Effects of new polymer-coated extracorporeal circuits on biocompatibility during cardiopulmonary bypass

Flow diverter surface modifications for aneurysm treatment: A review of the mechanisms and data behind existing technologies

Flow diversion (FD) has become a mainstay treatment for large wide-necked aneurysms. Despite excellent safety and efficacy, the risk of thromboembolic complications necessitates the use of dual antiplatelet therapy (DAPT). The use of DAPT makes hemorrhagic complications of stenting carry high morbidity and mortality. Additionally, DAPT usage carries a risk of "nuisance" complications that do not directly impact intracranial circulation but need to be managed nonetheless. To circumvent this issue, the most recent generation of flow diverters have undergone surface modification with various compounds to confer blood compatibility to limit clotting and thrombosis. While these newer generation flow diverters are marketed to enhance ease of deployment, the goal is to eventually facilitate single antiplatelet use with flow diverter treatment. This generation of FDs have potential to expand indications beyond unruptured wide-necked aneurysms to include ruptured intracranial aneurysms without the necessity of DAPT. Currently, no comprehensive review details the molecular mechanisms and pre-clinical and clinical data on these modifications. We seek to fill this gap in the literature by consolidating information on the coating technology for four major FDs currently in clinical use-PipelineTM Flex and Vantage Shield TechnologyTM, FREDTMX, p48/64 hydrophilic coating, and Acandis Dervio® 2heal-to serve as a reference guide in neurointerventional aneurysm treatment. Although the Balt silkTM was one of the first FDs, it is uncoated, thus we will not cover this device in our review. A literature review was performed to obtain information on each coating technology for the major flow diverters currently on the market using international databases (PUBMED, Embase, Medline, Google Scholar). The search criteria used the keywords for each coating technology of interest "phosphorylcholine," "poly 2-methoxyethyl acrylate," "hydrophilic polymer coating," and "fibrin-heparin" Keywords related to the device names "Pipeline Shield," "Pipeline Shield with Flex Technology," "FRED," "FREDX," "p64," "p64-HPC," "Derivo 2heal" were also used. Studies that detailed the mechanism of action of the coating, any pre-clinical studies with surface-modified intravascular devices, and any clinical retrospective series, prospective series, or randomized clinical trials with surface-modified devices for aneurysm treatment were included.

Bio-inspired hemocompatible surface modifications for biomedical applications

When blood first encounters the artificial surface of a medical device, a complex series of biochemical reactions is triggered, potentially resulting in clinical complications such as embolism/occlusion, inflammation, or device failure. Preventing thrombus formation on the surface of blood-contacting devices is crucial for maintaining device functionality and patient safety. As the number of patients reliant on blood-contacting devices continues to grow, minimizing the risk associated with these devices is vital towards lowering healthcare-associated morbidity and mortality. The current standard clinical practice primarily requires the systemic administration of anticoagulants such as heparin, which can result in serious complications such as post-operative bleeding and heparin-induced thrombocytopenia (HIT). Due to these complications, the administration of antithrombotic agents remains one of the leading causes of clinical drug-related deaths. To reduce the side effects spurred by systemic anticoagulation, researchers have been inspired by the hemocompatibility exhibited by natural phenomena, and thus have begun developing medical-grade surfaces which aim to exhibit total hemocompatibility via biomimicry. This review paper aims to address different bio-inspired surface modifications that increase hemocompatibility, discuss the limitations of each method, and explore the future direction for hemocompatible surface research.

Inflammation and Oxidative Stress in the Context of Extracorporeal Cardiac and Pulmonary Support

Extracorporeal circulation (ECC) systems, including cardiopulmonary bypass, and extracorporeal membrane oxygenation have been an irreplaceable part of the cardiothoracic surgeries, and treatment of critically ill patients with respiratory and/or cardiac failure for more than half a century. During the recent decades, the concept of extracorporeal circulation has been extended to isolated machine perfusion of the donor organ including thoracic organs (ex-situ organ perfusion, ESOP) as a method for dynamic, semi-physiologic preservation, and potential improvement of the donor organs. The extracorporeal life support systems (ECLS) have been lifesaving and facilitating complex cardiothoracic surgeries, and the ESOP technology has the potential to increase the number of the transplantable donor organs, and to improve the outcomes of transplantation. However, these artificial circulation systems in general have been associated with activation of the inflammatory and oxidative stress responses in patients and/or in the exposed tissues and organs. The activation of these responses can negatively affect patient outcomes in ECLS, and may as well jeopardize the reliability of the organ viability assessment, and the outcomes of thoracic organ preservation and transplantation in ESOP. Both ECLS and ESOP consist of artificial circuit materials and components, which play a key role in the induction of these responses. However, while ECLS can lead to systemic inflammatory and oxidative stress responses negatively affecting various organs/systems of the body, in ESOP, the absence of the organs that play an important role in oxidant scavenging/antioxidative replenishment of the body, such as liver, may make the perfused organ more susceptible to inflammation and oxidative stress during extracorporeal circulation. In the present manuscript, we will review the activation of the inflammatory and oxidative stress responses during ECLP and ESOP, mechanisms involved, clinical implications, and the interventions for attenuating these responses in ECC.

