Maturation of the extracellular material of the semilunar heart values in the mouse. A histochemical analysis of collagen and mucopolysaccharides

A Mathematical Model for Postimplant Collagen Remodeling in an Autologous Engineered Pulmonary Arterial Conduit

This study was undertaken to develop a mathematical model of the long-term in vivo remodeling processes in postimplanted pulmonary artery (PA) conduits. Experimental results from two extant ovine in vivo studies, wherein polyglycolic-acid (PGA)/poly-L-lactic acid tubular conduits were constructed, cell seeded, incubated for 4 weeks, and then implanted in mature sheep to obtain the remodeling data for up to two years. Explanted conduit analysis included detailed novel structural and mechanical studies. Results in both studies indicated that the in vivo conduits remained dimensionally stable up to 80 weeks, so that the conduits maintained a constant in vivo stress and deformation state. In contrast, continued remodeling of the constituent collagen fiber network as evidenced by an increase in effective tissue uniaxial tangent modulus, which then stabilized by one year postimplant. A mesostructural constitute model was then applied to extant planar biaxial mechanical data and revealed several interesting features, including an initial pronounced increase in effective collagen fiber modulus, paralleled by a simultaneous shift toward longer, more uniformly length-distributed collagen fibers. Thus, while the conduit remained dimensionally stable, its internal collagen fibrous structure and resultant mechanical behaviors underwent continued remodeling that stabilized by one year. A time-evolving structural mixture-based mathematical model specialized for this unique form of tissue remodeling was developed, with a focus on time-evolving collagen fiber stiffness as the driver for tissue-level remodeling. The remodeling model was able to fully reproduce (1) the observed tissue-level increases in stiffness by time-evolving simultaneous increases in collagen fiber modulus and lengths, (2) maintenance of the constant collagen fiber angular dispersion, and (3) stabilization of the remodeling processes at one year. Collagen fiber remodeling geometry was directly verified experimentally by histological analysis of the time-evolving collagen fiber crimp, which matches model predictions very closely. Interestingly, the remodeling model indicated that the basis for tissue homeostasis was maintenance of the collagen fiber ensemble stress for all orientations, and not individual collagen fiber stresses. Unlike other growth and remodeling models that traditionally treat changes in the external boundary conditions (e.g., changes in blood pressure) as the primary input stimuli, the driver herein is changes to the internal constituent collagen fiber themselves due to cellular mediated cross-linking.

In Vivo Three-Dimensional Geometric Reconstruction of the Mouse Aortic Heart Valve

Aortic valve (AV) disease is a common valvular lesion in the United States, present in about 5% of the population at age 65 with increasing prevalence with advancing age. While current replacement heart valves have extended life for many, their long-term use remains hampered by limited durability. Non-surgical treatments for AV disease do not yet exist, in large part because our understanding of AV disease etiology remains incomplete. The direct study of human AV disease remains hampered by the fact that clinical data is only available at the time of treatment, where the disease is at or near end stage and any time progression information has been lost. Large animal models, long used to assess replacement AV devices, cannot yet reproduce AV disease processes. As an important alternative mouse animal models are attractive for their ability to perform genetic studies of the AV disease processes and test potential pharmaceutical treatments. While mouse models have been used for cellular and genetic studies of AV disease, their small size and fast heart rates have hindered their use for tissue- and organ-level studies. We have recently developed a novel ex vivo micro-CT-based methodology to 3D reconstruct murine heart valves and estimate the leaflet mechanical behaviors (Feng et al. in Sci Rep 13(1):12852, 2023). In the present study, we extended our approach to 3D reconstruction of the in vivo functional murine AV (mAV) geometry using high-frequency four-dimensional ultrasound (4DUS). From the resulting 4DUS images we digitized the mAV mid-surface coordinates in the fully closed and fully opened states. We then utilized matched high-resolution µCT images of ex vivo mouse mAV to develop mAV NURBS-based geometric model. We then fitted the mAV geometric model to the in vivo data to reconstruct the 3D in vivo mAV geometry in the closed and open states in n = 3 mAV. Results demonstrated high fidelity geometric results. To our knowledge, this is the first time such reconstruction was ever achieved. This robust assessment of in vivo mAV leaflet kinematics in 3D opens up the possibility for longitudinal characterization of murine models that develop aortic valve disease.

