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UNIT II CARDIAC ASSIST DEVICES

1. ASSISTED THROUGH RESPIRATION

Cardiac assist devices play a crucial role in supporting cardiac function, particularly in
situations where the heart is unable to meet the body's demands adequately. This assistance
through respiration involves devices that aid not only in pumping blood but also integrate
with the respiratory system for optimal cardiovascular support.
Introduction to Cardiac Assist Devices:
 Cardiac assist devices are mechanical devices designed to augment or replace the
pumping action of the heart.
 They are utilized in conditions such as heart failure, post-cardiotomy shock, or during
cardiac surgery.
Integration with Respiration:
 Certain cardiac assist devices are designed to work in conjunction with the respiratory
system.
 This integration ensures synchronized support to both the circulatory and respiratory
systems.
Types of Devices Assisted through Respiration:
 Ventricular Assist Devices (VADs): Some VADs are synchronized with the patient's
respiratory cycle, optimizing blood flow.

Fig.1. Ventricular Assist Devices

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 Total Artificial Heart (TAH): TAHs are designed to mimic the natural heart's pumping
action and may coordinate with the respiratory cycle.
Physiological Impact:
 Integration with respiration helps in improving oxygenation and overall perfusion.
 It reduces the workload on the native heart, allowing it to recover or facilitating a
smoother transition to cardiac transplantation.
Patient Management:
 Adequate training of healthcare professionals is essential for the proper management
of these devices.
 Continuous monitoring of respiratory and circulatory parameters is crucial for
adjusting device settings.
Challenges and Considerations:
 Synchronization challenges may arise, requiring fine-tuning of device settings.
 Patient-specific factors, such as respiratory rate and tidal volume, need to be
considered for optimal device performance.
Clinical Applications:
 These devices find applications in critical care settings, cardiac surgery, and as a
bridge to transplant.
 They are instrumental in providing temporary circulatory support during periods of
cardiac recovery.
2. RIGHT AND LEFT VENTRICULAR BYPASS PUMP
Right Ventricular Bypass Pump:
Purpose: Used in cardiac surgery to assist or replace the function of the right ventricle.
Indications:
 Right heart failure.
 Pulmonary hypertension.
 Right ventricular infarction.
Components:
 Inflow cannula inserted into the right atrium.
 Outflow cannula positioned in the pulmonary artery.
Function:
 Diverts blood from the right atrium to the pulmonary artery.
 Relieves strain on the right ventricle.

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Applications:
 Cardiopulmonary bypass during cardiac surgeries.
 Support for patients with acute right ventricular dysfunction.
Considerations:
 Monitoring for pulmonary artery pressure.
 Minimizing right ventricular workload.
Left Ventricular Bypass Pump:
Purpose: Aids or takes over the function of the left ventricle during specific conditions.

Fig.2. Left Ventricular Bypass Pump

Indications:
 Left heart failure.
 Severe myocardial infarction.
 Cardiogenic shock.
Components:
 Inflow cannula inserted into the left atrium or ventricle.
 Outflow cannula directed towards the ascending aorta.

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Function:
 Redirects blood from the left atrium/ventricle to the systemic circulation.
 Supports cardiac output.
Applications:
 Coronary artery bypass grafting (CABG).

Fig.3. Coronary artery bypass grafting

 Treatment of refractory heart failure.
Considerations:
 Monitoring systemic arterial pressure.
 Maintaining appropriate preload and afterload.
Common Considerations for Both:
Monitoring:
 Continuous assessment of hemodynamic parameters.
 Adjustments based on central venous pressure (CVP) and arterial pressure.
Complications:
 Thrombosis, requiring anticoagulation.
 Infection at cannula insertion sites.
 Homolysis due to shear forces.
Weaning Process:

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 Gradual reduction of pump support.

 Monitoring for the recovery of native ventricular function.
Patient Selection:
 Criteria for pump initiation and discontinuation.
 Assessment of overall cardiac function.
Integration with Cardiopulmonary Bypass:
 Coordination with the overall bypass system.
 Contribution to the success of complex cardiac procedures.
3. OPEN CHEST AND CLOSED CHEST TYPE:
Open Chest
1. Definition: Involves surgical access to the chest cavity.
2. Common Procedures:
 Coronary artery bypass grafting (CABG).
 Heart valve repair or replacement.
 Lung surgery.
 Cardiac transplantation.

