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Peers de Nieuwburgh M, Dave A, Khan SA, Ngo M, Hayes KB, Slipenchuk M, Lieberman E, Youssef MR, Crompton D, Choudhry AM, Guo N, Tian Z, Rychik J, Davey MG, Flake AW. Assessment of extremely premature lambs supported by the Extrauterine Environment for Neonatal Development (EXTEND). Pediatr Res 2024:10.1038/s41390-024-03287-0. [PMID: 38834782 DOI: 10.1038/s41390-024-03287-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 03/28/2024] [Accepted: 05/07/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND Our team has previously reported physiologic support by the EXTra-uterine Environment for Neonatal Development (EXTEND) of 105 to 117 days gestational age (GA) lambs for up to 28 days with normal organ maturation. However, the fetal lamb brain matures more rapidly, requiring the study of 90-105 day GA fetal lambs to assess more neurodevelopmentally equivalent lambs to the 23-25 week GA extreme premature infant. METHODS Extremely preterm lambs (90-95 days of GA) were delivered by C-section and supported by EXTEND. Estimated circuit flows were maintained at around 325 ml/kg/min. After support on EXTEND, MRI and histopathologic analysis were performed and compared to 105-112 days GA control lambs. RESULTS The extremely preterm group includes 10 animals with a mean GA of 91.6 days, a mean weight at cannulation of 0.98 kg and a mean length of stay on EXTEND of 13.5 days (10-21 days). Hemodynamics and oxygenation showed stable parameters. Animals showed growth and physiologic cardiac function. MRI volumetric and diffusion analysis was comparable to controls. Histologic brain analysis revealed no difference between study groups. CONCLUSION EXTEND appears to support brain and cardiac development in an earlier gestation, less mature, lamb model. IMPACT Prolonged (up to 21 days) physiological support of extremely preterm lambs of closer neurodevelopmental equivalence to the 24-28 gestational week human was achieved using the EXTEND system. EXTEND treatment supported brain growth and development in extremely preterm fetal lambs and was not associated with intraventricular hemorrhage or white matter injury. Daily echocardiography demonstrated physiologic heart function, absence of cardiac afterload, and normal developmental increase in cardiac chamber dimensions. This study demonstrates hemodynamic and metabolic support by the EXTEND system in the extremely preterm ovine model.
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Affiliation(s)
| | - Apeksha Dave
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sameer A Khan
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michelle Ngo
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kevin B Hayes
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Evan Lieberman
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Mohanad R Youssef
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Alia Mohsin Choudhry
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nan Guo
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Zhiyun Tian
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jack Rychik
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Alan W Flake
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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2
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Gregorovicova M, Lashkarinia SS, Yap CH, Tomek V, Sedmera D. Hemodynamics During Development and Postnatal Life. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1441:201-226. [PMID: 38884713 DOI: 10.1007/978-3-031-44087-8_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Abstract
A well-developed heart is essential for embryonic survival. There are constant interactions between cardiac tissue motion and blood flow, which determine the heart shape itself. Hemodynamic forces are a powerful stimulus for cardiac growth and differentiation. Therefore, it is particularly interesting to investigate how the blood flows through the heart and how hemodynamics is linked to a particular species and its development, including human. The appropriate patterns and magnitude of hemodynamic stresses are necessary for the proper formation of cardiac structures, and hemodynamic perturbations have been found to cause malformations via identifiable mechanobiological molecular pathways. There are significant differences in cardiac hemodynamics among vertebrate species, which go hand in hand with the presence of specific anatomical structures. However, strong similarities during development suggest a common pattern for cardiac hemodynamics in human adults. In the human fetal heart, hemodynamic abnormalities during gestation are known to progress to congenital heart malformations by birth. In this chapter, we discuss the current state of the knowledge of the prenatal cardiac hemodynamics, as discovered through small and large animal models, as well as from clinical investigations, with parallels gathered from the poikilotherm vertebrates that emulate some hemodynamically significant human congenital heart diseases.
