WORK IN PROGRESS REPORT ADULT CARDIAC

Interactive CardioVascular and Thoracic Surgery 19 (2014) 1115

doi:10.1093/icvts/ivu073 Advance Access publication 9 April 2014

Pulsatile mode of operation of left ventricular assist devices

and pulmonary haemodynamics
Michael Poullis*
Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
* Corresponding author. Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK. Tel: +44-151-2281616;
fax: +44-151-2932254; e-mail: mpoullis@hotmail.com (M. Poullis).

Abstract
OBJECTIVES: To determine the effect of differing modes of left ventricular assist device (LVAD) operation: synchronous, independent
(asynchronous or pseudosynchronous) or counter pulsation (antisynchronous), on left atrial pressure, pulmonary artery pressure, pulmonary blood ow and right ventricular work load, utilizing a previously published electrical analogy of the systemic and pulmonary circulation
and the heart.
METHODS: A previously published electrical analogy of the systemic and pulmonary circulation was utilized. The Simulation Package with
Integrated Circuit Emphasis (LTSPICE IV) was utilized. Three LVAD operation mode scenarios were analysed: synchronous, counter pulsation and independent pulsatile. The root mean square of the pulmonary artery pressure (PAP), left atrial pressure (LAP) and pulmonary
blood ow (PBF) were calculated, as was the right ventricular work load.
RESULTS: Counter pulsation LVAD operation resulted in the lowest LAP, PAP, right ventricular work load and the highest pulmonary blood ow.
Independent pulsation resulted in the highest LAP, PAP and the lowest pulmonary blood ow. This technique actually increased RV work load.
CONCLUSIONS: If an LVAD is to be operated in a pulsatile mode, the counter pulsation mode reduces pulmonary artery and left atrial pressure
and increases pulmonary blood ow and thus cardiac output. This is in addition to the reduced right ventricular energetic requirement, a
nding previously described. Clinical validation of our ndings is necessary.
Keywords: Left ventricular assist device Electrical analogy Simulation

INTRODUCTION
Left ventricular assist devices (LVADs) are utilized for failing left ventricle function [1, 2]. LVADs can operate in a number of different
modes: continuous or pulsatile mode; the latter can be independent,
synchronous or counter pulsation with respect to the native heart.
LVADs work in a manner analogous to intra-aortic balloon
pumps increasing forward ow and decreasing the work of the left
ventricle [3].
The left and right ventricles contract essentially simultaneously.
This results in the pulmonary and aortic valves being open simultaneously and the mitral and tricuspid valves being closed simultaneously. As the mitral valve is closed when the right ventricle
contracts, right ventricular stroke volume has to be accommodated
by the pulmonary vasculature [4]. The rise in pulmonary artery pressure depends on the native pulmonary vascular compliance. If the
mitral valve was open when the right ventricle contracts or the LVAD
is lling during right ventricle systole, then the left atrial pressure will
be lower and the forward ow higher, i.e. counter pulsation.
Previous work has identied that operating an LVAD in a
counter pulsation manner results in reduced left ventricular work
[5]. We extend this analysis by analysing the differing modes of
LVAD operation: synchronous, independent or counter pulsation

(antisynchronous), on pulmonary artery pressure and ow utilizing

a previously published electrical analogy of the systemic and pulmonary circulation and the heart [6].

METHODS
The previously published electrical analogy of the systemic and
pulmonary circulation was utilized [6], Fig. 1. The Simulation Package
with Integrated. Circuit Emphasis (SPICE) circuit listing is detailed in
the Supplementary material.
Three LVAD operation mode scenarios were analysed: synchronous, counter pulsation (antisynchronous) and independent pulsatile
(pseudosynchronous or asynchronous).

Baseline variables for model

Systemic blood pressure of 140 mmHg, a cardiac output of 5.5 l/min.
It was assumed that 1 V ;1 mmHg of pressure. The intrinsic heart
rate was assumed to be 60 beats/min for all analyses, and 1 mA ;
1 l/min. The root mean square of the pulmonary artery pressure
(PAP), left atrial pressure (LAP) and pulmonary blood ow (PBF)

The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

WORK IN PROGRESS
REPORT

Received 2 December 2013; received in revised form 18 January 2014; accepted 22 January 2014

12

M. Poullis / Interactive CardioVascular and Thoracic Surgery

Figure 1: Electrical analogy of systemic and pulmonary circulation.

