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Govindarajan V, Wanna C, Johnson NP, Kolanjiyil AV, Kim H, Kitkungvan D, McPherson DM, Grande-Allen J, Chandran KB, Estrera A, Ramzy D, Prakash S. Unraveling aortic hemodynamics using fluid structure interaction: biomechanical insights into bicuspid aortic valve dynamics with multiple aortic lesions. Biomech Model Mechanobiol 2024:10.1007/s10237-024-01892-w. [PMID: 39365514 DOI: 10.1007/s10237-024-01892-w] [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: 05/22/2024] [Accepted: 09/22/2024] [Indexed: 10/05/2024]
Abstract
Aortic lesions, exemplified by bicuspid aortic valves (BAVs), can complicate congenital heart defects, particularly in Turner syndrome patients. The combination of BAV, dilated ascending aorta, and an elongated aortic arch presents complex hemodynamics, requiring detailed analysis for tailored treatment strategies. While current clinical decision-making relies on imaging modalities offering limited biomechanical insights, integrating high-performance computing and fluid-structure interaction algorithms with patient data enables comprehensive evaluation of diseased anatomy and planned intervention. In this study, a patient-specific workflow was utilized to biomechanically assess a Turner syndrome patient's BAV, dilated ascending aorta, and elongated arch. Results showed significant improvements in valve function (effective orifice area, EOA increased approximately twofold) and reduction in valve stress (~ 1.8-fold) following virtual commissurotomy, leading to enhanced flow dynamics and decreased viscous dissipation (~ twofold) particularly in the ascending aorta. However, increased viscous dissipation in the distal transverse aortic arch offset its local reduction in the AAo post-intervention, emphasizing the elongated arch's role in aortic hemodynamics. Our findings highlight the importance of comprehensive biomechanical evaluation and integrating patient-specific modeling with conventional imaging techniques for improved disease assessment, risk stratification, and treatment planning, ultimately enhancing patient outcomes.
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Affiliation(s)
- Vijay Govindarajan
- Division of Cardiology, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, 1881 East Road, Houston, TX, 77054, USA.
- Boston Children's Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Charles Wanna
- Division of Cardiology, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, 1881 East Road, Houston, TX, 77054, USA
| | - Nils P Johnson
- Division of Cardiology, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, 1881 East Road, Houston, TX, 77054, USA
| | | | | | - Danai Kitkungvan
- Division of Cardiology, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, 1881 East Road, Houston, TX, 77054, USA
| | - David M McPherson
- Division of Cardiology, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, 1881 East Road, Houston, TX, 77054, USA
| | | | - Krishnan B Chandran
- Division of Cardiology, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, 1881 East Road, Houston, TX, 77054, USA
- The University of Iowa, Iowa City, IA, USA
| | - Antony Estrera
- Division of Cardiology, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, 1881 East Road, Houston, TX, 77054, USA
| | - Danny Ramzy
- Division of Cardiology, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, 1881 East Road, Houston, TX, 77054, USA
| | - Siddharth Prakash
- Division of Cardiology, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, 1881 East Road, Houston, TX, 77054, USA
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2
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Kaiser AD, Haidar MA, Choi PS, Sharir A, Marsden AL, Ma MR. Simulation-based design of bicuspidization of the aortic valve. J Thorac Cardiovasc Surg 2024; 168:923-932.e4. [PMID: 38211896 DOI: 10.1016/j.jtcvs.2023.12.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 12/05/2023] [Accepted: 12/21/2023] [Indexed: 01/13/2024]
Abstract
OBJECTIVE Severe congenital aortic valve pathology in the growing patient remains a challenging clinical scenario. Bicuspidization of the diseased aortic valve has proven to be a promising repair technique with acceptable durability. However, most understanding of the procedure is empirical and retrospective. This work seeks to design the optimal gross morphology associated with surgical bicuspidization with simulations based on the hypothesis that modifications to the free edge length cause or relieve stenosis. METHODS Model bicuspid valves were constructed with varying free edge lengths and gross morphology. Fluid-structure interaction simulations were conducted in a single patient-specific model geometry. The models were evaluated for primary targets of stenosis and regurgitation. Secondary targets were assessed and included qualitative hemodynamics, geometric height, effective height, orifice area, and billow. RESULTS Stenosis decreased with increasing free edge length and was pronounced with free edge length less than or equal to 1.3 times the annular diameter d. With free edge length 1.5d or greater, no stenosis occurred. All models were free of regurgitation. Substantial billow occurred with free edge length 1.7d or greater. CONCLUSIONS Free edge length 1.5d or greater was required to avoid aortic stenosis in simulations. Cases with free edge length 1.7d or greater showed excessive billow and other changes in gross morphology. Cases with free edge length 1.5d to 1.6d have a total free edge length approximately equal to the annular circumference and appeared optimal. These effects should be studied in vitro and in animal studies.
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Affiliation(s)
- Alexander D Kaiser
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Stanford, Calif; Cardiovascular Institute, Stanford University, Stanford, Calif
| | - Moussa A Haidar
- Division of Pediatric Cardiac Surgery, Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
| | - Perry S Choi
- Division of Pediatric Cardiac Surgery, Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
| | - Amit Sharir
- Division of Pediatric Cardiac Surgery, Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
| | - Alison L Marsden
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Stanford, Calif; Cardiovascular Institute, Stanford University, Stanford, Calif; Department of Bioengineering, Stanford University, Stanford, Calif; Institute for Computational and Mathematical Engineering, Stanford University, Stanford, Calif
| | - Michael R Ma
- Cardiovascular Institute, Stanford University, Stanford, Calif; Division of Pediatric Cardiac Surgery, Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif.
