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Spencer BL, Fallon BP, McLeod JS, Cornell M, Perrone EE, Manthei DM, Rojas-Peña A, Hirschl RB, Bartlett RH, Mychaliska GB. The role of fetal hemoglobin in the artificial placenta: A premature ovine model. Perfusion 2024:2676591241240725. [PMID: 38519444 DOI: 10.1177/02676591241240725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2024]
Abstract
INTRODUCTION A radical paradigm shift in the treatment of premature infants failing conventional treatment is to recreate fetal physiology using an extracorporeal Artificial Placenta (AP). The aim of this study is to evaluate the effects of changing fetal hemoglobin percent (HbF%) on physiology and circuit function during AP support in an ovine model. METHODS Extremely premature lambs (n = 5) were delivered by cesarean section at 117-121 d estimated gestational age (EGA) (term = 145d), weighing 2.5 ± 0.35 kg. Lambs were cannulated using 10-14Fr cannulae for drainage via the right jugular vein and reinfusion via the umbilical vein. Lambs were intubated and lungs were filled with perfluorodecalin to a meniscus with a pressure of 5-8 cm H2O. The first option for transfusion was fetal whole blood from twins followed by maternal red blood cells. Arterial blood gases were used to titrate AP support to maintain fetal blood gas values. RESULTS The mean survival time on circuit was 119.6 ± 39.5 h. Hemodynamic parameters and lactate were stable throughout. As more adult blood transfusions were given to maintain hemoglobin at 10 mg/dL, the HbF% declined, reaching 40% by post operative day 7. The HbF% was inversely proportional to flow rates as higher flows were required to maintain adequate oxygen saturation and perfusion. CONCLUSIONS Transfusion of adult blood led to decreased fetal hemoglobin concentration during AP support. The HbF% was inversely proportional to flow rates. Future directions include strategies to decrease the priming volume and establishing a fetal blood bank to have blood rich in HbF.
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Affiliation(s)
- Brianna L Spencer
- Department of Surgery, ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Brian P Fallon
- Department of Surgery, ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jennifer S McLeod
- Department of Surgery, ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Marie Cornell
- Department of Surgery, ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Erin E Perrone
- Department of Surgery, Section of Pediatric Surgery, University of Michigan Michigan Medicine, Ann Arbor, MI, USA
| | - David M Manthei
- Department of Pathology, University of Michigan, Ann Arbor, MI, USA
| | - Alvaro Rojas-Peña
- Department of Surgery, ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI, USA
- Department of Surgery, Section of Transplantation, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Ronald B Hirschl
- Department of Surgery, ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI, USA
- Department of Surgery, Section of Pediatric Surgery, University of Michigan Michigan Medicine, Ann Arbor, MI, USA
| | - Robert H Bartlett
- Department of Surgery, ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI, USA
| | - George B Mychaliska
- Department of Surgery, ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI, USA
- Department of Surgery, Section of Pediatric Surgery, University of Michigan Michigan Medicine, Ann Arbor, MI, USA
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2
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Fallon BP, Lautner-Csorba O, Major TC, Lautner G, Harvey SL, Langley MW, Johnson MD, Saveski C, Matusko N, Rabah R, Rojas-Pena A, Meyerhoff ME, Bartlett RH, Mychaliska GB. Extracorporeal life support without systemic anticoagulation: a nitric oxide-based non-thrombogenic circuit for the artificial placenta in an ovine model. Pediatr Res 2024; 95:93-101. [PMID: 37087539 PMCID: PMC10600655 DOI: 10.1038/s41390-023-02605-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 01/26/2023] [Accepted: 03/20/2023] [Indexed: 04/24/2023]
Abstract
BACKGROUND Clinical translation of the extracorporeal artificial placenta (AP) is impeded by the high risk for intracranial hemorrhage in extremely premature newborns. The Nitric Oxide Surface Anticoagulation (NOSA) system is a novel non-thrombogenic extracorporeal circuit. This study aims to test the NOSA system in the AP without systemic anticoagulation. METHODS Ten extremely premature lambs were delivered and connected to the AP. For the NOSA group, the circuit was coated with DBHD-N2O2/argatroban, 100 ppm nitric oxide was blended into the sweep gas, and no systemic anticoagulation was given. For the Heparin control group, a non-coated circuit was used and systemic anticoagulation was administered. RESULTS Animals survived 6.8 ± 0.6 days with normal hemodynamics and gas exchange. Neither group had any hemorrhagic or thrombotic complications. ACT (194 ± 53 vs. 261 ± 86 s; p < 0.001) and aPTT (39 ± 7 vs. 69 ± 23 s; p < 0.001) were significantly lower in the NOSA group than the Heparin group. Platelet and leukocyte activation did not differ significantly from baseline in the NOSA group. Methemoglobin was 3.2 ± 1.1% in the NOSA group compared to 1.6 ± 0.6% in the Heparin group (p < 0.001). CONCLUSIONS The AP with the NOSA system successfully supported extremely premature lambs for 7 days without significant bleeding or thrombosis. IMPACT The Nitric Oxide Surface Anticoagulation (NOSA) system provides effective circuit-based anticoagulation in a fetal sheep model of the extracorporeal artificial placenta (AP) for 7 days. The NOSA system is the first non-thrombogenic circuit to consistently obviate the need for systemic anticoagulation in an extracorporeal circuit for up to 7 days. The NOSA system may allow the AP to be implemented clinically without systemic anticoagulation, thus greatly reducing the intracranial hemorrhage risk for extremely low gestational age newborns. The NOSA system could potentially be applied to any form of extracorporeal life support to reduce or avoid systemic anticoagulation.
