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Search Results for all work with filters:

  • cavopulmonari
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Work 1-10 of 19

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Article

Respiratory Effects on Fontan Circulation During Rest and Exercise Using Real-Time Cardiac Magnetic Resonance Imaging

by Zhenglun Wei; Kevin K. Whitehead; Reza H. Khiabani; Michael Tree; Elaine Tang; Stephen M Paridon; Mark A. Fogel; Ajit Yoganathan

2016

Subjects
  • Health Sciences, Medicine and Surgery
  • Health Sciences, Radiology
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Background It is known that respiration modulates cavopulmonary flows, but little data compare mean flows under breath-holding and free-breathing conditions to isolate the respiratory effects and effects of exercise on the respiratory modulation. Methods Real-time phase-contrast magnetic resonance combined with a novel method to track respiration on the same image acquisition was used to investigate respiratory effects on Fontan caval and aortic flows under breath-holding, free-breathing, and exercise conditions. Respiratory phasicity indices that were based on beat-averaged flow were used to quantify the respiratory effect. Results Flow during inspiration was substantially higher than expiration under the free-breathing and exercise conditions for both inferior vena cava (inspiration/expiration: 1.6 ± 0.5 and 1.8 ± 0.5, respectively) and superior vena cava (inspiration/expiration: 1.9 ± 0.6 and 2.6 ± 2.0, respectively). Changes from rest to exercise in the respiratory phasicity index for these vessels further showed the impact of respiration. Total systemic venous flow showed no significant statistical difference between the breath-holding and free-breathing conditions. In addition, no substantial difference was found between the descending aorta and inferior vena cava mean flows under either resting or exercise conditions. Conclusions This study demonstrated that inferior vena cava and superior vena cava flow time variance is dominated by respiratory effects, which can be detected by the respiratory phasicity index. However, the minimal respiration influence on net flow validates the routine use of breath-holding techniques to measure mean flows in Fontan patients. Moreover, the mean flows in the inferior vena cava and descending aorta are interchangeable.

Article

Maladaptive aortic properties after the Norwood procedure: An angiographic analysis of the Pediatric Heart Network Single Ventricle Reconstruction Trial

by Sarah T. Plummer; Christoph P. Hornik; Hamilton Baker; Gregory A. Fleming; Susan Foerster; Matthew Ferguson; Andrew C. Glatz; Russel Hirsch; Jeffrey P. Jacobs; Kyong-Jin Lee; Alan B. Lewis; Jennifer S. Li; Mary Martin; Diego Porras; Wolfgang A. K. Radtke; John F. Rhodes; Julie A. Vincent; Jeffrey D. Zampi; Kevin D. Hill

2016

Subjects
  • Health Sciences, Medicine and Surgery
  • Biology, Physiology
  • File Download
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Objectives: Aortic arch reconstruction in children with single ventricle lesions may predispose to circulatory inefficiency and maladaptive physiology leading to increased myocardial workload. We sought to describe neoaortic anatomy and physiology, risk factors for abnormalities, and impact on right ventricular function in patients with single right ventricle lesions after arch reconstruction. Methods: Prestage II aortic angiograms from the Pediatric Heart Network Single Ventricle Reconstruction trial were analyzed to define arch geometry (Romanesque [normal], crenel [elongated] , or gothic [angular]), indexed neoaortic dimensions, and distensibility. Comparisons were made with 50 single-ventricle controls without prior arch reconstruction. Factors associated with ascending neoaortic dilation, reduced distensibility, and decreased ventricular function on the 14-month echocardiogram were evaluated using univariate and multivariable logistic regression. Results: Interpretable angiograms were available for 326 of 389 subjects (84%). Compared with controls, study subjects more often demonstrated abnormal arch geometry (67% vs 22%, P  <  .01) and had increased ascending neoaortic dilation (Z score 3.8 ± 2.2 vs 2.6 ± 2.0, P  <  .01) and reduced distensibility index (2.2 ± 1.9 vs 8.0 ± 3.8, P  <  .01). Adjusted odds of neoaortic dilation were increased in subjects with gothic arch geometry (odds ratio [OR], 3.2 vs crenel geometry, P  <  .01) and a right ventricle-pulmonary artery shunt (OR, 3.4 vs Blalock–Taussig shunt, P  <  .01) but were decreased in subjects with aortic atresia (OR, 0.7 vs stenosis, P  <  .01) and those with recoarctation (OR, 0.3 vs no recoarctation, P = .04). No demographic, anatomic, or surgical factors predicted reduced distensibility. Neither dilation nor distensibility predicted reduced right ventricular function. Conclusions: After Norwood surgery, the reconstructed neoaorta demonstrates abnormal anatomy and physiology. Further study is needed to evaluate the longer-term impact of these features.

