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Original research article
Effect of Fontan geometry on exercise haemodynamics and its potential implications
  1. Elaine Tang1,
  2. Zhenglun (Alan) Wei2,
  3. Kevin K Whitehead3,
  4. Reza H Khiabani2,
  5. Maria Restrepo2,
  6. Lucia Mirabella2,
  7. James Bethel4,
  8. Stephen M Paridon3,
  9. Bradley S Marino5,
  10. Mark A Fogel3,
  11. Ajit P Yoganathan1,2
  1. 1 School of Chemical and Biomolecular Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA
  2. 2 Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, Georgia, USA
  3. 3 Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
  4. 4 Westat Inc, Rockville, Maryland, USA
  5. 5 Division of Cardiology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
  1. Correspondence to Dr Ajit P Yoganathan, Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Technology Enterprise Park, Suite 200, 387 Technology Circle, Atlanta, GA 30313-2412, USA; ajit.yoganathan{at}


Objective Exercise intolerance afflicts Fontan patients with total cavopulmonary connections (TCPCs) causing a reduction in quality of life. Optimising TCPC design is hypothesised to have a beneficial effect on exercise capacity. This study investigates relationships between TCPC geometries and exercise haemodynamics and performance.

Methods This study included 47 patients who completed metabolic exercise stress test with cardiac magnetic resonance (CMR). Phase-contrast CMR images were acquired immediately following supine lower limb exercise. Both anatomies and exercise vessel flow rates at ventilatory anaerobic threshold (VAT) were extracted. The vascular modelling toolkits were used to analyse TCPC geometries. Computational simulations were performed to quantify TCPC indexed power loss (iPL) at VAT.

Results A highly significant inverse correlation was found between the TCPC diameter index, which factors in the narrowing of TCPC vessels, with iPL at VAT (r=−0.723, p<0.001) but positive correlations with exercise performance variables, including minute oxygen consumption (VO2) at VAT (r=0.373, p=0.01), VO2 at peak exercise (r=0.485, p=0.001) and work at VAT/weight (r=0.368, p=0.01). iPL at VAT was negatively correlated with VO2 at VAT (r=−0.337, p=0.02), VO2 at peak exercise (r=−0.394, p=0.007) and work at VAT/weight (r=−0.208, p=0.17).

Conclusions Eliminating vessel narrowing in TCPCs and reducing elevated iPL at VAT could enhance exercise tolerance for patients with TCPCs. These findings could help plan surgical or catheter-based strategies to improve patients’ exercise capacity.

  • congenital heart disease; Fontan procedure; exercise hemodynamics; computational fluid dynamics

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  • Contributors All authors were fully involved in the study design, data analysis and interpretation of results, preparation of the manuscript and final approval of the manuscript. All authors have approved the submitted manuscript.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Ethics approval The Institutional Review Boards at Georgia Institute of Technology and Children’s Hospital of Philadelphia.

  • Provenance and peer review Not commissioned; externally peer reviewed.