. 2019 Nov 1;40(41):3421-3433.

doi: 10.1093/eurheartj/ehz551.

Expert recommendations on the assessment of wall shear stress in human coronary arteries: existing methodologies, technical considerations, and clinical applications

Frank Gijsen¹, Yuki Katagiri², Peter Barlis^{3

4

5}, Christos Bourantas^{6

7

8}, Carlos Collet², Umit Coskun⁹, Joost Daemen¹, Jouke Dijkstra¹⁰, Elazer Edelman^{9

11}, Paul Evans¹², Kim van der Heiden¹, Rod Hose^{12

13}, Bon-Kwon Koo^{14

15}, Rob Krams¹⁶, Alison Marsden¹⁷, Francesco Migliavacca¹⁸, Yoshinobu Onuma¹⁹, Andrew Ooi²⁰, Eric Poon²⁰, Habib Samady²¹, Peter Stone⁹, Kuniaki Takahashi², Dalin Tang²², Vikas Thondapu^{3

20

23}, Erhan Tenekecioglu²⁴, Lucas Timmins^{25

26}, Ryo Torii²⁷, Jolanda Wentzel¹, Patrick Serruys^{19

28

29}

Affiliations

¹ Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
² Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, the Netherlands.
³ Department of Medicine and Radiology, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia.
⁴ Department of Cardiology, Northern Hospital, 185 Cooper Street, Epping, Australia.
⁵ St Vincent's Heart Centre, Building C, 41 Victoria Parade, Fitzroy, Australia.
⁶ Institute of Cardiovascular Sciences, University College of London, London, UK.
⁷ Department of Cardiology, Barts Heart Centre, London, UK.
⁸ School of Medicine and Dentistry, Queen Mary University London, London, UK.
⁹ Division of Cardiovascular Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA.
¹⁰ LKEB-Division of Image Processing, Department of Radiology, Leiden University Medical Centre, Leiden, the Netherlands.
¹¹ Institute for Medical Engineering and Science, MIT, Cambridge, MA, USA.
¹² Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, UK.
¹³ Department of Circulation and Imaging, NTNU, Trondheim, Norway.
¹⁴ Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea.
¹⁵ Institute of Aging, Seoul National University, Seoul, Korea.
¹⁶ School of Engineering and Materials Science Queen Mary University of London, London, UK.
¹⁷ Departments of Bioengineering and Pediatrics, Institute of Computational and Mathematical Engineering, Stanford University, Stanford, CA, USA.
¹⁸ Laboratory of Biological Structure Mechanics (LaBS), Department of Chemistry, Materials and Chemical Engineering "Giulio Natta", Politecnico di Milano, Milan, Italy.
¹⁹ Erasmus University Medical Center, Rotterdam, the Netherlands.
²⁰ Department of Mechanical Engineering, Melbourne School of Engineering, The University of Melbourne, Melbourne, VIC, Australia.
²¹ Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.
²² Department of Mathematics, Southeast University, Nanjing, China; Mathematical Sciences Department, Worcester Polytechnic Institute, Worcester, MA, USA.
²³ Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
²⁴ Department of Interventional Cardiology, Thoraxcentre, Erasmus Medical Centre, Rotterdam, the Netherlands.
²⁵ Department of Biomedical Engineering, University of Utah, Salt Lake City, UT.
²⁶ Scientific Computing and Imaging Institute, University of Utah, Salt Lake City, UT.
²⁷ Department of Mechanical Engineering, University College London, UK.
²⁸ Imperial College London, London, UK.
²⁹ Melbourne School of Engineering, University of Melbourne, Melbourne, Australia.

PMID: 31566246
PMCID: PMC6823616
DOI: 10.1093/eurheartj/ehz551

Expert recommendations on the assessment of wall shear stress in human coronary arteries: existing methodologies, technical considerations, and clinical applications

Frank Gijsen et al. Eur Heart J. 2019.

. 2019 Nov 1;40(41):3421-3433.

doi: 10.1093/eurheartj/ehz551.

