Patient-specific Computational Simulations Research Articles

Preoperative computed tomography-imaging with patient-specific computer simulation in transcatheter aortic valve implantation: Design and rationale of the GUIDE-TAVI trial

Transcatheter aortic valve implantation (TAVI) is an established treatment option for patients with severe aortic valve stenosis, but is still associated with relatively high rates of pacemaker implantation and paravalvular regurgitation. Routine preoperative computed tomography (CT) combined with patient-specific computer modelling can predict the interaction between the TAVI device and the patient's unique anatomy, allowing physicians to assess the risk for paravalvular regurgitation and conduction disorders in advance to the procedure. The aim of this trial is to assess potential improvement in the procedural outcome of TAVI by applying CT-based patient-specific computer simulations in patients with suitable anatomy for TAVI. The GUIDE-TAVI trial is an international multicenter randomized controlled trial including patients accepted for TAVI by the Heart Team. Patients enrolled in the study will be randomized into 2 arms of each 227 patients. In patients randomized to the use of FEops HEARTGuide (FHG), patient-specific computer simulation with FHG is performed in addition to routine preoperative CT imaging and results of the FHG are available to the operator(s) prior to the scheduled intervention. In patients randomized to no use of FHG, only routine preoperative CT imaging is performed. The primary objective is to evaluate whether the use of FHG will reduce the incidence of mild to severe PVR, according to the Valve Academic Research Consortium 3. Secondary endpoints include the incidence of new conduction disorders requiring permanent pacemaker implantation, the difference between preoperative and final selected valve size, the difference between target and final implantation depth, change of preoperative decision, failure to implant valve, early safety composite endpoint and quality of life. The GUIDE-TAVI trial is the first multicenter randomized controlled trial to evaluate the value of 3-dimensional computer simulations in addition to standard preprocedural planning in TAVI procedures.

Patient-specific computational flow simulation reveals significant differences in paravisceral aortic hemodynamics between fenestrated and branched endovascular aneurysm repair

BackgroundEndovascular aneurysm repair with four-vessel fenestrated endovascular aneurysm repair (fEVAR) or branched endovascular aneurysm repair (bEVAR) currently represent the forefront of minimally invasive complex aortic aneurysm repair. This study sought to use patient-specific computational flow simulation (CFS) to assess differences in postoperative hemodynamic effects associated with fEVAR vs bEVAR. MethodsPatients from two institutions who underwent four-vessel fEVAR with the Cook Zenith Fenestrated platform and bEVAR with the Jotec E-xtra Design platform were retrospectively selected. Patients in both cohorts were treated for paravisceral and extent II, II, and V thoracoabdominal aortic aneurysms. Three-dimensional finite element volume meshes were created from preoperative and postoperative computed tomography scans. Boundary conditions were adjusted for body surface area, heart rate, and blood pressure. Pulsatile flow simulations were performed with equivalent boundary conditions between preoperative and postoperative states. Postoperative changes in hemodynamic parameters were compared between the fEVAR and bEVAR groups. ResultsPatient-specific CFS was performed on 20 patients (10 bEVAR, 10 fEVAR) with a total of 80 target vessels (40 renal, 20 celiac, 20 superior mesenteric artery stents). bEVAR was associated with a decrease in renal artery peak flow rate (−5.2% vs +2.0%; P < .0001) and peak pressure (−3.4 vs +0.1%; P < .0001) compared with fEVAR. Almost all renal arteries treated with bEVAR had a reduction in renal artery perfusion (n = 19 [95%]), compared with 35% (n = 7) treated with fEVAR. There were no significant differences in celiac or superior mesenteric artery perfusion metrics (P = .10-.27) between groups. Time-averaged wall shear stress in the paravisceral aorta and branches also varied significantly depending on endograft configuration, with bEVAR associated with large postoperative increases in renal artery (+47.5 vs +13.5%; P = .002) and aortic time-averaged wall shear stress (+200.1% vs −31.3%; P = .001) compared with fEVAR. Streamline analysis revealed areas of hemodynamic abnormalities associated with branched renal grafts which adopt a U-shaped geometry, which may explain the observed differences in postoperative changes in renal perfusion between bEVAR and fEVAR. ConclusionsbEVAR may be associated with subtle decreases in renal perfusion and a large increase in aortic wall shear stress compared with fEVAR. CFS is a novel tool for quantifying and visualizing the unique patient-specific hemodynamic effect of different complex EVAR strategies. Clinical RelevanceThis study used patient-specific CFS to compare postoperative hemodynamic effects of four-vessel fenestrated endovascular aneurysm repair (fEVAR) and branched endovascular aneurysm repair (bEVAR) in patients with complex aortic aneurysms. The findings indicate that bEVAR may result in subtle reductions in renal artery perfusion and a significant increase in aortic wall shear stress compared with fEVAR. These differences are clinically relevant, providing insights for clinicians choosing between these approaches. Understanding the patient-specific hemodynamic effects of complex EVAR strategies, as revealed by CFS, can aid in future personalized treatment decisions, and potentially reduce postoperative complications in aortic aneurysm repair.

