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van der Valk DC, Fomina A, Uiterwijk M, Hooijmans CR, Akiva A, Kluin J, Bouten CV, Smits AI. Calcification in Pulmonary Heart Valve Tissue Engineering. JACC Basic Transl Sci 2023. [DOI: 10.1016/j.jacbts.2022.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Uiterwijk M, van der Valk DC, van Vliet R, de Brouwer IJ, Hooijmans CR, Kluin J. Pulmonary valve tissue engineering strategies in large animal models. PLoS One 2021; 16:e0258046. [PMID: 34610023 PMCID: PMC8491907 DOI: 10.1371/journal.pone.0258046] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 09/16/2021] [Indexed: 01/10/2023] Open
Abstract
In the last 25 years, numerous tissue engineered heart valve (TEHV) strategies have been studied in large animal models. To evaluate, qualify and summarize all available publications, we conducted a systematic review and meta-analysis. We identified 80 reports that studied TEHVs of synthetic or natural scaffolds in pulmonary position (n = 693 animals). We identified substantial heterogeneity in study designs, methods and outcomes. Most importantly, the quality assessment showed poor reporting in randomization and blinding strategies. Meta-analysis showed no differences in mortality and rate of valve regurgitation between different scaffolds or strategies. However, it revealed a higher transvalvular pressure gradient in synthetic scaffolds (11.6 mmHg; 95% CI, [7.31-15.89]) compared to natural scaffolds (4,67 mmHg; 95% CI, [3,94-5.39]; p = 0.003). These results should be interpreted with caution due to lack of a standardized control group, substantial study heterogeneity, and relatively low number of comparable studies in subgroup analyses. Based on this review, the most adequate scaffold model is still undefined. This review endorses that, to move the TEHV field forward and enable reliable comparisons, it is essential to define standardized methods and ways of reporting. This would greatly enhance the value of individual large animal studies.
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Affiliation(s)
- M. Uiterwijk
- Heart Center, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - D. C. van der Valk
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
- Institute for Complex Molecular Systems, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - R. van Vliet
- Faculty of medicine, University of Amsterdam, Amsterdam, The Netherlands
| | - I. J. de Brouwer
- Faculty of medicine, University of Amsterdam, Amsterdam, The Netherlands
| | - C. R. Hooijmans
- Department for Health Evidence Unit SYRCLE, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Anesthesiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J. Kluin
- Heart Center, Amsterdam University Medical Center, Amsterdam, The Netherlands
- * E-mail:
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Motta SE, Lintas V, Fioretta ES, Dijkman PE, Putti M, Caliskan E, Rodriguez Cetina Biefer H, Lipiski M, Sauer M, Cesarovic N, Hoerstrup SP, Emmert MY. Human cell-derived tissue-engineered heart valve with integrated Valsalva sinuses: towards native-like transcatheter pulmonary valve replacements. NPJ Regen Med 2019; 4:14. [PMID: 31240114 PMCID: PMC6572861 DOI: 10.1038/s41536-019-0077-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 05/21/2019] [Indexed: 02/06/2023] Open
Abstract
Transcatheter valve replacement indication is currently being extended to younger and lower-risk patients. However, transcatheter prostheses are still based on glutaraldehyde-fixed xenogeneic materials. Hence, they are prone to calcification and long-term structural degeneration, which are particularly accelerated in younger patients. Tissue-engineered heart valves based on decellularized in vitro grown tissue-engineered matrices (TEM) have been suggested as a valid alternative to currently used bioprostheses, showing good performance and remodeling capacity as transcatheter pulmonary valve replacement (TPVR) in sheep. Here, we first describe the in vitro development of human cell-derived TEM (hTEM) and their application as tissue-engineered sinus valves (hTESVs), endowed with Valsalva sinuses for TPVR. The hTEM and hTESVs were systematically characterized in vitro by histology, immunofluorescence, and biochemical analyses, before they were evaluated in a pulse duplicator system under physiological pulmonary pressure conditions. Thereafter, transapical delivery of hTESVs was tested for feasibility and safety in a translational sheep model, achieving good valve performance and early cellular infiltration. This study demonstrates the principal feasibility of clinically relevant hTEM to manufacture hTESVs for TPVR.
