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Yaku H, Fudim M, Shah SJ. Role of splanchnic circulation in the pathogenesis of heart failure: State-of-the-art review. J Cardiol 2024; 83:330-337. [PMID: 38369183 DOI: 10.1016/j.jjcc.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 02/07/2024] [Accepted: 02/13/2024] [Indexed: 02/20/2024]
Abstract
A hallmark of heart failure (HF), whether it presents itself during rest or periods of physical exertion, is the excessive elevation of intracardiac filling pressures at rest or with exercise. Many mechanisms contribute to the elevated intracardiac filling pressures, and notably, the concept of volume redistribution has gained attention as a cause of the elevated intracardiac filling pressures in patients with HF, particularly HF with preserved ejection fraction, who often present without symptoms at rest, with shortness of breath and fatigue appearing only during exertion. This phenomenon suggests cardiopulmonary system non-compliance and inappropriate volume distribution between the stressed and unstressed blood volume components. A substantial proportion of the intravascular blood volume is in the splanchnic vascular compartment in the abdomen. Preclinical and clinical investigations support the critical role of the sympathetic nervous system in modulating the capacitance and compliance of the splanchnic vascular bed via modulation of the greater splanchnic nerve (GSN). The GSN activation by stressors such as exercise causes excessive splanchnic vasoconstriction, which may contribute to the decompensation of chronic HF via volume redistribution from the splanchnic vascular bed to the central compartment. Accordingly, for example, GSN ablation for volume management has been proposed as a potential therapeutic intervention to increase unstressed blood volume. Here we provide a comprehensive review of the role of splanchnic circulation in the pathogenesis of HF and potential novel treatment options for redistributing blood volume to improve symptoms and prognosis in patients with HF.
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Affiliation(s)
- Hidenori Yaku
- Division of Cardiology, Department of Medicine, and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Marat Fudim
- Duke Clinical Research Institute, Durham, NC, USA; Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA; Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine, and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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2
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Mamorita N, Takeuchi A, Kamata H. An interactive simulator to deepen the understanding of Guyton's venous return curve. J Physiol Sci 2024; 74:21. [PMID: 38555424 PMCID: PMC10981291 DOI: 10.1186/s12576-024-00912-9] [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: 08/25/2023] [Accepted: 03/05/2024] [Indexed: 04/02/2024]
Abstract
Mean circulatory filling pressure, venous return curve, and Guyton's graphical analysis are basic concepts in cardiovascular physiology. However, some medical students may not know how to view and interpret or understand them adequately. To deepen students' understanding of the graphical analysis, in place of having to perform live animal experiments, we developed an interactive cardiovascular simulator, as a self-learning tool, as a web application. The minimum closed-loop model consisted of a ventricle, an artery, resistance, and a vein, excluding venous resistance. The simulator consists of three modules: setting (parameters and simulation modes), calculation, and presentation. In the setting module, the user can interactively customize model parameters, compliances, resistance, Emax of the ventricular contractility, total blood volume, and unstressed volume. The hemodynamics are calculated in three phases: filling (late diastole), ejection (systole), and flow (early diastole). In response to the user's settings, the simulator graphically presents the hemodynamics: the pressure-volume relations of the artery, vein, and ventricle, the venous return curves, and the stroke volume curves. The mean filling pressure is calculated at approximately 7 mmHg at the initial setting. The venous return curves, linear and concave, are dependent on the venous compliance. The hemodynamic equilibrium point is marked on the crossing point of venous return curve and the stroke volume curve. Users can interactively do discovery learning, and try and confirm their interests and get their questions answered about hemodynamic concepts by using the simulator.
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Affiliation(s)
- Noritaka Mamorita
- Department of Medical Informatics, Kitasato University School of Allied Health Sciences, 1-15-1 Kitasato, Minami-Ku, Sagamihara, Kanagawa, 252-0373, Japan.
| | - Akihiro Takeuchi
- Department of Medical Informatics, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-Ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Hirotoshi Kamata
- Department of Hematology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-Ku, Sagamihara, Kanagawa, 252-0374, Japan
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3
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Chung CR, Ko RE, Jang GY, Lee K, Suh GY, Kim Y, Woo EJ. Comparison of noninvasive cardiac output and stroke volume measurements using electrical impedance tomography with invasive methods in a swine model. Sci Rep 2024; 14:2962. [PMID: 38316842 PMCID: PMC10844629 DOI: 10.1038/s41598-024-53488-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 02/01/2024] [Indexed: 02/07/2024] Open
Abstract
Pulmonary artery catheterization (PAC) has been used as a clinical standard for cardiac output (CO) measurements on humans. On animals, however, an ultrasonic flow sensor (UFS) placed around the ascending aorta or pulmonary artery can measure CO and stroke volume (SV) more accurately. The objective of this paper is to compare CO and SV measurements using a noninvasive electrical impedance tomography (EIT) device and three invasive devices using UFS, PAC-CCO (continuous CO) and arterial pressure-based CO (APCO). Thirty-two pigs were anesthetized and mechanically ventilated. A UFS was placed around the pulmonary artery through thoracotomy in 11 of them, while the EIT, PAC-CCO and APCO devices were used on all of them. Afterload and contractility were changed pharmacologically, while preload was changed through bleeding and injection of fluid or blood. Twenty-three pigs completed the experiment. Among 23, the UFS was used on 7 pigs around the pulmonary artery. The percentage error (PE) between COUFS and COEIT was 26.1%, and the 10-min concordance was 92.5%. Between SVUFS and SVEIT, the PE was 24.8%, and the 10-min concordance was 94.2%. On analyzing the data from all 23 pigs, the PE between time-delay-adjusted COPAC-CCO and COEIT was 34.6%, and the 10-min concordance was 81.1%. Our results suggest that the performance of the EIT device in measuring dynamic changes of CO and SV on mechanically-ventilated pigs under different cardiac preload, afterload and contractility conditions is at least comparable to that of the PAC-CCO device. Clinical studies are needed to evaluate the utility of the EIT device as a noninvasive hemodynamic monitoring tool.
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Affiliation(s)
- Chi Ryang Chung
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ryoung Eun Ko
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Geuk Young Jang
- Department of Biomedical Engineering, College of Medicine, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, Korea
| | - Kyounghun Lee
- Department of Biomedical Engineering, College of Medicine, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, Korea
| | - Gee Young Suh
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yongmin Kim
- Department of Convergence IT Engineering, POSTECH, Pohang, Korea
| | - Eung Je Woo
- Department of Biomedical Engineering, College of Medicine, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, Korea.
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4
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Kataoka Y, Fukuda Y, Peterson J, Shelly I, Alexander J, Sunagawa K. System Design for Optimizing Drug Infusions Using Cardiovascular Space Mapping for Acute Heart Failure. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2022; 2022:1388-1393. [PMID: 36086004 DOI: 10.1109/embc48229.2022.9871694] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Acute heart failure is caused by various factors and requires multiple drug therapies to remedy underlying causes. Due to the complexity of pharmacologic effects of cardiovascular agents, few studies have theoretically addressed the multidrug optimization problem. This paper proposes a drug infusion system for acute heart failure that controls cardiovascular performance metrics (cardiac output, left atrial pressure, and mean arterial pressure) within desired ranges as dictated by the cardiovascular parameters (systemic vascular resistance, cardiac contractility, heart rate, and stressed blood volume). The key to our system design is modeling and controlling cardiovascular parameters to yield the desired cardiovascular metrics. A 'tailored drug infusion' technique controls parameters by solving the optimization problem in order to conquer the complexity of multi-dependencies and the different dosage limits among multiple drugs. A 'cardiovascular space mapping' technique identifies the desired parameters from the desired metrics by deriving the analytical solutions of the metrics as functions of the parameters. To facilitate clinical discussions, parameters were set to realistic values in 5,600 simulated patients. Our results showed not only that the optimized drug combinations and dosages controlled the cardiovascular metrics to within the desired ranges, but also that they mostly corresponded to the recommended clinical use guidelines. An additional value of our system is that it proactively predicts the limitations of the tailored drug therapy, which supports the clinical decision of pivoting to alternative treatment strategies such as mechanical circulatory support.
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5
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Muir WW, Hughes D, Silverstein DC. Editorial: Fluid Therapy in Animals: Physiologic Principles and Contemporary Fluid Resuscitation Considerations. Front Vet Sci 2021; 8:744080. [PMID: 34746284 PMCID: PMC8563835 DOI: 10.3389/fvets.2021.744080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 09/21/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- William W Muir
- College of Veterinary Medicine, Lincoln Memorial University, Harrogate, TN, United States
| | - Dez Hughes
- Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Deborah C Silverstein
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States
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6
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Burkhoff D, Rich S, Pollesello P, Papp Z. Levosimendan-induced venodilation is mediated by opening of potassium channels. ESC Heart Fail 2021; 8:4454-4464. [PMID: 34716759 PMCID: PMC8712848 DOI: 10.1002/ehf2.13669] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 09/27/2021] [Indexed: 02/01/2023] Open
Abstract
Unique vascular responses adhere to the cardiovascular efficacy of the inodilator levosimendan. In particular, selective venodilation appears to explain its clinical benefit during pulmonary hypertension complicated by heart failure with preserved ejection fraction. Vasodilators increase vessel diameter in various parts of the vascular system to different degrees and thereby influence blood pressure, its distribution, and organ perfusion depending on their mechanisms of action. Levosimendan and its long‐lived active metabolite OR‐1896 mobilize a set of vasodilatory mechanisms, that is, the opening of the ATP‐sensitive K+ channels and other K+ channels on top of a highly selective inhibition of the phosphodiesterase III enzyme. A vessel‐specific combination of the above vasodilator mechanisms—in concert with cardiac effects and cardiovascular reflex regulations—illustrates the pharmacological profile of levosimendan in various cardiovascular disorders. While levosimendan has been known to be an inotrope, its properties as an activator of ATP‐sensitive K+ channels have gone largely ignored with respect to clinical applications. Here, we provide a summary of what is known about the ATP‐sensitive K+ channel properties in preclinical studies and now for the first time, its ATP‐sensitive K+ channel properties in a clinical trial.
