Statistical shape modeling reveals the link between right ventricular shape, hemodynamic force, and myocardial function in patients with repaired tetralogy of Fallot.

Patients with repaired tetralogy of Fallot (rTOF) can develop chronic pulmonary insufficiency (PI) with right ventricular (RV) dilation, progressive RV dysfunction, and decreased exercise capacity. Pulmonary valve replacement (PVR) can help reduce the amount of PI and RV dilation; however, optimal timing remains controversial; a better understanding of rTOF pathophysiology is of fundamental importance to inform clinical management of patients with rTOF and optimal timing of PVR. In this study, we hypothesize a tight interplay between RV shape, intracardiac biomechanics, and ventricular function in patients with rTOF. To explore this hypothesis and derive quantitative measures, we combined statistical shape modeling with physics-based analysis of in vivo 4D flow data in 36 patients with rTOF. Our study demonstrated for the first time a correlation between regional RV shape variations, hemodynamic forces (HDF), and clinical dysfunction in patients with rTOF. The main findings of this work include 1) general increase in RV size, due to both volume overload and physiological growth, correlated with decrease in strain magnitude in the respective directions, and with increased QRS; 2) regional PI-induced remodeling accounted for ∼10% of the shape variability of the population, and was associated with increased diastolic HDF along the diaphragm-to-right ventricular outflow tract (RVOT) direction, resulting in a net RV deformation along the same direction and decreased tricuspid annular plane systolic excursion (TAPSE); and 3) three shape modes independently correlated with systolic HDF and exercise capacity. Identification of patients based on the shape variations described in this study could help identify those at risk for irreversible dysfunction and guide optimal timing of PVR.NEW & NOTEWORTHY We combine statistical shape modeling with physics-based analysis of 4D flow data to elucidate the interplay between RV shape, hemodynamic forces, and clinical dysfunction in repaired tetralogy of Fallot. We are the first to show that ventricular remodeling is related to hemodynamic force magnitude and direction, global and regional functional parameters, and exercise intolerance. Identification of patients based on the shape variations described in this study could help identify those at risk for irreversible dysfunction.

Moving beyond size: vorticity and energy loss are correlated with right ventricular dysfunction and exercise intolerance in repaired Tetralogy of Fallot.

BACKGROUND: The global effect of chronic pulmonary regurgitation (PR) on right ventricular (RV) dilation and dysfunction in repaired Tetralogy of Fallot (rTOF) patients is well studied by cardiovascular magnetic resonance (CMR). However, the links between PR in the RV outflow tract (RVOT), RV dysfunction and exercise intolerance are not clarified by conventional measurements. Not all patients with RV dilation share the same intracardiac flow characteristics, now measurable by time resolved three-dimensional phase contrast imaging (4D flow). In our study, we quantified regional vorticity and energy loss in rTOF patients and correlated these parameters with RV dysfunction and exercise capacity. METHODS: rTOF patients with 4D flow datasets were retrospectively analyzed, including those with transannular/infundibular repair and conduit repair. Normal controls and RV dilation patients with atrial-level shunts (Qp:Qs > 1.2:1) were included for comparison. 4D flow was post-processed using IT Flow (Cardioflow, Japan). Systolic/diastolic vorticity (ω, 1/s) and viscous energy loss (VEL, mW) in the RVOT and RV inflow were measured. To characterize the relative influence of diastolic vorticity in the two regions, an RV Diastolic Vorticity Quotient (ωRVOT-Diastole/ωRV Inflow-Diastole, RV-DVQ) was calculated. Additionally, RVOT Vorticity Quotient (ωRVOT-Diastole/ωRVOT-Systole, RVOT-VQ) and RVOT Energy Quotient (VELRVOT-Diastole/VELRVOT-Systole, RVOT-EQ) was calculated. In rTOF, measurements were correlated against conventional CMR and exercise stress test results. RESULTS: 58 rTOF patients, 28 RV dilation patients and 12 controls were included. RV-DVQ, RVOT-VQ, and RVOT-EQ were highest in rTOF patients with severe PR compared to rTOF patients with non-severe PR, RV dilation and controls (p < 0.001). RV-DVQ positively correlated with RV end-diastolic volume (0.683, p < 0.001), PR fraction (0.774, p < 0.001) and negatively with RV ejection fraction (- 0.521, p = 0.003). Both RVOT-VQ, RVOT-EQ negatively correlated with VO2-max (- 0.587, p = 0.008 and - 0.617, p = 0.005) and % predicted VO2-max (- 0.678, p = 0.016 and - 0.690, p = 0.001). CONCLUSIONS: In rTOF patients, vorticity and energy loss dominate the RVOT compared to tricuspid inflow, correlating with RV dysfunction and exercise intolerance. These 4D flow-based measurements may be sensitive biomarkers to guide surgical management of rTOF patients.

