Document:

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                                                                  Exhibit 10.4.1

                                 FIRST AMENDMENT
                                       TO
                               FINANCING AGREEMENT

     FIRST AMENDMENT, dated as of August 30, 2001 (this "AMENDMENT"), to the
Financing Agreement, dated as of September 19, 2000 (the "FINANCING AGREEMENT"),
by and among INNOVATIVE CLINICAL SOLUTIONS, LTD., a Delaware corporation (THE
"PARENT"), CLINICAL STUDIES, LTD., a Delaware corporation ( the "BORROWER"), the
subsidiaries of the Parent (other than the Borrower) party thereto and
identified on the signature pages thereto as "Guarantors " (each a "LOAN PARTY"
and collectively, the "LOAN PARTIES"), and ABLECO FINANCE LLC, a Delaware
limited liability company (as lender and as agent for itself and each person or
entity that purchases any portion of Ableco Finance LLC's rights and obligations
pursuant to Section 10.07 of the Financing Agreement, collectively, the
"LENDER").

     WHEREAS, the Loan Parties and the Lender have entered into the Waiver,
Consent and Acknowledgment dated as of August 30, 2001 (the "WAIVER"), pursuant
to which the Lender has consented to the proposed sale of certain assets by the
Borrower, and granted certain other waivers, in each case subject to the terms
and conditions set forth therein; and

     WHEREAS, it is a condition precedent to the effectiveness of the Waiver
that the Loan Parties and the Lender shall have entered into an amendment to the
Financing Agreement to (i) amend the definitions of "Borrowing Base" and
"Commitment" set forth in the Financing Agreement and (ii) include additional
direct and indirect subsidiaries of the Parent within the term "Permitted
Subsidiaries" as defined in the Financing Agreement;

     NOW THEREFORE, the Loan Parties and the Lender hereby agree as follows:

     1. DEFINITIONS. All capitalized terms used herein and not otherwise defined
herein are used herein as defined in the Financing Agreement.

     2. AMENDMENTS. The Financing Agreement is hereby amended as follows:

        (a) The definition of "Borrowing Base" set forth in Section 1.01 of the
Financing Agreement is amended in its entirety to read as follows:

          "BORROWING BASE" means, at any date, (a) the LESSER of (i) the sum of
     (A) the product of eighty-five percent (85%) TIMES the Net Amount of
     Eligible Accounts Receivable of the Borrower as of such date PLUS (B) the
     product of fifty percent (50%) TIMES the Allocation For New Sales of the
     Borrower as of such date, PLUS (c) $3,500,000, and (ii) the aggregate
     amount of actual Collections by the Borrower from Accounts Receivable of
     the Borrower for the immediately preceding 120 day period to the extent
     such Collections are received in the ordinary course of business of the
     Borrower, MINUS (b) such reserves as the Lender may deem appropriate in the
     exercise of its reasonable business judgment based upon the lending
     practices of the Lender consistent with the practices customary in the
     commercial finance industry.

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        (b) The definition of "Commitment" set forth in Section 1.01 of the
Financing Agreement is amended in its entirety to read as follows:

          "COMMITMENT" means the commitment of the Lender to make Loans to the
     Borrower in an aggregate principal amount at any time outstanding not to
     exceed $8,500,000.00, as such amount may be terminated or reduced from time
     to time in accordance with the terms of this Agreement.

        (c) Schedule 5.01(f)(i) to the Financing Agreement is hereby replaced
with new Schedule 5.01(f)(i), attached hereto as EXHIBIT A.

        (d) Schedule 5.01(f)(ii) to the Financing Agreement is hereby replaced
with new Schedule 5.01(f)(ii), attached hereto as EXHIBIT B.

     3. CONDITIONS TO EFFECTIVENESS. (a) Except as set forth in subsection (b)
below, this Amendment shall become effective only upon satisfaction in full of
the following conditions precedent unless waived in writing by the Lender (the
first date upon which all such conditions have been satisfied or waived by the
Lender being herein called the "AMENDMENT EFFECTIVE DATE"):

           (i) The representations and warranties contained in this Amendment
and in the Loan Documents shall be correct on and as of the Amendment Effective
Date as though made on and as of such date (provided that, upon giving effect to
this Amendment (A) the Persons listed in SCHEDULE I hereto shall no longer be
deemed to be Subsidiaries of the Parent, Guarantors or Loan Parties and (B) the
Persons listed in SCHEDULE II hereto shall be deemed Permitted Subsidiaries);
and no Default or Event of Default shall have occurred and be continuing on the
Amendment Effective Date or result from this Amendment becoming effective in
accordance with its terms.

