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Huang X, Shen Y, Liu Y, Zhang H. Current status and future directions in pediatric ventricular assist device. Heart Fail Rev 2024; 29:769-784. [PMID: 38530587 DOI: 10.1007/s10741-024-10396-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/07/2024] [Indexed: 03/28/2024]
Abstract
A ventricular assist device (VAD) is a form of mechanical circulatory support that uses a mechanical pump to partially or fully take over the function of a failed heart. In recent decades, the VAD has become a crucial option in the treatment of end-stage heart failure in adult patients. However, due to the lack of suitable devices and more complicated patient profiles, this therapeutic approach is still not widely used for pediatric populations. This article reviews the clinically available devices, adverse events, and future directions of design and implementation in pediatric VADs.
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Affiliation(s)
- Xu Huang
- Heart Center and Shanghai Institute of Pediatric Congenital Heart Disease, Shanghai Children's Medical Center, National Children's Medical Center, Shanghai Jiaotong University School of Medicine, No. 1678, Dongfang Rd, Pudong District, Shanghai, 200127, China
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, National Children's Medical Center, Shanghai Jiaotong University School of Medicine, No. 1678, Dongfang Rd, Pudong District, Shanghai, 200127, China
- Shanghai Clinical Research Center for Rare Pediatric Diseases, Shanghai Children's Medical Center, National Children's Medical Center, Shanghai Jiaotong University School of Medicine, No. 1678, Dongfang Rd, Pudong District, Shanghai, 200127, China
| | - Yi Shen
- Heart Center and Shanghai Institute of Pediatric Congenital Heart Disease, Shanghai Children's Medical Center, National Children's Medical Center, Shanghai Jiaotong University School of Medicine, No. 1678, Dongfang Rd, Pudong District, Shanghai, 200127, China
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, National Children's Medical Center, Shanghai Jiaotong University School of Medicine, No. 1678, Dongfang Rd, Pudong District, Shanghai, 200127, China
- Shanghai Clinical Research Center for Rare Pediatric Diseases, Shanghai Children's Medical Center, National Children's Medical Center, Shanghai Jiaotong University School of Medicine, No. 1678, Dongfang Rd, Pudong District, Shanghai, 200127, China
| | - Yiwei Liu
- Heart Center and Shanghai Institute of Pediatric Congenital Heart Disease, Shanghai Children's Medical Center, National Children's Medical Center, Shanghai Jiaotong University School of Medicine, No. 1678, Dongfang Rd, Pudong District, Shanghai, 200127, China.
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, National Children's Medical Center, Shanghai Jiaotong University School of Medicine, No. 1678, Dongfang Rd, Pudong District, Shanghai, 200127, China.
- Shanghai Clinical Research Center for Rare Pediatric Diseases, Shanghai Children's Medical Center, National Children's Medical Center, Shanghai Jiaotong University School of Medicine, No. 1678, Dongfang Rd, Pudong District, Shanghai, 200127, China.
| | - Hao Zhang
- Heart Center and Shanghai Institute of Pediatric Congenital Heart Disease, Shanghai Children's Medical Center, National Children's Medical Center, Shanghai Jiaotong University School of Medicine, No. 1678, Dongfang Rd, Pudong District, Shanghai, 200127, China.
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, National Children's Medical Center, Shanghai Jiaotong University School of Medicine, No. 1678, Dongfang Rd, Pudong District, Shanghai, 200127, China.
- Shanghai Clinical Research Center for Rare Pediatric Diseases, Shanghai Children's Medical Center, National Children's Medical Center, Shanghai Jiaotong University School of Medicine, No. 1678, Dongfang Rd, Pudong District, Shanghai, 200127, China.
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2
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Saura O, Luyt CE. Procalcitonin as a biomarker to guide treatments for patients with lower respiratory tract infections. Expert Rev Respir Med 2023; 17:651-661. [PMID: 37639716 DOI: 10.1080/17476348.2023.2251394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 08/21/2023] [Indexed: 08/31/2023]
Abstract
INTRODUCTION Lower respiratory tract infections are amongst the main causes for hospital/intensive care unit admissions and antimicrobial prescriptions. In order to reduce antimicrobial pressure, antibiotic administration could be optimized through procalcitonin-based algorithms. AREAS COVERED In this review, we discuss the performances of procalcitonin for the diagnosis and the management of community-acquired and ventilator-associated pneumonia. We provide up-to-date evidence and deliver clear messages regarding the purpose of procalcitonin to reduce unnecessary antimicrobial exposure. EXPERT OPINION Antimicrobial pressure and resulting antimicrobial resistances are a major public health issue as well as a daily struggle in the management of patients with severe infectious diseases, especially in intensive care units where antibiotic exposure is high. Procalcitonin-guided antibiotic administration has proven its efficacy in reducing unnecessary antibiotic use in lower respiratory tract infections without excess in mortality, hospital length of stay or disease relapse. Procalcitonin-guided algorithms should be implemented in wards taking care of patients with severe infections. However, procalcitonin performances are different regarding the setting of the infection (community versus hospital-acquired infections) the antibiotic management (start or termination of antibiotic) as well as patient's condition (immunosuppressed or in shock) and we encourage the physicians to be aware of these limitations.
