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Shimoda T, Yokoyama Y, Takagi H, Kuno T, Fukuhara S. Treatment strategies and outcomes following acute type A aortic dissection repair in patients with bicuspid and tricuspid aortic valves: A meta-analysis. JTCVS OPEN 2024; 19:9-30. [PMID: 39015444 PMCID: PMC11247237 DOI: 10.1016/j.xjon.2024.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 01/28/2024] [Accepted: 02/26/2024] [Indexed: 07/18/2024]
Abstract
Background There is no consensus regarding the strategies for repairing acute type A aortic dissection (ATAAD) in patients with bicuspid aortic valve (BAV). This meta-analysis aimed to compare the treatment strategies and outcomes of ATAAD repair between patients with BAV and those with tricuspid aortic valve (TAV). Methods A systematic review of databases were performed from inception through March 2023. The primary outcome of interest was all-cause mortality, with a minimum follow-up of 1 year. The secondary outcomes of interest included ratios of performed procedures and rate of distal aortic reoperation. Data were extracted, and pooled analysis was performed using a random-effects model. Results Eight observational studies including a total of 3701 patients (BAV, n = 349; TAV, n = 3352) were selected for a meta-analysis. Concerning proximal aortic procedures, BAV patients exhibited a higher incidence of necessary root replacement (odds ratio [OR], 6.53; 95% confidence interval [CI], 3.84 to 11.09; P < .01). Regarding distal aortic procedures, extended arch replacement was performed less frequently in BAV patients (OR, 0.69; 95% CI, 0.49 to 0.99; P = .04), whereas hemiarch procedure rates were comparable in the 2 groups. All-cause mortality was lower in the BAV group (hazard ratio, 0.68; 95% CI, 0.50 to 0.92; P = .01). Distal aortic reoperation rates were comparable in the 2 groups. Conclusions This study highlights distinct procedural patterns in ATAAD patients with BAV and TAV. Despite differing baseline characteristics, BAV patients exhibited superior survival compared to TAV patients, with comparable distal aortic reoperation rates. These findings may be useful for decision making regarding limited versus extended aortic arch repair.
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Affiliation(s)
- Tomonari Shimoda
- Department of Surgery, University of Tsukuba Hospital, Ibaraki, Japan
| | - Yujiro Yokoyama
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Toshiki Kuno
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY
| | - Shinichi Fukuhara
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
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2
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Hohri Y, Chung MM, Kandula V, Kim I, Leb J, Hayashi H, Elmously A, O’Donnell TFX, Patel V, Vedula V, Takayama H. Blood flow assessment technology in aortic surgery: a narrative review. J Thorac Dis 2024; 16:2623-2636. [PMID: 38738252 PMCID: PMC11087597 DOI: 10.21037/jtd-23-1795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 02/23/2024] [Indexed: 05/14/2024]
Abstract
Background and Objective Blood flow assessment is an emerging technique that allows for assessment of hemodynamics in the heart and blood vessels. Recent advances in cardiovascular imaging technologies have made it possible for this technique to be more accessible to clinicians and researchers. Blood flow assessment typically refers to two techniques: measurement-based flow visualization using echocardiography or four-dimensional flow magnetic resonance imaging (4D flow MRI), and computer-based flow simulation based on computational fluid dynamics modeling. Using these methods, blood flow patterns can be visualized and quantitative measurements of mechanical stress on the walls of the ventricles and blood vessels, most notably the aorta, can be made. Thus, blood flow assessment has been enhancing the understanding of cardiac and aortic diseases; however, its introduction to clinical practice has been negligible yet. In this article, we aim to discuss the clinical applications and future directions of blood flow assessment in aortic surgery. We then provide our unique perspective on the technique's translational impact on the surgical management of aortic disease. Methods Articles from the PubMed database and Google Scholar regarding blood flow assessment in aortic surgery were reviewed. For the initial search, articles published between 2013 and 2023 were prioritized, including original articles, clinical trials, case reports, and reviews. Following the initial search, additional articles were considered based on manual searches of the references from the retrieved literature. Key Content and Findings In aortic root pathology and ascending aortic aneurysms, blood flow assessment can elucidate postoperative hemodynamic changes after surgical reconfiguration of the aortic valve complex or ascending aorta. In cases of aortic dissection, analysis of blood flow can predict future aortic dilatation. For complicated congenital aortic anomalies, surgeons may use preoperative imaging to perform "virtual surgery", in which blood flow assessment can predict postoperative hemodynamics for different surgical reconstructions and assist in procedural planning even before entering the operating room. Conclusions Blood flow assessment and computational modeling can evaluate hemodynamics and flow patterns by visualizing blood flow and calculating biomechanical forces in patients with aortic disease. We anticipate that blood flow assessment will become an essential tool in the treatment planning and understanding of the progression of aortic disease.
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Affiliation(s)
- Yu Hohri
- Division of Cardiothoracic Surgery, Department of Surgery, New York-Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
| | - Megan M. Chung
- Division of Cardiothoracic Surgery, Department of Surgery, New York-Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
| | - Viswajit Kandula
- Division of Cardiothoracic Surgery, Department of Surgery, New York-Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
| | - Ilya Kim
- Department of Medicine, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, USA
| | - Jay Leb
- Department of Radiology, New York-Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
| | - Hideyuki Hayashi
- Division of Cardiothoracic Surgery, Department of Surgery, New York-Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
| | - Adham Elmously
- Division of Cardiothoracic Surgery, Department of Surgery, New York-Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
| | - Thomas FX O’Donnell
- Division of Vascular Surgery, Department of Surgery, New York-Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
| | - Virendra Patel
- Division of Vascular Surgery, Department of Surgery, New York-Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
| | - Vijay Vedula
- Department of Mechanical Engineering, Columbia University in the City of New York, New York, NY, USA
| | - Hiroo Takayama
- Division of Cardiothoracic Surgery, Department of Surgery, New York-Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
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3
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Garg P, Markl M, Sathananthan J, Sellers SL, Meduri C, Cavalcante J. Restoration of flow in the aorta: a novel therapeutic target in aortic valve intervention. Nat Rev Cardiol 2024; 21:264-273. [PMID: 37880496 DOI: 10.1038/s41569-023-00943-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/25/2023] [Indexed: 10/27/2023]
Abstract
Aortic blood flow patterns are closely linked to the morphology and function of the left ventricle, aortic valve and aorta. These flow patterns demonstrate the exceptional adaptability of the cardiovascular system to maintain blood circulation under a broad range of haemodynamic workloads and can be altered in various pathophysiological states. For instance, normal ascending aortic systolic flow is predominantly laminar, whereas abnormal aortic systolic flow is associated with increased eccentricity, vorticity and flow reversal. These flow abnormalities result in reduced aortic conduit function and increased energy loss in the cardiovascular system. Emerging evidence details the association of these flow patterns with loss of aortic compliance, which leads to adverse left ventricular remodelling, poor tissue perfusion, and an increased risk of morbidity and death. In this Perspective article, we review the evidence for the link between aortic flow-related abnormalities and cardiovascular disease and how these changes in aortic flow patterns are emerging as a therapeutic target for aortic valve intervention in first-in-human studies.
