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Said SM, Mashadi A, Essa Y, Erb M. Fontan Conversion in an Adult With Hypoplastic Left Heart Syndrome: A 38-Year-Old Norwood Success. JACC Case Rep 2024; 29:102495. [PMID: 39359497 PMCID: PMC11442177 DOI: 10.1016/j.jaccas.2024.102495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 06/21/2024] [Accepted: 07/15/2024] [Indexed: 10/04/2024]
Abstract
A 38-year-old man with a functional single ventricle secondary to hypoplastic left heart syndrome presented with exertional fatigue. His last palliation was an intra-atrial conduit Fontan procedure. Comprehensive evaluation showed elevated liver enzyme values and a small, calcified conduit. Successful conversion to a nonfenestrated extracardiac conduit Fontan was performed with normalization of his liver enzyme values.
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Affiliation(s)
- Sameh M. Said
- Division of Pediatric and Adult Congenital Cardiac Surgery, Maria Fareri Children’s Hospital and Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Ali Mashadi
- Division of Pediatric and Adult Congenital Cardiac Surgery, Maria Fareri Children’s Hospital and Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Yasin Essa
- Division of Pediatric and Adult Congenital Cardiac Surgery, Maria Fareri Children’s Hospital and Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Markus Erb
- Division of Pediatric Cardiology, Boston Children’s Health Physicians, Maria Fareri Children’s Hospital, Valhalla, New York, USA
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2
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Sumitomo NF, Kodo K, Oyanagi T, Kimura N, Yamagishi H. Computed Fluid Dynamics Analysis for SVC-to-RPA Anastomosis With Antegrade Pulmonary Flow. JACC Case Rep 2024; 29:102263. [PMID: 38774793 PMCID: PMC11103595 DOI: 10.1016/j.jaccas.2024.102263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 12/07/2023] [Accepted: 12/18/2023] [Indexed: 05/24/2024]
Abstract
We report an infant case after superior vena cava -to-right pulmonary artery anastomosis with antegrade pulmonary flow in which computational fluid dynamics analysis showed that restriction of antegrade blood flow by the remaining right pulmonary stenosis resulted in reduced shear stress and energy loss in the superior vena cava.
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Affiliation(s)
| | - Kazuki Kodo
- Keio University School of Medicine, Department of Pediatrics, Tokyo, Japan
| | - Takayuki Oyanagi
- Keio University School of Medicine, Department of Pediatrics, Tokyo, Japan
| | - Naritaka Kimura
- Keio University School of Medicine, Department of Cardiovascular Surgery, Tokyo, Japan
| | - Hiroyuki Yamagishi
- Keio University School of Medicine, Department of Pediatrics, Tokyo, Japan
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Hirose K, Ikai A, Ito H, Ishidou M, Toritsuka D, Nakamura Y, Watanabe S, Nakatani E, Sakamoto K. The effect of the conduit size on middle-term outcomes in patients with extracardiac total cavopulmonary connection. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2024; 38:ivae013. [PMID: 38374222 PMCID: PMC10884530 DOI: 10.1093/icvts/ivae013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 12/05/2023] [Accepted: 02/16/2024] [Indexed: 02/21/2024]
Abstract
OBJECTIVES The 18- and 16-mm conduits in extracardiac total cavopulmonary connection (eTCPC) were reported to be optimal based on energy loss and flow stagnation at the relatively early phase. However, because the artificial conduit lacks growth potential, we have recently encountered some cases in which the conduit needs to be changed several years after eTCPC. These cases prompted us to reconsider the surgical strategy for eTCPC. METHODS We reviewed our 20-year single-centre experience with eTCPC patients (n = 256) to compare the 18-mm conduit (n = 195) and 16-mm conduit (n = 61) in terms of mortality and morbidity. RESULTS The 16-mm conduit was used significantly more frequently in patients whose main chamber was right ventricle (P < 0.001). There was also a significant difference in preoperative inferior vena cava pressure (P = 0.008). There was a significant difference in the actuarial rate of freedom from late-occurring complications, including mortality, between the 2 groups (P = 0.003). There was a significant difference in the actuarial rate of reoperation-free survival (P = 0.042); however, there was no significant difference in resurgical intervention for the conduit (P = 0.333). In multivariate analysis, preoperative inferior vena cava pressure was an independent predictor for late-occurring complications (hazard ratio 1.19; P = 0.026). Conduit size (18 or 16 mm) itself was not an independent predictive factor for late-occurring complications (P = 0.690). CONCLUSIONS The mid-term clinical outcomes in patients who underwent eTCPC were excellent with low mortality. Preoperative inferior vena cava pressure was the only predictive risk factor for postoperative morbidity, and the 16 mm conduit was not predictive thereof.
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Affiliation(s)
- Keiichi Hirose
- Department of Cardiovascular Surgery, Mt. Fuji Shizuoka Children's Hospital, Shizuoka, Japan
| | - Akio Ikai
- Department of Cardiovascular Surgery, Mt. Fuji Shizuoka Children's Hospital, Shizuoka, Japan
| | - Hiroki Ito
- Department of Cardiovascular Surgery, Mt. Fuji Shizuoka Children's Hospital, Shizuoka, Japan
| | - Motonari Ishidou
- Department of Cardiovascular Surgery, Mt. Fuji Shizuoka Children's Hospital, Shizuoka, Japan
| | - Daisuke Toritsuka
- Department of Cardiovascular Surgery, Mt. Fuji Shizuoka Children's Hospital, Shizuoka, Japan
| | - Yuji Nakamura
- Department of Cardiovascular Surgery, Mt. Fuji Shizuoka Children's Hospital, Shizuoka, Japan
| | - Seito Watanabe
- Department of Cardiovascular Surgery, Mt. Fuji Shizuoka Children's Hospital, Shizuoka, Japan
| | - Eiji Nakatani
- Division of Statistical Analysis, Research Support Center, Shizuoka General Hospital, Shizuoka, Japan
| | - Kisaburo Sakamoto
- Department of Cardiovascular Surgery, Mt. Fuji Shizuoka Children's Hospital, Shizuoka, Japan
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Hut T, Roest A, Gaillard D, Hazekamp M, van den Boogaard P, Lamb H, Kroft L, Jongbloed M, Westenberg J, Wentzel J, Rijnberg F, Kenjeres S. Virtual surgery to predict optimized conduit size for adult Fontan patients with 16-mm conduits. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2023; 37:ivad126. [PMID: 37522877 PMCID: PMC10686953 DOI: 10.1093/icvts/ivad126] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 06/18/2023] [Accepted: 07/30/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVES Recent evidence suggests that conduits implanted in Fontan patients at the age of 2-4 years become undersized for adulthood. The objective of this study is to use computational fluid dynamic models to evaluate the effect of virtual expansion of the Fontan conduit on haemodynamics and energetics of the total cavopulmonary connection (TCPC) under resting conditions and increased flow conditions. METHODS Patient-specific, magnetic resonance imaging-based simulation models of the TCPC were performed during resting and increased flow conditions. The original 16-mm conduits were virtually enlarged to 3 new sizes. The proposed conduit sizes were defined based on magnetic resonance imaging-derived conduit flow in each patient. Flow efficiency was evaluated based on power loss, pressure drop and resistance and thrombosis risk was based on flow stagnation volume and relative residence time (RRT). RESULTS Models of 5 adult patients with a 16-mm extracardiac Fontan connection were simulated and subsequently virtually expanded to 24-32 mm depending on patient-specific conduit flow. Virtual expansion led to a 40-65% decrease in pressure gradient across the TCPC depending on virtual conduit size. Despite improved energetics of the entire TCPC, the pulmonary arteries remained a significant contributor to energy loss (60-73% of total loss) even after virtual surgery. Flow stagnation volume inside the virtual conduit and surface area in case of elevated RRT (>20/Pa) increased after conduit enlargement but remained negligible (flow stagnation <2% of conduit volume in rest, <0.5% with exercise and elevated RRT <3% in rest, <1% with exercise). CONCLUSIONS Virtual expansion of 16-mm conduits to 24-32 mm, depending on patient-specific conduit flow, in Fontan patients significantly improves TCPC efficiency while thrombosis risk presumably remains low.
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Affiliation(s)
- Tjerry Hut
- Department of Chemical Engineering, Faculty of Applied Sciences, Delft University of Technology and J.M. Burgers Centrum Research School for Fluid Mechanics, Delft, Netherlands
| | - Arno Roest
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Duco Gaillard
- Department of Chemical Engineering, Faculty of Applied Sciences, Delft University of Technology and J.M. Burgers Centrum Research School for Fluid Mechanics, Delft, Netherlands
| | - Mark Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | | | - Hildo Lamb
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Lucia Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Monique Jongbloed
- Department of Cardiology and Anatomy & Embryology, Leiden University Medical Center, Leiden, Netherlands
| | - Jos Westenberg
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Jolanda Wentzel
- Department of Cardiology, Biomechanical Engineering, Erasmus MC, Rotterdam, Netherlands
| | - Friso Rijnberg
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Sasa Kenjeres
- Department of Chemical Engineering, Faculty of Applied Sciences, Delft University of Technology and J.M. Burgers Centrum Research School for Fluid Mechanics, Delft, Netherlands
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d’Udekem Y, Kisamori E, Yerebakan C. We were wrong on the benefits of the extra-cardiac Fontan. Should we go back to the lateral tunnel? INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2023; 37:ivad187. [PMID: 37991843 PMCID: PMC10686946 DOI: 10.1093/icvts/ivad187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 11/21/2023] [Indexed: 11/24/2023]
Affiliation(s)
- Yves d’Udekem
- Division of Cardiovascular Surgery, Children’s National Heart Institute, Children’s National Hospital, Washington, DC, USA
| | - Eiri Kisamori
- Division of Cardiovascular Surgery, Children’s National Heart Institute, Children’s National Hospital, Washington, DC, USA
| | - Can Yerebakan
- Division of Cardiovascular Surgery, Children’s National Heart Institute, Children’s National Hospital, Washington, DC, USA
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Agasthi P, Jain CC, Egbe AC, Hagler DJ, Cabalka AK, Taggart NW, Anderson JH, Cetta F, Connolly HM, Burchill LJ, Kamath PS, Miranda WR. Clinical Outcomes of Percutaneous Fontan Stenting in Adults. Can J Cardiol 2023; 39:1358-1365. [PMID: 37141988 DOI: 10.1016/j.cjca.2023.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 04/20/2023] [Accepted: 04/26/2023] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND Fontan pathway stenosis is a well-known complication after palliation. Percutaneous stenting is effective for angiographic/hemodynamic relief of Fontan obstruction, but its clinical impact in adults remains unknown. METHODS This was a retrospective cohort of 26 adults undergoing percutaneous stenting for Fontan obstruction from 2014 to 2022. Procedural details, functional capacity, and liver parameters were reviewed at baseline and during follow-up. RESULTS Median age was 22.5 years (interquartile range [IQR] 19-28.8 y); 69% were male. After stenting, Fontan gradient significantly decreased (2.0 ± 1.9 vs 0 [IQR 0-1] mm Hg; P < 0.005), and minimal Fontan diameter increased (11.3 ± 2.9 vs 19.3 [IQR 17-20] mm; P < 0.001). One patient developed acute kidney injury periprocedurally. During a follow-up of 2.1 years (IQR 0.6-3.7 y), 1 patient had thrombosis of the Fontan stent and 2 underwent elective Fontan re-stenting. New York Heart Association functional class improved in 50% of symptomatic patients. Changes in functional aerobic capacity on exercise testing were directly related to pre-stenting Fontan gradient (n = 7; r = 0.80; P = 0.03) and inversely related to pre-stenting minimal Fontan diameter (r = -0.79; P = 0.02). Thrombocytopenia (platelet count < 150 109/L) was present in 42.3% of patients before and in 32% after the procedure (P = 0.08); splenomegaly (spleen size > 13 cm) was present in 58.3% and 58.8% (P = 0.57), respectively. Liver fibrosis (aspartate transaminase to platelet ratio index and Fibrosis-4) scores were unchanged after the procedure compared with baseline. CONCLUSIONS Percutaneous stenting in adults is safe and effective in relieving Fontan obstruction, resulting in subjective improvement in functional capacity in some. A subset of patients demonstrated improvement in markers of portal hypertension, suggesting that Fontan stenting could improve Fontan-associated liver disease in select individuals.
