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Stehouwer M, Legg K, Vroege RD. Can a low prime volume arterial filter be used as an alternative for a venous bubble trap in minimal extracorporeal circulation? An in vitro investigation. Perfusion 2024:2676591241256532. [PMID: 38768652 DOI: 10.1177/02676591241256532] [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: 05/22/2024]
Abstract
BACKGROUND During cardiac surgery the use of a minimal extracorporeal circulation (MiECC) system may reduce the adverse effects for the patient. This is probably caused by reduced inflammation and hemodilution. For the use of a MiECC circuit, a venous bubble trap (VBT) is warranted for safety reasons. The aim of this study was to assess if an arterial filter with a small prime volume has the same (or better) air removal capacities as a VBT in a MiECC circuit and subsequentially may be used as an alternative. METHODS In an in vitro study, air removal properties were compared between the arterial filter and three VBT's on the market, VBT160 (Getinge), VBT 8 (LivaNova and VARD (Medtronic). In a MiECC circuit, the filter devices were placed in a venous position and challenged with massive and micro air. Gaseous microemboli (GME) were measured with a bubble counter proximal and distal of the VBT device. RESULTS More than 99.9 % of the air was removed after a bolus air challenge by all VBT's. Both the VARD and the AF100 showed better GME removal properties (not significant for the AF100) compared to the other devices. All filters showed GME generation after a challenge with massive air. Compared to the other filters, only the VARD showed no passing of larger bubbles when a volume of 50 mL of air was present in the filter. CONCLUSIONS The AF100 seems to be a safe and low prime alternative for use in a MiECC system as a venous air trap. A word of caution, placement of the AF100 arterial filter in the venous line is off label use.
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Affiliation(s)
- Marco Stehouwer
- Department of Extracorporeal Circulation, St Antonius Hospital, Nieuwegein, Netherlands
| | - Kristina Legg
- Department of Extracorporeal Circulation, St Antonius Hospital, Nieuwegein, Netherlands
| | - Roel de Vroege
- Department of Extracorporeal Circulation, Haga Hospital, Den Haag, Netherlands
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2
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Ganushchak YM, Körver EP, Maessen JG. Is there a "safe" suction pressure in the venous line of extracorporeal circulation system? Perfusion 2020; 35:521-528. [PMID: 32627671 PMCID: PMC7416326 DOI: 10.1177/0267659120936453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Successes of extracorporeal life support increased the use of centrifugal pumps.
However, reports of hemolysis call for caution in using these pumps, especially
in neonatology and in pediatric intensive care. Cavitation can be a cause of
blood damage. The aim of our study was to obtain information about the
cavitation conditions and to provide the safest operating range of centrifugal
pumps. A series of tests were undertaken to determine the points at which pump
performance decreases 3% and gas bubbles start to appear downstream of the pump.
Two pumps were tested; pump R with a closed impeller and pump S with a semiopen
impeller. The performance tests demonstrated that pump S has an optimal region
narrower than pump R and it is shifted to the higher flows. When the pump
performance started to decrease, the inlet pressure varies but close to
−150 mmHg in the test with low gas content and higher than −100 mmHg in the
tests with increased gas content. The same trend was observed at the points of
development of massive gas emboli. Importantly, small packages of bubbles
downstream of the pump were registered at relatively high inlet pressures. The
gaseous cavitation in centrifugal pumps is a phenomenon that appears with
decreasing inlet pump pressures. There are a few ways to increase inlet pump
pressures: (1) positioning the pump as low as possible in relation to the
patient; (2) selecting appropriate sized venous cannulas and their careful
positioning; and (3) controlling patient’s volume status.
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Affiliation(s)
- Yuri M Ganushchak
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Erik Pj Körver
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jos G Maessen
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
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3
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Ganushchak YM, Kurniawati ER, Maessen JG, Weerwind PW. Peripheral cannulae selection for veno-arterial extracorporeal life support: a paradox. Perfusion 2019; 35:331-337. [PMID: 31709887 PMCID: PMC7263036 DOI: 10.1177/0267659119885586] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Explosive penetration of veno-arterial extracorporeal life support in everyday practice has drawn awareness to complications of peripheral cannulation, resulting in recommendations to use smaller size cannulae. However, using smaller cannulae may limit the effectiveness of extracorporeal support and thereby the specific needs of the patient. Selection of proper size cannulae may therefore pose a dilemma, especially since pressure-flow characteristics at different hematocrits are lacking. This study evaluates the precision of cannula pressure drop prediction with increase of fluid viscosity from water flow-pressure charts by M-number, dynamic similarity law, and via fitted parabolic equation. Thirteen commercially available peripheral cannulae were used in this in vitro study. Pressure drop and flow were recorded using water and a water-glycerol solution as a surrogate for blood, at ambient temperature. Subsequently, pressure-flow curves were modeled with increased fluid viscosity (0.0031 N s m-2), and then compared by M-number, dynamic similarity law, and fitted parabolic equation. The agreement of predicted and measured values were significantly higher when the M-number (concordance correlation = 0.948), and the dynamic similarity law method (concordance correlation = 0.947) was used in comparison to the fitted parabolic equation (concordance correlation = 0.898, p < 0.01). The M-number and dynamic similarity based model allow for reliable prediction of peripheral cannula pressure drop with changes of fluid viscosity and could therefore aid in well-thought-out selection of cannulae for extracorporeal life support.
