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Ebel S, Köhler B, Aggarwal A, Preim B, Behrendt B, Jung B, Gohmann RF, Riekena B, Borger M, Lurz P, Denecke T, Grothoff M, Gutberlet M. Comparison of aortic blood flow rotational direction in healthy volunteers and patients with bicuspid aortic valves using volumetric velocity-sensitive cardiovascular magnetic resonance imaging. Quant Imaging Med Surg 2023; 13:7973-7986. [PMID: 38106267 PMCID: PMC10722022 DOI: 10.21037/qims-23-183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 09/13/2023] [Indexed: 12/19/2023]
Abstract
Background The rotational direction (RD) of helical blood flow can be classified as either a clockwise (RD+) or counter-clockwise (RD-) flow. We hypothesized that this simple classification might not be sufficient for analysis in vivo and a simultaneous existence of RD+/- may occur. We utilized volumetric velocity-sensitive cardiovascular magnetic resonance imaging (4D flow MRI) to analyze rotational blood flow in the thoracic aorta. Methods Forty volunteers (22 females; mean age, 41±16 years) and seventeen patients with bicuspid aortic valves (BAVs) (9 females; mean age, 42±14 years) were prospectively included. The RDs and the calculation of the rotating blood volumes (RBVs) in the thoracic aorta were performed using a pathline-projection strategy. Results We could confirm a mainly clockwise RD in the ascending, descending aorta and in the aortic arch. Furthermore, we found a simultaneous existence of RD+/RD-. The RD+/--volume in the ascending aorta was significantly higher in BAV patients, the mean RD+/RD- percentage was approximately 80%/20% vs. 60%/40% in volunteers (P<0.01). The maximum RBV always occurred during systole. There was significantly more clockwise than counter-clockwise rotational flow in the ascending aorta (P<0.01) and the aortic arch (P<0.01), but no significant differences in the descending aorta (P=0.48). Conclusions A simultaneous occurrence of RD+/RD- indicates that a simple categorization in either of both is insufficient to describe blood flow in vivo. Rotational flow in the ascending aorta and in the aortic arch differs significantly from flow in the descending aorta. BAV patients show significantly more clockwise rotating volume in the ascending aorta compared to healthy volunteers.
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Affiliation(s)
- Sebastian Ebel
- Department of Diagnostic and Interventional Radiology, University of Leipzig – Heart Centre, Leipzig, Germany
- Department of Diagnostic and Interventional Radiology, University of Leipzig, Leipzig, Germany
| | - Benjamin Köhler
- Department of Simulation and Graphics, University of Magdeburg, Magdeburg, Germany
| | | | - Bernhard Preim
- Department of Simulation and Graphics, University of Magdeburg, Magdeburg, Germany
| | - Benjamin Behrendt
- Department of Simulation and Graphics, University of Magdeburg, Magdeburg, Germany
| | - Bernd Jung
- Department of Diagnostic, Interventional and Paediatric Radiology, University of Bern, Bern, Switzerland
| | - Robin F. Gohmann
- Department of Diagnostic and Interventional Radiology, University of Leipzig – Heart Centre, Leipzig, Germany
| | - Boris Riekena
- Department of Diagnostic and Interventional Radiology, University of Leipzig – Heart Centre, Leipzig, Germany
| | - Michael Borger
- Department of Cardiac Surgery, University Leipzig – Heart Centre, Leipzig, Germany
| | - Philipp Lurz
- Department of Cardiology, University Leipzig – Heart Centre, Leipzig, Germany
| | - Timm Denecke
- Department of Diagnostic and Interventional Radiology, University of Leipzig, Leipzig, Germany
| | - Matthias Grothoff
- Department of Diagnostic and Interventional Radiology, University of Leipzig – Heart Centre, Leipzig, Germany
| | - Matthias Gutberlet
- Department of Diagnostic and Interventional Radiology, University of Leipzig – Heart Centre, Leipzig, Germany
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Rodríguez-Palomares JF, Dux-Santoy L, Guala A, Galian-Gay L, Evangelista A. Mechanisms of Aortic Dilation in Patients With Bicuspid Aortic Valve: JACC State-of-the-Art Review. J Am Coll Cardiol 2023; 82:448-464. [PMID: 37495282 DOI: 10.1016/j.jacc.2022.10.042] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 10/07/2022] [Accepted: 10/20/2022] [Indexed: 07/28/2023]
Abstract
Bicuspid aortic valve is the most common congenital heart disease and exposes patients to an increased risk of aortic dilation and dissection. Aortic dilation is a slow, silent process, leading to a greater risk of aortic dissection. The prevention of adverse events together with optimization of the frequency of the required lifelong imaging surveillance are important for both clinicians and patients and motivated extensive research to shed light on the physiopathologic processes involved in bicuspid aortic valve aortopathy. Two main research hypotheses have been consolidated in the last decade: one supports a genetic basis for the increased prevalence of dilation, in particular for the aortic root, and the second supports the damaging impact on the aortic wall of altered flow dynamics associated with these structurally abnormal valves, particularly significant in the ascending aorta. Current opinion tends to rule out mutually excluding causative mechanisms, recognizing both as important and potentially clinically relevant.
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Affiliation(s)
- Jose F Rodríguez-Palomares
- Department of Cardiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Vall d'Hebron Institut de Recerca, Barcelona, Spain; Biomedical Research Networking Center on Cardiovascular Diseases, Instituto de Salud Carlos III, Madrid, Spain; Departament of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain.
| | | | - Andrea Guala
- Vall d'Hebron Institut de Recerca, Barcelona, Spain; Biomedical Research Networking Center on Cardiovascular Diseases, Instituto de Salud Carlos III, Madrid, Spain.
| | - Laura Galian-Gay
- Department of Cardiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Arturo Evangelista
- Department of Cardiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Vall d'Hebron Institut de Recerca, Barcelona, Spain; Biomedical Research Networking Center on Cardiovascular Diseases, Instituto de Salud Carlos III, Madrid, Spain; Departament of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain; Instituto del Corazón, Quirónsalud-Teknon, Barcelona, Spain
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Weiss EK, Jarvis K, Maroun A, Malaisrie SC, Mehta CK, McCarthy PM, Bonow RO, Avery RJ, Allen BD, Carr JC, Rigsby CK, Markl M. Systolic reverse flow derived from 4D flow cardiovascular magnetic resonance in bicuspid aortic valve is associated with aortic dilation and aortic valve stenosis: a cross sectional study in 655 subjects. J Cardiovasc Magn Reson 2023; 25:3. [PMID: 36698129 PMCID: PMC9878800 DOI: 10.1186/s12968-022-00906-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 12/04/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Bicuspid aortic valve (BAV) disease is associated with increased risk of aortopathy. In addition to current intervention guidelines, BAV mediated changes in aortic 3D hemodynamics have been considered as risk stratification measures. We aimed to evaluate the association of 4D flow cardiovascular magnetic resonance (CMR) derived voxel-wise aortic reverse flow with aortic dilation and to investigate the role of aortic valve regurgitation (AR) and stenosis (AS) on reverse flow in systole and diastole. METHODS 510 patients with BAV (52 ± 14 years) and 120 patients with trileaflet aortic valve (TAV) (61 ± 11 years) and mid-ascending aorta diameter (MAAD) > 35 mm who underwent CMR including 4D flow CMR were retrospectively included. An age and sex-matched healthy control cohort (n = 25, 49 ± 12 years) was selected. Voxel-wise reverse flow was calculated in the aorta and quantified by the mean reverse flow in the ascending aorta (AAo) during systole and diastole. RESULTS BAV patients without AS and AR demonstrated significantly increased systolic and diastolic reverse flow (222% and 13% increases respectively, p < 0.01) compared to healthy controls and also had significantly increased systolic reverse flow compared to TAV patients with aortic dilation (79% increase, p < 0.01). In patients with isolated AR, systolic and diastolic AAo reverse flow increased significantly with AR severity (c = - 83.2 and c = - 205.6, p < 0.001). In patients with isolated AS, AS severity was associated with an increase in both systolic (c = - 253.1, p < 0.001) and diastolic (c = - 87.0, p = 0.02) AAo reverse flow. Right and left/right and non-coronary fusion phenotype showed elevated systolic reverse flow (> 17% increase, p < 0.01). Right and non-coronary fusion phenotype showed decreased diastolic reverse flow (> 27% decrease, p < 0.01). MAAD was an independent predictor of systolic (p < 0.001), but not diastolic, reverse flow (p > 0.1). CONCLUSION 4D flow CMR derived reverse flow associated with BAV was successfully captured even in the absence of AR or AS and in comparison to TAV patients with aortic dilation. Diastolic AAo reverse flow increased with AR severity while AS severity strongly correlated with increased systolic reverse flow in the AAo. Additionally, increasing MAAD was independently associated with increasing systolic AAo reverse flow. Thus, systolic AAo reverse flow may be a valuable metric for evaluating disease severity in future longitudinal outcome studies.
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Affiliation(s)
- Elizabeth K. Weiss
- Department of Radiology, Feinberg School of Medicine, Northwestern University, 737 North Michigan Avenue Suite 1600, Chicago, IL 60611 USA
| | - Kelly Jarvis
- Department of Radiology, Feinberg School of Medicine, Northwestern University, 737 North Michigan Avenue Suite 1600, Chicago, IL 60611 USA
| | - Anthony Maroun
- Department of Radiology, Feinberg School of Medicine, Northwestern University, 737 North Michigan Avenue Suite 1600, Chicago, IL 60611 USA
| | - S. Chris Malaisrie
- Division of Cardiac Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL USA
| | - Christopher K. Mehta
- Division of Cardiac Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL USA
| | - Patrick M. McCarthy
- Division of Cardiac Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL USA
| | - Robert O. Bonow
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, IL USA
| | - Ryan J. Avery
- Department of Radiology, Feinberg School of Medicine, Northwestern University, 737 North Michigan Avenue Suite 1600, Chicago, IL 60611 USA
| | - Bradley D. Allen
- Department of Radiology, Feinberg School of Medicine, Northwestern University, 737 North Michigan Avenue Suite 1600, Chicago, IL 60611 USA
| | - James C. Carr
- Department of Radiology, Feinberg School of Medicine, Northwestern University, 737 North Michigan Avenue Suite 1600, Chicago, IL 60611 USA
| | - Cynthia K. Rigsby
- Department of Medical Imaging, Lurie Children’s Hospital, Chicago, IL USA
| | - Michael Markl
- Department of Radiology, Feinberg School of Medicine, Northwestern University, 737 North Michigan Avenue Suite 1600, Chicago, IL 60611 USA
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Ito S, Lu HS, Daugherty A, Sawada H. Embryonic Heterogeneity of Smooth Muscle Cells in the Complex Mechanisms of Thoracic Aortic Aneurysms. Genes (Basel) 2022; 13:genes13091618. [PMID: 36140786 PMCID: PMC9498804 DOI: 10.3390/genes13091618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 09/02/2022] [Accepted: 09/05/2022] [Indexed: 11/24/2022] Open
Abstract
Smooth muscle cells (SMCs) are the major cell type of the aortic wall and play a pivotal role in the pathophysiology of thoracic aortic aneurysms (TAAs). TAAs occur in a region-specific manner with the proximal region being a common location. In this region, SMCs are derived embryonically from either the cardiac neural crest or the second heart field. These cells of distinct origins reside in specific locations and exhibit different biological behaviors in the complex mechanism of TAAs. The purpose of this review is to enhance understanding of the embryonic heterogeneity of SMCs in the proximal thoracic aorta and their functions in TAAs.
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Affiliation(s)
- Sohei Ito
- Saha Cardiovascular Research Center, College of Medicine, University of Kentucky, Lexington, KY 40536, USA
- Saha Aortic Center, College of Medicine, University of Kentucky, Lexington, KY 40536, USA
| | - Hong S. Lu
- Saha Cardiovascular Research Center, College of Medicine, University of Kentucky, Lexington, KY 40536, USA
- Saha Aortic Center, College of Medicine, University of Kentucky, Lexington, KY 40536, USA
- Department of Physiology, College of Medicine, University of Kentucky, Lexington, KY 40536, USA
| | - Alan Daugherty
- Saha Cardiovascular Research Center, College of Medicine, University of Kentucky, Lexington, KY 40536, USA
- Saha Aortic Center, College of Medicine, University of Kentucky, Lexington, KY 40536, USA
- Department of Physiology, College of Medicine, University of Kentucky, Lexington, KY 40536, USA
| | - Hisashi Sawada
- Saha Cardiovascular Research Center, College of Medicine, University of Kentucky, Lexington, KY 40536, USA
- Saha Aortic Center, College of Medicine, University of Kentucky, Lexington, KY 40536, USA
- Department of Physiology, College of Medicine, University of Kentucky, Lexington, KY 40536, USA
- Correspondence: ; Tel.: +1-(859)-218-1705
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Ebel S, Kühn A, Aggarwal A, Köhler B, Behrendt B, Gohmann R, Riekena B, Lücke C, Ziegert J, Vogtmann C, Preim B, Kropf S, Jung B, Denecke T, Grothoff M, Gutberlet M. Quantitative normal values of helical flow, flow jets and wall shear stress of healthy volunteers in the ascending aorta. Eur Radiol 2022; 32:8597-8607. [PMID: 35612663 DOI: 10.1007/s00330-022-08866-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 04/08/2022] [Accepted: 05/08/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVES 4D flow MRI enables quantitative assessment of helical flow. We sought to generate normal values and elucidate changes of helical flow (duration, volume, length, velocities and rotational direction) and flow jet (displacement, flow angle) as well as wall shear stress (WSS). METHODS We assessed the temporal helical existence (THEX), maximum helical volume (HVmax), accumulated helical volume (HVacc), accumulated helical volume length (HVLacc), maximum forward velocity (maxVfor), maximum circumferential velocity (maxVcirc), rotational direction (RD) and maximum wall shear stress (WSS) as reported elsewhere using the software tool Bloodline in 86 healthy volunteers (46 females, mean age 41 ± 13 years). RESULTS WSS decreased by 42.1% and maxVfor by 55.7% across age. There was no link between age and gender regarding the other parameters. CONCLUSION This study provides age-dependent normal values regarding WSS and maxVfor and age- and gender-independent normal values regarding THEX, HVmax, HVacc, HVLacc, RD and maxVcirc. KEY POINTS • 4D flow provides numerous new parameters; therefore, normal values are mandatory. • Wall shear stress decreases over age. • Maximum helical forward velocity decreases over age.
