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Ait Ali L, Martini N, Listo E, Valenti E, Sotelo J, Salvadori S, Passino C, Monteleone A, Stagnaro N, Trocchio G, Marrone C, Raimondi F, Catapano G, Festa P. Impact of 4D-Flow CMR Parameters on Functional Evaluation of Fontan Circulation. Pediatr Cardiol 2024; 45:998-1006. [PMID: 38519622 PMCID: PMC11056328 DOI: 10.1007/s00246-024-03446-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 02/06/2024] [Indexed: 03/25/2024]
Abstract
We sought to evaluate the potential clinical role of 4D-flow cardiac magnetic resonance (CMR)-derived energetics and flow parameters in a cohort of patients' post-Fontan palliation. In patients with Fontan circulation who underwent 4D-Flow CMR, streamlines distribution was evaluated, as well a 4D-flow CMR-derived energetics parameters as kinetic energy (KE) and energy loss (EL) normalized by volume. EL/KE index as a marker of flow efficiency was also calculated. Cardiopulmonary exercise test (CPET) was also performed in a subgroup of patients. The population study included 55 patients (mean age 22 ± 11 years). The analysis of the streamlines revealed a preferential distribution of the right superior vena cava flow for the right pulmonary artery (62.5 ± 35.4%) and a mild preferential flow for the left pulmonary artery (52.3 ± 40.6%) of the inferior vena cave-pulmonary arteries (IVC-PA) conduit. Patients with heart failure (HF) presented lower IVC/PA-conduit flow (0.75 ± 0.5 vs 1.3 ± 0.5 l/min/m2, p = 0.004) and a higher mean flow-jet angle of the IVC-PA conduit (39.2 ± 22.8 vs 15.2 ± 8.9, p < 0.001) than the remaining patients. EL/KE index correlates inversely with VO2/kg/min: R: - 0.45, p = 0.01 peak, minute ventilation (VE) R: - 0.466, p < 0.01, maximal voluntary ventilation: R:0.44, p = 0.001 and positively with the physiological dead space to the tidal volume ratio (VD/VT) peak: R: 0.58, p < 0.01. From our data, lower blood flow in IVC/PA conduit and eccentric flow was associated with HF whereas higher EL/KE index was associated with reduced functional capacity and impaired lung function. Larger studies are needed to confirm our results and to further improve the prognostic role of the 4D-Flow CMR in this challenging population.
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Affiliation(s)
- Lamia Ait Ali
- Institute of Clinical Physiology, National Research Council, Via Aurelia Sud, 54100, Massa, Pisa, Italy.
- Gabriele Monasterio Foundation, Pisa, Massa, Italy.
| | | | - Elisa Listo
- Azienda Ospedaliera ASL, 3-Ospedale Villascassi, Genoa, Italy
| | - Elisa Valenti
- Institute of Clinical Physiology, National Research Council, Via Aurelia Sud, 54100, Massa, Pisa, Italy
| | - Julio Sotelo
- Departamento de Informática, Universidad Técnica Federico Santa María, Santiago, Chile
| | - Stefano Salvadori
- Institute of Clinical Physiology, National Research Council, Via Aurelia Sud, 54100, Massa, Pisa, Italy
| | | | | | | | - Gianluca Trocchio
- ASST Ospedale Papa Giovanni XXIII, Piazza OMS, 1, 24127, Bergamo BG, Bergamo, Italy
| | | | - Francesca Raimondi
- ASST Ospedale Papa Giovanni XXIII, Piazza OMS, 1, 24127, Bergamo BG, Bergamo, Italy.
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Rasooli R, Holmstrom H, Giljarhus KET, Jolma IW, Vinningland JL, de Lange C, Brun H, Hiorth A. In vitro hemodynamic performance of a blood pump for self-powered venous assist in univentricular hearts. Sci Rep 2024; 14:6941. [PMID: 38521832 PMCID: PMC10960831 DOI: 10.1038/s41598-024-57269-7] [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: 09/05/2023] [Accepted: 03/15/2024] [Indexed: 03/25/2024] Open
Abstract
Univentricular heart anomalies represent a group of severe congenital heart defects necessitating early surgical intervention in infancy. The Fontan procedure, the final stage of single-ventricle palliation, establishes a serial connection between systemic and pulmonary circulation by channeling venous return to the lungs. The absence of the subpulmonary ventricle in this peculiar circulation progressively eventuates in failure, primarily due to chronic elevation in inferior vena cava (IVC) pressure. This study experimentally validates the effectiveness of an intracorporeally-powered venous ejector pump (VEP) in reducing IVC pressure in Fontan patients. The VEP exploits a fraction of aortic flow to create a jet-venturi effect for the IVC, negating the external power requirement and driveline infections. An invitro Fontan mock-up circulation loop is developed and the impact of VEP design parameters and physiological conditions is assessed using both idealized and patient-specific total cavopulmonary connection (TCPC) phantoms. The VEP performance in reducing IVC pressure exhibited an inverse relationship with the cardiac output and extra-cardiac conduit (ECC) size and a proportional relationship with the transpulmonary pressure gradient (TPG) and mean arterial pressure (MAP). The ideal VEP with fail-safe features provided an IVC pressure drop of 1.82 ± 0.49, 2.45 ± 0.54, and 3.12 ± 0.43 mm Hg for TPG values of 6, 8, and 10 mm Hg, respectively, averaged over all ECC sizes and cardiac outputs. Furthermore, the arterial oxygen saturation was consistently maintained above 85% during full-assist mode. These results emphasize the potential utility of the VEP to mitigate elevated venous pressure in Fontan patients.
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Affiliation(s)
- Reza Rasooli
- Department of Energy Resources, Faculty of Science and Technology, University of Stavanger, 4036, Stavanger, Norway.
| | - Henrik Holmstrom
- Department of Pediatric Cardiology, Division of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Knut Erik Teigen Giljarhus
- Department of Mechanical and Structural Engineering and Materials Science, University of Stavanger, 4036, Stavanger, Norway
| | - Ingunn Westvik Jolma
- Department of Chemistry, Bioscience and Environmental Engineering, University of Stavanger, 4036, Stavanger, Norway
| | | | - Charlotte de Lange
- Department of Pediatric Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Henrik Brun
- Department of Pediatric Cardiology, Division of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
- Section for Medical Cybernetics and Image Processing, The Intervention Centre, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Aksel Hiorth
- Department of Energy Resources, Faculty of Science and Technology, University of Stavanger, 4036, Stavanger, Norway
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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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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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Impact of pulmonary artery flow distribution on Fontan hemodynamics and flow energetics. Pediatr Radiol 2023; 53:900-909. [PMID: 36879047 PMCID: PMC10156799 DOI: 10.1007/s00247-023-05591-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 12/15/2022] [Accepted: 01/10/2023] [Indexed: 03/08/2023]
Abstract
BACKGROUND With improved life expectancy following Fontan palliation, there is an increasing population of patients with a total cavopulmonary connection. However, there is a poor understanding of which patients will experience Fontan failure and when. 4D flow MRI has identified several metrics of clinical interest, but longitudinal studies investigating hemodynamics in Fontan patients are lacking. OBJECTIVE We aimed to investigate the relationship between flow distribution to the pulmonary arteries and regional hemodynamic metrics in a unique cohort with follow-up 4D flow MRI. MATERIALS AND METHODS Patients with > 6 months of 4D flow MRI follow-up were included. Flow distribution from the caval veins to pulmonary arteries was measured in addition to regional measures of peak velocity, viscous energy loss (ELmean and ELtot), and kinetic energy. RESULTS Ten patients with total cavopulmonary connection (17.7 ± 8.8 years at baseline, follow-up: 4.4 ± 2.6 years) were included. Five subjects had unequal flow distribution from the IVC to the pulmonary arteries at baseline. Over time, these subjects tended to have larger increases in peak velocity (39.2% vs 6.6%), ELmean (11.6% vs -38.3%), ELtot (9.5% vs -36.2%), and kinetic energy (96.1% vs 36.3%) in the IVC. However, these differences were statistically insignificant. We found that changes in ELmean and ELtot were significantly associated with changes in peak velocity in the caval veins (R2 > 0.5, P < 0.001). CONCLUSION Unequal flow distribution from the IVC may drive increasing peak velocities and viscous energy losses, which have been associated with worse clinical outcomes. Changes in peak velocity may serve as a surrogate measure for changes in viscous energy loss.
