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Smith PA, Wang Y, Frazier OH. The Evolution of Durable, Implantable Axial-Flow Rotary Blood Pumps. Tex Heart Inst J 2023; 50:492012. [PMID: 37011366 PMCID: PMC10178652 DOI: 10.14503/thij-22-7908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
Left ventricular assist devices (LVADs) are increasingly used to treat patients with end-stage heart failure. Implantable LVADs were initially developed in the 1960s and 1970s. Because of technological constraints, early LVADs had limited durability (eg, membrane or valve failure) and poor biocompatibility (eg, driveline infections and high rates of hemolysis caused by high shear rates). As the technology has improved over the past 50 years, contemporary rotary LVADs have become smaller, more durable, and less likely to result in infection. A better understanding of hemodynamics and end-organ perfusion also has driven research into the enhanced functionality of rotary LVADs. This paper reviews from a historical perspective some of the most influential axial-flow rotary blood pumps to date, from benchtop conception to clinical implementation. The history of mechanical circulatory support devices includes improvements related to the mechanical, anatomical, and physiologic aspects of these devices. In addition, areas for further improvement are discussed, as are important future directions-such as the development of miniature and partial-support LVADs, which are less invasive because of their compact size. The ongoing development and optimization of these pumps may increase long-term LVAD use and promote early intervention in the treatment of patients with heart failure.
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Affiliation(s)
- P Alex Smith
- Innovative Design and Engineering Applications Laboratory, The Texas Heart Institute, Houston, Texas
| | - Yaxin Wang
- Innovative Design and Engineering Applications Laboratory, The Texas Heart Institute, Houston, Texas
| | - O H Frazier
- Innovative Design and Engineering Applications Laboratory, The Texas Heart Institute, Houston, Texas
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2
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Koh V, Pauls J, Wu E, Stevens M, Ho Y, Lovell N, Lim E. A centralized multi-objective model predictive control for a biventricular assist device: An in vitro evaluation. Biomed Signal Process Control 2020. [DOI: 10.1016/j.bspc.2020.101914] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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3
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A centralized multi-objective model predictive control for a biventricular assist device: An in silico evaluation. Biomed Signal Process Control 2019. [DOI: 10.1016/j.bspc.2018.10.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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4
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Clinical Implications of Physiologic Flow Adjustment in Continuous-Flow Left Ventricular Assist Devices. ASAIO J 2018; 63:241-250. [PMID: 28459742 DOI: 10.1097/mat.0000000000000477] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
There is increasing evidence for successful management of end-stage heart failure with continuous-flow left ventricular assist device (CF-LVAD) technology. However, passive flow adjustment at fixed CF-LVAD speed is susceptible to flow balancing issues as well as adverse hemodynamic effects relating to the diminished arterial pulse pressure and flow. With current therapy, flow cannot be adjusted with changes in venous return, which can vary significantly with volume status. This limits the performance and safety of CF-LVAD. Active flow adjustment strategies have been proposed to improve the synchrony between the pump and the native cardiovascular system, mimicking the Frank-Starling mechanism of the heart. These flow adjustment strategies include modulation by CF-LVAD pump speed by synchrony and maintenance of constant flow or constant pressure head, or a combination of these variables. However, none of these adjustment strategies have evolved sufficiently to gain widespread attention. Herein we review the current challenges and future directions of CF-LVAD therapy and sensor technology focusing on the development of a physiologic, long-term active flow adjustment strategy for CF-LVADs.
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5
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Kaufmann F, Krabatsch T. Using medical imaging for the detection of adverse events (“incidents”) during the utilization of left ventricular assist devices in adult patients with advanced heart failure. Expert Rev Med Devices 2016; 13:463-74. [DOI: 10.1586/17434440.2016.1166051] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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6
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Pauls JP, Stevens MC, Schummy E, Tansley G, Fraser JF, Timms D, Gregory SD. In Vitro Comparison of Active and Passive Physiological Control Systems for Biventricular Assist Devices. Ann Biomed Eng 2015; 44:1370-80. [PMID: 26283049 DOI: 10.1007/s10439-015-1425-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 08/10/2015] [Indexed: 11/29/2022]
Abstract
The low preload and high afterload sensitivities of rotary ventricular assist devices (VADs) may cause ventricular suction events or venous congestion. This is particularly problematic with rotary biventricular support (BiVAD), where the Starling response is diminished in both ventricles. Therefore, VADs may benefit from physiological control systems to prevent adverse events. This study compares active, passive and combined physiological controllers for rotary BiVAD support with constant speed mode. Systemic (SVR) and pulmonary (PVR) vascular resistance changes and exercise were simulated in a mock circulation loop to evaluate the capacity of each controller to prevent suction and congestion and increase exercise capacity. All controllers prevented suction and congestion at high levels of PVR (900 dynes s cm(-5)) and SVR (3000 dynes s cm(-5)), however these events occurred in constant speed mode. The controllers increased preload sensitivity (0.198-0.34 L min(-1) mmHg(-1)) and reduced afterload sensitivity (0.0001-0.008 L min(-1) mmHg(-1)) of the VADs when compared to constant speed mode (0.091 and 0.072 L min(-1) mmHg(-1) respectively). The active controller increased pump speeds (400-800 rpm) and pump flow by 2.8 L min(-1) during exercise, thus increasing exercise capacity. By reducing suction and congestion and by increasing exercise capacity, the control systems presented in this study may help increase quality of life of VAD patients.
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Affiliation(s)
- Jo P Pauls
- School of Engineering, Griffith University, Southport, QLD, Australia. .,Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.
