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Mao P, Jin M, Li W, Zhang H, Li H, Li S, Yang Y, Zhu M, Shi Y, Zhang X, Chen D. In Silico Trials of Prosthetic Valves Replicate Methodologies for Evaluating the Fatigue Life of Artificial Leaflets to Expand Beyond In Vitro Tests and Conventional Clinical Trials. Biomedicines 2025; 13:1135. [PMID: 40426962 PMCID: PMC12108928 DOI: 10.3390/biomedicines13051135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2025] [Revised: 04/17/2025] [Accepted: 04/29/2025] [Indexed: 05/29/2025] Open
Abstract
Background: Fatigue failure of artificial leaflets significantly limits the durability of prosthetic valves. However, the costs and complexities associated with in vitro testing and conventional clinical trials to investigate the fatigue life of leaflets are progressively escalating. In silico trials offer an alternative solution and validation pathway. This study presents in silico trials of prosthetic valves, along with methodologies incorporating nonlinear behaviors to evaluate the fatigue life of artificial leaflets. Methods: Three virtual patient models were established based on in vitro test and clinical trial data, and virtual surgeries and physiological homeostasis maintenance simulations were performed. These simulations modeled the hemodynamics of three virtual patients following transcatheter valve therapy to predict the service life and crack propagation of leaflets based on the fatigue damage assessment. Results and Conclusions: Compared to traditional trials, in silico trials enable a broader and more rapid investigation into factors related to leaflet damage. The fatigue life of the leaflets in two virtual patients with good implantation morphology exceeded 400 million cycles, meeting the requirements, while the fatigue life of a virtual patient with a shape fold in the leaflet was only 440,000 cycles. The fatigue life of the leaflets varied considerably with different implant morphologies. Postoperative balloon dilation positively enhanced fatigue life. Importantly, in silico trials yielded insights that are difficult or impossible to uncover through conventional experiments, such as the increased susceptibility of leaflets to fatigue damage under compressive loading.
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Affiliation(s)
- Pengzhi Mao
- School of Medical Technology, Beijing Institute of Technology, Beijing 100081, China; (P.M.); (H.L.); (S.L.); (Y.Y.)
| | - Min Jin
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Nanjing 210008, China; (M.J.); (H.Z.)
| | - Wei Li
- School of Mechanical Engineering, Beijing Institute of Technology, Beijing 100081, China;
| | - Haitao Zhang
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Nanjing 210008, China; (M.J.); (H.Z.)
- Graduate School, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Haozheng Li
- School of Medical Technology, Beijing Institute of Technology, Beijing 100081, China; (P.M.); (H.L.); (S.L.); (Y.Y.)
| | - Shilong Li
- School of Medical Technology, Beijing Institute of Technology, Beijing 100081, China; (P.M.); (H.L.); (S.L.); (Y.Y.)
| | - Yuting Yang
- School of Medical Technology, Beijing Institute of Technology, Beijing 100081, China; (P.M.); (H.L.); (S.L.); (Y.Y.)
| | - Minjia Zhu
- School of Disaster and Emergency Medicine, Tianjin University, Tianjin 300072, China;
| | - Yue Shi
- Enlight Medical Technologies (Shanghai) Co., Ltd., Shanghai 201318, China;
| | - Xuehuan Zhang
- School of Medical Technology, Beijing Institute of Technology, Beijing 100081, China; (P.M.); (H.L.); (S.L.); (Y.Y.)
| | - Duanduan Chen
- School of Medical Technology, Beijing Institute of Technology, Beijing 100081, China; (P.M.); (H.L.); (S.L.); (Y.Y.)