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Affiliation(s)
- Pradyumna Agasthi
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - C Charles Jain
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Alexander C Egbe
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Donald J Hagler
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA; Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Allison K Cabalka
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA; Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Nathaniel W Taggart
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA; Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jason H Anderson
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA; Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Frank Cetta
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA; Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Heidi M Connolly
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Luke J Burchill
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - William R Miranda
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA.
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Timofeeva M, Lav C, Cheung MMH, Ooi A. Numerical simulation of the cavopulmonary connection flow with conduit stenoses of varying configurations. Comput Biol Med 2023; 164:107358. [PMID: 37598480 DOI: 10.1016/j.compbiomed.2023.107358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/18/2023] [Accepted: 08/12/2023] [Indexed: 08/22/2023]
Abstract
The circulation in the total cavopulmonary connection (TCPC) is a low-energy system which operation and efficiency are subjected to multiple factors. Some retrospective studies report that the abnormal narrowing of vessels in the system, i.e. stenosis, is one of the most dangerous geometric factors which can result in heart failure. In the present study, the effect of varying extracardiac conduit (ECC) stenosis on the hemodynamics in a surrogate TCPC model is investigated using high-fidelity numerical simulations. The efficiency of the surrogate TCPC model was quantified according to the power loss, relative perfusion in lungs and the percentage of conduit surface area with abnormally low and high wall shear stress for venous flow. Additionally, the impact of respiration and asymmetry in the stenosis geometry to the system was examined. The results show that the flow in the TCPC model exhibits pronounced unsteadiness even under the steady initial boundary conditions, while the uneven pulmonary flow distribution and the presence of the ECC stenosis amplify the chaotic nature of the flow. Energy efficiency of the system is shown to strongly correlate with amount of vortical structures in the model and their range of scales. Finally, the study demonstrates that the presence of respiration in the model adds to perturbations in the flow which causes increase in the power loss. Results obtained in the study provide valuable insights on how the ECC stenosis effect the flow in the surrogate TCPC model under different flow conditions.
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Affiliation(s)
- Mariia Timofeeva
- The Faculty of Engineering and Information Technology, The University of Melbourne, 700 Swanston Street, Carlton, VIC, 3053, Australia.
| | - Chitrarth Lav
- The Faculty of Engineering and Information Technology, The University of Melbourne, 700 Swanston Street, Carlton, VIC, 3053, Australia; Scuderia AlphaTauri F1, Bicester, OX26 4LD, United Kingdom
| | - Michael M H Cheung
- Department of Cardiology, Royal Children's Hospital, Melbourne, Australia; Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia; Department of Paediatrics, The University of Melbourne, VIC, 3052, Australia
| | - Andrew Ooi
- The Faculty of Engineering and Information Technology, The University of Melbourne, 700 Swanston Street, Carlton, VIC, 3053, Australia
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8
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Mahendran AK, Katz D, Opotowsky AR, Lubert AM. Exercise Pathophysiology and Testing in Individuals With a Fontan Circulation. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:112-123. [PMID: 37969357 PMCID: PMC10642126 DOI: 10.1016/j.cjcpc.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 01/07/2023] [Indexed: 11/17/2023]
Abstract
The Fontan circulation, a surgical palliation for single-ventricle congenital heart disease, profoundly impacts the cardiopulmonary response to exercise. Reliant on passive pulmonary blood flow, the Fontan circulation has limited capacity to augment cardiac output as necessary to supply working muscles during exercise. Cardiopulmonary exercise testing (CPET) objectively assesses cardiorespiratory fitness and provides insight into the etiology of exercise intolerance. Furthermore, CPET variables, such as peak oxygen consumption and submaximal variables, have prognostic value and may be used as meaningful endpoints in research studies. CPET is also useful in clinical research applications to assess the effect of pharmacologic or other interventions. Medical therapies to improve exercise tolerance in individuals with a Fontan circulation, such as pulmonary vasodilators, may modestly improve peak oxygen consumption. Exercise training focused on aerobic fitness and lower extremity strength may have a more consistent and larger impact on these measures of aerobic fitness. CPET is a valuable diagnostic and prognostic tool for those with a Fontan circulation. Newer ancillary assessments, such as noninvasive peripheral venous pressure monitoring and cardiac output measurements, hold promise to provide a more nuanced insight into the underlying pathophysiology.
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Affiliation(s)
- Arjun K. Mahendran
- Department of Pediatrics, Heart Institute, Cincinnati Children’s Hospital, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - David Katz
- Department of Pediatrics, Heart Institute, Cincinnati Children’s Hospital, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Alexander R. Opotowsky
- Department of Pediatrics, Heart Institute, Cincinnati Children’s Hospital, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Adam M. Lubert
- Department of Pediatrics, Heart Institute, Cincinnati Children’s Hospital, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Lee GH, Koo HJ, Park KJ, Yang DH, Ha H. Characterization of baseline hemodynamics after the Fontan procedure: a retrospective cohort study on the comparison of 4D Flow MRI and computational fluid dynamics. Front Physiol 2023; 14:1199771. [PMID: 37304827 PMCID: PMC10248477 DOI: 10.3389/fphys.2023.1199771] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 05/16/2023] [Indexed: 06/13/2023] Open
Abstract
Introduction: The aim of this study was to characterize the hemodynamics of Fontan patients using both four-dimensional flow magnetic resonance imaging (4D Flow MRI) and computational fluid dynamics (CFD). Methods: Twenty-nine patients (3.5 ± 0.5 years) who had undergone the Fontan procedure were enrolled, and the superior vena cava (SVC), left pulmonary artery (LPA), right pulmonary artery (RPA), and conduit were segmented based on 4D Flow MRI images. Velocity fields from 4D Flow MRI were used as boundary conditions for CFD simulations. Hemodynamic parameters such as peak velocity (Vmax), pulmonary flow distribution (PFD), kinetic energy (KE), and viscous dissipation (VD) were estimated and compared between the two modalities. Results and discussion: The Vmax, KE, VD, PFDTotal to LPA, and PFDTotal to RPA of the Fontan circulation were 0.61 ± 0.18 m/s, 0.15 ± 0.04 mJ, 0.14 ± 0.04 mW, 41.3 ± 15.7%, and 58.7 ± 15.7% from 4D Flow MRI; and 0.42 ± 0.20 m/s, 0.12 ± 0.05 mJ, 0.59 ± 0.30 mW, 40.2 ± 16.4%, and 59.8 ± 16.4% from CFD, respectively. The overall velocity field, KE, and PFD from the SVC were in agreement between modalities. However, PFD from the conduit and VD showed a large discrepancy between 4D Flow MRI and CFD, most likely due to spatial resolution and data noise. This study highlights the necessity for careful consideration when analyzing hemodynamic data from different modalities in Fontan patients.
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Affiliation(s)
- Gyu-Han Lee
- Department of Interdisciplinary Program in Biohealth-Machinery Convergence Engineering, Kangwon National University, Chuncheon, Republic of Korea
| | - Hyun Jung Koo
- Department of Radiology, Asan Medical Center, Research Institute of Radiology, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kyung Jin Park
- Department of Radiology, Asan Medical Center, Research Institute of Radiology, University of Ulsan College of Medicine, Seoul, Republic of Korea
- Department of Electrical and Electronic Engineering, Yonsei University, Seoul, Republic of Korea
| | - Dong Hyun Yang
- Department of Radiology, Asan Medical Center, Research Institute of Radiology, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hojin Ha
- Department of Smart Health Science and Technology, Kangwon National University, Chuncheon, Republic of Korea
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Tsubata H, Nakanishi N, Itatani K, Takigami M, Matsubara Y, Ogo T, Fukuda T, Matsuda H, Matoba S. Pulmonary artery blood flow dynamics in chronic thromboembolic pulmonary hypertension. Sci Rep 2023; 13:6490. [PMID: 37081116 PMCID: PMC10119089 DOI: 10.1038/s41598-023-33727-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 04/18/2023] [Indexed: 04/22/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension is caused by incomplete resolution and organization of thrombi. Blood flow dynamics are involved in thrombus formation; however, only a few studies have reported on pulmonary artery blood flow dynamics in patients with chronic thromboembolic pulmonary hypertension. Furthermore, the effects of treatment interventions on pulmonary artery blood flow dynamics are not fully understood. The aim of the study was to evaluate pulmonary artery blood flow dynamics in patients with chronic thromboembolic pulmonary hypertension before and after pulmonary endarterectomy and balloon pulmonary angioplasty, using computational fluid dynamics. We analyzed patient-specific pulmonary artery models of 10 patients with chronic thromboembolic pulmonary hypertension and three controls using computational fluid dynamics. In patients with chronic thromboembolic pulmonary hypertension, flow velocity and wall shear stress in the pulmonary arteries were significantly decreased, and the oscillatory shear index and blood stagnation volume were significantly increased than in controls. Pulmonary endarterectomy induced redistribution of pulmonary blood flow and improved blood flow dynamics in the pulmonary artery. Balloon pulmonary angioplasty improved pulmonary blood flow disturbance, decreased blood flow stagnation, and increased wall shear stress, leading to vasodilatation of the distal portion of the pulmonary artery following balloon pulmonary angioplasty treatment.
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Affiliation(s)
- Hideo Tsubata
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho Kawaramachi-Hirokoji, Kamigyo-ward, Kyoto, 602-8566, Japan
| | - Naohiko Nakanishi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho Kawaramachi-Hirokoji, Kamigyo-ward, Kyoto, 602-8566, Japan.
| | - Keiichi Itatani
- Department of Cardiovascular Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Masao Takigami
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho Kawaramachi-Hirokoji, Kamigyo-ward, Kyoto, 602-8566, Japan
| | - Yuki Matsubara
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho Kawaramachi-Hirokoji, Kamigyo-ward, Kyoto, 602-8566, Japan
| | - Takeshi Ogo
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Tetsuya Fukuda
- Department of Radiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Hitoshi Matsuda
- Department of Vascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Satoaki Matoba
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho Kawaramachi-Hirokoji, Kamigyo-ward, Kyoto, 602-8566, Japan
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Horiguchi R, Takehara Y, Sugiyama M, Hyodo R, Komada T, Matsushima M, Naganawa S, Mizuno T, Sakurai Y, Sugimoto M, Banno H, Komori K, Itatani K. Postendovascular Aneurysmal Repair Increase in Local Energy Loss for Fusiform Abdominal Aortic Aneurysm: Assessments With 4D flow MRI. J Magn Reson Imaging 2023; 57:1199-1211. [PMID: 35861188 DOI: 10.1002/jmri.28359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 07/05/2022] [Accepted: 07/05/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Although endovascular aneurysmal repair (EVAR) is a preferred treatment for abdominal aortic aneurysm (AAA) owing to its low invasiveness, its impact on the local hemodynamics has not been fully assessed. PURPOSE To elucidate how EVAR affects the local hemodynamics in terms of energy loss (EL). STUDY TYPE Prospective single-arm study. FIELD STRENGTH/SEQUENCE A 3.0 T/4D flow MRI using a phase-contrast three-dimensional cine-gradient-echo sequence. POPULATION A total of 13 consecutive patients (median [interquartile range] age: 77.0 [73.0, 78.8] years, 11 male) scheduled for EVAR as an initial treatment for fusiform AAA. ASSESSMENT 4D flow MRI covering the abdominal aorta and bilateral common iliac arteries and the corresponding stent-graft (SG) lumen was performed before and after EVAR. Plasma brain natriuretic peptide (BNP) was measured within 1 week before and 1 month after EVAR. The hemodynamic data, including mean velocity and the local EL, were compared pre-/post-EVAR. EL was correlated with AAA neck angle and with BNP. Patients were subdivided into deformed (N = 5) and undeformed SG subgroups (N = 8) and pre-/post-EVAR BNP compared in each. STATISTICS Parametric or nonparametric methods. Spearman's rank correlation coefficients (r). The interobserver/intraobserver variabilities with Bland-Altman plots. A P value < 0.05 is considered significant. RESULTS The mean velocity (cm/sec) at the AAA was five times greater after EVAR: 4.79 ± 0.32 vs. 0.91 ± 0.02. The total EL (mW) increased by 1.7 times after EVAR: 0.487 (0.420, 0.706) vs. 0.292 (0.192, 0.420). The total EL was proportional to the AAA neck angle pre-EVAR (r = 0.691) and post-EVAR (r = 0.718). BNP (pg/mL) was proportional to the total EL post-EVAR (r = 0.773). In the deformed SG group, EL (0.349 [0.261, 0.416]) increased 2.4-fold to 0.848 (0.597, 1.13), and the BNP 90.3 (53.6, 105) to 100 (67.2, 123) post-EVAR. CONCLUSION The local EL showed a 1.7-fold increase after EVAR. The larger increase in the EL in the deformed SG group might be a potential concern for frail patients. EVIDENCE LEVEL 1 TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Ryota Horiguchi
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Yasuo Takehara
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan.,Department of Fundamental Development for Advanced Low Invasive Diagnostic Imaging, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Masataka Sugiyama
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Ryota Hyodo
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Tomohiro Komada
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Masaya Matsushima
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Shinji Naganawa
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Takashi Mizuno
- Department of Medical Technology, Nagoya University Hospital, Nagoya, Aichi, Japan
| | - Yasuo Sakurai
- Department of Medical Technology, Nagoya University Hospital, Nagoya, Aichi, Japan
| | - Masayuki Sugimoto
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroshi Banno
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kimihiro Komori
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Keiichi Itatani
- Department of Cardiovascular Surgery, Osaka City University, Osaka, Japan
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12
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Breuer T, Jimenez M, Humphrey JD, Shinoka T, Breuer CK. Tissue Engineering of Vascular Grafts: A Case Report From Bench to Bedside and Back. Arterioscler Thromb Vasc Biol 2023; 43:399-409. [PMID: 36633008 PMCID: PMC9974789 DOI: 10.1161/atvbaha.122.318236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 12/29/2022] [Indexed: 01/13/2023]
Abstract
For over 25 years, our group has used regenerative medicine strategies to develop improved biomaterials for use in congenital heart surgery. Among other applications, we developed a tissue-engineered vascular graft (TEVG) by seeding tubular biodegradable polymeric scaffolds with autologous bone marrow-derived mononuclear cells. Results of our first-in-human study demonstrated feasibility as the TEVG transformed into a living vascular graft having an ability to grow, making it the first engineered graft with growth potential. Yet, outcomes of this first Food and Drug Administration-approved clinical trial evaluating safety revealed a prohibitively high incidence of early TEVG stenosis, preventing the widespread use of this promising technology. Mechanistic studies in mouse models provided important insight into the development of stenosis and enabled advanced computational models. Computational simulations suggested both a novel inflammation-driven, mechano-mediated process of in vivo TEVG development and an unexpected natural history, including spontaneous reversal of the stenosis. Based on these in vivo and in silico discoveries, we have been able to rationally design strategies for inhibiting TEVG stenosis that have been validated in preclinical large animal studies and translated to the clinic via a new Food and Drug Administration-approved clinical trial. This progress would not have been possible without the multidisciplinary approach, ranging from small to large animal models and computational simulations. This same process is expected to lead to further advances in scaffold design, and thus next generation TEVGs.
