A Computational Fluid Mechanical Study on the Effects of Opening and Closing of the Mitral Orifice on a Transmitral Flow Velocity Profile and an Early Diastolic Intraventricular Flow* Masanori NAKAMURA**, Shigeo WADA**, Taisei MIKAMI***, Akira KITABATAKE**** and Takeshi KARINO** A computational fluid dynamics study of intraventricular flow during early dias- tole is carried out to examine the effect of a change in the size of the mitral orifice due to opening and closing of the mitral valve on the flow evolution in the left ventricle during carly diastole. It is found that a velocity profile of a transmitral flow with maximum velocity locating at the center of the mitral orifice is generated by gradual opening of the mitral orifice, and it remains even after the mitral orifice has fully opened. This transmitral flow causes the development of a vortex ring extending from the anterior to the posterior side of the left ventricle. The vortex ring keeps the main inflow to stream linearly toward the ventricular apex. Such a flow pattern produces an elongated shape of an aliasing area in a color M-mode Doppler echocardiogram obtained clinically. It is, therefore, considered that although opening and closing of the mitral orifice occur with a short period, they play an important role in characterizing intraventricular flow during early diastole. Key Words: Bio-fuid Mechanics, Computational Fluid Dynamics, Vortex, Left Ventricle, Mitral Valve, Blood Flow, Diastole, Color M-mode Doppler Echocardiography, Flow Pattern 913 1. Introduetion ‘Many computational fluid dynamics studies of intraventricular flow have been carvied out in order to grasp the flow structure in the left ventricle, Taylor and Yamaguchi” investigated the effects of su * Received 10th July, 2002 (No. 02-4137) ** Research Institute for Electronic Science, Hokkaido University, North 12, West 6, North District, Sapporo 060-0812, Japan. E-mail: nakamura@bfd.es.ho Kudai.aeje *** College of Medical Technology, Hokkaido Univer: sity, North 12, West 5, North District, Sapporo 060- 0812, Japan, Graduate School of Medicine, Hokkaido University, North 15, West 7, North District, Sapporo 060-8638, Japan ISME Insernational Journal pravalvular aortic stenosis on intraventricular pres- sure gradients with a canine heart model. Lemmon and Yoganathan‘®* studied a change in an intraventricular flow field and pressure due to a dete oration in left ventricular diastolic function. Nakamura et al and Vierendecls et al computed the ventricular filing flow in an axisymmetric model of the left ventricle to account for the relationship between a ventricular diastolic function and a Doppler~derived index named the flow wave propage: tion velocity. Saber et al constructed an anatomically realistic model of a human left ventricle bused on maymetic resonance imaging and simulated a flow evolution during a cardiac cycle. ‘These invest gations provided valuable information on the relation ship between internal fluid dymamics and left ventricular diastolic function, however, the presence Series C, Vol. 45, No.4, 2002g14 of the mitral valve has often been neglected for sim plicity. ‘The mitral valve consists of the mitral ring and the valve leaflets". The leaflets form a continuous veil attached to the circumference of the mitral ring. During left ventricular systole, the mitral valve closes completely to prevent blood from flowing back into the atrium, When the blood pressure in the atrium becomes greater than that in the ventricle, the mitral valve is pushed to open from the commissure of leaflets, forming an orifice at the tips of the mitral valve leafiets. During diastole, the mitral valve is fully open with the mitral valve leaflets positioned parallel to the blood flow. At the end of diastole, the mitral valve leaflets are brought back to the closing state for the subsequent systole, ‘Tsakiris et al.