Non-invasive cardiovascular magnetic resonance assessment of pressure recovery distance after aortic valve stenosis.

BACKGROUND: Decisions in the management of aortic stenosis are based on the peak pressure drop, captured by Doppler echocardiography, whereas gold standard catheterization measurements assess the net pressure drop but are limited by associated risks. The relationship between these two measurements, peak and net pressure drop, is dictated by the pressure recovery along the ascending aorta which is mainly caused by turbulence energy dissipation. Currently, pressure recovery is considered to occur within the first 40-50 mm distally from the aortic valve, albeit there is inconsistency across interventionist centers on where/how to position the catheter to capture the net pressure drop. METHODS: We developed a non-invasive method to assess the pressure recovery distance based on blood flow momentum via 4D Flow cardiovascular magnetic resonance (CMR). Multi-center acquisitions included physical flow phantoms with different stenotic valve configurations to validate this method, first against reference measurements and then against turbulent energy dissipation (respectively n = 8 and n = 28 acquisitions) and to investigate the relationship between peak and net pressure drops. Finally, we explored the potential errors of cardiac catheterisation pressure recordings as a result of neglecting the pressure recovery distance in a clinical bicuspid aortic valve (BAV) cohort of n = 32 patients. RESULTS: In-vitro assessment of pressure recovery distance based on flow momentum achieved an average error of 1.8 ± 8.4 mm when compared to reference pressure sensors in the first phantom workbench. The momentum pressure recovery distance and the turbulent energy dissipation distance showed no statistical difference (mean difference of 2.8 ± 5.4 mm, R2 = 0.93) in the second phantom workbench. A linear correlation was observed between peak and net pressure drops, however, with strong dependences on the valvular morphology. Finally, in the BAV cohort the pressure recovery distance was 78.8 ± 34.3 mm from vena contracta, which is significantly longer than currently accepted in clinical practise (40-50 mm), and 37.5% of patients displayed a pressure recovery distance beyond the end of the ascending aorta. CONCLUSION: The non-invasive assessment of the distance to pressure recovery is possible by tracking momentum via 4D Flow CMR. Recovery is not always complete at the ascending aorta, and catheterised recordings will overestimate the net pressure drop in those situations. There is a need to re-evaluate the methods that characterise the haemodynamic burden caused by aortic stenosis as currently clinically accepted pressure recovery distance is an underestimation.

Unlocking the Non-invasive Assessment of Conduit and Reservoir Function in the Aorta : The Obstructive Descending Aorta in HLHS.

Aortic surgeries in congenital conditions, such as hypoplastic left heart syndrome (HLHS), aim to restore and maintain the conduit and reservoir functions of the aorta. We proposed a method to assess these two functions based on 4D flow MRI, and we applied it to study the aorta in pre-Fontan HLHS. Ten pre-Fontan HLHS patients and six age-matched controls were studied to derive the advective pressure difference and viscous dissipation for conduit function, and pulse wave velocity and elastic modulus for reservoir function. The reconstructed neo-aorta in HLHS subjects achieved a good conduit function at a cost of an impaired reservoir function (69.7% increase of elastic modulus). The native descending HLHS aorta displayed enhanced reservoir (elastic modulus being 18.4% smaller) but impaired conduit function (three-fold increase in peak advection). A non-invasive and comprehensive assessment of aortic conduit and reservoir functions is feasible and has potentially clinical relevance in congenital vascular conditions.

Optimal Control of SonoVue Microbubbles to Estimate Hydrostatic Pressure.

The measurement of cardiac and aortic pressures enables diagnostic insight into cardiac contractility and stiffness. However, these pressures are currently assessed invasively using pressure catheters. It may be possible to estimate these pressures less invasively by applying microbubble ultrasound contrast agents as pressure sensors. The aim of this study was to investigate the subharmonic response of the microbubble ultrasound contrast agent SonoVue (Bracco Spa, Milan, Italy) at physiological pressures using a static pressure phantom. A commercially available cell culture cassette with Luer connections was used as a static pressure chamber. SonoVue was added to the phantom, and radio frequency data were recorded on the ULtrasound Advanced Open Platform (ULA-OP). The mean subharmonic amplitude over a 40% bandwidth was extracted at 0-200-mmHg hydrostatic pressures, across 1.7-7.0-MHz transmit frequencies and 3.5%-100% maximum scanner acoustic output. The Rayleigh-Plesset equation for single-bubble oscillations and additional hysteresis experiments were used to provide insight into the mechanisms underlying the subharmonic pressure response of SonoVue. The subharmonic amplitude of SonoVue increased with hydrostatic pressure up to 50 mmHg across all transmit frequencies and decreased thereafter. A decreasing microbubble surface tension may drive the initial increase in the subharmonic amplitude of SonoVue with hydrostatic pressure, while shell buckling and microbubble destruction may contribute to the subsequent decrease above 125-mmHg pressure. In conclusion, a practical operating regime that may be applied to estimate cardiac and aortic blood pressures from the subharmonic signal of SonoVue has been identified.

