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Jalal Z, Langouet E, Dib N, Le-Quellenec S, Mostefa-Kara M, Martin A, Roubertie F, Thambo JB. Role and Applications of Experimental Animal Models of Fontan Circulation. J Clin Med 2024; 13:2601. [PMID: 38731130 PMCID: PMC11084605 DOI: 10.3390/jcm13092601] [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: 02/29/2024] [Revised: 04/17/2024] [Accepted: 04/26/2024] [Indexed: 05/13/2024] Open
Abstract
Over the last four decades, the Fontan operation has been the treatment of choice for children born with complex congenital heart diseases and a single-ventricle physiology. However, therapeutic options remain limited and despite ongoing improvements in initial surgical repair, patients still experience a multiplicity of cardiovascular complications. The causes for cardiovascular failure are multifactorial and include systemic ventricular dysfunction, pulmonary vascular resistance, atrioventricular valve regurgitation, arrhythmia, development of collaterals, protein-losing enteropathy, hepatic dysfunction, and plastic bronchitis, among others. The mechanisms leading to these late complications remain to be fully elucidated. Experimental animal models have been developed as preclinical steps that enable a better understanding of the underlying pathophysiology. They furthermore play a key role in the evaluation of the efficacy and safety of new medical devices prior to their use in human clinical studies. However, these experimental models have several limitations. In this review, we aim to provide an overview of the evolution and progress of the various types of experimental animal models used in the Fontan procedure published to date in the literature. A special focus is placed on experimental studies performed on animal models of the Fontan procedure with or without mechanical circulatory support as well as a description of their impact in the evolution of the Fontan design. We also highlight the contribution of animal models to our understanding of the pathophysiology and assess forthcoming developments that may improve the contribution of animal models for the testing of new therapeutic solutions.
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Affiliation(s)
- Zakaria Jalal
- Department of Pediatric and Adult Congenital Cardiology, University Hospital of Bordeaux, 33600 Pessac, France; (N.D.); (F.R.); (J.-B.T.)
- LIRYC Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, 33600 Pessac, France
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, 33600 Pessac, France
| | - Elise Langouet
- Department of Pediatric and Adult Congenital Cardiology Anesthesiology, University Hospital of Bordeaux, 33600 Pessac, France;
| | - Nabil Dib
- Department of Pediatric and Adult Congenital Cardiology, University Hospital of Bordeaux, 33600 Pessac, France; (N.D.); (F.R.); (J.-B.T.)
- LIRYC Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, 33600 Pessac, France
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, 33600 Pessac, France
| | | | - Mansour Mostefa-Kara
- Adult Congenital Heart Disease Medico-Surgical Unit, European Georges Pompidou Hospital, 75015 Paris, France;
| | - Amandine Martin
- Department of Cardiac Surgery, University Hospital, 97400 Saint-Denis, France;
| | - François Roubertie
- Department of Pediatric and Adult Congenital Cardiology, University Hospital of Bordeaux, 33600 Pessac, France; (N.D.); (F.R.); (J.-B.T.)
- LIRYC Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, 33600 Pessac, France
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, 33600 Pessac, France
| | - Jean-Benoît Thambo
- Department of Pediatric and Adult Congenital Cardiology, University Hospital of Bordeaux, 33600 Pessac, France; (N.D.); (F.R.); (J.-B.T.)
- LIRYC Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, 33600 Pessac, France
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, 33600 Pessac, France
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Cleveland V, Contento J, Mass P, Hardikar P, Wu Q, Liu X, Aslan S, Loke YH, Krieger A, Lunos S, Olivieri L, Sinha P. In vitro investigation of axial mechanical support devices implanted in the novel convergent cavopulmonary connection Fontan. Eur J Cardiothorac Surg 2024; 65:ezad413. [PMID: 38180888 DOI: 10.1093/ejcts/ezad413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 11/08/2023] [Accepted: 01/02/2024] [Indexed: 01/07/2024] Open
Abstract
OBJECTIVES The 2 opposing inflows and 2 outflows in a total cavopulmonary connection make mechanical circulatory support (MCS) extremely challenging. We have previously reported a novel convergent cavopulmonary connection (CCPC) Fontan design that improves baseline characteristics and provides a single inflow and outflow, thus simplifying MCS. This study aims to assess the feasibility of MCS of this novel configuration using axial flow pumps in an in vitro benchtop model. METHODS Three-dimensional segmentations of 12 single-ventricle patients (body surface area 0.5-1.75 m2) were generated from cardiovascular magnetic resonance images. The CCPC models were designed by connecting the inferior vena cava and superior vena cava to a shared conduit ascending to the pulmonary arteries, optimized in silico. The 12 total cavopulmonary connection and their corresponding CCPC models underwent in vitro benchtop characterization. Two MCS devices were used, the Impella RP® and the PediPump. RESULTS MCS successfully and symmetrically reduced the pressure in both vena cavae by >20 mmHg. The devices improved the hepatic flow distribution balance of all CCPC models (Impella RP®P = 0.045, PediPump P = 0.055). CONCLUSIONS The CCPC Fontan design provides a feasible MCS solution for a failing Fontan by balancing hepatic flow distribution and symmetrically decompressing the central venous pressure. Cardiac index may also improve with MCS. Additional studies are needed to evaluate this concept for managing Fontan failure.
