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Hoganson DM, Govindarajan V, Schulz NE, Eickhoff ER, Breitbart RE, Marx GR, del Nido PJ, Hammer PE. Multiphysiologic State Computational Fluid Dynamics Modeling for Planning Fontan With Interrupted Inferior Vena Cava. JACC. ADVANCES 2024; 3:101057. [PMID: 39129987 PMCID: PMC11312337 DOI: 10.1016/j.jacadv.2024.101057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 03/01/2024] [Accepted: 04/21/2024] [Indexed: 08/13/2024]
Abstract
Background Single ventricle (SV) patients with interrupted inferior vena cava (iIVC) and azygos continuation are at high risk for unbalanced hepatic venous flow (HVF) distribution to the lungs after Fontan completion and subsequent pulmonary arteriovenous malformations (AVMs) formation. Objectives The aim of the study was to utilize computational fluid dynamics (CFD) analysis to avoid maldistribution of HVF to the lungs after Fontan surgery. Methods Four SV subjects with iIVC were prospectively studied with a 3-dimensional (3D) modeling workflow with digital 3D models created from segmented magnetic resonance images or computer tomography scans, virtual surgery, and CFD analysis over multiple physiologic states for the evaluation of operative plans to achieve balanced HVF to both lungs. Three of the patients were Fontan revision candidates with existing AVMs. All patients underwent Fontan completion or revision surgery. Results CFD predicted that existing or proposed Fontan completion in all patients would result in 100% of HVF to one lung. Improved HVF balance was achieved with CFD analysis of alternative surgical approaches resulting in the average distribution of HVF to the right/left pulmonary arteries of 37%/63% ± 10.4%. A hepatoazygos shunt was required in all patients and additional creation of an innominate vein in one. CFD analysis was validated by the comparison of pre-operative predicted and postoperative MRI-measured total right/left pulmonary flow (51%/49% ± 5.4% vs 49%/51% ± 8.5%). Conclusions A 3D modeling workflow with CFD simulation for SV patients with iIVC may avoid HVF maldistribution and development of AVMs after Fontan completion.
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Affiliation(s)
- David M. Hoganson
- Department of Cardiac Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Vijay Govindarajan
- Department of Cardiac Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Noah E. Schulz
- Department of Cardiac Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Emily R. Eickhoff
- Department of Cardiac Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Roger E. Breitbart
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Gerald R. Marx
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Pedro J. del Nido
- Department of Cardiac Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Peter E. Hammer
- Department of Cardiac Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
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Schafstedde M, Yevtushenko P, Nordmeyer S, Kramer P, Schleiger A, Solowjowa N, Berger F, Photiadis J, Mykychak Y, Cho MY, Ovroutski S, Kuehne T, Brüning J. Virtual treatment planning in three patients with univentricular physiology using computational fluid dynamics—Pitfalls and strategies. Front Cardiovasc Med 2022; 9:898701. [PMID: 35990961 PMCID: PMC9381838 DOI: 10.3389/fcvm.2022.898701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 07/18/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundUneven hepatic venous blood flow distribution (HFD) to the pulmonary arteries is hypothesized to be responsible for the development of intrapulmonary arteriovenous malformations (PAVM) in patients with univentricular physiology. Thus, achieving uniform distribution of hepatic blood flow is considered favorable. However, no established method for the prediction of the post-interventional hemodynamics currently exists. Computational fluid dynamics (CFD) offers the possibility to quantify HFD in patient-specific anatomies before and after virtual treatment. In this study, we evaluated the potential benefit of CFD-assisted treatment planning.Materials and methodsThree patients with total cavopulmonary connection (TCPC) and PAVM underwent cardiovascular magnetic resonance imaging (CMR) and computed tomography imaging (CT). Based on this imaging data, the patient-specific anatomy was reconstructed. These patients were considered for surgery or catheter-based intervention aiming at hepatic blood flow re-routing. CFD simulations were then performed for the untreated state as well as for different surgical and interventional treatment options. These treatment options were applied as suggested by treating cardiologists and congenital heart surgeons with longstanding experience in interventional and surgical treatment of patients with univentricular physiology. HFD was quantified for all simulations to identify the most viable treatment decision regarding redistribution of hepatic blood flow.ResultsFor all three patients, the complex TCPC anatomy could be reconstructed. However, due to the presence of metallic stent implants, hybrid models generated from CT as well as CMR data were required. Numerical simulation of pre-interventional HFD agreed well with angiographic assessment and physiologic considerations. One treatment option resulting in improvement of HFD was identified for each patient. In one patient follow-up data after treatment was available. Here, the virtual treatment simulation and the CMR flow measurements differed by 15%.ConclusionThe combination of modern computational methods as well as imaging methods for assessment of patient-specific anatomy and flow might allow to optimize patient-specific therapy planning in patients with pronounced hepatic flow mismatch and PAVM. In this study, we demonstrate that these methods can also be applied in patients with complex univentricular physiology and extensive prior interventions. However, in those cases, hybrid approaches utilizing information of different image modalities may be required.