Modification of a Polymer Surface by Partial Swelling Using Nonsolvents

Surface modification without changing the physical properties in the bulk is of pivotal importance for the development of polymers as devices. We recently proposed a simple surface functionalization method for polymer films by partial swelling using a nonsolvent and demonstrated the incorporation of poly(2-methoxyethyl acrylate) (PMEA), which has an excellent antibiofouling ability, only into the outermost region of a poly(methyl methacrylate) (PMMA) film. We here extend this technology to another versatile polymer, polystyrene (PS). In this case, PS and PMEA have different solubility parameters making it difficult to select a suitable solvent, which is a nonsolvent for PS and a good solvent for PMEA, unlike the combination of PMMA with PMEA. Thus, such a solvent was first sought by examining the swelling behavior of PS films in contact with various alcohols. Once a mixed solvent of methanol/1-butanol (50/50 (v/v)) was chosen, PMEA chains could be successfully incorporated at the outermost region of the PS film. Atomic force microscopy in conjunction with neutron reflectivity revealed that chains of PMEA incorporated in the PS surface region were well swollen in water. This leads to an excellent ability to suppress the adhesion of platelets on the PS film.

Hematologic concerns in extracorporeal membrane oxygenation

This ISTH "State of the Art" review aims to critically evaluate the hematologic considerations and complications in extracorporeal membrane oxygenation (ECMO). ECMO is experiencing a rapid increase in clinical use, but many questions remain unanswered. The existing literature does not address or explicitly state many pertinent details that may influence hematologic complications and, ultimately, patient outcomes. This review aims to broadly introduce modern ECMO practices, circuit designs, circuit materials, hematologic complications, transfusion-related considerations, age- and size-related differences, and considerations for choosing outcome measures. Relevant studies from the 2019 ISTH Congress in Melbourne, which further advanced our understanding of these processes, will also be highlighted.

The peripheral cannulas in extracorporeal life support

Femoral cannulation is a minimally invasive method which is an alternative method for central cannulation. This review focuses on the parameters and features of the available peripheral cannulas. Nowadays there exist many peripheral cannulas in a variety of sizes, configurations and lengths to meet the specific needs of the patients. Modern cannulas are strong, thin-walled and one piece reinforced constructions. Furthermore, modern cannulas are manufactured from a biocompatible material and surface coatings are applied to the cannulas to reduce the activation of the clotting. When peripheral cannulas are applied, bleeding, thrombosis and hemolysis are the most common complications.

Vascular endothelium damage from catheter-induced mechanical stimulation causes catheter sleeve formation in a rabbit model

BACKGROUND

Intravenous catheters are widely used but are often removed due to complications associated with catheter sleeve formation. A catheter sleeve can develop from a thrombus, and catheter-induced vascular endothelium damage may be a critical factor for thrombus formation. We investigated the effect of catheter-induced mechanical stimulation on venous endothelial cells and catheter sleeve formation and the efficacy of anti-thrombogenic technology for preventing catheter sleeve formation in vivo.

METHODS

We surgically implanted poly(2-methoxyethyl acrylate)-coated and uncoated catheters with and without a stylet into the right external jugular vein of a rabbit model for 14 days. Catheter sleeve formation and the ratio of residual venous endothelial cells were compared using histological examination and immunostaining with an anti-CD31 antibody, respectively.

RESULTS

Stiffening an uncoated catheter with a stylet induced catheter sleeve formation along more than two-thirds of the length of the catheter. The ratios of residual venous endothelial cells at the tip of uncoated catheters with and without a stylet were 3% and 36%, respectively. While poly(2-methoxyethyl acrylate) coating also reduced the ratio of venous endothelial cells at the tip of the stiffened catheter (12%), it prevented external thrombus and catheter sleeve formation.

CONCLUSION

High levels of mechanical stimulation can affect catheter-related thrombosis and promote catheter sleeve formation, and anti-thrombogenic technology such as a poly(2-methoxyethyl acrylate) coating reduces thrombus formation and can prevent catheter sleeve formation on stiffened catheters. Further studies are required to determine the maximum degree of venous endothelial cell damage before catheter sleeve formation and to compare other anti-thrombogenic technologies with poly(2-methoxyethyl acrylate) for preventing catheter sleeve formation.

Novel Surfaces in Extracorporeal Membrane Oxygenation Circuits

The balance between systemic anticoagulation and clotting is challenging. In normal hemostasis, the endothelium regulates the balance between anticoagulant and prothrombotic systems. It becomes particularly more challenging to maintain this physiologic hemostasis when we are faced with extracorporeal life support therapies, where blood is continuously in contact with a foreign extracorporeal circuit surface predisposing a prothrombotic state. The blood-surface interaction during extracorporeal life support therapies requires the use of systemic anticoagulation to decrease the risk of clotting. Unfractionated heparin is the most common anticoagulant agent widely used in this setting. New trends include the use of direct thrombin inhibitor agents for systemic anticoagulation; and surface modifications that aim to overcome the blood-biomaterial surface interaction by modifying the hydrophilicity or hydrophobicity of the polymer surface; and coating the circuit with substances that will mimic the endothelium or anti-thrombotic agents. To improve hemocompatibility in an extracorporeal circuit, replication of the anti-thrombotic and anti-inflammatory properties of the endothelium is ideal. Surface modifications can be classified into three major groups: biomimetic surfaces (heparin, nitric oxide, and direct thrombin inhibitors); biopassive surfaces [phosphorylcholine, albumin, and poly- 2-methoxyethylacrylate]; and endothelialization of blood contacting surface. The focus of this paper will be to review both present and future novel surface modifications that can obviate the need for systemic anticoagulation during extracorporeal life support therapies.

