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In Vitro Assessment of Pacing As Therapy for Aortic Regurgitation

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In Vitro Assessment of Pacing As Therapy for Aortic Regurgitation Open access Cardiac surgery Open Heart: first published as 10.1136/openhrt-2018-000976 on 24 May 2019. Downloaded from In vitro assessment of pacing as therapy for aortic regurgitation Paolo Peruzzo ,1 Francesca Maria Susin,1 Andrea Colli,2 Gaetano Burriesci3,4 ► Additional material is ABSTRACT Key questions published online only. To view Background and objective Clinical evaluation of please visit the journal online pacing therapy in mitigating the aortic insufficiency (http:// dx. doi. org/ 10. 1136/ What is already known about this subject? after transchateter aortic valve implantation often gives openhrt- 2018- 000976). Some in- vivo studies have debated the role of pac- contradictory outcomes. This study presents an in vitro ► ing to mitigate aortic regurgitation and its use as investigation aimed at clarifying the effect of pacing on To cite: Peruzzo P, Susin FM, therapy to this aim. Colli A, et al. In vitro assessment paravalvular leakage. ► The discrepancies on the results are mainly due to of pacing as therapy for aortic Methods A series of in vitro tests reproducing the heart some inaccuracies of in- vivo measurements and the regurgitation. Open Heart operating changes clinically obtained by pacing was improper use of aortic regurgitation index to assess 2019;6:e000976. doi:10.1136/ carried out in a 26 mm Edwards Sapien XT prosthesis the enhancement of the grade of insufficiency. openhrt-2018-000976 with mild paravalvular leakage. The effect of pacing on the regurgitant volumes per cycle and per minute was What does this study add? quantified, and the energy and power consumed by the Received 27 November 2018 ► The study indicates that pacing is ineffective as a Revised 22 March 2019 left ventricle were calculated. treatment for postoperative aortic regurgitation, and Accepted 26 April 2019 Results Results indicate that though pacing results may result detrimental both in term of regurgitation in some reduction in the total regurgitation per cycle, and heart power demand. the volume of fluid regurgitating per minute increases substantially, causing overload of left ventricle. How might this impact on clinical practice? Conclusions Our tests indicate no effective ► The findings suggest a more widespread use of haemodynamic benefit from pacing, suggesting a the left ventricular power as a heart performance prudential clinical use of this therapy for the treatment of parameter that allows an effective and consis- postoperative aortic regurgitation. tent comparison between different heart beating conditions. http://openheart.bmj.com/ the heart. In order to allow direct compar- INTRODUCTION ison between the different operating condi- Significant postoperative aortic regurgita- tions, an in vitro approach was adopted. This tion due to paravalvular leakage (PVL) is a enables full control of the working parame- common complication after transcatheter ters, as well as an accurate measurement of aortic valve implantation (TAVI), with inci- the functional quantities. Tests mimicking dence ranging from 5% to 25%, associated mild PVL after TAVI and different pacing with an increase in early and late postopera- were carried out, and the efficacy of pacing on September 26, 2021 by guest. Protected copyright. tive mortality.1–4 © Author(s) (or their was verified by investigating its effect on Pacing has been adopted as temporary employer(s)) 2020. Re-use the ventricular overload per beat and per or permanent therapy to mitigate PVL in permitted under CC BY. unit time (ie, per minute). The distinction Published by BMJ. patients affected by moderate/severe regur- between these two time references becomes 1Department of Civil, gitation after TAVI.5 This approach is based fundamental when adopting pacing, as quan- Environmental and Architectural on the concept that a shorter diastolic phase tities typically measured over a single heart Engineering, University of reduces the time available for blood to flow Padova, Padua, Italy cycle do not necessarily reflect the global 2 back into the ventricle, thus diminishing the Dipartimento di Scienze benefit and may lead to erroneous interpre- ventricular overload.6 7 However, the clinical Cardiologiche Toraciche e tations of the results. Vascolari, Universita degli Studi outcomes described in the literature are often di Padova, Padova, Italy 7–11 3 contradictory. These inconsistencies can UCL Mechanical Engineering, be attributed to the relatively reduced accu- METHODS University College London, 12 London, UK racy of