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Jalal Z, Langouet E, Dib N, Le-Quellenec S, Mostefa-Kara M, Martin A, Roubertie F, Thambo JB. Role and Applications of Experimental Animal Models of Fontan Circulation. J Clin Med 2024; 13:2601. [PMID: 38731130 PMCID: PMC11084605 DOI: 10.3390/jcm13092601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/17/2024] [Accepted: 04/26/2024] [Indexed: 05/13/2024] Open
Abstract
Over the last four decades, the Fontan operation has been the treatment of choice for children born with complex congenital heart diseases and a single-ventricle physiology. However, therapeutic options remain limited and despite ongoing improvements in initial surgical repair, patients still experience a multiplicity of cardiovascular complications. The causes for cardiovascular failure are multifactorial and include systemic ventricular dysfunction, pulmonary vascular resistance, atrioventricular valve regurgitation, arrhythmia, development of collaterals, protein-losing enteropathy, hepatic dysfunction, and plastic bronchitis, among others. The mechanisms leading to these late complications remain to be fully elucidated. Experimental animal models have been developed as preclinical steps that enable a better understanding of the underlying pathophysiology. They furthermore play a key role in the evaluation of the efficacy and safety of new medical devices prior to their use in human clinical studies. However, these experimental models have several limitations. In this review, we aim to provide an overview of the evolution and progress of the various types of experimental animal models used in the Fontan procedure published to date in the literature. A special focus is placed on experimental studies performed on animal models of the Fontan procedure with or without mechanical circulatory support as well as a description of their impact in the evolution of the Fontan design. We also highlight the contribution of animal models to our understanding of the pathophysiology and assess forthcoming developments that may improve the contribution of animal models for the testing of new therapeutic solutions.
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Affiliation(s)
- Zakaria Jalal
- Department of Pediatric and Adult Congenital Cardiology, University Hospital of Bordeaux, 33600 Pessac, France; (N.D.); (F.R.); (J.-B.T.)
- LIRYC Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, 33600 Pessac, France
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, 33600 Pessac, France
| | - Elise Langouet
- Department of Pediatric and Adult Congenital Cardiology Anesthesiology, University Hospital of Bordeaux, 33600 Pessac, France;
| | - Nabil Dib
- Department of Pediatric and Adult Congenital Cardiology, University Hospital of Bordeaux, 33600 Pessac, France; (N.D.); (F.R.); (J.-B.T.)
- LIRYC Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, 33600 Pessac, France
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, 33600 Pessac, France
| | | | - Mansour Mostefa-Kara
- Adult Congenital Heart Disease Medico-Surgical Unit, European Georges Pompidou Hospital, 75015 Paris, France;
| | - Amandine Martin
- Department of Cardiac Surgery, University Hospital, 97400 Saint-Denis, France;
| | - François Roubertie
- Department of Pediatric and Adult Congenital Cardiology, University Hospital of Bordeaux, 33600 Pessac, France; (N.D.); (F.R.); (J.-B.T.)
- LIRYC Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, 33600 Pessac, France
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, 33600 Pessac, France
| | - Jean-Benoît Thambo
- Department of Pediatric and Adult Congenital Cardiology, University Hospital of Bordeaux, 33600 Pessac, France; (N.D.); (F.R.); (J.-B.T.)
