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Kisamori E, Venna A, Chaudhry HE, Desai M, Tongut A, Mehta R, Clauss S, Yerebakan C, d'Udekem Y. Alarming rate of liver cirrhosis after the small conduit extracardiac Fontan: A comparative analysis with the lateral tunnel. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00311-8. [PMID: 38688450 DOI: 10.1016/j.jtcvs.2024.04.013] [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: 02/07/2024] [Revised: 03/28/2024] [Accepted: 04/10/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND The association between the prevalence of cirrhosis and the types of Fontan operations remains unclear. METHODS We conducted a retrospective chart review of 332 patients who underwent the Fontan procedure at our institution. Four patients who underwent the atriopulmonary connection Fontan were excluded from the analysis. Patients who had intracardiac-extracardiac conduit (126) between 1989 and 2021 were pooled with those having extracardiac conduit (ECC) (134). The 260 patients who underwent the ECC and the 68 patients who had the lateral tunnel (LT) Fontan constitute the core of the study. RESULTS Median age at the Fontan procedure was 23.7 months (interquartile range [IQR], 20.8-32.6) in the LT group, compared with 28.8 months (IQR, 24.6-39.5) in the ECC group (P < .01). The median follow-up was 14.8 years (IQR, 12.5-16.5) in the LT group and 7 years (IQR, 2.8-10.4) in the extracardiac conduit group. During the follow-up period, 3 patients (4.4%) with LT and 17 patients (6.5%) with ECC (11 patients with 16 mm or less conduit size) were diagnosed with cirrhosis. The prevalence of cirrhosis at 1, 5, 10, and 15 years was 0%, 0%, 0%, and 4.4% in the LT group, respectively, and 0%, 0.9%, 7.7%, and 29.8% in the ECC group (P < .01) Rates of mortality, Fontan revision, Fontan takedown, transplant, and complications were comparable between the 2 groups. CONCLUSIONS The extracardiac conduit Fontan seems to be associated with faster development of cirrhosis.
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Affiliation(s)
- Eiri Kisamori
- Division of Cardiovascular Surgery, Children's National Heart Institute, Children's National Hospital, Washington, DC
| | - Alyssia Venna
- Division of Cardiovascular Surgery, Children's National Heart Institute, Children's National Hospital, Washington, DC
| | - Hamzah Ejaz Chaudhry
- Division of Cardiovascular Surgery, Children's National Heart Institute, Children's National Hospital, Washington, DC
| | - Manan Desai
- Division of Cardiovascular Surgery, Children's National Heart Institute, Children's National Hospital, Washington, DC
| | - Aybala Tongut
- Division of Cardiovascular Surgery, Children's National Heart Institute, Children's National Hospital, Washington, DC
| | - Rittal Mehta
- Division of Cardiovascular Surgery, Children's National Heart Institute, Children's National Hospital, Washington, DC
| | - Sarah Clauss
- Division of Cardiology, Children's National Heart Institute, Children's National Hospital, Washington, DC
| | - Can Yerebakan
- Division of Cardiovascular Surgery, Children's National Heart Institute, Children's National Hospital, Washington, DC
| | - Yves d'Udekem
- Division of Cardiovascular Surgery, Children's National Heart Institute, Children's National Hospital, Washington, DC.
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Sakamoto K, Iwamoto Y, Ogawa K, Tamura K, Ito C, Iwata M, Sakamoto A, Shine M, Nishi Y, Uraoka M, Nagaoka T, Honjo M, Funamizu N, Takada Y. Impact of the inferior vena cava morphology on fluid dynamics of the hepatic veins. Surg Today 2024; 54:205-209. [PMID: 37516666 DOI: 10.1007/s00595-023-02733-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 07/16/2023] [Indexed: 07/31/2023]
Abstract
We reported previously that a large vertical interval between the hepatic segment of the inferior vena cava (IVC) and right atrium (RA), referred to as the IVC-RA gap, was associated with more intraoperative bleeding during hemi-hepatectomy. We conducted a computational fluid dynamics (CFD) study to clarify the impact of fluid dynamics resulting from morphologic variations around the liver. The subjects were 10 patients/donors with a large IVC-RA gap and 10 patients/donors with a small IVC-RA gap. Three-dimensional reconstructions of the IVC and hepatic vessels were created from CT images for the CFD study. Median pressure in the middle hepatic vein was significantly higher in the large-gap group than in the small-gap group (P = 0.008). Differences in hepatic vein pressure caused by morphologic variation in the IVC might be one of the mechanisms of intraoperative bleeding from the hepatic veins.