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Affiliation(s)
| | - Stuart Rich
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Zoltán Papp
- Division of Clinical Physiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, 22 Móricz Zsigmond Str., Debrecen, H-4032, Hungary.,HAS-UD Vascular Biology and Myocardial Pathophysiology Research Group, Hungarian Academy of Sciences, Budapest, Hungary
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7
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Kaye DM, Wolsk E, Nanayakkara S, Mariani J, Hassager C, Gustafsson F, Moller JE, Sunagawa K, Burkhoff D. Comprehensive Physiological Modeling Provides Novel Insights Into Heart Failure With Preserved Ejection Fraction Physiology. J Am Heart Assoc 2021; 10:e021584. [PMID: 34569288 PMCID: PMC8649144 DOI: 10.1161/jaha.121.021584] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background Although a rapid rise in left atrial pressure during exertion is considered pathognomonic of heart failure with preserved ejection fraction (HFpEF), the fundamental circulatory determinants of this response are not clear, impacting upon the development of more effective therapies. We aimed to comprehensively describe the circulatory mechanics of patients with HFpEF at rest and during exercise in comparison with controls. Methods and Results We performed simultaneous right‐heart catheterization and echocardiography at rest and during exercise in 22 healthy control volunteers and 60 patients with confirmed HFpEF. Using detailed individual patient‐level hemodynamic and left ventricular ejection fraction data we performed computer simulations to evaluate the circulatory parameters including the estimated stressed blood volumethat contribute to the resting and exercise pulmonary capillary pressure. At rest and during exercise, left ventricular stiffness (V30, the end‐diastolic pressure–volume relationship at a filling pressure of 30 mm Hg), left ventricular elastance, and arterial elastance were all significantly greater in HFpEF than in controls. Stressed blood volume was significantly greater in HFpEF (26.9±5.4 versus 20.2±4.7 mL/kg, P<0.001), becoming even more pronounced during exercise (40.9±3.7 versus 27.5±7.0 mL per 70 kg, P<0.001). During exercise, the magnitude of the change in stressed blood volume (r=0.67, P<0.001) and left ventricular stiffness (r=−0.44, P<0.001) were key determinants of the rise in pulmonary capillary wedge pressure. Further detailed modeling studies showed that the hemodynamic response to exercise results from a complex non‐linear interaction between circulatory parameters. Conclusions The circulatory determinants of HFpEF physiology are complex. We identified stressed blood volume at rest and during exercise is a novel, key factor, therebyrepresenting an important potential therapeutic target.
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Affiliation(s)
- David M Kaye
- Department of Cardiology Alfred Hospital Melbourne Australia.,Heart Failure Research Group Baker Heart and Diabetes Institute Melbourne Australia.,Department of Medicine Monash University Melbourne Australia
| | - Emil Wolsk
- Department of Cardiology Herlev-Gentofte Hospital Copenhagen Denmark
| | - Shane Nanayakkara
- Department of Cardiology Alfred Hospital Melbourne Australia.,Heart Failure Research Group Baker Heart and Diabetes Institute Melbourne Australia.,Department of Medicine Monash University Melbourne Australia
| | - Justin Mariani
- Department of Cardiology Alfred Hospital Melbourne Australia.,Heart Failure Research Group Baker Heart and Diabetes Institute Melbourne Australia.,Department of Medicine Monash University Melbourne Australia
| | - Christian Hassager
- Department of Cardiology, Rigshospitalet University of Copenhagen Denmark
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet University of Copenhagen Denmark
| | - Jacob E Moller
- Department of Cardiology, Rigshospitalet University of Copenhagen Denmark.,Department of Cardiology Odense University Hospital Denmark
| | - Kenji Sunagawa
- Department of Cardiovascular Medicine Kyushu University School of Medicine Fukuoka Japan
| | - Daniel Burkhoff
- Department of Medicine Columbia University Medical School New York NY
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8
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The Effect of Prone Position on Hemodynamics in Patients With Acute Respiratory Distress Syndrome. Crit Care Med 2021; 49:e1045-e1046. [PMID: 34529623 DOI: 10.1097/ccm.0000000000005042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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9
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Stiles TW, Morfin Rodriguez AE, Mohiuddin HS, Lee H, Dalal FA, Fuertes WW, Adams TH, Stewart RH, Quick CM. Algebraic formulas characterizing an alternative to Guyton's graphical analysis relevant for heart failure. Am J Physiol Regul Integr Comp Physiol 2021; 320:R851-R870. [PMID: 33596744 DOI: 10.1152/ajpregu.00260.2019] [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: 11/22/2022]
Abstract
Although Guyton's graphical analysis of cardiac output-venous return has become a ubiquitous tool for explaining how circulatory equilibrium emerges from heart-vascular interactions, this classical model relies on a formula for venous return that contains unphysiological assumptions. Furthermore, Guyton's graphical analysis does not predict pulmonary venous pressure, which is a critical variable for evaluating heart failure patients' risk of pulmonary edema. Therefore, the purpose of the present work was to use a minimal closed-loop mathematical model to develop an alternative to Guyton's analysis. Limitations inherent in Guyton's model were addressed by 1) partitioning the cardiovascular system differently to isolate left ventricular function and lump all blood volumes together, 2) linearizing end-diastolic pressure-volume relationships to obtain algebraic solutions, and 3) treating arterial pressures as constants. This approach yielded three advances. First, variables related to morbidities associated with left ventricular failure were predicted. Second, an algebraic formula predicting left ventricular function was derived in terms of ventricular properties. Third, an algebraic formula predicting flow through the portion of the system isolated from the left ventricle was derived in terms of mechanical properties without neglecting redistribution of blood between systemic and pulmonary circulations. Although complexities were neglected, approximations necessary to obtain algebraic formulas resulted in minimal error, and predicted variables were consistent with reported values.
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Affiliation(s)
- Thomas W Stiles
- Michael E. DeBakey Institute, Texas A&M University, College Station, Texas
| | | | - Hanifa S Mohiuddin
- Michael E. DeBakey Institute, Texas A&M University, College Station, Texas
| | - Hyunjin Lee
- Michael E. DeBakey Institute, Texas A&M University, College Station, Texas
| | - Fazal A Dalal
- Michael E. DeBakey Institute, Texas A&M University, College Station, Texas
| | - Wesley W Fuertes
- Michael E. DeBakey Institute, Texas A&M University, College Station, Texas
| | - Thaddeus H Adams
- Michael E. DeBakey Institute, Texas A&M University, College Station, Texas
| | - Randolph H Stewart
- Michael E. DeBakey Institute, Texas A&M University, College Station, Texas
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10
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Sorimachi H, Burkhoff D, Verbrugge FH, Omote K, Obokata M, Reddy YNV, Takahashi N, Sunagawa K, Borlaug BA. Obesity, venous capacitance, and venous compliance in heart failure with preserved ejection fraction. Eur J Heart Fail 2021; 23:1648-1658. [PMID: 34053158 DOI: 10.1002/ejhf.2254] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/22/2021] [Accepted: 05/26/2021] [Indexed: 12/17/2022] Open
Abstract
AIMS Circulating blood volume is functionally divided between the unstressed volume, which fills the vascular space, and stressed blood volume (SBV), which generates vascular wall tension and intravascular pressure. With decreases in venous capacitance, blood functionally shifts to the SBV, increasing central venous pressure and pulmonary venous pressures. Obesity is associated with both elevated venous pressure and heart failure with preserved ejection fraction (HFpEF). To explore the mechanisms underlying this association, we evaluated relationships between blood volume distribution, venous compliance, and body mass in patients with and without HFpEF. METHODS AND RESULTS Subjects with HFpEF (n = 62) and non-cardiac dyspnoea (NCD) (n = 79) underwent invasive haemodynamic exercise testing with echocardiography. SBV was estimated (eSBV) from measured haemodynamic variables fit to a comprehensive cardiovascular model. Compared to NCD, patients with HFpEF displayed a leftward-shifted central venous pressure-dimension relationship, indicating reduced venous compliance. eSBV was 81% higher at rest and 69% higher during exercise in HFpEF than NCD (both P < 0.0001), indicating reduced venous capacitance. Despite greater augmented eSBV with exercise, the increase in cardiac output was reduced in HFpEF, suggesting operation on the plateau of the Starling curve. Exercise eSBV was directly correlated with higher body mass index (r = 0.77, P < 0.0001) and inversely correlated with right ventricular-pulmonary arterial coupling (r = -0.57, all P < 0.0001). CONCLUSIONS Patients with HFpEF display reductions in systemic venous compliance and increased eSBV related to reduced venous capacitance, abnormalities in right ventricular-pulmonary artery interaction, and increased body fat. These data provide new evidence supporting an important role of venous dysfunction in obesity-related HFpEF and suggest that therapies that improve venous function may hold promise to improve clinical status in this cohort.
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Affiliation(s)
- Hidemi Sorimachi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Daniel Burkhoff
- Cardiovascular Research Foundation, New York Biomedical Research Institute, New York, NY, USA
| | - Frederik H Verbrugge
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.,Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Kazunori Omote
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Masaru Obokata
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Yogesh N V Reddy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Kenji Sunagawa
- Center for Disruptive Cardiovascular Medicine, Kyushu University, Fukuoka, Japan
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
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11
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Nishikawa T, Uemura K, Hayama Y, Kawada T, Saku K, Sugimachi M. Development of an automated closed-loop β-blocker delivery system to stably reduce myocardial oxygen consumption without inducing circulatory collapse in a canine heart failure model: a proof of concept study. J Clin Monit Comput 2021; 36:849-860. [PMID: 33969457 PMCID: PMC9162998 DOI: 10.1007/s10877-021-00717-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 05/03/2021] [Indexed: 12/01/2022]
Abstract
Beta-blockers are well known to reduce myocardial oxygen consumption (MVO2) and improve the prognosis of heart failure (HF) patients. However, its negative chronotropic and inotropic effects limit their use in the acute phase of HF due to the risk of circulatory collapse. In this study, as a first step for a safe β-blocker administration strategy, we aimed to develop and evaluate the feasibility of an automated β-blocker administration system. We developed a system to monitor arterial pressure (AP), left atrial pressure (PLA), right atrial pressure, and cardiac output. Using negative feedback of hemodynamics, the system controls AP and PLA by administering landiolol (an ultra-short-acting β-blocker), dextran, and furosemide. We applied the system for 60 min to 6 mongrel dogs with rapid pacing-induced HF. In all dogs, the system automatically adjusted the doses of the drugs. Mean AP and mean PLA were controlled within the acceptable ranges (AP within 5 mmHg below target; PLA within 2 mmHg above target) more than 95% of the time. Median absolute performance error was small for AP [median (interquartile range), 3.1% (2.2–3.8)] and PLA [3.6% (2.2–5.7)]. The system decreased MVO2 and PLA significantly. We demonstrated the feasibility of an automated β-blocker administration system in a canine model of acute HF. The system controlled AP and PLA to avoid circulatory collapse, and reduced MVO2 significantly. As the system can help the management of patients with HF, further validations in larger samples and development for clinical applications are warranted.
