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He W, Karmakar A, Kang J, Rowlands G, Schirmacher S, Méndez-Rojano R, Antaki J. In Vitro and In Silico Characterization of the Aggregation of Thrombi on Textured Ventricular Cannula. Ann Biomed Eng 2024:10.1007/s10439-024-03504-1. [PMID: 38679660 DOI: 10.1007/s10439-024-03504-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 03/25/2024] [Indexed: 05/01/2024]
Abstract
The unacceptably high stroke rate associated with HeartMate 3 ventricular assist device (VAD) without signs of adherent pump thrombosis is hypothesized to be the result of the emboli produced by the inflow cannula, that are ingested and ejected from the pump. This in vitro and numerical study aimed to emulate the surface features and supraphysiological shear of a ventricular cannula to provide insight into their effect on thrombogenesis. Human whole blood was perfused at calibrated flow rates in a microfluidic channel to achieve shear rates 1000-7500 s-1, comparable to that experienced on the cannula. The channel contained periodic teeth representative of the rough sintered surface of the HeartMate 3 cannula. The deposition of fluorescently labeled platelets was visualized in real time and analyzed with a custom entity tracking algorithm. Numerical simulations of a multi-constituent thrombosis model were performed to simulate laminar blood flow in the channel. The sustained growth of adherent platelets was observed in all shear conditions ( p < 0.05). However, the greatest deposition was observed at the lower shear rates. The location of deposition with respect to the microfluidic teeth was also found to vary with shear rate. This was confirmed by CFD simulation. The entity tracking algorithm revealed the spatial variation of instances of embolic events. This result suggests that the sintered surface of the ventricular cannula may engender unstable thrombi with a greater likelihood of embolization at supraphysiological shear rates.
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Affiliation(s)
- Wenxuan He
- Sibley School of Mechanical and Aerospace Engineering, Cornell University, Ithaca, NY, 14853, USA
| | - Abhishek Karmakar
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, NY, 14853, USA
| | - Junhyuk Kang
- Sibley School of Mechanical and Aerospace Engineering, Cornell University, Ithaca, NY, 14853, USA
| | - Grant Rowlands
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, NY, 14853, USA
| | - Samuel Schirmacher
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, NY, 14853, USA
| | | | - James Antaki
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, NY, 14853, USA.
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Bhuta S, Shaaban A, Binda NC, Antaki J, Augostini RS, Kalbfleisch SJ, Savona SJ, Okabe T, Houmsse M, Afzal MR, Daoud EG, Hummel JD. Direct current cardioversion practices following percutaneous left atrial appendage closure. J Cardiovasc Electrophysiol 2023; 34:1698-1705. [PMID: 37493499 DOI: 10.1111/jce.15999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/12/2023] [Accepted: 06/26/2023] [Indexed: 07/27/2023]
Abstract
INTRODUCTION Among patients with non-valvular atrial fibrillation (AF) and percutaneous left atrial appendage closure (LAAC) undergoing direct current cardioversion (DCCV), the need for and use of LAA imaging and oral anticoagulation (OAC) is unclear. OBJECTIVE The purpose of this study is to evaluate the real-world use of transesophageal echocardiography (TEE) or cardiac computed tomography angiography (CCTA) before DCCV and use of OAC pre- and post-DCCV in patients with AF status post percutaneous LAAC. METHODS This retrospective single center study included all patients who underwent DCCV after percutaneous LAAC from 2016 to 2022. Key measures were completion of TEE or CCTA pre-DCCV, OAC use pre- and post-DCCV, incidence of left atrial thrombus (LAT) or device-related thrombus (DRT), incidence of peri-device leak (PDL), and DCCV-related complications (stroke, systemic embolism, device embolization, major bleeding, or death) within 30 days. RESULTS A total of 76 patients with AF and LAAC underwent 122 cases of DCCV. LAAC consisted of 47 (62%), 28 (37%), and 1 (1%) case of Watchman 2.5, Watchman FLX, and Lariat, respectively. Among the 122 DCCV cases, 31 (25%) cases were identified as "non-guideline based" due to: (1) no OAC for 3 weeks and no LAA imaging within 48 h before DCCV in 12 (10%) cases, (2) no OAC for 4 weeks following DCCV in 16 (13%) cases, or (3) both in 3 (2%) cases. Among the 70 (57%) cases that underwent TEE or CCTA before DCCV, 16 (23%) cases had a PDL with a mean size of 3.0 ± 1.1 mm, and 4 (6%) cases had a LAT/DRT on TEE resulting in cancellation. There were no DCCV-related complications within 30 days. DISCUSSION There is a widely varied practice pattern of TEE, CCTA, and OAC use with DCCV after LAAC, with a 6% rate of LAT/DRT. LAA imaging before DCCV appears prudent in all cases, especially within 1 year of LAAC, to assess for device position, PDL, and LAT/DRT.