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Affiliation(s)
- Brian P Fallon
- Department of Surgery, ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Orsolya Lautner-Csorba
- Department of Surgery, ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Terry C Major
- Department of Surgery, ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Gergely Lautner
- Department of Surgery, ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Stephen L Harvey
- Department of Surgery, ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Mark W Langley
- Department of Surgery, ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Matthew D Johnson
- Department of Surgery, ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Claudia Saveski
- Department of Surgery, ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Niki Matusko
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Raja Rabah
- Department of Pathology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Alvaro Rojas-Pena
- Department of Surgery, ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI, USA
- Department of Surgery, Section of Transplantation, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Mark E Meyerhoff
- Department of Chemistry, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Robert H Bartlett
- Department of Surgery, ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI, USA
| | - George B Mychaliska
- Department of Surgery, Section of Pediatric Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
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3
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Kukora SK, Mychaliska GB, Weiss EM. Ethical challenges in first-in-human trials of the artificial placenta and artificial womb: not all technologies are created equally, ethically. J Perinatol 2023; 43:1337-1342. [PMID: 37400494 DOI: 10.1038/s41372-023-01713-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 06/07/2023] [Accepted: 06/21/2023] [Indexed: 07/05/2023]
Abstract
Artificial placenta and artificial womb technologies to support extremely premature neonates are advancing toward clinical testing in humans. Currently, no recommendations exist comparing these approaches to guide study design and optimal enrollment eligibility adhering to principles of research ethics. In this paper, we will explore how scientific differences between the artificial placenta and artificial womb approaches create unique ethical challenges to designing first-in-human trials of safety and provide recommendations to guide ethical study design for initial human translation.
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Affiliation(s)
- Stephanie K Kukora
- Division of Neonatology, Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO, USA.
- Children's Mercy Bioethics Center, Children's Mercy Hospital, Kansas City, MO, USA.
| | - George B Mychaliska
- Department of Surgery, Section of Pediatric Surgery, Fetal Diagnosis and Treatment Center, University of Michigan, Michigan Medicine, Ann Arbor, MI, USA
| | - Elliott Mark Weiss
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA, USA
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4
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Flake AW, De Bie FR, Munson DA, Feudtner C. The artificial placenta and EXTEND technologies: one of these things is not like the other. J Perinatol 2023; 43:1343-1348. [PMID: 37393398 DOI: 10.1038/s41372-023-01716-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 06/15/2023] [Accepted: 06/23/2023] [Indexed: 07/03/2023]
Abstract
The so called "Artificial Placenta" and "Artificial Womb" (EXTEND) technologies share a common goal of improving outcomes for extreme premature infants. Beyond that goal, they are very dissimilar and, in our view, differ sufficiently in their technology, intervention strategy, demonstrated physiology, and risk profiles that bundling them together for consideration of the ethical challenges in designing first in human trials is misguided. In this response to the commentary by Kukora and colleagues, we will provide our perspective on these differences, and how they impact ethical clinical study design for first-in-human trials of safety/feasibility, and subsequently efficacy of the two technologies.
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Affiliation(s)
- Alan W Flake
- Department of Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Felix R De Bie
- Department of Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David A Munson
- Division of Neonatology, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, Universityof Pennsylvania, Philadelphia, PA, USA
| | - Chris Feudtner
- Department of Medical Ethics, Children's Hospital of Philadelphia, and Departments of Pediatrics and of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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5
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Usuda H, Watanabe S, T H, Saito M, Sato S, Ikeda H, Kumagai Y, Choolani MC, Kemp MW. Artificial placenta technology: History, potential and perception. Placenta 2023; 141:10-17. [PMID: 37743742 DOI: 10.1016/j.placenta.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 09/20/2022] [Accepted: 10/02/2022] [Indexed: 11/06/2022]
Abstract
As presently conceptualised, the artificial placenta (AP) is an experimental life support platform for extremely preterm infants (i.e. 400-600 g; 21-23+6 weeks of gestation) born at the border of viability. It is based around the oxygenation of the periviable fetus using gas-exchangers connected to the fetal vasculature. In this system, the lung remains fluid-filled and the fetus remains in a quiescent state. The AP has been in development for some sixty years. Over this time, animal experimental models have evolved iteratively from employing external pump-driven systems used to support comparatively mature fetuses (generally goats or sheep) to platforms driven by the fetal heart and used successfully to maintain extremely premature fetuses weighing around 600 g. Simultaneously, sizable advances in neonatal and obstetric care mean that the nature of a potential candidate patient for this therapy, and thus the threshold success level for justifying its adoption, have both changed markedly since this approach was first conceived. Five landmark breakthroughs have occurred over the developmental history of the AP: i) the first human studies reported in the 1950's; ii) foundation animal studies reported in the 1960's; iii) the first extended use of AP technology combined with fetal pulmonary resuscitation reported in the 1990s; iv) the development of AP systems powered by the fetal heart reported in the 2000's; and v) the adaption of this technology to maintain extremely preterm fetuses (i.e. 500-600 g body weight) reported in the 2010's. Using this framework, the present paper will provide a review of the developmental history of this long-running experimental system and up-to-date assessment of the published field today. With the apparent acceleration of AP technology towards clinical application, there has been an increase in the attention paid to the field, along with some inaccurate commentary regarding its potential application and merits. Additionally, this paper will address several misrepresentations regarding the potential application of AP technology that serve to distract from the significant potential of this approach to greatly improve outcomes for extremely preterm infants born at or close to the present border of viability.
