Name: Author Spotlight: Simulating Pediatric Cardiac Surgery Using a Neonatal Piglet Model
Uploaded: 2023-05-26T12:55:00
Description: Watch this Scientific Journal Video about Author Spotlight: Simulating Pediatric Cardiac Surgery Using a Neonatal Piglet Model at JoVE.com

This project has received funding from the European Union&#39;s Horizon 2020 research and innovation program under grant agreement no 101017113, Instituto de Salud Carlos III (PI20/00298), Beca Carmen de Torres (Fundaci&#243; Sant Joan de D&#233;u), and the Vanderbilt Medical Scholars Program. We thank all the staff of CMCiB, including Jordi Grifols, Mar&#237;a del Mar Arevalo, Juan Ricardo Gonzalez, Sara Capdevila, Josep Puig, and Gemma Cristina Monte Rubi). We also give special thanks to Abril Culell Camprub&#237; and Dr. Sergi Cesar D&#237;az for their assistance in anatomical drawings.

The present procedure was approved by the Animal Experimentation Ethics Committee (CEEA) of the Comparative Medicine and Bioimage Centre of Catalonia (CEEA-CMCiB). The Government of Catalonia also authorized the experimental protocol (no. 11652), file identification number FUE-2022-02381434 and ID QBXQ3RY3J. Experienced practitioners, including certified veterinarians providing supervision and assistance, performed all experimentation. Piglets (Sus scrofa domestica), 4-6 days old, weighing 2.5-3.5 kg, were used ...

Extracorporeal Cardiopulmonary Resuscitation in Animal Model After Cardiac Arrest

<ol>
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P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Abnormal+brain+development+in+newborns+with+congenital+heart+disease.">Abnormal brain development in newborns with congenital heart disease.</a> The New England Journal of Medicine. 357 (19), 1928-1938 (2007).</li><li>Fang, A., Allen, K. Y., Marino, B. S., Brady, K. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Neurologic+outcomes+after+heart+surgery.">Neurologic outcomes after heart surgery.</a> Paediatric Anaesthesia. 29 (11), 1086-1093 (2019).</li><li>Carr, B. D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Inflammatory+effects+of+blood-air+interface+in+a+porcine+cardiopulmonary+bypass+model.">Inflammatory effects of blood-air interface in a porcine cardiopulmonary bypass model.</a> ASAIO Journal. 66 (1), 72-78 (2020).</li><li>Drabek, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Emergency+preservation+and+delayed+resuscitation+allows+normal+recovery+after+exsanguination+cardiac+arrest+in+rats:+A+feasibility+trial.">Emergency preservation and delayed resuscitation allows normal recovery after exsanguination cardiac arrest in rats: A feasibility trial.</a> Critical Care Medicine. 35 (2), 532-537 (2007).</li><li>Sheikh, A. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Proteomics+of+cerebral+injury+in+a+neonatal+model+of+cardiopulmonary+bypass+with+deep+hypothermic+circulatory+arrest.">Proteomics of cerebral injury in a neonatal model of cardiopulmonary bypass with deep hypothermic circulatory arrest.</a> The Journal of Thoracic and Cardiovascular Surgery. 132 (4), 820-828 (2006).</li><li>Khailova, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Tissue+alkaline+phosphatase+activity+and+expression+in+an+experimental+infant+swine+model+of+cardiopulmonary+bypass+with+deep+hypothermic+circulatory+arrest.">Tissue alkaline phosphatase activity and expression in an experimental infant swine model of cardiopulmonary bypass with deep hypothermic circulatory arrest.</a> Journal of Inflammation. 17, 27 (2020).</li><li>Mavroudis, C. D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Electroencephalographic+response+to+deep+hypothermic+circulatory+arrest+in+neonatal+swine+and+humans.">Electroencephalographic response to deep hypothermic circulatory arrest in neonatal swine and humans.</a> The Annals of Thoracic Surgery. 106 (6), 1841-1846 (2018).</li><li>Gabriel, G. 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H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Renal+and+cerebral+hypoxia+and+inflammation+during+cardiopulmonary+bypass.">Renal and cerebral hypoxia and inflammation during cardiopulmonary bypass.</a> Comprehensive Physiology. 12 (1), 2799-2834 (2021).</li><li>Nollert, G., Reichart, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cardiopulmonary+bypass+and+cerebral+injury+in+adults.">Cardiopulmonary bypass and cerebral injury in adults.</a> Shock. 16 (1), 16-19 (2001).</li><li>T&#243;th, Z., Gy&#246;rimoln&#225;r, I., Abrah&#225;m, H., Hevesi, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cannulation+and+cardiopulmonary+bypass+produce+selective+brain+lesions+in+pigs.">Cannulation and cardiopulmonary bypass produce selective brain lesions in pigs.</a> Asian Cardiovascular &amp; Thoracic Annals. 14 (4), 273-278 (2006).</li><li>Senra, D. 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Cardiopulmonary bypass is commonly used during cardiac surgery for adults, children, and neonates. It relies on a motorized extracorporeal circuit and membrane oxygenator that work together to oxygenate blood and provide pulmonary and cardiac stabilization. Previous studies have demonstrated that CPB may adversely impact many organ systems (renal, cerebral, pulmonary, cardiac, gastrointestinal) both in ill and formerly healthy patients22,23,<sup class=...

