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Larson AC, De Bie FR, Chang J, Davey MG, Flake AW. The EXTrauterine Environment for Neonatal Development: Present and Future. Pediatr Dev Pathol 2022; 25:253-262. [PMID: 35102770 DOI: 10.1177/10935266211067110] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Despite advances in clinical care and modest improvement in mortality rates for extreme prematurity, morbidity remains a significant challenge. The ideal environment to support prematurity would be fluidic and rely on natural fetal circulation to mimic the natural fetal amniotic environment, yet such an environment has been unsuccessful in long-term support until recently. Our group has succeeded in developing such a support system to foster fetal growth in the premature lamb model that shows promise for clinical translation. Here, we describe the EXTrauterine Environment for Neonatal Development (EXTEND) from its conception onwards, review published literature on fetal development and support of the premature lamb model in EXTEND, and discuss future applications.
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Affiliation(s)
- Abby C Larson
- Center for Fetal Research, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Felix R De Bie
- Center for Fetal Research, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Jonathan Chang
- Center for Fetal Research, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Marcus G Davey
- Center for Fetal Research, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alan W Flake
- Center for Fetal Research, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA
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2
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Burgos CM, Frenckner B, Broman LM. Premature and Extracorporeal Life Support: Is it Time? A Systematic Review. ASAIO J 2022; 68:633-645. [PMID: 34593681 DOI: 10.1097/mat.0000000000001555] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Early preterm birth < 34 gestational weeks (GA) and birth weight (BW) <2 kg are relative contraindications for extracorporeal membrane oxygenation (ECMO). However, with improved technology, ECMO is presently managed more safely and with decreasing complications. Thus, these relative contraindications may no longer apply. We performed a systematic review to evaluate the existing literature on ECMO in early and late (34-37 GA) prematurity focusing on survival to hospital discharge and the complication intracranial hemorrhage (ICH). Data sources: MEDLINE, PubMed, Web of Science, Embase, and the Cochrane Database. Only publications in the English language were evaluated. Of the 36 included studies, 23 were related to ECMO support for respiratory failure, 10 for cardiac causes, and four for congenital diaphragmatic hernia (CDH). Over the past decades, the frequency of ICH has declined (89-21%); survival has increased in both early prematurity (25-76%), and in CDH (33-75%), with outcome similar to late prematurity (48%). The study was limited by an inherent risk of bias from overlapping single-center and registry data. Both the risk of ICH and death have decreased in prematurely born treated with ECMO. We challenge the 34 week GA time limit for ECMO and propose an international task force to revise current guidelines. At present, gestational age < 34 weeks might no longer be considered a contraindication for ECMO in premature neonates.
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Affiliation(s)
- Carmen Mesas Burgos
- From the Department of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
- ECMO Centre Karolinska, Pediatric Perioperative Medicine and Intensive Care, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Björn Frenckner
- From the Department of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
- ECMO Centre Karolinska, Pediatric Perioperative Medicine and Intensive Care, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Lars Mikael Broman
- ECMO Centre Karolinska, Pediatric Perioperative Medicine and Intensive Care, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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A supportive physiologic environment for the extreme premature infant: Improving life outside the womb. J Pediatr Surg 2022; 57:167-171. [PMID: 34823842 DOI: 10.1016/j.jpedsurg.2021.10.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 10/22/2021] [Indexed: 11/23/2022]
Abstract
Extreme prematurity remains an unsolved problem and is the leading cause of pediatric mortality and morbidity in developed countries. The extreme premature infant is physiologically a fetus, and current supportive measures in our NICUs are for the most part non-physiologic. In order to improve morbidity and mortality in this population, we have developed the Extra-uterine environment for newborn development (EXTEND) system which seeks to mimic as closely as possible the environment of the womb. The primary components of EXTEND include a sterile fluid environment, a pumpless arteriovenous extracorporeal oxygenator circuit, and vascular access via umbilical arterial and venous vessels. While supported on the EXTEND system, premature fetal lambs grow and develop normally for up to 4 weeks. Fetal physiology is maintained, and detailed organ system analysis supports normal development. This article summarizes current progress in the development of EXTEND, the pathway for human translation, ethical considerations related to EXTEND, and anticipated clinical applications of this potentially paradigm changing technology. LEVEL OF EVIDENCE: IV.
