UNIT 1

CARDIAC ASSIST DEVICES

EXTERNAL COUNTERPULSATION
DEFINITION
 External counterpulsation (ECP) is a noninvasive therapy to
improve blood flow to the heart.
 It is most commonly used to relieve chronic stable chest pain for
heart patients who are refractory to medical and surgical
intervention.
METHODOLOGY
 Three compressive air cuffs are placed at:
 Calves
 Lower thighs
 Upper thighs
 These inflate and deflate in synchronization with the patient’s
cardiac cycle using cardiac monitors and a microprocessor.
 Inflation- onset of diastole
 Deflation-onset of systole
 The cuffs are sequentially inflated starting from the distal one
and moving towards the proximal cuff (wrt the heart) with a
pressure of 300mm Hg.
 This treatment is carried on for one hour per session.
 Five sessions are provided per week for seven weeks(i.e. on the
whole 35 treatments are to be provided).
HOW ECP WORKS
 ECP increases cardiac output by a combination of the increased
preload and the decreased afterload during the ECP session.
 Inflation of the cuffs during diastole compresses the venous
system in the legs, causing increased venous return to the heart,
thereby increasing left ventricular preload.
 This increased filling of the left ventricle increases cardiac
output.
 Deflation of the cuffs in systole decrease afterload (the pressure
the left ventricle has to overcome in order to eject blood),
decreasing the vascular impedance, thus increasing the cardiac
output.
THEORIES ASSOCIATED WITH ECP
 The most popular theory is that EECP triggers the body to create
tiny blood vessels (known as collaterals) that act like a natural
bypass, carrying blood around larger blocked vessels. Chest
pain is then reduced because the heart is again able to receive
oxygen-rich blood.
 Another theory is that cuff inflation/deflation increases the force
of the blood flow to the heart, causing the cells lining the blood
vessels to produce chemicals that widen the blood vessels,
allowing blood to flow through more freely.
CONTRAINDICATIONS
 Severe heart failure and heart valve problems
 Arrhythmias
 Peripheral heart diseases
 High blood pressure
 Pregnancy
BENEFITS OF ECP
 Safe and effective for angina pectoris
 Frequency and intensity of angina attacks is reduced
 Provides a higher quality of life
RISKS OF ECP
 Skin abrasions.
 Bruising.
 Blistering due to the inflatable cuffs.
 Minor pain in the legs and back.

INTRA AORTIC BALOON PUMP

• The Intra-aortic balloon pump (IABP) is a mechanical device
that is used to decrease myocardial oxygen demand while at the
same time increasing cardiac output.
• An intraaortic balloon pump (IABP) is a device that increases
blood flow to the heart muscle and decreases the heart’s
workload through a process called counterpulsation.
PRINCIPLE
 Intraaortic balloon counterpulsation is used in situations when
the heart's own cardiac output is insufficient to meet the
oxygenation demands of the body.
 By increasing cardiac output it also increases coronary blood
flow and therefore myocardial oxygen delivery.
 that the heart is doing two different kinds of work. The first type
of work occurs during the pumping part of the heartbeat .
 The second type of work occurs during the relaxed part of the
heartbeat (the diastole), during which the heart receives blood
via backflow from the aorta.
 This is described as the difference between pressure work
and flow work, respectively.
 The flow of blood to the heart muscle through the coronary
arteries mainly occurs during the diastole.
 A healthy heart is normally able to accomplish both types of
work effectively, but a weakened heart will have more
difficulty.
GOALS
• The primary goals of IABP treatment are to increase myocardial
oxygen supply and decrease myocardial oxygen demand.
• The primary goals of IABP treatment are to increase myocardial
oxygen supply and decrease myocardial oxygen demand.

