The effect of vortex formation on left ventricular filling and mitral valve efficiency

A new mechanism for quantifying the filling energetics in the left ventricle (LV) and past mechanical heart valves (MHV) is identified and presented. This mechanism is attributed to vortex formation dynamics past MHV leaflets. Recent studies support the conjecture that the natural healthy left ventricle (LV) performs in an optimum, energy-preserving manner by redirecting the flow with high efficiency. Yet to date, no quantitative proof has been presented. The present work provides quantitative results and validation of a theory based on the dynamics of vortex ring formation, which is governed by a critical formation number (FN) that corresponds to the dimensionless time at which the vortex ring has reached its maximum circulation content, in support of this hypothesis. Herein, several parameters (vortex ring circulation, vortex ring energy, critical FN, hydrodynamic efficiencies, vortex ring propagation speed) have been quantified and presented as a means of bridging the physics of vortex formation in the LV. In fact, the diastolic hydrodynamic efficiencies were found to be 60, 41, and 29%, respectively, for the porcine, anti-anatomical, and anatomical valve configurations. This assessment provides quantitative proof of vortex formation, which is dependent of valve design and orientation, being an important flow characteristic and associated to LV energetics. Time resolved digital particle image velocimetry with kilohertz sampling rate was used to study the ejection of fluid into the LV and resolve the spatiotemporal evolution of the flow. The clinical significance of this study is quantifying vortex formation and the critical FN that can potentially serve as a parameter to quantify the LV filling process and the performance of heart valves.     

Effect of spatial inlet velocity profiles on the vortex formation pattern in a dilated left ventricle

Despite the advancement of cardiac imaging technologies, these have traditionally been limited to global geometrical measurements. Computational fluid dynamics (CFD) has emerged as a reliable tool that provides flow ?eld information and other variables essential for the assessment of the cardiac function. Extensive studies have shown that vortex formation and propagation during the filling phase acts as a promising indicator for the diagnosis of the cardiac health condition. Proper setting of the boundary conditions is crucial in a CFD study as they are important determinants, that affect the simulation results. In this article, the effect of different transmitral velocity profiles (parabolic and uniform profile) on the vortex formation patterns during diastole was studied in a ventricle with dilated cardiomyopathy (DCM). The resulting vortex evolution pattern using the uniform inlet velocity profile agreed with that reported in the literature, which revealed an increase in thrombus risk in a ventricle with DCM. However the application of a parabolic velocity profile at the inlet yields a deviated vortical flow pattern and overestimates the propagation velocity of the vortex ring towards the apex of the ventricle. This study highlighted that uniform inlet velocity profile should be applied in the study of the filling dynamics in a left ventricle because it produces results closer to that observed experimentally.     

The Nature of the Disorder of Function in Chronic Postinfarction Aneurysm of the Left Ventricle

Assessment of left ventricular function in five patients with chronic postinfarction left ventricular aneurysm was carried out at the time of left heart catheterization and compared with that in six normal subjects. One patient was investigated before and after surgical resection of the aneurysm. The presence of the aneurysm placed the left ventricle at a mechanical disadvantage in systole and increased the resistance to diastolic filling (impedance). This was true even in patients with normal cardiac indices who were not badly disabled. Resection of the aneurysm corrected both these abnormalities, and, as well, lowered the time-tension index at a time when calculated left ventricular work was much increased. These differences between normals and patients with aneurysms, and the changes occurring as a result of resection of an aneurysm, show that the presence of the aneurysm places the left ventricle at a mechanical disadvantage in systole as well as altering its diastolic filling characteristics.     

