Heart rate effect on hemodynamics during mechanical assistance by the intra-aortic balloon pump

Heart rate (HR) has been characterized as an important cardiovascular parameter that affects acute hemodynamic performance of intra-aortic balloon counterpulsation (IABC). However, the effect of HR on hemodynamics during mechanical assistance by the IABC has neither been clarified nor quantified. We sought to evaluate the relationship between IABC and HR and also to examine whether there is a range of HR with optimum hemodynamic response to IABC. METHODS: 20 patients (14 males--6 females, mean age 64.4 +/- 11.4 years) with post-infarction cardiogenic shock undergoing IABC treatment were evaluated. Hemodynamics were recorded for each patient once per day during the assistance period; 131 measurements were taken and thus a wide range of heart rates was obtained (64-141 bpm). The following changes in aortic pressures were used to evaluate acute IABC performance on: a) the maximal increase of diastolic aortic pressure induced by IABC and b) the reduction in systolic and end-diastolic aortic pressure. RESULTS: Non-linear regression analysis and analysis of variance revealed that a significant correlation exists between IABC performance indices and heart rate. At HR<80 bpm, IABC performance tended to be reduced, whereas the increase in HR above 110 bpm resulted in a significant reduction of all IABC performance indices. In contrast, IABC operating at 80-110 bpm resulted in optimum hemodynamic performance. In conclusion, the effect of heart rate on IABC performance is non-linear indicating that IABC may be more effective when operating within 80-110 bpm.     

Hemodynamic properties of the hemopump HP14.

BACKGROUND: The Hemopump HP14 is a catheter-mounted, transvalvular, left ventricular assist device intended for femoral percutaneous insertion. The pump was developed for patients with postoperative or postinterventional low cardiac output and for CABG surgery on the beating heart. Little is known about the effect of afterload and hematocrit on the pump performance. METHODS: The influence of hematocrit and afterload on the pump flow was tested using an in vitro model filled with heparinized bovine blood. Regression analysis of the pump flow with respect to three hematocrit values (20%, 30%, 40%) and ten afterload levels (30 mmHg-120 mmHg in 10 mmHg increments) was performed for all pump speed levels (n = 7). RESULTS: At all pump speed levels reduction of afterload and hematocrit were significant predictors for increasing pump flow (p<0.001). For hematocrit values between 40% and 20% and highest pump speed, mean pump flow at lowest afterload ranged between 2.34 and 2.53 L/min; and at highest afterload between 1.31 and 1.53 L/min. For speed level 1, afterload of 120 mmHg and hematocrit of 40% there was a maximal retrograde flow of 230+/-35 ml/min. CONCLUSIONS: Pump performance is significantly improved by both afterload and hematocrit reduction. In the weaning phase and during the removal of the device, the pump should run at a speed level of at least three to prevent retrograde flow in the pump. Estimates for pump flow in vivo can be extrapolated from our diagrams. Our results show that the Hemopump HP14 is a valuable alternative to intra-aortic balloon counterpulsation.     

Myocardial mechanics, energetics, and hemodynamics during intraaortic balloon and transvalvular axial flow hemopump support with a bovine model of ischemic cardiac dysfunction

Unlike the mechanisms of intraaortic balloon pump (IABP) support, the mechanisms by which transvalvular axial flow Hemopump (HP) support benefit dysfunctional myocardium are less clearly understood. To help elucidate these mechanisms, hemodynamic, metabolic, and mechanical indexes of left ventricular function were measured during conditions of control, ischemic dysfunction, IABP support, and HP support. A large animal (calf) model of left ventricular dysfunction was created with multiple coronary ligations. Peak intraventricular pressure increased with HP support and decreased with IABP support. Intramyocardial pressure (an indicator of intramyocardial stress), time rate of pressure change (an indicator of contractility), and left ventricular myocardial oxygen consumption decreased with IABP and HP support. Left ventricular work decreased with HP support and increased with IABP support. During HP support, indexes of wall stress, work, and contractility, all primary determinants of oxygen consumption, were reduced. During IABP support, indexes of wall stress and contractility were reduced and external work increased. These changes were attributed primarily to changes in ventricular preload, and geometry for HP support, and to a reduction in afterload for IABP support. These findings support the hypothesis that both HP and IABP support reduce intramyocardial stress development and the corresponding oxygen consumption, although via different mechanisms.     

IABP assistance: a test bench for the analysis of its effects on ventricular energetics and hemodynamics.

