The central axis prosthetic cardiac valve: an in vitro study of pressure drop assessment under steady-state flow conditions

In this work, a new mechanical prosthetic heart valve, the central axis valve, is presented. This new prosthesis has been tested in vitro, and compared with four other common prosthetic cardiac valves (Starr-Edwards 6120, Bjork-Shiley monostrut, Medtronic-Hall, and St Jude Medical valves). All valves studied have the same orifice diameter of 22 mm. The prostheses were installed inside a transparent mitral test chamber, which enables pressure drop measurement to be made under steady-state flow conditions using a blood analogue fluid. Pressure drop loss is one important factor affecting the overall performance of a prosthetic heart valve. Steady-state flow tests are essential to predict certain flow characteristics and pressure gradient loss before more complicated, expensive, and difficult-to-interpret pulsatile flow tests are conducted. All experiments were performed in vitro and at steady volumetric flow rates of 10 to 30 l/min. The Starr-Edwards SE 6120 showed the highest values for pressure drop. The St Jude Medical valve offers the minimum resistance to flow. The central axis valve comes second to the Starr-Edwards valve for this type of measurement. The new valve is promising. A complete valve evaluation programme, covering initial conceptional design through to clinical use, is in progress. Materials for the fabrication of the new valve are also under consideration.     

Protocol for Relative Hydrodynamic Assessment of Tri-leaflet Polymer Valves

Limitations of currently available prosthetic valves, xenografts, and homografts have prompted a recent resurgence of developments in the area of tri-leaflet polymer valve prostheses. However, identification of a protocol for initial assessment of polymer valve hydrodynamic functionality is paramount during the early stages of the design process. Traditional in vitro pulse duplicator systems are not configured to accommodate flexible tri-leaflet materials; in addition, assessment of polymer valve functionality needs to be made in a relative context to native and prosthetic heart valves under identical test conditions so that variability in measurements from different instruments can be avoided. Accordingly, we conducted hydrodynamic assessment of i) native (n = 4, mean diameter, D = 20 mm), ii) bi-leaflet mechanical (n= 2, D = 23 mm) and iii) polymer valves (n = 5, D = 22 mm) via the use of a commercially available pulse duplicator system (ViVitro Labs Inc, Victoria, BC) that was modified to accommodate tri-leaflet valve geometries. Tri-leaflet silicone valves developed at the University of Florida comprised the polymer valve group. A mixture in the ratio of 35:65 glycerin to water was used to mimic blood physical properties. Instantaneous flow rate was measured at the interface of the left ventricle and aortic units while pressure was recorded at the ventricular and aortic positions. Bi-leaflet and native valve data from the literature was used to validate flow and pressure readings. The following hydrodynamic metrics were reported: forward flow pressure drop, aortic root mean square forward flow rate, aortic closing, leakage and regurgitant volume, transaortic closing, leakage, and total energy losses. Representative results indicated that hydrodynamic metrics from the three valve groups could be successfully obtained by incorporating a custom-built assembly into a commercially available pulse duplicator system and subsequently, objectively compared to provide insights on functional aspects of polymer valve design.     

Numerical simulation of steady turbulent flow through trileaflet aortic heart valves—II. Results on five models

Turbulent flow simulations are run for five aortic trileaflet valve geometries, ranging from a valve leaflet orifice area of 1.1 cm² (Model A1—very stenotic) to 5.0 cm² (Model A5—natural valve). The simulated data compares well with experimental measurements made downstream of various aortic trileaflet valves by Woo (PhD Thesis, 1984). The location and approximate width and length of recirculation regions are correctly predicted. The less stenotic valve models reattach at the end of the aortic sinus region, 1.1 diameters downstream of the valve. The central jet exiting the less stenotic valve models is not significantly different from fully developed flow, and therefore recovers very quickly downstream of the reattachment point. The more stenotic valves disturb the flow to a greater degree, generating recirculation regions large enough to escape the sinuses and reattach further downstream. Peak turbulent shear stress values downstream of the aortic valve models which approximated prosthetic valves are 125 and 300 N m⁻², very near experimental observations of 150 to 350 N m⁻². The predicted Reynolds stress profiles also present the correct shape, a double peak profile, with the location of the peak occuring at the location of maximum velocity gradient, which occurs near the recirculation region. The pressure drop across model A2 (leaflet orifice area 1.6 cm²) is 20 mmHg at 1.6 diameters downstream. This compares well with values ranging from 19.5 to 26.2 mmHg for valves of similar orifice areas. The pressure drop decreases with decreasing valve stenosis, to a negligible value across the least stenotic valve model. Based on the good agreement between experimental measurements of velocity, shear stress and pressure drop, compared to the simulated data, the model has the potential to be a valuable tool in the analysis of heart valve designs.     

