Cardiovascular prostheses

Presented by: Furugh Gharbalchi

Instructor: Prof. Nevzat G.Gener
METU-EE517-fall 2012

Overview
Introduction
History Heart anatomy Circulatory system

Cardiovascular prosthetic devices

Heart stents and cardiac angioplasty procedure Artificial heart valve Artificial heart

Brief introduction to heart-lung machine

Conclusion
References

Introduction
What is prosthetic device?
Prostheses are an artificial devices extension that replaces a missing body part. Traumatic Congenital Defective

Historical evidences show prosthetics were exist in ancient time!

Introduction-history
Egyptians are pioneers, they used to replace toe by woodenmade one.

Fig.1

Introduction
Romans used artificial dental crowns.

Fig.2

Introduction
Greeks used iron and wooden legs and arms.

Fig.3

Fig4

Fig.5

Introduction
All these primitive ideas came when there were a need to replace an organ when it was lost but what to do when the heart loses its vital function?

Today among all the available prosthetic devices heart assisting devices and cardiovascular prosthetics are of the great importance, prosthetic devices marketing says the same.

Introduction-heart anatomy and circulatory system

Circulatory system may be seen strictly as a blood distribution network which is sometimes called cardiovascular system.[10]

This system includes: pulmonary circulation systemic circulations

Fig.6

Fig.6

Introduction-heart anatomy and circulatory system

Introduction-heart anatomy and circulatory system

There are four valves:
i. ii. iii. iv. Tricuspid valve Pulmonary valve Mitral valve Aorta valve

An error in any of these valves and vessels may be fatal. There are some devices and procedures to reduce these fatal errors. Cardiovascular prosthetics are chronic alternative.

Cardio vascular prosthetics-heart stent

What is a stent in general term?
A stent is a small mesh tube that's used to treat narrow or weak arteries. It is placed in an artery as part of a procedure called angioplasty. [1]

Fig.7

Fig.8

Cardio vascular prosthetics-heart stent

In the case of coronary artery diseases coronary stents are used. What is coronary artery disease?
is caused by the buildup of plaque on the inside of the coronary arteries, the blood vessels that supply oxygen-rich blood to the heart muscle.[3]

Cardio vascular prosthetics-heart stent

Plaque is made up of excess cholesterol, calcium, and other substances that float in blood and, over time, build up on the inside walls of the coronary arteries and other arteries. Plaque deposit leads:
Poor blood flow which results in chest pain Blocking blood flow results in heart attack and formation of clot and rupture the artery.[3]

Fig.9

Cardio vascular prosthetics-heart stent

What is a coronary stent?
In patients with coronary heart disease, caused by the buildup of plaque, stents are used to open narrowed arteries and help reduce symptoms such as chest pain (angina), or to help treat a heart attack. These types of stents are commonly called heart stents, but they're also referred to as cardiac stents or coronary stents.[2]

Fig.10

Cardio vascular prosthetics-heart stent

Types of coronary stents:
Bare-metal stent Drug- diluting stent And upcoming stents: o A stent with a covering that delivers an anti-restenosis drug over a period of several months and then essentially becomes a bare-metal stent. o A stent that is absorbed by the body and disappears after it has done its work. o A stent which uses a bio-engineered coating to quickly create a thin, all-natural layer inside the artery.[3],[10]

Cardio vascular prosthetics-heart stent

Bare-metal stent:
First stent that licensed Mesh tube made up of bare metal No drug coating is applied Stainless steel(cobalt-chromium alloy) Eliminate risk of collapsing

Fig.11

Problem:
25% of all coronary arteries treated with bare-metal stents would close up again, usually within about six months.

Cardio vascular prosthetics-heart stent

Drug-diluting stent:
Latterly approved by FDA Prevents fibrosis and thrombosis which can lead to stenosis Strong metal(cobalt) Biodegradable and biocompatible polymer anti-restenosis drug combination

Fig.12 Advantage: In clinical trials, drug-eluting stents dramatically reduced the rate of restenosis to less than 10%.[3]

Cardio vascular prosthetics-heart stent

General Problems of heart stents
In-stent thrombosis(blood clot and sudden re-narrowing) Taking blood-thinning drugs(aspirin) Injury of cell wall(endothelium) Restenosis(re-narrowing during time), if it happens second stenting operation is applied but some times open heart surgery is unavoidable.

Drug-diluting stents are better than bare-metal, research shows.[3]

Video.1

Cardio vascular prosthetics-Coronary Angioplasty

What is angioplasty?
Angioplasty is the technique of mechanically widening narrowed or blocked arteries.

