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Kratz T, Gaukstern L, Wiebe W, Müller N, Freudenthal N, Breuer J, Luetkens J, Hart C. Pulmonary blood flow in children with univentricular heart and unilateral diaphragmatic paralysis. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2024; 38:ivae011. [PMID: 38216538 PMCID: PMC10809914 DOI: 10.1093/icvts/ivae011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 11/29/2023] [Accepted: 01/10/2024] [Indexed: 01/14/2024]
Abstract
OBJECTIVES Spontaneous breathing has an important effect on pulmonary arterial blood flow in patients with Glenn/Fontan circulation. Unilateral diaphragmatic paralysis (DP) is a frequent complication after heart surgery in congenital heart disease. The aim of this study was to investigate the influence of unilateral DP on blood flow distribution in the pulmonary arteries with Glenn/Fontan circulation. METHODS Magnetic resonance phase-contrast imaging was used to evaluate stroke volume index (SVI) in the left and right pulmonary arteries in patients with Glenn/Fontan circulation with unilateral DP. Data for 18 patients with univentricular heart and unilateral DP were analysed, 8 in the Glenn stage and 10 in the Fontan stage. Ten patients had right-sided DP, and 8 had left-sided DP. A diaphragmatic plication was performed in 7 patients. The control group consisted of 36 patients with Glenn (n = 16)/Fontan (n = 20) circulation without DP. RESULTS In both left- and right-sided DP, the SVI to the ipsilateral side was significantly lower than in controls [2.81 (1.45-4.50) ml/m2 left vs 11.97 (7.36-16.37) ml/m2 in controls, P < 0.0002; 8.2 (4.49-12.64) ml/m2 with right vs 12.64 (9.66-16.61) ml/m2 in controls; P = 0.0284]. The SVI to the contralateral side showed a slight but non-significant increase in the presence of unilateral DP. CONCLUSIONS Unilateral DP in patients with Glenn/Fontan circulation has a negative impact on pulmonary arterial SVI on the side of the paralysis.
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Affiliation(s)
- Tobias Kratz
- Department of Paediatric Cardiology, University Hospital Bonn, Bonn, Germany
| | - Lisa Gaukstern
- Department of Paediatric Cardiology, University Hospital Bonn, Bonn, Germany
| | - Walter Wiebe
- Department of Paediatric Cardiology, German Paediatric Heart Centre, Sankt Augustin, Germany
| | - Nicole Müller
- Department of Paediatric Cardiology, University Hospital Bonn, Bonn, Germany
| | - Noa Freudenthal
- Department of Paediatric Cardiology, University Hospital Bonn, Bonn, Germany
| | - Johannes Breuer
- Department of Paediatric Cardiology, University Hospital Bonn, Bonn, Germany
| | - Julian Luetkens
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Bonn, Germany
| | - Christopher Hart
- Department of Paediatric Cardiology, University Hospital Bonn, Bonn, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Bonn, Germany
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2
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Ridderbos FJS, Chan FP, van Melle JP, Ebels T, Feinstein JA, Berger RMF, Willems TP. Quantification of systemic-to-pulmonary collateral flow in univentricular physiology with 4D flow MRI. Cardiol Young 2023; 33:1634-1642. [PMID: 36120930 DOI: 10.1017/s1047951122002840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
PURPOSE Systemic-to-pulmonary collateral flow is a well-recognised phenomenon in patients with single ventricle physiology, but remains difficult to quantify. The aim was to compare the reported formula's that have been used for calculation of systemic-to-pulmonary-collateral flow to assess their consistency and to quantify systemic-to-pulmonary collateral flow in patients with a Glenn and/or Fontan circulation using four-dimensional flow MRI (4D flow MR). METHODS Retrospective case-control study of Glenn and Fontan patients who had a 4D flow MR study. Flows were measured at the ascending aorta, left and right pulmonary arteries, left and right pulmonary veins, and both caval veins. Systemic-to-pulmonary collateral flow was calculated using two formulas: 1) pulmonary veins - pulmonary arteries and 2) ascending aorta - caval veins. Anatomical identification of collaterals was performed using the 4D MR image set. RESULTS Fourteen patients (n = 11 Fontan, n = 3 Glenn) were included (age 26 [22-30] years). Systemic-to-pulmonary collateral flow was significantly higher in the patients than the controls (n = 10, age 31.2 [15.1-38.4] years) with both formulas: 0.28 [0.09-0.5] versus 0.04 [-0.66-0.21] l/min/m2 (p = 0.036, formula 1) and 0.67 [0.24-0.88] versus -0.07 [-0.16-0.08] l/min/m2 (p < 0.001, formula 2). In patients, systemic-to-pulmonary collateral flow differed significantly between formulas 1 and 2 (13% versus 26% of aortic flow, p = 0.038). In seven patients, veno-venous collaterals were detected and no aortopulmonary collaterals were visualised. CONCLUSION 4D flow MR is able to detect increased systemic-to-pulmonary collateral flow and visualise collaterals vessels in Glenn and Fontan patients. However, the amount of systemic-to-pulmonary collateral flow varies with the formula employed. Therefore, further research is necessary before it could be applied in clinical care.
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Affiliation(s)
- Floris-Jan S Ridderbos
- Department of Radiology, Stanford University Medical Center, Stanford University, Stanford, USA
- Department of Pediatric Cardiology, Center for Congenital Heart Diseases, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Frandics P Chan
- Department of Radiology, Stanford University Medical Center, Stanford University, Stanford, USA
| | - Joost P van Melle
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Tjark Ebels
- Department of Cardiothoracic Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
- Department of Cardiothoracic Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Jeffrey A Feinstein
- Department of Pediatrics (Cardiology), Stanford University Medical Center / Lucile Packard Children's Hospital, Stanford University, Stanford, USA
| | - Rolf M F Berger
- Department of Pediatric Cardiology, Center for Congenital Heart Diseases, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Tineke P Willems
- Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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Yang W, Conover TA, Figliola RS, Giridharan GA, Marsden AL, Rodefeld MD. Passive performance evaluation and validation of a viscous impeller pump for subpulmonary fontan circulatory support. Sci Rep 2023; 13:12668. [PMID: 37542111 PMCID: PMC10403595 DOI: 10.1038/s41598-023-38559-y] [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: 02/14/2023] [Accepted: 07/11/2023] [Indexed: 08/06/2023] Open
Abstract
Patients with single ventricle defects undergoing the Fontan procedure eventually face Fontan failure. Long-term cavopulmonary assist devices using rotary pump technologies are currently being developed as a subpulmonary power source to prevent and treat Fontan failure. Low hydraulic resistance is a critical safety requirement in the event of pump failure (0 RPM) as a modest 2 mmHg cavopulmonary pressure drop can compromise patient hemodynamics. The goal of this study is therefore to assess the passive performance of a viscous impeller pump (VIP) we are developing for Fontan patients, and validate flow simulations against in-vitro data. Two different blade heights (1.09 mm vs 1.62 mm) and a blank housing model were tested using a mock circulatory loop (MCL) with cardiac output ranging from 3 to 11 L/min. Three-dimensional flow simulations were performed and compared against MCL data. In-silico and MCL results demonstrated a pressure drop of < 2 mmHg at a cardiac output of 7 L/min for both blade heights. There was good agreement between simulation and MCL results for pressure loss (mean difference - 0.23 mmHg 95% CI [0.24-0.71]). Compared to the blank housing model, low wall shear stress area and oscillatory shear index on the pump surface were low, and mean washout times were within 2 s. This study demonstrated the low resistance characteristic of current VIP designs in the failed condition that results in clinically acceptable minimal pressure loss without increased washout time as compared to a blank housing model under normal cardiac output in Fontan patients.
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Affiliation(s)
- Weiguang Yang
- Department of Pediatrics (Cardiology), Stanford University, Stanford, CA, USA.
| | - Timothy A Conover
- Departments of Mechanical Engineering, Clemson University, Clemson, SC, USA
| | - Richard S Figliola
- Departments of Mechanical Engineering, Clemson University, Clemson, SC, USA
| | | | - Alison L Marsden
- Department of Pediatrics (Cardiology), Stanford University, Stanford, CA, USA
- Department of Bioengineering, Stanford University, Stanford, CA, USA
| | - Mark D Rodefeld
- Section of Cardiothoracic Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
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4
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Yang W, Conover TA, Figliola RS, Giridharan GA, Marsden AL, Rodefeld MD. Passive Performance Evaluation and Validation of a Viscous Impeller Pump for Subpulmonary Fontan Circulatory Support. RESEARCH SQUARE 2023:rs.3.rs-2584661. [PMID: 36909557 PMCID: PMC10002834 DOI: 10.21203/rs.3.rs-2584661/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
Patients with single ventricle defects undergoing the Fontan procedure eventually face Fontan failure. Long-term cavopulmonary assist devices using rotary pump technologies are currently being developed as a subpulmonary power source to prevent and treat Fontan failure. Low hydraulic resistance is a critical safety requirement in the event of pump failure (0 RPM) as a modest 2 mmHg cavopulmonary pressure drop can compromise patient hemodynamics. The goal of this study is therefore to assess the passive performance for a viscous impeller pump (VIP) we are developing for Fontan patients, and validate flow simulations against in-vitro data. Two different blade heights (1.09 mm vs 1.62 mm) and a blank housing model were tested using a mock circulatory loop (MCL) with cardiac output ranging from 3 to 11 L/min. Three-dimensional flow simulations were performed and compared against MCL data. In-silico and MCL results demonstrated a clinically insignificant pressure drop of $<$ 2 mmHg at a cardiac output of 7 L/min for both blade heights. There was good agreement between simulation and MCL results for pressure loss (mean difference -0.23 mmHg 95% CI [0.24 -0.71]). Compared to the blank housing model, low wall shear stress area and oscillatory shear index on the pump surface were low, and mean washout times were within 2 seconds. This study demonstrated the low resistance characteristic of current VIP designs in the failed condition that results in clinically acceptable minimal pressure loss with low risk of thrombosis.
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Affiliation(s)
- Weiguang Yang
- Departments of Pediatrics (Cardiology), Stanford University
| | | | | | | | - Alison L. Marsden
- Departments of Pediatrics (Cardiology), Stanford University
- Department of Bioengineering, Stanford University
| | - Mark D. Rodefeld
- Section of Cardiothoracic Surgery, Indiana University School of Medicine
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5
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Fogel MA, Anwar S, Broberg C, Browne L, Chung T, Johnson T, Muthurangu V, Taylor M, Valsangiacomo-Buechel E, Wilhelm C. Society for Cardiovascular Magnetic Resonance/European Society of Cardiovascular Imaging/American Society of Echocardiography/Society for Pediatric Radiology/North American Society for Cardiovascular Imaging Guidelines for the use of cardiovascular magnetic resonance in pediatric congenital and acquired heart disease : Endorsed by The American Heart Association. J Cardiovasc Magn Reson 2022; 24:37. [PMID: 35725473 PMCID: PMC9210755 DOI: 10.1186/s12968-022-00843-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 01/12/2022] [Indexed: 11/16/2022] Open
Abstract
Cardiovascular magnetic resonance (CMR) has been utilized in the management and care of pediatric patients for nearly 40 years. It has evolved to become an invaluable tool in the assessment of the littlest of hearts for diagnosis, pre-interventional management and follow-up care. Although mentioned in a number of consensus and guidelines documents, an up-to-date, large, stand-alone guidance work for the use of CMR in pediatric congenital 36 and acquired 35 heart disease endorsed by numerous Societies involved in the care of these children is lacking. This guidelines document outlines the use of CMR in this patient population for a significant number of heart lesions in this age group and although admittedly, is not an exhaustive treatment, it does deal with an expansive list of many common clinical issues encountered in daily practice.
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Affiliation(s)
- Mark A Fogel
- Departments of Pediatrics (Cardiology) and Radiology, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. .,Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Shaftkat Anwar
- Department of Pediatrics (Cardiology) and Radiology, The University of California-San Francisco School of Medicine, San Francisco, USA
| | - Craig Broberg
- Division of Cardiovascular Medicine, Oregon Health and Sciences University, Portland, USA
| | - Lorna Browne
- Department of Radiology, University of Colorado, Denver, USA
| | - Taylor Chung
- Department of Radiology and Biomedical Imaging, The University of California-San Francisco School of Medicine, San Francisco, USA
| | - Tiffanie Johnson
- Department of Pediatrics (Cardiology), Indiana University School of Medicine, Indianapolis, USA
| | - Vivek Muthurangu
- Department of Pediatrics (Cardiology), University College London, London, UK
| | - Michael Taylor
- Department of Pediatrics (Cardiology), University of Cincinnati School of Medicine, Cincinnati, USA
| | | | - Carolyn Wilhelm
- Department of Pediatrics (Cardiology), University Hospitals-Cleveland, Cleaveland, USA
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6
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Fogel MA, Anwar S, Broberg C, Browne L, Chung T, Johnson T, Muthurangu V, Taylor M, Valsangiacomo-Buechel E, Wilhelm C. Society for Cardiovascular Magnetic Resonance/European Society of Cardiovascular Imaging/American Society of Echocardiography/Society for Pediatric Radiology/North American Society for Cardiovascular Imaging Guidelines for the Use of Cardiac Magnetic Resonance in Pediatric Congenital and Acquired Heart Disease: Endorsed by The American Heart Association. Circ Cardiovasc Imaging 2022; 15:e014415. [PMID: 35727874 PMCID: PMC9213089 DOI: 10.1161/circimaging.122.014415] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Cardiovascular magnetic resonance has been utilized in the management and care of pediatric patients for nearly 40 years. It has evolved to become an invaluable tool in the assessment of the littlest of hearts for diagnosis, pre-interventional management and follow-up care. Although mentioned in a number of consensus and guidelines documents, an up-to-date, large, stand-alone guidance work for the use of cardiovascular magnetic resonance in pediatric congenital 36 and acquired 35 heart disease endorsed by numerous Societies involved in the care of these children is lacking. This guidelines document outlines the use of cardiovascular magnetic resonance in this patient population for a significant number of heart lesions in this age group and although admittedly, is not an exhaustive treatment, it does deal with an expansive list of many common clinical issues encountered in daily practice.