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Affiliation(s)
- Martina Gregorovicova
- Laboratory of Developmental Cardiology, Institute of Physiology, Czech Academy of Sciences, Prague, Czech Republic
- Institute of Anatomy, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | | | - Choon Hwai Yap
- Department of Bioengineering, Imperial College, London, UK
| | - Viktor Tomek
- Pediatric Cardiology, Motol University Hospital, Prague, Czech Republic
| | - David Sedmera
- Laboratory of Developmental Cardiology, Institute of Physiology, Czech Academy of Sciences, Prague, Czech Republic.
- Institute of Anatomy, First Faculty of Medicine, Charles University, Prague, Czech Republic.
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3
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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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Smith KLM, Swiderska A, Lock MC, Graham L, Iswari W, Choudhary T, Thomas D, Kowash HM, Desforges M, Cottrell EC, Trafford AW, Giussani DA, Galli GLJ. Chronic developmental hypoxia alters mitochondrial oxidative capacity and reactive oxygen species production in the fetal rat heart in a sex-dependent manner. J Pineal Res 2022; 73:e12821. [PMID: 35941749 PMCID: PMC9540814 DOI: 10.1111/jpi.12821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 07/28/2022] [Accepted: 08/03/2022] [Indexed: 11/29/2022]
Abstract
Insufficient oxygen supply (hypoxia) during fetal development leads to cardiac remodeling and a predisposition to cardiovascular disease in later life. Previous work has shown hypoxia causes oxidative stress in the fetal heart and alters the activity and expression of mitochondrial proteins in a sex-dependent manner. However, the functional effects of these modifications on mitochondrial respiration remain unknown. Furthermore, while maternal antioxidant treatments are emerging as a promising new strategy to protect the hypoxic fetus, whether these treatments convey similar protection to cardiac mitochondria in the male or female fetus has not been investigated. Therefore, using an established rat model, we measured the sex-dependent effects of gestational hypoxia and maternal melatonin treatment on fetal cardiac mitochondrial respiration, reactive oxygen species (ROS) production, and lipid peroxidation. Pregnant Wistar rats were subjected to normoxia or hypoxia (13% oxygen) during gestational days (GDs) 6-20 (term ~22 days) with or without melatonin treatment (5 µg/ml in maternal drinking water). On GD 20, mitochondrial aerobic respiration and H2 O2 production were measured in fetal heart tissue, together with lipid peroxidation and citrate synthase (CS) activity. Gestational hypoxia reduced maternal body weight gain (p < .01) and increased placental weight (p < .05) but had no effect on fetal weight or litter size. Cardiac mitochondria from male but not female fetuses of hypoxic pregnancy had reduced respiratory capacity at Complex II (CII) (p < .05), and an increase in H2 O2 production/O2 consumption (p < .05) without any changes in lipid peroxidation. CS activity was also unchanged in both sexes. Despite maternal melatonin treatment increasing maternal and fetal plasma melatonin concentration (p < .001), melatonin treatment had no effect on any of the mitochondrial parameters investigated. To conclude, we show that gestational hypoxia leads to ROS generation from the mitochondrial electron transport chain and affects fetal cardiac mitochondrial respiration in a sex-dependent manner. We also show that maternal melatonin treatment had no effect on these relationships, which has implications for the development of future therapies for hypoxic pregnancies.
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Affiliation(s)
- Kerri L. M. Smith
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
| | - Agnieszka Swiderska
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
| | - Mitchell C. Lock
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
| | - Lucia Graham
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
| | - Wulan Iswari
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
| | - Tashi Choudhary
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
| | - Donna Thomas
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
| | - Hager M. Kowash
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
| | - Michelle Desforges
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
| | - Elizabeth C. Cottrell
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
| | - Andrew W. Trafford
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
| | - Dino A. Giussani
- Department of Physiology Development and NeuroscienceUniversity of CambridgeCambridgeUK
| | - Gina L. J. Galli
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
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Larson AC, De Bie FR, Chang J, Davey MG, Flake AW. The EXTrauterine Environment for Neonatal Development: Present and Future. Pediatr Dev Pathol 2022; 25:253-262. [PMID: 35102770 DOI: 10.1177/10935266211067110] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Despite advances in clinical care and modest improvement in mortality rates for extreme prematurity, morbidity remains a significant challenge. The ideal environment to support prematurity would be fluidic and rely on natural fetal circulation to mimic the natural fetal amniotic environment, yet such an environment has been unsuccessful in long-term support until recently. Our group has succeeded in developing such a support system to foster fetal growth in the premature lamb model that shows promise for clinical translation. Here, we describe the EXTrauterine Environment for Neonatal Development (EXTEND) from its conception onwards, review published literature on fetal development and support of the premature lamb model in EXTEND, and discuss future applications.
