Prognostic implications of cardiac damage classification based on computed tomography in severe aortic stenosis.

AIMS: An echocardiographic staging system of severe aortic stenosis (AS) based on additional extra-valvular cardiac damage has been associated with prognosis after transcatheter aortic valve implantation (TAVI). Multidetector row computed tomography (MDCT) is key in the evaluation of AS patients undergoing TAVI and can potentially detect extra-valvular cardiac damage. This study aimed at evaluating the prognostic implications of an MDCT staging system of severe AS in patients undergoing TAVI. METHODS AND RESULTS: A total of 405 patients (80 ± 7 years, 52% men) who underwent full-beat MDCT prior to TAVI were included. The extent of cardiac damage was assessed by MDCT and classified in five categories; Stage 0 (no cardiac damage), Stage 1 (left ventricular damage), Stage 2 (left atrium and mitral valve damage), Stage 3 (right atrial damage), and Stage 4 (right ventricular damage). Twenty-seven (7%) patients were stratified as Stage 0, 96 (24%) as Stage 1, 152 (38%) as Stage 2, 78 (19%) as Stage 3, and 52 (13%) as Stage 4. During a median follow-up of 3.7 (IQR 1.7-5.5) years, 150 (37%) died. On multivariable Cox regression analysis, cardiac damage Stage 3 (HR vs. Stage 0: 4.496, P = 0.039) and Stage 4 (HR vs. Stage 0: 5.565, P = 0.020) were independently associated with all-cause mortality. CONCLUSION: The MDCT-based staging system of cardiac damage in severe AS effectively identifies the patients who are at higher risk of death after TAVI.

Bilateral multiple renal arteries with an extra-aortic origin and quadruple testicular veins.

Although variations in the urogenital vessels are relatively common, a rare case of asymmetric bilateral multiple renal arteries originating not only from the aorta but also from the testicular artery was found in a 75-year-old Korean male cadaver. Three renal arteries arose from the lateral aspect of the abdominal aorta on the right side and four from the left side. Two additional renal parenchymal branches originated from the left testicular artery, accompanied by a pair of veins out of the four testicular veins on the left side. Embryological development of the urogenital vessels is of particular importance for anatomists and clinicians.

Bilateral multiple renal arteries with an extra-aortic origin and quadruple testicular veins / 대한해부학회지

A Novel Idea to Improve Cardiac Output of Mechanical Circulatory Support Devices by Optimizing Kinetic Energy Transfer Available in Forward Moving Aortic Blood Flow.

Mechanical circulatory support devices (MCSDs) have gained widespread clinical acceptance as an effective heart failure (HF) therapy. The concept of harnessing the kinetic energy (KE) available in the forward aortic flow (AOF) is proposed as a novel control strategy to further increase the cardiac output (CO) provided by MCSDs. A complete mathematical development of the proposed theory and its application to an example MCSDs (two-segment extra-aortic cuff) are presented. To achieve improved device performance and physiologic benefit, the example MCSD timing is regulated to maximize the forward AOF KE and minimize retrograde flow. The proof-of-concept was tested to provide support with and without KE control in a computational HF model over a wide range of HF test conditions. The simulation predicted increased stroke volume (SV) by 20% (9 mL), CO by 23% (0.50 L/min), left ventricle ejection fraction (LVEF) by 23%, and diastolic coronary artery flow (CAF) by 55% (3 mL) in severe HF at a heart rate (HR) of 60 beats per minute (BPM) during counterpulsation (CP) support with KE control. The proposed KE control concept may improve performance of other MCSDs to further enhance their potential clinical benefits, which warrants further investigation. The next step is to investigate various assist technologies and determine where this concept is best applied. Then bench-test the combination of kinetic energy optimization and its associated technology choice and finally test the combination in animals.

Sunshine Heart C-Pulse: device for NYHA Class III and ambulatory Class IV heart failure.

Advanced heart failure (HF) patients not meeting criteria for ventricular assist device or heart transplant with life-limiting symptoms are limited to medical and resynchronization therapy. The Sunshine Heart C-Pulse, based on intra-aortic balloon pump physiology, provides implantable, on-demand, extra-aortic counterpulsation, which reduces afterload and improves cardiac perfusion in New York Heart Association Class III and ambulatory Class IV HF. The C-Pulse reduces New York Heart Association Class, improves 6-min walk distances, inotrope requirements and HF symptom questionnaires. Advantages include shorter operative times without cardiopulmonary bypass, no reported strokes or thrombosis and no need for anticoagulation. Driveline exit site infections, inability to provide full circulatory support and poor function with intractable arrhythmias remain concerns. Current randomized controlled studies will evaluate long-term efficacy and safety compared with medical and resynchronization therapy.

Ambulatory extra-aortic counterpulsation in patients with moderate to severe chronic heart failure.