- LIRYC Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, 33600 Pessac, France
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, 33600 Pessac, France
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Jalal Z, Gewillig M, Boudjemline Y, Guérin P, Pilati M, Butera G, Malekzadeh-Milani S, Avesani M, Thambo JB. Transcatheter interventions in patients with a Fontan circulation: Current practice and future developments. Front Pediatr 2022; 10:965989. [PMID: 36110107 PMCID: PMC9468446 DOI: 10.3389/fped.2022.965989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 08/08/2022] [Indexed: 11/24/2022] Open
Abstract
The Fontan operation represents the last of multiple steps that are offered a wide range of congenital cardiac lesions with a single ventricle (SV) physiology. Nowadays this surgical program consists of a total cavopulmonary connection (TCPC), by anastomosing systemic veins to the pulmonary arteries (PAs), excluding the right-sided circulation from the heart. As a result of imaging, surgical, percutaneous, and critical care improvements, survival in this population has steadily increased. However, the Fontan physiology chronically increases systemic venous pressure causing systemic venous congestion and decreased cardiac output, exposing patients to the failure of the Fontan circulation (FC), which is associated with a wide variety of clinical complications such as liver disease, cyanosis, thromboembolism, protein-losing enteropathy (PLE), plastic bronchitis (PB), and renal dysfunction, ultimately resulting in an increased risk of exercise intolerance, arrhythmias, and premature death. The pathophysiology of the failing Fontan is complex and multifactorial; i.e., caused by the single ventricle dysfunction (diastolic/systolic failure, arrhythmias, AV valve regurgitation, etc.) or caused by the specific circulation (conduits, pulmonary vessels, etc.). The treatment is still challenging and may include multiple options and tools. Among the possible options, today, interventional catheterization is a reliable option, through which different procedures can target various failing elements of the FC. In this review, we aim to provide an overview of indications, techniques, and results of transcatheter options to treat cavopulmonary stenosis, collaterals, impaired lymphatic drainage, and the management of the fenestration, as well as to explore the recent advancements and clinical applications of transcatheter cavopulmonary connections, percutaneous valvular treatments, and to discuss the future perspectives of percutaneous therapies in the Fontan population.
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Affiliation(s)
- Zakaria Jalal
- University Hospital of Bordeaux - Department of Pediatric and Adult Congenital Cardiology, Pessac, France.,IHU LIRYC Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac, France.,INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Pessac, France
| | - Marc Gewillig
- Department of Pediatric Cardiology, University Hospitals Leuven, Leuven, Belgium
| | | | - Patrice Guérin
- Interventional Cardiology Unit, Inserm UMR 1229, L'Institut du Thorax, University Hospital of Nantes, Nantes, France
| | - Mara Pilati
- Medical and Surgical Department of Pediatric Cardiology, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Gianfranco Butera
- Medical and Surgical Department of Pediatric Cardiology, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Sophie Malekzadeh-Milani
- Department of Congenital and Pediatric Cardiology, Centre de Reference Malformations Cardiaques Congenitales Complexes-M3C, Necker Hospital for Sick Children, Assistance Publique des Hôpitaux de Paris, Pediatric Cardiology, Paris, France
| | - Martina Avesani
- University Hospital of Bordeaux - Department of Pediatric and Adult Congenital Cardiology, Pessac, France.,IHU LIRYC Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac, France.,INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Pessac, France
| | - Jean-Benoit Thambo
- University Hospital of Bordeaux - Department of Pediatric and Adult Congenital Cardiology, Pessac, France.,IHU LIRYC Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac, France.,INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Pessac, France
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Construction and Evaluation of a Bio-Engineered Pump to Enable Subpulmonary Support of the Fontan Circulation: A Proof-of-Concept Study. ASAIO J 2021; 68:1063-1070. [PMID: 34860713 DOI: 10.1097/mat.0000000000001617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Our objective was to create a bio-engineered pump (BEP) for subpulmonary Fontan circulation support capable of luminal endothelialization and producing a 2-6 mmHg pressure gradient across the device without flow obstruction. To accomplish this, porcine urinary bladder submucosa was decellularized to produce a urinary bladder matrix (UBM) which produced acellular sheets of UBM. The UBM was cultured with human umbilical vein endothelial cells producing a nearly confluent monolayer of cells with the maintenance of typical histologic features demonstrating UBM to be a suitable substrate for endothelial cells. A lamination process created bilayer UBM sheets which were formed into biologic reservoirs. BEPs were constructed by securing the biologic reservoir between inlet and outlet valves and compressed with a polyurethane balloon. BEP function was evaluated in a simple flow loop representative of a modified subpulmonary Fontan circulation. A BEP with a 92-mL biologic reservoir operating at 60 cycles per minute produced pulsatile downstream flows without flow obstruction and generated a favorable pressure gradient across the device, maintaining upstream pressure of 6 mm Hg and producing downstream pressure of 13 mm Hg. The BEP represents potential long-term assistance for the Fontan circulation to relieve venous hypertension, provide pulsatile pulmonary blood flow and maintain cardiac preload.
