Name: implantation of the syncardia total artificial heart
Uploaded: 2014-07-18T06:00:00.000+00:00
Duration: 16 min 11 s
Description: Watch this Scientific Journal Video about Implantation of the Syncardia Total Artificial Heart at JoVE.com

病例报告： 该患者为60岁男性，肥厚型心肌病。他开发了渐进心脏衰竭症状，在过去10年，近期多个重新接纳失代偿心脏衰竭。他开始对慢性四米力农，并列出了心脏移植。他玛嘉烈医院值得注意的是房性心律失常S / P消融术，复发性肺栓塞，肺动脉高压，左心房血栓，中风之前。心肺运动试验证明低的最大耗氧量（VO 2 ​​最大10.6毫升/公斤分钟）。成像是值得注意的严重左心室肥厚伴中度至严重降低收缩功能，且无左室流出道梗阻（LVEF 25-30％，LVIDd比值5.0厘米，IVSD1.5厘米，后壁厚度1.5厘米）。他在附肢和一个可能的LV血栓有一个大的左心房血栓，以及。血流动力学（对米力农0.5微克/公斤/分钟）是著名的：RA 17毫米汞柱，肺毛细血管楔压37毫米​​汞柱，PA3分之745毫米汞柱，而菲克CI为1.4 L/min/m2。由于他的严格性肌病和小低压腔，他被认为是不适合作为孤立的左心室辅助装置。 1，设备<ol><li> SynCardia全人工心脏在临床使用的唯一FDA批准TAH。它最初于1982年推出的加维科-7心脏。 </li><li>该装置由2聚氨酯心室腔。每个腔室具​​有〜70 ml的最大行程容积。每室有2侧倾碟阀（美敦厅，27毫米流入为25mm流出）直接血液流入和流出。每一室之间由连接到外部驱动器（ 图1）一个单独的动力传动系统气动驱动。 </li></ol> 2，适应症<ol><li>该设备中置换出来的〜400毫升的总体积。一般最低收件人大小的建议包括BSA&gt;1.7米2和胸直径（美联社尺寸脊柱胸骨处的1级0 个胸椎）&gt; 10厘米（ 图2）。放置在较小的患者，可以通过移动设备进入左胸虽然这增加了风险的左侧面肺静脉及支气管压缩。较小尺寸的装置在较小的患者使用正在开发，预计在不久的将来。 </li><li> TAH支持表示患者的晚期重症双心室衰竭或未最佳孤立左心室的机械支持治疗等解剖异常。此类患者常出现在极端情况下有与他们的malperfusion并发症。通常情况下患者被列为INTERMACS（间注册处机械辅助循环支持），配置文件1（临界心源性休克）或​​2（上强心剂逐渐下降）。 </li><li>患者显著伴随心肌病理改变。危重患者的终末期心脏衰竭，需要机械SUPPO室温就不能很好的处理通过加入其他广泛的修复过程。这可能增加对右心室衰竭交LVAD植入，这增加了风险围手术期发病率和死亡率的风险。这包括：急性心肌梗死合并室间隔缺损;主动脉根部瘤/夹层，心脏移植失败，大量心室血栓，难治性恶性心律失常（独立充盈压），肥厚性/限制性心肌病，而复杂的先天性心脏疾病。 </li></ol>设备3的制备<ol><li>在涤纶主动脉和肺动脉移植物密封COSEAL外科密封剂（ 图3）。 </li><li>移植物和装置浸泡在利福平。 </li></ol> 4，植入<ol><li>常规准备和正中。胸部和腹部被prepped在日常时尚的心脏手术和中位数sternotOMY被执行。 </li><li>左上腹部腹膜前口袋的左侧膈肌和创造的分工。类似的心室辅助器的植入物，左隔膜分为内侧和左上腹腹膜前口袋的气动传动系统创建。两个切口〜5-10厘米以下的左肋缘来了，经腹直肌筋膜进行。创建和维护两个1“彭罗斯排水肌肉注射隧道气动传动系统。 </li><li>插管和体外循环开始。主动脉，SVC和IVC是空心。 