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Affiliation(s)
- Marie Schafstedde
- Department of Congenital Heart Disease–Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
- Institute for Cardiovascular Computer-Assisted Medicine, Charité–Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- German Centre for Cardiovascular Research, Partner Site Berlin, Berlin, Germany
- *Correspondence: Marie Schafstedde,
| | - Pavlo Yevtushenko
- Institute for Cardiovascular Computer-Assisted Medicine, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Sarah Nordmeyer
- Department of Congenital Heart Disease–Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
- Institute for Cardiovascular Computer-Assisted Medicine, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Kramer
- Department of Congenital Heart Disease–Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Anastasia Schleiger
- Department of Congenital Heart Disease–Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Natalia Solowjowa
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Felix Berger
- Department of Congenital Heart Disease–Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
- German Centre for Cardiovascular Research, Partner Site Berlin, Berlin, Germany
- Department of Pediatric Cardiology, Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Joachim Photiadis
- Department of Congenital Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Yaroslav Mykychak
- Department of Congenital Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Mi-Young Cho
- Department of Congenital Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Stanislav Ovroutski
- Department of Congenital Heart Disease–Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Titus Kuehne
- Department of Congenital Heart Disease–Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
- Institute for Cardiovascular Computer-Assisted Medicine, Charité–Universitätsmedizin Berlin, Berlin, Germany
- German Centre for Cardiovascular Research, Partner Site Berlin, Berlin, Germany
| | - Jan Brüning
- Institute for Cardiovascular Computer-Assisted Medicine, Charité–Universitätsmedizin Berlin, Berlin, Germany
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Pissarra D, Salgueiro E, Vaz T, Casanova J. The role of the hepatic factor on the improvement of arterial oxygenation after a Kawashima procedure: A case report. J Card Surg 2022; 37:1072-1075. [DOI: 10.1111/jocs.16265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 01/14/2022] [Indexed: 12/01/2022]
Affiliation(s)
- Diana Pissarra
- Department of Cardiothoracic SurgeryCentro Hospitalar Universitário S. JoãoPortoPortugal
- Department of Physiology and Surgery, Faculty of MedicineUniversity of PortoPortoPortugal
| | - Elson Salgueiro
- Department of Cardiothoracic SurgeryCentro Hospitalar Universitário S. JoãoPortoPortugal
- Department of Physiology and Surgery, Faculty of MedicineUniversity of PortoPortoPortugal
| | - Teresa Vaz
- Department of Pediatric CardiologyCentro Hospitalar Universitário S. JoãoPortoPortugal
| | - Jorge Casanova
- Department of Cardiothoracic SurgeryCentro Hospitalar Universitário S. JoãoPortoPortugal
- Department of Physiology and Surgery, Faculty of MedicineUniversity of PortoPortoPortugal
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Hepatic to azygos connection by autologous pericardial roll for Fontan completion. Cardiol Young 2020; 30:1356-1357. [PMID: 32662366 DOI: 10.1017/s1047951120001961] [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] [Indexed: 11/06/2022]
Abstract
Techniques for performing the Fontan completion procedure after Kawashima procedure have developed in recent years. This paper presents a case in which we performed an off-pump hepatic-to-azygos connection by autologous pericardial roll via thoracotomy as a modified Fontan completion. The operation wound was limited, and the short-term follow-up was satisfactory. Notably, it was found that the autologous pericardium might require a shorter period of anticoagulation treatment than what is needed for artificial prosthetic materials.
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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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