Role of the C-C chemokine receptor-2 in a murine model of injury-induced osteoarthritis

OBJECTIVE

We previously found in our embryonic studies that proper regulation of the chemokine CCL12 through its sole receptor CCR2, is critical for joint and growth plate development. In the present study, we examined the role of CCR2 in injury-induced-osteoarthritis (OA).

METHOD

We used a murine model of injury-induced-OA (destabilization of medial meniscus, DMM), and systemically blocked CCR2 using a specific antagonist (RS504393) at different times during disease progression. We examined joint degeneration by assessing cartilage (cartilage loss, chondrocyte hypertrophy, MMP-13 expression) and bone lesions (bone sclerosis, osteophytes formation) with or without the CCR2 antagonist. We also performed pain behavioral studies by assessing the weight distribution between the normal and arthritic hind paws using the IITS incapacitance meter.

RESULTS

Testing early vs delayed administration of the CCR2 antagonist demonstrated differential effects on joint damage. We found that OA changes in articular cartilage and bone were ameliorated by pharmacological CCR2 blockade, if given early in OA development: specifically, pharmacological targeting of CCR2 during the first 4 weeks (wks) following injury, reduced OA cartilage and bone damage, with less effectiveness with later treatments. Importantly, our pain-related behavioral studies showed that blockade of CCR2 signaling during early, 1-4 wks post-surgery or moderate, 4-8 wks post-surgery, OA was sufficient to decrease pain measures, with sustained improvement at later stages, after treatment was stopped.

CONCLUSIONS

Our data highlight the potential efficacy of antagonizing CCR2 at early stages to slow the progression of post-injury OA and, in addition, improve pain symptoms.

BMP2 Regulation of CXCL12 Cellular, Temporal, and Spatial Expression is Essential During Fracture Repair

The cellular and humoral responses that orchestrate fracture healing are still elusive. Here we report that bone morphogenic protein 2 (BMP2)-dependent fracture healing occurs through a tight control of chemokine C-X-C motif-ligand-12 (CXCL12) cellular, spatial, and temporal expression. We found that the fracture repair process elicited an early site-specific response of CXCL12(+)-BMP2(+) endosteal cells and osteocytes that was not present in unfractured bones and gradually decreased as healing progressed. Absence of a full complement of BMP2 in mesenchyme osteoprogenitors (BMP2(cKO/+)) prevented healing and led to a dysregulated temporal and cellular upregulation of CXCL12 expression associated with a deranged angiogenic response. Healing was rescued when BMP2(cKO/+) mice were systemically treated with AMD3100, an antagonist of CXCR4 and agonist for CXCR7 both receptors for CXCL12. We further found that mesenchymal stromal cells (MSCs), capable of delivering BMP2 at the endosteal site, restored fracture healing when transplanted into BMP2(cKO/+) mice by rectifying the CXCL12 expression pattern. Our in vitro studies showed that in isolated endosteal cells, BMP2, while inducing osteoblastic differentiation, stimulated expression of pericyte markers that was coupled with a decrease in CXCL12. Furthermore, in isolated BMP2(cKO/cKO) endosteal cells, high expression levels of CXCL12 inhibited osteoblastic differentiation that was restored by AMD3100 treatment or coculture with BMP2-expressing MSCs that led to an upregulation of pericyte markers while decreasing platelet endothelial cell adhesion molecule (PECAM). Taken together, our studies show that following fracture, a CXCL12(+)-BMP2(+) perivascular cell population is recruited along the endosteum, then a timely increase of BMP2 leads to downregulation of CXCL12 that is essential to determine the fate of the CXCL12(+)-BMP2(+) to osteogenesis while departing their supportive role to angiogenesis. Our findings have far-reaching implications for understanding mechanisms regulating the selective recruitment of distinct cells into the repairing niches and the development of novel pharmacological (by targeting BMP2/CXCL12) and cellular (MSCs, endosteal cells) interventions to promote fracture healing.

Expression levels of insulin receptor substrate-1 modulate the osteoblastic differentiation of mesenchymal stem cells and osteosarcoma cells

The insulin-like growth factor-1 system, including its critical mediator insulin receptor substrate-1 (IRS-1), is involved in regulating osteosarcoma (OS) cell proliferation or differentiation. The aim of this study is to define the role of IRS-1 in OS cells by assessing the contribution of IRS-1 in the differentiation of human and murine OS cell lines and mouse mesenchymal stem cells (MSCs) and found that the basal level of IRS-1 is important for the initiation of differentiation. Both down-regulation and over-expression of IRS-1 inhibited osteoblastic differentiation. In vivo studies showed that OS cells over-expressing IRS-1 have increased metastatic potential and tumor growth. The proteasome inhibitor MG-132 led to an increase in IRS-1 protein level that inhibited osteoblastic differentiation, suggesting a role for proteasomal regulation in maintaining the appropriate expression level of IRS-1. Thus, precise regulation of IRS-1 expression level is critical for determining the differentiating capacity of MSCs and OS cells, and that derangement of IRS-1 levels can be a critical step in OS transformation.

Joint TGF-β type II receptor-expressing cells: ontogeny and characterization as joint progenitors

TGF-β type II receptor (Tgfbr2) signaling plays an essential role in joint-element development. The Tgfbr2(PRX-1KO) mouse, in which the Tgfbr2 is conditionally inactivated in developing limbs, lacks interphalangeal joints and tendons. In this study, we used the Tgfbr2-β-Gal-GFP-BAC mouse as a LacZ/green fluorescent protein (GFP)-based read-out to determine: the spatial and temporally regulated expression pattern of Tgfbr2-expressing cells within joint elements; their expression profile; and their slow-cycling labeling with bromodeoxyuridine (BrdU). Tgfbr2-β-Gal activity was first detected at embryonic day (E) 13.5 within the interphalangeal joint interzone. By E16.5, and throughout adulthood, Tgfbr2-expressing cells clustered in a contiguous niche that comprises the groove of Ranvier and the synovio-entheseal complex including part of the perichondrium, the synovium, the articular cartilage superficial layer, and the tendon's entheses. Tgfbr2-expressing cells were found in the synovio-entheseal complex niche with similar temporal pattern in the knee, where they were also detected in meniscal surface, ligaments, and the synovial lining of the infrapatellar fat pad. Tgfbr2-β-Gal-positive cells were positive for phospho-Smad2, signifying that the Tgfbr2 reporter was accurate. Developmental-stage studies showed that Tgfbr2 expression was in synchrony with expression of joint-morphogenic genes such as Noggin, GDF5, Notch1, and Jagged1. Prenatal and postnatal BrdU-incorporation studies showed that within this synovio-entheseal-articular-cartilage niche most of the Tgfbr2-expressing cells labeled as slow-proliferating cells, namely, stem/progenitor cells. Tgfbr2-positive cells, isolated from embryonic limb mesenchyme, expressed joint progenitor markers in a time- and TGF-β-dependent manner. Our studies provide evidence that joint Tgfbr2-expressing cells have anatomical, ontogenic, slow-cycling trait and in-vivo and ex-vivo expression profiles of progenitor joint cells.

