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Vernon MJ, Lu J, Padman B, Lamb C, Kent R, Mela P, Doyle B, Ihdayhid AR, Jansen S, Dilley RJ, De-Juan-Pardo EM. Engineering Heart Valve Interfaces Using Melt Electrowriting: Biomimetic Design Strategies from Multi-Modal Imaging. Adv Healthc Mater 2022; 11:e2201028. [PMID: 36300603 DOI: 10.1002/adhm.202201028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 09/12/2022] [Indexed: 01/28/2023]
Abstract
Interfaces within biological tissues not only connect different regions but also contribute to the overall functionality of the tissue. This is especially true in the case of the aortic heart valve. Here, melt electrowriting (MEW) is used to engineer complex, user-defined, interfaces for heart valve scaffolds. First, a multi-modal imaging investigation into the interfacial regions of the valve reveals differences in collagen orientation, density, and recruitment in previously unexplored regions including the commissure and inter-leaflet triangle. Overlapping, suturing, and continuous printing methods for interfacing MEW scaffolds are then investigated for their morphological, tensile, and flexural properties, demonstrating the superior performance of continuous interfaces. G-codes for MEW scaffolds with complex interfaces are designed and generated using a novel software and graphical user interface. Finally, a singular MEW scaffold for the interfacial region of the aortic heart valve is presented incorporating continuous interfaces, gradient porosities, variable layer numbers across regions, and tailored fiber orientations inspired by the collagen distribution and orientation from the multi-modal imaging study. The scaffold exhibits similar yield strain, hysteresis, and relaxation behavior to porcine heart valves. This work demonstrates the ability of a bioinspired approach for MEW scaffold design to address the functional complexity of biological tissues.
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Affiliation(s)
- Michael J Vernon
- T3mPLATE, Harry Perkins Institute of Medical Research, QEII Medical Centre, and UWA Centre for Medical Research, The University of Western Australia, Perth, WA, 6009, Australia.,Vascular Engineering Laboratory, Harry Perkins Institute of Medical Research, QEII Medical Centre, and UWA Centre for Medical Research, The University of Western Australia, Perth, WA, 6009, Australia.,School of Engineering, The University of Western Australia, Perth, WA, 6009, Australia
| | - Jason Lu
- T3mPLATE, Harry Perkins Institute of Medical Research, QEII Medical Centre, and UWA Centre for Medical Research, The University of Western Australia, Perth, WA, 6009, Australia.,School of Engineering, The University of Western Australia, Perth, WA, 6009, Australia
| | - Benjamin Padman
- Centre for Microscopy, Characterisation and Analysis, The University of Western Australia, Perth, WA, 6009, Australia
| | - Christopher Lamb
- T3mPLATE, Harry Perkins Institute of Medical Research, QEII Medical Centre, and UWA Centre for Medical Research, The University of Western Australia, Perth, WA, 6009, Australia.,School of Engineering, The University of Western Australia, Perth, WA, 6009, Australia
| | - Ross Kent
- Regenerative Medicine Program, CIMA, Universidad de Navarra, Pamplona, Navarra, 31008, Spain
| | - Petra Mela
- Medical Materials and Implants, Department of Mechanical Engineering, Munich Institute of Biomedical Engineering and TUM School of Engineering and Design, Technical University of Munich, Boltzmannstr. 15, 85748, Garching, Germany
| | - Barry Doyle
- Vascular Engineering Laboratory, Harry Perkins Institute of Medical Research, QEII Medical Centre, and UWA Centre for Medical Research, The University of Western Australia, Perth, WA, 6009, Australia.,School of Engineering, The University of Western Australia, Perth, WA, 6009, Australia.,Australian Research Council Centre for Personalised Therapeutics Technologies, Australian Research Council, Parkville, ACT, 2609, Australia.,British Heart Foundation Centre of Cardiovascular Science, The University of Edinburgh, Edinburgh, EH1-3AT, UK
| | - Abdul Rahman Ihdayhid
- Department of Cardiology, Fiona Stanley Hospital, Perth, WA, 6150, Australia.,Curtin Medical School, Curtin University, Perth, WA, 6102, Australia
| | - Shirley Jansen
- Vascular Engineering Laboratory, Harry Perkins Institute of Medical Research, QEII Medical Centre, and UWA Centre for Medical Research, The University of Western Australia, Perth, WA, 6009, Australia.,Curtin Medical School, Curtin University, Perth, WA, 6102, Australia.,Department of Vascular and Endovascular Surgery, Sir Charles Gairdner Hospital, Perth, WA, 6009, Australia.,Heart and Vascular Research Institute, Harry Perkins Institute of Medical Research, Perth, WA, 6009, Australia
| | - Rodney J Dilley
- T3mPLATE, Harry Perkins Institute of Medical Research, QEII Medical Centre, and UWA Centre for Medical Research, The University of Western Australia, Perth, WA, 6009, Australia.,School of Engineering, The University of Western Australia, Perth, WA, 6009, Australia
| | - Elena M De-Juan-Pardo
- T3mPLATE, Harry Perkins Institute of Medical Research, QEII Medical Centre, and UWA Centre for Medical Research, The University of Western Australia, Perth, WA, 6009, Australia.,School of Engineering, The University of Western Australia, Perth, WA, 6009, Australia
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2
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Lu P, Wang P, Wu B, Wang Y, Liu Y, Cheng W, Feng X, Yuan X, Atteya MM, Ferro H, Sugi Y, Rydquist G, Esmaily M, Butcher JT, Chang CP, Lenz J, Zheng D, Zhou B. A SOX17-PDGFB signaling axis regulates aortic root development. Nat Commun 2022; 13:4065. [PMID: 35831318 PMCID: PMC9279414 DOI: 10.1038/s41467-022-31815-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 06/30/2022] [Indexed: 11/08/2022] Open
Abstract
Developmental etiologies causing complex congenital aortic root abnormalities are unknown. Here we show that deletion of Sox17 in aortic root endothelium in mice causes underdeveloped aortic root leading to a bicuspid aortic valve due to the absence of non-coronary leaflet and mispositioned left coronary ostium. The respective defects are associated with reduced proliferation of non-coronary leaflet mesenchyme and aortic root smooth muscle derived from the second heart field cardiomyocytes. Mechanistically, SOX17 occupies a Pdgfb transcriptional enhancer to promote its transcription and Sox17 deletion inhibits the endothelial Pdgfb transcription and PDGFB growth signaling to the non-coronary leaflet mesenchyme. Restoration of PDGFB in aortic root endothelium rescues the non-coronary leaflet and left coronary ostium defects in Sox17 nulls. These data support a SOX17-PDGFB axis underlying aortic root development that is critical for aortic valve and coronary ostium patterning, thereby informing a potential shared disease mechanism for concurrent anomalous aortic valve and coronary arteries.
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Affiliation(s)
- Pengfei Lu
- Department of Genetics, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ping Wang
- Department of Genetics, Albert Einstein College of Medicine, Bronx, NY, USA
- School of Medical Imaging, Tianjin Medical University, Tianjin, China
| | - Bingruo Wu
- Department of Genetics, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Yidong Wang
- Department of Genetics, Albert Einstein College of Medicine, Bronx, NY, USA
- Cardiovascular Research Center, School of Basic Medical Sciences, Jiaotong University, Xi'an, Shanxi, China
| | - Yang Liu
- Department of Genetics, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Wei Cheng
- Department of Genetics, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Xuhui Feng
- Department of Genetics, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Xinchun Yuan
- Department of Genetics, Albert Einstein College of Medicine, Bronx, NY, USA
- The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Miriam M Atteya
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC, USA
| | - Haleigh Ferro
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC, USA
| | - Yukiko Sugi
- Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC, USA
| | - Grant Rydquist
- School of Mechanical and Aerospace Engineering, Cornell University, Ithaca, NY, USA
| | - Mahdi Esmaily
- School of Mechanical and Aerospace Engineering, Cornell University, Ithaca, NY, USA
| | | | - Ching-Pin Chang
- Department of Genetics, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jack Lenz
- Department of Genetics, Albert Einstein College of Medicine, Bronx, NY, USA
- Departments of Microbiology & Immunology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Deyou Zheng
- Department of Genetics, Albert Einstein College of Medicine, Bronx, NY, USA.
- Departments of Neurology and Neuroscience, Albert Einstein College of Medicine, Bronx, NY, USA.
| | - Bin Zhou
- Department of Genetics, Albert Einstein College of Medicine, Bronx, NY, USA.
- Departments of Pediatrics and Medicine (Cardiology), Albert Einstein College of Medicine, Bronx, NY, USA.
