Ultrasound Based Wall Stress Analysis of Abdominal Aortic Aneurysms using Multiperspective Imaging.

BACKGROUND: Current clinical guidelines for surgical repair of abdominal aortic aneurysms (AAAs) are primarily based on maximum diameter assessment. From a biomechanical point of view, not only the diameter but also peak wall stresses will play an important role in rupture risk assessment. These methods require patient specific geometry which typically uses computed tomography (CT) or magnetic resonance imaging. Recently, wall stress analysis based on 3D ultrasound (US) has been proposed, and shows promising results. However, the major limitations in these studies were the use of manual segmentation and the limiting field of view of US. Therefore in this study, the AAA is imaged with multiperspective 3D ultrasound, merged to obtain a large field of view, and afterwards automatically segmented. Geometry and wall stress results were validated using CT imaging. METHODS: Three dimensional US and CT data were available for 40 AAA patients (maximum diameter 34-61 mm). The full US based AAA geometry was determined using automatic segmentation, and when the aneurysm exceeded a single 3D volume, automatic fusion of multiple 3D US volumes was used. Wall stress analysis was performed for all AAA patients and percentile wall stresses were derived. The accuracy of the US based geometry and wall stress prediction was measured by comparison with CT data. RESULTS: Estimated geometries derived from 3D US and CT data showed good similarity, with an overall median similarity index (SI) of 0.89 and interquartile range of 0.87-0.92, whereas the median Hausdorff distances (HD), a measure for the maximum local mismatch, was 4.6 (4.0-5.9) mm for all AAA geometries. Thereby, the wall stress results based on merged multiperspective 3D US data revealed a greater similarity to CT than single 3D US data. CONCLUSION: This study showed that large volume geometry assessment of AAAs using multiperspective 3D ultrasound, segmentation and fusion, and wall stress analysis is feasible in a robust and labour efficient manner.

Ultrasound-based estimation of remaining cardiac function in LVAD-supported ex vivo hearts.

Left ventricular assist devices (LVAD) provide cardiac support to patients with advanced heart failure. Methods that can directly measure remaining LV function following device implantation do not currently exist. Previous studies have shown that a combination of loading (LV pressure) and deformation (strain) measurements enables quantitation of myocardial work. We investigated the use of ultrasound (US) strain imaging and pressure-strain loop analysis in LVAD-supported hearts under different hemodynamic and pump unloading conditions, with the aim of determining LV function with and without LVAD support. Ex vivo porcine hearts (n = 4) were implanted with LVADs and attached to a mock circulatory loop. Measurements were performed at hemodynamically defined "heart conditions" as the hearts deteriorated from baseline. Hemodynamic (including LV pressure) and radio-frequency US data were acquired during a pump-ramp protocol at speeds from 0 (with no pump outflow) to 10 000 revolutions per minute (rpm). Regional circumferential (εcirc ) and radial (εrad ) strains were estimated over each heart cycle. Regional ventricular dyssynchrony was quantitated through time-to-peak strain. Mean change in LV pulse pressure and εcirc between 0 and 10 krpm were -21.8 mm Hg and -7.24% in the first condition; in the final condition -46.8 mm Hg and -19.2%, respectively. εrad was not indicative of changes in pump speed or heart condition. Pressure-strain loops showed a degradation in the LV function and an increased influence of LV unloading: loop area reduced by 90% between 0 krpm in the first heart condition and 10 krpm in the last condition. High pump speeds and degraded condition led to increased dyssynchrony between the septal and lateral LV walls. Functional measurement of the LV while undergoing LVAD support is possible by using US strain imaging and pressure-strain loops. This can provide important information about remaining pump function. Use of novel LV pressure estimation or measurement techniques would be required for any future use in LVAD patients.

A demonstration of high field-of-view stability in hands-free echocardiography.

