Elira Maksuti

Arterial Stiffness Estimation by Shear Wave Elastography: Validation in Phantoms with Mechanical Testing.

Arterial stiffness is an independent risk factor found to correlate with a wide range of cardiovascular diseases. It has been suggested that shear wave elastography (SWE) can be used to quantitatively measure local arterial shear modulus, but an accuracy assessment of the technique for arterial applications has not yet been performed. In this study, the influence of confined geometry on shear modulus estimation, by both group and phase velocity analysis, was assessed, and the accuracy of SWE in comparison with mechanical testing was measured in nine pressurized arterial phantoms. The results indicated that group velocity with an infinite medium assumption estimated shear modulus values incorrectly in comparison with mechanical testing in arterial phantoms (6.7 ± 0.0 kPa from group velocity and 30.5 ± 0.4 kPa from mechanical testing). To the contrary, SWE measurements based on phase velocity analysis (30.6 ± 3.2 kPa) were in good agreement with mechanical testing, with a relative error between the two techniques of 8.8 ± 6.0% in the shear modulus range evaluated (40-100 kPa). SWE by phase velocity analysis was validated to accurately measure stiffness in arterial phantoms.

Closed-loop real-time simulation model of hemodynamics and oxygen transport in the cardiovascular system

BackgroundComputer technology enables realistic simulation of cardiovascular physiology. The increasing number of clinical surgical and medical treatment options imposes a need for better understanding of patient-specific pathology and outcome prediction.MethodsA distributed lumped parameter real-time closed-loop model with 26 vascular segments, cardiac modelling with time-varying elastance functions and gradually opening and closing valves, the pericardium, intrathoracic pressure, the atrial and ventricular septum, various pathological states and including oxygen transport has been developed.ResultsModel output is pressure, volume, flow and oxygen saturation from every cardiac and vascular compartment. The model produces relevant clinical output and validation of quantitative data in normal physiology and qualitative directions in simulation of pathological states show good agreement with published data.ConclusionThe results show that it is possible to build a clinically relevant real-time computer simulation model of the normal adult cardiovascular system. It is suggested that understanding qualitative interaction between physiological parameters in health and disease may be improved by using the model, although further model development and validation is needed for quantitative patient-specific outcome prediction.

Modelling the heart with the atrioventricular plane as a piston unit

Medical imaging and clinical studies have proven that the heart pumps by means of minor outer volume changes and back-and-forth longitudinal movements in the atrioventricular (AV) region. The magnitude of AV-plane displacement has also shown to be a reliable index for diagnosis of heart failure. Despite this, AV-plane displacement is usually omitted from cardiovascular modelling. We present a lumped-parameter cardiac model in which the heart is described as a displacement pump with the AV plane functioning as a piston unit (AV piston). This unit is constructed of different upper and lower areas analogous with the difference in the atrial and ventricular cross-sections. The model output reproduces normal physiology, with a left ventricular pressure in the range of 8-130 mmHg, an atrial pressure of approximatly 9 mmHg, and an arterial pressure change between 75 mmHg and 130 mmHg. In addition, the model reproduces the direction of the main systolic and diastolic movements of the AV piston with realistic velocity magnitude (∼10 cm/s). Moreover, changes in the simulated systolic ventricular-contraction force influence diastolic filling, emphasizing the coupling between cardiac systolic and diastolic functions. The agreement between the simulation and normal physiology highlights the importance of myocardial longitudinal movements and of atrioventricular interactions in cardiac pumping.

Shear wave elastography for characterization of carotid artery plaques - A feasibility study in an experimental setup

Characterization of vulnerable plaques in the carotid artery is critical for the prevention of ischemic stroke. However, ultrasound-based methods for plaque characterization used in the clinics today are limited to visual assessment and evaluation of plaque echogenicity. Shear Wave Elastography (SWE) is a new tissue characterization technique based on radiation force-induced shear wave propagation with potential use in plaque vulnerability assessment. The purpose of this study was to develop an experimental setup to test the feasibility of SWE for carotid plaque characterization. A carotid artery phantom with a soft inclusion in the wall, mimicking a vulnerable plaque, was constructed (10% polyvinyl alcohol (PVA), 3% graphite) by exposing the vessel and plaque to three and one freeze-thaw cycles (6h freeze, 6h thaw) respectively. An Aixplorer SWE system (Supersonic Imagine) was used to measure the shear wave speed (cT) in the vessel wall and plaque. The Youngs modulus (E) was then calculated via the Moens-Korteweg (M-K) equation. For comparison, eight cylinders (d = 4 cm, h = 4 cm) were constructed for mechanical testing from the same PVA batch, of which four were exposed to three freeze-thaw cycles (mimicking the vessel wall) and four to one freeze-thaw cycle (mimicking the plaque). The Youngs moduli for the cylinders were obtained via a displacement controlled mechanical compression test (Instron 5567) by applying 5% strain. The mean shear wave speed was 2.6 (±0.7) m/s in the vessel wall, 1.8 (±0.7) m/s in the plaque, resulting in Evessel = 11.5 (±0.5) kPa, Eplaque = 4.3 (±0.5) kPa. The compression tests resulted in E = 64.2 (±11.1) kPa in the hard cylinder and E = 9.7 (±3.1) kPa in the soft cylinder. The results showed that it was possible to distinguish between the arterial wall and the plaque. The disagreement between mechanical testing and SWE can be explained by the fact tha- the shear wave does not propagate monochromatically in cylindrical geometry. To achieve a better calculation of the elastic modulus, the frequency dependency of the shear wave velocity must be considered.

Contribution of the Arterial System and the Heart to Blood Pressure during Normal Aging – A Simulation Study

During aging, systolic blood pressure continuously increases over time, whereas diastolic pressure first increases and then slightly decreases after middle age. These pressure changes are usually explained by changes of the arterial system alone (increase in arterial stiffness and vascular resistance). However, we hypothesise that the heart contributes to the age-related blood pressure progression as well. In the present study we quantified the blood pressure changes in normal aging by using a Windkessel model for the arterial system and the time-varying elastance model for the heart, and compared the simulation results with data from the Framingham Heart Study. Parameters representing arterial changes (resistance and stiffness) during aging were based on literature values, whereas parameters representing cardiac changes were computed through physiological rules (compensated hypertrophy and preservation of end-diastolic volume). When taking into account arterial changes only, the systolic and diastolic pressure did not agree well with the population data. Between 20 and 80 years, systolic pressure increased from 100 to 122 mmHg, and diastolic pressure decreased from 76 to 55 mmHg. When taking cardiac adaptations into account as well, systolic and diastolic pressure increased from 100 to 151 mmHg and decreased from 76 to 69 mmHg, respectively. Our results show that not only the arterial system, but also the heart, contributes to the changes in blood pressure during aging. The changes in arterial properties initiate a systolic pressure increase, which in turn initiates a cardiac remodelling process that further augments systolic pressure and mitigates the decrease in diastolic pressure.

Influence of wall thickness and diameter on arterial shear wave elastography: A phantom and finite element study

Quantitative, non-invasive and local measurements of arterial mechanical properties could be highly beneficial for early diagnosis of cardiovascular disease and follow up of treatment. Arterial shear wave elastography (SWE) and wave velocity dispersion analysis have previously been applied to measure arterial stiffness. Arterial wall thickness (h) and inner diameter (D) vary with age and pathology and may influence the shear wave propagation. Nevertheless, the effect of arterial geometry in SWE has not yet been systematically investigated. In this study the influence of geometry on the estimated mechanical properties of plates (h  =  0.5-3 mm) and hollow cylinders (h  =  1, 2 and 3 mm, D  =  6 mm) was assessed by experiments in phantoms and by finite element method simulations. In addition, simulations in hollow cylinders with wall thickness difficult to achieve in phantoms were performed (h  =  0.5-1.3 mm, D  =  5-8 mm). The phase velocity curves obtained from experiments and simulations were compared in the frequency range 200-1000 Hz and showed good agreement (R 2  =  0.80  ±  0.07 for plates and R 2  =  0.82  ±  0.04 for hollow cylinders). Wall thickness had a larger effect than diameter on the dispersion curves, which did not have major effects above 400 Hz. An underestimation of 0.1-0.2 mm in wall thickness introduces an error 4-9 kPa in hollow cylinders with shear modulus of 21-26 kPa. Therefore, wall thickness should correctly be measured in arterial SWE applications for accurate mechanical properties estimation.

Feasibility of shear wave elastography for plaque characterization

Determining plaque vulnerability is critical when selecting the most suitable treatment for patients with atherosclerotic plaque in the common carotid artery and quantitative characterization methods are needed. In this study, shear wave elastography (SWE) was used to characterize soft plaque mimicking inclusions in three atherosclerotic arterial phantoms by using phase velocity analysis in a static environment. The results were validated with axial tensile mechanical testing (MT). SWE measured a mean shear modulus of 5.8 ± 0.3 kPa and 25.0 ± 1.2 kPa versus 3.0 kPa and 30.0 kPa measured by mechanical testing in the soft plaques and phantom walls respectively. The results show good agreement between MT and SWE for both the plaque and phantom wall.

Strain and strain rate generated by shear wave elastography in an ex vivo porcine aorta

In order to generate trackable shear waves in soft tissues, transmitted pulses in shear wave elastography (SWE) are longer than conventional clinical ultrasound pulses. Nevertheless, they typically obey mechanical and thermal regulatory limits. In arterial applications, specific safety concerns may arise, as acoustic radiation (ARF)-induced stresses and strain rates could potentially affect the arterial wall. The aim of this study was to assess ARF-induced strain and strain rates in ex vivo arteries. A porcine aorta (diameters 8.5 mm, wall thickness 1.2 mm) was pressurized by a saline-filled water column at 60 and 120 mmHg. A Verasonics V1 system and a L7-4 transducer were used to generate the ARF in the middle of the anterior wall (F-number = 1, push length = [100, 200, 300] μs) and to perform plane-wave imaging (10 kHz). Cumulative axial displacement was estimated using 2D auto-correlation. The axial strain rate was calculated as the time-derivative of the axial strain, obtained by spatial linear regression of the displacement inside the anterior wall. The ex vivo peak strain and strain rate were compared with peak strain and strain rate values induced by the blood pressure changes in two healthy individuals and two patients with coronary artery disease at rest and measured by a dedicated in house speckle tracking algorithm. ARF-induced ex vivo peak strains were in the range 0.3–1% and strain rates in the range 6–23 s−1. Peak values were more affected by longer push duration than pressurization level. In vivo physiological peak strain was 33% and strain rate was 2 s−1. ARF-induced strain rates in vivo are likely to be lower than those assessed in this ex vivo setup due to ultrasound attenuation and the effect of surrounding tissue. Therefore, the results of the performed study suggest that SWE could be used in a safe manner for arterial applications even though specific effects of high strain rates are to be explored.

Evaluating arterial and plaque elasticity with shear wave elastography in an ex vivo porcine model

Our objective was to use shear wave elastography (SWE) to characterize the mechanical properties of an arterial wall with a simulated calcified plaque in an ex vivo setup. A small porcine aorta was used as a model for a human carotid artery and attached to a fixture while pressurized with a water column. The stiffness of the arterial wall and a simulated plaque were estimated using SWE. The mean arterial wall and plaque shear modulus varied from 42 ± 0 kPa to 100 ± 1 kPa and 81 ± 2 kPa to 174 ± 2 kPa respectively over a pressure range of 20-120 mmHg. The results show the ability of SWE to characterize the mechanical properties of an arterial wall with a simulated plaque and take steps toward an in vivo implementation for quantitative plaque assessment.