Abstract
Leaflet thrombosis is a complication associated with transcatheter aortic valve (TAV) replacement (TAVR) correlated with sinus flow stasis. Sinus hemodynamics are important because they dictate shear stress and washout necessary to avoid stasis on TAV leaflets. Sinus flow is controlled by TAV axial deployment position but little is known regarding TAV axis misalignment effect. This study aims to elucidate TAV angular misalignment with respect to aortic root axis effect on sinus flow stasis potentially leading to leaflet thrombosis. Sinus hemodynamics were assessed in vitro using particle-image velocimetry in three different angular misalignments with respect to aorta axis: untilted, tilted away from the sinus and tilted towards sinus. A 26 mm Edwards SAPIEN3 was implanted in a 3D printed model of an anatomically realistic aortic root. TAV hemodynamics, sinus vortex tracking, leaflet shear stress probability density functions, and sinus blood time to washout were calculated. While pressure gradients differed insignificantly, blood velocity and vorticity decreased significantly in both tilted cases sinuses. Shear stress probability near the leaflet decreases with tilt indicating stasis. TAV tilted away from the sinus is the most unfavorable scenario with poor washout. TAV axial misalignment adds to factors list that could influence leaflet thrombosis risk through modifying sinus hemodynamics and washout.
Similar content being viewed by others
References
Bark, D. L., A. N. Para, and D. N. Ku. Correlation of thrombosis growth rate to pathological wall shear rate during platelet accumulation. Biotechnol. Bioeng. 109:2642–2650, 2012.
Berk, B. C., J. I. Abe, W. Min, J. Surapisitchat, and C. Yan. Endothelial atheroprotective and anti-inflammatory mechanisms. Ann. N. Y. Acad. Sci. 947:93–111, 2001.
Casa, L. D., D. H. Deaton, and D. N. Ku. Role of high shear rate in thrombosis. J. Vasc. Surg. 61:1068–1080, 2015.
Chakravarty, T., L. Søndergaard, J. Friedman, O. De Backer, D. Berman, K. F. Kofoed, H. Jilaihawi, T. Shiota, Y. Abramowitz, and T. H. Jørgensen. Subclinical leaflet thrombosis in surgical and transcatheter bioprosthetic aortic valves: an observational study. Lancet 389(10087):2383–2392, 2017.
Chandra, S., N. M. Rajamannan, and P. Sucosky. Computational assessment of bicuspid aortic valve wall-shear stress: implications for calcific aortic valve disease. Biomech. Model Mechanobiol. 11:1085–1096, 2012.
Cunningham, K. S., and A. I. Gotlieb. The role of shear stress in the pathogenesis of atherosclerosis. Lab. Investig. 85:9, 2005.
Dasi, L. P., H. Hatoum, A. Kheradvar, R. Zareian, S. H. Alavi, W. Sun, C. Martin, T. Pham, Q. Wang, and P. A. Midha. On the mechanics of transcatheter aortic valve replacement. Ann. Biomed. Eng. 45:310–331, 2017.
Dhanak, M., and B. D. Bernardinis. The evolution of an elliptic vortex ring. J. Fluid Mech. 109:189–216, 1981.
Didden, N. On the formation of vortex rings: rolling-up and production of circulation. Z. Angew. Math. Phys. (ZAMP) 30:101–116, 1979.
Forleo, M., and L. P. Dasi. Effect of hypertension on the closing dynamics and lagrangian blood damage index measure of the B-Datum Regurgitant Jet in a bileaflet mechanical heart valve. Ann. Biomed. Eng. 42:110–122, 2014.
Gilard, M., H. Eltchaninoff, B. Iung, P. Donzeau-Gouge, K. Chevreul, J. Fajadet, P. Leprince, A. Leguerrier, M. Lievre, and A. Prat. Registry of transcatheter aortic-valve implantation in high-risk patients. N. Engl. J. Med. 366:1705–1715, 2012.