Age-related characteristics of the distribution and attachment of chordae tendineae to the valves of the human heart

In 50 cardiac preparations of persons of various age (children, teenagers, adolescents, persons of mature and elderly age) distribution of various branches of the tendinous chordae (basic, marginal, commissural, rough zone) and level of their fixation to the ventricular surface of the right and left cusps of the atrioventricular valves have been studied. The tendinous chordae in direction from the apex of the papillary muscles towards the cusps of the atrioventricular valves are divided into the branches of the 2d--9th orders. Total quantity increase of the tendinous chordae is noted in the mature age, especially those of the 1st order in the left ventricle, and their decrease in the elderly age with an increase of the chordae of the 4th, 5th and 6th orders. Single chordae of the 8th and 9th orders can be found in elderly persons. Certain age specificities are revealed in fixation of various tendinous chordae to the cusps of the atrioventricular valves; they are surely connected with functional peculiarities of their different zones, that ensure air-tightness of the atrioventricular openings. There are quantitative differences of the tendinous chordae, fixed to certain cusps of the left (anterior) and right (anterior, posterior) atrioventricular valves; this is evidently connected with the role of the cusps mentioned in the mechanism of the valves closing.     

Spiral arrangement of muscular elements in the walls of blood vessels and their role in hemodynamics

The article claims that contractions of the cardiac left ventricle produce a whirling (turbulent) movement of blood that is maintained in the aorta. In the walls of large and small arteries, as well as in the arteriolar walls, myocytes have a spiral arrangement. Their contraction maintains the turbulent blood stream in the vessels with a small diameter, in spite of the fact that the Reinolds' number for them is rather small. The author considers that while making a mathematical analysis of the blood flowing in the arteries, it is necessary to take into account that the walls of the arterial vessels actively influence the blood stream.     

Cardiac function of the leopard shark,Triakis semifasciata

Summary The pressure difference between the cardinal sinus and the pericardium, and the transmural ventricular diastolic pressure at rest and during swimming in the leopard shark, Triakis semifasciata, was measured to characterize the mechanism of cardiac filling in chronically-instrumented fish and to evaluate cardiac responses to swimming. Echo-Doppler and radiographic imaging were also used to fully describe the cardiac cycle. Swimming induces an increase in preload as manifested by a large increment of cardinal sinus pressure (0.26/0.20 [systolic/diastolic] to 0.49/0.32 kPa) which always exceeds pericardial pressure. Increases in both mean ventricular diastolic transmural pressure (0.30–0.77 kPa) and cardinal sinus pressure during swimming suggest increased cardiac filling by vis a tergo as the mechanism for augmenting cardiac output. In contrast to mammals, the fluid-filled pericardial space of elasmobranchs is considerably larger and the pericardium itself does not move in concert with the heart throughout the cardiac cycle. Also, modest increases in heart rate drastically curtail the duration of diastole, which becomes much less than that of systole, a phenomenon not found in mammals. In the absence of tachycardia (<40 bpm), ventricular filling is characterized by a period of early rapid filling, and a late period of filling owing to atrial systole, separated by a period of diastasis. Ventricular filling in elasmobranchs is thus biphasic and is not solely dependent on atrial systole. Atrial diastole is characterized by three filling periods associated with atrial relaxation, ventricular ejection, and sinus venosus contraction. The estimated ventricular ejection fraction of Triakis (80%) exceeds that of the mammalian left ventricle.     

Isoproterenol-induced responses in the regional polyamine metabolism of the rat heart

Rats were treated with a single dose of isoproterenol (25 mg/kg s.c.) and the levels of polyamines determined in various parts (right ventricle, basis, medial part and apex of the left ventricle) of the heart 24, 48 and 72 hours after the injection. The isoproterenol treatment produced marked alterations in the concentrations of cardiac polyamines. The most apparent changes were seen in the apex and medial part of the left ventricle where spermidine concentration exhibited a biphasic response with peaks at 24 and 72 hours. In the basis of the heart the spermidine concentration was significantly elevated only at 24 hours. In the right ventricle the spermidine level was significantly higher than control at 72 hours. Spermidine/spermine ratio was augmented in all cardiac tissues examined over the 72-hour period. Results appear to show that the isoproterenol-induced alterations in cardiac polyamine metabolism were not uniformly distributed in the various regions of the heart.     

