Name: use of two intracorporeal ventricular assist devices as a total artificial heart
Uploaded: 2018-05-11T12:30:00.000+00:00
Duration: 8 min 49 s
Description: Watch this Scientific Journal Video about Use of Two Intracorporeal Ventricular Assist Devices As a Total Artificial Heart at JoVE.com

我们要感谢劳拉 Janney 和方丈医疗部分资金。我们还要感谢公爵灌注服务和大型动物外科核心在手术中的帮助。

年龄匹配 (为献血如果需要) 小牛 (重量80–90公斤) 在动物设施被关心。住房和所有治疗程序都是按照杜克大学医学中心动物护理和使用委员会的指导方针进行的。
1. 麻醉的启动
<ol><li>禁食后 8–12 h, 前用药小牛与 Telazol (4.5 毫克/千克/肌肉), 然后管理异氟醚 (1–4%) 通过口罩。</li>
	<li>把母牛放在一个被加热的桌子和插管的仰卧位置。用沉重的领带把四肢固定在桌子上。</li>
	<li>将静脉导管 (14–20计) 放置在耳静脉内。</li>
	<li>管理安定 (0.22–0.44 毫克/千克/静脉注射) 如果咀嚼和吞咽是非常普遍的, 或如果动物是咬在气管管 (ET) 管。此外, 如果插管有困难, 以帮助促进气管插管。</li>
</ol>2. 生命体征和中心线设置
<ol><li>在10–15毫升/千克的潮汐量和 20–25 bpm 的速率下启动机械通气, 并在整个过程中保持异氟醚 (0.5–4%)。</li>
	<li>使用连接保护 ET 管, 确保在操作过程中不改变管位。</li>
	<li>持续监测整个实验中的氧饱和度和心率。立即处理通风或氧气饱和 (2) 的任何困难。这些都可能与管位置或呼吸机设置有关。如果是管位置, 调整 ET 管以达到足够的潮汐量。</li>
</ol>3. 中央血管通路
<ol><li>虽然以下可能是经皮使用超声引导, 使用削减的方法, 以更好地控制任何地方出血, 一旦动物抗凝。</li>
	<li>使用气管作为地标, 剃去颈部毛皮 (用发剪刀), 并使用 betadine 消毒区域。用一条10刃手术刀做一个平行的线性切口, 从气管到胸骨20厘米。</li>
	<li>用电动烧灼工具将胸锁乳突分离, 并小心暴露左颈总动脉和颈内静脉。使用自我保留的牵引器来帮助暴露。用大丝缝线 (0 或1丝) 或血管循环维持动脉和静脉的近端和远端控制。</li>
	<li>Cannulate 左颈总动脉用18口径导管进行血压监测。脱空气的线, 如果遇到出血, 将6-0 或7-0 聚丙烯缝合在一个钱包字符串的方式周围的导管。<ol>
<li>将压力传感器连接到控制台, 并在 "系统压力" 下将压力波形传感器到软件中。读取并记录输出。</li>
	</ol>
</li>
	<li>进入左颈内静脉的液体和药物管理和中心静脉压力监测。将压力传感器连接到控制台, 并在 "中心静脉压力" 下将压力波传感器到软件中。读取并记录输出。</li>
	<li>将两条线路远端固定在皮肤和显示器上。记录基线中心静脉压 (CVP) 和动脉血压。</li>
</ol>4. 中位胸骨和体外循环术 (CPB)
<ol><li>触及从胸骨到剑突的胸骨, 选择中线上的斑点, 用无菌手术标记标记。用发夹刮毛, 用 betadine 消毒。应用无菌的手术悬垂。</li>
	<li>使用从胸骨到剑突的10刀片进行切口。</li>
	<li>使用电动烧灼工具将胸大肌从胸骨中分离出来, 同时用胸骨侧缘的手动触诊与中线完全对准。使用电动烧灼工具得分的胸骨中线。从底部开始胸骨, 将剑突与重剪刀分开。</li>
	<li>将胸骨头侧与花园式快船延伸。每次切除后检查胸骨。在胸骨下进行数字触诊, 并进行钝性解剖, 帮助心脏和肺部从胸骨脱落。中途通过胸骨一些交叉腹横肌肉可能会遇到, 这些是分裂使用电烧灼。</li>
	<li>完成胸骨所有的方式到胸骨。注意保持沿中线, 这将是重要的愈合。</li>
	<li>胸骨完成后, 通过电动烧灼工具, 通过对出血肌肉边缘的评分, 实现止血。应用骨蜡在胸骨的骨髓, 以帮助任何残留出血。</li>
	<li>用电动烧灼工具识别胸腺并将其取出。以纵向方式进入心包, 从隔膜到主动脉反射。<ol>
<li>创建一个心包摇篮使用五2-0 丝缝合接近心包到皮肤, 拉心脏和支持它。选择打开的心包的所有角落, 并把他们直接在皮肤前使用丝缝线。</li>
	</ol>
</li>