Computational Study of Pulmonary Flow Patterns After Repair of Transposition of Great Arteries.

Patients that undergo the arterial switch operation (ASO) to repair transposition of great arteries (TGA) can develop abnormal pulmonary trunk morphology with significant long-term complications. In this study, cardiovascular magnetic resonance was combined with computational fluid dynamics to investigate the impact of the postoperative layout on the pulmonary flow patterns. Three ASO patients were analyzed and compared to a volunteer control. Results showed the presence of anomalous shear layer instabilities, vortical and helical structures, and turbulent-like states in all patients, particularly as a consequence of the unnatural curvature of the pulmonary bifurcation. Streamlined, mostly laminar flow was instead found in the healthy subject. These findings shed light on the correlation between the post-ASO anatomy and the presence of altered flow features, and may be useful to improve surgical planning as well as the long-term care of TGA patients.

Tetralogy of Fallot regurgitation energetics and kinetics: an intracardiac flow analysis of the right ventricle using computational fluid dynamics.

Repaired Tetralogy of Fallot (rTOF) patients suffer from pulmonary regurgitation and may require pulmonary valve replacement (PVR). Cardiac magnetic resonance imaging (cMRI) guides therapy, but conventional measurements do not quantify the intracardiac flow effects from pulmonary regurgitation or PVR. This study investigates intracardiac flow parameters of the right ventricle (RV) of rTOF by computational fluid dynamics (CFD). cMRI of rTOF patients and controls were retrospectively included. Feature-tracking captured RV endocardial contours from long-axis/short-axis cine. Ventricular motion was reconstructed via diffeomorphic mapping, serving as domain boundary for CFD simulations. Vorticity (1/s), viscous energy loss (ELoss, mJ/L) and turbulent kinetic energy (TKE, mJ/L) were quantified in RV outflow tract (RVOT) and RV inflow. These parameters were normalized against total RV kinetic energy (KE) and RV inflow vorticity to derive dimensionless metrics. Vorticity contours by Q-criterion were qualitatively compared. rTOF patients (n = 15) had mean regurgitant fraction 38 ± 12% and RV size 162 ± 35 mL/m2. Compared to controls (n = 12), rTOF had increased RVOT vorticity (142.6 ± 75.6/s vs. 40.4 ± 11.8/s, p < 0.0001), Eloss (55.6 ± 42.5 vs. 5.2 ± 4.4 mJ/L, p = 0.0004), and TKE (5.7 ± 5.9 vs. 0.84 ± 0.46 mJ/L, p = 0.0003). After PVR, there was decrease in normalized RVOT Eloss/TKE (p = 0.0009, p = 0.029) and increase in normalized tricuspid inflow vorticity/KE (p = 0.0136, p = 0.043), corresponding to reorganization of the "donut"-shaped tricuspid ring-vortex. The intracardiac flow in rTOF patients can be simulated to determine the impact of PVR and improve the clinical indications guided by cardiac imaging.

Pressure boundary conditions for immersed-boundary methods.

