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Cardiovascualar Diagnosis and Endoluminal Interventions Unit, Rovigo General Hospital, Italy

Busan 9-10 December 2016. Gianluca Rigatelli, MD, PhD, EBIR, FACC, FESC, FSCAI. Computed Flow Dynamic i n I nterventional C ardiology : coronary stenting , peripheral stenting , percutaneous valve implantation. Cardiovascualar Diagnosis and Endoluminal Interventions Unit,

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Cardiovascualar Diagnosis and Endoluminal Interventions Unit, Rovigo General Hospital, Italy

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  1. Busan 9-10 December2016 Gianluca Rigatelli, MD, PhD, EBIR, FACC, FESC, FSCAI Computed Flow Dynamicin InterventionalCardiology: coronarystenting, peripheralstenting, percutaneous valve implantation Cardiovascualar Diagnosis and EndoluminalInterventions Unit, Rovigo General Hospital, Italy

  2. What is CFD? Computational model of different forces and parameter involved in the fluid dynamic within a chamber or a vessel before and after surgical or interventional modification virtually simulated The software is able to calculate any parameter, given an anatomic model, some physiologic parameters, and the interventional or sugical technique to be tested.

  3. Fields of application of CFD • Coronary vessels included bifurcation • Abdominal aorta • Ascending and descending Thoracic aorta • Aortic and mitral valve • Peripheral vessels

  4. Why Computed flow dynamic? Reasons to approach interventional cardiology by CFD 1. It is extremely difficult to assess flow dynamic in vivo 2. Randomized trial comparing different techniques in interventional cardiology in vivo are extremely expensive and probably meaningless bacause of the extreme variability of anatomy/pathology 3. Deviation from the physiology may be assessed in a very cheap way with CFD

  5. Computed flow dynamic in coronary bifurcation

  6. Computed flow dynamic in coronary bifurcation

  7. Computed flow dynamic in coronary bifurcation Coronary bifurcation Model • left anterior descending diagonal bifurcation • the proximal main branch (PMB) is 3.5 mm while the diameter of the side branch (SB) is 2.5 mm

  8. Computed flow dynamic in coronary bifurcation - + Considered fluid parameters • Static pressure (Pa) • Reynolds number • Vorticity magnitude (1/s) • Stream function (Kg/s) • Strain rate (1/s) • Wall shear stress (Pa) • Skin friction coefficient Absolute number physiology - +

  9. Computed flow dynamic in coronary bifurcation Medina 1,1,1 bifurcation type with a stenosis of 80% at the proximal MB, 80% at the SB, and a stenosis of 80% at the distal MB

  10. Computed flow dynamic in coronary bifurcation

  11. Computed flow dynamic in coronary bifurcation Stent simulation the strut design and linkage pattern of a third-generation, everolimus-elunting stent (ORSIRO stent, Biotronik IC, Bulack, Switzerland), used in our institution. In particular, the strut thickness is characterized by a very ultrathin strut (60 µm up to 3.0 mm diameter stent and 80µm up to 4.0 mm stent) Virtual implantation After placed the stent model in the correct position, according to the different stenting techniques, material removal, depending on the considering techniques was applied. Using Boolean operation, the modified solid model is subtracted from the bifurcation model to obtain the final geometry

  12. Double stenting techniques Comparison among the 4 Techniques with and without additional POT: Deviation from the phyological model

  13. Which technique is the most physiological? General comments • Before final POT, the Nano-Crush and the Modified T techniques appeared to have the most phyisiologic fluid dynamic profile • After additional final POT, while the Nano-crush and the modified T reported no changes or little changes in almost all the fluid parameters, the DK-crush and in particular the Culotte techniques reported the highest increase • Any stenting technique destroy the physiological flow, as the values of the fluid parameters increase, the deviation from the physiology towards non-physiologic flow dynamic tend to increase with a gradient from Nano-crush to Culotte.

  14. Computed flow dynamic in peripheral interventions Iliac stenting

  15. Computed flow dynamic in peripheral interventions: iliac stenting

  16. Computed flow dynamic in peripheral interventions: iliac stenting

  17. Computed flow dynamic in peripheral interventions: Aortic aneurysm repair

  18. Computed flow dynamic in peripheral interventions: Aortic aneurysm repair

  19. Computed flow dynamic in peripheral interventions: Aortic aneurysm repair

  20. Computed flow dynamic in valvular interventions

  21. Computed flow dynamic in Congenital heart interventions

  22. Computed flow dynamic in valvular interventions

  23. CONCLUSIONS…. • ALTHOUGH OF LIMITED PRACTICAL VALUE, CFD GIVE AT LEAST AN IDEA OF HOW MUCH THE INTERVENTIONAL TECHNIQUES ARE ADHERENT TO PHYSIOLOGY • CFD SEEMS OF PRACTICAL VALUE IN CORONARY BIFURCATION, PERIPHERAL STENTING, AORTIC ANEURYSM REPAIR AND VALVE IMPLANTATION • FUTURE APPLICATIONS OF CFD MIGHT INCLUDE CALCULATION OF FLOW DYNAMICS COMBINED WITH ANGIOGRAPHY OR IVUS/OCT IN VIVO

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