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Hollis IB, Jennings DL, Krim S, Ton VK, Ducharme A, Cowger J, Looby M, Eulert-Green JJ, Bansal N, Horn E, Byku M, Katz J, Michaud CJ, Rajapreyar I, Campbell P, Vale C, Cosgrove R, Hernandez-Montfort J, Otero J, Ingemi A, Raj S, Weeks P, Agarwal R, Martinez ES, Tops LF, Ahmed MM, Kiskaddon A, Kremer J, Keebler M, Ratnagiri RK. An ISHLT consensus statement on strategies to prevent and manage hemocompatibility related adverse events in patients with a durable, continuous-flow ventricular assist device. J Heart Lung Transplant 2024; 43:1199-1234. [PMID: 38878021 DOI: 10.1016/j.healun.2024.04.065] [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] [Received: 04/26/2024] [Accepted: 04/26/2024] [Indexed: 07/15/2024] Open
Abstract
Life expectancy of patients with a durable, continuous-flow left ventricular assist device (CF-LVAD) continues to increase. Despite significant improvements in the delivery of care for patients with these devices, hemocompatability-related adverse events (HRAEs) are still a concern and contribute to significant morbility and mortality when they occur. As such, dissemination of current best evidence and practices is of critical importance. This ISHLT Consensus Statement is a summative assessment of the current literature on prevention and management of HRAEs through optimal management of oral anticoagulant and antiplatelet medications, parenteral anticoagulant medications, management of patients at high risk for HRAEs and those experiencing thrombotic or bleeding events, and device management outside of antithrombotic medications. This document is intended to assist clinicians caring for patients with a CF-LVAD provide the best care possible with respect to prevention and management of these events.
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Affiliation(s)
- Ian B Hollis
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina; University of North Carolina Medical Center, Chapel Hill, North Carolina.
| | - Douglas L Jennings
- New York Presbyterian Columbia Irving Medical Center/Long Island University College of Pharmacy, New York, New York
| | - Selim Krim
- John Ochsner Heart and Vascular Institute, New Orleans, Louisiana
| | - Van-Khue Ton
- Massachusetts General Hospital, Boston, Massachusetts
| | - Anique Ducharme
- Montreal Heart Institute/Université de Montréal, Montreal, Quebec, Canada
| | | | - Mary Looby
- Inova Fairfax Medical Campus, Falls Church, Virginia
| | | | - Neha Bansal
- Mount Sinai Kravis Children's Hospital, New York, New York
| | - Ed Horn
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mirnela Byku
- University of North Carolina Medical Center, Chapel Hill, North Carolina
| | - Jason Katz
- Division of Cardiology, NYU Grossman School of Medicine & Bellevue Hospital, New York, New York
| | | | | | | | - Cassandra Vale
- The Prince Charles Hospital, Chermside, Queensland, Australia
| | - Richard Cosgrove
- Cornerstone Specialty Hospital/University of Arizona College of Pharmacy, Tucson, Arizona
| | | | - Jessica Otero
- AdventHealth Littleton Hospital, Littleton, Colorado
| | | | | | - Phillip Weeks
- Memorial Hermann-Texas Medical Center, Houston, Texas
| | - Richa Agarwal
- Duke University Medical Center, Durham, North Carolina
| | | | - Laurens F Tops
- Leiden University Medical Center, Leiden, the Netherlands
| | | | - Amy Kiskaddon
- Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Mary Keebler
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Awad MA, Sun W, Han D, Griffith BP, Wu ZJ. Increased phagocytosis capacity of circulating neutrophils in patients on continuous flow ventricular assist device support. Artif Organs 2024; 48:636-645. [PMID: 38133151 PMCID: PMC11105991 DOI: 10.1111/aor.14693] [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] [Received: 08/09/2023] [Revised: 10/05/2023] [Accepted: 12/06/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Neutrophils take part in the innate immune response, phagocytosis, and pro-inflammatory cytokine release. The phagocytic capacity of circulating neutrophils in patients on continuous flow (CF) ventricular assist device (VAD) has not been well studied. METHODS Blood samples from 14 patients undergoing CF-VAD implantation were collected and analyzed preoperatively (at baseline) and on postoperative days (POD) 3, 7, 14, and 28. Flow cytometry was used to assess the surface expression levels of CD62L, CD162, and macrophage antigen-1 (MAC-1) and neutrophil phagocytic capacity. Interleukin 1 (IL1), IL6, IL8, TNF-α, neutrophil elastase, and myeloperoxidase in plasma were measured using enzyme-linked immunosorbent assays. RESULTS Among the 14 patients, seven patients had preoperative bridge device support. Relative to baseline, patients with no bridge device had elevated leukocyte count and neutrophil elastase by POD3 which normalized by POD7. Neutrophil activation level, IL6, IL8, and TNF-α increased by POD3 and sustained elevated levels for 7-14 days postoperatively. Elevated neutrophil phagocytic capacity persisted even until POD28. Similar patterns were observed in patients on a preoperative bridge device. CONCLUSIONS Neutrophil activation and phagocytic capacity increased in response to VAD support, while inflammatory cytokines remain elevated for up to 2 weeks postoperatively. These findings may indicate that VAD implantation elicits circulating neutrophils to an abnormal preemptive phagocytotic phenotype.
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Affiliation(s)
- Morcos A. Awad
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Wenji Sun
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Dong Han
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Bartley P. Griffith
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Zhongjun J. Wu
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Fischell Department of Bioengineering, A. James Clark School of Engineering, University of Maryland, College Park, MD, USA
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Arias K, Sun W, Han D, Griffith BP, Wu ZJ. Neutrophil Structural and Functional Alterations After High Mechanical Shear Stress Exposure. ASAIO J 2023; 69:841-848. [PMID: 37159479 DOI: 10.1097/mat.0000000000001985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023] Open
Abstract
Patients on mechanical circulatory support are prone to infections, increasing morbidity and mortality. These circulatory support devices generate high mechanical shear stress (HMSS) that can causes trauma to blood. When leukocytes become damaged, their immune response function may be impaired or weakened, leading to increased infection vulnerability. This study examined neutrophil structural and functional alterations after exposure to 75, 125, and 175 Pa HMSS for 1 second. Human blood was exposed to three levels of HMSS using a blood shearing device. Neutrophil morphological alteration was characterized by examining blood smears. Flow cytometry assays were used to analyze expression levels of CD62L and CD162 receptors, activation level (CD11b), and aggregation (platelet-neutrophil aggregates). Neutrophil phagocytosis and rolling were examined via functional assays. The results show neutrophil structure (morphology and surface receptors) and function (activation, aggregation, phagocytosis, rolling) were significantly altered after HMSS exposure. These alterations include cell membrane damage, loss of surface receptors (CD62L and CD162), initiation of activation and aggregation, upregulation of phagocytic ability and increased rolling speed. The alterations were the most severe after 175 Pa exposure. HMSS caused damage and activation of neutrophils, potentially impairing normal neutrophil function, leading to weakened immune defense and increasing a patient's vulnerability to infections.
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Affiliation(s)
- Katherin Arias
- From the Fischell Department of Bioengineering, A. James Clark School of Engineering, University of Maryland, College Park, Maryland
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Wenji Sun
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Dong Han
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Bartley P Griffith
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Zhongjun J Wu
- From the Fischell Department of Bioengineering, A. James Clark School of Engineering, University of Maryland, College Park, Maryland
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
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Thompson W, Papoutsakis ET. The role of biomechanical stress in extracellular vesicle formation, composition and activity. Biotechnol Adv 2023; 66:108158. [PMID: 37105240 DOI: 10.1016/j.biotechadv.2023.108158] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 04/23/2023] [Accepted: 04/24/2023] [Indexed: 04/29/2023]
Abstract
Extracellular vesicles (EVs) are cornerstones of intercellular communication with exciting fundamental, clinical, and more broadly biotechnological applications. However, variability in EV composition, which results from the culture conditions used to generate the EVs, poses significant fundamental and applied challenges and a hurdle for scalable bioprocessing. Thus, an understanding of the relationship between EV production (and for clinical applications, manufacturing) and EV composition is increasingly recognized as important and necessary. While chemical stimulation and culture conditions such as cell density are known to influence EV biology, the impact of biomechanical forces on the generation, properties, and biological activity of EVs remains poorly understood. Given the omnipresence of these forces in EV preparation and in biomanufacturing, expanding the understanding of their impact on EV composition-and thus, activity-is vital. Although several publications have examined EV preparation and bioprocessing and briefly discussed biomechanical stresses as variables of interest, this review represents the first comprehensive evaluation of the impact of such stresses on EV production, composition and biological activity. We review how EV biogenesis, cargo, efficacy, and uptake are uniquely affected by various types, magnitudes, and durations of biomechanical forces, identifying trends that emerge both generically and for individual cell types. We also describe implications for scalable bioprocessing, evaluating processes inherent in common EV production and isolation methods, and propose a path forward for rigorous EV quality control.
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Affiliation(s)
- Will Thompson
- Department of Chemical and Biomolecular Engineering, University of Delaware, 590 Avenue 1743, Newark, DE 19713, USA
| | - Eleftherios Terry Papoutsakis
- Department of Chemical and Biomolecular Engineering, University of Delaware, 590 Avenue 1743, Newark, DE 19713, USA.
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Roka-Moiia Y, Ammann KR, Miller-Gutierrez S, Sheriff J, Bluestein D, Italiano JE, Flaumenhaft RC, Slepian MJ. Shear-Mediated Platelet Microparticles Demonstrate Phenotypic Heterogeneity as to Morphology, Receptor Distribution, and Hemostatic Function. Int J Mol Sci 2023; 24:7386. [PMID: 37108551 PMCID: PMC10138836 DOI: 10.3390/ijms24087386] [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] [Received: 03/07/2023] [Revised: 04/09/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023] Open
Abstract
Implantable Cardiovascular Therapeutic Devices (CTD), while lifesaving, impart supraphysiologic shear stress to platelets, resulting in thrombotic and bleeding coagulopathy. We previously demonstrated that shear-mediated platelet dysfunction is associated with downregulation of platelet GPIb-IX-V and αIIbβ3 receptors via generation of Platelet-Derived MicroParticles (PDMPs). Here, we test the hypothesis that sheared PDMPs manifest phenotypical heterogeneity of morphology and receptor surface expression and modulate platelet hemostatic function. Human gel-filtered platelets were exposed to continuous shear stress. Alterations of platelet morphology were visualized using transmission electron microscopy. Surface expression of platelet receptors and PDMP generation were quantified by flow cytometry. Thrombin generation was quantified spectrophotometrically, and platelet aggregation was measured by optical aggregometry. Shear stress promotes notable alterations in platelet morphology and ejection of distinctive types of PDMPs. Shear-mediated microvesiculation is associated with the remodeling of platelet receptors, with PDMPs expressing significantly higher levels of adhesion receptors (αIIbβ3, GPIX, PECAM-1, P-selectin, and PSGL-1) and agonist receptors (P2Y12 and PAR1). Sheared PDMPs promote thrombin generation and inhibit platelet aggregation induced by collagen and ADP. Sheared PDMPs demonstrate phenotypic heterogeneity as to morphology and defined patterns of surface receptors and impose a bidirectional effect on platelet hemostatic function. PDMP heterogeneity suggests that a range of mechanisms are operative in the microvesiculation process, contributing to CTD coagulopathy and posing opportunities for therapeutic manipulation.