® showed that it takes 0.04 sec for the mitral valve to open in early: diastole. Although this is short compared to the length of left ventricular diastole, itis considered that a change in the area of the mitral orifice during opening of the mitral valve affects the velocity profile of the blood flow entering through the mitral orifice. ‘The generation of a vortex is a common feature of a left ventricular diastolic flow ©, Saber et ali” stated that the formation of the intraventricular vor- tex during diastole is the after effect of ventricular filling flow, and so the mitral valve leaflets themselves are not an absolute requirement for the vortex forma: tion, Additionally, since the mitral valve leaflets behave asa part of a fluid (blood), the mechanical resistance of the mitral valve leaflets to blood flow is considered to be small. On the other hand, regard: ing the effect of a change in the area of the mitral orifice due to opening of the mitral valve, it has not been well studied how the velocity profile of a blood inflow through it is affected and how it influences intraventricular flow during early diastole. In the present study, we investigate the velocity profile of a transmitral flow affected by a change in the area of the mitral orifice during valve opening and its effects on a left ventricular diastolic flow by means, of computational fluid dynamics (CFD). A CFD study of ventricular filling flow during early diastole is carried out using a three-dimensional model of the left ventricle that has an opening and closing mitral valve (open-close valve). Results such as intraventricular flow patterns, transmitral flow veloc- ity and a color M-mode Doppler image of the ventricular filling flow are compared with those obtained from the left ventricle model with an open valve where the mitral valve is fully open from the beginning and keeps its opening throughout early diastole. Series C, Vol. 45, No. 4, 2002 2. Method 2.1 Configuration of the left ventricle model at its maximum expansion ‘The configuration of the left ventricle model at its ‘maximum expansion is constructed on the basis of the data given in a standard medical textbook”, A. cylindrical conduit (10mm in length) is annexed concentrically to the mitral valve, and the top of the cylindrical conduit is reassigned to the mitral valve. In this study, whilst the presence of the mitral valve leaflets is neglected, the mitral valve is modeled as a planar camera-shutter-like device. The aortic valve is also modeled as a planar device that completely closes throughout early diastole. For simplicity, the left ventricle model ig assumed to be symmetric with respect to the common bisector plane of aortic and mitral valves. The origin O is located at a point where the planes containing two valves intersected the common bisector plane of the left ventricle model and a global Cartesian coordinate (2, #, 2) is defined as shown in Fig. 1(a). ‘The z-axis and y-axis are laid along the intersection of the plane containing the mitral valve and the common bisector plane, and along the intersection of two planes containing the mitral and aortic valves, respectively. ‘The cross~ section of the left ventricle model, 'Y”, obtained by cutting it with a plane containing the y-ax 101 mm apex —— 45mm @ () (a) Geometry of the left ventricle model at its rmasimum expansion with definitions of the global ‘coordinate used to construct the computational model of the left ventricle. AV : aortic valve, MV mitral valve, AW: anterior wall, PW: posterior wall.(b) Finite element model of a unit circle used for the construction of the left ventricle ‘model Fig. 1 JSME Inservosional Journalassumed to be ellipsoidal. In this model, mitral and aortic valves are circular with a radius of 19mm, and the angle between them is 140 degrees. At the maxi ‘mum expansion, the length of a long-axis defined as a line spanning from the center of the mitral valve to the ventricular apex is 101 mm, the distance from the aortic valve to the ventricular apex 86mm, and the volume of the left ventricle 117 10° mm, 2.2 Construction of the finite element model ‘The left ventricle is regarded as a U-shaped tube having the mitral orifice at one end.and the aortic orifice at the other end. A unit circle that is divided into finite elements (481 nodal points and 460 square elements) as shown in Fig.1(b) is placed on each cross-section, , so that the center of the unit circle is positioned on the centroid of 47. The position of nodal points in the unit circle are transformed linearly using a function of the distance from the center of the Circle to each nodal point such that the outline of the unit circle coincides with the outline of #. Finally, corresponding nodal points between neighboring cross-sections are linked up forming a hexagonal clement. The total numbers of nodal points and elements ate 24.531 and 23 000, respectively. 