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Affiliation(s)
- Takuya Nishikawa
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, Kishibe-Shinmachi 6-1, Suita, Japan.
| | - Kazunori Uemura
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, Kishibe-Shinmachi 6-1, Suita, Japan
| | - Yohsuke Hayama
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, Kishibe-Shinmachi 6-1, Suita, Japan
| | - Toru Kawada
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, Kishibe-Shinmachi 6-1, Suita, Japan
| | - Keita Saku
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, Kishibe-Shinmachi 6-1, Suita, Japan
| | - Masaru Sugimachi
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, Kishibe-Shinmachi 6-1, Suita, Japan
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12
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Pecchiari M, Pontikis K, Alevrakis E, Vasileiadis I, Kompoti M, Koutsoukou A. Cardiovascular Responses During Sepsis. Compr Physiol 2021; 11:1605-1652. [PMID: 33792902 DOI: 10.1002/cphy.c190044] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Sepsis is the life-threatening organ dysfunction arising from a dysregulated host response to infection. Although the specific mechanisms leading to organ dysfunction are still debated, impaired tissue oxygenation appears to play a major role, and concomitant hemodynamic alterations are invariably present. The hemodynamic phenotype of affected individuals is highly variable for reasons that have been partially elucidated. Indeed, each patient's circulatory condition is shaped by the complex interplay between the medical history, the volemic status, the interval from disease onset, the pathogen, the site of infection, and the attempted resuscitation. Moreover, the same hemodynamic pattern can be generated by different combinations of various pathophysiological processes, so the presence of a given hemodynamic pattern cannot be directly related to a unique cluster of alterations. Research based on endotoxin administration to healthy volunteers and animal models compensate, to an extent, for the scarcity of clinical studies on the evolution of sepsis hemodynamics. Their results, however, cannot be directly extrapolated to the clinical setting, due to fundamental differences between the septic patient, the healthy volunteer, and the experimental model. Numerous microcirculatory derangements might exist in the septic host, even in the presence of a preserved macrocirculation. This dissociation between the macro- and the microcirculation might account for the limited success of therapeutic interventions targeting typical hemodynamic parameters, such as arterial and cardiac filling pressures, and cardiac output. Finally, physiological studies point to an early contribution of cardiac dysfunction to the septic phenotype, however, our defective diagnostic tools preclude its clinical recognition. © 2021 American Physiological Society. Compr Physiol 11:1605-1652, 2021.
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Affiliation(s)
- Matteo Pecchiari
- Dipartimento di Fisiopatologia Medico Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
| | - Konstantinos Pontikis
- Intensive Care Unit, 1st Department of Pulmonary Medicine, National & Kapodistrian University of Athens, General Hospital for Diseases of the Chest 'I Sotiria', Athens, Greece
| | - Emmanouil Alevrakis
- 4th Department of Pulmonary Medicine, General Hospital for Diseases of the Chest 'I Sotiria', Athens, Greece
| | - Ioannis Vasileiadis
- Intensive Care Unit, 1st Department of Pulmonary Medicine, National & Kapodistrian University of Athens, General Hospital for Diseases of the Chest 'I Sotiria', Athens, Greece
| | - Maria Kompoti
- Intensive Care Unit, Thriassio General Hospital of Eleusis, Magoula, Greece
| | - Antonia Koutsoukou
- Intensive Care Unit, 1st Department of Pulmonary Medicine, National & Kapodistrian University of Athens, General Hospital for Diseases of the Chest 'I Sotiria', Athens, Greece
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13
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Fudim M, Patel MR, Boortz-Marx R, Borlaug BA, DeVore AD, Ganesh A, Green CL, Lopes RD, Mentz RJ, Patel CB, Rogers JG, Felker GM, Hernandez AF, Sunagawa K, Burkhoff D. Splanchnic Nerve Block Mediated Changes in Stressed Blood Volume in Heart Failure. JACC. HEART FAILURE 2021; 9:293-300. [PMID: 33714749 PMCID: PMC9990498 DOI: 10.1016/j.jchf.2020.12.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/30/2020] [Accepted: 12/21/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The authors estimated changes of stressed blood volume (SBV) induced by splanchnic nerve block (SNB) in patients with either decompensated or ambulatory heart failure with reduced ejection fraction (HFrEF). BACKGROUND The splanchnic vascular capacity is a major determinant of the SBV, which in turn determines cardiac filling pressures and may be modifiable through SNB. METHODS We analyzed data from 2 prospective, single-arm clinical studies in decompensated HFrEF (splanchnic HF-1; resting hemodynamics) and ambulatory heart failure (splanchnic HF-2; exercise hemodynamics). Patients underwent invasive hemodynamics and short-term SNB with local anesthetics. SBV was simulated using heart rate, cardiac output, central venous pressure, pulmonary capillary wedge pressure, systolic and diastolic systemic arterial and pulmonary artery pressures, and left ventricular ejection fraction. SBV is presented as ml/70 kg body weight. RESULTS Mean left ventricular ejection fraction was 21 ± 11%. In patients with decompensated HFrEF (n = 11), the mean estimated SBV was 3,073 ± 251 ml/70 kg. At 30 min post-SNB, the estimated SBV decreased by 10% to 2,754 ± 386 ml/70 kg (p = 0.003). In ambulatory HFrEF (n = 14) patients, the mean estimated SBV was 2,664 ± 488 ml/70 kg and increased to 3,243 ± 444 ml/70 kg (p < 0.001) at peak exercise. The resting estimated SBV was lower in ambulatory patients with HFrEF than in decompensated HFrEF (p = 0.019). In ambulatory patients with HFrEF, post-SNB, the resting estimated SBV decreased by 532 ± 264 ml/70 kg (p < 0.001). Post-SNB, with exercise, there was no decrease of estimated SBV out of proportion to baseline effects (p = 0.661). CONCLUSIONS The estimated SBV is higher in decompensated than in ambulatory heart failure. SNB reduced the estimated SBV in decompensated and ambulatory heart failure. The reduction in estimated SBV was maintained throughout exercise. (Splanchnic Nerve Anesthesia in Heart Failure, NCT02669407; Abdominal Nerve Blockade in Chronic Heart Failure, NCT03453151).
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Affiliation(s)
- Marat Fudim
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA.
| | - Manesh R Patel
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Richard Boortz-Marx
- Division of Pain Medicine, Department of Anesthesiology, Duke University, Durham, North Carolina, USA
| | | | - Adam D DeVore
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Arun Ganesh
- Division of Pain Medicine, Department of Anesthesiology, Duke University, Durham, North Carolina, USA
| | - Cynthia L Green
- Duke Clinical Research Institute, Durham, North Carolina, USA; Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Renato D Lopes
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Robert J Mentz
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Chetan B Patel
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Joseph G Rogers
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - G Michael Felker
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Adrian F Hernandez
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Kenji Sunagawa
- Center for Disruptive Cardiovascular Medicine, Kyushu University, Fukuoka, Japan
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A novel method of trans-esophageal Doppler cardiac output monitoring utilizing peripheral arterial pulse contour with/without machine learning approach. J Clin Monit Comput 2021; 36:437-449. [PMID: 33598822 DOI: 10.1007/s10877-021-00671-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 02/05/2021] [Indexed: 10/22/2022]
Abstract
Transesophageal Doppler (TED) velocity in the descending thoracic aorta (DA) is used to track changes in cardiac output (CO). However, CO tracking by this method is hampered by substantial change in aortic cross-sectional area (CSA) or proportionality between blood flow to the upper and lower body. To overcome this, we have developed a new method of TED CO monitoring. In this method, TED signal is obtained primarily from the aortic arch (AA). Using AA velocity signal, CO (COAA-CSA) is estimated by compensating changes in the aortic CSA with peripheral arterial pulse contour. When AA cannot be displayed properly or when the quality of AA velocity signal is unacceptable, our method estimates CO (CODA-ML) from DA velocity signal first by compensating changes in the aortic CSA, and by compensating changes in the blood flow proportionality through a machine learning of the relation between the CSA-adjusted CO and a reference CO (COref). In 12 anesthetized dogs, we compared COAA-CSA and CODA-ML with COref measured by an ascending aortic flow probe under diverse hemodynamic conditions (COref changed from 723 to 7316 ml·min-1). Between COAA-CSA and COref, concordance rate in the four-quadrant plot analysis was 96%, while angular concordance rate in the polar plot analysis was 91%. Between CODA-ML and COref, concordance rate was 93% and angular concordance rate was 94%. Both COAA-CSA and CODA-ML demonstrated "good to marginal" tracking ability of COref. In conclusion, our method may allow a robust and reliable tracking of CO during perioperative hemodynamic management.
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15
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Uike K, Saku K, Nishikawa T, Yamamura K, Nagata H, Muraoka M, Ohga S, Tsutsui H, Sunagawa K. Prediction of hemodynamics after atrial septal defect closure using a framework of circulatory equilibrium in dogs. Am J Physiol Heart Circ Physiol 2020; 319:H938-H947. [PMID: 32886004 DOI: 10.1152/ajpheart.00098.2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
In patients with heart failure, atrial septal defect (ASD) closure has a risk of inducing life-threatening acute pulmonary edema. The objective of this study was to develop a novel framework for quantitative prediction of hemodynamics after ASD closure. The generalized circulatory equilibrium comprises right and left cardiac output (CO) curves and pulmonary and systemic venous return surfaces. We incorporated ASD into the framework of circulatory equilibrium by representing ASD shunt flow (QASD) by the difference between pulmonary flow (QP) and systemic flow (QS). To examine the accuracy of prediction, we created ASD in six dogs. Four weeks after ASD creation, we measured left atrial pressure (PLA), right atrial pressure (PRA), QP, and Qs before and after ASD balloon occlusion. We then predicted postocclusion hemodynamics from measured preocclusion hemodynamics. Finally, we numerically simulated hemodynamics under various ASD diameters while changing left and right ventricular function. Predicted postocclusion PLA, PRA, and QS from preocclusion hemodynamics matched well with those measured [PLA: coefficient of determination (r2) = 0.96, standard error of estimate (SEE) = 0.89 mmHg, PRA: r2 = 0.98, SEE = 0.26 mmHg, QS: r2 = 0.97, SEE = 5.6 mL·min-1·kg-1]. A simulation study demonstrated that ASD closure increases the risk of pulmonary edema in patients with impaired left ventricular function and normal right ventricular function, indicating the importance of evaluation for the balance between right and left ventricular function. ASD shunt incorporated into the generalized circulatory equilibrium accurately predicted hemodynamics after ASD closure, which would facilitate safety management of ASD closure.NEW & NOTEWORTHY We developed a framework to predict the impact of atrial septal defect (ASD) closure on hemodynamics by incorporating ASD shunt flow into the framework of circulatory equilibrium. The proposed framework accurately predicted hemodynamics after ASD closure. Patient-specific prediction of hemodynamics may be useful for safety management of ASD closure.
