Fluid–structure interaction in a fully coupled three-dimensional mitral–atrium–pulmonary model

This paper aims to investigate detailed mechanical interactions between the pulmonary haemodynamics and left heart function in pathophysiological situations (e.g. atrial fibrillation and acute mitral regurgitation). This is achieved by developing a complex computational framework for a coupled pulmonary circulation, left atrium and mitral valve model. The left atrium and mitral valve are modelled with physiologically realistic three-dimensional geometries, fibre-reinforced hyperelastic materials and fluid–structure interaction, and the pulmonary vessels are modelled as one-dimensional network ended with structured trees, with specified vessel geometries and wall material properties. This new coupled model reveals some interesting results which could be of diagnostic values. For example, the wave propagation through the pulmonary vasculature can lead to different arrival times for the second systolic flow wave (S2 wave) among the pulmonary veins, forming vortex rings inside the left atrium. In the case of acute mitral regurgitation, the left atrium experiences an increased energy dissipation and pressure elevation. The pulmonary veins can experience increased wave intensities, reversal flow during systole and increased early-diastolic flow wave (D wave), which in turn causes an additional flow wave across the mitral valve (L wave), as well as a reversal flow at the left atrial appendage orifice. In the case of atrial fibrillation, we show that the loss of active contraction is associated with a slower flow inside the left atrial appendage and disappearances of the late-diastole atrial reversal wave (AR wave) and the first systolic wave (S1 wave) in pulmonary veins. The haemodynamic changes along the pulmonary vessel trees on different scales from microscopic vessels to the main pulmonary artery can all be captured in this model. The work promises a potential in quantifying disease progression and medical treatments of various pulmonary diseases such as the pulmonary hypertension due to a left heart dysfunction.

     

In vivo porcine left atrial wall stress: Effect of ventricular tachypacing on spatial and temporal stress distribution

Animal models of ventricular tachypacing (VTP) have been successfully used to reproduce the relevant features observed in patients with atrial fibrillation, such as increased atrial pressure and volume, ion-channel alterations and fibrosis. After performing VTP on a healthy Yorkshire pig, we measured an increase in volume of 60%, a two-fold rise in pressure, and a complex pattern of local mechanical, histological and biochemical changes, including a generalized stiffening of the wall. A protocol recently developed was employed to generate computational models of the porcine left atrium mechanics in healthy conditions and after VTP. Comparison of the stress distribution in the healthy vs. VTP case provided a map of how pressure overload affects and modifies left atrium mechanics. Overall, a positive increase in stress was computed after the VTP treatment. Regions of large increase in the stresses post-VTP were the appendage boundaries, the area around the lower pulmonary vein and the area in the front of the atrium towards the appendage. Due to the elevated stress, the back of the atrium mainly modified its mechanical response, while the appendage remodeled both its shape and its mechanical properties. Large changes in the shape of the mitral valve annulus could be observed as a consequence of the remodeling in the front of the atrium. The relation between local mechanical stress and remodeling that emerges from the results is in agreement with our hypothesis that the structural changes in the atrium are a consequence of a stress-mediated mechanism.     

Three-dimensional computational model of left heart diastolic function with fluid-structure interaction

Aided by advancements in computer speed and modeling techniques, computational modeling of cardiac function has continued to develop over the past twenty years. The goal of the current study was to develop a computational model that provides blood-tissue interaction under physiologic flow conditions, and apply it to a thin-walled model of the left heart. To accomplish this goal, the Immersed Boundary Method was used to study the interaction of the tissue and blood in response to fluid forces and changes in tissue pathophysiology. The fluid mass and momentum conservation equations were solved using Patankar's Semi-Implicit Method for Pressure Linked Equations (SIMPLE). A left heart model was developed to examine diastolic function, and consisted of the left ventricle, left atrium, and pulmonary flow. The input functions for the model included the pulmonary driving pressure and time-dependent relationship for changes in chamber tissue properties during the simulation. The results obtained from the left heart model were compared to clinically observed diastolic flow conditions for validation. The inflow velocities through the mitral valve corresponded with clinical values (E-wave = 74.4 cm/s, A-wave = 43 cm/s, and E/A = 1.73). The pressure traces for the atrium and ventricle, and the appearance of the ventricular flow fields throughout filling, agreed with those observed in the heart. In addition, the atrial flow fields could be observed in this model and showed the conduit and pump functions that current theory suggests. The ability to examine atrial function in the present model is something not described previously in computational simulations of cardiac function.     