	<li>在主动脉和肺动脉之间创建一个3英寸长的窗口, 通过解剖结缔组织, 以允许通过主动脉交叉钳。将一个钱包字符串4-0 聚丙烯缝合到上升主动脉在一个位置近的分岔。</li>
	<li>圆周用钝夹层释放上腔静脉 (SVC), 并应用第二包3-0 聚丙烯缝合线。建立系统性肝素化使用初始剂量 300 U/千克, 以达到活化凝血时间 (行为) 大于400s。</li>
	<li>一旦达到适当的行为, 使用11刀片进入主动脉, 并插入18法郎动脉插管。将套管脱气并附着在体外循环动脉线上。接下来, 在 svc 中放置一个28法郎的 svc 套管, 然后开始一个体外循环。</li>
	<li>在部分体外循环时, 确定 SVC 所描述的下腔静脉和 cannulate。这样做, 而在旁路, 因为它允许更好的血液动力学管理, 鉴于需要推动心脏的暴露。 注: 由于体外循环仅在这一点上得到部分支持, 可能仍有发展低血压的潜力。如果低血压是有经验的, 这一步应该做仔细和打破, 让动物的心脏间歇性地填充。</li>
	<li>一旦静脉插管安全地插入, 使用 Y 连接器拼接到主电路。循环的 SVC 和静脉与脐磁带, 以使完整的血液隔离从心脏。</li>
</ol>5. Ventriculectomy
<ol><li>在全心肺支持下, 用以前应用的脐带诱捕 SVC 和下腔静脉。在主动脉插管部位应用主动脉交叉钳。一旦钳位已确认, 启动 ventriculectomy。</li>
	<li>将心室组织圆周1-2 厘米远端至右、左房室沟。将心室肌的边缘与二尖瓣和三尖瓣套管, 为摆动环的植入提供进一步支持。</li>
	<li>横断面的二尖瓣和三尖瓣的子瓣膜 apparati, 因为他们遇到。</li>
	<li>用右心室流出道 (RVOT) 对右心室流出道肌进行切除, 包括肺瓣膜摘除术。此外, 保留左心室流出道 (LVOT), 但保持主动脉瓣的后部, 作为主动脉-二尖瓣帷幕的一部分。</li>
	<li>室隔膜最后。用5-0 聚丙烯缝线鉴别冠状窦和结扎的孔。</li>
</ol>6. 离心式流量泵 (CFP) 的植入
<ol><li>使用 pledgeted, 中断, 2-0 编织缝合, 以确保缝纫环的心室组织和二尖瓣环。退出心室肌环的心外膜表面缝合, 并通过缝纫环。这种技术避免了环上的组织 "聚束", 这将干扰缝合的环与泵。</li>
	<li>使用类似的方法将缝纫环连接到右心室肌环和三尖瓣环。</li>
	<li>将 CFPs 连接到缝纫环上, 并使用标准锁紧机构进行安全保护。将其定向到允许访问锁定机制。</li>
	<li>根据选择的方向调整流出物的长度。一旦确定了适当的长度, 就切断流出物。注意不要使移植物过长, 因为这可能导致扭结。</li>
	<li>使用运行4-0 聚丙烯缝合吻合的流出移植到主动脉 (左心 CFP) 和肺动脉 (为右心 CFP) 结束时尚。</li>
	<li>在完成吻合术前, 在 SVC 和静脉引流套管上释放胶带, 并允许血液填满右、左泵, 从而开始脱晾过程。将一根18口径的针放入每个流出物中, 以便进一步进行脱风口。使用呼吸机提供大容量呼吸, 以允许任何被困在肺静脉的空气被返回和取消播出。<ol>
<li>清除完后, 取出针, 用 pledgeted 5-0 聚丙烯缝线修复现场。</li>
	</ol>
</li>
	<li>启动泵以低转速 (3000 rpm), 以允许前血流量, 最初与钳位仍然到位。取出主动脉交叉钳, 留一些血量进入泵。</li>
	<li>随着心肺支持的断奶, 泵浦速度逐渐提高。终止体外循环, 完全支持右侧和左侧泵的循环。</li>
	<li>通过右侧和左侧的静脉充填压力确定最终的泵速设置。</li>
	<li>将压力导管直接插入肺动脉和肺静脉, 使用5-0 的包线聚丙烯缝合, 以确保它们到位。</li>
	<li>传感器压力信号对软件在标签之下 "肺动脉" 并且 "肺静脉"。另外, 在升主动脉和主肺动脉周围放置超声流量探头。 注: 所有4通道现在应该是活跃的: 1. "全身压力", 2. "中心静脉压力", 3. "肺动脉" 和4。"肺静脉"。</li>
</ol>7. 建立心室辅助装置流程
<ol><li>在逐渐减少体外循环流量的同时, 慢慢增加左 CFP, 然后右 CFP 速度, 同时始终保持右下 CFP 速度比左 CFP。</li>
	<li>仔细注意血液动力学, 包括全身血压和 CVP。肺 overcirculation 由肺动脉或肺静脉非生理压力指示。</li>
	<li>最后, 增加左 CFP 和右 CFP 速度, 以达到每一个设备4升/分钟的流量, 并摆脱体外循环。一旦达到血流动力学的稳定性, 取出 SVC 和静脉套管, 并栓在钱包线缝合。</li>
	<li>下一步, 取出主动脉插管, 并把钱包绳缝合。弄死在动物被麻醉时, 慢慢地向下翻转, 然后停止 CFP 泵。</li>
</ol>

