1. Introduction
Artificial biomaterials contacting blood are widely used in implantable cardiovascular devices, including heart valves and left ventricular assist devices (LVADs). A significant challenge in the application of artificial biomaterials is surface-induced thrombosis, which results from protein adsorption, platelet adhesion, and activation [
1,
2]. Therefore, long-term coagulation management is required. However, this comes with its own risks, primarily an increased chance of hemorrhage [
3]. Research indicates that patients with mechanical prosthetic heart valves face a significant risk of bleeding or clotting, with an accumulated risk as high as six percent per patient-year [
4]. A report on patients with advanced heart failure who were treated with HeartMate 3 LVAD presented major bleeding events of 0.61 per patient-year, the greatest among all major adverse events [
5].
This phenomenon starts with circulating plasma protein absorption on blood-contacting artificial material surface -- smaller proteins like human serum albumin, followed by larger proteins such as fibrinogen [
6]. The adsorbed fibrinogen provides binding sites for platelets, which then become activated and release factors that promote further platelet aggregation and coagulation [
7]. The foreign surface can also activate the intrinsic coagulation pathway through contact activation of Factor XII, leading to thrombin generation and fibrin formation [
6,
7]. This combination of activated platelets and the coagulation cascade results in the formation of a thrombus on the blood-wetted surfaces.
In contradistinction, endothelial cells (ECs) provide the natural thrombo-resistant lining of the blood-contacting surface and are deemed to be the only long-term hemocompatible material [
8,
9]. Healthy ECs utilize pathways such as the ecto-ADPase/CD39/NTPDase pathway, which limits the propagation of platelet activation and reduces the risk of thrombus formation; and the PGI2 and Nitric Oxide (NO) pathways, which inhibits platelet activation and aggregation through the stimulation of cAMP and cGMP production, respectively [
10].
Therefore, there is a clear benefit to endothelialize cardiovascular implants [
6,
11]. One method of promoting endothelialization is through surface modification processes [
12]. For instance, surfaces covered with microspheres (aka. sintering) are currently used in left ventricular assist devices (LVADs) [
13]. Such sintered surface topography is adopted in the hope of growing neointima tissue and a continuous endothelium lining to shield the artificial surface from direct contact with blood, ultimately reducing surface thrombogenicity [
13,
14]. Unfortunately, studies published over the decades indicate that surface sintering can lead to unpredictable results, hence it is not a reliable method to avoid thromboembolism [
13]. A critical limiting factor is the supraphysiological wall shear stress (WSS) commonly occurring in medical devices [
15,
16]. This limits endothelial attachment, and causes embolization. For example, the typical WSS associated with mechanical valve leaflets can range from 250 to 750 dynes/cm
2 [
17,
18], far in excess of the normal WSS in blood vessels (less than 50 dynes/cm
2) that allows endothelium to maintain its monolayer structure and perform its anticoagulation function [
16].
Previous studies have shown that creating groove-like surface topography, named “microtrenches,” can enhance EC retention in a supraphysiological shear environment, and consequently reduce platelet adhesion [
17,
19,
20,
21,
22,
23,
24]. The underlying mechanism is that trenches create one or more vortices that attenuate WSS to a level tolerable for ECs. Daxini et al. created a grooving pattern of 32 μm deep and 35°, lowering WSS by 23% which helped to promote EC wound recovery [
22]. To work with the shear range above 500 dynes/cm
2, Frendl et al. created several fold deeper trenches in pyrolytic carbon [
23]. Therefore, the modified surface encouraged EC retention, inducing the release of anticoagulant molecules (e.g., nitric oxide) and reducing platelet adhesion greatly [
23]. The efficacy of “microtrenches” was demonstrated to provide EC protection for over 48 hours of perfusion [
23]. One of the objectives of the present study is to perform numerical simulations of these experimental results and further optimize the dimensions of the microtrench to maximize EC coverage. This is achieved by coupling automatic optimization software CAESES
® (Friendship Systems AG, Potsdam, Germany) with the open-source CFD toolkit OpenFOAM.
4. Discussion
This study presented a framework for optimizing the surface topography to promote endothelial cell retention and improve biocompatibility of implantable medical devices. Specifically, this study sought to optimize a trench-shaped surface topography under a single ultra-high shear environment, representative of the condition in devices such as mechanical prosthetic heart valves and inflow cannula of ventricular assist devices.
The optimization process began with pre-validated vertical microtrenches, investigating how the variation in the trench dimensions (height, width, and gaps) could influence the WSS profile and subsequently influence the EC coverage. However, the EC coverage achieved with this design was limited. The rationale for transitioning from vertical to trapezoidal trenches was twofold. Firstly, we observed that decreasing the gap between the vertical trenches did not result in a significant alteration of the WSS distribution inside the trench, as shown in
Figure S2, yet the partition between two trenches is guaranteed to have undesirable high shear. This finding motivated us to reduce the gap further to increase the EC coverage while maintaining the mechanical integrity of the topography. Secondly, although the WSS on the vertical trench can be optimal, it failed to increase the projected EC coverage on a limited area of surface.