Bicaval插管通过心房（比对SVC /下腔静脉直接插管）进行后续的移植过程中保留网站使用。心包内不必要的解剖最小化，以保持组织的飞机。 </li><li>主动脉是交叉夹紧。主动脉根部和肺动脉的valvar连合的水平是一致的。右心室切除沿急性缘开始，1-2厘米远离并且平行于右房室沟。室间隔切开开口左心室。右心室切口优一直持续到右室流出道。同样地，左心室切口延伸横向平行于左房室沟。左室流出道横向开口。其余室间隔划分和标本被删除（ 图4）。 </li><li>冠状静脉窦的oversewn。如果PFO被确定它同样oversewn。左心耳结扎用非切削内镜缝合器，以消除血栓的潜在来源（ 图5和6）。 </li><li>二尖瓣和三尖瓣瓣叶被切除留下了几个毫米袖口的环。心室袖口被修整而使组织的1厘米边缘。袖口，然后oversewn用2-0 Prolene线（MH）为hemostaSIS和精简架构的孔口到TAH心房快速接头的大小。一些中心选择使用毡的加固带。 </li><li>腹式心房快速连接的袖口被修整，以0.5-1厘米。袖口，然后倒装到各自的左，右心室的袖口。 </li><li>以类似的方式，在主动脉和肺动脉接枝快速连接被修剪。肺动脉移植物留几厘米比主动脉移植更长的时间来让空间主动脉移植物下方通过。将移植物缝合到它们各自的孔（ 图7）。 </li><li>在移植以后再进入的时候，心包强烈的炎症反应屡见不鲜。通过本组织在移植时解剖可以与显著失血相关联。这似乎是大于时重做胸骨什么通常看到。排除心包膜用于排队心包和维持无血管组织的飞机。这是沿左下侧壁心包开始作为访问这个空间将受到阻碍，一旦设备到位。被排除带也放在周围的主动脉和肺动脉吻合。一些中心使用灭菌橡胶止血带包裹吻合。 </li><li>该动力传动系统是通过先前建立的隧道。 13-15毫米有解扩张器用于通过先前放置烟卷式引流指导传动系统。排除膜的片材被卷绕在动力传动系统，以及。外部控制台传动系统原来的金属连接器将被替换为塑料连接器，也将与便携式放电驱动程序连接。 </li><li>在TAH脱气乳头左，右心室连接。左并右心室人工被刷新，然后连接到各自的小孔。柔韧快速连接都掌握有2个重针驱动程序和伸过来的硬塑料ç的人工心室确保紧密连接（ 图8）onnectors。 </li><li>主动脉根部排气口放置。低速率，低压力泵启动（左驱动压力40，右驱动压力0，％收缩40，速度40，真空0）和肺部通气的除气。通过右侧的流动最初是被动的。 </li><li>交叉夹紧被删除。一旦充分除气是由TEE证实，体外循环可以相对较快地被终止。 TAH支持增加。典型的初始直接TAH参数为：左驱动压力180-200毫米汞柱，右驱动压力30〜60毫米汞柱，心率100-120 BPM和％收缩50真空一般保留为0，直到胸部被关闭（或盖章）到。防止空气夹带。一旦密封，增加真空度（通常以15毫米汞柱），将导致增加的填充量和心输出量增加。参数，然后滴定局部心室充盈和射血齐全。 </li><li>鱼精蛋白e的给予和体外循环插管被删除。需要与显著终末器官功能障碍，包括慢性肝淤血往往存在一个TAH和患者可有显著相关的潜在凝血功能障碍。最常见的并发症如下TAH植入出血。我们建议采用低门槛纵隔包装和延迟关胸。 </li><li>一旦胸部是随时可以关闭，沿右侧心包年剩余时间和优越的内衬排除。该TAH的配置不保持正常的椭圆形。有关该设备的心包收缩会限制可用于后续的移植的空间。盐水乳房植入物是用来维持后续移植心尖心包腔。光滑盐水乳房植入物被放置在顶点和充满200-250毫升生理盐水（ 图9）。 </li><li>胸部是封闭在日常时尚。虽然imgagin术中ŦEE是有限的，它仍然是在手术结束时的有用工具，以评估对的右压缩和左心房由设备闭合期间的静脉回流。这是正确的（无论是静脉和右片面肺静脉）更常见，一般可以用位移装置的inferiorly并向左治疗。这可以确保以沉重的缝线周围放置肋缘绑在人工右心室。硅橡胶的带留在胸骨中下移植再进入，以保护泵。 </li></ol>

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A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+SynCardia+freedom+driver:+a+portable+driver+for+discharge+home+with+the+total+artificial+heart.">The SynCardia freedom driver: a portable driver for discharge home with the total artificial heart.</a> J Heart Lung Transplant. 30, 844-845 (2011).</li><li>Yankah, L., Shah, K. B., Hess, M. L., Kasirajan, V., Tang, D. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Response+of+the+Syncardia+TAH+Pneumatic+Drivers+to+Afterload+Challenge+on+a+Mock+Loop.">Response of the Syncardia TAH Pneumatic Drivers to Afterload Challenge on a Mock Loop.</a> ASAIO Journal. 58 (7), (2012).</li></ol>

生产这种视频文章的赞助，SynCardia。 MH和VK曾担任顾问SynCardia系统公司的其他作者什么都没有透露。

人工替代人的心脏早已抓住了公众的想象力。早期经验与全人工心脏的标志是次优结果1-3。设计和植入技术为今天所用的TAH没有因为DeVries医师博士的原始描述6显著改变。然而，在改进患者选择（作为一个桥梁移植）及围术期管理的理解导致了显著改善的成果。 2004年，81 TAH植入一个具有里程碑意义的研究结果发表。该试验建立了TAH的功效为桥梁，以移植，并导致Syncardia TAH的FDA的批准。在这种非随机研究中，79％已成功桥接移植。 1年总生存率为70％。在谁符合研究标准，但并没有经过TAH植入术35例匹配的队列中，46％存活移植，1年生存率为31％，7。 <p类=“jove_content”&gt;病人的选择是好的结果8,9至关重要。重要的是要找出那些尚未开发的不可逆的终器官衰竭或其他并发症，将限制他们的可能性进行复苏或移植病人的候选人是非常重要的。在我们的机构，肝硬化肝活检，慢性透析依赖，或其他心理因素会妨碍移植候选人的调查结果也将排除竞选一个TAH。相反，急性失代偿或其他证据的潜在终末器官恢复被考虑。 同样重要的是要确定患者的双心室衰竭的右心室（RV）的功能障碍将改善与孤立的LV卸载，因此不需要双心室辅助循环。右心衰竭以下心室辅助器植入与增加发病率和死亡率10相关。早期使用的双心室支持相比，推迟救援为右心衰竭以下心室辅助器也有改进的成果11相关联。一些危险因素的右心衰竭已经确定和几个风险评分系统已被开发。对于需要正性肌力/主动脉内球囊反搏支持下，证据的肾功能和肝功能不全（肌酐升高，谷草转氨酶，胆红素），右室功能不全血流动力学证据（RV降低中风的工作指标，增加右心房/楔压）和超声心动图右室功能不全的证据（右室扩张，减少右心室射血分数/三尖瓣环运动，增加三尖瓣关闭不全）都被认定为风险因素12-15。然而，决心风险是LVAD植入后右心衰竭的仍然困难。最近的一个小编从几个评分系统在预测需要RV支持16没有表现出预测值。 手术时机是一个重点考虑的问题忧思。一旦决定已经作出了双心室机械的支持是必要的，早期的植入提供恢复血流和抢救病人的最有效方法。然而，患者可以与深刻的急性心源性休克，严重malperfusion，和最小的评估之前突然呈现。 24-48小时自由使用的临时支持选项（如ECMO / IABP）就可以开始复苏的进程，同时对于神经系统状态或移植候选人的其他问题，问题被回答了。长期使用高剂量的强心剂可能会增加风险不可逆的终器官衰竭或其他并发症。 植入的一般技术已经不是发生了巨大变化，因为该设备是首次推出6,17。然而，抽出时间来保护和维持心包空间的好处应该强调18。该设备似乎煽动强烈的炎性厚厄宁心包。衬里的Goretex心包和维护根尖空间用盐水植入物大大方便移植的重新进入。围手术期出血仍然是最常见的围手术期并发症。包装胸前延迟关胸是一种有效的策略，以限制扭转底层凝血功能障碍，并尽量减少对填塞的风险所需的围手术期血液制品的数量。尽管相对刚性的外壳的人工心室它有可能为足够纵隔流体积聚并妨碍静脉流入造成填塞。表面超声心动图检查以下TAH植入具有有限的效用。 CT成像，如果经常被底层肾功能不全的限制，需要避免静脉造影。我们建议早期纵隔再探查任何TAH患者是谁，否则表现不佳，原因不明。 植入后，该装置被调节到最大程度的心输出量。它能够产生一个输出&gt; 9 LPM的。为了尽量减少淤滞，设备参数调整为“部分填充和完全退出。”典型术后早期TAH参数为：左驱动压力180-200毫米汞柱，右驱动压力30〜60毫米汞柱，心率100-120 BPM，％收缩50，和真空15毫米汞柱。患者长期的肺动脉高压，需要完全有权单方面弹射较高的RV传动的压力可能是有害的。这是可能的“超速”右双面输出。 2例，这导致了深刻的肺水肿需要临时静脉 - 静脉ECMO支持。一个病人有进行性多系统器官功能衰竭而过期。另一个是支持的，直到水肿的消退，并成功地脱离ECMO治疗的。 关胸后抗凝治疗，一般开始24小时。病人开始比伐卢定（0.005毫克/公斤/小时），阿司匹林（81毫克），和双嘧达莫（50毫克TID）。运算外erating室，肝素被避免以减少肝素诱导的血小板减少症的风险。比伐卢定，一般不滴定，一旦稳定过渡到口服华法林。治疗目标是一个INR 2-3和血小板功能的20-40％的正常光学集合度。患者增加溶血（LDH&gt; 1000）的证据，可能会受益于加己酮可可碱（400毫克TID）19,20。 好重症患者肾功能衰竭显然是多因素的。然而，我们注意到对肾功能衰竭以下TAH植入不成比例的倾向。我们猜测，这是部分相关的突然减少原生钠肽的生产与心室切除有关。围手术期补充低剂量的奈西立肽输注（0.005微克/公斤/分钟）似乎降低肾衰竭的发病率21。此外，输注奈西立肽的具有TAH的impl后增加尿量产生深远的影响antation 22。一旦患者已经康复，我们已经能够停止输液，大多数患者。不过，我们已经有一些病人谁不能从输液断奶，直到它们被移植。 TAH患者常表现出显著慢性贫血。原因包括低品位溶血和无效erthryopoesis。尽管贫血，TAH患者表现出良好的运动性和耐受性症状轻微甚至用5-6克/升血红蛋白浓度。为了避免人类白细胞抗原致敏和其他相关的并发症，输血可以避免，除非病人有症状或有终末器官malperfusion 23的另一侧。 除了术后早期，护理的重点是积极的物理康复治疗。尽管面临严峻的介绍，广大患者能够启动物理治疗在术后第一周，最能开始treadmi由第二周LL锻炼。然而，我们已经发现，TAH患者表现出血压反应的异常钝化锻炼。这部分地是关系到使用血管扩张剂，以限制后负荷24。虽然这可能会限制身体恢复的量，大多数患者去移植在此之前就达到了。 直到最近，TAH患者住院约束，并拴在418磅控制台。至于轮候时间，供体器官继续增加，这是伴随着生命的显著质量下降以及财务成本增加。便携式驱动器允许出院回家的引进，甚至恢复工作一直在TAH的实际效用的一大进步。该Syncardia自由驱动（根据临床试验，而不是FDA认证）是14磅，背包大小的驱动器与电动气动活塞25。早期经验的司机已经证明，它是传感可持续的竞争到后负荷条件和积极的抗高血压药物治疗是必要的26。 综上所述，目前的结果建立了TAH作为一种有效的设备复苏和随后的桥梁移植。患者这个世代代表终末期心脏衰竭患者的频谱的末端。通常没有其他合适耐用的治疗选择。

