Mitral Valve Regurgitation in the LVAD-Assisted Heart Studied in a Mock Circulatory Loop.

Permanent closure of the aortic valve (AVC) is sometimes performed In LVAD patients, usually when a mechanical valve prosthesis or significant aortic insufficiency is present. Mitral valve regurgitation (MVR) present at the time of LVAD implantation can remain unresolved, representing a limitation for exercise tolerance and a potential predictor of mortality. To investigate the effect of MVR on hemodynamics of the LVAD-supported heart following AVC, studies were performed using a mock circulatory loop. Pressure and flow measured for a range of cardiac function, LVAD speed, and MVR show that cardiac contraction augments aortic pressure by 10-27% over nonpulsatile conditions when the mitral valve functions normally, but decreases with MVR until it reaches the nonpulsatile level. Aortic flow displays a similar trend, demonstrating a 25% decrease from fully functioning to open at 7 krpm, a 5% decrease at 9 krpm, and no observable effect at 11 krpm. Pulsatility decreases with increased LVAD speed and MVR. The data indicate that a modest level of cardiac output (1.5-2 L/min) can be maintained by the native heart through the LVAD when the LVAD is off. These results demonstrate that MVR decreases the augmentation of forward flow by improved cardiac function at lower LVAD speeds. While some level of MVR can be tolerated in LVAD recipients, this condition represents a risk, particularly in those patients that undergo AVC closure, and may warrant repair at the time of surgery.

Intraventricular flow patterns and stasis in the LVAD-assisted heart.

Left ventricular assist device (LVAD) support disrupts the natural blood flow path through the heart, introducing flow patterns associated with thrombosis, especially in the presence of medical devices. The aim of this study was to quantitatively evaluate the flow patterns in the left ventricle (LV) of the LVAD-assisted heart, with a focus on alterations in vortex development and stasis. Particle image velocimetry of a LVAD-supported LV model was performed in a mock circulatory loop. In the Pre-LVAD flow condition, a vortex ring initiating from the LV base migrated toward the apex during diastole and remained in the LV by the end of ejection. During LVAD support, vortex formation was relatively unchanged although vortex circulation and kinetic energy increased with LVAD speed, particularly in systole. However, as pulsatility decreased and aortic valve opening ceased, a region of fluid stasis formed near the left ventricular outflow tract. These findings suggest that LVAD support does not substantially alter vortex dynamics unless cardiac function is minimal. The altered blood flow introduced by the LVAD results in stasis adjacent to the LV outflow tract, which increases the risk of thrombus formation in the heart.

Effect of LVAD outflow conduit insertion angle on flow through the native aorta.

BACKGROUND AND AIM: The goal of this study was to evaluate the effect of surgical anastomosis configuration of the aortic outflow conduit (AOC) from a continuous flow left ventricular assist device (LVAD) on the flow fields in the aorta using CFD simulations. The geometry of the surgical integration of the LVAD is an important factor in the flow pattern that develops both in series (aortic valve closed, all flow through LVAD) and in parallel (heart pumping in addition to LVAD). METHODS: CFD models of the AOC junctions simulate geometry as cylindrical tubes that intersect at angles ranging from 30 degrees to 90 degrees. Velocity fields are computed over a range of cardiac output for both series and parallel flow. RESULTS: Our results demonstrate that the flow patterns are significantly affected by the angle of insertion of the AOC into the native aorta, both during series and parallel flow conditions. Zones of flow recirculation and high shear stress on the aortic wall can be observed at the highest angle, gradually decreasing in size until disappearing at the lowest angle of 30 degrees. The highest velocity and shear stress values were associated with series flow. CONCLUSIONS: The results suggest that connecting the LVAD outflow conduit to the proximal aorta at a shallower angle produces fewer secondary flow patterns in the native cardiovascular system.

Ischemia-reperfusion injury at the microvascular level: treatment by endothelin A-selective antagonist and evaluation by myocardial contrast echocardiography.

BACKGROUND: The purpose of this study was to verify whether endothelin A-antagonist administration at the time of coronary reperfusion preserves postischemic microvasculature and whether myocardial contrast echo (MCE) is able to detect pharmacologically induced changes in microvascular reflow. METHODS AND RESULTS: Twenty dogs underwent 90 minutes of LAD occlusion (OCC) followed by 180 minutes of reperfusion (RP). Five minutes before LAD reopening, an intravenous bolus (5 mg/kg) of LU 135252 was given in 10 dogs and vehicle in the remaining 10. At baseline (BSL), OCC, and 90 and 180 minutes of RP, microvascular flow (BF) was assessed by microspheres, and MCE was performed with intravenous echo contrast. MCE videointensity and BF were expressed as risk area/control ratio. Myocardial thickness of the risk area was calculated by 2D echo. No differences in BF between the 2 groups were observed at BSL, OCC, and 90 minutes of RP. At 180 minutes of RP, BF was decreased in controls (70+/-7.4% of BSL; P:<0.005 versus BSL) and preserved in LU 135252-treated animals (89+/-4% of BSL; P=NS versus BSL; P<0.05 versus controls). Videointensity at MCE closely followed the changes in BF observed in both groups throughout the protocol. Myocardial thickness at 180 minutes of RP increased to 138.6+/-9.9% of BSL in controls and remained at 108.9+/-7.4% of BSL in treated dogs (P<0.05). CONCLUSIONS: Endothelin A-antagonist treatment at the time of reperfusion significantly limited the progressive decrease in postischemic microvascular reflow and the increase in myocardial thickness. MCE allowed a reliable evaluation of pharmacologically induced changes in microvascular flow.

Effects of water exchange on the measurement of myocardial perfusion using paramagnetic contrast agents.

To investigate the effects of water exchange on quantification of perfusion, data were acquired in isolated hearts (n = 11) and used to develop a model of exchange. Myocardial T1 was measured 3 times/sec during step changes in concentration of intravascular (polylysine-gadolinium-diethylene-triamine-pentaacetic acid) and extracellular (gadoteridol) agents. For the intravascular agent, the change in 1/T1 (deltaR1) was lower than predicted by fast exchange (2.7+/-0.5 vs. 7.8 sec(-1), respectively), and suggested an intra-extravascular exchange rate of 3 Hz. For the extracellular agent, contrast kinetics were similar to those of similarly sized molecules (wash-in time constant 38+/-5 sec), and the data suggested fast interstitial-cellular exchange. Modeling showed that perfusion is underestimated for both agents if exchange is ignored, although the relationships of measured to actual perfusion were monotonic. We conclude that myocardial water exchange strongly affects first-pass enhancement but that ignoring the effects of exchange may still provide reasonable estimates of regional perfusion differences.

Homogenization modeling for the mechanics of perfused myocardium.

Altered coronary perfusion can change the apparent diastolic stiffness of ventricular myocardium--the 'garden hose' effect. Our recent findings showed that myocardial strains are reduced during ventricular filling, primarily along the directions transverse to the coronary microvessels. In this article, we review hypotheses and theoretical models regarding the role that regional wall stress plays in the mechanical interaction between myocardium and coronary circulation. Various mechanisms have been used to explain the effects of the tissue stress on coronary flow, as well as the effect of coronary dynamics on myocardial mechanics. Many models of coronary pressure-flow relations using lumped parameter circuit analogs. Poroelasticity and swelling theories have been used to model the mechanics of perfused muscle. Here, we describe a new mathematical model of the mechanics of perfused myocardium derived using homogenization theory. In this model, perfused myocardium is treated as a nonlinear anisotropic elastic solid embedded with cylindrical vessels of known distensibility. The solid compartment is incompressible but the vascular compartment may change volume according to a simple relation between vessel diameter and perfusion pressure. The work done by the perfusion pressure in changing vascular volume contributes to the macroscopic strain energy and hence affects the stress and stiffness of the composite. Conversely, the stress in the tissue affects microvessel diameter and volume, since tractions transverse to the vessel axis oppose the internal blood pressure. Finite element simulations of passive filling show good agreement of model with experimental results.