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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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Rijnberg FM, Westenberg JJM, van Assen HC, Juffermans JF, Kroft LJM, van den Boogaard PJ, Terol Espinosa de Los Monteros C, Warmerdam EG, Leiner T, Grotenhuis HB, Jongbloed MRM, Hazekamp MG, Roest AAW, Lamb HJ. 4D flow cardiovascular magnetic resonance derived energetics in the Fontan circulation correlate with exercise capacity and CMR-derived liver fibrosis/congestion. J Cardiovasc Magn Reson 2022; 24:21. [PMID: 35346249 PMCID: PMC8962091 DOI: 10.1186/s12968-022-00854-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 03/15/2022] [Indexed: 12/12/2022] Open
Abstract
AIM This study explores the relationship between in vivo 4D flow cardiovascular magnetic resonance (CMR) derived blood flow energetics in the total cavopulmonary connection (TCPC), exercise capacity and CMR-derived liver fibrosis/congestion. BACKGROUND The Fontan circulation, in which both caval veins are directly connected with the pulmonary arteries (i.e. the TCPC) is the palliative approach for single ventricle patients. Blood flow efficiency in the TCPC has been associated with exercise capacity and liver fibrosis using computational fluid dynamic modelling. 4D flow CMR allows for assessment of in vivo blood flow energetics, including kinetic energy (KE) and viscous energy loss rate (EL). METHODS Fontan patients were prospectively evaluated between 2018 and 2021 using a comprehensive cardiovascular and liver CMR protocol, including 4D flow imaging of the TCPC. Peak oxygen consumption (VO2) was determined using cardiopulmonary exercise testing (CPET). Iron-corrected whole liver T1 (cT1) mapping was performed as a marker of liver fibrosis/congestion. KE and EL in the TCPC were computed from 4D flow CMR and normalized for inflow. Furthermore, blood flow energetics were compared between standardized segments of the TCPC. RESULTS Sixty-two Fontan patients were included (53% male, 17.3 ± 5.1 years). Maximal effort CPET was obtained in 50 patients (peak VO2 27.1 ± 6.2 ml/kg/min, 56 ± 12% of predicted). Both KE and EL in the entire TCPC (n = 28) were significantly correlated with cT1 (r = 0.50, p = 0.006 and r = 0.39, p = 0.04, respectively), peak VO2 (r = - 0.61, p = 0.003 and r = - 0.54, p = 0.009, respectively) and % predicted peak VO2 (r = - 0.44, p = 0.04 and r = - 0.46, p = 0.03, respectively). Segmental analysis indicated that the most adverse flow energetics were found in the Fontan tunnel and left pulmonary artery. CONCLUSIONS Adverse 4D flow CMR derived KE and EL in the TCPC correlate with decreased exercise capacity and increased levels of liver fibrosis/congestion. 4D flow CMR is promising as a non-invasive screening tool for identification of patients with adverse TCPC flow efficiency.
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Affiliation(s)
- Friso M Rijnberg
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, The Netherlands.
| | - Jos J M Westenberg
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Hans C van Assen
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Joe F Juffermans
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | | | - Tim Leiner
- Department of Radiology, Utrecht Medical Center, Utrecht, The Netherlands
| | - Heynric B Grotenhuis
- Department of Pediatric Cardiology, Utrecht Medical Center, Utrecht, The Netherlands
| | - Monique R M Jongbloed
- Department of Cardiology and Anatomy and Embryology, Leiden University Medical Center, Leiden, The Netherlands
| | - Mark G Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, The Netherlands
| | - Arno A W Roest
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Hildo J Lamb
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
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Johnson A, Cupp G, Armour N, Warren K, Stone C, Lee D, Gilbert N, Hammond C, Moore J, Kang YA. An Inexpensive Cardiovascular Flow Simulator for Cardiac Catheterization Procedure Using a Pulmonary Artery Catheter. FRONTIERS IN MEDICAL TECHNOLOGY 2022; 3:764007. [PMID: 35047963 PMCID: PMC8757711 DOI: 10.3389/fmedt.2021.764007] [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] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/06/2021] [Indexed: 11/20/2022] Open
Abstract
Cardiac catheterization associated with central vein cannulation can involve potential thrombotic and infectious complications due to multiple cannulation trials or improper placement. To minimize the risks, medical simulators are used for training. Simulators are also employed to test medical devices such as catheters before performing animal tests because they are more cost-effective and still reveal necessary improvements. However, commercial simulators are expensive, simplified for their purpose, and provide limited access sites. Inexpensive and anatomical cardiovascular simulators with central venous access for cannulation are sparse. Here, we developed an anatomically and physiologically accurate cardiovascular flow simulator to help train medical professionals and test medical devices. Our simulator includes an anatomical right atrium/ventricle, femoral and radial access sites, and considers the variability of arm position. It simulates physiological pulsatile blood flow with a setting for constant flow from 3 to 6 L/min and mimics physiological temperature (37°C). We demonstrated simulation by inserting a catheter into the system at radial/femoral access sites, passing it through the vasculature, and advancing it into the heart. We expect that our simulator can be used as an educational tool for cardiac catheterization as well as a testing tool that will allow for design iteration before moving to animal trials.
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Affiliation(s)
- Annika Johnson
- Department of Mechanical, Civil, and Biomedical Engineering, George Fox University, Newberg, OR, United States
| | - Grace Cupp
- Department of Mechanical, Civil, and Biomedical Engineering, George Fox University, Newberg, OR, United States
| | - Nicholas Armour
- Department of Mechanical, Civil, and Biomedical Engineering, George Fox University, Newberg, OR, United States
| | - Kyle Warren
- Department of Mechanical, Civil, and Biomedical Engineering, George Fox University, Newberg, OR, United States
| | - Christopher Stone
- Department of Mechanical, Civil, and Biomedical Engineering, George Fox University, Newberg, OR, United States
| | - Davin Lee
- Department of Mechanical, Civil, and Biomedical Engineering, George Fox University, Newberg, OR, United States
| | - Nicholas Gilbert
- Department of Mechanical, Civil, and Biomedical Engineering, George Fox University, Newberg, OR, United States
| | | | - John Moore
- TZ Medical Inc, Portland, OR, United States
| | - Youngbok Abraham Kang
- Department of Mechanical, Civil, and Biomedical Engineering, George Fox University, Newberg, OR, United States
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Jalal Z, Gewillig M, Boudjemline Y, Guérin P, Pilati M, Butera G, Malekzadeh-Milani S, Avesani M, Thambo JB. Transcatheter interventions in patients with a Fontan circulation: Current practice and future developments. Front Pediatr 2022; 10:965989. [PMID: 36110107 PMCID: PMC9468446 DOI: 10.3389/fped.2022.965989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 08/08/2022] [Indexed: 11/24/2022] Open
Abstract
The Fontan operation represents the last of multiple steps that are offered a wide range of congenital cardiac lesions with a single ventricle (SV) physiology. Nowadays this surgical program consists of a total cavopulmonary connection (TCPC), by anastomosing systemic veins to the pulmonary arteries (PAs), excluding the right-sided circulation from the heart. As a result of imaging, surgical, percutaneous, and critical care improvements, survival in this population has steadily increased. However, the Fontan physiology chronically increases systemic venous pressure causing systemic venous congestion and decreased cardiac output, exposing patients to the failure of the Fontan circulation (FC), which is associated with a wide variety of clinical complications such as liver disease, cyanosis, thromboembolism, protein-losing enteropathy (PLE), plastic bronchitis (PB), and renal dysfunction, ultimately resulting in an increased risk of exercise intolerance, arrhythmias, and premature death. The pathophysiology of the failing Fontan is complex and multifactorial; i.e., caused by the single ventricle dysfunction (diastolic/systolic failure, arrhythmias, AV valve regurgitation, etc.) or caused by the specific circulation (conduits, pulmonary vessels, etc.). The treatment is still challenging and may include multiple options and tools. Among the possible options, today, interventional catheterization is a reliable option, through which different procedures can target various failing elements of the FC. In this review, we aim to provide an overview of indications, techniques, and results of transcatheter options to treat cavopulmonary stenosis, collaterals, impaired lymphatic drainage, and the management of the fenestration, as well as to explore the recent advancements and clinical applications of transcatheter cavopulmonary connections, percutaneous valvular treatments, and to discuss the future perspectives of percutaneous therapies in the Fontan population.
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Affiliation(s)
- Zakaria Jalal
- University Hospital of Bordeaux - Department of Pediatric and Adult Congenital Cardiology, Pessac, France.,IHU LIRYC Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac, France.,INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Pessac, France
| | - Marc Gewillig
- Department of Pediatric Cardiology, University Hospitals Leuven, Leuven, Belgium
| | | | - Patrice Guérin
- Interventional Cardiology Unit, Inserm UMR 1229, L'Institut du Thorax, University Hospital of Nantes, Nantes, France
| | - Mara Pilati
- Medical and Surgical Department of Pediatric Cardiology, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Gianfranco Butera
- Medical and Surgical Department of Pediatric Cardiology, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Sophie Malekzadeh-Milani
- Department of Congenital and Pediatric Cardiology, Centre de Reference Malformations Cardiaques Congenitales Complexes-M3C, Necker Hospital for Sick Children, Assistance Publique des Hôpitaux de Paris, Pediatric Cardiology, Paris, France
| | - Martina Avesani
- University Hospital of Bordeaux - Department of Pediatric and Adult Congenital Cardiology, Pessac, France.,IHU LIRYC Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac, France.,INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Pessac, France
| | - Jean-Benoit Thambo
- University Hospital of Bordeaux - Department of Pediatric and Adult Congenital Cardiology, Pessac, France.,IHU LIRYC Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac, France.,INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Pessac, France
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10
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Liu X, Kim B, Loke YH, Mass P, Olivieri L, Hibino N, Fuge M, Krieger A. Semi-Automatic Planning and Three-Dimensional Electrospinning of Patient-Specific Grafts for Fontan Surgery. IEEE Trans Biomed Eng 2022; 69:186-198. [PMID: 34156934 PMCID: PMC8753752 DOI: 10.1109/tbme.2021.3091113] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
This paper proposes a semi-automatic Fontan surgery planning method for designing and manufacturing hemodynamically optimized patient-specific grafts. Fontan surgery is a palliative procedure for patients with a single ventricle heart defect by creating a new path using a vascular graft for the deoxygenated blood to be directed to the lungs, bypassing the heart. However, designing patient-specific grafts with optimized hemodynamic performance is a complex task due to the variety of patient-specific anatomies, confined surgical planning space, and the requirement of simultaneously considering multiple design criteria for vascular graft optimization. To address these challenges, we used parameterized Fontan pathways to explore patient-specific vascular graft design spaces and search for optimal solutions by formulating a nonlinear constrained optimization problem, which minimizes indexed power loss (iPL) of the Fontan model by constraining hepatic flow distribution (HFD), percentage of abnormal wall shear stress (%WSS) and geometric interference between Fontan pathways and the heart models (InDep) within clinically acceptable thresholds. Gaussian process regression was employed to build surrogate models of the hemodynamic parameters as well as InDep and [Formula: see text] (conduit model smoothness indicator) for optimization by pattern search. We tested the proposed method on two patient-specific models (n=2). The results showed the automatically optimized (AutoOpt) Fontan models hemodynamically outperformed or at least are comparable to manually optimized Fontan models with significantly reduced surgical planning time (15 hours versus over 2 weeks). We also demonstrated feasibility of manufacturing the AutoOpt Fontan conduits by using electrospun nanofibers.