Fig.3. Open Chest Surgery

3. Procedure Steps:
 Median sternotomy or lateral thoracotomy.
 Use of heart-lung machine in cardiac surgeries.

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 Precise exposure for surgical interventions.

4. Advantages:
 Direct visualization of structures.
 Allows complex cardiac surgeries.
5. Disadvantages:
 Invasive.
 Longer recovery.
Closed Chest:
1. Definition: Procedures without open-heart surgery or thoracotomy.
2. Common Procedures:
 Percutaneous coronary interventions (angioplasty).
 Minimally invasive heart surgeries.
 Transcatheter valve replacements.

Fig.4. Angioplasty
3. Procedure Steps:
 Catheter-based procedures through blood vessels.
 Guided by fluoroscopy or echocardiography.
 Smaller incisions or entry points.
4. Advantages:
 Less invasive.
 Quicker recovery.

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 Lower risk of infection.

5. Disadvantages:
 Limited visualization.
 Some complex procedures may not be feasible.
Summary:
 Open Chest: Involves surgical access to the chest cavity for various cardiac and
thoracic procedures. Provides direct visualization but is more invasive.
 Closed Chest: Involves procedures without open-heart surgery or thoracotomy, often
using catheters through blood vessels. Less invasive with quicker recovery but has
limitations in visualization.
4. INTRA-AORTIC BALLOON PUMPING (IABP)
Introduction:
Intra-Aortic Balloon Pumping (IABP) is a mechanical circulatory support device used in
cardiac care to enhance coronary perfusion and reduce workload on the heart. Here are
detailed notes on its mechanism, indications, insertion, and potential complications.

Fig.4. Intra-Aortic Balloon Pumping

Mechanism:
 IABP augments coronary blood flow by inflating and deflating a balloon in the
descending aorta.

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 Inflation occurs during diastole, reducing afterload, and deflation during systole aids
in ejection.
Indications:
 Ischemic Heart Disease: IABP is often used in acute myocardial infarction to improve
coronary perfusion.
 Cardiogenic Shock: It provides temporary circulatory support in severe cardiac
failure.
 High-Risk Coronary Interventions: Facilitates stable hemodynamic during procedures.
Insertion:
 Usually done in the catheterization laboratory or the intensive care unit.
 The balloon-tipped catheter is advanced through the femoral artery into the
descending aorta under fluoroscopic guidance.
 Proper positioning is crucial for optimal support.
Balloon Inflation and Deflation Timing:
 Inflation coincides with the onset of diastole, augmenting coronary blood flow.
 Deflation occurs just before systole, reducing afterload and improving left ventricular
ejection.
 Monitoring:
Continuous hemodynamic monitoring is essential during IABP therapy.
 Parameters such as blood pressure, heart rate, and balloon augmentation are closely
observed.
Complications:
 Ischemia: Inadequate augmentation may lead to coronary ischemia.
 Vascular Complications: Femoral artery issues, bleeding, and thrombosis.
 Balloon Rupture: Rare, but a serious complication requiring immediate intervention.
Weaning and Removal:
 Weaning is a gradual reduction of balloon support as the heart's function improves.
 Removal is typically a simple bedside procedure, but careful monitoring continues.
Limitations:
 IABP may not be effective in certain conditions, such as severe aortic regurgitation.
 Long-term use is limited due to the risk of complications.
5. PROSTHETIC CARDIAC VALVES
Types of Heart Valves:

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 Aortic Valve: Connects the left ventricle to the aorta.

 Mitral Valve: Located between the left atrium and left ventricle.
 Tricuspid Valve: Found between the right atrium and right ventricle.
 Pulmonary Valve: Connects the right ventricle to the pulmonary artery.
Classification of Prosthetic Valves:
1. Mechanical Valves:
 Materials: Commonly made of pyrolytic carbon or titanium.
 Durability: Longer lifespan but may require anticoagulation therapy.
 Sounds: Often associated with audible clicking sounds.
 Advantages: Durable, less degeneration over time.
2. Bioprosthetic Valves:
 Materials: Typically made from animal tissues (porcine or bovine) or human
cadaveric tissues.
 Durability: Limited lifespan but may not require long-term anticoagulation.
 Sounds: More natural sounds compared to mechanical valves.
 Advantages: Lower risk of thrombosis, no long-term anticoagulation in some
cases.