Evaluation of dynamic changes in microvascular flow during ischemia-reperfusion by myocardial contrast echocardiography.

BACKGROUND: Dynamic changes of myocardial blood flow have been observed after reperfusion of an occluded coronary artery. MCE performed by intracoronary contrast injection can provide an estimate of microvascular flow. We hypothesized that MCE performed using intravenous infusion of a new generation contrast agent and electrocardiogram-gated harmonic imaging would be able to assess serial changes of microvascular perfusion. OBJECTIVE: To study the potential of myocardial contrast echocardiography (MCE) to assess serial changes of microvascular flow during ischemia-reperfusion. METHODS: Sixteen dogs underwent 90 or 180 min of left anterior descending coronary occlusion, followed by 180 min of reperfusion. Regional blood flow (RBF) was measured with fluorescent microspheres at baseline, during coronary occlusion, and at 5, 30, 90, and 180 min during reperfusion. At the same time points, MCE was performed with intravenous infusion of AF0150 (4 mg/min). Gated end-systolic images in short axis were acquired in harmonic mode and digitized on-line. Background-subtracted videointensity measured from MCE and RBF obtained from fluorescent microspheres were calculated for the risk area and for a control area, and were expressed as the ratio of the two areas. RESULTS: After initial hyperemia, a progressive reduction in flow was observed during reperfusion. MCE correctly detected the time course of changes in flow during occlusion-reperfusion. Videointensity ratio significantly correlated with RBF data (r=0.79; p < 0.0001). CONCLUSIONS: The progressive reduction in blood flow occurring within the postischemic microcirculation was accurately detected by MCE. This approach has potential application in the evaluation and management of postischemic reperfusion in humans.

A constitutive law for mitral valve tissue.

Biaxial mechanical testing and theoretical continuum mechanics analysis are employed to formulate a constitutive law for cardiac mitral valve anterior and posterior leaflets. A strain energy description is formulated based on the fibrous architecture of the tissue, accurately describing the large deformation, highly nonlinear transversely isotropic material behavior. The results show that a simple three-coefficient exponential constitutive law provides an accurate prediction of stress-stretch behavior over a wide range of deformations. Regional heterogenity may be accommodated by spatially varying a single coefficient and incorporating collagen fiber angle. The application of this quantitative information to mechanical models and bioprosthetic development could provide substantial improvement in the evaluation and treatment of valvular disease, surgery, and replacement.

Three-dimensional residual strain in midanterior canine left ventricle.

All previous studies of residual strain in the ventricular wall have been based on one- or two-dimensional measurements. Transmural distributions of three-dimensional (3-D) residual strains were measured by biplane radiography of columns of lead beads implanted in the midanterior free wall of the canine left ventricle (LV). 3-D bead coordinates were reconstructed with the isolated arrested LV in the zero-pressure state and again after local residual stress had been relieved by excising a transmural block of tissue. Nonhomogeneous 3-D residual strains were computed by finite element analysis. Mean +/- SD (n = 8) circumferential residual strain indicated that the intact unloaded myocardium was prestretched at the epicardium (0.07 +/- 0.06) and compressed in the subendocardium (-0.04 +/- 0.05). Small but significant longitudinal shortening and torsional shear residual strains were also measured. Residual fiber strain was tensile at the epicardium (0.05 +/- 0.06) and compressive in the subendocardium (-0.01 +/- 0.04), with residual extension and shortening, respectively, along structural axes parallel and perpendicular to the laminar myocardial sheets. Relatively small residual shear strains with respect to the myofiber sheets suggest that prestretching in the plane of the myocardial laminae may be a primary mechanism of residual stress in the LV.