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Affiliation(s)
- Mark A Fogel
- Departments of Pediatrics (Cardiology) and Radiology, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA, (M.A.F.).,Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA, (M.A.F.)
| | - Shaftkat Anwar
- Department of Pediatrics (Cardiology) and Radiology, The University of California-San Francisco School of Medicine, San Francisco, USA, (S.A.)
| | - Craig Broberg
- Division of Cardiovascular Medicine, Oregon Health and Sciences University, Portland, USA, (C.B.)
| | - Lorna Browne
- Department of Radiology, University of Colorado, Denver, USA, (L.B.)
| | - Taylor Chung
- Department of Radiology and Biomedical Imaging, The University of California-San Francisco School of Medicine, San Francisco, USA, (T.C.)
| | - Tiffanie Johnson
- Department of Pediatrics (Cardiology), Indiana University School of Medicine, Indianapolis, USA, (T.J.)
| | - Vivek Muthurangu
- Department of Pediatrics (Cardiology), University College London, London, UK, (V.M.)
| | - Michael Taylor
- Department of Pediatrics (Cardiology), University of Cincinnati School of Medicine, Cincinnati, USA, (M.T.)
| | | | - Carolyn Wilhelm
- Department of Pediatrics (Cardiology), University Hospitals-Cleveland, Cleaveland, USA (C.W.)
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7
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Lam CZ, David D, Acosta Izquierdo L, Pezeshkpour P, Dipchand AI, Jean-St-Michel E, Chaturvedi RR, Ling SC, Wald RM, Chavhan GB, Seed M, Yoo SJ. MRI Phase-Contrast Blood Flow in Fasting Pediatric Patients with Fontan Circulation Correlates with Exercise Capacity. Radiol Cardiothorac Imaging 2022; 4:e210303. [PMID: 35506132 PMCID: PMC9059244 DOI: 10.1148/ryct.210303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/18/2022] [Accepted: 03/22/2022] [Indexed: 11/11/2022]
Abstract
Purpose To assess regional blood flow in fasting pediatric patients with Fontan circulation by using MRI and to explore associations with clinical parameters. Materials and Methods In this retrospective study, pediatric patients who had undergone the Fontan procedure (<18 years of age) and had undergone clinical cardiac MRI, performed after at least 4 hours of fasting, between 2018 and 2021 were included. Regional blood flow was compared with published healthy volunteer data (n = 19) and assessed in relation to hemodynamic parameters and clinical status. Data are presented as medians, with first to third quartiles in parentheses. Mann-Whitney U, Kruskal-Wallis, χ2, and Spearman rank correlation tests were used. Results Fifty-five patients (38 boys) with median age at MRI of 14 years (IQR, 11-16 years) and median time from Fontan procedure to MRI of 10 years (IQR, 8-12 years) were included. Patients after Fontan procedure had lower ascending aortic, inferior vena cava, and total systemic blood flow compared with healthy volunteers (3.00 L/min/m2 [IQR, 2.75-3.30 L/min/m2] vs 3.61 L/min/m2 [IQR, 3.29-4.07 L/min/m2]; 1.73 L/min/m2 [IQR, 1.40-1.94 L/min/m2] vs 2.24 L/min/m2 [IQR, 2.06-2.75 L/min/m2]; 2.78 L/min/m2 [IQR, 2.45-3.10 L/min/m2] vs 3.95 L/min/m2 [IQR, 3.20-4.30 L/min/m2], respectively; P < .001). Portal vein flow was greater than hepatic vein flow in 25% of patients. Fontan blood flow was inversely correlated with pre-Fontan mean pulmonary artery pressure (Spearman rank correlation coefficient [rs ]= -0.42, P = .005) and ventricular end diastolic pressure (rs = -0.33, P = .04) and positively correlated with post-Fontan percent predicted oxygen consumption at peak workload (rs = 0.34, P = .02). Conclusion Reference ranges are provided for regional systemic blood flow derived by using MRI in fasting pediatric patients with Fontan circulation, who had lower systemic blood flow compared with healthy volunteers. Lower fasting Fontan blood flow correlated with lower exercise capacity.Keywords: Pediatrics, Heart, Congenital, MR Imaging, Hemodynamics/Flow Dynamics, Cardiac Supplemental material is available for this article. © RSNA, 2022.
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Affiliation(s)
- Christopher Z. Lam
- From the Department of Diagnostic Imaging (C.Z.L., D.D., L.A.I.,
P.P., G.B.C., M.S., S.J.Y.), Division of Cardiology, Department of Paediatrics
(A.I.D., E.J.S.M., R.R.C., R.M.W., M.S., S.J.Y.), and Division of
Gastroenterology, Department of Paediatrics (S.C.L.), Hospital for Sick
Children, University of Toronto, 555 University Ave, Toronto, ON, Canada M5G
1X8; Department of Medical Imaging, University of Toronto, Toronto, Canada
(C.Z.L., L.A.I., G.B.C., S.J.Y.); Joint Department of Medical Imaging,
University Health Network, Toronto, Canada (R.M.W.); and Peter Munk Cardiac
Centre, University Health Network, Toronto General Hospital, Toronto, Canada
(R.M.W.)
| | - Dawn David
- From the Department of Diagnostic Imaging (C.Z.L., D.D., L.A.I.,
P.P., G.B.C., M.S., S.J.Y.), Division of Cardiology, Department of Paediatrics
(A.I.D., E.J.S.M., R.R.C., R.M.W., M.S., S.J.Y.), and Division of
Gastroenterology, Department of Paediatrics (S.C.L.), Hospital for Sick
Children, University of Toronto, 555 University Ave, Toronto, ON, Canada M5G
1X8; Department of Medical Imaging, University of Toronto, Toronto, Canada
(C.Z.L., L.A.I., G.B.C., S.J.Y.); Joint Department of Medical Imaging,
University Health Network, Toronto, Canada (R.M.W.); and Peter Munk Cardiac
Centre, University Health Network, Toronto General Hospital, Toronto, Canada
(R.M.W.)
| | - Laura Acosta Izquierdo
- From the Department of Diagnostic Imaging (C.Z.L., D.D., L.A.I.,
P.P., G.B.C., M.S., S.J.Y.), Division of Cardiology, Department of Paediatrics
(A.I.D., E.J.S.M., R.R.C., R.M.W., M.S., S.J.Y.), and Division of
Gastroenterology, Department of Paediatrics (S.C.L.), Hospital for Sick
Children, University of Toronto, 555 University Ave, Toronto, ON, Canada M5G
1X8; Department of Medical Imaging, University of Toronto, Toronto, Canada
(C.Z.L., L.A.I., G.B.C., S.J.Y.); Joint Department of Medical Imaging,
University Health Network, Toronto, Canada (R.M.W.); and Peter Munk Cardiac
Centre, University Health Network, Toronto General Hospital, Toronto, Canada
(R.M.W.)
| | - Parneyan Pezeshkpour
- From the Department of Diagnostic Imaging (C.Z.L., D.D., L.A.I.,
P.P., G.B.C., M.S., S.J.Y.), Division of Cardiology, Department of Paediatrics
(A.I.D., E.J.S.M., R.R.C., R.M.W., M.S., S.J.Y.), and Division of
Gastroenterology, Department of Paediatrics (S.C.L.), Hospital for Sick
Children, University of Toronto, 555 University Ave, Toronto, ON, Canada M5G
1X8; Department of Medical Imaging, University of Toronto, Toronto, Canada
(C.Z.L., L.A.I., G.B.C., S.J.Y.); Joint Department of Medical Imaging,
University Health Network, Toronto, Canada (R.M.W.); and Peter Munk Cardiac
Centre, University Health Network, Toronto General Hospital, Toronto, Canada
(R.M.W.)
| | - Anne I. Dipchand
- From the Department of Diagnostic Imaging (C.Z.L., D.D., L.A.I.,
P.P., G.B.C., M.S., S.J.Y.), Division of Cardiology, Department of Paediatrics
(A.I.D., E.J.S.M., R.R.C., R.M.W., M.S., S.J.Y.), and Division of
Gastroenterology, Department of Paediatrics (S.C.L.), Hospital for Sick
Children, University of Toronto, 555 University Ave, Toronto, ON, Canada M5G
1X8; Department of Medical Imaging, University of Toronto, Toronto, Canada
(C.Z.L., L.A.I., G.B.C., S.J.Y.); Joint Department of Medical Imaging,
University Health Network, Toronto, Canada (R.M.W.); and Peter Munk Cardiac
Centre, University Health Network, Toronto General Hospital, Toronto, Canada
(R.M.W.)
| | - Emilie Jean-St-Michel
- From the Department of Diagnostic Imaging (C.Z.L., D.D., L.A.I.,
P.P., G.B.C., M.S., S.J.Y.), Division of Cardiology, Department of Paediatrics
(A.I.D., E.J.S.M., R.R.C., R.M.W., M.S., S.J.Y.), and Division of
Gastroenterology, Department of Paediatrics (S.C.L.), Hospital for Sick
Children, University of Toronto, 555 University Ave, Toronto, ON, Canada M5G
1X8; Department of Medical Imaging, University of Toronto, Toronto, Canada
(C.Z.L., L.A.I., G.B.C., S.J.Y.); Joint Department of Medical Imaging,
University Health Network, Toronto, Canada (R.M.W.); and Peter Munk Cardiac
Centre, University Health Network, Toronto General Hospital, Toronto, Canada
(R.M.W.)
| | - Rajiv R. Chaturvedi
- From the Department of Diagnostic Imaging (C.Z.L., D.D., L.A.I.,
P.P., G.B.C., M.S., S.J.Y.), Division of Cardiology, Department of Paediatrics
(A.I.D., E.J.S.M., R.R.C., R.M.W., M.S., S.J.Y.), and Division of
Gastroenterology, Department of Paediatrics (S.C.L.), Hospital for Sick
Children, University of Toronto, 555 University Ave, Toronto, ON, Canada M5G
1X8; Department of Medical Imaging, University of Toronto, Toronto, Canada
(C.Z.L., L.A.I., G.B.C., S.J.Y.); Joint Department of Medical Imaging,
University Health Network, Toronto, Canada (R.M.W.); and Peter Munk Cardiac
Centre, University Health Network, Toronto General Hospital, Toronto, Canada
(R.M.W.)
| | - Simon C. Ling
- From the Department of Diagnostic Imaging (C.Z.L., D.D., L.A.I.,
P.P., G.B.C., M.S., S.J.Y.), Division of Cardiology, Department of Paediatrics
(A.I.D., E.J.S.M., R.R.C., R.M.W., M.S., S.J.Y.), and Division of
Gastroenterology, Department of Paediatrics (S.C.L.), Hospital for Sick
Children, University of Toronto, 555 University Ave, Toronto, ON, Canada M5G
1X8; Department of Medical Imaging, University of Toronto, Toronto, Canada
(C.Z.L., L.A.I., G.B.C., S.J.Y.); Joint Department of Medical Imaging,
University Health Network, Toronto, Canada (R.M.W.); and Peter Munk Cardiac
Centre, University Health Network, Toronto General Hospital, Toronto, Canada
(R.M.W.)
| | - Rachel M. Wald
- From the Department of Diagnostic Imaging (C.Z.L., D.D., L.A.I.,
P.P., G.B.C., M.S., S.J.Y.), Division of Cardiology, Department of Paediatrics
(A.I.D., E.J.S.M., R.R.C., R.M.W., M.S., S.J.Y.), and Division of
Gastroenterology, Department of Paediatrics (S.C.L.), Hospital for Sick
Children, University of Toronto, 555 University Ave, Toronto, ON, Canada M5G
1X8; Department of Medical Imaging, University of Toronto, Toronto, Canada
(C.Z.L., L.A.I., G.B.C., S.J.Y.); Joint Department of Medical Imaging,
University Health Network, Toronto, Canada (R.M.W.); and Peter Munk Cardiac
Centre, University Health Network, Toronto General Hospital, Toronto, Canada
(R.M.W.)
