Effects of hydroxycinnamic acids on blue color expression of cyanidin derivatives and their metal chelates.

Mechanisms to recreate many anthocyanin blue hues in nature are not fully understood, but interactions with metal ions and phenolic compounds are thought to play important roles. Bluing effects of hydroxycinnamic acids on cyanidin and chelates were investigated by addition of the acids to triglycosylated cyanidin (0-50×[anthocyanin]) and by comparison to hydroxycinnamic acid monoacylated and diacylated Cy fractions by spectrophotometry (380-700nm) and colorimetry in pH 5-8. With no metal ions, λmax and absorbance was greatest for cyanidin with diacylation>monoacylation>increasing [acids]. Hydroxycinnamic acids added to cyanidin solutions weakly impacted color characteristics (ΔE<5); while acylation (covalent acid attachment) resulted in ΔE 5-15. Triglycosylated cyanidin expressed blue color (pH 7-8), suggesting glycosylation pattern also plays a role. Al3+ chelation increased absorbance 2-42× and λmax≳40nm (pH 5-6) compared to added hydroxycinnamic acids. Metal chelation and aromatic diacylation resulted in the most blue hues.

Spectral and colorimetric characteristics of metal chelates of acylated cyanidin derivatives.

Colorants derived from nature are increasingly popular due to consumer demand. Anthocyanins are a class of naturally occurring pigments that produce red-purple-blue hues in nature, especially when interacting with metal ions and co-pigments. The role of various acylations of cyanidin (Cy) derivatives on color expression and stability of Al3+ and Fe3+ chelates in pH 6-7 were evaluated by spectrophotometry (380-700nm) and colorimetry (CIE-L∗a∗b∗) during dark, ambient storage (48h). Increased substitution generally increased λmax of Cy chelates: malonic acid monoacylationferulic-sinapic>sinapic-sinapic)>monoacylated (malonic≈sinapic>ferulic>p-coumaric).

Evaluating the role of metal ions in the bathochromic and hyperchromic responses of cyanidin derivatives in acidic and alkaline pH.

In many food products, colorants derived from natural sources are increasingly popular due to consumer demand. Anthocyanins are one class of versatile and abundant naturally occurring chromophores that produce different hues in nature, especially with metal ions and other copigments assisting. The effects of chelation of metal ions (Mg(2+), Al(3+), Cr(3+), Fe(3+), and Ga(3+)) in factorial excesses to anthocyanin concentration (0-500×) on the spectral characteristics (380-700nm) of cyanidin and acylated cyanidin derivatives were evaluated to better understand the color evolution of anthocyanin-metal chelates in pH 3-8. In all pH, anthocyanins exhibited bathochromic and hyperchromic shifts. Largest bathochromic shifts most often occurred in pH 6; while largest hyperchromic shifts occurred in pH 5. Divalent Mg(2+) showed no observable effect on anthocyanin color while trivalent metal ions caused bathochromic shifts and hue changes. Generally, bathochromic shifts on anthocyanins were greatest with more electron rich metal ions (Fe(3+)≈Ga(3+)>Al(3+)>Cr(3+)).

A consensus report of the role of serum thyroglobulin as a monitoring method for low-risk patients with papillary thyroid carcinoma.

Recent studies have provided new information regarding the optimal surveillance protocols for low-risk patients with differentiated thyroid cancer (DTC). This article summarizes the main issues brought out in a consensus conference of thyroid cancer specialists who analyzed and discussed this new data. There is growing recognition of the value of serum thyroglobulin (Tg) as part of routine surveillance. An undetectable serum Tg measured during thyroid hormone suppression of TSH (THST) is often misleading. Eight studies show that 21% of 784 patients who had no clinical evidence of tumor with baseline serum Tg levels usually below 1 micro g/liter during THST had, in response to recombinant human TSH (rhTSH), a rise in serum Tg to more than 2 micro g/liter. When this happened, 36% of the patients were found to have metastases (36% at distant sites) that were identified in 91% by an rhTSH-stimulated Tg above 2 micro g/liter. Diagnostic whole body scanning, after either rhTSH or thyroid hormone withdrawal, identified only 19% of the cases of metastases. Ten studies comprising 1599 patients demonstrate that a TSH-stimulated Tg test using a Tg cutoff of 2 micro g/liter (either after thyroid hormone withdrawal or 72 h after rhTSH) is sufficiently sensitive to be used as the principal test in the follow-up management of low-risk patients with DTC and that the routine use of diagnostic whole body scanning in follow-up should be discouraged. On the basis of the foregoing, we propose a surveillance guideline using TSH-stimulated Tg levels for patients who have undergone total or near-total thyroidectomy and (131)I ablation for DTC and have no clinical evidence of residual tumor with a serum Tg below 1 micro g/liter during THST.

