OBJECTIVES: To date, it is not known if 16–20-mm extracardiac conduits are outgrown during somatic growth from childhood to adolescence. This study aims to determine total cavopulmonary connection (TCPC) haemodynamics in adolescent Fontan patients at rest and during simulated exercise and to assess the relationship between conduit size and haemodynamics. METHODS: Patient-specific, magnetic resonance imaging-based computational fluid dynamic models of the TCPC were performed in 51 extracardiac Fontan patients with 16–20-mm conduits. Power loss, pressure gradient and normalized resistance were quantified in rest and during simulated exercise. The cross-sectional area (CSA) (mean and minimum) of the vessels of the TCPC was determined and normalized for flow rate (mm2/l/min). Peak (predicted) oxygen uptake was assessed. RESULTS: The median age was 16.2 years (Q1–Q3 14.0–18.2). The normalized mean conduit CSA was 35–73% smaller compared to the inferior and superior vena cava, hepatic veins and left/right pulmonary artery (all P < 0.001). The median TCPC pressure gradient was 0.7 mmHg (Q1–Q3 0.5–0.8) and 2.0 (Q1–Q3 1.4–2.6) during rest and simulated exercise, respectively. A moderate–strong inverse nonlinear relationship was present between normalized mean conduit CSA and TCPC haemodynamics in rest and exercise. TCPC pressure gradients of >_1.0 at rest and >_3.0 mmHg during simulated exercise were observed in patients with a conduit CSA <_ 45 mm2/l/min and favourable haemodynamics (<1 mmHg during both rest and exercise) in conduits >_125 mm2/l/min. Normalized TCPC resistance correlated with (predicted) peak oxygen uptake. CONCLUSIONS: Extracardiac conduits of 16–20 mm have become relatively undersized in most adolescent Fontan patients leading to suboptimal haemodynamics.@en