Patent Application
20200364936
The present invention relates to the field of pre-operative planning of trans-catheter valve implantation.
The left ventricle of the heart pumps the blood to the aorta through the aortic valve. Aortic (valve) stenosis is a pathology occurring when the aortic valve does not open fully because the leaflets calcify, thicken and stiffen and, as a result, the blood flow going from the heart to the systemic circulation decreases. Aortic stenosis manifests itself in elderly people, with a prevalence going from 1.3% in over 65 and 4% in over 85 year old people. Currently it is the most common valvular heart disease in the Western world and its prevalence is increasing with the aging population.
The standard treatment for an aortic stenosis is the Surgical Aortic Valve Replacement (SAVR) aiming at reproducing the correct function of the native valve with an implanted valve. This invasive procedure requires total anesthesia, sternotomy (open-heart surgery) and cardiopulmonary bypass (the blood is pumped and oxygenated using an external machine), and is associated with about 6% in-hospital mortality for over 65 year old patients. Moreover, at least one-third of the patients with severe aortic stenosis are denied valve surgery as the risks associated with surgery are too high.
Trans-catheter aortic valve implantation (TAVI) or trans-catheter aortic valve repair (TAVR) is a minimally-invasive procedure for treating aortic stenosis: (1) the valve (e.g. a bioprosthetic valve made of porcine pericardium sutured on a metal stent) is crimped inside a catheter, (2) the catheter is inserted, for example, in the femoral artery, (3) pushed upstream along the aorta up to the aortic annulus and (4) the new valve is deployed within the diseased native valve. TAVI has the potential of treating high-risk patients and replacing the SAVR with a minimally-invasive intervention (no need for open-heart surgery or cardiopulmonary bypass) which can be performed in e.g. about 80 minutes.
Main TAVI complications are vascular injury, stroke, cardiac injury (heart block, coronary obstruction, cardiac perforation), aortic regurgitation, cardiac conduction abnormalities and valve misplacement. Accurate pre operative planning is crucial to select the optimal device size and to anticipate potential difficulties.
Unclersizing of a valve implant may lead to paravalvular aortic regurgitation, while oversizing may result in a rupture of the aortic annulus or in a suboptimal functional behavior of the implant. Currently available planning tools (Philips, Siemens, Pie Medical, Paeion) provide insights into the patient anatomy and can, for example, be used to determine the size of the aortic annulus, or to measure the distance between the valve plane and the coronary ostia. A problem with these tools is that they do not provide preoperative insights into the interaction between a certain implant device and the specific patient anatomy, and can thus not be used to predict complications such as regurgitation. Such insights are extremely valuable for interventional cardiologists.
Another problem is that is difficult to reconstruct native leaflets from e.g. CT images. In the currently deployed methods, an incomplete leaflet image is obtained, comprising gaps whereby the gaps represent a lack of data.
Document US 2011/0153286 A1 discloses a method and system for virtual percutaneous valve implantation. In one embodiment of the application a patient-specific anatomical model of a heart valve is estimated based on 3D cardiac medical image data. An implant model representing a valve implant is virtually deployed into the patient-specific anatomical model of the heart valve. A library of implant models, each modeling geometrical properties of a corresponding valve implant, can be maintained. The implant models maintained in the library can be virtually deployed into the patient specific anatomical model of the heart valve to select one of the implant models for use in a percutaneous valve implantation procedure.
US 2011/0153286 A1 does not provide a prediction of the mechanical behavior and interaction of the patient-specific aortic root, ascending aorta and aortic valve leaflets with the deployment of a valve implant. Said document also does not account for calcification of aortic valve leaflets. Neither does it provide a means to study the hemodynamic performance of an implant deployed in the aortic valve. Balloon-expandable devices whose deployment is based on permanent plastic deformations of the metal cannot be modeled.
There is a need for more precise valve sizing and positioning. Problem is that the aortic annulus is not circular, that the aortic annulus may deform and that calcium deposits may deform a valve frame.
Another problem is that the aortic root visualised with Computed Tomography (CT) imaging changes in shape and size after TAVI. Also the geometry of the stent frame of the TAV is affected by the stiffness of the aortic root, by the presence of stiff calcified regions and by the exact device position. Sub-optimal treatment planning can have two socio-economic effects.
