The Clinical Importance of Pulsatile Flow in Extracorporeal Life Support: The Penn State Health Approach

Ündar, Akif; Wang, Shigang; Izer, Jenelle; Clark, Joseph B.; Kunselman, Allen R.; Patel, Sunil; Shank, Kaitlyn; Profeta, Elizabeth; Wilson, Ronald P.; Ošťádal, Petr

doi:10.1111/aor.12875

Cited by 14 publications

(17 citation statements)

References 16 publications

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“…Our results once again showed that the i‐cor diagonal pump can generate non‐pulsatile and ECG‐synchronized pulsatile flow in our simulated pediatric and adult ECLS circuits . The i‐cor diagonal pump can generate pulsatile flow by changing the rotational speed.…”

Section: Discussionsupporting

confidence: 64%

Evaluation of Two Femoral Arterial Cannulae With Conventional Non‐Pulsatile and Alternative Pulsatile Flow in a Simulated Adult ECLS Circuit

et al. 2018

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The objective of this study is to evaluate the hemodynamic characteristics of two femoral arterial cannulae in terms of circuit pressure, pressure drop, and hemodynamic energy transmission under non-pulsatile and pulsatile modes in a simulated adult extracorporeal life support (ECLS) system. The ECLS circuit consisted of i-cor diagonal pump and console (Xenios AG, Heilbronn, Germany), an iLA membrane ventilator (Xenios AG), an 18 Fr or 16 Fr femoral arterial cannula (Xenios AG), and a 23/25 Fr Estech remote access perfusion (RAP) femoral venous cannula (San Ramon, CA, USA). The circuit was primed with lactated Ringer's solution and packed red blood cells to achieve a hematocrit of 35%. All trials were conducted at room temperature with flow rates of 1-4 L/min (1 L/min increments). The pulsatile flow settings were set at pulsatile frequency of 75 bpm and pulsatile amplitudes of 1000-4000 rpm (1000 rpm increments). Flow and pressure data were collected using a custom data acquisition system. Total hemodynamic energy (THE) is calculated by multiplying the ratio between the area under the hemodynamic power curve (∫flow × pressure dt) and the area under the pump flow curve (∫flow dt) by 1332. The pressure drop across the arterial cannula increased with increasing flow rate and decreasing cannula size. The pressure drops of 18 Fr and 16 Fr cannulae were 19.4-24.5 and 38.4-45.3 mm Hg at 1 L/min, 55.2-56.8 and 110.9-118.3 mm Hg at 2 L/min, 94.1-105.1 and 209.7-215.1 mm Hg at 3 L/min, and 169.2-172.6 and 376.4 mm Hg at 4 L/min, respectively. Pulsatile flow created more hemodynamic energy than non-pulsatile flow, especially at lower flow rates. The percentages of THE loss across 18 Fr and 16 Fr cannula were 16.0-18.7 and 27.5-30.8% at 1 L/min, 35.1-35.7 and 52.3-53.8% at 2 L/min, 48.3-50.3 and 67.3-68.4% at 3 L/min and 62.9-63.1 and 79.0% at 4 L/min. The hemodynamic performance of the arterial cannula should be evaluated before use in clinical practice. The pressure drops and percentages of THE loss across two cannulae tested using human blood were higher compared to the manufacturer's data tested using water. The cannula size should be chosen to match the expected flow rate. In addition, this novel i-cor ECLS system can provide non-pulsatile and ECG-synchronized pulsatile flow without significantly increasing the cannula pressure drop and hemodynamic energy loss.

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Section: Discussionsupporting

confidence: 64%

Evaluation of Two Femoral Arterial Cannulae With Conventional Non‐Pulsatile and Alternative Pulsatile Flow in a Simulated Adult ECLS Circuit

et al. 2018

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“…It can also be used as a bridge to a ventricular assist device (VAD) or cardiac transplantation, and it may be conveniently placed at the catheterization laboratory, the intensive care unit, the emergency department, or the operating room. Recently, significant technological advances have led to improved VA‐ECMO survival and reduced complications . However, according to the July 2017 Extracorporeal Life Support Organization (ELSO) Registry Report, the survival‐to‐hospital discharge rate in adult patients with cardiogenic shock on ECMO is only 42% .…”

mentioning

confidence: 99%

“…The combination therapy using nonpulsatile centrifugal pump with a pulsatile IABP has conflicting reports regarding the patients' outcomes despite an additional cost of usage of IABP . The ideal ECLS system should provide synchronized pulsatile blood flow to mimic the physiological pulsatile flow patterns and match with patient's pulse .…”

mentioning

confidence: 99%

Evaluation and Comparison of Hemodynamic Performance of Three ECLS Systems in a Simulated Adult Cardiogenic Shock Model