<ol>
	<li>Mozzafarian, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Heart+disease+and+stroke+statistics&#8212;2016+update:+a+report+from+the+American+Heart+Association.">Heart disease and stroke statistics&#8212;2016 update: a report from the American Heart Association.</a> Circulation. 133 (4), e38-e360 (2016).</li><li>Slaughter, M. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Advanced+heart+failure+treated+with+continuous-flow+left+ventricular+assist+device.">Advanced heart failure treated with continuous-flow left ventricular assist device.</a> N Engl J Med. 361 (23), 2241-2251 (2009).</li><li>Fang, J. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Rise+of+the+Machines+&#8212;+Left+Ventricular+Assist+Devices+as+Permanent+Therapy+for+Advanced+Heart+Failure.">Rise of the Machines &#8212; Left Ventricular Assist Devices as Permanent Therapy for Advanced Heart Failure.</a> N Engl J Med. 361, 2282-2285 (2009).</li><li>Kirklin, J. K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Seventh+INTERMACS+annual+report:+15,000+patients+and+counting.">Seventh INTERMACS annual report: 15,000 patients and counting.</a> J Heart Lung Transplant. 34 (12), 1495-1504 (2015).</li><li>Leidenfrost, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Right+ventricular+assist+device+with+membrane+oxygenator+support+for+right+ventricular+failure+following+implantable+left+ventricular+assist+device+placement.">Right ventricular assist device with membrane oxygenator support for right ventricular failure following implantable left ventricular assist device placement.</a> Eur J Cardiothorac Surg. 49 (1), 73-77 (2016).</li><li>Gerosa, G., Gallo, M., Bottio, T., Tarzia, V. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Successful+heart+transplant+after+1374+days+living+with+a+total+artificial+heart.">Successful heart transplant after 1374 days living with a total artificial heart.</a> Eur J Cardiothorac Surg. 49 (4), e88-e89 (2016).</li><li>Pelletier, B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=System+overview+of+the+fully+implantable+destination+therapy--ReinHeart-total+artificial+heart.">System overview of the fully implantable destination therapy--ReinHeart-total artificial heart.</a> Eur J Cardiothorac Surg. 47 (1), 80-86 (2015).</li><li>Krabatsch, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Biventricular+circulatory+support+with+two+miniaturized+implantable+assist+devices.">Biventricular circulatory support with two miniaturized implantable assist devices.</a> Circulation. 124, S179-S186 (2011).</li><li>Milano, C. A., Schroder, J., Daneshmand, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Total+Artificial+Heart+Replacement+With+2+Centrifugal+Blood+Pumps.">Total Artificial Heart Replacement With 2 Centrifugal Blood Pumps.</a> Oper Tech Thorac Cardiovasc Surg. 20 (3), 306-321 (2016).</li><li>Strueber, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Placement+of+2+implantable+centrifugal+pumps+to+serve+as+a+total+artificial+heart+after+cardiectomy.">Placement of 2 implantable centrifugal pumps to serve as a total artificial heart after cardiectomy.</a> J Thorac Cardiovasc Surg. 143 (2), 507-509 (2012).</li></ol>

这项工作是通过从方丈医学到米兰博士的研究补助金得以实现的。

在这篇手稿中, 我们描述了使用两个离心流 VADs 作为一个体内 TAH。这项技术也许对研究人工循环对肺和肝脏等次生器官的影响非常有用。此外, 它可能有助于研究不同的泵方向和流动情况下的血流动力学变化。本协议中的关键步骤涉及如何将缝纫环连接到心室组织, 同时也纳入瓣膜套管的力量。确保正确执行此操作是非常关键的, 因为这会影响设备的稳定性。此外, 重要的是要确保流出物的测量和削减在适当的长度。设备不稳定性和流出物梗阻是指如果不仔细执行这两个步骤, 可能会发生的重要问题。
该议定书描述了两种不同的方法来定向外流移植, 这可能是重要的, 以避免流出移植物梗阻。在第一个方向, 流出的移植物直接连接到各自的大血管的方向类似的辛卡迪亚总人工心脏。在第二个方向上, 移植的旋转周围的其他心室, 是通常使用的临床病例。
利用这一实验模型, 我们可以仔细研究不同泵速组合的血流动力学情况, 以确定如何避免左右侧环流失衡。例如, 直接测量主动脉、肺动脉和肺静脉压力, 可以实时评估动物的全身血流动力学状况。这将是非常重要的设置正确的速度参数的水泵, 以允许平衡的权利和左循环与: 充分的动脉灌注压力;正常的肺动脉压力, 以避免肺部充血的可能性;和正常的中心静脉压力, 以避免肾脏或肝静脉充血。在临床上可用的设备中, "流" 是一个不直接测量的计算参数。在本议定书中, 我们将直接测量两个位置的流量, 以进一步精确评估血流动力学。
总之, 这篇手稿描述了使用两个离心流泵作为一个整体人工心脏体内心室替代奶牛模型。

心力衰竭患者的数量有所增长, 据估计, 目前美国有570万成年人患有这种情况, 今天为1。约30万例患者终末期心力衰竭, 预期寿命不到一年。虽然心脏移植仍然是治疗终末期心力衰竭的金本位疗法, 但它受现有捐献器官数量的限制很大。MCS 作为心脏移植的一种可行的替代方案, 特别是通过使用 VADs2来实施。VADs 工作通过卸载左心室和提供向前流动 (由泵支持) 直接进入动脉循环。VADs 可能被植入为一座桥梁移植, 以及一个目的地治疗的病人, 不符合移植的3。自从他们的 FDA 批准不到十年前, 每年的 VADs 植入的数量已经超过心脏移植的数字, 这个数字呈指数递增的4。然而, 在患者的一个子集, 心力衰竭是心室 (i. e. 影响左、右心室), 仅支持左心室可能无法提供足够的灌注。在这种情况下, 右心室需要临时机械支持5。这种类型的 "RVAD" 需要使用大型套管连接到一个体外循环泵, 限制病人的重症监护病房 (ICU), 而心室恢复。对于有限的病人子集, 另一个选项是 TAH67。TAH 使用的适应症是: 后梗塞后心室失败, 心室间隔缺损 (VSD), 严重限制性肌病, 排除心室插管, 和失败的心脏移植需要长期支持。然而, 目前 FDA 批准的 TAH 设备很大, 不能用于较小的患者。此外, 气动驱动程序也相当可观, 限制了病人的机动性。
对于某些患者, 一个实验性的策略是使用第二个辅助心室来支持右侧脑室8,9,10。在这种情况下, 两个心室被切除, 两个 VADs 作为 TAH 植入。由于设备设计的改进和设备配置文件的收缩, 使得这一点成为可能。新的离心 VADs 更小, 允许两个 VADs 被植入相邻, 以支持左和右循环。这种方法仍然是实验的许多重要的挑战, 包括设备设置平衡的权利和左循环, 设备的方向和流出的影响对溶血和其他不利事件。本协议的目的是为奶牛模型中的两个离心 VADs 提供一种可重现的 TAH 替换方法。