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Ismail MF, Elmahrouk AF, Arafat AA, Hamouda TE, Edrees A, Bogis A, Arfi AM, Dohain AM, Alkhattabi A, Alharbi AW, Shihata MS, Al‐Radi OO, Al‐Ata JA, Jamjoom AA. Bovine jugular vein valved xenograft for extracardiac total cavo‐pulmonary connection: The risk of thrombosis and the potential liver protection effect. J Card Surg 2020; 35:845-853. [DOI: 10.1111/jocs.14484] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Mohamed F. Ismail
- Department of Cardiothoracic SurgeryKing Faisal Specialist Hospital and Research CenterJeddah Saudi Arabia
- Department of Cardiothoracic Surgery, Faculty of MedicineMansoura UniversityMansoura Egypt
| | - Ahmed F. Elmahrouk
- Department of Cardiothoracic SurgeryKing Faisal Specialist Hospital and Research CenterJeddah Saudi Arabia
- Department of Cardiothoracic Surgery, Faculty of MedicineTanta UniversityTanta Egypt
| | - Amr A. Arafat
- Department of Cardiothoracic Surgery, Faculty of MedicineTanta UniversityTanta Egypt
| | - Tamer E. Hamouda
- Department of Cardiothoracic SurgeryKing Faisal Specialist Hospital and Research CenterJeddah Saudi Arabia
- Department of Cardiothoracic Surgery, Faculty of MedicineBenha UniversityBenha Egypt
| | - Azzahra Edrees
- Department of Cardiothoracic SurgeryKing Faisal Specialist Hospital and Research CenterJeddah Saudi Arabia
| | - Abdulbadee Bogis
- Department of Cardiothoracic SurgeryKing Faisal Specialist Hospital and Research CenterJeddah Saudi Arabia
| | - Amin M. Arfi
- Section of Pediatric Cardiology, Department of PediatricsKing Faisal Specialist Hospital and Research CenterJeddah Saudi Arabia
| | - Ahmed M. Dohain
- Division of Pediatric Cardiology, Department of PediatricsFaculty of Medicine Cairo UniversityCairo Egypt
- Section of Pediatric Cardiology, Department of PediatricsKing Abdulaziz UniversityJeddah Saudi Arabia
| | - Abdullah Alkhattabi
- Section of Gastroenterology, Department of Internal MedicineKing Faisal Specialist Hospital and Research CenterJeddah Saudi Arabia
| | - Ahmed W. Alharbi
- Section of Gastroenterology, Department of Internal MedicineKing Faisal Specialist Hospital and Research CenterJeddah Saudi Arabia
| | - Mohammad S. Shihata
- Department of Cardiothoracic SurgeryKing Faisal Specialist Hospital and Research CenterJeddah Saudi Arabia
| | - Osman O. Al‐Radi
- Department of Cardiothoracic SurgeryKing Faisal Specialist Hospital and Research CenterJeddah Saudi Arabia
- Section of Cardiothoracic Surgery, Department of SurgeryKing Abdulaziz UniversityJeddah Saudi Arabia
| | - Jameel A. Al‐Ata
- Section of Pediatric Cardiology, Department of PediatricsKing Faisal Specialist Hospital and Research CenterJeddah Saudi Arabia
- Section of Pediatric Cardiology, Department of PediatricsKing Abdulaziz UniversityJeddah Saudi Arabia
| | - Ahmed A. Jamjoom
- Department of Cardiothoracic SurgeryKing Faisal Specialist Hospital and Research CenterJeddah Saudi Arabia
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Heart beat but not respiration is the main driving force of the systemic venous return in the Fontan circulation. Sci Rep 2019; 9:2034. [PMID: 30765829 PMCID: PMC6376003 DOI: 10.1038/s41598-019-38848-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 01/11/2019] [Indexed: 01/05/2023] Open
Abstract
The Fontan procedure provides relief from cyanosis in patients with univentricular hearts. A major clinical unmet need is to understand whether the venous flow patterns of the Fontan circulation lead to the development of congestive hepatopathy and other life-threatening complications. Currently, there is no consensus on whether heart beat or respiration is the main driving force of venous return and which one affects the periodic flow changes for the most (i. e., pulsatility). The present study, for the first time, quantified respiratory and cardiac components of the venous flow in the inferior vena cava (IVC) of 14 Fontan patients and 11 normal controls using a novel approach (“physio-matrix”). We found that in contrast to the normal controls, respiration in Fontan patients had a significant effect on venous flow pulsatility, and the ratio of respiration-dependent to the cardiac-dependent pulsatility was positively associated with the retrograde flow. Nevertheless, the main driving force of net IVC flow was the heart beat and not respiration. The separate analysis of the effects of respiration and heart beat provides new insights into the abnormal venous return patterns that may be responsible for adverse effects on liver and bowel of the patients with Fontan circulation.
