Ghost Cells for Mechanical Circulatory Support In Vitro Testing: A Novel Large Volume Production

The aim of this work is to establish a large volume batch production system to produce sufficient volumes of ghost cells to facilitate hemolysis testing of mechanical circulatory support devices. A volume of more than 405 mL with a hematocrit of at least 28% is required to perform in vitro hemolysis testing of mechanical circulatory support devices according to international standards. The established ghost cell production method performed at the institute is limited to 3.1 mL of concentrated cells, that is, cells with 100% hematocrit, due to predominantly manual process steps. Through semi‐automation of the existing method by using the large volume batch production system, productivity is increased 60‐fold to 188 mL while almost doubling process efficiency to 23.5%. Time‐consuming manual work such as pipetting is now supported by sensor‐based process engineering. With the help of the large volume batch production system, the objective of producing large quantities of ghost cells is successfully achieved. Thus, this work lays the foundation for spatially resolved hemolysis evaluation of mechanical circulatory support devices in combination with the small‐scale fluorescent hemolysis detection method.     

The mechanical consequences of dynamic frontal plane limb alignment for non-contact ACL injury

This study investigated the mechanical consequences of differences in dynamic frontal plane alignment of the support limb and the influence of anticipatory muscle activation at the hip and ankle on reducing the potential for non-contact ACL injury during single-limb landing. A frontal plane, three-link passive dynamic model was used to estimate an ACL non-contact injury threshold. This threshold was defined as the maximum axial force that the knee could sustain before the joint opened 8 degrees either medially or laterally, which was deemed sufficient to cause injury. The limb alignment and hip and ankle muscle contractions were varied to determine their effects on the ACL injury threshold. Valgus or varus alignment reduced the injury threshold compared to neutral alignment, but increasing the anticipatory contraction of hip abduction and adduction muscle groups increased the injury threshold. Increasing anticipatory ankle inversion/eversion muscle contraction had no effect. This study provides a mechanical rationale for the conclusion that a neutral limb alignment (compared to valgus or varus) during landing and increasing hip muscle contraction (abductors/adductors) prior to landing can reduce the possibility of ACL rupture through a valgus or varus opening mechanism.     

X-ray diffraction studies of the contractile mechanism in single muscle fibres

The molecular mechanism of muscle contraction was investigated in intact muscle fibres by X-ray diffraction. Changes in the intensities of the axial X-ray reflections produced by imposing rapid changes in fibre length establish the average conformation of the myosin heads during active isometric contraction, and show that the heads tilt during the elastic response to a change in fibre length and during the elementary force generating process: the working stroke. X-ray interference between the two arrays of myosin heads in each filament allows the axial motions of the heads following a sudden drop in force from the isometric level to be measured in situ with unprecedented precision. At low load, the average working stroke is 12 nm, which is consistent with crystallographic studies. The working stroke is smaller and slower at a higher load. The compliance of the actin and myosin filaments was also determined from the change in the axial spacings of the X-ray reflections following a force step, and shown to be responsible for most of the sarcomere compliance. The mechanical properties of the sarcomere depend on both the motor actions of the myosin heads and the compliance of the myosin and actin filaments.     

Joint Modeling of Multivariate Longitudinal Data and Competing Risks Using Multiphase Sub-models

In many clinical studies that involve follow-up, it is common to observe one or more sequences of longitudinal measurements, as well as one or more time to event outcomes. A competing risks situation arises when the probability of occurrence of one event is altered/hindered by another time to event. Recently, there has been much attention paid to the joint analysis of a single longitudinal response and a single time to event outcome, when the missing data mechanism in the longitudinal process is non-ignorable. We, in this paper, propose an extension where multiple longitudinal responses are jointly modeled with competing risks (multiple time to events). Our shared parameter joint model consists of a system of multiphase non-linear mixed effects sub-models for the multiple longitudinal responses, and a system of cause-specific non-proportional hazards frailty sub-models for competing risks, with associations among multiple longitudinal responses and competing risks modeled using latent parameters. The joint model is applied to a data set of patients who are on mechanical circulatory support and are awaiting heart transplant, using readily available software. While on the mechanical circulatory support, patient liver and renal functions may worsen and these in turn may influence one of the two possible competing outcomes: (i) death before transplant; (ii) transplant. In one application, we propose a system of multiphase cause-specific non-proportional hazard sub-model where frailty can be time varying. Performance under different scenarios was assessed using simulation studies. By using the proposed joint modeling of the multiphase sub-models, one can identify: (i) non-linear trends in multiple longitudinal outcomes; (ii) time-varying hazards and cumulative incidence functions of the competing risks; (iii) identify risk factors for the both types of outcomes, where the effect may or may not change with time; and (iv) assess the association between multiple longitudinal and competing risks outcomes, where the association may or may not change with time.     

