Protein-platelet interaction on heparinized surfaces

Heparinization of Biological Vascular Graft Reduces Fibrin Deposition

An alternative graft is needed for coronary bypass operations in patients lacking suitable autologous vessels. We therefore studied Denaflex™, a biologic graft, in a dog ex-vivo shunt model to determine whether heparin treatment makes this graft less thrombogenic. Comparison was also made to Bioflow™, a nonheparinized biologic graft. Fibrinogen deposition during high flow (593 ± 202 ml/min) decreased from 672 ± 467 ngl mm2 in nonheparinized Denaflex grafts to 448 ± 298 ng/mm2 (p<0.05) in heparinized Denaflex grafts. At low flow (117 ± 13 ml/min), heparinization of Denaflex grafts similarly decreased fibrinogen deposition from 1102 ± 601 ng/mm2 to 703 ± 405 ng/mm2 (p<0.05). At both flow rates fibrinogen deposition in Bioflow grafts was less than in nonheparinized Denaflex, but was similar to heparinized Denaflex grafts. Platelet deposition was not influenced by heparinization of Denaflex grafts and was similar among Denaflex and Bioflow preparations. Whether Denaflex performs acceptably in vivo as a xenograft requires extensive study.

Biocompatible and biodegradable phosphorylcholine ionomers with reduced protein adsorption and cell adhesion

In this paper a recently developed biodegradable phosphorylcholine ionomer (PC ionomer) was evaluated in different biological environments with a focus on the adsorption of proteins (fibrinogen) and the adhesion of cells. Our results have shown that the polar phosphoryl choline (PC) group may be enriched at the surface of cast films with an added hydrophilic environment. X-ray photoelectron spectroscopy confirmed the surface depletion of PC groups in dry conditions, as nitrogen and phosphorous atoms were found in the bulk of the material but not at the outermost surface layer. The surface enrichment leads to a strongly hydrophilic surface that prevents the adsorption of proteins and reduces the adhesion of cells. The non-functional and hydrophobic reference poly(trimethylene carbonate) (PTMC) adsorbs both proteins and cells, thus the wetting and low adhesion behavior of the PC ionomer can be attributed to the introduced PC functionality. Since the in vivo acceptance of biomaterials is determined by their ability to withstand protein adsorption the PC ionomer described in this paper is highly interesting for a number of in vivo applications in which the adsorption of proteins may be critical, for example, blood contact events.

Study of single protein adsorption onto monoamino oligoglycerol derivatives: a structure-activity relationship

This paper describes a structure-property study of mixed self-assembled monolayers (SAMs) on gold that present methylated or hydroxyl-terminated polyglycerol (PG) structures that vary in size and architecture, and their ability to resist the adsorption of four test proteins from solution. Mixed SAMs were prepared by the reaction of an amine of the polyglycerol structures with a SAM that presents interchain anhydrides (the anhydride method). Surface plasmon resonance spectroscopy was used to measure the adsorption of fibrinogen, lysozyme, albumin, and pepsin to the resulting mixed PG amide/carboxylate-terminated SAMs. In addition, FTIR infrared reflection-absorption spectroscopy (IRRAS) and contact angle goniometry were used to characterize the mixed SAMs. The study showed that even though methylation increases the hydrophobicity of these mixed PG SAMs, it greatly improved their ability to resist the adsorption of the test protein with the best performing surface demonstrating better resistance than a mixed SAM that presented poly(ethylene glycol) (PEG350). It was also shown that increasing the molecular weight of the PG structures (oligomer length or higher dendritic generations) generally resulted in decreased protein adsorption. With respect to the architecture, the linear oligoglycerols showed better resistance than their equal weight branched dendrons, while hyperbranched dendrons were more resistant to protein adsorption than perfect dendrons of equal weight.

HLA sensitization in ventricular assist device recipients: does type of device make a difference?

BACKGROUND

We sought to (1) characterize the temporal pattern of T-cell panel reactive antibody during ventricular assist device support, (2) identify predictors of higher T-cell panel reactive antibody during ventricular assist device support, and (3) determine whether device type remained a predictor after accounting for nonrandom device selection.

METHODS

Between December 1991 and August 2000, 239 patients received implantable ventricular assist devices, of whom 231 had T-cell panel reactive antibody measured. Panel reactive antibody was measured before implantation of the assist device, approximately 2 weeks after device implantation, irregularly thereafter depending on clinical events and length of support, and at transplantation. Longitudinal mixed modeling was used to characterize the temporal pattern of sensitization and its predictors during ventricular assist device support. To account for nonrandom factors in device selection when comparing HeartMate (Thermo Cardiosystems, Inc, Woburn, Mass) and Novacor (Baxter Healthcare Corp, Novacor Div, Oakland, Calif) devices, we propensity-matched patients according to baseline characteristics.

RESULTS

T-cell panel reactive antibody increased rapidly after implantation of the ventricular assist device and then immediately began to decrease. Predictors of higher T-cell panel reactive antibody during support with the assist device were a shorter interval from device implantation to T-cell panel reactive antibody measurement (P <.0001), female sex (P =.0004), younger age (P =.01), higher T-cell panel reactive antibody before device implantation (P =.03), more perioperative red blood cell transfusions (P =.006), and an earlier date of device implantation (P =.001). In matched patients, device type was not a predictor of higher T-cell panel reactive antibody during ventricular assist device support (P =.8).

CONCLUSIONS

HLA sensitization during ventricular assist device support is not constant but increases rapidly at implantation and then decreases. This temporal pattern of sensitization is influenced by patient factors and not by the type of device.

