Hydrodynamic gene delivery is an attractive option for non-viral liver gene therapy, but requires evaluation of efficacy, safety and clinically applicable techniques in large animal models. We have evaluated retrograde delivery of DNA to the whole liver via the isolated segment of inferior vena cava (IVC) draining the hepatic veins. Pigs (18-20 kg weight) were given the pGL3 plasmid via two programmable syringe pumps in parallel. Volumes corresponding to 2% of body weight (360-400 ml) were delivered at 100 ml s À1 via a Y connector. The IVC segment pressure, portal venous pressure, arterial pressure, electrocardiogram (ECG) and pulse were monitored. Concurrent studies were performed in rats for interspecies comparisons. The hydrodynamic procedure generated intrahepatic vascular pressures of 101-126 mm Hg, which is B4 times higher than in rodents, but levels of gene delivery were B200-fold lower. Suprahepatic IVC clamping caused a fall in arterial pressure, with the development of ECG signs of myocardial ischaemia, but these abnormalities resolved rapidly. The IVC segment approach is a clinically acceptable approach to liver gene therapy. However, it is less effective in pigs than in rodents, possibly because of larger liver size or a less compliant connective tissue framework.

Hydrodynamic gene delivery to the liver has potential as a safe and effective approach for clinical liver gene therapy. However, the simplicity of the technique in rodents - an intravenous injection - belies the theoretical and practical complexity for clinical application. A key issue is that outflow obstruction of the DNA solution from the liver is a critical factor for raising intrahepatic vascular pressure, which in turn provides the force to swell the liver and effect gene delivery. For conventional hydrodynamic gene delivery via tail vein injection, this outflow obstruction is provided naturally by the vascular resistance of the gut, spleen and pancreas. For regional hydrodynamic gene delivery to the liver, outflow obstruction to create a closed system requires surgical intervention, making it unlikely that minimally invasive techniques will be possible in the clinic. Intrinsic factors, in particular compliance (elasticity) of the liver are likely to be crucial in determining the degree of swelling for a given level of intrahepatic vascular pressure. Liver compliance is likely to be the major reason for the low level of hydrodynamic gene delivery in the pig model, and will influence the effectiveness of the approach in man, both in general and in different disease states.

Hydrodynamic gene delivery to the liver is a valuable experimental tool and an attractive option for nonviral gene therapy of liver disease. However, little attention has been paid to the major obstacle to clinical application: acute volume overload of the cardiovascular system. We delivered volumes of DNA solution (pGL3 plasmid) corresponding to 1, 2, 4, 6 and 8% of the body weight at 100 ml/min to the inferior vena cava (IVC) of DA strain rats. Central venous pressure (CVP), arterial pressure, pulse and electrocardiogram (ECG) were continuously recorded for subsequent analysis. Each volume produced a characteristic response, but all (including the 1% volume) caused severe falls in blood pressure and pulse within 1-2 s of the infusion, with ectopic beats and widening of the QRS complex in the ECG. The response to volumes of 4% and higher suggested that the liver acted as a volume sink, mitigating the immediate effects of volume overload. The 6 and 8% volumes caused profound and protracted falls in blood pressure and pulse, with a multitude of severe electrical abnormalities in the heart, including electromechanical dissociation. Vagal blockade with atropine, and the use of Ringer's solution to prevent electrolyte disturbances, did not ameliorate this picture.

Hydrodynamic gene delivery to the liver is a promising approach for liver gene therapy in the clinic, but levels of gene expression in larger species have been much less than in rodents. The development of surgical techniques for pressurizing individual liver segments and the establishment of whether hepatic vascular anatomy in fact permits pressurization of individual segments are critical issues that need to be addressed. We have evaluated these issues using hydrodynamic delivery to individual segments of the pig liver, via branches of both portal and hepatic veins. Our objective was to develop surgical techniques that achieve elevated vascular pressures within individual liver segments with small volumes, but without interruption of portal blood flow or reduction in venous return to the heart. We report that, without specific surgical interventions to obstruct outflow of DNA solution from the targeted liver segment, little or no increase in intrahepatic vascular pressure occurs. We demonstrate, for the first time, that selective pressurization of individual liver segments is possible without compromising portal venous flow or venous return to the heart. Thus, hydrodynamic gene delivery to individual liver segments is technically achievable in a clinical setting, but will require open abdominal surgery rather than minimally invasive techniques.