Ross procedure in neonates and infants: A valuable operation with defined limits

OBJECTIVE

The Ross procedure is an important tool that offers autologous tissue repair for severe left ventricular outflow tract (LVOT) pathology. Previous reports show that risk of mortality is highest among neonates and infants. We analyzed our institutional experience within this patient cohort to identify factors that most affect clinical outcome.

METHODS

A retrospective chart review identified all Ross operations in neonates and infants at our institution over 27 years. The entire study population was analyzed to determine risk factors for mortality and define outcomes for survival and reintervention.

RESULTS

Fifty-eight patients underwent a Ross operation at a median age of 63 (range, 9-156) days. Eighteen (31%) were neonates. Eleven (19%) patients died before hospital discharge. Multiple regression analysis of the entire cohort identified young age (hazard ratio [HR], 1.037; P = .0045), Shone complex (HR, 17.637; P = .009), and interrupted aortic arch with ventricular septal defect (HR, 16.01; P = .031) as independent predictors of in-hospital mortality. Receiver operating characteristic analysis (area under the curve, 0.752) indicated age younger than 84 days to be the inflection point at which mortality risk increases. Of the 47 survivors, there were 2 late deaths with a mean follow-up of 6.7 (range, 2.1-13.1) years. Three patients (6%) required LVOT reintervention at 3, 8, and 17.5 years, respectively, and 26 (55%) underwent right ventricular outflow tract reintervention at a median of 6 (range, 2.5-10.3) years.

CONCLUSIONS

Ross procedure is effective in children less than one year of age with left sided obstructive disease isolated to the aortic valve and/or aortic arch. Patients less than 3 months of age with Shone or IAA/VSD are at higher risk for morbidity and mortality. Survivors experience excellent intermediate-term freedom from LVOT reintervention.

Structural remodelling of the heart valves extracellular matrix during embryo development

Alterations in heart valve development represent more than 20% of congenital cardiovascular malformations. Most of the functional properties of heart valves depend on extracellular matrix. Despite its relevance, little is known about fibrillar components on developing stages. Our objective is to define histological changes on valves fibrillar components in late embryonic development of Mus musculus. We found type III collagen as the predominant fibre type in the ECM in prenatal stages followed by a switch to a type I predominance for postnatal ages. The change in fibrillar components is necessary to support the normal mechanical function of adult heart valves.

Rac1 Signaling Is Required for Anterior Second Heart Field Cellular Organization and Cardiac Outflow Tract Development

BACKGROUND

The small GTPase Rac1 regulates diverse cellular functions, including both apicobasal and planar cell polarity pathways; however, its role in cardiac outflow tract (OFT) development remains unknown. In the present study, we aimed to examine the role of Rac1 in the anterior second heart field (SHF) splanchnic mesoderm and subsequent OFT development during heart morphogenesis.

METHODS AND RESULTS

Using the Cre/loxP system, mice with an anterior SHF-specific deletion of Rac1 (Rac1(SHF)) were generated. Embryos were collected at various developmental time points for immunostaining and histological analysis. Intrauterine echocardiography was also performed to assess aortic valve blood flow in embryos at embryonic day 18.5. The Rac1(SHF) splanchnic mesoderm exhibited disruptions in SHF progenitor cellular organization and proliferation. Consequently, this led to a spectrum of OFT defects along with aortic valve defects in Rac1(SHF) embryos. Mechanistically, it was found that the ability of the Rac1(SHF) OFT myocardial cells to migrate into the proximal OFT cushion was severely reduced. In addition, expression of the neural crest chemoattractant semaphorin 3c was decreased. Lineage tracing showed that anterior SHF contribution to the OFT myocardium and aortic valves was deficient in Rac1(SHF) hearts. Furthermore, functional analysis with intrauterine echocardiography at embryonic day 18.5 showed aortic valve regurgitation in Rac1(SHF) hearts, which was not seen in control hearts.

