An interactive simulation tool for patient-specific clinical decision support in single- ventricle physiology Timothy Conover, PhD, Anthony M. Hlavacek,

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An interactive simulation tool for patient-specific clinical decision support in single- ventricle physiology Timothy Conover, PhD, Anthony M. Hlavacek, MD, Francesco Migliavacca, PhD, Ethan Kung, PhD, Adam Dorfman, MD, Richard S. Figliola, PhD, Tain-Yen Hsia, MD, MSc Andrew Taylor, Sachin Khambadkone, Silvia Schievano, Marc de Leval, T.-Y. Hsia, Edward Bove, Adam Dorfman, G. Hamilton Baker, Anthony Hlavacek, Francesco Migliavacca, Giancarlo Pennati, Gabriele Dubini, Alison Marsden, Irene Vignon-Clementel, Richard Figliola, John McGregor Timothy Conover, PhD, Anthony M. Hlavacek, MD, Francesco Migliavacca, PhD, Ethan Kung, PhD, Adam Dorfman, MD, Richard S. Figliola, PhD, Tain-Yen Hsia, MD, MSc Andrew Taylor, Sachin Khambadkone, Silvia Schievano, Marc de Leval, T.-Y. Hsia, Edward Bove, Adam Dorfman, G. Hamilton Baker, Anthony Hlavacek, Francesco Migliavacca, Giancarlo Pennati, Gabriele Dubini, Alison Marsden, Irene Vignon-Clementel, Richard Figliola, John McGregor The Journal of Thoracic and Cardiovascular Surgery Volume 155, Issue 2, Pages 712-721 (February 2018) DOI: 10.1016/j.jtcvs.2017.09.046 Copyright © 2017 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 In Step 3, the user makes any patient-specific changes to the given default values of rest-state parameters, and clicks “Set Baseline” to run the simulation. BSA, Body surface area; HR, heart rate; MAP, mean arterial pressure; SAP, single-atrium pressure; PVRI, indexed pulmonary vascular resistance; SVRI, indexed systemic vascular resistance. The Journal of Thoracic and Cardiovascular Surgery 2018 155, 712-721DOI: (10.1016/j.jtcvs.2017.09.046) Copyright © 2017 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 The results of the baseline and modified simulations are displayed in a table, along with the appropriate heart diagram. Clicking on any of the labels in the heart sketch displays a plot of pressure or flow. In this example, the circulation has been changed from mBT (Baseline) to Stage 2 superior cavopulmonary connection (Modified). Note that there is a decrease in the COI and Qp:Qs, but an increase in the systemic oxygen saturation and indexed oxygen delivery. Aorta, atrium, and pulmonary artery parameters: systolic/diastolic/mean pressures/oxygen saturation. Ventricle parameter: systolic/end-diastolic pressures/oxygen saturation. SVC and IVC parameters: flow in L/min and oxygen saturation. COI, Cardiac output index; Qp:Qs, pulmonary to systemic flow ratio; SVC, superior vena cava; PAP, pulmonary arterial pressure; IVC, inferior vena cava. The Journal of Thoracic and Cardiovascular Surgery 2018 155, 712-721DOI: (10.1016/j.jtcvs.2017.09.046) Copyright © 2017 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 Example of plots resulting from the baseline and modified runs. The ventricular pressure–volume loops in the upper left plot show the expected changes with change from mBTS (Baseline) to Stage 2 (Modified) circulation. The upper right plot shows the aortic pressure, and the lower plot is the atrial pressure. The Journal of Thoracic and Cardiovascular Surgery 2018 155, 712-721DOI: (10.1016/j.jtcvs.2017.09.046) Copyright © 2017 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 Schematics of the lumped parameter network models for each stage of single-ventricle physiology. A, Stage 1 circulation with modified Blalock-Taussig shunt. B, Stage 2 Glenn circulation model. C, Fontan circulation model. The Journal of Thoracic and Cardiovascular Surgery 2018 155, 712-721DOI: (10.1016/j.jtcvs.2017.09.046) Copyright © 2017 The American Association for Thoracic Surgery Terms and Conditions

Figure 5 Linear regression analyses for catheterization and model output variables. Qp:Qs, Pulmonary to systemic flow ratio; mPAp, mean pulmonary artery pressure; SaO2–SvO2, difference between arterial saturation and venous saturation. The Journal of Thoracic and Cardiovascular Surgery 2018 155, 712-721DOI: (10.1016/j.jtcvs.2017.09.046) Copyright © 2017 The American Association for Thoracic Surgery Terms and Conditions

Figure 6 Bland–Altman analyses for catheterization and model output variables. The vertical axis is the difference between the catheterization result and the model prediction, and the horizontal axis is the catheterization result. Qp:Qs, Pulmonary to systemic flow ratio; mPAp, mean pulmonary artery pressure; SaO2–SvO2, difference between arterial saturation and venous saturation. The Journal of Thoracic and Cardiovascular Surgery 2018 155, 712-721DOI: (10.1016/j.jtcvs.2017.09.046) Copyright © 2017 The American Association for Thoracic Surgery Terms and Conditions

Icon for the iOS app. The Journal of Thoracic and Cardiovascular Surgery 2018 155, 712-721DOI: (10.1016/j.jtcvs.2017.09.046) Copyright © 2017 The American Association for Thoracic Surgery Terms and Conditions

Video 1 Example of using the simulation application: A video walk-through. Video available at: http://www.jtcvsonline.org/article/S0022-5223(17)31963-3/fulltext. The Journal of Thoracic and Cardiovascular Surgery 2018 155, 712-721DOI: (10.1016/j.jtcvs.2017.09.046) Copyright © 2017 The American Association for Thoracic Surgery Terms and Conditions