Aortic flow after valve sparing root replacement with or without neosinuses reconstruction

Gaudino, Mario; Piatti, Filippo; Lau, Christopher; Sturla, Francesco; Weinsaft, Jonathan W.; Weltert, Luca; Votta, Emiliano; Galea, Nicola; Chirichilli, Ilaria; Francone, Marco; Catalano, Carlo; Redaelli, Alberto; Girardi, Leonard N.; Paulis, Ruggero De

doi:10.1016/j.jtcvs.2018.06.094

Cited by 39 publications

(21 citation statements)

References 31 publications

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“…Comparing both prostheses to healthy subjects, significant differences in the AAo were only found for the TP but not the SP. Albeit comparison of different works is hampered by a lack of standardized protocols regarding the evaluation of WSS, the results in the aortic bulb and the AAo are in concordance with a previous study that assessed WSS in a prosthesis with neo-sinuses of a different vendor using a volumetric approach [16]. Arguably, Gaudino and colleagues also reported significant differences for WSS avg and maximum WSS in the DAo, which was only partially reproducible in our study.…”

Section: Discussionsupporting

confidence: 90%

“…Of note, in a previous study using 4D Flow CMR, we could confirm almost physiological flow patterns in the aortic root of the SP compared to disturbed flow in the TP [ 15 ]. Nonetheless, distal to both prostheses types, significantly more secondary flow patterns than in healthy subjects were detected [ 8 , 16 ]. These secondary flow patterns were only evaluated semi-quantitatively on a Likert scale; the study lacked a quantitative parameter to objectively quantify flow abnormalities.…”

Section: Introductionmentioning

confidence: 99%

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4D flow CMR analysis comparing patients with anatomically shaped aortic sinus prostheses, tube prostheses and healthy subjects introducing the wall shear stress gradient: a case control study

Sieren¹,

Schultz²,

Fujita

et al. 2020

Journal of Cardiovascular Magnetic Resonance

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Background: Anatomically pre-shaped sinus prostheses (SP) were developed to mimic the aortic sinus with the goal to preserve near physiological hemodynamic conditions after valve-sparing aortic root replacement. Although SP have shown more physiological flow patterns, a comparison to straight tube prosthesis and the analysis of derived quantitative parameters is lacking. Hence, this study sought to analyze differences in aortic wall shear stress (WSS) between anatomically pre-shaped SP, conventional straight tube prostheses (TP), and age-matched healthy subjects) using time-resolved 3-dimensional flow cardiovascular magnetic resonance (4D Flow CMR). Moreover, the WSS gradient was introduced and analyzed regarding its sensitivity to detect changes in hemodynamics and its dependency on the expression of secondary flow patterns. Methods: Twelve patients with SP (12 male, 62 ± 9yr), eight patients with TP (6 male, 59 ± 9yr), and twelve healthy subjects (2 male, 55 ± 6yr) were examined at 3 T with a 4D Flow CMR sequence in this case control study. Six analysis planes were placed in the thoracic aorta at reproducible landmarks. The following WSS parameters were recorded: WSS avg (spatially averaged over the contour at peak systole), max. WSS seg (maximum segmental WSS), min. WSS seg (minimum segmental WSS) and the WSS Gradient, calculated as max. WSS segmin. WSS seg. Kruskal-Wallis-and Mann-Whitney-U-Test were used for statistical comparison of groups. Occurrence and expression of secondary flow patterns were evaluated and correlated to WSS values using Spearman's correlation coefficient.

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Section: Discussionsupporting

confidence: 90%

Section: Introductionmentioning

confidence: 99%

4D flow CMR analysis comparing patients with anatomically shaped aortic sinus prostheses, tube prostheses and healthy subjects introducing the wall shear stress gradient: a case control study

Sieren¹,

Schultz²,

Fujita

et al. 2020

Journal of Cardiovascular Magnetic Resonance

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“…Fourdimensional magnetic resonance imaging, echo-particle image velocimetry, Doppler, and computational fluid dynamics can generate excellent flow visualizations, and many groups have studied the influence of sinuses on aortic root fluid dynamics. 5,[31][32][33][34][35][36][37][38][39][40] These studies clearly show that the sinuses of Valsalva critically influence the behavior of the aortic valve and root. Although we did not detect any meaningful differences in coronary blood flow, valve hemodynamics, or flow profiles between the conduits we compared, the benefits of neosinus creation might be overshadowed by the consequences of commissural distortion.…”