Three-dimensional diastolic blood flow in the left ventricle

Three-dimensional blood flow in a human left ventricle is studied via a computational analysis with magnetic resonance imaging of the cardiac motion. Formation, growth and decay of vortices during the myocardial dilation are analyzed with flow patterns on various diametric planes. They are dominated by momentum transfer during flow acceleration and deceleration through the mitral orifice. The posterior and anterior vortices form an asymmetric annular vortex at the mitral orifice, providing a smooth transition for the rapid inflow to the ventricle. The development of core vortex accommodates momentum for deceleration and for acceleration at end diastolic atrial contraction. The rate of energy dissipation and that of work done by viscous stresses are small; they are approximately balanced with each other. The kinetic energy flux and the rate of work done by pressure delivered to blood from ventricular dilation is well balanced by the total energy influx at the mitral orifice and the rate change of kinetic energy in the ventricle.     

Topography and parameters of the intertrabecular spaces of the heart ventricles in man and laboratory animals

The heart of the man, dog, cat and rabbit have been investigated using biometry and corrosive methods. In the horizontal sections the volume of the intertrabecular spaces (IS) of the ventricles has been estimated and the "coefficient of the myocardial sponginess" has been calculated as the ratio of the cavities volume to the myocardial volume. In the corrosive casts of the ventricular cavities the deviation angles of the IS casts from the axial line along the afferent and deferent tracts have been measured. Differences in manifestation of the IS in the hearts of the mammals studied have been revealed. The IS are best pronounced in the human heart, less in the dog heart and still less in the cat and rabbit hearts. For all the hearts studied predominance of the volume of the IS in the right ventricle is specific. The deviation angle of the IS casts from the axial line along the afferent tract increases from the cardiac basis towards its apex, while the deviation angle of the IS along the deferent tract decreases from the apex towards the basis. The functional predisposition of the IS is supposed to consist in providing systolic reserves of the cardiac ventricular cavities. The results of the mathematical analysis of the changes in the cast deviation angles of the IS along the afferent and deferent tracts demonstrate their role in twisting and acceleration of the blood stream in the systolic phase and slowing down of the blood stream in the diastolic phase.     

Morphologic aspects of local blood flow regulation in the myocardium

In 67 preparations of the human hearts at the first and second periods of mature age, spatial interrelations between blood vessels and cardiac muscle fibers in the ventricle myocardium have been studied. All the elements of the myocardial blood bed are oriented under a certain angle in relation to the cardiac muscle fibers. Regular arrangement of the arteries and sinusoid dilated veins under endocardium on the top of the papillary muscles and in the muscular trabecules is demonstrated. As proves the mathematical model, the slope orientation of the blood bed elements towards the cardiac muscle fibers ensures and adequate realization of the external influence of the contractile cardiomyocytes to the successive movement of blood along the intramural myocardial vessels. From morphological positions, a conclusion on the mechanism of the intracavitary pressure effect on blood movement along the intramural veins of the ventricular myocardium is argued. A conclusion is made on the leading role of the extravascular factors (intramyocardial and intercavitary pressure) in the local regulation of the blood stream in the myocardium and in development of working cardiac hyperemia.     

Estimation of diastolic intraventricular pressure gradients by Doppler M-mode echocardiography

Previous studies have shown that small intraventricular pressure gradients (IVPG) are important for efficient filling of the left ventricle (LV) and as a sensitive marker for ischemia. Unfortunately, there has previously been no way of measuring these noninvasively, severely limiting their research and clinical utility. Color Doppler M-mode (CMM) echocardiography provides a spatiotemporal velocity distribution along the inflow tract throughout diastole, which we hypothesized would allow direct estimation of IVPG by using the Euler equation. Digital CMM images, obtained simultaneously with intracardiac pressure waveforms in six dogs, were processed by numerical differentiation for the Euler equation, then integrated to estimate IVPG and the total (left atrial to left ventricular apex) pressure drop. CMM-derived estimates agreed well with invasive measurements (IVPG: y = 0.87x + 0.22, r = 0.96, P < 0.001, standard error of the estimate = 0.35 mmHg). Quantitative processing of CMM data allows accurate estimation of IVPG and tracking of changes induced by beta-adrenergic stimulation. This novel approach provides unique information on LV filling dynamics in an entirely noninvasive way that has previously not been available for assessment of diastolic filling and function.     

