A metastatic haemangiopericytoma of the floor of the mouth.

A case of metastatic haemangiopericytoma in the floor of the mouth is described. Haemangiopericytoma is a relatively rare slow-growing vascular tumour with variable malignant potential. This tumour has been identified in almost every region of the body, but its occurrence in the oral cavity has been rarely reported. The rate of regional and distant metastasis of the tumour is low. This case, presented 12 years after initial surgery suggested the need for careful long-term follow-ups of patients with haemangiopericytoma.

Observation and quantification of cavitation on a mechanical heart valve with an electro-hydraulic total artificial heart.

In previous studies, we investigated the cavitation phenomenon in a mechanical heart valve using an electro-hydraulic total artificial heart. With this system, a 50% glycerin solution kept at 37 degrees C was used as the working fluid. We reported that most of the cavitation bubbles were observed near the valve stop and were caused by the squeeze flow. However, in these studies, the effect of the partial pressure of CO(2) on the mechanical heart valve cavitation was neglected. In this study, in order to investigate the effect of the partial pressure of CO(2) on mechanical heart valve cavitation using an electro-hydraulic total artificial heart, we controlled the partial pressure of the CO(2) in vitro. A 25-mm Medtronic Hall valve was installed in the mitral position of an electro-hydraulic total artificial heart. In order to quantify the mechanical heart valve cavitation, we used a high-speed camera. Even though cavitation intensity slightly increased with increases in the PCO(2) at heart rates of 60, 70 and 100 bpm, throughout the experiment, there was no significant difference between the PCO(2) and cavitation intensity.

Comparison of an implanted abdominal aortic counterpulsation device with the intraaortic balloon pump in a heart failure model.

The abdominal aortic counterpulsation device is a round pumping chamber with a valveless opening which is implanted retroperitoneally on the abdominal aorta. The Utah driver is connected to the device through an air conduit and is synchronized on the electrocardiographic signal to provide diastolic aortic augmentation. For comparison an intraaortic balloon was also driven by the Utah driver system. The abdominal aortic counterpulsation device (stroke volume = 30, 40 and 60 ml) and the intraaortic balloon pump (balloon volume = 20 ml) were tested in dogs with acute left ventricular failure. The abdominal aortic counterpulsation device was also tested in normal animals. In acute left ventricular failure the abdominal aortic counterpulsation device at a stroke volume of 30, 40 or 60 ml decreased left ventricular end-diastolic pressure by an average of 28.56 (p less than 0.001), 39.56 (p less than 0.001) and 44.14% (p less than 0.005), respectively; aortic end-diastolic pressure by 24.11 (p less than 0.001), 26.67 (p less than 0.001) and 19.57% (p less than 0.01); and aortic systolic pressure by 18.56 (p less than 0.002), 26.0 (p less than 0.001) and 22.43% (p less than 0.005). It increased cardiac index by 27.58 (p less than 0.02), 35.59 (p less than 0.005) and 43.42% (p less than 0.001) and it provided peak aortic diastolic augmentation of 64.5 (p less than 0.001), 69.78 (p less than 0.001) and 74.43% (p less than 0.001), respectively, above the control aortic end-diastolic pressure.(ABSTRACT TRUNCATED AT 250 WORDS)

Influences of nonpulsatile pulmonary flow on pulmonary function. Evaluation in a chronic animal model.

To clarify the influences of nonpulsatile blood flow on the physiologic function of the lung, we established nonpulsatile pulmonary circulation with a centrifugal pump in a chronic animal model (adult goats, n = 6). As the initial phase, a pulsatile right ventricular assist device was implanted to bypass the whole blood supply from both the right atrium and right ventricle to the pulmonary artery. After 2 weeks of pumping, the pulsatile pump was replaced with a centrifugal pump without anesthesia, and nonpulsatile pulmonary circulation was instituted. In this experimental model, no significant change was observed in either mean pulmonary arterial pressure or pulmonary vascular resistance index during the pulsatile pumping compared with that on the fourteenth day of nonpulsatile pumping. Blood gas data, extravascular lung water content, and serum level of angiotensin-converting enzyme were maintained within normal ranges. There was also no significant change in the ventral to dorsal blood perfusion ratio of the lower lobe of the right lung. These results indicate that pulmonary functions are not affected by nonpulsatile pulmonary circulation for a period of 14 days in this animal model.

Long-term circulatory maintenance with a left-sided single artificial heart.