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Affiliation(s)
- Abby C Larson
- Center for Fetal Research, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Felix R De Bie
- Center for Fetal Research, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Jonathan Chang
- Center for Fetal Research, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Marcus G Davey
- Center for Fetal Research, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alan W Flake
- Center for Fetal Research, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA
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6
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Chronic foetal hypoxaemia does not cause elevation of serum markers of brain injury. Cardiol Young 2022; 32:732-737. [PMID: 34365994 DOI: 10.1017/s1047951121002894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES The objective of this study was to investigate changes in serum biomarkers of acute brain injury, including white matter and astrocyte injury during chronic foetal hypoxaemia. We have previously shown histopathological changes in myelination and neuronal density in fetuses with chronic foetal hypoxaemia at a level consistent with CHD. METHODS Mid-gestation foetal sheep (110 ± 3 days gestation) were cannulated and attached to a pumpless, low-resistance oxygenator circuit, and incubated in a sterile fluid environment mimicking the intrauterine environment. Fetuses were maintained with an oxygen delivery of 20-25 ml/kg/min (normoxemia) or 14-16 ml/kg/min (hypoxaemia). Myelin Basic Protein and Glial Fibrillary Acidic Protein serum levels in the two groups were assessed by ELISA at baseline and at 7, 14, and 21 days of support. RESULTS Based on overlapping 95% confidence intervals, there were no statistically significant differences in either Myelin Basic Protein or Glial Fibrillary Acidic Protein serum levels between the normoxemic and hypoxemic groups, at any time point. No statistically significant correlations were observed between oxygen delivery and levels of Myelin Basic Protein and Glial Fibrillary Acidic Protein. CONCLUSION Chronic foetal hypoxaemia during mid-gestation is not associated with elevated serum levels of acute white matter (Myelin Basic Protein) or astrocyte injury (Glial Fibrillary Acidic Protein), in this model. In conjunction with our previously reported findings, our data support the hypothesis that the brain dysmaturity with impaired myelination found in fetuses with chronic hypoxaemia is caused by disruption of normal developmental pathways rather than by direct cellular injury.
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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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8
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Prenatal Hypoxia Affects Foetal Cardiovascular Regulatory Mechanisms in a Sex- and Circadian-Dependent Manner: A Review. Int J Mol Sci 2022; 23:ijms23052885. [PMID: 35270026 PMCID: PMC8910900 DOI: 10.3390/ijms23052885] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 02/28/2022] [Accepted: 03/05/2022] [Indexed: 11/17/2022] Open
Abstract
Prenatal hypoxia during the prenatal period can interfere with the developmental trajectory and lead to developing hypertension in adulthood. Prenatal hypoxia is often associated with intrauterine growth restriction that interferes with metabolism and can lead to multilevel changes. Therefore, we analysed the effects of prenatal hypoxia predominantly not associated with intrauterine growth restriction using publications up to September 2021. We focused on: (1) The response of cardiovascular regulatory mechanisms, such as the chemoreflex, adenosine, nitric oxide, and angiotensin II on prenatal hypoxia. (2) The role of the placenta in causing and attenuating the effects of hypoxia. (3) Environmental conditions and the mother's health contribution to the development of prenatal hypoxia. (4) The sex-dependent effects of prenatal hypoxia on cardiovascular regulatory mechanisms and the connection between hypoxia-inducible factors and circadian variability. We identified that the possible relationship between the effects of prenatal hypoxia on the cardiovascular regulatory mechanism may vary depending on circadian variability and phase of the days. In summary, even short-term prenatal hypoxia significantly affects cardiovascular regulatory mechanisms and programs hypertension in adulthood, while prenatal programming effects are not only dependent on the critical period, and sensitivity can change within circadian oscillations.