Congenital heart disease (CHD) is the most prevalent congenital malformation, with about one million births impacted&#160;worldwide per year1. Though modern advances in cardiothoracic surgery (CTS) and intensive care treatment have improved mortality rates, comorbidities remain extremely common2,3,4,5. Neurodevelopmental abnormalities, including cognitive and motor impairments as well as learning disabilities, are reported in around 25%-50% of these patients6,7,8. Surgery during the first days of life, especially those that require circulatory and cardiac arrest (CA), has been demonstrated to increase morbidity9. Hemodynamic alterations during surgery may have an important effect on the vulnerable developing newborn brain. Experimental models are essential to better understand the origin of these abnormalities and investigate neuroprotective strategies to improve the prognoses of these patients.
The use of animal models to study this population has been widely documented5,10,11,12,13,14. Notably, piglets offer an excellent option, given close approximations in cardiac anatomy (Figure 1), genome, and physiology, as well as their relatively larger size in comparison to other animal models15 (Figure 2). The use of piglet models to study the effects of both cardiopulmonary bypass (CPB) and CA has been previously described. These experimental animal models are useful for studying hemodynamic changes and associated end-tissue organ complications14,16,17,18,19,20. These models were developed to allow researchers to study human conditions in a controlled setting, with flexibility for a variety of experimental conditions. Most studies report the use of central cannulation, a technique that demands advanced surgical skills, requires higher resource utilization, and makes it difficult to ensure long-term survival. Though previous studies have documented the use of piglets in studying CPB12,15, few have proposed the peripheral cannulation technique.
This new peripheral cannulation technique is easier, less aggressive, and more feasible when compared to other published studies19. Moreover, validating this technique in newborns and small animals is novel and should be considered for use by all researchers interested in using an animal model to study CHD and its associated comorbidities. It is particularly appropriate for individuals with access to a laboratory equipped with supplies, resources, and personnel experienced in conducting animal model experiments.
In summary, the main aim of this study is to describe and validate a neonatal piglet model of CPB with CA. The protocol aims to study severe brain damage and other possible complications of CPB surgery in a controlled setting with varying experimental conditions. This method provides a model that is generalizable, reliable, and of high quality, which can be used for a wide variety of experimental protocols.

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			<td>1.5% sevofluorane</td>
			<td>Zoetis</td>
			<td>20070289</td>
			<td></td>
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			<td>2.5 mm endotracheal tube</td>
			<td>Henry Schein</td>
			<td>988-1782</td>
			<td></td>
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			<td>3 Fr catheter for peripheral arterial access</td>
			<td>Prodimed</td>
			<td>3872.1</td>
			<td></td>
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			<td>4 Fr catheter for peripheral venous access</td>
			<td>Prodimed</td>
			<td>3872.13</td>
			<td></td>
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			<td>6 French ECMO pediatric arterial cannula&#160;</td>
			<td>Medtronic&#160;</td>
			<td>77206</td>
			<td></td>
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			<td>8 French ECMO pediatric venous cannula&#160;</td>
			<td>Medtronic&#160;</td>
			<td>68112</td>
			<td></td>
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			<td>Adrenaline</td>
			<td>B Braun</td>
			<td>469801-1119</td>
			<td></td>
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			<td>Adson forceps</td>
			<td>Allgaier instruments</td>
			<td>08-030-130</td>
			<td>Any brand may be substituted</td>
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			<td>BP cuff&#160;</td>
			<td>Mindray</td>
			<td></td>
			<td></td>
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			<td>Buprenorfine (0.01 mg/kg)</td>
			<td>Richter Pharma</td>
			<td>#9004114000537</td>
			<td></td>
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			<td>Calcium gluconate (2.25 mmol/10 mL)</td>
			<td>B Braun</td>
			<td>570-12606194-1119</td>
			<td></td>
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		<tr>
			<td>Dexmedetomidine (0.5-2.0 &#181;g/kg/min)</td>
			<td>Orion farma</td>
			<td>GTN 064321000017253</td>
			<td></td>
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			<td>Dolethol</td>
			<td>vetoquinol</td>
			<td>#3605870004904</td>
			<td></td>
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			<td>Dopamine</td>
			<td>hikma</td>
			<td>A044098010</td>
			<td></td>
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			<td>Fentanyl (25-200 &#181;g/kg/min)</td>
			<td>Kern Pharma</td>
			<td>756650.2H</td>
			<td></td>
		</tr>
		<tr>
			<td>Fresh donor pig blood Type O</td>
			<td>Any&#160;</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Heat Exchanger</td>
			<td>Maquet Gmbh &#38; Co</td>
			<td>MCP70107.2130</td>
			<td></td>
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			<td>Heparin (1350 UI)</td>
			<td>ROVI</td>
			<td>641641.1</td>
			<td></td>
		</tr>
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			<td>Irwin retractor</td>
			<td>Aesculap</td>
			<td>BV104R</td>
			<td>Any brand may be substituted</td>
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			<td>Ketamine (20 mg/kg)</td>
			<td>Richter Pharma</td>
			<td>#9004114000452</td>
			<td></td>
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			<td>Lubricant</td>
			<td>Any orotracheal lubricant</td>
			<td></td>
			<td></td>
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			<td>Midazolam (0.3 mg/kg)</td>
			<td>Serra Pamies</td>
			<td>619627.4</td>
			<td></td>
		</tr>
		<tr>
			<td>Mosquito forceps</td>
			<td>Aesculap</td>
			<td>BH109R</td>
			<td>Any brand may be substituted</td>
		</tr>
		<tr>
			<td>Needle forceps</td>
			<td>Aesculap</td>
			<td>BM016R</td>
			<td>Any brand may be substituted</td>
		</tr>
		<tr>
			<td>Normal&#160;saline (0.9%)</td>
			<td>B Braun Fisiovet</td>
			<td>5/469827/0610</td>
			<td>Any brand may be substituted</td>
		</tr>
		<tr>
			<td>Plastic clamps for tubing</td>
			<td>Achim Schulz-Lauterbach</td>
			<td>DBGM</td>
			<td>Any brand may be substituted</td>
		</tr>
		<tr>
			<td>Potassium chloride (9 mEq)</td>
			<td>B Braun</td>
			<td>3545156</td>
			<td></td>
		</tr>
		<tr>
			<td>Propofol (0.5 mg/kg)</td>
			<td>Zoetis</td>
			<td>579742.7</td>
			<td></td>
		</tr>
		<tr>
			<td>Quadrox Membrane Oxygenator&#160;</td>
			<td>Maquet Gmbh &#38; Co</td>
			<td>BE-HMOSD 300000</td>
			<td></td>
		</tr>
		<tr>
			<td>Rectal thermometer</td>
			<td>Any</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>RotaFlow Console ECMO system&#160;</td>
			<td>Maquet Gmbh &#38; Co</td>
			<td>MCP00703177</td>
			<td>Neonatal ECMO System</td>
		</tr>
		<tr>
			<td>Scalpel</td>
			<td>Aesculap</td>
			<td>BB074R</td>
			<td>Any brand may be substituted</td>
		</tr>
		<tr>
			<td>Sodium bicarbonate (1 M)</td>
			<td>Fresenius Kabi</td>
			<td>634477.4 OH</td>
			<td></td>
		</tr>
		<tr>
			<td>Surgical scissors</td>
			<td>Talmed Inox</td>
			<td>112</td>
			<td>Any brand may be substituted</td>
		</tr>
		<tr>
			<td>Suture (3/0 poly absorbable)</td>
			<td>B Braun Novosyn (R)</td>
			<td>0068030N1</td>
			<td>Any brand may be substituted</td>
		</tr>
	</tbody>
</table>

pediatric animal model of extracorporeal cardiopulmonary resuscitation after prolonged circulatory arrest

Congenital heart disease (CHD) is the most prevalent congenital malformation, with about one million births impacted worldwide per year. Comprehensive investigation of this disease requires appropriate and validated animal models. Piglets are commonly used for translational research due to their analogous anatomy and physiology. This work aimed to describe and validate a neonatal piglet model of cardiopulmonary bypass (CPB) with circulatory and cardiac arrest (CA) as a tool for studying severe brain damage and other complications of cardiac surgery. In addition to including a list of materials, this work provides a roadmap for other investigators to plan and execute this protocol. After experienced practitioners performed several trials, the representative results of the model demonstrated a 92% success rate, with failures attributed to small piglet size and variant vessel anatomy. Furthermore, the model allowed practitioners to select from a wide variety of experimental conditions, including varying times in CA, temperature alterations, and pharmacologic interventions. In summary, this method uses materials readily available in most hospital settings, is reliable and reproducible, and can be widely employed to enhance translational research in children undergoing heart surgery.