IABP assistance is frequently used to support heart recovery, improving coronary circulation and re-establishing the balance between oxygen availability and consumption. Hemodynamic and energetic parameters (endocardial viability ratio, ventricular energetics) are used to evaluate its effectiveness which depends on internal (timing, balloon volume and position) and external factors (circulatory conditions). Considering short, medium and long-term effects of IABP, the first depends on its mechanical action, the latter on the changes induced in circulatory parameters. The analysis of the first is important because conditions for the onset of a virtuous cycle able to support ventricular recovery are created. Simulation systems could be helpful in this analysis for the implicit reliability and reproducibility of the experiments, provided that they are able to reproduce both hemodynamic phenomena and energetic relationships. The aim of this paper is to present a system originally developed to test mechanical heart assist devices and modified for IABP testing. Data reported here are obtained from in vitro experiments. A partial verification, obtained from the literature is presented.     

Coronary hemodynamics and atherosclerotic wall stiffness: a vicious cycle

Local hemodynamic environment, including low shear stress and increased tensile stress, determines the localization, growth and progression of coronary atherosclerosis. As atherosclerotic lesions evolve, the diseased coronary arteries undergo local quantitative and qualitative changes in their wall, and progressively become stiff. Arterial stiffening amplifies the atherogenic local hemodynamic environment, initiating a self-perpetuating vicious cycle, which drives the progression of atherosclerosis and the formation of atherosclerotic plaque. In vivo evidence indicates that endothelial dysfunction is associated with arterial stiffness, an association that creates a challenging perspective of utilizing stiffness as an early marker of endothelial dysfunction and future atherosclerosis. Coronary stiffening is also associated with vascular remodeling, which is a major determinant of the natural history of atherosclerotic plaques. Thus, arterial stiffness may constitute a useful marker for the identification of the remodeling pattern, in particular expansive remodeling, which is closely associated with high-risk plaques. The early identification of endothelial dysfunction, or a high-risk plaque may enable the early adoption of preventive measures to improve endothelial function, or justify pre-emptive local interventions in high-risk regions to prevent future acute coronary syndromes. Further experimental and perspective clinical studies are needed for the investigation of these perspectives, whereas the development of new modalities for non-invasive and reliable assessment of coronary stiffness is anticipated to serve these studies.     

Sequential changes in intrarenal hemodynamics during saline infusion in the dog.

Intrarenal blood flow and volume (indicator-dilution technique), kidney volume (mercury-in-rubber resistance gage), intr-renal venous pressure, filtration fraction, and sodium excretion were determined dequentially before and during a l-h infusion of isotonicsaline 80 ml/kg in anesthetized dogs. The cortical fraction of renal blood flow roseduring the first 20 min of infusion from an average of 70 to 77%, butreturned nearly to control levels during the last 20 min of infusion because ofa low rise in noncortical flow. During the first 20 min a 23% increase in cortical blood volume accounted for one-third of the 8.5% increase in kidney volume, whereasin the last 20 min cortical blood volume had fallen nearly to control values and kidneyvolume was increased by 17.2%. Intrarenal resistances calculated from intrarenalpressure and flow indicated persistent cortical prevenous dilatation, progressive cortical venous constriction, and only a slight late reduction in noncortical resistance.These data indicate that hemodynamics are shanging continuously during saline infusion and the natriuresis probably is multifactorial.     

Cardiopulmonary dynamics during pumpless arteriovenous bypass for respiratory assistance

The effect of a pumpless arteriovenous bypass with a microporous membrane oxygenator (MO) on the cardiopulmonary dynamics of dogs revealed an increase in cardiac output and cardiac work proportional to the increase in extracorporeal blood flow. Several current MOs offer so little resistance to blood flow that shunt flows exceeding a third of the normal cardiac output can easily be obtained. This should be enough for CO2 extraction covering metabolic production, and would add a non negligible amount of O2 to the blood.     

Coronary artery thrombosis developing during angiography. A case report

A case of coronary thrombosis developing during coronary arteriography is described. In spite of obstruction of a main coronary artery, only a small myocardial infarction developed. Increased coagulability probably contributed to the thrombus formation.     

Changes in renal hemodynamics and sodium excretion during saline infusion in lambs.

