title: Individualized computer-based surgical planning to address pulmonary arteriovenous malformations in patients with a single ventricle with an interrupted inferior vena cava and azygous continuation.
abstract: OBJECTIVE
  Pulmonary arteriovenous malformations caused by abnormal hepatic flow distribution can develop in patients with a single ventricle with an interrupted inferior vena cava. However, preoperatively determining the hepatic baffle design that optimizes hepatic flow distribution is far from trivial. The current study combines virtual surgery and numeric simulations to identify potential surgical strategies for patients with an interrupted inferior vena cava.
  
  
  METHODS
  Five patients with an interrupted inferior vena cava and severe pulmonary arteriovenous malformations were enrolled. Their in vivo anatomies were reconstructed from magnetic resonance imaging (n = 4) and computed tomography (n = 1), and alternate virtual surgery options (intracardiac/extracardiac, Y-grafts, hepato-to-azygous shunts, and azygous-to-hepatic shunts) were generated for each. Hepatic flow distribution was assessed for all options using a fully validated computational flow solver.
  
  
  RESULTS
  For patients with a single superior vena cava (n = 3), intracardiac/extracardiac connections proved dangerous, because even a small left or right offset led to a highly preferential hepatic flow distribution to the associated lung. The best results were obtained with either a Y-graft spanning the Kawashima to split the flow or hepato-to-azygous shunts to promote mixing. For patients with bilateral superior vena cavae (n = 2), results depended on the balance between the left and right superior inflows. When those were equal, connecting the hepatic baffle between the superior vena cavae performed well, but other options should be pursued otherwise.
  
  
  CONCLUSIONS
  This study demonstrates how virtual surgery environments can benefit the clinical community, especially for patients with a single ventricle with an interrupted inferior vena cava. Furthermore, the sensitivity of the optimal baffle design to the superior inflows underscores the need to characterize both preoperative anatomy and flows to identify the best option.
authors.affiliation: Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, Ga 30332-0535, USA.
authors.forename: Diane A
authors.initials: DA
authors.lastname: de Zélicourt
authors.forename: Christopher M
authors.initials: CM
authors.lastname: Haggerty
authors.forename: Kartik S
authors.initials: KS
authors.lastname: Sundareswaran
authors.forename: Brian S
authors.initials: BS
authors.lastname: Whited
authors.forename: Jarek R
authors.initials: JR
authors.lastname: Rossignac
authors.forename: Kirk R
authors.initials: KR
authors.lastname: Kanter
authors.forename: J William
authors.initials: JW
authors.lastname: Gaynor
authors.forename: Thomas L
authors.initials: TL
authors.lastname: Spray
authors.forename: Fotis
authors.initials: F
authors.lastname: Sotiropoulos
authors.forename: Mark A
authors.initials: MA
authors.lastname: Fogel
authors.forename: Ajit P
authors.initials: AP
authors.lastname: Yoganathan
mesh_terms: D000015:Abnormalities, Multiple; D001165:Arteriovenous Malformations / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D001401:Azygos Vein / Q000002:abnormalities / Q000503:physiopathology / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D003198:Computer Simulation; D005260:Female; D018729:Fontan Procedure / Q000009:adverse effects; D006330:Heart Defects, Congenital / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D006352:Heart Ventricles / Q000002:abnormalities / Q000601:surgery*; D006439:Hemodynamics; D006801:Humans; D008102:Liver Circulation; D008279:Magnetic Resonance Imaging; D008297:Male; D009716:Numerical Analysis, Computer-Assisted; D011651:Pulmonary Artery / Q000002:abnormalities / Q000503:physiopathology / Q000601:surgery*; D011667:Pulmonary Veins / Q000002:abnormalities / Q000503:physiopathology / Q000601:surgery*; D012039:Regional Blood Flow; D018570:Risk Assessment; D025321:Surgery, Computer-Assisted; D014057:Tomography, X-Ray Computed; D014481:United States; D014682:Vena Cava, Inferior / Q000002:abnormalities / Q000503:physiopathology / Q000601:surgery*