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Affiliation(s)
- Sapan Bhuta
- Section of Electrophysiology, Division of Cardiovascular Medicine, Ross Heart Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Adnan Shaaban
- Section of Electrophysiology, Division of Cardiovascular Medicine, Ross Heart Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Nkongho C Binda
- Section of Electrophysiology, Division of Cardiovascular Medicine, Ross Heart Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - James Antaki
- Section of Electrophysiology, Division of Cardiovascular Medicine, Ross Heart Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ralph S Augostini
- Section of Electrophysiology, Division of Cardiovascular Medicine, Ross Heart Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Steven J Kalbfleisch
- Section of Electrophysiology, Division of Cardiovascular Medicine, Ross Heart Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Salvatore J Savona
- Section of Electrophysiology, Division of Cardiovascular Medicine, Ross Heart Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Toshimasa Okabe
- Section of Electrophysiology, Division of Cardiovascular Medicine, Ross Heart Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Mahmoud Houmsse
- Section of Electrophysiology, Division of Cardiovascular Medicine, Ross Heart Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Muhammad R Afzal
- Section of Electrophysiology, Division of Cardiovascular Medicine, Ross Heart Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Emile G Daoud
- Section of Electrophysiology, Division of Cardiovascular Medicine, Ross Heart Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - John D Hummel
- Section of Electrophysiology, Division of Cardiovascular Medicine, Ross Heart Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Kanwar MK, Selzman CH, Ton VK, Miera O, Cornwell WK, Antaki J, Drakos S, Shah P. Clinical myocardial recovery in advanced heart failure with long term left ventricular assist device support. J Heart Lung Transplant 2022; 41:1324-1334. [PMID: 35835680 PMCID: PMC10257189 DOI: 10.1016/j.healun.2022.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 05/16/2022] [Accepted: 05/23/2022] [Indexed: 10/18/2022] Open
Abstract
Left ventricular assist-device (LVAD) implantation is a life-saving therapy for patients with advanced heart failure (HF). With chronic unloading and circulatory support, LVAD-supported hearts often show significant reverse remodeling at the structural, cellular and molecular level. However, translation of these changes into meaningful cardiac recovery allowing LVAD explant is lagging. Part of the reason for this discrepancy is lack of anticipation and hence promotion and evaluation for recovery post LVAD implant. There is additional uncertainty about the long-term course of HF following LVAD explant. In selected patients, however, guided by the etiology of HF, duration of disease and other clinical factors, significant functional improvement and LVAD explantation with long-term freedom from recurrent HF events has been demonstrated to be feasible in a reproducible manner. The identified predictors of myocardial recovery suggest that the elective therapeutic use of potentially less invasive VADs for reversal of HF earlier in the disease process is a future goal that warrants further investigation. Hence, it is prudent to develop and implement tools to predict HF reversibility prior to LVAD implant, optimize unloading-promoted recovery with guideline directed medical therapy and monitor for myocardial improvement. This review article summarizes the clinical aspects of myocardial recovery and together with its companion review article focused on the biological aspects of recovery, they aim to provide a useful framework for clinicians and investigators.
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Affiliation(s)
- Manreet K Kanwar
- Cardiovascular Institute, Allegheny Health Network, Pittsburgh, Pennsylvania.
| | - Craig H Selzman
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Van-Khue Ton
- Massachusetts General Hospital, Harvard Medical School, Boston, Maryland
| | - Oliver Miera
- Department of Congenital Heart Disease, Pediatric Cardiology, German Heart Center, Berlin, Germany
| | - William K Cornwell
- Department of Medicine Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - James Antaki
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, New York
| | - Stavros Drakos
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah
| | - Palak Shah
- Inova Heart and Vascular Institute, Falls Church, Virginia
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Mattila JP, Amaro A, Longo M, Antaki J, Koirala S, Gandini A. RapidQ: A reader-free microfluidic platform for the quantitation of antibodies against the SARS-CoV-2 spike protein. Biomicrofluidics 2022; 16:024105. [PMID: 35356130 PMCID: PMC8933056 DOI: 10.1063/5.0079054] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 03/04/2022] [Indexed: 06/14/2023]
Abstract
We describe RapidQ, a fast, disposable, easy-to-use microfluidic assay for the quantitation of the anti-SARS-CoV-2 spike (S) protein IgG in plasma samples. The assay utilizes antigen-coated paramagnetic microbeads, which are induced to aggregate inside the RapidQ microfluidic device in the presence of the target antibody. Aggregation occurs via interaction between the biotinylated detection antibody and polymeric streptavidin. The mobility of the beads inside the two microchannels of the device depends on their aggregation state, with larger clusters moving at higher velocities under a given liquid flow rate. One of the microchannels incorporates a permanent magnet that captures arriving beads and forms a localized constriction that retards liquid flow. Since the constriction grows faster when the beads are more aggregated, the length of the liquid column accumulated downstream from the constriction relative to that of the unconstricted control channel is proportional to the sample antibody concentration. The assay demonstrates a detection limit of 4 μg/ml of monoclonal anti-S protein antibody diluted in plasma with CV ≤ 13%, as well as negative and positive percent agreements of 100% (95% CI: 92.75%-100%) and 100% (95% CI: 80.5%-100%), respectively, when compared to a nucleic acid amplification test used to identify COVID-19 positive individuals, whose samples were collected ≥17 d from a positive PCR test. Finally, the RapidQ assay was used to monitor the kinetics of antibody responses to COVID-19 vaccination in a small study cohort.