At the one hand this gives higher costs for the health system. If the incorrect device/size of the TAV is chosen, the first TAVI procedure may fail and additional treatments, including a second TAVI procedure (valve-in-valve), SAVR, or rehospitalization may be necessary, with a considerable increase of the costs per patient. As a reference, one single TAVI procedure costs about 40 k Euro and the stented valve itself costs about 20 k Euro. At the other hand this leads to a lower prognosis. Sub-optimal treatment planning may result in peri-procedural complications, which affect both the life quality and the life expectancy of the patient. An oversized valve may rupture the annulus or dissect the aorta whereas an undersized valve may dislodge and migrate or can induce paravalvular regurgitation.
The aim of the present invention is to provide a solution to overcome at least part of the above mentioned disadvantages. The invention thereto aims to provide an improved method for preoperative insights into the interaction of an implant device and specific patient anatomy, for better prediction of complications, such as regurgitation, for better prediction of the hemodynamic performance of an implant deployed in an aortic valve, and for better patient selection and stratification. Also the invention aims to provide a web-based pre-operative planning service for TAVI using computer simulations that predict stent frame deformation and incomplete frame apposition, allowing to assess the risk on regurgitation and other complications such as coronary obstruction and conduction abnormalities prior to the intervention. Also the invention aims to give valuable insights for optimal device position, size and type.
In a further aspect, the invention aims to provide an improved stent device obtained by said method and a system for the execution of said method.
In a first aspect, the present invention aims to provide a method for patient-specific virtual percutaneous implantation according to claim 1. The method allows accurate prediction of an optimal size of the implant, specifically adapted to the anatomy of the patient. Furthermore, correct positioning of the implant or optimal implantation depth is predicted and calculated. The method according the current invention will hence minimize the risk of peri- and post-procedural complications. The method will also improve patient-specific selection of implants.
In a second aspect, the present invention provides a method according to claim 17. The method allows for incorporating the impact of surrounding tissue and structures of the aorta and therefore improving accuracy of functional behavior prediction.
In a third aspect, the present invention provides an implant for virtual percutaneous implantation according to claim 19.
In a fourth aspect, the present invention provides a system for virtual percutaneous implantation according to claim 20.
Further features, advantages and objects of the present invention will become apparent for the skilled person when reading the following detailed description of embodiments of the present invention, when taken in conjunction with the figures of the enclosed drawings.
The present invention relates to a method for patient-specific virtual percutaneous implantation as well as to an implant obtained by the current method and a system employing the method of the current invention.
The present invention will be described on the basis of the figures and detailed description of the invention, which complete content is to be regarded as an integral part of the detailed description of the invention.
Unless otherwise defined, all terms used in disclosing the invention, including technical and scientific terms, have the meaning as commonly understood by one of ordinary skill in the art to which this invention belongs. By means of further guidance, term definitions are included to better appreciate the teaching of the present invention.
As used herein, the following terms have the following meanings:
“A”, “an”, and “the” as used herein refers to both singular and plural referents unless the context clearly dictates otherwise. By way of example, “a compartment” refers to one or more than one compartment.
“Comprise,” “comprising,” and “comprises” and “comprised of” as used herein are synonymous with “include”, “including”, “includes” or “contain”, “containing”, “contains” and are inclusive or open-ended terms that specifies the presence of what follows e.g. component and do not exclude or preclude the presence of additional, non-recited components, features, element, members, steps, known in the art or disclosed therein.
“Point” and “node” as used herein are synonymous and are used interchangeable herein.
In a first aspect, the current invention comprises a method for patient-specific virtual percutaneous implantation, comprising:
Preferably, said transformed leaflet mesh is defined by said leaflet points and said leaflet nodes.
In a further aspect, the current invention comprises a method for patient-specific virtual percutaneous implantation, comprising:
The term ‘cardiovascular 2D or 3D medical image data’ as used herein is to be understood as all data related to an object to be analysed, said data is obtained by 2D or 3D imaging means. 2D or 3D imaging means may comprise, but are not limited to Nuclear Magnetic Resonance (NMR) imaging, Computed Tomography (CT) imaging, Positron Emission Tomography (PET), Single-photon emission computed tomography (SPECT) and echographic imaging. Preferably, said cardiovascular 2D or 3D medical image data is obtained through computed tomography.
