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J Thorac Cardiovasc Surg 1999;117:697-704
© 1999 Mosby, Inc.
SURGERY FOR CONGENITAL HEART DISEASE |
From the Cardiac Dynamics Laboratory,a Division of Cardiology, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pa, and Department of Cardiac Surgery,b Boston Children's Hospital, Harvard University, Boston, Mass.
Received for publication June 23, 1998. Revisions requested Sept 17, 1998. Revisions received Oct 30, 1998. Accepted for publication Nov 30, 1998. Address for reprints: Albert C. Lardo, PhD, Johns Hopkins University School of Medicine, 407 Traylor Building, 720 Rutland Ave, Baltimore, MD 21205.
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Abstract |
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Introduction |
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1 The great enthusiasm for the use of this procedure was driven by the contention that elimination of the right atrial chamber would result in improved hemodynamic efficiency and might also reduce the incidence of right atrium–related complications encountered in the atriopulmonary connection (supraventricular arrhythmias and atrial thrombus formation). Although TCPC may reduce the incidence of these complications in the early postoperative course, 2 this issue is controversial, 3 and moderate to late outcome remains complicated in many patients by rhythm disturbances, thrombus formation, low-output states, protein-losing enteropathy, and chronic effusions. 4-6 Since some of these complications are related to extensive intra-atrial suture lines and the placement of intracardiac prosthetic material, exploration of alternative means for achieving the TCPC circulation is warranted.
Extracardiac procedures have received recent attention because they are technically simpler, do not require intra-atrial suture lines, and eliminate potentially thrombogenic intra-atrial material. Within the extracardiac approach, an epicardial tunnel or a conduit can be used to divert inferior vena cava flow to the pulmonary arteries. The extracardiac conduit approach has several important theoretical advantages, including simplicity of offsetting superior and inferior vena cava flow streams, which has been shown to improve hydrodynamic efficiency. 7-10 Subtle geometric differences between the extracardiac procedures and the commonly used intra-atrial lateral tunnel TCPC may have significant implications for the fluid dynamics and hydrodynamic efficiency of the surgical connection. Whereas previous researchers have described the clinical advantages of extracardiac procedures, a quantitative fluid-dynamic assessment of this approach has not been previously performed. The purpose of this study was to compare the fluid dynamics of the extracardiac tunnel and conduit procedures to the intra-atrial TCPC and establish an independent fluid mechanical rationale for the use of one or more of these procedures.
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Methods |
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11 Three procedures were studied: (1) intra-atrial lateral tunnel, (2) extracardiac epicardial tunnel, and (3) extracardiac conduit with and without 5 mm conduit offset toward the distal right pulmonary artery. This offset was selected on the basis of previous caval offset optimization studies on the total cavopulmonary anastomosis performed in our laboratory. 10 To determine the effect of the extracardiac conduit to inferior vena cava diameter ratio, we tested 2 diameter ratios (1.0 and 1.5) to simulate a uniform extracardiac conduit–inferior vena cava transition and an oversized conduit as would be required in younger children to allow for vessel growth, respectively. The pressure in each inlet and outlet vessel was measured by using side-hole fluid-filled catheters inserted through the respective vessel cannula. The total flow rate was measured by using a calibrated rotometer, and the flows in the inferior vena cava and the right pulmonary artery were determined with ultrasound flow probes placed loosely around each vessel wall (Transonic Systems, Utica, NY). For the approximation of the normal pulmonary vascular resistance, distal pulmonary artery resistances were set to achieve a 55%/45% pulmonary artery flow split, favoring the right pulmonary artery, and held constant throughout the study. Explanted preparations were perfused by means of a steady-flow pump at four flow indices (1-6 L/min/m2), with the inferior vena cava carrying 65% of the total venous return. The Reynolds number, which is a dimensionless quantity that characterizes the ratio of inertial to viscous forces in a flow field, ranged from approximately 200 to 3000 in the caval veins and pulmonary arteries. A rate of fluid-energy loss (power) analysis was performed for each model by using simultaneous measurement of pressure, flow, and velocity at each inlet and outlet of the right side of the heart, as described previously. 11
Flow models and surgical procedures
Intra-atrial lateral tunnel.
The intra-atrial lateral tunnel TCPC was constructed by the method described by de Leval and colleagues. 1 Briefly, the superior vena cava was transected and its proximal end connected directly to the superior aspect of the right pulmonary artery. The right atrium was then opened with an oblique incision, and an appropriately sized semicircular polytetrafluoroethylene tunnel was sutured into the right atrium such that the lateral wall of the atrium represented approximately one third of the total flow area. The distal end of the transected superior vena cava was then connected to the inferior aspect of the right pulmonary artery with the caval veins aligned (n = 6).
Extracardiac lateral tunnel.