由丹顿库利在一个47岁的男性谁是无法脱离体外循环下左心室动脉瘤修补断奶执行的全人工心脏（TAH）于1969年人类第一次植入。提供64小时血流动力学支持，直到捐赠心脏的实验装置可以找到。虽然技术上成功，设备支持是并发溶血和肾功能衰竭。病人会去从移植后1铺天盖地败血症32小时死亡。在1981年由库利第二次尝试过类似的不幸的结果2。 1982年，威廉·DeVries医师进行加维科-7 TAH的广泛宣传，永先植入一名61岁的牙医。病人有困难的术后病程特点是反复发作性呼吸衰竭，假肢二尖瓣支柱需要更换设备的骨折，败血症，中风，间歇性肾功能衰竭，出血与抗凝分页。他112天后最终屈服于伪膜性肠炎3。 尽管这些初步的结果令人沮丧，逐步细化的装置设计，选择病人，和病人管理已导致显着改善的结果。加维科-7已经发展成为了Syncardia TAH，这仍然是唯一获得FDA今天批准TAH在临床上使用。迄今为止，已有超过1,000植入物已在世界范围内4执行。 我们提出我们的体制手术操作技术在视频情况报告的范围内。

<table><tbody><tr><td>Total artificial heart (implant kit)</td><td><a href="http://www.syncardia.com" target="_blank"><img src="/img/new_window.png"> Syncardia</a></td><td>500101</td><td></td></tr><tr><td>PRECLUDE pericardial membrane</td><td><a href="http://www.goremedical.com" target="_blank"><img src="/img/new_window.png"> Gore Medical</a></td><td>1PCM101</td><td></td></tr><tr><td>Smooth Round Saline Implant</td><td><a href="http://www.mentorwwllc.com" target="_blank"><img src="/img/new_window.png"> Mentor</a></td><td>350-1645</td><td></td></tr><tr><td>CoSeal Surgical Sealant</td><td><a href="http://www.ecomm.baxter.com/" target="_blank"><img src="/img/new_window.png"> Baxter</a></td><td>93407</td><td></td></tr></tbody></table>

implantation of the syncardia total artificial heart

随着科技的进步，采用机械辅助循环装置的终末期心脏衰竭迅速增加。此类患者绝大多数都普遍受到左心室担任辅助装置（LVADs）。然而，患者的晚期双心室衰竭或其他显著解剖病变的一个子集没有充分被孤立的左心室机械支持治疗。可通过切除TAH更换更好地处理随之而来的心肌病理改变的例子包括：在梗死后室间隔缺损，主动脉根部瘤/夹层，心脏移植失败，大量心室血栓，难治性恶性心律失常（独立充盈压），肥厚性/限制性心肌病，复杂先天性心脏疾病。患者常合并心源性休克和多系统器官功能障碍呈现。两个心室和原位更换的总人工智能切除IAL心脏（TAH）是一种有效的，虽然极端，治疗血流复苏和快速恢复。围手术期管理的重点是终末器官复苏和身体康复。除了感染的血栓栓塞共同所有的机械支撑患者通常关注的问题，出血，和，TAH患者面临独特的风险对于肾功能衰竭和贫血。在脑利钠肽的急剧下降以下ventriculectomy补充似乎有保护肾功能的影响。贫血以下TAH植入可以是深刻而持久的。尽管如此，贫血一般耐受良好和输血被限制，以避免HLA致敏。直到最近，TAH患者只限于住院病人拴在500磅气动控制台驱动程序。近期出台一个背包大小的便携式驱动器（目前正在进行临床试验），使患者出院回家，甚至重返工作岗位。尽管目前深刻这些病的患者的振动性，有一个79-87％的成功的桥梁移植。

2006年4月至2012年7月，66例患者植入TAH在弗吉尼亚联邦大学医疗中心。患者为重症：18％是其他机械支撑（ECMO治疗，心室辅助器，或BiVAD），58％是在主动脉内球囊反搏，58％的人对性肌力药物治疗，17％的机械通气，17％为上血液透析。病人被支撑为总共7863天。支持的中位时间为87.5天（范围为1至602天）。 10例患者在便携式放电驱动程序（作为临床试验的一部分，而不是FDA批准）出院回家。 50（76％）患者被成功桥接移植，7（11％）残留在设备正在等待移植，和图9（14％）死亡，而该设备（ 图10）上。 3死亡发生在第一周后植入，并与渐进多系统器官功能衰竭。其他6人死亡32至169天后植入物（3 s时发生epsis /器官功能衰竭，1纵隔出血，1颅内出血，1高血压危象）。最常见的围手术期不良事件是出血纵隔需要重新勘探30％。 <img alt="图1" fo:content-width="5in" src="/files/ftp_upload/50377/50377fig1highres.jpg" width="500" /> 图1。SynCardia全人工心脏。 <img alt="图2" fo:content-width="4in" src="/files/ftp_upload/50377/50377fig2highres.jpg" width="400" /> 图2。测量前后径经CT。一般要求的设备，以适应胸骨和10 个椎体前缘之间的空格&gt; 10厘米。 <img alt="图3" fo:content-width="4in" src="/files/ftp_upload/50377/50377fig3highres.jpg" width="400"<html> /&gt; 图3。预处理动脉流出移植的主动脉和肺动脉移植物预先密封与​​COSEAL外科密封胶，用来作为辅助密封的血管移植物的合成水凝胶。此前，移植物preclotted用病人自己的血液前，肝素化。 <img alt="图4" fo:content-width="5in" src="/files/ftp_upload/50377/50377fig4highres.jpg" width="500" /> 图4。切除的左，右心室，右心室和左心室被切除留下1厘米心室袖口超越了二尖瓣和三尖瓣环。箭头指向沿RV前壁切口。切口是通过左，右心室流出道和通过主动脉和肺动脉瓣膜延长。 oad/50377/50377fig5highres.jpg“宽度=”500“/&gt; 图5。Oversewing冠状静脉窦的冠状静脉窦（箭头）是通过房车袖口（三尖瓣单张已切除）止血oversewn。 <img alt="图6" fo:content-width="5in" src="/files/ftp_upload/50377/50377fig6highres.jpg" width="500" /> 图6。结扎心耳，左心耳结扎用Seamguard增强内GIA订书机，以减少全身栓子的潜在来源。 <img alt="图7" src="/files/ftp_upload/50377/50377fig7.jpg" /> 图7。快速连接和排除的Goretex植入。心房快速连接和血管移植物缝合到各自的小孔。心包是内衬的Goretex膜，以方便后续的再入移植。 <img alt="图8" src="/files/ftp_upload/50377/50377fig8highres.jpg" /> 图8。设备植入。只是之前胸部闭合植入的装置。 <img alt="图9" fo:content-width="5in" src="/files/ftp_upload/50377/50377fig9highres.jpg" width="500" /> 图9为展示在CT成像和胸部X光心包心尖盐水植入物。甲盐水植入物（单箭头），是用来维持移植心包心尖空间。在胸部X光检查时，TAH（其中心包否则合同）是由中央气泡（双箭头）划定的边缘。 <img alt="图10" src="/files/ftp_upload/50377/50377fig10.jpg" /> 图10。VCU成果。Kaplan-Meier生存曲线表明河畔存活力移植和总生存期以下TAH植入。

Watch this Scientific Journal Video about Implantation of the Syncardia Total Artificial Heart at JoVE.com

Implantation of the Syncardia Total Artificial Heart

这个手稿的目的是简要回顾适应症，管理和成果的全人工心脏。视频手术操作技术的设备植入呈现。

SynCardia全人工心脏植入术

With advances in technology, the use of mechanical circulatory support devices for end stage heart failure has rapidly increased. The vast majority of ...

implantation-of-the-syncardia-total-artificial-heart

Universidad San Sebastian

Research

JoVE Journal

Medicine

35.0K 次观看.  Virginia Commonwealth University. 这个手稿的目的是简要回顾适应症，管理和成果的全人工心脏。视频手术操作技术的设备植入呈现。 

视频: Implantation of the Syncardia Total Artificial Heart

A New Single Chamber Implantable Defibrillator with Atrial Sensing: A Practical Demonstration of Sensing and  Ease of Implantation

Implantable cardioverter-defibrillators (ICDs) terminate ventricular tachycardia (VT) and ventricular fibrillation (VF) with high efficacy and can protect patients from sudden cardiac death (SCD). However, inappropriate shocks may occur if tachycardias are misdiagnosed. Inappropriate shocks are harmful and impair patient quality of life. The risk of inappropriate therapy increases with lower detection rates programmed in the ICD. Single-chamber detection poses greater risks for misdiagnosis when compared with dual-chamber devices that have the benefit of additional atrial information. However, using a dual-chamber device merely for the sake of detection is generally not accepted, since the risks associated with the second electrode may outweigh the benefits of detection. Therefore, BIOTRONIK developed a ventricular lead called the LinoxSMART S DX, which allows for the detection of atrial signals from two electrodes positioned at the atrial part of the ventricular electrode. This device contains two ring electrodes; one that contacts the atrial wall at the junction of the superior vena cava (SVC) and one positioned at the free floating part of the electrode in the atrium. The excellent signal quality can only be achieved by a special filter setting in the ICD (Lumax 540 and 740 VR-T DX, BIOTRONIK). Here, the ease of implantation of the system will be demonstrated.