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Affiliation(s)
- Pankaj Garg
- University of East Anglia, Norwich Medical School, Norwich, UK.
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK.
| | - Michael Markl
- Departments of Radiology & Biomedical Engineering, Northwestern University, Feinberg School of Medicine & McCormick School of Engineering, Chicago, IL, USA
| | | | - Stephanie L Sellers
- Cardiovascular Translational Lab, St. Paul's Hospital, University of British Columbia Centre for Heart Lung Innovation, Vancouver, British Columbia, Canada
| | - Chris Meduri
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - João Cavalcante
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
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4
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Lee J, Huh H, Scott MB, Elbaz MSM, Puthumana JJ, McCarthy P, Malaisrie SC, Markl M, Thomas JD, Barker AJ. Valvular and ascending aortic hemodynamics of the On-X aortic valved conduit by same-day echocardiography and 4D flow MRI. Front Cardiovasc Med 2023; 10:1256420. [PMID: 38034383 PMCID: PMC10682731 DOI: 10.3389/fcvm.2023.1256420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 10/17/2023] [Indexed: 12/02/2023] Open
Abstract
This study aims to assess whether the On-X aortic valved conduit better restores normal valvular and ascending aortic hemodynamics than other commonly used bileaflet mechanical valved conduit prostheses from St. Jude Medical and Carbomedics by using same-day transthoracic echocardiography (TTE) and 4D flow magnetic resonance imaging (MRI) examinations. TTE and 4D flow MRI were performed back-to-back in 10 patients with On-X, six patients with St. Jude (two) and Carbomedics (four) prostheses, and 36 healthy volunteers. TTE evaluated valvular hemodynamic parameters: transvalvular peak velocity (TPV), mean and peak transvalvular pressure gradient (TPG), and effective orifice area (EOA). 4D flow MRI evaluated the peak systolic 3D viscous energy loss rate (VELR) density and mean vorticity magnitude in the ascending aorta (AAo). While higher TPV and mean and peak TPG were recorded in all patients compared to healthy subjects, the values in On-X patients were closer to those in healthy subjects (TPV 1.9 ± 0.3 vs. 2.2 ± 0.3 vs. 1.2 ± 0.2 m/s, mean TPG 7.4 ± 1.9 vs. 9.2 ± 2.3 vs. 3.1 ± 0.9 mmHg, peak TPG 15.3 ± 5.2 vs. 18.9 ± 5.2 vs. 6.1 ± 1.8 mmHg, p < 0.001). Likewise, while higher VELR density and mean vorticity magnitude were recorded in all patients than in healthy subjects, the values in On-X patients were closer to those in healthy subjects (VELR: 50.6 ± 20.1 vs. 89.8 ± 35.2 vs. 21.4 ± 9.2 W/m3, p < 0.001) and vorticity (147.6 ± 30.0 vs. 191.2 ± 26.0 vs. 84.6 ± 20.5 s-1, p < 0.001). This study demonstrates that the On-X aortic valved conduit may produce less aberrant hemodynamics in the AAo while maintaining similar valvular hemodynamics to St. Jude Medical and Carbomedics alternatives.
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Affiliation(s)
- Jeesoo Lee
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Hyungkyu Huh
- Medical Device Development Center, Daegu-Gyeongbuk Medical Innovation Foundation, Daegu, Republic of Korea
| | - Michael B. Scott
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
- Department of Biomedical Engineering, McCormick School of Engineering, Northwestern University, Evanston, IL, United States
| | - Mohammed S. M. Elbaz
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Jyothy J. Puthumana
- Department of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Patrick McCarthy
- Division of Cardiac Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - S. Christopher Malaisrie
- Division of Cardiac Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Michael Markl
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
- Department of Biomedical Engineering, McCormick School of Engineering, Northwestern University, Evanston, IL, United States
| | - James D. Thomas
- Department of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Alex J. Barker
- Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
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5
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The role of mechanical valves in the aortic position in the era of bioprostheses and TAVR: Evidence-based appraisal and focus on the On-X valve. Prog Cardiovasc Dis 2022; 72:31-40. [PMID: 35738422 DOI: 10.1016/j.pcad.2022.06.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 06/05/2022] [Indexed: 11/24/2022]
Abstract
Patients who need a prosthetic aortic heart valve may decide, working with their cardiologist and cardiac surgeon, among a variety of options: surgical or transcatheter approach, bioprosthetic or mechanical valve, or a Ross procedure if suitable to their age and anatomy. This review article examines the evidence for survival benefit with mechanical aortic valves, discusses bioprosthetic structural valve degeneration and its consequences, and considers the risks of redo aortic valve surgery or subsequent valve-in-valve (ViV) transcatheter intervention. It highlights the unique characteristics of the On-X aortic valve, including the US Food and Drug Administration approved and American College of Cardiology/American Heart Association guideline supported reduced anticoagulation target INR of 1.5 to 2.0, and discusses the PROACT Xa trial comparing apixaban vs warfarin anticoagulation. The choice of prosthetic valve should be individualized, carefully considering each patient's unique circumstances. In that context, the On-X aortic valve offers a potential lifetime solution without need for a repeat operation, while minimizing the risks of long-term anticoagulation. In an era of enthusiasm for bioprosthetic and transcatheter-based approaches, the option of a second-generation bileaflet mechanical valve with optimized hemodynamics-the On-X aortic valve-may well align with patient expectations.
