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Sahni A, Marshall L, Cetatoiu MA, Davee J, Schulz N, Eickhoff ER, St Clair N, Ghelani S, Prakash A, Hammer PE, Hoganson DM, Del Nido PJ, Rathod RH, Govindarajan V. Biomechanical Analysis of Age-Dependent Changes in Fontan Power Loss. Ann Biomed Eng 2024; 52:2440-2456. [PMID: 38753109 DOI: 10.1007/s10439-024-03534-9] [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: 11/08/2023] [Accepted: 05/02/2024] [Indexed: 08/17/2024]
Abstract
The hemodynamics in Fontan patients with single ventricles rely on favorable flow and energetics, especially in the absence of a subpulmonary ventricle. Age-related changes in energetics for extracardiac and lateral tunnel Fontan procedures are not well understood. Vorticity (VOR) and viscous dissipation rate (VDR) are two descriptors that can provide insights into flow dynamics and dissipative areas in Fontan pathways, potentially contributing to power loss. This study examined power loss and its correlation with spatio-temporal flow descriptors (vorticity and VDR). Data from 414 Fontan patients were used to establish a relationship between the superior vena cava (SVC) to inferior vena cava (IVC) flow ratio and age. Computational flow modeling was conducted for both extracardiac conduits (ECC, n = 16) and lateral tunnels (LT, n = 25) at different caval inflow ratios of 2, 1, and 0.5 that corresponded with ages 3, 8, and 15+. In both cohorts, vorticity and VDR correlated well with PL, but ECC cohort exhibited a slightly stronger correlation for PL-VOR (>0.83) and PL-VDR (>0.89) than that for LT cohort (>0.76 and > 0.77, respectively) at all ages. Our data also suggested that absolute and indexed PL increase (p < 0.02) non-linearly as caval inflow changes with age and are highly patient-specific. Comparison of indexed power loss between our ECC and LT cohort showed that while ECC had a slightly higher median PL for all 3 caval inflow ratio examined (3.3, 8.3, 15.3) as opposed to (2.7, 7.6, 14.8), these differences were statistically non-significant. Lastly, there was a consistent rise in pressure gradient across the TCPC with age-related increase in IVC flows for both ECC and LT Fontan patient cohort. Our study provided hemodynamic insights into Fontan energetics and how they are impacted by age-dependent change in caval inflow. This workflow may help assess the long-term sustainability of the Fontan circulation and inform the design of more efficient Fontan conduits.
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Affiliation(s)
- A Sahni
- Department of Cardiac Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - L Marshall
- Department of Cardiac Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - M A Cetatoiu
- Department of Cardiac Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - J Davee
- Department of Cardiac Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - N Schulz
- Department of Cardiac Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - E R Eickhoff
- Department of Cardiac Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - N St Clair
- Department of Cardiac Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - S Ghelani
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - A Prakash
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - P E Hammer
- Department of Cardiac Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Department of Surgery, Harvard Medical School, Boston, MA, USA
| | - D M Hoganson
- Department of Cardiac Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Department of Surgery, Harvard Medical School, Boston, MA, USA
| | - P J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Department of Surgery, Harvard Medical School, Boston, MA, USA
| | - R H Rathod
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Vijay Govindarajan
- Department of Cardiac Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA.
- Department of Surgery, Harvard Medical School, Boston, MA, USA.
- Department of Internal Medicine (Cardiology), The University of Texas Health Science Center at Houston, Houston, TX, USA.
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Rasooli R, Holmstrom H, Giljarhus KET, Jolma IW, Vinningland JL, de Lange C, Brun H, Hiorth A. In vitro hemodynamic performance of a blood pump for self-powered venous assist in univentricular hearts. Sci Rep 2024; 14:6941. [PMID: 38521832 PMCID: PMC10960831 DOI: 10.1038/s41598-024-57269-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 03/15/2024] [Indexed: 03/25/2024] Open
Abstract
Univentricular heart anomalies represent a group of severe congenital heart defects necessitating early surgical intervention in infancy. The Fontan procedure, the final stage of single-ventricle palliation, establishes a serial connection between systemic and pulmonary circulation by channeling venous return to the lungs. The absence of the subpulmonary ventricle in this peculiar circulation progressively eventuates in failure, primarily due to chronic elevation in inferior vena cava (IVC) pressure. This study experimentally validates the effectiveness of an intracorporeally-powered venous ejector pump (VEP) in reducing IVC pressure in Fontan patients. The VEP exploits a fraction of aortic flow to create a jet-venturi effect for the IVC, negating the external power requirement and driveline infections. An invitro Fontan mock-up circulation loop is developed and the impact of VEP design parameters and physiological conditions is assessed using both idealized and patient-specific total cavopulmonary connection (TCPC) phantoms. The VEP performance in reducing IVC pressure exhibited an inverse relationship with the cardiac output and extra-cardiac conduit (ECC) size and a proportional relationship with the transpulmonary pressure gradient (TPG) and mean arterial pressure (MAP). The ideal VEP with fail-safe features provided an IVC pressure drop of 1.82 ± 0.49, 2.45 ± 0.54, and 3.12 ± 0.43 mm Hg for TPG values of 6, 8, and 10 mm Hg, respectively, averaged over all ECC sizes and cardiac outputs. Furthermore, the arterial oxygen saturation was consistently maintained above 85% during full-assist mode. These results emphasize the potential utility of the VEP to mitigate elevated venous pressure in Fontan patients.
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Affiliation(s)
- Reza Rasooli
- Department of Energy Resources, Faculty of Science and Technology, University of Stavanger, 4036, Stavanger, Norway.
| | - Henrik Holmstrom
- Department of Pediatric Cardiology, Division of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Knut Erik Teigen Giljarhus
- Department of Mechanical and Structural Engineering and Materials Science, University of Stavanger, 4036, Stavanger, Norway
| | - Ingunn Westvik Jolma
- Department of Chemistry, Bioscience and Environmental Engineering, University of Stavanger, 4036, Stavanger, Norway
| | | | - Charlotte de Lange
- Department of Pediatric Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Henrik Brun
- Department of Pediatric Cardiology, Division of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
- Section for Medical Cybernetics and Image Processing, The Intervention Centre, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Aksel Hiorth
- Department of Energy Resources, Faculty of Science and Technology, University of Stavanger, 4036, Stavanger, Norway
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Rajagopalan G, Balakrishnan KR, Suresh Rao KG, Ravi Kumar R, Kumar RK. Low Mean Perfusion Pressure Indexed to Body Surface Area is a Powerful Predictor of Poor Outcomes After Heart Transplantation in Patients With High Pre-Transplant Venous Pressure: A Clinical Study With Physiological Insights From Mathematical Modelling of Biventricular Heart Failure. Heart Lung Circ 2024; 33:292-303. [PMID: 38360502 DOI: 10.1016/j.hlc.2023.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 12/13/2023] [Indexed: 02/17/2024]
Abstract
BACKGROUND & AIM The deleterious consequences of chronically elevated venous pressure in patients with profound right ventricular or biventricular dysfunction are well known, including renal and hepatic dysfunction, and volume overload. The only option for these patients, if they fail optimal medical treatment, is a heart transplant, as they are not candidates for left ventricular assist device therapy. Mean perfusion pressure (MPP) is important in the outcomes of critically ill patients with high venous pressure. The question arises whether MPP is important for the outcomes of heart transplants in patients with elevated pre-transplant venous pressure. Medical management of heart failure patients with reduced ejection fraction involves lowering the systemic afterload with vasodilators while awaiting a transplant. We hypothesised that when venous pressure is elevated prior to transplant, a substantial reduction in systemic arterial elastance (Ea) through vasodilation may significantly decrease MPP, resulting in compromised end-organ function and consequent unfavourable outcomes after heart transplantation. This study aims to investigate whether a low MPP serves as a risk factor for adverse outcomes in heart transplant recipients with high venous pressure. METHOD A retrospective analysis was conducted on 250 heart transplant recipients undergoing isolated heart transplantation at a single institution from October 2012 to March 2020. Right atrial pressure (RAP) of more than 15 mmHg was considered high. Additionally, Ea calculated as the ratio of end-systolic pressure to stroke volume, and MPP calculated as the difference between mean arterial pressure and RAP were considered in our analysis. The outcomes of transplantation were measured in terms of 90-day mortality and survival up to 7 years. RESULTS High RAP was a significant risk factor for short-term and medium-term survival if Ea was low (<2.7 mmHg/mL, the median value). This group had 39.39% in-hospital mortality compared to 14.49% for RAP<15 mmHg (p∼0.005). When Ea was high, this difference in survival was not evident: 8% for RAP<15 mmHg vs 4.8% for RAP>15 mmHg (p∼0.550). This effect was mediated through a lower MPP, and the mortality due to lower MPP increased strikingly with higher body surface area (BSA). A negative correlation was observed between MPP indexed to BSA (MPPI) and the Model for End-Stage Liver Disease score (r∼-0.3580, p<0.0001) as well as creatinine (r∼-0.3551, p<0.0001). MPPI less than 40 mmHg/m2 was associated with poorer short-term (23.2% for MPPI<40 mmHg/m2 vs 7.1% for MPPI>40 mmHg/m2, p∼0.001) and medium-term survival. The impact of high RAP and low Ea on survival was evident even on medium-term follow-up; only 30% survival at 7 years follow-up for high RAP and low Ea vs 75% for RAP<15 mmHg (p∼0.0033). CONCLUSION The acceptable blood pressure during vasodilator therapy in patients with high RAP needs to be higher, especially in those with higher BSA. MPPI less than 40 mmHg/m2 is a risk factor for survival, in the short and medium-term, after heart transplantation.
