In vivo hemodynamic responses to thoracic artificial lung attachment

A zwitterionic macro-crosslinker for durable non-fouling coatings

A novel zwitterionic macro-crosslinker coating achieved superior durability over the traditional brush polymer coating.

Interactive simulator for e-Learning environments: a teaching software for health care professionals

There is an established tradition of cardiovascular simulation tools, but the application of this kind of technology in the e-Learning arena is a novel approach. This paper presents an e-Learning environment aimed at teaching the interaction of cardiovascular and lung systems to health-care professionals. Heart-lung interaction must be analyzed while assisting patients with severe respiratory problems or with heart failure in intensive care unit. Such patients can be assisted by mechanical ventilatory assistance or by thoracic artificial lung.

“In silico” cardiovascular simulator was experimented during a training course given to graduate students of the School of Specialization in Cardiology at ‘Sapienza’ University in Rome.

The training course employed CARDIOSIM^©: a numerical simulator of the cardiovascular system. Such simulator is able to reproduce pathophysiological conditions of patients affected by cardiovascular and/or lung disease. In order to study the interactions among the cardiovascular system, the natural lung and the thoracic artificial lung (TAL), the numerical model of this device has been implemented. After having reproduced a patient’s pathological condition, TAL model was applied in parallel and hybrid model during the training course.

Results obtained during the training course show that TAL parallel assistance reduces right ventricular end systolic (diastolic) volume, but increases left ventricular end systolic (diastolic) volume. The percentage changes induced by hybrid TAL assistance on haemodynamic variables are lower than those produced by parallel assistance. Only in the case of the mean pulmonary arterial pressure, there is a percentage reduction which, in case of hybrid assistance, is greater (about 40%) than in case of parallel assistance (20-30%).

At the end of the course, a short questionnaire was submitted to students in order to assess the quality of the course. The feedback obtained was positive, showing good results with respect to the degree of students’ learning and the ease of use of the software simulator.

Mechanical ventilation and thoracic artificial lung assistance during mechanical circulatory support with PUCA pump: in silico study

Patients assisted with left ventricular assist device (LVAD) may require prolonged mechanical ventilatory assistance secondary to postoperative respiratory failure. The goal of this work is the study of the interdependent effects LVAD like pulsatile catheter (PUCA) pump and mechanical ventilatory support or thoracic artificial lung (TAL), by the hemodynamic point of view, using a numerical simulator of the human cardiovascular system. In the simulator, different circulatory sections are described using lumped parameter models. Lumped parameter models have been designed to describe the hydrodynamic behavior of both PUCA pump and thoracic artificial lung. Ventricular behavior atrial and septum functions were reproduced using variable elastance model. Starting from simulated pathological conditions we studied the effects produced on some hemodynamic variables by simultaneous PUCA pump, thoracic artificial lung or mechanical ventilation assistance. Thoracic artificial lung was applied in parallel or in hybrid mode. The effects of mechanical ventilation have been simulated by changing mean intrathoracic pressure value from -4 mmHg to +5 mmHg. The hemodynamic variables observed during the simulations, in different assisted conditions, were: left and right ventricular end systolic (diastolic) volume, systolic/diastolic aortic pressure, mean pulmonary arterial pressure, left and right mean atrial pressure, mean systemic venous pressure and the total blood flow. Results show that the application of PUCA (without mechanical ventilatory assistance) increases the total blood flow, reduces the left ventricular end systolic volume and increases the diastolic aortic pressure. Parallel TAL assistance increases the right ventricular end diastolic (systolic) volume reduction both when PUCA is switched "ON" and both when PUCA is switched "OFF". By switching "OFF" the PUCA pump, it seems that parallel thoracic artificial lung assistance produces a greater cardiac output (respect to hybrid TAL assistance). Results concerning PUCA and TAL interaction produced by simulations cannot be compared with "in vivo" results since they are not presented in literature. But results concerning the effects produced by LVAD and mechanical ventilation have a trend consistent with those presented in literature.

Design and in vitro assessment of an improved, low-resistance compliant thoracic artificial lung

Current thoracic artificial lungs (TALs) have blood flow impedances greater than the natural lungs, which can result in abnormal pulmonary hemodynamics. This study investigated the impedance and gas transfer performance of a compliant TAL (cTAL). Fluid-structure interaction analysis was performed using ADINA (ADINA R&D Inc., Watertown, MA) to examine the effect of the inlet and outlet expansion angle, θ, on device impedance and blood flow patterns. Based on the results, the θ = 45° model was chosen for prototyping and in vitro testing. Glycerol was pumped through this cTAL at 2, 4, and 6 L/min at 80 and 100 beats/min, and the zeroth and first harmonic impedance moduli, Z(0) and Z(1), were calculated. Gas transfer testing was conducted at blood flow rates of 3, 5, and 7 L/min. Fluid-structure interaction results indicated that the 45° model had an ideal combination of low impedance and even blood flow patterns and was thus chosen for prototyping. In vitro, Z(0) = 0.53 ± 0.06 mm Hg/(L/min) and Z(1) = 0.86 ± 0.08 mm Hg/(L/min) at 4 L/min and 100 beats/min. Outlet PO(2) and SO(2) values were above 200 mm Hg and 99.5%, respectively, at each flow rate. Thus, the cTAL had lower impedance than hard shell TALs and excellent gas transfer.

Use of a low-resistance compliant thoracic artificial lung in the pulmonary artery to pulmonary artery configuration

BACKGROUND

Thoracic artificial lungs have been proposed as a bridge to transplant in patients with end-stage lung disease. Systemic embolic complications can occur after thoracic artificial lung attachment in the pulmonary artery to left atrium configuration. Therefore, we evaluated the function of a compliant thoracic artificial lung attached via the proximal pulmonary artery to distal main pulmonary artery configuration.

METHODS

The compliant thoracic artificial lung was attached to 5 sheep (63 ± 0.9 kg) in the proximal pulmonary artery to distal main pulmonary artery configuration. Device function and animal hemodynamics were assessed at baseline and with approximately 60%, 75%, and 90% of cardiac output diverted to the compliant thoracic artificial lung. At each condition, dobutamine (0 and 5 μg·kg(-1)·min(-1)) was used to simulate rest and exercise conditions.

RESULTS

At rest, cardiac output decreased from 6.20 ± 0.53 L/min at baseline to 5.40 ± 0.43, 4.66 ± 0.31, and 4.05 ± 0.27 L/min with 60%, 75%, and 90% of cardiac output to the compliant thoracic artificial lung, respectively (P < .01 for each flow diversion vs baseline). During exercise, cardiac output decreased from 7.85 ± 0.70 L/min at baseline to 7.46 ± 0.55, 6.93 ± 0.51, and 5.96 ± 0.44 L/min (P = .82, P = .19, and P < .01 with respect to baseline) with 60%, 75%, and 90% of cardiac output to the compliant thoracic artificial lung, respectively. The artificial lung resistance averaged 0.46 ± 0.02 and did not vary significantly with blood flow rate.

CONCLUSIONS

Use of a compliant thoracic artificial lung may be feasible in the proximal pulmonary artery to distal main pulmonary artery setting if its blood flow is held at less than 75% of cardiac output. To ensure a decrease in cardiac output of less than 10%, a blood flow rate less than 60% of cardiac output is advised.

Hemodynamic design requirements for in-series thoracic artificial lung attachment in a model of pulmonary hypertension

Recent thoracic artificial lung (TAL) prototypes have impedances lower than the natural lung. With these devices, proximal pulmonary artery (PA) to distal PA TAL attachment may be possible in patients without right ventricular dysfunction. This study examined the relationship between pulmonary system impedance and cardiac output (CO) to create TAL design constraints. A circuit with adjustable resistance and compliance (C) was attached in a PA-PA fashion with the pulmonary circulation of seven sheep with chronic pulmonary hypertension. The pulmonary system zeroth harmonic impedance modulus (Z(0)) was increased by 1, 2.5, and 4 mmHg/(L/min) above baseline. At each Z(0), C was set to 0, 0.34, and 2.1 ml/mmHg. The change in pulmonary system zeroth and first harmonic impedance moduli (ΔZ(0) and ΔZ(1)), the percent change in CO (%ΔCO), and the inlet and outlet anastomoses resistances were calculated for each situation. Results indicate that ΔZ(0) (p < 0.001) but not ΔZ(1) (p = 0.5) had a significant effect on %ΔCO and that %ΔCO = -7.45*ΔZ(0) (R(2) = 0.57). Inlet and outlet anastomoses resistances averaged 0.77 ± 0.16 and 0.10 ± 0.19 mmHg/(L/min), respectively, and the relationship between %ΔCO and TAL resistance, R(T), in mmHg/(L/min) was determined to be %ΔCO = -(7.45f)×(R(T) + 0.87), in which f = the fraction of CO through the TAL. Thus, newer TAL designs can limit %ΔCO to less than 10% if f < 0.75.