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Affiliation(s)
- Ouriel Saura
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Charles-Edouard Luyt
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France
- INSERM, UMRS_1166, ICAN Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France
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3
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Kanagarajan D, Heinsar S, Gandini L, Suen JY, Dau VT, Pauls J, Fraser JF. Preclinical Studies on Pulsatile Veno-Arterial Extracorporeal Membrane Oxygenation: A Systematic Review. ASAIO J 2023; 69:e167-e180. [PMID: 36976324 DOI: 10.1097/mat.0000000000001922] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
Refractory cardiogenic shock is increasingly being treated with veno-arterial extracorporeal membrane oxygenation (V-A ECMO), without definitive proof of improved clinical outcomes. Recently, pulsatile V-A ECMO has been developed to address some of the shortcomings of contemporary continuous-flow devices. To describe current pulsatile V-A ECMO studies, we conducted a systematic review of all preclinical studies in this area. We adhered to PRISMA and Cochrane guidelines for conducting systematic reviews. The literature search was performed using Science Direct, Web of Science, Scopus, and PubMed databases. All preclinical experimental studies investigating pulsatile V-A ECMO and published before July 26, 2022 were included. We extracted data relating to the 1) ECMO circuits, 2) pulsatile blood flow conditions, 3) key study outcomes, and 4) other relevant experimental conditions. Forty-five manuscripts of pulsatile V-A ECMO were included in this review detailing 26 in vitro , two in silico , and 17 in vivo experiments. Hemodynamic energy production was the most investigated outcome (69%). A total of 53% of studies used a diagonal pump to achieve pulsatile flow. Most literature on pulsatile V-A ECMO focuses on hemodynamic energy production, whereas its potential clinical effects such as favorable heart and brain function, end-organ microcirculation, and decreased inflammation remain inconclusive and limited.
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Affiliation(s)
- Dhayananth Kanagarajan
- From the Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- School of Engineering and Built Environment, Griffith University, Gold Coast, Queensland, Australia
| | - Silver Heinsar
- From the Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Department of Intensive Care, North Estonia Medical Centre, Tallinn, Estonia
| | - Lucia Gandini
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Jacky Y Suen
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Van Thanh Dau
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Jo Pauls
- From the Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- School of Engineering and Built Environment, Griffith University, Gold Coast, Queensland, Australia
| | - John F Fraser
- From the Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- School of Engineering and Built Environment, Griffith University, Gold Coast, Queensland, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
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4
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Liebetrau C, Eggebrecht H, Schmermund A. Mechanische Kreislaufunterstützungssysteme. Herz 2022; 47:513-517. [DOI: 10.1007/s00059-022-05145-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2022] [Indexed: 11/06/2022]
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Malfertheiner MV, Broman LM, Vercaemst L, Belliato M, Aliberti A, Di Nardo M, Swol J, Barrett N, Pappalardo F, Bělohlávek J, Taccone FS, Millar JE, Crawford L, Lorusso R, Suen JY, Fraser JF. Ex vivo models for research in extracorporeal membrane oxygenation: a systematic review of the literature. Perfusion 2021; 35:38-49. [PMID: 32397884 DOI: 10.1177/0267659120907439] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
With ongoing progress of components of extracorporeal membrane oxygenation including improvements of oxygenators, pumps, and coating materials, extracorporeal membrane oxygenation became increasingly accepted in the clinical practice. A suitable testing in an adequate setup is essential for the development of new technical aspects. Relevant tests can be conducted in ex vivo models specifically designed to test certain aspects. Different setups have been used in the past for specific research questions. We conducted a systematic literature review of ex vivo models of extracorporeal membrane oxygenation components. MEDLINE and Embase were searched between January 1996 and October 2017. The inclusion criteria were ex vivo models including features of extracorporeal membrane oxygenation technology. The exclusion criteria were clinical studies, abstracts, studies in which the model of extracorporeal membrane oxygenation has been reported previously, and studies not reporting on extracorporeal membrane oxygenation components. A total of 50 studies reporting on different ex vivo extracorporeal membrane oxygenation models have been identified from the literature search. Models have been grouped according to the specific research question they were designed to test for. The groups are focused on oxygenator performance, pump performance, hemostasis, and pharmacokinetics. Pre-clinical testing including use of ex vivo models is an important step in the development and improvement of extracorporeal membrane oxygenation components and materials. Furthermore, ex vivo models offer valuable insights for clinicians to better understand the consequences of choice of components, setup, and management of an extracorporeal membrane oxygenation circuit in any given condition. There is a need to standardize the reporting of pre-clinical studies in this area and to develop best practice in their design.
