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Maroun A, Quinn S, Dushfunian D, Weiss EK, Allen BD, Carr JC, Markl M. Clinical Applications of Four-Dimensional Flow MRI. Magn Reson Imaging Clin N Am 2023; 31:451-460. [PMID: 37414471 DOI: 10.1016/j.mric.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
Four-dimensional flow MRI is a powerful phase contrast technique used for assessing three-dimensional (3D) blood flow dynamics. By acquiring a time-resolved velocity field, it enables flexible retrospective analysis of blood flow that can include qualitative 3D visualization of complex flow patterns, comprehensive assessment of multiple vessels, reliable placement of analysis planes, and calculation of advanced hemodynamic parameters. This technique provides several advantages over routine two-dimensional flow imaging techniques, allowing it to become part of clinical practice at major academic medical centers. In this review, we present the current state-of-the-art cardiovascular, neurovascular, and abdominal applications.
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Affiliation(s)
- Anthony Maroun
- Department of Radiology, Northwestern University, Feinberg School of Medicine, 737 North Michigan Avenue Suite 1600, Chicago, IL 60611, USA.
| | - Sandra Quinn
- Department of Radiology, Northwestern University, Feinberg School of Medicine, 737 North Michigan Avenue Suite 1600, Chicago, IL 60611, USA
| | - David Dushfunian
- Department of Radiology, Northwestern University, Feinberg School of Medicine, 737 North Michigan Avenue Suite 1600, Chicago, IL 60611, USA
| | - Elizabeth K Weiss
- Department of Radiology, Northwestern University, Feinberg School of Medicine, 737 North Michigan Avenue Suite 1600, Chicago, IL 60611, USA
| | - Bradley D Allen
- Department of Radiology, Northwestern University, Feinberg School of Medicine, 737 North Michigan Avenue Suite 1600, Chicago, IL 60611, USA
| | - James C Carr
- Department of Radiology, Northwestern University, Feinberg School of Medicine, 737 North Michigan Avenue Suite 1600, Chicago, IL 60611, USA
| | - Michael Markl
- Department of Radiology, Northwestern University, Feinberg School of Medicine, 737 North Michigan Avenue Suite 1600, Chicago, IL 60611, USA
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2
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Sivakumar K. A catheter-based interventional strategy redirects hepatic vein flows after Fontan procedure in left isomerism to treat severe hypoxemia. Ann Pediatr Cardiol 2022; 15:212-215. [PMID: 36246757 PMCID: PMC9564401 DOI: 10.4103/apc.apc_80_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 06/01/2021] [Accepted: 06/03/2021] [Indexed: 11/24/2022] Open
Abstract
Pulmonary arteriovenous malformations after the Kawashima procedure causing severe hypoxemia are treated by Fontan surgery that redirects hepatic venous blood to the pulmonary circulation. Alignment of the hepatic venous conduit toward both pulmonary arteries is crucial for their regression. Persistent hypoxemia due to nonregressed malformations in one lung often warrants a repeat surgery to redirect hepatic venous flows. Catheter-based redirection of Fontan flows is not commonly performed as metallic stents and devices may predispose to thrombus formation in the circuit. This report highlights a patient with persistent arteriovenous malformations in the left lung leading to severe disabling hypoxemia that was managed in the catheterization laboratory with an innovative strategy to redirect Fontan flows toward the affected left lung.
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3
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Rizk J. 4D flow MRI applications in congenital heart disease. Eur Radiol 2020; 31:1160-1174. [PMID: 32870392 DOI: 10.1007/s00330-020-07210-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 07/04/2020] [Accepted: 08/19/2020] [Indexed: 12/15/2022]
Abstract
Advances in the diagnosis and management of congenital heart disease (CHD) have resulted in a growing population of patients surviving well into adulthood and requiring lifelong follow-up. Flow quantification is a central component in the assessment of patients with CHD. 4D flow magnetic resonance imaging (MRI) has emerged as a tool that enables comprehensive study of flow. It involves the acquisition of a three-dimensional time-resolved volume with velocity encoding in all three spatial directions along the cardiac cycle. This allows flow quantification and visualization of blood flow patterns as well as the study of advanced hemodynamic parameters as kinetic energy and wall shear stress. 4D flow MRI-based study of flow has given insight into the altered hemodynamics in CHD particularly in bicuspid aortic valve disease and Fontan circulation. The aim of this review is to discuss the expanding clinical and research applications of 4D flow MRI in CHD as well its limitations.Key Points• Three-dimensional velocity encoding allows not only flow quantification but also the visualization of multidirectional flow patterns and the study of advanced hemodynamic parameters.• 4D flow MRI has added insight into the abnormal hemodynamics involved in congenital heart disease in particular in bicuspid aortic valve and Fontan circulation.• The main limitation of 4D flow MRI in congenital heart disease is the relatively long scan duration required for the complete coverage of the heart and great vessels with adequate spatiotemporal resolution.