Abstract 18514: A Simulation Study on the Inducibility of Atrial Fibrillation Drivers From Intra-Atrial Electrode Catheters Using Personalized Computational Models Based on LGE-MRI

Introduction: Although non-inducibility of atrial fibrillation (AF) drivers just after pulmonary vein isolation (PVI) with or without substrate ablation for persistent AF (PsAF) has been proposed as an acute outcome suggesting a successful long-term outcome, recent studies have found no association with long-term freedom from atrial tachyarrhythmias. It is unclear whether the latter finding is due to complete elimination of all AF drivers or the inadequacy of an AF induction test. Recently, patient-specific computer simulation based on late gadolinium enhancement (LGE)-MRI has been proposed to be useful for detecting rotors as PsAF drivers. Hypothesis: By investigating the accuracy of an induction test following PsAF ablation from the sites commonly used in clinical practice, particularly coronary sinus (CS), we might establish the promising method to confirm non-inducibility during ablation procedure. Methods: Thirty-five consecutive PsAF patients underwent LGE-MRI tests for fibrosis-based computational models. Rotors were induced by rapid pacing from 40 bi-atrial sites near fibrosis after PVI then ablated, repeated until obtaining non-inducibility of rotors. Each induced rotor was investigated for whether it was induced by pacing at lateral right atrium (RA), high RA or CS where electrode catheters were typically placed and used for induction test (Figure). Results: Except for 9 patients having poor LGE-MRI images or low fibrosis burden, 21 patients had a total of 136 locations capable of sustaining extra-PVI rotors. Of the total amount of rotors induced, 24% were induced by pacing at lateral RA, 11% at high RA and 45% at CS, respectively. The capture of all arrhythmogenic locations capable of sustaining rotors improved to 59% by performing induction test from all 3 pacing sites instead of a single one (p&lt;0.01). Conclusions: Although CS is the reasonable pacing site for induction test, that from RA should be also conducted for the optimal rotor detection.

Preventing Acute Limb Ischemia during VA-ECMO-In Silico Analysis of Physical Parameters Associated with Lower Limb Perfusion.

Peripheral femoro-femoral veno-arterial extracorporeal membrane oxygenation is increasingly used in refractory cardiogenic shock. However, the obstruction of the femoral artery by the return cannula could lead to acute limb ischemia, a frequently encountered situation that is inconstantly prevented by the adjunction of a distal perfusion cannula (DPC). The aim of this study was to investigate the influence of three physical parameters on the perfusion of the cannulated lower limb. Using patient-specific arterial models and computational fluid dynamic simulations, we studied four diameters of arterial cannula, three diameters of DPC, and two percentages of arterial section limitation. We found that adequate perfusion of the cannulated limb was achieved in only two out of the twenty-one configurations tested, specifically, when the arterial cannula had a diameter of 17 Fr, was considered to limit the section of the artery by 90%, and was associated with an 8 Fr or a 10 Fr DPC. Multivariable analysis revealed that the perfusion of the cannulated lower limb was correlated with the diameter of the DPC, but also with the diameter of the arterial cannula and the percentage of arterial section limitation. In most of the cases simulated here, the current system combining unsized arterial cannula and non-specific DPC was not sufficient to provide adequate perfusion of the cannulated lower limb, urging the need for innovative strategies to efficiently prevent acute limb ischemia during peripheral femoro-femoral veno-arterial extracorporeal membrane oxygenation.

