Changes in aortic rotational flow during cardiopulmonary bypass studied by transesophageal echocardiography and magnetic resonance velocity imaging: a potential mechanism for atheroembolism during cardiopulmonary bypass

Abstract

The human aorta is a curved conduit with a complex three-dimensional geometry. The curvature influences axial velocity distribution and introduces transverse velocity components. Rotational flow in the aorta can be demonstrated during normal pulsatile flow using transesophageal echocardiography. Cardiopulmonary bypass may affect the pattern of rotational flow in the aorta and thus influence the generation of atheroemboli. We investigated rotational flow in the descending aorta using color flow mapping and pulse-wave Doppler on transesophageal echocardiography before and during cardiopulmonary bypass. We correlated our findings with magnetic resonance velocity imaging in a model of a human aortic arch connected to a cardiopulmonary bypass circuit. Before cardiopulmonary bypass, rotational flow in the descending aorta was seen in 37 of 40 patients (93%). In the majority of these patients, rotational flow was in the clockwise direction during systole, looking in the direction of flow (30 of 37 patients, 81%, P < 0.01 vs counterclockwise rotation). During cardiopulmonary bypass, there were almost equal numbers of patients with clockwise (18 patients) and counterclockwise rotation (19 patients). Forty-seven percent of patients with clockwise rotation before cardiopulmonary bypass developed reversal in the direction of rotation to counterclockwise during cardiopulmonary bypass. Twenty-nine percent of patients with counterclockwise rotation developed reversal of the direction of rotation during cardiopulmonary bypass. The transverse velocity component increased during cardiopulmonary bypass regardless of the direction of rotation. We also demonstrated clockwise rotation in the descending aorta of a human aortic arch model connected to a cardiopulmonary bypass circuit using magnetic resonance velocity mapping. Before cardiopulmonary bypass, rotation was predominantly clockwise, while during cardiopulmonary bypass, there was no preferred direction of rotation. The geometry of the aorta, which is fairly constant in all patients, imposes handedness to aortic flow before cardiopulmonary bypass. However, during cardiopulmonary bypass, other extrinsic factors such as aortic cannula orientation may influence the direction of rotation. The change in direction of rotational flow and increase in its transverse velocity component during cardiopulmonary bypass may have implications for atheroembolism and arterial branch perfusion during extended periods of non-pulsatile flow.