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Szafron JM, Heng EE, Boyd J, Humphrey JD, Marsden AL. Hemodynamics and Wall Mechanics of Vascular Graft Failure. Arterioscler Thromb Vasc Biol 2024; 44:1065-1085. [PMID: 38572650 PMCID: PMC11043008 DOI: 10.1161/atvbaha.123.318239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 03/12/2024] [Indexed: 04/05/2024]
Abstract
Blood vessels are subjected to complex biomechanical loads, primarily from pressure-driven blood flow. Abnormal loading associated with vascular grafts, arising from altered hemodynamics or wall mechanics, can cause acute and progressive vascular failure and end-organ dysfunction. Perturbations to mechanobiological stimuli experienced by vascular cells contribute to remodeling of the vascular wall via activation of mechanosensitive signaling pathways and subsequent changes in gene expression and associated turnover of cells and extracellular matrix. In this review, we outline experimental and computational tools used to quantify metrics of biomechanical loading in vascular grafts and highlight those that show potential in predicting graft failure for diverse disease contexts. We include metrics derived from both fluid and solid mechanics that drive feedback loops between mechanobiological processes and changes in the biomechanical state that govern the natural history of vascular grafts. As illustrative examples, we consider application-specific coronary artery bypass grafts, peripheral vascular grafts, and tissue-engineered vascular grafts for congenital heart surgery as each of these involves unique circulatory environments, loading magnitudes, and graft materials.
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Affiliation(s)
- Jason M Szafron
- Departments of Pediatrics (J.M.S., A.L.M.), Stanford University, CA
| | - Elbert E Heng
- Cardiothoracic Surgery (E.E.H., J.B.), Stanford University, CA
| | - Jack Boyd
- Cardiothoracic Surgery (E.E.H., J.B.), Stanford University, CA
| | - Jay D Humphrey
- Department of Biomedical Engineering, Yale University, New Haven, CT (J.D.H.)
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2
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Hiebing AA, Pieper RG, Witzenburg CM. A Computational Model of Ventricular Dimensions and Hemodynamics in Growing Infants. J Biomech Eng 2023; 145:101007. [PMID: 37338264 DOI: 10.1115/1.4062779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 06/13/2023] [Indexed: 06/21/2023]
Abstract
Previous computer models have successfully predicted cardiac growth and remodeling in adults with pathologies. However, applying these models to infants is complicated by the fact that they also undergo normal, somatic cardiac growth and remodeling. Therefore, we designed a computational model to predict ventricular dimensions and hemodynamics in healthy, growing infants by modifying an adult canine left ventricular growth model. The heart chambers were modeled as time-varying elastances coupled to a circuit model of the circulation. Circulation parameters were allometrically scaled and adjusted for maturation to simulate birth through 3 yrs of age. Ventricular growth was driven by perturbations in myocyte strain. The model successfully matched clinical measurements of pressures, ventricular and atrial volumes, and ventricular thicknesses within two standard deviations of multiple infant studies. To test the model, we input 10th and 90th percentile infant weights. Predicted volumes and thicknesses decreased and increased within normal ranges and pressures were unchanged. When we simulated coarctation of the aorta, systemic blood pressure, left ventricular thickness, and left ventricular volume all increased, following trends in clinical data. Our model enables a greater understanding of somatic and pathological growth in infants with congenital heart defects. Its flexibility and computational efficiency when compared to models employing more complex geometries allow for rapid analysis of pathological mechanisms affecting cardiac growth and hemodynamics.
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Affiliation(s)
- Ashley A Hiebing
- Cardiovascular Biomechanics Laboratory, Department of Biomedical Engineering, University of Wisconsin-Madison, Engineering Centers Building, 1550 Engineering Drive, Madison, WI 53706-1609
| | - Riley G Pieper
- Cardiovascular Biomechanics Laboratory, Department of Biomedical Engineering, University of Wisconsin-Madison, Engineering Centers Building, 1550 Engineering Drive, Madison, WI 53706-1609
| | - Colleen M Witzenburg
- Cardiovascular Biomechanics Laboratory, Department of Biomedical Engineering, University of Wisconsin-Madison, Engineering Centers Building, 1550 Engineering Drive, Madison, WI 53706-1609
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3
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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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Zhang D, Lindsey SE. Recasting Current Knowledge of Human Fetal Circulation: The Importance of Computational Models. J Cardiovasc Dev Dis 2023; 10:240. [PMID: 37367405 PMCID: PMC10299027 DOI: 10.3390/jcdd10060240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 05/16/2023] [Accepted: 05/23/2023] [Indexed: 06/28/2023] Open
Abstract
Computational hemodynamic simulations are becoming increasingly important for cardiovascular research and clinical practice, yet incorporating numerical simulations of human fetal circulation is relatively underutilized and underdeveloped. The fetus possesses unique vascular shunts to appropriately distribute oxygen and nutrients acquired from the placenta, adding complexity and adaptability to blood flow patterns within the fetal vascular network. Perturbations to fetal circulation compromise fetal growth and trigger the abnormal cardiovascular remodeling that underlies congenital heart defects. Computational modeling can be used to elucidate complex blood flow patterns in the fetal circulatory system for normal versus abnormal development. We present an overview of fetal cardiovascular physiology and its evolution from being investigated with invasive experiments and primitive imaging techniques to advanced imaging (4D MRI and ultrasound) and computational modeling. We introduce the theoretical backgrounds of both lumped-parameter networks and three-dimensional computational fluid dynamic simulations of the cardiovascular system. We subsequently summarize existing modeling studies of human fetal circulation along with their limitations and challenges. Finally, we highlight opportunities for improved fetal circulation models.
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Affiliation(s)
| | - Stephanie E. Lindsey
- Department of Mechanical and Aerospace Engineering, University of California, San Diego, CA 92093, USA;
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5
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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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6
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Zhang Y, Fang M, Wang Z, Liu Y, Zhang C, Wang Z, Wang H. The prediction and verification of outcome of extracardiac conduits fontan based on computational fluid dynamics simulation. Front Physiol 2022; 13:1078140. [PMID: 36505086 PMCID: PMC9729743 DOI: 10.3389/fphys.2022.1078140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 11/14/2022] [Indexed: 11/25/2022] Open
Abstract
Objective: This study applied preoperative computed tomography angiography (CTA) and computational fluid dynamics (CFD) simulation to predicte and verify the outcome of Y-shaped extracardiac conduits Fontan for functional single ventricle. Methods: Based on the preoperative CTA data of functional single ventricle (FSV), 4 types of spatial structures of extracardiac conduits were designed for 4 experimental groups: Group A, a traditional TCPC group (20 mm); Group B, a diameter-preserving Y-shaped TCPC (YCPC) group (branch 10 mm); Group C, YCPC group (branch 12 mm); and Group D, an area-preserving YCPC group (branch14 mm). Four indicators including flow velocity, pressure gradient (PG), energy efficiency and inferior vena cava (IVC) blood flow distribution were compared. The optimal procedure was applied. The radionuclide lung perfusion, CTA, echocardiography, cardiovascular angiography and catheterization were performed postoperatively. Results: There were the lowest PG, the lowest flow velocity of branches, the highest energy efficiency, and a relatively balanced and stable distribution of IVC flow for group D. Subsequently, the group D, a handcrafted Y-shaped conduit (14 mm) was used for the YCPC procedure. There was no postoperative PG between the conduit and pulmonary artery with normal pressure and resistance. IVC flow was distributed uniformly. Conclusion: CTA-based CFD provided more guidance for the clinical application of TCPC. A comprehensive surgical design could bring good postoperative outcome. Area-preserving YCPC has more advantages than TCPC and the diameter-preserving YCPC. The study effectively improved the feasibility of clinical applications of YCPC.