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Affiliation(s)
- Thomas Breuer
- Nationwide Children's Hospital, Columbus, OH (T.B., M.J., T.S., C.K.B.)
| | - Michael Jimenez
- Nationwide Children's Hospital, Columbus, OH (T.B., M.J., T.S., C.K.B.)
| | - Jay D Humphrey
- Yale University, School of Engineering and Applied Science, New Haven, CT (J.D.H.)
| | - Toshiharu Shinoka
- Nationwide Children's Hospital, Columbus, OH (T.B., M.J., T.S., C.K.B.)
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13
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Das A, Hameed M, Prather R, Farias M, Divo E, Kassab A, Nykanen D, DeCampli W. In-Silico and In-Vitro Analysis of the Novel Hybrid Comprehensive Stage II Operation for Single Ventricle Circulation. Bioengineering (Basel) 2023; 10:bioengineering10020135. [PMID: 36829630 PMCID: PMC9952694 DOI: 10.3390/bioengineering10020135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 12/22/2022] [Accepted: 01/05/2023] [Indexed: 01/20/2023] Open
Abstract
Single ventricle (SV) anomalies account for one-fourth of all congenital heart disease cases. The existing palliative treatment for this anomaly achieves a survival rate of only 50%. To reduce the trauma associated with surgical management, the hybrid comprehensive stage II (HCSII) operation was designed as an alternative for a select subset of SV patients with the adequate antegrade aortic flow. This study aims to provide better insight into the hemodynamics of HCSII patients utilizing a multiscale Computational Fluid Dynamics (CFD) model and a mock flow loop (MFL). Both 3D-0D loosely coupled CFD and MFL models have been tuned to match baseline hemodynamic parameters obtained from patient-specific catheterization data. The hemodynamic findings from clinical data closely match the in-vitro and in-silico measurements and show a strong correlation (r = 0.9). The geometrical modification applied to the models had little effect on the oxygen delivery. Similarly, the particle residence time study reveals that particles injected in the main pulmonary artery (MPA) have successfully ejected within one cardiac cycle, and no pathological flows were observed.
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Affiliation(s)
- Arka Das
- Department of Mechanical Engineering, Embry-Riddle Aeronautical University, Daytona Beach, FL 32114, USA
- Correspondence: ; Tel.: +1-386-241-1457
| | - Marwan Hameed
- Department of Mechanical Engineering, American University of Bahrain, Riffa 942, Bahrain
| | - Ray Prather
- Department of Mechanical Engineering, Embry-Riddle Aeronautical University, Daytona Beach, FL 32114, USA
- Department of Mechanical and Aerospace Engineering, University of Central Florida, Orlando, FL 32816, USA
- The Heart Center at Orlando Health Arnold Palmer Hospital for Children, Orlando, FL 32806, USA
| | - Michael Farias
- The Heart Center at Orlando Health Arnold Palmer Hospital for Children, Orlando, FL 32806, USA
- Department of Clinical Sciences, College of Medicine, University of Central Florida, Orlando, FL 32816, USA
| | - Eduardo Divo
- Department of Mechanical Engineering, Embry-Riddle Aeronautical University, Daytona Beach, FL 32114, USA
| | - Alain Kassab
- Department of Mechanical and Aerospace Engineering, University of Central Florida, Orlando, FL 32816, USA
| | - David Nykanen
- The Heart Center at Orlando Health Arnold Palmer Hospital for Children, Orlando, FL 32806, USA
- Department of Clinical Sciences, College of Medicine, University of Central Florida, Orlando, FL 32816, USA
| | - William DeCampli
- The Heart Center at Orlando Health Arnold Palmer Hospital for Children, Orlando, FL 32806, USA
- Department of Clinical Sciences, College of Medicine, University of Central Florida, Orlando, FL 32816, USA
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14
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Gregory DA, Fricker ATR, Mitrev P, Ray M, Asare E, Sim D, Larpnimitchai S, Zhang Z, Ma J, Tetali SSV, Roy I. Additive Manufacturing of Polyhydroxyalkanoate-Based Blends Using Fused Deposition Modelling for the Development of Biomedical Devices. J Funct Biomater 2023; 14:jfb14010040. [PMID: 36662087 PMCID: PMC9865795 DOI: 10.3390/jfb14010040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/26/2022] [Accepted: 12/30/2022] [Indexed: 01/12/2023] Open
Abstract
In the last few decades Additive Manufacturing has advanced and is becoming important for biomedical applications. In this study we look at a variety of biomedical devices including, bone implants, tooth implants, osteochondral tissue repair patches, general tissue repair patches, nerve guidance conduits (NGCs) and coronary artery stents to which fused deposition modelling (FDM) can be applied. We have proposed CAD designs for these devices and employed a cost-effective 3D printer to fabricate proof-of-concept prototypes. We highlight issues with current CAD design and slicing and suggest optimisations of more complex designs targeted towards biomedical applications. We demonstrate the ability to print patient specific implants from real CT scans and reconstruct missing structures by means of mirroring and mesh mixing. A blend of Polyhydroxyalkanoates (PHAs), a family of biocompatible and bioresorbable natural polymers and Poly(L-lactic acid) (PLLA), a known bioresorbable medical polymer is used. Our characterisation of the PLA/PHA filament suggest that its tensile properties might be useful to applications such as stents, NGCs, and bone scaffolds. In addition to this, the proof-of-concept work for other applications shows that FDM is very useful for a large variety of other soft tissue applications, however other more elastomeric MCL-PHAs need to be used.
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15
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Rijnberg FM, van ‘t Hul LC, Hazekamp MG, van den Boogaard PJ, Juffermans JF, Lamb HJ, Terol Espinosa de Los Monteros C, Kroft LJM, Kenjeres S, le Cessie S, Jongbloed MRM, Westenberg JJM, Roest AAW, Wentzel JJ. Haemodynamic performance of 16-20-mm extracardiac Goretex conduits in adolescent Fontan patients at rest and during simulated exercise. Eur J Cardiothorac Surg 2022; 63:6808623. [PMID: 36342204 PMCID: PMC9972516 DOI: 10.1093/ejcts/ezac522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 10/03/2022] [Accepted: 11/06/2022] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES To date, it is not known if 16-20-mm extracardiac conduits are outgrown during somatic growth from childhood to adolescence. This study aims to determine total cavopulmonary connection (TCPC) haemodynamics in adolescent Fontan patients at rest and during simulated exercise and to assess the relationship between conduit size and haemodynamics. METHODS Patient-specific, magnetic resonance imaging-based computational fluid dynamic models of the TCPC were performed in 51 extracardiac Fontan patients with 16-20-mm conduits. Power loss, pressure gradient and normalized resistance were quantified in rest and during simulated exercise. The cross-sectional area (CSA) (mean and minimum) of the vessels of the TCPC was determined and normalized for flow rate (mm2/l/min). Peak (predicted) oxygen uptake was assessed. RESULTS The median age was 16.2 years (Q1-Q3 14.0-18.2). The normalized mean conduit CSA was 35-73% smaller compared to the inferior and superior vena cava, hepatic veins and left/right pulmonary artery (all P < 0.001). The median TCPC pressure gradient was 0.7 mmHg (Q1-Q3 0.5-0.8) and 2.0 (Q1-Q3 1.4-2.6) during rest and simulated exercise, respectively. A moderate-strong inverse non-linear relationship was present between normalized mean conduit CSA and TCPC haemodynamics in rest and exercise. TCPC pressure gradients of ≥1.0 at rest and ≥3.0 mmHg during simulated exercise were observed in patients with a conduit CSA ≤ 45 mm2/l/min and favourable haemodynamics (<1 mmHg during both rest and exercise) in conduits ≥125 mm2/l/min. Normalized TCPC resistance correlated with (predicted) peak oxygen uptake. CONCLUSIONS Extracardiac conduits of 16-20 mm have become relatively undersized in most adolescent Fontan patients leading to suboptimal haemodynamics.