Polymer-coated cardiopulmonary bypass circuit attenuates upregulation of both proteases/protease inhibitors and platelet degranulation in pigs

Introduction:

Interaction of blood with a cardiopulmonary bypass (CPB) circuit activates the coagulation-fibrinolysis, complement and kinin-kallikrein systems that are mainly supported by proteases and their inhibitors.

Methods:

Biocompatibility of a new polymer-coated (SEC-coated) CPB circuit was globally evaluated and compared with that of a non-coated CPB circuit by quantitative proteomics, using isobaric tags for relative and absolute quantification labeling tandem mass spectrometry. Plasma samples were taken three times (5 min after initiation of CPB, just before declamping and just before termination of CPB) in 12 pigs undergoing 120 min of CPB with the SEC-coated CPB circuit or a non-coated CPB circuit (n = 6, respectively).

Results:

Identified were 224 proteins having high protein confidence (>99%) and false discovery rate (FDR) <5%. Among these proteins, there were 25 significantly upregulated proteins in the non-coated CPB group compared to those in the SEC-coated CPB group. Dominant protein functions were platelet degranulation, serine-type (cysteine-type) endopeptidase inhibitor activity and serine-type endopeptidase activity in the 25 proteins. Bioinformatics analysis similarly revealed upregulation of proteins belonging to platelet degranulation and negative regulation of endopeptidase activity in the non-coated CPB group; these upregulations were effectively attenuated in the SEC-coated CPB group.

Conclusion:

The new polymer (SEC)-coated CPB circuit effectively attenuated upregulation of proteins compared to the non-coated CPB circuit. These proteins were associated with both proteases/protease inhibitors and platelet degranulation.

Evaluation of a new condensed extra-corporeal circuit for cardiac surgery: a prospective randomized clinical pilot study

This prospective randomized clinical pilot study was conducted to evaluate a recently introduced reduced volume CPB system that is coated with the biopassive Xcoating™. Twenty-two patients undergoing coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB), either with a fully heparin-coated CPB circuit (control, n=11) or with an Xcoating™ coated condensed extra-corporeal circuit (CondECC, n=11), were included.

We examined activation of the complement system (C3bc and C4bc), activation of neutrophils (BPI), the acute phase response (interleukin (IL)-6, and acute phase proteins (LBP, AGP, and CRP)), myocardial tissue injury (troponin T), hemolysis (free hemoglobin (FHb)), and clinical outcome parameters. Preoperative risk profiles were identical for both patient groups. All patients went through the procedure without major complications and were discharged from the hospital. FHb and BPI levels at the end of pump support ( p <0.01) and at 15 min after the administration of protamine ( p <0.05) were significantly higher in the control group. In addition, FHb levels were still significantly elevated upon arrival on the cardiothoracic intensive care unit (CICU) in the control group ( p <0.05). C3bc and C4bc, acute phase proteins, IL-6, and troponin T concentrations, and clinical outcome variables were identical in both patient groups.

In conclusion, the evaluated condensed extracorporeal circuit is a flexible and multifunctional CPB sytem that offers safe procedures. Furthermore, the results indicate improved biocompatibility of this option for extracorporeal circulation.

Dynamics of a bioinert polymer in hydrated states by dielectric relaxation spectroscopy

The segmental dynamics of poly(2-methoxyethyl acrylate) at the water interface is extremely faster and comparable to the side chain motion.

Investigation of Blood Compatibility of PMEA Coated Extracorporeal Circuits

In this study, the blood compatibility of the PMEA-coated and uncoated hollow fibers was investigated using poly(2-methoxyethyl acrylate) PMEA-coated (X-coating, Terumo Corp., Japan) and uncoated (Capiox SX 18, Terumo Inc., Japan) oxygenators. Total protein, human serum albumin, fibrinogen, erythrocyte, leukocyte and platelets loss quantities were detected on blood samples taken in five different times during cardiopulmonarybypass (CPB) such as; baseline (T1), during CPB (T2), end of CPB (T3), after protamine injection (T4) and intensive care (T5). The average loss of fibrinogen for uncoated and PMEA-coated fiber surfaces was 1.34 and 0.25 g/L, respectively. After operation protein desorption assayfrom the PMEA-coated and uncoated fiber surfaces were examined, and significant protein desorption differences were found as 1.46 and 5.70 mg/dL, respectively. More platelet aggregation was observed for the uncoated fibers. Also for platelet loss quantities, significant differences were found as 116,000 and 36,000 cell/mm3,respectively,for uncoated and PMEA-coated fibers. Less bleeding was observed in the patients operated with oxygenator containing PMEA-coated fibers; more and longer postoperative haemorrhaging were observed when uncoated circuits have been used; fibrinogen losses caused longer blood clotting times. Differences in adsorbed protein quantities on hollow fiber surface and denaturation were examined by the aid of STM images, which showed that more proteins existed in the sample solution of uncoated fiber surfaces.

