Sinha Pranava, Contento Jacqueline, Kim Byeol, Wang Kevin, Wu Qiyuan, Cleveland Vincent, Mass Paige, Loke Yue-Hin, Krieger Axel, Olivieri Laura
Department of Pediatric Cardiac Surgery, M Health Fairview, University of Minnesota, Minneapolis, Minn.
Sheikh Zayed Institute of Pediatric Surgical Innovation, Children's National Hospital, Washington, DC.
JTCVS Open. 2023 Jan 11;13:320-329. doi: 10.1016/j.xjon.2022.12.009. eCollection 2023 Mar.
The current total cavopulmonary connection Fontan has competing inflows and outflows, creating hemodynamic inefficiencies that contribute to Fontan failure and complicate placement and efficiency of mechanical circulatory support. We propose a novel convergent cavopulmonary connection (CCPC) Fontan design to create a single, converged venous outflow to the pulmonary arteries, thus increasing efficiency and mechanical circulatory support access. We then evaluate the feasibility and hemodynamic performance of the CCPC in various patient sizes using computational fluid dynamic assessments of computer-aided designs.
Cardiac magnetic resonance imaging data from 12 patients with single ventricle (10 total cavopulmonary connection, 2 Glenn) physiology (body surface area, 0.5-2.0 m) were segmented to create 3-dimensional replicas of all thoracic structures. Surgically feasible CCPC shapes within constraints of anatomy were created using iterative computational fluid dynamic and clinician input. Designs varied based on superior and inferior vena cava conduit sizes, coronal attachment height, coronal entry angle, and axial entry angle of the superior vena cava to the inferior vena cava. CCPC designs were optimized based on efficiency (indexed power loss), risk of arteriovenous malformations (hepatic flow distribution), and risk of flow stasis (% nonphysiologic wall shear stress).
All CCPC designs met hemodynamic performance thresholds for indexed power loss and hepatic flow distribution. CCPC designs showed improvements in reducing % nonphysiologic wall shear stress and balancing HFD.
CCPC is physiologically and surgically feasible in various patient sizes using validated computational fluid dynamic models. CCPC configuration has analogous indexed power loss, hepatic flow distribution, and % nonphysiologic wall shear stress compared with total cavopulmonary connection, and the single inflow and outflow may ease mechanical circulatory support therapies. Further studies are required for design optimization and mechanical circulatory support institution.
目前的全腔静脉肺动脉连接（Fontan）手术存在相互竞争的流入和流出，导致血流动力学效率低下，进而引发Fontan衰竭，并使机械循环支持的植入和效率变得复杂。我们提出一种新型的汇聚式腔静脉肺动脉连接（CCPC）Fontan设计，以创建单一的、汇聚的静脉流出道至肺动脉，从而提高效率并改善机械循环支持的接入。然后，我们使用计算机辅助设计的计算流体动力学评估，来评估CCPC在不同患者体型中的可行性和血流动力学性能。
对12例单心室生理状态（10例全腔静脉肺动脉连接，2例Glenn手术）患者（体表面积0.5 - 2.0平方米）的心脏磁共振成像数据进行分割，以创建所有胸部结构的三维模型。在解剖学限制范围内，通过迭代计算流体动力学和临床医生的输入，创建手术可行的CCPC形状。设计根据上腔静脉和下腔静脉导管尺寸、冠状附着高度、冠状入口角度以及上腔静脉与下腔静脉的轴向入口角度而有所不同。基于效率（指数功率损失）、动静脉畸形风险（肝血流分布）和血流淤滞风险（非生理性壁面剪应力百分比）对CCPC设计进行优化。
所有CCPC设计均达到指数功率损失和肝血流分布的血流动力学性能阈值。CCPC设计在降低非生理性壁面剪应力百分比和平衡肝血流分布方面有所改善。
使用经过验证的计算流体动力学模型，CCPC在不同患者体型中在生理和手术上都是可行的。与全腔静脉肺动脉连接相比，CCPC构型具有类似的指数功率损失、肝血流分布和非生理性壁面剪应力百分比，并且单一的流入和流出可能会简化机械循环支持治疗。需要进一步研究以优化设计并建立机械循环支持体系。