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Affiliation(s)
- Friso M Rijnberg
- Corresponding author. Department of Cardiothoracic surgery, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, the Netherlands, Telephone number:+31715262348 (F.M. Rijnberg)
| | - Luca C van ‘t Hul
- Department of Cardiology, Biomechanical Engineering, Erasmus MC, Rotterdam, Netherlands
| | - Mark G Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | | | - Joe F Juffermans
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Hildo J Lamb
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | | | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Sasa Kenjeres
- Department of Chemical Engineering, Faculty of Applied Sciences, Delft University of Technology and J.M. Burgers centrum Research School for Fluid Mechanics, Delft, Netherlands
| | - Saskia le Cessie
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
| | - Monique R M Jongbloed
- Department of Cardiology and Anatomy & Embryology, Leiden University Medical Center, Leiden, Netherlands
| | - Jos J M Westenberg
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
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16
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Salaets T, Cools B, De Meester P, Heying R, Boshoff D, Eyskens B, Brown S, Meyns B, Rega F, Van Puyvelde J, Budts W, Gewillig M. Stent expansion of restrictive Fontan conduits to nominal diameter and beyond. Catheter Cardiovasc Interv 2022; 100:1059-1066. [DOI: 10.1002/ccd.30438] [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: 03/08/2022] [Revised: 09/09/2022] [Accepted: 10/02/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Thomas Salaets
- Department of Cardiovascular Sciences, Pediatric & Congenital Cardiology, University Hospitals Leuven Catholic University Leuven Leuven Belgium
| | - Bjorn Cools
- Department of Cardiovascular Sciences, Pediatric & Congenital Cardiology, University Hospitals Leuven Catholic University Leuven Leuven Belgium
| | - Pieter De Meester
- Department of Cardiovascular Sciences Catholic University Leuven Leuven Belgium
| | - Ruth Heying
- Department of Cardiovascular Sciences, Pediatric & Congenital Cardiology, University Hospitals Leuven Catholic University Leuven Leuven Belgium
| | - Derize Boshoff
- Department of Cardiovascular Sciences, Pediatric & Congenital Cardiology, University Hospitals Leuven Catholic University Leuven Leuven Belgium
| | - Benedicte Eyskens
- Department of Cardiovascular Sciences, Pediatric & Congenital Cardiology, University Hospitals Leuven Catholic University Leuven Leuven Belgium
| | - Stephen Brown
- Department of Cardiovascular Sciences, Pediatric & Congenital Cardiology, University Hospitals Leuven Catholic University Leuven Leuven Belgium
- Pediatric Cardiology University of the Free State Bloemfontein Free State South Africa
| | - Bart Meyns
- Department of Cardiovascular Sciences Catholic University Leuven Leuven Belgium
| | - Filip Rega
- Department of Cardiovascular Sciences Catholic University Leuven Leuven Belgium
| | - Joeri Van Puyvelde
- Department of Cardiovascular Sciences Catholic University Leuven Leuven Belgium
| | - Werner Budts
- Department of Cardiovascular Sciences Catholic University Leuven Leuven Belgium
| | - Marc Gewillig
- Department of Cardiovascular Sciences, Pediatric & Congenital Cardiology, University Hospitals Leuven Catholic University Leuven Leuven Belgium
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17
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Venna A, Cetta F, d'Udekem Y. Fontan candidacy, optimizing Fontan circulation, and beyond. JTCVS OPEN 2022; 9:227-232. [PMID: 36003486 PMCID: PMC9390390 DOI: 10.1016/j.xjon.2021.07.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Indexed: 10/24/2022]
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18
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Şimşek B, Özyüksel A, Demiroluk Ş, Saygı M, Bilal MS. Early outcomes of fenestrated intra-extracardiac Fontan procedure: Insights, experiences, and expectations. J Card Surg 2022; 37:1301-1308. [PMID: 35226377 DOI: 10.1111/jocs.16366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 01/04/2022] [Accepted: 01/18/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Intraextracardiac Fontan procedure (FP) aimed to combine the advantages of lateral tunnel and extracardiac conduit modifications of the original technique. Herein, we present our early outcomes in patients with intraextracardiac fenestrated FP. METHODS A retrospective analysis was performed to evaluate intraextracardiac fenestrated Fontan patients between 2014 and 2021. Seventeen patients were operated on with a mean age and body weight of 9.1 ± 5.5 years and 28.6 ± 14.6 kg. RESULTS Sixteen patients (94%) were palliated as univentricular physiology with hypoplasia of one of the ventricles. One patient (6%) with well-developed two ventricles with double outlet right ventricle and complete atrioventricular septal defect had straddling of the chordae prohibiting a biventricular repair. All of the patients had cavopulmonary anastomosis before Fontan completion, except one case. Fenestration was performed in all cases. Postoperative mean pulmonary artery pressures and arterial oxygen saturation levels at follow-up were 10 ± 2.4 mmHg and 91.3 ± 2.7%, respectively. Mean duration of pleural drainage was 5.4 ± 2.3 days. All of the fenestrations are patent at a mean follow-up period of 4.8 ± 7.7 years, except one case. Any morbidity and mortality were not encountered. CONCLUSIONS Early outcomes of intraextracardiac fenestrated FP are encouraging. This procedure may improve the results in a patient population who should be palliated as univentricular physiology, especially in cases with complex cardiac anatomy.
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Affiliation(s)
- Baran Şimşek
- Department of Cardiovascular Surgery, Medicana International Hospital, Istanbul, Turkey
| | - Arda Özyüksel
- Department of Cardiovascular Surgery, Medicana International Hospital, Istanbul, Turkey.,Department of Cardiovascular Surgery, Biruni University, Istanbul, Turkey
| | - Şener Demiroluk
- Department of Anesthesiology, Medicana International Hospital, Istanbul, Turkey
| | - Murat Saygı
- Department of Pediatric Cardiology, Medicana International Hospital, Istanbul, Turkey
| | - Mehmet S Bilal
- Department of Cardiovascular Surgery, Medicana International Hospital, Istanbul, Turkey
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19
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Itatani K, Sekine T, Yamagishi M, Maeda Y, Higashitani N, Miyazaki S, Matsuda J, Takehara Y. Hemodynamic Parameters for Cardiovascular System in 4D Flow MRI: Mathematical Definition and Clinical Applications. Magn Reson Med Sci 2022; 21:380-399. [PMID: 35173116 DOI: 10.2463/mrms.rev.2021-0097] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Blood flow imaging becomes an emerging trend in cardiology with the recent progress in computer technology. It not only visualizes colorful flow velocity streamlines but also quantifies the mechanical stress on cardiovascular structures; thus, it can provide the detailed inspections of the pathophysiology of diseases and predict the prognosis of cardiovascular functions. Clinical applications include the comprehensive assessment of hemodynamics and cardiac functions in echocardiography vector flow mapping (VFM), 4D flow MRI, and surgical planning as a simulation medicine in computational fluid dynamics (CFD).For evaluation of the hemodynamics, novel mathematically derived parameters obtained using measured velocity distributions are essential. Among them, the traditional and typical parameters are wall shear stress (WSS) and its related parameters. These parameters indicate the mechanical damages to endothelial cells, resulting in degenerative intimal change in vascular diseases. Apart from WSS, there are abundant parameters that describe the strength of the vortical and/or helical flow patterns. For instance, vorticity, enstrophy, and circulation indicate the rotating flow strength or power of 2D vortical flows. In addition, helicity, which is defined as the cross-linking number of the vortex filaments, indicates the 3D helical flow strength and adequately describes the turbulent flow in the aortic root in cases with complicated anatomies. For the description of turbulence caused by the diseased flow, there exist two types of parameters based on completely different concepts, namely: energy loss (EL) and turbulent kinetic energy (TKE). EL is the dissipated energy with blood viscosity and evaluates the cardiac workload related to the prognosis of heart failure. TKE describes the fluctuation in kinetic energy during turbulence, which describes the severity of the diseases that cause jet flow. These parameters are based on intuitive and clear physiological concepts, and are suitable for in vivo flow measurements using inner velocity profiles.
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Affiliation(s)
- Keiichi Itatani
- Department of Cardiovascular Surgery, Osaka City University.,Cardio Flow Design Inc
| | - Tetsuro Sekine
- Department of Radiology, Nippon Medical School Musashi Kosugi Hospital
| | - Masaaki Yamagishi
- Department of Pediatric Cardiovascular Surgery, Kyoto Prefectural University of Medicine
| | - Yoshinobu Maeda
- Department of Pediatric Cardiovascular Surgery, Kyoto Prefectural University of Medicine
| | - Norika Higashitani
- Cardio Flow Design Inc.,Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine
| | | | - Junya Matsuda
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Yasuo Takehara
- Department of Fundamental Development for Advanced Low Invasive Diagnostic Imaging, Nagoya university Graduate School of Medicine
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20
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Prather R, Das A, Farias M, Divo E, Kassab A, DeCampli W. Parametric investigation of an injection-jet self-powered Fontan circulation. Sci Rep 2022; 12:2161. [PMID: 35140260 PMCID: PMC8828777 DOI: 10.1038/s41598-022-05985-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 01/17/2022] [Indexed: 12/04/2022] Open
Abstract
Approximately \documentclass[12pt]{minimal}
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\begin{document}$$1/2500$$\end{document}1/2500 babies are born with only one functioning ventricle and the Fontan is the third and, ideally final staged palliative operation for these patients. This altered circulation is prone to failure with survival rates below \documentclass[12pt]{minimal}
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\begin{document}$$50\%$$\end{document}50% into adulthood. Chronically elevated inferior vena cava (IVC) pressure is implicated as one cause of the mortality and morbidity in this population. An injection jet shunt (IJS) drawing blood-flow directly from the aortic arch to significantly lower IVC pressure is proposed. A computer-generated 3D model of a 2–4 year old patient with a fenestrated Fontan and a cardiac output of 2.3 L/min was generated. The detailed 3D pulsatile hemodynamics are resolved in a zero-dimensional lumped parameter network tightly-coupled to a 3D computational fluid dynamics model accounting for non-Newtonian blood rheology and resolving turbulence using large eddy simulation. IVC pressure and systemic oxygen saturation were tracked for various IJS-assisted Fontan configurations, altering design parameters such as shunt and fenestration diameters and locations. A baseline “failing” Fontan with a 4 mm fenestration was tuned to have an elevated IVC pressure (+ 17.8 mmHg). Enlargement of the fenestration to 8 mm resulted in a 3 mmHg IVC pressure drop but an unacceptable reduction in systemic oxygen saturation below 80%. Addition of an IJS with a 2 mm nozzle and minor volume load to the ventricle improved the IVC pressure drop to 3.2 mmHg while increasing systemic oxygen saturation above 80%. The salutary effects of the IJS to effectively lower IVC pressure while retaining acceptable levels of oxygen saturation are successfully demonstrated.
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Affiliation(s)
- Ray Prather
- Department of Mechanical and Aerospace Engineering, University of Central Florida, 4000 Central Florida Blvd., Orlando, FL, 32816, USA. .,Department of Mechanical Engineering, Embry-Riddle Aeronautical University, 1 Aerospace Blvd., Daytona Beach, FL, 32114, USA. .,The Heart Center, Arnold Palmer Hospital for Children, 92 West Miller Street, Orlando, FL, 32806, USA.
| | - Arka Das
- Department of Mechanical Engineering, Embry-Riddle Aeronautical University, 1 Aerospace Blvd., Daytona Beach, FL, 32114, USA
| | - Michael Farias
- The Heart Center, Arnold Palmer Hospital for Children, 92 West Miller Street, Orlando, FL, 32806, USA
| | - Eduardo Divo
- Department of Mechanical Engineering, Embry-Riddle Aeronautical University, 1 Aerospace Blvd., Daytona Beach, FL, 32114, USA
| | - Alain Kassab
- Department of Mechanical and Aerospace Engineering, University of Central Florida, 4000 Central Florida Blvd., Orlando, FL, 32816, USA
| | - William DeCampli
- The Heart Center, Arnold Palmer Hospital for Children, 92 West Miller Street, Orlando, FL, 32806, USA.,College of Medicine, University of Central Florida, 6850 Lake Nona Blvd, Orlando, FL, 32827, USA
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21
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McGovern E, Alsaied T, Szugye N, Pradhan S, Batlivala SP, Lubert A, Hirsch R. The Fontan Pathway: Change in Dimension and Catheter-Based Intervention over Time. Pediatr Cardiol 2021; 42:1740-1748. [PMID: 34136951 DOI: 10.1007/s00246-021-02658-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 06/07/2021] [Indexed: 11/29/2022]
Abstract
An unobstructed Fontan pathway is essential for optimal hemodynamics. We hypothesize that more extracardiac conduit (ECC) Fontan pathways develop obstruction compared to lateral tunnel (LT) Fontans and that the dilation typically observed in LTs results in similar mid-term clinical outcomes. A single-center, retrospective study was done including all Fontan cardiac catheterizations from 2006 to 2019. Angiography and medical records were reviewed to define Fontan pathway dimensions, interventions, and clinical outcomes. 232 patients underwent cardiac catheterization, where 60% were ECCs and 30% LTs. The minimum cross-sectional area (CSA) of ECCs was significantly smaller than LTs and LTs dilated over time. 13% of patients had Fontan pathway stenting at a median age of 16.2 years. The minimum CSA for patients who underwent intervention was significantly smaller than patients who did not. Lower weight at Fontan surgery was associated with intervention on the Fontan pathway, with a threshold weight of 15 kg for patients with an ECC. The median follow-up was 3.3 years. Patients who had Fontan pathway intervention were not more likely to experience the composite adverse clinical outcome. LTs were more likely than ECCs to have worse clinical outcome, when liver fibrosis was included. This is the first study to describe angiographic dimensions of the Fontan pathway in a large number of patients over time. ECCs tend to become stenotic. Lower weight at Fontan surgery is a potential risk for Fontan pathway intervention. LTs may experience worse clinical outcomes in follow-up. This information can help inform the optimal timing and method of post-Fontan surveillance.