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Qin T, Mao W, Caballero A, Kamioka N, Lerakis S, Lain S, Elefteriades J, Liang L, Sun W. Patient-specific analysis of bicuspid aortic valve hemodynamics using a fully coupled fluid-structure interaction model. Comput Biol Med 2024; 172:108191. [PMID: 38457932 DOI: 10.1016/j.compbiomed.2024.108191] [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: 09/29/2023] [Revised: 01/10/2024] [Accepted: 02/18/2024] [Indexed: 03/10/2024]
Abstract
Bicuspid aortic valve (BAV), the most common congenital heart disease, is prone to develop significant valvular dysfunction and aortic wall abnormalities such as ascending aortic aneurysm. Growing evidence has suggested that abnormal BAV hemodynamics could contribute to disease progression. In order to investigate BAV hemodynamics, we performed 3D patient-specific fluid-structure interaction (FSI) simulations with fully coupled blood flow dynamics and valve motion throughout the cardiac cycle. Results showed that the hemodynamics during systole can be characterized by a systolic jet and two counter-rotating recirculation vortices. At peak systole, the jet was usually eccentric, with asymmetric recirculation vortices and helical flow motion in the ascending aorta. The flow structure at peak systole was quantified using the vorticity, flow rate reversal ratio and local normalized helicity (LNH) at four locations from the aortic root to the ascending aorta. The systolic jet was evaluated with the peak velocity, normalized flow displacement, and jet angle. It was found that peak velocity and normalized flow displacement (rather than jet angle) gave a strong correlation with the vorticity and LNH in the ascending aorta, which suggests that these two metrics could be used for clinical noninvasive evaluation of abnormal blood flow patterns in BAV patients.
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Affiliation(s)
- Tongran Qin
- Tissue Mechanics Laboratory, The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA; Sutra Medical Inc, Lake Forest, CA, USA
| | - Wenbin Mao
- Mechanical Engineering, University of South Florida, FL, USA
| | - Andrés Caballero
- Tissue Mechanics Laboratory, The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA; PAI+ Research Group, Mechanical Engineering Department, Universidad Autónoma de Occidente, Cali, Colombia
| | | | - Stamatios Lerakis
- Emory University, School of Medicine, Atlanta, GA, USA; Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Santiago Lain
- PAI+ Research Group, Mechanical Engineering Department, Universidad Autónoma de Occidente, Cali, Colombia
| | - John Elefteriades
- Aortic Institute, School of Medicine, Yale University, New Haven, CT, USA
| | - Liang Liang
- Department of Computer Science, University of Miami, Coral Gables, FL, USA
| | - Wei Sun
- Tissue Mechanics Laboratory, The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA; Sutra Medical Inc, Lake Forest, CA, USA.
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4
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Morany A, Lavon K, Gomez Bardon R, Kovarovic B, Hamdan A, Bluestein D, Haj-Ali R. Fluid-structure interaction modeling of compliant aortic valves using the lattice Boltzmann CFD and FEM methods. Biomech Model Mechanobiol 2023; 22:837-850. [PMID: 36763197 DOI: 10.1007/s10237-022-01684-0] [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: 08/07/2022] [Accepted: 12/28/2022] [Indexed: 02/11/2023]
Abstract
The lattice Boltzmann method (LBM) has been increasingly used as a stand-alone CFD solver in various biomechanical applications. This study proposes a new fluid-structure interaction (FSI) co-modeling framework for the hemodynamic-structural analysis of compliant aortic valves. Toward that goal, two commercial software packages are integrated using the lattice Boltzmann (LBM) and finite element (FE) methods. The suitability of the LBM-FE hemodynamic FSI is examined in modeling healthy tricuspid and bicuspid aortic valves (TAV and BAV), respectively. In addition, a multi-scale structural approach that has been employed explicitly recognizes the heterogeneous leaflet tissues and differentiates between the collagen fiber network (CFN) embedded within the elastin matrix of the leaflets. The CFN multi-scale tissue model is inspired by monitoring the distribution of the collagen in 15 porcine leaflets. Different simulations have been examined, and structural stresses and resulting hemodynamics are analyzed. We found that LBM-FE FSI approach can produce good predictions for the flow and structural behaviors of TAV and BAV and correlates well with those reported in the literature. The multi-scale heterogeneous CFN tissue structural model enhances our understanding of the mechanical roles of the CFN and the elastin matrix behaviors. The importance of LBM-FE FSI also emerges in its ability to resolve local hemodynamic and structural behaviors. In particular, the diastolic fluctuating velocity phenomenon near the leaflets is explicitly predicted, providing vital information on the flow transient nature. The full closure of the contacting leaflets in BAV is also demonstrated. Accordingly, good structural kinematics and deformations are captured for the entire cardiac cycle.
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Affiliation(s)
- Adi Morany
- School of Mechanical Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Karin Lavon
- School of Mechanical Engineering, Tel Aviv University, Tel Aviv, Israel
| | | | - Brandon Kovarovic
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, USA
| | - Ashraf Hamdan
- Department of Cardiology, Rabin Medical Center, Petach Tikva, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Danny Bluestein
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, USA
| | - Rami Haj-Ali
- School of Mechanical Engineering, Tel Aviv University, Tel Aviv, Israel. .,Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, USA.
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García-Galindo A, Agujetas R, López-Mínguez JR, Ferrera C. Assessment of valve implantation in the descending aorta as an alternative for aortic regurgitation patients not treatable with conventional procedures. Biomech Model Mechanobiol 2022; 22:575-591. [PMID: 36550245 PMCID: PMC10097802 DOI: 10.1007/s10237-022-01665-3] [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: 09/15/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Aortic Regurgitation (AR) produces the entrance of an abnormal amount of blood in the left ventricle. This disease is responsible for high morbidity and mortality worldwide and may be caused by an aortic valve dysfunction. Surgical and transcatheter aortic valve replacement (TAVR) are the current options for treating AR. They have replaced older procedures such as Hufnagel's one. However, some physicians have reconsidered this procedure as a less aggressive alternative for patients not eligible for surgical or TAVR. Although Hufnagel suggested a 75% regurgitation reduction when a valve is placed in the descending aorta, a quantification of this value has not been reported. METHODS In this paper, CFD/FSI numerical simulation is conducted on an idealized geometry. We quantify the effect of placing a bileaflet mechanical heart valve in the descending aorta on a moderate-severe AR case. A three-element Windkessel model is employed to prescribe pressure outlet boundary conditions. We calculate the resulting flow rates and pressures at the aorta and first-generation vessels. Moreover, we evaluate several indices to assess the improvement due to the valve introduction. RESULTS AND CONCLUSIONS Regurgitation fraction (RF) is reduced from 37.5% (without valve) to 18.0% (with valve) in a single cardiac cycle. This reduction clearly shows the remarkable efficacy of the rescued technique. It will further ameliorate the left ventricle function in the long-term. Moreover, the calculations show that the implantation in that location introduces fewer incompatibilities' risks than a conventional one. The proposed methodology can be extended to any particular conditions (pressure waveforms/geometry) and is designed to assess usual clinical parameters employed by physicians.
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Affiliation(s)
- A García-Galindo
- Departamento de Ingeniería Mecánica, Energética y de los Materiales and Instituto de Computación Científica Avanzada (ICCAEx), Universidad de Extremadura, E-06006, Badajoz, Spain
| | - R Agujetas
- Departamento de Ingeniería Mecánica, Energética y de los Materiales and Instituto de Computación Científica Avanzada (ICCAEx), Universidad de Extremadura, E-06006, Badajoz, Spain
| | - J R López-Mínguez
- Sección de Cardiologıa Intervencionista, Servicio de Cardiologıa, Hospital Universitario de Badajoz, Avda. de Elvas s/n, E-06006, Badajoz, Spain
| | - C Ferrera
- Departamento de Ingeniería Mecánica, Energética y de los Materiales and Instituto de Computación Científica Avanzada (ICCAEx), Universidad de Extremadura, E-06006, Badajoz, Spain.
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Kaiser AD, Shad R, Schiavone N, Hiesinger W, Marsden AL. Controlled Comparison of Simulated Hemodynamics Across Tricuspid and Bicuspid Aortic Valves. Ann Biomed Eng 2022; 50:1053-1072. [PMID: 35748961 PMCID: PMC10775905 DOI: 10.1007/s10439-022-02983-4] [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: 10/13/2021] [Accepted: 05/16/2022] [Indexed: 11/01/2022]
Abstract
Bicuspid aortic valve is the most common congenital heart defect, affecting 1-2% of the global population. Patients with bicuspid valves frequently develop dilation and aneurysms of the ascending aorta. Both hemodynamic and genetic factors are believed to contribute to dilation, yet the precise mechanism underlying this progression remains under debate. Controlled comparisons of hemodynamics in patients with different forms of bicuspid valve disease are challenging because of confounding factors, and simulations offer the opportunity for direct and systematic comparisons. Using fluid-structure interaction simulations, we simulate flows through multiple aortic valve models in a patient-specific geometry. The aortic geometry is based on a healthy patient with no known aortic or valvular disease, which allows us to isolate the hemodynamic consequences of changes to the valve alone. Four fully-passive, elastic model valves are studied: a tricuspid valve and bicuspid valves with fusion of the left- and right-, right- and non-, and non- and left-coronary cusps. The resulting tricuspid flow is relatively uniform, with little secondary or reverse flow, and little to no pressure gradient across the valve. The bicuspid cases show localized jets of forward flow, excess streamwise momentum, elevated secondary and reverse flow, and clinically significant levels of stenosis. Localized high flow rates correspond to locations of dilation observed in patients, with the location related to which valve cusps are fused. Thus, the simulations support the hypothesis that chronic exposure to high local flow contributes to localized dilation and aneurysm formation.
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Affiliation(s)
- Alexander D Kaiser
- Institute for Computational & Mathematical Engineering, Stanford University, Stanford, CA, USA
- Department of Pediatrics (Cardiology), Stanford University, Stanford, CA, USA
- Stanford Cardiovascular Institute, Stanford, CA, USA
| | - Rohan Shad
- Stanford Cardiovascular Institute, Stanford, CA, USA
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
| | - Nicole Schiavone
- Department of Mechanical Engineering, Stanford University, Stanford, CA, USA
| | - William Hiesinger
- Stanford Cardiovascular Institute, Stanford, CA, USA
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
| | - Alison L Marsden
- Institute for Computational & Mathematical Engineering, Stanford University, Stanford, CA, USA.
- Department of Pediatrics (Cardiology), Stanford University, Stanford, CA, USA.
- Stanford Cardiovascular Institute, Stanford, CA, USA.
- Department of Mechanical Engineering, Stanford University, Stanford, CA, USA.
- Department of Bioengineering, Stanford University, Stanford, CA, USA.
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7
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Hou Q, Tao K, Du T, Wei H, Zhang H, Chen S, Pan Y, Qiao A. A computational analysis of potential aortic dilation induced by the hemodynamic effects of bicuspid aortic valve phenotypes. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2022; 220:106811. [PMID: 35447428 DOI: 10.1016/j.cmpb.2022.106811] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 03/01/2022] [Accepted: 04/10/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND AND OBJECTIVES The bicuspid aortic valve (BAV) is a major risk factor for the progression of aortic dilation (AD) because of the induced abnormal blood flow environment in aorta. The differences in the development of AD induced by BAV phenotypes remains unclear. Therefore, the objective of this study was to assess the potential locations of AD induced by different phenotypes of BAV. The different effects of opening orifice area and leaflet orientation on ascending aortic hemodynamics in Type-1 BAV was investigated by means of numerical simulation. METHODS Finite element dynamic analysis was performed on tricuspid aortic valve (TAV) and BAV models to simulate the motion of the leaflets and obtain the geometrical characteristics of AV at peak systole as a reference, which were used for aortic models. Then, four sets of aortic fluid models were designed according to the leaflet fusion types [TAV; BAV (left-right-coronary cusp fusion, LR; right-non-coronary cusp fusion, RN; left-non-coronary cusp fusion, LN)], and the computational fluid dynamics method was applied to compare the hemodynamic differences within the aorta at peak systole. RESULTS The maximum opening area of BAV was significantly reduced, resulting in alterations in aortic hemodynamics compared with TAV. The velocity streamlines were essentially parallel to the aortic wall in TAV. The average pressure and wall shear stress in aorta tend to be stable. In contrary, the eccentricity of BAV orifice jet resulted in high-velocity flow directed toward the ascending aorta (AA) wall and aortic arch for LR and LN; RN features an asymmetrical velocity distribution toward the outer bend of the middle AA, and eccentric flow tends to impact the distal AA. As the flow angle is associated with distinct flow impingement locations, different degrees of WSS and pressure concentration occur along the aortic wall from the AA to the aortic arch in three BAV types. CONCLUSIONS The BAV morphotype affects the aortic hemodynamics, and the abnormal blood flow associated with BAV may play a role in AD. The different BAV phenotypes determine the direction of blood flow jet and change the expression of dilation. LR is likely to cause dilation of the tubular AA; RN results in dilation of the middle AA to proximal aortic arch; and LN causes an increased incidence of the tubular AA and the proximal aortic arch.
