2008 12 03 Schima

Zentrum für Biomedizinische
Technik und Physik

CARDIAC ASSIST DEVICES
and the Application of Data Analysis,
Modelling and Information Processing
H. Schima
Dept. of Biomedical Engineering &
Dept. of Cardiothoracic Surgery,
Univ. of Vienna, Austria
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Contents:
1. History of the mechanical cardiac assist and
replacement
2. Pump systems:
- Pulsatile systems
- Rotary blood pumps with conventional
bearings
- Rotary blood pumps with touchless
bearings
3. Controllers and monitoring of Card. Assist Devices
4. Research (selected examples):
- Control for physiological adaptation
- Interaction of Pump and Cardiovasc Sys.
- Flow simulation in the carotic artery
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A blood pump has to:
- generate sufficient blood flow (5-8 L/min) at physiological
pressures (up to 150mmHg  25 kPa);
- to treat the blood particles gently (otherwise the destruction of
erythrocytes and the activiation of platelets occur);
- avoid thrombus formation, which can occur due to stagnation
points, recirculation areas, heat generation or improper material
transitions;
- require minimal traumatization during and after implant (Size of
surgical field, diameter and flexibility of tubings, cables);
- depending on the indication be failsafe up to several years,
easy replacable, to adapt to the flow request, to be small and
silent;
- be inexpensive in acquisition, implant and postoperative care.
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Principles of Blood Pumps:

Application: for TOTAL ARTIFICIAL HEART as orthotopic heart
replacement (TAH)
for VENTRICULAR ASSIST for left (LVAD), right
(RVAD) or biventricular (BiVAD) application;
Pump type: PULSATILE PUMPS, with membrane and valves
driven pneumatically or electrically;
ROTARY PUMPS
Roller pumps with squeezed tubing
Centrifugal pumps with conventional or
touchless bearings
Axial pumps with conventional or touchless
bearings;
Duration of Application: SHORT TERM,
BRIDGE to transplant or recovery
LONG TERM (Destination Therapy)
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Milestones of Mechanical Cardiac Assist (I):

1934 Roller pump for cardiopulmonary bypass (DeBakey - USA)
1957 First animal implant with Total Artificial Heart (Kolff, Akutsu
– Cleveland)
1963 First clinical implant of a cardiac assist system (Liotta -
Houston)
1968 First clinical implant of a balloon pump (Kantrowitz - USA)
1968 Rotary pumps for blood transport (Blackshear, Kletschka,
Rafferty - Minneapolis)
1975 Clinical use of an industrially produced rotary pump for the
heart lung machine (Biomedicus, Minneapolis)
1982 First clinical use of a Total Artificial Heart for destination
therapy (Kolff, Jarvik, De Vries – Salt Lake City)
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Milestones in Mechanical Cardiac Assist (II):

1984 First clinical application of an electrically driven cardiac
assist device (Portner -Stanford)
1986 First clinical implants of TAH as bridge to transplant
(Unger - Salzburg, Wolner - Wien, Hetzer - Berlin)
1988 First clinical application of high speed axial pumps
(Wampler, Fraser - Houston)
1993 First discharge to home with a pulsatile pump
(Loisance, Portner - Paris)
1998 Fully implantable rotary pumps implanted for extended
cardiac assist (AB180, Micromed Westerby - London,
Hetzer - Berlin, Wolner - Wien)
1999/2000 First discharge of a patient with rotary pump
(Wolner - Wien)
2007 Patient on device for 7 years (Jarvik, Westaby, London)
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The expectations have changed:

1986: ”The safety standards as in animal experiments are
sufficient, otherwise the patient will be dead tomorrow”,
patient stays in intensive care
1990: Implant for several weeks seems to be sufficient,
mobilization of the patient in the standard ward
1993: Full mobilization of the patient for several months must
be possible, temporary discharge from hospital
2000: The system must be small and silent, at low
anticoagulation and freedom of infection
2003: Implantation of devices for destination therapy, as final
solution for several years.
2008: The heart should be particularly protected or even
recover during cardiac support
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Schematic of a pneumatic blood pump:
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Example: Artificial Heart in Vienna - Phase 1
Clinical Use 1986

On the right side thedriving
unit, on the left side the
spare unit
Left Ventricle of a TAH Patient during 2-week
bridge to transplant and
1972 Development of the “Elliptic Heart” after transplant
1979 Clinical use for Assist
1884 Start of the clinical transplantation
program
1986 First implant of the elliptic heart as
bridge to transplant
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Example: The “New Vienna TAH”, 1985-1991
Patient, 1990 on TAH

support, 1 year after
transplantation
Driving and Monitoring
System
1985 Start of Construction and anatomical

studies;
1987 Animal experiments up to 180 days;
1988 Clinical use as TAH and VAD, 60%
are transplanted;
1991 Industrial transfer does not work out,
production has to be stopped due
to limitations in the old laboratory.
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Technik und Physik
Frontpanel of a pneumatic
drive with microcontrolled
Alarm System;
The two pumps are balanced
via a Master-Slave-
Adjustment, the necessary
Flow was determined via
venous oxygen saturation. Schima 07

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Pulsatile Membran-Blood pumps as assist device in

LVAD and BiVAD-Configuration (Thoratec):
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Electromagnetically driven pulsatile pump:

NOVACOR, fully portable support since 1993
Novacor-Pumpe
(Gehäuse entfernt)
Novacor-Patient,
mountaineering.
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Arrow-Lionheart als Final-Therapie:
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Compliance
Outlet Cannula Inlet
Chamber:
Cannula 5” dia x 1/2”;
0.2 lb
Internal Coil
2 7/8” dia x 5/8”;
0.3 lb Access
Port :
Blood Pump
2.7 ” dia. x 2 13/16”; 1.5 lb
Motor Controller:
4” x 3.75” x 1 1/8”; 1.1 lb
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The Total Artificial Heart
with integrated Motor
ABIOCOR
ABIOCOR®
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Classification of Rotary Blood Pumps
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Rotary Blood pumps: The bearing of the rotor is

crucial for blood trauma and thrombus formation:
Mechanical bearings include areas of high shear stress,
heat and low washout. These factors contribute to blood
trauma (hemolysis) and thrombus formation (via platelet
activation and stagnation).
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Classification of Rotary Blood Pumps

depending on the Bearing Technology:
First Generation:
Mechanical Bearing, sealed or blood immersed:
Area of high shear at the bearing rim,
heat and stagnation.
Second Generation:
Magnetic bearing, actively controlled by
electromagnets
Third Generation:
Magnetic bearing combined with hydrodynamic
stabilization
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Rotary Pumps for short term Assist: Biomedicus®
The discs forward the blood by adhesion and centrifugal force: CFD of shear stress
(Keyhani et al.)
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Impeller Pumps for short term Cardiac Assist:
Example: Cobe® : Pump for extracorporeal circulation and short term assist
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Impella Miniature Axial Pump
Ø 6.4 mm, 4.5l/min, with pressure sensors for placement and flow monitoring
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Second Generation:
Magnetic bearing, actively controlled by
electromagnets; The control is done based on
magnetic sensors and the voltage in the coils
(so called Back ElectroMagnetic Force) with
a high speed signal processor.
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CentriMagR Bearingless Pump

pump housing Inlet
impeller
outlet
rotor
winding
stator
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CentriMagRBearingless Pump
•First disposable centrifugal blood pump based on

bearingless motor design
•No bearings, No seals, No wearable components
•Magnetically levitated rotor
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Underside of pump after 11 days

of support
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Terumo Duraheart: actively controlled rotor position
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Berlin Heart Incor:

Axial Flow pump with
actively controlled rotor
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Third Generation:
Magnetic bearing combined with hydrodynamic
stabilization
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HeartWare® - HVAD
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HeartWare® - HVAD
Controller with monitoring and trend data storage (up to 1 months of trends
and event loggings (current, flow pattern, supply voltage etc); Battery with
loading status and history storage.
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HeartWare® - HVAD
Monitoring Laptop for pump adjustment and alarm setting, trend data display
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Micromed-DeBakey:
Fully implantable rotary Pump, 1st Implants
in Berlin and Vienna 1998
In 1998, fully implantable rotary blood pumps became available in
the clinical arena for long term clinical use.
The new situation of small, implantable, valveless systems with
continuous flow brought up a boom of questions, which could only
partially be answered before in animals, concerning:
- implant technique,
- optimal pump adjustment and postoperative
management,
- physiological compatibility of “pulseless” flow,
- rehabilitation of patients and requirements
for discharge from hospital
- diagnostics and procedures specific for rotary pumps. Schima 07