Stimuli-responsive poly(N-vinylcaprolactam-co-2-methoxyethyl acrylate) core–shell microgels: facile synthesis, modulation of surface properties and controlled internalisation into cells

Poly(N-vinylcaprolactam-co-2-methoxyethyl acrylate) core–shell microgels as imaging/diagnostic system.

A prospective randomized trial comparing the clinical effectiveness and biocompatibility of heparin-coated circuits and PMEA-coated circuits in pediatric cardiopulmonary bypass

OBJECT

We compared the clinical effectiveness and biocompatibility of poly-2-methoxyethyl acrylate (PMEA)-coated and heparin-coated cardiopulmonary bypass (CPB) circuits in a prospective pediatric trial.

METHODS

Infants randomly received heparin-coated (n=7) or PMEA-coated (n=7) circuits in elective pediatric cardiac surgery with CPB for ventricular septum defects. Clinical and hematologic variables, respiratory indices and hemodynamic changes were analyzed perioperatively.

RESULTS

Demographic and clinical variables were similar in both groups. Leukocyte counts were significantly lower 5 minutes after CPB in the PMEA group than the heparin group. Hemodynamic data showed that PMEA caused hypotension within 5 minutes of CPB. The respiratory index was significantly higher immediately after CPB and 1 hour after transfer to the intensive care unit (ICU) in the PMEA group, as were levels of C-reactive protein 24 hours after transfer to the ICU.

CONCLUSION

Our study shows that PMEA-coated circuits, unlike heparin-coated circuits, cause transient leukopenia during pediatric CPB and, perhaps, systemic inflammatory respiratory syndrome after pediatric CPB.

Antithrombogenic Properties of Amphiphilic Block Copolymer Coatings: Evaluation of Hemocompatibility Using Whole Blood

Antithrombogenicity is one of the most critical properties required for materials used in biomedical devices, particularly in devices that contact blood. The antithrombogenicity of surfaces coated with amphiphilic block copolymers composed of hydrophobic poly(2-methoxyethyl acrylate) (M) and hydrophilic poly(N,N-dimethylacrylamide) (D) segments was investigated using plasma protein and whole blood with regard to protein adsorption, thrombus formation, platelet activation, and clotting kinetics. Three types of block copolymers and a random copolymer were synthesized using one-pot reversible addition-fragmentation chain-transfer (RAFT) polymerization under conditions of high yield and high molecular weight. Triblock and 4-arm block copolymers with MDM and (MD)₄ architecture, respectively, showed good adhesion to both organic and inorganic substrates, including polyvinyl chloride (PVC) tubes, and the resulting coated surfaces showed superior protein repellency and hemocompatibility compared to the diblock or random copolymer coatings and noncoated control. In a Chandler-loop method with whole blood, PVC tubes coated with MDM and (MD)₄ showed improved thromboresistance and adsorption resistance to blood-derived proteins. This high hemocompatibility was also confirmed with human whole blood by thrombelastography (suppression of blood-clotting behavior in both intrinsic and extrinsic coagulation pathways) and platelet function analyses (significant reductions in the aggregation activity of platelets under two types of stimulation). The antithrombogenicity has been discussed based on the structural analyses of the MDM-coated surface. The results of this study will enable the development of more effective biomedical and analytical devices with excellent antithrombogenic characteristics by using a simple and environmentally friendly approach.

Biocompatibility of cardiopulmonary bypass circuit with new polymer Senko E-Ternal CoatingTM

Objective:

The aim of this study was to compare the biocompatibility of a new Senko E-Ternal coating (SEC) for cardiopulmonary bypass (CPB) circuits with the well-established poly-2-methoxyethyl acrylate (PMEA) coating.

Methods:

Forty patients undergoing aortic valve replacement were randomly assigned to either an SEC-coated group (n = 20) or a PMEA-coated group (n = 20). Clinical data and the following markers were analyzed: platelet count, platelet factor (PF) 4, fibrinogen, fibrinogen degradation products (FDPs), antithrombin III (AT III), thrombin-antithrombin complex (TAT), plasminogen, complement hemolytic activity (CH50), complement 3 (C3) and interleukin-6 (IL-6). Blood samples were obtained at five time points in both groups.

Results:

CPB time, aortic cross-clamp time and blood loss and transfusion were similar in both groups. There were no significant differences between the groups in terms of platelet count, PF4 and all coagulation and fibrinolytic parameters (FDP, AT III, TAT, and plasminogen) at any time points. Inflammatory markers (CH50, C3 and IL-6) were also similar in both groups at all time points.

Conclusions:

The SEC-coated circuit demonstrated equivalent biocompatibility to the PMEA-coated circuit. SEC-coated circuits are, therefore, favorably comparable to PMEA-coated circuits for clinical use in CPB.