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3
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The Choice of Pulmonary Autograft in Aortic Valve Surgery: A State-of-the-Art Primer. BIOMED RESEARCH INTERNATIONAL 2021; 2021:5547342. [PMID: 33937396 PMCID: PMC8060091 DOI: 10.1155/2021/5547342] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 03/31/2021] [Accepted: 04/05/2021] [Indexed: 11/18/2022]
Abstract
The Ross procedure has long been seen as an optimal operation for a select few. The detractors of it highlight the issue of an additional harvesting of the pulmonary artery, subjecting the native PA to systemic pressures and the need for reintervention as reasons to avoid it. However, the PA is a living tissue and capable of adapting and remodeling to growth. We therefore review the current evidence available to discuss the indications, contraindications, harvesting techniques, and modifications in a state-of-the-art narrative review of the PA as an aortic conduit. Due to the lack of substantial well-designed randomized controlled trials (RCTs), we also highlight the areas of need to reiterate the importance of the Ross procedure as part of the surgical armamentarium.
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4
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Karwat P, Klimonda Z, Styczyński G, Szmigielski C, Litniewski J. Aortic root movement correlation with the function of the left ventricle. Sci Rep 2021; 11:4473. [PMID: 33627700 PMCID: PMC7904934 DOI: 10.1038/s41598-021-83278-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 02/01/2021] [Indexed: 12/12/2022] Open
Abstract
Echocardiographic assessment of systolic and diastolic function of the heart is often limited by image quality. However, the aortic root is well visualized in most patients. We hypothesize that the aortic root motion may correlate with the systolic and diastolic function of the left ventricle of the heart. Data obtained from 101 healthy volunteers (mean age 46.6 ± 12.4) was used in the study. The data contained sequences of standard two-dimensional (2D) echocardiographic B-mode (brightness mode, classical ultrasound grayscale presentation) images corresponding to single cardiac cycles. They also included sets of standard echocardiographic Doppler parameters of the left ventricular systolic and diastolic function. For each B-mode image sequence, the aortic root was tracked with use of a correlation tracking algorithm and systolic and diastolic values of traveled distances and velocities were determined. The aortic root motion parameters were correlated with the standard Doppler parameters used for the assessment of LV function. The aortic root diastolic distance (ARDD) mean value was 1.66 ± 0.26 cm and showed significant, moderate correlation (r up to 0.59, p < 0.0001) with selected left ventricular diastolic Doppler parameters. The aortic root maximal diastolic velocity (ARDV) was 10.8 ± 2.4 cm/s and also correlated (r up to 0.51, p < 0.0001) with some left ventricular diastolic Doppler parameters. The aortic root systolic distance (ARSD) was 1.63 ± 0.19 cm and showed no significant moderate correlation (all r values < 0.40). The aortic root maximal systolic velocity (ARSV) was 9.2 ± 1.6 cm/s and correlated in moderate range only with peak systolic velocity of medial mitral annulus (r = 0.44, p < 0.0001). Based on these results, we conclude, that in healthy subjects, aortic root motion parameters correlate significantly with established measurements of left ventricular function. Aortic root motion parameters can be especially useful in patients with low ultrasound image quality precluding usage of typical LV function parameters.
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Affiliation(s)
- Piotr Karwat
- Institute of Fundamental Technological Research, Polish Academy of Sciences, Pawińskiego 5B, 02-106, Warsaw, Poland.
| | - Ziemowit Klimonda
- Institute of Fundamental Technological Research, Polish Academy of Sciences, Pawińskiego 5B, 02-106, Warsaw, Poland
| | - Grzegorz Styczyński
- Department of Internal Medicine, Hypertension and Angiology, Medical University of Warsaw, Banacha 1A, 02-097, Warsaw, Poland
| | - Cezary Szmigielski
- Department of Internal Medicine, Hypertension and Angiology, Medical University of Warsaw, Banacha 1A, 02-097, Warsaw, Poland
| | - Jerzy Litniewski
- Institute of Fundamental Technological Research, Polish Academy of Sciences, Pawińskiego 5B, 02-106, Warsaw, Poland
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5
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Goodwin ML, Bobba CM, Mokadam NA, Whitson BA, Essandoh M, Hasan A, Ganapathi AM. Continuous-Flow Left Ventricular Assist Devices and the Aortic Valve: Interactions, Issues, and Surgical Therapy. Curr Heart Fail Rep 2020; 17:97-105. [DOI: 10.1007/s11897-020-00464-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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6
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Chester AH, Grande-Allen KJ. Which Biological Properties of Heart Valves Are Relevant to Tissue Engineering? Front Cardiovasc Med 2020; 7:63. [PMID: 32373630 PMCID: PMC7186395 DOI: 10.3389/fcvm.2020.00063] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 03/27/2020] [Indexed: 12/30/2022] Open
Abstract
Over the last 20 years, the designs of tissue engineered heart valves have evolved considerably. An initial focus on replicating the mechanical and structural features of semilunar valves has expanded to endeavors to mimic the biological behavior of heart valve cells as well. Studies on the biology of heart valves have shown that the function and durability of native valves is underpinned by complex interactions between the valve cells, the extracellular matrix, and the mechanical environment in which heart valves function. The ability of valve interstitial cells to synthesize extracellular matrix proteins and remodeling enzymes and the protective mediators released by endothelial cells are key factors in the homeostasis of valve function. The extracellular matrix provides the mechanical strength and flexibility required for the valve to function, as well as communicating with the cells that are bound within. There are a number of regulatory mechanisms that influence valve function, which include neuronal mechanisms and the tight regulation of growth and angiogenic factors. Together, studies into valve biology have provided a blueprint for what a tissue engineered valve would need to be capable of, in order to truly match the function of the native valve. This review addresses the biological functions of heart valve cells, in addition to the influence of the cells' environment on this behavior and examines how well these functions are addressed within the current strategies for tissue engineering heart valves in vitro, in vivo, and in situ.
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Affiliation(s)
- Adrian H Chester
- Heart Science Centre, The Magdi Yacoub Institute, Harefield, United Kingdom
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Oveissi F, Naficy S, Lee A, Winlaw D, Dehghani F. Materials and manufacturing perspectives in engineering heart valves: a review. Mater Today Bio 2020; 5:100038. [PMID: 32211604 PMCID: PMC7083765 DOI: 10.1016/j.mtbio.2019.100038] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 11/26/2019] [Accepted: 11/27/2019] [Indexed: 12/27/2022] Open
Abstract
Valvular heart diseases (VHD) are a major health burden, affecting millions of people worldwide. The treatments for such diseases rely on medicine, valve repair, and artificial heart valves including mechanical and bioprosthetic valves. Yet, there are countless reports on possible alternatives noting long-term stability and biocompatibility issues and highlighting the need for fabrication of more durable and effective replacements. This review discusses the current and potential materials that can be used for developing such valves along with existing and developing fabrication methods. With this perspective, we quantitatively compare mechanical properties of various materials that are currently used or proposed for heart valves along with their fabrication processes to identify challenges we face in creating new materials and manufacturing techniques to better mimick the performance of native heart valves.