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Affiliation(s)
- Judy Rizk
- Department of Cardiology, Faculty of Medicine, Alexandria University, El-Khartoum Square, Alexandria, 21521, Egypt.
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4
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Chen X, Yuan H, Liu J, Zhang N, Zhou C, Huang M, Jian Q, Zhuang J. Hemodynamic Effects of Additional Pulmonary Blood Flow on Glenn and Fontan Circulation. Cardiovasc Eng Technol 2020; 11:268-282. [PMID: 32072439 DOI: 10.1007/s13239-020-00459-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 02/10/2020] [Indexed: 10/25/2022]
Abstract
PURPOSE Additional pulmonary blood flow (APBF) can provide better pulsating blood flow and systemic arterial oxygen saturation, while low blood pulsation and low oxygen saturation are defects of the Fontan and Glenn procedure. Studying the hemodynamic effect of APBF is beneficial for clinical decisions. This study aimed to explore the effect on particle washout, as well as the differences among the sensitivities of both different hemodynamic parameters and different procedures to APBF. METHODS The patient-specific clinical datasets of a patient who underwent bilateral bidirectional Glenn (BBDG) with APBF were enrolled in this study, and using these datasets, Glenn- and Fontan-type artery models were reconstructed. A series of parameters, including the total caval flow pulsatility index (TCPI), indexed energy loss (iPL), wall shear stress (WSS), systemic arterial oxygen saturation (Satart), particle washout time (WOT), pressure in the right superior vena cava (PRSVC), pulmonary flow distribution (PFD) and hepatic flow distribution (HFD), were computed from computational fluid dynamic (CFD) simulation to evaluate the hemodynamic effect of APBF. RESULTS The result showed that APBF led to better iPL and Satart but worse PRSVC and heart load accompanied by a great impact on HFD, making hepatic flow easier to perfuse the side without MPA and APBF. The increase in the APBF rate also effectively results in larger flow pulsation, region velocity, and wall shear stress and lower WOT, and this effect may be more effective for patients with persistent left superior vena cava (PLSVC). However, APBF might have little effect on PFD. Furthermore, APBF might affect WOT, iPL and HFD more significantly than PRSVC and has a greater improvement effect in patients with poorer iPL and WOT. CONCLUSIONS Moderate APBF is not only a measure to promote pulmonary artery growth and systemic arterial oxygen saturation but also an effective method against endothelial dysfunction and thrombosis. However, moderate APBF is patient-specific and should be determined based on hemodynamic preference that leads to desired patient outcomes, and care should be taken to prevent PRSVC and heart load from being too high as well as an imbalance in HFD.
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Affiliation(s)
- Xiangyu Chen
- School of Mechanical and Automotive Engineering, South China University of Technology, Guangzhou, 510000, China
| | - Haiyun Yuan
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Department of Cardiovascular Surgery, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, 510000, China
| | - Jiawei Liu
- School of Mechanical and Automotive Engineering, South China University of Technology, Guangzhou, 510000, China
| | - Neichuan Zhang
- School of Mechanical and Automotive Engineering, South China University of Technology, Guangzhou, 510000, China
| | - Chengbin Zhou
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Department of Cardiovascular Surgery, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, 510000, China
| | - Meiping Huang
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Department of Catheterization Lab, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Qifei Jian
- School of Mechanical and Automotive Engineering, South China University of Technology, Guangzhou, 510000, China.
| | - Jian Zhuang
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Department of Cardiovascular Surgery, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, 510000, China.