CONCLUSIONS

Disruptions of Rac1 signaling in the anterior SHF results in aberrant progenitor cellular organization and defects in OFT development. Our data show Rac1 signaling to be a critical regulator of cardiac OFT formation during embryonic heart development.

RAGE influences the development of aortic valve stenosis in mice on a high fat diet

Advanced glycation end product (AGE) accumulations as well as a high fat diet are associated with cardiovascular diseases. AGEs are recognized by several receptor molecules of which the receptor of AGEs (RAGE) is currently the most intensively studied. Activation of RAGE causes an unfavorable pro-inflammatory state. The hypothesis of this study was that metabolic stress due to a high fat diet results in the development of aortic valve stenosis and that knockout of RAGE should be protective. Six week old male C57BL/6N and C57BL/6N RAGE-/- mice (n=28) were randomly assigned to 4 groups and fed with normal or high fat diet for 32weeks. Weight gain was determined weekly. At the start of the experiment and after 2, 4 and 7months, echocardiographic assessments of the aortic valve were made. At the end of the experiment, plasma lipid levels and histological changes of the valves were determined. The high fat diet resulted in accelerated weight gain. However, after 7month, only C57BL/6 mice developed increased trans-aortic-valve velocities, leaflet thickness and reduced valve area index (p<0.0001). Immunohistochemistry of the aortic valves revealed in C57BL/6N mice on a high fat diet more calcification, AGE accumulation and RAGE expression when compared to normal fed control. Hearts and aortic valves of RAGE-/- mice showed less morphometric changes, calcification and AGE accumulation. After 7months of high fat feeding C57BL/6 mice (p<0.0001) as well as RAGE-/- mice (p=0.007) had significantly increased cholesterol levels compared to normal fed control, however RAGE-/- mice were probably protected due to a better HDL/LDL ratio when compared to wild type animals (p=0.003). These data suggest that AGEs and RAGE are involved in the development of obesity, hypercholesterolemia and aortic valve changes due to metabolic stress from high fat intake.

The living aortic valve: From molecules to function

The aortic valve lies in a unique hemodynamic environment, one characterized by a range of stresses (shear stress, bending forces, loading forces and strain) that vary in intensity and direction throughout the cardiac cycle. Yet, despite its changing environment, the aortic valve opens and closes over 100,000 times a day and, in the majority of human beings, will function normally over a lifespan of 70–90 years. Until relatively recently heart valves were considered passive structures that play no active role in the functioning of a valve, or in the maintenance of its integrity and durability. However, through clinical experience and basic research the aortic valve can now be characterized as a living, dynamic organ with the capacity to adapt to its complex mechanical and biomechanical environment through active and passive communication between its constituent parts. The clinical relevance of a living valve substitute in patients requiring aortic valve replacement has been confirmed. This highlights the importance of using tissue engineering to develop heart valve substitutes containing living cells which have the ability to assume the complex functioning of the native valve.

Outcomes of the infant Ross procedure for congenital aortic stenosis followed into adolescence

OBJECTIVES

The Ross procedure is used to treat aortic valve disease in children. The advantages include autograft growth, long-term durability, and avoidance of anticoagulation. Long-term follow-up of the Ross procedure in infancy is limited. We sought to characterize the long-term outcomes of infants undergoing the Ross procedure.

METHODS

We performed a retrospective review of all patients who underwent a Ross operation at 18 months of age or younger at New-York Presbyterian and Cardiothoracic Center of Monaco from 1991 to 2010. The clinical, catheterization, and surgical records were reviewed. The most recent follow-up information, including echocardiogram and electrocardiogram, was obtained and analyzed.

