Artificial Placenta - Lung Assist Devices for Term and Preterm Newborns with Respiratory Failure

Dual surface modification of polydimethylsiloxane (PDMS) with antithrombin-heparin complex (ATH) and tissue plasminogen activator (t-PA) for enhanced antithrombotic activity

Medical devices used in contact with blood trigger coagulation and activate platelets leading to thrombotic complications. To prevent these effects, systemic anticoagulants and antiplatelet agents are typically prescribed, but these agents tend to increase the risk of bleeding. Modification of the surface of the blood-contacting material is an alternative approach to the inhibition of coagulation and thrombosis. In this work, the dual surface modification of polydimethylsiloxane (PDMS) with an antithrombin-heparin complex (ATH) to inhibit coagulation, and tissue plasminogen activator (t-PA) to lyse incipient clot, was investigated. Three different modification processes were used to immobilize ATH and t-PA: sequentially, with one component followed by the other; and with both components present simultaneously. Polydopamine (PDA) was used as a "bioglue" to enhance adhesion of the modifiers. The surface hydrophilicity and roughness were found to increase with increasing extent of modification. The surface density of the modifiers and their stability in plasma were significantly influenced by the modification process. The sequential method with t-PA first followed by ATH led to increased heparin activity. Data from plasma clotting time experiments showed that the combination of ATH and t-PA provides a synergistic effect, wherein both the anticoagulant activity of ATH and the clot lysis activity of t-PA on the surface are enhanced. This dual modification approach using both an anticoagulant and a thrombolytic agent shows promise to improve the blood compatibility of PDMS. The strategy can be applied to materials other than PDMS since the PDA coating is generic, thus providing a method for improving the performance of many blood-contacting devices.

Scaled-up Microfluidic Lung Assist Device for Artificial Placenta Application with High Gas Exchange Capacity

Premature neonates with underdeveloped lungs experience respiratory issues and need respiratory support, such as mechanical ventilation or extracorporeal membrane oxygenation (ECMO). The "artificial placenta" (AP) is a noninvasive approach that supports their lungs and reduces respiratory distress, using a pumpless oxygenator connected to the systemic circulation, and can address some of the morbidity issues associated with ECMO. Over the past decade, microfluidic blood oxygenators have garnered significant interest for their ability to mimic physiological conditions and incorporate innovative biomimetic designs. Achieving sufficient gas transfer at a low enough pressure drop for a pumpless operation without requiring a large volume of blood to prime such an oxygenator has been the main challenge with microfluidic lung assist devices (LAD). In this study, we improved the gas exchange capacity of our microfluidic-based artificial placenta-type LAD while reducing its priming volume by using a modified fabrication process that can accommodate large-area thin film microfluidic blood oxygenator (MBO) fabrication with a very high gas exchange surface. Additionally, we demonstrate the effectiveness of a LAD assembled by using these scaled-up MBOs. The LAD based on our artificial placenta concept effectively increases oxygen saturation levels by 30% at a flow rate of 40 mL/min and a pressure drop of 23 mmHg in room air, which is sufficient to support partial oxygenation for 1 kg preterm neonates in respiratory distress. When the gas ambient environment was changed to pure oxygen at atmospheric pressure, the LAD would be able to support premature neonates weighing up to 2 kg. Furthermore, our experiments reveal that the LAD can handle high blood flow rates of up to 150 mL/min and increase oxygen saturation levels by ∼20%, which is equal to an oxygen transfer of 7.48 mL/min in an enriched oxygen environment and among the highest for microfluidic AP type devices. Such performance makes this LAD suitable for providing essential support to 1-2 kg neonates in respiratory distress.