BACKGROUND: Exercise stress echocardiography is clinically used to assess cardiovascular diseases. For accurate cardiac evaluation, a stable field-of-view is required. However, transducer orientation and position are difficult to preserve. Hands-free acquisitions might provide more consistent and reproducible results. In this study, the field-of-view stability and variability of hands-free acquisitions are objectively quantified in a comparison with manually obtained images, based on image structural and feature similarities. In addition, the feasibility and consistency of hands-free strain imaging is assessed. METHODS: In twelve healthy males, apical and parasternal images were acquired hands-free, using a fixation device, and manually, during semi-supine exercise sessions. In the final ten seconds of every exercise period, the image structural similarity and cardiac feature consistency were computed using a steerable pyramid employing complex, oriented wavelets. An algorithm discarding images displaying lung artifacts was created. Hands-free strain consistency was analyzed. RESULTS: Hands-free acquisitions were possible in 9 of the 12 subjects, whereas manually 10 out of 12 could be imaged. The image structural similarity was significantly improved in the hands-free apical window acquisitions (0.91 versus 0.82), and at least equally good in the parasternal window (0.90 versus 0.82). The change in curvature and orientation of the interventricular septum also appeared to be lower in the hands-free acquisitions. The variability in field-of-view was similar in both acquisitions. Longitudinal, septal strain was shown to be at least as consistent when obtained hands-free compared to manual acquisitions. CONCLUSIONS: The field-of-view was shown to be more or equally stable and consistent in the hands-free data in comparison to manually obtained images. The variability was similar, thus respiration- and exercise-induced motions were comparable for manual and hands-free acquisitions. Additionally, the feasibility of hands-free strain has been demonstrated. Furthermore, the results suggest the hands-free measurements to be more reproducible, though further analysis is required.

A comparative study of geometry-based methods and intra-arterial pressure measurements to assess the hemodynamic significance of equivocal iliac artery stenoses.

OBJECTIVES: To date, the ultimate decision to treat iliac artery stenoses in patients suffering from symptomatic peripheral arterial disease is based on the patient's symptoms and on visual inspection of angiographical images. The primary aim of this study was to investigate the accuracy of geometry-based methods (i.e. visual inspection and quantitative vascular analysis (Viewforum version R7.2v1 Advanced vessel analysis, Philips Healthcare, Best, The Netherlands) of 3D rotational angiography) to identify the severity of equivocal iliac artery stenosis in peripheral arterial disease patients with intra-arterial hyperemic pressure measurements (gold standard) as a reference. METHODS: Twenty patients with symptomatic iliac artery stenoses were subjected to 3D rotational angiography. Intra-arterial pressure measurements under hyperemic conditions were performed across 24 visually identified iliac artery stenoses. Three experienced interventional-radiologists retrospectively estimated the lumen diameter reduction by visual inspection. Furthermore, quantitative vascular analysis was performed on the 3D rotational angiography data. Geometry-based estimates were classified into two groups: lumen diameter reduction of <50% (non-significant) and diameter reduction ≥ 50% (significant), and compared to the intra-arterial hyperemic pressure gradients. A stenosis causing a pressure gradient (Δp) ≥10 mmHg was considered hemodynamically significant. RESULTS: Visual inspection and quantitative vascular analysis correctly identified hemodynamically significant stenoses in, respectively, 83% and 67% of the 24 iliac artery stenoses. Quantitative vascular analysis-based identification of hemodynamic significant stenoses (Δp ≥ 10 mmHg) could be optimized by lowering the threshold to a 42% lumen diameter reduction which improved the accuracy from 67% to 83%. CONCLUSIONS: Visual inspection of 3D rotational angiography by experienced interventional-radiologists has an 83% accuracy to identify hemodynamic significant iliac artery stenoses (Δ p ≥10 mmHg). The use of quantitative vascular analysis software did not improve accuracy.

Buffers Strongly Modulate Fibrin Self-Assembly into Fibrous Networks.