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Affiliation(s)
- Kiyoshi Uike
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Keita Saku
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Takuya Nishikawa
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kenichiro Yamamura
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hazumu Nagata
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Mamoru Muraoka
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shouichi Ohga
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kenji Sunagawa
- Department of Therapeutic Regulation of Cardiovascular Homeostasis, Center for Disruptive Cardiovascular Medicine, Kyushu University, Fukuoka, Japan
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Kakino T, Saku K, Nishikawa T, Sunagawa K. The Partial Support of the Left Ventricular Assist Device Shifts the Systemic Cardiac Output Curve Upward in Proportion to the Effective Left Ventricular Ejection Fraction in Pressure-Volume Loop. Front Cardiovasc Med 2020; 7:163. [PMID: 33102535 PMCID: PMC7522370 DOI: 10.3389/fcvm.2020.00163] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 08/10/2020] [Indexed: 11/26/2022] Open
Abstract
Left ventricular assist device (LVAD) has been saving many lives in patients with severe left ventricular (LV) failure. Recently, a minimally invasive transvascular LVAD such as Impella enables us to support unstable hemodynamics in severely ill patients. Although LVAD support increases total LV cardiac output (COTLV) at the expense of decreases in the native LV cardiac output (CONLV), the underlying mechanism determining COTLV remains unestablished. This study aims to clarify the mechanism and develop a framework to predict COTLV under known LVAD flow (COLVAD). We previously developed a generalized framework of circulatory equilibrium that consists of the integrated CO curve and the VR surface as common functions of right atrial pressure (PRA) and left atrial pressure (PLA). The intersection between the integrated CO curve and the VR surface defines circulatory equilibrium. Incorporating LVAD into this framework indicated that LVAD increases afterload, which in turn decreases CONLV. The total LV cardiac output (COTLV) under LVAD support becomes COTLV = CONLV+EFe · COLVAD, where EFe is effective ejection fraction, i.e., Ees/(Ees+Ea). Ees and Ea represent LV end-systolic elastance (Ees) and effective arterial elastance (Ea), respectively. In other words, LVAD shifts the total LV cardiac output curve upward by EFe · COLVAD. In contrast, LVAD does not change the VR surface or the right ventricular CO curve. In six anesthetized dogs, we created LV failure by the coronary ligation of the left anterior descending artery and inserted LVAD by withdrawing blood from LV and pumping out to the femoral artery. We determined the parameters of the CO curve with a volume-change technique. We then changed the COLVAD stepwise from 0 to 70–100 ml/kg/min and predicted hemodynamics by using the proposed circulatory equilibrium. Predicted COTLV, PRA, and PLA for each step correlated well with those measured (SEE; 2.8 ml/kg/min 0.17 mmHg, and 0.65 mmHg, respectively, r2; 0.993, 0.993, and 0.965, respectively). The proposed framework quantitatively predicted the upward-shift of the total CO curve resulting from the synergistic effect of LV systolic function and LVAD support. The proposed framework can contribute to the safe management of patients with LVAD.
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Affiliation(s)
| | - Keita Saku
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan.,Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takuya Nishikawa
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan
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Nishikawa T, Saku K, Uike K, Uemura K, Sunagawa G, Tohyama T, Yoshida K, Kishi T, Sunagawa K, Tsutsui H. Prediction of haemodynamics after interatrial shunt for heart failure using the generalized circulatory equilibrium. ESC Heart Fail 2020; 7:3075-3085. [PMID: 32750231 PMCID: PMC7524226 DOI: 10.1002/ehf2.12935] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 07/13/2020] [Accepted: 07/19/2020] [Indexed: 02/02/2023] Open
Abstract
Aims Interatrial shunting (IAS) reduces left atrial pressure in patients with heart failure. Several clinical trials reported that IAS improved the New York Heart Association score and exercise capacity. However, its effects on haemodynamics vary depending on shunt size, cardiovascular properties, and stressed blood volume. To maximize the benefit of IAS, quantitative prediction of haemodynamics under IAS in individual patients is essential. The generalized circulatory equilibrium framework determines circulatory equilibrium as the intersection of the cardiac output curve and the venous return surface. By incorporating IAS into the framework, we predict the impact of IAS on haemodynamics. Methods and results In seven mongrel dogs, we ligated the left anterior descending artery and created impaired cardiac function with elevated left atrial pressure (baseline: 7.8 ± 1.0 vs. impaired: 11.9 ± 3.2 mmHg). We established extracorporeal left‐to‐right atrial shunting with a centrifugal pump. After recording pre‐IAS haemodynamics, we changed IAS flow stepwise to various levels and measured haemodynamics under IAS. To predict the impact of IAS on haemodynamics, we modelled the fluid mechanics of IAS by Newton's second law and incorporated IAS into the generalized circulatory equilibrium framework. Using pre‐IAS haemodynamic data obtained from the dogs, we predicted the impact of IAS flow on haemodynamics under IAS condition using a set of equations. We compared the predicted haemodynamic data with those measured. The predicted pulmonary flow [r2 = 0.88, root mean squared error (RMSE) 11.4 mL/min/kg, P < 0.001), systemic flow (r2 = 0.92, RMSE 11.2 mL/min/kg, P < 0.001), right atrial pressure (r2 = 0.92, RMSE 0.71 mmHg, P < 0.001), and left atrial pressure (r2 = 0.83, RMSE 0.95 mmHg, P < 0.001) matched well with those measured under normal and impaired cardiac function. Using this framework, we further performed a simulation study to examine the haemodynamic benefit of IAS in heart failure with preserved ejection fraction. We simulated the IAS haemodynamics under volume loading and exercise conditions. Volume loading and exercise markedly increased left atrial pressure. IAS size‐dependently attenuated the increase in left atrial pressure in both volume loading and exercise. These results indicate that IAS improves volume and exercise intolerance. Conclusions The framework developed in this study quantitatively predicts the haemodynamic impact of IAS. Simulation study elucidates how IAS improve haemodynamics under volume loading and exercise conditions. Quantitative prediction of IAS haemodynamics would contribute to maximizing the benefit of IAS in patients with heart failure.
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Affiliation(s)
- Takuya Nishikawa
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, Japan.,Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Keita Saku
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, Japan.,Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kiyoshi Uike
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kazunori Uemura
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, Japan
| | - Genya Sunagawa
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takeshi Tohyama
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Keimei Yoshida
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takuya Kishi
- Department of Fukuoka Health and Welfare Sciences, International University of Health and Welfare, Okawa, Japan
| | | | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Low-Dose Landiolol Reduces Heart Rate and Cardiac Oxygen Consumption Without Compromising Initial Hemodynamic Resuscitation in a Canine Model of Endotoxin Shock. Shock 2018; 52:102-110. [PMID: 30052577 DOI: 10.1097/shk.0000000000001224] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In septic shock, it is not known whether β-blocker can be used to reduce heart rate (HR) safely during the initial phase of hemodynamic resuscitation. The purpose of this study was to experimentally investigate the effects of low-dose landiolol, a β-blocker, on initial hemodynamic resuscitation in dogs with endotoxin shock. In 13 anesthetized dogs [n = 7 in control (CT) group, n = 6 in β-blockade (BB) group], after endotoxin shock was induced by intravenous infusion of lipopolysaccharide (4 mg kg), we started hemodynamic resuscitation to restore mean arterial pressure (AP) and cardiac output (CO) by infusing noradrenaline (NA) and Ringer acetate solution (RiA). During 4 h of hemodynamic resuscitation, dose of NA and RiA were automatically titrated with use of a computer-controlled drug infusion system that we developed previously. In BB group, landiolol was administered at a low-dose range (1-10 μg kg min) to lower HR to lower than 140 bpm. Hemodynamic resuscitation using the system restored AP to 70 mmHg and CO to greater than 90% of baseline level similarly in both groups. Throughout resuscitation, HR and indices of cardiac contractility were significantly lower in BB group than in CT group. However, there were no significant intergroup differences in the dose of NA and RiA. During First 2 h of resuscitation, cardiac oxygen consumption was significantly lower in BB group than in CT group. In conclusion, low-dose landiolol may reduce HR without compromising initial hemodynamic resuscitation in septic shock. To clearly establish this, large-size randomized study using animal models more relevant to septic shock is needed.
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Uemura K, Kawada T, Zheng C, Li M, Sugimachi M. Computer-controlled closed-loop drug infusion system for automated hemodynamic resuscitation in endotoxin-induced shock. BMC Anesthesiol 2017; 17:145. [PMID: 29061119 PMCID: PMC5654105 DOI: 10.1186/s12871-017-0437-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 10/16/2017] [Indexed: 12/29/2022] Open
Abstract
Background Hemodynamic resuscitation in septic shock requires aggressive fluid replacement and appropriate use of vasopressors to optimize arterial pressure (AP) and cardiac output (CO). Because responses to these drugs vary between patients and within patient over time, strict monitoring of patient condition and repetitive adjustment of drug dose are required. This task is time and labor consuming, and is associated with poor adherence to resuscitation guidelines. To overcome this issue, we developed a computer-controlled closed-loop drug infusion system for automated hemodynamic resuscitation in septic shock, and evaluated the performance of the system in a canine model of endotoxin shock. Methods Our system monitors AP, CO and central venous pressure, and computes arterial resistance (R), stressed blood volume (V) and Frank-Starling slope of left ventricle (S). The system controls R with noradrenaline (NA), and V with Ringer’s acetate solution (RiA), thereby controlling AP and CO. In 4 dogs, AP and CO were measured invasively. In another 4 dogs, AP and CO were measured less invasively using clinically acceptable modalities, aiming to make the system clinically feasible. In all 8 dogs, endotoxin shock was induced by injecting Escherichia coli lipopolysaccharide, which significantly decreased AP from 95 (91–108) to 43 (39–45) mmHg, and CO from 112 (104–142) to 62 (51–73) ml·min−1·kg−1. The system was then connected to the dogs, and activated. System performance was observed over a period of 4 h. Results Our system immediately started infusions of NA and RiA. Within 40 min, RiA increased V to target level, and NA maintained R at target level, while S was concomitantly increased. These resulted in restoration of AP to 70 (69–71) mmHg and CO to 130 (125–138) ml·min−1·kg−1. Median of absolute performance error, an index of precision of control, was small in AP [2.5 (2.1–4.5) %] and CO [2.4 (1.4–5.5) %], which were not increased even when the variables were measured less invasively. Conclusions In a canine model of endotoxin shock, our system automatically improved and maintained AP and CO at their target values with small performance error. Our system is potentially an attractive clinical tool for rescuing patients with septic shock. Electronic supplementary material The online version of this article (10.1186/s12871-017-0437-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kazunori Uemura
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 5-7-1 Fujishirodai, Suita, 565-8565, Japan.
| | - Toru Kawada
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 5-7-1 Fujishirodai, Suita, 565-8565, Japan
| | - Can Zheng
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 5-7-1 Fujishirodai, Suita, 565-8565, Japan
| | - Meihua Li
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 5-7-1 Fujishirodai, Suita, 565-8565, Japan
| | - Masaru Sugimachi
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 5-7-1 Fujishirodai, Suita, 565-8565, Japan
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Sunagawa K. Guyton's venous return curves should be taught at medical schools (complete English translation of Japanese version). J Physiol Sci 2017; 67:447-458. [PMID: 28349325 PMCID: PMC10717807 DOI: 10.1007/s12576-017-0533-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 03/06/2017] [Indexed: 11/24/2022]
Abstract
Guyton's most significant contributions are the exploration into the development of venous return and circulatory equilibrium. Recently, several physiologists challenged the validity of venous return as a function of venous pressure. Guyton's experiment in effect controlled venous pressure by changing cardiac output. Thus, critics claimed that cardiac output is the determinant of venous return. This claim is true, but in the presence of constant stressed volume, venous return and venous pressure have a fixed reciprocal relationship. Thus, it is meaningless to argue which one is the independent variable. We fully support Guyton's venous return and in particular circulatory equilibrium. Guyton's framework should be taught at medical schools worldwide.
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Affiliation(s)
- Kenji Sunagawa
- Center for Disruptive Cardiovascular Medicine, Kyushu University, 3-1-1 Maidashi, Higashiku, Fukuoka, 8128582, Japan.
