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Ann Thorac Surg 2003;76:1911-1916
© 2003 The Society of Thoracic Surgeons

Original article: cardiovascular

Cavopulmonary assist: circulatory support for the univentricular fontan circulation

Mark D. Rodefeld, MDa*, Jack H. Boyd, MDa, Cynthia D. Myers, MDa, Brian J. LaLone, CCP, PhDa, Alex J. Bezruczko, CCPa, Andrew W. Potter, BSa, John W. Brown, MDa

a Section of Cardiothoracic Surgery, Department of Surgery, Indiana University School of Medicine and James Whitcomb Riley Hospital for Children, Indianapolis, Indiana, USA

* Address reprint requests to Dr Rodefeld, MD, Section of Cardiothoracic Surgery, Indiana University School of Medicine, Emerson Hall 215, 545 Barnhill Dr, Indianapolis, IN 46202, USA
e-mail: rodefeld{at}iupui.edu

Presented at the Poster Session of the Thirty-ninth Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 31–Feb 2, 2003.


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 References
 
BACKGROUND: Following Fontan palliation, the univentricular circulation is notable for coexisting systemic venous hypertension and pulmonary arterial hypotension. Assisted cavopulmonary blood flow to overcome this pressure gradient would restore the circulation to one more closely resembling normal two-ventricle physiology. We hypothesized that mechanical augmentation of cavopulmonary blood flow would provide physiologic stability in a model of cavopulmonary diversion and univentricular circulation.

METHODS: Yearling sheep (n = 13, mean weight 56.5 kg) underwent total cavopulmonary diversion on cardiopulmonary bypass. The superior and inferior vena cavae were anastomosed directly to the right pulmonary artery. Axial flow pumps were positioned within both vena cavae to assist blood flow from the systemic venous circulation into the pulmonary vasculature. Baseline ventilation was resumed, cardiopulmonary bypass was weaned, and pump support was titrated to obtain normal physiologic measurement. Cardiopulmonary data were collected for 6 hours.

RESULTS: All animals demonstrated hemodynamic stability without need for volume loading, inotropic support, or pulmonary vasodilator therapy. Cardiac output, pulmonary vascular resistance, pulmonary arterial pressure, inferior vena caval pressure, and arterial pCO2 and pO2 values 6 hours after intervention were similar to baseline values. Arterial lactate levels steadily decreased throughout the cavopulmonary assist period.

CONCLUSIONS: Cavopulmonary assist with a percutaneous pump provides physiologic stability in a model of total cavopulmonary diversion and univentricular Fontan circulation without altering regional volume distribution or cardiac output. This mode of circulatory support may have potential to benefit patients with marginal Fontan hemodynamics in both the early and late time periods.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 References
 
Fontan palliation for single-ventricle cardiac anomalies diverts all systemic venous return directly to the pulmonary arteries. Because there is no dedicated power source to pump blood through the pulmonary capillary bed, the single ventricle must perfuse both the systemic and pulmonary circulations in series. This arrangement results in relative systemic venous hypertension, pulmonary arterial hypotension, and consequently decreased cardiac output. Despite several decades of refinement, problems related to failing Fontan physiology may arise not only in the early postoperative period but also many years after the Fontan operation [1]. Management of patients with marginal Fontan hemodynamics is often unsatisfactory, and patients in whom medical therapy fails may require reversal of the Fontan connection, a procedure associated with significant morbidity and mortality [2].

Substituting a mechanical pump as a pulmonary ventricle until the circulation can more readily accommodate unassisted Fontan hemodynamics could alleviate the problem of coexisting systemic venous hypertension and pulmonary arterial hypotension, and improve cardiac output by restoring the circulation to one more closely resembling two-ventricle physiology. In prior animal models of univentricular Fontan circulation, in which mechanical support was not utilized, transient hemodynamic stability was achieved only after nonphysiologic volume loading [3, 4]. We hypothesized that pump-assisted augmentation of cavopulmonary blood flow would yield normal pulmonary and systemic hemodynamics, as well as maintain normal pulmonary gas exchange function, without altering regional volume distribution or cardiac output. This concept was tested in an animal model of total cavopulmonary diversion using a percutaneous pump.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 References
 
The experimental protocol was approved by the Animal Care and Use Committee of the Indiana University School of Medicine. All animals received humane care in accordance with the "Principles of Laboratory Animal Care" formulated by the National Society for Medical Research and the "Guide for the Care and Use of Laboratory Animals" prepared by the Institute of Laboratory Animal Resources and published by the National Institutes of Health (National Institutes of Health publication 85-23, revised 1985).