The purpose of this study is to examine the feasibility of long-term circulatory maintenance with only a left-sided single artificial heart that is inserted between the left atrium and the aorta to assist a nonfunctioning heart. The basic hemodynamics were determined in short-term experiments in goats (n = 4), and feasibility studies of long-term circulatory maintenance with a single artificial heart during cardiac arrest were performed in long-term experiments (n = 12). When pulmonary vascular resistance was less than 15,000 dynes .sec.cm-5.kg, which was twice the normal value, the circulation was well maintained with the single artificial heart alone, so long as the right atrial pressure was kept at 14 to 16 mm Hg. Under such conditions the flow yielded by the single artificial heart fluctuated between 80 and 140 ml/kg/min depending on the animal's demand, while the mean arterial pressure was kept above 80 mm Hg. The goats behaved normally, although retention of pleural effusion was a serious problem in maintaining normal circulation over a long-term. Maintaining the plasma total protein level above 6.0 gm/dl delayed the onset of retention or even prevented pooling of pleural effusion. The longest survival period to date has been 38 days. We conclude that when the pulmonary vascular resistance is less than twice the normal value and the total protein level is above 6.0 gm/dl, a left-sided single artificial heart alone can maintain normal circulation and provide time for patients with a nonfunctioning heart to undergo a further treatment, such as heart transplantation.

Effects of implantation on the mechanical properties of the polyurethane diaphragm of left ventricular assist devices.

Tensile properties of blood pump diaphragms made from a segmented polyether polyurethane (Toyobo TM5) were studied after implanting in goats for variable periods of time up to 72 days. The implantation decreased the tensile strength and ultimate elongation at break, while the elastic modulus increased very slightly. These changes in the strength and ductility were primarily caused by the contact of material with blood rather than by the mechanical fatigue of material. Mechanical stability was greatly improved by removing residual oligomers from the material by a refining procedure. The refined polyurethane has characteristics favourable for blood pump applications.

Clinical experience with ventricular assist systems in Japan.

In Japan, five types of ventricular assist system, including the government-approved National Cardiovascular Center type and the Tokyo University type, were applied to 202 patients as of September 30, 1991. Adult-sized ventricular assist systems were used in 194 patients and a pediatric one in 8. The major primary diagnosis was ischemic heart disease (52.5%). Sixty-three patients in cardiogenic shock with acute myocardial infarction were treated using a ventricular assist system, and the results were fairly good. The predominant indication was failure to be weaned from cardiopulmonary bypass (72.8%), and there was no case of bridging to heart transplantation. Left ventricular assist was performed in most patients (85.1%). The duration of ventricular assist system application ranged from 1 hour to 70 days, and the mean duration was 6.8 +/- 9.6 days. Duration of circulatory support had no relation to the results, and the longest support in survivors was 25 days. The weaning rate was 50.0%, and the survival rate was 26.2%. Main causes of death were heart failure, including unrecoverable heart failure, and multiple organ failure. It should be kept in mind that the decision to use a ventricular assist system should be made quickly, before major organs, including the heart itself, are irreversibly damaged.

Impact of systemic depulsation on tissue perfusion and sympathetic nerve activity.

BACKGROUND: We postulated that pathophysiologic processes under nonpulsatile circulation are related to the behavior of the sympathetic nerve activity that regulates tissue perfusion. METHODS: Pulsatile and nonpulsatile pumps were installed in parallel in the left heart bypass circuit of anesthetized goats (n = 9) so that pulsatile circulation could be converted to nonpulsatile circulation instantly. At 5 minutes before and after systemic depulsation, we measured hemodynamic indices, renal nerve activity, and regional blood flow of the brain, heart, and renal cortex. RESULTS: Renal nerve activity was significantly elevated after systemic depulsation (15.6 +/- 9.3 versus 19.4 +/- 9.8 microV), when mean aortic pressure remained almost constant. The renal cortical flow was significantly reduced after depulsation (3.61 +/- 1.23 versus 2.93 +/- 1.19 mL.min-1.g-1), whereas no significant difference was found in the regional blood flow of the brain or the heart. CONCLUSIONS: The significant reduction of renal cortical blood flow after systemic depulsation is associated with a significant increase in renal nerve activity. Our results suggest that increased renal nerve activity plays an important role in the reduction of renal function after systemic depulsation.

Influence of prolonged ventricular assistance on myocardial histopathology in intact heart.

BACKGROUND: The unloading effect of ventricular assistance on the injured myocardium may adversely affect the compensatory hypertrophy of the residual intact myocardium because myocardial protein synthesis is partly controlled by cardiac work. The influence of prolonged ventricular assistance on normal myocardium was evaluated from a pathologic point of view. METHODS: A ventricular assist device was chronically implanted in 5 goats using left atrium-aorta bypass. The pumping ratio was fixed at 70 beats/min. Left ventricular biopsy samples were taken before and 1 month after assistance. RESULTS: Although the volume densities of myocytes and interstitial tissue in the myocardium showed no significant changes after 1 month of support, the myocyte volume density to nuclear volume density ratio and the interstitial tissue volume density to nuclear volume density ratio decreased significantly (p < 0.01 and p < 0.05, respectively). A cross-sectional area of myocyte showed decreases of 20.9% to 49.5%, whereas the nuclear cross-sectional area showed no significant changes. In addition, myofibrillar volume density in the cytoplasm decreased from 54.9 +/- 2.3% to 49.1 +/- 4.4%. CONCLUSIONS: The results indicate that long-term ventricular assistance in the intact heart leads to myocardial atrophy. This suggests that in the damaged heart subjected to prolonged unloading by ventricular assistance, there is the possibility of limiting compensatory hypertrophic changes in the residual intact myocardium.

State-of-the-art and clinically applied pneumatic artificial hearts.

This article is intended to inform the reader of the current state of the art of pneumatically powered artificial hearts, including animal experiments and information available on 11 recipients of orthotopically placed devices.

Tandem Operation of a Turbo Blood Pump (BP-80-Type Centrifugal Pump) to Reduce Hemolysis.

When operating turbo blood pumps in tandem, the strength of shear stress is reduced, but the exposure duration of the stress is increased. The purpose of this experiment was to compare the degree of contribution of these two factors on hemolysis as well as to evaluate the effectiveness of the tandem operation of turbo blood pumps. Tandem operation of two Bio-pumps (BP-80; Medtronics Bio-medicus, Inc., Eden Prairie, Minnesota, U.S.A.) were compared with single operation of a BP-80 in in vitro hemolysis tests in three different driving conditions, that is, pumping heads of 200, 350, and 500 mm Hg under a pump flow rate of 5 L/min. The Allen's hemolytic indexes of the tandem operation at pumping heads of 200, 350, and 500 mm Hg were 0.014, 0.020, and 0.080 mg/dl, respectively. The hemolytic indexes of the single operation at pumping heads of 200, 350, and 500 mm Hg were 0.014, 0.056, and 0.12 mg/dl, respectively. These results indicate that tandem operation is a useful method of reducing hemolysis with the BP-80 under high pumping heads and that the effect on hemolysis of exposure to higher shear stresses may be more serious than that of longer durations of exposure to shear stress in turbo blood pumps.

Performance of a newly developed implantable centrifugal blood pump.

The performance of the newly developed implantable centrifugal blood pump was investigated in vitro. The pump was developed with the end goal of building a versatile system that includes a left ventricular assist system with an internal secondary battery or an implantable biventricular assist system with two implantable blood pumps. The hydrodynamic characteristics and efficiency of the blood pump were evaluated, and the mechanical damage to the blood caused by the blood pump was assessed through a hemolysis test using fresh goat blood. The pump could generate 120 mm Hg at a flow rate of 5 L/min and a motor speed of 2,500 rpm. The electric input power to the pump was approximately 5 watts under these working conditions. The hemolysis caused by the pump was a bit higher than that by the former model, but stayed within an acceptable range. Performance of the pump in vitro was considered sufficient for a left ventricular assist device, although further design improvement is necessary in terms of hemolysis and system efficiency to improve biocompatibility of the pump.

Influence of pulsatile and nonpulsatile left heart bypass on the hormonal circadian rhythm.

We investigated endocrine circadian rhythm (CR) during pulsatile and nonpulsatile left heart bypass (PLHB and NLHB). A ventricular assist device (VAD) was installed in five goats. After 2 weeks of PLHB, NLHB was subsequently conducted for 4 weeks. The levels of melatonin, cortisol, and renin activity were measured every 2 hours for 24 hours on the last day of the second PLHB week and the second and fourth NLHB weeks. Acquired data were compared with those of the normal control goats (Cont) to determine the presence or absence of CR, as well as the timing, acrophase, amplitude, and mesor of CR. Variations in melatonin, CR were consistently detected at all sampling points. In contrast, CR of cortisol during PLHB and NLHB was observed in a few cases, although considerable CR was noted in most of the Cont cases. The variations in renin activity indicated CR in most of the Cont cases and in all cases at all sampling points during PLHB and NLHB, whereas their acrophases were diversified. In conclusion, the CR of melatonin, reflecting the fundamental circadian clock, was maintained during both PLHB and NLHB, while it could be modified for stress sensitive cortisol and hemodynamic responsive renin during these bypass modalities.