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Affiliation(s)
- Xiaolong Liu
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD, USA,Department of Mechanical Engineering, University of Maryland, College Park, MD, USA
| | - Byeol Kim
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD, USA,Department of Mechanical Engineering, University of Maryland, College Park, MD, USA
| | - Yue-Hin Loke
- Division of Cardiology, Children’s National Hospital, Washington DC, USA
| | - Paige Mass
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, Washington DC, USA
| | - Laura Olivieri
- Division of Cardiology, Children’s National Hospital, Washington DC, USA,Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, Washington DC, USA
| | - Narutoshi Hibino
- Section of Cardiac Surgery, Department of Surgery, The University of Chicago Medicine, Chicago, IL, USA,Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Mark Fuge
- Department of Mechanical Engineering, University of Maryland, College Park, MD, USA
| | - Axel Krieger
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD, USA,Department of Mechanical Engineering, University of Maryland, College Park, MD, USA
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11
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Frieberg P, Aristokleous N, Sjöberg P, Töger J, Liuba P, Carlsson M. Computational Fluid Dynamics Support for Fontan Planning in Minutes, Not Hours: The Next Step in Clinical Pre-Interventional Simulations. J Cardiovasc Transl Res 2021; 15:708-720. [PMID: 34961904 PMCID: PMC9622535 DOI: 10.1007/s12265-021-10198-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 12/13/2021] [Indexed: 12/13/2022]
Abstract
Computational fluid dynamics (CFD) modeling may aid in planning of invasive interventions in Fontan patients. Clinical application of current CFD techniques is however limited by complexity and long computation times. Therefore, we validated a “lean” CFD method to magnetic resonance imaging (MRI) and an “established” CFD method, ultimately aiming to reduce complexity to enable predictive CFD during ongoing interventions. Fifteen Fontan patients underwent MRI for CFD modeling. The differences between lean and established approach, in hepatic and total flow percentage to the left pulmonary artery (%LPA), power loss and relative wall shear stress area were 1.5 ± 4.0%, -0.17 ± 1.1%, -0.055 ± 0.092 mW and 1.1 ± 1.4%. Compared with MRI, the lean and established method showed a bias in %LPA of -1.9 ± 3.4% and -1.8 ± 3.1%. Computation time was for the lean and established approach 3.0 ± 2.0 min and 7.0 ± 3.4 h, respectively. We conclude that the proposed lean method provides fast and reliable results for future CFD support during interventions.
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Affiliation(s)
- Petter Frieberg
- Department of Clinical Sciences Lund, Clinical Physiology, Skåne University Hospital, Lund University, Lund, Sweden.
| | - Nicolas Aristokleous
- Department of Clinical Sciences Lund, Clinical Physiology, Skåne University Hospital, Lund University, Lund, Sweden.
- Department of Mechanical & Manufacturing Engineering, University of Cyprus, Nicosia, Cyprus.
| | - Pia Sjöberg
- Department of Clinical Sciences Lund, Clinical Physiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Johannes Töger
- Department of Clinical Sciences Lund, Clinical Physiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Petru Liuba
- Department of Clinical Sciences Lund, Pediatric Heart Center, Skåne University Hospital, Lund University, Lund, Sweden
| | - Marcus Carlsson
- Department of Clinical Sciences Lund, Clinical Physiology, Skåne University Hospital, Lund University, Lund, Sweden
- Laboratory of Clinical Physiology, NHLBI, National Institutes of Health, Bethesda, MD, USA
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12
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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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13
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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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14
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Rijnberg FM, van Assen HC, Hazekamp MG, Roest AAW, Westenberg JJM. Hemodynamic Consequences of an Undersized Extracardiac Conduit in an Adult Fontan Patient Revealed by 4-Dimensional Flow Magnetic Resonance Imaging. Circ Cardiovasc Imaging 2021; 14:e012612. [PMID: 34380326 DOI: 10.1161/circimaging.121.012612] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Friso M Rijnberg
- Departments of Cardiothoracic Surgery (F.M.R., M.G.H.), Leiden University Medical Center, the Netherlands
| | - Hans C van Assen
- Radiology (H.C.v.A., J.J.M.W.), Leiden University Medical Center, the Netherlands
| | - Mark G Hazekamp
- Departments of Cardiothoracic Surgery (F.M.R., M.G.H.), Leiden University Medical Center, the Netherlands
| | - Arno A W Roest
- Pediatric Cardiology (A.A.W.R.), Leiden University Medical Center, the Netherlands
| | - Jos J M Westenberg
- Radiology (H.C.v.A., J.J.M.W.), Leiden University Medical Center, the Netherlands
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15
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Alsaied T, Rathod RH, Aboulhosn JA, Budts W, Anderson JB, Baumgartner H, Brown DW, Cordina R, D'udekem Y, Ginde S, Goldberg DJ, Goldstein BH, Lubert AM, Oechslin E, Opotowsky AR, Rychik J, Schumacher KR, Valente AM, Wright G, Veldtman GR. Reaching consensus for unified medical language in Fontan care. ESC Heart Fail 2021; 8:3894-3905. [PMID: 34190428 PMCID: PMC8497335 DOI: 10.1002/ehf2.13294] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 02/03/2021] [Accepted: 02/19/2021] [Indexed: 02/04/2023] Open
Abstract
Aims The Fontan operation has resulted in improved survival in patients with single‐ventricle congenital heart disease. As a result, there is a growing population of teenagers and adults with a Fontan circulation. Many co‐morbidities have been increasingly recognized in this population due to the unique features of the Fontan circulation. Standardization of how Fontan co‐morbid conditions are defined will help facilitate understanding, consistency and interpretability of research and clinical experience. Unifying common language usage in Fontan is a critical precursor step for data comparison of research findings and clinical outcomes and ultimately accelerating improvements in management for this growing group of patients. This manuscript aimed to create unified definitions for morbidities seen after the Fontan palliation. Methods In association of many congenital heart disease organizations, this work used Delphi methodology to reach a broad consensus among recognized experts regarding commonly used terms in Fontan care and research. Each definition underwent at least three rounds of revisions to reach a final definition through surveys sent to experts in the field of single‐ventricle care. Results The process of reaching a consensus on multiple morbidities associated with the Fontan procedure is summarized in this manuscript. The different versions that preceded reaching the consensus are also presented in the Supporting Information. Table 1 represents the final definitions according to the consensus. Conclusions We propose the use of these definitions for clinical care, future research studies, registry development and clinical trials.
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Affiliation(s)
- Tarek Alsaied
- Heart Institute, Department of Pediatrics, Pittsburgh Children's Hospital Medical Center, Pittsburgh, PA, USA.,Heart Institute, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Rahul H Rathod
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Jamil A Aboulhosn
- Ahmanson/UCLA Adult Congenital Heart Disease Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Werner Budts
- Division of Congenital and Structural Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Jeffrey B Anderson
- Heart Institute, Department of Pediatrics, Pittsburgh Children's Hospital Medical Center, Pittsburgh, PA, USA
| | - Helmut Baumgartner
- Department of Cardiology: Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Muenster, Germany
| | - David W Brown
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Rachael Cordina
- Adult Congenital Heart Disease Service and Pulmonary Hypertension Service, Royal Prince Alfred Hospital, Sydney, Australia
| | - Yves D'udekem
- Department of Cardiac Surgery and Children's National Heart Institute, Children's National Hospital, Washington, DC, USA
| | - Salil Ginde
- Division of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - David J Goldberg
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Bryan H Goldstein
- Heart Institute, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Adam M Lubert
- Heart Institute, Department of Pediatrics, Pittsburgh Children's Hospital Medical Center, Pittsburgh, PA, USA
| | - Erwin Oechslin
- Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, Canada
| | - Alexander R Opotowsky
- Heart Institute, Department of Pediatrics, Pittsburgh Children's Hospital Medical Center, Pittsburgh, PA, USA
| | - Jack Rychik
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Kurt R Schumacher
- Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | | | - Gail Wright
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Santa Clara, CA, USA
| | - Gruschen R Veldtman
- Adult Congenital Heart Disease Service, Heart Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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16
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Engineering Perspective on Cardiovascular Simulations of Fontan Hemodynamics: Where Do We Stand with a Look Towards Clinical Application. Cardiovasc Eng Technol 2021; 12:618-630. [PMID: 34114202 DOI: 10.1007/s13239-021-00541-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 04/30/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND Cardiovascular simulations for patients with single ventricles undergoing the Fontan procedure can assess patient-specific hemodynamics, explore surgical advances, and develop personalized strategies for surgery and patient care. These simulations have not yet been broadly accepted as a routine clinical tool owing to a number of limitations. Numerous approaches have been explored to seek innovative solutions for improving methodologies and eliminating these limitations. PURPOSE This article first reviews the current state of cardiovascular simulations of Fontan hemodynamics. Then, it will discuss the technical progress of Fontan simulations with the emphasis of its clinical impact, noting that substantial improvements have been made in the considerations of patient-specific anatomy, flow, and blood rheology. The article concludes with insights into potential future directions involving clinical validation, uncertainty quantification, and computational efficiency. The advancements in these aspects could promote the clinical usage of Fontan simulations, facilitating its integration into routine clinical practice.