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5
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Montesa C, Karamlou T, Ratnayaka K, Pophal SG, Ryan J, Nigro JJ. Hepatic Vein Incorporation Into the Azygos System in Heterotaxy and Interrupted Inferior Vena Cava. World J Pediatr Congenit Heart Surg 2019; 10:330-337. [DOI: 10.1177/2150135119842869] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Patients with heterotaxy, single ventricle and interrupted inferior vena cava are at risk of developing significant pulmonary arteriovenous malformations and cyanosis, and inequitable distribution of hepatic factor has been implicated in their development. We describe our experience with a technique for hepatic vein incorporation that reliably provides resolution of cyanosis and presumably equitable hepatic factor distribution. Methods: A retrospective review of a single-surgeon experience was conducted for patients who underwent this modified Fontan operation utilizing an extracardiac conduit from the hepatic veins to the dominant superior cavopulmonary connection. Preoperative characteristics and imaging, operative details, and postoperative course and imaging were abstracted. Results: Median age at operation was 5 years (2-10 years) and median weight was 19.6 kg (11.8-23 kg). Sixty percent (3/5) of patients had Fontan completion without cardiopulmonary bypass, and follow-up was complete at a median of 14 months (range 1-20 months). Systemic saturations increased significantly from 81% ± 1.9% preoperatively to 95% ± 3.5% postoperatively, P = .0008. Median length of stay was 10 days (range: 7-14 days). No deaths occurred. One patient required reoperation for bleeding and one was readmitted for pleural effusion. Postoperative imaging suggested distribution of hepatic factor to all lung segments with improved pulmonary arteriovenous malformation burden. Conclusions: Hepatic vein incorporation for patients with heterotaxy and interrupted inferior vena cava should optimally provide equitable pulmonary distribution of hepatic factor with resolution of cyanosis. The described technique is performed through a conventional approach, is facile, and improves cyanosis in these complex patients.
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Affiliation(s)
- Christine Montesa
- Division of Cardiovascular Surgery, Heart Institute, Rady Children’s Hospital, San Diego, CA, USA
| | - Tara Karamlou
- Division of Pediatric Cardiac Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kanishka Ratnayaka
- Division of Cardiology, Heart Institute, Rady Children’s Hospital, San Diego, CA, USA
| | - Stephen G. Pophal
- Children’s Heart Center, Phoenix Children’s Hospital, Phoenix, AZ, USA
| | - Justin Ryan
- 3D Innovations Lab, Heart Institute, Rady Children’s Hospital, San Diego, CA, USA
| | - John J. Nigro
- Division of Cardiovascular Surgery, Heart Institute, Rady Children’s Hospital, San Diego, CA, USA
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6
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Adamson GT, Peng LF, Lui GK, Perry SB. Transcatheter redirection of hepatic venous blood to treat unilateral pulmonary arteriovenous malformations in a Fontan circulation by short-term total exclusion of the unaffected lung. Catheter Cardiovasc Interv 2019; 93:660-663. [PMID: 30629315 DOI: 10.1002/ccd.28073] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 11/13/2018] [Accepted: 12/22/2018] [Indexed: 11/09/2022]
Abstract
Clinically significant unilateral pulmonary arteriovenous malformations (PAVM) can develop in patients with a Fontan circulation when there is unbalanced distribution of hepatic venous (HV) blood flow to the lungs. There are reported surgical and transcatheter techniques to treat PAVMs by rerouting HV return, with promising short-term results. We report a case of a novel, technically simple transcatheter approach to redirect HV blood flow in an adult Fontan patient with polysplenia syndrome and severe unilateral PAVMs. Our patient had a two-stage procedure, the first to redirect all HV blood flow to the affected lung with a single covered stent, and a second to confirm resolution of PAVMs and to reintroduce HV effluent to the unaffected lung. At 10-month follow-up, her oxygen saturations had increased from 75% to 93% with a marked improvement in her functional status.
