adverse events (HRAE) including stroke, bleeding and pump thrombosis. Mainstream imaging techniques currently in use to assess appropriate device function and troubleshoot complications, such as echocardiography and cardiac computed tomography, provide some insight but do not provide a holistic understanding of pump induced flow alterations that leads to HRAEs. In contrast, there are technologies restricted to the benchtop-such as computational fluid dynamics and mock circulatory loops paired with methods like particle image velocimetry-that can assess flow metrics but have not been optimized for clinical care. In this review, we outline the potential role and current limitations of converging available technologies to produce novel imaging techniques, and the potential utility in evaluating hemodynamic flow to determine whether LVAD patients may be at higher risk of HRAEs. This addition to diagnostic and monitoring capabilities could improve prevention and treatment of LVAD-induced complications in heart failure patients.
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Affiliation(s)
- Shannon I. Wilson
- Department of Biomedical Engineering, Texas A&M University, College Station, TX, United States
| | - Katelyn E. Ingram
- DeBakey Heart and Vascular- Heart Center Research, Houston Methodist Research Institute, Houston, TX, United States
| | - Albert Oh
- School of Engineering Medicine, Texas A&M University, Houston, TX, United States
| | - Michael R. Moreno
- J. Mike Walker ‘66 Department of Mechanical Engineering, Texas A&M University, College Station, TX, United States
| | - Mahwash Kassi
- Cardiology, DeBakey Heart and Vascular, Houston Methodist Hospital, Houston, TX, United States
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Sahni A, Majee S, Pal JD, McIntyre EE, Cao K, Mukherjee D. Hemodynamics Indicates Differences Between Patients With And Without A Stroke Outcome After Left Ventricular Assist Device Implantation. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.08.03.23292572. [PMID: 37609263 PMCID: PMC10441504 DOI: 10.1101/2023.08.03.23292572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
Stroke remains a leading cause of complications and mortality in heart failure patients treated with LVAD circulatory support. Hemodynamics plays a central role in affecting risk and etiology of stroke during LVAD support. Yet, detailed quantitative assessment of hemodynamic variables and their relation to stroke outcomes in patients with an implanted LVAD remains a challenge. We present an in silico hemodynamics analysis in a set of 12 patients on LVAD support; 6 with reported stroke outcomes and 6 without. We conducted patient-specific hemodynamics simulations for models with the LVAD outflow graft reconstructed from cardiac-gated CT images. A pre-implantation baseline flow model was virtually generated for each case by removing the LVAD outflow graft and driving flow from the aortic root. Hemodynamics was characterized using quantitative descriptors for helical flow, vortex generation, and wall shear stress. Our analysis showed higher average values for descriptors of positive helical flow, vortex generation, and wall shear stress, across the 6 cases with stroke outcomes on LVAD support, when compared with cases without stroke. When the descriptors for LVAD-driven flow were compared against estimated baseline flow pre-implantation, extent of positive helicity was higher, and vorticity and wall shear were lower in cases with stroke compared to those without. The study suggests that quantitative analysis of hemodynamics after LVAD implantation; and hemodynamic alterations from a pre-implant flow scenario, can potentially reveal hidden information linked to stroke outcomes during LVAD support. This has broad implications on understanding stroke etiology, LVAD treatment planning, surgical optimization, and efficacy assessment.
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Guglin M, Rao RA. Aortic Thrombosis in Patients on Mechanical Circulatory Support: A Systematic Literature Review. Heart Lung Circ 2023; 32:926-937. [PMID: 37202310 DOI: 10.1016/j.hlc.2023.04.295] [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: 11/06/2022] [Revised: 04/18/2023] [Accepted: 04/27/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Aortic valve (AV) thrombosis is an uncommon but ominous complication in patients managed with mechanical circulatory support (MCS) devices. In this systematic review, we summarised the data on clinical presentations and outcomes in such patients. METHODS We searched articles on PubMed and Google Scholar, reporting at least one adult patient with aortic thrombosis on MCS support and where the individual patient data could be extracted. We grouped the patients by the type of MCS (temporary or durable), and the type of the AV (prosthetic, surgically modified, or native) RESULTS: We identified reports on six patients with aortic thrombus on short-term MCS, and on 41 patients on durable left ventricular assist devices (LVADs). On temporary MCS, AV thrombus typically causes no symptoms and is found incidentally pre- or intra-operatively. For those with durable MCS, the occurrence of aortic thrombus forming on prosthetic or surgically modified valves appears to be more related to the intervention on the valve, rather than from the presence of LVAD. The mortality in this group was 18%. In patients with native AV on durable LVAD support, 60% of patients presented with acute myocardial infarction, acute stroke, or acute heart failure, and mortality in this cohort was 45%. In terms of management, heart transplantation was most successful. CONCLUSIONS While the outcomes of aortic thrombosis were good in patients where temporary MCS was used in the setting of aortic valve surgery, patients with native AV who develop this complication on durable LVAD have high morbidity and mortality. Cardiac transplantation should be strongly considered in eligible candidates because other therapies provide inconsistent results.
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Affiliation(s)
- Maya Guglin
- Indiana University School of Medicine, Division of Cardiovascular Disease, Krannert Institute of Cardiology, Indianapolis, IN, USA.
| | - Roopa A Rao
- Indiana University School of Medicine, Division of Cardiovascular Disease, Krannert Institute of Cardiology, Indianapolis, IN, USA
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11
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Sahni A, McIntyre EE, Pal JD, Mukherjee D. Quantitative Assessment of Aortic Hemodynamics for Varying Left Ventricular Assist Device Outflow Graft Angles and Flow Pulsation. Ann Biomed Eng 2023; 51:1226-1243. [PMID: 36705866 DOI: 10.1007/s10439-022-03127-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 12/25/2022] [Indexed: 01/28/2023]
Abstract
Left ventricular assist devices (LVADs) comprise a primary treatment choice for advanced heart failure patients. Treatment with LVAD is commonly associated with complications like stroke and gastro-intestinal (GI) bleeding, which adversely impacts treatment outcomes, and causes fatalities. The etiology and mechanisms of these complications can be linked to the fact that LVAD outflow jet leads to an altered state of hemodynamics in the aorta as compared to baseline flow driven by aortic jet during ventricular systole. Here, we present a framework for quantitative assessment of aortic hemodynamics in LVAD flows realistic human vasculature, with a focus on quantifying the differences between flow driven by LVAD jet and the physiological aortic jet when no LVAD is present. We model hemodynamics in the aortic arch proximal to the LVAD outflow graft, as well as in the abdominal aorta away from the LVAD region. We characterize hemodynamics using quantitative descriptors of flow velocity, stasis, helicity, vorticity and mixing, and wall shear stress. These are used on a set of 27 LVAD scenarios obtained by parametrically varying LVAD outflow graft anastomosis angles, and LVAD flow pulse modulation. Computed descriptors for each of these scenarios are compared against the baseline flow, and a detailed quantitative characterization of the altered state of hemodynamics due to LVAD operation (when compared to baseline aortic flow) is compiled. These are interpreted using a conceptual model for LVAD flow that distinguishes between flow originating from the LVAD outflow jet (and its impingement on the aorta wall), and flow originating from aortic jet during aortic valve opening in normal physiological state.
