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Govindarajan V, Marshall L, Sahni A, Cetatoiu MA, Eickhoff EE, Davee J, St Clair N, Schulz NE, Hoganson DM, Hammer PE, Ghelani SJ, Prakash A, Del Nido PJ, Rathod RH. Impact of Age-Related Change in Caval Flow Ratio on Hepatic Flow Distribution in the Fontan Circulation. Circ Cardiovasc Imaging 2024; 17:e016104. [PMID: 38567518 PMCID: PMC11073583 DOI: 10.1161/circimaging.123.016104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 03/15/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND The Fontan operation is a palliative technique for patients born with single ventricle heart disease. The superior vena cava (SVC), inferior vena cava (IVC), and hepatic veins are connected to the pulmonary arteries in a total cavopulmonary connection by an extracardiac conduit or a lateral tunnel connection. A balanced hepatic flow distribution (HFD) to both lungs is essential to prevent pulmonary arteriovenous malformations and cyanosis. HFD is highly dependent on the local hemodynamics. The effect of age-related changes in caval inflows on HFD was evaluated using cardiac magnetic resonance data and patient-specific computational fluid dynamics modeling. METHODS SVC and IVC flow from 414 patients with Fontan were collected to establish a relationship between SVC:IVC flow ratio and age. Computational fluid dynamics modeling was performed in 60 (30 extracardiac and 30 lateral tunnel) patient models to quantify the HFD that corresponded to patient ages of 3, 8, and 15 years, respectively. RESULTS SVC:IVC flow ratio inverted at ≈8 years of age, indicating a clear shift to lower body flow predominance. Our data showed that variation of HFD in response to age-related changes in caval inflows (SVC:IVC, 2, 1, and 0.5 corresponded to ages, 3, 8, and 15+, respectively) was not significant for extracardiac but statistically significant for lateral tunnel cohorts. For all 3 caval inflow ratios, a positive correlation existed between the IVC flow distribution to both the lungs and the HFD. However, as the SVC:IVC ratio changed from 2 to 0.5 (age, 3-15+) years, the correlation's strength decreased from 0.87 to 0.64, due to potential flow perturbation as IVC flow momentum increased. CONCLUSIONS Our analysis provided quantitative insights into the impact of the changing caval inflows on Fontan's long-term HFD, highlighting the importance of SVC:IVC variations over time on Fontan's long-term hemodynamics. These findings broaden our understanding of Fontan hemodynamics and patient outcomes.
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Affiliation(s)
- Vijay Govindarajan
- Departments of Cardiovascular Surgery (V.G., L.M., A.S., M.A.C., E.E.E., J.D., N.S.C., N.E.S., D.M.H., P.E.H., S.J.G., A.P., P.J.d.N.), Boston Children's Hospital, MA
- Surgery (V.G., D.M.H., P.E.H.), Harvard Medical School, Boston, MA
- Department of Internal Medicine, University of Texas Health Science Center at Houston (V.G.)