Immersed boundary methods have seen an enormous increase in popularity over the past two decades, especially for problems involving complex moving/deforming boundaries. In most cases, the boundary conditions on the immersed body are enforced via forcing functions in the momentum equations, which in the case of fractional step methods may be problematic due to: i) creation of slip-errors resulting from the lack of explicitly enforcing boundary conditions on the (pseudo-)pressure on the immersed body; ii) coupling of the solution in the fluid and solid domains via the Poisson equation. Examples of fractional-step formulations that simultaneously enforce velocity and pressure boundary conditions have also been developed, but in most cases the standard Poisson equation is replaced by a more complex system which requires expensive iterative solvers. In this work we propose a new formulation to enforce appropriate boundary conditions on the pseudo-pressure as part of a fractional-step approach. The overall treatment is inspired by the ghost-fluid method typically utilized in two-phase flows. The main advantage of the algorithm is that a standard Poisson equation is solved, with all the modifications needed to enforce the boundary conditions being incorporated within the right-hand side. As a result, fast solvers based on trigonometric transformations can be utilized. We demonstrate the accuracy and robustness of the formulation for a series of problems with increasing complexity.

Intracardiac Flow Analysis of the Right Ventricle in Pediatric Patients With Repaired Tetralogy of Fallot Using a Novel Color Doppler Velocity Reconstruction.

BACKGROUND: Repaired tetralogy of Fallot (RTOF) patients will develop right ventricular (RV) dysfunction from chronic pulmonary regurgitation (PR). Cardiac magnetic resonance sequences such as four-dimensional flow can demonstrate altered vorticity and flow energy loss (FEL); however, they are not as available as conventional echocardiography (echo). The study determined whether a novel, vendor-independent Doppler velocity reconstruction (DoVeR) could measure RV intracardiac flow in conventional echo of RTOF patients. The primary hypothesis was that DoVeR could detect increased vorticity and diastolic FEL in RTOF patients. METHODS: Repaired tetralogy of Fallot patients with echo were retrospectively paired with age-/size-matched controls. Doppler velocity reconstruction employed the stream function-vorticity equation to approximate intracardiac flow fields from color Doppler. A velocity field of the right ventricle was reconstructed from the apical 4-chamber view. Vortex strength (VS, area integral of vorticity) and FEL were derived from DoVeR. Cardiac magnetic resonance and exercise stress parameters (performed within 1 year of echo) were collected for analysis. RESULTS: Twenty RTOF patients and age-matched controls were included in the study. Mean regurgitant fraction was 40.5% ± 7.6%, and indexed RV end-diastolic volume was 158 ± 36 mL/m2. Repaired tetralogy of Fallot patients had higher total, mean diastolic, and peak diastolic VS (P = .0013, P = .0012, P = .0032, respectively) and higher total, mean diastolic, and peak diastolic body surface area-indexed FEL (P = .0016, P = .0022, P < .001, respectively). Peak diastolic indexed FEL and peak diastolic VS had weak-to-moderate negative correlation with RV ejection fraction (r = -0.52 [P = .019] and r = -0.49 [P = .030], respectively) and left ventricular ejection fraction (r = -0.47 [P = .034] and r = -0.64 [P = .002], respectively). Mean diastolic indexed FEL and VS had moderate-to-strong negative correlation with percent predicted maximal oxygen consumption (r = -0.69 [P = .012] and r = -0.75 [P = .006], respectively). CONCLUSIONS: DoVeR can detect alterations to intracardiac flow in RTOF patients from conventional color Doppler imaging. Echo-based measures of diastolic VS and FEL correlated with ventricular function. DoVeR has the potential to provide serial evaluation of abnormal flow dynamics in RTOF patients.

Computational Modeling of Right Ventricular Motion and Intracardiac Flow in Repaired Tetralogy of Fallot.