CONSTRUCTION
 It consists of a cylindrical balloon that sits in the aorta and
counterpulsates. That is, it actively deflates in systole increasing
forward blood flow by reducing afterload thus, and actively
inflates in diastole increasing blood flow to the coronary
arteries.
 These actions have the combined result of decreasing
myocardial oxygen demand and increasing myocardial oxygen
supply.
 The balloon is inflated during diastole by a computer controlled
mechanism, usually linked to either an ECG or a pressure
transducer at the distal tip of the catheter.
 Helium is used because its low viscosity allows it to travel
quickly through the long connecting tubes, and has a lower risk
of causing a harmful embolism should the balloon rupture while
in use.
 Whereas carbon dioxide has an increased solubility in blood and
thereby reduces the potential consequences of gas embolization
following a balloon rupture.
INSERTION TECHNIQUE
 In the early years of IABP - therapy, insertion of the balloon
was performed by surgical cut down to the femoral vessels.
 a percutaneous placement of the IAB via the femoral artery
using a modified Seldinger technique allows an easy and rapid
insertion in the majority of situations.
 sheathless insertion kits are available now. Removal of a
percutaneously placed IAB may either be via surgical removal
or closed technique
 The most common strategy for inserting an intraaortic balloon
pump (IABP) is a catheter-based procedure.
 Just prior to the procedure, the area to receive the catheter is
shaved (if necessary) and sterilized to prevent infection.

WORKING
 By increasing cardiac output it also increases coronary blood
flow and therefore myocardial oxygen delivery.
 It consists of a cylindrical balloon that sits in the aorta and
counterpulsates. That is, it actively deflates in systole increasing
forward blood flow by reducing afterload.
 actively inflates in diastole increasing blood flow to
the coronary arteries.
 These actions have the combined result of decreasing
myocardial oxygen demand and increasing myocardial oxygen
supply
TRIGGERING
 Inflation and deflation is accomplished by either using the
patient’s ECG signal, the patient’s arterial waveform or an
intrinsic pump rate.
 The most common method of triggering the IAB is from the R
wave of the patient’s ECG signal.
 Mainly balloon inflation is set automatically to start in the
middle of the T wave and to deflate prior to the ending QRS
complex.
 Tachyarrhythmias, cardiac pacemaker function and poor ECG
signals may cause difficulties in obtaining synchronization when
the ECG mode is used. In such cases the arterial waveform for
triggering may be used.
TIMING AND WEANING
 It is important that the inflation of the IAB occurs at the
beginning of diastole, noted on the dicrotic notch on the arterial
waveform.
 Deflation of the balloon should occur immediately prior to the
arterial upstroke.
 Balloon synchronization starts usually at a beat ratio of 1:2. This
ratio facilitates comparison between the patient’s own
ventricular beats and augmented beats to determine ideal IABP
timing.
 If the patient’s cardiac performance improves, weaning from the
IABP may begin by gradually decreasing the balloon
augmentation ratio (from 1:1 to 1:2 to 1:4 to 1:8) under control
of hemodynamic stability
INDICATIONS
The following situations may benefit from this device:
 Cardiogenic shock when used alone as treatment for myocardial
infarction 9-22% survive the first year.
 Reversible intracardial mechanical defects complicating
infarction, i.e. acute mitral regurgitation and septal perforation.
 Unstable angina pectoris benefits from counterpulsation.
 Percutaneous coronary angioplasty.
 assist in complicated balloon angioplasty procedures and
various other cardiac situations.
 Cardiac patients requiring procedural support during coronary
angiography.
 Post cardiothoracic surgery most common and useful is the use
of counterpulsation in weaning patients from cardiopulmonary
bypass after continued perioperative injury to myocardial tissue.
 Preoperative use has been suggested for high-risk patients such
as those with unstable angina with stenosis greater than 70% of
main coronary artery, in ventricaular dysfunction with
an ejection fraction less than 35%.
 Bridge to heart transplant for those patients with left ventricular
failure.
 wean patients off the heart-lung machine during open-heart
surgery.
CONTRAINDICATIONS
• Aortic valve insufficiency.
• Aortic dissection.
• Severe aortoiliac occlusive disease.
• Prosthetic vascular grafts in the aorta.
• Aortic aneurysm.
• Aortofemoral grafts.
• Irreversible brain damage.
• Severe vascular disease
LONGEVITY
• The intraaortic balloon pump (IABP) usually remains implanted
for a short period of time, such as in the following situations:
• Before, during or after open-heart surgery or balloon
angioplasty (in high-risk patients)
• During acute attacks of angina
• In emergency situations (e.g., heart attack, heart failure, very
low blood pressure due to cardiogenic shock)
BENEFITS
The IABP offers the following potential benefits:
 Improved circulation
 Lower heart rate and decreased workload of the heart
 Improved efficiency of the heart’s pumping
 Increased supply of oxygen to heart tissues and decreased
demand for it
 Less pressure resistance in the aorta when the heart pumps
(during the systole)
 More pressure in the aorta when the heart is relaxing, thus
increasing blood flow to the heart muscle (during the diastole)
RISKS
some complications that are reported in some patients include:
 Damage to the aorta or femoral artery
 Heavy bleeding (hemorrhaging), occasionally from the site of
insertion
 Infection
 Lack of oxygen-rich blood to either a limb (limb ischemia) or an
organ (visceral ischemia), due to narrowed blood vessels
 Tearing or bursting of the balloon, releasing gas into the
bloodstream with potentially dangerous results

