1
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Kwartler CS, Pinelo JEE. Use of iPSC-Derived Smooth Muscle Cells to Model Physiology and Pathology. Arterioscler Thromb Vasc Biol 2024; 44:1523-1536. [PMID: 38695171 PMCID: PMC11209779 DOI: 10.1161/atvbaha.123.319703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Abstract
The implementation of human induced pluripotent stem cell (hiPSC) models has introduced an additional tool for identifying molecular mechanisms of disease that complement animal models. Patient-derived or CRISPR/Cas9-edited induced pluripotent stem cells differentiated into smooth muscle cells (SMCs) have been leveraged to discover novel mechanisms, screen potential therapeutic strategies, and model in vivo development. The field has evolved over almost 15 years of research using hiPSC-SMCs and has made significant strides toward overcoming initial challenges such as the lineage specificity of SMC phenotypes. However, challenges both specific (eg, the lack of specific markers to thoroughly validate hiPSC-SMCs) and general (eg, a lack of transparency and consensus around methodology in the field) remain. In this review, we highlight the recent successes and remaining challenges of the hiPSC-SMC model.
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Affiliation(s)
- Callie S. Kwartler
- Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030
| | - Jose Emiliano Esparza Pinelo
- Division of Medical Genetics, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030
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2
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Kiskin FN, Yang Y, Yang H, Zhang JZ. Cracking the code of the cardiovascular enigma: hPSC-derived endothelial cells unveil the secrets of endothelial dysfunction. J Mol Cell Cardiol 2024; 192:65-78. [PMID: 38761989 DOI: 10.1016/j.yjmcc.2024.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 05/08/2024] [Accepted: 05/10/2024] [Indexed: 05/20/2024]
Abstract
Endothelial dysfunction is a central contributor to the development of most cardiovascular diseases and is characterised by the reduced synthesis or bioavailability of the vasodilator nitric oxide together with other abnormalities such as inflammation, senescence, and oxidative stress. The use of patient-specific and genome-edited human pluripotent stem cell-derived endothelial cells (hPSC-ECs) has shed novel insights into the role of endothelial dysfunction in cardiovascular diseases with strong genetic components such as genetic cardiomyopathies and pulmonary arterial hypertension. However, their utility in studying complex multifactorial diseases such as atherosclerosis, metabolic syndrome and heart failure poses notable challenges. In this review, we provide an overview of the different methods used to generate and characterise hPSC-ECs before comprehensively assessing their effectiveness in cardiovascular disease modelling and high-throughput drug screening. Furthermore, we explore current obstacles that will need to be overcome to unleash the full potential of hPSC-ECs in facilitating patient-specific precision medicine. Addressing these challenges holds great promise in advancing our understanding of intricate cardiovascular diseases and in tailoring personalised therapeutic strategies.
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Affiliation(s)
- Fedir N Kiskin
- Institute of Neurological and Psychiatric Disorders, Shenzhen Bay Laboratory, Shenzhen 518132, China.
| | - Yuan Yang
- Institute of Neurological and Psychiatric Disorders, Shenzhen Bay Laboratory, Shenzhen 518132, China.
| | - Hao Yang
- Institute of Neurological and Psychiatric Disorders, Shenzhen Bay Laboratory, Shenzhen 518132, China.
| | - Joe Z Zhang
- Institute of Neurological and Psychiatric Disorders, Shenzhen Bay Laboratory, Shenzhen 518132, China.
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3
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Liang KX. The application of brain organoid for drug discovery in mitochondrial diseases. Int J Biochem Cell Biol 2024; 170:106556. [PMID: 38423381 DOI: 10.1016/j.biocel.2024.106556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 02/26/2024] [Accepted: 02/26/2024] [Indexed: 03/02/2024]
Abstract
Mitochondrial diseases are difficult to treat due to the complexity and multifaceted nature of mitochondrial dysfunction. Brain organoids are three-dimensional (3D) structures derived from human pluripotent stem cells designed to mimic brain-like development and function. Brain organoids have received a lot of attention in recent years as powerful tools for modeling human diseases, brain development, and drug screening. Screening compounds for mitochondrial diseases using brain organoids could provide a more physiologically relevant platform for drug discovery. Brain organoids offer the possibility of personalized medicine because they can be derived from patient-specific cells, allowing testing of drugs tailored to specific genetic mutations. In this article, we highlight how brain organoids offer a promising avenue for screening compounds for mitochondrial diseases and address the challenges and limitations associated with their use. We hope this review will provide new insights into the further progress of brain organoids for mitochondrial screening studies.
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4
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Singh AA, Shetty DK, Jacob AG, Bayraktar S, Sinha S. Understanding genomic medicine for thoracic aortic disease through the lens of induced pluripotent stem cells. Front Cardiovasc Med 2024; 11:1349548. [PMID: 38440211 PMCID: PMC10910110 DOI: 10.3389/fcvm.2024.1349548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 01/31/2024] [Indexed: 03/06/2024] Open
Abstract
Thoracic aortic disease (TAD) is often silent until a life-threatening complication occurs. However, genetic information can inform both identification and treatment at an early stage. Indeed, a diagnosis is important for personalised surveillance and intervention plans, as well as cascade screening of family members. Currently, only 20% of heritable TAD patients have a causative mutation identified and, consequently, further advances in genetic coverage are required to define the remaining molecular landscape. The rapid expansion of next generation sequencing technologies is providing a huge resource of genetic data, but a critical issue remains in functionally validating these findings. Induced pluripotent stem cells (iPSCs) are patient-derived, reprogrammed cell lines which allow mechanistic insights, complex modelling of genetic disease and a platform to study aortic genetic variants. This review will address the need for iPSCs as a frontline diagnostic tool to evaluate variants identified by genomic discovery studies and explore their evolving role in biological insight through to drug discovery.
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Affiliation(s)
| | | | | | | | - Sanjay Sinha
- Wellcome-MRC Cambridge Stem Cell Institute, Jeffrey Cheah Biomedical Centre, Cambridge, United Kingdom
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5
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Raghavan A, Pirruccello JP, Ellinor PT, Lindsay ME. Using Genomics to Identify Novel Therapeutic Targets for Aortic Disease. Arterioscler Thromb Vasc Biol 2024; 44:334-351. [PMID: 38095107 PMCID: PMC10843699 DOI: 10.1161/atvbaha.123.318771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 11/21/2023] [Indexed: 01/04/2024]
Abstract
Aortic disease, including dissection, aneurysm, and rupture, carries significant morbidity and mortality and is a notable cause of sudden cardiac death. Much of our knowledge regarding the genetic basis of aortic disease has relied on the study of individuals with Mendelian aortopathies and, until recently, the genetic determinants of population-level variance in aortic phenotypes remained unclear. However, the application of machine learning methodologies to large imaging datasets has enabled researchers to rapidly define aortic traits and mine dozens of novel genetic associations for phenotypes such as aortic diameter and distensibility. In this review, we highlight the emerging potential of genomics for identifying causal genes and candidate drug targets for aortic disease. We describe how deep learning technologies have accelerated the pace of genetic discovery in this field. We then provide a blueprint for translating genetic associations to biological insights, reviewing techniques for locus and cell type prioritization, high-throughput functional screening, and disease modeling using cellular and animal models of aortic disease.