Investigation of in vitro interactions between different polymeric surfaces and blood proteins via phagocytosis phenomena

The effect of various polymeric materials on blood components and their in vitro phagocytosis was the object of the present research. Polystyrene- (PS) and polymethylmetacrylate- (PMMA) based microspheres were produced by phase-inversion polymerization and chemically modified to obtain different surface hydrophilicities. The interactions between blood proteins and chemically- and biologically-modified surfaces were investigated and compared to plain microspheres. Adsorption properties of albumin, fibrinogen and total immunoglobulines on microspheres were tested. Hydrophilic surfaces have high ability for human serum albumin (HSA) adsorption, which also leads to less phagocytosis of microspheres in vitro. In the case of activated PMMA(PVA) microspheres, both protein adsorption and phagocytosis were significant. Interaction of blood proteins with microspheres did not cause any change in phagocytosis by leukocytes and monocytes. BSA adsorption on microspheres with different hydrophilicities showed the same blood protein adsorption results and phagocytosis was not detected. On the other hand, the highest level of phagocytosis was found with fibronectin-modified microspheres. The changes occurring in intrinsic and extrinsic coagulation mechanisms were determined by measuring the activated partial tromboplastin time (APTT) and the prothrombin time (PT). PT values of blood samples did not increase by treatment with microspheres, except for PS/HEMA, while chemical modification caused important prolongation in APTT.

Use of autologous blood as part of the perfusate for cardiopulmonary bypass: a priming technique

In an attempt to replace the oncotic and protein coating capabilities of serum albumin in the perfusate, we established a priming protocol that used autologous blood as part of the perfusate solution. Prior to March 1, 1999, our standard priming protocol was 1650 ml of crystalloid with 250 ml of 5% serum albumin and 5,000 units of heparin. After removing albumin from our prime, our standard protocol was altered to include 40 ml of the patient's autologous blood in 1,800 ml of crystalloid and 10,000 units of heparin. To determine the intraoperative effects of using albumin/crystalloid primes (Group A), autologous blood/crystalloid primes (Group B) and crystalloid primes (Group C), a total of 178 patients were sequentially evaluated. Intraoperative parameters evaluated were total protein (TP), colloid osmotic pressure (COP), platelets (Plts) and fluid requirements during cardiopulmonary bypass (CPB). During an overlapping 12-month period of time, 1,092 consecutive cardiac surgical cases using CPB (584 albumin prime; 508 autologous blood prime) were evaluated for clinical outcomes in terms of mortality and length of hospitalization. In addition, over a period of 15 months, 1,458 patients in both the autologous blood/crystalloid group and the crystalloid only group were evaluated for the incidence of high-pressure excursions (HPE) after going on bypass. Comparative reviews of TP, COP and Plts demonstrated no significant difference 10 min after the start of bypass between Groups A and B. However, in Group C, there was a statistically significant increase in the intraoperative fluid requirements during CPB, compared to both of the other groups. There was no significant difference in the incidence of HPE, with an occurrence of 1.04% in the crystalloid only group and 1.11% in the autologous blood/crystalloid group. Autologous blood perfusates were identical to albumin perfusates in their platelet protection and reduction of fluid shifts during the intraoperative period.

Albumin in the cardiopulmonary bypass prime: how little is enough?

Previous studies have demonstrated high transoxygenator pressures with noncoated hollow-fiber membrane oxygenators. These reports have been associated with dramatic platelet count drops during cardiopulmonary bypass (CPB). It has also been shown that adding human albumin to the prime of the bypass circuit reduces, if not eliminates, these problems. This study was conducted to determine what is the smallest amount of albumin added to the prime that will still display its protective effects. Eighty patients undergoing nonemergency open-heart surgery were randomly divided into four groups. Groups I and II received the Sarns Turbo 440 oxygenator with 0.0375 g of albumin/100 ml of prime and 0.125 g of albumin/100 ml of prime, respectively, added to the pump prime. Groups III and IV received the Medtronic Maxima-PRF oxygenator with 0.0375 g of albumin/100 ml of prime and 0.125 g of albumin/100 ml of prime, respectively, added to the pump prime. Pre-CPB, on CPB (15-20 min after the initiation of bypass) and warming hemoglobin, hematocrit and platelet counts were drawn on all patients. Net platelet count drop, which accounted for hemodilutional effects, was calculated for all specimens and compared to previous results obtained from the test oxygenators without albumin in the prime. The net platelet count drops for the study groups were as follows: Sarns oxygenator with no albumin in the prime = 11.8+/-12.5%; Sarns oxygenator with 0.0375 g of albumin/100 ml prime = -3.7+/-10.8%; Sarns oxygenator with 0.125 g of albumin/100 ml prime = -2.0+/-12.6%; Medtronic oxygenator with no albumin in the prime = 20.1+/-14.5%; Medtronic oxygenator with 0.0375 g albumin/100 ml prime = -6.9+/-8.7%; and Medtronic oxygenator with 0.125 g albumin/100 ml prime = -14.0+/-12.4%. Our results illustrate that adding as little as 0.0375 g albumin/100 ml prime (3 ml of 25% solution/2000 ml of prime) to the pump prime illicits the beneficial effects of surface coating on platelet loss during CPB.