When arteries are narrowed or blocked from coronary artery disease, angioplasty can be done with or without the stent. Angioplasty is not surgery, in is non-invasive method which is done using a thin, soft tube called a catheter that's inserted in your artery, it has balloon tip, no anesthesia is needed.[4],[10]

Cardio vascular prosthetics-Coronary Angioplasty

Angioplasty procedure:
During the procedure, a thin, flexible catheter with a balloon at its tip is threaded through a blood vessel to the affected artery. Then, the balloon is inflated to compress the plaque against the artery wall. This restores blood flow through the artery. A small amount of contrast material is injected through the catheter and is photographed with an X-ray as it moves through the heart's chambers, valves, and major vessels. From the digital pictures of the contrast material, the doctors can tell whether the coronary arteries are narrowed and whether the heart valves are working correctly.(video.2)

Fig.13

Simulation of stent in realistic coronary-artery

A process called in-stent restenosis limits the clinical success of bare metal stents. The stent design as well as the modality of stent expansion could produce a different arterial response to the mechanical action induced by the stent. Knowledge of the local stress distribution in the vessel wall, generated during the intervention, may help in understanding some aspects of neointimal hyperplasia. [11]

Simulation of stent in realistic coronary-artery

Method:
Biplane angiography and intravascular ultrasound (IVUS) were applied prior to the intervention and these measurements were combined to obtain the 3-dimensional shape of the lumen and the vessel wall. Finite element method computations were performed to simulate the deployment of a stent inside the reconstructed coronary artery model at inflation pressure of 1.0 MPa. A finite element program was used to compute the deployment of the stent by means of increasing inflation pressure.[11]

Simulation of stent in realistic coronary-artery

The intravascular ultrasound images of a mildly stenosed right coronary artery (panel A), the corresponding contrast angiogram (panel B) and the 3D reconstruction (panel C).

Fig.14

Simulation of stent in realistic coronary-artery

Method:(3D construction technique)
Sheath-based IVUS catheter is positioned in the vessel segment To eliminate respiratory and cardiac motion artifacts, a single biplane view at end-diastole of the catheter position is selected and digitized. From the biplane views, the transducer path is reconstructed in 3D space. Finally, a 3D reconstruction of lumen and vessel wall is generated with the software package Rhinoceros 2.0 Evaluation CAD program.

Once the surfaces were created the volume between them was generated and by means of the software GAMBIT.

Simulation of stent in realistic coronary-artery

Method:(3D construction technique)
Mesh of the vessel with an inset showing the internal lumen (panel A). Geometry and mesh of the stent in its un-deformed configuration (Panel B). The model of the right coronary artery with the unexpanded stent is show in panel C. The location of the minimal lumen diameter (MLD) is indicated by the dashed line.

Fig.15

Simulation of stent in realistic coronary-artery

Method:(Finite element solution procedure)
The stent was positioned inside the coronary artery. It expanded under load control conditions until a pressure of 1.0 MPa was reached. The artery was constrained in the proximal and distal sections preventing any displacements and rotations. The stent was constrained to allow only radial displacements. A large deformation analysis was performed using ABAQUS/Standard commercial code.

Simulation of stent in realistic coronary-artery

Method:(Finite element solution procedure)
Panel A: Shapes of the lumen at the beginning (green) of the expansion and at the maximum inflation pressure of 1.0 MPa for three different axial locations in the stent (shown in the middle left side). Panel B: The corresponding von Mises contour maps. The stresses in the vessel wall at the three locations at maximum deployment pressure are also given in this figure.

Fig.16

Simulation of stent in realistic coronary-artery

Method:(Finite element solution procedure)

Expansion of the lumen area versus the inflation pressure for the three different axial locations in the stent depicted by the dotted red lines.

Fig.17

Simulation of stent in realistic coronary-artery

Method:(Finite element solution procedure)
Von Mises contour maps in the anterior and posterior views of the luminal surface at the maximum inflation pressure of 1.0 MPa.

Fig.18

Simulation of stent in realistic coronary-artery

Method:(Finite element solution procedure)

Von Mises stresses in the stent at the inflation pressure of 1.0 MPa.