Dual-chamber implantable cardioverter-defibrillators (ICDs) may improve detection of atrial fibrillation as well as differentiation of tachycardias. However, this advantage is undermined by complications associated with the second electrode, which is required in conventional dual chamber devices. Therefore, BIOTRONIK has developed a new electrode called the LinoxSMART S DX that, when used in conjunction with the Lumax DX ICD, offers dual-chamber detection without the risks associated with the second electrode.

心房遥感新的单一商会植入去纤颤器：一个实用的遥感示范和易于植入

Implantable cardioverter-defibrillators (ICDs) terminate ventricular tachycardia (VT) and ventricular fibrillation (VF) with high efficacy and can protect ...

科研

医学

Cell-based Therapy for Heart Failure in Rat: Double Thoracotomy for Myocardial Infarction and Epicardial Implantation of Cells and Biomatrix

Cardiac cell therapy has gained increasing interest and implantation of biomaterials associated with cells has become a major issue to optimize myocardial cell delivery. Rodent model of myocardial infarction (MI) consisting of Left Anterior Descending Artery (LAD) ligation has commonly been performed via a thoracotomy; a second open-heart surgery via a sternotomy has traditionally been performed for epicardial application of the treatment. Since the description of LAD ligation model, post-surgery mortality rate has dropped from 35-13%, however the second surgery has remained critical. In order to improve post-surgery recovery and reduce pain and infection, minimally invasive surgical procedures are presented.&#160;Two thoracotomies were performed, the initial one for LAD ligation and the second one for treatment epicardial administration. Biografts consisting of cells associated with solid or gel type matrices were applied onto the infarcted area.&#160;LAD ligation resulted in loss of heart function as confirmed by echocardiography performed after 2 and 6 weeks. Goldner trichrome staining performed on heart sections confirmed transmural scar formation. First and second surgeries resulted in less that 10%&#160;post-operative mortality.&#160;

Implantation of a biograft to treat myocardial infarction induced by LAD ligation in a rodent model has conventionally required two open-heart surgeries. In order to reduce mortality and provide optimal conditions for fixation of solid and gelatinous biomatrices associated with cells, minimally invasive procedures have been developed.

基于细胞治疗心脏衰竭大鼠：双开胸心肌梗死和细胞与生物基质植入心外膜

Cardiac cell therapy has gained increasing interest and implantation of biomaterials associated with cells has become a major issue to optimize myocardial ...

生物工程

Implantation of Engineered Tissue in the Rat Heart

Rodent surgery is often an important component in assessing the utility of engineered tissues. A wide variety of surgical procedures can be performed in common laboratory rats or mice and these quite frequently serve as an intermediate step between bench-top experiments and large animal testing or human trials. Given that rodents provide an established, cost-effective, and physiologically-relevant model system in which to test novel combinations of scaffolding materials and cells, they are particularly well-suited for cardiovascular tissue engineering studies. Presently, we describe an open-heart surgical procedure to implant engineered tissue containing myogenic progenitor cells in the atrioventricular (AV) groove of a rat heart. These implants are intended to create an electrical conduit between the right atrium and right ventricle with the ultimate goal of providing an alternative treatment to conventional pacemaker implantation in pediatric patients with complete heart block[1]. The engineered tissue is implanted in the AV-groove by means of a thoracotomy. For our purposes, Lewis rats are anesthetized and invasively ventilated to maintain positive airway pressure during the sterile surgical procedure. The approach to the heart is performed by a right thoracotomy through an antero-lateral incision at the 5th intercostal space. The tissue construct is fixed in the AV groove using a single 7-0 Prolene suture and positioned between the right ventricle and atrium at the ventral portion of the heart. The epicardium is partially removed to allow direct contact between the recipient myocardial cells and those contained in the engineered tissue. Following implantation, the chest wall is closed in layers, any pneumothorax is evacuated, and the animal is extubated and treated with analgesic.

Here, we describe a cardiac surgical procedure to implant engineered tissue in the atrioventricular (AV)-groove of an adult Lewis rat.

大鼠心脏中植入的工程组织

Rodent surgery is often an important component in assessing the utility of engineered tissues. A wide variety of surgical procedures can be performed in ...

