Long-term mechanical circulatory support system reliability recommendation: American Society for Artificial Internal Organs and The Society of Thoracic Surgeons: long-term mechanical circulatory support system reliability recommendation

Review of Systemic Mock Circulation Loops for Evaluation of Implantable Cardiovascular Devices and Biological Tissues

CLINICAL IMPACT

On needs-based ex vivo monitoring of implantable devices or tissues/organs in cardiovascular simulators provides new insights and paves new paths for device prototypes. The insights gained could not only support the needs of patients, but also inform engineers, scientists and clinicians about undiscovered aspects of diseases (during routine monitoring). We analyze seminal and current work and highlight a variety of opportunities for developing preclinical tools that would improve strategies for future implantable devices. Holistically, mock circulation loop studies can bridge the gap between in vivo and in vitro approaches, as well as clinical and laboratory settings, in a mutually beneficial manner.

Mock circulatory loop applications for testing cardiovascular assist devices and in vitro studies

The mock circulatory loop (MCL) is an in vitro experimental system that can provide continuous pulsatile flows and simulate different physiological or pathological parameters of the human circulation system. It is of great significance for testing cardiovascular assist device (CAD), which is a type of clinical instrument used to treat cardiovascular disease and alleviate the dilemma of insufficient donor hearts. The MCL installed with different types of CADs can simulate specific conditions of clinical surgery for evaluating the effectiveness and reliability of those CADs under the repeated performance tests and reliability tests. Also, patient-specific cardiovascular models can be employed in the circulation of MCL for targeted pathological study associated with hemodynamics. Therefore, The MCL system has various combinations of different functional units according to its richful applications, which are comprehensively reviewed in the current work. Four types of CADs including prosthetic heart valve (PHV), ventricular assist device (VAD), total artificial heart (TAH) and intra-aortic balloon pump (IABP) applied in MCL experiments are documented and compared in detail. Moreover, MCLs with more complicated structures for achieving advanced functions are further introduced, such as MCL for the pediatric application, MCL with anatomical phantoms and MCL synchronizing multiple circulation systems. By reviewing the constructions and functions of available MCLs, the features of MCLs for different applications are summarized, and directions of developing the MCLs are suggested.

Circulatory loop design and components introduce artifacts impacting in vitro evaluation of ventricular assist device thrombogenicity: A call for caution

Mechanical circulatory support (MCS) devices continue to be hampered by thrombotic adverse events (AEs), a consequence of device-imparted supraphysiologic shear stresses, leading to shear-mediated platelet activation (SMPA). In advancing MCS devices from design to clinical use, in vitro circulatory loops containing the device under development and testing are utilized as a means of assessing device thrombogenicity. Physical characteristics of these test circulatory loops may also contribute to inadvertent platelet activation through imparted shear stress, adding inadvertent error in evaluating MCS device thrombogenicity. While investigators normally control for the effect of a loop, inadvertent addition of what are considered innocuous connectors may impact test results. Here, we tested the effect of common, additive components of in vitro circulatory test loops, that is, connectors and loop geometry, as to their additive contribution to shear stress via both in silico and in vitro models. A series of test circulatory loops containing a ventricular assist device (VAD) with differing constituent components, were established in silico including: loops with 0~5 Luer connectors, a loop with a T-connector creating 90° angulation, and a loop with 90° angulation. Computational fluid dynamics (CFD) simulations were performed using a k - ω shear stress transport turbulence model to platelet activation index (PAI) based on a power law model. VAD-operated loops replicating in silico designs were assembled in vitro and gel-filtered human platelets were recirculated within (1 hour) and SMPA was determined. CFD simulations demonstrated high shear being introduced at non-smooth regions such as edge-connector boundaries, tubing, and at Luer holes. Noticeable peaks' shifts of scalar shear stress (sss) distributions toward high shear-region existed with increasing loop complexity. Platelet activation also increased with increasing shear exposure time, being statistically higher when platelets were exposed to connector-employed loop designs. The extent of platelet activation in vitro could be successfully predicted by CFD simulations. Loops employing additional components (non-physiological flow pattern connectors) resulted in higher PAI. Loops with more components (5-connector loop and 90° T-connector) showed 63% and 128% higher platelet activation levels, respectively, versus those with fewer (0-connector (P = .023) and a 90° heat-bend loop (P = .0041). Our results underscore the importance of careful consideration of all component elements, and suggest the need for standardization in designing in vitro circulatory loops for MCS device evaluation to avoid inadvertent additive SMPA during device evaluation, confounding overall results. Specifically, we caution on the use and inadvertent introduction of additional connectors, ports, and other shear-generating elements which introduce artifact, clouding primary device evaluation via introduction of additive SMPA.