Postsystolic shortening of ischemic myocardium: a mechanism of abnormal intraventricular filling

Acute myocardial ischemia has been associated with abnormal filling patterns in the left ventricular (LV) apex. We hypothesized that this may in part be due to postsystolic shortening of ischemic apical segments, which leads to reversal of early diastolic apical flow. Fourteen open-chest anesthetized dogs were instrumented with micromanometers in the LV apex and left atrium and myocardial sonomicrometers in the anterior apical LV wall. Intraventricular filling by color Doppler and wall motion by strain Doppler echocardiography (SDE) were assessed from an apical view. Measurements were taken before and after 5 min of left anterior descending coronary artery (LAD) occlusion. In four dogs, we measured the pressure difference between the LV apex and outflow tract. At baseline, peak early diastolic flow velocities in the distal one-third of the LV were directed toward apex (9.2 +/- 1.6 cm/s). After LAD occlusion, the velocities reversed (-2.3 +/- 0.4 cm/s, P < 0.01), indicating that blood was ejected from the apex toward the base during early filling. This interpretation was confirmed by wall motion analysis, which showed postsystolic shortening of apical myocardial segments. The postsystolic shortening represented 9.7 +/- 1.7% (P < 0.01) and 14.2 +/- 2.4% (P < 0.01) of end-diastolic segment length by SDE and sonomicrometry, respectively. Consistent with the velocity changes, we found reversal of the early diastolic pressure gradient from the LV apex to outflow tract. In the present model, acute LAD occlusion resulted in reversal of early diastolic apical flow, and this was attributed to postsystolic shortening of dyskinetic apical segments. The clinical diagnostic importance of this finding remains to be determined.     

Fluid dynamics of the left ventricular filling in dilated cardiomyopathy

Modifications in diastolic function occur in a broad range of cardiovascular diseases and there is an increasing evidence that abnormalities in left ventricular function may contribute significantly to the symptomatology. The flow inside the left ventricle during the diastole is here investigated by numerical solution of the Navier-Stokes equations under the axisymmetric assumption. The equation are written in a body-fitted, moving prolate spheroid, system of coordinates and solved using a fractional step method. The system is forced by a given volume time-law derived from clinical data, and varying the two-degrees-of-freedom ventricle geometry on the basis of a simple model. The solution under healthy conditions is analysed in terms of vorticity dynamics, showing that the flow field is characterised by the presence of a vortex wake; it is attached to the mitral valve during the accelerating phase of the E-wave, and it detaches and translate towards the ventricle apex afterwards. The flow evolution is discussed, results are also reported as an M-mode representation of colour-coded Doppler velocity maps. In the presence of ventricle dilatation the mitral jet extends farther inside the ventricle, propagation velocity decreases, and the fluid stagnates longer at the apex.     

Transthoracic Doppler echocardiography – noninvasive diagnostic window for coronary flow reserve assessment

Background

Strain Rate Imaging shows the filling phases of the left ventricle to consist of a wave of myocardial stretching, propagating from base to apex. The propagation velocity of the strain rate wave is reduced in delayed relaxation. This study examined the relation between the propagation velocity of strain rate in the myocardium and the propagation velocity of flow during early filling.

Methods

12 normal subjects and 13 patients with treated hypertension and normal systolic function were studied. Patients and controls differed significantly in diastolic early mitral flow measurements, peak early diastolic tissue velocity and peak early diastolic strain rate, showing delayed relaxation in the patient group. There were no significant differences in EF or diastolic diameter.

