Hostname: page-component-7c8c6479df-fqc5m Total loading time: 0 Render date: 2024-03-29T01:35:09.369Z Has data issue: false hasContentIssue false

Pulsatile venous waveform quality affects the conduit performance in functional and “failing” Fontan circulations

Published online by Cambridge University Press:  19 October 2011

Onur Dur
Affiliation:
Department of Biomedical Engineering, Carnegie Mellon University, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
Ergin Kocyildirim
Affiliation:
Section of Pediatric Cardiothoracic Surgery of the Heart, Lung and Esophageal Surgical Institute, University of Pittsburgh Medical School, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
Ozlem Soran
Affiliation:
Cardiovascular Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
Peter D. Wearden
Affiliation:
Section of Pediatric Cardiothoracic Surgery of the Heart, Lung and Esophageal Surgical Institute, University of Pittsburgh Medical School, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
Victor O. Morell
Affiliation:
Section of Pediatric Cardiothoracic Surgery of the Heart, Lung and Esophageal Surgical Institute, University of Pittsburgh Medical School, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
Curt G. DeGroff
Affiliation:
Congenital Heart Center, University of Florida, Gainesville, Florida, United States of America
Kerem Pekkan*
Affiliation:
Department of Biomedical Engineering, Carnegie Mellon University, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, United States of America Department of Mechanical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania, United States of America
*
Correspondence to: Dr K. Pekkan, PhD, Assistant Professor, Biomedical Engineering Department, Carnegie Mellon University, 700 Technology Drive, Pittsburgh, Pennsylvania 15219, United States of America. Tel: 412 268 3027; Fax: 404 268 9807; E-mail: kpekkan@andrew.cmu.edu

Abstract

Objective

To investigate the effect of pulsatility of venous flow waveform in the inferior and superior caval vessels on the performance of functional and “failing” Fontan patients based on two primary performance measures – the conduit power loss and the distribution of inferior caval flow (hepatic factors) to the lungs.

Methods

Doppler angiography flows were acquired from two typical extra-cardiac conduit “failing” Fontan patients, aged 13 and 25 years, with ventricle dysfunction. Using computational fluid dynamics, haemodynamic efficiencies of “failing”, functional, and in vitro-generated mechanically assisted venous flow waveforms were evaluated inside an idealised total cavopulmonary connection with a caval offset. To investigate the effect of venous pulsatility alone, cardiac output was normalised to 3 litres per minute in all cases. To quantify the pulsatile behaviour of venous flows, two new performance indices were suggested.

Results

Variations in the pulsatile content of venous waveforms altered the conduit efficiency notably. High-frequency and low-amplitude oscillations lowered the pulsatile component of the power losses in “failing” Fontan flow waveforms. Owing to the offset geometry, hepatic flow distribution depended strongly on the ratio of time-dependent caval flows and the pulsatility content rather than mixing at the junction. “Failing” Fontan flow waveforms exhibited less balanced hepatic flow distribution to lungs.

Conclusions

The haemodynamic efficiency of single-ventricle circulation depends strongly on the pulsatility of venous flow waveforms. The proposed performance indices can be calculated easily in the clinical setting in efforts to better quantify the energy efficiency of Fontan venous waveforms in pulsatile settings.