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Pekkan K, Aka IB, Tutsak E, Ermek E, Balim H, Lazoglu I, Turkoz R. In vitro validation of a self-driving aortic-turbine venous-assist device for Fontan patients. J Thorac Cardiovasc Surg 2018; 156:292-301.e7. [PMID: 29666009 PMCID: PMC6021195 DOI: 10.1016/j.jtcvs.2018.02.088] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 01/11/2018] [Accepted: 02/08/2018] [Indexed: 11/30/2022]
Abstract
Background Palliative repair of single ventricle defects involve a series of open-heart surgeries where a single-ventricle (Fontan) circulation is established. As the patient ages, this paradoxical circulation gradually fails, because of its high venous pressure levels. Reversal of the Fontan paradox requires an extra subpulmonic energy that can be provided through mechanical assist devices. The objective of this study was to evaluate the hemodynamic performance of a totally implantable integrated aortic-turbine venous-assist (iATVA) system, which does not need an external drive power and maintains low venous pressure chronically, for the Fontan circulation. Methods Blade designs of the co-rotating turbine and pump impellers were developed and 3 prototypes were manufactured. After verifying the single-ventricle physiology at a pulsatile in vitro circuit, the hemodynamic performance of the iATVA system was measured for pediatric and adult physiology, varying the aortic steal percentage and circuit configurations. The iATVA system was also tested at clinical off-design scenarios. Results The prototype iATVA devices operate at approximately 800 revolutions per minute and extract up to 10% systemic blood from the aorta to use this hydrodynamic energy to drive a blood turbine, which in turn drives a mixed-flow venous pump passively. By transferring part of the available energy from the single-ventricle outlet to the venous side, the iATVA system is able to generate up to approximately 5 mm Hg venous recovery while supplying the entire caval flow. Conclusions Our experiments show that a totally implantable iATVA system is feasible, which will eliminate the need for external power for Fontan mechanical venous assist and combat gradual postoperative venous remodeling and Fontan failure.
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Affiliation(s)
- Kerem Pekkan
- Department of Mechanical Engineering, Koç University, Sarıyer, Istanbul, Turkey.