21毫米人造心脏瓣膜泵的设计及研制

为了研究能够长期置入主动脉瓣环的左心室辅助装置,研制出直径21毫米重27克可植入的主动脉瓣膜泵.装置包括一个转子和一个定子.转子由驱动磁钢和叶轮组成;定子装有带铁心的电机线圈和出口导叶.装置被置於主动脉瓣位置,所以不占用额外的解剖空间.血泵能像自然心脏一样直接将血液由心室输送到主动脉,不需要连接管道和旁路,因此对自然生理循环的干扰可以减到最低.血泵流量由最大到零周期变化.血液动力学测试表明,当血泵转速为17500转/分钟时,可以产生流量5升/分钟、压力增益50毫米汞柱的血流;同一转速下,当流量为零时,血泵能保持主动脉舒张压为80毫米汞柱.     

Insights from in-vitro flow visualization into the mechanism of systolic anterior motion of the mitral valve in hypertrophic cardiomyopathy under steady flow conditions.

Hypertrophic obstructive cardiomyopathy is a heart disease characterized by a thickened interventricular septum which narrows the left ventricular outflow tract, and by systolic anterior motion (SAM) of the mitral valve which can contact the septum and create dynamic subaortic obstruction. The most common explanation for SAM has been the Venturi mechanism which postulates that septal hypertrophy, by narrowing the outflow tract, produces high velocities and thus low pressure between the mitral valve and the septum, causing the valve leaflets to move anteriorly. This hypothesis, however, fails to explain why SAM often begins early in systole, when outflow tract velocities are low or negligible or why it may occur in the absence of septal hypertrophy. The goal of this study was therefore to investigate an alternative hypothesis in which structural abnormalities of the papillary muscles act as a primary cause of SAM by altering valve restraint and thereby changing the geometry of the closed mitral apparatus and its relationship to the surrounding flow field. In order to test this hypothesis, an in vitro model of the left ventricle which included an explanted human mitral valve with intact chords and papillary muscle apparatus was constructed. Flow visualization was used to observe the ventricular flow field and the mitral valve geometry. Displacing the papillary muscles anteriorly and closer to each other, as observed clinically in patients with cardiomyopathy and obstruction produced SAM in the absence of septal hypertrophy. Flow could be seen impacting on the upstream (posterior) surface of the leaflets; such flow is capable of producing form drag forces which can initiate and maintain SAM.(ABSTRACT TRUNCATED AT 250 WORDS)     

Determinants of valve gating in collecting lymphatic vessels from rat mesentery

Secondary lymphatic valves are essential for minimizing backflow of lymph and are presumed to gate passively according to the instantaneous trans-valve pressure gradient. We hypothesized that valve gating is also modulated by vessel distention, which could alter leaflet stiffness and coaptation. To test this hypothesis, we devised protocols to measure the small pressure gradients required to open or close lymphatic valves and determine if the gradients varied as a function of vessel diameter. Lymphatic vessels were isolated from rat mesentery, cannulated, and pressurized using a servo-control system. Detection of valve leaflet position simultaneously with diameter and intraluminal pressure changes in two-valve segments revealed the detailed temporal relationships between these parameters during the lymphatic contraction cycle. The timing of valve movements was similar to that of cardiac valves, but only when lymphatic vessel afterload was elevated. The pressure gradients required to open or close a valve were determined in one-valve segments during slow, ramp-wise pressure elevation, either from the input or output side of the valve. Tests were conducted over a wide range of baseline pressures (and thus diameters) in passive vessels as well as in vessels with two levels of imposed tone. Surprisingly, the pressure gradient required for valve closure varied >20-fold (0.1-2.2 cmH(2)O) as a passive vessel progressively distended. Similarly, the pressure gradient required for valve opening varied sixfold with vessel distention. Finally, our functional evidence supports the concept that lymphatic muscle tone exerts an indirect effect on valve gating.     