| | - Govind B. Chavhan
- From the Department of Diagnostic Imaging (C.Z.L., D.D., L.A.I.,
P.P., G.B.C., M.S., S.J.Y.), Division of Cardiology, Department of Paediatrics
(A.I.D., E.J.S.M., R.R.C., R.M.W., M.S., S.J.Y.), and Division of
Gastroenterology, Department of Paediatrics (S.C.L.), Hospital for Sick
Children, University of Toronto, 555 University Ave, Toronto, ON, Canada M5G
1X8; Department of Medical Imaging, University of Toronto, Toronto, Canada
(C.Z.L., L.A.I., G.B.C., S.J.Y.); Joint Department of Medical Imaging,
University Health Network, Toronto, Canada (R.M.W.); and Peter Munk Cardiac
Centre, University Health Network, Toronto General Hospital, Toronto, Canada
(R.M.W.)
| | - Michael Seed
- From the Department of Diagnostic Imaging (C.Z.L., D.D., L.A.I.,
P.P., G.B.C., M.S., S.J.Y.), Division of Cardiology, Department of Paediatrics
(A.I.D., E.J.S.M., R.R.C., R.M.W., M.S., S.J.Y.), and Division of
Gastroenterology, Department of Paediatrics (S.C.L.), Hospital for Sick
Children, University of Toronto, 555 University Ave, Toronto, ON, Canada M5G
1X8; Department of Medical Imaging, University of Toronto, Toronto, Canada
(C.Z.L., L.A.I., G.B.C., S.J.Y.); Joint Department of Medical Imaging,
University Health Network, Toronto, Canada (R.M.W.); and Peter Munk Cardiac
Centre, University Health Network, Toronto General Hospital, Toronto, Canada
(R.M.W.)
| | - Shi-Joon Yoo
- From the Department of Diagnostic Imaging (C.Z.L., D.D., L.A.I.,
P.P., G.B.C., M.S., S.J.Y.), Division of Cardiology, Department of Paediatrics
(A.I.D., E.J.S.M., R.R.C., R.M.W., M.S., S.J.Y.), and Division of
Gastroenterology, Department of Paediatrics (S.C.L.), Hospital for Sick
Children, University of Toronto, 555 University Ave, Toronto, ON, Canada M5G
1X8; Department of Medical Imaging, University of Toronto, Toronto, Canada
(C.Z.L., L.A.I., G.B.C., S.J.Y.); Joint Department of Medical Imaging,
University Health Network, Toronto, Canada (R.M.W.); and Peter Munk Cardiac
Centre, University Health Network, Toronto General Hospital, Toronto, Canada
(R.M.W.)
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8
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Cysyk JP, Lukic B, Joseph Brian C, Newswanger R, Jhun CS, Izer J, Flory H, Reibson J, Doxtater B, Weiss W, Rosenberg G. Miniaturized Fontan Circulation Assist Device: Chronic In Vivo Evaluation. ASAIO J 2021; 67:1240-1249. [PMID: 33883510 DOI: 10.1097/mat.0000000000001439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
We have miniaturized and optimized our implantable rotary blood pump developed to provide long-term mechanical right heart support for patients who have failing Fontan circulation. The objective of this study was to evaluate the miniaturized Fontan circulation assist device (mini-FCAD) during 30-day sheep studies (n = 5). A complete right heart bypass was performed and all return flow was supported by the pump. Postoperatively, unfractionated heparin was given to maintain thromboelastography R times of 2× normal. The first two studies were terminated on day 0 and day 4 due to complications. In the final three studies, the animals remained healthy and were electively terminated at 30 ± 2 days. Pump flow was between 5 and 7 lpm, left atrial pressure remained normal, and inlet pressures were between 3 and 18 mm Hg with no incidents of suction. There was no evidence of hemolysis, end organ or pulmonary dysfunction, thromboembolic events, nor thermal damage to the surrounding tissue. Explanted devices from two studies were free of thrombi and in the third study there were unattached thrombi on the SVC inlet of the rotor. The mini-FCAD was successfully tested in vivo as a right heart replacement device demonstrating adequate circulatory support and normal physiologic pulmonary and venous pressures.
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Affiliation(s)
- Joshua P Cysyk
- From the Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - Branka Lukic
- From the Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - Clark Joseph Brian
- From the Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
- Department of Pediatrics, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - Ray Newswanger
- From the Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - Choon-Sik Jhun
- From the Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - Jenelle Izer
- Department of Comparative Medicine, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - Heidi Flory
- From the Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - John Reibson
- From the Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - Bradley Doxtater
- From the Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - William Weiss
- From the Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
| | - Gerson Rosenberg
- From the Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania
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9
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van der Woude SFS, Rijnberg FM, Hazekamp MG, Jongbloed MRM, Kenjeres S, Lamb HJ, Westenberg JJM, Roest AAW, Wentzel JJ. The Influence of Respiration on Blood Flow in the Fontan Circulation: Insights for Imaging-Based Clinical Evaluation of the Total Cavopulmonary Connection. Front Cardiovasc Med 2021; 8:683849. [PMID: 34422920 PMCID: PMC8374887 DOI: 10.3389/fcvm.2021.683849] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 07/05/2021] [Indexed: 12/18/2022] Open
Abstract
Congenital heart disease is the most common birth defect and functionally univentricular heart defects represent the most severe end of this spectrum. The Fontan circulation provides an unique solution for single ventricle patients, by connecting both caval veins directly to the pulmonary arteries. As a result, the pulmonary circulation in Fontan palliated patients is characterized by a passive, low-energy circulation that depends on increased systemic venous pressure to drive blood toward the lungs. The absence of a subpulmonary ventricle led to the widely believed concept that respiration, by sucking blood to the pulmonary circulation during inspiration, is of great importance as a driving force for antegrade blood flow in Fontan patients. However, recent studies show that respiration influences pulsatility, but has a limited effect on net forward flow in the Fontan circulation. Importantly, since MRI examination is recommended every 2 years in Fontan patients, clinicians should be aware that most conventional MRI flow sequences do not capture the pulsatility of the blood flow as a result of the respiration. In this review, the unique flow dynamics influenced by the cardiac and respiratory cycle at multiple locations within the Fontan circulation is discussed. The impact of (not) incorporating respiration in different MRI flow sequences on the interpretation of clinical flow parameters will be covered. Finally, the influence of incorporating respiration in advanced computational fluid dynamic modeling will be outlined.
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Affiliation(s)
- Séline F S van der Woude
- Department of Cardiology, Biomedical Engineering, Biomechanics Laboratory, Rotterdam, Netherlands
| | - Friso M Rijnberg
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Mark G Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Monique R M Jongbloed
- Department of Anatomy, Embryology and Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Sasa Kenjeres
- Department of Chemical Engineering, Faculty of Applied Sciences, Delft University of Technology and J. M. Burgerscentrum Research School for Fluid Mechanics, Delft, Netherlands
| | - Hildo J Lamb
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Jos J M Westenberg
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Arno A W Roest
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Jolanda J Wentzel
- Department of Cardiology, Biomedical Engineering, Biomechanics Laboratory, Rotterdam, Netherlands
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10
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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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11
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Rubinstein J, Woo JG, Garcia AM, Alsaied T, Li J, Lunde PK, Moore RA, Laasmaa M, Sammons A, Mays WA, Miyamoto SD, Louch WE, Veldtman GR. Probenecid Improves Cardiac Function in Subjects with a Fontan Circulation and Augments Cardiomyocyte Calcium Homeostasis. Pediatr Cardiol 2020; 41:1675-1688. [PMID: 32770262 PMCID: PMC7704717 DOI: 10.1007/s00246-020-02427-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 07/21/2020] [Indexed: 10/23/2022]
Abstract
Subjects with functionally univentricular circulation who have completed staged single ventricle palliation, with the final stage culminating in the Fontan procedure, are often living into adulthood. However, high morbidity and mortality remain prevalent in these patients, as diastolic and systolic dysfunction of the single systemic ventricle are linked to Fontan circulatory failure. We presently investigated the effects of probenecid in post-Fontan patients. Used for decades for the treatment of gout, probenecid has been shown in recent years to positively influence cardiac function via effects on the Transient Receptor Potential Vanilloid 2 (TRPV2) channel in cardiomyocytes. Indeed, we observed that probenecid improved cardiac function and exercise performance in patients with a functionally univentricular circulation. This was consistent with our findings from a retrospective cohort of patients with single ventricle physiology where TRPV2 expression was increased. Experiments in isolated cardiomyocytes associated these positive actions to augmentation of diastolic calcium homeostasis.
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Affiliation(s)
- Jack Rubinstein
- Department of Internal Medicine, Division of Cardiovascular Health & Disease, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH, 45267, USA.
| | - Jessica G Woo
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Anastacia M Garcia
- Department of Pediatrics, Division of Cardiology, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Tarek Alsaied
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jia Li
- Institute for Experimental Medical Research, Oslo University Hospital and University of Oslo, Oslo, Norway
- K. G. Jebsen Cardiac Research Center, University of Oslo, Oslo, Norway
| | - Per Kristian Lunde
- Institute for Experimental Medical Research, Oslo University Hospital and University of Oslo, Oslo, Norway
- K. G. Jebsen Cardiac Research Center, University of Oslo, Oslo, Norway
| | - Ryan A Moore
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Martin Laasmaa
- Institute for Experimental Medical Research, Oslo University Hospital and University of Oslo, Oslo, Norway
- K. G. Jebsen Cardiac Research Center, University of Oslo, Oslo, Norway
| | - Amanda Sammons
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Wayne A Mays
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Shelley D Miyamoto
- Department of Pediatrics, Division of Cardiology, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - William E Louch
- Institute for Experimental Medical Research, Oslo University Hospital and University of Oslo, Oslo, Norway
- K. G. Jebsen Cardiac Research Center, University of Oslo, Oslo, Norway
| | - Gruschen R Veldtman
- Adult Congenital Heart Disease Service, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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12
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Kodama Y, Ishikawa Y, Kuraoka A, Nakamura M, Oda S, Nakano T, Kado H, Sakamoto I, Ohtani K, Ide T, Tsutsui H, Sagawa K. Systemic-to-Pulmonary Collateral Flow Correlates with Clinical Condition Late After the Fontan Procedure. Pediatr Cardiol 2020; 41:1800-1806. [PMID: 32915292 DOI: 10.1007/s00246-020-02450-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 08/30/2020] [Indexed: 11/29/2022]
Abstract
In the Fontan circulation, there is a substantial degree of systemic-to-pulmonary collateral flow (SPCF), which can be measured by cardiac magnetic resonance (CMR). However, the correlation between the degree of SPCF and long-term outcomes is not fully understood. We retrospectively studied 321 patients who underwent the Fontan procedure and CMR at a single center. Using CMR, we calculated SPCF as pulmonary blood flow - systemic blood flow. %SPCF was defined as SPCF ÷ pulmonary blood flow. The mean age of patients at CMR was 14.3 ± 7.5 years. The average %SPCF was 13.0% ± 11.0%. With a multivariate analysis, %SPCF was significantly correlated with time (i.e., the longer the time period since the Fontan procedure, the lower the %SPCF) (p = 0.006), previous total anomalous pulmonary vein drainage (p = 0.007), a low pulmonary artery index (Nakata index) before the Fontan procedure (p = 0.04), and older age at the time of the Fontan procedure (p = 0.002). Regarding the findings after the Fontan procedure, %SPCF was significantly correlated with ventricular end-diastolic volume (p < 0.001), ventricular end-systolic volume (p < 0.001), central venous pressure (p < 0.001), plasma brain natriuretic peptide concentration (p < 0.001), hemoptysis (p = 0.009), and poor New York Heart Association functional class (p = 0.007). SPCF was correlated with clinical condition after the Fontan procedure. The importance of sufficient growth of the pulmonary vascular bed should be emphasized because the development of SPCF is believed to result from the poor condition of the pulmonary circulation.
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Affiliation(s)
- Yoshihiko Kodama
- Department of Pediatric Cardiology, Fukuoka Children's Hospital, 5-1-1 Kashiiteriha, Fukuoka, Japan. .,Department of Cardiovascular Medicine, Kyushu University Hospital, Fukuoka, Japan.
| | - Yuichi Ishikawa
- Department of Pediatric Cardiology, Fukuoka Children's Hospital, 5-1-1 Kashiiteriha, Fukuoka, Japan
| | - Ayako Kuraoka
- Department of Pediatric Cardiology, Fukuoka Children's Hospital, 5-1-1 Kashiiteriha, Fukuoka, Japan
| | - Makoto Nakamura
- Department of Pediatric Cardiology, Fukuoka Children's Hospital, 5-1-1 Kashiiteriha, Fukuoka, Japan
| | - Shinichiro Oda
- Department of Cardiovascular Surgery, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Toshihide Nakano
- Department of Cardiovascular Surgery, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Hideaki Kado
- Department of Cardiovascular Surgery, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Ichiro Sakamoto
- Department of Cardiovascular Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Kisho Ohtani
- Department of Cardiovascular Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Tomomi Ide
- Department of Cardiovascular Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Koichi Sagawa
- Department of Pediatric Cardiology, Fukuoka Children's Hospital, 5-1-1 Kashiiteriha, Fukuoka, Japan
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13
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Siripornpitak S, Goo HW. CT and MRI for Repaired Complex Adult Congenital Heart Diseases. Korean J Radiol 2020; 22:308-323. [PMID: 33289363 PMCID: PMC7909854 DOI: 10.3348/kjr.2020.0895] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 08/21/2020] [Accepted: 09/01/2020] [Indexed: 12/30/2022] Open
Abstract
An increasing number of adult congenital heart disease (ACHD) patients continue to require life-long diagnostic imaging surveillance using cardiac CT and MRI. These patients typically exhibit a large spectrum of unique anatomical and functional changes resulting from either single- or multi-stage palliation and surgical correction. Radiologists involved in the diagnostic task of monitoring treatment effects and detecting potential complications should be familiar with common cardiac CT and MRI findings observed in patients with repaired complex ACHD. This review article highlights the contemporary role of CT and MRI in three commonly encountered repaired ACHD: repaired tetralogy of Fallot, transposition of the great arteries after arterial switch operation, and functional single ventricle after Fontan operation.
