Alexander Assmann

Shear-thinning nanocomposite hydrogels for the treatment of hemorrhage.

Internal hemorrhaging is a leading cause of death after traumatic injury on the battlefield. Although several surgical approaches such as the use of fibrin glue and tissue adhesive have been commercialized to achieve hemostasis, these approaches are difficult to employ on the battlefield and cannot be used for incompressible wounds. Here, we present shear-thinning nanocomposite hydrogels composed of synthetic silicate nanoplatelets and gelatin as injectable hemostatic agents. These materials are demonstrated to decrease in vitro blood clotting times by 77%, and to form stable clot-gel systems. In vivo tests indicated that the nanocomposites are biocompatible and capable of promoting hemostasis in an otherwise lethal liver laceration. The combination of injectability, rapid mechanical recovery, physiological stability, and the ability to promote coagulation result in a hemostat for treating incompressible wounds in out-of-hospital, emergency conditions.

Highly Elastic and Conductive Human‐Based Protein Hybrid Hydrogels

A highly elastic hybrid hydrogel of methacryloyl-substituted recombinant human tropoelastin (MeTro) and graphene oxide (GO) nanoparticles are developed. The synergistic effect of these two materials significantly enhances both ultimate strain (250%), reversible rotation (9700°), and the fracture energy (38.8 ± 0.8 J m(-2) ) in the hybrid network. Furthermore, improved electrical signal propagation and subsequent contraction of the muscles connected by hybrid hydrogels are observed in ex vivo tests.

Acceleration of autologous in vivo recellularization of decellularized aortic conduits by fibronectin surface coating

Decellularization is a promising option to diminish immune and inflammatory response against donor grafts. In order to accelerate the autologous in vivo recellularization of aortic conduits for an enhanced biocompatibility, we tested fibronectin surface coating in a standardized rat implantation model. Detergent-decellularized rat aortic conduits (n = 36) were surface-coated with covalently Alexa488-labeled fibronectin (50 μg/ml, 24 h) and implanted into the systemic circulation of Wistar rats for up to 8 weeks (group FN; n = 18). Uncoated implants served as controls (group C; n = 18). Fibronectin-bound fluorescence on both surfaces of the aortic conduits was persistent for at least 8 weeks. Cellular repopulation was examined by histology and immunofluorescence (n = 24). Luminal endothelialization was significantly accelerated in group FN (p = 0.006 after 8 weeks), however, local myofibroblast hyperplasia with significantly increased ratio of intima-to-media thickness occurred (p = 0.0002 after 8 weeks). Originating from the adventitial surface, alpha-smooth muscle actin and desmin positive cell invasion into the media of fibronectin-coated conduits was significantly increased as compared to group C (p < 0.0001). In these medial areas, in situ zymography revealed enhanced matrix metalloproteinase activity. In both groups, inflammatory cell markers (CD3 and CD68) and signs of thrombosis proved negative. With regard to several markers of cell adhesion, inflammation and calcification, quantitative real-time PCR (n = 12) revealed no significant inter-group differences. Fibronectin surface coating of decellularized cardiovascular implants proved feasible and persistent for at least 8 weeks in the systemic circulation. Biofunctional protein coating accelerated the autologous in vivo endothelialization and induced a significantly increased medial recellularization. Therefore, this strategy may contribute to the improvement of current clinically applied bioprostheses.

Development of a Growing Rat Model for the In Vivo Assessment of Engineered Aortic Conduits

BACKGROUND Numerous limitations of aortic valve grafts currently used in pediatric patients cause the need for alternative prostheses. For the purpose of in vivo evaluation of novel engineered aortic conduit grafts, we aimed at downsizing a previously described model to create a growing rodent model. MATERIALS AND METHODS U-shaped aortic conduits were sutured to the infrarenal aorta of young Wistar rats (70-80 g, n = 10) in an end-to-side manner. Functional assessment was performed by Doppler sonography and high resolution rodent MRI. Histology and immunohistochemistry followed after 8 wk. RESULTS Postoperative recovery rate was 80%. Conforming to clinical observations, postoperative MRI (d 5) and Doppler sonography (wk 8) revealed unimpaired conduit perfusion. Explanted implants were luminally completely covered by an endothelial cell layer with local hyperplasia and accumulation of α-smooth muscle actin (+) cells. Moreover microcalcification of the decellularized scaffolds was observed. CONCLUSIONS Our downsized model of aortic conduit transplantation enables overall characterization with detailed analysis of maturation of engineered aortic grafts in a growing organism.