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Affiliation(s)
- Akshita Sahni
- Department of Mechanical Engineering, University of Colorado Boulder, Boulder, USA
| | - Erin E McIntyre
- Division of Cardiothoracic Surgery, University of Colorado, Anschutz Medical Campus, Aurora, USA
| | - Jay D Pal
- Department of Surgery, University of Washington, Seattle, USA
| | - Debanjan Mukherjee
- Department of Mechanical Engineering, University of Colorado Boulder, Boulder, USA.
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12
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Vriz O, Mushtaq A, Shaik A, El-Shaer A, Feras K, Eltayeb A, Alsergnai H, Kholaif N, Al Hussein M, Albert-Brotons D, Simon AR, Tsai FW. Reciprocal interferences of the left ventricular assist device and the aortic valve competence. Front Cardiovasc Med 2023; 9:1094796. [PMID: 36698950 PMCID: PMC9870593 DOI: 10.3389/fcvm.2022.1094796] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 12/22/2022] [Indexed: 01/12/2023] Open
Abstract
Patients suffering from end-stage heart failure tend to have high mortality rates. With growing numbers of patients progressing into severe heart failure, the shortage of available donors is a growing concern, with less than 10% of patients undergoing cardiac transplantation (CTx). Fortunately, the use of left ventricular assist devices (LVADs), a variant of mechanical circulatory support has been on the rise in recent years. The expansion of LVADs has led them to be incorporated into a variety of clinical settings, based on the goals of therapy for patients ailing from heart failure. However, with an increase in the use of LVADs, there are a host of complications that arise with it. One such complication is the development and progression of aortic regurgitation (AR) which is noted to adversely influence patient outcomes and compromise pump benefits leading to increased morbidity and mortality. The underlying mechanisms are likely multifactorial and involve the aortic root-aortic valve (AV) complex, as well as the LVAD device, patient, and other factors, all of them alter the physiological mechanics of the heart resulting in AV dysfunction. Thus, it is imperative to screen patients before LVAD implantation for AR, as moderate or greater AR requires a concurrent intervention at the time of LVADs implantation. No current strict guidelines were identified in the literature search on how to actively manage and limit the development and/or progression of AR, due to the limited information. However, some recommendations include medical management by targeting fluid overload and arterial blood pressure, along with adjusting the settings of the LVADs device itself. Surgical interventions are to be considered depending on patient factors, goals of care, and the underlying pathology. These interventions include the closure of the AV, replacement of the valve, and percutaneous approach via percutaneous occluding device or transcatheter aortic valve implantation. In the present review, we describe the interaction between AV and LVAD placement, in terms of patient management and prognosis. Also it is provided a comprehensive echocardiographic strategy for the precise assessment of AV regurgitation severity.
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Affiliation(s)
- Olga Vriz
- Heart Centre Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia,*Correspondence: Olga Vriz,
| | - Ali Mushtaq
- School of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Abdullah Shaik
- School of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Ahmed El-Shaer
- School of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Khalid Feras
- Heart Centre Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Abdalla Eltayeb
- Heart Centre Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Hani Alsergnai
- Heart Centre Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Naji Kholaif
- Heart Centre Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mosaad Al Hussein
- Heart Centre Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Dimpna Albert-Brotons
- Heart Centre Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Andre Rudiger Simon
- Heart Centre Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Felix Wang Tsai
- Heart Centre Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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13
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Calin E, Ducharme A, Carrier M, Lamarche Y, Ben Ali W, Noly PE. Key questions about aortic insufficiency in patients with durable left ventricular assist devices. Front Cardiovasc Med 2022; 9:1068707. [PMID: 36505355 PMCID: PMC9729243 DOI: 10.3389/fcvm.2022.1068707] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 11/09/2022] [Indexed: 11/27/2022] Open
Abstract
The development of the latest generation of durable left ventricular assist devices (LVAD) drastically decreased adverse events such as pump thrombosis or disabling strokes. However, time-related complications such as aortic insufficiency (AI) continue to impair outcomes following durable LVAD implantation, especially in the context of long-term therapy. Up to one-quarter of patients with durable LVAD develop moderate or severe AI at 1 year and its incidence increases with the duration of support. The continuous regurgitant flow within the left ventricle can compromise left ventricular unloading, increase filling pressures, decrease forward flow and can thus lead to organ hypoperfusion and heart failure. This review aims to give an overview of the epidemiology, pathophysiology, and clinical consequences of AI in patients with durable LVAD.
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Affiliation(s)
- Eliza Calin
- Department of Surgery, Montreal Heart Institute, Université de Montreal, Montreal, QC, Canada
| | - Anique Ducharme
- Department of Medicine, Montreal Heart Institute, Université de Montreal, Montreal, QC, Canada
| | - Michel Carrier
- Department of Surgery, Montreal Heart Institute, Université de Montreal, Montreal, QC, Canada
| | - Yoan Lamarche
- Department of Surgery, Montreal Heart Institute, Université de Montreal, Montreal, QC, Canada
| | - Walid Ben Ali
- Department of Surgery, Montreal Heart Institute, Université de Montreal, Montreal, QC, Canada
| | - Pierre-Emmanuel Noly
- Department of Surgery, Montreal Heart Institute, Université de Montreal, Montreal, QC, Canada,*Correspondence: Pierre-Emmanuel Noly,
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14
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Dimarakis I, Callan P, Khorsandi M, Pal JD, Bravo CA, Mahr C, Keenan JE. Pathophysiology and management of valvular disease in patients with destination left ventricular assist devices. Front Cardiovasc Med 2022; 9:1029825. [PMID: 36407458 PMCID: PMC9669306 DOI: 10.3389/fcvm.2022.1029825] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 09/29/2022] [Indexed: 11/06/2022] Open
Abstract
Over the last two decades, implantable continuous flow left ventricular assist devices (LVAD) have proven to be invaluable tools for the management of selected advanced heart failure patients, improving patient longevity and quality of life. The presence of concomitant valvular pathology, including that involving the tricuspid, mitral, and aortic valve, has important implications relating to the decision to move forward with LVAD implantation. Furthermore, the presence of concomitant valvular pathology often influences the surgical strategy for LVAD implantation. Concomitant valve repair or replacement is not uncommonly required in such circumstances, which increases surgical complexity and has demonstrated prognostic implications both short and longer term following LVAD implantation. Beyond the index operation, it is also well established that certain valvular pathologies may develop or worsen over time following LVAD support. The presence of pre-existing valvular pathology or that which develops following LVAD implant is of particular importance to the destination therapy LVAD patient population. As these patients are not expected to have the opportunity for heart transplantation in the future, optimization of LVAD support including ameliorating valvular disease is critical for the maximization of patient longevity and quality of life. As collective experience has grown over time, the ability of clinicians to effectively address concomitant valvular pathology in LVAD patients has improved in the pre-implant, implant, and post-implant phase, through both medical management and procedural optimization. Nevertheless, there remains uncertainty over many facets of concomitant valvular pathology in advanced heart failure patients, and the understanding of how to best approach these conditions in the LVAD patient population continues to evolve. Herein, we present a comprehensive review of the current state of the field relating to the pathophysiology and management of valvular disease in destination LVAD patients.
