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Switching the Left and the Right Hearts: A Novel Bi-ventricle Mechanical Support Strategy with Spared Native Single-Ventricle

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Abstract

End-stage Fontan patients with single-ventricle (SV) circulation are often bridged-to-heart transplantation via mechanical circulatory support (MCS). Donor shortage and complexity of the SV physiology demand innovative MCS. In this paper, an out-of-the-box circulation concept, in which the left and right ventricles are switched with each other is introduced as a novel bi-ventricle MCS configuration for the “failing” Fontan patients. In the proposed configuration, the systemic circulation is maintained through a conventional mechanical ventricle assist device (VAD) while the venous circulation is delegated to the native SV. This approach spares the SV and puts it to a new use at the right-side providing the most-needed venous flow pulsatility to the failed Fontan circulation. To analyze its feasibility and performance, eight SV failure modes have been studied via an established multi-compartmental lumped parameter cardiovascular model (LPM). Here the LPM model is experimentally validated against the corresponding pulsatile mock-up flow loop measurements of a representative 15-year-old Fontan patient employing a clinically-approved VAD (Medtronic-HeartWare). The proposed surgical configuration maintained the healthy cardiac index (3–3.5 l/min/m2) and the normal mean systemic arterial pressure levels. For a failed SV with low ejection fraction (EF = 26%), representing a typical systemic Fontan failure, the proposed configuration enabled a ~ 28 mmHg amplitude in the venous/pulmonary waveforms and a 2 mmHg decrease in the central venous pressure (CVP) together with acceptable mean pulmonary artery pressures (17.5 mmHg). The pulmonary vascular resistance (PVR)—SV failure case provided a ~ 5 mmHg drop in the CVP, with venous/pulmonary pulsatility reaching to ~ 22 mmHg. For the high PVR failure case with a healthy SV (EF = 44%) pulmonary hypertension is likely to occur as expected. While this condition is routinely encountered during the heart transplantation and managed through pulmonary vasodilators a need for precise functional assessment of the spared failed-ventricle is recommended if utilized in the PVR failure mode. Comprehensive in vitro and in silico results encourage this novel concept as a low-cost, more physiological alternative to the conventional bi-ventricle MCS pending animal experiments.

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Data Availability

There are no restrictions on the availability of materials or information. The compliance and resistance parameters with the datasets generated and/or analyzed during the current study are available via https://doi.org/10.5281/zenodo.6300829. For any questions, please contact corresponding authors.

Abbreviations

BiVAD:

Biventricular assist device

CA:

Common atrium

CI:

Cardiac index

CO:

Cardiac output

CPB:

Cardiopulmonary bypass

CVP:

Central venous pressure

EF:

Ejection fraction

HR:

Heart rate

LPM:

Lumped parameter model

LVAD:

Left ventricle assist device

MCS:

Mechanical circulatory support

PA:

Pulmonary artery

PVR:

Pulmonary vascular resistance

RV:

Right ventricle

RVAD:

Right ventricle assist device

SV:

Single ventricle

SVR:

Systemic vascular resistance

TCPC:

Total cavopulmonary connection

VAD:

Ventricle assist device

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Acknowledgements

We would like to express our gratitude to Medtronic for providing a loaner HeartWare MCS pump during the in vitro experiments.

Funding

Funding was provided by Research Grants from the European Research Council (ERC) Proof of Concept 966765 BloodTurbine, TUBITAK 118M369 and TUBITAK 118S108 (PI: Kerem Pekkan).

Author information

Author notes

  1. This study is conducted through joint corresponding authors Emrah Şişli and Kerem Pekkan.

Authors and Affiliations

  1. Pediatric Cardiovascular Surgery, Department of Cardiovascular Surgery, Osmangazi University Faculty of Medicine, Büyükdere District, Campus of Meşelik, Tepebaşı, 26480, Eskisehir, Turkey

    Emrah Şişli

  2. Department of Biomedical Sciences and Engineering, Koç University, Istanbul, Turkey

    Canberk Yıldırım

  3. Department of Mechatronics Engineering, İstanbul Bilgi University, Istanbul, Turkey

    İbrahim Başar Aka

  4. Pediatric Cardiovascular Surgery, Department of Cardiovascular Surgery, Ege University Faculty of Medicine, Izmir, Turkey

    Osman Nuri Tuncer & Yüksel Atay

  5. Heart Transplantation, Department of Cardiovascular Surgery, Ege University Faculty of Medicine, Izmir, Turkey

    Mustafa Özbaran

  6. Department of Mechanical Engineering, Koç University, Rumeli Feneri Campus, Sarıyer, Istanbul, Turkey

    Kerem Pekkan

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  1. Emrah Şişli
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Contributions

ES, ONT, YA, MO, KP hypothesized and introduced the proposed concept. CY, BA, KP designed and conducted computational and experimental work. All authors wrote and edited the manuscript text.

Corresponding authors

Correspondence to Emrah Şişli or Kerem Pekkan.

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Conflict of interest

KP and CY hold patents on Fontan assist devices but not directly related to the proposed configuration. Authors have no other conflict of interest.

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Associate Editor Lakshmi Prasad Dasi oversaw the review of this article.

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Appendices

Appendix 1

See Tables 5, 6, and 7.

Table 5 Compliance data used in case Fontan
Full size table
Table 6 Compliance data used in case VD-Cr and VD-cmcs
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Table 7 Compliance data used in case VD-switch
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Appendix 2

See Tables 8, 9, and 10.

Table 8 Resistance data used in case Fontan
Full size table
Table 9 Resistance data used in case VD-Cr and VD-cmcs
Full size table
Table 10 Resistance data used in case VD-switch
Full size table

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Şişli, E., Yıldırım, C., Aka, İ.B. et al. Switching the Left and the Right Hearts: A Novel Bi-ventricle Mechanical Support Strategy with Spared Native Single-Ventricle. Ann Biomed Eng 51, 2853–2872 (2023). https://doi.org/10.1007/s10439-023-03348-1

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  • DOI: https://doi.org/10.1007/s10439-023-03348-1

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