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Javadi E, Laudenschlager S, Kheyfets V, Di Maria M, Stone M, Jamali S, Powell AJ, Moghari MH. Predicting Hemodynamic Performance of Fontan Operation for Glenn Physiology using Computational Fluid Dynamics: Ten Patient-specific Cases. JOURNAL OF CLINICAL IMAGES AND MEDICAL CASE REPORTS 2022; 3:1916. [PMID: 36339935 PMCID: PMC9631545 DOI: 10.52768/2766-7820/1916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Single ventricle hearts have only one ventricle that can pump blood effectively and the treatment requires three stages of operations to reconfigure the heart and circulatory system. At the second stage, Glenn procedure is performed to connect superior vena cava (SVC) to the pulmonary arteries (PA). For the third and most complex operation, called Fontan, an extracardiac conduit is used to connect inferior vena cava (IVC) to the PL and thereafter no deoxygenated blood goes to the heart. Predicting Hemodynamic Performance of Fontan Operation using computational fluid dynamics (CFD) is hypothesized to improve outcomes and optimize this treatment planning in children with single-ventricle heart disease. An important reason for this surgical planning is to reduce the development of pulmonary arteriovenous malformations (PAVM) and the need to perform Fontan revisions. The purpose of this study was to develop amodel for Fontan surgical planning and use this model to compare blood circulation in two designed graft types of Fontan operation known as T-shape and Y-graft. The functionality of grafts was compared in terms of power loss (PL) and hepatic flow distribution (HFD), a known factor in PAVM development. To perform this study, ten single-ventricle children with Glenn physiology were included and a CFD model was developed to estimate the blood flow circulation to the left and right pulmonary arteries. The estimated blood flow by CFD was compared with that measured by cardiovascular magnetic resonance. Results showed that there was an excellent agreement between the net blood flow in the right and left pulmonary arteries computed by CFD and CMR (ICC= 0.98, P-value ≥0.21). After validating the accuracy of each CFD model, Fontan operations using T-shape and Y-graft conduits were performed in silico for each patient and the developed CFD model was used to predict the post-surgical PL and HFD. We found that the PL in the Y-graft was significantly lower than in the T-shape (P-value ≤0.001) and HFD was significantly better balanced in Y-graft compared to the T-shape (P-value=0.004).
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Affiliation(s)
- Elahe Javadi
- Mechanical and Industrial Engineering Department, Northeastern University, Boston, MA, USA
| | - Sebastian Laudenschlager
- School of Medicine, University of Colorado Aurora, and Department of Radiology, Children’s Hospital Colorado, Aurora, CO, USA
| | - Vitaly Kheyfets
- Paediatric Critical Care Medicine; Developmental Lung Biology and CVP Research Laboratories, School of Medicine, University of Colorado, Aurora, CO, USA
| | - Michael Di Maria
- Department of Pediatrics, University of Colorado, and Department of Cardiology, Children’s Hospital Colorado, Aurora, CO, USA
| | - Matthew Stone
- Department of Surgery, University of Colorado, and Children’s Hospital Colorado, Aurora, CO, USA
| | - Safa Jamali
- Mechanical and Industrial Engineering Department, Northeastern University, Boston, MA, USA
| | - Andrew J. Powell
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, USA
| | - Mehdi H. Moghari
- School of Medicine, University of Colorado Aurora, and Department of Radiology, Children’s Hospital Colorado, Aurora, CO, USA
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Lashkarinia SS, Cicek M, Kose B, Rezaeimoghaddam M, Yılmaz EH, Aydemir NA, Rasooli R, Ozkok S, Yurtseven N, Erdem H, Pekkan K, Sasmazel A. OUP accepted manuscript. Interact Cardiovasc Thorac Surg 2022; 34:1095-1105. [PMID: 35134949 PMCID: PMC9159461 DOI: 10.1093/icvts/ivac001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 10/21/2021] [Accepted: 01/14/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
| | - Murat Cicek
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Banu Kose
- Department of Biomedical Engineering, Istanbul Medipol University, Istanbul, Turkey
| | | | - Emine Hekim Yılmaz
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Numan Ali Aydemir
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Reza Rasooli
- Department of Mechanical Engineering, Koc University, Istanbul, Turkey
| | - Sercin Ozkok
- Research Hospital Radiology Department, Medeniyet University Goztepe Training, Istanbul, Turkey
| | - Nurgul Yurtseven
- Anesthesiology, Pediatric Cardiac Intensive Care Unit, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Hasan Erdem
- Department of Cardiovascular Surgery, Kosuyolu Yuksek Ihtisas Training and Research Hospital, Istanbul, Turkey
| | - Kerem Pekkan
- Department of Mechanical Engineering, Koc University, Istanbul, Turkey
- Mechanical Engineering Department Koç University Rumeli Feneri Campus, Sarıyer, 34450 Istanbul, Turkey. Tel: +90-(533)-356-35-95; e-mail: (K.Pekkan)
| | - Ahmet Sasmazel
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
- Corresponding author. Pediatric Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Research Hospital, Tibbiye Cad. No: 13, Uskudar, 34668 Istanbul,Turkey. Tel: +90-(216)-542-44-44; e-mail: (A. Sasmazel)
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Talwar S, Marathe SP, Choudhary SK, Airan B. Where are we after 50 years of the Fontan operation? Indian J Thorac Cardiovasc Surg 2020; 37:42-53. [PMID: 33584026 DOI: 10.1007/s12055-019-00906-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 11/02/2019] [Accepted: 11/08/2019] [Indexed: 01/11/2023] Open
Abstract
First introduced in 1971, the Fontan procedure is the final common destination for all patients with a functional single ventricle. The procedure itself has evolved tremendously over the last five decades. This review traces this journey and presents the importance, outcomes and future outlook of the procedure in the current era.