Authors

Affiliations

¹ Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
² Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, the Netherlands.
³ Department of Medicine and Radiology, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia.
⁴ Department of Cardiology, Northern Hospital, 185 Cooper Street, Epping, Australia.
⁵ St Vincent's Heart Centre, Building C, 41 Victoria Parade, Fitzroy, Australia.
⁶ Institute of Cardiovascular Sciences, University College of London, London, UK.
⁷ Department of Cardiology, Barts Heart Centre, London, UK.
⁸ School of Medicine and Dentistry, Queen Mary University London, London, UK.
⁹ Division of Cardiovascular Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA.
¹⁰ LKEB-Division of Image Processing, Department of Radiology, Leiden University Medical Centre, Leiden, the Netherlands.
¹¹ Institute for Medical Engineering and Science, MIT, Cambridge, MA, USA.
¹² Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, UK.
¹³ Department of Circulation and Imaging, NTNU, Trondheim, Norway.
¹⁴ Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea.
¹⁵ Institute of Aging, Seoul National University, Seoul, Korea.
¹⁶ School of Engineering and Materials Science Queen Mary University of London, London, UK.
¹⁷ Departments of Bioengineering and Pediatrics, Institute of Computational and Mathematical Engineering, Stanford University, Stanford, CA, USA.
¹⁸ Laboratory of Biological Structure Mechanics (LaBS), Department of Chemistry, Materials and Chemical Engineering "Giulio Natta", Politecnico di Milano, Milan, Italy.
¹⁹ Erasmus University Medical Center, Rotterdam, the Netherlands.
²⁰ Department of Mechanical Engineering, Melbourne School of Engineering, The University of Melbourne, Melbourne, VIC, Australia.
²¹ Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.
²² Department of Mathematics, Southeast University, Nanjing, China; Mathematical Sciences Department, Worcester Polytechnic Institute, Worcester, MA, USA.
²³ Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
²⁴ Department of Interventional Cardiology, Thoraxcentre, Erasmus Medical Centre, Rotterdam, the Netherlands.
²⁵ Department of Biomedical Engineering, University of Utah, Salt Lake City, UT.
²⁶ Scientific Computing and Imaging Institute, University of Utah, Salt Lake City, UT.
²⁷ Department of Mechanical Engineering, University College London, UK.
²⁸ Imperial College London, London, UK.
²⁹ Melbourne School of Engineering, University of Melbourne, Melbourne, Australia.

PMID: 31566246
PMCID: PMC6823616
DOI: 10.1093/eurheartj/ehz551

No abstract available

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Figures

**Figure 1**
A schematic representation of the forces the vessel wall is exposed to. The red arrow is the normal force component, associated with blood pressure, and the green arrow is the tangential component force, associated with wall shear stress. Note that the size of the arrows does not represents the magnitude of the forces, only the direction.

**Figure 2**
A schematic illustration of some of the processes that are involved in plaque development and rupture, and how these are related to wall shear stress. In low wall shear stress regions, monocytes are recruited by the endothelium through the expression of various adhesion molecules. Recruited monocytes transform into foam cells which subsequently can accumulate and are the main source for the development of the necrotic core. Expansive remodelling initially prevents lumen intrusion of the plaque, but once this process fails, the wall shear patterns the plaque is exposed to changes. High wall shear stress will be present at the upstream part and the throat of the plaque, while in the downstream region, low wall shear stress will be accompanied by elevated levels of oscillatory flow. Although there is no direct effect of wall shear stress on plaque rupture, shear stress does influence endothelial function, potentially leading to cap thinning in the high wall shear stress regions.

**Figure 3**
Methodology developed to fuse computed tomography angiography and intravascular imaging data: (A) Extraction of lumen centreline from computed tomography angiography. (B) Cross-sectional computed tomography angiography images are generated perpendicularly to the centreline and anatomical landmarks that are seen in intravascular ultrasound/optical coherence tomography images are detected. After matching the intravascular imaging contours are rotated so as to obtain the correct orientation (middle panel). (C) The orientated intravascular imaging contours are placed perpendicular to the lumen centreline extracted by computed tomography angiography to reconstruct the coronary artery anatomy that is shown in (D).

**Figure 4**
(A) Coronary tree showing multiple curvatures and bifurcation. (B) Secondary flow in the presence of the proximal curvature. (C) Macro-recirculation due to varying lumen geometries such as bifurcation and stenosis.

**Figure 5**
Changes in red blood cells under shear. Red blood cells aggregate at low shear rate, resulting in high blood viscosity. The process is reversed as shear rate increases.

**Figure 6**
Overview of micro flow environment around a stent strut (left) and the resulting high and low wall shear stress regions around the strut (right).

**Take home figure**
Wall shear stress in coronary arteries from imaging to modelling.

See this image and copyright information in PMC

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Expert recommendations on the assessment of wall shear stress in human coronary arteries: existing methodologies, technical considerations, and clinical applications

Affiliations

Expert recommendations on the assessment of wall shear stress in human coronary arteries: existing methodologies, technical considerations, and clinical applications

Authors

Affiliations

Figures

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References

Publication types

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Grants and funding

LinkOut - more resources

Full Text Sources

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Medical