Nanoengineered biomimetic hydrogels for guiding human stem cell osteogenesis in three dimensional microenvironments

The ability to modulate stem cell differentiation in a three dimensional (3D) microenvironment for bone tissue engineering in absence of exogenous pharmaceutical agents such as bone morphogenic protein (BMP-2) remains a challenge. In this study, we introduce extracellular matrix (ECM)-mimicking nanocomposite hydrogels to induce osteogenic differentiation of human mesenchymal stem cells (hMSCs) for bone regeneration in absence of any osteoinducting factors. In particular, we have reinforced photocrosslinkable collagen-based matrix (gelatin methacryloyl, GelMA) used disk-shaped nanosilicates (nSi), a new class of two-dimensional (2D) nanomaterials. We show that nanoengineered hydrogels supported migration and proliferation of encapsulated hMSCs, with no signs of cell apoptosis or inflammatory cytokine responses. The addition of nSi significantly enhances osteogenic differentiation of encapsulated hMSCs as evident by the increase in alkaline phosphates (ALP) activity and deposition of biomineralized matrix compared to GelMA without nSi. We also show that microfabricated nanoengineered microgels can be used to pattern and control cellular behaviour. Furthermore, we also show that nanoengineered hydrogel have high biocompatibility as determined by in vivo experiments using immunocompetent rat model. Specifically, the hydrogels showed minimum localized immune responses, indicating it ability for tissue engineering applications. Overall, we showed the ability of nanoengineered hydrogels loaded with 2D nanosilicates for osteogenic differentiation of stem cells in vitro, in absence of any growth factors such as BMP-2. Our in vivo studies show high biocompatibility of nanocomposites and show the potential for growth factor free bone regeneration.

Vacuum-assisted wound closure is superior to primary rewiring in patients with deep sternal wound infection.

OBJECTIVE Deep sternal wound infections are serious complications after cardiac surgery. The aim of the present study is to compare the outcome after vacuum-assisted wound closure to that after primary rewiring with disinfectant irrigation. The study additionally focuses on defining predictors for the failure of primary rewiring and its impact on postoperative outcome. METHODS Retrospective analysis was performed in 5232 patients who underwent cardiac surgery with a median sternotomy. 192 patients postoperatively developed deep sternal wound infections and were distributed into 2 therapy groups: a vacuum-assisted wound closure (= VAC) group and a primary rewiring (= RW) group, which was subdivided into healing after rewiring (= RW-h) and failure of rewiring (= RW-f). These groups were compared statistically to reveal coincidental pre-, intra- and postoperative parameters. RESULTS Compared to the VAC group, the RW group showed a poorer outcome, although RW baseline characteristics were apparently beneficial. Primary rewiring failed in 45.8 % of all cases, which led to even worse outcomes. Important predictors for failure of primary rewiring were morbid obesity, diabetes mellitus type II, chronic obstructive pulmonary disease, preoperatively impaired left ventricular function, postoperatively positive blood and wound cultures, bilateral harvesting of internal thoracic arteries and the need for surgical reexploration. CONCLUSIONS In spite of patients being in a worse condition, vacuum-assisted wound closure therapy resulted in improved outcomes and thus should be preferred to primary rewiring. Moreover we report on predictors which may indicate whether there is a high risk of rewiring failure.

Heparin-induced thrombocytopenia type II after cardiac surgery: predictors and outcome.

BACKGROUND Heparin-induced thrombocytopenia (HIT) is a serious complication after cardiac surgery. The aim of the present study was to identify pre- and intraoperative predictors for the postoperative occurrence of HIT. The study additionally focused on the impact of HIT on postoperative outcome. METHODS Retrospective analysis was performed for 5073 patients who had required extracorporeal circulation during cardiac surgery. Patients were divided into 3 groups: 1) patients who had postoperative HIT (HIT+); 2) patients with postoperative thrombocytopenia but without HIT (HIT-); and 3) patients with normal platelet count (C). The groups were statistically compared with regard to pre-, intra- and postoperative parameters. RESULTS Statistically significant predictors were renal insufficiency, intravenous application of heparin for more than 3 days, previous percutaneous coronary intervention within the last 4 weeks, urgency/emergency operation, combined surgery, prolonged extracorporeal circulation or cross-clamping time, and low cardiac output syndrome. Postoperative HIT was associated with an enhanced risk of renal failure, infectious and thromboembolic complications and in-hospital mortality. CONCLUSION Postoperative HIT increases morbidity and mortality. The predictors presented in this study can be used to identify patients at risk of developing HIT.

Cardiac surgery in nonagenarians: not only feasible, but also reasonable?