The phrase “selecting a number of leaflet attachment points” as used herein is to be understood as a number of leaflet attachment points is chosen, selected and/or positioned on said aorta mesh.
The phrase “estimating a number of leaflet points” as used herein is to be understood as a number and/or the position of said leaflet points is estimated.
The term “mapping to” in the current invention is to be understood as assigning properties of said leaflet attachment points and said leaflet nodes to said transformed leaflet mesh. Preferably said properties comprise a 3-dimensional location. As such said transformed leaflet mesh is overlayed with said leaflet attachment points and said leaflet nodes.
The finite element mesh is programmed to contain the material and structural properties which define how the structure will react to certain loading conditions. Nodes are assigned at a certain density throughout the material depending on the anticipated stress levels of a particular area. Regions which will receive large amounts of stress usually have a higher node density than those which experience little or no stress. Points of interest may consist of: fracture point of previously tested material, fillets, corners, complex detail, and high stress areas.
A mesh transformation technique is used to create a grid or mesh of constant or variable thickness based on anatomical data of non-calcified leaflets, but calcifications may lead to higher local thicknesses. Preferably, said transformed leaflet mesh is an isoparametric leaflet mesh.
The method of the present invention is advantageous as it improves the accuracy of the medical intervention, clinical outcomes and reduces the associated risks. The method provides a better medical prediction of the functional behavior of the implant procedure. It allows to better understand the performance of an implant device or how to efficiently deploy an implant device into a patient. Also the method allows for an applicability of parameters sufficiently accurate for a broad population together with an acceptable calculation time. Testing new implant devices in realistic anatomies can be performed early in the development cycle to better understand the performance of a new device.
Preferably, said patient-specific model and implant model is a 3-dimensional finite element model.
It is also aim of the invention to provide pre-operative insights for different types of procedures (transcatheter aortic valve implantation, transcatheter mitral valve repair, endovascular aneurysm repair, left atrial appendage closure devices, etc.). The patient-specific model will then of course be based on a different part of the cardiovascular system, and the output will also be different.
Preferably, an alternative for said patient-specific aorta comprises a patient-specific blood vessel and said blood vessel comprises a valve.
The invention can also be applied for other heart valves, so not only the aortic valves. Therefore, the term “aorta” in underlying invention could also be interpreted as another patient-specific blood vessel e.g. the left atrium and/or ventricle, wherein “aortic valve” could be interpreted as the mitral valve and wherein corresponding patient-specific models are incorporated in the invention. Other valves such as the pulmonary valve in the pulmonary artery should be incorporated in the invention as well.
More preferably, said blood vessel comprises a patient-specific left atrium and/or ventricle, and said valve comprises a mitral valve.
More preferably, said blood vessel comprises a patient-specific right atrium and/or ventricle, and said valve comprises a tricuspid valve.
Preferably, stiffness elements are provided to a plurality of nodes of said aorta mesh, wherein a stiffness element induces a reacting force on the corresponding node of said aorta mesh, wherein said force is dependent on the displacement of said node or on the distance between said node and a fixed position equal or very close to the initial position of said node.
The deformation of the aorta and the annulus is affected by the surrounding tissue and structures. The mechanical impact of these tissues is important for a correct prediction of the stent structure obtained from simulated TAVI. The surrounding tissue could theoretically be included in the model by also segmenting based on the medical images. The making of such a model with all the surrounding tissues would be very time consuming, and simulation time would increase significantly. This method is advantageous as the virtual percutaneous implantation takes the impact of surrounding tissue and structures of the aorta into account, such as the stiffness or resistance. So if e.g. the aorta deforms, these stiffness elements (said displacements) will induce reacting forces which will work against this distortion. This way a better accuracy of simulation and therefore functional behavior prediction is achieved along with an acceptable calculation or simulation time.
More preferably, said reacting force depends on said displacements via a linear relationship. One can determine a spring constant k determining said linearity. A linear equation could therefore be Freact=k x, with Freact the reacting force and x said displacement. The spring constant k represents the stiffness or resistance of the surrounding tissue and structures of the aorta.
In another more preferred embodiment of the current invention, said reacting force depends on said displacement via a non-linear relationship.
More preferably, between different zones of said aorta mesh different stiffnesses or dependencies are assigned. Said different zones can have different material or tissue dependent properties.
Preferably, said steps a) and b) of the method according to the current invention further comprise:
Preferably, an alternative for said patient-specific anatomical model comprises a patient-based anatomical model wherein said steps a, b and c are replaceable by:
The term ‘patient-based model’ as used herein is to be understood as a generic and/or parametric adaptable model. Based on measurement(s) and/or 2D or 3D medical images of a patient, certain parameters will be determined for the patient-based model.
It is advantageous as a patient-based anatomical model can also give insights into pre-operative planning of trans-catheter valve implantation, without the need of segmentation techniques.
Preferably, the method according to the current invention further comprises:
It is advantageous as the method also accounts for aberrant tissue such as e.g. calcifications for patients with aortic stenosis. This leads to a more accurate patient-specific model, which will give rise to better functional behavior prediction and clinical outcomes and again reduces the associated risks.
In a preferred embodiment, said implant model will comprise a skirt and leaflet elements.
In a more preferred embodiment, said implant model will comprise a stent, to be implanted in a passage or conduit of the body of the patient. In the current invention, said passage or conduit is preferably a vessel, such as an aorta.
More preferably, said implant model comprises a finite element mesh wherein each element of said mesh is featured by a set of nodes wherein adjacent elements of said element comprise mutually shared nodes with said element, wherein said element is featured by material dependent parameters and wherein each element of said mesh can differ in material dependent parameters from an adjacent element of said element of said mesh.
It is advantageous to take into account different material parameters in order to provide even more accurate results in functional behavior prediction.
In a further preferred embodiment of the current invention, the method step of virtually deploying an implant model representing an implant into the patient-specific anatomical model comprises a three-dimensional finite element analysis. The finite element method (FEM) (its practical application often known as finite element analysis (FEA)) is a solution technique based on subdividing the volume into a large number of small elements of simple shape, the behavior of which can be described in function of a small number of variables at a limited number of points (nodes) of the element. For steady state problems this reduces the partial differential equations to a large set of algebraic equations which can be easily solved. Time dependent problems will result in a set of ordinary different equations in time which can numerically be integrated using standard techniques, like finite difference methods.
Each FEA program may come with an element library, or one is constructed over time. Some sample elements are rod elements, beam elements, plate/shell/composite elements, shear panel, solid elements, spring elements, mass elements, rigid elements or viscous damping elements.
Preferably, said tissue dependent parameter and/or a material dependent parameter is chosen from the following group of parameters: Poisson's ratio, Young's modulus, density, shear modulus, yield stress, ultimate stress, elasto-plastic parameter, energy density function, material damage parameter, superelastic material parameter, shape-memory material parameter, isotropic material parameter and anisotropic material parameter.
It is aim of the invention to provide patient-specific models sufficiently accurate by taking into account mechanical material properties of e.g. different layers, areas of layers, etc., together with a sufficiently fast calculating time.
The method of the current invention comprises furthermore preferably a step whereby a blood mesh is created, comprising a finite volume mesh, wherein the blood mesh describes the volume within said patient-specific anatomical model exclusive said deployed implant model; and whereby the blood flow is calculated for said blood mesh using computational fluid dynamics analysis.
The finite volume method is a method for representing and evaluating partial differential equations in the form of algebraic equations [LeVeque, 2002; Toro, 1999]. Similar to the finite difference method or finite element method, values are calculated at discrete places on a meshed geometry. “Finite volume” refers to the small volume surrounding each node point on a mesh. In the finite volume method, volume integrals in a partial differential equation that contain a divergence term are converted to surface integrals, using the divergence theorem. These terms are then evaluated as fluxes at the surfaces of each finite volume. Because the flux entering a given volume is identical to that leaving the adjacent volume, these methods are conservative. Another advantage of the finite volume method is that it is easily formulated to allow for unstructured meshes. The method is used in many computational fluid dynamics packages. For more info on the finite volume method, we refer integrally to Eymard et al., Handbook of Numeral Analysis (2000).