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Affiliation(s)
- Ioannis Dimarakis
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, United States
- Department of Cardiothoracic Transplantation, Manchester University Hospital NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom
| | - Paul Callan
- Department of Cardiothoracic Transplantation, Manchester University Hospital NHS Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom
| | - Maziar Khorsandi
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, United States
| | - Jay D. Pal
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, United States
| | - Claudio A. Bravo
- Division of Cardiology, Department of Medicine, University of Washington Medical Center, Seattle, WA, United States
| | - Claudius Mahr
- Division of Cardiology, Department of Medicine, University of Washington Medical Center, Seattle, WA, United States
| | - Jeffrey E. Keenan
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, United States
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15
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Cheng S, Liu X, Qian Y, Maitusong M, Yu K, Cao N, Fang J, Liu F, Chen J, Xu D, Zhu G, Ren T, Wang J. Double-Network Hydrogel Armored Decellularized Porcine Pericardium as Durable Bioprosthetic Heart Valves. Adv Healthc Mater 2022; 11:e2102059. [PMID: 34969157 DOI: 10.1002/adhm.202102059] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 12/02/2021] [Indexed: 12/20/2022]
Abstract
Heart valves have extraordinary fatigue resistance which beat ≈3 billion times in a lifetime. Bioprosthetic heart valves (BHVs) made from fixed heteroplasm that are incrementally used in heart valve replacement fail to sustain the expected durability due to thrombosis, poor endothelialization, inflammation, calcification, and especially mechanical damage induced biocompatibility change. No effective strategy has been reported to conserve the biological properties of BHV after long-term fatigue test. Here, a double-network tough hydrogel is introduced, which interpenetrate and anchor into the matrix of decellularized porcine pericardium (dCell-PP) to form robust and stable conformal coatings and reduce immunogenicity. The ionic crosslinked hyaluronic acid (HA) network mimics the glycocalyx on endothelium which improves antithrombosis and accelerates endothelialization; the chemical crosslinked hydrophilic polyacrylamide (PAAm) network further enhances antifouling properties and strengthens the shielding hydrogels and their interaction with dCell-PP. In vitro and rabbit ex vivo shunt assay demonstrate great hemocompatibility of polyacrylamide/HA hydrogel hybrid PP (P/H-PP). Cell experiments and rat subcutaneous implantation confirm satisfactory endothelialization, biocompatibility, and anticalcification properties. For hydrodynamic experiment, P/H-PP gains full mark at different flow conditions and sustains excellent biomechanical and biological properties after 200 000 000 cycles. P/H double-network hydrogel armoring dCell-PP is a promising progress to extend BHV durability for clinical implantation therapy.
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Affiliation(s)
- Si Cheng
- Department of Cardiology of The Second Affiliated Hospital Zhejiang University School of Medicine Hangzhou 310009 P. R. China
- Cardiovascular Key Laboratory of Zhejiang Province Hangzhou 310009 P. R. China
| | - Xianbao Liu
- Department of Cardiology of The Second Affiliated Hospital Zhejiang University School of Medicine Hangzhou 310009 P. R. China
- Cardiovascular Key Laboratory of Zhejiang Province Hangzhou 310009 P. R. China
| | - Yi Qian
- Department of Cardiology of The Second Affiliated Hospital Zhejiang University School of Medicine Hangzhou 310009 P. R. China
- Cardiovascular Key Laboratory of Zhejiang Province Hangzhou 310009 P. R. China
| | - Miribani Maitusong
- Department of Cardiology of The Second Affiliated Hospital Zhejiang University School of Medicine Hangzhou 310009 P. R. China
- Cardiovascular Key Laboratory of Zhejiang Province Hangzhou 310009 P. R. China
| | - Kaixiang Yu
- Department of Cardiology of The Second Affiliated Hospital Zhejiang University School of Medicine Hangzhou 310009 P. R. China
- Cardiovascular Key Laboratory of Zhejiang Province Hangzhou 310009 P. R. China
| | - Naifang Cao
- Department of Cardiology of The Second Affiliated Hospital Zhejiang University School of Medicine Hangzhou 310009 P. R. China
- Cardiovascular Key Laboratory of Zhejiang Province Hangzhou 310009 P. R. China
| | - Juan Fang
- Department of Cardiology of The Second Affiliated Hospital Zhejiang University School of Medicine Hangzhou 310009 P. R. China
- Cardiovascular Key Laboratory of Zhejiang Province Hangzhou 310009 P. R. China
| | - Feng Liu
- Department of Cardiology of The Second Affiliated Hospital Zhejiang University School of Medicine Hangzhou 310009 P. R. China
- Cardiovascular Key Laboratory of Zhejiang Province Hangzhou 310009 P. R. China
| | - Jinyong Chen
- Department of Cardiology of The Second Affiliated Hospital Zhejiang University School of Medicine Hangzhou 310009 P. R. China
- Cardiovascular Key Laboratory of Zhejiang Province Hangzhou 310009 P. R. China
| | - Dilin Xu
- Department of Cardiology of The Second Affiliated Hospital Zhejiang University School of Medicine Hangzhou 310009 P. R. China
- Cardiovascular Key Laboratory of Zhejiang Province Hangzhou 310009 P. R. China
| | - Gangjie Zhu
- Department of Cardiology of The Second Affiliated Hospital Zhejiang University School of Medicine Hangzhou 310009 P. R. China
- Cardiovascular Key Laboratory of Zhejiang Province Hangzhou 310009 P. R. China
| | - Tanchen Ren
- Department of Cardiology of The Second Affiliated Hospital Zhejiang University School of Medicine Hangzhou 310009 P. R. China
- Cardiovascular Key Laboratory of Zhejiang Province Hangzhou 310009 P. R. China
| | - Jian'an Wang
- Department of Cardiology of The Second Affiliated Hospital Zhejiang University School of Medicine Hangzhou 310009 P. R. China
- Cardiovascular Key Laboratory of Zhejiang Province Hangzhou 310009 P. R. China
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16
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Left Ventricular Assist Device Support-Induced Alteration of Mechanical Stress on Aortic Valve and Aortic Wall. ASAIO J 2021; 68:516-523. [PMID: 34261872 DOI: 10.1097/mat.0000000000001522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
The aim of this study was to evaluate the fluid dynamics in the aortic valve and proximal aorta during continuous-flow left ventricular assist device (LVAD) support using epiaortic echocardiography and vector flow mapping technology. A total of 12 patients who underwent HeartMate 3 implantation between December 2018 and February 2020 were prospectively examined. The wall shear stress (WSS) on the ascending aorta, aortic root, and aortic valve was evaluated before and after LVAD implantation. The median age of the cohort was 62 years and 17% were women. The peak WSS on the ascending aorta (Pre 1.48 [0.86-1.69] [Pascal {Pa}] vs. Post 0.33 [0.21-0.58] [Pa]; p = 0.002), aortic root (Pre 0.46 [0.31-0.58] (Pa) vs. Post 0.18 [0.12-0.25] (Pa); p = 0.001), and ventricularis of the aortic valve (Pre 1.76 [1.59-2.30] (Pa) vs. Post 0.30 [0.10-0.61] (Pa); p = 0.001) was significantly lower after LVAD implantation. No difference in WSS was observed on the fibrosa of the aortic valve (Pre 0.36 [0.22-0.53] (Pa) vs. Post 0.38 [0.38-0.52] (Pa); p = 0.850) before and after implantation. The WSS on the ascending aorta, aortic root, and ventricularis of the aortic valve leaflets was significantly altered by LVAD implantation, providing preliminary data on the potential contribution of fluid dynamics to LVAD-induced aortic insufficiency and root thrombus.
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17
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Ashraf F, Ambreen T, Park CW, Kim DI. Comparative evaluation of ballet-type and conventional stent graft configurations for endovascular aneurysm repair: A CFD analysis. Clin Hemorheol Microcirc 2021; 78:1-27. [PMID: 33459700 PMCID: PMC8293652 DOI: 10.3233/ch-200996] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE: Cross limb stent graft (SG) configuration technique for endovascular aneurysm repair (EVAR) is employed for splayed aortic bifurcations to avoid device kinking and smoothen cannulation. The present study investigates three types of stent graft (SG) configurations for endovascular aneurysm repair (EVAR) in abdominal aortic aneurysm. A computational fluid dynamic analysis was performed on the pulsatile non-Newtonian flow characteristics in three ideally modeled geometries of abdominal aortic (AA) SG configurations. METHODS: The three planar and crosslimb SG configurations were ideally modeled, namely, top-down nonballet-type, top-down ballet-type, and bottom-up nonballet-type configurations. In top-down SG configuration, most of the device is deployed in the main body in the vicinity of renal artery and the limbs are extended to the iliac artery. While in the bottom-up configuration, some of the SG device is deployed in the main body, the limbs are deployed in aortic bifurcation, and the extra stent graft of the main body is extended to the proximal aorta until the below of the renal artery. The effects of non-Newtonian pulsatile flow on the wall stresses and flow patterns of the three models were investigated and compared. Moreover, the average wall shear stress (AWSS), oscillatory shear stress index (OSI), absolute helicity, pressure distribution, graft displacement and flow visualization plots were analyzed. RESULTS: The top-down ballet-type showed less branch blockage effect than the top-down nonballet-type models. Furthermore, the top-down ballet-type configuration showed an increased tendency to sustain high WSS and higher helicity characteristics than that of the bottom-up and top-down non-ballet type configurations. However, displacement forces of the top-down ballet-type configuration were 40% and 9.6% higher than those of the bottom-up and top-down nonballet-type configurations, respectively. CONCLUSIONS: Some complications such as graft tearing, thrombus formation, limb disconnection during long term follow up periods might be relevant to hemodynamic characteristics according to the configurations of EVAR. Hence, the reported data required to be validated with the clinical results.
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Affiliation(s)
- Fahmida Ashraf
- School of Mechanical Engineering, Kyungpook National University, Daegu, South Korea
| | - Tehmina Ambreen
- School of Mechanical Engineering, Kyungpook National University, Daegu, South Korea
| | - Cheol Woo Park
- School of Mechanical Engineering, Kyungpook National University, Daegu, South Korea
| | - Dong-Ik Kim
- Division of Vascular Surgery, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, South Korea
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18
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Kronfli A, Atnip RG, Aziz F. Carotid artery duplex velocity criteria might be equivocal after left ventricular assist device implantation. J Vasc Surg 2021; 74:1609-1617.e1. [PMID: 33957226 DOI: 10.1016/j.jvs.2021.03.062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 03/28/2021] [Indexed: 01/20/2023]
Abstract
BACKGROUND Although conventional angiography remains the reference standard for the grading of carotid stenosis, carotid duplex ultrasound (CDUS) is the most commonly used modality for determining the degree of carotid stenosis. The validity of CDUS findings for patients after left ventricular assist device (LVAD) implantation is questionable, because the velocities are often altered secondary to the continuous flow nature of the devices. METHODS A retrospective review was performed of all patients who had undergone LVAD implantation from January 2007 to December 2019. All patients who had undergone CDUS before and after LVAD implantation were included. Patients receiving extracorporeal membrane oxygenation, those with unusable carotid imaging studies, and those with internal carotid artery (ICA) occlusion were excluded. The peak systolic velocity (PSV) and end-diastolic velocity (EDV) in the ICA and common carotid artery (CCA) and the ICA/CCA ratios were compared before and after LVAD implantation. RESULTS A total of 36 patients (mean age 59 years; 30 men; 6 women) had undergone CDUS both before and after LVAD implantation (mean, 647 days between imaging studies). A total of 61 ICAs had met the criteria for inclusion. Before LVAD, 7 carotid arteries (13%) had had >50% carotid stenosis and 53 (87%) had had 0% to 50% stenosis. The mean changes in the velocities after LVAD were as follows. The ICA PSV had decreased by 6.12 ± 4.34 cm/s, and the ICA EDV had increased by 13.44 ± 4.23 cm/s. The CCA PSV had decreased by 17.22 ± 4.95 cm/s, and the CCA EDV had increased by 10.83 ± 2.59 cm/s. The mean ICA/CCA ratio had increased by 0.18 ± 0.05. All the mean changes in velocity were significant (P < .01), except for the ICA PSV (P = .167). Among four patients with known stenosis of 60% to 69%, the degree of increase in the ICA and CCA EDVs (75.8 and 13.3 cm/s, respectively) was significantly greater than that for patients with <50% or no stenosis. Carotid artery laterality did not significantly affect the differences in mean velocity. Centrifugal LVADs resulted in a significantly larger increase in the ICA EDV compared with axial LVADs (26.0 vs 6.3 cm/s; P < .01). CONCLUSIONS LVADs were associated with significant changes in CCA PSV, ICA and CCA EDV, and ICA/CCA ratios. However, the magnitude of these changes in patients with <50% stenosis was minimal and might not be clinically significant. The LVAD type might only have an effect on EDV measurements in the CCA, and the left and right carotid arteries did not appear to have different degrees of change in velocity. The currently used criteria for determining carotid stenosis might result in an under- or overestimation of carotid stenosis in patients with an LVAD.
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Affiliation(s)
- Anthony Kronfli
- Department of Surgery, College of Medicine, The Pennsylvania State University, Hershey, Pa
| | - Robert G Atnip
- Division of Vascular Surgery, Penn State Hershey Heart and Vascular Institute, College of Medicine, The Pennsylvania State University, Hershey, Pa
| | - Faisal Aziz
- Division of Vascular Surgery, Penn State Hershey Heart and Vascular Institute, College of Medicine, The Pennsylvania State University, Hershey, Pa.