| | - Lauren Marshall
- Departments of Cardiovascular Surgery (V.G., L.M., A.S., M.A.C., E.E.E., J.D., N.S.C., N.E.S., D.M.H., P.E.H., S.J.G., A.P., P.J.d.N.), Boston Children's Hospital, MA
| | - Akshita Sahni
- Departments of Cardiovascular Surgery (V.G., L.M., A.S., M.A.C., E.E.E., J.D., N.S.C., N.E.S., D.M.H., P.E.H., S.J.G., A.P., P.J.d.N.), Boston Children's Hospital, MA
| | - Maria A Cetatoiu
- Departments of Cardiovascular Surgery (V.G., L.M., A.S., M.A.C., E.E.E., J.D., N.S.C., N.E.S., D.M.H., P.E.H., S.J.G., A.P., P.J.d.N.), Boston Children's Hospital, MA
| | - Emily E Eickhoff
- Departments of Cardiovascular Surgery (V.G., L.M., A.S., M.A.C., E.E.E., J.D., N.S.C., N.E.S., D.M.H., P.E.H., S.J.G., A.P., P.J.d.N.), Boston Children's Hospital, MA
| | - Jocelyn Davee
- Departments of Cardiovascular Surgery (V.G., L.M., A.S., M.A.C., E.E.E., J.D., N.S.C., N.E.S., D.M.H., P.E.H., S.J.G., A.P., P.J.d.N.), Boston Children's Hospital, MA
| | - Nicole St Clair
- Departments of Cardiovascular Surgery (V.G., L.M., A.S., M.A.C., E.E.E., J.D., N.S.C., N.E.S., D.M.H., P.E.H., S.J.G., A.P., P.J.d.N.), Boston Children's Hospital, MA
| | - Noah E Schulz
- Departments of Cardiovascular Surgery (V.G., L.M., A.S., M.A.C., E.E.E., J.D., N.S.C., N.E.S., D.M.H., P.E.H., S.J.G., A.P., P.J.d.N.), Boston Children's Hospital, MA
| | - David M Hoganson
- Departments of Cardiovascular Surgery (V.G., L.M., A.S., M.A.C., E.E.E., J.D., N.S.C., N.E.S., D.M.H., P.E.H., S.J.G., A.P., P.J.d.N.), Boston Children's Hospital, MA
- Surgery (V.G., D.M.H., P.E.H.), Harvard Medical School, Boston, MA
| | - Peter E Hammer
- Departments of Cardiovascular Surgery (V.G., L.M., A.S., M.A.C., E.E.E., J.D., N.S.C., N.E.S., D.M.H., P.E.H., S.J.G., A.P., P.J.d.N.), Boston Children's Hospital, MA
- Surgery (V.G., D.M.H., P.E.H.), Harvard Medical School, Boston, MA
| | - Sunil J Ghelani
- Departments of Cardiovascular Surgery (V.G., L.M., A.S., M.A.C., E.E.E., J.D., N.S.C., N.E.S., D.M.H., P.E.H., S.J.G., A.P., P.J.d.N.), Boston Children's Hospital, MA
- Cardiology (S.J.G., A.P., P.J.d.N., R.H.R.), Boston Children's Hospital, MA
| | - Ashwin Prakash
- Departments of Cardiovascular Surgery (V.G., L.M., A.S., M.A.C., E.E.E., J.D., N.S.C., N.E.S., D.M.H., P.E.H., S.J.G., A.P., P.J.d.N.), Boston Children's Hospital, MA
- Cardiology (S.J.G., A.P., P.J.d.N., R.H.R.), Boston Children's Hospital, MA
| | - Pedro J Del Nido
- Departments of Cardiovascular Surgery (V.G., L.M., A.S., M.A.C., E.E.E., J.D., N.S.C., N.E.S., D.M.H., P.E.H., S.J.G., A.P., P.J.d.N.), Boston Children's Hospital, MA
- Cardiology (S.J.G., A.P., P.J.d.N., R.H.R.), Boston Children's Hospital, MA
| | - Rahul H Rathod
- Cardiology (S.J.G., A.P., P.J.d.N., R.H.R.), Boston Children's Hospital, MA
- Departments of Pediatrics (R.H.R.), Harvard Medical School, Boston, MA
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Govindarajan V, Marshall L, Sahni A, Cetatoiu M, Eickhoff E, Davee J, St Clair N, Schulz N, Hoganson DM, Hammer PE, Ghelani S, Prakash A, Del Nido PJ, Rathod RH. Impact of Age-related change in Caval Flow Ratio on Hepatic Flow Distribution in Fontan. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.09.06.23295166. [PMID: 37732201 PMCID: PMC10508792 DOI: 10.1101/2023.09.06.23295166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
Background The Fontan operation is a palliative technique for patients born with single ventricle heart disease. The superior vena cava (SVC), inferior vena cava (IVC), and hepatic veins are connected to the pulmonary arteries in a total cavopulmonary connection by an extracardiac (EC) conduit or a lateral tunnel (LT) connection. A balanced hepatic flow distribution (HFD) to both lungs is essential to prevent pulmonary arteriovenous malformations and cyanosis. HFD is highly dependent on the local hemodynamics. Objective The effect of age-related changes in caval inflows on HFD was evaluated using cardiac MRI (CMR) data and patient-specific computational fluid dynamics (CFD) modeling. Methods SVC and IVC flow