HEART LUNG MACHINE CONDITIONS

Abstract Conditions:
An apparatus is described for taking over the functions of the
human heart and lungs for short periods of time to permit a surgeon
to perform certain open-heart surgical procedures in a blood-free
field.
This equipment is capable of receiving venous blood from the
patient, removing excess carbon dioxide and restoring the proper
oxygen content, and finally of pumping the blood back into the
patient‘s arterial system.
The heart-lung apparatus is provided with controls that
automatically maintain the pH of the blood at its correct value,
maintain proper blood temperature and safeguard the patient
against unwanted changes in blood volume and against excessive
blood pressure during the course of the operation.
The machine requires the attention of only two persons during
normal surgical procedures.
The basic tasks to be performed by the heart-lung apparatus are to
ensure the proper flow of the patient’s blood through his veins and
arteries, the removal of excess carbon dioxide from his blood
stream, and the addition of the proper amount of oxygen to it.
 A more general, but nonetheless important requirement, is that all
factors pertaining to the patient’s physiology be maintained as
close to normal as the conditions of the operation will permit.
This means that the rate of flow of blood, its temperature, its
oxygen and carbon dioxide content, its degree ofalkalinity or pH
value, and its water content be kept as near their normal values as
possible.
The use of a minimum amount of drugs is also indicated under this
heading. The blood must be handled with extreme care to avoid
damage, aswill be described in detail later, and, of course, strict
adherence must be maintained at all times to the requirements for
surgical sterility and to other factors which might affect the success
of the operation

HEART LUNG MACHINE

FUNCTIONS OF HEART
• Deoxygenated blood through Superior Vena Cava flows to the
RA at a pressure of 0 to 5 mm of Hg.
• Through the Tricuspid valve it enters the RV.
• The Semi lunar Valve opens and it flows into the Lungs through
the PA.
• In Lungs it gets oxygenated to 95 to 98% sat and flows into the
LA through the PV.
• Then to the LV through Mitral Valve,from there to the Internal
organs through Aorta.
Necessity of a Heart Lung Machine
• During OHS for installation of a Valve Prothesis.
• Correction of a Congenital Malformation-When Circulation
cannot be maintained by the Heart.
MODEL OF HLM

MODEL OF HLM From Heart

From coronary sinus

To Artery
To coronary arteries Venous input

Coronory
Filter Coronary Sinus
Pump Receiving Pump
Reservoir

Arterial Heat Coronary Heat

Exchanger Exchanger Settling
Reservoir

Arterial
Pump Oxygenator

FUNCTIONS
• LUNGS--------- OXYGENATOR
• HEART--------- PUMPS
OXYGENATORS
• For Oxygenation of Blood, upto 5 l/min of blood.
• Ideal oxygenation req:
1. Lower Priming Volume.
2. Simple,Safe ,Reliable operation.
3. Short preparation time.
4. No Microembolus formation.
Types of Oxygenators
• BUBBLE OXYGENATOR
• FILM OXYGENATOR
• MEMBRANE OXYGENATOR
• LIQUID-LIQUID OXYGENATOR
BUBBLE OXYGENATOR-
Principle
• Oxygen is bubbled through a large column of blood and made to
flow through a slanting path to remove Carbon dioxide.