Type
Original Article
Copyright
Copyright © Cambridge University Press 2012

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1.de Leval, MR, Kilner, P, Gewillig, M, Bull, C. Total cavopulmonary connection: a logical alternative to atriopulmonary connection for complex Fontan operations. Experimental studies and early clinical experience. J Thorac Cardiovasc Surg 1988; 96: 682695.CrossRefGoogle ScholarPubMed
2.Ghanayem, NS, Berger, S, Tweddell, JS. Medical management of the failing Fontan. Pediatr Cardiol 2007; 28: 465471.CrossRefGoogle ScholarPubMed
3.Anderson, PA, Sleeper, LA, Mahony, L, et al. . Contemporary outcomes after the Fontan procedure: a Pediatric Heart Network multicenter study. J Am Coll Cardiol 2008; 52: 8598.CrossRefGoogle ScholarPubMed
4.Dasi, LP, Krishnankuttyrema, R, Kitajima, HD, et al. . Fontan hemodynamics: importance of pulmonary artery diameter. J Thorac Cardiovasc Surg 2009; 137: 560564.CrossRefGoogle ScholarPubMed
5.Sundareswaran, KS, Pekkan, K, Dasi, LP, et al. . The total cavopulmonary connection resistance: a significant impact on single ventricle hemodynamics at rest and exercise. Am J Physiol Heart Circ Physiol 2008; 295: H2427H2435.CrossRefGoogle ScholarPubMed
6.Whitehead, KK, Pekkan, K, Kitajima, HD, Paridon, SM, Yoganathan, AP, Fogel, MA. Nonlinear power loss during exercise in single-ventricle patients after the Fontan: insights from computational fluid dynamics. Circulation 2007; 116 (Suppl. 11): I165I171.CrossRefGoogle ScholarPubMed
7.Pekkan, K, Frakes, D, De Zelicourt, D, Lucas, CW, Parks, WJ, Yoganathan, AP. Coupling pediatric ventricle assist devices to the Fontan circulation: simulations with a lumped-parameter model. ASAIO J 2005; 51: 618628.CrossRefGoogle Scholar
8.Krishnan, US, Taneja, I, Gewitz, M, Young, R, Stewart, J. Peripheral vascular adaptation and orthostatic tolerance in Fontan physiology. Circulation 2009; 120: 17751783.CrossRefGoogle ScholarPubMed
9.Myers, CD, Ballman, K, Riegle, LE, Mattix, KD, Litwak, K, Rodefeld, MD. Mechanisms of systemic adaptation to univentricular Fontan conversion. J Thorac Cardiovasc Surg 2010; 140: 850856.e6.CrossRefGoogle ScholarPubMed
10.Wang, C, Pekkan, K, de Zelicourt, D, et al. . Progress in the CFD modeling of flow instabilities in anatomical total cavopulmonary connections. Ann Biomed Eng 2007; 35: 18401856.CrossRefGoogle ScholarPubMed
11.Pekkan, K, de Zelicourt, D, Ge, L, et al. . Physics-driven CFD modeling of complex anatomical cardiovascular flows – a TCPC case study. Ann Biomed Eng 2005; 33: 284300.CrossRefGoogle ScholarPubMed
12.Khunatorn, Y, Mahalingam, S, DeGroff, CG, Shandas, R. Influence of connection geometry and SVC–IVC flow rate ratio on flow structures within the total cavopulmonary connection: a numerical study. J Biomech Eng 2002; 124: 364377.CrossRefGoogle ScholarPubMed
13.Bove, EL, de Leval, MR, Migliavacca, F, Guadagni, G, Dubini, G. Computational fluid dynamics in the evaluation of hemodynamic performance of cavopulmonary connections after the Norwood procedure for hypoplastic left heart syndrome. J Thorac Cardiovasc Surg 2003; 126: 10401047.CrossRefGoogle ScholarPubMed
14.DeGroff, CG. Modeling the Fontan circulation: where we are and where we need to go. Pediatr Cardiol 2008; 29: 312.CrossRefGoogle ScholarPubMed
15.Pekkan, K, Kitajima, HD, de Zelicourt, D, et al. . Total cavopulmonary connection flow with functional left pulmonary artery stenosis: angioplasty and fenestration in vitro. Circulation 2005; 112: 32643271.CrossRefGoogle ScholarPubMed
16.Dasi, LP, Pekkan, K, Katajima, HD, Yoganathan, AP. Functional analysis of Fontan energy dissipation. J Biomech 2008; 41: 22462252.CrossRefGoogle ScholarPubMed
17.Marsden, AL, Reddy, VM, Shadden, SC, Chan, FP, Taylor, CA, Feinstein, JA. A new multiparameter approach to computational simulation for Fontan assessment and redesign. Congenit Heart Dis 2010; 5: 104117.CrossRefGoogle ScholarPubMed
18.Sundareswaran, KS, de Zelicourt, D, Sharma, S, et al. . Correction of pulmonary arteriovenous malformation using image-based surgical planning. JACC Cardiovasc Imaging 2009; 2: 10241030.CrossRefGoogle ScholarPubMed
19.Hjortdal, VE, Emmertsen, K, Stenbog, E, et al. . Effects of exercise and respiration on blood flow in total cavopulmonary connection: a real-time magnetic resonance flow study. Circulation 2003; 108: 12271231.CrossRefGoogle ScholarPubMed
20.Dur, O, DeGroff, GC, Keller, BB, Pekkan, K. Optimization of inflow waveform phase-difference for minimized total cavopulmonary power loss. J Biomech Eng 2010; 132: 031012 (9 pages).CrossRefGoogle ScholarPubMed
