Muscle-powered mechanical blood pumps

Muscle-Powered Counterpulsation for Untethered, Non-Blood-Contacting Cardiac Support: A Path to Destination Therapy

Conventional long-term ventricular assist devices continue to be extremely problematic due to infections caused by percutaneous drivelines and thrombotic events associated with the use of blood-contacting surfaces. Here we describe a muscle-powered cardiac assist device that avoids both these problems by using an internal muscle energy converter to drive a non-blood-contacting extra-aortic balloon pump. The technology was developed previously in this lab and operates by converting the contractile energy of the latissimus dorsi muscle into hydraulic power that can be used, in principle, to drive any blood pump amenable to pulsatile actuation. The two main advantages of this implantable power source are that it 1) significantly reduces infection risk by avoiding a constant skin wound, and 2) improves patient quality-of-life by eliminating all external hardware components. The counterpulsatile balloon pumps, which compress the external surface of the ascending aorta during the diastolic phase of the cardiac cycle, offer another critical advantage in the setting of long-term circulatory support in that they increase cardiac output and improve coronary perfusion without touching the blood. The goal of this work is to combine these two technologies into a single circulatory support system that eliminates driveline complications and avoids surface-mediated thromboembolic events, thereby providing a safe, tether-free means to support the failing heart over extended - or even indefinite - periods of time.

In vitro validation of a self-driving aortic-turbine venous-assist device for Fontan patients

Background

Palliative repair of single ventricle defects involve a series of open-heart surgeries where a single-ventricle (Fontan) circulation is established. As the patient ages, this paradoxical circulation gradually fails, because of its high venous pressure levels. Reversal of the Fontan paradox requires an extra subpulmonic energy that can be provided through mechanical assist devices. The objective of this study was to evaluate the hemodynamic performance of a totally implantable integrated aortic-turbine venous-assist (iATVA) system, which does not need an external drive power and maintains low venous pressure chronically, for the Fontan circulation.

Methods

Blade designs of the co-rotating turbine and pump impellers were developed and 3 prototypes were manufactured. After verifying the single-ventricle physiology at a pulsatile in vitro circuit, the hemodynamic performance of the iATVA system was measured for pediatric and adult physiology, varying the aortic steal percentage and circuit configurations. The iATVA system was also tested at clinical off-design scenarios.

Results

The prototype iATVA devices operate at approximately 800 revolutions per minute and extract up to 10% systemic blood from the aorta to use this hydrodynamic energy to drive a blood turbine, which in turn drives a mixed-flow venous pump passively. By transferring part of the available energy from the single-ventricle outlet to the venous side, the iATVA system is able to generate up to approximately 5 mm Hg venous recovery while supplying the entire caval flow.

Conclusions

Our experiments show that a totally implantable iATVA system is feasible, which will eliminate the need for external power for Fontan mechanical venous assist and combat gradual postoperative venous remodeling and Fontan failure.

Enabling personalized implant and controllable biosystem development through 3D printing

The impact of additive manufacturing in our lives has been increasing constantly. One of the frontiers in this change is the medical devices. 3D printing technologies not only enable the personalization of implantable devices with respect to patient-specific anatomy, pathology and biomechanical properties but they also provide new opportunities in related areas such as surgical education, minimally invasive diagnosis, medical research and disease models. In this review, we cover the recent clinical applications of 3D printing with a particular focus on implantable devices. The current technical bottlenecks in 3D printing in view of the needs in clinical applications are explained and recent advances to overcome these challenges are presented. 3D printing with cells (bioprinting); an exciting subfield of 3D printing, is covered in the context of tissue engineering and regenerative medicine and current developments in bioinks are discussed. Also emerging applications of bioprinting beyond health, such as biorobotics and soft robotics, are introduced. As the technical challenges related to printing rate, precision and cost are steadily being solved, it can be envisioned that 3D printers will become common on-site instruments in medical practice with the possibility of custom-made, on-demand implants and, eventually, tissue engineered organs with active parts developed with biorobotics techniques.

Potential mechanisms for muscle-powered cardiac support

Biomechanical actuation of an implanted ventricular assist device (VAD) is an attractive means of providing long-term circulatory support. Studies show that energy from electrically stimulated skeletal muscle can, in principle, be used to provide tether-free cardiac assistance without the need for percutaneous drivelines or bulky energy transmission hardware. A mechanical prosthesis designed to harness the contractile power of in situ skeletal muscle has been developed in this laboratory that collects energy from the latissimus dorsi muscle and transmits it in the form of hydraulic power. In order to use this technique to pump blood however, a practical means to deliver this energy to the bloodstream must be devised. Presented here are six prospective mechanisms designed to accomplish this task, five of which also eliminate blood contacting surfaces that often lead to thromboembolic complications in chronic VAD patients.