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Reza S, Kovarovic B, Bluestein D. Assessing post-TAVR cardiac conduction abnormalities risk using an electromechanically coupled beating heart. Biomech Model Mechanobiol 2025; 24:29-45. [PMID: 39361113 PMCID: PMC12083778 DOI: 10.1007/s10237-024-01893-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 09/22/2024] [Indexed: 10/09/2024]
Abstract
Transcatheter aortic valve replacement (TAVR) has rapidly displaced surgical aortic valve replacement (SAVR). However, certain post-TAVR complications persist, with cardiac conduction abnormalities (CCA) being one of the major ones. The elevated pressure exerted by the TAVR stent onto the conduction fibers situated between the aortic annulus and the His bundle, in proximity to the atrioventricular (AV) node, may disrupt the cardiac conduction leading to the emergence of CCA. In this study, an in silico framework was developed to assess the CCA risk, incorporating the effect of a dynamic beating heart and preprocedural parameters such as implantation depth and preexisting cardiac asynchrony in the new onset of post-TAVR CCA. A self-expandable TAVR device deployment was simulated inside an electromechanically coupled beating heart model in five patient scenarios, including three implantation depths and two preexisting cardiac asynchronies: (i) a right bundle branch block (RBBB) and (ii) a left bundle branch block (LBBB). Subsequently, several biomechanical parameters were analyzed to assess the post-TAVR CCA risk. The results manifested a lower cumulative contact pressure on the conduction fibers following TAVR for aortic deployment (0.018 MPa) compared to nominal condition (0.29 MPa) and ventricular deployment (0.52 MPa). Notably, the preexisting RBBB demonstrated a higher cumulative contact pressure (0.34 MPa) compared to the nominal condition and preexisting LBBB (0.25 MPa). Deeper implantation and preexisting RBBB cause higher stresses and contact pressure on the conduction fibers leading to an increased risk of post-TAVR CCA. Conversely, implantation above the MS landmark and preexisting LBBB reduces the risk.
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Affiliation(s)
- Symon Reza
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, 11794-8084, USA
| | - Brandon Kovarovic
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, 11794-8084, USA
| | - Danny Bluestein
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, 11794-8084, USA.
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Shi W, Niu G, Feng D, Hu X, Wang C, Zhao Z, Zhang H, Wang M, Wu Y. Morphological Characteristics Following Self-Expanding Transcatheter Heart Valve Implantation and Implications for Hypoattenuating Leaflet Thickening. Catheter Cardiovasc Interv 2024. [PMID: 39718363 DOI: 10.1002/ccd.31364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Revised: 12/02/2024] [Accepted: 12/06/2024] [Indexed: 12/25/2024]
Abstract
BACKGROUND Hypoattenuating leaflet thickening (HALT) following transcatheter aortic valve replacement (TAVR) may compromise valve durability, posing a significant barrier to the broader adoption of this technology among younger patients. Self-expanding valves (SEVs) are the most commonly used transcatheter heart valves (THVs) among Chinese patients with aortic stenosis. Understanding the potential mechanisms underlying HALT is, therefore, critical to guide future THV design and development. AIMS Identify morphological factors associated with HALT Unidentified after SEVs implantation. METHODS This study included 195 consecutive patients from Fuwai Hospital who underwent TAVR with SEVs. All participants underwent their first postoperative 4D-CT scan within 6 months of the procedure. Key parameters following THV implantation were measured and recorded using 3mensio software. Univariate and multivariable logistic regression models were applied to identify associations between variables and HALT. Discriminatory ability was assessed using receiver operating characteristic (ROC) analysis, followed by bootstrap validation for model robustness. RESULTS HALT was observed in 36.4% of patients (71 out of 195 patients). New sinus height (NSH) and leaflet outflow area were identified as independent risk factors for HALT. The areas under the curve (AUC) for NSH and leaflet outflow area were 0.689 (95% CI: 0.612-0.767) and 0.602 (95% CI: 0.521-0.683), respectively, with no significant difference between them (p = 0.082). Bootstrap validation confirmed the robustness of both NSH and leaflet outflow area, showing performance comparable to the initial stepwise model. CONCLUSION NSH and leaflet outflow area were identified as critical post-THV implantation parameters associated with HALT in TAVR patients treated with SEVs. These findings provide valuable insights that could inform the future design and optimization of SEVs.