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Affiliation(s)
| | - Lars Mikael Broman
- ECMO Centre Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Leen Vercaemst
- Perfusion Department, University Hospital Gasthuisberg, Louvain, Belgium
| | - Mirko Belliato
- U.O.C. Anestesia e Rianimazione 1, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Anna Aliberti
- U.O.C. Anestesia e Rianimazione 1, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Matteo Di Nardo
- Pediatric Intensive Care Unit, Children's Hospital Bambino Gesù, IRCCS, Rome, Italy
| | - Justyna Swol
- Department of Pulmonology, Intensive Care Medicine, Paracelsus Medical University, Nuremberg, Germany
| | - Nicholas Barrett
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Federico Pappalardo
- Department of Cardiothoracic Anesthesia and Intensive Care, San Raffaele Hospital, Milan, Italy
| | - Jan Bělohlávek
- Second Department of Medicine, Cardiovascular Medicine, General University Hospital in Prague, First Faculty of Medicine, Charles University in Prague, Praha, Czech Republic
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | | | - Lachlan Crawford
- Critical Care Research Group, Prince Charles Hospital, Brisbane, QLD, Australia
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Hospital (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Jacky Y Suen
- Critical Care Research Group, Prince Charles Hospital, Brisbane, QLD, Australia
| | - John F Fraser
- Critical Care Research Group, Prince Charles Hospital, Brisbane, QLD, Australia
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Emced K. Atrial fibrillation and gamma glutamyl transferase; Off-pump versus on-pump Coronary Artery Bypass surgery. SANAMED 2020. [DOI: 10.24125/sanamed.v15i2.440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Introduction: Atrial fibrillation (AF) which can be seen as a complication of the open-heart surgery, may cause serious problems on postoperative period. The exact pathophysiology of AF is unknown but it is thought that factors such as oxidative stress might cause AF. Material and methods: We retrospectively surveyed the serum gamma-glutamyl transferase (GGT) levels which is accepted as a mediator of oxidative stres, for the Post Operative Atrial Fibrillation (POAF) that occur after of-pump versus on-pump Coronary Artery Bypass Graft (CABG) surgery. Our study included 183 cases (101 male, 72 female; median age 63 ± 4.3 years) of which CABG was performed. Results: Echocardiography, routine blood tests, electrocardiography (ECG), test for the serum GGT levels were performed in preoperative and postoperative period to all participants. AF developed in 34 patients (35 %) in Group I and 19 patients (20 %) in Group II. There were no significant differences between two groups (of-pump versus on-pump) in terms of gender, cardiovascular risk factors and the severity of the coronary artery disease. In patients who has developed AF in postoperative period had significantly higher serum GGT levels. Conclusion: This study has shown that serum GGT levels were found to be significantly higher in patients whom AF has developed after on-pump CABG surgery.
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Wang S, Moroi MK, Force M, Kunselman AR, Ündar A. Impact of Heart Rate on Pulsatile Hemodynamic Performance in a Neonatal ECG-Synchronized ECLS System. Artif Organs 2018; 43:81-89. [PMID: 30151915 DOI: 10.1111/aor.13273] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The experimental circuit consisted of an i-cor diagonal pump, a Medos Hilite 800 LT oxygenator, an 8Fr Biomedicus arterial cannula, a 10Fr Biomedicus venous cannula, and six feet of 1/4 in ID tubing for arterial and venous lines. The circuit was primed with lactated Ringer's solution and packed red blood cells (hematocrit 40%). Trials were conducted at various heart rates (90, 120, and 150 bpm) and flow rates (200, 400, and 600mL/min) under nonpulsatile and pulsatile mode with pulsatile amplitudes of 1000-4000rpm (1000 rpm increments). Real-time pressure and flow data were recorded for analysis. The i-cor pump was capable of creating nonpulsatile and electrocardiography (ECG)-synchronized pulsatile flow, and automatically reducing pulsatile frequency by increasing the assist ratio at higher heart rates. Reduced pulsatile frequency led to lower hemodynamic energy generation but did not affect circuit pressure drop. Pulsatile flow delivered more hemodynamic energy to the pseudopatient when compared with nonpulsatile flow. The pump generated more hemodynamic energy with higher pulsatile amplitudes. The i-cor pump can automatically adjust the pulsatile assist ratio to create pulsatile flow at higher heart rates, although this caused some hemodynamic energy loss. Compared with nonpulsatile flow, pulsatile flow generated and transferred more hemodynamic energy to the neonate during ECLS (200-600mL/min), especially at high pulsatile amplitudes and low flow rates.
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Affiliation(s)
- Shigang Wang
- Penn State Health Pediatric Cardiovascular Research Center, Department of Pediatrics, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, PA, USA
| | - Morgan K Moroi
- Penn State Health Pediatric Cardiovascular Research Center, Department of Pediatrics, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, PA, USA
| | - Madison Force
- Penn State Health Pediatric Cardiovascular Research Center, Department of Pediatrics, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, PA, USA
| | - Allen R Kunselman
- Health and Sciences, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, PA, USA
| | - Akif Ündar
- Penn State Health Pediatric Cardiovascular Research Center, Department of Pediatrics, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, PA, USA.,Department of Surgery and Bioengineering, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, PA, USA
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Wang S, Moroi M, Brehm CE, Kunselman AR, Ündar A. In Vitro Hemodynamic Evaluation of an Adult Pulsatile Extracorporeal Membrane Oxygenation System. Artif Organs 2018; 42:E234-E245. [PMID: 29774551 DOI: 10.1111/aor.13156] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 03/14/2018] [Accepted: 03/15/2018] [Indexed: 01/02/2023]
Abstract
The objective of this study was to evaluate a pulsatile extracorporeal membrane oxygenation (ECMO) system in terms of hemodynamic energy generation and transmission under various pulsatile amplitudes, flow rates, and pseudopatient pressures in a simulated adult ECMO circuit. Surplus hemodynamic energy (SHE), a measure of the quality of pulsatility, was used to quantify pulsatile flow. The circuit consisted of an i-cor diagonal pump, an adult XLung oxygenator, a 21 Fr Medtronic Biomedicus femoral arterial cannula, a 23/25 Fr Sorin RAP femoral venous cannula, and 3/8 in ID tubing for both arterial and venous lines. The circuit was primed with lactated Ringer's solution and then packed red blood cells (hematocrit 37%). Trials were conducted at 36°C with flow rates of 2-5 L/min (1 L/min increments) under nonpulsatile and pulsatile mode with pulsatile amplitudes of 1000-5000 rpm (1000 rpm increments). The pseudopatient pressure was maintained at 40-100 mm Hg (20 mm Hg increments). Real-time pressure and flow data were recorded for analysis using a custom-made data acquisition system. There was no SHE generated by the pump under nonpulsatile mode. Under pulsatile mode, SHE levels increased with increasing pulsatile amplitude and pseudopatient pressure (P < 0.01) but decreased with increasing flow rate. SHE levels were significantly higher at flow rates of 2-4 L/min. In addition, the XLung oxygenator had acceptable pressure drops (36.1-104.9 mm Hg) and percentages of total hemodynamic energy loss (19.6-43.9%) during all trials. The novel pulsatile ECMO system can create nonpulsatile and pulsatile flow in an adult ECMO model. However, pulsatility gradually weakened with increasing flow rates. Pulsatile amplitude settings were found to have a great impact on pulsatility.