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Affiliation(s)
- Vincent Cleveland
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
| | | | - Paige Mass
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
| | - Priyanka Hardikar
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
| | - Qiyuan Wu
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Xiaolong Liu
- Department of Mechanical Engineering, Texas Tech University, Lubbock, TX, USA
| | - Seda Aslan
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Yue-Hin Loke
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
| | - Axel Krieger
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Scott Lunos
- Biostatistical Design and Analysis Center, Clinical and Translational Science Institute, University of Minnesota, Minneapolis, MN, USA
| | - Laura Olivieri
- Division of Pediatric Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Pranava Sinha
- Department of Pediatric Cardiac Surgery, M Health Fairview University of Minnesota, Minneapolis, MN, USA
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Goto T, Ousaka D, Hirai K, Kotani Y, Kasahara S. Intravenous infusion of cardiac progenitor cells in animal models of single ventricular physiology. Eur J Cardiothorac Surg 2023; 64:ezad304. [PMID: 37824193 PMCID: PMC10576638 DOI: 10.1093/ejcts/ezad304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 08/17/2023] [Accepted: 10/11/2023] [Indexed: 10/13/2023] Open
Abstract
OBJECTIVES The goal of this study was to identify the practical applications of intravenous cell therapy for single-ventricle physiology (SVP) by establishing experimental SVP models. METHODS An SVP with a three-stage palliation was constructed in an acute swine model without cardiopulmonary bypass. A modified Blalock-Taussig (MBT) shunt was created using an aortopulmonary shunt with the superior and inferior venae cavae (SVC and IVC, respectively) connected to the left atrium (n = 10). A bidirectional cavopulmonary shunt (BCPS) was constructed using a graft between the IVC and the left atrium with an SVC cavopulmonary connection (n = 10). The SVC and the IVC were connected to the pulmonary artery to establish a total cavopulmonary connection (TCPC, n = 10). The survival times of half of the animal models were studied. The other half and the biventricular sham control (n = 5) were injected intravenously with cardiosphere-derived cells (CDCs), and the cardiac retention of CDCs was assessed after 2 h. RESULTS All SVP models died within 20 h. Perioperative mortality was higher in the BCPS group because of lower oxygen saturation (P < 0.001). Cardiac retention of intravenously delivered CDCs, as detected by magnetic resonance imaging and histologic analysis, was significantly higher in the modified Blalock-Taussig and BCPS groups than in the TCPC group (P < 0.01). CONCLUSIONS Without the total right heart exclusion, stage-specific SVP models can be functionally constructed in pigs with stable outcomes. Intravenous CDC injections may be applicable in patients with SVP before TCPC completion, given that the initial lung trafficking is efficiently bypassed and sufficient systemic blood flow is supplied from the single ventricle.
