Long-Term Survival and Growth of Pulsatile Myocardial Tissue Grafts Engineered by the Layering of Cardiomyocyte Sheets

Toward clinical application of stem cells for cardiac regeneration

Heart failure affects more than 10% of the Australian population over age 65, and the ageing population will ensure continued growth of this significant problem. There are various treatment options available, but the growing field of regenerative therapy offers promise to restore or replace tissue lost in those with either congenital or acquired cardiac defects. Stem cells have many potential properties, but they need multiple discussed qualities to succeed in this field such as ease of harvest and multiplication, and most importantly minimal ethical concerns. There are multiple cell types available and one of the challenges will be to find the most appropriate cell type for cardiac regeneration. Cardiac tissue engineering is being explored using both in vitro and in vivo techniques. In vitro methods are primarily limited in terms of the vascularisation and size of the construct. In vivo engineered constructs overcome these limitations in early models, but they are still not ready for human trials. This review aims to provide the reader with an outline of the cell-based and tissue engineering therapies currently being used and developed for cardiac regeneration, as well as some insight into the potential problems that may hamper its progress in the future.

Tissue engineering by self-assembly and bio-printing of living cells

Biofabrication of living structures with desired topology and functionality requires the interdisciplinary effort of practitioners of the physical, life and engineering sciences. Such efforts are being undertaken in many laboratories around the world. Numerous approaches are pursued, such as those based on the use of natural or artificial scaffolds, decellularized cadaveric extracellular matrices and, most lately, bioprinting. To be successful in this endeavor, it is crucial to provide in vitro micro-environmental clues for the cells resembling those in the organism. Therefore, scaffolds, populated with differentiated cells or stem cells, of increasing complexity and sophistication are being fabricated. However, no matter how sophisticated scaffolds are, they can cause problems stemming from their degradation, eliciting immunogenic reactions and other a priori unforeseen complications. It is also being realized that ultimately the best approach might be to rely on the self-assembly and self-organizing properties of cells and tissues and the innate regenerative capability of the organism itself, not just simply prepare tissue and organ structures in vitro followed by their implantation. Here we briefly review the different strategies for the fabrication of three-dimensional biological structures, in particular bioprinting. We detail a fully biological, scaffoldless, print-based engineering approach that uses self-assembling multicellular units as bio-ink particles and employs early developmental morphogenetic principles, such as cell sorting and tissue fusion.

Cell sheet transplantation of cultured mesenchymal stem cells enhances bone formation in a rat nonunion model

Orthopedic surgeons have long been troubled by cases involving nonunion of fractured bones. This study aimed to enhance bone union by cell sheet transplantation of mesenchymal stem cells. A nonunion model was made in rat femur, and rat bone marrow cells were cultured in medium containing dexamethasone and ascorbic acid phosphate to create a cell sheet that could be scraped off as a single sheet. Cell sheets were transplanted onto fractured femurs without a scaffold in the model. X-ray and histological analysis were performed at 2, 4 and 8 weeks. Ultrasonography and biomechanical analysis were performed at 8 weeks. X-ray photographs and histological sections showed callus formation around the fracture site in the cell sheet-transplanted group (sheet group). Bone union was obtained in the sheet group at 8 weeks. By contrast, the control group (without sheet transplantation) showed nonunion of the femur. The results of pullout evaluation in the vertical direction of the femur in the sheet group were significantly better than that of the control group. Analysis of the origin of de novo formed bone using the Sry gene, which was used as a marker for donor cells, showed that transplanted cells without scaffolds could survive and differentiate into osteogenic lineage cells in vivo. These results showed that the femoral fracture in our model was completely cured by the transplantation of a cell sheet created by tissue engineering techniques. Thus, we think that cell sheet transplantation can contribute to hard tissue reconstruction in cases involving nonunion, bone defects and osteonecrosis.