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Affiliation(s)
- E McGovern
- Division of Pediatric Cardiology, Department of Pediatrics, University of Kentucky, Lexington, KY, USA.
| | - T Alsaied
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - N Szugye
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - S Pradhan
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - S P Batlivala
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - A Lubert
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - R Hirsch
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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22
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Rijnberg FM, van der Woude SFS, Hazekamp MG, van den Boogaard PJ, Lamb HJ, Terol Espinosa de Los Monteros C, Kroft LJM, Kenjeres S, Karim T, Jongbloed MRM, Westenberg JJM, Wentzel JJ, Roest AAW. Extracardiac conduit adequacy along the respiratory cycle in adolescent Fontan patients. Eur J Cardiothorac Surg 2021; 62:6423130. [PMID: 34747442 PMCID: PMC9257669 DOI: 10.1093/ejcts/ezab478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 09/12/2021] [Accepted: 09/26/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
- Friso M Rijnberg
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | | | - Mark G Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | | | - Hildo J Lamb
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | | | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Sasa Kenjeres
- Department of Chemical Engineering, Faculty of Applied Sciences, Delft University of Technology and J.M. Burgers Centrum Research School for Fluid Mechanics, Delft, Netherlands
| | - Tawab Karim
- Department of Cardiology, Biomechanical Engineering, Erasmus MC, Rotterdam, Netherlands
| | - Monique R M Jongbloed
- Department of Cardiology and Anatomy and Embryology, Leiden University Medical Center, Leiden, Netherlands
| | - Jos J M Westenberg
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Jolanda J Wentzel
- Department of Cardiology, Biomechanical Engineering, Erasmus MC, Rotterdam, Netherlands
| | - Arno A W Roest
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, Netherlands
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23
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In-Vitro Validation of Self-Powered Fontan Circulation for Treatment of Single Ventricle Anomaly. FLUIDS 2021. [DOI: 10.3390/fluids6110401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Around 8% of all newborns with a Congenital Heart Defect (CHD) have only a single functioning ventricle. The Fontan operation has served as palliation for this anomaly for decades, but the surgery entails multiple complications, and the survival rate is less than 50% by adulthood. A rapidly testable novel alternative is proposed by creating a bifurcating graft, or Injection Jet Shunt (IJS), used to “entrain” the pulmonary flow and thus provide assistance while reducing the caval pressure. A dynamically scaled Mock Flow Loop (MFL) has been configured to validate this hypothesis. Three IJS nozzles of varying diameters 2, 3, and 4 mm with three aortic anastomosis angles and pulmonary vascular resistance (PVR) reduction have been tested to validate the hypothesis and optimize the caval pressure reduction. The MFL is based on a Lumped-Parameter Model (LPM) of a non-fenestrated Fontan circulation. The best outcome was achieved with the experimental testing of a 3 mm IJS by producing an average caval pressure reduction of more than 5 mmHg while maintaining the clinically acceptable pulmonary flow rate (Qp) to systemic flow rate (Qs) ratio of ~1.5. Furthermore, alteration of the PVR helped in achieving higher caval pressure reduction with the 3 mm IJS at the expense of an increase in Qp/Qs ratio.
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24
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van der Woude SFS, Rijnberg FM, Hazekamp MG, Jongbloed MRM, Kenjeres S, Lamb HJ, Westenberg JJM, Roest AAW, Wentzel JJ. The Influence of Respiration on Blood Flow in the Fontan Circulation: Insights for Imaging-Based Clinical Evaluation of the Total Cavopulmonary Connection. Front Cardiovasc Med 2021; 8:683849. [PMID: 34422920 PMCID: PMC8374887 DOI: 10.3389/fcvm.2021.683849] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 07/05/2021] [Indexed: 12/18/2022] Open
Abstract
Congenital heart disease is the most common birth defect and functionally univentricular heart defects represent the most severe end of this spectrum. The Fontan circulation provides an unique solution for single ventricle patients, by connecting both caval veins directly to the pulmonary arteries. As a result, the pulmonary circulation in Fontan palliated patients is characterized by a passive, low-energy circulation that depends on increased systemic venous pressure to drive blood toward the lungs. The absence of a subpulmonary ventricle led to the widely believed concept that respiration, by sucking blood to the pulmonary circulation during inspiration, is of great importance as a driving force for antegrade blood flow in Fontan patients. However, recent studies show that respiration influences pulsatility, but has a limited effect on net forward flow in the Fontan circulation. Importantly, since MRI examination is recommended every 2 years in Fontan patients, clinicians should be aware that most conventional MRI flow sequences do not capture the pulsatility of the blood flow as a result of the respiration. In this review, the unique flow dynamics influenced by the cardiac and respiratory cycle at multiple locations within the Fontan circulation is discussed. The impact of (not) incorporating respiration in different MRI flow sequences on the interpretation of clinical flow parameters will be covered. Finally, the influence of incorporating respiration in advanced computational fluid dynamic modeling will be outlined.
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Affiliation(s)
- Séline F S van der Woude
- Department of Cardiology, Biomedical Engineering, Biomechanics Laboratory, Rotterdam, Netherlands
| | - Friso M Rijnberg
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Mark G Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Monique R M Jongbloed
- Department of Anatomy, Embryology and Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Sasa Kenjeres
- Department of Chemical Engineering, Faculty of Applied Sciences, Delft University of Technology and J. M. Burgerscentrum Research School for Fluid Mechanics, Delft, Netherlands
| | - Hildo J Lamb
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Jos J M Westenberg
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Arno A W Roest
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Jolanda J Wentzel
- Department of Cardiology, Biomedical Engineering, Biomechanics Laboratory, Rotterdam, Netherlands
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25
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Cao JY, Marathe SP, Zannino D, Celermajer DS, Justo RN, Alphonso N, d'Udekem Y, Winlaw DS. Fontan operation at less than 3 years of age is not a risk factor for long-term failure. Eur J Cardiothorac Surg 2021; 61:497-504. [PMID: 34355744 DOI: 10.1093/ejcts/ezab355] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 06/14/2021] [Accepted: 06/17/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The age at which the Fontan operation is performed varies globally. Over the last decade, the median age of patients having the Fontan in Australia and New Zealand has been 4.6 years, including 6% of patients younger than 3 years. Long-term outcomes of an early Fontan operation are unclear and are described in this study. METHODS Patients from the Australian and New Zealand Fontan Registry were grouped by age at Fontan. A Fontan before 3 years (early Fontan) was compared to the combined second and third quartiles by age at surgery in the Registry (3.6-6.1 years; control). Outcomes included Fontan failure (death, transplant, New York Heart Association functional group III/IV heart failure, Fontan takedown or conversion, protein losing enteropathy and plastic bronchitis), arrhythmias, thromboembolism and reinterventions. RESULTS A total of 191 patients who had early Fontan operations were compared to 781 controls. Profound or progressive cyanosis was noted more frequently in the early than in the control group (63% vs 23%; P < 0.001). The early group was followed up for a median 22.1 years. The incidence of long-term failure was similar between the 2 groups (early, 1.08 failures per 100 patient-years of follow-up vs control, 0.99; log-rank P = 0.79). Adjusted for risk factors, early age at Fontan was not a risk factor for long-term failure [hazard ratio (HR) 1.16, 95% confidence interval (CI) 0.77-1.76; P = 0.48], new-onset arrhythmia (HR 0.93, 95% CI 0.63-1.39; P = 0.73), thromboembolism (HR 0.50, 95% CI 0.28-0.91; P = 0.024) or reintervention (HR 1.08, 95% CI 0.80-1.45; P = 0.62). CONCLUSIONS Having the Fontan operation at an early age was not a risk factor for short- or long-term adverse outcomes in our cohort.
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Affiliation(s)
- Jacob Y Cao
- Sydney Medical School, University of Sydney, Sydney, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Supreet P Marathe
- Queensland Children's Hospital, Brisbane, Australia.,University of Queensland, Brisbane, Australia
| | - Diana Zannino
- Murdoch Children's Research Institute, Melbourne, Australia
| | - David S Celermajer
- Sydney Medical School, University of Sydney, Sydney, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Robert N Justo
- Queensland Children's Hospital, Brisbane, Australia.,University of Queensland, Brisbane, Australia
| | - Nelson Alphonso
- Queensland Children's Hospital, Brisbane, Australia.,University of Queensland, Brisbane, Australia
| | - Yves d'Udekem
- Murdoch Children's Research Institute, Melbourne, Australia.,Royal Children's Hospital, Melbourne, Australia
| | - David S Winlaw
- Heart Centre for Children, The Children's Hospital at Westmead, Sydney, Australia.,Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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26
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Progression in Fontan conduit stenosis and hemodynamic impact during childhood and adolescence. J Thorac Cardiovasc Surg 2021; 162:372-380.e2. [DOI: 10.1016/j.jtcvs.2020.09.140] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 09/29/2020] [Accepted: 09/30/2020] [Indexed: 01/09/2023]
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27
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Schwarz EL, Kelly JM, Blum KM, Hor KN, Yates AR, Zbinden JC, Verma A, Lindsey SE, Ramachandra AB, Szafron JM, Humphrey JD, Shin'oka T, Marsden AL, Breuer CK. Hemodynamic performance of tissue-engineered vascular grafts in Fontan patients. NPJ Regen Med 2021; 6:38. [PMID: 34294733 PMCID: PMC8298568 DOI: 10.1038/s41536-021-00148-w] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 06/11/2021] [Indexed: 02/06/2023] Open
Abstract
In the field of congenital heart surgery, tissue-engineered vascular grafts (TEVGs) are a promising alternative to traditionally used synthetic grafts. Our group has pioneered the use of TEVGs as a conduit between the inferior vena cava and the pulmonary arteries in the Fontan operation. The natural history of graft remodeling and its effect on hemodynamic performance has not been well characterized. In this study, we provide a detailed analysis of the first U.S. clinical trial evaluating TEVGs in the treatment of congenital heart disease. We show two distinct phases of graft remodeling: an early phase distinguished by rapid changes in graft geometry and a second phase of sustained growth and decreased graft stiffness. Using clinically informed and patient-specific computational fluid dynamics (CFD) simulations, we demonstrate how changes to TEVG geometry, thickness, and stiffness affect patient hemodynamics. We show that metrics of patient hemodynamics remain within normal ranges despite clinically observed levels of graft narrowing. These insights strengthen the continued clinical evaluation of this technology while supporting recent indications that reversible graft narrowing can be well tolerated, thus suggesting caution before intervening clinically.
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Affiliation(s)
- Erica L Schwarz
- Department of Bioengineering, Stanford University, Stanford, CA, USA.
| | - John M Kelly
- Center for Regenerative Medicine, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
- The Heart Center, Nationwide Children's Hospital, Columbus, OH, USA
| | - Kevin M Blum
- Center for Regenerative Medicine, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
- Department of Biomedical Engineering, The Ohio State University, Columbus, OH, USA
| | - Kan N Hor
- The Heart Center, Nationwide Children's Hospital, Columbus, OH, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Andrew R Yates
- The Heart Center, Nationwide Children's Hospital, Columbus, OH, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Jacob C Zbinden
- Center for Regenerative Medicine, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
- Department of Biomedical Engineering, The Ohio State University, Columbus, OH, USA
| | - Aekaansh Verma
- Department of Bioengineering, Stanford University, Stanford, CA, USA
| | - Stephanie E Lindsey
- Department of Bioengineering, Stanford University, Stanford, CA, USA
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | | | - Jason M Szafron
- Department of Biomedical Engineering, Yale University, New Haven, CT, USA
| | - Jay D Humphrey
- Department of Biomedical Engineering, Yale University, New Haven, CT, USA
| | - Toshiharu Shin'oka
- Center for Regenerative Medicine, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
- The Heart Center, Nationwide Children's Hospital, Columbus, OH, USA
- Department of Cardiothoracic Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Alison L Marsden
- Department of Bioengineering, Stanford University, Stanford, CA, USA
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Christopher K Breuer
- Center for Regenerative Medicine, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Department of Surgery, Nationwide Children's Hospital, Columbus, OH, USA
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28
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Assessment of biventricular hemodynamics and energy dynamics using lumen-tracking 4D flow MRI without contrast medium. J Cardiol 2021; 78:79-87. [PMID: 33536147 DOI: 10.1016/j.jjcc.2021.01.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 10/25/2020] [Accepted: 01/12/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Biventricular physiological interaction remains a challenging problem in cardiology. We developed a four-dimensional (4D) flow magnetic resonance imaging (MRI) scan and clinically available analysis protocol based on beat tracking of the cardiovascular lumen without contrast medium, which enabled measurement of the biventricular hemodynamics and energetic performance by calculating flow energy loss (EL) and kinetic energy (KE). The aim of this study was to observe the flow patterns and energy dynamics to reveal the physiology of the right and left ventricular systems. METHODS 4D flow MRI studies were performed in 19 healthy volunteers including 11 male and 8 female. The right and left ventricular systems were segmented to visualize the flow patterns and to quantify the hemodynamics and energy dynamics. RESULTS A large vortex was observed in the left ventricle (LV), along the longitudinal axis, during end diastole and early systole. At early systole, the vortex appeared to facilitate smooth ejection with little EL. In contrast, in the right ventricle (RV), there were vortices near the free wall in both the short and long axes during the diastolic filling phase. Mean EL index during a single cardiac cycle in the right and left heart systems was 0.63 ± 0.16 (0.42-0.99) mW/m2, and 1.02 ± 0.26 (0.58-1.58) mW/m2, respectively. EL is inevitable loss caused by the vortex flow to facilitate smooth right and left ventricular function and left-sided EL tended to correlate positively with heart rate and right ventricular stroke volume. Kinetic energy at the aortic valve was influenced by LV end-diastolic volume/stroke volume. No gender difference was observed. CONCLUSIONS The RV appears to function as a regulator of the energy dynamics of the LV system.
