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Effect of mechanical assistance of the systemic ventricle in single ventricle circulation with cavopulmonary connection

Published:January 06, 2014DOI:https://doi.org/10.1016/j.jtcvs.2013.12.018

      Background

      Previous attempts to support single ventricle circulation mechanically have suggested that a custom-built assist device is needed to push, rather than pull, through the pulmonary circulation. We hypothesized that using a conventional ventricular assist device, with or without conversion of a total cavopulmonary connection to a bidirectional Glenn cavopulmonary connection, would allow assistance by pulling blood through the circuit and improve the cardiac index (CI).

      Methods

      Cavopulmonary connections were established in each of 5 Yorkshire pigs (25 kg) using ePTFE conduits in a Y configuration with appropriate clamping of the limbs of the Y to achieve a total cavopulmonary Fontan connection (TCPC), superior vena cava cavopulmonary connection (SVC Glenn), and inferior vena cava cavopulmonary connection (IVC Glenn). A common atrium had been established previously by balloon septostomy. Mechanical circulatory assistance of the single systemic ventricle was achieved using a centrifugal pump with common atrial inflow and proximal ascending aortic outflow. The CI was calculated using an ultrasonic flow meter placed on the distal ascending aorta and compared between the assisted and nonassisted circulation for 3 conditions: TCPC, SVC Glenn, and IVC Glenn. The mean pulmonary artery pressure, common atrial pressure, arterial oxygen saturation, partial pressure of arterial oxygen, and oxygen delivery were calculated.

      Results

      The unassisted SVC Glenn CI tended to be greater than the TCPC or IVC Glenn CI. Significant augmentation of total CI was achieved with mechanical assistance for SVC Glenn (109% ± 24%, P = .04) and TCPC (130% ± 109%, P = .01). The assisted CI achieved at least a mean baseline biventricular CI for all 3 support modes. Oxygen delivery was greatest for assisted SVC Glenn (1786 ± 1307 mL/L/min) and lowest for TCPC (1146 ± 386 mL/L/min), with a trend toward lower common atrial and pulmonary artery pressures for SVC Glenn.

      Conclusions

      SVC bidirectional Glenn circulation might allow optimal augmentation of the CI and oxygen delivery in a failing single ventricle using a conventional pediatric ventricular assist device. The results from our model also suggest that the Fontan circulation itself can be supported with systemic ventricular assistance of the single ventricle.

      CTSNet classification

      Abbreviations and Acronyms:

      CI (cardiac index), IVC (inferior vena cava), IVC Glenn (IVC cavopulmonary connection), MPA (main pulmonary artery), PAP (pulmonary artery pressure), SVC (superior vena cava), SVC Glenn (SVC cavopulmonary connection), TCPC (total cavopulmonary Fontan connection), VAD (ventricular assist device)
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      References