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Affiliation(s)
- G Rajagopalan
- Department of Engineering Design, Indian Institute of Technology Madras, Chennai, India. https://twitter.com/iitmadras
| | - Komarakshi R Balakrishnan
- Institute of Heart and Lung Transplant & Mechanical Circulatory Support, MGM Healthcare Pvt Ltd, Chennai, India
| | - K G Suresh Rao
- Institute of Heart and Lung Transplant & Mechanical Circulatory Support, MGM Healthcare Pvt Ltd, Chennai, India
| | - R Ravi Kumar
- Institute of Heart and Lung Transplant & Mechanical Circulatory Support, MGM Healthcare Pvt Ltd, Chennai, India
| | - Ramarathnam Krishna Kumar
- Department of Medical Sciences and Technology, Indian Institute of Technology Madras, Chennai, India.
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Haeffele C, McElhinney DB. Fontan Associated Liver Disease: Canary in the Coal Mine or Silent Killer? J Am Heart Assoc 2023; 12:e031597. [PMID: 37776191 PMCID: PMC10727260 DOI: 10.1161/jaha.123.031597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/02/2023]
Affiliation(s)
- Christiane Haeffele
- Departments of Medicine, Cardiothoracic Surgery, and PediatricsStanford University School of MedicinePalo AltoCAUSA
| | - Doff B. McElhinney
- Departments of Medicine, Cardiothoracic Surgery, and PediatricsStanford University School of MedicinePalo AltoCAUSA
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Ponder R, Chez L, Rosenthal CJ, Bravo K, Lluri G, Reardon L, Lin J, Levi DS, Aboulhosn JA. Clinical and invasively-measured predictors of high exercise capacity in Fontan patients. Int J Cardiol 2023; 388:131166. [PMID: 37433405 DOI: 10.1016/j.ijcard.2023.131166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 07/04/2023] [Accepted: 07/06/2023] [Indexed: 07/13/2023]
Abstract
INTRODUCTION Fontan patients have variable exercise capacity. Contemporary understanding as to which factors predict high tolerance is limited. METHODS Records from the Ahmanson/University of California, Los Angeles Adult Congenital Heart Disease Center were reviewed for adult Fontan patients who underwent CPET. Patients were considered "high performers" if their maximum oxygen uptake (VO2 max/kg)-predicted was greater than 80%. Cross-sectional clinical, hemodynamic, and liver biopsy data was gathered. High-performers were compared to control patients across these parameters via associations and regression. RESULTS A total of 195 adult patients were included; 27 patients were considered "high performers". They had lower body mass indices (BMI, p < 0.001), mean Fontan pressures (p = 0.026), and cardiac outputs (p = 0.013). High performers also had higher activity levels (p < 0.001), serum albumin levels (p = 0.003), non-invasive and invasive systemic arterial oxygen saturations (p < 0.001 and p = 0.004), lower New York Heart Association (NYHA) heart failure class (p = 0.002), and were younger at Fontan completion (p = 0.011). High performers had less severe liver fibrosis (p = 0.015). Simple regression found Fontan pressure, non-invasive O2 saturation, albumin level, activity level, age at Fontan surgery, NYHA class, and BMI to predict significant changes in VO2 max/kg %-predicted. These associations persisted in multiple regression for non-invasive O2 saturation, NYHA class II, activity level, and BMI. CONCLUSIONS Thin Fontan patients who exercise more had better exercise capacity, Fontan hemodynamic profiles, and less liver fibrosis.
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Affiliation(s)
- Reid Ponder
- Department of Medicine, Tufts University School of Medicine, Boston, MA, United States of America; Division of Cardiology, Ahmanson/UCLA Adult Congenital Heart Disease Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America.
| | - Luke Chez
- Division of Pediatric Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Carl J Rosenthal
- University of California-Los Angeles, Los Angeles, CA, United States of America
| | - Katia Bravo
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, United States of America
| | - Gentian Lluri
- Division of Cardiology, Ahmanson/UCLA Adult Congenital Heart Disease Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Leigh Reardon
- Division of Pediatric Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America; Division of Cardiology, Ahmanson/UCLA Adult Congenital Heart Disease Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Jeannette Lin
- Division of Cardiology, Ahmanson/UCLA Adult Congenital Heart Disease Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Daniel S Levi
- Division of Pediatric Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Jamil A Aboulhosn
- Division of Cardiology, Ahmanson/UCLA Adult Congenital Heart Disease Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
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Moscatelli S, Borrelli N, Sabatino J, Leo I, Avesani M, Montanaro C, Di Salvo G. Role of Cardiovascular Imaging in the Follow-Up of Patients with Fontan Circulation. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9121875. [PMID: 36553321 PMCID: PMC9777137 DOI: 10.3390/children9121875] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 11/27/2022] [Accepted: 11/28/2022] [Indexed: 12/02/2022]
Abstract
Since its first description in 1971, the Fontan procedure and its modifications have led to a substantial improvement in the survival rates of patients with a variety of types of complex Congenital Heart Disease (CHD) characterised by the presence of a single, dominant ventricle. However, despite the significant improvement of the prognosis over the years, Fontan patients are still exposed to several cardiovascular and systemic complications. It is, therefore, important to fully understand the pitfalls hidden behind a Fontan anatomy and the potential predictors of ventricular failure. Cardiovascular imaging plays a key role in this context, allowing for the early identification of complications with important prognostic implications. Echocardiography remains the first-line imaging modality for serial evaluation of Fontan patients. However, there is a growing role of cardiovascular magnetic resonance and cardiac computed tomography from pre-operative assessment to longitudinal follow-up. The aim of this paper will be to provide a comprehensive overview of the role, strengths, and weaknesses of each imaging modality in the assessment of congenital cardiac conditions palliated with the Fontan procedure.