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Affiliation(s)
- Takuya Goto
- Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences and Okayama University Hospital, Okayama, Japan
| | - Daiki Ousaka
- Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences and Okayama University Hospital, Okayama, Japan
| | - Kenta Hirai
- Department of Cardiovascular Pediatrics, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences and Okayama University Hospital, Okayama, Japan
| | - Yasuhiro Kotani
- Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences and Okayama University Hospital, Okayama, Japan
| | - Shingo Kasahara
- Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences and Okayama University Hospital, Okayama, Japan
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Corno AF, Findley TO, Salazar JD. Narrative review of single ventricle: where are we after 40 years? Transl Pediatr 2023; 12:221-244. [PMID: 36891374 PMCID: PMC9986776 DOI: 10.21037/tp-22-573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 01/10/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Key medical and surgical advances have been made in the longitudinal management of patients with "functionally" single ventricle physiology, with the principles of Fontan circulation applied to other complex congenital heart defects. The purpose of this article is to review all of the innovations, starting from fetal life, that led to a change of strategy for single ventricle. METHODS Our literature review included all full articles published in English language on the Cochrane, MedLine, and Embase with references to "single ventricle" and "univentricular hearts", including the initial history of the treatments for this congenital heart defects as well as the innovations reported within the last decades. KEY CONTENT AND FINDINGS All innovations introduced have been analyzed, including: (I) fetal diagnosis and interventions, in particular to prevent or reduce brain damages; (II) neonatal care; (III) post-natal diagnosis; (IV) interventional cardiology procedures; (V) surgical procedures, including neonatal palliations, hybrid procedures, bidirectional Glenn and variations, Fontan completion, biventricular repair; (VI) peri-operative management; (VII) Fontan failure, with Fontan take-down and conversion, and mechanical circulatory support; (VIII) transplantation, including heart, heart and lung, heart and liver; (IX) exercise; (X) pregnancy; (XI) adolescents and adults without Fontan completion; (XII) future studies, including experimental studies on animals, computational studies, genetics, stem cells and bioengineering. CONCLUSIONS These last 40 years have certainly changed the course of natural history for children born with any form of "functionally" single ventricle, thanks to the improvement in diagnostic and treatment techniques, and particularly to the increased knowledge of the morphology and function of these complex hearts, from fetal to adult life. There is still much left unexplored and room for improvement, and all efforts should be concentrated in collaborations among different institutions and specialties, focused on the same matter.
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Affiliation(s)
- Antonio F Corno
- Pediatric and Congenital Cardiac Surgery, Children's Heart Institute, Department of Pediatrics, Memorial Hermann Children's Hospital, McGovern Medical School at the University of Texas Health Science Center in Houston, Houston, TX, USA
| | - Tina O Findley
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Memorial Hermann Children's Hospital, McGovern Medical School at the University of Texas Health Science Center in Houston, Houston, TX, USA
| | - Jorge D Salazar
- Pediatric and Congenital Cardiac Surgery, Children's Heart Institute, Department of Pediatrics, Memorial Hermann Children's Hospital, McGovern Medical School at the University of Texas Health Science Center in Houston, Houston, TX, USA
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Venna A, Cetta F, d'Udekem Y. Fontan candidacy, optimizing Fontan circulation, and beyond. JTCVS OPEN 2022; 9:227-232. [PMID: 36003486 PMCID: PMC9390390 DOI: 10.1016/j.xjon.2021.07.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Indexed: 10/24/2022]
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Gorbea M. A Review of Physiologic Considerations and Challenges in Pediatric Patients With Failing Single- Ventricle Physiology Undergoing Ventricular Assist Device Placement. J Cardiothorac Vasc Anesth 2021; 36:1756-1770. [PMID: 34229925 DOI: 10.1053/j.jvca.2021.05.045] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/16/2021] [Accepted: 05/21/2021] [Indexed: 11/11/2022]
Abstract
Advances in surgical techniques and outpatient cardiac care have led to a growing population of pediatric patients surviving well into adulthood with previous single-ventricle palliation. Continued improvement in survival has resulted in subsequent increases in the number of patients with single-ventricle physiology listed for heart transplantations. Some of these patients require mechanical circulatory support as a bridge to transplantation, although establishing successful mechanical circulatory support in these complex patients remains challenging. Only limited published data exist describing the perioperative anesthetic management and key considerations dedicated to patients with failing single-ventricle physiology presenting for ventricular assist devices. This clinical review aims to provide a focused evaluation of the vital perioperative considerations encountered in this novel population.
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Affiliation(s)
- Mikel Gorbea
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Children's Medical Center, Dallas, TX.