Haemodynamics and cerebral oxygenation of neonatal piglets in the immediate ex utero period supported by mechanical ventilation or ex utero oxygenator

KEY POINTS

The margin of human viability has extended to the extremes of gestational age (<24 weeks) when the lungs are immature and ventilator-induced lung injury is common. Artificial placenta technology aims to extend gestation ex utero in order to allow the lungs additional time to develop prior to entering an air-breathing environment. We compared the haemodynamics and cerebral oxygenation of piglets in the immediate period post-oxygenator (OXY) transition against both paired in utero measures and uniquely against piglets transitioned onto mechanical ventilation (VENT). Post-transition, OXY piglets became hypotensive with reduced carotid blood flow in comparison with both paired in utero measures and VENT piglets. The addition of a pump to the oxygenator circuit may be required to ensure haemodynamic stability in the immediate post-transition period.

ABSTRACT

Gestational age at birth is a major predictor of wellbeing; the lower the gestational age, the greater the risk of mortality and morbidity. At the margins of human viability (<24 weeks gestation) immature lungs combined with the need for early ventilatory support means lung injury and respiratory morbidity is common. The abrupt haemodynamic changes consequent on birth may also contribute to preterm-associated brain injury, including intraventricular haemorrhage. Artificial placenta technology aims to support oxygenation, haemodynamic stability and ongoing fetal development ex utero until mature enough to safely transition to a true ex utero environment. We aimed to characterize the impact of birth transition onto either an oxygenator circuit or positive pressure ventilation on haemodynamic and cerebral oxygenation of the neonatal piglet. At 112 days gestation (term = 115 days), fetal pigs underwent instrumentation surgery and transitioned onto either an oxygenator (OXY, n = 5) or ventilatory support (VENT, n = 8). Blood pressure (BP), carotid blood flow and cerebral oxygenation in VENT piglets rose from in utero levels to be significantly higher than OXY piglets post-transition. OXY piglet BP, carotid blood flow and carotid oxygen delivery (DO₂ ) decreased from in utero levels post-transition; however, cerebral regional oxygen saturation (rSO₂ ) was maintained at fetal-like levels. OXY piglets became hypoxaemic and retained CO₂ . Whether OXY piglets are able to maintain cerebral rSO₂ under these conditions for a prolonged period is yet to be determined. Improvements to OXY piglet oxygenation may lie in maintaining piglet BP at in utero levels and enhancing oxygenator circuit flow.

Achieving sustained extrauterine life: Challenges of an artificial placenta in fetal pigs as a model of the preterm human fetus

Artificial placenta (AP) technology aims to maintain fetal circulation, while promoting the physiologic development of organs. Recent reports of experiments performed in sheep indicate the intrauterine environment can be recreated through the cannulation of umbilical vessels, replacement of the placenta with a low-resistance membrane oxygenator, and incubation of the fetus in fluid. However, it remains to be seen whether animal fetuses similar in size to the extremely preterm human infant that have been proposed as a potential target for this technology can be supported in this way. Preterm Yucatan miniature piglets are similar in size to extremely preterm human infants and share similar umbilical cord anatomy, raising the possibility to serve as a good model to investigate the AP. To characterize fetal cardiovascular physiology, the carotid artery (n = 24) was cannulated in utero and umbilical vein (UV) and umbilical artery were sampled. Fetal UV flow was measured by MRI (n = 16). Piglets were delivered at 98 ± 4 days gestation (term = 115 days), cannulated, and supported on the AP (n = 12) for 684 ± 228 min (range 195-3077 min). UV flow was subphysiologic (p = .002), while heart rate was elevated on the AP compared with in utero controls (p = .0007). We observed an inverse relationship between heart rate and UV flow (r2  = .4527; p < .001) with progressive right ventricular enlargement that was associated with reduced contractility and ultimately hydrops and circulatory collapse. We attribute this to excessive afterload imposed by supraphysiologic circuit resistance and augmented sympathetic activity. We conclude that short-term support of the preterm piglet on the AP is feasible, although we have not been able to attain normal fetal physiology. In the future, we propose to investigate the feasibility of an AP circuit that incorporates a centrifugal pump in our miniature pig model.