2.8 Motion of the ventricular wall during, early diastole With respect to the motion of the ventricular wall, two assumptions are made. First, the present study assumes that the movement of the ventricular wall is independent of its internal fluid dynamics, because the maximum pressure during early diastole in a healthy human heart is comparatively not sufficiently high to deform the left ventricle from the internal side Second, it is assumed that a point P fon the outline of each cross-section, #7, moves in the direction of O'P where O' is the centroid of In this study, the moving velocity of the ventricular wall, vw, at a point P is given as ve= vat) (8) Wa) am where is an angle between 00’ and the position vector O'P on each ¥, a is an angle from a cross section, ¥, to the mitral orifice, Wi(8) and Wi(a) are ‘weighting functions for the moving velocity of the wall in the directions of 0 and a, respectively, and va(?) is the velocity at the ventricular apex. In the present computer simulation, Wi(#) and Waa) are given by wey) os Wa FO=P @ where D(a) is the length of the long axis of the cross~ section at an angle @ at the maximum expansion of the left ventricle, and Dras is the maximum of D(a) JSME Iniermatiznal Journal 915 that is obtained at a=4x/9 corresponding to the cross-section containing the ventricular apex. The ‘weighting function Wi(8) is given so that the moving velocity of a point on the wall decreases on approach ing to the point O, and the weighting function Wa) determined so as to maintain the radi of the aortic orifice and the cylindrical part including the mitral otifice constant, and provide the maximum velocity of the wall at the ventricular apex. The relationship between the rate of volume change, dVidt, and ve(¢) is written as LO oo ff mlowiae nds (4) where e is a unit vector in the direction of O'P, dS is the element of an area of the surface of the left ventricle model, and 7 is a unit vector normal to the surface. If the rate of ventricular volume change, aV(i)/dt, and weighting functions Wi() and Wala) are provided, the velocity at the ventricular apex, val}, can be determined from Eq.(4), and then the moving velocity, dw», at each time and each nodal point is obtained from Eq.(1). ‘The time course of the rate of ventricular volume change, dV(J) dt, used for the present computation shown in Fig. 2, Times from the beginning of diastole 0) to the peak of transmitral velocity, To, and to the end of early diastole, 72, are set to be 0.12 sec and 0.24 sec, respectively, based on clinical data". The time course of the ventricular volume, V(t), is also shown in Fig.2. The net change in the ventricular volume is 5.44% 10* mm 2.4 Modeling of the mitral orifice ‘The opening and closing of the mitral valve is F x0 a = 7 20 E F500 no S g z F; 0 2 S 400 g & 3 z g 2 lo 2 3 ee 0.06 0.12 0.18 0.24 ‘Time, ¢, [sec] Plots of the volume of the left ventricle, V(O, (dashdot line) and its rate of change, dV (Aidt, (coli line) as a function of the time elapsed from the onset of early diastole Fig. 2 Series C, Vol. 45, No. 4, 2002916 expressed as a circular orifice that opens and closes from its center and its circumference, respectively. The opened part of the mitral valve is hereinafter referred to as the mitral orifice. It is assumed in the case of a left ventricle model with an opening and closing mitral valve (open-close valve) that it takes 0.05 see (= Ti) for the valve to open at the beginning, and the same period to close at the endl of the early diastole. ‘The radius of the orifice, r(t), is given as a function of time; rAVS=US CoAT for O<1< Ty rt) n for Ti) ¢=0.1 see, (€) £=0.16 see and (d) £=0.22 sec, Arrows located on the top and the bottom of the left ventricle model (4) indicate a line along which the velocity information is obtained to draw the color M-mode Doppler echocardiogram shown in Fig. 6(b). Series G, Vol. 4 5, No. 4, 2002 JSME Intemational Journal2 , copes F'S[-C- openciose valve FI #1 #1 Fos] Fos : é _— fens Sy o 13 “13 3 Position fr] ‘atetor Poseror Position sa) fa) (») qs 13 i 1 Zo 0s iz Ih Peston im ost Co) @ Pfots of instantaneous mitral low velocity profiles along the z-axis during early diastole; (a) 0 04 sec, (b) #=011 sec, (c) £0.16 see and (d) 15022 sec. Triangular and circular marks indi cate the results obtained for the left ventricle model with an open valve and with an open-close valve, respectively Fig. 5 ventricular filling flow (indicated by arrows in Figs. 3 (4), 4(4)) at each time point from the onset to.the end of early