           (ii) The Lender shall have executed this Amendment and received
counterparts to this Amendment which bear the signatures of the Loan Parties.

           (iii) Each of the conditions to effectiveness of the Waiver set forth
in clauses (a), (e) and (g) of Section 4 thereof (other than the effectiveness
of this Amendment) shall have been satisfied.

           (iv) All legal matters incident to this Amendment shall be
satisfactory to the Lender and its counsel.

        (b) The amendments set forth in Sections 2(a) and 2(b) hereof shall
become effective concurrently with the closing of the Sale (as such term is
defined in the Waiver).

     4. COVENANT. Each of the Loan Parties covenants and agrees that, not later
than September 20, 2001, it will deliver to the Lender stock certificates
evidencing all of the issued and outstanding shares of each Subsidiary of the
Parent named in SCHEDULE II hereto,

                                      -2-

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together with stock powers, undated and endorsed in blank by the parent company
of each such Subsidiary.

     5. REPRESENTATIONS AND WARRANTIES. Each of the Loan Parties represents and
warrants to the Lenders as follows:

        (a) Each Loan Party (i) is a corporation, limited liability company or
limited partnership duly organized, validly existing and in good standing under
the laws of the state of its organization and (ii) has all requisite power,
authority and legal right to execute and deliver this Amendment and to perform
the Financing Agreement, as amended hereby.

        (b) The execution, delivery and performance by each Loan Party of this
Amendment and the performance by each Loan Party of the Financing Agreement as
amended hereby (i) have been duly authorized by all necessary action, (ii) do
not and will not violate or create a default under such Loan Party's
organizational documents, any applicable law or any contractual restriction
binding on or otherwise affecting such Loan Party or any of such Loan Party's
properties, and (iii) except as provided in the Loan Documents, do not and will
not result in or require the creation of any lien, security interest or other
charge or encumbrance upon or with respect to such Loan Party 's property.

        (c) No authorization or approval or other action by, and no notice to or
filing with, any Governmental Authority or other regulatory body is required in
connection with the due execution and delivery by any of the Loan Parties of
this Amendment and the performance by the Loan Parties of the Financing
Agreement as amended hereby.

        (d) This Amendment and the Financing Agreement, as amended hereby,
constitute the legal, valid and binding obligations of the Loan Parties,
enforceable against each such Loan Party in accordance with their terms.

        (e) The representations and warranties contained in the Loan Documents
are correct on and as of the Amendment Effective Date as though made on and as
of such date (provided that, upon giving effect to this Amendment (i) the
Persons listed in SCHEDULE I hereto shall no longer be deemed to be Subsidiaries
of the Parent, Guarantors or Loan Parties and (ii) the Persons listed in
SCHEDULE II hereto shall be deemed Permitted Subsidiaries); and no Default or
Event of Default has occurred and is continuing on and as of the Amendment
Effective Date.

     6. RESERVATION OF RIGHTS. No action or acquiescence by the Lender,
including, without limitation, this Amendment of, or the acceptance of any
payments under, the Financing Agreement, shall constitute a waiver of any
Default or Event of Default which may exist as of the Amendment Effective Date.
Accordingly, the Lender reserves all of its rights under the Financing
Agreement, under the Loan Documents, at law and otherwise regarding any such
Default or Event of Default.

     7. CONTINUED EFFECTIVENESS OF LOAN DOCUMENTS. Each of the Loan Parties
hereby (i) confirms and agrees that each Loan Document to which it is a party
is, and shall continue to be, in full force and effect and is hereby ratified
and confirmed in all respects except

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that on and after the Amendment Effective Date, all references in any such Loan
Document to "the Financing Agreement", "thereto", "thereof", "thereunder" or
words of like import referring to the Financing Agreement shall mean the
Financing Agreement as amended by this Amendment and (ii) confirms and agrees
that to the extent that any such Loan Document purports to assign or pledge to
the Lender or to grant to the Lender a security interest in or lien on, any
collateral as security for the Obligations of the Loan Parties from time to time
existing in respect of the Financing Agreement and the Loan Documents, such
pledge, assignment and/or grant of the security interest or lien is hereby
ratified and confirmed in all respects.

