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  • Perspective
  • Published:

Restoration of flow in the aorta: a novel therapeutic target in aortic valve intervention

Nature Reviews Cardiology volume 21, pages 264–273 (2024)Cite this article

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Abstract

Aortic blood flow patterns are closely linked to the morphology and function of the left ventricle, aortic valve and aorta. These flow patterns demonstrate the exceptional adaptability of the cardiovascular system to maintain blood circulation under a broad range of haemodynamic workloads and can be altered in various pathophysiological states. For instance, normal ascending aortic systolic flow is predominantly laminar, whereas abnormal aortic systolic flow is associated with increased eccentricity, vorticity and flow reversal. These flow abnormalities result in reduced aortic conduit function and increased energy loss in the cardiovascular system. Emerging evidence details the association of these flow patterns with loss of aortic compliance, which leads to adverse left ventricular remodelling, poor tissue perfusion, and an increased risk of morbidity and death. In this Perspective article, we review the evidence for the link between aortic flow-related abnormalities and cardiovascular disease and how these changes in aortic flow patterns are emerging as a therapeutic target for aortic valve intervention in first-in-human studies.

Key points

  • Aortic flow is a complex and dynamic process that is influenced by several factors, including the aortic valve, the left ventricle and the aorta itself.

  • Aortic flow after aortic valve intervention is characterized by eccentric jets and abnormal vorticity.

  • Doppler echocardiography allows basic aortic flow visualization and quantification; complex flow assessment is restricted by the limitations of ultrasonography.

  • 2D and 4D flow cardiac MRI are non-invasive imaging modalities that can accurately quantify aortic flow and provide insights into aortic flow patterns.

  • Systolic flow displacement on cardiac MRI is a marker of flow eccentricity that is associated with further ascending aortic dilatation, whereas the systolic flow reversal ratio can be used to quantify aortic conduit function; increases in these biomarkers are associated with ageing and reduced exercise capacity.

  • Novel prosthetic aortic valves are being developed to restore normal aortic flow and increase prosthesis longevity, preserve the aortic root, and improve patient outcomes.

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Fig. 1: Aortic compliance.
Fig. 2: Aortic flow during systole.
Fig. 3: Vortical and helical flows in the ascending aorta.
Fig. 4: Aortic flow distributions in patients with shortness of breath and/or aortic stenosis.
Fig. 5: Cardiovascular MRI aortic PWV assessment.

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Authors and Affiliations

  1. University of East Anglia, Norwich Medical School, Norwich, UK

    Pankaj Garg

  2. Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK

    Pankaj Garg

  3. Departments of Radiology & Biomedical Engineering, Northwestern University, Feinberg School of Medicine & McCormick School of Engineering, Chicago, IL, USA

    Michael Markl

  4. St. Paul’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada

    Janarthanan Sathananthan

  5. Cardiovascular Translational Lab, St. Paul’s Hospital, University of British Columbia Centre for Heart Lung Innovation, Vancouver, British Columbia, Canada

    Stephanie L. Sellers

  6. Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden

    Chris Meduri

  7. Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA

    João Cavalcante

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P.G., S.L.S. and J.C. researched data for the article. All the authors were involved in writing, reviewing, editing and discussing the content of the manuscript.

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P.G. has an advisory role with Medis Medical Imaging and Pie Medical, and is a consultant for Anteris Technologies and Edward Lifesciences. M.M. has received research support from Circle Cardiovascular Imaging and Siemens. J.S. is a consultant for Anteris, Boston Scientific, Edwards Lifesciences and Medtronic, has received research funding from Edwards Lifesciences and Medtronic, and has received speaking fees from New Valve Technology. S.L.S. is a consultant for Anteris, Edwards Lifesciences and Medtronic, has received research support from Edwards Lifesciences, Heartflow, Medtronic and Vivitro Labs, and is supported by a Scholar award from Michael Smith Health Research BC. C.M. is the Chief Medical Officer of Anteris Technologies, has received research support from Boston Scientific, and has received honoraria, consultation or proctoring fees from Abbott, Alleviant, Boston Scientific, Cardiovalve, V2V, VDyne and XDot. J.C. has received consulting fees from 4C Medical, Abbott Structural, Anteris, AriaCV, Boston Scientific, Edwards Lifesciences, Medtronic, VDyne, WL Gore and Xylocor, and has received research grant support from Abbott Northwestern Hospital Foundation.

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Garg, P., Markl, M., Sathananthan, J. et al. Restoration of flow in the aorta: a novel therapeutic target in aortic valve intervention. Nat Rev Cardiol 21, 264–273 (2024). https://doi.org/10.1038/s41569-023-00943-6

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