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Affiliation(s)
- Avanthi Raghavan
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Cardiovascular Disease Initiative, Broad Institute, Cambridge, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - James P. Pirruccello
- Division of Cardiology, University of California San Francisco, San Francisco, CA, USA
| | - Patrick T. Ellinor
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Cardiovascular Disease Initiative, Broad Institute, Cambridge, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Mark E. Lindsay
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Cardiovascular Disease Initiative, Broad Institute, Cambridge, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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6
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Feaver RE, Bowers MS, Cole BK, Hoang S, Lawson MJ, Taylor J, LaMoreaux BD, Zhao L, Henke BR, Johns BA, Nyborg AC, Wamhoff BR, Figler RA. Human cardiovascular disease model predicts xanthine oxidase inhibitor cardiovascular risk. PLoS One 2023; 18:e0291330. [PMID: 37682977 PMCID: PMC10490929 DOI: 10.1371/journal.pone.0291330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 08/27/2023] [Indexed: 09/10/2023] Open
Abstract
Some health concerns are often not identified until late into clinical development of drugs, which can place participants and patients at significant risk. For example, the United States Food and Drug Administration (FDA) labeled the xanthine oxidase inhibitor febuxostat with a"boxed" warning regarding an increased risk of cardiovascular death, and this safety risk was only identified during Phase 3b clinical trials after its approval. Thus, better preclinical assessment of drug efficacy and safety are needed to accurately evaluate candidate drug risk earlier in discovery and development. This study explored whether an in vitro vascular model incorporating human vascular cells and hemodynamics could be used to differentiate the potential cardiovascular risk associated with molecules that have similar on-target mechanisms of action. We compared the transcriptomic responses induced by febuxostat and other xanthine oxidase inhibitors to a database of 111 different compounds profiled in the human vascular model. Of the 111 compounds in the database, 107 are clinical-stage and 33 are FDA-labelled for increased cardiovascular risk. Febuxostat induces pathway-level regulation that has high similarity to the set of drugs FDA-labelled for increased cardiovascular risk. These results were replicated with a febuxostat analog, but not another structurally distinct xanthine oxidase inhibitor that does not confer cardiovascular risk. Together, these data suggest that the FDA warning for febuxostat stems from the chemical structure of the medication itself, rather than the target, xanthine oxidase. Importantly, these data indicate that cardiovascular risk can be evaluated in this in vitro human vascular model, which may facilitate understanding the drug candidate safety profile earlier in discovery and development.
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Affiliation(s)
- Ryan E. Feaver
- HemoShear Therapeutics, Incorporated., Charlottesville, Virginia, United States of America
| | - M. Scott Bowers
- Horizon Therapeutics plc, Deerfield, Illinois, United States of America
| | - Banumathi K. Cole
- HemoShear Therapeutics, Incorporated., Charlottesville, Virginia, United States of America
| | - Steve Hoang
- HemoShear Therapeutics, Incorporated., Charlottesville, Virginia, United States of America
| | - Mark J. Lawson
- HemoShear Therapeutics, Incorporated., Charlottesville, Virginia, United States of America
| | - Justin Taylor
- HemoShear Therapeutics, Incorporated., Charlottesville, Virginia, United States of America
| | | | - Lin Zhao
- Horizon Therapeutics plc, Deerfield, Illinois, United States of America
| | - Brad R. Henke
- HemoShear Therapeutics, Incorporated., Charlottesville, Virginia, United States of America
| | - Brian A. Johns
- HemoShear Therapeutics, Incorporated., Charlottesville, Virginia, United States of America
| | - Andrew C. Nyborg
- Horizon Therapeutics plc, Deerfield, Illinois, United States of America
| | - Brian R. Wamhoff
- HemoShear Therapeutics, Incorporated., Charlottesville, Virginia, United States of America
| | - Robert A. Figler
- HemoShear Therapeutics, Incorporated., Charlottesville, Virginia, United States of America
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7
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Chavarria D, Abbaspour A, Celestino N, Shah N, Sankar S, Baker AB. A high throughput blood-brain barrier model incorporating shear stress with improved predictive power for drug discovery. BIOMICROFLUIDICS 2023; 17:044105. [PMID: 37614679 PMCID: PMC10444201 DOI: 10.1063/5.0150887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 08/01/2023] [Indexed: 08/25/2023]
Abstract
The blood-brain barrier is a key structure regulating the health of the brain and access of drugs and pathogens to neural tissue. Shear stress is a key regulator of the blood-brain barrier; however, the commonly used multi-well vitro models of the blood-brain barrier do not incorporate shear stress. In this work, we designed and validated a high-throughput system for simulating the blood-brain barrier that incorporates physiological flow and incorporates an optimized cellular model of the blood-brain barrier. This system can perform assays of blood-brain barrier function with shear stress, with 48 independent assays simultaneously. Using the high throughput assay, we conducted drug screening assays to explore the effects of compounds for opening or closing blood-brain barrier. Our studies revealed that assays with shear stress were more predictive and were able to identify compounds known to modify the blood-brain barrier function while static assays were not. Overall, we demonstrate an optimized, high throughput assay for simulating the blood-brain barrier that incorporates shear stress and is practical for use in drug screening and other high throughput studies of toxicology.
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Affiliation(s)
- Daniel Chavarria
- Department of Biomedical Engineering, University of Texas at Austin, Austin, Texas 78712, USA
| | - Ali Abbaspour
- Department of Biomedical Engineering, University of Texas at Austin, Austin, Texas 78712, USA
| | - Natalie Celestino
- Department of Biomedical Engineering, University of Texas at Austin, Austin, Texas 78712, USA
| | - Nehali Shah
- Department of Biomedical Engineering, University of Texas at Austin, Austin, Texas 78712, USA
| | | | - Aaron B. Baker
- Author to whom correspondence should be addressed:. Tel.:+512-232-7114
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8
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Sivaraman S, Ravishankar P, Rao RR. Differentiation and Engineering of Human Stem Cells for Smooth Muscle Generation. TISSUE ENGINEERING. PART B, REVIEWS 2023; 29:1-9. [PMID: 35491587 DOI: 10.1089/ten.teb.2022.0039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Cardiovascular diseases are responsible for 31% of global deaths and are considered the main cause of death and disability worldwide. Stem cells from various sources have become attractive options for a range of cell-based therapies for smooth muscle tissue regeneration. However, for efficient myogenic differentiation, the stem cell characteristics, cell culture conditions, and their respective microenvironments need to be carefully assessed. This review covers the various approaches involved in the regeneration of vascular smooth muscles by conditioning human stem cells. This article delves into the different sources of stem cells used in the generation of myogenic tissues, the role of soluble growth factors, use of scaffolding techniques, biomolecular cues, relevance of mechanical stimulation, and key transcription factors involved, aimed at inducing myogenic differentiation. Impact statement The review article's main goal is to discuss the recent advances in the field of smooth muscle tissue regeneration. We look at various cell sources, growth factors, scaffolds, mechanical stimuli, and factors involved in smooth muscle formation. These stem cell-based approaches for vascular muscle formation will provide various options for cell-based therapies with long-term beneficial effects on patients.
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Affiliation(s)
- Srikanth Sivaraman
- Department of Biomedical Engineering, University of Arkansas, Fayetteville, Arkansas, USA
| | - Prashanth Ravishankar
- Department of Biomedical Engineering, University of Arkansas, Fayetteville, Arkansas, USA
| | - Raj R Rao
- Department of Biomedical Engineering, University of Arkansas, Fayetteville, Arkansas, USA
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9
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Islam S, Parker J, Dash BC, Hsia HC. Human iPSC-Vascular smooth muscle cell spheroids demonstrate size-dependent alterations in cellular viability and secretory function. J Biomed Mater Res A 2022; 110:1813-1823. [PMID: 35815599 DOI: 10.1002/jbm.a.37423] [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: 03/31/2022] [Revised: 06/08/2022] [Accepted: 06/15/2022] [Indexed: 11/11/2022]
Abstract
Human-induced pluripotent stem cells (hiPSC) and their differentiated vascular cells have been revolutionizing the field of regenerative wound healing. These cells are shown to be rejuvenated with immense potentials in secreting paracrine factors. Recently, hiPSC-derived vascular smooth muscle cells (hiPSC-VSMC) have shown regenerative wound healing ability via their paracrine secretion. The quest to modulate the secretory function of these hiPSC-VSMC is an ongoing effort and involves the use of both biochemical and biophysical stimuli. This study explores the development and optimization of a reproducible, inexpensive protocol to form hiPSC-VSMC derived spheroids to investigate the implications of spheroid size on viability and paracrine secretion. Our data show the successful formation of different sizes of spheroids using various amount of hiPSC-VSMC. The hiPSC-VSMC spheroids formed with 10,000 cells strike an ideal balance between overall cell health and maximal paracrine secretion. The conditioned medium from these spheroids was found to be bioactive in enhancing human dermal fibroblast cell proliferation and migration. This research will inform future studies on the optimal spheroid size for regenerative wound healing applications.