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The Micromed™/De-Bakey Axial Blood Pump
- Titanium pump with

inflow and outflow guide vanes,
apical inflow cannula,
implanted subdiaphragmatically
- Driven by a brushless DC-motor,
which couples directly
magnetically to the pump rotor,
with manually adjustable speed.
- Pump flow measured with an im-
plantable ultrasound flow probe.
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Micromed™/De-Bakey –LVAD:
Arrangement of pump, flowprobe, controller and power
supplies
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Nov.1998: First
Human Implants
of the MicroMed-
MicroMed-
DeBakey-
DeBakey-VAD in
Berlin and Vienna
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With axial pumps, the operating field

can be kept small !
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Continuous Flow  nonpulsatile flow !
Arterial Pressure
Low pulsatile Flow,
Coughing, Suction
Pump flow stays somewhat

pulsatile due to remaining
heart contractility.
Pulsatility usually increases
during recovery.
Flow at recovered pulsatility

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Technik und Physik
Low aortic pressure pulsatility:

We proudly came up to the standard ward with the first patient.
He was the worldwide first recipient ofa rotary blood pump
without any catheters!
But after only two hours, we got a call of the nurse:
How should a measure blood pressure?

The cuff method does not work, I do not hear a pulse!
Solution: Distal measurement of arterial flow with a handheld

ultrasound probe (like in vascular diagnostics of peripheral
perfusion).
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Blood Pressure Monitoring at low arterial

Pulsatility with a Wristwatch Blood-Flow-Detector
Wrist-Watch Ultrasound Arrangement for Riva-
Detector Rocci-Cuff-Measurement
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Automatic System with Microcontroller

(Prototype with external Ultrasound System)
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Signal Analysis:
1. Cuff inflation
2 2. Slow cuff deflation
4
1 3. Determination of
5 flow recurrence
point and flow
signal validity…
4. …results in
3 determination of
systolic pressure
5. Cuff pressure
release
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Technik und Physik
Results:
Correlation of Pressure Correlation of Heart rate
with invasively measured with rate measured by
systolic pressure: ECG:
P= 2.6mmHg; r=0.93 HR= 2.5 bpm; r= 0.98
ISRP2001
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......343 steps to the top of
St. Stephan´s Cathedral.......
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Back to nearly normal life : Technik und Physik
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Data Reported by Home Patients:
Hemodynamics: * AoP
* Heart frequency
Pump: # Performance (flow, power, speed)
+ Alarms (caused by pump and handling)
Anticoagulation: & INR (either home or laboratory data)

Others: * Body temperature (indicator for infection)
* Body weight (indicator for fluid balance)
& Subjective feeling (ranking 1-5)
* Noted twice daily; & daily; + On demand; # by E-Mail
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Technik und Physik
Do we still need physiologically responsive

control ?
Yes, we do :
-to adapt to changes in aortic pressure,
- to adapt to changes in fluid balance and circardian rhythm,
- to adapt to sudden changes in homeostasis (sitting up, standing
up, coughing, Valsalva-Maneuver),
- to maximize available flow in case of impaired right heart
contractility, without impeding the right heart functionality,
- to react to persistent suction, which may not only damage blood
and the intra-ventricular wall, but additionally cause right heart
failure due to septum shift and subsequent tricuspid insufficiency.
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Technik und Physik
A control system has to provide :
- proper adaptation to venous return and physical activity;

-safe and robust performance,
- adaptation to special conditions in the pathologic patient
(such as arrythmia, collapsible septum),
- minimal sensor requirements, limited to long-term stable signals,
- minimal and simple settings by the physician to adapt to
individual patients should be necessary.
We chose an approach, which is based on determination of

venous return and on heart rate. Additionally, a very reliable
detection system for eventual suction was developed.
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Technik und Physik
Analysis of flow patterns for eventual suction:

1. Extraction of pattern properties in the
time domain;
2. Design of a decision system, which
uses these properties like a human VIE 201 n-variation
23.11.98
flow [L/min]
"12_53_15"
n = 11,3 krpm
expert.
7
6
VIE 201 n-variation
"12_46_46"
23.11.98
flow [L/min]
n = 10 krpm
5
7
VIE 201 n-variation
"12_40_32"
23.11.98
flow [L/min]
n = 9 krpm 6
4
6
3
5
5
4 2
4 1
3
3 2 0
0 1 2 3 4 5
time [sec]
2 1
0
1 0 1 2 3 4 5
time [sec]
0
0 1 2 3 4 5
time [sec]
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[(Qmean-Q-minimum)-(Qmaximum-Qmean)] = (2Qmean-Qminimum-Qmaximum) < Threshold [l/min]

