Pathogenetic mechanisms of venous congestion after the Fontan procedure

Buchhorn, Reiner; Bartmus, D.; Buhre, W.; Bürsch, J. H.

doi:10.1017/s1047951101000051

Cited by 22 publications

(12 citation statements)

References 19 publications

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“…Conceptually, at the level of the heart, systemic and pulmonary venous flows are separated and a single ventricle provides the pumping function. However, the sustainability of this situation over a lifetime after surgery has been a source of intense speculation and research 2-15, 16, 28, 29. The question why some patients remain symptom free in the face of such abnormal circulatory physiology whilst others become edematous, develop protein losing enteropathy and succumb early to cardiac failure (failed Fontan) remains unclear but is of paramount importance for patient health 2-14,16…”

Section: Discussionmentioning

confidence: 99%

“…For example, venous compliance and function changes may produce increased microvascular filtration resulting in edema and extravascular fluid collection often found in “failed-Fontan” patients 13-15. Although this is most easily evident in dependent extremities, we hypothesize that vascular properties are also abnormal within the splanchnic vasculature with more important circulatory consequences because the splanchnic compartment is the single largest venous reservoir.…”

Section: Introductionmentioning

confidence: 89%

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Peripheral Vascular Adaptation and Orthostatic Tolerance in Fontan Physiology

et al. 2009

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Background-The Fontan circulation is critically dependent on elevated venous pressures to sustain effective venous return. We hypothesized that chronically increased systemic venous pressures lead to adaptive changes in regional and peripheral vessels to maintain cardiac output, especially when patients are upright. Methods and Results-Nine post-Fontan procedure patients (aged 13 to 24 years) and 6 age-and sex-matched controls were compared with techniques to measure circulatory responses (peripheral and compartmental blood flow, venous capacity, and microvascular filtration). Parameters studied included strain-gauge plethysmography measures of peripheral circulatory function, regional blood volume distribution by impedance plethysmography, and head-up tilt testing. Important differences between Fontan patients and controls were seen in several vascular compartments: (1) Calf capacitance was lower (median, 3.5 versus 5.5 mL/100 mL tissue; Pϭ0.005), and resting venous pressure was higher (13.0 versus 10.5 mm Hg; Pϭ0.004); (2) higher leg arterial resistance was observed (32.1 versus 22.2; Pϭ0.03); (3) microvascular filtration pressures and threshold for edema were elevated; and (4)

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 89%

Peripheral Vascular Adaptation and Orthostatic Tolerance in Fontan Physiology

et al. 2009

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“…3,4 One of the proposed mechanisms of pleural effusion and chylothorax in the Fontan physiology is the increase in hydrostatic capillary pressure, resulting in excessive filtration in the interstitial space and overwhelming drainage into the lymphatic system. 5 A large multicenter study showed that chylothorax is associated with longer hospital stay, higher in-hospital mortality, and higher cost in children who underwent various types of congenital heart surgeries. 6 In that study, the Fontan operation had the highest incidence of associated chylothorax, but a detailed subanalysis of the patients who underwent the Fontan operation was not performed.…”

Section: See Editorial Commentary Page 2078mentioning

confidence: 99%

Chylothorax and pleural effusion in contemporary extracardiac fenestrated fontan completion

Rito

Al‐Radi

Saedi

et al. 2018

The Journal of Thoracic and Cardiovascular Surgery

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“…The physiological Fontan was also predicted, with 95% statistical confidence, to lower the IVC pressure compared to the conventional Fontan. The certainty in the direction of change of the IVC pressure is of prime importance, since high blood pressure has a strong causation link to liver and kidney failure in patients with Fontan circulation in the 20–30 years age group (43, 47, 50, 51, 60, 62, 64, 67, 69). The authors have used an idealized model for this comparative analysis, therefore the magnitude of the IVC pressure change is comparatively less significant, as this is dependent on the specific vascular geometry of the subject that is not rendered by the generalized geometry used in this work.…”

Section: Discussionmentioning

confidence: 99%

Physiological Fontan Procedure

et al. 2019

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Objective: The conventional Fontan circulation deviates the superior vena cava (SVC = 1/3 of the systemic venous return) toward the right lung (3/5 of total lung volume) and the inferior vena cava (IVC = 2/3 of the systemic venous return) toward the left lung (2/5 of total lung volume). A “physiological” Fontan deviating the SVC toward the left lung and the IVC toward the right lung was compared with the conventional setting by computational fluid dynamics, studying whether this setting achieves a more favorable hemodynamics than the conventional Fontan circulation. Materials and Methods: An in-silico 3D parametric model of the Fontan procedure was developed using idealized vascular geometries with invariant sizes of SVC, IVC, right pulmonary artery (RPA), and left pulmonary artery (LPA), steady inflow velocities at IVC and SVC, and constant equal outflow pressures at RPA and LPA. These parameters were set to perform finite-volume incompressible steady flow simulations, assuming a single-phase, Newtonian, isothermal, laminar blood flow. Numerically converged finite-volume mass and momentum flow balances determined the inlet pressures and the outflow rates. Numerical closed-path integration of energy fluxes across domain boundaries determined the flow energy loss rate through the Fontan circulation. The comparison evaluated: (1) mean IVC pressure; (2) energy loss rate; (3) kinetic energy maximum value throughout the domain volume. Results: The comparison of the physiological vs. conventional Fontan provided these results: (1) mean IVC pressure 13.9 vs. 14.1 mmHg (= 0.2 mmHg reduction); (2) energy loss rate 5.55 vs. 6.61 mW (= 16% reduction); (3) maximum kinetic energy 283 vs. 396 J/m 3 (= 29% reduction). Conclusions: A more physiological flow distribution is accompanied by a reduction of mean IVC pressure and by substantial reductions of energy loss rate and of peak kinetic energy. The potential clinical impact of these hemodynamic changes in reducing the incidence and severity of the adverse long-term effects of the Fontan circulation, in particular liver failure and protein-losing enteropathy, still remains to be assessed and will be the subject of future work.

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Pathogenetic mechanisms of venous congestion after the Fontan procedure

Cited by 22 publications

References 19 publications

Peripheral Vascular Adaptation and Orthostatic Tolerance in Fontan Physiology

Peripheral Vascular Adaptation and Orthostatic Tolerance in Fontan Physiology

Chylothorax and pleural effusion in contemporary extracardiac fenestrated fontan completion

Physiological Fontan Procedure

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