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Local Hemodynamic Differences Between Commercially Available Y-Grafts and Traditional Fontan Baffles Under Simulated Exercise Conditions: Implications for Exercise Tolerance

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Abstract

Fontan completion, resulting in a total cavopulmonary connection (TCPC), is accomplished using a lateral tunnel (LT), extracardiac conduit (ECC), or recently a bifurcated Y-graft. The local energetic differences between these graft types have not been substantially analyzed under exercise conditions. The present study evaluates the energetic performance of Y-grafts under simulated exercise conditions, compares their performance to the previous LT/ECC Fontan options, and discusses implications for exercise tolerance and hemodynamic predictability. Twenty Y-graft and 20 LT/ECC patients were analyzed. TCPC anatomies and flow waveforms were reconstructed using patient-specific cardiac magnetic resonance (CMR) images and phase-contrast CMR. Computational fluid dynamics simulations were performed to quantify indexed power loss (iPL) under both resting and simulated exercise conditions. Comparisons between graft types were investigated. iPL was significantly higher (p < 0.01) for Y-grafts at all activity levels. No significant interaction effects were observed between graft type and activity level. iPL at rest was strongly correlated (r 2 = 0.97, p < 0.001) with iPL at moderate exercise for Y-grafts, but less so for the LT/ECC cohort (r 2 = 0.66, p < 0.001). Similar results were seen for intense exercise, with a strong correlation for Y-grafts (r 2 = 0.94, p < 0.001) and a moderate correlation for LT/ECC (r 2 = 0.52, p < 0.001). Commercially available Y-grafts were found to have significantly higher iPL at all activity levels, suggesting worse exercise tolerance than the LT/ECC alternatives. Y-grafts offered impressive hemodynamic predictability which was not seen in the LT/ECC cohort. Our results encourage the further evaluation of an area-preserving Y-graft design to offer both improved energetic performance and hemodynamic predictability. Commercial Y-grafts show worse energetics, but more predictable responses than traditional Fontan connections under simulated exercise conditions. During simulated exercise conditions, commercially available Y-grafts show predictable but inferior energetic performance compared to lateral tunnel and extracardiac conduit Fontan connections, suggesting poorer exercise capacity. If Y-graft use is continued, these results encourage further evaluation of a cross sectional area-preserving Y-graft design as a additional alternative for Fontan completion.

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Abbreviations

BSA:

Body surface area

CFD:

Computational fluid dynamics

CMR:

Cardiac magnetic resonance

ECC:

Extracardiac conduit

HLHS:

Hypoplastic left heart syndrome

iPL:

Indexed power loss

IVC:

Inferior vena cava

LPA:

Left pulmonary artery

LT:

Lateral tunnel

PA:

Pulmonary artery

PL:

Power loss

Qs:

Systemic flow

RPA:

Right pulmonary artery

SVC:

Superior vena cava

TCPC:

Total cavopulmonary connection

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Funding

Mark Fogel has received funding through: Research Grant; Modest; NIH R01. Consultant/Advisory Board; Modest; Edwards Lifesciences - MRI Core Lab. Other; Modest; AMAG FACT trial site, Cooley’s Anemia Foundation MRI Core Lab.

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Authors and Affiliations

  1. Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA

    Phillip M. Trusty, Zhenglun Wei & Ajit P. Yoganathan

  2. George W. Woodruff School of Mechanical Engineering, Georgia Institute of Technology, Atlanta, GA, USA

    Michael Tree

  3. Division of Cardiothoracic Surgery, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA

    Kirk R. Kanter

  4. Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA

    Mark A. Fogel

  5. Division of Cardiology, Department of Pediatrics, Children’s Healthcare of Atlanta, Emory University School of Medicine, Philadelphia, PA, USA

    Timothy C. Slesnick

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  1. Phillip M. Trusty
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Correspondence to Ajit P. Yoganathan.

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No animal studies were carried out by the authors for this article.

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All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000. Informed consent was obtained from all individual participants included in the study.

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Associate Editor Pedro del Nido oversaw the review of this article.

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Trusty, P.M., Wei, Z., Tree, M. et al. Local Hemodynamic Differences Between Commercially Available Y-Grafts and Traditional Fontan Baffles Under Simulated Exercise Conditions: Implications for Exercise Tolerance. Cardiovasc Eng Tech 8, 390–399 (2017). https://doi.org/10.1007/s13239-017-0310-5

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