Fig.5. Types of Prosthetic Valves

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Surgical Techniques:
1. Valve Replacement Surgery:
 Open-Heart Surgery: Traditional method involving a sternotomy (cutting through
the breastbone).
 Minimally Invasive Surgery: Involves smaller incisions, reduced recovery time.
2. Transcatheter Valve Replacement (TAVR):
 A less invasive procedure where a new valve is implanted through a catheter, often
suitable for high-risk or inoperable patients.
Complications and Considerations:
1. Anticoagulation Therapy:
 Required for mechanical valves to prevent clot formation.
 Regular monitoring of INR levels.
2. Valve Degeneration:
 Bioprosthetic valves may degenerate over time, requiring re-replacement.
3. Infection:
 Risk of infective endocarditis, especially with mechanical valves.
4. Thrombosis and Embolism:
 Potential complications leading to strokes or other vascular events.
5. Patient Selection:
 Choosing the appropriate type of valve based on the patient's age, lifestyle, and
medical history.
Follow-up and Rehabilitation:
1. Postoperative Care:
 Monitoring for complications such as bleeding, infection, or valve dysfunction.
 Cardiac rehabilitation for physical recovery.
2. Long-term Monitoring:
 Regular follow-up appointments to assess valve function and overall
cardiovascular health.
Emerging Technologies:
1. Tissue Engineering:
 Advancements in creating synthetic materials that mimic natural tissue properties.
2. Nanotechnology:
 Potential for improving the durability and performance of prosthetic valves.

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6. PRINCIPLE OF EXTERNAL COUNTER PULSATION TECHNIQUES

External Counter Pulsation (ECP) is a non-invasive medical treatment used to
increase coronary blood flow in patients with coronary artery disease (CAD) or
angina. The principle of ECP involves the use of inflatable cuffs or sleeves that are
wrapped around the patient's legs and buttocks. These cuffs are inflated and deflated
in synchronization with the cardiac cycle to augment blood flow to the coronary
arteries.
1. Introduction to External Counter Pulsation (ECP):
 External Counter Pulsation is a non-surgical, non-pharmacological treatment
for coronary artery disease.
 Developed as a therapeutic modality to improve myocardial perfusion and
reduce angina symptoms.
2. Basic Physiology of Coronary Blood Flow:
 Coronary arteries supply oxygen and nutrients to the heart muscle.
 During diastole (relaxation phase of the heart), coronary arteries receive blood
flow.
 Coronary blood flow is crucial for myocardial oxygenation and function.

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Fig. 6. External Counter Pulsation Procedure

3. Mechanism of ECP:
 ECP involves the use of inflatable cuffs placed around the patient's lower
limbs (legs and buttocks).
 Inflation and deflation of cuffs are synchronized with the cardiac cycle.
 Inflation occurs during diastole, augmenting blood flow to the coronary
arteries.

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 Deflation occurs just before systole, reducing resistance and enhancing

coronary perfusion.
4. Cuff Inflation and Deflation Phases:
 Cuffs inflate sequentially from the lower extremities towards the buttocks.
 Inflation phase increases pressure in the lower limbs, pushing blood centrally.
 Deflation occurs rapidly just before the next cardiac cycle, reducing
impedance for blood ejection from the heart.
5. Hemodynamic Effects of ECP:
 Augmented diastolic pressure in the aorta leads to increased coronary
perfusion.
 Improved myocardial oxygen supply without increased workload on the heart.
 Enhanced collateral circulation may develop over time.
6. Indications for ECP:
 Chronic stable angina not responsive to conventional treatments.
 Patients not suitable for revascularization procedures.
 Post-myocardial infarction patients with persistent angina.
7. Contraindications and Safety Considerations:
 Acute myocardial infarction.
 Severe congestive heart failure.
 Significant aortic insufficiency.
 Uncontrolled hypertension.
8. ECP Treatment Protocol:
 Typically administered in outpatient settings.
 Sessions last about an hour, with multiple sessions scheduled over several
weeks.
 Gradual increase in pressure and duration over the course of treatment.
9. Clinical Efficacy and Outcomes:
 Reduction in angina symptoms.
 Improved exercise tolerance.
 Potential for enhanced quality of life.

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