PURPOSE: Patients with repaired Tetralogy of Fallot (rTOF) will develop dilation of the right ventricle (RV) from chronic pulmonary insufficiency and require pulmonary valve replacement (PVR). Cardiac MRI (cMRI) is used to guide therapy but has limitations in studying novel intracardiac flow parameters. This pilot study aimed to demonstrate feasibility of reconstructing RV motion and simulating intracardiac flow in rTOF patients, exclusively using conventional cMRI and an immersed-boundary method computational fluid dynamic (CFD) solver. METHODS: Four rTOF patients and three normal controls underwent cMRI including 4D flow. 3D RV models were segmented from cMRI images. Feature-tracking software captured RV endocardial contours from cMRI long-axis and short-axis cine stacks. RV motion was reconstructed via diffeomorphic mapping (Deformetrica, deformetrica.org), serving as the domain boundary for CFD. Fully-resolved direct numerical simulations were performed over several cardiac cycles. Intracardiac vorticity, kinetic energy (KE) and turbulent kinetic energy (TKE) was measured. For validation, RV motion was compared to manual tracings, results of KE were compared between CFD and 4D flow. RESULTS: Diastolic vorticity and TKE in rTOF patients were 4.12 ± 2.42 mJ/L and 115 ± 27/s, compared to 2.96 ± 2.16 mJ/L and 78 ± 45/s in controls. There was good agreement between RV motion and manual tracings. The difference in diastolic KE between CFD and 4D flow by Bland-Altman analysis was - 0.89910 to 2 mJ/mL (95% limits of agreement: - 1.351 × 10-2 mJ/mL to 1.171 × 10-2 mJ/mL). CONCLUSION: This CFD framework can produce intracardiac flow in rTOF patients. CFD has the potential for predicting the effects of PVR in rTOF patients and improve the clinical indications guided by cMRI.

Abnormal Diastolic Hemodynamic Forces: A Link Between Right Ventricular Wall Motion, Intracardiac Flow, and Pulmonary Regurgitation in Repaired Tetralogy of Fallot.

Background and Objective: The effect of chronic pulmonary regurgitation (PR) on right ventricular (RV) dysfunction in repaired Tetralogy of Fallot (RTOF) patients is well recognized by cardiac magnetic resonance (CMR). However, the link between RV wall motion, intracardiac flow and PR has not been established. Hemodynamic force (HDF) represents the global force exchanged between intracardiac blood volume and endocardium, measurable by 4D flow or by a novel mathematical model of wall motion. In our study, we used this novel methodology to derive HDF in a cohort of RTOF patients, exclusively using routine CMR imaging. Methods: RTOF patients and controls with CMR imaging were retrospectively included. Three-dimensional (3D) models of RV were segmented, including RV outflow tract (RVOT). Feature-tracking software (QStrain 2.0, Medis Medical Imaging Systems, Leiden, Netherlands) captured endocardial contours from long/short-axis cine and used to reconstruct RV wall motion. A global HDF vector was computed from the moving surface, then decomposed into amplitude/impulse of three directional components based on reference (Apical-to-Basal, Septal-to-Free Wall and Diaphragm-to-RVOT direction). HDF were compared and correlated against CMR and exercise stress test parameters. A subset of RTOF patients had 4D flow that was used to derive vorticity (for correlation) and HDF (for comparison against cine method). Results: 68 RTOF patients and 20 controls were included. RTOF patients had increased diastolic HDF amplitude in all three directions (p<0.05). PR% correlated with Diaphragm-RVOT HDF amplitude/impulse (r = 0.578, p<0.0001, r = 0.508, p < 0.0001, respectively). RV ejection fraction modestly correlated with global HDF amplitude (r = 0.2916, p = 0.031). VO2-max correlated with Septal-to-Free Wall HDF impulse (r = 0.536, p = 0.007). Diaphragm-to-RVOT HDF correlated with RVOT vorticity (r = 0.4997, p = 0.001). There was no significant measurement bias between Cine-derived HDF and 4D flow-derived HDF by Bland-Altman analysis. Conclusion: RTOF patients have abnormal diastolic HDF that is correlated to PR, RV function, exercise capacity and vorticity. HDF can be derived from conventional cine, and is a potential link between RV wall motion and intracardiac flow from PR in RTOF patients.