Article

Risk factors for prolonged length of stay after the stage 2 procedure in the single-ventricle reconstruction trial

by Steven M. Schwartz; Minmin Lu; Richard G. Ohye; Kevin D. Hill; Andrew M. Atz; Maryam Y. Naim; Ismee A. Williams; Caren S. Goldberg; Alan Lewis; Frank Pigula; Peter Manning; Christian Pizarro; Paul Chai; Rachel McCandless; Carolyn Dunbar-Masterson; Jonathan R. Kaltman; Kirk Kanter; Lynn A. Sleeper; Julie V. Schonbeck; Nancy Ghanayem

2014

Subjects
  • Health Sciences, Medicine and Surgery
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Background: The single-ventricle reconstruction trial randomized patients with single right ventricle lesions to a modified Blalock-Taussig or right ventricle-to-pulmonary artery shunt at the Norwood. This analysis describes outcomes at the stage 2 procedure and factors associated with a longer hospital length of stay (LOS). Methods: We examined the association of shunt type with stage 2 hospital outcomes. Cox regression and bootstrapping were used to evaluate risk factors for longer LOS. We also examined characteristics associated with in-hospital death. Results: There were 393 subjects in the analytic cohort. Median stage 2 procedure hospital LOS (8 days; interquartile range [IQR], 6-14 days), hospital mortality (4.3%), transplantation (0.8%), median ventilator time (2 days; IQR, 1-3 days), median intensive care unit LOS (4 days; IQR, 3-7 days), number of additional cardiac procedures or complications, and serious adverse events did not differ by shunt type. Longer LOS was associated (R2 = 0.26) with center, longer post-Norwood LOS (hazard ratio [HR], 1.93 per log day; P <.001), nonelective timing of the stage 2 procedure (HR, 1.78; P <.001), and pulmonary artery (PA) stenosis (HR, 1.56; P <.001). By univariate analysis, nonelective stage 2 (65% vs 32%; P =.009), moderate or greater atrioventricular valve (AVV) regurgitation (75% vs 24%; P <.001), and AVV repair (53% vs 9%; P <.001) were among the risk factors associated with in-hospital death. Conclusions: Norwood LOS, PA stenoses, and nonelective stage 2 procedure, but not shunt type, are independently associated with longer LOS. Nonelective stage 2 procedure, moderate or greater AVV regurgitation, and need for AVV repair are among the risk factors for death.

Article

Multicenter Study Comparing Shunt Type in the Norwood Procedure for Single-Ventricle Lesions Three-Dimensional Echocardiographic Analysis

by Gerald R. Marx; Girish Shirali; Jami C. Levine; Lin T. Guey; James F. Cnota; Jeanne M. Baffa; William L Border; Steve Colan; Gregory Ensing; Mark K. Friedberg; David J. Goldberg; Salim F. Idriss; J. Blaine John; Wyman W. Lai; Minmin Lu; Shaji C. Menon; Richard G. Ohye; David Saudek; Pierre C. Wong; Gail D. Pearson