| | - Michael C Stevens
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,School of Information Technology and Electrical Engineering, University of Queensland, Brisbane, QLD, Australia
| | - Emma Schummy
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Geoff Tansley
- School of Engineering, Griffith University, Southport, QLD, Australia.,Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - John F Fraser
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Daniel Timms
- Center for Technology Innovation, Texas Heart Institute, Houston, TX, USA.,BiVACOR Inc., Houston, TX, USA
| | - Shaun D Gregory
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,School of Medicine, University of Queensland, Brisbane, QLD, Australia
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7
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Rosengart TK. The 1000th VAD, the great rivalry, and the grand experiment of the Texas Medical Center. Semin Thorac Cardiovasc Surg 2014; 26:1-3. [PMID: 24952751 DOI: 10.1053/j.semtcvs.2014.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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8
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Rosengart TK. The 1,000 th VAD, the great rivalry, and the grand experiment of the Texas Medical Center. Tex Heart Inst J 2014; 41:112-4; discussion 114. [PMID: 24808766 DOI: 10.14503/thij-14-4117] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Todd K Rosengart
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas 77030
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9
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Stevens MC, Wilson S, Bradley A, Fraser J, Timms D. Physiological control of dual rotary pumps as a biventricular assist device using a master/slave approach. Artif Organs 2014; 38:766-74. [PMID: 24749848 DOI: 10.1111/aor.12303] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Dual rotary left ventricular assist devices (LVADs) can provide biventricular mechanical support during heart failure. Coordination of left and right pump speeds is critical not only to avoid ventricular suction and to match cardiac output with demand, but also to ensure balanced systemic and pulmonary circulatory volumes. Physiological control systems for dual LVADs must meet these objectives across a variety of clinical scenarios by automatically adjusting left and right pump speeds to avoid catastrophic physiological consequences. In this study we evaluate a novel master/slave physiological control system for dual LVADs. The master controller is a Starling-like controller, which sets flow rate as a function of end-diastolic ventricular pressure (EDP). The slave controller then maintains a linear relationship between right and left EDPs. Both left/right and right/left master/slave combinations were evaluated by subjecting them to four clinical scenarios (rest, postural change, Valsalva maneuver, and exercise) simulated in a mock circulation loop. The controller's performance was compared to constant-rotational-speed control and two other dual LVAD control systems: dual constant inlet pressure and dual Frank-Starling control. The results showed that the master/slave physiological control system produced fewer suction events than constant-speed control (6 vs. 62 over a 7-min period). Left/right master/slave control had lower risk of pulmonary congestion than the other control systems, as indicated by lower maximum EDPs (15.1 vs. 25.2-28.4 mm Hg). During exercise, master/slave control increased total flow from 5.2 to 10.1 L/min, primarily due to an increase of left and right pump speed. Use of the left pump as the master resulted in fewer suction events and lower EDPs than when the right pump was master. Based on these results, master/slave control using the left pump as the master automatically adjusts pump speed to avoid suction and increases pump flow during exercise without causing pulmonary venous congestion.
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Affiliation(s)
- Michael C Stevens
- Innovative Cardiovascular Engineering and Technology Laboratory, The Prince Charles Hospital, Brisbane, Queensland, Australia; Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Brisbane, Queensland, Australia; School of Information Technology and Electrical Engineering, University of Queensland, Brisbane, Queensland, Australia
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10
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Riebandt J, Haberl T, Mahr S, Laufer G, Rajek A, Steinlechner B, Schima H, Zimpfer D. Preoperative patient optimization using extracorporeal life support improves outcomes of INTERMACS Level I patients receiving a permanent ventricular assist device. Eur J Cardiothorac Surg 2014; 46:486-92; discussion 492. [PMID: 24648428 DOI: 10.1093/ejcts/ezu093] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVES Interagency Registry for Mechanical Assisted Circulatory Support (INTERMACS) Level I patients have the highest early mortality after ventricular assist device (VAD) implantation. This is determined by the exposure of patients in shock with acutely damaged end-organs and high catecholamine support to a significant surgical trauma. We report our experience with a bridge-to-bridge concept consisting of initial veno-arterial extracorporeal life support (ECLS) and deferral of VAD implantation to recovery of end-organ function in INTERMACS Level I patients. METHODS We reviewed the concept of initial ECLS implantation and deferral of VAD implantation to end-organ recovery in 22 consecutive patients (mean age 54 ± 14 years; 72.2% males; 50% ischemic cardiomyopathy; 100% INTERMACS Level I; 18.2% Heartmate II, 68.2% Heartware HVAD, 4.5% Heartware BiVAD, 9.1% DeBakey LVAD) receiving a VAD for refractory cardiogenic shock between June 2004 and February 2013. Study endpoints were end-organ recovery during ECLS and survival. RESULTS ECLS significantly improved renal (creatinine 1.86 ± 0.91 vs 1.32 ± 0.52 mg/dl, P = 0.02), hepatic (aspartate aminotransferase 1426 ± 2176 vs 277 ± 259 U/l, P = 0.04; alanine aminotransferase 982 ± 1466 vs 357 ± 447 U/l, P = 0.04) and pulmonary functions (fraction of inspired oxygen 52 ± 18 vs 26 ± 23%, P < 0.01; positive end-expiratory pressure 7 ± 3 vs 5 ± 4 mbar, P = 0.02) over a period of 8 ± 7 days. Catecholamines could be reduced during ECLS (levosimendan 0.056 ± 0.085 vs 0.010 ± 0.032 μg/kg/min, P = 0.06; dobutamine 4.362 ± 5.268 vs 0.056 ± 0.097 μg/kg/min, P = 0.06; noradrenaline 0.408 ± 0.355 vs 0.056 ± 0.097 μg/kg/min, P < 0.01). Thirty-day and in-hospital mortality after VAD implantation were 4.5 and 9.1%, respectively, and 1-year survival was 86.4%. CONCLUSIONS Preoperative patient optimization using ECLS improves outcomes of INTERMACS Level I patients receiving a permanent VAD.
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Affiliation(s)
- Julia Riebandt
- Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria
| | - Thomas Haberl
- Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria
| | - Stephane Mahr
- Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria
| | - Guenther Laufer
- Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria Ludwig Boltzmann Cluster for Cardiovascular Research, Vienna, Austria
| | - Angela Rajek
- Department of Anesthesia, General Intensive Care and Pain Management, Medical University Vienna, Vienna, Austria
| | - Barbara Steinlechner
- Department of Anesthesia, General Intensive Care and Pain Management, Medical University Vienna, Vienna, Austria
| | - Heinrich Schima
- Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria Ludwig Boltzmann Cluster for Cardiovascular Research, Vienna, Austria Center for Medical Physics and Biomedical Engineering, Medical University Vienna, Vienna, Austria
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria Ludwig Boltzmann Cluster for Cardiovascular Research, Vienna, Austria
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Rosengart TK. The 1,000th VAD, the great rivalry, and the grand experiment of the Texas Medical Center. J Thorac Cardiovasc Surg 2014; 147:1745-7; discussion 1747. [PMID: 24837721 DOI: 10.1016/j.jtcvs.2014.02.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 02/14/2014] [Indexed: 11/15/2022]
Affiliation(s)
- Todd K Rosengart
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex.
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12
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Rosengart TK. WITHDRAWN: The 1000th VAD, the Great Rivalry, and the Grand Experiment at the Texas Medical Center. Semin Thorac Cardiovasc Surg 2014. [DOI: 10.1053/j.semtcvs.2014.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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13
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Abstract
Today's healthcare delivery system is challenged with an escalating number of heart failure patients who have exhausted medical therapy and overwhelmed the limits of organ transplantation. Scientific and technological advances over the last 20 years have now brought new surgical options to this vast patient population, ranging from ventricular restoration surgery to surgical gene therapy and beyond. This article reviews the myriad of surgical options that are available to these patients, their benefits and shortcomings, as well as potential future directions.