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Affiliation(s)
- Sarah E Motta
- 1Institute for Regenerative Medicine (IREM), University of Zurich, Zurich, Switzerland
| | - Valentina Lintas
- 1Institute for Regenerative Medicine (IREM), University of Zurich, Zurich, Switzerland
| | - Emanuela S Fioretta
- 1Institute for Regenerative Medicine (IREM), University of Zurich, Zurich, Switzerland
| | - Petra E Dijkman
- 1Institute for Regenerative Medicine (IREM), University of Zurich, Zurich, Switzerland
| | - Matilde Putti
- 2Department of Biomedical Engineering, Technische Universiteit Eindhoven, Eindhoven, The Netherlands
| | - Etem Caliskan
- 3Department of Cardiovascular Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany.,Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Héctor Rodriguez Cetina Biefer
- 3Department of Cardiovascular Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany.,Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Miriam Lipiski
- 5Division of Surgical Research, University Hospital Zürich, University of Zurich, Zurich, Switzerland
| | - Mareike Sauer
- 5Division of Surgical Research, University Hospital Zürich, University of Zurich, Zurich, Switzerland
| | - Nikola Cesarovic
- 5Division of Surgical Research, University Hospital Zürich, University of Zurich, Zurich, Switzerland
| | - Simon P Hoerstrup
- 1Institute for Regenerative Medicine (IREM), University of Zurich, Zurich, Switzerland.,6Wyss Translational Center Zurich, University of Zurich and ETH Zurich, Zurich, Switzerland
| | - Maximilian Y Emmert
- 1Institute for Regenerative Medicine (IREM), University of Zurich, Zurich, Switzerland.,3Department of Cardiovascular Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany.,Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,6Wyss Translational Center Zurich, University of Zurich and ETH Zurich, Zurich, Switzerland
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Motta SE, Fioretta ES, Dijkman PE, Lintas V, Behr L, Hoerstrup SP, Emmert MY. Development of an Off-the-Shelf Tissue-Engineered Sinus Valve for Transcatheter Pulmonary Valve Replacement: a Proof-of-Concept Study. J Cardiovasc Transl Res 2018; 11:182-191. [PMID: 29560553 DOI: 10.1007/s12265-018-9800-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 03/05/2018] [Indexed: 11/30/2022]
Abstract
Tissue-engineered heart valves with self-repair and regeneration properties may overcome the problem of long-term degeneration of currently used artificial prostheses. The aim of this study was the development and in vivo proof-of-concept of next-generation off-the-shelf tissue-engineered sinus valve (TESV) for transcatheter pulmonary valve replacement (TPVR). Transcatheter implantation of off-the-shelf TESVs was performed in a translational sheep model for up to 16 weeks. Transapical delivery of TESVs was successful and showed good acute and short-term performance (up to 8 weeks), which then worsened over time most likely due to a non-optimized in vitro valve design. Post-mortem analyses confirmed the remodelling potential of the TESVs, with host cell infiltration, polymer degradation, and collagen and elastin deposition. TESVs proved to be suitable as TPVR in a preclinical model, with encouraging short-term performance and remodelling potential. Future studies will enhance the clinical translation of such approach by improving the valve design to ensure long-term functionality.
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Affiliation(s)
- Sarah E Motta
- Institute for Regenerative Medicine (IREM), University of Zurich, Zurich, Switzerland
| | - Emanuela S Fioretta
- Institute for Regenerative Medicine (IREM), University of Zurich, Zurich, Switzerland
| | - Petra E Dijkman
- Institute for Regenerative Medicine (IREM), University of Zurich, Zurich, Switzerland
| | - Valentina Lintas
- Institute for Regenerative Medicine (IREM), University of Zurich, Zurich, Switzerland
| | - Luc Behr
- Institute Mutualiste Montsouris (IMMR), Paris, France
| | - Simon P Hoerstrup
- Institute for Regenerative Medicine (IREM), University of Zurich, Zurich, Switzerland.,Wyss Translational Center Zurich, University and ETH Zurich, Zurich, Switzerland
| | - Maximilian Y Emmert
- Institute for Regenerative Medicine (IREM), University of Zurich, Zurich, Switzerland. .,Wyss Translational Center Zurich, University and ETH Zurich, Zurich, Switzerland. .,Heart Center Zurich, University Hospital Zurich, Zurich, Switzerland.
