Superior cavopulmonary circulation (SCPC) can be achieved by either the Hemi-Fontan
(hF) or Bidirectional Glenn (bG) connection. Debate remains as to which results in
best hemodynamic results. Adopting patient-specific multiscale computational modeling,
we examined both the local dynamics and global physiology to determine if surgical
choice can lead to different hemodynamic outcomes. Six patients (age: 3–6 months)
underwent cardiac magnetic resonance imaging and catheterization prior to SCPC surgery.
For each patient: (1) a finite 3-dimensional (3D) volume model of the preoperative
anatomy was constructed to include detailed definition of the distal branch pulmonary
arteries, (2) virtual hF and bG operations were performed to create 2 SCPC 3D models,
and (3) a specific lumped network representing each patient's entire cardiovascular
circulation was developed from clinical data. Using a previously validated multiscale
algorithm that couples the 3D models with lumped network, both local flow dynamics,
that is, power loss, and global systemic physiology can be quantified. In 2 patients
whose preoperative imaging demonstrated significant left pulmonary artery (LPA) stenosis,
we performed virtual pulmonary arterioplasty to assess its effect. In one patient,
the hF model showed higher power loss (107%) than the bG, while in 3, the power losses
were higher in the bG models (18–35%). In the remaining 2 patients, the power loss
differences were minor. Despite these variations, for all patients, there were no
significant differences between the hF and bG models in hemodynamic or physiological
outcomes, including cardiac output, superior vena cava pressure, right-left pulmonary
flow distribution, and systemic oxygen delivery. In the 2 patients with LPA stenosis,
arterioplasty led to better LPA flow (5–8%) while halving the power loss, but without
important improvements in SVC pressure or cardiac output. Despite power loss differences,
both hF and bG result in similar SCPC hemodynamics and physiology outcome. This suggests
that for SCPC, the pre-existing patient-specific physiology and condition, such as
pulmonary vascular resistance, are more deterministic in the hemodynamic performance
than the type of surgical palliation. Multiscale modeling can be a decision-assist
tool to assess whether an extensive LPA reconstruction is needed at the time of SCPC
for LPA stenosis.
Keywords
Abbreviations:
artsat-pre (preoperative arterial oxygen saturation), artsat-post (postoperative arterial oxygen saturation), bG (bidirectional Glenn), BSA (body surface area), CFD (computational fluid dynamics), CI (cardiac index), CMR (cardiac magnetic resonance imaging), CS (central shunt), GA (general anesthetic), Hb (hemoglobin), hF (hemi-Fontan), HLHS (hypoplastic left heart syndrome), IVC (inferior vena cava), LPA (left pulmonary artery), LPN (lumped parameter network), maxO2cap (maximum oxygen capacity), mBTS (modified Blalock-Taussig shunt), O2del (systemic oxygen delivery), O2cons (oxygen consumption), PA (pulmonary arteries), PAP (pulmonary artery pressure), PVR (pulmonary vascular resistance), PVsat-pre (preoperative pulmonary venous oxygen saturation), Qp (pulmonary blood flow rate), Qp-pre (preoperative pulmonary blood flow rate), Qs (systemic blood flow rate), SVC (superior vena cava), SCPC (superior cavopulmonary connection/circulation), TPG (transpulmonary gradient), 3D (three-dimensional)To read this article in full you will need to make a payment
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Article info
Publication history
Published online: September 11, 2019
Footnotes
Funding: This work received funding support from Leducq Foundation (France), National Institute of Health Research (UK), Burroughs Wellcome Fund (UK), American Heart Association (US), National Science Foundation (US), and British Heart Foundation (UK).
Disclosures: The authors have nothing to disclose with regard to commercial support.
Conflicts of Interest: All authors have nothing to disclose regarding possible conflicts of interest.
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- Commentary: Flow Through Dynamic ThinkingSeminars in Thoracic and Cardiovascular SurgeryVol. 32Issue 4
- PreviewThe modified Hemi-Fontan (mHF) and the Bidirectional Glenn (BDG) operations are alternative surgical approaches for a second stage single ventricle palliation. Differences in surgical technique, blood flow dynamics, and handling of a potential pulmonary artery reconstruction have potential implications on the type of final total cavopulmonary connection (TCPC).
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