TGF-β type II receptor/MCP-5 axis: at the crossroad between joint and growth plate development

Despite its clinical significance, the mechanisms of joint morphogenesis are elusive. By combining laser-capture microdissection for RNA sampling with microarrays, we show that the setting in which joint-forming interzone cells develop is distinct from adjacent growth plate chondrocytes and is characterized by downregulation of chemokines, such as monocyte-chemoattractant protein-5 (MCP-5). Using in vivo, ex vivo, and in vitro approaches, we show that low levels of interzone-MCP-5 are essential for joint formation and contribute to proper growth plate organization. Mice lacking the TGF-β-type-II-receptor (TβRII) in their limbs (Tgfbr2(Prx1KO)), which lack joint development and fail chondrocyte hypertrophy, show upregulation of interzone-MCP-5. In vivo and ex vivo blockade of the sole MCP-5 receptor, CCR2, led to the rescue of joint formation and growth plate maturation in Tgfbr2(Prx1KO) but an acceleration of growth plate mineralization in control mice. Our study characterized the TβRII/MCP-5 axis as an essential crossroad for joint development and endochondral growth.

Systemically delivered insulin-like growth factor-I enhances mesenchymal stem cell-dependent fracture healing

In this study, we examined the effectiveness of systemic subcutaneous delivery of recombinant Insulin-like growth factor (IGF)-I concurrently with primary cultured bone marrow-derived mesenchymal stem cell (MSC) transplant on fracture repair. We found that the fracture callus volume increased in mice with a stabilized tibia fracture that received IGF-I+MSC when compared with that in either untreated or MSC alone treated mice. In evaluating the callus tissue components, we found that the soft and new bone tissue volumes were significantly increased in IGF-I+MSC recipients. Histological and in-situ hybridization analyses confirmed a characteristic increase of newly forming bone in IGF-I+MSC recipients and that healing progressed mostly through endochondral ossification. The increase in soft and new bone tissue volumes correlated with increased force and toughness as determined by biomechanical testing. In conclusion, MSC transplant concurrent with systemic delivery of IGF-I improves fracture repair suggesting that IGF-I+MSC could be a novel therapeutic approach in patients who have inadequate fracture repair.

Mesenchymal stem cells expressing insulin-like growth factor-I (MSCIGF) promote fracture healing and restore new bone formation in Irs1 knockout mice: analyses of MSCIGF autocrine and paracrine regenerative effects

Failures of fracture repair (nonunions) occur in 10% of all fractures. The use of mesenchymal stem cells (MSC) in tissue regeneration appears to be rationale, safe, and feasible. The contributions of MSC to the reparative process can occur through autocrine and paracrine effects. The primary objective of this study is to find a novel mean, by transplanting primary cultures of bone marrow-derived MSCs expressing insulin-like growth factor-I (MSC(IGF)), to promote these seed-and-soil actions of MSC to fully implement their regenerative abilities in fracture repair and nonunions. MSC(IGF) or traceable MSC(IGF)-Lac-Z were transplanted into wild-type or insulin-receptor-substrate knockout (Irs1(-/-)) mice with a stabilized tibia fracture. Healing was assessed using biomechanical testing, microcomputed tomography (μCT), and histological analyses. We found that systemically transplanted MSC(IGF) through autocrine and paracrine actions improved the fracture mechanical strength and increased new bone content while accelerating mineralization. We determined that IGF-I adapted the response of transplanted MSC(IGF) to promote their differentiation into osteoblasts. In vitro and in vivo studies showed that IGF-I-induced osteoglastogenesis in MSCs was dependent of an intact IRS1-PI3K signaling. Furthermore, using Irs1(-/-) mice as a nonunion fracture model through altered IGF signaling, we demonstrated that the autocrine effect of IGF-I on MSC restored the fracture new bone formation and promoted the occurrence of a well-organized callus that bridged the gap. A callus that was basically absent in Irs1(-/-) left untransplanted or transplanted with MSCs. We provided evidence of effects and mechanisms for transplanted MSC(IGF) in fracture repair and potentially to treat nonunions.

Temporary Ventricular Assist Devices in the Intensive Care Unit as a Bridge to Decision

Morbidity and mortality in patients with cardiogenic shock remain high despite the recent advances in therapy. New temporary ventricular assist devices (VADs) that are rapidly applied to normalize cardiac output in patients with severe heart failure are being used more frequently. Bridge to decision describes the temporary use of a VAD to stabilize critically ill patients until complete diagnostic tests are performed and decisions about more definitive therapy are made. The CentriMag, Tandem-Heart, and Impella VADs offer versatility for use in many patients and in multiple hospital settings. These VADs provide continuous blood flow, altering the usual assessment of arterial blood pressure. Patients are usually immobilized during support to prevent dislodgement of cannulas. Anticoagulation therapy is commonly required, and bleeding is a frequent complication. Infection prevention measures must be used to avoid septic complications. In the past 10 years, clinical experience with these devices has expanded, but they remain underused.

Transcutaneous energy transmission for mechanical circulatory support systems: history, current status, and future prospects

A totally implantable mechanical circulatory support system would be very desirable for destination therapy. However, implanting all components of a pulsatile total artificial heart (TAH) or left ventricular assist device (LVAD) is complex because of the requirement for a continuous electrical power supply and the need for volume compensation. Implantable compliance chambers were developed for early LVAD designs, and although they functioned properly during initial laboratory tests, air loss by diffusion and the development of fibrous tissue around the sac eventually rendered them ineffective. Because these problems have not yet been overcome, volume displacement LVADs are currently designed with either a direct communication to an external drive console or an atmospheric vent. Transcutaneous energy transmission systems (TETSs) were also developed, but because the skin was being penetrated for volume compensation, it seemed more efficient to transmit electrical power through wires incorporated into the venting apparatus. More recently, TETSs were used clinically for both a pulsatile TAH and LVAD in a small number of patients, but for reasons unrelated to the TETS, neither of these devices is presently in use. Because the newer continuous-flow LVADs do not require a compliance chamber, they present a potential future application for TETS technology, because infections of the percutaneous tube continue to be one of the most important limitations of long-term circulatory support. A totally implantable LVAD with an incorporated TETS for destination therapy could become an important advance in the treatment of end-stage heart failure.

Mesenchymal stem cells at the intersection of cell and gene therapy

IMPORTANCE OF THE FIELD

Mesenchymal stem cells have the ability to differentiate into osteoblasts, chondrocytes and adipocytes. Along with differentiation, MSCs can modulate inflammation, home to damaged tissues and secrete bioactive molecules. These properties can be enhanced through genetic-modification that would combine the best of both cell and gene therapy fields to treat monogenic and multigenic diseases.

