Pericardium-lined skeletal muscle ventricles: up to two years' in-circulation experience

Autobionics: a new paradigm in regenerative medicine and surgery

The concept of bionics was developed 50 years ago and represented the development of engineering and technology based on natural biological systems. Traditional applications of bionics in healthcare include artificial bionic organs that apply engineering principles to replace or augment physiological functions by integrating electronic, mechanical or electromechanical components to inherent body tissues/organs (we term this as 'exobionics'). Recently, there has been a new wave of bio-inspired treatments that act through the reorganization of the existing biological organs in an individual to enhance physiology. Here, the technology does not replace biological tissue, but rather applies engineering principles to replace or augment physiological functions by the rearrangement and manipulation of inherent tissue/organs; we term this autobionics. Examples include: dynamic cardiomyoplasty (artificial heart pump using skeletal muscle), the Ross procedure (pulmonary autograft), dynamic graciloplasty (artificial sphincter) and metabolic gastric bypass (rearranging the gastrointestinal tract to modify gut- and pancreatic-hormone release). Autobionic therapies can be classified into dynamic, static and metabolic procedures. This results in tissue redesignation (one tissue used in place of another), tissue replacement and systems reorganization (rearranging inherent organ/tissue anatomy). In some cases autobionic procedures can enhance physiological function beyond normality and represents a new era in bio-inspired versatility.

The functional and histological effects of clenbuterol on the canine skeletal muscle ventricle

BACKGROUND

We investigated the anabolic effects of the sympatho-mimetic drug clenbuterol upon pumping chambers constructed from latissimus dorsi muscle (LDM).

METHODS AND RESULTS

In control and treatment groups (n = 4 dogs each), skeletal muscle ventricles (SMVs) were constructed followed by a 3-week recuperative delay and 6-7 weeks of electrical conditioning at 2 Hz to induce phenotypic expression of fatigue resistant slow muscle fibers. The treatment group received oral administration of clenbuterol (8 microg/kg, 2x/day) during this period. The clenbuterol group increased significantly in body weight as compared with the control group (P < 0.05). In a terminal experiment, the SMVs were assessed with a mock circulation device to determine pumping performance and also were examined with regard to fiber type distribution and area in the SMVs and their contralateral in situ LDMs. Initially the clenbuterol group performed better than the control group, but by the end of a 60-min fatigue test, there were no significant differences. With regard to fiber type distribution and areas, the SMVs of the clenbuterol group exhibited a fast fiber distribution similar to unconditioned muscles (28% +/- 4%), whereas the control group showed complete transformation (100%) to slow fibers. The fast fibers of the clenbuterol group were larger than control (P < 0.05), but the slow fibers were not significantly different.

CONCLUSIONS

At the dose given, clenbuterol does induce hypertrophy and preserves the normal percentages of fiber types, possibly by hyperplasia, but it does not affect chronic pumping performance of skeletal muscle ventricles in the canine model.

Skeletal Muscle Ventricles with a Single‐Limb Conduit:. The Importance of Hemodynamic Design

BACKGROUND

Skeletal muscle ventricles (SMVs) connected to the descending thoracic aorta have the potential for providing long-term diastolic augmentation. A successful existing design employs a bifurcated conduit, but aortic constriction between the limbs of the conduit is required to ensure obligatory flow-through. Here we evaluate an alternative approach in which connection to the aorta is made by a single-limb conduit.

METHODS

In two groups of dogs SMVs were constructed from the left latissimus dorsi muscle and connected to the circulation via a single-limb conduit of length 110-120 mm (Group 1, n = 5) or 70 mm (Group 2, n = 5). The animals were followed over 10 weeks.

RESULTS

Although all animals showed significant augmentation of diastolic aortic pressure at the outset, substantial thrombus developed in the SMVs of both groups. The results were analyzed by reference to design criteria for a single-limb conduit SMV, developed from empirical, in-vitro flow studies and formulated mathematically.

CONCLUSION

The SMVs constructed in this experiment appeared to meet the criteria for adequate mixing of blood within the ventricle. They did not, however, achieve adequate exchange of blood with the circulation. Thrombosis was therefore attributable to excessive residence time of blood in the SMV and conduit. Both the experimental study and the mathematical analysis point to the need for SMVs of this configuration to be constructed closer to the aorta. Preliminary results are reported for such an experiment in the pig, in which the SMV was thrombus-free when terminated electively after 1 week.