diastole, and plotting it as a spatiotemporal map where the magnitude of velocity is expressed by color according to the scale of the color bar presented between the echocardiograms in Fig. 6. In the color M-mode Doppler echocardiogram, the horizontal and vertical axes show the time lapsed from the onset of early diastole and the distance from the mitral valve, respectively. The area that appears in blue in each figure indicates the region where the velocity of fluid elements is larger than 75% of the spatiotemporal maximum velocity (aliasing limit) in carly diastolic phase, and it is called an aliasing area, In the case of the left ventricle with an open valve, the aliasing area is short and rounded at its tip, and the whole area is confined within one-fifth of the axis (Fig.6(a)), In contrast, in the case of the left ventticle with an open-close valve, the aliasing area is elongated and sharpened at the tip, reaching the midpoint of the axis (Fig. 6¢)) ISME International Journal 919 @ velocity ® 109- [esc] 100 iste 13 wo E 12 2 vise 128 4 iF s oF os. q Joo 3 0 a 06 8 03 p20 8 Hos 1 ° Meet Os 2 eeaelinegT 0 12 24 o 12 2 Time [> 10" see] Time [10" see] Fig. 6 Spatiotemporal map of the calculated inflow velocity obtained along the axis shown in Figs. 3 (4) and 4 (4), expressed in the same manner as a color M-mode Doppler echocardiogram ; (a) left ventricle model with an open valve, (b) left ventricle model with an open-elose valve, 4. Discussion 4.1 Effect of opening of the mitral orifice on a transmitral flow velocity profile As shown in Fig.§, there is a difference in the velocity profile of a transmitral flow between the results obtained for the left ventricle model with an open-close vaive and with an open valve. By opening the mitral valve gradually, a velocity profile with the maximum velocity locating at the center of the mitral orifice is formed during opening of the mitral valve. It Gevelops with the progression of the ventricular expansion even after the mitral valve has completely opened. As a result, a jet-type flow is created. On the other hand, in the case that the mitral valve is fully open from the onset of early diastole, the velocity profile obtained is initially flat, and it develops into a skewed one with the maximum velocity positioned at the anterior side. The transmitral flow velocity profile obtained in a left ventricle model with an open-close valve is similar to that measured by Fujimoto et al." However, not only the jet-type velocity profile but also various types of a transmitral flow velocity profile have been observed experimentally‘! Taylor and Whamond" measured the velocity profile of the flow through the mitral orifice in dogs, and reported a flat velocity profile at the mitral annulus. Samstad et al." and Kupari et al.°° found a velocity profile skewed to the anterior side of the mitral valve Series C, Vol. 45, No. 4, 2002920 leafiet during early diastole. Inconsistency in the mitral velocity profile in the literature could be attributed to the limited spatiotemporal resolution of the measurement devices, Therefore, it is not ade ‘quate to evaluate all of our results solely on the basis of a comparison of a transmitral flow velocity profile obtained in the present computational study with those shown in experimental studies. Thus, it is necessary to discuss the intraventricular flow dynamics created by the transmitral flow. 4.2 Relationship between the transmitral velo- city profile and the formation of a vortical flow in the left ventricle Our computer simulation shows that a pair of vortices is formed in the symmetry plane of the left ventricle at the end stage of early diastole in the left ventricle model both with an open valve and with an open-close valve. However, there is a difference in the size and location of vortices between them. In the left ventricle model with an open-close valve, a jet~ type transmitral flow where the maximum velocity is located at its center ereates a large vortex on the left of a mainflow streaming along the long-axis of the left ventricle, and a small one on the right of the mainflow. This appearance of twin vortices is similar to that found by in vivo observations of blood flow in a human heart™, In contrast, in the left ventricle model with an open valve, a transmitral flow that is, skewed to the anterior side generates a small vortex. on the left of a mainflow streaming near the aortic valve and a large one