AREAS COVERED IN THIS REVIEW

Findings demonstrating the immunomodulation, homing and paracrine activities of MSCs followed by a summary of the current research utilizing MSCs as a vector for gene therapy, focusing on skeletal disorders, but also cardiovascular disease, ischemic damage and cancer.

WHAT THE READER WILL GAIN

MSCs are a possible therapy for many diseases, especially those related to the musculoskeletal system, as a standalone treatment, or in combination with factors that enhance the abilities of these cells to migrate, survive or promote healing through anti-inflammatory and immunomodulatory effects, differentiation, angiogenesis or delivery of cytolytic or anabolic agents.

TAKE HOME MESSAGE

Genetically-modified MSCs are a promising area of research that would be improved by focusing on the biology of MSCs that could lead to identification of the natural and engrafting MSC-niche and a consensus on how to isolate and expand MSCs for therapeutic purposes.

Mitochondrial reactive oxygen species mediate GPCR-induced TACE/ADAM17-dependent transforming growth factor-alpha shedding

Epidermal growth factor receptor (EGFR) activation by GPCRs regulates many important biological processes. ADAM metalloprotease activity has been implicated as a key step in transactivation, yet the regulatory mechanisms are not fully understood. Here, we investigate the regulation of transforming growth factor-alpha (TGF-alpha) shedding by reactive oxygen species (ROS) through the ATP-dependent activation of the P2Y family of GPCRs. We report that ATP stimulates TGF-alpha proteolysis with concomitant EGFR activation and that this process requires TACE/ADAM17 activity in both murine fibroblasts and CHO cells. ATP-induced TGF-alpha shedding required calcium and was independent of Src family kinases and PKC and MAPK signaling. Moreover, ATP-induced TGF-alpha shedding was completely inhibited by scavengers of ROS, whereas calcium-stimulated shedding was partially inhibited by ROS scavenging. Hydrogen peroxide restored TGF-alpha shedding after calcium chelation. Importantly, we also found that ATP-induced shedding was independent of the cytoplasmic NADPH oxidase complex. Instead, mitochondrial ROS production increased in response to ATP and mitochondrial oxidative complex activity was required to activate TACE-dependent shedding. These results reveal an essential role for mitochondrial ROS in regulating GPCR-induced growth factor shedding.

Clinical management of continuous-flow left ventricular assist devices in advanced heart failure

Continuous-flow left ventricular assist devices (LVAD) have emerged as the standard of care for advanced heart failure patients requiring long-term mechanical circulatory support. Evidence-based clinical management of LVAD-supported patients is becoming increasingly important for optimizing outcomes. In this state-of-art review, we propose key elements in managing patients supported with the new continuous-flow LVADs. Although most of the presented information is largely based on investigator experience during the 1,300-patient HeartMate II clinical trial, many of the discussed principles can be applied to other emerging devices as well. Patient selection, pre-operative preparation, and the timing of LVAD implant are some of the most important elements critical to successful circulatory support and are principles universal to all devices. In addition, proper nutrition management and avoidance of infectious complications can significantly affect morbidity and mortality during LVAD support. Optimizing intraoperative and peri-operative care, and the monitoring and treatment of other organ system dysfunction as it relates to LVAD support, are discussed. A multidisciplinary heart failure team must be organized and charged with providing comprehensive care from initial referral until support is terminated. Preparing for hospital discharge requires detailed education for the patient and family or friends, with provisions for emergencies and routine care. Implantation techniques, troubleshooting device problems, and algorithms for outpatient management, including the diagnosis and treatment of related problems associated with the HeartMate II, are discussed as an example of a specific continuous-flow LVAD. Ongoing trials with other continuous-flow devices may produce additional information in the future for improving clinical management of patients with these devices.

Use of glycol chitosan modified by 5beta-cholanic acid nanoparticles for the sustained release of proteins during murine embryonic limb skeletogenesis

Murine embryonic limb cultures have invaluable roles in studying skeletogenesis. Substance delivery is an underdeveloped area in developmental biology that has primarily relied on Affi-Gel-Blue-agarose-beads. However, the lack of information about the efficiency of agarose-bead loading and release and difficulties for a single-bead implantation represent significant limitations. We optimized the use of glycol chitosan-5beta-cholanic acid conjugates (HGC) as a novel protein delivery system in mouse embryonic limbs. To this purpose, we loaded HGC either with recombinant Noggin, or bovine serum albumin (BSA). The size, morphology and stability of the protein-loaded-HGC were determined by transmission electron microscopy and dynamic-light-scattering. HGC-BSA and HGC-Noggin loading efficiencies were 80-90%. Time-course study revealed that Noggin and BSA were 80-90% released after 48 h. We developed several techniques to implant protein-loaded-HGC into murine embryonic joints from embryonic age E13.5 to E15.5, including a micro-injection system dispensing nanoliters. HGC did not interfere with skeletogenesis. Using CBR-3BA staining, we detected HGC nanoparticles within implanted tissues. Furthermore, a sustained release of BSA and Noggin was demonstrated in HGC-BSA and HGC-Noggin injected regions. HGC-released Noggin was biologically active in blocking the BMP signaling in in vitro mesenchyme limb micromasses as well as in ex-vivo limb cultures. Results reveal that HGC is a valuable protein-delivery system in developmental biology.

Regenerative effects of transplanted mesenchymal stem cells in fracture healing

Mesenchymal stem cells (MSC) have a therapeutic potential in patients with fractures to reduce the time of healing and treat nonunions. The use of MSC to treat fractures is attractive for several reasons. First, MSCs would be implementing conventional reparative process that seems to be defective or protracted. Secondly, the effects of MSCs treatment would be needed only for relatively brief duration of reparation. However, an integrated approach to define the multiple regenerative contributions of MSC to the fracture repair process is necessary before clinical trials are initiated. In this study, using a stabilized tibia fracture mouse model, we determined the dynamic migration of transplanted MSC to the fracture site, their contributions to the repair process initiation, and their role in modulating the injury-related inflammatory responses. Using MSC expressing luciferase, we determined by bioluminescence imaging that the MSC migration at the fracture site is time- and dose-dependent and, it is exclusively CXCR4-dependent. MSC improved the fracture healing affecting the callus biomechanical properties and such improvement correlated with an increase in cartilage and bone content, and changes in callus morphology as determined by micro-computed tomography and histological studies. Transplanting CMV-Cre-R26R-Lac Z-MSC, we found that MSCs engrafted within the callus endosteal niche. Using MSCs from BMP-2-Lac Z mice genetically modified using a bacterial artificial chromosome system to be beta-gal reporters for bone morphogenic protein 2 (BMP-2) expression, we found that MSCs contributed to the callus initiation by expressing BMP-2. The knowledge of the multiple MSC regenerative abilities in fracture healing will allow design of novel MSC-based therapies to treat fractures.