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17
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Ordoñez MV, Biglino G, Caputo M, Curtis SL. Pregnancy in the FONTAN palliation: physiology, management and new insights from bioengineering. JOURNAL OF CONGENITAL CARDIOLOGY 2021. [DOI: 10.1186/s40949-021-00058-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
AbstractFontan palliation for the single ventricle results in a challenging and delicate physiological state. At rest, the body adapts to a low cardiac output and high systemic venous pressure. However, when physiological demands increase, such as in the case of exercise or pregnancy, this delicate physiology struggles to adapt due to the inability of the heart to pump blood into the lungs and the consequent lack of augmentation of the cardiac output.Due to the advances in paediatric cardiology, surgery and intensive care, today most patients born with congenital heart disease reach adulthood. Consequently, many women with a Fontan circulation are becoming pregnant and so far data suggest that, although maternal risk is not high, the outcomes are poor for the foetus. Little is known about the reasons for this disparity and how the Fontan circulation adapts to the physiological demands of pregnancy.Here we review current knowledge about pregnancy in Fontan patients and explore the potential role of computational modelling as a means of better understanding this complex physiology in order to potentially improve outcomes, particularly for the foetus.
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18
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Rijnberg FM, van der Woude SFS, van Assen HC, Juffermans JF, Hazekamp MG, Jongbloed MRM, Kenjeres S, Lamb HJ, Westenberg JJM, Wentzel JJ, Roest AAW. Non-uniform mixing of hepatic venous flow and inferior vena cava flow in the Fontan conduit. J R Soc Interface 2021; 18:20201027. [PMID: 33823607 PMCID: PMC8086942 DOI: 10.1098/rsif.2020.1027] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Fontan patients require a balanced hepatic blood flow distribution (HFD) to prevent pulmonary arteriovenous malformations. Currently, HFD is quantified by tracking Fontan conduit flow, assuming hepatic venous (HV) flow to be uniformly distributed within the Fontan conduit. However, this assumption may be unvalid leading to inaccuracies in HFD quantification with potential clinical impact. The aim of this study was to (i) assess the mixing of HV flow and inferior vena caval (IVC) flow within the Fontan conduit and (ii) quantify HFD by directly tracking HV flow and quantitatively comparing results with the conventional approach. Patient-specific, time-resolved computational fluid dynamic models of 15 total cavopulmonary connections were generated, including the HV and subhepatic IVC. Mixing of HV and IVC flow, on a scale between 0 (no mixing) and 1 (perfect mixing), was assessed at the caudal and cranial Fontan conduit. HFD was quantified by tracking particles from the caudal (HFDcaudal conduit) and cranial (HFDcranial conduit) conduit and from the hepatic veins (HFDHV). HV flow was non-uniformly distributed at both the caudal (mean mixing 0.66 ± 0.13) and cranial (mean 0.79 ± 0.11) level within the Fontan conduit. On a cohort level, differences in HFD between methods were significant but small; HFDHV (51.0 ± 20.6%) versus HFDcaudal conduit (48.2 ± 21.9%, p = 0.033) or HFDcranial conduit (48.0 ± 21.9%, p = 0.044). However, individual absolute differences of 8.2–14.9% in HFD were observed in 4/15 patients. HV flow is non-uniformly distributed within the Fontan conduit. Substantial individual inaccuracies in HFD quantification were observed in a subset of patients with potential clinical impact.
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Affiliation(s)
- Friso M Rijnberg
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Hans C van Assen
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Joe F Juffermans
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Mark G Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Monique R M Jongbloed
- Department of Cardiology and Anatomy and Embryology, Leiden University Medical Center, Leiden, The 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, The Netherlands
| | - Hildo J Lamb
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jos J M Westenberg
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jolanda J Wentzel
- Department of Cardiology, Biomedical Engineering, Erasmus MC, Rotterdam, The Netherlands
| | - Arno A W Roest
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, The Netherlands
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19
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Reduced scan time and superior image quality with 3D flow MRI compared to 4D flow MRI for hemodynamic evaluation of the Fontan pathway. Sci Rep 2021; 11:6507. [PMID: 33753790 PMCID: PMC7985309 DOI: 10.1038/s41598-021-85936-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 03/03/2021] [Indexed: 12/14/2022] Open
Abstract
Long scan times prohibit a widespread clinical applicability of 4D flow MRI in Fontan patients. As pulsatility in the Fontan pathway is minimal during the cardiac cycle, acquiring non-ECG gated 3D flow MRI may result in a reduction of scan time while accurately obtaining time-averaged clinical parameters in comparison with 2D and 4D flow MRI. Thirty-two Fontan patients prospectively underwent 2D (reference), 3D and 4D flow MRI of the Fontan pathway. Multiple clinical parameters were assessed from time-averaged flow rates, including the right-to-left pulmonary flow distribution (main endpoint) and systemic-to-pulmonary collateral flow (SPCF). A ten-fold reduction in scan time was achieved [4D flow 15.9 min (SD 2.7 min) and 3D flow 1.6 min (SD 7.8 s), p < 0.001] with a superior signal-to-noise ratio [mean ratio of SNRs 1.7 (0.8), p < 0.001] and vessel sharpness [mean ratio 1.2 (0.4), p = 0.01] with 3D flow. Compared to 2D flow, good–excellent agreement was shown for mean flow rates (ICC 0.82–0.96) and right-to-left pulmonary flow distribution (ICC 0.97). SPCF derived from 3D flow showed good agreement with that from 4D flow (ICC 0.86). 3D flow MRI allows for obtaining time-averaged flow rates and derived clinical parameters in the Fontan pathway with good–excellent agreement with 2D and 4D flow, but with a tenfold reduction in scan time and significantly improved image quality compared to 4D flow.
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20
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Wei ZA, Ratnayaka K, Si B, Singh-Gryzbon S, Cetatoiu MA, Fogel MA, Slesnick T, Yoganathan AP, Nigro JJ. An Anterior Anastomosis for the Modified Fontan Connection: A Hemodynamic Analysis. Semin Thorac Cardiovasc Surg 2021; 33:816-823. [PMID: 33662555 DOI: 10.1053/j.semtcvs.2021.01.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 01/05/2021] [Indexed: 12/25/2022]
Abstract
This hemodynamic feasibility study examined total cavopulmonary connection (TCPC) designs connecting the extracardiac conduit to the anterior surface of pulmonary arteries (PAs) or superior vena cava (SVC) rather than to the inferior PA surface (traditional TCPC). The study involved twenty-five consecutive Fontan patients meeting inclusion criteria from a single institution. A virtual surgical platform mimicked the completed traditional TCPC and generated three anterior anastomosis designs: Anterior-PA, Middle-SVC, and SVC-Inn (Inn: innominate vein). Hemodynamic performance of anterior anastomosis designs was compared with the traditional TCPC regarding indexed power loss (iPL) and hepatic flow distribution (HFD). Compared to the traditional TCPC, the Anterior-PA design produces a similar iPL. The Middle-SVC design is also similar, though the iPL difference is positively correlated with the anastomosing height. The SVC-Inn design had significantly more iPL. The three anterior anastomosis designs did not have a significant difference in HFD (from traditional TCPC). Pulmonary flow distribution (PFD) has a stronger correlation with HFD from the anterior anastomosis designs than the traditional TCPC. This hemodynamic feasibility study examined anterior anastomosis, extracardiac TCPC designs that may offer surgeons clinical dexterity. The Anterior-PA design may be equivalent to the traditional TCPC. Fontan extracardiac conduit anastomosis just superior to the PAs (Middle-SVC) also preserves hemodynamic performance and avoids direct PA anastomosis. These designs could simplify surgical Fontan completion, and may particularly benefit patients requiring surgical dissection, having atypical PA orientation, or after PA stent angioplasty.
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Affiliation(s)
- Zhenglun Alan Wei
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia; Department of Biomedical Engineering, University of Massachusetts Lowell, Lowell, Massachusetts
| | - Kanishka Ratnayaka
- Division of Pediatric Cardiology, Rady Children's Hospital and UC San Diego School of Medicine, San Diego, California
| | - Biao Si
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia
| | - Shelly Singh-Gryzbon
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia
| | | | - Mark A Fogel
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Timothy Slesnick
- Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Ajit P Yoganathan
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia.
| | - John J Nigro
- Division of Cardiovascular Surgery, Rady Children's Hospital and UC San Diego School of Medicine, San Diego, California
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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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22
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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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23
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Wei ZA, Johnson C, Trusty P, Stephens M, Wu W, Sharon R, Srimurugan B, Kottayil BP, Sunil GS, Fogel MA, Yoganathan AP, Kappanayil M. Comparison of Fontan Surgical Options for Patients with Apicocaval Juxtaposition. Pediatr Cardiol 2020; 41:1021-1030. [PMID: 32377893 PMCID: PMC7325867 DOI: 10.1007/s00246-020-02353-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 04/23/2020] [Indexed: 12/22/2022]
Abstract
Apicocaval juxtaposition (ACJ) is a rare form of viscerocardiac malpositions in association with single-ventricle congenital heart defects. The Fontan surgery is the common palliation, and possible surgical options include ipsilateral, contralateral, and intra-atrial conduits. Concerns include lower hemodynamic performances or risks of conduit compression by the cardiac mass. This study investigates the hemodynamics and clinical outcomes of ACJ patients and potential surgical improvements. Ten consecutive ACJ patients were included, along with a reference cohort of ten non-ACJ patients. Magnetic resonance images were acquired at 6 ± 0.6 year follow-up for anatomical analysis and hemodynamic assessments using computational fluid dynamics. Metrics of interest are deformation index (DI), indexed power loss (iPL), and hepatic flow distribution (HFDoff). A "virtual" surgery was performed to explore potential hemodynamic improvements using a straightened conduit. DI for ACJ patients fell within the DI range of non-ACJ patients. Contralateral conduits had insignificantly higher iPL (0.070 [0.032,0.137]) than ipsilateral conduits (0.041 [0.013,0.095]) and non-ACJ conduits (0.034 [0.011,0.061]). HFDoff was similar for the ipsilateral (21 [12,35]), contralateral (26 [7,41]), and non-ACJ Fontan conduits (17 [0,48]). Virtual surgery demonstrated that a straightened conduit reduced HFDoff and iPL for the contralateral and ipsilateral conduits, potentially leading to improved clinical outcomes. In this limited sample, the hemodynamic performance of ACJ patients was not significantly different from their non-ACJ counterparts. The use of a straightened conduit option could potentially improve patient outcomes. Additionally, the fear of significant compression of conduits for ACJ patients was unsupported.
