The Influence of Mitral Annuloplasty on Left Ventricular Flow Dynamics

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Presentation transcript:

The Influence of Mitral Annuloplasty on Left Ventricular Flow Dynamics Walter R.T. Witschey, PhD, Donald Zhang, Francisco Contijoch, MS, Jeremy R. McGarvey, MD, Madonna Lee, MD, Satoshi Takebayashi, MD, Chikashi Aoki, MD, Yuchi Han, MD, MMS, Joyce Han, Alex J. Barker, PhD, James J. Pilla, PhD, Robert C. Gorman, MD, Joseph H. Gorman, MD The Annals of Thoracic Surgery Volume 100, Issue 1, Pages 114-121 (July 2015) DOI: 10.1016/j.athoracsur.2015.02.028 Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Methods for analysis of diastolic blood flow and assessment of inflow angle. (a) Streamlines showing the orientation of the flow field during mid diastole. S indicates the surface positioned at the vena contracta for assessment of peak inflow velocity. (b) Cine magnetic resonance image of the position of the left ventricle (LV) and left atrium (LA) in a four-chamber perspective, indicating the relative orientation of the left heart chambers in (a). (c) Calculation of the diastolic inflow angle α between the line intersecting the mitral coaptation point and apex and the line parallel to flow at the vena contracta (VC). (Ao = aorta.) (d) Cine magnetic resonance image of the position of the LV and LA in a three-chamber perspective, indicating the relative orientation of the left heart chambers in (c). The Annals of Thoracic Surgery 2015 100, 114-121DOI: (10.1016/j.athoracsur.2015.02.028) Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Left ventricular (LV) flow dynamics (a–c) before and (d–f) 1 week after mitral valve (MV) annuloplasty ring placement with an undersized 24-mm Physio annuloplasty ring. Cardiac phases are indicated (a, d) mid diastole, (b, e) late diastole, and (c, f) early systole. (a) Counterrotating vortices are positioned distal to the anterior and posterior MV leaflets, as seen from a three-chamber perspective. (Ao = aorta; LA = left atrium; RV = right ventricle.) (b, c) The vortices reduce intensity and unwind, as blood is redirected toward the LV outflow tract. In (d), there is a single prominent posterior vortex after annuloplasty replacement. In (e), the posterior vortex continues to circulate deep into the apex throughout diastole, sustained by MV stenosis, and in (f) is unwound in early systole. Arrows indicate the pathline direction. Animations of LV hemodynamics at baseline and postsurgery are provided in Videos 1 and 2. The Annals of Thoracic Surgery 2015 100, 114-121DOI: (10.1016/j.athoracsur.2015.02.028) Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Left ventricular (LV) hemodynamics (a–c) before and (d–f) 1 week after mitral valve (MV) annuloplasty ring placement with a 26-mm Physio annuloplasty ring. Cardiac phases are indicated (a, d) mid diastole, (b, e) late diastole, and (c, f) early systole. (a) Counterrotating vortices are positioned distal to the anterior and posterior MV leaflets, as seen from a three-chamber perspective. (Ao = aorta; LA = left atrium; RV = right ventricle.) (b, c) The vortices reduce intensity and unwind, as blood is redirected toward the LV outflow tract. (d) After MV annuloplasty ring placement, diastolic flow is oriented toward the septum (cf Fig 3a), although the overall peak velocity is reduced and reorientation of flow is somewhat reduced compared with the 24-mm undersized ring (cf Fig 2d). (e, f) A single vortex distal to the MV, rotating counterclockwise, is sustained during late diastole and is unwound toward the LV outflow tract in systole. Arrows indicate the pathline direction. Animations of LV hemodynamics at baseline and after surgery are provided in Videos 3 and 4. The Annals of Thoracic Surgery 2015 100, 114-121DOI: (10.1016/j.athoracsur.2015.02.028) Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Left ventricular (LV) hemodynamics (a–c) before and (d–f) 1 week after mitral valve (MV) annuloplasty ring placement with a 32-mm Physio annuloplasty ring. Cardiac phases are indicated (a, d) mid diastole, (b, e) late diastole, and (c, f) early systole. (a–c) Normal hemodynamics resemble those of other animals (cf Figs 2 and 3). (Ao = aorta; LA = left atrium; RV = right ventricle.) (d) As compared with 24-mm and 26-mm undersized Physio rings (cf Fig 2d and 3d, respectively), the 32-mm ring preserves normal mid diastolic hemodynamics at higher peak velocity. Anterior and posterior counterrotating vortices resemble hemodynamics of a normal animal. (e) In late diastole, the counterrotating vortices propagate toward the apex and reverse rotation. (f) Vortices reduce intensity and unwind flow directed toward the outflow tract in early systole. Arrows indicate the pathline direction. Animations of LV hemodynamics at baseline and after surgery are provided in Videos 5 and 6. The Annals of Thoracic Surgery 2015 100, 114-121DOI: (10.1016/j.athoracsur.2015.02.028) Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 (a) Influence of ring size on inflow angle and (b) peak diastolic velocity, as measured at the vena contracta, before (blue circles) and after (red circles) annuloplasty ring placement for all five ring sizes. The x-axis refers to postsurgery ring area. A correlation between peak velocity and ring area was observed for all rings. The Annals of Thoracic Surgery 2015 100, 114-121DOI: (10.1016/j.athoracsur.2015.02.028) Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions