Dynamic Modulation of Device-Arterial Coupling to Determine Cardiac Output and Vascular Resistance
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Annals of Biomedical Engineering (Ó 2020) https://doi.org/10.1007/s10439-020-02510-3
Original Article
Dynamic Modulation of Device-Arterial Coupling to Determine Cardiac Output and Vascular Resistance STEVEN P. KELLER ,1,2 BRIAN Y. CHANG,1 QING TAN,3 ZHENGYANG ZHANG,1 AHMAD EL KATERJI,3 and ELAZER R. EDELMAN1,4 1
Institute for Medical Engineering and Science, Massachusetts Institutes of Technology, 77 Massachusetts Avenue, Cambridge, MA 02139, USA; 2Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA; 3Abiomed Inc., Danvers, MA 01923, USA; and 4Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA (Received 9 December 2019; accepted 7 April 2020) Associate Editor Lakshmi Prasad Dasi oversaw the review of this article.
Abstract—Clinical adoption of mechanical circulatory support for shock is rapidly expanding. Achieving optimal therapeutic benefit requires metrics of state to guide titration and weaning of support. Using the transvalvular positioning of a percutaneous ventricular assist device (pVAD), device:heart interactions are leveraged to determine cardiac output (CO) and systemic vascular resistance (SVR) near-continuously without disrupting therapeutic function. An automated algorithm rapidly alternates between device support levels to dynamically modulate physiological response. Employing a two-element lumped parameter model of the vasculature, SVR and CO are quantified directly from measurements obtained by the pVAD without external calibration or invasive catheters. The approach was validated in an acute porcine model across a range of cardiac (CO = 3–10.6 L/ min) and vascular (SVR = 501–1897 dyn s/cm5) states. Cardiac output calculations closely correlated (r = 0.82) to measurements obtained by the pulmonary artery catheterbased thermodilution method with a mean bias of 0.109 L/ min and limits of agreement from 2 1.67 to 1.89 L/min. SVR was also closely correlated (r = 0.86) to traditional catheterbased measurements with a mean bias of 62.1 dyn s/cm5 and limits of agreement from 2 260 to 384 dyn s/cm5. Use of diagnostics integrated into therapeutic device function enables the potential for optimizing support to improve outcomes for cardiogenic shock.
Address correspondence to Steven P. Keller, Institute for Medical Engineering and Science, Massachusetts Institutes of Technology, 77 Massachusetts Avenue, Cambridge, MA 02139, USA. Electronic mail: [email protected]
Keywords—Cardiogenic shock, Mechanical circulatory support, Ventricular assist device.
INTRODUCTION Clinical use of mechanical circulatory support (MCS) devices to support patients with cardiovascular disease is increasing exponetially.14 New devices offer physiological advantages over medical therapy and aortic counter-pulsation to more fully maintain systemic perfusion and homeostasis.1 At present, there are limited prospective clinical trials evaluating the efficacy of newer support devices and none employing
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