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Affiliation(s)
- H Usuda
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia; Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - S Watanabe
- Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - Hanita T
- Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - M Saito
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia; Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - S Sato
- Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - H Ikeda
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia; Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - Y Kumagai
- Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan
| | - M C Choolani
- Women and Infants Research Foundation, King Edward Memorial Hospital, Perth, Western Australia, Australia
| | - M W Kemp
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia; Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, Japan; School of Veterinary and Life Sciences, Murdoch University, Perth, Western Australia, Australia; Women and Infants Research Foundation, King Edward Memorial Hospital, Perth, Western Australia, Australia; Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
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6
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Shah NR, Mychaliska GB. The new frontier in ECLS: Artificial placenta and artificial womb for premature infants. Semin Pediatr Surg 2023; 32:151336. [PMID: 37866171 DOI: 10.1016/j.sempedsurg.2023.151336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
Outcomes for extremely low gestational age newborns (ELGANs), defined as <28 weeks estimated gestational age (EGA), remain disproportionately poor. A radical paradigm shift in the treatment of prematurity is to recreate the fetal environment with extracorporeal support and provide an environment for organ maturation using an extracorporeal VV-ECLS artificial placenta (AP) or an AV-ECLS artificial womb (AW). In this article, we will review clinical indications, current approaches in development, ongoing challenges, remaining milestones and ethical considerations prior to clinical translation.
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Affiliation(s)
- Nikhil R Shah
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Ann Arbor, MI, USA
| | - George B Mychaliska
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Ann Arbor, MI, USA.
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7
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An Artificial Placenta Experimental System in Sheep: Critical Issues for Successful Transition and Survival up to One Week. Biomedicines 2023; 11:biomedicines11030702. [PMID: 36979681 PMCID: PMC10044909 DOI: 10.3390/biomedicines11030702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 02/21/2023] [Accepted: 02/22/2023] [Indexed: 03/03/2023] Open
Abstract
Objective: To describe the development of an artificial placenta (AP) system in sheep with learning curve and main bottlenecks to allow survival up to one week. Methods: A total of 28 fetal sheep were transferred to an AP system at 110–115 days of gestation. The survival goal in the AP system was increased progressively in three consecutive study groups: 1–3 h (n = 8), 4–24 h (n = 10) and 48–168 h (n = 10). Duration of cannulation procedure, technical complications, pH, lactate, extracorporeal circulation (EC) circuit flows, fetal heart rate, and outcomes across experiments were compared. Results: There was a progressive reduction in cannulation complications (75%, 50% and 0%, p = 0.004), improvement in initial pH (7.20 ± 0.06, 7.31 ± 0.04 and 7.33 ± 0.02, p = 0.161), and increment in the rate of experiments reaching survival goal (25%, 70% and 80%, p = 0.045). In the first two groups, cannulation accidents, air bubbles in the extracorporeal circuit, and thrombotic complications were the most common cause of AP system failure. Conclusions: Achieving a reproducible experimental setting for an AP system is extremely challenging, time- and effort-consuming, and requires a highly multidisciplinary team. As a result of the learning curve, we achieved reproducible transition and survival up to 7 days. Extended survival requires improving instrumentation with custom-designed devices.
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8
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Omecinski KS, Frankowski BJ, Federspiel WJ. Design and In Vitro Evaluation of an Artificial Placenta Made From Hollow Fiber Membranes. ASAIO J 2023; 69:e86-e92. [PMID: 36716073 PMCID: PMC9897463 DOI: 10.1097/mat.0000000000001862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
For infants born at the border of viability, care practices and morbimortality rates vary widely between centers. Trends show significant improvement, however, with increasing gestational age and weight. For periviable infants, the goal of critical care is to bridge patients to improved outcomes. Current practice involves ventilator therapy, resulting in chronic lung injuries. Research has turned to artificial uterine environments, where infants are submerged in an artificial amniotic fluid bath and provided respiratory assistance via an artificial placenta. We have developed the Preemie-Ox, a hollow fiber membrane bundle that provides pumpless respiratory support via umbilical cord cannulation. Computational fluid dynamics was used to design an oxygenator that could achieve a carbon dioxide removal rate of 12.2 ml/min, an outlet hemoglobin saturation of 100%, and a resistance of less than 71 mmHg/L/min at a blood flow rate of 165 ml/min. A prototype was utilized to evaluate in-vitro gas exchange, resistance, and plasma-free hemoglobin generation. In-vitro gas exchange was 4% higher than predicted results and no quantifiable plasma-free hemoglobin was produced.
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Affiliation(s)
- Katelin S Omecinski
- From the McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Brian J Frankowski
- From the McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - William J Federspiel
- From the McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Chemical and Petroleum Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
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9
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Spencer BL, Mychaliska GB. Milestones for clinical translation of the artificial placenta. Semin Fetal Neonatal Med 2022; 27:101408. [PMID: 36437184 DOI: 10.1016/j.siny.2022.101408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Despite significant advances in the treatment of prematurity, premature birth results in significant mortality and morbidity. In particular, extremely low gestational age newborns (ELGANs) defined as <28 weeks estimated gestational age (EGA) suffer from disproportionate mortality and morbidity. A radical paradigm shift in the treatment of prematurity is to recreate fetal physiology using an extracorporeal VV-ECLS artificial placenta (AP) or an AV-ECLS artificial womb (AW). Over the past 15 years, tremendous advances have been made in the laboratory confirming long-term support and organ protection and ongoing development. The major milestones to clinical application are miniaturization, anticoagulation, clinical risk stratification, specialized critical care protocols, a regulatory path and a strategy and platform to translate technology to the bedside. Currently, several groups are addressing the remaining milestones for clinical translation.