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6
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Doyle CM, Orr J, Greenwood JP, Plein S, Tsoumpas C, Bissell MM. Four-Dimensional Flow Magnetic Resonance Imaging in the Assessment of Blood Flow in the Heart and Great Vessels: A Systematic Review. J Magn Reson Imaging 2021; 55:1301-1321. [PMID: 34416048 DOI: 10.1002/jmri.27874] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 07/22/2021] [Accepted: 07/23/2021] [Indexed: 12/28/2022] Open
Abstract
Four-dimensional (4D) flow magnetic resonance imaging (MRI) allows multidirectional quantification of blood flow in the heart and great vessels. Comparability of the technique to the current reference standards of flow assessment-two-dimensional (2D) flow MRI and Doppler echocardiography-varies in the literature. Image acquisition parameters likely impact upon the accuracy and reproducibility of 4D flow MRI. We therefore sought to review the current literature on 4D flow MRI in the heart and great vessels, in comparison to 2D flow MRI, Doppler echocardiography, and invasive catheterization. Using a predefined search strategy and inclusion and exclusion criteria, the databases EMBASE and Medline were searched in January 2021 for peer-reviewed research articles comparing cardiac 4D flow MRI to 2D flow MRI, Doppler echocardiography and/or invasive catheterization. The data from all relevant articles were assimilated and analyzed using Mann-Whitney U and chi χ2 test. Forty-four manuscripts met the eligibility criteria and were included in the review. The review showed agreement of 4D flow MRI to the reference standard methods of flow assessment, particular in the measurement of peak velocity and stroke volume in 55% of manuscripts. The use of valve tracking significantly improves agreement between 4D flow MRI and the reference modalities (79% matching with the use of valve tracking vs. 50% without, P = 0.04). This review highlights that the impact of acquisition parameters on 4D flow MRI accuracy is multifactorial. It is therefore important that each center conducts its own quality assurance prior to using 4D flow MRI for clinical decision-making. LEVEL OF EVIDENCE: 2 TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Ciara M Doyle
- Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, UK
| | - Jenny Orr
- Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, UK
| | - John P Greenwood
- Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, UK
| | - Sven Plein
- Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, UK
| | - Charalampos Tsoumpas
- Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, UK.,Biomedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Malenka M Bissell
- Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, UK
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7
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Nordmeyer S, Hellmeier F, Yevtushenko P, Kelm M, Lee CB, Lehmann D, Kropf S, Berger F, Falk V, Knosalla C, Kuehne T, Goubergrits L. Abnormal aortic flow profiles persist after aortic valve replacement in the majority of patients with aortic valve disease: how model-based personalized therapy planning could improve results. A pilot study approach. Eur J Cardiothorac Surg 2021; 57:133-141. [PMID: 31131388 DOI: 10.1093/ejcts/ezz149] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 04/17/2019] [Accepted: 04/18/2019] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES Complex blood flow profiles in the aorta are known to contribute to vessel dilatation. We studied flow profiles in the aorta in patients with aortic valve disease before and after surgical aortic valve replacement (AVR). METHODS Thirty-four patients with aortic valve disease underwent 4-dimensional velocity-encoded magnetic resonance imaging before and after AVR (biological valve = 27, mechanical valve = 7). Seven healthy volunteers served as controls. Eccentricity (ES) and complex flow scores (CFS) were determined from the degree of helicity, vorticity and eccentricity of flow profiles in the aorta. Model-based therapy planning was used in 4 cases to improve in silico postoperative flow profiles by personalized adjustment of size, rotation and angulation of the valve as well as aorta diameter. RESULTS Patients with aortic valve disease showed more complex flow than controls [median ES 2.5 (interquartile range (IQR) 2.3-2.7) vs 1.0 (IQR 1.0-1.0), P < 0.001, median CFS 4.7 (IQR 4.3-4.8) vs 1.0 (IQR 1.0-2.0), P < 0.001]. After surgery, flow complexity in the total patient cohort was reduced, but remained significantly higher compared to controls [median ES 2.3 (IQR 1.9-2.3) vs 1.0 (IQR 1.0-1.0), P < 0.001, median CFS 3.8 (IQR 3.0-4.3) vs 1.0 (IQR 1.0-2.0), P < 0.001]. In patients after mechanical AVR, flow complexity fell substantially and showed no difference from controls [median ES 1.0 (IQR 1.0-2.3) vs 1.0 (IQR 1.0-1.0), P = 0.46, median CFS 1.0 (IQR 1.0-3.3) vs 1.0 (IQR 1.0-2.0), P = 0.71]. In all 4 selected cases (biological, n = 2; mechanical, n = 2), model-based therapy planning reduced in silico complexity of flow profiles compared to the existing post-surgical findings [median ES 1.7 (IQR 1.4-1.7) vs 2.3 (IQR 2.3-2.3); CFS 1.7 (IQR 1.4-2.5) vs 3.8 (IQR 3.3-4.3)]. CONCLUSIONS Abnormal flow profiles in the aorta more frequently persist after surgical AVR. Model-based therapy planning might have the potential to optimize treatment for best possible individual outcome. CLINICAL TRIAL REGISTRATION NUMBER clinicaltrials.gov NCT03172338, 1 June 2017, retrospectively registered; NCT02591940, 30 October 2015, retrospectively registered.