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Affiliation(s)
- Wence Shi
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Guannan Niu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Dejing Feng
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xiangming Hu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Can Wang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Zhenyan Zhao
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Hongliang Zhang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Moyang Wang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yongjian Wu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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Sadri V, Midha PA, Madukauwa-David ID, Kamioka N, Trusty PM, Nair PJ, Cohen S, Raghav V, Sharma R, Babaliaros V, Yoganathan AP. Benchtop Flow Stasis Quantification: In Vitro Methods and In Vivo Possibilities. Cardiovasc Eng Technol 2024; 15:749-759. [PMID: 39285066 DOI: 10.1007/s13239-024-00750-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 09/05/2024] [Indexed: 12/18/2024]
Abstract
PURPOSE Neo-sinus flow stasis has ben correlated with transcatheter heart valve (THV) thrombosis severity and occurrence. Standard benchtop flow field quantification techniques require optical access or modified prosthesis models that may not reflect the true nature of the original valve. En face and fluoroscopic videodensitometry enable visualization of washout in regions otherwise unviewable. METHODS This study compares two in vitro methods of assessing flow stasis in scenarios with insufficient optical access for traditional techniques such as particle image velocimetry (PIV). A series of seven paired experiments were conducted using a previously described laser-enhanced video densitometry (LEVD) and fluoroscopic video densitometry (FVD). Both sets of experiments were analyzed to calculate washout time as a measure of flow stasis. A novel flow stasis measure termed contrast attenuation ratio (CAR) is proposed as a viable single measure of flow stasis obtainable from only a small number of cardiac cycles of in vitro or in vivo fluoroscopic data. Retrospective fluoroscopic datasets (n = 72) were analyzed to assess the feasibility of obtaining this metric from routine clinical practice and its ability to stratify results. RESULTS Neo-sinus flow stasis calculated from in vitro fluoroscopy was well correlated with LEVD (r2 = 0.77, p = 0.009). The newly proposed CAR metric showed good agreement with the commonly used "washout time" measure of flow stasis (r2 = 0.91, p < 0.001) while allowing for assessment with incomplete or truncated data. As a proof of concept, CAR was measured in 72 consecutive retrospective fluoroscopic datasets. CAR averaged 10.6 ± 4.6% with a range of 1.5-20.3% in these patients. CONCLUSIONS This study demonstrates two in vitro methods that can be used to assess relative flow stasis in otherwise optically inaccessible regions surrounding cardiac or vascular implants. In addition, the fluoroscopic benchtop technique was used to validate a metric that allows for extension to routine clinical fluoroscopy. This contrast attenuation ratio (CAR) metric was found to be both accurate and clinically obtainable, and potentially offers a new method for valve thrombosis risk stratification.
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Affiliation(s)
- Vahid Sadri
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology & Emory University, Technology Enterprise Park, Suite 200, 387 Technology Circle, Atlanta, GA, 30313-2412, USA
- Abbott, Atlanta, GA, USA
| | - Prem A Midha
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology & Emory University, Technology Enterprise Park, Suite 200, 387 Technology Circle, Atlanta, GA, 30313-2412, USA
- Abbott, Little Canada, MN, USA
| | - Immanuel David Madukauwa-David
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology & Emory University, Technology Enterprise Park, Suite 200, 387 Technology Circle, Atlanta, GA, 30313-2412, USA
| | | | - Phillip M Trusty
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology & Emory University, Technology Enterprise Park, Suite 200, 387 Technology Circle, Atlanta, GA, 30313-2412, USA
- Abbott, Santa Clara, CA, USA
| | - Priya J Nair
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology & Emory University, Technology Enterprise Park, Suite 200, 387 Technology Circle, Atlanta, GA, 30313-2412, USA
| | - Samuel Cohen
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology & Emory University, Technology Enterprise Park, Suite 200, 387 Technology Circle, Atlanta, GA, 30313-2412, USA
| | - Vrishank Raghav
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology & Emory University, Technology Enterprise Park, Suite 200, 387 Technology Circle, Atlanta, GA, 30313-2412, USA
- Auburn University, Auburn, AL, USA
| | | | | | - Ajit P Yoganathan
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology & Emory University, Technology Enterprise Park, Suite 200, 387 Technology Circle, Atlanta, GA, 30313-2412, USA.