2013

Subjects
  • Health Sciences, Medicine and Surgery
  • Health Sciences, Radiology
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Background-The Pediatric Heart Network's Single Ventricle Reconstruction (SVR) trial randomized infants with single right ventricles (RVs) undergoing a Norwood procedure to a modified Blalock-Taussig or RV-to-pulmonary artery shunt. This report compares RV parameters in the 2 groups using 3-dimensional echocardiography. Methods and Results-Three-dimensional echocardiography studies were obtained at 10 of 15 SVR centers. Of the 549 subjects, 314 underwent 3-dimensional echocardiography studies at 1 to 4 time points (pre-Norwood, post-Norwood, pre-stage II, and 14 months) for a total of 757 3-dimensional echocardiography studies. Of these, 565 (75%) were acceptable for analysis. RV volume, mass, mass:volume ratio, ejection fraction, and severity of tricuspid regurgitation did not differ by shunt type. RV volumes and mass did not change after the Norwood, but increased from pre-Norwood to pre-stage II (end-diastolic volume [milliliters]/body surface area [BSA]1.3, end-systolic volume [milliliters]/BSA1.3, and mass [grams]/BSA1.3 mean difference [95% confidence interval]=25.0 [8.7-41.3], 19.3 [8.3-30.4], and 17.9 [7.3-28.5], then decreased by 14 months (end-diastolic volume/BSA1.3, end-systolic volume/BSA1.3, and mass/BSA1.3 mean difference [95% confidence interval]=-24.4 [-35.0 to -13.7], -9.8 [-17.9 to -1.7], and -15.3 [-22.0 to -8.6]. Ejection fraction decreased from pre-Norwood to pre-stage II (mean difference [95% confidence interval]=-3.7 [-6.9 to -0.5]), but did not decrease further by 14 months. Conclusions-We found no statistically significant differences between study groups in 3-dimensional echocardiography measures of RV size and function, or magnitude of tricuspid regurgitation. Volume unloading was seen after stage II, as expected, but ejection fraction did not improve. This study provides insights into the remodeling of the operated univentricular RV in infancy.

Article

Fontan Surgical Planning: Previous Accomplishments, Current Challenges, and Future Directions

by Phillip M. Trusty; Timothy C. Slesnick; Zhenglun Alan Wei; Jarek Rossignac; Kirk R Kanter; Mark A. Fogel; Ajit Yoganathan

2018

Subjects
  • Engineering, Biomedical
  • Health Sciences, Medicine and Surgery
  • File Download
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Abstract:Close

The ultimate goal of Fontan surgical planning is to provide additional insights into the clinical decision-making process. In its current state, surgical planning offers an accurate hemodynamic assessment of the pre-operative condition, provides anatomical constraints for potential surgical options, and produces decent post-operative predictions if boundary conditions are similar enough between the pre-operative and post-operative states. Moving forward, validation with post-operative data is a necessary step in order to assess the accuracy of surgical planning and determine which methodological improvements are needed. Future efforts to automate the surgical planning process will reduce the individual expertise needed and encourage use in the clinic by clinicians. As post-operative physiologic predictions improve, Fontan surgical planning will become an more effective tool to accurately model patient-specific hemodynamics.

Article

Hypoplastic Left Heart Syndrome Current Considerations and Expectations

by Jeffrey A. Feinstein; D. Woodrow Benson; Anne M. Dubin; Meryl S. Cohen; Dawn M. Maxey; William Mahle; Elfriede Pahl; Juan Villafane; Ami B. Bhatt; Lynn F. Peng; Beth Ann Johnson; Alison L. Marsden; Curt J. Daniels; Nanacy A. Rudd; Christopher A. Caldarone; Kathleen A. Mussatto; David L. Morales; D. Dunbar Ivy; J. William Gaynor; James S. Tweddell; Barbara J. Deal; Anke K. Furck; Geoffrey L. Rosenthal; Richard G. Ohye; Nancy S. Ghanayem; John P. Cheatham; Wayne Tworetzky; Gerard R. Martin