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Affiliation(s)
- Sarah Nordmeyer
- Department of Congenital Heart Disease and Paediatric Cardiology, German Heart Center Berlin, Berlin, Germany.,Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Florian Hellmeier
- Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Pavel Yevtushenko
- Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Marcus Kelm
- Department of Congenital Heart Disease and Paediatric Cardiology, German Heart Center Berlin, Berlin, Germany.,Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Chong-Bin Lee
- Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Daniel Lehmann
- Institute for Gender in Medicine, Center for Cardiovascular Research, Berlin, Germany
| | - Siegfried Kropf
- Institute for Biometrics and Medical Informatics, Otto-von-Guericke Universität Magdeburg, Magdeburg, Germany
| | - Felix Berger
- Department of Congenital Heart Disease and Paediatric Cardiology, German Heart Center Berlin, Berlin, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Volkmar Falk
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.,Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Christoph Knosalla
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.,Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Titus Kuehne
- Department of Congenital Heart Disease and Paediatric Cardiology, German Heart Center Berlin, Berlin, Germany.,Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Leonid Goubergrits
- Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
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8
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Cave DGW, Panayiotou H, Bissell MM. Hemodynamic Profiles Before and After Surgery in Bicuspid Aortic Valve Disease-A Systematic Review of the Literature. Front Cardiovasc Med 2021; 8:629227. [PMID: 33842561 PMCID: PMC8024488 DOI: 10.3389/fcvm.2021.629227] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 03/02/2021] [Indexed: 11/25/2022] Open
Abstract
Bicuspid aortic valve (BAV) disease presents a unique management challenge both pre- and post-operatively. 4D flow MRI offers multiple tools for the assessment of the thoracic aorta in aortic valve disease. In particular, its assessment of flow patterns and wall shear stress have led to new understandings around the mechanisms of aneurysm development in BAV disease. Novel parameters have now been developed that have the potential to predict pathological aortic dilatation and may help to risk stratify BAV patients in future. This systematic review analyses the current 4D flow MRI literature after aortic valve and/or ascending aortic replacement in bicuspid aortic valve disease. 4D flow MRI has also identified distinct challenges posed by this cohort at the time of valve replacement compared to standard management of tri-leaflet disorders, and may help tailor the type and timing of replacement. Eccentric pathological flow patterns seen after bioprosthetic valve implantation, but not with mechanical prostheses, might be an important future consideration in intervention planning. 4D flow MRI also has promising potential in supporting the development of artificial valve prostheses and aortic conduits with more physiological flow patterns.
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Affiliation(s)
- Daniel G W Cave
- Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Hannah Panayiotou
- Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Malenka M Bissell
- Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
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9
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Abstract
Magnetic resonance imaging (MRI) has become an important tool for the clinical evaluation of patients with cardiac and vascular diseases. Since its introduction in the late 1980s, quantitative flow imaging with MRI has become a routine part of standard-of-care cardiothoracic and vascular MRI for the assessment of pathological changes in blood flow in patients with cardiovascular disease. More recently, time-resolved flow imaging with velocity encoding along all three flow directions and three-dimensional (3D) anatomic coverage (4D flow MRI) has been developed and applied to enable comprehensive 3D visualization and quantification of hemodynamics throughout the human circulatory system. This article provides an overview of the use of 4D flow applications in different cardiac and vascular regions in the human circulatory system, with a focus on using 4D flow MRI in cardiothoracic and cerebrovascular diseases.
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Affiliation(s)
- Gilles Soulat
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611, USA
| | - Patrick McCarthy
- Division of Cardiac Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611, USA
| | - Michael Markl
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611, USA
- Department of Biomedical Engineering, McCormick School of Engineering, Northwestern University, Evanston, Illinois 60208, USA
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10
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Jarral OA, Tan MKH, Salmasi MY, Pirola S, Pepper JR, O'Regan DP, Xu XY, Athanasiou T. Phase-contrast magnetic resonance imaging and computational fluid dynamics assessment of thoracic aorta blood flow: a literature review. Eur J Cardiothorac Surg 2020; 57:438-446. [PMID: 31638698 DOI: 10.1093/ejcts/ezz280] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 09/06/2019] [Accepted: 09/17/2019] [Indexed: 11/14/2022] Open
Abstract
The death rate from thoracic aortic disease is on the rise and represents a growing global health concern as patients are often asymptomatic before acute events, which have devastating effects on health-related quality of life. Biomechanical factors have been found to play a major role in the development of both acquired and congenital aortic diseases. However, much is still unknown and translational benefits of this knowledge are yet to be seen. Phase-contrast cardiovascular magnetic resonance imaging of thoracic aortic blood flow has emerged as an exceptionally powerful non-invasive tool enabling visualization of complex flow patterns, and calculation of variables such as wall shear stress. This has led to multiple new findings in the areas of phenotype-dependent bicuspid valve flow patterns, thoracic aortic aneurysm formation and aortic prosthesis performance assessment. Phase-contrast cardiovascular magnetic resonance imaging has also been used in conjunction with computational fluid modelling techniques to produce even more sophisticated analyses, by allowing the calculation of haemodynamic variables with exceptional temporal and spatial resolution. Translationally, these technologies may potentially play a major role in the emergence of precision medicine and patient-specific treatments in patients with aortic disease. This clinically focused review will provide a systematic overview of key insights from published studies to date.
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Affiliation(s)
- Omar A Jarral
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Matthew K H Tan
- Department of Surgery and Cancer, Imperial College London, London, UK
| | | | - Selene Pirola
- Department of Chemical Engineering, Imperial College London, London, UK
| | - John R Pepper
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Declan P O'Regan
- MRC London Institute of Medical Sciences, Imperial College London, London, UK
| | - Xiao Y Xu
- Department of Chemical Engineering, Imperial College London, London, UK
| | - Thanos Athanasiou
- Department of Surgery and Cancer, Imperial College London, London, UK
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11
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Cocomello L, Meloni M, Rapetto F, Baquedano M, Ordoñez MV, Biglino G, Bucciarelli-Ducci C, Parry A, Stoica S, Caputo M. Long-Term Comparison Between Pulmonary Homograft Versus Bioprosthesis for Pulmonary Valve Replacement in Tetralogy of Fallot. J Am Heart Assoc 2019; 8:e013654. [PMID: 31838974 PMCID: PMC6951084 DOI: 10.1161/jaha.119.013654] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background Tetralogy of Fallot repair results in late occurrence of pulmonary regurgitation, which requires pulmonary valve replacement in a large proportion of patients. Both homografts and bioprostheses are used for pulmonary valve replacement as uncertainty remains on which prosthesis should be considered superior. We performed a long‐term imaging and clinical comparison between these 2 strategies. Methods and Results We compared echocardiographic and clinical follow‐up data of 209 patients with previous tetralogy of Fallot repair who underwent pulmonary valve replacement with homograft (n=75) or bioprosthesis (n=134) between 1995 and 2018 at a tertiary hospital. The primary end point was the composite of pulmonary valve replacement reintervention and structural valve deterioration, defined as a transpulmonary pressure decrease ≥50 mm Hg or pulmonary regurgitation degree of ≥2. Mixed linear model and Cox regression model were used for comparisons. Echocardiographic follow‐up duration was longer in the homograft group (8 [interquartile range, 4–12] versus 4 [interquartile range, 3–6] years; P<0.001). At the latest echocardiographic follow‐up, homografts showed a significantly lower transpulmonary systolic pressure decrease (16 [interquartile range, 12–25] mm Hg) when compared with bioprostheses (28 [interquartile range, 18–41] mm Hg; mixed model P<0.001) and a similar degree of pulmonary regurgitation (degree 0‐4) (1 [interquartile range, 0–2] versus 2 [interquartile range, 0–2]; mixed model P=0.19). At 9 years, freedom from structural valve deterioration and reintervention was 81.6% (95% CI, 71.5%–91.6%) versus 43.4% (95% CI, 23.6%–63.2%) in the homograft and bioprosthesis groups, respectively (adjusted hazard ratio, 0.27; 95% CI, 0.13–0.55; P<0.001). Conclusions When compared with bioprostheses, pulmonary homografts were associated lower transvalvular gradient during follow‐up and were associated with a significantly lower risk of reintervention or structural valve degeneration.
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Affiliation(s)
- Lucia Cocomello
- Bristol Heart Institute University Hospitals Bristol National Health Service Foundation Trust Bristol United Kingdom
| | - Marco Meloni
- Bristol Heart Institute University Hospitals Bristol National Health Service Foundation Trust Bristol United Kingdom
| | - Filippo Rapetto
- Bristol Heart Institute University Hospitals Bristol National Health Service Foundation Trust Bristol United Kingdom
| | - Mai Baquedano
- Bristol Heart Institute University Hospitals Bristol National Health Service Foundation Trust Bristol United Kingdom
| | - Maria Victoria Ordoñez
- Bristol Heart Institute University Hospitals Bristol National Health Service Foundation Trust Bristol United Kingdom
| | - Giovanni Biglino
- Bristol Heart Institute University Hospitals Bristol National Health Service Foundation Trust Bristol United Kingdom
| | - Chiara Bucciarelli-Ducci
- Bristol Heart Institute University Hospitals Bristol National Health Service Foundation Trust Bristol United Kingdom
| | - Andrew Parry
- Bristol Heart Institute University Hospitals Bristol National Health Service Foundation Trust Bristol United Kingdom
| | - Serban Stoica
- Bristol Heart Institute University Hospitals Bristol National Health Service Foundation Trust Bristol United Kingdom
| | - Massimo Caputo
- Bristol Heart Institute University Hospitals Bristol National Health Service Foundation Trust Bristol United Kingdom
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12
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Oechtering TH, Sieren M, Schubert K, Schaller T, Scharfschwerdt M, Panagiotopoulos A, Fujita B, Auer C, Barkhausen J, Ensminger S, Sievers HH, Frydrychowicz A. In vitro 4D Flow MRI evaluation of aortic valve replacements reveals disturbed flow distal to biological but not to mechanical valves. J Card Surg 2019; 34:1452-1457. [PMID: 31638731 DOI: 10.1111/jocs.14253] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIM OF THE STUDY Aortic hemodynamics influence the integrity of the vessel wall and cardiac afterload. The aim of this study was to compare hemodynamics distal to biological (BV) and mechanical aortic valve (MV) replacements by in vitro 4D Flow MRI excluding confounding factors of in-vivo testing potentially influencing hemodynamics. METHODS Two BV (Perimount MagnaEase [Carpentier-Edwards], Trifecta [Abbott]) and two MV (On-X [CryoLife], prototype trileaflet valve) were scanned in a flexible aortic phantom at 3T using a recommended 4D Flow MR sequence. A triphasic aortic flow profile with blood-mimicking fluid was established. Using GTFlow (Gyrotools), area and velocity of the ejection jet were measured. Presence and extent of sinus vortices and secondary flow patterns were graded on a 0 to 3 scale. RESULTS A narrow, accelerated central ejection jet (Area = 27 ± 7% of vessel area, Velocity = 166 ± 13 cm/s; measured at sinotubular junction) was observed in BV as compared to MV (Area = 53 ± 13%, Velocity = 109 ± 21 cm/s). As opposed to MV, the jet distal to BV impacted the outer curvature of the ascending aorta and resulted in large secondary flow patterns (BV: n = 4, grades 3, 3, 2, 1; MV: n = 1, grade 1). Sinus vortices only formed distal to MV. Although physiologically configured, they were larger than normal (grade 3). CONCLUSIONS In contrast to mechanical valves, biological valve replacements induced accelerated and increased flow patterns deviating from physiological ones. While it remains speculative whether this increases the risk of aneurysm formation through wall shear stress changes, findings are contrasted by almost no secondary flow patterns and typical, near-physiological sinus vortex formation distal to mechanical valves.
