in-vitro-assessment-aortic-regurgitation-using-four-dimensional-flow

<em>In vitro</em> Assessment of Aortic Regurgitation Using Four-Dimensional Flow Magnetic Resonance Imaging

Aortic regurgitation (AR) refers to backward blood flow from the aorta into the left ventricle (LV) during ventricular diastole. The regurgitant jet ...

particle-image-velocimetry-investigation-hemodynamics-via-aortic

Particle Image Velocimetry Investigation of Hemodynamics <em>via</em> Aortic Phantom

Aortic valve dysfunction and stroke have recently been reported in transcatheter aortic valve implantation (TAVI) patients. Thrombus in the aortic sinus ...

Kangwon National University

Turbulent blood flow is implicated in the pathogenesis of several aortic diseases but the extent and degree of turbulent blood flow in the normal aorta is unknown. We aimed to quantify the extent and degree of turbulece in the normal aorta and to assess whether age impacts the degree of turbulence. 22 young normal males (23.7 ± 3.0 y.o.) and 20 old normal males (70.9 ± 3.5 y.o.) were examined using four dimensional flow magnetic resonance imaging (4D Flow MRI) to quantify the turbulent kinetic energy (TKE), a measure of the intensity of turbulence, in the aorta. All healthy subjects developed turbulent flow in the aorta, with total TKE of 3-19 mJ. The overall degree of turbulence in the entire aorta was similar between the groups, although the old subjects had about 73% more total TKE in the ascending aorta compared to the young subjects (young = 3.7 ± 1.8 mJ, old = 6.4 ± 2.4 mJ,  < 0.001). This increase in ascending aorta TKE in old subjects was associated with age-related dilation of the ascending aorta which increases the volume available for turbulence development. Conversely, age-related dilation of the descending and abdominal aorta decreased the average flow velocity and suppressed the development of turbulence. In conclusion, turbulent blood flow develops in the aorta of normal subjects and is impacted by age-related geometric changes. Non-invasive assessment enables the determination of normal levels of turbulent flow in the aorta which is a prerequisite for understanding the role of turbulence in the pathophysiology of cardiovascular disease.

Age-Related Vascular Changes Affect Turbulence in Aortic Blood Flow.

Although pannus is an important cause of prosthetic valve dysfunction, the minimum pannus size that can induce hemodynamic dysfunction has not yet been determined. This study investigated the correlation between the limitation of motion (LOM) of the prosthetic valve and pannus extent and determined the pannus extent that could induce severe aortic stenosis.

Impact of pannus formation on hemodynamic dysfunction of prosthetic aortic valve: pannus extent and its relationship to prosthetic valve motion and degree of stenosis.

Although hemodynamic influence of the subprosthetic tissue, termed as pannus, may contribute to prosthetic aortic valve dysfunction, the relationship between pannus extent and hemodynamics in the prosthetic valve has rarely been reported. We investigated the fluid dynamics of pannus formation using in vitro experiments with particle image velocimetry. Subvalvular pannus formation caused substantial changes in prosthetic valve transvalvular peak velocity, transvalvular pressure gradient (TPG) and opening angle. Maximum flow velocity and corresponding TPG were mostly affected by pannus width. When the pannus width was 25% of the valve diameter, pannus formation elevated TPG to >2.5 times higher than that without pannus formation. Opening dysfunction was observed only for a pannus involvement angle of 360°. Although circumferential pannus with an involvement angle of 360° decreased the opening angle of the valve from approximately 82° to 58°, eccentric pannus with an involvement angle of 180° did not induce valve opening dysfunction. The pannus involvement angle largely influenced the velocity flow field at the aortic sinus and corresponding hemodynamic indices, including wall shear stress, principal shear stress and viscous energy loss distributions. Substantial discrepancy between the velocity-based TPG estimation and direct pressure measurements was observed for prosthetic valve flow with pannus formation.

Effect of pannus formation on the prosthetic heart valve: In vitro demonstration using particle image velocimetry.

To validate pressure drop measurements using 4D flow MRI-based turbulence production in various shapes of stenotic stenoses.

Validation of pressure drop assessment using 4D flow MRI-based turbulence production in various shapes of aortic stenoses.

To assess valvular flow characteristics and pressure drop in a variety of normal and stenotic prosthetic heart valves (PHVs) using 4D Flow MRI.

4D Flow MRI quantification of blood flow patterns, turbulence and pressure drop in normal and stenotic prosthetic heart valves.