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Affiliation(s)
- Sara Islam
- Section of Plastic Surgery, Department of Surgery, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Jackson Parker
- Section of Plastic Surgery, Department of Surgery, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Biraja C Dash
- Section of Plastic Surgery, Department of Surgery, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Henry C Hsia
- Section of Plastic Surgery, Department of Surgery, Yale School of Medicine, Yale University, New Haven, Connecticut, USA.,Department of Biomedical Engineering, Yale University, New Haven, Connecticut, USA
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10
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Raniga K, Vo NTN, Denning C. Differentiation and Characterization of Human Pluripotent Stem Cell-Derived Cardiac Endothelial Cells for In Vitro Applications. METHODS IN MOLECULAR BIOLOGY (CLIFTON, N.J.) 2022; 2441:339-348. [PMID: 35099750 DOI: 10.1007/978-1-0716-2059-5_27] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Various protocols have been developed to generate endothelial cells for disease modeling, angiogenesis, vascular regeneration, and drug screening. These protocols often require cell sorting, as most differentiation strategies result in a heterogenous population of endothelial cells (ECs). For any given model system, one important consideration is choosing the appropriate EC subtype, as different EC populations have unique molecular signatures.Herein, we describe a protocol for cardiac EC differentiation and a protocol for endothelial cell characterization. This protocol is aimed at investigating differentiation efficiency by measuring endothelial lineage markers, CD31, VE-Cadherin, and VEGFR2 by flow cytometry. Collectively, these protocols comprise the tools required to generate cardiac ECs efficiently and reproducibly from different hPSC lines without the need for cell sorting. Our protocol adds to the panel of hPSCs for cardiac EC differentiation and addresses reproducibility concerns of hPSC-based experiments. The approaches described are also applicable for complex model generation where multiple cardiovascular cell types are involved and may assist in optimizing differentiations for different cell lineages, including cardiomyocytes, cardiac endothelial cells, and cardiac fibroblasts.
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Affiliation(s)
- Kavita Raniga
- Department of Stem Cell Biology, Biodiscovery Institute, University of Nottingham, Nottingham, UK
| | - Nguyen T N Vo
- Department of Stem Cell Biology, Biodiscovery Institute, University of Nottingham, Nottingham, UK
| | - Chris Denning
- Department of Stem Cell Biology, Biodiscovery Institute, University of Nottingham, Nottingham, UK.
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11
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Liu C, Niu K, Xiao Q. Updated perspectives on vascular cell specification and pluripotent stem cell-derived vascular organoids for studying vasculopathies. Cardiovasc Res 2022; 118:97-114. [PMID: 33135070 PMCID: PMC8752356 DOI: 10.1093/cvr/cvaa313] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 09/15/2020] [Accepted: 10/19/2020] [Indexed: 02/07/2023] Open
Abstract
Vasculopathy is a pathological process occurring in the blood vessel wall, which could affect the haemostasis and physiological functions of all the vital tissues/organs and is one of the main underlying causes for a variety of human diseases including cardiovascular diseases. Current pharmacological interventions aiming to either delay or stop progression of vasculopathies are suboptimal, thus searching novel, targeted, risk-reducing therapeutic agents, or vascular grafts with full regenerative potential for patients with vascular abnormalities are urgently needed. Since first reported, pluripotent stem cells (PSCs), particularly human-induced PSCs, have open new avenue in all research disciplines including cardiovascular regenerative medicine and disease remodelling. Assisting with recent technological breakthroughs in tissue engineering, in vitro construction of tissue organoid made a tremendous stride in the past decade. In this review, we provide an update of the main signal pathways involved in vascular cell differentiation from human PSCs and an extensive overview of PSC-derived tissue organoids, highlighting the most recent discoveries in the field of blood vessel organoids as well as vascularization of other complex tissue organoids, with the aim of discussing the key cellular and molecular players in generating vascular organoids.
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MESH Headings
- Blood Vessels/metabolism
- Blood Vessels/pathology
- Blood Vessels/physiopathology
- Cell Culture Techniques
- Cell Differentiation
- Cell Lineage
- Cells, Cultured
- Endothelial Cells/metabolism
- Endothelial Cells/pathology
- Humans
- Induced Pluripotent Stem Cells/metabolism
- Muscle, Smooth, Vascular/metabolism
- Muscle, Smooth, Vascular/pathology
- Muscle, Smooth, Vascular/physiopathology
- Myocytes, Smooth Muscle/metabolism
- Myocytes, Smooth Muscle/pathology
- Neovascularization, Pathologic
- Neovascularization, Physiologic
- Organoids
- Phenotype
- Signal Transduction
- Vascular Diseases/metabolism
- Vascular Diseases/pathology
- Vascular Diseases/physiopathology
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Affiliation(s)
- Chenxin Liu
- Centre for Clinical Pharmacology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Heart Centre, Charterhouse Square, London EC1M 6BQ, UK
| | - Kaiyuan Niu
- Centre for Clinical Pharmacology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Heart Centre, Charterhouse Square, London EC1M 6BQ, UK
| | - Qingzhong Xiao
- Centre for Clinical Pharmacology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Heart Centre, Charterhouse Square, London EC1M 6BQ, UK
- Key Laboratory of Cardiovascular Diseases at The Second Affiliated Hospital
- Guangzhou Municipal and Guangdong Provincial Key Laboratory of Protein Modification and Degradation, School of Basic Medical Sciences, Guangzhou Medical University, Xinzao Town, Panyu District, Guangzhou, Guangdong 511436, China
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12
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Validation of a multicellular tumor microenvironment system for modeling patient tumor biology and drug response. Sci Rep 2021; 11:5535. [PMID: 33692370 PMCID: PMC7946945 DOI: 10.1038/s41598-021-84612-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 02/09/2021] [Indexed: 02/06/2023] Open
Abstract
Lung cancer rates are rising globally and non-small cell lung cancer (NSCLC) has a five year survival rate of only 24%. Unfortunately, the development of drugs to treat cancer is severely hampered by the inefficiency of translating pre-clinical studies into clinical benefit. Thus, we sought to apply a tumor microenvironment system (TMES) to NSCLC. Using microvascular endothelial cells, lung cancer derived fibroblasts, and NSCLC tumor cells in the presence of in vivo tumor-derived hemodynamic flow and transport, we demonstrate that the TMES generates an in-vivo like biological state and predicts drug response to EGFR inhibitors. Transcriptomic and proteomic profiling indicate that the TMES recapitulates the in vivo and patient molecular biological state providing a mechanistic rationale for the predictive nature of the TMES. This work further validates the TMES for modeling patient tumor biology and drug response indicating utility of the TMES as a predictive tool for drug discovery and development and potential for use as a system for patient avatars.
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13
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Shen M, Quertermous T, Fischbein MP, Wu JC. Generation of Vascular Smooth Muscle Cells From Induced Pluripotent Stem Cells: Methods, Applications, and Considerations. Circ Res 2021; 128:670-686. [PMID: 33818124 PMCID: PMC10817206 DOI: 10.1161/circresaha.120.318049] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The developmental origin of vascular smooth muscle cells (VSMCs) has been increasingly recognized as a major determinant for regional susceptibility or resistance to vascular diseases. As a human material-based complement to animal models and human primary cultures, patient induced pluripotent stem cell iPSC-derived VSMCs have been leveraged to conduct basic research and develop therapeutic applications in vascular diseases. However, iPSC-VSMCs (induced pluripotent stem cell VSMCs) derived by most existing induction protocols are heterogeneous in developmental origins. In this review, we summarize signaling networks that govern in vivo cell fate decisions and in vitro derivation of distinct VSMC progenitors, as well as key regulators that terminally specify lineage-specific VSMCs. We then highlight the significance of leveraging patient-derived iPSC-VSMCs for vascular disease modeling, drug discovery, and vascular tissue engineering and discuss several obstacles that need to be circumvented to fully unleash the potential of induced pluripotent stem cells for precision vascular medicine.