[(Q
MeanMinMax Criteria
Maximum Mean-
Mean-, Min-
Min- and Max-
Max-
Mean
Pump Flow are evaluated
between two local
minima
Minimum
Low Flow Criteria

Mean Flow < a1 [l/min]
P2P < a2 [l/min]
a3 [l/min] < Flow < a4 [l/min]
for more than 300 ms
a1,a2,a3,a4 … Threshold values

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Technik und Physik
Plateau Criteria
Abs(dQ/dt) < a1 [l/min/sec] for more than a2 [ms] A flow decrease after a plateau
dQ/dt < a3 [l/min/sec] situated at the top of a flow peak
will be detected as suction if a
consecutive increase in pump flow
< a5 [ms]
dQ/dt > a4 [l/min/sec] can be observed
dQ/dt < b1 [l/min/sec]
Saddle Criteria
dQ/dt > b2 [l/min/sec]
A significant flow decrease

followed by a phase of low flow
changes will be assessed as
suction if a consecutive flow
dQ/dt < b3 [l/min/sec]
decrease occurs
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Asymmetry Criteria
Abs(dQ/dt max)-Abs(dQ/dt min) < AsymThreshold l/min/sec

The calculation of the asymmetry criteria
is based on the determination of local
flow minima. Suction will be assessed if
the falling arch of one flow peak is much
steeper than the rising one.
SlewRate Criteria
Suction is assumed if the slew rate of a

falling edge exceed a threshold level of
60 l/min/sec. Certainly the slew rate
criteria and the asymmetry criteria yield
to the same result.
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Technik und Physik
Development of a reliable suction detection system

based on beat-
beat-to-
to-beat analysis of the pump flow signal
approx.
Definition of distinct indicators for 1000 data records
Suction Based on Clinical Experience from 100 patients
Calculation of
Algorithm Results for Classification of Data Records
all Data Records
Manually
Computerized
Selection of the most efficient algorithm combination

based on numerical optimization
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Calculation of the individual algorithm results at

Classified
Snap Shots distinct threshold values and generation of a
data base for the numerical optimization
Snap 1
Snap 2
Snap 3
Snap n-2 a1 b1 … e1 f1
Snap n-1 a2 b2 … e2 f2
Snap n Threshold Values =
a5 b5 … e5 f5
Evaluation of a6 b6 … e6 f6
the algorithm Algorithm 1

results for the
Algorithm 2 Results of the
whole data individual algorithms
set at at different
different threshold values
threshold Algorithm n-1

levels Algorithm n
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Technik und Physik
Algorithm Combination:
ALGO 1 ALGO 2 … ALGO n-1 ALGO n

0 0 … 0 1 Applied Optimization
0 0 … 1 0 Criteria:
1 1 … 1 0
Opt1 = FalsePositive +
1 1 … 1 1
FalseNegative
Results of the
individual algorithms
at different
threshold values
Opt2 =
Evaluation of the Optimization Criteria (a1*FalsePositive)
FalsePositive)
for all threshold combinations +
of the involved algorithm (a2*FalseNegative)
FalseNegative)
Evaluation of the
optimization criteria Opt3 = FalsePositive
for all permutations
of the threshold Algorithm combination and related
values at every threshold values, which are best a1, a2 … weighting
algorithm
combination concerning the Optimization Criteria factors
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ROC-
ROC-Diagram of the Optimization Results
In the chosen
optimum compared
to the expert decision
of the 784 relevant
pattern 4 were
classified false
positive and 6 false
negative.
From the set of the
certain expert
decision (Type 1,5)
only 1 file was
classified false
positive
Mal-
Mal-detection distribution of four different algorithm combinations
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Technik und Physik
Desired flow at
Exercise
Desired
Desired flow flow
at
If venous return is limited, the
Pump Flow
Rest
pump flow is reduced to the
highest possible "Maximal Flow"
depending on the P2P-flow value
Minimal acceptable flow
Heart Rate
-Adjusts speed to obtain a desired flow;

- In case of sufficient venous return, a target desired flow
depending on heart rate is achieved;
- In case of lack of venous return (suction indicated, too low flow
P2P-amplitude), the maximal possible flow is achieved.
- If the maximal possible flow falls below a certain level, a fail-safe
mode is activated. Schima 07