Development and hemocompatibility testing of nitric oxide releasing polymers using a rabbit model of thrombogenicity

Hemocompatibility is the goal for any biomaterial contained in extracorporeal life supporting medical devices. The hallmarks for hemocompatibility include nonthrombogenicity, platelet preservation, and maintained platelet function. Both in vitro and in vivo assays testing for compatibility of the blood/biomaterial interface have been used over the last several decades to ascertain if the biomaterial used in medical tubing and devices will require systemic anticoagulation for viability. Over the last 50 years systemic anticoagulation with heparin has been the gold standard in maintaining effective extracorporeal life supporting. However, the biomaterial that maintains effective ECLS without the use of any systemic anticoagulant has remained elusive. In this review, the in vivo 4-h rabbit thrombogenicity model genesis will be described with emphasis on biomaterials that may require no systemic anticoagulation for extracorporeal life supporting longevity. These novel biomaterials may improve extracorporeal circulation hemocompatibility by preserving near resting physiology of the major blood components, the platelets and monocytes. The rabbit extracorporeal circulation model provides a complete assessment of biomaterial interactions with the intrinsic coagulation players, the circulating platelet and monocytes. This total picture of blood/biomaterial interaction suggests that this rabbit thrombogenicity model could provide a standardization for biomaterial hemocompatibility testing.

Currently available biomaterials for use in cardiopulmonary bypass

Cardiopulmonary bypass (CPB) represents one of the most important technical innovations in healthcare history, yet the systemic responses to CPB remain a fundamentally unresolved problem. Study of the blood-biomaterial interaction and development of biocompatible materials is intimately related to efforts to optimize patient outcome following CPB. This article reviews the design innovations in biomaterial surfaces that have been introduced into clinical practice in an attempt to ameliorate the detrimental consequences of CPB, contrasting the actual clinical improvements and patient benefits achieved against those predicted on the basis of theory and in vitro testing. Some discussion of the underlying mechanisms of action as presently understood is provided and the current limitations of biomaterial-dependent strategies to improve outcome following CPB are addressed.

ECMO cannula review

This paper reviews the basic fluid dynamics underlying extracorporeal membrane oxygenation (ECMO) cannula design. General cannula features and their effect on flow are discussed and the specific requirements of different ECMO circuits are explained. The current commercially available cannula options for veno-arterial and veno-venous circuits are reviewed and the main characteristics presented.

Development of soft nanocomposite materials and their applications in cell culture and tissue engineering

Novel soft nanocomposite materials with unique organic/inorganic network structures have been developed by extending the strategy of “organic/inorganic nanocomposites” to the field of soft materials. The structures described here were synthesized by in-situ free-radical polymerization of various monomers in the presence of exfoliated clay (hectorite) in aqueous media. The nanocomposite hydrogels (NC gels) and soft nanocomposites (M-NCs) obtained were flexible and transparent soft materials, regardless of the clay content, that could be prepared in various shapes and surface forms, each consisting of individually different polymer/clay network structures. Owing to these unique network structures, both NC gels and M-NCs showed extraordinary mechanical properties such as ultrahigh elongation at break and widely controlled modulus and strength, which could overcome the problems (e.g., mechanical fragility, optical turbidity, poor processing ability) associated with conventional chemically crosslinked materials. In addition, the NC gels and M-NCs exhibited a number of new characteristics related to optical anisotropy, morphology, biocompatibility, stimulus sensitivity and cell culture. In the present review, we outline the novel features of these soft nanocomposites, and demonstrate their potential as soft culture substrates useful for tissue engineering as well as soft, transparent, absorbing, and mechanically tough biomaterials for many bio-applications.

Investigation of inflammatory response at blood–poly (2-methoxyethyl acrylate) (PMEA) interface in vivo via scanning tunneling microscope

The effects of an amphiphilic polymer coating of poly(2-methoxyethyl acrylate) (PMEA) on immunoglobulin adsorption and leukocyte adhesion were investigated. Forty patients were operated on using noncoated and PMEA-coated oxygenator fibers; leukocyte counts adhered onto the noncoated and coated fibers. It appears that the adsorbed immunoglobulin on noncoated fiber surfaces plays a role in leukocyte adhesion and complement activation by an alternative pathway, while the PMEA coating reduced the complement activation on the oxygenator hollow fibers. The biomaterial and blood interaction at the interface could potentially be used as an indicator for predicting the artificial devices long-term clinical performance.

Advances in assay of complement function and activation

The main function of the complement system is pattern recognition of danger. Typical exogenous danger signals are pathogen associated molecular patterns inducing a protective inflammatory response. Other examples are exposure to foreign surfaces of biomedical materials including nanoparticles, which principally induce the same inflammatory response. If a surface is "foreign" to the host, it induces complement activation. Development of monoclonal antibodies to neoepitopes on complement activation products introduced an entirely new set of methods for assay of complement activation. Activation of complement by a surface occurs by impairment of the fine balance of the control system, e.g. by preferred binding of factor B at the expense of factor H. Sensitive methods to detect complement activation on surfaces and in the fluid phase are a prerequisite for investigation of the biocompatibility of artificial materials. This information can be used to develop new materials with enhanced biocompatibility. Here we review available methods to study human and animal complement function and activation in vitro and in vivo.