from 414 Fontan patients were collected to establish a relationship between SVC:IVC flow ratio and age. CFD modeling was performed in 60 (30 EC and 30 LT) patient models to quantify the HFD that corresponded to patient ages of 3, 8, and 15 years, respectively. Results SVC:IVC flow ratio inverted at ∼8 years of age, indicating a clear shift to lower body flow predominance. Our data showed that variation of HFD in response to age-related changes in caval inflows (SVC:IVC = 2,1, and 0.5 corresponded to ages 3, 8, and 15+ respectively) was not significant for EC but statistically significant for LT cohorts. For all three caval inflow ratios, a positive correlation existed between the IVC flow distribution to both the lungs and the HFD. However, as the SVC:IVC ratio changed from 2→0.5 (age 3→15+), the correlation's strength decreased from 0.87→0.64, due to potential flow perturbation as IVC flow momentum increased. Conclusion Our analysis provided quantitative insights into the impact of the changing caval inflows on Fontan's long-term HFD, highlighting the importance of including SVC:IVC variations over time to understand Fontan's long-term hemodynamics. These findings broaden our understanding of Fontan hemodynamics and patient outcomes. Clinical Perspective With improvement in standard of care and management of single ventricle patients with Fontan physiology, the population of adults with Fontan circulation is increasing. Consequently, there is a clinical need to comprehend the impact of patient growth on Fontan hemodynamics. Using CMR data, we were able to quantify the relationship between changing caval inflows and somatic growth. We then used patient-specific computational flow modeling to quantify how this relationship affected the distribution of long-term hepatic flow in extracardiac and lateral tunnel Fontan types. Our findings demonstrated the significance of including SVC:IVC changes over time in CFD modeling to learn more about the long-term hemodynamics of Fontan. Fontan surgical approaches are increasingly planned and optimized using computational flow modeling. For a patient undergoing a Fontan procedure, the workflow presented in this study that takes into account the variations in Caval inflows over time can aid in predicting the long-term hemodynamics in a planned Fontan pathway.
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Abdulkarim A, Shaji S, Elfituri M, Gunsaulus M, Zafar MA, Zaidi AN, Pass RH, Feingold B, Kurland G, Kreutzer J, Ghassemzadeh R, Goldstein B, West S, Alsaied T. Pulmonary Complications in Patients With Fontan Circulation: JACC Review Topic of the Week. J Am Coll Cardiol 2023; 81:2434-2444. [PMID: 37344046 DOI: 10.1016/j.jacc.2023.04.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 04/03/2023] [Accepted: 04/10/2023] [Indexed: 06/23/2023]
Abstract
The Fontan operation has resulted in significant improvement in survival of patients with single ventricle physiology. As a result, there is a growing population of individuals with Fontan physiology reaching adolescence and adulthood. Despite the improved survival, there are long-term morbidities associated with the Fontan operation. Pulmonary complications are common and may contribute to both circulatory and pulmonary insufficiency, leading ultimately to Fontan failure. These complications include restrictive lung disease, sleep abnormalities, plastic bronchitis, and cyanosis. Cyanosis post-Fontan procedure can be attributed to multiple causes including systemic to pulmonary venous collateral channels and pulmonary arteriovenous malformations. This review presents the unique cardiopulmonary interactions in the Fontan circulation. Understanding the cardiopulmonary interactions along with improved recognition and treatment of pulmonary abnormalities may improve the long-term outcomes in this growing patient population. Interventions focused on improving pulmonary function including inspiratory muscle training and endurance training have shown a promising effect post-Fontan procedure.