Predicted oxygenation efficacy of a thoracic artificial lung

A thoracic artificial lung (TAL) provides respiratory support for lung disease. How well a TAL improves blood oxygenation for a specific pathology depends on how the TAL is attached to the pulmonary circulation: in series with the natural lungs (NLs), in parallel, or in a hybrid series/parallel combination. A computational model, including hemodynamic and O(2) and CO(2) exchange components, predicts TAL effects on blood flow rates and gas transport in pulmonary disease states modeled by elevated pulmonary vascular resistance (PVR) or reduced oxygen diffusivity in the NLs. In most cases, parallel and series TAL attachment provide comparable, maximal oxygenation. Series, with passage of total cardiac output (CO) through the NLs, is preferred for its filtration of emboli. Hybrid TAL attachment is more complicated, requiring a third graft, yet oxygenates less well than parallel and series. With extreme elevations of PVR, as in primary pulmonary hypertension, parallel TAL attachment provides an oxygenating shunt around the high resistance of the NLs, thus unloading the right ventricle, normalizing CO, and maximizing oxygenation.

Extracorporeal CO(2) removal in ARDS

Acute respiratory distress syndrome remains one of the most clinically vexing problems in critical care. As technology continues to evolve, it is likely that extracorporeal CO(2) removal devices will become smaller, more efficient, and safer. As the risk of extracorporeal support decreases, devices' role in acute respiratory distress syndrome patients remains to be defined. This article discusses the functional properties and management techniques of CO(2) removal and intracorporeal membrane oxygenation and provides a glimpse into the future of long-term gas-exchange devices.

In-parallel artificial lung attachment at high flows in normal and pulmonary hypertension models

BACKGROUND

End-stage lung disease patients who require a thoracic artificial lung (TAL) must be extubated and rehabilitated prior to lung transplantation. The purpose of this study is to evaluate hemodynamics and TAL function under simulated rest and exercise conditions in normal and pulmonary hypertension sheep models.

METHODS

The TAL, the MC3 Biolung (MC3, Inc, Ann Arbor, MI), was attached between the pulmonary artery and left atrium in nine normal sheep and eight sheep with chronic pulmonary hypertension. An adjustable band was placed around the distal pulmonary artery to control the percentage of cardiac output (CO) diverted to the TAL. Pulmonary system hemodynamics and TAL function were assessed at baseline (no flow to the TAL) and with approximately 60%, 75%, and 90% of CO diverted to the TAL. Intravenous dobutamine (0, 2, and 5 mcg . kg(-1). min(-1)) was used to simulate rest and exercise conditions.

RESULTS

At 0 and 2 mcg . kg(-1). min(-1), CO did not change significantly with flow diversion to the TAL for both models. At 5 mcg . kg(-1). min(-1), CO decreased with increasing TAL flow up to 28% +/- 5% in normal sheep and 23% +/- 5% in pulmonary hypertension sheep at 90% flow diversion to the artificial lung. In normal sheep, the pulmonary system zeroth harmonic impedance modulus, Z(0), increased with increasing flow diversion. In hypertensive sheep, Z(0) decreased at 60% and 75% flow diversion and returned to baseline levels at 90%. The TAL outlet blood oxygen saturation was 95% or greater under all conditions.

CONCLUSIONS

Pulmonary artery to left atrial TAL use will not decrease CO during rest or mild exercise but may not allow more vigorous exercise.

Thirty-Day In-Parallel Artificial Lung Testing in Sheep

BACKGROUND

Thirty-day testing of the MC3 Biolung (MC3 Inc, Ann Arbor, MI) total artificial lung (TAL) was performed to prepare for future clinical testing.

METHODS

TAL inlet and outlet grafts were sewn to the pulmonary artery and left atrium of 8 sheep (35.6 +/- 1.6 kg), and the TAL was attached the next day. Hemodynamic and sheep blood gas data were measured every 1 to 4 hours. TAL blood gases were measured twice daily, and organ function was assessed three times per week. The TAL was replaced if its resistance increased 300% or if the oxygen content difference across the TAL decreased 25% versus baseline. After 30 days, the sheep were euthanized and necropsied.

RESULTS

Five sheep survived 30 days. Three sheep were euthanized before 30 days due to bleeding, mechanical graft failure, or gastric distress. Survivors had normal, stable hemodynamics and blood gases. Average device use was 9.5 +/- 2.1 days. TAL oxygen transfer was 108 +/- 9.2 mL/min with 51% +/- 6.3% of cardiac output flowing to the TAL. TAL resistance and flow were 1.3 +/- 0.3 mm Hg x min/L and 2.4 +/- 0.2 L/min at baseline versus 2.6 +/- 0.9 mm Hg x min/L and 2.0 +/- 0.2 L/min for the remaining 30 days. Platelet and white blood cell counts increased 88% and 84% from baseline, respectively, after 10 days and were stable thereafter. Ischemic lesions in the kidney were seen in most sheep at necropsy, but organ function was normal.

CONCLUSIONS

Thirty-day respiratory support was feasible with the Biolung, but improvements in biocompatibility and anticoagulation regimen are warranted to reduce the thrombogenicity of the device.