Vascular pressure differences are established risk markers for a number of cardiovascular diseases. Relative pressures are, however, often driven by turbulence-induced flow fluctuations, where conventional non-invasive methods may yield inaccurate results. Recently, we proposed a novel method for non-turbulent flows, νWERP, utilizing the concept of virtual work-energy to accurately probe relative pressure through complex branching vasculature. Here, we present an extension of this approach for turbulent flows: νWERP-t. We present a theoretical method derivation based on flow covariance, quantifying the impact of flow fluctuations on relative pressure. νWERP-t is tested on a set of in-vitro stenotic flow phantoms with data acquired by 4D flow MRI with six-directional flow encoding, as well as on a patient-specific in-silico model of an acute aortic dissection. Over all tests νWERP-t shows improved accuracy over alternative energy-based approaches, with excellent recovery of estimated relative pressures. In particular, the use of a guaranteed divergence-free virtual field improves accuracy in cases where turbulent flows skew the apparent divergence of the acquired field. With the original νWERP allowing for assessment of relative pressure into previously inaccessible vasculatures, the extended νWERP-t further enlarges the method's clinical scope, underlining its potential as a novel tool for assessing relative pressure in-vivo.

Non-invasive estimation of relative pressure in turbulent flow using virtual work-energy.

In-vitro cardiovascular experiments provide an effective means for characterizing structural or hemodynamic features of medical devices before they are tested on animals or used in clinical practice. In-vitro experiments simulate complicated cardiovascular systems with blood pumps, vessels and valves, but without human or animal subjects. Therefore, such experiments are free from ethical issues and present large cost savings in comparison to in-vivo experiments. In this study, we aimed to design a fully programmable pulsatile flow pump that can consistently and accurately reproduce a wide range of physiological flow waveforms without costly transient flowmeter in the system. An iterative control algorithm (ICA) was used to minimize the differences between the desired and produced flow waveforms. Our results confirm that the developed pulsatile pump can replicate flow waveforms accurately, with root mean square errors (RMSEs) of 0.64 L/min and 0.52 mL for the flow rate and stroke volume, respectively.

Pulsatile flow pump based on an iterative controlled piston pump actuator as an in-vitro cardiovascular flow model.

To perform comprehensive in vitro experiments using six-directional icosahedral flow encoding (ICOSA6) 4D flow magnetic resonance imaging (MRI) under various scan conditions to analyze the robustness of velocity and turbulence quantification.

In vitro experiments on ICOSA6 4D flow MRI measurement for the quantification of velocity and turbulence parameters.

A multimodality approach was applied using four-dimensional flow magnetic resonance imaging (4D flow MRI), time-of-flight magnetic resonance angiography (TOF-MRA) signal intensity gradient (SIG), and computational fluid dynamics (CFD) to investigate the 3D blood flow characteristics and wall shear stress (WSS) of the cerebral arteries. TOF-MRA and 4D flow MRI were performed on the major cerebral arteries in 16 healthy volunteers (mean age 34.7 ± 7.6 years). The flow rate measured with 4D flow MRI in the internal carotid artery, middle cerebral artery, and anterior cerebral artery were 3.8, 2.5, and 1.2 mL/s, respectively. The 3D blood flow pattern obtained through CFD and 4D flow MRI on the cerebral arteries showed reasonable consensus. CFD delivered much greater resolution than 4D flow MRI. TOF-MRA SIG and CFD WSS of the major cerebral arteries showed reasonable consensus with the locations where the WSS was relatively high. However, the visualizations were very different between TOF-MRA SIG and CFD WSS at the internal carotid artery bifurcations, the anterior cerebral arteries, and the anterior communicating arteries. 4D flow MRI, TOF-MRA SIG, and CFD are complementary methods that can provide additional insight into the hemodynamics of the human cerebral artery.

Comparison of Hemodynamic Visualization in Cerebral Arteries: Can Magnetic Resonance Imaging Replace Computational Fluid Dynamics?

Assessment of carotid bulb hemodynamics using four-dimensional (4D) flow magnetic resonance imaging (MRI) requires accurate segmentation of recirculation regions that is frequently hampered by limited resolution. This study aims to improve the accuracy of 4D flow MRI carotid bulb segmentation and subsequent recirculation regions analysis. Time-of-flight (TOF) MRI and 4D flow MRI were performed on bilateral carotid artery bifurcations in seven healthy volunteers. TOF-MRI data was segmented into 3D geometry for computational fluid dynamics (CFD) simulations. ITK-SNAP segmentation software was included in the workflow for the semi-automatic generation of 4D flow MRI angiographic data. This study compared the velocities calculated at the carotid bifurcations and the 3D blood flow visualization at the carotid bulbs obtained by 4D flow MRI and CFD. By applying ITK-SNAP segmentation software, an obvious improvement in the 4D flow MRI visualization of the recirculation regions was observed. The 4D flow MRI images of the recirculation flow characteristics of the carotid artery bulbs coincided with the CFD. A reasonable agreement was found in terms of velocity calculated at the carotid bifurcation between CFD and 4D flow MRI. However, the dispersion of velocity data points relative to the local errors of measurement in 4D flow MRI remains. Our proposed strategy showed the feasibility of improving recirculation regions segmentation and the potential for reliable blood flow visualization in 4D flow MRI. However, quantitative analysis of recirculation regions in 4D flow MRI with ITK-SNAP should be enhanced for use in clinical situations.

Improving Blood Flow Visualization of Recirculation Regions at Carotid Bulb in 4D Flow MRI Using Semi-Automatic Segmentation with ITK-SNAP.

We aimed to simulate blood flow at an aortic dissection in an in vitro vascular model and assess the impact of the cannulation method on visceral perfusion.

Quantification of visceral perfusion and impact of femoral cannulation: in vitro model of aortic dissection.

Imaging hemodynamics play an important role in the diagnosis of abnormal blood flow due to vascular and valvular diseases as well as in monitoring the recovery of normal blood flow after surgical or interventional treatment. Recently, characterization of turbulent blood flow using 4D flow magnetic resonance imaging (MRI) has been demonstrated by utilizing the changes in signal magnitude depending on intravoxel spin distribution. The imaging sequence was extended with a six-directional icosahedral (ICOSA6) flow-encoding to characterize all elements of the Reynolds stress tensor (RST) in turbulent blood flow. In the present study, we aimed to demonstrate the feasibility of full RST analysis using ICOSA6 4D flow MRI under physiological conditions. First, the turbulence analysis was performed through  experiments with a physiological pulsatile flow condition. Second, a total of 12 normal subjects and one patient with severe aortic stenosis were analyzed using the same sequence. The  study showed that total turbulent kinetic energy (TKE) was less affected by the signal-to-noise ratio (SNR), however, maximum principal turbulence shear stress (MPTSS) and total turbulence production (TP) had a noise-induced bias. Smaller degree of the bias was observed for TP compared to MPTSS.  study showed that the subject-variability on turbulence quantification was relatively low for the consistent scan protocol. The  demonstration of the stenosis patient showed that the turbulence analysis could clearly distinguish the difference in all turbulence parameters as they were at least an order of magnitude larger than those from the normal subjects.

ArticleTotal : 2	Year
Publication title	2022
Publication title Cited by 4	2022

Article	Year
Age-Related Vascular Changes Affect Turbulence in Aortic Blood Flow. Frontiers in physiology\| PubMed ID: 29422871	2018
Impact of pannus formation on hemodynamic dysfunction of prosthetic aortic valve: pannus extent and its relationship to prosthetic valve motion and degree of stenosis. Clinical research in cardiology : official journal of the German Cardiac Society\| PubMed ID: 29460005	2018
Effect of pannus formation on the prosthetic heart valve: In vitro demonstration using particle image velocimetry. PloS one\| PubMed ID: 29953485	2018
Validation of pressure drop assessment using 4D flow MRI-based turbulence production in various shapes of aortic stenoses. Magnetic resonance in medicine\| PubMed ID: 30252155	2019
4D Flow MRI quantification of blood flow patterns, turbulence and pressure drop in normal and stenotic prosthetic heart valves. Magnetic resonance imaging\| PubMed ID: 30266627	2019
Non-invasive estimation of relative pressure in turbulent flow using virtual work-energy. Medical image analysis\| PubMed ID: 31865280	2020
Pulsatile flow pump based on an iterative controlled piston pump actuator as an in-vitro cardiovascular flow model. Medical engineering & physics\| PubMed ID: 31924498	2020
In vitro experiments on ICOSA6 4D flow MRI measurement for the quantification of velocity and turbulence parameters. Magnetic resonance imaging\| PubMed ID: 32619720	2020
Comparison of Hemodynamic Visualization in Cerebral Arteries: Can Magnetic Resonance Imaging Replace Computational Fluid Dynamics? Journal of personalized medicine\| PubMed ID: 33808514	2021
Improving Blood Flow Visualization of Recirculation Regions at Carotid Bulb in 4D Flow MRI Using Semi-Automatic Segmentation with ITK-SNAP. Diagnostics (Basel, Switzerland)\| PubMed ID: 34679588	2021
Quantification of visceral perfusion and impact of femoral cannulation: in vitro model of aortic dissection. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery\| PubMed ID: 34921317	2021
and Assessment of 4D Flow MRI Reynolds Stress Mapping for Pulsatile Blood Flow. Frontiers in bioengineering and biotechnology\| PubMed ID: 34950643	2021

Hojin Ha

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