Respiration influences pulsatility but has a limited effect on net forward flow in the Fontan circulation, highlighting the importance of incorporating respiratory effects in MRI flow sequences.
Clinicians evaluating Fontan patients should recognize that respiration primarily drives flow pulsatility rather than net forward flow, and that conventional MRI flow sequences often fail to capture this respiratory-induced pulsatility.
Congenital heart disease is the most common birth defect and functionally univentricular heart defects represent the most severe end of this spectrum. The Fontan circulation provides an unique solution for single ventricle patients, by connecting both caval veins directly to the pulmonary arteries. As a result, the pulmonary circulation in Fontan palliated patients is characterized by a passive, low-energy circulation that depends on increased systemic venous pressure to drive blood toward the lungs. The absence of a subpulmonary ventricle led to the widely believed concept that respiration, by sucking blood to the pulmonary circulation during inspiration, is of great importance as a driving force for antegrade blood flow in Fontan patients. However, recent studies show that respiration influences pulsatility, but has a limited effect on net forward flow in the Fontan circulation. Importantly, since MRI examination is recommended every 2 years in Fontan patients, clinicians should be aware that most conventional MRI flow sequences do not capture the pulsatility of the blood flow as a result of the respiration. In this review, the unique flow dynamics influenced by the cardiac and respiratory cycle at multiple locations within the Fontan circulation is discussed. The impact of (not) incorporating respiration in different MRI flow sequences on the interpretation of clinical flow parameters will be covered. Finally, the influence of incorporating respiration in advanced computational fluid dynamic modeling will be outlined.
Woude et al. (Thu,) conducted a review in Fontan circulation in congenital heart disease. Respiration influences pulsatility but has a limited effect on net forward flow in the Fontan circulation, highlighting the importance of incorporating respiratory effects in MRI flow sequences.