Advances in swine biomedical model genomics

This review is a short update on the diversity of swine biomedical models and the importance of genomics in their continued development. The swine has been used as a major mammalian model for human studies because of the similarity in size and physiology, and in organ development and disease progression. The pig model allows for deliberately timed studies, imaging of internal vessels and organs using standard human technologies, and collection of repeated peripheral samples and, at kill, detailed mucosal tissues. The ability to use pigs from the same litter, or cloned or transgenic pigs, facilitates comparative analyses and genetic mapping. The availability of numerous well defined cell lines, representing a broad range of tissues, further facilitates testing of gene expression, drug susceptibility, etc. Thus the pig is an excellent biomedical model for humans. For genomic applications it is an asset that the pig genome has high sequence and chromosome structure homology with humans. With the swine genome sequence now well advanced there are improving genetic and proteomic tools for these comparative analyses. The review will discuss some of the genomic approaches used to probe these models. The review will highlight genomic studies of melanoma and of infectious disease resistance, discussing issues to consider in designing such studies. It will end with a short discussion of the potential for genomic approaches to develop new alternatives for control of the most economically important disease of pigs, porcine reproductive and respiratory syndrome (PRRS), and the potential for applying knowledge gained with this virus for human viral infectious disease studies.

Hemodynamic Consequences of Thoracic Artificial Lung Attachment Configuration: A Computational Model

A thoracic artificial lung (TAL) is being developed to assist treatment of acute and chronic pulmonary dysfunction. The TAL is attached directly to the pulmonary circulation. Depending on pathophysiology, the TAL may be attached in series with the natural lungs (NLs), in parallel with the NLs, or in an intermediate, hybrid configuration. We developed a computational model to study hemodynamic consequences of TAL attachment configuration under pathologic conditions. The pulmonary and systemic circulations, heart, and TAL are modeled as interconnected compliances and conductances, some valved. Time-varying cardiac compliance drives the system and generates pressures and flow rates. The model includes blood pressure feedback from the sympathetic nervous system, renin-angiotensin system, and renal volume control mechanism. We used previously published results from porcine experiments to verify model accuracy. We modeled normal physiology and four disease states. A hybrid configuration with 100% cardiac output through the TAL and 40% through the NLs would deliver maximal blood flow, 3.6 to 4.6 l/min, to the TAL and be tolerated by the right ventricle. Additionally, the model suggests that reducing the large "minor loss" resistances at the graft anastomoses to the pulmonary artery would improve the hemodynamics of all TAL attachment configurations.

Hemodynamic analysis and design of a paracorporeal artificial lung device

We have extended our model of the ovine pulmonary circulation to include a model of a paracorporeal artificial lung (AL) and its attachments to the natural pulmonary circulation in two configurations: in series and in parallel. Our model of the natural lung (NL) circulation is first shown to be in agreement with hemodynamic and input impedance data from the open literature. We then study design efficacy of the AL in terms of its housing and attachments. A sensitivity analysis of the modified pulmonary circulation model reveals that there are three key parameters: inlet graft length (IGL) and the compliances of the inlet compliance chamber (CC) and housing of the artificial lung. Based on literature reports, we assume the right ventricle is well-matched to the impedance of the natural pulmonary circulation and adjust the parameters of the modeled AL circuit to achieve the best least-squares fit to natural pulmonary input impedance data. Best-fit parameters produce impedance curves that fit natural impedance well, particularly below 3 Hz, where both compliance and graft length have their largest effects. Of these parameters, the impedance profile is most sensitive to IGL. However, the compliances are important, as well, particularly at low frequencies.

Hemodynamic and Gas Transfer Properties of a Compliant Thoracic Artificial Lung

A compliant thoracic artificial lung (TAL) has been developed for acute respiratory failure or as a bridge to transplantation. The development goal was to increase TAL compliance, lower TAL impedance, and improve right ventricular function during use. Prototypes were tested in vitro and in vivo in eight pigs between 67 and 79 kg to determine hemodynamic and gas transfer properties. The in vitro compliance was 16.2 +/- 4.4 ml/mm Hg at pressures < 7.8 mm Hg and 4.3 +/- 1.1 ml/mm Hg above 7.8 mm Hg. In vivo, this compliance significantly reduced blood flow pulsatility from 1.7 at the inlet to 0.36 at the outlet. Device resistance was 1.9 and 1.8 mm Hg/(L/min) at a flow rate of 4 L/min in vitro and in vivo, respectively. Approximately 75% of the resistance was at the inlet and outlet. In vivo TAL O2 and CO2 transfer rates were 188 and 186 ml/min, respectively, at 4 L/min of blood and gas flow, and average outlet O2 saturations exceeded 98% for average flow rates up to and including the maximum tested, 5.3 L/min. The new design has a markedly improved compliance and excellent gas transfer but also possesses inlet and outlet resistances that must be reduced in future designs.