Study on in vitro performance verification protocol for left ventricular assist device

OBJECTIVE

In vitro performance verification of ventricular assist devices using a mock circulatory loop is a prominent step to guarantee the system responses and the device performance and safety before the in vivo tests and ultimately clinical trials.

METHODS

In this article, we performed a comprehensive literature research to establish a verification matrix consisting of 12 test cases, defined by a set of physiological parameters which are commonly used to characterize a physiological condition. The clinical hemodynamic indicators for defining successful mechanical support were used as the acceptance criteria. A mock circulatory loop was customized to simulate the test cases, and a full verification protocol was described in details. An example left ventricular assist device was incorporated in the loop to accomplish a standard ventricular assist device performance verification.

RESULT

The test cases based on clinical data with sufficient safety margin represent our understanding in defining the extremes of operation. The mock circulatory loop was capable of generating the test conditions in the verification matrix and reproducing the Frank-Starling law of the native heart. The effect of the left ventricular assist device assistance (characterized by the total systemic flow, mean aortic pressure, and left atrial pressure) was well verified by the proposed protocol and acceptance criteria.

CONCLUSION

To date, all left ventricular assist devices made in China have been evaluated according this protocol and some of them have entered the clinical trial stage. We are closely observing the clinical data in order to further improve the performance of the platform and encourage more advances in mechanical circulatory assist devices.

Long-term durability test of axial-flow ventricular assist device under pulsatile flow

A long-term durability test was conducted on a newly developed axial-flow ventricular assist device (VAD) with hydrodynamic bearings. The mock circulatory loop consisted of a diaphragm pump with a mechanical heart valve, a reservoir, a compliance tank, a resistance valve, and flow paths made of polymer or titanium. The VAD was installed behind the diaphragm pump. The blood analog fluid was a saline solution with added glycerin at a temperature of 37 °C. A pulsatile flow was introduced into the VAD over a range of flow rates to realize a positive flow rate and a positive pressure head at a given impeller rotational speed, yielding a flow rate of 5 L/min and a pressure of 100 mmHg. Pulsatile flow conditions were achieved with the diastolic and systolic flow rates of ~0 and 9.5 L/min, respectively, and an average flow rate of ~5 L/min at a pulse rate of 72 bpm. The VAD operation was judged by not only the rotational speed of the impeller, but also the diastolic, systolic, and average flow rates and the average pressure head of the VAD. The conditions of the mock circulatory loop, including the pulse rate of the diaphragm pump, the fluid temperature, and the fluid viscosity were maintained. Eight VADs were tested with testing periods of 2 years, during which they were continuously in operation. The VAD performance factors, including the power consumption and the vibration characteristics, were kept almost constant. The long-term durability of the developed VAD was successfully demonstrated.

Six-year in-vitro reliability results of the HeartWare HVAD pump

As a result of stagnant heart transplantation rates, ventricular assist devices (VADs) have become a widely accepted therapy for the treatment of advanced-stage heart failure. Long-term reliability of VADs will become increasingly vital as the population of destination therapy patients expands. In this study, eight HVAD pumps (n = 8) completed a 6-year reliability test in the HeartWare Life Cycle Testing System, an in-vitro mock circulatory loop that simulated physiologic pressures and flows. Cumulative runtime for the pumps was 2,408 ± 60 days. During this time, no device failures of any type occurred. These results strongly support the durability of the pump design.

Design and Evaluation of a Hybrid Mock Circulatory Loop for total Artificial Heart Testing

Aims

A hybrid mock circulatory loop (MCL) was developed for total artificial heart (TAH) performance evaluation. The hybrid MCL consists of hydraulic hardware components and a software computer model.