Technik und Physik
Vienna-Micromed-Control: Physician Settings:

The physician sets (depending on patient condition, on venous
oxygen saturation, lactate etc., eventual weaning) a desired flow
level for rest and exercise, and the heart rate for rest and exercise.
He further sets a certain minimal acceptable flow level, at which
automatic control should be left.
Finally he may set a level of ventri-
cular unloading in case of
diminished venous return.
Further preset boundary safety
conditions include minimal/maximal
speed and maximal power.
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Technik und Physik
This setting can be easily done to fit to all

patient conditions!
- In the ICU, maximal possible cardiac output may be desired,
independently of heart rate: Just set one heart rate and a high
desired flow;
- To protect the right ventricle, flow may be desired limited: Just
set a low desired flow value;
- To allow maximal exercise capacity,
just set a high desired flow level
at exercise;
- To train the ventricle for weaning,
just set a low desired flow level.
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The “Landscape of control”:

Depending on speed,
h
H ig time, subjective changes
P2P-AMPLITUDE
ing like exercise, coughing,

Low nload
U
pressing etc. the relation
Suction of speed and P2P-Ampli-
t
h if tude of waviness changes.
a lS
e pt
The system should try to
S
stay in the optimal wor-
king point, where
some peak-to-peak-flow
TI
D
waviness remains
M EE
E SP at the “good side”.
This is done by efficiency
optimization.
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Technik und Physik
The limited Observability of the

“Landscape of control”:
Due to the limited

number of speed
P2P-AMPLITUDE
modifications and the

necessity of filtering,
Suction only a small part of the
Detectio
n control landscape is
known to the system.
Speed
Variatio
It must therefore rely
n on local changes of
the environment and
TI
M EE
D react proper to local
E SP
alterations
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Implementation:
Algorithms were developed in Matlab®, implemented in a PC-
Environment with dSpace® signal processor card.
For control, the PC uses only the information available in the pump
controller (flow, speed, current) and generates a speed signal,
which is transferred to the controller.
For safety reasons, beside other measures, the system could be

switched immedeately to standard manual mode by a clinically
experienced supervisor.
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Technik und Physik
Clinical Feasibility Study:

To proove the safety and functionality of the system, 57 tests were
done at three different settings for up to 3 hours:
a) During ICU stay at rest and standard routine like mobilization,
cleaning of respiratory tract, change of bed-linnens;
b) At the standard ward and after hospital release mimicking daily
life conditions for 3 hours: Laying, sitting standing, coughing,
Valsalva, eating, walking around. This series included also
repeated bicylcle exercise (5 minutes bicycling, 5 minutes rest)
with blinded evaluation of the subjective reactions to control/non-
control
c) At right-heart catheterization (required for pretransplant
evaluation),
spiroergometry with non-controlled versus controlled load cycles
was performed.
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Results of the feasibility study:

- The system remained stable also under conditions of extreme
arrythmia (up 240% variation), very thin septum and suddenly
diminished venous return.
- The system did take proper action in case of sudden events like
Valsalva, coughing, and change of position
- No switchover to manual mode was required in any test.
- Suction did occur very rarerly and short, and was never
identified by the patient himself.
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1st Various Zentrum für Biomedizinische
Technik und Physik
3rd
bicycle
exercises at
40 W during
5 minutes
Physiological Control System

2nd 4th
Constant Speed
5th 6th
Research Group on Cardiovascular

Dynamics, Univ. of Vienna, Austria
MicroMed,
MicroMed, Houston TX, USA Schima 07

Technik und Physik
Nonfiltered data at arrythmia:

Vie220 - 19082002 - MediumUnloadingLevel
18 250
16
14 200
[l/min],[A],[W],[krpm]
12 MeanFlow [l/min]
150 P2P-Flow [l/min]
10
[bpm]
MeanCurrent [A]
8 MeanPower [W]
100 MeanSpeed [krpm]
6 HeartRate [bpm]
4 50
2
0 0
2500 2600 2700 2800 2900 3000
Time [sec]
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Technik und Physik
Test Protocol, Catheter Ergometry