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Affiliation(s)
| | - Arlene Amaro
- Accel Diagnostics, LLC, Houston, Texas 77057, USA
| | - Monica Longo
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas Health Science Center at Houston, Houston, Texas 77030, USA
| | - James Antaki
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, New York 14853, USA
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Kostick-Quenet KM, Cohen IG, Gerke S, Lo B, Antaki J, Movahedi F, Njah H, Schoen L, Estep JE, Blumenthal-Barby JS. Mitigating Racial Bias in Machine Learning. J Law Med Ethics 2022; 50:92-100. [PMID: 35243993 DOI: 10.1017/jme.2022.13] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
When applied in the health sector, AI-based applications raise not only ethical but legal and safety concerns, where algorithms trained on data from majority populations can generate less accurate or reliable results for minorities and other disadvantaged groups.
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Kanwar M, Krainsangka J, Scott J, Barrett T, Everett A, Perer A, Antaki J, Benza R. Hemodynamic Parameters in Predicting Survival in Pulmonary Arterial Hypertension. J Heart Lung Transplant 2021. [DOI: 10.1016/j.healun.2021.01.548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Kanwar MK, Gomberg-Maitland M, Hoeper M, Pausch C, Pittrow D, Strange G, Anderson JJ, Zhao C, Scott JV, Druzdzel MJ, Kraisangka J, Lohmueller L, Antaki J, Benza RL. Risk stratification in pulmonary arterial hypertension using Bayesian analysis. Eur Respir J 2020; 56:13993003.00008-2020. [PMID: 32366491 DOI: 10.1183/13993003.00008-2020] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 04/22/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Current risk stratification tools in pulmonary arterial hypertension (PAH) are limited in their discriminatory abilities, partly due to the assumption that prognostic clinical variables have an independent and linear relationship to clinical outcomes. We sought to demonstrate the utility of Bayesian network-based machine learning in enhancing the predictive ability of an existing state-of-the-art risk stratification tool, REVEAL 2.0. METHODS We derived a tree-augmented naïve Bayes model (titled PHORA) to predict 1-year survival in PAH patients included in the REVEAL registry, using the same variables and cut-points found in REVEAL 2.0. PHORA models were validated internally (within the REVEAL registry) and externally (in the COMPERA and PHSANZ registries). Patients were classified as low-, intermediate- and high-risk (<5%, 5-20% and >10% 12-month mortality, respectively) based on the 2015 European Society of Cardiology/European Respiratory Society guidelines. RESULTS PHORA had an area under the curve (AUC) of 0.80 for predicting 1-year survival, which was an improvement over REVEAL 2.0 (AUC 0.76). When validated in the COMPERA and PHSANZ registries, PHORA demonstrated an AUC of 0.74 and 0.80, respectively. 1-year survival rates predicted by PHORA were greater for patients with lower risk scores and poorer for those with higher risk scores (p<0.001), with excellent separation between low-, intermediate- and high-risk groups in all three registries. CONCLUSION Our Bayesian network-derived risk prediction model, PHORA, demonstrated an improvement in discrimination over existing models. This is reflective of the ability of Bayesian network-based models to account for the interrelationships between clinical variables on outcome, and tolerance to missing data elements when calculating predictions.
