Improving transcatheter aortic valve interventional predictability via fluid-structure interaction modelling using patient-specific anatomy

Transcatheter aortic valve replacement (TAVR) is now a standard treatment for high-surgical-risk patients with severe aortic valve stenosis. TAVR is being explored for broader indications including degenerated bioprosthetic valves, bicuspid valves and for aortic valve (AV) insufficiency. It is, however, challenging to predict whether the chosen valve size, design or its orientation would produce the most-optimal haemodynamics in the patient. Here, we present a novel patient-specific evaluation framework to realistically predict the patient\u27s AV performance with a high-fidelity fluid-structure interaction analysis that included the patient\u27s left ventricle and ascending aorta (AAo). We retrospectively evaluated the pre- and post-TAVR dynamics of a patient who underwent a 23 mm TAVR and evaluated against the patient\u27s virtually de-calcified AV serving as a hypothetical benchmark. Our model predictions were consistent with clinical data. Stenosed AV produced a turbulent flow during peak-systole, while aortic flow with TAVR and de-calcified AV were both in the laminar-to-turbulent transitional regime with an estimated fivefold reduction in viscous dissipation. For TAVR, dissipation was highest during early systole when valve deformation was the greatest, suggesting that an efficient valve opening may reduce energy loss. Our study demonstrates that such patient-specific modelling frameworks can be used to improve predictability and in the planning of AV interventions

1004-59 Vascular Acoustic Emissions During Angioplasty: Potential Role in Identification of Induced Dissection

A fundamental mechanism of balloon angioplasty (BA) is plaque rupture. Rupture leading to dissection, however, has been implicated as an underlyIng factor responsible for both acute and chronic adverse outcomes. Acoustic emissions (AE) — transient sound waves generated by microstructural alterations of a material subjected to mechanical stress — may provide a novel means of characterizing BA-induced tissue trauma. Using a novel acoustic sensor system, we examined the relationship between cumulative AE energy released by human arterial tissue during BA and the observed pathologic injury. Post-mortem human arterial specimens (19) were subjected to identical SA with simultaneous monitoring of intraluminal pressure and AE. Sound energy was integrated throughout the pressurization period to obtain an estimate of the cumulative AE energy released during dilatation. Postangioplasty inspection revealed a marked difference in AE energy released by specimens that experienced traumatic dissection vs. non-dissection dilatation:Sound energy released by vascular tissue undergoing balloon angioplasty discriminates dissection from non-dissection tissue trauma. Given the deleterious role that dissection can play in SA, this novel system may provide a means of improving procedural outcome

Subcellular fractionation method to study endosomal trafficking of Kaposi’s sarcoma-associated herpesvirus

Background Virus entry involves multiple steps and is a highly orchestrated process on which successful infection collectively depends. Entry processes are commonly analyzed by monitoring internalized virus particles via Western blotting, polymerase chain reaction, and imaging techniques that allow scientist to track the intracellular location of the pathogen. Such studies have provided abundant direct evidence on how viruses interact with receptor molecules on the cell surface, induce cell signaling at the point of initial contact with the cell to facilitate internalization, and exploit existing endocytic mechanisms of the cell for their ultimate infectious agenda. However, there is dearth of knowledge in regards to trafficking of a virus via endosomes. Herein, we describe an optimized laboratory procedure to isolate individual organelles during different stages of endocytosis by performing subcellular fractionation. This methodology is established using Kaposi’s sarcoma-associated herpesvirus (KSHV) infection of human foreskin fibroblast (HFF) cells as a model. With KSHV and other herpesviruses alike, envelope glycoproteins have been widely reported to physically engage target cell surface receptors, such as integrins, in interactions leading to entry and subsequent infection. Results Subcellular fractionation was used to isolate early and late endosomes (EEs and LEs) by performing a series of centrifugations steps. Specifically, a centrifugation step post-homogenization was utilized to obtain the post-nuclear supernatant containing intact intracellular organelles in suspension. Successive fractionation via sucrose density gradient centrifugation was performed to isolate specific organelles including EEs and LEs. Intracellular KSHV trafficking was directly traced in the isolated endosomal fractions. Additionally, the subcellular fractionation approach demonstrates a key role for integrins in the endosomal trafficking of KSHV. The results obtained from fractionation studies corroborated those obtained by traditional imaging studies. Conclusions This study is the first of its kind to employ a sucrose flotation gradient assay to map intracellular KSHV trafficking in HFF cells. We are confident that such an approach will serve as a powerful tool to directly study intracellular trafficking of a virus, signaling events occurring on endosomal membranes, and dynamics of molecular events within endosomes that are crucial for uncoating and virus escape into the cytosol