生物学

Microinjection-based System for In Vivo Implantation of Embryonic Cardiomyocytes in the Avian Embryo

Interpreting the relative impact of cell autonomous patterning versus extrinsic microenvironmental influence on cell lineage determination represents a general challenge in developmental biology research. In the embryonic heart, this can be particularly difficult as regional differences in the expression of transcriptional regulators, paracrine/juxtacrine signaling cues, and hemodynamic force are all known to influence cardiomyocyte maturation. A simplified method to alter a developing cardiomyocyte's molecular and biomechanical microenvironment would, therefore, serve as a powerful technique to examine how local conditions influence cell fate and function. To address this, we have optimized a method to physically transplant juvenile cardiomyocytes into ectopic locations in the heart or the surrounding embryonic tissue. This allows us to examine how microenvironmental conditions influence cardiomyocyte fate transitions at single cell resolution within the intact embryo. Here, we describe a protocol in which embryonic myocytes can be isolated from a variety of cardiac sub-domains, dissociated, fluorescently labeled, and microinjected into host embryos with high precision. Cells can then be directly analyzed in situ using a variety of imaging and histological techniques. This protocol is a powerful alternative to traditional grafting experiments that can be prohibitively difficult in a moving tissue such as the heart. The general outline of this method can also be adapted to a variety of donor tissues and host environments, and its ease of use, low cost, and speed make it a potentially useful application for a variety of developmental studies.

In this method, embryonic cardiac tissues are surgically microdissected, dissociated, fluorescently labeled, and implanted into host embryonic tissues. This provides a platform for studying the individual or tissue level developmental organization under ectopic hemodynamic conditions, and/or altered paracrine/juxtacrine environments.

基于微注射的免疫胚胎心肌细胞体内植入系统

Interpreting the relative impact of cell autonomous patterning versus extrinsic microenvironmental influence on cell lineage determination represents a ...

发育生物学

Implantation of Total Artificial Heart in Congenital Heart Disease

In patients with end-stage heart failure (HF), a total artificial heart (TAH) may be implanted as a bridge to cardiac transplant. However, in congenital heart disease (CHD), the malformed heart presents a challenge to TAH implantation. 
In the case presented here, a 17 year-old patient with congenital transposition of the great arteries (CCTGA) experienced progressively worsening HF due to his congenital condition. He was hospitalized multiple times and received an implantable cardioverter defibrillator (ICD). However, his condition soon deteriorated to end-stage HF with multisystem organ failure. 
Due to the patient's grave clinical condition and the presence of complex cardiac lesions, the decision was made to proceed with a TAH. The abnormal arrangement of the patient's ventricles and great arteries required modifications to the TAH during implantation.
With the TAH in place, the patient was able to return home and regain strength and physical well-being while awaiting a donor heart. He was successfully bridged to heart transplantation 5 months after receiving the device. This report highlights the TAH is feasible even in patients with structurally abnormal hearts, with technical modification.

This is a case report of a patient with congenitally corrected transposition of the great arteries (CCTGA) who received a total artificial heart (TAH) as a bridge to heart transplant. The TAH was successfully implanted with modifications to accommodate the patient's congenitally malformed heart.

的全人工心脏的先天性心脏病植入

In patients with end-stage heart failure (HF), a total artificial heart (TAH) may be implanted as a bridge to cardiac transplant. However, in congenital ...

Decellularization of Whole Human Heart Inside a Pressurized Pouch in an Inverted Orientation

The ultimate solution for patients with end-stage heart failure is organ transplant. But donor hearts are limited, immunosuppression is required, and ultimately rejection can occur. Creating a functional, autologous bio-artificial heart could solve these challenges. Biofabrication of a heart comprised of scaffold and cells is one option. A natural scaffold with tissue-specific composition as well as micro- and macro-architecture can be obtained by decellularizing hearts from humans or large animals such as pigs. Decellularization involves washing out cellular debris while preserving 3D extracellular matrix and vasculature and allowing &#34;cellularization&#34; at a later timepoint. Capitalizing on our novel finding that perfusion decellularization of complex organs is possible, we developed a more &#34;physiological&#34; method to decellularize non-transplantable human hearts by placing them inside a pressurized pouch, in an inverted orientation, under controlled pressure. The purpose of using a pressurized pouch is to create pressure gradients across the aortic valve to keep it closed and improve myocardial perfusion. Simultaneous assessment of flow dynamics and cellular debris removal during decellularization allowed us to monitor both fluid inflow and debris outflow, thereby generating a scaffold that can be used either for simple cardiac repair (e.g. as a patch or valve scaffold) or as a whole-organ scaffold.

This method enables decellularization of a complex solid organ using a simple protocol based on osmotic shock and perfusion of ionic detergent with minimal organ matrix disruption. It comprises a novel decellularization technique for human hearts inside a pressurized pouch with real-time monitoring of flow dynamics and cellular debris outflow.

倒置方向下整个人的心脏在加压袋内的去细胞化

The ultimate solution for patients with end-stage heart failure is organ transplant. But donor hearts are limited, immunosuppression is required, and ...

Use of Two Intracorporeal Ventricular Assist Devices As a Total Artificial Heart

Mechanical circulatory support (MCS) has been introduced as a viable alternative to heart transplantation primarily through the use of intracorporeal ventricular assist devices (VADs) for support of the left ventricle. However, certain clinical scenarios warrant biventricular mechanical support. One strategy for some patients is the excision of both ventricles and the implantation of two VAD pumps as a total artificial heart (TAH). This has recently been made possible by the improvements in device design and the small profile of centrifugal devices. This TAH approach remains experimental with many important challenges such as the device settings to balance the right and left circulation, the orientation of the devices and the outflow graft with their influence on hemolysis and stability, and the outcome of chronic support using such an orientation. This protocol aims to provide a reproducible approach for total artificial heart replacement with two intracorporeal centrifugal VADs in a cow model.

