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Non-surgical bleeding is a common complication in patients on continuous flow left ventricular assist device (CF-VAD) support. Angiopoietin-2 (ANGPT-2) and von Willebrand Factor (VWF) are important contributors to non-surgical bleeding. 

Patients on continuous flow ventricular assist devices (CF-VADs) are at high risk for the development of Acquired von-Willebrand Syndrome (AVWS) and non-surgical bleeding. von Willebrand Factor (vWF) plays an essential role in maintaining hemostasis via platelet binding to the damaged endothelium to facilitate coagulation. In CF-VAD patients, degradation of vWF into low MW multimers that are inefficient in facilitating coagulation occurs and has been primarily attributed to the supraphysiological shear stress associated with the CF-VAD impeller. Methods In this review, we evaluate information from the literature regarding the unraveling behavior of surface-immobilized vWF under pulsatile and continuous flow pertaining to: (A) the process of arterial endothelial vWF production and release into circulation, (B) the critical shear stress required to unravel surface bound versus soluble vWF which leads to degradation, and (C) the role of pulsatility in on the production and degradation of vWF. Results and Conclusion Taken together, these data suggests that the loss of pulsatility and its impact on arterial endothelial cells plays an important role in the production, release, unraveling, and proteolytic degradation of vWF into low MW multimers, contributing to the development of AVWS. Restoration of pulsatility can potentially mitigate this issue by preventing AVWS and minimizing the risk of non-surgical bleeding. 

Nonsurgical bleeding occurs in a significant proportion of patients implanted with continuous-flow ventricular assist devices (CF-VADs) and is associated with nonphysiologic flow with diminished pulsatility. An in vitro vascular pulse perfusion model seeded with adult human aortic endothelial cells (HAECs) was used to identify biomarkers sensitive to changes in pulsatility. Diminished pulsatility resulted in an ~45% decrease in von Willebrand factor (vWF) levels from 9.80 to 5.32 ng/ml (n = 5, p < 0.05) and a threefold increase in angiopoietin-2 (ANGPT-2) levels from 775.29 to 2471.93 pg/ml (n = 5, p < 0.05) in cultured HAECs. These changes are in agreement with evaluation of patient blood samples obtained pre-CF-VAD implant and 30-day postimplant: a decrease in plasma vWF level by 50% from ~45.59 to ~22.49 μg/ml (n = 15, p < 0.01) and a 64% increase in plasma ANGPT-2 level from 7,073 to 11,615 pg/ml (n = 8, p < 0.05). This study identified vWF and ANGPT-2 as highly sensitive to changes in pulsatility, in addition to interleukin-6 (IL-6), IL-8, and tumor necrosis-α (TNF-α). These biomarkers may help determine the optimal level of pulsatility and help identify patients at high risk of nonsurgical bleeding. 

Children are said to be a product of both nature and nurture – of their genes and the environment in which they are raised. The cells of the growing liver are not so different in this sense. As the liver of a fetus develops, immature cells called liver progenitors mature to become one of two types of adult cells: the hepatocytes that form the bulk of the liver, or the biliary cells that make up the bile duct. The traditional view is that genetic factors mainly control which cell type the progenitor cells become. However, recent research suggests that the environment around the cells matters more in this process than once thought. Cells can respond to the physical properties of their environment, such as the structure and stiffness of the surrounding tissue. These properties change as the liver develops, and can also be altered by disease. For example, damaged liver cells can spit out proteins that harden and form stiff scars. This raises a question: do changes in stiffness affect how progenitor cells behave? To answer this question, Kaylan et al. printed collagen in circular patterns and grew liver progenitor cells on them. The cells at the edges of the circular patterns matured into bile duct cells, while those in the center became hepatocytes. The stiffness felt by the cells was then determined by measuring the level of mechanical stress that they experienced. This revealed that the cells at the edge of the collagen pattern – the cells that became bile duct cells – were under most stress. In addition, more bile duct cells formed when progenitor cells were grown on a stiffer collagen pattern. Overall, the results reported by Kaylan et al. suggest that the stiffness of the environment, and the resulting stresses on a progenitor cell, can influence how it matures. As well as helping us to understand how the liver develops, this knowledge could also help us to treat a group of diseases called cholangiopathies, in which the bile ducts become inflamed. These diseases are thought to be caused by certain cells (which are similar to liver progenitor cells) maturing to become incorrect cell types. Future studies could determine if preventing changes in stiffness in the environment of these cells, or slowing their response to such changes, would help patients.