Studies on bound water restrained by poly(2-methacryloyloxyethyl phosphorylcholine): Comparison with polysaccharide-water systems

The structural change of water restrained by poly(2-methacryloyloxyethyl phosphorylcholine) (PMPC) was investigated by differential scanning calorimetry (DSC), since the biocompatibility of PMPC and related biopolymers is affected by the structure of water on the polymer surface. The phase transition behaviour of PMPC-water systems with a water content (W(c)=mass of water/mass of dry sample, gg(-1)) in the range 0-2.0 was measured in the temperature range -150 to 50 degrees C. Glass transition, cold crystallization and melting were observed. Cold crystallization, which has been suggested as an index of biocompatibility, was detected for PMPC with a W(c) in the range 0.5-0.9. The amounts of two types of bound water, non-freezing water and freezing bound water, were calculated from the melting enthalpy. The amount of non-freezing water of PMPC was approximately 0.48. It was found that the phase transition behaviour and amount of bound water of PMPC were quite similar to those of water-soluble polysaccharide electrolytes. The results indicate that the bound water, not the free water, is restrained by PMPC.

Evaluation of blood components exposed to coated arterial filters in extracorporeal circuits

Background: Biocompatible surfaces play an important role in the inflammatory response during cardiopulmonary bypass (CBP), with the arterial filter contributing a large surface area of the circuit. Different filter-coating materials designed to improve blood-filter biocompatibility are currently used in CPB circuits. This study evaluates eight biocompatible coatings used for arterial filters and their effects on blood components during circulation. Methods: Arterial filters were randomly assigned in eight independent heparin-bonded tubing loops and perfused by a single swine (n=8). Arterial blood was routed simultaneously, but separately, into each circuit and circulated for 30 minutes at 37°C. Blood samples were drawn for CBC, ACT, and TAT III measurements at baseline, post-heparinization and post-circulation. At study completion, filters were imaged using multiphoton microscopy. Results: RBC, platelet, and WBC counts, and TAT III complex were all decreased after 30 minutes of circulation; however, WBC count was the only parameter that showed statistically significant differences between the filters. Circulating WBC reduction ranged from 6% (Carmeda and Trillium) to 41% (Terumo-X-coating) with corresponding microscopic confirmation of increased WBC entrapment. Conclusion: All eight filter coatings altered the blood components to varying degrees. Selection of the most effective filter, in conjunction with a heparin-bonded circuit for CPB, may decrease the intraoperative foreign-surface activation of blood cells.

Nonsolvents cause swelling at the interface with poly(methyl methacrylate) films

Density profiles of a perdeuterated poly(methyl methacrylate) (dPMMA) film spin-coated on a substrate in water, hexane, and methanol, which are "nonsolvents" for dPMMA, were examined along the direction normal to the interface by specular neutron reflectivity (NR). The interfaces of dPMMA with the liquids were diffuse in comparison with the pristine interface with air; the interfacial width with water was thicker than that with hexane. Interestingly, in water, the dPMMA film was composed of a swollen layer and the interior region, which also contained water, in addition to the diffused layer. The interface of dPMMA with hexane was sharper than that with water. Although there were slight indications of a swollen layer for the dPMMA in hexane, the solvent molecules did not penetrate significantly into the film. On the other hand, in methanol, the whole region of the dPMMA film was strikingly swollen. To conserve mass, the swelling of the film by the nonsolvents is accompanied by an increase in the film thickness. The change in the film thickness estimated by NR was in excellent accord with the results of direct observations using atomic force microscopy (AFM). The modulus of dPMMA in the vicinity of the interfaces with liquids was also examined on the basis of force-distance curves measured by AFM. The modulus decreased closer to the outermost region of the film. The extent to which the modulus decreased in the interfacial region was consistent with the amount of liquid sorbed into the film.

Effect of Polymer Coating (Poly 2-Methoxyethylacrylate) of the Oxygenator on Hemostatic Markers During Cardiopulmonary Bypass in Children

OBJECTIVE

Heparin and other oxygenator coatings have been used in attempts to reduce hemostatic activation during cardiopulmonary bypass (CPB). This study evaluated whether an oxygenator coated with poly 2-methoxyethylacrylate (PMEA) (X-coating; Terumo Corporation, Tokyo, Japan) would cause less activation of coagulation and fibrinolytic systems during CPB in children than a noncoated oxygenator.

DESIGN

Observational study.

SETTING

University-affiliated children's hospital.

PATIENTS

Twenty-six patients, 3 months to 5 years old, who underwent congenital heart surgery for repair of a ventricular septal defect, atrial septal defect, or both.

INTERVENTIONS

Patients were divided into 2 age-matched groups based on the type of oxygenator used: a noncoated oxygenator (group NC) versus a PMEA-coated oxygenator (group C).

MEASUREMENTS AND MAIN RESULTS

Blood samples for coagulation and fibrinolytic markers were compared before, during, and after CPB. Despite increases in thrombin generation markers (F1.2 and TAT) at certain times during CPB in group C compared to group NC, a comparison over all times during CPB were not statistically different between groups. Overall D-dimer concentrations during CPB were elevated in group C compared to group NC (p = 0.02). Active tPA and active PAI-1 were not different between groups during or after CPB. Group C had higher platelet counts (181,000 +/- 29,000) during CPB than group NC (155,000 +/- 57,000, p = 0.04) but not postoperatively. Twelve hours postoperatively, chest tube outputs were 8.8 +/- 3 mL/kg in group C and 19.1 +/- 12 mL/kg in group NC (p = 0.003). The corresponding outputs 24 hours after surgery were 12.4 +/- 3 mL/kg and 24 +/- 11 mL/kg, respectively (p = 0.005).

