Underfilled Balloon-Expandable Transcatheter Aortic Valve Implantation With Ad Hoc Post-Dilation - Pulsatile Flow Simulation Using a Patient-Specific Three-Dimensional Printing Model

Masahiro Yamawaki, Kazuto Obama, Saeko Sasuga, Azuma Takahashi, Yoshiaki Ito, Mitsuo Umezu, Kiyotaka Iwasaki

    Research output: Contribution to journalArticle

    Abstract

    BACKGROUND: Underfilled transcatheter aortic-valve implantation with ad hoc post-dilation is a therapeutic option for patients with borderline annuli to avoid acute complication. The effects of this technique on valve leaflet behavior, hydrodynamic performances, and paravalvular leakage (PVL) using patient-specific three-dimensional (3D) aortic-valve models were investigated. Methods and Results: A female octogenarian patient was treated with this technique by using a 23-mm Sapien-XT. Patient-specific models were constructed from pre-procedure computed tomography (CT) data. Change in aortic annulus areas during systolic/diastolic phases and post-procedure stent areas were adjusted to those of the patient. The following was performed: (1) -3 cc initial and -2 cc underfilled post-dilation to the scale-down model by adjusting percent oversizing; and (2) -1 cc initial underfilling, nominal volume, and repeat nominal volume post-dilation using the patient-specific model. Underfilling was associated with higher %PVL. Observation using a high-speed camera revealed distorted leaflets after underfilled implantation, with a longer valve-closing time and smaller effective orifice areas, especially in the -3 cc underfilled implantation. Micro-CT analysis revealed that the transcatheter valves shifted to the opposite side of the large annulus calcification after post-dilation and reduced the malapposition there. CONCLUSIONS: Excessive underfilled implantation showed unacceptable acute hemodynamics. Abnormal leaflet motions after underfilled implantation raised concerns about durability. Flow simulations using patient-oriented 3D models could help to investigate hemodynamics, leaflet motions, and the PVL mechanism.

    Original languageEnglish
    Pages (from-to)461-470
    Number of pages10
    JournalCirculation journal : official journal of the Japanese Circulation Society
    Volume83
    Issue number2
    DOIs
    Publication statusPublished - 2019 Jan 25

    Fingerprint

    Pulsatile Flow
    Dilatation
    Hemodynamics
    Tomography
    Patient Simulation
    Hydrodynamics
    Aortic Valve
    Stents
    Transcatheter Aortic Valve Replacement
    Three Dimensional Printing
    Observation

    Keywords

    • Ad hoc post-dilation
    • Paravalvular leakage
    • Pulsatile flow simulation
    • Transcatheter aortic valve implantation
    • Underfilled implantation

    ASJC Scopus subject areas

    • Cardiology and Cardiovascular Medicine

    Cite this

    @article{055bb25456b748b09e306a9bd3a164e9,
    title = "Underfilled Balloon-Expandable Transcatheter Aortic Valve Implantation With Ad Hoc Post-Dilation - Pulsatile Flow Simulation Using a Patient-Specific Three-Dimensional Printing Model",
    abstract = "BACKGROUND: Underfilled transcatheter aortic-valve implantation with ad hoc post-dilation is a therapeutic option for patients with borderline annuli to avoid acute complication. The effects of this technique on valve leaflet behavior, hydrodynamic performances, and paravalvular leakage (PVL) using patient-specific three-dimensional (3D) aortic-valve models were investigated. Methods and Results: A female octogenarian patient was treated with this technique by using a 23-mm Sapien-XT. Patient-specific models were constructed from pre-procedure computed tomography (CT) data. Change in aortic annulus areas during systolic/diastolic phases and post-procedure stent areas were adjusted to those of the patient. The following was performed: (1) -3 cc initial and -2 cc underfilled post-dilation to the scale-down model by adjusting percent oversizing; and (2) -1 cc initial underfilling, nominal volume, and repeat nominal volume post-dilation using the patient-specific model. Underfilling was associated with higher {\%}PVL. Observation using a high-speed camera revealed distorted leaflets after underfilled implantation, with a longer valve-closing time and smaller effective orifice areas, especially in the -3 cc underfilled implantation. Micro-CT analysis revealed that the transcatheter valves shifted to the opposite side of the large annulus calcification after post-dilation and reduced the malapposition there. CONCLUSIONS: Excessive underfilled implantation showed unacceptable acute hemodynamics. Abnormal leaflet motions after underfilled implantation raised concerns about durability. Flow simulations using patient-oriented 3D models could help to investigate hemodynamics, leaflet motions, and the PVL mechanism.",
    keywords = "Ad hoc post-dilation, Paravalvular leakage, Pulsatile flow simulation, Transcatheter aortic valve implantation, Underfilled implantation",
    author = "Masahiro Yamawaki and Kazuto Obama and Saeko Sasuga and Azuma Takahashi and Yoshiaki Ito and Mitsuo Umezu and Kiyotaka Iwasaki",
    year = "2019",
    month = "1",
    day = "25",
    doi = "10.1253/circj.CJ-18-0582",
    language = "English",
    volume = "83",
    pages = "461--470",
    journal = "Circulation Journal",
    issn = "1346-9843",
    publisher = "Japanese Circulation Society",
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    TY - JOUR

