In this perspective we address a fundamental and unresolved issue in biomaterials science: What are the molecular mechanisms which make a material blood compatible - or not? Despite the widespread use and the billion-dollar industry producing medical devices and implants, there is still a lack of fundamental understanding of the –admittedly– complicated and interlinked reactions that occur when an artificial material is exposed to blood. The increasing number of clinical reports about in vivo dysfunctional cardiovascular devices underlines the importance to understand –and be able to predict– the pathophysiological events occurring upon contact of blood with “hemocompatible” materials. The missing knowledge about the pathophysiological processes in the material/blood interphase and the lack of reliable correlations between in vitro-in vivo experiments, hinders us to develop scientific design principles to avoid complications in a clinical situation and achieve the optimal and lasting treatment. One may ask why this is the case, despite the huge research efforts taking place in laboratories worldwide to improve existing biomaterials and to develop new and better ones. One reason is certainly the analytical, intellectual and financial efforts it takes to unravel the interlinked biochemical reactions taking place in the interphase between the material and the body. But what actually slows the scientific community from developing models and theories on hemocompatibility is the fact that hardly any publication targeted at developing hemocompatible biomaterials conducts and describes the experiments and results in enough detail to allow a direct comparison to data in the literature or results of other laboratories. The lack of defined and certified positive or negative standards and experimental protocols even prevents us from concluding if a material is relatively better than another material, which may or may not be in use in medical practice. Hence, the literature is full with claims for “new” or “better” biomaterials, which have not undergone an in vitro side by side comparison to a standard, nor animal tests or clinical evaluation. If such in vitro comparisons with accepted standards would be performed according to standardized protocols, respective reports could contribute in a meaningful way to a database, which ultimately would provide the basis for a roadmap to better implants.
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