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Key Words
- 3D printing
- Biofabrication
- Biomaterials
- E, Young's modulus
- Electrospinning
- Gal, galactose-α1,3-galactose
- GelMa, gelatin methacrylate
- HA, hyaluronic acid
- HAVIC, human aortic valvular interstitial cells
- MA-HA, methacrylated hyaluronic acid
- NeuGc, N-glycolylneuraminic acid
- P4HB, poly(4-hydroxybutyrate)
- PAAm, polyacrylamide
- PCE, polycitrate-(ε-polypeptide)
- PCL, polycaprolactone
- PE, polyethylene
- PEG, polyethylene glycol
- PEGDA, polyethylene glycol diacrylate
- PGA, poly(glycolic acid)
- PHA, poly(hydroxyalkanoate)
- PLA, polylactide
- PMMA, poly(methyl methacrylate)
- PPG, polypropylene glycol
- PTFE, polytetrafluoroethylene
- PU, polyurethane
- SIBS, poly(styrene-b-isobutylene-b-styrene)
- SMC, smooth muscle cells
- VHD, valvular heart disease
- VIC, aortic valve leaflet interstitial cells
- Valvular heart diseases
- dECM, decellularized extracellular matrix
- ePTFE, expanded PTFE
- xSIBS, crosslinked version of SIBS
- α-SMA, alpha-smooth muscle actin
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Affiliation(s)
- F. Oveissi
- School of Chemical and Biomolecular Engineering, The University of Sydney, Sydney, New South Wales, 2006, Australia
| | - S. Naficy
- School of Chemical and Biomolecular Engineering, The University of Sydney, Sydney, New South Wales, 2006, Australia
| | - A. Lee
- School of Chemical and Biomolecular Engineering, The University of Sydney, Sydney, New South Wales, 2006, Australia
- Discipline of Child and Adolescent Health, Sydney Medical School, Faculty of Health and Medicine, The University of Sydney, New South Wales, 2006, Australia
- Heart Centre for Children, The Children's Hospital at Westmead, New South Wales, 2145, Australia
| | - D.S. Winlaw
- Discipline of Child and Adolescent Health, Sydney Medical School, Faculty of Health and Medicine, The University of Sydney, New South Wales, 2006, Australia
- Heart Centre for Children, The Children's Hospital at Westmead, New South Wales, 2145, Australia
| | - F. Dehghani
- School of Chemical and Biomolecular Engineering, The University of Sydney, Sydney, New South Wales, 2006, Australia
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8
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Armstrong AA, Norato J, Alleyne AG, Wagoner Johnson AJ. Direct process feedback in extrusion-based 3D bioprinting. Biofabrication 2019; 12:015017. [DOI: 10.1088/1758-5090/ab4d97] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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9
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Salmonsmith JA, Ducci A, Burriesci G. Does transcatheter aortic valve alignment matter? Open Heart 2019; 6:e001132. [PMID: 31803486 PMCID: PMC6887501 DOI: 10.1136/openhrt-2019-001132] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 10/10/2019] [Accepted: 11/07/2019] [Indexed: 11/06/2022] Open
Abstract
Objective This study investigates the effect of transcatheter aortic valve (TAV) angular alignment on the postprocedure haemodynamics. TAV implantation has emerged as an effective alternative to surgery when treating valve dysfunction. However, the benefit of avoiding surgery is paid back by the inability to remove the native diseased leaflets and accurately position the device in relation to the aortic root, and the literature has shown the root anatomy and substitute position can play an essential role on valve function. Methods A commercial TAV was placed in a silicone mock aortic root in vitro, including mock native leaflets, and either aligned commissure-to-commissure or in maximum misalignment. Haemodynamic performance data at various stroke volumes were measured, and Particle Image Velocimetry analysis was performed at a typical stroke volume for rest conditions. The two configurations were also studied without mock native leaflets, for comparison with previous in vitro studies. Results Haemodynamic performance data were similar for all configurations. However, imaging analysis indicated that valve misalignment resulted in the central jet flow not extending to the root wall in the native commissures’ vicinity, replaced by a low shear flow, and a reduction of upper sinus flow of 40%, increasing flow stagnation in the sinus. Conclusions TAV misalignment did not result in a significant change in valve hydrodynamic performance, but determined some change in the fluid flow patterns, which may promote pathological scenarios, such as increased thrombogenicity of blood flow within the sinuses of Valsalva, and plaque formation around the lumen of the sinotubular junction.
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Affiliation(s)
| | - Andrea Ducci
- UCL Mechanical Engineering, University College London, London, UK
| | - Gaetano Burriesci
- UCL Mechanical Engineering, University College London, London, UK.,Unit of Bioengineering, Ri.MED Foundation, Palermo, Italy
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10
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Petersen J, Voigtländer L, Schofer N, Neumann N, von Kodolitsch Y, Reichenspurner H, Girdauskas E. Geometric changes in the aortic valve annulus during the cardiac cycle: impact on aortic valve repair. Eur J Cardiothorac Surg 2019. [PMID: 29514226 DOI: 10.1093/ejcts/ezy099] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The growing experience in aortic valve (AV) repair showed that annular stabilization is a crucial component to achieve stable long-term results after AV repair. Dynamic changes in the AV annulus during the cardiac cycle may have an impact on annuloplasty design. METHODS We retrospectively analysed full cardiac cycle multislice computed tomography data from 58 consecutive patients (mean age 75.9 ± 6.5 years, 36% men) with normally functioning tricuspid AVs (normal AV subgroup). The following computed tomography parameters were measured during systole and diastole: maximum, minimum and mean AV annulus diameter, AV annular area and AV annular perimeter. The AV annular eccentricity index was calculated (%) [(max AV annulus × 100/min AV annulus) - 100] in systole and diastole. Subsequently, multislice computed tomography data from 20 patients with severe aortic regurgitation were analysed [aortic valve regurgitation (AR) subgroup]. RESULTS In the normal AV subgroup, there was a significant decrease in the mean AV annulus diameter from systole to diastole (i.e. 24.6 ± 2.5 mm vs 23.9 ± 2.4 mm, respectively; P < 0.001), which occurred predominantly in the short annular axis (i.e. 21.2 ± 2.4 mm in systole vs 19.9 ± 2.3 mm in diastole; P < 0.001). The mean AV annular area decreased significantly in diastole (i.e. 467.5 ± 94.5 mm2 in systole vs 444.8 ± 86.1 mm2 in diastole; P = 0.012). The annular eccentricity index increased significantly in diastole (33.0 ± 12.2% in systole vs 41.4 ± 13.5% in diastole; P < 0.001). Furthermore, we found an inverse linear correlation between the mean AV annulus diameter and the annular eccentricity index (r = -0.40, P = 0.034). The diastolic annular eccentricity index was significantly reduced in the AR subgroup (i.e. 41.4 ± 13.5% in the normal AV subgroup vs 33.7 ± 14.8% in the AR cohort; P = 0.035). CONCLUSIONS The normal AV annulus undergoes important geometric deformation during the cardiac cycle that is significantly reduced in diastole in the AR scenario. A novel AV annuloplasty system should ideally adapt for this marked diastolic annular eccentricity and thereby allow for dynamic aortic root changes during the cardiac cycle.
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Affiliation(s)
- Johannes Petersen
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany
| | - Lisa Voigtländer
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany
| | - Niklas Schofer
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany
| | - Niklas Neumann
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany
| | - Yskert von Kodolitsch
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany
| | | | - Evaldas Girdauskas
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany
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11
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Yanagawa B, Mazine A, El-Hamamsy I. Predictors of Aortic Valve Repair Failure. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2019; 14:199-208. [PMID: 31084444 DOI: 10.1177/1556984519845905] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aortic valve repair is the preferred approach for the treatment of severe aortic insufficiency (AI), as it allows patients to keep their native aortic valve, thus substantially reducing the risk of prosthesis-related complications. Several studies have documented excellent long-term outcomes of aortic valve repair. The major complication of this operation is AI recurrence, with ensuingneed for reoperation. The surgical experience accumulated over the last two decades has allowed for better understanding of the mechanisms of recurrent AI after aortic valve repair. Herein, we review the current state of knowledge on predictors of aortic valve repair failure. These include unaddressed annular dilation, residual cusp prolapse or retraction, commissural orientation, and use of patch material. This enhanced understanding has led to the development of increasingly refined techniques and improved patient outcomes. Continued follow-up and detailed data collection at the time of surgery, together with three-dimensional echo imaging, will allow further improvements in aortic valve repair.
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Affiliation(s)
- Bobby Yanagawa
- 1 Divisions of Cardiac Surgery, St Michael's Hospital, University of Toronto, Canada
| | - Amine Mazine
- 1 Divisions of Cardiac Surgery, St Michael's Hospital, University of Toronto, Canada
| | - Ismail El-Hamamsy
- 2 Division of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Quebec, Canada
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12
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Lansac E, Lim HS, Shomura Y, Lim KH, Rice NT, Di Centa I, Youssefi P, Goetz W, Duran CMG. Aortic valve opening and closure: the clover dynamics. Ann Cardiothorac Surg 2019; 8:351-361. [PMID: 31240179 DOI: 10.21037/acs.2019.05.03] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Systolic aortic root expansion is reported to facilitate valve opening, but the precise dynamics remain unknown. A sonometric study with a high data sampling rate (200 to 800 Hz) was conducted in an acute ovine model to better understand the timing, mechanisms, and shape of aortic valve opening and closure. Methods Eighteen piezoelectric crystals were implanted in 8 sheep at each annular base, commissures, sinus of Valsalva, sinotubular junction, nodulus of Arantius, and ascending aorta (AA). Geometric changes were time related to pressures and flows. Results The aortic root was hemodynamically divided into left ventricular (LV) and aortic compartments situated, respectively, below and above the leaflets. During isovolumetric contraction (IVC), aortic root expansion started in the LV compartment, most likely due to volume redistribution in the LV outflow tract below the leaflets. This expansion initiated leaflet separation prior to ejection (2.1%±0.5% of total opening area). Aortic compartment expansion was delayed toward the end of IVC, likely related to volume redistribution above the leaflets due to accelerating aortic backflow toward the aortic valve and coronary flow reduction due to myocardial contraction. Maximum valve opening during the first third of ejection acquired a truncated cone shape [leaflet free edge area smaller than annular base area (-41.5%±5.5%)]. The distal orifice became clover shaped because the leaflet free edge area is larger than the commissural area by 16.3%±2.0%. Conclusions Aortic valve opening is initiated prior to ejection related to delicate balance between LV, aortic root, and coronary dynamics. It is clover shaped at maximum opening in systole. A better understanding of these mechanisms should stimulate more physiological surgical approaches of valve repair and replacement.