Fibrin is a plasma protein with a central role in blood clotting and wound repair. Upon vascular injury, fibrin forms resilient fibrillar networks (clots) via a multistep self-assembly process, from monomers, to double-stranded protofibrils, to a branched network of thick fibers. In vitro, fibrin self-assembly is sensitive to physicochemical conditions like the solution pH and ionic strength, which tune the strength of the noncovalent driving forces. Here we report a surprising finding that the buffer-which is necessary to control the pH and is typically considered to be inert-also significantly influences fibrin self-assembly. We show by confocal microscopy and quantitative light scattering that various common buffering agents have no effect on the initial assembly of fibrin monomers into protofibrils but strongly hamper the subsequent lateral association of protofibrils into thicker fibers. We further find that the structural changes are independent of the molecular structure of the buffering agents as well as of the activation mechanism and even occur in fibrin networks formed from platelet-poor plasma. This buffer-mediated decrease in protofibril bundling results in a marked reduction in the permeability of fibrin networks but only weakly influences the elastic modulus of fibrin networks, providing a useful tuning parameter to independently control the elastic properties and the permeability of fibrin networks. Our work raises the possibility that fibrin assembly in vivo may be regulated by variations in the acute-phase levels of bicarbonate and phosphate, which act as physiological buffering agents of blood pH. Moreover, our findings add a new example of buffer-induced effects on biomolecular self-assembly to recent findings for a range of proteins and lipids.

Application of an Adaptive Polynomial Chaos Expansion on Computationally Expensive Three-Dimensional Cardiovascular Models for Uncertainty Quantification and Sensitivity Analysis.

When applying models to patient-specific situations, the impact of model input uncertainty on the model output uncertainty has to be assessed. Proper uncertainty quantification (UQ) and sensitivity analysis (SA) techniques are indispensable for this purpose. An efficient approach for UQ and SA is the generalized polynomial chaos expansion (gPCE) method, where model response is expanded into a finite series of polynomials that depend on the model input (i.e., a meta-model). However, because of the intrinsic high computational cost of three-dimensional (3D) cardiovascular models, performing the number of model evaluations required for the gPCE is often computationally prohibitively expensive. Recently, Blatman and Sudret (2010, "An Adaptive Algorithm to Build Up Sparse Polynomial Chaos Expansions for Stochastic Finite Element Analysis," Probab. Eng. Mech., 25(2), pp. 183-197) introduced the adaptive sparse gPCE (agPCE) in the field of structural engineering. This approach reduces the computational cost with respect to the gPCE, by only including polynomials that significantly increase the meta-model's quality. In this study, we demonstrate the agPCE by applying it to a 3D abdominal aortic aneurysm (AAA) wall mechanics model and a 3D model of flow through an arteriovenous fistula (AVF). The agPCE method was indeed able to perform UQ and SA at a significantly lower computational cost than the gPCE, while still retaining accurate results. Cost reductions ranged between 70-80% and 50-90% for the AAA and AVF model, respectively.

Enhancement of Arterial Pressure Pulsatility by Controlling Continuous-Flow Left Ventricular Assist Device Flow Rate in Mock Circulatory System.

Continuous-flow left ventricular assist devices (CF-LVADs) generally operate at a constant speed, which reduces pulsatility in the arteries and may lead to complications such as functional changes in the vascular system, gastrointestinal bleeding, or both. The purpose of this study is to increase the arterial pulse pressure and pulsatility by controlling the CF-LVAD flow rate. A MicroMed DeBakey pump was used as the CF-LVAD. A model simulating the flow rate through the aortic valve was used as a reference model to drive the pump. A mock circulation containing two synchronized servomotor-operated piston pumps acting as left and right ventricles was used as a circulatory system. Proportional-integral control was used as the control method. First, the CF-LVAD was operated at a constant speed. With pulsatile-speed CF-LVAD assistance, the pump was driven such that the same mean pump output was generated. Continuous and pulsatile-speed CF-LVAD assistance provided the same mean arterial pressure and flow rate, while the index of pulsatility increased significantly for both arterial pressure and pump flow rate signals under pulsatile speed pump support. This study shows the possibility of improving the pulsatility of CF-LVAD support by regulating pump speed over a cardiac cycle without reducing the overall level of support.

Feasibility of wall stress analysis of abdominal aortic aneurysms using three-dimensional ultrasound.

