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Angiographic Anatomy of Major Aortopulmonary Collateral Arteries and Association With Early Surgical Outcomes in Tetralogy of Fallot.

ABSTRACT: Background Due in part to the heterogeneity of the pulmonary circulation in patients with tetralogy of Fallot and major aortopulmonary collateral arteries (MAPCAs), research on this condition has focused on relatively basic anatomic characteristics. We aimed to detail pulmonary artery (PA) and MAPCA anatomy in a large group of infants, assess relationships between anatomy and early surgical outcomes, and consider systems for classifying MAPCAs. Methods and Results All infants ( <1 year of age) undergoing first cardiac surgery for tetralogy of Fallot/MAPCAs from 2001 to 2019 at Stanford University were identified. Preoperative angiograms delineating supply to all 18 pulmonary segments were reviewed for details of each MAPCA and the arborization and size of central PAs. We studied 276 patients with 1068 MAPCAs and the following PA patterns: 152 (55%) incompletely arborizing PAs, 48 (17%) normally arborizing PAs, 45 (16%) absent PAs, and 31 (11%) unilateral MAPCAs. There was extensive anatomic variability, but no difference in early outcomes according to PA arborization or the predominance of PAs or MAPCAs. Patients with low total MAPCA and/or PA cross-sectional area were less likely to undergo complete repair. Conclusions MAPCA anatomy is highly variable and essentially unique for each patient. Though each pulmonary segment can be supplied by a MAPCA, central PA, or both, all anatomic combinations are similarly conducive to a good repair. Total cross-sectional area of central PA and MAPCA material is an important driver of outcome. We elucidate a number of novel associations between anatomic features, but the extreme variability of the pulmonary circulation makes a granular tetralogy of Fallot/MAPCA classification system unrealistic.

SUBMITTER: Adamson GT

PROVIDER: S-EPMC7955371 | biostudies-literature | 2020 Dec

REPOSITORIES: biostudies-literature

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Angiographic Anatomy of Major Aortopulmonary Collateral Arteries and Association With Early Surgical Outcomes in Tetralogy of Fallot.

Adamson Gregory T GT McElhinney Doff B DB Zhang Yulin Y Feinstein Jeffrey A JA Peng Lynn F LF Ma Michael M Algaze Claudia A CA Hanley Frank L FL Perry Stanton B SB

Journal of the American Heart Association 20201205 24

Background Due in part to the heterogeneity of the pulmonary circulation in patients with tetralogy of Fallot and major aortopulmonary collateral arteries (MAPCAs), research on this condition has focused on relatively basic anatomic characteristics. We aimed to detail pulmonary artery (PA) and MAPCA anatomy in a large group of infants, assess relationships between anatomy and early surgical outcomes, and consider systems for classifying MAPCAs. Methods and Results All infants ( <1 year of age) u ...[more]

PMID: 33283588

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Project description:Background Tetralogy of Fallot with major aortopulmonary collateral arteries is a heterogeneous form of pulmonary artery (PA) stenosis that requires multiple forms of intervention. We present a patient-specific in vitro platform capable of sustained flow that can be used to train proceduralists and surgical teams in current interventions, as well as in developing novel therapeutic approaches to treat various vascular anomalies. Our objective is to develop an in vitro model of PA stenosis based on patient data that can be used as an in vitro phantom to model cardiovascular disease and explore potential interventions. Methods and Results From patient-specific scans obtained via computer tomography or 3-dimensional (3D) rotational angiography, we generated digital 3D models of the arteries. Subsequently, in vitro models of tetralogy of Fallot with major aortopulmonary collateral arteries were first 3D printed using biocompatible resins and next bioprinted using gelatin methacrylate hydrogel to simulate neonatal vasculature or second-order branches of an older patient with tetralogy of Fallot with major aortopulmonary collateral arteries. Printed models were used to study creation of extraluminal connection between an atretic PA and a major aortopulmonary collateral artery using a catheter-based interventional method. Following the recanalization, engineered PA constructs were perfused and flow was visualized using contrast agents and x-ray angiography. Further, computational fluid dynamics modeling was used to analyze flow in the recanalized model. Conclusions New 3D-printed and computational fluid dynamics models for vascular atresia were successfully created. We demonstrated the unique capability of a printed model to develop a novel technique for establishing blood flow in atretic vessels using clinical imaging, together with 3D bioprinting-based tissue engineering techniques. Additive biomanufacturing technologies can enable fabrication of functional vascular phantoms to model PA stenosis conditions that can help develop novel clinical applications.

Project description:ObjectivesThe aim of this study was to characterize the anatomy of aortopulmonary collateral (APC) arteries in tetralogy of Fallot and pulmonary stenosis and to determine whether APC density identified on preoperative multidetector cardiac computed tomography predicts in-hospital outcome.MethodsThe retrospective single-centre study includes consecutive 135 (2015-2019) patients who underwent one-stage repair. Preoperative multidetector cardiac computed tomography, echocardiography and clinical outcomes were reviewed. The cut-off value of indexed total distal APC cross-sectional area (APC-CSA) was identified by receiver operating characteristic curve. Logistic regression was used for predictors analysis.ResultsThe median age and body weight were 19.7 (10.1-89.7) months and 10 (8.3-18) kg. A total of 337 APCs were detected with only one demonstrating severe stenosis. There was a strong and significant correlation between mean APC diameter per patient and age (r = 0.70, P < 0.001). APCs were imaged but mainly received no interventions. In-hospital mortality was similar between patients with high (indexed APC-CSA ≥3.0 mm2/m2) and low (<3.0 mm2/m2) APC density (P = 0.642). Significantly greater patients with high indexed APC-CSA experienced the in-hospital composite outcome of death, arrest, renal/hepatic injury, lactic acidosis or extracorporeal membrane oxygenation (P = 0.007). High APC density was associated with greater dosing (P = 0.008) and longer (P = 0.01) use of inotropic support, prolonged pleural drainage (P = 0.013), longer ventilation (P = 0.042), intensive care unit (P = 0.014) and hospital (P = 0.027) duration. No reintervention and death occurred in the follow-up with the median duration of 24.4 (11-36.6) months. Multivariable analysis showed the Nakata index (P = 0.05) and high APC density (P = 0.02) independently predicted the composite outcome.ConclusionsIn tetralogy of Fallot and pulmonary stenosis, APCs are likely to be dilated bronchial arteries. Preoperative multidetector cardiac computed tomography-derived APC density was as important as Nakata index in predicting the occurrence of in-hospital composite outcome. The APC-CSA of 3.0 mm2/m2 maybe considered as a threshold for risk stratification.

Dataset Information

Angiographic Anatomy of Major Aortopulmonary Collateral Arteries and Association With Early Surgical Outcomes in Tetralogy of Fallot.

Publications

Angiographic Anatomy of Major Aortopulmonary Collateral Arteries and Association With Early Surgical Outcomes in Tetralogy of Fallot.

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