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Motta SE, Lintas V, Fioretta ES, Hoerstrup SP, Emmert MY. Off-the-shelf tissue engineered heart valves for in situ regeneration: current state, challenges and future directions. Expert Rev Med Devices 2017; 15:35-45. [PMID: 29257706 DOI: 10.1080/17434440.2018.1419865] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Transcatheter aortic valve replacement (TAVR) is continuously evolving and is expected to surpass surgical valve implantation in the near future. Combining durable valve substitutes with minimally invasive implantation techniques might increase the clinical relevance of this therapeutic option for younger patient populations. Tissue engineering offers the possibility to create tissue engineered heart valves (TEHVs) with regenerative and self-repair capacities which may overcome the pitfalls of current TAVR prostheses. AREAS COVERED This review focuses on off-the-shelf TEHVs which rely on a clinically-relevant in situ tissue engineering approach and which have already advanced into preclinical or first-in-human investigation. EXPERT COMMENTARY Among the off-the-shelf in situ TEHVs reported in literature, the vast majority covers pulmonary valve substitutes, and only few are combined with transcatheter implantation technologies. Hence, further innovations should include the development of transcatheter tissue engineered aortic valve substitutes, which would considerably increase the clinical relevance of such prostheses.
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Affiliation(s)
- Sarah E Motta
- a Institute for Regenerative Medicine (IREM) , University of Zurich , Zurich , Switzerland
| | - Valentina Lintas
- a Institute for Regenerative Medicine (IREM) , University of Zurich , Zurich , Switzerland
| | - Emanuela S Fioretta
- a Institute for Regenerative Medicine (IREM) , University of Zurich , Zurich , Switzerland
| | - Simon P Hoerstrup
- a Institute for Regenerative Medicine (IREM) , University of Zurich , Zurich , Switzerland.,b Wyss Translational Center Zurich , University and ETH Zurich , Zurich , Switzerland
| | - Maximilian Y Emmert
- a Institute for Regenerative Medicine (IREM) , University of Zurich , Zurich , Switzerland.,b Wyss Translational Center Zurich , University and ETH Zurich , Zurich , Switzerland.,c Heart Center Zurich , University Hospital Zurich , Zurich , Switzerland
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Transcatheter implantation of homologous "off-the-shelf" tissue-engineered heart valves with self-repair capacity: long-term functionality and rapid in vivo remodeling in sheep. J Am Coll Cardiol 2013; 63:1320-1329. [PMID: 24361320 DOI: 10.1016/j.jacc.2013.09.082] [Citation(s) in RCA: 121] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Revised: 09/12/2013] [Accepted: 09/19/2013] [Indexed: 10/25/2022]
Abstract
OBJECTIVES This study sought to evaluate long-term in vivo functionality, host cell repopulation, and remodeling of "off-the-shelf" tissue engineered transcatheter homologous heart valves. BACKGROUND Transcatheter valve implantation has emerged as a valid alternative to conventional surgery, in particular for elderly high-risk patients. However, currently used bioprosthetic transcatheter valves are prone to progressive dysfunctional degeneration, limiting their use in younger patients. To overcome these limitations, the concept of tissue engineered heart valves with self-repair capacity has been introduced as next-generation technology. METHODS In vivo functionality, host cell repopulation, and matrix remodeling of homologous transcatheter tissue-engineered heart valves (TEHVs) was evaluated up to 24 weeks as pulmonary valve replacements (transapical access) in sheep (n = 12). As a control, tissue composition and structure were analyzed in identical not implanted TEHVs (n = 5). RESULTS Transcatheter implantation was successful in all animals. Valve functionality was excellent displaying sufficient leaflet motion and coaptation with only minor paravalvular leakage in some animals. Mild central regurgitation was detected after 8 weeks, increasing to moderate after 24 weeks, correlating to a compromised leaflet coaptation. Mean and peak transvalvular pressure gradients were 4.4 ± 1.6 mm Hg and 9.7 ± 3.0 mm Hg, respectively. Significant matrix remodeling was observed in the entire valve and corresponded with the rate of host cell repopulation. CONCLUSIONS For the first time, the feasibility and long-term functionality of transcatheter-based homologous off-the-shelf tissue engineered heart valves are demonstrated in a relevant pre-clinical model. Such engineered heart valves may represent an interesting alternative to current prostheses because of their rapid cellular repopulation, tissue remodeling, and therewith self-repair capacity. The concept of homologous off-the-shelf tissue engineered heart valves may therefore substantially simplify previous tissue engineering concepts toward clinical translation.
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