Four patients received right heart chaTwo exercise tests,
one in constant speed mode and one in controlled mode
with a break of 45 minutes between:
1) Preparation for exercise and recording of baseline
parameters
2) Warm up: 5 minutes bicycling without load
3) Exercise: 5 minute steps of 25 Watt, 50 Watt, 75 Watt,
until Respiratory Quotient RQ Â 1.1
4) Cool down: 2 minutes bicycling without load
5) Recording of final haemodynamic values at rest after 5
minutes
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Patient Monitoring for catheter-ergometry:
1. Swan-Ganz-
Catheter: CVP; PA;
PCWP; CO
2. Invasive Arterial
Blood Pressure
Measurement
3. Spiro-Analysis:
Oxygen uptake,
Respiratory Quotient
4. DeBakey VAD:
Flow; Speed;
Current
5. ECG
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35
300 40 300
50
250
35
Technik und Physik 250
30
40
200 200
25
[mmHg]
[mmHg]
30
[W]
[W]
150 20 150
20 15
100 100
10
10 50 50
5
0 0 0 0
1 6 11 16 21 26 31 1 6 11 16 21 26 31 36
Vie218 Time [min] Vie220 Time [min]
Constant Speed: PAmean [mmHg]
Pulmonary Arterial and CLCS: PAmean [mmHg]

Constant Speed: PCWP [mmHg] Research Group on Cardiovascular
Wedge Pressure at Constant CLCS: PCWP [mmHg] Dynamics, Univ. of Vienna, Austria
and Controlled Pump Speed Constant Speed: Load [W]
CLCS: Load [W]
40 300 45 300
35 40
250 250
35
30
200 30 200
25
[mmHg]
[mmHg]
25
[W]
[W]
20 150 150
20
15
100 15 100
10
10
50 50
5 5
0 0 0 0
6 11 16 21 26 31 36 1 6 11 16 21 26 31
Vie223 Time [min] Vie224 Time [min]

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Conclusions:
- The algorithm proved safety, reliability, stability and
functionality also in patients with massive arrythmia, very
thin septal wall, and intensive care conditions;
- The system did properly react to physical exercise, with a
massive increase of flow, compared to the low intrinsic flow
increase at constant speed.
- In catheter-ergometry, pulmonary arterial (mean -26%) and
wedge pressure (mean -50%) could be significantly reduced.
- In catheter-ergometry, the control system could increase the
physical capacity up to 17% (mean 10%)
- In first blinded tests (which already exceeded the feasibility
scope of the study) patients did report some subjective
increase of wellness even in short exercise periods.
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Center for Biomedical Eng. & Physics,
Physics,
Dept.
Dept. for Cardiothoracic Surgery,
LBI for Cardiosurgical Research
Assessment of cardiac contractility

during rotary blood pump support using
an index derived from pump flow
P. Naiyanetr1,3, M. Vollkron1, F. Moscato1,4, D. Zimpfer2,
G. Wieselthaler2, H. Schima1,2,3
Department of Biomedical Engineering and Physics,
1
2Department for Cardiothoracic Surgery,
Medical University of Vienna, Austria

3Ludwig-Boltzmann-Cluster for Cardiovascular Research, Austria
4Department of Mechanical Engineering, University of Calabria,
Arcavacata di Rende, Italy

Research Group on
Cardiovascular Dynamics ISRBP 2008
and Artificial Organs

Physics,
Dept.
Background
With the increasing number of clinical applications of rotary
blood pumps (RBPs), the remaining contractile function of
the heart comes into the focus of interest. This is
particularly important for approaches to recovery and
explants of RBP, but also for cardiac protection in long term
implants.
Determination of cardiac function under ventricular support

is challenging: Standard contractility indexes can only be
partially applied (due to continuous unloading), and can be
determined only from time to time (due to complexity of the
measurement procedures).
Research Group on
37
Physics,
Dept.
Aim of the Study
To develop a parameter for assessing contractility of the

heart, which is independent on preload and afterload,
and which can be determined frequently from already
available data.
Research Group on

Physics,
Dept.
A good contractility index has to be:
• sensitive to changes in myocardial properties

• insensitive to changes in preload, afterload, heart rate
• simply accessible
Research Group on
38
Physics,
Dept.
Selected classical cardiac contractility indexes
– Preload-recruitable stroke work

(stroke work vs end-diastolic volume):
SW
PRSW  (Glower D et al. Circulation 1985)
EDV  b0
– Left ventricular dP/dtmax vs end-diastolic volume:
dP dt max
dP dt max EDV  (Little WC Circ Res 1985)
EDV  c0
Disadvantage of these indexes:
Additional (invasive) measurement required
Research Group on

Physics,
Dept.
Proposed pump flow derived index (IQ)