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19
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Left Ventricular Assist Device Flow Pattern Analysis Using a Novel Model Incorporating Left Ventricular Pulsatility. ASAIO J 2021; 67:724-732. [DOI: 10.1097/mat.0000000000001341] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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20
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Estimating aortic thoracic aneurysm rupture risk using tension-strain data in physiological pressure range: an in vitro study. Biomech Model Mechanobiol 2021; 20:683-699. [PMID: 33389275 DOI: 10.1007/s10237-020-01410-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 12/02/2020] [Indexed: 12/17/2022]
Abstract
Previous studies have shown that the rupture properties of an ascending thoracic aortic aneurysm (ATAA) are strongly correlated with the pre-rupture response features. In this work, we present a two-step machine learning method to predict where the rupture is likely to occur in ATAA and what safety reserve the structure may have. The study was carried out using ATAA specimens from 15 patients who underwent surgical intervention. Through inflation test, full-field deformation data and post-rupture images were collected, from which the wall tension and surface strain distributions were computed. The tension-strain data in the pressure range of 9-18 kPa were fitted to a third-order polynomial to characterize the response properties. It is hypothesized that the region where rupture is prone to initiate is associated with a high level of tension buildup. A machine learning method is devised to predict the peak risk region. The predicted regions were found to match the actual rupture sites in 13 samples out of the total 15. In the second step, another machine learning model is utilized to predict the tissue's rupture strength in the peak risk region. Results suggest that the ATAA rupture risk can be reasonably predicted using tension-strain response in the physiological range. This may open a pathway for evaluating the ATAA rupture propensity using information of in vivo response.
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21
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Nguyen SN, Nguyen TC. Commentary: Less-invasive approaches to big complex problems in patients with end-stage heart disease. JTCVS Tech 2020; 4:200-201. [PMID: 34318012 PMCID: PMC8306215 DOI: 10.1016/j.xjtc.2020.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 08/29/2020] [Accepted: 09/05/2020] [Indexed: 11/25/2022] Open
Affiliation(s)
- Stephanie N Nguyen
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, New York Presbyterian-Columbia University Irving Medical Center, New York, NY
| | - Tom C Nguyen
- Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center Houston, McGovern Medical School, Memorial Hermann Hospital-Heart and Vascular Institute, Houston, Tex
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22
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Gao B, Zhang Q. Biomechanical effects of the working modes of LVADs on the aortic valve: A primary numerical study. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2020; 193:105512. [PMID: 32344270 DOI: 10.1016/j.cmpb.2020.105512] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 04/08/2020] [Accepted: 04/15/2020] [Indexed: 06/11/2023]
Abstract
Aortic valve diseases caused by the support from left ventricular assist devices (LVADs) have attracted increasing attention due to the wide application of the LVADs. However, the biomechanical effects of the working modes of LVADs on the aortic valve are still poorly understood. Hence, in this study, these biomechanical effects are investigated using a novel fluid-structure interaction method, which combines the lattice Boltzmann and the finite element methods. On the basis of the clinical practice, three working modes of LVADs, namely, the constant flow, co-pulse, and counter pulse modes, are chosen. Results demonstrate that the working mode of LVADs is an important factor as it can change the biomechanical states of the aortic valve and the hemodynamic environment in the aortic root directly. Compared with the constant flow mode, the two other working modes can provide better biomechanical effects on the aortic valve. However, the advantages of the co-pulse and the counter pulse modes on the aortic valve are not the same. The LVADs in the co-pulse mode can remarkable reduce the pressure load of the leaflets during the diastolic phase (maximum stress: co-pulse mode, 0.85 MPa; constant flow mode, 1.23 MPa; counter pulse mode, 1.50 MPa). By contrast, the LVADs in the counter pulse mode can achieve the highest effective orifice area of the aortic valve (co-pulse mode: 0.12 cm2, constant flow mode: 0.17 cm2, counter pulse mode: 0.25 cm2). In sum, the co-pulse mode is suitable for patients with certain cardiac function, because this mode keeps the valve open intermittently and reduces the pressure load on the aortic leaflets during the diastolic phase to prevent valve remodeling. By contrast, the counter pulse mode is suitable for patients with severely impaired cardiac function, because this mode keeps the valve open as much as possible and provides high blood perfusion.
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Affiliation(s)
- Bin Gao
- School of Life Science and Bioengineering, Beijing University of Technology, Beijing, 100124, PR China.
| | - Qi Zhang
- National Energy Conservation Center, Beijing, PR China
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23
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Poredos P, Jezovnik MK, Radovancevic R, Gregoric ID. Endothelial Function in Patients With Continuous-Flow Left Ventricular Assist Devices. Angiology 2020; 72:9-15. [PMID: 32757767 DOI: 10.1177/0003319720946977] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The endothelium plays a crucial role in maintaining cardiovascular homeostasis. Shear stress generated by flowing blood regulates the release of substances that provide adequate tissue perfusion. The extent of damage to endothelial cells depends on locally disturbed shear stress caused by the deteriorated flow. Patients with heart failure have reduced cardiac output, which results in reduced blood flow and negative shear stress. Reduced shear stress also affects microcirculation and reduces tissue perfusion. Consequently, the production of free oxygen radicals is increased and bioavailability of nitric oxide is additionally decreased. Therefore, endothelial dysfunction is involved in the progression of heart failure and cardiovascular events. Left ventricular assist devices (LVAD) are used for the treatment of patients with advanced heart failure. Older pulsatile flow LVADs were mostly substituted by continuous-flow LVADs (cf-LVADs). Despite the advantages of the cf-LVADs, the loss of pulsatility leads to different complications on the micro- and macrovascular levels. One of the pathogenetic mechanisms of cardiovascular complications with cf-LVADs may be endothelial dysfunction, which after the implantation of the device does not improve and may even deteriorate. In contrast, the pulsatile pattern of LVADs on blood flow could preserve endothelial function.
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Affiliation(s)
- Pavel Poredos
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, 12340The University of Texas Health Science Center at Houston, Houston, TX, USA.,Department of Vascular Disease, 37663University Medical Center, Ljubljana, Slovenia
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, 12340The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Rajko Radovancevic
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, 12340The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Igor D Gregoric
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, 12340The University of Texas Health Science Center at Houston, Houston, TX, USA
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Gallo M, Spigolon L, Bejko J, Gerosa G, Bottio T. How to evaluate the outflow tract of LVAD after minimally invasive implantation by 3D CT-scan. Artif Organs 2020; 44:1306-1309. [PMID: 32668042 DOI: 10.1111/aor.13777] [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: 06/08/2020] [Revised: 07/03/2020] [Accepted: 07/10/2020] [Indexed: 12/27/2022]
Abstract
During a minimally invasive implantation technique, the outflow graft of left ventricular assist device (LVAD) is tunnelled blindly through the pericardium or left pleura, with an inability to assess for twisting or malposition. Three-dimensional computed tomography scan (CT-scan) has a role in qualitative evaluation of the different outflow tract configurations. The different surgical minimally invasive approaches include: (a) mini-sternotomy and left mini-thoracotomy, (b) right mini-thoracotomy and left mini-thoracotomy, (c) subclavian artery access and left mini-thoracotomy. The outflow graft could be anastomosed to the left axillary artery or the ascending aorta. CT-scan reconstruction using syngo InSpace4D (Siemens, Muenchen, Germany) was used to provide fast segmentation and high-resolution images. The 3D reconstructions permit an evaluation of different anastomosis configurations and to assess the route of outflow graft.