Here, we present a protocol using two centrifugal pumps as a total artificial heart replacement.

两体内心室辅助装置作为全人工心脏的应用

Mechanical circulatory support (MCS) has been introduced as a viable alternative to heart transplantation primarily through the use of intracorporeal ...

Implantation of Human-Sized Coronary Stents into Rat Abdominal Aorta Using a Trans-Femoral Access

Percutaneous coronary intervention (PCI), combined with the deployment of a coronary stent, represents the gold standard in interventional treatment of coronary artery disease. In-stent restenosis (ISR) is determined by an excessive proliferation of neointimal tissue within the stent and limits the long-term success of stents. A variety of animal models have been used to elucidate pathophysiological processes underlying in-stent restenosis (ISR), with the porcine coronary and the rabbit iliac artery models being the most frequently used. Murine models provide the advantages of high throughput, ease of handling and housing, reproducibility, and a broad availability of molecular markers. The apolipoprotein E deficient (apoE-/- ) mouse model has been widely used to study cardiovascular diseases. However, stents must be miniaturized to be implanted into mice, involving important changes of their mechanical and (potentially) biological properties. The use of apoE-/- rats can overcome these shortcomings as apoE-/- rats allow for the evaluation of human-sized coronary stents while at the same time providing an atherogenic phenotype. This makes them an excellent and reliable model to investigate ISR after stent implantation. Here, we describe, in detail, the implantation of commercially available human coronary stents into the abdominal aorta of rats with an apoE-/- background using a trans-femoral access.

This protocol describes the implantation of human coronary stents into the abdominal aorta of rats with an apoE-/- background using a trans-femoral access. Compared with other animal models, murine models carry the advantages of high throughput, reproducibility, ease of handling and housing, and a broad availability of molecular markers.

使用跨女性访问将人类大小的冠状动脉支架植入大鼠腹主动脉

Percutaneous coronary intervention (PCI), combined with the deployment of a coronary stent, represents the gold standard in interventional treatment of ...

Use of a Percutaneous Ventricular Assist Device/Left Atrium to Femoral Artery Bypass System for Cardiogenic Shock

The left atrial to femoral artery bypass (LAFAB) system is a mechanical circulatory support (MCS) device used in cardiogenic shock (CS) that bypasses the left ventricle by draining blood from the left atrium (LA) and returning it to the systemic arterial circulation via the femoral artery. It can provide flows ranging from 2.5-5 L/min depending on the size of the cannula. Here, we discuss the mechanism of action of LAFAB, available clinical data, indications for its use in cardiogenic shock, steps of implantation, post-procedural care, and complications associated with the use of this device and their management.
We also provide a brief video of the procedural component of device therapy, including the pre-placement preparation, percutaneous placement of the device via transseptal puncture under echocardiographic guidance and the post-operative management of device parameters.

The following article describes the stepwise procedure for placement of a device (e.g., Tandemheart) in cardiogenic shock (CS) that is a percutaneous left ventricular assist device (pLVAD) and a left atrial to femoral artery bypass (LAFAB) system that bypasses and supports the left ventricle (LV) in CS.

使用经皮心室辅助装置/左心房至股动脉旁路系统治疗心源性休克

The left atrial to femoral artery bypass (LAFAB) system is a mechanical circulatory support (MCS) device used in cardiogenic shock (CS) that bypasses the ...

A Porcine Heterotopic Heart Transplantation Protocol for Delivery of Therapeutics to a Cardiac Allograft

Cardiac transplantation is the gold standard treatment for end-stage heart failure. However, it remains limited by the number of available donor hearts and complications such as primary graft dysfunction and graft rejection. The recent clinical use of an ex vivo perfusion device in cardiac transplantation introduces a unique opportunity for treating cardiac allografts with therapeutic interventions to improve function and avoid deleterious recipient responses. Establishing a translational, large-animal model for therapeutic delivery to the entire allograft is essential for testing novel therapeutic approaches in cardiac transplantation. The porcine, heterotopic heart transplantation model in the intraabdominal position serves as an excellent model for assessing the effects of novel interventions and the immunopathology of graft rejection. This model additionally offers long-term survival for the pig, given that the graft is not required to maintain the recipient's circulation. The aim of this protocol is to provide a reproducible and robust approach for achieving ex vivo delivery of a therapeutic to the entire cardiac allograft prior to transplantation and provide technical details to perform a survival heterotopic transplant of the ex vivo perfused heart.

We present a protocol for utilizing a normothermic ex vivo sanguinous perfusion system for the delivery of therapeutics to an entire cardiac allograft in a porcine heterotopic heart transplant model.

一种猪异位心脏移植方案，用于向心脏同种异体移植物提供治疗药物

Cardiac transplantation is the gold standard treatment for end-stage heart failure. However, it remains limited by the number of available donor hearts ...