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Affiliation(s)
- Ali Abdulkarim
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Shawn Shaji
- Heart Institute, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Pediatric Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Mahmud Elfituri
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Megan Gunsaulus
- Heart Institute, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Pediatric Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Muhammad A Zafar
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Ali N Zaidi
- Mount Sinai Heart, Mount Sinai Kravis Children's Heart Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Robert H Pass
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, Division of Pediatric Cardiology and Mount Sinai Kravis Children's Heart Center, New York, New York, USA
| | - Brian Feingold
- Heart Institute, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Pediatric Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Geoffrey Kurland
- University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Pediatric Pulmonology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jacqueline Kreutzer
- Heart Institute, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Pediatric Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Rod Ghassemzadeh
- University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Department of Critical Care, Pittsburgh, Pennsylvania, USA
| | - Bryan Goldstein
- Heart Institute, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Pediatric Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Shawn West
- Heart Institute, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Pediatric Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Tarek Alsaied
- Heart Institute, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Pediatric Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
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Schafstedde M, Yevtushenko P, Nordmeyer S, Kramer P, Schleiger A, Solowjowa N, Berger F, Photiadis J, Mykychak Y, Cho MY, Ovroutski S, Kuehne T, Brüning J. Virtual treatment planning in three patients with univentricular physiology using computational fluid dynamics—Pitfalls and strategies. Front Cardiovasc Med 2022; 9:898701. [PMID: 35990961 PMCID: PMC9381838 DOI: 10.3389/fcvm.2022.898701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 07/18/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundUneven hepatic venous blood flow distribution (HFD) to the pulmonary arteries is hypothesized to be responsible for the development of intrapulmonary arteriovenous malformations (PAVM) in patients with univentricular physiology. Thus, achieving uniform distribution of hepatic blood flow is considered favorable. However, no established method for the prediction of the post-interventional hemodynamics currently exists. Computational fluid dynamics (CFD) offers the possibility to quantify HFD in patient-specific anatomies before and after virtual treatment. In this study, we evaluated the potential benefit of CFD-assisted treatment planning.Materials and methodsThree patients with total cavopulmonary connection (TCPC) and PAVM underwent cardiovascular magnetic resonance imaging (CMR) and computed tomography imaging (CT). Based on this imaging data, the patient-specific anatomy was reconstructed. These patients were considered for surgery or catheter-based intervention aiming at hepatic blood flow re-routing. CFD simulations were then performed for the untreated state as well as for different surgical and interventional treatment options. These treatment options were applied as suggested by treating cardiologists and congenital heart surgeons with longstanding experience in interventional and surgical treatment of patients with univentricular physiology. HFD was quantified for all simulations to identify the most viable treatment decision regarding redistribution of hepatic blood flow.ResultsFor all three patients, the complex TCPC anatomy could be reconstructed. However, due to the presence of metallic stent implants, hybrid models generated from CT as well as CMR data were required. Numerical simulation of pre-interventional HFD agreed well with angiographic assessment and physiologic considerations. One treatment option resulting in improvement of HFD was identified for each patient. In one patient follow-up data after treatment was available. Here, the virtual treatment simulation and the CMR flow measurements differed by 15%.ConclusionThe combination of modern computational methods as well as imaging methods for assessment of patient-specific anatomy and flow might allow to optimize patient-specific therapy planning in patients with pronounced hepatic flow mismatch and PAVM. In this study, we demonstrate that these methods can also be applied in patients with complex univentricular physiology and extensive prior interventions. However, in those cases, hybrid approaches utilizing information of different image modalities may be required.