Animal preparation
Thirteen yearling sheep (mean weight 56.5 kg, range 33 to 78.6 kg) were premedicated with intramuscular injection of ketamine (50 mg/kg). After placement of a jugular venous catheter, anesthesia was induced by bolus intravenous ketamine (50 mg/kg). Animals were intubated and mechanically ventilated using a Servo 900 C volume-cycled respirator (Siemens, Danvers, MA) with 100% oxygen and 1% to 2% isoflurane. Ventilation was maintained at 10 to 15 breaths/min with tidal volumes of 10 to 15 mL/kg and 4 cm H2O positive end expiratory pressure. Minor adjustments in ventilator rate or tidal volume were made to provide a pCO2 of approximately 35 mm Hg.

A 16-gauge femoral arterial line (Intracath, Becton Dickinson, Sandy, UT) was placed for systemic blood pressure monitoring. A 16-gauge femoral venous line (Intracath, 30.5 cm) was advanced to the level of the infradiaphragmatic vena cava. Systemic venous pressure was measured at this site to avoid spuriously low pressure values produced adjacent to the inflow of the cavopulmonary assist pump. The opposite femoral vessels were exposed for cardiopulmonary bypass arterial inflow, and for pulmonary artery catheter placement.

The heart was exposed through a median sternotomy and the pericardium was suspended. The azygos vein was ligated and divided, and the superior and inferior vena cavae were circumferentially dissected. A 16-gauge left atrial pressure monitoring line (Intracath) was placed in the left atrial appendage. A fiberoptic pulmonary artery catheter (Opticath, Abbott Laboratories, North Chicago, IL) was advanced from the femoral vein into the pulmonary artery. Baseline systemic arterial pressure, pulmonary arterial pressure, left atrial pressure, vena caval pressure, mixed venous oxygen saturation, and cardiac output were measured. Baseline activated clotting time, arterial blood gas, and lactate values were also obtained at this time. Cardiac output was calculated with a cardiac output computer (Oximetrix 3, Abbott Laboratories) using thermodilution technique. Three determinations were averaged to yield a mean value. The pulmonary artery catheter was withdrawn, and the animal was systemically heparinized (sodium heparin, 300 U/kg).

The femoral artery was cannulated for cardiopulmonary bypass inflow. Bicaval venous cannulation was performed. The bypass circuit was primed with balanced electrolyte crystalloid, and used a Capiox SX-10 membrane oxygenator (Terumo Corp, Elkton, MD). Mild hypothermia (35°C) was maintained during the surgical intervention.

Total cavopulmonary diversion
The superior and inferior vena cavae were sequentially detached from the right atrium and anastomosed to the proximal right pulmonary artery to completely bypass the right heart. After tightening the corresponding caval occlusion tourniquet, a vascular clamp was placed across the cavoatrial junction, and the vena cava was divided from the right atrium. The right atrial end was oversewn. A partial-occluding clamp was placed on the proximal right pulmonary artery, and the artery was incised longitudinally. The vena cava was then anastomosed to the pulmonary artery using a short intervening segment of 15- to 19-mm diameter polytetrafluoroethylene vascular conduit (Impra, Murray Hill, NJ). After completion of the superior cavopulmonary anastomosis, the caval tourniquet was released, and the procedure was repeated for the inferior cavopulmonary anastomosis.