| | - Ibrahim Basar Aka
- Department of Mechanical Engineering, Koç University, Sarıyer, Istanbul, Turkey
| | - Ece Tutsak
- Department of Mechanical Engineering, Koç University, Sarıyer, Istanbul, Turkey
| | - Erhan Ermek
- Department of Mechanical Engineering, Koç University, Sarıyer, Istanbul, Turkey
| | - Haldun Balim
- Department of Mechanical Engineering, Koç University, Sarıyer, Istanbul, Turkey
| | - Ismail Lazoglu
- Department of Mechanical Engineering, Koç University, Sarıyer, Istanbul, Turkey
| | - Riza Turkoz
- Department of Cardiovascular Surgery, School of Medicine, Acıbadem University, Istanbul, Turkey
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In Vitro Examination of the HeartWare CircuLite Ventricular Assist Device in the Fontan Connection. ASAIO J 2018; 63:482-489. [PMID: 28118264 DOI: 10.1097/mat.0000000000000521] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The failing Fontan physiology may benefit from ventricular assist device (VAD) mechanical circulatory support, although a subpulmonary VAD placed at the Fontan connection has never successfully supported the Fontan circulation long term. The HeartWare CircuLite continuous flow VAD was examined for Fontan circulatory support in an in vitro mock circulation. The VAD was tested in three different scenarios: VAD in parallel, baffle restricted VAD in parallel, and VAD in series. Successful support was defined as simultaneous decrease in inferior vena cava (IVC) pressure of 5 mm Hg or more and an increase in cardiac output (CO) to 4.25 L/min or greater. The VAD in parallel scenario resulted in a CO decrease to 3.46 L/min and 2.22 mm Hg decrease in IVC pressure. The baffle restricted VAD in parallel scenario resulted in a CO increase to 3.9 L/min increase in CO and 20.5 mm Hg decrease in IVC pressure (at 90% restriction). The VAD in series scenario resulted in a CO of 1.75 L/min and 5.9 mm Hg decrease in IVC pressure. We successfully modeled chronic failing Fontan physiology using patient-specific hemodynamic and anatomic data. Although unsuccessful in supporting Fontan patients as defined here, the HeartWare CircuLite VAD demonstrates the possibility to reduce Fontan pressure and increase CO with a VAD in the Fontan connection. This study provides insight into pump performance and design issues when attempting to support Fontan circulation. Refinements in VAD design with specific parameters to help support this patient population is the subject of our future work.
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Tree M, Wei ZA, Trusty PM, Raghav V, Fogel M, Maher K, Yoganathan A. Using a Novel In Vitro Fontan Model and Condition-Specific Real-Time MRI Data to Examine Hemodynamic Effects of Respiration and Exercise. Ann Biomed Eng 2018; 46:135-147. [PMID: 29067563 PMCID: PMC5756106 DOI: 10.1007/s10439-017-1943-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 10/09/2017] [Indexed: 12/20/2022]
Abstract
Several studies exist modeling the Fontan connection to understand its hemodynamic ties to patient outcomes (Chopski in: Experimental and Computational Assessment of Mechanical Circulatory Assistance of a Patient-Specific Fontan Vessel Configuration. Dissertation, 2013; Khiabani et al. in J Biomech 45:2376-2381, 2012; Taylor and Figueroa in Annu Rev Biomed 11:109-134, 2009; Vukicevic et al. in ASAIO J 59:253-260, 2013). The most patient-accurate of these studies include flexible, patient-specific total cavopulmonary connections. This study improves Fontan hemodynamic modeling by validating Fontan model flexibility against a patient-specific bulk compliance value, and employing real-time phase contrast magnetic resonance flow data. The improved model was employed to acquire velocity field information under breath-held, free-breathing, and exercise conditions to investigate the effect of these conditions on clinically important Fontan hemodynamic metrics including power loss and viscous dissipation rate. The velocity data, obtained by stereoscopic particle image velocimetry, was visualized for qualitative three-dimensional flow field comparisons between the conditions. Key hemodynamic metrics were calculated from the velocity data and used to quantitatively compare the flow conditions. The data shows a multi-factorial and extremely patient-specific nature to Fontan hemodynamics.
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Affiliation(s)
- Michael Tree
- George W. Woodruff School of Mechanical Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Zhenglun Alan Wei
- Wallace H. Coulter School of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, USA
- Institute of Computational Science and Cardiovascular Disease, Nanjing Medical University, Nanjing, China
| | - Phillip M Trusty
- Wallace H. Coulter School of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Vrishank Raghav
- Wallace H. Coulter School of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Mark Fogel
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kevin Maher
- Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Ajit Yoganathan
- Wallace H. Coulter School of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, USA.