It is worth noting that a few assumptions were made thence the key simplifications have been applied for computing at a reasonable expense yet achieving realistic results. First, we assumed a 2D parallel plate channel which was chosen to be consistent with the in vitro validation experiment. Second, a uniform inlet velocity was introduced, and an ample entrance length allowed for the flow field to become fully developed at the leading edge of the trench. Third, we applied a steady-state flow instead of the pulsatile blood flow, which does not account for the complexity of the flow in vivo. This simulation also does not account for biological responses beyond the initial interaction of platelet deposition. The behavior of endothelial cells and thrombosis formation could vary under different flow conditions, including endothelial cell migration, mitosis, and or the secretion of anti-thrombotic substances in response to the shear stress.
Future studies should address these limitations by incorporating the cellular interaction between the endothelium and the blood, the secretion and transport of the anti-thrombotic substances, and its effect on platelet activation and aggregation. Such a model could also be applied in complex flow conditions, e.g., pulsatile flow, to represent the physiological environment; and more complex geometries.
The width of the trenches was examined as a parameter that could not be optimized within the constraints of the study. It is illustrated through an extreme case, where the microtrenches are reduced to a parallel plate. See
Figure S3. Ideally, the wall shear stress is governed by the total height of the flow as explained in Equation (3):
where
represents the wall shear stress,
is the total height of the channel without trenches. We hypothesize that there exists a critical height of the channel (10.952 mm) so that the WSS equals the desired threshold (10 dynes/cm
2). To validate this mathematical interpretation, we set the height at the critical value and compared the projected area coverage with varying channel widths. Results show that the objective function approaches an asymptotic value while the w extends to infinity. See
Figure S3. This might result in an optimized design that has a width at the upper bound, such a value lacks practical meaning. In reality, the width of the trench is constrained by manufacturing limitations, mechanical stability, and other factors. Though it is not directly optimized, its selection is still guided by practical applications. Nevertheless, the addition of microtrenches will promote endothelial retention and can be improved through optimal selection of geometric parameters.
As a proof of concept of our optimized geometry, we evaluated endothelial retention on the trapezoidal microtrench by embossing a 45° trapezoidal geometry (shown using fluorescence image in
Figure 5 (d) on a polymeric substrate. We then coated the embossed channel with collagen and seeded the channels with endothelial cells. CFD simulation
Figure 5 (a) determined that the ECs experienced a shear range about 5-fold less than the applied bulk shear (120 dyn/cm
2), which supports the throttling capacity of the trapezoidal microtrench. Also, we found that the trench surface provided three times the surface area (Upstream, Base, and Downstream) in comparison to flat control, effectively increasing the surface area for EC adhesion. Twenty-four hours post-seeding, we applied continuous shear at a maximum pump flow rate for 48 hours. Endothelial retention on the flat microtrench control was completely diminished as shown in
Figure 5 (b). However, we found a retained, confluent EC monolayer with visible junction integrity in the Upstream (U), Base(B), and Downstream (D) regions of the no-flow control microtrench (
Figure 5 (c)) and sheared sample microtrench (
Figure 5 (e)). Immunofluorescence staining showed expressed endothelial cell junction as marked by VE Caherin stain (CD144 monoclonal antibody, Bio-Rad, United States). Although comparable, we observed significant differences in endothelial coverage area fraction between the different regions of the sheared microtrench (84%, 87%, and 82%) vs. control (74%, 77%, and 69%) as shown in
Figure 5 (f).
The above validates endothelial retention in the optimized trapezoidal microtrench under high shear stress, as ECs remain adhered to the microtrench channel, similar to Frendl et al. [
23]. The downstream region in sheared samples showed higher degradation, which can be attributed to the force of fluid against the downstream wall. Furthermore, the endothelial retention rate corroborates our CFD optimization as we observed above 50% retention rate at the different regions within the microtrench post-shear, thus alluding to its potential to support more EC segments for monolayer formation. Although the height, width, and angle used in this experiment vary from the optimized geometry and cell culture medium was adopted to assess the long-term retention of the ECs, the results of EC retention on such microtrench were encouraging regarding the feasibility of seeding and the protection of the EC monolayer. In the future, we plan to address the difference between the simulation and the experiment and examine the effect of anti-platelet on the EC-coated microtrenches by incorporating blood as a fluid medium.
Author Contributions
Conceptualization, W.H. and J.F.A.; methodology, W.H., A.M.I., and A.K.; software, W.H. and A.K.; validation, W.H.; formal analysis, W.H.; investigation, W.H.; resources, J.F.A. and J.B.; data curation, W.H.; writing—original draft preparation, W.H., A.M.I., and S.T.; writing—review and editing, A.K., J.B., and J.F.A.; visualization, W.H. and A.M.I.; supervision, J.B. and J.F.A.; project administration, J.F.A.; funding acquisition, J.F.A. All authors have read and agreed to the published version of the manuscript.