Placement of cavopulmonary assist pumps
The pulmonary artery catheter was advanced from the femoral vein, through the inferior cavopulmonary connection, into the left pulmonary artery. The superior vena caval cardiopulmonary bypass cannula was clamped and removed. An axial flow pump (Hemopump HP-24, 24F; Medtronic Inc, Minneapolis, MN) [5, 6] was advanced through a right internal jugular venotomy, through the superior vena cava, across the cavopulmonary connection, and positioned in the inferior vena cava. The design of the pumps mandated that they cross the cavopulmonary anastomosis in order to augment blood flow in the desired direction (Fig 1). Cardiopulmonary bypass was weaned and discontinued. The inferior vena caval bypass cannula was removed. A second axial flow pump was then rapidly inserted through this site, advanced across the cavopulmonary connection, and positioned in the superior vena cava. After confirming placement, the pumps were activated. The time from termination of cardiopulmonary bypass to initiation of cavopulmonary assist typically spanned less than 30 seconds. Within this interval, hemodynamics were adequate to maintain stability. Caval tourniquets were gently snugged around the pump bodies to prevent recirculation of ejected blood around the pumps and ensure effective output.



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  		Fig 1. Total cavopulmonary diversion by anastomosis of the superior and inferior vena cava to the proximal right pulmonary artery. Axial flow pumps are positioned in the superior and inferior vena cava to assist cavopulmonary flow.

 
Cavopulmonary support was titrated to obtain normal physiologic measurements. Pump rates, based on previously determined output calibration curves against a pressure gradient of 25 mm Hg, were set to approximate baseline cardiac output. Because the axial flow pumps are preload and afterload sensitive and have limited factory preset speed settings, only approximate cavopulmonary flow rates could be delivered. In most cases, the lowest settings were used for each of the pumps, yielding a combined output of approximately 5 L/min.

Exclusion of right ventricular contribution to pulmonary blood flow
In the last three studies of this series, the main pulmonary artery was clamped to exclude right ventricular contribution to pulmonary blood flow. Right ventricular blood was vented through an 18F decompression cannula into the superior vena cava for drainage into the low-pressure systemic venous circulation (Fig 2).



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  		Fig 2. Right ventricular decompression cannula placed into the right ventricle to divert coronary sinus and thebesian blood flow into the low-pressure systemic venous circulation. The proximal main pulmonary artery is clamped to exclude right ventricular contribution to pulmonary blood flow.

 
Fluid management
Intravenous fluids were administered at maintenance rates (100 mL/h) before cardiopulmonary bypass and at 1.5 times maintenance (150 mL/h) after termination of cardiopulmonary bypass. The higher infusion rate postintervention accounts for capillary leak–related third space loss after cardiopulmonary bypass and insensible loss in an open chest animal preparation after major surgical intervention. Postoperative blood loss was replaced one-to-one with autologous blood conserved from the cardiopulmonary bypass circuit. If necessary, crystalloid was used after transfusion of all autologous blood. In the last 3 animals in the series, fresh heparinized homologous blood was transfused after all autologous blood had been reinfused to maintain serum hemoglobin concentrations.

Data acquisition
A surface electrocardiogram and systemic arterial waveforms were continuously monitored (HP7354C physiologic monitor; Hewlett-Packard, Palo Alto, CA). Hemoglobin was measured with an OSM3 hemoximeter (Radiometer, Westlake, OH) specifically calibrated for measurement of sheep/goat hemoglobin. Arterial blood gases, corrected for hemoglobin level, were measured using an ABL 500 blood gas analyzer (Radiometer). Arterial lactate values were measured using a YSI 2300 Stat Plus glucose and lactate analyzer (YSI, Yellow Springs, OH). Hemodynamic data and arterial blood gases were measured at hourly intervals for 6 hours after initiation of cavopulmonary assist. Activated clotting time was maintained at longer than 1.5 baseline.

Statistical analysis
Samples are reported as mean ± standard deviation. Comparison of baseline values to 1- and 6-hour time points after initiation of cavopulmonary assist was performed using ANOVA. Statistical significance was defined as p less than 0.05. Statistical analysis was performed with Sigmastat software (SPSS Inc, Cary, NC).