Subcellular localization of IRS-1 in IGF-I-mediated chondrogenic proliferation, differentiation and hypertrophy of bone marrow mesenchymal stem cells

Bone marrow derived mesenchymal stem cells (BM-MSC) can differentiate into chondrocytes. Understanding the mechanisms and growth factors that control the MSC stemness is critical to fully implement their therapeutic use in cartilage diseases. The activated type 1 insulin-like growth factor receptor (IGF-IR), interacting with the insulin receptor substrate-1 (IRS-1), can induce cancer cell proliferation and transformation. In cancer or transformed cells, IRS-1 has been shown to localize in the cytoplasm where it activates the canonical Akt pathway, as well as in the nucleus where it binds to nuclear proteins. We have previously demonstrated that IGF-I has distinct time-dependent effect on primary BM-MSC chondrogenic pellets: initially (2-day culture), IGF-I induces proliferation; subsequently, IGF-I promotes chondrocytic differentiation (7-day culture). In the present study, by using MSC from the BM of IRS-1(- / - ) mice we show that IRS-1 mediates almost 50% of the IGF-I mitogenic response and the MAPK-MEK/ERK signalling accounts for the other 50%. After stimulation with IGF-I, we found that in 2-day old human and mouse derived BM-MSC pellets, IRS-1 (total and phosphorylated) is nuclearly localized and that proliferation prevails over differentiation. The IGF-I mitogenic effect is Akt-independent. In 7-day MSC pellets, IGF-I stimulates the chondrogenic differentiation of MSC into chondrocytes, pre-hypertrophic and hypertrophic chondrocytes and IRS-1 accumulates in the cytoplasm. IGF-I-dependent differentiation is exclusively Akt-dependent. Our data indicate that in the physiologically relevant model of primary cultured MSC, IGF-I induces a temporally regulated nuclear or cytoplasmic localization of IRS-1 that correlate with the transition from proliferation to chondrogenic differentiation.

Reducing aluminum dust explosion hazards: case study of dust inerting in an aluminum buffing operation

Metal powders or dusts can represent significant dust explosion hazards in industry, due to their relatively low ignition energy and high explosivity. The hazard is well known in industries that produce or use aluminum powders, but is sometimes not recognized by facilities that produce aluminum dust as a byproduct of bulk aluminum processing. As demonstrated by the 2003 dust explosion at aluminum wheel manufacturer Hayes Lemmerz, facilities that process bulk metals are at risk due to dust generated during machining and finishing operations [U.S. Chemical Safety and Hazard Investigation Board, Investigation Report, Aluminum Dust Explosion Hayes Lemmerz International, Inc., Huntington, Indiana, Report No. 2004-01-I-IN, September 2005]. Previous studies have shown that aluminum dust explosions are more difficult to suppress with flame retardants or inerting agents than dust explosions fueled by other materials such as coal [A.G. Dastidar, P.R. Amyotte, J. Going, K. Chatrathi, Flammability limits of dust-minimum inerting concentrations, Proc. Saf. Progr., 18-1 (1999) 56-63]. In this paper, an inerting method is discussed to reduce the dust explosion hazard of residue created in an aluminum buffing operation as the residue is generated. This technique reduces the dust explosion hazard throughout the buffing process and within the dust collector systems making the process inherently safer. Dust explosion testing results are presented for process dusts produced during trials with varying amounts of flame retardant additives.

Intestinal IgA response and immunity to rotavirus infection in normal and antibody-deficient chickens

Rotavirus inoculation by oesophageal cannulation resulted in subclinical infection without decreasing intestinal D-xylose absorption in both intact and embryonally bursectomised, antibody-deficient (EBx) 8-week-old specific-pathogen-free chickens. In intact chickens, rotavirus-specific IgM, IgG and IgA responses were detected in serum, while the intestinal antibody response consisted almost entirely of IgA Serum IgG and intestinal IgA levels were increased for at least 70 days following a single inoculation with the virus. Intact chickens recovered from a primary rotavirus infection between 4 and 14 days post inoculation (dpi) and developed resistance to homotypic challenge between 14 and 28 dpi. These responses were only slightly delayed in EBx birds, which recovered from primary infection between 8 and 28 dpi and developed resistance between 14 and 42 dpi. This suggested that the intestinal IgA response in chickens participated in both recovery from and resistance to rotavirus infection, but that it was not the only mediator of recovery and resistance.

Environmental stress-corrosion cracking of fiberglass: lessons learned from failures in the chemical industry

Fiberglass reinforced plastic (FRP) composite materials are often used to construct tanks, piping, scrubbers, beams, grating, and other components for use in corrosive environments. While FRP typically offers superior and cost effective corrosion resistance relative to other construction materials, the glass fibers traditionally used to provide the structural strength of the FRP can be susceptible to attack by the corrosive environment. The structural integrity of traditional FRP components in corrosive environments is usually dependent on the integrity of a corrosion-resistant barrier, such as a resin-rich layer containing corrosion resistant glass fibers. Without adequate protection, FRP components can fail under loads well below their design by an environmental stress-corrosion cracking (ESCC) mechanism when simultaneously exposed to mechanical stress and a corrosive chemical environment. Failure of these components can result in significant releases of hazardous substances into plants and the environment. In this paper, we present two case studies where fiberglass components failed due to ESCC at small chemical manufacturing facilities. As is often typical, the small chemical manufacturing facilities relied largely on FRP component suppliers to determine materials appropriate for the specific process environment and to repair damaged in-service components. We discuss the lessons learned from these incidents and precautions companies should take when interfacing with suppliers and other parties during the specification, design, construction, and repair of FRP components in order to prevent similar failures and chemical releases from occurring in the future.

Vascular Thrombosis During Support With Continuous Flow Ventricular Assist Devices: Correlation With Computerized Flow Simulations

Continuous flow pumps are increasingly used to treat severe heart failure. These pumps alter flow physiology by lowering pulsatility in the arterial circulation. In patients with peripheral stenosis, continuous flow pumps may lead to thrombosis of peripheral vessels, possibly predisposing to vascular thrombosis in areas of non-flow-limiting stenosis. The authors performed a computerized flow modeling simulation to analyze the effects of altered hemodynamics in a stenotic area. Drawing on previous clinical experience, we modeled a stenotic area in the common carotid artery. Computerized flow modeling revealed blood stagnation zones with low shear stress and velocity adjacent to the stenotic area during nonpulsatile flow. Such stagnation was not present during pulsatile flow. These results indicate a mechanism by which altered physiologic flow may accelerate occlusion of arterial conduits in patients with preexisting stenosis. This finding may be important for patients with continuous flow devices who have peripheral vascular disease; therefore, further study is warranted.

