Flow simulations and validation for the first cohort of patients undergoing the Y-graft Fontan procedure Weiguang Yang, PhD, Frandics P. Chan, MD, PhD,

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Flow simulations and validation for the first cohort of patients undergoing the Y-graft Fontan procedure Weiguang Yang, PhD, Frandics P. Chan, MD, PhD, V. Mohan Reddy, MD, Alison L. Marsden, PhD, Jeffrey A. Feinstein, MD, MPH The Journal of Thoracic and Cardiovascular Surgery Volume 149, Issue 1, Pages 247-255 (January 2015) DOI: 10.1016/j.jtcvs.2014.08.069 Copyright © 2015 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 Postoperative MRI/CT images and models. Because thrombus developed in the left limb in patient YF5, an unblocked Y-graft was reconstructed for study. LPA, Left pulmonary artery; RPA, right pulmonary artery. The Journal of Thoracic and Cardiovascular Surgery 2015 149, 247-255DOI: (10.1016/j.jtcvs.2014.08.069) Copyright © 2015 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 Hepatic flow distribution represented by percentage of inferior vena cava (IVC) flow to the right pulmonary artery (RPA) (IVC-RPA) and the left pulmonary artery (LPA) (IVC-LPA). A, Comparison between early postoperative simulation-derived HFD and lung perfusion data for patients YF1, YF2, and YF3. B, Changes in HFD from the early to 6-month postoperative stages derived from simulations. PFS, Pulmonary flow split. The Journal of Thoracic and Cardiovascular Surgery 2015 149, 247-255DOI: (10.1016/j.jtcvs.2014.08.069) Copyright © 2015 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 Time-averaged WSS magnitude for patients YF1, YF2, YF3, and YF5 in the early postoperative stage. YF5 R14-L10 and YF5 R12-L12 are 2 modified Y-graft designs for patient YF5. In the baseline model for patient YF5, a distal anastomosis for the left limb and a highly skewed pulmonary flow split resulted in a larger low WSS area in the left limb. In model R12-L12, WSS in the left limb was enhanced because of a proximal anastomosis that allowed SVC flow to wash the left limb. The Journal of Thoracic and Cardiovascular Surgery 2015 149, 247-255DOI: (10.1016/j.jtcvs.2014.08.069) Copyright © 2015 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 A, Percentage of low WSS area for 2 limbs in patients YF1, YF2, YF3, and YF5. For each threshold value τ (dynes/cm2), the low WSS area relative to each limb surface was computed. B, Percentage of low WSS area for the left limb in patient YF5's modified designs. In model R12-L12, the low WSS area in the left limb can be effectively minimized by using a proximal anastomosis in which the SVC jet impinged the wall and the impact of the SVC jet on the WSS was reduced with increasing LPA flow. The Journal of Thoracic and Cardiovascular Surgery 2015 149, 247-255DOI: (10.1016/j.jtcvs.2014.08.069) Copyright © 2015 The American Association for Thoracic Surgery Terms and Conditions

Figure 5 Velocity fields in the Y-graft for patient YF5 under 2 pulmonary flow splits. Flow stagnation is evident in the left limb under a pulmonary flow split of 81/19 that represents PAVMs in the right lung. In contrast, flow is increased and streamlined in the left limb under a pulmonary flow split of 54/45. PFS, Pulmonary flow split. The Journal of Thoracic and Cardiovascular Surgery 2015 149, 247-255DOI: (10.1016/j.jtcvs.2014.08.069) Copyright © 2015 The American Association for Thoracic Surgery Terms and Conditions