Model for deformation of cells from external electric fields at or near resonant frequencies.

This paper presents a numerical model to investigate the deformation of biological cells by applying external electric fields operating at or near cell resonant frequencies. Cells are represented as pseudo solids with high viscosity suspended in liquid media. The electric field source is an atmospheric plasma jet developed inhouse, for which the emitted energy distribution has been measured. Viscoelastic response is resolved in the entire cell structure by solving a deformation matrix assuming an isotropic material with a prescribed modulus of elasticity. To investigate cell deformation at resonant frequencies, one mode of natural cell oscillation is considered in which the cell membrane is made to radially move about its eigenfrequency. An electromagnetic wave source interacts with the cell and induces oscillation and viscoelastic response. The source carries energy in the form of a distribution function which couples a range of oscillating frequencies with electric field amplitudes. Results show that cell response may be increased by the external electric field operating at or near resonance. In the elastic regime, response increases until a steady threshold value, and the structure moves as a damped oscillator. Generally, this response is a function of both frequency and magnitude of the source, with a maximum effect found at resonance. To understand the full effect of the source energy spectrum, the system is solved by considering five frequency-amplitude couplings. Results show that the total solution is a nonlinear combination of the individual solutions. Additionally, sources with different signal phases are simulated to determine the effect of initial conditions on the evolution of the system, and the result suggests that there may be multiple solutions within the same order of magnitude for elastic response and velocity. Cell rupture from electric stress may occur during application given a high energy source.

Direct Numerical Simulations of a Great Horn Owl in Flapping Flight.

The fluid dynamics of owls in flapping flight is studied by coordinated experiments and computations. The great horned owl was selected, which is nocturnal, stealthy, and relatively large sized raptor. On the experimental side, perch-to-perch flight was considered in an open wind tunnel. The owl kinematics was captured with multiple cameras from different view angles. The kinematic extraction was central in driving the computations, which were designed to resolve all significant spatio-temporal scales in the flow with an unprecedented level of resolution. The wing geometry was extracted from the planform image of the owl wing and a three-dimensional model, the reference configuration, was reconstructed. This configuration was then deformed in time to best match the kinematics recorded during flights utilizing an image-registration technique based on the large deformation diffeomorphic metric mapping framework. All simulations were conducted using an eddy-resolving, high-fidelity, solver, where the large displacements/deformations of the flapping owl model were introduced with an immersed boundary formulation. We report detailed information on the spatio-temporal flow dynamics in the near wake including variables that are challenging to measure with sufficient accuracy, such as aerodynamic forces. At the same time, our results indicate that high-fidelity computations over smooth wings may have limitations in capturing the full range of flow phenomena in owl flight. The growth and subsequent separation of the laminar boundary layers developing over the wings in this Reynolds number regime is sensitive to the surface micro-features that are unique to each species.

Abnormal Pulmonary Artery Bending Correlates With Increased Right Ventricular Afterload Following the Arterial Switch Operation.

PURPOSE: In transposition of great arteries, increased right ventricular (RV) afterload is observed following arterial switch operation (ASO), which is not always related to pulmonary artery (PA) stenosis. We hypothesize that abnormal PA bending from the Lecompte maneuver may affect RV afterload in the absence of stenosis. Thus, we sought to identify novel measurements of three-dimensional cardiac magnetic resonance (CMR) images of the pulmonary arteries and compare with conventional measurements in their ability to predict RV afterload. METHODS: Conventional measurements and novel measurements of the pulmonary arteries were performed using CMR data from 42 ASO patients and 13 age-matched controls. Novel measurements included bending angle, normalized radius of curvature (Rc), and normalized weighted radius of curvature (Rc-w). Right ventricular systolic pressures (as the surrogate for RV afterload) were measured by either recent echocardiogram or cardiac catheterization. RESULTS: Conventional measurements of proximal PA size correlated with differential pulmonary blood flow (r = 0.49, P = .001), but not with RV peak systolic pressures (r = -0.26, P = .18). In ASO patients, Rc-w correlated with higher RV systolic pressures (r = -0.57, P = .002). Larger neoaortic areas and rightward bending angles correlated with smaller right pulmonary artery Rc (r = -0.48, P = .001; r = 0.41, P = .01, respectively). Finally, both pulmonary arteries had significantly smaller Rc compared to normal controls. CONCLUSIONS: Pulmonary arteries exhibit abnormal bends following ASO that correlate with increased RV afterload, independent of PA stenosis. Future work should focus on clinical and hemodynamic contributions of these shape parameters.