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Affiliation(s)
- Marie Schafstedde
- Department of Congenital Heart Disease–Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
- Institute for Cardiovascular Computer-Assisted Medicine, Charité–Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- German Centre for Cardiovascular Research, Partner Site Berlin, Berlin, Germany
- *Correspondence: Marie Schafstedde,
| | - Pavlo Yevtushenko
- Institute for Cardiovascular Computer-Assisted Medicine, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Sarah Nordmeyer
- Department of Congenital Heart Disease–Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
- Institute for Cardiovascular Computer-Assisted Medicine, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Kramer
- Department of Congenital Heart Disease–Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Anastasia Schleiger
- Department of Congenital Heart Disease–Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Natalia Solowjowa
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Felix Berger
- Department of Congenital Heart Disease–Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
- German Centre for Cardiovascular Research, Partner Site Berlin, Berlin, Germany
- Department of Pediatric Cardiology, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Joachim Photiadis
- Department of Congenital Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Yaroslav Mykychak
- Department of Congenital Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Mi-Young Cho
- Department of Congenital Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Stanislav Ovroutski
- Department of Congenital Heart Disease–Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Titus Kuehne
- Department of Congenital Heart Disease–Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
- Institute for Cardiovascular Computer-Assisted Medicine, Charité–Universitätsmedizin Berlin, Berlin, Germany
- German Centre for Cardiovascular Research, Partner Site Berlin, Berlin, Germany
| | - Jan Brüning
- Institute for Cardiovascular Computer-Assisted Medicine, Charité–Universitätsmedizin Berlin, Berlin, Germany
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Ewert P, Eicken A, Tanase D, Georgiev S, Will A, Pankalla C, Nagdyman N, Meierhofer C, Hörer J. Transcatheter implantation of covered stents serving as extravascular conduits-Proof of a CT-based approach in three cases. Catheter Cardiovasc Interv 2022; 99:2054-2063. [PMID: 35395135 DOI: 10.1002/ccd.30190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 03/11/2022] [Accepted: 03/23/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Covered stents perform similar to surgically implanted conduits, although the stents work inside of vessels. We present a computed tomography (CT)-based workflow for the implantation of covered stents as extravascular conduits. METHODS We selected three different use cases: 1. Connecting a left-sided partially anomalous drainage of a pulmonary vein to the left atrium. 2. Bypassing an outgrown Dacron conduit in aortic recoarctation. 3. Re-directing hepatic venous blood to the left lung in a Fontan patient with heterotaxy, connecting the innominate vein to the right pulmonary artery like a right-sided cavopulmonary connection. By postprocessing and analyzing CT scans for planning and by the use of long needles under biplane fluoroscopy for the realization of the procedure, we projected and performed the exit of a long needle out of a vessel, the re-entering of a target vessel, and the bridging of the extravascular distance by implantation of covered stents. RESULTS In all three cases, the covered stents were placed successfully, connecting vessels of 15-50 mm distance from each other with very good hemodynamic results. In one case, two stents were placed consecutively, overlapping each other to accomplish an exact fitting at the connection sites to the native vessels.
