Computational Fluid Dynamics Analysis of Surgical Adjustment of Ventricular Assist Device Implantation to Minimize Stroke Risk

Abstract

Presently, mechanical support is the most promising alternative to cardiac transplantation. Ventricular Assist Devices (VADs) were originally used to provide mechanical circulatory support in patients waiting planned heart transplantation (“bridge-to-transplantation” therapy). The success of short-term bridge devices led to clinical trials evaluating the clinical suitability of long-term support (“destination” therapy) with left ventricular assist devices (LVADs). The first larger-scale, randomized trial that tested long-term support with a LVAD reported a 44% reduction in the risk of stroke or death in patients with a LVAD. In spite of the success of LVADs as bridge-to-transplantation and long-term support. Patients carrying these devices are still at risk of several adverse events. The most devastating complication is caused by embolization of thrombi formed within the LVAD or inside the heart into the brain. Prevention of thrombi formation is attempted through anticoagulation management and by improving LVADs design; however there is still significant occurrence of thromboembolic events in patients. Investigators have reported that the incidence of thromboembolic cerebral events ranges from 14% to 47% over a period of 6–12 months. An alternative method to reduce the incidence of cerebral embolization has been proposed by one of the co-authors, namely William DeCampli M.D., Ph.D. The hypothesis is that it is possible to minimize the number of thrombi flowing into the carotid arteries by an optimal placement of the LVAD outflow conduit, and/or the addition of aortic bypass connecting the ascending aorta (AO) and the innominate artery (IA), or left carotid artery (LCA). This paper presents the computational fluid dynamics (CFD) analysis of the aortic arch hemodynamics using a representative geometry of the human aortic arch and an alternative aortic bypass. The alternative aortic bypass is intended to reduce thrombi flow incidence into the carotid arteries in patients with LVAD implants with the aim to reduce thromboembolisms. In order to study the trajectory of the thrombi within the aortic arch, a Lagrangian particle-tracking model is coupled to the CFD model. Results are presented in the form of percentage of thrombi flowing to the carotid arteries as a function of LVAD conduit placement and aortic bypass implantation, revealing promising improvement.