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Affiliation(s)
- Katsunori Sakamoto
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, 454 Kou, Shitsukawa, Toon, Ehime, 791-0295, Japan.
| | - Yukiharu Iwamoto
- Department of Mechanical Engineering, Ehime University Graduate School of Science and Engineering, 3 Bunkyo-Cho, Matsuyama, Ehime, 790-8577, Japan
| | - Kohei Ogawa
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, 454 Kou, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Kei Tamura
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, 454 Kou, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Chihiro Ito
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, 454 Kou, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Miku Iwata
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, 454 Kou, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Akimasa Sakamoto
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, 454 Kou, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Mikiya Shine
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, 454 Kou, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Yusuke Nishi
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, 454 Kou, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Mio Uraoka
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, 454 Kou, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Tomoyuki Nagaoka
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, 454 Kou, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Masahiko Honjo
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, 454 Kou, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Naotake Funamizu
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, 454 Kou, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Yasutsugu Takada
- Department of Hepato-Biliary-Pancreatic and Breast Surgery, Ehime University Graduate School of Medicine, 454 Kou, Shitsukawa, Toon, Ehime, 791-0295, Japan
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Hut T, Roest A, Gaillard D, Hazekamp M, van den Boogaard P, Lamb H, Kroft L, Jongbloed M, Westenberg J, Wentzel J, Rijnberg F, Kenjeres S. Virtual surgery to predict optimized conduit size for adult Fontan patients with 16-mm conduits. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2023; 37:ivad126. [PMID: 37522877 PMCID: PMC10686953 DOI: 10.1093/icvts/ivad126] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 06/18/2023] [Accepted: 07/30/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVES Recent evidence suggests that conduits implanted in Fontan patients at the age of 2-4 years become undersized for adulthood. The objective of this study is to use computational fluid dynamic models to evaluate the effect of virtual expansion of the Fontan conduit on haemodynamics and energetics of the total cavopulmonary connection (TCPC) under resting conditions and increased flow conditions. METHODS Patient-specific, magnetic resonance imaging-based simulation models of the TCPC were performed during resting and increased flow conditions. The original 16-mm conduits were virtually enlarged to 3 new sizes. The proposed conduit sizes were defined based on magnetic resonance imaging-derived conduit flow in each patient. Flow efficiency was evaluated based on power loss, pressure drop and resistance and thrombosis risk was based on flow stagnation volume and relative residence time (RRT). RESULTS Models of 5 adult patients with a 16-mm extracardiac Fontan connection were simulated and subsequently virtually expanded to 24-32 mm depending on patient-specific conduit flow. Virtual expansion led to a 40-65% decrease in pressure gradient across the TCPC depending on virtual conduit size. Despite improved energetics of the entire TCPC, the pulmonary arteries remained a significant contributor to energy loss (60-73% of total loss) even after virtual surgery. Flow stagnation volume inside the virtual conduit and surface area in case of elevated RRT (>20/Pa) increased after conduit enlargement but remained negligible (flow stagnation <2% of conduit volume in rest, <0.5% with exercise and elevated RRT <3% in rest, <1% with exercise). CONCLUSIONS Virtual expansion of 16-mm conduits to 24-32 mm, depending on patient-specific conduit flow, in Fontan patients significantly improves TCPC efficiency while thrombosis risk presumably remains low.