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Affiliation(s)
- Zhenglun Alan Wei
- Department of Biomedical Engineering, Georgia Institute of Technology, Suite 200, 387 Technology Circle, Atlanta, GA, 30313-2412, USA
| | - Camille Johnson
- Department of Biomedical Engineering, Georgia Institute of Technology, Suite 200, 387 Technology Circle, Atlanta, GA, 30313-2412, USA
| | - Phillip Trusty
- Department of Biomedical Engineering, Georgia Institute of Technology, Suite 200, 387 Technology Circle, Atlanta, GA, 30313-2412, USA
| | - Morgan Stephens
- Department of Biomedical Engineering, Georgia Institute of Technology, Suite 200, 387 Technology Circle, Atlanta, GA, 30313-2412, USA
| | - Wenjun Wu
- Department of Biomedical Engineering, Georgia Institute of Technology, Suite 200, 387 Technology Circle, Atlanta, GA, 30313-2412, USA
| | - Ritchie Sharon
- Amrita Institute of Medical Sciences and Research Centre, Kochi, India
| | - Balaji Srimurugan
- Amrita Institute of Medical Sciences and Research Centre, Kochi, India
| | | | - G S Sunil
- Amrita Institute of Medical Sciences and Research Centre, Kochi, India
| | - Mark A Fogel
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ajit P Yoganathan
- Department of Biomedical Engineering, Georgia Institute of Technology, Suite 200, 387 Technology Circle, Atlanta, GA, 30313-2412, USA.
| | - Mahesh Kappanayil
- Amrita Institute of Medical Sciences and Research Centre, Kochi, India
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24
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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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25
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Chen X, Yuan H, Liu J, Zhang N, Zhou C, Huang M, Jian Q, Zhuang J. Hemodynamic Effects of Additional Pulmonary Blood Flow on Glenn and Fontan Circulation. Cardiovasc Eng Technol 2020; 11:268-282. [PMID: 32072439 DOI: 10.1007/s13239-020-00459-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 02/10/2020] [Indexed: 10/25/2022]
Abstract
PURPOSE Additional pulmonary blood flow (APBF) can provide better pulsating blood flow and systemic arterial oxygen saturation, while low blood pulsation and low oxygen saturation are defects of the Fontan and Glenn procedure. Studying the hemodynamic effect of APBF is beneficial for clinical decisions. This study aimed to explore the effect on particle washout, as well as the differences among the sensitivities of both different hemodynamic parameters and different procedures to APBF. METHODS The patient-specific clinical datasets of a patient who underwent bilateral bidirectional Glenn (BBDG) with APBF were enrolled in this study, and using these datasets, Glenn- and Fontan-type artery models were reconstructed. A series of parameters, including the total caval flow pulsatility index (TCPI), indexed energy loss (iPL), wall shear stress (WSS), systemic arterial oxygen saturation (Satart), particle washout time (WOT), pressure in the right superior vena cava (PRSVC), pulmonary flow distribution (PFD) and hepatic flow distribution (HFD), were computed from computational fluid dynamic (CFD) simulation to evaluate the hemodynamic effect of APBF. RESULTS The result showed that APBF led to better iPL and Satart but worse PRSVC and heart load accompanied by a great impact on HFD, making hepatic flow easier to perfuse the side without MPA and APBF. The increase in the APBF rate also effectively results in larger flow pulsation, region velocity, and wall shear stress and lower WOT, and this effect may be more effective for patients with persistent left superior vena cava (PLSVC). However, APBF might have little effect on PFD. Furthermore, APBF might affect WOT, iPL and HFD more significantly than PRSVC and has a greater improvement effect in patients with poorer iPL and WOT. CONCLUSIONS Moderate APBF is not only a measure to promote pulmonary artery growth and systemic arterial oxygen saturation but also an effective method against endothelial dysfunction and thrombosis. However, moderate APBF is patient-specific and should be determined based on hemodynamic preference that leads to desired patient outcomes, and care should be taken to prevent PRSVC and heart load from being too high as well as an imbalance in HFD.
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Affiliation(s)
- Xiangyu Chen
- School of Mechanical and Automotive Engineering, South China University of Technology, Guangzhou, 510000, China
| | - Haiyun Yuan
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Department of Cardiovascular Surgery, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, 510000, China
| | - Jiawei Liu
- School of Mechanical and Automotive Engineering, South China University of Technology, Guangzhou, 510000, China
| | - Neichuan Zhang
- School of Mechanical and Automotive Engineering, South China University of Technology, Guangzhou, 510000, China
| | - Chengbin Zhou
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Department of Cardiovascular Surgery, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, 510000, China
| | - Meiping Huang
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Department of Catheterization Lab, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Qifei Jian
- School of Mechanical and Automotive Engineering, South China University of Technology, Guangzhou, 510000, China.
| | - Jian Zhuang
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Department of Cardiovascular Surgery, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, 510000, China.
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26
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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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27
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Impact of Free-Breathing Phase-Contrast MRI on Decision-Making in Fontan Surgical Planning. J Cardiovasc Transl Res 2019; 13:640-647. [DOI: 10.1007/s12265-019-09930-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 10/21/2019] [Indexed: 11/26/2022]
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28
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Fogel MA, Trusty PM, Nicolson S, Spray T, Gaynor JW, Whitehead KK, Yoganathan AP. Cross-Sectional Magnetic Resonance and Modeling Comparison From Just After Fontan to the Teen Years. Ann Thorac Surg 2019; 109:574-582. [PMID: 31518584 DOI: 10.1016/j.athoracsur.2019.07.066] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 07/15/2019] [Accepted: 07/22/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Little is known of baseline anatomic, hemodynamic, and fluid dynamic cardiac magnetic resonance data in single-ventricle patients immediately after Fontan. A comparison from that time point to the teen years can demonstrate clinical course, potentially predict future events, and may shed some light regarding how to optimize outcome. This cross-sectional study is meant to characterize these variables from just after Fontan to the teenage years. METHODS The anatomy, flows, and computational fluid dynamic modeling of 22 patients 3 to 9 months after Fontan (age 3 ± 1.1 years) and 25 teens (age 16 ± 1.8 years) were compared. Significance was defined as P less than .05. RESULTS The percentage of Fontan pathway stenosis was greater with cardiac index and fenestration flow while caval return was lower in teens than in younger patients (for Fontan pathway stenosis, 43% vs 21%, P = .009); however, hepatic flow distribution was more evenly distributed in older patients. Pulmonary artery size kept up with somatic growth. In the teen group, indexed power loss (R = .39), percentage of Fontan pathway stenosis (R = .62), and particle resident time (R = .42) deteriorated as time from Fontan increased (P < .04 for all). CONCLUSIONS There are mostly aspects of deterioration with a few bright spots of stability in anatomy, blood flow, and fluid dynamic variables in Fontan patients from the postoperative period to the teenage years. Most notably, Fontan pathway stenosis increases with decreasing flows while pulmonary artery size and hepatic flow distribution remain stable or improved. These data may be aid in designing improved Fontan reconstruction to optimize clinical outcome and to understand future complications.
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Affiliation(s)
- Mark A Fogel
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia/The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; Department of Radiology, The Children's Hospital of Philadelphia/The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.
| | - Phillip M Trusty
- Department of Biomedical Engineering, The Georgia Institute of Technology, Atlanta, Georgia
| | - Susan Nicolson
- Department of Anesthesia, The Children's Hospital of Philadelphia/The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Thomas Spray
- Department of Cardiothoracic Surgery, The Children's Hospital of Philadelphia/The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - J William Gaynor
- Department of Cardiothoracic Surgery, The Children's Hospital of Philadelphia/The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Kevin K Whitehead
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia/The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; Department of Radiology, The Children's Hospital of Philadelphia/The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Ajit P Yoganathan
- Department of Biomedical Engineering, The Georgia Institute of Technology, Atlanta, Georgia
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29
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Rodefeld MD, Marsden A, Figliola R, Jonas T, Neary M, Giridharan GA. Cavopulmonary assist: Long-term reversal of the Fontan paradox. J Thorac Cardiovasc Surg 2019; 158:1627-1636. [PMID: 31564543 DOI: 10.1016/j.jtcvs.2019.06.112] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 06/13/2019] [Accepted: 06/14/2019] [Indexed: 01/16/2023]
Abstract
OBJECTIVE Fontan circulatory inefficiency can be addressed by replacing the missing subpulmonary power source to reverse the Fontan paradox. An implantable cavopulmonary assist device is described that will simultaneously reduce systemic venous pressure and increase pulmonary arterial pressure, improving preload and cardiac output, in a univentricular Fontan circulation on a long-term basis. METHODS A rotary blood pump that was based on the von Karman viscous pump was designed for implantation into the total cavopulmonary connection (TCPC). It will impart modest pressure energy to augment Fontan flow without risk of obstruction. In the event of rotational failure, it is designed to default to a passive flow diverter. Pressure-flow performance was characterized in vitro in a Fontan mock circulatory loop with blood analog. RESULTS The pump performed through the fully specified operating range, augmenting flow in all 4 directions of the TCPC. Pressure rise of 6 to 8 mm Hg was readily achieved, ranging to 14 mm Hg at highest speed (5600 rpm). Performance was consistent across a wide range of cardiac outputs. In stalled condition (0 rpm), there was no discernible pressure loss across the TCPC. CONCLUSIONS A blood pump technology is described that can reverse the Fontan paradox and may permit a surgical strategy of long-term biventricular maintenance of a univentricular Fontan circulation. The technology is intended for Fontan failure in which right-sided circulatory inefficiencies predominate and ventricular systolic function is preserved. It may also apply before clinical Fontan failure as health maintenance to preempt the progression of Fontan disease.