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Affiliation(s)
- Brianna L Spencer
- Department of Surgery, University of Michigan, 2101 Taubman Center 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA.
| | - George B Mychaliska
- Section of Pediatric Surgery, Department of Surgery, Fetal Diagnosis and Treatment Center, C.S. Mott Children's Hospital, 1540 E Hospital Dr, Ann Arbor, MI, 48109, USA.
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10
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Charest-Pekeski AJ, Cho SKS, Aujla T, Sun L, Floh AA, McVey MJ, Sheta A, Estrada M, Crawford-Lean L, Foreman C, Mroczek D, Belik J, Saini BS, Lim JM, Moir OJ, Lee FT, Quinn M, Darby JRT, Seed M, Morrison JL, Haller C. Impact of the Addition of a Centrifugal Pump in a Preterm Miniature Pig Model of the Artificial Placenta. Front Physiol 2022; 13:925772. [PMID: 35941934 PMCID: PMC9356302 DOI: 10.3389/fphys.2022.925772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 06/22/2022] [Indexed: 11/28/2022] Open
Abstract
The recent demonstration of normal development of preterm sheep in an artificial extrauterine environment has renewed interest in artificial placenta (AP) systems as a potential treatment strategy for extremely preterm human infants. However, the feasibility of translating this technology to the human preterm infant remains unknown. Here we report the support of 13 preterm fetal pigs delivered at 102 ± 4 days (d) gestation, weighing 616 ± 139 g with a circuit consisting of an oxygenator and a centrifugal pump, comparing these results with our previously reported pumpless circuit (n = 12; 98 ± 4 days; 743 ± 350 g). The umbilical vessels were cannulated, and fetuses were supported for 46.4 ± 46.8 h using the pumped AP versus 11 ± 13 h on the pumpless AP circuit. Upon initiation of AP support on the pumped system, we observed supraphysiologic circuit flows, tachycardia, and hypertension, while animals maintained on a pumpless AP circuit exhibited subphysiologic flows. On the pumped AP circuit, there was a progressive decline in umbilical vein (UV) flow and oxygen delivery. We conclude that the addition of a centrifugal pump to the AP circuit improves survival of preterm pigs by augmenting UV flow through the reduction of right ventricular afterload. However, we continued to observe the development of heart failure within a matter of days.
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Affiliation(s)
- Alex J. Charest-Pekeski
- Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Translational Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Steven K. S. Cho
- Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Translational Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Tanroop Aujla
- Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Translational Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Liqun Sun
- Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - Alejandro A. Floh
- Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Mark J. McVey
- Translational Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Department of Physics, Ryerson University, Toronto, ON, Canada
| | - Ayman Sheta
- Department of Pediatrics, Division of Neonatology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Marvin Estrada
- Lab Animal Services, Peter Gilgan Center for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada
| | - Lynn Crawford-Lean
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Celeste Foreman
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Dariusz Mroczek
- Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - Jaques Belik
- Department of Pediatrics, Division of Neonatology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Brahmdeep S. Saini
- Translational Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Jessie Mei Lim
- Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Translational Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Olivia J. Moir
- Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Translational Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Fu-Tsuen Lee
- Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Translational Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Megan Quinn
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Jack R. T. Darby
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Mike Seed
- Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, ON, Canada
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Janna L. Morrison
- Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Translational Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Christoph Haller
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- *Correspondence: Christoph Haller,
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11
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Harvey SL, Fallon BP, McLeod JS, Matusko N, Rabah R, Arnold MA, Rojas-Pena A, Bartlett RH, Mychaliska GB. Hepatic Function in Premature Lambs Supported by the Artificial Placenta and Total Parenteral Nutrition. ASAIO J 2022; 68:949-955. [PMID: 35383597 PMCID: PMC9246820 DOI: 10.1097/mat.0000000000001586] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The artificial placenta (AP) promotes organ development and reduces organ injury in a lamb model of extreme prematurity. This study evaluates hepatic outcomes after AP support with total parenteral nutrition (TPN) administration. Premature lambs (116-121 days estimated gestational age; term = 145) were cannulated for 7 days of AP support. Lambs received TPN with SMOFlipid (n = 7) or Intralipid (n = 5). Liver function and injury were compared between the two groups biochemically and histologically. Groups were compared by ANOVA with Tukey's multiple comparisons or linear-mixed effects models. From baseline to day 7, total bilirubin (Intralipid 2.6 ± 2.3 to 7.9 ± 4.4 mg/dl; SMOFlipid 0.3 ± 0.1 to 5.5 ± 2.3 mg/dl), alanine aminotransferase, and gamma-glutamyl transferase increased in both groups ( p < 0.001 for all). Direct bilirubin (0.3 ± 0.2 to 1.8 ± 1.4 mg/dl; p = 0.006) and AST (27 ± 5 to 309 ± 242 mg/dl; p < 0.001) increased in SMOFlipid group (not measured in Intralipid group). On liver histology, Intralipid showed more cholestasis than SMOFlipid; both groups showed more than tissue controls. The Intralipid group alone showed hepatocyte injury and had more congestion than controls. Lambs supported by the AP with TPN administration maintain normal hepatic function and sustain minimal hepatic injury. SMOFlipid is associated with decreased cholestasis and hepatic injury versus Intralipid.
