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(Circulation. 2007;116:I-165 – I-171.)
© 2007 American Heart Association, Inc.

Surgery for Congenital Heart Disease

Nonlinear Power Loss During Exercise in Single-Ventricle Patients After the Fontan

Insights From Computational Fluid Dynamics

Kevin K. Whitehead, MD, PhD; Kerem Pekkan, PhD; Hiroumi D. Kitajima, MS; Stephen M. Paridon, MD; Ajit P. Yoganathan, PhD; Mark A. Fogel, MD

From the Division of Cardiology (K.K.W., S.M.P., M.A.F.), Children’s Hospital of Philadelphia, Philadelphia, Pa; the Cardiovascular Fluid Mechanics Laboratory, Wallace H. Coulter Department of Biomedical Engineering (H.D.K., A.P.Y.), Georgia Institute of Technology, Atlanta, Ga; the Biomedical Engineering Department (K.P.), Carnegie Mellon University, Pittsburgh, Pa.

Correspondence to Kevin K. Whitehead, MD, PhD, Children’s Hospital of Philadelphia, Cardiology, Main Hospital, 2^nd Floor, 34^th and Civic Center Blvd, Philadelphia, PA 19104. E-mail whiteheadk{at}email.chop.edu

Background— We previously demonstrated that power loss (PL) through the total cavopulmonary connection (TCPC) in single-ventricle patients undergoing Fontan can be calculated by computational fluid dynamic analysis using 3-dimensional MRI anatomic reconstructions. PL through the TCPC may play a role in single-ventricle physiology and is a function of cardiac output. We hypothesized that PL through the TCPC increases significantly under exercise flow conditions.

Methods and Results— MRI data of 10 patients with a TCPC were analyzed to obtain 3-dimensional geometry and flow rates through the superior vena cava, inferior vena cava, left pulmonary artery, and right pulmonary artery. Steady computational fluid dynamic simulations were performed at baseline conditions using MRI-derived flows. Simulated exercise conditions of twice (2x) and three times (3x) baseline flow were performed by increasing inferior vena cava flow. PL, head loss, and effective resistance through the TCPC were calculated for each condition. Each condition was repeated at left pulmonary artery/right pulmonary artery ratios of 30/70 and 70/30 to determine the effects of pulmonary flow splits on exercise PL. For each patient, PL increases dramatically in a nonlinear fashion with increasing cardiac output, even when normalized to calculate head loss or resistance. Flow splits had a significant effect on PL at exercise, with most geometries favoring right pulmonary artery flow.

Conclusions— The relationship between cardiac output and PL is nonlinear and highly dependent on TCPC geometry and pulmonary flow splits. This study demonstrates the importance of studying the TCPC under exercise conditions, because baseline conditions may not adequately characterize TCPC efficiency.

Key Words: blood flow • computational fluid dynamics • exercise • Fontan procedure • hemodynamics • magnetic resonance imaging