Myocardial Perfusion As Assessed by Positron Emission Tomography During Long‐Term Mechanical Circulatory Support

Although mechanical circulatory support (MCS) can improve myocardial function in patients with advanced heart failure, its effects on relative myocardial perfusion are unclear. Using positron emission tomographic imaging techniques, the authors assessed relative myocardial perfusion in patients with ischemic or idiopathic cardiomyopathy who were receiving chronic MCS with a left ventricular assist device (pulsatile HeartMate [n = 2] [Thoratec Corporation, Pleasanton, CA] or nonpulsatile Jarvik 2000 [n = 4] [Jarvik Heart, Inc., New York, NY]). Relative myocardial perfusion was compared at lower and higher levels of MCS (50 vs. 100 - 110 ejections/min for the HeartMate and 8000 vs. 12,000 rpm for the Jarvik 2000). The size and severity of perfusion defects at rest and after dipyridamole stress were measured objectively and subjectively by computer algorithms and visual inspection, respectively. Relative myocardial perfusion increased > 5% from baseline in only one of six patients when MCS was increased. No change in relative myocardial perfusion of > 5% was seen in any of the other five patients, even after subsequent dipyridamole stress positron emission tomographic imaging. These pilot study findings suggest that the decreased metabolic requirements induced by ventricular unloading correspondingly decreased blood flow requirements to physiologically inactive myocardium.

Management of air embolism during HeartMate XVE exchange

Air embolism is a rare and usually fatal complication of major cardiac surgery. We present a case in which a 45-year-old man supported by a HeartMate(R) XVE left ventricular assist device required a pump exchange due to failure of the device motor. During pump dissection, a massive amount of air entered the systemic circulation. Urgent cannulation for cardiopulmonary bypass was performed, and cardiopulmonary bypass was initiated, followed by profound hypothermia, circulatory arrest, retrograde cerebral perfusion, retrograde coronary sinus perfusion, and then barbiturate coma and steroid therapy. The HeartMate XVE left ventricular assist device was removed, and a HeartMate II was implanted. After 5 days, the patient awoke with left hemiparesis, which nearly resolved with aggressive physical therapy. Forty-four days after the pump exchange operation, the patient was discharged from the hospital with only mild left hemiparesis. Exposure of the left ventricular assist device or its external components requires careful monitoring, because air can enter the pump-particularly in a hypovolemic patient. Rapid response after massive air entry into the left ventricular assist device system, as in our patient, can result in a successful outcome.

Management of Multiple Left Ventricular Assist Device Failures in a Patient

Device failure is a rare but life-threatening complication in patients receiving mechanical circulatory support. Because patients are supported by these devices for longer periods, the incidence of device failure has increased. We report 3 instances of device failure and successful surgical management in a single patient.

Initial clinical experience with the HeartMate II axial-flow left ventricular assist device

The redesigned HeartMate II, an axial-flow left ventricular assist device, is simpler, smaller, and easier to operate than are pulsatile pumps. These design characteristics should make the HeartMate II more reliable and durable and broaden the eligible population base. We implanted the HeartMate II in 43 patients (average age, 42 yr). The indication for use was bridge-to-heart transplantation in 26 patients and destination therapy in 17. The average duration of device support was 258 days (range, 1-761 days), and cumulative duration, more than 31 patient-years. Hemodynamic function improved in all patients during support. By 48 hours after implantation, the mean cardiac index had increased from 1.9+/-0.27 L/(min.m(2)) (baseline) to 3.5+/-0.8 L/(min.m(2)), and the pulmonary capillary wedge pressure had decreased from 24.8+/-11 mmHg to 18.5+/-5.3 mmHg. Of the 43 patients, 35 were discharged from the hospital. Support is ongoing in 27 patients (longest duration, >700 days). Nine patients died during support. Four patients had sufficient heart recovery to undergo pump explantation. Three patients underwent transplantation. One patient underwent device replacement after the pump driveline was fractured in a skateboarding accident; the device was removed in another patient because of a pump-pocket infection after 749 days of support. Of the 10 patients in whom the HeartMate II replaced a failed HeartMate I, 8 were discharged from the hospital. We have seen excellent results with use of the HeartMate II. Functional status and quality of life have greatly improved in patients who survived the perioperative period.

Simultaneous insertion of a left ventricular assist system and repair of an ascending aortic dissection

Operative methods for repairing ascending aortic dissections and for implanting left ventricular assist systems have been thoroughly presented in the medical literature. Only a few reports, however, describe the concomitant performance of these procedures in 1 patient. We report the repair of an acute ascending aortic dissection with simultaneous placement of a long-term left ventricular assist system. One week earlier, the patient had undergone emergent coronary artery bypass grafting and short-term postcardiotomy ventricular assistance when he could not be weaned from cardiopulmonary bypass. By creating a graft-to-graft anastomosis on the bench during cooling of the patient on cardiopulmonary bypass, we were able to shorten to 21 minutes the period of hypothermic circulatory arrest required during ascending aortic dissection repair. The procedures were completed successfully. However, the patient developed pneumonia and sepsis during his extended hospital stay and died of multiorgan failure 5 weeks postoperatively.

Replacement of a Malfunctioning HeartMate II Left Ventricular Assist Device in a 14-year-old After a Sudden Fall

An increasing number of patients are returning to normal activity after implantation of intracorporeal left ventricular assist devices. We describe the emergency replacement of the impeller portion of a HeartMate II left ventricular assist system that had stopped functioning after the 14-year-old recipient experienced a sudden fall from a skateboard.

Direct thrombolytic therapy for intraventricular thrombosis in patients with the Jarvik 2000 left ventricular assist device

One of the complications that can occur with continuous, axial-flow left ventricular assist devices (LVADs) is thrombosis within the left ventricle, adjacent to the device's inflow conduit, which may cause inflow obstruction and recurrent heart failure. We describe 2 cases in which we used a catheter to continuously infuse recombinant tissue plasminogen activator (tPA) into the left ventricle until signs of successful thrombolysis was achieved. By monitoring the result and administering only as much tPA as necessary to achieve thrombolysis, we were able to successfully lyse the obstructing thrombus with a minimal dose of tPA without causing any significant bleeding problems. This technique may be useful for managing this potentially serious complication while minimizing the risk of treatment.

Reversal of myocyte hypertrophy by ventricular unloading: cardiac improvement without adrenergic receptor up-regulation and relocalization

In previous studies, we found that the improved contractile ability of cardiac myocytes from patients who have had left ventricular assist device (LVAD) support was due to a number of beneficial changes, most notably in calcium handling (increased sarcoplasmic reticulum calcium binding and uptake), improved integrity of cell membranes due to phospholipid reconstruction (reduced lysophospholipid content), and an upregulation of adrenoreceptors (increased adrenoreceptor numbers). However, in the case presented here, there was no increase in adrenoreceptor number, which is something that we usually find in core tissue at the time of LVAD removal or organ transplantation; also, there was no homogeneous postassist device receptor distribution. However, the patient was well maintained for 10 months following LVAD implantation, until a donor organ was available, regardless of the lack of adrenoreceptor improvement. We conclude from these studies that cardiac recovery is the result of the initiation of multiple repair mechanisms, and that the lack of expected changes, in this case increased adrenoreceptors, is not always an accurate indicator of anticipated outcome. We suggest that interventions and strategies have to consider multiple, beneficial changes due to unloading and target a number of biochemical and structural areas to produce improvement, even if not all of these improvements occur.