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De Bie FR, Davey MG, Larson AC, Deprest J, Flake AW. Artificial placenta and womb technology: Past, current, and future challenges towards clinical translation. Prenat Diagn 2020; 41:145-158. [PMID: 32875581 DOI: 10.1002/pd.5821] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/24/2020] [Accepted: 08/29/2020] [Indexed: 01/12/2023]
Abstract
Extreme prematurity remains a major cause of neonatal mortality and severe long-term morbidity. Current neonatal care is associated with significant morbidity due to iatrogenic injury and developmental immaturity of extreme premature infants. A more physiologic approach, replacing placental function and providing a womb-like environment, is the foundational principle of artificial placenta (AP) and womb (AW) technology. The concept has been studied during the past 60 years with limited success. However, recent technological advancements and a greater emphasis on mimicking utero-placental physiology have improved the success of experimental models, bringing the technology closer to clinical translation. Here, we review the rationale for and history of AP and AW technology, discuss the challenges that needed to be overcome, and compare recent successful models. We conclude by outlining some remaining challenges to be addressed on the path towards clinical translation and opportunities for future research.
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Affiliation(s)
- Felix R De Bie
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Marcus G Davey
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Abby C Larson
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jan Deprest
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Alan W Flake
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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5
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Baumgarten HD, Wright CM, Rossidis AC, Lawrence KM, Kim AG, Mejaddam AY, McGovern PE, Orr MN, Coons BE, Butt Z, Li H, Hwang G, Radu A, Brown LJ, Rubenstein RC, Peranteau WH, Davey M, Heuckeroth RO, Flake AW. The EXTrauterine Environment for Neonatal Development Supports Normal Intestinal Maturation and Development. Cell Mol Gastroenterol Hepatol 2020; 10:623-637. [PMID: 32474164 PMCID: PMC7408362 DOI: 10.1016/j.jcmgh.2020.05.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 05/17/2020] [Accepted: 05/18/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND AIMS The Extra-Uterine Environment for Neonatal Development (EXTEND) aims to avoid the complications of prematurity, such as NEC. Our goal was to determine if bowel development occurs normally in EXTEND-supported lambs, with specific emphasis on markers of immaturity associated with NEC. METHODS We compared terminal ileum from 17 pre-term lambs supported on EXTEND for 2- 4 weeks to bowel from age-matched fetal lambs that developed in utero. We evaluated morphology, markers of epithelial integrity and maturation, enteric nervous system structure, and bowel motility. RESULTS EXTEND-supported lamb ileum had normal villus height, crypt depth, density of mucin-containing goblet cells, and enteric neuron density. Expression patterns for I-FABP, activated caspase-3 and EGFR were normal in bowel epithelium. Transmural resistance assessed in Ussing chambers was normal. Bowel motility was also normal as assessed by ex vivo organ bath and video imaging. However, Peyer's patch organization did not occur normally in EXTEND ileum, resulting in fewer circulating B cells in experimental animals. CONCLUSION EXTEND supports normal ileal epithelial and enteric nervous system maturation in pre-term lambs. The classic morphologic changes and cellular expression profiles associated with NEC are not seen. However, immune development within the EXTEND supported lamb bowel does not progress normally.
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Affiliation(s)
- Heron D Baumgarten
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christina M Wright
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Avery C Rossidis
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kendall M Lawrence
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Aimee G Kim
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ali Y Mejaddam
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Patrick E McGovern
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Melissa N Orr
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Barbara E Coons
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Zoya Butt
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Haiying Li
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Grace Hwang
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Antoneta Radu
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lauren J Brown
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ronald C Rubenstein
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - William H Peranteau
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marcus Davey
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert O Heuckeroth
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alan W Flake
- Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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Chitty LS, Hui L, Ghidini A, Levy B, Deprest J, Van Mieghem T, Bianchi DW. In case you missed it: The Prenatal Diagnosis editors bring you the most significant advances of 2019. Prenat Diagn 2020; 40:287-293. [PMID: 31875323 DOI: 10.1002/pd.5632] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 12/18/2019] [Indexed: 12/21/2022]
Affiliation(s)
- L S Chitty
- London North Genomic Laboratory, Great Ormond Street NHS Foundation Trust, and Genetics and Genomic Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
| | - L Hui
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - A Ghidini
- Antenatal Testing Centre, Inova Alexandria Hospital, Alexandria, VA
| | - B Levy
- Departments of Pathology and Cell Biology, Columbia University, New York, NY
| | - J Deprest
- Departments of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - T Van Mieghem
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada
| | - D W Bianchi
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
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