Serum vascular endothelial growth factor levels are elevated in metastatic differentiated thyroid cancer but not increased by short-term TSH stimulation.

Solid tumor formation requires the development of a blood supply adequate to meet the metabolic demands of the enlarging tumor mass that cannot be sustained by simple diffusion. One principal stimulant to endothelial cell growth and migration, vascular endothelial growth factor (VEGF), is synthesized and secreted by thyroid cancer cells. Furthermore, VEGF overexpression is associated with an aggressive thyroid cancer phenotype in both animal models and clinical-pathological studies. In other malignancies, elevated serum levels of VEGF often correlate with stage of disease and other poor prognostic clinical features. Therefore, we hypothesized that serum VEGF levels would be significantly higher in patients with persistent or recurrent thyroid cancer than in those cured of the disease. Because TSH stimulates both normal and neoplastic thyroid cells, we also proposed that serum VEGF would be further increased by TSH stimulation. Sixty-nine patients with either papillary or follicular thyroid cancer, status post total thyroidectomy, and prior radioactive iodine ablation, who had undergone routine recombinant human TSH (rhTSH, Thyrogen, Genzyme Transgenics Corp., Cambridge, MA) assisted whole-body radioactive iodine scanning, were included in this study. This cohort (mean age 53 +/- 16 yr, 51% female) included 21 patients with no evidence of disease and 48 patients with local or distant metastases. Stored serum samples obtained for standard Tg determinations before and 72 h following standard rhTSH stimulation were identified and assayed for VEGF 165 (R \[amp ]\ D Systems, Minneapolis, MN). Baseline serum VEGF levels obtained at a time of TSH suppression were significantly higher in patients with known metastatic disease than in those with no evidence of disease (416 +/- 62 pg/ml vs. 185 +/- 25 pg/ml, P = 0.001). Patients with distant metastases had baseline serum VEGF levels that did not differ significantly from patients with only cervical recurrences (455 +/- 90 pg/ml in distant metastases vs. 330 +/- 44 pg/ml for local cervical recurrences). Short-term TSH stimulation, although causing a significant rise in serum Tg, resulted in no significant increase in serum VEGF measured 72 h after rhTSH injection in either the patients with known metastatic disease (416 +/- 62 pg/ml baseline vs. 419 +/- 71 pg/ml after TSH stimulation) or in cured patients (185 +/- 25 pg/ml baseline vs. 191 +/- 33 pg/ml after TSH stimulation). Subgroup analysis revealed that patients with metastatic disease arising from well differentiated primary thyroid cancers had significantly higher serum VEGF levels than patients with metastatic disease arising from poorly differentiated thyroid cancer primaries (485 +/- 74 pg/ml vs. 167 +/- 32 pg/ml, P = 0.003 by ANOVA). Poorly differentiated metastatic thyroid cancers had serum VEGF levels indistinguishable from patients cured of disease (167 +/- 32 pg/ml vs. 186 +/- 25 pg/ml). In summary, serum VEGF is significantly elevated in patients with metastatic differentiated thyroid cancer but not in those with poorly differentiated thyroid cancer metastases. No measurable increase in serum VEGF levels can be detected 72 h after short-term TSH stimulation with rhTSH. We conclude that serum VEGF may serve as a clinical useful marker of residual differentiated thyroid cancer.

Radioiodine ablation of thyroid remnants after preparation with recombinant human thyrotropin.

Radioiodine ablation (RA) of normal thyroid remnants after thyroidectomy for differentiated thyroid carcinoma improves the sensitivity of subsequent radioiodine scans and serum thyroglobulin measurements for detection of residual thyroid carcinoma. Local cancer recurrences are also lower after RA. One standard preparation for RA involves rendering the patient hypothyroid in order to stimulate endogenous thyrotropin (TSH) secretion and sodium iodide symporter (NIS) activity. An alternative approach is to prescribe thyroxine after thyroidectomy and to stimulate NIS with exogenous recombinant human thyrotropin (rhTSH). This latter approach was used in 10 patients at our medical center. Complete resolution of all visible 131I thyroid bed uptake was achieved in all when follow-up scans were performed 5 to 13 months later. This approach has the potential to successfully ablate thyroid remnants without the need to induce hypothyroidism.