   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 References
 
Hemodynamic data are shown in Table 1. Cardiopulmonary function remained stable throughout the postintervention period. Inotropic support was not provided in any case. Because hemolysis rates with axial flow pumps have been shown to be minor, declining hemoglobin levels are attributed to surgical blood loss [5]. No thrombotic events occurred in this series. Thermodilution curves remained monophasic and values were consistent, indicating that axial flow pump turbulence or streaming did not alter cardiac output determinations. At baseline, pulmonary arterial pressure is expressed as the mean of pulsatile flow. Under cavopulmonary assist conditions, pulmonary blood flow was continuous; the absolute pressure is expressed. The decrease in systolic and diastolic blood pressure seen late in the study is attributable to myocardial dysfunction after cardiopulmonary bypass, judicious fluid administration, withholding of inotropic support, and vasoactive effects of chronic inhaled anesthetic. Arterial lactate values are shown in Figure 3. The trend of declining arterial lactate values under cavopulmonary assist conditions is consistent with optimal hemodynamics. In no case was sodium bicarbonate administered to treat metabolic acidosis.


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  		Table 1. Hemodynamic Data With Cavopulmonary Assist

 


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  		Fig 3. Arterial lactate levels. Values are expressed as mean ± standard deviation. Time 0 indicates the commencement of cavopulmonary assist immediately after cessation of cardiopulmonary bypass. During postintervention cavopulmonary assist conditions, arterial lactate levels trended toward baseline values. Hour 1 and hour 6 values are significantly different compared with baseline (p < 0.05).

 
Two significant hemodynamic observations were noted in this study. First, systemic venous pressure remained unchanged from baseline conditions. This finding is an important difference in comparison with similar models of univentricular Fontan circulation [3]. Blood volume translocation cannot be ascribed to hydrostatic factors in the high capacitance systemic venous territory. A second observation was that pulmonary arterial pressures were maintained. The mild increase in pulmonary arterial pressure and vascular resistance, which did not reach statistical significance, is explained by the effect of increased pulmonary vascular resistance in response to continuous rather than pulsatile pulmonary perfusion [7]. As a consequence of these two factors, cardiac output was preserved.

Gas exchange data are shown in Table 2. Pulmonary function remained excellent in all cases. Ventilator adjustments did not deviate more than 5% from baseline settings. Peak airway pressures remained less than 25 cm H2O. Pulmonary edema or hemorrhage was not observed. In the last three studies of the series in which continuity between the right ventricle and the main pulmonary artery was interrupted, no significant difference in hemodynamic or blood gas measurements was observed when compared with the first 10 studies for all measurements shown in Tables 1 and 2. An exception to this is hemoglobin levels, because homologous donor blood was available only in the latter three experiments. Because combined coronary sinus blood flow and thebesian blood flow accounts for less than 5% total cardiac output, these factors were not expected to contribute to stability of the experimental preparation.


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  		Table 2. Gas Exchange Data With Cavopulmonary Assist

 

   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
References
 
The Fontan operation is increasingly utilized for palliation of single-ventricle cardiac anomalies [8]. Although excellent functional capacity can be achieved without a right ventricle equivalent in the circulation, this type of circulatory arrangement has inherent limitations. Clinicians may face patients with failing Fontan physiology whose complications are related to systemic venous hypertension, pulmonary arterial hypotension, or ventricular dysfunction. Acute hemodynamic problems may be encountered in the early postoperative period. Late morbidity and mortality, however, are also serious issues that will become increasingly important as more patients with Fontan palliation reach adulthood and the problem of late Fontan attrition becomes more apparent [9].

Beginning in the 1940s, animal investigations in acute right heart bypass laid the foundation for clinical application of the Glenn and Fontan cavopulmonary connections for palliation of single-ventricle cardiac anomalies [10–13]. While not vital for normal pulmonary circulation, the essential function of the right ventricle is to maintain low systemic venous pressure and adequate preload for the ventricle [14, 15]. Unsupported, acute bypass of the right ventricle causes volume shift into the high capacitance systemic venous circulation, reduced pulmonary blood flow, and low cardiac output. In previous models of univentricular Fontan circulation, volume loading (1.6 versus 50.1 mL/kg in biventricular versus Fontan circulations) to achieve an inferior vena caval pressure of 20 to 25 mm Hg was necessary to overcome the cavopulmonary pressure gradient and provide adequate preload to the systemic ventricle [3, 4]. Meaningful hemodynamic stability beyond several hours was not achieved in these studies because of volume-related complications.

