Intra-aortic Balloon Pump Use With Extra Corporeal Membrane Oxygenation—A Mock Circulation Loop Study

Abstract

Venoarterial extracorporeal membrane oxygenation (ECMO) is used in cardiogenic shock refractory to inotropic support and intra-aortic balloon pump (IABP) support. Peripheral ECMO can lead to ventricular distention, and IABP can be used to mitigate these effects. The aim of this study was to quantify the effects of IABP concomitant with ECMO, under different simulated hemodynamic conditions in a mock circulatory loop. Different simulated states of isolated left ventricular (LV) failure and biventricular failure with graded LV failure severities were supported with ECMO and ECMO with IABP. The impact on left ventricular end-diastolic pressure (LVEDP), volume (LVEDV), coronary flow rate, and cerebral flow rate were evaluated. Left ventricular volumes and pressures increased from the heart failure states with the addition of ECMO. The IABP provided between 3% and 7% reductions in LVEDP and between 1% and 10% reductions in LVEDV. The addition of IABP had minimal effect on cerebral blood flow (0% to 7%), but the variable impact on coronary blood flow with increased diastolic coronary flow of 23% to 50%, but the reduction in mean coronary flow by up to 30%. The efficacy of the IABP was strongly related to ventricular contractility. This study demonstrates the need for careful IABP selection concomitant with ECMO.

Validation of a Multiscale Computational Model Using a Mock Circulatory Loop to Simulate Cardiogenic Shock

“…Similar oscillations have been observed in other MCL studies simulating healthy and failing heart hemodynamics. 30,32,33 On the contrary, aortic pressure and flow waveforms are not influenced by these perturbations and show a smoother profile than the numerical results because 1) perturbations caused by retrograde flow at aortic valve closing are not seen (Figure 4C) because of the 3 Hz pulsatile frequency response of the flowmeter (Supplement Digital Content 4, http://links.lww.com/ASAIO/B114) and 2) there is no prominent dicrotic notch in the aortic pressure waveform (Figure 4D) because of the inherent limitation of the MCL in accurately characterizing the cardiac and peripheral pressure pulse wave dynamics, including reflected waves. 36–39…”

“…28,29 Sophisticated MCLs modeling multiple circulations are used to simulate left heart failure including CS and assess device performance. 30–33 Our study employs a simpler MCL, simulating left heart, and systemic circulation hemodynamics (Figure 1) that has been developed at the US Food and Drug Administration. A Newtonian blood analog fluid (dynamic viscosity falseμ=3.95 normalcnormalP and density falseρ=1.095 normalg/normalcm3) was prepared to represent the fluid properties of human blood with a composition of 60% by volume of water, 40% by volume of glycerin, and 1.7 g of sodium chloride per 100 ml of solution.…”

Mock circulatory loop applications for testing cardiovascular assist devices and in vitro studies

“…The specificity of the MCL for testing the IABP lies in the need for an aorta resembling component with the IABP insertion (e.g., aorta model) as well as a device for synchronizing the IABP. Typically, researchers design a simple structure such as a piece of pipe in the MCL for the IABP placement ( Wolf and Clinch, 1972 ; Niederer and Schilt, 1988 ; Sakamoto et al, 1996 ; Papaioannou et al, 2004 ; Schampaert et al, 2011 ; Farag et al, 2022 ). Moreover, in order to simulate the clinical placement process more realistically, the aortic trunk model can be included to the MCL ( Imanishi et al, 1989 ; Biglino et al, 2012b ; Kolyva et al, 2012 ).…”

“…Moreover, in order to simulate the clinical placement process more realistically, the aortic trunk model can be included to the MCL ( Imanishi et al, 1989 ; Biglino et al, 2012b ; Kolyva et al, 2012 ). In response to synchronization with the IABP, the IABP can be triggered by an MCL-simulated electrocardiographic signals ( Schampaert et al, 2011 ), by pressure signals from the ventricles ( Farag et al, 2022 ), or synchronously by ventricular driver signals ( Wieting et al, 1971 ; Niederer and Schilt, 1988 ; Papaioannou et al, 2004 ; Biglino et al, 2012b ; Kolyva et al, 2012 ). For example, Schampaert et al (2011) mimicked the aorta using a cylindrical polyurethane tube with the diameter close to the human aorta.…”

Afterload Pressure and Left Ventricular Contractility Synergistically Affect Left Atrial Pressure During Veno-Arterial Extra-Corporeal Membrane Oxygenation

“…Mock circulatory loops (MCLs) allow for precise control of a number of hemodynamic and circuit-related variables and systematic assessment of the interactions between mechanical circulatory support devices and the cardiovascular system, and have previously been used to investigate the effects of different VA-ECMO unloading techniques and cannula properties [9][10][11][12] . We sought to utilize an MCL to systematically assess the effects of changes in afterload pressure, ventricular contractility, and ECMO ow and direction on left atrial pressure (LAP) during VA-ECMO support.…”