Figure 2: Baseline aortic, pulmonary artery pressure, left atrium pressure traces and pulmonary blood ow. I[Lungs1] represents pulmonary blood ow which is essentially cardiac output assuming no intracardiac shunts.

were calculated utilizing LTSPICE (CTRL and left click on the variable to be measured). Simulation assumed no aortic regurgitation
and the absence of a patent foramen ovale.

normalized (referenced) to the baseline function of the RV in a

normally functioning heart.

Effect of heart rate

Incorporation of left ventricular assist device
into circulatory model
The different modes of operation of the LVAD were simulated by
adjusting the mode of operation of the voltage source, labeled as
left ventricle in Fig. 1. For the settings of the voltage source shown
in Fig. 1, for synchronous operation was DC offset (V) 0, amplitude
(V) 120, frequency (Hz) 1.00 and delay (s) 0.0, counter pulsation operation was DC offset (V) 0, amplitude (V) 120, frequency (Hz) 1.00
and delay (s) 0.5, and asynchronous operation was achieved via
two different frequency voltage sources, DC offset (V) 0, amplitude
(V) 120, frequency (Hz) 1.00 and delay (s) 0.0, and DC offset (V) 0,
amplitude (V) 120, frequency (Hz) 0.75 and delay (s) 0.0equivalent
to a native ventricular rate of 45/s and an LVAD rate of 60.

The effect of varying the native heart rate from 30 to 120 beats/
min was investigated. For asynchronous operation, the native
heart rate was kept at 60/min and the LVAD rate was varied.

Software
LTSPICE IV (www.linear.com) was utilized for circuit simulation.
The oscilloscope function was utilized to read blood pressure
aortic, LAP and PAP (voltage) and pulmonary blood ow (current)
values from the simulated circuit.

RESULTS

Right ventricular work load

Baseline

The right ventricular work load was calculated form the cardiac
output multiplied by the root mean square PAP. The results were

The baseline output of the model for comparison purposes is

shown in Fig. 2.

M. Poullis / Interactive CardioVascular and Thoracic Surgery

Counter pulsation
The effect of counter pulsation LVAD operation on LAP and PBF is
shown in Fig. 3. It should be noted that the aortic trace is 180 out
of phase compared with Fig. 2, which is due to the technique
counter pulsation.

13

asynchronous operation is associated with a higher pulmonary

artery pressure, increased LAP and reduced PBF. Counter pulsation results in the lowest PAP, LAP and the greatest PBF. The increase in cardiac output possible with counter pulsation assumes
the right ventricle to be unlimited in its function and the pulmonary compliance to be normal, a situation that is uncommon in
clinical practice.

Asynchronous

Synchronous

The normalized RV work load for the differing LVAD pulsatile

support strategies is shown in Fig. 7. It can be seen that the
counter pulsation technique has the lowest RV work load (84%),
and the asynchronous mode has the highest (118%, which indicated that the technique actually increases RV work load), compared with a normal RV (100%).

The effect of synchronous LVAD operation on LAP and PBF is shown

in Fig. 5.

Effect of heart rate

Comparative analysis
The effect of differing LVAD pulsatile support strategies on LAP,
PAP and PBF is shown in Fig. 6. It can readily be seen that

The effect of heart rate on left atrial pressure is shown in Fig. 8. It

can be seen that regardless of heart rate, the counter pulsation
mode is associated with a lower left atrial pressure. A lower left
atrial pressure results in a reduced pulmonary artery pressure
and/or increases pulmonary blood ow (data not shown).

Figure 3: The effect of counter pulsation left ventricular assist device function on aortic, pulmonary artery and left atrium pressure traces and pulmonary blood ow.

Figure 4: The effect of asynchronous left ventricular assist device operation on aortic, pulmonary artery, left atrium pressure traces and pulmonary blood ow.

Figure 5: The effect of synchronous left ventricular assist device function on aortic, pulmonary artery, left atrium pressure traces and pulmonary blood ow.

WORK IN PROGRESS
REPORT

Right ventricular work load

The effect of asynchronous LVAD function on pulmonary blood
ow and left atrial pressure is shown in Fig. 4. It can be seen that
asynchrony causes highly variable differences in LAP and pulmonary blood ow.

14

M. Poullis / Interactive CardioVascular and Thoracic Surgery

Figure 6: Comparison between left atrial pressure, pulmonary atrial pressure

and pulmonary blood ow for different left ventricular assist device operation
modes.