Noninvasive, patient-specific computational fluid dynamics simulations of dural venous sinus pressures in idiopathic intracranial hypertension

BackgroundThe pathophysiology of Idiopathic Intracranial Hypertension (IIH) is poorly understood, making the disease difficult to properly diagnose and treat. Endovascular venous stenting has emerged as an effective non-invasive treatment option for a select cohort of IIH patients with venous sinus stenosis and elevated venous sinus pressure gradient. Unfortunately, current methods of determining patient eligibility for stenting treatment depend on highly invasive and insufficient measurement methods such as venous manometry, which can only measure pressure gradients and not other components of the complex 3D hemodynamic environment. Thus, there is a need for a non-invasive methodology for determining the 3D flow environment of the dural venous sinuses. ObjectiveTo develop a novel method of non-invasive, patient-specific computational fluid dynamic (CFD) simulation of venous sinus hemodynamics for evaluating stenting eligibility. MethodA patient with IIH and elevated sinus pressure gradient underwent MR venography, phase-contrast MR venography, and venous manometry. Patient-specific dural venous anatomy was segmented from the MR venography to construct 3D models of the venous sinuses. 3D transient patient-specific computational fluid dynamic simulations were conducted using flow velocities measured with phase-contrast MR venography as boundary conditions. ResultsSuccessful computational simulations were completed, allowing for the calculation of the spatio-temporal evolution of blood flow through the dural venous sinuses, and the quantitative examination of pressure gradients. Calculated pressure gradients from CFD were validated against venous manometry with an error of only ∼5%. ConclusionsWe have successfully developed time-resolved, patient-specific 3D computational simulations of the dural venous sinuses without assumptions at the boundary conditions for the first time. The methodology can accurately and non-invasively measure venous pressure gradients. This preliminary study serves as a proof of concept for our method to be used as a diagnostic tool for determining venous stenting eligibility, as well as a tool for advancing the general understanding of IIH pathophysiology. Statement of SignificanceThe pathophysiology of Idiopathic Intracranial Hypertension (IIH) is poorly understood making the disease difficult to properly diagnose and treat. Endovascular venous stenting has emerged as an effective non-invasive treatment option for a select cohort of IIH patients with venous sinus stenosis and elevated venous sinus pressure gradient. Our work provides a method for noninvasively determining eligibility for venous sinus stenting, avoiding costly and invasive venous manometry.

Patient-specific computational simulations of wound healing following midline laparotomy closure.

In the current study, we developed a new computational methodology to simulate wound healing in soft tissues. We assumed that the injured tissue recovers partially its mechanical strength and stiffness by gradually increasing the volume fraction of collagen fibers. Following the principles of the constrained mixture theory, we assumed that new collagen fibers are deposited at homeostatic tension while the already existing tissue undergoes a permanent deformation due to the effects of remodeling. The model was implemented in the finite-element software Abaqus® through a VUMAT subroutine and applied to a complex and realistic case: simulating wound healing following midline laparotomy closure. The incidence of incisional hernia is still quite significant clinically, and our goal was to investigate different conditions hampering the success of these procedures. We simulated wound healing over periods of 6months on a patient-specific geometry. One of the outcomes of the finite-element simulations was the width of the wound tissue, which was found to be clinically correlated with the development of incisional hernia after midline laparotomy closure. We studied the impact of different suturing modalities and the effects of situations inducing increased intra-abdominal pressure or its intermittent variations such as coughing. Eventually, the results showed that the main risks of developing an incisional hernia mostly depend on the elastic strains reached in the wound tissue after degradation of the suturing wires. Despite the need for clinical validation, these results are promising for establishing a digital twin of wound healing in midline laparotomy incision.

Predictors of Myocardial Ischemia in Patients with Kawasaki Disease: Insights from Patient-Specific Simulations of Coronary Hemodynamics.

Current treatments for patients with coronary aneurysms caused by Kawasaki disease (KD) are based primarily on aneurysm size. This ignores hemodynamic factors influencing myocardial ischemic risk. We performed patient-specific computational hemodynamics simulations for 15 KD patients, with parameters tuned to patients' arterial pressure and cardiac function. Ischemic risk was evaluated in 153 coronary arteries from simulated fractional flow reserve (FFR), wall shear stress, and residence time. FFR correlated weakly with aneurysm [Formula: see text]-scores (correlation coefficient, [Formula: see text]) but correlated better with the ratio of maximum-to-minimum aneurysmal lumen diameter ([Formula: see text]). FFR dropped more rapidly distal to aneurysms, and this correlated more with the lumen diameter ratio ([Formula: see text]) than [Formula: see text]-score ([Formula: see text]). Wall shear stress correlated better with the diameter ratio ([Formula: see text]), while residence time correlated more with [Formula: see text]-score ([Formula: see text]). Overall, the maximum-to-minimum diameter ratio predicted ischemic risk better than [Formula: see text]-score. Although FFR immediately distal to aneurysms was nonsignificant, its rapid rate of decrease suggests elevated risk.