The paradox of the Fontan circulation, as elegantly stated by de Leval, is the presence of simultaneous systemic venous hypertension and pulmonary arterial hypotension [1]. Chronic hypertension in the inferior vena caval territory is responsible for hepatic dysfunction, coagulation disorders, and protein losing enteropathy. Pulmonary vascular impedance is increased and capillary recruitment is decreased as a result of nonpulsatile pulmonary perfusion [7]. In aggregate, these factors produce inadequate preload to the systemic ventricle, diastolic dysfunction, decreased ventricular performance, and a chronic low output state [16]. The concept of mechanical support for the failing Fontan circulation is appealing because the pulmonary and systemic circulations would have their own power source, systemic venous pressure would be minimized, and pulmonary arterial pressure would be maintained. This would in turn reduce the workload on the systemic ventricle and improve cardiac output by increasing ventricular preload. Theoretically, minimal circulatory support would be required to overcome the 10 to 20 mm Hg pressure gradient to augment cavopulmonary flow and reverse the paradox. Implantable devices, which have been developed for systemic circulatory support, are capable of performing this task. Mechanical support has been applied experimentally in a valved or nonvalved atriopulmonary Fontan connection using balloon counterpulsation or sac-like assist devices [17–20]. This study demonstrates that cavopulmonary assist can be applied in a model of total cavopulmonary connection.

Axial flow pumps, which use a rotating impeller to produce forward flow, were successfully applied in this study even though they were not specifically designed for cavopulmonary augmentation. An ideal pump for cavopulmonary assist would require several features including pulsatile, unidirectional flow, minimal thrombogenicity, and minimally invasive methods for placement and removal. Bidirectional pumping capability would be desirable if support of both superior and inferior vena caval distributions is required. Conceivably, cavopulmonary support would be weaned after physiologic optimization beyond the perioperative period to facilitate gradual adaptation to passive pulmonary blood flow and elevated systemic venous pressure. The duration of assist needed for univentricular support would presumably depend on patient-specific physiologic variables.

The anatomy of a total cavopulmonary connection is favorable for circulatory assistance in that it provides a relatively straight longitudinal axis for instrumentation. In an adult, pump support in the extracardiac conduit or lateral tunnel alone may be all that is required because chronic hypertension in the inferior vena caval territory accounts for most Fontan-related morbidity, and inferior vena caval flow represents 70% of total systemic venous return [21]. Substituting for the right heart or pulmonary ventricle until the pulmonary vasculature and the systemic venous circulation can accommodate Fontan hemodynamics could be a potential advantage in cases in which medical therapy has failed. To broaden this concept further, cavopulmonary assist could be theoretically applied in the neonate to resolve the problem of an inherently unstable, systemic shunt-dependent, parallel arrangement of the systemic and pulmonary circulations found in Norwood stage I palliation of hypoplastic left heart syndrome.

This study is limited by the fact that the model does not have true single-ventricle anatomy or increased pulmonary vascular resistance as seen in Fontan physiology. Oxygen at 100%, which is nonphysiologic and can induce pulmonary and myocardial toxicity on a more chronic basis, was used to demonstrate that high partial pressures of oxygen could be achieved in a univentricular circulation without inducing circulatory balance instability, as occurs in Norwood stage I physiology. Finally, a conclusive measure of systemic volume status would require measurement of mean circulatory filling pressure which was not performed [22]. Despite these limitations, this study demonstrates the feasibility of using cavopulmonary assist to maintain stability in a model of total cavopulmonary diversion and univentricular Fontan circulation without altering regional volume distribution or cardiac output. Supplementation of cavopulmonary blood flow could beneficially impact early postoperative Fontan stability and may hold potential to address the problem of late Fontan attrition.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 References
 