Evaluation of a skeletal muscle energy convertor in a chronic animal model

A device is under development for powering cardiac assist devices with skeletal muscle contracting in a linear configuration by converting muscle work to hydraulic energy. Prototype devices are being implanted in goats to study device performance and associated muscle mechanics. Percutaneous hydraulic lines provide the means to control muscle load and evaluate muscle performance during an electrical conditioning protocol. Chronic implant durations ranged from 36 to 87 days in 7 goats. The latissimus dorsi muscle (LDM) insertion was reconnected to the device with a tendon loop. A sternal plate attached with bone screws, and a rib clamp secured the device. A new modular sternal mount design was implemented to eliminate plate loosening that complicated early implants. Extensive bone remodeling around the rib clamp was observed. The tendon attachment demonstrated sufficient initial strength; however, in five implants, efforts to repair the tendon were required. Device encapsulation was observed, but the device continued to cycle freely and no tethering adhesions to the device were found. Interactions between the capsule wall and LDM seemed to limit LDM movement in some cases. Development of a long-term animal model for energy convertor evaluations is an important step toward skeletal muscle powered cardiac assist.

Skeletal muscle as a myocardial substitute

Skeletal muscle has long been used in the field of cardiac surgery. Its use has progressed from providing myocardial reinforcement to assisting the heart by actively pumping blood. Early experiments revealed that skeletal muscle assistance could augment pressures and blood flow; however, the results were short-lived due to muscle fatigue. It was later shown that skeletal muscle can be conditioned electrically to be fatigue resistant and therefore may be useful for performing cardiac-type work. Once the details were formed of how to stimulate and manipulate the muscle to assist the heart, several configurations were devised. Cardiomyoplasty and aortomyoplasty refer to wrapping skeletal muscle around the heart or aorta, respectively. These techniques have been applied in humans; however, the effectiveness is controversial. Although most patients improve clinically, the hemodynamic parameters have not shown consistent improvements, and survival data are unknown. Skeletal muscle ventricles offer a promising alternative to both cardiomyoplasty and aortomyoplasty. These are completely separate pumping chambers constructed from skeletal muscle and connected to the circulation in a variety of configurations. Although these have not been tried in humans, the animal data appear quite convincing. The skeletal muscle ventricles have shown the greatest improvements on hemodynamic parameters with great stability over time.

Aortic valve repair by cusp extension with the use of fresh autologous pericardium in children with rheumatic aortic insufficiency

OBJECTIVES

Our goal was to evaluate the midterm results of aortic valve repair by a more sophisticated tailoring of cusp extension-taking into account the dimensions of the native aortic cusps-with the use of fresh autologous pericardium.

PATIENTS AND METHODS

Forty-one children who had severe rheumatic aortic insufficiency (mean age 11.5 +/- 2.7 years) underwent aortic valve repair by means of this cusp extension technique over a 5-year period. Twenty-four of them underwent concomitant mitral valve repair for associated rheumatic mitral valve disease. All children were then followed up by transthoracic echocardiography before discharge, at 3 and 6 months after the operation, and at yearly intervals thereafter.

RESULTS

Follow-up was complete in all patients and ranged from 3 months to 5 years (median 3 years). No operative and no early postoperative deaths occurred. Only 1 patient died, 9 months after the operation, of septicemia and multiple organ failure. Actuarial survival was 97% at 1 year and has remained unchanged at 3 years. On discharge, the degree of aortic insufficiency was grade 0 for 27 children and grade I for 14. Exacerbation of aortic insufficiency from grade I to grade II was observed in only 1 patient, and none of the children required reoperation for aortic insufficiency during the follow-up period. Mean peak systolic aortic valve gradients at discharge were lower than preoperative values (P =.04), and no significant increase in the peak systolic transvalvular gradient was detected thereafter during the follow-up period. Mean left ventricular dimensions were significantly reduced at discharge when compared with preoperative values (P <.0001).

CONCLUSIONS

Functional results of aortic valve repair with cusp extension using fresh pericardium have been satisfactory at medium term, particularly in children with a small aortic anulus at the time of initial repair, because the expansion potential of fresh autologous pericardium is equivalent to that of the growing sinotubular junction and aortic anulus diameters.