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14
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DeBakey ME, Teitel ER. Use of the MicroMed®DeBakey VAD®for the treatment of end-stage heart failure. Expert Rev Med Devices 2014; 2:137-40. [PMID: 16293049 DOI: 10.1586/17434440.2.2.137] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Congestive heart failure poses a serious health risk to millions of Americans. Medical therapy for advanced stages of this condition has offered a minimal benefit and surgical treatment through transplantation is limited by the donor organ shortage. Although left ventricular assist devices may represent the future of therapy for this disease, the first generation of these pumps are limited by a number of factors that restrict their use to only the sickest of patients. The development and clinical use of the MicroMed DeBakey VAD represents a paradigm shift in the field of heart disease, supporting the notion that mechanical assistance can be achieved with continuous flow pumps. Axial flow devices, such as the DeBakey VAD, may open new doors for smaller patients and children, as well as improve the current standard of care for adults who require long-term circulatory support.
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Affiliation(s)
- Michael E DeBakey
- DeBakey Heart Center, Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA.
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15
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Pektok E, Demirozu ZT, Arat N, Yildiz O, Oklu E, Eker D, Ece F, Ciftci C, Yazicioglu N, Bayindir O, Kucukaksu DS. Remote monitoring of left ventricular assist device parameters after HeartAssist-5 implantation. Artif Organs 2013; 37:820-5. [PMID: 24033470 DOI: 10.1111/aor.12144] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Although several left ventricular assist devices (LVADs) have been used widely, remote monitoring of LVAD parameters has been available only recently. We present our remote monitoring experience with an axial-flow LVAD (HeartAssist-5, MicroMed Cardiovascular, Inc., Houston, TX, USA). Five consecutive patients who were implanted a HeartAssist-5 LVAD because of end-stage heart failure due to ischemic (n=4) or idiopathic (n=1) cardiomyopathy, and discharged from hospital between December 2011 and January 2013 were analyzed. The data (pump speed, pump flow, power consumption) obtained from clinical visits and remote monitoring were studied. During a median follow-up of 253 (range: 80-394) days, fine tuning of LVADs was performed at clinical visits. All patients are doing well and are in New York Heart Association Class-I/II. A total of 39 alarms were received from three patients. One patient was hospitalized for suspected thrombosis and was subjected to physical examinations as well as laboratory and echocardiographic evaluations; however, no evidence of thrombus washout or pump thrombus was found. The patient was treated conservatively. Remaining alarms were due to insufficient water intake and were resolved by increased water consumption at night and summer times, and fine tuning of pump speed. No alarms were received from the remaining two patients. We believe that remote monitoring is a useful technology for early detection and treatment of serious problems occurring out of hospital thereby improving patient care. Future developments may ease troubleshooting, provide more data from the patient and the pump, and eventually increase physician and patient satisfaction. Despite all potential clinical benefits, remote monitoring should be taken as a supplement to rather than a substitute for routine clinical visits for patient follow-up.
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Affiliation(s)
- Erman Pektok
- Heart Transplantation and Mechanical Circulatory Support Center, Sisli Florence Nightingale Hospital, Istanbul, Turkey
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16
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Tuzun E, Pennings K, van Tuijl S, de Hart J, Stijnen M, van de Vosse F, de Mol B, Rutten M. Assessment of aortic valve pressure overload and leaflet functions in an ex vivo beating heart loaded with a continuous flow cardiac assist device. Eur J Cardiothorac Surg 2013; 45:377-83. [DOI: 10.1093/ejcts/ezt355] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Moazami N, Hoercher KJ, Fukamachi K, Kobayashi M, Smedira NG, Massiello A, Horvath DJ. Mechanical circulatory support for heart failure: past, present and a look at the future. Expert Rev Med Devices 2013; 10:55-71. [PMID: 23278224 DOI: 10.1586/erd.12.69] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Heart transplantation remains the gold standard for long-term cardiac replacement, but a shortage of donor organs will always limit this option. For both transplant-eligible and noneligible patients, advances in mechanical circulatory support have revolutionized the options for the management of end-stage heart failure, and this technology continues to bring us closer to a true alternative to heart transplantation. This review provides a perspective on the past, present and future of mechanical circulatory support and addresses the changes in technology, patient selection and management strategies needed to have this therapy fully embraced by the heart failure community, and perhaps replace heart transplantation either as the therapy of choice or as a strategy by which to delay transplantation in younger patients.
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Affiliation(s)
- Nader Moazami
- Department of Thoracic and Cardiovascular Surgery, Miller Family Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH 44195, USA.
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18
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Evaluation of a morphological filter in mean cardiac output determination: application to left ventricular assist devices. Med Biol Eng Comput 2013; 51:891-9. [DOI: 10.1007/s11517-013-1061-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Accepted: 03/07/2013] [Indexed: 11/25/2022]
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Pulsatile vs. continuous flow in ventricular assist device therapy. Best Pract Res Clin Anaesthesiol 2013; 26:105-15. [PMID: 22910084 DOI: 10.1016/j.bpa.2012.03.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Accepted: 03/14/2012] [Indexed: 12/15/2022]
Abstract
A left ventricular assist device (LVAD) is an important treatment option for a patient with end-stage heart failure. Both continuous and non-pulsatile devices are available, each with different effects on a patient's physiology. In general, these effects are not clinically significant with the exception of bleeding events which are more common with continuous-flow devices in some series. Both devices increase survival beyond medical management. Continuous-flow devices are smaller and are associated with less overall morbidity than pulsatile devices.
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Yuki K, Sharma R, DiNardo J. Ventricular-assist device therapy in children. Best Pract Res Clin Anaesthesiol 2012; 26:247-64. [PMID: 22910093 DOI: 10.1016/j.bpa.2012.03.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2011] [Accepted: 03/14/2012] [Indexed: 11/26/2022]
Abstract
Mechanical circulatory support is an important modality in the management of paediatric patients with circulatory failure. The field of ventricular assist device (VAD) is particularly evolving. We review the currently available and developing VADs in the paediatric population, and the anaesthetic management of patients presenting for VAD implantation and with VADs for non-cardiac surgery.
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Affiliation(s)
- Koichi Yuki
- Division of Cardiac Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Children's Hospital Boston, Boston, MA 02115, USA.