Computational fluid dynamics analysis of surgical adjustment of left ventricular assist device implantation to minimise stroke risk

Background. Currently, mechanical support is the most promising alternative to cardiac transplantation. Ventricular assist devices (VADs) were originally used to provide mechanical circulatory support in patients awaiting planned heart transplantation (‘bridge-to-transplantation’ therapy). The success of short-term bridge devices led to clinical trials evaluating the clinical suitability of long-term support (‘destination’ therapy) with left ventricular assist devices (LVADs). The first larger scale, randomised trial that tested long-term support with an LVAD reported a 44% reduction in the risk of stroke or death in patients with an LVAD. In spite of the success of LVADs as bridge-to-transplantation and long-term support, patients managed by these devices are still at risk of several adverse events. The most devastating complication is caused by embolisation of thrombi formed within the LVAD or inside the heart into the brain. Prevention of thrombi formation is attempted through anticoagulation management and by improving LVADs design; however, there is still significant occurrence of thromboembolic events in patients. Investigators have reported that the incidence of thromboembolic cerebral events ranges from 14% to 47% over a period of 6–12 months.

Methods and approach. An alternative method to reduce the incidence of cerebral embolisation is proposed by the co-authors, and the hypothesis is that it is possible to minimise the number of thrombi flowing into the carotid and vertebral arteries by an optimal placement of the LVAD outflow conduit, with or without the addition of aortic bypass connecting the ascending aorta and the innominate artery (IA), or left carotid artery. This paper presents the computational fluid dynamics (CFD) analysis of the aortic arch haemodynamics using a representative geometry of the human aortic arch with or without an alternative aortic bypass. In order to study the trajectory of the thrombi within the aortic arch bed, the CFD code, Fluent 6.3, is utilised to resolve the flow field and to solve the Lagrangian particle tracking of thrombi released randomly at the inlet of the LVAD cannula.

Results. Results are presented for simulations of thrombi in the range of 2–5 mm. The percentage of individual diameter as well as aggregate diameter thrombi flowing to the carotid and vertebral arteries as a function of LVAD conduit placement and aortic bypass implantation is reported. The influence of the LVAD conduit implantation and bypass reveals a nearly 50% variation in predicted cerebral embolism rates.

Conclusions. The adjustment of the location of the anastomosis of the LVAD outflow cannula as well as its angle of incidence plays a significant role in the level of thromboembolisms. By proper adjustment in this CFD study of a synthetic model of an aortic arch bed, we found that nearly a 50% reduction in cerebral embolism could be achieved for a configuration consisting of a shallow angle of implantation over a baseline normal incidence of the LVAD cannula. Within the limitations of our model, we have established that the LVAD implantation geometry is an important factor and should be taken into consideration when implanting an LVAD. It is possible that other parameters such as distance of the LVAD outflow cannula to the root of the IA could affect the thrombi embolisation probabilities. However, the results of this study suggest that the risk of stroke may be significantly reduced by as much as 50% by tailoring the VAD implantation by a simple surgical manoeuvre. The results of this line of research may ultimately lead to techniques that can be used to estimate the optimal LVAD configuration in a patient-specific manner by pre-operative imaging.     

The role of long-term mechanical circulatory support in patients with advanced heart failure

In patients with end-stage heart failure, advanced therapies such as heart transplantation and long-term mechanical circulatory support (MCS) with a left ventricular assist device (LVAD) have to be considered. LVADs can be implanted as a bridge to transplantation or as an alternative to heart transplantation: destination therapy. In the Netherlands, long-term LVAD therapy is gaining importance as a result of increased prevalence of heart failure together with a low number of heart transplantations due to shortage of donor hearts. As a result, the difference between bridge to transplantation and destination therapy is becoming more artificial since, at present, most patients initially implanted as bridge to transplantation end up receiving extended LVAD therapy. Following LVAD implantation, survival after 1, 2 and 3 years is 83%, 76% and 70%, respectively. Quality of life improves substantially despite important adverse events such as device-related infection, stroke, major bleeding and right heart failure. Early referral of potential candidates for long-term MCS is of utmost importance and positively influences outcome. In this review, an overview of the indications, contraindications, patient selection, clinical outcome and optimal time of referral for long-term MCS is given.

