An Evaluation of the Influence of Coronary Flow on Transcatheter Heart Valve Neo-Sinus Flow Stasis
Transcatheter heart valve (THV) leaflet thrombosis in the neo-sinus and associated reduced leaflet motion is of clinical concern due to risks of embolism and worsened valve hemodynamics. Flow stasis in the neo-sinus (the space between the native and THV leaflets) is a known risk factor, but the role of proximal coronary flow is yet to be investigated. We tested two replicas of FDA approved commercial THVs—intra-annular and supra-annular (similar to the SAPIEN 3 and CoreValve families)—in a left heart simulator with coronary flow. Velocity fields in the left coronary cusp (LCC) and non (NCC) neo-sinus were quantified using high speed particle image velocimetry and particle residence times (PRT) were computed to evaluate flow stasis in the region. The supra-annular THV LCC neo-sinus had shorter PRT than its NCC neo-sinus (0.66 ± 0.00 vs. 0.76 ± 0.04, p = 0.038), while the intra-annular THV LCC neo-sinus had similar PRT to its NCC neo-sinus (1.93 ± 0.05 vs. 1.92 ± 0.03 cycles, p = 0.889). The supra-annular valve LCC and NCC neo-sinuses had shorter PRT than their intra-annular valve counterparts (p < 0.001). These results showed that coronary flow reduces flow stasis in the supra-annular THV neo-sinus and, ostensibly, thrombosis risk in the region. This effect was not significant in the intra-annular valve.
KeywordsTAVR Coronary flow Neo-sinus Flow Stasis Thrombosis Particle image velocimetry
Transcatheter heart valve
Left coronary cusp
Right coronary cusp
Particle residence time
Georgia Tech TAVR intra-annular device
Georgia Tech TAVR supra-annular device
Particle image velocimetry
The authors would like to acknowledge the members of the Cardiovascular Fluid Mechanics Laboratory for their assistance and feedback.
The work at the Cardiovascular Fluid Mechanics Laboratory at the Georgia Institute of Technology was funded through the BME Gurley Foundation and the Mary and James Wesley Fellowship Endowment, as well as discretionary funds made available to the Principal Investigator, such as the Wallace H Coulter Endowed Chair.
Conflict of interest
No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.
Supplementary material 5 Video 1: Velocity contours and streamlines for the supra-annular valve LCC. (MP4 37794 kb)
Supplementary material 6 Video 2: Velocity contours and streamlines for the intra-annular valve LCC. (MP4 45106 kb)
Supplementary material 7 Video 3: Velocity contours and streamlines for the supra-annular valve NCC. (MP4 25784 kb)
Supplementary material 8 Video 4: Velocity contours and streamlines for the intra-annular valve NCC. (MP4 41932 kb)
- 2.Chakravarty, T., L. Søndergaard, J. Friedman, O. De Backer, D. Berman, K. F. Kofoed, H. Jilaihawi, T. Shiota, Y. Abramowitz, T. H. Jørgensen, T. Rami, S. Israr, G. Fontana, M. de Knegt, A. Fuchs, P. Lyden, A. Trento, D. L. Bhatt, M. B. Leon, R. R. Makkar, D. Ramzy, W. Cheng, R. J. Siegel, L. M. Thomson, G. Mangat, B. Hariri, F. J. Sawaya, and H. K. Iversen. Subclinical leaflet thrombosis in surgical and transcatheter bioprosthetic aortic valves: an observational study. Lancet 389:2383–2392, 2017.CrossRefGoogle Scholar
