Patient Specific Computational Modeling of Coronary Obstruction for Procedural Planning of Valve-in-valve TAVR

Abstract

Objective: Coronary obstruction is a procedural complication of TAVR that is associated with high mortality rates. BASILICA is a novel technique that is successful in mitigating coronary obstruction in ViV TAVR. The objective of this study is to illustrate the role of patient specific computational modeling in TAVR planning for ViV patients with high risk of coronary obstruction. Methods: Pre-procedural computed tomography (CT) images for a 74-year-old patient who had a St. Jude Trifecta 21mm valve through prior surgical AVR were obtained through an IRB approved protocol. CT images were imported to Mimics 21.0 (Materialise NV) and geometries of the aortic root and the bioprosthetic valve were generated by segmentation (Figure 1 a-b). Lacerations were introduced in the geometry at the center and near the commissure of the left coronary leaflet (Figure 1 d-e). Using Abaqus Explicit (Dassault Systems), an idealized TAV was expanded inside the valve geometry by finite element methods for all three cases. Results: Cross-sectional views were generated using 3-Matic postprocessing tools (Figure 1 f-h). From Figure 1, deployment of idealized TAV without laceration of the bioprosthetic leaflet resulted in complete obstruction of the left coronary artery. Figure 1 g-h show that a laceration at the center of the bioprosthetic leaflet does not mitigate the obstruction and one close to the commissure of the bioprosthetic valve removes the risk of obstruction, establishing a path for left coronary flow. Conclusions: This study shows that computational patient specific modeling can provide the necessary visualization for successful planning of TAVR procedures in valve-in-valve patients. Patient specific computational structural modeling in combination with computational fluid dynamic simulations has immense potential in helping prevent adverse outcomes associated with TAVR.