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(Circulation. 2005;112:3264-3271.)
© 2005 American Heart Association, Inc.

Congenital Heart Disease

Total Cavopulmonary Connection Flow With Functional Left Pulmonary Artery Stenosis

Angioplasty and Fenestration In Vitro

Kerem Pekkan, PhD; Hiroumi D. Kitajima, MSc; Diane de Zelicourt, MSc; Joseph M. Forbess, MD; W. James Parks, MD; Mark A. Fogel, MD; Shiva Sharma, MD; Kirk R. Kanter, MD; David Frakes, PhD; Ajit P. Yoganathan, PhD

From the Cardiovascular Fluid Mechanics Laboratory, Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta (K.P., H.D.K., D.d.Z., D.F., A.P.Y.); Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga (J.M.F., K.R.K.); Department of Cardiology, Emory University School of Medicine, Sibley Heart Center Cardiology, Atlanta, Ga (W.J.P.); Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, Pa (M.A.F.); and Pediatric Cardiology Associates, Atlanta, Ga.

Correspondence to Ajit P. Yoganathan, PhD, The Wallace H. Coulter Distinguished Faculty Chair in Biomedical Engineering, Regents Professor, Associate Chair for Research, Wallace H. Coulter School of Biomedical Engineering, Georgia Institute of Technology and Emory University, Room 2119, U.A. Whitaker Bldg, 313 Ferst Dr, Atlanta, GA 30332–0535. E-mail ajit.yoganathan{at}bme.gatech.edu

Received December 20, 2004; revision received July 14, 2005; accepted August 26, 2005.

Background— In our multicenter study of the total cavopulmonary connection (TCPC), a cohort of patients with long-segment left pulmonary artery (LPA) stenosis was observed (35%). The clinically recognized detrimental effects of LPA stenosis motivated a computational fluid dynamic simulation study within 3-dimensional patient-specific and idealized TCPC pathways. The goal of this study was to quantify and evaluate the hemodynamic impact of LPA stenosis and to judge interventional strategies aimed at treating it.

Methods and Results— Simulations were conducted at equal vascular lung resistance, modeling both discrete stenosis (DS) and diffuse long-segment hypoplasia with varying degrees of obstruction (0% to 80%). Models having fenestrations of 2 to 6 mm and atrium pressures of 4 to 14 mm Hg were explored. A patient-specific, extracardiac TCPC with 85% DS was studied in its original configuration and after virtual surgery that dilated the LPA to 0% stenosis in the computer medium. Performance indices improved exponentially (R²>0.99) with decreasing obstruction. Diffuse long-segment hypoplasia was 50% more severe with regard to lung perfusion and cardiac energy loss than DS. Virtual angioplasty performed on the 3-dimensional Fontan anatomy exhibiting an 85% DS stenosis produced a 61% increase in left lung perfusion and a 50% decrease in cardiac energy dissipation. After 4-mm fenestration, TCPC baffle pressure dropped by 10% and left lung perfusion decreased by 8% compared with the 80% DS case.

Conclusions— DS <60% and diffuse long-segment hypoplasia <40% could be considered tolerable because both resulted in only a 12% decrease in left lung perfusion. In contrast to angioplasty, a fenestration (right-to-left shunt) reduced TCPC pressure at the cost of decreased left and right lung perfusion. These results suggest that pre-Fontan computational fluid dynamic simulation may be valuable for determining both the hemodynamic significance of LPA stenosis and the potential benefits of intervention.

Key Words: angioplasty • blood flow • Fontan procedure • stenosis • magnetic resonance imaging

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