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Affiliation(s)
- Shigang Wang
- Department of Pediatrics, Penn State Health Pediatric Cardiovascular Research Center, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, PA, USA
| | - Morgan Moroi
- Department of Pediatrics, Penn State Health Pediatric Cardiovascular Research Center, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, PA, USA
| | - Christoph E Brehm
- Heart and Vascular Institute Critical Care Unit and Adult ECMO Program, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, PA, USA
| | - Allen R Kunselman
- Department of Public Health and Sciences, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, PA, USA
| | - Akif Ündar
- Department of Pediatrics, Penn State Health Pediatric Cardiovascular Research Center, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, PA, USA.,Department of Surgery and Bioengineering, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, PA, USA
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9
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Force M, Moroi M, Wang S, Kunselman AR, Ündar A. In Vitro Hemodynamic Evaluation of ECG-Synchronized Pulsatile Flow Using i-Cor Pump as Short-Term Cardiac Assist Device for Neonatal and Pediatric Population. Artif Organs 2018; 42:E153-E167. [PMID: 29682761 DOI: 10.1111/aor.13136] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 12/19/2017] [Accepted: 01/11/2018] [Indexed: 01/30/2023]
Abstract
The objective of this study was to assess the hemodynamic properties of the i-cor ECG-synchronized cardiac assist system for off-label use as a short-term cardiac assist device for neonatal and pediatric patients and compare nonpulsatile to pulsatile flow with different amplitudes. The circuit consisted of the i-cor diagonal pump with 3 feet of ¼ inch arterial and venous tubing and a soft-shell reservoir, primed with lactated Ringer's solution and human packed red blood cells (hematocrit 42%). Trials were conducted with three different sets of cannulas (8-Fr arterial 10-Fr venous, 10-Fr arterial 12 Fr-venous, and 12-Fr arterial 14-Fr venous) with increasing flow rates at varying pseudo-patient pressures (40, 60, 80, and 100 mm Hg) and under nonpulsatile mode and pulsatile mode with pulsatile amplitudes 2000, 2500, and 3000 rpm at 36°C. Pressure and flow waveforms were recorded using a custom-made data acquisition device for each trial. Energy equivalent pressure (EEP) was higher than mean pressure under pulsatile mode, and increased with increasing pseudo-patient's pressure and flow rate while EEP was the same as the mean pressure under nonpulsatile mode. Total hemodynamic energy (THE) levels increased with pressure and pulsatile amplitude and slightly decreased with increasing flow rate. The percent THE lost throughout the circuit increased with flow rate and pulsatile amplitude and decreased with pseudo-patient's pressure. SHE levels also increased with pseudo-patient pressure and pulsatile amplitude and decreased with increasing flow rate. The i-cor diagonal pump can be used as a short term cardiac assist device for neonatal and pediatric patients and is able to provide nonpulsatile as well as pulsatile flow. Compared with nonpulsatile flow, pulsatile flow can generate and deliver more hemodynamic energy to the patients.
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Affiliation(s)
- Madison Force
- Department of Pediatrics, Penn State Health Pediatric Cardiovascular Research Center, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, PA, USA
| | - Morgan Moroi
- Department of Pediatrics, Penn State Health Pediatric Cardiovascular Research Center, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, PA, USA
| | - Shigang Wang
- Department of Pediatrics, Penn State Health Pediatric Cardiovascular Research Center, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, PA, USA
| | - Allen R Kunselman
- Public Health and Sciences, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, PA, USA
| | - Akif Ündar
- Department of Pediatrics, Penn State Health Pediatric Cardiovascular Research Center, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, PA, USA.,Department of Surgery and Department of Bioengineering, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, PA, USA
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10
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Wang S, Patel S, Izer JM, Clark JB, Kunselman AR, Wilson RP, Ündar A. Impact of Different Perfusion Modalities on Coronary and Carotid Blood Flow Velocities in an Adult ECLS Swine Model. Artif Organs 2018; 42:918-921. [PMID: 29660857 DOI: 10.1111/aor.13141] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 01/19/2018] [Accepted: 02/13/2018] [Indexed: 11/29/2022]
Abstract
The objective of this study was to compare the effects of nonpulsatile and ECG-synchronized pulsatile extracorporeal life support on coronary and carotid blood flow velocities using transthoracic echocardiography and vascular ultrasound, respectively. Nine adult swine were randomly separated into nonpulsatile (NP, n = 5) and pulsatile (P, N = 4) groups and placed on ECLS for 24 h using an i-cor ECLS system. Noninvasive transthoracic images of the left and right coronary artery and the left carotid artery were acquired at the pre-ECLS (baseline), 30 min, 3, 6, 9, 12, and 24 h on-ECLS stages. The mean diastolic velocity of the left and right coronary arteries in the NP group significantly decreased after 24 h on ECLS compared to the baseline and 30 min ECLS stages (P < 0.05). There was no statistical difference in the mean diastolic velocity of the coronary arteries in the P group at 30 min, 3-, 6-, 9-, 12-, and 24-h ECLS compared to baseline. The P group showed a smaller decrease in the mean diastolic velocity of coronary arteries between the 30-min ECLS and 3-, 6-, 9-, 13-, 24-h ECLS stages compared to the NP group. The diastolic velocity of the left carotid artery in the NP group significantly decreased during 24-h ECLS compared to the P group (P < 0.05). An ECG-synchronized pulsatile ECLS system appeared to maintain coronary and carotid artery diastolic velocities better than conventional nonpulsatile ECLS. Further investigation of the perfusion modes during ECLS is warranted.