Transmural distribution of capillary morphology as a function of coronary perfusion pressure in the resting canine heart.

Changes in coronary perfusion pressure lead to alterations in intracoronary myocardial volume that may be associated with regionally altered microvascular morphology. Transmural variations in coronary capillary geometry were quantified as a function of coronary perfusion pressure in glutaraldehyde-fixed canine hearts. Capillary volume fractions, diameter, numerical density, anisotropy, and sarcomere length were measured using computer analysis of light microscopic images of sections taken transverse or longitudinal to the muscle fiber axis. Capillary volume was 4-6% of myocardial wall volume and exhibited a significant transmural gradient, increasing from epicardium to endocardium. Vessels 4 to 5 microns in diameter with a density of 2900 mm-2 appear to increase in diameter and alter their cross-sectional shape with increasing pressure, rather than increasing in number, suggesting an effective distensibility of approximately 0.007 mm Hg-1. Quantification of vessel anisotropy was directly related to cross-sectional shape and demonstrated that the capillaries are highly oriented. These findings indicate that intramyocardial capacitance is at least in part associated with nonhomogeneous changes in coronary capillary morphology with altered perfusion pressure.

Biaxial mechanical behavior of excised porcine mitral valve leaflets.

Anterior and posterior leaflets from excised porcine mitral valves were mechanically tested under cyclic equibiaxial and strip biaxial stretch protocols at a strain rate of 4-12%/s after preconditioning. Cauchy stress and Lagrangian strain were calculated for both membrane and three-dimensional cases. The leaflets exhibited nonlinearly elastic, anisotropic behavior. Both anterior and posterior leaflets were less extensible in the circumferential than in the radial direction under equibiaxial stretch, with stress ratios of 5.7 and 4.3, respectively. The posterior leaflets exhibited greater extensibility in both directions and lower circumferential posttransitional moduli (ranges 690-820 vs. 2,500-3,200 N/m for anterior). This larger posterior extensibility may be due to the greater number of chordal attachments, which provide additional mechanical stability to this structure. Coupling of radial and circumferential mechanical behavior was evidenced by the response to different stretch protocols, indicating a complex microstructural coupling between individual collagen fibers or bundles. These are the first biaxial data for mitral valves and are a foundation for the development of a more detailed quantitative material description.

Three-dimensional transmural mechanical interaction between the coronary vasculature and passive myocardium in the dog.

The "garden hose" effect of coronary perfusion on diastolic left ventricular (LV) mechanics has been proposed to cause changes in systolic function by altering diastolic sarcomere length. We measured transmural distributions of three-dimensional shape change using radiopaque markers implanted in the LV free wall of eight isolated arrested canine hearts as functions of coronary arterial perfusion pressure (Pp) and LV pressure (PLV) and related these deformations to the local muscle fiber architecture. Increased Pp from 0 to 110 mm Hg produced a 10% reduction in LV chamber volume (P < .01) and 25% to 40% decreases in local three-dimensional wall strain at matched PLV, indicating myocardial stiffening. Significant decreases in the magnitudes of local deformation occurred preferentially in the cross-fiber and radial directions (P < .02), with no change in fiber strain. This suggests that changing coronary Pp does not alter diastolic fiber length; hence, the Frank-Starling law may not mediate the Gregg effect. Since the myocardial microvessels are primarily oriented parallel to the muscle fibers, the observed myocardial stiffening occurs in the directions transverse to the microvessels rather than along their length. Local myocardial wall volume in the unloaded LV demonstrated a uniform 5% increase from the unperfused state to Pp of 50 mm Hg. With further increases in Pp up to 110 mm Hg, the change in regional wall volume from the unperfused state developed a substantial transmural gradient increasing by 7% at the epicardium and 15% at the subendocardium. This reflects a significant increase (P < .02) in intramyocardial coronary capacitance from epicardium to endocardium, which may be related to a transmural gradient in coronary distensibility or vascularity.