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Affiliation(s)
- Michele Gallo
- Cardiovascular Surgery, Cardiocentro Ticino, Lugano, Switzerland.,Division of Cardiac Surgery, University of Padova, Padova, Italy
| | - Luca Spigolon
- Division of Radiology, Vicenza Hospital, Vicenza, Italy
| | - Jonida Bejko
- Division of Cardiac Surgery, University of Padova, Padova, Italy
| | - Gino Gerosa
- Division of Cardiac Surgery, University of Padova, Padova, Italy
| | - Tomaso Bottio
- Division of Cardiac Surgery, University of Padova, Padova, Italy
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Goodwin ML, Bobba CM, Mokadam NA, Whitson BA, Essandoh M, Hasan A, Ganapathi AM. Continuous-Flow Left Ventricular Assist Devices and the Aortic Valve: Interactions, Issues, and Surgical Therapy. Curr Heart Fail Rep 2020; 17:97-105. [DOI: 10.1007/s11897-020-00464-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Kasinpila P, Kong S, Fong R, Shad R, Kaiser AD, Marsden AL, Woo YJ, Hiesinger W. Use of patient-specific computational models for optimization of aortic insufficiency after implantation of left ventricular assist device. J Thorac Cardiovasc Surg 2020; 162:1556-1563. [PMID: 32653292 DOI: 10.1016/j.jtcvs.2020.04.164] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 03/29/2020] [Accepted: 04/01/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Aortic incompetence (AI) is observed to be accelerated in the continuous-flow left ventricular assist device (LVAD) population and is related to increased mortality. Using computational fluid dynamics (CFD), we investigated the hemodynamic conditions related to the orientation of the LVAD outflow in these patients. METHOD We identified 10 patients with new aortic regurgitation, and 20 who did not, after LVAD implantation between 2009 and 2018. Three-dimensional models of patients' aortas were created from their computed tomography scans. The geometry of the LVAD outflow graft in relation to the aorta was quantified using azimuth angles (AA), polar angles (PAs), and distance from aortic root. The models were used to run CFD simulations, which calculated the pressures and wall shear stress (rWSS) exerted on the aortic root. RESULTS The AA and PA were found to be similar. However, for combinations of high values of AA and low values of PA, there were no patients with AI. The distance from aortic root to the outflow graft was also smaller in patients who developed AI (3.39 ± 0.7 vs 4.07 ± 0.77 cm, P = .04). There was no significant difference in aortic root pressures in the 2 groups. The rWSS was greater in AI patients (4.60 ± 5.70 vs 2.37 ± 1.20 dyne/cm2, P < .001). Qualitatively, we observed a trend of greater perturbations, regions of high rWSS, and flow eddies in the AI group. CONCLUSIONS Using CFD simulations, we demonstrated that patients who developed de novo AI have greater rWSS at the aortic root, and their outflow grafts were placed closer to the aortic roots than those patients without de novo AI.
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Affiliation(s)
- Patpilai Kasinpila
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Sandra Kong
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Robyn Fong
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Rohan Shad
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Alexander D Kaiser
- Departments of Bioengineering, Stanford University, Stanford, Calif; Pediatrics (Cardiology), Stanford University, Stanford, Calif
| | - Alison L Marsden
- Pediatrics (Cardiology), Stanford University, Stanford, Calif; Institute for Computational and Mathematical Engineering, Stanford University, Stanford, Calif
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - William Hiesinger
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif.
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Yoshida S, Toda K, Miyagawa S, Yoshikawa Y, Hata H, Yoshioka D, Kainuma S, Kawamura T, Kawamura A, Nakatani S, Sawa Y. Impact of turbulent blood flow in the aortic root on de novo aortic insufficiency during continuous‐flow left ventricular‐assist device support. Artif Organs 2020; 44:883-891. [DOI: 10.1111/aor.13671] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 01/13/2020] [Accepted: 02/12/2020] [Indexed: 01/18/2023]
Affiliation(s)
| | - Koichi Toda
- Cardiovascular Surgery Osaka University Suita Japan
| | | | | | - Hiroki Hata
- Cardiovascular Surgery Osaka University Suita Japan
| | | | | | | | - Ai Kawamura
- Cardiovascular Surgery Osaka University Suita Japan
| | | | - Yoshiki Sawa
- Cardiovascular Surgery Osaka University Suita Japan
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28
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Noly PE, Pagani FD, Noiseux N, Stulak JM, Khalpey Z, Carrier M, Maltais S. Continuous-Flow Left Ventricular Assist Devices and Valvular Heart Disease: A Comprehensive Review. Can J Cardiol 2019; 36:244-260. [PMID: 32036866 DOI: 10.1016/j.cjca.2019.11.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 11/17/2019] [Accepted: 11/19/2019] [Indexed: 12/15/2022] Open
Abstract
Mechanical circulatory support with implantable durable continuous-flow left ventricular assist devices (CF-LVADs) represents an established surgical treatment option for patients with advanced heart failure refractory to guideline-directed medical therapy. CF-LVAD therapy has been demonstrated to offer significant survival, functional, and quality-of-life benefits. However, nearly one-half of patients with advanced heart failure undergoing implantation of a CF-LVAD have important valvular heart disease (VHD) present at the time of device implantation or develop VHD during support that can lead to worsening right or left ventricular dysfunction and result in development of recurrent heart failure, more frequent adverse events, and higher mortality. In this review, we summarize the recent evidence related to the pathophysiology and treatment of VHD in the setting of CF-LAVD support and include a review of the specific valve pathologies of aortic insufficiency (AI), mitral regurgitation (MR), and tricuspid regurgitation (TR). Recent data demonstrate an increasing appreciation and understanding of how VHD may adversely affect the hemodynamic benefits of CF-LVAD support. This is particularly relevant for MR, where increasing evidence now demonstrates that persistent MR after CF-LVAD implantation can contribute to worsening right heart failure and recurrent heart failure symptoms. Standard surgical interventions and novel percutaneous approaches for treatment of VHD in the setting of CF-LVAD support, such as transcatheter aortic valve replacement or transcatheter mitral valve repair, are available, and indications to intervene for VHD in the setting of CF-LVAD support continue to evolve.
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Affiliation(s)
- Pierre-Emmanuel Noly
- Department of Cardiac Surgery, Montréal Heart Institute, Montréal, Québec, Canada
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Nicolas Noiseux
- Department of Cardiac Surgery, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - John M Stulak
- Department of Cardiac Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Zain Khalpey
- Department of Surgery, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Michel Carrier
- Department of Cardiac Surgery, Montréal Heart Institute, Montréal, Québec, Canada
| | - Simon Maltais
- Department of Cardiac Surgery, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada.
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Left Ventricular Assist Device Inflow Cannula Insertion Depth Influences Thrombosis Risk. ASAIO J 2019; 66:766-773. [DOI: 10.1097/mat.0000000000001068] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Thaker R, Araujo-Gutierrez R, Marcos-Abdala HG, Agrawal T, Fida N, Kassi M. Innovative Modeling Techniques and 3D Printing in Patients with Left Ventricular Assist Devices: A Bridge from Bench to Clinical Practice. J Clin Med 2019; 8:E635. [PMID: 31075841 PMCID: PMC6572374 DOI: 10.3390/jcm8050635] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 04/24/2019] [Accepted: 05/01/2019] [Indexed: 02/07/2023] Open
Abstract
Left ventricular assist devices (LVAD) cause altered flow dynamics that may result in complications such as stroke, pump thrombosis, bleeding, or aortic regurgitation. Understanding altered flow dynamics is important in order to develop more efficient and durable pump configurations. In patients with LVAD, hemodynamic assessment is limited to imaging techniques such as echocardiography which precludes detailed assessment of fluid dynamics. In this review article, we present some innovative modeling techniques that are often used in device development or for research purposes, but have not been utilized clinically. Computational fluid dynamic (CFD) modeling is based on computer simulations and particle image velocimetry (PIV) employs ex vivo models that helps study fluid characteristics such as pressure, shear stress, and velocity. Both techniques may help elaborate our understanding of complications that occur with LVAD and could be potentially used in the future to troubleshoot LVAD-related alarms. These techniques coupled with 3D printing may also allow for patient-specific device implants, lowering the risk of complications increasing device durability.