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Affiliation(s)
- Sara Moscatelli
- Paediatric Cardiology Department, Royal Brompton Hospital Harefield NHS Foundation Trust, London SW3 5NP, UK
| | - Nunzia Borrelli
- Adult Congenital Heart Disease Unit, A.O. dei Colli, Monaldi Hospital, 80131 Naples, Italy
| | - Jolanda Sabatino
- Division of Paediatric Cardiology, Department of Women and Children’s Health, University Hospital Padua, 35128 Padua, Italy
- Paediatric Research Institute (IRP), Città Della Speranza, 35127 Padua, Italy
| | - Isabella Leo
- Department of Medical and Surgical Sciences, Magna Grecia University, 88100 Catanzaro, Italy
- Cardiac Magnetic Resonance Department, Royal Brompton Hospital Harefield NHS Foundation Trust, London SW3 5NP, UK
| | - Martina Avesani
- Division of Paediatric Cardiology, Department of Women and Children’s Health, University Hospital Padua, 35128 Padua, Italy
| | - Claudia Montanaro
- Adult Congenital Department, Royal Brompton Hospital & Harefield NHS Foundation Trust, London SW3 5NP, UK
| | - Giovanni Di Salvo
- Division of Paediatric Cardiology, Department of Women and Children’s Health, University Hospital Padua, 35128 Padua, Italy
- Paediatric Research Institute (IRP), Città Della Speranza, 35127 Padua, Italy
- Correspondence:
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Noninvasive surrogates are poor predictors of liver fibrosis in patients with Fontan circulation. J Thorac Cardiovasc Surg 2022; 164:1176-1185.e3. [PMID: 35034765 DOI: 10.1016/j.jtcvs.2021.12.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 12/02/2021] [Accepted: 12/16/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Patients with Fontan circulation exhibit a high incidence of liver fibrosis and cirrhosis. Transient elastography (TE) and the enhanced liver fibrosis (ELF) test have proven useful as noninvasive surrogate markers of liver fibrosis for other chronic liver diseases. We evaluated whether TE and the ELF score can predict the degree of liver fibrosis in patients with Fontan circulation. METHODS We retrospectively reviewed the medical records of 45 adult patients with at least 10 years of Fontan duration who had undergone liver biopsy and investigated the relation between the fibrosis stage and TE and the ELF test results. Additionally, the association of these variables and other biochemical and hemodynamic parameters was assessed. RESULTS The mean age was 25.9 years and the mean Fontan duration was 20.8 years. Advanced liver fibrosis was present in 36 (80.0%) patients. TE or ELF score are comparable for patients with and without advanced liver fibrosis (mean 23.3 vs 24.8 kPa [P = .85] for TE; mean 8.94 vs 9.25 [P = .44] for the ELF score). However, N-terminal pro-brain natriuretic peptide level and ventricular end-diastolic pressure were higher in patients with advanced liver fibrosis (mean 224 vs 80 pg/mL [P < .01]; and mean 12 vs 9 mm Hg [P = .04], respectively). No independent predictor of advanced liver fibrosis was found in multivariate analysis. CONCLUSIONS TE and the ELF score were unable to predict the degree of liver fibrosis in Fontan patients. Liver biopsy remains as the only valid method to assess fibrotic burden in this population.
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Chaloupecký V, Jičínská D, Tomek V, Materna O, Gebauer R, Poruban R, Antonová P, Adla T, Štefánek M, Illinger V, Kotaška K, Janoušek J. Impact of liver fibrosis and nodules formation on hemodynamics in young adults after total cavopulmonary connection. A magnetic resonance study. Front Cardiovasc Med 2022; 9:986653. [PMID: 36247450 PMCID: PMC9558211 DOI: 10.3389/fcvm.2022.986653] [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: 07/05/2022] [Accepted: 09/08/2022] [Indexed: 11/15/2022] Open
Abstract
Background The aim of this study was to analyze the relation between the hepatic fibrosis markers, liver morphology and hemodynamics assessed by magnetic resonance imaging (MRI) after total cavopulmonary connection (TCPC). Materials and methods Adult patients after TCPC performed in childhood between 1993 and 2003 are the subjects of this observational study. The follow-up protocol consisted of clinical and echocardiographic examination, liver elastography, cardiopulmonary exercise test, MRI hemodynamics and liver morphology assessment and direct enhanced liver fibrosis (ELF) test. Results The cohort consisted of 39 patients (46% female) with a median age at study 26 (IQR 23–28) years and interval from TCPC 21 (IQR 20–23) years. There was no correlation between ELF test and any MRI variables, but procollagen III amino-terminal peptide (PIIINP), a single component of ELF test, correlated significantly with ventricular end-diastolic volume (r = 0.33; p = 0.042) and inferior vena cava flow (r = 0.47; p = 0.003). Fifteen (38%) patients with liver nodules had compared to other 24 patients higher end-diastolic volume (ml/m2) 102.8 ± 20.0 vs. 88.2 ± 17.7; p = 0.023, respectively. PIIINP correlated significantly with inferior vena cava flow (r = 0.56; p = 0.030) and with end-diastolic volume (r = 0.53; p = 0.043), but only in patients with liver nodules. Conclusion Gradual progression of liver fibrosis, particularly hepatic arterialization caused by liver nodules formation, increases inferior vena cava flow and subsequent ventricular volume overload may further compromise single ventricle functional reserve in adult patients after TCPC.
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Affiliation(s)
- Václav Chaloupecký
- Children’s Heart Centre, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czechia
- *Correspondence: Václav Chaloupecký,
| | - Denisa Jičínská
- Children’s Heart Centre, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czechia
| | - Viktor Tomek
- Children’s Heart Centre, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czechia
| | - Ondřej Materna
- Children’s Heart Centre, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czechia
| | - Roman Gebauer
- Children’s Heart Centre, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czechia
| | - Rudolf Poruban
- Children’s Heart Centre, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czechia
| | - Petra Antonová
- Department of Cardiovascular Surgery, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czechia
| | - Theodor Adla
- Department of Radiology, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czechia
| | - Matěj Štefánek
- Department of Radiology, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czechia
| | - Vojtěch Illinger
- Department of Rehabilitation and Sports Medicine, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czechia
| | - Karel Kotaška
- Department of Medical Chemistry and Clinical Biochemistry, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czechia
| | - Jan Janoušek
- Children’s Heart Centre, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czechia
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Ghosh RM, Whitehead KK, Harris MA, Kalb E, Chen JM, Partington SL, Biko DM, Faerber J, Fogel MA. Longitudinal Trends of Vascular Flow and Growth in Patients Undergoing Fontan Operation. Ann Thorac Surg 2022; 115:1486-1492. [PMID: 35988737 DOI: 10.1016/j.athoracsur.2022.07.051] [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: 02/07/2022] [Revised: 07/05/2022] [Accepted: 07/19/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Single ventricle (SV) patients undergo multiple surgeries with subsequent changes in anatomy and hemodynamics. There is little cardiac magnetic resonance (CMR) data on serial changes in these patients. This study aimed to assess longitudinal changes of SV anatomy and hemodynamics in a large cohort. METHODS Anatomy and flow in SV patients with serial CMRs performed between 2008-2019 at a single institution were retrospectively reviewed. Mixed-effects linear regression was used to estimate changes over time at 3-9 months, 1-5 years, and >5 years after Fontan. RESULTS 119 patients were included (51% with hypoplastic left heart;77% underwent extra-cardiac Fontan). 88 patients had 3 serial CMRs. Indexed right superior vena cava (RSVC), inferior vena cava (IVC), neo-aortic valve and descending aorta area decreased over time (beta -0.19,-0.44,-0.23 respectively;p<0.01) as did indexed RSVC, neo and native aorta and descending aorta flow (beta -0.49,-0.53,-0.59 respectively;p<0.0001). IVC flow and its contribution to total caval flow increased (beta 0.33;p<0.0001). Indexed right and left right pulmonary artery (LPA) flow did not change, however indexed LPA area decreased (beta -0.16;p=0.0014) with time. Systemic to pulmonary collateral flow remained unchanged prior to, and early after Fontan (beta -0.54;p=0.42) but decreased with time from Fontan (beta coefficient -0.22;p<0.0001). CONCLUSIONS In this cohort of longitudinally followed SV patients, there are significant trends in vascular size and flow over time from Fontan. These findings can be used as a framework to interpret serial CMR data in the SV, and non-invasively identify deviations from expected patterns prior to the development of clinical symptoms.