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Affiliation(s)
- Stephen L. Harvey
- Department of Surgery, ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI
| | - Brian P. Fallon
- Department of Surgery, ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI
| | - Jennifer S. McLeod
- Department of Surgery, ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI
| | - Niki Matusko
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Raja Rabah
- Department of Pathology, University of Michigan Medical School, Ann Arbor, MI
| | - Meghan A. Arnold
- Department of Surgery, Section of Pediatric Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Alvaro Rojas-Pena
- Department of Surgery, ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI
- Department of Surgery, Section of Transplantation, University of Michigan Medical School, Ann Arbor, MI
| | - Robert H. Bartlett
- Department of Surgery, ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI
| | - George B. Mychaliska
- Department of Surgery, Section of Pediatric Surgery, University of Michigan Medical School, Ann Arbor, MI
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Burgos CM, Frenckner B, Broman LM. Premature and Extracorporeal Life Support: Is it Time? A Systematic Review. ASAIO J 2022; 68:633-645. [PMID: 34593681 DOI: 10.1097/mat.0000000000001555] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Early preterm birth < 34 gestational weeks (GA) and birth weight (BW) <2 kg are relative contraindications for extracorporeal membrane oxygenation (ECMO). However, with improved technology, ECMO is presently managed more safely and with decreasing complications. Thus, these relative contraindications may no longer apply. We performed a systematic review to evaluate the existing literature on ECMO in early and late (34-37 GA) prematurity focusing on survival to hospital discharge and the complication intracranial hemorrhage (ICH). Data sources: MEDLINE, PubMed, Web of Science, Embase, and the Cochrane Database. Only publications in the English language were evaluated. Of the 36 included studies, 23 were related to ECMO support for respiratory failure, 10 for cardiac causes, and four for congenital diaphragmatic hernia (CDH). Over the past decades, the frequency of ICH has declined (89-21%); survival has increased in both early prematurity (25-76%), and in CDH (33-75%), with outcome similar to late prematurity (48%). The study was limited by an inherent risk of bias from overlapping single-center and registry data. Both the risk of ICH and death have decreased in prematurely born treated with ECMO. We challenge the 34 week GA time limit for ECMO and propose an international task force to revise current guidelines. At present, gestational age < 34 weeks might no longer be considered a contraindication for ECMO in premature neonates.
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Affiliation(s)
- Carmen Mesas Burgos
- From the Department of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
- ECMO Centre Karolinska, Pediatric Perioperative Medicine and Intensive Care, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Björn Frenckner
- From the Department of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
- ECMO Centre Karolinska, Pediatric Perioperative Medicine and Intensive Care, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Lars Mikael Broman
- ECMO Centre Karolinska, Pediatric Perioperative Medicine and Intensive Care, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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13
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Fallon BP, Mychaliska GB. Development of an artificial placenta for support of premature infants: narrative review of the history, recent milestones, and future innovation. Transl Pediatr 2021; 10:1470-1485. [PMID: 34189106 PMCID: PMC8192990 DOI: 10.21037/tp-20-136] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Over 50 years ago, visionary researchers began work on an extracorporeal artificial placenta to support premature infants. Despite rudimentary technology and incomplete understanding of fetal physiology, these pioneering scientists laid the foundation for future work. The research was episodic, as medical advances improved outcomes of premature infants and extracorporeal life support (ECLS) was introduced for the treatment of term and near-term infants with respiratory or cardiac failure. Despite ongoing medical advances, extremely premature infants continue to suffer a disproportionate burden of mortality and morbidity due to organ immaturity and unintended iatrogenic consequences of medical treatment. With advancing technology and innovative approaches, there has been a resurgence of interest in developing an artificial placenta to further diminish the mortality and morbidity of prematurity. Two related but distinct platforms have emerged to support premature infants by recreating fetal physiology: a system based on arteriovenous (AV) ECLS and one based on veno-venous (VV) ECLS. The AV-ECLS approach utilizes only the umbilical vessels for cannulation. It requires immediate transition of the infant at the time of birth to a fluid-filled artificial womb to prevent umbilical vessel spasm and avoid gas ventilation. In contradistinction, the VV-ECLS approach utilizes the umbilical vein and the internal jugular vein. It would be applied after birth to infants failing maximal medical therapy or preemptively if risk stratified for high mortality and morbidity. Animal studies are promising, demonstrating prolonged support and ongoing organ development in both systems. The milestones for clinical translation are currently being evaluated.
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Affiliation(s)
- Brian P Fallon
- Department of Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - George B Mychaliska
- Department of Surgery, Section of Pediatric Surgery, Fetal Diagnosis and Treatment Center, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
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Charest‐Pekeski AJ, Sheta A, Taniguchi L, McVey MJ, Floh A, Sun L, Aujla T, Cho SKS, Ren J, Crawford‐Lean L, Foreman C, Lim JM, Saini BS, Estrada M, Lam A, Belik J, Mroczek D, Quinn M, Holman SL, Darby JRT, Seed M, Morrison JL, Haller C. Achieving sustained extrauterine life: Challenges of an artificial placenta in fetal pigs as a model of the preterm human fetus. Physiol Rep 2021; 9:e14742. [PMID: 33650787 PMCID: PMC7923578 DOI: 10.14814/phy2.14742] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 01/12/2021] [Indexed: 11/24/2022] Open
Abstract
Artificial placenta (AP) technology aims to maintain fetal circulation, while promoting the physiologic development of organs. Recent reports of experiments performed in sheep indicate the intrauterine environment can be recreated through the cannulation of umbilical vessels, replacement of the placenta with a low-resistance membrane oxygenator, and incubation of the fetus in fluid. However, it remains to be seen whether animal fetuses similar in size to the extremely preterm human infant that have been proposed as a potential target for this technology can be supported in this way. Preterm Yucatan miniature piglets are similar in size to extremely preterm human infants and share similar umbilical cord anatomy, raising the possibility to serve as a good model to investigate the AP. To characterize fetal cardiovascular physiology, the carotid artery (n = 24) was cannulated in utero and umbilical vein (UV) and umbilical artery were sampled. Fetal UV flow was measured by MRI (n = 16). Piglets were delivered at 98 ± 4 days gestation (term = 115 days), cannulated, and supported on the AP (n = 12) for 684 ± 228 min (range 195-3077 min). UV flow was subphysiologic (p = .002), while heart rate was elevated on the AP compared with in utero controls (p = .0007). We observed an inverse relationship between heart rate and UV flow (r2 = .4527; p < .001) with progressive right ventricular enlargement that was associated with reduced contractility and ultimately hydrops and circulatory collapse. We attribute this to excessive afterload imposed by supraphysiologic circuit resistance and augmented sympathetic activity. We conclude that short-term support of the preterm piglet on the AP is feasible, although we have not been able to attain normal fetal physiology. In the future, we propose to investigate the feasibility of an AP circuit that incorporates a centrifugal pump in our miniature pig model.