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Affiliation(s)
- Suvipaporn Siripornpitak
- Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Hyun Woo Goo
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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14
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Latus H, Kruppa P, Hofmann L, Reich B, Jux C, Apitz C, Schranz D, Voges I, Khalil M, Gummel K. Impact of aortopulmonary collateral flow and single ventricle morphology on longitudinal hemodynamics in Fontan patients: A serial CMR study. Int J Cardiol 2020; 311:28-34. [DOI: 10.1016/j.ijcard.2020.01.065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 12/06/2019] [Accepted: 01/27/2020] [Indexed: 11/30/2022]
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15
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Hemodynamic Effects of A Simplified Venturi Conduit for Fontan Circulation: A Pilot, In Silico Analysis. Sci Rep 2020; 10:817. [PMID: 31964953 PMCID: PMC6972950 DOI: 10.1038/s41598-020-57634-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 12/31/2019] [Indexed: 12/28/2022] Open
Abstract
Objectives: To study the effects of a self-powered Fontan circulation in both idealized Fontan models and patient-specific models. Methods: In silico, a conduit with a nozzle was introduced from ascending aorta into the anastomosis of superior vena cava and pulmonary artery. Computational fluid dynamics (CFD) simulation was applied to calculate the fluid fields of models. Three 3-dimentional idealized models with different offsets were reconstructed by computer-aided design to evaluate the effects of the self-powered conduit. Furthermore, to validate the effects in patient-specific models, the conduit was introduced to three reconstructed models with different offsets. Results: The pressures at superior venae cavae and inferior venae cavae were decreased in both idealized models (0.4 mmHg) and patient-specific models (0.7 mmHg). In idealized models, the flows to left lungs were decreased (70%) by the jets from the conduits. However, in patient-specific models, the reductions of blood to the left lungs were relatively limited (30%) comparing to idealized models. Conclusions: CFD simulation was applied to analyze the effectiveness of the Fontan self-powered conduit. This self-powered conduit may help to decrease the venae cavae pressures and increase the flow to pulmonary arteries.
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16
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Ono M, Burri M, Mayr B, Anderl L, Cleuziou J, Strbad M, Hager A, Hörer J, Lange R. Flow Dynamics of Bilateral Superior Cavopulomonary Shunts Influence Outcomes After Fontan Completion. Pediatr Cardiol 2020; 41:816-826. [PMID: 32157396 PMCID: PMC7256021 DOI: 10.1007/s00246-020-02318-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Accepted: 02/13/2020] [Indexed: 11/25/2022]
Abstract
Bilateral superior vena cava (SVC), which occurs following bilateral bidirectional cavopulmonary shunt (BCPS), is an anomaly marked by unique hemodynamics. This study aimed to determine its effects on outcomes after Fontan completion. Among 405 patients who underwent BCPS and total cavopulmonary connection (TCPC) between 1997 and 2017, 40 required a bilateral-BCPS. The dominant SVC prior to TCPC was identified according to the direction of blood flow in the central pulmonary artery, and its relationship to the inferior vena cava (IVC) was classified as a concordant or discordant relationship. Preoperative factors were analyzed to identify the risk factors for specific adverse outcomes. The length of intensive care unit (ICU) stay after TCPC was longer in the 40 patients who underwent bilateral-BCPS than in those who underwent unilateral BCPS (p = 0.024), and the survival rate was lower in the former group than in the latter group (p = 0.004). In the patients who underwent bilateral-BCPS, the dominant SVC was concordant with the IVC in 30 patients and discordant in 10 patients. With regard to whether certain morphological, hemodynamic, and flow dynamics-related variables were risk factors for adverse outcomes following TCPC, a discordant relationship between dominant SVC and IVC was identified as an independent risk factor for both a longer ICU stay (p = 0.037, HR 2.370) and worse survival (p = 0.019, HR 13.880). Therefore, in patients with a bilateral SVC who have previously undergone bilateral-BCPS, a discordant relationship between dominant SVC and IVC might contribute to worse outcomes following TCPC.
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Affiliation(s)
- Masamichi Ono
- Department of Pediatric and Congenital Heart Surgery, German Heart Center Munich, Technische Universität München, Lazarettstraße 36, 80636, Munich, Germany.
| | - Melchior Burri
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Lazarettstraße 36, 80636, Munich, Germany
| | - Benedikt Mayr
- Department of Pediatric and Congenital Heart Surgery, German Heart Center Munich, Technische Universität München, Lazarettstraße 36, 80636, Munich, Germany
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Lazarettstraße 36, 80636, Munich, Germany
| | - Lisa Anderl
- Department of Pediatric and Congenital Heart Surgery, German Heart Center Munich, Technische Universität München, Lazarettstraße 36, 80636, Munich, Germany
| | - Julie Cleuziou
- Department of Pediatric and Congenital Heart Surgery, German Heart Center Munich, Technische Universität München, Lazarettstraße 36, 80636, Munich, Germany
| | - Martina Strbad
- Department of Pediatric and Congenital Heart Surgery, German Heart Center Munich, Technische Universität München, Lazarettstraße 36, 80636, Munich, Germany
| | - Alfred Hager
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technische Universität München, Lazarettstraße 36, 80636, Munich, Germany
| | - Jürgen Hörer
- Department of Pediatric and Congenital Heart Surgery, German Heart Center Munich, Technische Universität München, Lazarettstraße 36, 80636, Munich, Germany
| | - Rüdiger Lange
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Lazarettstraße 36, 80636, Munich, Germany
- German Center for Cardiovascular Research, Munich, Germany
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17
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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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18
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Chronic In Vivo Test of a Right Heart Replacement Blood Pump for Failed Fontan Circulation. ASAIO J 2019; 65:593-600. [DOI: 10.1097/mat.0000000000000888] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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19
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Trusty PM, Wei Z, Sales M, Kanter KR, Fogel MA, Yoganathan AP, Slesnick TC. Y-graft modification to the Fontan procedure: Increasingly balanced flow over time. J Thorac Cardiovasc Surg 2019; 159:652-661. [PMID: 31399233 DOI: 10.1016/j.jtcvs.2019.06.063] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 06/03/2019] [Accepted: 06/13/2019] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The use of Y-grafts for Fontan completion is hypothesized to offer more balanced hepatic flow distribution (HFD) and decreased energy losses. The purpose of this study was to evaluate the hemodynamic performance of Y-grafts over time using serial cardiac magnetic resonance data and to compare their performance with extracardiac Fontan connections. METHODS Ten Fontan patients with commercially available Y-graft connections and serial postoperative cardiac magnetic resonance data were included in this study. Patient-specific computational fluid dynamics simulations were used to estimate HFD and energy losses. Y-graft performance was compared with 3 extracardiac conduit Fontan groups (n = 10 for each) whose follow-up times straddle the Y-graft time points. RESULTS Y-graft HFD became significantly more balanced over time (deviation from 50% decreased from 18% ± 14% to 8% ± 8%; P = .015). Total cavopulmonary connection resistance did not significantly change. Y-grafts at 3-year follow-up showed more balanced HFD than the extracardiac conduit groups at both the earlier and later follow-up times. Total cavopulmonary connection resistance was not significantly different between any Y-graft or extracardiac conduit group. CONCLUSIONS Y-grafts showed significantly more balanced HFD over a 3-year follow-up without an increase in total cavopulmonary connection resistance, and therefore may be a valuable option for Fontan completion. Additional follow-up data at longer follow-up times are still needed to thoroughly characterize the potential advantages of Y-graft use.
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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 Wei
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Ga
| | - Megan Sales
- School of Chemical and Biomolecular Engineering, Georgia Institute of Technology, Atlanta, Ga
| | - Kirk R Kanter
- Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | - 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.
| | - Timothy C Slesnick
- Division of Cardiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
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20
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Alsaied T, van der Ven JP, Juggan S, Sleeper LA, Azcue N, Kroft LJ, Powell AJ, Helbing WA, Rathod RH. Relation of Fontan Baffle Stroke Volume to Fontan Failure and Lower Exercise Capacity in Patients With an Atriopulmonary Fontan. Am J Cardiol 2019; 124:151-157. [PMID: 31027653 DOI: 10.1016/j.amjcard.2019.03.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 03/11/2019] [Accepted: 03/15/2019] [Indexed: 02/08/2023]
Abstract
Fontan failure remains a significant problem, especially in patients with an atriopulmonary Fontan. Fontan baffle volume change during the cardiac cycle (Fontan baffle stroke volume) may affect outcomes in Fontan circulation. Assuming that increased Fontan baffle stroke volume is associated with increased energy loss in the baffle, we hypothesized that higher baffle stroke volume is associated with worse exercise capacity and increased incidence of Fontan failure. Patients from 6 centers with an atriopulmonary or lateral tunnel Fontan operation were included if they had a cardiac magnetic resonance (CMR) study and an adequate cardiopulmonary exercise test. Fontan baffle stroke volume was defined as the difference between maximum and minimum Fontan baffle volumes. Fontan failure was defined as death, listing for transplantation, heart failure symptoms requiring medications, or peak VO2 below 16 ml/kg/min. The study group consisted of 107 patients (median age 19 years, interquartile range, 14 to 29 years). Most patients (84%) had lateral tunnel procedure. During a median follow-up period of 6.8 [interquartile range: 3.2 to 8.8] years after the CMR, 25 (23%) patients had Fontan failure (7 deaths, 3 listed for transplantation, and 15 with heart failure symptoms). Predictors of Fontan failure on multivariable analysis were ventricular tachycardia, protein losing enteropathy, and additionally in atriopulmonary Fontan only, larger Fontan baffle stroke volume. Predictors of lower peak VO2 on multivariable analysis were older age at CMR and additionally in atriopulmonary Fontan only, larger Fontan baffle stroke volume. In conclusion, larger Fontan baffle stroke volume was independently associated with lower peak VO2 and Fontan failure in atriopulmonary Fontan.
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21
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Alsaied T, Sleeper LA, Masci M, Ghelani SJ, Azcue N, Geva T, Powell AJ, Rathod RH. Maldistribution of pulmonary blood flow in patients after the Fontan operation is associated with worse exercise capacity. J Cardiovasc Magn Reson 2018; 20:85. [PMID: 30558626 PMCID: PMC6296022 DOI: 10.1186/s12968-018-0505-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 11/09/2018] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Maldistribution of pulmonary artery blood flow (MPBF) is a potential complication in patients who have undergone single ventricle palliation culminating in the Fontan procedure. Cardiovascular magnetic resonance (CMR) is the best modality that can evaluate MPBF in this population. The purpose of this study is to identify the prevalence and associations of MPBF and to determine the impact of MPBF on exercise capacity after the Fontan operation. METHODS This retrospective single-center study included all patients after Fontan operation who had maximal cardiopulmonary exercise test (CPET) and CMR with flow measurements of the branch pulmonary arteries. MPBF was defined as > 20% difference in branch pulmonary artery flow. Exercise capacity was measured as percent of predicted oxygen consumption at peak exercise (% predicted VO2). Linear and logistic regression models were used to determine univariate and multivariable predictors of exercise capacity and correlates of MPBF, respectively. RESULTS A total of 147 patients who had CMR between 1999 and 2017 were included (median age at CMR 21.8 years [interquartile range (IQR) 16.5-30.6]) and the median time between CMR and CPET was 2.8 months [IQR 0-13.8]. Fifty-three patients (36%) had MPBF (95% CI 29-45%). The mean % predicted VO2 was 63 ± 16%. Patients with MPBF had lower mean % predicted VO2 compared to patients without MPBF (60 ± 14% versus 65 ± 16%, p = 0.04). On multivariable analysis, a lower % predicted VO2 was independently associated with longer time since Fontan, higher ventricular mass-to-volume ratio, and MPBF. On multivariable analysis, only compression of the branch pulmonary arteries by the ascending aorta or aortic root was associated with MPBF (OR 6.5, 95% CI 5.6-7.4, p < 0.001). CONCLUSION In patients after the Fontan operation, MPBF is common and is independently associated with lower exercise capacity. MPBF was most likely to be caused by pulmonary artery compression by the aortic root or the ascending aorta. This study identifies MPBF as an important risk factor and as a potential target for therapeutic interventions in this fragile patient population.