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Affiliation(s)
- Reena M Ghosh
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia PA.
| | - Kevin K Whitehead
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia PA
| | - Matthew A Harris
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia PA
| | - Elizabeth Kalb
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia PA; Division of Cardiology, Ann and Robert Lurie Children's Hospital of Chicago, Chicago IL
| | - Jonathan M Chen
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia PA
| | - Sara L Partington
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia PA
| | - David M Biko
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia PA
| | - Jennifer Faerber
- Department of Biomedical and Health Informatics. The Children's Hospital of Philadelphia, Philadelphia PA
| | - Mark A Fogel
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia PA
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In Vitro Measurement of Hepatic Flow Distribution in Fontan Vascular Conduits: Towards Rapid Validation Techniques. J Biomech 2022; 137:111092. [DOI: 10.1016/j.jbiomech.2022.111092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 04/08/2022] [Accepted: 04/08/2022] [Indexed: 11/24/2022]
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Miklin DJ, Mendoza M, DePasquale EC. Two is better than one: when to consider multiorgan transplant. Curr Opin Organ Transplant 2022; 27:86-91. [PMID: 34890379 DOI: 10.1097/mot.0000000000000951] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW Patients with end-stage heart failure often present with concomitant end-stage renal or end-stage liver disease requiring transplantation. There are limited data regarding the risks, benefits and long-term outcomes of heart-kidney (HKT) and heart-liver transplantation (HLT), and guidelines are mainly limited to expert consensus statements. RECENT FINDINGS The incidence of HKT and HLT has steadily increased in recent years with favourable outcomes. Both single-centre and large database studies have shown benefits of HKT/HLT through improved survival, freedom from dialysis and lower rates of rejection and coronary allograft vasculopathy. Current guidelines are institution dependent and controversial due to the ethical considerations surrounding multiorgan transplantation (MOT). SUMMARY MOT is an effective and necessary option for patients with end-stage heart and kidney/liver failure. MOT is ethically permissible, and efforts should be made to consider eligible patients as early as possible to limit morbidity and mortality. Further research is needed regarding appropriate listing criteria and long-term outcomes.
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Affiliation(s)
| | - Matthew Mendoza
- Keck School of Medicine of University of Southern California, Los Angeles, California, USA
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12
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Villa C, Greenberg JW, Morales DL. Mechanical Support for the Failing Single Ventricle After Fontan. JTCVS Tech 2022; 13:174-181. [PMID: 35713590 PMCID: PMC9195612 DOI: 10.1016/j.xjtc.2021.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 12/04/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
| | | | - David L.S. Morales
- Address for reprints: David L. S. Morales, MD, Pediatric Cardiothoracic Surgery, The Heart Institute, Cincinnati Children's Hospital Medical Center, The University of Cincinnati College of Medicine, 3333 Burnet Ave – MLC 2004, Cincinnati, OH 45229.
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13
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Affiliation(s)
- Jack Rychik
- Corresponding author. Cardiac Center, the Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA. Tel: +1 215 5902192, Fax: +1 267 426 5082,
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Padalino MA, Ponzoni M, Castaldi B, Leoni L, Chemello L, Toscano G, Gerosa G, Di Salvo G, Vida VL. Surgical management of failing Fontan circulation: results from 30 cases with 285 patient-years follow-up. Eur J Cardiothorac Surg 2021; 61:338-345. [PMID: 34687535 DOI: 10.1093/ejcts/ezab450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 09/15/2021] [Accepted: 09/16/2021] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES Fontan patients are known to suffer from clinical attrition over the years, which has been characterized as Fontan failure. We sought to evaluate the clinical outcomes of such Fontan patients undergoing surgical management in a 25-year, single-centre experience. METHODS A retrospective single-centre analysis of patients undergoing surgical treatment for failing Fontan between 1995 and 2020, including any reoperations when ventricular function was preserved, or a heart transplant (HTx), when ventricular contractility was impaired. We analysed survival, indications for surgery and early and late complication rates. RESULTS We collected 30 patients (mean age 24.7 years) who required surgery after a mean time of 19.3 years from the original Fontan procedure: Fontan conversion in 21 (70%, extracardiac conduit in 19, lateral tunnel in 2), a HTx in 4 (13.3%) and other reoperations in 5 (16.7%). The most common indications for surgery were tachyarrhythmias (63.3%) and severe right atrial dilatation (63.3%). Overall survival at the 1-, 5-, 10- and 20-year follow-up examinations were 75.9% [95% confidence interval (CI): 91.4-60.4%], 75.9% (95% CI: 91.4-60.4%), 70% (95% CI: 78-52%) and 70% (95% CI: 78-52%), respectively. The most frequent complications were postoperative tachyarrhythmias (50%) and late Fontan-associated liver disease (56.5%). HTx and Fontan conversion provided comparably good outcomes compared to other reoperations (P = 0.022). CONCLUSIONS Surgery for failing Fontan can be performed effectively with overall good long-term survival. However, early and late morbidities are still a significant burden. Because other reoperations performed when patients presented with contraindications for a HTx have carried high mortality, close clinical follow-up is mandatory, and an earlier indication for Fontan conversion or a HTx is advisable to optimize outcomes.
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Affiliation(s)
- Massimo A Padalino
- Pediatric and Congenital Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova Medical School, Padova, Italy
| | - Matteo Ponzoni
- Pediatric and Congenital Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova Medical School, Padova, Italy
| | - Biagio Castaldi
- Pediatric Cardiology Unit, Department of Woman and Child's Health, University of Padova Medical School, Padova, Italy
| | - Loira Leoni
- Cardiology Clinic, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova Medical School, Padova, Italy
| | - Liliana Chemello
- Department of Internal Medicine-DIMED, University of Padova Medical School, Padova, Italy
| | - Giuseppe Toscano
- Cardiac Surgery and Heart Transplant Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova Medical School, Padova, Italy
| | - Gino Gerosa
- Cardiac Surgery and Heart Transplant Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova Medical School, Padova, Italy
| | - Giovanni Di Salvo
- Pediatric Cardiology Unit, Department of Woman and Child's Health, University of Padova Medical School, Padova, Italy
| | - Vladimiro L Vida
- Pediatric and Congenital Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova Medical School, Padova, Italy
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15
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Villa CR, Lorts A, Morales DLS. Ventricular Assist Device Therapy in the Fontan Circulation. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2021; 24:19-25. [PMID: 34116777 DOI: 10.1053/j.pcsu.2021.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 01/04/2021] [Accepted: 01/14/2021] [Indexed: 12/25/2022]
Abstract
The number of Fontan patients with circulatory failure and systolic dysfunction is growing rapidly. The last decade has demonstrated that ventricular assist device (VAD) is an effective therapy in properly selected patients. Herein, we discuss the current approach to patient selection, implantation, and patient management.
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Affiliation(s)
- Chet R Villa
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Angela Lorts
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David L S Morales
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio.
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16
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Engineering Perspective on Cardiovascular Simulations of Fontan Hemodynamics: Where Do We Stand with a Look Towards Clinical Application. Cardiovasc Eng Technol 2021; 12:618-630. [PMID: 34114202 DOI: 10.1007/s13239-021-00541-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 04/30/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND Cardiovascular simulations for patients with single ventricles undergoing the Fontan procedure can assess patient-specific hemodynamics, explore surgical advances, and develop personalized strategies for surgery and patient care. These simulations have not yet been broadly accepted as a routine clinical tool owing to a number of limitations. Numerous approaches have been explored to seek innovative solutions for improving methodologies and eliminating these limitations. PURPOSE This article first reviews the current state of cardiovascular simulations of Fontan hemodynamics. Then, it will discuss the technical progress of Fontan simulations with the emphasis of its clinical impact, noting that substantial improvements have been made in the considerations of patient-specific anatomy, flow, and blood rheology. The article concludes with insights into potential future directions involving clinical validation, uncertainty quantification, and computational efficiency. The advancements in these aspects could promote the clinical usage of Fontan simulations, facilitating its integration into routine clinical practice.