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Affiliation(s)
- Qianwen Hou
- Faculty of Environment and Life, Beijing University of Technology, Beijing, China; Intelligent Physiological Measurement and Clinical Translation, Beijing International Base for Scientific and Technological Cooperation, Beijing, China
| | - Keyi Tao
- Faculty of Environment and Life, Beijing University of Technology, Beijing, China; Intelligent Physiological Measurement and Clinical Translation, Beijing International Base for Scientific and Technological Cooperation, Beijing, China
| | - Tianming Du
- Faculty of Environment and Life, Beijing University of Technology, Beijing, China; Intelligent Physiological Measurement and Clinical Translation, Beijing International Base for Scientific and Technological Cooperation, Beijing, China.
| | - Hongge Wei
- Faculty of Environment and Life, Beijing University of Technology, Beijing, China; Intelligent Physiological Measurement and Clinical Translation, Beijing International Base for Scientific and Technological Cooperation, Beijing, China
| | - Honghui Zhang
- Faculty of Environment and Life, Beijing University of Technology, Beijing, China; Intelligent Physiological Measurement and Clinical Translation, Beijing International Base for Scientific and Technological Cooperation, Beijing, China
| | - Shiliang Chen
- Faculty of Environment and Life, Beijing University of Technology, Beijing, China; Intelligent Physiological Measurement and Clinical Translation, Beijing International Base for Scientific and Technological Cooperation, Beijing, China
| | - Youlian Pan
- Faculty of Environment and Life, Beijing University of Technology, Beijing, China; Intelligent Physiological Measurement and Clinical Translation, Beijing International Base for Scientific and Technological Cooperation, Beijing, China
| | - Aike Qiao
- Faculty of Environment and Life, Beijing University of Technology, Beijing, China; Intelligent Physiological Measurement and Clinical Translation, Beijing International Base for Scientific and Technological Cooperation, Beijing, China.
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Computational Methods for Fluid-Structure Interaction Simulation of Heart Valves in Patient-Specific Left Heart Anatomies. FLUIDS 2022. [DOI: 10.3390/fluids7030094] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Given the complexity of human left heart anatomy and valvular structures, the fluid–structure interaction (FSI) simulation of native and prosthetic valves poses a significant challenge for numerical methods. In this review, recent numerical advancements for both fluid and structural solvers for heart valves in patient-specific left hearts are systematically considered, emphasizing the numerical treatments of blood flow and valve surfaces, which are the most critical aspects for accurate simulations. Numerical methods for hemodynamics are considered under both the continuum and discrete (particle) approaches. The numerical treatments for the structural dynamics of aortic/mitral valves and FSI coupling methods between the solid Ωs and fluid domain Ωf are also reviewed. Future work toward more advanced patient-specific simulations is also discussed, including the fusion of high-fidelity simulation within vivo measurements and physics-based digital twining based on data analytics and machine learning techniques.
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9
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Karnibad M, Sharabi M, Lavon K, Morany A, Hamdan A, Haj-Ali R. The effect of the fibrocalcific pathological process on aortic valve stenosis in female patients: a finite element study. Biomed Phys Eng Express 2022; 8. [PMID: 35120335 DOI: 10.1088/2057-1976/ac5223] [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: 11/10/2021] [Accepted: 02/04/2022] [Indexed: 11/11/2022]
Abstract
Calcific aortic valve disease (CAVD) is the most common heart valvular disease in the developed world. Most of the relevant research has been sex-blind, ignoring sex-related biological variables and thus under-appreciate sex differences. However, females present pronounced fibrosis for the same aortic stenosis (AS) severity compared with males, who exhibit more calcification. Herein, we present a computational model of fibrocalcific AV, aiming to investigate its effect on AS development. A parametric study was conducted to explore the influence of the total collagen fiber volume and its architecture on the aortic valve area (AVA). Towards that goal, computational models were generated for three females with stenotic AVs and different volumes of calcium. We have tested the influence of fibrosis on various parameters as fiber architecture, fibrosis location, and transvalvular pressure. We found that increased fiber volume with a low calcium volume could actively contribute to AS and reduce the AVA similarly to high calcium volume. Thus, the computed AVAs for our fibrocalcific models were 0.94 and 0.84 cm2and the clinical (Echo) AVAs were 0.82 and 0.8 cm2. For the heavily calcified model, the computed AVA was 0.8 cm2and the clinical AVA was 0.73 cm2. The proposed models demonstrated how collagen thickening influence the fibrocalcific-AS process in female patients. These models can assist in the clinical decision-making process and treatment development in valve therapy for female patients.