et al. 2018

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The objective of this study was to evaluate three commercially available ECLS systems with rotary pumps in terms of circuit pressure, pressure drop, perfusion modes, and hemodynamic energy transmission in a simulated adult cardiogenic shock model. One circuit consisted of a Cardiohelp system, which included a Cardiohelp console and HLS Module Advanced 7.0 tubing set with integrated centrifugal pump and oxygenator. The alternative circuit was composed of a Quadrox-D Adult oxygenator connected in series with either an i-cor diagonal pump and console or a Rotaflow centrifugal pump and console. The circuit was primed with lactated Ringer's solution and packed red blood cells (hematocrit 40%). The trials were conducted at flow rates of 1-5 L/min with pseudo patient pressures of 60 mm Hg and 80 mm Hg. Pulsatile flow was tested when using the i-cor system. Mean pre-oxygenator pressure and pressure drop across ECLS circuit (including oxygenator and arterial tubing) were lower when using the Cardiohelp system as compared to the Rotaflow and i-cor systems (P < 0.01). The i-cor system was able to deliver more hemodynamic energy to the pseudo patient because of its ability to produce pulsatile flow (P < 0.01). The Cardiohelp HLS Module Advanced 7.0 integrated oxygenator had a lower resistance than the Quadrox-D oxygenator. Although the compact Cardiohelp system had a better hemodynamic performance when compared to Rotaflow and i-cor systems, the pulsatile flow of the i-cor system delivered more hemodynamic energy to the pseudo patient. This may render more physiological benefits in high-risk patients on ECLS.

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“…The use of pulsatile flow during acute or chronic mechanical circulatory support for pediatric or adult patients is one of the major research areas at the Penn State Hershey Pediatric Cardiovascular Research Center. [16][17][18][19] The predecessor of the PediMag centrifugal pump was the Levitronix PediVAS system, which is capable of generating pulsatile flow and has been tested in an experimental setting at our research center. This pulsatile module was intended for experimental use only and has not been approved by the Food and Drug Administration (FDA) for use in clinical practice.…”

Section: Discussionmentioning

confidence: 99%

Evaluation of centrifugal blood pumps in term of hemodynamic performance using simulated neonatal and pediatric ECMO circuits

et al. 2019

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The objective of this translational study was to evaluate the FDA‐approved PediMag, CentriMag, and RotaFlow centrifugal blood pumps in terms of hemodynamic performance using simulated neonatal and pediatric extracorporeal membrane oxygenation (ECMO) circuits with different sizes of arterial and venous cannulae. Cost of disposable pump heads was another important variable for this particular study. The experimental circuit was composed of one of the centrifugal pump heads, a polymethylpentene membrane oxygenator, neonatal and pediatric arterial/venous cannulae, and 1/4‐inch ID tubing. Circuits were primed with lactated Ringer’s solution and packed human red blood cells (hematocrit 35%). Trials were conducted at 36°C using the three pump heads and different cannulae (arterial/venous cannulae: 8 Fr/18 Fr, 10 Fr/20 Fr, and 12 Fr/22 Fr) at various flow rates (200–2400 mL/min, 200 mL/min increments) and rotational speeds. Pseudo patient pressure was 60 mm Hg. Real‐time pressure and flow data were recorded for analysis. The RotaFlow pump had a higher pressure head and flow range compared with the PediMag and CentriMag pumps at the same rotational speed and identical experimental settings (P < 0.001). The PediMag pump had lower flow output than others (P < 0.001). Small‐caliber arterial cannulae and higher flow rates predictably created higher circuit pressures and pressure drops. There was no significant difference in hemodynamic energy delivered to the pseudo patient with each of the three pumps. The arterial cannula had the highest pressure drop and hemodynamic energy loss in the circuit when compared to the oxygenator and arterial tubing. The RotaFlow centrifugal pump had a significantly better hemodynamic performance when compared to the PediMag and CentriMag blood pumps at identical experimental conditions in simulated neonatal and pediatric ECMO settings. In addition, the cost of the RotaFlow pump head ($400) is 20 to 30‐fold less than the other centrifugal pumps [CentriMag ($12 000) or PediMag ($8000)] that were evaluated in this translational study.

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The Clinical Importance of Pulsatile Flow in Extracorporeal Life Support: The Penn State Health Approach

Cited by 14 publications

References 16 publications

Evaluation of Two Femoral Arterial Cannulae With Conventional Non‐Pulsatile and Alternative Pulsatile Flow in a Simulated Adult ECLS Circuit

Evaluation of Two Femoral Arterial Cannulae With Conventional Non‐Pulsatile and Alternative Pulsatile Flow in a Simulated Adult ECLS Circuit

Evaluation and Comparison of Hemodynamic Performance of Three ECLS Systems in a Simulated Adult Cardiogenic Shock Model

Evaluation of centrifugal blood pumps in term of hemodynamic performance using simulated neonatal and pediatric ECMO circuits

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