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Affiliation(s)
- Alex J. Charest‐Pekeski
- Department of PhysiologyUniversity of TorontoTorontoOntarioCanada
- Translational MedicineThe Hospital for Sick ChildrenTorontoOntarioCanada
| | - Ayman Sheta
- Department of PediatricsDivision of NeonatologyThe Hospital for Sick ChildrenTorontoOntarioCanada
| | - Luiza Taniguchi
- Division of CardiologyThe Labatt Family Heart CentreThe Hospital for Sick ChildrenTorontoOntarioCanada
| | - Mark J. McVey
- Department of Anesthesia and Pain MedicineDepartment of Anesthesiology and Pain MedicineThe Hospital for Sick ChildrenUniversity of TorontoTorontoOntarioCanada
- Department of PhysicsRyerson UniversityTorontoOntarioCanada
| | - Alejandro Floh
- Division of CardiologyThe Labatt Family Heart CentreThe Hospital for Sick ChildrenTorontoOntarioCanada
- Department of Critical Care MedicineThe Hospital for Sick ChildrenTorontoOntarioCanada
| | - Liqun Sun
- Division of CardiologyThe Labatt Family Heart CentreThe Hospital for Sick ChildrenTorontoOntarioCanada
| | - Tanroop Aujla
- Department of PhysiologyUniversity of TorontoTorontoOntarioCanada
- Translational MedicineThe Hospital for Sick ChildrenTorontoOntarioCanada
- Early Origins of Adult Health Research GroupHealth and Biomedical InnovationClinical and Health SciencesUniversity of South AustraliaAdelaideSouth AustraliaAustralia
| | - Steven K. S. Cho
- Department of PhysiologyUniversity of TorontoTorontoOntarioCanada
- Translational MedicineThe Hospital for Sick ChildrenTorontoOntarioCanada
- Early Origins of Adult Health Research GroupHealth and Biomedical InnovationClinical and Health SciencesUniversity of South AustraliaAdelaideSouth AustraliaAustralia
| | - Jiaqi Ren
- Department of PhysiologyUniversity of TorontoTorontoOntarioCanada
- Translational MedicineThe Hospital for Sick ChildrenTorontoOntarioCanada
| | - Lynn Crawford‐Lean
- Division of Cardiovascular SurgeryThe Labatt Family Heart CentreThe Hospital for Sick ChildrenUniversity of TorontoTorontoCanada
| | - Celeste Foreman
- Division of Cardiovascular SurgeryThe Labatt Family Heart CentreThe Hospital for Sick ChildrenUniversity of TorontoTorontoCanada
| | - Jessie Mei Lim
- Department of PhysiologyUniversity of TorontoTorontoOntarioCanada
- Translational MedicineThe Hospital for Sick ChildrenTorontoOntarioCanada
| | - Brahmdeep S. Saini
- Translational MedicineThe Hospital for Sick ChildrenTorontoOntarioCanada
- Institute of Medical ScienceUniversity of TorontoTorontoOntarioCanada
| | - Marvin Estrada
- Lab Animal ServicesResearch InstituteThe Hospital for Sick ChildrenTorontoOntarioCanada
| | - Anson Lam
- Lab Animal ServicesResearch InstituteThe Hospital for Sick ChildrenTorontoOntarioCanada
| | - Jaques Belik
- Department of PhysiologyUniversity of TorontoTorontoOntarioCanada
| | - Dariusz Mroczek
- Division of CardiologyThe Labatt Family Heart CentreThe Hospital for Sick ChildrenTorontoOntarioCanada
| | - Megan Quinn
- Early Origins of Adult Health Research GroupHealth and Biomedical InnovationClinical and Health SciencesUniversity of South AustraliaAdelaideSouth AustraliaAustralia
| | - Stacey L. Holman
- Early Origins of Adult Health Research GroupHealth and Biomedical InnovationClinical and Health SciencesUniversity of South AustraliaAdelaideSouth AustraliaAustralia
| | - Jack R. T. Darby
- Early Origins of Adult Health Research GroupHealth and Biomedical InnovationClinical and Health SciencesUniversity of South AustraliaAdelaideSouth AustraliaAustralia
| | - Mike Seed
- Department of PhysiologyUniversity of TorontoTorontoOntarioCanada
- Division of CardiologyThe Labatt Family Heart CentreThe Hospital for Sick ChildrenTorontoOntarioCanada
- Institute of Medical ScienceUniversity of TorontoTorontoOntarioCanada
| | - Janna L. Morrison
- Early Origins of Adult Health Research GroupHealth and Biomedical InnovationClinical and Health SciencesUniversity of South AustraliaAdelaideSouth AustraliaAustralia
| | - Christoph Haller
- Division of Cardiovascular SurgeryThe Labatt Family Heart CentreThe Hospital for Sick ChildrenUniversity of TorontoTorontoCanada
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15
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Fallon BP, Gadepalli SK, Hirschl RB. Pediatric and neonatal extracorporeal life support: current state and continuing evolution. Pediatr Surg Int 2021; 37:17-35. [PMID: 33386443 PMCID: PMC7775668 DOI: 10.1007/s00383-020-04800-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/26/2020] [Indexed: 12/24/2022]
Abstract
The use of extracorporeal life support (ECLS) for the pediatric and neonatal population continues to grow. At the same time, there have been dramatic improvements in the technology and safety of ECLS that have broadened the scope of its application. This article will review the evolving landscape of ECLS, including its expanding indications and shrinking contraindications. It will also describe traditional and hybrid cannulation strategies as well as changes in circuit components such as servo regulation, non-thrombogenic surfaces, and paracorporeal lung-assist devices. Finally, it will outline the modern approach to managing a patient on ECLS, including anticoagulation, sedation, rehabilitation, nutrition, and staffing.