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Affiliation(s)
- Peter Ewert
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technical University of Munich, Munich, Germany.,Deutsches Zentrum für Herz-Kreislaufforschung (DZHK), Munich Heart Alliance, Munich, Germany
| | - Andreas Eicken
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Daniel Tanase
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Stanimir Georgiev
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Albrecht Will
- Department of Radiology and Nuclear Medicine, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Cornelia Pankalla
- Department of Radiology and Nuclear Medicine, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Nicole Nagdyman
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Christian Meierhofer
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Jürgen Hörer
- Department of Congenital and Pediatric Heart Surgerym, German Heart Center Munich, Technical University of Munich, Munich, Germany.,Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
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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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7
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Joshi K, Sharma C, Misra N, Kholwadwala D, Georgekutty J, Friedman R, Parnell V. A unique approach to Fontan revision in a cyanotic patient. PROGRESS IN PEDIATRIC CARDIOLOGY 2020. [DOI: 10.1016/j.ppedcard.2020.101298] [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: 10/23/2022]
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8
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Rutkowski D, Medero R, Ruesink T, Roldan-Alzate A. Modeling Physiological Flow Variation in Fontan Models with 4d Flow Mri, Particle Image Velocimetry, and Arterial Spin Labeling. J Biomech Eng 2019; 141:1065454. [PMID: 31596919 DOI: 10.1115/1.4045110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Indexed: 11/08/2022]
Abstract
The Fontan procedure is a successful palliation for single ventricle defect. Yet, a number of complications still occur in Fontan patients due to abnormal blood flow dynamics, necessitating improved flow analysis and treatment methods. Phase-contrast magnetic resonance imaging (MRI) has emerged as a suitable method for such flow analysis. However, limitations on altering physiological blood flow conditions in the patient while in the MRI bore inhibit experimental investigation of a variety of factors that contribute to impaired cardiovascular health in these patients. Furthermore, resolution and flow regime limitations in phase contrast MRI pose a challenge for accurate and consistent flow characterization. In this study, patient-specific physical models were created based on nine Fontan geometries and MRI experiments mimicking low and high flow conditions, as well as steady and pulsatile flow, were conducted. Additionally, an optically transparent Fontan model was created for flow analyses using a particle image velocimetry (PIV) system, arterial spin labeling (ASL), and four-dimensional (4D) flow MRI. Differences, though non-statistically significant, were observed between flow conditions and between patient-specific models. Large between-model variation supported the need for further improvement for patient-specific modeling on each unique Fontan anatomical configuration. Furthermore, high resolution PIV and flow tracking ASL data provided flow information that was not obtainable with 4D flow MRI alone.
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Affiliation(s)
- David Rutkowski
- Mechanical Engineering, University of Wisconsin - Madison, Madison, WI, United States; Radiology, University of Wisconsin - Madison, Madison, WI, United States
| | - Rafael Medero
- Mechanical Engineering, University of Wisconsin - Madison, Madison, WI, United States; Radiology, University of Wisconsin - Madison, Madison, WI, United States
| | - Timothy Ruesink
- Mechanical Engineering, University of Wisconsin - Madison, Madison, WI, United States; Radiology, University of Wisconsin - Madison, Madison, WI, United States
| | - Alejandro Roldan-Alzate
- Mechanical Engineering, University of Wisconsin - Madison, Madison, WI, United States; Radiology, University of Wisconsin - Madison, Madison, WI, United States; Biomedical Engineering, University of Wisconsin - Madison, Madison, WI, United States
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9
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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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10
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Appropriation is the mother of invention. J Thorac Cardiovasc Surg 2018; 156:330-331. [PMID: 29680716 DOI: 10.1016/j.jtcvs.2018.03.091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 03/23/2018] [Indexed: 11/24/2022]
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11
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Paul EA, Torres AJ, Chelliah A, Martinez M, Ferris AM, Kalfa DM. Extra-anatomic suprahepatic to innominate vein conduit in heterotaxy. J Thorac Cardiovasc Surg 2018; 156:327-329. [PMID: 29655540 DOI: 10.1016/j.jtcvs.2018.03.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Revised: 03/05/2018] [Accepted: 03/07/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Erin A Paul
- Division of Pediatric Cardiology, Department of Pediatrics, New York-Presbyterian Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY.