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Affiliation(s)
- Tarek Alsaied
- Department of Cardiology, Boston Children’s Hospital, Boston, MA USA
| | - Lynn A. Sleeper
- Department of Cardiology, Boston Children’s Hospital, Boston, MA USA
- Department of Pediatrics, Harvard Medical School, Boston, MA USA
| | - Marco Masci
- Department of Cardiology, Boston Children’s Hospital, Boston, MA USA
| | - Sunil J. Ghelani
- Department of Cardiology, Boston Children’s Hospital, Boston, MA USA
- Department of Pediatrics, Harvard Medical School, Boston, MA USA
| | - Nina Azcue
- Department of Cardiology, Boston Children’s Hospital, Boston, MA USA
| | - Tal Geva
- Department of Cardiology, Boston Children’s Hospital, Boston, MA USA
- Department of Pediatrics, Harvard Medical School, Boston, MA USA
| | - Andrew J. Powell
- Department of Cardiology, Boston Children’s Hospital, Boston, MA USA
- Department of Pediatrics, Harvard Medical School, Boston, MA USA
| | - Rahul H. Rathod
- Department of Cardiology, Boston Children’s Hospital, Boston, MA USA
- Department of Pediatrics, Harvard Medical School, Boston, MA USA
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22
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Jarvis K, Schnell S, Barker AJ, Rose M, Robinson JD, Rigsby CK, Markl M. Caval to pulmonary 3D flow distribution in patients with Fontan circulation and impact of potential 4D flow MRI error sources. Magn Reson Med 2018; 81:1205-1218. [PMID: 30277276 DOI: 10.1002/mrm.27455] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 06/07/2018] [Accepted: 06/26/2018] [Indexed: 11/08/2022]
Abstract
PURPOSE Uneven flow distribution in patients with Fontan circulation is suspected to lead to complications. 4D flow MRI offers evaluation using time-resolved pathlines; however, the potential error is not well understood. The aim of this study was to systematically assess variability in flow distribution caused by well-known sources of error. METHODS 4D flow MRI was acquired in 14 patients with Fontan circulation. Flow distribution was quantified by the % of caval venous flow pathlines reaching the left and right pulmonary arteries. Impact of data acquisition and data processing uncertainties were investigated by (1) probabilistic 4D blood flow tracking at varying noise levels, (2) down-sampling to mimic acquisition at different spatial resolutions, (3) pathline calculation with and without eddy current correction, and (4) varied segmentation of the Fontan geometry to mimic analysis errors. RESULTS Averaged among the cohort, uncertainties accounted for flow distribution errors from noise ≤3.2%, low spatial resolution ≤2.3% to 3.8%, eddy currents ≤6.4%, and inaccurate segmentation ≤3.9% to 9.1% (dilation and erosion, respectively). In a worst-case scenario (maximum additive errors for all 4 sources), flow distribution errors were as high as 22.5%. CONCLUSION Inaccuracies related to postprocessing (segmentation, eddy currents) resulted in the largest potential error (≤15.5% combined) whereas errors related to data acquisition (noise, low spatial resolution) had a lower impact (≤5.5%-7.0% combined). Whereas it is unlikely that these errors will be additive or affect the identification of severe asymmetry, these results illustrate the importance of eddy current correction and accurate segmentation to minimize Fontan flow distribution errors.
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Affiliation(s)
- Kelly Jarvis
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,Department of Biomedical Engineering, McCormick School of Engineering, Northwestern University, Chicago, Illinois
| | - Susanne Schnell
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Alex J Barker
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Michael Rose
- Department of Medical Imaging, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Joshua D Robinson
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,Department of Medical Imaging, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,Division of Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Cynthia K Rigsby
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,Department of Medical Imaging, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,Division of Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Michael Markl
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,Department of Biomedical Engineering, McCormick School of Engineering, Northwestern University, Chicago, Illinois
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23
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Batlivala SP, Briscoe WE, Ebeid MR. Particle embolization of systemic-to-pulmonary collateral artery networks in congenital heart disease: Technique and special considerations. Ann Pediatr Cardiol 2018; 11:181-186. [PMID: 29922015 PMCID: PMC5963232 DOI: 10.4103/apc.apc_93_17] [Citation(s) in RCA: 3] [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] [Indexed: 11/16/2022] Open
Abstract
Systemic-to-pulmonary artery collateral networks commonly develop in patients with single-ventricle physiology and chronic hypoxemia. Although these networks augment pulmonary blood flow, much of the flow is ineffective and contributes to cardiac volume loading. This volume loading can have detrimental effects, especially for single-ventricle patients. Some data suggest that occluding collaterals may improve outcomes after subsequent operations, especially when the volume of collateral flow is significant. Traditional practice has been to coil occlude the feeding vessel. We perform particle embolization of these collateral networks for two primary reasons. First, access to the feeding vessel is not blocked as collaterals may redevelop. Second, particles occlude the most distal connections. Thus, embolization with particles should be considered as an alternative to coil occluding the proximal feeding vessel.
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Affiliation(s)
- Sarosh P Batlivala
- University of Mississippi Medical Center, School of Medicine, Jackson, Mississippi, USA.,Division of Pediatric Cardiology, Batson Children's Hospital, Jackson, Mississippi, USA
| | - William E Briscoe
- University of Mississippi Medical Center, School of Medicine, Jackson, Mississippi, USA
| | - Makram R Ebeid
- University of Mississippi Medical Center, School of Medicine, Jackson, Mississippi, USA.,Division of Pediatric Cardiology, Batson Children's Hospital, Jackson, Mississippi, USA
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24
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Update on the Role of Cardiac Magnetic Resonance Imaging in Congenital Heart Disease. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2017; 19:2. [PMID: 28144782 DOI: 10.1007/s11936-017-0504-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OPINION STATEMENT Cardiac magnetic resonance imaging (CMR) is an important imaging modality in the evaluation of congenital heart diseases (CHD). CMR has several strengths including good spatial and temporal resolutions, wide field-of-view, and multi-planar imaging capabilities. CMR provides significant advantages for imaging in CHD through its ability to measure function, flow and vessel sizes, create three-dimensional reconstructions, and perform tissue characterization, all in a single imaging study. Thus, CMR is the most comprehensive imaging modality available today for the evaluation of CHD. Newer MRI sequences and post-processing tools will allow further development of quantitative methods of analysis, and opens the door for risk stratification in CHD. CMR also can interface with computer modeling, 3D printing, and other methods of understanding the complex anatomic and physiologic relationships in CHD.
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25
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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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26
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Avitabile CM, Whitehead KK, Fogel MA, Kim DW, Kim TS, Rose JD, Keller MS, Fu GL, Harris MA. Holodiastolic Flow Reversal at the Descending Aorta on Cardiac Magnetic Resonance is Neither Sensitive Nor Specific for Significant Aortic Regurgitation in Patients with Congenital Heart Disease. Pediatr Cardiol 2016; 37:1284-9. [PMID: 27312779 DOI: 10.1007/s00246-016-1430-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 05/26/2016] [Indexed: 10/21/2022]
Abstract
Holodiastolic flow reversal in the descending aorta on echocardiogram suggests significant aortic regurgitation. The study aim was to determine whether the presence of holodiastolic flow reversal on cardiac magnetic resonance imaging (MRI) correlates with aortic valve regurgitant fraction. We retrospectively reviewed 166 cardiac MRIs (64 % male, age 14.1 ± 9.5 years) from January 2011 to May 2012 where velocity mapping was acquired at both the aortic valve and the descending aorta at the level of the diaphragm. Descending aorta velocity maps were checked for baseline offset using a static reference region. Holodiastolic flow reversal was defined as flow reversal throughout diastole both before and after baseline correction. Significant aortic regurgitation was defined as regurgitant fraction >10 %. Aortic valve regurgitant fraction was <10 % in 144 patients (Group A), 10-20 % inclusive in 7 patients (Group B), and >20 % in 15 patients (Group C). Though the aortic valve regurgitant fraction was significantly higher for patients with holodiastolic flow reversal versus those without (8.5 ± 14.2 vs. 3.8 ± 6.6 %, p = 0.02), holodiastolic flow reversal was present in 32 Group A patients (22 %). In comparison, 4 Group B patients (57 %) and 7 Group C patients (47 %) had holodiastolic flow reversal. The sensitivity (Groups B and C) was 0.5, and the specificity (Group A) was 0.78. Holodiastolic flow reversal in the descending aorta on cardiac MRI was neither sensitive nor specific for predicting significant aortic regurgitation in this study population. Holodiastolic flow reversal in the absence of significant aortic regurgitation may be a relatively common finding in patients with congenital heart disease.
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Affiliation(s)
- Catherine M Avitabile
- Division of Cardiology, St. Christopher's Hospital for Children, 160 East Erie Avenue, Philadelphia, PA, 19134, USA. .,Division of Cardiology, The Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA, 19104, USA.
| | - Kevin K Whitehead
- Division of Cardiology, The Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA, 19104, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 295 John Morgan Building, 3620 Hamilton Walk, Philadelphia, PA, 19104, USA.,Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, 295 John Morgan Building, 3620 Hamilton Walk, Philadelphia, PA, 19104, USA
| | - Mark A Fogel
- Division of Cardiology, The Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA, 19104, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 295 John Morgan Building, 3620 Hamilton Walk, Philadelphia, PA, 19104, USA.,Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, 295 John Morgan Building, 3620 Hamilton Walk, Philadelphia, PA, 19104, USA
| | - Daniel W Kim
- Division of Cardiology, The Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Timothy S Kim
- Division of Cardiology, The Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Julian D Rose
- Division of Cardiology, The Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Marc S Keller
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 295 John Morgan Building, 3620 Hamilton Walk, Philadelphia, PA, 19104, USA.,Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, 295 John Morgan Building, 3620 Hamilton Walk, Philadelphia, PA, 19104, USA
| | - Gregory L Fu
- Division of Cardiology, The Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Matthew A Harris
- Division of Cardiology, The Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA, 19104, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 295 John Morgan Building, 3620 Hamilton Walk, Philadelphia, PA, 19104, USA.,Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, 295 John Morgan Building, 3620 Hamilton Walk, Philadelphia, PA, 19104, USA
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27
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Rajabzadeh-Oghaz H, Firoozabadi B, Saidi MS, Monjezi M, Navabi Shirazi MA, Malakan Rad E. Pulsatile blood flow in total cavopulmonary connection: a comparison between Y-shaped and T-shaped geometry. Med Biol Eng Comput 2016; 55:213-224. [DOI: 10.1007/s11517-016-1499-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 03/26/2016] [Indexed: 11/30/2022]
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28
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Latus H, Gerstner B, Kerst G, Moysich A, Gummel K, Apitz C, Bauer J, Schranz D. Effect of Inhaled Nitric Oxide on Blood Flow Dynamics in Patients After the Fontan Procedure Using Cardiovascular Magnetic Resonance Flow Measurements. Pediatr Cardiol 2016; 37:504-11. [PMID: 26547436 DOI: 10.1007/s00246-015-1307-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Accepted: 11/02/2015] [Indexed: 10/22/2022]
Abstract
Invasive hemodynamic studies have shown that nitric oxide (NO), a selective pulmonary vasodilator, can lower pulmonary vascular resistance in Fontan patients. Because oximetry-derived flow quantification may be unreliable, we sought to detect changes in blood flow within the Fontan circulation after inhalation of NO using cardiovascular magnetic resonance (CMR). Thirty-three patients (mean age 12.8 ± 7.0 years) after the Fontan procedure underwent CMR as part of their routine clinical assessment. Standard two-dimensional blood flow measurements were performed in the Fontan tunnel, superior vena cava (SVC) and ascending aorta (AAO) before and after inhalation of 40 ppm NO for 8-10 min. Systemic-to-pulmonary collateral (SPC) flow was calculated as AAO - (SVC + tunnel). Heart rate (82 ± 18 to 81 ± 18 bpm; p = 0.31) and transcutaneous oxygen saturations (93 ± 4 to 94 ± 3 %; p = 0.13) did not change under NO inhalation. AAO flow (3.23 ± 0.72 to 3.12 ± 0.79 l/min/m(2); p = 0.08) decreased, tunnel flow (1.58 ± 0.40 to 1.65 ± 0.46 l/min/m(2); p = 0.032) increased, and SVC flow (1.01 ± 0.39 to 1.02 ± 0.40 l/min/m(2); p = 0.50) remained unchanged resulting in higher total caval flow (Qs) (2.59 ± 0.58 to 2.67 ± 0.68 l/min/m(2); p = 0.038). SPC flow decreased significantly from 0.64 ± 0.52 to 0.45 ± 0.51 l/min/m(2) (p = 0.002) and resulted in a significant decrement of the Qp/Qs ratio (1.23 ± 0.23 to 1.15 ± 0.23; p = 0.001). Inhalation of NO in Fontan patients results in significant changes in pulmonary and systemic blood flow. The reduction in SPC flow is accompanied by a net increase in effective systemic blood flow suggesting beneficial effects of pulmonary vasodilators on cardiac output, tissue perfusion and exercise capacity.