A Pumpless Microfluidic Neonatal Lung Assist Device for Support of Preterm Neonates in Respiratory Distress

Premature neonates suffer from respiratory morbidity as their lungs are immature, and current supportive treatment such as mechanical ventilation or extracorporeal membrane oxygenation causes iatrogenic injuries. A non-invasive and biomimetic concept known as the "artificial placenta" (AP) would be beneficial to overcome complications associated with the current respiratory support of preterm infants. Here, a pumpless oxygenator connected to the systemic circulation supports the lung function to relieve respiratory distress. In this paper, the first successful operation of a microfluidic, artificial placenta type neonatal lung assist device (LAD) on a newborn piglet model, which is the closest representation of preterm human infants, is demonstrated. This LAD has high oxygenation capability in both pure oxygen and room air as the sweep gas. The respiratory distress that the newborn piglet is put under during experimentation, repeatedly and over a significant duration of time, is able to be relieved. These findings indicate that this LAD has a potential application as a biomimetic artificial placenta to support the respiratory needs of preterm neonates.

Artificial placenta and womb technology: Past, current, and future challenges towards clinical translation

Extreme prematurity remains a major cause of neonatal mortality and severe long-term morbidity. Current neonatal care is associated with significant morbidity due to iatrogenic injury and developmental immaturity of extreme premature infants. A more physiologic approach, replacing placental function and providing a womb-like environment, is the foundational principle of artificial placenta (AP) and womb (AW) technology. The concept has been studied during the past 60 years with limited success. However, recent technological advancements and a greater emphasis on mimicking utero-placental physiology have improved the success of experimental models, bringing the technology closer to clinical translation. Here, we review the rationale for and history of AP and AW technology, discuss the challenges that needed to be overcome, and compare recent successful models. We conclude by outlining some remaining challenges to be addressed on the path towards clinical translation and opportunities for future research.

An ultra-thin, all PDMS-based microfluidic lung assist device with high oxygenation capacity

Preterm neonates with immature lungs require a lung assist device (LAD) to maintain oxygen saturation at normal levels. Over the last decade, microfluidic blood oxygenators have attracted considerable interest due to their ability to incorporate unique biomimetic design and to oxygenate in a physiologically relevant manner. Polydimethylsiloxane (PDMS) has become the main material choice for these kinds of devices due to its high gas permeability. However, fabrication of large area ultrathin microfluidic devices that can oxygenate sufficient blood volumes at clinically relevant flow rates, entirely made of PDMS, have been difficult to achieve primarily due to failure associated with stiction of thin PDMS membranes to each other at undesired locations during assembly. Here, we demonstrate the use of a modified fabrication process to produce large area ultrathin oxygenators entirely made of PDMS and robust enough to withstand the hydraulic conditions that are encountered physiologically. We also demonstrate that a LAD assembled from these ultrathin double-sided microfluidic blood oxygenators can increase the oxygen saturation level by 30% at a flow rate of 30 ml/min and a pressure drop of 21 mm Hg in room air which is adequate for 1 kg preterm neonates. In addition, we demonstrated that our LAD could withstand high blood flow rate of 150 ml/min and increase oxygen saturation by 26.7% in enriched oxygen environment which is the highest gas exchange reported so far by any microfluidic-based blood oxygenators. Such performance makes this LAD suitable to provide support to 1 kg neonate suffering from respiratory distress syndrome.