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21
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Tan TC, Sindone AP, Denniss AR. Cardiac Electronic Implantable Devices in the Treatment of Heart Failure. Heart Lung Circ 2012; 21:338-51. [DOI: 10.1016/j.hlc.2012.03.124] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Revised: 03/26/2012] [Accepted: 03/31/2012] [Indexed: 10/28/2022]
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22
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Backes D, van den Bergh WM, van Duijn AL, Lahpor JR, van Dijk D, Slooter AJC. Cerebrovascular complications of left ventricular assist devices. Eur J Cardiothorac Surg 2012; 42:612-20. [PMID: 22659892 DOI: 10.1093/ejcts/ezs320] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Left ventricular assist devices (LVADs) are increasingly being used as a bridge to heart transplantation or destination therapy. It is unclear which antithrombotic regimen should be used to reduce the risk of stroke. We systematically reviewed the literature on all types of antithrombotic regimens and stroke in patients with any type of LVADs. Our primary outcome measure was the mean incidence of any type of stroke. Twenty-six articles were selected as relevant, comprehending 1989 patients with a mean LVAD support of 200 days (range 30-621). The mean proportion of patients affected with stroke was 20% (range 0-55%), with a mean incidence of 0.74 (range 0-6.91) events/patient-year. Support with HeartMate II and a regimen of postoperative heparin converted to coumarins, acetylsalicylic acid (ASA) and dipyridamole resulted in 0.17 (mean; range 0.06-0.29) strokes/patient-year. HeartMate II support and the same regime without heparin was associated with 0.07 (mean; range 0.03-0.11) strokes/patient-year. A Novacor device with heparin, converted to coumarins, was associated with 3.82 (mean; range 1.03-6.91) strokes/patient-year, while ASA added to this regime resulted in 0.97 ischaemic strokes/patient-year (mean; range 0.53-1.48). Other combinations of assist devices and antithrombotic regimes were investigated in one or two studies only. This systematic review provides risk estimates for stroke for various LVADs and antithrombotic regimes. Our findings indicate that the postoperative use of heparin in HeartMate II patients is doubtful, and suggest an important role for antiplatelet drugs to prevent stroke in patients supported with a Novacor device.
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Affiliation(s)
- Daan Backes
- Department of Intensive Care Medicine, University Medical Centre Utrecht, Utrecht, Netherlands
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23
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Girdhar G, Xenos M, Alemu Y, Chiu WC, Lynch BE, Jesty J, Einav S, Slepian MJ, Bluestein D. Device thrombogenicity emulation: a novel method for optimizing mechanical circulatory support device thromboresistance. PLoS One 2012; 7:e32463. [PMID: 22396768 PMCID: PMC3292570 DOI: 10.1371/journal.pone.0032463] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Accepted: 01/27/2012] [Indexed: 12/22/2022] Open
Abstract
Mechanical circulatory support (MCS) devices provide both short and long term hemodynamic support for advanced heart failure patients. Unfortunately these devices remain plagued by thromboembolic complications associated with chronic platelet activation--mandating complex, lifelong anticoagulation therapy. To address the unmet need for enhancing the thromboresistance of these devices to extend their long term use, we developed a universal predictive methodology entitled Device Thrombogenicity Emulation (DTE) that facilitates optimizing the thrombogenic performance of any MCS device--ideally to a level that may obviate the need for mandatory anticoagulation. DTE combines in silico numerical simulations with in vitro measurements by correlating device hemodynamics with platelet activity coagulation markers--before and after iterative design modifications aimed at achieving optimized thrombogenic performance. DTE proof-of-concept is demonstrated by comparing two rotary Left Ventricular Assist Devices (LVADs) (DeBakey vs HeartAssist 5, Micromed Houston, TX), the latter a version of the former following optimization of geometrical features implicated in device thrombogenicity. Cumulative stresses that may drive platelets beyond their activation threshold were calculated along multiple flow trajectories and collapsed into probability density functions (PDFs) representing the device 'thrombogenic footprint', indicating significantly reduced thrombogenicity for the optimized design. Platelet activity measurements performed in the actual pump prototypes operating under clinical conditions in circulation flow loops--before and after the optimization with the DTE methodology, show an order of magnitude lower platelet activity rate for the optimized device. The robust capability of this predictive technology--demonstrated here for attaining safe and cost-effective pre-clinical MCS thrombo-optimization--indicates its potential for reducing device thrombogenicity to a level that may significantly limit the extent of concomitant antithrombotic pharmacotherapy needed for safe clinical device use.
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Affiliation(s)
- Gaurav Girdhar
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York, United States of America
| | - Michalis Xenos
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York, United States of America
| | - Yared Alemu
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York, United States of America
| | - Wei-Che Chiu
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York, United States of America
| | - Bryan E. Lynch
- MicroMed Cardiovascular Inc., Houston, Texas, United States of America
| | - Jolyon Jesty
- Department of Hematology, Stony Brook University, Stony Brook, New York, United States of America
| | - Shmuel Einav
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York, United States of America
| | - Marvin J. Slepian
- Sarver Heart Center, University of Arizona, Tucson, Arizona, United States of America
| | - Danny Bluestein
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York, United States of America
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Numerical Simulation of LVAD Inflow Cannulas with Different Tip. INTERNATIONAL JOURNAL OF CHEMICAL ENGINEERING 2012. [DOI: 10.1155/2012/596960] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The tip structure of LVAD inflow cannula is one of major factors to lead adverse events such as thrombosis and suction leading to obstruction. In this research, four kinds of tips that had been used in inflow cannulas were selected and designed. The flow field of the four inflow cannulas inserted into the apex of left ventricle (LV) was numerically computed by computational fluid dynamics. The flow behavior was analyzed in order to compare the blood compatibility and suction in left ventricle and cannulas after the inflow cannulas with different tips were inserted to the apex of LV. The results showed that the cannula tip structure affected the LVAD performance. Among these four cannulas, the trumpet-tipped inflow cannula owned the best performance in smooth flow velocity distribution without backflow or low-velocity flow so that it was the best in blood compatibility. Nevertheless, the caged tipped cannula was the worst in blood compatibility. And the blunt-tipped and beveled tipped inflow cannulas may obstruct more easily than trumpet and caged tipped inflow cannulas because of their shape. The study indicated that the trumpet tip was the most preferable for the inflow cannula of long-term LVAD.