Preparation by recombinant human thyrotropin or thyroid hormone withdrawal are comparable for the detection of residual differentiated thyroid carcinoma.

Clinical recurrences of differentiated thyroid carcinoma occur in 20% of patients after thyroid surgery. We performed a retrospective analysis of a cohort of patients undergoing routine follow-up testing to detect recurrent thyroid carcinoma over a 2-yr period. One group was prepared for testing by thyroid hormone withdrawal (THW), and the other group remained on thyroid hormone and received injections of recombinant human TSH (rhTSH) before diagnostic whole-body radioiodine scanning (DxWBS). We hypothesized that no differences in the ability to detect residual disease would exist between these 2 groups. Two hundred and eighty-nine patients were examined by both DxWBS and by measurement of the serum thyroglobulin (Tg) response to elevated TSH levels. THW was used for 161 patients, and rhTSH preparation was used for 128 patients. Based on all available testing results, we categorized patients as having metastatic disease, thyroid bed uptake only, or no evidence of disease. We examined the sensitivity, specificity, positive and negative predictive values of the DxWBS, and the stimulated Tg after preparation by THW or rhTSH. Patients with thyroid bed were not considered in accuracy testing. The sensitivity and specificity of the 2 tests were comparable between groups. No significant differences were present in the positive or negative predictive values between groups. The highest negative predictive value (97%) was in patients who had both a negative DxWBS and low stimulated Tg levels after rhTSH. In summary, we were unable to demonstrate a difference in the diagnostic accuracy of DxWBS and/or Tg between patients prepared by either THW or rhTSH. We conclude that preparing patients by rhTSH is diagnostically equivalent to preparing them by THW.

Resistance of [18f]-fluorodeoxyglucose-avid metastatic thyroid cancer lesions to treatment with high-dose radioactive iodine.

Radioactive iodine (131I) is an important therapeutic option for the treatment of metastatic thyroid carcinoma. Survival in patients with metastases that concentrate radioiodine is better than those whose metastatic lesions do not take up radioiodine. Survival is markedly reduced in patients who have metastatic lesions that concentrate 18F-fluorodeoxyglucose (FDG) on positron emission tomography (PET). In this retrospective study, we evaluated the ability of 131I to destroy FDG-avid metastatic lesions in thyroid cancer patients. Twenty-five patients with positive FDG-PET scans received at least one dose of 131I treatment before a second FDG-PET was performed. The average interval between the two PET scans was 12.9 months. The average interval between the 131I treatment and the follow-up FDG-PET was 10.1 months. We measured posttherapy changes in lesional volume, in standard uptake values (SUV) of FDG, and in serum thyroglobulin (Tg) levels. The total volume of FDG-avid metastases rose significantly (p = 0.036) from a mean of 159 mL to 235 mL after 131I therapy, the maximum SUV rose from 9.3 to 11.9, the median Tg at the time of the second PET scan was 132% of that at baseline. Statistical analyses demonstrated no significant changes in maximum SUV, or serum Tg levels after 131I in the FDG-PET-positive group. In a control group of FDG-PET-negative patients, the serum Tg decreased to 38% of baseline after 131I therapy (p < 0.001). We conclude that high-dose 131I therapy appears to have little or no effect on the viability of metastatic FDG-avid thyroid cancer lesions.

Bone metastases from thyroid carcinoma: a histopathologic study with clinical correlates.

CONTEXT: Only limited information exists on the pathologic aspects of thyroid carcinomas with bone metastases, most large studies having concentrated mainly on their clinical features. OBJECTIVE: To study in detail the morphologic features of thyroid carcinomas with skeletal metastases. DESIGN: Seventy-nine cases of thyroid carcinoma with bone metastases treated at Memorial Sloan-Kettering Cancer Center, New York, NY, between 1964 and 1998 were investigated, with emphasis on the pathology of the primary and/or metastatic tumors and comparison of the morphologic features of the tumors at both the sites, wherever possible. The tumors were also compared for various clinical parameters. RESULTS: The cohort consisted of 22 papillary, 17 follicular, 16 insular, 10 anaplastic, 9 Hürthle cell, and 5 medullary carcinomas. Of these cases, 68% had poorly differentiated or undifferentiated features in the primary and/or metastatic tumors. The metastatic tumors were better differentiated than the primary in one third of the cases (6 of 18). Only one case showed a less differentiated metastasis. The overall 5- and 10-year survival probabilities after the bone metastases were 29% and 13%, respectively (Kaplan-Meier method). Although both the tumor type and differentiation seemed to affect survivals after bone metastasis (P =.007 and.012, respectively) (log-rank test), this was primarily due to the much worse prognosis in the cases of anaplastic and medullary carcinoma. Cases of Hürthle cell carcinoma showed the longest median survival. There was no significant difference in survival among patients up to or older than 45 years at the time of metastases (P =.31). CONCLUSIONS: Most thyroid carcinomas with bone metastases are of papillary type, and most have poorly differentiated or undifferentiated features. The influence of the microscopic tumor type and tumor differentiation on survival after bone metastasis primarily appears to be due to the much worse prognosis among anaplastic and medullary carcinomas. Age at diagnosis of bone metastases does not influence survivals.

Bone metastases from thyroid carcinoma: clinical characteristics and prognostic variables in one hundred forty-six patients.

To describe the clinical characteristics and define the indicators that best predict survival in patients with bone metastases from thyroid carcinomas. We collected data from medical records of 146 patients with documented bone metastases from thyroid carcinoma seen at our medical center over a 38-year period. Univariate and multivariate analyses of prognostic indicators for survival were performed. Bone metastases were present at the initial diagnosis in 47% of patients. Vertebrae (29%), pelvis (22%), ribs (17%), and femur (11%) were the most common sites of metastases. Multiple lesions were present in 53% of the cases. The overall 10-year survival rate from the time of diagnosis of thyroid cancer was 35%, and from diagnosis of initial bone metastasis was 13%. By univariate analysis from the time of the initial bone metastasis, radioiodine uptake by skeletal metastases, the absence of nonosseous metastases and treatment with radioiodine were significant prognostic factors. By multivariate analysis, radioiodine uptake by skeletal metastases and the absence of nonosseous metastases were independent favorable prognostic variables for survival. In a subgroup of patients in which histologic specimens were available and were reviewed, Hurthle cell carcinoma was the most favorable histologic subtype for survival with the undifferentiated subtype being the worst. The spread of thyroid carcinoma to bone is more common in patients over 45 years of age, is usually symptomatic, and is often multicentric. Overall survival is best in those whose lesions concentrate radioactive iodine and those who have no nonosseous metastases.

Inhibition of metabolic activity in papillary thyroid carcinoma by a somatostatin analogue.

Two patients with widely metastatic papillary thyroid cancer demonstrated progressive growth of diffuse pulmonary lesions. One patient had no apparent response to high doses of 131I and the other hand no 131I uptake. 111In-pentetreotide scans revealed that many of the metastatic lesions expressed somatostatin receptors. The baseline metabolic activity and three-dimensional volume of the lesions were determined by 18F-fluoro-de-oxyglucose positron emission tomography (FDG-PET). After 3 or 4 months of octreotide (Sandostatin LAR Depot; Novartis Pharmaceutical, East Hanover, NJ) therapy, repeat FDG-PET scans revealed reductions in tumor volume and decreases in the standard uptake values of FDG. We conclude that octreotide therapy can change the biological activity of metastatic thyroid cancer lesions that exhibit somatostatin receptors.

Prognostic value of [18F]fluorodeoxyglucose positron emission tomographic scanning in patients with thyroid cancer.