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29
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Daley M, d'Udekem Y. The optimal Fontan operation: Lateral tunnel or extracardiac conduit? J Thorac Cardiovasc Surg 2020; 162:1825-1834. [PMID: 33581907 DOI: 10.1016/j.jtcvs.2020.11.179] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 11/09/2020] [Accepted: 11/26/2020] [Indexed: 01/14/2023]
Affiliation(s)
- Michael Daley
- Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Australia; Department of Paediatrics, The University of Melbourne, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia
| | - Yves d'Udekem
- Department of Paediatrics, The University of Melbourne, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia; Division of Cardiac Surgery, Children's National Hospital, Washington, DC.
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30
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Kelly JM, Mirhaidari GJM, Chang YC, Shinoka T, Breuer CK, Yates AR, Hor KN. Evaluating the Longevity of the Fontan Pathway. Pediatr Cardiol 2020; 41:1539-1547. [PMID: 33161457 PMCID: PMC10017017 DOI: 10.1007/s00246-020-02452-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 09/02/2020] [Indexed: 11/25/2022]
Abstract
Children born with single ventricle physiology who undergo Fontan palliation face a diverse set of long-term complications. However, patient follow-up has in large part been limited to single institutional experiences without uniform application of diagnostic modalities to screen for relevant outcomes. Additionally, the use of different graft materials and variable surgical technique as part of the Fontan procedure has further complicated the evaluation of single ventricle patients. The purpose of this review is to define the changes in the Fontan pathway specific to the graft material used and its relationship to patient outcomes. As a means of introduction, we briefly review the historical evolution of the Fontan procedure with a focus on the intent behind design changes and incorporation of different biomaterials. We further delineate changes to the Fontan pathway which include the development of stenosis, differential growth, thrombosis, and calcification. Ultimately, the recognition of the changes noted within the Fontan pathway need to be assessed relative to their impact on patient hemodynamics, functional capacity, and Fontan-associated comorbidities.
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Affiliation(s)
- John M Kelly
- Center for Regenerative Medicine, Abigail Wexner Research Institute At Nationwide Children's Hospital, Columbus, OH, USA.
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.
- The Heart Center, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Gabriel J M Mirhaidari
- Center for Regenerative Medicine, Abigail Wexner Research Institute At Nationwide Children's Hospital, Columbus, OH, USA
- Biomedical Sciences Graduate Program, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Yu-Chun Chang
- Center for Regenerative Medicine, Abigail Wexner Research Institute At Nationwide Children's Hospital, Columbus, OH, USA
- Biomedical Sciences Graduate Program, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Toshiharu Shinoka
- Center for Regenerative Medicine, Abigail Wexner Research Institute At Nationwide Children's Hospital, Columbus, OH, USA
- The Heart Center, Nationwide Children's Hospital, Columbus, OH, USA
- Department of Cardiothoracic Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Christopher K Breuer
- Center for Regenerative Medicine, Abigail Wexner Research Institute At Nationwide Children's Hospital, Columbus, OH, USA
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Department of Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Andrew R Yates
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
- The Heart Center, Nationwide Children's Hospital, Columbus, OH, USA
- Department of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Kan N Hor
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
- The Heart Center, Nationwide Children's Hospital, Columbus, OH, USA
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31
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Well A, Beckerman Z. Commentary: The heart of the matter: Close clinical follow-up and exercise capacity in Fontan circulation. J Thorac Cardiovasc Surg 2020; 162:382-383. [PMID: 33220971 DOI: 10.1016/j.jtcvs.2020.10.094] [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: 10/19/2020] [Revised: 10/19/2020] [Accepted: 10/21/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Andrew Well
- Division of Pediatric and Congenital Cardiothoracic Surgery, Department of Surgery and Perioperative Care, University of Texas Dell Medical School, Austin, Tex; Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin/Dell Children's Medical Center, Austin, Tex
| | - Ziv Beckerman
- Division of Pediatric and Congenital Cardiothoracic Surgery, Department of Surgery and Perioperative Care, University of Texas Dell Medical School, Austin, Tex; Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin/Dell Children's Medical Center, Austin, Tex.
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32
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Fontan Hemodynamics Investigation via Modeling and Experimental Characterization of Idealized Pediatric Total Cavopulmonary Connection. APPLIED SCIENCES-BASEL 2020. [DOI: 10.3390/app10196910] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Simulation of the human body normal operating conditions is the important issue in the engineering process of designing biomedical devices intended for implantation. As an example of such process the Fontan procedure aims to support the human body function. It is a standard palliative treatment method for patients with a functionally univentricular heart. Nevertheless, this procedure has significant drawbacks. For instance, overload of the only functional ventricle leads to the inevitability of the heart transplantation. Herein, we perform simulation and experimental characteristics of the pediatric total cavopulmonary connection (TCPC) influence on the blood flow. We investigate and design three different types of pediatric TCPC configurations; we detect fluorescent particles via a high-speed camera in order to analyze distribution of the blood flow velocity modulus in different types of TCPCs. Finally, we evaluate hydraulic power losses for various cases. This work is particularly relevant for the improvement of existing TCPCs quality that can extend the life of Fontan patients. Moreover, it also applies to the reduction of morbidity and mortality of the patients waiting for a heart transplantation.
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33
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Kittaka D, Sato H, Nakai Y, Kato K. Relationship Between Coronary Fractional Flow Reserve and Computational Fluid Dynamics Analysis in Moderate Stenosis of the Coronary Artery. Circ Rep 2020; 2:545-551. [PMID: 33693179 PMCID: PMC7932814 DOI: 10.1253/circrep.cr-20-0078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background:
Fractional flow reserve (FFR) is used to evaluate the need for percutaneous coronary intervention (PCI) in cases of moderate stenosis of the coronary artery. Recently, diagnostic imaging support with computational fluid dynamics (CFD) analysis has been garnering attention. This study defines the relationship between FFR conducted for cardiac catheterization and CFD analyses conducted using coronary computed tomography (CT) for moderate stenosis, in addition to considering whether wall pressure (WP) and wall shear stress (WSS) can be used to evaluate ischemia. Methods and Results:
Cases in which FFR was measured via coronary CT and cardiac catheterization was performed within 3 months were collected retrospectively. In the CFD analysis, WP and WSS were calculated and compared with FFR. Three groups were created to compare results of CFD analysis and FFR values according to the location of the stenosis: the right coronary artery, the left anterior descending artery, and the left circumflex artery. There was a correlation between FFR and WSS according to CFD analysis for moderate stenosis of the coronary artery, with a cut-off value for treatment able to be calculated. Conclusions:
The results of this study suggest that ischemia can be evaluated by conducting CFD analysis (WSS) using coronary CT.
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Affiliation(s)
- Daisuke Kittaka
- Department of Radiological Technology, Showa University Hospital Tokyo Japan
| | - Hisaya Sato
- Department of Radiological Technology, Showa University Hospital Tokyo Japan.,Showa University Graduate School of Health Sciences Tokyo Japan
| | - Yuichi Nakai
- Department of Radiological Technology, Showa University Northern Yokohama Hospital Yokohama Japan
| | - Kyoichi Kato
- Showa University Graduate School of Health Sciences Tokyo Japan.,Showa University Radiological Technology Tokyo Japan
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34
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Gerrah R, Haller SJ. Computational fluid dynamics: a primer for congenital heart disease clinicians. Asian Cardiovasc Thorac Ann 2020; 28:520-532. [PMID: 32878458 DOI: 10.1177/0218492320957163] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Computational fluid dynamics has become an important tool for studying blood flow dynamics. As an in-silico collection of methods, computational fluid dynamics is noninvasive and provides numerical values for the most important parameters of blood flow, such as velocity and pressure that are crucial in hemodynamic studies. In this primer, we briefly explain the basic theory and workflow of the two most commonly applied computational fluid dynamics techniques used in the congenital heart disease literature: the finite element method and the finite volume method. We define important terminology and include specific examples of how using these methods can answer important clinical questions in congenital cardiac surgery planning and perioperative patient management.
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Affiliation(s)
- Rabin Gerrah
- Stanford University, Samaritan Cardiovascular Surgery, Corvallis, OR, USA
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35
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Hirose K, Ikai A, Murata M, Ito H, Koshiyama H, Ishidou M, Ota K, Watanabe K, Nakatani E, Sakamoto K. Intra-Extracardiac Total Cavopulmonary Connection for Patients With Anatomical Complexity. Ann Thorac Surg 2020; 111:958-965. [PMID: 32763269 DOI: 10.1016/j.athoracsur.2020.05.176] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 05/07/2020] [Accepted: 05/27/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Currently, the extracardiac conduit total cavopulmonary connection (eTCPC) is the most widely used for Fontan modification worldwide. Nevertheless, there have been some cases that are difficult for performing eTCPC because of their anatomical complexity, such as apicocaval juxtaposition. For such cases, in 2002, we introduced the intra-extracardiac TCPC (ieTCPC). METHODS We reviewed our 20-year single-center experience with 316 TCPC patients to compare eTCPC (n = 277) and ieTCPC (n = 39) in terms of mortality and morbidity. ieTCPC was indicated for the cases in which there was concern that the TCPC conduit would be too curved for ordinary eTCPC. RESULTS Early death occurred in 1 patient and late death occurred in 15 patients. The actuarial survival rate in the eTCPC and the ieTCPC groups at 10 years were 95.1% and 100.0%, respectively. There was no significant difference in actuarial survival between eTCPC and ieTCPC patients. In the multivariate analysis, preoperative superior vena cava pressure and preoperative oxygen saturation were found to be the independent predictor for postoperative mortality. There was also no significant difference in actuarial rate of freedom from late-occurring complications between eTCPC and ieTCPC groups. In the multivariate analysis, dominant right ventricle and preoperative SVC pressure were independent predictors for late-occurring complications. CONCLUSIONS The clinical outcomes in patients who undergo eTCPC and ieTCPC appear to be excellent, with low mortality and morbidity rates in the midterm. ieTCPC may be a good option for TCPC cases with anatomical complexity such as apicocaval juxtaposition and separated hepatic vein drainage.