The extracardiac lateral tunnel procedure is shown in Fig. 1, a. After the creation of an end-to-side bidirectional superior cavopulmonary anastomosis, the atrial end of the superior vena cava was oversewn and the inferior aspect of the right pulmonary artery was incised to create an appropriately sized opening. The posterior border of the opening was then anastomosed to the epicardial surface of the atrium at the level of the atrial appendage. The inferior vena cava was then divided close to the atrium, oversewn on the atrial side, and the posteromedial border of the inferior vena cava was attached to the anterolateral epicardial atrial surface. Finally, a polytetrafluoroethylene baffle was sutured to the anterior borders of the inferior and superior venae cavae and the lateral epicardial surface of the right atrium to divert inferior vena cava blood into the proximal right pulmonary artery. Thus, the lumen cross-section for flow consists of the epicardial surface of the right atrium and the anterolateral portion of the prosthetic tunnel. Suture lines are largely epicardial, although some full-thickness bites were necessary (n = 6).
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b. As described for the intra-atrial procedure, venous return from the upper extremities was diverted to the pulmonary arteries via a superior vena cava to superior right pulmonary artery end-to-side anastomosis. After the division of the inferior vena cava 2 cm proximal to its entrance to the right atrium, lower extremity venous return was diverted to the pulmonary arteries via a polytetrafluoroethylene conduit of uniform cross-section sutured end to side to the inferior aspect of the proximal right pulmonary artery. Two extracardiac conduit to inferior vena cava diameter ratios were created (1.0 and 1.5). A group of extracardiac conduit procedures were also created with a 5 mm extracardiac conduit offset toward the distal right pulmonary artery, as shown in Fig. 1, c (n = 6).
Rate of fluid-energy dissipation
To quantify the fluid-dynamic efficiency of each model, an analysis of the rate of fluid-energy dissipation was performed over a physiologic range of flow rates and conditions for each model. This analysis requires knowledge of pressure, flow, and velocity at the inlets and outlets of the right side of the heart and is especially useful because it includes all potential source of energy loss: static and kinetic energy losses caused by entrance and exit effects, and viscous dissipation losses caused by flow collision and mixing. The rate of fluid-energy dissipation analysis is simply a fluid-energy balance over the flow model. That is, the total fluid energy entering the model must equal the fluid energy leaving the model plus any incurred loss:
is the average velocity (in meters per second), and 
is the fluid density (in kilograms per cubic meter). Combining Equations 1 and 2, we arrive at an equation that represents the total energy loss occurring across each model:
E):
E < 100).
Statistical analysis.
Data on the rate of fluid-energy dissipation were compared for the intracardiac and extracardiac lateral tunnel and conduit procedures for equivalent flow conditions and were expressed as the mean ± SD of three consecutive measurements for each flow condition. Differences in the rate of fluid-energy dissipation between models and with flow index were determined by using 2-way ANOVA at a level of P < .05. Additionally, the effect of caval vein offset and conduit-inferior vena cava diameter ratio in the extracardiac conduit technique was determined by using a paired t test.
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Results |
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E for all procedures studied is shown in Fig. 3. The y-axis represents the ratio of the rate of fluid-energy dissipation divided by the total energy input into the model (as defined by Equation 4) for the specified model. At a flow index of 4 L/min/m2, the extracardiac conduit procedure with caval vein offset had the highest overall efficiency, followed by the extracardiac conduit without offset. The intra-atrial and extracardiac tunnel procedures were least efficient and comparable (P = .564), with each dissipating more than 15% of the total energy available to drive flow across the pulmonary vasculature. At a flow index of 6 L/min/m2, the efficiency coefficients decreased for each model, with the tunnel models dissipating 21% of the total energy compared with 16% for the extracardiac conduit and only 10% for the extracardiac conduit procedure with caval offset. The effect of the extracardiac conduit to inferior vena cava ratio on the rate of fluid-energy dissipation is shown in Fig. 4 for the extracardiac conduit procedure with no caval offset. At a flow index of 6 L/min/m2 , the 1.5 diameter ratio had slightly higher losses compared with the diameter ratio of 1.0 representing equal inferior vena cava and extracardiac conduit diameters (P = .032), although losses were still significantly less than those for the tunnel procedures.
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionConclusionsReferences |
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1 quickly gained popularity in the late 1980s and replaced the atriopulmonary anastomosis at many centers. While there has been ample in vitro data to confirm the hemodynamic advantage of the TCPC over atriopulmonary connection, 12-14 several serious complications observed in atriopulmonary connection still occur in patients with TCPC, including arrhythmias and thrombus formation. Recently, because of several theoretical and practical advantages, extracardiac procedures have been advocated for final stage conversion to the Fontan circulation. The extracardiac approach was first successfully implemented by Humes and associates 15 in a patient with complex heterotaxy, and it was subsequently implemented by Marcelletti and colleagues 16 in 4 patients with complex congenital heart disease and anomalies of venous return. More recently, early and intermediate-term efficacies of this approach in a larger group of patients have been reported. 17-19 To date, however, no studies have quantitatively characterized the flow dynamics of extracardiac Fontan procedures. This study compared the fluid dynamic efficiency of the intracardiac and the extracardiac total cavopulmonary procedures and offers insight into possible optimization of these procedures. Results from these experiments suggest that the extracardiac conduit procedure with caval vein offset provides the best overall performance of the TCPCs studied.