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Affiliation(s)
- Sebastian Ebel
- Department of Diagnostic and Interventional Radiology, University of Leipzig - Heart Centre, Leipzig, Germany.
- Department of Diagnostic and Interventional Radiology, University of Leipzig, Liebigstr. 20, 04103, Leipzig, Germany.
| | - Alexander Kühn
- Department of Diagnostic and Interventional Radiology, University of Leipzig - Heart Centre, Leipzig, Germany
| | - Abhinav Aggarwal
- Department of Diagnostic and Interventional Radiology, University of Leipzig - Heart Centre, Leipzig, Germany
- Department of Radiology, Mata Chanan Devi Hospital of New Delhi, New Delhi, India
| | - Benjamin Köhler
- Department of Simulation and Graphics, University of Magdeburg, Magdeburg, Germany
| | - Benjamin Behrendt
- Department of Simulation and Graphics, University of Magdeburg, Magdeburg, Germany
| | - Robin Gohmann
- Department of Diagnostic and Interventional Radiology, University of Leipzig - Heart Centre, Leipzig, Germany
| | - Boris Riekena
- Department of Diagnostic and Interventional Radiology, University of Leipzig - Heart Centre, Leipzig, Germany
| | - Christian Lücke
- Department of Diagnostic and Interventional Radiology, University of Leipzig - Heart Centre, Leipzig, Germany
| | - Juliane Ziegert
- Department of Diagnostic and Interventional Radiology, University of Leipzig - Heart Centre, Leipzig, Germany
| | - Charlotte Vogtmann
- Department of Diagnostic and Interventional Radiology, University of Leipzig - Heart Centre, Leipzig, Germany
| | - Bernhard Preim
- Department of Simulation and Graphics, University of Magdeburg, Magdeburg, Germany
| | - Siegfried Kropf
- Department for Biometry and Medical Informatics, University of Magdeburg, Magdeburg, Germany
| | - Bernd Jung
- Department of Diagnostic, Interventional and Paediatric Radiology, University of Bern, Bern, Switzerland
| | - Timm Denecke
- Department of Diagnostic and Interventional Radiology, University of Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Matthias Grothoff
- Department of Diagnostic and Interventional Radiology, University of Leipzig - Heart Centre, Leipzig, Germany
| | - Matthias Gutberlet
- Department of Diagnostic and Interventional Radiology, University of Leipzig - Heart Centre, Leipzig, Germany
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Sotelo J, Franco P, Guala A, Dux-Santoy L, Ruiz-Muñoz A, Evangelista A, Mella H, Mura J, Hurtado DE, Rodríguez-Palomares JF, Uribe S. Fully Three-Dimensional Hemodynamic Characterization of Altered Blood Flow in Bicuspid Aortic Valve Patients With Respect to Aortic Dilatation: A Finite Element Approach. Front Cardiovasc Med 2022; 9:885338. [PMID: 35665243 PMCID: PMC9157575 DOI: 10.3389/fcvm.2022.885338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 04/22/2022] [Indexed: 11/13/2022] Open
Abstract
Background and PurposePrognostic models based on cardiovascular hemodynamic parameters may bring new information for an early assessment of patients with bicuspid aortic valve (BAV), playing a key role in reducing the long-term risk of cardiovascular events. This work quantifies several three-dimensional hemodynamic parameters in different patients with BAV and ranks their relationships with aortic diameter.Materials and MethodsUsing 4D-flow CMR data of 74 patients with BAV (49 right-left and 25 right-non-coronary) and 48 healthy volunteers, aortic 3D maps of seventeen 17 different hemodynamic parameters were quantified along the thoracic aorta. Patients with BAV were divided into two morphotype categories, BAV-Non-AAoD (where we include 18 non-dilated patients and 7 root-dilated patients) and BAV-AAoD (where we include the 49 patients with dilatation of the ascending aorta). Differences between volunteers and patients were evaluated using MANOVA with Pillai's trace statistic, Mann–Whitney U test, ROC curves, and minimum redundancy maximum relevance algorithm. Spearman's correlation was used to correlate the dilation with each hemodynamic parameter.ResultsThe flow eccentricity, backward velocity, velocity angle, regurgitation fraction, circumferential wall shear stress, axial vorticity, and axial circulation allowed to discriminate between volunteers and patients with BAV, even in the absence of dilation. In patients with BAV, the diameter presented a strong correlation (> |+/−0.7|) with the forward velocity and velocity angle, and a good correlation (> |+/−0.5|) with regurgitation fraction, wall shear stress, wall shear stress axial, and vorticity, also for morphotypes and phenotypes, some of them are correlated with the diameter. The velocity angle proved to be an excellent biomarker in the differentiation between volunteers and patients with BAV, BAV morphotypes, and BAV phenotypes, with an area under the curve bigger than 0.90, and higher predictor important scores.ConclusionsThrough the application of a novel 3D quantification method, hemodynamic parameters related to flow direction, such as flow eccentricity, velocity angle, and regurgitation fraction, presented the best relationships with a local diameter and effectively differentiated patients with BAV from healthy volunteers.
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Affiliation(s)
- Julio Sotelo
- School of Biomedical Engineering, Universidad de Valparaíso, Valparaíso, Chile
- Biomedical Imaging Center, Pontificia Universidad Católica de Chile, Santiago, Chile
- Millennium Institute for Intelligent Healthcare Engineering, iHEALTH, Santiago, Chile
- Millennium Nucleus in Cardiovascular Magnetic Resonance, Cardio MR, Santiago, Chile
| | - Pamela Franco
- Biomedical Imaging Center, Pontificia Universidad Católica de Chile, Santiago, Chile
- Millennium Institute for Intelligent Healthcare Engineering, iHEALTH, Santiago, Chile
- Millennium Nucleus in Cardiovascular Magnetic Resonance, Cardio MR, Santiago, Chile
- Department of Electrical Engineering, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Andrea Guala
- Department of Cardiology, Hospital Universitari Vall d'Hebron, CIBER-CV, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Lydia Dux-Santoy
- Department of Cardiology, Hospital Universitari Vall d'Hebron, CIBER-CV, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Aroa Ruiz-Muñoz
- Department of Cardiology, Hospital Universitari Vall d'Hebron, CIBER-CV, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Arturo Evangelista
- Department of Cardiology, Hospital Universitari Vall d'Hebron, CIBER-CV, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Hernan Mella
- Biomedical Imaging Center, Pontificia Universidad Católica de Chile, Santiago, Chile
- Millennium Nucleus in Cardiovascular Magnetic Resonance, Cardio MR, Santiago, Chile
- Department of Electrical Engineering, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Joaquín Mura
- Millennium Nucleus in Cardiovascular Magnetic Resonance, Cardio MR, Santiago, Chile
- Department of Mechanical Engineering, Universidad Técnica Federico Santa María, Santiago, Chile
| | - Daniel E. Hurtado
- Millennium Nucleus in Cardiovascular Magnetic Resonance, Cardio MR, Santiago, Chile
- Department of Structural and Geotechnical Engineering, Pontificia Universidad Católica de Chile, Santiago, Chile
- Institute for Biological and Medical Engineering, Schools of Engineering, Medicine and Biological Sciences, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - José F. Rodríguez-Palomares
- Department of Cardiology, Hospital Universitari Vall d'Hebron, CIBER-CV, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Sergio Uribe
- Biomedical Imaging Center, Pontificia Universidad Católica de Chile, Santiago, Chile
- Millennium Institute for Intelligent Healthcare Engineering, iHEALTH, Santiago, Chile
- Millennium Nucleus in Cardiovascular Magnetic Resonance, Cardio MR, Santiago, Chile
- Institute for Biological and Medical Engineering, Schools of Engineering, Medicine and Biological Sciences, Pontificia Universidad Católica de Chile, Santiago, Chile
- Department of Radiology, Schools of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
- *Correspondence: Sergio Uribe
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4D Flow MRI in Ascending Aortic Aneurysms: Reproducibility of Hemodynamic Parameters. APPLIED SCIENCES-BASEL 2022. [DOI: 10.3390/app12083912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
(1) Background: Aorta hemodynamics have been associated with aortic remodeling, but the reproducibility of its assessment has been evaluated marginally in patients with thoracic aortic aneurysm (TAA). The current study evaluated intra- and interobserver reproducibility of 4D flow MRI-derived hemodynamic parameters (normalized flow displacement, flow jet angle, wall shear stress (WSS) magnitude, axial WSS, circumferential WSS, WSS angle, vorticity, helicity, and local normalized helicity (LNH)) in TAA patients; (2) Methods: The thoracic aorta of 20 patients was semi-automatically segmented on 4D flow MRI data in 5 systolic phases by 3 different observers. Each time-dependent segmentation was manually improved and partitioned into six anatomical segments. The hemodynamic parameters were quantified per phase and segment. The coefficient of variation (COV) and intraclass correlation coefficient (ICC) were calculated; (3) Results: A total of 2400 lumen segments were analyzed. The mean aneurysm diameter was 50.8 ± 2.7 mm. The intra- and interobserver analysis demonstrated a good reproducibility (COV = 16–30% and ICC = 0.84–0.94) for normalized flow displacement and jet angle, a very good-to-excellent reproducibility (COV = 3–26% and ICC = 0.87–1.00) for all WSS components, helicity and LNH, and an excellent reproducibility (COV = 3–10% and ICC = 0.96–1.00) for vorticity; (4) Conclusion: 4D flow MRI-derived hemodynamic parameters are reproducible within the thoracic aorta in TAA patients.
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8
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Gontijo B. Is slim better than paunchy? J Card Surg 2021; 36:3662-3664. [PMID: 34270121 DOI: 10.1111/jocs.15817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 06/30/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Aortopulmonary mismatch (APM) in transposition of the great arteries (TGA) may be accountable for dilatation of neoaortic root and regurgitation of neoaortic valve as late complications of arterial switch operation (ASO). The manuscript from Arcieri et al. highlights an important aspect of the ASO technique: should we approach APM during ASO and what would be the best strategy to do so? DISCUSSION Techniques to approach APM at the time of ASO have been published sporadically and are very rarely employed by surgeons. Reconstruction of the neoaorta is generally achieved by trimming the suture line between the pulmonary root (neoaortic root) and ascending aorta resulting in an abnormal dilated and bulky neoaortic root already at the time of ASO. CONCLUSION Reduction of the pulmonary root dimension by ressection of a fragment of the pulmonary artery wall possibly results in a more homogenous neoaorta with consequent better hemodynamics. We believe that approaching APM during ASO will have a compelling positive impact on the late survival of patients with complex TGA.
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Affiliation(s)
- Bayard Gontijo
- Fernanda Lübe Antunes Pereira, Biocor Institute, Belo Horizonte, Brazil
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9
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Cave DGW, Panayiotou H, Bissell MM. Hemodynamic Profiles Before and After Surgery in Bicuspid Aortic Valve Disease-A Systematic Review of the Literature. Front Cardiovasc Med 2021; 8:629227. [PMID: 33842561 PMCID: PMC8024488 DOI: 10.3389/fcvm.2021.629227] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 03/02/2021] [Indexed: 11/25/2022] Open
Abstract
Bicuspid aortic valve (BAV) disease presents a unique management challenge both pre- and post-operatively. 4D flow MRI offers multiple tools for the assessment of the thoracic aorta in aortic valve disease. In particular, its assessment of flow patterns and wall shear stress have led to new understandings around the mechanisms of aneurysm development in BAV disease. Novel parameters have now been developed that have the potential to predict pathological aortic dilatation and may help to risk stratify BAV patients in future. This systematic review analyses the current 4D flow MRI literature after aortic valve and/or ascending aortic replacement in bicuspid aortic valve disease. 4D flow MRI has also identified distinct challenges posed by this cohort at the time of valve replacement compared to standard management of tri-leaflet disorders, and may help tailor the type and timing of replacement. Eccentric pathological flow patterns seen after bioprosthetic valve implantation, but not with mechanical prostheses, might be an important future consideration in intervention planning. 4D flow MRI also has promising potential in supporting the development of artificial valve prostheses and aortic conduits with more physiological flow patterns.
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Affiliation(s)
- Daniel G W Cave
- Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Hannah Panayiotou
- Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Malenka M Bissell
- Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
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10
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Xu H, Baroli D, Veneziani A. Global Sensitivity Analysis for Patient-Specific Aortic Simulations: The Role of Geometry, Boundary Condition and Large Eddy Simulation Modeling Parameters. J Biomech Eng 2021; 143:021012. [PMID: 32879943 DOI: 10.1115/1.4048336] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Indexed: 11/08/2022]
Abstract
Numerical simulations for computational hemodynamics in clinical settings require a combination of many ingredients, mathematical models, solvers and patient-specific data. The sensitivity of the solutions to these factors may be critical, particularly when we have a partial or noisy knowledge of data. Uncertainty quantification is crucial to assess the reliability of the results. We present here an extensive sensitivity analysis in aortic flow simulations, to quantify the dependence of clinically relevant quantities to the patient-specific geometry and the inflow boundary conditions. Geometry and inflow conditions are generally believed to have a major impact on numerical simulations. We resort to a global sensitivity analysis, (i.e., not restricted to a linearization around a working point), based on polynomial chaos expansion (PCE) and the associated Sobol' indices. We regard the geometry and the inflow conditions as the realization of a parametric stochastic process. To construct a physically consistent stochastic process for the geometry, we use a set of longitudinal-in-time images of a patient with an abdominal aortic aneurysm (AAA) to parametrize geometrical variations. Aortic flow is highly disturbed during systole. This leads to high computational costs, even amplified in a sensitivity analysis -when many simulations are needed. To mitigate this, we consider here a large Eddy simulation (LES) model. Our model depends in particular on a user-defined parameter called filter radius. We borrowed the tools of the global sensitivity analysis to assess the sensitivity of the solution to this parameter too. The targeted quantities of interest (QoI) include: the total kinetic energy (TKE), the time-average wall shear stress (TAWSS), and the oscillatory shear index (OSI). The results show that these indexes are mostly sensitive to the geometry. Also, we find that the sensitivity may be different during different instants of the heartbeat and in different regions of the domain of interest. This analysis helps to assess the reliability of in silico tools for clinical applications.