on the right. ‘There are no experimental data that support this result. ‘The present study also shows that there is a difference in the location of a high-velocity portion of ventricular filling flow during carly diastole between the left ventricle model with an open-close valve and with an open valve. A high-velocity portion is positioned at the midpoint of the long-axis at the end of early diastole in the left ventricle with an open~ close valve, while it is located near the aortic valve when the mitral valve is fully open from the beginning of early diastole, Nakamura et al" showed that the position of a high-velocity portion of a mainflow is related to the location of the intraventricular vortex ing formed during early diastole. When the vortex ing is formed so that it surrounds a mainflow, the vortex ring narrows the passage of the mainflow. As a result, the velocity of the mainflow is locally in- creased, and a high-velocity portion appears at the level of the center of the vortex ring, In the left ventricle with an open-close valve, the vortex ring is formed about a main‘low of blood that heads linearly towards the ventricular apex along the long-axis of the left ventricle, Thus, a high-velocity portion of the Series C, Vol. 45, No, 4, 2002 blood flow is found along the long-axis. Also, since the vortex ring is highly developed in the longitudinal direction, the high-velocity portion of the mainflow ‘moves up to the midpoint of the long-axis of the left ventricle by the end stage of early diastole. However, in a case that the mitral valve is fully open from the beginning of early diastole, since the vortex ring is generated about a mainflow streaming near the aortic valve, the high-velocity portion of the mainflow does not emerge on the long axis of the left ventricle. Furthermore, since the vortex below the aortic valve (to the left of the mainflow) does not develop in a ongitudinal direction compared to the one on the posterior side, the center of the vortex ring is positioned at the level of the posterior edge of the aortic valve, and therefore the high-velocity portion of the mainflow does not move very far from the mitral orifice. ‘Thus, itis found that a transmitral flow velocity profile largely affects the location of main blood inflow in the left ventricle, and it actually determines the location and size of the vortex ring formed about it during early diastole. 4.3 Effect of closing of the mitral orifice on intraventricular flow dynamics At the end stage of early diastole, whereas two vortices rise below the mitral orifice (one placed below another) in the left ventricle model with an open-close valve, one open vortex that partially runs out from the posterior side of the mitral orifice is formed in the left ventricle model with an open valve. In the latter case, since the mitral valve is kept fully ‘open during early diastole, there is no restriction on the growth of the vortex below the mitral orifice. As ‘a result, the vortex overgrows in a longitudinal direc. tion, and it causes a large amount of outflow from the mitral orifice. However, in the former case, since another vortex is formed above the one that is a part, of the vortex ring resulting from a lateral extension of a vortex below the aortic valve, the vortex formed below is in a closed form, Asa result, the overgrowth of the vortex ring on the posterior side (below the mitral orifice) is fairly restricted, and the mainflow is kkept to stream linearly along the long-axis of the left ventricle, Although the upper vortex causes a sinall amount of regurgitation from a posterior edge of the ‘mitral orifice even in this case, this vortex does not have any essential influences on the mainflow. 4.4 Importance of opening and closing of a mitral orifice for a simulation of color M- mode Doppler echocardiogram obtained clinically ‘The present study shows that there is a difference in the shape of an aliasing area in the color M-mode Doppler echocardiogram constructed from the results JSMB Inseraatznal Journalof the computer simulation of flow dynamics during early diastole in the left ventricle model, between with an open-close valve and with an open valve. When the mitral valve is opened gradually, the aliasing area is sharply elongated and its tip reaches the midpoint of the long-axis. In contrast, when the mitral valve is fully opened from the onset of early diastole, it shows @ rounded and shortened