An ultra-thin highly flexible microfluidic device for blood oxygenation

Many neonates who are born premature suffer from respiratory distress syndrome (RDS) for which mechanical ventilation and an extracorporeal membrane oxygenation (ECMO) device are used in treatment. However, the use of these invasive techniques results in higher risk of complications like bronchopulmonary dysplasia or requires surgery to gain vascular access. An alternative biomimetic approach is to use the umbilical cord as a vascular access and to connect a passive device to the baby that functions like a placenta. This concept, known as the artificial placenta, provides enough oxygenation and causes minimal distress or complications. Herein, we have developed a new artificial placenta-type microfluidic blood oxygenator (APMBO) with high gas exchange, low priming volume and low hydraulic resistance such that it can be operated only by pressure differential provided by the baby's heart. Mimicking the placenta, we have made our new device ultra-thin and flexible so that it can be folded into a desired shape without losing its capability for gas exchange and achieve a compact form factor. The ability to fold allowed optimization of connectors and reduced the overall priming volume to the sub-milliliter range while achieving a high oxygen uptake which would be sufficient for preterm neonates with a birth-weight of around 0.5 kg.

An artificial placenta type microfluidic blood oxygenator with double-sided gas transfer microchannels and its integration as a neonatal lung assist device

Preterm neonates suffering from respiratory distress syndrome require assistive support in the form of mechanical ventilation or extracorporeal membrane oxygenation, which may lead to long-term complications or even death. Here, we describe a high performance artificial placenta type microfluidic oxygenator, termed as a double-sided single oxygenator unit (dsSOU), which combines microwire stainless-steel mesh reinforced gas permeable membranes on both sides of a microchannel network, thereby significantly reducing the diffusional resistance to oxygen uptake as compared to the previous single-sided oxygenator designs. The new oxygenator is designed to be operated in a pumpless manner, perfused solely due to the arterio-venous pressure difference in a neonate and oxygenate blood through exposure directly to ambient atmosphere without any air or oxygen pumping. The best performing dsSOUs showed up to ∼343% improvement in oxygen transfer compared to a single-sided SOU (ssSOU) with the same height. Later, the dsSOUs were optimized and integrated to build a lung assist device (LAD) that could support the oxygenation needs for a 1-2 kg neonate under clinically relevant conditions for the artificial placenta, namely, flow rates ranging from 10 to 60 ml/min and a pressure drop of 10-60 mmHg. The LAD provided an oxygen uptake of 0.78-2.86 ml/min, which corresponded to the increase in oxygen saturation from 57 ± 1% to 93%-100%, under pure oxygen environment. This microfluidic lung assist device combines elegant design with new microfabrication methods to develop a pumpless, microfluidic blood oxygenator that is capable of supporting 30% of the oxygen needs of a pre-term neonate.

Postnatal dilatation of umbilical cord vessels and its impact on wall integrity: Prerequisite for the artificial placenta

INTRODUCTION

A lung assist device, which acts as an artificial placenta, can provide additional gas exchange for preterm and term newborns with respiratory failure. The concept of the lung assist device requires a large bore access via umbilical vessels to allow pumpless extracorporeal blood flow rates up to 30 mL/kg/min. After birth, constricted umbilical vessels need to be reopened for vascular access. The objective is to study the impact of umbilical vessel expansion on vessel integrity for achieving large bore access.

METHODS

Umbilical cords from healthy term deliveries were cannulated and dilatated with percutaneous transluminal angioplasty catheters in 1 mm increments from 4 to 8 mm for umbilical artery and from 4 to 15 mm for umbilical vein, n = 6 per expansion diameter. Paraffin-embedded transverse sections of dilated and control samples were HE & Van Gieson stained. Effects of dilatation, shown by splitting, were measured.

RESULTS

Umbilical vessel expansion led to concentric splitting, shown by areas devoid of extracellular matrix and nuclei in the tunica intima and media. No radial splitting was observed. Results suggest an expansion threshold of umbilical artery at 6 mm and umbilical vein at 7 mm, while maximal splitting was observed above this threshold (3.6 ± 0.8%, p = 0.043 for umbilical artery 7 mm and 6.3 ± 1.8%, p = 0.048 for umbilical vein 8 mm). Endothelial cell sloughing was present in all dilated samples but not in the control samples.

CONCLUSION

The suggested thresholds for safe expansions are similar to in utero umbilical vessel diameters and demonstrate a proof of concept for attaining large bore access for the lung assist device.