Distally based free flap using retrograde arterial flow

In lower extremity injuries, the major arteries are frequently damaged and the remaining artery may be located in the traumatized zone. Recently, vascular anastomoses to recipient vessels distal to the zone of injuries have been advocated in the lower limb reconstruction and flaps by using retrograde arterial flow are well established in island flaps. Twelve patients with soft-tissue defects below the knee underwent lower extremity reconstruction with distally based free flaps by using retrograde arterial flow. For assessment of retrograde flow, the intraoperative retrograde arterial pressure was quantitated and compared with the systolic blood pressure taken at the same time (n = 6). In this study, suitable candidates had been chosen with pulsatile retrograde flow from the distal cut end of the vessel because patients without pulsatile flow had recorded diastolic and systolic retrograde arterial pressures that were very low. Four different free flaps were used. All flaps were successful. Retrograde flow anastomosis could not interrupt the major blood vessels, which were essential for survival of the distal limb, the compromise of fracture or wound healing might be prevented. In cases in which arteriography demonstrates significant vascular flow interruption within the zone of injury, retrograde arterial anastomosis may also be a candidate.     

Filtration performance of microporous ceramic supports

The use of inorganic membranes in pollution treatment is actually limited by the cost of such membranes. Advantages of inorganic membranes are their chemical, thermal and pH properties. The purpose of this work was the development of microporous ceramic materials based on clay for liquid waste processing. The supports or ceramic filters having various compositions were prepared and thermally treated at 1100 °C. The results show that, at the temperature studied, porosity varied according to the support composition from 12% for the double-layered (ceramic) support to 47% for the activated carbon- filled support with a mean pore diameter between 0.8 and 1.3 μm, respectively. Volumes of 5 l of distilled water were filtered tangentially for 3 h under an applied pressure of 3.5 and 5.5 bar. The retention of tubular supports prepared was tested with molecules of varying size (Evans blue, NaCl and Sacharose). The study of the liquid filtration and flow through these supports showed that the retention rate depends on support composition and pore diameter, and solute molecular weight. The S1 support (mixture of barbotine and 1% (w/w) activated carbon) gave a flux for distilled water of 68 L/m² h while the double-layered support resulted in a flux of 8 L/m² h for the same solution at the pressure of 3.5 bar. At a pressure of 5.5 bar an increase in the distilled water flux through the various supports was observed. It was significant for the S1 support (230 L/m h).     

Secondary ischemia time in rodents: contrasting complete pedicle interruption with venous obstruction

The current study investigated the effect of secondary ischemic insults on ultimate flap survival. Rodent skin flaps subjected to 8 hours of secondary ischemia with total pedicle obstruction had 56 percent survival (7 of 12) compared with primary ischemic flaps of the same time, which all survived. At 10 hours of ischemia, only 42 percent of secondary ischemic flaps survived compared with 67 percent (8 of 12) of primary ischemic flaps. When the secondary ischemia was caused by venous obstruction, the results were even more striking. Ninety-two percent (11 of 12) of primary venous obstruction flaps survived 3 hours of ischemia and 75 percent (9 of 12) survived 5 hours of ischemia, while only 56 percent (7 of 12) and 8 percent (1 of 12) of flaps subjected to secondary venous obstruction survived at the same times, respectively. The explanation of these observations on the basis of tissue pathophysiologic changes will require further study. The results support the need for close monitoring of clinical flaps to ensure optimal survival.     