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Affiliation(s)
- Thekla H Oechtering
- Department of Radiology and Nuclear Medicine, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Malte Sieren
- Department of Radiology and Nuclear Medicine, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Kathrin Schubert
- Department of Cardiac and Thoracic Vascular Surgery, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Tim Schaller
- Department of Cardiac and Thoracic Vascular Surgery, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Michael Scharfschwerdt
- Department of Cardiac and Thoracic Vascular Surgery, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Apostolos Panagiotopoulos
- Department of Radiology and Nuclear Medicine, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Buntaro Fujita
- Department of Cardiac and Thoracic Vascular Surgery, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Christian Auer
- Department of Cardiac and Thoracic Vascular Surgery, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Jörg Barkhausen
- Department of Radiology and Nuclear Medicine, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Stephan Ensminger
- Department of Cardiac and Thoracic Vascular Surgery, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Hans-Hinrich Sievers
- Department of Cardiac and Thoracic Vascular Surgery, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Alex Frydrychowicz
- Department of Radiology and Nuclear Medicine, University Hospital Schleswig-Holstein, Lübeck, Germany
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13
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Johnson EMI, Etemadi M, Malaisrie SC, McCarthy PM, Markl M, Barker AJ. Seismocardiography and 4D flow MRI reveal impact of aortic valve replacement on chest acceleration and aortic hemodynamics. J Card Surg 2019; 35:232-235. [PMID: 31614028 DOI: 10.1111/jocs.14289] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Aortic valve replacement (AVR) is a common treatment for severe aortic valve disease, which can adversely affect blood flow in the aorta. Seismocardiography (SCG) measures physical vibrations at the exterior of the chest, which can be sensitive to altered cardiac function and flow dynamics. Magnetic resonance imaging (MRI) can image blood movement, and it can provide depiction and quantification of aortic flow. Here we present SCG and MRI measurements from before and after AVR and ascending aorta replacement, in the case of a woman with bicuspid aortic valve disease and a dilated ascending aorta. SCG measurements show elevated energy during systole indicating stenotic flow before surgery and lowered systolic energy levels after replacement with a prosthetic valve. MRI shows jetting, helical flow before surgery, and cohesive flow after.
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Affiliation(s)
| | - Mozziyar Etemadi
- Biomedical Engineering, Anesthesiology, Northwestern University, Evanston, Illinois
| | | | | | - Michael Markl
- Radiology, Biomedical Engineering, Northwestern University, Evanston, Illinois
| | - Alex J Barker
- Radiology, Bioengineering, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
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14
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Automatic correction of background phase offset in 4D-flow of great vessels and of the heart in MRI using a third-order surface model. MAGNETIC RESONANCE MATERIALS IN PHYSICS BIOLOGY AND MEDICINE 2019; 32:629-642. [DOI: 10.1007/s10334-019-00765-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 06/03/2019] [Accepted: 06/13/2019] [Indexed: 10/26/2022]
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15
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Rajiah P, Moore A, Saboo S, Goerne H, Ranganath P, MacNamara J, Joshi P, Abbara S. Multimodality Imaging of Complications of Cardiac Valve Surgeries. Radiographics 2019; 39:932-956. [PMID: 31150303 DOI: 10.1148/rg.2019180177] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Replacement with a prosthetic heart valve (PHV) remains the definitive surgical procedure for management of severe cardiac valve disease. PHV dysfunction is uncommon but can be a life-threatening condition. The broad hemodynamic and pathophysiologic manifestations of PHV dysfunction are stenosis, regurgitation, and a stuck leaflet. Specific structural abnormalities that cause PHV dysfunction include prosthetic valve-patient mismatch, structural failure, valve calcification, dehiscence, paravalvular leak, infective endocarditis, abscess, pseudoaneurysm, abnormal connections, thrombus, hypoattenuating leaflet thickening, and pannus. Multiple imaging modalities are available for evaluating a PHV and its dysfunction. Transthoracic echocardiography is often the first-line imaging modality, with additional modalities such as transesophageal echocardiography, CT, MRI, cine fluoroscopy, and nuclear medicine used for further characterization and establishing a specific cause. The authors review PHVs and the role of imaging modalities in evaluation of PHV dysfunction and illustrate the imaging appearances of different complications. Online supplemental material is available for this article. ©RSNA, 2019.
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Affiliation(s)
- Prabhakar Rajiah
- From the Department of Radiology, Division of Cardiothoracic Imaging (P. Rajiah, A.M., S.S., H.G., P. Ranganath., S.A.), and Department of Cardiology (J.M., P.J.), UT Southwestern Medical Center, 5323 Harry Hines Blvd, E6.122G, Mail Code 9316, Dallas, TX 75390-8896; Department of Radiology, UT Health Science Center, San Antonio, Tex (S.S.); IMSS Centro Medico Nacional de Occidente, Guadalajara, Mexico (H.G.); and CID Imaging and Diagnostic Center, Guadalajara, Mexico (H.G.)
| | - Alastair Moore
- From the Department of Radiology, Division of Cardiothoracic Imaging (P. Rajiah, A.M., S.S., H.G., P. Ranganath., S.A.), and Department of Cardiology (J.M., P.J.), UT Southwestern Medical Center, 5323 Harry Hines Blvd, E6.122G, Mail Code 9316, Dallas, TX 75390-8896; Department of Radiology, UT Health Science Center, San Antonio, Tex (S.S.); IMSS Centro Medico Nacional de Occidente, Guadalajara, Mexico (H.G.); and CID Imaging and Diagnostic Center, Guadalajara, Mexico (H.G.)
| | - Sachin Saboo
- From the Department of Radiology, Division of Cardiothoracic Imaging (P. Rajiah, A.M., S.S., H.G., P. Ranganath., S.A.), and Department of Cardiology (J.M., P.J.), UT Southwestern Medical Center, 5323 Harry Hines Blvd, E6.122G, Mail Code 9316, Dallas, TX 75390-8896; Department of Radiology, UT Health Science Center, San Antonio, Tex (S.S.); IMSS Centro Medico Nacional de Occidente, Guadalajara, Mexico (H.G.); and CID Imaging and Diagnostic Center, Guadalajara, Mexico (H.G.)
| | - Harold Goerne
- From the Department of Radiology, Division of Cardiothoracic Imaging (P. Rajiah, A.M., S.S., H.G., P. Ranganath., S.A.), and Department of Cardiology (J.M., P.J.), UT Southwestern Medical Center, 5323 Harry Hines Blvd, E6.122G, Mail Code 9316, Dallas, TX 75390-8896; Department of Radiology, UT Health Science Center, San Antonio, Tex (S.S.); IMSS Centro Medico Nacional de Occidente, Guadalajara, Mexico (H.G.); and CID Imaging and Diagnostic Center, Guadalajara, Mexico (H.G.)