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Affiliation(s)
- Yana Roka-Moiia
- Sarver Heart Center, Departments of Medicine and Biomedical Engineering, University of Arizona, 1501 N Campbell Ave, Building 201E, Room 6139, Tucson, AZ 85724, USA; (Y.R.-M.)
| | - Kaitlyn R. Ammann
- Sarver Heart Center, Departments of Medicine and Biomedical Engineering, University of Arizona, 1501 N Campbell Ave, Building 201E, Room 6139, Tucson, AZ 85724, USA; (Y.R.-M.)
| | - Samuel Miller-Gutierrez
- Sarver Heart Center, Departments of Medicine and Biomedical Engineering, University of Arizona, 1501 N Campbell Ave, Building 201E, Room 6139, Tucson, AZ 85724, USA; (Y.R.-M.)
| | - Jawaad Sheriff
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY 11794, USA
| | - Danny Bluestein
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY 11794, USA
| | - Joseph E. Italiano
- Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Robert C. Flaumenhaft
- Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Marvin J. Slepian
- Sarver Heart Center, Departments of Medicine and Biomedical Engineering, University of Arizona, 1501 N Campbell Ave, Building 201E, Room 6139, Tucson, AZ 85724, USA; (Y.R.-M.)
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Roka-Moiia Y, Ammann K, Miller-Gutierrez S, Sheriff J, Bluestein D, Italiano JE, Flaumenhaft RC, Slepian MJ. Shear-Mediated Platelet Microparticles Demonstrate Phenotypic Heterogeneity as to Morphology, Receptor Distribution, and Hemostatic Function. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.02.08.527675. [PMID: 36798322 PMCID: PMC9934663 DOI: 10.1101/2023.02.08.527675] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Objective Implantable cardiovascular therapeutic devices (CTD) including stents, percutaneous heart valves and ventricular assist devices, while lifesaving, impart supraphysiologic shear stress to platelets resulting in thrombotic and bleeding device-related coagulopathy. We previously demonstrated that shear-mediated platelet dysfunction is associated with downregulation of platelet GPIb-IX-V and αIIbβ3 receptors via generation of platelet-derived microparticles (PDMPs). Here, we test the hypothesis that shear-generated PDMPs manifest phenotypical heterogeneity of their morphology and surface expression of platelet receptors, and modulate platelet hemostatic function. Approach and Results Human gel-filtered platelets were exposed to continuous shear stress and sonication. Alterations of platelet morphology were visualized using transmission electron microscopy. Surface expression of platelet receptors and PDMP generation were quantified by flow cytometry. Thrombin generation was quantified spectrophotometrically, and platelet aggregation in plasma was measured by optical aggregometry. We demonstrate that platelet exposure to shear stress promotes notable alterations in platelet morphology and ejection of several distinctive types of PDMPs. Shear-mediated microvesiculation is associated with the differential remodeling of platelet receptors with PDMPs expressing significantly higher levels of both adhesion (α IIb β 3 , GPIX, PECAM-1, P-selectin, and PSGL-1) and agonist-evoked receptors (P 2 Y 12 & PAR1). Shear-mediated PDMPs have a bidirectional effect on platelet hemostatic function, promoting thrombin generation and inhibiting platelet aggregation induced by collagen and ADP. Conclusions Shear-generated PDMPs demonstrate phenotypic heterogeneity as to morphologic features and defined patterns of surface receptor alteration, and impose a bidirectional effect on platelet hemostatic function. PDMP heterogeneity suggests that a range of mechanisms are operative in the microvesiculation process, contributing to CTD coagulopathy and posing opportunities for therapeutic manipulation.
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Hidiatov O, Gaupp A, Marini I, Pelzl L, Wagner M, Rigoni F, Witzemann A, Häberle H, Martus P, Ngamsri KC, Konrad FM, Rosenberger P, Straub A, Bakchoul T, Althaus K. Characterization of Shear Stress Mediated Platelet Dysfunction: Data from an Ex Vivo Model for Extracorporeal Circulation and a Prospective Clinical Study. Thromb Haemost 2023; 123:415-426. [PMID: 36442804 DOI: 10.1055/a-1988-3174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Extracorporeal circulation (ECC) is frequently used in intensive care patients with impaired lung or cardiac function. Despite being a life-saving therapeutic option, ECC is associated with increased risk for both bleeding and thrombosis. The management of bleeding and thromboembolic events in ECC patients is still challenging partly due to the lack of information on the pathophysiological changes in hemostasis and platelet function during the procedure. Using a combination of an ex vivo model for shear stress and a sensitive and easy-to-use laboratory method, we analyzed platelet responsiveness during ECC. After shear stress simulation in an ex vivo closed-loop ECC model, we found a significantly decreased response of α-granules after activation with adenosine diphosphate and thrombin receptor activating peptide (TRAP-6) and CD63 expression after activation with TRAP-6. Mepacrine uptake was also significantly reduced in the ex vivo shear stress model.In the same line, platelets from patients under ECC with venovenous systems and venoarterial systems showed impaired CD62P degranulation after stimulation with ADP and TRAP-6 compared with healthy control on day 1, 6, and 10 after implantation of ECC. However, no correlation between platelet degranulation and the occurrence of bleeding or thromboembolic events was observed.The used whole blood flow cytometry with immediate fixation after drawing introduces a sensitive and easy-to-use method to determine platelet activation status and our data confirm that increased shear stress conditions under ECC can cause impaired degranulation of platelet.
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Affiliation(s)
- Oleg Hidiatov
- Department of Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen, Tübingen, Germany
| | - Alisha Gaupp
- Department of Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen, Tübingen, Germany
| | - Irene Marini
- Department of Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen, Tübingen, Germany
| | - Lisann Pelzl
- Department of Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen, Tübingen, Germany
| | - Miriam Wagner
- Department of Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen, Tübingen, Germany
| | - Flavianna Rigoni
- Department of Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen, Tübingen, Germany
| | - Andreas Witzemann
- Department of Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen, Tübingen, Germany
| | - Helene Häberle
- Department of Anesthesiology and Intensive Care Medicine, University of Tübingen, Tübingen, Germany
| | - Peter Martus
- Institute for Epidemiology and Applied Biometry, University of Tübingen, Tübingen, Germany
| | | | - Franziska M Konrad
- Department of Anesthesiology and Intensive Care Medicine, University of Tübingen, Tübingen, Germany
| | - Peter Rosenberger
- Department of Anesthesiology and Intensive Care Medicine, University of Tübingen, Tübingen, Germany
| | - Andreas Straub
- Department of Anesthesiology and Intensive Care Medicine, University of Tübingen, Tübingen, Germany.,Department of Anesthesiology, Intensive Care, Emergency, and Pain Medicine, St. Elisabethen Klinikum, Ravensburg, Germany
| | - Tamam Bakchoul
- Department of Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen, Tübingen, Germany.,Centre for Clinical Transfusion Medicine, Tübingen ZKT gGmbH, Tübingen, Germany
| | - Karina Althaus
- Department of Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen, Tübingen, Germany.,Centre for Clinical Transfusion Medicine, Tübingen ZKT gGmbH, Tübingen, Germany
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Arias K, Sun W, Wang S, Sorensen EN, Feller E, Kaczorowski D, Griffith B, Wu ZJ. Acquired platelet defects are responsible for nonsurgical bleeding in left ventricular assist device recipients. Artif Organs 2022; 46:2244-2256. [PMID: 35596611 DOI: 10.1111/aor.14319] [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] [Received: 09/15/2021] [Revised: 04/02/2022] [Accepted: 05/13/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Left ventricular assist devices (LVADs) have been used as a standard treatment option for patients with advanced heart failure. However, these devices are prone to adverse events. Nonsurgical bleeding (NSB) is the most common complication in patients with continuous flow (CF) LVADs. The development of acquired von Willebrand syndrome (AVWS) in CF-LVAD recipients is thought to be a key factor. However, AVWS is seen across a majority of LVAD patients, not just those with NSB. The purpose of this study was to examine the link between acquired platelet defects and NSB in CF-LVAD patients. METHODS Blood samples were collected from 62 CF-LVAD patients at pre- and 4 post-implantation timepoints. Reduced adhesion receptor expression (GPIbα and GPVI) and activation of platelets (GPIIb/IIIa activation) were used as markers for acquired platelet defects. RESULTS Twenty-three patients experienced at least one NSB episode. Significantly higher levels of platelet activation and receptor reduction were seen in the postimplantation blood samples from bleeders compared with non-bleeders. All patients experienced the loss of high molecular weight monomers (HMWM) of von Willebrand Factor (vWF), but no difference was seen between the two groups. Multivariable logistic regression showed that biomarkers for reduced platelet receptor expression (GPIbα and GPVI) and activation (GPIIb/IIIa) have more predictive power for NSB, with the area under curve (AUC) values of 0.72, 0.68, and 0.62, respectively, than the loss of HMWM of vWF (AUC: 0.57). CONCLUSION The data from this study indicated that the severity of acquired platelet defects has a direct link to NSB in CF-LVAD recipients.
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Affiliation(s)
- Katherin Arias
- Fischell Department of Bioengineering, A. James Clark School of Engineering, University of Maryland, College Park, Maryland, USA
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Wenji Sun
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Shigang Wang
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Erik N Sorensen
- Division of Perioperative Services, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Erika Feller
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - David Kaczorowski
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Bartley Griffith
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Zhongjun J Wu
- Fischell Department of Bioengineering, A. James Clark School of Engineering, University of Maryland, College Park, Maryland, USA
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Setiadi H, El-Banayosy AM, George S, Schmidtke DW, El-Banayosy A, Horstmanshof DA, Long JW. Oncostatin M: a Potential Biomarker to Predict Infection in Patients with Left Ventricular Assist Devices. ASAIO J 2022; 68:1036-1043. [PMID: 34772849 PMCID: PMC9110559 DOI: 10.1097/mat.0000000000001608] [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: 11/25/2022] Open
Abstract
Infection is a serious adverse event limiting left ventricular assist device (LVAD) therapy in advanced heart failure patients, but a reliable means to identify patients at increased risk of infection is still lacking. We hypothesized that preoperative elevated levels of plasma Oncostatin M (OSM), a cytokine marker of leukocyte activation and inflammation, would be predictive of subsequent infection. We measured plasma OSM in 41 LVAD patients one day before LVAD implantation and postoperatively over two months. Preoperative plasma OSM levels were normal in 27 patients (group A, 4.9 ± 3.2 pg/ml) but elevated in 14 patients (group B, 1649.0 ± 458.9 pg/ml) ( p = 0.003). Early postoperative levels rose in both groups and declined rapidly in group A, with group B declining slowly over two months. Significantly more infections developed in group B than group A patients over two months postimplantation ( p = 0.004). No other routine clinical assessment or laboratory testing afforded this differentiation. These findings suggest that preoperative plasma OSM levels may assist in identifying patients at increased risk of infections after LVAD implantation.