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Affiliation(s)
- Gregory T Adamson
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Lynn F Peng
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - George K Lui
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California.,Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Stanton B Perry
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
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7
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Rutkowski DR, Barton G, François CJ, Bartlett HL, Anagnostopoulos PV, Roldán-Alzate A. Analysis of cavopulmonary and cardiac flow characteristics in fontan Patients: Comparison with healthy volunteers. J Magn Reson Imaging 2019; 49:1786-1799. [PMID: 30635978 DOI: 10.1002/jmri.26583] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 11/06/2018] [Accepted: 11/06/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Characterizing the flow of the Fontan circuit, and correlating flow characteristics with the development of complications, is an important clinical challenge. Past work has analyzed the flow characteristics of Fontan circulation on a component-by-component basis. 4D flow MRI with radial projections allows for large volumetric coverage, and therefore can be used to analyze the flow through many codependent cardiovascular components in a single imaging session. PURPOSE To describe flow characteristics across the entire Fontan circuit and to compare these with the flow characteristics in healthy volunteers. STUDY TYPE Prospective. SUBJECTS Eleven single ventricle patients with a Fontan connection and 15 healthy controls. SEQUENCE Phase contrast with vastly undersampled isotropic projection reconstruction (PC-VIPR) at a field strength of 3 T. ASSESSMENT Cavopulmonary and ventricular flow distributions, blood flow kinetic energy, vorticities, efficiency indices, and other flow parameters were analyzed using Ensight and MatLab. STATISTICAL TESTS The results were compared across Fontan subjects, between respiratory phases, and between Fontan subjects and healthy volunteers using a Student's t-test for unequal sample sizes and linear regression. RESULTS Cava-specific pulmonary flow distributions of Fontan patients varied significantly between respiratory phases (P < 0.05). Ventricular kinetic energy (KE) was significantly higher in Fontan patients than it was in healthy controls, leading to a lower cardiac efficiency metric in the Fontan group. A significant diastolic KE time-shift was also observed in the Fontan patient group. Peak diastolic KE was significantly higher in the single ventricle of patients with right ventricle morphology than it was in left ventricle morphology patients. DATA CONCLUSION Radial 4D flow MRI can be used for comprehensive analysis of single ventricle Fontan flow characteristics. LEVEL OF EVIDENCE 2 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019.
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Affiliation(s)
- David R Rutkowski
- Mechanical Engineering, University of Wisconsin - Madison, Madison, Wisconsin, USA.,Radiology, University of Wisconsin - Madison, Madison, Wisconsin, USA
| | - Gregory Barton
- Radiology, University of Wisconsin - Madison, Madison, Wisconsin, USA.,Medical Physics, University of Wisconsin - Madison, Madison, Wisconsin, USA
| | | | - Heather L Bartlett
- Pediatrics and Medicine, University of Wisconsin - Madison, Madison, Wisconsin, USA
| | | | - Alejandro Roldán-Alzate
- Mechanical Engineering, University of Wisconsin - Madison, Madison, Wisconsin, USA.,Radiology, University of Wisconsin - Madison, Madison, Wisconsin, USA.,Biomedical Engineering, University of Wisconsin - Madison, Madison, Wisconsin, USA
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8
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Lee JW, Park JJ, Goo HW, Ko JK. Fontan Revision with Y-Graft in a Patient with Unilateral Pulmonary Arteriovenous Malformation. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2017; 50:207-210. [PMID: 28593158 PMCID: PMC5460969 DOI: 10.5090/kjtcs.2017.50.3.207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 10/27/2016] [Accepted: 10/28/2016] [Indexed: 11/18/2022]
Abstract
The extracardiac conduit Fontan procedure is the last surgical step in the treatment of patients with a functional single ventricle. An acquired pulmonary arteriovenous malformation may appear perioperatively or postoperatively due to an uneven hepatic flow distribution. Here we report a case of a bifurcated Y-graft Fontan operation in a 15-year-old male patient with a unilateral pulmonary arteriovenous malformation after an extracardiac conduit Fontan operation.
