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Right ventricular afterload in repaired D-TGA is associated with inefficient flow patterns, rather than stenosis alone

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Abstract

Treatment of D- transposition of great arteries (DTGA) involves the Arterial Switch Operation (ASO), which can create PA branch stenosis (PABS) and alter PA blood flow energetics. This altered PA flow may contribute to elevated right ventricular (RV) afterload more significantly than stenosis alone. Our aim was to correlate RV afterload and PA flow characteristics using 4D flow cardiac magnetic resonance (CMR) imaging of a mock circulatory system (MCS) incorporating 3D printed replicas. CMR imaging and clinical characteristics were analyzed from 22 ASO patients (age 11.9 ± 8.7 years, 68% male). Segmentation was performed to create 3D printed PA replicas that were mounted in an MRI-compatible MCS. Pressure drop across the PA replica was recorded and 4D flow CMR acquisitions were analyzed for blood flow inefficiency (energy loss, vorticity). In post-ASO patients, there is no difference in RV mass (p = 0.07), nor RV systolic pressure (p = 0.26) in the presence or absence of PABS. 4D flow analysis of MCS shows energy loss is correlated to RV mass (p = 0.01, r = 0.67) and MCS pressure differential (p = 0.02, r = 0.57). Receiver operating characteristic curve shows energy loss detects elevated RV mass above 30 g/m2 (p = 0.02, AUC 0.88) while index of PA dimensions (Nakata) does not (p = 0.09, AUC 0.79). PABS alone does not account for differences in RV mass or afterload in post-ASO patients. In MCS simulations, energy loss is correlated with both RV mass and PA pressure, and can moderately detect elevated RV mass. Inefficient PA flow may be an important predictor of RV afterload in this population.

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Data availability

The datasets generated and analyzed during the current study are not publicly available in order to protect subject anonymity, but are available from the corresponding author on reasonable request.

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Acknowledgements

The authors would like to acknowledge Nicholas Mouzakis, the cardiovascular magnetic resonance technologist for assistance in scanning in vitro experiments.

Funding

This project was supported by Award Number R38AI140298 from the NIH National Center of Allergy and Infectious Diseases. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Center of Allergy and Infectious Diseases or the National Institutes of Health.

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Authors and Affiliations

  1. Division of Pediatrics, Children’s National Medical Center, 111 Michigan Ave, NW, Washington, DC, 20010, USA

    Marc Delaney

  2. Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Medical Center, Washington, DC, USA

    Vincent Cleveland & Paige Mass

  3. Department of Mechanics, Mathematics and Management, Politecnico di Bari, Bari, Italy

    Francesco Capuano

  4. Division of Cardiology, Children’s National Medical Center, Washington, DC, USA

    Jason G. Mandell, Yue-Hin Loke & Laura Olivieri

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  1. Marc Delaney
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  2. Vincent Cleveland
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  3. Paige Mass
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  6. Yue-Hin Loke
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Contributions

VC and PM made substantial contributions to experiment execution and engineering iterative design. FC provided technical oversight and guidance in optimizing patient-specific parameters of experimental setup. YL, JM, and LO provided scientific guidance and cardiology imaging expertise throughout and directly contributed to the study conception and execution. LO also served as the primary mentor and principal investigator for this research and contributed significantly to manuscript editing. All authors read and approved the final manuscript.

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Correspondence to Marc Delaney.

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This study was approved by the Children’s National Hospital Institutional Review Board.

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Delaney, M., Cleveland, V., Mass, P. et al. Right ventricular afterload in repaired D-TGA is associated with inefficient flow patterns, rather than stenosis alone. Int J Cardiovasc Imaging 38, 653–662 (2022). https://doi.org/10.1007/s10554-021-02436-4

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