Cell sheet engineering: a unique nanotechnology for scaffold-free tissue reconstruction with clinical applications in regenerative medicine

Cell sheet technology (CST) is based on the use of thermoresponsive polymers, poly(N-isopropylacrylamide) (PIPAAm). The surface of PIPAAms is formulated in such a way as to make its typical thickness <100 nm. In this review, we first focus on how the methods of PIPAAm-grafted surface preparations and functionalization are important to be able to harvest a functional cell sheet, to be further transplanted. Then, we present aspects of tissue mimics and three-dimensional reconstruction of a tissue in vitro. Finally, we give an overview of clinical applications and clinically relevant animal experimentations of the technology, such as cardiomyopathy, visual acuity, periodonty, oesophageal ulcerations and type 1 diabetes.

Myocardial tissue engineering: the quest for the ideal myocardial substitute

There has been an intense and competitive quest to manufacture bioartificial heart muscle in the last decade. Numerous biocompatible scaffolds and scaffold-free systems, enriched with various cell types, have been used to fabricate 3D grafts for myocardial repair. In spite of the impressive achievements in the myocardial tissue-engineering field, many issues remain to be addressed before clinical application of this strategy becomes feasible. This is largely due to the uniqueness of the heart's structure and function. This review provides a survey upon the reported strategies, and indicates caveats and perspectives in the field of myocardial tissue engineering.

Bioengineering of a functional sheet of islet cells for the treatment of diabetes mellitus

The present study was designed to establish a novel tissue engineering approach for diabetes mellitus (DM) by fabricating a tissue sheet composed of pancreatic islet cells for in vivo transplantation. Pancreatic islet cell suspensions were obtained from Lewis rats, and plated onto temperature-responsive culture dishes coated with extracellular matrix (ECM) proteins. After the cells reached confluency, islet cells cultured on laminin-5 coated dishes were successfully harvested as a uniformly spread tissue sheet by lowering the culture temperature to 20 degrees C for 20 min. The functional activity of the islet cell sheets was confirmed by histological examination and Insulin secretion assay prior to in vivo transplantation. Histological examination revealed that the harvested islet cell sheet was comprised of insulin- (76%) and glucagon- (19%) positive cells, respectively. In vivo functionality of the islet cell sheet was maintained even 7 days after transplantation into the subcutaneous space of Lewis rats. The present study describes an approach to generate a functional sheet of pancreatic islet cells on laminin-5 coated temperature-responsive dishes, which can be subsequently transplanted in vivo. This study serves as the foundation for the creation of a novel cell-based therapy for DM to provide patients an alternative method.

Physiological function and transplantation of scaffold-free and vascularized human cardiac muscle tissue

Success of human myocardial tissue engineering for cardiac repair has been limited by adverse effects of scaffold materials, necrosis at the tissue core, and poor survival after transplantation due to ischemic injury. Here, we report the development of scaffold-free prevascularized human heart tissue that survives in vivo transplantation and integrates with the host coronary circulation. Human embryonic stem cells (hESCs) were differentiated to cardiomyocytes by using activin A and BMP-4 and then placed into suspension on a rotating orbital shaker to create human cardiac tissue patches. Optimization of patch culture medium significantly increased cardiomyocyte viability in patch centers. These patches, composed only of enriched cardiomyocytes, did not survive to form significant grafts after implantation in vivo. To test the hypothesis that ischemic injury after transplantation would be attenuated by accelerated angiogenesis, we created "second-generation," prevascularized, and entirely human patches from cardiomyocytes, endothelial cells (both human umbilical vein and hESC-derived endothelial cells), and fibroblasts. Functionally, vascularized patches actively contracted, could be electrically paced, and exhibited passive mechanics more similar to myocardium than patches comprising only cardiomyocytes. Implantation of these patches resulted in 10-fold larger cell grafts compared with patches composed only of cardiomyocytes. Moreover, the preformed human microvessels anastomosed with the rat host coronary circulation and delivered blood to the grafts. Thus, inclusion of vascular and stromal elements enhanced the in vitro performance of engineered human myocardium and markedly improved viability after transplantation. These studies demonstrate the importance of including vascular and stromal elements when designing human tissues for regenerative therapies.