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Affiliation(s)
- Sachin Talwar
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029 India
| | | | - Shiv Kumar Choudhary
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Balram Airan
- Mahatma Gandhi Hospital, Mahatma Gandhi University of Medical Sciences Technology, Jaipur, India
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Lee W, Hong Y, Dai G. 3D bioprinting of vascular conduits for pediatric congenital heart repairs. Transl Res 2019; 211:35-45. [PMID: 31034816 PMCID: PMC6702035 DOI: 10.1016/j.trsl.2019.03.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 03/21/2019] [Accepted: 03/24/2019] [Indexed: 12/27/2022]
Abstract
In children with congenital heart defects, surgical correction often involves the use of valves, patches or vascular conduits to establish anatomic continuity. Due to the differences between the pediatric and adult populations, tissue reconstruction in pediatric patients requires a substantially different approach from those in adults. Cardiovascular anatomy of children with congenital heart defect vary, which requires tailored surgical operations for each patient. Since grafts used in these palliative surgeries are sensitive to the local hemodynamic environments, their geometries need to be precisely designed to ensure long-term performance. Tissue engineered vascular grafts (TEVGs) have made tremendous progress over the past decade, but it remains difficult to fabricate patient- and operation-specific vascular grafts. This review summarizes historical milestones of TEVG development for repairing pediatric congenital defects and current clinical outcomes. We also highlight ongoing works on 3D bioprinting of TEVGs with complex geometries and address the current limitations of each technique. Although 3D bioprinted vascular grafts with appropriate functions are yet to be developed, some of the current researches are promising to create better patient specific tissue engineered vascular grafts in the future.
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Affiliation(s)
- Wenhan Lee
- Department of Bioengineering, Northeastern University, Boston, Massachusetts
| | - Yi Hong
- Department of Bioengineering, University of Texas at Arlington, Arlington, Texas
| | - Guohao Dai
- Department of Bioengineering, Northeastern University, Boston, Massachusetts.
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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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Montesa C, Karamlou T, Ratnayaka K, Pophal SG, Ryan J, Nigro JJ. Hepatic Vein Incorporation Into the Azygos System in Heterotaxy and Interrupted Inferior Vena Cava. World J Pediatr Congenit Heart Surg 2019; 10:330-337. [DOI: 10.1177/2150135119842869] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Patients with heterotaxy, single ventricle and interrupted inferior vena cava are at risk of developing significant pulmonary arteriovenous malformations and cyanosis, and inequitable distribution of hepatic factor has been implicated in their development. We describe our experience with a technique for hepatic vein incorporation that reliably provides resolution of cyanosis and presumably equitable hepatic factor distribution. Methods: A retrospective review of a single-surgeon experience was conducted for patients who underwent this modified Fontan operation utilizing an extracardiac conduit from the hepatic veins to the dominant superior cavopulmonary connection. Preoperative characteristics and imaging, operative details, and postoperative course and imaging were abstracted. Results: Median age at operation was 5 years (2-10 years) and median weight was 19.6 kg (11.8-23 kg). Sixty percent (3/5) of patients had Fontan completion without cardiopulmonary bypass, and follow-up was complete at a median of 14 months (range 1-20 months). Systemic saturations increased significantly from 81% ± 1.9% preoperatively to 95% ± 3.5% postoperatively, P = .0008. Median length of stay was 10 days (range: 7-14 days). No deaths occurred. One patient required reoperation for bleeding and one was readmitted for pleural effusion. Postoperative imaging suggested distribution of hepatic factor to all lung segments with improved pulmonary arteriovenous malformation burden. Conclusions: Hepatic vein incorporation for patients with heterotaxy and interrupted inferior vena cava should optimally provide equitable pulmonary distribution of hepatic factor with resolution of cyanosis. The described technique is performed through a conventional approach, is facile, and improves cyanosis in these complex patients.
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Affiliation(s)
- Christine Montesa
- Division of Cardiovascular Surgery, Heart Institute, Rady Children’s Hospital, San Diego, CA, USA
| | - Tara Karamlou
- Division of Pediatric Cardiac Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kanishka Ratnayaka
- Division of Cardiology, Heart Institute, Rady Children’s Hospital, San Diego, CA, USA
| | - Stephen G. Pophal
- Children’s Heart Center, Phoenix Children’s Hospital, Phoenix, AZ, USA
| | - Justin Ryan
- 3D Innovations Lab, Heart Institute, Rady Children’s Hospital, San Diego, CA, USA
| | - John J. Nigro
- Division of Cardiovascular Surgery, Heart Institute, Rady Children’s Hospital, San Diego, CA, USA
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Alsoufi B, Rosenblum J, Travers C, Kanter K, Trusty PM, Yoganathan AP, Slesnick TP. Outcomes of Single Ventricle Patients Undergoing the Kawashima Procedure: Can We Do Better? World J Pediatr Congenit Heart Surg 2019; 10:20-27. [DOI: 10.1177/2150135118809082] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Objectives: Current technology advances in virtual surgery modeling and computational flow dynamics allow preoperative individualized computer-based design of Fontan operation. To determine potential role of those innovations in patients undergoing hepatic vein incorporation (HVI) following Kawashima operation, we retrospectively examined historic cohort of patients who underwent HVI following Kawashima with focus on regression of pulmonary arteriovenous malformations (PAVMs). Methods: Twenty-two children with single ventricle and interrupted inferior vena cava underwent Kawashima operation (2002-12). Twenty-one (96%) patients had left atrial isomerism and 21 (96%) had undergone prior first-stage palliation. Clinical outcomes were examined. Results: Mean O2 saturation (SaO2) increased from 77% ± 8% to 85% ± 6% ( P = .002) after Kawashima. Fifteen (68%) patients developed PAVMs. Eighteen patients underwent HVI (median age and interval from Kawashima: 4.4 and 3.7 years, respectively). Mean SaO2 prior to HVI was 77% ± 8% and increased to 81% ± 10% at the time of hospital discharge ( P = .250), with five patients requiring home oxygen. On follow-up, mean SaO2 increased to 95% ± 4% ( P < .001). Overall ten-year survival following Kawashima was 94%. Conclusions: A large number of patients develop PAVMs and subsequent cyanosis after Kawashima operation. Early following HVI, SaO2 is commonly low and insignificantly different from that prior to HVI. Although SaO2 will improve on follow-up in most patients, a number of patients continue to have low saturations, indicating incomplete resolution of PAVMs. Given the heterogeneity of those patients and lack of preoperative predictors for complete PAVM regression, our findings suggest a role for virtual surgery to determine optimal individual procedure design that would provide even distribution of hepatic blood flow to both pulmonary arteries.