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Baylous K, Kovarovic B, Paz RR, Anam S, Helbock R, Horner M, Slepian M, Bluestein D. Thrombogenic Risk Assessment of Transcatheter Prosthetic Heart Valves Using a Fluid-Structure Interaction Approach. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2024; 257:108469. [PMID: 39461118 DOI: 10.1016/j.cmpb.2024.108469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Revised: 10/10/2024] [Accepted: 10/16/2024] [Indexed: 10/29/2024]
Abstract
BACKGROUND AND OBJECTIVE Prosthetic heart valve interventions such as TAVR have surged over the past decade, but the associated complication of long-term, life-threatening thrombotic events continues to undermine patient outcomes. Thus, improving thrombogenic risk analysis of TAVR devices is crucial. In vitro studies for thrombogenicity are typically difficult to perform. However, revised ISO testing standards include computational testing for thrombogenic risk assessment of cardiovascular implants. We present a fluid-structure interaction (FSI) approach for assessing thrombogenic risk of transcatheter aortic valves. METHODS An FSI framework was implemented via the incompressible computational fluid dynamics multi-physics solver of the ANSYS LS-DYNA software. The numerical modeling approach for flow analysis was validated by comparing the derived flow rate of the 29 mm CoreValve device from benchtop testing and orifice areas of commercial TAVR valves in the literature to in silico results. Thrombogenic risk was analyzed by computing stress accumulation (SA) on virtual platelets seeded in the flow fields via ANSYS EnSight. The integrated FSI-thrombogenicity methodology was subsequently employed to examine hemodynamics and thrombogenic risk of TAVR devices with two approaches: 1) engineering optimization and 2) clinical assessment. RESULTS Simulated effective orifice areas for commercial valves were in reported ranges. In silico cardiac output and flow rate during the positive pressure differential period matched experimental results by approximately 93 %. The approach was used to analyze the effect of various TAVR leaflet designs on hemodynamics, where platelets experienced instantaneous stresses reaching around 10 Pa. Post-TAVR deployment hemodynamics in patient-specific bicuspid aortic valve anatomies revealed varying degrees of thrombogenic risk with the highest median SA around 70 dyn·s/cm2 - nearly double the activation threshold - despite those being clinically classified as "mild" paravalvular leaks. CONCLUSIONS Our methodology can be used to improve the thromboresistance of prosthetic valves from the initial design stage to the clinic. It allows for unparalleled optimization of devices, uncovering key TAVR leaflet design parameters that can be used to mitigate thrombogenic risk, in addition to patient-specific modeling to evaluate device performance. This work demonstrates the utility of advanced in silico analysis of TAVR devices that can be utilized for thrombogenic risk assessment of other blood recirculating devices.
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Affiliation(s)
- Kyle Baylous
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY 11794, USA
| | - Brandon Kovarovic
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY 11794, USA
| | - Rodrigo R Paz
- ANSYS Inc., 7374 Las Positas Rd., Livermore, CA 94551, USA; CONICET (IMIT), Argentina
| | - Salwa Anam
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY 11794, USA
| | - Ryan Helbock
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY 11794, USA
| | | | - Marvin Slepian
- Department of Medicine and Biomedical Engineering Sarver Heart Center, University of Arizona, Tucson, AZ, 85721, USA
| | - Danny Bluestein
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY 11794, USA.
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Androshchuk V, Montarello N, Lahoti N, Hill SJ, Zhou C, Patterson T, Redwood S, Niederer S, Lamata P, De Vecchi A, Rajani R. Evolving capabilities of computed tomography imaging for transcatheter valvular heart interventions - new opportunities for precision medicine. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2024:10.1007/s10554-024-03247-z. [PMID: 39347934 DOI: 10.1007/s10554-024-03247-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Accepted: 09/16/2024] [Indexed: 10/01/2024]
Abstract
The last decade has witnessed a substantial growth in percutaneous treatment options for heart valve disease. The development in these innovative therapies has been mirrored by advances in multi-detector computed tomography (MDCT). MDCT plays a central role in obtaining detailed pre-procedural anatomical information, helping to inform clinical decisions surrounding procedural planning, improve clinical outcomes and prevent potential complications. Improvements in MDCT image acquisition and processing techniques have led to increased application of advanced analytics in routine clinical care. Workflow implementation of patient-specific computational modeling, fluid dynamics, 3D printing, extended reality, extracellular volume mapping and artificial intelligence are shaping the landscape for delivering patient-specific care. This review will provide an insight of key innovations in the field of MDCT for planning transcatheter heart valve interventions.