A prospective study was conducted with the aims of 1) determining the normal trans-oxygenator pressure gradient characteristics for a range of oxygenators and 2) determining the characteristics, incidence and outcome of abnormally raised gradients. The trans-oxygenator pressure gradient was monitored in 3684 patients undergoing open-heart surgery in eight different hospitals. When the normal pressure gradient was measured during cardiopulmonary bypass in mmHg/L blood flow, a constant figure was obtained which was specific for each oxygenator. This gradient was abnormally raised in 16 cases (one in every 230 cases) and was raised to such an extent in three of these cases that an emergency oxygenator changeout was required (one in every 1228 cases). Among the 16 reported incidents, three different patterns of gradient changes occurred, suggesting the possibility that there were three different aetiologies. In nine of these incidents, the pressure gradient was normal immediately upon going on bypass, but rose rapidly to a plateau value, which then returned to the normal value within 40 minutes. In three cases, the pressure gradient was raised immediately upon going on bypass and then rapidly returned to the baseline. In one case, the pressure gradient was raised immediately upon going on bypass and stayed raised throughout the operation.

The intra-aortic balloon pump (IABP) is the most widely used cardiac assist device, whose main benefits are augmentation of coronary flow and reduction of left-ventricular afterload. The aim of this study is to investigate the pressure and flow-volume distribution associated with balloon inflation. We hypothesize that in order to displace fluid on both sides of the balloon, a pressure locus must be present along the balloon during inflation. In vitro experiments were performed in two positions, horizontal and angled, using four balloon sizes: 25, 34, 40, and 50 cc. Along and on both sides of each balloon, we measured pressure, flow rate, and calculated flow velocity, volume displacement, wave intensity and energy. A pressure locus was found at the center of each balloon and the average flow volume displaced toward the tip at the horizontal position was about 57% of the balloon volume. In the angled position, the location of the pressure locus was less obvious and average volume displacement toward the top end of the balloon was reduced to 45%. These results confirm the existence of a pressure locus at the center of each of the balloons we tested. Because a clear reduction in flow volume was observed at the angled position, these results may have clinical implications as most patients using IABP in the intensive care units are nursed in semirecumbent position.

This study aims to investigate the mechanics of the intra-aortic balloon (IAB) under different aortic pressure (P(ao)) and inclination (0-75 degrees). Pressure and flow were measured in an artificial aorta during IAB pumping with a frequency of 1:3. Volume displaced toward the "coronary arteries" during inflation (V(prox)) and "intra-aortic" pressure reduction during deflation (P(r)) were derived. IAB duration of inflation and deflation was determined with a high-speed camera visualization. When the aorta was horizontal, P(ao) raised from 45 mm Hg to 115 mm Hg, V(prox) reduced by 18% (25.0 +/- 1.0 mL vs. 30.4 +/- 1.9 mL) and P(r) increased by 117% (106.4 +/- 0.3 mm Hg vs. 48.9 +/- 0.6 mm Hg). When the aorta was inclined, at low P(ao) of 45 mm Hg, V(prox) was reduced by 30% from 0 degrees to 45 degrees (19.8 +/- 2.3 mL vs. 28.3 +/- 1.7 mL) and P(r) was reduced by 66% (16.5 +/- 0.1 mm Hg vs. 48.9 +/- 0.6 mm Hg). However, at high P(ao) of 115 mm Hg, V(prox) remained unchanged with increasing angle (20.0 +/- 1.0 mL) and P(r) was reduced by 24% (80.6 +/- 0.8 mm Hg vs. 106.4 +/- 0.3 mm Hg). Increasing P(ao) increased duration of inflation. At low P(ao), increasing angle resulted in increasing duration of inflation, but at high P(ao), increasing angle had the opposite effect. Duration of deflation generally decreased with P(ao) and increased with increasing angle. The IAB pump is affected by both P(ao) and angle, indicating that non-normotensive patients or patients in the semi-recumbent position might not receive the full benefits of IAB counterpulsation.

The IVC segment approach enables excellent gene delivery to the whole liver with small volumes, but causes severe cardiovascular disturbances in the rat. Portal venous pressures are slightly higher than in the mouse, and suggest functional outflow obstruction by the capillary bed of the intestines.