Simulation of aortopulmonary collateral flow in Fontan patients for use in prediction of interventional outcomes.

Abstract

Patients with complex congenital heart disease may need to be converted to a Fontan circulation with systemic venous return surgically connected to the pulmonary circulation. These patients frequently form aortopulmonary collaterals (APC), that is arterial inflows to the pulmonary artery vascular tree. The aim of this study was to develop a method to calculate the effect of APC on the pulmonary flow distribution based on magnetic resonance imaging (MRI) measurements and computational fluid dynamics simulations in order to enable prediction of interventional outcomes in Fontan patients. Patient-specific models of 11 patients were constructed in a 3D-design software based on MRI segmentations. APC flow was quantified as the difference between pulmonary venous flow and pulmonary artery flow, measured by MRI. A method was developed to include the modulating effect of the APC flow by calculating the patient-specific relative pulmonary vascular resistance. Simulations, including interventions with a Y-graft replacement and a stent dilatation, were validated against MRI results. The bias between simulated and MRI-measured fraction of blood to the left lung was 2·9±5·3%. Including the effects of the APC flow in the simulation (n=6) reduced simulation error from 9·8±7·0% to 5·2±6·3%. Preliminary findings in two patients show that the effect of surgical and catheter interventions could be predicted using the demonstrated methods. The work demonstrates a novel method to include APC flow in predictive simulations of Fontan hemodynamics. APC flow was found to have a significant contribution to the pulmonary flow distribution in Fontan patients.