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Granegger M, Valencia A, Quandt D, Dave H, Kretschmar O, Hübler M, Schweiger M. Approaches to Establish Extracardiac Total Cavopulmonary Connections in Animal Models—A Review. World J Pediatr Congenit Heart Surg 2019; 10:81-89. [DOI: 10.1177/2150135118802788] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Long-term survival of patients with a single ventricle palliated with a Fontan procedure is still limited. No curative treatment options are available. To investigate the pathophysiology and potential treatment options, such as mechanical circulatory support (MCS), appropriate large animal models are required. The aim of this review was to analyze all full-text manuscripts presenting approaches for an extracardiac total cavopulmonary connection (TCPC) animal model to identify the feasibility and limitations in the acute and chronic setting. Methods: A literature search was performed for full-text publications presenting large animal models with extracardiac TCPCs on Pubmed and Embase. Out of 454 reviewed papers, 23 manuscripts fulfilled the inclusion criteria. Surgical procedures were categorized and hemodynamic changes at the transition from the biventricular to the univentricular condition analyzed. Results: Surgical procedures varied especially regarding coronary venous flow handling and anatomic shape of the TCPC. In most studies (n = 14), the main pulmonary artery was clamped and the coronary venous flow redirected by additional surgical interventions. Only in five reports, the caval veins were connected to the right pulmonary artery to create a true TCPC shape, whereas in all others (n = 18), the veins were connected to the main pulmonary artery. An elevated pulmonary vascular resistance was identified as a limiting hemodynamic factor for TCPC completion in healthy animals. Conclusions: A variety of acute TCPC animal models were successfully established with and without MCS, reflecting the most important hemodynamic features of a Fontan circulation; however, chronic animal models were not reported.
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Affiliation(s)
- Marcus Granegger
- Pediatric Cardiovascular Surgery, Pediatric Heart Center, Department of Surgery, University Children’s Hospital Zurich, Zurich, Switzerland
- Children’s Research Center, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Anna Valencia
- Pediatric Cardiovascular Surgery, Pediatric Heart Center, Department of Surgery, University Children’s Hospital Zurich, Zurich, Switzerland
- Children’s Research Center, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Daniel Quandt
- Children’s Research Center, University Children’s Hospital Zurich, Zurich, Switzerland
- Pediatric Cardiology, Pediatric Heart Center, Department of Surgery, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Hitendu Dave
- Pediatric Cardiovascular Surgery, Pediatric Heart Center, Department of Surgery, University Children’s Hospital Zurich, Zurich, Switzerland
- Children’s Research Center, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Oliver Kretschmar
- Children’s Research Center, University Children’s Hospital Zurich, Zurich, Switzerland
- Pediatric Cardiology, Pediatric Heart Center, Department of Surgery, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Michael Hübler
- Pediatric Cardiovascular Surgery, Pediatric Heart Center, Department of Surgery, University Children’s Hospital Zurich, Zurich, Switzerland
- Children’s Research Center, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Martin Schweiger
- Pediatric Cardiovascular Surgery, Pediatric Heart Center, Department of Surgery, University Children’s Hospital Zurich, Zurich, Switzerland
- Children’s Research Center, University Children’s Hospital Zurich, Zurich, Switzerland
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An Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) analysis of hospitalization, functional status, and mortality after mechanical circulatory support in adults with congenital heart disease. J Heart Lung Transplant 2018; 37:619-630. [DOI: 10.1016/j.healun.2017.11.010] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Revised: 10/12/2017] [Accepted: 11/13/2017] [Indexed: 11/19/2022] Open
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Mosca RS. Super Glenn: Able to Defeat Recalcitrant Pulmonary Vascular Adversaries? Semin Thorac Cardiovasc Surg 2018; 30:189-190. [PMID: 29684550 DOI: 10.1053/j.semtcvs.2018.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Ralph S Mosca
- Department of Cardiac Surgery, NYU Langone Health, New York, New York.
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Miller JR, Lancaster TS, Callahan C, Abarbanell AM, Eghtesady P. An overview of mechanical circulatory support in single-ventricle patients. Transl Pediatr 2018; 7:151-161. [PMID: 29770296 PMCID: PMC5938256 DOI: 10.21037/tp.2018.03.03] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The population of people with a single-ventricle is continually increasing due to improvements across the spectrum of medical care. Unfortunately, a proportion of these patients will develop heart failure. Often, for these patients, mechanical circulatory support (MCS) represents the only available treatment option. While single-ventricle patients currently represent a small proportion of the total number of patients who receive MCS, as the single-ventricle patient population increases, this number will increase as well. Outcomes for these complex single-ventricle patients who require MCS has begun to be evaluated. When considering the entire population, survival to hospital discharge is 30-50%, though this must be considered with the significant heterogeneity of the single-ventricle patient population. Patients with a single-ventricle have unique anatomy, mechanisms of failure, indications for MCS and the type of support utilized. This has made the interpretation and the generalizability of the limited available data difficult. It is likely that some subsets will have a significantly worse prognosis and others a better one. Unfortunately, with these limited data, indications of a favorable or poor outcome have not yet been elucidated. Though currently, a database has been constructed to address this issue. While the outcomes for these complex patients is unclear, at least in some situations, they are poor. However, significant advances may provide improvements going forward, including new devices, computer simulations and 3D printed models. The most important factor, however, will be the increased experience gained by the heart failure team to improve patient selection, timing, device and configuration selection and operative approach.