Steel reinforced composite silicone membranes and its integration to microfluidic oxygenators for high performance gas exchange

Respiratory distress syndrome (RDS) is one of the main causes of fatality in newborn infants, particularly in neonates with low birth-weight. Commercial extracorporeal oxygenators have been used for low-birth-weight neonates in neonatal intensive care units. However, these oxygenators require high blood volumes to prime. In the last decade, microfluidics oxygenators using enriched oxygen have been developed for this purpose. Some of these oxygenators use thin polydimethylsiloxane (PDMS) membranes to facilitate gas exchange between the blood flowing in the microchannels and the ambient air outside. However, PDMS is elastic and the thin membranes exhibit significant deformation and delamination under pressure which alters the architecture of the devices causing poor oxygenation or device failure. Therefore, an alternate membrane with high stability, low deformation under pressure, and high gas exchange was desired. In this paper, we present a novel composite membrane consisting of an ultra-thin stainless-steel mesh embedded in PDMS, designed specifically for a microfluidic single oxygenator unit (SOU). In comparison to homogeneous PDMS membranes, this composite membrane demonstrated high stability, low deformation under pressure, and high gas exchange. In addition, a new design for oxygenator with sloping profile and tapered inlet configuration has been introduced to achieve the same gas exchange at lower pressure drops. SOUs were tested by bovine blood to evaluate gas exchange properties. Among all tested SOUs, the flat design SOU with composite membrane has the highest oxygen exchange of 40.32 ml/min m². The superior performance of the new device with composite membrane was demonstrated by constructing a lung assist device (LAD) with a low priming volume of 10 ml. The LAD was achieved by the oxygen uptake of 0.48-0.90 ml/min and the CO₂ release of 1.05-2.27 ml/min at blood flow rates ranging between 8 and 48 ml/min. This LAD was shown to increase the oxygen saturation level by 25% at the low pressure drop of 29 mm Hg. Finally, a piglet was used to test the gas exchange capacity of the LAD in vivo. The animal experiment results were in accordance with in-vitro results, which shows that the LAD is capable of providing sufficient gas exchange at a blood flow rate of ∼24 ml/min.

Artificial placenta: Analysis of recent progress

The artificial placenta (AP) has for many decades captured the imagination of scientists and authors with popular fiction including The Matrix and Aldous Huxley's "Brave New World", depicting a human surviving ex-utero in an artificial uterine environment (AUE). For scientists this has fascinated as a way forward for extremely preterm infants (EPIs) born less than 28 weeks of gestation. Early successes with mechanical ventilation (MV) for infants born above 28 weeks of gestation meant that AP research lost momentum. More recently, the gestational age limit for survival now borders on 23 weeks and corresponds to the biological milestone of lung development marked by the early canalicular stage of lung morphogenesis. The so called greyzone of 23-25 weeks represents a steep increase in mortality with decreasing gestational age and current options in neonatal care are on the fringes of efficacy for this population. A shift in thinking recognizes the vitality of EPIs as a fetus rather than a 37-40 week neonate and this has reinvigorated the concept of the AP. This review will discuss the scale of extreme preterm birth with special reference to previable infants born in the greyzone. Recent AP studies using sheep models are compared, technical obstacles discussed and future research themes identified.

Artificial placenta: Recent advances and potential clinical applications

Lung immaturity remains a major cause of morbidity and mortality in extremely premature infants. Positive-pressure mechanical ventilation, the method of choice for respiratory support in premature infants, frequently promotes by itself lung injury and a negative impact in the circulatory function. Extracorporeal lung support has been proposed for more than 50 years as a potential alternative to mechanical ventilation in the treatment of severe respiratory failure of extremely premature infants. Recent advances in this field included the development of miniaturized centrifugal pumps and polymethylpentene oxygenators, as well as the successful use of pump-assisted veno-venous extracorporeal gas exchange systems in experimental artificial placenta models. This review, which includes studies published from 1958 to 2015, presents an update on the artificial placenta concept and its potential clinical applications. Special focus will be devoted to the milestones achieved so far and to the limitations that must be overcome before its clinical application. Notwithstanding, the artificial placenta stands as a promising alternative to mechanical ventilation in extremely premature infants. Pediatr Pulmonol. 2016;51:643-649. © 2016 Wiley Periodicals, Inc.