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.

     

Initial hydrodynamic study on a new intraaortic axial flow pump: Dynamic aortic valve

Rotary blood pumps have been researched as implantable ventricular assist devices for years. To further reduce the complex of implanted axial pumps, the authors proposed a new concept of intraaortic axial pump, termed previously as “dynamic aortic valve (DAV)”. Instead of being driven by an intraaortic micro-electric motor, it was powered by a magnetic field from outside of body. To ensure the perfusion of coronary artery, the axial flow pump is to be implanted in the position of aortic valve. It could serve as either a blood pump or a mechanical valve depending on the power input. This research tested the feasibility of the new concept in model study. A column, made from permanent magnet, is jointed to an impeller in a concentric way to form a “rotor-impeller”. Supported by a hanging shaft cantilevered in the center of a rigid cage, the rotor-impeller can be turned by the magnetic field in the surrounding space. In the present prototype, the rotor is 8 mm in diameter and 15 mm in length, the impeller has 3 vanes with an outer diameter of 18 mm. The supporting cage is 22 mm in outer diameter and 20 mm in length. When tested, the DAV prototype is inserted into the tube of a mock circuit. The alternative magnetic field is produced by a rotating magnet placed side by side with the rotor-impeller at a distance of 30 mm. Once the alternative magnetic field is presented in the surrounding space, the DAV starts to turn, leading to a pressure difference and liquid flow in the tube. The flow rate or pressure difference is proportioned to rotary speed. At the maximal output of hydraulic power, the flow rate reached 5 L/min against an afterload of 100 mmHg. The maximal pressure difference generated by DAV at a rotation rate of 12600 r/min was 147 mmHg. The preliminary results demonstrated the feasibility of “DAV”, further research on this concept is justifiable.     

Effects of inspiratory resistance loading on lung fluid balance in awake sheep

Because pulmonary edema has been associated clinically with airway obstruction, we sought to determine whether decreased intrathoracic pressure, created by selective inspiratory obstruction, would affect lung fluid balance. We reasoned that if decreased intrathoracic pressure caused an increase in the transvascular hydrostatic pressure gradient, then lung lymph flow would increase and the lymph-to-plasma protein concentration ratio (L/P) would decrease. We performed experiments in six awake sheep with chronic lung lymph cannulas. After a base-line period, we added an inspiratory load (20 cmH2O) and allowed normal expiration at atmospheric pressure. Inspiratory loading was associated with a 12-cmH2O decrease in mean central airway pressure. Mean left atrial pressure fell 11 cmH2O, and mean pulmonary arterial pressure was unchanged; calculated microvascular pressure decreased 8 cmH2O. The changes that occurred in lung lymph were characteristic of those seen after other causes of increased transvascular hydrostatic gradient, such as increased intravascular pressure. Lung lymph flow increased twice base line, and L/P decreased. We conclude that inspiratory loading is associated with an increase in the pulmonary transvascular hydrostatic gradient, possibly by causing a greater fall in interstitial perimicrovascular pressure than in microvascular pressure.     

Evaluation of Compliance of Arterial Vessel Using Coupled Fluid Structure Interaction Analysis

The in vivo and ex vivo compliance of arteries are expected to be closely related and estimated. Fluid-structure interaction analysis can assess the agreement between the two compliances. To evaluate this hypothesis, a pulsatile fluid-structure interaction analysis of blood flow in femoral artery of a dog was conducted using: (1) measured in vivo mean pressure (72.5 mmHg), mean pressure drop (0.59 mmHg), mean velocity (15.1 cm/sec); and (2) ex vivo measurements of non -- linear elastic properties of femoral artery. Additional analyses were conducted for physiological pressures (104.1 and 140.7 mmHg) and blood flow using a characteristic linear pressure -- flow relationship. The computed compliance decreased from 0.198% diameter change/mmHg at 72.5 mmHg to 0.145% diameter change/mmHg at 140.7 mmHg. The computed compliance tends to match well with in vivo compliance of femoral artery at lower pressure but is overestimated at higher pressure. This suggests an alteration in the compliance of the artery during ex vivo elasticity measurements.     