Co2

Filter

O2 Blood

DESCRIPTION
Two components
1.Oxygen is bubbled in finely dispersed form
2. Gas separating component- gaseous exchange
takes place
Bubbles and foam are removed-if bubbles present causes
air emboli, to remove it defoaming agent like silicon is used.
 Types::
1.Permanent type
2.Disposable type
DISC TYPE FILM OXYGENATOR

O2
CO2

Blood Blood

Film oxygenator
• A thin film of blood is spread on a rotating disc or a metal
screen and oxygen mixture flows over it.
TYPES:::
1.FOAM::: Blood is poured on top of the blood foam
and oxygen mixture is bubbled through it in opposite direction.
Blood spreads over the surface of the bubble in a thin
form and it is exposed to oxygen.the filmed blood is oxygenated
2.SCREEN TYPE:::
1.A thin film of blood over a screen is exposed to oxygen.
* Disposable.
3.BLOOD FILM OVERSPONGE
1. A small volume of sponges saturated with blood provides a
large surface area if oxygen is distributed in the sponge.
* Artificial alveoli
. ROTATING DISC FILM OXYGENATOR:::
1.Rotating disc are present as vertical lines.
2.Blood level is maintained at the bottom of the cylinder
so that only the outer edge is immersed in the blood.
3.Rotation of the cylinder causes a thin film to form the
periphery of the disc ,after short exposure the blood is washed off
and a new film is formed on it it is also washed off.
4. Exposure of blood film is only for shorter period.
MEMBRANE OXYGENATOR
• PRINCIPLE:
Effective oxygenation is done when blood and oxygen are
running in opposite direction through a thin porous membrane

Blood Blood

Membrane

CO2 O2
Metal mesh

LIQUID –LIQUID OXYGENATOR

• PRINCIPLE:::
Oxygen dissolved fluoridised organic fluid and blood are flowing
in opposite direction and oxygenation of blood takes place.
 Description
• Fluoridised organic liquid is the liquid in which O2 is dissolved
readily and diffuses from it the Carbon dioxide content.
• No chemical reaction occurs between blood and it.
BLOOD PUMPS
• IDEAL PUMP REQUIREMENTS:::
1. Must pump 6 ltr of blood per minute with app pressure.
2. Should not cause any damage to the cellular and Non cellular
components.
3. Must be easy to clean and sterilize.
4. Calibration must be exact.
5. In emergency it should operate manually.
TYPES OF PUMPS
PULSATILE PUMPS:::
• Diaphragm pump is similar to the Artificial
heart .
• Diaphragm is activated by a Pneumatic system.
• It has two chambers inner and outer .
• When the pumping fluid is injected inside the outer chamber,the
inner is compressed and blood is ejected through the outlet
valve.
• When the pumping medium is withdrawn it retains its shape.
NON PULSATILE PUMP:::
• Done by squeezing a tube filled with blood by a roller.
– Roller pump.
–
CARDIAC VALVE IMPLANTS
• The heart is a hollow, cone-shaped muscular organ located
between the lungs and behind the sternum . Two-thirds of the
heart is located to the left of the midline of the body and 1/3 is
to the right