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Affiliation(s)
- Mengcheng Shen
- Stanford Cardiovascular Institute
- Division of Cardiovascular Medicine, Department of Medicine
| | - Thomas Quertermous
- Stanford Cardiovascular Institute
- Division of Cardiovascular Medicine, Department of Medicine
| | | | - Joseph C. Wu
- Stanford Cardiovascular Institute
- Division of Cardiovascular Medicine, Department of Medicine
- Department of Radiology, Stanford University School of Medicine, Stanford, CA
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14
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Iosef C, Pedroza AJ, Cui JZ, Dalal AR, Arakawa M, Tashima Y, Koyano TK, Burdon G, Churovich SMP, Orrick JO, Pariani M, Fischbein MP. Quantitative proteomics reveal lineage-specific protein profiles in iPSC-derived Marfan syndrome smooth muscle cells. Sci Rep 2020; 10:20392. [PMID: 33230159 PMCID: PMC7683538 DOI: 10.1038/s41598-020-77274-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 11/09/2020] [Indexed: 12/27/2022] Open
Abstract
Marfan syndrome (MFS) is a connective tissue disorder caused by mutations in the FBN1 gene that produces wide disease phenotypic variability. The lack of ample genotype-phenotype correlation hinders translational study development aimed at improving disease prognosis. In response to this need, an induced pluripotent stem cell (iPSC) disease model has been used to test patient-specific cells by a proteomic approach. This model has the potential to risk stratify patients to make clinical decisions, including timing for surgical treatment. The regional propensity for aneurysm formation in MFS may be related to distinct smooth muscle cell (SMC) embryologic lineages. Thus, peripheral blood mononuclear cell (PBMC)-derived induced pluripotent stem cells (iPSC) were differentiated into lateral mesoderm (LM, aortic root) and neural crest (NC, ascending aorta/transverse arch) SMC lineages to model MFS aortic pathology. Isobaric Tags for Relative and Absolute Quantitation (iTRAQ) proteomic analysis by tandem mass spectrometry was applied to profile LM and NC iPSC SMCs from four MFS patients and two healthy controls. Analysis revealed 45 proteins with lineage-dependent expression in MFS patients, many of which were specific to diseased samples. Single protein-level data from both iPSC SMCs and primary MFS aortic root aneurysm tissue confirmed elevated integrin αV and reduced MRC2 in clinical disease specimens, validating the iPSC iTRAQ findings. Functionally, iPSC SMCs exhibited defective adhesion to a variety of extracellular matrix proteins, especially laminin-1 and fibronectin, suggesting altered cytoskeleton dynamics. This study defines the aortic embryologic origin-specific proteome in a validated iPSC SMC model to identify novel protein markers associated with MFS aneurysm phenotype. Translating iPSC findings into clinical aortic aneurysm tissue samples highlights the potential for iPSC-based methods to model MFS disease for mechanistic studies and therapeutic discovery in vitro.
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Affiliation(s)
- Cristiana Iosef
- Department of Cardiothoracic Surgery, Stanford University, 300 Pasteur Dr, Falk CVRB, Stanford, CA, 94305, USA
| | - Albert J Pedroza
- Department of Cardiothoracic Surgery, Stanford University, 300 Pasteur Dr, Falk CVRB, Stanford, CA, 94305, USA
| | - Jason Z Cui
- Department of Cardiothoracic Surgery, Stanford University, 300 Pasteur Dr, Falk CVRB, Stanford, CA, 94305, USA
| | - Alex R Dalal
- Department of Cardiothoracic Surgery, Stanford University, 300 Pasteur Dr, Falk CVRB, Stanford, CA, 94305, USA
| | - Mamoru Arakawa
- Department of Cardiothoracic Surgery, Stanford University, 300 Pasteur Dr, Falk CVRB, Stanford, CA, 94305, USA
| | - Yasushi Tashima
- Department of Cardiothoracic Surgery, Stanford University, 300 Pasteur Dr, Falk CVRB, Stanford, CA, 94305, USA
| | - Tiffany K Koyano
- Department of Cardiothoracic Surgery, Stanford University, 300 Pasteur Dr, Falk CVRB, Stanford, CA, 94305, USA
| | - Grayson Burdon
- Department of Cardiothoracic Surgery, Stanford University, 300 Pasteur Dr, Falk CVRB, Stanford, CA, 94305, USA
| | - Samantha M P Churovich
- Department of Cardiothoracic Surgery, Stanford University, 300 Pasteur Dr, Falk CVRB, Stanford, CA, 94305, USA
| | - Joshua O Orrick
- Department of Cardiothoracic Surgery, Stanford University, 300 Pasteur Dr, Falk CVRB, Stanford, CA, 94305, USA
| | - Mitchel Pariani
- Department of Pediatrics-Genetics, Stanford University, Stanford, CA, USA
| | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University, 300 Pasteur Dr, Falk CVRB, Stanford, CA, 94305, USA.
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15
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Zhu K, Ma W, Li J, Zhang YS, Zhang W, Lai H, Wang C. Modeling aortic diseases using induced pluripotent stem cells. Stem Cells Transl Med 2020; 10:190-197. [PMID: 33179450 PMCID: PMC7848399 DOI: 10.1002/sctm.20-0322] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 10/02/2020] [Accepted: 10/15/2020] [Indexed: 12/11/2022] Open
Abstract
Induced pluripotent stem cells (iPSCs) offer an effective platform for studies of human physiology and have revealed new possibilities for disease modeling at the cellular level. These cells also have the potential to be leveraged in the practice of precision medicine, including personalized drug testing. Aortic diseases result in significant morbidity and mortality and pose a global burden to healthcare. Their pathogenesis is mostly associated with functional alterations of vascular components, such as endothelial cells and vascular smooth muscle cells. Drugs that have been proven to be effective in animal models often fail to protect patients from adverse aortic events in clinical studies, provoking researchers to develop reliable in vitro models using human cells. In this review, we summarize the patient iPSC-derived aortic cells that have been utilized to model aortic diseases in vitro. In advanced models, hemodynamic factors, such as blood flow-induced shear stress and cyclic strain, have been added to the systems to replicate cellular microenvironments in the aortic wall. Examples of the utility of such factors in modeling various aortopathies, such as Marfan syndrome, Loeys-Dietz syndrome, and bicuspid aortic valve-related aortopathy, are also described. Overall, the iPSC-based in vitro cell models have shown the potential to promote the development and practice of precision medicine in the treatment of aortic diseases.
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Affiliation(s)
- Kai Zhu
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China.,Shanghai Institute of Cardiovascular Diseases, Shanghai, People's Republic of China
| | - Wenrui Ma
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China.,Shanghai Institute of Cardiovascular Diseases, Shanghai, People's Republic of China
| | - Jun Li
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China.,Shanghai Institute of Cardiovascular Diseases, Shanghai, People's Republic of China
| | - Yu Shrike Zhang
- Division of Engineering in Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Cambridge, Massachusetts, USA
| | - Weijia Zhang
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China.,Shanghai Institute of Cardiovascular Diseases, Shanghai, People's Republic of China.,Institutes of Biomedical Sciences and Department of Systems Biology for Medicine, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China.,The State Key Laboratory of Molecular Engineering of Polymers, Fudan University, Shanghai, People's Republic of China
| | - Hao Lai
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China.,Shanghai Institute of Cardiovascular Diseases, Shanghai, People's Republic of China
| | - Chunsheng Wang
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China.,Shanghai Institute of Cardiovascular Diseases, Shanghai, People's Republic of China
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16
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Davaapil H, Shetty DK, Sinha S. Aortic "Disease-in-a-Dish": Mechanistic Insights and Drug Development Using iPSC-Based Disease Modeling. Front Cell Dev Biol 2020; 8:550504. [PMID: 33195187 PMCID: PMC7655792 DOI: 10.3389/fcell.2020.550504] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 10/08/2020] [Indexed: 12/24/2022] Open
Abstract
Thoracic aortic diseases, whether sporadic or due to a genetic disorder such as Marfan syndrome, lack effective medical therapies, with limited translation of treatments that are highly successful in mouse models into the clinic. Patient-derived induced pluripotent stem cells (iPSCs) offer the opportunity to establish new human models of aortic diseases. Here we review the power and potential of these systems to identify cellular and molecular mechanisms underlying disease and discuss recent advances, such as gene editing, and smooth muscle cell embryonic lineage. In particular, we discuss the practical aspects of vascular smooth muscle cell derivation and characterization, and provide our personal insights into the challenges and limitations of this approach. Future applications, such as genotype-phenotype association, drug screening, and precision medicine are discussed. We propose that iPSC-derived aortic disease models could guide future clinical trials via “clinical-trials-in-a-dish”, thus paving the way for new and improved therapies for patients.