Figure 7: Normalized right ventricular work load for the differing left ventricular assist device pulsatile support strategies.

LVADs providing continuous ow is the most common mode of

operation [14]. Continuous ow from an electrical analogy would
provide the lowest left atrial and pulmonary artery pressures. An
electrical model is unable to assess the merits and detrimental
effects of continuous (non-pulsatile ow). We did not model continuous ow as the electrical analogy model has not been veried
under direct current (DC or continuous ow) conditions.
If an LVAD functions in a pulsatile manner, but independently of
the heart, it can be described as functioning in a pseudosynchronous or isochronous mode. Our analysis predicts that this is potentially highly detrimental to pulmonary ow and pulmonary
pressure. This nding explains and conrms previous clinical
ndings [7], and we would strongly suggest against this mode of
operation.
Our model assumes normal valvular function and the absence
of cardiac arrhythmias. Atrial brillation is quite common clinically
and, depending on the mode of LVAD operation, could be quite
detrimental, as this situation is analogous to the asynchronous
mode of operation. We hypothesize, but we offer no direct evidence, that rate control and pacing a failing heart to create a
regular rhythm and operating an LVAD in the counter pulsation
mode may offer the best haemodynamic solution.
As the LV ejection fraction reduces to zero, the haemodynamics
(LAP, PAP and PBF) gradually switch to the LVAD mode modelled
above. It should be noted that the counter pulsation mode is the only
mode capable of increasing the cardiac output above the resting
state, due to the lowering of left atrial pressure below pre-LVAD levels.
The use of an electrical analogy to analyse cardiovascular
haemodynamics is well described [1517] and complements computational uid dynamics analysis with regard to cardiovascular pressures and ows [18, 19]. Randomized trials are logistically difcult,
time consuming and would have to be large to avoid being underpowered due to biological variation, unlike electrical analogies.

Figure 8: The effect of left ventricular assist device (LVAD) rate on left atrial pressure for differing LVAD pulsatile support strategies.

LIMITATION
DISCUSSION
LVAD operation in a counter pulsation mode results in lower pulmonary artery pressure, lower left atrial pressure and increased pulmonary artery ow, and hence cardiac output. The results of our
analysis compliment previous modelling and clinical work [5, 7, 8].
Increasing pulmonary blood ow increases cardiac output, as
no right-to-left shunt exists. Reducing left atrial pressure, so increasing pulmonary blood ow, also reduces the stroke work
index of the right ventricle. This may reduce the incidence of right
ventricle failure post LVAD implantation requiring replacement for
a biventricular assist device [9]. Reducing left atrial pressure may
also reduce capillary uid exudation secondary to Starlings law;
however, our model cannot conrm this.
Counter pulsation (antisynchronous) is analogous to intra-aortic
balloon pump mechanics [10]. Intra-aortic balloon pump has
been shown to reduce left ventricular and right ventricular work
load [1113].
In the setting of left ventricular dysfunction, especially if longstanding, pulmonary vascular compliance is frequently raised, there
arises the need for assessment for biventricular assist device
support. Counter pulsation may be particularly important in this
subset of patients. The benet in previously t patients with normal
pulmonary compliance (e.g. acute massive myocardial infarction) of
counter pulsation will be reduced but still present.

No model can accurately reect complex biological systems, and

our data should be interpreted as such. A strength and a potential
weakness of using an electrical analogy is the fact that the effect of
biological variation is essentially removed. Simulation assumed no
valvular heart disease or intra cardiac shunt such as a patent
foramen ovale. Dynamic regulation and interaction between the
heart/lung block and the peripheral circulation was not modelled
for. At present, the counter pulsation mode of LVAD operation is
not routinely available, although working models have been previously described [8].
The model assumed normal right ventricular function, i.e. pure
left ventricular dysfunction. This is clinically an unusual situation;
however in the clinical setting, any cause of a raised pulmonary
artery pressure will be detrimental in the setting of reduced right
ventricular function.
LVADs are frequently operational in patients with sepsis and
vasodilatation. The electrical analogy model we utilized has not
been validated in this scenario and its use may lead to errors.

CONCLUSION
If an LVAD is to be operated in a pulsatile mode, the counter pulsation mode reduces pulmonary artery and left atrial pressure and
increases pulmonary blood ow and thus cardiac output. This is in

addition to the reduced right ventricular energetic requirement, a

nding previously described. Clinical validation of our ndings is
necessary.