The effect of albumin priming solution on platelet activation during experimental long-term perfusion

The objective of this study was to evaluate the effect of albumin priming on platelet consumption and activation during long-term perfusion. Two identical in vitro extracorporeal membrane oxygenation circuits were used; one was primed with Ringer's solution containing human serum albumin, the other with Ringer's solution only. Fresh heparinized human blood was pooled, divided between the two systems and circulated for 24 h at 37 degrees C. Platelet count, plasma concentration of betathromboglobulin (BTG), platelet membrane density of glycoprotein (GP) Ib and of GPIIb/IIIa were assayed before the start and at 0.5, 1, 3, 12 and 24 h of perfusion. In total, seven experiments were performed. We found that during the first hour of perfusion, slightly higher platelet counts (p = 0.058) and lower BTG values (p = 0.0005) were observed in the circuits primed with albumin, compared to the control circuits. No statistically significant differences were observed for the platelet membrane expression of GPIb and GPIIb/IIIa. We conclude that albumin priming appears to transiently prevent platelet consumption and activation during long-term perfusion.

Cell activation and thrombin generation in heparin bonded cardiopulmonary bypass circuits using a novel in vitro model

OBJECTIVE

It is generally agreed that when the blood contact surfaces of a cardiopulmonary bypass circuit are treated with a layer of heparin molecules the activation of the humoral pathways is attenuated. However, there is still debate as to whether heparin-bonded circuits reduce thrombin generation. This study aims to examine the effects of immobilized heparin on cell activation and thrombin generation in a novel, well controlled model of cardiopulmonary bypass.

METHODS

The model used consisted of a heparin-bonded and a non-bonded cardiopulmonary bypass circuit perfused in tandem with the same unit of fresh heparinized (3.3 U/ml) human blood for a period of 6 h. Samples were taken for analysis from the bag just prior to perfusion and at 30, 60, 120 and 360 min of perfusion. Whole blood was used to analyse platelet and white blood cell count, haematocrit and activated coagulation time. Plasma samples were prepared for batch analysis of the cell activation markers p-selectin, elastase and interleukin-8, and the thrombin generation markers thrombin-antithrombin and prothrombin fragment F1 + 2. A sample of tubing was taken from each circuit at the end of the perfusion and prepared for visualization by scanning electron microscopy.

RESULTS

Platelet counts were significantly reduced in the non-bonded circuits compared with the heparin-bonded circuits at 30 (22 versus 200 x 10(9)/L P < 0.01), 60 (26 versus 193 x 10(9)/L P < 0.01) and 120 min (28 versus 193 x 10(9)/L P < 0.01) as were white blood cell counts at 30(1.5 versus 2.7 x 10(9)/L P < 0.01), 60 (0.9 versus 2.4 x 10(9)/L P < 0.01), 120 (0.9 versus 1.8 x 10(9)/L P < 0.01) and 360 min (0.4 versus 0.9 x 10(9)/L P < 0.05). The concentration of p-selectin was found to be significantly higher in the non-bonded circuits than in the heparin-bonded circuits at 30 (37 versus 29 ng/ml P < 0.01), 60 (37 versus 28 ng/ml P < 0.01). 120 (42 versus 27 ng/ml P < 0.01) and at 360 min (72 versus 46 ng/ml P < 0.01). Elastase was elevated in the non-bonded circuits at 30 (570 versus 145 micrograms/l P < 0.01), 60 (646 versus 278 micrograms/l P < 0.01) and 120 min (613 versus 403 micrograms/l P < 0.05) and interleukin-8 at 120 (705 versus 520 pg/ml P < 0.05) and 360 min (11326 versus 9910 pg/ml P < 0.05). A similar picture was found for the thrombin generation markers. Thrombin-antithrombin complexes were raised in the non-bonded circuits compared with heparin-bonded circuits at 60 (24 versus 13 micrograms/l P < 0.05) and 120 min (46 versus 17 micrograms/l P < 0.05) as was prothrombin fragment F1 + 2 at 30 (1.1 versus 0.7 nmol/l P < 0.01), 60 (1.3 versus 0.7 nmol/l P < 0.01), 120 (1.8 versus 0.9 nmol/l P < 0.01) and 360 min (15.0 versus 13.6 nmol/l P < 0.05). Scanning electron microscopy revealed a greater amount of adherent material on the non-bonded surface relative to the heparin-bonded surface.

CONCLUSIONS

In a cardiopulmonary bypass circuit perfused with human blood the activation of platelets and white blood cells has been seen to be significantly reduced in the presence of a heparin-bonded surface. Thrombin generation due to contact activation of the intrinsic coagulation pathway is also reduced.

Haemocompatibility of invasive sensors

In recent years the importance and utilisation of invasive chemical sensors have increased, especially in respect to their function and behaviour in a biological environment. This review aims to highlight the development of various sensors and reflect on the problems which can occur when the sensors come into contact with blood. Thus their haemocompatibility is a key area of importance. A clear understanding of their interaction with plasma proteins at the point of interface is fundamental as this determines their ultimate capability to function safely and effectively. There is also an overview of various techniques that have been developed, together with a broad summary of inherent problems which may arise when aiming to improve the haemocompatibility of invasive sensors for in vivo applications.