    T1 - Underfilled Balloon-Expandable Transcatheter Aortic Valve Implantation With Ad Hoc Post-Dilation - Pulsatile Flow Simulation Using a Patient-Specific Three-Dimensional Printing Model

    AU - Yamawaki, Masahiro

    AU - Obama, Kazuto

    AU - Sasuga, Saeko

    AU - Takahashi, Azuma

    AU - Ito, Yoshiaki

    AU - Umezu, Mitsuo

    AU - Iwasaki, Kiyotaka

    PY - 2019/1/25

    Y1 - 2019/1/25

    N2 - BACKGROUND: Underfilled transcatheter aortic-valve implantation with ad hoc post-dilation is a therapeutic option for patients with borderline annuli to avoid acute complication. The effects of this technique on valve leaflet behavior, hydrodynamic performances, and paravalvular leakage (PVL) using patient-specific three-dimensional (3D) aortic-valve models were investigated. Methods and Results: A female octogenarian patient was treated with this technique by using a 23-mm Sapien-XT. Patient-specific models were constructed from pre-procedure computed tomography (CT) data. Change in aortic annulus areas during systolic/diastolic phases and post-procedure stent areas were adjusted to those of the patient. The following was performed: (1) -3 cc initial and -2 cc underfilled post-dilation to the scale-down model by adjusting percent oversizing; and (2) -1 cc initial underfilling, nominal volume, and repeat nominal volume post-dilation using the patient-specific model. Underfilling was associated with higher %PVL. Observation using a high-speed camera revealed distorted leaflets after underfilled implantation, with a longer valve-closing time and smaller effective orifice areas, especially in the -3 cc underfilled implantation. Micro-CT analysis revealed that the transcatheter valves shifted to the opposite side of the large annulus calcification after post-dilation and reduced the malapposition there. CONCLUSIONS: Excessive underfilled implantation showed unacceptable acute hemodynamics. Abnormal leaflet motions after underfilled implantation raised concerns about durability. Flow simulations using patient-oriented 3D models could help to investigate hemodynamics, leaflet motions, and the PVL mechanism.

    AB - BACKGROUND: Underfilled transcatheter aortic-valve implantation with ad hoc post-dilation is a therapeutic option for patients with borderline annuli to avoid acute complication. The effects of this technique on valve leaflet behavior, hydrodynamic performances, and paravalvular leakage (PVL) using patient-specific three-dimensional (3D) aortic-valve models were investigated. Methods and Results: A female octogenarian patient was treated with this technique by using a 23-mm Sapien-XT. Patient-specific models were constructed from pre-procedure computed tomography (CT) data. Change in aortic annulus areas during systolic/diastolic phases and post-procedure stent areas were adjusted to those of the patient. The following was performed: (1) -3 cc initial and -2 cc underfilled post-dilation to the scale-down model by adjusting percent oversizing; and (2) -1 cc initial underfilling, nominal volume, and repeat nominal volume post-dilation using the patient-specific model. Underfilling was associated with higher %PVL. Observation using a high-speed camera revealed distorted leaflets after underfilled implantation, with a longer valve-closing time and smaller effective orifice areas, especially in the -3 cc underfilled implantation. Micro-CT analysis revealed that the transcatheter valves shifted to the opposite side of the large annulus calcification after post-dilation and reduced the malapposition there. CONCLUSIONS: Excessive underfilled implantation showed unacceptable acute hemodynamics. Abnormal leaflet motions after underfilled implantation raised concerns about durability. Flow simulations using patient-oriented 3D models could help to investigate hemodynamics, leaflet motions, and the PVL mechanism.

    KW - Ad hoc post-dilation

    KW - Paravalvular leakage

    KW - Pulsatile flow simulation

    KW - Transcatheter aortic valve implantation

    KW - Underfilled implantation

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    U2 - 10.1253/circj.CJ-18-0582

    DO - 10.1253/circj.CJ-18-0582

    M3 - Article

    VL - 83

    SP - 461

    EP - 470

    JO - Circulation Journal

    JF - Circulation Journal

    SN - 1346-9843

    IS - 2

    ER -