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Affiliation(s)
- Mark D Rodefeld
- Section of Cardiothoracic Surgery, Department of Surgery, Indiana University School of Medicine and James Whitcomb Riley Hospital for Children, Indianapolis, Ind.
| | - Alison Marsden
- Department of Bioengineering and Pediatrics, Stanford University, Stanford, Calif
| | - Richard Figliola
- Department of Mechanical Engineering, Clemson University, Clemson, SC
| | | | - Michael Neary
- Rotor Bearing Technology and Software Inc, Phoenixville, Pa
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Granegger M, Thamsen B, Hubmann EJ, Choi Y, Beck D, Valsangiacomo Buechel E, Voutat M, Schweiger M, Meboldt M, Hübler M. A long-term mechanical cavopulmonary support device for patients with Fontan circulation. Med Eng Phys 2019; 70:9-18. [DOI: 10.1016/j.medengphy.2019.06.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 06/15/2019] [Accepted: 06/19/2019] [Indexed: 12/28/2022]
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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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Trusty PM, Wei ZA, Slesnick TC, Kanter KR, Spray TL, Fogel MA, Yoganathan AP. The first cohort of prospective Fontan surgical planning patients with follow-up data: How accurate is surgical planning? J Thorac Cardiovasc Surg 2018; 157:1146-1155. [PMID: 31264966 DOI: 10.1016/j.jtcvs.2018.11.102] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 11/17/2018] [Accepted: 11/22/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Fontan surgical planning is an image-based, collaborative effort, which is hypothesized to result in improved patient outcomes. A common motivation for Fontan surgical planning is the progression (or concern for progression) of pulmonary arteriovenous malformations. The purpose of this study was to evaluate the accuracy of surgical planning predictions, specifically hepatic flow distribution (HFD), a known factor in pulmonary arteriovenous malformation progression, and identify methodological improvements needed to increase prediction accuracy. METHODS Twelve single-ventricle patients who were enrolled in a surgical planning protocol for Fontan surgery with pre- and postoperative cardiac imaging were included in this study. Computational fluid dynamics were used to compare HFD in the surgical planning prediction and actual postoperative conditions. RESULTS Overall, HFD prediction error was 17 ± 13%. This error was similar between surgery types (15 ± 18% and 18 ± 10% for revisions vs Fontan completions respectively; P = .73), but was significantly lower (6 ± 7%; P = .05) for hepatic to azygous shunts. Y-grafts and extracardiac conduits showed a strong correlation between prediction error and discrepancies in graft insertion points (r = 0.99; P < .001). Improving postoperative anatomy prediction significantly reduced overall HFD prediction error to 9 ± 6% (P = .03). CONCLUSIONS Although Fontan surgical planning can offer accurate HFD predictions for specific graft types, methodological improvements are needed to increase overall accuracy. Specifically, improving postoperative anatomy prediction was shown to be an important target for future work. Future efforts and refinements to the surgical planning process will benefit from an improved understanding of the current state and will rely heavily on increased follow-up data.
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Affiliation(s)
- Phillip M Trusty
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Ga
| | - Zhenglun Alan Wei
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Ga
| | - Timothy C Slesnick
- Division of Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | - Kirk R Kanter
- Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | - Thomas L Spray
- Division of Pediatric Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Mark A Fogel
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Ajit P Yoganathan
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Ga.
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33
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Accuracy evaluation of blood flow distribution in the Fontan circulation: effects of resolution and velocity noise. J Vis (Tokyo) 2018. [DOI: 10.1007/s12650-018-0536-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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34
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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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35
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Trusty PM, Slesnick TC, Wei ZA, Rossignac J, Kanter KR, Fogel MA, Yoganathan AP. Fontan Surgical Planning: Previous Accomplishments, Current Challenges, and Future Directions. J Cardiovasc Transl Res 2018; 11:133-144. [PMID: 29340873 PMCID: PMC5910220 DOI: 10.1007/s12265-018-9786-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 01/05/2018] [Indexed: 11/29/2022]
Abstract
The ultimate goal of Fontan surgical planning is to provide additional insights into the clinical decision-making process. In its current state, surgical planning offers an accurate hemodynamic assessment of the pre-operative condition, provides anatomical constraints for potential surgical options, and produces decent post-operative predictions if boundary conditions are similar enough between the pre-operative and post-operative states. Moving forward, validation with post-operative data is a necessary step in order to assess the accuracy of surgical planning and determine which methodological improvements are needed. Future efforts to automate the surgical planning process will reduce the individual expertise needed and encourage use in the clinic by clinicians. As post-operative physiologic predictions improve, Fontan surgical planning will become an more effective tool to accurately model patient-specific hemodynamics.
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Affiliation(s)
- Phillip M Trusty
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
| | - Timothy C Slesnick
- Department of Pediatrics, Division of Cardiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Zhenglun Alan Wei
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
- School of Life Science, Fudan University, Shanghai, China
| | - Jarek Rossignac
- School of Interactive Computing, Georgia Institute of Technology, Atlanta, GA, USA
| | - Kirk R Kanter
- Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Mark A Fogel
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ajit P Yoganathan
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA.
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36
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The Advantages of Viscous Dissipation Rate over Simplified Power Loss as a Fontan Hemodynamic Metric. Ann Biomed Eng 2017; 46:404-416. [PMID: 29094292 DOI: 10.1007/s10439-017-1950-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 10/20/2017] [Indexed: 12/12/2022]
Abstract
Flow efficiency through the Fontan connection is an important factor related to patient outcomes. It can be quantified using either a simplified power loss or a viscous dissipation rate metric. Though practically equivalent in simplified Fontan circulation models, these metrics are not identical. Investigation is needed to evaluate the advantages and disadvantages of these metrics for their use in in vivo or more physiologically-accurate Fontan modeling. Thus, simplified power loss and viscous dissipation rate are compared theoretically, computationally, and statistically in this study. Theoretical analysis was employed to assess the assumptions made for each metric and its clinical calculability. Computational simulations were then performed to obtain these two metrics. The results showed that apparent simplified power loss was always greater than the viscous dissipation rate for each patient. This discrepancy can be attributed to the assumptions derived in theoretical analysis. Their effects were also deliberately quantified in this study. Furthermore, statistical analysis was conducted to assess the correlation between the two metrics. Viscous dissipation rate and its indexed quantity show significant, strong, linear correlation to simplified power loss and its indexed quantity (p < 0.001, r > 0.99) under certain assumptions. In conclusion, viscous dissipation rate was found to be more advantageous than simplified power loss as a hemodynamic metric because of its lack of limiting assumptions and calculability in the clinic. Moreover, in addition to providing a time-averaged bulk measurement like simplified power loss, viscous dissipation rate has spatial distribution contours and time-resolved values that may provide additional clinical insight. Finally, viscous dissipation rate could maintain the relationship between Fontan connection flow efficiency and patient outcomes found in previous studies. Consequently, future Fontan hemodynamic studies should calculate both simplified power loss and viscous dissipation rate to maintain ties to previous studies, but also provide the most accurate measure of flow efficiency. Additional attention should be paid to the assumptions required for each metric.
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Gerrah R, Haller SJ, George I. Mechanical Concepts Applied in Congenital Heart Disease and Cardiac Surgery. Ann Thorac Surg 2017; 103:2005-2014. [DOI: 10.1016/j.athoracsur.2017.01.068] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 01/04/2017] [Accepted: 01/16/2017] [Indexed: 11/30/2022]
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Local Hemodynamic Differences Between Commercially Available Y-Grafts and Traditional Fontan Baffles Under Simulated Exercise Conditions: Implications for Exercise Tolerance. Cardiovasc Eng Technol 2017; 8:390-399. [DOI: 10.1007/s13239-017-0310-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 05/23/2017] [Indexed: 10/19/2022]
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Tang E, Wei ZA, Whitehead KK, Khiabani RH, Restrepo M, Mirabella L, Bethel J, Paridon SM, Marino BS, Fogel MA, Yoganathan AP. Effect of Fontan geometry on exercise haemodynamics and its potential implications. Heart 2017; 103:1806-1812. [PMID: 28522658 DOI: 10.1136/heartjnl-2016-310855] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 03/21/2017] [Accepted: 03/29/2017] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Exercise intolerance afflicts Fontan patients with total cavopulmonary connections (TCPCs) causing a reduction in quality of life. Optimising TCPC design is hypothesised to have a beneficial effect on exercise capacity. This study investigates relationships between TCPC geometries and exercise haemodynamics and performance. METHODS This study included 47 patients who completed metabolic exercise stress test with cardiac magnetic resonance (CMR). Phase-contrast CMR images were acquired immediately following supine lower limb exercise. Both anatomies and exercise vessel flow rates at ventilatory anaerobic threshold (VAT) were extracted. The vascular modelling toolkits were used to analyse TCPC geometries. Computational simulations were performed to quantify TCPC indexed power loss (iPL) at VAT. RESULTS A highly significant inverse correlation was found between the TCPC diameter index, which factors in the narrowing of TCPC vessels, with iPL at VAT (r=-0.723, p<0.001) but positive correlations with exercise performance variables, including minute oxygen consumption (VO2) at VAT (r=0.373, p=0.01), VO2 at peak exercise (r=0.485, p=0.001) and work at VAT/weight (r=0.368, p=0.01). iPL at VAT was negatively correlated with VO2 at VAT (r=-0.337, p=0.02), VO2 at peak exercise (r=-0.394, p=0.007) and work at VAT/weight (r=-0.208, p=0.17). CONCLUSIONS Eliminating vessel narrowing in TCPCs and reducing elevated iPL at VAT could enhance exercise tolerance for patients with TCPCs. These findings could help plan surgical or catheter-based strategies to improve patients' exercise capacity.