Design

The hydraulic components are divided into the systemic and pulmonary circulation, each of which includes electrically controlled compliances, resistors, and a venous volume which can be adjusted for a wide range of physiological and pathological conditions. The software model simulates the baroreflex autoregulatory response by automatically adjusting the hydraulic parameters according to changes of condition in the MCL.

Results

The experimental results demonstrated a good representation of the human cardiovascular system and the capability of real-time variation of physiological and pathological conditions. The functionality of the baroreflex autoregulatory mechanism was evaluated by simulation of a postural change.

Conclusions

The hybrid MCL that we developed allows variable and continuous in vitro evaluation of mechanical circulatory support devices in TAH configuration and particularly their control algorithms in response to various cardiovascular conditions. The system has been built in a modular configuration to allow testing of different types of devices and thus provides a valuable test platform prior to animal experiments.

A durability study of a paracorporeal pulsatile electro-mechanical pneumatic biventricular assist device

In 2002, the paracorporeal pulsatile electro-mechanical pneumatic ventricular assist device (VAD) began to be developed by the Korea Artificial Organ Center at Korea University under a Health & Medical Technology Research and Development program which finished in 2008. In vitro durability testing was conducted on the paracorporeal pulsatile pneumatic VAD to determine device durability and to evaluate device failures. The 1- and 2-year reliability of the paracorporeal pulsatile pneumatic VAD was shown to be 91.2% and 54.9%, respectively, with an 80% confidence level. Failure modes were analyzed using fault tree analysis, with customized software continuously acquiring data during the test period. After this period, 21 in vivo animal tests were done, with 14 cases of left atrium to left ventricle (LV) inflow cannulation (36Fr)/outflow grafting to descending aorta, and seven cases of apex cannulation of LV to descending aorta (12 mm). The longest postoperative day (182 days) in Korea was recently recorded in in vivo animal testing (bovine, 90 kg, male, 3.5-4.0 L/min flow rate, and 55 bpm).

Japanese guidance for ventricular assist devices/total artificial hearts

To facilitate research and development (R&D) and to expedite the review processes of medical devices, the Ministry of Health, Labor and Welfare (MHLW) and the Ministry of Economy, Trade and Industry (METI) founded a joint committee to establish guidance for newly emerging technology. From 2005 to 2007, two working groups held discussions on ventricular assist devices and total artificial hearts, including out-of-hospital programs, based on previous guidance documents and standards. Based on this discussion, the METI published the R&D Guidelines for innovative artificial hearts in 2007, and in 2008 the MHLW published a Notification by Director regarding the evaluation criteria for emerging technology.

Development of a hybrid decision support model for optimal ventricular assist device weaning

BACKGROUND

Despite the small but promising body of evidence for cardiac recovery in patients that have received ventricular assist device (VAD) support, the criteria for identifying and selecting candidates who might be weaned from a VAD have not been established.

METHODS

A clinical decision support system was developed based on a Bayesian Belief Network that combined expert knowledge with multivariate statistical analysis. Expert knowledge was derived from interviews of 11 members of the Artificial Heart Program at the University of Pittsburgh Medical Center. This was supplemented by retrospective clinical data from the 19 VAD patients considered for weaning between 1996 and 2004. Artificial Neural Networks and Natural Language Processing were used to mine these data and extract sensitive variables.

RESULTS

Three decision support models were compared. The model exclusively based on expert-derived knowledge was the least accurate and most conservative. It underestimated the incidence of heart recovery, incorrectly identifying 4 of the successfully weaned patients as transplant candidates. The model derived exclusively from clinical data performed better but misidentified 2 patients: 1 weaned successfully, and 1 that needed a cardiac transplant ultimately. An expert-data hybrid model performed best, with 94.74% accuracy and 75.37% to 99.07% confidence interval, misidentifying only 1 patient weaned from support.

CONCLUSIONS

A clinical decision support system may facilitate and improve the identification of VAD patients who are candidates for cardiac recovery and may benefit from VAD removal. It could be potentially used to translate success of active centers to those less established and thereby expand use of VAD therapy.