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Affiliation(s)
- Heiner Latus
- Pediatric Heart Center, Justus-Liebig-University of Giessen, Feulgenstr. 12, 35392, Giessen, Germany.
| | - Bettina Gerstner
- Pediatric Heart Center, Justus-Liebig-University of Giessen, Feulgenstr. 12, 35392, Giessen, Germany
| | - Gunter Kerst
- Pediatric Heart Center, Justus-Liebig-University of Giessen, Feulgenstr. 12, 35392, Giessen, Germany
| | - Axel Moysich
- Pediatric Heart Center, Justus-Liebig-University of Giessen, Feulgenstr. 12, 35392, Giessen, Germany
| | - Kerstin Gummel
- Pediatric Heart Center, Justus-Liebig-University of Giessen, Feulgenstr. 12, 35392, Giessen, Germany
| | - Christian Apitz
- Pediatric Heart Center, Justus-Liebig-University of Giessen, Feulgenstr. 12, 35392, Giessen, Germany
| | - Juergen Bauer
- Pediatric Heart Center, Justus-Liebig-University of Giessen, Feulgenstr. 12, 35392, Giessen, Germany
| | - Dietmar Schranz
- Pediatric Heart Center, Justus-Liebig-University of Giessen, Feulgenstr. 12, 35392, Giessen, Germany
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29
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Melchiorri AJ, Hibino N, Best CA, Yi T, Lee YU, Kraynak CA, Kimerer LK, Krieger A, Kim P, Breuer CK, Fisher JP. 3D-Printed Biodegradable Polymeric Vascular Grafts. Adv Healthc Mater 2016; 5:319-325. [PMID: 26627057 PMCID: PMC4749136 DOI: 10.1002/adhm.201500725] [Citation(s) in RCA: 104] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 09/29/2015] [Indexed: 01/24/2023]
Abstract
Congenital heart defect interventions may benefit from the fabrication of patient-specific vascular grafts because of the wide array of anatomies present in children with cardiovascular defects. 3D printing is used to establish a platform for the production of custom vascular grafts, which are biodegradable, mechanically compatible with vascular tissues, and support neotissue formation and growth.
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Affiliation(s)
- AJ Melchiorri
- Fischell Department of Bioengineering, University of Maryland, College Park, MD 20742
| | - N Hibino
- Tissue Engineering Program and Surgical Research, Nationwide Children's Hospital, Columbus, OH 43205
- Department of Cardiothoracic Surgery, Nationwide Children's Hospital, Columbus, OH 43205
| | - CA Best
- Tissue Engineering Program and Surgical Research, Nationwide Children's Hospital, Columbus, OH 43205
| | - T Yi
- Tissue Engineering Program and Surgical Research, Nationwide Children's Hospital, Columbus, OH 43205
| | - YU Lee
- Tissue Engineering Program and Surgical Research, Nationwide Children's Hospital, Columbus, OH 43205
| | - CA Kraynak
- Fischell Department of Bioengineering, University of Maryland, College Park, MD 20742
| | - LK Kimerer
- Fischell Department of Bioengineering, University of Maryland, College Park, MD 20742
| | - A Krieger
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Health System, Washington, DC 200010
| | | | - CK Breuer
- Department of Cardiothoracic Surgery, Nationwide Children's Hospital, Columbus, OH 43205
| | - JP Fisher
- Fischell Department of Bioengineering, University of Maryland, College Park, MD 20742
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KAWASAKI SHIORI, NAKANISHI KEISUKE, TAKAHASHI KEN, AMANO ATSUSHI. Evaluation of a Venous Unifocalization of the Bilateral Superior Vena Cava and Comparison with the Bilateral Bidirectional Glenn Procedure. JUNTENDO IJI ZASSHI 2016. [DOI: 10.14789/jmj.62.141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- SHIORI KAWASAKI
- Department of Cardiovascular Surgery, Juntendo University Faculty of Medicine
| | - KEISUKE NAKANISHI
- Department of Cardiovascular Surgery, Juntendo University Faculty of Medicine
| | - KEN TAKAHASHI
- Department of Pediatrics, Juntendo University Faculty of Medicine
| | - ATSUSHI AMANO
- Department of Cardiovascular Surgery, Juntendo University Faculty of Medicine
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31
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Rajabzadeh Oghaz H, Firoozabadi B, Saidi M, Monjezi M, Navabi Shirazi M, Malakan Rad E. Evaluation of a novel extra-cardiac Fontan procedure with implantation of a biocompatible membrane. Ing Rech Biomed 2015. [DOI: 10.1016/j.irbm.2015.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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32
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Vallecilla C, Khiabani RH, Trusty P, Sandoval N, Fogel M, Briceño JC, Yoganathan AP. Exercise capacity in the Bidirectional Glenn physiology: Coupling cardiac index, ventricular function and oxygen extraction ratio. J Biomech 2015; 48:1997-2004. [PMID: 25913242 PMCID: PMC4492809 DOI: 10.1016/j.jbiomech.2015.03.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 03/18/2015] [Accepted: 03/27/2015] [Indexed: 11/25/2022]
Abstract
In Bi-directional Glenn (BDG) physiology, the superior systemic circulation and pulmonary circulation are in series. Consequently, only blood from the superior vena cava is oxygenated in the lungs. Oxygenated blood then travels to the ventricle where it is mixed with blood returning from the lower body. Therefore, incremental changes in oxygen extraction ratio (OER) could compromise exercise tolerance. In this study, the effect of exercise on the hemodynamic and ventricular performance of BDG physiology was investigated using clinical patient data as inputs for a lumped parameter model coupled with oxygenation equations. Changes in cardiac index, Qp/Qs, systemic pressure, oxygen extraction ratio and ventricular/vascular coupling ratio were calculated for three different exercise levels. The patient cohort (n=29) was sub-grouped by age and pulmonary vascular resistance (PVR) at rest. It was observed that the changes in exercise tolerance are significant in both comparisons, but most significant when sub-grouped by PVR at rest. Results showed that patients over 2 years old with high PVR are above or close to the upper tolerable limit of OER (0.32) at baseline. Patients with high PVR at rest had very poor exercise tolerance while patients with low PVR at rest could tolerate low exercise conditions. In general, ventricular function of SV patients is too poor to increase CI and fulfill exercise requirements. The presented mathematical model provides a framework to estimate the hemodynamic performance of BDG patients at different exercise levels according to patient specific data.
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Affiliation(s)
| | - Reza H Khiabani
- Wallace H Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
| | - Phillip Trusty
- Wallace H Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
| | - Néstor Sandoval
- Department of Cardiovascular Surgery, Fundación Cardioinfantil, Bogotá, Colombia
| | - Mark Fogel
- Division of Cardiology, Children׳s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Juan Carlos Briceño
- Group of Biomedical Engineering, Universidad de los Andes, Bogotá, Colombia; Research Department, Fundación Cardioinfantil, Bogotá, Colombia
| | - Ajit P Yoganathan
- Wallace H Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA.
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Whitehead KK, Harris MA, Glatz AC, Gillespie MJ, DiMaria MV, Harrison NE, Dori Y, Keller MS, Rome JJ, Fogel MA. Status of systemic to pulmonary arterial collateral flow after the fontan procedure. Am J Cardiol 2015; 115:1739-45. [PMID: 25907503 DOI: 10.1016/j.amjcard.2015.03.022] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 03/10/2015] [Accepted: 03/10/2015] [Indexed: 10/23/2022]
Abstract
The investigators recently validated a method of quantifying systemic-to-pulmonary arterial collateral flow using phase-contrast magnetic resonance imaging velocity mapping. Cross-sectional data suggest decreased collateral flow in patients with total cavopulmonary connections (TCPCs) compared with those with superior cavopulmonary connections (SCPCs). However, no studies have examined serial changes in collateral flow from SCPCs to TCPCs in the same patients. The aim of this study was to examine differences in collateral flow between patients with SCPCs and those with TCPCs. Collateral flow was quantified by 2 independent measures from 250 single-ventricle studies in 219 different patients (115 SCPC and 135 TCPC studies, 31 patients with both) and 18 controls, during routine studies using through-plane phase-contrast magnetic resonance imaging. Collateral flow was indexed to body surface area, aortic flow, and pulmonary venous flow. Regardless of indexing method, SCPC patients had significantly higher collateral flow than TCPC patients (1.64 ± 0.8 vs 1.03 ± 0.8 L/min/m(2), p <0.001). In 31 patients who underwent serial examinations, collateral flow as a fraction of aortic flow increased early after TCPC completion. In TCPC patients, indexed collateral flow demonstrated a significant negative correlation with time from TCPC. In conclusion, SCPC and TCPC patients demonstrate substantial collateral flow, with SCPC patients having higher collateral flow than TCPC patients overall. On the basis of the paired subset analysis, collateral flow does not decrease in the short term after TCPC completion and trends toward an increase. In the long term, however, collateral flow decreases over time after TCPC completion.
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34
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Jhun CS, Newswanger R, Cysyk JP, Stauffer M, Weiss W, Rosenberg G. Fontan Circulatory Assist Device1. J Med Device 2015. [DOI: 10.1115/1.4030136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Choon-Sik Jhun
- Department of Surgery, College of Medicine, Penn State University, State College, PA 16801
| | - Raymond Newswanger
- Department of Surgery, College of Medicine, Penn State University, State College, PA 16801
| | - Joshua P. Cysyk
- Department of Surgery, College of Medicine, Penn State University, State College, PA 16801
| | - Megan Stauffer
- Department of Surgery, College of Medicine, Penn State University, State College, PA 16801
| | - William Weiss
- Department of Surgery, College of Medicine, Penn State University, State College, PA 16801
- Department of Biomedical Engineering, College of Engineering, Penn State University, State College, PA 16801
| | - Gerson Rosenberg
- Department of Surgery, College of Medicine, Penn State University, State College, PA 16801
- Department of Biomedical Engineering, College of Engineering, Penn State University, State College, PA 16801
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35
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Navarro-Aguilar V, Flors L, Calvillo P, Merlos P, Buendía F, Igual B, Melero-Ferrer J, Soriano JR, Leiva-Salinas C. Fontan procedure: imaging of normal post-surgical anatomy and the spectrum of cardiac and extracardiac complications. Clin Radiol 2015; 70:295-303. [DOI: 10.1016/j.crad.2014.10.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 09/27/2014] [Accepted: 10/13/2014] [Indexed: 10/24/2022]
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Assessment of Hemodynamics by Magnetic Resonance Imaging. CONGENIT HEART DIS 2015. [DOI: 10.1007/978-4-431-54355-8_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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37
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Vallecilla C, Khiabani RH, Sandoval N, Fogel M, Briceño JC, Yoganathan AP. Effect of high altitude exposure on the hemodynamics of the bidirectional Glenn physiology: modeling incremented pulmonary vascular resistance and heart rate. J Biomech 2014; 47:1846-52. [PMID: 24755120 DOI: 10.1016/j.jbiomech.2014.03.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 01/22/2014] [Accepted: 03/11/2014] [Indexed: 10/25/2022]
Abstract
The considerable blood mixing in the bidirectional Glenn (BDG) physiology further limits the capacity of the single working ventricle to pump enough oxygenated blood to the circulatory system. This condition is exacerbated under severe conditions such as physical activity or high altitude. In this study, the effect of high altitude exposure on hemodynamics and ventricular function of the BDG physiology is investigated. For this purpose, a mathematical approach based on a lumped parameter model was developed to model the BDG circulation. Catheterization data from 39 BDG patients at stabilized oxygen conditions was used to determine baseline flows and pressures for the model. The effect of high altitude exposure was modeled by increasing the pulmonary vascular resistance (PVR) and heart rate (HR) in increments up to 80% and 40%, respectively. The resulting differences in vascular flows, pressures and ventricular function parameters were analyzed. By simultaneously increasing PVR and HR, significant changes (p <0.05) were observed in cardiac index (11% increase at an 80% PVR and 40% HR increase) and pulmonary flow (26% decrease at an 80% PVR and 40% HR increase). Significant increase in mean systemic pressure (9%) was observed at 80% PVR (40% HR) increase. The results show that the poor ventricular function fails to overcome the increased preload and implied low oxygenation in BDG patients at higher altitudes, especially for those with high baseline PVRs. The presented mathematical model provides a framework to estimate the hemodynamic performance of BDG patients at different PVR increments.
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Affiliation(s)
| | - Reza H Khiabani
- Wallace H Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, 313 Ferst Dr., Atlanta, GA 30332, USA
| | - Néstor Sandoval
- Department of Cardiovascular Surgery, Fundación Cardioinfantil, Bogotá, Colombia
| | - Mark Fogel
- Division of Cardiology, Children׳s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Juan Carlos Briceño
- Group of Biomedical Engineering, Universidad de los Andes, Bogotá, Colombia; Research Department, Fundación Cardioinfantil, Bogotá, Colombia
| | - Ajit P Yoganathan
- Wallace H Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, 313 Ferst Dr., Atlanta, GA 30332, USA.