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Affiliation(s)
- Elaine Tang
- School of Chemical and Biomolecular Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Zhenglun Alan Wei
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, Georgia, USA
| | - Kevin K Whitehead
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Reza H Khiabani
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, Georgia, USA
| | - Maria Restrepo
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, Georgia, USA
| | - Lucia Mirabella
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, Georgia, USA
| | | | - Stephen M Paridon
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Bradley S Marino
- Division of Cardiology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Mark A Fogel
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Ajit P Yoganathan
- School of Chemical and Biomolecular Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA.,Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, Georgia, USA
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Udink ten Cate FEA, Trieschmann U, Germund I, Hannes T, Emmel M, Bennink G, Sreeram N. Stenting the Fontan pathway in paediatric patients with obstructed extracardiac conduits. Heart 2017; 103:1111-1116. [DOI: 10.1136/heartjnl-2016-310511] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 01/09/2017] [Accepted: 01/16/2017] [Indexed: 11/04/2022] Open
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Izumi G, Senzaki H, Takeda A, Yamazawa H, Takei K, Furukawa T, Inai K, Shinohara T, Nakanishi T. Significance of right atrial tension for the development of complications in patients after atriopulmonary connection Fontan procedure: potential indicator for Fontan conversion. Heart Vessels 2017; 32:850-855. [PMID: 28064364 DOI: 10.1007/s00380-016-0941-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 12/26/2016] [Indexed: 12/19/2022]
Abstract
Elevated right atrial (RA) pressure and progressive RA dilation are thought to play pivotal roles in the development of late complications after atriopulmonary connection (APC) Fontan surgery. However, no clear cut-off value for RA pressure or RA volume has been determined for stratifying the risk of developing Fontan complications. We hypothesized that RA tension, which incorporates information about both RA pressure and volume, might help predict the risk of developing complications. We retrospectively studied 51 consecutive APC Fontan patients (median postoperative period 14 years). RA tension was computed from the RA pressure and RA radius, which was calculated from RA volume measured by RA angiography. The correlation between the cardiac catheterization hemodynamic data and the complications of APC Fontan was investigated. Of the 51 patients, 28 had complications, including liver fibrosis (n = 28), arrhythmia (n = 8), protein-losing enteropathy (n = 1), and RA thrombosis (n = 1). Among the hemodynamic data, RA volume and RA tension, but not RA pressure, were significantly higher in patients with complications than in those without (P = 0.004 and P = 0.001, respectively). The cut-off level for RA tension to predict Fontan complications was 26,131 dyne/cm by receiver operating characteristic curve (area under the curve 0.79, sensitivity 71.4%, and specificity 73.9%). The present study demonstrated the significance of RA tension rather than high venous pressure for the development of Fontan complications. Amid the uncertainty about clinical outcomes, the present results, subject to further validation, may contribute to the indications for Fontan conversion.
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Affiliation(s)
- Gaku Izumi
- Department of Pediatrics, Hokkaido University Graduate School, North-15 West-7, Sapporo, 060-8638, Japan.
- Department of Pediatric Cardiology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjyuku-ku, Tokyo, 162-8666, Japan.
| | - Hideaki Senzaki
- Department of Pediatric Cardiology, Saitama Medical Centre, Saitama Medical University, 1981 Kamoda, Kawagoe, 350-8550, Japan
| | - Atsuhito Takeda
- Department of Pediatrics, Hokkaido University Graduate School, North-15 West-7, Sapporo, 060-8638, Japan
| | - Hirokuni Yamazawa
- Department of Pediatrics, Hokkaido University Graduate School, North-15 West-7, Sapporo, 060-8638, Japan
| | - Kohta Takei
- Department of Pediatrics, Hokkaido University Graduate School, North-15 West-7, Sapporo, 060-8638, Japan
| | - Takuo Furukawa
- Department of Pediatrics, Hokkaido University Graduate School, North-15 West-7, Sapporo, 060-8638, Japan
| | - Kei Inai
- Department of Pediatric Cardiology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjyuku-ku, Tokyo, 162-8666, Japan
| | - Tokuko Shinohara
- Department of Pediatric Cardiology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjyuku-ku, Tokyo, 162-8666, Japan
| | - Toshio Nakanishi
- Division of Clinical Research for Adult Congenital Heart Disease Life-long Care and Pathophysiology, Department of Pediatric Cardiology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjyuku-ku, Tokyo, 162-8666, Japan
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The E-wave propagation index (EPI): A novel echocardiographic parameter for prediction of left ventricular thrombus. Derivation from computational fluid dynamic modeling and validation on human subjects. Int J Cardiol 2017; 227:662-667. [DOI: 10.1016/j.ijcard.2016.10.079] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 10/28/2016] [Indexed: 01/19/2023]
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Biermann D, Eder A, Arndt F, Seoudy H, Reichenspurner H, Mir T, Riso A, Kozlik-Feldmann R, Peldschus K, Kaul MG, Schuler T, Krasemann S, Hansen A, Eschenhagen T, Sachweh JS. Towards a Tissue-Engineered Contractile Fontan-Conduit: The Fate of Cardiac Myocytes in the Subpulmonary Circulation. PLoS One 2016; 11:e0166963. [PMID: 27875570 PMCID: PMC5119816 DOI: 10.1371/journal.pone.0166963] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 11/06/2016] [Indexed: 11/20/2022] Open
Abstract
The long-term outcome of patients with single ventricles improved over time, but remains poor compared to other congenital heart lesions with biventricular circulation. Main cause for this unfavourable outcome is the unphysiological hemodynamic of the Fontan circulation, such as subnormal systemic cardiac output and increased systemic-venous pressure. To overcome this limitation, we are developing the concept of a contractile extracardiac Fontan-tunnel. In this study, we evaluated the survival and structural development of a tissue-engineered conduit under in vivo conditions. Engineered heart tissue was generated from ventricular heart cells of neonatal Wistar rats, fibrinogen and thrombin. Engineered heart tissues started beating around day 8 in vitro and remained contractile in vivo throughout the experiment. After culture for 14 days constructs were implanted around the right superior vena cava of Wistar rats (n = 12). Animals were euthanized after 7, 14, 28 and 56 days postoperatively. Hematoxylin and eosin staining showed cardiomyocytes arranged in thick bundles within the engineered heart tissue-conduit. Immunostaining of sarcomeric actin, alpha-actin and connexin 43 revealed a well -developed cardiac myocyte structure. Magnetic resonance imaging (d14, n = 3) revealed no constriction or stenosis of the superior vena cava by the constructs. Engineered heart tissues survive and contract for extended periods after implantation around the superior vena cava of rats. Generation of larger constructs is warranted to evaluate functional benefits of a contractile Fontan-conduit.
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Affiliation(s)
- Daniel Biermann
- Cardiac Surgery for Congenital Heart Disease, University Heart Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- * E-mail:
| | - Alexandra Eder
- Department of Experimental Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Florian Arndt
- Department for Paediatric Cardiology, University Heart Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hatim Seoudy
- Department for Cardiovascular Surgery, University Heart Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hermann Reichenspurner
- Department for Cardiovascular Surgery, University Heart Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Thomas Mir
- Department for Paediatric Cardiology, University Heart Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Arlindo Riso
- Cardiac Surgery for Congenital Heart Disease, University Heart Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rainer Kozlik-Feldmann
- Department for Paediatric Cardiology, University Heart Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kersten Peldschus
- Department of Diagnostic and Interventional Radiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael G. Kaul
- Department of Diagnostic and Interventional Radiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tillman Schuler
- Department of Diagnostic and Interventional Radiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Krasemann
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Arne Hansen
- Department of Experimental Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Thomas Eschenhagen
- Department of Experimental Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Jörg S. Sachweh
- Cardiac Surgery for Congenital Heart Disease, University Heart Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Fukunishi T, Best CA, Sugiura T, Opfermann J, Ong CS, Shinoka T, Breuer CK, Krieger A, Johnson J, Hibino N. Preclinical study of patient-specific cell-free nanofiber tissue-engineered vascular grafts using 3-dimensional printing in a sheep model. J Thorac Cardiovasc Surg 2016; 153:924-932. [PMID: 27938900 DOI: 10.1016/j.jtcvs.2016.10.066] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 10/12/2016] [Accepted: 10/13/2016] [Indexed: 01/22/2023]
Abstract
BACKGROUND Tissue-engineered vascular grafts (TEVGs) offer potential to overcome limitations of current approaches for reconstruction in congenital heart disease by providing biodegradable scaffolds on which autologous cells proliferate and provide physiologic functionality. However, current TEVGs do not address the diverse anatomic requirements of individual patients. This study explores the feasibility of creating patient-specific TEVGs by combining 3-dimensional (3D) printing and electrospinning technology. METHODS An electrospinning mandrel was 3D-printed after computer-aided design based on preoperative imaging of the ovine thoracic inferior vena cava (IVC). TEVG scaffolds were then electrospun around the 3D-printed mandrel. Six patient-specific TEVGs were implanted as cell-free IVC interposition conduits in a sheep model and explanted after 6 months for histologic, biochemical, and biomechanical evaluation. RESULTS All sheep survived without complications, and all grafts were patent without aneurysm formation or ectopic calcification. Serial angiography revealed significant decreases in TEVG pressure gradients between 3 and 6 months as the grafts remodeled. At explant, the nanofiber scaffold was nearly completely resorbed and the TEVG showed similar mechanical properties to that of native IVC. Histological analysis demonstrated an organized smooth muscle cell layer, extracellular matrix deposition, and endothelialization. No significant difference in elastin and collagen content between the TEVG and native IVC was identified. There was a significant positive correlation between wall thickness and CD68+ macrophage infiltration into the TEVG. CONCLUSIONS Creation of patient-specific nanofiber TEVGs by combining electrospinning and 3D printing is a feasible technology as future clinical option. Further preclinical studies involving more complex anatomical shapes are warranted.