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Affiliation(s)
- Hongorzul Davaapil
- Wellcome-MRC Cambridge Stem Cell Institute, Jeffrey Cheah Biomedical Centre, Cambridge, United Kingdom
| | - Deeti K Shetty
- Wellcome-MRC Cambridge Stem Cell Institute, Jeffrey Cheah Biomedical Centre, Cambridge, United Kingdom
| | - Sanjay Sinha
- Wellcome-MRC Cambridge Stem Cell Institute, Jeffrey Cheah Biomedical Centre, Cambridge, United Kingdom
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17
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Paik DT, Chandy M, Wu JC. Patient and Disease-Specific Induced Pluripotent Stem Cells for Discovery of Personalized Cardiovascular Drugs and Therapeutics. Pharmacol Rev 2020; 72:320-342. [PMID: 31871214 PMCID: PMC6934989 DOI: 10.1124/pr.116.013003] [Citation(s) in RCA: 106] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Human induced pluripotent stem cells (iPSCs) have emerged as an effective platform for regenerative therapy, disease modeling, and drug discovery. iPSCs allow for the production of limitless supply of patient-specific somatic cells that enable advancement in cardiovascular precision medicine. Over the past decade, researchers have developed protocols to differentiate iPSCs to multiple cardiovascular lineages, as well as to enhance the maturity and functionality of these cells. Despite significant advances, drug therapy and discovery for cardiovascular disease have lagged behind other fields such as oncology. We speculate that this paucity of drug discovery is due to a previous lack of efficient, reproducible, and translational model systems. Notably, existing drug discovery and testing platforms rely on animal studies and clinical trials, but investigations in animal models have inherent limitations due to interspecies differences. Moreover, clinical trials are inherently flawed by assuming that all individuals with a disease will respond identically to a therapy, ignoring the genetic and epigenomic variations that define our individuality. With ever-improving differentiation and phenotyping methods, patient-specific iPSC-derived cardiovascular cells allow unprecedented opportunities to discover new drug targets and screen compounds for cardiovascular disease. Imbued with the genetic information of an individual, iPSCs will vastly improve our ability to test drugs efficiently, as well as tailor and titrate drug therapy for each patient.
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Affiliation(s)
- David T Paik
- Stanford Cardiovascular Institute, Stanford University, Stanford, California
| | - Mark Chandy
- Stanford Cardiovascular Institute, Stanford University, Stanford, California
| | - Joseph C Wu
- Stanford Cardiovascular Institute, Stanford University, Stanford, California
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18
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Dash BC, Setia O, Gorecka J, Peyvandi H, Duan K, Lopes L, Nie J, Berthiaume F, Dardik A, Hsia HC. A Dense Fibrillar Collagen Scaffold Differentially Modulates Secretory Function of iPSC-Derived Vascular Smooth Muscle Cells to Promote Wound Healing. Cells 2020; 9:E966. [PMID: 32295218 PMCID: PMC7226960 DOI: 10.3390/cells9040966] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 04/06/2020] [Accepted: 04/11/2020] [Indexed: 12/20/2022] Open
Abstract
The application of human-induced pluripotent stem cells (hiPSCs) to generate vascular smooth muscle cells (hiPSC-VSMCs) in abundance is a promising strategy for vascular regeneration. While hiPSC-VSMCs have already been utilized for tissue-engineered vascular grafts and disease modeling, there is a lack of investigations exploring their therapeutic secretory factors. The objective of this manuscript was to understand how the biophysical property of a collagen-based scaffold dictates changes in the secretory function of hiPSC-VSMCs while developing hiPSC-VSMC-based therapy for durable regenerative wound healing. We investigated the effect of collagen fibrillar density (CFD) on hiPSC-VSMC's paracrine secretion and cytokines via the construction of varying density of collagen scaffolds. Our study demonstrated that CFD is a key scaffold property that modulates the secretory function of hiPSC-VSMCs. This study lays the foundation for developing collagen-based scaffold materials for the delivery of hiPSC-VSMCs to promote regenerative healing through guiding paracrine signaling pathways.
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Affiliation(s)
- Biraja C. Dash
- Section of Plastic Surgery, Department of Surgery Yale School of Medicine, Yale University, New Haven, CT 06510, USA; (H.P.); (K.D.); (J.N.)
| | - Ocean Setia
- Vascular Biology and Therapeutics Program and the Department of Surgery, Yale School of Medicine, Yale University, New Haven, CT 06510, USA; (O.S.); (J.G.); (L.L.); (A.D.)
| | - Jolanta Gorecka
- Vascular Biology and Therapeutics Program and the Department of Surgery, Yale School of Medicine, Yale University, New Haven, CT 06510, USA; (O.S.); (J.G.); (L.L.); (A.D.)
| | - Hassan Peyvandi
- Section of Plastic Surgery, Department of Surgery Yale School of Medicine, Yale University, New Haven, CT 06510, USA; (H.P.); (K.D.); (J.N.)
| | - Kaiti Duan
- Section of Plastic Surgery, Department of Surgery Yale School of Medicine, Yale University, New Haven, CT 06510, USA; (H.P.); (K.D.); (J.N.)
| | - Lara Lopes
- Vascular Biology and Therapeutics Program and the Department of Surgery, Yale School of Medicine, Yale University, New Haven, CT 06510, USA; (O.S.); (J.G.); (L.L.); (A.D.)
| | - James Nie
- Section of Plastic Surgery, Department of Surgery Yale School of Medicine, Yale University, New Haven, CT 06510, USA; (H.P.); (K.D.); (J.N.)
| | - Francois Berthiaume
- Department of Biomedical Engineering, Rutgers University, The State University New Jersey, Piscataway, NJ 08854, USA;
| | - Alan Dardik
- Vascular Biology and Therapeutics Program and the Department of Surgery, Yale School of Medicine, Yale University, New Haven, CT 06510, USA; (O.S.); (J.G.); (L.L.); (A.D.)
| | - Henry C. Hsia
- Section of Plastic Surgery, Department of Surgery Yale School of Medicine, Yale University, New Haven, CT 06510, USA; (H.P.); (K.D.); (J.N.)
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19
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Stephenson M, Reich DH, Boheler KR. Induced pluripotent stem cell-derived vascular smooth muscle cells. VASCULAR BIOLOGY 2019; 2:R1-R15. [PMID: 32923972 PMCID: PMC7439844 DOI: 10.1530/vb-19-0028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 12/12/2019] [Indexed: 12/31/2022]
Abstract
The reproducible generation of human-induced pluripotent stem cell (hiPSC)-derived vascular smooth muscle cells (vSMCs) in vitro has been critical to overcoming many limitations of animal and primary cell models of vascular biology and disease. Since this initial advance, research in the field has turned toward recapitulating the naturally occurring subtype specificity found in vSMCs throughout the body, and honing functional models of vascular disease. In this review, we summarize vSMC derivation approaches, including current phenotype and developmental origin-specific methods, and applications of vSMCs in functional disease models and engineered tissues. Further, we discuss the challenges of heterogeneity in hiPSC-derived tissues and propose approaches to identify and isolate vSMC subtype populations.
