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Cleveland V, Contento J, Mass P, Hardikar P, Wu Q, Liu X, Aslan S, Loke YH, Krieger A, Lunos S, Olivieri L, Sinha P. In vitro investigation of axial mechanical support devices implanted in the novel convergent cavopulmonary connection Fontan. Eur J Cardiothorac Surg 2024; 65:ezad413. [PMID: 38180888 DOI: 10.1093/ejcts/ezad413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 11/08/2023] [Accepted: 01/02/2024] [Indexed: 01/07/2024] Open
Abstract
OBJECTIVES The 2 opposing inflows and 2 outflows in a total cavopulmonary connection make mechanical circulatory support (MCS) extremely challenging. We have previously reported a novel convergent cavopulmonary connection (CCPC) Fontan design that improves baseline characteristics and provides a single inflow and outflow, thus simplifying MCS. This study aims to assess the feasibility of MCS of this novel configuration using axial flow pumps in an in vitro benchtop model. METHODS Three-dimensional segmentations of 12 single-ventricle patients (body surface area 0.5-1.75 m2) were generated from cardiovascular magnetic resonance images. The CCPC models were designed by connecting the inferior vena cava and superior vena cava to a shared conduit ascending to the pulmonary arteries, optimized in silico. The 12 total cavopulmonary connection and their corresponding CCPC models underwent in vitro benchtop characterization. Two MCS devices were used, the Impella RP® and the PediPump. RESULTS MCS successfully and symmetrically reduced the pressure in both vena cavae by >20 mmHg. The devices improved the hepatic flow distribution balance of all CCPC models (Impella RP®P = 0.045, PediPump P = 0.055). CONCLUSIONS The CCPC Fontan design provides a feasible MCS solution for a failing Fontan by balancing hepatic flow distribution and symmetrically decompressing the central venous pressure. Cardiac index may also improve with MCS. Additional studies are needed to evaluate this concept for managing Fontan failure.
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Affiliation(s)
- Vincent Cleveland
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
| | | | - Paige Mass
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
| | - Priyanka Hardikar
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
| | - Qiyuan Wu
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Xiaolong Liu
- Department of Mechanical Engineering, Texas Tech University, Lubbock, TX, USA
| | - Seda Aslan
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Yue-Hin Loke
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
| | - Axel Krieger
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Scott Lunos
- Biostatistical Design and Analysis Center, Clinical and Translational Science Institute, University of Minnesota, Minneapolis, MN, USA
| | - Laura Olivieri
- Division of Pediatric Cardiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Pranava Sinha
- Department of Pediatric Cardiac Surgery, M Health Fairview University of Minnesota, Minneapolis, MN, USA
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Yang W, Conover TA, Figliola RS, Giridharan GA, Marsden AL, Rodefeld MD. Passive performance evaluation and validation of a viscous impeller pump for subpulmonary fontan circulatory support. Sci Rep 2023; 13:12668. [PMID: 37542111 PMCID: PMC10403595 DOI: 10.1038/s41598-023-38559-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 07/11/2023] [Indexed: 08/06/2023] Open
Abstract
Patients with single ventricle defects undergoing the Fontan procedure eventually face Fontan failure. Long-term cavopulmonary assist devices using rotary pump technologies are currently being developed as a subpulmonary power source to prevent and treat Fontan failure. Low hydraulic resistance is a critical safety requirement in the event of pump failure (0 RPM) as a modest 2 mmHg cavopulmonary pressure drop can compromise patient hemodynamics. The goal of this study is therefore to assess the passive performance of a viscous impeller pump (VIP) we are developing for Fontan patients, and validate flow simulations against in-vitro data. Two different blade heights (1.09 mm vs 1.62 mm) and a blank housing model were tested using a mock circulatory loop (MCL) with cardiac output ranging from 3 to 11 L/min. Three-dimensional flow simulations were performed and compared against MCL data. In-silico and MCL results demonstrated a pressure drop of < 2 mmHg at a cardiac output of 7 L/min for both blade heights. There was good agreement between simulation and MCL results for pressure loss (mean difference - 0.23 mmHg 95% CI [0.24-0.71]). Compared to the blank housing model, low wall shear stress area and oscillatory shear index on the pump surface were low, and mean washout times were within 2 s. This study demonstrated the low resistance characteristic of current VIP designs in the failed condition that results in clinically acceptable minimal pressure loss without increased washout time as compared to a blank housing model under normal cardiac output in Fontan patients.
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Affiliation(s)
- Weiguang Yang
- Department of Pediatrics (Cardiology), Stanford University, Stanford, CA, USA.
| | - Timothy A Conover
- Departments of Mechanical Engineering, Clemson University, Clemson, SC, USA
| | - Richard S Figliola
- Departments of Mechanical Engineering, Clemson University, Clemson, SC, USA
| | | | - Alison L Marsden
- Department of Pediatrics (Cardiology), Stanford University, Stanford, CA, USA
- Department of Bioengineering, Stanford University, Stanford, CA, USA
| | - Mark D Rodefeld
- Section of Cardiothoracic Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
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Abstract
To address the increasing number of failing Fontan patients, Penn State University and the Penn State Hershey Medical Center are developing a centrifugal blood pump for long-term mechanical support. Computational fluid dynamics (CFD) modeling of the Penn State Fontan Circulatory Assist Device (FCAD) was performed to understand hemodynamics within the pump and its potential for hemolysis and thrombosis. CFD velocity and pressure results were first validated against experimental data and found to be within the standard deviations of the velocities and within 5% of the pressures. Further simulations performed with a human blood model found that most of the fluid domain was subjected to low shear stress (<50 Pa), with areas of highest stress around the rotor blade tips that increased with pump flow rate and rotor speed (138-178 Pa). However, the stresses compared well to previous CFD studies of commercial blood pumps and remained mostly below common thresholds of hemolysis and platelet activation. Additionally, few regions of low shear rate were observed within the FCAD, signifying minimal potential for platelet adhesion. These results further emphasize the FCAD's potential that has been observed previously in experimental and animal studies.
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Haranal M, Luo S, Honjo O. Mechanical Circulatory Support for Patients With Adult Congenital Heart Disease. Circ J 2020; 84:533-541. [DOI: 10.1253/circj.cj-19-0821] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Maruti Haranal
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children
| | - Shuhua Luo
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children
| | - Osami Honjo
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children
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Hemodynamic Effects of A Simplified Venturi Conduit for Fontan Circulation: A Pilot, In Silico Analysis. Sci Rep 2020; 10:817. [PMID: 31964953 PMCID: PMC6972950 DOI: 10.1038/s41598-020-57634-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 12/31/2019] [Indexed: 12/28/2022] Open
Abstract
Objectives: To study the effects of a self-powered Fontan circulation in both idealized Fontan models and patient-specific models. Methods: In silico, a conduit with a nozzle was introduced from ascending aorta into the anastomosis of superior vena cava and pulmonary artery. Computational fluid dynamics (CFD) simulation was applied to calculate the fluid fields of models. Three 3-dimentional idealized models with different offsets were reconstructed by computer-aided design to evaluate the effects of the self-powered conduit. Furthermore, to validate the effects in patient-specific models, the conduit was introduced to three reconstructed models with different offsets. Results: The pressures at superior venae cavae and inferior venae cavae were decreased in both idealized models (0.4 mmHg) and patient-specific models (0.7 mmHg). In idealized models, the flows to left lungs were decreased (70%) by the jets from the conduits. However, in patient-specific models, the reductions of blood to the left lungs were relatively limited (30%) comparing to idealized models. Conclusions: CFD simulation was applied to analyze the effectiveness of the Fontan self-powered conduit. This self-powered conduit may help to decrease the venae cavae pressures and increase the flow to pulmonary arteries.