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Affiliation(s)
- Jeong-Woo Lee
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Jeong-Jun Park
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Hyun Woo Goo
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine
| | - Jae Kon Ko
- Department of Pediatric Cardiology, Asan Medical Center, University of Ulsan College of Medicine
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9
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Vaughn G, Moore J, Lamberti J, Canter C. Management of the failing Fontan: Medical, interventional and surgical treatment. PROGRESS IN PEDIATRIC CARDIOLOGY 2016. [DOI: 10.1016/j.ppedcard.2016.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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10
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Ohuchi H. Adult patients with Fontan circulation: What we know and how to manage adults with Fontan circulation? J Cardiol 2016; 68:181-9. [PMID: 27134136 DOI: 10.1016/j.jjcc.2016.04.001] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Accepted: 03/28/2016] [Indexed: 02/02/2023]
Abstract
Most of patients after the Fontan operation can reach their adulthood, however, the management strategy for this complex pathophysiology has not been yet established. In general, elevated central venous pressure (CVP) and low cardiac output (CO) due to impaired ventricular preload characterize the Fontan circulation and the ideal hemodynamics could be a combination of a lower CVP with a higher CO. Thus, preserved functional systemic ventricle with low pulmonary artery resistance is thought to be crucial for better long-term outcome. However, on the other hand, because of the unique hemodynamics, these patients have significantly higher incidence of complications, sequelae, and even mortality. The major complications are supraventricular arrhythmias, heart failure, and Fontan-related problems, including protein-losing enteropathy and pulmonary arteriovenous fistulae, both of which are refractory to the treatments, and most of these "Fontan inconveniences" increase as patients age. In addition, one of the recent emerging problems is Fontan-associated liver disease that includes liver cirrhosis and hepatocellular carcinoma. Furthermore, women with Fontan circulation also reach childbearing age and there have been increasing numbers of reports showing a high incidence of pregnancy-associated complications. All these problems may be a part of "Fontan inconveniences" because most of the current Fontan patients are still "young" i.e. in their twenties or thirties and it may be not surprising that more new Fontan-associated pathophysiology emerges as patients age. Recent evidence reminds us of the concept that adult Fontan pathophysiology is not just a cardiovascular disease, rather, a multiorgan disease with many interactions between cardiovascular and non-cardiovascular organs. Therefore, a multidisciplinary approach is mandatory to take care of and anticipate the better long-term outcome.
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Affiliation(s)
- Hideo Ohuchi
- Department of Pediatric Cardiology and Adult Congenital Heart Disease, National Cerebral and Cardiovascular Center, Osaka, Japan.
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11
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Flow simulations and validation for the first cohort of patients undergoing the Y-graft Fontan procedure. J Thorac Cardiovasc Surg 2015; 149:247-55. [DOI: 10.1016/j.jtcvs.2014.08.069] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 08/19/2014] [Accepted: 08/23/2014] [Indexed: 12/26/2022]
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12
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Larsen SH, Emmertsen K, Bjerre J, Hjortdal VE. Progressive cyanosis following Kawashima operation: slow resolution after redirection of hepatic veins. J Cardiothorac Surg 2013; 8:67. [PMID: 23561447 PMCID: PMC3622568 DOI: 10.1186/1749-8090-8-67] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Accepted: 03/21/2013] [Indexed: 11/12/2022] Open
Abstract
Progressive cyanosis often develops following Kawashima operation in patients with left atrial isomerism, interrupted inferior vena cava and hepatic veins draining to the atria. Knowledge on the timing and extend of resolution following hepatic venous redirection is sparse. A girl developed progressing cyanosis following Kawashima operation at the age of ten months. Arterial oxygen saturations at rest dropped to 60-65%. Surgical redirection of hepatic veins into the cavopulmonary circulation at the age of three years had no immediate effect. However, arterial oxygen saturations increased gradually over nine months to 90-93% and 95-100% after three years.
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Affiliation(s)
- Signe Holm Larsen
- Department of Cardiology, Aarhus University Hospital, Brendstrupgaardsvej, 8200 Aarhus N, Denmark.
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13
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Yang W, Feinstein JA, Shadden SC, Vignon-Clementel IE, Marsden AL. Optimization of a Y-Graft Design for Improved Hepatic Flow Distribution in the Fontan Circulation. J Biomech Eng 2012; 135:011002. [DOI: 10.1115/1.4023089] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Single ventricle heart defects are among the most serious congenital heart diseases, and are uniformly fatal if left untreated. Typically, a three-staged surgical course, consisting of the Norwood, Glenn, and Fontan surgeries is performed, after which the superior vena cava (SVC) and inferior vena cava (IVC) are directly connected to the pulmonary arteries (PA). In an attempt to improve hemodynamic performance and hepatic flow distribution (HFD) of Fontan patients, a novel Y-shaped graft has recently been proposed to replace the traditional tube-shaped extracardiac grafts. Previous studies have demonstrated that the Y-graft is a promising design with the potential to reduce energy loss and improve HFD. However these studies also found suboptimal Y-graft performance in some patient models. The goal of this work is to determine whether performance can be improved in these models through further design optimization. Geometric and hemodynamic factors that influence the HFD have not been sufficiently investigated in previous work, particularly for the Y-graft. In this work, we couple Lagrangian particle tracking to an optimal design framework to study the effects of boundary conditions and geometry on HFD. Specifically, we investigate the potential of using a Y-graft design with unequal branch diameters to improve hepatic distribution under a highly uneven RPA/LPA flow split. As expected, the resulting optimal Y-graft geometry largely depends on the pulmonary flow split for a particular patient. The unequal branch design is demonstrated to be unnecessary under most conditions, as it is possible to achieve the same or better performance with equal-sized branches. Two patient-specific examples show that optimization-derived Y-grafts effectively improve the HFD, compared to initial nonoptimized designs using equal branch diameters. An instance of constrained optimization shows that energy efficiency slightly increases with increasing branch size for the Y-graft, but that a smaller branch size is preferred when a proximal anastomosis is needed to achieve optimal HFD.