Endothelial cell coculture within tissue-engineered cardiomyocyte sheets enhances neovascularization and improves cardiac function of ischemic hearts

BACKGROUND

Regenerative therapies, including myocardial tissue engineering, have been pursued as a new possibility to repair the damaged myocardium, and previously the transplantation of layered cardiomyocyte sheets has been shown to be able to improve cardiac function after myocardial infarction. We examined the effects of promoting neovascularization by controlling the densities of cocultured endothelial cells (ECs) within engineered myocardial tissues created using our cell sheet-based tissue engineering approach.

METHODS AND RESULTS

Neonatal rat cardiomyocytes were cocultured with GFP-positive rat-derived ECs on temperature-responsive culture dishes. Cocultured ECs formed cell networks within the cardiomyocyte sheets, which were preserved during cell harvest from the dishes using simple temperature reduction. We also observed significantly increased in vitro production of vessel-forming cytokines by the EC-positive cardiac cell sheets. After layering of 3 cardiac cell sheets to create 3-dimensional myocardial tissues, these patch-like tissue grafts were transplanted onto infarcted rat hearts. Four weeks after transplantation, recovery of cardiac function could be significantly improved by increasing the EC densities within the engineered myocardial tissues. Additionally, when the EC-positive cardiac tissues were transplanted to myocardial infarction models, we observed significantly greater numbers of capillaries in the grafts as compared with the EC-negative cell sheets. Finally, blood vessels originating from the engineered EC-positive cardiac tissues bridged into the infarcted myocardium to connect with capillaries of the host heart.

CONCLUSIONS

In vitro engineering of 3-dimensional cardiac tissues with preformed EC networks that can be easily connected to host vessels can contribute to the reconstruction of myocardial tissue grafts with a high potential for cardiac function repair. These results indicate that neovascularization can contribute to improved cardiac function after the transplantation of engineered cardiac tissues.

Osteogenic matrix sheet-cell transplantation using osteoblastic cell sheet resulted in bone formation without scaffold at an ectopic site

We previously reported that in vivo bone formation could be observed in composites of porous hydroxyapatite (HA) scaffolds and cultured mesenchymal stem cells (MSCs). In the present study, we developed a new method for transplantation of cultured MSCs without the necessity of using a scaffold to form bone tissue. MSCs were culture-expanded and lifted as cell sheet structures. These cell sheets, designated osteogenic matrix sheets, showed positive alkaline phosphatase (ALP) staining, high ALP activities and high osteocalcin (OC) contents, indicating their osteogenic potential. We transplanted these sheets into subcutaneous sites in rats to assess whether they possessed in vivo bone-forming capability. The transplanted sheets showed mineralized matrix together with osteocytes and an active osteoblast lining, indicating new bone formation, at 6 weeks after transplantation. HA scaffolds were also wrapped with the sheets to make HA/sheet composites and implanted into subcutaneous sites in rats. Histological sections of the composites revealed bone formation in the HA pores at 4 weeks after implantation. Our present results indicate that MSCs can be cultured as sheet structures, and the resulting sheets themselves or HA-sheet composites represent osteogenic implants that can be used for hard tissue reconstruction.