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Affiliation(s)
- Emmanuel Lansac
- Department of Cardiovascular Surgery, Institut Mutualiste Montsouris, Paris, France
| | - Hou-Sen Lim
- The International Heart Institute of Montana Foundation at St. Patrick Hospital and Health Sciences Center and The University of Montana, Missoula, Montana, USA
| | - Yu Shomura
- The International Heart Institute of Montana Foundation at St. Patrick Hospital and Health Sciences Center and The University of Montana, Missoula, Montana, USA
| | - Khee Hiang Lim
- The International Heart Institute of Montana Foundation at St. Patrick Hospital and Health Sciences Center and The University of Montana, Missoula, Montana, USA
| | - Nolan T Rice
- The International Heart Institute of Montana Foundation at St. Patrick Hospital and Health Sciences Center and The University of Montana, Missoula, Montana, USA
| | - Isabelle Di Centa
- The International Heart Institute of Montana Foundation at St. Patrick Hospital and Health Sciences Center and The University of Montana, Missoula, Montana, USA
| | - Pouya Youssefi
- Department of Cardiovascular Surgery, Institut Mutualiste Montsouris, Paris, France.,Hospital Foch, Suresnes, France
| | - Wolfgang Goetz
- The International Heart Institute of Montana Foundation at St. Patrick Hospital and Health Sciences Center and The University of Montana, Missoula, Montana, USA
| | - Carlos M G Duran
- The International Heart Institute of Montana Foundation at St. Patrick Hospital and Health Sciences Center and The University of Montana, Missoula, Montana, USA
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Bechsgaard T, Lindskow T, Lading T, Røpcke DM, Nygaard H, Johansen P, Nielsen SL, Hasenkam JM. Biomechanical characterization and comparison of different aortic root surgical techniques. Interact Cardiovasc Thorac Surg 2019; 28:112-119. [PMID: 29961835 DOI: 10.1093/icvts/ivy187] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Accepted: 05/12/2018] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Understanding the biomechanical impact of aortic valve-sparing techniques is important in an era in which surgical techniques are developing and are increasingly being used based on biomechanical understanding that is essential in the refining of existing techniques. The objective of this study was to describe how the valve-sparing remodelling (Yacoub) and reimplantation (David Type-1) techniques affect the biomechanics of the native aortic root in terms of force distribution and geometrical changes. METHODS Two force transducers were implanted into 22 pigs, randomized to 1 of 3 groups (David = 7, native = 7 and Yacoub = 8) along with 11 sonomicrometry crystals and 2 pressure catheters. Force and geometry data were combined to obtain the local structural stiffness in different segments of the aortic root. RESULTS The radial structural stiffness was not different between groups (P = 0.064) at the annular level; however, the David technique seemed to stabilize the aortic annulus more than the Yacoub technique. In the sinotubular junction, the native group was more compliant (P = 0.036) with the right-left coronary segment than the intervention groups. Overall, the native aortic root appeared to be more dynamic at both the annular level and the sinotubular junction than both intervention groups. CONCLUSIONS In conclusion, the David procedure may stabilize the aortic annulus more than the Yacoub procedure, whereas the leaflet opening area was larger in the latter (P = 0.030). No difference (P = 0.309) was found in valve-opening delay between groups. The 2 interventions show similar characteristics at the sinotubular junction, whereas the David technique seemed more restrictive at the annular level than the Yacoub technique.
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Affiliation(s)
- Tommy Bechsgaard
- Department of Engineering, Faculty of Science and Technology, Aarhus University, Aarhus N, Denmark
- Department of Cardiothoracic & Vascular Surgery, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus N, Denmark
| | - Thomas Lindskow
- Department of Cardiothoracic & Vascular Surgery, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus N, Denmark
| | - Troels Lading
- Department of Cardiothoracic & Vascular Surgery, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus N, Denmark
| | - Diana M Røpcke
- Department of Cardiothoracic & Vascular Surgery, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus N, Denmark
| | - Hans Nygaard
- Department of Cardiothoracic & Vascular Surgery, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus N, Denmark
| | - Peter Johansen
- Department of Engineering, Faculty of Science and Technology, Aarhus University, Aarhus N, Denmark
- Department of Cardiothoracic & Vascular Surgery, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus N, Denmark
| | - Sten L Nielsen
- Department of Cardiothoracic & Vascular Surgery, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus N, Denmark
| | - J Michael Hasenkam
- Department of Cardiothoracic & Vascular Surgery, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus N, Denmark
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Padala M. Aortic root anatomy as a factor in the fluid mechanics of transcatheter aortic valve replacement. J Thorac Cardiovasc Surg 2018; 157:550-551. [PMID: 30527722 DOI: 10.1016/j.jtcvs.2018.10.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 10/18/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Muralidhar Padala
- Structural Heart Research & Innovation Laboratory, Carlyle Fraser Heart Center, Emory University Hospital Midtown, Atlanta, Ga; Division of Cardiothoracic Surgery, Joseph P. Whitehead Department of Surgery, Emory University, Atlanta, Ga.
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Mazine A, El-Hamamsy I, Verma S, Peterson MD, Bonow RO, Yacoub MH, David TE, Bhatt DL. Ross Procedure in Adults for Cardiologists and Cardiac Surgeons. J Am Coll Cardiol 2018; 72:2761-2777. [DOI: 10.1016/j.jacc.2018.08.2200] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 08/19/2018] [Indexed: 01/07/2023]
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Ibrahim M, Spelde AE, Carter TI, Patel PA, Desai N. The Ross Operation in the Adult: What, Why, and When? J Cardiothorac Vasc Anesth 2018. [DOI: 10.1053/j.jvca.2017.12.047] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Bechsgaard T, Lindskow T, Lading T, Hasenkam J, Røpcke D, Nygaard H, Johansen P, L. Nielsen S. Biomechanical characterization of the native porcine aortic root. J Biomech 2018; 74:156-162. [DOI: 10.1016/j.jbiomech.2018.04.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 04/02/2018] [Accepted: 04/22/2018] [Indexed: 11/27/2022]
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Fleerakkers J, Schepens M, Ranschaert W, Verrelst P, Graulus E. Aortic valve replacement using the Freedom SOLO stentless bioprosthesis: clinical and haemodynamic performance in 625 patients at medium-term follow-up. Eur J Cardiothorac Surg 2018; 54:1073-1080. [DOI: 10.1093/ejcts/ezy202] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 04/13/2018] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Marc Schepens
- Department of Cardiac Surgery, AZ St-Jan, Brugge, Belgium
| | | | - Paul Verrelst
- Department of Cardiac Surgery, AZ St-Jan, Brugge, Belgium
| | - Eric Graulus
- Department of Cardiac Surgery, AZ St-Jan, Brugge, Belgium
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Klotz S, Stock S, Sievers HH, Diwoky M, Petersen M, Stierle U, Richardt D. Survival and reoperation pattern after 20 years of experience with aortic valve–sparing root replacement in patients with tricuspid and bicuspid valves. J Thorac Cardiovasc Surg 2018; 155:1403-1411.e1. [DOI: 10.1016/j.jtcvs.2017.12.039] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 11/15/2017] [Accepted: 12/05/2017] [Indexed: 11/26/2022]
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Elattar MA, Vink LW, van Mourik MS, Baan J, vanBavel ET, Planken RN, Marquering HA. Dynamics of the aortic annulus in 4D CT angiography for transcatheter aortic valve implantation patients. PLoS One 2017; 12:e0184133. [PMID: 28886071 PMCID: PMC5590871 DOI: 10.1371/journal.pone.0184133] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 08/18/2017] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Transcatheter aortic valve implantation (TAVI) is a well-established treatment for patients with severe aortic valve stenosis. This procedure requires pre-operative planning by assessment of aortic dimensions on CT Angiography (CTA). It is well-known that the aortic root dimensions vary over the heart cycle. However, sizing is commonly performed at either mid-systole or end-diastole only, which has resulted in an inadequate understanding of its full dynamic behavior. STUDY GOAL We studied the variation in annulus measurements during the cardiac cycle and determined if this variation is dependent on the amount of calcification at the annulus. METHODS We measured and compared aortic root annular dimensions and calcium volume in CTA acquisitions at 10 cardiac cycle phases in 51 aortic stenosis patients. Sub-group analysis was performed based on the volume of calcium by splitting the population into mildly and severely calcified valves subgroups. RESULTS For most annulus measurements, the largest differences were found between 10% and 70 to 80% cardiac cycle phases. Mean difference (±standard deviation) in annular minimum diameter, maximum diameter, area, and aspect ratio between mid-systole and end-diastole phases were 1.0 ± 0.29 mm (p = 0.065), 0.30 ± 0.24 mm (p = 0.7), 24.1 ± 7.6 mm2 (p < 0.001), and 0.041 ± 0.012 (p = 0.039) respectively. Calcium volume measurements varied strongly during the cardiac cycle. The dynamic annulus area was behaving differently between mildly and severely calcified subgroups (p = 0.02). Furthermore, patients with severe aortic calcification were associated with larger annulus diameters. CONCLUSION There is a significant variation of annulus area and calcium volume measurement during the cardiac cycle. In our measurements, only the dynamic variation of the annulus area is dependent on the severity of the aortic calcification. For TAVI candidates, the annulus area is significantly larger in mid-systole compared to end-diastole.