Hemodynamics and Patient Safety During Pump-off Studies of an Axial-flow Left Ventricular Assist Device

BACKGROUND

Axial-flow left ventricular assist devices (LVADs), when inactivated, may result in regurgitant blood flow. We assessed the effects of regurgitant pump flow with the intraventricular Jarvik 2000 Heart LVAD (Jarvik Heart, Inc., New York, NY) on hemodynamics and patient safety under pump-off conditions.

METHODS

Thirty patients being supported by a Jarvik 2000 as a bridge to heart transplantation underwent pump-off studies. Hemodynamics, vital signs and cognitive function were monitored; Doppler echocardiographic studies were done with the pump turned off for 5 minutes if tolerated. Regurgitant flow was assessed in terms of the difference between left ventricular and right ventricular outflow tract cardiac output (LVOT CO - RVOT CO).

RESULTS

During pump-off periods, the mean regurgitant flow was 0.42 +/- 0.41 liter/min, and the mean arterial blood pressure was 63.1 +/- 11.6 mm Hg. There was no regurgitant flow when the pump was on. Three patients did not tolerate the pump being off for periods of 5 minutes; in these tests, the mean regurgitant flow rate was 0.54 +/- 0.50 liter/min, the mean arterial blood pressure was 52.8 +/- 9.8 mm Hg, and the mean pump-off time was 3.1 +/- 1.1 minutes. All patients remained conscious during the pump-off period, and none showed lasting adverse effects.

CONCLUSIONS

Our findings suggest that patients being supported with the axial-flow Jarvik 2000 Heart LVAD can generally tolerate pump-off times of 5 minutes.

Is Native Aortic Valve Commissural Fusion in Patients With Long-term Left Ventricular Assist Devices Associated With Clinically Important Aortic Insufficiency?

BACKGROUND

Long-term left ventricular assist device (LVAD) support diminishes flow through the native aortic valve and decreases valve motion. This may cause aortic valve commissural fusion. The clinical importance of such fusion is not well understood.

METHODS

Thirty-three consecutive patients receiving long-term LVAD support were followed up until transplantation or death. In each case, the native aortic valve was examined pathologically for commissural fusion. Pathology findings were correlated with hemodynamic performance as assessed by both LVAD pump flow and echocardiography.

RESULTS

Seventeen of the 33 patients had some degree of native aortic valve commissural fusion. Four patients had fusion at 2 commissures; of these, 2 had clinically significant native valve aortic insufficiency (2+ or greater), and 1 exhibited trace insufficiency of the native aortic valve. Thirteen patients had fusion at only 1 aortic commissure; of these, 2 had clinically significant aortic insufficiency (2+ or greater), and 3 had trace or mild (1+) insufficiency of native aortic valve. Two of the 4 patients with fusion at 2 commissures required increased LVAD support of >3 liters/min/cm2. No patient with fusion of only 1 commissure required increased LVAD support. Three patients with no commissural fusion of the aortic valve required increased LVAD support secondary to sepsis.

CONCLUSIONS

Commissural fusion of the native aortic valve occurs in a significant number of patients receiving long-term LVAD support and can necessitate increased levels of LVAD support. Recognition of this phenomenon may allow development of strategies to minimize commissural fusion and extend LVAD pump life.

Clinical experience with the TandemHeart percutaneous ventricular assist device

The TandemHeart percutaneous ventricular assist device can be used to support patients in cardiogenic shock (until cardiac recovery occurs or as a bridge to definitive therapy) or as a temporary application during high-risk coronary interventions. The TandemHeart is a left atrial-to-femoral artery bypass system comprising a transseptal cannula, arterial cannulae, and a centrifugal blood pump. The pump can deliver flow rates up to 4.0 L/min at a maximum speed of 7500 rpm. From May 2003 through May 2005, the TandemHeart was used to support 18 patients (11 in cardiogenic shock and 7 undergoing high-risk percutaneous transluminal coronary angioplasty). The patients in cardiogenic shock were supported for a mean of 88.8 +/- 74.3 hours (range, 4-264 hr) at a mean pump flow rate of 2.87 +/- 0.56 L/min (range, 1.8-3.5 L/min). The mean cardiac index improved from 1.57 +/- 0.31 L/min/m2 before support to 2.60 +/- 0.34 L/min/m2 during support. The mean duration of support for the high-risk percutaneous transluminal coronary angioplasty patients was 5.5 +/- 8.3 hours (range, 1-24 hr). The mean flow rate was 2.42 +/- 0.55 L/min (range, 1.5-3.0 L/ min). The overall 30-day survival rate was 61%. In our experience, the TandemHeart device was easy to insert and provided a means either to cardiac recovery or to continued support with an implantable left ventricular assist device.

Catheterization of the AbioCor implantable replacement heart: evaluation of the unique physiology created by the device

We performed the 1st catheterization of an AbioCor implantable replacement heart, in a patient who had developed high right-sided pump pressures, to determine whether the high pressures were caused by graft kinking or obstruction.

Saphenous vein graft flow during left ventricular assistance with an axial-flow pump

The effects of continuous-flow support on bypass graft flow have not been quantified clinically. Continuous-flow left ventricular assist devices unload the left ventricle throughout the cardiac cycle, which narrows pulse pressure and converts passive left ventricular filling during diastole to active flow throughout the cardiac cycle. We report the case of a 63-year-old man with severe congestive heart failure who underwent coronary artery bypass grafting and was supported with an axial-flow pump. In this patient, saphenous vein graft flow during left ventricular assistance provided adequate coronary perfusion.

Gastrointestinal bleeding from arteriovenous malformations in patients supported by the Jarvik 2000 axial-flow left ventricular assist device

The long-term effects of axial-flow mechanical circulatory support in humans are unclear. We report 3 cases of chronic gastrointestinal bleeding after implantation of a Jarvik 2000 axial-flow left ventricular assist device. The bleeding was refractory to aggressive management and in 2 cases resolved only after orthotopic cardiac transplantation.

Role of B-Type Natriuretic Peptide and Effect of Nesiritide After Total Cardiac Replacement With the AbioCor Total Artificial Heart

Endogenous B-type natriuretic peptide (BNP) is thought to be produced in the cardiac ventricles. After sub-total cardiectomy and implantation of a total artificial heart (TAH), the abrupt withdrawal of BNP impairs renal function despite normal hemodynamic variables. We hypothesized that abrupt withdrawal of endogenous BNP may impair renal function and volume homeostasis and BNP may have a direct renal influence unrelated to its cardiovascular effect. Nesiritide infusion should be supplemented in the interim and weaned slowly until BNP levels normalize, which suggests that BNP is produced in tissues other than the cardiac ventricles.

Left Ventricular Unloading with an Assist Device Results in Receptor Relocalization as well as Increased Beta-Adrenergic Receptor Numbers: Are These Changes Indications for Outcome?