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Affiliation(s)
- Bahaaldin Alsoufi
- Department of Cardiothoracic Surgery, University of Louisville, Norton Children’s Hospital, Louisville, KY, USA
| | - Joshua Rosenblum
- Department of Cardiothoracic Surgery, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Curtis Travers
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Kirk Kanter
- Department of Cardiothoracic Surgery, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Philip M. Trusty
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Ajit P. Yoganathan
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Timothy P. Slesnick
- Sibley Heart Center, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
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Talwar S, Sankhyan L, Patel C, Sreenivas V, Choudhary SK, Airan B. Evaluation of differential pulmonary perfusion using 99mTc macroaggregated albumin after the Fontan procedure. Interact Cardiovasc Thorac Surg 2018; 26:651-659. [PMID: 29240900 DOI: 10.1093/icvts/ivx377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 10/30/2017] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The Fontan procedure [total cavopulmonary connection (TCPC)] is the final palliation for patients with univentricular physiology. We studied differential perfusion ratio and percentage uptake of a radiotracer in different zones of each lung following TCPC. METHODS Between July 2015 and June 2017, 45 patients underwent 99mTc macroaggregated albumin lung perfusion scan at a mean follow-up period of 49.3 ± SD 26.1 days following TCPC. Differential perfusion ratio and percentage uptake of the radiotracer in the upper, middle and lower zones of each lung were calculated. RESULTS Post-foot injection [inferior vena cava (IVC) injection], preferential flow to the lungs was as follows: left lung (n = 13, 30.2%), right lung (n = 13, 30.2%) and uniformly to both lungs (n= 17, 39.6%). Post-arm injection [superior vena cava (SVC) injection], preferential flow to the lungs was as follows: left lung (n = 13, 30.2%), right lung (n = 22, 51.2%) and uniformly to both lungs (n= 8, 18.6%). The middle zone was perfused the most in both lungs. Total lower zone mean perfusion was higher than the upper zone following both SVC injection and IVC injection (34.1 ± SD 5.3% vs 17. ± SD 4.1% and 33 ± SD 5.0% vs 17.5 ± SD 4.1%, respectively). In patients with bilateral SVC, post-IVC injection, 6 (75%) patients had preferential flow to the right lung, whereas post-SVC injection, preferential flow to the left lung was visualized in 7 (87.5%) patients. CONCLUSIONS Following TCPC, IVC blood was distributed uniformly in both lungs. SVC blood preferentially perfused the right lung. The middle zone was perfused the most in both lungs.
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Affiliation(s)
- Sachin Talwar
- Department of Cardiothoracic and Vascular Surgery, Cardiothoracic Center, All India Institute of Medical Sciences, New Delhi, India
| | - Lakshmi Sankhyan
- Department of Cardiothoracic and Vascular Surgery, Cardiothoracic Center, All India Institute of Medical Sciences, New Delhi, India
| | - Chetan Patel
- Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | | | - Shiv Kumar Choudhary
- Department of Cardiothoracic and Vascular Surgery, Cardiothoracic Center, All India Institute of Medical Sciences, New Delhi, India
| | - Balram Airan
- Department of Cardiothoracic and Vascular Surgery, Cardiothoracic Center, All India Institute of Medical Sciences, New Delhi, India
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Chen JM. Bespoke surgery: We're virtually there. J Thorac Cardiovasc Surg 2018; 155:1743-1744. [PMID: 29409611 DOI: 10.1016/j.jtcvs.2017.12.109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 12/27/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Jonathan M Chen
- Congenital Cardiac Surgery, Seattle Children's Hospital, Seattle, Wash; Pediatric Cardiovascular Surgery, University of Washington School of Medicine, Seattle, Wash.
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Kverneland LS, Kramer P, Ovroutski S. Five decades of the Fontan operation: A systematic review of international reports on outcomes after univentricular palliation. CONGENIT HEART DIS 2018; 13:181-193. [DOI: 10.1111/chd.12570] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 11/08/2017] [Accepted: 12/08/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Laura S. Kverneland
- Department of Internal Medicine; Herlev Hospital; Copenhagen Denmark
- Department of Congenital Heart Disease/Pediatric Cardiology; German Heart Center Berlin; Berlin Germany
| | - Peter Kramer
- Department of Congenital Heart Disease/Pediatric Cardiology; German Heart Center Berlin; Berlin Germany
| | - Stanislav Ovroutski
- Department of Congenital Heart Disease/Pediatric Cardiology; German Heart Center Berlin; Berlin Germany
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Sharma R, Baruah SD, Marwah A, Chauhan CPS. Intra-Atrial Y-Graft Fontan for Univentricular Heart With Discontinuous Pulmonary Arteries. World J Pediatr Congenit Heart Surg 2017; 8:529-532. [PMID: 28696884 DOI: 10.1177/2150135117705638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The Y-graft Fontan as described today suffers from the disadvantage of being hostage to restrictions imposed upon the design of the limbs of the Y by existent cardiac anatomy. We describe a patient with discontinuous pulmonary arteries following a prior Glenn shunt, who underwent Fontan completion using an intra-atrial Y-limb placement for recruitment of the discontinuous pulmonary artery. Intracardiac placement of the limb(s) of the Y-graft could potentially increase the applicability of this Fontan modification without being constrained by external cardiac anatomy.
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Affiliation(s)
- Rajesh Sharma
- 1 Department of Pediatric Cardiology and Cardiac Surgery, Jaypee Hospital, Noida, Uttar Pradesh, India
| | - Sudip Dutta Baruah
- 1 Department of Pediatric Cardiology and Cardiac Surgery, Jaypee Hospital, Noida, Uttar Pradesh, India
| | - Ashutosh Marwah
- 1 Department of Pediatric Cardiology and Cardiac Surgery, Jaypee Hospital, Noida, Uttar Pradesh, India
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Lee JW, Park JJ, Goo HW, Ko JK. Fontan Revision with Y-Graft in a Patient with Unilateral Pulmonary Arteriovenous Malformation. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2017; 50:207-210. [PMID: 28593158 PMCID: PMC5460969 DOI: 10.5090/kjtcs.2017.50.3.207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 10/27/2016] [Accepted: 10/28/2016] [Indexed: 11/18/2022]
Abstract
The extracardiac conduit Fontan procedure is the last surgical step in the treatment of patients with a functional single ventricle. An acquired pulmonary arteriovenous malformation may appear perioperatively or postoperatively due to an uneven hepatic flow distribution. Here we report a case of a bifurcated Y-graft Fontan operation in a 15-year-old male patient with a unilateral pulmonary arteriovenous malformation after an extracardiac conduit Fontan operation.
