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Impact of assuming a circular orifice on flow error through elliptical regurgitant orifices: computational fluid dynamics and in vitro analysis of proximal flow convergence

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Abstract

Grounded in hydrodynamic theory, proximal isovelocity surface area (PISA) is a simplistic and practical technique widely used to quantify valvular regurgitation flow. PISA provides a relatively reasonable, though slightly underestimated flow rate for circular orifices. However, for elliptical orifices frequently seen in functional mitral regurgitation, PISA underestimates the flow rate. Based on data obtained with computational fluid dynamics (CFD) and in vitro experiments using systematically varied orifice parameters, we hypothesized that flow rate underestimation for elliptical orifices by PISA is predictable and within a clinically acceptable range. We performed 45 CFD simulations with varying orifice areas 0.1, 0.3 and 0.5 cm2, orifice aspect ratios 1:1, 2:1, 3:1, 5:1, and 10:1, and peak velocities (Vmax) 400, 500 and 600 cm/s. The ratio of computed effective regurgitant orifice area to true effective area (EROAC/EROA) against the ratio of aliasing velocity to peak velocity (VA/Vmax) was analyzed for orifice shape impact. Validation was conducted with in vitro imaging in round and 3:1 elliptical orifices. Plotting EROAC/EROA against VA/Vmax revealed marginal flow underestimation with 2:1 and 3:1 elliptical axis ratios against a circular orifice (< 10% for 8% VA/Vmax), rising to ≤ 35% for 10:1 ratio. In vitro modeling confirmed CFD findings; there was a 8.3% elliptical EROA underestimation compared to the circular orifice estimate. PISA quantification for regurgitant flow through elliptical orifices produces predictable, but generally small, underestimation deemed clinically acceptable for most regurgitant orifices.

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Funding

Dr. James Thomas is supported by the Irene D. Pritzker Foundation and by grants from Abbott Vascular and GE Medical. Dr. Greg Wagner is supported by a grant from Abbott Vascular. Dr. Alex Barker is supported by NIH NHLBI Grants K25HL119608 & R01HL133504. Dr. Michael Markl is supported by NIH NHLBI Grants R01HL115828.

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Author notes

  1. Sumeet S. Mitter

    Present address: Division of Cardiology, Department of Medicine, Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, 1190 5th Avenue, New York, NY, 10029, USA

  2. Lowie Van Assche

    Present address: Cardiovascular Medicine Associates PA, 6200 Sunset Dr Ste 401, South Miami, FL, 33143, USA

  3. Hyungkyu Huh

    Present address: Medical Device Development Center, Daegu-Gyungbuk Medical Innovation Foundation, Cheombok-ro 80, Dae-gu, South Korea

  4. Alex J. Barker

    Present address: Department of Radiology and Bioengineering, University of Colorado, Anschutz Medical Campus, 13123 E 16th Ave B125, Aurora, CO, 80045, USA

Authors and Affiliations

  1. Division of Cardiology, Department of Medicine, Bluhm Cardiovascular Institute, Feinberg School of Medicine, Northwestern University, 676 N. St. Claire Street, Suite 600, Chicago, IL, 60611, USA

    Sumeet S. Mitter, Lowie Van Assche, Erik Wu & James D. Thomas

  2. Department of Radiology, Feinberg School of Medicine, Northwestern University, 767 N. Michigan Avenue, Suite 1600, Chicago, IL, 60611, USA

    Jeesoo Lee, Hyungkyu Huh, Alex J. Barker & Michael Markl

  3. Department of Mechanical Engineering, McCormick School of Engineering and Applied Science, Northwestern University, 2145 Sheridan Road, Evanston, IL, 60208, USA

    Gregory J. Wagner

  4. Department of Biomedical Engineering, McCormick School of Engineering, Northwestern University, Evanston, IL, USA

    Michael Markl

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Correspondence to James D. Thomas.

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Conflict of interest

Dr. Thomas reports consulting fees from Abbott Vascular, egnite, GE Medical, EchoIQ and Caption Health and spouse employment with Caption Health. Dr. Mitter reports honoraria from Alnylam and the National Minority Quality Forum.

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Lee, J., Mitter, S.S., Van Assche, L. et al. Impact of assuming a circular orifice on flow error through elliptical regurgitant orifices: computational fluid dynamics and in vitro analysis of proximal flow convergence. Int J Cardiovasc Imaging 39, 307–318 (2023). https://doi.org/10.1007/s10554-022-02729-2

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