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Affiliation(s)
- Huijuan Xu
- School of Mechanical Engineering, Georgia Institute of Technology, Atlanta, GA 30332; Siemens Coporate Technology, Princeton, NJ 08540
| | - Davide Baroli
- Aachen Institute for Advanced Study in Computational Engineering Science, Aachen 52062, Germany
| | - Alessandro Veneziani
- Department of Mathematics, Emory University, Atlanta, GA 30322; Department of Computer Science, Emory University, Atlanta, GA 30322
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11
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Capellini K, Gasparotti E, Cella U, Costa E, Fanni BM, Groth C, Porziani S, Biancolini ME, Celi S. A novel formulation for the study of the ascending aortic fluid dynamics with in vivo data. Med Eng Phys 2020; 91:68-78. [PMID: 33008714 DOI: 10.1016/j.medengphy.2020.09.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 08/20/2020] [Accepted: 09/12/2020] [Indexed: 01/18/2023]
Abstract
Numerical simulations to evaluate thoracic aortic hemodynamics include a computational fluid dynamic (CFD) approach or fluid-structure interaction (FSI) approach. While CFD neglects the arterial deformation along the cardiac cycle by applying a rigid wall simplification, on the other side the FSI simulation requires a lot of assumptions for the material properties definition and high computational costs. The aim of this study is to investigate the feasibility of a new strategy, based on Radial Basis Functions (RBF) mesh morphing technique and transient simulations, able to introduce the patient-specific changes in aortic geometry during the cardiac cycle. Starting from medical images, aorta models at different phases of cardiac cycle were reconstructed and a transient shape deformation was obtained by proper activating incremental RBF solutions during the simulation process. The results, in terms of main hemodynamic parameters, were compared with two performed CFD simulations for the aortic model at minimum and maximum volume. Our implemented strategy copes the actual arterial variation during cardiac cycle with high accuracy, capturing the impact of geometrical variations on fluid dynamics, overcoming the complexity of a standard FSI approach.
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Affiliation(s)
- Katia Capellini
- BioCardioLab, Fondazione Toscana Gabriele Monasterio, Massa, Italy; Department of Information Engineering, University of Pisa, Pisa, Italy
| | - Emanuele Gasparotti
- BioCardioLab, Fondazione Toscana Gabriele Monasterio, Massa, Italy; Department of Information Engineering, University of Pisa, Pisa, Italy
| | - Ubaldo Cella
- Department of Enterprise Engineering, University of Rome Tor Vergata, Rome, Italy
| | | | - Benigno Marco Fanni
- BioCardioLab, Fondazione Toscana Gabriele Monasterio, Massa, Italy; Department of Information Engineering, University of Pisa, Pisa, Italy
| | - Corrado Groth
- Department of Enterprise Engineering, University of Rome Tor Vergata, Rome, Italy
| | - Stefano Porziani
- Department of Enterprise Engineering, University of Rome Tor Vergata, Rome, Italy
| | | | - Simona Celi
- BioCardioLab, Fondazione Toscana Gabriele Monasterio, Massa, Italy.
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12
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Pisano C, D'Amico F, Balistreri CR, Vacirca SR, Nardi P, Altieri C, Scioli MG, Bertoldo F, Santo L, Bellisario D, Talice M, Verzicco R, Ruvolo G, Orlandi A. Biomechanical properties and histomorphometric features of aortic tissue in patients with or without bicuspid aortic valve. J Thorac Dis 2020; 12:2304-2316. [PMID: 32642135 PMCID: PMC7330388 DOI: 10.21037/jtd.2020.03.122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background We sought to investigate and compare biomechanical properties and histomorphometric findings of thoracic ascending aorta aneurysm (TAA) tissue from patients with bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV) in order to clarify mechanisms underlying differences in the clinical course. Methods Circumferential sections of TAA tissue in patients with BAV (BAV-TAA) and TAV (TAV-TAA) were obtained during surgery and used for biomechanical tests and histomorphometrical analysis. Results In BAV-TAA, we observed biomechanical higher peak stress and lower Young modulus values compared with TAV-TAA wall. The right lateral longitudinal region seemed to be the most fragile zone of the TAA wall. Mechanical stress-induced rupture of BAV-TAA tissue was sudden and uniform in all aortic wall layers, whereas a gradual and progressive aortic wall breakage was described in TAV-TAA. Histomorphometric analysis revealed higher amount of collagen but not elastin in BAV-TAA tunica media. Conclusions The higher deformability of BAV-TAA tissue supports the hypothesis that increased wall shear stress doesn’t explain the increased risk of sudden onset of rupture and dissection; other mechanisms, likely related to alteration of specific genetic pathways and epigenetic signals, could be investigated to explain differences in aortic dissection and rupture in BAV patients.
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Affiliation(s)
- Calogera Pisano
- Department of Cardiac Surgery, Tor Vergata University Hospital, Rome, Italy
| | - Federico D'Amico
- Anatomic Pathology, Department of Biomedicine and Prevention Tor Vergata University, Rome, Italy
| | - Carmela Rita Balistreri
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (Bi.N.D.), University of Palermo, Palermo, Italy
| | - Sara Rita Vacirca
- Department of Cardiac Surgery, Tor Vergata University Hospital, Rome, Italy
| | - Paolo Nardi
- Department of Cardiac Surgery, Tor Vergata University Hospital, Rome, Italy
| | - Claudia Altieri
- Department of Cardiac Surgery, Tor Vergata University Hospital, Rome, Italy
| | - Maria Giovanna Scioli
- Anatomic Pathology, Department of Biomedicine and Prevention Tor Vergata University, Rome, Italy
| | - Fabio Bertoldo
- Department of Cardiac Surgery, Tor Vergata University Hospital, Rome, Italy
| | - Loredana Santo
- Department of Industrial Engineering, Tor Vergata University, Rome, Italy
| | - Denise Bellisario
- Department of Industrial Engineering, Tor Vergata University, Rome, Italy
| | | | - Roberto Verzicco
- Department of Industrial Engineering, Tor Vergata University, Rome, Italy
| | - Giovanni Ruvolo
- Department of Cardiac Surgery, Tor Vergata University Hospital, Rome, Italy
| | - Augusto Orlandi
- Anatomic Pathology, Department of Biomedicine and Prevention Tor Vergata University, Rome, Italy.,Department of Biomedical Sciences, Catholic University Our Lady of Good Counsel, Tirana, Albania
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13
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Lübe Antunes Pereira F, Nunes Martins C, Lopes RM, Ferber Drummond M, Fantini FA, Correa Vrandecic E, Vrandecic Peredo MO, Gontijo Filho B. Impact of pulmonary artery reduction during arterial switch operation: 14 years follow-up. Interact Cardiovasc Thorac Surg 2020; 30:917-924. [DOI: 10.1093/icvts/ivaa034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 01/16/2020] [Accepted: 02/10/2020] [Indexed: 12/29/2022] Open
Abstract
Abstract
OBJECTIVES
Pulmonary artery/aorta (PA/Ao) size discrepancy plays an important role in the development of neoaortic root growth and valve regurgitation. Since 2004, we started using PA reduction to manage severe great vessels root mismatch at the time of arterial switch operation. The purpose of this study is to evaluate the impact of this technique in the mid- and long-term follow-up.
METHODS
Patients considered to have severe PA/Ao mismatch (>2:1 ratio) underwent resection of a 3- to 4-mm flap of the posterior PA wall. Patients submitted to this technique were followed up with clinical and image examinations. Echocardiographic findings were reviewed, and Z-scores were recorded to evaluate the incidence and progression of neoaortic root dilatation and valve regurgitation.
RESULTS
The median (Q1–Q3) follow-up time was 8 years (3–11). Before arterial switch operation, the median (Q1–Q3) Z-score of the PA annulus was 2.90 (2.75–3.75). At the latest follow-up, the median Z-score of the neoaortic annulus was 1.34 (0.95–1.66). The mean difference between the Z-scores of PA annulus and neoaortic annulus was 1.56 (P < 0.0001). The mean value of the sinus of Valsalva was +0.29 ± 1, that of sinotubular junction was +0.71 ± 0.6 and that of ascending Ao was +1.09 ± 0.7. There was no severe dilatation of the neoaortic annulus, neoaortic root or ascending Ao during follow-up. Neoaortic valve regurgitation was none or mild in 93% of patients.
CONCLUSIONS
PA reduction proved to be a feasible and low-risk procedure to approach PA/Ao mismatch in arterial switch operation. Mid- and long-term follow-up showed a tendency towards stabilization of the neoaortic root dilatation and satisfactory valve performance after the procedure. Further investigation is required with a larger population and longer-term follow-up.
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Affiliation(s)
| | | | - Roberto Max Lopes
- Department of Paediatric Cardiology, Biocor Instituto, Belo Horizonte, Brazil
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14
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Blais S, Meloche-Dumas L, Fournier A, Dallaire F, Dahdah N. Long-Term Risk Factors for Dilatation of the Proximal Aorta in a Large Cohort of Children With Bicuspid Aortic Valve. Circ Cardiovasc Imaging 2020; 13:e009675. [DOI: 10.1161/circimaging.119.009675] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Patients with bicuspid aortic valve (BAV) have a higher risk of developing aortic valve dysfunction and progressive proximal aorta dilatation, which can lead to aortic dissection. To this day, identification of children at risk of developing severe aortic dilatation during their pediatric follow-up is still challenging because most studies were restricted to adult subjects. The overarching goal of this study was to identify risk factors of aortic dilatation in children with BAV.
Methods:
We extracted clinical and echocardiographic data of all BAV subjects aged 0 to 20 years followed at Centre Hospitalier Universitaire Sainte-Justine between 1999 and 2016. We excluded subjects with concomitant heart defects and conditions affecting proximal aorta dimensions. Proximal aorta diameters (expressed as
Z
scores) were modeled in relation to age and potential predictive variables in a linear mixed model. The primary outcome was the rate of dilatation.
Results:
We included 761 subjects (3134 echocardiograms) in final analyses. The mean ascending aorta
Z
score progression rate for BAV patient with a normally functioning aortic valve was estimated at 0.05
Z
score unit per year. The strongest predictors of an increased dilatation rate were severe aortic stenosis, moderate and severe aortic regurgitation, and uncorrected coarctation of the aorta. Aortic valve leaflet fusion pattern and sex were not associated with progression rate.
Conclusions:
Children with a normally functioning BAV exhibited a very slow proximal aorta dilatation rate. Ascending aorta dilatation rate was significantly increased in patients with more than mild aortic valve dysfunction but was independent from BAV leaflet fusion type.
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Affiliation(s)
- Samuel Blais
- Department of Pediatrics, Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Canada (S.B., F.D.)
| | - Léamarie Meloche-Dumas
- Department of General Surgery, Maisonneuve-Rosemont Hospital, Montreal, Canada (L.M.-D.)
| | - Anne Fournier
- Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Canada (A.F., N.D.)
| | - Frederic Dallaire
- Department of Pediatrics, Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Canada (S.B., F.D.)
| | - Nagib Dahdah
- Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Canada (A.F., N.D.)
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15
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Mahon C, Mohiaddin RH. The emerging applications of cardiovascular magnetic resonance imaging in transcatheter aortic valve implantation. Clin Radiol 2019; 76:73.e21-73.e37. [PMID: 31879023 DOI: 10.1016/j.crad.2019.11.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 11/13/2019] [Indexed: 12/22/2022]
Abstract
Transcatheter aortic valve implantation (TAVI) is an alternative to surgical aortic valve replacement in selected patients with severe symptomatic aortic stenosis (AS) and high surgical risk. The planning and follow-up of TAVI requires an array of imaging techniques, each has advantages and limitations. Echocardiography and multidetector computer tomography (MDCT) have established applications in patient selection and procedure guidance, but are limited in some patients. TAVI applications of cardiovascular magnetic resonance imaging (CMRI) are emerging. CMRI can provide the structural and functional imaging details required for TAVI procedure in away comparable or superior to that obtained by echocardiography and MDCT combined. In this review, we look at the continuously evolving role of CMRI as a complimentary or an alternative to more established imaging techniques and address the advantages and disadvantages of CMRI in this setting. We discuss the role of CMRI in selecting anatomically suitable patients for the TAVI procedure and in the post-TAVI follow-up with particular emphasis on its applications for assessing AS severity and haemodynamic impact, vascular imaging for TAVI access route, quantification of paravalvular leaks and LV remodelling in the post TAVI setting as well as providing imaging biomarkers tool for AS risk-stratification.
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Affiliation(s)
- C Mahon
- Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - R H Mohiaddin
- Royal Brompton and Harefield NHS Foundation Trust, London, UK; National Heart and Lung Institute, Imperial College London, London, UK.
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16
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Li RL, Russ J, Paschalides C, Ferrari G, Waisman H, Kysar JW, Kalfa D. Mechanical considerations for polymeric heart valve development: Biomechanics, materials, design and manufacturing. Biomaterials 2019; 225:119493. [PMID: 31569017 PMCID: PMC6948849 DOI: 10.1016/j.biomaterials.2019.119493] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 08/21/2019] [Accepted: 09/11/2019] [Indexed: 01/12/2023]
Abstract
The native human heart valve leaflet contains a layered microstructure comprising a hierarchical arrangement of collagen, elastin, proteoglycans and various cell types. Here, we review the various experimental methods that have been employed to probe this intricate microstructure and which attempt to elucidate the mechanisms that govern the leaflet's mechanical properties. These methods include uniaxial, biaxial, and flexural tests, coupled with microstructural characterization techniques such as small angle X-ray scattering (SAXS), small angle light scattering (SALS), and polarized light microscopy. These experiments have revealed complex elastic and viscoelastic mechanisms that are highly directional and dependent upon loading conditions and biochemistry. Of all engineering materials, polymers and polymer-based composites are best able to mimic the tissue-level mechanical behavior of the native leaflet. This similarity to native tissue permits the fabrication of polymeric valves with physiological flow patterns, reducing the risk of thrombosis compared to mechanical valves and in some cases surpassing the in vivo durability of bioprosthetic valves. Earlier work on polymeric valves simply assumed the mechanical properties of the polymer material to be linear elastic, while more recent studies have considered the full hyperelastic stress-strain response. These material models have been incorporated into computational models for the optimization of valve geometry, with the goal of minimizing internal stresses and improving durability. The latter portion of this review recounts these developments in polymeric heart valves, with a focus on mechanical testing of polymers, valve geometry, and manufacturing methods.
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Affiliation(s)
- Richard L Li
- Department of Mechanical Engineering, Fu Foundation School of Engineering and Applied Science, Columbia University, New York, NY, USA; Division of Cardiac, Thoracic and Vascular Surgery, Section of Pediatric and Congenital Cardiac Surgery, New-York Presbyterian - Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY, USA
| | - Jonathan Russ
- Department of Civil Engineering and Engineering Mechanics, Fu Foundation School of Engineering and Applied Science, Columbia University, New York, NY, USA
| | - Costas Paschalides
- Department of Mechanical Engineering, Fu Foundation School of Engineering and Applied Science, Columbia University, New York, NY, USA
| | - Giovanni Ferrari
- Department of Surgery and Biomedical Engineering, Columbia University Medical Center, New York, NY, USA
| | - Haim Waisman
- Department of Civil Engineering and Engineering Mechanics, Fu Foundation School of Engineering and Applied Science, Columbia University, New York, NY, USA
| | - Jeffrey W Kysar
- Department of Mechanical Engineering, Fu Foundation School of Engineering and Applied Science, Columbia University, New York, NY, USA; Department of Otolaryngology - Head and Neck Surgery, Columbia University Medical Center, New York, NY, USA.
| | - David Kalfa
- Division of Cardiac, Thoracic and Vascular Surgery, Section of Pediatric and Congenital Cardiac Surgery, New-York Presbyterian - Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY, USA.
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17
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Kim D, Shim CY, Kim YJ, Nam K, Hong GR, Lee SH, Lee S, Ha JW. Differences in Flow-Gradient Patterns Between Severe Bicuspid Aortic Stenosis and Severe Tricuspid Aortic Stenosis - Mechanistic Insight From Multimodal Imaging. Circ J 2019; 84:119-126. [PMID: 31787664 DOI: 10.1253/circj.cj-19-0702] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND We investigated the flow-gradient pattern characteristics and associated factors in severe bicuspid aortic stenosis (AS) compared with severe tricuspid AS.Methods and Results:A total of 252 patients with severe AS (115 bicuspid vs. 137 tricuspid) who underwent aortic valve (AV) replacement were retrospectively analyzed. Patients were classified into 4 groups according to stroke volume index and mean pressure gradient across the AV [normal-flow-high-gradient (NF-HG), low-flow-high-gradient, normal-flow-low-gradient, low-flow-low-gradient (LF-LG)]. In 89 patients who underwent cardiac computed tomography (CT), influential structural parameters of the left ventricular outflow tract (LVOT), AV and ascending aorta were assessed. Bicuspid AS was more likely to present a NF-HG pattern (83.5% vs. 64.2%, P<0.001), and significantly fewer presented a LF-LG pattern compared with tricuspid AS. In bicuspid AS, there was a significant mismatch between geometric orifice area (GOA) on CT planimetry and effective orifice area (EOA) calculated using the echocardiographic continuity equation. Bicuspid AS presented with a larger angle between the LVOT-AV and aorta. Multivariate analysis of bicuspid AS revealed that systemic arterial compliance (β=-0.350, P=0.031) and the LVOT-AV-aorta angle (β=-0.538, P=0.001), and stroke volume index (β=0.409, P=0.008) were associated with a discrepancy between GOA and EOA. CONCLUSIONS Flow-gradient patterns in bicuspid AS differ from those of tricuspid AS and are associated with the structural and functional characteristics of the aorta.
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Affiliation(s)
- Darae Kim
- Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Chi Young Shim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Young Jin Kim
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine
| | - Kyungsun Nam
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine
| | - Geu-Ru Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine
| | - Seung Hyun Lee
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine
| | - Sak Lee
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine
| | - Jong-Won Ha
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine
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18
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Cobey FC, Khoche S. Double Envelope With Continuous Wave Doppler: Not an Artifact. J Cardiothorac Vasc Anesth 2019; 33:3223-3227. [DOI: 10.1053/j.jvca.2019.05.050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 05/31/2019] [Indexed: 11/11/2022]
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19
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Borger MA, Fedak PWM, Stephens EH, Gleason TG, Girdauskas E, Ikonomidis JS, Khoynezhad A, Siu SC, Verma S, Hope MD, Cameron DE, Hammer DF, Coselli JS, Moon MR, Sundt TM, Barker AJ, Markl M, Della Corte A, Michelena HI, Elefteriades JA. The American Association for Thoracic Surgery consensus guidelines on bicuspid aortic valve-related aortopathy: Full online-only version. J Thorac Cardiovasc Surg 2019; 156:e41-e74. [PMID: 30011777 DOI: 10.1016/j.jtcvs.2018.02.115] [Citation(s) in RCA: 169] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 01/17/2018] [Accepted: 02/12/2018] [Indexed: 12/11/2022]
Abstract
Bicuspid aortic valve disease is the most common congenital cardiac disorder, being present in 1% to 2% of the general population. Associated aortopathy is a common finding in patients with bicuspid aortic valve disease, with thoracic aortic dilation noted in approximately 40% of patients in referral centers. Several previous consensus statements and guidelines have addressed the management of bicuspid aortic valve-associated aortopathy, but none focused entirely on this disease process. The current guidelines cover all major aspects of bicuspid aortic valve aortopathy, including natural history, phenotypic expression, histology and molecular pathomechanisms, imaging, indications for surgery, surveillance, and follow-up, and recommendations for future research. It is intended to provide clinicians with a current and comprehensive review of bicuspid aortic valve aortopathy and to guide the daily management of these complex patients.
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Affiliation(s)
- Michael A Borger
- Leipzig Heart Center, Cardiac Surgery, University of Leipzig, Leipzig, Germany.
| | - Paul W M Fedak
- Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Thomas G Gleason
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Evaldas Girdauskas
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany
| | - John S Ikonomidis
- Division of Cardiothoracic Surgery, University of North Carolina, Chapel Hill, NC
| | - Ali Khoynezhad
- Memorial Care Heart and Vascular Institute, Memorial Care Long Beach Medical Center, Long Beach, Calif
| | - Samuel C Siu
- Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Subodh Verma
- Department of Cardiac Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Michael D Hope
- San Francisco (UCSF) Department of Radiology & Biomedical Imaging, University of California, San Francisco, Calif
| | - Duke E Cameron
- Department of Cardiac Surgery, Massachusetts General Hospital, Boston, Mass
| | - Donald F Hammer
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Texas Heart Institute, Baylor College of Medicine, Houston, Tex
| | - Marc R Moon
- Section of Cardiac Surgery, Washington University School of Medicine, St Louis, Mo
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Mass
| | - Alex J Barker
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Ill
| | - Michael Markl
- Departments of Radiology and Biomedical Engineering, Feinberg School of Medicine, Northwestern University, Chicago, Ill
| | | | | | - John A Elefteriades
- Department of Cardiothoracic Surgery, Yale University School of Medicine, New Haven, Conn
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20
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Hiraoka T, Komiya T, Shimamoto T. Enlargement Rate of the Ascending Aorta After Thoracic Endovascular Aortic Repair. Semin Thorac Cardiovasc Surg 2019; 32:211-217. [PMID: 31546005 DOI: 10.1053/j.semtcvs.2019.09.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 09/17/2019] [Indexed: 01/25/2023]
Abstract
It is known that the elasticity of the thoracic aorta decreases when it is covered with endografts. It remains to be clarified, however, whether endografts in the descending aorta affect aortic stiffening in the ascending aorta. We analyzed 46 patients who underwent thoracic endovascular aortic repair for descending thoracic aortic aneurysm between January 2008 and June 2016. We calculated the preoperative and postoperative rate of enlargement of the mid-ascending aorta using enhanced computed tomography. In 3 of these patients, we evaluated the peak systolic and time-averaged wall shear stress and relative cross-section area change at the level of the mid-ascending aorta using 4-dimensional flow magnetic resonance imaging. The postoperative rate of enlargement of the mid-ascending aorta was significantly greater than the preoperative rate (0.78 [0.31-1.38] mm/y vs 0.32 [0.12-0.60] mm/y; P < 0.001). In 2 of the 3 patients analyzed by 4-dimensional flow magnetic resonance imaging, the waveform of time-averaged wall shear stress had changed, and the relative cross-section area change decreased after thoracic endovascular aortic repair. There were no secondary surgical interventions for the ascending aorta after thoracic endovascular aortic repair. The rate of enlargement of the ascending aorta may be affected by the change in wall shear stress or aortic stiffening after thoracic endovascular aortic repair.
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Affiliation(s)
- Toshifumi Hiraoka
- Department of Cardiovascular Surgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan.
| | - Tatsuhiko Komiya
- Department of Cardiovascular Surgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan
| | - Takeshi Shimamoto
- Department of Cardiovascular Surgery, Kurashiki Central Hospital, Kurashiki, Okayama, Japan
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22
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Yevtushenko P, Hellmeier F, Bruening J, Nordmeyer S, Falk V, Knosalla C, Kelm M, Kuehne T, Goubergrits L. Surgical Aortic Valve Replacement: Are We Able to Improve Hemodynamic Outcome? Biophys J 2019; 117:2324-2336. [PMID: 31427066 DOI: 10.1016/j.bpj.2019.07.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 06/18/2019] [Accepted: 07/17/2019] [Indexed: 01/16/2023] Open
Abstract
Aortic valve replacement (AVR) does not usually restore physiological flow profiles. Complex flow profiles are associated with aorta dilatation, ventricle remodeling, aneurysms, and development of atherosclerosis. All these affect long-term morbidity and often require reoperations. In this pilot study, we aim to investigate an ability to optimize the real surgical AVR procedure toward flow profile associated with healthy persons. Four cases of surgical AVR (two with biological and two with mechanical valve prosthesis) with available post-treatment cardiac magnetic resonance imaging (MRI), including four-dimensional flow MRI and showing abnormal complex post-treatment hemodynamics, were investigated. All cases feature complex hemodynamic outcomes associated with valve-jet eccentricity and strong secondary flow characterized by helical flow and recirculation regions. A commercial computational fluid dynamics solver was used to simulate peak systolic hemodynamics of the real post-treatment outcome using patient-specific MRI measured boundary conditions. Then, an attempt to optimize hemodynamic outcome by modifying valve size and orientation as well as ascending aorta size reduction was made. Pressure drop, wall shear stress, secondary flow degree, helicity, maximal velocity, and turbulent kinetic energy were evaluated to characterize the AVR hemodynamic outcome. The proposed optimization strategy was successful in three of four cases investigated. Although no single parameter was identified as the sole predictor for a successful flow optimization, downsizing of the ascending aorta in combination with the valve orientation was the most effective optimization approach. Simulations promise to become an effective tool to predict hemodynamic outcome. The translation of these tools requires, however, studies with a larger cohort of patients followed by a prospective clinical validation study.
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Affiliation(s)
- Pavlo Yevtushenko
- Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Germany
| | - Florian Hellmeier
- Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Germany
| | - Jan Bruening
- Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Germany
| | - Sarah Nordmeyer
- Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Germany; Department of Congenital Heart Disease and Paediatric Cardiology, DHZB (German Heart Center Berlin), Berlin, Germany
| | - Volkmar Falk
- Partner Site Berlin, DZHK (German Centre for Cardiovascular Research), Berlin, Germany; Department of Cardiothoracic and Vascular Surgery, DHZB, Berlin, Germany
| | - Christoph Knosalla
- Partner Site Berlin, DZHK (German Centre for Cardiovascular Research), Berlin, Germany; Department of Cardiothoracic and Vascular Surgery, DHZB, Berlin, Germany
| | - Marcus Kelm
- Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Germany; Department of Congenital Heart Disease and Paediatric Cardiology, DHZB (German Heart Center Berlin), Berlin, Germany
| | - Titus Kuehne
- Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Germany; Partner Site Berlin, DZHK (German Centre for Cardiovascular Research), Berlin, Germany; Department of Congenital Heart Disease and Paediatric Cardiology, DHZB (German Heart Center Berlin), Berlin, Germany
| | - Leonid Goubergrits
- Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Germany.
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23
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Berdajs D, Mosbahi S, Eckstein FS, Charbonnier D, Ferrari E, von Segesser LK. Impact of the bicuspid aortic valve on aortic root haemodynamics: three-dimensional computed fluid dynamics simulation. Interact Cardiovasc Thorac Surg 2019; 27:446-454. [PMID: 29579303 DOI: 10.1093/icvts/ivy044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 01/08/2018] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The aim was to evaluate the impact of a bicuspid aortic valve (BAV) on local shear stress and on the pressure profile on the elements of the aortic root (AoR). METHODS The experiment setup included a BAV with aortic valve stenosis (n = 5 pigs, 67 ± 3.5 kg) and insufficiency (n = 5 pigs, 66.7 ± 4.4 kg). By implanting 6 high-fidelity microsonometric crystals in each AoR, we determined the 3-dimensional (3D) geometry of the AoR. Experimental and geometric data were used to create a 3D time- and pressure-dependent computed fluid dynamic model of the AoR with the BAV. RESULTS 3D AoR geometry was determined by AoR tilt (α) and rotation angle (β). Both values were maximal at the end of diastole: 24.41 ± 1.70° (α) and 20.90 ± 2.11° (β) for BAV with stenosis and 31.92 ± 11.51° (α) and 20.84 ± 9.80° (β) for BAV with insufficiency and minimal at peak ejection 23.42 ± 1.65° (α), 20.38 ± 1.61° (β) for stenosis and 26.62 ± 7.86° (α), 19.79 ± 8.45° (β) for insufficiency. In insufficiency, low shear stress of 0-0.08 Pa and moderate pressure (60-80 mmHg) were present. In BAV with stenosis, low shear stress of 0-0.5 Pa and moderate pressure (0-20 mmHg) were present at diastole; at peak ejection high shear stress >2 Pa and elevated pressure of >80 mmHg were present. CONCLUSIONS In a BAV with aortic valve stenosis, the haemodynamics are less favourable. The elevated pressure with elevated shear stress may over the long term promote degenerative processes in the leaflets and consequently valve function failure.
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Affiliation(s)
- Denis Berdajs
- Department of Surgery and Anesthesiology, Cardiovascular Research, University Hospital Lausanne, Lausanne, Switzerland.,Department of Cardiac Surgery, University Hospital Basel, Basel, Switzerland
| | - Selim Mosbahi
- Department of Surgery and Anesthesiology, Cardiovascular Research, University Hospital Lausanne, Lausanne, Switzerland
| | | | | | - Enrico Ferrari
- Department of Surgery and Anesthesiology, Cardiovascular Research, University Hospital Lausanne, Lausanne, Switzerland
| | - Ludwig K von Segesser
- Department of Surgery and Anesthesiology, Cardiovascular Research, University Hospital Lausanne, Lausanne, Switzerland
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24
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Rahman O, Scott M, Bollache E, Suwa K, Collins J, Carr J, Fedak P, McCarthy P, Malaisrie C, Barker AJ, Markl M. Interval changes in aortic peak velocity and wall shear stress in patients with bicuspid aortic valve disease. Int J Cardiovasc Imaging 2019; 35:1925-1934. [PMID: 31144256 DOI: 10.1007/s10554-019-01632-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Accepted: 05/18/2019] [Indexed: 11/28/2022]
Abstract
Bicuspid aortic valve (BAV) is associated with abnormal valve-mediated hemodynamics including high velocity jets and elevated wall shear stress (WSS). This study investigated interval changes in flow and WSS in a multi-year follow-up study. This cross-sectional study included n = 44 patients with BAV (age = 44.9 ± 12 years), n = 17 patients with tricuspid aortic valve and thoracic aortic dilatation (TAV with dilation, age = 54.6 ± 16.5 years), and n = 9 healthy controls (age = 49.3 ± 14.7 years) underwent baseline and serial aortic 4D flow MRI (follow-up duration: BAV: 2.6 ± 0.7 years, TAV with dilation: 2.7 ± 0.5 years, controls: 1.1 ± 0.5 years). Data analysis included quantification of aortic dimensions, peak systolic velocities, as well as regional 3D WSS in the ascending aorta. At baseline, BAV patients demonstrated uniformly elevated peak velocity and WSS compared to TAV with dilation and control groups (peak velocity 2.2 m/s vs. 1.6 m/s vs. 1.5 m/s, p < 0.004; WSS: 0.74 Pa vs. 0.45 Pa vs. 0.55 Pa, p < 0.001). For BAV, peak velocity increased from baseline to follow up (2.2 ± 0.8 to 2.3 ± 0.9 m/s, p < 0.001) while WSS decreased (0.74 ± 0.22 to 0.65 ± 0.21 Pa, p < 0.001). Aortic growth was minimal for both BAV (0.05 cm/year) and TAV with dilation (0.03-0.04 cm/year) patients. For BAV patients, increase of ascending aorta peak velocities indicated worsening of valve function at follow-up. Compared to TAV with dilation patients, BAV patients demonstrated a reduction in WSS which may indicate a compensatory mechanism to reduce elevated WSS forces by aortic remodeling.
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Affiliation(s)
- Ozair Rahman
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Michael Scott
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.,Department of Biomedical Engineering, McCormick School of Engineering, Northwestern University, Evanston, IL, USA
| | - Emilie Bollache
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Kenichiro Suwa
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jeremy Collins
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - James Carr
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Paul Fedak
- Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada.,Division of Surgery-Cardiac Surgery, Northwestern University, Chicago, IL, USA
| | - Patrick McCarthy
- Bluhm Cardiovascular Institute and Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Chris Malaisrie
- Bluhm Cardiovascular Institute and Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Alex J Barker
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Michael Markl
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA. .,Department of Biomedical Engineering, McCormick School of Engineering, Northwestern University, Evanston, IL, USA. .,Department of Radiology, Northwestern University, 737 N. Michigan Avenue Suite 1600, Chicago, IL, 60611, USA.
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25
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Messner B, Bernhard D. Bicuspid aortic valve-associated aortopathy: Where do we stand? J Mol Cell Cardiol 2019; 133:76-85. [PMID: 31152748 DOI: 10.1016/j.yjmcc.2019.05.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 05/23/2019] [Accepted: 05/28/2019] [Indexed: 01/30/2023]
Abstract
Herein we summarize the current knowledge on the bicuspid aortic valve (BAV)-associated aortopathy regarding clinical presentation and disease sub-classification, genetic background, hemodynamics, histopathology, cells and signaling, animal models, and biomarkers. Despite enormous efforts in research in all of the above areas, important issues remain unknown: (i) what is the ontogenetic basis of BAV development? (ii) how can we explain the diversity of BAV and associated aortopathy phenotypes? (iii) what are the signaling processes in aortopathy pathogenesis and how can we interfere with these processes? Despite undoubtedly great progress that has been made in the understanding of BAV-associated aortopathy, so far researchers have put together a heap of Lego bricks, but at present it is unclear if the bricks are compatible, how they fit together, and which parts are missing to build the true model of the BAV aorta. A joint approach is needed to accelerate research progress.
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Affiliation(s)
- Barbara Messner
- Cardiac Surgery Research Laboratory, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - David Bernhard
- Center for Medical Research, Medical Faculty, Johannes Kepler University Linz, Linz, Austria.
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26
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Abstract
Untreated thoracoabdominal aortic aneurysms are associated with an exceedingly high mortality rate, and surgery carries a high complication rate. Crawford's classification system of thoracoabdominal aortic aneurysms describes aneurysm morphology and stratifies patients on the basis of risk of major postoperative complications including mortality, spinal cord injury, and renal failure. Computed tomography and magnetic resonance angiography are essential for classifying thoracoabdominal aortic aneurysms and identifying other important features that impact prognosis and surgical management. Four-dimensional flow-sensitive magnetic resonance imaging is an emerging technique that may help predict complications and further impact timing of intervention.
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27
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Singh A, Horsfield MA, Bekele S, Greenwood JP, Dawson DK, Berry C, Hogrefe K, Kelly DJ, Houston JG, Guntur Ramkumar P, Uddin A, Suzuki T, McCann GP. Aortic stiffness in aortic stenosis assessed by cardiovascular MRI: a comparison between bicuspid and tricuspid valves. Eur Radiol 2018; 29:2340-2349. [PMID: 30488106 PMCID: PMC6443917 DOI: 10.1007/s00330-018-5775-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 08/03/2018] [Accepted: 09/19/2018] [Indexed: 11/17/2022]
Abstract
Objectives To compare aortic size and stiffness parameters on MRI between bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV) patients with aortic stenosis (AS). Methods MRI was performed in 174 patients with asymptomatic moderate-severe AS (mean AVAI 0.57 ± 0.14 cm2/m2) and 23 controls on 3T scanners. Valve morphology was available/analysable in 169 patients: 63 BAV (41 type-I, 22 type-II) and 106 TAV. Aortic cross-sectional areas were measured at the level of the pulmonary artery bifurcation. The ascending and descending aorta (AA, DA) distensibility, and pulse wave velocity (PWV) around the aortic arch were calculated. Results The AA and DA areas were lower in the controls, with no difference in DA distensibility or PWV, but slightly lower AA distensibility than in the patient group. With increasing age, there was a decrease in distensibility and an increase in PWV. After correcting for age, the AA maximum cross-sectional area was higher in bicuspid vs. tricuspid patients (12.97 [11.10, 15.59] vs. 10.06 [8.57, 12.04] cm2, p < 0.001), but there were no significant differences in AA distensibility (p = 0.099), DA distensibility (p = 0.498) or PWV (p = 0.235). Patients with BAV type-II valves demonstrated a significantly higher AA distensibility and lower PWV compared to type-I, despite a trend towards higher AA area. Conclusions In patients with significant AS, BAV patients do not have increased aortic stiffness compared to those with TAV despite increased ascending aortic dimensions. Those with type-II BAV have less aortic stiffness despite greater dimensions. These results demonstrate a dissociation between aortic dilatation and stiffness and suggest that altered flow patterns may play a role. Key Points • Both cellular abnormalities secondary to genetic differences and abnormal flow patterns have been implicated in the pathophysiology of aortic dilatation and increased vascular complications associated with bicuspid aortic valves (BAV). • We demonstrate an increased ascending aortic size in patients with BAV and moderate to severe AS compared to TAV and controls, but no difference in aortic stiffness parameters, therefore suggesting a dissociation between dilatation and stiffness. • Sub-group analysis showed greater aortic size but lower stiffness parameters in those with BAV type-II AS compared to BAV type-I. Electronic supplementary material The online version of this article (10.1007/s00330-018-5775-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anvesha Singh
- Department of Cardiovascular Sciences, University of Leicester and Cardiovascular Theme, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Groby road, Leicester, LE3 9QP, UK.
| | | | - Soliana Bekele
- Department of Cardiovascular Sciences, University of Leicester and Cardiovascular Theme, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Groby road, Leicester, LE3 9QP, UK
| | - John P Greenwood
- Multidisciplinary Cardiovascular Research Centre & The Division of Biomedical Imaging, Leeds Institute of Cardiovascular & Metabolic Medicine, Leeds University, Leeds, LS2 9JT, UK
| | - Dana K Dawson
- Cardiovascular Medicine Research Unit, School of Medicine and Dentistry, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - Colin Berry
- BHF Glasgow Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | - Kai Hogrefe
- Cardiology Department, Kettering General Hospital Foundation Trust, Rothwell Rd, Kettering, NN16 8UZ, UK
| | - Damian J Kelly
- Cardiology Department, Royal Derby Hospital, Uttoxeter Rd, Derby, DE22 3NE, UK
| | - John G Houston
- Division of Molecular & Clinical Medicine, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
| | - Prasad Guntur Ramkumar
- Division of Molecular & Clinical Medicine, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
| | - Akhlaque Uddin
- Multidisciplinary Cardiovascular Research Centre & The Division of Biomedical Imaging, Leeds Institute of Cardiovascular & Metabolic Medicine, Leeds University, Leeds, LS2 9JT, UK
| | - Toru Suzuki
- Department of Cardiovascular Sciences, University of Leicester and Cardiovascular Theme, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Groby road, Leicester, LE3 9QP, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester and Cardiovascular Theme, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Groby road, Leicester, LE3 9QP, UK
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28
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Affiliation(s)
- Anvesha Singh
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.,NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.,NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
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29
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Sophocleous F, Milano EG, Pontecorboli G, Chivasso P, Caputo M, Rajakaruna C, Bucciarelli-Ducci C, Emanueli C, Biglino G. Enlightening the Association between Bicuspid Aortic Valve and Aortopathy. J Cardiovasc Dev Dis 2018; 5:E21. [PMID: 29671812 PMCID: PMC6023468 DOI: 10.3390/jcdd5020021] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 04/16/2018] [Accepted: 04/16/2018] [Indexed: 12/11/2022] Open
Abstract
Bicuspid aortic valve (BAV) patients have an increased incidence of developing aortic dilation. Despite its importance, the pathogenesis of aortopathy in BAV is still largely undetermined. Nowadays, intense focus falls both on BAV morphology and progression of valvular dysfunction and on the development of aortic dilation. However, less is known about the relationship between aortic valve morphology and aortic dilation. A better understanding of the molecular pathways involved in the homeostasis of the aortic wall, including the extracellular matrix, the plasticity of the vascular smooth cells, TGFβ signaling, and epigenetic dysregulation, is key to enlighten the mechanisms underpinning BAV-aortopathy development and progression. To date, there are two main theories on this subject, i.e., the genetic and the hemodynamic theory, with an ongoing debate over the pathogenesis of BAV-aortopathy. Furthermore, the lack of early detection biomarkers leads to challenges in the management of patients affected by BAV-aortopathy. Here, we critically review the current knowledge on the driving mechanisms of BAV-aortopathy together with the current clinical management and lack of available biomarkers allowing for early detection and better treatment optimization.
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Affiliation(s)
- Froso Sophocleous
- Bristol Heart Institute, Bristol Medical School, University of Bristol, Bristol BS2 89HW, UK.
| | - Elena Giulia Milano
- Bristol Heart Institute, Bristol Medical School, University of Bristol, Bristol BS2 89HW, UK.
- Department of Medicine, Division of Cardiology, University of Verona, 37100 Verona, Italy.
| | - Giulia Pontecorboli
- Structural Interventional Cardiology Division, Department of Experimental and Clinical Medicine, University of Florence, 50100 Florence, Italy.
| | - Pierpaolo Chivasso
- Cardiac Surgery, University Hospitals Bristol, NHS Foundation Trust, Bristol BS2 8HW, UK.
| | - Massimo Caputo
- Bristol Heart Institute, Bristol Medical School, University of Bristol, Bristol BS2 89HW, UK.