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Affiliation(s)
- Deborah J Kozik
- Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, KY, USA
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Stevens MC, Gaddum NR, Pearcy M, Salamonsen RF, Timms DL, Mason DG, Fraser JF. Frank-starling control of a left ventricular assist device. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2011; 2011:1335-1338. [PMID: 22254563 DOI: 10.1109/iembs.2011.6090314] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
A physiological control system was developed for a rotary left ventricular assist device (LVAD) in which the target pump flow rate (LVADQ) was set as a function of left atrial pressure (LAP), mimicking the Frank-Starling mechanism. The control strategy was implemented using linear PID control and was evaluated in a pulsatile mock circulation loop using a prototyped centrifugal pump by varying pulmonary vascular resistance to alter venous return. The control strategy automatically varied pump speed (2460 to 1740 to 2700 RPM) in response to a decrease and subsequent increase in venous return. In contrast, a fixed-speed pump caused a simulated ventricular suction event during low venous return and higher ventricular volumes during high venous return. The preload sensitivity was increased from 0.011 L/min/mmHg in fixed speed mode to 0.47L/min/mmHg, a value similar to that of the native healthy heart. The sensitivity varied automatically to maintain the LAP and LVADQ within a predefined zone. This control strategy requires the implantation of a pressure sensor in the left atrium and a flow sensor around the outflow cannula of the LVAD. However, appropriate pressure sensor technology is not yet commercially available and so an alternative measure of preload such as pulsatility of pump signals should be investigated.
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Affiliation(s)
- Michael Charles Stevens
- School of Information Technology and Electrical Engineering, University of Queensland, Brisbane, Australia.
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27
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Sasaoka T, Kato TS, Komamura K, Takahashi A, Nakajima I, Oda N, Hanatani A, Mano A, Asakura M, Hashimura K, Niwaya K, Funatsu T, Kobayashi J, Kitamura S, Shishido T, Wada K, Miyata S, Nakatani T, Isobe M, Kitakaze M. Improved long-term performance of pulsatile extracorporeal left ventricular assist device. J Cardiol 2010; 56:220-8. [DOI: 10.1016/j.jjcc.2010.05.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2009] [Revised: 04/10/2010] [Accepted: 05/21/2010] [Indexed: 01/08/2023]
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28
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Francis GS, Greenberg BH, Hsu DT, Jaski BE, Jessup M, LeWinter MM, Pagani FD, Piña IL, Semigran MJ, Walsh MN, Wiener DH, Yancy CW. ACCF/AHA/ACP/HFSA/ISHLT 2010 Clinical Competence Statement on Management of Patients With Advanced Heart Failure and Cardiac Transplant. J Am Coll Cardiol 2010; 56:424-53. [DOI: 10.1016/j.jacc.2010.04.014] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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29
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Spillner J, Kopp R, Finocchiaro T, Behbahani M, Rossaint R, Steinseifer U, Behr M, Autschbach R. [Assisted circulation: an overview from a clinical perspective]. BIOMED ENG-BIOMED TE 2009; 54:255-67. [PMID: 19807289 DOI: 10.1515/bmt.2009.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A higher grade cardiac failure is associated with poor prognosis. In addition to medical conservative treatment and traditional cardiac surgery, in the past years different forms of an assisted circulation evolved. Short-term devices serve to bridge an acute life-threatening situation. The chosen system is dependent on the anticipated clinical course. It is possible to fall back on slightly assisting techniques up to a complete takeover of the cardiac pump function. In the case of severe cardiac failure, the question for transplantation has to be addressed because transplantation is the treatment of choice to date. For an assisted circulation in cases of chronic congestive failure, devices of different generations are available. First generation pulsatile systems are used for assistance of the left ventricle and results have been shown to be superior to medical therapy (REMATCH). With second generation continuous-flow systems, results regarding infections, thromboembolism and also quality of life appear to be further improved. Contact-free centrifugal pumps as third generation systems are in clinical evaluation. So-called "total artificial hearts" are successfully used for bridge-to-transplantation. Taken together, a graded safe treatment of cardiac failure is available today. In the near future, it could be possible to reach results similar to those of cardiac transplantation.
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Affiliation(s)
- Jan Spillner
- Klinik für Thorax-, Herz- und Gefässchirurgie, Universitätsklinikum RWTH Aachen, Aachen, Deutschland.
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Liden H, Haraldsson Å, Ricksten SE, Kjellman U, Wiklund L. Does pretransplant left ventricular assist device therapy improve results after heart transplantation in patients with elevated pulmonary vascular resistance? Eur J Cardiothorac Surg 2009; 35:1029-34; discussion 1034-5. [DOI: 10.1016/j.ejcts.2008.12.024] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2008] [Revised: 12/15/2008] [Accepted: 12/16/2008] [Indexed: 11/29/2022] Open
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31
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Dispositivos de asistencia ventricular de tipo axial. CIRUGIA CARDIOVASCULAR 2009. [DOI: 10.1016/s1134-0096(09)70158-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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32
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Antz M, Hullmann B, Neufert C, Vocke W. Antikoagulation bei Vorhofflimmern – Update. Herz 2009. [DOI: 10.1007/s00059-009-3225-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Komoda T, Komoda S, Dandel M, Weng Y, Hetzer R. Explantation of INCOR Left Ventricular Assist Device After Myocardial Recovery. J Card Surg 2008; 23:642-7. [DOI: 10.1111/j.1540-8191.2008.00665.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Takeshi Komoda
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum, Berlin, Germany
| | - Satsuki Komoda
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum, Berlin, Germany
| | - Michael Dandel
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum, Berlin, Germany
| | - Yuguo Weng
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum, Berlin, Germany
| | - Roland Hetzer
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum, Berlin, Germany
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34
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Right Heart Dysfunction After Left Ventricular Assist Device Implantation: A Comparison of the Pulsatile HeartMate I and Axial-Flow HeartMate II Devices. Ann Thorac Surg 2008; 86:832-40; discussion 832-40. [DOI: 10.1016/j.athoracsur.2008.05.016] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2008] [Revised: 04/30/2008] [Accepted: 05/05/2008] [Indexed: 11/23/2022]
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35
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Sandner SE, Zimpfer D, Zrunek P, Dunkler D, Schima H, Rajek A, Grimm M, Wolner E, Wieselthaler GM. Renal Function After Implantation of Continuous Versus Pulsatile Flow Left Ventricular Assist Devices. J Heart Lung Transplant 2008; 27:469-73. [DOI: 10.1016/j.healun.2007.12.012] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2007] [Revised: 12/01/2007] [Accepted: 12/17/2007] [Indexed: 10/22/2022] Open
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36
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Potapov EV, Loforte A, Weng Y, Jurmann M, Pasic M, Drews T, Loebe M, Hennig E, Krabatsch T, Koster A, Lehmkuhl HB, Hetzer R. Experience with over 1000 Implanted Ventricular Assist Devices. J Card Surg 2008; 23:185-94. [PMID: 18435629 DOI: 10.1111/j.1540-8191.2008.00606.x] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Evgenij V Potapov
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Germany.