Permanent cardiac assistance from skeletal muscle: a prospect for the new millennium

This paper looks at the prospects for new surgical solutions to the problem of end-stage heart failure based on cardiac assistance from skeletal muscle. The current status of the main biological approaches, cardiomyoplasty, aortomyoplasty, and the skeletal muscle ventricle, are discussed, followed by a consideration of some of the important basic issues that need to be addressed if these techniques are to achieve their full potential. Although there is a review element to the paper, the main emphasis is on the work of our own research group and collaborating workers.

Multifunctional implantable nerve stimulator for cardiac assistance by skeletal muscle

Different methods are used, clinically and experimentally, to assist severely impaired heart function by means of skeletal muscle. The efficiency of these methods is restricted by skeletal muscle losing strength after transpositioning and during conditioning and not being sufficiently resistant to fatigue. This is mainly due to the nonphysiological activation of the nerves by electrical stimulation. We have developed a battery operated, ECG triggered multichannel implant that is capable of implementing various advanced stimulation techniques. The stimulator can activate 2 skeletal muscles via the motor nerves. It allows for application of multichannel stimulation methods, i.e., carousel stimulation and sequential stimulation, as well as the programming of optimized pulse trains. Synchronization delay and burst duration can be automatically and dynamically adapted to the heart rate. The multichannel stimulator is hermetically sealed in a titanium case. Its calculated life span on the basis of the integrated battery is 3-5 years, depending on the programmed stimulation parameters. The implant dimensions are 65 x 17 mm (diameter x height), and it weighs 93 g. The implant has been tested in vitro as well as in vivo.

Power output of pericardium-lined skeletal muscle ventricles, left ventricular apex to aorta configuration: up to eight months in circulation

OBJECTIVE

The purpose of this experiment was to evaluate the potential for a skeletal muscle ventricle connected to the circulation between the left ventricle and the aorta to provide effective, long-term cardiac assist.

METHODS

Skeletal muscle ventricles were constructed from the latissimus muscle in 10 dogs. After conditioning, the skeletal muscle ventricles were connected to the left ventricle and the aorta with 2 valved conduits. The skeletal muscle ventricle was programmed to contract during diastole.

RESULTS

At time of implantation, skeletal muscle ventricles stimulated at 33 Hz and in a 1:2 ratio with the heart significantly decreased left ventricular work by 56% (P <.01) and at 50 Hz by 65% (P <.01). At a 1:2 ratio, the power output of the skeletal muscle ventricles was 59% of left ventricular power output at 33 Hz (P <. 01) and 93% at 50 Hz (P <.01). Animals survived 7, 11, 16, 17, 72, 99, 115, 214, and 249 days. Three deaths were directly related to the skeletal muscle ventricle. One animal is alive at 228 days. In the animal that survived 249 days, skeletal muscle ventricle power output at 8 months with a 33 Hz stimulation frequency and a 1:2 contraction ratio was 57% of left ventricular power output and 82% at 50 Hz. At a 1:1 ratio, skeletal muscle ventricle power output was 97% and 173% of the left ventricle at 33 and 50 Hz, respectively.

CONCLUSIONS

Left ventricular assist with a skeletal muscle ventricle connected between the left ventricle and the aorta is the most hemodynamically effective configuration we have tested and can maintain significant power output up to 8 months.

Skeletal muscle ventricles: full versus half aortic ligation

BACKGROUND

Skeletal muscle ventricles have been shown to provide effective aortic diastolic counterpulsation in an experimental model. Construction has included full ligation of the thoracic aorta. The authors sought to determine if these muscle pumps could function effectively without fully ligating the aorta.

METHODS

Skeletal muscle ventricles were constructed in two groups of dogs. Group 1 had their aortas fully ligated (n = 10) while group 2 had their aortas narrowed by 50% (n = 10). The animals were followed for 10 weeks.

RESULTS

There was no significant difference in femoral diastolic augmentation at implant or at 10 weeks (19.1% +/- 9.9% in group 1 [full ligation] versus 16.3% +/- 10.2% in group 2 [half ligation] p = 0.502). Survival to 10 weeks was significantly better in group 1 (full ligation). Nine of 10 animals in this group survived versus 4 of 10 in group 2 (p = 0.019). Two animals survived in the half ligation group with effective augmentation and without thrombus formation.

CONCLUSION

Both models produce effective diastolic counterpulsation. Survival was decreased in this model using half ligation, and survival without complication was observed in 2 of 10 animals. Currently the overall results are better with the full aortic ligation model. However, design modifications will probably result in an effective model of diastolic counterpulsation without full aortic ligation.