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Affiliation(s)
- Keiichi Hirose
- Department of Cardiovascular Surgery, Mt. Fuji Shizuoka Children's Hospital, Shizuoka, Japan.
| | - Akio Ikai
- Department of Cardiovascular Surgery, Mt. Fuji Shizuoka Children's Hospital, Shizuoka, Japan
| | - Masaya Murata
- Department of Cardiovascular Surgery, Mt. Fuji Shizuoka Children's Hospital, Shizuoka, Japan
| | - Hiroki Ito
- Department of Cardiovascular Surgery, Mt. Fuji Shizuoka Children's Hospital, Shizuoka, Japan
| | - Hiroshi Koshiyama
- Department of Cardiovascular Surgery, Mt. Fuji Shizuoka Children's Hospital, Shizuoka, Japan
| | - Motonari Ishidou
- Department of Cardiovascular Surgery, Mt. Fuji Shizuoka Children's Hospital, Shizuoka, Japan
| | - Keisuke Ota
- Department of Cardiovascular Surgery, Mt. Fuji Shizuoka Children's Hospital, Shizuoka, Japan
| | - Kentaro Watanabe
- Department of Cardiovascular Surgery, Mt. Fuji Shizuoka Children's Hospital, Shizuoka, Japan
| | - Eiji Nakatani
- Division of Statistical Analysis, Research Support Center, Shizuoka General Hospital, Shizuoka, Japan
| | - Kisaburo Sakamoto
- Department of Cardiovascular Surgery, Mt. Fuji Shizuoka Children's Hospital, Shizuoka, Japan
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Ismail MF, Elmahrouk AF, Arafat AA, Hamouda TE, Edrees A, Bogis A, Arfi AM, Dohain AM, Alkhattabi A, Alharbi AW, Shihata MS, Al‐Radi OO, Al‐Ata JA, Jamjoom AA. Bovine jugular vein valved xenograft for extracardiac total cavo‐pulmonary connection: The risk of thrombosis and the potential liver protection effect. J Card Surg 2020; 35:845-853. [DOI: 10.1111/jocs.14484] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Mohamed F. Ismail
- Department of Cardiothoracic SurgeryKing Faisal Specialist Hospital and Research CenterJeddah Saudi Arabia
- Department of Cardiothoracic Surgery, Faculty of MedicineMansoura UniversityMansoura Egypt
| | - Ahmed F. Elmahrouk
- Department of Cardiothoracic SurgeryKing Faisal Specialist Hospital and Research CenterJeddah Saudi Arabia
- Department of Cardiothoracic Surgery, Faculty of MedicineTanta UniversityTanta Egypt
| | - Amr A. Arafat
- Department of Cardiothoracic Surgery, Faculty of MedicineTanta UniversityTanta Egypt
| | - Tamer E. Hamouda
- Department of Cardiothoracic SurgeryKing Faisal Specialist Hospital and Research CenterJeddah Saudi Arabia
- Department of Cardiothoracic Surgery, Faculty of MedicineBenha UniversityBenha Egypt
| | - Azzahra Edrees
- Department of Cardiothoracic SurgeryKing Faisal Specialist Hospital and Research CenterJeddah Saudi Arabia
| | - Abdulbadee Bogis
- Department of Cardiothoracic SurgeryKing Faisal Specialist Hospital and Research CenterJeddah Saudi Arabia
| | - Amin M. Arfi
- Section of Pediatric Cardiology, Department of PediatricsKing Faisal Specialist Hospital and Research CenterJeddah Saudi Arabia
| | - Ahmed M. Dohain
- Division of Pediatric Cardiology, Department of PediatricsFaculty of Medicine Cairo UniversityCairo Egypt
- Section of Pediatric Cardiology, Department of PediatricsKing Abdulaziz UniversityJeddah Saudi Arabia
| | - Abdullah Alkhattabi
- Section of Gastroenterology, Department of Internal MedicineKing Faisal Specialist Hospital and Research CenterJeddah Saudi Arabia
| | - Ahmed W. Alharbi
- Section of Gastroenterology, Department of Internal MedicineKing Faisal Specialist Hospital and Research CenterJeddah Saudi Arabia
| | - Mohammad S. Shihata
- Department of Cardiothoracic SurgeryKing Faisal Specialist Hospital and Research CenterJeddah Saudi Arabia
| | - Osman O. Al‐Radi
- Department of Cardiothoracic SurgeryKing Faisal Specialist Hospital and Research CenterJeddah Saudi Arabia
- Section of Cardiothoracic Surgery, Department of SurgeryKing Abdulaziz UniversityJeddah Saudi Arabia
| | - Jameel A. Al‐Ata
- Section of Pediatric Cardiology, Department of PediatricsKing Faisal Specialist Hospital and Research CenterJeddah Saudi Arabia
- Section of Pediatric Cardiology, Department of PediatricsKing Abdulaziz UniversityJeddah Saudi Arabia
| | - Ahmed A. Jamjoom
- Department of Cardiothoracic SurgeryKing Faisal Specialist Hospital and Research CenterJeddah Saudi Arabia
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Personalized Interventions: A Reality in the Next 20 Years or Pie in the Sky. Pediatr Cardiol 2020; 41:486-502. [PMID: 32198592 DOI: 10.1007/s00246-020-02303-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 01/17/2020] [Indexed: 12/22/2022]
Abstract
There is no better representation of the need for personalization of care than the breadth and complexity of congenital heart disease. Advanced imaging modalities are now standard of care in the field, and the advancements being made to three-dimensional visualization technologies are growing as a means of pre-procedural preparation. Incorporating emerging modeling approaches, such as computational fluid dynamics, will push the limits of our ability to predict outcomes, and this information may be both obtained and utilized during a single procedure in the future. Artificial intelligence and customized devices may soon surface as realistic tools for the care of patients with congenital heart disease, as they are showing growing evidence of feasibility within other fields. This review illustrates the great strides that have been made and the persistent challenges that exist within the field of congenital interventional cardiology, a field which must continue to innovate and push the limits to achieve personalization of the interventions it provides.
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Role of surgeon intuition and computer-aided design in Fontan optimization: A computational fluid dynamics simulation study. J Thorac Cardiovasc Surg 2020; 160:203-212.e2. [PMID: 32057454 DOI: 10.1016/j.jtcvs.2019.12.068] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 11/27/2019] [Accepted: 12/13/2019] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Customized Fontan designs, generated by computer-aided design (CAD) and optimized by computational fluid dynamics simulations, can lead to novel, patient-specific Fontan conduits unconstrained by off-the-shelf grafts. The relative contributions of both surgical expertise and CAD to Fontan optimization have not been addressed. In this study, we assessed hemodynamic performance of Fontans designed by both surgeon's unconstrained modeling (SUM) and by CAD. METHODS Ten cardiac magnetic resonance imaging datasets were used to create 3-dimensional (3D) models of Fontans. Baseline computational fluid dynamics simulations assessed Fontan indexed power loss (iPL), hepatic flow distribution, and percentage of conduit surface area with abnormally low wall shear stress for venous flow (<1 dyne/cm2). Fontans not meeting thresholds were redesigned using 2 methods: SUM (ie, original venous anatomy without the Fontan was 3D printed and sent to surgeon for Fontan redesign with clay modeling) and CAD (ie, the same 3D geometry was sent to engineers for iterative Fontan redesign guided by computational fluid dynamics). Both groups were blinded to each other's results. RESULTS Eight Fontans were redesigned by SUM and CAD methods. Both SUM and CAD redesigns met iPL thresholds. SUM had lower iPL, whereas CAD demonstrated balanced hepatic flow distribution and lower wall shear stress percentage. Wall shear stress percentage shared an inverse relationship with iPL, preventing oversized Fontan designs. CONCLUSIONS Customized Fontan conduits with low iPL can be created by either a surgeon or CAD. CAD can also improve hepatic flow distribution and prevent oversized Fontan designs. Future studies should investigate workflows that combine SUM and CAD to optimize Fontan conduits.
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Kutty S, Jacobs ML, Thompson WR, Danford DA. Fontan Circulation of the Next Generation: Why It's Necessary, What it Might Look Like. J Am Heart Assoc 2019; 9:e013691. [PMID: 31852419 PMCID: PMC6988165 DOI: 10.1161/jaha.119.013691] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Shelby Kutty
- The Helen B. Taussig Heart Center The Johns Hopkins Hospital and Johns Hopkins University Baltimore MD
| | - Marshall L Jacobs
- The Helen B. Taussig Heart Center The Johns Hopkins Hospital and Johns Hopkins University Baltimore MD
| | - W Reid Thompson
- The Helen B. Taussig Heart Center The Johns Hopkins Hospital and Johns Hopkins University Baltimore MD
| | - David A Danford
- Pediatric Cardiology University of Nebraska College of Medicine Omaha NE
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Relation Between Exercise Capacity and Extracardiac Conduit Size in Patients with Fontan Circulation. Pediatr Cardiol 2019; 40:1584-1590. [PMID: 31473799 DOI: 10.1007/s00246-019-02190-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 08/23/2019] [Indexed: 10/26/2022]
Abstract
Because Fontan circulation does not have a subpulmonary ventricle, the preload is limited. In Fontan circulation with extracardiac conduit, the size of conduit could be an important factor in determining the preload. We compared exercise capacity with each conduit size and tried to search for optimal conduit size in Fontan circulation. We reviewed the medical record of 677 patients with Fontan circulation. Patients who had other type Fontan circulation (Kawashima, atriopulmonary, lateral tunnel), SpO2 < 85%, protein losing enteropathy, results of inappropriate exercise test were excluded. As a result, 150 patients were enrolled and classified according to conduit size. We compared with their exercise capacity and analyzed correlation between exercise capacity and conduit size per body surface area (BSA). 97 Males were included and mean age was 17.5 ± 5.1 years old. In cardiac catheterization, central venous pressure (CVP) was 12.4 ± 2.5 mmHg and pulmonary vascular resistance was 1.2 ± 0.5 wu m2. In cardiopulmonary exercise test, predictive peak VO2 was 59.1 ± 9.7% and VE/VCO2 was 36.2 ± 6.9. In analysis using quadratic model, impacts of gender, age at Fontan operation, ventricular morphology, isomerism, and fenestration on exercise capacity were excluded and conduit size per BSA had a significant curved correlation with predictive peak VO2 and VE/VCO2. Our results showed that patients with about 12.5 mm/m2 conduit per BSA have the best exercise capacity. Patients with larger than smaller-sized conduit were found to be more attenuated in their ability to exercise.
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41
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Mirvakili N, Di Labbio G, Saleh W, Kadem L. Flow characteristics in a model of a left ventricle in the presence of a dysfunctional mitral mechanical heart valve. J Vis (Tokyo) 2019. [DOI: 10.1007/s12650-019-00611-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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42
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Rychik J, Atz AM, Celermajer DS, Deal BJ, Gatzoulis MA, Gewillig MH, Hsia TY, Hsu DT, Kovacs AH, McCrindle BW, Newburger JW, Pike NA, Rodefeld M, Rosenthal DN, Schumacher KR, Marino BS, Stout K, Veldtman G, Younoszai AK, d'Udekem Y. Evaluation and Management of the Child and Adult With Fontan Circulation: A Scientific Statement From the American Heart Association. Circulation 2019; 140:e234-e284. [PMID: 31256636 DOI: 10.1161/cir.0000000000000696] [Citation(s) in RCA: 435] [Impact Index Per Article: 87.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
It has been 50 years since Francis Fontan pioneered the operation that today bears his name. Initially designed for patients with tricuspid atresia, this procedure is now offered for a vast array of congenital cardiac lesions when a circulation with 2 ventricles cannot be achieved. As a result of technical advances and improvements in patient selection and perioperative management, survival has steadily increased, and it is estimated that patients operated on today may hope for a 30-year survival of >80%. Up to 70 000 patients may be alive worldwide today with Fontan circulation, and this population is expected to double in the next 20 years. In the absence of a subpulmonary ventricle, Fontan circulation is characterized by chronically elevated systemic venous pressures and decreased cardiac output. The addition of this acquired abnormal circulation to innate abnormalities associated with single-ventricle congenital heart disease exposes these patients to a variety of complications. Circulatory failure, ventricular dysfunction, atrioventricular valve regurgitation, arrhythmia, protein-losing enteropathy, and plastic bronchitis are potential complications of the Fontan circulation. Abnormalities in body composition, bone structure, and growth have been detected. Liver fibrosis and renal dysfunction are common and may progress over time. Cognitive, neuropsychological, and behavioral deficits are highly prevalent. As a testimony to the success of the current strategy of care, the proportion of adults with Fontan circulation is increasing. Healthcare providers are ill-prepared to tackle these challenges, as well as specific needs such as contraception and pregnancy in female patients. The role of therapies such as cardiovascular drugs to prevent and treat complications, heart transplantation, and mechanical circulatory support remains undetermined. There is a clear need for consensus on how best to follow up patients with Fontan circulation and to treat their complications. This American Heart Association statement summarizes the current state of knowledge on the Fontan circulation and its consequences. A proposed surveillance testing toolkit provides recommendations for a range of acceptable approaches to follow-up care for the patient with Fontan circulation. Gaps in knowledge and areas for future focus of investigation are highlighted, with the objective of laying the groundwork for creating a normal quality and duration of life for these unique individuals.