Etiology of fluid-energy losses.
The improvement in the fluid dynamic efficiency of the extracardiac conduit versus the tunnel may possibly be explained by the geometry of the tunnel cross-section and the inferior vena cava to pulmonary artery connection. Short-axis B-mode echocardiographic views of the intracardiac and extracardiac tunnel procedures demonstrated irregular non-circular cross-sections up to a flow index of 5 L/min/m2. Flow through such geometries results in asymmetric and flattened velocity profiles that are associated with increased frictional and pressure losses compared with Poiseuille flow in tubes of circular cross-section. 20 As conduit flow increased further, the transmural pressure was transmitted completely to the epicardial medial side of flow area (extracardiac tunnel) and the posterior lateral wall of the right atrium (intra-atrial tunnel), thus allowing the conduit to approach a more symmetric shape radially, although longitudinal irregularity remained. An additional factor that may help explain the lower energy requirements for the conduit, compared with the extracardiac tunnel procedure, is the convex curvature of the epicardial surface of the heart. Flow through curved vessels/channels results in increased fluid-energy losses because of the development of secondary flows, separation zones, and velocity profile skewing that leads to high shear stress gradients at the outer wall. 21 At the highest flow rate, the radius of curvature measured in the extracardiac tunnel tissue models would be expected to result in an additional efficiency loss of approximately 7% based on empirically derived relationships. 20 Finally, in all 3 configurations, the caval veins are aligned directly across from each other (the distance between inferior and superior vena cava centerlines is zero). Caval flow stream collision and interaction results in kinetic energy losses and viscous dissipation that decreases fluid dynamic efficiency. 7-10 Thus, the anatomic simplicity of achieving caval vein offset may represent a significant advantage of the extracardiac conduit technique.
In addition to the hemodynamic advantages demonstrated in these studies, the extracardiac approach has several important theoretical advantages over intra-atrial procedures, including reduced cardiopulmonary bypass time and elimination of intra-atrial suture lines, which have been shown to cause atrial dysarrhythmias in acute canine models. 22-23 Table I provides a summary of the advantages and the disadvantages for the intra-atrial tunnel, extracardiac tunnel, and extracardiac conduit procedures.
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24,25
Conversion of failing atriopulmonary connections.
Besides cardiac transplantation, there are few therapeutic options for symptomatic patients with failing atriopulmonary circulations. A recently proposed option for the management of these patients, however, is lateral tunnel cavopulmonary conversion. 19,26,27 The goal of this technique is to improve hemodynamic efficiency and cardiac output and reduce the occurrence of supraventricular arrhythmias and right atrial thrombus formation. However, in addition to lengthy cardiopulmonary bypass and aortic crossclamping times, which may be associated with significant mortality and morbidity in this group of very sick patients, this operation requires additional intra-atrial suture lines that may further exacerbate existing atrial conduction abnormalities. Results from these studies suggest that conversion to an extracardiac conduit may be a simpler and a more hemodynamically efficient alternative to intra-atrial lateral tunnel conversion.
Study limitations. While our in vitro experimental approach allowed us to reproduce the major physiologic parameters of the Fontan circulation, there are limitations worth noting. First, respiratory-induced alterations in pulmonary flow were not modeled. Although this is not expected to affect relative performance between procedures, it is possible that respiratory-induced pulsatility may affect absolute hydrodynamic efficiency for each model. Second, conduit velocity profiles were not measured directly. Compliant tissue models were used in these studies to reproduce the complex 3-dimensional geometry of the cavopulmonary junction that is routinely oversimplified in computational and in vitro models. The limitation of this approach, however, is that direct measurement of velocity profiles using quantitative methodology (eg, laser Doppler anemometry) is not possible because of the opaque nature of heart. Thus, we were forced to use theoretical rationale to explain the etiology of higher fluid-power losses in the tunnel compared with the conduit. Lastly, the model does not address changes in flow dynamics associated with the growth of the heart. In practice, longitudinal and radial tunnel/conduit growth is a concern for each of the procedures studied. Because models were constructed on subjects of equal body surface area and weight, the issue of growth-induced changes in tunnel/conduit and caval vein pulmonary artery junction geometry could not be quantified.
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Conclusions |
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References |
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TopAbstractIntroductionMethodsResultsDiscussionConclusionsReferences |
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