<table><tbody><tr><td>SPO2&amp;nbsp; and heart rates are to be monitored: Multiparameter</td><td>Meditech Equipment, Co., Ltd.</td><td>MD-908</td><td>hemodynamic monitor intraoperatively</td></tr><tr><td>Viscot Mini XL Surgical Markers</td><td>Amazon</td><td>B007P550WG</td><td>marking sternum before incision</td></tr><tr><td>60W High Power Electric Pet Cat Rabbits Horse Animal Hair Cutting Clipper</td><td>LILY International Business CO., LIMITED&amp;nbsp;</td><td>ZP-293</td><td>Fur shaving</td></tr><tr><td>No. 10 scalpel blade</td><td>Swann-Mortan, England</td><td>301</td><td>Skin incision</td></tr><tr><td>Matzenbaum scissor</td><td>BD-V. Mueller, USA</td><td>CH2006-001</td><td>Vascular exploration</td></tr><tr><td>Scissors</td><td>Felco, USA</td><td>FELCO 200A-50, Felco Professional Bypass Lopper</td><td>For sternotomy</td></tr><tr><td>A self-retractor</td><td>BD-V. Mueller, USA</td><td>AU19270</td><td>SCHUKNECHT Self-Retaining Postauricular Retractor,&amp;nbsp;</td></tr><tr><td>Sternal retractor</td><td>BD-V. Mueller, USA</td><td>CH6950-007</td><td>Cooley sternal retractor</td></tr><tr><td>Pressure transducer (Millar Mikro-Tip, 5Fr)</td><td>Millar, USA</td><td>MillarMikro-Tip, SPR-350S</td><td>Assessment for pulmonary artery or venous pressure</td></tr><tr><td>AD instruments (PowerLab)</td><td>AD instruments, USA</td><td>PowerLab 16/35</td><td>Pressure signal transduction</td></tr><tr><td>Umbilical tapes</td><td>Medline industries Inc., USA</td><td>U11</td><td>For isolation and snaring of superior or inferior vena cava</td></tr><tr><td>Vessel loops</td><td>Aspen Surgical, USA</td><td>3901, 3902 and 3904</td><td>Isolation of vessels</td></tr><tr><td>Silk sutures, 2-0</td><td>Ethicon US, LLC, USA</td><td>SA11G</td><td>For snare of superior or inferior vena cava</td></tr><tr><td>Ticron 2-0</td><td>Covidien, USA</td><td>TicronTM suture</td><td>Vascular suture</td></tr><tr><td>Prolene, 7-0</td><td>Covidien, USA</td><td>Surgipro II</td><td>Vascular suture</td></tr><tr><td>Prolene, 6-0</td><td>Covidien, USA</td><td>Surgipro II</td><td>Vascular suture</td></tr><tr><td>Prolene, 4-0</td><td>Covidien, USA</td><td>Surgipro II</td><td>Vascular suture</td></tr><tr><td>Prolene, 3-0</td><td>Covidien, USA</td><td>Surgipro II</td><td>Vascular suture</td></tr><tr><td>Aortic cannula, 15-18 Fr</td><td>Medtronic, USA</td><td>Elongated-One-Piece-Arterial cannula 3D</td><td>Aortic cannula for setting of cardiopulmonary bypass</td></tr><tr><td>Venous cannula, 28Fr</td><td>Edwards Lifesciences</td><td>single stage</td><td>Venous cannula for setting of cardiopulmonary bypass</td></tr></tbody></table>

use of two intracorporeal ventricular assist devices as a total artificial heart

机械循环支持 (MCS) 是一种可行的替代心脏移植主要通过使用体内心室辅助装置 (VADs), 以支持左心室。然而, 某些临床方案需要心室机械支持。对于一些患者来说, 其中一个策略是切除两脑室, 并将两个心室泵作为全人工心脏 (TAH) 植入。最近, 由于设备设计的改进和离心装置的小外形, 使得这一点成为可能。这种 TAH 方法仍然是实验的许多重要的挑战, 如设备设置平衡的权利和左循环, 设备的方向和流出移植物对溶血和稳定性的影响, 和结果使用这种方向的慢性支持。本协议旨在为奶牛模型中两体内离心 VADs 的全人工心脏置换提供一种可重现的方法。

图 1中演示的是缝纫环的附件。图 1A显示了可能造成泵附件问题的脑室组织的 "群聚"。图 1B表示正确的附件。
图 2和图 3是泵的两个不同方向。在图 2中, 泵处于定位状态, 因此流出的移植物是短的, 并直接出口到连接的动脉中。在图 3中, 泵的方向是使右侧 CFP 和左 CFP 的流出物在与肺动脉和主动脉吻合之前旋转。它仍然没有答案, 哪个方向允许不太纯粹的压力, 血液, 并有更好的整体血流动力学剖面的泵。此外, 目前还不清楚哪个方向可以减少扭结。
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/55961/55961fig1.jpg"> 图 1: 缝合环的附件。 面板 A 显示正确的附件的右心更换缝纫环与 "束" 心室组织。小组 B 显示正确的缝合环纳入心室组织。<a href="https://cloudflare-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/55961/55961fig1large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/55961/55961fig2.jpg"> 图 2: 直接流出移植物方向, 表明直接附着右心置换至肺动脉和左心置换至主动脉.<a href="https://cloudflare-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/55961/55961fig2large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/55961/55961fig3.jpg"> 图 3: 流向肺动脉和主动脉的流出物的不同方向.<a href="https://cloudflare-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/55961/55961fig3large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>