BLOOD SUPPLY TO HEART

There are two main coronary arteries –
• The left main coronary artery and the right coronary artery.
• The left main coronary artery divides into the left anterior
descending branch
and the left circumflex arteries
• Each artery supplies blood to different parts of the heart muscle
and the electrical system.
 Chambers and Valves
The heart is divided into four chambers:
• right atrium (RA)
• right ventricle (RV)
• left atrium (LA)
• left ventricle (LV)
Each chamber has a sort of one-way valve at its exit that prevents
blood from flowing backwards. When each chamber contracts, the
valve at its exit opens. When it is finished contracting, the valve
closes so that blood does not flow backwards
• The tricuspid valve is at the exit of the right atrium.
• The pulmonary valve is at the exit of the right ventricle.
• The mitral valve is at the exit of the left atrium.
• The aortic valve is at the exit of the left ventricle
Blood from the body flows: to the superior and inferior vena cava,
then to the right atrium through the tricuspid valve to the right
ventricle through the pulmonic valve to the pulmonary artery to the
lungs .
The blood picks up oxygen in the lungs, and then flows from the
lungs: to the pulmonary veins to the left atrium through the mitral
valve to the left ventricle through the aortic valve to the aorta to the
body.
VALVES OF THE HEART
Mitral valve
Also known as the bicuspid valve, the mitral valve gets its name from
the resemblance to a bishop's mitre (a type of hat). It prevents blood
flow from the left ventricle into the left atrium. It is on the left side of
the heart and has two leaflets.
Tricuspid valve
The tricuspid valve is on the right side of the heart, between the right
atrium and the right ventricle
Semilunar valves
These are positioned on the pulmonary artery and the aorta..
Aortic valve
The aortic valve lies between the left ventricle and the aorta. The
aortic valve has three cusps
Pulmonic valve
The pulmonic valve lies between the right ventricle and the
pulmonary artery and also has three cusps
Heart Valve Problems
There are numerous complications and diseases of the heart
valves that prevent the proper flow of blood. Heart valve
diseases fall into two categories,
Stenosis and Incompetence.
The stenotic heart valve prevents the valve from opening fully,
due to stiffened valve tissue. Hence, there is more work required
to push blood through the valve.
Whereas, the incompetent valves cause inefficient blood
circulation by permitting backflow of blood in the heart.
Treatment Options
An enormous amount of research and development has
proven to be most beneficial, as prosthetic heart valve
technology has saved hundreds of thousands of lives. Engineers
and scientists have done much work to design a valve that can
withstand millions, if not billions, of cardiac cycles.
Artificial heart valve
An artificial heart valve is a device which is implanted in the heart
of patients who suffer from valvular diseases in their heart. When one
or two of the four heart valves of the heart have a malfunction, the
choice is normally to replace the natural valve by an artificial valve.
This requires open-heart surgery.
Why do we need valves
Valves are integral to the normal physiological functioning of the
human heart. Natural heart valves are structures which have evolved a
form which meets their functional requirements, which is to induce
largely unidirectional flow through themselves. Natural heart valves
may become dysfunctional due to a variety of pathological causes.
Certain heart valve pathologies may necessitate the complete surgical
replacement of the natural heart valves with heart valve prostheses
Types of heart valve prostheses
There are two main types of artificial heart valves:
Mechanical heart valves
Biological heart valves
Mechanical valves
Modern mechanical valves can last indefinitely.
However, current mechanical heart valves all require lifelong
treatment with a blood thinner, e.g. warfarin, which requires
monthly blood tests to monitor.
 A mechanical heart valve is intended to replace a diseased heart
valve with its prosthetic equivalent.
This process of thinning the blood is called anticoagulation.
Biological valves
Tissue heart valves, in contrast, do not require the use of
anticoagulant drugs due to the improved blood flow dynamics
resulting in less red cell damage and hence less clot formation.
Their main weakness however, is their limited lifespan.
Traditional tissue valves, made of pig heart valves, will last on
average 15 years before they require replacement.
Types of MHV's
There are three major types of mechanical valves –
caged-ball,
tilting-disk and
bileaflet - with many modifications on these designs.
The caged ball design is one of the early mechanical heart valves, that
uses a small ball that is held in place by a welded metal cage.. Natural
heart valves allow blood to flow straight through the center of the
valve. This property is known as central flow, which keeps the
amount of work done by the heart to a minimum. With non-central
flow, the heart must work harder to compensate for the momentum
lost to the change of direction of the fluid. Caged-ball valves
completely block central flow, therefore the blood requires more
energy to flow around the central ball. In addition, the ball is
notorious for causing damage to blood cells due to collisions.
Damaged blood cells release blood clotting ingredients, hence the
patients are required to take lifelong prescriptions of anticoagulants.
The tilting-disc valves have a polymer disc held in place by two
welded struts. The disc floats between the two struts in such a way, as
to close when the blood begins to travel backward and then reopens
when blood begins to travel forward again. The tilting-disc valves are
vastly superior to the ball-cage design. The titling-disc valves open at
an angle of 60° and close shut completely at a rate of 70
times/minute. This tilting pattern provides improved central , reduce
mechanical damage to blood cells.. However, the only problem with
this design is its tendency for the outlet struts to fracture as a result of
fatigue from the repeated ramming of the struts by the disc.
In 1979, a new mechanical heart valve was introduced. These
valves were known as bileaflet valves, and consisted of two
semicircular leaflets that pivot on hinges.
The carbon leaflets exhibit high strength and excellent
biocompatibility. The leaflets swing open completely, parallel to
the direction of the blood flow.
They do not close completely, which allows some backflow.
Since backflow is one of the properties of defective valves, the
bileaflet valves are still not ideal valves.
One of the main advantages of these valves is that they are well
tolerated by the body. Only a small amount of blood thinner is
needed to be taken by the patient each day in order to prevent
clotting of the blood when flowing through the valve
Blood damage
One of the major drawbacks of mechanical heart valves is that
patients with these implants require consistent anti-coagulation
therapy.
Clots formed by red blood cell (RBC) and platelet damage can
block up blood vessels and lead to very serious consequences.
Mechanical heart valves can also cause hemolytic anemia with
hemolysis of the red blood cells as they pass through the valve.
Materials
Current research has been able to produce materials that do
not cause clotting in the blood stream. However, they have yet
to design an entire valve that will not induce coagulation.
Most commonly used materials include:
- stainless steel alloys
- molybdenum alloys
- pyrolitic carbon for the valve housings and leaflets
- silicone, teflon®
- polyester (Dacron®) for sewing rings
A new generation of mechanical valves made of materials
with improved blood contact properties, better wear
characteristics and resistance to infection are under
development.
PROSTHETIC TISSUE VALVES
Prosthetic tissue valves can be broken into two groups: human
tissue valves, and animal tissue valves. Both types are often referred
to as bioprosthetic valves, which hold many advantages over
mechanical valves. The design of bioprosthetic valves are closer to
the design of the natural valve. Bioprosthetic valves do not require
long-term anticoagulats, have better hemodynamics, do not cause
damage to blood cells, and do not suffer from many of the structural
problems experienced by the mechanical heart valves