New polyurethane compositions able to bond high amounts of both albumin and heparin. Part I

In order to prepare polymers provided with better haemocompatibility with respect both to the coagulative cascade and to platelet aggregation and activation, we have synthesized new polyurethanes containing in the chain-extender [di(2-hydroxyethyl)hexadecylamine] both a long chain alkyl group (able to bond albumin) and a tertiary ammonium group able, after suitable quaternization reaction, to bind ionically significant amounts of heparin. The amounts of heparin and albumin bonded to the polymer films were determined spectrophotometrically. A biological in vitro evaluation of the heparinized and albuminized films was also carried out with respect to blood coagulation factors (by activated partial thromboplastin time measurements) and to platelet adhesion and activation (by platelet count and scanning electron microscopy examination). It was seen that the type of adsorption sequence for albumin and heparin, respectively, onto the various homo- and copolymer films, plays an important role on their biological properties; the possible mechanisms involved are also discussed on the basis of X-ray photoelectron spectroscopy and attenuated transmission reflectance evaluation of the polymer surfaces.

Biomaterials for blood-contacting applications

Consideration of biomaterials for blood-contacting applications should take into account blood-biomaterial interactions, factors influencing the blood response and evaluation procedures. Examination of blood-biomaterial interactions indicates that relevant features are protein adsorption, platelet reactions, intrinsic coagulation, fibrinolytic activity, erythrocytes, leucocytes and complement activation. Factors influencing the blood response to a biomaterial in clinical application are the biomaterial structure, the presence of an antithrombotic agent, the patient status as determined by the disease and drug therapy, and the nature of the application. Evaluation options for biomaterials are clinical, in vivo, ex vivo and in vitro, with ex vivo and in vitro procedures relevant for biomaterial development.

Heparin-coated cardiopulmonary bypass circuits

The indications for heparin-coated extracorporeal circuits cannot be defined or limited at present. Clinical investigation remains at an early stage of development. In situations where the risk of systemic anticoagulation is high, this technology would seem to hold great promise. Examples include extracorporeal lung assist and resuscitation from accidental hypothermia. Some have also suggested the use of heparin-coated circuits for percutaneous bypass in cardiopulmonary resuscitation. A significant advantage might also accrue in noncardiac surgical procedures requiring cardiopulmonary bypass, such as complex cerebral aneurysm or arteriovenous malformation resections, resections of the tracheal carina, or bilateral lung transplantations. Its role in routine cardiac surgical procedures remains uncertain, but the work of von Segesser et al suggests a need for continued investigation in that setting using reduced levels of systemic anticoagulation. That endeavor will be greatly assisted by the recent development of heparin-coated cardiotomy reservoirs. Although heparin-coated circuits have been safely used for extracorporeal lung assist with little or no systemic anticoagulation, prospective studies are clearly needed to determine if this approach is advantageous, and it would seem appropriate to develop heparin coating for silicone-based membrane oxygenators.

The endothelium: a key to the future

The vascular endothelium is a complex modulator of a variety of biological systems and may well be the key to definitive success in the treatment of cardiovascular disorders. Surgically-induced endothelial injury may occur preoperatively during cardiac catheterization and intraoperatively from mechanical manipulation, ischemia, hypothermia, and exposure to cardioplegic solutions. The normal endothelium is antithrombogenic and yet promotes platelet aggregation and coagulation if injured. Vasospasm, occlusive intimal hyperplasia, and accelerated arteriosclerosis can also all occur as a result of endothelial injury. Furthermore, endothelial injury is harmful even in the absence of disruption of its monolayer integrity. Thus, preservation of the endothelium should be an additional objective for all cardiovascular surgeons. Synthetic vascular grafts, cardiac valves, and artificial ventricles do not spontaneously endothelialize and thus usually require some form of anticoagulation to maintain patency. Hence, endothelialization of prosthetic implants became an attractive concept. A number of different methods of obtaining an endothelial lining of prosthetic material has since been developed; these include facilitated endothelial cell migration, and endothelial cell seeding by using either venous or microvascular endothelial cells. Manipulating the endothelium might well provide the next major advancement for therapeutic and preventive measures for cardiovascular disease.

Ultrastructure of cells cultured onto various intraocular lens materials

The response of three cell types (human fibroblasts, monocytes, and platelets), cultured or seeded onto different intraocular lens materials, was analyzed by ultrastructural examination. The materials considered were poly(methyl methacrylate) (PMMA), heparin surface-modified PMMA, plasma-treated PMMA, and hydrogel. Significant differences in density and distribution of the cultured cells were demonstrated among these materials. The ultrastructure of the cells appeared to be normal, except in one case. Disorganization of the points of focal contact and of the cytoskeletal elements was found in the fibroblasts cultured onto all materials except PMMA. Morphological evidence of cell activation was observed for some materials, but this requires confirmation by more specific immunocytochemical tests.

Inhibition of platelet and red blood cell accumulation on damaged arterial surfaces with albumin pretreatment

