The first cohort of prospective Fontan surgical planning patients with follow-up data: How accurate is surgical planning?

• Authors: Phillip M. Trusty, Georgia Institute of Technology; Zhenglun Alan Wei, Georgia Institute of Technology; Timothy Slesnick, Emory University; Kirk Kanter, Emory University; Thomas L. Spray, Children's Hospital of Philadelphia; Mark A. Fogel, Children's Hospital of Philadelphia; Ajit Yoganathan, Emory University
• Journal Title: JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY
• Volume: Volume 157, Number 3
• Publisher: MOSBY-ELSEVIER | 2019-03-01, Pages 1146-1155
• Type of Work: Article | Post-print: After Peer Review
• Publisher DOI: http://doi.org/10.1016/j.jtcvs.2018.11.102
• Subjects: Health Sciences, Medicine and Surgery; Education, Health; Biology, Anatomy
• Keywords: Science & Technology; Life Sciences & Biomedicine; Cardiac & Cardiovascular Systems; Respiratory System; Surgery; Cardiovascular System & Cardiology; Fontan; congenital heart defect; surgical planning; hepatic flow distribution; preprocedural planning; pulmonary arteriovenous malformations; PULMONARY ARTERIOVENOUS-MALFORMATIONS; HEPATIC VENOUS-BLOOD; VIRTUAL-REALITY; FLOW; GROWTH; TIME

Abstract

Objective: Fontan surgical planning is an image-based, collaborative effort, which is hypothesized to result in improved patient outcomes. A common motivation for Fontan surgical planning is the progression (or concern for progression) of pulmonary arteriovenous malformations. The purpose of this study was to evaluate the accuracy of surgical planning predictions, specifically hepatic flow distribution (HFD), a known factor in pulmonary arteriovenous malformation progression, and identify methodological improvements needed to increase prediction accuracy. Methods: Twelve single-ventricle patients who were enrolled in a surgical planning protocol for Fontan surgery with pre- and postoperative cardiac imaging were included in this study. Computational fluid dynamics were used to compare HFD in the surgical planning prediction and actual postoperative conditions. Results: Overall, HFD prediction error was 17 ± 13%. This error was similar between surgery types (15 ± 18% and 18 ± 10% for revisions vs Fontan completions respectively; P =.73), but was significantly lower (6 ± 7%; P =.05) for hepatic to azygous shunts. Y-grafts and extracardiac conduits showed a strong correlation between prediction error and discrepancies in graft insertion points (r = 0.99; P <.001). Improving postoperative anatomy prediction significantly reduced overall HFD prediction error to 9 ± 6% (P =.03). Conclusions: Although Fontan surgical planning can offer accurate HFD predictions for specific graft types, methodological improvements are needed to increase overall accuracy. Specifically, improving postoperative anatomy prediction was shown to be an important target for future work. Future efforts and refinements to the surgical planning process will benefit from an improved understanding of the current state and will rely heavily on increased follow-up data.