Patient-specific computational simulation of coronary artery bypass grafting.

Coronary artery bypass graft surgery (CABG) is an intervention in patients with extensive obstructive coronary artery disease diagnosed with invasive coronary angiography. Here we present and test a novel application of non-invasive computational assessment of coronary hemodynamics before and after bypass grafting. We tested the computational CABG platform in n = 2 post-CABG patients. The computationally calculated fractional flow reserve showed high agreement with the angiography-based fractional flow reserve. Furthermore, we performed multiscale computational fluid dynamics simulations of pre- and post-CABG under simulated resting and hyperemic conditions in n = 2 patient-specific anatomies 3D reconstructed from coronary computed tomography angiography. We computationally created different degrees of stenosis in the left anterior descending artery, and we showed that increasing severity of native artery stenosis resulted in augmented flow through the graft and improvement of resting and hyperemic flow in the distal part of the grafted native artery. We presented a comprehensive patient-specific computational platform that can simulate the hemodynamic conditions before and after CABG and faithfully reproduce the hemodynamic effects of bypass grafting on the native coronary artery flow. Further clinical studies are warranted to validate this preliminary data.

Ongoing Experience With Patient-Specific Computer Simulation of Transcatheter Aortic Valve Replacement in Bicuspid Aortic Valve

BackgroundTranscatheter aortic valve replacement (TAVR) is increasingly being used to treat younger, lower-risk patients with bicuspid aortic valve (BAV). Patient-specific computer simulation may identify patients at risk for developing paravalvular regurgitation (PVR) and major conduction disturbance. Only limited prospective experience of this technology exist. We wished to describe our ongoing experience with patient-specific computer simulation. MethodsPatients who were referred for consideration of TAVR with a self-expanding transcatheter heart valve (THV) and had BAV identified on pre-procedural cardiac computed tomography imaging underwent patient-specific computer simulation. The computer simulations were reviewed by the Heart Team and used to guide surgical or transcatheter treatment approaches and to aid in THV sizing and positioning. Clinical outcomes were recorded. ResultsBetween May 2019 and May 2021, 16 patients with BAV were referred for consideration of TAVR with a self-expanding THV. Sievers Type 1 morphology was present in 15 patients and Type 0 in the remaining patient. Two patients were predicted to develop moderate-to-severe PVR with a TAVR procedure and these patients underwent successful surgical aortic valve replacement. In the remaining 14 patients, computer simulation was used to optimize THV sizing and positioning to minimise PVR and conduction disturbance. One patient with a low valve implantation depth developed moderate PVR and this complication was correctly predicted by the computer simulations. No patient required insertion of a new permanent pacemaker. ConclusionPatient-specific computer simulation may be used to guide the most appropriate treatment modality for patients with BAV. The usage of computer simulation to guide THV sizing and positioning was associated with favourable clinical outcomes.

On the Finite Element Modeling of the Lumbar Spine: A Schematic Review

Finite element modelling of the lumbar spine is a challenging problem. Lower back pain is among the most common pathologies in the global populations, owing to which the patient may need to undergo surgery. The latter may differ in nature and complexity because of spinal disease and patient contraindications (i.e., aging). Today, the understanding of spinal column biomechanics may lead to better comprehension of the disease progression as well as to the development of innovative therapeutic strategies. Better insight into the spine’s biomechanics would certainly guarantee an evolution of current device-based treatments. In this setting, the computational approach appears to be a remarkable tool for simulating physiological and pathological spinal conditions, as well as for various aspects of surgery. Patient-specific computational simulations are constantly evolving, and require a number of validation and verification challenges to be overcome before they can achieve true and accurate results. The aim of the present schematic review is to provide an overview of the evolution and recent advances involved in computational finite element modelling (FEM) of spinal biomechanics and of the fundamental knowledge necessary to develop the best modeling approach in terms of trustworthiness and reliability.