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Latus H, Gummel K, Diederichs T, Bauer A, Rupp S, Kerst G, Jux C, Akintuerk H, Schranz D, Apitz C. Aortopulmonary collateral flow is related to pulmonary artery size and affects ventricular dimensions in patients after the fontan procedure. PLoS One 2013; 8:e81684. [PMID: 24303064 PMCID: PMC3841134 DOI: 10.1371/journal.pone.0081684] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Accepted: 10/15/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Aortopulmonary collaterals (APCs) are frequently found in patients with a single-ventricle (SV) circulation. However, knowledge about the clinical significance of the systemic-to-pulmonary shunt flow in patients after the modified Fontan procedure and its potential causes is limited. Accordingly, the aim of our study was to detect and quantify APC flow using cardiovascular magnetic resonance (CMR) and assess its impact on SV volume and function as well as to evaluate the role of the size of the pulmonary arteries in regard to the development of APCs. METHODS 60 patients (mean age 13.3 ± 6.8 years) after the Fontan procedure without patent tunnel fenestration underwent CMR as part of their routine clinical assessment that included ventricular functional analysis and flow measurements in the inferior vena cava (IVC), superior vena cava (SVC) and ascending aorta (Ao). APC flow was quantified using the systemic flow estimator: (Ao) - (IVC + SVC). Pulmonary artery index (Nakata index) was calculated as RPA + LPA area/body surface area using contrast enhanced MR angiography. The patient cohort was divided into two groups according to the median APC flow: group 1 < 0.495 l/min/m(2) and group 2 > 0.495 l/min/m(2). RESULTS Group 1 patients had significant smaller SV enddiastolic (71 ± 16 vs 87 ± 25 ml/m(2); p=0.004) and endsystolic volumes (29 ± 11 vs 40 ± 21 ml/m(2); p=0.02) whereas ejection fraction (59 ± 9 vs 56 ± 13%; p=0.38) differed not significantly. Interestingly, pulmonary artery size showed a significant inverse correlation with APC flow (r=-0.50, p=0.002). CONCLUSIONS Volume load due to APC flow in Fontan patients affected SV dimensions, but did not result in an impairment of SV function. APC flow was related to small pulmonary artery size, suggesting that small pulmonary arteries represent a potential stimulus for the development of APCs.
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Affiliation(s)
- Heiner Latus
- Pediatric Heart Center, Justus-Liebig University Clinic, Giessen, Germany
- * E-mail:
| | - Kerstin Gummel
- Pediatric Heart Center, Justus-Liebig University Clinic, Giessen, Germany
| | - Tristan Diederichs
- Pediatric Heart Center, Justus-Liebig University Clinic, Giessen, Germany
| | - Anna Bauer
- Pediatric Heart Center, Justus-Liebig University Clinic, Giessen, Germany
| | - Stefan Rupp
- Pediatric Heart Center, Justus-Liebig University Clinic, Giessen, Germany
| | - Gunter Kerst
- Pediatric Heart Center, Justus-Liebig University Clinic, Giessen, Germany
| | - Christian Jux
- Department of Pediatric Cardiology, University Children’s Hospital Muenster, Muenster, Germany
| | - Hakan Akintuerk
- Pediatric Heart Center, Justus-Liebig University Clinic, Giessen, Germany
| | - Dietmar Schranz
- Pediatric Heart Center, Justus-Liebig University Clinic, Giessen, Germany
| | - Christian Apitz
- Pediatric Heart Center, Justus-Liebig University Clinic, Giessen, Germany
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Hong H, Dur O, Zhang H, Zhu Z, Pekkan K, Liu J. Fontan conversion templates: patient-specific hemodynamic performance of the lateral tunnel versus the intraatrial conduit with fenestration. Pediatr Cardiol 2013; 34:1447-54. [PMID: 23475255 DOI: 10.1007/s00246-013-0669-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Accepted: 02/11/2013] [Indexed: 11/25/2022]
Abstract
Intraatrial-conduit Fontan is considered a modification of both extracardiac and lateral-tunnel Fontan. In this study, the patient-specific hemodynamic performance of intraatrial-conduit and lateral-tunnel Fontan with fenestration, considered as conversion templates, was investigated based on the authors' patient cohort. Pulsatile computational fluid dynamics simulations were performed using patient-specific models of intraatrial-conduit and lateral-tunnel Fontan patients. Real-time "simultaneous" inferior and superior vena cava, pulmonary artery, and fenestration flow waveforms were acquired from ultrasound. Multiple hemodynamic performance indices were investigated, with particular focus on evaluation of the pulsatile flow performance. Power loss inside the lateral-tunnel Fontan appeared to be significantly higher than with the intraatrial-conduit Fontan for patient-specific cardiac output and normalized connection size. Inclusion of the 4-mm fenestration at a 0.24 L/min mean flow resulted in a lower cavopulmonary pressure gradient and less time-averaged power loss for both Fontan connections. Flow structures within the intraatrial conduit were notability more uniform than within the lateral tunnel. Hepatic flow majorly favored the left lung in both surgical connections: conversion from lateral-tunnel to intraatrial-conduit Fontan resulted in better hemodynamics with less power loss, a lower pressure gradient, and fewer stagnant flow zones along the conduit. This patient-specific computational case study demonstrated superior hemodynamics of intraatrial-conduit Fontan over those of lateral-tunnel Fontan with or without fenestration and improved performance after conversion of the lateral tunnel to the intraatrial conduit. The geometry-specific effect of the nonuniform hepatic flow distribution may motivate new rationales for the surgical design.
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Affiliation(s)
- Haifa Hong
- The Cardiothoracic Surgery Department, Shanghai Children's Medical Center, Medical School Shanghai Jiaotong University, 1678 Dongfang Road, Shanghai 200127, China
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40
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Voges I, Jerosch-Herold M, Hart C, Scheewe J, Gabbert DD, Pardun E, Kramer HH, Rickers C. Anatomical and functional assessment of the intra-atrial lateral tunnel in the Fontan circulation. Eur J Cardiothorac Surg 2013; 44:462-7. [PMID: 23447475 DOI: 10.1093/ejcts/ezt066] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES In patients after completion of the total cavopulmonary connection (TCPC) with an intra-atrial lateral tunnel, deviations of the tunnel from an ideal straight tubular shape were observed. However, little is known about frequency and adverse effects of such shape deviations. We sought to analyse tunnel anatomy, dimensions and blood flow using cardiac magnetic resonance imaging (CMR). METHODS Fifty-four patients with hypoplastic left heart syndrome (HLHS; mean age 6.0 ± 2.4 years) underwent CMR with gradient-echo cine sequences, 2D- and 3D-phase-contrast imaging. We analysed anatomy, diameters, cross-sectional areas, volumes and blood flow of the tunnel. RESULTS Twenty-five patients had a tubular tunnel. In 29 patients, bulging and/or narrowing of the tunnel were present. Cross-sectional areas and volumes of the tunnel were not significantly different between the two groups. There were also no differences for the mean blood flow and the mean and maximal flow velocity (P = 0.05-0.6). In all the patients, the normalized tunnel volume was related to age (r = 0.44; P = 0.002) and body surface area (BSA; r = 0.42; P = 0.005). The mean tunnel blood flow correlated with age (r = 0.73; P = 0.001) and BSA (r = 0.83; P < 0.0001). CONCLUSIONS A considerable percentage of patients with an intra-atrial lateral tunnel develop mild deviations of the tunnel from ideal tubular shape. The correlation between tunnel volume and mean blood flow with age and BSA suggests that the capacity of the tunnel adjusts to body growth, independent of tunnel shapes that deviate from a fluid-dynamically favourable shape. Follow-up CMRs are needed to detect long-term effects of irregular tunnel shapes on flow dynamics.
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Affiliation(s)
- Inga Voges
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Kiel, Germany
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Dori Y, Glatz AC, Hanna BD, Gillespie MJ, Harris MA, Keller MS, Fogel MA, Rome JJ, Whitehead KK. Acute effects of embolizing systemic-to-pulmonary arterial collaterals on blood flow in patients with superior cavopulmonary connections: a pilot study. Circ Cardiovasc Interv 2013; 6:101-6. [PMID: 23322742 DOI: 10.1161/circinterventions.112.972265] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The significance and optimal treatment of systemic-to-pulmonary arterial collateral (SPC) vessels in single ventricle patients are poorly understood. The acute efficacy of SPC embolization has not been demonstrated in a quantifiable fashion. We sought to assess the acute efficacy of SPC embolization on blood flow as quantified by phase contrast magnetic resonance imaging and hypothesized that embolization acutely decreases SPC flow and increases systemic blood flow (Q(S)). METHODS AND RESULTS Six superior cavopulmonary connection patients underwent SPC flow quantification by phase contrast magnetic resonance imaging, including quantification of superior and inferior caval, total pulmonary artery, total pulmonary vein, ascending and descending aortic flows (Q(SVC), Q(IVC), Q(PA), Q(PV), Q(Ao), and Q(Dao), respectively), both immediately before and after cardiac catheterization with coil and particle embolization of angiographically evident SPC vessels. All studies were performed under a single anesthetic. After embolization, we found a significant decrease in SPC flow of 0.9 (range, 0.6-1.3) L/(min·m(2)) (P=0.03); a median reduction of 47% (range, 32-60). There was a significant decrease in the median Q(P):Q(S) from 1.3 before to 0.8 after embolization (P=0.03), and an increase in Q(S) from a median of 3.4 to 4.4 L/(min·m(2)) (P<0.05), and Q(SVC) from a median of 1.7 to 2.3 L/(min·m(2)) (P=0.03). CONCLUSIONS We report on the acute efficacy of SPC embolization, demonstrating a significant decrease in SPC flow and Q(P):Q(S) and increase in Q(SVC) and Q(S). Further studies are needed to assess the durability of the procedure and the effect on Fontan and longer-term outcomes.
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Affiliation(s)
- Yoav Dori
- Department of Radiology, Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA. ..edu
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Grosse-Wortmann L, Dragulescu A, Drolet C, Chaturvedi R, Kotani Y, Mertens L, Taylor K, La Rotta G, van Arsdell G, Redington A, Yoo SJ. Determinants and clinical significance of flow via the fenestration in the Fontan pathway: a multimodality study. Int J Cardiol 2012; 168:811-7. [PMID: 23164583 DOI: 10.1016/j.ijcard.2012.10.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Revised: 09/19/2012] [Accepted: 10/07/2012] [Indexed: 11/18/2022]
Abstract
BACKGROUND The use of a fenestration in the Fontan pathway remains controversial, partly because its hemodynamic effects and clinical consequences are insufficiently understood. The objective of this study was to quantify the magnitude of fenestration flow and to characterize its hemodynamic consequences after an intermediate interval after surgery. METHODS Twenty three patients with a fenestrated extracardiac conduit prospectively underwent investigation by cardiac magnetic resonance (CMR), echocardiography, and invasive manometry under the same general anesthetic 12 ± 4 months after Fontan surgery. Fenestration flow was determined using phase contrast CMR by subtracting flow in the Fontan pathway above the fenestration from Fontan flow below the fenestration. RESULTS Fenestration flow constituted a mean of 31 ± 12% (range 8-50%) of ventricular preload. It was associated with a lower Qp/Qs (r = -0.64, p=0.001) and oxygen saturation (r = -0.74, p<0.0001). Fenestration flow volume was correlated with pulmonary vascular resistance (r = 0.45, p = 0.04) and markers of ventricular diastolic function (early diastolic strain rate r = 0.57, p = 0.008 and ventricular untwist rate r = 0.54, p = 0.02). In 14 patients (61%) all of the net inferior vena cava flow and part of the superior vena cava flow were diverted into the systemic atrium and did not reach the lungs. CONCLUSIONS Fenestration flow can be measured accurately with CMR. In two-thirds of the patients not only all of the inferior vena cava flow, but also some of the superior vena cava flow is diverted through the fenestration. Fenestration flow is driven by a balance between pulmonary vascular resistance and early diastolic ventricular function.
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Affiliation(s)
- Lars Grosse-Wortmann
- The Labatt Family Heart Centre and Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, Canada.
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Valverde I, Nordmeyer S, Uribe S, Greil G, Berger F, Kuehne T, Beerbaum P. Systemic-to-pulmonary collateral flow in patients with palliated univentricular heart physiology: measurement using cardiovascular magnetic resonance 4D velocity acquisition. J Cardiovasc Magn Reson 2012; 14:25. [PMID: 22541134 PMCID: PMC3438058 DOI: 10.1186/1532-429x-14-25] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Accepted: 04/12/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Systemic-to-pulmonary collateral flow (SPCF) may constitute a risk factor for increased morbidity and mortality in patients with single-ventricle physiology (SV). However, clinical research is limited by the complexity of multi-vessel two-dimensional (2D) cardiovascular magnetic resonance (CMR) flow measurements. We sought to validate four-dimensional (4D) velocity acquisition sequence for concise quantification of SPCF and flow distribution in patients with SV. METHODS 29 patients with SV physiology prospectively underwent CMR (1.5 T) (n = 14 bidirectional cavopulmonary connection [BCPC], age 2.9 ± 1.3 years; and n = 15 Fontan, 14.4 ± 5.9 years) and 20 healthy volunteers (age, 28.7 ± 13.1 years) served as controls. A single whole-heart 4D velocity acquisition and five 2D flow acquisitions were performed in the aorta, superior/inferior caval veins, right/left pulmonary arteries to serve as gold-standard. The five 2D velocity acquisition measurements were compared with 4D velocity acquisition for validation of individual vessel flow quantification and time efficiency. The SPCF was calculated by evaluating the disparity between systemic (aortic minus caval vein flows) and pulmonary flows (arterial and venour return). The pulmonary right to left and the systemic lower to upper body flow distribution were also calculated. RESULTS The comparison between 4D velocity and 2D flow acquisitions showed good Bland-Altman agreement for all individual vessels (mean bias, 0.05 ± 0.24 l/min/m2), calculated SPCF (-0.02 ± 0.18 l/min/m2) and significantly shorter 4D velocity acquisition-time (12:34 min/17:28 min,p < 0.01). 4D velocity acquisition in patients versus controls revealed (1) good agreement between systemic versus pulmonary estimator for SPFC; (2) significant SPCF in patients (BCPC 0.79 ± 0.45 l/min/m2; Fontan 0.62 ± 0.82 l/min/m2) and not in controls (0.01 + 0.16 l/min/m2), (3) inverse relation of right/left pulmonary artery perfusion and right/left SPCF (Pearson = -0.47,p = 0.01) and (4) upper to lower body flow distribution trend related to the weight (r = 0.742, p < 0.001) similar to the controls. CONCLUSIONS 4D velocity acquisition is reliable, operator-independent and more time-efficient than 2D flow acquisition to quantify SPCF. There is considerable SPCF in BCPC and Fontan patients. SPCF was more pronounced towards the respective lung with less pulmonary arterial flow suggesting more collateral flow where less anterograde branch pulmonary artery perfusion.