Durability improvement of polymer chamber of pulsatile extracorporeal life support system in terms of mechanical change

Twin Pulse Life Support, T-PLS has received the CE mark (2003) and Korea Food and Drug Administration (KFDA) approval (2004) for short-term application as an Extracorporeal Life Support system (ECLS). T-PLS's original intention was to apply for not only short-term but also long-term application such as Extracorporeal ventricular assist device (VAD). Hence, a long-term durability test was conducted. The 1-year reliability of the systems tested in this study did not meet the STS/ASAIO standard of 80% reliability with 60% confidence for a 1-year mission life. However, without the disposable units, which are only designed to operate for 6 h, the 1-year reliability exceeded the STS/ASAIO standard of 80% reliability with 60% confidence. In this study, by using the existing analysis methods and analyzing the root cause of the failure used by a numerical analysis. As eliminating or mitigating of the root cause of the failure, we improved the durability of blood chamber and evaluated the performance of the modified system via the hemolysis test.

A Complete Mock Circulation Loop for the Evaluation of Left, Right, and Biventricular Assist Devices

A new mock circulation loop was developed to replicate the necessary features of the systemic and pulmonic circulatory systems, including pulsatile left and right ventricles coupled with vascular compliances and resistances. A brief description of the mock loop construction is provided before results are presented confirming the recreation of perfusion rates and pressures found in the natural systemic and pulmonic vascular trees for a normal and failing heart at rest. This rig provides the ability to evaluate the hemodynamic effect of left, right, and biventricular assist devices in vitro. The small and compact mock circulation rig has the potential to reduce device evaluation costs by simulating the natural circulatory system, thus providing valuable device performance feedback prior to expensive in vivo animal trials.

The Status of Failure and Reliability Testing of Artificial Blood Pumps

Artificial blood pumps are today's most promising bridge-to-transplant, bridge-to-recovery, and destination therapy solutions for patients with congestive heart failure. There is a critical need for increased reliability and safety as the next generation of artificial blood pumps approach final development for long-term destination therapy. To date, extensive failure and reliability studies of these devices are considered intellectual property and thus remain unpublished. Presently, the Novacor N100PC, Thoratec VAD, and HeartMate LVAS (IP and XVE) comprise the only four artificial blood pumps commercially available for the treatment of congestive heart failure in the United States. The CardioWest TAH recently received premarket approval from the US Food and Drug Administration. With investigational device exemptions, the AB-180, AbioCor, LionHeart, DeBakey, and Flowmaker are approved for clinical testing. Other blood pumps, such as the American BioMed-Baylor TAH, CorAide, Cleveland Clinic-Nimbus TAH, HeartMate III, Hemadyne, and MagScrew TAH are currently in various stages of mock loop and animal testing, as indicated in published literature. This article extensively reviews in vitro testing, in vivo testing, and the early clinical testing of artificial blood pumps in the United States, as it relates to failure and reliability. This detailed literature review has not been published before and provides a thorough documentation of available data and testing procedures regarding failure and reliability of these various pumps.

Durability Testing of a Completely Implantable Electric Total Artificial Heart

In vitro durability testing was conducted on the Penn State/3M electric total artificial heart (ETAH) to determine device durability and to evaluate device failures. A specialized mock circulatory loop was developed for this testing. Customized software continuously acquired data during the test period, and failures were analyzed using FMEA (failure modes and effects analysis) and FMECA (failure modes, effects, and criticality analysis) principles. Redesigns were implemented when appropriate. Reliability growth principles were then applied to calculate the 1 and 2 year reliability. The 1 and 2 year reliability of the Penn State/3M ETAH was shown to be 96.1% and 59.9%, respectively, at 80% confidence.