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Affiliation(s)
- Manreet K Kanwar
- Cardiovascular Institute at Allegheny Health Network, Pittsburgh, PA, USA
| | | | - Marius Hoeper
- Dept of Respiratory Medicine, Hannover Medical School, German Center for Lung Research (DZL), Hannover, Germany
| | | | - David Pittrow
- Faculty of Institute for Clinical Pharmacology, Technical University, Dresden, Germany
| | - Geoff Strange
- School of Medicine, University of Notre Dame, Fremantle, Australia
| | - James J Anderson
- Respiratory Dept, Sunshine Coast University Hospital, Nambour, Australia
| | - Carol Zhao
- Actelion Pharmaceuticals US, A Janssen Pharmaceutical Company of Johnson & Johnson, San Francisco, CA, USA
| | - Jacqueline V Scott
- School of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Marek J Druzdzel
- Faculty of Computer Science, Bialystok University of Technology, Bialystok, Poland
| | - Jidapa Kraisangka
- Faculty of Information and Communication Technology, Mahidol University, Salaya, Thailand
| | - Lisa Lohmueller
- Language Technologies Institute, Carnegie Mellon University, Pittsburgh, PA, USA
| | - James Antaki
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, NY, USA
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Seese L, Movahedi F, Antaki J, Kilic A, Padman R, Zhang Y, Kanwar M, Burki S, Sciortino C, Keebler M, Hirji S, Kormos R. Delineating Pathways to Death by Multisystem Organ Failure in Patients With a Left Ventricular Assist Device. Ann Thorac Surg 2020; 111:881-888. [PMID: 32739256 DOI: 10.1016/j.athoracsur.2020.05.164] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 03/25/2020] [Accepted: 05/27/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND This study delineates the sequences of adverse events (AEs) preceding mortality attributed to multisystem organ failure (MSOF) in patients with a left ventricular assist device (LVAD). METHODS We analyzed 3765 AEs after 536 LVAD implants recorded in The Society of Thoracic Surgeons Intermacs data registry between 2006 and 2015 that resulted in MSOF death. Hierarchical clustering identified and visualized quantitatively unique clusters of patients with similar AE profiles. Markov modeling was used to illustrate the AE sequences that led to MSOF death within the clusters. Cox proportional hazard models determined the risk-adjusted, preimplant predictors of MSOF. RESULTS We identified 2 distinct MSOF clusters based on their proportion of AE types and survival time. The early-death cluster (418 patients, 2304 AEs) had a median survival of 1 month (interquartile range, 3-6 months), whereas the late-death cluster (118 patients, 1,461 AEs) had a median survival of 11 months (interquartile range, 6-22 months). The predominant AE sequences in the early-death and late-death clusters were renal failure, to respiratory failure, to death (62%) and bleeding, to infection, to respiratory failure, to death (45%), respectively. Significant risk-adjusted preimplant predictors of MSOF included line sepsis (hazard ratio [HR] 3.0; 95% confidence interval [CI], 1.1-8.2), extracorporeal membrane oxygenation (HR, 2.2; 95% CI, 1.2-3.9), and dialysis or ultrafiltration (HR, 2.1; 95% CI, 1.5-3.0). CONCLUSIONS This analysis identified 2 AE clusters and the predominant sequences that result in MSOF-associated mortality. MSOF develops in 1 cluster of patients after chronic bleeding and repeated infections but has prolonged survival, while another group dies early after renal and respiratory complications.
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Affiliation(s)
- Laura Seese
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Faezeh Movahedi
- Department of Electrical and Computer Engineering, University of Pittsburgh, Pennsylvania
| | - James Antaki
- Department of Biomedical Engineering, Cornell University, Ithaca, New York
| | - Arman Kilic
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Rema Padman
- The Heinz College of Information Systems and Public Policy, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Yiye Zhang
- Department of Healthcare Policy and Research, Weill Cornell Medicine, Ithaca, New York
| | - Manreet Kanwar
- Division of Heart Failure Cardiology, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Sarah Burki
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Christopher Sciortino
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mary Keebler
- Division of Heart Failure Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Sameer Hirji
- Division of General Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Robert Kormos
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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Kanwar M, Khan M, Raina A, Badagliacca R, Antaki J, Amin E, Benza R. Role of Echocardiogram in Predicting Prognosis in Pulmonary Arterial Hypertension: A Meta-Analysis. J Heart Lung Transplant 2020. [DOI: 10.1016/j.healun.2020.01.121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Vidula H, Wang M, Antaki J, Polonsky B, Sherazi S, Alexis J, Gosev I, Kutyifa V, McNitt S, Goldenberg I. Risk Score for Mortality Prediction after One-Year on Left Ventricular Assist Device Support. J Heart Lung Transplant 2020. [DOI: 10.1016/j.healun.2020.01.761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Kanwar M, Khoo C, Lohmueller L, Bailey S, Murali S, Antaki J. Predicting Post LVAD Acute Severe Right Heart Failure Using Bayesian Analysis. J Heart Lung Transplant 2019. [DOI: 10.1016/j.healun.2019.01.907] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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12
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Seese L, Movahedi F, Antaki J, Padman R, Murali S, Zhang Y, Kilic A, Sciortino C, Keebler M, Kormos R. Delineating Pathways to Death by Multisystem Organ Failure in Patients with a Left Ventricular Assist Device (LVAD). J Heart Lung Transplant 2019. [DOI: 10.1016/j.healun.2019.01.900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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13