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Affiliation(s)
- Hendra Setiadi
- INTEGRIS Advanced Cardiac Care, Nazih Zuhdi Transplant Institute, INTEGRIS Baptist Medical Center, Oklahoma City, Oklahoma
| | - Ahmed M. El-Banayosy
- INTEGRIS Advanced Cardiac Care, Nazih Zuhdi Transplant Institute, INTEGRIS Baptist Medical Center, Oklahoma City, Oklahoma
| | - Susan George
- INTEGRIS Advanced Cardiac Care, Nazih Zuhdi Transplant Institute, INTEGRIS Baptist Medical Center, Oklahoma City, Oklahoma
| | - David W. Schmidtke
- Department of Bioengineering, University of Texas at Dallas, Richardson, Texas
| | - Aly El-Banayosy
- INTEGRIS Advanced Cardiac Care, Nazih Zuhdi Transplant Institute, INTEGRIS Baptist Medical Center, Oklahoma City, Oklahoma
| | - Douglas A. Horstmanshof
- INTEGRIS Advanced Cardiac Care, Nazih Zuhdi Transplant Institute, INTEGRIS Baptist Medical Center, Oklahoma City, Oklahoma
| | - James W. Long
- INTEGRIS Advanced Cardiac Care, Nazih Zuhdi Transplant Institute, INTEGRIS Baptist Medical Center, Oklahoma City, Oklahoma
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Comparison of the Hemocompatibility of an Axial and a Centrifugal Left Ventricular Assist Device in an In Vitro Test Circuit. J Clin Med 2022; 11:jcm11123431. [PMID: 35743501 PMCID: PMC9225365 DOI: 10.3390/jcm11123431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/08/2022] [Accepted: 06/13/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Hemocompatibility of left ventricular assist devices is essential for preventing adverse events. In this study, we compared the hemocompatibility of an axial-flow (Sputnik) to a centrifugal-flow (HeartMate 3) pump. METHODS Both pumps were integrated into identical in vitro test circuits, each filled with 75 mL heparinized human blood of the same donor. During each experiment (n = 7), the pumps were operated with equal flow for six hours. Blood sampling and analysis were performed on a regular schedule. The analytes were indicators of hemolysis, coagulation activation, platelet count and activation, as well as extracellular vesicles. RESULTS Sputnik induced higher hemolysis compared to the HeartMate 3 after 360 min. Furthermore, platelet activation was higher for Sputnik after 120 min onward. In the HeartMate 3 circuit, the platelet count was reduced within the first hour. Furthermore, Sputnik triggered a more pronounced increase in extracellular vesicles, a potential trigger for adverse events in left ventricular assist device application. Activation of coagulation showed a time-dependent increase, with no differences between both groups. CONCLUSIONS This experimental study confirms the hypothesis that axial-flow pumps may induce stronger hemolysis compared to centrifugal pumps, coming along with larger amounts of circulating extracellular vesicles and a stronger PLT activation.
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11
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Sun W, Zhang J, Shah A, Arias K, Berk Z, Griffith BP, Wu ZJ. Neutrophil dysfunction due to continuous mechanical shear exposure in mechanically assisted circulation in vitro. Artif Organs 2022; 46:83-94. [PMID: 34516005 PMCID: PMC8688241 DOI: 10.1111/aor.14068] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 08/10/2021] [Accepted: 09/04/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Leukocytes play an important role in the body's immune system. The aim of this study was to assess alterations in neutrophil phenotype and function in pump-assisted circulation in vitro. METHODS Human blood was circulated for four hours in three circulatory flow loops with a CentriMag blood pump operated at a flow of 4.5 L/min at three rotational speeds (2100, 2800, and 4000 rpm), against three pressure heads (75, 150, and 350 mm Hg), respectively. Blood samples were collected hourly for analyses of neutrophil activation state (Mac-1, CD62L, CD162), neutrophil reactive oxygen species (ROS) production, apoptosis, and neutrophil phagocytosis. RESULTS Activated neutrophils indicated by both Mac-1 expression and decreased surface expression of CD62L and CD162 receptors increased with time in three loops. The highest level of neutrophil activation was observed in the loop with the highest rotational speed. Platelet-neutrophil aggregates (PNAs) progressively increased in two loops with lower rotational speeds. PNAs peaked at one hour after circulation and decreased subsequently in the loop with the highest rotational speed. Neutrophil ROS production dramatically increased at one hour after circulation and decreased subsequently in all three loops with similar levels and trends. Apoptotic neutrophils increased with time in all three loops. Neutrophil phagocytosis capacity in three loops initially elevated at one hour after circulation and decreased subsequently. Apoptosis and altered phagocytosis were dependent on rotational speed. CONCLUSIONS Our study revealed that the pump-assisted circulation induced neutrophil activation, apoptosis, and functional impairment. The alterations were strongly associated with pump operating condition and duration.
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Affiliation(s)
- Wenji Sun
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jiafeng Zhang
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Aakash Shah
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Katherin Arias
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA,Fischell Department of Bioengineering, A. James Clark School of Engineering, University of Maryland, College Park, Maryland, USA
| | - Zachary Berk
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Bartley P Griffith
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Zhongjun J Wu
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA,Fischell Department of Bioengineering, A. James Clark School of Engineering, University of Maryland, College Park, Maryland, USA
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12
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Siegel PM, Hentschel D, Bojti I, Wengenmayer T, Helbing T, Moser M, Duerschmied D, Trummer G, Bode C, Diehl P. Annexin V positive microvesicles are elevated and correlate with flow rate in patients receiving veno-arterial extracorporeal membrane oxygenation. Interact Cardiovasc Thorac Surg 2021; 31:884-891. [PMID: 33164057 DOI: 10.1093/icvts/ivaa198] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 07/21/2020] [Accepted: 08/16/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is used in critically ill patients requiring haemodynamic support. Microvesicles (MV) are released by activated blood cells acting as mediators of intercellular communication. We aimed to determine MV count and composition over time in patients with VA-ECMO and explore what drives MV formation. METHODS VA-ECMO patients and healthy controls were recruited prospectively, and blood was taken at different time points (day 0, 1, 3 after ECMO placement and after explantation) for MV analysis. RESULTS Annexin V positive MV were increased in patients (n = 14, mean age = 61.4 ± 9.0 years, 11 males, 3 females) compared to healthy controls (n = 6, Annexin V positive MV count per millilitre day 1 versus healthy controls: 2.3 × 106 vs 1.3 × 105, P < 0.001). Furthermore, patients had higher proportions of endothelial and leukocyte MV [leukocyte MV day 1 versus healthy controls (%): 32.8 vs 17.5, P = 0.001; endothelial MV day 1 versus healthy controls (%): 10.5 vs 5.5, P = 0.01]. Annexin V positive and leucocyte MV correlated with the flow rate (r = 0.46, P = 0.01). CONCLUSIONS Patients on VA-ECMO have increased levels of circulating MV and a changed MV composition. Our data support the hypothesis that MV release may be driven by higher flow rate and cellular activation in the extracorporeal circuit leading to poor outcomes in these patients. CLINICAL TRIAL REGISTRATION NUMBER German Clinical Trials Register-ID: DRKS00011106.
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Affiliation(s)
- Patrick M Siegel
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Dominik Hentschel
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Medical Faculty, University of Freiburg, Freiburg, Germany
| | - István Bojti
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Tobias Wengenmayer
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Thomas Helbing
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Martin Moser
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Daniel Duerschmied
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Georg Trummer
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Christoph Bode
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Philipp Diehl
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Medical Faculty, University of Freiburg, Freiburg, Germany
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13
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Roka-Moiia Y, Ammann KR, Miller-Gutierrez S, Sweedo A, Palomares D, Italiano J, Sheriff J, Bluestein D, Slepian MJ. Shear-mediated platelet activation in the free flow II: Evolving mechanobiological mechanisms reveal an identifiable signature of activation and a bi-directional platelet dyscrasia with thrombotic and bleeding features. J Biomech 2021; 123:110415. [PMID: 34052772 DOI: 10.1016/j.jbiomech.2021.110415] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 03/03/2021] [Indexed: 01/17/2023]
Abstract
Shear-mediated platelet activation (SMPA) in the "free flow" is the net result of a range of cell mechanobiological mechanisms. Previously, we outlined three main groups of mechanisms including: 1) mechano-destruction - i.e. additive platelet (membrane) damage; 2) mechano-activation - i.e. activation of shear-sensitive ion channels and pores; and 3) mechano-transduction - i.e. "outside-in" signaling via a range of transducers. Here, we report on recent advances since our original report which describes additional features of SMPA. A clear "signature" of SMPA has been defined, allowing differentiation from biochemically-mediated activation. Notably, SMPA is characterized by mitochondrial dysfunction, platelet membrane eversion, externalization of anionic phospholipids, and increased thrombin generation on the platelet surface. However, SMPA does not lead to integrin αIIbβ3 activation or P-selectin exposure due to platelet degranulation, as is commonly observed in biochemical activation. Rather, downregulation of GPIb, αIIbβ3, and P-selectin surface expression is evident. Furthermore, SMPA is accompanied by a decrease in overall platelet size coupled with a concomitant, progressive increase in microparticle generation. Shear-ejected microparticles are highly enriched in GPIb and αIIbβ3. These observations indicate the enhanced diffusion, migration, or otherwise dispersion of platelet adhesion receptors to membrane zones, which are ultimately shed as receptor-rich PDMPs. The pathophysiological consequence of this progressive shear accumulation phenomenon is an associated dyscrasia of remaining platelets - being both reduced in size and less activatable via biochemical means - a tendency to favor bleeding, while concomitantly shed microparticles are highly prothrombotic and increase the tendency for thrombosis in both local and systemic milieu. These mechanisms and observations offer direct clinical utility in allowing measurement and guidance of the net balance of platelet driven events in patients with implanted cardiovascular therapeutic devices.
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Affiliation(s)
- Yana Roka-Moiia
- Departments of Medicine and Biomedical Engineering, Sarver Heart Center, University of Arizona, Tucson, AZ 85721, United States; Arizona Center for Accelerated Biomedical Innovation, University of Arizona, Tucson, AZ 85721, United States
| | - Kaitlyn R Ammann
- Departments of Medicine and Biomedical Engineering, Sarver Heart Center, University of Arizona, Tucson, AZ 85721, United States; Arizona Center for Accelerated Biomedical Innovation, University of Arizona, Tucson, AZ 85721, United States
| | - Samuel Miller-Gutierrez
- Departments of Medicine and Biomedical Engineering, Sarver Heart Center, University of Arizona, Tucson, AZ 85721, United States; Arizona Center for Accelerated Biomedical Innovation, University of Arizona, Tucson, AZ 85721, United States
| | - Alice Sweedo
- Departments of Medicine and Biomedical Engineering, Sarver Heart Center, University of Arizona, Tucson, AZ 85721, United States; Arizona Center for Accelerated Biomedical Innovation, University of Arizona, Tucson, AZ 85721, United States
| | - Daniel Palomares
- Departments of Medicine and Biomedical Engineering, Sarver Heart Center, University of Arizona, Tucson, AZ 85721, United States; Arizona Center for Accelerated Biomedical Innovation, University of Arizona, Tucson, AZ 85721, United States
| | - Joseph Italiano
- Department of Medicine, Harvard Medical School, Boston, MA 02115, United States
| | - Jawaad Sheriff
- Department of Biomedical Engineering, Stony Brook University, NY 11794, United States
| | - Danny Bluestein
- Department of Biomedical Engineering, Stony Brook University, NY 11794, United States
| | - Marvin J Slepian
- Departments of Medicine and Biomedical Engineering, Sarver Heart Center, University of Arizona, Tucson, AZ 85721, United States; Department of Biomedical Engineering, Stony Brook University, NY 11794, United States; Arizona Center for Accelerated Biomedical Innovation, University of Arizona, Tucson, AZ 85721, United States.
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14
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Thromboembolic Events in Patients With Left Ventricular Assist Devices Are Related to Microparticle-Induced Coagulation. ASAIO J 2021; 67:59-66. [PMID: 33346991 DOI: 10.1097/mat.0000000000001200] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Thromboembolic events (TEs) are a feared complication in patients supported by a continuous-flow left ventricular assist device (LVAD). The aim of the study was to analyze the role of circulating microparticles (MPs) in activating the coagulation system in LVAD patients, which might contribute to the occurrence of TEs. First, we analyzed the effect of LVAD support on endothelial function, on the levels of endothelial MPs (EMPs) and platelet MPs (PMPs), and on the procoagulative activity of circulating MPs (measured as MP-induced thrombin formation) before LVAD implantation, post-implantation, and at a 3 month follow-up (n = 15). Second, these parameters were analyzed in 43 patients with ongoing LVAD support who were followed up for the occurrence of TEs in the following 12 months. In patients undergoing LVAD implantation, the levels of PMPs and MP-induced thrombin formation increased post-LVAD implantation. The flow-mediated vasodilation (FMD) decreased, while the levels of EMPs increased post-LVAD implantation. TEs occurred in eight patients with ongoing LVAD support despite adequate coagulation. The levels of PMPs and MP-induced thrombin formation were higher in LVAD patients with TEs than in LVAD patients without TEs and were independent predictors for the risk of TEs under LVAD support. As conclusion, implantation of LVAD enhanced MP-induced coagulation, which was independently associated with the occurrence of TEs. These parameters may serve in risk stratification for early transplantation and individualized modification of standard LVAD therapy.