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Affiliation(s)
- Mustafa A. Elattar
- Department of Biomedical Engineering and Physics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Leon W. Vink
- Department of Biomedical Engineering and Physics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Martijn S. van Mourik
- Department of Heart Center, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Jan Baan
- Department of Heart Center, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Ed T. vanBavel
- Department of Biomedical Engineering and Physics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - R. Nils Planken
- Department of Radiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Henk A. Marquering
- Department of Biomedical Engineering and Physics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Department of Radiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Cockburn J, Dooley M, Parker J, Hill A, Hutchinson N, de Belder A, Trivedi U, Hildick-Smith D. Transcatheter aortic valve-in-valve treatment of degenerative stentless supra-annular Freedom Solo valves: A single centre experience. Catheter Cardiovasc Interv 2016; 89:438-444. [DOI: 10.1002/ccd.26623] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 05/20/2016] [Accepted: 05/23/2016] [Indexed: 11/10/2022]
Affiliation(s)
- James Cockburn
- Sussex Cardiac Centre, Brighton and Sussex University Hospital, Eastern Road; Brighton, BN2 5BE UK
| | - Maureen Dooley
- Sussex Cardiac Centre, Brighton and Sussex University Hospital, Eastern Road; Brighton, BN2 5BE UK
| | - Jessica Parker
- Sussex Cardiac Centre, Brighton and Sussex University Hospital, Eastern Road; Brighton, BN2 5BE UK
| | - Andrew Hill
- Sussex Cardiac Centre, Brighton and Sussex University Hospital, Eastern Road; Brighton, BN2 5BE UK
| | - Nevil Hutchinson
- Sussex Cardiac Centre, Brighton and Sussex University Hospital, Eastern Road; Brighton, BN2 5BE UK
| | - Adam de Belder
- Sussex Cardiac Centre, Brighton and Sussex University Hospital, Eastern Road; Brighton, BN2 5BE UK
| | - Uday Trivedi
- Sussex Cardiac Centre, Brighton and Sussex University Hospital, Eastern Road; Brighton, BN2 5BE UK
| | - David Hildick-Smith
- Sussex Cardiac Centre, Brighton and Sussex University Hospital, Eastern Road; Brighton, BN2 5BE UK
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Catheter-induced dissection of a normal right coronary artery: Reappraisal of the underlying mechanisms. Egypt Heart J 2016. [DOI: 10.1016/j.ehj.2015.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Bioprinting a cardiac valve. Biotechnol Adv 2015; 33:1503-21. [DOI: 10.1016/j.biotechadv.2015.07.006] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 06/30/2015] [Accepted: 07/27/2015] [Indexed: 12/13/2022]
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Stanger O, Bleuel I, Gisler F, Göber V, Reineke S, Gahl B, Aymard T, Englberger L, Carrel T, Tevaearai H. The Freedom Solo pericardial stentless valve: Single-center experience, outcomes, and long-term durability. J Thorac Cardiovasc Surg 2015; 150:70-7. [DOI: 10.1016/j.jtcvs.2015.01.060] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 01/08/2015] [Accepted: 01/24/2015] [Indexed: 11/30/2022]
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Cheung DY, Duan B, Butcher JT. Current progress in tissue engineering of heart valves: multiscale problems, multiscale solutions. Expert Opin Biol Ther 2015; 15:1155-72. [PMID: 26027436 DOI: 10.1517/14712598.2015.1051527] [Citation(s) in RCA: 128] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Heart valve disease is an increasingly prevalent and clinically serious condition. There are no clinically effective biological diagnostics or treatment strategies. The only recourse available is replacement with a prosthetic valve, but the inability of these devices to grow or respond biologically to their environments necessitates multiple resizing surgeries and life-long coagulation treatment, especially in children. Tissue engineering has a unique opportunity to impact heart valve disease by providing a living valve conduit, capable of growth and biological integration. AREAS COVERED This review will cover current tissue engineering strategies in fabricating heart valves and their progress towards the clinic, including molded scaffolds using naturally derived or synthetic polymers, decellularization, electrospinning, 3D bioprinting, hybrid techniques, and in vivo engineering. EXPERT OPINION Whereas much progress has been made to create functional living heart valves, a clinically viable product is not yet realized. The next leap in engineered living heart valves will require a deeper understanding of how the natural multi-scale structural and biological heterogeneity of the tissue ensures its efficient function. Related, improved fabrication strategies must be developed that can replicate this de novo complexity, which is likely instructive for appropriate cell differentiation and remodeling whether seeded with autologous stem cells in vitro or endogenously recruited cells.
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Affiliation(s)
- Daniel Y Cheung
- Cornell University, Department of Biomedical Engineering , Ithaca, NY , USA
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Looi JL, Lee APW, Fang F, Hsiung MC, Sun JP, Yin WH, Wei J, Tsai SK, Wan S, Wong RHL, Underwood MJ, Lin QS, Jin CN, Chen L, Yu CM. Abnormal mitral–aortic intervalvular coupling in mitral valve diseases: a study using real-time three-dimensional transesophageal echocardiography. Clin Res Cardiol 2015; 104:831-42. [DOI: 10.1007/s00392-015-0851-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 03/31/2015] [Indexed: 11/28/2022]
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Contino M, Mangini A, Lemma MG, Romagnoni C, Zerbi P, Gelpi G, Antona C. A geometric approach to aortic root surgical anatomy. Eur J Cardiothorac Surg 2015; 49:93-100. [DOI: 10.1093/ejcts/ezv059] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 01/23/2015] [Indexed: 11/13/2022] Open
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Abstract
The key for successful valve repair is full understanding of the regurgitant mechanism and sufficient evaluation of the valve. Currently, multidetector computed tomography has been introduced for evaluation. The aortic valve can be analyzed in details preoperatively. The main causes of aortic regurgitation (AR) in the adult population are degenerative leaflet change and annulus dilatation. Restoration to normal structure can be accomplished mainly by plication. Central leaflet plication near the Arantius nodule is a simple technique for redundant tissue. For leaflet deficiency, pericardial patch plasty may be an option. No universal technique exists for plication of the aortic annulus. The valve-sparing aortic root replacement firmly stabilizes the ventriculo-aortic junction (VAJ) and assures repair durability even in patients with mild to moderate root dilatation. Subcommissural annuloplasty (Cabrol stitch) does not seem sufficient for the prevention of VAJ dilatation. Circumferential annuloplasties may have a greater potential. However, convenient device for annular plication is still in development. The bicuspid aortic valve is a congenital heart valve lesion. A basic technique is free margin plication of the fused leaflet. Aortic root dilatation may contribute to AR severity. Valve-sparing aortic root replacement may improve repair durability. Considering the great advances in valve repair, young patients with AR should be informed that valve repair is a promising option for surgical treatment.
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Song MG, Yang HS, Choi JB, Shin JK, Chee HK, Kim JS. Aortic valve reconstruction with use of pericardial leaflets in adults with bicuspid aortic valve disease: early and midterm outcomes. Tex Heart Inst J 2015; 41:585-91. [PMID: 25593520 DOI: 10.14503/thij-13-3619] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
In this study, we retrospectively analyzed the outcomes of adults with bicuspid aortic valve (BAV) disease who underwent aortic valve reconstructive surgery (AVRS), consisting of replacement of the diseased BAV with 2 or 3 pericardial leaflets plus fixation of the sinotubular junction for accurate and constant leaflet coaptation. From December 2007 through April 2013, 135 consecutive patients (mean age, 49.2 ± 13.1 yr; 73.3% men) with symptomatic BAV disease underwent AVRS. Raphe was observed in 84 patients (62.2%), and the remaining 51 patients had pure BAV without raphe. A total of 122 patients (90.4%) underwent 3-leaflet reconstruction, and 13 (9.6%) underwent 2-leaflet reconstruction. Concomitant aortic wrapping with an artificial graft was performed in 63 patients (46.7%). There were no in-hospital deaths and 2 late deaths (1.5%); 6 patients (4.4%) needed valve-related reoperation. The 5-year cumulative survival rate was 98% ± 1.5%, and freedom from valve-related reoperation at 5 years was 92.7% ± 3.6%. In the last available echocardiograms, aortic regurgitation was absent or trivial in 116 patients (85.9%), mild in 16 (11.9%), moderate in 2 (1.5%), and severe in one (0.7%). The mean aortic valve gradient was 10.2 ± 4.5 mmHg, and the mean aortic valve orifice area index was 1.3 ± 0.3 cm(2)/m(2). The 3-leaflet technique resulted in lower valve gradients and greater valve areas than did the 2-leaflet technique. Thus, in patients with BAV, AVRS yielded satisfactory early and midterm results with low mortality rates and low reoperation risk after the initial procedure.