Dieldrin uptake by vegetable crops grown in contaminated soils.

The aim of these trials was to study the distribution of dieldrin in soil and its translocation to roots and the aerial parts of vegetable crops grown in greenhouses and fields. The main objectives were to characterize dieldrin accumulation in plant tissues in relation to the levels of soil contamination; uptake capability among plants belonging to different species, varieties and cultivars. The presence of the contaminant was quantified by gas chromatography-electron capture detector (GC-ECD) and confirmed by gas chromatography-mass spectrometer (GC-MS). The results showed a translocation of residues in cucurbitaceous fruits and flowers confirming that zucchini, cucumber and melon are crops with high uptake capability. The maximum level of dieldrin residue at 0.01 mg/kg was found to be a threshold value to safeguard the quality production of cucurbits. Tomato, lettuce and celery were identified as substitute crops to grow in contaminated fields.

Online remeshing for soft tissue simulation in surgical training.

To graphically model and animate the realistic behavior of deformable tissue in surgical simulations, the authors' system adapts tetrahedra resolution by dynamically retessellating the mesh in and around the regions of interest. This technique overcomes limitations of previous methods that made it difficult to modify the mesh's topology online.

Soft tissue deformation using a nonlinear hierarchical finite element model with real-time online refinement.

Simulating soft tissue deformation in real-time is a requirement for realistically rendering the VR interaction between human organs and surgical tools. Finite Element Model (FEM) describes complex mechanical and physiological behaviour but it is computationally too demanding especially when a nonlinear model is to be implemented. For this reason, we introduce a multiresolution approach to FEM that only employs the region of the object under deformation to find the solution of the differential equations of motion. In order to increase the quality of the deformation, refinement of the original mesh is performed with the insertion of new surface nodes in real-time in the region of interaction. To guarantee the stability of the nonlinear model, the presence of flat tetrahedra (slivers) has to be avoided; therefore a sliver elimination technique has been implemented resulting in a more stable simulation.

Soft tissue deformation using a Hierarchical Finite Element Model.

Simulating soft tissue deformation in real-time has become increasingly important in order to provide a realistic virtual environment for training surgical skills. Several methods have been proposed with the aim of rendering in real-time the mechanical and physiological behaviour of human organs, one of the most popular being Finite Element Method (FEM). In this paper we present a new approach to the solution of the FEM problem introducing the concept of parent and child mesh within the development of a hierarchical FEM. The online selection of the child mesh is presented with the purpose to adapt the mesh hierarchy in real-time. This permits further refinement of the child mesh increasing the detail of the deformation without slowing down the simulation and giving the possibility of integrating force feedback. The results presented demonstrate the application of our proposed framework using a desktop virtual reality (VR) system that incorporates stereo vision with integrated haptics co-location via a desktop Phantom force feedback device.

Segmentation and generation of patient-specific 3D models of anatomy for surgical simulation.

Patient-specific simulation requires detailed 3D anatomical models. This paper describes how using optimised MRI sequences and clear segmentation criteria, together with adequate segmentation tools can produce high fidelity models able to reflect anatomical variability and allow realistic simulation of operative techniques and conditions.

Validation of soft tissue properties in surgical simulation with haptic feedback.

Numerous experiments are being conducted to extract soft tissue values for their integration into VR surgical simulations with haptic feedback. Haptic feedback has been shown to be relevant in laparoscopic surgery, however to date no experiments have been conducted to test user sensitivity to changes in soft tissue values in surgical simulations, and how users perception of 'reality' differs from experimentally determined soft tissue values. In this study we conduct a series of experiments investigating haptic sensitivity, haptic differentiation and comparing experimental and empirical values.