Section: Discussionmentioning

confidence: 68%

Modeling conduit choice for valve-sparing aortic root replacement on biomechanics with a 3-dimensional–printed heart simulator

Paulsen

Kasinpila

Imbrie-Moore

et al. 2019

The Journal of Thoracic and Cardiovascular Surgery

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Objective: The optimal conduit for valve-sparing aortic root replacement is still debated, with several conduit variations available, ranging from straight tubular grafts to Valsalva grafts. Benefits of neosinus reconstruction include enhanced flow profiles and improved hemodynamics. Curiously, however, some clinical data suggest that straight grafts may have greater long-term durability. In this study, we hypothesized that straight tubular grafts may help maintain the native cylindrical position of the aortic valve commissures radially, resulting in preserved leaflet coaptation, reduced stresses, and potentially improved valve performance.Methods: Using 3D printing, a left heart simulator with a valve-sparing root replacement model and a physiologic coronary circulation was constructed. Aortic valves were dissected from fresh porcine hearts and reimplanted into either straight tubular grafts (n ¼ 6) or Valsalva grafts (n ¼ 6). Conduits were mounted into the heart simulator and hemodynamic, echocardiographic, and high-speed videometric data were collected.Results: Hemodynamic parameters and coronary blood flow were similar between straight and Valsalva grafts, although the former were associated with lower regurgitant fractions, less peak intercommissural radial separation, preserved leaflet coaptation, decreased leaflet velocities, and lower relative leaflet forces compared with Valsalva grafts.Conclusions: Valsalva grafts and straight grafts perform equally well in terms of gross hemodyanics and coronary blood flow. Interestingly, however, the biomechanics of these 2 conduits differ considerably, with straight grafts providing increased radial commissural stability and leaflet coaptation. Further investigation into how these parameters influence clinical outcomes is warranted. (J Thorac Cardiovasc Surg 2019;158:392-403) Variation (yellow arrows) between Valsalva graft and radial position of aortic commissures. Central MessageStraight grafts maintain the radial position of the aortic valve commissures in their native cylindrical conformation, preserving leaflet coaptation and decreasing regurgitation, cusp velocities, and forces. PerspectiveValve-sparing root replacement is an effective treatment for aortic root aneurysms, although the ideal conduit is unknown. While neosinus reconstruction is believed to generate more physiologic flow profiles and optimized hemodynamics, it does not appear to increase longterm clinical durability over straight grafts. Ex vivo testing was used to provide a mechanistic comparison and demonstrated decreased cusp velocities, forces, and regurgitation in straight grafts.

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“…Four-dimensional flow MRI offers high potential in measuring and characterizing blood stream patterns, and it has recently been increasingly reported in the cardiovascular literature, particularly in relation to aortic surgery. 2 Altered blood flow patterns have been found to increase wall shear stress, which potentially promotes vessel wall change, aortic remodeling, atherosclerotic plaque induction, and aneurysm development. It also potentially increases the left ventricular workload.…”

Section: Tohru Asai MD Phdmentioning

confidence: 99%

Commentary: More valuable data on aortic blood flow patterns in valve-sparing aortic root replacements

Asai

2020

The Journal of Thoracic and Cardiovascular Surgery

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Aortic flow after valve sparing root replacement with or without neosinuses reconstruction

Abstract: Re-creation of the sinuses of Valsalva during valve-sparing root replacement is associated with more physiologic flow and significantly lower WSS in the aortic root. Lower WSSs in the distal thoracic aorta is a novel finding with potential implications on distal aortic remodeling.

Cited by 39 publications

References 31 publications

4D flow CMR analysis comparing patients with anatomically shaped aortic sinus prostheses, tube prostheses and healthy subjects introducing the wall shear stress gradient: a case control study

4D flow CMR analysis comparing patients with anatomically shaped aortic sinus prostheses, tube prostheses and healthy subjects introducing the wall shear stress gradient: a case control study

Modeling conduit choice for valve-sparing aortic root replacement on biomechanics with a 3-dimensional–printed heart simulator

Commentary: More valuable data on aortic blood flow patterns in valve-sparing aortic root replacements

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