Blood Stasis on Transcatheter Valve Leaflets and Implications for Valve-in-Valve Leaflet Thrombosis Koohyar Vahidkhah, PhD, Shahnaz Javani, MS, Mostafa.

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Blood Stasis on Transcatheter Valve Leaflets and Implications for Valve-in-Valve Leaflet Thrombosis Koohyar Vahidkhah, PhD, Shahnaz Javani, MS, Mostafa Abbasi, MS, Peyman N. Azadani, MD, Anwar Tandar, MD, Danny Dvir, MD, Ali N. Azadani, PhD The Annals of Thoracic Surgery Volume 104, Issue 3, Pages 751-759 (September 2017) DOI: 10.1016/j.athoracsur.2017.02.052 Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 (a) Thrombotic material adhered to the three leaflets of the Sapien XT after valve-in-valve in the CoreValve. (Reprinted from [8] with permission from Elsevier.) (b) Note the greater presence of a red-brown post–transcatheter aortic valve replacement thrombus (red arrow) on the aortic surface of the right coronary cusp (RCC) of the CoreValve. (Reprinted from [7] with permission from Elsevier.) (LCC = left coronary cusp; NCC = noncoronary cusp.) (c) The aortic portion of the transcatheter aortic valve stent frame is circumferentially surrounded by leaflets and frame of the degenerated bioprosthesis in the valve-in-valve setting. (Reprinted from Silva D, Stripling JH, Hansen L, Riess FC. Aortic valve replacement after transapical valve-in-valve implantation. Ann Thorac Surg 2011;91:E5–7, with permission from The Society of Thoracic Surgeons.) (d) The aortic portion of the transcatheter aortic valve stent frame is circumferentially surrounded by the calcified leaflets in transcatheter aortic valve replacement. (Reprinted from Krishnaswamy A, Tuzcu EM, Kapadia SR. Percutaneous paravalvular leak closure. Curr Treat Options Cardiovasc Med 2013;15:565–74, with permission of Springer.) Short axis cut off at 12–3–6–9 o'clock positions. (L = left coronary cusp; N = noncoronary cusp; R = right coronary cusp.) The Annals of Thoracic Surgery 2017 104, 751-759DOI: (10.1016/j.athoracsur.2017.02.052) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 (a) Construction of the three-dimensional patient-specific geometry through processing of computed tomography angiography images. (b) Computational three-dimensional models for the surgical aortic valve (SAV [left]) and the transcatheter aortic valve (TAV [right]). In the TAV model, the confining geometry was created represents the leaflets and frame of the failed bioprosthesis in the valve-in-valve setting (top right). It may also represent the leaflets of the native valve in TAV replacement with intraannular function of TAV devices (bottom right). The Annals of Thoracic Surgery 2017 104, 751-759DOI: (10.1016/j.athoracsur.2017.02.052) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 (a) Comparison of the in vitro leaflet motion and deformation with the finite element simulation throughout a complete cardiac cycle. (b) Comparison of the in vitro particle image velocimetry measurement of the detailed flow structure (left) with the computational fluid dynamics simulation results for the flow structure (right) at a time instant during opening. The flow configuration is represented by contours of the flow velocity magnitude and the streamlines in the midplane longitudinally cutting through the computational domain. (Modified with permission from Koohyar Vahidkhah, Mohammed Barakat, Mostafa Abbasi, Shahnaz Javani, Peyman N. Azadani, Anwar Tandar, Danny Dvir, Ali N. Azadani; Valve thrombosis following transcatheter aortic valve replacement: significance of blood stasis on the leaflets. Eur J Cardiothorac Surg 2017;51(5):927–35.) The Annals of Thoracic Surgery 2017 104, 751-759DOI: (10.1016/j.athoracsur.2017.02.052) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Snapshots showing the configuration of the flow field and the particles released on the leaflets at different time instances during forward flow in a cardiac cycle for (a) the surgical aortic valve (SAV) model and (b) the transcatheter aortic valve (TAV) model. The Annals of Thoracic Surgery 2017 104, 751-759DOI: (10.1016/j.athoracsur.2017.02.052) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Snapshots showing the configuration of the flow field and the particles released on the leaflets at different time instances during diastole in a cardiac cycle for (a) the surgical aortic valve (SAV) model and (b) the transcatheter aortic valve (TAV) model. The Annals of Thoracic Surgery 2017 104, 751-759DOI: (10.1016/j.athoracsur.2017.02.052) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 6 Comparison of the surface averaged blood residence time (BRT) on the noncoronary leaflet (black lines), right coronary leaflet (red lines), and left coronary valve leaflets (green lines) in (a) the surgical aortic valve (SAV) model and (b) the transcatheter aortic valve (TAV) model during a complete cardiac cycle. The Annals of Thoracic Surgery 2017 104, 751-759DOI: (10.1016/j.athoracsur.2017.02.052) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 7 Snapshots showing the time evolution of the contours of blood residence time on the valve leaflets for (a) the surgical aortic valve (SAV) model and (b) the transcatheter aortic valve (TAV) model during a complete cardiac cycle. The Annals of Thoracic Surgery 2017 104, 751-759DOI: (10.1016/j.athoracsur.2017.02.052) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 8 Contours of blood residence time on the valve leaflets and aortic sinuses at the end of diastole for the surgical aortic valve (SAV) model (left) and the transcatheter aortic valve (TAV) model (right). The Annals of Thoracic Surgery 2017 104, 751-759DOI: (10.1016/j.athoracsur.2017.02.052) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Supplemental Figure 1 The Annals of Thoracic Surgery 2017 104, 751-759DOI: (10.1016/j.athoracsur.2017.02.052) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions