On the effect of aortic root geometry on the coronary entry-flow after a bileaflet mechanical heart valve implant: a numerical study

The simultaneous replacement of a diseased aortic valve, aortic root and ascending aorta with a prosthesis is known as Bentall procedure (Bentall and De Bono in Thorax 23:338, 1968). This is a nowadays standard surgical approach in which the Valsalva sinuses of the aortic root are sacrificed and the coronary arteries are reconnected directly to the graft. The important function of the natural sinuses in the presence of the natural valve is well established; however, very little information is available about whether or not their presence can affect the functioning of a prosthetic hi-leaflet valve and the coronary flow. In the present work, we study the effect of the aortic root geometry on the blood flow through such devices, focusing the attention on the coronary entry-flow. Three root geometries have been considered, two mimicking the prostheses used in practice by surgeons (a straight tube, and the more recent tube with a circular pseudo-sinus), and a third maintaining the natural shape with three sinuses, Obtained by Reul et al. (J Biomech 23:181-191, 1990) by averaging numerous angiographies of the aortic root in healthy patients. Direct numerical simulations of the flow inside the three prostheses, assumed as undeformable, under physiological pulsatile inflow conditions are presented. The dynamics of the valvular leaflets is obtained by a fully-coupled fluid structure-interaction approach and the coronary perfusion is reproduced by modulating in time an equivalent porosity, an thus the resistance, of the coronary channels. The results indicate that the sinuses do not significantly influence the coronary entry flow, in agreement with the in vivo observations of De Paulis et al. (Eur J Cardio-thorac Surg 26:66-72, 2004). Nevertheless, the peak pressure at the joints of the coronary arteries is smaller in the natural-like aortic root geometry. The latter also produces a further beneficial effect of a reduction in the leaflets' angular velocity at the closure onto the valvular ring. These phenomena, if confirmed in more realistic clinical conditions, suggest that the use of a prothesis with physiologic sinuses would potentially reduce the local pressure peak, with the associated risk of post-operative bleeding and pseudo-aneurysm formation. It would also reduce the haemolysis effects caused by the red blood cells squashing between impacting solid artificial surfaces.