Abstract
Pulmonary arteriovenous malformations can occur after the Fontan procedure and are believed to be associated with disproportionate pulmonary distribution of hepatic venous effluent. We studied the effect of total cavopulmonary connection geometry and the effect of increased cardiac output on distribution of inferior vena caval return to the lungs. Ten patients undergoing the Fontan procedure, 5 with extracardiac and 5 with intracardiac configurations of the total cavopulmonary connection, previously analyzed for power loss were processed for calculating the distribution of inferior vena caval return to the lungs (second-order accuracy). One idealized total cavopulmonary connection was similarly analyzed under parametric variation of inferior vena caval offset and cardiac output flow split. Streaming of the inferior vena caval return in the idealized total cavopulmonary connection model was dependent on both inferior vena caval offset magnitude and cardiac output flow-split ratio. For patient-specific total cavopulmonary connections, preferential streaming of the inferior vena caval return was directly proportional to the cardiac output flow-split ratio in the intracardiac total cavopulmonary connections (P < .0001). Preferential streaming in extracardiac total cavopulmonary connections correlated to the inferior vena caval offset (P < .05) and did not correlate to cardiac output flow split. Enhanced mixing in intracardiac total cavopulmonary connections is speculated to explain the contrasting results. Exercising tends to reduce streaming toward the left pulmonary artery in intracardiac total cavopulmonary connections, whereas for extracardiac total cavopulmonary connections, exercising tends to equalize the streaming. Extracardiac and intracardiac total cavopulmonary connections have inherently different streaming characteristics because of contrasting mixing characteristics caused by their geometric differences. Pulmonary artery diameters and inferior vena caval offsets might together determine hepatic flow streaming.
Highlights
Pulmonary arteriovenous malformations (PAVMs), referred to as pulmonary arteriovenous fistulas (PAVFs) can occur after the Fontan procedure resulting in decreased systemic oxygenation
Streaming of the inferior vena caval (IVC) return in the idealized total cavo-pulmonary connection (TCPC) model was dependent on both IVC offset magnitude and cardiac output (CO) flow split ratio
For patient-specific TCPCs, preferential streaming of the IVC return was directly proportional to CO flow split ratio in the IC type TCPCs (p < 0.0001)
Summary
Pulmonary arteriovenous malformations (PAVMs), referred to as pulmonary arteriovenous fistulas (PAVFs) can occur after the Fontan procedure resulting in decreased systemic oxygenation. PAVMs have been postulated in the past to be secondary to disproportionate distribution of hepatic factors between the two lungs[1,2,3,4,5]. More recent studies confirmed that geometric configuration of the total cavopulmonary connection (TCPC) that preferentially stream hepatic vein (HV) flow to a single lung leads to PAVMs6. A recent study underscores the importance of geometric characteristics in a complex case of PAVMs7. Pulmonary arteriovenous malformations (PAVMs) can occur after the Fontan and are believed to be associated with disproportionate pulmonary distribution of hepatic venous effluent. We studied the impact of total cavo-pulmonary connection (TCPC) geometry and the effect of increased cardiac output (CO) on distribution of inferior vena caval (IVC) return to the lungs
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