Poorly differentiated thyroid cancer lesions often lose the ability to concentrate radioactive [131I]iodine (RAI) and exhibit increased metabolic activity, as evidenced by enhanced glucose uptake. We incorporated [18F]fluorodeoxyglucose (FDG) positron emission tomography (PET) scanning into the routine follow-up of a cohort of thyroid cancer patients undergoing annual evaluations. One hundred and twenty-five patients who had previous thyroidectomies were included. They had diagnostic RAI whole body scans, serum thyroglobulin measurements, and additional imaging studies as clinically indicated. During 41 months of follow-up, 14 patients died. Univariate analysis demonstrated that survival was reduced in those with age over 45 yr, distant metastases, PET positivity, high rates of FDG uptake, and high volume of the FDG-avid disease (>125 mL). Survival did not correlate with gender, RAI uptake, initial histology, or grade. Multivariate analysis demonstrated that the single strongest predictor of survival was the volume of FDG-avid disease. The 3-yr survival probability of patients with FDG volumes of 125 mL or less was 0.96 (95% confidence interval, 0.91, 1.0) compared with 0.18 (95% confidence interval, 0.04, 0.85) in patients with FDG volume greater than 125 mL. Only 1 death (of leukemia) occurred in the PET-negative group (n = 66). Of the 10 patients with distant metastases and negative PET scans, all were alive and well. Patients over 45 yr with distant metastases that concentrate FDG are at the highest risk. Once distant metastases are discovered in patients with differentiated thyroid carcinoma, FDG-PET can identify high and low risk subsets. Subjects with a FDG volume greater than 125 mL have significantly reduced short term survival.

Compassionate use of recombinant human thyrotropin to facilitate radioiodine therapy: case report and review of literature.

OBJECTIVE: To describe the use of recombinant human thyrotropin (thyroid-stimulating hormone) (rhTSH) to assist in radioiodine therapy in a patient with thyroid carcinoma who was unable to produce sufficient endogenous thyrotropin when hypothyroid and to review the related literature. METHODS: The study patient underwent formal dosimetric analysis and received radioiodine in conjunction with rhTSH. Follow-up scanning studies were performed. RESULTS: We found good localization of radioiodine on the posttherapy scans after administration of (131)I while the patient continued to receive thyroxine replacement after two intramuscularly administered injections of rhTSH. Some of his metastatic lesions disappeared and his serum thyroglobulin level decreased after the first rhTSH-assisted dose of (131)I was administered. His blood radioiodine clearance rate was unexpectedly more rapid in the hypothyroid state than when he was euthyroid (taking thyroxine) after administration of rhTSH. His whole-body clearance rate was more delayed when he was hypothyroid. Swelling of some of the metastatic thyroid cancer lesions developed when the patient was hypothyroid and after rhTSH was administered, the latter being much more rapid in onset. CONCLUSION: Therapeutic doses of radioiodine can be delivered with the assistance of rhTSH administration while patients continue to take suppressive doses of thyroxine. Metastatic thyroid carcinoma lesions can swell rapidly after administration of rhTSH. The commercially available form of rhTSH is approved only for diagnostic use. Its safety and efficacy in assisting radioiodine therapy have not been fully determined.

[18F]-2-fluoro-2-deoxy-D-glucose positron emission tomography localizes residual thyroid cancer in patients with negative diagnostic (131)I whole body scans and elevated serum thyroglobulin levels.

Progressive dedifferentiation of thyroid cancer cells leads to a loss of iodine-concentrating ability, with resultant false negative, whole body radioactive iodine scans in approximately 20% of all differentiated metastatic thyroid cancer lesions. We tested the hypothesis that all metastatic thyroid cancer lesions that did not concentrate iodine, but did produce thyroglobulin (Tg), could be localized by [18F]2-fluoro-2-deoxy-D-glucose (FDG)-positron emission tomography (PET). We performed FDG-PET on 37 patients with differentiated thyroid cancer after surgery and radioiodine ablation who had negative diagnostic 131I whole body scans during routine follow-up. Serum Tg, Tg autoantibodies, neck ultrasounds, and other clinically indicated imaging procedures were performed to detect residual disease. In those with elevated Tg levels, FDG-PET localized occult disease in 71%, was false positive in one, and was false negative in five patients. The majority of false negative FDG-PET occurred in patients with minimal cervical adenopathy. Surgical resections, biopsies, 131 therapy, and differentiation therapy were performed based on the PET results. The FDG-PET result changed the clinical management in 19 of the 37 patients. In patients with elevated Tg levels, FDG-PET had a positive predictive value of 92%. In patients with low Tg levels, FDG-PET had a negative predictive value of 93%. No FDG-PET scans were positive in stage I patients; however, they were always positive in stage IV patients with elevated Tg levels. An elevated TSH level (i.e. hypothyroidism) did not increase the ability to detect lesions. FDG-PET is able to localize residual thyroid cancer lesions in patients who have negative diagnostic 131I whole body scans and elevated Tg levels, although it was not sensitive enough to detect minimal residual disease in cervical nodes.