Damaged arterial surfaces initiate platelet accumulation which leads to thrombus formation. On artificial surfaces, albumin pretreatment inhibits platelet deposition. To investigate albumin pretreatment on damaged vessel surfaces, 16 carotid arteries were obtained from 8 anesthetized dogs (11-15 kg). Each artery was divided into 2 segments. Each segment was mounted in a perfusion system, distended to 100 mmHg, and the middle section damaged. One segment was perfused with Tyrodes solution plus bovine albumin (5 g/100 ml), while the other segment was perfused only with Tyrodes solution. After 120 mins, both segments were perfused with whole citrated blood containing Indium-111 labeled platelets. Without albumin pretreatment, the proximal section contained 11 +/- 8 (X +/- SEM) percent of total blood radioactivity, while the damaged section contained 53 +/- 11 percent (p less than 0.01). Albumin pretreatment significantly reduced platelet deposition in the damaged section (53 +/- 11 versus 9 +/- 6 percent, p less than 0.01). Further, with albumin pretreatment the radioactive counts in the damaged section were not significantly different from the nondamaged proximal section (9 +/- 6 vs 8 +/- 7 percent, p greater than .8). Quantitative examination of the scanning electron micrographs demonstrated significantly more platelet and red blood cell coverage of the damaged segments (60 +/- 12.8 percent) than of the albumin treated segments (12.9 +/- 5 percent). In four additional experiments, we pretreated arterial segments with albumin for varying time intervals. After 15, 30 and 60 mins of albumin pretreatment, each artery was perfused with radiolabeled platelets and whole blood for 5 mins at 100 mmHg perfusion pressure. Radioactive evidence of platelet deposition on arterial segments treated with albumin for 15, 30, and 60 minutes was also significantly less than control (p less than .05). Beneficial effects of albumin were apparent up to 30 mins of blood flow at 100 mm Hg. Our results suggest that albumin may inhibit platelet and red blood cell deposition on damaged arteries. This could be an adjunct therapy for vessel preservation during artery bypass procedures.

In vitro platelet interactions with a heparin-polyvinyl alcohol hydrogel

No difference in in vitro platelet reactivity was found between an immobilized heparin containing hydrogel (heparin-PVA) and the hydrogel without heparin (PVA), in a variety of experimental assays. There was no significant difference between the heparin-PVA and PVA coated polyethylene tubing in the number of 51Cr-labeled platelets, the extent of 14C serotonin release by the adherent platelets or in the degree of platelet count decrease after 1 h exposure to citrated canine whole blood in a Chandler loop system. Furthermore, adhesion and release values were lower than those observed with the uncoated polyethylene tubing (e.g., 9.3 +/- 4.3 plt/10(3) microns 2 on PVA; 18.3 +/- 4.6 plt/10(3) microns 2 on polyethylene). There was also no significant difference between heparin-PVA and PVA in bead column retention values with canine blood and with the previously reported washed human platelet adhesion/release values. Thus there appears to be no effect of the immobilized heparin by itself on the in vitro interactions of PVA with platelets, with the reactivity towards platelets dominated by that of the underlying substrate (i.e., PVA).

Effect of heparin-PVA hydrogel on platelets in a chronic canine arterio-venous shunt

Polyvinyl alcohol (PVA) hydrogel, with or without heparin, was reactive towards canine platelets in a chronic arteriovenous shunt as demonstrated by an increase in platelet regeneration time, a systemic decrease in platelet count and transient decrease in platelet serotonin content. Immobilized heparin (heparin-PVA) had no effect whereas unmodified polyethylene was found to be unreactive despite similar levels of platelet deposition as measured by SEM and a higher in vitro reactivity (J. Biomed. Mater. Res., this issue). Twenty-centimeter lengths of hydrogel coated polyethylene tubing were inserted between the arterial and venous portions of the shunt and left in place for 4-6 days, without the complicating artifacts of anticoagulation, anesthesia, or surgical intervention. Regeneration time was measured as the return to normal platelet cyclooxygenase (co) activity after a single 240-mg dose of aspirin, with co activity measured in vitro as malondialdehyde production. Although measuring new platelet production, regeneration time is an indirect measure of platelet consumption, so that the reduced regeneration time seen here was presumed to reflect enhanced material associated consumption and thromboembolism. Like other hydrogels, PVA does not appear to be "thromboadherent" but it does appear thrombogenic. Immobilized heparin had no additional effect, presumably because the platelet response was dominated by the reactivity of the underlying substrate.

Platelet adhesion onto protein-coated and uncoated polyetherurethaneurea having tertiary amino groups in the substituents and its derivatives

Interactions of platelet with novel polyetherurethaneurea and its heparinized derivative were investigated. Platelet adhesion onto the material and release of serotonin or adenosine phosphate from platelet-rich plasma (PRP) were suppressed by an introduction of amino groups to polyetherurethaneurea, by quaternization of the polymer, and further by heparinization of the polymer. When the material was precoated with one of major plasma proteins and the protein-coated materials were taken to contact with washed platelet suspension (WP), the dependence of platelet adhesion and activation on the properties of polymers was different from that observed for PRP interaction. Platelet adhesion and activation were promoted according to the nature of coating proteins in the order albumin less than gamma-globulin less than fibrinogen and with increasing degree of denaturation of coating proteins. When the polymer materials were coated with proteins by immersing in aqueous solution containing two kinds of plasma proteins, adhesion behaviors of platelet were similar to those observed for PRP-uncoated material interaction. These experimental facts indicate that the selectivity of platelet for protein-coated material cannot be assessed by the interaction of WP with materials coated with a single kind of protein. It was concluded that material surface to which albumin is selectively adsorbed without denaturation does not stimulate adhering platelets for release reactions.

Antithrombogenic heparin-bound polyurethanes

Many kinds of heparin-bound polyurethanes have been developed. Polyurethanes are a family of elastomers displaying better blood-compatibility than other polymeric materials. It is useful to modify this material by heparinization. Several approaches to heparinization have been devised: 1) a general method of heparinization, applicable to all polymeric materials, 2) a heparinization method specific to polyurethanes, and 3) the design of heparinizable polyurethane derivatives. These three approaches are first explained in detail. Then, the antithrombogenic mechanism of the heparinized polymers is discussed. Finally, the interactions of the heparinized polymers with blood coagulation factors, plasma proteins, and platelets are discussed.