BACKGROUND

The use of left ventricular (LV) assist devices (LVADs) can improve performance and recovery of failing human hearts.

AIM

Following our alpha-adrenergic receptor work, we hypothesized that mechanical unloading in patients with low output syndrome and LV failure would yield similar results with beta-adrenergic receptors ((beta)AR), that being increased numbers and intra-myocytic relocalization.

METHODS

(beta)AR density and localization were investigated by fluorescence deconvolution microscopy and compared at LVAD insertion and removal in 13 heart failure patients, the patients therefore acting as their own control. (beta)AR densities and distribution were determined in snap frozen sections of human core biopsy left ventricular apical tissue. Samples were probed with tagged CGP 12177 for visualization of (beta)AR and challenged with cold agonists and antagonists. (beta)AR density was measured by two independent methods. Localization of receptors was examined in reconstructed, deconvoluted, stacked section images.

RESULTS

There was an increase in (beta)AR density following ventricular unloading in most of the patients, and also significant normalization in the location of the receptors in the myocardium comparing pre- and post-LVAD tissue.

CONCLUSIONS

These findings suggest that supporting an ailing heart via unloading initiates mechanisms and pathways responsible for myocardial recovery and repair. With appropriate pharmacological support, patients with LVAD might recover to the point where they no longer depend on eventual organ transplantation, and (beta)AR number, type, and distribution in pre-LVAD myocardial tissue, could predict outcome with regard to recovery, repair, and improvement in cardiac function.

Nitric Oxide Versus Prostaglandin E1 for Reduction of Pulmonary Hypertension in Heart Transplant Candidates

BACKGROUND

We sought to directly compare the effects of prostaglandin E1 (PGE1) and nitric oxide (NO) in testing for pulmonary hypertension reversibility in heart transplant candidates.

METHODS

We included 19 heart transplant candidates who fulfilled at least 1 of 3 criteria: pulmonary vascular resistance (PVR) of >4 Wood units; transpulmonary gradient (TPG) of >12 mmHg; or systolic pulmonary artery pressure (PAP) of >60 mmHg. Patients randomly received either PGE1 (0.05, 0.2 and 0.5 microg/kg/min) or NO (40, 60 and 80 ppm) and were crossed-over to the second medication after receiving the maximal dose of the first.

RESULTS

With PGE1, TPG decreased by 21% (baseline 20.3 +/- 6.8 mmHg; final 16.0 +/- 7.0 mmHg) compared to a 34% decrease with NO (baseline 20.8 +/- 6.2 mmHg; final 13.8 +/- 5.4 mmHg) (p = 0.13). PVR decreased by 42% with PGE1 (baseline 6.2 +/- 4.0 Wood units; final 3.6 +/- 1.8 Wood units) and by 47% with NO (baseline 6.0 +/- 3.9 Wood units; final 3.2 +/- 1.6 Wood units) (p = 0.87). Mean systemic pressure decreased with PGE1 (baseline 76.1 +/- 10.5 mmHg; final 69.4 +/- 12.2 mmHg; -9%) but not with NO administration (baseline 70.2 +/- 14.7 mmHg; final 71.6 +/- 10.9 mmHg; +2%) (p = 0.01). TPG was lowered to <12 mmHg in 14 patients. Of these, 6 (46%) responded to both PGE1 and NO, 4 (27%) responded only to PGE1, and 4 (27%) responded only to NO.

CONCLUSIONS

The effects of PGE1 and NO on pulmonary hypertension are comparable, with PGE1 having more systemic hypotensive effects. Due to variability of patient responses, we recommend multiple rather than single-agent pharmacologic testing for the reversibility of pulmonary hypertension.

A novel reconstruction algorithm to extend the CT scan field-of-view

For various reasons, a projection dataset acquired on a computed tomography (CT) scanner can be truncated. That is, a portion of the scanned object is positioned outside the scan field-of-view (SFOV) and the line integrals corresponding to those regions are not measured. A projection truncation problem causes imaging artifacts that lead to suboptimal image quality. In this paper, we propose a reconstruction algorithm that enables an adequate estimation of the projection outside the SFOV. We make use of the fact that the total attenuation of each ideal projection in a parallel sampling geometry remains constant over views. We use the magnitudes and slopes of the projection samples at the location of truncation to estimate water cylinders that can best fit to the projection data outside the SFOV. To improve the robustness of the algorithm, continuity constraints are placed on the fitting parameters. Extensive phantom and patient experiments were conducted to test the robustness and accuracy of the proposed algorithm.

Thirty-five years of mechanical circulatory support at the Texas Heart Institute: an updated overview

Since the 1960s, the Texas Heart Institute has been intimately involved in the development of mechanical circulatory support devices (for example, ventricular assist devices, aortic counterpulsation pumps, and total artificial hearts) for both short- and long-term use. Here, we review the varied clinical experience with these technologies at the Texas Heart Institute over the last 35 years.

The effect of LVAD aortic outflow-graft placement on hemodynamics and flow: Implantation technique and computer flow modeling

Axial-flow ventricular assist devices (VADs) can be implanted either through a left thoracotomy with outflow-graft anastomosis to the descending thoracic aorta or through a midline sternotomy with anastomosis to the ascending aorta. Each method has advantages and disadvantages. Because these VADs produce nonpulsatile flow, their hemodynamic characteristics differ from those of pulsatile devices. These differences may have important clinical consequences, particularly in relation to the outflow-graft configuration. We describe a computer-generated flow model that we created to illustrate the flow dynamics and possible clinical consequences of each method. The simulations indicate that the location of the anastomosis has important qualitative effects on flow in the ascending aorta and aortic arch. At high VAD outputs (> or =75%), native cardiac output cannot supply the carotid and subclavian arteries. With a descending aortic anastomosis, net backward flow occurs in the descending aorta to supply these branches. Consequently, the aortic arch has a region with almost no net flow, where fluid particles stagnate over many cardiac cycles, possibly causing thrombogenesis. With an ascending aortic anastomosis, the arch has no stagnant region, although flow turbulence still occurs. When the aortic valve remains closed, so that the total output occurs through the VAD, the aortic root has a region of nearly stagnant flow. With an ascending aortic anastomosis, a small degree of recirculatory flow may prevent complete stagnation at the aortic root. With the descending aortic anastomosis, however, no recirculation occurs. These results help delineate the complex flow dynamics and the advantages and drawbacks of each technique.