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Kamiya A, Hayama Y, Shimizu S, Kawada T. State-space representation of the extended Guyton's model. Am J Physiol Heart Circ Physiol 2017. [PMID: 28626078 DOI: 10.1152/ajpheart.00315.2017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Atsunori Kamiya
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan
| | - Yohsuke Hayama
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan
| | - Shuji Shimizu
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan
| | - Toru Kawada
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan
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Tobushi T, Nakano M, Hosokawa K, Koga H, Yamada A. Improved Diastolic Function Is Associated With Higher Cardiac Output in Patients With Heart Failure Irrespective of Left Ventricular Ejection Fraction. J Am Heart Assoc 2017; 6:e003389. [PMID: 28246077 PMCID: PMC5523986 DOI: 10.1161/jaha.116.003389] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 02/06/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Little is known regarding the impact of diastolic function on cardiac output (CO) in patients with heart failure, particularly in patients with lower ejection fraction. This study aimed to evaluate the impact of end-diastolic pressure-volume relationship (EDPVR) on CO and end-diastolic pressure (EDP). METHODS AND RESULTS We retrospectively analyzed 1840 consecutive patients who underwent heart catheterization. We divided patients into 8 groups according to ejection fraction (EF) (35-45%, 46-55%, 56-65%, and 66-75%) and EDP (>16 or ≤16 mm Hg). We estimated EDPVR from single measurements in the catheterization data set. Then, we replaced EDPVRs of high-EDP groups with those of normal-EDP groups and compared CO before and after EDPVR replacement. Normalized EDPVR significantly increased CO at EDP=10 mm Hg regardless of EF (EF 35-45%, from 4.5±1.6 to 4.9±1.0; EF 46-55%, 4.6±1.3 to 5.1±1.1; EF 56-65%, 4.9±1.5 to 5.2±1.0; EF 66-75%, 4.9±1.5 to 5.2±1.1). Changes in CO were similar across EF groups. CONCLUSIONS Diastolic function normalization was associated with higher CO irrespective of EF. Diastolic dysfunction plays an important role in determining CO irrespective of EF in heart failure patients.
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Affiliation(s)
- Tomoyuki Tobushi
- Department of Cardiology, Aso-Iizuka Hospital, Iizuka Fukuoka, Japan
| | - Masatsugu Nakano
- Department of Cardiology, Aso-Iizuka Hospital, Iizuka Fukuoka, Japan
| | - Kazuya Hosokawa
- Department of Cardiovascular Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Hidenobu Koga
- Department of Health Information Management, Aso-Iizuka Hospital, Fukuoka, Japan
| | - Akira Yamada
- Department of Cardiology, Aso-Iizuka Hospital, Iizuka Fukuoka, Japan
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Kakino T, Saku K, Sakamoto T, Sakamoto K, Akashi T, Ikeda M, Ide T, Kishi T, Tsutsui H, Sunagawa K. Prediction of hemodynamics under left ventricular assist device. Am J Physiol Heart Circ Physiol 2017; 312:H80-H88. [DOI: 10.1152/ajpheart.00617.2016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 10/21/2016] [Accepted: 10/23/2016] [Indexed: 11/22/2022]
Abstract
Left ventricular assist device (LVAD) saves lives in patients with severe left ventricular (LV) failure. However, predicting how much LVAD boosts total cardiac output (CO) remains difficult. This study aimed to develop a framework to quantitatively predict the impact of LVAD on hemodynamics. We adopted the circulatory equilibrium framework and incorporated LVAD into the integrated CO curve to derive the circulatory equilibrium. In anesthetized dogs, we ligated left coronary arteries to create LV failure and inserted a centrifugal pump as LVAD. Using CO and right (PRA) and left atrial pressure (PLA) measured before LVAD support, we predetermined the stressed volume (V) and logarithmic slope of right heart CO curve (SR). Next, we initiated LVAD at maximum level and then decreased LVAD flow stepwise while monitoring hemodynamic changes. We predicted LVAD-induced CO and PRA for given PLA from the predetermined SR and V and compared with those measured experimentally. The predicted CO [ r2 = 0.907, SE of estimate (SEE) = 5.59 ml·min−1·kg−1, P < 0.001] and PRA ( r2 = 0.967, SEE = 0.307 mmHg, P < 0.001) matched well with measured values indicating the validity of the proposed framework. We further conducted simulation using the validated framework to analyze the impact of LVAD on PRA under various right ventricular (RV) functions. It indicated that PRA is relatively insensitive to changes in RV end-systolic elastance or pulmonary arterial resistance, but sensitive to changes in V. In conclusion, the circulatory equilibrium framework predicts quantitatively the hemodynamic impact of LVAD. This knowledge would contribute to safe management of patients with LV failure undergoing LVAD implantation. NEW & NOTEWORTHY Hemodynamic response to left ventricular assist device (LVAD) has not been quantitatively investigated. This is the first report of quantitative prediction of the hemodynamics on LVAD using circulatory equilibrium framework. The validated framework allows us to simulate the impact of LVAD on right atrial pressure under various right ventricular functions.
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Affiliation(s)
- Takamori Kakino
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Keita Saku
- Department of Therapeutic Regulation of Cardiovascular Homeostasis, Center for Disruptive Cardiovascular Medicine, Kyushu University, Fukuoka, Japan; and
| | - Takafumi Sakamoto
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Kazuo Sakamoto
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Takuya Akashi
- Department of Therapeutic Regulation of Cardiovascular Homeostasis, Center for Disruptive Cardiovascular Medicine, Kyushu University, Fukuoka, Japan; and
| | - Masataka Ikeda
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Tomomi Ide
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Takuya Kishi
- Collaborative Research Institute of Innovative Therapeutics for Cardiovascular Diseases, Center for Disruptive Cardiovascular Medicine, Kyushu University, Fukuoka, Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Kenji Sunagawa
- Department of Therapeutic Regulation of Cardiovascular Homeostasis, Center for Disruptive Cardiovascular Medicine, Kyushu University, Fukuoka, Japan; and
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Berger D, Moller PW, Weber A, Bloch A, Bloechlinger S, Haenggi M, Sondergaard S, Jakob SM, Magder S, Takala J. Effect of PEEP, blood volume, and inspiratory hold maneuvers on venous return. Am J Physiol Heart Circ Physiol 2016; 311:H794-806. [DOI: 10.1152/ajpheart.00931.2015] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 07/13/2016] [Indexed: 11/22/2022]
Abstract
According to Guyton's model of circulation, mean systemic filling pressure (MSFP), right atrial pressure (RAP), and resistance to venous return (RVR) determine venous return. MSFP has been estimated from inspiratory hold-induced changes in RAP and blood flow. We studied the effect of positive end-expiratory pressure (PEEP) and blood volume on venous return and MSFP in pigs. MSFP was measured by balloon occlusion of the right atrium (MSFPRAO), and the MSFP obtained via extrapolation of pressure-flow relationships with airway occlusion (MSFPinsp_hold) was extrapolated from RAP/pulmonary artery flow (QPA) relationships during inspiratory holds at PEEP 5 and 10 cmH2O, after bleeding, and in hypervolemia. MSFPRAO increased with PEEP [PEEP 5, 12.9 (SD 2.5) mmHg; PEEP 10, 14.0 (SD 2.6) mmHg, P = 0.002] without change in QPA [2.75 (SD 0.43) vs. 2.56 (SD 0.45) l/min, P = 0.094]. MSFPRAO decreased after bleeding and increased in hypervolemia [10.8 (SD 2.2) and 16.4 (SD 3.0) mmHg, respectively, P < 0.001], with parallel changes in QPA. Neither PEEP nor volume state altered RVR ( P = 0.489). MSFPinsp_hold overestimated MSFPRAO [16.5 (SD 5.8) vs. 13.6 (SD 3.2) mmHg, P = 0.001; mean difference 3.0 (SD 5.1) mmHg]. Inspiratory holds shifted the RAP/QPA relationship rightward in euvolemia because inferior vena cava flow (QIVC) recovered early after an inspiratory hold nadir. The QIVC nadir was lowest after bleeding [36% (SD 24%) of preinspiratory hold at 15 cmH2O inspiratory pressure], and the QIVC recovery was most complete at the lowest inspiratory pressures independent of volume state [range from 80% (SD 7%) after bleeding to 103% (SD 8%) at PEEP 10 cmH2O of QIVC before inspiratory hold]. The QIVC recovery thus defends venous return, possibly via hepatosplanchnic vascular waterfall.
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Affiliation(s)
- David Berger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Per W. Moller
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Alberto Weber
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas Bloch
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stefan Bloechlinger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; and
| | - Matthias Haenggi
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Soren Sondergaard
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Stephan M. Jakob
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Sheldon Magder
- Department of Critical Care, McGill University Health Centre, Montreal, Quebec, Canada
| | - Jukka Takala
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Kawada T, Sugimachi M. Open-loop static and dynamic characteristics of the arterial baroreflex system in rabbits and rats. J Physiol Sci 2016; 66:15-41. [PMID: 26541155 PMCID: PMC4742515 DOI: 10.1007/s12576-015-0412-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 09/30/2015] [Indexed: 02/07/2023]
Abstract
The arterial baroreflex system is the most important negative feedback system for stabilizing arterial pressure (AP). This system serves as a key link between the autonomic nervous system and the cardiovascular system, and is thus essential for understanding the pathophysiology of cardiovascular diseases and accompanying autonomic abnormalities. This article focuses on an open-loop systems analysis using a baroreceptor isolation preparation to identify the characteristics of two principal subsystems of the arterial baroreflex system, namely, the neural arc from pressure input to efferent sympathetic nerve activity (SNA) and the peripheral arc from SNA to AP. Studies on the static and dynamic characteristics of the two arcs under normal physiological conditions and also under various interventions including diseased conditions are to be reviewed. Quantitative understanding of the arterial baroreflex function under diseased conditions would help develop new treatment strategies such as electrical activation of the carotid sinus baroreflex for drug-resistant hypertension.
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Affiliation(s)
- Toru Kawada
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka, 565-8565, Japan.
| | - Masaru Sugimachi
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka, 565-8565, Japan
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Uemura K, Kawada T, Zheng C, Sugimachi M. Less Invasive and Inotrope-Reduction Approach to Automated Closed-Loop Control of Hemodynamics in Decompensated Heart Failure. IEEE Trans Biomed Eng 2015; 63:1699-708. [PMID: 26571509 DOI: 10.1109/tbme.2015.2499782] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
We have been developing an automated cardiovascular drug infusion system for simultaneous control of arterial pressure (AP), cardiac output (CO), and left atrial pressure (PLA) in decompensated heart failure (HF). In our prototype system, CO and PLA were measured invasively through thoracotomy. Furthermore, the control logic inevitably required use of inotropes to improve hemodynamics, which was not in line with clinical HF guidelines. The goal of this study was to solve these problems and develop a clinically feasible system. We integrated to the system minimally invasive monitors of CO and pulmonary capillary wedge pressure (PCWP, surrogates for PLA) that we developed recently. We also redesigned the control logic to reduce the use of inotrope. We applied the newly developed system to nine dogs with decompensated HF. Once activated, our system started to control the infusion of vasodilator and diuretics in all the animals. Inotrope was not infused in three animals, and infused at minimal doses in six animals that were intolerant of vasodilator infusion alone. Within 50 min, our system controlled AP, CO, and PCWP to their respective targets accurately. Pulmonary artery catheterization confirmed optimization of hemodynamics (AP, from 98 ± 4 to 74 ± 11 mmHg; CO, from 2.2 ± 0.5 to 2.9 ± 0.3 L·min(-1)·m(-2); PCWP, from 27.0 ± 6.6 to 13.8 ± 3.0 mmHg). In a minimally invasive setting while reducing the use of inotrope, our system succeeded in automatically optimizing the overall hemodynamics in canine models of HF. The present results pave the way for clinical application of our automated drug infusion system.
