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Hemodynamic Performance of Stage-2 Univentricular Reconstruction: Glenn vs. Hemi-Fontan Templates

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Abstract

Flow structures, hemodynamics and the hydrodynamic surgical pathway resistances of the final stage functional single ventricle reconstruction, namely the total cavopulmonary connection (TCPC) anatomy, have been investigated extensively. However, the second stage surgical anatomy (i.e., bi-directional Glenn or hemi-Fontan template) has received little attention. We thus initiated a multi-faceted study, involving magnetic resonance imaging (MRI), phase contrast MRI, computational and experimental fluid dynamics methodologies, focused on the second stage of the procedure. Twenty three-dimensional computer and rapid prototype models of 2nd stage TCPC anatomies were created, including idealized parametric geometries (n = 6), patient-specific anatomies (n = 7), and their virtual surgery variant (n = 7). Results in patient-specific and idealized models showed that the Glenn connection template is hemodynamically more efficient with (83% p = 0.08 in patient-specific models and 66% in idealized models) lower power losses compared to hemi-Fontan template, respectively, due to its direct end-to-side anastomosis. Among the several secondary surgical geometrical features, stenosis at the SVC anastomosis or in pulmonary branches was found to be the most critical parameter in increasing the power loss. The pouch size and flare shape were found to be less significant. Compared to the third stage surgery the hydrodynamic resistance of the 2nd stage is considerably lower (both in idealized models and in anatomical models at MRI resting conditions) for both hemi- and Glenn templates. These results can impact the surgical design and planning of the staged TCPC reconstruction.

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Acknowledgments

This work was supported by a grant from the National Heart, Lung, and Blood Institute, HL67622. We also acknowledge Dr. Dave Frakes for providing the ACGI technology and Dr. Hiroumi Kitajima for processing the patient MRI datasets. Experimental and computational studies were made possible by the help of our brilliant undergraduate students: Vasu Yernini, Maria Restrepo, Kiyu Kim, and Quantez Freeman.

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Authors and Affiliations

  1. Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA, USA

    Kerem Pekkan

  2. Wallace H. Coulter School of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, USA

    Lakshimi P. Dasi, Diane de Zélicourt, Kartik S. Sundareswaran & Ajit P. Yoganathan

  3. Children’s Hospital of Philadelphia, Philadelphia, PA, USA

    Mark A. Fogel

  4. Department of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, USA

    Kirk R. Kanter

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  1. Kerem Pekkan
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Appendix

Appendix

Effects of Secondary Morphological Features on Hydrodynamic Power Loss

The effects of secondary and peripheral anatomical features on the computed TCPC power loss values (S3R) have been well established in the earlier verification studies. This communication is an appropriate place to summarize these briefly for the S2R. These factors should influence the computed fluid dynamics of both Glenn and hemi-Fontan models more-or-less in the same magnitude thus should not influence the stated conclusions of this manuscript. The effect of the extra 3D reconstruction smoothing has studied in the Glenn model (CHOA030), Fig. A1. Calculated power loss values are −0.250 mW and −0.277 mW with our standard reconstruction protocol and with the extra surface smoothed model, respectively. The effect of PA branch length and proximal bending is studied in another Glenn model (CHOP057), Fig. A2. As expected the PA bending increased the power loss values from 0.044 mW to 0.045 mW which was negligible for this configuration. For all other models morphology of the PA branches are relatively straight with gentler radii of curvature.

Figure A1
figure 11

Effect of extra smoothing on the pressure distribution (mmHg) for a Glenn model (Database ID: CHOA030). Top: is the 3D reconstruction from the standard methodology (For the coronal view please refer to Fig. 8). Bottom: Over smoothed model, see arrow. No major differences were apparent in the streamline patterns of these two models

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Figure A2
figure 12

Effect of distal PA morphology (arrow) on the computed flow fields and pressure drop (mmHg). For the model with a straight PA please refer to Fig. 8. (Database ID: Chop057)

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Pekkan, K., Dasi, L.P., de Zélicourt, D. et al. Hemodynamic Performance of Stage-2 Univentricular Reconstruction: Glenn vs. Hemi-Fontan Templates. Ann Biomed Eng 37, 50–63 (2009). https://doi.org/10.1007/s10439-008-9591-z

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