A Computational Framework for Personalized Blood Flow Analysis in the Human Left Atrium
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Atrial fibrillation (AF), the most common human arrhythmia, is a marker of an increased risk of embolic stroke. However, recent studies suggest that AF may not be mechanistically responsible for the stroke events. An alternative explanation for the mechanism of intracardiac thrombosis and stroke in patients with AF is structural remodeling of the left atrium (LA). Nevertheless, a mechanistic link between LA structural remodeling and intracardiac thrombosis is unclear, because there is no clinically feasible methodology to evaluate the complex relationship between these two phenomena in individual patients. Computational fluid dynamics (CFD) is a powerful tool that could potentially link LA structural remodeling and intracardiac thrombosis in individual patients by evaluating the patient-specific LA blood flow characteristics. However, the lack of knowledge of the material and mechanical properties of the heart wall in specific patients makes it challenging to solve the complexity of fluid–structure interaction. In this study, our aim was to develop a clinically feasible methodology to perform personalized blood flow analysis within the heart. We propose an alternative computational approach to perform personalized blood flow analysis by providing the three-dimensional LA endocardial surface motion estimated from patient-specific cardiac CT images. In two patients (case 1 and 2), a four-dimensional displacement vector field was estimated using nonrigid registration. The LA blood outflow across the mitral valve (MV) was calculated from the LV volume, and the flow field within the LA was derived from the incompressible Navier–Stokes equation. The CFD results successfully captured characteristic features of LA blood flow observed clinically by transesophageal echocardiogram. The LA global flow characteristics and vortex structures also agreed well with previous reports. The time course of LAA emptying was similar in both cases, despite the substantial difference in the LA structure and function. We conclude that our CT-based, personalized LA blood flow analysis is a clinically feasible methodology that can be used to improve our understanding of the mechanism of intracardiac thrombosis and stroke in individual patients with LA structural remodeling.
KeywordsImage-based simulation Computed tomography Computational fluid dynamics Cardiac mechanics Left atrium
Computational fluid dynamics
Left atrial appendage
The authors thank Satoshi Ii for valuable input as to the CFD methodology. The authors also thank Yuko Inoue and Susumu Tao for clinical input. This work was supported by research grants from the Japan Society for the Promotion of Science (JSPS) (Research Fellowship for Young Scientist A2616220, to Otani), Magic That Matters Fund for Cardiovascular Research (to Ashikaga) and Zegar Family Foundation (to Ashikaga).
Conflict of interest
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- 2.Al-Issa, A., Y. Inoue, J. Cammin, Q. Tang, S. Nazarian, H. Calkins, E. K. Fishman, K. Taguchi, and H. Ashikaga. Regional function analysis of left atrial appendage using motion estimation CT and risk of stroke in patients with atrial fibrillation. Eur. Hear. J. Cardiovasc. Imaging jev207, 2015. doi: 10.1093/ehjci/jev207.
- 5.Brambatti, M., S. J. Connolly, M. R. Gold, C. A. Morillo, A. Capucci, C. Muto, C. P. Lau, I. C. Van Gelder, S. H. Hohnloser, M. Carlson, E. Fain, J. Nakamya, G. H. Mairesse, M. Halytska, W. Q. Deng, C. W. Israel, and J. S. Healey. Temporal relationship between subclinical atrial fibrillation and embolic events. Circulation 129:2094–2099, 2014. doi: 10.1161/CIRCULATIONAHA.113.007825.CrossRefPubMedGoogle Scholar
- 7.Daccarett, M., T. J. Badger, N. Akoum, N. S. Burgon, C. Mahnkopf, G. Vergara, E. Kholmovski, C. J. McGann, D. Parker, J. Brachmann, R. S. MacLeod, and N. F. Marrouche. Association of left atrial fibrosis detected by delayed-enhancement magnetic resonance imaging and the risk of stroke in patients with atrial fibrillation. J. Am. Coll. Cardiol. 57:831, 2011. doi: 10.1016/j.jacc.2010.09.049.CrossRefPubMedPubMedCentralGoogle Scholar
- 8.Daoud, E. G., T. V. Glotzer, D. G. Wyse, M. D. Ezekowitz, C. Hilker, J. Koehler, P. D. Ziegler, and T. Investigators. Temporal relationship of atrial tachyarrhythmias, cerebrovascular events, and systemic emboli based on stored device data: a subgroup analysis of TRENDS. Heart Rhythm 8:1416–1423, 2011. doi: 10.1016/j.hrthm.2011.04.022.CrossRefPubMedGoogle Scholar