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Affiliation(s)
- Jeong-Woo Lee
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Jeong-Jun Park
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Hyun Woo Goo
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine
| | - Jae Kon Ko
- Department of Pediatric Cardiology, Asan Medical Center, University of Ulsan College of Medicine
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Slesnick TC. Role of Computational Modelling in Planning and Executing Interventional Procedures for Congenital Heart Disease. Can J Cardiol 2017; 33:1159-1170. [PMID: 28843327 DOI: 10.1016/j.cjca.2017.05.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 05/26/2017] [Accepted: 05/27/2017] [Indexed: 10/19/2022] Open
Abstract
Increasingly, computational modelling and numerical simulations are used to help plan complex surgical and interventional cardiovascular procedures in children and young adults with congenital heart disease. From its origins more than 30 years ago, surgical planning with analysis of flow hemodynamics and energy loss/efficiency has helped design and implement many modifications to existing techniques. On the basis of patient-specific medical imaging, surgical planning allows accurate model production that can then be manipulated in a virtual surgical environment, with the proposed solutions finally tested with advanced computational fluid dynamics to evaluate the results. Applications include a broad range of congenital heart disease, including patients with single-ventricle anatomy undergoing staged palliation, those with arch obstruction, with double outlet right ventricle, or with tetralogy of Fallot. In the present work, we focus on clinical applications of this exciting field. We describe the framework for these techniques, including brief descriptions of the engineering principles applied and the interaction between "benchtop" data with medical decision-making. We highlight some early insights learned from pioneers over the past few decades, including refinements in Fontan baffle geometries and configurations. Finally, we offer a glimpse into exciting advances that are presently being explored, including use of modelling for transcatheter interventions. In this era of personalized medicine, computational modelling and surgical planning allows patient-specific tailoring of interventions to optimize clinical outcomes.
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Affiliation(s)
- Timothy C Slesnick
- Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia.
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20
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Local Hemodynamic Differences Between Commercially Available Y-Grafts and Traditional Fontan Baffles Under Simulated Exercise Conditions: Implications for Exercise Tolerance. Cardiovasc Eng Technol 2017; 8:390-399. [DOI: 10.1007/s13239-017-0310-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 05/23/2017] [Indexed: 10/19/2022]
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21
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A pulsatile hemodynamic evaluation of the commercially available bifurcated Y-graft Fontan modification and comparison with the lateral tunnel and extracardiac conduits. J Thorac Cardiovasc Surg 2016; 151:1529-36. [DOI: 10.1016/j.jtcvs.2016.03.019] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 03/01/2016] [Accepted: 03/05/2016] [Indexed: 11/22/2022]
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Restrepo M, Crouch AC, Haggerty CM, Rossignac J, Slesnick TC, Kanter KR, Yoganathan AP. Hemodynamic Impact of Superior Vena Cava Placement in the Y-Graft Fontan Connection. Ann Thorac Surg 2015; 101:183-9. [PMID: 26431925 DOI: 10.1016/j.athoracsur.2015.07.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 06/03/2015] [Accepted: 07/09/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND A Fontan Y-shaped graft using a commercially available aortoiliac graft has been used to connect the inferior vena cava (IVC) to the pulmonary arteries. This modification of the Fontan procedure seeks to improve hepatic flow distribution (HFD) to the lungs. However, patient-specific anatomical restrictions might limit the space available for graft placement. Altering the superior vena cava (SVC) positioning is hypothesized to provide more space for an optimal connection, avoiding caval flow collision. Computational modeling tools were used to retrospectively study the effect of SVC placement on Y-graft hemodynamics. METHODS Patient-specific anatomies (N = 10 patients) and vessel flows were reconstructed from retrospective cardiac magnetic resonance (CMR) images after Fontan Y-graft completion. Alternative geometries were created using a virtual surgery environment, altering the SVC position and the offset in relation to the Y-graft branches. Geometric characterization and computational fluid dynamics simulations were performed. Hemodynamic factors (power loss and HFD) were computed. RESULTS Patients with a higher IVC return showed less sensitivity to SVC positioning. Patients with low IVC flow showed varied HFD results, depending on SVC location. Balanced HFD values (50% to each lung) were obtained when the SVC lay completely between the Y-graft branches. The effect on power loss was patient specific. CONCLUSIONS SVC positioning with respect to the Y-graft affects HFD, especially in patients with lower IVC flow. Careful positioning of the SVC at the time of a bidirectional Glenn (BDG) procedure based on patient-specific anatomy can optimize the hemodynamics of the eventual Fontan completion.
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Affiliation(s)
- Maria Restrepo
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta
| | - A Colleen Crouch
- School of Material Sciences and Engineering, Georgia Institute of Technology, Atlanta
| | - Christopher M Haggerty
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta
| | - Jarek Rossignac
- College of Computing, Georgia Institute of Technology, Atlanta
| | - Timothy C Slesnick
- Division of Pediatric Cardiology, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Kirk R Kanter
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Ajit P Yoganathan
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta.
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Abstract
PURPOSE OF REVIEW Recent methodological advances in computational simulations are enabling increasingly realistic simulations of hemodynamics and physiology, driving increased clinical utility. We review recent developments in the use of computational simulations in pediatric and congenital heart disease, describe the clinical impact in modeling in single-ventricle patients, and provide an overview of emerging areas. RECENT FINDINGS Multiscale modeling combining patient-specific hemodynamics with reduced order (i.e., mathematically and computationally simplified) circulatory models has become the de-facto standard for modeling local hemodynamics and 'global' circulatory physiology. We review recent advances that have enabled faster solutions, discuss new methods (e.g., fluid structure interaction and uncertainty quantification), which lend realism both computationally and clinically to results, highlight novel computationally derived surgical methods for single-ventricle patients, and discuss areas in which modeling has begun to exert its influence including Kawasaki disease, fetal circulation, tetralogy of Fallot (and pulmonary tree), and circulatory support. SUMMARY Computational modeling is emerging as a crucial tool for clinical decision-making and evaluation of novel surgical methods and interventions in pediatric cardiology and beyond. Continued development of modeling methods, with an eye towards clinical needs, will enable clinical adoption in a wide range of pediatric and congenital heart diseases.
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Cavopulmonary assist for the failing Fontan circulation: impact of ventricular function on mechanical support strategy. ASAIO J 2015; 60:707-15. [PMID: 25158887 DOI: 10.1097/mat.0000000000000135] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Mechanical circulatory support--either ventricular assist device (VAD, left-sided systemic support) or cavopulmonary assist device (CPAD, right-sided support)--has been suggested as treatment for Fontan failure. The selection of left- versus right-sided support for failing Fontan has not been previously defined. Computer simulation and mock circulation models of pediatric Fontan patients (15-25 kg) with diastolic, systolic, and combined systolic and diastolic dysfunction were developed. The global circulatory response to assisted Fontan flow using VAD (HeartWare HVAD, Miami Lakes, FL) support, CPAD (Viscous Impeller Pump, Indianapolis, IN) support, and combined VAD and CPAD support was evaluated. Cavopulmonary assist improves failing Fontan circulation during diastolic dysfunction but preserved systolic function. In the presence of systolic dysfunction and elevated ventricular end-diastolic pressure (VEDP), VAD support augments cardiac output and diminishes VEDP, while increased preload with cavopulmonary assist may worsen circulatory status. Fontan circulation can be stabilized to biventricular values with modest cavopulmonary assist during diastolic dysfunction. Systemic VAD support may be preferable to maintain systemic output during systolic dysfunction. Both systemic and cavopulmonary support may provide best outcome during combined systolic and diastolic dysfunction. These findings may be useful to guide clinical cavopulmonary assist strategies in failing Fontan circulations.