     8. AMENDMENT AS LOAN DOCUMENT. The Loan Parties hereby acknowledge and
agree that this Amendment constitutes a "Loan Document" under the Financing
Agreement. Accordingly, it shall be an Event of Default under the Financing
Agreement if (i) any representation or warranty made by the Loan Parties under
or in connection with this Amendment shall have been untrue, false or misleading
in any material respect when made, or (ii) the Loan Parties shall fail to
perform or observe any term, covenant or agreement contained in this Amendment.

     9. MISCELLANEOUS.

        (a) This Amendment may be executed in any number of counterparts and by
different parties hereto in separate counterparts, each of which shall be deemed
to be an original, but all of which taken together shall constitute one and the
same agreement.

        (b) Section and paragraph headings herein are included for convenience
of reference only and shall not constitute a part of this Amendment for any
other purpose.

        (c) THIS AMENDMENT SHALL BE GOVERNED BY, AND CONSTRUED IN ACCORDANCE
WITH, THE LAWS OF THE STATE OF NEW YORK.

        (d) THE LOAN PARTIES AND THE LENDER EACH HEREBY IRREVOCABLY WAIVE ALL
RIGHT TO TRIAL BY JURY IN ANY ACTION, PROCEEDING OR COUNTERCLAIM (WHETHER BASED
ON CONTRACT, TORT OR OTHERWISE) ARISING OUT OF OR RELATING TO THIS AMENDMENT OR
THE ACTIONS OF THE LENDER IN THE NEGOTIATION, ADMINISTRATION, PERFORMANCE OR
ENFORCEMENT HEREOF.

        (e) The Borrower will pay on demand all fees, costs and expenses of the
Lender in connection with the preparation, execution and delivery of this
Amendment, including, without limitation, the reasonable fees, disbursements and
other charges of counsel to the Lender.

                [REMAINDER OF THIS PAGE INTENTIONALLY LEFT BLANK]

                                      -4-

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                  IN WITNESS WHEREOF, the parties hereto have caused this
Amendment to be executed by their respective officers thereunto duly authorized,
as of the date first above written.

                                            PARENT:
                                            ------

                                            INNOVATIVE CLINICAL SOLUTIONS, LTD.

                                            By:  /s/ MICHAEL T. HEFFERNAN
                                                 ------------------------
                                                 Name: Michael T. Heffernan
                                                 Title: President and
                                                        Chief Executive Officer

                                            BORROWER:
                                            --------

                                            CLINICAL STUDIES, LTD.

                                            By:  /s/ MICHAEL T. HEFFERNAN
                                                 ------------------------
                                                 Name: Michael T. Heffernan
                                                 Title: President and
                                                        Chief Executive Officer

                                            GUARANTORS:
                                            ----------

                                            BABRAD, INC.

                                            Breathco Incorporated

                                            CCC-Indiana Lithotripsy, Inc.

                                            CCC Lithotripsy, Inc.

                                            CCC National Lithotripsy, Inc.

                                            Clinical Marketing, Ltd.

                                            College Park Radiation Care, Inc.

                                            Dasco Development West, Inc.

                                            DDC Real Estate Corp.

                                            Deer Co., Inc.

                                            DeKalb Endoscopy Center, Inc.

                                            Diagnostic Imaging of Biltmore, Inc.

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                                            First Choice Health Care Services of
                                            Ft. Lauderdale, Inc.

                                            Lithotripsy America, Inc.

                                            Montgomery Radiation Care at
                                            Baptist, Inc.

                                            Nashville Radiation Care, Inc.

                                            Oncology Therapies of America, Inc.

                                            Oncology Therapies, Inc.

                                            PhyMatrix Diagnostic Imaging, Inc.

                                            PhyMatrix Management Company, Inc.