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Chumnanvej S, Wood MJ, MacGillivray TE, Melo MFV. Perioperative echocardiographic examination for ventricular assist device implantation. Anesth Analg 2007; 105:583-601. [PMID: 17717209 DOI: 10.1213/01.ane.0000278088.22952.82] [Citation(s) in RCA: 130] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Ventricular assist devices (VADs) are systems for mechanical circulatory support of the patient with severe heart failure. Perioperative transesophageal echocardiography is a major component of patient management, and important for surgical and anesthetic decision making. In this review we present the rationale and available data for a comprehensive echocardiographic assessment of patients receiving a VAD. In addition to the standard examination, device-specific pre-, intra-, and postoperative considerations are essential to the echocardiographic evaluation. These include: (a) the pre-VAD insertion examination of the heart and large vessels to exclude significant aortic regurgitation, tricuspid regurgitation, mitral stenosis, patent foramen ovale, or other cardiac abnormality that could lead to right-to-left shunt after left VAD placement, intracardiac thrombi, ventricular scars, pulmonic regurgitation, pulmonary hypertension, pulmonary embolism, and atherosclerotic disease in the ascending aorta; and to assess right ventricular function; and (b) the post-VAD insertion examination of the device and reassessment of the heart and large vessels. The examination of the device aims to confirm completeness of device and heart deairing, cannulas alignment and patency, and competency of device valves using two-dimensional, and color, continuous and pulsed wave Doppler modalities. The goal for the heart examination after implantation should be to exclude aortic regurgitation, or an uncovered right-to-left shunt; and to assess right ventricular function, left ventricular unloading, and the effect of device settings on global heart function. The variety of VAD models with different basic and operation principles requires specific echocardiographic assessment targeted to the characteristics of the implanted device.
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Affiliation(s)
- Siriluk Chumnanvej
- Department of Anesthesia and Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114, USA
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38
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Nessar G, Kucukaksu S, Zengin NI, Tasdemir O, Kayaalp C. Ischemic necrosis of the right colon in a patient with a ventricular assist device system. Tech Coloproctol 2007; 11:275-7. [PMID: 17676260 DOI: 10.1007/s10151-007-0365-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2004] [Accepted: 10/29/2004] [Indexed: 10/23/2022]
Abstract
Despite improvements in medical therapy, the annual high mortality rate from end-stage heart failure continues. Although cardiac transplantation is a successful treatment for these patients, the shortage of donor hearts has led surgeons to seek other options. Ventricular assist device (VAD) technology is applied to a broader population of heart failure patients, and clinicians are confronted with the specialized perioperative and chronic care of patients who receive these devices. VAD implantation is now an acceptable means of bridging to heart transplantation. We report a case of isolated right colon necrosis in a patient with VAD, who was successfully treated with right hemicolectomy and ileocolostomy.
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Affiliation(s)
- G Nessar
- Department of Gastrointestinal Surgery, Yuksek Ihtisas Hospital, Ankara, Turkey.
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39
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Abe Y, Isoyama T, Saito I, Mochizuki S, Ono M, Nakagawa H, Taniguchi N, Mitsumune N, Sugino A, Mitsui M, Takiura K, Ono T, Kouno A, Chinzei T, Takamoto S, Imachi K. Development of mechanical circulatory support devices at the University of Tokyo. J Artif Organs 2007; 10:60-70. [PMID: 17574507 DOI: 10.1007/s10047-006-0368-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2005] [Accepted: 12/12/2006] [Indexed: 10/23/2022]
Abstract
The development of mechanical circulatory support devices at the University of Tokyo has focused on developing a small total artificial heart (TAH) since achieving 532 days of survival of an animal with a paracorporial pneumatically driven TAH. The undulation pump was invented to meet this purpose. The undulation pump total artificial heart (UPTAH) is an implantable TAH that uses an undulation pump. To date, the UPTAH has been implanted in 71 goats weighting from 39 to 72 kg. The control methods are very important in animal experiments, and sucking control was developed to prevent atrial sucking. Rapid left-right balance control was performed by monitoring left atrial pressure to prevent acute lung edema caused by the rapid increase in both arterial pressure and venous return associated with the animal becoming agitated. Additionally, 1/R control was applied to stabilize the right atrial pressure. By applying these control methods, seven goats survived more than 1 month. The maximum survival period was 63 days. We are expecting to carry out longer term animal experiments with a recent model of TAH. In addition to the TAH, an undulation pump ventricular assist device (UPVAD), which is an implantable ventricular assist device (VAD), has been in development since 2002, based on the technology of the UPTAH. The UPVAD was implanted in six goats; three goats survived for more than 1 month. While further research and development is required to complete the the UPVAD system, the UPVAD has good potential to be realized as an implantable pulsatile-flow VAD.
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Affiliation(s)
- Yusuke Abe
- Department of Biomedical Engineering, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.
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40
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Polska E, Schima H, Wieselthaler G, Schmetterer L. Choroidal Microcirculation in Patients With Rotary Cardiac Assist Device. J Heart Lung Transplant 2007; 26:572-8. [PMID: 17543779 DOI: 10.1016/j.healun.2007.03.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2006] [Revised: 02/14/2007] [Accepted: 03/09/2007] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND In recent years, fully implanted rotary blood pumps have been used for long-term cardiac assist in patients with end-stage heart failure. With these pumps, the pulsatility of arterial blood flow and arterial pressure pulse is considerably reduced. Effects on end-organ perfusion, particularly microcirculation, have been assessed. METHODS The ocular choroid offers a unique opportunity to study the pulsatile component of blood flow by measurement of fundus pulsation amplitude (FPA) as well as the microcirculation by laser Doppler flowmetry. Both techniques were applied in three male patients with rotary pumps (MicroMed DeBakey VAD), in whom pump velocity was adjusted to four levels of flow between individual minimal need and maximal support. In addition, blood flow velocities in the ophthalmic artery (peak, end-diastolic and mean flow velocity--PSV, EDV and MFV, respectively) were measured using color Doppler imaging. RESULTS Systolic blood pressure increased by 6 to 22 mm Hg with increasing support. At maximal support FPA was reduced by -60% to -52% as compared with minimal pump support. Blood flow in the choroidal microvasculature, however, did not show relevant changes. A reduction in PSV (-31%, range -47% to -21%) and a pronounced rise in EDV (+93%, range +28% to +147%) was observed, whereas MFV was independent of pump flow. CONCLUSIONS Our data indicate that mean choroidal blood flow is maintained when pump support is varied within therapeutic values, whereas the ratio of pulsatile to non-pulsatile choroidal flow changes. This study shows that, in patients with ventricular assist devices, a normal perfusion rate in the ocular microcirculation is maintained over a wide range of support conditions.