OBJECTIVES Changes in the age profile of the population in the western world and improvement in surgical techniques and postoperative care have contributed to a growing number of cardiosurgical patients aged over 90. In periods when transapical and transfemoral aortic valve replacement were done, we aimed at evaluating the outcome of nonagenarians after conventional aortic valve replacement and cardiac surgery in general, and determining perioperative parameters to predict a complicated postoperative course. METHODS Between 1995 and 2011, 49 nonagenarians (aged 91.2±3.1 years) underwent cardiac surgery. A subgroup of 30 patients received aortic valve replacement alone (63%; n=19), in combination with coronary artery bypass grafting (27%; n=8) or other surgical procedures (10%; n=3). Most of the patients suffered from combined aortic valve disease with a mean valve orifice area of 0.6±0.3 cm2 and a mean antegrade pressure gradient of 86±22 mmHg. RESULTS Cardiac surgery in nonagenarians resulted in remarkable postoperative morbidity and an overall in-hospital mortality of 10% (n=5). In the AVR subgroup, biological valve prostheses were implanted in 29 patients. In this subgroup, the length of stay was 2.9±0.9 days in the intensive care unit and 17.0±5.5 days in the hospital. The in-hospital mortality amounted to 13% (n=4). Although several general preoperative risk factors of postoperative complications such as renal failure, low cardiac output syndrome and New York Heart Association Class IV were remarkably more frequent among the patients who died after the operation, the small cohort of non-surviving nonagenarians did not allow for significant differences. CONCLUSIONS Cardiac surgery in the very elderly, particularly with regard to aortic valve replacement, carries a high risk of early morbidity and mortality. However, in selected nonagenarians, surgery can be performed with an acceptable outcome. The risk may even be reduced by an individual approach to the procedure. With regard to potential risk factors, the selection of these patients should be carried out very carefully.

Pulsatile extracorporeal circulation during on-pump cardiac surgery enhances aortic wall shear stress.

Controversy on superiority of pulsatile versus non-pulsatile extracorporeal circulation in cardiac surgery still continues. Stroke as one of the major adverse events during cardiopulmonary bypass is, in the majority of cases, caused by mobilization of aortic arteriosclerotic plaques that is inducible by pathologically elevated wall shear stress values. The present study employs computational fluid dynamics to evaluate the aortic blood flow and wall shear stress profiles under the influence of antegrade or retrograde perfusion with pulsatile versus non-pulsatile extracorporeal circulation. While, compared to physiological flow, a non-pulsatile perfusion resulted in generally decreased blood velocities and only moderately increased shear forces (48 Pa versus 20 Pa antegradely and 127 Pa versus 30 Pa retrogradely), a pulsatile perfusion extensively enhanced the occurrence of turbulences, maximum blood flow speed and maximum wall shear stress (1020 Pa versus 20 Pa antegradely and 1178 Pa versus 30 Pa retrogradely). Under these circumstances arteriosclerotic embolism has to be considered. Further simulations and experimental work are necessary to elucidate the impact of our findings on the scientific discourse of pulsatile versus non-pulsatile extracorporeal circulation.

Engineering a highly elastic human protein–based sealant for surgical applications

A highly elastic and adhesive photocrosslinkable surgical sealant using a modified human protein controls liquid leakages without the need for suturing. A stretchy, sticky alternative to sutures Repairing tissue ruptures during surgery can be complicated: Suturing requires piercing an already damaged tissue, and sealants such as glues may not match the material properties of the tissue, leading to subsequent leakage or rupture. Annabi et al. capitalized on the elastic properties of the human protein tropoelastin to engineer a photocrosslinkable hydrogel sealant material. The injectable material, MeTro, successfully sealed surgical incisions in blood vessels in rats and in lungs in pigs without evidence of leakage or rupture. Tunable elastic hydrogel sealants offer a promising adhesive, biocompatible, biodegradable material for tissue repair. Surgical sealants have been used for sealing or reconnecting ruptured tissues but often have low adhesion, inappropriate mechanical strength, cytotoxicity concerns, and poor performance in biological environments. To address these challenges, we engineered a biocompatible and highly elastic hydrogel sealant with tunable adhesion properties by photocrosslinking the recombinant human protein tropoelastin. The subcutaneous implantation of the methacryloyl-substituted tropoelastin (MeTro) sealant in rodents demonstrated low toxicity and controlled degradation. All animals survived surgical procedures with adequate blood circulation by using MeTro in an incisional model of artery sealing in rats, and animals showed normal breathing and lung function in a model of surgically induced rat lung leakage. In vivo experiments in a porcine model demonstrated complete sealing of severely leaking lung tissue in the absence of sutures or staples, with no clinical or sonographic signs of pneumothorax during 14 days of follow-up. The engineered MeTro sealant has high potential for clinical applications because of superior adhesion and mechanical properties compared to commercially available sealants, as well as opportunity for further optimization of the degradation rate to fit desired surgical applications on different tissues.