Abstract
Virtual modeling of cardiothoracic surgery is a new paradigm that allows for systematic exploration of various operative strategies and uses engineering principles to predict the optimal patient-specific plan. This study investigates the predictive accuracy of such methods for the surgical palliation of single ventricle heart defects. Computational fluid dynamics (CFD)-based surgical planning was used to model the Fontan procedure for four patients prior to surgery. The objective for each was to identify the operative strategy that best distributed hepatic blood flow to the pulmonary arteries. Post-operative magnetic resonance data were acquired to compare (via CFD) the post-operative hemodynamics with predictions. Despite variations in physiologic boundary conditions (e.g., cardiac output, venous flows) and the exact geometry of the surgical baffle, sufficient agreement was observed with respect to hepatic flow distribution (90% confidence interval—14 ± 4.3% difference). There was also good agreement of flow-normalized energetic efficiency predictions (19 ± 4.8% error). The hemodynamic outcomes of prospective patient-specific surgical planning of the Fontan procedure are described for the first time with good quantitative comparisons between preoperatively predicted and postoperative simulations. These results demonstrate that surgical planning can be a useful tool for single ventricle cardiothoracic surgery with the ability to deliver significant clinical impact.
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Baretta, A., C. Corsini, W. Yang, I. Vignon-Clementel, A. L. Marsden, J. A. Feinstein, T.-Y. Hsia, G. Dubini, F. Migliavacca, and G. Pennati. Virtual surgeries in patients with congenital heart disease: a multi-scale modelling test case. Philos. Trans. R. Soc. A 369:4316–4330, 2011.
Dasi, L. P., R. Krishnankutty, H. Kitajima, K. Pekkan, K. Sundareswaran, M. Fogel, S. Sharma, K. Whitehead, K. Kanter, and A. P. Yoganathan. Fontan hemodynamics: importance of pulmonary artery diameter. J. Thorac. Cardiovasc. Surg. 137:560–564, 2009.
Dasi, L. P., K. Whitehead, K. Pekkan, D. de Zelicourt, K. Sundareswaran, K. Kanter, M. A. Fogel, and A. P. Yoganathan. Pulmonary hepatic flow distribution in total cavopulmonary connections: extracardiac versus intracardiac. J. Thorac. Cardiovasc. Surg. 141:207–214, 2011.
de Leval, M. R., P. Kilner, M. Gewillig, and C. Bull. Total cavopulmonary connection: a logical alternative to atriopulmonary connection for complex fontan operations. J. Thorac. Cardiovasc. Surg. 96:682–695, 1988.
de Zelicourt, D. Pulsatile fontan hemodynamics and patient-specific surgical planning: a numerical investigation. PhD. Georgia Institute of Technology, Atlanta, GA, 2010.
de Zélicourt, D., L. Ge, C. Wang, F. Sotiropoulos, A. Gilmanov, and A. P. Yoganathan. Flow simulations in arbitrarily complex cardiovascular anatomies—an unstructured Cartesian grid approach. Comput. Fluids 38:1749–1762, 2009.
De Zelicourt, D., C. M. Haggerty, K. S. Sundareswaran, B. Whited, J. Rossignac, K. Kanter, J. W. Gaynor, T. L. Spray, F. Sotiropoulos, M. A. Fogel, and A. P. Yoganathan. Individualized computer-based surgical planning to address pulmonary ateriovenous malformations in patients with a single ventricle with an interrupted inferior vena cava and azygous continuation. J. Thorac. Cardiovasc. Surg. 141:1170–1177, 2011.
De Zelicourt, D., A. L. Marsden, M. Fogel, and A. P. Yoganathan. Imaging and patient-specific simulations for the fontan surgery: current methodologies and clinical applications. Prog. Pediatr. Cardiol. 30:31–44, 2010.
Duncan, B., and S. Desai. Pulmonary arteriovenous malformations after cavopulmonary anastomosis. Ann. Thorac. Surg. 76:1759–1766, 2003.
Fogel, M., P. M. Weinberg, A. J. Chin, K. E. Fellows, and E. A. Hoffman. Late ventricular geometry and performance changes of functional single ventricle throughout staged fontan reconstruction assessed by magnetic resonance imaging. J. Am. Coll. Cardiol. 28:212–221, 1996.
Fontan, F., and E. Baudet. Surgical repair of tricuspid atresia. Thorax 26:240–248, 1971.
Frakes, D. H., C. P. Conrad, T. M. Healy, J. W. Monaco, M. Fogel, S. Sharma, M. J. Smith, and A. P. Yoganathan. Application of an adaptive control grid interpolation technique to morphological vascular reconstruction. IEEE Trans. Biomed. Eng. 50:197–206, 2003.
Gilmanov, A., and F. Sotiropoulos. A hybrid cartesian/immersed boundary method for simulating flows with 3d, geometrically complex, moving bodies. J. Comput. Phys. 207:457–492, 2005.
Haggerty, C. M., D. De Zelicourt, J. Kanter, K. Sundareswaran, M. Fogel and A. P. Yoganathan. Pulsatile hemodynamics of the fontan connection: A tri-modal investigation (abstract). Proceedings of the ASME Summer Bioengineering Conference, 2011.
Haggerty, C. M., K. R. Kanter, M. Restrepo, D. de Zelicourt, W. J. Parks, J. Rossignac, M. A. Fogel, and A. P. Yoganathan. Simulating hemodynamics of the fontan y-graft based on patient-specific in vivo connections. J. Thorac. Cardiovasc. Surg. 2012. (in press)
Kanter, K. R., C. M. Haggerty, M. Restrepo, D. De Zelicourt, J. Rossignac, W. J. Parks and A. P. Yoganathan. Preliminary clinical experience with a bifurcated y-graft fontan procedure—a feasibility study. J. Thorac. Cardiovasc. Surg. 2012. (in press)
Khairy, P., S. M. Fernandes, J. John, E. Mayer, J. K. Triedman, E. P. Walsh, J. E. Lock, and M. J. Landzberg. Long-term survival, modes of death, and predictors of martality in patients with fontan surgery. Circulation 117:85–92, 2008.
