Die Muskelfaserkonstante und das Wachstumsgesetz der menschlichen Herzkammern

[Cardiac cell therapy-Lost in translation?]

Cardiac cell therapy covers more than two decades of tumultuous history. In this period of time, the perception of the heart as an organ consisting of a fixed number of terminally differentiated cardiomyocytes fundamentally changed. Suddenly, the myocardium was (or is) considered to be regenerative by intrinsic progenitor cells, inducible proliferation, and in particular by exogenic transplanted cells. While the clinical translation of real cardiomyocytes obtained by cellular reprogramming has progressed only slowly, a multitude of clinical studies were carried out with cell products of somatic origin. This was mostly based on assumptions and experimentally acquired data with respect to the plasticity of adult precursor cells that, in retrospect, lacked validity. Accordingly, on closer inspection the results of the clinical studies were not convincing but they were nevertheless often presented and viewed in a very optimistic light. Today, cardiac cell therapy with cells of a somatic origin is considered to have failed. Recapitulating the stages of this era can help recognize and avoid such undesirable developments in the future.

Cardiac regeneration based on mechanisms of cardiomyocyte proliferation and differentiation

Cardiomyocyte proliferation and progenitor differentiation are endogenous mechanisms of myocardial development. Cardiomyocytes continue to proliferate in mammals for part of post-natal development. In adult mammals under homeostatic conditions, cardiomyocytes proliferate at an extremely low rate. Because the mechanisms of cardiomyocyte generation provide potential targets for stimulating myocardial regeneration, a deep understanding is required for developing such strategies. We will discuss approaches for examining cardiomyocyte regeneration, review the specific advantages, challenges, and controversies, and recommend approaches for interpretation of results. We will also draw parallels between developmental and regenerative principles of these mechanisms and how they could be targeted for treating heart failure.

Cardiomyocyte proliferation contributes to heart growth in young humans

The human heart is believed to grow by enlargement but not proliferation of cardiomyocytes (heart muscle cells) during postnatal development. However, recent studies have shown that cardiomyocyte proliferation is a mechanism of cardiac growth and regeneration in animals. Combined with evidence for cardiomyocyte turnover in adult humans, this suggests that cardiomyocyte proliferation may play an unrecognized role during the period of developmental heart growth between birth and adolescence. We tested this hypothesis by examining the cellular growth mechanisms of the left ventricle on a set of healthy hearts from humans aged 0-59 y (n = 36). The percentages of cardiomyocytes in mitosis and cytokinesis were highest in infants, decreasing to low levels by 20 y. Although cardiomyocyte mitosis was detectable throughout life, cardiomyocyte cytokinesis was not evident after 20 y. Between the first year and 20 y of life, the number of cardiomyocytes in the left ventricle increased 3.4-fold, which was consistent with our predictions based on measured cardiomyocyte cell cycle activity. Our findings show that cardiomyocyte proliferation contributes to developmental heart growth in young humans. This suggests that children and adolescents may be able to regenerate myocardium, that abnormal cardiomyocyte proliferation may be involved in myocardial diseases that affect this population, and that these diseases might be treatable through stimulation of cardiomyocyte proliferation.

The human heart: a self-renewing organ

The dogma that the heart is a static organ which contains an irreplaceable population of cardiomyocytes prevailed in the cardiovascular field for the last several decades. However, the recent identification of progenitor cells that give rise to differentiated myocytes has prompted a re-interpretation of cardiac biology. The heart cannot be viewed any longer as a postmitotic organ characterized by a predetermined number of myocytes that is defined at birth and is preserved throughout life. The myocardium constitutes a dynamic entity in which new young parenchymal cells are formed to substitute old damaged dying myocytes. The regenerative ability of the heart was initially documented with a classic morphometric approach and more recently with the demonstration that DNA synthesis, mitosis, and cytokinesis take place in the newly formed myocytes of the normal and pathologic heart. Importantly, replicating myocytes correspond to the differentiated progeny of cardiac stem cells. These findings point to the possibility of novel therapeutic strategies for the diseased heart.

