Assessing the Impact of Valve Sizing and Orientation on Bioprosthetic Pulmonary Valve Hemodynamics Using In Vitro 4D-Flow MRI

Purpose Pulmonary valve replacement (PVR) using bioprosthetic valves is a common procedure performed in patients with repaired Tetralogy of Fallot and other conditions, but these valves frequently become dysfunctional within 15 years of implantation. Since PVR is often performed in adolescence, valves are typically oversized to account for somatic growth. However, the contribution of oversizing to early valve failure are not clearly understood. The purpose of this study was to explore the impact of valve sizing and orientation on local hemodynamics and valve performance. Methods Different valve sizes were represented by changing the cardiac output through a 25 mm bioprosthetic valve implanted in an idealized 3D-printed model of the right ventricular outflow tract (RVOT). The local hemodynamics at three valve sizes and two valve orientations were assessed using 4D-Flow MRI and high-speed camera imaging. Results Noticeable differences in jet asymmetry, the amount of recirculation, leaflet opening patterns, as well as the size and location of reversed flow regions were observed with varying valve sizes. Rotation of the valve resulted in drastic differences in reversed flow regions, but not forward flow. Conclusion Flow features observed in the oversized valve in this study have previously been correlated with calcification, hemolysis, and leaflet fatigue. Therefore, valve oversizing can negatively impact local hemodynamics and leaflet performance. ### Competing Interest Statement The authors have declared no competing interest.