Long, C. C., M.-C. Hsu, Y. Bazilevs, J. A. Feinstein and A. L. Marsden. Fluid-structure interaction simulations of the fontan procedure using variable wall properties. Int. J. Numer. Methods Biomed. Eng. 28:513–527, 2012.
Mair, D. D., F. J. Puga, and G. K. Danielson. The fontan procedure for tricuspid atresia: early and late results of a 25-year experience with 216 patients. J. Am. Coll. Cardiol. 37:933–939, 2001.
Marsden, A. L., A. J. Bernstein, V. M. Reddy, S. C. Shadden, R. L. Spilker, F. P. Chan, C. A. Taylor, and J. A. Feinstein. Evaluation of a novel y-shaped extracardiac fontan baffle using computational fluid dynamics. J. Thorac. Cardiovasc. Surg. 137:394–403, 2009.
Pekkan, K., B. Whited, K. Kanter, S. Sharma, D. de Zelicourt, K. Sundareswaran, D. Frakes, J. Rossignac, and A. P. Yoganathan. Patient-specific surgical planning and hemodynamic computational fluid dynamics optimization through free-form haptic anatomy editing tool (surgem). Med. Biol. Eng. Comput. 46:1139–1152, 2008.
Pennati, G., C. Corsini, D. Cosentino, T.-Y. Hsia, V. S. Luisi, G. Dubini, and F. Migliavacca. Boundary conditions of patient-specific fluid dynamics modelling of cavopulmonary connections: possible adaptation of pulmonary resistances results is a critical issue for virtual surgical planning. Interface Focus 1:297–307, 2011.
Rosenthal, M., A. Bush, J. Deanfield, and A. Redington. Comparison of cardiopulmonary adaptation during exercise in children after the atriopulmonary and total cavopulmonary connection fontan procedures. Circulation 91:372–378, 1995.
Sankaran, S., and A. L. Marsden. A stochastic collocation method for uncertainty quantification and propagation in cardiovascular simulations. J. Biomech. Eng. 133:031001, 2011.
Senzaki, H., S. Masutani, H. Ishido, M. Taketazu, T. Kobayashi, N. Saski, H. Asano, T. Katogi, S. Kyo, and Y. Yokote. Cardiac rest and reserve function in patients with fontan circulation. J. Am. Coll. Cardiol. 47:2528–2535, 2006.
Shachar, G., B. Fuhrman, Y. Wang, R. J. Lucas, and J. Lock. Rest and exercise hemodynamics after the fontan procedure. Circulation 65:1043–1048, 1982.
Soerensen, D. D., K. Pekkan, D. de Zelicourt, S. Sharma, K. Kanter, M. Fogel, and A. P. Yoganathan. Introduction of a new optimized total cavopulmonary connection. Ann. Thorac. Surg. 83:2182–2190, 2007.
Sundareswaran, K., D. de Zélicourt, S. Sharma, K. Kanter, T. Spray, J. R. Rossignac, F. Sotiropoulos, M. Fogel, and A. P. Yoganathan. Correction of pulmonary arteriovenous malformation using image based surgical planning. JACC Imaging 2:1024–1030, 2009.
Sundareswaran, K., D. Frakes, M. Fogel, D. Soerensen, J. N. Oshinski, and A. Yoganathan. Optimum fuzzy filters for phase-contrast magnetic resonance imaging segmentation. J. Magn. Reson. Imaging 29:155–165, 2009.
Sundareswaran, K. S., C. M. Haggerty, D. de Zelicourt, L. P. Dasi, K. Pekkan, D. Frakes, A. J. Powell, K. R. Kanter, M. A. Fogel, and A. P. Yoganathan. Visualization of flow structures in fontan patients using three-dimensional phase contrast magnetic resonance imaging. J. Thorac. Cardiovasc. Surg. 143:1108–1116, 2012.
Sundareswaran, K. S., K. Pekkan, L. P. Dasi, K. Whitehead, S. Sharma, K. Kanter, M. Fogel, and A. P. Yoganathan. The total cavopulmonary connection resistance: a significant impact on single ventricle hemodynamics at rest and exercise. Am. J. Physiol Heart Circ. Physiol. 295:H2427–H2435, 2008.
Vignon-Clementel, I. E., C. Alberto Figueroa, K. E. Jansen, and C. A. Taylor. Outflow boundary conditions for three-dimensional finite element modeling of blood flow and pressure in arteries. Comput. Methods Appl. Mech. Eng. 195:3776–3796, 2006.
Whitehead, K. K., K. Pekkan, H. D. Kitajima, S. M. Paridon, A. P. Yoganathan, and M. A. Fogel. Nonlinear power loss during exercise in single-ventricle patients after the fontan: Insights from computational fluid dynamics. Circulation 116:I165–I171, 2007.
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This study was supported by the National Heart, Lung, and Blood Institute Grants HL67622 and HL098252, and a Pre-Doctoral Fellowship Award (10PRE3720002) from the American Heart Association.
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Associate Editor Peter E. McHugh oversaw the review of this article.
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Haggerty, C.M., de Zélicourt, D.A., Restrepo, M. et al. Comparing Pre- and Post-operative Fontan Hemodynamic Simulations: Implications for the Reliability of Surgical Planning. Ann Biomed Eng 40, 2639–2651 (2012). https://doi.org/10.1007/s10439-012-0614-4
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DOI: https://doi.org/10.1007/s10439-012-0614-4