- Cardiac Surgery, University Hospitals Bristol, NHS Foundation Trust, Bristol BS2 8HW, UK.
| | - Cha Rajakaruna
- Bristol Heart Institute, Bristol Medical School, University of Bristol, Bristol BS2 89HW, UK.
- Cardiac Surgery, University Hospitals Bristol, NHS Foundation Trust, Bristol BS2 8HW, UK.
| | - Chiara Bucciarelli-Ducci
- Bristol Heart Institute, Bristol Medical School, University of Bristol, Bristol BS2 89HW, UK.
- Cardiac Surgery, University Hospitals Bristol, NHS Foundation Trust, Bristol BS2 8HW, UK.
| | - Costanza Emanueli
- Bristol Heart Institute, Bristol Medical School, University of Bristol, Bristol BS2 89HW, UK.
- Cardiac Surgery, University Hospitals Bristol, NHS Foundation Trust, Bristol BS2 8HW, UK.
- National Heart and Lung Institute, Imperial College London, London SW7 2AZ, UK.
| | - Giovanni Biglino
- Bristol Heart Institute, Bristol Medical School, University of Bristol, Bristol BS2 89HW, UK.
- Cardiorespiratory Unit, Great Ormond Street Hospital for Children, NHS Foundation Trust, London WC1N 3JH, UK.
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30
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Tiago J, Guerra T, Sequeira A. A velocity tracking approach for the data assimilation problem in blood flow simulations. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2017; 33:e2856. [PMID: 27883273 DOI: 10.1002/cnm.2856] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 11/20/2016] [Indexed: 06/06/2023]
Abstract
Several advances have been made in data assimilation techniques applied to blood flow modeling. Typically, idealized boundary conditions, only verified in straight parts of the vessel, are assumed. We present a general approach, on the basis of a Dirichlet boundary control problem, that may potentially be used in different parts of the arterial system. The relevance of this method appears when computational reconstructions of the 3D domains, prone to be considered sufficiently extended, are either not possible, or desirable, because of computational costs. On the basis of taking a fully unknown velocity profile as the control, the approach uses a discretize then optimize methodology to solve the control problem numerically. The methodology is applied to a realistic 3D geometry representing a brain aneurysm. The results show that this data assimilation approach may be preferable to a pressure control strategy and that it can significantly improve the accuracy associated to typical solutions obtained using idealized velocity profiles.
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Affiliation(s)
- J Tiago
- Department of Mathematics and CEMAT, IST, ULisboa, Portugal
| | - T Guerra
- ESTBarreiro, Instituto Politécnico de Setúbal, Portugal
| | - A Sequeira
- Department of Mathematics and CEMAT, IST, ULisboa, Portugal
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31
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Aortic Valve Pathology as a Predictive Factor for Acute Aortic Dissection. Ann Thorac Surg 2017; 104:1340-1348. [DOI: 10.1016/j.athoracsur.2017.02.076] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 02/16/2017] [Accepted: 02/24/2017] [Indexed: 11/21/2022]
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32
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Stock S, Mohamed SA, Sievers HH. Bicuspid aortic valve related aortopathy. Gen Thorac Cardiovasc Surg 2017; 67:93-101. [DOI: 10.1007/s11748-017-0821-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 08/22/2017] [Indexed: 11/28/2022]
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33
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Pasta S, Gentile G, Raffa G, Bellavia D, Chiarello G, Liotta R, Luca A, Scardulla C, Pilato M. In Silico Shear and Intramural Stresses are Linked to Aortic Valve Morphology in Dilated Ascending Aorta. Eur J Vasc Endovasc Surg 2017; 54:254-263. [DOI: 10.1016/j.ejvs.2017.05.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 05/25/2017] [Indexed: 10/19/2022]
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34
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Fatehi Hassanabad A, Barker AJ, Guzzardi D, Markl M, Malaisrie C, McCarthy PM, Fedak PWM. Evolution of Precision Medicine and Surgical Strategies for Bicuspid Aortic Valve-Associated Aortopathy. Front Physiol 2017; 8:475. [PMID: 28740468 PMCID: PMC5502281 DOI: 10.3389/fphys.2017.00475] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 06/21/2017] [Indexed: 12/15/2022] Open
Abstract
Bicuspid aortic valve (BAV) is a common congenital cardiac malformation affecting 1–2% of people. BAV results from fusion of two adjacent aortic valve cusps, and is associated with dilatation of the aorta, known as bicuspid valve associated aortopathy. Bicuspid valve aortopathy is progressive and associated with catastrophic clinical events, such as aortic dissection and rupture. Therefore, frequent monitoring and early intervention with prophylactic surgical resection of the proximal aorta is often recommended. However, the specific pattern of aortopathy is highly variable among patients, with different segments of the ascending aorta being affected. Individual patient risks are sometimes difficult to predict. Resection strategies are informed by current surgical guidelines which are primarily based on aortic size and growth criteria. These criteria may not optimally reflect the risk of important aortic events. To address these issues in the care of patients with bicuspid valve aortopathy, our translational research group has focused on validating use of novel imaging techniques to establish non-invasive hemodynamic biomarkers for risk-stratifying BAV patients. In this article, we review recent efforts, successes, and ongoing challenges in the development of more precise and individualized surgical approaches for patients with bicuspid aortic valves and associated aortic disease.
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Affiliation(s)
- Ali Fatehi Hassanabad
- Section of Cardiac Surgery, Department of Cardiac Sciences, Cumming School of Medicine, Libin Cardiovascular Institute of Alberta, University of CalgaryCalgary, AB, Canada
| | - Alex J Barker
- Department of Radiology, Feinberg School of Medicine, Northwestern UniversityChicago, IL, United States
| | - David Guzzardi
- Section of Cardiac Surgery, Department of Cardiac Sciences, Cumming School of Medicine, Libin Cardiovascular Institute of Alberta, University of CalgaryCalgary, AB, Canada
| | - Michael Markl
- Department of Radiology, Feinberg School of Medicine, Northwestern UniversityChicago, IL, United States.,Department of Bioengineering, Feinberg School of Medicine, Northwestern UniversityChicago, IL, United States
| | - Chris Malaisrie
- Martha and Richard Melman Family Bicuspid Aortic Valve Program, Division of Cardiothoracic Surgery, Bluhm Cardiovascular Institute, Northwestern UniversityChicago, IL, United States
| | - Patrick M McCarthy
- Martha and Richard Melman Family Bicuspid Aortic Valve Program, Division of Cardiothoracic Surgery, Bluhm Cardiovascular Institute, Northwestern UniversityChicago, IL, United States
| | - Paul W M Fedak
- Section of Cardiac Surgery, Department of Cardiac Sciences, Cumming School of Medicine, Libin Cardiovascular Institute of Alberta, University of CalgaryCalgary, AB, Canada.,Martha and Richard Melman Family Bicuspid Aortic Valve Program, Division of Cardiothoracic Surgery, Bluhm Cardiovascular Institute, Northwestern UniversityChicago, IL, United States
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35
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Aortic shear stress in patients with bicuspid aortic valve with stenosis and insufficiency. J Thorac Cardiovasc Surg 2017; 153:1263-1272.e1. [PMID: 28268004 DOI: 10.1016/j.jtcvs.2016.12.059] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 12/13/2016] [Accepted: 12/27/2016] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Bicuspid aortic valve, characterized by valve malformation and risk for aortopathy, displays profound alteration in systolic aortic outflow and wall shear stress distribution. The present study performed 4-dimensional flow magnetic resonance imaging in patients with bicuspid aortic valve with right-left cusp fusion, focusing on the impact of valve function on hemodynamic status within the ascending aorta. METHODS Four-dimensional flow magnetic resonance imaging was performed in 50 subjects with right-left bicuspid aortic valve and 15 age- and aortic size-matched controls with tricuspid aortic valve. Patients with bicuspid aortic valve were categorized into 3 groups according to their aortic valve function as follows: bicuspid aortic valve with no more than mild aortic valve dysfunction (bicuspid aortic valve control, n = 20), bicuspid aortic valve with severe aortic insufficiency (n = 15), and bicuspid aortic valve with severe aortic stenosis (n = 15). RESULTS All patients with right-left bicuspid aortic valve exhibited peak wall shear stress at the right-anterior position of the ascending aorta (bicuspid aortic valve vs trileaflet aortic valve at the right-anterior position: 0.91 ± 0.23 N/m2 vs 0.43 ± 0.12 N/m2, P < .001) with no distinct alteration between bicuspid aortic valve with severe aortic insufficiency and bicuspid aortic valve with severe aortic stenosis. The predominance of dilatation involving the tubular ascending aorta (82%, type 2 aortopathy) persisted, with or without valve dysfunction. Compared with bicuspid aortic valve control subjects, the bicuspid aortic valve with severe aortic insufficiency group displayed universally elevated wall shear stress (0.75 ± 0.12 N/m2 vs 0.57 ± 0.09 N/m2, P < .01) in the ascending aorta, which was associated with elevated cardiac stroke volume (P < .05). The bicuspid aortic valve with severe aortic stenosis group showed elevated flow eccentricity in the form of significantly increased standard deviation of circumferential wall shear stress, which correlated with markedly increased peak aortic valve velocity (P < .01). CONCLUSIONS The location of peak aortic wall shear stress and type of aortopathy remained homogeneous among patients with right-left bicuspid aortic valve irrespective of valve dysfunction. Severe aortic insufficiency or stenosis resulted in further elevated aortic wall shear stress and exaggerated flow eccentricity.
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Pasta S, Gentile G, Raffa GM, Scardulla F, Bellavia D, Luca A, Pilato M, Scardulla C. Three-dimensional parametric modeling of bicuspid aortopathy and comparison with computational flow predictions. Artif Organs 2017; 41:E92-E102. [PMID: 28185277 DOI: 10.1111/aor.12866] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 08/17/2016] [Accepted: 08/24/2016] [Indexed: 12/16/2022]
Abstract
Bicuspid aortic valve (BAV)-associated ascending aneurysmal aortopathy (namely "bicuspid aortopathy") is a heterogeneous disease making surgeon predictions particularly challenging. Computational flow analysis can be used to evaluate the BAV-related hemodynamic disturbances, which likely lead to aneurysm enlargement and progression. However, the anatomic reconstruction process is time consuming so that predicting hemodynamic and structural evolution by computational modeling is unfeasible in routine clinical practice. The aim of the study was to design and develop a parametric program for three-dimensional (3D) representations of aneurysmal aorta and different BAV phenotypes starting from several measures derived by computed-tomography angiography (CTA). Assuming that wall shear stress (WSS) has an important implication on bicuspid aortopathy, computational flow analyses were then performed to estimate how different would such an important parameter be, if a parametric aortic geometry was used as compared to standard geometric reconstructions obtained by CTA scans. Morphologic parameters here documented can be used to rapidly model the aorta and any phenotypes of BAV. t-test and Bland-Altman plot demonstrated that WSS obtained by flow analysis of parametric aortic geometries was in good agreement with that obtained from the flow analysis of CTA-related geometries. The proposed program offers a rapid and automated tool for 3D anatomic representations of bicuspid aortopathy with promising application in routine clinical practice by reducing the amount of time for anatomic reconstructions.
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Affiliation(s)
- Salvatore Pasta
- Fondazione Ri.MED.,Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT
| | | | - Giuseppe M Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT
| | - Francesco Scardulla
- Dipartimento dell'Innovazione Industriale e Digitale (DIID), Universita di Palermo, Palermo, Italy
| | - Diego Bellavia
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT
| | - Angelo Luca
- Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT
| | - Michele Pilato
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT
| | - Cesare Scardulla
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT
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Owen JW, Raptis CA. Emerging Clinical Applications of 4D Flow MR in the Heart and Aorta. CURRENT RADIOLOGY REPORTS 2016. [DOI: 10.1007/s40134-016-0188-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Andersson M, Lantz J, Ebbers T, Karlsson M. Multidirectional WSS disturbances in stenotic turbulent flows: A pre- and post-intervention study in an aortic coarctation. J Biomech 2016; 51:8-16. [PMID: 27919417 DOI: 10.1016/j.jbiomech.2016.11.064] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 09/29/2016] [Accepted: 11/19/2016] [Indexed: 01/01/2023]
Abstract
Wall shear stress (WSS) disturbances are commonly expressed at sites of abnormal flow obstructions and may play an essential role in the pathogenesis of various vascular diseases. In laminar flows these disturbances have recently been assessed by the transverse wall shear stress (transWSS), which accounts for the WSS multidirectionality. Site-specific estimations of WSS disturbances in pulsatile transitional and turbulent type of flows are more challenging due to continuous and unpredictable changes in WSS behavior. In these complex flow settings, the transWSS may serve as a more comprehensive descriptor for assessing WSS disturbances of general nature compared to commonly used parameters. In this study large eddy simulations (LES) were used to investigate the transWSS properties in flows subjected to different pathological turbulent flow conditions, governed by a patient-specific model of an aortic coarctation pre and post balloon angioplasty. Results showed that regions of strong near-wall turbulence were collocated with regions of elevated transWSS and turbulent WSS, while in more transitional-like near-wall flow regions a closer resemblance was found between transWSS and low, and oscillatory WSS. Within the frame of this study, the transWSS parameter demonstrated a more multi-featured picture of WSS disturbances when exposed to different types of flow regimes, characteristics which were not depicted by the other parameters alone.