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Corno AF, Owen MJ, Cangiani A, Hall EJC, Rona A. Physiological Fontan Procedure. Front Pediatr 2019; 7:196. [PMID: 31179252 PMCID: PMC6543709 DOI: 10.3389/fped.2019.00196] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 04/29/2019] [Indexed: 11/13/2022] Open
Abstract
Objective: The conventional Fontan circulation deviates the superior vena cava (SVC = 1/3 of the systemic venous return) toward the right lung (3/5 of total lung volume) and the inferior vena cava (IVC = 2/3 of the systemic venous return) toward the left lung (2/5 of total lung volume). A "physiological" Fontan deviating the SVC toward the left lung and the IVC toward the right lung was compared with the conventional setting by computational fluid dynamics, studying whether this setting achieves a more favorable hemodynamics than the conventional Fontan circulation. Materials and Methods: An in-silico 3D parametric model of the Fontan procedure was developed using idealized vascular geometries with invariant sizes of SVC, IVC, right pulmonary artery (RPA), and left pulmonary artery (LPA), steady inflow velocities at IVC and SVC, and constant equal outflow pressures at RPA and LPA. These parameters were set to perform finite-volume incompressible steady flow simulations, assuming a single-phase, Newtonian, isothermal, laminar blood flow. Numerically converged finite-volume mass and momentum flow balances determined the inlet pressures and the outflow rates. Numerical closed-path integration of energy fluxes across domain boundaries determined the flow energy loss rate through the Fontan circulation. The comparison evaluated: (1) mean IVC pressure; (2) energy loss rate; (3) kinetic energy maximum value throughout the domain volume. Results: The comparison of the physiological vs. conventional Fontan provided these results: (1) mean IVC pressure 13.9 vs. 14.1 mmHg (= 0.2 mmHg reduction); (2) energy loss rate 5.55 vs. 6.61 mW (= 16% reduction); (3) maximum kinetic energy 283 vs. 396 J/m3 (= 29% reduction). Conclusions: A more physiological flow distribution is accompanied by a reduction of mean IVC pressure and by substantial reductions of energy loss rate and of peak kinetic energy. The potential clinical impact of these hemodynamic changes in reducing the incidence and severity of the adverse long-term effects of the Fontan circulation, in particular liver failure and protein-losing enteropathy, still remains to be assessed and will be the subject of future work.
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Affiliation(s)
| | - Matt J. Owen
- University of Leicester, Leicester, United Kingdom
| | - Andrea Cangiani
- School of Mathematical Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Edward J. C. Hall
- School of Mathematical Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Aldo Rona
- University of Leicester, Leicester, United Kingdom
- Department of Engineering, University of Leicester, Leicester, United Kingdom
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Extracardiac Versus Lateral Tunnel Fontan: A Meta-Analysis of Long-Term Results. Ann Thorac Surg 2019; 107:837-843. [DOI: 10.1016/j.athoracsur.2018.08.041] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 07/20/2018] [Accepted: 08/20/2018] [Indexed: 11/22/2022]
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Hagler DJ, Miranda WR, Haggerty BJ, Anderson JH, Johnson JN, Cetta F, Said SM, Taggart NW. Fate of the Fontan connection: Mechanisms of stenosis and management. CONGENIT HEART DIS 2019; 14:571-581. [PMID: 30801968 PMCID: PMC6850024 DOI: 10.1111/chd.12757] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 01/19/2019] [Accepted: 01/23/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Stenosis of the venous connections and conduits is a well-known late complication of the Fontan procedure. Currently, data on the outcomes of percutaneous intervention for the treatment of extra- or intracardiac conduits and lateral tunnel baffles obstruction are limited. In an attempt to better define the nature and severity of the stenosis and the results of catheter interventional management, we reviewed Fontan patients with obstructed extra- or intracardiac conduits and lateral tunnel baffles. METHODS Retrospective review of all Fontan patients who had cardiac catheterization from January 2002 to October 2018 was performed. Hemodynamic and angiographic data that assessed extra- or intracardiac conduit, or lateral tunnel baffle obstruction/stenosis were evaluated. RESULTS Twenty patients underwent catheter intervention because of conduit stenosis, including calcified homografts, stenotic Gore-Tex conduits and obstructed lateral tunnels. Six other patients had Fontan obstruction but were referred for surgical revision. After stenting, there was a significant reduction in the connection gradient [2.0 mm Hg (IQR 2; 3) vs 0 mm Hg (IQR 0; 1), P < .0001]. Fontan conduit/connection diameter increased [10.5 mm (IQR 9; 12) vs 18 mm (IQR 14.9; 18); P < .0001] and New York Heart Association class [III (IQR II; III) vs I (IQR II; III); P = .03) with stent placement. CONCLUSIONS We demonstrated the hemodynamics and angiographic subtypes of conduit stenosis in patients after Fontan, We showed that calcified homografts, stenotic Gore-Tex conduits and lateral tunnels pathways can be safely and effectively stented to eliminate obstruction. Percutaneous stenting is associated with a decrease in connection gradients and improvement in functional capacity.
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Affiliation(s)
- Donald J Hagler
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota.,Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - William R Miranda
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Brielle J Haggerty
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Jason H Anderson
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Jonathan N Johnson
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Frank Cetta
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota.,Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Sameh M Said
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota.,Department of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Nathaniel W Taggart
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
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Matsuura K, Jin WW, Liu H, Matsumiya G. Computational fluid dynamic study of different incision length of coronary artery bypass grafting in a native coronary stenosis model. J Thorac Dis 2019; 11:393-399. [PMID: 30962982 DOI: 10.21037/jtd.2019.01.35] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The objective of this study was to evaluate hemodynamic patterns in end-side coronary artery bypass grafting with different anastomosis length by computational fluid dynamic study in the native coronary stenosis model. Methods The fluid dynamic computations were carried out using ANSYS CFX. Incision length was set to be 2, 4, 6, 8, 10 mm. The angle between the two blood vessels corresponded to the length of the incision. Native vessels were set to be 90% stenosis. The radius of both native and graft vessels was set to be 2 mm. The inlet boundary condition was set by the sample of the transient time flow which was measured intraoperatively. Results The energy efficiency was higher and energy loss was lower when the anastomosis length was longer until 8 mm. However, energy efficiency was lowest and energy loss was highest in the 10-mm model. In the 10-mm incision model, the streamline showed the scanty bypass flow in the bottom. Vortex showed that only 10-mm model showed the vortex just distal to the stenosis in the native inlet, and more vortex in native outlet than other length models. The oscillatory shear index (OSI) was higher in the outlet top in all models. And only 10-mm model showed high oscillatory index just distal to the stenosis. Conclusions In the end-side anastomosis, an anastomosis length of 8 mm was the ideal length with less flow complexity, low OSI, and less energy loss and high energy efficiency in the native 90% stenosis model.
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Affiliation(s)
- Kaoru Matsuura
- Department of Cardiovascular Surgery, Chiba University Hospital, Chiba, Japan
| | - Wei Wei Jin
- Graduate School of Engineering, Chiba University, Chiba, Japan.,Department of Biomedical Engineering, School of Biomedical Engineering & Imaging Sciences, Faculty of Life Science and Medicine, King's College London, London, UK
| | - Hao Liu
- Graduate School of Engineering, Chiba University, Chiba, Japan
| | - Goro Matsumiya
- Department of Cardiovascular Surgery, Chiba University Hospital, Chiba, Japan
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47
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Rijnberg FM, Elbaz MSM, Westenberg JJM, Kamphuis VP, Helbing WA, Kroft LJ, Blom NA, Hazekamp MG, Roest AAW. Four-dimensional flow magnetic resonance imaging-derived blood flow energetics of the inferior vena cava-to-extracardiac conduit junction in Fontan patients. Eur J Cardiothorac Surg 2018; 55:1202-1210. [DOI: 10.1093/ejcts/ezy426] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 10/30/2018] [Accepted: 11/08/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Friso M Rijnberg
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Mohammed S M Elbaz
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jos J M Westenberg
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Vivian P Kamphuis
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, Netherlands
- Netherlands Heart Institute, Utrecht, Netherlands
| | - Willem A Helbing
- Department of Pediatrics, Division of Pediatric Cardiology, Erasmus University Medical Center, Rotterdam and Radboud University Medical Center, Nijmegen, Netherlands
| | - Lucia J Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Nico A Blom
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Mark G Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Arno A W Roest
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, Netherlands
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48
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Affiliation(s)
- Frank Cetta
- Division of Pediatric Cardiology, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Harold M Burkhart
- Division of Thoracic and Cardiovascular Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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49
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Rijnberg FM, Hazekamp MG, Wentzel JJ, de Koning PJ, Westenberg JJ, Jongbloed MR, Blom NA, Roest AA. Energetics of Blood Flow in Cardiovascular Disease. Circulation 2018; 137:2393-2407. [DOI: 10.1161/circulationaha.117.033359] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
| | | | - Jolanda J. Wentzel
- Leiden University Medical Center, The Netherlands. Department of Biomechanical Engineering, Erasmus Medical Center, Rotterdam, The Netherlands (J.J.W.)
| | | | | | | | - Nico A. Blom
- Department of Pediatric Cardiology (N.A.B., A.A.W.R.)
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50
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Miyazaki S, Miyaji K, Itatani K, Oka N, Goto S, Nakamura M, Kitamura T, Horai T, Sughimoto K, Nakamura Y, Yoshimura N. Surgical strategy for aortic arch reconstruction after the Norwood procedure based on numerical flow analysis. Interact Cardiovasc Thorac Surg 2018; 26:460-467. [PMID: 29049796 DOI: 10.1093/icvts/ivx332] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 09/01/2017] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVES Inefficient aortic flow after the Norwood procedure is known to lead to the deterioration of ventricular function due to an increased cardiac workload. To prevent the progression of aortic arch obstruction, arch reconstruction concomitant with second-stage surgery is recommended. The aim of this study was to determine the indications for reconstruction based on numerical simulation and to reveal the morphology that affects the haemodynamic parameters. METHODS Fifteen patients who underwent the Norwood procedure or arch repair and Damus-Kaye-Stansel anastomosis were enrolled. The pressure gradient in aortic arch was 1.6 ± 3.9 mmHg (ranged from 0 to 12 mmHg) on catheter examination. Six patients who had prominent turbulent flow accompanied with a large flow energy loss index greater than 40 mW/m2 and high wall shear stress greater than 100 Pa underwent arch reconstruction. RESULTS After arch reconstruction, the energy loss index significantly decreased from 88.5 ± 50.0 mW/m2 to 23.1 ± 10.4 mW/m2 (P = 0.026) and wall shear stress significantly decreased from 194.5 ± 87.4 Pa to 60.3 ± 40.5 Pa (P = 0.0062). There were 3 late deaths due to heart failure caused by progressive atrioventricular valve regurgitation during the follow-up period (60 months). The systemic ventricular function was preserved in the remaining patients without any pressure gradients in the arch. CONCLUSIONS Determining the surgical strategy for arch reconstruction based on numerical flow analysis may effectively reduce the ventricular load even if no stenosis or pressure gradients are observed on catheter examination or echocardiography.
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Affiliation(s)
- Shohei Miyazaki
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Kanagawa, Japan
| | - Kagami Miyaji
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Kanagawa, Japan
| | - Keiichi Itatani
- Department of Cardiovascular Surgery, Cardiovascular Imaging Research Laboratory, Kyoto Prefectural University of Medicine, Kyoto City, Kyoto, Japan
| | - Norihiko Oka
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Kanagawa, Japan
| | - Shinji Goto
- Department of Mechanical Engineering, Saitama University, Saitama City, Saitama, Japan
| | - Masanori Nakamura
- Department of Mechanical Engineering, Nagoya Institute of Technology, Nagoya, Aichi, Japan
| | - Tadashi Kitamura
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Kanagawa, Japan
| | - Tetsuya Horai
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Kanagawa, Japan
| | - Koichi Sughimoto
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Kanagawa, Japan
| | - Yuki Nakamura
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Kanagawa, Japan
| | - Naoki Yoshimura
- Department of Surgery I, Toyama University School of Medicine, Toyama City, Toyama, Japan
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