OBJECTIVE: Abdominal aortic aneurysms (AAAs) are local dilations that can lead to a fatal hemorrhage when ruptured. Wall stress analysis of AAAs is a novel tool that has proven high potential to improve risk stratification. Currently, wall stress analysis of AAAs is based on computed tomography (CT) and magnetic resonance imaging; however, three-dimensional (3D) ultrasound (US) has great advantages over CT and magnetic resonance imaging in terms of costs, speed, and lack of radiation. In this study, the feasibility of 3D US as input for wall stress analysis is investigated. Second, 3D US-based wall stress analysis was compared with CT-based results. METHODS: The 3D US and CT data were acquired in 12 patients (diameter, 35-90 mm). US data were segmented manually and compared with automatically acquired CT geometries by calculating the similarity index and Hausdorff distance. Wall stresses were simulated at P = 140 mm Hg and compared between both modalities. RESULTS: The similarity index of US vs CT was 0.75 to 0.91 (n = 12), with a median Hausdorff distance ranging from 4.8 to 13.9 mm, with the higher values found at the proximal and distal sides of the AAA. Wall stresses were in accordance with literature, and a good agreement was found between US- and CT-based median stresses and interquartile stresses, which was confirmed by Bland-Altman and regression analysis (n = 8). Wall stresses based on US were typically higher (+23%), caused by geometric irregularities due to the registration of several 3D volumes and manual segmentation. In future work, an automated US registration and segmentation approach is the essential point of improvement before pursuing large-scale patient studies. CONCLUSIONS: This study is a first step toward US-based wall stress analysis, which would be the modality of choice to monitor wall stress development over time because no ionizing radiation and contrast material are involved.

Intra-Aortic Balloon Pump Support in the Isolated Beating Porcine Heart in Nonischemic and Ischemic Pump Failure.

The blood pressure changes induced by the intra-aortic balloon pump (IABP) are expected to create clinical improvement in terms of coronary perfusion and myocardial oxygen consumption. However, the measured effects reported in literature are inconsistent. The aim of this study was to investigate the influence of ischemia on IABP efficacy in healthy hearts and in shock. Twelve slaughterhouse porcine hearts (hearts 1-12) were connected to an external circulatory system, while physiologic cardiac performance was restored. Different clinical scenarios, ranging from healthy to cardiogenic shock, were simulated by step-wise administration of negative inotropic drugs. In hearts 7-12, severe global myocardial ischemia superimposed upon the decreased contractile states was created. IABP support was applied in all hearts under all conditions. Without ischemia, the IABP induced a mild increase in coronary blood flow and cardiac output. These effects were strongly augmented in the presence of persisting ischemia, where coronary blood flow increased by 49 ± 24% (P < 0.01) and cardiac output by 17 ± 6% (P < 0.01) in case of severe pump failure. As expected, myocardial oxygen consumption increased in case of ischemia (21 ± 17%; P < 0.01), while it slightly decreased without (-3 ± 6%; P < 0.01). In case of progressive pump failure due to persistent myocardial ischemia, the IABP increased hyperemic coronary blood flow and cardiac output significantly, and reversed the progressive hemodynamic deterioration within minutes. This suggests that IABP therapy in acute myocardial infarction is most effective in patients with viable myocardium, suffering from persistent myocardial ischemia, despite adequate epicardial reperfusion.

A constitutive model for a maturing fibrin network.

Blood clot formation is crucial to maintain normal physiological conditions but at the same time involved in many diseases. The mechanical properties of the blood clot are important for its functioning but complicated due to the many processes involved. The main structural component of the blood clot is fibrin, a fibrous network that forms within the blood clot, thereby increasing its mechanical rigidity. A constitutive model for the maturing fibrin network is developed that captures the evolving mechanical properties. The model describes the fibrin network as a network of fibers that become thicker in time. Model parameters are related to the structural properties of the network, being the fiber length, bending stiffness, and mass-length ratio. Results are compared with rheometry experiments in which the network maturation is followed in time for various loading frequencies and fibrinogen concentrations. Three parameters are used to capture the mechanical behavior including the mass-length ratio. This parameter agrees with values determined using turbidimetry experiments and is subsequently used to derive the number of protofibrils and fiber radius. The strength of the model is that it describes the mechanical properties of the maturing fibrin network based on it structural quantities. At the same time the model is relatively simple, which makes it suitable for advanced numerical simulations of blood clot formation during flow in blood vessels.

Generation of synthetic aortic valve stenosis geometries for in silico trials.