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Affiliation(s)
- Jacob R Miller
- Division of Cardiothoracic Surgery, Barnes-Jewish Hospital/Washington University School of Medicine, St. Louis, MO, USA
| | - Timothy S Lancaster
- Division of Cardiothoracic Surgery, Barnes-Jewish Hospital/Washington University School of Medicine, St. Louis, MO, USA
| | - Connor Callahan
- Department of Surgery, Barnes-Jewish Hospital/Washington University School of Medicine, St. Louis, MO, USA
| | - Aaron M Abarbanell
- Section of Pediatric Cardiothoracic Surgery, St. Louis Children's Hospital/Washington University School of Medicine, St. Louis, MO, USA
| | - Pirooz Eghtesady
- Section of Pediatric Cardiothoracic Surgery, St. Louis Children's Hospital/Washington University School of Medicine, St. Louis, MO, USA
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Pump in Parallel—Mechanical Assistance of Partial Cavopulmonary Circulation Using a Conventional Ventricular Assist Device. ASAIO J 2018; 64:238-244. [DOI: 10.1097/mat.0000000000000613] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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12
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Peer SM, Deatrick KB, Johnson TJ, Haft JW, Pagani FD, Ohye RG, Bove EL, Rojas-Peña A, Si MS. Mechanical Circulatory Support for the Failing Fontan: Conversion to Assisted Single Ventricle Circulation—Preliminary Observations. World J Pediatr Congenit Heart Surg 2018; 9:31-37. [DOI: 10.1177/2150135117733968] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background: Mechanical circulatory support (MCS) of a failing Fontan circulation remains challenging. We hypothesized that MCS can be provided by converting the Fontan circulation into a mechanically assisted single ventricle parallel circulation (MASVC). Methods: A porcine model of functionally univentricular circulation was created under cardiopulmonary bypass (CPB) by performing an atrial septectomy, tricuspid valvectomy, and interrupting antegrade pulmonary blood flow. A centrifugal flow pump was placed with inflow from the common atrium. Eight millimeter Dacron grafts anastomosed to the ascending aorta and main pulmonary artery supplied systemic (Qs) and pulmonary (Qp) blood flow. Ultrasonic flow probes were used to measure Qs and Qp after weaning from CPB. The Qp/Qs ratio was regulated using an adjustable clamp. Hemodynamic and laboratory data were recorded. Results: All four animals were successfully weaned from CPB onto the MASVC for a duration of two hours. Mechanically assisted single ventricle parallel circulation achieved satisfactory hemodynamics. As anticipated, the arterial oxygen saturation and partial pressure of oxygen in arterial blood were lower in the MASVC compared to baseline biventricular circulation. At the conclusion of the study, there was a trend towards a decrease in the mixed venous saturation with increasing oxygen extraction compared to the baseline. Serum lactate levels increased after weaning from CPB and did not return to baseline after two hours of support. Conclusion: Mechanically assisted single ventricle parallel circulation can be established in a single ventricle animal model. This strategy could potentially provide MCS of a single ventricle circulation. Studies with longer duration of support are required to assess adequacy of support and long-term sustainability.