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Affiliation(s)
- Shigang Wang
- Department of Pediatrics, Penn State Hershey Pediatric Cardiovascular Research Center, Penn State Hershey Children's Hospital, Hershey, PA, USA
| | - Sunil Patel
- Department of Pediatrics, Penn State Hershey Pediatric Cardiovascular Research Center, Penn State Hershey Children's Hospital, Hershey, PA, USA
| | - Jenelle M Izer
- Department of Comparative Medicine, Penn State Milton S. Hershey Medical Center, Penn State Hershey College of Medicine, Penn State Hershey Children's Hospital, Hershey, PA, USA
| | - Joseph B Clark
- Department of Pediatrics, Penn State Hershey Pediatric Cardiovascular Research Center, Penn State Hershey Children's Hospital, Hershey, PA, USA.,Department of Surgery, Penn State Milton S. Hershey Medical Center, Penn State Hershey College of Medicine, Penn State Hershey Children's Hospital, Hershey, PA, USA
| | - Allen R Kunselman
- Department of Public Health and Sciences, Penn State Milton S. Hershey Medical Center, Penn State Hershey College of Medicine, Penn State Hershey Children's Hospital, Hershey, PA, USA
| | - Ronald P Wilson
- Department of Comparative Medicine, Penn State Milton S. Hershey Medical Center, Penn State Hershey College of Medicine, Penn State Hershey Children's Hospital, Hershey, PA, USA
| | - Akif Ündar
- Department of Pediatrics, Penn State Hershey Pediatric Cardiovascular Research Center, Penn State Hershey Children's Hospital, Hershey, PA, USA.,Department of Surgery, Penn State Milton S. Hershey Medical Center, Penn State Hershey College of Medicine, Penn State Hershey Children's Hospital, Hershey, PA, USA.,Department of Bioengineering, Penn State Milton S. Hershey Medical Center, Penn State Hershey College of Medicine, Penn State Hershey Children's Hospital, Hershey, PA, USA
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11
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Moroi M, Force M, Wang S, Kunselman AR, Ündar A. In Vitro Evaluation of ECG-Synchronized Pulsatile Flow Using the i-cor Diagonal Pump in Neonatal and Pediatric ECLS Systems. Artif Organs 2018; 42:E127-E140. [PMID: 29473652 DOI: 10.1111/aor.13103] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 11/30/2017] [Accepted: 12/05/2017] [Indexed: 01/02/2023]
Abstract
The objective was to assess the i-cor electrocardiogram-synchronized diagonal pump in terms of hemodynamic energy properties for off-label use in neonatal and pediatric extracorporeal life support (ECLS) circuits. The neonatal circuit consisted of an i-cor pump and console, a Medos Hilite 800 LT oxygenator, an 8Fr arterial cannula, a 10Fr venous cannula, 91 cm of 0.6-cm ID arterial tubing, and 91 cm of 0.6-cm ID venous tubing. The pediatric circuit was identical except it included a 12Fr arterial cannula, a 14Fr venous cannula, and a Medos Hilite 2400 LT oxygenator. Neonatal trials were conducted at 36°C with hematocrit 40% using varying flow rates (200-600 mL/min, 200 mL increments) and postarterial cannula pressures (40-100 mm Hg, 20 mm Hg increments) under nonpulsatile mode and pulsatile mode with various pulsatile amplitudes (1000-4000 rpm, 1000 rpm increments). Pediatric trials were conducted at different flow rates (800-1600 mL/min, 400 mL/min increments). Mean pressure and energy equivalent pressure increased with increasing postarterial cannula pressure, flow rate, and pulsatile amplitude. Physiologic-like pulsatility was achieved between pulsatile amplitudes of 2000-3000 rpm. Pressure drops were greatest across the arterial cannula. Pulsatile flow generated significantly higher total hemodynamic energy (THE) levels than nonpulsatile flow. THE levels at postarterial cannula site increased with increasing postarterial cannula pressure, pulsatile amplitude, and flow rate. No surplus hemodynamic energy (SHE) was generated under nonpulsatile mode. Under pulsatile mode, preoxygenator SHE increased with increasing postarterial cannula pressure and pulsatile amplitude, but decreased with increasing flow rate. The i-cor system can provide nonpulsatile and pulsatile flow for neonatal and pediatric ECLS. Pulsatile amplitudes of 2000-3000 rpm are recommended for use in neonatal and pediatric patients.