Prediction of bird-beak configuration in thoracic endovascular aortic repair preoperatively using patient-specific finite element simulations

ObjectivesFormation of bird-beak configuration in thoracic endovascular aortic repair (TEVAR) has been shown to be correlated with the risk of complications such as type Ia endoleaks, stent graft migration, and collapse. The aim of this study was to use patient-specific computational simulations of TEVAR to predict the formation of bird-beak configuration preoperatively. MethodsPatient-specific TEVAR computational simulations are developed using a retrospective cohort of patients treated for thoracic aortic aneurysm. The preoperative computed tomography images were segmented to develop three-dimensional geometry of the thoracic aorta. These geometries were used in finite element simulations of stent graft deployment during TEVAR. Simulated results were compared against the postoperative computed tomography images to assess the accuracy of simulations in predicting the proximal position of a deployed stent graft and presence of bird-beak. In cases with a bird-beak configuration, the length and angle of the bird-beak were measured and compared between the simulated and postoperative results. ResultsTwelve TEVAR patient cases were simulated. Computational simulations were able to accurately predict whether the proximal stent graft was fully apposed, proximal bare stents were protruded, or bird-beak configuration was present. In three cases with bird-beak configuration, simulations predicted the length and angle of the bird-beak with less than 10% and 24% error, respectively. Other factors such as a small aortic arch angle, small oversizing value, and landing zones close to the arch apex may have played a role in formation of bird-beak in these patients. ConclusionsComputational simulations of TEVAR accurately predicted the proximal position of a deployed stent graft and the presence of bird-beak preoperatively. The computational models were able to predict the length and angle of bird-beak configurations with good accuracy. These simulations can provide insight into the surgical planning process with the goal of minimizing bird-beak occurrence.

Patient-Specific Computational Flow Simulation Reveals Significant Differences in Paravisceral Aortic Hemodynamics Between Fenestrated and Branched Endovascular Aneurysm Repair

Endovascular aneurysm repair (EVAR) with four-vessel fenestrated (fEVAR) or branched (bEVAR) endografts currently represents the forefront of minimally invasive complex aortic aneurysm repair. In the present study, we used patient-specific computational flow simulation (CFS) to assess the differences in postoperative hemodynamic effects associated with fEVAR vs bEVAR.

Abstract No. 168 Real-time physics-based simulation of the ablation volume: early clinical outcomes in radiofrequency ablation of hepatocellular carcinoma

Evaluate the utility of a radiofrequency ablation (RFA) guidance software (Accublate, NE Scientific, Boston, MA) that incorporates a patient-specific physics-based computer simulation of the ablation volume for immediate assessment of the adequacy of each ablation.

Patient-Specific Computer Simulation to Predict Conduction Disturbance With Current-Generation Self-Expanding Transcatheter Heart Valves

BackgroundPatient-specific computer simulation may predict the development of conduction disturbance following transcatheter aortic valve replacement (TAVR). Validation of the computer simulations with current-generation devices has not been undertaken. MethodsA retrospective study was performed on patients who had undergone TAVR with a current-generation self-expanding transcatheter heart valve (THV). Preprocedural computed tomography imaging was used to create finite element models of the aortic root. Procedural contrast angiography was reviewed, and finite element analysis performed using a matching THV device size and implantation depth. A region of interest corresponding to the atrioventricular bundle and proximal left bundle branch was identified. The percentage of this area (contact pressure index [CPI]) and maximum contact pressure (CPMax) exerted by THV were recorded. Postprocedural electrocardiograms were reviewed, and major conduction disturbance was defined as the development of persistent left bundle branch block or high-degree atrioventricular block. ResultsA total of 80 patients were included in the study. THVs were 23- to 29-mm Evolut PRO (n = 53) and 34-mm Evolut R (n = 27). Major conduction disturbance occurred in 27 patients (33.8%). CPI (28.3 ± 15.8 vs. 15.6 ± 11.2%; p < 0.001) and CPMax (0.51 ± 0.20 vs. 0.36 ± 0.24 MPa; p = 0.008) were higher in patients who developed major conduction disturbance. CPI (area under the receiver operating characteristic curve [AUC], 0.74; 95% CI, 0.63-0.86; p < 0.001) and CPMax (AUC, 0.69; 95% CI, 0.57-0.81; p = 0.006) demonstrated a discriminatory power to predict the development of major conduction disturbance. ConclusionsPatient-specific computer simulation may identify patients at risk for conduction disturbance after TAVR with current-generation self-expanding THVs.