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The Advantages of Viscous Dissipation Rate over Simplified Power Loss as a Fontan Hemodynamic Metric. Ann Biomed Eng 2017; 46:404-416. [PMID: 29094292 DOI: 10.1007/s10439-017-1950-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 10/20/2017] [Indexed: 12/12/2022]
Abstract
Flow efficiency through the Fontan connection is an important factor related to patient outcomes. It can be quantified using either a simplified power loss or a viscous dissipation rate metric. Though practically equivalent in simplified Fontan circulation models, these metrics are not identical. Investigation is needed to evaluate the advantages and disadvantages of these metrics for their use in in vivo or more physiologically-accurate Fontan modeling. Thus, simplified power loss and viscous dissipation rate are compared theoretically, computationally, and statistically in this study. Theoretical analysis was employed to assess the assumptions made for each metric and its clinical calculability. Computational simulations were then performed to obtain these two metrics. The results showed that apparent simplified power loss was always greater than the viscous dissipation rate for each patient. This discrepancy can be attributed to the assumptions derived in theoretical analysis. Their effects were also deliberately quantified in this study. Furthermore, statistical analysis was conducted to assess the correlation between the two metrics. Viscous dissipation rate and its indexed quantity show significant, strong, linear correlation to simplified power loss and its indexed quantity (p < 0.001, r > 0.99) under certain assumptions. In conclusion, viscous dissipation rate was found to be more advantageous than simplified power loss as a hemodynamic metric because of its lack of limiting assumptions and calculability in the clinic. Moreover, in addition to providing a time-averaged bulk measurement like simplified power loss, viscous dissipation rate has spatial distribution contours and time-resolved values that may provide additional clinical insight. Finally, viscous dissipation rate could maintain the relationship between Fontan connection flow efficiency and patient outcomes found in previous studies. Consequently, future Fontan hemodynamic studies should calculate both simplified power loss and viscous dissipation rate to maintain ties to previous studies, but also provide the most accurate measure of flow efficiency. Additional attention should be paid to the assumptions required for each metric.
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Tree M, Wei ZA, Munz B, Maher K, Deshpande S, Slesnick T, Yoganathan A. A Method for In Vitro TCPC Compliance Verification. J Biomech Eng 2017; 139:2621590. [DOI: 10.1115/1.4036474] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Indexed: 01/29/2023]
Abstract
The Fontan procedure is a common palliative intervention for sufferers of single ventricle congenital heart defects that results in an anastomosis of the venous return to the pulmonary arteries called the total cavopulmonary connection (TCPC). Local TCPC and global Fontan circulation hemodynamics are studied with in vitro circulatory models because of hemodynamic ties to Fontan patient long-term complications. The majority of in vitro studies, to date, employ a rigid TCPC model. Recently, a few studies have incorporated flexible TCPC models, but provide no justification for the model material properties. The method set forth in this study successfully utilizes patient-specific flow and pressure data from phase contrast magnetic resonance images (PCMRI) (n = 1) and retrospective pulse-pressure data from an age-matched patient cohort (n = 10) to verify the compliance of an in vitro TCPC model. These data were analyzed, and the target compliance was determined as 1.36 ± 0.78 mL/mm Hg. A method of in vitro compliance testing and computational simulations was employed to determine the in vitro flexible TCPC model material properties and then use those material properties to estimate the wall thickness necessary to match the patient-specific target compliance. The resulting in vitro TCPC model compliance was 1.37 ± 0.1 mL/mm Hg—a value within 1% of the patient-specific compliance. The presented method is useful to verify in vitro model accuracy of patient-specific TCPC compliance and thus improve patient-specific hemodynamic modeling.