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Affiliation(s)
- Syed M. Peer
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
- Department of Pediatric Cardiac Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Kristopher B. Deatrick
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Thomas J. Johnson
- Department of Surgery-Section of Transplantation, ECMO Laboratory, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jonathan W. Haft
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Francis D. Pagani
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Richard G. Ohye
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Edward L. Bove
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Alvaro Rojas-Peña
- Department of Surgery-Section of Transplantation, ECMO Laboratory, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Ming-Sing Si
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
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13
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VanderPluym CJ, Cedars A, Eghtesady P, Maxwell BG, Gelow JM, Burchill LJ, Maltais S, Koehl DA, Cantor RS, Blume ED. Outcomes following implantation of mechanical circulatory support in adults with congenital heart disease: An analysis of the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS). J Heart Lung Transplant 2018; 37:89-99. [DOI: 10.1016/j.healun.2017.03.005] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 02/14/2017] [Accepted: 03/03/2017] [Indexed: 11/27/2022] Open
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14
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Carlo WF, Villa CR, Lal AK, Morales DL. Ventricular assist device use in single ventricle congenital heart disease. Pediatr Transplant 2017; 21. [PMID: 28921937 DOI: 10.1111/petr.13031] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2017] [Indexed: 11/29/2022]
Abstract
As VAD have become an effective therapy for end-stage heart failure, their application in congenital heart disease has increased. Single ventricle congenital heart disease introduces unique physiologic challenges for VAD use. However, with regard to the mixed clinical results presented within this review, we suggest that patient selection, timing of implant, and center experience are all important contributors to outcome. This review focuses on the published experience of VAD use in single ventricle patients and details physiologic challenges and novel approaches in this growing pediatric and adult population.
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Affiliation(s)
- Waldemar F Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Chet R Villa
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Ashwin K Lal
- Primary Children's Hospital, University of Utah, Salt Lake City, UT, USA
| | - David L Morales
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Mongé MC, Kulat BT, Eltayeb O, Zingle NR, Moss ST, Gossett JG, Pahl E, Costello JM, Backer CL. Successful Bridge-to-Transplant of Functionally Univentricular Patients With a Modified Continuous-Flow Ventricular Assist Device. Artif Organs 2017; 41:25-31. [DOI: 10.1111/aor.12881] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 08/19/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Michael C. Mongé
- Divisions of Cardiovascular-Thoracic Surgery; Chicago IL, USA
- Departments of Surgery, Northwestern University Feinberg School of Medicine; Chicago IL, USA
| | | | - Osama Eltayeb
- Divisions of Cardiovascular-Thoracic Surgery; Chicago IL, USA
- Departments of Surgery, Northwestern University Feinberg School of Medicine; Chicago IL, USA
| | - Neale R. Zingle
- Divisions of Cardiovascular-Thoracic Surgery; Chicago IL, USA
| | - Steven T. Moss
- Divisions of Cardiovascular-Thoracic Surgery; Chicago IL, USA
| | - Jeffrey G. Gossett
- Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago; Chicago IL, USA
- Pediatrics, Northwestern University Feinberg School of Medicine; Chicago IL, USA
| | - Elfriede Pahl
- Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago; Chicago IL, USA
- Pediatrics, Northwestern University Feinberg School of Medicine; Chicago IL, USA
| | - John M. Costello
- Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago; Chicago IL, USA
- Pediatrics, Northwestern University Feinberg School of Medicine; Chicago IL, USA
| | - Carl L. Backer
- Divisions of Cardiovascular-Thoracic Surgery; Chicago IL, USA
- Departments of Surgery, Northwestern University Feinberg School of Medicine; Chicago IL, USA
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Chopski SG, Moskowitz WB, Stevens RM, Throckmorton AL. Mechanical Circulatory Support Devices for Pediatric Patients With Congenital Heart Disease. Artif Organs 2016; 41:E1-E14. [DOI: 10.1111/aor.12760] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Revised: 03/21/2016] [Accepted: 03/22/2016] [Indexed: 01/03/2023]
Affiliation(s)
- Steven G. Chopski
- BioCirc Research Laboratory, School of Biomedical Engineering, Science and Health Systems; Drexel University; Philadelphia PA
| | - William B. Moskowitz
- Division of Pediatric Cardiology, Children's Hospital of Richmond and School of Medicine; Virginia Commonwealth University; Richmond VA
| | - Randy M. Stevens
- St. Christopher's Hospital for Children, Tenet Healthcare Corporation; Philadelphia PA USA
| | - Amy L. Throckmorton
- BioCirc Research Laboratory, School of Biomedical Engineering, Science and Health Systems; Drexel University; Philadelphia PA
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Lin SN, Huang SC, Chen YS, Chih NH, Wang CH, Chou NK, Yu HY, Wu IH, Shun CT, Wang SS. Case Series: Heart Transplantation After Fontan Operation-Single-Center Experience. Transplant Proc 2016; 48:959-64. [PMID: 27234779 DOI: 10.1016/j.transproceed.2016.01.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 01/14/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Fontan failure (FF) occurs rarely. In patients with Fontan failure, heart transplantation is believed to be the most effective therapy. We review our experience in heart transplantations after the Fontan operation. METHODS From July 1987 to December 2014, 4 of 513 patients underwent orthotopic heart transplantation (OHT). Among them, 4 were due to FF. We reviewed these 4 cases via retrospective chart review. Clinical history, laboratory data, surgical technique, perioperative variables, and outcomes of long-term follow-up are presented herein. The primary outcomes were hospital mortality, 1-year-survival rate, and 4-year-survival rate. The secondary outcome is the improvement in patients with protein-losing enteropathy. RESULTS The hospital mortality rate was 0% in the 4 FF patients receiving OHT. No surgically related hemorrhage or infection was observed. The 1-year-survival rate was 100% (n = 4) and the 4-year-survival rate 50% (n = 2). One patient died of posttransplantation lymphoproliferative disorder. Hypoalbuminemia improved in 1 of 3 patients 4 months after OHT. CONCLUSIONS Despite technical challenges, heart transplantation can be performed successfully in patients with Fontan operation. However, protein-losing enteropathy might not be resolved quickly after heart transplantation.