OBJECTIVES: The study sought to assess feasibility, safety, and potential efficacy of a novel implantable extra-aortic counterpulsation system (C-Pulse) in functional class III and ambulatory functional class IV heart failure (HF) patients. BACKGROUND: 30% to 40% of HF patients suffer from poor functional status and quality of life (QoL) but are not in need of end-stage treatments. We undertook a multicenter single-arm study to assess the C-Pulse System in such patients. METHODS: New York Heart Association (NYHA) functional class III or ambulatory functional class IV HF patients were eligible. Safety was assessed continuously through 12 months. Efficacy measurements included changes from baseline to 6 and 12 months in NYHA functional class, Minnesota Living with Heart Failure (MLWHF) and Kansas City Cardiomyopathy Questionnaire (KCCQ) scores, 6-min walk distance (6MWD), and exercise peak oxygen consumption (pVO2; 6 months only). RESULTS: Twelve men and 8 women (56.7 ± 7 years, 34 to 71 years of age) with ischemic (n = 7) or nonischemic (n = 13) cardiomyopathy were implanted. There was no 30-day mortality and no neurological events or myocardial infarctions through 12 months. At 6 months, there were 3 deaths (1 device-related). One-year survival was 85%. At 6 months, C-Pulse produced improvements in NYHA functional class (3.1 ± 0.3 to 1.9 ± 0.7, p = 0.0005), MLWHF (63.6 ± 19.9 to 40.2 ± 23.2, p = 0.0005), and KCCQ scores (43.6 ± 21.1 to 65.6 ± 21.5, p = 0.0002), but not 6MWD (275.5 ± 64.0 to 296.4 ± 104.9, p = NS) or pVO2 (14.5 ± 3.6 to 13.1 ± 4.4, p = NS). Improvements continued at 12 months, with 6MWD change becoming statistically significant (336.5 ± 91.8, p = 0.0425). CONCLUSIONS: Use of C-Pulse in this population is feasible, appears safe, and improves functional status and QoL. A prospective, multicenter, randomized controlled trial is underway. (C-Pulse IDE Feasability Study-A Heart Assist System; NCT00815880).

Concept and first experimental results of a new ferromagnetic assist device for extra-aortic counterpulsation.

OBJECTIVES: Based on a ferromagnetic silicone cuff for extra-aortic counterpulsation, a new assist device concept was developed. The driving force is generated by an external magnetic field, which leads to contraction of a soft magnetic cuff. The force generation capacity of the device was tested in a silicone aorta model. METHODS: Magnetic elastomers can be constructed through dispersion of micro- or nanoparticles in polymer matrices and were designed to act as soft actuators. Two magnetically active silicone cuffs were produced with a nanomagnet loading of 250 wt% (Cuff 1) and a micromagnet loading of 67 wt% (Cuff 2). The magnetic cuffs were applied on a silicone aorta model and contracted against hydrostatic pressure. RESULTS: A full contraction of Cuff 1 was possible against a maximal hydrostatic pressure of 30 cmH2O (22 mmHg) at a magnetic flux density of 0.4 T (Tesla) and 65 cmH2O (48 mmHg) at a magnetic flux density of 1.2 T. A 50% contraction of Cuff 2 was possible against a maximal hydrostatic pressure of 80 cmH2O (59 mmHg) at a magnet-cuff-distance (MCD) of 0 cm. At MCDs of 1 and 2 cm a 50% contraction was possible against 33 cmH2O (24 mmHg) and 10 cmH2O (7 mmHg), respectively. CONCLUSIONS: Combining the advantages of magnetic elastomers with the principle of extra-aortic counterpulsation in a new assist device concept avoids the need for anticoagulation (no contact with bloodstream). With regard to the magnetic principle of action, no intra- to extracorporeal connection is needed. More experimental work is needed to further increase the force generated by the silicone cuff and to transfer the device concept into an in vivo setting.

The cardiac assistant effect of extra-aortic balloon pump on animals / 中华胸心血管外科杂志

Objective The aim of this study was to determine the effect of a new method of cardiac assistant therapy with an extra-aortic balloon pump on the experimental dogs in which myocardial ischemia or infarction were induced, and to ob serve its effectiveness and feasibility. Methods Twelve animal models of myocardia 1 infarction were established with the method of left anterior descending coronary artery ligation. They were divided randomly into two groups, six in the experimental group and six in the untreated group. The end points observed were the differences between the two groups in the blood pressure, cardiac function, myocardial enzymes, infarction size and routine blood variables before procedure, 1,2, 3, 4, 5 and 6 hours after myocardial infarction. Results All six dogs in the experimental group were survived, with a mortality rate of 0.The number of death in the control group was three, with a mortality rate of 50%. Measurements such as mean blood pressure,cardiac output, cardiac index in the experimental group were better than those in the control group ( P ＜ 0.05 ). Mean heart rate before myocardial infarction in the experimental group was 156 beats per minute, as compared with 148 beats per minute in the control group, and was 128 vs. 67 beats per minute respectively six hours after myocardial infarction. The cardiac output was 3.48 vs. 4.98 liters per minute before myocardial infarction and was 6.10 vs. 0.85 liters per minute six hours after myocardial infarction. The average pressure was 94 mm Hg vs. 99 mm Hg before myocardial infarction and was 70 mm Hg vs. 33 mm Hg six hours after myocardial infarction. Conclusion The extra-aortic balloon pump significantly improved the hemodynamic variables of the experimental animals after myocardial infarction and reduced mortality. Injury to the blood cells may be the potential disadvantage.