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Affiliation(s)
- Maya Karnibad
- Tel Aviv University, School of Mechanical Engineering, Tel Aviv, 69978, ISRAEL
| | - Mirit Sharabi
- Ariel University, Department of Mechanical engineering and Mechatronics, Ariel, 407000, ISRAEL
| | - Karin Lavon
- Tel Aviv University, School of Mechanical Engineering, Tel Aviv, 69978, ISRAEL
| | - Adi Morany
- Tel Aviv University, School of Mechanical Engineering, Tel Aviv, 69978, ISRAEL
| | - Ashraf Hamdan
- Tel Aviv University, Department of Cardiology, Rabin Medical Center, Tel Aviv, 69978, ISRAEL
| | - Rami Haj-Ali
- Tel Aviv University, School of Mechanical Engineering, Tel Aviv, 69978, ISRAEL
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10
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Sadeghi R, Tomka B, Khodaei S, Garcia J, Ganame J, Keshavarz‐Motamed Z. Reducing Morbidity and Mortality in Patients With Coarctation Requires Systematic Differentiation of Impacts of Mixed Valvular Disease on Coarctation Hemodynamics. J Am Heart Assoc 2022; 11:e022664. [PMID: 35023351 PMCID: PMC9238522 DOI: 10.1161/jaha.121.022664] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Background Despite ongoing advances in surgical techniques for coarctation of the aorta (COA) repair, the long-term results are not always benign. Associated mixed valvular diseases (various combinations of aortic and mitral valvular pathologies) are responsible for considerable postoperative morbidity and mortality. We investigated the impact of COA and mixed valvular diseases on hemodynamics. Methods and Results We developed a patient-specific computational framework. Our results demonstrate that mixed valvular diseases interact with COA fluid dynamics and contribute to speed up the progression of the disease by amplifying the irregular flow patterns downstream of COA (local) and exacerbating the left ventricular function (global) (N=26). Velocity downstream of COA with aortic regurgitation alone was increased, and the situation got worse when COA and aortic regurgitation coexisted with mitral regurgitation (COA with normal valves: 5.27 m/s, COA with only aortic regurgitation: 8.8 m/s, COA with aortic and mitral regurgitation: 9.36 m/s; patient 2). Workload in these patients was increased because of the presence of aortic stenosis alone, aortic regurgitation alone, mitral regurgitation alone, and when they coexisted (COA with normal valves: 1.0617 J; COA with only aortic stenosis: 1.225 J; COA with only aortic regurgitation: 1.6512 J; COA with only mitral regurgitation: 1.3599 J; patient 1). Conclusions Not only the severity of COA, but also the presence and the severity of mixed valvular disease should be considered in the evaluation of risks in patients. The results suggest that more aggressive surgical approaches may be required, because regularly chosen current surgical techniques may not be optimal for such patients.
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Affiliation(s)
- Reza Sadeghi
- Department of Mechanical EngineeringMcMaster UniversityHamiltonOntarioCanada
| | - Benjamin Tomka
- Department of Mechanical EngineeringMcMaster UniversityHamiltonOntarioCanada
| | - Seyedvahid Khodaei
- Department of Mechanical EngineeringMcMaster UniversityHamiltonOntarioCanada
| | - Julio Garcia
- Stephenson Cardiac Imaging CentreLibin Cardiovascular Institute of AlbertaCalgaryAlbertaCanada,Department of RadiologyUniversity of CalgaryCalgaryAlbertaCanada,Department of Cardiac SciencesUniversity of CalgaryCalgaryAlbertaCanada,Alberta Children’s Hospital Research InstituteCalgaryAlbertaCanada
| | - Javier Ganame
- Division of CardiologyDepartment of MedicineMcMaster UniversityHamiltonOntarioCanada
| | - Zahra Keshavarz‐Motamed
- Department of Mechanical EngineeringMcMaster UniversityHamiltonOntarioCanada,School of Biomedical EngineeringMcMaster UniversityHamiltonOntarioCanada,School of Computational Science and EngineeringMcMaster UniversityHamiltonOntarioCanada,The Thrombosis & Atherosclerosis Research InstituteMcMaster UniversityHamiltonOntarioCanada
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11
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Progressive Calcification in Bicuspid Valves: A Coupled Hemodynamics and Multiscale Structural Computations. Ann Biomed Eng 2021; 49:3310-3322. [PMID: 34708308 DOI: 10.1007/s10439-021-02877-x] [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: 05/09/2021] [Accepted: 10/13/2021] [Indexed: 10/20/2022]
Abstract
Bicuspid aortic valve (BAV) is the most common congenital heart disease. Calcific aortic valve disease (CAVD) accounts for the majority of aortic stenosis (AS) cases. Half of the patients diagnosed with AS have a BAV, which has an accelerated progression rate. This study aims to develop a computational modeling approach of both the calcification progression in BAV, and its biomechanical response incorporating fluid-structure interaction (FSI) simulations during the disease progression. The calcification is patient-specifically reconstructed from Micro-CT images of excised calcified BAV leaflets, and processed with a novel reverse calcification technique that predicts prior states of CAVD using a density-based criterion, resulting in a multilayered calcified structure. Four progressive multilayered calcified BAV models were generated: healthy, mild, moderate, and severe, and were modeled by FSI simulations during the full cardiac cycle. A valve apparatus model, composed of the excised calcified BAV leaflets, was tested in an in-vitro pulse duplicator, to validate the severe model. The healthy model was validated against echocardiography scans. Progressive AS was characterized by higher systolic jet flow velocities (2.08, 2.3, 3.37, and 3.85 m s-1), which induced intense vortices surrounding the jet, coupled with irregular recirculation backflow patterns that elevated viscous shear stresses on the leaflets. This study shed light on the fluid-structure mechanism that drives CAVD progression in BAV patients.
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12
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Froede L, Schäfers S, Wagenpfeil G, Raddatz A, Hoffmann K, Schäfers HJ. Simplified determination of commissural orientation in bicuspid aortic valves. Eur J Cardiothorac Surg 2021; 58:1153-1160. [PMID: 32864689 DOI: 10.1093/ejcts/ezaa230] [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: 04/10/2020] [Revised: 05/16/2020] [Accepted: 05/26/2020] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES In bicuspid aortic valves (BAV), commissural orientation (CO) varies between 180° and close to 120°. Postoperative CO has a strong effect on repair durability, and different repair approaches have been proposed according to CO; it is thus important for aortic repair. A precise, simple and reproducible determination by preoperative echocardiography would facilitate intraoperative decision-making. We compared 4 different methods of determination of CO in BAV. METHODS Preoperative transoesophageal echocardiograms of 62 patients with BAV were analysed. CO was measured using either the coaptation centre or the geometric centre of the root. The geometric centre of the root was determined through approximation using a circle or an ellipse, or the midpoint of a line between the centre of the non-fused and the fused sinuses. RESULTS The 3 different geometric methods led to almost identical results (interclass coefficient 0.98-0.99), with the line segment being the easiest to use. The use of the coaptation centre was associated with the underestimation of commissural angle of up to 30° compared to the geometric centre; the discrepancy was significant and most pronounced for asymmetric BAV (140-160°; P = 0.005). CONCLUSIONS CO can reproducibly be determined using a line segment between the centre of the non-fused and fused sinuses. The use of the coaptation centre can lead to misleading results, in particular in asymmetric BAVs.