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Affiliation(s)
- Brian P Fallon
- Department of Surgery, ECLS Laboratory, B560 MSRB II/SPC 5686, Michigan Medicine, University of Michigan, 1150 W. Medical Center Drive, Ann Arbor, MI, 48109, USA.
| | - Samir K Gadepalli
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Ronald B Hirschl
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Ann Arbor, MI, USA
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16
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De Bie FR, Davey MG, Larson AC, Deprest J, Flake AW. Artificial placenta and womb technology: Past, current, and future challenges towards clinical translation. Prenat Diagn 2020; 41:145-158. [PMID: 32875581 DOI: 10.1002/pd.5821] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/24/2020] [Accepted: 08/29/2020] [Indexed: 01/12/2023]
Abstract
Extreme prematurity remains a major cause of neonatal mortality and severe long-term morbidity. Current neonatal care is associated with significant morbidity due to iatrogenic injury and developmental immaturity of extreme premature infants. A more physiologic approach, replacing placental function and providing a womb-like environment, is the foundational principle of artificial placenta (AP) and womb (AW) technology. The concept has been studied during the past 60 years with limited success. However, recent technological advancements and a greater emphasis on mimicking utero-placental physiology have improved the success of experimental models, bringing the technology closer to clinical translation. Here, we review the rationale for and history of AP and AW technology, discuss the challenges that needed to be overcome, and compare recent successful models. We conclude by outlining some remaining challenges to be addressed on the path towards clinical translation and opportunities for future research.
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Affiliation(s)
- Felix R De Bie
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Marcus G Davey
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Abby C Larson
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jan Deprest
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Alan W Flake
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Chitty LS, Hui L, Ghidini A, Levy B, Deprest J, Van Mieghem T, Bianchi DW. In case you missed it: The Prenatal Diagnosis editors bring you the most significant advances of 2019. Prenat Diagn 2020; 40:287-293. [PMID: 31875323 DOI: 10.1002/pd.5632] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 12/18/2019] [Indexed: 12/21/2022]
Affiliation(s)
- L S Chitty
- London North Genomic Laboratory, Great Ormond Street NHS Foundation Trust, and Genetics and Genomic Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
| | - L Hui
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - A Ghidini
- Antenatal Testing Centre, Inova Alexandria Hospital, Alexandria, VA
| | - B Levy
- Departments of Pathology and Cell Biology, Columbia University, New York, NY
| | - J Deprest
- Departments of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - T Van Mieghem
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada
| | - D W Bianchi
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
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18
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Usuda H, Watanabe S, Saito M, Sato S, Musk GC, Fee ME, Carter S, Kumagai Y, Takahashi T, Kawamura MS, Hanita T, Kure S, Yaegashi N, Newnham JP, Kemp MW. Successful use of an artificial placenta to support extremely preterm ovine fetuses at the border of viability. Am J Obstet Gynecol 2019; 221:69.e1-69.e17. [PMID: 30853365 DOI: 10.1016/j.ajog.2019.03.001] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 02/26/2019] [Accepted: 03/04/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Ex vivo uterine environment therapy is an experimental life support platform designed to reduce the risk of morbidity and mortality for extremely preterm infants born at the border of viability (21-24 weeks' gestation). To spare the functionally immature lung, this platform performs gas exchange via a membranous oxygenator connected to the umbilical vessels, and the fetus is submerged in a protective bath of artificial amniotic fluid. We and others have demonstrated the feasibility of extended survival with ex vivo uterine environment therapy therapy in late preterm fetuses; however, there is presently no evidence to show that the use of such a platform can support extremely preterm fetuses, the eventual translational target for therapy of this nature. OBJECTIVE The objective of the study was to use our ex vivo uterine environment therapy platform to support the healthy maintenance of 600-700 g/95 days gestational age (equivalent to 24 weeks of human gestation) sheep fetuses. Primary outcome measures were as follows: (1) maintenance of key physiological variables; (2) absence of infection; (3) absence of brain injury; and (4) growth and cardiovascular function patterns matching that of noninstrumented, age-matched in utero controls. STUDY DESIGN Singleton fetuses from 8 ewes underwent surgical delivery at 95 days' gestation (term, 150 days). Fetuses were adapted to ex vivo uterine environment therapy and maintained for 120 hours with real-time monitoring of key physiological variables. Umbilical artery blood samples were regularly collected to assess blood gas data, differential counts, inflammation, and microbial load to exclude infection. Brain injury was evaluated by gross anatomical and histopathological approaches after euthanasia. Nine pregnant control animals were euthanized at 100 days' gestation to allow comparative postmortem analyses. Data were tested for mean differences with an analysis of variance. RESULTS Seven of 8 ex vivo uterine environment group fetuses (87.5%) completed 120 hours of therapy with key parameters maintained in a normal physiological range. There were no significant intergroup differences (P > .05) in final weight, crown-rump length, and body weight-normalized lung and brain weights at euthanasia compared with controls. There were no biologically significant differences in hematological parameters (total or differential leucocyte counts and plasma concentration of tumor necrosis factor-α and monocyte chemoattractant protein 1) (P > .05). Daily blood cultures were negative for aerobic and anaerobic growth in all ex vivo uterine environment animals. There was no difference in airspace consolidation between control and ex vivo uterine environment animals, and there was no increase in the number of lung cells staining positive for the T-cell marker CD3. There were no increases in interleukin-1, interleukin-6, interleukin-8, tumor necrosis factor-α, and monocyte chemoattractant protein 1 mRNA expression in lung tissues compared with the control group. No cases of intraventricular hemorrhage were observed, and white matter injury was identified in only 1 ex vivo uterine environment fetus. CONCLUSION For several decades, there has been little improvement in outcomes of extremely preterm infants born at the border of viability. In the present study, we report the use of artificial placenta technology to support, for the first time, extremely preterm ovine fetuses (equivalent to 24 weeks of human gestation) in a stable, growth-normal state for 120 hours. With additional refinement, the data generated by this study may inform a treatment option to improve outcomes for extremely preterm infants.