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Affiliation(s)
- Morgan Moroi
- Department of Pediatrics, Penn State Health Pediatric Cardiovascular Research Center, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, PA, USA
| | - Madison Force
- Department of Pediatrics, Penn State Health Pediatric Cardiovascular Research Center, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, PA, USA
| | - Shigang Wang
- Department of Pediatrics, Penn State Health Pediatric Cardiovascular Research Center, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, PA, USA
| | - Allen R Kunselman
- Public Health and Sciences, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, PA, USA
| | - Akif Ündar
- Department of Pediatrics, Penn State Health Pediatric Cardiovascular Research Center, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, PA, USA.,Department of Surgery, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, PA, USA.,Department of Bioengineering, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, PA, USA
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12
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Ündar A. The Relative Citation Ratio: Measuring Impact of Publications From an International Conference With a New NIH Metric. Artif Organs 2017; 41:1085-1091. [DOI: 10.1111/aor.13079] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 10/16/2017] [Indexed: 01/01/2023]
Affiliation(s)
- Akif Ündar
- Department of Pediatrics - H085. Penn State College of Medicine; Penn State Health Children's Hospital, 500 University Drive; Hershey PA 17033-0850 USA
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13
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Influence of Cannulation Site on Carotid Perfusion During Extracorporeal Membrane Oxygenation in a Compliant Human Aortic Model. Ann Biomed Eng 2017. [DOI: 10.1007/s10439-017-1875-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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14
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Wang S, Spencer SB, Kunselman AR, Ündar A. Novel ECG-Synchronized Pulsatile ECLS System With Various Heart Rates and Cardiac Arrhythmias: An In Vitro Study. Artif Organs 2017; 41:55-65. [DOI: 10.1111/aor.12904] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 09/30/2016] [Accepted: 11/10/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Shigang Wang
- Department of Pediatrics, Public Health and Sciences; Penn State Hershey Pediatric Cardiovascular Research Center
| | - Shannon B. Spencer
- Department of Pediatrics, Public Health and Sciences; Penn State Hershey Pediatric Cardiovascular Research Center
| | | | - Akif Ündar
- Department of Pediatrics, Public Health and Sciences; Penn State Hershey Pediatric Cardiovascular Research Center
- Surgery and Bioengineering, Penn State Hershey College of Medicine, Penn State Milton S. Hershey Medical Center; Penn State Hershey Children's Hospital; Hershey PA USA
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15
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Ündar A, Wang S, Izer JM, Clark JB, Kunselman AR, Patel S, Shank K, Profeta E, Wilson RP, Ostadal P. The Clinical Importance of Pulsatile Flow in Extracorporeal Life Support: The Penn State Health Approach. Artif Organs 2016; 40:1101-1104. [PMID: 27911024 DOI: 10.1111/aor.12875] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 08/31/2016] [Indexed: 12/25/2022]
Affiliation(s)
- Akif Ündar
- Department of Pediatrics, Penn State Health, Pediatric Cardiovascular Research Center, Department of Surgery Department of Bioengineering, Penn State College of Medicine, H085, 500 University Drivem, P.O. Box 850, Hershey, PA 17033-0850, USA
| | - Shigang Wang
- Department of Pediatrics, Penn State Health, Pediatric Cardiovascular Research Center, Penn State College of Medicine
| | - Jenelle M Izer
- Department of Comparative Medicine, Penn State College of Medicine
| | - Joseph B Clark
- Department of Pediatrics, Penn State Health, Pediatric Cardiovascular Research Center, Department of Surgery, Penn State College of Medicine
| | - Allen R Kunselman
- Department of Public Health and Sciences, Penn State College of Medicine
| | - Sunil Patel
- Department of Pediatrics, Penn State Health, Pediatric Cardiovascular Research Center
| | - Kaitlyn Shank
- Department of Pediatrics, Penn State Health, Pediatric Cardiovascular Research Center, Penn State College of Medicine
| | - Elizabeth Profeta
- Department of Pediatrics, Penn State Health, Pediatric Cardiovascular Research Center, Penn State College of Medicine
| | - Ronald P Wilson
- Department of Comparative Medicine, Penn State College of Medicine
| | - Petr Ostadal
- Cardiovascular Center, Na Homolce Hospital, Prague, Czech Republic
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Abstract
In this Editor's Review, articles published in 2015 are organized by category and briefly summarized. We aim to provide a brief reflection of the currently available worldwide knowledge that is intended to advance and better human life while providing insight for continued application of technologies and methods of organ Replacement, Recovery, and Regeneration. As the official journal of The International Federation for Artificial Organs, The International Faculty for Artificial Organs, the International Society for Rotary Blood Pumps, the International Society for Pediatric Mechanical Cardiopulmonary Support, and the Vienna International Workshop on Functional Electrical Stimulation, Artificial Organs continues in the original mission of its founders "to foster communications in the field of artificial organs on an international level." Artificial Organs continues to publish developments and clinical applications of artificial organ technologies in this broad and expanding field of organ Replacement, Recovery, and Regeneration from all over the world. We take this time also to express our gratitude to our authors for providing their work to this journal. We offer our very special thanks to our reviewers who give so generously of their time and expertise to review, critique, and especially provide meaningful suggestions to the author's work whether eventually accepted or rejected. Without these excellent and dedicated reviewers, the quality expected from such a journal could not be possible. We also express our special thanks to our Publisher, John Wiley & Sons for their expert attention and support in the production and marketing of Artificial Organs. We look forward to reporting further advances in the coming years.