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Kanwar MK, Lohmueller LC, Kormos RL, Teuteberg JJ, Rogers JG, Lindenfeld J, Bailey SH, McIlvennan CK, Benza R, Murali S, Antaki J. A Bayesian Model to Predict Survival After Left Ventricular Assist Device Implantation. JACC Heart Fail 2018; 6:771-779. [PMID: 30098967 DOI: 10.1016/j.jchf.2018.03.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 02/02/2018] [Accepted: 03/28/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVES This study investigates the use of a Bayesian statistical models to predict survival at various time points in patients undergoing left ventricular assist device (LVAD) implantation. BACKGROUND LVADs are being increasingly used in patients with end-stage heart failure. Appropriate patient selection continues to be key in optimizing post-LVAD outcomes. METHODS Data used for this study were derived from 10,277 adult patients from the INTERMACS (Inter-Agency Registry for Mechanically Assisted Circulatory Support) who had a primary LVAD implanted between January 2012 and December 2015. Risk for mortality was calculated retrospectively for various time points (1, 3, and 12 months) after LVAD implantation, using multiple pre-implantation variables. For each of these endpoints, a separate tree-augmented naïve Bayes model was constructed using the most predictive variables. RESULTS A set of 29, 26, and 31 pre-LVAD variables were found to be predictive at 1, 3, and 12 months, respectively. Predictors of 1-month mortality included low Inter-Agency Registry for Mechanically Assisted Circulatory Support profile, number of acute events in the 48 h before surgery, temporary mechanical circulatory support, and renal and hepatic dysfunction. Variables predicting 12-month mortality included advanced age, frailty, device strategy, and chronic renal disease. The accuracy of all Bayesian models was between 76% and 87%, with an area under the receiver operative characteristics curve of between 0.70 and 0.71. CONCLUSIONS A Bayesian prognostic model for predicting survival based on the comprehensive INTERMACS registry provided highly accurate predictions of mortality based on pre-operative variables. These models may facilitate clinical decision-making while screening candidates for LVAD therapy.
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Affiliation(s)
- Manreet K Kanwar
- Cardiovascular Institute, Allegheny Health Network, Pittsburgh, Pennsylvania.
| | - Lisa C Lohmueller
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Robert L Kormos
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jeffrey J Teuteberg
- Department of Cardiovascular Medicine, Stanford University Medical Center, Stanford, California
| | - Joseph G Rogers
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - JoAnn Lindenfeld
- Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Stephen H Bailey
- Cardiovascular Institute, Allegheny Health Network, Pittsburgh, Pennsylvania
| | | | - Raymond Benza
- Cardiovascular Institute, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Srinivas Murali
- Cardiovascular Institute, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - James Antaki
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania
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Kanwar M, Lohmueller L, Bailey S, Mcilvennan C, Kormos R, Murali S, Antaki J. Predicting Post-LVAD Mortality Across a Diverse HF Population Using Bayesian Analysis. J Heart Lung Transplant 2018. [DOI: 10.1016/j.healun.2018.01.1204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Kanwar M, Lohmueller L, Kormos R, Bailey S, Mcilvennan C, Murali S, Antaki J. Risk Predictors for Ischemic Stroke in CF-LVAD Patients by Pump Flow Type. J Heart Lung Transplant 2018. [DOI: 10.1016/j.healun.2018.01.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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16
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Kanwar M, Lohmueller L, Kormos R, Mcilvennan C, Bailey S, Murali S, Antaki J. Bayesian Model for Predicting 90 Day Event Free Survival in LVAD Patients. J Heart Lung Transplant 2018. [DOI: 10.1016/j.healun.2018.01.470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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Kanwar M, Lohmueller L, Correa P, Kraisangka J, Druzdzel M, Antaki J, Benza R. Application of Bayesian Model to Predict Outcomes in Pulmonary Arterial Hypertension. J Heart Lung Transplant 2018. [DOI: 10.1016/j.healun.2018.01.504] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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Movahedi F, Lohmueller L, Zhang Y, Padman R, Antaki J. Clinical Journey of Severe Heart Failure Patients after Left Ventricular Assistance Device Implant. J Card Fail 2017. [DOI: 10.1016/j.cardfail.2017.07.313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Movahedi F, Carey L, Zhang Y, Padman R, Antaki J, Kanwar M. Analysis of Post-LVAD Clinical Pathways. J Heart Lung Transplant 2017. [DOI: 10.1016/j.healun.2017.01.988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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20
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Abstract
BACKGROUND Spontaneous pneumothorax (SP) is uncommon and can present as a primary disease process or as a result of underlying lung pathology. Several parenchymal lung diseases, such as malignancy, are known to cause SP. One such malignancy, angiosarcoma, has a high propensity to metastasize to the lung and present as cavitary and cystic lesions. CASE We present a case of a 76-year-old male diagnosed with angiosarcoma of the scalp that was found to have extensive cystic pulmonary metastatic lesions. Soon after his initial diagnosis, he presented with severe respiratory distress secondary to a spontaneous left-sided pneumothorax. After intubation and left-sided chest tube placement, the patient developed a right-sided tension pneumothorax requiring emergent chest tube placement. CONCLUSION Cutaneous angiosarcoma is a rare malignancy that frequently metastasizes the lung. Spontaneous pneumothorax can be the presenting manifestation of the disease and often results in respiratory failure.