- 9.Di Biase, L., P. Santangeli, M. Anselmino, P. Mohanty, I. Salvetti, S. Gili, R. Horton, J. E. Sanchez, R. Bai, S. Mohanty, A. Pump, M. Cereceda Brantes, G. J. Gallinghouse, J. D. Burkhardt, M. Cereceda Brantes, F. Cesarani, M. Scaglione, A. Natale, and F. Gaita. Does the left atrial appendage morphology correlate with the risk of stroke in patients with atrial fibrillation? Results from a multicenter study. J. Am. Coll. Cardiol. 60:531–538, 2012. doi: 10.1016/j.jacc.2012.04.032.CrossRefPubMedGoogle Scholar
- 10.Fatema, K., K. R. Bailey, G. W. Petty, I. Meissner, M. Osranek, A. A. Alsaileek, B. K. Khandheria, T. S. Tsang, and J. B. Seward. Increased left atrial volume index: potent biomarker for first-ever ischemic stroke. Mayo Clin. Proc. 83:1107–1115, 2008. doi: 10.4065/83.10.1107.CrossRefPubMedGoogle Scholar
- 13.Healey, J. S., S. J. Connolly, M. R. Gold, C. W. Israel, I. C. Van Gelder, A. Capucci, C. P. Lau, E. Fain, S. Yang, C. Bailleul, C. A. Morillo, M. Carlson, E. Themeles, E. S. Kaufman, and S. H. Hohnloser. Subclinical atrial fibrillation and the risk of stroke. N. Engl. J. Med. 366:120–129, 2012. doi: 10.1056/NEJMoa1105575.CrossRefPubMedGoogle Scholar
- 14.Inoue, Y. Y., A. Alissa, I. M. Khurram, K. Fukumoto, M. Habibi, B. A. Venkatesh, S. L. Zimmerman, S. Nazarian, R. D. Berger, H. Calkins, J. A. Lima, and H. Ashikaga. Quantitative tissue-tracking cardiac magnetic resonance (CMR) of left atrial deformation and the risk of stroke in patients with atrial fibrillation. J. Am. Heart Assoc. 4:e001844–e001844, 2015. doi: 10.1161/JAHA.115.001844.CrossRefPubMedPubMedCentralGoogle Scholar
- 15.Khurram, I. M., J. Dewire, M. Mager, F. Maqbool, S. L. Zimmerman, V. Zipunnikov, R. Beinart, J. E. Marine, D. D. Spragg, R. D. Berger, H. Ashikaga, S. Nazarian, and H. Calkins. Relationship between left atrial appendage morphology and stroke in patients with atrial fibrillation. Heart Rhythm 10:1843–1849, 2013. doi: 10.1016/j.hrthm.2013.09.065.CrossRefPubMedGoogle Scholar
- 17.Kimura, T., S. Takatsuki, K. Inagawa, Y. Katsumata, T. Nishiyama, N. Nishiyama, K. Fukumoto, Y. Aizawa, Y. Tanimoto, K. Tanimoto, M. Jinzaki, and K. Fukuda. Anatomical characteristics of the left atrial appendage in cardiogenic stroke with low CHADS2 scores. Heart Rhythm 10:921–925, 2013. doi: 10.1016/j.hrthm.2013.01.036.CrossRefPubMedGoogle Scholar
- 18.Kizer, J. R., J. N. Bella, V. Palmieri, J. E. Liu, L. G. Best, E. T. Lee, M. J. Roman, and R. B. Devereux. Left atrial diameter as an independent predictor of first clinical cardiovascular events in middle-aged and elderly adults: the Strong Heart Study (SHS). Am. Heart J. 151:412–418, 2006. doi: 10.1016/j.ahj.2005.04.031.CrossRefPubMedGoogle Scholar
- 21.Miller, J. M., C. E. Rochitte, M. Dewey, A. Arbab-Zadeh, H. Niinuma, I. Gottlieb, N. Paul, M. E. Clouse, E. P. Shapiro, J. Hoe, A. C. Lardo, D. E. Bush, A. de Roos, C. Cox, J. Brinker, and J. A. C. Lima. Diagnostic performance of coronary angiography by 64-row CT. N. Engl. J. Med. 359:2324–2336, 2008. doi: 10.1056/NEJMoa0806576.CrossRefPubMedGoogle Scholar
- 22.Morales, H., I. Larrabide, A. Geers, L. San Roman, J. Blasco, J. Macho, and A. Frangi. A virtual coiling technique for image-based aneurysm models by dynamic path planning. IEEE Trans. Med. Imaging 1–11, 2012. doi: 10.1109/TMI.2012.2219626.
- 25.Pourmorteza, A., K. H. Schuleri, D. A. Herzka, A. C. Lardo, and E. R. McVeigh. A new method for cardiac computed tomography regional function assessment: Stretch quantifier for endocardial engraved zones (SQUEEZ). Circ. cardiovasc. Imaging 5:243–250, 2012. doi: 10.1161/CIRCIMAGING.111.970061.CrossRefPubMedGoogle Scholar
- 26.Russo, C., Z. Jin, R. Liu, S. Iwata, A. Tugcu, M. Yoshita, S. Homma, M. S. V. Elkind, T. Rundek, C. Decarli, B. Wright, R. L. Sacco, and M. R. Di Tullio. LA volumes and reservoir function are associated with subclinical cerebrovascular disease: The CABL (Cardiovascular Abnormalities and Brain Lesions) study. JACC. Cardiovasc. Imaging 6:313–324, 2013. doi: 10.1016/j.jcmg.2012.10.019.Google Scholar
- 29.Smiseth, O. A., C. R. Thompson, K. Lohavanichbutr, H. Ling, J. G. Abel, R. T. Miyagishima, S. V. Lichtenstein, and J. Bowering. The pulmonary venous systolic flow pulse–its origin and relationship to left atrial pressure. J. Am. Coll. Cardiol. 34:802–809, 1999. doi: 10.1016/S0735-1097(99)00300-9.CrossRefPubMedGoogle Scholar
- 30.Tsang, T. S. M., W. P. Abhayaratna, M. E. Barnes, Y. Miyasaka, B. J. Gersh, K. R. Bailey, S. S. Cha, and J. B. Seward. Prediction of cardiovascular outcomes with left atrial size: Is volume superior to area or diameter? J. Am. Coll. Cardiol. 47:1018–1023, 2006. doi: 10.1016/j.jacc.2005.08.077.CrossRefPubMedGoogle Scholar
- 33.Wong, J. M., C. C. Welles, F. Azarbal, M. A. Whooley, N. B. Schiller, and M. P. Turakhia. Relation of left atrial dysfunction to ischemic stroke in patients with coronary heart disease (from the Heart and Soul Study). Am. J. Cardiol. 113:1679–1684, 2014. doi: 10.1016/j.amjcard.2014.02.021.CrossRefPubMedGoogle Scholar