21.Dasi, L, Sundareswaran, K, Zelicourt, D, et al. . Fontan hemodynamics: what is the problem? JTCVS 2010; 139: 16731674.Google Scholar
22.Yoshimura, N, Yamaguchi, M, Oshima, Y, et al. . Risk factors influencing early and late mortality after total cavopulmonary connection. Eur J Cardiothorac Surg 2001; 20: 598602.CrossRefGoogle ScholarPubMed
23.Williams, IA, Sleeper, LA, Colan, SD, et al. . Functional state following the Fontan procedure. Cardiol Young 2009; 19: 320330.CrossRefGoogle ScholarPubMed
24.Khairy, P, Fernandes, SM, Mayer, JE Jr, et al. . Long-term survival, modes of death, and predictors of mortality in patients with Fontan surgery. Circulation 2008; 117: 8592.CrossRefGoogle ScholarPubMed
25.Hosein, RB, Clarke, AJ, McGuirk, SP, et al. . Factors influencing early and late outcome following the Fontan procedure in the current era. The ‘Two Commandments’? Eur J Cardiothorac Surg 2007; 31: 344352, discussion 353.CrossRefGoogle ScholarPubMed
26.Marsden, AL, Vignon-Clementel, IE, Chan, FP, Feinstein, JA, Taylor, CA. Effects of exercise and respiration on hemodynamic efficiency in CFD simulations of the total cavopulmonary connection. Ann Biomed Eng 2007; 35: 250263.CrossRefGoogle ScholarPubMed
27.Hsia, TY, Khambadkone, S, Redington, AN, Migliavacca, F, Deanfield, JE, de Leval, MR. Effects of respiration and gravity on infradiaphragmatic venous flow in normal and Fontan patients. Circulation 2000; 102 (19 Suppl. 3): III148III153.CrossRefGoogle ScholarPubMed
28.Klimes, K, Abdul-Khaliq, H, Ovroutski, S, et al. . Pulmonary and caval blood flow patterns in patients with intracardiac and extracardiac Fontan: a magnetic resonance study. Clin Res Cardiol 2007; 96: 160167.CrossRefGoogle Scholar
29.Pekkan, K, Sasmazel, A, Sundareswaran, K, et al. Respiratory augmentation of blood flow in the early post-op Fontan circulation – feasibility of intra-pulmonic balloon pumping and external counterpulsation of systemic venous return. 16th World Congress of the World Society of Cardio-Thoracic Surgeons, Ottawa, Canada, 2006.Google Scholar
30.Throckmorton, AL, Ballman, KK, Myers, CD, Frankel, SH, Brown, JW, Rodefeld, MD. Performance of a 3-bladed propeller pump to provide cavopulmonary assist in the failing Fontan circulation. Ann Thorac Surg 2008; 86: 13431347.CrossRefGoogle ScholarPubMed
31.Dur, O, Lara, M, Arnold, D, et al. . Pulsatile in vitro simulation of the pediatric univentricular circulation for evaluation of cardiopulmonary assist scenarios. Artif Organs 2009; 33: 967976.CrossRefGoogle ScholarPubMed
32.Dasi, LP, Whitehead, K, Pekkan, K, et al. . Pulmonary hepatic flow distribution in total cavopulmonary connections: extracardiac versus intracardiac. J Thorac Cardiovasc Surg 2011; 141: 207214.CrossRefGoogle ScholarPubMed
33.Marsden, AL, Bernstein, AJ, Reddy, VM, et al. . Evaluation of a novel Y-shaped extracardiac Fontan baffle using computational fluid dynamics. J Thorac Cardiovasc Surg 2009; 137: 394403, e392.CrossRefGoogle ScholarPubMed
34.Migliavacca, F, Dubini, G, Bove, EL, de Leval, MR. Computational fluid dynamics simulations in realistic 3-D geometries of the total cavopulmonary anastomosis: the influence of the inferior caval anastomosis. J Biomech Eng 2003; 125: 805813.CrossRefGoogle ScholarPubMed
35.Dur, O. Investigation of the Unsteady Venous Hemodynamics in Fontan Patients to Enable New Therapeutic Options for Improving the Long Term Outcome. Biomedical Engineering, Carnegie Mellon University, Pittsburgh, 2011.Google Scholar
36.Dur, O, Kocyildirim, E, Degroff, CG, Wearden, P, Morell, V, Pekkan, K. Effect of caval waveform on energy dissipation of failing Fontan patients. Paper presented at: Proceedings of the ASME Summer Bioengineering Conference, Lake Tahoe, 2009.CrossRefGoogle Scholar
37.Guyton, JR, Hartley, CJ. Flow restriction of one carotid artery in juvenile rats inhibits growth of arterial diameter. Am J Physiol 1985; 248 (4 Pt 2): H540H546.Google ScholarPubMed
38.Ghabili, K, Khosroshahi, HT, Shakeri, A, Tubbs, RS, Bahluli, A, Shoja, MM. Can Doppler ultrasonographic indices of the renal artery predict the presence of supernumerary renal arteries? Transplant Proc 2009; 41: 27312733.CrossRefGoogle ScholarPubMed
39.Evans, DH, Barrie, WW, Asher, MJ, Bentley, S, Bell, PR. The relationship between ultrasonic pulsatility index and proximal arterial stenosis in a canine model. Circ Res 1980; 46: 470475.CrossRefGoogle Scholar
40.Justino, H, Benson, LN, Freedom, RM. Development of unilateral pulmonary arteriovenous malformations due to unequal distribution of hepatic venous flow. Circulation 2001; 103: E39E40.CrossRefGoogle ScholarPubMed