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Sakamoto K, Saku K, Kishi T, Kakino T, Tanaka A, Sakamoto T, Ide T, Sunagawa K. Prediction of the impact of venoarterial extracorporeal membrane oxygenation on hemodynamics. Am J Physiol Heart Circ Physiol 2015; 308:H921-30. [DOI: 10.1152/ajpheart.00603.2014] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 12/26/2014] [Indexed: 11/22/2022]
Abstract
Although venoarterial extracorporeal membrane oxygenation (ECMO) was developed to rescue patients with cardiogenic shock, the impact of ECMO on hemodynamics is often unpredictable and can lead to hemodynamic collapse. In this study, we developed a framework in which we incorporated ECMO into the extended Guyton's model of circulatory equilibrium and predicted hemodynamic changes in response to ECMO. We first determined the cardiac output (CO) curves of left and right heart (to generate the integrated CO curve) without ECMO in eight normal and seven dogs with left ventricular dysfunction. Using the CO curves obtained and standard parameters for the venous return surface, we predicted the circulatory equilibrium under various levels of ECMO support. The predicted total flow (native left heart flow plus ECMO flow), right atrial pressure (PRA), and left atrial pressure (PLA) matched well with those measured [total flow: coefficient of determination ( r2) = 0.99, standard error of estimate (SEE) = 5.8 ml·min−1·kg−1, PRA: r2 = 0.95, SEE = 0.23 mmHg, PLA: r2 = 0.99, SEE = 0.59 mmHg]. Lastly, we estimated the CO curves under ECMO support from minute changes in hemodynamics induced by change in ECMO. From the CO curves estimated, we predicted the circulatory equilibrium. The predicted total flow ( r2 = 0.93, SEE = 0.5 ml·min−1·kg−1), PRA ( r2 = 0.99, SEE = 0.54 mmHg), and PLA ( r2 = 0.95, SEE = 0.89 mmHg) matched reasonably well with those measured. A numerical simulation indicated that ECMO support may cause pulmonary edema, if right ventricular function is compromised. We conclude that the proposed framework may enhance the benefit and reduce the risk of ECMO support in patients with critical hemodynamic conditions.
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Affiliation(s)
- Kazuo Sakamoto
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan; and
| | - Keita Saku
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan; and
| | - Takuya Kishi
- Department of Advanced Therapeutics for Cardiovascular Diseases, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Takamori Kakino
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan; and
| | - Atsushi Tanaka
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan; and
| | - Takafumi Sakamoto
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan; and
| | - Tomomi Ide
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan; and
| | - Kenji Sunagawa
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan; and
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Arutunyan AH. Atrioventricular plane displacement is the sole mechanism of atrial and ventricular refill. Am J Physiol Heart Circ Physiol 2015; 308:H1317-20. [PMID: 25795710 DOI: 10.1152/ajpheart.00058.2015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Accepted: 03/19/2015] [Indexed: 11/22/2022]
Affiliation(s)
- Ara H Arutunyan
- Department of Pharmacology and Physiology, George Washington University, Washington, District of Columbia
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Sakamoto T, Kakino T, Sakamoto K, Tobushi T, Tanaka A, Saku K, Hosokawa K, Onitsuka K, Murayama Y, Tsutsumi T, Ide T, Sunagawa K. Changes in vascular properties, not ventricular properties, predominantly contribute to baroreflex regulation of arterial pressure. Am J Physiol Heart Circ Physiol 2014; 308:H49-58. [PMID: 25362137 DOI: 10.1152/ajpheart.00552.2014] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Baroreflex modulates both the ventricular and vascular properties and stabilizes arterial pressure (AP). However, how changes in those mechanical properties quantitatively impact the dynamic AP regulation remains unknown. We developed a framework of circulatory equilibrium, in which both venous return and cardiac output are expressed as functions of left ventricular (LV) end-systolic elastance (Ees), heart rate (HR), systemic vascular resistance (R), and stressed blood volume (V). We investigated the contribution of each mechanical property using the framework of circulatory equilibrium. In six anesthetized dogs, we vascularly isolated carotid sinuses and randomly changed carotid sinus pressure (CSP), while measuring the LV Ees, aortic flow, right and left atrial pressure, and AP for at least 60 min. We estimated transfer functions from CSP to Ees, HR, R, and V in each dog. We then predicted these parameters in response to changes in CSP from the transfer functions using a data set not used for identifying transfer functions and predicted changes in AP using the equilibrium framework. Predicted APs matched reasonably well with those measured (r2=0.85-0.96, P<0.001). Sensitivity analyses indicated that Ees and HR (ventricular properties) accounted for 14±4 and 4±2%, respectively, whereas R and V (vascular properties) accounted for 32±4 and 39±4%, respectively, of baroreflex-induced AP regulation. We concluded that baroreflex-induced dynamic AP changes can be accurately predicted by the transfer functions from CSP to mechanical properties using our framework of circulatory equilibrium. Changes in the vascular properties, not the ventricular properties, predominantly determine baroreflex-induced AP regulation.
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Affiliation(s)
- Takafumi Sakamoto
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan;
| | - Takamori Kakino
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Kazuo Sakamoto
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | | | | | - Keita Saku
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Kazuya Hosokawa
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Ken Onitsuka
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Yoshinori Murayama
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | | | - Tomomi Ide
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Kenji Sunagawa
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
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Uemura K, Inagaki M, Zheng C, Li M, Kawada T, Sugimachi M. A novel technique to predict pulmonary capillary wedge pressure utilizing central venous pressure and tissue Doppler tricuspid/mitral annular velocities. Heart Vessels 2014; 30:516-26. [PMID: 24879503 DOI: 10.1007/s00380-014-0525-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 05/09/2014] [Indexed: 11/28/2022]
Abstract
Assessing left ventricular (LV) filling pressure (pulmonary capillary wedge pressure, PCWP) is an important aspect in the care of patients with heart failure (HF). Physicians rely on right ventricular (RV) filling pressures such as central venous pressure (CVP) to predict PCWP, assuming concordance between CVP and PCWP. However, the use of this method is limited because discordance between CVP and PCWP is observed. We hypothesized that PCWP can be reliably predicted by CVP corrected by the relationship between RV and LV function, provided by the ratio of tissue Doppler peak systolic velocity of tricuspid annulus (S(T)) to that of mitral annulus (S(M)) (corrected CVP:CVP·S(T)/S(M)). In 16 anesthetized closed-chest dogs, S T and S M were measured by transthoracic tissue Doppler echocardiography. PCWP was varied over a wide range (1.8-40.0 mmHg) under normal condition and various types of acute and chronic HF. A significantly stronger linear correlation was observed between CVP·S(T)/S(M) and PCWP (R2 = 0.78) than between CVP and PCWP (R2 = 0.22) (P < 0.01). Receiver-operating characteristic (ROC) analysis indicated that CVP·S(T)/S(M) >10.5 mmHg predicted PCWP >18 mmHg with 85% sensitivity and 88% specificity. Area under ROC curve for CVP·S T/S M to predict PCWP >18 mmHg was 0.93, which was significantly larger than that for CVP (0.66) (P < 0.01). Peripheral venous pressure (PVP) corrected by S T/S M (PVP·S(T)/S(M) also predicted PCWP reasonably well, suggesting that PVP·S(T)/S (M) may be a minimally invasive alternative to CVP·S(T)/S(M) In conclusion, our technique is potentially useful for the reliable prediction of PCWP in HF patients.
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Affiliation(s)
- Kazunori Uemura
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 5-7-1 Fujishirodai, Suita, 565-8565, Japan,
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Maas JJ, de Wilde RB, Aarts LP, Pinsky MR, Jansen JR. Determination of vascular waterfall phenomenon by bedside measurement of mean systemic filling pressure and critical closing pressure in the intensive care unit. Anesth Analg 2012; 114:803-10. [PMID: 22344243 DOI: 10.1213/ane.0b013e318247fa44] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Mean systemic filling pressure (Pmsf) can be determined at the bedside by measuring central venous pressure (Pcv) and cardiac output (CO) during inspiratory hold maneuvers. Critical closing pressure (Pcc) can be determined using the same method measuring arterial pressure (Pa) and CO. If Pcc > Pmsf, there is then a vascular waterfall. In this study, we assessed the existence of a waterfall and its implications for the calculation of vascular resistances by determining Pmsf and Pcc at the bedside. METHODS In 10 mechanically ventilated postcardiac surgery patients, inspiratory hold maneuvers were performed, transiently increasing Pcv and decreasing Pa and CO to 4 different steady-state levels. For each patient, values of Pcv and CO were plotted in a venous return curve to determine Pmsf. Similarly, Pcc was determined with a ventricular output curve plotted for Pa and CO. Measurements were performed in each patient before and after volume expansion with 0.5 L colloid, and vascular resistances were calculated. RESULTS For every patient, the relationship between the 4 measurements of Pcv and CO and of Pa and CO was linear. Baseline Pmsf was 18.7 ± 4.0 mm Hg (mean ± SD) and differed significantly from Pcc 45.5 ± 11.1 mm Hg (P < 0.0001). The difference of Pcc and Pmsf was 26.8 ± 10.7 mm Hg, indicating the presence of a systemic vascular waterfall. Volume expansion increased Pmsf (26.3 ± 3.2 mm Hg), Pcc (51.5 ± 9.0 mm Hg), and CO (5.5 ± 1.8 to 6.8 ± 1.8 L · min(-1)). Arterial (upstream of Pcc) and venous (downstream of Pmsf) vascular resistance were 8.27 ± 4.45 and 2.75 ± 1.23 mm Hg · min · L(-1); the sum of both (11.01 mm Hg · min · L(-1)) was significantly different from total systemic vascular resistance (16.56 ± 8.57 mm Hg · min · L(-1); P = 0.005). Arterial resistance was related to total resistance. CONCLUSIONS Vascular pressure gradients in cardiac surgery patients suggest the presence of a vascular waterfall phenomenon, which is not affected by CO. Thus, measures of total systemic vascular resistance may become irrelevant in assessing systemic vasomotor tone.
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Affiliation(s)
- Jacinta J Maas
- Department of Intensive Care, B4, Leiden University Medical Center, P.O.B. 9600, 2300 RC Leiden, The Netherlands.
