Newly shaped intra-aortic balloons improve the performance of counterpulsation at the semirecumbent position: an In Vitro study

The major hemodynamic benefits of intra‐aortic balloon pump (IABP) counterpulsation are augmentation in diastolic aortic pressure (Paug) during inflation, and decrease in end‐diastolic aortic pressure (ΔedP) during deflation. When the patient is nursed in the semirecumbent position these benefits are diminished. Attempts to change the shape of the IAB in order to limit or prevent this deterioration have been scarce. The aim of the present study was to investigate the hemodynamic performance of six new IAB shapes, and compare it to that of a traditional cylindrical IAB. A mock circulation system, featuring an artificial left ventricle and an aortic model with 11 branches and physiological resistance and compliance, was used to test one cylindrical and six newly shaped IABs at angles 0, 10, 20, 30, and 40°. Pressure was measured continuously at the aortic root during 1:1 and 1:4 IABP support. Shape 2 was found to consistently achieve, in terms of absolute magnitude, larger ΔedP at angles than the cylindrical IAB. Although ΔedP was gradually diminished with angle, it did so to a lesser degree than the cylindrical IAB; this diminishment was only 53% (with frequency 1:1) and 40% (with frequency 1:4) of that of the cylindrical IAB, when angle increased from 0 to 40°. During inflation Shape 1 displayed a more stable behavior with increasing angle compared to the cylindrical IAB; with an increase in angle from 0 to 40°, diastolic aortic pressure augmentation dropped only by 45% (with frequency 1:1) and by 33% (with frequency 1:4) of the drop reached with the cylindrical IAB. After compensating for differences in nominal IAB volume, Shape 1 generally achieved higher Paug over most angles. Newly shaped IABs could allow for IABP therapy to become more efficient for patients nursed at the semirecumbent position. The findings promote the idea of personalized rather than generalized patient therapy for the achievement of higher IABP therapeutic efficiency, with a choice of IAB shape that prioritizes the recovery of those hemodynamic indices that are more in need of support in the unassisted circulation

Does conventional intra-aortic balloon pump trigger timing produce optimal hemodynamic effects in vivo?

Purpose The intra-aortic balloon pump (IABP) provides circulatory support through counterpulsation. The hemodynamic effects of the IABP may vary with assisting frequency and depend on IAB inflation/deflation timing. We aimed to assess in vivo the IABP benefits on coronary, aortic, and left ventricular hemodynamics at different assistance frequencies and trigger timings. Methods Six healthy, anesthetized, open-chest sheep received IABP support at 5 timing modes (EC, LC, CC, CE, CL, corresponding to early/late/conventional/conventional/conventional inflation and conventional/conventional/conventional/early/late deflation, respectively) with frequency 1:3 and 1:1. Aortic (Qao) and coronary (Qcor) flow, and aortic (Pao) and left ventricular (PLV) pressure were recorded simultaneously, with and without IABP support. Integrating systolic Qao yielded stroke volume (SV). Results EC at 1:1 produced the lowest end-diastolic Pao (59.5 ± 7.8 mmHg [EC], 63.4 ± 11.1 mmHg [CC]), CC at 1:1 the lowest systolic PLV (69.1 ± 6.5 mmHg [CC], 76.4 ± 6.5 mmHg [control]), CC at 1:1 the highest SV (88.5 ± 34.4 ml [CC], 76.6 ± 31.9 ml [control]) and CC at 1:3 the highest diastolic Qcor (187.2 ± 25.0 ml/min [CC], 149.9 ± 16.6 ml/min [control]). Diastolic Pao augmentation was enhanced by both assistance frequencies alike, and optimal timings were EC for 1:3 (10.4 ± 2.8 mmHg [EC], 6.7 ± 3.8 mmHg [CC]) and CC for 1:1 (10.8 ± 6.7 mmHg [CC], −3.0 ± 3.8 mmHg [control]). Conclusions In our experiments, neither a single frequency nor a single inflation/deflation timing, including conventional IAB timing, has shown superiority by uniformly benefiting all studied hemodynamic parameters. A choice of optimal frequency and IAB timing might need to be made based on individual patient hemodynamic needs rather than as a generalized protocol