In silico trials are a promising way to increase the efficiency of the development, and the time to market of cardiovascular implantable devices. The development of transcatheter aortic valve implantation (TAVI) devices, could benefit from in silico trials to overcome frequently occurring complications such as paravalvular leakage and conduction problems. To be able to perform in silico TAVI trials virtual cohorts of TAVI patients are required. In a virtual cohort, individual patients are represented by computer models that usually require patient-specific aortic valve geometries. This study aimed to develop a virtual cohort generator that generates anatomically plausible, synthetic aortic valve stenosis geometries for in silico TAVI trials and allows for the selection of specific anatomical features that influence the occurrence of complications. To build the generator, a combination of non-parametrical statistical shape modeling and sampling from a copula distribution was used. The developed virtual cohort generator successfully generated synthetic aortic valve stenosis geometries that are comparable with a real cohort, and therefore, are considered as being anatomically plausible. Furthermore, we were able to select specific anatomical features with a sensitivity of around 90%. The virtual cohort generator has the potential to be used by TAVI manufacturers to test their devices. Future work will involve including calcifications to the synthetic geometries, and applying high-fidelity fluid-structure-interaction models to perform in silico trials.

Efficient sensitivity analysis for biomechanical models with correlated inputs.

In most variance-based sensitivity analysis (SA) approaches applied to biomechanical models, statistical independence of the model input is assumed. However, often the model inputs are correlated. This might alter the interpretation of the SA results, which may severely impact the guidance provided during model development and personalization. Potential reasons for the infrequent usage of SA techniques that account for input correlation are the associated high computational costs, especially for models with many parameters, and the fact that the input correlation structure is often unknown. The aim of this study was to propose an efficient correlated global sensitivity analysis method by applying a surrogate model-based approach. Furthermore, this article demonstrates how correlated SA should be interpreted and how the applied method can guide the modeler during model development and personalization, even when the correlation structure is not entirely known beforehand. The proposed methodology was applied to a typical example of a pulse wave propagation model and resulted in accurate SA results that could be obtained at a theoretically 27,000× lower computational cost compared to the correlated SA approach without employing a surrogate model. Furthermore, our results demonstrate that input correlations can significantly affect SA results, which emphasizes the need to thoroughly investigate the effect of input correlations during model development. We conclude that our proposed surrogate-based SA approach allows modelers to efficiently perform correlated SA to complex biomechanical models and allows modelers to focus on input prioritization, input fixing and model reduction, or assessing the dependency structure between parameters.

Strain-controlled electrophysiological wave propagation alters in silico scar-based substrate for ventricular tachycardia.

Introduction: Assessing a patient's risk of scar-based ventricular tachycardia (VT) after myocardial infarction is a challenging task. It can take months to years after infarction for VT to occur. Also, if selected for ablation therapy, success rates are low. Methods: Computational ventricular models have been presented previously to support VT risk assessment and to provide ablation guidance. In this study, an extension to such virtual-heart models is proposed to phenomenologically incorporate tissue remodeling driven by mechanical load. Strain amplitudes in the heart muscle are obtained from simulations of mechanics and are used to adjust the electrical conductivity. Results: The mechanics-driven adaptation of electrophysiology resulted in a more heterogeneous distribution of propagation velocities than that of standard models, which adapt electrophysiology in the structural substrate from medical images only. Moreover, conduction slowing was not only present in such a structural substrate, but extended in the adjacent functional border zone with impaired mechanics. This enlarged the volumes with high repolarization time gradients (≥10 ms/mm). However, maximum gradient values were not significantly affected. The enlarged volumes were localized along the structural substrate border, which lengthened the line of conduction block. The prolonged reentry pathways together with conduction slowing in functional regions increased VT cycle time, such that VT was easier to induce, and the number of recommended ablation sites increased from 3 to 5 locations. Discussion: Sensitivity testing showed an accurate model of strain-dependency to be critical for low ranges of conductivity. The model extension with mechanics-driven tissue remodeling is a potential approach to capture the evolution of the functional substrate and may offer insight into the progression of VT risk over time.

Validation of a patient-specific hemodynamic computational model for surgical planning of vascular access in hemodialysis patients.