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Affiliation(s)
- Makeda Stephenson
- Department of Biomedical Engineering, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Daniel H Reich
- Department of Physics and Astronomy, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Kenneth R Boheler
- Department of Biomedical Engineering, The Johns Hopkins University, Baltimore, Maryland, USA
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20
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Huang CY, Liu CL, Ting CY, Chiu YT, Cheng YC, Nicholson MW, Hsieh PCH. Human iPSC banking: barriers and opportunities. J Biomed Sci 2019; 26:87. [PMID: 31660969 PMCID: PMC6819403 DOI: 10.1186/s12929-019-0578-x] [Citation(s) in RCA: 117] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/09/2019] [Indexed: 12/31/2022] Open
Abstract
The introduction of induced pluripotent stem cells (iPSCs) has opened up the potential for personalized cell therapies and ushered in new opportunities for regenerative medicine, disease modeling, iPSC-based drug discovery and toxicity assessment. Over the past 10 years, several initiatives have been established that aim to collect and generate a large amount of human iPSCs for scientific research purposes. In this review, we compare the construction and operation strategy of some iPSC banks as well as their ongoing development. We also introduce the technical challenges and offer future perspectives pertaining to the establishment and management of iPSC banks.
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Affiliation(s)
- Ching-Ying Huang
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
| | - Chun-Lin Liu
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
| | - Chien-Yu Ting
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
| | - Yueh-Ting Chiu
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
| | - Yu-Che Cheng
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
| | | | - Patrick C H Hsieh
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan.
- Graduate Institute of Medical Genomics and Proteomics and Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan.
- Cardiovascular Surgery Division, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan.
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21
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Tang X, Su X, Zhong Z, Wen C, Zhang T, Zhu Y. Molecular mechanisms involved in TGF-β1-induced Muscle-derived stem cells differentiation to smooth muscle cells. Am J Transl Res 2019; 11:5150-5161. [PMID: 31497230 PMCID: PMC6731421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 07/30/2019] [Indexed: 06/10/2023]
Abstract
We investigated the molecular mechanisms involved in transforming growth factor beta 1 (TGF-β1)-induced myogenic stem cell differentiation to smooth muscle cells. We isolated muscle-derived stem cells (MDSCs) from gastrocnemius muscles following their identification by immunohistochemistry analysis of desmin and flow cytometry analysis of SCA-1, CD34, and CD45. MDSCs at passage 3 (PP3) were cultured in vitro to examine the effects of MDSC induction. Gene ontology and KEGG pathway analyses were performed to analyze these differentially expressed genes. Reduced representation bisulfite sequencing was performed in TGF-β1-treated and untreated cells to evaluate differences in the methylation status and analyze the chromosomal distribution of differentially methylated sites (DMSs). Significant morphological changes to cells were observed at PP3, and most PP3 cells were positive for desmin and SCA-1, and were confirmed to be MDSCs. Results of western blot and immunohistochemistry analyses suggested that expressions of a-SMA and CNN1 significantly increased after treatment with TGF-β1. Global transcriptome analysis identified 1996 differentially expressed genes (MSC_TGFβ1/MSC_NC). Results of methylome analysis indicated that there were more hypermethylation sites in the untreated group than in the TGF-β1-treated group. Most DMSs were hypermethylated, whereas a small portion was hypomethylated. The chromosomal distribution of DMSs indicated that chromosome 1 had the highest proportion of DMSs, whereas the Y chromosome had the fewest DMSs. Sud2, Pcdh19, and Nat14 are potential core genes involved in cell differentiation. These results may explain the mechanisms of cell differentiation and provide useful information regarding diseases such as pelvic organ prolapse.
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Affiliation(s)
- Xiang Tang
- Department of Gynecology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University Guangzhou 510623, China
| | - Xianghui Su
- Department of Gynecology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University Guangzhou 510623, China
| | - Zhuohui Zhong
- Department of Gynecology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University Guangzhou 510623, China
| | - Canliang Wen
- Department of Gynecology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University Guangzhou 510623, China
| | - Tiansong Zhang
- Department of Gynecology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University Guangzhou 510623, China
| | - Yali Zhu
- Department of Gynecology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University Guangzhou 510623, China
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22
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HiPS-Cardiac Trilineage Cell Generation and Transplantation: a Novel Therapy for Myocardial Infarction. J Cardiovasc Transl Res 2019; 13:110-119. [PMID: 31152358 DOI: 10.1007/s12265-019-09891-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 04/29/2019] [Indexed: 12/12/2022]
Abstract
Despite primary percutaneous coronary intervention (PPCI) and the availability of optimal medications, including dual antiplatelet therapy (DAPT), most patients still experience major adverse cardiovascular events (MACEs) due to frequent recurrence of thrombotic complications and myocardial infarction (MI). MI occurs secondary to a massive loss of endothelial cells (ECs), vascular smooth muscle cells (VSMCs), and cardiomyocytes (CMs). The adult cardiovascular system gradually loses the ability to spontaneously and regularly regenerate ECs, VSMCs, and CMs. However, human cells can be induced by cytokines and growth factors to regenerate human-induced pluripotent stem cells (hiPSCs), which progress to produce cardiac trilineage cells (CTCs) such as ECs, VSMCs, and CMs, replacing lost cells and inducing myocardial repair. Nevertheless, the processes and pathways involved in hiPSC-CTC generation and their potential therapeutic effects remain unknown. Herein, we provide evidence of in vitro CTC generation, the pathways involved, in vivo transplantation, and its therapeutic effect, which may provide novel targets in regenerative medicine for the treatment of cardiovascular diseases (CVDs).
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23
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Williams IM, Wu JC. Generation of Endothelial Cells From Human Pluripotent Stem Cells. Arterioscler Thromb Vasc Biol 2019; 39:1317-1329. [PMID: 31242035 DOI: 10.1161/atvbaha.119.312265] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Endothelial cells (ECs) are critical for several aspects of cardiovascular disease therapy, including vascular regeneration, personalized drug development, and tissue engineering. Human pluripotent stem cells (hPSCs) afford us with an unprecedented opportunity to produce virtually unlimited quantities of human ECs. In this review, we highlight key developments and outstanding challenges in our ability to derive ECs de novo from hPSCs. Furthermore, we consider strategies for recapitulating the vessel- and tissue-specific functional heterogeneity of ECs in vitro. Finally, we discuss ongoing attempts to utilize hPSC-derived ECs and their progenitors for various therapeutic applications. Continued progress in generating hPSC-derived ECs will profoundly enhance our ability to discover novel drug targets, revascularize ischemic tissues, and engineer clinically relevant tissue constructs. Visual Overview- An online visual overview is available for this article.
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Affiliation(s)
- Ian M Williams
- From the Stanford Cardiovascular Institute, Division of Cardiovascular Medicine, Department of Medicine, and Institute for Stem Cell Biology and Regenerative Medicine, Stanford University, CA
| | - Joseph C Wu
- From the Stanford Cardiovascular Institute, Division of Cardiovascular Medicine, Department of Medicine, and Institute for Stem Cell Biology and Regenerative Medicine, Stanford University, CA
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24
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Waldau B. Using miniature brain implants in rodents for novel drug discovery. Expert Opin Drug Discov 2019; 14:379-386. [DOI: 10.1080/17460441.2019.1577816] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Ben Waldau
- Department of Neurological Surgery, University of California, Davis Medical Center, Sacramento, CA, USA
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25
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Cochrane A, Albers HJ, Passier R, Mummery CL, van den Berg A, Orlova VV, van der Meer AD. Advanced in vitro models of vascular biology: Human induced pluripotent stem cells and organ-on-chip technology. Adv Drug Deliv Rev 2019; 140:68-77. [PMID: 29944904 DOI: 10.1016/j.addr.2018.06.007] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 06/11/2018] [Accepted: 06/12/2018] [Indexed: 02/06/2023]
Abstract
The vascular system is one of the first to develop during embryogenesis and is essential for all organs and tissues in our body to develop and function. It has many essential roles including controlling the absorption, distribution and excretion of compounds and therefore determines the pharmacokinetics of drugs and therapeutics. Vascular homeostasis is under tight physiological control which is essential for maintaining tissues in a healthy state. Consequently, disruption of vascular homeostasis plays an integral role in many disease processes, making cells of the vessel wall attractive targets for therapeutic intervention. Experimental models of blood vessels can therefore contribute significantly to drug development and aid in predicting the biological effects of new drug entities. The increasing availability of human induced pluripotent stem cells (hiPSC) derived from healthy individuals and patients have accelerated advances in developing experimental in vitro models of the vasculature: human endothelial cells (ECs), pericytes and vascular smooth muscle cells (VSMCs), can now be generated with high efficiency from hiPSC and used in 'microfluidic chips' (also known as 'organ-on-chip' technology) as a basis for in vitro models of blood vessels. These near physiological scaffolds allow the controlled integration of fluid flow and three-dimensional (3D) co-cultures with perivascular cells to mimic tissue- or organ-level physiology and dysfunction in vitro. Here, we review recent multidisciplinary developments in these advanced experimental models of blood vessels that combine hiPSC with microfluidic organ-on-chip technology. We provide examples of their utility in various research areas and discuss steps necessary for further integration in biomedical applications so that they can be contribute effectively to the evaluation and development of new drugs and other therapeutics as well as personalized (patient-specific) treatments.