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Affiliation(s)
- Yuri M Ganushchak
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Eva R Kurniawati
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Jos G Maessen
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Patrick W Weerwind
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht, Maastricht University Medical Center+, Maastricht, The Netherlands
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4
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Born F, König F, Chen J, Günther S, Hagl C, Thierfelder N. Generation of microbubbles in extracorporeal life support and assessment of new elimination strategies. Artif Organs 2019; 44:268-277. [DOI: 10.1111/aor.13557] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 07/08/2019] [Accepted: 08/09/2019] [Indexed: 12/26/2022]
Affiliation(s)
- Frank Born
- Department of Cardiac Surgery, Grosshadern Medical Center Ludwig Maximilian University of Munich Munich Germany
| | - Fabian König
- Department of Cardiac Surgery, Grosshadern Medical Center Ludwig Maximilian University of Munich Munich Germany
- Institute of Medical and Polymer Engineering Technical University of Munich Garching Germany
| | - Jinchi Chen
- Institute of Medical and Polymer Engineering Technical University of Munich Garching Germany
| | - Sabina Günther
- Department of Cardiac Surgery, Grosshadern Medical Center Ludwig Maximilian University of Munich Munich Germany
| | - Christian Hagl
- Department of Cardiac Surgery, Grosshadern Medical Center Ludwig Maximilian University of Munich Munich Germany
| | - Nikolaus Thierfelder
- Department of Cardiac Surgery, Grosshadern Medical Center Ludwig Maximilian University of Munich Munich Germany
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5
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Stehouwer MC, de Vroege R. Air removal capacity of two different minimal invasive ECC systems: an in vitro comparison. Perfusion 2019; 34:561-567. [PMID: 30915891 DOI: 10.1177/0267659119837823] [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: 11/16/2022]
Abstract
Minimally invasive extracorporeal circulation systems are developed to decrease the deleterious effects of cardiopulmonary bypass. For instance, prime volume and foreign surface area are decreased in these systems. However, because of the lack of a venous reservoir in minimized systems, air handling properties of these minimally invasive extracorporeal circulation systems may be decreased as compared to conventional cardiopulmonary bypass systems. The aim of this in vitro study is to compare the air handling properties of two complete minimized cardiopulmonary bypass systems of two manufacturers, of which one system is provided with the air purge control. In an in vitro study, two minimally invasive extracorporeal circulation systems, Inspire Min.I manufactured by Sorin Group Italia, Mirandola, Italy (LivaNova, London, United Kingdom) and minimized extracorporeal circulation manufactured by Maquet, Rastatt, Germany (Getinge, Germany), were challenged with two types of air challenges; a bolus air challenge and a gaseous microemboli challenge. The air removal characteristics of the venous bubble traps and of the complete minimally invasive extracorporeal circulation systems were assessed by measuring the gaseous microemboli volume and number downstream of the venous bubble traps in the arterial line with a bubble counter. No significant differences were observed in air reduction between the venous bubble traps of Getinge (venous bubble traps) and LivaNova (Inspire venous bubble traps 8 in conjunction with the air purge control). Similarly, no significant differences were observed in volume and number of gaseous microemboli in the arterial line of both complete minimally invasive extracorporeal circulation systems. However, the gaseous microemboli load of the Inspire Min.I system was marginally lower after both the bolus air and the gaseous microemboli challenges. Both minimally invasive extracorporeal circulation systems assessed in this study, the LivaNova Inspire Min.I and the Getinge minimized extracorporeal circulation, showed comparable air removal properties, after both bolus and gaseous microemboli air challenges. Besides, air purge control automatic air removal system provided with the LivaNova Inspire Min.I. system may enhance patient's safety with the use of a minimally invasive extracorporeal circulation system. We consider both systems equally safe for clinical use.