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Affiliation(s)
- Lennart Froede
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Germany
| | - Sebastian Schäfers
- Industrial Organization, Faculty of Business and Economics, University of Basel, Basel, Switzerland
| | - Gudrun Wagenpfeil
- Institute for Biometrics, Saarland University Medical Center, Homburg, Germany
| | - Alexander Raddatz
- Department of Anesthesia, Saarland University Medical Center, Homburg, Germany
| | - Klaus Hoffmann
- Department of Anesthesia, Saarland University Medical Center, Homburg, Germany
| | - Hans-Joachim Schäfers
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Germany
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13
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Kazik HB, Kandail HS, LaDisa JF, Lincoln J. Molecular and Mechanical Mechanisms of Calcification Pathology Induced by Bicuspid Aortic Valve Abnormalities. Front Cardiovasc Med 2021; 8:677977. [PMID: 34124206 PMCID: PMC8187581 DOI: 10.3389/fcvm.2021.677977] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 04/29/2021] [Indexed: 11/13/2022] Open
Abstract
Bicuspid aortic valve (BAV) is a congenital defect affecting 1-2% of the general population that is distinguished from the normal tricuspid aortic valve (TAV) by the existence of two, rather than three, functional leaflets (or cusps). BAV presents in different morphologic phenotypes based on the configuration of cusp fusion. The most common phenotypes are Type 1 (containing one raphe), where fusion between right coronary and left coronary cusps (BAV R/L) is the most common configuration followed by fusion between right coronary and non-coronary cusps (BAV R/NC). While anatomically different, BAV R/L and BAV R/NC configurations are both associated with abnormal hemodynamic and biomechanical environments. The natural history of BAV has shown that it is not necessarily the primary structural malformation that enforces the need for treatment in young adults, but the secondary onset of premature calcification in ~50% of BAV patients, that can lead to aortic stenosis. While an underlying genetic basis is a major pathogenic contributor of the structural malformation, recent studies have implemented computational models, cardiac imaging studies, and bench-top methods to reveal BAV-associated hemodynamic and biomechanical alterations that likely contribute to secondary complications. Contributions to the field, however, lack support for a direct link between the external valvular environment and calcific aortic valve disease in the setting of BAV R/L and R/NC BAV. Here we review the literature of BAV hemodynamics and biomechanics and discuss its previously proposed contribution to calcification. We also offer means to improve upon previous studies in order to further characterize BAV and its secondary complications.
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Affiliation(s)
- Hail B. Kazik
- Department of Biomedical Engineering, Marquette University and Medical College of Wisconsin, Milwaukee, WI, United States
| | | | - John F. LaDisa
- Department of Biomedical Engineering, Marquette University and Medical College of Wisconsin, Milwaukee, WI, United States
- Division of Cardiovascular Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
- Section of Pediatric Cardiology, The Herma Heart Institute, Children's Wisconsin, Milwaukee, WI, United States
| | - Joy Lincoln
- Section of Pediatric Cardiology, The Herma Heart Institute, Children's Wisconsin, Milwaukee, WI, United States
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, United States
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14
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Karliova I, Ehrlich T, Matsushima S, Ewen S, Schäfers HJ. Mid-term durability of polytetrafluoroethylene patches in unicuspid aortic valve repair. Interact Cardiovasc Thorac Surg 2021; 31:555-558. [PMID: 32865192 DOI: 10.1093/icvts/ivaa136] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 06/18/2020] [Accepted: 06/19/2020] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES Unicuspid aortic valve (UAV) morphology is a cause for aortic valve dysfunction in childhood or adolescence. Repair requires the use of patch material, and polytetrafluoroethylene (PTFE) has been proposed for this purpose because of lack of calcification. We reviewed our mid-term experience with PTFE for the repair of UAV to analyse the durability of this technique. METHODS Out of 21 patients with an UAV undergoing aortic valve repair for severe aortic regurgitation between 2014 and 2016, 11 patients (52%) were treated using PTFE patch material. Aortic regurgitation was present in all patients, the primary indication for surgery was regurgitation in 8, stenosis in 2 and aneurysm in 1. Symmetric bicuspidization of the UAV was performed in all. One patient required additional root remodelling for root dilatation, and another 3 tubular ascending aortic replacement. RESULTS No patient died in hospital or during follow-up. Seven patients (63.6%) required reoperation for progressive AR. Freedom from reoperation was 58% at 1 and 35% at 5 years postoperatively. At reoperation the PTFE patches were found dehisced from aortic wall and/or native cusp tissue. In 3 patients re-repair was performed; a stable result was achieved in 1. Two patients underwent valve replacement 3 months and 1 year postoperatively. The other 4 patients underwent valve replacement. CONCLUSIONS The repair of UAVs using PTFE patch is associated with poor durability, a more durable patch with better healing characteristics material is needed.
