Effect of reduced cardiac output on blood stasis on transcatheter aortic valve leaflets: implications for valve thrombosis.

AIMS: There is an increasing awareness of leaflet thrombosis following transcatheter aortic valve implantation (TAVI) and valve-in-valve (ViV) procedures. Nevertheless, the predisposing factors affecting transcatheter aortic valve (TAV) thrombosis have remained unclear. This study aimed to quantify the effects of reduced cardiac output (CO) on blood stasis on the TAV leaflets as a permissive factor for valve thrombosis. METHODS AND RESULTS: An idealised computational model representing a TAV was developed in a patient-specific geometry. Three-dimensional flow fields were obtained via a fluid-solid interaction modelling approach at different COs: 5.0, 3.5, 2.0 L/min. Blood residence time (BRT) was subsequently calculated on the leaflets. An association between reduced CO and increased blood stasis on the TAV leaflets was observed. At the end of diastole, larger areas of high BRT (>1.2 s) were observed at the leaflet's fixed edge at low COs. Such areas were calculated to be 2, 8, and 11% of the total surface area of leaflets at CO=5.0, 3.5, and 2.0 L/min, respectively, indicating a ~sixfold increase of BRT on the leaflets from the highest to the lowest CO. CONCLUSIONS: This study indicates an association between reduced CO and increased blood stasis on the TAV leaflets which can be regarded as a precursor of valve thrombosis.

Blood Stasis on Transcatheter Valve Leaflets and Implications for Valve-in-Valve Leaflet Thrombosis.

BACKGROUND: Leaflet thrombosis after valve-in-valve (ViV) procedure has been increasingly recognized. This study aimed to investigate the flow dynamics aspect of leaflet thrombosis by quantifying the blood stasis on the noncoronary and coronary leaflets of a surgical aortic valve (SAV) and a transcatheter aortic valve (TAV) in a ViV setting. METHODS: Two computational models, representing a SAV and a TAV in ViV setting, were developed in a patient-specific geometry. Three-dimensional flow fields were obtained through a fluid-solid interaction modeling approach to study the difference in blood residence time (BRT) on the coronary and noncoronary leaflets. RESULTS: Longer BRT was observed on the TAV leaflets compared with the SAV, specifically near the leaflet fixed boundary. Particularly, at the end of diastole, the areas of high BRT (≥1.2 seconds) on the surface of the TAV model leaflets were four times larger than those of the SAV model. The distribution of BRT on the three leaflets exhibited a similar pattern in the model for the TAV in ViV setting. That was in contrast to the SAV model where large areas of high BRT were observed on the noncoronary leaflet. CONCLUSIONS: Geometric confinement of the TAV by the leaflets and the frame of the degenerated bioprosthesis that circumferentially surround the TAV stent increases the BRT on the leaflets, which may act as a permissive factor in the TAV leaflet thrombosis after ViV procedure. A similar distribution pattern of BRT observed on the TAV leaflets may explain the similar rate of occurrence of thrombosis on the three leaflets.

Supra-annular Valve-in-Valve implantation reduces blood stasis on the transcatheter aortic valve leaflets.

Leaflet thrombosis following transcatheter aortic valve replacement (TAVR) and Valve-in-Valve (ViV) procedures has been increasingly recognized. This study aimed to investigate the effect of positioning of the transcatheter aortic valve (TAV) in ViV setting on the flow dynamics aspect of post-ViV thrombosis by quantifying the blood stasis in the intra-annular and supra-annular settings. To that end, two idealized computational models, representing ViV intra-annular and supra-annular positioning of a TAV were developed in a patient-specific geometry. Three-dimensional flow fields were then obtained via fluid-solid interaction modeling to study the difference in blood residence time (BRT) on the TAV leaflets in the two settings. At the end of diastole, a strip of high BRT (⩾1.2s) region was observed on the TAV leaflets in the ViV intra-annular positioning at the fixed boundary where the leaflets are attached to the frame. Such a high BRT region was absent on the TAV leaflets in the supra-annular positioning. The maximum value of BRT on the surface of non-, right, and left coronary leaflets of the TAV in the supra-annular positioning were 53%, 11%, and 27% smaller compared to the intra-annular positioning, respectively. It was concluded that the geometric confinement of TAV by the leaflets of the failed bioprosthetic valve in ViV intra-annular positioning increases the BRT on the leaflets and may act as a permissive factor in valvular thrombosis. The absence of such a geometric confinement in the ViV supra-annular positioning leads to smaller BRT and subsequently less likelihood of leaflet thrombosis.