        • Kirklin J.K.
        • Naftel D.C.
        • Pagani F.D.
        • Kormos R.L.
        • Stevenson L.
        • Miller M.
        • et al.
        Long-term mechanical circulatory support (destination therapy): on track to compete with heart transplantation?.
        J Thorac Cardiovasc Surg. 2012; 144 (discussion 597-88): 584-603
        • Park S.J.
        • Milano C.A.
        • Tatooles A.J.
        • Rogers J.G.
        • Adamson R.M.
        • Steidley D.E.
        • et al.
        Outcomes in advanced heart failure patients with left ventricular assist devices for destination therapy: clinical perspective.
        Circulation. 2012; 5: 241-248
        • Rodefeld M.D.
        • Coats B.
        • Fisher T.
        • Giridharan G.A.
        • Chen J.
        • Brown J.W.
        • et al.
        Cavopulmonary assist for the univentricular Fontan circulation: von Karman viscous impeller pump.
        J Thorac Cardiovasc Surg. 2010; 140: 529-536
        • Throckmorton A.L.
        • Kapadia J.Y.
        • Chopski S.G.
        • Bhavsar S.S.
        • Moskowitz W.B.
        • Gullquist S.D.
        • et al.
        Numerical, hydraulic, and hemolytic evaluation of an intravascular axial flow blood pump to mechanically support Fontan patients.
        Ann Biomed Eng. 2011; 39: 324-336
        • Wang D.
        • Plunkett M.
        • Lynch J.
        • Zhou X.
        • Ballard-Croft C.
        • Zwischenberger J.B.
        Wang-Zwische double-lumen cannula leads to total cavopulmonary support in a failing Fontan sheep model.
        Ann Thorac Surg. 2011; 91: 1956-1960
        • Anderson P.A.W.
        • Sleeper L.A.
        • Mahony L.
        • Colan S.D.
        • Atz A.M.
        • Breitbart R.E.
        • et al.
        Contemporary outcomes after the Fontan procedure: a Pediatric Heart Network multicenter study.
        J Am Coll Cardiol. 2008; 52: 85-98
        • Khairy P.
        • Fernandes S.M.
        • Mayer Jr., J.E.
        • Triedman J.K.
        • Walsh E.P.
        • Lock J.E.
        • et al.
        Long-term survival, modes of death, and predictors of mortality in patients with Fontan surgery.
        Circulation. 2008; 117: 85-92
        • Paridon S.M.
        • Mitchell P.D.
        • Colan S.D.
        • Williams R.V.
        • Blaufox A.
        • Li J.S.
        • et al.
        A cross-sectional study of exercise performance during the first 2 decades of life after the Fontan operation.
        J Am Coll Cardiol. 2008; 52: 99-107
        • Diller G.-P.
        • Giardini A.
        • Dimopoulos K.
        • Gargiulo G.
        • Müller J.
        • Derrick G.
        • et al.
        Predictors of morbidity and mortality in contemporary Fontan patients: results from a multicenter study including cardiopulmonary exercise testing in 321 patients.
        Eur Heart J. 2010; 31: 3073-3083
        • Pretre R.
        • Haussler A.
        • Bettex D.
        • Genoni M.
        Right-sided univentricular cardiac assistance in a failing Fontan circulation.
        Ann Thorac Surg. 2008; 86: 1018-1020
        • Lacour-Gayet F.G.
        • Lanning C.J.
        • Stoica S.
        • Wang R.
        • Rech B.A.
        • Goldberg S.
        • et al.
        An artificial right ventricle for failing Fontan: in vitro and computational study.
        Ann Thorac Surg. 2009; 88: 170-176
        • Durham L.A.
        • Dearani J.A.
        • Burkhart H.M.
        • Joyce L.D.
        • Cetta F.
        • Cabalka A.K.
        • et al.
        Application of computer modeling in systemic VAD support of failing Fontan physiology.
        World J Pediatr Congenit Heart Surg. 2011; 2: 243-248
        • Myers C.D.
        • Boyd J.H.
        • Presson Jr., R.G.
        • Vijay P.
        • Coats A.C.
        • Brown J.W.
        • et al.
        Neonatal cavopulmonary assist: pulsatile versus steady-flow pulmonary perfusion.
        Ann Thorac Surg. 2006; 81: 257-263
        • Myers C.D.
        • Mattix K.
        • Presson Jr., R.G.
        • Vijay P.
        • Maynes D.
        • Litwak K.N.
        • et al.
        Twenty-four hour cardiopulmonary stability in a model of assisted newborn Fontan circulation.
        Ann Thorac Surg. 2006; 81 (discussion 270, 261): 264-270
        • Rodefeld M.D.
        • Frankel S.H.
        • Giridharan G.A.
        Cavopulmonary assist: (em)powering the univentricular Fontan circulation.
        Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2011; 14: 45-54
        • Cardarelli M.G.
        • Salim M.
        • Love J.
        • Simone S.
        • Tumulty J.
        • Conway D.
        • et al.
        Berlin heart as a bridge to recovery for a failing Fontan.
        Ann Thorac Surg. 2009; 87: 943-946
        • Chu M.W.A.
        • Sharma K.
        • Tchervenkov C.I.
        • Jutras L.F.
        • Lavoie J.
        • Shemie S.D.
        • et al.
        Berlin heart ventricular assist device in a child with hypoplastic left heart syndrome.
        Ann Thorac Surg. 2007; 83: 1179-1181
        • Frazier O.H.
        • Gregoric I.D.
        • Messner G.N.
        Total circulatory support with an LVAD in an adolescent with a previous Fontan procedure.
        Tex Heart Inst J. 2005; 32: 402-404
        • Morales D.L.S.
        • Adachi I.
        • Heinle J.S.
        • Fraser Jr., C.D.
        A new era: use of an intracorporeal systemic ventricular assist device to support a patient with a failing Fontan circulation.
        J Thorac Cardiovasc Surg. 2011; 142: e138-e140
        • Nathan M.
        • Baird C.
        • Fynn-Thompson F.
        • Almond C.
        • Thiagarajan R.
        • Laussen P.
        • et al.
        Successful implantation of a Berlin heart biventricular assist device in a failing single ventricle.
        J Thorac Cardiovasc Surg. 2006; 131: 1407-1408
        • Pearce F.B.
        • Kirklin J.K.
        • Holman W.L.
        • Barrett C.S.
        • Romp R.L.
        • Lau Y.R.
        Successful cardiac transplant after Berlin heart bridge in a single ventricle heart: use of aortopulmonary shunt as a supplementary source of pulmonary blood flow.
        J Thorac Cardiovasc Surg. 2009; 137: e40-e42
        • VanderPluym C.J.
        • Rebeyka I.M.
        • Ross D.B.
        • Buchholz H.
        The use of ventricular assist devices in pediatric patients with univentricular hearts.
        J Thorac Cardiovasc Surg. 2011; 141: 588-590