Pump flow (Q)
dQ/dt
Values accessible from flow signal:

dQ dt max
IQ  1. Maximal derivative of pump flow (dQ/dtmax)
QP 2 P  a0
2. Peak to peak pump flow (QP2P)
Advantage of IQ-index: *Moderate speed variation required for a0
A flow signal (either measured or derived) is available in most of the

pumps. It can be easily assessed continuously in RBP recipients.
Research Group on
39
Physics,
Dept.
Computer simulation
Cardiac contractility
(100% 60% and 30% of Emax)
Preload conditions by
increasing end-diastolic volume (EDV) Cardiovascular model
with rotary blood pump
LV-pressure
Afterload conditions by
increasing systemic vascular resistance
LV- volume
Rotary blood pump
(8-12krpm) Pump flow
Model Inputs Simulation Model Outputs
Research Group on

Physics,
Dept.
Indexes from simulations in different preload, afterload, and

contractility during RBP support (mean ± SD)
IQ dP/dtmax /EDV PRSW
Step1:Normal contractility Step2: Reduced contractility Step3: Reduced contractility

(100%) (60%) (30%)
Conditions: afterload (1x, 1.5x, and 2x of systemic vascular resistance), and preload (110, 120, and 130 ml, EDV)
with different contractility (100%, 60% and 30%)
→ Similar trends of the new flow pattern index (IQ) as classical indexes
Research Group on
40
Physics,
Dept.
% change of indexes in different preload, and

afterload (computer simulations)
Cardiac contractility 60%
Conditions: afterload (1x, 1.5x, and 2x of systemic vascular resistance), and preload (110, 120, and 130 ml, EDV)
→ IQ-index changes less than 20% in different preload/afterload conditions
Research Group on

Physics,
Dept.
Acute animal experiments
• Implant MicroMed DeBakey

VAD ® in 7 healthy sheep.
• Adjust pump speeds:
– 7.5-12 krpm
• Use pharmacological
interventions to reduce and
increase cardiac contractility.
– Normal contractility
– Reduced contractility (Verapamil)
Operational situs – Increased contractility & afterload
(Noradrenalin)
Research Group on
41
Physics,
Dept.
Results: Cardiac contractility indexes from

animal experiments (n= 7, mean ± SD)
Step1:Normal contractility Step2: Reduced contractility Step3: Increased contractility

(Pathological case) (Recovery case)
→ Similar trends of the new flow pattern index (IQ) as classical indexes
Research Group on

Physics,
Dept.
% change of indexes after heart rate change

by pacemaker in animal experiments
(Heart rate:100, 110, and 130bpm)
→ IQ-index is less sensitive to heart rate change than other classical indexes
Research Group on
42
Physics,
Dept.
Discussion (I)
• The IQ-index was sensitive to contractility changes and only slightly
sensitive to preload and afterload during RBP support in a similar
manner as other classical contractility indexes.
• The IQ-index was less sensitive than classical contractility indexes to

heart rate changes induced by pacemaker.
• The IQ-index does not rely on any geometric or volumetric

assessment. It is not affected by artifacts created from LV-volume
measurement.
Research Group on

Physics,
Dept.
Discussion (II)
• The IQ-index can be easily continuously assessed in RBP recipients.
• However, for accurate determination of IQ-index a sufficient

frequency response of the flow signal is necessary.
• In the next step clinical data shall be analyzed.
Research Group on
43
Physics,
Dept.
Conclusion
The flow derived index, IQ, is a useful parameter to

continuously indicate cardiac contractility changes in
patients with RBP support without additional
measurements.
Research Group on

Technik und Physik
THREE-DIMENSIONAL SIMULATION OF
VASCULAR FLOW PATTERNS AT
CONTINUOUS ROTARY PUMP
ASSISTANCE
H. Schima2, B. Lackner1, M. Prosi1,
G. Wieselthaler2, K. Perktold1
1Instituteof Numerical Mathematics, TU Graz,

Austria
2Dept. of Cardiovasc. Surgery, Univ. of Vienna,
Austria
Schima 07
44
Technik und Physik
BACKGROUND:
In angiology, deadwater and stagnation areas particularly in

vascular branches are considered to be at high risk for depositions
and plaque growth.
Internal
Particularly the carotid bulb has Carotid
been investigated in detail for
flow conditions and risks of Common
atherosclerosis. Carotid
External
Carotid
With low-pulsatile flow as occuring in rotary pump recipients, recir-

culating areas may even persist during the whole cycle - as
predicted by older twodimensional studies. This may have
detrimental consequences particularly for patients with
atherosclerotic preconditions.
Schima 07