Fig.19

Simulation of stent in realistic coronary-artery

Method:(Finite element solution procedure)
Results from the simulation with a strut thickness of 0.14 mm. The top panel shows the expansion versus the inflation pressure location 2. The panels at the bottom show the von Mises stress distribution at the luminal surface (left) and the stresses von Mises stress in the stent (right)

Fig.20

Simulation of stent in realistic coronary-artery

Conclusion:
The method presented in this paper can be used to predict stresses in the stent struts and the vessel wall, and thus evaluate whether a specific stent design is optimal for a specific patient. The results of the simulations also showed that thicker stent struts require higher inflation pressure, which might result in more damage to the vessel wall. Thinner struts are therefore preferable, especially since the stresses in the struts do not seem to be influenced significantly by the variation in strut thickness.

Cardio vascular prosthetics-prosthetic heart valve

Prosthetic heart valve:
Prosthetic heart valve is a device implanted in the heart of a patient with heart valvular disease.

What causes valvular heart disease?

Valve disease can develop before birth (congenital) or can be acquired sometime during one's lifetime. Sometimes the cause of valve disease is unknown.[4]

What are the types of valve disease?

Valve stenosis Valve insufficiency

Cardio vascular prosthetics-prosthetic heart valve

Valve stenosis:
Valve opening is smaller than normal due to stiff or fused leaflets. The narrowed opening may make the heart work very hard to pump blood through it. This can lead to heart failure and other symptoms.

All four valves can be stenotic:

tricuspid stenosis pulmonic stenosis mitral stenosis aortic stenosis

Fig.21

Cardio vascular prosthetics-prosthetic heart valve

Valve insufficiency(regurgitation/ leaky valve):
valve does not close tightly. So some blood will leak backwards across the valve. As a result the heart has to work harder to make up for the leaky valve, and less blood may flow to the rest of the body.

All four valves can be leaky:

Tricuspid regurgitation Pulmonary regurgitation Mitral regurgitation Aortic regurgitation
(Video.3)
Fig.22

Cardio vascular prosthetics-Prosthetic heart valve

More than 80 models of artificial valves have been introduced since 1950. In day-to-day emergency practice, however, it is necessary to be familiar with a few basic types.[4] There are two types of prosthetic cardiac valves:
Mechanical valves i. Caged ball valve ii. Tilting disc (single leaflet) valve iii. Bi-leaflet valve 2. Bio-prosthetic valves 1.

Cardio vascular prosthetics-Prosthetic heart valve

1. Mechanical valve:
i. Caged ball model It utilizes a metal cage to house a silicone elastomer ball. When blood pressure in the chamber of the heart exceeds that of the pressure on the outside of the chamber the ball is pushed against the cage and allows blood to flow. At the completion of the heart's contraction, the pressure inside the chamber drops and is lower than beyond the valve, so the ball moves back against the base of the valve forming a seal.

Fig.23

Cardio vascular prosthetics-Prosthetic heart valve

Caged ball valve is the first model developed. Edwards LifeSciences company was its developer.

This company stops producing this valve in 2007.[4]

Fig.24

Cardio vascular prosthetics-Prosthetic heart valve

1. Mechanical valve:
ii. Tilting disc This valve has a single circular occluder controlled by a metal strut. They are made of a metal ring covered by a ePTFE fabric, into which the suture threads are stitched in order to hold the valve in place. The metal ring holds, by means of two metal supports, a disc which opens and closes as the heart pumps blood through the valve. The disc is usually made of an extremely hard carbon material (Pyrolytic-carbon), in order to allow the valve to function for years without wearing out.

Fig.25

Cardio vascular prosthetics-Prosthetic heart valve

1. Mechanical valve:
iii. Bileaflet valve
Bileaflet heart valves consist of two semicircular leaflets that rotate about struts attached to the valve housing. Bileaflets are vulnerable to backflow and so they cannot be considered as ideal. Bileaflet valves provide much more natural blood flow than caged-ball or tilting-disc implants. These valves 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.

Fig.26

Cardio vascular prosthetics-Prosthetic heart valve

The procedure of replacing heart valves is invasive most of the time and needs bypass surgery. Although there is noninvasive method to place the prosthetic valve.(video.4) The disadvantage of the mechanical heart valve is its murmur sound that is produced in every diastole!(video.5)

Cardio vascular prosthetics-Prosthetic heart valve

Criteria for designing prosthetic valve:[10]
produce minimal pressure drops have small regurgitation volumes minimize turbulence reduce prevalence of high stresses not to create flow separations in the vicinity of the valve

One measure of the quality of a valve is the effective orifice area (EOA).