SUPPLEMENTARY MATERIAL
Supplementary material is available at ICVTS online.
Conict of interest: none declared.

REFERENCES
[1] Garbade J, Bittner HB, Barten MJ, Mohr FW. Current trends in implantable
left ventricular assist devices. Cardiol Res Pract 2011;2011:290561.
[2] Stevenson LW, Rose EA. Left ventricular assist devices: bridges to transplantation, recovery, and destination for whom? Circulation 2003;108:
305963.
[3] Chang Y, Gao B. Modeling and identication of an intra-aorta pump.
ASAIO J 2010;56:5049.
[4] Piene H. Pulmonary arterial impedance and right ventricular function.
Physiol Rev 1986;66:60652.
[5] Drzewiecki GM, Pilla JJ, Welkowitz W. Design and control of the
atrio-aortic left ventricular assist device based on O2 consumption. IEEE
Trans Biomed Eng 1990;37:12837.
[6] Abdolrazaghi M, Navidbakhsh M, Hassani K. Mathematical modelling and
electrical analog equivalent of the human cardiovascular system.
Cardiovasc Eng 2010;10:4551.
[7] Maybaum S, Williams M, Barbone A, Levin H, Oz M, Mancini D.
Assessment of synchrony relationships between the native left ventricle
and the HeartMate left ventricular assist device. J Heart Lung Transplant
2002;21:50915.

15

[8] Ando M, Takewa Y, Nishimura T, Yamazaki K, Kyo S, Ono M et al. A novel

counterpulsation mode of rotary left ventricular assist devices can
enhance myocardial perfusion. J Artif Organs 2011;14:18591.
[9] Patlolla B, Beygui R, Haddad F. Right-ventricular failure following left ventricle assist device implantation. Curr Opin Cardiol 2013;28:22333.
[10] Kolyva C, Pantalos GM, Pepper JR, Khir AW. How much of the intraaortic
balloon volume is displaced toward the coronary circulation? J Thorac
Cardiovasc Surg 2010;140:1106.
[11] Nordhaug D, Steensrud T, Muller S, Husnes KV, Myrmel T. Intraaortic
balloon pumping improves hemodynamics and right ventricular efciency
in acute ischemic right ventricular failure. Ann Thorac Surg 2004;78:
142632.
[12] Powell WJ Jr, Daggett WM, Magro AE, Bianco JA, Buckley MJ, Sanders CA
et al. Effects of intra-aortic balloon counterpulsation on cardiac performance, oxygen consumption, and coronary blood ow in dogs. Circ Res
1970;26:75364.
[13] Liakopoulos OJ, Ho JK, Yezbick AB, Sanchez E, Singh V, Mahajan A. Right
ventricular failure resulting from pressure overload: role of intra-aortic
balloon counterpulsation and vasopressor therapy. J Surg Res 2010;164:
5866.
[14] Carrel T, Englberger L, Martinelli MV, Takala J, Boesch C, Sigurdadottir V
et al. Continuous ow left ventricular assist devices: a valid option for
heart failure patients. Swiss Med Wkly 2012;142:w13701.
[15] Ridgway T, Al Rawi O, Palmer K, Pullan M, Poullis M. Theoretical treatise:
arterial pressure during aortic surgery. J Extra Corpor Technol 2012;44:
1514.
[16] Palmer K, Ridgway T, Al Rawi O, Johnson I, Poullis M. Lissajous gures: an
engineering tool for root cause analysis of individual cases--a preliminary
concept. J Extra Corpor Technol 2011;43:1536.
[17] Warwick R, Poole R, Palmer K, Johnson I, Poullis M. Patient directed perfusion pressure on bypass, an analogy from electrical engineering--a new
concept. J Extra Corpor Technol 2010;42:5760.
[18] Heim L, Poole RJ, Warwick R, Poullis M. The concept of aortic replacement
based on computational uid dynamic analysis: patient-directed aortic
replacement. Interact CardioVasc Thorac Surg 2013;16:5838.
[19] Poullis M. Computational uid dynamic analysis to prevent aortic root and
valve clots during left ventricular assist device support. J Extra Corpor
Technol 2012;44:2105.

WORK IN PROGRESS
REPORT

M. Poullis / Interactive CardioVascular and Thoracic Surgery