The renal response to a progressive isotonic extracellular volume (ECV) expansion was studied in 13 lambs of two age groups (5-28 days and 48-57 days). Changes in renal hemodynamics induced by the ECV expansion were followed. Intrarenal blood flow was determined by the microsphere method. For determination of the glomerular filtration rate (GFR) standard clearance techniques were used. Recordings were made during control conditions and when normal saline had been infused in amounts up to 4.5% of the body weight. During the infusion there was an increase in sodium excretion both in absolute values and in relationship to GFR. The increase was, however, much less pronounced in the younger lambs. The GFR did not change significantly during saline infusion. The cortical blood flow increased only in the older lambs. As a consequence the quotient between GFR and cortical blood flow decreased in the older lambs. The possibility of a causal relationship between the fall in filtration fraction so obtained and the more pronounced natriuretic response in the older lambs is discussed. The inner to outer cortical blood flow ratio increased more in the younger lambs during saline infusion. The functional significance of an age related blood flow redistribution is, however, not clear.     

Physiopathology and management of coagulation during long-term extracorporeal respiratory assistance

Thrombohemorrhagic risk is one of the main limiting factors in extracorporeal circulation. We describe here our experience in managing some life-threatening hematological complications in 58 patients with acute respiratory failure treated with long-term extracorporeal assistance. These patients were studied by clinical and laboratory means to assess questions related to heparin monitoring, coagulation complications and bleeding incidence. We found that two clotting tests, activated partial thromboplastin time (APTT) and activated clotting time (ACT) can be easily used to assess the safety of anticoagulant treatment (therapeutic ranges: APTT from 55 to 95 sec and ACT from 170 to 220 sec). A certain degree of coagulation activation, despite heparin, was indicated by the constant finding of thrombin-antithrombin complexes, while fibrinolytic activation, measured as plasminogen activator activity, was confined to the time of bypass connection and was of no clinical consequence. Platelet function was always impaired without relation to the platelet loss. Disseminated intravascular coagulation (DIC) (13 episodes) and severe bleeding (11 episodes) were major complications. DIC was corrected with a good outcome for 8 of 13 patients, while severe bleeding was correlated with a poor outcome in 8 of the 11 patients, probably because of the severity of the underlying disease.     

Central and peripheral hemodynamics during maximal leg extension exercise

Summary The purpose of this study was to examine the central and peripheral hemodynamic adaptations to maximal leg extension exercise. Seventeen men (¯X=25 years, 84 kg) performed leg extension exercise (Universal equipment) for 12 repetitions (90s) to fatigue. Each repetition consisted of a 3s lifting motion, 1s pause, and 3s lowering motion. Impedance cardiography was used to measure stroke volume (SV), cardiac output ( ), systolic time intervals, and impedance contractility indices on a beat-by-beat basis. There were significant increases in systolic, diastolic, mean arterial pressure, total peripheral resistance, and HR during exercise. The mean remained similar throughout the protocol. SV decreased even though indices of myocardial performance indicated an enhancement of contractility. The magnitude of and SV were dependent upon the phase of leg extension. SV and during the lifting portions of the exercise were smaller than the lowering portions. The differences in SV and during the concentric and eccentric phases of the exercise most likely reflect the large static forces in exercising muscle which impeded venous return and increased afterload.     

Rheoencephalographic study of the cerebral hemodynamics during mental work

Rheoencephalographic investigation of healthy persons engaged in mental work revealed an increase in the volume blood flow through the left hemisphere on account of an increase in the period of filling of the vessels; the incoming blood volume was increased in the temporal region. By the end of the working day these changes were replaced by a disturbance of regulation of the volume blood flow in the temporal regions.Presented by Academician V. V. Parin.Translated from Byulleten' Éksperimental'noi Biologii i Meditsiny, Vol. 70, No. 12, pp. 9–11, December, 1970.     

Short- and long-term mechanical cardiac assistance.

With the increase in high risk patients undergoing cardiac surgery and the substantial mortality among patients waiting for cardiac transplantation, the need for mechanical circulatory support is growing. Several devices are currently available, ranging from the intra-aortic balloon pump to fully implantable ventricular assist devices. Each system has its own features, and proper patient selection as well as the timing of implantation is sometimes difficult. Algorithms for stepwise management in subgroups of patients remain controversial and the concepts of weaning patients after myocardial recovery during mechanical circulatory support need further evaluation for their long-term effects. Future identification of valuable prognostic and risk factors may help in decision-making and allow for improved survival of these often very ill patients. In this report we review the concepts of mechanical circulatory support at our institution with emphasis on a detailed overview of technical features of extracorporeal life support.