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Clark JB, Wang S, Palanzo DA, Wise R, Baer LD, Brehm C, Ündar A. Current Techniques and Outcomes in Extracorporeal Life Support. Artif Organs 2015; 39:926-30. [DOI: 10.1111/aor.12527] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Joseph B. Clark
- Department of Pediatrics; Penn State Hershey Pediatric Cardiovascular Research Center; Penn State College of Medicine; Penn State Hershey Children's Hospital; 500 University Drive, Mail Code 850 Hershey PA 17033-0850 USA
- Department of Surgery; Penn State Hershey Pediatric Cardiovascular Research Center; Penn State College of Medicine; Penn State Hershey Children's Hospital; 500 University Drive, Mail Code 850 Hershey PA 17033-0850 USA
| | - Shigang Wang
- Department of Pediatrics; Penn State Hershey Pediatric Cardiovascular Research Center; Penn State College of Medicine; Penn State Hershey Children's Hospital; 500 University Drive, Mail Code 850 Hershey PA 17033-0850 USA
| | - David A. Palanzo
- Penn State Hershey Heart and Vascular Institute; 500 University Drive, Mail Code 850 Hershey PA 17033-0850 USA
| | - Robert Wise
- Penn State Hershey Heart and Vascular Institute; 500 University Drive, Mail Code 850 Hershey PA 17033-0850 USA
| | - Larry D. Baer
- Penn State Hershey Heart and Vascular Institute; 500 University Drive, Mail Code 850 Hershey PA 17033-0850 USA
| | - Christoph Brehm
- Penn State Hershey Heart and Vascular Institute; 500 University Drive, Mail Code 850 Hershey PA 17033-0850 USA
| | - Akif Ündar
- Department of Pediatrics; Penn State Hershey Pediatric Cardiovascular Research Center; Penn State College of Medicine; Penn State Hershey Children's Hospital; 500 University Drive, Mail Code 850 Hershey PA 17033-0850 USA
- Department of Surgery; Penn State Hershey Pediatric Cardiovascular Research Center; Penn State College of Medicine; Penn State Hershey Children's Hospital; 500 University Drive, Mail Code 850 Hershey PA 17033-0850 USA
- Department of Bioengineering; Penn State Hershey Pediatric Cardiovascular Research Center; Penn State College of Medicine; Penn State Hershey Children's Hospital; 500 University Drive, Mail Code 850 Hershey PA 17033-0850 USA
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Simundic I, Gorhan H, Matheis G, Laufs U. Reply to letter: pulsatile venoarterial perfusion using a novel synchronized cardiac assist device augments coronary artery blood flow during ventricular fibrillation. Artif Organs 2015; 39:452-4. [PMID: 25953236 DOI: 10.1111/aor.12524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
| | | | | | - Ulrich Laufs
- Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg, Germany.
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Wang S, Krawiec C, Patel S, Kunselman AR, Song J, Lei F, Baer LD, Ündar A. Laboratory Evaluation of Hemolysis and Systemic Inflammatory Response in Neonatal Nonpulsatile and Pulsatile Extracorporeal Life Support Systems. Artif Organs 2015; 39:774-81. [DOI: 10.1111/aor.12466] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Shigang Wang
- Penn State Hershey Pediatric Cardiovascular Research Center; Department of Pediatrics; Penn State Hershey College of Medicine; Penn State Hershey Children's Hospital; Penn State Milton S. Hershey Medical Center; Hershey PA USA
| | - Conrad Krawiec
- Penn State Hershey Pediatric Cardiovascular Research Center; Department of Pediatrics; Penn State Hershey College of Medicine; Penn State Hershey Children's Hospital; Penn State Milton S. Hershey Medical Center; Hershey PA USA
- Pediatric Critical Care Unit; Penn State Hershey College of Medicine; Penn State Hershey Children's Hospital; Penn State Milton S. Hershey Medical Center; Hershey PA USA
| | - Sunil Patel
- Penn State Hershey Pediatric Cardiovascular Research Center; Department of Pediatrics; Penn State Hershey College of Medicine; Penn State Hershey Children's Hospital; Penn State Milton S. Hershey Medical Center; Hershey PA USA
- Pediatric Cardiology; Penn State Hershey College of Medicine; Penn State Hershey Children's Hospital; Penn State Milton S. Hershey Medical Center; Hershey PA USA
| | - Allen R. Kunselman
- Department of Public Health Sciences; Penn State Hershey College of Medicine; Penn State Hershey Children's Hospital; Penn State Milton S. Hershey Medical Center; Hershey PA USA
| | - Jianxun Song
- Department of Microbiology & Immunology; Penn State Hershey College of Medicine; Penn State Hershey Children's Hospital; Penn State Milton S. Hershey Medical Center; Hershey PA USA
| | - Fengyang Lei
- Department of Microbiology & Immunology; Penn State Hershey College of Medicine; Penn State Hershey Children's Hospital; Penn State Milton S. Hershey Medical Center; Hershey PA USA
| | - Larry D. Baer
- Heart and Vascular Institute; Penn State Hershey College of Medicine; Penn State Hershey Children's Hospital; Penn State Milton S. Hershey Medical Center; Hershey PA USA
| | - Akif Ündar
- Penn State Hershey Pediatric Cardiovascular Research Center; Department of Pediatrics; Penn State Hershey College of Medicine; Penn State Hershey Children's Hospital; Penn State Milton S. Hershey Medical Center; Hershey PA USA
- Surgery and Bioengineering; Penn State Hershey College of Medicine; Penn State Hershey Children's Hospital; Penn State Milton S. Hershey Medical Center; Hershey PA USA