- 4.De Marchena, E., J. Mesa, S. Pomenti, C. Marin y Kall, X. Marincic, K. Yahagi, E. Ladich, R. Kutz, Y. Aga, M. Ragosta, A. Chawla, M. E. Ring, and R. Virmani. Thrombus formation following transcatheter aortic valve replacement. J. Am. Coll. Cardiol. Cardiovasc. Interv. 8:728–739, 2015.CrossRefGoogle Scholar
- 7.Fuchs, A., O. De Backer, M. Brooks, M. C. De Knegt, G. Bieliauskas, M. Yamamoto, R. Yanagisawa, K. Hayashida, L. Søndergaard, and K. F. Kofoed. Subclinical leaflet thickening and stent frame geometry in self-expanding transcatheter heart valves. EuroIntervention 13:1067–1075, 2017.CrossRefGoogle Scholar
- 12.Kasel, A. M., J. M. Khan, A. B. Greenbaum, and J. M. Michel. Intentional transcatheter laceration of the coronary cusp to prevent left main stem obstruction during transcatheter aortic valve implantation: first European experience with the BASILICA technique in a native aortic valve. Eur. Heart J. 40(17):1384–1385, 2018. https://doi.org/10.1093/eurheartj/ehy711.CrossRefGoogle Scholar
- 13.Khan, J. M., D. Dvir, A. B. Greenbaum, V. C. Babaliaros, T. Rogers, G. Aldea, M. Reisman, G. B. Mackensen, M. H. K. Eng, G. Paone, D. D. Wang, R. A. Guyton, C. M. Devireddy, W. H. Schenke, and R. J. Lederman. Transcatheter laceration of aortic leaflets to prevent coronary obstruction during transcatheter aortic valve replacement: concept to first-in-human. JACC Cardiovasc. Interv. 11(7):677–689, 2018. https://doi.org/10.1016/j.jcin.2018.01.247.CrossRefPubMedPubMedCentralGoogle Scholar
- 15.Leetmaa, T., N. C. Hansson, J. Leipsic, K. Jensen, S. H. Poulsen, H. R. Andersen, J. M. Jensen, J. Webb, P. Blanke, M. Tang, and B. L. Norgaard. Early aortic transcatheter heart valve thrombosis: diagnostic value of contrast-enhanced multidetector computed tomography. Circ. Cardiovasc. Interv. 8:e001596, 2015.CrossRefGoogle Scholar
- 17.Makkar, R. R., G. Fontana, H. Jilaihawi, T. Chakravarty, K. F. Kofoed, O. de Backer, F. M. Asch, C. E. Ruiz, N. T. Olsen, A. Trento, J. Friedman, D. Berman, W. Cheng, M. Kashif, V. Jelnin, C. A. Kliger, H. Guo, A. D. Pichard, N. J. Weissman, S. Kapadia, E. Manasse, D. L. Bhatt, M. B. Leon, and L. Søndergaard. Possible subclinical leaflet thrombosis in bioprosthetic aortic valves. N. Engl. J. Med. 373:2015–2024, 2015.CrossRefGoogle Scholar
- 18.Midha, P. A. A Parametric Investigation of Transcatheter Aortic Valve Replacement Performance. Dr. Thesis, 2017.Google Scholar
- 20.Midha, P. A., V. Raghav, R. Sharma, J. F. Condado, I. U. Okafor, T. Rami, G. Kumar, V. H. Thourani, H. Jilaihawi, V. Babaliaros, R. R. Makkar, and A. P. Yoganathan. The fluid mechanics of transcatheter heart valve leaflet thrombosis in the neosinus. Circulation 136:1598–1609, 2017.CrossRefGoogle Scholar
- 25.Sakamoto, S., S. Takahashi, A. U. Coskun, M. I. Papafaklis, A. Takahashi, S. Saito, P. H. Stone, and C. L. Feldman. Relation of distribution of coronary blood flow volume to coronary artery dominance. Am. J. Cardiol. 111(10):1420–1424, 2013. https://doi.org/10.1016/j.amjcard.2013.01.290.CrossRefPubMedGoogle Scholar
- 28.Trusty, P., V. Sadri, I. D. Madukauwa-David, N. Kamioka, R. Sharma, R. Makkar, V. Babaliaros, and A. P. Yoganathan. Neosinus flow stasis correlates with thrombus volume post-TAVR: a patient-specific in vitro study. JACC. Cardiovasc. Interv. 12(13):1288–1290, 2019. https://doi.org/10.1016/j.jcin.2017.10.017.CrossRefPubMedGoogle Scholar