Two-dimensional echocardiography in the diagnosis of unusual left atrial myxomas

In two patients with atypical myxomas of the left atrium, two-dimensional echocardiography furnished valuable diagnostic information. In one patient, who had previously developed an embolism at the right brachial artery, M-mode echocardiography revealed an abnormal band of echoes within the left atrium. Two-dimensional echocardiography showed a globular cluster of echoes that remained within the left atrial cavity throughout the cardiac cycle; left ventricular angiography confirmed the ultrasonic findings of an intraatrial mass. At surgery, a calcified, nonprolapsing myxoma was excised from the interatrial septum. The second patient had clinical as well as M-mode echographic features of mitral stenosis. Cardiac catheterization showed a significant gradient across the mitral valve, but the left ventriculogram was normal except for an unusual pattern of mitral regurgitation. Subsequent two-dimensional echocardiography revealed a mass of echoes that prolapsed through the mitral valve during diastole. At surgery, a left atrial myxoma was found attached to the posterior mitral annulus. Our experience indicates that two-dimensional ultrasound is superior to conventional echocardiography for detecting unusual cardiac masses.     

Probe for production and measurement of acute mitral regurgitant flow in dog.

A probe for production and measurement of acute mitral regurgitation in dogs is described. It consists of a tube that is introduced into the mitral valve through the left atrial appendage. Regurgitant flow through the tube is measured by an electromagnetic device. Variation of flow and zero flow are achieved by narrowing or occluding the tube with a rubber cuff. In animals weighing 30-50 kg, the probe does not produce significant mitral stenosis and the mitral leaflets fit closely around the probe during ventricular systole. The instantaneous relationship between mitral regurgitant flow (MRF) and the gradient between left ventricular and left atrial pressure shows a marked delay of MRF at the beginning and end of regurgitation. This delay can be attributed to some extent to electrical phase lag and to the small movement of the probe relative to the mitral valve during the cardiac cycle. Measurement of regurgitant stroke volume is affected by this movement only to a small extent.     

Tangential triangular resection: an option to treat the giant left atrium

A 21-year-old woman presented with congestive heart failure caused by congenital mitral and tricuspid insufficiency, associated with great left atrium enlargement. Transthoracic echocardiogram revealed heart dextroversion associated with mitral and tricuspid severe insufficiency and left atrium enlargement (14 cm), confirmed by magnetic resonance study. The left atrium was reduced by a tangential triangular resection of the posterior wall, between the pulmonary veins, suturing the edges of the left atrium with bovine pericardium strip reinforcement. Mitral and tricuspid valves were repaired. The postoperative course was uneventful, and the patient was discharged in the 15th postoperative day. A control magnetic resonance study revealed a 50% reduction in left atrium size. Evolution of left atrium resection is excellent, with low recurrence of arrhythmias, embolism, or heart failure.     

Sudden interruption of leaflet opening by ventricular contractions: a mechanism of mitral regurgitation.

The motion of both mitral cusps and the presence of valvular regurgitation during ventricular contractions were investigated in seven experiments on dogs in which radiopaque markers had been sutured to the cusps and the valve annulus 1-32 wk before the studies. Cineangiograms of the left ventricle were obtained during ventricular ectopic beats, interposed throughout the cardiac cycle (20-99% of cycle length) and during induced variations in the P-R interval (0-200 ms). Mitral regurgitation was observed only during a) weak, early ectopic beats (peak pressure below 34 mmHg) which were incapable of closing the cusps and b) when ventricular contractions suddenly interrupted normal leaflet motion toward the ventricle, during three well-defined periods of diastole (diastolic valve opening, diastolic rebound, and atrial opening). Valve closure following sudden reversal of cusp opening was slow and the leaflets often did not arrive simultaneously at their closed positions. These findings suggest that sudden interruption of leaflet opening by ventricular contractions is an important mechanism of transient mitral regurgitation in the normal heart.     