Model studies at mechanical aortic heart valve prostheses--Part I: Steady-state flow fields and pressure loss coefficients

In a 3:1 scaled model of the human aorta models of the Omniscience, Bj?rk-Shiley Convexo-Concave, Bj?rk-Shiley Monostrut, Medtronic-Hall, Duromedics (Hemex) and the Saint Jude Medical heart valve prostheses are studied in steady flow representing the systolic peak flow phase. Detailed flow visualization experiments show flow separations at all inner ring surfaces as well as at most of the occluders. The resulting stagnation areas increase the risk of thrombus accumulation. Flow separations also stimulate vortex formation and turbulent mixing at the downstream jet boundaries and thus may intensify blood damage by turbulent shear stresses. The different influences of struts and occluder guides on the flow around the occluders are discussed. The effects of the individual valve components on the flow fields are analyzed and correlated with the resulting pressure losses.     

Simulation of a chain of collapsible contracting lymphangions with progressive valve closure

The aim of this investigation was to achieve the first step toward a comprehensive model of the lymphatic system. A numerical model has been constructed of a lymphatic vessel, consisting of a short series chain of contractile segments (lymphangions) and of intersegmental valves. The changing diameter of a segment governs the difference between the flows through inlet and outlet valves and is itself governed by a balance between transmural pressure and passive and active wall properties. The compliance of segments is maximal at intermediate diameters and decreases when the segments are subject to greatly positive or negative transmural pressure. Fluid flow is the result of time-varying active contraction causing diameter to reduce and is limited by segmental viscous and valvular resistance. The valves effect a smooth transition from low forward-flow resistance to high backflow resistance. Contraction occurs sequentially in successive lymphangions in the forward-flow direction. The behavior of chains of one to five lymphangions was investigated by means of pump function curves, with variation of valve opening parameters, maximum contractility, lymphangion size gradation, number of lymphangions, and phase delay between adjacent lymphangion contractions. The model was reasonably robust numerically, with mean flow-rate generally reducing as adverse pressure was increased. Sequential contraction was found to be much more efficient than synchronized contraction. At the highest adverse pressures, pumping failed by one of two mechanisms, depending on parameter settings: either mean leakback flow exceeded forward pumping or contraction failed to open the lymphangion outlet valve. Maximum pressure and maximum flow-rate were both sensitive to the contractile state; maximum pressure was also determined by the number of lymphangions in series. Maximum flow-rate was highly sensitive to the transmural pressure experienced by the most upstream lymphangions, suggesting that many feeding lymphatics would be needed to supply one downstream lymphangion chain pumping at optimal transmural pressure.     

Two-dimensional tracking and TDI are consistent methods for evaluating myocardial longitudinal peak strain in left and right ventricle basal segments in athletes

Background

Surgical "anatomical" repair is the most frequent technique used to correct mitral regurgitation due to severe myxomatous valve disease. Debate, however, persists on the efficacy of this technique, as well as on the durability of the repaired valve, and on its functioning and hemodynamics under stress conditions. Thus, a basal and Dobutamine echocardiographic (DSE) study was carried out to evaluate these parameters at mid-term follow-up.

Methods and Results

Twenty patients selected for the study (12 men and 8 women, mean age 60 ± 9 years) underwent pre- and post-operative transthoracic echocardiography (TTE) and intra-operative transesophageal echocardiography (TEE). At mid-term follow-up (20 ± 5 months) all patients underwent rest TTE and DSE (3 min. dose increments up to 40 microg/Kg/min protocol). Pre-discharge and one-month TTE showed absence of MR in 11 pts., trivial or mild MR in 9 pts. and normal mitral valve area and gradients. Mid-term TTE showed decrease in left atrial and ventricular dimension, in pulmonary artery pressure (sPAP) and grade of MR. During DSE a significant increase in mitral valve area, maximum and mean gradients, sPAP, heart rate and cardiac output and a decrease in systolic annular diameter and left ventricular volume were found; in 6 pts. a transient left ventricular outflow tract obstruction was observed.

