title: Cavopulmonary assist for the failing Fontan circulation: impact of ventricular function on mechanical support strategy.
abstract: Mechanical circulatory support--either ventricular assist device (VAD, left-sided systemic support) or cavopulmonary assist device (CPAD, right-sided support)--has been suggested as treatment for Fontan failure. The selection of left- versus right-sided support for failing Fontan has not been previously defined. Computer simulation and mock circulation models of pediatric Fontan patients (15-25 kg) with diastolic, systolic, and combined systolic and diastolic dysfunction were developed. The global circulatory response to assisted Fontan flow using VAD (HeartWare HVAD, Miami Lakes, FL) support, CPAD (Viscous Impeller Pump, Indianapolis, IN) support, and combined VAD and CPAD support was evaluated. Cavopulmonary assist improves failing Fontan circulation during diastolic dysfunction but preserved systolic function. In the presence of systolic dysfunction and elevated ventricular end-diastolic pressure (VEDP), VAD support augments cardiac output and diminishes VEDP, while increased preload with cavopulmonary assist may worsen circulatory status. Fontan circulation can be stabilized to biventricular values with modest cavopulmonary assist during diastolic dysfunction. Systemic VAD support may be preferable to maintain systemic output during systolic dysfunction. Both systemic and cavopulmonary support may provide best outcome during combined systolic and diastolic dysfunction. These findings may be useful to guide clinical cavopulmonary assist strategies in failing Fontan circulations.
authors.affiliation: From the *Department of Bioengineering, University of Louisville, Louisville, Kentucky; †School of Medicine, University of Louisville, Louisville, Kentucky; ‡Department of Thoracic and Cardiovascular Surgery, University of Louisville, Louisville, Kentucky; §College of Mechanical Engineering, Purdue University, West Lafayette, Indiana; and ¶Section of Cardiothoracic Surgery, Indiana University School of Medicine, James Whitcomb Riley Hospital for Children, Indianapolis, Indiana.
authors.forename: Guruprasad A
authors.initials: GA
authors.lastname: Giridharan
authors.forename: Mickey
authors.initials: M
authors.lastname: Ising
authors.forename: Michael A
authors.initials: MA
authors.lastname: Sobieski
authors.forename: Steven C
authors.initials: SC
authors.lastname: Koenig
authors.forename: Jun
authors.initials: J
authors.lastname: Chen
authors.forename: Steven
authors.initials: S
authors.lastname: Frankel
authors.forename: Mark D
authors.initials: MD
authors.lastname: Rodefeld
mesh_terms: D000465:Algorithms; D001698:Biomedical Engineering; D002648:Child; D003198:Computer Simulation; D003971:Diastole; D018729:Fontan Procedure / Q000009:adverse effects*; D018610:Heart Bypass, Right; D006330:Heart Defects, Congenital / Q000503:physiopathology / Q000601:surgery*; D006352:Heart Ventricles / Q000002:abnormalities* / Q000503:physiopathology / Q000601:surgery; D006353:Heart-Assist Devices; D006439:Hemodynamics; D006801:Humans; D008955:Models, Cardiovascular; D011652:Pulmonary Circulation; D013599:Systole; D017211:Treatment Failure