Dynamics of left ventricular wall and mitral valve mechanics--a model study

The relation between global left ventricular pumping characteristics and local cardiac muscle fiber mechanics is represented by a mathematical model of left ventricular mechanics in which the mitral valve papillary muscle system is incorporated. The wall of the left ventricle is simulated by a thick-walled cylinder. Transmural differences in fiber orientation are incorporated by changing the direction of material anisotropy across the wall. The cylinder is free to twist. The upper end of the cylinder is covered by a thin, flexible sheet, representing the base of the left ventricle. The mitral valve is incorporated in this sheet. The tips of the mitral leaflets are connected by chordae tendineae to the papillary muscles which are attached to the bottom of the cylinder. Canine cardiac cycles were simulated for various end-diastolic values of left ventricular volume (25-120 ml, control 60 ml), left atrial pressure (0-2.7 kPa, control 0.22 kPa) and aortic pressure (5-11 kPa, control 11 kPa). In this wide range of preload and afterload mechanical loading of the muscle fibers appeared to be distributed quite evenly (SD: +/- 5% of control value) over all muscular structures of the left ventricle, including the papillary muscles.     

Patient-specific CFD models for intraventricular flow analysis from 3D ultrasound imaging: Comparison of three clinical cases

BackgroundAs the intracardiac flow field is affected by changes in shape and motility of the heart, intraventricular flow features can provide diagnostic indications. Ventricular flow patterns differ depending on the cardiac condition and the exploration of different clinical cases can provide insights into how flow fields alter in different pathologies.MethodsIn this study, we applied a patient-specific computational fluid dynamics model of the left ventricle and mitral valve, with prescribed moving boundaries based on transesophageal ultrasound images for three cardiac pathologies, to verify the abnormal flow patterns in impaired hearts. One case (P1) had normal ejection fraction but low stroke volume and cardiac output, P2 showed low stroke volume and reduced ejection fraction, P3 had a dilated ventricle and reduced ejection fraction.ResultsThe shape of the ventricle and mitral valve, together with the pathology influence the flow field in the left ventricle, leading to distinct flow features. Of particular interest is the pattern of the vortex formation and evolution, influenced by the valvular orifice and the ventricular shape. The base-to-apex pressure difference of maximum 2 mmHg is consistent with reported data.ConclusionWe used a CFD model with prescribed boundary motion to describe the intraventricular flow field in three patients with impaired diastolic function. The calculated intraventricular flow dynamics are consistent with the diagnostic patient records and highlight the differences between the different cases. The integration of clinical images and computational techniques, therefore, allows for a deeper investigation intraventricular hemodynamics in patho-physiology.     

Use of pattern recognition to classify beef cardiovascular tissues on the basis of their trace metal compositions.

The pattern recognition procedure of discriminant analysis has been used to characterize the trace metal profiles created by the concentrations of 8 trace metals in 15 anatomic sites of beef heart tissue. Metals analyzed were copper, tin, lead, molybdenum, strontium, cesium, barium, and aluminum. Anatomic sites sampled included main pulmonary artery, aorta, mitral and tricuspid valves, left and right coronary arteries, os cordis, right atrium, left atrial appendage, crista supraventricularis, left bundle branch, free wall of the right and left ventricles, interventricular septum, and papillary muscle of the left ventricle. The striking features of the data were: (1) All specimens of the mitral valve, tricuspid valve, and os cordis were ambiguously described by their trace metal profiles; (2) the four blood vessels constituted two groups of two tissues each (aorta, main pulmonary artery; left and right coronary arteries); (3) tissues derived from ordinary and specialized myocardium were quite different from blood vessels, heart valves and os cordis. Using these profiles, 85% of the specimens analyzed were correctly classified by discriminant analysis with respect to their anatomic origin.     

Wave intensity analysis of left atrial mechanics and energetics in anesthetized dogs

The left atrium (LA) acts as a booster pump during late diastole, generating the Doppler transmitral A wave and contributing incrementally to left ventricular (LV) filling. However, after volume loading and in certain disease states, LA contraction fills the LV less effectively, and retrograde flow (i.e., the Doppler Ar wave) into the pulmonary veins increases. The purpose of this study was to provide an energetic analysis of LA contraction to clarify the mechanisms responsible for changes in forward and backward flow. Wave intensity analysis was performed at the mitral valve and a pulmonary vein orifice. As operative LV stiffness increased with progressive volume loading, the reflection coefficient (i.e., energy of reflected wave/energy of incident wave) also increased. This reflected wave decelerated the forward movement of blood through the mitral valve and was transmitted through the LA, accelerating retrograde blood flow in the pulmonary veins. Although total LA work increased with volume loading, the forward hydraulic work decreased and backward hydraulic work increased. Thus wave reflection due to increased LV stiffness accounts for the decrease in the A wave and the increase in the Ar wave measured by Doppler.     