Pulsatile perfusion bioreactor for cardiac tissue engineering

Cardiovascular disease is the number one cause of mortality in North America. Cardiac tissue engineering aims to engineer a contractile patch of physiological thickness to use in surgical repair of diseased heart tissue. We previously reported that perfusion of engineered cardiac constructs resulted in improved tissue assembly. Because heart tissues respond to mechanical stimuli in vitro and experience rhythmic mechanical forces during contraction in vivo, we hypothesized that provision of pulsatile interstitial medium flow to an engineered cardiac patch would result in enhanced tissue assembly by way of mechanical conditioning and improved mass transport. Thus, we constructed a novel perfusion bioreactor capable of providing pulsatile fluid flow at physiologically relevant shear stresses and flow rates. Pulsatile perfusion (PP) was achieved by incorporation of a normally closed solenoid pinch valve into the perfusion loop and was carried out at a frequency of 1 Hz and a flow rate of 1.50 mL/min (PP) or 0.32 mL/min (PP-LF). Nonpulsatile flow at 1.50 mL/min (NP) or 0.32 mL/min (NP-LF) served as controls. Static controls were cultivated in well plates. The main experimental groups were seeded with cells enriched for cardiomyocytes by one preplating step (64% cardiac Troponin I+, 34% prolyl-4-hydroxylase+), whereas pure cardiac fibroblasts and cells enriched for cardiomyocytes by two preplating steps (81% cardiac Troponin I+, 16% prolyl-4-hydroxylase+) served as controls. Cultivation under pulsatile flow had beneficial effects on contractile properties. Specifically, the excitation threshold was significantly lower in the PP condition (pulsatile perfusion at 1.50 mL/min) than in the Static control, and the contraction amplitude was the highest; whereas high maximum capture rate was observed for the PP-LF conditions (pulsatile perfusion at 0.32 mL/min). The enhanced hypertrophy index observed for the PP-LF group was consistent with the highest cellular length and diameter in this group. Within the same cultivation groups (Static, NP-LF, PP-LF, PP, and NP) there were no significant differences in the diameter between fibroblasts and cardiomyocytes, although cardiomyocytes were significantly more elongated than fibroblasts under PP-LF conditions. Cultivation of control cell populations resulted in noncontractile constructs when cardiac fibroblasts were used (as expected) and no overall improvement in functional properties when two steps of preplating were used to enrich for cardiomyocytes in comparison with only one step of preplating.

Tissue engineering by self-assembly of cells printed into topologically defined structures

Understanding the principles of biological self-assembly is indispensable for developing efficient strategies to build living tissues and organs. We exploit the self-organizing capacity of cells and tissues to construct functional living structures of prescribed shape. In our technology, multicellular spheroids (bio-ink particles) are placed into biocompatible environment (bio-paper) by the use of a three-dimensional delivery device (bio-printer). Our approach mimics early morphogenesis and is based on the realization that the genetic control of developmental patterning through self-assembly involves physical mechanisms. Three-dimensional tissue structures are formed through the postprinting fusion of the bio-ink particles, in analogy with early structure-forming processes in the embryo that utilize the apparent liquid-like behavior of tissues composed of motile and adhesive cells. We modeled the process of self-assembly by fusion of bio-ink particles, and employed this novel technology to print extended cellular structures of various shapes. Functionality was tested on cardiac constructs built from embryonic cardiac and endothelial cells. The postprinting self-assembly of bio-ink particles resulted in synchronously beating solid tissue blocks, showing signs of early vascularization, with the endothelial cells organized into vessel-like conduits.

Myocardial tissue engineering: a review

Myocardial tissue engineering, a concept that intends to overcome the obstacles to prolonging patients' life after myocardial infarction, is continuously improving. It comprises a biomaterial based 'vehicle', either a porous scaffold or dense patch, made of either natural or synthetic polymeric materials, to aid transportation of cells into the diseased region in the heart. Many different cell types have been suggested for cell therapy and myocardial tissue engineering. These include both autologous and embryonic stem cells, both having their advantages and disadvantages. Biomaterials suggested for this specific tissue-engineering application need to be biocompatible with the cardiac cells and have particular mechanical properties matching those of native myocardium, so that the delivered donor cells integrate and remain intact in vivo. Although much research is being carried out, many questions still remain unanswered requiring further research efforts. In this review, we discuss the various approaches reported in the field of myocardial tissue engineering, focusing on the achievements of combining biomaterials and cells by various techniques to repair the infarcted region, also providing an insight on clinical trials and possible cell sources in cell therapy. Alternative suggestions to myocardial tissue engineering, in situ engineering and left ventricular devices are also discussed.

Cell sheet engineering for heart tissue repair

Recently, myocardial tissue engineering has emerged as one of the most promising therapies for patients suffering from severe heart failure. Nevertheless, conventional methods in tissue engineering involving the seeding of cells into biodegradable scaffolds have intrinsic shortcomings, such as inflammatory reactions and fibrous tissue formation caused by scaffold degradation. On the other hand, we have developed cell sheet engineering as scaffoldless tissue engineering, and applied it for myocardial tissue engineering. Using temperature-responsive culture surfaces, cells can be harvested as intact sheets and cell-dense thick tissues are constructed by layering these cell sheets. Myocardial cell sheets non-invasively harvested from temperature-responsive culture surfaces are successfully layered, resulting in electrically communicative 3-dimensional (3-D) cardiac constructs. Transplantation of cell sheets onto damaged hearts improved heart function in several animal models. In this review, we summarize the development of myocardial tissue engineering using cell sheets harvested from temperature-responsive culture surfaces and discuss about future views.