Cardio vascular prosthetics-Prosthetic heart valve

Effective Orifice Area(EOA) can be calculated as follows:

o where Qrms is the root mean square systolic/diastolic flow rate (cm/s) and P is the mean systolic/diastolic pressure drop (mmHg). o A higher EOA corresponds to a smaller energy loss.

Cardio vascular prosthetics-Prosthetic heart valve

2. Bio-prosthetic valve/tissue valve:
Biological valves are valves of animals, pigs, which undergo several chemical procedures in order to make them suitable for implantation in the human heart. The porcine (or pig) heart is most similar to the human heart, and therefore represents the best anatomical fit for replacement. Implantation of a porcine valve is a type of xenotransplantation. There are some risks associated with a xenograft such as the human body's tendency to reject foreign material. Medication can be used to retard this effect, but is not always successful.[4]

Fig.27

Cardio vascular prosthetics-Prosthetic heart valve

Porcine models include the Carpentier-Edwards valves (Edwards Lifesciences) and Hancock II and Mosaic valves (Medtronic); both valves are shown in the images below.(video.6)

Fig.28

Fig.29

Cardio vascular prosthetics-Prosthetic heart valve

The fact is that:
The ideal prosthetic valve that combines excellent hemodynamic performance and long-term durability without increased thromboembolic risk or the need for long-term anticoagulation does not exist.
Hemo-dynamisity: physical laws that govern the flow of blood in the blood vessels. Thrombo-embolic: The blocking of a blood vessel by a blood clot dislodged from its site of origin.

Cardio vascular prosthetics-Prosthetic heart valve

Mechanical valves vs. bio-prosthetic valves:
In general, the advantageous durability of mechanical valves is offset by the risk of thromboembolism and the need for long-term anticoagulation and its associated risk of bleeding. In contrast, bioprosthetic valves do not require long-term anticoagulation yet carry the risk of structural failure and reoperation.

Considering all these doctors and their patients should chose one of a kind. There are trends in the United States and Europe toward the increasing use of tissue rather than mechanical valves and toward the use of bio-prostheses in progressively younger patients.[4]

Cardio vascular prosthetics-Prosthetic heart valve

The problems of prosthetic heart valve(review):
primary valve failure prosthetic valve endocarditis (PVE) prosthetic valve thrombosis (PVT) Thromboembolism mechanical hemolytic anemia In addition, because many of these patients require long-term anticoagulation, anticoagulant-related hemorrhage may occur.[4]

Cardio vascular prosthetics-Prosthetic heart valve

Factors to select successive valve for different patients:
advances in myocardial protection cardiac surgical techniques total energy loss closing volumes coronary perfusion lifestyle and quality of life individual patient life expectancy, the patients tolerance to the need for repeat valve replacement and the use of oral anticoagulants with its associated changes in lifestyle

Cardio vascular prosthetics-Prosthetic heart valve

Non-invasive method to deliver the prosthetic valve to its proper location![5] Non invasive delivery is applicable for two kinds of valves:
exchangeable heart valve(without stent) expandable heart valve

Cardio vascular prosthetics-Prosthetic heart valve

exchangeable heart valve:
It is a two-component device, consisting of a permanent docking station that remains affixed to the patient's aorta, and a collapsible frame that supports the exchangeable leaflet set and plugs into the docking station.[5][8]

Fig.30

Cardio vascular prosthetics-Prosthetic heart valve

expandable heart valve: Implanted by the transluminal catheter technique without open heart surgery.(video.7)

Fig.31

Cardio vascular prosthetics-Prosthetic heart valve(rivew)

I. Mechanical valves [10]
Percutaneous implantation(Angioplasty) Stent framed Not framed Sternotomy/Thoracotomy implantation Ball and cage Tilting disk Bi-leaflet Tri-leaflet

II. Tissue(biological) heart valves

Allograft/isograft Xenograft (video.8)

Cardio vascular prosthetics-Artificial heart

Artificial heart is: the device that replaces to ventricles. used in End stage.
End stage means the condition has become so severe that all treatments, except heart transplant, have failed. [1]

Cardio vascular prosthetics-Artificial heart

You might need a TAH for one of two reasons:
To keep you alive while you wait for a heart transplant If you're not eligible for a heart transplant, but you have end-stage heart failure in both ventricles [1]

Currently, the two types of TAHs are the CardioWest and the AbioCor. The main difference between these TAHs is that the CardioWest is connected to an outside power source and the AbioCor isn't.