in vivo measurements approaches, as A 26 mm diameter Edwards SAPIEN XT was 4Ri.MED Foundation, Palermo, well as the difficulty in comparing different used as testing valve. This was released into Italy courts of patients examined at various centres. a silicon cylindrical holder of 23 mm diam- The present study aims at assessing in vitro eter by standard implantation procedure. Correspondence to Dr Paolo Peruzzo; paolo. the effect of pacing on the cardiac load and The holder included a crescent shape axial peruzzo@ dicea. unipd. it its impact on the power consumption of grove (5 mm of minor axis, 3 mm of major Peruzzo P, et al. Open Heart 2019;6:e000976. doi:10.1136/openhrt-2018-000976 1 Open Heart Open Heart: first published as 10.1136/openhrt-2018-000976 on 24 May 2019. Downloaded from E J P Figure 1 Sketch of the housing valve apparatus as reported by Burriesci et al.13 2 semiaxis and total area Aorifice 12 mm ) (figure 1) causing mild PVL.13 Following well- developed methodologies for evaluation of cardiovascular devices and in vitro haemodynamics features,14 15 physiological pulsatile flow conditions were mL/min mL/min mL/min W replicated in a hydromechanical pulse duplicator (ViVitro System, ViVitro Labs Inc, Victoria, Canada). The equip- ment includes a hydraulic circuit mimicking the human systemic circulation, comprising an atrial, a ventricular and an aortic chamber. The pulsatile flow is produced RF CFR LFR RFR by a computer- driven piston pump, and localised dissipa- tion and compliance chambers are placed downstream of the aortic root to account for the Windkessel effect. Flow http://openheart.bmj.com/ through the ventricular and aortic chambers is measured RV with an electromagnetic flowmeter (model 501, Caro- data ed parameters and postprocessing lina Medical Electronics, Inc, King, North Carolina, USA), and pressure in the three chambers is recorded from three 8- French Millar microtip transducers (Millar LV Instruments, Houston, Texas, USA). Phosphate buffered saline solution at 37°C was adopted as testing fluid. Six tests were carried out at different hydrodynamic on September 26, 2021 by guest. Protected copyright. CV working conditions, as reported in table 1. Heart rate mL mL mL % (HR) was varied in the range 60–110 bpm. The cardiac output (CO) and mean aortic pressure (pAo) were set to replicate conditions observed in vivo,16 17 but conve- niently scaled to match the optimum operating range of the pulse duplicator. In particular, CO was increased about proportionally with HR in the range 3.4–6.2 L/ parameters Measured min (ie, a range twice smaller than the one measured 14 in vivo ), while pAo was maintained constant at 100 mm Hg. To better represent the changes in physiological contraction of the left ventricle with the increase of HR, the systolic percentage of the cycle was also extended, in L/ min % mL agreement with the clinical evidence.18 Summary of experimental work conditions and main measur 60 3.4 31.8 107.4 (0.05) 5.3 (0.6) 9.3 (2.0) 14.6 (2.5) 20.4 (3.5) 318 (4.6) 558 (15.5) 876 (19.3) 1.31 (0.02) 1.31 (0.02) 70 4.0 31.9 104.6 (0.04) 5.5 (0.4) 8.9 (1.9) 14.4 (2.1) 20.4 (3.0) 385 (3.3) 623 (15.9) 1008 (17.6) 1.54 (0.02) 1.32 (0.01) 80 4.5 36.6 102.7 (0.05) 6.2 (0.6) 7.7 (1.6) 13.9 (1.7) 19.7 (2.4) 496 (5.4) 616 (14.3) 1112 (15.2) 1.80 (0.01) 1.35 (0.01) For each testing condition, the instantaneous pressures 90 5.0 39.3 98.9 (0.05) 6.6 (0.8) 6.3 (2.0) 12.9 (2.5) 18.8 (3.6) 594 (7.6) 567 (19.0) 1161 (23.7) 1.99 (0.02) 1.33 (0.02) HR CO Systole SV in the aortic and ventricular chambers and the flow rate 100 5.5110 6.2 41.4 43.1 96.8 (0.03) 99.4 (0.00) 7.8 (0.9) 8.2 (1.7) 5.1 (1.8) 5.2 (1.9) 12.9 (2.2) 13.4 (2.3) 19.1 (3.2) 19.3 (3.4) 780 (9.0) 902 (17.8) 510 (18.0) 572 (19.9) 1290 (22.0) 1474 (24.1) 2.16 (0.01) 2.60 (0.02) 1.29 (0.01) 1.42 (0.02) thorough the valve were measured during the entire Ao Table 1 Table Work conditions Work p the SD. are averaged over the 10 cycles; values in parentheses Data are Total fraction; RFR, regurgitant RF, LV, leakage volume; closing volume; HR, heart rate; LFR, Leakage mean flow output; CV, mean flow rate; CO, cardiac CFR, closing regurgitant volume. stroke volume; SV, regurgitant RV, flow rate; regurgitant mm Hg bpm cycle, collecting 256 samples per cycle. 100 2 Peruzzo P, et al. Open Heart 2019;6:e000976. doi:10.1136/openhrt-2018-000976 Cardiac surgery Open Heart: first published as 10.1136/openhrt-2018-000976 on 24 May 2019. Downloaded from Data were averaged over 10 consecutive cycles and used The transaortic flow wave behaviour for the six study to extract the following quantities: cases is depicted in figure 2. Peak flow ranges from ► Stroke volume (SV (mL)).
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