Factor XII promotes the thromboinflammatory response in a rat model of venoarterial extracorporeal membrane oxygenation

Mousa Kharnaf; Farhan Zafar; Spencer Hogue; Leah Rosenfeldt; Rachel L Cantrell; Bal Krishan Sharma; Amelia Pearson; Cassandra Sprague; Daniel Leino; William A Abplanalp; Wioleta M Zelek; Keith R McCrae; Young Jun Shim; David Morales; James Tweddell; Joseph E Qualls; Joseph S Palumbo

doi:10.1016/j.jtcvs.2023.08.045

Factor XII promotes the thromboinflammatory response in a rat model of venoarterial extracorporeal membrane oxygenation

J Thorac Cardiovasc Surg. 2023 Sep 7:S0022-5223(23)00756-0. doi: 10.1016/j.jtcvs.2023.08.045. Online ahead of print.

Authors

Mousa Kharnaf¹, Farhan Zafar², Spencer Hogue², Leah Rosenfeldt³, Rachel L Cantrell³, Bal Krishan Sharma³, Amelia Pearson³, Cassandra Sprague³, Daniel Leino⁴, William A Abplanalp², Wioleta M Zelek⁵, Keith R McCrae⁶, Young Jun Shim⁶, David Morales², James Tweddell², Joseph E Qualls⁷, Joseph S Palumbo⁸

Affiliations

¹ The Heart Institute, Cincinnati Children's Hospital Medical Center and The University of Cincinnati College of Medicine, Cincinnati, Ohio. Electronic address: moosakernaf@gmail.com.
² The Heart Institute, Cincinnati Children's Hospital Medical Center and The University of Cincinnati College of Medicine, Cincinnati, Ohio.
³ Cancer and Blood Disease Institute, Cincinnati Children's Hospital Medical Center and The University of Cincinnati College of Medicine, Cincinnati, Ohio.
⁴ Department of Pathology, Cincinnati Children's Hospital Medical Center and The University of Cincinnati College of Medicine, Cincinnati, Ohio.
⁵ Systems Immunity Research Institute and Dementia Research Institute, Cardiff University, Cardiff, United Kingdom.
⁶ Department of Cardiovascular and Metabolic Sciences, Cleveland Clinic, Cleveland, Ohio.
⁷ Department of Biological Sciences, St Elizabeth College of Natural and Health Sciences, Thomas More University, Crestview Hills, Ky.
⁸ Cancer and Blood Disease Institute, Cincinnati Children's Hospital Medical Center and The University of Cincinnati College of Medicine, Cincinnati, Ohio. Electronic address: joe.palumbo@cchmc.org.

PMID: 37683721
PMCID: PMC10918029 (available on 2025-03-07)
DOI: 10.1016/j.jtcvs.2023.08.045

Abstract

Background: Factor XII (FXII) is a multifunctional protease capable of activating thrombotic and inflammatory pathways. FXII has been linked to thrombosis in extracorporeal membrane oxygenation (ECMO), but the role of FXII in ECMO-induced inflammatory complications has not been studied. We used novel gene-targeted FXII- deficient rats to evaluate the role of FXII in ECMO-induced thromboinflammation.

Methods: FXII-deficient (FXII^-/-) Sprague-Dawley rats were generated using CRISPR/Cas9. A minimally invasive venoarterial (VA) ECMO model was used to compare wild-type (WT) and FXII^-/- rats in 2 separate experimental cohorts: rats placed on ECMO without pharmacologic anticoagulation and rats anticoagulated with argatroban. Rats were maintained on ECMO for 1 hour or until circuit failure occurred. Comparisons were made with unchallenged rats and rats that underwent a sham surgical procedure without ECMO.

Results: FXII^-/- rats were maintained on ECMO without pharmacologic anticoagulation with low resistance throughout the 1-hour experiment. In contrast, WT rats placed on ECMO without anticoagulation developed thrombotic circuit failure within 10 minutes. Argatroban provided a means to maintain WT and FXII^-/- rats on ECMO for the 1-hour time frame without thrombotic complications. Analyses of these rats demonstrated that ECMO resulted in increased neutrophil migration into the liver that was significantly blunted by FXII deficiency. ECMO also resulted in increases in high molecular weight kininogen cleavage and complement activation that were abrogated by genetic deletion of FXII.

Conclusions: FXII initiates hemostatic system activation and key inflammatory sequelae in ECMO, suggesting that therapies targeting FXII could limit both thromboembolism and inopportune inflammatory complications in this setting.

Keywords: complement; extracorporeal circulation; factor XII; high molecular weight cleavage; inflammation; neutrophil.

Grants and funding

R01 HL160582/HL/NHLBI NIH HHS/United States