Vascular access dysfunction is one of the main causes of morbidity and hospitalization in hemodialysis patients. This major clinical problem points out the need for prediction of hemodynamic changes induced by vascular access surgery. Here we reviewed the potential of a patient-specific computational vascular network model that includes vessel wall remodeling to predict blood flow change within 6 weeks after surgery for different arteriovenous fistula configurations. For model validation, we performed a multicenter, prospective clinical study to collect longitudinal data on arm vasculature before and after surgery. Sixty-three patients with newly created arteriovenous fistula were included in the validation data set and divided into four groups based on fistula configuration. Predicted brachial artery blood flow volumes 40 days after surgery had a significantly high correlation with measured values. Deviation of predicted from measured brachial artery blood flow averaged 3% with a root mean squared error of 19.5%, showing that the computational tool reliably predicted patient-specific blood flow increase resulting from vascular access surgery and subsequent vascular adaptation. This innovative approach may help the surgeon to plan the most appropriate fistula configuration to optimize access blood flow for hemodialysis, potentially reducing the incidence of vascular access dysfunctions and the need of patient hospitalization.

Autoregulation of coronary blood flow in the isolated beating pig heart.

The isolated beating pig heart model is an accessible platform to investigate the coronary circulation in its truly morphological and physiological state, whereas its use is beneficial from a time, cost, and ethical perspective. However, whether the coronary autoregulation is still intact is not known. Here, we study the autoregulation of coronary blood flow in the working isolated pig heart in response to brief occlusions of the coronary artery, to step-wise changes in left ventricular loading conditions and contractile states, and to pharmacologic vasodilating stimuli. Six slaughterhouse pig hearts (473 ± 40 g) were isolated, prepared, and connected to an external circulatory system. Through coronary reperfusion and controlled cardiac loading, physiological cardiac performance was achieved. After release of a coronary occlusion, coronary blood flow rose rapidly to an equal (maximum) level as the flow during control beats, independent of the duration of occlusion. Moreover, a linear relation was found between coronary blood flow and coronary driving pressure for a wide variation of preload, afterload, and contractility. In addition, intracoronary administration of papaverine did not yield a transient increase in blood flow indicating the presence of maximum coronary hyperemia. Together, this indicates that the coronary circulation in the isolated beating pig heart is in a permanent state of maximum hyperemia. This makes the model excellently suitable for testing and validating cardiovascular devices (i.e., heart valves, stent grafts, and ventricular assist devices) under well-controlled circumstances, whereas it decreases the necessity of sacrificing large mammalians for performing classical animal experiments.

The Impact of a Limited Field-of-View on Computed Hemodynamics in Abdominal Aortic Aneurysms: Evaluating the Feasibility of Completing Ultrasound Segmentations with Parametric Geometries.

To improve abdominal aortic aneurysm (AAA) rupture risk assessment, a large, longitudinal study on AAA hemodynamics and biomechanics is necessary, using personalized fluid-structure interaction (FSI) modeling. 3-dimensional, time-resolved ultrasound (3D+t US) is the preferred image modality to obtain the patient-specific AAA geometry for such a study, since it is safe, affordable and provides temporal information. However, the 3D+t US field-of-view (FOV) is limited and therefore often fails to capture the inlet and aorto-iliac bifurcation geometry. In this study, a framework was developed to add parametric inlet and bifurcation geometries to the abdominal aortic aneurysm geometry by employing dataset statistics and parameters of the AAA geometry. The impact of replacing the patient-specific inlet and bifurcation geometries, acquired using computed tomography (CT) scans, by parametric geometries was evaluated by examining the differences in hemodynamics (systolic and time-averaged wall shear stress and oscillatory shear index) in the aneurysm region. The results show that the inlet geometry has a larger effect on the AAA hemodynamics (median differences of 7.5 to 18.8%) than the bifurcation geometry (median differences all below 1%). Therefore, it is not feasible to replace the patient-specific inlet geometry by a generic one. Future studies should investigate the possibilities of extending the proximal FOV of 3D+t US. However, this study did show the feasibility of adding a parametric bifurcation geometry to the aneurysm geometry. After extending the proximal FOV, the obtained framework can be used to extract AAA geometries from 3D+t US for FSI simulations, despite the absence of the bifurcation geometry.

Deep Learning Method for Estimation of Morphological Parameters Based on CT Scans.