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Hansen JH, Khodami JK, Moritz JD, Rinne K, Voges I, Scheewe J, Kramer HH, Uebing A. Surveillance of Fontan Associated Liver Disease in Childhood and Adolescence. Semin Thorac Cardiovasc Surg 2021; 34:642-650. [PMID: 33979666 DOI: 10.1053/j.semtcvs.2021.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 04/12/2021] [Indexed: 02/06/2023]
Abstract
Fontan associated liver disease (FALD) has been recognized as a potentially serious sequela of the Fontan circulation. Prevalence of FALD among different age groups and risk factors for advanced changes were assessed. FALD screening included abdominal ultrasound and laboratory tests. A "liver disease score (LDS)" incorporating items from ultrasound and blood testing was calculated to grade FALD severity (5 items each, maximum score 10 points). 240 patients (male: n = 139, female: n = 101, systemic right ventricle: n = 160) underwent FALD screening 10 (IQR 7-15) years after Fontan surgery. Ultrasound was abnormal in 184 (76.6%) patients (surface nodularity / blunted liver edge: n = 133, 55.4%; heterogeneous parenchyma: n = 93, 38.8%; splenomegaly: n = 68, 28.3%; ascites: n = 23, 9.6%). At least one abnormal laboratory test was detected in 218 (90.8%) patients. Gamma-glutamyl-transpeptidase was elevated in the majority of patients (n = 206, 85.8%). Median LDS was 3 (2-4). Scores ≥5 were observed in 32 (13.3%) patients. Longer follow-up (15 (11-20) vs 9 (6-14) years, P <0.001), higher central venous (13 (11-15) vs 10 (9-12) mmHg, P <0.001) and end-diastolic pressure (8 (5-10) vs 6 (5-7) mmHg, P = 0.001), impaired ventricular function and absence of sinus rhythm were associated with LDS ≥5. Longer follow-up (OR 1.2 (1.1-1.3), P <0.001) and higher central venous pressure (OR 1.6 (1.3-2.1), p < 0.001) were the only independent predictors of advanced FALD. Abdominal ultrasound and laboratory abnormalities suggestive of FALD are common during routine follow-up already in childhood and adolescence irrespective of ventricular morphology. More advanced findings are associated with longer follow-up and higher central venous pressure.
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Affiliation(s)
- Jan Hinnerk Hansen
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital Schleswig-Holstein, Campus Kiel; DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Germany.
| | - Joshua Kian Khodami
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital Schleswig-Holstein, Campus Kiel
| | - Jörg Detlev Moritz
- Department of Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel
| | - Katy Rinne
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital Schleswig-Holstein, Campus Kiel
| | - Inga Voges
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital Schleswig-Holstein, Campus Kiel; DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Germany
| | - Jens Scheewe
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Campus Kiel
| | - Hans-Heiner Kramer
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital Schleswig-Holstein, Campus Kiel; DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Germany
| | - Anselm Uebing
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital Schleswig-Holstein, Campus Kiel; DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Germany
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18
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Fogel MA. The Fontan: "Straining" to Understand That "The Bigger They Come, The Harder They Fall". J Am Coll Cardiol 2021; 77:2490-2493. [PMID: 34016262 DOI: 10.1016/j.jacc.2021.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 04/06/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Mark A Fogel
- Department of Pediatrics (Cardiology) and Radiology, The Children's Hospital of Philadelphia, The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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19
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Is Doppler Echocardiography Adequate for Surgical Planning of Single Ventricle Patients? Cardiovasc Eng Technol 2021; 12:606-617. [PMID: 33931807 DOI: 10.1007/s13239-021-00533-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 03/12/2021] [Indexed: 12/13/2022]
Abstract
PURPOSE Surgical planning has shown great potential for optimizing outcomes for patients affected by single ventricle (SV) malformations. Phase-contrast magnetic resonance imaging (PC-MRI) is the routine technique used for flow acquisition in the surgical planning paradigm. However, PC-MRI may suffer from possible artifacts in certain cases; furthermore, this technology may not be readily available for patients in low and lower-middle-income countries. Therefore, this study aims to investigate the effectiveness of using Doppler echocardiography (echo-Doppler) for flow acquisitions of SV surgical planning. METHODS This study included eight patients whose blood flow data was acquired by both PC-MRI and echo-Doppler. A virtual surgery platform was used to generate two surgical options for each patient: (1) a traditional Fontan conduit and (2) a Y-graft. Computational fluid dynamics (CFD) simulations were conducted using the two flow acquisitions to assess clinically relevant hemodynamic metrics: indexed power loss (iPL) and hepatic flow distribution (HFD). RESULTS Differences exist in flow data acquired by PC-MRI and echo-Doppler, but no statistical significance was obtained. Flow fields, therefore, exhibit discrepancies between simulations using flow acquisitions by PC-MRI and echo-Doppler. In virtual surgery, the two surgical options were ranked based on these metrics. No difference was observed in the ranking of surgical options between using different flow acquisitions. CONCLUSION Doppler echocardiography is an adequate alternative approach to acquire flow data for SV surgical planning. This finding encourages broader usage of SV surgical planning with echo-Doppler when MRI may present artifacts or is not available, especially in low and lower-middle-income countries.
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20
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Fluid-Structure Interaction Simulation of an Intra-Atrial Fontan Connection. BIOLOGY 2020; 9:biology9120412. [PMID: 33255292 PMCID: PMC7760396 DOI: 10.3390/biology9120412] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 11/19/2020] [Accepted: 11/20/2020] [Indexed: 12/15/2022]
Abstract
Simple Summary A fluid-structure interaction (FSI) simulation of an intra-atrial Fontan connection was performed. Power loss and pressure drop results fluctuated less during the FSI simulation than during the simulation run with rigid walls, but there were no observable differences in time-averaged pressure drop, connection power loss or hepatic flow distribution. These results suggested that employing a rigid wall is a reasonable assumption when evaluating time-averaged hemodynamic quantities of the Fontan connection under resting breath-held flow conditions. Abstract Total cavopulmonary connection (TCPC) hemodynamics has been hypothesized to be associated with long-term complications in single ventricle heart defect patients. Rigid wall assumption has been commonly used when evaluating TCPC hemodynamics using computational fluid dynamics (CFD) simulation. Previous study has evaluated impact of wall compliance on extra-cardiac TCPC hemodynamics using fluid-structure interaction (FSI) simulation. However, the impact of ignoring wall compliance on the presumably more compliant intra-atrial TCPC hemodynamics is not fully understood. To narrow this knowledge gap, this study aims to investigate impact of wall compliance on an intra-atrial TCPC hemodynamics. A patient-specific model of an intra-atrial TCPC is simulated with an FSI model. Patient-specific 3D TCPC anatomies were reconstructed from transverse cardiovascular magnetic resonance images. Patient-specific vessel flow rate from phase-contrast magnetic resonance imaging (MRI) at the Fontan pathway and the superior vena cava under resting condition were prescribed at the inlets. From the FSI simulation, the degree of wall deformation was compared with in vivo wall deformation from phase-contrast MRI data as validation of the FSI model. Then, TCPC flow structure, power loss and hepatic flow distribution (HFD) were compared between rigid wall and FSI simulation. There were differences in instantaneous pressure drop, power loss and HFD between rigid wall and FSI simulations, but no difference in the time-averaged quantities. The findings of this study support the use of a rigid wall assumption on evaluation of time-averaged intra-atrial TCPC hemodynamic metric under resting breath-held condition.