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Affiliation(s)
- Rishi Thaker
- Touro College of Osteopathic Medicine, Middletown, New York, NY 10940, USA.
| | - Raquel Araujo-Gutierrez
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX 77030, USA.
| | - Hernan G Marcos-Abdala
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX 77030, USA.
| | - Tanushree Agrawal
- Department of Internal Medicine, Houston Methodist Hospital, Houston, TX 77030, USA.
| | - Nadia Fida
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX 77030, USA.
| | - Mahwash Kassi
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX 77030, USA.
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31
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Iyengar A, Atluri P. Commentary: Mapping a future for continuous-flow ventricular assist devices. J Thorac Cardiovasc Surg 2019; 159:e209-e210. [PMID: 30922635 DOI: 10.1016/j.jtcvs.2019.02.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 02/13/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Amit Iyengar
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa.
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Aortic regurgitation in patients with a left ventricular assist device: A contemporary review. J Heart Lung Transplant 2018; 37:1289-1297. [DOI: 10.1016/j.healun.2018.07.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 06/24/2018] [Accepted: 07/05/2018] [Indexed: 01/12/2023] Open
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Fried J, Garan AR, Shames S, Masoumi A, Yuzefpolskaya M, Takeda K, Takayama H, Uriel N, Naka Y, Colombo PC, Topkara VK. Aortic root thrombosis in patients supported with continuous-flow left ventricular assist devices. J Heart Lung Transplant 2018; 37:1425-1432. [PMID: 30241886 DOI: 10.1016/j.healun.2018.07.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Revised: 07/13/2018] [Accepted: 07/18/2018] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Aortic root thrombosis (ART) is a recently recognized complication of continuous-flow left ventricular assist device (CF-LVAD) therapy. However, little is known about the prevalence or clinical significance of this complication. The aim of our study was to systematically evaluate the incidence and significance of ART on CF-LVAD support. METHODS We retrospectively reviewed all patients who underwent HeartMate II or HeartWare HVAD CF-LVAD implantation from April 2004 through June 2016 at the Columbia University Medical Center. Echocardiography studies were systematically reviewed to identify patients who developed ART. Study outcomes included post-ART survival on CF-LVAD support, stroke, pump thrombosis, and clinically significant myocardial infarction (MI). RESULTS The study cohort consisted of 436 CF-LVAD patients with 21 patients (4.8%) diagnosed with confirmed ART at a median time of 22 days (interquartile range [IQR] 3 to 56 days) after CF-LVAD implantation. Involvement of the non-coronary cusp was the most common location of the ART (n = 15, 71.4%) and concomitant RV failure occurred in 14 patients (66.7%). Actuarial survival at 1 and 2 years after diagnosis of ART was 73.8% and 44.3%, respectively. ART was associated with a high rate of complications, including stroke (28.6%, 0.337 episode per patient-year [EPPY]) and clinically significant MI (28.6%, 0.337 EPPY). CONCLUSIONS ART is not uncommon after CF-LVAD implantation and is associated with significant morbidity and mortality in CF-LVAD patients. Given the early occurrence and high incidence of stroke and MI in patients who develop ART, surveillance and treatment strategies should be implemented to address this potentially devastating complication.
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Affiliation(s)
- Justin Fried
- Division of Cardiology, Department of Medicine, Columbia University Medical Center-New York Presbyterian Hospital, New York, New York, USA
| | - Arthur R Garan
- Division of Cardiology, Department of Medicine, Columbia University Medical Center-New York Presbyterian Hospital, New York, New York, USA
| | - Sophia Shames
- Division of Cardiology, Department of Medicine, Columbia University Medical Center-New York Presbyterian Hospital, New York, New York, USA
| | - Amirali Masoumi
- Division of Cardiology, Department of Medicine, Columbia University Medical Center-New York Presbyterian Hospital, New York, New York, USA
| | - Melana Yuzefpolskaya
- Division of Cardiology, Department of Medicine, Columbia University Medical Center-New York Presbyterian Hospital, New York, New York, USA
| | - Koji Takeda
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center-New York Presbyterian Hospital, New York, New York, USA
| | - Hiroo Takayama
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center-New York Presbyterian Hospital, New York, New York, USA
| | - Nir Uriel
- Division of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Yoshifumi Naka
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center-New York Presbyterian Hospital, New York, New York, USA
| | - Paolo C Colombo
- Division of Cardiology, Department of Medicine, Columbia University Medical Center-New York Presbyterian Hospital, New York, New York, USA
| | - Veli K Topkara
- Division of Cardiology, Department of Medicine, Columbia University Medical Center-New York Presbyterian Hospital, New York, New York, USA.
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34
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Visualization of vortex flow and shear stress in the aortic root during left ventricular assist device support. J Thorac Cardiovasc Surg 2017; 154:877-878.e1. [DOI: 10.1016/j.jtcvs.2017.01.060] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 01/03/2017] [Accepted: 01/18/2017] [Indexed: 11/22/2022]
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35
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Hanke JS, Rojas SV, Cvitkovic T, Wiegmann B, Horke A, Warnecke G, Haverich A, Schmitto JD. First results of HeartWare left ventricular assist device implantation with tunnelling of the outflow graft through the transverse sinus. Interact Cardiovasc Thorac Surg 2017; 25:503-508. [DOI: 10.1093/icvts/ivx124] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 03/04/2017] [Indexed: 11/12/2022] Open
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36
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Left Ventricular Assist Devices: Challenges Toward Sustaining Long-Term Patient Care. Ann Biomed Eng 2017; 45:1836-1851. [DOI: 10.1007/s10439-017-1858-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 05/22/2017] [Indexed: 11/25/2022]
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37
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A modified implantation technique of left ventricular assist device: optimal outflow tract positioning. Int J Cardiol 2016; 223:776-778. [PMID: 27573606 DOI: 10.1016/j.ijcard.2016.08.209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 08/11/2016] [Indexed: 11/22/2022]
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38
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Gu K, Gao B, Chang Y, Zeng Y. Pulsatile Support Mode of BJUT-II Ventricular Assist Device (VAD) has Better Hemodynamic Effects on the Aorta than Constant Speed Mode: A Primary Numerical Study. Med Sci Monit 2016; 22:2284-94. [PMID: 27363758 PMCID: PMC4933548 DOI: 10.12659/msm.896291] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background BJUT-II VAD is a novel left ventricular assist device (LVADs), directly implanted into the ascending aorta. The pulsatile support mode is proposed to achieve better unloading performance than constant speed mode. However, the hemodynamic effects of this support mode on the aorta are still unclear. The aim of this study was to clarify the hemodynamic effects BJUT-II VAD under pulsatile support mode on the aorta. Material/Methods Computational fluid dynamics (CFD) studies, based on a patient-specific aortic geometric model, were conducted. Wall shear stress (WSS), averaged WSS (avWSS), oscillatory shear index (OSI), and averaged helicity density (Ha) were calculated to compare the differences in hemodynamic effects between pulsatile support mode and constant speed mode. Results The results show that avWSS under pulsatile support mode is significantly higher than that under constant speed mode (0.955Pa vs. 0.675Pa). Similarly, the OSI value under pulsatile mode is higher than that under constant speed mode (0.104 vs. 0.057). In addition, Ha under pulsatile mode for all selected cross-sections is larger than that under constant mode. Conclusions BJUT-II VAD, under pulsatile control mode, may prevent atherosclerosis lesions and aortic remodeling. The precise effects of pulsatile support mode on atherosclerosis and aortic remodeling need to be further studied in animal experiments.