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Telyshev D, Denisov M, Markov A, Fresiello L, Verbelen T, Selishchev S. Energetics of blood flow in Fontan circulation under VAD support. Artif Organs 2019; 44:50-57. [DOI: 10.1111/aor.13564] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 08/21/2019] [Accepted: 08/26/2019] [Indexed: 12/27/2022]
Affiliation(s)
- Dmitry Telyshev
- Institute of Biomedical Systems National Research University of Electronic Technology Zelenograd Russian Federation
- Institute for Bionic Technologies and Engineering I. M. Sechenov First Moscow State Medical University Moscow Russian Federation
| | - Maxim Denisov
- Institute of Biomedical Systems National Research University of Electronic Technology Zelenograd Russian Federation
| | - Aleksandr Markov
- Institute for Bionic Technologies and Engineering I. M. Sechenov First Moscow State Medical University Moscow Russian Federation
| | - Libera Fresiello
- Department of Cardiac Surgery Katholieke Universiteit Leuven Leuven Belgium
| | - Tom Verbelen
- Department of Cardiac Surgery Katholieke Universiteit Leuven Leuven Belgium
| | - Sergey Selishchev
- Institute of Biomedical Systems National Research University of Electronic Technology Zelenograd Russian Federation
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Honjo O, Doyle MG, Amon CH. Commentary: Engineering an optimal mechanical circulatory support system for the cavopulmonary connection. J Thorac Cardiovasc Surg 2019; 159:e143-e144. [PMID: 31540736 DOI: 10.1016/j.jtcvs.2019.08.001] [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: 08/05/2019] [Revised: 08/05/2019] [Accepted: 08/12/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Osami Honjo
- Division of Cardiovascular Surgery, Department of Surgery, Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
| | - Matthew G Doyle
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada; Division of Vascular Surgery, Department of Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Cristina H Amon
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada; Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
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Computational fluid dynamic simulations of a cavopulmonary assist device for failing Fontan circulation. J Thorac Cardiovasc Surg 2019; 158:1424-1433.e5. [PMID: 31005303 DOI: 10.1016/j.jtcvs.2019.03.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 01/13/2019] [Accepted: 03/02/2019] [Indexed: 01/23/2023]
Abstract
OBJECTIVES Adult patients who have undergone the Fontan procedure are highly vulnerable to gradual, progressive circulatory failure, and options to reverse this situation are few. A cavopulmonary assist device could decongest the venous and lymphatic systems, overcome elevated pulmonary vascular resistance, increase cardiac output, and support some of these patients to heart transplant. This study characterizes the performance and challenges of a novel multilumen cannula coupled to an external blood pump proposed as a potential Fontan cavopulmonary assist strategy. METHODS Computational fluid dynamic simulations were conducted for 3 extracardiac Fontan geometries consisting of 1 idealized model and 2 patient-specific models. A range of physiologic flow rates and pump assist levels were simulated to calculate the pressure gain provided by the multilumen cannula. Hemolysis index was estimated for the idealized model with Lagrangian particle tracking and 2 variations of the power-law. Wall shear stresses were also examined. RESULTS Pressure gains up to 4 and 9 mm Hg were achieved for the idealized and patient-specific models, respectively. Pressure gains increased with both higher cardiac output and larger pump intake through the external pump. Flow-weighted hemolysis show hemoglobin damage levels to be several times lower than the 2% threshold at the highest pump intake flow cases. Wall shear stress predictions depict elevated areas in the pulmonary vessels and regions of the cannula device. CONCLUSIONS The cannula tested in this study shows promise as a percutaneous option to bridge support in some patients with a failing extracardiac Fontan. Limitations identified will be addressed in future design iterations and in ongoing experimental tests.