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15
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Increased platelet glycoprotein IIb/IIIa activation precedes continuous-flow left ventricular assist device pump thrombosis events. Thromb Res 2021; 201:143-146. [PMID: 33798825 DOI: 10.1016/j.thromres.2021.02.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 01/27/2021] [Accepted: 02/22/2021] [Indexed: 01/27/2023]
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16
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Roka-Moiia Y, Li M, Ivich A, Muslmani S, Kern KB, Slepian MJ. Impella 5.5 Versus Centrimag: A Head-to-Head Comparison of Device Hemocompatibility. ASAIO J 2021; 66:1142-1151. [PMID: 33136602 PMCID: PMC7594535 DOI: 10.1097/mat.0000000000001283] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Despite growing use of mechanical circulatory support, limitations remain related to hemocompatibility. Here, we performed a head-to-head comparison of the hemocompatibility of a centrifugal cardiac assist system-the Centrimag, with that of the latest generation of an intravascular microaxial system-the Impella 5.5. Specifically, hemolysis, platelet activation, microparticle (MP) generation, and von Willebrand factor (vWF) degradation were evaluated for both devices. Freshly obtained porcine blood was recirculated within device propelled mock loops for 4 hours, and alteration of the hemocompatibility parameters was monitored over time. We found that the Impella 5.5 and Centrimag exhibited low levels of hemolysis, as indicated by minor increase in plasma free hemoglobin. Both devices did not induce platelet degranulation, as no alteration of β-thromboglobulin and P-selectin in plasma occurred, rather minor downregulation of platelet surface P-selectin was detected. Furthermore, blood exposure to shear stress via both Centrimag and Impella 5.5 resulted in a minor decrease of platelet count with associated ejection of procoagulant MPs, and a decrease of vWF functional activity (but not plasma level of vWF-antigen). Greater MP generation was observed with the Centrimag relative to the Impella 5.5. Thus, the Impella 5.5 despite having a lower profile and higher impeller rotational speed demonstrated good and equivalent hemocompatibility, in comparison with the predicate Centrimag, with the advantage of lower generation of MPs.
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Affiliation(s)
- Yana Roka-Moiia
- From the Department of Medicine, Sarver Heart Center, University of Arizona, Tucson, Arizona
| | - Mengtang Li
- Department of Mechanical Engineering, Vanderbilt University, Nashville, Tennessee
| | - Adriana Ivich
- Department of Mechanical Engineering, Vanderbilt University, Nashville, Tennessee
| | - Sami Muslmani
- From the Department of Medicine, Sarver Heart Center, University of Arizona, Tucson, Arizona
| | - Karl B. Kern
- From the Department of Medicine, Sarver Heart Center, University of Arizona, Tucson, Arizona
| | - Marvin J. Slepian
- From the Department of Medicine, Sarver Heart Center, University of Arizona, Tucson, Arizona
- Department of Biomedical Engineering, Sarver Heart Center, University of Arizona, Tucson, Arizona
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17
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Wang S, Griffith BP, Wu ZJ. Device-Induced Hemostatic Disorders in Mechanically Assisted Circulation. Clin Appl Thromb Hemost 2021; 27:1076029620982374. [PMID: 33571008 PMCID: PMC7883139 DOI: 10.1177/1076029620982374] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Mechanically assisted circulation (MAC) sustains the blood circulation in the body of a patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) or on ventricular assistance with a ventricular assist device (VAD) or on extracorporeal membrane oxygenation (ECMO) with a pump-oxygenator system. While MAC provides short-term (days to weeks) support and long-term (months to years) for the heart and/or lungs, the blood is inevitably exposed to non-physiological shear stress (NPSS) due to mechanical pumping action and in contact with artificial surfaces. NPSS is well known to cause blood damage and functional alterations of blood cells. In this review, we discussed shear-induced platelet adhesion, platelet aggregation, platelet receptor shedding, and platelet apoptosis, shear-induced acquired von Willebrand syndrome (AVWS), shear-induced hemolysis and microparticle formation during MAC. These alterations are associated with perioperative bleeding and thrombotic events, morbidity and mortality, and quality of life in MCS patients. Understanding the mechanism of shear-induce hemostatic disorders will help us develop low-shear-stress devices and select more effective treatments for better clinical outcomes.
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Affiliation(s)
- Shigang Wang
- Department of Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Bartley P Griffith
- Department of Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Zhongjun J Wu
- Department of Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA.,Fischell Department of Bioengineering, A. James Clark School of Engineering, University of Maryland, College Park, MD, USA
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18
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Ki KK, Millar JE, Langguth D, Passmore MR, McDonald CI, Shekar K, Shankar-Hari M, Cho HJ, Suen JY, Fraser JF. Current Understanding of Leukocyte Phenotypic and Functional Modulation During Extracorporeal Membrane Oxygenation: A Narrative Review. Front Immunol 2021; 11:600684. [PMID: 33488595 PMCID: PMC7821656 DOI: 10.3389/fimmu.2020.600684] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 11/23/2020] [Indexed: 12/12/2022] Open
Abstract
A plethora of leukocyte modulations have been reported in critically ill patients. Critical illnesses such as acute respiratory distress syndrome and cardiogenic shock, which potentially require extracorporeal membrane oxygenation (ECMO) support, are associated with changes in leukocyte numbers, phenotype, and functions. The changes observed in these illnesses could be compounded by exposure of blood to the non-endothelialized surfaces and non-physiological conditions of ECMO. This can result in further leukocyte activation, increased platelet-leukocyte interplay, pro-inflammatory and pro-coagulant state, alongside features of immunosuppression. However, the effects of ECMO on leukocytes, in particular their phenotypic and functional signatures, remain largely overlooked, including whether these changes have attributable mortality and morbidity. The aim of our narrative review is to highlight the importance of studying leukocyte signatures to better understand the development of complications associated with ECMO. Increased knowledge and appreciation of their probable role in ECMO-related adverse events may assist in guiding the design and establishment of targeted preventative actions.
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Affiliation(s)
- Katrina K Ki
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Jonathan E Millar
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Roslin Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Daman Langguth
- Clinical Immunology and Allergy, and Sullivan Nicolaides Pathology, Wesley Hospital, Brisbane, QLD, Australia
| | - Margaret R Passmore
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Charles I McDonald
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Department of Anaesthesia and Perfusion, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Kiran Shekar
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Adult Intensive Care Service, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Manu Shankar-Hari
- Department of Intensive Care Unit, Guy's and St Thomas' Hospital NHS Foundation Trust, London, United Kingdom.,School of Immunology & Microbial Sciences, King's College London, London, United Kingdom
| | - Hwa Jin Cho
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Department of Paediatrics, Chonnam National University Children's Hospital and Medical School, Gwangju, South Korea
| | - Jacky Y Suen
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
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19
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Sun W, Wang S, Zhang J, Arias K, Griffith BP, Wu ZJ. Neutrophil injury and function alterations induced by high mechanical shear stress with short exposure time. Artif Organs 2020; 45:577-586. [PMID: 33237583 DOI: 10.1111/aor.13874] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 10/09/2020] [Accepted: 11/17/2020] [Indexed: 12/15/2022]
Abstract
High mechanical shear stresses (HMSS) can cause damage to blood, which manifests as morphologic changes, shortened life span, biochemical alterations, and complete rupture of blood cells and proteins, leading to the alterations of normal blood function. The aim of this study is to determine the state of neutrophil activation and function alterations caused by HMSS with short exposure time relevant to ventricular assist devices. Blood from healthy donors was exposed to three levels of HMSS (75Pa, 125Pa, and 175Pa) for a short exposure time (0.5 s) using our Couette-type blood-shearing device. Neutrophil activation (Mac-1, platelet-neutrophil aggregates) and surface expression levels of two key functional receptors (CD62L and CD162) on neutrophils were evaluated by flow cytometry. Neutrophil phagocytosis and transmigration were also examined with functional assays. Results showed that the expression of Mac-1 on neutrophils and platelet-neutrophil aggregates increased significantly while the level of CD62L expression on neutrophils decreased significantly after the exposure to HMSS. The Mac-1 expression progressively increased while the CD62L expression progressively decreased with the increased level of HMSS. The level of CD162 expression on neutrophils slightly increased after the exposure to HMSS, but the increase was not significant. The phagocytosis assay data revealed that the ability of neutrophils to phagocytose latex beads coated with fluorescently labeled rabbit IgG increased significantly with the increased level of HMSS. The transmigration ability of neutrophils slightly increased after the exposure to HMSS, but did not reach a significant level. In summary, HMSS with a short exposure time of 0.5 seconds could induce neutrophil activation, platelet-neutrophil aggregation, shedding of CD62L receptor, and increased phagocytic ability. However, the exposure to the three levels of HMSS did not cause a significant change in neutrophil transmigration capacity and shedding of CD162 receptor on neutrophils.
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Affiliation(s)
- Wenji Sun
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Shigang Wang
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jiafeng Zhang
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Katherin Arias
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA.,Fischell Department of Bioengineering, A. James Clark School of Engineering, University of Maryland, College Park, MD, USA
| | - Bartley P Griffith
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Zhongjun J Wu
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA.,Fischell Department of Bioengineering, A. James Clark School of Engineering, University of Maryland, College Park, MD, USA
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20
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Liu H, Liu S, Ma X. Varying speed modulation of continuous-flow left ventricular assist device based on cardiovascular coupling numerical model. Comput Methods Biomech Biomed Engin 2020; 24:956-972. [PMID: 33347766 DOI: 10.1080/10255842.2020.1861601] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Continuous-flow left ventricular assist devices (CFLVADs) routinely operate at a constant speed for the support of a failing heart, which decreases the pulsatility in the arteries. Some late complications could be related to a long-term lack of pulsatility. Modulating the CFLVAD speed is a solution to enhance the pulsatility. The purpose of this study is to modulate multiple varying speed patterns and investigate their effects on the ventricle and vascular system. A cardiovascular coupling numerical model is developed to provide a simulation platform for testing the varying speed patterns. The varying speed patterns are modulated by combining the shape, amplitude, frequency, phase shift, and pulsatile duty cycle of the speed profile. The influence of varying speed support is examined by analyzing the indexes of pulsatility, indexes of ventricular unloading, and hemodynamic variables. The results show that the synchronous counterpulsation pattern can effectively reduce the ventricular unloading indexes, whereas the low-frequency asynchronous pattern can effectively increase the vascular pulsatility indexes. Also, the hemodynamics with synchronous varying speed support is more physiological than that with asynchronous varying speed support. This study provides valuable insight for further optimization of varying speed modulation by weighing vascular pulsatility, ventricular unloading, and hemodynamics.