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Affiliation(s)
- Tjerry Hut
- Department of Chemical Engineering, Faculty of Applied Sciences, Delft University of Technology and J.M. Burgers Centrum Research School for Fluid Mechanics, Delft, Netherlands
| | - Arno Roest
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Duco Gaillard
- Department of Chemical Engineering, Faculty of Applied Sciences, Delft University of Technology and J.M. Burgers Centrum Research School for Fluid Mechanics, Delft, Netherlands
| | - Mark Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | | | - Hildo Lamb
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Lucia Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Monique Jongbloed
- Department of Cardiology and Anatomy & Embryology, Leiden University Medical Center, Leiden, Netherlands
| | - Jos Westenberg
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Jolanda Wentzel
- Department of Cardiology, Biomechanical Engineering, Erasmus MC, Rotterdam, Netherlands
| | - Friso Rijnberg
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Sasa Kenjeres
- Department of Chemical Engineering, Faculty of Applied Sciences, Delft University of Technology and J.M. Burgers Centrum Research School for Fluid Mechanics, Delft, Netherlands
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d’Udekem Y, Kisamori E, Yerebakan C. We were wrong on the benefits of the extra-cardiac Fontan. Should we go back to the lateral tunnel? INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2023; 37:ivad187. [PMID: 37991843 PMCID: PMC10686946 DOI: 10.1093/icvts/ivad187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 11/21/2023] [Indexed: 11/24/2023]
Affiliation(s)
- Yves d’Udekem
- Division of Cardiovascular Surgery, Children’s National Heart Institute, Children’s National Hospital, Washington, DC, USA
| | - Eiri Kisamori
- Division of Cardiovascular Surgery, Children’s National Heart Institute, Children’s National Hospital, Washington, DC, USA
| | - Can Yerebakan
- Division of Cardiovascular Surgery, Children’s National Heart Institute, Children’s National Hospital, Washington, DC, USA
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Lee GH, Koo HJ, Park KJ, Yang DH, Ha H. Characterization of baseline hemodynamics after the Fontan procedure: a retrospective cohort study on the comparison of 4D Flow MRI and computational fluid dynamics. Front Physiol 2023; 14:1199771. [PMID: 37304827 PMCID: PMC10248477 DOI: 10.3389/fphys.2023.1199771] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 05/16/2023] [Indexed: 06/13/2023] Open
Abstract
Introduction: The aim of this study was to characterize the hemodynamics of Fontan patients using both four-dimensional flow magnetic resonance imaging (4D Flow MRI) and computational fluid dynamics (CFD). Methods: Twenty-nine patients (3.5 ± 0.5 years) who had undergone the Fontan procedure were enrolled, and the superior vena cava (SVC), left pulmonary artery (LPA), right pulmonary artery (RPA), and conduit were segmented based on 4D Flow MRI images. Velocity fields from 4D Flow MRI were used as boundary conditions for CFD simulations. Hemodynamic parameters such as peak velocity (Vmax), pulmonary flow distribution (PFD), kinetic energy (KE), and viscous dissipation (VD) were estimated and compared between the two modalities. Results and discussion: The Vmax, KE, VD, PFDTotal to LPA, and PFDTotal to RPA of the Fontan circulation were 0.61 ± 0.18 m/s, 0.15 ± 0.04 mJ, 0.14 ± 0.04 mW, 41.3 ± 15.7%, and 58.7 ± 15.7% from 4D Flow MRI; and 0.42 ± 0.20 m/s, 0.12 ± 0.05 mJ, 0.59 ± 0.30 mW, 40.2 ± 16.4%, and 59.8 ± 16.4% from CFD, respectively. The overall velocity field, KE, and PFD from the SVC were in agreement between modalities. However, PFD from the conduit and VD showed a large discrepancy between 4D Flow MRI and CFD, most likely due to spatial resolution and data noise. This study highlights the necessity for careful consideration when analyzing hemodynamic data from different modalities in Fontan patients.
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Affiliation(s)
- Gyu-Han Lee
- Department of Interdisciplinary Program in Biohealth-Machinery Convergence Engineering, Kangwon National University, Chuncheon, Republic of Korea
| | - Hyun Jung Koo
- Department of Radiology, Asan Medical Center, Research Institute of Radiology, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kyung Jin Park
- Department of Radiology, Asan Medical Center, Research Institute of Radiology, University of Ulsan College of Medicine, Seoul, Republic of Korea
- Department of Electrical and Electronic Engineering, Yonsei University, Seoul, Republic of Korea
| | - Dong Hyun Yang
- Department of Radiology, Asan Medical Center, Research Institute of Radiology, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hojin Ha
- Department of Smart Health Science and Technology, Kangwon National University, Chuncheon, Republic of Korea
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Rijnberg FM, van ‘t Hul LC, Hazekamp MG, van den Boogaard PJ, Juffermans JF, Lamb HJ, Terol Espinosa de Los Monteros C, Kroft LJM, Kenjeres S, le Cessie S, Jongbloed MRM, Westenberg JJM, Roest AAW, Wentzel JJ. Haemodynamic performance of 16-20-mm extracardiac Goretex conduits in adolescent Fontan patients at rest and during simulated exercise. Eur J Cardiothorac Surg 2022; 63:6808623. [PMID: 36342204 PMCID: PMC9972516 DOI: 10.1093/ejcts/ezac522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 10/03/2022] [Accepted: 11/06/2022] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES To date, it is not known if 16-20-mm extracardiac conduits are outgrown during somatic growth from childhood to adolescence. This study aims to determine total cavopulmonary connection (TCPC) haemodynamics in adolescent Fontan patients at rest and during simulated exercise and to assess the relationship between conduit size and haemodynamics. METHODS Patient-specific, magnetic resonance imaging-based computational fluid dynamic models of the TCPC were performed in 51 extracardiac Fontan patients with 16-20-mm conduits. Power loss, pressure gradient and normalized resistance were quantified in rest and during simulated exercise. The cross-sectional area (CSA) (mean and minimum) of the vessels of the TCPC was determined and normalized for flow rate (mm2/l/min). Peak (predicted) oxygen uptake was assessed. RESULTS The median age was 16.2 years (Q1-Q3 14.0-18.2). The normalized mean conduit CSA was 35-73% smaller compared to the inferior and superior vena cava, hepatic veins and left/right pulmonary artery (all P < 0.001). The median TCPC pressure gradient was 0.7 mmHg (Q1-Q3 0.5-0.8) and 2.0 (Q1-Q3 1.4-2.6) during rest and simulated exercise, respectively. A moderate-strong inverse non-linear relationship was present between normalized mean conduit CSA and TCPC haemodynamics in rest and exercise. TCPC pressure gradients of ≥1.0 at rest and ≥3.0 mmHg during simulated exercise were observed in patients with a conduit CSA ≤ 45 mm2/l/min and favourable haemodynamics (<1 mmHg during both rest and exercise) in conduits ≥125 mm2/l/min. Normalized TCPC resistance correlated with (predicted) peak oxygen uptake. CONCLUSIONS Extracardiac conduits of 16-20 mm have become relatively undersized in most adolescent Fontan patients leading to suboptimal haemodynamics.