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Affiliation(s)
- Magnus Andersson
- Department of Management and Engineering (IEI), Linköping University, Linköping, Sweden.
| | - Jonas Lantz
- Department of Medical and Health Sciences (IMH), Linköping University, Linköping, Sweden; Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden
| | - Tino Ebbers
- Department of Medical and Health Sciences (IMH), Linköping University, Linköping, Sweden; Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden
| | - Matts Karlsson
- Department of Management and Engineering (IEI), Linköping University, Linköping, Sweden; Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden
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Abstract
PURPOSE OF REVIEW This article outlines the key research contribution to bicuspid aortic valve (BAV) aortopathy over the past 18 months. RECENT FINDINGS Investigators have further defined the current gaps in knowledge and the scope of the clinical problem of BAV aortopathy. Support for aggressive resection strategies is waning as evidence mounts to suggest that BAV is not similar to genetic connective tissue disorders with respect to aortic risks. The role of cusp fusion patterns and valve-mediated hemodynamics in disease progression is a major area of discovery. Molecular and cellular mechanisms remain elusive and contradictory. SUMMARY BAV aortopathy is a major public health problem that remains poorly understood. New insights on valve-mediated hemodynamics using novel imaging modalities may lead to more individualized resection strategies and improved clinical guidelines.
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Affiliation(s)
- Paul W M Fedak
- aDepartment of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary bDivision of Cardiac Surgery, Li Ka Shing Knowledge Institute of St Michael's Hospital, University of Toronto, Toronto, Canada cDepartment of Radiology, Northwestern University dDivision of Surgery - Cardiac Surgery, Bluhm Cardiovascular Institute, Chicago, USA
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SOUDAH E, CASACUBERTA J, GAMEZ-MONTERO PJ, PÉREZ JS, RODRÍGUEZ-CANCIO M, RAUSH G, LI CH, CARRERAS F, CASTILLA R. ESTIMATION OF WALL SHEAR STRESS USING 4D FLOW CARDIOVASCULAR MRI AND COMPUTATIONAL FLUID DYNAMICS. J MECH MED BIOL 2016. [DOI: 10.1142/s0219519417500464] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
In the last few years, wall shear stress (WSS) has arisen as a new diagnostic indicator in patients with arterial disease. There is a substantial evidence that the WSS plays a significant role, together with hemodynamic indicators, in initiation and progression of the vascular diseases. Estimation of WSS values, therefore, may be of clinical significance and the methods employed for its measurement are crucial for clinical community. Recently, four-dimensional (4D) flow cardiovascular magnetic resonance (CMR) has been widely used in a number of applications for visualization and quantification of blood flow, and although the sensitivity to blood flow measurement has increased, it is not yet able to provide an accurate three-dimensional (3D) WSS distribution. The aim of this work is to evaluate the aortic blood flow features and the associated WSS by the combination of 4D flow cardiovascular magnetic resonance (4D CMR) and computational fluid dynamics technique. In particular, in this work, we used the 4D CMR to obtain the spatial domain and the boundary conditions needed to estimate the WSS within the entire thoracic aorta using computational fluid dynamics. Similar WSS distributions were found for cases simulated. A sensitivity analysis was done to check the accuracy of the method. 4D CMR begins to be a reliable tool to estimate the WSS within the entire thoracic aorta using computational fluid dynamics. The combination of both techniques may provide the ideal tool to help tackle these and other problems related to wall shear estimation.
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Affiliation(s)
- E. SOUDAH
- Centre Internacional de Métodes Numérics en Enginyeria (CIMNE), Universitat Politécnica de Catalunya, Edificio C1, Campus Norte, Jordi Girona 1-3, Barcelona 08034, Spain
| | - J. CASACUBERTA
- E.T.S. d’Enginyeries Industrial i Aeronáutica de Terrassa, Universitat Politécnica de Catalunya, C/Colom, 11, Terrassa 08222, Spain
| | - P. J. GAMEZ-MONTERO
- E.T.S. d’Enginyeries Industrial i Aeronáutica de Terrassa, Universitat Politécnica de Catalunya, C/Colom, 11, Terrassa 08222, Spain
| | - J. S. PÉREZ
- Centre Internacional de Métodes Numérics en Enginyeria (CIMNE), Universitat Politécnica de Catalunya, Edificio C1, Campus Norte, Jordi Girona 1-3, Barcelona 08034, Spain
| | - M. RODRÍGUEZ-CANCIO
- Centre Internacional de Métodes Numérics en Enginyeria (CIMNE), Universitat Politécnica de Catalunya, Edificio C1, Campus Norte, Jordi Girona 1-3, Barcelona 08034, Spain
| | - G. RAUSH
- E.T.S. d’Enginyeries Industrial i Aeronáutica de Terrassa, Universitat Politécnica de Catalunya, C/Colom, 11, Terrassa 08222, Spain
| | - C. H. LI
- Unidad de Imagen Cardiaca, Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, Sant Antoni Maria Claret 167, Barcelona 08025, Spain
| | - F. CARRERAS
- Unidad de Imagen Cardiaca, Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, Sant Antoni Maria Claret 167, Barcelona 08025, Spain
| | - R. CASTILLA
- E.T.S. d’Enginyeries Industrial i Aeronáutica de Terrassa, Universitat Politécnica de Catalunya, C/Colom, 11, Terrassa 08222, Spain
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Tsamis A, Phillippi JA, Koch RG, Chan PG, Krawiec JT, D'Amore A, Watkins SC, Wagner WR, Vorp DA, Gleason TG. Extracellular matrix fiber microarchitecture is region-specific in bicuspid aortic valve-associated ascending aortopathy. J Thorac Cardiovasc Surg 2016; 151:1718-1728.e5. [PMID: 26979916 DOI: 10.1016/j.jtcvs.2016.02.019] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 01/25/2016] [Accepted: 02/07/2016] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Ascending thoracic aortic aneurysm (ATAA) in patients with bicuspid aortic valve (BAV) commonly dilate asymmetrically compared with patients with tricuspid aortic valve (TAV). This discrepancy in aneurysm geometry led us to hypothesize that microarchitectural differences underlie the observed asymmetric dilatation pattern. The purpose of this study was to characterize the microarchitectural distinctions of the extracellular matrix of the 2 phenotypes with a focus on the proportion of radially oriented elastin and collagen fibers in different circumferential aortic regions. METHODS Aortic tissue rings were obtained just distal to the sinotubular junction from patients with BAV or TAV undergoing elective aneurysm repair. They were sectioned into three circumferentially based regions according to adjacent aortic sinus segment (left coronary sinus [L], right coronary sinus [R], or noncoronary sinus [N]). Multiphoton microscopy was used to quantify and characterize the number of radially oriented elastin and collagen fibers. RESULTS There were fewer radially oriented fibers in medial region N and medial-intimal region R of BAV-ATAAs when compared with TAV-ATAAs (medial region N, amplitude of angular undulation of elastin = 10.67° ± 1.35° vs 15.58° ± 1.91°; P = .041; medial-intimal region R, amplitude of angular undulation of elastin = 9.83° ± 0.83° vs 14.72° ± 1.64°; P = .015). Conversely, fibers became more radially oriented in the medial-intimal region L of BAV-ATAA when compared with TAV-ATAA (amplitude of angular undulation of collagen = 18.67° ± 0.95° vs 14.56° ± 1.37°; P = .041). CONCLUSIONS The differential pattern of fiber orientation noted between L and N-R regions help explain the unique pattern of greater curvature dilatation of BAV-ATAA. The distinctions noted in matrix microarchitecture may form the basis of differing aneurysm geometries and aortic wall integrities in ATAAs arising in these different valve morphologies.
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Affiliation(s)
- Alkiviadis Tsamis
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pa; Center for Vascular Remodeling and Regeneration, University of Pittsburgh, Pittsburgh, Pa; McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pa
| | - Julie A Phillippi
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pa; Center for Vascular Remodeling and Regeneration, University of Pittsburgh, Pittsburgh, Pa; McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pa; Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Ryan G Koch
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pa
| | - Patrick G Chan
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Jeffrey T Krawiec
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pa; Center for Vascular Remodeling and Regeneration, University of Pittsburgh, Pittsburgh, Pa; McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pa
| | - Antonio D'Amore
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pa; McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pa; Department of Surgery, University of Pittsburgh, Pittsburgh, Pa; Fondazione Ri.MED, University of Palermo, Palermo, Italy; Department of Chemical, Management, Computer and Mechanical Engineering (DICIGIM), University of Palermo, Palermo, Italy
| | - Simon C Watkins
- Center for Biologic Imaging, University of Pittsburgh, Pittsburgh, Pa
| | - William R Wagner
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pa; Center for Vascular Remodeling and Regeneration, University of Pittsburgh, Pittsburgh, Pa; McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pa; Department of Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - David A Vorp
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pa; Center for Vascular Remodeling and Regeneration, University of Pittsburgh, Pittsburgh, Pa; McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pa; Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Department of Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Thomas G Gleason
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pa; Center for Vascular Remodeling and Regeneration, University of Pittsburgh, Pittsburgh, Pa; McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pa; Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa.
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Emmott A, Garcia J, Chung J, Lachapelle K, El-Hamamsy I, Mongrain R, Cartier R, Leask RL. Biomechanics of the Ascending Thoracic Aorta: A Clinical Perspective on Engineering Data. Can J Cardiol 2016; 32:35-47. [DOI: 10.1016/j.cjca.2015.10.015] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 10/17/2015] [Accepted: 10/18/2015] [Indexed: 12/14/2022] Open
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Voges I, Jerosch-Herold M, Wegner P, Hart C, Gabbert D, Al Bulushi A, Fischer G, Andrade AC, Pham HM, Kristo I, Kramer HH, Rickers C. Frequent Dilatation of the Descending Aorta in Children With Hypoplastic Left Heart Syndrome Relates to Decreased Aortic Arch Elasticity. J Am Heart Assoc 2015; 4:e002107. [PMID: 26438562 PMCID: PMC4845122 DOI: 10.1161/jaha.115.002107] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Patients with hypoplastic left heart syndrome after a Norwood operation show dilatation and reduced distensibility of the reconstructed proximal aorta. Cardiac magnetic resonance imaging (CMR) and angiographic examinations indicate that the native descending aorta (DAo) is also dilated, but this has not been studied in detail. Methods and Results Seventy‐nine children with hypoplastic left heart syndrome in Fontan circulation (aged 6.3±3.2 years) and 18 control participants (aged 6.8±2.4 years) underwent 3.0‐tesla CMR. Gradient‐echo cine and phase‐contrast imaging was applied to measure cross‐sectional areas (CSAs), distensibility, pulse wave velocity, and the incremental elastic modulus of the thoracic aorta. CSA of the DAo in patients was also compared with published percentiles for aortic CSA. Patients had significantly larger CSA of the DAo at the level of pulmonary artery bifurcation (229.1±97.2 versus 175.7±24.3 mm/m2, P=0.04) and the diaphragm (196.2±66.0 versus 142.6±16.7 mm/m2, P<0.01). In 41 patients (52%), CSA of the DAo was >95th percentile level for control participants, and the incremental elastic modulus of the aortic arch and the DAo was higher than in patients with normal CSAs (arch: 90.1±64.3 versus 45.6±38.9 m/s; DAo: 86.3±53.7 versus 47.1±47.6 m/s; P<0.01). Incremental elastic modulus of the aortic arch and the DAo correlated with the CSA of the DAo (arch: r=0.5; DAo: r=0.49; P<0.01). Conclusions Children with hypoplastic left heart syndrome frequently show dilatation of their DAo associated with increased stiffness of the aortic arch. Higher aortic impedance increases the afterload of the systemic circulation and likely contributes to the burden of the systemic right ventricle.
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Affiliation(s)
- Inga Voges
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Kiel, Germany (I.V., P.W., C.H., D.G., A.A.B., G.F., A.C.A., H.M.P., I.K., H.H.K., C.R.)
| | - Michael Jerosch-Herold
- Department of Radiology, Brigham & Women's Hospital & Harvard Medical School, Boston, MA (M.J.H.)
| | - Philip Wegner
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Kiel, Germany (I.V., P.W., C.H., D.G., A.A.B., G.F., A.C.A., H.M.P., I.K., H.H.K., C.R.)
| | - Christopher Hart
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Kiel, Germany (I.V., P.W., C.H., D.G., A.A.B., G.F., A.C.A., H.M.P., I.K., H.H.K., C.R.)
| | - Dominik Gabbert
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Kiel, Germany (I.V., P.W., C.H., D.G., A.A.B., G.F., A.C.A., H.M.P., I.K., H.H.K., C.R.)
| | - Abdullah Al Bulushi
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Kiel, Germany (I.V., P.W., C.H., D.G., A.A.B., G.F., A.C.A., H.M.P., I.K., H.H.K., C.R.)
| | - Gunther Fischer
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Kiel, Germany (I.V., P.W., C.H., D.G., A.A.B., G.F., A.C.A., H.M.P., I.K., H.H.K., C.R.)
| | - Ana Cristina Andrade
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Kiel, Germany (I.V., P.W., C.H., D.G., A.A.B., G.F., A.C.A., H.M.P., I.K., H.H.K., C.R.)
| | - Hoang Minh Pham
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Kiel, Germany (I.V., P.W., C.H., D.G., A.A.B., G.F., A.C.A., H.M.P., I.K., H.H.K., C.R.)
| | - Ines Kristo
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Kiel, Germany (I.V., P.W., C.H., D.G., A.A.B., G.F., A.C.A., H.M.P., I.K., H.H.K., C.R.)
| | - Hans-Heiner Kramer
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Kiel, Germany (I.V., P.W., C.H., D.G., A.A.B., G.F., A.C.A., H.M.P., I.K., H.H.K., C.R.)
| | - Carsten Rickers
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Kiel, Germany (I.V., P.W., C.H., D.G., A.A.B., G.F., A.C.A., H.M.P., I.K., H.H.K., C.R.)
