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Penov K, Haugen MA, Radakovic D, Hamouda K, Gorski A, Leyh R, Bening C. Decellularized Pulmonary Xenograft Matrix PplusN versus Cryopreserved Homograft for RVOT Reconstruction during Ross Procedure in Adults. Thorac Cardiovasc Surg 2024; 72:205-213. [PMID: 34972237 DOI: 10.1055/s-0041-1740539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Decellularized pulmonary homografts are being increasingly adopted for right ventricular outflow tract reconstruction in adult patients undergoing the Ross procedure. Few reports presented Matrix PplusN xenograft (Matrix) in a negative light. The objective of this study was to compare our midterm outcomes of Matrix xenograft versus standard cryopreserved pulmonary homograft (CPHG). METHODS Eighteen patients received Matrix xenograft between January 2012 and June 2016, whereas 66 patients received CPHG. Using nonparametric statistical tests and survival analysis, we compared midterm echocardiographic and clinical outcomes between the groups. RESULTS Except for significant age difference (the Matrix group was significantly older with 57 ± 8 years than the CPHG group, 48 ± 9 years, p = 0.02), the groups were similar in all other baseline characteristics. There were no significant differences in cardiopulmonary bypass times (208.3 ± 32.1 vs. 202.8 ± 34.8) or in cross-clamp times (174 ± 33.9 vs. 184.4 ± 31.1) for Matrix and CPHG, respectively. The Matrix group had significantly inferior freedom from reintervention than the CPHG group with 77.8 versus 98.5% (p = 0.02). Freedom from pulmonary valve regurgitation ≥ 2 was not significantly different between the groups with 82.4 versus 90.5% for Matrix versus CPHG, respectively. After median follow-up of 4.9 years, Matrix xenograft developed significantly higher peak pressure gradients compared with CPHG (20.4 ± 15.5 vs. 12.2 ± 9.0 mm Hg; p = 0.04). CONCLUSION After 5 years of clinical and echocardiographic follow-up, the decellularized Matrix xenograft had inferior freedom from reintervention compared with the standard CPHG. Closer follow-up is necessary to avoid progression of valve failure into right ventricular deterioration.
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Affiliation(s)
- Kiril Penov
- Department of Thoracic and Cardiovascular Surgery, University Clinic Würzburg, Julius Maximilians University Würzburg, Würzburg, Bayern, Germany
| | | | - Dejan Radakovic
- Department of Thoracic and Cardiovascular Surgery, University Clinic Würzburg, Julius Maximilians University Würzburg, Würzburg, Bayern, Germany
| | - Khaled Hamouda
- Department of Thoracic and Cardiovascular Surgery, University Clinic Würzburg, Julius Maximilians University Würzburg, Würzburg, Bayern, Germany
| | - Armin Gorski
- Department of Thoracic and Cardiovascular Surgery, University Clinic Würzburg, Julius Maximilians University Würzburg, Würzburg, Bayern, Germany
| | - Rainer Leyh
- Department of Thoracic and Cardiovascular Surgery, University Clinic Würzburg, Julius Maximilians University Würzburg, Würzburg, Bayern, Germany
| | - Constanze Bening
- Department of Thoracic and Cardiovascular Surgery, University Clinic Würzburg, Julius Maximilians University Würzburg, Würzburg, Bayern, Germany
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2
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Konsek H, Sherard C, Bisbee C, Kang L, Turek JW, Rajab TK. Growing Heart Valve Implants for Children. J Cardiovasc Dev Dis 2023; 10:jcdd10040148. [PMID: 37103027 PMCID: PMC10143004 DOI: 10.3390/jcdd10040148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/28/2023] [Accepted: 03/29/2023] [Indexed: 04/03/2023] Open
Abstract
The current standard of care for pediatric patients with unrepairable congenital valvular disease is a heart valve implant. However, current heart valve implants are unable to accommodate the somatic growth of the recipient, preventing long-term clinical success in these patients. Therefore, there is an urgent need for a growing heart valve implant for children. This article reviews recent studies investigating tissue-engineered heart valves and partial heart transplantation as potential growing heart valve implants in large animal and clinical translational research. In vitro and in situ designs of tissue engineered heart valves are discussed, as well as the barriers to clinical translation.
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3
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Biological Scaffolds for Congenital Heart Disease. BIOENGINEERING (BASEL, SWITZERLAND) 2023; 10:bioengineering10010057. [PMID: 36671629 PMCID: PMC9854830 DOI: 10.3390/bioengineering10010057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 12/20/2022] [Accepted: 12/26/2022] [Indexed: 01/05/2023]
Abstract
Congenital heart disease (CHD) is the most predominant birth defect and can require several invasive surgeries throughout childhood. The absence of materials with growth and remodelling potential is a limitation of currently used prosthetics in cardiovascular surgery, as well as their susceptibility to calcification. The field of tissue engineering has emerged as a regenerative medicine approach aiming to develop durable scaffolds possessing the ability to grow and remodel upon implantation into the defective hearts of babies and children with CHD. Though tissue engineering has produced several synthetic scaffolds, most of them failed to be successfully translated in this life-endangering clinical scenario, and currently, biological scaffolds are the most extensively used. This review aims to thoroughly summarise the existing biological scaffolds for the treatment of paediatric CHD, categorised as homografts and xenografts, and present the preclinical and clinical studies. Fixation as well as techniques of decellularisation will be reported, highlighting the importance of these approaches for the successful implantation of biological scaffolds that avoid prosthetic rejection. Additionally, cardiac scaffolds for paediatric CHD can be implanted as acellular prostheses, or recellularised before implantation, and cellularisation techniques will be extensively discussed.
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Barbulescu GI, Bojin FM, Ordodi VL, Goje ID, Barbulescu AS, Paunescu V. Decellularized Extracellular Matrix Scaffolds for Cardiovascular Tissue Engineering: Current Techniques and Challenges. Int J Mol Sci 2022; 23:13040. [PMID: 36361824 PMCID: PMC9658138 DOI: 10.3390/ijms232113040] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 10/18/2022] [Accepted: 10/26/2022] [Indexed: 08/13/2023] Open
Abstract
Cardiovascular diseases are the leading cause of global mortality. Over the past two decades, researchers have tried to provide novel solutions for end-stage heart failure to address cardiac transplantation hurdles such as donor organ shortage, chronic rejection, and life-long immunosuppression. Cardiac decellularized extracellular matrix (dECM) has been widely explored as a promising approach in tissue-regenerative medicine because of its remarkable similarity to the original tissue. Optimized decellularization protocols combining physical, chemical, and enzymatic agents have been developed to obtain the perfect balance between cell removal, ECM composition, and function maintenance. However, proper assessment of decellularized tissue composition is still needed before clinical translation. Recellularizing the acellular scaffold with organ-specific cells and evaluating the extent of cardiomyocyte repopulation is also challenging. This review aims to discuss the existing literature on decellularized cardiac scaffolds, especially on the advantages and methods of preparation, pointing out areas for improvement. Finally, an overview of the state of research regarding the application of cardiac dECM and future challenges in bioengineering a human heart suitable for transplantation is provided.
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Affiliation(s)
- Greta Ionela Barbulescu
- Immuno-Physiology and Biotechnologies Center (CIFBIOTEH), Department of Functional Sciences, “Victor Babes” University of Medicine and Pharmacy, No 2 Eftimie Murgu Square, 300041 Timisoara, Romania
- Department of Clinical Practical Skills, “Victor Babes” University of Medicine and Pharmacy, No 2 Eftimie Murgu Square, 300041 Timisoara, Romania
| | - Florina Maria Bojin
- Immuno-Physiology and Biotechnologies Center (CIFBIOTEH), Department of Functional Sciences, “Victor Babes” University of Medicine and Pharmacy, No 2 Eftimie Murgu Square, 300041 Timisoara, Romania
- Clinical Emergency County Hospital “Pius Brinzeu” Timisoara, Center for Gene and Cellular Therapies in the Treatment of Cancer Timisoara-OncoGen, No 156 Liviu Rebreanu, 300723 Timisoara, Romania
| | - Valentin Laurentiu Ordodi
- Clinical Emergency County Hospital “Pius Brinzeu” Timisoara, Center for Gene and Cellular Therapies in the Treatment of Cancer Timisoara-OncoGen, No 156 Liviu Rebreanu, 300723 Timisoara, Romania
- Faculty of Industrial Chemistry and Environmental Engineering, “Politehnica” University Timisoara, No 2 Victoriei Square, 300006 Timisoara, Romania
| | - Iacob Daniel Goje
- Department of Medical Semiology I, “Victor Babes” University of Medicine and Pharmacy, No 2 Eftimie Murgu Square, 300041 Timisoara, Romania
- Advanced Cardiology and Hemostaseology Research Center, “Victor Babes” University of Medicine and Pharmacy, No 2 Eftimie Murgu Square, 300041 Timisoara, Romania
| | - Andreea Severina Barbulescu
- Center for Advanced Research in Gastroenterology and Hepatology, Department of Internal Medicine II, Division of Gastroenterology and Hepatology, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Virgil Paunescu
- Immuno-Physiology and Biotechnologies Center (CIFBIOTEH), Department of Functional Sciences, “Victor Babes” University of Medicine and Pharmacy, No 2 Eftimie Murgu Square, 300041 Timisoara, Romania
- Clinical Emergency County Hospital “Pius Brinzeu” Timisoara, Center for Gene and Cellular Therapies in the Treatment of Cancer Timisoara-OncoGen, No 156 Liviu Rebreanu, 300723 Timisoara, Romania
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5
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Pulmonary valve replacement: a new paradigm with tissue engineering. Curr Probl Cardiol 2022:101212. [PMID: 35460681 DOI: 10.1016/j.cpcardiol.2022.101212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/13/2022] [Indexed: 11/21/2022]
Abstract
Prevalence of congenital heart diseases worldwide is around 9 per 1000 newborns, 20% of which affect the pulmonary valve or right ventricular outflow tract. As survival after surgical repair of these defects has improved over time, there is the need to address the long-term issues of older children and young adults with "repaired" congenital heart diseases. In recent decades, the most used types of valves are the mechanical and bioprosthetic valves. Despite improving patients' quality of life, these effects are suboptimal due to their limitations, such as the inability to grow and adapt to hemodynamic changes. These issues have led to the search for living valve solutions through tissue engineering to respond to these challenges. This review aims to review the performance of traditional pulmonary valves and understand how tissue engineering-based valves can improve the management of these patients.
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Naso F, Gandaglia A. Can Heart Valve Decellularization Be Standardized? A Review of the Parameters Used for the Quality Control of Decellularization Processes. Front Bioeng Biotechnol 2022; 10:830899. [PMID: 35252139 PMCID: PMC8891751 DOI: 10.3389/fbioe.2022.830899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 01/31/2022] [Indexed: 11/13/2022] Open
Abstract
When a tissue or an organ is considered, the attention inevitably falls on the complex and delicate mechanisms regulating the correct interaction of billions of cells that populate it. However, the most critical component for the functionality of specific tissue or organ is not the cell, but the cell-secreted three-dimensional structure known as the extracellular matrix (ECM). Without the presence of an adequate ECM, there would be no optimal support and stimuli for the cellular component to replicate, communicate and interact properly, thus compromising cell dynamics and behaviour and contributing to the loss of tissue-specific cellular phenotype and functions. The limitations of the current bioprosthetic implantable medical devices have led researchers to explore tissue engineering constructs, predominantly using animal tissues as a potentially unlimited source of materials. The high homology of the protein sequences that compose the mammalian ECM, can be exploited to convert a soft animal tissue into a human autologous functional and long-lasting prosthesis ensuring the viability of the cells and maintaining the proper biomechanical function. Decellularization has been shown to be a highly promising technique to generate tissue-specific ECM-derived products for multiple applications, although it might comprise very complex processes that involve the simultaneous use of chemical, biochemical, physical and enzymatic protocols. Several different approaches have been reported in the literature for the treatment of bone, cartilage, adipose, dermal, neural and cardiovascular tissues, as well as skeletal muscle, tendons and gastrointestinal tract matrices. However, most of these reports refer to experimental data. This paper reviews the most common and latest decellularization approaches that have been adopted in cardiovascular tissue engineering. The efficacy of cells removal was specifically reviewed and discussed, together with the parameters that could be used as quality control markers for the evaluation of the effectiveness of decellularization and tissue biocompatibility. The purpose was to provide a panel of parameters that can be shared and taken into consideration by the scientific community to achieve more efficient, comparable, and reliable experimental research results and a faster technology transfer to the market.
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7
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Tissue Engineered Transcatheter Pulmonary Valved Stent Implantation: Current State and Future Prospect. Int J Mol Sci 2022; 23:ijms23020723. [PMID: 35054905 PMCID: PMC8776029 DOI: 10.3390/ijms23020723] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 01/04/2022] [Accepted: 01/05/2022] [Indexed: 02/07/2023] Open
Abstract
Patients with the complex congenital heart disease (CHD) are usually associated with right ventricular outflow tract dysfunction and typically require multiple surgical interventions during their lives to relieve the right ventricular outflow tract abnormality. Transcatheter pulmonary valve replacement was used as a non-surgical, less invasive alternative treatment for right ventricular outflow tract dysfunction and has been rapidly developing over the past years. Despite the current favorable results of transcatheter pulmonary valve replacement, many patients eligible for pulmonary valve replacement are still not candidates for transcatheter pulmonary valve replacement. Therefore, one of the significant future challenges is to expand transcatheter pulmonary valve replacement to a broader patient population. This review describes the limitations and problems of existing techniques and focuses on decellularized tissue engineering for pulmonary valve stenting.