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9
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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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10
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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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11
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Bates ML, Levy PT, Nuyt AM, Goss KN, Lewandowski AJ, McNamara PJ. Adult Cardiovascular Health Risk and Cardiovascular Phenotypes of Prematurity. J Pediatr 2020; 227:17-30. [PMID: 32931771 DOI: 10.1016/j.jpeds.2020.09.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 08/25/2020] [Accepted: 09/09/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Melissa L Bates
- Department of Health and Human Physiology, University of Iowa, Iowa City, IA; Division of Neonatology, Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA
| | - Philip T Levy
- Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA.
| | - Anne Monique Nuyt
- Division of Neonatology, Department of Pediatrics, CHU Sainte-Justine, Faculty of Medicine, Université de Montréal, Montréal, Quebec, Canada
| | - Kara N Goss
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI; Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI
| | - Adam J Lewandowski
- Oxford Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Patrick J McNamara
- Division of Neonatology, Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA
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12
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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: 27] [Impact Index Per Article: 6.8] [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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13
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Ozawa K, Davey MG, Tian Z, Hornick MA, Mejaddam AY, McGovern PE, Flake AW, Rychik J. Fetal echocardiographic assessment of cardiovascular impact of prolonged support on EXTrauterine Environment for Neonatal Development (EXTEND) system. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:516-522. [PMID: 30989734 PMCID: PMC7187205 DOI: 10.1002/uog.20295] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Revised: 03/21/2019] [Accepted: 04/05/2019] [Indexed: 05/10/2023]
Abstract
OBJECTIVE EXTrauterine Environment for Neonatal Development (EXTEND) is a system to support ongoing fetal growth and organ development in an extrauterine environment, utilizing a pumpless low-resistance oxygenator circuit. The aim of this study was to evaluate hemodynamics and cardiac function in fetal sheep sustained on the EXTEND system. METHODS This was a prospective study of fetal sheep supported for a minimum of 3 weeks on EXTEND. Hemodynamic parameters were assessed weekly and included heart rate, mean arterial pressure (MAP), Doppler-echocardiography-derived cardiac output (CO), pulsatility indices (PIs) of the fetal middle cerebral artery (MCA), umbilical artery (UA) and ductus venosus and cardiac function, as assessed by speckle-tracking-derived global longitudinal strain and strain rate in the right (RV) and left (LV) ventricles. Parameters were compared at 0 days and 1, 2 and 3 weeks following placement on EXTEND. RESULTS Of 10 fetal sheep enrolled, seven survived for 3 weeks and were included in the analysis. Median gestational age at cannulation was 107 (range, 95-109) days. Heart rate decreased and MAP increased significantly, but within acceptable ranges, during the study period. The quantities and relative ratios of right and left CO remained stable within the anticipated physiological range throughout the study period. Vascular tracings and PIs appeared to be similar to those seen normally in the natural in-utero state, with MCA-PI being higher than UA-PI. UA tracings demonstrated maintained abundant diastolic flow despite the absence of placental circulation. In both the RV and LV, strain decreased significantly at 1 and 2 weeks relative to baseline but returned to baseline values by week 3. CONCLUSIONS The EXTEND mechanical support system replicates natural physiology and creates a stable and sustainable cardiovascular construct that supports growth over a 3-week period. However, there is a period of depressed contractility within the first week with subsequent improvement by week 3. This may reflect a period of physiological accommodation that warrants further investigation. This study lays the foundation for further exploration as the EXTEND system moves towards human application. © 2019 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- K. Ozawa
- Center for Fetal Research, Department of SurgeryThe Children's Hospital of PhiladelphiaPhiladelphiaPAUSA
- Fetal Heart ProgramCardiac Center at The Children's Hospital of PhiladelphiaPhiladelphiaPAUSA
- Center of Maternal–FetalNeonatal and Reproductive Medicine, National Center for Child Health and Development (NCCHD)TokyoJapan
| | - M. G. Davey
- Center for Fetal Research, Department of SurgeryThe Children's Hospital of PhiladelphiaPhiladelphiaPAUSA