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26
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Jang S, Collin de l'Hortet A, Soto-Gutierrez A. Induced Pluripotent Stem Cell-Derived Endothelial Cells: Overview, Current Advances, Applications, and Future Directions. THE AMERICAN JOURNAL OF PATHOLOGY 2019; 189:502-512. [PMID: 30653953 DOI: 10.1016/j.ajpath.2018.12.004] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 11/12/2018] [Accepted: 12/05/2018] [Indexed: 12/13/2022]
Abstract
Endothelial cells are prevalent in our bodies and serve multiple functions. By lining the vasculature, they provide a barrier to tissues and facilitate the transport of molecules and cells. They also maintain hemostasis and modulate blood flow by reacting to chemokines and releasing signal molecules. Thus, endothelial dysfunction leads to a wide variety of diseases, including atherosclerosis and coronary artery disease. In today's era of stem cell research, induced pluripotent stem cell-derived endothelial cells (iPSC-ECs) have emerged for research and engineering purposes. They are not only tools for studying disease states but are also a crucial part of efforts to engineer vessel and organ grafts. As the techniques in cell culture, microfluidics, and personalized medicine concomitantly improve, the potential for iPSC-ECs is enormous. We review functions of endothelium in our bodies, the development and uses of iPSC-ECs, and the possible avenues to explore in the future.
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Affiliation(s)
- Sae Jang
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota.
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27
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Vilà-González M, Kelaini S, Magee C, Caines R, Campbell D, Eleftheriadou M, Cochrane A, Drehmer D, Tsifaki M, O'Neill K, Pedrini E, Yang C, Medina R, McDonald D, Simpson D, Zampetaki A, Zeng L, Grieve D, Lois N, Stitt AW, Margariti A. Enhanced Function of Induced Pluripotent Stem Cell-Derived Endothelial Cells Through ESM1 Signaling. Stem Cells 2018; 37:226-239. [PMID: 30372556 PMCID: PMC6392130 DOI: 10.1002/stem.2936] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 09/14/2018] [Accepted: 10/07/2018] [Indexed: 01/11/2023]
Abstract
The mortality rate for (cardio)‐vascular disease is one of the highest in the world, so a healthy functional endothelium is of outmost importance against vascular disease. In this study, human induced pluripotent stem (iPS) cells were reprogrammed from 1 ml blood of healthy donors and subsequently differentiated into endothelial cells (iPS‐ECs) with typical EC characteristics. This research combined iPS cell technologies and next‐generation sequencing to acquire an insight into the transcriptional regulation of iPS‐ECs. We identified endothelial cell‐specific molecule 1 (ESM1) as one of the highest expressed genes during EC differentiation, playing a key role in EC enrichment and function by regulating connexin 40 (CX40) and eNOS. Importantly, ESM1 enhanced the iPS‐ECs potential to improve angiogenesis and neovascularisation in in vivo models of angiogenesis and hind limb ischemia. These findings demonstrated for the first time that enriched functional ECs are derived through cell reprogramming and ESM1 signaling, opening the horizon for drug screening and cell‐based therapies for vascular diseases. Therefore, this study showcases a new approach for enriching and enhancing the function of induced pluripotent stem (iPS) cell‐derived ECs from a very small amount of blood through ESM1 signaling, which greatly enhances their functionality and increases their therapeutic potential. Stem Cells2019;37:226–239
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Affiliation(s)
- Marta Vilà-González
- Centre for Experimental Medicine, Queen's University Belfast, Belfast, Co Antrim, United Kingdom
| | - Sophia Kelaini
- Centre for Experimental Medicine, Queen's University Belfast, Belfast, Co Antrim, United Kingdom
| | - Corey Magee
- Centre for Experimental Medicine, Queen's University Belfast, Belfast, Co Antrim, United Kingdom
| | - Rachel Caines
- Centre for Experimental Medicine, Queen's University Belfast, Belfast, Co Antrim, United Kingdom
| | - David Campbell
- Centre for Experimental Medicine, Queen's University Belfast, Belfast, Co Antrim, United Kingdom
| | - Magdalini Eleftheriadou
- Centre for Experimental Medicine, Queen's University Belfast, Belfast, Co Antrim, United Kingdom
| | - Amy Cochrane
- Centre for Experimental Medicine, Queen's University Belfast, Belfast, Co Antrim, United Kingdom
| | - Daiana Drehmer
- Centre for Experimental Medicine, Queen's University Belfast, Belfast, Co Antrim, United Kingdom
| | - Marianna Tsifaki
- Centre for Experimental Medicine, Queen's University Belfast, Belfast, Co Antrim, United Kingdom
| | - Karla O'Neill
- Centre for Experimental Medicine, Queen's University Belfast, Belfast, Co Antrim, United Kingdom
| | - Edoardo Pedrini
- Centre for Experimental Medicine, Queen's University Belfast, Belfast, Co Antrim, United Kingdom
| | - Chunbo Yang
- Centre for Experimental Medicine, Queen's University Belfast, Belfast, Co Antrim, United Kingdom
| | - Reinhold Medina
- Centre for Experimental Medicine, Queen's University Belfast, Belfast, Co Antrim, United Kingdom
| | - Denise McDonald
- Centre for Experimental Medicine, Queen's University Belfast, Belfast, Co Antrim, United Kingdom
| | - David Simpson
- Centre for Experimental Medicine, Queen's University Belfast, Belfast, Co Antrim, United Kingdom
| | - Anna Zampetaki
- Cardiovascular Division, King's College London, London, United Kingdom
| | - Lingfang Zeng
- Cardiovascular Division, King's College London, London, United Kingdom
| | - David Grieve
- Centre for Experimental Medicine, Queen's University Belfast, Belfast, Co Antrim, United Kingdom
| | - Noemi Lois
- Centre for Experimental Medicine, Queen's University Belfast, Belfast, Co Antrim, United Kingdom
| | - Alan W Stitt
- Centre for Experimental Medicine, Queen's University Belfast, Belfast, Co Antrim, United Kingdom
| | - Andriana Margariti
- Centre for Experimental Medicine, Queen's University Belfast, Belfast, Co Antrim, United Kingdom
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Klein D. iPSCs-based generation of vascular cells: reprogramming approaches and applications. Cell Mol Life Sci 2018; 75:1411-1433. [PMID: 29243171 PMCID: PMC5852192 DOI: 10.1007/s00018-017-2730-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 12/08/2017] [Accepted: 12/11/2017] [Indexed: 12/15/2022]
Abstract
Recent advances in the field of induced pluripotent stem cells (iPSCs) research have opened a new avenue for stem cell-based generation of vascular cells. Based on their growth and differentiation potential, human iPSCs constitute a well-characterized, generally unlimited cell source for the mass generation of lineage- and patient-specific vascular cells without any ethical concerns. Human iPSCs-derived vascular cells are perfectly suited for vascular disease modeling studies because patient-derived iPSCs possess the disease-causing mutation, which might be decisive for full expression of the disease phenotype. The application of vascular cells for autologous cell replacement therapy or vascular engineering derived from immune-compatible iPSCs possesses huge clinical potential, but the large-scale production of vascular-specific lineages for regenerative cell therapies depends on well-defined, highly reproducible culture and differentiation conditions. This review will focus on the different strategies to derive vascular cells from human iPSCs and their applications in regenerative therapy, disease modeling and drug discovery approaches.