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Affiliation(s)
- Hongtao Liu
- School of Electrical Engineering, Shandong University, Jinan, PR China
| | - Shuqin Liu
- School of Electrical Engineering, Shandong University, Jinan, PR China
| | - Xiaoxu Ma
- School of Electrical Engineering, Shandong University, Jinan, PR China
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21
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Wang Y, Karnik S, Smith PA, Elgalad A, Frazier OH, Kurita N. Numerical and Experimental Approach to Characterize a BLDC Motor with Different Radial-gap to Improve Hemocompatibility Performance. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2020; 2020:2662-2666. [PMID: 33018554 DOI: 10.1109/embc44109.2020.9175989] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Left ventricular assist devices (LVADs) have increasingly been used clinically to treat heart failure patients. However, hemolysis, pump thrombosis, infection and bleeding still persist as major limitations of LVAD technology. Assessing LVAD hemocompatibility using a blood shear stress device (BSSD) has clear advantages, as the BSSD could provide a better experimental platform to develop reliable, quantifiable blood trauma assays to perform iterative testing of LVAD designs. In this study, a BSSD was proposed with short blood exposure time and no seals or contact bearings to reduce blood trauma caused by the test platform. Enlarged air-gap drive motor in BSSD is essential to avoid high shear stress; however, it would significantly reduce the motor torque, which may result in inadequate force to drive the entire system. In order to evaluate and optimize the drive motor air-gap to ensure adequate motor torque as well as acceptable range for blood exposure time and shear stress, a numerical brushless DC (BLDC) motor model was established using finite element method (FEM) in numerical simulation software COMSOL. The model was first validated by the experimental results. Then numerical model with different air-gap was evaluated on the torque and speed constant changes. In the end, two equations were generated based on the curves derived from the torque and speed constant calculations. Determining these relationships between motor performance and motor air-gap will facilitate the development of an appropriate BLDC motor size for the BSSD, considering the design limitations in our future work.
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22
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Meyer AD, Rishmawi AR, Kamucheka R, Lafleur C, Batchinsky AI, Mackman N, Cap AP. Effect of blood flow on platelets, leukocytes, and extracellular vesicles in thrombosis of simulated neonatal extracorporeal circulation. J Thromb Haemost 2020; 18:399-410. [PMID: 31628728 PMCID: PMC7350929 DOI: 10.1111/jth.14661] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 10/10/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) has frequent and sometimes lethal thrombotic complications. The role that activated platelets, leukocytes, and small (0.3-micron to 1-micron) extracellular vesicles (EVs) play in ECMO thrombosis is not well understood. OBJECTIVES To test the effect of blood flow rate on the generation of activated platelets, leukocytes, and EVs in a simulated neonatal ECMO circuit using heparinized human whole blood. METHODS Simulated neonatal roller pump circuits circulated whole blood at low, nominal, and high flow rates (0.3, 0.5, and 0.7 L/min) for 6 h. Coagulopathy was defined by thromboelastography (TEG), STA® -procoagulant phospholipid clot time (STA®- Procoag-PPL), and calibrated automated thrombogram. High-resolution flow cytometry measured the cellular expression of prothrombotic phospholipids and proteins on platelets, leukocytes, and EV. RESULTS Despite heparinization, occlusive thrombosis halted flow in two of five circuits at 0.3 L/min and three of five circuits at 0.7 L/min. None of the five circuits at 0.5 L/min exhibited occlusive thrombosis. Phosphatidylserine (PS)-positive platelets and EVs increased at all flow rates more than blood under static conditions (P < .0002). Tissue factor (TF)-positive leukocytes and EVs increased only in low-flow and high-flow circuits (P < .0001). Tissue factor pathway inhibitor (TFPI), at 50 times more than the concentration in healthy adults, failed to suppress thrombin initiation in low-flow and high-flow circuits. CONCLUSIONS This in vitro study informs ECMO specialists to avoid low and high blood flow that increases TF expression on leukocytes and EVs, which likely initiate clot formation. Interventions to decrease TF generated by ECMO may be an effective approach to decrease thrombosis.
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Affiliation(s)
- Andrew D. Meyer
- Division of Pediatric Critical Care, Department of Pediatrics, University of Texas Health, San Antonio, Texas
- Coagulation and Blood Research, U.S. Army Institute of Surgical Research (USAISR), Ft. Sam Houston, Texas
| | - Anjana R. Rishmawi
- Division of Pediatric Critical Care, Department of Pediatrics, University of Texas Health, San Antonio, Texas
| | - Robin Kamucheka
- Coagulation and Blood Research, U.S. Army Institute of Surgical Research (USAISR), Ft. Sam Houston, Texas
| | - Crystal Lafleur
- Coagulation and Blood Research, U.S. Army Institute of Surgical Research (USAISR), Ft. Sam Houston, Texas
| | - Andriy I. Batchinsky
- Extracorporeal Life Support, U.S. Army Institute of Surgical Research (USAISR), Ft. Sam Houston, Texas
| | - Nigel Mackman
- Thrombosis and Hemostasis Program, Division of Hematology and Oncology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Andrew P. Cap
- Coagulation and Blood Research, U.S. Army Institute of Surgical Research (USAISR), Ft. Sam Houston, Texas
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23
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Nanofiber membranes as biomimetic and mechanically stable surface coatings. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2020; 108:110417. [PMID: 31923973 DOI: 10.1016/j.msec.2019.110417] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 09/24/2019] [Accepted: 11/10/2019] [Indexed: 11/24/2022]
Abstract
Elastomers have been extensively exploited to study cell physiology in fields such as mechanobiology, however, their intrinsic high hydrophobicity renders their surfaces incompatible for prolonged cell adhesion and proliferation. Electrospun fiber networks on the other side provide a promising environment for enhanced cell adhesion and growth due to their architecture closely mimicking the structure of the extracellular matrix present within tissues of the human body. Here, we explored the stable integration of electrospun fibers onto the surfaces of elastomeric materials to promote cytocompatibility of these composites. Elastomers based on room temperature vulcanizing silicone (RTV), polydimethylsiloxane (PDMS) as well as functionalized PDMS-based materials were chosen as wafer substrates for attachment of poly(vinylidene fluoride-co-hexafluoropropylene) (PVDFhfp) fibers, a well-known antithrombotic polymer. Electrospinning the fibers onto uncured interfaces acted as bonding agents on the wafers, enabling penetration and formation of a stable bond between the fibers surfaces and the elastomers after curing the interface. Dimensional analysis revealed a relationship between peeling force, intrusion depth and the elastic modulus of the wafers. A design parameter Πα was extrapolated to be used as a predictive tool of the peeling force when intrusion depth of PVDFhfp fibers and elastic modulus of the wafers are known. Cultivating fibroblasts on these hybrid membranes showed cell attachment and growth over 7 days regardless of the composition of the substrate, confirming high cytocompatibility for all composite materials. The presented approach opens avenues to establish nanofiber morphologies as a novel, stable surface texturing tool for tissue engineering, cell biology, medical devices and textiles.
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24
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In Vitro Benchmarking Study of Ventricular Assist Devices in Current Clinical Use. J Card Fail 2020; 26:70-79. [DOI: 10.1016/j.cardfail.2019.09.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 09/24/2019] [Accepted: 09/28/2019] [Indexed: 01/26/2023]
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25
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Non-physiological shear stress-induced blood damage in ventricular assist device. MEDICINE IN NOVEL TECHNOLOGY AND DEVICES 2019. [DOI: 10.1016/j.medntd.2019.100024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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26
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Mezger M, Nording H, Sauter R, Graf T, Heim C, von Bubnoff N, Ensminger SM, Langer HF. Platelets and Immune Responses During Thromboinflammation. Front Immunol 2019; 10:1731. [PMID: 31402914 PMCID: PMC6676797 DOI: 10.3389/fimmu.2019.01731] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 07/09/2019] [Indexed: 12/17/2022] Open
Abstract
Besides mediating hemostatic functions, platelets are increasingly recognized as important players of inflammation. Data from experiments in mice and men revealed various intersection points between thrombosis, hemostasis, and inflammation, which are addressed and discussed in this review in detail. One such example is the intrinsic coagulation cascade that is initiated after platelet activation thereby further propagating and re-enforcing wound healing or thrombus formation but also contributing to the pathophysiology of severe diseases. FXII of the intrinsic pathway connects platelet activation with the coagulation cascade during immune reactions. It can activate the contact system thereby either creating an inflammatory state or accelerating inflammation. Recent insights into platelet biology could show that platelets are equipped with complement receptors. Platelets are important for tissue remodeling after injury has been inflicted to the endothelial barrier and to the subendothelial tissue. Thus, platelets are increasingly recognized as more than just cells relevant for bleeding arrest. Future insights into platelet biology are to be expected. This research will potentially offer novel opportunities for therapeutic intervention in diseases featuring platelet abundance.
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Affiliation(s)
- Matthias Mezger
- University Hospital, Medical Clinic II, University Heart Center Lübeck, Lübeck, Germany
| | - Henry Nording
- University Hospital, Medical Clinic II, University Heart Center Lübeck, Lübeck, Germany.,DZHK (German Research Centre for Cardiovascular Research), Partner Site Hamburg/Lübeck/Kiel, Lübeck, Germany
| | - Reinhard Sauter
- University Hospital, Medical Clinic II, University Heart Center Lübeck, Lübeck, Germany
| | - Tobias Graf
- University Hospital, Medical Clinic II, University Heart Center Lübeck, Lübeck, Germany
| | - Christian Heim
- Department of Cardiac Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Nikolas von Bubnoff
- Department of Hematology and Oncology, Medical Center, University of Schleswig-Holstein, Lübeck, Germany
| | - Stephan M Ensminger
- Department of Cardiac and Thoracic Vascular Surgery, University Heart Center Lübeck, Lübeck, Germany
| | - Harald F Langer
- University Hospital, Medical Clinic II, University Heart Center Lübeck, Lübeck, Germany.,DZHK (German Research Centre for Cardiovascular Research), Partner Site Hamburg/Lübeck/Kiel, Lübeck, Germany
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27
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Significant impact of left ventricular assist device models on the value of flow-mediated dilation: effects of LVAD on endothelial function. Heart Vessels 2019; 35:207-213. [DOI: 10.1007/s00380-019-01474-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 07/12/2019] [Indexed: 10/26/2022]
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28
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Apostoli A, Bianchi V, Bono N, Dimasi A, Ammann KR, Moiia YR, Montisci A, Sheriff J, Bluestein D, Fiore GB, Pappalardo F, Candiani G, Redaelli A, Slepian MJ, Consolo F. Prothrombotic activity of cytokine-activated endothelial cells and shear-activated platelets in the setting of ventricular assist device support. J Heart Lung Transplant 2019; 38:658-667. [PMID: 30846234 DOI: 10.1016/j.healun.2019.02.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 02/11/2019] [Accepted: 02/13/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND We systematically analyzed the synergistic effect of: (i) cytokine-mediated inflammatory activation of endothelial cells (ECs) with and (ii) shear-mediated platelet activation (SMPA) as a potential contributory mechanism to intraventricular thrombus formation in the setting of left ventricular assist device (LVAD) support. METHODS Intact and shear-activated human platelets were exposed to non-activated and cytokine-activated ECs. To modulate the level of LVAD-related shear activation, platelets were exposed to shear stress patterns of varying magnitude (30, 50, and 70 dynes/cm2, 10 minutes) via a hemodynamic shearing device. ECs were activated via exposure to inflammatory tumor necrosis factor-α (TNF-α 10 and 100 ng/ml, 24 hours), consistent with inflammatory activation recorded in patients on LVAD circulatory support. RESULTS Adhesivity of shear-activated platelets to ECs was significantly higher than that of intact/unactivated platelets, regardless of the initial activation level (70 dynes/cm2 shear-activated platelets vs intact platelets: +80%, p < 0.001). Importantly, inflammatory activation of ECs amplified platelet prothrombinase activity progressively with increasing shear stress magnitude and TNF-α concentration: thrombin generation of 70 dynes/cm2 shear-activated platelets was 2.6-fold higher after exposure and adhesion to 100 ng/ml TNF-α‒activated ECs (p < 0.0001). CONCLUSIONS We demonstrated synergistic effect of SMPA and cytokine-mediated EC inflammatory activation to enhance EC‒platelet adhesion and platelet prothrombotic function. These mechanisms may contribute to intraventricular thrombosis in the setting of mechanical circulatory support.