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Vafaee T, Walker F, Thomas D, Roderjan JG, Veiga Lopes S, da Costa FDA, Desai A, Rooney P, Jennings LM, Fisher J, Berry HE, Ingham E. Repopulation of decellularised porcine pulmonary valves in the right ventricular outflow tract of sheep: Role of macrophages. J Tissue Eng 2022; 13:20417314221102680. [PMID: 35782993 PMCID: PMC9243591 DOI: 10.1177/20417314221102680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 05/09/2022] [Indexed: 11/16/2022] Open
Abstract
The primary objective was to evaluate performance of low concentration SDS decellularised porcine pulmonary roots in the right ventricular outflow tract of juvenile sheep. Secondary objectives were to explore the cellular population of the roots over time. Animals were monitored by echocardiography and roots explanted at 1, 3, 6 (n = 4) and 12 months (n = 8) for gross analysis. Explanted roots were subject to histological, immunohistochemical and quantitative calcium analysis (n = 4 at 1, 3 and 12 months) and determination of material properties (n = 4; 12 months). Cryopreserved ovine pulmonary root allografts (n = 4) implanted for 12 months, and non-implanted cellular ovine roots were analysed for comparative purposes. Decellularised porcine pulmonary roots functioned well and were in very good condition with soft, thin and pliable leaflets. Morphometric analysis showed cellular population by 1 month. However, by 12 months the total number of cells was less than 50% of the total cells in non-implanted native ovine roots. Repopulation of the decellularised porcine tissues with stromal (α-SMA+; vimentin+) and progenitor cells (CD34+; CD271+) appeared to be orchestrated by macrophages (MAC 387+/ CD163low and CD163+/MAC 387-). The calcium content of the decellularised porcine pulmonary root tissues increased over the 12-month period but remained low (except suture points) at 401 ppm (wet weight) or below. The material properties of the decellularised porcine pulmonary root wall were unchanged compared to pre-implantation. There were some changes in the leaflets but importantly, the porcine tissues did not become stiffer. The decellularised porcine pulmonary roots showed good functional performance in vivo and were repopulated with ovine cells of the appropriate phenotype in a process orchestrated by M2 macrophages, highlighting the importance of these cells in the constructive tissue remodelling of cardiac root tissues.
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Affiliation(s)
- Tayyebeh Vafaee
- Institute of Medical and Biological
Engineering, School of Biomedical Sciences, Faculty of Biological Sciences,
University of Leeds, Leeds, UK
| | - Fiona Walker
- Institute of Medical and Biological
Engineering, School of Biomedical Sciences, Faculty of Biological Sciences,
University of Leeds, Leeds, UK
| | - Dan Thomas
- Institute of Medical and Biological
Engineering, School of Biomedical Sciences, Faculty of Biological Sciences,
University of Leeds, Leeds, UK
| | - João Gabriel Roderjan
- Department of Cardiac Surgery, Santa
Casa de Curitiba, Pontifica Universidade Catolica do Parana, Curitiba, Brazil
| | - Sergio Veiga Lopes
- Department of Cardiac Surgery, Santa
Casa de Curitiba, Pontifica Universidade Catolica do Parana, Curitiba, Brazil
| | - Francisco DA da Costa
- Department of Cardiac Surgery, Santa
Casa de Curitiba, Pontifica Universidade Catolica do Parana, Curitiba, Brazil
| | - Amisha Desai
- Institute of Medical and Biological
Engineering, School of Mechanical Engineering, University of Leeds, Leeds, UK
| | - Paul Rooney
- NHS Blood and Transplant, Tissue and
Eye Services, Estuary Banks, Liverpool, UK
| | - Louise M Jennings
- Institute of Medical and Biological
Engineering, School of Mechanical Engineering, University of Leeds, Leeds, UK
| | - John Fisher
- Institute of Medical and Biological
Engineering, School of Mechanical Engineering, University of Leeds, Leeds, UK
| | - Helen E Berry
- Institute of Medical and Biological
Engineering, School of Biomedical Sciences, Faculty of Biological Sciences,
University of Leeds, Leeds, UK
| | - Eileen Ingham
- Institute of Medical and Biological
Engineering, School of Biomedical Sciences, Faculty of Biological Sciences,
University of Leeds, Leeds, UK
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Bozso SJ, Kang JJH, El-Andari R, Fialka N, Zhu LF, Meyer SR, Freed DH, Nagendran J, Nagendran J. Recellularization of xenograft heart valves reduces the xenoreactive immune response in an in vivo rat model. Eur J Cardiothorac Surg 2021; 61:427-436. [PMID: 34633028 DOI: 10.1093/ejcts/ezab439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 08/20/2021] [Accepted: 09/10/2021] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Our aim was to address the role of autologous mesenchymal stem cell recellularization of xenogenic valves on the activation of the xenoreactive immune response in an in vivo rat model. METHODS Explanted aortic valve constructs from female Hartley guinea pigs were procured and decellularized, followed by recellularization with autologous Sprague-Dawley rat mesenchymal stem cells. Aortic valve xenografts were then implanted into the infrarenal aorta of recipient rats. Grafts were implanted as either autologous grafts, non-decellularized (NGP), decellularized and recellularized xenografts (RGP). Rats were euthanized after 7 and 21 days and exsanguinated and the grafts were explanted. RESULTS The NGP grafts demonstrated significant burden of granulocytes (14.3 cells/HPF) and CD3+ T cells (3.9 cells/HPF) compared to the autologous grafts (2.1 granulocytes/HPF and 0.72 CD3+ T cells/HPF) after 7 days. A lower absolute number of infiltrating granulocytes (NGP vs autologous, 6.4 vs 2.4 cells/HPF) and CD3+ T cells (NGP vs autologous, 2.8 vs 0.8 cells/HPF) was seen after 21 days. Equivalent granulocyte cell infiltration in the RGP grafts (2.4 cells/HPF) compared to the autologous grafts (2.1 cells/HPF) after 7 and 21 days (2.8 vs 2.4 cells/HPF) was observed. Equivalent CD3+ T-cell infiltration in the RGP grafts (0.63 cells/HPF) compared to the autologous grafts (0.72 cells/HPF) after 7 and 21 days (0.7 vs 0.8 cells/HPF) was observed. Immunoglobulin production was significantly greater in the NGP grafts compared to the autologous grafts at 7 (123.3 vs 52.7 mg/mL) and 21 days (93.3 vs 71.6 mg/mL), with a similar decreasing trend in absolute production. Equivalent immunoglobulin production was observed in the RGP grafts compared to the autologous grafts at 7 (40.8 vs 52.7 mg/mL) and 21 days (29.5 vs 71.6 mg/mL). CONCLUSIONS Autologous mesenchymal stem cell recellularization of xenogenic valves reduces the xenoreactive immune response in an in vivo rat model and may be an effective approach to decrease the progression of xenograft valve dysfunction.
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Affiliation(s)
- Sabin J Bozso
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Jimmy J H Kang
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Ryaan El-Andari
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Nicholas Fialka
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Lin Fu Zhu
- Department of Surgery, Surgical Medical Research Institute, University of Alberta, Edmonton, AB, Canada
| | - Steven R Meyer
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Darren H Freed
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Jayan Nagendran
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Jeevan Nagendran
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
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Mirani B, Parvin Nejad S, Simmons CA. Recent Progress Toward Clinical Translation of Tissue-Engineered Heart Valves. Can J Cardiol 2021; 37:1064-1077. [PMID: 33839245 DOI: 10.1016/j.cjca.2021.03.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 03/04/2021] [Accepted: 03/14/2021] [Indexed: 01/02/2023] Open
Abstract
Surgical replacement remains the primary option to treat the rapidly growing number of patients with severe valvular heart disease. Although current valve replacements-mechanical, bioprosthetic, and cryopreserved homograft valves-enhance survival and quality of life for many patients, the ideal prosthetic heart valve that is abundantly available, immunocompatible, and capable of growth, self-repair, and life-long performance has yet to be developed. These features are essential for pediatric patients with congenital defects, children and young adult patients with rheumatic fever, and active adult patients with valve disease. Heart valve tissue engineering promises to address these needs by providing living valve replacements that function similarly to their native counterparts. This is best evidenced by the long-term clinical success of decellularised pulmonary and aortic homografts, but the supply of homografts cannot meet the demand for replacement valves. A more abundant and consistent source of replacement valves may come from cellularised valves grown in vitro or acellular off-the-shelf biomaterial/tissue constructs that recellularise in situ, but neither tissue engineering approach has yet achieved long-term success in preclinical testing. Beyond the technical challenges, heart valve tissue engineering faces logistical, economic, and regulatory challenges. In this review, we summarise recent progress in heart valve tissue engineering, highlight important outcomes from preclinical and clinical testing, and discuss challenges and future directions toward clinical translation.
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Affiliation(s)
- Bahram Mirani
- Translational Biology and Engineering Program, Ted Rogers Centre for Heart Research, Toronto, Ontario, Canada; Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada; Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Shouka Parvin Nejad
- Translational Biology and Engineering Program, Ted Rogers Centre for Heart Research, Toronto, Ontario, Canada; Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Craig A Simmons
- Translational Biology and Engineering Program, Ted Rogers Centre for Heart Research, Toronto, Ontario, Canada; Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada; Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada.
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11
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Filova E, Steinerova M, Travnickova M, Knitlova J, Musilkova J, Eckhardt A, Hadraba D, Matejka R, Prazak S, Stepanovska J, Kucerova J, Riedel T, Brynda E, Lodererova A, Honsova E, Pirk J, Konarik M, Bacakova L. Accelerated in vitro recellularization of decellularized porcine pericardium for cardiovascular grafts. Biomed Mater 2021; 16:025024. [PMID: 33629665 DOI: 10.1088/1748-605x/abbdbd] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
An ideal decellularized allogenic or xenogeneic cardiovascular graft should be capable of preventing thrombus formation after implantation. The antithrombogenicity of the graft is ensured by a confluent endothelial cell layer formed on its surface. Later repopulation and remodeling of the scaffold by the patient's cells should result in the formation of living autologous tissue. In the work presented here, decellularized porcine pericardium scaffolds were modified by growing a fibrin mesh on the surface and inside the scaffolds, and by attaching heparin and human vascular endothelial growth factor (VEGF) to this mesh. Then the scaffolds were seeded with human adipose tissue-derived stem cells (ASCs). While the ASCs grew only on the surface of the decellularized pericardium, the fibrin-modified scaffolds were entirely repopulated in 28 d, and the scaffolds modified with fibrin, heparin and VEGF were already repopulated within 6 d. Label free mass spectrometry revealed fibronectin, collagens, and other extracellular matrix proteins produced by ASCs during recellularization. Thin layers of human umbilical endothelial cells were formed within 4 d after the cells were seeded on the surfaces of the scaffold, which had previously been seeded with ASCs. The results indicate that an artificial tissue prepared by in vitro recellularization and remodeling of decellularized non-autologous pericardium with autologous ASCs seems to be a promising candidate for cardiovascular grafts capable of accelerating in situ endothelialization. ASCs resemble the valve interstitial cells present in heart valves. An advantage of this approach is that ASCs can easily be collected from the patient by liposuction.
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Affiliation(s)
- Elena Filova
- Laboratory of Biomaterials and Tissue Engineering, Institute of Physiology of the Czech Academy of Sciences, Videnska 1083, 142 20 Prague, Czech Republic
| | - Marie Steinerova
- Laboratory of Biomaterials and Tissue Engineering, Institute of Physiology of the Czech Academy of Sciences, Videnska 1083, 142 20 Prague, Czech Republic
| | - Martina Travnickova
- Laboratory of Biomaterials and Tissue Engineering, Institute of Physiology of the Czech Academy of Sciences, Videnska 1083, 142 20 Prague, Czech Republic
| | - Jarmila Knitlova
- Laboratory of Biomaterials and Tissue Engineering, Institute of Physiology of the Czech Academy of Sciences, Videnska 1083, 142 20 Prague, Czech Republic
| | - Jana Musilkova
- Laboratory of Biomaterials and Tissue Engineering, Institute of Physiology of the Czech Academy of Sciences, Videnska 1083, 142 20 Prague, Czech Republic
| | - Adam Eckhardt
- Laboratory of Biomaterials and Tissue Engineering, Institute of Physiology of the Czech Academy of Sciences, Videnska 1083, 142 20 Prague, Czech Republic
| | - Daniel Hadraba
- Laboratory of Biomaterials and Tissue Engineering, Institute of Physiology of the Czech Academy of Sciences, Videnska 1083, 142 20 Prague, Czech Republic
| | - Roman Matejka
- Laboratory of Biomaterials and Tissue Engineering, Institute of Physiology of the Czech Academy of Sciences, Videnska 1083, 142 20 Prague, Czech Republic
- Department of Biomedical Technology, Faculty of Biomedical Engineering, Czech Technical University in Prague, Sitna sq. 3105, 27201 Kladno, Czech Republic
| | - Simon Prazak
- Laboratory of Biomaterials and Tissue Engineering, Institute of Physiology of the Czech Academy of Sciences, Videnska 1083, 142 20 Prague, Czech Republic
- Department of Biomedical Technology, Faculty of Biomedical Engineering, Czech Technical University in Prague, Sitna sq. 3105, 27201 Kladno, Czech Republic
| | - Jana Stepanovska
- Laboratory of Biomaterials and Tissue Engineering, Institute of Physiology of the Czech Academy of Sciences, Videnska 1083, 142 20 Prague, Czech Republic
- Department of Biomedical Technology, Faculty of Biomedical Engineering, Czech Technical University in Prague, Sitna sq. 3105, 27201 Kladno, Czech Republic
| | - Johanka Kucerova
- Institute of Macromolecular Chemistry of the Czech Academy of Sciences, Heyrovskeho sq. 1888, 162 00 Prague, Czech Republic
| | - Tomáš Riedel
- Institute of Macromolecular Chemistry of the Czech Academy of Sciences, Heyrovskeho sq. 1888, 162 00 Prague, Czech Republic
| | - Eduard Brynda
- Institute of Macromolecular Chemistry of the Czech Academy of Sciences, Heyrovskeho sq. 1888, 162 00 Prague, Czech Republic
| | - Alena Lodererova
- Institute for Clinical and Experimental Medicine, Videnská 1958/9, 140 21 Prague, Czech Republic
| | - Eva Honsova
- Institute for Clinical and Experimental Medicine, Videnská 1958/9, 140 21 Prague, Czech Republic
| | - Jan Pirk
- Institute for Clinical and Experimental Medicine, Videnská 1958/9, 140 21 Prague, Czech Republic
| | - Miroslav Konarik
- Institute for Clinical and Experimental Medicine, Videnská 1958/9, 140 21 Prague, Czech Republic
| | - Lucie Bacakova
- Laboratory of Biomaterials and Tissue Engineering, Institute of Physiology of the Czech Academy of Sciences, Videnska 1083, 142 20 Prague, Czech Republic
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12
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Chang TI, Hsu KH, Li SJ, Chuang MK, Luo CW, Chen YJ, Chang CI. Evolution of pulmonary valve reconstruction with focused review of expanded polytetrafluoroethylene handmade valves. Interact Cardiovasc Thorac Surg 2020; 32:585-592. [PMID: 33377488 DOI: 10.1093/icvts/ivaa302] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/17/2020] [Accepted: 10/04/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Many surgeons develop unique techniques for unmet needs for right ventricular outflow reconstruction to resolve pulmonary regurgitation after corrective surgery for congenital heart diseases. Expanded polytetrafluoroethylene (ePTFE) stands out as a reliable synthetic material, and clinical results with handmade ePTFE valves have been promising. This review focuses on the historical evolution of the use of ePTFE in pulmonary valve replacement and in the techniques for pioneering the translation of the handmade ePTFE trileaflet design for the transcatheter approach. METHODS We searched for and reviewed publications from 1990 to 2020 in the Pubmed database. Nineteen clinical studies from 2005 to 2019 that focused on ePTFE-based valves were summarized. The evolution of the ePTFE-based valve over 3 decades and recent relevant in vitro studies were investigated. RESULTS The average freedom from reintervention or surgery in the recorded ePTFE-based valve population was 90.2% at 5 years, and the survival rate was 96.7% at 3 years. CONCLUSIONS Non-inferior clinical results of this ePTFE handmade valve were revealed compared to allograft or xenograft options for pulmonary valve replacement. Future investigations on transferring ePTFE trileaflet design to transcatheter devices should be considered.
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Affiliation(s)
- Te-I Chang
- Division of Cardiovascular Surgery, Department of Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, Taipei, Taiwan
| | - Kang-Hong Hsu
- Division of Cardiovascular Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Shao-Jung Li
- Division of Cardiovascular Surgery, Department of Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Min-Kai Chuang
- Division of Cardiovascular Surgery, Department of Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Chi-Wen Luo
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yi-Jen Chen
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Division of Cardiovascular Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Chung-I Chang
- Division of Cardiovascular Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan
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13
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Waqanivavalagi SWFR, Bhat S, Ground MB, Milsom PF, Cornish J. Clinical performance of decellularized heart valves versus standard tissue conduits: a systematic review and meta-analysis. J Cardiothorac Surg 2020; 15:260. [PMID: 32948234 PMCID: PMC7501674 DOI: 10.1186/s13019-020-01292-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 09/03/2020] [Indexed: 02/06/2023] Open
Abstract
Background Valve replacement surgery is the definitive management strategy for patients with severe valvular disease. However, valvular conduits currently in clinical use are associated with significant limitations. Tissue-engineered (decellularized) heart valves are alternative prostheses that have demonstrated promising early results. The purpose of this systematic review and meta-analysis is to perform robust evaluation of the clinical performance of decellularized heart valves implanted in either outflow tract position, in comparison with standard tissue conduits. Methods Systematic searches were conducted in the PubMed, Scopus, and Web of Science databases for articles in which outcomes between decellularized heart valves surgically implanted within either outflow tract position of human subjects and standard tissue conduits were compared. Primary endpoints included postoperative mortality and reoperation rates. Meta-analysis was performed using a random-effects model via the Mantel-Haenszel method. Results Seventeen articles were identified, of which 16 were included in the meta-analysis. In total, 1418 patients underwent outflow tract reconstructions with decellularized heart valves and 2725 patients received standard tissue conduits. Decellularized heart valves were produced from human pulmonary valves and implanted within the right ventricular outflow tract in all cases. Lower postoperative mortality (4.7% vs. 6.1%; RR 0.94, 95% CI: 0.60–1.47; P = 0.77) and reoperation rates (4.8% vs. 7.4%; RR 0.55, 95% CI: 0.36–0.84; P = 0.0057) were observed in patients with decellularized heart valves, although only reoperation rates were statistically significant. There was no statistically significant heterogeneity between the analyzed articles (I2 = 31%, P = 0.13 and I2 = 33%, P = 0.10 respectively). Conclusions Decellularized heart valves implanted within the right ventricular outflow tract have demonstrated significantly lower reoperation rates when compared to standard tissue conduits. However, in order to allow for more accurate conclusions about the clinical performance of decellularized heart valves to be made, there need to be more high-quality studies with greater consistency in the reporting of clinical outcomes.
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Affiliation(s)
- Steve W F R Waqanivavalagi
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Grafton, Auckland, 1023, New Zealand. .,Adult Emergency Department, Auckland City Hospital, Auckland District Health Board, Grafton, Auckland, 1023, New Zealand.
| | - Sameer Bhat
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Grafton, Auckland, 1023, New Zealand.,Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Grafton, Auckland, 1023, New Zealand
| | - Marcus B Ground
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Grafton, Auckland, 1023, New Zealand.,Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, 9054, New Zealand
| | - Paget F Milsom
- Green Lane Cardiothoracic Surgical Unit, Auckland City Hospital, Auckland District Health Board, Grafton, Auckland, 1023, New Zealand
| | - Jillian Cornish
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Grafton, Auckland, 1023, New Zealand
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14
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Next-generation tissue-engineered heart valves with repair, remodelling and regeneration capacity. Nat Rev Cardiol 2020; 18:92-116. [PMID: 32908285 DOI: 10.1038/s41569-020-0422-8] [Citation(s) in RCA: 109] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/09/2020] [Indexed: 02/06/2023]
Abstract
Valvular heart disease is a major cause of morbidity and mortality worldwide. Surgical valve repair or replacement has been the standard of care for patients with valvular heart disease for many decades, but transcatheter heart valve therapy has revolutionized the field in the past 15 years. However, despite the tremendous technical evolution of transcatheter heart valves, to date, the clinically available heart valve prostheses for surgical and transcatheter replacement have considerable limitations. The design of next-generation tissue-engineered heart valves (TEHVs) with repair, remodelling and regenerative capacity can address these limitations, and TEHVs could become a promising therapeutic alternative for patients with valvular disease. In this Review, we present a comprehensive overview of current clinically adopted heart valve replacement options, with a focus on transcatheter prostheses. We discuss the various concepts of heart valve tissue engineering underlying the design of next-generation TEHVs, focusing on off-the-shelf technologies. We also summarize the latest preclinical and clinical evidence for the use of these TEHVs and describe the current scientific, regulatory and clinical challenges associated with the safe and broad clinical translation of this technology.
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15
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Gonzalez de Torre I, Alonso M, Rodriguez-Cabello JC. Elastin-Based Materials: Promising Candidates for Cardiac Tissue Regeneration. Front Bioeng Biotechnol 2020; 8:657. [PMID: 32695756 PMCID: PMC7338576 DOI: 10.3389/fbioe.2020.00657] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 05/27/2020] [Indexed: 11/15/2022] Open
Abstract
Stroke and cardiovascular episodes are still some of the most common diseases worldwide, causing millions of deaths and costing billions of Euros to healthcare systems. The use of new biomaterials with enhanced biological and physical properties has opened the door to new approaches in cardiovascular applications. Elastin-based materials are biomaterials with some of the most promising properties. Indeed, these biomaterials have started to yield good results in cardiovascular and angiogenesis applications. In this review, we explore the latest trends in elastin-derived materials for cardiac regeneration and the different possibilities that are being explored by researchers to regenerate an infarcted muscle and restore its normal function. Elastin-based materials can be processed in different manners to create injectable systems or hydrogel scaffolds that can be applied by simple injection or as patches to cover the damaged area and regenerate it. Such materials have been applied to directly regenerate the damaged cardiac muscle and to create complex structures, such as heart valves or new bio-stents that could help to restore the normal function of the heart or to minimize damage after a stroke. We will discuss the possibilities that elastin-based materials offer in cardiac tissue engineering, either alone or in combination with other biomaterials, in order to illustrate the wide range of options that are being explored. Moreover, although tremendous advances have been achieved with such elastin-based materials, there is still room for new approaches that could trigger advances in cardiac tissue regeneration.
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16
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Personalized Interventions: A Reality in the Next 20 Years or Pie in the Sky. Pediatr Cardiol 2020; 41:486-502. [PMID: 32198592 DOI: 10.1007/s00246-020-02303-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 01/17/2020] [Indexed: 12/22/2022]
Abstract
There is no better representation of the need for personalization of care than the breadth and complexity of congenital heart disease. Advanced imaging modalities are now standard of care in the field, and the advancements being made to three-dimensional visualization technologies are growing as a means of pre-procedural preparation. Incorporating emerging modeling approaches, such as computational fluid dynamics, will push the limits of our ability to predict outcomes, and this information may be both obtained and utilized during a single procedure in the future. Artificial intelligence and customized devices may soon surface as realistic tools for the care of patients with congenital heart disease, as they are showing growing evidence of feasibility within other fields. This review illustrates the great strides that have been made and the persistent challenges that exist within the field of congenital interventional cardiology, a field which must continue to innovate and push the limits to achieve personalization of the interventions it provides.
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17
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The Potential Impact and Timeline of Engineering on Congenital Interventions. Pediatr Cardiol 2020; 41:522-538. [PMID: 32198587 DOI: 10.1007/s00246-020-02335-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 02/22/2020] [Indexed: 10/24/2022]
Abstract
Congenital interventional cardiology has seen rapid growth in recent decades due to the expansion of available medical devices. Percutaneous interventions have become standard of care for many common congenital conditions. Unfortunately, patients with congenital heart disease often require multiple interventions throughout their lifespan. The availability of transcatheter devices that are biodegradable, biocompatible, durable, scalable, and can be delivered in the smallest sized patients will rely on continued advances in engineering. The development pipeline for these devices will require contributions of many individuals in academia and industry including experts in material science and tissue engineering. Advances in tissue engineering, bioresorbable technology, and even new nanotechnologies and nitinol fabrication techniques which may have an impact on the field of transcatheter congenital device in the next decade are summarized in this review. This review highlights recent advances in the engineering of transcatheter-based therapies and discusses future opportunities for engineering of transcatheter devices.
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18
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Chang TI, Hsu KH, Luo CW, Yen JH, Lu PC, Chang CI. In vitro study of trileaflet polytetrafluoroethylene conduit and its valve-in-valve transformation. Interact Cardiovasc Thorac Surg 2020; 30:408-416. [DOI: 10.1093/icvts/ivz274] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 09/27/2019] [Accepted: 10/18/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
OBJECTIVES
Handmade trileaflet expanded polytetrafluoroethylene valved conduit developed using the flip-over method has been tailored for pulmonary valve reconstruction with satisfactory outcomes. We investigated the in vitro performance of the valve design in a mock circulatory system with various conduit sizes. In our study, the design was transformed into a transcatheter stent graft system which could fit in original valved conduits in a valve-in-valve fashion.
METHODS
Five different sizes of valved polytetrafluoroethylene vascular grafts (16, 18, 20, 22 and 24 mm) were mounted onto a mock circulatory system with a prism window for direct leaflets motion observation. Transvalvular pressure gradients were recorded using pressure transducers. Mean and instant flows were determined via a rotameter and a flowmeter. Similar flip-over trileaflet valve design was then carried out in 3 available stent graft sizes (23, 26 and 28.5 mm, Gore aortic extender), which were deployed inside the valved conduits.
RESULTS
Peak pressure gradient across 5 different sized graft valves, in their appropriate flow setting (2.0, 2.5 and 5.0 l/min), ranged from 4.7 to 13.2 mmHg. No significant valve regurgitation was noted (regurgitant fraction: 1.6–4.9%) in all valve sizes and combinations. Three sizes of the trileaflet-valved stent grafts were implanted in the 4 sizes of valved conduits except for the 16-mm conduit. Peak pressure gradient increase after valved-stent graft-in-valved-conduit setting was <10 mmHg in all 4 conduits.
CONCLUSIONS
The study showed excellent in vitro performance of trileaflet polytetrafluoroethylene valved conduits. Its valved stent graft transformation provided data which may serve as a reference for transcatheter valve-in-valve research in the future.
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Affiliation(s)
- Te-I Chang
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Division of Cardiovascular Surgery, Department of Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, Taipei, Taiwan
| | - Kang-Hong Hsu
- Division of Cardiovascular Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan
| | - Chi-Wen Luo
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Jen-Hong Yen
- Department of Water Resources and Environmental Engineering, Tamkang University, New Taipei City, Taiwan
| | - Po-Chien Lu
- Department of Water Resources and Environmental Engineering, Tamkang University, New Taipei City, Taiwan
| | - Chung-I Chang
- Division of Cardiovascular Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan
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19
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Wang RM, Duran P, Christman KL. Processed Tissues. Biomater Sci 2020. [DOI: 10.1016/b978-0-12-816137-1.00027-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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20
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Liao J, Xu B, Zhang R, Fan Y, Xie H, Li X. Applications of decellularized materials in tissue engineering: advantages, drawbacks and current improvements, and future perspectives. J Mater Chem B 2020; 8:10023-10049. [PMID: 33053004 DOI: 10.1039/d0tb01534b] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Decellularized materials (DMs) are attracting more and more attention in tissue engineering because of their many unique advantages, and they could be further improved in some aspects through various means.
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Affiliation(s)
- Jie Liao
- Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education
- School of Biological Science and Medical Engineering
- Beijing Advanced Innovation Center for Biomedical Engineering
- Beihang University
- Beijing 100083
| | - Bo Xu
- Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education
- School of Biological Science and Medical Engineering
- Beijing Advanced Innovation Center for Biomedical Engineering
- Beihang University
- Beijing 100083
| | - Ruihong Zhang
- Department of Research and Teaching
- the Fourth Central Hospital of Baoding City
- Baoding 072350
- China
| | - Yubo Fan
- Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education
- School of Biological Science and Medical Engineering
- Beijing Advanced Innovation Center for Biomedical Engineering
- Beihang University
- Beijing 100083
| | - Huiqi Xie
- Laboratory of Stem Cell and Tissue Engineering
- State Key Laboratory of Biotherapy and Cancer Center
- West China Hospital
- Sichuan University and Collaborative Innovation Center of Biotherapy
- Chengdu 610041
| | - Xiaoming Li
- Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education
- School of Biological Science and Medical Engineering
- Beijing Advanced Innovation Center for Biomedical Engineering
- Beihang University
- Beijing 100083
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21
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Assessment of the healing process after percutaneous implantation of a cardiovascular device: a systematic review. Int J Cardiovasc Imaging 2019; 36:385-394. [PMID: 31745743 DOI: 10.1007/s10554-019-01734-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 11/10/2019] [Indexed: 01/16/2023]
Abstract
The healing process, occurring after intra-cardiac and intra-vascular device implantation, starts with fibrin condensation and attraction of inflammatory cells, followed by the formation of fibrous tissue that slowly covers the device. The duration of this process is variable and may be incomplete, which can lead to thrombus formation, dislodgement of the device or stenosis. To better understand this process and the neotissue formation, animal models were developed: small (rats and rabbits) and large (sheep, pigs, dogs and baboons) animal models for intra-vascular device implantation; sheep and pigs for intra-cardiac device implantation. After intra-vascular and intra-cardiac device implantation in these animal models, in vitro techniques, i.e. histology, which is the gold standard and scanning electron microscopy, were used to assess the device coverage, characterize the cell constitution and detect complications such as thrombosis. In humans, optical coherence tomography and intra-vascular ultrasounds are both invasive modalities used after stent implantation to assess the structure of the vessels, atheroma plaque and complications. Non-invasive techniques (computed tomography and magnetic resonance imaging) are in development in humans and animal models for tissue characterization (fibrosis), device remodeling evaluation and device implantation complications (thrombosis and stenosis). This review aims to (1) present the experimental models used to study this process on cardiac devices; (2) focus on the in vitro techniques and invasive modalities used currently in humans for intra-vascular and intra-cardiac devices and (3) assess the future developments of non-invasive techniques in animal models and humans for intra-cardiac devices.
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22
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Driesen BW, Warmerdam EG, Sieswerda GJ, Meijboom FJ, Molenschot MMC, Doevendans PA, Krings GJ, van Dijk APJ, Voskuil M. Percutaneous Pulmonary Valve Implantation: Current Status and Future Perspectives. Curr Cardiol Rev 2019; 15:262-273. [PMID: 30582483 PMCID: PMC8142351 DOI: 10.2174/1573403x15666181224113855] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 12/12/2018] [Accepted: 12/17/2018] [Indexed: 02/07/2023] Open
Abstract
Patients with congenital heart disease (CHD) with right ventricle outflow tract (RVOT) dysfunction need sequential pulmonary valve replacements throughout their life in the majority of cases. Since their introduction in 2000, the number of percutaneous pulmonary valve implantations (PPVI) has grown and reached over 10,000 procedures worldwide. Overall, PPVI has been proven safe and effective, but some anatomical variations can limit procedural success. This review discusses the current status and future perspectives of the procedure.
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Affiliation(s)
- Bart W Driesen
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands.,Department of Cardiology, Radboudumc, Nijmegen, Netherlands
| | | | - Gert-Jan Sieswerda
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Folkert J Meijboom
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | | | - Pieter A Doevendans
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands.,Netherlands Heart Institute, Utrecht, Netherlands.,Central Military Hospital, Utre cht, Netherlands
| | - Gregor J Krings
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | | | - Michiel Voskuil
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
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23
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Fernández-Colino A, Iop L, Ventura Ferreira MS, Mela P. Fibrosis in tissue engineering and regenerative medicine: treat or trigger? Adv Drug Deliv Rev 2019; 146:17-36. [PMID: 31295523 DOI: 10.1016/j.addr.2019.07.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Revised: 05/11/2019] [Accepted: 07/04/2019] [Indexed: 02/07/2023]
Abstract
Fibrosis is a life-threatening pathological condition resulting from a dysfunctional tissue repair process. There is no efficient treatment and organ transplantation is in many cases the only therapeutic option. Here we review tissue engineering and regenerative medicine (TERM) approaches to address fibrosis in the cardiovascular system, the kidney, the lung and the liver. These strategies have great potential to achieve repair or replacement of diseased organs by cell- and material-based therapies. However, paradoxically, they might also trigger fibrosis. Cases of TERM interventions with adverse outcome are also included in this review. Furthermore, we emphasize the fact that, although organ engineering is still in its infancy, the advances in the field are leading to biomedically relevant in vitro models with tremendous potential for disease recapitulation and development of therapies. These human tissue models might have increased predictive power for human drug responses thereby reducing the need for animal testing.
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24
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Roderjan JG, Noronha L, Stimamiglio MA, Correa A, Leitolis A, Bueno RRL, da Costa FDA. Structural assessments in decellularized extracellular matrix of porcine semilunar heart valves: Evaluation of cell niches. Xenotransplantation 2019; 26:e12503. [DOI: 10.1111/xen.12503] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Revised: 01/03/2019] [Accepted: 01/21/2019] [Indexed: 12/16/2022]
Affiliation(s)
- João Gabriel Roderjan
- Programa de Pós‐Graduação em Engenharia Biomédica Universidade Tecnológica Federal do Paraná Curitiba Brazil
| | - Lúcia Noronha
- Laboratório de Patologia Experimental Pontifícia Universidade Católica do Paraná Curitiba Brazil
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Taylor DA, Sampaio LC, Ferdous Z, Gobin AS, Taite LJ. Decellularized matrices in regenerative medicine. Acta Biomater 2018; 74:74-89. [PMID: 29702289 DOI: 10.1016/j.actbio.2018.04.044] [Citation(s) in RCA: 171] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 04/19/2018] [Accepted: 04/23/2018] [Indexed: 01/04/2023]
Abstract
Of all biologic matrices, decellularized extracellular matrix (dECM) has emerged as a promising tool used either alone or when combined with other biologics in the fields of tissue engineering or regenerative medicine - both preclinically and clinically. dECM provides a native cellular environment that combines its unique composition and architecture. It can be widely obtained from native organs of different species after being decellularized and is entitled to provide necessary cues to cells homing. In this review, the superiority of the macro- and micro-architecture of dECM is described as are methods by which these unique characteristics are being harnessed to aid in the repair and regeneration of organs and tissues. Finally, an overview of the state of research regarding the clinical use of different matrices and the common challenges faced in using dECM are provided, with possible solutions to help translate naturally derived dECM matrices into more robust clinical use. STATEMENT OF SIGNIFICANCE Ideal scaffolds mimic nature and provide an environment recognized by cells as proper. Biologically derived matrices can provide biological cues, such as sites for cell adhesion, in addition to the mechanical support provided by synthetic matrices. Decellularized extracellular matrix is the closest scaffold to nature, combining unique micro- and macro-architectural characteristics with an equally unique complex composition. The decellularization process preserves structural integrity, ensuring an intact vasculature. As this multifunctional structure can also induce cell differentiation and maturation, it could become the gold standard for scaffolds.
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26
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Choe JA, Jana S, Tefft BJ, Hennessy RS, Go J, Morse D, Lerman A, Young MD. Biomaterial characterization of off-the-shelf decellularized porcine pericardial tissue for use in prosthetic valvular applications. J Tissue Eng Regen Med 2018; 12:1608-1620. [PMID: 29749108 PMCID: PMC6055610 DOI: 10.1002/term.2686] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 12/12/2017] [Accepted: 04/16/2018] [Indexed: 01/03/2023]
Abstract
Fixed pericardial tissue is commonly used for commercially available xenograft valve implants, and has proven durability, but lacks the capability to remodel and grow. Decellularized porcine pericardial tissue has the promise to outperform fixed tissue and remodel, but the decellularization process has been shown to damage the collagen structure and reduce mechanical integrity of the tissue. Therefore, a comparison of uniaxial tensile properties was performed on decellularized, decellularized-sterilized, fixed, and native porcine pericardial tissue versus native valve leaflet cusps. The results of non-parametric analysis showed statistically significant differences (p < .05) between the stiffness of decellularized versus native pericardium and native cusps as well as fixed tissue, respectively; however, decellularized tissue showed large increases in elastic properties. Porosity testing of the tissues showed no statistical difference between decellularized and decell-sterilized tissue compared with native cusps (p > .05). Scanning electron microscopy confirmed that valvular endothelial and interstitial cells colonized the decellularized pericardial surface when seeded and grown for 30 days in static culture. Collagen assays and transmission electron microscopy analysis showed limited reductions in collagen with processing; yet glycosaminoglycan assays showed great reductions in the processed pericardium relative to native cusps. Decellularized pericardium had comparatively low mechanical properties among the groups studied; yet the stiffness was comparatively similar to the native cusps and demonstrated a lack of cytotoxicity. Suture retention, accelerated wear, and hydrodynamic testing of prototype decellularized and decell-sterilized valves showed positive functionality. Sterilized tissue could mimic valvular mechanical environment in vitro, therefore making it a viable potential candidate for off-the-shelf tissue-engineered valvular applications.
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Affiliation(s)
- Joshua A. Choe
- Department of Cardiovascular DiseasesMayo ClinicRochesterMNUSA
| | - Soumen Jana
- Department of Cardiovascular DiseasesMayo ClinicRochesterMNUSA
| | | | | | - Jason Go
- Department of Cardiovascular DiseasesMayo ClinicRochesterMNUSA
| | - David Morse
- Department of Cardiovascular DiseasesMayo ClinicRochesterMNUSA
| | - Amir Lerman
- Department of Cardiovascular DiseasesMayo ClinicRochesterMNUSA
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27
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Ye H, Zhang K, Kai D, Li Z, Loh XJ. Polyester elastomers for soft tissue engineering. Chem Soc Rev 2018; 47:4545-4580. [PMID: 29722412 DOI: 10.1039/c8cs00161h] [Citation(s) in RCA: 116] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Polyester elastomers are soft, biodegradable and biocompatible and are commonly used in various biomedical applications, especially in tissue engineering. These synthetic polyesters can be easily fabricated using various techniques such as solvent casting, particle leaching, molding, electrospinning, 3-dimensional printing, photolithography, microablation etc. A large proportion of tissue engineering research efforts have focused on the use of allografts, decellularized animal scaffolds or other biological materials as scaffolds, but they face the major concern of triggering immunological responses from the host, on top of other issues. This review paper will introduce the recent developments in elastomeric polyesters, their synthesis and fabrication techniques, as well as their application in the biomedical field, focusing primarily on tissue engineering in ophthalmology, cardiac and vascular systems. Some of the commercial and near-commercial polyesters used in these tissue engineering fields will also be described.
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Affiliation(s)
- Hongye Ye
- Institute of Materials Research and Engineering (IMRE), 2 Fusionopolis Way, #08-03 Innovis, Singapore 138634, Singapore.
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Cardiovascular tissue engineering: From basic science to clinical application. Exp Gerontol 2018; 117:1-12. [PMID: 29604404 DOI: 10.1016/j.exger.2018.03.022] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 03/26/2018] [Indexed: 12/20/2022]
Abstract
Valvular heart disease is an increasing population health problem and, especially in the elderly, a significant cause of morbidity and mortality. The current treatment options, such as mechanical and bioprosthetic heart valve replacements, have significant restrictions and limitations. Considering the increased life expectancy of our aging population, there is an urgent need for novel heart valve concepts that remain functional throughout life to prevent the need for reoperation. Heart valve tissue engineering aims to overcome these constraints by creating regenerative, self-repairing valve substitutes with life-long durability. In this review, we give an overview of advances in the development of tissue engineered heart valves, and describe the steps required to design and validate a novel valve prosthesis before reaching first-in-men clinical trials. In-silico and in-vitro models are proposed as tools for the assessment of valve design, functionality and compatibility, while in-vivo preclinical models are required to confirm the remodeling and growth potential of the tissue engineered heart valves. An overview of the tissue engineered heart valve studies that have reached clinical translation is also presented. Final remarks highlight the possibilities as well as the obstacles to overcome in translating heart valve prostheses into clinical application.
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Straka F, Schornik D, Masin J, Filova E, Mirejovsky T, Burdikova Z, Svindrych Z, Chlup H, Horny L, Daniel M, Machac J, Skibová J, Pirk J, Bacakova L. A human pericardium biopolymeric scaffold for autologous heart valve tissue engineering: cellular and extracellular matrix structure and biomechanical properties in comparison with a normal aortic heart valve. JOURNAL OF BIOMATERIALS SCIENCE-POLYMER EDITION 2018; 29:599-634. [PMID: 29338582 DOI: 10.1080/09205063.2018.1429732] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The objective of our study was to compare the cellular and extracellular matrix (ECM) structure and the biomechanical properties of human pericardium (HP) with the normal human aortic heart valve (NAV). HP tissues (from 12 patients) and NAV samples (from 5 patients) were harvested during heart surgery. The main cells in HP were pericardial interstitial cells, which are fibroblast-like cells of mesenchymal origin similar to the valvular interstitial cells in NAV tissue. The ECM of HP had a statistically significantly (p < 0.001) higher collagen I content, a lower collagen III and elastin content, and a similar glycosaminoglycans (GAGs) content, in comparison with the NAV, as measured by ECM integrated density. However, the relative thickness of the main load-bearing structures of the two tissues, the dense part of fibrous HP (49 ± 2%) and the lamina fibrosa of NAV (47 ± 4%), was similar. In both tissues, the secant elastic modulus (Es) was significantly lower in the transversal direction (p < 0.05) than in the longitudinal direction. This proved that both tissues were anisotropic. No statistically significant differences in UTS (ultimate tensile strength) values and in calculated bending stiffness values in the longitudinal or transversal direction were found between HP and NAV. Our study confirms that HP has an advantageous ECM biopolymeric structure and has the biomechanical properties required for a tissue from which an autologous heart valve replacement may be constructed.
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Affiliation(s)
- Frantisek Straka
- a Cardiology Centre and Cardiovascular Surgery Department , Institute for Clinical and Experimental Medicine , Prague , Czech Republic.,b Department of Biomaterials and Tissue Engineering , Institute of Physiology, Academy of Sciences of the Czech Republic , Prague , Czech Republic
| | - David Schornik
- b Department of Biomaterials and Tissue Engineering , Institute of Physiology, Academy of Sciences of the Czech Republic , Prague , Czech Republic
| | - Jaroslav Masin
- a Cardiology Centre and Cardiovascular Surgery Department , Institute for Clinical and Experimental Medicine , Prague , Czech Republic
| | - Elena Filova
- b Department of Biomaterials and Tissue Engineering , Institute of Physiology, Academy of Sciences of the Czech Republic , Prague , Czech Republic
| | - Tomas Mirejovsky
- c Clinical and Transplant Pathology Department, Institute for Clinical and Experimental Medicine , Prague , Czech Republic
| | - Zuzana Burdikova
- d Department of Cell Biology, School of Medicine , University of Virginia , Charlottesville , VA , USA
| | - Zdenek Svindrych
- e Department of Biology, W. M, Keck Center for Cellular Imaging , University of Virginia , Charlottesville , VA , USA
| | - Hynek Chlup
- f Faculty of Mechanical Engineering, Department of Mechanics, Biomechanics and Mechatronics , Czech Technical University in Prague , Prague , Czech Republic
| | - Lukas Horny
- f Faculty of Mechanical Engineering, Department of Mechanics, Biomechanics and Mechatronics , Czech Technical University in Prague , Prague , Czech Republic
| | - Matej Daniel
- f Faculty of Mechanical Engineering, Department of Mechanics, Biomechanics and Mechatronics , Czech Technical University in Prague , Prague , Czech Republic
| | - Jiri Machac
- g Institute of Botany CAS, Academy of Sciences of the Czech Republic , Pruhonice , Czech Republic
| | - Jelena Skibová
- h Department of Medical Statistics , Institute for Clinical and Experimental Medicine , Prague , Czech Republic
| | - Jan Pirk
- a Cardiology Centre and Cardiovascular Surgery Department , Institute for Clinical and Experimental Medicine , Prague , Czech Republic
| | - Lucie Bacakova
- b Department of Biomaterials and Tissue Engineering , Institute of Physiology, Academy of Sciences of the Czech Republic , Prague , Czech Republic
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van Steenberghe M, Schubert T, Xhema D, Bouzin C, Guiot Y, Duisit J, Abdelhamid K, Gianello P. Enhanced vascular regeneration with chemically/physically treated bovine/human pericardium in rodents. J Surg Res 2017; 222:167-179. [PMID: 29273368 DOI: 10.1016/j.jss.2017.09.043] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 08/23/2017] [Accepted: 09/29/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Glutaraldehyde-treated pericardia for cardiovascular applications have poor long-term clinical results. The efficacy of a combined physical/chemical treatment to improve pericardium biocompatibility and vascular regeneration was assessed and compared with detergent treatment and two commercial bovine pericardia: PeriGuard (DGBP) and Edwards pericardium (nDGBP). The physical and chemical process was applied to bovine and human pericardia (DBP-DHP), and the detergent process was applied to bovine (DDBP). MATERIAL AND METHODS Native (NBP) and treated bovine tissues were assessed for decellularization (HE/DAPI/DNA/α-Gal and MHC-1 staining) and mechanical integrity ex vivo. Twenty Wistar rats received subcutaneous patches of each bovine tissue to assess immunogenic response up to 4 months (flow cytometry). Ten additional rats received four subcutaneous bovine-treated patches (one/condition) to evaluate the inflammatory reaction (CD3/CD68 immunostaining), calcification (von Kossa staining/calcium quantification), and integration assessment (Hematoxylin and eosin staining). Finally, 15 rodents received a patch on the aorta (DBP n = 5, DHP n = 5, and DGBP n = 5), and vascular biocompatibility and arterial wall regeneration were assessed after 4 months (CD3/CD68/CD31/ASMA and Miller staining). RESULTS DBP reached the higher level of decellularization, no immunogenic response whereas maintaining mechanical properties. DBP induced the lowest level grade of inflammation after 2 months (P < 0.05) concomitantly for better remodeling. No complications occurred with DBP and DHP where vascular regeneration was confirmed. Moreover, they induced a low level of CD3/CD68 infiltrations. CONCLUSIONS This process significantly reduces immunogenicity and improves biocompatibility of bovine and human pericardia for better vascular regeneration.
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Affiliation(s)
- Mathieu van Steenberghe
- Université catholique de Louvain (UCL), Secteur des Sciences de la Santé, Institut de Recherche expérimentale et clinique (IREC), Pôle de Chirurgie expérimentale et Transplantation (CHEX), Brussels, Belgium.
| | - Thomas Schubert
- Université catholique de Louvain (UCL), Secteur des Sciences de la Santé, Institut de Recherche expérimentale et clinique (IREC), Pôle de Chirurgie expérimentale et Transplantation (CHEX), Brussels, Belgium; Cliniques Universitaires Saint-Luc, Service d'orthopédie et de traumatologie de l'appareil locomoteur, Brussels, Belgium
| | - Daela Xhema
- Université catholique de Louvain (UCL), Secteur des Sciences de la Santé, Institut de Recherche expérimentale et clinique (IREC), Pôle de Chirurgie expérimentale et Transplantation (CHEX), Brussels, Belgium
| | - Caroline Bouzin
- Université catholique de Louvain, IREC Imaging Platform (2IP), Institut de Recherche expérimentale et clinique (IREC), Brussels, Belgium
| | - Yves Guiot
- Cliniques universitaires Saint-Luc, Service d'anatomopathologie, Brussels, Belgium
| | - Jérôme Duisit
- Université catholique de Louvain (UCL), Secteur des Sciences de la Santé, Institut de Recherche expérimentale et clinique (IREC), Pôle de Chirurgie expérimentale et Transplantation (CHEX), Brussels, Belgium
| | - Karim Abdelhamid
- Centre Hospitalier Universitaire Vaudois, polyclinique médicale universitaire, Lausanne, Switzerland
| | - Pierre Gianello
- Université catholique de Louvain (UCL), Secteur des Sciences de la Santé, Institut de Recherche expérimentale et clinique (IREC), Pôle de Chirurgie expérimentale et Transplantation (CHEX), Brussels, Belgium
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31
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VeDepo MC, Detamore MS, Hopkins RA, Converse GL. Recellularization of decellularized heart valves: Progress toward the tissue-engineered heart valve. J Tissue Eng 2017; 8:2041731417726327. [PMID: 28890780 PMCID: PMC5574480 DOI: 10.1177/2041731417726327] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 07/24/2017] [Indexed: 01/08/2023] Open
Abstract
The tissue-engineered heart valve portends a new era in the field of valve replacement. Decellularized heart valves are of great interest as a scaffold for the tissue-engineered heart valve due to their naturally bioactive composition, clinical relevance as a stand-alone implant, and partial recellularization in vivo. However, a significant challenge remains in realizing the tissue-engineered heart valve: assuring consistent recellularization of the entire valve leaflets by phenotypically appropriate cells. Many creative strategies have pursued complete biological valve recellularization; however, identifying the optimal recellularization method, including in situ or in vitro recellularization and chemical and/or mechanical conditioning, has proven difficult. Furthermore, while many studies have focused on individual parameters for increasing valve interstitial recellularization, a general understanding of the interacting dynamics is likely necessary to achieve success. Therefore, the purpose of this review is to explore and compare the various processing strategies used for the decellularization and subsequent recellularization of tissue-engineered heart valves.
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Affiliation(s)
- Mitchell C VeDepo
- Cardiac Regenerative Surgery Research Laboratories of the Ward Family Heart Center, Children's Mercy Kansas City, Kansas City, MO, USA.,Bioengineering Program, The University of Kansas, Lawrence, KS, USA
| | - Michael S Detamore
- Stephenson School of Biomedical Engineering, The University of Oklahoma, Norman, OK, USA
| | - Richard A Hopkins
- Cardiac Regenerative Surgery Research Laboratories of the Ward Family Heart Center, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Gabriel L Converse
- Cardiac Regenerative Surgery Research Laboratories of the Ward Family Heart Center, Children's Mercy Kansas City, Kansas City, MO, USA
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32
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Jeinsen N, Mägel L, Jonigk D, Klingenberg M, Haverich A, Wilhelmi M, Böer U. Biocompatibility of Intensified Decellularized Equine Carotid Arteries in a Rat Subcutaneous Implantation Model and in a Human In Vitro Model. Tissue Eng Part A 2017; 24:310-321. [PMID: 28530164 DOI: 10.1089/ten.tea.2016.0542] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Limited biocompatibility of decellularized scaffolds is an ongoing challenge in tissue engineering. We recently demonstrated that intensified detergent-based decellularization of equine carotid artery (dEACintens) removed residual cellular molecules from the scaffold more efficiently than a conventional decellularization (dEACcon), although this approach did not eliminate its immunogenicity entirely. CCN1 has been shown to improve biocompatibility of dEACcon in a sheep model. In this study, we tested the biocompatibility of dEACintens and dEACcon with or without CCN1 coating after subcutaneous implantation in rats for up to 12 weeks. Explants were assessed by conventional histopathology and immunostaining for infiltrating M2 macrophages. Moreover, human macrophages derived from monocytes (MDM) or THP-1 cells (THP-derived macrophages [TDM]) were seeded onto dEACcon and dEACintens, and activation was assessed either by cytokine expression or matrix metalloprotease 2 and 7 staining. dEACintens showed a significantly reduced inflammatory infiltration (52%; p < 0.0001), as well as an earlier and denser neovascularization (1.4-fold, p < 0.0001) independent of CCN1 coating, which, however, reduced fibrosis exclusively with dEACintens (26-53%; p < 0.05). Human MDM seeded for 48 h onto dEACintens showed higher transcript levels for anti-inflammatory IL-10 (2.3-fold), proinflammatory TNFα (2.2-fold), and macrophage/monocyte recruiting MIP1α (3.5-fold; all p < 0.05) and MCP (2.7-fold; p < 0.01), whereas 1.92-fold more TDM on dEACintens showed staining for MMP2 (p > 0.001). Thus, although being advantageous in regard to fibrosis, CCN1 coating of dEACintens does not appear to be necessary for further improving dEACintens excellent biocompatibility in rats. In humans, the unspecific cellular immune response toward dEACintens seemed to be more complex, but generally comparable to the mild acute inflammatory tissue reaction with high remodeling activity as observed after rat subcutaneous implantation.
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Affiliation(s)
- Niklas Jeinsen
- 1 Lower Saxony Centre of Biotechnology, Implant Research and Development (NIFE), Hannover Medical School , Hannover, Germany
| | - Lavinia Mägel
- 2 Institute of Pathology , Hannover Medical School, Hannover, Germany
| | - Danny Jonigk
- 2 Institute of Pathology , Hannover Medical School, Hannover, Germany
| | - Melanie Klingenberg
- 1 Lower Saxony Centre of Biotechnology, Implant Research and Development (NIFE), Hannover Medical School , Hannover, Germany .,3 Division for Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School , Hannover, Germany
| | - Axel Haverich
- 1 Lower Saxony Centre of Biotechnology, Implant Research and Development (NIFE), Hannover Medical School , Hannover, Germany .,3 Division for Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School , Hannover, Germany
| | - Mathias Wilhelmi
- 1 Lower Saxony Centre of Biotechnology, Implant Research and Development (NIFE), Hannover Medical School , Hannover, Germany .,3 Division for Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School , Hannover, Germany
| | - Ulrike Böer
- 1 Lower Saxony Centre of Biotechnology, Implant Research and Development (NIFE), Hannover Medical School , Hannover, Germany .,3 Division for Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School , Hannover, Germany
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Fioretta ES, Dijkman PE, Emmert MY, Hoerstrup SP. The future of heart valve replacement: recent developments and translational challenges for heart valve tissue engineering. J Tissue Eng Regen Med 2017; 12:e323-e335. [PMID: 27696730 DOI: 10.1002/term.2326] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 07/25/2016] [Accepted: 09/26/2016] [Indexed: 12/18/2022]
Abstract
Heart valve replacement is often the only solution for patients suffering from valvular heart disease. However, currently available valve replacements require either life-long anticoagulation or are associated with valve degeneration and calcification. Moreover, they are suboptimal for young patients, because they do not adapt to the somatic growth. Tissue-engineering has been proposed as a promising approach to fulfil the urgent need for heart valve replacements with regenerative and growth capacity. This review will start with an overview on the currently available valve substitutes and the techniques for heart valve replacement. The main focus will be on the evolution of and different approaches for heart valve tissue engineering, namely the in vitro, in vivo and in situ approaches. More specifically, several heart valve tissue-engineering studies will be discussed with regard to their shortcomings or successes and their possible suitability for novel minimally invasive implantation techniques. As in situ heart valve tissue engineering based on cell-free functionalized starter materials is considered to be a promising approach for clinical translation, this review will also analyse the techniques used to tune the inflammatory response and cell recruitment upon implantation in order to stir a favourable outcome: controlling the blood-material interface, regulating the cytokine release, and influencing cell adhesion and differentiation. In the last section, the authors provide their opinion about the future developments and the challenges towards clinical translation and adaptation of heart valve tissue engineering for valve replacement. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Emanuela S Fioretta
- Institute for Regenerative Medicine (IREM), University of Zurich, Switzerland
| | - Petra E Dijkman
- Institute for Regenerative Medicine (IREM), University of Zurich, Switzerland
| | - Maximilian Y Emmert
- Institute for Regenerative Medicine (IREM), University of Zurich, Switzerland.,Heart Center Zurich, University Hospital Zurich, Switzerland.,Wyss Translational Center Zurich, Switzerland
| | - Simon P Hoerstrup
- Institute for Regenerative Medicine (IREM), University of Zurich, Switzerland.,Wyss Translational Center Zurich, Switzerland.,Department of Biomedical Engineering, Eindhoven University of Technology, The Netherlands
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34
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Emmert MY, Fioretta ES, Hoerstrup SP. Translational Challenges in Cardiovascular Tissue Engineering. J Cardiovasc Transl Res 2017; 10:139-149. [PMID: 28281240 DOI: 10.1007/s12265-017-9728-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 01/03/2017] [Indexed: 01/23/2023]
Abstract
Valvular heart disease and congenital heart defects represent a major cause of death around the globe. Although current therapy strategies have rapidly evolved over the decades and are nowadays safe, effective, and applicable to many affected patients, the currently used artificial prostheses are still suboptimal. They do not promote regeneration, physiological remodeling, or growth (particularly important aspects for children) as their native counterparts. This results in the continuous degeneration and subsequent failure of these prostheses which is often associated with an increased morbidity and mortality as well as the need for multiple re-interventions. To overcome this problem, the concept of tissue engineering (TE) has been repeatedly suggested as a potential technology to enable native-like cardiovascular replacements with regenerative and growth capacities, suitable for young adults and children. However, despite promising data from pre-clinical and first clinical pilot trials, the translation and clinical relevance of such TE technologies is still very limited. The reasons that currently limit broad clinical adoption are multifaceted and comprise of scientific, clinical, logistical, technical, and regulatory challenges which need to be overcome. The aim of this review is to provide an overview about the translational problems and challenges in current TE approaches. It further suggests directions and potential solutions on how these issues may be efficiently addressed in the future to accelerate clinical translation. In addition, a particular focus is put on the current regulatory guidelines and the associated challenges for these promising TE technologies.
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Affiliation(s)
- Maximilian Y Emmert
- Institute for Regenerative Medicine (IREM), University of Zurich, Moussonstrasse 13, 8091, Zurich, Switzerland.,Heart Center Zurich, University Hospital Zurich, Zurich, Switzerland.,Wyss Translational Center Zurich, Zurich, Switzerland
| | - Emanuela S Fioretta
- Institute for Regenerative Medicine (IREM), University of Zurich, Moussonstrasse 13, 8091, Zurich, Switzerland
| | - Simon P Hoerstrup
- Institute for Regenerative Medicine (IREM), University of Zurich, Moussonstrasse 13, 8091, Zurich, Switzerland. .,Wyss Translational Center Zurich, Zurich, Switzerland.
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35
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Böer U, Buettner FFR, Schridde A, Klingenberg M, Sarikouch S, Haverich A, Wilhelmi M. Antibody formation towards porcine tissue in patients implanted with crosslinked heart valves is directed to antigenic tissue proteins and αGal epitopes and is reduced in healthy vegetarian subjects. Xenotransplantation 2017; 24. [DOI: 10.1111/xen.12288] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 12/14/2016] [Accepted: 12/27/2016] [Indexed: 12/31/2022]
Affiliation(s)
- Ulrike Böer
- Lower Saxony Centre of Biotechnology Implant Research and Development (NIFE); Hannover Medical School; Hannover Germany
- Division for Cardiothoracic-, Transplantation- and Vascular Surgery; Hannover Medical School; Hannover Germany
| | | | - Ariane Schridde
- Lower Saxony Centre of Biotechnology Implant Research and Development (NIFE); Hannover Medical School; Hannover Germany
| | - Melanie Klingenberg
- Lower Saxony Centre of Biotechnology Implant Research and Development (NIFE); Hannover Medical School; Hannover Germany
- Division for Cardiothoracic-, Transplantation- and Vascular Surgery; Hannover Medical School; Hannover Germany
| | - Samir Sarikouch
- Division for Cardiothoracic-, Transplantation- and Vascular Surgery; Hannover Medical School; Hannover Germany
| | - Axel Haverich
- Lower Saxony Centre of Biotechnology Implant Research and Development (NIFE); Hannover Medical School; Hannover Germany
- Division for Cardiothoracic-, Transplantation- and Vascular Surgery; Hannover Medical School; Hannover Germany
| | - Mathias Wilhelmi
- Lower Saxony Centre of Biotechnology Implant Research and Development (NIFE); Hannover Medical School; Hannover Germany
- Division for Cardiothoracic-, Transplantation- and Vascular Surgery; Hannover Medical School; Hannover Germany
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36
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Best C, Onwuka E, Pepper V, Sams M, Breuer J, Breuer C. Cardiovascular Tissue Engineering: Preclinical Validation to Bedside Application. Physiology (Bethesda) 2017; 31:7-15. [PMID: 26661524 DOI: 10.1152/physiol.00018.2015] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Advancements in biomaterial science and available cell sources have spurred the translation of tissue-engineering technology to the bedside, addressing the pressing clinical demands for replacement cardiovascular tissues. Here, the in vivo status of tissue-engineered blood vessels, heart valves, and myocardium is briefly reviewed, illustrating progress toward a tissue-engineered heart for clinical use.
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Affiliation(s)
- Cameron Best
- Tissue Engineering and Surgical Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Ekene Onwuka
- Tissue Engineering and Surgical Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio; Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, Ohio; and
| | - Victoria Pepper
- Tissue Engineering and Surgical Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Malik Sams
- Tissue Engineering and Surgical Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Jake Breuer
- Tissue Engineering and Surgical Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Christopher Breuer
- Tissue Engineering and Surgical Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio; Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, Ohio; and Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio
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37
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Nakamura N, Kimura T, Kishida A. Overview of the Development, Applications, and Future Perspectives of Decellularized Tissues and Organs. ACS Biomater Sci Eng 2016; 3:1236-1244. [DOI: 10.1021/acsbiomaterials.6b00506] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Naoko Nakamura
- Institute of Biomaterials
and Bioengineering, Tokyo Medical and Dental University, 2-3-10 Kanda-Surugadai, Chiyoda-ku, Tokyo 101-0062 Japan
| | - Tsuyoshi Kimura
- Institute of Biomaterials
and Bioengineering, Tokyo Medical and Dental University, 2-3-10 Kanda-Surugadai, Chiyoda-ku, Tokyo 101-0062 Japan
| | - Akio Kishida
- Institute of Biomaterials
and Bioengineering, Tokyo Medical and Dental University, 2-3-10 Kanda-Surugadai, Chiyoda-ku, Tokyo 101-0062 Japan
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38
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Kennamer A, Sierad L, Pascal R, Rierson N, Albers C, Harpa M, Cotoi O, Harceaga L, Olah P, Terezia P, Simionescu A, Simionescu D. Bioreactor Conditioning of Valve Scaffolds Seeded Internally with Adult Stem Cells. Tissue Eng Regen Med 2016; 13:507-515. [PMID: 30337944 DOI: 10.1007/s13770-016-9114-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The goal of this study was to test the hypothesis that stem cells, as a response to valve-specific extracellular matrix "niches" and mechanical stimuli, would differentiate into valvular interstitial cells (VICs). Porcine aortic root scaffolds were prepared by decellularization. After verifying that roots exhibited adequate hemodynamics in vitro, we seeded human adipose-derived stem cells (hADSCs) within the interstitium of the cusps and subjected the valves to in vitro pulsatile bioreactor testing in pulmonary pressures and flow conditions. As controls we incubated cell-seeded valves in a rotator device which allowed fluid to flow through the valves ensuring gas and nutrient exchange without subjecting the cusps to significant stress. After 24 days of conditioning, valves were analyzed for cell phenotype using immunohistochemistry for vimentin, alpha-smooth muscle cell actin (SMA) and prolyl-hydroxylase (PHA). Fresh native valves were used as immunohistochemistry controls. Analysis of bioreactor-conditioned valves showed that almost all seeded cells had died and large islands of cell debris were found within each cusp. Remnants of cells were positive for vimentin. Cell seeded controls, which were only rotated slowly to ensure gas and nutrient exchange, maintained about 50% of cells alive; these cells were positive for vimentin and negative for alpha-SMA and PHA, similar to native VICs. These results highlight for the first time the extreme vulnerability of hADSCs to valve-specific mechanical forces and also suggest that careful, progressive mechanical adaptation to valve-specific forces might encourage stem cell differentiation towards the VIC phenotype.
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Affiliation(s)
- Allison Kennamer
- Biocompatibility and Tissue Regeneration Laboratories, Department of Bioengineering, Clemson University, Clemson, SC, USA
| | - Leslie Sierad
- Biocompatibility and Tissue Regeneration Laboratories, Department of Bioengineering, Clemson University, Clemson, SC, USA
| | - Richard Pascal
- Biocompatibility and Tissue Regeneration Laboratories, Department of Bioengineering, Clemson University, Clemson, SC, USA
| | - Nicholas Rierson
- Biocompatibility and Tissue Regeneration Laboratories, Department of Bioengineering, Clemson University, Clemson, SC, USA
| | - Christopher Albers
- Biocompatibility and Tissue Regeneration Laboratories, Department of Bioengineering, Clemson University, Clemson, SC, USA
| | - Marius Harpa
- Tissue Engineering and Regenerative Medicine Laboratory, Department of Anatomy, University of Medicine and Pharmacy, Targu Mures, Romania
| | - Ovidiu Cotoi
- Tissue Engineering and Regenerative Medicine Laboratory, Department of Anatomy, University of Medicine and Pharmacy, Targu Mures, Romania
| | - Lucian Harceaga
- Tissue Engineering and Regenerative Medicine Laboratory, Department of Anatomy, University of Medicine and Pharmacy, Targu Mures, Romania
| | - Peter Olah
- Tissue Engineering and Regenerative Medicine Laboratory, Department of Anatomy, University of Medicine and Pharmacy, Targu Mures, Romania
| | - Preda Terezia
- Tissue Engineering and Regenerative Medicine Laboratory, Department of Anatomy, University of Medicine and Pharmacy, Targu Mures, Romania
| | - Agneta Simionescu
- Cardiovascular Tissue Engineering and Regenerative Medicine Laboratory, Department of Bioengineering, Clemson University, Clemson, SC, USA
| | - Dan Simionescu
- Biocompatibility and Tissue Regeneration Laboratories, Department of Bioengineering, Clemson University, Clemson, SC, USA.,Tissue Engineering and Regenerative Medicine Laboratory, Department of Anatomy, University of Medicine and Pharmacy, Targu Mures, Romania
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Sierad LN, Shaw EL, Bina A, Brazile B, Rierson N, Patnaik SS, Kennamer A, Odum R, Cotoi O, Terezia P, Branzaniuc K, Smallwood H, Deac R, Egyed I, Pavai Z, Szanto A, Harceaga L, Suciu H, Raicea V, Olah P, Simionescu A, Liao J, Movileanu I, Harpa M, Simionescu DT. Functional Heart Valve Scaffolds Obtained by Complete Decellularization of Porcine Aortic Roots in a Novel Differential Pressure Gradient Perfusion System. Tissue Eng Part C Methods 2016; 21:1284-96. [PMID: 26467108 DOI: 10.1089/ten.tec.2015.0170] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
There is a great need for living valve replacements for patients of all ages. Such constructs could be built by tissue engineering, with perspective of the unique structure and biology of the aortic root. The aortic valve root is composed of several different tissues, and careful structural and functional consideration has to be given to each segment and component. Previous work has shown that immersion techniques are inadequate for whole-root decellularization, with the aortic wall segment being particularly resistant to decellularization. The aim of this study was to develop a differential pressure gradient perfusion system capable of being rigorous enough to decellularize the aortic root wall while gentle enough to preserve the integrity of the cusps. Fresh porcine aortic roots have been subjected to various regimens of perfusion decellularization using detergents and enzymes and results compared to immersion decellularized roots. Success criteria for evaluation of each root segment (cusp, muscle, sinus, wall) for decellularization completeness, tissue integrity, and valve functionality were defined using complementary methods of cell analysis (histology with nuclear and matrix stains and DNA analysis), biomechanics (biaxial and bending tests), and physiologic heart valve bioreactor testing (with advanced image analysis of open-close cycles and geometric orifice area measurement). Fully acellular porcine roots treated with the optimized method exhibited preserved macroscopic structures and microscopic matrix components, which translated into conserved anisotropic mechanical properties, including bending and excellent valve functionality when tested in aortic flow and pressure conditions. This study highlighted the importance of (1) adapting decellularization methods to specific target tissues, (2) combining several methods of cell analysis compared to relying solely on histology, (3) developing relevant valve-specific mechanical tests, and (4) in vitro testing of valve functionality.
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Affiliation(s)
- Leslie Neil Sierad
- 1 Biocompatibility and Tissue Regeneration Laboratories, Department of Bioengineering, Clemson University , Clemson, South Carolina
| | - Eliza Laine Shaw
- 1 Biocompatibility and Tissue Regeneration Laboratories, Department of Bioengineering, Clemson University , Clemson, South Carolina
| | - Alexander Bina
- 1 Biocompatibility and Tissue Regeneration Laboratories, Department of Bioengineering, Clemson University , Clemson, South Carolina
| | - Bryn Brazile
- 2 Tissue Bioengineering Laboratory, Department of Agricultural and Biological Engineering, Mississippi State University , Starkville, Mississippi
| | - Nicholas Rierson
- 1 Biocompatibility and Tissue Regeneration Laboratories, Department of Bioengineering, Clemson University , Clemson, South Carolina
| | - Sourav S Patnaik
- 2 Tissue Bioengineering Laboratory, Department of Agricultural and Biological Engineering, Mississippi State University , Starkville, Mississippi
| | - Allison Kennamer
- 1 Biocompatibility and Tissue Regeneration Laboratories, Department of Bioengineering, Clemson University , Clemson, South Carolina
| | - Rebekah Odum
- 1 Biocompatibility and Tissue Regeneration Laboratories, Department of Bioengineering, Clemson University , Clemson, South Carolina
| | - Ovidiu Cotoi
- 3 Tissue Engineering and Regenerative Medicine Laboratory, Department of Anatomy, University of Medicine and Pharmacy , Targu Mures, Romania
| | - Preda Terezia
- 3 Tissue Engineering and Regenerative Medicine Laboratory, Department of Anatomy, University of Medicine and Pharmacy , Targu Mures, Romania
| | - Klara Branzaniuc
- 3 Tissue Engineering and Regenerative Medicine Laboratory, Department of Anatomy, University of Medicine and Pharmacy , Targu Mures, Romania
| | - Harrison Smallwood
- 1 Biocompatibility and Tissue Regeneration Laboratories, Department of Bioengineering, Clemson University , Clemson, South Carolina
| | - Radu Deac
- 3 Tissue Engineering and Regenerative Medicine Laboratory, Department of Anatomy, University of Medicine and Pharmacy , Targu Mures, Romania
| | - Imre Egyed
- 3 Tissue Engineering and Regenerative Medicine Laboratory, Department of Anatomy, University of Medicine and Pharmacy , Targu Mures, Romania
| | - Zoltan Pavai
- 3 Tissue Engineering and Regenerative Medicine Laboratory, Department of Anatomy, University of Medicine and Pharmacy , Targu Mures, Romania
| | - Annamaria Szanto
- 3 Tissue Engineering and Regenerative Medicine Laboratory, Department of Anatomy, University of Medicine and Pharmacy , Targu Mures, Romania
| | - Lucian Harceaga
- 3 Tissue Engineering and Regenerative Medicine Laboratory, Department of Anatomy, University of Medicine and Pharmacy , Targu Mures, Romania
| | - Horatiu Suciu
- 3 Tissue Engineering and Regenerative Medicine Laboratory, Department of Anatomy, University of Medicine and Pharmacy , Targu Mures, Romania
| | - Victor Raicea
- 3 Tissue Engineering and Regenerative Medicine Laboratory, Department of Anatomy, University of Medicine and Pharmacy , Targu Mures, Romania
| | - Peter Olah
- 3 Tissue Engineering and Regenerative Medicine Laboratory, Department of Anatomy, University of Medicine and Pharmacy , Targu Mures, Romania
| | - Agneta Simionescu
- 4 Cardiovascular Tissue Engineering and Regenerative Medicine Laboratory, Department of Bioengineering, Clemson University , Clemson, South Carolina
| | - Jun Liao
- 2 Tissue Bioengineering Laboratory, Department of Agricultural and Biological Engineering, Mississippi State University , Starkville, Mississippi
| | - Ionela Movileanu
- 3 Tissue Engineering and Regenerative Medicine Laboratory, Department of Anatomy, University of Medicine and Pharmacy , Targu Mures, Romania
| | - Marius Harpa
- 3 Tissue Engineering and Regenerative Medicine Laboratory, Department of Anatomy, University of Medicine and Pharmacy , Targu Mures, Romania
| | - Dan Teodor Simionescu
- 1 Biocompatibility and Tissue Regeneration Laboratories, Department of Bioengineering, Clemson University , Clemson, South Carolina
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Dijkman PE, Fioretta ES, Frese L, Pasqualini FS, Hoerstrup SP. Heart Valve Replacements with Regenerative Capacity. Transfus Med Hemother 2016; 43:282-290. [PMID: 27721704 DOI: 10.1159/000448181] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 07/04/2016] [Indexed: 01/14/2023] Open
Abstract
The incidence of severe valvular dysfunctions (e.g., stenosis and insufficiency) is increasing, leading to over 300,000 valves implanted worldwide yearly. Clinically used heart valve replacements lack the capacity to grow, inherently requiring repetitive and high-risk surgical interventions during childhood. The aim of this review is to present how different tissue engineering strategies can overcome these limitations, providing innovative valve replacements that proved to be able to integrate and remodel in pre-clinical experiments and to have promising results in clinical studies. Upon description of the different types of heart valve tissue engineering (e.g., in vitro, in situ, in vivo, and the pre-seeding approach) we focus on the clinical translation of this technology. In particular, we will deepen the many technical, clinical, and regulatory aspects that need to be solved to endure the clinical adaptation and the commercialization of these promising regenerative valves.
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Affiliation(s)
- Petra E Dijkman
- Institute for Regenerative Medicine (IREM), University of Zurich, Zurich, Switzerland
| | - Emanuela S Fioretta
- Institute for Regenerative Medicine (IREM), University of Zurich, Zurich, Switzerland
| | - Laura Frese
- Institute for Regenerative Medicine (IREM), University of Zurich, Zurich, Switzerland
| | | | - Simon P Hoerstrup
- Institute for Regenerative Medicine (IREM), University of Zurich, Zurich, Switzerland; Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands; Wyss Translational Center Zurich, University of Zurich and ETH Zurich, Zurich, Switzerland
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41
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Nozynska J, Stiller B, Grohmann J. Management of a dissection of matrix P right ventricular-to-pulmonary artery conduit by implanting two pre-stents and a melody valve. Catheter Cardiovasc Interv 2016; 91:E64-E67. [PMID: 27246262 DOI: 10.1002/ccd.26581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 04/21/2016] [Indexed: 11/05/2022]
Abstract
Reconstructing the right ventricular outflow tract and pulmonary valve via a bovine-derived valve conduit such as Matrix-P-Xenograft is a common surgical repair technique for pulmonary atresia and ventricular septal defect. After conduit degeneration due to calcification or aneurysmal dilatation, percutaneous transvenous stenting of the right ventricular outflow tract followed by pulmonary valve implantation has become the standard interventional treatment. Applied to stenotic conduits, the method is considered safe and effective. An important but seldom-reported problem is graft failure related to the formation of a Matrix membrane due to inflammation and fibrosis inside the xenograft, which can cause serious problems when dissection and rupture occur during transcatheter intervention. The torn pseudomembrane may cause the complete obstruction of both pulmonary arteries, resulting in a life-threatening situation requiring rapid intervention, as in this case presentation. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Joanna Nozynska
- Department of Congenital Heart Defects and Pediatric Cardiology, Heart Centre, University of Freiburg, Freiburg, Germany
| | - Brigitte Stiller
- Department of Congenital Heart Defects and Pediatric Cardiology, Heart Centre, University of Freiburg, Freiburg, Germany
| | - Jochen Grohmann
- Department of Congenital Heart Defects and Pediatric Cardiology, Heart Centre, University of Freiburg, Freiburg, Germany
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Schmidt EJ. Magnetic Resonance Imaging-Guided Cardiac Interventions. Magn Reson Imaging Clin N Am 2015; 23:563-77. [PMID: 26499275 DOI: 10.1016/j.mric.2015.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Performing intraoperative cardiovascular procedures inside an MR imaging scanner can potentially provide substantial advantage in clinical outcomes by reducing the risk and increasing the success rate relative to the way such procedures are performed today, in which the primary surgical guidance is provided by X-ray fluoroscopy, by electromagnetically tracked intraoperative devices, and by ultrasound. Both noninvasive and invasive cardiologists are becoming increasingly familiar with the capabilities of MR imaging for providing anatomic and physiologic information that is unequaled by other modalities. As a result, researchers began performing animal (preclinical) interventions in the cardiovascular system in the early 1990s.
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Affiliation(s)
- Ehud J Schmidt
- Radiology Department, Brigham and Women's Hospital, 221 Longwood Avenue, Room BRB 34C, Boston, MA 02115, USA.
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Guided tissue regeneration in heart valve replacement: from preclinical research to first-in-human trials. BIOMED RESEARCH INTERNATIONAL 2015; 2015:432901. [PMID: 26495295 PMCID: PMC4606187 DOI: 10.1155/2015/432901] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 05/21/2015] [Indexed: 11/18/2022]
Abstract
Heart valve tissue-guided regeneration aims to offer a functional and viable alternative to current prosthetic replacements. Not requiring previous cell seeding and conditioning in bioreactors, such exceptional tissue engineering approach is a very fascinating translational regenerative strategy. After in vivo implantation, decellularized heart valve scaffolds drive their same repopulation by recipient's cells for a prospective autologous-like tissue reconstruction, remodeling, and adaptation to the somatic growth of the patient. With such a viability, tissue-guided regenerated conduits can be delivered as off-the-shelf biodevices and possess all the potentialities for a long-lasting resolution of the dramatic inconvenience of heart valve diseases, both in children and in the elderly. A review on preclinical and clinical investigations of this therapeutic concept is provided with evaluation of the issues still to be well deliberated for an effective and safe in-human application.
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Vossler JD, Min Ju Y, Williams JK, Goldstein S, Hamlin J, Lee SJ, Yoo JJ, Atala A. CD133 antibody conjugation to decellularized human heart valves intended for circulating cell capture. ACTA ACUST UNITED AC 2015; 10:055001. [PMID: 26333364 DOI: 10.1088/1748-6041/10/5/055001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The long term efficacy of tissue based heart valve grafts may be limited by progressive degeneration characterized by immune mediated inflammation and calcification. To avoid this degeneration, decellularized heart valves with functionalized surfaces capable of rapid in vivo endothelialization have been developed. The aim of this study is to examine the capacity of CD133 antibody-conjugated valve tissue to capture circulating endothelial progenitor cells (EPCs). Decellularized human pulmonary valve tissue was conjugated with CD133 antibody at varying concentrations and exposed to CD133 expressing NTERA-2 cl.D1 (NT2) cells in a microflow chamber. The amount of CD133 antibody conjugated on the valve tissue surface and the number of NT2 cells captured in the presence of shear stress was measured. Both the amount of CD133 antibody conjugated to the valve leaflet surface and the number of adherent NT2 cells increased as the concentration of CD133 antibody present in the surface immobilization procedure increased. The data presented in this study support the hypothesis that the rate of CD133(+) cell adhesion in the presence of shear stress to decellularized heart valve tissue functionalized by CD133 antibody conjugation increases as the quantity of CD133 antibody conjugated to the tissue surface increases.
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Affiliation(s)
- John D Vossler
- Wake Forest Institute for Regenerative Medicine and, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157, USA. Department of General Surgery, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157, USA
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Suchá D, Symersky P, Tanis W, Mali WP, Leiner T, van Herwerden LA, Budde RP. Multimodality Imaging Assessment of Prosthetic Heart Valves. Circ Cardiovasc Imaging 2015; 8:e003703. [DOI: 10.1161/circimaging.115.003703] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Echocardiography and fluoroscopy are the main techniques for prosthetic heart valve (PHV) evaluation, but because of specific limitations they may not identify the morphological substrate or the extent of PHV pathology. Cardiac computed tomography (CT) and magnetic resonance imaging (MRI) have emerged as new potential imaging modalities for valve prostheses. We present an overview of the possibilities and pitfalls of CT and MRI for PHV assessment based on a systematic literature review of all experimental and patient studies. For this, a comprehensive systematic search was performed in PubMed and Embase on March 24, 2015, containing CT/MRI and PHV synonyms. Our final selection yielded 82 articles on surgical valves. CT allowed adequate assessment of most modern PHVs and complemented echocardiography in detecting the obstruction cause (pannus or thrombus), bioprosthesis calcifications, and endocarditis extent (valve dehiscence and pseudoaneurysms). No clear advantage over echocardiography was found for the detection of vegetations or periprosthetic regurgitation. Whereas MRI metal artifacts may preclude direct prosthesis analysis, MRI provided information on PHV-related flow patterns and velocities. MRI demonstrated abnormal asymmetrical flow patterns in PHV obstruction and allowed prosthetic regurgitation assessment. Hence, CT shows great clinical relevance as a complementary imaging tool for the diagnostic work-up of patients with suspected PHV obstruction and endocarditis. MRI shows potential for functional PHV assessment although more studies are required to provide diagnostic reference values to allow discrimination of normal from pathological conditions.
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Affiliation(s)
- Dominika Suchá
- From the Departments of Radiology (D.S., W.P.Th.M.M., T.L., R.P.J.B.) and Cardiothoracic Surgery (L.A.v.H.), University Medical Center Utrecht, Utrecht, The Netherlands; Department of Cardiothoracic Surgery, VU University Medical Center, Amsterdam, The Netherlands (P.S.); Department of Cardiology, HagaZiekenhuis, The Hague, The Netherlands (W.T.); and Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands (R.P.J.B.)
| | - Petr Symersky
- From the Departments of Radiology (D.S., W.P.Th.M.M., T.L., R.P.J.B.) and Cardiothoracic Surgery (L.A.v.H.), University Medical Center Utrecht, Utrecht, The Netherlands; Department of Cardiothoracic Surgery, VU University Medical Center, Amsterdam, The Netherlands (P.S.); Department of Cardiology, HagaZiekenhuis, The Hague, The Netherlands (W.T.); and Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands (R.P.J.B.)
| | - W. Tanis
- From the Departments of Radiology (D.S., W.P.Th.M.M., T.L., R.P.J.B.) and Cardiothoracic Surgery (L.A.v.H.), University Medical Center Utrecht, Utrecht, The Netherlands; Department of Cardiothoracic Surgery, VU University Medical Center, Amsterdam, The Netherlands (P.S.); Department of Cardiology, HagaZiekenhuis, The Hague, The Netherlands (W.T.); and Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands (R.P.J.B.)
| | - Willem P.Th.M. Mali
- From the Departments of Radiology (D.S., W.P.Th.M.M., T.L., R.P.J.B.) and Cardiothoracic Surgery (L.A.v.H.), University Medical Center Utrecht, Utrecht, The Netherlands; Department of Cardiothoracic Surgery, VU University Medical Center, Amsterdam, The Netherlands (P.S.); Department of Cardiology, HagaZiekenhuis, The Hague, The Netherlands (W.T.); and Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands (R.P.J.B.)
| | - Tim Leiner
- From the Departments of Radiology (D.S., W.P.Th.M.M., T.L., R.P.J.B.) and Cardiothoracic Surgery (L.A.v.H.), University Medical Center Utrecht, Utrecht, The Netherlands; Department of Cardiothoracic Surgery, VU University Medical Center, Amsterdam, The Netherlands (P.S.); Department of Cardiology, HagaZiekenhuis, The Hague, The Netherlands (W.T.); and Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands (R.P.J.B.)
| | - Lex A. van Herwerden
- From the Departments of Radiology (D.S., W.P.Th.M.M., T.L., R.P.J.B.) and Cardiothoracic Surgery (L.A.v.H.), University Medical Center Utrecht, Utrecht, The Netherlands; Department of Cardiothoracic Surgery, VU University Medical Center, Amsterdam, The Netherlands (P.S.); Department of Cardiology, HagaZiekenhuis, The Hague, The Netherlands (W.T.); and Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands (R.P.J.B.)
| | - Ricardo P.J. Budde
- From the Departments of Radiology (D.S., W.P.Th.M.M., T.L., R.P.J.B.) and Cardiothoracic Surgery (L.A.v.H.), University Medical Center Utrecht, Utrecht, The Netherlands; Department of Cardiothoracic Surgery, VU University Medical Center, Amsterdam, The Netherlands (P.S.); Department of Cardiology, HagaZiekenhuis, The Hague, The Netherlands (W.T.); and Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands (R.P.J.B.)
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Cheung DY, Duan B, Butcher JT. Current progress in tissue engineering of heart valves: multiscale problems, multiscale solutions. Expert Opin Biol Ther 2015; 15:1155-72. [PMID: 26027436 DOI: 10.1517/14712598.2015.1051527] [Citation(s) in RCA: 128] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Heart valve disease is an increasingly prevalent and clinically serious condition. There are no clinically effective biological diagnostics or treatment strategies. The only recourse available is replacement with a prosthetic valve, but the inability of these devices to grow or respond biologically to their environments necessitates multiple resizing surgeries and life-long coagulation treatment, especially in children. Tissue engineering has a unique opportunity to impact heart valve disease by providing a living valve conduit, capable of growth and biological integration. AREAS COVERED This review will cover current tissue engineering strategies in fabricating heart valves and their progress towards the clinic, including molded scaffolds using naturally derived or synthetic polymers, decellularization, electrospinning, 3D bioprinting, hybrid techniques, and in vivo engineering. EXPERT OPINION Whereas much progress has been made to create functional living heart valves, a clinically viable product is not yet realized. The next leap in engineered living heart valves will require a deeper understanding of how the natural multi-scale structural and biological heterogeneity of the tissue ensures its efficient function. Related, improved fabrication strategies must be developed that can replicate this de novo complexity, which is likely instructive for appropriate cell differentiation and remodeling whether seeded with autologous stem cells in vitro or endogenously recruited cells.
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Affiliation(s)
- Daniel Y Cheung
- Cornell University, Department of Biomedical Engineering , Ithaca, NY , USA
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The Immune Response to Crosslinked Tissue is Reduced in Decellularized Xenogeneic and Absent in Decellularized Allogeneic Heart Valves. Int J Artif Organs 2015; 38:199-209. [DOI: 10.5301/ijao.5000395] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2015] [Indexed: 11/20/2022]
Abstract
Background The degeneration and failure of xenogeneic heart valves, such as the Matrix P Plus valve (MP-V) consisting of decellularized porcine valves (dec-pV) and equine glutaraldehyde-fixed conduits (ga-eC) have been linked to tissue immunogenicity accompanied by antibody formation. In contrast, decellularized allograft valves (dec-aV) are well-tolerated. Here, we determined tissue-specific antibody levels in patients after implantation of MP-V or dec-aV and related them to valve failure or time period after implantation. Methods and Results Specific antibodies toward whole tissue-homogenates or alphaGal were determined retrospectively by ELISA analyses from patients who received MP-V with an uneventful course of 56.1 ± 5.1 months (n = 15), or with valve failure after 25.3 ± 14.6 months (n = 3), dec-aV for various times from 4 to 46 months (n = 14, uneventful) and from healthy controls (n = 4). All explanted valves were assessed histopathologically. MP-V induced antibodies toward both tissue components with significantly higher levels toward ga-eC than toward dec-pV (68.7 and 26.65 μg/ml IgG). In patients with valve failure, levels were not significantly higher and were related to inflammatory tissue infiltration. Anti-Gal antibodies in MP-V patients were significantly increased in both, the uneventful and the failure group. In contrast, in dec-aV patients only a slight tissue-specific antibody formation was observed after 4 months (6.24 μg/ml) that normalized to control levels after 1 year. Conclusions The strong humoral immune response to glutaraldehyde-fixed tissues is reduced in decellularized xenogeneic valves and almost absent in decellularized allogeneic tissue up to 4.5 years after implantation.
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Nam SY, Ricles LM, Suggs LJ, Emelianov SY. Imaging strategies for tissue engineering applications. TISSUE ENGINEERING. PART B, REVIEWS 2015; 21:88-102. [PMID: 25012069 PMCID: PMC4322020 DOI: 10.1089/ten.teb.2014.0180] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 07/08/2014] [Indexed: 12/18/2022]
Abstract
Tissue engineering has evolved with multifaceted research being conducted using advanced technologies, and it is progressing toward clinical applications. As tissue engineering technology significantly advances, it proceeds toward increasing sophistication, including nanoscale strategies for material construction and synergetic methods for combining with cells, growth factors, or other macromolecules. Therefore, to assess advanced tissue-engineered constructs, tissue engineers need versatile imaging methods capable of monitoring not only morphological but also functional and molecular information. However, there is no single imaging modality that is suitable for all tissue-engineered constructs. Each imaging method has its own range of applications and provides information based on the specific properties of the imaging technique. Therefore, according to the requirements of the tissue engineering studies, the most appropriate tool should be selected among a variety of imaging modalities. The goal of this review article is to describe available biomedical imaging methods to assess tissue engineering applications and to provide tissue engineers with criteria and insights for determining the best imaging strategies. Commonly used biomedical imaging modalities, including X-ray and computed tomography, positron emission tomography and single photon emission computed tomography, magnetic resonance imaging, ultrasound imaging, optical imaging, and emerging techniques and multimodal imaging, will be discussed, focusing on the latest trends of their applications in recent tissue engineering studies.
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Affiliation(s)
- Seung Yun Nam
- Department of Biomedical Engineering, The University of Texas at Austin, Austin, Texas
- Department of Electrical and Computer Engineering, The University of Texas at Austin, Austin, Texas
| | - Laura M. Ricles
- Department of Biomedical Engineering, The University of Texas at Austin, Austin, Texas
| | - Laura J. Suggs
- Department of Biomedical Engineering, The University of Texas at Austin, Austin, Texas
| | - Stanislav Y. Emelianov
- Department of Biomedical Engineering, The University of Texas at Austin, Austin, Texas
- Department of Electrical and Computer Engineering, The University of Texas at Austin, Austin, Texas
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Abstract
The field of regenerative medicine has experienced considerable growth in recent years as the translation of pre-clinical biomaterials and cell- and gene-based therapies begin to reach clinical application. Until recently, the ability to monitor the serial responses to therapeutic treatments has been limited to post-mortem tissue analyses. With improvements in existing imaging modalities and the emergence of hybrid imaging systems, it is now possible to combine information related to structural remodeling with associated molecular events using non-invasive imaging. This review summarizes the established and emerging imaging modalities that are available for in vivo monitoring of clinical regenerative medicine therapies and discusses the strengths and limitations of each imaging modality.
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Affiliation(s)
- Mitchel R. Stacy
- Department of Internal Medicine, Yale University School of Medicine, P.O. Box 208017, Dana-3, New Haven, CT 06520 USA
| | - Albert J. Sinusas
- Departments of Internal Medicine & Diagnostic Radiology, Yale University School of Medicine, P.O. Box 208017, Dana-3, New Haven, CT 06520 USA
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50
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Taylor DA, Sampaio LC, Gobin A. Building new hearts: a review of trends in cardiac tissue engineering. Am J Transplant 2014; 14:2448-59. [PMID: 25293671 DOI: 10.1111/ajt.12939] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Revised: 06/26/2014] [Accepted: 07/12/2014] [Indexed: 01/25/2023]
Abstract
Cardiovascular disease (CVD) is the number one cause of death in the United States. However, few treatments for CVD provide a means to regain full cardiac function with no long-term side effects. Novel tissue-engineered products may provide a way to overcome the limitations of current CVD therapies by replacing injured myocardium with functioning tissue or by inducing more constructive forms of endogenous repair. In this review, we discuss some of the factors that should be considered in the development of tissue-engineered products, and we review the methods currently being investigated to generate more effective heart valves, cardiac patches and whole hearts.
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Affiliation(s)
- D A Taylor
- Department of Regenerative Medicine Research, Texas Heart Institute, Houston, TX
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