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21
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Farahmand M, Kavarana MN, Trusty PM, Kung EO. Target Flow-Pressure Operating Range for Designing a Failing Fontan Cavopulmonary Support Device. IEEE Trans Biomed Eng 2020; 67:2925-2933. [PMID: 32078526 DOI: 10.1109/tbme.2020.2974098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Fontan operation as the current standard of care for the palliation of single ventricle defects results in significant late complications. Using a mechanical circulatory device for the right circulation to serve the function of the missing subpulmonary ventricle could potentially stabilize the failing Fontan circulation. This study aims to elucidate the hydraulic operating regions that should be targeted for designing cavopulmonary blood pumps. By integrating numerical analysis and available clinical information, the interaction of the cavopulmonary support via the IVC and full assist configurations with a wide range of simulated adult failing scenarios was investigated; with IVC and full assist corresponding to the inferior venous return or the entire venous return, respectively, being routed through the device. We identified the desired hydraulic operating regions for a cavopulmonary assist device by clustering all head pressures and corresponding pump flows that result in hemodynamic improvement for each simulated failing Fontan physiology. Results show that IVC support can produce beneficial hemodynamics in only a small fraction of failing Fontan scenarios. Cavopulmonary assist device could increase cardiac index by 35% and decrease the inferior vena cava pressure by 45% depending on the patient's pre-support hemodynamic state and surgical configuration of the cavopulmonary assist device (IVC or full support). The desired flow-pressure operating regions we identified can serve as the performance criteria for designing cavopulmonary assist devices as well as evaluating off-label use of commercially available left-side blood pumps for failing Fontan cavopulmonary support.
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Abstract
Hypoplastic left heart syndrome (HLHS) is a complex form of congenital heart disease defined by anatomic and functional inadequacy of the left side of the heart with nonviability of the left ventricle to perform systemic perfusion. Lethal if not treated, a strategy for survival currently is well established, with continuing improvement in outcomes over the past 30 years. Prenatal diagnosis, good newborn care, improved surgical skills, specialized postoperative care, and unique strategies for interstage monitoring all have contributed to increasing likelihood of survival. The unique life with a single right ventricle and a Fontan circulation is a focused area of investigation.
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23
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Emamaullee J, Zaidi AN, Schiano T, Kahn J, Valentino PL, Hofer RE, Taner T, Wald JW, Olthoff K, Bucuvalas J, Fischer R. Fontan-Associated Liver Disease: Screening, Management, and Transplant Considerations. Circulation 2020; 142:591-604. [PMID: 32776846 PMCID: PMC7422927 DOI: 10.1161/circulationaha.120.045597] [Citation(s) in RCA: 104] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Surgical innovation and multidisciplinary management have allowed children born with univentricular physiology congenital heart disease to survive into adulthood. An estimated global population of 70 000 patients have undergone the Fontan procedure and are alive today, most of whom are <25 years of age. Several unexpected consequences of the Fontan circulation include Fontan-associated liver disease. Surveillance biopsies have demonstrated that virtually 100% of these patients develop clinically silent fibrosis by adolescence. As they mature, there are increasing reports of combined heart-liver transplantation resulting from advanced liver disease, including bridging fibrosis, cirrhosis, and hepatocellular carcinoma, in this population. In the absence of a transplantation option, these young patients face a poor quality of life and overall survival. Acknowledging that there are no consensus guidelines for diagnosing and monitoring Fontan-associated liver disease or when to consider heart transplantation versus combined heart-liver transplantation in these patients, a multidisciplinary working group reviewed the literature surrounding Fontan-associated liver disease, with a specific focus on considerations for transplantation.
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Affiliation(s)
- Juliet Emamaullee
- Liver Transplant Center, Children’s Hospital-Los Angeles, Los Angeles, CA
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Ali N. Zaidi
- Mount Sinai Cardiovascular Institute & The Children’s Heart Center, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Thomas Schiano
- Division of Hepatology, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jeff Kahn
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine of USC, Los Angeles, CA
| | - Pamela L. Valentino
- Section of Gastroenterology and Hepatology, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Ryan E. Hofer
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Timucin Taner
- Departments of Surgery and Immunology, Mayo Clinic, Rochester, MN
| | - Joyce W. Wald
- Division of Cardiology, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Kim Olthoff
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - John Bucuvalas
- Division of Pediatric Hepatology, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ryan Fischer
- Department of Gastroenterology, Liver Care Center, Children’s Mercy Kansas City, Kansas City, MO
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Wei ZA, Johnson C, Trusty P, Stephens M, Wu W, Sharon R, Srimurugan B, Kottayil BP, Sunil GS, Fogel MA, Yoganathan AP, Kappanayil M. Comparison of Fontan Surgical Options for Patients with Apicocaval Juxtaposition. Pediatr Cardiol 2020; 41:1021-1030. [PMID: 32377893 PMCID: PMC7325867 DOI: 10.1007/s00246-020-02353-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 04/23/2020] [Indexed: 12/22/2022]
Abstract
Apicocaval juxtaposition (ACJ) is a rare form of viscerocardiac malpositions in association with single-ventricle congenital heart defects. The Fontan surgery is the common palliation, and possible surgical options include ipsilateral, contralateral, and intra-atrial conduits. Concerns include lower hemodynamic performances or risks of conduit compression by the cardiac mass. This study investigates the hemodynamics and clinical outcomes of ACJ patients and potential surgical improvements. Ten consecutive ACJ patients were included, along with a reference cohort of ten non-ACJ patients. Magnetic resonance images were acquired at 6 ± 0.6 year follow-up for anatomical analysis and hemodynamic assessments using computational fluid dynamics. Metrics of interest are deformation index (DI), indexed power loss (iPL), and hepatic flow distribution (HFDoff). A "virtual" surgery was performed to explore potential hemodynamic improvements using a straightened conduit. DI for ACJ patients fell within the DI range of non-ACJ patients. Contralateral conduits had insignificantly higher iPL (0.070 [0.032,0.137]) than ipsilateral conduits (0.041 [0.013,0.095]) and non-ACJ conduits (0.034 [0.011,0.061]). HFDoff was similar for the ipsilateral (21 [12,35]), contralateral (26 [7,41]), and non-ACJ Fontan conduits (17 [0,48]). Virtual surgery demonstrated that a straightened conduit reduced HFDoff and iPL for the contralateral and ipsilateral conduits, potentially leading to improved clinical outcomes. In this limited sample, the hemodynamic performance of ACJ patients was not significantly different from their non-ACJ counterparts. The use of a straightened conduit option could potentially improve patient outcomes. Additionally, the fear of significant compression of conduits for ACJ patients was unsupported.
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Affiliation(s)
- Zhenglun Alan Wei
- Department of Biomedical Engineering, Georgia Institute of Technology, Suite 200, 387 Technology Circle, Atlanta, GA, 30313-2412, USA
| | - Camille Johnson
- Department of Biomedical Engineering, Georgia Institute of Technology, Suite 200, 387 Technology Circle, Atlanta, GA, 30313-2412, USA
| | - Phillip Trusty
- Department of Biomedical Engineering, Georgia Institute of Technology, Suite 200, 387 Technology Circle, Atlanta, GA, 30313-2412, USA
| | - Morgan Stephens
- Department of Biomedical Engineering, Georgia Institute of Technology, Suite 200, 387 Technology Circle, Atlanta, GA, 30313-2412, USA
| | - Wenjun Wu
- Department of Biomedical Engineering, Georgia Institute of Technology, Suite 200, 387 Technology Circle, Atlanta, GA, 30313-2412, USA
| | - Ritchie Sharon
- Amrita Institute of Medical Sciences and Research Centre, Kochi, India
| | - Balaji Srimurugan
- Amrita Institute of Medical Sciences and Research Centre, Kochi, India
| | | | - G S Sunil
- Amrita Institute of Medical Sciences and Research Centre, Kochi, India
| | - Mark A Fogel
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ajit P Yoganathan
- Department of Biomedical Engineering, Georgia Institute of Technology, Suite 200, 387 Technology Circle, Atlanta, GA, 30313-2412, USA.
| | - Mahesh Kappanayil
- Amrita Institute of Medical Sciences and Research Centre, Kochi, India
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25
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Invited Commentary. Ann Thorac Surg 2020; 109:1911-1912. [DOI: 10.1016/j.athoracsur.2020.02.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 02/23/2020] [Indexed: 11/22/2022]
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26
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Non-Newtonian Effects on Patient-Specific Modeling of Fontan Hemodynamics. Ann Biomed Eng 2020; 48:2204-2217. [PMID: 32372365 DOI: 10.1007/s10439-020-02527-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 04/29/2020] [Indexed: 12/15/2022]
Abstract
The Fontan procedure is a common palliative surgery for congenital single ventricle patients. In silico and in vitro patient-specific modeling approaches are widely utilized to investigate potential improvements of Fontan hemodynamics that are related to long-term complications. However, there is a lack of consensus regarding the use of non-Newtonian rheology, warranting a systematic investigation. This study conducted in silico patient-specific modeling for twelve Fontan patients, using a Newtonian and a non-Newtonian model for each patient. Differences were quantified by examining clinically relevant metrics: indexed power loss (iPL), indexed viscous dissipation rate (iVDR), hepatic flow distribution (HFD), and regions of low wall shear stress (AWSS). Four sets of "non-Newtonian importance factors" were calculated to explore their effectiveness in identifying the non-Newtonian effect. No statistical differences were observed in iPL, iVDR, and HFD between the two models at the population-level, but large inter-patient variations exist. Significant differences were detected regarding AWSS, and its correlations with non-Newtonian importance factors were discussed. Additionally, simulations using the non-Newtonian model were computationally faster than those using the Newtonian model. These findings distinguish good importance factors for identifying non-Newtonian rheology and encourage the use of a non-Newtonian model to assess Fontan hemodynamics.