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Affiliation(s)
- Alice Apostoli
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milano, Italy
| | - Valentina Bianchi
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milano, Italy
| | - Nina Bono
- Politecnico di Milano Research Unit, National Interuniversity Consortium of Materials Science and Technology, Milano, Italy
| | - Annalisa Dimasi
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milano, Italy
| | - Kaitlyn R Ammann
- Department of Biomedical Engineering, University of Arizona, Tucson, Arizona, USA
| | - Yana Roka Moiia
- Department of Biomedical Engineering, University of Arizona, Tucson, Arizona, USA
| | - Andrea Montisci
- Anesthesia and Intensive Care, Sant'Ambrogio Cardiothoracic Center, Milano, Italy
| | - Jawaad Sheriff
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York, USA
| | - Danny Bluestein
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, New York, USA
| | - Gianfranco B Fiore
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milano, Italy
| | - Federico Pappalardo
- Advanced Heart Failure and Mechanical Circulatory Support Program, San Raffaele Scientific Institute, Milano, Italy; Università Vita Salute San Raffaele, Milano, Italy
| | - Gabriele Candiani
- Biocompatibility and Cell Culture Laboratory "BioCell," Department of Chemistry, Materials and Chemical Engineering "Giulio Natta," Politecnico di Milano, Milano, Italy
| | - Alberto Redaelli
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milano, Italy
| | - Marvin J Slepian
- Department of Biomedical Engineering, University of Arizona, Tucson, Arizona, USA
| | - Filippo Consolo
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milano, Italy; Advanced Heart Failure and Mechanical Circulatory Support Program, San Raffaele Scientific Institute, Milano, Italy; Università Vita Salute San Raffaele, Milano, Italy.
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29
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Radley G, Laura Pieper I, Thomas BR, Hawkins K, Thornton CA. Artificial shear stress effects on leukocytes at a biomaterial interface. Artif Organs 2019; 43:E139-E151. [PMID: 30537257 DOI: 10.1111/aor.13409] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 10/17/2018] [Accepted: 11/29/2018] [Indexed: 12/11/2022]
Abstract
Medical devices, such as ventricular assist devices (VADs), introduce both foreign materials and artificial shear stress to the circulatory system. The effects these have on leukocytes and the immune response are not well understood. Understanding how these two elements combine to affect leukocytes may reveal why some patients are susceptible to recurrent device-related infections and provide insight into the development of pump thrombosis. Biomaterials-DLC: diamond-like carbon-coated stainless steel; Sap: single-crystal sapphire; and Ti: titanium alloy (Ti6 Al4 V) were attached to the parallel plates of a rheometer. Whole human blood was left between the two discs for 5 minutes at +37°C with or without the application of shear stress (0 s-1 or 1000 s-1 ). Blood was removed and used for complete blood cell counts, flow cytometry (leukocyte activation, cell death, microparticle generation, phagocytic ability, and reactive oxygen species [ROS] production), and the production of pro-inflammatory cytokines. L-selectin expression on monocytes was decreased when blood was exposed to the biomaterials both with and without shear. Applying shear stress to blood on a Sap and Ti surface led to activation of neutrophils shown as decreased L-selectin expression. Sap and Ti blunted the LPS-stimulated macrophage migration inhibitory factor (MIF) production, most notably when sheared on Ti. The biomaterials used here have been shown to activate leukocytes in a static environment. The introduction of shear appears to exacerbate this activation. Interestingly, a widely accepted biocompatible material (Ti) utilized in many different types of devices has the capacity for immune cell activation and inhibition of MIF secretion when combined with shear stress. These findings contribute to our understanding of the contribution of biomaterials and shear stress to recurrent infections and vulnerability to sepsis in some VAD patients as well as pump thrombosis.
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Affiliation(s)
- Gemma Radley
- Swansea University Medical School, Swansea, UK.,Calon Cardio-Technology Ltd, Institute of Life Science, Swansea, UK
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30
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Radley G, Ali S, Pieper IL, Thornton CA. Mechanical shear stress and leukocyte phenotype and function: Implications for ventricular assist device development and use. Int J Artif Organs 2018; 42:133-142. [PMID: 30585115 DOI: 10.1177/0391398818817326] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Heart failure remains a disease of ever increasing prevalence in the modern world. Patients with end-stage heart failure are being referred increasingly for mechanical circulatory support. Mechanical circulatory support can assist patients who are ineligible for transplant and stabilise eligible patients prior to transplantation. It is also used during cardiopulmonary bypass surgery to maintain circulation while operating on the heart. While mechanical circulatory support can stabilise heart failure and improve quality of life, complications such as infection and thrombosis remain a common risk. Leukocytes can contribute to both of these complications. Contact with foreign surfaces and the introduction of artificial mechanical shear stress can lead to the activation of leukocytes, reduced functionality and the release of pro-inflammatory and pro-thrombogenic microparticles. Assessing the impact of mechanical trauma to leukocytes is largely overlooked in comparison to red blood cells and platelets. This review provides an overview of the available literature on the effects of mechanical circulatory support systems on leukocyte phenotype and function. One purpose of this review is to emphasise the importance of studying mechanical trauma to leukocytes to better understand the occurrence of adverse events during mechanical circulatory support.
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Affiliation(s)
- Gemma Radley
- Swansea University Medical School, Swansea, UK
- Calon Cardio-Technology Ltd, Institute of Life Science, Swansea, UK
| | - Sabrina Ali
- Calon Cardio-Technology Ltd, Institute of Life Science, Swansea, UK
| | - Ina Laura Pieper
- Swansea University Medical School, Swansea, UK
- Scandinavian Real Heart AB, Västerås, Sweden
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31
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McVey MJ, Kuebler WM. Extracellular vesicles: biomarkers and regulators of vascular function during extracorporeal circulation. Oncotarget 2018; 9:37229-37251. [PMID: 30647856 PMCID: PMC6324688 DOI: 10.18632/oncotarget.26433] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Accepted: 11/26/2018] [Indexed: 12/12/2022] Open
Abstract
Extracellular vesicles (EVs) are generated at increased rates from parenchymal and circulating blood cells during exposure of the circulation to abnormal flow conditions and foreign materials associated with extracorporeal circuits (ExCors). This review describes types of EVs produced in different ExCors and extracorporeal life support (ECLS) systems including cardiopulmonary bypass circuits, extracorporeal membrane oxygenation (ECMO), extracorporeal carbon dioxide removal (ECCO2R), apheresis, dialysis and ventricular assist devices. Roles of EVs not only as biomarkers of adverse events during ExCor/ECLS use, but also as mediators of vascular dysfunction are explored. Manipulation of the number or subtypes of circulating EVs may prove a means of improving vascular function for individuals requiring ExCor/ECLS support. Strategies for therapeutic manipulation of EVs during ExCor/ECLS use are discussed such as accelerating their clearance, preventing their genesis or pharmacologic options to reduce or select which and how many EVs circulate. Strategies to reduce or select for specific types of EVs may prove beneficial in preventing or treating other EV-related diseases such as cancer.
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Affiliation(s)
- Mark J McVey
- Keenan Research Centre for Biomedical Science, St Michael's Hospital, Toronto, ON, Canada.,Department of Physiology, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia and Pain Medicine, SickKids, Toronto, ON, Canada
| | - Wolfgang M Kuebler
- Keenan Research Centre for Biomedical Science, St Michael's Hospital, Toronto, ON, Canada.,Department of Physiology, University of Toronto, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada.,Institute of Physiology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,German Heart Institute, Berlin, Germany
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32
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Radley G, Pieper IL, Ali S, Bhatti F, Thornton CA. The Inflammatory Response to Ventricular Assist Devices. Front Immunol 2018; 9:2651. [PMID: 30498496 PMCID: PMC6249332 DOI: 10.3389/fimmu.2018.02651] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 10/26/2018] [Indexed: 12/27/2022] Open
Abstract
The therapeutic use of ventricular assist devices (VADs) for end-stage heart failure (HF) patients who are ineligible for transplant has increased steadily in the last decade. In parallel, improvements in VAD design have reduced device size, cost, and device-related complications. These complications include infection and thrombosis which share underpinning contribution from the inflammatory response and remain common risks from VAD implantation. An added and underappreciated difficulty in designing a VAD that supports heart function and aids the repair of damaged myocardium is that different types of HF are accompanied by different inflammatory profiles that can affect the response to the implanted device. Circulating inflammatory markers and changes in leukocyte phenotypes receive much attention as biomarkers for mortality and disease progression. However, they are seldom used to monitor progress during and outcomes from VAD therapy or during the design phase for new devices. Even the partial reversal of heart damage associated with heart failure is a desirable outcome from VAD use. Therefore, improved understanding of the interplay between VADs and the recipient's inflammatory response would potentially increase their uptake, improve patient lives, and fuel research related to other blood-contacting medical devices. Here we provide a review of what is currently known about inflammation in heart failure and how this inflammatory profile is altered in heart failure patients receiving VAD therapy.
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Affiliation(s)
- Gemma Radley
- Swansea University Medical School, Swansea, United Kingdom.,Calon Cardio-Technology Ltd, Institute of Life Science, Swansea, United Kingdom
| | - Ina Laura Pieper
- Swansea University Medical School, Swansea, United Kingdom.,Scandinavian Real Heart AB, Västerås, Sweden
| | - Sabrina Ali
- Calon Cardio-Technology Ltd, Institute of Life Science, Swansea, United Kingdom
| | - Farah Bhatti
- Department of Cardiology, Morriston Hospital, Abertawe Bro Morgannwg University Health Board, Swansea, United Kingdom
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33
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The Physiological Rationale for Incorporating Pulsatility in Continuous-Flow Left Ventricular Assist Devices. Cardiol Rev 2018; 26:294-301. [DOI: 10.1097/crd.0000000000000202] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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34
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Abstract
Despite improvements in left ventricular assist device (LVAD) technology, bleeding and thrombotic complications are major concerns that adversely influence morbidity and mortality. Current antithrombotic therapy recommendations for LVAD thrombosis prophylaxis are largely derived from clinical device trials that implement a one-size-fits-all strategy. Objective serial laboratory-based assessment of thrombogenicity is needed to balance the risk of bleeding and thrombotic complications. Finally, the newest-generation device, the HeartMate 3, has been associated with lower levels of shear and reduced hemolysis that may mitigate thrombotic event occurrences.
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35
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Toomasian CJ, Aiello SR, Drumright BL, Major TC, Bartlett RH, Toomasian JM. The effect of air exposure on leucocyte and cytokine activation in an in-vitro model of cardiotomy suction. Perfusion 2018; 33:538-545. [DOI: 10.1177/0267659118766157] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Introduction: Cardiopulmonary bypass (CPB) is known to cause a systemic inflammatory and immune response. Objective: An in-vitro model of cardiotomy suction was designed to quantify the effects of incrementally increased air-blood exposure on leucocyte marker CD11b and cytokine activation in two common anticoagulants, heparin and citrate. Methods: Fresh human blood was exposed to increasing amounts of air flow for ten minutes. Leucocyte and cytokine levels were measured prior to and after ten minutes of air flow. Cytokine levels were also measured after air exposure when incubated for 24 hours at 37oC. Results: Leucocyte activation, measured by CD11b, was elevated between baseline and air flow rates up to 50 mL/min. After 10 minutes of air exposure, no measured cytokine levels were elevated. After 24 hours of incubation, cytokine levels of TNFα, IL-10, IL-6, and IL-8 were elevated. However, only IL-8 was significantly elevated in citrated blood, but not in heparinized blood, when compared to baseline samples that were also incubated for 24 hours. Conclusion: This study investigates CD11b levels in response to an air stimulus in blood that was anticoagulated with citrate or heparin. Exposure to an air stimulus activates leucocytes. Activation of CD11b was less when using heparin as an anticoagulant compared to citrate. Cytokine activation occurs with air stimulation, but levels do not immediately rise, indicating that time is required to generate free cytokines.