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Martufi G, Forneris A, Appoo JJ, Di Martino ES. Is There a Role for Biomechanical Engineering in Helping to Elucidate the Risk Profile of the Thoracic Aorta? Ann Thorac Surg 2015; 101:390-8. [PMID: 26411753 DOI: 10.1016/j.athoracsur.2015.07.028] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Revised: 06/29/2015] [Accepted: 07/13/2015] [Indexed: 11/29/2022]
Abstract
Clinical estimates of rupture and dissection risk of thoracic aortic aneurysms are based on nonsophisticated measurements of maximum diameter and growth rate. The use of aortic size alone may overlook the role that vessel heterogeneity plays in assessing the risk of catastrophic complications. Biomechanics may help provide a more nuanced approach to predict the behavior of thoracic aortic aneurysms. In this report, we review modeling studies with an emphasis on mechanical and fluid dynamics analyses. We identify open problems and highlight the future possibility of a multidisciplinary approach that includes biomechanics and imaging to evaluate the likelihood of rupture or dissection.
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Affiliation(s)
- Giampaolo Martufi
- Department of Civil Engineering, University of Calgary, Calgary, Alberta, Canada
| | - Arianna Forneris
- Biomedical Engineering Graduate Program, University of Calgary, Calgary, Alberta, Canada
| | - Jehangir J Appoo
- Division of Cardiac Surgery, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Elena S Di Martino
- Department of Civil Engineering, Centre for Bioengineering Research and Education, and Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada.
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Erratum to: Quantitative Assessment of Turbulence and Flow Eccentricity in an Aortic Coarctation: Impact of Virtual Interventions. Cardiovasc Eng Technol 2015; 6:577-89. [DOI: 10.1007/s13239-015-0243-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Dyverfeldt P, Bissell M, Barker AJ, Bolger AF, Carlhäll CJ, Ebbers T, Francios CJ, Frydrychowicz A, Geiger J, Giese D, Hope MD, Kilner PJ, Kozerke S, Myerson S, Neubauer S, Wieben O, Markl M. 4D flow cardiovascular magnetic resonance consensus statement. J Cardiovasc Magn Reson 2015; 17:72. [PMID: 26257141 PMCID: PMC4530492 DOI: 10.1186/s12968-015-0174-5] [Citation(s) in RCA: 548] [Impact Index Per Article: 60.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 07/17/2015] [Indexed: 02/07/2023] Open
Abstract
Pulsatile blood flow through the cavities of the heart and great vessels is time-varying and multidirectional. Access to all regions, phases and directions of cardiovascular flows has formerly been limited. Four-dimensional (4D) flow cardiovascular magnetic resonance (CMR) has enabled more comprehensive access to such flows, with typical spatial resolution of 1.5×1.5×1.5 - 3×3×3 mm(3), typical temporal resolution of 30-40 ms, and acquisition times in the order of 5 to 25 min. This consensus paper is the work of physicists, physicians and biomedical engineers, active in the development and implementation of 4D Flow CMR, who have repeatedly met to share experience and ideas. The paper aims to assist understanding of acquisition and analysis methods, and their potential clinical applications with a focus on the heart and greater vessels. We describe that 4D Flow CMR can be clinically advantageous because placement of a single acquisition volume is straightforward and enables flow through any plane across it to be calculated retrospectively and with good accuracy. We also specify research and development goals that have yet to be satisfactorily achieved. Derived flow parameters, generally needing further development or validation for clinical use, include measurements of wall shear stress, pressure difference, turbulent kinetic energy, and intracardiac flow components. The dependence of measurement accuracy on acquisition parameters is considered, as are the uses of different visualization strategies for appropriate representation of time-varying multidirectional flow fields. Finally, we offer suggestions for more consistent, user-friendly implementation of 4D Flow CMR acquisition and data handling with a view to multicenter studies and more widespread adoption of the approach in routine clinical investigations.
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Affiliation(s)
- Petter Dyverfeldt
- Division of Cardiovascular Medicine, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
- Center for Medical Image Science and Visualization, Linköping University, Linköping, Sweden.
| | - Malenka Bissell
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford Centre for Clinical Magnetic Resonance Research, Oxford, UK.
| | - Alex J Barker
- Department of Radiology, Northwestern University, Chicago, USA.
| | - Ann F Bolger
- Division of Cardiovascular Medicine, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
- Center for Medical Image Science and Visualization, Linköping University, Linköping, Sweden.
- Department of Medicine, University of California San Francisco, San Francisco, CA, United States.
| | - Carl-Johan Carlhäll
- Division of Cardiovascular Medicine, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
- Center for Medical Image Science and Visualization, Linköping University, Linköping, Sweden.
- Department of Clinical Physiology, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
| | - Tino Ebbers
- Division of Cardiovascular Medicine, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.
- Center for Medical Image Science and Visualization, Linköping University, Linköping, Sweden.
| | | | - Alex Frydrychowicz
- Klinik für Radiologie und Nuklearmedizin, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany.
| | - Julia Geiger
- Department of Radiology, University Children's Hospital Zurich, Zurich, Switzerland.
| | - Daniel Giese
- Department of Radiology, University Hospital of Cologne, Cologne, Germany.
| | - Michael D Hope
- Department of Radiology, University of California San Francisco, San Francisco, CA, United States.
| | - Philip J Kilner
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College, London, UK.
| | - Sebastian Kozerke
- Institute for Biomedical Engineering, University and ETH Zurich, Zurich, Switzerland.
| | - Saul Myerson
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford Centre for Clinical Magnetic Resonance Research, Oxford, UK.
| | - Stefan Neubauer
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford Centre for Clinical Magnetic Resonance Research, Oxford, UK.
| | - Oliver Wieben
- Department of Radiology, University of Wisconsin, Madison, Wisconsin, USA.
- Department of Medical Physics, University of Wisconsin, Madison, Wisconsin, USA.
| | - Michael Markl
- Department of Radiology, Northwestern University, Chicago, USA.
- Department of Biomedical Engineering, Northwestern University, Chicago, IL, USA.
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47
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Sigovan M, Dyverfeldt P, Wrenn J, Tseng EE, Saloner D, Hope MD. Extended 3D approach for quantification of abnormal ascending aortic flow. Magn Reson Imaging 2015; 33:695-700. [PMID: 25721998 PMCID: PMC4426228 DOI: 10.1016/j.mri.2015.02.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Revised: 08/27/2014] [Accepted: 02/16/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND Flow displacement quantifies eccentric flow, a potential risk factor for aneurysms in the ascending aorta, but only at a single anatomic location. The aim of this study is to extend flow displacement analysis to 3D in patients with aortic and aortic valve pathologies. METHODS 43 individuals were studied with 4DFlow MRI in 6 groups: healthy, tricuspid aortic valve (TAV) with aortic stenosis (AS) but no dilatation, TAV with dilatation but no AS, and TAV with both AS and dilatation, BAV without AS or dilatation, BAV without AS but with dilation. The protocol was approved by our institutional review board, and informed consent was obtained. Flow displacement was calculated for multiple planes along the ascending aorta, and 2D and 3D analyses were compared. RESULTS Good correlation was found between 2D flow displacement and both maximum and average 3D values (r>0.8). Healthy controls had significantly lower flow displacement values with all approaches (p<0.05). The highest flow displacement was seen with stenotic TAV and aortic dilation (0.24±0.02 with maximum flow displacement). The 2D approach underestimated the maximum flow displacement by more than 20% in 13 out of 36 patients (36%). CONCLUSIONS The extended 3D flow displacement analysis offers a more comprehensive quantitative evaluation of abnormal systolic flow in the ascending aorta than 2D analysis. Differences between patient subgroups are better demonstrated, and maximum flow displacement is more reliably assessed.
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Affiliation(s)
- Monica Sigovan
- Department of Radiology and Biomedical Imaging, UCSF, CA, USA; Université de Lyon, CREATIS; CNRS UMR5220; Inserm U1044; INSA-Lyon; Université Lyon 1; Hospices Civils de Lyon, France.
| | - Petter Dyverfeldt
- Department of Radiology and Biomedical Imaging, UCSF, CA, USA; Linkoping University, Linkoping, Sweden
| | - Jarrett Wrenn
- Department of Radiology and Biomedical Imaging, UCSF, CA, USA
| | | | - David Saloner
- Department of Radiology and Biomedical Imaging, UCSF, CA, USA
| | - Michael D Hope
- Department of Radiology and Biomedical Imaging, UCSF, CA, USA
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48
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Influence of the aortic valve leaflets on the fluid-dynamics in aorta in presence of a normally functioning bicuspid valve. Biomech Model Mechanobiol 2015; 14:1349-61. [DOI: 10.1007/s10237-015-0679-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 04/22/2015] [Indexed: 01/28/2023]
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49
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Girdauskas E, Rouman M, Disha K, Espinoza A, Dubslaff G, Fey B, Theis B, Petersen I, Borger MA, Kuntze T. Aortopathy in patients with bicuspid aortic valve stenosis: role of aortic root functional parameters. Eur J Cardiothorac Surg 2015; 49:635-43; discussion 643-4. [PMID: 25855595 DOI: 10.1093/ejcts/ezv123] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 02/19/2015] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES We prospectively examined functional characteristics of the aortic root and transvalvular haemodynamic flow in order to define factors associated with the severity of aortopathy in patients undergoing surgery for bicuspid aortic valve (BAV) stenosis. METHODS A total of 103 consecutive patients with BAV stenosis (mean age 61 ± 9 years, 66% male) underwent aortic valve replacement ± concomitant aortic surgery from January 2012 through March 2014. All patients underwent preoperative cardiac magnetic resonance imaging (MRI) in order to evaluate the systolic transvalvular flow and the following functional parameters: (i) angulation between the left ventricular outflow axis and the aortic root, (ii) geometrical orientation of residual aortic valve orifice and (iii) BAV cusp fusion pattern. MRI data were used to guide sampling of the ascending aorta during surgery [i.e. jet-sample from the area where the flow-jet impacts on the aortic wall and control sample from the opposite aortic wall (obtained from the aortotomy site)]. Aortopathy was quantified by means of a histological sum-score (0 to 21+) in each sample. RESULTS A significant correlation was found between histological sum-score in the jet-sample and the angle between the LV outflow axis and the aortic root (r = 0.6, P = 0.007). Moreover, there was a linear correlation between proximal aortic diameter and the angle between systolic flow-jet and ascending aortic wall (r = 0.5, P = 0.006). Logistic regression identified the angle between the LV outflow axis and the aortic root (OR 1.1, P = 0.04) and the angle between the flow-jet and the aortic wall (OR 1.2, P = 0.001) as independent predictors of an indexed proximal aortic diameter ≥22 mm/m(2). CONCLUSIONS Functional parameters of the aortic root may be used to predict the severity of aortopathy in patients with BAV stenosis, and may be useful in predicting future risk of aortic disease in such patients.
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Affiliation(s)
- Evaldas Girdauskas
- Department of Cardiac Surgery, Central Clinic Bad Berka, Bad Berka, Germany
| | - Mina Rouman
- Department of Cardiac Surgery, Central Clinic Bad Berka, Bad Berka, Germany
| | - Kushtrim Disha
- Department of Cardiac Surgery, Central Clinic Bad Berka, Bad Berka, Germany
| | - Andres Espinoza
- Department of Cardiac Surgery, Central Clinic Bad Berka, Bad Berka, Germany
| | - Georg Dubslaff
- Department of Radiology, Central Clinic Bad Berka, Bad Berka, Germany
| | - Beatrix Fey
- Department of Radiology, Central Clinic Bad Berka, Bad Berka, Germany
| | - Bernhard Theis
- Institute of Pathology, Friedrich-Schiller University Jena, Jena, Germany
| | - Iver Petersen
- Institute of Pathology, Friedrich-Schiller University Jena, Jena, Germany
| | - Michael A Borger
- Department of Cardiac Surgery, Heart Center Leipzig, Germany Columbia University Medical Center, NY, New York, USA
| | - Thomas Kuntze
- Department of Cardiac Surgery, Central Clinic Bad Berka, Bad Berka, Germany
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50
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Andersson M, Lantz J, Ebbers T, Karlsson M. Quantitative Assessment of Turbulence and Flow Eccentricity in an Aortic Coarctation: Impact of Virtual Interventions. Cardiovasc Eng Technol 2015; 6:281-93. [PMID: 26577361 DOI: 10.1007/s13239-015-0218-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 02/13/2015] [Indexed: 01/01/2023]
Abstract
Turbulence and flow eccentricity can be measured by magnetic resonance imaging (MRI) and may play an important role in the pathogenesis of numerous cardiovascular diseases. In the present study, we propose quantitative techniques to assess turbulent kinetic energy (TKE) and flow eccentricity that could assist in the evaluation and treatment of stenotic severities. These hemodynamic parameters were studied in a pre-treated aortic coarctation (CoA) and after several virtual interventions using computational fluid dynamics (CFD), to demonstrate the effect of different dilatation options on the flow field. Patient-specific geometry and flow conditions were derived from MRI data. The unsteady pulsatile flow was resolved by large eddy simulation including non-Newtonian blood rheology. Results showed an inverse asymptotic relationship between the total amount of TKE and degree of dilatation of the stenosis, where turbulent flow proximal the constriction limits the possible improvement by treating the CoA alone. Spatiotemporal maps of TKE and flow eccentricity could be linked to the characteristics of the jet, where improved flow conditions were favored by an eccentric dilatation of the CoA. By including these flow markers into a combined MRI-CFD intervention framework, CoA therapy has not only the possibility to produce predictions via simulation, but can also be validated pre- and immediate post treatment, as well as during follow-up studies.
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Affiliation(s)
- Magnus Andersson
- Department of Management and Engineering (IEI), Linköping University, 581 83, Linköping, Sweden. .,Swedish e-Science Research Center (SeRC), Stockholm, Sweden.
| | - Jonas Lantz
- Department of Science and Technology, Linköping University, Linköping, Sweden.,Swedish e-Science Research Center (SeRC), Stockholm, Sweden
| | - Tino Ebbers
- Department of Science and Technology, Linköping University, Linköping, Sweden.,Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.,Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden.,Swedish e-Science Research Center (SeRC), Stockholm, Sweden
| | - Matts Karlsson
- Department of Management and Engineering (IEI), Linköping University, 581 83, Linköping, Sweden.,Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden.,Swedish e-Science Research Center (SeRC), Stockholm, Sweden
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