Valve thrombosis following transcatheter aortic valve replacement: significance of blood stasis on the leaflets.

OBJECTIVES: Leaflet thrombosis following transcatheter aortic valve replacement (TAVR) and valve-in-valve (ViV) procedures has been increasingly recognized. However, the factors affecting the post-TAVR/ViV thrombosis are not fully understood. This study aimed to investigate the effect of the geometric confinement of transcatheter aortic valve (TAV) on blood residence time (BRT) on the TAV leaflets and in turn on the post-TAVR valve thrombosis. METHODS: Two computational models, representing a surgical bioprosthesis and a TAV, were developed to study the effect of the geometric confinement on BRT on the leaflets in ViV setting/TAVR Intra-annular positioning. 3D flow fields were obtained via a one-way fluid-solid interaction modelling approach validated by experimental testing. BRT was compared between the two models by quantification and statistical analysis of the residence time of randomly distributed particles in close proximity of the leaflets. RESULTS: Significantly longer BRT on the leaflets was observed in the TAV compared to the surgical valve during different stages of the cardiac cycle. During forward flow, the mean value of BRT was found to be 39% higher in the TAV compared to the surgical bioprosthesis ( P < 0.0001). During diastole, specifically from end-systole to mid-diastole and from mid-diastole to the beginning of systole, the amount by which the mean BRT was higher for TAV compared to the surgical valve was 150% and 40%, respectively ( P < 0.0005). CONCLUSIONS: The geometric confinement of TAV by the failed bioprosthesis or the calcified native valve increases the BRT on the TAV leaflets. This may act as a permissive factor in valve thrombosis.

Flow of Red Blood Cells in Stenosed Microvessels.

A computational study is presented on the flow of deformable red blood cells in stenosed microvessels. It is observed that the Fahraeus-Lindqvist effect is significantly enhanced due to the presence of a stenosis. The apparent viscosity of blood is observed to increase by several folds when compared to non-stenosed vessels. An asymmetric distribution of the red blood cells, caused by geometric focusing in stenosed vessels, is observed to play a major role in the enhancement. The asymmetry in cell distribution also results in an asymmetry in average velocity and wall shear stress along the length of the stenosis. The discrete motion of the cells causes large time-dependent fluctuations in flow properties. The root-mean-square of flow rate fluctuations could be an order of magnitude higher than that in non-stenosed vessels. Several folds increase in Eulerian velocity fluctuation is also observed in the vicinity of the stenosis. Surprisingly, a transient flow reversal is observed upstream a stenosis but not downstream. The asymmetry and fluctuations in flow quantities and the flow reversal would not occur in absence of the cells. It is concluded that the flow physics and its physiological consequences are significantly different in micro- versus macrovascular stenosis.

Characterization of three-dimensional anisotropic heart valve tissue mechanical properties using inverse finite element analysis.