Noninvasive assessment method to determine the anatomic compatibility of an implantable artificial heart system.

To assess the anatomic compatibility of an artificial heart (AH), we attempted to develop a computer environment that would facilitate a reliable simulation of an AH implanted in the human thorax. A three-dimensional thoracic computer model with a ventricle-resected heart was constructed, by using manually extracted contour points of the aorta, pulmonary artery, atria, atrioventricular valves, diaphragm, and thoracic wall from a set of consecutive CT images. Such a model enabled simulation of an AH implantation by orienting the AH model in it. Error evaluation on CT imaging and contour extraction with a Plexiglas cylindrical phantom showed that the diameter of the extracted phantom contour was approximately 2 mm smaller than its original with a standard deviation of <0.5 mm. Errors in contour and surface reconstruction could be reduced to far less than 1 mm under constrained conditions. A study on the influence of breathing revealed that variations in some thoracic dimensions between inspiration and expiration could reach 10 mm. In summary, computer simulation of AH implantation is a worthwhile approach with acceptable accuracy, although further considerations of extreme thoracic situations will be required.

Prostaglandin synthesis inhibitor improves hypotension during normothermic cardiopulmonary bypass.

Hypotension is a major systemic side effect during cardiopu monary bypass (CPB), especially at normothermia. We previously reported that prostaglandin (PG) might play a substantial role in hypotension. The purpose of this study was to clarify whether a PG synthesis inhibitor (PGSI) could improve hypotension during CPB. Thirty-six patients undergoing cardiac surgery with normothermic CPB (35-37 degrees C) were divided into two groups: a PGSI group (n = 18), whose members wer given a PGSI before and during CPB, and a control group (n = 18). In both groups, perfusion flow was sufficient and pressure was maintained at above 45 mm Hg by infusion of metaraminol, a vasoconstrictor. The mean arterial pressure throughout CPB was significantly higher in the PGSI group than in the control group (57 +/- 4 vs. 48 +/- 3 mm Hg, p < 0.01), whereas the dose of infused metaraminol was significantly lower in the PGSI group (13 +/- 7 vs. 21 +/- 6 mg, p < 0.01). The blood base excess was not significantly different (1.0 +/- 1.6 vs. 1.7 +/- 1.9 mmol/L, p = 0.28), and urine output was significantly higher in the PGSI group (503 +/- 179 vs. 354 +/- 112 ml/hr, p < 0.01). In conclusion, PGSI can improve hypotension during CPB and increase urine output without impairing peripheral circulation.

Development of an implantable centrifugal blood pump for circulatory assist.

An implantable centrifugal pump (ICP) for prolonged circulatory assist has been developed, at 320 ml and 830 g. A central balancing hole was made in its impeller for better antithrombogenicity. Waterproofing and histocompatibility were supported by a silicone seal and a casing made of titanium and acrylic resin. Overall efficiency was 30% and normalized index of homolysis was 0.003 mg/dl, the same value as the BP-80, at a flow rate of 5 L/min and a head of 100 mmHg. Antithrombogenicity and hemolytic properties of the ICP were investigated in paracorporeal implantation in three goats (61-71 kg). Exothermicity, anatomic fit, and water tightness of the ICP were evaluated in intrathoracic implantation in an adult goat (66 kg). The ICP could run paracorporeally for 50, 200, and 381 days. There was no thrombus in the ICP after 381 days' pumping, and the ICP could run in the chest cavity for 40 days. The temperature of the motor rose 1.8 +/- 0.3 degrees C from that of the pleura. Moisture content of the seal remained normal. The ICP was completely covered with smooth fibrous tissue. Although a small area of atelectasis was found in the lingula, neither lung adhesion nor necrosis of the chest wall was observed. The ICP has satisfactory antithrombogenicity, hemolytic property, water tightness, anatomic fit, and exothermicity for use as an implantable circulatory assist device.

Establishment of flow estimation for an implantable centrifugal blood pump.