CONCLUSIONS

Except for a somewhat higher platelet count during CPB, there was no indication that PMEA coating resulted in less activation of coagulation and fibrinolytic systems. The lower postoperative chest tube output observed after CPB with PMEA-coated oxygenators needs to be studied further.

Relationship between blood compatibility and water structure—Comparative study between 2-methoxyethylacrylate- and 2-methoxyethylmethacrylate-based random copolymers

We have proposed that the excellent blood compatibility of poly(2-methoxyethylacrylate (MEA)) is caused by freezing bound water contained in it on the basis of results on platelet activation (Tanaka and Mochizuki, J Biomed Mater Res A 2004; 68:684-695). To clarify the applicability of this mechanism to other indexes for blood compatibility, the relationship between complement activation and water structure was investigated by using two copolymers, poly(MEA-2-hydroxyethylmethacrylate (HEMA)) and poly(2-methoxyethylmethacrylate (MEMA)-HEMA), where HEMA content was varied from 25 to 90 mol %. ESCA analysis revealed that the surface compositions of these copolymers (dry state) agreed with the compositions determined by (1)H NMR. However, analysis by water contact angle (wet state) showed that their surfaces were quite different. The contact angle of poly(MEMA-HEMA) depended on the monomer composition, whereas the angle of poly(MEA-HEMA) was close to that of polyHEMA regardless of the monomer composition. The effect of HEMA content in the copolymers on complement activation (production of C3a) was investigated in an in vitro test. The activation by poly(MEMA-HEMA) was enhanced according to the HEMA content, while the activation by poly(MEA-HEMA) with 0-40 mol % of HEMA was weak and did not depend on the HEMA content. These properties are discussed from the viewpoints of the water structure observed by DSC and the surface structure.

Study on blood compatibility with poly(2-methoxyethylacrylate)—relationship between surface structure, water structure, and platelet compatibility in 2-methoxyethylacrylate/2-hydroxyethylmethacrylate diblock copolymer

Diblock copolymers composed of 2-methoxyethylacrylate (MEA) and 2-hydroxyethylmethacrylate (HEMA) were firstly prepared (the composition ratio = 90/10, 79/21, 66/34, and 48/52 mol/mol) by anion living polymerization. ESCA analysis of their surface structures (dry state) revealed that PMEA segment was segregated to the top surface in all of the polymers, whereas the results of contact angle of water (wet state) showed that the surfaces were covered with PHEMA segment. In vitro platelet adhesion test showed that these polymers had the excellent compatibility with platelet compared to PHEMA homopolymer. Water structure in the hydrated copolymers was investigated by DSC and freezing bound water was observed for all the polymers like PMEA homopolymer, whereas it was not found in PHEMA homopolymer. Further investigation of water structure based on the results of DSC and EWCMS (equilibrium water content by moisture sorption) suggested that freezing bound water existed in PHEMA segment in addition to PMEA segment. We have proposed that the water plays a key role in the appearance of good blood compatibility of the copolymer, according to our previous works (Tanaka et al. Biomacromolecules 2002;3:36-41, Tanaka et al. J Biomed Mater Res A 2004;68:684-695).

PMEA Coating of Pump Circuit and Oxygenator May Attenuate the Early Systemic Inflammatory Response in Cardiopulmonary Bypass Surgery

We investigated the effects of coating a cardiopulmonary bypass (CPB) circuit and oxygenator with poly-2-methoxy-ethyl acrylate (PMEA) on the systemic inflammatory response during and after CPB. Thirty patients undergoing elective cardiac surgery were randomized into three groups (each group n = 10): noncoated (group N), heparin coated (group H), and PMEA coated circuit and oxygenator (group X). Bradykinin (BK), complement 3 activation (C3a) and interleukin-6 (IL-6) levels were measured as early phase indicators of inflammatory response, as were maximum C reactive proteins (CRP) and white blood cell (WBC) levels. The alveolar-arterial oxygen gradient (A-a DO2) was measured as a parameter of respiratory function. IL-6 levels after CPB were significantly higher in group N than in groups H and X (p < 0.05). Serum BK and C3a levels showed similar patterns in all groups. A-a DO2 was lower at the end of and 3 hours after CPB in groups H and X than in group N (p < 0.05). Maximum CRP levels were lower in group X than in groups N (p < 0.05). This prospective study suggests that PMEA coated CPB may improve respiratory function and decrease systemic inflammatory response after cardiac surgery, possibly because this circuit is as biocompatible as heparin coated CPB circuit.