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Affiliation(s)
- Daniel Jimenez
- 1 Department of Medicine, Olive View-UCLA Medical Center, UCLA David Geffen School of Medicine, Sylmar, CA, USA
| | - James Antaki
- 2 Division of Pulmonary and Critical Care Medicine, Department of Medicine, Olive View-UCLA Medical Center, UCLA David Geffen School of Medicine, Sylmar, CA, USA
| | - Nader Kamangar
- 2 Division of Pulmonary and Critical Care Medicine, Department of Medicine, Olive View-UCLA Medical Center, UCLA David Geffen School of Medicine, Sylmar, CA, USA
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21
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Antaki J, Loghmanpour N, Kanwar M, Benza R, Murali S. Development of Predictive Models for Continuous Flow Left Ventricular Assist Device Patients using Bayesian Networks. ACTA ACUST UNITED AC 2014. [DOI: 10.6000/1929-6029.2014.03.04.11] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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22
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Wang Y, Loghmanpour N, Vandenberghe S, Ferreira A, Keller B, Gorcsan J, Antaki J. Simulation of dilated heart failure with continuous flow circulatory support. PLoS One 2014; 9:e85234. [PMID: 24465511 PMCID: PMC3894974 DOI: 10.1371/journal.pone.0085234] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Accepted: 11/25/2013] [Indexed: 11/19/2022] Open
Abstract
Lumped parameter models have been employed for decades to simulate important hemodynamic couplings between a left ventricular assist device (LVAD) and the native circulation. However, these studies seldom consider the pathological descending limb of the Frank-Starling response of the overloaded ventricle. This study introduces a dilated heart failure model featuring a unimodal end systolic pressure-volume relationship (ESPVR) to address this critical shortcoming. The resulting hemodynamic response to mechanical circulatory support are illustrated through numerical simulations of a rotodynamic, continuous flow ventricular assist device (cfVAD) coupled to systemic and pulmonary circulations with baroreflex control. The model further incorporated septal interaction to capture the influence of left ventricular (LV) unloading on right ventricular function. Four heart failure conditions were simulated (LV and bi-ventricular failure with/without pulmonary hypertension) in addition to normal baseline. Several metrics of LV function, including cardiac output and stroke work, exhibited a unimodal response whereby initial unloading improved function, and further unloading depleted preload reserve thereby reducing ventricular output. The concept of extremal loading was introduced to reflect the loading condition in which the intrinsic LV stroke work is maximized. Simulation of bi-ventricular failure with pulmonary hypertension revealed inadequacy of LV support alone. These simulations motivate the implementation of an extremum tracking feedback controller to potentially optimize ventricular recovery.
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Affiliation(s)
- Yajuan Wang
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania, United States of America
| | - Natasha Loghmanpour
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania, United States of America
| | | | - Antonio Ferreira
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania, United States of America
- Mathematics, Universidade Federal do Maranhão, Maranhão, Brazil
| | - Bradley Keller
- Cardiovascular Innovation Institute, University of Louisville, Louisville, Kentucky, United States of America
| | - John Gorcsan
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States of America
| | - James Antaki
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania, United States of America
- * E-mail:
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23
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Kanwar M, Loghmanpour N, Wang Y, Snyder T, Horstmanshof D, Long J, Gorcsan J, Antaki J, Murali S. A NOVEL, RISK STRATIFICATION MODEL USING BAYESIAN NETWORKS FOR CONTINUOUS-FLOW LEFT VENTRICULAR ASSIST DEVICE 90-DAY SURVIVAL. J Am Coll Cardiol 2013. [DOI: 10.1016/s0735-1097(13)61541-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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24
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Cleveland JC, Naftel DC, Reece TB, Murray M, Antaki J, Pagani FD, Kirklin JK. Survival after biventricular assist device implantation: an analysis of the Interagency Registry for Mechanically Assisted Circulatory Support database. J Heart Lung Transplant 2011; 30:862-9. [PMID: 21621423 DOI: 10.1016/j.healun.2011.04.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2010] [Revised: 02/18/2011] [Accepted: 04/10/2011] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Patients requiring biventricular assist device (BiVAD) for mechanical circulatory support (MCS) have substantially worse outcomes than patients requiring left VAD (LVAD) support only. Patient-specific risk factors have yet to be consistently identified in a large, multicenter registry, which may underlie the poorer outcomes for BiVAD patients. The Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) is a registry of U.S. Food and Drug Administration-approved durable MCS devices used for bridge-to-transplantation, destination therapy, or recovery. The purposes of this study were to 1) identify the underlying pre-implant characteristics of the population requiring BiVAD support that contribute to reduced