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Affiliation(s)
- Mike Tree
- The George W. Woodruff School of Mechanical Engineering, Georgia Institute of Technology, Atlanta, GA 30332
| | - Zhenglun Alan Wei
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA 30332
| | - Brady Munz
- School of Chemical and Biomolecular Engineering, Georgia Institute of Technology, Atlanta, GA 30332
| | - Kevin Maher
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA 30332
| | - Shriprasad Deshpande
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA 30332
| | - Timothy Slesnick
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA 30332
| | - Ajit Yoganathan
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA 30332
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Hebson C, Book W, Elder RW, Ford R, Jokhadar M, Kanter K, Kogon B, Kovacs AH, Levit RD, Lloyd M, Maher K, Reshamwala P, Rodriguez F, Romero R, Tejada T, Marie Valente A, Veldtman G, McConnell M. “Frontiers in Fontan failure: A summary of conference proceedings”. CONGENIT HEART DIS 2016; 12:6-16. [DOI: 10.1111/chd.12407] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 07/24/2016] [Indexed: 12/16/2022]
Affiliation(s)
- Camden Hebson
- Division of Cardiology; Department of Medicine, Emory University; Atlanta GA
- Division of Pediatric Cardiology; Department of Pediatrics, Emory University; Atlanta GA
| | - Wendy Book
- Division of Cardiology; Department of Medicine, Emory University; Atlanta GA
| | - Robert W. Elder
- Division of Cardiology; Department of Medicine, Yale University; New Haven CT
| | - Ryan Ford
- Division of Gastroenterology; Department of Medicine, Emory University; Atlanta GA
| | - Maan Jokhadar
- Division of Cardiology; Department of Medicine, Emory University; Atlanta GA
| | - Kirk Kanter
- Division of Cardiothoracic Surgery; Department of Surgery, Emory University; Atlanta GA
| | - Brian Kogon
- Division of Cardiothoracic Surgery; Department of Surgery, Emory University; Atlanta GA
| | - Adrienne H. Kovacs
- Division of Cardiology; Department of Medicine, Oregon Health and Science University; Portland OR
| | - Rebecca D. Levit
- Division of Cardiology; Department of Medicine, Emory University; Atlanta GA
| | - Michael Lloyd
- Division of Cardiology; Department of Medicine, Emory University; Atlanta GA
| | - Kevin Maher
- Division of Pediatric Cardiology; Department of Pediatrics, Emory University; Atlanta GA
| | - Preeti Reshamwala
- Division of Gastroenterology; Department of Medicine, Emory University; Atlanta GA
| | - Fred Rodriguez
- Division of Cardiology; Department of Medicine, Emory University; Atlanta GA
- Division of Pediatric Cardiology; Department of Pediatrics, Emory University; Atlanta GA
| | - Rene Romero
- Division of Pediatric Gastroenterology; Department of Pediatrics, Emory University; Atlanta GA
| | - Thor Tejada
- Division of Cardiology; Department of Medicine, Emory University; Atlanta GA
| | - Anne Marie Valente
- Division of Cardiology; Department of Medicine, Harvard University; Boston MA
| | - Gruschen Veldtman
- Division of Pediatric Cardiology; Department of Pediatrics, University of Cincinnati; Cincinnati OH
| | - Michael McConnell
- Division of Cardiology; Department of Medicine, Emory University; Atlanta GA
- Division of Pediatric Cardiology; Department of Pediatrics, Emory University; Atlanta GA
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12
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Yigit B, Pekkan K. Non-dimensional physics of pulsatile cardiovascular networks and energy efficiency. J R Soc Interface 2016; 13:20151019. [PMID: 26819334 PMCID: PMC4759807 DOI: 10.1098/rsif.2015.1019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 01/04/2016] [Indexed: 11/12/2022] Open
Abstract
In Nature, there exist a variety of cardiovascular circulation networks in which the energetic ventricular load has both steady and pulsatile components. Steady load is related to the mean cardiac output (CO) and the haemodynamic resistance of the peripheral vascular system. On the other hand, the pulsatile load is determined by the simultaneous pressure and flow waveforms at the ventricular outlet, which in turn are governed through arterial wave dynamics (transmission) and pulse decay characteristics (windkessel effect). Both the steady and pulsatile contributions of the haemodynamic power load are critical for characterizing/comparing disease states and for predicting the performance of cardiovascular devices. However, haemodynamic performance parameters vary significantly from subject to subject because of body size, heart rate and subject-specific CO. Therefore, a 'normalized' energy dissipation index, as a function of the 'non-dimensional' physical parameters that govern the circulation networks, is needed for comparative/integrative biological studies and clinical decision-making. In this paper, a complete network-independent non-dimensional formulation that incorporates pulsatile flow regimes is developed. Mechanical design variables of cardiovascular flow systems are identified and the Buckingham Pi theorem is formally applied to obtain the corresponding non-dimensional scaling parameter sets. Two scaling approaches are considered to address both the lumped parameter networks and the distributed circulation components. The validity of these non-dimensional number sets is tested extensively through the existing empirical allometric scaling laws of circulation systems. Additional validation studies are performed using a parametric numerical arterial model that represents the transmission and windkessel characteristics, which are adjusted to represent different body sizes and non-dimensional haemodynamic states. Simulations demonstrate that the proposed non-dimensional indices are independent of body size for healthy conditions, but are sensitive to deviations caused by off-design disease states that alter the energetic load. Sensitivity simulations are used to identify the relationship between pulsatile power loss and non-dimensional characteristics, and optimal operational states are computed.