     

Haemodynamic efficacy of microaxial left ventricular assist device in cardiogenic shock: a systematic review and meta-analysis

Netherlands Heart Journal - The Impella percutaneous mechanical circulatory support device is designed to augment cardiac output and reduce left ventricular wall stress and aims to improve survival...     

Correlation between mechanical and enzymatic events in contracting skeletal muscle fiber

The conventional hypothesis of muscle contraction postulates that the interaction between actin and myosin involves tight coupling between the power stroke and hydrolysis of ATP. However, some in vitro experiments suggested that hydrolysis of a single molecule of ATP caused multiple mechanical cycles. To test whether the tight coupling is present in contracting muscle, we simultaneously followed mechanical and enzymatic events in a small population of cross-bridges of glycerinated rabbit psoas fibers. Such small population behaves as a single cross-bridge when muscle contraction is initiated by a sudden release of caged ATP. Mechanical events were measured by changes of orientation of probes bound to the regulatory domain of myosin. Enzymatic events were simultaneously measured from the same cross-bridge population by the release of fluorescent ADP from the active site. If the conventional view were true, ADP desorption would occur simultaneously with dissociation of cross-bridges from thin filaments and would be followed by cross-bridge rebinding to thin filaments. Such sequence of events was indeed observed in contracting muscle fibers, suggesting that mechanical and enzymatic events are tightly coupled in vivo.     

Simulation of Dilated Heart Failure with Continuous Flow Circulatory Support

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.     

Deciphering the metabolic and mechanical contributions to the exercise-induced circulatory response: insights from eccentric cycling

Metabolic demand and muscle mechanical tension are closely coupled during exercise, making their respective drives to the circulatory response difficult to establish. This coupling being altered in eccentric cycling, we implemented an experimental design featuring eccentric vs. concentric constant-load cycling bouts to gain insights into the control of the exercise-induced circulatory response in humans. Heart rate (HR), stroke volume (SV), cardiac output (Q), oxygen uptake (V(.-)(O(2))), and electromyographic (EMG) activity of quadriceps muscles were measured in 11 subjects during heavy concentric (heavy CON: 270 +/- 13 W; V(.-)(O(2)) = 3.59 +/- 0.20 l/min), heavy eccentric (heavy ECC: 270 +/- 13 W, V(.-)(O(2)) = 1.17 +/- 0.15 l/min), and light concentric (light CON: 70 +/- 9 W, V(.-)(O(2)) = 1.14 +/- 0.12 l/min) cycle bouts. Using a reductionist approach, the circulatory responses observed between heavy CON vs. light CON (difference in V(.-)(O(2)) and power output) was ascribed either to metabolic demand, as estimated from heavy CON vs. heavy ECC (similar power output, different V(.-)(O(2))), or to muscle mechanical tension, as estimated from heavy ECC vs. light CON (similar V(.-)(O(2)), different power output). 74% of the Q response was determined by the metabolic demand, also accounting for 65% and 84% of HR and SV responses, respectively. Consequently, muscle mechanical tension determined 26%, 35%, and 16% of the Q, HR, and SV responses, respectively. Q was significantly related to V(.-)(O(2)) (r(2) = 0.83) and EMG activity (r(2) = 0.82; both P < 0.001). These results suggest that the exercise-induced circulatory response is mainly under metabolic control and support the idea that the level of muscle activation plays a role in the cardiovascular regulation during cycle exercise in humans.     

A new method to model change in cutaneous blood flow due to mechanical skin irritation part II: parameter identification procedure

Mechanical skin irritation, for example a light scratch with a needle, induces histamine and neuropeptide release on the line of stroke and in the surrounding tissue. Both histamine and neuropeptides are vasodilators. They cause vasodilation by changing the contraction state of the vascular smooth muscles and hence vessel compliance. Smooth muscle contraction state is very difficult to measure in vivo. For that reason we propose in this article an identification procedure to establish an irritation law. The law gives change in vessel compliance as a function of space, time and the intensity of the stroke. We have showed that vessel compliance increases immediately after the stroke not only on the line of stroke, but also in the surrounding tissue. Then, after a short delay, vessel compliance starts decreasing in the surrounding tissue, whereas vessel compliance on the line of stroke keeps increasing. Hence, blood is transported from the surrounding tissue to the line of stroke. In this way, higher blood volume on the line of stroke can be obtained than by only changing vessel compliance locally.     

Recent X-ray diffraction studies of muscle contraction and their implications

Recent studies on the interference fringes in the myosin meridional reflections provide a new source of structural information on cross-bridge movement during mechanical transients and steady shortening. Many observations can be interpreted satisfactorily by the tilting lever-arm model, with some assumptions, including the presence of fixed repeating structures contributing to the M3 and higher-order meridional reflections. In isometric contraction, the lever arms are oriented near the start of the working stroke, with a dispersion of ca+/-20-25 degrees . Upon a rapid release of 10-12 nm, they move to the end of the stroke, with a well-known T2 delay of 1-2 ms. This delay must represent additional processes, which have to occur even in tension-generating heads, or activation of attached heads, which initially do not develop force. Surprisingly, in muscles shortening at moderate loads (0.5-0.6 P0), the mean position of the heads moves only 2-3 nm closer to the M-line than in the isometric case, reminiscent of the Piazzesi-Lombardi model.     

The Mechanics of Metastasis: Insights from a Computational Model

Although it may seem obvious that mechanical forces are required to drive metastatic cell movements, understanding of the mechanical aspects of metastasis has lagged far behind genetic and biochemical knowledge. The goal of this study is to learn about the mechanics of metastasis using a cell-based finite element model that proved useful for advancing knowledge about the forces that drive embryonic cell and tissue movements. Metastasis, the predominant cause of cancer-related deaths, involves a series of mechanical events in which one or more cells dissociate from a primary tumour, migrate through normal tissue, traverse in and out of a multi-layer circulatory system vessel and resettle. The present work focuses on the dissemination steps, from dissociation to circulation. The model shows that certain surface tension relationships must be satisfied for cancerous cells to dissociate from a primary tumour and that these equations are analogous to those that govern dissociation of embryonic cells. For a dissociated cell to then migrate by invadopodium extension and contraction and exhibit the shapes seen in experiments, the invadopodium must generate a contraction equal to approximately twice that produced by the interfacial tension associated with surrounding cells. Intravasation through the wall of a vessel is governed by relationships akin to those in the previous two steps, while release from the vessel wall is governed by equations that involve surface and interfacial tensions. The model raises a number of potential research questions. It also identifies how specific mechanical properties and the sub-cellular structural components that give rise to them might be changed so as to thwart particular metastatic steps and thereby block the spread of cancer.     

Fast Simulation of Mechanical Heterogeneity in the Electrically Asynchronous Heart Using the MultiPatch Module

Cardiac electrical asynchrony occurs as a result of cardiac pacing or conduction disorders such as left bundle-branch block (LBBB). Electrically asynchronous activation causes myocardial contraction heterogeneity that can be detrimental for cardiac function. Computational models provide a tool for understanding pathological consequences of dyssynchronous contraction. Simulations of mechanical dyssynchrony within the heart are typically performed using the finite element method, whose computational intensity may present an obstacle to clinical deployment of patient-specific models. We present an alternative based on the CircAdapt lumped-parameter model of the heart and circulatory system, called the MultiPatch module. Cardiac walls are subdivided into an arbitrary number of patches of homogeneous tissue. Tissue properties and activation time can differ between patches. All patches within a wall share a common wall tension and curvature. Consequently, spatial location within the wall is not required to calculate deformation in a patch. We test the hypothesis that activation time is more important than tissue location for determining mechanical deformation in asynchronous hearts. We perform simulations representing an experimental study of myocardial deformation induced by ventricular pacing, and a patient with LBBB and heart failure using endocardial recordings of electrical activation, wall volumes, and end-diastolic volumes. Direct comparison between simulated and experimental strain patterns shows both qualitative and quantitative agreement between model fibre strain and experimental circumferential strain in terms of shortening and rebound stretch during ejection. Local myofibre strain in the patient simulation shows qualitative agreement with circumferential strain patterns observed in the patient using tagged MRI. We conclude that the MultiPatch module produces realistic regional deformation patterns in the asynchronous heart and that activation time is more important than tissue location within a wall for determining myocardial deformation. The CircAdapt model is therefore capable of fast and realistic simulations of dyssynchronous myocardial deformation embedded within the closed-loop cardiovascular system.     

An introduction to biofluid mechanics--basic models and applications

Cardiovascular disease is the primary cause of morbidity and mortality in the western world. Complex hemodynamics play a critical role in the development of atherosclerosis and the processes of aging, as well as many other disease processes. Biofluid mechanics play a major role in the cardiovascular system and it is important to understand the forces and movement of blood cells and whole blood as well as the interaction between blood cells and the vessel wall. Fundamental fluid mechanical, which are important for the understanding of the blood flow in the cardiovascular circulatory system of the human body aspects are presented. Measurement techniques for model studies such as LDA, ultrasound, and MRI studies will be discussed. Viscosity and flow behavior changes specifically the creation of vortices and flow disturbances can be used to show how medication can influence flow behavior. Experiments have shown that hemodynamics may have a strong influence on the creation of aneurysms and varicose veins. Other factors such as vessel wall structure are also important. In preliminary studies, it has been demonstrated that geometry and elasticity of vessel walls help determine flow behavior. High velocity fluctuations indicate flow disturbances that should be avoided. Health care practitioners must understand fluid dynamic factors such as flow rate ratio, pressure and velocity gradients, and flow behavior, velocity distribution, shear stress on the wall and on blood cells. These mechanical factors are largely responsible for the deposit of blood cells and lipids, a leading cause of atherosclerosis. The interaction between blood cells and of the cells with the vessel, leads to the formation of plaques and agglomerations. These deposits are found predominantly at arterial bends and bifurcations where blood flow is disturbed, where a secondary flow is created, and where flow separation regions are found. Experiments on hemodynamic effects in elastic silicon rubber models of the cardiovascular system with flow wire, stents, or patches for vessel surgery will be discussed. These studies can be important in improving diagnostics and therapeutic applications.     

Mathematical Model for Skeletal Muscle to Simulate the Concentric and Eccentric Contraction

Skeletal muscles are responsible for the relative motion of the bones at the joints and provide the required strength. They exhibit highly nonlinear mechanical behaviour and are described by nonlinear hyperelastic constitutive relations. It is distinct from other biological soft tissue. Its hyperelastic or viscoelastic behaviour is modelled by using CE, SEE, and PEE. Contractile element simulates the behaviour of skeletal muscle when it is subjected to eccentric and concentric contraction. This research aims to estimate the stress induced in skeletal muscle in eccentric and concentric contraction with respect to the predefined strain. With the use of mathematical model for contraction of skeletal muscle for eccentric and concentric contraction, the stress induced in the skeletal muscle is estimated in this research. Mathematical model is developed for the muscle using EMG signals and Force-velocity relationship calculated. With the use of force-velocity of contraction of muscle, mathematical model is developed. This can be useful to understand the mechanical behaviour of skeletal muscles in eccentric and concentric contraction with clinical relevance. Authors are further working to develop the mathematical model with torsion force with proper activation function of muscle and experimentation for extraction of the anisotropic mechanical properties of skeletal muscle.     

Effect of anoxia on energy supply and isotonic work performance in the myocardium of the frog]

To investigate correlations between energy supply and mechanical work in the frog's myocardium in true anoxia, the stroke volume, systolic and diastolic volumes and the parameters of velocity of contraction and relaxation of frog hearts were compared to the levels of high energy phosphates and the delivery of lactate. During perfusion with N2 saturated Ringer solution, stroke volume, systolic contractility and diastolic relaxation decrease till a contracture. High preload produces a dilatation growing up to the contracture after retarded and weakened relaxation. The ATP-content decreases during the first quarter of the experiment to 60%. CP decreases continuously to 15%, ADP and AMP remain constant. There is a production of lactate increasing considerably with the onset of contracture. The measured glycolysis is not sufficient for production of mechanical work. The effect of anoxia on the action potential and the reduction of the sequestration of Ca++ and of the break of actomyosin bridges following the decrease of ATP are considered as causing the series of the mechanical events.     

BIOCHEMICAL, HEMATOLOGIC AND COAGULATION VALUES IN THE HEREFORD CALF

Biochemical, hematologic and coagulation values have been determined in normal Hereford calves of both sexes, two to six months of age. These data generally agree with those of others and indicate a similarity in calves irrespective of their age, sex or breed. Prothrombin times are markedly longer in the calf than in man. This has resulted in alterations of anticoagulation regimens after implantation of mechanical circulatory support systems.     

Local temperature changes and human skeletal muscle metabolism

The aim of this review is to describe the effects induced by local temperature changes on human skeletal muscle metabolism. More specifically, we will consider the influence of temperature on the mechanical properties of muscle contraction, on aerobic metabolism, anaerobic metabolism and on the Lohmann reaction. The text has been voluntarily organized on the basis of a simple bioenergetic model describing the different energy fluxes appearing in the muscle system. This approach should better highlight some of the points that still need to be investigated. Although it was not always possible to restrict the discussion to human muscle, the references report mainly data obtained directly on humans or on isolated human fibres. A short comment on skeletal muscle temperature measurement techniques, on humans, is also included.