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Affiliation(s)
- Israel Valverde
- Division of Imaging Sciences and Biomedical Engineering, King’s College London. NIHR Biomedical Research Centre at Guy’s & St Thomas’ NHS Foundation Trust, 4th Floor Lambeth Wing, St. Thomas Hospital, SE1 7EH, London, UK
- Department of Congenital Heart Diseases, Evelina Children’s Hospital, Guy’s & St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, UK
| | - Sarah Nordmeyer
- Department of Congenital Heart Disease and Paediatric Cardiology, Deutsches Herzzentrum Berlin, Unit of Cardiovascular Imaging, Berlin, Germany
| | - Sergio Uribe
- Radiology Department, Pontificia Universidad Católica de Chile, Santiago de Chile, Chile
| | - Gerald Greil
- Division of Imaging Sciences and Biomedical Engineering, King’s College London. NIHR Biomedical Research Centre at Guy’s & St Thomas’ NHS Foundation Trust, 4th Floor Lambeth Wing, St. Thomas Hospital, SE1 7EH, London, UK
- Department of Congenital Heart Diseases, Evelina Children’s Hospital, Guy’s & St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, UK
| | - Felix Berger
- Department of Congenital Heart Disease and Paediatric Cardiology, Deutsches Herzzentrum Berlin, Unit of Cardiovascular Imaging, Berlin, Germany
- Department of Pediatric Cardiology, Charité Universitaetsmedizin Berlin, Berlin, Germany
| | - Titus Kuehne
- Department of Congenital Heart Disease and Paediatric Cardiology, Deutsches Herzzentrum Berlin, Unit of Cardiovascular Imaging, Berlin, Germany
- Department of Pediatric Cardiology, Charité Universitaetsmedizin Berlin, Berlin, Germany
| | - Philipp Beerbaum
- Division of Imaging Sciences and Biomedical Engineering, King’s College London. NIHR Biomedical Research Centre at Guy’s & St Thomas’ NHS Foundation Trust, 4th Floor Lambeth Wing, St. Thomas Hospital, SE1 7EH, London, UK
- Department of Congenital Heart Diseases, Evelina Children’s Hospital, Guy’s & St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, UK
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Feinstein JA, Benson DW, Dubin AM, Cohen MS, Maxey DM, Mahle WT, Pahl E, Villafañe J, Bhatt AB, Peng LF, Johnson BA, Marsden AL, Daniels CJ, Rudd NA, Caldarone CA, Mussatto KA, Morales DL, Ivy DD, Gaynor JW, Tweddell JS, Deal BJ, Furck AK, Rosenthal GL, Ohye RG, Ghanayem NS, Cheatham JP, Tworetzky W, Martin GR. Hypoplastic left heart syndrome: current considerations and expectations. J Am Coll Cardiol 2012; 59:S1-42. [PMID: 22192720 PMCID: PMC6110391 DOI: 10.1016/j.jacc.2011.09.022] [Citation(s) in RCA: 349] [Impact Index Per Article: 29.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Revised: 09/06/2011] [Accepted: 09/20/2011] [Indexed: 01/25/2023]
Abstract
In the recent era, no congenital heart defect has undergone a more dramatic change in diagnostic approach, management, and outcomes than hypoplastic left heart syndrome (HLHS). During this time, survival to the age of 5 years (including Fontan) has ranged from 50% to 69%, but current expectations are that 70% of newborns born today with HLHS may reach adulthood. Although the 3-stage treatment approach to HLHS is now well founded, there is significant variation among centers. In this white paper, we present the current state of the art in our understanding and treatment of HLHS during the stages of care: 1) pre-Stage I: fetal and neonatal assessment and management; 2) Stage I: perioperative care, interstage monitoring, and management strategies; 3) Stage II: surgeries; 4) Stage III: Fontan surgery; and 5) long-term follow-up. Issues surrounding the genetics of HLHS, developmental outcomes, and quality of life are addressed in addition to the many other considerations for caring for this group of complex patients.
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Affiliation(s)
- Jeffrey A Feinstein
- Department of Pediatrics, Stanford University School of Medicine, Lucile Salter Packard Children's Hospital, Palo Alto, California 94304, USA.
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Ntsinjana HN, Hughes ML, Taylor AM. The role of cardiovascular magnetic resonance in pediatric congenital heart disease. J Cardiovasc Magn Reson 2011; 13:51. [PMID: 21936913 PMCID: PMC3210092 DOI: 10.1186/1532-429x-13-51] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2011] [Accepted: 09/21/2011] [Indexed: 12/13/2022] Open
Abstract
Cardiovascular magnetic resonance (CMR) has expanded its role in the diagnosis and management of congenital heart disease (CHD) and acquired heart disease in pediatric patients. Ongoing technological advancements in both data acquisition and data presentation have enabled CMR to be integrated into clinical practice with increasing understanding of the advantages and limitations of the technique by pediatric cardiologists and congenital heart surgeons. Importantly, the combination of exquisite 3D anatomy with physiological data enables CMR to provide a unique perspective for the management of many patients with CHD. Imaging small children with CHD is challenging, and in this article we will review the technical adjustments, imaging protocols and application of CMR in the pediatric population.
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Affiliation(s)
- Hopewell N Ntsinjana
- Centre for Cardiovascular MR, UCL Institute of Cardiovascular Sciences, Great Ormond Street Hospital for Children, London, UK
| | - Marina L Hughes
- Centre for Cardiovascular MR, UCL Institute of Cardiovascular Sciences, Great Ormond Street Hospital for Children, London, UK
| | - Andrew M Taylor
- Centre for Cardiovascular MR, UCL Institute of Cardiovascular Sciences, Great Ormond Street Hospital for Children, London, UK
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One and a Half Ventricle Repair in Adults: Postoperative Hemodynamic Assessment Using Phase-Contrast Magnetic Resonance Imaging. Ann Thorac Surg 2011; 92:193-8. [DOI: 10.1016/j.athoracsur.2011.03.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2010] [Revised: 02/28/2011] [Accepted: 03/07/2011] [Indexed: 11/24/2022]
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Benk C, Lorenz R, Beyersdorf F, Bock J, Klemm R, Korvink JG, Markl M. Three-dimensional flow characteristics in ventricular assist devices: impact of valve design and operating conditions. J Thorac Cardiovasc Surg 2011; 142:1019-26. [PMID: 21397258 DOI: 10.1016/j.jtcvs.2011.01.058] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2010] [Revised: 01/10/2011] [Accepted: 01/29/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The use of paracorporeal ventricular assist devices has become a well-established procedure for patients with cardiogenic shock. However, implantation of ventricular assist devices is often associated with severe complications, such as thrombosis inside the ventricular assist device and subsequent embolic events. It was the purpose of this study to use flow-sensitive 4-dimensional magnetic resonance imaging for a detailed analysis of the 3-dimensional (3D) flow dynamics inside a clinical routine ventricular assist device and to study the effect of different system adjustments and a new valve design on flow patterns. METHODS A routinely used clinical paracorporeal ventricular assist device was integrated into a magnetic resonance-compatible mock loop. Flow-sensitive 3D magnetic resonance imaging was performed to measure time-resolved 3-directional flow velocities (spatial resolution ∼ 1.2 mm, temporal resolution = 42.4 ms) in the entire device under ideal conditions (full fill, full empty, ejection fraction = 88%), insufficient filling (ejection fraction = 81%), and insufficient emptying (ejection fraction = 67%) of the pump chamber. In addition, a new valve design was evaluated. Flexible control and monitoring of pressures at inlet and outlet were used to generate realistic boundary conditions. RESULTS Flow pattern changes for different operating conditions were clearly identified and included reduced velocities during systolic outflow for impaired filling (78% reduction in pump flow compared with optimal operating conditions) and impaired clearing of the pump chamber for insufficient emptying (52% reduction). For all operating conditions, 3D visualization revealed vortex flow inside the ventricular assist device at typical locations of thrombus formation near the valve systems. Most noticeably, the new valve design provided similar global ventricular assist device function (pump flow 3.6 L/min), but vortex formation was eliminated. CONCLUSIONS The results of this study provide insight into the mechanisms underlying possible thrombus formation inside a ventricular assist device and the effect of different system adjustments. The presented methods may permit the optimization of future ventricular assist device systems with respect to optimal flow conditions.
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Affiliation(s)
- Christoph Benk
- Department of Cardiovascular Surgery, University Hospital, Freiburg, Germany
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Chin AJ, Whitehead KK, Watrous RL. Insights After 40 Years of the Fontan Operation. World J Pediatr Congenit Heart Surg 2010; 1:328-43. [DOI: 10.1177/2150135110379623] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Fontan’s visionary operation and its modifications over the ensuing decades have re-established nonturbulent flow and substantially reduced cyanosis for patients with severe hypoplasia of one ventricle. However, a long list of largely unexpected sequelae has emerged over the last 40 years. Although it is not difficult to understand how care providers could become discouraged, a number of myths have arisen, which we will attempt to dispel with real-world counterexamples as well as with lessons learned from other disciplines: evolutionary, developmental, and computational biology. We argue that distinctive biochemical abnormalities pointing to dysfunction in multiple organs, including the largest organ system in the body, the endothelium, occur long before grossly observable changes in cardiac imaging can be recognized. With a rational redesign of both our surveillance scheme and our wellness strategies, we hope that Fontan survivors and their families, as well as physicians, nurses, and therapists, will see why Fontan’s principle remains just as vibrant today as it was in 1971.
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Affiliation(s)
- Alvin J. Chin
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kevin K. Whitehead
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Raymond L. Watrous
- Department of Electrical and Systems Engineering, University of Pennsylvania School of Engineering and Applied Science, Philadelphia, Pennsylvania
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Brown DW, Powell AJ, Geva T. Imaging complex congenital heart disease — functional single ventricle, the Glenn circulation and the Fontan circulation: A multimodality approach. PROGRESS IN PEDIATRIC CARDIOLOGY 2010. [DOI: 10.1016/j.ppedcard.2009.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Whitehead KK, Gillespie MJ, Harris MA, Fogel MA, Rome JJ. Noninvasive quantification of systemic-to-pulmonary collateral flow: a major source of inefficiency in patients with superior cavopulmonary connections. Circ Cardiovasc Imaging 2009; 2:405-11. [PMID: 19808629 DOI: 10.1161/circimaging.108.832113] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Systemic-to-pulmonary collateral flow (SPCF) is common in single-ventricle patients with superior cavopulmonary connections (SCPC). Because no validated method to quantify that SPCF exists, neither its hemodynamic burden nor its clinical impact can be systematically evaluated. We hypothesize that (1) the difference in total ascending aortic (Ao) and caval flow (superior vena cava [SVC]+inferior vena cava [IVC]) and (2) the difference between pulmonary vein and pulmonary artery flow (PV-PA) provide 2 independent estimators of SPCF. METHODS AND RESULTS We measured Ao, SVC, IVC, right (RPA) and left (LPA) PA, and left (LPV) and right (RPV) PV flows in 17 patients with SCPC during routine cardiac MRI studies using through-plane phase-contrast velocity mapping. Two independent measures of SPCF were obtained: model 1, Ao-(SVC+IVC); and model 2, (LPV-LPA)+(RPV-RPA). Values were normalized to body surface area, Ao, and PV, and comparisons were made using linear regression and Bland-Altman analysis. SPCF ranged from 0.2 to 1.4 L/min for model 1 and 0.2 to 1.6 L/min for model 2, for an average indexed SPCF of 0.5 to 2.8 L/min/m(2): 11% to 53% (mean, 37%) of Ao and 19% to 77% (mean, 54%) of PV. The mean difference between model 1 and model 2 was 0.01 L/min (P=0.40; 2-SD range, -0.45 to 0.47 L/min). CONCLUSIONS We present a noninvasive method for SPCF quantification in patients with SCPC. It should provide an important clinical tool in treating these patients. Furthermore, we show that SPCF is a significant hemodynamic burden in many patients with bidirectional Glenn shunt physiology. Future investigations will allow objective study of the impact of collateral flow on outcome.
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Affiliation(s)
- Kevin K Whitehead
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
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