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McRae RO, Lambert LM, Williams RV, Martin MH, Burch PT. Modification of Hepatic Venous Conduit to Manage Pulmonary Arteriovenous Malformations. World J Pediatr Congenit Heart Surg 2015; 6:477-9. [DOI: 10.1177/2150135115577431] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
While the Fontan operation is a reliable treatment option for many complex congenital heart defects, the development of pulmonary arteriovenous malformations (PAVMs) remains a problematic outcome for some Fontan patients. Pulmonary arteriovenous malformations stem from an imbalance of hepatic blood flow in the pulmonary system. Balancing this hepatic flow has shown promising results in the treatment of PAVMs. We report the clinical course of a young patient with heterotaxy syndrome and an unbalanced right dominant atrioventricular septal defect. This patient developed PAVMs following a Fontan procedure, however, the PAVMs were resolved following the revision of the original Fontan conduit to a bifurcated conduit.
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Affiliation(s)
- Robert O. McRae
- Department of Surgery, Section of Pediatric Cardiothoracic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Linda M. Lambert
- Division of Pediatric Cardiothoracic Surgery, Primary Children’s Hospital, Salt Lake City, UT, USA
| | - Richard V. Williams
- Department of Pediatrics, Division of Cardiology, University of Utah, Salt Lake City, UT, USA
| | - Mary H. Martin
- Department of Pediatrics, Division of Cardiology, University of Utah, Salt Lake City, UT, USA
| | - Phillip T. Burch
- Department of Surgery, Section of Pediatric Cardiothoracic Surgery, University of Utah, Salt Lake City, UT, USA
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Roldán-Alzate A, García-Rodríguez S, Anagnostopoulos PV, Srinivasan S, Wieben O, François CJ. Hemodynamic study of TCPC using in vivo and in vitro 4D Flow MRI and numerical simulation. J Biomech 2015; 48:1325-30. [PMID: 25841292 DOI: 10.1016/j.jbiomech.2015.03.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 03/06/2015] [Accepted: 03/10/2015] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Altered total cavopulmonary connection (TCPC) hemodynamics can cause long-term complications. Patient-specific anatomy hinders generalized solutions. 4D Flow MRI allows in vivo assessment, but not predictions under varying conditions and surgical approaches. Computational fluid dynamics (CFD) improves understanding and explores varying physiological conditions. This study investigated a combination of 4D Flow MRI and CFD to assess TCPC hemodynamics, accompanied with in vitro measurements as CFD validation. 4D Flow MRI was performed in extracardiac and atriopulmonary TCPC subjects. Data was processed for visualization and quantification of velocity and flow. Three-dimensional (3D) geometries were generated from angiography scans and used for CFD and a physical model construction through additive manufacturing. These models were connected to a perfusion system, circulating water through the vena cavae and exiting through the pulmonary arteries at two flow rates. Models underwent 4D Flow MRI and image processing. CFD simulated the in vitro system, applying two different inlet conditions from in vitro 4D Flow MRI measurements; no-slip was implemented at rigid walls. Velocity and flow were obtained and analyzed. The three approaches showed similar velocities, increasing proportionally with high inflow. Atriopulmonary TCPC presented higher vorticity compared to extracardiac at both inflow rates. Increased inflow balanced flow distribution in both TCPC cases. Atriopulmonary IVC flow participated in atrium recirculation, contributing to RPA outflow; at baseline, IVC flow preferentially traveled through the LPA. The combination of patient-specific in vitro and CFD allows hemodynamic parameter control, impossible in vivo. Physical models serve as CFD verification and fine-tuning tools.
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Affiliation(s)
| | | | - Petros V Anagnostopoulos
- Department of Pediatric Cardiology, University of Wisconsin-Madison, USA; Department of Pediatric Cardiothoracic Surgery, University of Wisconsin-Madison, USA
| | - Shardha Srinivasan
- Department of Pediatric Cardiology, University of Wisconsin-Madison, USA
| | - Oliver Wieben
- Department of Radiology, University of Wisconsin-Madison, USA; Department of Medical Physics, University of Wisconsin-Madison, USA
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Haggerty CM, Whitehead KK, Bethel J, Fogel MA, Yoganathan AP. Relationship of single ventricle filling and preload to total cavopulmonary connection hemodynamics. Ann Thorac Surg 2015; 99:911-7. [PMID: 25620596 DOI: 10.1016/j.athoracsur.2014.10.043] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Revised: 10/14/2014] [Accepted: 10/21/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Single ventricle lesions are associated with gradual attrition after surgical palliation with the total cavopulmonary connection (TCPC). Ventricular dysfunction is frequently noted, particularly impaired diastolic performance. This study seeks to relate TCPC hemodynamic energy losses to single ventricle volumes and filling characteristics. METHODS Cardiac magnetic resonance (CMR) data were retrospectively analyzed for 30 single ventricle patients at an average age of 12.7 ± 4.8 years. Cine ventricular short-axis scans were semiautomatically segmented for all cardiac phases. Ventricular volumes, ejection fraction, peak filling rate, peak ejection rate, and time to peak filling were calculated. Corresponding patient-specific TCPC geometry was acquired from a stack of transverse CMR images; relevant flow rates were segmented from through-plane phase contrast CMR data at TCPC inlets and outlets. The TCPC indexed power loss was calculated from computational fluid dynamics simulations using a validated custom solver. Time-averaged flow conditions and rigid vessel walls were assumed in all cases. Pearson correlations were used to detect relationships between variables, with p less than 0.05 considered significant. RESULTS Ventricular end-diastolic (R = -0.48) and stroke volumes (R = -0.37) had significant negative correlations with the natural logarithm of a flow-independent measure of power loss. This power loss measure also had a significant positive relationship to time to peak filling rate (normalized to cycle time; R = 0.67). CONCLUSIONS Flow-independent TCPC power loss is inversely related with ventricular end-diastolic and stroke volumes. Elevated power losses may contribute to impaired diastolic filling and limited preload reserve in single ventricle patients.
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Affiliation(s)
- Christopher M Haggerty
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia
| | - Kevin K Whitehead
- Division of Pediatric Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Mark A Fogel
- Division of Pediatric Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ajit P Yoganathan
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia.