Measurements of intra-aortic balloon wall movement during inflation and deflation: effects of angulation

The intra‐aortic balloon pump (IABP) is a ventricular assist device that is used with a broad range of pre‐, intra‐, and postoperative patients undergoing cardiac surgery. Although the clinical efficacy of the IABP is well documented, the question of reduced efficacy when patients are nursed in the semi‐recumbent position remains outstanding. The aim of the present work is therefore to investigate the underlying mechanics responsible for the loss of IABP performance when operated at an angle to the horizontal. Simultaneous recordings of balloon wall movement, providing an estimate of its diameter (D), and fluid pressure were taken at three sites along the intra‐aortic balloon (IAB) at 0 and 45°. Flow rate, used for the calculation of displaced volume, was also recorded distal to the tip of the balloon. An in vitro experimental setup was used, featuring physiological impedances on either side of the IAB ends. IAB inflation at an angle of 45° showed that D increases at the tip of the IAB first, presenting a resistance to the flow displaced away from the tip of the balloon. The duration of inflation decreased by 15.5%, the inflation pressure pulse decreased by 9.6%, and volume decreased by 2.5%. Similarly, changing the position of the balloon from 0 to 45°, the balloon deflation became slower by 35%, deflation pressure pulse decreased by 14.7%, and volume suctioned was decreased by 15.2%. IAB wall movement showed that operating at 45° results in slower deflation compared with 0°. Slow wall movement, and changes in inflation and deflation onsets, result in a decreased volume displacement and pressure pulse generation. Operating the balloon at an angle to the horizontal, which is the preferred nursing position in intensive care units, results in reduced IAB inflation and deflation performance, possibly compromising its clinical benefits

Changes in non-invasive wave intensity parameters with variations of Savitzky-Golay filter settings

Ultrasound-measured waveforms, such as vessel diameter and blood flow velocity, are used to perform analysis of waves in the cardiovascular system. Wave intensity analysis is one of the tools used for this purpose. The waveforms are commonly filtered to eliminate high-frequency noise, however the filter settings affect the features of these signals and especially of their time derivatives, upon which wave intensity analysis is based. This study aims to investigate the alterations of wave intensity parameters with varying Savitzky-Golay filter settings, one of the most common smoothing algorithms used in this context. A broad spectrum of variations was observed in all the wave intensity variables. It is therefore important to always specify the filter settings applied to the signals in a wave intensity study, so that appropriate comparisons can be mad

Hyperoxia results in increased aerobic metabolism following acute brain injury

Acute brain injury is associated with depressed aerobic metabolism. Below a critical mitochondrial pO2 cytochrome c oxidase, the terminal electron acceptor in the mitochondrial respiratory chain, fails to sustain oxidative phosphorylation. After acute brain injury, this ischaemic threshold might be shifted into apparently normal levels of tissue oxygenation. We investigated the oxygen dependency of aerobic metabolism in 16 acutely brain-injured patients using a 120-min normobaric hyperoxia challenge in the acute phase (24–72 h) post-injury and multimodal neuromonitoring, including transcranial Doppler ultrasound-measured cerebral blood flow velocity, cerebral microdialysis-derived lactate-pyruvate ratio (LPR), brain tissue pO2 (pbrO2), and tissue oxygenation index and cytochrome c oxidase oxidation state (oxCCO) measured using broadband spectroscopy. Increased inspired oxygen resulted in increased pbrO2 [ΔpbrO2 30.9 mmHg p < 0.001], reduced LPR [ΔLPR −3.07 p = 0.015], and increased cytochrome c oxidase (CCO) oxidation (Δ[oxCCO] + 0.32 µM p < 0.001) which persisted on return-to-baseline (Δ[oxCCO] + 0.22 µM, p < 0.01), accompanied by a 7.5% increase in estimated cerebral metabolic rate for oxygen (p = 0.038). Our results are consistent with an improvement in cellular redox state, suggesting oxygen-limited metabolism above recognised ischaemic pbrO2 thresholds. Diffusion limitation or mitochondrial inhibition might explain these findings. Further investigation is warranted to establish optimal oxygenation to sustain aerobic metabolism after acute brain injury