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Affiliation(s)
- Elzbieta Polska
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
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41
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Pae WE, Connell JM, Adelowo A, Boehmer JP, Korfer R, El-Banayosy A, Hetzer R, Vigano M, Pavie A. Does total implantability reduce infection with the use of a left ventricular assist device? The LionHeart experience in Europe. J Heart Lung Transplant 2007; 26:219-29. [PMID: 17346623 DOI: 10.1016/j.healun.2006.12.007] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2005] [Revised: 10/18/2006] [Accepted: 12/12/2006] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Infection is the leading cause of death for left ventricular assist device (LVAD) patients with end-stage heart failure. Decreased infection may be possible with fully implantable LVADs such as the LionHeart, which lacks percutaneous conduits (PCs), a common source of device-related infection (DRI). This sub-study reports infections with the LionHeart and compares these results with historic data from the REMATCH trial, bridge to recovery (BTR) and bridge-to-transplantation (BTT) studies. METHODS Twenty-three patients were implanted with the LionHeart LVAD and followed until death or heart transplant during a non-randomized, multicenter, European trial from October 1999 to April 2004. The nature and incidence of infection were analyzed and adjudicated to definitions similar to, or the same as, the REMATCH definitions. RESULTS The combined number of implant days was 7,980, with a mean of 347 days (median 112, range 17 to 1,259 days). Survival at 1 year was 39%, with 2-year survival at 22%. Seventy-four percent of patients developed one or more infections, with 30% developing sepsis, and 35% developing pump-pocket infections (PSIs). No patients developed pump-housing or inflow- or outflow-tract infections (PI). For comparison, the prevalence rates of sepsis, PSI and PI in REMATCH were 51%, 35% and 19%, respectively. CONCLUSIONS The patients in the European LionHeart Clinical Utility Baseline Study (CUBS) trial had less sepsis and less overall DRI compared with the REMATCH LVAD group. Therefore, the fully implanted device may cause less infection than PC devices during destination therapy (DT). Although lower for DT, these rates are still higher than for some BTT experiences. Areas for future improvement include miniaturization of controller/battery components to reduce wound complications related to pocket size, and installation of more modern lithium-ion batteries to decrease the need for re-operations due to battery end-of-life.
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Affiliation(s)
- Walter E Pae
- Heart and Vascular Institute, Milton S. Hershey Medical Center, Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033-0850, USA.
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Jahanyar J, Noon GP, Koerner MM, Youker KA, Malaisrie SC, Ngo UQ, Torre-Amione G, Loebe M. Recurrent device thrombi during mechanical circulatory support with an axial-flow pump is a treatable condition and does not preclude successful long-term support. J Heart Lung Transplant 2007; 26:200-3. [PMID: 17258157 DOI: 10.1016/j.healun.2006.11.602] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2006] [Revised: 09/27/2006] [Accepted: 11/21/2006] [Indexed: 11/27/2022] Open
Abstract
The formation of pump thrombus after implantation of axial-flow ventricular assist devices has been described previously. We report a case of recurrent pump thrombus formation in a 63-year-old man who was bridged to heart transplantation with a MicroMed DeBakey ventricular assist device. He was treated with a low, dose-adjusted thrombolytic treatment protocol, and was subsequently successfully bridged to transplantation. Transient pump thrombus formation does not preclude safe long-term support with an axial-flow pump when diagnosed and treated appropriately.
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Affiliation(s)
- Jama Jahanyar
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas 77030, USA.
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Flecher E, Joudinaud T. [The results of the artificial heart]. Ann Cardiol Angeiol (Paris) 2007; 56:54-9. [PMID: 17343040 DOI: 10.1016/j.ancard.2006.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The artificial heart is no more a dream but a reality. Over the last 40 years, many circulatory assist devices have been developed. First were the pneumatic devices, external or implantable, providing uni- or biventricular support; next were the partially implantable electromecanical devices. We went from the first generation of devices with all components (pump, energy power, control system) outside of the body to the second generation of devices with the pump and the motor implanted inside the body. Recently, the third generation of artificial hearts appeared with all components implanted inside the body allowing better mobility and quality of life. Results depend on the indication and on the kind of artificial heart implanted: partial (native heart still in place) or total (native heart removed). Essentially developped as a bridge to transplant, the artificial heart is now allowed as destination therapy.
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Affiliation(s)
- E Flecher
- Service de chirurgie thoracique et cardiovasculaire, hôpital Pontchaillou, 2, rue Henri-Le-Guilloux, 35000 Rennes, France.
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Abstract
Ventricular assist device therapy is continuing to evolve in the practice of pediatric cardiac surgery. Although ECMO is still the most often applied mechanical support for infants and young children, a broader range of pulsatile, paracorporeal, as well as implantable ventricular assist devices are now available for pediatric application. A number of these innovative devices have been developed specifically for pediatric use with miniaturized pumps and optimized cannulas suitable for the entire age range of pediatric patients including neonates. Unlike ECMO, these devices can offer medium- to long-term support and have been successfully utilized as a bridge to transplant as well as a bridge to recovery. This review examines the different types of devices currently available, their clinical indications for use, future devices, and the current results of pediatric ventricular assist device therapy in the treatment of heart failure in the pediatric population.
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Affiliation(s)
- Francis Fynn-Thompson
- Department of Cardiac Surgery, Childrens Hospital Boston, Harvard Medical School, 300 Longwood Avenue, Bader 273, Boston, MA 02115, USA.
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Pae WE, Connell JM, Boehmer JP, Korfer R, El-Banayosy A, Hetzer R, Vigano M, Pavie A. Neurologic Events With a Totally Implantable Left Ventricular Assist Device: European LionHeart Clinical Utility Baseline Study (CUBS). J Heart Lung Transplant 2007; 26:1-8. [PMID: 17234510 DOI: 10.1016/j.healun.2006.10.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2006] [Revised: 09/15/2006] [Accepted: 10/19/2006] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Neurologic events such as thromboembolic and hemorrhagic strokes are common complications of mechanical circulatory support. We report the neurologic events observed in patients treated for end-stage heart failure with the implantable, pulsatile LionHeart left ventricular assist device (LVAD). This sub-study was part of the LionHeart European Clinical Utility Baseline Study (CUBS). METHODS Twenty-three male patients were implanted with the LionHeart LVAD in a non-randomized, observational study. Neurologic events were classified into three categories: (1) transient ischemic attacks (TIAs); (2) strokes, including cerebrovascular accidents (CVAs) and intracranial bleeding (ICB); and (3) "other," including hypoperfusion, coma and brain death. Neurologic injuries were also categorized as transient/reversible or permanent/disabling. RESULTS Thirteen of 23 patients (57%) had a total of 30 neurologic events. Eight patients (35%) had 18 TIAs. Eight patients (35%) also had a stroke, either CVA (n = 5, 22%) or ICB (n = 3, 13%), and 5 of these patients (22%) also had 12 TIAs. Three patients (13%) had 4 "other" neurologic events. Ten patients (43%) had transient/reversible neurologic deficits and 10 (43%) had permanent/disabling events. One patient (4%) had intracranial bleeding as a primary cause of death (anti-coagulation-related hemorrhage). The combined incidence of neurologic events was 1.37 events/patient-year. The incidences of transient and permanent events were 0.91 and 0.46 event/patient-year, respectively. CONCLUSIONS Neurologic events caused morbidity in the CUBS trial, with infrequent mortality. These results are similar to previous experiences with destination therapy and underscore the need for improvements in LVAD design, patient selection and patient management to reduce the incidence of neurologic events.