Surface modification of poly(dimethylsiloxane) with a covalent antithrombin-heparin complex for the prevention of thrombosis: use of polydopamine as bonding agent

A modified poly(dimethyl siloxane) (PDMS) material is under development for use in an extracorporeal microfluidic blood oxygenator designed as an artificial placenta to treat newborn infants suffering from severe respiratory insufficiency. To prevent thrombosis triggered by blood-material contact, an antithrombin-heparin (ATH) covalent complex was coated on PDMS surface using polydopamine (PDA) as a "bioglue". Experiments using radiolabelled ATH showed that the ATH coating on PDA-modified PDMS remained substantially intact after incubation in plasma, 2% SDS solution, or whole blood over a three day period. The anticoagulant activity of the ATH-modified surfaces was also demonstrated: in contact with plasma the ATH-coated PDMS was shown to bind antithrombin (AT) selectively from plasma and to inhibit clotting factor Xa. It is concluded that modification of PDMS with polydopamine and ATH shows promise as a means of improving the blood compatibility of PDMS and hence of the oxygenator device.

Extracorporeal fetal support: a new animal model with preservation of the placenta

BACKGROUND

Previous models of support for premature sheep fetuses have consisted of cesarean delivery followed by catheterization of umbilical or central vessels and support with extracorporeal membrane oxygenation (ECMO). The limitations of these models have been insufficient blood flow, significant fetal edema, and hemorrhage related to anticoagulation.

METHODS

We performed a gravid hysterectomy on 13 ewes between 135 and 145days gestational age. The uterine vessels were cannulated bilaterally and circulatory support was provided via ECMO. Successful transition was defined as maintenance of fetal heart rate for 30minutes after establishing full extracorporeal support. Circuit flow was titrated to maintain mixed venous oxygen saturation (SvO2) of 70-75%.

RESULTS

Seven experiments were successfully transitioned to ECMO, with an average survival time of 2hours 9minutes. The longest recorded time from cannulation to death was 6hours 14minutes. By delivering a circuit flow of up to 2120ml/min, all but one of the transitioned uteri were maintained within the desired SvO2 range.

CONCLUSION

We report a novel animal model of fetal ECMO support that preserves the placenta, mitigates the effects of heparin, and allows for increased circuit flow compared to prior techniques. This approach may provide insight into a technique for future studies of fetal physiology.

Lung assist device: development of microfluidic oxygenators for preterm infants with respiratory failure

This paper reports the development of microfluidic oxygenator (MFO) units designed for a lung assist device (LAD) for newborn infants. This device will be connected to the umbilical vessels like the natural placenta and provide gas exchange. The extracorporeal blood flow is only driven by the pressure difference between the umbilical artery and vein without the use of external pumps. The LAD is designed for use in ambient air (~21% of 760 mmHg). The main focus of this paper is the presentation of the development of the MFO units testing various membrane materials with human blood to enhance gas exchange and in the design of fluidic inlets to lower the pressure drop across the oxygenator. Four different membranes, including thin film PDMS, porous PDMS, and two different pore size porous polycarbonate membranes are compared in this study. Among them, the microfluidic oxygenator with porous PDMS membrane has the highest gas exchange rate of 1.46 μL min(-1) cm(2) for oxygen and 5.27 μL min(-1) cm(2) for carbon dioxide and performs better than a commercial hollow fiber-based oxygenator by 367 and 233%, respectively. A new tapered inlet configuration was designed to reduce the pressure drop across the oxygenator and showed a further 57% improvement over the traditional perpendicular inlet configuration.