Introduction of a New Optimized Total Cavopulmonary Connection

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Introduction of a New Optimized Total Cavopulmonary Connection Dennis D. Soerensen, MS, Kerem Pekkan, PhD, Diane de Zélicourt, MS, Shiva Sharma, MD, Kirk Kanter, MD, Mark Fogel, MD, Ajit P. Yoganathan, PhD The Annals of Thoracic Surgery Volume 83, Issue 6, Pages 2182-2190 (June 2007) DOI: 10.1016/j.athoracsur.2006.12.079 Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 The new idealized total cavopulmonary connection model design, code-named OptiFlo. (IVC = inferior vena cava; LPA = left pulmonary artery; RPA = right pulmonary artery; SVC = superior vena cava.) The Annals of Thoracic Surgery 2007 83, 2182-2190DOI: (10.1016/j.athoracsur.2006.12.079) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Power loss comparisons between the OptiFlo model (■) and flared planar one-diameter (1D) offset model (◊) at cardiac output of 4 L/minute, and with a 40:60 superior vena cava to inferior vena cava flow ratio. Both are rapid prototyping models with a 13.34-mm diameter. Error bars indicate one standard deviation. (RPA = right pulmonary artery.) The Annals of Thoracic Surgery 2007 83, 2182-2190DOI: (10.1016/j.athoracsur.2006.12.079) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Power loss versus right lung perfusion (%RPA [right pulmonary artery]) at increasing cardiac outputs (2, 4, and 6 L/minute [LPM]) for the OptiFlo (red squares) and one-diameter (1D) offset reference model (blue diamonds) at a 40:60 superior vena cava to inferior vena cava flow ratio. The physiological operating points for representative left and right lung resistances (Rleft and Rright) are shown with circles for both models at the three cardiac outputs (Rright=1.8 Woods Units). The Annals of Thoracic Surgery 2007 83, 2182-2190DOI: (10.1016/j.athoracsur.2006.12.079) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Flow through OptiFlo (right column) is compared with the one-diameter offset (left column) total cavopulmonary connection reference model using computational fluid dynamics simulations at a cardiac output of 4 L/minute 40:60 SVC/IVC flow ratio, and 40:60 LPA/RPA flow ratio. Three flow parameters are plotted along the midcoronal plane (that sliced both models along the coronal direction in half). (Top row, A and B) Through-plane velocity component; blue and red color tones represent flow going in and out of the page, respectively. (Middle row, C and D) Total velocity magnitudes, and (bottom row, E and F) viscous power dissipation (loss). The color coding is the same for each figure pair; A/B, C/D, and E/F, where blue color tones correspond to lower flow parameter values. Note the increasingly disturbed flow patterns and power loss hot spots of the one-diameter offset model compared with the OptiFlo. Arrows in panel A highlight the irregular pulmonary artery branch flows specific to the one-diameter offset model. Arrow in panel C indicates point of IVC stream collision. (Refer chapter on Three-Dimensional Flow Structures in text.) (IVC = inferior vena cava; LPA = left pulmonary artery; RPA = right pulmonary artery; SVC = superior vena cava.) The Annals of Thoracic Surgery 2007 83, 2182-2190DOI: (10.1016/j.athoracsur.2006.12.079) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Five steps in the creation of split-anastomosis of the native blood vessels. (A) Vessel-end to be split-anastomosed. (B) Bisection parallel to the vessel axis. (C) Configuration for end-to-side anastomosis to branch PA, used in inferior vena cava-only split design (Fig 6B); center-piece graft not shown here. (D) Configuration for end-to-end split anastomosis (as in Fig 1); center-piece graft not shown here. (E) After the center-piece graft (Fig 6) is sutured; center-piece graft shown partially. Anticipated suture lines are shown in (C) and (E). The Annals of Thoracic Surgery 2007 83, 2182-2190DOI: (10.1016/j.athoracsur.2006.12.079) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Fig 6 (A) Center-piece graft for the OptiFlo connection. (B) Alternative OptiFlo configuration with primarily IVC split. Insert illustrates an all-graft connection, where the middle part could feature a similar center-piece graft shape but now with a flatter SVC bifurcation section. (C) OptiFlo configuration for bilateral-SVC Fontan templates which utilizes a prefabricated Y-graft. (D) Alternative bilateral-SVC OptiFlo configuration with crossover SVCs. Limited feasibility, but will lead lower power loss due to increased caval-to-branch pulmonary artery pathway curvature. Anticipated suture lines are shown in (B) and (C). (IVC = inferior vena cava; L = left; LPA = left pulmonary artery; R = right; RPA = right pulmonary artery; SVC = superior vena cava.) The Annals of Thoracic Surgery 2007 83, 2182-2190DOI: (10.1016/j.athoracsur.2006.12.079) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions