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Original Articles

Noninvasive Quantification of Systemic-to-Pulmonary Collateral Flow

A Major Source of Inefficiency in Patients With Superior Cavopulmonary Connections

Kevin K. Whitehead, MD, PhD; Matthew J. Gillespie, MD; Matthew A. Harris, MD; Mark A. Fogel, MD and Jonathan J. Rome, MD

From the Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, Pa.

Correspondence to Kevin K. Whitehead, MD, PhD, Cardiology, 8th Floor Main Bldg, 8NW71, Children’s Hospital of Philadelphia, Philadelphia, PA 19104. E-mail whiteheadk{at}email.chop.edu

Received November 10, 2008; accepted July 7, 2009.

Background— Systemic-to-pulmonary collateral flow (SPCF) is common in single-ventricle patients with superior cavopulmonary connections (SCPC). Because no validated method to quantify SPCF exists, neither its hemodynamic burden nor its clinical impact can be systematically evaluated. We hypothesize that (1) the difference in total ascending aortic (Ao) and caval flow (superior vena cava [SVC]+inferior vena cava [IVC]) and (2) the difference between pulmonary vein and pulmonary artery flow (PV–PA) provide 2 independent estimators of SPCF.

Methods and Results— We measured Ao, SVC, IVC, right (RPA) and left (LPA) PA, and left (LPV) and right (RPV) PV flows in 17 patients with SCPC during routine cardiac MRI studies using through-plane phase-contrast velocity mapping. Two independent measures of SPCF were obtained: model 1, Ao–(SVC+IVC); and model 2, (LPV–LPA)+(RPV–RPA). Values were normalized to body surface area, Ao, and PV, and comparisons were made using linear regression and Bland-Altman analysis. SPCF ranged from 0.2 to 1.4 L/min for model 1 and 0.2 to 1.6 L/min for model 2, for an average indexed SPCF of 0.5 to 2.8 L/min/m²: 11% to 53% (mean, 37%) of Ao and 19% to 77% (mean, 54%) of PV. The mean difference between model 1 and model 2 was 0.01 L/min (P=0.40; 2-SD range, –0.45 to 0.47 L/min).

Conclusions— We present a noninvasive method for SPCF quantification in patients with SCPC. It should provide an important clinical tool in treating these patients. Furthermore, we show that SPCF is a significant hemodynamic burden in many patients with bidirectional Glenn shunt physiology. Future investigations will allow objective study of the impact of collateral flow on outcome.

Key Words: single ventricle • collateral circulation • MRI • blood flow • superior cavopulmonary connection

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