Imaging Single Retrovirus Entry through Alternative Receptor Isoforms and Intermediates of Virus-Endosome Fusion

A large group of viruses rely on low pH to activate their fusion proteins that merge the viral envelope with an endosomal membrane, releasing the viral nucleocapsid. A critical barrier to understanding these events has been the lack of approaches to study virus-cell membrane fusion within acidic endosomes, the natural sites of virus nucleocapsid capsid entry into the cytosol. Here we have investigated these events using the highly tractable subgroup A avian sarcoma and leukosis virus envelope glycoprotein (EnvA)-TVA receptor system. Through labeling EnvA pseudotyped viruses with a pH-sensitive fluorescent marker, we imaged their entry into mildly acidic compartments. We found that cells expressing the transmembrane receptor (TVA950) internalized the virus much faster than those expressing the GPI-anchored receptor isoform (TVA800). Surprisingly, TVA800 did not accelerate virus uptake compared to cells lacking the receptor. Subsequent steps of virus entry were visualized by incorporating a small viral content marker that was released into the cytosol as a result of fusion. EnvA-dependent fusion with TVA800-expressing cells occurred shortly after endocytosis and delivery into acidic endosomes, whereas fusion of viruses internalized through TVA950 was delayed. In the latter case, a relatively stable hemifusion-like intermediate preceded the fusion pore opening. The apparent size and stability of nascent fusion pores depended on the TVA isoforms and their expression levels, with TVA950 supporting more robust pores and a higher efficiency of infection compared to TVA800. These results demonstrate that surface receptor density and the intracellular trafficking pathway used are important determinants of efficient EnvA-mediated membrane fusion, and suggest that early fusion intermediates play a critical role in establishing low pH-dependent virus entry from within acidic endosomes

Effects of fluoxetine on functional outcomes after acute stroke (FOCUS): a pragmatic, double-blind, randomised, controlled trial

Background Results of small trials indicate that fluoxetine might improve functional outcomes after stroke. The FOCUS trial aimed to provide a precise estimate of these effects. Methods FOCUS was a pragmatic, multicentre, parallel group, double-blind, randomised, placebo-controlled trial done at 103 hospitals in the UK. Patients were eligible if they were aged 18 years or older, had a clinical stroke diagnosis, were enrolled and randomly assigned between 2 days and 15 days after onset, and had focal neurological deficits. Patients were randomly allocated fluoxetine 20 mg or matching placebo orally once daily for 6 months via a web-based system by use of a minimisation algorithm. The primary outcome was functional status, measured with the modified Rankin Scale (mRS), at 6 months. Patients, carers, health-care staff, and the trial team were masked to treatment allocation. Functional status was assessed at 6 months and 12 months after randomisation. Patients were analysed according to their treatment allocation. This trial is registered with the ISRCTN registry, number ISRCTN83290762. Findings Between Sept 10, 2012, and March 31, 2017, 3127 patients were recruited. 1564 patients were allocated fluoxetine and 1563 allocated placebo. mRS data at 6 months were available for 1553 (99·3%) patients in each treatment group. The distribution across mRS categories at 6 months was similar in the fluoxetine and placebo groups (common odds ratio adjusted for minimisation variables 0·951 [95% CI 0·839–1·079]; p=0·439). Patients allocated fluoxetine were less likely than those allocated placebo to develop new depression by 6 months (210 [13·43%] patients vs 269 [17·21%]; difference 3·78% [95% CI 1·26–6·30]; p=0·0033), but they had more bone fractures (45 [2·88%] vs 23 [1·47%]; difference 1·41% [95% CI 0·38–2·43]; p=0·0070). There were no significant differences in any other event at 6 or 12 months. Interpretation Fluoxetine 20 mg given daily for 6 months after acute stroke does not seem to improve functional outcomes. Although the treatment reduced the occurrence of depression, it increased the frequency of bone fractures. These results do not support the routine use of fluoxetine either for the prevention of post-stroke depression or to promote recovery of function. Funding UK Stroke Association and NIHR Health Technology Assessment Programme