A less invasive and non thrombogenic flow estimation of an implantable centrifugal blood pump (ICBP) has been developed, which was derived from electric power consumption, the rotating speed of a motor, and blood viscosity presumed by hematocrit and body temperature. The power consumption and the rotating speed of the motor were measured by a wattmeter every 0.2 sec. Accuracy and stability of the estimated flow (EF) were investigated during in vitro and in vivo experiments. The EF was compared with a measured flow rate (MF) monitored by an electromagnetic flowmeter. During in vitro experiments, the EF and MF were measured at 79 operating points. The ICBP was driven in a closed mock loop filled with goat blood with hematocrit values of 21.5, 28, 34, and 42%. During in vivo experiments, the ICBP was implanted in the chest cavity of a goat and driven for 40 days with continuous estimation of the bypass flow rate. Blood was taken to determine hematocrit value several times a week. The temperature of the pleura away from the ICBP was measured every 15 min. A linear correlation between the EF and MF was observed, and the correlation coefficient between the EF and MF was 0.99 during in vitro examinations. An averaged error of the EF was 0.5 L/min, with the MF ranging from 2.3 to 8.1 L/min during in vivo experiments. In conclusion, flow estimation was established with good stability and accuracy in both in vitro and in vivo experiments.

Mixed venous oxygen saturation as a promising parameter for physiologic control of total artificial heart.

Mixed venous oxygen saturation (SvO2) has been proposed as one of the suitable parameters for physiologic control of a total artificial heart (TAH). To establish the practical application of SvO2, we investigated the response of cardiac output (CO) and SvO2 to step-loaded exercise. A normal calf was surgically equipped with an ultrasonic flowmeter probe and an oximetry catheter in the pulmonary artery to measure CO and SvO2, respectively. Three stage step treadmill exercise tests (1, 2, and 4 km/h) were performed three times. While CO increased from 8.9 L/min at preexercise level to 9.7, 10.2 and 11.4 L/min at 1, 2, and 4 km/h, respectively, SvO2 decreased from 59.6% to 56.8, 55.3, and 52.2%, respectively. There existed a linear correlation between the magnitude of changes in CO and SvO2. CO and SvO2 exhibited a similar course of change, expressing an inverted exponential curve. The time constant of SvO2 was from 19 to 35 seconds, whereas that of CO was from 21 to 39 seconds. We conclude that SvO2 changes in close association with CO during exercise and has good potential to be a parameter for physiologic control of a TAH, by reflecting the recipient's CO demand without conspicuous time delay.

Development of an electrohydraulic total artificial heart at the National Cardiovascular Center, Osaka, Japan.

The authors have been developing an electrohydraulic total artificial heart with a basic concept placing the blood pumps and an electrohydraulic energy converter separately, in the thorax and the abdominal region, respectively, to minimize anatomic constraints. Major problems of the system were a high energy consumption of 56 W at 6 L/min output and an insufficient maximum output of 6.7 L/min. The energy converter was redesigned to overcome these problems. A three phase, 4 pole brushless DC motor, which has maximum efficiency of 79% at a motor rotation of 2500 rpm with a load of 0.1 Nm, was developed for the new energy converter. Flow-channel design of the regenerative oil pump was optimized, which resulted in increasing the maximum flow rate at one directional motor rotation from 18 to 29 L/min. In vitro performance of the electrohydraulic total artificial heart was evaluated in a mock circulation with physiologic pressure conditions. Maximum output was increased to 10.7 L/min at a pump rate of 120 bpm and energy consumption of the motor at 6 L/min output was reduced to 18 W. Based upon these favorable results, the system is now being assembled for chronic animal implantation.

Heat generation and hemolysis at the shaft seal in centrifugal blood pumps.

The heat and hemolysis around a shaft seal were investigated. Materials were original pumps (Nikkiso HMS-15:N-original, and 3M Delphin:D-original), vane-removed pumps (Nvane(-), Dvane(-)), and a small chamber with a shaft coiled by nichrome wire (mock pump). The original pumps were driven at 500 mmHg and 5 L/min, and vane-removed pumps were driven at the same rotation number. An electrical powers of 0, 0.5, 2, and 10 W was supplied to the mock pumps. In vitro hemolytic testing showed that hemolytic indices were 0.027 g/100 L in N-original, 0.013 in Nvane(-), 0.061 in D-original, and 0.012 in Dvane(-). Measurement of heat with a thermally insulated water chamber showed total heat within the pump of 8.62 and 10.85 W, and heat at the shaft seal of 0.87 and 0.62 W in the Nikkiso and Delphin pumps, respectively. Hemolysis and heat generation of mock pumps remained low. The results indicate that the heat generated around the shaft seal was minimal. Hemolysis at the shaft-seal was considerable but not major. Local heat did not affect hemolysis. It was concluded that the shaft-seal affected hemolysis, not by local heat but friction itself.