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Van Puyvelde J, Rega F, Minami T, Claus P, Cools B, Gewillig M, Meyns B. Creation of the Fontan circulation in sheep: a survival model. Interact Cardiovasc Thorac Surg 2019; 29:15-21. [DOI: 10.1093/icvts/ivz022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 12/30/2018] [Accepted: 01/13/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Joeri Van Puyvelde
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Filip Rega
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Tomoyuki Minami
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Piet Claus
- Department of Cardiovascular Imaging and Dynamics, University Hospitals Leuven, Leuven, Belgium
| | - Bjorn Cools
- Department of Paediatric Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Marc Gewillig
- Department of Paediatric Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Bart Meyns
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
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Dual-Propeller Cavopulmonary Pump for Assisting Patients with Hypoplastic Right Ventricle. ASAIO J 2019; 65:888-897. [PMID: 30688694 DOI: 10.1097/mat.0000000000000907] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Various congenital heart defects (CHDs) are characterized by the existence of a single functional ventricle, which perfuses both the systemic and pulmonary circulation. A three-stage palliation procedure, including the final Fontan completion, is often adopted by surgeons to treat patients with such CHDs. The completion Fontan involves the creation of a total cavopulmonary connection (TCPC), commonly accomplished with an extracardiac conduit. This TCPC results in nonphysiologic flow conditions that can lead to systemic venous hypertension, reduced cardiac output, and ultimately the need for heart transplantation. A modest pressure rise of 5-6 mm Hg could correct the abnormal flow dynamics in these patients. To achieve this, we propose a novel conceptual design of a dual-propeller pump inside a flared TCPC. The TCPC dual-propeller conjunction was examined for hydraulic performance, blood flow pattern, and potential for hemolysis inside the TCPC using computational fluid dynamics (CFD). The effect of axial distance between the two propellers on the blood flow interference and energy loss was studied to determine the optimal separation distance. Both the inferior vena cava (IVC) and superior vena cava (SVC) propellers provided a pressure rise of 1-20 mm Hg at flow rates ranging from 0.4 to 7 lpm while rotating at speeds of 6,000-12,000 rpm. Larger separation distance provided favorable performance in terms of flow interference, energy loss, and blood damage potential. The ability of a dual-propeller micropump to provide the required pressure rise would help to augment the cavopulmonary flow and mimic flows seen in normal biventricular circulation.
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11
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Broda CR, Taylor DA, Adachi I. Progress in experimental and clinical subpulmonary assistance for Fontan circulation. J Thorac Cardiovasc Surg 2018; 156:1949-1956. [PMID: 29884497 DOI: 10.1016/j.jtcvs.2018.04.102] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 04/09/2018] [Accepted: 04/24/2018] [Indexed: 11/15/2022]
Affiliation(s)
- Christopher R Broda
- Department of Pediatric Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, Tex.
| | - Doris A Taylor
- Regenerative Medicine Research, Texas Heart Institute, Houston, Tex
| | - Iki Adachi
- Department of Congenital Heart Surgery, Baylor College of Medicine/Texas Children's Hospital, Houston, Tex
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12
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Buratto E, Shi WY, Ye XT, Konstantinov IE. Ventricular assist devices for the failing univentricular circulation. Expert Rev Med Devices 2017; 14:449-459. [DOI: 10.1080/17434440.2017.1332523] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Edward Buratto
- Department of Cardiac Surgery, The Royal Children’s Hospital, Melbourne, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Australia
- Murdoch Children’s Research Institute, Melbourne, Australia
| | - William Y. Shi
- Department of Cardiac Surgery, The Royal Children’s Hospital, Melbourne, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Australia
- Murdoch Children’s Research Institute, Melbourne, Australia
| | - Xin Tao Ye
- Department of Cardiac Surgery, The Royal Children’s Hospital, Melbourne, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Australia