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Affiliation(s)
- Cory J. Toomasian
- Department of Surgery, Extracorporeal Life Support Laboratory, University of Michigan, Ann Arbor, MI, USA
| | - Salvatore R. Aiello
- Department of Surgery, Extracorporeal Life Support Laboratory, University of Michigan, Ann Arbor, MI, USA
| | - Benjamin L. Drumright
- Department of Surgery, Extracorporeal Life Support Laboratory, University of Michigan, Ann Arbor, MI, USA
| | - Terry C. Major
- Department of Surgery, Extracorporeal Life Support Laboratory, University of Michigan, Ann Arbor, MI, USA
| | - Robert H. Bartlett
- Department of Surgery, Extracorporeal Life Support Laboratory, University of Michigan, Ann Arbor, MI, USA
| | - John M. Toomasian
- Department of Surgery, Extracorporeal Life Support Laboratory, University of Michigan, Ann Arbor, MI, USA
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36
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McClane N, Jeske W, Walenga JM, Escalante V, Hoppensteadt D, Schwartz J, Bakhos M. Identification of Novel Hemostatic Biomarkers of Adverse Clinical Events in Patients Implanted With a Continuous-Flow Left Ventricular Assist Device. Clin Appl Thromb Hemost 2018; 24:965-972. [PMID: 29552914 PMCID: PMC6714718 DOI: 10.1177/1076029618760235] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Heart failure affects over 5 million people in the United States. Its rising prevalence and the limited supply of donor hearts is increasing the use of mechanical cardiac support with the implantation of continuous-flow ventricular assist devices (CF-VAD). Patients with CF-VAD implants are at risk of complications, specifically adverse hemostatic events such as nonsurgical bleeding and thrombosis. Development of a pump thrombus requires clinical intervention and/or surgical replacement significantly increasing the risk of patient morbidity and mortality. Identification of biomarkers for these events could improve current risk assessment models, subsequent treatment, and quality of life prognoses for VAD-implanted patients. The standard means for identifying thrombus in VAD patients is currently limited to monitoring levels of lactate dehydrogenase (>2× upper limit of normal), which is incapable of predicting a future event, but describes the risk of a present thrombus. Surface-enhanced laser desorption ionization time-of-flight mass spectrometry is a technique used to identify biomarkers. In this study, 3 groups of unique peaks were identified in plasma from patients with left ventricular assist devices: 8.1-kDa, 11.7-kDa, and a 15.2-/16.1-kDa pair. Unique correlations were found for each peak, respectively, with microparticles (MPs) and MP procoagulant activity, C-reactive protein, and MP-tissue factor. Furthermore, the use of 8.1-kDa peaks may be able to differentiate thrombotic events from other hemostatic events.
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Affiliation(s)
- Nathan McClane
- 1 Health Sciences Division, Department of Thoracic and Cardiovascular Surgery, Loyola University Chicago, Maywood, IL, USA
| | - Walter Jeske
- 1 Health Sciences Division, Department of Thoracic and Cardiovascular Surgery, Loyola University Chicago, Maywood, IL, USA
| | - Jeanine M Walenga
- 1 Health Sciences Division, Department of Thoracic and Cardiovascular Surgery, Loyola University Chicago, Maywood, IL, USA
| | - Vicki Escalante
- 1 Health Sciences Division, Department of Thoracic and Cardiovascular Surgery, Loyola University Chicago, Maywood, IL, USA
| | - Debra Hoppensteadt
- 2 Health Sciences Division, Department of Pathology, Loyola University Chicago, Maywood, IL, USA
| | - Jeffrey Schwartz
- 1 Health Sciences Division, Department of Thoracic and Cardiovascular Surgery, Loyola University Chicago, Maywood, IL, USA
| | - Mamdouh Bakhos
- 1 Health Sciences Division, Department of Thoracic and Cardiovascular Surgery, Loyola University Chicago, Maywood, IL, USA
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37
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Pieper IL, Radley G, Christen A, Ali S, Bodger O, Thornton CA. Ovine Leukocyte Microparticles Generated by the CentriMag Ventricular Assist Device In Vitro. Artif Organs 2018; 42:E78-E89. [PMID: 29512167 DOI: 10.1111/aor.13068] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Revised: 10/06/2017] [Accepted: 10/12/2017] [Indexed: 12/13/2022]
Abstract
Ventricular assist devices (VADs) are a life-saving form of mechanical circulatory support in heart failure patients. However, VADs have not yet reached their full potential due to the associated side effects (thrombosis, bleeding, infection) related to the activation and damage of blood cells and proteins caused by mechanical stress and foreign materials. Studies of the effects of VADs on leukocytes are limited, yet leukocyte activation and damage including microparticle generation can influence both thrombosis and infection rates. Therefore, the aim was to develop a multicolor flow cytometry assessment of leukocyte microparticles (LMPs) using ovine blood and the CentriMag VAD as a model for shear stress. Ovine blood was pumped for 6 h in the CentriMag and regular samples analyzed for hemolysis, complete blood counts and LMP by flow cytometry during three different pump operating conditions (low flow, standard, high speed). The high speed condition caused significant increases in plasma-free hemoglobin; decreases in total leukocytes, granulocytes, monocytes, and platelets; increases in CD45+ LMPs as well as two novel LMP populations: CD11bbright /HLA-DR- and CD11bdull /HLA-DR+ , both of which were CD14- /CD21- . CD11bbright /HLA-DR- LMPs appeared to respond to an increase in shear magnitude whereas the CD11bdull /HLA-DR+ LMPs significantly increased in all pumping conditions. We propose that these two populations are released from granulocytes and T cells, respectively, but further research is needed to better characterize these two populations.
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Affiliation(s)
- Ina Laura Pieper
- Institute of Life Science, Swansea University Medical School, Swansea, UK.,Calon Cardio-Technology Ltd, Institute of Life Science, Swansea, UK
| | - Gemma Radley
- Institute of Life Science, Swansea University Medical School, Swansea, UK.,Calon Cardio-Technology Ltd, Institute of Life Science, Swansea, UK
| | - Abigail Christen
- Calon Cardio-Technology Ltd, Institute of Life Science, Swansea, UK
| | - Sabrina Ali
- Calon Cardio-Technology Ltd, Institute of Life Science, Swansea, UK
| | - Owen Bodger
- Institute of Life Science, Swansea University Medical School, Swansea, UK
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38
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Patricia Massicotte M, Bauman ME. Developmental hemostasis and ventricular assist devices: A troubled relationship. PROGRESS IN PEDIATRIC CARDIOLOGY 2017. [DOI: 10.1016/j.ppedcard.2017.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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39
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Padera RF. A perfect storm: Understanding hemostasis, coagulation and inflammation with artificial material. PROGRESS IN PEDIATRIC CARDIOLOGY 2017. [DOI: 10.1016/j.ppedcard.2017.10.001] [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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40
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Electron Microscopy as a Tool for Assessment of Anticoagulation Strategies During Extracorporeal Life Support: The Proof Is on the Membrane. ASAIO J 2017; 62:525-32. [PMID: 27258220 DOI: 10.1097/mat.0000000000000394] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Extracorporeal life support (ECLS) is fast becoming more common place for use in adult patients failing mechanical ventilation. Management of coagulation and thrombosis has long been a major complication in the use of ECLS therapies. Scanning electron microscopy (SEM) of membrane oxygenators (MOs) after use in ECLS circuits can offer novel insight into any thrombotic material deposition on the MO. In this pilot study, we analyzed five explanted MOs immediately after use in a sheep model of different acute respiratory distress syndrome (ARDS). We describe our methods of MO dissection, sample preparation, image capture, and results. Of the five MOs analyzed, those that received continuous heparin infusion showed very little thrombosis formation or other clot material, whereas those that were used with only initial heparin bolus showed readily apparent thrombotic material.
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41
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Bleeding and thrombosis associated with ventricular assist device therapy. J Heart Lung Transplant 2017; 36:1164-1173. [DOI: 10.1016/j.healun.2017.05.008] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 05/03/2017] [Accepted: 05/09/2017] [Indexed: 01/03/2023] Open
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42
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Chan CHH, Pieper IL, Robinson CR, Friedmann Y, Kanamarlapudi V, Thornton CA. Shear Stress-Induced Total Blood Trauma in Multiple Species. Artif Organs 2017; 41:934-947. [PMID: 28744884 DOI: 10.1111/aor.12932] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 12/26/2016] [Accepted: 01/24/2017] [Indexed: 12/16/2022]
Abstract
The common complications in heart failure patients with implanted ventricular assist devices (VADs) include hemolysis, thrombosis, and bleeding. These are linked to shear stress-induced trauma to erythrocytes, platelets, and von Willebrand factor (vWF). Novel device designs are being developed to reduce the blood trauma, which will need to undergo in vitro and in vivo preclinical testing in large animal models such as cattle, sheep, and pig. To fully understand the impact of device design and enable translation of preclinical results, it is important to identify any potential species-specific differences in the VAD-associated common complications. Therefore, the purpose of this study was to evaluate the effects of shear stress on cells and proteins in bovine, ovine, and porcine blood compared to human. Blood from different species was subjected to various shear rates (0-8000/s) using a rheometer. It was then analyzed for complete blood counts, hemolysis by the Harboe assay, platelet activation by flow cytometry, vWF structure by immunoblotting, and function by collagen binding activity ELISA (vWF : CBA). Overall, increasing shear rate caused increased total blood trauma in all tested species. This analysis revealed species-specific differences in shear-induced hemolysis, platelet activation, and vWF structure and function. Compared to human blood, porcine blood was the most resilient and showed less hemolysis, similar blood counts, but less platelet activation and less vWF damage in response to shear. Compared to human blood, sheared bovine blood showed less hemolysis, similar blood cell counts, greater platelet activation, and similar degradation of vWF structure, but less impact on its activity in response to shear. The shear-induced effect on ovine blood depended on whether the blood was collected via gravity at the abattoir or by venepuncture from live sheep. Overall, ovine abattoir blood was the least resilient in response to shear and bovine blood was the most similar to human blood. These results lay the foundations for developing blood trauma evaluation standards to enable the extrapolation of in vitro and in vivo animal data to predict safety and biocompatibility of blood-handling medical devices in humans. We advise using ovine venepuncture blood instead of ovine abattoir blood due to the greater overall damage in the latter. We propose using bovine blood for total blood damage in vitro device evaluation but multiple species could be used to create a full understanding of the complication risk profile of new devices. Further, this study highlights that choice of antibody clone for evaluating platelet activation in bovine blood can influence the interpretation of results from different studies.