A multi-modality approach for enhancing 4D flow magnetic resonance imaging via sparse representation.

This work evaluates and applies a multi-modality approach to enhance blood flow measurements and haemodynamic analysis with phase-contrast magnetic resonance imaging (4D flow MRI) in cerebral aneurysms (CAs). Using a library of high-resolution velocity fields from patient-specific computational fluid dynamic simulations and in vitro particle tracking velocimetry measurements, the flow field of 4D flow MRI data is reconstructed as the sparse representation of the library. The method was evaluated with synthetic 4D flow MRI data in two CAs. The reconstruction enhanced the spatial resolution and velocity accuracy of the synthetic MRI data, leading to reliable pressure and wall shear stress (WSS) evaluation. The method was applied on in vivo 4D flow MRI data acquired in the same CAs. The reconstruction increased the velocity and WSS by 6-13% and 39-61%, respectively, suggesting that the accuracy of these quantities was improved since the raw MRI data underestimated the velocity and WSS by 10-20% and 40-50%, respectively. The computed pressure fields from the reconstructed data were consistent with the observed flow structures. The results suggest that using the sparse representation flow reconstruction with in vivo 4D flow MRI enhances blood flow measurement and haemodynamic analysis.

Patient-specific computer simulation to predict long-term outcomes after transcatheter aortic valve replacement

BackgroundPatient-specific computer simulation may predict the development of paravalvular regurgitation (PVR) after transcatheter aortic valve replacement (TAVR). We hypothesised that patient-specific computer simulation might identify patients at risk for long-term adverse outcomes after TAVR. MethodsA multi-centre retrospective study was performed on patients with symptomatic severe aortic stenosis who had undergone TAVR with a self-expanding transcatheter heart valve (THV). Pre-procedural cardiac computed tomography imaging was used to create finite element models of the aortic root. Finite element analysis (FEA) was performed in order to simulate the interaction between the THV and the native anatomy. The blood domain was extracted from the FEA output and computational fluid dynamics (CFD) simulation undertaken. Predicted PVR was recorded in the left ventricular outflow tract. Patients were classified into those where computer simulation predicted no significant PVR (predicted PVR from CFD <16.0 ​mL/s) and those where computer simulation predicted significant PVR (predicted PVR from CFD ≥16.0 ​mL/s). ResultsA total of 203 patients were included in the study. THVs implanted were CoreValve (n ​= ​20), Evolut R (n ​= ​90) and Evolut PRO (n ​= ​93). At 2 years, the Kaplan-Meier estimate of the rate of death from any cause was higher in the group where CFD simulation predicted significant PVR (35.8% vs. 16.3%; hazard ratio, 2.62; 95% confidence interval, 1.29 to 5.30; P ​= ​0.006 by log-rank test). ConclusionsComputer simulation may identify patients who are at a higher risk for death after TAVR.

Patient-Specific Computer Simulation to Optimize Transcatheter Heart Valve Sizing and Positioning in Bicuspid Aortic Valve

ABSTRACT Background Outcomes of transcatheter aortic valve replacement (TAVR) in bicuspid aortic valve (BAV) might be improved through better transcatheter heart valve (THV) sizing and positioning. Patient-specific computer simulation may be used to identify an optimal THV size and implant depth that minimizes paravalvular regurgitation. We sought to examine whether the usage of optimal THV sizing and positioning would be associated with improved clinical outcomes. Methods A multi-center retrospective study was performed on patients who had undergone TAVR in BAV. Finite element models of the aortic root were created and then finite element analysis was performed using different THV sizes and implant depths. Computational fluid dynamics was undertaken. Patients were classified as having optimal THV sizing and positioning if the predicted paravalvular regurgitation of the computer simulation corresponding to the implanted THV size and implant depth was within 5 mL/sec of the best possible computer simulation, and non-optimal if not. Clinical outcomes were compared between the two patient groups. Results A total of 50 patients were included in the study. Paravalvular regurgitation severity was higher in patients where non-optimal THV sizing and positioning was used (P < 0.001). At 2 years, the Kaplan-Meier estimate of the rate of death from any cause was higher in the group where non-optimal THV sizing and positioning was used (34.5% vs. 9.1%; hazard ratio, 6.23; 95% confidence interval, 1.04 to 37.44; P = 0.02 by log-rank test). Conclusion Computer simulation suggests that the usage of optimal THV sizing and positioning might improve clinical outcomes of TAVR in BAV. Abbreviations: AUC: area under the receiver operating characteristic curve; BAV: bicuspid aortic valve; BAVi: bicuspid aortic valve imaging; CI: confidence interval; CPI: contact pressure index; CT: computed tomography; TAVR: transcatheter aortic valve replacement; THV: transcatheter heart valve

Myocardial adaptation and exercise performance in patients with pulmonary arterial hypertension assessed with patient-specific computer simulations.