Cardio vascular prosthetics-Artificial heart

CardioWest model:
This model has tubes that, through holes in the abdomen, run from inside the chest to an outside power source. Tubes exit the body and connect to a machine that powers the TAH and controls how it works.[6]

Fig.32

Cardio vascular prosthetics-Artificial heart

How does CardioWest model work?
It duplicate the action of the natural ventricles. The two ventricles of the TAH are split into two parts by a diaphragm. Blood fills one side of each ventricle, and is ejected when a pulse of air pressure is applied to the opposite side of the diaphragm. Once set, a patients blood flow adjusts automatically as more blood fills each ventricle and is ejected. This circulation by the TAH provides blood flow to both the lungs and the body.[6]

Cardio vascular prosthetics-Artificial heart

How does CardioWest model work?

Fig.33

Cardio vascular prosthetics-Artificial heart

When is it used?
The temporary CardioWest is used only in the hospital. The device is used as a "bridge to transplant" for patients waiting for a heart transplant who: have both sides of their heart failing (biventricular heart failure) For patients do not respond to other treatments Who are at imminent risk of death Who are waiting for a donor heart

In a clinical study, 79 percent of patients implanted with the temporary CardioWest received a donor heart with an average mean time of device implantation of 79 days, demonstrating that the artificial heart could successfully serve as a bridge to transplant. [6]

Cardio vascular prosthetics-Artificial heart

Fig.34

Cardio vascular prosthetics-Artificial heart

Fig.35

Cardio vascular prosthetics-Artificial heart

ABIOCOR model:
The AbioCor TAH is completely contained inside the chest. A battery powers this TAH. The battery is charged through the skin with a special magnetic charger. Energy from the external charger reaches the internal battery through an energy transfer device called transcutaneous energy transmission, or TET.

Fig.36

Cardio vascular prosthetics-Artificial heart

Mechanism:
A coil attached to the battery pack sends power through the skin to an implanted coil. The same coil then transmits the energy to the AbioCor. The AbioCor also contains an internal, continually charging short-term battery, that can keep the device pumping for up to 30 minutes without the external battery pack. Similar to a pacemaker, the AbioCor contains an activity sensor that can tell when the patient is active, and can automatically increase the rate of pumping during exertion. [6]

Cardio vascular prosthetics-Artificial heart

Fig.37

Cardio vascular prosthetics-Artificial heart

Both CardioWest and AbioCor models are temporary solutions ,and not long-term, thus they are used to bridge the implantation time. There is limited use of these models. They are only left solution at End Stage.

Brief introduction to heart-lung machine

The open heart surgery has advanced a lot generally by the two factors: Stopping the heart and restating it again And heart-lung machine The machine is used to support the body during the surgical procedure while the heart is stopped. The heart-lung machine is often referred to as the "pump, and does the work of the heart and lungs during the operation. [6][10]

Brief introduction to heart-lung machine

The heart-lung machine consists of:
A chamber that receives the blood from the body(right atrium) Pumped(right ventricle) Oxygenator(lungs) Pump (left ventricle)

The heart-lung machine is connected to the patient by a series of tubes that the surgical team places. At the end of the operation, the surgeon gradually allows the patients heart to resume its normal function[9]

Fig.38

Brief introduction to heart-lung machine

Working diagram of heart-lung machine: (video.9)

Fig.39

Brief introduction to heart-lung machine

Step by step:
Give the patient a drug called heparin(powerful anticoagulant) Place cannula in right atrium(tube from the heart-lung machine is placed in the upper-right chamber of the heart, which contains oxygen-poor blood from the body) Place cannula in aorta(pumping oxygen-rich blood trough the body)[12]

Brief introduction to heart-lung machine

Are there risks of complications with a heart-lung machine?
more stroke in women than men formation of small blood clots in the blood stroke , heart attack or kidney failure an inflammatory process that can damage many of the body's systems and organs, called post-pericardiotomy syndrome post-operative temporary confusion or memory[12]

Conclusion
Failure in any of coronary and heart valves can be fatal. Drug-diluting stents are better than bare metal ones. Simulation prior to any operation is advantages to reduce risks. Bio-prosthetic heart valves are preferable to mechanical ones.

Artificial heart is used to bridge implantation time.

Heart-lung machine is very vital device in open heart surgeries to temporary replace heart and lungs functions.