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Affiliation(s)
- Irem Karliova
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Tristan Ehrlich
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Shunsuke Matsushima
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Sebastian Ewen
- Department of Cardiology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Hans-Joachim Schäfers
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
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15
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Arimura S, Takada J, Nishimura G, Nakama N, Kawasaki E, Matsuhama M, Iwasaki K, Kasegawa H, Kunihara T. The efficacy of sinus plication in aortic valvuloplasty for bicuspid aortic valve: experiments in a pulsatile flow simulation model. Eur J Cardiothorac Surg 2021; 60:859-864. [PMID: 33760025 DOI: 10.1093/ejcts/ezab115] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 01/11/2021] [Accepted: 01/31/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Sinus plication has emerged as a promising tool that can lead to better stability in bicuspid aortic valve (BAV) repair. However, the mechanisms underlying the efficacy of this technique are unclear. We evaluated the hydrodynamic effect of sinus plication using the experimental pulsatile flow simulator and our original BAV model in vitro. METHODS Based on the computed tomography data of a BAV patient who had undergone aortic valvuloplasty, a BAV model (group C, n = 6) was developed with bovine pericardium and vascular prosthesis (J-graft Shield Neo Valsalva 24 mm). We performed sinus plication (group SP, n = 6) in the BAV model and compared hydrodynamic data with the control model in the pulsatile flow simulator. Non-fused cusp angle, annulus diameter and effective height were measured by ultrasonography. RESULTS The average flow was significantly increased in group SP compared to group C (4.24 ± 0.14 l/min vs 4.14 ± 0.15 l/min, respectively, P = 0.034). The mean transvalvular pressure gradient and regurgitant fraction were significantly decreased in group SP compared to group C (11.6 ± 4.3 mmHg vs 16.6 ± 5.0 mmHg, respectively, P = 0.009 and 14.1 ± 2.0% vs 17.4 ± 2.1%, respectively, P = 0.001). Ultrasound measurement indicated that non-fused cusp angle was significantly increased in group SP compared to group C (163.8° ± 9.2° vs 153.0° ± 4.6°, respectively, P = 0.012). CONCLUSIONS Sinus plication in the BAV model significantly increased the commissural angle. It was effective in not only controlling regurgitation but also improving valve opening. These finding should be confirmed by evaluating cusp stress and/or long-term durability in the future studies.
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Affiliation(s)
- Satoshi Arimura
- Department of Cardiac Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Jumpei Takada
- Department of Integrative Bioscience and Biomedical Engineering, Graduate School of Advanced Science and Engineering, Waseda University, Tokyo, Japan
| | - Gohki Nishimura
- Department of Modern Mechanical Engineering, Graduate School of Creative Science and Engineering, Waseda University, Tokyo, Japan
| | - Natsuki Nakama
- Department of Integrative Bioscience and Biomedical Engineering, Graduate School of Advanced Science and Engineering, Waseda University, Tokyo, Japan
| | - Eita Kawasaki
- Department of Integrative Bioscience and Biomedical Engineering, Graduate School of Advanced Science and Engineering, Waseda University, Tokyo, Japan
| | - Minoru Matsuhama
- Department of Cardiovascular Surgery, The Cardiovascular Institute, Tokyo, Japan
| | - Kiyotaka Iwasaki
- Department of Integrative Bioscience and Biomedical Engineering, Graduate School of Advanced Science and Engineering, Waseda University, Tokyo, Japan.,Department of Modern Mechanical Engineering, Graduate School of Creative Science and Engineering, Waseda University, Tokyo, Japan
| | - Hitoshi Kasegawa
- Department of Cardiac Surgery, International University of Health and Welfare Mita Hospital, Tokyo, Japan
| | - Takashi Kunihara
- Department of Cardiac Surgery, The Jikei University School of Medicine, Tokyo, Japan
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16
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Emendi M, Sturla F, Ghosh RP, Bianchi M, Piatti F, Pluchinotta FR, Giese D, Lombardi M, Redaelli A, Bluestein D. Patient-Specific Bicuspid Aortic Valve Biomechanics: A Magnetic Resonance Imaging Integrated Fluid-Structure Interaction Approach. Ann Biomed Eng 2020; 49:627-641. [PMID: 32804291 DOI: 10.1007/s10439-020-02571-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 07/14/2020] [Indexed: 12/15/2022]
Abstract
Congenital bicuspid aortic valve (BAV) consists of two fused cusps and represents a major risk factor for calcific valvular stenosis. Herein, a fully coupled fluid-structure interaction (FSI) BAV model was developed from patient-specific magnetic resonance imaging (MRI) and compared against in vivo 4-dimensional flow MRI (4D Flow). FSI simulation compared well with 4D Flow, confirming direction and magnitude of the flow jet impinging onto the aortic wall as well as location and extension of secondary flows and vortices developing at systole: the systolic flow jet originating from an elliptical 1.6 cm2 orifice reached a peak velocity of 252.2 cm/s, 0.6% lower than 4D Flow, progressively impinging on the ascending aorta convexity. The FSI model predicted a peak flow rate of 22.4 L/min, 6.7% higher than 4D Flow, and provided BAV leaflets mechanical and flow-induced shear stresses, not directly attainable from MRI. At systole, the ventricular side of the non-fused leaflet revealed the highest wall shear stress (WSS) average magnitude, up to 14.6 Pa along the free margin, with WSS progressively decreasing towards the belly. During diastole, the aortic side of the fused leaflet exhibited the highest diastolic maximum principal stress, up to 322 kPa within the attachment region. Systematic comparison with ground-truth non-invasive MRI can improve the computational model ability to reproduce native BAV hemodynamics and biomechanical response more realistically, and shed light on their role in BAV patients' risk for developing complications; this approach may further contribute to the validation of advanced FSI simulations designed to assess BAV biomechanics.
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Affiliation(s)
- Monica Emendi
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milan, Italy.,Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, USA
| | - Francesco Sturla
- 3D and Computer Simulation Laboratory, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Ram P Ghosh
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, USA
| | - Matteo Bianchi
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, USA
| | - Filippo Piatti
- 3D and Computer Simulation Laboratory, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Francesca R Pluchinotta
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milan, Italy.,Multimodality Cardiac Imaging, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy.,Department of Pediatric and Adult Congenital Heart Disease, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | | | - Massimo Lombardi
- Multimodality Cardiac Imaging, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Alberto Redaelli
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milan, Italy
| | - Danny Bluestein
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, USA.