RESULTS

A total of 34 patients underwent a Ross procedure at a median age of 6 months (range, 4 days to 18.4 months). All had congenital aortic stenosis. All but 1 patient had undergone previous surgical or catheter-based interventions. The median follow-up was 10.6 years (range, 1.4-20.4 years). There were 4 early deaths and 1 late transplant. The freedom from right ventricular outflow tract reintervention was 85% at 5 years and 64% at 10 years. The freedom from autograft reintervention was 95.5% at 10 years. In 20 subjects, late follow-up echocardiograms showed a significant difference between the mean early and late Z scores of the autograft annulus (0.8 vs 2.4, P = .03), sinus (0.8 vs 2.8, P = .002), and sinotubular junction (1.2 vs 2.7, P = .04). Mild or less aortic insufficiency occurred in 17 subjects. None had significant aortic stenosis.

CONCLUSIONS

The long-term outcomes of the Ross procedure in infants and toddlers are favorable despite moderate dilatation of the autograft. Reintervention at the right ventricular outflow tract is common.

Valvulogenesis: the moving target

Valvulogenesis is an extremely complex process by which a fragile gelatinous matrix is populated and remodelled during embryonic development into thin fibrous leaflets capable of maintaining unidirectional flow over a lifetime. This process occurs during exposure to constantly changing haemodynamic forces, with a success rate of approximately 99%. Defective valvulogenesis results in impaired cardiac function and lifelong complications. This review integrates what is known about the roles of genetics and mechanics in the development of valves and how changes in either result in impaired morphogenesis. It is hoped that appropriate developmental cues and phenotypic endpoints could help engineers and clinicians in their efforts to regenerate living valve alternatives.

Angiogenic modulators in valve development and disease: does valvular disease recapitulate developmental signaling pathways?

PURPOSE OF REVIEW

Neovascularization is a recognized feature of many valvular diseases and is established by numerous angiogenic modulators. Less known is that angiogenic modulators are multifunctional and have additional roles in valve development and disease. Recent advancements in this area are described.

RECENT FINDINGS

Initiation of epithelial to mesenchymal transformation, a developmental induction that specifies primordial interstitial cells (mesenchymal cells), requires vascular endothelial growth factor A, which stimulates matrix metalloproteinase 2 production and the invasive migration of mesenchymal cells. Epithelial to mesenchymal transformation also requires the matrix component hyaluronan to facilitate signaling through ErbB2/ErbB3 receptors and then is terminated by an increase in vascular endothelial growth factor A expression. Fibroblast growth factor 4 has been implicated in stimulating the following stage of proliferative expansion. Subsequently, in the remodeling phase, heparin-binding epidermal growth factor-like growth factor limits mesenchymal cell proliferation by signaling through the EGFR/ErbB1 receptor. Many adult valvular lesions appear similar to the embryonic proliferative expansion phase as they exhibit accumulations of extracellular matrix and myofibroblasts (a mesenchyme-like interstitial cell). The origins of such lesions may involve transforming growth factor beta 1. Similar to epithelial to mesenchymal transformation, tumor growth factor beta1 can induce cultured valvular endothelial cells to transdifferentiate to a myofibroblast-like phenotype. This scenario may occur in carcinoid valve disease because serotonin can induce interstitial cell expression of tumor growth factor beta1. Additionally, prolonged tumor growth factor beta1 activity may predispose to calcific degeneration. Calcific leaflets also exhibit tenascin-C, which may facilitate inflammatory cell migration through upregulation of pro-matrix metalloproteinase 2.

SUMMARY

Numerous angiogenic modulators control multiple stages of valvulogenesis and in the context of adult valvular disease may recapitulate their embryonic roles. Thus, lessons learned from valvulogenesis may provide insights into the molecular basis of adult valvular disease.

The Ross/Konno procedure in neonates and infants: intermediate-term survival and autograft function

BACKGROUND

The Ross procedure has been increasingly applied to neonates and infants. Addition of a modified Konno-type enlargement of the aortic annulus allows the application of this procedure to neonates and infants with significant annular hypoplasia. The potential for growth and the proven durability make the autograft an ideal aortic valve replacement.