Myocardial function and exercise reserve are important determinants of outcome in pulmonary arterial hypertension (PAH) but are incompletely understood. For this study, we performed subject-specific computer simulations, based on invasive measurements and cardiac magnetic resonance imaging (CMR), to investigate whole circulation properties in PAH at rest and exercise and determinants of exercise reserve. CMR and right heart catheterization were performed in nine patients with idiopathic PAH, and CMR in 10 healthy controls. CMR during exercise was performed in seven patients with PAH. A full-circulation computer model was developed, and model parameters were optimized at the individual level. Patient-specific simulations were used to analyze the effect of right ventricular (RV) inotropic reserve on exercise performance. Simulations achieved a high consistency with observed data. RV contractile force was increased in patients with PAH (127.1 ± 28.7 kPa vs. 70.5 ± 14.5 kPa, P < 0.001), whereas left ventricular contractile force was reduced (107.5 ± 17.5 kPa vs. 133.9 ± 10.3 kPa, P = 0.002). During exercise, RV contractile force increased by 1.56 ± 0.17, P = 0.001. In silico experiments confirmed RV inotropic reserve as the important limiting factor for cardiac output. Subject-specific computer simulation of myocardial mechanics in PAH is feasible and can be used to evaluate myocardial performance. With this method, we demonstrate marked functional myocardial adaptation to PAH in the resting state, primarily composed of increased contractile force development by RV myofibers, and we show the negative impact of reduced RV inotropic reserve on cardiac output during exercise.NEW & NOTEWORTHY Computer simulations of the myocardial mechanics and hemodynamics of rest and exercise were performed in nine patients with pulmonary arterial hypertension and 10 control subjects, with the use of data from invasive catheterization and from cardiac magnetic resonance. This approach allowed a detailed analysis of myocardial adaptation to pulmonary arterial hypertension and showed how reduction in right ventricular inotropic reserve is the important limiting factor for an increase in cardiac output during exercise.

TCT-192 Patient-Specific Computer Simulation to Predict the Development of Conduction Disturbance Following Transcatheter Aortic Valve Replacement

TCT-192 Patient-Specific Computer Simulation to Predict the Development of Conduction Disturbance Following Transcatheter Aortic Valve Replacement

Force distribution within the frame of self-expanding transcatheter aortic valve: Insights from in-vivo finite element analysis

We sought to assess the amount and distribution of force on the valve frame after transcatheter aortic valve replacement (TAVR) via patient-specific computer simulation. Patients successfully treated with the self-expanding Venus A-Valve and multislice computed tomography (MSCT) pre- and post-TAVR were retrospectively included. Patient-specific finite element models of the aortic root and prosthesis were constructed. The force (in Newton) on the valve frame was derived at every 3 mm from the inflow and at every 22.5° on each level. Twenty patients of whom 10 had bicuspid aortic valve (BAV) were analyzed. The total force on the frame was 74.9 N in median (interquartile range 24.0). The maximal force was observed at level 5 that corresponds with the nadir of the bioprosthetic leaflets and was 9.9 (7.1) N in all patients, 10.3 (6.6) N in BAV and 9.7 (9.2) N for patients with tricuspid aortic valve (TAV). The level of maximal force located higher from the native annulus in BAV and TAV patients (8.8 [4.8] vs. 1.8 [7.4] mm). The area of the valve frame at the level of maximal force decreased from 437.4 (239.7) mm2 at the annulus to 377.6 (114.3) mm2 in BAV, but increased from 397.5 (114.3) mm2 at the annulus to 406.7 (108.9) mm2 in TAV. The maximum force on the bioprosthetic valve frame is located at the plane of the nadir of the bioprosthetic leaflets. It remains to be elucidated whether this may be associated with bioprosthetic frame and leaflet integrity and/or function.