Technik und Physik
Methods (I):
• Surface grids from carotid arteries provided by anatomical

casts;
• Flow Flow patterns derived by Ultrasound from standard
patients and
pump recipients, with interpolation for various degrees of assist;
Cast provided by D.Liepsch
Schima 07
45
Technik und Physik
Methods (II):
Numerical Simulation using:
• 49536 elements, with 420081 velocity nodes and 55601 pressure
nodes
• Time-dependent, three dimensional Navier Stokes Equations;
• Assuming incompressible Newtonian Fluid;
• Boundary conditions with fully developed flow-field and no-slip-
condition at the surface;
• Solver using a Finite Element Galerkin Method,
with Picard relaxation,
based on a biconjugate gradient solvation,
assuming a convection dominated problem,
Stabilization, upwind method: streamline upwind Petrov-
Galerkin.
Schima 07

Technik und Physik
Local velocity profiles without support:
Schima 07
46
Technik und Physik
Local velocity profiles at high support:
Schima 07

Peak wall shear stress: Technik und Physik
Schima 07
47
Technik und Physik
Particle Residence Time at the Sinus:

Particle Particle Part.No. Part.No.
residence Number Medium High
Time at No Support Support
Support
0,00-0,05 369 277 290
0,10-0,15 317 349 245
0,20-0,25 201 324 428 5000 particles

0,30-0,40 156 125 106 randomly started
during a pulse cycle at
Mean 0,161 0,177 0,182 the common carotid
Res. artery
Time
(sec)
Schima 07

Technik und Physik
Summary of Results:
• The maximal extent of the recirculation area depends on the

waveform;
• Secondary flow patterns in the transversal plane provide
considerable washout also at low pulsatile conditions: This
effect is even more pronounced in non-planar bifurcations;
• Particle residence time does not differ considerably between
pulsatile and supported conditions;
• Peak wall shear stress values differ considerably between the
different degrees of pump support;
• Mean wall shear stress is very similar for all conditions at all
locations.
Schima 07
48
Many thanks to: Zentrum für Biomedizinische
Technik und Physik
- my partner: - our department head:

Dr. Wieselthaler Prof. Wolner
and coworkers
- my Working Group,
especially M. Vollkron
- the Physicians and Nurses of the Departments of Cardiac Surgery,

Cardiovascular Anaesthesiology, and Physical Medicine;
- Micromed Company, particularly Dallas Anderson, Bob Benkowski, and
Gino Morello
- the Patients and their Relatives
and last not least my Family!
Schima 07
49

2008 12 03 Schima

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Zentrum für Biomedizinische

Technik und Physik

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Principles of Blood Pumps:

Milestones of Mechanical Cardiac Assist (I):

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Milestones in Mechanical Cardiac Assist (II):

The expectations have changed:

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Schematic of a pneumatic blood pump:

Example: Artificial Heart in Vienna - Phase 1

Clinical Use 1986

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Example: The “New Vienna TAH”, 1985-1991

Patient, 1990 on TAH

1985 Start of Construction and anatomical

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Pulsatile Membran-Blood pumps as assist device in

Electromagnetically driven pulsatile pump:

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Arrow-Lionheart als Final-Therapie:

Arrow-Lionheart als Final-Therapie:

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Arrow-Lionheart als Final-Therapie:

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Classification of Rotary Blood Pumps

Rotary Blood pumps: The bearing of the rotor is

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Classification of Rotary Blood Pumps

Rotary Pumps for short term Assist: Biomedicus®

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Impeller Pumps for short term Cardiac Assist:

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CentriMagR Bearingless Pump

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•First disposable centrifugal blood pump based on

Underside of pump after 11 days

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Terumo Duraheart: actively controlled rotor position

Berlin Heart Incor:

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The Micromed™/De-Bakey Axial Blood Pump

- Titanium pump with

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With axial pumps, the operating field

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Continuous Flow  nonpulsatile flow !

Pump flow stays somewhat

Flow at recovered pulsatility

Low aortic pressure pulsatility:

But after only two hours, we got a call of the nurse:

How should a measure blood pressure?

Solution: Distal measurement of arterial flow with a handheld

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Blood Pressure Monitoring at low arterial

Automatic System with Microcontroller

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