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Affiliation(s)
- Diana Klein
- Institute for Cell Biology (Cancer Research), University Hospital Essen, University of Duisburg-Essen, Virchowstr. 173, 45122, Essen, Germany.
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29
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Sinha S, Santoro MM. New models to study vascular mural cell embryonic origin: implications in vascular diseases. Cardiovasc Res 2018; 114:481-491. [PMID: 29385541 DOI: 10.1093/cvr/cvy005] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 01/23/2018] [Indexed: 02/15/2024] Open
Abstract
A key question in vascular biology is how the diversity of origin of vascular mural cells, namely smooth muscle cells (SMCs) and pericytes influences vessel properties, in particular the regional propensity to vascular diseases. This review therefore first describes the role and regulation of mural cells during vascular formation, with a focus on embryonic origin. We then consider the evidence that connects heterogeneities in SMC and pericyte origins with disease. Since this idea has major implications for understanding and modelling human disease, then there is a pressing need for new model systems to investigate mural cell development and the consequences of heterogeneity. Recent advances arising from in vitro strategies for deriving mural cells from human pluripotent stem cells as well as from the zebrafish model will be discussed and the medical relevance of these discoveries will be highlighted.
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Affiliation(s)
- Sanjay Sinha
- Anne McLaren Laboratory, Wellcome Trust and Medical Research Council Cambridge Stem Cell Institute, Forvie Site, University of Cambridge, Robinson Way, Cambridge CB2 0SZ, UK
- Department of Medicine, Addenbrookes Hospital, Box 157, Hills Rd, Cambridge, CB2 0QQ, UK
| | - Massimo Mattia Santoro
- Laboratory of Angiogenesis and Redox Metabolism, Department of Biology, University of Padua, 35131 Padova, Italy
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30
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Overexpressed ACBD3 has prognostic value in human breast cancer and promotes the self-renewal potential of breast cancer cells by activating the Wnt/beta-catenin signaling pathway. Exp Cell Res 2018; 363:39-47. [PMID: 29307786 DOI: 10.1016/j.yexcr.2018.01.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 12/25/2017] [Accepted: 01/02/2018] [Indexed: 01/30/2023]
Abstract
Acyl-CoA binding domain containing 3 (ACBD3) is involved in the maintenance of Golgi structure and function through its interaction with the integral membrane protein. However, the clinical significance and biological role of ACBD3 in breast cancer remain unclear. Herein, we found that the mRNA and protein levels of ACBD3 were markedly up-regulated in breast cancer cells and tissues. Immunohistochemical analysis of breast cancer tissues demonstrated that ACBD3 overexpression was significantly associated with advanced clinicopathological features. Univariate and multivariate analysis indicated that ACBD3 overexpression correlates with poor prognosis in breast cancer. Furthermore, overexpressing ACBD3 promoted, while silencing ACBD3 inhibited, self-renewal and tumorigenesis in breast cancer cells in vitro and in vivo respectively. Importantly, upregulating ACBD3 promoted the self-renewal and tumorigenesis of breast cancer cells via activating the Wnt/beta-catenin signaling, and the pro-self-renewal effect of ACBD3 in breast cancer was antagonized by the Wnt signaling inhibitor TCF4-siRNA and Lef1-siRNA.These findings indicate that ACBD3 may represent candidate therapeutic targets to enable the elimination of breast cancer stem cells, providing the preclinical proof-of-concept for the prevention and treatment of breast cancer.
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31
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Lin Y, Gil CH, Yoder MC. Differentiation, Evaluation, and Application of Human Induced Pluripotent Stem Cell-Derived Endothelial Cells. Arterioscler Thromb Vasc Biol 2017; 37:2014-2025. [PMID: 29025705 DOI: 10.1161/atvbaha.117.309962] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 09/26/2017] [Indexed: 12/13/2022]
Abstract
The emergence of induced pluripotent stem cell (iPSC) technology paves the way to generate large numbers of patient-specific endothelial cells (ECs) that can be potentially delivered for regenerative medicine in patients with cardiovascular disease. In the last decade, numerous protocols that differentiate EC from iPSC have been developed by many groups. In this review, we will discuss several common strategies that have been optimized for human iPSC-EC differentiation and subsequent studies that have evaluated the potential of human iPSC-EC as a cell therapy or as a tool in disease modeling. In addition, we will emphasize the importance of using in vivo vessel-forming ability and in vitro clonogenic colony-forming potential as a gold standard with which to evaluate the quality of human iPSC-EC derived from various protocols.
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Affiliation(s)
- Yang Lin
- From the Department of Pediatrics, Herman B. Wells Center for Pediatric Research (Y.L., C.-H.G., M.C.Y.) and Department of Biochemistry and Molecular Biology (Y.L., M.C.Y.), Indiana University School of Medicine, Indianapolis
| | - Chang-Hyun Gil
- From the Department of Pediatrics, Herman B. Wells Center for Pediatric Research (Y.L., C.-H.G., M.C.Y.) and Department of Biochemistry and Molecular Biology (Y.L., M.C.Y.), Indiana University School of Medicine, Indianapolis
| | - Mervin C Yoder
- From the Department of Pediatrics, Herman B. Wells Center for Pediatric Research (Y.L., C.-H.G., M.C.Y.) and Department of Biochemistry and Molecular Biology (Y.L., M.C.Y.), Indiana University School of Medicine, Indianapolis.
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32
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Carcamo-Orive I, Huang NF, Quertermous T, Knowles JW. Induced Pluripotent Stem Cell-Derived Endothelial Cells in Insulin Resistance and Metabolic Syndrome. Arterioscler Thromb Vasc Biol 2017; 37:2038-2042. [PMID: 28729365 DOI: 10.1161/atvbaha.117.309291] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 07/10/2017] [Indexed: 02/06/2023]
Abstract
Insulin resistance leads to a number of metabolic and cellular abnormalities including endothelial dysfunction that increase the risk of vascular disease. Although it has been particularly challenging to study the genetic determinants that predispose to abnormal function of the endothelium in insulin-resistant states, the possibility of deriving endothelial cells from induced pluripotent stem cells generated from individuals with detailed clinical phenotyping, including accurate measurements of insulin resistance accompanied by multilevel omic data (eg, genetic and genomic characterization), has opened new avenues to study this relationship. Unfortunately, several technical barriers have hampered these efforts. In the present review, we summarize the current status of induced pluripotent stem cell-derived endothelial cells for modeling endothelial dysfunction associated with insulin resistance and discuss the challenges to overcoming these limitations.
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Affiliation(s)
- Ivan Carcamo-Orive
- From the Department of Medicine and Cardiovascular Institute (I.C.-O., T.Q., J.W.K.) and Department of Cardiothoracic Surgery and Cardiovascular Institute (N.F.H.), Stanford University School of Medicine, CA; and Veterans Affairs Palo Alto Health Care System, CA (N.F.H.).
| | - Ngan F Huang
- From the Department of Medicine and Cardiovascular Institute (I.C.-O., T.Q., J.W.K.) and Department of Cardiothoracic Surgery and Cardiovascular Institute (N.F.H.), Stanford University School of Medicine, CA; and Veterans Affairs Palo Alto Health Care System, CA (N.F.H.)
| | - Thomas Quertermous
- From the Department of Medicine and Cardiovascular Institute (I.C.-O., T.Q., J.W.K.) and Department of Cardiothoracic Surgery and Cardiovascular Institute (N.F.H.), Stanford University School of Medicine, CA; and Veterans Affairs Palo Alto Health Care System, CA (N.F.H.)
| | - Joshua W Knowles
- From the Department of Medicine and Cardiovascular Institute (I.C.-O., T.Q., J.W.K.) and Department of Cardiothoracic Surgery and Cardiovascular Institute (N.F.H.), Stanford University School of Medicine, CA; and Veterans Affairs Palo Alto Health Care System, CA (N.F.H.)
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