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Affiliation(s)
- Chris H H Chan
- Institute of Life Science, Swansea University Medical School, Swansea, Wales, UK.,Institute of Life Science, Calon Cardio-Technology Ltd., Swansea, Wales, UK
| | - Ina Laura Pieper
- Institute of Life Science, Swansea University Medical School, Swansea, Wales, UK.,Institute of Life Science, Calon Cardio-Technology Ltd., Swansea, Wales, UK
| | - Christian R Robinson
- Institute of Life Science, Swansea University Medical School, Swansea, Wales, UK.,Institute of Life Science, Calon Cardio-Technology Ltd., Swansea, Wales, UK
| | - Yasmin Friedmann
- Institute of Life Science, Swansea University Medical School, Swansea, Wales, UK
| | | | - Catherine A Thornton
- Institute of Life Science, Swansea University Medical School, Swansea, Wales, UK
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Abstract
PURPOSE OF REVIEW Left ventricular assist devices (LVADs) have markedly improved the survival for patients with advanced heart failure but are plagued with significant morbidity, including pump thrombosis and bleeding. Better understanding of the platelet, and its role in the balance of bleeding and thrombosis, stands to impact the frequency and treatment of these significant complications. RECENT FINDINGS In patients with LVADs, there is little consistency linking traditional biomarkers of platelet activation and clinical events. A number of innovative methods of assessing platelet functionality, including shedding of platelet receptors and formation of microparticle complexes as well as measuring mitochondrial membrane potentials, exist and appear to be clinically relevant. Acquired von Willebrand syndrome, while not explaining all bleeding events, is a central feature of mechanical support and offers a target for innovative therapies. SUMMARY Although the platelet is only one component of impacting thrombosis and bleeding in patients supported with LVADs, it plays a central role in mediating these two opposing forces. Innovations in understanding platelet physiology as well as manipulating genomic and receptor interactions for an individual patient will be critical if we are to decrease these serious adverse events in the future.
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Low-Dose Heparin Anticoagulation During Extracorporeal Life Support for Acute Respiratory Distress Syndrome in Conscious Sheep. Shock 2016; 44:560-8. [PMID: 26263439 PMCID: PMC4851223 DOI: 10.1097/shk.0000000000000459] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background: Over 32% of burned battlefield causalities develop trauma-induced hypoxic respiratory failure, also known as acute respiratory distress syndrome (ARDS). Recently, 9 out of 10 US combat soldiers’ survived life-threatening trauma-induced ARDS supported with extracorporeal membrane oxygenation (ECMO), a portable form of cardiopulmonary bypass. Unfortunately, the size, incidence of coagulation complications, and the need for systematic anticoagulation for traditional ECMO devices have prevented widespread use of this lifesaving technology. Therefore, a compact, mobile, ECMO system using minimal anticoagulation may be the solution to reduce ARDS in critically ill military and civilian patients. Methods: We conducted a prospective cohort laboratory investigation to evaluate the coagulation function in an ovine model of oleic acid induced ARDS supported with veno-venous ECMO. The experimental design approximated the time needed to transport from a battlefield setting to an advanced facility and compared bolus versus standard heparin anticoagulation therapy. Results: Comprehensive coagulation and hemostasis assays did not show any difference because of ECMO support over 10 h between the two groups but did show changes because of injury. Platelet count and function did decrease with support on ECMO, but there was no significant bleeding or clot formation during the entire experiment. Conclusions: A bolus heparin injection is sufficient to maintain ECMO support for up to 10 h in an ovine model of ARDS. With a reduced need for systematic anticoagulation, ECMO use for battlefield trauma could reduce significant morbidity and mortality from ventilator-induced lung injury and ARDS. Future studies will investigate the mechanisms and therapies to support patients for longer periods on ECMO without coagulation complications. Level of Evidence: V—therapeutic animal experiment.
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Jeske WP, Walenga JM, Menapace B, Schwartz J, Bakhos M. Blood cell microparticles as biomarkers of hemostatic abnormalities in patients with implanted cardiac assist devices. Biomark Med 2016; 10:1095-1104. [DOI: 10.2217/bmm-2016-0150] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
For heart failure patients unable to undergo cardiac transplantation, mechanical circulatory support with left ventricular assist devices can be utilized. These devices improve quality of life and prolong life expectancy, but they are associated with bleeding and thrombotic complications impacting patient survival. Little is known of the relevant mechanisms of these hemostatic issues, hindering identification of a clinically useful biomarker. However, there is suggestive evidence that blood cell-derived microparticles may fulfill this unmet clinical need. Recent publications have shown an association of up regulated microparticle production with implanted left ventricular assist devices and the potential to use this as a biomarker to predict thrombosis (and perhaps other adverse events) with an onset time earlier than currently used clinical indicators.
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Affiliation(s)
- Walter P Jeske
- Department of Thoracic & Cardiovascular Surgery, Loyola University Medical Center, Maywood, IL 60153, USA
| | - Jeanine M Walenga
- Department of Thoracic & Cardiovascular Surgery, Loyola University Medical Center, Maywood, IL 60153, USA
| | - Bryan Menapace
- Department of Thoracic & Cardiovascular Surgery, Loyola University Medical Center, Maywood, IL 60153, USA
| | - Jeffrey Schwartz
- Department of Thoracic & Cardiovascular Surgery, Loyola University Medical Center, Maywood, IL 60153, USA
| | - Mamdouh Bakhos
- Department of Thoracic & Cardiovascular Surgery, Loyola University Medical Center, Maywood, IL 60153, USA
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Ivak P, Pitha J, Netuka I. Circulating microparticles as a predictor of vascular properties in patients on mechanical circulatory support; hype or hope? Physiol Res 2016; 65:727-735. [PMID: 27429109 DOI: 10.33549/physiolres.933246] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Microparticles are small circulating vesicles originating from circulatory system and vascular wall cells released during their activation or damage. They possess different roles in regulation of endothelial function, inflammation, thrombosis, angiogenesis, and in general, cellular stress. Microparticles are the subject of intensive research in pulmonary hypertension, atherosclerotic disease, and heart failure. Another recently emerging role is the evaluation of the status of vasculature in end-stage heart failure patients treated with implantable ventricular assist devices. In patients implanted as destination therapy, assessment of the long-term effect of currently used continuous-flow left ventricular assist devices (LVADs) on vasculature might be of critical importance. However, unique continuous flow pattern generated by LVADs makes it difficult to assess reliably the vascular function with most currently used methods, based mainly on ultrasound detection of changes of arterial dilatation during pulsatile flow. In this respect, the measurement of circulating microparticles as a marker of vascular status may help to elucidate both short- and long-term effects of LVADs on the vascular system. Because data regarding this topic are very limited, this review is focused on the advantages and caveats of the circulating microparticles as markers of vascular function in patients on continuous-flow LVADs.
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Affiliation(s)
- P Ivak
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic.
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47
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Pieper IL, Radley G, Chan CHH, Friedmann Y, Foster G, Thornton CA. Quantification methods for human and large animal leukocytes using DNA dyes by flow cytometry. Cytometry A 2016; 89:565-74. [DOI: 10.1002/cyto.a.22874] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 02/19/2016] [Accepted: 04/26/2016] [Indexed: 01/18/2023]
Affiliation(s)
- Ina Laura Pieper
- Institute of Life Science, Swansea University Medical School; Swansea SA2 8PP United Kingdom
- Calon Cardio-Technology, Institute of Life Science; Swansea SA2 8PP United Kingdom
| | - Gemma Radley
- Institute of Life Science, Swansea University Medical School; Swansea SA2 8PP United Kingdom
- Calon Cardio-Technology, Institute of Life Science; Swansea SA2 8PP United Kingdom
| | - Chris H. H. Chan
- Institute of Life Science, Swansea University Medical School; Swansea SA2 8PP United Kingdom
- Calon Cardio-Technology, Institute of Life Science; Swansea SA2 8PP United Kingdom
| | - Yasmin Friedmann
- Institute of Life Science, Swansea University Medical School; Swansea SA2 8PP United Kingdom
| | - Graham Foster
- Calon Cardio-Technology, Institute of Life Science; Swansea SA2 8PP United Kingdom
| | - Catherine A. Thornton
- Institute of Life Science, Swansea University Medical School; Swansea SA2 8PP United Kingdom
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Muthiah K, Connor D, Ly K, Gardiner EE, Andrews RK, Qiao J, Rutgers D, Robson D, Low J, Jarvis S, Macdonald P, Dhital K, Jansz P, Joseph J, Hayward CS. Longitudinal changes in hemostatic parameters and reduced pulsatility contribute to non-surgical bleeding in patients with centrifugal continuous-flow left ventricular assist devices. J Heart Lung Transplant 2016; 35:743-51. [DOI: 10.1016/j.healun.2015.12.024] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Revised: 11/09/2015] [Accepted: 12/15/2015] [Indexed: 01/14/2023] Open
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49
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Grosman-Rimon L, Billia F, Fuks A, Jacobs I, A McDonald M, Cherney DZ, Rao V. New therapy, new challenges: The effects of long-term continuous flow left ventricular assist device on inflammation. Int J Cardiol 2016; 215:424-30. [PMID: 27131263 DOI: 10.1016/j.ijcard.2016.04.133] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 04/16/2016] [Indexed: 10/21/2022]
Abstract
Surgically implanted continuous flow left ventricular assist devices (CF-LVADs) are currently used in patients with end-stage heart failure (HF). However, CF-LVAD therapy introduces a new set of complications and adverse events in these patients. Major adverse events with the CF-LVAD include right heart failure, vascular dysfunction, stroke, hepatic failure, and multi-organ failure, complications that may have inflammation as a common etiology. Our aim was to review the current evidence showing a relationship between these adverse events and elevated levels of inflammatory biomarkers in CF-LVAD recipients.
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Affiliation(s)
- Liza Grosman-Rimon
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Canada.
| | - Filio Billia
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Canada
| | - Avi Fuks
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Canada
| | - Ira Jacobs
- Faculty of Kinesiology and Physical Education, University of Toronto, Canada
| | - Michael A McDonald
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Canada
| | - David Z Cherney
- Division of Nephrology, University Health Network, University of Toronto, Canada
| | - Vivek Rao
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Canada.
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50
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Pieper IL, Friedmann Y, Jones A, Thornton C. Evaluation of Four Veterinary Hematology Analyzers for Bovine and Ovine Blood Counts for In Vitro Testing of Medical Devices. Artif Organs 2016; 40:1054-1061. [PMID: 27087058 DOI: 10.1111/aor.12703] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Revised: 12/28/2015] [Accepted: 12/30/2015] [Indexed: 01/17/2023]
Abstract
Small affordable automated hematology analyzers that produce rapid and accurate complete blood cell counts are a valuable tool to researchers developing blood-handling medical devices, such as ventricular assist devices, for in vitro safety assessments. In such studies, it is common to use the blood of large animals such as cattle and sheep. However, the commercially available instruments have not been evaluated for their ability to measure the blood counts of these animals. In this study, we compare, for the first time, four veterinary analyzers for blood counts on bovine and ovine blood samples. We look at ease of use, repeatability and agreement with a view to inform researchers of the benefits of these instruments in routine measurement of ovine and bovine bloods during in vitro testing. Complete blood cell counts and a three-part differential (granulocytes, monocytes, and lymphocytes) were measured by each of the instruments, and the results compared to those obtained from two additional analyzers used in a reference laboratory. Repeatability and agreement were evaluated using the Bland-Altman method; bias and 95% limits of agreement between the instruments, and between the instruments and two reference instruments, were used to evaluate instrument performance. In summary, there are advantages and disadvantages with all instruments. Of the four instruments tested, the repeatability and agreement was fairly similar for all instruments except one instrument which cannot be recommended for bovine or ovine blood counts.
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Affiliation(s)
- Ina Laura Pieper
- Calon Cardio-Technology Ltd, Institute of Life Science, Swansea, United Kingdom
| | - Yasmin Friedmann
- Calon Cardio-Technology Ltd, Institute of Life Science, Swansea, United Kingdom
| | - Alyssa Jones
- Calon Cardio-Technology Ltd, Institute of Life Science, Swansea, United Kingdom
| | - Catherine Thornton
- Calon Cardio-Technology Ltd, Institute of Life Science, Swansea, United Kingdom
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