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Affiliation(s)
- Weiguang Yang
- Mechanical and Aerospace Engineering, University of California San Diego, La Jolla, CA 92093 e-mail:
| | | | - Shawn C. Shadden
- Mechanical, Materials, and
Aerospace Engineering, Illinois Institute of Technology, Chicago, IL 60616 e-mail:
| | | | - Alison L. Marsden
- Mechanical and Aerospace Engineering, University of California San Diego, La Jolla, CA 92093 e-mail:
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14
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Grosse-Wortmann L, Dragulescu A, Drolet C, Chaturvedi R, Kotani Y, Mertens L, Taylor K, La Rotta G, van Arsdell G, Redington A, Yoo SJ. Determinants and clinical significance of flow via the fenestration in the Fontan pathway: a multimodality study. Int J Cardiol 2012; 168:811-7. [PMID: 23164583 DOI: 10.1016/j.ijcard.2012.10.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Revised: 09/19/2012] [Accepted: 10/07/2012] [Indexed: 11/18/2022]
Abstract
BACKGROUND The use of a fenestration in the Fontan pathway remains controversial, partly because its hemodynamic effects and clinical consequences are insufficiently understood. The objective of this study was to quantify the magnitude of fenestration flow and to characterize its hemodynamic consequences after an intermediate interval after surgery. METHODS Twenty three patients with a fenestrated extracardiac conduit prospectively underwent investigation by cardiac magnetic resonance (CMR), echocardiography, and invasive manometry under the same general anesthetic 12 ± 4 months after Fontan surgery. Fenestration flow was determined using phase contrast CMR by subtracting flow in the Fontan pathway above the fenestration from Fontan flow below the fenestration. RESULTS Fenestration flow constituted a mean of 31 ± 12% (range 8-50%) of ventricular preload. It was associated with a lower Qp/Qs (r = -0.64, p=0.001) and oxygen saturation (r = -0.74, p<0.0001). Fenestration flow volume was correlated with pulmonary vascular resistance (r = 0.45, p = 0.04) and markers of ventricular diastolic function (early diastolic strain rate r = 0.57, p = 0.008 and ventricular untwist rate r = 0.54, p = 0.02). In 14 patients (61%) all of the net inferior vena cava flow and part of the superior vena cava flow were diverted into the systemic atrium and did not reach the lungs. CONCLUSIONS Fenestration flow can be measured accurately with CMR. In two-thirds of the patients not only all of the inferior vena cava flow, but also some of the superior vena cava flow is diverted through the fenestration. Fenestration flow is driven by a balance between pulmonary vascular resistance and early diastolic ventricular function.
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Affiliation(s)
- Lars Grosse-Wortmann
- The Labatt Family Heart Centre and Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, Canada.
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15
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McElhinney DB, Marx GR, Marshall AC, Mayer JE, del Nido PJ. Cavopulmonary pathway modification in patients with heterotaxy and newly diagnosed or persistent pulmonary arteriovenous malformations after a modified Fontan operation. J Thorac Cardiovasc Surg 2011; 141:1362-70.e1. [PMID: 21146835 DOI: 10.1016/j.jtcvs.2010.08.088] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2010] [Revised: 08/02/2010] [Accepted: 08/05/2010] [Indexed: 11/24/2022]
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16
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Burstein DS, Mavroudis C, Puchalski MD, Stewart RD, Blanco CJ, Jacobs ML. Pulmonary Arteriovenous Malformations in Heterotaxy Syndrome. World J Pediatr Congenit Heart Surg 2010; 2:119-28. [PMID: 23804943 DOI: 10.1177/2150135110387310] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We report a surgical approach using hepatic vein–to–azygos vein connection without cardiopulmonary bypass or deep hypothermic circulatory arrest in a patient with heterotaxy syndrome and interrupted inferior vena cava with persistence of pulmonary arteriovenous malformations (PAVMs) after previous Fontan completion. We advocate early performance of hepatic vein–to–azygos vein connection following the Kawashima operation for heterotaxy with functionally univentricular heart and interrupted inferior vena cava. We review the physiology of heterotaxy syndrome with congenital heart disease and justify our approach in the context of a review of previous surgical strategies used in this patient population.