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Affiliation(s)
- Marco C Stehouwer
- Department of Extracorporeal Circulation, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Roel de Vroege
- Department of Extracorporeal Circulation, HAGA Hospital, The Hague, The Netherlands
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Perioperative Management of the Adult Patient on Venovenous Extracorporeal Membrane Oxygenation Requiring Noncardiac Surgery. Anesthesiology 2018; 128:181-201. [DOI: 10.1097/aln.0000000000001887] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Abstract
The use of venovenous extracorporeal membrane oxygenation is increasing worldwide. These patients often require noncardiac surgery. In the perioperative period, preoperative assessment, patient transport, choice of anesthetic type, drug dosing, patient monitoring, and intraoperative and postoperative management of common patient problems will be impacted. Furthermore, common monitoring techniques will have unique limitations. Importantly, patients on venovenous extracorporeal membrane oxygenation remain subject to hypoxemia, hypercarbia, and acidemia in the perioperative setting despite extracorporeal support. Treatments of these conditions often require both manipulation of extracorporeal membrane oxygenation settings and physiologic interventions. Perioperative management of anticoagulation, as well as thresholds to transfuse blood products, remain highly controversial and must take into account the specific procedure, extracorporeal membrane oxygenation circuit function, and patient comorbidities. We will review the physiologic management of the patient requiring surgery while on venovenous extracorporeal membrane oxygenation.
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Venovenous Extracorporeal Membrane Oxygenation in Intractable Pulmonary Insufficiency: Practical Issues and Future Directions. BIOMED RESEARCH INTERNATIONAL 2016; 2016:9367464. [PMID: 27127794 PMCID: PMC4835630 DOI: 10.1155/2016/9367464] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 03/03/2016] [Indexed: 01/19/2023]
Abstract
Venovenous extracorporeal membrane oxygenation (vv-ECMO) is a highly invasive method for organ support that is gaining in popularity due to recent technical advances and its successful application in the recent H1N1 epidemic. Although running a vv-ECMO program is potentially feasible for many hospitals, there are many theoretical concepts and practical issues that merit attention and require expertise. In this review, we focus on indications for vv-ECMO, components of the circuit, and management of patients on vv-ECMO. Concepts regarding oxygenation and decarboxylation and how they can be influenced are discussed. Day-to-day management, weaning, and most frequent complications are covered in light of the recent literature.
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8
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Wang S, Chin BJ, Gentile F, Kunselman AR, Palanzo D, Ündar A. Potential Danger of Pre-Pump Clamping on Negative Pressure-Associated Gaseous Microemboli Generation During Extracorporeal Life Support--An In Vitro Study. Artif Organs 2015; 40:89-94. [PMID: 26153848 DOI: 10.1111/aor.12540] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The objectives of this study were to investigate the relationship between revolution speed of a conventional centrifugal pump and negative pressure at the inlet of the pump by clamping the tubing upstream of the pump, and to verify whether negative pressure leads to gaseous microemboli (GME) production in a simulated adult extracorporeal life support (ECLS) system. The experimental circuit, including a Maquet Rotaflow centrifugal pump and a Medos Hilite 7000 LT polymethyl-pentene membrane oxygenator, was primed with packed red blood cells (hematocrit 35%). Negative pressure was created in the circuit by clamping the tubing upstream of the pump for 10 s, and then releasing the clamp. An emboli detection and classification quantifier was used to record GME volume and count at pre-oxygenator and post-oxygenator sites, and pressure and flow rate data were collected using a custom-based data acquisition system. All trials were conducted at 36°C at revolution speeds of 2000-4000 rpm (500 rpm increment). The flow rates were 1092.5-4708.4 mL/min at the revolution speeds of 2000-4000 rpm. Higher revolution speed generated higher negative pressure at the pre-pump site when clamping the tubing upstream of the pump (-108.3 ± 0.1 to -462.0 ± 0.5 mm Hg at 2000-4000 rpm). Moreover, higher negative pressure was associated with a larger number and volume of GME at pre-oxygenator site after de-clamp (GME count 10,573 ± 271 at pre-oxygenator site at 4000 rpm). The results showed that there was a potential danger of delivering GME to the patient when clamping pre-pump tubing during ECLS using a centrifugal pump. Our results warrant further clinical studies to investigate this phenomenon.
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Affiliation(s)
- Shigang Wang
- Penn State Hershey Pediatric Cardiovascular Research Center, Department of Pediatrics, Penn State Milton S. Hershey Medical Center, Penn State Hershey College of Medicine, Penn State Hershey Children's Hospital, Hershey, PA, USA
| | - Brian J Chin
- Penn State Hershey Pediatric Cardiovascular Research Center, Department of Pediatrics, Penn State Milton S. Hershey Medical Center, Penn State Hershey College of Medicine, Penn State Hershey Children's Hospital, Hershey, PA, USA
| | - Frank Gentile
- Penn State Hershey Pediatric Cardiovascular Research Center, Department of Pediatrics, 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
- 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
| | - David Palanzo
- Perfusion Department, Penn State Heart and Vascular Institute, Penn State Milton S. Hershey Medical Center, Penn State Hershey College of Medicine, Penn State Hershey Children's Hospital, Hershey, PA, USA
| | - Akif Ündar
- Penn State Hershey Pediatric Cardiovascular Research Center, Department of Pediatrics, 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 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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9
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Ganushchak YM, Simons AP, Weerwind PW. The hidden limitations in "advertising" a novel synchronized cardiac assist device. Artif Organs 2015; 39:451-2. [PMID: 25953235 DOI: 10.1111/aor.12503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Yuri M Ganushchak
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Antoine P Simons
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, The Netherlands. .,Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands.