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Affiliation(s)
- Walter E Pae
- Heart and Vascular Institute, Milton S. Hershey Medical Center, Pennsylvania State University College of Medicine, Hershey, Pennsylvania 17033-0850, USA.
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Flecher E, Joudinaud T. [Clinical experiences with the new electromagnetic ventricular assist devices]. Ann Cardiol Angeiol (Paris) 2006; 55:276-81. [PMID: 17078265 DOI: 10.1016/j.ancard.2006.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Recently, the third generation of partial electromagnetic artificial hearts appeared, which are a real technological advancement. These new ventricular assist devices are small, implantable, silent and increase the patients' quality of life in comparison with the electromechanical pump of second generation. Their clinical efficiency is at least as good as the second generation in light of the first experiences reported on animals and human beings. Their use as a bridge to transplant and especially as a destination therapy should increase in the coming years as they represent an answer to the health problem, which is the increasing population of patients in heart failure.
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Affiliation(s)
- E Flecher
- Service de chirurgie thoracique et cardiovasculaire, hôpital Pontchaillou, 2, rue Henri-Le-Guilloux, 35033 Rennes cedex 09, France.
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Sharples LD, Dyer M, Cafferty F, Demiris N, Freeman C, Banner NR, Large SR, Tsui S, Caine N, Buxton M. Cost-effectiveness of Ventricular Assist Device Use in the United Kingdom: Results From the Evaluation of Ventricular Assist Device Programme in the UK (EVAD-UK). J Heart Lung Transplant 2006; 25:1336-43. [DOI: 10.1016/j.healun.2006.09.011] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2006] [Revised: 07/27/2006] [Accepted: 09/09/2006] [Indexed: 11/15/2022] Open
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Grinda JM, Bricourt MO, Amrein C, Salvi S, Guillemain R, Francois A, Guibourt P, Deloche A, Fabiani JN. Human leukocyte antigen sensitization in ventricular assist device recipients: a lesser risk with the DeBakey axial pump. Ann Thorac Surg 2006; 80:945-8. [PMID: 16122460 DOI: 10.1016/j.athoracsur.2005.03.096] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2005] [Revised: 03/18/2005] [Accepted: 03/23/2005] [Indexed: 11/30/2022]
Abstract
BACKGROUND Previous reports, all concerning pulsatile devices, have indicated an increased risk of development of circulating antileukocyte antigen (HLA; human leukocyte antigen) antibodies during ventricular assist device (VAD) support. We investigated sensitization in patients implanted with the DeBakey VAD (MicroMed Technology, Inc, Houston, TX) axial flow pump as a bridge to heart transplantation. METHODS Inclusion criteria for this prospective study were the following. Patients implanted with the DeBakey VAD axial flow pump, without HLA antibodies prior to implantation, with a duration of support of at least one month. The HLA antibody testing for IgG and IgM class I and II antibodies was performed weekly during support, using both a complement dependant cytotoxicity assay and an enzyme-linked immunosorbent assay (ELISA). Retrospective cross match was performed for all patients transplanted. The occurrence of graft rejection was determined by regular endomyocardial biopsies after heart transplantation, graded according to the International Society for Heart and Lung Transplantation (ISHLT) guidelines. Additionally, the transfusion history was reviewed for all patients. RESULTS Fourteen patients were included representing 1,220 cumulative patient-days of support (mean duration time on support, 87 days). No patient developed detectable IgG antibodies to class I or II. One patient had a positive ELISA, corresponding to nonsignificant (6/30) class I IgM antibodies at 3 weeks postimplantation. Ten patients underwent successful heart transplantation, representing 156 cumulative months. No retrospective cross match was positive. The percentage of significant acute rejection episodes (ISHLT grade 3A or more) was 6% and 4.3% in the first 6 months and from 6 to 12 months, respectively. No vascular rejection was noted. The posttransplantation survival rate was 87% at 6 months and 75% at 1 year, respectively. CONCLUSIONS Patients implanted with the DeBakey VAD axial flow pump as a bridge to heart transplantation do not appear to be exposed to an increased risk of sensitization.
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Affiliation(s)
- Jean-Michel Grinda
- Department of Cardiovascular Surgery and Thoracic Transplantation, Hôpital Européen Georges Pompidou, Paris, France.
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Carrier M, Farinas MI, Garon A. Hemodynamic characteristics of a mixed flow pump prototype: progress report of in vitro and acute animal experiments. ASAIO J 2006; 52:373-7. [PMID: 16883115 DOI: 10.1097/01.mat.0000225264.27444.fa] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
A new dual-inlet mixed-flow blood pump was designed and tested in our laboratory. The objective of the present study was to analyze hemodynamic characteristics of the pump prototype in vitro and during acute in vivo experiments. The mixed-flow pump was first tested in vitro and then implanted in 11 pigs and 3 calves. The left ventricular apex was cannulated with the pump and an outflow graft was anastomosed to the descending thoracic aorta. Flow and pressure probes were also implanted. Animals were killed 3 to 12 hours after surgery. In 11 pigs, pump outflow averaged 3.8 +/- 0.4, 4.5 +/- 0.4, 5.2 +/- 0.8, 5.9 +/- 0.3, and 6.5 l/min at 8,000, 9,000, 10,000, 11,000, and 12,000 pump speed in rpm. Differential pressure at the pump averaged 45 +/- 6, 54 +/- 8, 68 +/- 16, 70 +/- 12, and 85 +/- 7 mm Hg at 8,000, 9,000, 10,000, 11,000 and 12,000 rpm. Mean aortic pressure averaged 64 +/- 15 mm Hg throughout the procedures. In 3 calves, mean aortic pressure and left ventricular pressure remained stable during 4, 6, and 9 hours of support at 9,500, 10,000, 10,500, 11,000, and 11,500 rpm. The hemodynamic performance of our mixed-flow pump appears satisfactory during short-term support in animals. It supports similarly to axial-flow blood pumps in clinical trials. Based on these findings, an ameliorated design of this mixed-flow pump running at smaller rotational speed against a similar pressure head is under way.
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Affiliation(s)
- Michel Carrier
- Department of Surgery, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
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