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17
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de Oliveira DMC, Abdullah N, Green NC, Espino DM. Biomechanical Assessment of Bicuspid Aortic Valve Phenotypes: A Fluid-Structure Interaction Modelling Approach. Cardiovasc Eng Technol 2020; 11:431-447. [PMID: 32519086 DOI: 10.1007/s13239-020-00469-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 06/04/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE Bicuspid aortic valve (BAV) is a congenital heart malformation with phenotypic heterogeneity. There is no prior computational study that assesses the haemodynamic and valve mechanics associated with BAV type 2 against a healthy tricuspid aortic valve (TAV) and other BAV categories. METHODS A proof-of-concept study incorporating three-dimensional fluid-structure interaction (FSI) models with idealised geometries (one TAV and six BAVs, namely type 0 with lateral and anterior-posterior orientations, type 1 with R-L, N-R and N-L leaflet fusion and type 2) has been developed. Transient physiological boundary conditions have been applied and simulations were run using an Arbitrary Lagrangian-Eulerian formulation. RESULTS Our results showed the presence of abnormal haemodynamics in the aorta and abnormal valve mechanics: type 0 BAVs yielded the best haemodynamical and mechanical outcomes, but cusp stress distribution varied with valve orifice orientation, which can be linked to different cusp calcification location onset; type 1 BAVs gave rise to similar haemodynamics and valve mechanics, regardless of raphe position, but this position altered the location of abnormal haemodynamic features; finally, type 2 BAV constricted the majority of blood flow, exhibiting the most damaging haemodynamic and mechanical repercussions when compared to other BAV phenotypes. CONCLUSION The findings of this proof-of-concept work suggest that there are specific differences across haemodynamics and valve mechanics associated with BAV phenotypes, which may be critical to subsequent processes associated with their pathophysiology processes.
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Affiliation(s)
- Diana M C de Oliveira
- Department of Mechanical Engineering, University of Birmingham, Birmingham, B15 2TT, UK.
| | - Nazirul Abdullah
- Department of Mechanical Engineering, University of Birmingham, Birmingham, B15 2TT, UK
| | - Naomi C Green
- Department of Mechanical Engineering, University of Birmingham, Birmingham, B15 2TT, UK
| | - Daniel M Espino
- Department of Mechanical Engineering, University of Birmingham, Birmingham, B15 2TT, UK
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18
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Ehrlich T, de Kerchove L, Vojacek J, Boodhwani M, El-Hamamsy I, De Paulis R, Lansac E, Bavaria JE, El Khoury G, Schäfers HJ. State-of-the art bicuspid aortic valve repair in 2020. Prog Cardiovasc Dis 2020; 63:457-464. [PMID: 32380025 DOI: 10.1016/j.pcad.2020.04.010] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 04/13/2020] [Indexed: 02/07/2023]
Abstract
Patients with a bicuspid aortic valve (BAV) frequently require surgical intervention for aortic regurgitation (AR) and/or aneurysm. Valve-preserving surgery and repair of regurgitant BAVs have evolved into an increasingly used alternative to replacement. Anatomic predictors of possible repair failures have been identified and solutions developed. Using current techniques most non-calcified BAVs can be preserved or repaired. Excellent repair durability and freedom from valve-related complications can be achieved if all pathologic components of aortic valve and root including annular dilatation are corrected. Anatomic variations must be addressed using tailored approaches.
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Affiliation(s)
- Tristan Ehrlich
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Laurent de Kerchove
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain and Division of Cardiothoracic and Vascular Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Jan Vojacek
- Department of Cardiac Surgery, University Hospital Hradec K0ralove, Czech Republic
| | - Munir Boodhwani
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Canada
| | - Ismail El-Hamamsy
- Department of Cardiovascular Surgery, Mount Sinai Hospital, Icahn Scholl of Medicine at Mount Sinai, New York, USA
| | | | - Emmanuel Lansac
- Departement of Cardiac Surgery, Institut Mutualiste Montsouris, Paris, France
| | - Joseph E Bavaria
- Division of Cardiac Surgery, University of Pennsylvania, Philadelphia, United States of America
| | - Gebrine El Khoury
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain and Division of Cardiothoracic and Vascular Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Hans-Joachim Schäfers
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany.
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19
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Concepts of Bicuspid Aortic Valve Repair: A Review. Ann Thorac Surg 2020; 109:999-1006. [DOI: 10.1016/j.athoracsur.2019.09.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 08/16/2019] [Accepted: 09/03/2019] [Indexed: 12/27/2022]
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20
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Biomechanical modeling of transcatheter aortic valve replacement in a stenotic bicuspid aortic valve: deployments and paravalvular leakage. Med Biol Eng Comput 2019; 57:2129-2143. [PMID: 31372826 DOI: 10.1007/s11517-019-02012-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 07/08/2019] [Indexed: 12/17/2022]
Abstract
Calcific aortic valve disease (CAVD) is characterized by stiffened aortic valve leaflets. Bicuspid aortic valve (BAV) is the most common congenital heart disease. Transcatheter aortic valve replacement (TAVR) is a treatment approach for CAVD where a stent with mounted bioprosthetic valve is deployed on the stenotic valve. Performing TAVR in calcified BAV patients may be associated with post-procedural complications due to the BAV asymmetrical structure. This study aims to develop refined computational models simulating the deployments of Evolut R and PRO TAVR devices in a representative calcified BAV. The paravalvular leakage (PVL) was also calculated by computational fluid dynamics simulations. Computed tomography scan of severely stenotic BAV patient was acquired. The 3D calcium deposits were generated and embedded inside a parametric model of the BAV. Deployments of the Evolut R and PRO inside the calcified BAV were simulated in five bioprosthesis leaflet orientations. The hypothesis of asymmetric and elliptic stent deployment was confirmed. Positioning the bioprosthesis commissures aligned with the native commissures yielded the lowest PVL (15.7 vs. 29.5 mL/beat). The Evolut PRO reduced the PVL in half compared with the Evolut R (15.7 vs. 28.7 mL/beat). The proposed biomechanical computational model could optimize future TAVR treatment in BAV patients. Graphical abstract.
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