| | - Praveen Ranganath
- From the Department of Radiology, Division of Cardiothoracic Imaging (P. Rajiah, A.M., S.S., H.G., P. Ranganath., S.A.), and Department of Cardiology (J.M., P.J.), UT Southwestern Medical Center, 5323 Harry Hines Blvd, E6.122G, Mail Code 9316, Dallas, TX 75390-8896; Department of Radiology, UT Health Science Center, San Antonio, Tex (S.S.); IMSS Centro Medico Nacional de Occidente, Guadalajara, Mexico (H.G.); and CID Imaging and Diagnostic Center, Guadalajara, Mexico (H.G.)
| | - James MacNamara
- From the Department of Radiology, Division of Cardiothoracic Imaging (P. Rajiah, A.M., S.S., H.G., P. Ranganath., S.A.), and Department of Cardiology (J.M., P.J.), UT Southwestern Medical Center, 5323 Harry Hines Blvd, E6.122G, Mail Code 9316, Dallas, TX 75390-8896; Department of Radiology, UT Health Science Center, San Antonio, Tex (S.S.); IMSS Centro Medico Nacional de Occidente, Guadalajara, Mexico (H.G.); and CID Imaging and Diagnostic Center, Guadalajara, Mexico (H.G.)
| | - Parag Joshi
- From the Department of Radiology, Division of Cardiothoracic Imaging (P. Rajiah, A.M., S.S., H.G., P. Ranganath., S.A.), and Department of Cardiology (J.M., P.J.), UT Southwestern Medical Center, 5323 Harry Hines Blvd, E6.122G, Mail Code 9316, Dallas, TX 75390-8896; Department of Radiology, UT Health Science Center, San Antonio, Tex (S.S.); IMSS Centro Medico Nacional de Occidente, Guadalajara, Mexico (H.G.); and CID Imaging and Diagnostic Center, Guadalajara, Mexico (H.G.)
| | - Suhny Abbara
- From the Department of Radiology, Division of Cardiothoracic Imaging (P. Rajiah, A.M., S.S., H.G., P. Ranganath., S.A.), and Department of Cardiology (J.M., P.J.), UT Southwestern Medical Center, 5323 Harry Hines Blvd, E6.122G, Mail Code 9316, Dallas, TX 75390-8896; Department of Radiology, UT Health Science Center, San Antonio, Tex (S.S.); IMSS Centro Medico Nacional de Occidente, Guadalajara, Mexico (H.G.); and CID Imaging and Diagnostic Center, Guadalajara, Mexico (H.G.)
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16
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Bissell MM, Loudon M, Hess AT, Stoll V, Orchard E, Neubauer S, Myerson SG. Differential flow improvements after valve replacements in bicuspid aortic valve disease: a cardiovascular magnetic resonance assessment. J Cardiovasc Magn Reson 2018; 20:10. [PMID: 29422054 PMCID: PMC5804071 DOI: 10.1186/s12968-018-0431-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 01/26/2018] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Abnormal aortic flow patterns in bicuspid aortic valve disease (BAV) may be partly responsible for the associated aortic dilation. Aortic valve replacement (AVR) may normalize flow patterns and potentially slow the concomitant aortic dilation. We therefore sought to examine differences in flow patterns post AVR. METHODS Ninety participants underwent 4D flow cardiovascular magnetic resonance: 30 BAV patients with prior AVR (11 mechanical, 10 bioprosthetic, 9 Ross procedure), 30 BAV patients with a native aortic valve and 30 healthy subjects. RESULTS The majority of subjects with mechanical AVR or Ross showed normal flow pattern (73% and 67% respectively) with near normal rotational flow values (7.2 ± 3.9 and 10.6 ± 10.5 mm2/ms respectively vs 3.8 ± 3.1 mm2/s for healthy subjects; both p > 0.05); and reduced in-plane wall shear stress (0.19 ± 0.13 N/m2 for mechanical AVR vs. 0.40 ± 0.28 N/m2 for native BAV, p < 0.05). In contrast, all subjects with a bioprosthetic AVR had abnormal flow patterns (mainly marked right-handed helical flow), with comparable rotational flow values to native BAV (20.7 ± 8.8 mm2/ms and 26.6 ± 16.6 mm2/ms respectively, p > 0.05), and a similar pattern for wall shear stress. Data before and after AVR (n = 16) supported these findings: mechanical AVR showed a significant reduction in rotational flow (30.4 ± 16.3 → 7.3 ± 4.1 mm2/ms; p < 0.05) and in-plane wall shear stress (0.47 ± 0.20 → 0.20 ± 0.13 N/m2; p < 0.05), whereas these parameters remained similar in the bioprosthetic AVR group. CONCLUSIONS Abnormal flow patterns in BAV disease tend to normalize after mechanical AVR or Ross procedure, in contrast to the remnant abnormal flow pattern after bioprosthetic AVR. This may in part explain different aortic growth rates post AVR in BAV observed in the literature, but requires confirmation in a prospective study.