Effect of systolic flow rate on the prediction of effective prosthetic valve orifice area

The Gorlin equation for the hemodynamic assessment of valve area is commonly used in cardiac catheterization laboratories. A study was performed to test the prediction capabilities of the Gorlin formula as well as the Aaslid and Gabbay formula for the effective orifice area of prosthetic heart valves. Pressure gradient, flow, and valve opening area measurements were performed on four 27 mm valve prostheses (two mechanical bileaflet designs, St. Jude and Edwards-Duromedics, an Edwards pericardial tissue valve, and a trileaflet polyurethane valve) each mounted in the aortic position of an in vitro pulse duplicator. With the known valve orifice area, a different discharge coefficient was computed for each of the four valves and three orifice area formulas. After some theoretical considerations, it was proposed that the discharge coefficient would be a function of the flow rate through the valve. All discharge coefficients were observed to increase with increasing systolic flow rate. An empirical relationship of discharge coefficient as a linear function of systolic flow rate was determined through a regression analysis, with a different relationship for each valve and each orifice area formula. Using this relationship in the orifice area formulas improved the accuracy of the prediction of the effective orifice area with all three formulas performing equally well. © 1989

Velocity and turbulence measurements past mitrial valve prostheses in a model left ventricle

Thrombogenesis and hemolysis have both been linked to the flow dynamics past heart valve prostheses. To learn more about the particular flow dynamics past mitral valve prostheses in the left ventricle under controlled experimental conditions, an in vitro study was performed. The experimental methods included velocity and turbulent shear stress measurements past caged-ball, tilting disc, bileaflet, and polyurethane trileaflet mitral valves in an acrylic rigid model of the left ventricle using laser Doppler anemometry. The results indicate that all four prosthetic heart valves studied create at least mildly disturbed flow fields. The effect of the left ventricular geometry on the flow development is to produce a stabilizing vortex which engulfs the entire left ventricular cavity, depending on the orientation of the valve. The measured turbulent shear stress magnitudes for all four valves did not exceed the reported value for hemolytic damage. However, the measured turbulent shear stresses were near or exceeded the critical shear stress reported in the literature for platelet lysis, a known precursor to thrombus formation. © 1991

Prediction of stenotic valve orifice area: An in vitro study on a bioprosthesis

The Gorlin equation for the hemodynamic assessment of valve area is commonly used in cardiac catheterization laboratories. A study was performed to test the prediction capabilities of the Gorlin formula, as well as those of the Aaslid and Gabbay formulas for the effective orifice area of a porcine valve of varying degrees of stenosis. Pressure gradient, flow, and valve opening area measurements were performed on Carpentier‐Edwards porcine valve prostheses (made stenotic by suturing at the commissures) mounted in the aortic position of an in vitro pulse duplicator. With the known valve orifice area, a discharge coefficient was computed for each of the three orifice area formulas. After some theoretical considerations, it was proposed that the discharge coefficient would be a function of the flow rate through the valve. The discharge coefficient was observed to increase with increasing systolic flow rate. An empirical relationship of the discharge coefficient as a linear function of the systolic flow rate was determined through a regression analysis, with a different relationship for each orifice area formula. Using this relationship in the orifice area formulas improved the accuracy of the prediction of the effective orifice area with all three formulas performing equally well. Copyright © 1989 John Wiley & Sons, Ltd