Stem cells for tissue engineering of myocardial constructs

Cardiovascular diseases are the leading cause of morbidity and mortality. Tissue engineering offers new option in the myocardial repair techniques. The cellular component of this regenerative approach will play a key role in bringing these tissue engineered constructs from the laboratory bench to the clinical bedside. However, the ideal source of cells still remains unclear and may differ depending upon the application. Current research for many applications is focused on the use of stem cells. The combination of stem cell technology and tissue engineering has been investigated and offers promising avenues for myocardial tissue regeneration, and this shows great promise in future reconstructive surgery. We explore the basic concepts and methods for myocardial tissue reconstruction and emphasize the progress made and remaining challenges of stem cells in myocardial tissue engineering.

Biological cells on microchips: New technologies and applications

Integration of various chemical devices and complex operations onto a microchip, which is often referred to as a micro total analysis system (mu-TAS) or lab-on-a-chip, creates extremely efficient devices that exploit the advantages of a microspace. Furthermore, as the scale of the fluidic microvolume is roughly proportional to living cell sizes and processing capabilities, cells and micro chemical systems can be combined to develop practical prototypical microdevices. This approach has led to development of tools for investigating cellular functions, biochemical reactors and bioassay systems, as well as hybrid bio/artificial tissue engineered organs. Recently, bio-microactuators exploiting mechanical properties of cells powered without external energy sources have also been reported. This review focuses on new technologies involving cell-based devices on microchips, with a special emphasis on bio-microactuators. Firstly, we review systems to place and handle cells on a microchip. Secondly, we review bio-microactuators developed using single or a few driving cells. Finally, we review bio-microactuators developed using numerous cells or tissue to generate stronger forces. Understanding fundamental concepts behind the distinct features and performance characteristics of these cell-based micro-systems will lead to development of new devices that will be exploited in various fields in the future.

Reconstruction of functional tissues with cell sheet engineering

The field of tissue engineering has yielded several successes in early clinical trials of regenerative medicine using living cells seeded into biodegradable scaffolds. In contrast to methods that combine biomaterials with living cells, we have developed an approach that uses culture surfaces grafted with the temperature-responsive polymer poly(N-isoproplyacrylamide) that allows for controlled attachment and detachment of living cells via simple temperature changes. Using cultured cell sheets harvested from temperature-responsive surfaces, we have established cell sheet engineering to create functional tissue sheets to treat a wide range of diseases from corneal dysfunction to esophageal cancer, tracheal resection, and cardiac failure. Additionally, by exploiting the unique ability of cell sheets to generate three-dimensional tissues composed of only cultured cells and their deposited extracellular matrix, we have also developed methods to create thick vascularized tissues as well as, organ-like systems for the heart and liver. Cell sheet engineering therefore provides a novel alternative for regenerative medicine approaches that require the re-creation of functional tissue structures.

Hydrogels as Extracellular Matrices for Skeletal Tissue Engineering: State-of-the-Art and Novel Application in Organ Printing

Organ printing, a novel approach in tissue engineering, applies layered computer-driven deposition of cells and gels to create complex 3-dimensional cell-laden structures. It shows great promise in regenerative medicine, because it may help to solve the problem of limited donor grafts for tissue and organ repair. The technique enables anatomical cell arrangement using incorporation of cells and growth factors at predefined locations in the printed hydrogel scaffolds. This way, 3-dimensional biological structures, such as blood vessels, are already constructed. Organ printing is developing fast, and there are exciting new possibilities in this area. Hydrogels are highly hydrated polymer networks used as scaffolding materials in organ printing. These hydrogel matrices are natural or synthetic polymers that provide a supportive environment for cells to attach to and proliferate and differentiate in. Successful cell embedding requires hydrogels that are complemented with biomimetic and extracellular matrix components, to provide biological cues to elicit specific cellular responses and direct new tissue formation. This review surveys the use of hydrogels in organ printing and provides an evaluation of the recent advances in the development of hydrogels that are promising for use in skeletal regenerative medicine. Special emphasis is put on survival, proliferation and differentiation of skeletal connective tissue cells inside various hydrogel matrices.