Conclusion

Basal and Dobutamine stress echocardiography proved to be valuable tools for evaluation of mid-term results of mitral valve repair. In our study population, the surgical technique employed had a favourable impact on several cardiac parameters, evaluated by these methods.     

Design of a system for the accelerated loading of heart valve prostheses

In this paper an equipment is described for the loading of heart valve prostheses under physiological pressure conditions at a frequency of 10 Hz. The system consists essentially of two reservoirs between which a housing is mounted for holding the valve prosthesis. The reservoirs are partly filled with liquid. The physiological pressure variation across the valve is obtained by pressure control within the two reservoirs. A phase difference between the pressures in the two reservoirs compensates for the mass-inertia effects which normally occur at these high frequencies. The system without a valve has been analysed on the basis of simplified relationships between pressure and flow. The predicted values for the phase difference between the flow and the pressure curves within the valve housing, have been verified experimentally for various values of phase difference and amplitude ratios of the pressure variations within the reservoirs. The agreement between theory and experiment is fair. For the system with a valve the experimentally observed patterns closely resemble the theoretically predicted ones. From experiments with a Bj?rk-Shiley ( 21ABP ) and a Hancock (242-A21) valve prosthesis it is concluded that the valves open and close completely and that the pressure and flow patterns around the valves mimic the essential features of the in-vivo signals.     

Effect of arteriovenous flow reversal on blood flow and metabolism in a skin flap

Twelve pig buttock island flaps (10 X 10 cm) were studied for 6 hours after arteriovenous flow reversal at the level of the pedicle. Follow-up was 48 hours. Blood pressure, Po2, pH, and lactate were measured in flap arteries and veins. Oxygen consumption was calculated. Data indicated true flow reversal. Blood pressure and Po2 in flap veins increased to systemic arterial levels. Outflow was provided by the arterial system, demonstrating venous pressure and Po2 values. Lactate increased significantly (1.8 +/- 0.5 to 4.0 +/- 2.3 mmol/liter), while pH dropped from 7.43 +/- 0.03 to 7.11 +/- 0.02. Oxygen consumption remained below baseline. In four flaps thrombosis occurred within 6 hours; no flap survived 48 hours. The results of this study do not encourage clinical application of the concept of flow reversal.     

Estimation of airway obstruction using oximeter plethysmograph waveform data

Background

Validated measures to assess the severity of airway obstruction in patients with obstructive airway disease are limited. Changes in the pulse oximeter plethysmograph waveform represent fluctuations in arterial flow. Analysis of these fluctuations might be useful clinically if they represent physiologic perturbations resulting from airway obstruction. We tested the hypothesis that the severity of airway obstruction could be estimated using plethysmograph waveform data.

Methods

Using a closed airway circuit with adjustable inspiratory and expiratory pressure relief valves, airway obstruction was induced in a prospective convenience sample of 31 healthy adult subjects. Maximal change in airway pressure at the mouthpiece was used as a surrogate measure of the degree of obstruction applied. Plethysmograph waveform data and mouthpiece airway pressure were acquired for 60 seconds at increasing levels of inspiratory and expiratory obstruction. At each level of applied obstruction, mean values for maximal change in waveform area under the curve and height as well as maximal change in mouth pressure were calculated for sequential 7.5 second intervals. Correlations of these waveform variables with mouth pressure values were then performed to determine if the magnitude of changes in these variables indicates the severity of airway obstruction.

Results

There were significant relationships between maximal change in area under the curve (P < .0001) or height (P < 0.0001) and mouth pressure.

Conclusion

The findings suggest that mathematic interpretation of plethysmograph waveform data may estimate the severity of airway obstruction and be of clinical utility in objective assessment of patients with obstructive airway diseases.