Heterogeneity of the myocardium. Function of the left and right ventricle under normal and pathological conditions

A number of important differences can be found between the left ventricle (LV) and right ventricle (RV) of the heart under physiological conditions. In anatomy, the most important is probably the architecture of the atrioventricular valve and its annulus. The LV has a mitral valve (with two cusps) and a firm annulus, while the RV has a tricuspid valve with a greater total area, but relatively small cuspid areas, and an elastic annulus. The difference in the blood supply is important. Owing to high intramural pressure, the coronary flow in the wall of the LV occurs only during the diastole; in the RV it is limited only in the presence of a significant increase in intracavitary pressure. The LV myocardium is functionally "accustomed" to short-term marked changes in the systolic load (in extreme static exercise the arterial pressure rises for a short time to three times the normal value), while the RV is adapted to changes in the diastolic load (marked filling changes associated with deep breathing, for instance). The difference in the response to a long-term volume load is difficult to evaluate: between a defect of the interatrial septum and aortic insufficiency there are too many differences. A long-term pressure load seems to be tolerated better by the right ventricle: patients with severe pulmonary stenosis and a pressure six times higher than the physiological value have lived 25 years and patients with isolated corrected L-transposition of the great arteries can reach 35 years without any signs of impaired RV function.(ABSTRACT TRUNCATED AT 250 WORDS)     

Left atrial endocardium and prostacyclin.

In patients with rheumatic mitral stenosis, intracardiac thrombi are found mostly, for reasons still unknown, in the left atrium. We compared the release of PGI2 from the endocardium of the left atrium with that of the right ventricle and from the endothelium of the pulmonary arteries. Endocardial endothelial cells (EECs) were isolated from right ventricles (RV) and left atrial appendages (LAA) of porcine hearts, and vascular endothelial cells (VECs) from pulmonary arteries (PA) were obtained from the same animals. Cultured EEC and PA-VEC monolayers were placed in a pressure loading apparatus and incubated for 30 min under various pressures. After incubation, the supernatants were sampled and the 6-keto-PGF1 alpha contents measured. PGI2 release from LAA-EEC was much less than from RV-EEC or from PA-VEC. Moreover, transmural pressure did not enhance PGI2 release from LAA-EEC, although it did from RV-EEC and PA-EEC in a pressure-dependent manner. These results may explain why the left atrium is a common site for intracardiac thrombus formation in patients with mitral valve disease.     

In-vivo transducer to measure dynamic mitral annular forces

Limited knowledge exists regarding the forces which act on devices implanted to the heart's mitral valve. Developing a transducer to measure the peak force magnitudes, time rates of change, and relationship with left ventricular pressure will aid in device development. A novel force transducer was developed and implanted in the mitral valve annulus of an ovine subject. In the post-cardioplegic heart, septal-lateral and transverse forces were continuously measured for cardiac cycles reaching a peak left ventricular pressure of 90 mmHg. Each force was seen to increase from ventricular diastole and found to peak at mid-systole. The mean change in septal-lateral and transverse forces throughout the cardiac cycle was 4.4±0.2 N and 1.9±0.1 N respectively. During isovolumetric contraction, the septal-lateral and transverse forces were found to increase at peak rate of 143±8 N/s and 34±9 N/s, respectively. Combined, this study provides the first quantitative assessment of septal-lateral and transverse forces within the contractile mitral annulus. The developed transducer was successful in measuring these forces whose methods may be extended to future studies. Upon additional investigation, these data may contribute to the safer development and evaluation of devices aimed to repair or replace mitral valve function.     

Paracardioscopy provides endoscopic visualization of the heart

Paracardioscopy provides totally endoscopic access to the heart via a transabdominal, transdiaphragmatic approach. Structures such as the pulmonary veins, inferior vena cava, left and right atrial appendage, and posterior left atrium can be visualized. Epicardial cardiac procedures, such as ablation procedures for atrial fibrillation, can be successfully performed using this development. This report describes paracardioscopy.     

Hemodynamic Response to Exercise After Beta-Adrenergic Blockade with Propranolol in Patients with Mitral Valve Obstruction

Propranolol (P) .13 mg./kg. was given to seven patients with mitral valve obstruction the changes in resting and exercise hemodynamics were followed by means of combined right and left heart catheterization. Changes were variable. At rest there was a decrease in heart rate of 10 beats/min. with no consistent change in stroke volume, cardiac output, left ventricular systolic (LVS) or left atrial (LA) pressure after P. Mean left ventricular end-diastolic (LVED) pressure was increased 3 mm., mean pulmonary artery (PA) pressure was increased 4 mm., and mean mitral valve gradient was reduced 3 mm. Hg by P. During exercise, mean LVS pressure was decreased 31 mm., mean LVED pressure increased 3 mm., mean LA pressure decreased 3 mm., and mean mitral valve gradient was reduced 5 mm. Hg after P. Mean exercise PA pressure was unchanged, cardiac output was reduced 0.9 1./min., and mean heart rate was reduced 37 beats/min., while stroke volume increased 3 ml./beat after P. Exercise pulmonary vascular resistance was increased from 6.1 to 8.2 units by P. Despite a slower heart rate, the diastolic filling period was not increased. P has no place in the treatment of the majority of patients with mitral stenosis because it further reduces cardiac performance below normal.     

The role of the pericardium in cardiac function in the dogfish, Squalus acanthias

Opening the pericardium to the ambient bathing fluid surrounding the in situ perfused dogfish ( Squalus acanthias ) heart caused a precipitous fall in cardiac output. Cardiac output fell by 55% despite the rise of mean input pressure from subambient, to near zero levels. Lower cardiac output caused a fall in mean output pressure but not diastolic pressure as this was set by the experimenters. With the pericardium intact, the heart was filled by suction. With an open pericardium the magnitude of negative input pressures was severely reduced. None the less, far short periods within the cardiac cycle, the heart was still able to generate subambient pressures in the atrium and so draw fluid from the central veins.     

Effect of prosthetic mitral valve geometry and orientation on flow dynamics in a model human left ventricle

Pulsatile flow dynamics through bileaflet (St Jude and Duromedics), tilting disc (Bjork-Shiley and Omniscience), caged ball (Starr-Edwards), pericardial (Edwards) and porcine (Carpentier-Edwards) mitral valves in a model human left ventricle (LV) were studied. The model human ventricle, obtained from an in situ diastolic casting, was incorporated into a mock circulatory system. Measurements were made at various heart rates and flow rates. These included the transvalvular pressure drop and regurgitation in percent and cm3 beat-1. The effect of valve geometry and the orientation of the valve with respect to the valve annulus was analyzed using a flow visualization technique. Qualitative flow visualization study indicates certain preferred orientations for the tilting disc and bileaflet valve prostheses in order to obtain a smooth washout of flow in the LV chamber.     

A theoretical model for the noninvasive assessment of the transmitral pressure-flow relation.

The purpose of this paper is to formulate from the equations of fluid mechanics an equation which describes the transmitral pressure-flow relationship. According to the linear momentum equation applied to the atrioventricular coupling, the left-atrium-left-ventricle pressure difference (Pa-Pv) can be written as Pa-P v = A delta v/delta t + B v 2 + C v, where v is the transmitral blood velocity and A, B, and C are variables related to the geometry of the atrium, ventricle and mitral orifice, respectively. Based on this theory, Pa-Pv is calculated noninvasively in a patient with a nonobstructive mitral valve. Mitral flow and cardiac dimensions recorded by Doppler echocardiography are digitized and analyzed. Calculation shows that Pa-Pv reaches its peak value at the time of flow peak acceleration and has already considerably decreased at the time of peak velocity. The time course of calculated Pa-Pv is in close agreement with the published experimental catherization data. Numerical computation of early diastolic left atrium and left ventricle pressure curves based on the experimental data of others for the time constant of left ventricular relaxation, left atrial and ventricular chambers stiffness constants, combined with sine-waveform-simulated mitral flow, verifies the time course and the magnitude of Pa-Pv as predicted from flow equations. This paper provides a theoretical method for the noninvasive assessment of the transmitral pressure-flow relationship using ultrasound technique and might help to achieve a better understanding of the diastolic function as assessed by Doppler echocardiography.