Design Improvements and In Vitro Testing of an Implantable Muscle Energy Converter for Powering Pulsatile Cardiac Assist Devices

Harnessing skeletal muscle for circulatory support would improve on current blood pump technologies by eliminating infection-prone drivelines and cumbersome transcutaneous energy transmission systems. Toward that end, we have built and tested an implantable muscle energy converter (MEC) designed to transmit the contractile energy of the latissimus dorsi muscle in hydraulic form. The MEC weighs less than 300 g and comprises a metallic bellows formed from AM350 stainless steel actuated by a rotary cam (440C) attached to a titanium rocker arm (Ti–6Al–4V). The rocker arm is fixed to the humeral insertion of the muscle via a looped artificial tendon developed specifically for this purpose. The device housing (Ti–6Al–4V) is anchored to the ribcage using a perforated mounting ring and a wire suture. Lessons learned through seven previous design iterations have produced an eighth-generation pump with excellent durability, energy transfer efficiency, anatomic fit, and tissue interface characteristics. This report describes recent improvements in MEC design and summarizes results from in silico and in vitro testing. Long-term implant studies will be needed to confirm these findings prior to clinical testing.

Improved mechanism for capturing muscle power for circulatory support

Although it is now understood that trained skeletal muscle can generate enough steady-state power to provide significant circulatory support, there are currently no means by which to tap this endogenous energy source to aid the failing heart. To that end, an implantable muscle energy converter (MEC) has been constructed and its function has been improved to optimize durability, anatomic fit, and mechanical efficiency. Bench tests show that MEC transmission losses average less than 10% of total work input and that about 85% of this muscle power is successfully transferred to the working fluid of the pump. Results from canine implant trials confirm excellent biocompatibility and demonstrate that contractile work of the latissimus dorsi muscle-measured to 290 mJ/stroke in one dog-can be transmitted within the body at levels consistent with cardiac assist requirements. These findings suggest that muscle-powered cardiac assist devices are feasible and that efforts to further develop this technology are warranted.

Demand dynamic bio-girdling in heart failure: improved efficacy of dynamic cardiomyoplasty by LD contraction during aortic out-flow

PURPOSE

The value of dynamic cardiomyoplasty has been brought into question by the disappointing results produced by slow contraction-relaxation cycle and possibly degeneration of the latissimus dorsi muscle (LD) secondary to temporary tenotomy and chronic daily electrical stimulation. Objective of our study is to determine whether daily periods of rest introduced by demand stimulation in the continuous contraction protocol produce systolic assistance and improve clinical results.

METHODS

Twelve dynamic cardiomyoplasty patients (mean age 58.2 +/- 5.8 years, M/F=11/1, sinus rhythm/atrial fibrillation=11/1) with dilated myocardiopathy were enrolled in an unrandomized trial of Demand Dynamic Heart Bio-Girdling in a public regional teaching hospital. Periods of LD inactivity, each lasting several hours, were introduced daily on a heart rate-based demand regime. To avoid full transformation of LD, fewer impulses per day were delivered, daily providing the LD with long periods of rest (Demand light stimulation). The contractile properties were measured by transcutaneous non-invasive LD tensiomyogram interrogation (LD tensiomyogram). Bio-Girdle activation was synchronized to heart beat by combining tensiomyogram and echocardiography. Clinical, echocardiographic and hemodynamic records, as well as aortic flow measurements by Doppler aortic flow wire were taken during the follow-up.

MAIN FINDINGS

Mean duration of the demand stimulation follow-up was 40.2+13.8 months. At five years, "Demand stimulation" shows: 1) no operative death; 2) 83% actuarial survival; 3) highly significant 47.4% decrease of the NYHA class (from 3.17 +/- 0.38 to 1.67 +/- 0.77, p=0.0001); 4) 41.6% improvement of LVEF (from 22.6 +/- 4.38 to 32.0 +/- 7.0, p=0.001); 5) 7.5 +/- 3.0% increase in aortic flow velocity peak in assisted vs. unassisted beats, and 6) preservation of LD from slowness (TFF value 33 +/- 7.86 at follow-up versus 15.8 +/- 11.1 Hz just before switching from continuous to demand stimulation, p=0.0001) and muscle degenerative atrophy.

CONCLUSIONS

In dynamic cardiomyoplasty the demand light stimulation maintains LD contraction properties over time, produces effective systolic assistance, and improves clinical results. Demand dynamic bio-girdling is a safe and effective treatment for end-stage heart failure in selected patients.