Watch this Scientific Journal Video about Use of Two Intracorporeal Ventricular Assist Devices As a Total Artificial Heart at JoVE.com

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

两体内心室辅助装置作为全人工心脏的应用

在这里, 我们提出了一个协议使用两个离心泵作为一个全人工心脏置换。

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

use-two-intracorporeal-ventricular-assist-devices-as-total-artificial

Universidad San Sebastian

Research

JoVE Journal

Medicine

9.3K 次观看.  Duke University. 在这里, 我们提出了一个协议使用两个离心泵作为一个全人工心脏置换。

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

Reverse Total Shoulder Arthroplasty

Reverse total shoulder arthroplasty was initially approved for use in rotator cuff arthropathy and well as chronic pseudoparalysis without arthritis in patients who were not appropriate for tendon transfer reconstructions. Traditional surgical options for these patients were limited and functional results were sub-optimal and at times catastrophic. The use of reverse shoulder arthroplasty has been found to effectively restore these patients function and relieve symptoms associated with their disease. The procedure can be done through two approaches, the deltopectoral or the superolateral. Complication rates associated with the use of the prosthesis have ranged from 8-60% with more recent reports trending lower as experienced is gained. Salvage options for a failed reverse shoulder prosthesis are limited and often have significant associated disability. Indications for the use of this prosthesis continue to be evaluated including its use for revision arthroplasty, proximal humeral fracture and tumor. Careful patient selection is essential because of the significant risks associated with the procedure.

Reverse total shoulder arthroplasty is indicated for the treatment of conditions that cannot be treated with conventional arthroplasty or other procedures. These primarily include degenerative and incapacitating conditions with irreparable rotator cuff and loss of the normal biomechanical coupling of the shoulder.

反向共肩关节置换术

Reverse total shoulder arthroplasty was initially approved for use in rotator cuff arthropathy and well as chronic pseudoparalysis without arthritis in ...

科研

医学

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 ...

Reduction in Left Ventricular Wall Stress and Improvement in Function in Failing Hearts using Algisyl-LVR

Injection of Algisyl-LVR, a treatment under clinical development, is intended to treat patients with dilated cardiomyopathy. This treatment was recently used for the first time in patients who had symptomatic heart failure. In all patients, cardiac function of the left ventricle (LV) improved significantly, as manifested by consistent reduction of the LV volume and wall stress. Here we describe this novel treatment procedure and the methods used to quantify its effects on LV wall stress and function.
Algisyl-LVR is a biopolymer gel consisting of Na+-Alginate and Ca2+-Alginate. The treatment procedure was carried out by mixing these two components and then combining them into one syringe for intramyocardial injections. This mixture was injected at 10 to 19 locations mid-way between the base and apex of the LV free wall in patients.
Magnetic resonance imaging (MRI), together with mathematical modeling, was used to quantify the effects of this treatment in patients before treatment and at various time points during recovery. The epicardial and endocardial surfaces were first digitized from the MR images to reconstruct the LV geometry at end-systole and at end-diastole. Left ventricular cavity volumes were then measured from these reconstructed surfaces.
Mathematical models of the LV were created from these MRI-reconstructed surfaces to calculate regional myofiber stress. Each LV model was constructed so that 1) it deforms according to a previously validated stress-strain relationship of the myocardium, and 2) the predicted LV cavity volume from these models matches the corresponding MRI-measured volume at end-diastole and end-systole. Diastolic filling was simulated by loading the LV endocardial surface with a prescribed end-diastolic pressure. Systolic contraction was simulated by concurrently loading the endocardial surface with a prescribed end-systolic pressure and adding active contraction in the myofiber direction. Regional myofiber stress at end-diastole and end-systole was computed from the deformed LV based on the stress-strain relationship.

This article describes procedures for implanting a novel hydrogel in failing hearts and quantifying its effect on left ventricular wall stress and function. These procedures have been successfully applied in dogs and humans.

左室壁应力和改进功能衰竭心脏使用Algisyl LVR减少

Injection of  Algisyl-LVR, a treatment under clinical development, is intended to treat  patients with dilated cardiomyopathy. This treatment was recently ...