  1. de Leval M.R. The Fontan circulation: what have we learned? What to expect?. Pediatr Cardiol 1998;19:316-320.[Medline]
  2. Stamm C., Friehs I., Mayer J.E., et al. Long-term results of the lateral tunnel Fontan operation. J Thorac Cardiovasc Surg 2001;121:28-41.
  3. Mace L., Dervanian P., Bourriez A., et al. Changes in venous return parameters associated with univentricular Fontan circulations. Am J Physiol Heart Circ Physiol 2000;279:H2335-2343.[Abstract/Free Full Text]
  4. Kaku K., Matsuda H., Kaneko M., et al. Experimental complete right heart bypass. Proposal of a new model and acute hemodynamic assessment with vasoactive drugs in dogs. J Thorac Cardiovasc Surg 1990;99:161-166.[Abstract]
  5. Butler K.C., Moise J.C., Wampler R.K. The Hemopump—a new cardiac prosthesis device. IEEE Trans Biomed Eng 1990;37:193-196.[Medline]
  6. Lonn U., Wulff J., Keck K., et al. Flow characteristics of the Hemopump: an experimental in vitro study. Ann Thorac Surg 1997;63:162-166.[Abstract/Free Full Text]
  7. Presson R.G., Baumgartner W.A., Peterson A.J., Glenny R.W., Wagner W.W. Pulmonary capillaries are recruited during pulsatile flow. J Appl Physiol 2002;92:1183-1190.[Abstract/Free Full Text]
  8. Mayer J.E., Jr, Helgason H., Jonas R.A., et al. Extending the limits for modified Fontan procedures. J Thorac Cardiovasc Surg 1986;92:1021-1028.[Abstract]
  9. Fontan F., Kirklin J.W., Fernandez G., et al. Outcome after a "perfect" Fontan operation. Circulation 1990;81:1520-1536.[Abstract/Free Full Text]
  10. Rodbard S., Wagner D. By-passing the right ventricle. Proc Soc Exper Biol Med 1949;71:69.[Medline]
  11. Rose J.C., Cosimano S.J., Hufnagel C.A., Massullo E.A. The effects of exclusion of the right ventricle from the circulation in dogs. J Clin Invest 1955;34:1625-1631.
  12. Nuland S.B., Glenn W.W.L., Guilfoil P.H. Circulatory bypass of the right heart. III. Some observations on long-term survivors. Surgery 1958;43:184-201.
  13. Puga F.J., McGoon D.C. Exclusion of the right ventricle from the circulation: hemodynamic observations. Surgery 1973;73:607-613.[Medline]
  14. Sade R.M., Castaneda A.R. The dispensable right ventricle. Surgery 1975;77:624-631.[Medline]
  15. Kresh J.Y., Izrailtyan I., Morris R.J., Wechsler A.S. Vascular determinants of univentricular support. ASAIO J 1998;44:M330-335.[Medline]
  16. Penny D.J., Rigby M.L., Redington A.N. Abnormal patterns of intraventricular flow and diastolic filling after the Fontan operation: evidence of incoordinate ventricular wall motion. Br Heart J 1991;66:375-378.[Abstract/Free Full Text]
  17. Jacobs M.L., Vlahakes G.J., D'ambra M.N., et al. Augmentation of pulmonary blood flow by a right atrial balloon pump after the Fontan operation. Circulation 1987;76(Suppl 3):III-72-76.
  18. Sade R.M., Dearing J.P. Augmentation of pulmonary blood flow after right ventricular bypass. J Thorac Cardiovasc Surg 1981;81:928-933.[Abstract]
  19. Brutel de la Riviere A., Haasler G., Malm J.R., Bregman D. Mechanical assistance of the pulmonary circulation after right ventricular exclusion. J Thorac Cardiovasc Surg 1983;85:809-814.[Abstract]
  20. Gaines W.E., Pierce W.S., Prophet G.A. Pulmonary circulatory support. A quantitative comparison of four methods. J Thorac Cardiovasc Surg 1984;88:958-964.[Abstract]
  21. Salim M.A., DiSessa T.G., Arheart K.L., Alpert B.S. Contributions of superior vena caval flow to total cardiac output in children. A Doppler echocardiographic study. Circulation 1995;92:1860-1865.[Abstract/Free Full Text]
  22. Rothe C.F. Mean circulatory filling pressure: its meaning and measurements. J Appl Physiol 1993;74:499-509.[Abstract/Free Full Text]



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