Hatoum, H., J. A. Crestanello, and L. P. Dasi. Possible subclinical leaflet thrombosis in bioprosthetic aortic valves. N. Engl. J. Med. 374:1591–1591, 2016.
Hatoum, H., J. Dollery, S. M. Lilly, J. Crestanello, and L. P. Dasi. Impact of patient morphologies on sinus flow stasis in transcatheter aortic valve replacement: an in vitro study. J. Thorac. Cardiovasc. Surg. 2018.
Hatoum, H., J. Dollery, S. M. Lilly, J. A. Crestanello, and L. P. Dasi. Implantation depth and rotational orientation effect on valve-in-valve hemodynamics and sinus flow. Ann. Thorac. Surg. 2018.
Hatoum, H., J. Dollery, S. M. Lilly, J. A. Crestanello, and L. P. Dasi. Effect of severe bioprosthetic valve tissue ingrowth and inflow calcification on valve-in-valve performance. J. Biomech. 74:171–179, 2018.
Hatoum, H., F. Heim, and L. P. Dasi. Stented valve dynamic behavior induced by polyester fiber leaflet material in transcatheter aortic valve devices. J. Mech. Behav. Biomed. Mater. 86:232–239, 2018.
Hatoum, H., B. L. Moore, and L. P. Dasi. On the significance of systolic flow waveform on aortic valve energy loss. Ann. Biomed. Eng. 2018.
Hatoum, H., B. L. Moore, P. Maureira, J. Dollery, J. A. Crestanello, and L. P. Dasi. Aortic sinus flow stasis likely in valve-in-valve transcatheter aortic valve implantation. J. Thorac. Cardiovasc. Surg. 154(1):32–43, 2017.
Hatoum, H., B. L. Moore, P. Maureira, J. Dollery, J. A. Crestanello, and L. P. Dasi. Aortic sinus flow stasis likely in valve-in-valve transcatheter aortic valve implantation. J. Thorac. Cardiovasc. Surg. 154(32–43):e1, 2017.
Hatoum, H., A. Yousefi, S. Lilly, P. Maureira, J. Crestanello, and L. P. Dasi. An in-vitro evaluation of turbulence after transcatheter aortic valve implantation. J Thorac. Cardiovasc. Surg. 2018.
Kasel, A. M., S. Cassese, S. Bleiziffer, M. Amaki, R. T. Hahn, A. Kastrati, and P. P. Sengupta. Standardized imaging for aortic annular sizing. JACC 6:249–262, 2013.
Klotz, S., M. Scharfschwerdt, D. Richardt, and H. H. Sievers. Failed valve-in-valve transcatheter aortic valve implantation. JACC 5:591–592, 2012.
Kumar, G., V. Raghav, S. Lerakis, and A. P. Yoganathan. High transcatheter valve replacement may reduce washout in the aortic sinuses: an in-vitro study. J. Heart Valve Dis. 24:22–29, 2015.
Lerakis, S., S. S. Hayek, and P. S. Douglas. Paravalvular aortic leak after transcatheter aortic valve replacement. Circulation 127:397–407, 2013.
Makkar, R. R., G. Fontana, H. Jilaihawi, T. Chakravarty, K. F. Kofoed, O. De Backer, F. M. Asch, C. E. Ruiz, N. T. Olsen, and A. Trento. Possible subclinical leaflet thrombosis in bioprosthetic aortic valves. N. Engl. J. Med. 373:2015–2024, 2015.
Mangione, F. M., T. Jatene, A. Gonçalves, G. A. Fishbein, R. N. Mitchell, M. P. Pelletier, T. Kaneko, P. B. Shah, C. B. Nyman, and D. Shook. Leaflet thrombosis in surgically explanted or post-mortem TAVR valves. JACC 1:82–85, 2017.
Maragiannis, D., M. S. Jackson, S. R. Igo, R. C. Schutt, P. Connell, J. Grande-Allen, C. M. Barker, S. M. Chang, M. J. Reardon, and W. A. Zoghbi. Replicating patient-specific severe aortic valve stenosis with functional 3D modeling. Circulation 8:e003626, 2015.
Midha, P. A., V. Raghav, I. Okafor, and A. P. Yoganathan. The effect of valve-in-valve implantation height on sinus flow. Ann. Biomed. Eng. 1–8, 2016.
Mittal, R., P. Rampunggoon, and H. Udaykumar. Interaction of a synthetic jet with a flat plate boundary layer. AIAA Pap. 2773:1, 2001.
Moore, B. L., and L. P. Dasi. Coronary flow impacts aortic leaflet mechanics and aortic sinus hemodynamics. Ann. Biomed. Eng. 43:2231–2241, 2015.
Peacock, J. A. An in vitro study of the onset of turbulence in the sinus of Valsalva. Circ. Res. 67:448–460, 1990.
Saw, S. N., C. Dawn, A. Biswas, C. N. Z. Mattar, and C. H. Yap. Characterization of the in vivo wall shear stress environment of human fetus umbilical arteries and veins. Biomech. Model. Mechanobiol. 16:197–211, 2017.
Toggweiler, S., K. Schmidt, M. Paul, F. Cuculi, R. Kobza, and P. Jamshidi. Valve thrombosis 3 years after transcatheter aortic valve implantation. Int. J. Cardiol. 207:122–124, 2016.
Trantalis, G., K. Toutouzas, G. Latsios, A. Synetos, S. Brili, D. Logitsi, V. Penesopoulou, and D. Tousoulis. TAVR and thrombosis. JACC 10:86–87, 2017.
Traub, O., and B. C. Berk. Laminar shear stress: mechanisms by which endothelial cells transduce an atheroprotective force. Arterioscler. Thromb. Vasc. Biol. 18:677–685, 1998.
Vahidkhah, K., and A. N. Azadani. Supra-annular valve-in-valve implantation reduces blood stasis on the transcatheter aortic valve leaflets. J. Biomech. 58:114–122, 2017.
Walker, J., C. Smith, A. Cerra, and T. Doligalski. The impact of a vortex ring on a wall. J. Fluid Mech. 181:99–140, 1987.
Wu, M., Y. Kouchi, Y. Onuki, Q. Shi, H. Yoshida, S. Kaplan, R. F. Viggers, R. Ghali, and L. R. Sauvage. Effect of differential shear stress on platelet aggregation, surface thrombosis, and endothelialization of bilateral carotid-femoral grafts in the dog. J. Vasc. Surg. 22:382–390, 1995; (discussion 390–392).
Yanagisawa, R., K. Hayashida, Y. Yamada, M. Tanaka, F. Yashima, T. Inohara, T. Arai, T. Kawakami, Y. Maekawa, and H. Tsuruta. Incidence, predictors, and mid-term outcomes of possible leaflet thrombosis after TAVR. JACC 10:1–11, 2017.
Yap, C. H., X. Liu, and K. Pekkan. Characterizaton of the vessel geometry, flow mechanics and wall shear stress in the great arteries of wildtype prenatal mouse. PLoS ONE 9:e86878, 2014.
Acknowledgments
The research done was partly supported by National Institutes of Health (NIH) under Award Number R01HL119824.
Conflict of interest
Dr. Dasi reports having a patent application filed on novel polymeric valves, vortex generators, and superhydrophobic/superomniphobic heart valves, and Dr. Crestanello reports having grants from Medtronic, Boston Scientific and Abbot in addition to being part of the advisory board for Medtronic. No other conflicts were reported.
Author information
Authors and Affiliations
Corresponding author
Additional information
Associate Editor Umberto Morbiducci oversaw the review of this article.
Rights and permissions
About this article
Cite this article
Hatoum, H., Dollery, J., Lilly, S.M. et al. Sinus Hemodynamics Variation with Tilted Transcatheter Aortic Valve Deployments. Ann Biomed Eng 47, 75–84 (2019). https://doi.org/10.1007/s10439-018-02120-0
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10439-018-02120-0