survival, and 2) identify differences in postoperative outcomes with respect to adverse events compared with patients supported with LVAD alone. METHODS From June 2006 to September 2009, 1,646 patients were entered into the INTERMACS database in which adverse events and outcomes were recorded for primary implants with LVAD or BiVAD. Competing outcomes methodology was used to estimate the time-related probability of death, transplant, or recovery. Overall survival for all groups was analyzed with Kaplan-Meier methods and Cox proportional regression analysis. RESULTS The distribution of primary device implants included 1,440 LVADs and 206 BiVADs. BiVAD patients presented with a lower INTERMACS profile 93% in INTERMACS 1 or 2, compared with 73% for LVAD patients (p < 0.001). Survival at 6 months was 86% for LVADs and 56% for BiVADs (p < .0001). Adverse event rates, expressed as episodes/100 patient-months for the BiVAD group compared with LVAD, were significantly higher for infection (33.2 vs 14.3), bleeding (71.6 vs 15.5), neurologic events (7.9 vs 2.6), and for device failure (4.9 vs 2.0). CONCLUSIONS Patients requiring BiVAD support at the time of durable MCS implant are more critically ill at the time of MCS implant. BiVAD patients experience worse survival than patients supported with LVAD alone and higher rates of serious adverse events. Characteristics of the population present at the time of BiVAD implant likely influence post-implant MCS outcomes.
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Affiliation(s)
- Joseph C Cleveland
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado Anschutz Medical Center, Aurora, Colorado 80045, USA.
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25
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Borovetz HS, Badylak S, Boston JR, Johnson C, Kormos R, Kameneva MV, Simaan M, Snyder TA, Tsukui H, Wagner WR, Woolley J, Antaki J, Diao C, Vandenberghe S, Keller B, Morell V, Wearden P, Webber S, Gardiner J, Li CM, Paden D, Paden B, Snyder S, Wu J, Bearnson G, Hawkins JA, Jacobs G, Kirk J, Khanwilkar P, Kouretas PC, Long J, Shaddy RE. Towards the development of a pediatric ventricular assist device. Cell Transplant 2006; 15 Suppl 1:S69-74. [PMID: 16826798 DOI: 10.3727/000000006783982304] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The very limited options available to treat ventricular failure in children with congenital and acquired heart diseases have motivated the development of a pediatric ventricular assist device at the University of Pittsburgh (UoP) and University of Pittsburgh Medical Center (UPMC). Our effort involves a consortium consisting of UoP, Children's Hospital of Pittsburgh (CHP), Carnegie Mellon University, World Heart Corporation, and LaunchPoint Technologies, Inc. The overall aim of our program is to develop a highly reliable, biocompatible ventricular assist device (VAD) for chronic support (6 months) of the unique and high-risk population of children between 3 and 15 kg (patients from birth to 2 years of age). The innovative pediatric ventricular assist device we are developing is based on a miniature mixed flow turbodynamic pump featuring magnetic levitation, to assure minimal blood trauma and risk of thrombosis. This review article discusses the limitations of current pediatric cardiac assist treatment options and the work to date by our consortium toward the development of a pediatric VAD.
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Affiliation(s)
- Harvey S Borovetz
- Department of Bioengineering & McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA 15261, USA.
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26
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Abstract
"Nonpulsatile" or "continuous flow" blood pumps are a relatively new application of the rotary dynamic blood pumping principle. They fall outside the normal envelop of pumps, considering their small size, viscosity of the fluid pumped, need for particularly good internal flow patterns, and desire for high efficiency. This article establishes the state of the art in the field of blood pump performance. Trends in efficiency, shut off pressure coefficient, and nondimensional power behavior as a function of nondimensional flow are identified. Blood pumps show agreement with the published effects of low Reynolds numbers in conventional pumps.
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Affiliation(s)
- W A Smith
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
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27
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Chen C, Paden B, Antaki J, Ludlow J, Paden D, Crowson R, Bearnson G. A magnetic suspension theory and its application to the HeartQuest ventricular assist device. Artif Organs 2002; 26:947-51. [PMID: 12406149 DOI: 10.1046/j.1525-1594.2002.07125.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Motivated by the design of the HeartQuest magnetically levitated left ventricular assist device, closed form expressions have been developed to compute forces and stiffnesses of magnetic suspensions. The theory applies to any combination of concentric permanent magnet rings, and its accuracy and versatility were verified by experiments. The equations adapt to spreadsheet implementation and numerical optimization, providing a powerful tool of optimal design of magnetically levitated ventricular assist devices (VADs). The method was applied to the development of the HeartQuest VAD which achieved remarkable compactness and stable operation.