Thoracoscopic surgery.

Video-assisted thorascopic surgery has evolved rapidly and has demonstrated utility in the diagnosis and management of a variety of chest disorders. An historical perspective, considerations on patient selection, anesthetic and operative management, and a summary of the Ochsner Clinic institutional experience with this procedure are presented. Special emphasis is given to the treatment of disorders of the autonomic nervous system, esophageal achalasia, and a rare symptomatic congenital pericardial defect. Video-assisted thorascopy provides a promising alternative to many of the more invasive open thoracic surgical procedures.

Recent advances in the management of adrenal incidentalomas.

Modern imaging techniques have made adrenal incidentaloma a relatively common diagnostic problem. When an incidental adrenal mass is found, the clinician must try to determine its etiology and functionality, and the likelihood of malignancy. This task is complicated further in patients with a history of extra-adrenal malignancy. In this article, we present a review of the literature and propose a diagnostic algorithm for management of adrenal incidentalomas.

Radioiodine treatment of thyroid cancer with the aid of recombinant human thyrotropin.

OBJECTIVE: To update endocrinologists on the use of recombinant human thyrotropin (thyroid-stimulating hormone or TSH) (rhTSH) in thyroid diseases, with an emphasis on thyroid cancer. METHODS: We reviewed the available literature on potential uses of rhTSH, including published studies and case reports. RESULTS: Clinical trials have shown that rhTSH injections stimulate radioiodine uptake into normal and malignant thyroid tissue almost as well as that found in the hypothyroid state. The benefit to the athyreotic patient is the avoidance of the disability of hypothyroidism. When rhTSH is used in the doses currently recommended for scanning, few negative side effects occur. The more rapid clearance of iodine in the euthyroid state, however, may necessitate the use of more radioiodine to achieve the same amount of irradiation to metastatic lesions. We have used rhTSH for both dosimetric studies and therapy. This approach is essential in patients who cannot make sufficient endogenous TSH (because of hypothalamic-pituitary disease or medications that suppress TSH). Other patients with widespread metastatic lesions who have serious complications when allowed to become hypothyroid also benefit from rhTSH. Finally, we have found that rhTSH may provide new insights into the biologic features of thyroid cancer when used in combination with positron emission tomographic scanning. Use in the treatment of nonmalignant thyroid conditions such as toxic multinodular goiter is also feasible. CONCLUSION: Overall, rhTSH provides a new and clinically important advance for patients with thyroid disease, especially thyroid cancer.

Giant-cell granulomatous hypophysitis.

OBJECTIVE: To describe the clinical features of giant-cell granulomatous hypophysitis and to report on the results of corticosteroid treatment. METHODS: A case of giant-cell granulomatous hypophysitis is presented, and the pertinent literature is reviewed. RESULTS: A 41-year-old woman with anterior pituitary dysfunction had a pituitary mass that was 18 by 16 by 13 mm by magnetic resonance imaging. The pituitary stalk was thickened and enhanced after intravenous administration of gadolinium. A biopsy specimen that was obtained at transsphenoidal pituitary exploration revealed that the patient had giant-cell granulomatous hypophysitis, a rare inflammatory pituitary disorder. High-dose corticosteroid therapy failed to reverse her anterior pituitary dysfunction. CONCLUSION: The coincidence of a contrast-enhancing pituitary mass with a thickened pituitary stalk and the awareness of the rare occurrence of endocrine inactive tumors in women of childbearing age should suggest an inflammatory pituitary condition. Such lesions should also be suspected in otherwise healthy young women with hypopituitarism and no evidence of hormone hypersecretion. On the basis of the literature and our experience, corticosteroid treatment does not seem to improve anterior pituitary function.

Technique of right heart protection and deairing during heartmate vented electric LVAD implantation.

Continued experience with the TCI Heartmate Ventricular Assist System has led to improvements in our ability to avoid and manage right heart dysfunction during weaning from cardiopulmonary bypass. The advent of the electric device has intensified the need for these techniques because of its elevated minimal heart rate (50 beats/min) at start-up and the demands this places on the native right heart. We have developed and here describe a technique we have used successfully in our last 8 patients to assist in deairing and filling of the ventricular assist device, to partially support the right heart during the initial wean from cardiopulmonary bypass, and to avoid occasional overdistention of the right heart during early high left ventricular assist device flow.