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27
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Reddy S, Handler SS, Wu S, Rabinovitch M, Wright G. Proceedings From the 2019 Stanford Single Ventricle Scientific Summit: Advancing Science for Single Ventricle Patients: From Discovery to Clinical Applications. J Am Heart Assoc 2020; 9:e015871. [PMID: 32188306 PMCID: PMC7428620 DOI: 10.1161/jaha.119.015871] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Because of remarkable advances in survival over the past 40 years, the worldwide population of individuals with single ventricle heart disease living with Fontan circulation has grown to ≈70 000, with nearly half aged >18 years. Survival to at least 30 years of age is now achievable for 75% of Fontan patients. On the other hand, single ventricle patients account for the largest group of the 6000 to 8000 children hospitalized with circulation failure, with or without heart failure annually in the United States, with the highest in‐hospital mortality. Because there is little understanding of the underlying mechanisms of heart failure, arrhythmias, pulmonary and lymphatic vascular abnormalities, and other morbidities, there are no specific treatments to maintain long‐term myocardial performance or to optimize overall patient outcomes.
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Affiliation(s)
- Sushma Reddy
- Department of Pediatrics (Cardiology) Stanford University Palo Alto CA
| | | | - Sean Wu
- Department of Medicine (Cardiology) Stanford University Palo Alto CA
| | | | - Gail Wright
- Department of Pediatrics (Cardiology) Stanford University Palo Alto CA
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Impact of Free-Breathing Phase-Contrast MRI on Decision-Making in Fontan Surgical Planning. J Cardiovasc Transl Res 2019; 13:640-647. [DOI: 10.1007/s12265-019-09930-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 10/21/2019] [Indexed: 11/26/2022]
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Trusty PM, Wei ZA, Rychik J, Graham A, Russo PA, Surrey LF, Goldberg DJ, Yoganathan AP, Fogel MA. Cardiac Magnetic Resonance-Derived Metrics Are Predictive of Liver Fibrosis in Fontan Patients. Ann Thorac Surg 2019; 109:1904-1911. [PMID: 31734244 DOI: 10.1016/j.athoracsur.2019.09.070] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 09/12/2019] [Accepted: 09/23/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Liver fibrosis is a serious complication of single ventricle Fontan survivors. Its causes are of great interest, and potential solutions to halt or delay progression are needed. The purpose of this study is to investigate if prior hemodynamics and anatomy can predict liver fibrosis severity in these patients. METHODS Twenty-one Fontan patients with cardiac magnetic resonance (CMR) data obtained greater than 1 year before liver biopsy data were included. Computational fluid dynamic simulations were performed to quantify total cavopulmonary connection (TCPC) flow dynamics using patient-specific anatomies and blood flow waveforms reconstructed from CMR data. Collagen deposition (a measure of liver fibrosis) was quantified by digital image analysis of Sirius red-stained slides. Statistical analyses were performed to investigate potential relationships between Fontan hemodynamics and liver fibrosis. RESULTS With an average time of 6.7 ± 2.9 years (range, 2-11 years) between CMR and biopsy, TCPC resistance and left pulmonary artery stenosis showed significant, positive correlations with magnitude of liver fibrosis (r = 0.54, P = .026; and r = 0.55, P = .028, respectively). The change in inferior vena cava flow rate over time also showed a significant positive correlation with magnitude of liver fibrosis (r = 0.91, P = .001). CONCLUSIONS TCPC resistance, left pulmonary artery stenosis, and increased inferior vena cava flow are positively associated with liver fibrosis after Fontan operation and hold promise as important predictors of hepatic decline. These findings encourage preprocedural planning and interventional strategies to improve TCPC performance and reduce vessel stenosis. Further investigation is warranted to design the ideal Fontan circulation and optimize flow dynamics to reduce the risk of liver fibrosis.
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Affiliation(s)
- Phillip M Trusty
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia
| | - Zhenglun Alan Wei
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia
| | - Jack Rychik
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Alexa Graham
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia
| | - Pierre A Russo
- Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Lea F Surrey
- Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - David J Goldberg
- Division of Cardiology, 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.
| | - Mark A Fogel
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Rychik J, Atz AM, Celermajer DS, Deal BJ, Gatzoulis MA, Gewillig MH, Hsia TY, Hsu DT, Kovacs AH, McCrindle BW, Newburger JW, Pike NA, Rodefeld M, Rosenthal DN, Schumacher KR, Marino BS, Stout K, Veldtman G, Younoszai AK, d'Udekem Y. Evaluation and Management of the Child and Adult With Fontan Circulation: A Scientific Statement From the American Heart Association. Circulation 2019; 140:e234-e284. [PMID: 31256636 DOI: 10.1161/cir.0000000000000696] [Citation(s) in RCA: 407] [Impact Index Per Article: 81.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
It has been 50 years since Francis Fontan pioneered the operation that today bears his name. Initially designed for patients with tricuspid atresia, this procedure is now offered for a vast array of congenital cardiac lesions when a circulation with 2 ventricles cannot be achieved. As a result of technical advances and improvements in patient selection and perioperative management, survival has steadily increased, and it is estimated that patients operated on today may hope for a 30-year survival of >80%. Up to 70 000 patients may be alive worldwide today with Fontan circulation, and this population is expected to double in the next 20 years. In the absence of a subpulmonary ventricle, Fontan circulation is characterized by chronically elevated systemic venous pressures and decreased cardiac output. The addition of this acquired abnormal circulation to innate abnormalities associated with single-ventricle congenital heart disease exposes these patients to a variety of complications. Circulatory failure, ventricular dysfunction, atrioventricular valve regurgitation, arrhythmia, protein-losing enteropathy, and plastic bronchitis are potential complications of the Fontan circulation. Abnormalities in body composition, bone structure, and growth have been detected. Liver fibrosis and renal dysfunction are common and may progress over time. Cognitive, neuropsychological, and behavioral deficits are highly prevalent. As a testimony to the success of the current strategy of care, the proportion of adults with Fontan circulation is increasing. Healthcare providers are ill-prepared to tackle these challenges, as well as specific needs such as contraception and pregnancy in female patients. The role of therapies such as cardiovascular drugs to prevent and treat complications, heart transplantation, and mechanical circulatory support remains undetermined. There is a clear need for consensus on how best to follow up patients with Fontan circulation and to treat their complications. This American Heart Association statement summarizes the current state of knowledge on the Fontan circulation and its consequences. A proposed surveillance testing toolkit provides recommendations for a range of acceptable approaches to follow-up care for the patient with Fontan circulation. Gaps in knowledge and areas for future focus of investigation are highlighted, with the objective of laying the groundwork for creating a normal quality and duration of life for these unique individuals.