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Flow simulations and validation for the first cohort of patients undergoing the Y-graft Fontan procedure. J Thorac Cardiovasc Surg 2015; 149:247-55. [DOI: 10.1016/j.jtcvs.2014.08.069] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 08/19/2014] [Accepted: 08/23/2014] [Indexed: 12/26/2022]
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Martin MH, Feinstein JA, Chan FP, Marsden AL, Yang W, Reddy VM. Technical feasibility and intermediate outcomes of using a handcrafted, area-preserving, bifurcated Y-graft modification of the Fontan procedure. J Thorac Cardiovasc Surg 2015; 149:239-45.e1. [DOI: 10.1016/j.jtcvs.2014.08.058] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 08/16/2014] [Accepted: 08/23/2014] [Indexed: 11/16/2022]
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Tang E, Yoganathan AP. Optimizing hepatic flow distribution with the Fontan Y-graft: Lessons from computational simulations. J Thorac Cardiovasc Surg 2015; 149:255-6. [DOI: 10.1016/j.jtcvs.2014.09.094] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2014] [Accepted: 09/25/2014] [Indexed: 10/24/2022]
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Computational modeling of Fontan physiology: at the crossroads of pediatric cardiology and biomedical engineering. Int J Cardiovasc Imaging 2014; 30:1073-84. [DOI: 10.1007/s10554-014-0442-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Accepted: 04/29/2014] [Indexed: 02/05/2023]
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Hashemi S, Parks WJ, Slesnick TC. 3D inversion recovery gradient echo respiratory navigator imaging using Gadofosveset Trisodium in a Fontan Y-graft patient. Int J Cardiovasc Imaging 2014; 30:993-4. [DOI: 10.1007/s10554-014-0452-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 05/13/2014] [Indexed: 10/25/2022]
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Abstract
The Fontan procedure, although an imperfect solution for children born with a single functional ventricle, is the only reconstruction at present short of transplantation. The haemodynamics associated with the total cavopulmonary connection, the modern approach to Fontan, are severely altered from the normal biventricular circulation and may contribute to the long-term complications that are frequently noted. Through recent technological advances, spear-headed by advances in medical imaging, it is now possible to virtually model these surgical procedures and evaluate the patient-specific haemodynamics as part of the pre-operative planning process. This is a novel paradigm with the potential to revolutionise the approach to Fontan surgery, help to optimise the haemodynamic results, and improve patient outcomes. This review provides a brief overview of these methods, presents preliminary results of their clinical usage, and offers insights into its potential future directions.
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Biglino G, Giardini A, Hsia TY, Figliola R, Taylor AM, Schievano S. Modeling single ventricle physiology: review of engineering tools to study first stage palliation of hypoplastic left heart syndrome. Front Pediatr 2013; 1:31. [PMID: 24400277 PMCID: PMC3864195 DOI: 10.3389/fped.2013.00031] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 10/11/2013] [Indexed: 12/27/2022] Open
Abstract
First stage palliation of hypoplastic left heart syndrome, i.e., the Norwood operation, results in a complex physiological arrangement, involving different shunting options (modified Blalock-Taussig, RV-PA conduit, central shunt from the ascending aorta) and enlargement of the hypoplastic ascending aorta. Engineering techniques, both computational and experimental, can aid in the understanding of the Norwood physiology and their correct implementation can potentially lead to refinement of the decision-making process, by means of patient-specific simulations. This paper presents some of the available tools that can corroborate clinical evidence by providing detailed insight into the fluid dynamics of the Norwood circulation as well as alternative surgical scenarios (i.e., virtual surgery). Patient-specific anatomies can be manufactured by means of rapid prototyping and such models can be inserted in experimental set-ups (mock circulatory loops) that can provide a valuable source of validation data as well as hydrodynamic information. Such models can be tuned to respond to differing the patient physiologies. Experimental set-ups can also be compatible with visualization techniques, like particle image velocimetry and cardiovascular magnetic resonance, further adding to the knowledge of the local fluid dynamics. Multi-scale computational models include detailed three-dimensional (3D) anatomical information coupled to a lumped parameter network representing the remainder of the circulation. These models output both overall hemodynamic parameters while also enabling to investigate the local fluid dynamics of the aortic arch or the shunt. As an alternative, pure lumped parameter models can also be employed to model Stage 1 palliation, taking advantage of a much lower computational cost, albeit missing the 3D anatomical component. Finally, analytical techniques, such as wave intensity analysis, can be employed to study the Norwood physiology, providing a mechanistic perspective on the ventriculo-arterial coupling for this specific surgical scenario.
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Affiliation(s)
- Giovanni Biglino
- Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science , London , UK ; Cardiorespiratory Unit, Great Ormond Street Hospital for Children, NHS Foundation Trust , London , UK
| | - Alessandro Giardini
- Cardiorespiratory Unit, Great Ormond Street Hospital for Children, NHS Foundation Trust , London , UK
| | - Tain-Yen Hsia
- Cardiorespiratory Unit, Great Ormond Street Hospital for Children, NHS Foundation Trust , London , UK
| | - Richard Figliola
- Departments of Bioengineering and Mechanical Engineering, Clemson University , Clemson, SC , USA
| | - Andrew M Taylor
- Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science , London , UK ; Cardiorespiratory Unit, Great Ormond Street Hospital for Children, NHS Foundation Trust , London , UK
| | - Silvia Schievano
- Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science , London , UK ; Cardiorespiratory Unit, Great Ormond Street Hospital for Children, NHS Foundation Trust , London , UK
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36
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Marsden AL. Simulation based planning of surgical interventions in pediatric cardiology. PHYSICS OF FLUIDS (WOODBURY, N.Y. : 1994) 2013; 25:101303. [PMID: 24255590 PMCID: PMC3820639 DOI: 10.1063/1.4825031] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Accepted: 09/22/2013] [Indexed: 05/17/2023]
Abstract
Hemodynamics plays an essential role in the progression and treatment of cardiovascular disease. However, while medical imaging provides increasingly detailed anatomical information, clinicians often have limited access to hemodynamic data that may be crucial to patient risk assessment and treatment planning. Computational simulations can now provide detailed hemodynamic data to augment clinical knowledge in both adult and pediatric applications. There is a particular need for simulation tools in pediatric cardiology, due to the wide variation in anatomy and physiology in congenital heart disease patients, necessitating individualized treatment plans. Despite great strides in medical imaging, enabling extraction of flow information from magnetic resonance and ultrasound imaging, simulations offer predictive capabilities that imaging alone cannot provide. Patient specific simulations can be used for in silico testing of new surgical designs, treatment planning, device testing, and patient risk stratification. Furthermore, simulations can be performed at no direct risk to the patient. In this paper, we outline the current state of the art in methods for cardiovascular blood flow simulation and virtual surgery. We then step through pressing challenges in the field, including multiscale modeling, boundary condition selection, optimization, and uncertainty quantification. Finally, we summarize simulation results of two representative examples from pediatric cardiology: single ventricle physiology, and coronary aneurysms caused by Kawasaki disease. These examples illustrate the potential impact of computational modeling tools in the clinical setting.