A kinetic study on the effects of anticoagulants on the interaction of fibrinogen and thrombin

The inhibitory effect of heparin and antithrombin III (AT) on the interaction of fibrinogen and thrombin was investigated in preference to studies on heparinizing devices. The turbidity was measured kinetically as a measure of the concentration of fibrin polymer formed in the system. It was found that AT did not act on fibrinogen but, rather, on thrombin, and the main role of heparin is to accelerate the AT-thrombin reaction. On the other hand, dextran sulfate (DSc) did not accelerate the AT-thrombin reaction. When heparin and AT were incubated with thrombin, inhibition did not depend on the mixing order but on the incubation time. Thus, a ternary complex of heparin, AT, and thrombin was supposed to form for the inhibition. The reaction of heparin with fibrinogen and thrombin in the presence of AT was well-explained by assuming a Freundlich-type adsorption of heparin analogous with the reaction of heparin with fibrinogen.

Adsorption of plasma proteins to the derivatives of polyetherurethaneurea carrying tertiary amino groups in the side chains

Polyetherurethaneureas carrying tertiary amino groups in the side chains were synthesized, quaternized, and heparinized. The adsorption of plasma proteins to the polyurethane derivatives was investigated using Fourier-transform infrared, surface fluorescence, ultraviolet, and circular dichroism spectroscopy. Bovine gamma-globulin and bovine plasma fibrinogen were easily adsorbed to hydrophobic polyurethanes and denatured. It was found that the beta structure was generated during the irreversible conformational change of the proteins on adsorption to hydrophobic polyurethane materials. On the other hand, bovine serum albumin was easily adsorbed to hydrophilic quaternized and heparinized polyurethanes without a serious conformational change. The conclusion was drawn that a polymer material that selectively adsorbs bovine serum albumin in a native state could be antithrombogenic.

Fibrinogen adsorption and platelet adhesion at the surface of modified polypropylene glycol/polysiloxane networks

The protein film adsorbed at an artificial surface ultimately affects platelet adhesion and activation. This study examines the role of fibrinogen in platelet adhesion at the surface of crosslinked polypropylene glycol (PPG)/polyglycidoxy propyl methyl siloxane (PGPMS) networks which contain polyethylene glycol monomethyl ether (PEGME) chains. These crosslinked networks were produced by reacting the epoxy groups of PGPMS with the hydroxyl groups of the polyethers. PEGME chains were attached covalently to the network at only one end while PPG chains were attached at both ends. The incorporation of PEGME resulted in a substantial reduction in fibrinogen adsorption as compared to the model network (PPG + PGPMS only), but the expected concomitant decrease in platelet adhesion was not observed.

Why small caliber vascular grafts fail: a review of clinical and experimental experience and the significance of the interaction of blood at the interface

The results using polytetrafluoroethylene (PTFE) and tanned human umbilical cord vein (HUV) grafts are discussed. These two grafts perform well for reconstructions above the knee and the results are similar to the autogenous saphenous vein (ASV) grafts in several series; however, in more distal reconstructions the PTFE and HUV are far inferior to ASV grafts. The factors responsible for graft failure including the events which take place at the blood interface are reviewed. New material surfaces under investigation such as degradable grafts, heparin-bonded surfaces, and endothelial-seeded fabrics are also addressed.

Effect of heparin bonding on catheter-induced fibrin formation and platelet activation

Pathologic and experimental evidence indicates that platelet activation and fibrin formation contribute to the pathogenesis of angina pectoris, coronary vasospasm and myocardial infarction. Detection of localized intravascular platelet activation and fibrin formation in vivo by selective blood sampling requires catheters that do not induce coagulation ex vivo. We studied the effect of heparin bonding of catheter surfaces on activation of the coagulation system by cardiovascular catheters. Woven Dacron, polyvinylchloride, and polyurethane catheters were tested and compared with identical catheters with heparin-bonded surfaces in 47 patients undergoing percutaneous cardiac catheterization. Platelet activation was measured by radioimmunoassay of plasma platelet factor 4 (PF4), beta-thromboglobulin (BTG), and thromboxane B2 (TXB2) in blood samples withdrawn through catheters, and fibrin formation was assessed by determination of fibrinopeptide A (FPA) levels. In blood samples collected through conventional catheters, FPA, PF4, BTG, and TXB2 levels were markedly elevated; blood sampling through heparin-bonded catheters had no significant effect on FPA, PF4, BTG, or TXB2 levels. Scanning electron microscopy disclosed extensive platelet aggregates and fibrin strands adherent to the surface of conventional catheters but not to heparin-bonded catheter surfaces. This study demonstrates that (1) collection of blood samples through cardiovascular catheters causes artifactual elevation of FPA, PF4, BTG, and TXB2 levels, and (2) heparin-bonded catheter surfaces effectively prevent catheter-induced platelet alpha-granule release and fibrin formation on catheter surfaces. Heparin-bonded catheters will facilitate investigation of the role of intravascular coagulation in coronary artery disease by eliminating catheter-induced fibrin formation and platelet activation.