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McLeod JS, Church JT, Coughlin MA, Carr B, Poling C, Sarosi E, Perkins EM, Quinones MC, Hala P, Rabah R, Freiheit E, Rojas-Pena A, Bartlett RH, Mychaliska GB. Splenic development and injury in premature lambs supported by the artificial placenta. J Pediatr Surg 2019; 54:1147-1152. [PMID: 30902457 PMCID: PMC6545267 DOI: 10.1016/j.jpedsurg.2019.02.041] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 02/21/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The purpose of this study is to evaluate splenic effects during artificial placenta (AP) support. METHODS AP lambs (118-121 d, n = 14) were delivered and placed on the AP support for a goal of 10-14 days. Cannulation used right jugular drainage and umbilical vein reinfusion. Early (ETC; 115-120 d; n = 7) and late (LTC; 125-131 d; n = 7) tissue controls were delivered and immediately sacrificed. Spleens were formalin fixed, H&E stained, and graded for injury, response to inflammation, and extramedullary hematopoiesis (EMH). CD68 and CD163 stains were used to assess for macrophage activation and density. Clinical variables were correlated with splenic scores. Groups were compared using Fisher's Exact Test and descriptive statistics. p < 0.05 indicated significance. RESULTS Mean survival for AP lambs was 12 ± 5 d. There was no necrosis found in any of the groups. Vascular congestion and sinusoidal histiocytosis did not significantly differ between AP and control groups (p = 0.72; p = 0.311). There were significantly more pigmented macrophages (p = 0.008), CD163 (p = <0.001), and CD68 (p = <0.001) stained cells in the AP group. ETC and LTC demonstrated more EMH than AP spleens (p = <0.001). CONCLUSIONS During AP support, spleens appear to develop normally and exhibit an appropriate inflammatory response. After initiation of AP support, EMH transitions away from the spleen. STUDY TYPE Research Paper/Therapeutic Potential. LEVEL OF EVIDENCE N/A.
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Affiliation(s)
- Jennifer S. McLeod
- Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Joseph T. Church
- Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Megan A. Coughlin
- Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Benjamin Carr
- Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Clinton Poling
- Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Ellery Sarosi
- Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
| | | | - Matias Caceres Quinones
- Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Pavel Hala
- Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Raja Rabah
- Department of Statistics, Michigan Medicine, Ann Arbor, Michigan
| | | | - Alvaro Rojas-Pena
- Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - Robert H Bartlett
- Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
| | - George B. Mychaliska
- Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine, Ann Arbor, Michigan,Fetal Diagnosis and Treatment Center, C.S. Mott Children’s Hospital, Michigan Medicine, Ann Arbor, Michigan
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20
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The artificial womb: What is the next step? J Pediatr Surg 2019; 54:362. [PMID: 30611526 DOI: 10.1016/j.jpedsurg.2018.08.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 08/26/2018] [Indexed: 11/21/2022]
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21
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Mohr EL. Modeling Zika Virus-Associated Birth Defects in Nonhuman Primates. J Pediatric Infect Dis Soc 2018; 7:S60-S66. [PMID: 30590626 PMCID: PMC8506225 DOI: 10.1093/jpids/piy120] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 10/31/2018] [Indexed: 01/22/2023]
Abstract
In utero infection with Zika virus (ZIKV) during pregnancy can lead to the development of birth defects and postnatal deficits. A nonhuman primate (NHP) model of congenital ZIKV infection can help fill the gaps in knowledge where tissue studies are required to define viral pathogenesis and identify targets for therapeutic intervention. This model system has already identified critical features of ZIKV pathogenesis in congenital infection. Before translating these NHP studies to human clinical trials, we must understand the similarities and differences between human and NHP fetal immune system development, neural development, and infant assessment tools. Because of the overall similarity between fetal and infant development in humans and NHPs, this NHP model can complement human clinical trials by defining immune correlates of protection and evaluating therapeutic interventions.
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Affiliation(s)
- Emma L Mohr
- Department of Pediatrics, University of Wisconsin-Madison
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