| | - Alejandro J Torres
- Division of Pediatric Cardiology, Department of Pediatrics, New York-Presbyterian Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY
| | - Anjali Chelliah
- Division of Pediatric Cardiology, Department of Pediatrics, New York-Presbyterian Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY
| | - Mercedes Martinez
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, New York-Presbyterian Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY
| | - Anne M Ferris
- Division of Pediatric Cardiology, Department of Pediatrics, New York-Presbyterian Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY
| | - David M Kalfa
- Section of Congenital and Pediatric Cardiac Surgery, Division of Cardiac, Thoracic and Vascular Surgery, New York-Presbyterian Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY
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12
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McRae RO, Lambert LM, Williams RV, Martin MH, Burch PT. Modification of Hepatic Venous Conduit to Manage Pulmonary Arteriovenous Malformations. World J Pediatr Congenit Heart Surg 2015; 6:477-9. [DOI: 10.1177/2150135115577431] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
While the Fontan operation is a reliable treatment option for many complex congenital heart defects, the development of pulmonary arteriovenous malformations (PAVMs) remains a problematic outcome for some Fontan patients. Pulmonary arteriovenous malformations stem from an imbalance of hepatic blood flow in the pulmonary system. Balancing this hepatic flow has shown promising results in the treatment of PAVMs. We report the clinical course of a young patient with heterotaxy syndrome and an unbalanced right dominant atrioventricular septal defect. This patient developed PAVMs following a Fontan procedure, however, the PAVMs were resolved following the revision of the original Fontan conduit to a bifurcated conduit.
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Affiliation(s)
- Robert O. McRae
- Department of Surgery, Section of Pediatric Cardiothoracic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Linda M. Lambert
- Division of Pediatric Cardiothoracic Surgery, Primary Children’s Hospital, Salt Lake City, UT, USA
| | - Richard V. Williams
- Department of Pediatrics, Division of Cardiology, University of Utah, Salt Lake City, UT, USA
| | - Mary H. Martin
- Department of Pediatrics, Division of Cardiology, University of Utah, Salt Lake City, UT, USA
| | - Phillip T. Burch
- Department of Surgery, Section of Pediatric Cardiothoracic Surgery, University of Utah, Salt Lake City, UT, USA
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13
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Dori Y, Sathanandam S, Glatz AC, Gillespie MJ, Rome JJ. Catheter approach to redirect hepatic venous return for treatment of unilateral pulmonary arteriovenous malformations after fontan. Catheter Cardiovasc Interv 2014; 84:86-93. [PMID: 24327433 DOI: 10.1002/ccd.25326] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Revised: 10/08/2013] [Accepted: 11/28/2013] [Indexed: 11/08/2022]
Abstract
OBJECTIVES The goal of this report is to describe a percutaneous approach to rerouting hepatic venous return in patients who developed progressive cyanosis due to unilateral pulmonary arteriovenous malformations (PAVM) after the total cavopulmonary connection (TCPC) operation. BACKGROUND Unilateral PAVM can develop in patients after TCPC operation when there is unequal distribution of hepatic venous return between the two lungs. This often results in progressive cyanosis and the need for surgical re-intervention. A percutaneous based approach for rerouting hepatic venous return has never been described. METHODS We retrospectively reviewed the clinical data on four patients who underwent percutaneous rerouting procedures. One patient with a misaligned TCPC underwent realignment of the circuit with a bare metal stent. In three patients a combination of bare metal and covered stents were needed to achieve the desired results. RESULTS The rerouting procedures were successful in all patients with significant improvement in oxygen saturation from a median of 75% (range 55-80%) to a median of 90% (range 84-92%) (P = 0.02). There were no recorded short term or intermediate term complications with maximum follow-up time of 43 months. CONCLUSIONS Percutaneous rerouting of hepatic venous flow is feasible and should be considered when a surgical approach is not possible; this strategy may serve as a viable alternative to complex operative approaches in select cases. Furthermore studies are needed to determine the long-term efficacy of this procedure.
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Affiliation(s)
- Yoav Dori
- Division of Cardiology, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Pennsylvania
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14
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Abstract
Severe cyanosis due to pulmonary arteriovenous fistulas occurs often after a bidirectional superior cavopulmonary anastomosis (Glenn operation) and also in some congenital anomalies in which hepatic venous blood bypasses the lungs in the first passage. Relocation of hepatic flow into the lungs usually causes these fistulas to disappear. Similar pulmonary arteriovenous fistulas are observed in hereditary haemorrhagic telangiectasia, and in liver disease (hepatopulmonary syndrome). There is no convincing identification yet of a responsible hepatic factor that produces these lesions. Candidates for such a factor are reviewed, and the possibility of angiotensin or bradykinin contributing to the fistulas is discussed.