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Sakamoto T, Murayama Y, Tanaka A, Sakamoto K, Tobushi T, Saku K, Hosokawa K, Onitsuka K, Fujino T, Sunagawa K. Impact of baroreflex on venous return surface. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2011; 2011:4295-4296. [PMID: 22255289 DOI: 10.1109/iembs.2011.6091066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND Although Guyton's concept of venous return (VR) revolutionized circulatory physiology, the pulmonary circulation is invisible in its original framework. Since the pulmonary circulation is critical in left heart failure, we characterized the VR as a surface described by right (P(RA)) and left atrial (P(LA)) pressures and demonstrated that the VR surface was capable of representing mechanics of pulmonary as well as systemic circulation. However how baroreflex impacts the VR surface remains unknown. METHODS/RESULTS In 8 dogs, we isolated the carotid sinuses and replaced both ventricles with pumps. We varied cardiac output, shifted blood distribution between the systemic and pulmonary circulation at carotid sinus pressures (CSP) of 100 or 140 mmHg. The coefficient of determination of the VR surface ranged 0.96-0.99 indicating how flat the surface is. Increasing CSP decreased maximum VR (233 ± 27 vs. 216 ± 33 ml/kg/min, p<0.05), whereas did not change the slopes of VR along P(RA) or P(LA) axes. CONCLUSIONS Baroreflex parallel shifts the VR surface, thereby stressed volume, without changing its slopes.
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Sakamoto T, Murayama Y, Tobushi T, Sakamoto K, Tanaka A, Tsutsumi T, Sunagawa K. How to quantitatively synthesize dynamic changes in arterial pressure from baroreflexly modulated ventricular and arterial properties. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2010; 2010:2869-2871. [PMID: 21095975 DOI: 10.1109/iembs.2010.5626358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Baroreflex regulates arterial pressure by modulating ventricular and vascular properties. We investigated if the framework of circulatory equilibrium that we developed previously (Am J Physiol 2004, 2005) by extending the classic Guyton's framework is capable of predicting baroreflex induced changes in arterial pressure. In animal experiments, we estimated open loop transfer functions of baroreflexly modulated ventricular and vascular properties, synthesized baroreflex induced dynamic changes in arterial pressure using the estimated transfer functions and compared the predicted responses with measured responses. We demonstrated that the predicted baroreflex induced changes in arterial pressure matched reasonable well with those measured. We conclude that the framework of circulatory equilibrium is generalizable under the condition where baroreflex dynamically changes arterial pressure.
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Sunagawa K. The pressure-volume relationship of the heart: past, present and future. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2010; 2010:3554-3555. [PMID: 21096827 DOI: 10.1109/iembs.2010.5627485] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
The pressure-volume relationship of the heart was first reported more than a century ago. It was not widely accepted, however, until the mid-1970s. The pressure-volume diagram became a central theme of cardiac mechanics once it was shown to be a good representation of ventricular mechanics. Early in 1980s, the introduction of the ventricular interaction with afterload using effective arterial elastance made it possible to translate ventricular mechanical properties represented by the pressure-volume relationship to the pumping ability of the heart. Furthermore incorporating the framework of ventricular arterial interaction into the classic Guyton's circulatory equilibrium early in 2000s enabled us to express quantitatively how mechanical properties of the ventricles and vascular systems determine the circulatory equilibrium. Successful quantitative descriptions of circulatory equilibrium using the pressure-volume concept would promote basic cardiovascular physiology and accelerate its clinical applications.
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Sugimachi M, Sunagawa K, Uemura K, Kamiya A, Shimizu S, Inagaki M, Shishido T. Estimated venous return surface and cardiac output curve precisely predicts new hemodynamics after volume change. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2010; 2010:5205-5208. [PMID: 21096038 DOI: 10.1109/iembs.2010.5626268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
In our extended Guyton's model, the ability of heart to pump blood is characterized by a cardiac output curve and the ability of vasculature to pool blood by a venous return surface. These intersect in a three-dimensional coordinate system at the operating right atrial pressure, left atrial pressure, and cardiac output. The baseline cardiac output curve and venous return surface and their changes after volume change would predict new hemodynamics. The invasive methods needed to precisely characterize cardiac output curve and venous return surface led us to aim at estimating cardiac output curve and venous return surface from a single hemodynamic measurement. Using the average values for two logarithmic function parameters, and for two slopes of a surface, we were able to estimate cardiac output curve and venous return surface. The estimated curve and surface predicted new hemodynamics after volume change precisely.
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Affiliation(s)
- Masaru Sugimachi
- National Cardiovascular Center Research Institute, Suita, Osaka 5658565, Japan.
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Uemura K, Sugimachi M, Kawada T, Sunagawa K. Automated drug delivery system for the management of hemodynamics and cardiac energetic in acute heart failure. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2010; 2010:5222-5225. [PMID: 21096042 DOI: 10.1109/iembs.2010.5626279] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
We have developed a novel automated drug delivery system for simultaneous control of systemic arterial pressure (AP), cardiac output (CO), and left atrial pressure (P(LA)) in acute heart failure. The circulatory equilibrium framework we established previously discloses that AP, CO, and P(LA) are determined by equilibrium of the mechanical properties of the circulation, i.e. pumping ability of the left heart, stressed blood volume and systemic arterial resistance. Our system directly controls the three mechanical properties with cardiovascular drugs including inotropes and vasodilators, thereby controlling AP, CO, and P(LA). Furthermore, by precisely controlling bradycardia and LV inotropy, our system enables to improve cardiac energetic efficiency while preserving AP, CO, and P(LA) within acceptable ranges. In conclusion, by directly controlling the mechanical properties of the heart and vessel, our automated system realizes comprehensive management of hemodynamics in acute heart failure.
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Affiliation(s)
- Kazunori Uemura
- National Cerebral and Cardiovascular Center Research Institute, Suita, Osaka 5658565, Japan.
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Sugimachi M, Uemura K, Kamiya A, Shimizu S, Inagaki M, Shishido T. Feedback control of multiple hemodynamic variables with multiple cardiovascular drugs. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2009; 2009:2030-2. [PMID: 19964770 DOI: 10.1109/iembs.2009.5334417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The ultimate goal of disease treatment is to control the biological system beyond the native regulation to combat pathological process. To maximize the advantage of drugs, we attempted to pharmacologically control the biological system at will, e.g., control multiple hemodynamic variables with multiple cardiovascular drugs. A comprehensive physiological cardiovascular model enabled us to evaluate cardiovascular properties (pump function, vascular resistance, and blood volume) and the feedback control of these properties. In 12 dogs, with dobutamine (5+/-3 mug.kg(-1).min(-1)), nitroprusside (4+/-2 mug.kg(-1).min(-1)), dextran (2+/-2 ml.kg(-1)), and furosemide (10 mg in one, 20 mg in one), rapid, sufficient and stable control of pump function, vascular resistance and blood volume resulted in similarly quick and stable control of blood pressure, cardiac output and left atrial pressure in 5+/-7, 7+/-5, and 12+/-10 minutes, respectively. These variables remained stable for 60 minutes (RMS 4+/-3 mmHg, 5+/-2 ml.min(-1).kg(-1), 0.8+/-0.6 mmHg, respectively).
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Affiliation(s)
- Masaru Sugimachi
- National Cardiovascular Center Research Institute, Suita, Osaka 5658565, Japan.
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Sugimachi M, Sunagawa K, Uemura K, Kamiya A, Shimizu S, Inagaki M, Shishido T. Macroscopic two-pump two-vasculature cardiovascular model to support treatment of acute heart failure. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2009; 2009:2365-8. [PMID: 19965188 DOI: 10.1109/iembs.2009.5335017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Comprehensive understanding of hemodynamics remains a challenge even for expert cardiologists, partially due to a lack of an appropriate macroscopic model. We attempted to amend three major problems of Guyton's conceptual model (unknown left atrial pressure, unilateral heart damage, blood redistribution) and developed a comprehensive macroscopic model of hemodynamics that provides quantitative information. We incorporated a third axis of left atrial pressure, resulting in a 3D coordinate system. Pump functions of left and right heart are expressed by an integrated cardiac output curve, and the capacitive function of total vasculature by a venous return surface. The equations for both the cardiac output curve and venous return surface would facilitate precise diagnosis (especially evaluation of blood volume) and choice of appropriate treatments, including application to autopilot systems.
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Affiliation(s)
- Masaru Sugimachi
- National Cardiovascular Center Research Institute, Suita, Osaka 5658565, Japan.
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Assessment of venous return curve and mean systemic filling pressure in postoperative cardiac surgery patients. Crit Care Med 2009; 37:912-8. [PMID: 19237896 DOI: 10.1097/ccm.0b013e3181961481] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To measure the relationship between blood flow and central venous pressure (Pcv) and to estimate mean systemic filling pressure (Pmsf), circulatory compliance, and stressed volume in patients in the intensive care unit. DESIGN Intervention study. SETTING Intensive care unit of a university hospital. PATIENTS Twelve mechanically ventilated postoperative cardiac surgery patients. INTERVENTIONS Inspiratory holds were performed during normovolemia in supine position (baseline), relative hypovolemia by placing the patients in 30 degree head-up position (hypo), and relative hypervolemia by volume loading with 0.5 L colloid (hyper). MEASUREMENTS AND MAIN RESULTS We measured the relationship between blood flow and Pcv using 12-second inspiratory-hold maneuvers transiently increasing Pcv to three different steady-state levels and monitored the resultant blood flow via the pulse contour method during the last 3 seconds. The Pcv to blood flow relation was linear for all measurements with a slope unaltered by relative volume status. Pmsf decreased with hypo and increased with hyper (18.8 +/- 4.5 mm Hg, to 14.5 +/- 3.0 mm Hg, to 29.1 +/- 5.2 mm Hg [baseline, hypo, hyper, respectively, p < 0.05]). Baseline total circulatory compliance was 0.98 mL x mm Hg x kg and stressed volume was 1677 mL. CONCLUSIONS Pmsf can be determined in intensive care patients with an intact circulation with use of inspiratory pause procedures, making serial measures of circulatory compliance and circulatory stressed volume feasible.
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Sugimachi M, Sunagawa K. Bionic cardiology: exploration into a wealth of controllable body parts in the cardiovascular system. IEEE Rev Biomed Eng 2009; 2:172-86. [PMID: 22275044 DOI: 10.1109/rbme.2009.2034623] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Bionic cardiology is the medical science of exploring electronic control of the body, usually via the neural system. Mimicking or modifying biological regulation is a strategy used to combat diseases. Control of ventricular rate during atrial fibrillation by selective vagal stimulation, suppression of ischemia-related ventricular fibrillation by vagal stimulation, and reproduction of neurally commanded heart rate are some examples of bionic treatment for arrhythmia. Implantable radio-frequency-coupled on-demand carotid sinus stimulators succeeded in interrupting or preventing anginal attacks but were replaced later by coronary revascularization. Similar but fixed-intensity carotid sinus stimulators were used for hypertension but were also replaced by drugs. Recently, however, a self-powered implantable device has been reappraised for the treatment of drug-resistant hypertension. Closed-loop spinal cord stimulation has successfully treated severe orthostatic hypotension in a limited number of patients. Vagal nerve stimulation is effective in treating heart failure in animals, and a small-size clinical trial has just started. Simultaneous corrections of multiple hemodynamic abnormalities in an acute decompensated state are accomplished simply by quantifying fundamental cardiovascular parameters and controlling these parameters. Bionic cardiology will continue to promote the development of more sophisticated device-based therapies for otherwise untreatable diseases and will inspire more intricate applications in the twenty-first century.