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Affiliation(s)
- Vitaliy Androshchuk
- School of Cardiovascular Medicine & Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK.
- Guy's & St Thomas' NHS Foundation Trust, King's College London, St Thomas' Hospital, The Reyne Institute, 4th Floor, Lambeth Wing, London, SE1 7EH, UK.
| | - Natalie Montarello
- Cardiovascular Department, St Thomas' Hospital, King's College London, London, UK
| | - Nishant Lahoti
- Cardiovascular Department, St Thomas' Hospital, King's College London, London, UK
| | - Samuel Joseph Hill
- School of Cardiovascular Medicine & Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Can Zhou
- Cardiovascular Department, St Thomas' Hospital, King's College London, London, UK
| | - Tiffany Patterson
- Cardiovascular Department, St Thomas' Hospital, King's College London, London, UK
| | - Simon Redwood
- School of Cardiovascular Medicine & Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Steven Niederer
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Pablo Lamata
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Adelaide De Vecchi
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Ronak Rajani
- Cardiovascular Department, St Thomas' Hospital, King's College London, London, UK
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
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Bornemann KM, Jahren SE, Obrist D. The relation between aortic morphology and transcatheter aortic heart valve thrombosis: Particle tracing and platelet activation in larger aortic roots with and without neo-sinus. Comput Biol Med 2024; 179:108828. [PMID: 38996554 DOI: 10.1016/j.compbiomed.2024.108828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 06/05/2024] [Accepted: 06/29/2024] [Indexed: 07/14/2024]
Abstract
Transcatheter aortic heart valve thrombosis (THVT) affects long-term valve durability, transvalvular pressure gradient and leaflet mobility. In this study, we conduct high-fidelity fluid-structure interaction simulations to perform Lagrangian particle tracing in a generic model with larger aortic diameters (THVT model) with and without neo-sinus which is compared to a model of unaffected TAVI patients (control model). Platelet activation indices are computed for each particle to assess the risk of thrombus formation induced by high shear stresses followed by flow stagnation. Particle tracing indicates that fewer particles contribute to sinus washout of the THVT model with and without neo-sinus compared to the control model (-34.9%/-34.1%). Stagnating particles in the native sinus of the THVT model show higher platelet activation indices than for the control model (+39.6% without neo-sinus, +45.3% with neo-sinus). Highest activation indices are present for particles stagnating in the neo-sinus of the larger aorta representing THVT patients (+80.2% compared to control). This fluid-structure interaction (FSI) study suggests that larger aortas lead to less efficient sinus washout in combination with higher risk of platelet activation among stagnating particles, especially within the neo-sinus. This could explain (a) a higher occurrence of thrombus formation in transcatheter valves compared to surgical valves without neo-sinus and (b) the neo-sinus as the prevalent region for thrombi in TAV. Pre-procedural identification of larger aortic roots could contribute to better risk assessment of patients and improved selection of a patient-specific anti-coagulation therapy.
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Affiliation(s)
- Karoline-Marie Bornemann
- ARTORG Center for Biomedical Engineering Research, University of Bern, Freiburgstrasse 3, Bern, 3010, Switzerland.
| | - Silje Ekroll Jahren
- ARTORG Center for Biomedical Engineering Research, University of Bern, Freiburgstrasse 3, Bern, 3010, Switzerland
| | - Dominik Obrist
- ARTORG Center for Biomedical Engineering Research, University of Bern, Freiburgstrasse 3, Bern, 3010, Switzerland
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