Echocardiographic evaluation of the Jarvik 2000 axial-flow LVAD

From April 2000 through September 2001, we studied 11 patients with the Jarvik 2000--a left ventricular assist device with an axial-flow pump that provides continuous blood flow--to determine the echocardiographic characteristics. All patients underwent complete echocardiographic examination, including outflow-graft flow evaluation 24 hours after implantation and each month thereafter for the duration of support. Data were obtained at each pump setting (8000-12000 rpm in 1000-rpm increments) and with the pump off. Left ventricular dimensions and shortening fraction and the duration of aortic valve systolic opening decreased as pump speed increased. Although the aortic valve remained closed at higher pump speeds, pump outflow-graft flow remained pulsatile, because of the systolic thrust of the assisted ventricle. Systolic dominance of phasic flow was more pronounced at lower pump speeds, due to normalization of the diseased heart's Starling response. When the aortic valve was closed continuously, echocardiographic contrast (indicating blood stasis) was noted in the aortic root. Because of the pump outflow graft's proximity to the chest wall, device output could be measured independently of cardiac contributions. Mean peak outflow-graft flow velocities were 0.75 +/- 0.30 m/s (systolic) and 0.41 +/- 0. 13 m/s (diastolic). When the pump was turned off briefly there was minimal regurgitation through the device into the left ventricle. This 1st echocardiographic heart function analysis of the Jarvik 2000 confirms that the device unloads the ventricle and increases cardiac output. Cardiac responses to device-speed changes can be evaluated readily with echocardiography in the early and late postoperative period.

Quality of Life in Bridge-to-Transplant Patients With Chronic Heart Failure After Implantation of an Axial Flow Ventricular Assist Device

Research suggests that ventricular assist devices improve quality of life for congestive heart failure patients awaiting heart transplantation. Axial flow ventricular assist devices like the Jarvik 2000 (Jarvik Heart, Inc., New York, NY) represent the newest type of ventricular assist device technology, but their effects on quality of life are not well understood. Therefore, the authors administered the Minnesota Living with Heart Failure Questionnaire to patients who had the Jarvik 2000 implanted as a bridge to heart transplantation. Patients completed the Minnesota Living with Heart Failure Questionnaire immediately before device implantation, 1 month after implantation, immediately before heart transplantation, and 1 month after transplantation. One month after implantation of the device, the nine patients who completed the study showed significant improvements in physical (p<0.008), emotional (p<0.02), and overall (p<0.008) quality of life. These improvements were maintained until the device was explanted. The authors conclude that implantation of the Jarvik 2000 ventricular assist device can substantially improve quality of life for patients awaiting heart transplantation.

Use of the Flowmaker (Jarvik 2000) left ventricular assist device for destination therapy and bridging to transplantation

The Flowmaker left ventricular assist device (formerly known as the Jarvik 2000) is an axial-flow pump that provides continuous flow from the left ventricle to the aorta. Designed for either temporary or permanent use, the Flowmaker is undergoing clinical trials in the United States and Europe. The goal of this therapy is to provide adequate circulatory flow while partially reducing the left ventricular size and end-diastolic pressure. This gives the native ventricle an opportunity to remodel itself. Those who benefit the most from this technology are patients who require only true left ventricular assistance rather than total capture of the left ventricular output. Because of the Flowmaker's simplicity and safety of implantation, as well as the absence of late pump failure, its use may be justified in severely impaired class III and IV (but not preterminal) heart failure patients.

Hemodynamic support with a percutaneous left ventricular assist device during stenting of an unprotected left main coronary artery

Coronary artery bypass grafting prolongs survival in patients with left main coronary artery stenosis. However, this benefit is denied to patients who refuse the procedure or who are poor surgical candidates due to comorbid conditions. We describe a novel technique for the percutaneous revascularization of stenosis in an unprotected left main coronary artery in high-risk patients. The TandemHeart, a percutaneously inserted left ventricular assist device, was used to provide periprocedural hemodynamic support during angioplasty and stenting of an unprotected left main coronary artery for stenosis in a 70-year-old woman. The device was removed immediately after the procedure, and the patient was discharged from the hospital on the 2nd postprocedural day. The potential advantages of angioplasty with the support of percutaneous left ventricular assist devices in high-risk patients are discussed.

First clinical use of the redesigned HeartMate II left ventricular assist system in the United States: a case report

Axial flow ventricular assist devices show great promise as a potential treatment for patients with end-stage heart failure. The HeartMate II system, redesigned on the basis of initial clinical experiences in Europe, is now in clinical trials in the United States. We report on the 1st use of the newly redesigned HeartMate II in the United States. The system has unique features, which include an accurate flow estimator and the ability to automatically detect and correct excessive left ventricular unloading. The new design also incorporates changes in the texturing of the blood-contacting surfaces to prevent thrombosis. The implantation technique and configuration are similar to those of the HeartMate XVE LVAS and require a median sternotomy for access. The 1st patient to receive the device in the United States has had an uncomplicated perioperative course and now awaits transplantation.

Clinical experience with an implantable, intracardiac, continuous flow circulatory support device: physiologic implications and their relationship to patient selection

BACKGROUND

We have been investigating continuous-flow circulatory support devices for 20 years. Unlike pulsatile assist devices, continuous-flow pumps have a simplified pumping mechanism and they do not require compliance chambers or valves. In the 1980s, clinical experience with the Hemopump proved a high-speed, intravascular, continuous-flow pump could safely augment the circulation. Subsequently, a decade of animal experiments with a larger, longer-term continuous-flow pump (the Jarvik 2000) confirmed the safety and efficacy of intraventricular placement, leading to its clinical application.

METHODS

We analyzed the physiologic and anatomic effect of using the Jarvik 2000 pump for cardiac support in 23 patients in whom the device was applied as a bridge to transplant under the protocol approved by the Food and Drug Administration Investigational Device Exemption. The device was used as a bridge to transplantation in 20 patients and as destination therapy in 3 patients.

RESULTS

In the bridge-to-transplant group, 14 patients underwent transplantation, 5 died during the circulatory support period and 1 is in an ongoing study. The support period lasted an average of 90 days. For the survivors, the follow-up period has averaged 16 months. Within the first 48 postoperative hours, the average cardiac index increased by 65% (from 1.77 +/- 0.24 to 2.92 +/- 0.60 L. min(-1). m(-2), p = 0.00000002), the systemic vascular resistance decreased by 42% (from 1604 +/- 427 to 930 +/- 330 dynes/sec per cm(2), p = 0.00001), and the pulmonary capillary wedge pressure (PCWP) decreased by 41.8% (from 23 +/- 5.1 to 13.4 +/- 6.6 mm Hg, p = 0.00009). Similar results were seen for the patients undergoing destination therapy. Cardiac index increased 89.5% (from 1.9 +/- 0.1 to 3.6 +/- 0.6, p = 0.046) and PCWP decreased by 52.2% (from 23 +/- 10 to 11 +/- 2, p = 0.22). In that group, 1 patient died unexpectedly from an accident 382 days after device implantation. The 2 survivors remain in New York Heart Association (NYHA) functional class I at 700 to 952 days after implantation.

CONCLUSIONS

The Jarvik 2000 can offer effective long-term support for patients with chronic heart failure and NYHA class IV status. However, the new physiology produced by continuous offloading of the heart throughout the cardiac cycle has introduced unique clinical problems. The understanding of the problems generated by this biotechnological interface is essential for obtaining optimal clinical outcomes.