Vol 1, No 1 (2022): Debut issue

Background. Patients afflicted with aortic stenosis (AS) may present chest pain (CP), shortness of breath (SOB), syncope, and no lesion in the coronary arteries. So far, no clear mechanism could convincingly elucidate the pathophysiology of symptoms in such patients. We conducted a study to clarify the mechanism of CP, SOB, and syncope in AS patients without coronary artery stenosis based on coronary flow patterns or abnormalities.

Methods. One hundred and thirty two (132) patients visiting the emergency room with CP, SOB, or syncope were screened for AS. Forty four (44) patients with a clinical diagnosis of AS underwent right and left heart catheterization and a novel dynamic coronary angiographic technique. Twenty AS patients without coronary artery disease (CAD) were enrolled. All patients were divided into either: group A for severe AS or group B for mild to moderate AS. The control group consisted of Five patients with normal left ventricular function without CAD or AS (group C). The flow data included the coronary transit time duration, the presence of retrograde flow at the proximal coronary segment, and the persistence of contrast spill-out from the coronary ostium.

Results            There was prolonged arterial phase and retrograde flow in the proximal coronary segment, including persistent spilling of contrast into the coronary sinus (p<0.01 when compared with groups B and C) in 20 patients with severe AS (group A). In 24 patients in the mild to moderate AS group (group C), there was only a moderately prolonged arterial phase without retrograde flow nor spilling of contrast from the ostium (p=0.99 when compared with control group C). 

Conclusions    In patients with AS, significantly prolonged arterial coronary transit time, reversed coronary flow, and retrograde ejection of contrast into the coronary sinus correlated statistically with the severity of AS. In patients with mild to moderate AS, with only moderate prolongation of the arterial phase without reversed coronary flow nor retrograde ejection of contrast into the coronary sinus.

Heart Failure (HF) is on the end stage of the disease spectrum with many confounders and thus no specific symptoms and signs. There is a need for a test that can effectively confirm the diagnosis of volume overload in HF at its earliest to guide the initial approach and subsequent management. This study aimed to evaluate the effectiveness of a new test noted as the Size and Expansion of Femoral Vein (SEFV) in the diagnosis and management of patients with HF. This test was used specifically on asymptomatic patients or those who presented with severe comorbidities. The patients who arrived at the emergency room with a diagnosis of HF or suspected HF were enrolled. Ten patients without HF formed the control group. All patients received a standard physical examination (PE). The patients with the obvious diagnosis of HF by PE formed the HF control group. All patients with tentative diagnoses formed the HF study group. All patients underwent the ultrasound test to measure the size of the common femoral vein (CFV) and artery (CFA). The study enlisted 167 patients with HF or suspected HF. The results showed that the SEFV test was more accurate (98%) than the PE (54%). The SEFV test accurately differentiated between severely sick patients with intravascular overload and moderately sick patients with extravascular overflow. The test was accurate in patients with severe comorbidities (93%) or hypotension (100%). The SEFV test was more accurate in confirming the presence of fluid overload in patients with severe comorbidities or hypotension.   

Background. The differential diagnosis of chest pain in women is complex, ranging from atypical angina to chest pain in the absence of coronary artery disease (i.e., Syndrome X). The mechanism of these conditions remains unexplained. The purpose of this study was to examine coronary blood flow based on a new angiographic technique.  

Methods. Patients with chest pain were enrolled. In the new technique, as the contrast injection stopped, the blood in white color moved in and displaced the black contrast. Characteristics of blood flow could be observed and classified by type and time.  The duration of the arterial phase was calculated and compared with the control.  

Results.  Sixty patients were enrolled. Ten patients with normal coronary arteries and ventricular function; without chest pain served as controls. In the control group, the duration of the arterial phase in the RCA was 1.76 sec, while it was 3.76 sec for the syndrome X group (p<0.05). From the mMID segment to the distal segment, syndrome X patients had a much longer delay compared to control subjects (0.81 vs. 0.26 sec) (p<0.05). From the distal segment (bDIS) to the origin of the PDA, syndrome X patients had an average duration of 0.81 sec compared to 0.40 sec in controls (p<0.05). The largest difference was the period of time when the contrast left the PDA until flushed from the distal vasculature, which was 1.66 sec and 0.40 sec in syndrome X vs. control. Syndrome X patients with prolonged myocardial phase (1.89 sec) had dense and prolonged contrast retention at the myocardium.

Conclusions.  In patients with syndrome X, the prolonged arterial phase deprived the myocardium of highly oxygenated blood and triggered ischemia. This new imaging method allows for a better understanding of the mechanism of ischemia in Syndrome X patients.

In the continuing debate regarding the mechanism of atherosclerotic plaque formation in arteries, one question remains unanswered: While all arteries in a patient are exposed to the same systemic risk factors (hypertension, diabetes, aging, nicotine of cigarettes, etc.), why do plaques frequently present in the coronary arteries, and to a lesser extent in the arteries of the lower extremities, and still less in the carotid or renal arteries? Over the past five years, in order to find an answer to the above question, there has been a radical shift in our research strategy: The principles of fluid dynamics in industrial and domestic pipes/pipelines were employed to decipher changes in the cardiovascular system. The types of flow under investigation included laminar, entrance, turbulent, and helical flows in systole and diastole, as well as the interface between antegrade and retrograde flows resulting in water hammer shock and cavitation phenomena. We aim to highlight the similarities and differences among flow types in arteries and pipes and to apply the same methodologies to study the formation, growth, and rupture of coronary plaques leading to inactive and active clinical syndromes as well as the beneficial mechanism of percutaneous coronary interventions (PCI). In this article, we list the questions and the answers based on the main data of several completed studies and the preliminary results of ongoing projects from a fluid mechanics perspective. The angiographic coronary images of recirculation flow, vortex formation, collision, hammer water shock, and cavitation will be showcased in detail, and their videos in slow motion are uploaded in the addendum for further in-depth review.

Coronary artery disease (CAD) is one of the most common and severe medical conditions worldwide. The current research focused on investigating the mechanisms and prevention of the detrimental effects of CAD. Recently, the principles and practices of fluid mechanics were used to explain the formation of CAD with the help of a new angiographic recording and reviewing technique. This new method focused on identifying the types of blood flows and their effects on the intima. To automate the process, an Artificial Intelligence program was utilized to support the investigators in reviewing coronary flow. This paper analyzes AI methods that assisted physician investigators in the measurement of the arterial phase and in the identification of the types of coronary flows.