Hemocompatibility of PMEA Coated Oxygenators Used for Extracorporeal Circulation Procedures

An inflammatory response to cardiopulmonary bypass (CPB) caused by bioincompatibility of extracorporeal circuits is one of the major clinical issues in cardiac surgery. Recently a new coating material, poly-2-methoxyethylacrylate (PMEA), was developed to improve the biocompatibility of blood contacting surfaces. In a simulated cardiopulmonary bypass model, using fresh human whole blood, 15 membrane oxygenators (Capiox SX18, Terumo Corp., Tokyo, Japan) were compared. Five of them had the PMEA coating, five had a heparin-coated surface, and five had no surface treatment. Blood samples were taken at several time-points during a 90 minute circulation period. Changes in coagulation, complement, and blood cell alteration factors were measured by ELISA methods, plasma bradykinin levels were measured by radioimmunoassay, and expression of genes encoding cytokines TNF-alpha, interleukin-1beta, interleukin-6, and interleukin-8 was determined by semiquantitative real time RT-PCR. Platelet adhesion was significantly reduced in both the PMEA and the heparin coated circuits. Release of platelet activation marker beta-thromboglobulin was significantly higher in the uncoated control group (p < 0.01). After 5 minutes of blood circulation bradykinin levels significantly increased in all three groups (p < 0.01); however, the group with the PMEA coated oxygenators showed the lowest values. Expression of genes encoding proinflammatory cytokines in monocytes was increased in all groups, with the lowest being in the PMEA coated group. PMEA coated CPB surfaces in an in vitro experimental model showed an improved thrombogenicity, reduced bradykinin release, less platelet activation and less proinflammatory cytokines gene expression in comparison with a noncoated group. The authors assume that PMEA coating may ameliorate some of intra- and postperfusion syndromes, particularly hypotension, unspecific inflammation, hyperfibrinolysis, and blood loss.

A new poly-2-methoxyethylacrylate-coated cardiopulmonary bypass circuit possesses superior platelet preservation and inflammatory suppression efficacy

BACKGROUND

Poly-2-methoxyethylacrylate (PMEA) is a new coating material, and several studies have revealed that PMEA-coated cardiopulmonary bypass (CPB) circuits have good biocompatibility. This study sought to compare this biocompatibility with those of heparin-coated and noncoated circuits.

METHODS

Forty-five patients undergoing coronary artery bypass grafting were randomly assigned to PMEA-coated (group P, n = 15), heparin-coated (group H, n = 15), or noncoated (group N, n = 15) circuit groups. Clinical data and the following markers were analyzed: (1) platelet preservation by number of platelets; (2) complement (C) activation by C3a and C4a levels; (3) inflammatory response by interleukin-6 (IL-6) and interleukin-8 (IL-8) levels.

RESULTS

Platelet numbers were significantly preserved in group P compared with groups N and H. Postoperative blood loss did not differ among the groups. During CPB, C3a values were significantly lower in group H (536 +/- 145 ng/mL) than in group P (1,458 +/- 433 ng/mL, p < 0.01) and group N (1,815 +/- 845 ng/mL, p < 0.01). The C4a values did not differ 60 minutes after CPB initiation among the groups. The IL-6 and IL-8 levels were significantly lower in group P and group H than in group N.

CONCLUSIONS

The PMEA coating was superior to heparin coating and noncoating in preserving platelets, and was equivalent to heparin coating in terms of the perioperative clinical course and inhibition of inflammatory cytokines, but slightly inferior in reducing complement activation.

Effect of water structure on blood compatibility? thermal analysis of water in poly(meth)acrylate

The purpose of this study is to clarify the main factor causing excellent blood compatibility of poly(2-methoxyethyl acrylate)(PMEA) by the comparison between PMEA and seven PMEA analogous polymers. The polymers have a typical functional group as ester side chains such as methoxyethyl, hydroxyethyl, phenoxyethyl, and alkyl groups. The properties of the polymers relating to water were investigated in terms of contact angle, equilibrium water content (EWC), and thermal analysis by differential scanning calorimetry. The water in PMEA could be classified into three types: nonfreezing water, freezing bound water, and free water while the water in the analogous polymers was classified into just two types: free and nonfreezing waters, regardless of the chemical structure of the side chain. The surface property represented by the contact angle of water corresponded to the content of the bound water (nonfreezing water + freezing bound water). The platelet compatibility in vitro did not depend on the contents of these waters, or on the contact angle. On the basis of the results of this work and the previous work on the platelet compatibility of poly(MEA-co-HEMA) (Tanaka et al. Biomacromolecules 2002;3;36-41), the main factor causing the excellent compatibility of PMEA is discussed.

Cardiopulmonary bypass technology transfer: musings of a cardiac surgeon

The development of cardiopulmonary bypass (CPB) has been one of the greatest technical advancements in cardiovascular medicine. With heparin anticoagulation, this device can safely replace the circulatory and gas-exchanging functions of the heart and lung, facilitating complex cardiac operations. Limitations still exist however, related to blood reactions at the biomaterial surface, such as cell activation, inflammation and low-grade thrombosis. In this brief review, the thought processes which paralleled the development of CPB biocompatible surfaces such as heparin-coating, will be explored, as well as current theories on the suspected mechanisms by which heparin-coated surfaces act as an anti-inflammatory device during CPB. Results with new surfaces for CPB designed to capitalize on superior protein adsorption properties, such as surface modifying additive (SMA) and poly (2-methoxyethylacrylate) (PMEA), will also be described. Finally, the significance of biomaterial-independent blood activation will be discussed, emphasizing the current need to develop strategies utilizing optimal biomaterials, modified surgical technique and pharmacologic therapy to minimize the systemic complications of CPB.