Results

Strain rate propagation velocity was reduced in the patient group while flow propagation velocity was increased. There was a negative correlation (R = -0.57) between strain rate propagation and deceleration time of the mitral flow E-wave (R = -0.51) and between strain rate propagation and flow propagation velocity and there was a positive correlation (R = 0.67) between the ratio between peak mitral flow velocity/strain rate propagation velocity and flow propagation velocity.

Conclusion

The present study shows strain rate propagation to be a measure of filling time, but flow propagation to be a function of both flow velocity and strain rate propagation. Thus flow propagation is not a simple index of diastolic function in delayed relaxation.     

Quantification of left and right ventricular kinetic energy using four-dimensional intracardiac magnetic resonance imaging flow measurements

We aimed to quantify kinetic energy (KE) during the entire cardiac cycle of the left ventricle (LV) and right ventricle (RV) using four-dimensional phase-contrast magnetic resonance imaging (MRI). KE was quantified in healthy volunteers (n = 9) using an in-house developed software. Mean KE through the cardiac cycle of the LV and the RV were highly correlated (r(2) = 0.96). Mean KE was related to end-diastolic volume (r(2) = 0.66 for LV and r(2) = 0.74 for RV), end-systolic volume (r(2) = 0.59 and 0.68), and stroke volume (r(2) = 0.55 and 0.60), but not to ejection fraction (r(2) < 0.01, P = not significant for both). Three KE peaks were found in both ventricles, in systole, early diastole, and late diastole. In systole, peak KE in the LV was lower (4.9 ± 0.4 mJ, P = 0.004) compared with the RV (7.5 ± 0.8 mJ). In contrast, KE during early diastole was higher in the LV (6.0 ± 0.6 mJ, P = 0.004) compared with the RV (3.6 ± 0.4 mJ). The late diastolic peaks were smaller than the systolic and early diastolic peaks (1.3 ± 0.2 and 1.2 ± 0.2 mJ). Modeling estimated the proportion of KE to total external work, which comprised ～0.3% of LV external work and 3% of RV energy at rest and 3 vs. 24% during peak exercise. The higher early diastolic KE in the LV indicates that LV filling is more dependent on ventricular suction compared with the RV. RV early diastolic filling, on the other hand, may be caused to a higher degree of the return of the atrioventricular plane toward the base of the heart. The difference in ventricular geometry with a longer outflow tract in the RV compared with the LV explains the higher systolic KE in the RV.     

Energetics of ventricular contraction as traced in the pressure-volume diagram

The pressure-volume (P-V) relationship of the canine left ventricle can reasonably be simulated by a time-varying elastance model. In this model the total mechanical energy generated by a contraction can be determined theoretically from the change in the elastance. Applying this theory to the actual left ventricle, we have found that the area in the P-V diagram circumscribed by the end-systolic P-V relation line, the end-diastolic P-V relation curve, and the systolic segment of the P-V trajectory is equivalent to the total mechanical energy generated by ventricular contraction. We call this area the systolic P-V area (PVA). We have studied experimentally the correlation between the PVA and myocardial oxygen consumption (VO2) in the canine left ventricle. VO2 was linearly correlated with PVA regardless of the contraction mode and loading conditions in a given left ventricle. The VO2-PVA relation parallel shifted upward with positive inotropic agents. This shift comprised a significant increase in VO2 component for the unloaded contraction. We therefore consider that further analyses of the VO2-PVA relationship will greatly promote our understanding of cardiac energetics.     