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Affiliation(s)
- Danielle S. Burstein
- Center for Pediatric and Congenital Heart Diseases, Cleveland Clinic, Cleveland, Ohio
| | - Constantine Mavroudis
- Center for Pediatric and Congenital Heart Diseases, Cleveland Clinic, Cleveland, Ohio
| | - Michael D. Puchalski
- Department of Pediatrics, University of Utah and Primary Children’s Medical Center, Salt Lake City, Utah
| | - Robert D. Stewart
- Center for Pediatric and Congenital Heart Diseases, Cleveland Clinic, Cleveland, Ohio
| | - Carlos J. Blanco
- Center for Pediatric and Congenital Heart Diseases, Cleveland Clinic, Cleveland, Ohio
| | - Marshall L. Jacobs
- Center for Pediatric and Congenital Heart Diseases, Cleveland Clinic, Cleveland, Ohio
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CT findings in unilateral hepatopulmonary syndrome after the Fontan operation. Pediatr Radiol 2009; 39:336-42. [PMID: 19189098 DOI: 10.1007/s00247-008-1120-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2007] [Revised: 10/22/2008] [Accepted: 11/18/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Patients with complex congenital heart defects palliated by connecting the systemic veins directly to the pulmonary circulation are known to develop hepatopulmonary syndrome (HPS). Although rare, HPS can develop following the Fontan operation. OBJECTIVE To present and analyse the CT findings of HPS in patients with a Fontan circulation. MATERIALS AND METHODS From May to December 2005, six patients with HPS following the completion of a Fontan circulation were evaluated. CT findings were reviewed and were compared with angiographic findings. RESULTS All six patients showed unilateral involvement. All patients except one had inferior vena cava (IVC) interruption with azygos continuation. CT scans showed abnormal vascular dilatation in one lung, and properly demonstrated the anatomy causing the hepatic venous blood to flow preferentially into one lung. These CT findings correlated well with the angiography findings. CONCLUSION HPS that develops after the Fontan procedure is typically unilateral and is often associated with IVC interruption and azygos or hemiazygos continuation. CT demonstrates dilatation of pulmonary vessels in the affected lung and may be able to demonstrate the underlying anatomical cause for the predilection of hepatic venous flow to the contralateral lung.
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Rigelsky CM, Jennings C, Lehtonen R, Minai OA, Eng C, Aldred MA. BMPR2 mutation in a patient with pulmonary arterial hypertension and suspected hereditary hemorrhagic telangiectasia. Am J Med Genet A 2008; 146A:2551-6. [PMID: 18792970 DOI: 10.1002/ajmg.a.32468] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Pulmonary arterial hypertension (PAH) and hereditary hemorrhagic telangiectasia (HHT) are distinct clinical entities caused by germline mutations in genes encoding members of the TGFbeta/BMP superfamily: BMPR2 in PAH and ACVRL1, ENG, or SMAD4 in HHT. When PAH and HHT occasionally co-exist within the same family, ACVRL1 mutations predominate. We report a 36-year-old woman initially diagnosed with PAH at age 24. At 35, following massive hemoptysis, multiple pulmonary arteriovenous malformations were discovered, prompting evaluation for HHT. She met the Curaçao diagnostic criteria for suspected HHT based on additional findings of nasal telangiectases and epistaxis. Mutation analysis of ACVRL1, ENG, and SMAD4 was normal, but a germline nonsense mutation in BMPR2 was identified. This is the first known report of HHT features, particularly pulmonary AVMs, associated with a BMPR2 mutation. It adds further weight to a common molecular pathogenesis in PAH and HHT, and highlights that BMPR2 gene analysis is indicated in patients affected with both HHT and PAH.
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