Author Spotlight: Simulating Pediatric Cardiac Surgery Using a Neonatal Piglet Model

Pediatric Animal Model of Extracorporeal Cardiopulmonary Resuscitation After Prolonged Circulatory Arrest

Mortality rates for children with congenital heart defects have improved significantly in recent years given improvements in cardiac surgery. However, comorbidities remain extremely common, and that's the goal of our lab. We aim to investigate these comorbidities, uncover underlying causes, and develop preventative measures.Right now, we are studying neuro abnormalities that develop after cardiac surgery. This protocol offers a feasible and reproducible animal model of simulating pediatric cardiac surgery. So with that, researchers can use it as a base to test many different experimental conditions and a wide variety of other hypotheses.The peripheral cannulation technique for porcine cardiopulmonary bypass in our model is both practical and cost effective. Furthermore, it does allow a more reliable way to assess postoperative outcomes than the traditional central cannulation technique. The flexibility of our model encourages future work in congenital heart disease and comorbidity studies.For example, our lab is currently planning to expand this model to study real-time monitoring of cerebral parameters such as oxygenation status and cerebral blood flow.

During a 6 month period, the complete protocol was performed 12 times by an interdisciplinary team of pediatric critical care physicians, pediatric cardiologists, veterinarians, and technicians (Supplementary Figure 2 and Supplementary Figure 3).
Figure 1&#160;and Figure 2 demonstrate the expected anatomy of the animals used in this protocol. The included piglets were an average of 4.8 days old (4-6 d...

Watch this Scientific Journal Video about Author Spotlight: Simulating Pediatric Cardiac Surgery Using a Neonatal Piglet Model at JoVE.com

This protocol describes a neonatal porcine model of cardiopulmonary bypass (CPB), with circulatory and cardiac arrest as a tool for studying severe brain damage and other complications secondary to CPB.

Congenital heart disease (CHD) is the most prevalent congenital malformation, with about one million births impacted worldwide per year. Comprehensive ...

pediatric-animal-model-extracorporeal-cardiopulmonary-resuscitation

Research

JoVE Journal

Medicine

Cardiopulmonary Bypass (CPB) Circuit Setup for Cardiac Arrest and Resuscitation in Pediatric Animal Model

To begin, place the four-to-six-days-old anesthetized piglet in the dorsal recumbent position. After performing orotracheal intubation using a cuffed tube, auscultate the lung bases to confirm appropriate endotracheal tube placement. Set up mechanical ventilation and continuously monitor the depth of anesthesia during surgery through heart rate, blood pressure, and oxygen saturation.Adjust ventilatory and sedation parameters as required. Then insert a 3 French catheter in the femoral artery, followed by a 4 French catheter in the vein. Next, initiate the cardiopulmonary bypass, or CPB, circuit set up by shortening the CPB tubing while maintaining enough distance between the animal and the machine.Create a tubing bridge to connect the membrane oxygenator outflow and pump inflow. Once all the connection points are sealed, sweep the circuit with 300 microliters of heparin saline solution and 300 milliliters of fresh donor pig blood, followed by sodium bicarbonate, heparin, and calcium gluconate. Once the CPB circuit is ready, expose the left internal jugular vein, and insert the needle catheter into it.Similarly, expose the right carotid artery to prepare for cannulation. Once a blood flash is visible, carefully insert a guide wire into the vessel. Thread a dilator over the wire and into the vessel.Then remove the dilator. Slowly thread an 8 French venous cannula approximately four centimeters into the vessel, and remove the wire, ensuring the cannula remains in place. Then place a 6 French pediatric arterial cannula into the right carotid artery as previously demonstrated with dilation.Finally, administer an intravenous heparin bolus through the newly placed arterial cannula. After achieving access, use 3-0 absorbable sutures to fix both cannulas to the animal, and tape to prevent inadvertent removal. Connect the cannulas to the CPB circuit, ensuring heparin saline is added to the connection points to prevent air in the circuit.Set the initial flow to 80 to 85 milliliters per kilogram per minute. To induce cardiac arrest, administer nine milliequivalents of potassium chloride. Once the heart is stopped, isolate the animal from the circuit.Then maintain the CPB circuit flow to circulate at 1, 500 RPM. After achieving appropriate cardiac arrest conditions, begin extracorporeal cardiopulmonary resuscitation by reconnecting the piglet to the CPB circuit. Administer three milliliters of calcium gluconate and six milliliters of sodium bicarbonate through peripheral arterial access, adding doses as necessary.The vessel cannulation and CPB with cardiac arrest achieved a 92%success rate in the experiments. MRIs demonstrated clear signs of early brain damage in the CPB with cardiac arrest animals compared to control. The acute diffusion tensor imaging modality better identified the signs of infarction than other conventional MRI sequences.