shape, It is observed in clinical studies that the aliasing area in the left ventricle with = normal diastolic function shows a longitudinally extended shape, which is similar to the cone obtained in the left ventricle model with an open~ close valve, Elongation of the aliasing area in the vertical direction of a color M-mode Doppler echocardiogram is related to the movement of a high-velocity portion of the mainflow corresponding to the development of an intraventricular vortex ringM™*909-38, Ag dis- cussed in section 4.2, at the end of early diastole, a high-velocity portion of the mainflow is positioned further from the mitral orifice in the left ventricle ‘model with an open-close valve than in the model with aan open valve, In the left ventricle model with an ‘open-close valve, gradual opening of the mitral valve generates the jet-type flow at the mitral orifice, the mainflow of blood inflow streams along the long-axis of the left ventricle, and the vortex ring generated about the mainflow develops in a well-balanced man- ner. As a result, the high-velocity portion of the mainflow is conveyed up to the center of the left ventricle, and thereby the aliasing area shows a sharp- ly elongated shape. On the other hand, in the left ventricle model with an open valve, a transmitral flow whose velocity profile is initially flat and later skewed to the anterior side does not enlarge the vortex ring as much as the jet-type transmitral flow created by a gradual opening of the mitral valve does. , Thus, a high-velocity portion of a mainflow streaming near the anterior side of the mitral orifice stays near the aortic valve, and consequently the aliasing arca appearing in a color M-mode Doppler echocardio. gram is shortened, Therefore, in order to obtain a color M-mode Doppler echocardiogram similar to the one obtained clinically, itis important to consider the effect of gradual opening of the mitral valve on trans- mitral flow and intraventricular flow dynamics. 5. Conelusion In the present study, computational fluid dynamics of intraventricular flow during early dias- tole is carried out to investigate the effect of a change in the area of the mitral orifice due to opening and closing of the mitral valve. mary of the findings : ISME International Journal 921 (1) tis found that a jet-type velocity profile is created when a mitral orifice is gradually opened whereas a flat velocity profile and later an anteriorly skewed one are produced when the mitral orifice is itially fully opened from the onset of early diastole, (2) The mode of opening of a mitral orifice affects the velocity profile of a transmitral flow not only during the opening of the mitral valve but also during the rest of early diastole, although the time required for mitral valve opening accounts for 20% of the total length of early diastole. (3) The pattern of a transmitral flow velocity profile determined by the mode of opening of the mitral orifice is related to the site of a main blood inflow streaming in the left ventricle as well as the location and size of the vortex ring formed in the left ventricle during early diastole. (4) Closing of a mitral orifice contributes to restricting the overgrowth of a vortex formed below the mitral orifice. (5) By changing the mode of mitral valve open- ing, the movement of a high-velocity portion of blood inflow towards the ventricular apex is changed. This is clearly reflected in the shape of the aliasing area appearing in a color M-mode Doppler echocardio. gram, (6) Although a planar camera-shutter-like mitral valve introduced in this study is not realistic in its anatomical structure, it functions well as a regula: tor of a transmitral flow velocity profile, Acknowledgements ‘This work is supported by a Research Grant for Cardiovascular Diseases (12C-12) from the Ministry of Health and Welfare of Japan and a Grant from the Ministry of Education, Culture, Sports, Seience and Technology of Japan, Grant-in-Aid for Scientific Research (B), No. 13480284, 2001. References (2) Taylor, T.W. and Yamaguchi, T., Flow Patterns in Three-Dimensional Left Ventricular Systolic land Diastolic Flows Determined from Compu: tational Fluid Dynamics, Biorheology, Vol. 32, No.1 (1995), pp. 61-71, (2) Lemmon, JD. and Yoganathan, A.P., Three~ Dimensional Computational Model of Left Heart Diastolic Function with Fluid-Structure Interac: tion, J. Biomech. 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