| | - Patrick W Weerwind
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
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10
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Simons AP, Martens EGHJ, Ganushchak YM, Weerwind PW. Centrifugal pump performance during low-flow extracorporeal CO2 removal; safety considerations. Perfusion 2014; 30:17-23. [PMID: 24919405 DOI: 10.1177/0267659114540024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
AIM The aim of this study was to examine the hydrodynamic performance and gaseous microemboli (GME) activity of two centrifugal pumps for possible use in low-flow extracorporeal CO2 removal. MATERIALS & METHODS The performance of a Rotassist 2.8 and a Rotaflow 32 centrifugal pump (Maquet Cardiopulmonary AG, Hirrlingen, Germany) was evaluated in a water-glycerine mixture-filled in vitro circuit that enabled measurement of pressures and GME at the pump inlet and pump outlet. Pressure-flow curves were acquired in a 1,000 to 5,000 rpm range while increasing drainage resistance in one series and outlet resistance in another. RESULTS Respective minimum pump inlet and maximum pump outlet pressures were -539 mmHg and 754 mmHg for the Rotassist 2.8 and -606 mmHg and 806 mmHg for the Rotaflow 32. Maximum standard deviations on pump pressures and flow amounted to 3.0 mmHg and 0.03 L/min, respectively, regardless of pump type and drainage or outlet resistance. The GME at the pump outlet were detectable at pump inlet pressures below -156 mmHg at 0.2 L/min and 2,500 rpm for the Rotassist 2.8 and below -224 mmHg at 0.9 L/min and 3,000 rpm for the Rotaflow 32. CONCLUSION Both the Rotassist 2.8 and Rotaflow 32 centrifugal pumps show a comparably high hydrodynamic stability, but potential GME formation with decreasing pump inlet pressures should be taken into account to ensure safe centrifugal pump-based low-flow extracorporeal CO2 removal.
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Affiliation(s)
- A P Simons
- Deptartment of Cardiothoracic Surgery, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - E G H J Martens
- Department of Clinical Neurophysiology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Y M Ganushchak
- Deptartment of Cardiothoracic Surgery, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - P W Weerwind
- Deptartment of Cardiothoracic Surgery, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
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Simons AP, Weerwind PW. A volume buffer capacity device dynamically reduces excessive venous line pressure and arterial gaseous embolic load during minimized cardiopulmonary bypass. Eur J Cardiothorac Surg 2014; 47:391. [PMID: 24771755 DOI: 10.1093/ejcts/ezu180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Antoine P Simons
- Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC), Maastricht, Netherlands
| | - Patrick W Weerwind
- Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC), Maastricht, Netherlands
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Abstract
In this Editor's Review, articles published in 2013 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 offering their work to this journal. We offer our very special thanks to our reviewers who give so generously of time and expertise to review, critique, and especially provide so meaningful suggestions to the author's work whether eventually accepted or rejected and especially to those whose native tongue is not English. 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, Wiley Periodicals, for their expert attention and support in the production and marketing of Artificial Organs. We look forward to recording further advances in the coming years.
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13
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Wang S, Kunselman AR, Ündar A. In Vitro Performance Analysis of a Novel Pulsatile Diagonal Pump in a Simulated Pediatric Mechanical Circulatory Support System. Artif Organs 2013; 38:64-72. [DOI: 10.1111/aor.12181] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Shigang Wang
- Pediatric Cardiovascular Research Center; Penn State Hershey Children's Hospital; Penn State Milton S. Hershey Medical Center; Department of Pediatrics; Penn State Hershey College of Medicine; Hershey USA
| | - Allen R. Kunselman
- Department of Public Health Sciences; Penn State Hershey College of Medicine; Hershey USA
| | - Akif Ündar
- Pediatric Cardiovascular Research Center; Penn State Hershey Children's Hospital; Penn State Milton S. Hershey Medical Center; Department of Pediatrics; Penn State Hershey College of Medicine; Hershey USA
- Department of Surgery; Penn State Milton S. Hershey Medical Center; Penn State Hershey College of Medicine; Pennsylvania State University; Hershey USA
- Department of Bioengineering; College of Engineering; Pennsylvania State University; University Park PA USA
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