| | - Z. Tian
- Fetal Heart ProgramCardiac Center at The Children's Hospital of PhiladelphiaPhiladelphiaPAUSA
| | - M. A. Hornick
- Center for Fetal Research, Department of SurgeryThe Children's Hospital of PhiladelphiaPhiladelphiaPAUSA
| | - A. Y. Mejaddam
- Center for Fetal Research, Department of SurgeryThe Children's Hospital of PhiladelphiaPhiladelphiaPAUSA
| | - P. E. McGovern
- Center for Fetal Research, Department of SurgeryThe Children's Hospital of PhiladelphiaPhiladelphiaPAUSA
| | - A. W. Flake
- Center for Fetal Research, Department of SurgeryThe Children's Hospital of PhiladelphiaPhiladelphiaPAUSA
| | - J. Rychik
- Fetal Heart ProgramCardiac Center at The Children's Hospital of PhiladelphiaPhiladelphiaPAUSA
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Chen JM. The 19th annual C. Walton Lillehei memorial lecture in cardiovascular surgery customizing single ventricle care. PROGRESS IN PEDIATRIC CARDIOLOGY 2019. [DOI: 10.1016/j.ppedcard.2019.101132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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15
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Lawrence KM, McGovern PE, Mejaddam A, Rossidis AC, Baumgarten H, Kim AG, Grinspan JB, Licht DJ, Radaelli E, Rychik J, Peranteau WH, Davey MG, Flake AW, Gaynor JW. Prenatal hypoxemia alters microglial morphology in fetal sheep. J Thorac Cardiovasc Surg 2019; 159:270-277. [PMID: 31597618 DOI: 10.1016/j.jtcvs.2019.06.102] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 06/06/2019] [Accepted: 06/25/2019] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Neuroimmune cells, particularly microglia and astrocytes, play a critical role in neurodevelopment. Neurocognitive delays are common in children with congenital heart disease, but their etiology is poorly understood. Our objective was to determine whether prenatal hypoxemia, at levels common in congenital heart disease, induced neuroimmune activation to better understand the origins of neurobehavioral disorders in congenital heart disease. METHODS Eight fetal sheep at gestational age 109 ± 3 days (term ∼145 days) were cannulated onto a pumpless extracorporeal oxygenator via the umbilical vessels and supported in a fluid environment for 22 ± 2 days under normoxic (n = 4) or hypoxic (n = 4) conditions. Control fetuses (n = 7) were harvested at gestational age 133 ± 4 days. At necropsy, brains were stained with ionized calcium-binding adaptor molecule 1 and glial fibrillary acidic protein antibodies to quantify microglia and astrocytes, respectively, in gray and white matter in frontotemporal and cerebellar sections. Microglia were classified into 4 morphologic types based on cell shape. Data were analyzed with 1-way analysis of variance or Fisher exact test, as appropriate. RESULTS Oxygen delivery was significantly reduced in hypoxic fetuses (15.6 ± 1.8 mL/kg/min vs 24.3 ± 2.3 mL/kg/min; P < .01). Rates of apoptosis were similar in hypoxic, normoxic, and intrauterine control animals in all examined areas. There were also no differences between groups in area occupied by glial fibrillary acidic protein-labeled astrocytes or ionized calcium-binding adaptor molecule 1-labeled microglia in all examined areas. However, round microglia were significantly increased in hypoxic animals compared with normoxic animals (33% vs 6%; P < .01) and control animals (33% vs 11%; P < .01). CONCLUSIONS Prenatal hypoxemia altered microglial morphology without significant gliosis. Additional studies characterizing these mechanisms may provide insight into the origins of neurobehavioral disabilities in children with congenital heart disease.
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Affiliation(s)
- Kendall M Lawrence
- Department of Surgery, Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Patrick E McGovern
- Department of Surgery, Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Ali Mejaddam
- Department of Surgery, Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Avery C Rossidis
- Department of Surgery, Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Heron Baumgarten
- Department of Surgery, Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Aimee G Kim
- Department of Surgery, Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Judith B Grinspan
- Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Daniel J Licht
- Division of Neurology, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Enrico Radaelli
- Division of Pathobiology, University of Pennsylvania School of Veterinary Medicine, Philadelphia, Pa
| | - Jack Rychik
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - William H Peranteau
- Department of Surgery, Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Marcus G Davey
- Department of Surgery, Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Alan W Flake
- Department of Surgery, Center for Fetal Research, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - J William Gaynor
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pa.
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