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Affiliation(s)
- Kaiyun Gu
- School of Life Sciences and BioEngineering, Beijing University of Technology, Beijing, China (mainland)
| | - Bin Gao
- School of Life Sciences and BioEngineering, Beijing University of Technology, Beijing, China (mainland)
| | - Yu Chang
- School of Life Science and BioEngineering, Beijing University of Technology, Beijing, China (mainland)
| | - Yi Zeng
- School of Life Science and BioEngineering, Beijing University of Technology, Beijing, China (mainland)
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Neidlin M, Corsini C, Sonntag SJ, Schulte-Eistrup S, Schmitz-Rode T, Steinseifer U, Pennati G, Kaufmann TAS. Hemodynamic analysis of outflow grafting positions of a ventricular assist device using closed-loop multiscale CFD simulations: Preliminary results. J Biomech 2016; 49:2718-2725. [PMID: 27298155 DOI: 10.1016/j.jbiomech.2016.06.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 05/30/2016] [Accepted: 06/01/2016] [Indexed: 11/17/2022]
Abstract
Subclavian arteries are a possible alternate location for left ventricular assist device (LVAD) outflow grafts due to easier surgical access and application in high risk patients. As vascular blood flow mechanics strongly influence the clinical outcome, insights into the hemodynamics during LVAD support can be used to evaluate different grafting locations. In this study, the feasibility of left and right subclavian artery (SA) grafting was investigated for the HeartWare HVAD with a numerical multiscale model. A 3-D CFD model of the aortic arch was coupled to a lumped parameter model of the cardiovascular system under LVAD support. Grafts in the left and right SA were placed at three different anastomoses angles (90°, 60° and 30°). Additionally, standard grafting of the ascending and descending aorta was modelled. Full support LVAD (5l/min) and partial support LVAD (3l/min) in co-pulsation and counter-pulsation mode were analysed. The grafting positions were investigated regarding coronary and cerebral perfusion. Furthermore, the influence of the anastomosis angle on wall shear stress (WSS) was evaluated. Grafting of left or right subclavian arteries has similar hemodynamic performance in comparison to standard cannula positions. Angularity change of the graft anastomosis from 90° to 30° slightly increases the coronary and cerebral blood flow by 6-9% while significantly reduces the WSS by 35%. Cannulation of the SA is a feasible anastomosis location for the HVAD in the investigated vessel geometry.
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Affiliation(s)
- Michael Neidlin
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Aachen, Germany; Enmodes GmbH, Aachen, Germany.
| | - Chiara Corsini
- Laboratory of Biological Structure Mechanics, Department of Chemistry, Materials and Chemical Engineering ''Giulio Natta'', Politecnico di Milano, Milano, Italy
| | - Simon J Sonntag
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Aachen, Germany; Enmodes GmbH, Aachen, Germany
| | | | - Thomas Schmitz-Rode
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Aachen, Germany
| | - Ulrich Steinseifer
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Aachen, Germany
| | - Giancarlo Pennati
- Laboratory of Biological Structure Mechanics, Department of Chemistry, Materials and Chemical Engineering ''Giulio Natta'', Politecnico di Milano, Milano, Italy
| | - Tim A S Kaufmann
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Aachen, Germany; Enmodes GmbH, Aachen, Germany
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Choi YJ, Constantino J, Vedula V, Trayanova N, Mittal R. A New MRI-Based Model of Heart Function with Coupled Hemodynamics and Application to Normal and Diseased Canine Left Ventricles. Front Bioeng Biotechnol 2015; 3:140. [PMID: 26442254 PMCID: PMC4585083 DOI: 10.3389/fbioe.2015.00140] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 08/31/2015] [Indexed: 11/22/2022] Open
Abstract
A methodology for the simulation of heart function that combines an MRI-based model of cardiac electromechanics (CE) with a Navier–Stokes-based hemodynamics model is presented. The CE model consists of two coupled components that simulate the electrical and the mechanical functions of the heart. Accurate representations of ventricular geometry and fiber orientations are constructed from the structural magnetic resonance and the diffusion tensor MR images, respectively. The deformation of the ventricle obtained from the electromechanical model serves as input to the hemodynamics model in this one-way coupled approach via imposed kinematic wall velocity boundary conditions and at the same time, governs the blood flow into and out of the ventricular volume. The time-dependent endocardial surfaces are registered using a diffeomorphic mapping algorithm, while the intraventricular blood flow patterns are simulated using a sharp-interface immersed boundary method-based flow solver. The utility of the combined heart-function model is demonstrated by comparing the hemodynamic characteristics of a normal canine heart beating in sinus rhythm against that of the dyssynchronously beating failing heart. We also discuss the potential of coupled CE and hemodynamics models for various clinical applications.
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Affiliation(s)
- Young Joon Choi
- Department of Mechanical Engineering, Johns Hopkins University , Baltimore, MD , USA ; Institute for Computational Medicine, Johns Hopkins University , Baltimore, MD , USA
| | - Jason Constantino
- Institute for Computational Medicine, Johns Hopkins University , Baltimore, MD , USA ; Department of Biomedical Engineering, Johns Hopkins University , Baltimore, MD , USA
| | - Vijay Vedula
- Department of Mechanical Engineering, Johns Hopkins University , Baltimore, MD , USA
| | - Natalia Trayanova
- Institute for Computational Medicine, Johns Hopkins University , Baltimore, MD , USA ; Department of Biomedical Engineering, Johns Hopkins University , Baltimore, MD , USA
| | - Rajat Mittal
- Department of Mechanical Engineering, Johns Hopkins University , Baltimore, MD , USA ; Institute for Computational Medicine, Johns Hopkins University , Baltimore, MD , USA
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Mallidi HR. Computational fluid dynamics: Solidifying fluid concepts in left ventricular assist device therapy. J Thorac Cardiovasc Surg 2015; 150:704-6. [PMID: 26149101 DOI: 10.1016/j.jtcvs.2015.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 06/03/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Hari R Mallidi
- Department of Surgery, Division of Transplant and Assist Devices, Baylor College of Medicine, Houston, Tex.
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