Cell Sorting Technique Based on Thermoresponsive Differential Cell Adhesiveness

Cell sorting of specific target cells from a mixture of different cell types is a prerequisite for development of functional engineered tissues based on stem-cell and tissue engineering. This paper presents a new method of cell sorting that uses a mixture of thermoresponsive cell-adhesive and non-cell-adhesive substances. The former substance is poly(N-isopropylacrylamide)-grafted gelatin (PNIPAM-gelatin) and the latter is PNIPAM. Graded cell adhesion, produced by mixed coating of these thermoresponsive substances at an appropriate mixing ratio, clearly differentiated the adhesive potentials of two bovine vascular cell types (endothelial cell and smooth muscle cell). The sequential procedures of detachment at room temperature and subsequent replating at 37 degrees C on dishes coated with a mixed coating with the same composition as that employed previously yielded remarkably pure target cells, as determined using confocal laser scanning fluorescence microscopy. This method, leading to harvesting of target cells, is characteristic of simple manipulation with no cell damage. Such advantages are expected to facilitate stem-cell and tissue engineering.

A tissue engineering approach to progenitor cell delivery results in significant cell engraftment and improved myocardial remodeling

Cell replacement therapy has become an attractive solution for myocardial repair. Typical cell delivery techniques, however, suffer from poor cell engraftment and inhomogeneous cell distributions. Therefore, we assessed the hypothesis that an epicardially applied, tissue-engineered cardiac patch containing progenitor cells would result in enhanced exogenous cell engraftment. Human mesenchymal stem cells (hMSCs) were embedded into a rat tail type I collagen matrix to form the cardiac patch. Myocardial infarction was induced by left anterior descending coronary artery ligation in immunocompetent male cesarean-derived fischer rats, and patches with or without cells were secured to hearts with fibrin sealant. After patch formation, hMSCs retained a viability of >90% over 5 days in culture. In addition, >75% of hMSCs maintained a high degree of potency prior to patch implantation. After 4 days in culture, patches were applied to the epicardial surface of the infarct area and resulted in 23% +/- 4% engraftment of hMSCs at 1 week (n = 6). Patch application resulted in a reduction in left ventricle interior diameter at systole, increased anterior wall thickness, and a 30% increase in fractional shortening. Despite this improvement in myocardial remodeling, hMSCs were not detectable at 4 weeks after patch application, implying that improvement did not require long-term cell engraftment. Patches devoid of progenitor cells showed no improvement in remodeling. In conclusion, pluripotent hMSCs can be efficiently delivered to a site of myocardial injury using an epicardial cardiac patch, and such delivery results in improved myocardial remodeling after infarction. Disclosure of potential conflicts of interest is found at the end of this article.

Cell delivery in regenerative medicine: the cell sheet engineering approach

Recently, cell-based therapies have developed as a foundation for regenerative medicine. General approaches for cell delivery have thus far involved the use of direct injection of single cell suspensions into the target tissues. Additionally, tissue engineering with the general paradigm of seeding cells into biodegradable scaffolds has also evolved as a method for the reconstruction of various tissues and organs. With success in clinical trials, regenerative therapies using these approaches have therefore garnered significant interest and attention. As a novel alternative, we have developed cell sheet engineering using temperature-responsive culture dishes, which allows for the non-invasive harvest of cultured cells as intact sheets along with their deposited extracellular matrix. Using this approach, cell sheets can be directly transplanted to host tissues without the use of scaffolding or carrier materials, or used to create in vitro tissue constructs via the layering of individual cell sheets. In addition to simple transplantation, cell sheet engineered constructs have also been applied for alternative therapies such as endoscopic transplantation, combinatorial tissue reconstruction, and polysurgery to overcome limitations of regenerative therapies and cell delivery using conventional approaches.