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Stanger O, Bleuel I, Reineke S, Banz Y, Erdoes G, Tevaearai H, Göber V, Carrel T, Englberger L. Pitfalls and premature failure of the Freedom SOLO stentless valve. Eur J Cardiothorac Surg 2014; 48:562-70. [DOI: 10.1093/ejcts/ezu473] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Accepted: 11/11/2014] [Indexed: 11/14/2022] Open
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Kim KH, Choi JB, Kim MH, Kim WH, Lee MK, Lee SY. Aortic valve leaflet replacement with bovine pericardium to preserve native dynamic capabilities of the aortic annulus. Tex Heart Inst J 2014; 41:97-9. [PMID: 24512414 DOI: 10.14503/thij-12-2983] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Valve replacement is typically the most appropriate option for treating aortic valve stenotic insufficiency. However, neither mechanical nor bioprosthetic replacement components preserve the circumferential expansion and contraction of a native aortic annulus during the cardiac cycle, because the prosthetic ring is affixed to the annulus. A 64-year-old man presented with a bicuspid and stenotic aortic valve, and the native annulus was too small to accommodate a porcine replacement valve. We fashioned new aortic leaflets from bovine pericardium with use of a template, and we affixed the sinotubular junction with use of inner and outer stabilization rings. Postoperative echocardiograms revealed coaptation of the 3 new leaflets with no regurgitation. At the patient's 5.5-year follow-up examination, echocardiograms showed flexible leaflet movement with a coaptation height of 7 mm, and expansion and contraction of the aortic annulus similar to that of a normal native annulus. The transvalvular pressure gradient was insignificant. If long-term durability of the new leaflets is confirmed, this method of leaflet replacement and fixation of the sinotubular junction might serve as an acceptable alternative to valve replacement in the treatment of aortic valve stenosis. We describe the patient's case and present our methods and observations.
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Affiliation(s)
- Kyung Hwa Kim
- Department of Thoracic and Cardiovascular Surgery (Drs. Choi, K. Kim, and M. Kim) and Division of Cardiology (Dr. W. Kim), Chonbuk National University Medical School, Jeonju, 561-712 Chonbuk; and Department of Thoracic and Cardiovascular Surgery (Drs. M. Lee and S. Lee), Wonkwang University School of Medicine, Iksan, 570-711 Chonbuk; Republic of Korea
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Holtz J, Teuteberg J. Management of aortic insufficiency in the continuous flow left ventricular assist device population. Curr Heart Fail Rep 2014; 11:103-10. [PMID: 24193452 DOI: 10.1007/s11897-013-0172-6] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
With the current generation of continuous-flow (CF) left ventricular assist devices (LVADs), patients are able to be supported for longer periods of time. As a result, there has been increasing focus on long-term complications from prolonged mechanical circulatory support, such as acquired aortic insufficiency (AI). In the presence of an LVAD, AI leads to a blind circulatory loop, with a portion of LVAD output regurgitating through the aortic valve (AV) into the left ventricle and back again through the device, limiting effective forward flow and ultimately leading to organ malperfusion and increased left ventricular diastolic pressures. The AV also experiences abnormal biomechanics as a result of limited valve opening in the presence of a CF LVAD. Increased shear stress, elevated transvalvular pressure gradients, and decreased valve open time all contribute to acquired AI. The prognosis of moderate to severe AI in LVAD patients is generally poor and leads to a higher rate of AV replacement and potentially reduced survival. However, there are no evidence-based guidelines for management of this challenging population. In severe AI, experts generally advocate AV replacement or repair, while lesser degrees of AI can be managed medically and/or with adjustments in pump parameters.
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Affiliation(s)
- Jonathan Holtz
- Heart and Vascular Institute, University of Pittsburgh Medical Center, S-553 Scaife Hall, 200 Lothrop Street, Pittsburgh, PA, 15213, USA,
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Chester AH, El-Hamamsy I, Butcher JT, Latif N, Bertazzo S, Yacoub MH. The living aortic valve: From molecules to function. Glob Cardiol Sci Pract 2014; 2014:52-77. [PMID: 25054122 PMCID: PMC4104380 DOI: 10.5339/gcsp.2014.11] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 04/28/2014] [Indexed: 12/12/2022] Open
Abstract
The aortic valve lies in a unique hemodynamic environment, one characterized by a range of stresses (shear stress, bending forces, loading forces and strain) that vary in intensity and direction throughout the cardiac cycle. Yet, despite its changing environment, the aortic valve opens and closes over 100,000 times a day and, in the majority of human beings, will function normally over a lifespan of 70–90 years. Until relatively recently heart valves were considered passive structures that play no active role in the functioning of a valve, or in the maintenance of its integrity and durability. However, through clinical experience and basic research the aortic valve can now be characterized as a living, dynamic organ with the capacity to adapt to its complex mechanical and biomechanical environment through active and passive communication between its constituent parts. The clinical relevance of a living valve substitute in patients requiring aortic valve replacement has been confirmed. This highlights the importance of using tissue engineering to develop heart valve substitutes containing living cells which have the ability to assume the complex functioning of the native valve.
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What Is the Role of the Ross Procedure in Today's Armamentarium? Can J Cardiol 2013; 29:1569-76. [DOI: 10.1016/j.cjca.2013.08.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Revised: 07/23/2013] [Accepted: 08/11/2013] [Indexed: 11/23/2022] Open
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Sturla F, Votta E, Stevanella M, Conti CA, Redaelli A. Impact of modeling fluid–structure interaction in the computational analysis of aortic root biomechanics. Med Eng Phys 2013; 35:1721-30. [DOI: 10.1016/j.medengphy.2013.07.015] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Revised: 07/10/2013] [Accepted: 07/19/2013] [Indexed: 10/26/2022]
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Yoshikawa H, Suzuki M, Hashimoto G, Kusunose Y, Otsuka T, Hara H, Noro M, Nakamura M, Sugi K. Assessment of cyclic changes in the diameter of the aortic annulus using speckle-tracking trans-esophageal echocardiography. ULTRASOUND IN MEDICINE & BIOLOGY 2013; 39:2084-2090. [PMID: 23953499 DOI: 10.1016/j.ultrasmedbio.2013.06.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Revised: 06/16/2013] [Accepted: 06/21/2013] [Indexed: 06/02/2023]
Abstract
It is uncertain whether dynamic variation in the diameter of the aortic annulus occurs during the cardiac cycle in humans. The purpose of this study was to analyze cyclic changes of the aortic annulus using speckle-tracking trans-esophageal echocardiography. The subjects were 40 patients with aortic stenosis and 40 controls. Absolute and relative changes in the diameter of the aortic annulus and the times at which the maximum and minimum diameters occurred during the cardiac cycle were determined using speckle-tracking trans-esophageal echocardiography. The maximum and minimum diameters were 22.9 ± 2.7 and 20.0 ± 2.9 mm, respectively, in controls. The change in diameter of the aortic annulus was 2.9 ± 0.7 mm, and the relative change was 12.9 ± 3.5%. The maximum aortic annulus diameter was reached at the onset of aortic valve opening, and the minimum diameter occurred in the rapid filling phase. The change in diameter of the aortic annulus was significantly smaller (2.2 ± 0.6 mm vs. 2.9 ± 0.7 mm, p < 0.0001), and the time to reach the maximum diameter was significantly longer (98.5 ± 17.5 ms vs. 83.4 ± 18.2 ms, p = 0.0004), in the aortic stenosis group than in the control group. The study found that dynamic changes of the aortic annulus occur in the cardiac cycle and can be measured using speckle-tracking trans-esophageal echocardiography. We also found that aortic stenosis has an effect on the extent and timing of these changes. This suggests that accurate assessment of aortic annulus diameter requires consideration of the timing of the cardiac cycle.
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Affiliation(s)
- Hisao Yoshikawa
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan.