Reduction of cytochrome C oxidase during vasovagal hypoxia-ischemia in human adult brain: a case study

Near-infrared spectroscopy (NIRS)-derived measurement of oxidized cytochrome c oxidase concentration ([oxCCO]) has been used as an assessment of the adequacy of cerebral oxygen delivery. We report a case in which a reduction in conscious level was associated with a reduction in [oxCCO]. Hypoxaemia was induced in a 31-year-old, healthy male subject as part of an ongoing clinical study. Midway through the hypoxaemic challenge, the subject experienced an unexpected vasovagal event with bradycardia, hypotension and reduced cerebral blood flow (middle cerebral artery blood flow velocity decrease from 70 to 30 cm s(-1)) that induced a brief reduction in conscious level. An associated decrease in [oxCCO] was observed at 35 mm (-1.6 μM) but only minimal change (-0.1 μM) at 20-mm source-detector separation. A change in optical scattering was observed, but path length remained unchanged. This unexpected physiological event provides an unusual example of a severe reduction in cerebral oxygen delivery and is the first report correlating change in clinical status with changes in [oxCCO]

Common carotid artery diameter, blood flow velocity and wave intensity responses at rest and during exercise in young healthy humans: a reproducibility study

The aim of this study was to assess the reproducibility of non-invasive, ultrasound-derived wave intensity (WI) in humans at the common carotid artery. Common carotid artery diameter and blood velocity of 12 healthy young participants were recorded at rest and during mild cycling, to assess peak diameter, change in diameter, peak velocity, change in velocity, time derivatives, non-invasive wave speed and WI. Diameter, velocity and WI parameters were fairly reproducible. Diameter variables exhibited higher reproducibility than corresponding velocity variables (intra-class correlation coefficient [ICC] = 0.79 vs. 0.73) and lower dispersion (coefficient of variation [CV] = 5% vs. 9%). Wave speed had fair reproducibility (ICC = 0.6, CV = 16%). WI energy variables exhibited higher reproducibility than corresponding peaks (ICC = 0.78 vs. 0.74) and lower dispersion (CV = 16% vs. 18%). The majority of variables had higher ICCs and lower CVs during exercise. We conclude that non-invasive WI analysis is reliable both at rest and during exercise

Non-invasive assessment of the common carotid artery hemodynamics with Increasing exercise workrate using wave intensity analysis

Non-invasively determined local wave speed (c) and wave intensity (WI) parameters provide insight into arterial stiffness and cardiac-vascular interactions in response to physiological perturbations. However, the effects of incremental exercise and subsequent recovery on c and WI are not fully established. We examined the changes in c and WI parameters in the common carotid artery (CCA) during exercise and recovery in 8 young healthy male athletes. Ultrasound measurements of CCA diameter (D) and blood flow velocity (U) were acquired at rest, during 5 stages of incremental exercise (up to 70% maximum workrate) and throughout 1 h of recovery and non-invasive WI analysis (DU approach) was performed. During exercise, c increased (+136%), showing increased stiffness with workrate. All peak and area of forward compression (FCW), backward compression (BCW) and forward expansion waves (FEW) increased during exercise (+452%, +700%, +900%, respectively). However, WI reflection indices and CCA resistance did not significantly change from rest to exercise. Further, wave speed and magnitude of all waves returned to baseline within 5 min of recovery, suggesting the effects of exercise in the investigated parameters of young healthy individuals were transient. In conclusion, incremental exercise was associated with an increase in local CCA stiffness and increases in all wave parameters, indicative of enhanced ventricular contractility and improved late-systolic blood flow deceleration