Development of an Audio-based Virtual Gaming Environment to Assist with Navigation Skills in the Blind

Audio-based Environment Simulator (AbES) is virtual environment software designed to improve real world navigation skills in the blind. Using only audio based cues and set within the context of a video game metaphor, users gather relevant spatial information regarding a building's layout. This allows the user to develop an accurate spatial cognitive map of a large-scale three-dimensional space that can be manipulated for the purposes of a real indoor navigation task. After game play, participants are then assessed on their ability to navigate within the target physical building represented in the game. Preliminary results suggest that early blind users were able to acquire relevant information regarding the spatial layout of a previously unfamiliar building as indexed by their performance on a series of navigation tasks. These tasks included path finding through the virtual and physical building, as well as a series of drop off tasks. We find that the immersive and highly interactive nature of the AbES software appears to greatly engage the blind user to actively explore the virtual environment. Applications of this approach may extend to larger populations of visually impaired individuals.

Audio-based Environment Simulator (AbES) is virtual environment software designed to improve real world navigation skills in the blind.

基于音频的虚拟游戏环境的发展，以帮助盲人的导航技巧

Audio-based Environment Simulator (AbES) is virtual environment software designed to improve real world navigation skills in the blind. Using only audio ...

Implantation of the Syncardia Total Artificial Heart

With advances in technology, the use of mechanical circulatory support devices for end stage heart failure has rapidly increased. The vast majority of such patients are generally well served by left ventricular assist devices (LVADs). However, a subset of patients with late stage biventricular failure or other significant anatomic lesions are not adequately treated by isolated left ventricular mechanical support. Examples of concomitant cardiac pathology that may be better treated by resection and TAH replacement includes: post infarction ventricular septal defect,&#160;aortic root aneurysm / dissection, cardiac allograft failure, massive ventricular thrombus, refractory malignant arrhythmias (independent of filling pressures), hypertrophic / restrictive cardiomyopathy, and complex congenital heart disease. Patients often present with cardiogenic shock and multi system organ dysfunction. Excision of both ventricles and orthotopic replacement with a total artificial heart (TAH) is an effective, albeit extreme, therapy for rapid restoration of blood flow and resuscitation. Perioperative management is focused on end organ resuscitation and physical rehabilitation. In addition to the usual concerns of infection, bleeding, and thromboembolism common to all mechanically supported patients, TAH patients face unique risks with regard to renal failure and anemia. Supplementation of the abrupt decrease in brain natriuretic peptide following ventriculectomy appears to have protective renal effects. Anemia following TAH implantation can be profound and persistent. Nonetheless, the anemia is generally well tolerated and transfusion are limited to avoid HLA sensitization. Until recently, TAH patients were confined as inpatients tethered to a 500 lb pneumatic console driver. Recent introduction of a backpack sized portable driver (currently under clinical trial) has enabled patients to be discharged home and even return to work. Despite the profound presentation of these sick patients, there is a 79-87% success in bridge to transplantation.

The purpose of this manuscript is to briefly review indications, management, and outcomes for the total artificial heart. Video operative techniques for device implantation are presented.

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 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 ...

In Vitro Thrombosis Test for Ventricular Assist Devices

The risk of thrombosis remains a significant concern in the development and clinical use of ventricular assist devices (VADs). Traditional assessments of VAD thrombogenicity, primarily through animal studies, are costly and time-consuming, raise ethical concerns, and ultimately may not accurately reflect human outcomes. To address these limitations, we developed an aggressive in vitro testing protocol designed to provoke thrombosis and identify potential high-risk areas within the blood flow path. This protocol, motivated by the work of Maruyama et al., employs a modified anticoagulation strategy and utilizes readily available components, making it accessible to most laboratories conducting in vitro blood testing of VADs. We demonstrated the utility of this method through iterative testing and refinement of a miniature magnetically levitated pediatric VAD (PediaFlow PF5). The method has been effective in identifying thrombogenic hotspots caused by design and manufacturing flaws in early VAD prototypes, enabling targeted improvements before advancing to animal studies. Despite its limitations, including the absence of pulsatile flow and the influence of donor blood characteristics, this protocol serves as a practical tool for early-stage VAD development and risk mitigation.

We present a benchtop protocol to induce thrombosis in ventricular assist devices (VAD) within a recirculating test platform. This method serves to identify thrombogenic hotspots in the blood flow path and can help improve thromboresistance ahead of preclinical testing in animal models.

体外研究 心室辅助装置的血栓形成试验

The risk of thrombosis remains a significant concern in the development and clinical use of ventricular assist devices (VADs). Traditional assessments of ...