2012

Subjects
  • Health Sciences, Medicine and Surgery
  • Health Sciences, General
  • File Download
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In the recent era, no congenital heart defect has undergone a more dramatic change in diagnostic approach, management, and outcomes than hypoplastic left heart syndrome (HLHS). During this time, survival to the age of 5 years (including Fontan) has ranged from 50% to 69%, but current expectations are that 70% of newborns born today with HLHS may reach adulthood. Although the 3-stage treatment approach to HLHS is now well founded, there is significant variation among centers. In this white paper, we present the current state of the art in our understanding and treatment of HLHS during the stages of care: 1) pre-Stage I: fetal and neonatal assessment and management; 2) Stage I: perioperative care, interstage monitoring, and management strategies; 3) Stage II: surgeries; 4) Stage III: Fontan surgery; and 5) long-term follow-up. Issues surrounding the genetics of HLHS, developmental outcomes, and quality of life are addressed in addition to the many other considerations for caring for this group of complex patients.

Article

Can time-averaged flow boundary conditions be used to meet the clinical timeline for Fontan surgical planning?

by Zhenglun (Alan) Wei; Phillip M. Trusty; Mike Tree; Christopher M. Haggerty; Elaine Tang; Mark Fogel; Ajit Yoganathan

2017

Subjects
  • Engineering, Biomedical
  • File Download
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Abstract:Close

Cardiovascular simulations have great potential as a clinical tool for planning and evaluating patient-specific treatment strategies for those suffering from congenital heart diseases, specifically Fontan patients. However, several bottlenecks have delayed wider deployment of the simulations for clinical use; the main obstacle is simulation cost. Currently, time-averaged clinical flow measurements are utilized as numerical boundary conditions (BCs) in order to reduce the computational power and time needed to offer surgical planning within a clinical time frame. Nevertheless, pulsatile blood flow is observed in vivo, and its significant impact on numerical simulations has been demonstrated. Therefore, it is imperative to carry out a comprehensive study analyzing the sensitivity of using time-averaged BCs. In this study, sensitivity is evaluated based on the discrepancies between hemodynamic metrics calculated using time-averaged and pulsatile BCs; smaller discrepancies indicate less sensitivity. The current study incorporates a comparison between 3D patient-specific CFD simulations using both the time-averaged and pulsatile BCs for 101 Fontan patients. The sensitivity analysis involves two clinically important hemodynamic metrics: hepatic flow distribution (HFD) and indexed power loss (iPL). Paired demographic group comparisons revealed that HFD sensitivity is significantly different between single and bilateral superior vena cava cohorts but no other demographic discrepancies were observed for HFD or iPL. Multivariate regression analyses show that the best predictors for sensitivity involve flow pulsatilities, time-averaged flow rates, and geometric characteristics of the Fontan connection. These predictors provide patient-specific guidelines to determine the effectiveness of analyzing patient-specific surgical options with time-averaged BCs within a clinical time frame.

Article

Visualization of flow structures in Fontan patients using 3-dimensional phase contrast magnetic resonance imaging

by Kartik S. Sundareswaran; Christopher M. Haggerty; Diane de Zelicourt; Lakshmi P. Dasi; Kerem Pekkan; David H. Frakes; Andrew J. Powell; Kirk R Kanter; Mark A. Fogel; Ajit Yoganathan