                                            PhyMatrix Network Management IPA I,
                                            Inc.

                                            PhyMatrix Network Management IPA II,
                                            Inc.

                                            PhyMatrix Network Management, Inc.

                                            PhyMatrix Northeast, Inc.

                                            PhyMatrix of Atlanta, Inc.

                                            PhyMatrix of Central Georgia, Inc.

                                            PhyMatrix of Manatee County, Inc.

                                            PhyMatrix Physician Management, Inc.

                                            PhyMatrix Pulmonary Network, Inc.

                                            PhyMatrix Urology Network, Inc.

                                            Physician Consultant & Management
                                            Co. of NC, Inc.

                                            Physician Consultant & Management
                                            Co. of NY, Inc.

                                            Physicians Consultant and Management
                                            Corporation

                                            Pinnacle Associates, Inc.

                                            Urology Consultant of South Florida,
                                            Inc.

                                            By:   /s/ GARY S. GILLHEENEY
                                                  -----------------------
                                                  Gary S. Gillheeney, as Chief
                                                  Financial Officer of each of
                                                  the foregoing companies

<PAGE>

                                            LENDER:
                                            ------

                                            ABLECO FINANCE LLC

                                            By:  /s/ KEVIN GENDA
                                                 -----------------
                                            Name: Kevin Genda
                                            Title: SVP -Chief Credit Officer

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                                   SCHEDULE I

                   PERSONS NO LONGER DEEMED TO BE SUBSIDIARIES

<PAGE>

                                   SCHEDULE II

                           NEW PERMITTED SUBSIDIARIES

<PAGE>

                                    EXHIBIT A

                             NEW SCHEDULE 5.01(F)(I)

<PAGE>

                                    EXHIBIT B

                            NEW SCHEDULE 5.01(F)(II)<Page>

                                                                     EXHIBIT 4.4

                                 MEDICALCV, INC.
              INCORPORATED UNDER THE LAWS OF THE STATE OF MINNESOTA

No. U-                              Certificate for __________ Units
    -----------------------------

         Units consisting of One Share of Common Stock and One Redeemable
              Class A Warrant to Purchase One Share of Common Stock

         Unit CUSIP 584639 20 7

THIS CERTIFIES that

         is the owner of the number of Units set forth above.

         Each Unit consists of one share of MedicalCV, Inc. Common Stock, $0.01
par value per share ("Common Stock"), and one (1) redeemable Class A Warrant
("Warrant") to purchase one share of Common Stock for $6.50 per share at any
time on or after ________________, ______, but before 5:00 P.M., Minneapolis
time on ________________, ______ (the "Expiration Date"). The terms of this
Warrant are governed by a Warrant Agreement dated as of ________________, 2001,
between MedicalCV, Inc. and The Registrar & Transfer Company as Warrant agent
(the "Warrant Agent") and subject to the terms and conditions contained therein,
to all of which terms and conditions the holder of this Unit certificate
consents by acceptance hereof. The Warrants shall be void unless exercised
before 5:00 P.M., Minneapolis time on the Expiration Date.

         This Certificate is not valid unless countersigned by the Transfer
Agent and Registrar of the Company.

         The Warrants and the shares of Common Stock represented by this Unit
certificate shall be non-detachable and shall not be separately transferable
until ________________, ______, or such earlier date as shall be determined by
MedicalCV, Inc.

Dated:
                                                    MEDICALCV, INC.

COUNTERSIGNED AND REGISTERED                                 By

THE REGISTRAR & TRANSFER COMPANY.
          as Transfer Agent and Registrar                   [TITLE]

By
                                                            Attest:

        AUTHORIZED SIGNATURE                                          SECRETARY

<Page>

                                 UNIT PROVISIONS

         This certificate certifies that for value received the registered
holder hereby is entitled, at any time on or after ________________, ______, or
such earlier date as MedicalCV, Inc. shall determine, that the Warrants and
Common Stock which comprise the Units shall be separately transferable (the
"Separation Date"), to exchange this Unit Certificate for one Common Stock
Certificate and one Warrant Certificate upon surrender of this Unit Certificate
to the Transfer Agent at the office of the Transfer Agent together with any
documentation required by such Transfer Agent. At any time on or after
________________, ______, and before 5:00 P.M. Minneapolis Time on the
Expiration Date, upon surrender of the Warrant Certificate at the office of the
Warrant Agent, with the Purchase Form on the reverse side thereof completed and
duly executed and accompanied by payment, in cash or check payable to the
Warrant Agent for the account of the Company, the registered holder of such
Warrant Certificate shall be entitled to purchase from MedicalCV, Inc. one share
of Common Stock of MedicalCV, Inc. for each Warrant represented by the Warrant
Certificate, which shares shall be fully paid and nonassessable, at the exercise
price of $______. The Purchase Price and the number of shares purchaseable upon
exercise of each Warrant are subject to adjustment upon the occurrence of
certain events set forth in the Warrant Agreement.

         Once separated by the holder, Warrants may not be later recombined
with Common Stock to form Units. A Unit ceases to exist once the Common
Stock or Warrant is sold separately. After 5:00 P.M., Minneapolis Time on
________________, ______, the Warrants shall become null and void and of no
value.

         REFERENCE IS MADE TO THE WARRANT AGREEMENT REFERRED TO ON THE REVERSE
SIDE HEREOF, AND THE PROVISIONS OF SUCH WARRANT AGREEMENT SHALL FOR ALL PURPOSES
HAVE THE SAME EFFECT AS THOUGH FULLY SET FORTH ON THE FRONT OF THIS CERTIFICATE.

         The Warrant shall be governed by and construed in accordance with the
laws of the State of Minnesota.

         The following abbreviations, when used in the inscription on the face
of this certificate shall be construed as though they were written out in full
according to applicable laws or regulations:

<Table>
<Caption>
<S>            <C>                                   <C>
TEN COM        -  as tenants in common               UNIF GIFT MIN ACT - ...........Custodian............
TEN ENT        -  as tenants by the entireties                           (Cust)                  (Minor)
JT TEN         -  as joint tenants with right of                         under Uniform Gifts to Minors
survivorship and not as tenants                                               Act..........................
                                                                         ...........
                  in common                                                                (State)
COM PROP       -  as community property              UNIF TRF MIN ACT -  ..........Custodian         (until
                                                                         age..............)
                                                                         (Cust)

                                                                         ...................under Uniform
                                                                         Transfers
                                                                         (Minor)
                                                                         to Minors
                                                                         Act...............................
                                                                         (State)
</Table>

        Additional abbreviations may also be used though not in the above list.

<Page>

         For Value Received, __________________ hereby sell, assign and transfer
unto

PLEASE INSERT SOCIAL SECURITY OR OTHER
      IDENTIFYING NUMBER OF ASSIGNEE

____________________________________________

________________________________________________________________________________
(PLEASE PRINT OR TYPEWRITE NAME AND ADDRESS, INCLUDING ZIP CODE, OF ASSIGNEE)

________________________________________________________________________________

________________________________________________________________________________
(Units) represented by the within Certificate, and do hereby irrevocably
constitute and appoint
________________________________________________________________________
Attorney to transfer the said Unit(s) on the books of the within named
Corporation with full power of substitution in the premises.

Dated ________________________________

                           NOTICE:  THE SIGNATURE TO THIS ASSIGNMENT MUST
                                    CORRESPOND WITH THE NAME AS WRITTEN UPON THE
                                    FACE OF THE CERTIFICATE, IN EVERY
                                    PARTICULAR, WITHOUT ALTERATION OR
                                    ENLARGEMENT OR ANY CHANGE WHATEVER.

IMPORTANT:          ALL SIGNATURES MUST BE GUARANTEED IN THE SPACE PROVIDED
                    BELOW BY A FIRM THAT IS A MEMBER OF A NATIONAL SECURITIES
                    EXCHANGE OR OF THE NATIONAL ASSOCIATION OF SECURITIES
                    DEALERS, INC. OR BY A COMMERCIAL BANK OR TRUST COMPANY
                    LOCATED IN THE UNITED STATES.

SIGNATURE GUARANTEE:

Name:___________________________________________________________________________
                                 (Please print)

By:_____________________________________________________________________________

Title:__________________________________________________________________________

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