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Relationship of cerebral blood flow to aortic-to-pulmonary collateral/shunt flow in single ventricles
  1. Mark A Fogel1,2,
  2. Christine Li1,
  3. Felice Wilson1,
  4. Tom Pawlowski1,
  5. Susan C Nicolson3,
  6. Lisa M Montenegro3,
  7. Laura Diaz Berenstein3,
  8. Thomas L Spray4,
  9. J William Gaynor4,
  10. Stephanie Fuller4,
  11. Marc S Keller2,
  12. Matthew A Harris1,2,
  13. Kevin K Whitehead1,2,
  14. Robert Clancy5,
  15. Okan Elci6,
  16. Jim Bethel6,
  17. Arastoo Vossough2,
  18. Daniel J Licht5
  1. 1Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
  2. 2Department of Radiology, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
  3. 3Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
  4. 4Division of Cardiothoracic Surgery, Department of Surgery, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
  5. 5Department of Neurology, The Children's Hospital of Philadelphia/The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
  6. 6Westat, Rockville, Maryland, USA
  1. Correspondence to Dr Mark A Fogel, Division of Cardiology, The Children's Hospital of Philadelphia, 34th Street and Civic Center Blvd, Philadelphia, Pennsylvania, PA 19104, USA; fogel{at}email.chop.edu

Abstract

Objective Patients with single ventricle can develop aortic-to-pulmonary collaterals (APCs). Along with systemic-to-pulmonary artery shunts, these structures represent a direct pathway from systemic to pulmonary circulations, and may limit cerebral blood flow (CBF). This study investigated the relationship between CBF and APC flow on room air and in hypercarbia, which increases CBF in patients with single ventricle.

Methods 106 consecutive patients with single ventricle underwent 118 cardiac magnetic resonance (CMR) scans in this cross-sectional study; 34 prior to bidirectional Glenn (BDG) (0.50±0.30 years old), 50 prior to Fontan (3.19±1.03 years old) and 34 3–9 months after Fontan (3.98±1.39 years old). Velocity mapping measured flows in the aorta, cavae and jugular veins. Analysis of variance (ANOVA) and multiple linear regression were used. Significance was p<0.05.

Results A strong inverse correlation was noted between CBF and APC/shunt both on room air and with hypercarbia whether CBF was indexed to aortic flow or body surface area, independent of age, cardiopulmonary bypass time, Po2 and Pco2 (R=−0.67–−0.70 for all patients on room air, p<0.01 and R=−0.49–−0.90 in hypercarbia, p<0.01). Correlations were not different between surgical stages. CBF was lower, and APCs/shunt flow was higher prior to BDG than in other stages.

Conclusions There is a strong inverse relationship between CBF and APC/shunt flow in patients with single ventricle throughout surgical reconstruction on room air and in hypercarbia independent of other factors. We speculate that APC/shunt flow may have a negative impact on cerebral development and neurodevelopmental outcome. Interventions on APC may modify CBF, holding out the prospect for improving neurodevelopmental trajectory.

Trial Registration Number NCT02135081.

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