METHODS

Between March 1993 and December 2000, 10 patients under 1 year of age underwent a Ross/Konno procedure at our institution (range, 2 to 349 days; median 16). All patients had severe to critical aortic stenosis. All patients required aortic annulus enlargement for size mismatch between the aortic and pulmonary valves.

RESULTS

There were no deaths at a median follow-up of 48 months (range, 1 to 74 months). All patients had none to mild aortic stenosis on Doppler echocardiography. Eight patients had a 0 to 1+ aortic insufficiency, 1 patient had a 2+ aortic insufficiency, and 1 patient had a 3+ aortic insufficiency. Aortic annular dilatation was not observed. Aortic sinus dilatation occurred initially (mean change in z-value: 0 to 12 months, +2.1) and then stabilized (mean change in z-value: 12 to > 36 months, +0.6). No patient required additional procedures for aortic valve disease. Two patients required three pulmonary allograft replacements.

CONCLUSIONS

The Ross procedure with a modified Konno-type enlargement of the aortic annulus is an excellent approach to aortic valve disease in the neonate and infant. The procedure can be accomplished with low morbidity and mortality, and low rates of reoperation. The pulmonary autograft demonstrates durability without developing aortic stenosis, aortic insufficiency, or progressive dilatation. Enlargement of the aortic annulus parallels somatic growth.

Cartilage in pulmonary valves of Syrian hamsters

The presence of cartilage in the pulmonary valve has been reported in birds, but not in mammals. We describe here the occurrence of cartilaginous tissue in the pulmonary valves of 40 (11.4%) of 351 Syrian hamsters examined using histological, histochemical and/or immunohistochemical techniques. The cartilaginous deposits were located along the fibrous attachments of the valve leaflets to the wall of the pulmonary artery trunk. Our findings indicate that the proximal attachments of the leaflets to their respective sinuses, and especially that of the ventral leaflet, are the most prone valvular regions to develop cartilaginous foci. Nonetheless, the possible function of these foci remains an open question. Formation of cartilage in the pulmonary valve starts within the first month of life, that is during the period in which the valve reaches histological maturation. The earliest evidence of chondrogenesis is the presence of small groups of cells embedded in a type II collagen-positive extracellular matrix. These groups of cells, which can appear as early as one day after birth, increase moderately in size and differentiate into hyaline cartilaginous tissue. The precursors of the cartilaginous cells are presumed to be neural crest-derived elements. However, the factor or factors involved in the differentiation of these precursors into chondrocytes are still unknown. In this regard, our observations cast doubt on the hypothesis that the formation of cardiac cartilages is primarily due to locally intense mechanical stimulation.

Production of a monoclonal antibody by in vitro immunization that recognizes a native chondroitin sulfate epitope in the embryonic chick limb and heart

We report the production of a monoclonal antibody (d1C4) by in vitro immunization that has immunoreactivity with a native chondroitin sulfate epitope in embryonic chick limb and heart. Murine lymphocytes were stimulated by direct exposure to unfixed, unsolubilized precartilage mesenchymal aggregates in high-density micromass culture derived from Stage 22-23 chick limb buds. Specificity of d1C4 reactivity was demonstrated by sensitivity of immunohistochemical staining to pretreatment with chondroitinase ABC or AC, preferential immunoreactivity with chondroitin-6-sulfate glycosaminoglycan (CS-C GAG) in ELISA, and competition of immunohistochemical staining with CS-C GAG. Immunohistochemical analysis of the expression of the d1C4 epitope revealed a striking localization of immunoreactivity in the extracellular matrix (ECM) of precartilage aggregates of chick limb mesenchyme in high-density micromass culture by 16 hr and the prechondrogenic limb core at Stage 23 in vivo. Immunoreactivity in both cultured limb mesenchyme and the embryonic limb continued through differentiation of prechondrogenic condensations into cartilage tissue. In the developing chick heart, d1C4 staining was found throughout the ECM of atrioventricular cushion tissue by Stage 25, but was localized to mesenchyme adjacent to the myocardium in the outflow tract cushions. There was an abrupt demarcation between d1C4-reactive intracardiac mesenchyme and unreactive extracardiac mesenchyme of the dorsal mesocardium in the Stage 22 embryo. This study demonstrates the efficacy of in vitro immunization of lymphocytes for the production of MAbs to native ECM constituents, such as CS-GAGs. Immunohistochemical data utilizing d1C4 suggest that CS-GAGs bearing this epitope may be important in early morphogenetic events leading to cartilage differentiation in the limb and valvuloseptal morphogenesis in the heart.

Histogenesis of the semilunar valves: an immunohistochemical analysis of tenascin and type-I collagen distribution in developing chick heart valves

The development of the semilunar valves takes place in association with septation of the outflow tract in the embryonic heart. Although numerous studies have focused on this process, the causal mechanisms of valvular development remain obscure. This paper reports an immunohistochemical analysis of tenascin and type-I collagen distribution in developing chick heart valves. Tenascin is a glycoprotein that is present on some embryonic extracellular matrices. It plays several significant roles in tissue differentiation, cell growth, and tissue interactions; it is also important for the formation of specific zones of connective tissue that fulfill mechanical functions. Our results show that tenascin is present during valvular morphogenesis and histogenesis, and that its distribution is associated with zones specialized in bearing mechanical loads.

Cell shape and cytoskeletal organization of the endothelial cells of the semilunar heart valves in the developing chick

The composition and arrangement of the cytoskeletal elements of the endothelium of the semilunar valves have been studied in the embryonic chick heart during the stages 30 to 38. Microtubules, vimentin intermediate filaments and actin microfilaments were constant components of the valvular endothelial cells in the studied stages. Scanning electron microscopy after Triton-X-100 extraction revealed significant differences in the tridimensional arrangement of the cytoskeleton in the course of valve development. In the ventricular face of the cusps the cytoskeletal elements displayed a progressive longitudinal alignment, while in the arterial face of the cusps the cytoskeleton maintained the appearance of a network. Transmission electron microscopy revealed that these differences were especially prominent for vimentin intermediate filaments, although a similar tendency was also observed for microtubules. Microfilaments were scarce in the endothelial cells of both faces of the cusps, and the stress fibers typical of the endothelial cells of the adult valves were not observed in the embryonic material. The significance of these results in valve morphogenesis and histogenesis and a possible linkage with differences in the local characteristics of the blood flow are discussed.

Malformations of the semilunar valves produced in chick embryos by mechanical interference with cardiogenesis. An experimental approach to the role of hemodynamics in valvular development

The purpose of the present work was to analyze the role of hemodynamics in the morphogenesis and histogenesis of the semilunar valves. To achieve this goal we have studied the development of the chick semilunar valves in conditions of abnormal local flow. To obtain an abnormal pattern of local flow we have induced alterations of the cardiac septation process by mechanical interference of the development of the conus cordis. The malformations obtained by this procedure consisted of a spectrum of alterations in the process of incorporation of the aortic conus into the left ventricle. These malformations ranged from a simple widening of the outflow tract of the left ventricle to severe forms of double-outlet right ventricle and ventricular septal defects. Malformations of the semilunar valves consisting of extensive thickening of the leaflets and lack of maturation of the valve tissues were very often present in the malformed hearts. The malformation of the valve leaflets was more frequent and severe in the aortic valve at more advanced stages of development and in the hearts showing more severe alteration of the septation process. The absence of alterations in the semilunar valves of the control embryos and in the experimental embryos without alteration of the cardiac septation suggest a close relationship between the semilunar valves anomalies and the hemodynamic alterations present in the malformed hearts.

Changes in the endothelial morphology of the developing semilunar heart valves. A TEM and SEM study in the chick

In view of recent evidence showing that shape and orientation of endothelial cells is determined by blood flow, the endothelium of the semilunar valves was studied in the developing chick heart using transmission and scanning electron microscopy. The results reveal significant developmental modifications of endothelial morphology and structure. These modifications can be linked to modifications of local blood flow and can also explain several aspects of valvular morphogenesis. The results substantially support the hypothesis of an involvement of hemodynamics in the development of the semilunar valves.