A strain-based model for mechanical hemolysis based on a coarse-grained red blood cell model.

Mechanical hemolysis is a major concern in the design of cardiovascular devices, such as prosthetic heart valves and ventricular assist devices. The primary cause of mechanical hemolysis is the impact of the device on the local blood flow, which exposes blood elements to non-physiologic conditions. The majority of existing hemolysis models correlate red blood cell (RBC) damage to the imposed fluid shear stress and exposure time. Only recently more realistic, strain-based models have been proposed, where the RBC's response to the imposed hydrodynamic loading is accounted for. In the present work we extend strain-based models by introducing a high-fidelity representation of RBCs, which is based on existing coarse-grained particle dynamics approach. We report a series of numerical experiments in simple shear flows of increasing complexity, to illuminate the basic differences between existing models and establish their accuracy in comparison to the high-fidelity RBC approach. We also consider a practical configuration, where the flow through an artificial heart valve is computed. Our results shed light on the strengths and weaknesses of each approach and identify the key gaps that should be addressed in the development of new models.

Early and midterm hemodynamics after aortic valve bypass (apicoaortic conduit) surgery.

BACKGROUND: Aortic valve bypass (AVB [apicoaortic conduit]) relieves aortic stenosis (AS) by connecting the apex of the left ventricle to the descending thoracic aorta with a valved conduit. AVB is performed through a small left thoracotomy, without cardiopulmonary bypass, aortic cross-clamping, cardiac arrest, or debridement of the native aortic valve. Little is known about hemodynamics, including ventricular performance, relative conduit blood flow, and progression of native AS after AVB. METHODS: Forty-seven very high risk patients underwent AVB for AS between 2003 and 2009. The mean age was 82 years. Predismissal and interval transthoracic quantitative two-dimensional and Doppler echocardiography was performed in a core laboratory. RESULTS: No patient had obstruction of the native aortic valve or the conduit during follow-up. The AVB effectively relieved left ventricular outflow tract obstruction (average peak gradient across the conduit was 5.6 +/- 3.8 mm Hg). Native aortic valve stenosis did not progress after AVB (0.63 +/- 0.16 cm(2) before surgery to 0.7 +/- 0.24 cm(2) at latest follow-up more than 6 months; p = 0.16). Total stroke volume increased after AVB from 60 mL +/- 22 mL to 107 mL +/- 27 mL (p < 0.0001). Left ventricular outflow was distributed in a predictable fashion between the conduit and the native aortic valve, with 63% +/- 10% of the flow directed to the conduit. Relative conduit flow remained stable (68% +/- 8%) at latest follow-up more than 6 months (p = 0.17). CONCLUSIONS: Aortic valve bypass effectively relieves the outflow tract obstruction of AS. Placement of an apical valved conduit halts the biologic progression of AS.

Influence of flexibility on the aerodynamic performance of a hovering wing.

