Total cavopulmonary connection flow with functional left pulmonary artery stenosis

Angioplasty and fenestration in vitro

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

Research output: Contribution to journalArticle

55 Citations (Scopus)

Abstract

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.

Original languageEnglish (US)
Pages (from-to)3264-3271
Number of pages8
JournalCirculation
Volume112
Issue number21
DOIs
StatePublished - Nov 2005
Externally publishedYes

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Angioplasty
Pathologic Constriction
Perfusion
Lung
Hydrodynamics
Pressure
Hemodynamics
In Vitro Techniques
Pulmonary Artery Stenosis
Vascular Resistance
Pulmonary Artery
Multicenter Studies
Anatomy

Keywords

  • Angioplasty
  • Blood flow
  • Fontan procedure
  • Magnetic resonance imaging
  • Stenosis

ASJC Scopus subject areas

  • Physiology
  • Cardiology and Cardiovascular Medicine

Cite this

Pekkan, K., Kitajima, H. D., De Zelicourt, D., Forbess, J. M., Parks, W. J., Fogel, M. A., ... Yoganathan, A. P. (2005). Total cavopulmonary connection flow with functional left pulmonary artery stenosis: Angioplasty and fenestration in vitro. Circulation, 112(21), 3264-3271. https://doi.org/10.1161/CIRCULATIONAHA.104.530931

Total cavopulmonary connection flow with functional left pulmonary artery stenosis : Angioplasty and fenestration in vitro. / Pekkan, Kerem; Kitajima, Hiroumi D.; De Zelicourt, Diane; Forbess, Joseph M.; Parks, W. James; Fogel, Mark A.; Sharma, Shiva; Kanter, Kirk R.; Frakes, David; Yoganathan, Ajit P.

In: Circulation, Vol. 112, No. 21, 11.2005, p. 3264-3271.

Research output: Contribution to journalArticle

Pekkan, K, Kitajima, HD, De Zelicourt, D, Forbess, JM, Parks, WJ, Fogel, MA, Sharma, S, Kanter, KR, Frakes, D & Yoganathan, AP 2005, 'Total cavopulmonary connection flow with functional left pulmonary artery stenosis: Angioplasty and fenestration in vitro', Circulation, vol. 112, no. 21, pp. 3264-3271. https://doi.org/10.1161/CIRCULATIONAHA.104.530931
Pekkan, Kerem ; Kitajima, Hiroumi D. ; De Zelicourt, Diane ; Forbess, Joseph M. ; Parks, W. James ; Fogel, Mark A. ; Sharma, Shiva ; Kanter, Kirk R. ; Frakes, David ; Yoganathan, Ajit P. / Total cavopulmonary connection flow with functional left pulmonary artery stenosis : Angioplasty and fenestration in vitro. In: Circulation. 2005 ; Vol. 112, No. 21. pp. 3264-3271.
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abstract = "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.",
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AU - Pekkan, Kerem

AU - Kitajima, Hiroumi D.

AU - De Zelicourt, Diane

AU - Forbess, Joseph M.

AU - Parks, W. James

AU - Fogel, Mark A.

AU - Sharma, Shiva

AU - Kanter, Kirk R.

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N2 - 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.

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