Model and influence of mitral valve opening during the left ventricular filling

The flow inside a model left ventricle during filling (diastole) is simulated by the numerical solution of the equations of motion under the axisymmetric approximation. The left ventricle is taken with a truncated ellipsoid geometry, and a simple conceptual model is introduced to simulate the presence of the moving mitral valve. A relevant role during the left ventricle diastolic flow, as already discussed by other authors, is played by the travelling vortex wake that is formed from the transmitral jet during the early filling acceleration phase. The presence of a moving valve is found to produce a non-simultaneous spatial development of the entering bulk flow and a slightly more complex vortex wake structure; the results are discussed in comparison with fixed valve ones. They are analysed also in terms of M-mode representation suggesting a physical interpretation of the pattern detected in the clinical measurements that extends the one given previously on the basis of fixed valve models.     

超声心动图对心肌致密化不全的诊断及临床意义探讨

目的：探讨超声心动图对心肌致密化不全的诊断及临床意义。方法：应用Vivid7、HP5500彩色多普勒超声诊断仪（探头频率为2～4MHz）对32例左室心肌致密化不全患者进行检查,采用二维、M型、彩色及频谱多普勒观察病变心肌及心内膜改变,重点观察心尖段。常规测量各腔室内径、左室壁正常段心肌厚度及动度,评价心室舒张功能、计算左心室射血分数EF及瓣膜反流等基本信息。结果：①受累的心室内膜面可见多发异常粗大的、呈蜂窝状的肌小梁和交错深陷的隐窝形成网状结构。②病变区域心室壁外层的致密心肌明显变薄,为中低回声,较正常心肌薄2~4mm,其心肌厚度〈6mm,而内层心肌疏松增厚为强回声。③病变以近心尖部1/3室壁节段最为明显,很少累及室间隔及基底段室壁。④彩色多普勒可示隐窝间隙之间有低速血流与心腔相通。⑤多数患者以渐进性的心功能不全、呼吸困难、体循环栓塞、心律失常为主要表现,本组患者临床表现为心力衰竭22例,心脏杂音3例,心律失常2例,5例无明显不适症状。结论：超声心动图检查是准确、无创诊断心肌致密化不全的首选方法,能够对房室结构和心功能进行全面评价,有助于明确心力衰竭病因并协助治疗,同时也有助于筛查心肌致密化不全家族,对临床治疗起着很好的指导作用。     

Structure of the cardiac systole in mammals and birds

The comparative analysis of the contractile function of the heart left ventricle in four species of homoeothermic tetrapods (chicken, quail, rat, sheep) who differ in their spatio-temporal pattern of ventricular excitation, heart rate, and heart weight was performed. The analysis of cardiac cycle structure was performed on the basis of synchronous recording of ECG, phonocardiogram, and apex cardiogram. Indices of myocardial contractility of the left ventricle calculated on the basis of the analysis of the cardiac dynamics indicate disadvantageous contractile function of the left ventricle in rodents and non-flying birds in comparison with sheep. The functioning of the left ventricle in male rats is more strained than in female rats. One fundamental factor determining a more strained functioning of the left ventricle in birds in comparison with mammals is the heart rate. The relative weight and activation pattern of the left ventricular myocardium govern the contractile function of the left ventricle to a lesser extent.     

A two-phase finite element model of the diastolic left ventricle

A porous medium finite element model of the passive left ventricle is presented. The model is axisymmetric and allows for finite deformation, including torsion about the axis of symmetry. An anisotropic quasi-linear viscoelastic constitutive relation is implemented in the model. The model accounts for changing fibre orientation across the myocardial wall. During passive filling, the apex rotates in a clockwise direction relative to the base for an observer looking from apex to base. Within an intraventricular pressure range of 0-3 kPa the rotation angle of all nodes remained below 0.1 rad. Diastolic viscoelasticity of myocardial tissue is shown to reduce transmural differences of preload-induced sarcomere stretch and to generate residual stresses in an unloaded ventricular wall, consistent with the observation of opening angles seen when the heart is slit open. It is shown that the ventricular model stiffens following an increase of the intracoronary blood volume. At a given left ventricular volume, left ventricular pressure increases from 1.5 to 2.0 kPa when raising the intracoronary blood volume from 9 to 14 ml (100 g)-1 left ventricle.