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Affiliation(s)
- Malenka M. Bissell
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Headley Way, Oxford, OX3 9DU UK
| | - Margaret Loudon
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Headley Way, Oxford, OX3 9DU UK
| | - Aaron T. Hess
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Headley Way, Oxford, OX3 9DU UK
| | - Victoria Stoll
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Headley Way, Oxford, OX3 9DU UK
| | - Elizabeth Orchard
- Department of Cardiology, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Stefan Neubauer
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Headley Way, Oxford, OX3 9DU UK
| | - Saul G. Myerson
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Headley Way, Oxford, OX3 9DU UK
- Department of Cardiology, Oxford University Hospitals NHS Trust, Oxford, UK
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17
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Bollache E, Fedak PWM, van Ooij P, Rahman O, Malaisrie SC, McCarthy PM, Carr JC, Powell A, Collins JD, Markl M, Barker AJ. Perioperative evaluation of regional aortic wall shear stress patterns in patients undergoing aortic valve and/or proximal thoracic aortic replacement. J Thorac Cardiovasc Surg 2017; 155:2277-2286.e2. [PMID: 29248286 DOI: 10.1016/j.jtcvs.2017.11.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 10/11/2017] [Accepted: 11/06/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVES To assess in patients with aortopathy perioperative changes in thoracic aortic wall shear stress (WSS), which is known to affect arterial remodeling, and the effects of specific surgical interventions. METHODS Presurgical and postsurgical aortic 4D flow MRI were performed in 33 patients with aortopathy (54 ± 14 years; 5 women; sinus of Valsalva (d_SOV)/midascending aortic (d_MAA) diameters = 44 ± 5/45 ± 6 mm) scheduled for aortic valve (AVR) and/or root (ARR) replacement. Control patients with aortopathy who did not have surgery were matched for age, sex, body size, and d_MAA (n = 20: 52 ± 14 years; 3 women; d_SOV/d_MAA = 42 ± 4/42 ± 4 mm). Regional aortic 3D systolic peak WSS was calculated. An atlas of WSS normal values was used to quantify the percentage of at-risk tissue area with abnormally high WSS, excluding the area to be resected/graft. RESULTS Peak WSS and at-risk area showed low interobserver variability (≤0.09 [-0.3; 0.5] Pa and 1.1% [-7%; 9%], respectively). In control patients, WSS was stable over time (follow-up-baseline differences ≤0.02 Pa and 0.0%, respectively). Proximal aortic WSS decreased after AVR (n = 5; peak WSS difference ≤-0.41 Pa and at-risk area ≤-10%, P < .05 vs controls). WSS was increased after ARR in regions distal to the graft (peak WSS difference ≥0.16 Pa and at-risk area ≥4%, P < .05 vs AVR). Follow-up duration had no significant effects on these WSS changes, except when comparing ascending aortic peak WSS between ARR and AVR (P = .006). CONCLUSIONS Serial perioperative 4D flow MRI investigations showed distinct patterns of postsurgical changes in aortic WSS, which included both reductions and translocations. Larger longitudinal studies are warranted to validate these findings with clinical outcomes and prediction of risk of future aortic events.
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Affiliation(s)
- Emilie Bollache
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Ill
| | - Paul W M Fedak
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Division of Surgery-Cardiac Surgery, Northwestern University, Chicago, Ill
| | - Pim van Ooij
- Department of Radiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Ozair Rahman
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Ill
| | - S Chris Malaisrie
- Division of Surgery-Cardiac Surgery, Northwestern University, Chicago, Ill
| | - Patrick M McCarthy
- Division of Surgery-Cardiac Surgery, Northwestern University, Chicago, Ill
| | - James C Carr
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Ill
| | - Alex Powell
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Ill
| | - Jeremy D Collins
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Ill
| | - Michael Markl
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Ill; Department of Biomedical Engineering, McCormick School of Engineering, Northwestern University, Chicago, Ill
| | - Alex J Barker
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Ill.
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18
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Itatani K, Miyazaki S, Furusawa T, Numata S, Yamazaki S, Morimoto K, Makino R, Morichi H, Nishino T, Yaku H. New imaging tools in cardiovascular medicine: computational fluid dynamics and 4D flow MRI. Gen Thorac Cardiovasc Surg 2017; 65:611-621. [PMID: 28929446 DOI: 10.1007/s11748-017-0834-5] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 09/06/2017] [Indexed: 11/28/2022]
Abstract
Blood flow imaging is a novel technology in cardiovascular medicine and surgery. Today, two types of blood flow imaging tools are available: measurement-based flow visualization including 4D flow MRI (or 3D cine phase-contrast magnetic resonance imaging), or echocardiography flow visualization software, and computer flow simulation modeling based on computational fluid dynamics (CFD). MRI and echocardiography flow visualization provide measured blood flow but have limitations in temporal and spatial resolution, whereas CFD flow calculates the flow according to assumptions instead of flow measurement, and it has sufficiently fine resolution up to the computer memory limit, and it enables even virtual surgery when combined with computer graphics. Blood flow imaging provides profound insight into the pathophysiology of cardiovascular diseases, because it quantifies and visualizes mechanical stress on the vessel walls or heart ventricle. Wall shear stress (WSS) is a stress on the endothelial wall caused by the near wall blood flow, and it is thought to be a predictor of atherosclerosis progression in coronary or aortic diseases. Flow energy loss (EL) is the loss of blood flow energy caused by viscous friction of turbulent diseased flow, and it is expected to be a predictor of ventricular workload on various heart diseases including heart valve disease, cardiomyopathy, and congenital heart diseases. Blood flow imaging can provide useful information for developing predictive medicine in cardiovascular diseases, and may lead to breakthroughs in cardiovascular surgery, especially in the decision-making process.
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Affiliation(s)
- Keiichi Itatani
- Department of Cardiovascular Surgery, Cardiovascular Imaging Research Laboratory, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji Kajicho 465, Kamigyo-ku, Kyoto, 602-8566, Japan.
| | | | | | - Satoshi Numata
- Department of Cardiovascular Surgery, Cardiovascular Imaging Research Laboratory, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji Kajicho 465, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Sachiko Yamazaki
- Department of Cardiovascular Surgery, Cardiovascular Imaging Research Laboratory, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji Kajicho 465, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Kazuki Morimoto
- Department of Cardiovascular Surgery, Cardiovascular Imaging Research Laboratory, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji Kajicho 465, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Rina Makino
- Department of Cardiovascular Surgery, Cardiovascular Imaging Research Laboratory, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji Kajicho 465, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Hiroko Morichi
- Department of Cardiovascular Surgery, Cardiovascular Imaging Research Laboratory, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji Kajicho 465, Kamigyo-ku, Kyoto, 602-8566, Japan
| | | | - Hitoshi Yaku
- Department of Cardiovascular Surgery, Cardiovascular Imaging Research Laboratory, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji Kajicho 465, Kamigyo-ku, Kyoto, 602-8566, Japan
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