Computational modeling has an important role in design and assessment of medical devices. In computational simulations, considering accurate constitutive models is of the utmost importance to capture mechanical response of soft tissue and biomedical materials under physiological loading conditions. Lack of comprehensive three-dimensional constitutive models for soft tissue limits the effectiveness of computational modeling in research and development of medical devices. The aim of this study was to use inverse finite element (FE) analysis to determine three-dimensional mechanical properties of bovine pericardial leaflets of a surgical bioprosthesis under dynamic loading condition. Using inverse parameter estimation, 3D anisotropic Fung model parameters were estimated for the leaflets. The FE simulations were validated using experimental in-vitro measurements, and the impact of different constitutive material models was investigated on leaflet stress distribution. The results of this study showed that the anisotropic Fung model accurately simulated the leaflet deformation and coaptation during valve opening and closing. During systole, the peak stress reached to 3.17MPa at the leaflet boundary while during diastole high stress regions were primarily observed in the commissures with the peak stress of 1.17MPa. In addition, the Rayleigh damping coefficient that was introduced to FE simulations to simulate viscous damping effects of surrounding fluid was determined.

Flow-Induced Damage to Blood Cells in Aortic Valve Stenosis.

Valvular hemolysis and thrombosis are common complications associated with stenotic heart valves. This study aims to determine the extent to which hemodynamics induce such traumatic events. The viscous shear stress downstream of a severely calcified bioprosthetic valve was evaluated via in vitro 2D particle image velocimetry measurements. The blood cell membrane response to the measured stresses was then quantified using 3D immersed-boundary computational simulations. The shear stress level at the boundary layer of the jet flow formed downstream of the valve orifice was observed to reach a maximum of 1000-1700 dyn/cm(2), which was beyond the threshold values reported for platelet activation (100-1000 dyn/cm(2)) and within the range of thresholds reported for red blood cell (RBC) damage (1000-2000 dyn/cm(2)). Computational simulations demonstrated that the resultant tensions at the RBC membrane surface were unlikely to cause instant rupture, but likely to lead to membrane plastic failure. The resultant tensions at the platelet surface were also calculated and the potential damage was discussed. It was concluded that although shear-induced thrombotic trauma is very likely in stenotic heart valves, instant hemolysis is unlikely and the shear-induced damage to RBCs is mostly subhemolytic.

Microparticle shape effects on margination, near-wall dynamics and adhesion in a three-dimensional simulation of red blood cell suspension.

We present a 3D computational modeling study of the transport of micro-scale drug carriers modeled as microparticles of different shapes (spherical, oblate, and prolate) in whole blood represented as a suspension of deformable red blood cells. The objective is to quantify the effect of microparticle shapes on their margination, near-wall dynamics and adhesion. We observe that the near-wall accumulation is highest for oblate particles of moderate aspect ratio, followed by spherical particles, and lowest for very elongated prolate particles. The result is explained using micro-scale dynamics of individual particles, and their interaction with red blood cells. We observe that the orientation of microparticles in 3D space and the frequency of their collisions with red blood cells are the key factors affecting their margination. We show that due to repeated collisions with red blood cells in the presence of a bounding wall, the axes of revolution of oblate particles align near the plane of the shear flow, but those of prolate particles shift towards the vorticity axis with a wider distribution. Such specific orientations lead to more frequent collisions and a greater lateral drift for oblate particles than microspheres, but less frequent collisions and a reduced lateral drift for elongated prolate particles, resulting in the observed differences in their near-wall accumulation. Once marginated, the particle shape has an entirely different effect on the likelihood of making particle-wall contacts. We find that marginated prolate particles, due to their alignment along the vorticity axis and large angular fluctuations, are more likely to make contacts with the wall than spherical and oblate particles. We further simulate the adhesion between flowing microparticles and the wall in the presence of red blood cells, and observe that once wall contacts are established, the likelihood of firm adhesion is greater for disk-like particles, followed by elongated prolates, and microspheres. Consequently, this study suggests that the local hemorheological conditions near the targeted sites must be taken into consideration while selecting the optimum shape of micro-scale vascular drug carriers.

Platelet dynamics in three-dimensional simulation of whole blood.