- Murdoch Children’s Research Institute, Melbourne, Australia
| | - Igor E. Konstantinov
- Department of Cardiac Surgery, The Royal Children’s Hospital, Melbourne, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Australia
- Murdoch Children’s Research Institute, Melbourne, Australia
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13
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Morray BH, Dimas VV, Lim S, Balzer DT, Parekh DR, Van Mieghem NM, Ewert P, Kim DW, Justino H, McElhinney DB, Jones TK. Circulatory support using the impella device in fontan patients with systemic ventricular dysfunction: A multicenter experience. Catheter Cardiovasc Interv 2017; 90:118-123. [DOI: 10.1002/ccd.26885] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 10/12/2016] [Accepted: 11/20/2016] [Indexed: 11/12/2022]
Affiliation(s)
- Brian H. Morray
- Division of Cardiology; Seattle Children's Hospital; Seattle Washington
| | - Vivian V. Dimas
- Division of Cardiology; University of Texas Southwestern Medical Center; Dallas Texas
| | - Scott Lim
- Division of Pediatric Cardiology; University of Virginia; Charlottesville Virginia
| | - David T. Balzer
- Division of Pediatric Cardiology; Washington University School of Medicine; St. Louis Missouri
| | - Dhaval R. Parekh
- Division of Pediatric Cardiology, Department of Pediatrics, The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine; Houston Texas
| | - Nicolas M. Van Mieghem
- Department of Cardiology; Thoraxcenter, Erasmus Medical Center; Rotterdam The Netherlands
| | - Peter Ewert
- Department of Pediatric Cardiology and Congenital Heart Disease; Deutsches Herzzentrum München; München Germany
| | - Dennis W. Kim
- Division of Pediatric Cardiology; Children's Healthcare of Atlanta, Emory University; Atlanta Georgia
| | - Henri Justino
- Division of Pediatric Cardiology, Department of Pediatrics, The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine; Houston Texas
| | - Doff B. McElhinney
- Department of Cardiothoracic Surgery; Lucille Packard Children's Hospital at Stanford; Palo Alto California
| | - Thomas K. Jones
- Division of Cardiology; Seattle Children's Hospital; Seattle Washington
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Vaughn G, Moore J, Lamberti J, Canter C. Management of the failing Fontan: Medical, interventional and surgical treatment. PROGRESS IN PEDIATRIC CARDIOLOGY 2016. [DOI: 10.1016/j.ppedcard.2016.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Clift P, Celermajer D. Managing adult Fontan patients: where do we stand? Eur Respir Rev 2016; 25:438-450. [PMID: 27903666 PMCID: PMC9487559 DOI: 10.1183/16000617.0091-2016] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 10/13/2016] [Indexed: 01/10/2023] Open
Abstract
The Fontan operation is performed as a palliative procedure to improve survival in infants born with a functionally univentricular circulation. The success of the operation is demonstrated by a growing adult Fontan population that exists with this unique physiology. Late follow-up has demonstrated expected and unexpected sequelae, and has shown multisystem effects of this circulation. This review discusses the challenges of managing the late complications in terms of understanding this unique physiology and the innovative therapeutic interventions that are being investigated. The challenge remains to maintain quality of life for adult survivors, as well as extending life expectancy. Innovative solutions are required to meet the challenges of the Fontan circulation faced in adult lifehttp://ow.ly/XTSm305oH8b
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Chopski SG, Moskowitz WB, Stevens RM, Throckmorton AL. Mechanical Circulatory Support Devices for Pediatric Patients With Congenital Heart Disease. Artif Organs 2016; 41:E1-E14. [DOI: 10.1111/aor.12760] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Revised: 03/21/2016] [Accepted: 03/22/2016] [Indexed: 01/03/2023]
Affiliation(s)
- Steven G. Chopski
- BioCirc Research Laboratory, School of Biomedical Engineering, Science and Health Systems; Drexel University; Philadelphia PA
| | - William B. Moskowitz
- Division of Pediatric Cardiology, Children's Hospital of Richmond and School of Medicine; Virginia Commonwealth University; Richmond VA
| | - Randy M. Stevens
- St. Christopher's Hospital for Children, Tenet Healthcare Corporation; Philadelphia PA USA
| | - Amy L. Throckmorton
- BioCirc Research Laboratory, School of Biomedical Engineering, Science and Health Systems; Drexel University; Philadelphia PA
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