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Affiliation(s)
- Berk Yigit
- Department of Mechanical Engineering, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Kerem Pekkan
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA, USA Department of Mechanical Engineering, Koç University, Istanbul, Turkey
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Tree M, White J, Midha P, Kiblinger S, Yoganathan A. Validation of Cardiac Output as Reported by a Permanently Implanted Wireless Sensor. J Med Device 2015. [DOI: 10.1115/1.4031799] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
The CardioMEMS heart failure (HF) system was tested for cardiac output (CO) measurement accuracy using an in vitro mock circulatory system. A software algorithm calculates CO based on analysis of the pressure waveform as measured from the pulmonary artery, where the CardioMEMS system resides. Calculated CO was compared to that from reference flow probe in the circulatory system model. CO measurements were compared over a clinically relevant range of stroke volumes and heart rates with normal, pulmonary hypertension (PH), decompensated left heart failure (DLHF), and combined DHLF + PH hemodynamic conditions. The CardioMEMS CO exhibited minimal fixed and proportional bias.
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Affiliation(s)
- Michael Tree
- The George W. Woodruff School of Mechanical Engineering, Georgia Institute of Technology, 387 Technology Circle, Suite 200, Atlanta, GA 30313 e-mail:
| | - Jason White
- Mem. ASME St. Jude Medical, Inc., 387 Technology Circle, Suite 500, Atlanta, GA 30313 e-mail:
| | - Prem Midha
- The George W. Woodruff School of Mechanical Engineering, Georgia Institute of Technology, 387 Technology Circle, Suite 200, Atlanta, GA 30313 e-mail:
| | - Samantha Kiblinger
- Coulter Department of Biomedical Engineering, Georgia Institute of Technology, 387 Technology Circle, Suite 200, Atlanta, GA 30313 e-mail:
| | - Ajit Yoganathan
- Mem. ASME Coulter Department of Biomedical Engineering, Georgia Institute of Technology, 387 Technology Circle, Suite 200, Atlanta, GA 30313 e-mail:
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Control of respiration-driven retrograde flow in the subdiaphragmatic venous return of the Fontan circulation. ASAIO J 2015; 60:391-9. [PMID: 24814833 DOI: 10.1097/mat.0000000000000093] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Respiration influences the subdiaphragmatic venous return in the total cavopulmonary connection (TCPC) of the Fontan circulation whereby both the inferior vena cava (IVC) and hepatic vein flows can experience retrograde motion. Controlling retrograde flows could improve patient outcomes. Using a patient-specific model within a Fontan mock circulatory system with respiration, we inserted a valve into the IVC to examine its effects on local hemodynamics while varying retrograde volumes by changing vascular impedances. A bovine valved conduit reduced IVC retrograde flow to within 3% of antegrade flow in all cases. The valve closed only under conditions supporting retrograde flow and its effects on local hemodynamics increased with larger retrograde volume. Liver and TCPC pressures improved only when the valve leaflets were closed whereas cycle-averaged pressures improved only slightly (<1 mm Hg). Increased pulmonary vascular resistance raised mean circulation pressures, but the valve functioned and cardiac output improved and stabilized. Power loss across the TCPC improved by 12%-15% (p < 0.05) with a valve. The effectiveness of valve therapy is dependent on patient vascular impedance.
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Malekzadeh-Milani S, Ladouceur M, Iserin L, Boudjemline Y. Percutaneous valvulation of failing Fontan: Rationale, acute effects and follow-up. Arch Cardiovasc Dis 2014; 107:599-606. [DOI: 10.1016/j.acvd.2014.07.050] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Revised: 07/06/2014] [Accepted: 07/22/2014] [Indexed: 01/08/2023]
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