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Affiliation(s)
- Chen Chen
- Magnetic Moments, LLC, Goleta, California 93117, USA.
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28
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Butler K, Thomas D, Antaki J, Borovetz H, Griffith B, Kameneva M, Kormos R, Litwak P. Development of the Nimbus/Pittsburgh axial flow left ventricular assist system. Artif Organs 1997; 21:602-10. [PMID: 9212925 DOI: 10.1111/j.1525-1594.1997.tb03708.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Nimbus, Inc. and the University of Pittsburgh's School of Medicine have been collaborators developing rotary blood pump technology since 1992. Currently, a major focus is on an implantable left ventricular assist system (LVAS) that utilizes an electric powered axial flow blood pump. In addition to the blood pump, a major development item is the electronic controller and the control algorithm for modulating the pump speed in response to varying physiologic demands. Methods being used in developing the axial flow LVAS include the use of computational fluid dynamic modeling of the interior flow field of the pump, flow visualization of the flow field using laser based imaging, and computer simulation of blood pump-physiological interactions as well as an extensive in vivo test program. Results to date include successful in vivo tests of blood pumps with nonlubricated bearings and demonstrations of auto speed control using electrical current as the observable parameter.
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Affiliation(s)
- K Butler
- Nimbus, Inc., Rancho Cordova, California 95670, USA
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29
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Antaki J. Biotransport phenomena. Ann Biomed Eng 1997. [DOI: 10.1007/bf02647343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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30
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Borovetz H, Antaki J, Litwak P, Kameneva M, Burgreen G, Kerrigan J, Pristas J, Winowich S, Mandarino W, Kormos R, Griffith B. The Pittsburgh experience: Biomechanics and testing of total artificial hearts and ventricular assist devices. Cardiovasc Pathol 1996. [DOI: 10.1016/1054-8807(96)80361-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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31
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Yamazaki K, Kormos R, Mori T, Umezu M, Kameneva M, Antaki J, Outa E, Litwak P, Kerrigan J, Tomczak J. An intraventricular axial flow blood pump integrated with a bearing purge system. ASAIO J 1995; 41:M327-32. [PMID: 8573818 DOI: 10.1097/00002480-199507000-00024] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
The future development of implantable axial flow blood pumps must address two major issues: mechanically induced hemolysis and shaft seal reliability. The recent revisions to our miniature intraventricular axial flow left ventricular assist device (LVAD) were aimed particularly at addressing these concerns. To improve hemocompatibility, a new impeller has been designed according to the following criteria: 1) gradual pressure rise along the blade chord; 2) minimized local fluid acceleration to prevent cavitation; 3) minimum surface roughness; and 4) radius edges. Subsequent in vitro hemolysis tests conducted with bovine and ovine blood have demonstrated very low hemolysis (normalized index of hemolysis = 0.0051 +/- 0.0047 g/100 L) with this new impeller design. To address the need for a reliable seal, we have developed a purged seal system consisting of a miniature lip seal and ceramic pressure groove journal bearing that also acts as a purge pump. Several spiral grooves formed on the bearing surface provide viscous pumping of the purge fluid, generating more than 3,000 mmHg at 10,000 rpm. This purge flow flushes the lip seal and prevents blood backflow into the bearing. We have found this purge pump to offer several advantages because it is simple, compact, durable, does not require separate actuation, and offers a wide range of flow, depending upon the groove design. In vivo animal tests demonstrated the potential of the purged seal system.
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Affiliation(s)
- K Yamazaki
- University of Pittsburgh, Department of Surgery, Pennsylvania 15219, USA
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32
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Kormos RL, Gasior T, Antaki J, Armitage JM, Miyamoto Y, Borovetz HS, Hardesty RL, Griffith BP. Evaluation of right ventricular function during clinical left ventricular assistance. ASAIO Trans 1989; 35:547-50. [PMID: 2597530 DOI: 10.1097/00002480-198907000-00121] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Hemodynamic and mechanical parameters of right ventricular (RV) performance were measured in eight patients undergoing left ventricular (LV) assistance as a bridge to cardiac transplantation. All patients, even those with impaired RV performance, survived support and transplantation. The reduction of LV afterload produced by the left ventricular assist system (LVAS) results in RV afterload reduction, which permits even the marginal RV to function adequately during LVAS support.
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Affiliation(s)
- R L Kormos
- Department of Surgery, University of Pittsburgh School of Medicine, PA 15261
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