Thank you

References
Content:

[1]http://www.nhlbi.nih.gov/health/health-topics/topics/stents/ [2]http://www.chestnet.org/accp/article/endobronchial-lung-volume-reduction-continuedsearch-physiology-based-therapies [3]http://www.webmd.com/ [4]http://emedicine.medscape.com/article/780702-overview) [5]http://www.sbir.gov/sbirsearch/detail/343697 [6]http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsand[ Clearances/Recently-ApprovedDevices/ucm080816.htm [7]http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsand[ Clearances/Recently-ApprovedDevices/ucm080816.htm [8]http://heartdisease.about.com/cs/heartfailure/a/abiocor.htm [9]http://www.cts.usc.edu/zglossary-heartlungmachine.html [10]http://en.wikipedia.org/wiki/ [11]http://www.biomedical-engineering-online.com/content/7/1/23 [12]http://www.heartonline.org/heartlung.htm

References
Figures:
Fig.1(http://en.wikipedia.org/wiki/Prosthesis) Fig.2(http://en.wikipedia.org/wiki/Prosthesis) Fig.3(http://invention.smithsonian.org/centerpieces/inventingourselves/pop-ups/01-01.htm) Fig.4(http://invention.smithsonian.org/centerpieces/inventingourselves/pop-ups/01-01.htm) Fig.5(http://now-here-this.timeout.com/2012/08/30/faster-higher-stronger-meet-thesuperhumans/) Fig.6(http://en.wikipedia.org/wiki/Heart) Fig.7(http://topnews.net.nz/content/221467-stent-operations-rise-us) Fig.8(http://upload.wikimedia.org/wikipedia/en/4/44/Covered_Stent_Graft.jpg) Fig.9(http://www.omnimedicalsearch.com/conditions-diseases/angina-introduction.html) Fig.10(http://www.chestnet.org/accp/article/endobronchial-lung-volume-reduction-continuedsearch-physiology-based-therapies) Fig.11(http://www.alvimedica.com/index.php/en/bare-metal-stents) Fig.12(http://jama.jamanetwork.com/article.aspx?articleid=198180) Fig.13(http://en.wikipedia.org/wiki/Angioplasty) Fig.21(http://www.medicinenet.com/heart_valve_disease/article.htm#what_is_valvular_heart _disease)

References
Fig.22(http://www.heart-valve-surgery.com/aortic-valve-regurgitation-symptoms.php) Fig.23(http://emedicine.medscape.com/article/780702-overview) Fig.24(http://emedicine.medscape.com/article/780702-overview ) Fig.25(http://emedicine.medscape.com/article/780702-overview) Fig.26(http://emedicine.medscape.com/article/780702-overview) Fig.27(http://en.wikipedia.org/wiki/File:BiologicalValves.JPG) Fig.28(http://emedicine.medscape.com/article/780702-overview) Fig.29(http://emedicine.medscape.com/article/780702-overview) Fig.30(http://www.medgadget.com/2009/03/exchangeable_cardiac_valves_from_valvexchan ge.html) Fig.31(http://circ.ahajournals.org/content/124/3/355/F3.expansion.html) Fig.32(http://en.wikipedia.org/wiki/File:The_SynCardia_temporary_Total_Artificial_Heart_ with_pink_heart_background.jpg) Fig.33(http://www.musikji.net/2011/08/father-40-is-first-person-in-uk-fitted.html) Fig.34(http://www.fda.gov/ohrms/dockets/ac/04/briefing/4029b1_final.pdf) Fig.35(http://www.syncardia.com/2009-Press-Release/cardiowest-artificial-heart-patientgoes-home-for-christmas.html) Fig.36(http://artificialheart.ucla.edu/abiodiagrams.html)

References
Fig.37(http://erfanhospitalmedicalnews.blogspot.com/2009/06/artificial-hearts-use-marksmilestone.html) Fig.38(http://www.pemed.com/surgery/heartlung/heartlung.htm) Fig.39(http://www.sciencephoto.com/media/277938/view)

References
Videos:
Video.1(http://www.youtube.com/watch?v=9FPapBbbS4o) Video.2(http://www.youtube.com/watch?v=4EJLQ7fkzcc0 Video.3(http://www.youtube.com/watch?v=Rjmy9OrDTVA0 Video.4(http://www.youtube.com/watch?v=-3wwQ-HEZX) Video.5(http://www.youtube.com/watch?v=OQ9xrxDg3uc) Video.6(http://www.youtube.com/watch?v=rkW1smPoXKA) Video.7(http://www.youtube.com/watch?v=4Fq3hVaUQbQ) Video.8(http://www.youtube.com/watch?v=z5yRcRHuow8) Video.9(http://www.youtube.com/watch?v=BDlvwSdmrHo)