The pathogenesis of pneumococcus infections is characterized by a multifaceted interaction with a diversity of extracellular matrix compounds and components of the human hemostasis, such as plasminogen and VWF1,2,3,4,5,6,7,8. The multidomain glycoprotein VWF serves as key regulator of a balanced hemostasis by mediating thrombocyte recruitment and fibrin incorporation at the site of vascular thrombus formation9. The importance of functional, active VWF for bleeding control and wound healing is demonstrated by von Willebrand’s disease, a common inherited bleeding disorder10.
Globular VWF circulates in the human blood system at a concentration of up to 14.0 µg/mL11,10. In response to vascular injury, the local release of VWF by endothelial Weibel Palade Bodies (WBP) is markedly increased11,12. Previous studies show that pneumococcus adherence to human endothelial cells and its production of the pore-forming toxin pneumolysin significantly stimulates luminal VWF secretion13. The hydrodynamic forces of the blood flow induce a structural opening of the mechanoresponsive VWF domains. At flow rates of 10 dyn/cm2 the VWF multimerizes to long protein strings of up to several hundred micrometers in length that remain attached to the subendothelium10,12.
To understand the function of multimerized VWF strings generated under shear stress in the interaction of pneumococcus with the endothelial surface, a microfluidic-based cell culture infection approach was established. A microfluidic device with a software-controlled air-pressure pump system was used. This enabled a continuous, unidirectional recirculation of cell culture medium with a defined flow rate. Thereby, the system applied a defined shear stress on the surface of endothelial cells, which remained attached inside specialized channel slides. This approach enabled the simulation of the shear force within the blood stream of the human vascular system, in which VWF strings are generated on differentiated endothelial cells under defined constant flow conditions. For this purpose, the endothelial cells were cultivated in specific channel slides (see Table of Materials), which were adapted for microscopic analyses during flow. The microfluidic pump system provided the highly defined and controlled shear stress situation required for the formation of extended VWF strings on the confluent endothelial cell layer. After the stimulation of VWF-secretion of confluently grown human umbilical vein endothelial cells (HUVEC) by histamine supplementation, the string formation was induced by applying a shear stress (ԏ) of 10 dyn/cm2. The shear stress is defined as the force acting on the cell layer. It is calculated approximately according to Cornish et. al.14 with equation 1:

Where ԏ = shear stress in dyn/cm2, η = viscosity in (dyn∙s)/cm2, h =half of channel height, w = half of channel width, and Φ = flowrate in mL/min.
The result of equation 1 depends on the different heights and widths of the different slides used (see Table of Materials). In this study a Luer channel slide of 0.4 µm resulting in a chamber slide factor of 131.6 was used (see formula 2).

Viscosity of the medium at 37 °C is 0.0072 dyn∙s/cm² and a shear stress of 10 dyn/cm² was used. This resulted in a flow rate of 10.5 mL/min (see formula 3).

Here, the adaptation and advancement of a microfluidic cell culturing procedure using a unidirectional laminar flow system for the investigation and visualization of bacterial infection mechanisms in the host vasculature is described in detail. The generation of VWF strings on endothelial layers can also be stimulated by using other pump systems that are able to apply a continuous and steady shear stress15.
After cultivation of primary endothelial cells to confluence in flow and stimulation of VWF string formation, pneumococci expressing red fluorescence protein (RFP)16 were added to the endothelial cell layer under constant microscopic control. The attachment of bacteria to VWF strings on the surface of endothelial cells was microscopically visualized and monitored for up to three hours in real time by using VWF-specific fluorescent-labelled antibodies. With this approach, the role of VWF as an adhesion cofactor promoting bacterial attachment to the vascular endothelium was determined8.
In addition to the microscopic visualization of protein secretion and conformational changes, this method could be used to monitor single steps of bacterial infection processes in real time and to quantify the amount of attached bacteria at different time points of infection. The specific software-controlled pump system also provides the possibility to culture the endothelial cells in defined constant flow conditions for up to several days and enables a defined pulsed medium flow incubation. Moreover, this method can be applied using different cell types. Adapting the staining protocol also enables the detection and visualization of bacteria internalized into eukaryotic cells.
This manuscript describes this advanced experimental protocol that can be used as a defined, reliable, and reproducible approach for an efficient and versatile characterization of pathophysiological processes.