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37
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de Kerchove L, El Khoury G. Anatomy and pathophysiology of the ventriculo-aortic junction: implication in aortic valve repair surgery. Ann Cardiothorac Surg 2013; 2:57-64. [PMID: 23977560 DOI: 10.3978/j.issn.2225-319x.2012.12.05] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2012] [Accepted: 12/20/2012] [Indexed: 11/14/2022]
Affiliation(s)
- Laurent de Kerchove
- Division of Cardiothoracic and Vascular Surgery St-Luc University Hospital, Catholic University of Louvain, Brussels, Belgium
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38
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Li K, Wang Q, Pham T, Sun W. Quantification of structural compliance of aged human and porcine aortic root tissues. J Biomed Mater Res A 2013; 102:2365-74. [PMID: 23894117 DOI: 10.1002/jbm.a.34884] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 07/15/2013] [Indexed: 11/08/2022]
Abstract
The structural compliance of the aortic root has a significant implication for valve procedures such as transcatheter aortic valve implantation and valve-sparing aortic root replacement. However, a detailed quantification of human aortic root structural compliance, particularly in different regions, has been incomplete. In this study, the structural properties of human aortic roots (81 ± 8.74 years, n = 10) were characterized and compared with those of porcine ones (6-9 months, n = 10) using a vessel pressure-inflation test. The test involved tracking three-dimensional deformation of the markers affixed on the different surface regions of the aortic roots, including the three sinuses: the noncoronary sinus (NCS), the left-coronary sinus (LCS), and the right-coronary sinus (RCS), and at three regions along the longitudinal direction of each sinus: the upper sinus (US), the middle sinus (MS), and the lower sinus (LS), and the ascending aorta (AA) region above the NCS. We found that tissue stiffness in physiological pressure range was similar among the three human sinuses. A variation in regional structural stiffness of human aorta was observed. In the circumferential direction, the LS regions were the stiffest in the LCS and RCS, whereas NCS had relatively uniform stiffness. In the longitudinal direction, the human AA regions were more compliant than all sinuses. There was a significant difference in tissue stiffness between human and porcine aortic tissues, suggesting that the mechanical properties of porcine tissues may not be analogous to aged human ones.
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Affiliation(s)
- Kewei Li
- Tissue Mechanics Laboratory, Biomedical Engineering Program and Department of Mechanical Engineering, University of Connecticut, Storrs, Connecticut, 06269
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39
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Dormand H, Mohiaddin RH. Cardiovascular magnetic resonance in Marfan syndrome. J Cardiovasc Magn Reson 2013; 15:33. [PMID: 23587220 PMCID: PMC3651373 DOI: 10.1186/1532-429x-15-33] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Accepted: 03/15/2013] [Indexed: 12/20/2022] Open
Abstract
This review provides an overview of Marfan syndrome with an emphasis on cardiovascular complications and cardiovascular imaging. Both pre- and post-operative imaging is addressed with an explanation of surgical management. All relevant imaging modalities are discussed with a particular focus on cardiovascular MR.
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Affiliation(s)
- Helen Dormand
- Manchester Heart Centre, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK
| | - Raad H Mohiaddin
- Royal Brompton Hospital and National Heart & Lung Institute, Imperial College, Sydney Street, London SW3 6NP, UK
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40
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Pouch AM, Wang H, Takabe M, Jackson BM, Sehgal CM, Gorman JH, Gorman RC, Yushkevich PA. Automated segmentation and geometrical modeling of the tricuspid aortic valve in 3D echocardiographic images. MEDICAL IMAGE COMPUTING AND COMPUTER-ASSISTED INTERVENTION : MICCAI ... INTERNATIONAL CONFERENCE ON MEDICAL IMAGE COMPUTING AND COMPUTER-ASSISTED INTERVENTION 2013; 16:485-92. [PMID: 24505702 PMCID: PMC3918680 DOI: 10.1007/978-3-642-40811-3_61] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The aortic valve has been described with variable anatomical definitions, and the consistency of 2D manual measurement of valve dimensions in medical image data has been questionable. Given the importance of image-based morphological assessment in the diagnosis and surgical treatment of aortic valve disease, there is considerable need to develop a standardized framework for 3D valve segmentation and shape representation. Towards this goal, this work integrates template-based medial modeling and multi-atlas label fusion techniques to automatically delineate and quantitatively describe aortic leaflet geometry in 3D echocardiographic (3DE) images, a challenging task that has been explored only to a limited extent. The method makes use of expert knowledge of aortic leaflet image appearance, generates segmentations with consistent topology, and establishes a shape-based coordinate system on the aortic leaflets that enables standardized automated measurements. In this study, the algorithm is evaluated on 11 3DE images of normal human aortic leaflets acquired at mid systole. The clinical relevance of the method is its ability to capture leaflet geometry in 3DE image data with minimal user interaction while producing consistent measurements of 3D aortic leaflet geometry.
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Affiliation(s)
- Alison M. Pouch
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA
| | - Hongzhi Wang
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Manabu Takabe
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA
| | - Benjamin M. Jackson
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA,Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Chandra M. Sehgal
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph H. Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA,Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert C. Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA,Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Paul A. Yushkevich
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
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Hockaday LA, Kang KH, Colangelo NW, Cheung PYC, Duan B, Malone E, Wu J, Girardi LN, Bonassar LJ, Lipson H, Chu CC, Butcher JT. Rapid 3D printing of anatomically accurate and mechanically heterogeneous aortic valve hydrogel scaffolds. Biofabrication 2012; 4:035005. [PMID: 22914604 DOI: 10.1088/1758-5082/4/3/035005] [Citation(s) in RCA: 371] [Impact Index Per Article: 30.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The aortic valve exhibits complex three-dimensional (3D) anatomy and heterogeneity essential for the long-term efficient biomechanical function. These are, however, challenging to mimic in de novo engineered living tissue valve strategies. We present a novel simultaneous 3D printing/photocrosslinking technique for rapidly engineering complex, heterogeneous aortic valve scaffolds. Native anatomic and axisymmetric aortic valve geometries (root wall and tri-leaflets) with 12-22 mm inner diameters (ID) were 3D printed with poly-ethylene glycol-diacrylate (PEG-DA) hydrogels (700 or 8000 MW) supplemented with alginate. 3D printing geometric accuracy was quantified and compared using Micro-CT. Porcine aortic valve interstitial cells (PAVIC) seeded scaffolds were cultured for up to 21 days. Results showed that blended PEG-DA scaffolds could achieve over tenfold range in elastic modulus (5.3±0.9 to 74.6±1.5 kPa). 3D printing times for valve conduits with mechanically contrasting hydrogels were optimized to 14 to 45 min, increasing linearly with conduit diameter. Larger printed valves had greater shape fidelity (93.3±2.6, 85.1±2.0 and 73.3±5.2% for 22, 17 and 12 mm ID porcine valves; 89.1±4.0, 84.1±5.6 and 66.6±5.2% for simplified valves). PAVIC seeded scaffolds maintained near 100% viability over 21 days. These results demonstrate that 3D hydrogel printing with controlled photocrosslinking can rapidly fabricate anatomical heterogeneous valve conduits that support cell engraftment.
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Affiliation(s)
- L A Hockaday
- Department of Biomedical Engineering, Cornell University, Ithaca, NY, USA
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42
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Bertaso AG, Wong DTL, Liew GYH, Cunnington MS, Richardson JD, Thomson VS, Lorraine B, Kourlis G, Leech D, Worthley MI, Worthley SG. Aortic annulus dimension assessment by computed tomography for transcatheter aortic valve implantation: differences between systole and diastole. Int J Cardiovasc Imaging 2012; 28:2091-8. [PMID: 22318541 DOI: 10.1007/s10554-012-0018-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Accepted: 01/16/2012] [Indexed: 01/17/2023]
Abstract
Accurate assessment of aortic annular dimensions is essential for successful transcatheter aortic valve implantation (TAVI). Annular dimensions are conventionally measured in mid-systole by multidetector computed tomography (MDCT), echocardiography and angiography. Significant differences in systolic and diastolic aortic annular dimensions have been demonstrated in cohorts without aortic stenosis (AS), but it is unknown whether similar dynamic variation in annular dimensions exists in patients with severe calcific AS in whom aortic compliance is likely to be substantially reduced. We investigated the variation in aortic annular dimensions between systole and diastole in patients with severe calcific AS. Patients with severe calcific AS referred for TAVI were evaluated by 128-slice MDCT. Aortic annular diameter was measured during diastole and systole in the modified coronal, modified sagittal, and basal ring planes (maximal, minimal and mean diameters). Differences between systole and diastole were analysed by paired t test. Fifty-nine patients were included in the analysis. Three of the five aortic dimensions measured increased significantly during systole. The largest change was a 0.75 mm (3.4%) mean increase in the minimal diameter of the basal ring during systole (p = 0.004). This corresponds closely to the modified sagittal view, which also increased by mean 0.42 mm (1.9%) during systole (p = 0.008). There was no significant change in the maximal diameter of the basal ring or the modified coronal view during systole (p > 0.05). There is a small magnitude but statistically significant difference in aortic annulus dimensions of patients with severe AS referred for TAVI when measured in diastole and systole. This small difference is unlikely to alter clinical decisions regarding prosthesis size or suitability for TAVI.