In a further preferred step, the amount of paravalvular regurgitation is predicted based on a geometrical analysis of said blood mesh. Hemodynamic performance of the implant can be predicted by quantifying paravalvular leakages, valve insufficiency, and effective orifice and systolic gradients across the aortic prosthesis.
It is advantageous to predict paravalvular regurgitation as it has been associated with increased mortality. This regurgitation is the result of several factors related to the aortic root anatomy and its relation to the implanted prosthesis including the shape and size of the aortic annulus, degree of annular and leaflet calcifications, left-ventricular outflow tract (LVOT) anatomy, and the prosthesis/annulus discongruence.
More preferably, the position and the orientation for implanting the implant is determined based on the complications predicted by said virtually deployed implant model. Even more preferably, said complications comprise the amount of paravalvular regurgitation, obstruction of coronary artery and/or electrical conductivity problems (e.g. related to an implementation of a pacemaker). Most preferably, the position and the orientation for implanting the implant is determined based on the amount of paravalvular regurgitation predicted by said virtually deployed implant model.
This will improve the accuracy of the medical deploying intervention, clinical outcomes and reduce associated risks.
In a further preferred step, the risk of coronary obstruction, annular rupture and conduction abnormalities is predicted by virtually deploying an implant model representing an implant into the patient-specific anatomical model.
The model parameters of the implant model and the patient-specific anatomical model are calibrated by comparing said calculations with postoperative medical image data.
It is advantageous to determine or calibrate model parameters and specifications in order to provide improving and/or optimal results for a broad population of patients or a number of subpopulations of patients. These parameters can be material dependent parameters, tissue dependent parameters, layer thicknesses, etc.
Preferably, said virtually deploying of an implant model representing an implant into said patient-specific anatomical model comprises:
By providing a database of device models representing the actual device geometry and having similar mechanical behavior, interventional cardiologists or hospitals can select optimal device size and type for patients.
More preferably, this will equally comprise:
This method is advantageous for the development of implant models based on the functional behavior on a plurality of patient specific anatomical models. This leads to better, cheaper, more effective implants, an optimal understanding of an implant model and therefore less risk for patients.
Taking the expansion of an implant model into account will lead to a better understanding in functional behavior of the implant model.
In a second aspect, the current invention discloses an implant for virtual percutaneous implantation, obtained by the method as explained above.
Preferably, said implant for virtual percutaneous implantation is obtained by selecting an implant model based on the amount of paravalvular regurgitation predicted by said virtually deployed implant model.
In a preferred embodiment, the valve implant is balloon-expendable or self-expendable.
In a third aspect, the current invention discloses a method for patient-specific virtual percutaneous implantation, comprising:
The deformation of the aorta and the annulus is affected by the surrounding tissue and structures. The mechanical impact of these tissues is important for a correct prediction of the stent structure obtained from simulated TAVI. The surrounding tissue could theoretically be included in the model by also segmenting based on the medical images. The making of such a model with all the surrounding tissues would be very time consuming, and simulation time would increase significantly. This method is advantageous as the virtual percutaneous implantation takes the impact of surrounding tissue and structures of the aorta into account, such as the stiffness or resistance. So if e.g. the aorta deforms, these stiffness elements (said displacements) will induce reacting forces which will work against this distortion. This way a better accuracy of simulation and therefore functional behavior prediction is achieved along with an acceptable calculation or simulation time.
Preferably, said reacting force depends on said displacements via a linear relationship. One can determine a spring constant k determining said linearity. A linear equation could therefore be Freact=k·x, with Freact the reacting force and x said displacement. The spring constant k represents the stiffness or resistance of the surrounding tissue and structures of the aorta.
In another preferred embodiment of the current invention, said reacting force depends on said displacement via a non-linear relationship.
Preferably, between different zones of said aorta mesh different stiffnesses or dependencies are assigned. Said different zones can have different material or tissue dependent properties.