2012

Subjects
  • Health Sciences, Medicine and Surgery
  • Engineering, Biomedical
  • File Download
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Objective: Our objective was to analyze 3-dimensional (3D) blood flow patterns within the total cavopulmonary connection (TCPC) using in vivo phase contrast magnetic resonance imaging (PC MRI). Methods: Sixteen single-ventricle patients were prospectively recruited at 2 leading pediatric institutions for PC MRI evaluation of their Fontan pathway. Patients were divided into 2 groups. Group 1 comprised 8 patients with an extracardiac (EC) TCPC, and group 2 comprised 8 patients with a lateral tunnel (LT) TCPC. A coronal stack of 5 to 10 contiguous PC MRI slices with 3D velocity encoding (5-9 ms resolution) was acquired and a volumetric flow field was reconstructed. Results: Analysis revealed large vortices in LT TCPCs and helical flow structures in EC TCPCs. On average, there was no difference between LT and EC TCPCs in the proportion of inferior vena cava flow going to the left pulmonary artery (43% ± 7% vs 46% ± 5%; P = .34). However, for EC TCPCs, the presence of a caval offset was a primary determinant of inferior vena caval flow distribution to the pulmonary arteries with a significant bias to the offset side. Conclusions: 3D flow structures within LT and EC TCPCs were reconstructed and analyzed for the first time using PC MRI. TCPC flow patterns were shown to be different, not only on the basis of LT or EC considerations, but with significant influence from the superior vena cava connection as well. This work adds to the ongoing body of research demonstrating the impact of TCPC geometry on the overall hemodynamic profile.

Article

Fontan hemodynamics from 100 patient-specific cardiac magnetic resonance studies: A computational fluid dynamics analysis

by Christopher M. Haggerty; Maria Restrepo; Elaine Tang; Diane A. de Zelicourt; Kartik S. Sundareswaran; Lucia Mirabella; James Bethel; Kevin K. Whitehead; Mark A. Fogel; Ajit Yoganathan

2014

Subjects
  • Engineering, Biomedical
  • Health Sciences, Medicine and Surgery
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Objectives: This study sought to quantify average hemodynamic metrics of the Fontan connection as reference for future investigations, compare connection types (intra-atrial vs extracardiac), and identify functional correlates using computational fluid dynamics in a large patient-specific cohort. Fontan hemodynamics, particularly power losses, are hypothesized to vary considerably among patients with a single ventricle and adversely affect systemic hemodynamics and ventricular function if suboptimal. Methods: Fontan connection models were created from cardiac magnetic resonance scans for 100 patients. Phase velocity cardiac magnetic resonance in the aorta, vena cavae, and pulmonary arteries was used to prescribe patient-specific time-averaged flow boundary conditions for computational fluid dynamics with a customized, validated solver. Comparison with 4-dimensional cardiac magnetic resonance velocity data from selected patients was used to provide additional verification of simulations. Indexed Fontan power loss, connection resistance, and hepatic flow distribution were quantified and correlated with systemic patient characteristics. Results: Indexed power loss varied by 2 orders of magnitude, whereas, on average, Fontan resistance was 15% to 20%of published values of pulmonary vascular resistance in single ventricles. A significant inverse relationship was observed between indexed power loss and both systemic venous flow and cardiac index. Comparison by connection type showed no differences between intra-atrial and extracardiac connections. Instead, the least efficient connections revealed adverse consequences from localized Fontan pathway stenosis. Conclusions: Fontan power loss varies from patient to patient, and elevated levels are correlated with lower systemic flow and cardiac index. Fontan connection type does not influence hemodynamic efficiency, but an undersized or stenosed Fontan pathway or pulmonary arteries can be highly dissipative.

Article

Magnetic resonance imaging-guided surgical design: can we optimise the Fontan operation?

by Christopher M. Haggerty; Ajit Yoganathan; Mark A. Fogel

2013

Subjects
  • Health Sciences, Medicine and Surgery
  • Engineering, Biomedical
  • Health Sciences, Radiology
  • File Download
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The Fontan procedure, although an imperfect solution for children born with a single functional ventricle, is the only reconstruction at present short of transplantation. The haemodynamics associated with the total cavopulmonary connection, the modern approach to Fontan, are severely altered from the normal biventricular circulation and may contribute to the long-term complications that are frequently noted. Through recent technological advances, spear-headed by advances in medical imaging, it is now possible to virtually model these surgical procedures and evaluate the patient-specific haemodynamics as part of the pre-operative planning process. This is a novel paradigm with the potential to revolutionise the approach to Fontan surgery, help to optimise the haemodynamic results, and improve patient outcomes. This review provides a brief overview of these methods, presents preliminary results of their clinical usage, and offers insights into its potential future directions.
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