The new frontier in ECLS: Artificial placenta and artificial womb for premature infants

Outcomes for extremely low gestational age newborns (ELGANs), defined as <28 weeks estimated gestational age (EGA), remain disproportionately poor. A radical paradigm shift in the treatment of prematurity is to recreate the fetal environment with extracorporeal support and provide an environment for organ maturation using an extracorporeal VV-ECLS artificial placenta (AP) or an AV-ECLS artificial womb (AW). In this article, we will review clinical indications, current approaches in development, ongoing challenges, remaining milestones and ethical considerations prior to clinical translation.

Trends in aEEG Cyclicity and Amplitudes During Transition in Extremely Low Gestational Age Infants

AIM

To describe aEEG cyclicity, background pattern, voltage margins and maturation scores in extremely low gestational age neonates (ELGANs) in the first 72 hours.

METHODS

Fifty infants with gestational age (GA) 23⁰ - 27⁶ weeks were prospectively studied. Infants with intraventricular hemorrhage ≦ Grade I and no disorders of transition [persistent pulmonary hypertension, hypotension, pulmonary hemorrhage] belonged to the 'Uncomplicated' group and those with intraventricular hemorrhage > Grade I and/or disorders of transition, to the 'Complicated' group.

RESULTS

Thirty-six infants without opioid exposure were included: 23 with GA 25.9 (23.1-27.7) weeks in the 'Uncomplicated' group and 13 with GA 24.6 (23.3-27.4) weeks in the 'Complicated' group. Cyclicity was more common in the 'Uncomplicated' group [20/ 23 (87%) vs. 7/13 (54%), p=0.045] with more cycles/hour [0.2 (0-0.78) vs. 0.03 (0-67), p=0.036]. Age at appearance of cyclicity were similar [20 (7.7- 40.7) hours in 'Uncomplicated' vs. 23.7 (5.4-60) hours in 'Complicated' group, p=0.8]. In the 'Uncomplicated' group, maturation scores (p=0.02), high (p<0.0001) and low (p=0.03) base voltage increased over time.

CONCLUSION

During the first 72 hours, clinically stable ELGANs without neurological injury demonstrate increased cyclicity compared to those with a complicated course. Maturation score, high and low base voltage increase over time.

Milestones for clinical translation of the artificial placenta

Despite significant advances in the treatment of prematurity, premature birth results in significant mortality and morbidity. In particular, extremely low gestational age newborns (ELGANs) defined as <28 weeks estimated gestational age (EGA) suffer from disproportionate mortality and morbidity. A radical paradigm shift in the treatment of prematurity is to recreate fetal physiology using an extracorporeal VV-ECLS artificial placenta (AP) or an AV-ECLS artificial womb (AW). Over the past 15 years, tremendous advances have been made in the laboratory confirming long-term support and organ protection and ongoing development. The major milestones to clinical application are miniaturization, anticoagulation, clinical risk stratification, specialized critical care protocols, a regulatory path and a strategy and platform to translate technology to the bedside. Currently, several groups are addressing the remaining milestones for clinical translation.