In the present study, a computational investigation was carried out to understand the influence of flexibility on the aerodynamic performance of a hovering wing. A flexible, two-dimensional, two-link model moving within a viscous fluid was considered. The Navier-Stokes equations governing the fluid dynamics were solved together with the equations governing the structural dynamics by using a strongly coupled fluid-structure interaction scheme. Harmonic kinematics was used to prescribe the motions of one of the links, thus effectively reducing the wing to a single degree-of-freedom oscillator. The wing's flexibility was characterized by the ratio of the flapping frequency to the natural frequency of the structure. Apart from the rigid case, different values of this frequency ratio (only in the range of 1/2 to 1/6) were considered at the Reynolds numbers of 75, 250 and 1000. It was found that flexibility can enhance aerodynamic performance and that the best performance is realized when the wing is excited by a non-linear resonance at 1/3 of the natural frequency. Specifically, at Reynolds numbers of 75, 250 and 1000, the aerodynamic performance that is characterized by the ratio of lift coefficient to drag coefficient is respectively increased by 28%, 23% and 21% when compared with the corresponding ratios of a rigid wing driven with the same kinematics. For all Reynolds numbers, the lift generated per unit driving power is also enhanced in a similar manner. The wake capture mechanism is enhanced, due to a stronger flow around the wing at stroke reversal, resulting from a stronger end of stroke vortex at the trailing edge. The present study provides some clues about how flexibility affects the aerodynamic performance in low Reynolds number flapping flight. In addition, it points to the importance of considering non-linear resonances for enhancing aerodynamic performance.

Treatment of aortic stenosis with aortic valve bypass (apicoaortic conduit) surgery: an assessment using computational modeling.

BACKGROUND: Aortic valve bypass surgery treats aortic valve stenosis with a valve-containing conduit that connects the left ventricular apex to the descending thoracic aorta. After aortic valve bypass, blood is ejected from the left ventricle via both the native stenotic aortic valve and the conduit. We performed computational modeling to determine the effects of aortic valve bypass on aortic and cerebral blood flow, as well as the effect of conduit size on relative blood flow through the conduit and the native valve. METHODS: The interaction of blood flow with the vascular boundary was modeled using a hybrid Eurelian-Lagrangian formulation, where an unstructured Galerkin finite element method was coupled with an immersed boundary approach. RESULTS: Our model predicted native (stenotic) valve to conduit flow ratios of 45:55, 52:48, and 60:40 for conduits with diameters of 20, 16, and 10 mm, respectively. Mean gradients across the native aortic valve were calculated to be 12.5, 13.8, and 17.6 mm Hg, respectively. Post-aortic valve bypass cerebral blood flow was unchanged from preoperative aortic valve stenosis configurations and was constant across all conduit sizes. In all cases modeled, cerebral blood flow was completely supplied by blood ejected across the native aortic valve. CONCLUSIONS: An aortic valve bypass conduit as small as 10 mm results in excellent relief of left ventricular outflow tract obstruction in critical aortic valve stenosis. The presence of an aortic valve bypass conduit has no effect on cerebral blood flow. All blood flow to the brain occurs via antegrade flow across the native stenotic valve; this configuration may decrease the long-term risk of cerebral thromboembolism.

Modeling the interaction of coils with the local blood flow after coil embolization of intracranial aneurysms.

Aneurysmal recanalization and coil compaction after coil embolization of intracranial aneurysms are seen in as many as 40% of cases. Higher packing density has been suggested to reduce both coil compaction and recanalization. Basilar bifurcation aneurysms remain a challenge due possibly to the hemodynamics of this specific aneurysm/parent vessel architecture, which subjects the coil mass at the aneurysm neck to elevated and repetitive impingement forces. In the present study, we propose a new modeling strategy that facilitates a better understanding of the complex interactions between detachable coils and the local blood flow. In particular, a semiheuristic porous media set of equations used to describe the intra-aneurysmal flow is coupled to the incompressible Navier-Stokes equations governing the dynamics of the flow in the involved vessels. The resulting system of equations is solved in a strongly coupled manner using a finite element formulation. Our results suggest that there is a complex interaction between the local hemodynamics and intra-aneurysmal flow that induces significant forces on the coil mass. Although higher packing densities have previously been advocated to reduce coil compaction, our simulations suggest that lower permeability of the coil mass at a given packing density could also promote faster intra-aneurysmal thrombosis due to increased residence times.