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Affiliation(s)
- Alison L Marsden
- Mechanical and Aerospace Engineering Department, University of California San Diego, La Jolla, California 92093, USA
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Desai K, Haggerty CM, Kanter KR, Rossignac J, Spray TL, Fogel MA, Yoganathan AP. Haemodynamic comparison of a novel flow-divider Optiflo geometry and a traditional total cavopulmonary connection. Interact Cardiovasc Thorac Surg 2013; 17:1-7. [PMID: 23563054 DOI: 10.1093/icvts/ivt099] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The total cavopulmonary connection (TCPC), the current palliation of choice for single-ventricle heart defects, is typically created with a single cylindrical tunnel or conduit routing inferior vena caval (IVC) flow to the pulmonary arteries. Previous studies have shown the haemodynamic efficiency of the TCPC to be sub-optimal due to the collision of vena caval flow, thus placing an extra energy burden on the single ventricle. The use of a bifurcated graft as the Fontan baffle (i.e. the 'Optiflo') has previously been proposed on the basis of theoretically improved flow efficiency; however, anatomical constraints may limit its effectiveness in some patients. METHODS In this study, an alternative approach to flow bifurcation is proposed, where a triangular insert is placed at the distal end of the IVC graft. The proof of concept for this design is demonstrated in two steps: first, determining the optimal insert size at a fixed Fontan graft size through a parametric study; then, characterizing the efficiency as a function of graft size when compared with a TCPC control. TCPC power loss and IVC flow distribution were the primary metrics of interest and were evaluated under both resting and simulated exercise conditions using an in-house computational fluid dynamics solver. RESULTS Results demonstrated that there was an optimal insert size that improved efficiency compared with the TCPC. For an 18-mm Fontan baffle, TCPC power loss was 4.1 vs 3.7 mW with the optimal flow-divider. The optimal insert was then scaled up for a 20-mm graft, with a similar reduction in power loss observed. Flow distribution results were inconsistent, based on sensitivity to the placement of the insert within the baffle. CONCLUSION This study demonstrated proof of concept that the flow-divider has the potential to reduce power loss and streamline IVC flow through the TCPC. An appropriate size for the insert in proportion to the Fontan baffle size was identified that reduced losses compared with a TCPC control under both resting and simulated exercise flow conditions.
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Affiliation(s)
- Kalpi Desai
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology & Emory University, Atlanta, GA 30332, USA
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Yang W, Feinstein JA, Shadden SC, Vignon-Clementel IE, Marsden AL. Optimization of a Y-Graft Design for Improved Hepatic Flow Distribution in the Fontan Circulation. J Biomech Eng 2012; 135:011002. [DOI: 10.1115/1.4023089] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Single ventricle heart defects are among the most serious congenital heart diseases, and are uniformly fatal if left untreated. Typically, a three-staged surgical course, consisting of the Norwood, Glenn, and Fontan surgeries is performed, after which the superior vena cava (SVC) and inferior vena cava (IVC) are directly connected to the pulmonary arteries (PA). In an attempt to improve hemodynamic performance and hepatic flow distribution (HFD) of Fontan patients, a novel Y-shaped graft has recently been proposed to replace the traditional tube-shaped extracardiac grafts. Previous studies have demonstrated that the Y-graft is a promising design with the potential to reduce energy loss and improve HFD. However these studies also found suboptimal Y-graft performance in some patient models. The goal of this work is to determine whether performance can be improved in these models through further design optimization. Geometric and hemodynamic factors that influence the HFD have not been sufficiently investigated in previous work, particularly for the Y-graft. In this work, we couple Lagrangian particle tracking to an optimal design framework to study the effects of boundary conditions and geometry on HFD. Specifically, we investigate the potential of using a Y-graft design with unequal branch diameters to improve hepatic distribution under a highly uneven RPA/LPA flow split. As expected, the resulting optimal Y-graft geometry largely depends on the pulmonary flow split for a particular patient. The unequal branch design is demonstrated to be unnecessary under most conditions, as it is possible to achieve the same or better performance with equal-sized branches. Two patient-specific examples show that optimization-derived Y-grafts effectively improve the HFD, compared to initial nonoptimized designs using equal branch diameters. An instance of constrained optimization shows that energy efficiency slightly increases with increasing branch size for the Y-graft, but that a smaller branch size is preferred when a proximal anastomosis is needed to achieve optimal HFD.
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Affiliation(s)
- Weiguang Yang
- Mechanical and Aerospace Engineering, University of California San Diego, La Jolla, CA 92093 e-mail:
| | | | - Shawn C. Shadden
- Mechanical, Materials, and
Aerospace Engineering, Illinois Institute of Technology, Chicago, IL 60616 e-mail:
| | | | - Alison L. Marsden
- Mechanical and Aerospace Engineering, University of California San Diego, La Jolla, CA 92093 e-mail:
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Haggerty CM, de Zélicourt DA, Restrepo M, Rossignac J, Spray TL, Kanter KR, Fogel MA, Yoganathan AP. Comparing pre- and post-operative Fontan hemodynamic simulations: implications for the reliability of surgical planning. Ann Biomed Eng 2012; 40:2639-51. [PMID: 22777126 DOI: 10.1007/s10439-012-0614-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2011] [Accepted: 06/27/2012] [Indexed: 11/25/2022]
Abstract
Virtual modeling of cardiothoracic surgery is a new paradigm that allows for systematic exploration of various operative strategies and uses engineering principles to predict the optimal patient-specific plan. This study investigates the predictive accuracy of such methods for the surgical palliation of single ventricle heart defects. Computational fluid dynamics (CFD)-based surgical planning was used to model the Fontan procedure for four patients prior to surgery. The objective for each was to identify the operative strategy that best distributed hepatic blood flow to the pulmonary arteries. Post-operative magnetic resonance data were acquired to compare (via CFD) the post-operative hemodynamics with predictions. Despite variations in physiologic boundary conditions (e.g., cardiac output, venous flows) and the exact geometry of the surgical baffle, sufficient agreement was observed with respect to hepatic flow distribution (90% confidence interval-14 ± 4.3% difference). There was also good agreement of flow-normalized energetic efficiency predictions (19 ± 4.8% error). The hemodynamic outcomes of prospective patient-specific surgical planning of the Fontan procedure are described for the first time with good quantitative comparisons between preoperatively predicted and postoperative simulations. These results demonstrate that surgical planning can be a useful tool for single ventricle cardiothoracic surgery with the ability to deliver significant clinical impact.
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Affiliation(s)
- Christopher M Haggerty
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, 313 Ferst Drive, Atlanta, GA 30332, USA
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