Preferably, an alternative for said patient-specific aorta comprises a patient-specific left atrium and left atrial appendage and wherein said steps b and c are replaceable by:
The left atrium comprises a muscular pouch called the “left atrial appendage”. Some people can have blood clots formed in this appendix. To prevent these clots from going into the bloodstream, implant devices exist that can be inserted in this appendix in order to blocking clots. This procedure is called “left atrial appendage closure (LAAC)”. The invention therefore likewise can improve this LAAC intervention and procedure.
Preferably, an alternative for said patient-specific aorta comprises a patient-specific blood vessel and said blood vessel comprises a valve.
The invention can also be applied for other heart valves, so not only the aortic valves. Therefore, the term “aorta” in underlying invention could also be interpreted as another patient-specific blood vessel e.g. the left atrium and/or ventricle, wherein “aortic valve” could be interpreted as the mitral valve and wherein corresponding patient-specific models are incorporated in the invention. Other valves such as the pulmonary valve in the pulmonary artery should be incorporated in the invention as well.
More preferably, said blood vessel comprises a patient-specific left atrium and/or ventricle, and said valve comprises a mitral valve.
More preferably, said blood vessel comprises a patient-specific right atrium and/or ventricle, and said valve comprises a tricuspid valve.
In a final aspect, the current invention discloses a system for virtual percutaneous implantation, comprising:
Preferably, said storage medium, said secured server and said computing system are web-connected.
It is the aim of the current invention to provide a report to the medical doctor, comprising:
It is also the aim of the current invention to provide 3D models showing the interaction between one or more implant models representing implants and a patient-specific anatomical model.
The values currently used in clinical practice describe the amount of regurgitation (grade 0, 1, 2, 3 or 4; grade 0 corresponds with no or minimal regurgitation, grade 1 is mild regurgitation, grade 2 is moderate regurgitation, grade 3 is moderately severe regurgitation, grade 4 is severe regurgitation). In clinical practice, aortic regurgitation after TAVI can be observed using medical imaging (angiogram, echo). The physicians then assign a grade to the amount of regurgitation that they observe. In the current invention, a quantitative value based on, for example, the volume of backflow (regurgitation) during diastole (when the valve is closed) will be derived from the computational fluid dynamics analyses
In a preferred embodiment of the invention an anatomical model of the aortic root and of the ascending aorta is generated from CT images using traditional image segmentation methods or software. The resulting 3D anatomical model is a triangulated surface mesh.
Element 20 depicts the transformed finite elements 24 of leaflet 1, the transformed finite elements 25 of leaflet 2 and the transformed finite elements 26 of leaflet 3. Element 21 comprises overlayed calcified region elements 27. Element 22 comprises an additional layer finite elements 28 of leaflet 1, an additional layer finite elements 29 of leaflet 2 and an additional layer finite elements 30 of leaflet 3. Element 23 comprises calcified elements 31 of leaflet 1, calcified elements 32 of leaflet 2 and calcified elements 33 of leaflet 3.
Example 70 comprises a native ascending aorta model 40, a native aortic root model 41, a native left ventricle 42, a native aortic leaflet model 43, a native aortic valve annulus 44 and a native left coronary artery 45. Example 71 comprises a predilated balloon 46. Example 72 comprises an implant model 47.
An example of a simulated deployment of a self-expandable CoreValve (Medtronic) transcatheter aortic valve is shown in
In
Based on the deformed structures (stent, aorta, native leaflets, etc.) obtained from the finite element simulation, a computational grid of the fluid domain is created. The generation of such a grid or mesh is complex but required to model the backflow or regurgitation using computational fluid dynamics. The following method has been developed to create this computational mesh: —a regular grid of small cubes or hexahedral elements is created within the bounding box of the patient-based model—the cubes within the fluid domain are automatically detected. Other approaches are also possible.
Although the present invention has been described with reference to preferred embodiments thereof, many modifications and alternations may be made by a person having ordinary skill in the art without departing from the scope of this invention which is defined by the appended claims.
| Number | Date | Country | Kind |
|---|---|---|---|
| PCT/EP2012/059207 | May 2012 | EP | regional |
| PCT/EP2013/054276 | Mar 2013 | EP | regional |
| Number | Date | Country | |
|---|---|---|---|
| Parent | 14399781 | Nov 2014 | US |
| Child | 16987794 | US |