A high-fidelity computational model using a 3D immersed boundary method is used to study platelet dynamics in whole blood. We focus on the 3D effects of the platelet-red blood cell (RBC) interaction on platelet margination and near-wall dynamics in a shear flow. We find that the RBC distribution in whole blood becomes naturally anisotropic and creates local clusters and cavities. A platelet can enter a cavity and use it as an express lane for a fast margination toward the wall. Once near the wall, the 3D nature of the platelet-RBC interaction results in a significant platelet movement in the transverse (vorticity) direction and leads to anisotropic platelet diffusion within the RBC-depleted zone or cell-free layer (CFL). We find that the anisotropy in platelet motion further leads to the formation of platelet clusters, even in the absence of any platelet-platelet adhesion. The transverse motion, and the size and number of the platelet clusters are observed to increase with decreasing CFL thickness. The 3D nature of the platelet-RBC collision also induces fluctuations in off-shear plane orientation and, hence, a rotational diffusion of the platelets. Although most marginated platelets are observed to tumble just outside the RBC-rich zone, platelets further inside the CFL are observed to flow with an intermittent dynamics that alters between sliding and tumbling, as a result of the off-shear plane rotational diffusion, bringing them even closer to the wall. To our knowledge, these new findings are based on the fundamentally 3D nature of the platelet-RBC interaction, and they underscore the importance of using cellular-scale 3D models of whole blood to understand platelet margination and near-wall platelet dynamics.

Hydrodynamic interaction between a platelet and an erythrocyte: effect of erythrocyte deformability, dynamics, and wall proximity.

We present three-dimensional numerical simulations of hydrodynamic interaction between a red blood cell (RBC) and a platelet in a wall-bounded shear flow. The dynamics and large deformation of the RBC are fully resolved in the simulations using a front-tracking method. The objective is to quantify the influence of tank treading and tumbling dynamics of the RBC, and the presence of a bounding wall on the deflection of platelet trajectories. We observe two types of interaction: A crossing event in which the platelet comes in close proximity to the RBC, rolls over it, and continues to move in the same direction; and a turning event in which the platelet turns away before coming close to the RBC. The crossing events occur when the initial lateral separation between the cells is above a critical separation, and the turning events occur when it is below the critical separation. The critical lateral separation is found to be higher during the tumbling motion than that during the tank treading. When the RBC is flowing closer to the wall than the platelet, the critical separation increases by several fold, implying the turning events have higher probability to occur than the crossing events. On the contrary, if the platelet is flowing closer to the wall than the RBC, the critical separation decreases by several folds, implying the crossing events are likely to occur. Based on the numerical results, we propose a mechanism of continual platelet drift from the RBC-rich region of the vessel towards the wall by a succession of turning and crossing events. The trajectory deflection in the crossing events is found to depend nonmonotonically on the initial lateral separation, unlike the monotonic trend observed in tracer particle deflection and in deformable sphere-sphere collision. This nonmonotonic trend is shown to be a consequence of the deformation of the RBC caused by the platelet upon collision. An estimation of the platelet diffusion coefficient yields values that are similar to those reported in experiments and computer simulations with multicellular suspension.

Numerical simulation of red blood cell behavior in a stenosed arteriole using the immersed boundary-lattice Boltzmann method.

Because of their deformability and tendency to form aggregates, red blood cells (RBCs) immensely affect the hydrodynamic properties of blood flow in microcirculation. In this paper, RBCs' two-dimensional deformation and motion in Poiseuille flow and in a stenosed arteriole is numerically investigated by the immersed boundary-lattice Boltzmann method. The RBCs are modeled as suspended capsules of fluid in plasma flow. A neo-Hookean elastic model with bending resistance is utilized for the RBC membrane. Also, the suspending plasma is modeled as an incompressible Newtonian fluid. To take the effects of aggregation and dissociation of RBCs into account, intercellular interaction is modeled by the Morse potential. The effects of essential parameters namely, mechanical resistance of the RBC membrane, plasma viscous forces, and cell membrane adhesion strength on RBC behavior are presented. Motions and deformations of RBCs in a stenosis and the effects of the stenosed zone on the behavior of cell aggregates were also simulated and analyzed in this study.