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Wolfe R, Strother A, Wang S, Kunselman AR, Ündar A. Impact of Pulsatility and Flow Rates on Hemodynamic Energy Transmission in an Adult Extracorporeal Life Support System. Artif Organs 2015; 39:E127-37. [DOI: 10.1111/aor.12484] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Rachel Wolfe
- Penn State Hershey Pediatric Cardiovascular Research Center; Department of Pediatrics; Penn State Hershey Children's Hospital; Hershey PA USA
| | - Ashton Strother
- Penn State Hershey Pediatric Cardiovascular Research Center; Department of Pediatrics; Penn State Hershey Children's Hospital; Hershey PA USA
| | - Shigang Wang
- Penn State Hershey Pediatric Cardiovascular Research Center; Department of Pediatrics; Penn State Hershey Children's Hospital; Hershey PA USA
| | - Allen R. Kunselman
- Public Health and Sciences; Penn State Hershey Children's Hospital; Hershey PA USA
| | - Akif Ündar
- Penn State Hershey Pediatric Cardiovascular Research Center; Department of Pediatrics; Penn State Hershey Children's Hospital; Hershey PA USA
- Surgery and Bioengineering; Penn State Milton S. Hershey Medical Center; Penn State Hershey College of Medicine; Penn State Hershey Children's Hospital; Hershey PA USA
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21
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Wang S, Izer JM, Clark JB, Patel S, Pauliks L, Kunselman AR, Leach D, Cooper TK, Wilson RP, Ündar A. In Vivo Hemodynamic Performance Evaluation of Novel Electrocardiogram-Synchronized Pulsatile and Nonpulsatile Extracorporeal Life Support Systems in an Adult Swine Model. Artif Organs 2015; 39:E90-E101. [DOI: 10.1111/aor.12482] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Shigang Wang
- Department of Pediatrics; Penn State Hershey Pediatric Cardiovascular Research Center; Penn State Milton S. Hershey Medical Center; Penn State Hershey College of Medicine; Penn State Hershey Children's Hospital; Hershey PA USA
| | - Jenelle M. Izer
- Department of Comparative Medicine; Penn State Hershey Pediatric Cardiovascular Research Center; Penn State Milton S. Hershey Medical Center; Penn State Hershey College of Medicine; Penn State Hershey Children's Hospital; Hershey PA USA
| | - Joseph B. Clark
- Department of Pediatrics; Penn State Hershey Pediatric Cardiovascular Research Center; Penn State Milton S. Hershey Medical Center; Penn State Hershey College of Medicine; Penn State Hershey Children's Hospital; Hershey PA USA
- Department of Surgery; Penn State Hershey Pediatric Cardiovascular Research Center; Penn State Milton S. Hershey Medical Center; Penn State Hershey College of Medicine; Penn State Hershey Children's Hospital; Hershey PA USA
| | - Sunil Patel
- Department of Pediatrics; Penn State Hershey Pediatric Cardiovascular Research Center; Penn State Milton S. Hershey Medical Center; Penn State Hershey College of Medicine; Penn State Hershey Children's Hospital; Hershey PA USA
| | - Linda Pauliks
- Department of Pediatrics; Penn State Hershey Pediatric Cardiovascular Research Center; Penn State Milton S. Hershey Medical Center; Penn State Hershey College of Medicine; Penn State Hershey Children's Hospital; Hershey PA USA
| | - Allen R. Kunselman
- Department of Public Health and Sciences; Penn State Hershey Pediatric Cardiovascular Research Center; Penn State Milton S. Hershey Medical Center; Penn State Hershey College of Medicine; Penn State Hershey Children's Hospital; Hershey PA USA
| | - Donald Leach
- Department of Pediatrics; Penn State Hershey Pediatric Cardiovascular Research Center; Penn State Milton S. Hershey Medical Center; Penn State Hershey College of Medicine; Penn State Hershey Children's Hospital; Hershey PA USA
| | - Timothy K. Cooper
- Department of Comparative Medicine; Penn State Hershey Pediatric Cardiovascular Research Center; Penn State Milton S. Hershey Medical Center; Penn State Hershey College of Medicine; Penn State Hershey Children's Hospital; Hershey PA USA
- Department of Pathology; Penn State Hershey Pediatric Cardiovascular Research Center; Penn State Milton S. Hershey Medical Center; Penn State Hershey College of Medicine; Penn State Hershey Children's Hospital; Hershey PA USA
| | - Ronald P. Wilson
- Department of Comparative Medicine; Penn State Hershey Pediatric Cardiovascular Research Center; Penn State Milton S. Hershey Medical Center; Penn State Hershey College of Medicine; Penn State Hershey Children's Hospital; Hershey PA USA
| | - Akif Ündar
- Department of Pediatrics; Penn State Hershey Pediatric Cardiovascular Research Center; Penn State Milton S. Hershey Medical Center; Penn State Hershey College of Medicine; Penn State Hershey Children's Hospital; Hershey PA USA
- Department of Comparative Medicine; Penn State Hershey Pediatric Cardiovascular Research Center; Penn State Milton S. Hershey Medical Center; Penn State Hershey College of Medicine; Penn State Hershey Children's Hospital; Hershey PA USA
- Department of Bioengineering; Penn State Hershey Pediatric Cardiovascular Research Center; Penn State Milton S. Hershey Medical Center; Penn State Hershey College of Medicine; Penn State Hershey Children's Hospital; Hershey PA USA
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