Extracorporeal left ventricular assistance with prostacyclin and heparinized centrifugal pump

A temporary left ventricular assist system utilizing an improved left atrial catheter and centrifugal pump was developed and tried in 22 anesthetized sheep to test the hypothesis that prostacyclin (PGI2) and ionically bound heparin-coated surfaces could prevent thrombosis in this perfusion system without inhibiting soluble, circulating coagulation factors. Sheep were perfused at 53.6 ml/kg/min (standard error, 1.5) from left atrium to aorta for two hours. The pump maintained flow at left atrial pressures of 3 to 4 mm Hg. As expected, systemic heparin inhibited coagulation, mildly activated platelets, and prevented thrombosis in uncoated perfusion circuits and wounds. Infusion of PGI2 (30 ng/kg)min) without systemic heparin or heparin-bonded extracorporeal surfaces prevented platelet activation and did not alter coagulation measurements; however, bleeding times increased and thrombi formed in every circuit. When heparin was ionically bound to all extracorporeal surfaces, infusion of PGI2 completely prevented thrombosis within the circuit, inhibited platelet activation, and did not alter coagulation measurements. Blood spontaneously clotted in three of six thoracotomy wounds during perfusion. When PGI2 infusion was stopped, heparin-coated surfaces alone failed to prevent thrombosis within the system in 3 of 5 animals. The combination of PGI2 infusion and heparin-coated extracorporeal surfaces prevents thrombosis within the perfusion circuit without inhibiting soluble coagulation factors. This method, using the assist system, overcomes many of the implementation and bleeding problems associated with other temporary left ventricular assist devices.

On the mechanism of enhanced thromboresistance of polymeric materials in the presence of heparin

Polymeric materials with covalently immobilized heparin were shown to display enhanced thromboresistance in vitro and in vivo experiments. This property of heparin-containing polymers is due to the specific effect of immobilized heparin for every step of interaction of a polymer with blood. The presence of heparin substantially changes the character of adsorbed proteins on a polymer surface and the number of adhered platelets. Thromboresistance enhancement is largely carried out by the interaction of immobilized heparin with plasma proteins which is accompanied by the decrease in total blood coagulant activity, by the decrease in fibrinogen, prothrombin and thrombin concentrations, and by the supression of fibrinstabilizing factor activity. The free heparin content in blood is not changed. It was found that immobilized heparin forms complexes with fibrinogen, thrombin and plasmin that produce lytic action on unstabilized fibrin.

The influence of heparinized polymers on the retention of platelets aggregability during storage

The change in aggregability of the platelets stored in the storage tube fabricated from a newly developed heparinized hydrophilic polymer (H-RSD) has been studied in comparison with plasticized poly(vinyl chloride) (PVC) which is widely used for blood bags. Rabbit blood was directly withdrawn into the storage tube containing an anticoagulant from the carotid. Then the tube was mechanically sealed with screw cocks and centrifugated to prepare platelet-rich plasma (PRP) in the tube and again mechanically clamped to separate the PRP from the residual precipitate. The PRP was stored in situ in the storage tube at room temperature under agitation. During storage, the change in the aggregability of the PRP induced by adenosine diphosphate (ADP) was studied and the morphological change in the platelets adhered onto the inner surface of the storage tube was observed by scanning electron microscopy. In the H-RSD tube, the aggregability was maintained during two-day storage, while in the PVC tube, the aggregability was completely lost after one-day storage. The scanning electron microscopic studies demonstrated that the reduction in the aggregability of the stored platelets is closely correlated with the morphological deformation of the platelets adhered onto the surface of the storage tube.

Adsorption of proteins from plasma to a series of hydrophilic-hydrophobic copolymers. I. Analysis with the in situ radioiodination technique

The adsorption of proteins affects cellular interactions with foreign surfaces and thus plays an important role in determining the biocompatibility of implants. Previous studies have indicated differences in the affinity of various proteins for a given polymer, and differences in the affinity of fibrinogen for a series of polymers varying in hydrophilicity. These studies suggest that differences in the composition of the protein layer adsorbed to polymers from plasma might exist. To examine this hypothesis, the proteins adsorbed from plasma to a series of polymers varying in hydrophilicity were analyzed with the iodogram technique. Copolymers of hydroxyethyl methacrylate and ethyl methacrylate made by the radiation grafting technique were exposed to plasma for 0.5 or 150 min. The adsorbed proteins were iodinated, eluted with SDS, and separated with polyacrylamide gel electrophoresis. Fibrinogen, immunoglobulin G, hemoglobin, and a peak tentatively ascribed to prothrombin were the major proteins detected. Very little iodine was incorporated into adsorbed albumin, even though it was shown to be present by a separate experiment using dye binding. The fraction of total radioactivity associated with each of nine proteins was found to vary markedly and systematically among the surfaces. The distribution of radioactivity into the proteins was very different on 0.5 and 150-min plasma exposed polymers. The results reflect both compositional differences in the adsorbed protein layer on the polymers and differences in the accessibility of proteins to the labeling reagent in the adsorbed state. Differences in the organization of the adsorbed protein layer may play a key role in determining whether cell surface receptors can come in contact with the specific plasma protein able to further stimulate the cell.

Evaluation of plasma polymerized hexamethylcyclotrisiloxane biomaterials towards adhesion of canine platelets and leucocytes

Silicone coated Celgard-2400 and Silastic membranes were prepared by plasma polymerization of hexamethylcyclotrisiloxane. The adhesion of canine platelets and leucocytes was tested by passing whole blood from the anaesthetized mongrel dog in an ex-vivo shunt system. The silicone control Celgard and silicone coated Silastic membranes had fewer platelets and fewer leucocytes compared to those on the control Silastic membranes. Furthermore, these blood cells underwent fewer morphological changes on the silicone coated Celgard and Silastic compared to those on the control Silastic. From these observations the silicone coated biomaterials were judged to be better than the Silastic as far as the adhesion of platelets and leucocytes are concerned.