生物工程

Utilizing Percutaneous Ventricular Assist Devices in Acute Myocardial Infarction Complicated by Cardiogenic Shock

Cardiogenic shock is defined as persistent hypotension, accompanied by evidence of end organ hypo-perfusion. Percutaneous ventricular assist devices (PVADs) are used for the treatment of cardiogenic shock in an effort to improve hemodynamics. Impella is currently the most common PVAD and actively pumps blood from the left ventricle into the aorta. PVADs unload the left ventricle, increase cardiac output and improve coronary perfusion. PVADs are typically placed in the cardiac catheterization laboratory under fluoroscopic guidance via the femoral artery when feasible. In cases of severe peripheral arterial disease, PVADs can be implanted through an alternative access. In this article, we summarize the mechanism of action of PVAD and the data supporting their use in the treatment of cardiogenic shock.

Percutaneous ventricular assist devices are increasingly being utilized in patients with acute myocardial infarction and cardiogenic shock. Herein, we discuss the mechanism of action and hemodynamic effects of such devices. We also review algorithms and best practices for the implantation, management and weaning of these complex devices.

经皮心室辅助装置治疗急性心肌梗死并发心源性休克

Cardiogenic shock is defined as persistent hypotension, accompanied by evidence of end organ hypo-perfusion. Percutaneous ventricular assist devices ...

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 ...

Insertion, Maintenance, and Removal of the Percutaneous Dual Lumen Cannula Right Ventricular Assist Device

Right ventricular (RV) shock, classically characterized by elevated central venous pressure (CVP) with&#160;normal to low pulmonary artery (PA) and pulmonary capillary wedge pressures (PCWP),&#160;remains a significant cause of morbidity and mortality worldwide if left untreated.&#160;Therapies for the treatment of RV shock range&#160;from medical management to durable or percutaneous mechanical circulatory support (MCS). A unique MCS device, a percutaneous right ventricular assist device (pRVAD), approved for use by the Food and Drug Administration (FDA) in 2014, works by temporarily off-loading the RV through a single, dual lumen catheter with extracorporeal mechanical support and is capable of shunting blood from the right atrium (RA) to the main PA. Although initially approved as venous-venous extracorporeal membrane oxygenation (VV-ECMO) device, this work will focus on the use of RV support, as ambulatory VV-ECMO strategies have been described previously. The catheter is most commonly inserted through the right internal jugular (IJ) vein into the PA and connected to an external pump, allowing flow up to 5 L/min. This device may be an attractive choice for the treatment of RV shock due to its percutaneous, minimally invasive insertion and removal and its ability to allow patient ambulation while the device is in place. This protocol discusses in detail the equipment, hemodynamic effects, indications, contraindications, complications, currently available research in the literature, and step-by-step instructions on how to implant, manage, and extract the device, along with the guidance on use and troubleshooting complications from one of the largest, single-center experiences with the device.

The present protocol provides a detailed description of a percutaneous dual lumen right ventricular assist device and illustrates step-by-step instructions on the safe implanting, managing, and removing the device. Guidance on its use and troubleshooting complications from one of the most significant single-center experiences is also included.

Right ventricular (RV) shock, classically characterized by elevated central venous pressure (CVP) with&#160;normal to low pulmonary artery (PA) and ...

两体内心室辅助装置作为全人工心脏的应用

摘要

探索更多视频

此视频中的章节

反向共肩关节置换术

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

左室壁应力和改进功能衰竭心脏使用Algisyl LVR减少

基于音频的虚拟游戏环境的发展，以帮助盲人的导航技巧

SynCardia全人工心脏植入术

的全人工心脏的先天性心脏病植入

体外研究心室辅助装置的血栓形成试验

经皮心室辅助装置治疗急性心肌梗死并发心源性休克

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

Insertion, Maintenance, and Removal of the Percutaneous Dual Lumen Cannula Right Ventricular Assist Device

两体内心室辅助装置作为全人工心脏的应用

摘要

探索更多视频

此视频中的章节

反向共肩关节置换术

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

左室壁应力和改进功能衰竭心脏使用Algisyl LVR减少

基于音频的虚拟游戏环境的发展，以帮助盲人的导航技巧

SynCardia全人工心脏植入术

的全人工心脏的先天性心脏病植入

体外研究 心室辅助装置的血栓形成试验

经皮心室辅助装置治疗急性心肌梗死并发心源性休克

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

Insertion, Maintenance, and Removal of the Percutaneous Dual Lumen Cannula Right Ventricular Assist Device

体外研究心室辅助装置的血栓形成试验