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Affiliation(s)
- S-N Lin
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - S-C Huang
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Y-S Chen
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - N-H Chih
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - C-H Wang
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - N-K Chou
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - H-Y Yu
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - I-H Wu
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - C-T Shun
- Department of Pathology, National Taiwan University Hospital, Taipei, Taiwan
| | - S-S Wang
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan; Department of Surgery, Fu Jen Catholic University Hospital, and Fu Jen Catholic University College of Medicine, New Taipei City, Taiwan.
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Jaquiss RDB, Aziz H. Is Four Stage Management the Future of Univentricular Hearts? Destination Therapy in the Young. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2016; 19:50-54. [PMID: 27060043 DOI: 10.1053/j.pcsu.2015.12.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 12/10/2015] [Accepted: 12/10/2015] [Indexed: 06/05/2023]
Abstract
For the child born with a functionally univentricular heart, multi-stage surgical palliation culminating in the Fontan operation is now well established as the standard of care. Though this is an effective approach, there are several inherent disadvantages to the Fontan circulation: subnormal resting cardiac output, impaired exercise capacity, increased risk of thromboembolism, and increased risk of arrhythmia. Perhaps most importantly, the long-term deleterious effects of substantial systemic venous hypertension, which is necessary to "drive" blood through the pulmonary vascular bed, include progressive dysfunction of other organ systems, particularly renal, lymphatic, gastrointestinal, and hepatic systems. When such dysfunction is advanced, heart transplantation or even heart-liver transplantation may be a reasonable option. However, because the syndrome seems to be increasingly widespread and there is already a significant donor shortage, alternative solutions are required. Because many patients with "failing Fontan" physiology have preserved systemic ventricular function, application of a systemic ventricular assist device is unlikely to be effective. However, for such patients, a right-sided sub-pulmonary ventricular assist device is an intellectually appealing solution. Several such devices have been proposed or are in varying stages of evaluation. The lack of economic incentive for development of right-sided pumps may be partially ameliorated both by recognition of the size of the cohort of Fontan patients now surviving into adulthood as well as by the increasing recognition of important right-sided heart failure in adults with biventricular hearts supported only with durable left-sided ventricular assist devices.
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Affiliation(s)
- Robert D B Jaquiss
- Duke Children's Hospital and Department of Surgery, Division of Cardiothoracic Surgery, Duke University School of Medicine, Durham, NC.