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Affiliation(s)
- Takuma Fukunishi
- Department of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Cameron A Best
- Tissue Engineering and Surgical Research, Nationwide Children's Hospital, Columbus, Ohio
| | - Tadahisa Sugiura
- Tissue Engineering and Surgical Research, Nationwide Children's Hospital, Columbus, Ohio
| | - Justin Opfermann
- The Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Medical Center, Washington, DC
| | - Chin Siang Ong
- Department of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Toshiharu Shinoka
- Tissue Engineering and Surgical Research, Nationwide Children's Hospital, Columbus, Ohio
| | - Christopher K Breuer
- Tissue Engineering and Surgical Research, Nationwide Children's Hospital, Columbus, Ohio
| | - Axel Krieger
- The Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Medical Center, Washington, DC
| | | | - Narutoshi Hibino
- Department of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Md.
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Wei ZA, Trusty PM, Tree M, Haggerty CM, Tang E, Fogel M, Yoganathan AP. Can time-averaged flow boundary conditions be used to meet the clinical timeline for Fontan surgical planning? J Biomech 2016; 50:172-179. [PMID: 27855985 DOI: 10.1016/j.jbiomech.2016.11.025] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 11/02/2016] [Indexed: 11/15/2022]
Abstract
Cardiovascular simulations have great potential as a clinical tool for planning and evaluating patient-specific treatment strategies for those suffering from congenital heart diseases, specifically Fontan patients. However, several bottlenecks have delayed wider deployment of the simulations for clinical use; the main obstacle is simulation cost. Currently, time-averaged clinical flow measurements are utilized as numerical boundary conditions (BCs) in order to reduce the computational power and time needed to offer surgical planning within a clinical time frame. Nevertheless, pulsatile blood flow is observed in vivo, and its significant impact on numerical simulations has been demonstrated. Therefore, it is imperative to carry out a comprehensive study analyzing the sensitivity of using time-averaged BCs. In this study, sensitivity is evaluated based on the discrepancies between hemodynamic metrics calculated using time-averaged and pulsatile BCs; smaller discrepancies indicate less sensitivity. The current study incorporates a comparison between 3D patient-specific CFD simulations using both the time-averaged and pulsatile BCs for 101 Fontan patients. The sensitivity analysis involves two clinically important hemodynamic metrics: hepatic flow distribution (HFD) and indexed power loss (iPL). Paired demographic group comparisons revealed that HFD sensitivity is significantly different between single and bilateral superior vena cava cohorts but no other demographic discrepancies were observed for HFD or iPL. Multivariate regression analyses show that the best predictors for sensitivity involve flow pulsatilities, time-averaged flow rates, and geometric characteristics of the Fontan connection. These predictors provide patient-specific guidelines to determine the effectiveness of analyzing patient-specific surgical options with time-averaged BCs within a clinical time frame.
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Affiliation(s)
- Zhenglun Alan Wei
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, 387 Technology Circle, Suite 232, Atlanta, GA 30313-2412, USA
| | - Phillip M Trusty
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, 387 Technology Circle, Suite 232, Atlanta, GA 30313-2412, USA
| | - Mike Tree
- George W. Woodruff School of Mechanical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
| | | | - Elaine Tang
- School of Chemical and Biomolecular Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
| | - Mark Fogel
- Division of Cardiology, Children׳s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ajit P Yoganathan
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, 387 Technology Circle, Suite 232, Atlanta, GA 30313-2412, USA.
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Jarvis K, Schnell S, Barker AJ, Garcia J, Lorenz R, Rose M, Chowdhary V, Carr J, Robinson JD, Rigsby CK, Markl M. Evaluation of blood flow distribution asymmetry and vascular geometry in patients with Fontan circulation using 4-D flow MRI. Pediatr Radiol 2016; 46:1507-19. [PMID: 27350377 PMCID: PMC5039076 DOI: 10.1007/s00247-016-3654-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 05/04/2016] [Accepted: 06/02/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Asymmetrical caval to pulmonary blood flow is suspected to cause complications in patients with Fontan circulation. The aim of this study was to test the feasibility of 4-D flow MRI for characterizing the relationship between 3-D blood flow distribution and vascular geometry. OBJECTIVE We hypothesized that both flow distribution and geometry can be calculated with low interobserver variability and will detect a direct relationship between flow distribution and Fontan geometry. MATERIALS AND METHODS Four-dimensional flow MRI was acquired in 10 Fontan patients (age: 16 ± 4 years [mean ± standard deviation], range: 9-21 years). The Fontan connection was isolated by 3-D segmentation to evaluate flow distribution from the inferior vena cava (IVC) and superior vena cava (SVC) to the left and right pulmonary arteries (LPA, RPA) and to characterize geometry (cross-sectional area, caval offset, vessel angle). RESULTS Flow distribution results indicated SVC flow tended toward the RPA while IVC flow was more evenly distributed (SVC to RPA: 78% ± 28 [9-100], IVC to LPA: 54% ± 28 [4-98]). There was a significant relationship between pulmonary artery cross-sectional area and flow distribution (IVC to RPA: R(2)=0.50, P=0.02; SVC to LPA: R(2)=0.81, P=0.0004). Good agreement was found between observers and for flow distribution when compared to net flow values. CONCLUSION Four-dimensional flow MRI was able to detect relationships between flow distribution and vessel geometry. Future studies are warranted to investigate the potential of patient specific hemodynamic analysis to improve diagnostic capability.
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Affiliation(s)
- Kelly Jarvis
- Department of Radiology, Feinberg School of Medicine, Northwestern University, 737 N. Michigan Ave., Suite 1600, Chicago, IL, 60611, USA.
- Department of Biomedical Engineering, McCormick School of Engineering, Northwestern University, Chicago, IL, USA.
| | - Susanne Schnell
- Department of Radiology, Feinberg School of Medicine, Northwestern University, 737 N. Michigan Ave., Suite 1600, Chicago, IL, 60611, USA
| | - Alex J Barker
- Department of Radiology, Feinberg School of Medicine, Northwestern University, 737 N. Michigan Ave., Suite 1600, Chicago, IL, 60611, USA
| | - Julio Garcia
- Department of Radiology, Feinberg School of Medicine, Northwestern University, 737 N. Michigan Ave., Suite 1600, Chicago, IL, 60611, USA
| | - Ramona Lorenz
- Department of Radiology, University Medical Center Freiburg, Freiburg, Germany
| | - Michael Rose
- Department of Medical Imaging, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Varun Chowdhary
- Department of Radiology, Feinberg School of Medicine, Northwestern University, 737 N. Michigan Ave., Suite 1600, Chicago, IL, 60611, USA
| | - James Carr
- Department of Radiology, Feinberg School of Medicine, Northwestern University, 737 N. Michigan Ave., Suite 1600, Chicago, IL, 60611, USA
| | - Joshua D Robinson
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Division of Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Cynthia K Rigsby
- Department of Radiology, Feinberg School of Medicine, Northwestern University, 737 N. Michigan Ave., Suite 1600, Chicago, IL, 60611, USA
- Department of Medical Imaging, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Michael Markl
- Department of Radiology, Feinberg School of Medicine, Northwestern University, 737 N. Michigan Ave., Suite 1600, Chicago, IL, 60611, USA
- Department of Biomedical Engineering, McCormick School of Engineering, Northwestern University, Chicago, IL, USA
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Clinical-Physiological Considerations in Patients Undergoing Staged Palliation for a Functionally Single Ventricle. Pediatr Crit Care Med 2016; 17:S347-55. [PMID: 27490622 DOI: 10.1097/pcc.0000000000000821] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The objectives of this review are to discuss the pathophysiology of the circulation with a functionally univentricular heart, with a focus on the unique physiologic characteristics, which provide the underpinnings for the management of these complex patients. DATA SOURCE MEDLINE and PubMed. CONCLUSIONS The circulation of the patient with a functionally univentricular heart displays unique physiologic characteristics, which are quite different from those of the normal biventricular circulation. There are profound differences within the heart itself in terms of ventricular function, interventricular interactions, and myocardial architecture, which are likely to have significant implications for the efficiency of ventricular ejection and metabolism. The coupling between the systemic ventricle and the aorta also displays unique features. The 3D orientation of the Fontan anastomosis itself can profoundly impact cardiac output, although the "portal" pulmonary arterial bed is a crucial determinant of overall cardiovascular function. As a result, disease-specific approaches to improve cardiovascular function are required at all stages during the care of these complex patients.
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A pulsatile hemodynamic evaluation of the commercially available bifurcated Y-graft Fontan modification and comparison with the lateral tunnel and extracardiac conduits. J Thorac Cardiovasc Surg 2016; 151:1529-36. [DOI: 10.1016/j.jtcvs.2016.03.019] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 03/01/2016] [Accepted: 03/05/2016] [Indexed: 11/22/2022]
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