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Deshaies C, Hamilton RM, Shohoudi A, Trottier H, Poirier N, Aboulhosn J, Broberg CS, Cohen S, Cook S, Dore A, Fernandes SM, Fournier A, Kay J, Mondésert B, Mongeon FP, Opotowsky AR, Proietti A, Ting J, Zaidi A, Khairy P. Thromboembolic Risk After Atriopulmonary, Lateral Tunnel, and Extracardiac Conduit Fontan Surgery. J Am Coll Cardiol 2019; 74:1071-1081. [DOI: 10.1016/j.jacc.2019.06.051] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 05/24/2019] [Accepted: 06/12/2019] [Indexed: 10/26/2022]
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Roncati L, Manenti A, Pecchi AR, Gallo G. Deeper Insights Into the Fontan Circulation. World J Pediatr Congenit Heart Surg 2019; 10:520. [PMID: 31307307 DOI: 10.1177/2150135119849654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Byrne RD, Weingarten AJ, Clark DE, Huang S, Perri RE, Scanga AE, Menachem JN, Markham LW, Frischhertz BP. More than the heart: Hepatic, renal, and cardiac dysfunction in adult Fontan patients. CONGENIT HEART DIS 2019; 14:765-771. [PMID: 31282062 DOI: 10.1111/chd.12820] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 06/11/2019] [Accepted: 06/19/2019] [Indexed: 12/12/2022]
Abstract
SETTING Fontan-associated liver disease universally affects adults with single ventricle heart disease. Chronic kidney disease is also highly prevalent in adult Fontan patients. In this study, we evaluate the relationship of Fontan hemodynamics invasively and noninvasively with extra-cardiac dysfunction as measured by MELD and MELD-XI. OBJECTIVE We hypothesize that invasive and noninvasive measures of Fontan circuit congestion and ventricular dysfunction are associated with increased MELD and MELD-XI scores. DESIGN Single-center data from adults with Fontan palliation who had ongoing care, including cardiac catheterization, were retrospectively collected. Hemodynamic data from cardiac catheterization and echocardiographic assessment of ventricular and atrioventricular valve function were tested for association with serum creatinine, MELD, and MELD-XI. Linear regression was used to perform multivariable analysis in the echocardiogram cohort. RESULTS Fifty-seven patients had congruent lab and catheterization data for analysis. Sixty-three and sixty-nine patients had congruent lab and echocardiogram data for MELD and MELD-XI, respectively. Of the hemodynamic variables analyzed, only decreased systemic oxygen saturation had significant correlation with elevated MELD and MELD-XI (P = .045). Patients with moderately or severely reduced ejection fraction by echocardiogram had significantly higher MELD and MELD-XI scores compared to those with normal or mildly depressed systolic ventricular function (P = .008 and P < .001 for MELD and MELD-XI, respectively). Significant differences in creatinine were also found among the ventricular dysfunction groups (P = .02). CONCLUSIONS In adults following Fontan palliation, systolic ventricular dysfunction and decreased oxygen saturation were associated with hepatic and renal dysfunction as assessed by elevated serum creatinine, MELD, and MELD-XI scores.
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Affiliation(s)
- Ryan D Byrne
- Departments of Internal Medicine and Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Angela J Weingarten
- Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Daniel E Clark
- Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Shi Huang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Roman E Perri
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Andrew E Scanga
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan N Menachem
- Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Larry W Markham
- Departments of Pediatrics and Internal Medicine, Division of Cardiology, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana
| | - Benjamin P Frischhertz
- Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, Tennessee
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Corno AF, Owen MJ, Cangiani A, Hall EJC, Rona A. Physiological Fontan Procedure. Front Pediatr 2019; 7:196. [PMID: 31179252 PMCID: PMC6543709 DOI: 10.3389/fped.2019.00196] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 04/29/2019] [Indexed: 11/13/2022] Open
Abstract
Objective: The conventional Fontan circulation deviates the superior vena cava (SVC = 1/3 of the systemic venous return) toward the right lung (3/5 of total lung volume) and the inferior vena cava (IVC = 2/3 of the systemic venous return) toward the left lung (2/5 of total lung volume). A "physiological" Fontan deviating the SVC toward the left lung and the IVC toward the right lung was compared with the conventional setting by computational fluid dynamics, studying whether this setting achieves a more favorable hemodynamics than the conventional Fontan circulation. Materials and Methods: An in-silico 3D parametric model of the Fontan procedure was developed using idealized vascular geometries with invariant sizes of SVC, IVC, right pulmonary artery (RPA), and left pulmonary artery (LPA), steady inflow velocities at IVC and SVC, and constant equal outflow pressures at RPA and LPA. These parameters were set to perform finite-volume incompressible steady flow simulations, assuming a single-phase, Newtonian, isothermal, laminar blood flow. Numerically converged finite-volume mass and momentum flow balances determined the inlet pressures and the outflow rates. Numerical closed-path integration of energy fluxes across domain boundaries determined the flow energy loss rate through the Fontan circulation. The comparison evaluated: (1) mean IVC pressure; (2) energy loss rate; (3) kinetic energy maximum value throughout the domain volume. Results: The comparison of the physiological vs. conventional Fontan provided these results: (1) mean IVC pressure 13.9 vs. 14.1 mmHg (= 0.2 mmHg reduction); (2) energy loss rate 5.55 vs. 6.61 mW (= 16% reduction); (3) maximum kinetic energy 283 vs. 396 J/m3 (= 29% reduction). Conclusions: A more physiological flow distribution is accompanied by a reduction of mean IVC pressure and by substantial reductions of energy loss rate and of peak kinetic energy. The potential clinical impact of these hemodynamic changes in reducing the incidence and severity of the adverse long-term effects of the Fontan circulation, in particular liver failure and protein-losing enteropathy, still remains to be assessed and will be the subject of future work.
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Affiliation(s)
| | - Matt J. Owen
- University of Leicester, Leicester, United Kingdom
| | - Andrea Cangiani
- School of Mathematical Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Edward J. C. Hall
- School of Mathematical Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Aldo Rona
- University of Leicester, Leicester, United Kingdom
- Department of Engineering, University of Leicester, Leicester, United Kingdom
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Ridderbos FS, Hoendermis ES, Berger RM, van Melle JP. The Janus‐faced Fontan circulation: unravelling its elusive pathophysiology. Eur J Heart Fail 2019; 21:810-812. [DOI: 10.1002/ejhf.1415] [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: 11/27/2018] [Accepted: 12/06/2018] [Indexed: 12/27/2022] Open
Affiliation(s)
- Floris‐Jan S. Ridderbos
- Center for Congenital Heart Diseases, Department of Pediatric Cardiology, Beatrix Children's HospitalUniversity Medical Center Groningen, University of Groningen The Netherlands
| | - Elke S. Hoendermis
- Center for Congenital Heart Diseases, Department of CardiologyUniversity Medical Center Groningen, University of Groningen The Netherlands
| | - Rolf M.F. Berger
- Center for Congenital Heart Diseases, Department of Pediatric Cardiology, Beatrix Children's HospitalUniversity Medical Center Groningen, University of Groningen The Netherlands
| | - Joost P. van Melle
- Center for Congenital Heart Diseases, Department of CardiologyUniversity Medical Center Groningen, University of Groningen The Netherlands
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Miranda WR, Borlaug BA, Hagler DJ, Connolly HM, Egbe AC. Haemodynamic profiles in adult Fontan patients: associated haemodynamics and prognosis. Eur J Heart Fail 2019; 21:803-809. [DOI: 10.1002/ejhf.1365] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 07/27/2018] [Accepted: 10/21/2018] [Indexed: 02/02/2023] Open
Affiliation(s)
| | - Barry A. Borlaug
- Department of Cardiovascular DiseasesMayo Clinic Rochester MN USA
| | - Donald J. Hagler
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent MedicineMayo Clinic Rochester MN USA
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Kalfa D. Fontan-associated liver disease: Is it all about hemodynamics? J Thorac Cardiovasc Surg 2018; 156:276-277. [PMID: 29730114 DOI: 10.1016/j.jtcvs.2018.03.104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 03/27/2018] [Indexed: 10/17/2022]
Affiliation(s)
- David Kalfa
- Division of Cardiac, Thoracic, and Vascular Surgery, Section of Pediatric and Congenital Cardiac Surgery, New York Presbyterian-Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY.
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