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Affiliation(s)
- Angela G Bertaso
- Cardiovascular Research Centre, Royal Adelaide Hospital, Adelaide, Australia
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de Heer LM, Budde RP, van Prehn J, Mali WP, Bartels LW, Stella PR, van Herwerden LA, Kluin J, Vincken KL. Pulsatile Distention of the Nondiseased and Stenotic Aortic Valve Annulus: Analysis With Electrocardiogram-Gated Computed Tomography. Ann Thorac Surg 2012; 93:516-22. [DOI: 10.1016/j.athoracsur.2011.08.068] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Revised: 08/22/2011] [Accepted: 08/24/2011] [Indexed: 10/14/2022]
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Abstract
The aortic root has a unique 3-dimensional configuration and the distinctive function of supporting the aortic valve and blood vessels. The sinuses of Valsalva are crucial to create appropriate eddy currents that are important in initiating and coordinating aortic valve closure and promoting coronary artery blood flow. Most aneurysms in the aortic root are associated with degenerative changes in the elastic media rather than atherosclerosis. Valve-sparing root repair has become widely accepted, although the Bentall procedure remains the gold standard. Because reimplantation using the Valsalva graft allows root geometry to be retained and theoretically and practically prevents recurrent aortic valve regurgitation, it is considered the most reliable and preferred technique among various valve-sparing aortic root repair procedures.
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Affiliation(s)
- Hideyuki Shimizu
- Division of Cardiovascular Surgery, School of Medicine, Keio University, Shinjuku-ku, Tokyo, Japan.
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de Heer LM, Budde RPJ, Mali WPTM, de Vos AM, van Herwerden LA, Kluin J. Aortic root dimension changes during systole and diastole: evaluation with ECG-gated multidetector row computed tomography. Int J Cardiovasc Imaging 2011; 27:1195-204. [PMID: 21359833 PMCID: PMC3230759 DOI: 10.1007/s10554-011-9838-x] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Accepted: 02/16/2011] [Indexed: 10/27/2022]
Abstract
Cardiac pulsatility and aortic compliance may result in aortic area and diameter changes throughout the cardiac cycle in the entire aorta. Until this moment these dynamic changes could never be established in the aortic root (aortic annulus, sinuses of Valsalva and sinotubular junction). The aim of this study was to visualize and characterize the changes in aortic root dimensions during systole and diastole with ECG-gated multidetector row computed tomography (MDCT). MDCT scans of subjects without aortic root disease were analyzed. Retrospectively, ECG-gated reconstructions at each 10% of the cardiac cycle were made and analyzed during systole (30-40%) and diastole (70-75%). Axial planes were reconstructed at three different levels of the aortic root. At each level the maximal and its perpendicular luminal dimension were measured. The mean dimensions of the total study group (n = 108, mean age 56 ± 13 years) do not show any significant difference between systole and diastole. The individual dimensions vary up to 5 mm. However, the differences range between minus 5 mm (diastolic dimension is greater than systolic dimensions) and 5 mm (vice versa). This variability is independent of gender, age, height and weight. This study demonstrated a significant individual dynamic change in the dimensions of the aortic root. These results are highly unpredictable. Most of the healthy subjects have larger systolic dimensions, however, some do have larger diastolic dimensions.
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Affiliation(s)
- Linda M de Heer
- Department of Cardio-Thoracic Surgery, Division of Heart and Lungs, University Medical Center Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands.
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46
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Song JM. Aortic root volume and geometry: ready for clinical application? J Cardiovasc Ultrasound 2011; 19:126-7. [PMID: 22073321 PMCID: PMC3209590 DOI: 10.4250/jcu.2011.19.3.126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2011] [Revised: 08/17/2011] [Accepted: 08/17/2011] [Indexed: 11/22/2022] Open
Affiliation(s)
- Jong-Min Song
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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47
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Warraich HJ, Shahul S, Matyal R, Mahmood F. Bench to Bedside: Dynamic Mitral Valve Assessment. J Cardiothorac Vasc Anesth 2011; 25:863-6. [DOI: 10.1053/j.jvca.2011.06.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Indexed: 11/11/2022]
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Regional analysis of dynamic deformation characteristics of native aortic valve leaflets. J Biomech 2011; 44:1459-65. [PMID: 21458817 DOI: 10.1016/j.jbiomech.2011.03.017] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2010] [Revised: 01/06/2011] [Accepted: 03/14/2011] [Indexed: 11/21/2022]
Abstract
BACKGROUND The mechanical environment of the aortic valve (AV) has a significant impact on valve cellular biology and disease progression, but the regional variation in stretch across the AV leaflet is not well understood. This study, therefore, sought to quantify the regional variation in dynamic deformation characteristics of AV leaflets in the native mechanical environment in order to link leaflet stretch variation to reported AV calcification patterns. METHODS Whole porcine AVs (n=6) were sutured into a physiological left heart simulator and subjected to pulsatile and physiologically normal hemodynamic conditions. A grid of ink dots was marked on the entire ventricular surface of the AV leaflet. Dual camera stereo photogrammetry was used to determine the stretch magnitudes across the entire ventricular surface over the entire diastolic duration. RESULTS Elevated stretch magnitudes were observed along the leaflet base and coaptation line consistent with previously reported calcification patterns suggesting the higher mechanical stretch experienced by the leaflets in these regions may contribute to increased disease propensity. Transient stretch overloads were observed during diastolic closing, predominantly along the leaflet base, indicating the presence of a dynamic fluid hammer effect resulting from retrograde blood flow impacting the leaflet. We speculate the function of the leaflet base to act in cooperation with the sinuses of Valsalva to dampen the fluid hammer effect and reduce stress levels imparted on the rest of the leaflet.
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49
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Martin C, Pham T, Sun W. Significant differences in the material properties between aged human and porcine aortic tissues. Eur J Cardiothorac Surg 2010; 40:28-34. [PMID: 21177118 DOI: 10.1016/j.ejcts.2010.08.056] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2010] [Revised: 08/24/2010] [Accepted: 08/27/2010] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE Currently, percutaneous aortic valve (PAV) replacement devices are being investigated to treat aortic stenosis in patients deemed to be of too high a risk for conventional open-chest surgery. Successful PAV deployment and function are heavily reliant on the tissue-stent interaction. Many PAV feasibility trials have been conducted with porcine models under the assumption that these tissues are similar to human; however, this assumption may not be valid. The goal of this study was to characterize and compare the biomechanical properties of aged human and porcine aortic tissues. METHODS The biaxial mechanical properties of the left coronary sinus, right coronary sinus, non-coronary sinus, and ascending aorta of eight aged human (90.1 ± 6.8 years) and 10 porcine (6-9 months) hearts were quantified. Tissue structure was analyzed via histological techniques. RESULTS Aged human aortic tissues were significantly stiffer than the corresponding porcine tissues in both the circumferential and longitudinal directions (p < 0.001). In addition, the nearly linear stress-strain behavior of the porcine tissues, compared with the highly nonlinear response of the human tissues at a low strain range, suggested structural differences between the aortic tissues from these two species. Histological analysis revealed that porcine samples were composed of more elastin and less collagen fibers than the respective human samples. CONCLUSIONS Significant material and structural differences were observed between the human and porcine tissues, which raise questions on the validity of using porcine models to investigate the biomechanics involved in PAV intervention.
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Affiliation(s)
- Caitlin Martin
- Tissue Mechanics Laboratory, Biomedical Engineering Program and Mechanical Engineering Department, University of Connecticut, Storrs, CT 06269, USA
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50
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El-Hamamsy I, Eryigit Z, Stevens LM, Sarang Z, George R, Clark L, Melina G, Takkenberg JJM, Yacoub MH. Long-term outcomes after autograft versus homograft aortic root replacement in adults with aortic valve disease: a randomised controlled trial. Lancet 2010; 376:524-31. [PMID: 20684981 DOI: 10.1016/s0140-6736(10)60828-8] [Citation(s) in RCA: 251] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The ideal substitute for aortic valve replacement in patients with aortic valve disease is not known. Our hypothesis was that the regulatory and adaptive properties of a living valve substitute could improve the long-term outcomes in patients. We therefore compared these outcomes after autograft aortic root replacement (Ross procedure) versus homograft aortic root replacement in adults. METHODS Male and female patients (<69 years) requiring aortic valve surgery were randomly assigned in a one-to-one ratio to receive an autograft or a homograft aortic root replacement in one centre in the UK. The random allocation sequence was computer generated. Treatment was not masked. The primary endpoint was survival of patients at 10 years after surgery. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN03530985. FINDINGS 228 patients were randomly assigned to receive an autograft or a homograft aortic root replacement. 12 patients were excluded because they were younger than 18 years; 108 in each group received the surgery they were assigned to and were analysed. There was one (<1%) perioperative death in the autograft group versus three (3%) in the homograft group (p=0.621). At 10 years, four patients died in the autograft group versus 15 in the homograft group. Actuarial survival at 10 years was 97% (SD 2) in the autograft group versus 83% (4) in the homograft group. Hazard ratio for death in the homograft group was 4.61 (95% CI 1.71-16.03; p=0.0060). Survival of patients in the autograft group was similar to that in an age-matched and sex-matched British population (96%). INTERPRETATION Our findings support the hypothesis that a living valve implanted in the aortic position can significantly improve the long-term outcomes in patients. FUNDING Funding Magdi Yacoub Institute.
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Affiliation(s)
- Ismail El-Hamamsy
- Department of Cardiac Surgery, Royal Brompton and Harefield NHS Trust, London, UK
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