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Affiliation(s)
- Masaru Sugimachi
- Department of Cardiovascular Dynamics, Advanced Medical Engineering Center, National Cardiovascular Center Research Institute, 5658565 Suita, Japan.
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Uemura K, Sunagawa K, Sugimachi M. Computationally managed bradycardia improved cardiac energetics while restoring normal hemodynamics in heart failure. Ann Biomed Eng 2008; 37:82-93. [PMID: 19003538 DOI: 10.1007/s10439-008-9595-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2008] [Accepted: 10/29/2008] [Indexed: 01/16/2023]
Abstract
In acute heart failure, systemic arterial pressure (AP), cardiac output (CO), and left atrial pressure (P (LA)) have to be controlled within acceptable ranges. Under this condition, cardiac energetic efficiency should also be improved. Theoretically, if heart rate (HR) is reduced while AP, CO, and P (LA) are maintained by preserving the functional slope of left ventricular (LV) Starling's curve (S (L)) with precisely increased LV end-systolic elastance (E (es)), it is possible to improve cardiac energetic efficiency and reduce LV oxygen consumption per minute (MVO (2)). We investigated whether this hemodynamics can be accomplished in acute heart failure using an automated hemodynamic regulator that we developed previously. In seven anesthetized dogs with acute heart failure (CO < 70 mL min(-1) kg(-1), P (LA) > 15 mmHg), the regulator simultaneously controlled S (L) with dobutamine, systemic vascular resistance with nitroprusside and stressed blood volume with dextran or furosemide, thereby controlling AP, CO, and P (LA). Normal hemodynamics were restored and maintained (CO; 88 +/- 3 mL min(-1) kg(-1), P (LA); 10.9 +/- 0.4 mmHg), even when zatebradine significantly reduced HR (-27 +/- 3%). Following HR reduction, E (es) increased (+34 +/- 14%), LV mechanical efficiency (stroke work/oxygen consumption) increased (+22 +/- 6%), and MVO (2) decreased (-17 +/- 4%) significantly. In conclusion, in a canine acute heart failure model, computationally managed bradycardia improved cardiac energetic efficiency while restoring normal hemodynamic conditions.
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Affiliation(s)
- Kazunori Uemura
- Department of Cardiovascular Dynamics, Advanced Medical Engineering Center, National Cardiovascular Center Research Institute, Fujishirodai, Suita, Japan.
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A Large-Scale, Energetic Model of Cardiovascular Homeostasis Predicts Dynamics of Arterial Pressure in Humans. IEEE Trans Biomed Eng 2008; 55:407-18. [DOI: 10.1109/tbme.2007.912668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Uemura K, Kamiya A, Shimizu S, Shishido T, Sugimachi M, Sunagawa K. Comprehensive physiological cardiovascular model enables automatic correction of hemodynamics in patients with acute life-threatening heart failure. CONFERENCE PROCEEDINGS : ... ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL CONFERENCE 2007; 2006:198-201. [PMID: 17945972 DOI: 10.1109/iembs.2006.259935] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Saving life of patients with acute life-threatening heart failure is a major challenge. One has to correct several fatal hemodynamic abnormalities at the same time within a limited time frame. The formulation of such complicated treatments enables the development of a system that can be used to save automatically lives of patients with acute heart failure, an autopilot system. To accomplish this, we established a comprehensive physiological cardiovascular model, on which we based the design of the autopilot system. By translating hemodynamics into cardiovascular parameters (pumping ability, vascular resistance, blood volume), and by controlling each of these with individual drugs, we were able to correct blood pressure, cardiac output, and left atrial pressure to the target values rapidly (5.2 +/- 6.6, 6.8 +/- 4.6, and 11.7 +/- 9.8 minutes), stably, and simultaneously.
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Affiliation(s)
- Kazunori Uemura
- National Cardiovascular Center Research Institute, Suita, Osaka, Japan.
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Uemura K, Kamiya A, Hidaka I, Kawada T, Shimizu S, Shishido T, Yoshizawa M, Sugimachi M, Sunagawa K. Automated drug delivery system to control systemic arterial pressure, cardiac output, and left heart filling pressure in acute decompensated heart failure. J Appl Physiol (1985) 2005; 100:1278-86. [PMID: 16373447 DOI: 10.1152/japplphysiol.01206.2005] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Pharmacological support with inotropes and vasodilators to control decompensated hemodynamics requires strict monitoring of patient condition and frequent adjustments of drug infusion rates, which is difficult and time-consuming, especially in hemodynamically unstable patients. To overcome this difficulty, we have developed a novel automated drug delivery system for simultaneous control of systemic arterial pressure (AP), cardiac output (CO), and left atrial pressure (Pla). Previous systems attempted to directly control AP and CO by estimating their responses to drug infusions. This approach is inapplicable because of the difficulties to estimate simultaneous AP, CO, and Pla responses to the infusion of multiple drugs. The circulatory equilibrium framework developed previously (Uemura K, Sugimachi M, Kawada T, Kamiya A, Jin Y, Kashihara K, and Sunagawa K. Am J Physiol Heart Circ Physiol 286: H2376-H2385, 2004) indicates that AP, CO, and Pla are determined by an equilibrium of the pumping ability of the left heart (SL), stressed blood volume (V), and systemic arterial resistance (R). Our system directly controls SL with dobutamine, V with dextran/furosemide, and R with nitroprusside, thereby controlling the three variables. We evaluated the efficacy of our system in 12 anesthetized dogs with acute decompensated heart failure. Once activated, the system restored SL, V, and R within 30 min, resulting in the restoration of normal AP, CO, and Pla. Steady-state deviations from target values were small for AP [4.4 mmHg (SD 2.6)], CO [5.4 ml x min(-1) x kg(-1) (SD 2.4)] and Pla [0.8 mmHg (SD 0.6)]. In conclusion, by directly controlling the mechanical determinants of circulation, our system has enabled simultaneous control of AP, CO, and Pla with good accuracy and stability.
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Affiliation(s)
- Kazunori Uemura
- Department of Cardiovascular Dynamics, National Cardiovascular Center Research Institute, 5-7-1 Fujishirodai, Suita 565-8565, Japan.
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Wang JJ, Flewitt JA, Shrive NG, Parker KH, Tyberg JV. Systemic venous circulation. Waves propagating on a windkessel: relation of arterial and venous windkessels to systemic vascular resistance. Am J Physiol Heart Circ Physiol 2005; 290:H154-62. [PMID: 16113064 DOI: 10.1152/ajpheart.00494.2005] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Compared with arterial hemodynamics, there has been relatively little study of venous hemodynamics. We propose that the venous system behaves just like the arterial system: waves propagate on a time-varying reservoir, the windkessel, which functions as the reverse of the arterial windkessel. During later diastole, pressure increases exponentially to approach an asymptotic value as inflow continues in the absence of outflow. Our study in eight open-chest dogs showed that windkessel-related arterial resistance was approximately 62% of total systemic vascular resistance, whereas windkessel-related venous resistance was only approximately 7%. Total venous compliance was found to be 21 times larger than arterial compliance (n = 3). Inferior vena caval compliance (0.32 +/- 0.015 ml x mmHg(-1) x kg(-1); mean +/- SE) was approximately 14 times the aortic compliance (0.023 +/- 0.002 ml x mmHg(-1) x kg(-1); n = 8). Despite greater venous compliance, the variation in venous windkessel volume (i.e., compliance x windkessel pulse pressure; 7.8 +/- 1.1 ml) was only approximately 32% of the variation in aortic windkessel volume (24.3 +/- 2.9 ml) because of the larger arterial pressure variation. In addition, and contrary to previous understanding, waves generated by the right heart propagated upstream as far as the femoral vein, but excellent proportionality between the excess pressure and venous outflow suggests that no reflected waves returned to the right atrium. Thus the venous windkessel model not only successfully accounts for variations in the venous pressure and flow waveforms but also, in combination with the arterial windkessel, provides a coherent view of the systemic circulation.
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Affiliation(s)
- Jiun-Jr Wang
- Dept. of Cardiac Sciences, Univ. of Calgary, Health Sciences Center, 3330 Hospital Dr. NW, Calgary, Alberta, Canada T2N 4N1
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Uemura K, Kawada T, Kamiya A, Aiba T, Hidaka I, Sunagawa K, Sugimachi M. Prediction of circulatory equilibrium in response to changes in stressed blood volume. Am J Physiol Heart Circ Physiol 2005; 289:H301-7. [PMID: 15708956 DOI: 10.1152/ajpheart.01237.2004] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Accurate prediction of cardiac output (CO), left atrial pressure (PLA), and right atrial pressure (PRA) is a prerequisite for management of patients with compromised hemodynamics. In our previous study (Uemura et al. Am J Physiol Heart Circ Physiol 286: H2376-H2385, 2004), we demonstrated a circulatory equilibrium framework, which permits the prediction of CO, PLA, and PRA once the venous return surface and integrated CO curve are known. Inasmuch as we also showed that the surface can be estimated from single-point CO, PLA, and PRA measurements, we hypothesized that a similar single-point estimation of the CO curve would enable us to predict hemodynamics. In seven dogs, we measured the PLA-CO and PRA-CO relations and derived a standardized CO curve using the logarithmic function CO = SL[ln(PLA - 2.03) + 0.80] for the left heart and CO = SR[ln(PRA - 2.13) + 1.90] for the right heart, where SL and SR represent the preload sensitivity of CO, i.e., pumping ability, of the left and right heart, respectively. To estimate the integrated CO curve in each animal, we calculated SL and SR from single-point CO, PLA, and PRA measurements. Estimated and measured CO agreed reasonably well. In another eight dogs, we altered stressed blood volume (-8 to +8 ml/kg of reference volume) under normal and heart failure conditions and predicted the hemodynamics by intersecting the surface and the CO curve thus estimated. We could predict CO [y = 0.93x + 6.5, r2 = 0.96, standard error of estimate (SEE) = 7.5 ml.min(-1).kg(-1)], PLA (y = 0.90x + 0.5, r2= 0.93, SEE = 1.4 mmHg), and PRA (y = 0.87x + 0.4, r2= 0.91, SEE = 0.4 mmHg) reasonably well. In conclusion, single-point estimation of the integrated CO curve enables accurate prediction of hemodynamics in response to extensive changes in stressed blood volume.
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Affiliation(s)
- Kazunori Uemura
- Dept. of Cardiovascular Dynamics, National Cardiovascular Center Research Institute, 5-7-1 Fujishirodai, Suita 565-8565, Japan.
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