In this study, we propose a Convolutional Neural Network (CNN) with an assembly of non-linear fully connected layers for estimating body height and weight using a limited amount of data. This method can predict the parameters within acceptable clinical limits for most of the cases even when trained with limited data.

Evaluating the Arteriotomy Size of a New Sutureless Coronary Anastomosis Using a Finite Volume Approach.

OBJECTIVES: The ELANA® Heart Bypass creates a standardized sutureless anastomosis. Hereby, we investigate the influence of arteriotomy and graft size on coronary hemodynamics. METHODS: A computational fluid dynamics (CFD) model was developed. Arteriotomy size (standard 1.43 mm2; varied 0.94 - 3.6 mm2) and graft diameter (standard 2.5 mm; varied 1.5 - 5.0 mm) were independent parameters. Outcome parameters were coronary pressure and flow, and fractional flow reserve (FFR). RESULTS: The current size ELANA (arteriotomy 1.43 mm2) presented an estimated FFR 0.65 (39 mL/min). Enlarging arteriotomy increased FFR, coronary pressure, and flow. All reached a maximum once the arteriotomy (2.80 mm2) surpassed the coronary cross-sectional area (2.69 mm2, i.e. 1.85 mm diameter), presenting an estimated FFR 0.75 (46 mL/min). Increasing graft diameter was positively related to FFR, coronary pressure, and flow. CONCLUSION: The ratio between the required minimal coronary diameter for application and the ELANA arteriotomy size effectuates a pressure drop that could be clinically relevant. Additional research and eventual lengthening of the anastomosis is advised.

Spatiotemporal Registration of 3-D Multi-perspective Ultrasound Images of Abdominal Aortic Aneurysms.

Methods for patient-specific abdominal aortic aneurysm (AAA) progression monitoring and rupture risk assessment are widely investigated. Three-dimensional ultrasound can visualize the AAA's complex geometry and displacement fields. However, ultrasound has a limited field of view and low frame rate (i.e., 3-8 Hz). This article describes an approach to enhance the temporal resolution and the field of view. First, the frame rate was increased for each data set by sequencing multiple blood pulse cycles into one cycle. The sequencing method uses the original frame rate and the estimated pulse wave rate obtained from AAA distension curves. Second, the temporal registration was applied to multi-perspective acquisitions of the same AAA. Third, the field of view was increased through spatial registration and fusion using an image feature-based phase-only correlation method and a wavelet transform, respectively. Temporal sequencing was fully correct in aortic phantoms and was successful in 51 of 62 AAA patients, yielding a factor 5 frame rate increase. Spatial registration of proximal and distal ultrasound acquisitions was successful in 32 of 37 different AAA patients, based on the comparison between the fused ultrasound and computed tomography segmentation (95th percentile Haussdorf distances and similarity indices of 4.2 ± 1.7 mm and 0.92 ± 0.02 mm, respectively). Furthermore, the field of view was enlarged by 9%-49%.

MarioHeart: Novel In-Vitro Flow Model for Testing Heart Valve Prostheses and Anticoagulant Therapies.

Mechanical heart valve (MHV) prostheses present a risk of thromboembolic complications despite antithrombotic therapy. Further steps in the development of more hemocompatible MHVs and new anticoagulants are impeded due to the lack of adequate in-vitro models. With the development of a novel in-vitro model (MarioHeart), a pulsatile flow similar to the arterial circulation is emulated. The MarioHeart design owns unique features as 1) a single MHV within a torus with low surface/volume ratio, 2) a closed loop system, and 3) a dedicated external control system driving the oscillating rotational motion of the torus. For verification purposes, a blood analog fluid seeded with particles was used to assess fluid velocity and flow rate using a speckle tracking method on high-speed video recordings of the rotating model. The flow rate resembled the physiological flow rate in the aortic root, in both shape and amplitude. Additional in-vitro runs with porcine blood showed thrombi on the MHV associated with the suture ring, which is similar to the in-vivo situation. MarioHeart is a simple design which induces well-defined fluid dynamics resulting in physiologically nonturbulent flow without stasis of the blood. MarioHeart seems suitable for testing the thrombogenicity of MHVs and the potential of new anticoagulants.