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15
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Krieger EV, Valente AM, Landzberg MJ, Stout KK. Acute dyspnea in a young man with an old sternotomy. CONGENIT HEART DIS 2012; 7:E73-7. [PMID: 22471669 DOI: 10.1111/j.1747-0803.2012.00641.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Described is a 42-year-old man with complex congenital heart disease with single-ventricle physiology who underwent a Fontan operation at 27 years of age. He presented with sudden-onset chest pain and dyspnea and was initially misdiagnosed with a pulmonary embolism. This case is described in order to highlight the challenges in the evaluation of common presentations in adults with congenital heart disease.
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Affiliation(s)
- Eric V Krieger
- Division of Cardiology, Department of Medicine, University of Washington Medical Center, Seattle, WA 98195, USA.
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16
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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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17
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Dasi LP, Whitehead K, Pekkan K, de Zelicourt D, Sundareswaran K, Kanter K, Fogel MA, Yoganathan AP. Pulmonary hepatic flow distribution in total cavopulmonary connections: extracardiac versus intracardiac. J Thorac Cardiovasc Surg 2011; 141:207-14. [PMID: 20621314 DOI: 10.1016/j.jtcvs.2010.06.009] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2009] [Revised: 05/20/2010] [Accepted: 06/06/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Pulmonary arteriovenous malformations can occur after the Fontan procedure and are believed to be associated with disproportionate pulmonary distribution of hepatic venous effluent. We studied the effect of total cavopulmonary connection geometry and the effect of increased cardiac output on distribution of inferior vena caval return to the lungs. METHODS Ten patients undergoing the Fontan procedure, 5 with extracardiac and 5 with intracardiac configurations of the total cavopulmonary connection, previously analyzed for power loss were processed for calculating the distribution of inferior vena caval return to the lungs (second-order accuracy). One idealized total cavopulmonary connection was similarly analyzed under parametric variation of inferior vena caval offset and cardiac output flow split. RESULTS Streaming of the inferior vena caval return in the idealized total cavopulmonary connection model was dependent on both inferior vena caval offset magnitude and cardiac output flow-split ratio. For patient-specific total cavopulmonary connections, preferential streaming of the inferior vena caval return was directly proportional to the cardiac output flow-split ratio in the intracardiac total cavopulmonary connections (P < .0001). Preferential streaming in extracardiac total cavopulmonary connections correlated to the inferior vena caval offset (P < .05) and did not correlate to cardiac output flow split. Enhanced mixing in intracardiac total cavopulmonary connections is speculated to explain the contrasting results. Exercising tends to reduce streaming toward the left pulmonary artery in intracardiac total cavopulmonary connections, whereas for extracardiac total cavopulmonary connections, exercising tends to equalize the streaming. CONCLUSIONS Extracardiac and intracardiac total cavopulmonary connections have inherently different streaming characteristics because of contrasting mixing characteristics caused by their geometric differences. Pulmonary artery diameters and inferior vena caval offsets might together determine hepatic flow streaming.
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Affiliation(s)
- Lakshmi P Dasi
- Department of Mechanical Engineering & School of Biomedical Engineering, Colorado State University, Fort Collins, Colo, USA
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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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de Zélicourt DA, Marsden A, Fogel MA, Yoganathan AP. Imaging and patient-specific simulations for the Fontan surgery: current methodologies and clinical applications. PROGRESS IN PEDIATRIC CARDIOLOGY 2010; 30:31-44. [PMID: 25620865 PMCID: PMC4302339 DOI: 10.1016/j.ppedcard.2010.09.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Diane A. de Zélicourt
- Wallace H. Coulter School of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA
| | - Alison Marsden
- Department of Mechanical and Aerospace Engineering, University of California San Diego, La Jolla, CA
| | - Mark A. Fogel
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Ajit P. Yoganathan
- Wallace H. Coulter School of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA
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20
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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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