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Affiliation(s)
- Friso M Rijnberg
- Corresponding author. Department of Cardiothoracic surgery, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, the Netherlands, Telephone number:+31715262348 (F.M. Rijnberg)
| | - Luca C van ‘t Hul
- Department of Cardiology, Biomechanical Engineering, Erasmus MC, Rotterdam, Netherlands
| | - Mark G Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | | | - Joe F Juffermans
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Hildo J Lamb
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | | | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Sasa Kenjeres
- Department of Chemical Engineering, Faculty of Applied Sciences, Delft University of Technology and J.M. Burgers centrum Research School for Fluid Mechanics, Delft, Netherlands
| | - Saskia le Cessie
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
| | - Monique R M Jongbloed
- Department of Cardiology and Anatomy & Embryology, Leiden University Medical Center, Leiden, Netherlands
| | - Jos J M Westenberg
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
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Salaets T, Cools B, De Meester P, Heying R, Boshoff D, Eyskens B, Brown S, Meyns B, Rega F, Van Puyvelde J, Budts W, Gewillig M. Stent expansion of restrictive Fontan conduits to nominal diameter and beyond. Catheter Cardiovasc Interv 2022; 100:1059-1066. [DOI: 10.1002/ccd.30438] [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: 03/08/2022] [Revised: 09/09/2022] [Accepted: 10/02/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Thomas Salaets
- Department of Cardiovascular Sciences, Pediatric & Congenital Cardiology, University Hospitals Leuven Catholic University Leuven Leuven Belgium
| | - Bjorn Cools
- Department of Cardiovascular Sciences, Pediatric & Congenital Cardiology, University Hospitals Leuven Catholic University Leuven Leuven Belgium
| | - Pieter De Meester
- Department of Cardiovascular Sciences Catholic University Leuven Leuven Belgium
| | - Ruth Heying
- Department of Cardiovascular Sciences, Pediatric & Congenital Cardiology, University Hospitals Leuven Catholic University Leuven Leuven Belgium
| | - Derize Boshoff
- Department of Cardiovascular Sciences, Pediatric & Congenital Cardiology, University Hospitals Leuven Catholic University Leuven Leuven Belgium
| | - Benedicte Eyskens
- Department of Cardiovascular Sciences, Pediatric & Congenital Cardiology, University Hospitals Leuven Catholic University Leuven Leuven Belgium
| | - Stephen Brown
- Department of Cardiovascular Sciences, Pediatric & Congenital Cardiology, University Hospitals Leuven Catholic University Leuven Leuven Belgium
- Pediatric Cardiology University of the Free State Bloemfontein Free State South Africa
| | - Bart Meyns
- Department of Cardiovascular Sciences Catholic University Leuven Leuven Belgium
| | - Filip Rega
- Department of Cardiovascular Sciences Catholic University Leuven Leuven Belgium
| | - Joeri Van Puyvelde
- Department of Cardiovascular Sciences Catholic University Leuven Leuven Belgium
| | - Werner Budts
- Department of Cardiovascular Sciences Catholic University Leuven Leuven Belgium
| | - Marc Gewillig
- Department of Cardiovascular Sciences, Pediatric & Congenital Cardiology, University Hospitals Leuven Catholic University Leuven Leuven Belgium
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