Patency of heparinized SBS shunts at high shear rates

The patency of 50 cm long, 1.7 mm ID heparin-polyvinyl alcohol (PVA) coated SBS arterio-venous shunts in pigs at shear rates greater than 1000 s-1 was found to be not different from that of identical shunts coated with PVA but without heparin. This was attributed to the absence of any measureable effect of surface bound heparin on platelet related thrombus formation at high shear rates. On the other hand, platelet adhesion values determined in the absence of flow by the open static method decreased with increasing heparin content in heparin-PVA films. The low overall patency (average life of 170 minutes) of the PVA coated SBS shunts (with and without heparin) was presumed to be related to the absence of circulating heparin during surgery and the consequent presence of tissue thromboplastin or cellular debris during the immediate postoperative period. Alternative protocols are needed to test heparinized materials at low shear rates in the absence of systemic heparin to properly assess the potential thrombo-resistance of such materials.

In vivo assessment in sheep of thromboresistant materials by determination of platelet survival

The thromboresistance of 13 potentially blood-compatible polymers was assessed in sheep by determining survival of 51Cr-labeled platelets. Polymer tubing (120-150 cm x 2.0-2.3 mm i.d.) coiled around the neck was incorporated into the circulation through silicone rubber connectors as a carotid artery-external jugular vein shunt. The mean platelet half-life in control animals ("shunt control") was 78.2 +/- 2.8 (SEM) hours. Eleven of the 13 polymers tested significantly shortened platelet half-life. Polyvinyl chloride (T1/2 = 45.4 +/- 3.0 hours), polyperfluoro ethylene (T1/2 = 47.0 +/-1.6 hours), and a polymethylacrylate (PMA)/acrilonitrile copolymer (T1/2 = 50.7 +/- 7.0 hours) produced the greatest shortening. Only silica-free polydimethyl siloxane (T1/2 = 74.7 +/- 4.9 hours) and PMA (T1/2 = 81.5 +/- 3.4 hours) were indistinguishable from shunt controls. Pretreatment of PMA tubing with autologous plasma in a paired trial significantly increased platelet half-life (P less than 0.05 vs. untreated PMA). This system offers an economical, reproducible, sensitive, and biologically relevant method for assessment of the reactivity of artificial surfaces with platelets.

Heparinized styrene-butadiene-styrene elastomers

A heparinized high-strength elastomer has been developed which is potentially useful as a nonthrombogenic vascular prosthesis. A surface hydroxylated styrene-butadiene-styrene (SBS) block copolymer with at least 40% extent of reaction after glow-discharge cleaning was coated with a 20% acetylated polyvinyl alcohol/heparin mixture containing glutaraldehyde and magnesium chloride. After curing at 80 degrees C for 100 min, the polyvinyl alcohol, heparin, and hydroxylated SBS were covalently bound to each other by acetal bridges. The effects of the various substrate and coating parameters were optimized to achieve very strong adhesion between the coating layer and the surface hydroxylated SBS. Heparin was not leached from the surface of the new material using 3M saline at pH 7.4 despite a detection limit of 10(-5) micrograms heparin/cm2 min. Prolonged partial thromboplastin times of greater than 1200 sec were observed (control: PTT = 120 sec). Preliminary ex vivo testing using a simple arteriovenous shunt in the leg of a rabbit showed good thromboresistance. The heparinized SBS shunt chamber remained patent for more than two hours without desorption of heparin. It was concluded that surface hydroxylated SBS heparinized by acetal coupling owed its thromboresistance to the heparin covalently bound to the surface and not to a microenvironment of heparin in solution at the blood/material interface.

Influence of antiplatelet drugs on platelet-surface interactions

Platelet aggregates are important in the thromboembolic complications of prosthetic devices, and drugs that alter platelet function have shown promise in clinical trials. Results with these drugs have increased insight into the interaction of platelets with artificial materials, particularly when the clinical experience has been correlated with the results of in vitro models. In a bead column/surface contact model, the characteristic interactions of platelets with artificial surfaces resemble effects of adding thrombin ADP to platelet-rich plasma. Anti-inflammatory agents and other antiplatelet drugs inhibit these reactions. Results in an in vivo model, survival of 51 Cr-labeled platelets in sheep bearing arteriovenous shunts of test materials, correlate systems indicate that the initial events upon contact of a surface with plasma proteins persistently influence the long-term behavior of that surface toward blood. A review of clinical studies discusses the effect of antiplatelet drugs on platelet survival and also on thrombotic complications of heart valve replacement and other conditions employing prosthetic devices.

In vivo interactions between novel filler free silicone rubber and blood

To evaluate the thrombogenicity of the novel filler free silicone rubber (FFSR) prepared in our laboratory, its interactions with blood were studied. The test samples (FFSR) along with control Silastic samples were placed in an extracorporeal shunt and primed with sterilized normal saline. The blood from an anaesthetized and systemically heparinized dog was passed over these samples for predetermined time intervals. After washing, fixing, etc., the platelets adhering to the samples were counted under light microscopy. To study the morphological changes of the platelets adhering to the samples, they were examined under scanning electron microscope. The number of platelets adhering to the FFSR samples was very small compared to the Silastic samples. For example, when the blood was passed over the samples for 10 min the number of platelets sticking per 0.14 mm2 surface area was 10 for FFSR samples compared to 380 for Silastic. Furthermore, there were no leukocytes on FFSR samples compared to 10 on Silastic. From these studies, the novel filler free silicone rubber prepared in our laboratory was judged to be more compatible with formed elements of blood compared to the Silastic material.