Human Tissue Valves

Human tissue valves fall into two categories: Homograft, which are
valves that are transplanted from another human being, and Autograft
, which are valves that are transplanted from one position to another
within the same person.
Animal Tissue Valves
Animal tissue valves are often referred to as heterograft or
xenograft valves. These valves are most often heart tissues recovered
from animals at the time of commercial meat processing. The leaflet
valve tissue of the animals is inspected, and the highest quality leaflet
tissues are then preserved. They are then stiffened by a tanning
solution, most often glutaraldehyde. The most commonly used animal
tissues are: porcine, which is valve tissue from a pig, and bovine
pericardial tissue, which is from a cow.
Functional requirements of heart valve prostheses
Minimal regurgitation - This means that the amount of blood lost
upstream as the valve closes is small. A desirable characteristic of
heart valve prostheses is that regurgitation is minimal over the full
range of physiological heart function
Minimal transvalvular pressure gradient - Whenever a fluid flows
through a valve, a pressure gradient arises over the restriction. This
pressure gradient is a result of the increased resistance to flow . A
desirable characteristic of heart valve prostheses is that their
transvalvular pressure gradient is as small as possible.
A desirable characteristic of heart valve prostheses is that they are non
or minimally thrombogenic.
Self-repairing No heart valve prostheses can currently self-repair but
replacement tissues grown using stem cell technology may eventually
offer such capabilities

CONCLUSION
Many people have benefited from prosthetic heart valves over the past
30 years. Chemical engineers believe that the future of prosthetic
valves lies in the regime of tissue engineering. This would improve
the biocompatibily factor, and increase the life expectancy of the heart
valve.