Methods of Failure and Reliability Assessment for Mechanical Heart Pumps

Artificial blood pumps are today's most promising bridge-to-recovery (BTR), bridge-to-transplant (BTT), and destination therapy solutions for patients suffering from intractable congestive heart failure (CHF). Due to an increased need for effective, reliable, and safe long-term artificial blood pumps, each new design must undergo failure and reliability testing, an important step prior to approval from the United States Food and Drug Administration (FDA), for clinical testing and commercial use. The FDA has established no specific standards or protocols for these testing procedures and there are only limited recommendations provided by the scientific community when testing an overall blood pump system and individual system components. Product development of any medical device must follow a systematic and logical approach. As the most critical aspects of the design phase, failure and reliability assessments aid in the successful evaluation and preparation of medical devices prior to clinical application. The extent of testing, associated costs, and lengthy time durations to execute these experiments justify the need for an early evaluation of failure and reliability. During the design stages of blood pump development, a failure modes and effects analysis (FMEA) should be completed to provide a concise evaluation of the occurrence and frequency of failures and their effects on the overall support system. Following this analysis, testing of any pump typically involves four sequential processes: performance and reliability testing in simple hydraulic or mock circulatory loops, acute and chronic animal experiments, human error analysis, and ultimately, clinical testing. This article presents recommendations for failure and reliability testing based on the National Institutes of Health (NIH), Society for Thoracic Surgeons (STS) and American Society for Artificial Internal Organs (ASAIO), American National Standards Institute (ANSI), the Association for Advancement of Medical Instrumentation (AAMI), and the Bethesda Conference. It further discusses studies that evaluate the failure, reliability, and safety of artificial blood pumps including in vitro and in vivo testing. A descriptive summary of mechanical and human error studies and methods of artificial blood pumps is detailed.

Multicenter clinical evaluation of the HeartMate vented electric left ventricular assist system in patients awaiting heart transplantation

BACKGROUND

Despite advances in heart transplantation and mechanical circulatory support, mortality among transplant candidates remains high. Better ways are needed to ensure the survival of transplant candidates both inside and outside the hospital.

METHODS

In a prospective, multicenter clinical trial conducted at 24 centers in the United States, 280 transplant candidates (232 men, 48 women; median age, 55 years; range, 11-72 years) unresponsive to inotropic drugs, intra-aortic balloon counterpulsation, or both, were treated with the HeartMate Vented Electric Left Ventricular Assist System (VE LVAS). A cohort of 48 patients (40 men, 8 women; median age, 50 years; range, 21-67 years) not supported with an LVAS served as a historical control group. Outcomes were measured in terms of laboratory data (hemodynamic, hematologic, and biochemical), adverse events, New York Heart Association functional class, and survival.

RESULTS

The VE LVAS-treated and non-VE LVAS-treated (control) groups were similar in terms of age, sex, and distribution of patients by diagnosis (ischemic cardiomyopathy, idiopathic cardiomyopathy, and subacute myocardial infarction). VE LVAS support lasted an average of 112 days (range, < 1-691 days), with 54 patients supported for > 180 days. Mean VE LVAS flow (expressed as pump index) throughout support was 2.8 L x min(-1) x m(-2). Median total bilirubin values decreased from 1.2 mg/dL at baseline to 0.7 mg/dL (P =.0001); median creatinine values decreased from 1.5 mg/dL at baseline to 1.1 mg/dL (P =.0001). VE LVAS-related adverse events included bleeding in 31 patients (11%), infection in 113 (40%), neurologic dysfunction in 14 (5%), and thromboembolic events in 17 (6%). A total of 160 (58%) patients were enrolled in a hospital release program. Twenty-nine percent of the VE LVAS-treated patients (82/280) died before receiving a transplant, compared with 67% of controls (32/48) (P <.001). Conversely, 71% of the VE LVAS-treated patients (198/280) survived: 67% (188/280) ultimately received a heart transplant, and 4% (10/280) had the device removed electively. One-year post-transplant survival of VE LVAS-treated patients was significantly better than that of controls (84% [158/188] vs 63% [10/16]; log rank analysis P =.0197).

CONCLUSION

The HeartMate VE LVAS provides adequate hemodynamic support, has an acceptably low incidence of adverse effects, and improves survival in heart transplant candidates both inside and outside the hospital. The studies of the HeartMate LVAS (both pneumatic and electric) for Food and Drug Administration approval are the only studies with a valid control group to show a survival benefit for cardiac transplantation.