| | - Hamza Aziz
- Duke Children's Hospital and Department of Surgery, Division of Cardiothoracic Surgery, Duke University School of Medicine, Durham, NC
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19
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Greenway SC, Crossland DS, Hudson M, Martin SR, Myers RP, Prieur T, Hasan A, Kirk R. Fontan-associated liver disease: Implications for heart transplantation. J Heart Lung Transplant 2016; 35:26-33. [DOI: 10.1016/j.healun.2015.10.015] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Revised: 09/26/2015] [Accepted: 10/14/2015] [Indexed: 01/19/2023] Open
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20
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Di Molfetta A, Amodeo A, Fresiello L, Filippelli S, Pilati M, Iacobelli R, Adorisio R, Colella D, Ferrari G. The use of a numerical model to simulate the cavo-pulmonary assistance in Fontan circulation: a preliminary verification. J Artif Organs 2015; 19:105-13. [PMID: 26545595 DOI: 10.1007/s10047-015-0874-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 10/26/2015] [Indexed: 12/30/2022]
Abstract
The lack of an established experience on the use of VAD for the cavo-pulmonary assistance leads to the need of dedicated VADs development and animal experiments. A dedicated numerical model could support clinical and experimental strategies design and new VADs testing. The aim of this work is to perform a preliminary verification of a lumped parameter model of the cardiovascular system to simulate Fontan physiology and the effect of cavo-pulmonary assistance. Literature data of 4 pigs were used to simulate animals' baseline, and then the model was tested in simulating Fontan circulation and cavo-pulmonary-assisted condition comparing the simulation outcome (Sim) with measured literature data (Me). The results show that the numerical model can well reproduce experimental data in all three conditions (baseline, Fontan and assisted Fontan) [cardiac output (l/min): Me = 2.8 ± 1.7, Sim = 2.8 ± 1.8; ejection fraction (%): Me = 57 ± 17, Sim = 54 ± 17; arterial systemic pressure (mmHg): Me = 41.8 ± 18.6, Sim = 43.8 ± 18.1; pulmonary arterial pressure (mmHg): Me = 15.4 ± 8.9, Sim = 17.7 ± 9.9; caval pressure (mmHg): Me = 6.8 ± 4.1, Sim = 7 ± 4.6]. Systolic elastance, arterial systemic and arterial pulmonary resistances increase (10, 69, and 100 %) passing from the biventricular circulation to the Fontan physiology and then decrease (21, 39, and 50 %) once the VAD was implanted. The ventricular external work decreases (71 %) passing from the biventricular circulation to the Fontan physiology and it increases three times after the VAD implantation in parallel with the VAD power consumption. A numerical model could support clinicians in an innovative and challenging field as the use of VAD to assist the Fontan physiology and it could be helpful to personalize the VAD insertion on the base of ventricular systo-diastolic function, circulatory parameters and energetic variables.
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Affiliation(s)
- Arianna Di Molfetta
- Department of Pediatric Cardiology and Cardiosurgery, Pediatric Hospital Bambino Gesù, Via San Martino della Battaglia, 44, 00185, Rome, Italy.
| | - Antonio Amodeo
- Department of Pediatric Cardiology and Cardiosurgery, Pediatric Hospital Bambino Gesù, Via San Martino della Battaglia, 44, 00185, Rome, Italy
| | | | - Sergio Filippelli
- Department of Pediatric Cardiology and Cardiosurgery, Pediatric Hospital Bambino Gesù, Via San Martino della Battaglia, 44, 00185, Rome, Italy
| | - Mara Pilati
- Department of Pediatric Cardiology and Cardiosurgery, Pediatric Hospital Bambino Gesù, Via San Martino della Battaglia, 44, 00185, Rome, Italy
| | - Roberta Iacobelli
- Department of Pediatric Cardiology and Cardiosurgery, Pediatric Hospital Bambino Gesù, Via San Martino della Battaglia, 44, 00185, Rome, Italy
| | - Rachele Adorisio
- Department of Pediatric Cardiology and Cardiosurgery, Pediatric Hospital Bambino Gesù, Via San Martino della Battaglia, 44, 00185, Rome, Italy
| | - Dionisio Colella
- Cardiac Surgery Intensive Care Unit, University of Tor Vergata, Rome, Italy
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22
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Horne D, Conway J, Rebeyka IM, Buchholz H. Mechanical circulatory support in univentricular hearts: current management. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2015; 18:17-24. [PMID: 25939838 DOI: 10.1053/j.pcsu.2015.02.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Failing single-ventricle patients have now come into focus as the next cohort where improvement in outcomes for mechanical circulatory support can be realized. There is a paucity of published patient reports or management protocols in this patient population. Increased interest exists in finding answers of how to bridge these patients to transplant. We review the current literature and describe our approach to the patient with univentricular heart needing mechanical circulatory support.
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Affiliation(s)
- David Horne
- Division of Cardiac Surgery, University of Alberta, Stollery Children׳s Hospital, Edmonton, Alberta, Canada.
| | - Jennifer Conway
- Division of Pediatric Cardiology, University of Alberta, Stollery Children׳s Hospital, Edmonton, Alberta, Canada
| | - Ivan M Rebeyka
- Division of Cardiac Surgery, University of Alberta, Stollery Children׳s Hospital, Edmonton, Alberta, Canada
| | - Holger Buchholz
- Division of Cardiac Surgery, University of Alberta, Stollery Children׳s Hospital, Edmonton, Alberta, Canada
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