Incorporating turnover in estimates of protein retention efficiency for different body tissues

Formulated in terms of protein synthesis (PS) and protein retention (PR), a definition of turnover-related protein retention efficiency (kP) allows the expression kP=[1+(PS/PR)/6]−1, 6 representing the ratio of the energy equivalent of protein to the cost of synthesis. By combining plausible hormonal and cellular control mechanisms of protein (P) growth, it is possible to derive (PS/PR)=[Q{(P/α)−(4/9)Y−1}]−1+1, allowing the calculation of kPby substitution. The symbol α represents the limit value of protein growth, while the term 4/9 derives from the power in the relationship between the concentration of growth factor-related activator in the nucleus and cell volume (cv). Y is the power in the relationship between cv and total tissue protein, and Q represents the proportion of growth factor-activated nuclei in a tissue. The proportion Q can be estimated from simple functions of intake rates or blood growth factor concentrations. Estimates of Y are derived from histological considerations or calculated from experimental observations; Y=1 for multinucleated skeletal muscle fibres and Y=1/3, 1/2, 1/6 on average for mononucleated cell tissues, skin or bone and viscera, respectively. To apply kPto the whole body, an average value of Y=1/2 can be taken. Experimental observations on tissue protein synthesis and breakdown rates yield direct estimates of kPin satisfactory agreement with comparable theoretical predictions.

Concise review: stem cells, myocardial regeneration, and methodological artifacts

This review discusses the current controversy about the role that endogenous and exogenous progenitor cells have in cardiac homeostasis and myocardial regeneration following injury. Although great enthusiasm was created by the possibility of reconstituting the damaged heart, the opponents of this new concept of cardiac biology have interpreted most of the findings supporting this possibility as the product of technical artifacts. This article challenges this established, static view of cardiac growth and favors the notion that the mammalian heart has the inherent ability to replace its cardiomyocytes through the activation of a pool of resident primitive cells or the administration of hematopoietic stem cells.

Properties of myocardium in cardiomegaly

The adult rat's ventricular myocardium is able to increase its mass markedly while maintaining its unit quality. It does so by maintaining constant the design of the sarcomeres: an increase in length is accomplished by the addition of sarcomeres in series; an increase in tension production is accomplished by the addition of more cross-sectional area of a uniform quality. This was shown by the almost constant concentration of the contractile protein, actomyosin, as well as by the histologic evidence of the constancy in the sarcomere lengths. Functional support was obtained by the finding of an identity in the parameters of the length-tension curves; the curves differed only in the absolute magnitude of the tensions, a difference that completely disappeared when suitable corrections were made for the size of the muscle. The electrical parameters also indicated a lack of change in the quality of the excitatory membrane phenomena. However, some data were presented that suggest that the myocardium may show altered properties dependent on the age of the animal. No evidence was found in support of the concept of detrimental consequences at least with this degree of cardiomegaly. It is rather concluded that this degree of cardiomegaly is accomplished without change in the basic architecture, properties, or concentration of the contractile mechanism.

Incidence and natural course of trabecular ventricular septal defect: two-dimensional echocardiography and color Doppler flow imaging study

This study was designed to determine the prevalence of trabecular ventricular septal defect (t-VSD) in neonates and to evaluate the effects of its location, morphologic features, and size on its natural course during infancy. One thousand twenty-eight term newborn infants were examined by color Doppler flow imaging with orthogonal ultrasonographic views. Ten girls and 11 boys (2.0%) were found to have t-VSD. The natural course of the defect was examined in 42 consecutive cases, consisting of this group of 21 neonates and another group of 21 neonates with t-VSD. The morphologic features of the defect within the trabecular septum were classified as one or two defects (36 cases) and as a mesh-like defect (six cases). Reduction in size began from the right ventricular side or from within the trabecular septum. Spontaneous closure occurred most commonly during the first 6 months of life and was observed in 32 cases (76%) by 12 months of age: the frequency of closure was not related to the morphologic features and the initial size of the defect, but apical defects tended to have higher persistent patency than did defects in other locations (p less than 0.05). We conclude that the frequency of t-VSD in neonates and the frequency of spontaneous closure during early infancy are higher than previously believed. This information is important for predicting the natural course of t-VSD and deciding on its proper management.

Reversal of left ventricular hypertrophy by drug treatment of hypertension

Both essential hypertension and the development of left ventricular hypertrophy are multifactorial. Several types of hypertrophy may develop. There is evidence that different agents used to treat hypertension may cause varying degrees of regression of left ventricular hypertrophy. In many instances in which regression of left ventricular hypertrophy has occurred in human subjects, there has been an associated improvement in echocardiographic evidence of ventricular function. Although most current evidence suggests that therapy should aim at both the control of blood pressure and the regression of left ventricular hypertrophy, one should be aware that an individual who is successfully treated for hypertension with a regimen that also produces regression of the compensatory left ventricular hypertrophy may be more susceptible to left ventricular failure if the severe hypertension should ever recur from whatever cause.

The influence of non-coronary collateral blood supply on the electively arrested heart during ischemia and reperfusion

To study the influence of non-coronary collateral blood circulation (NCCBC) on the integrity of the ischemic myocardium a right-sided thoracotomy was performed on 15 anesthetized dogs. Following a total cardiopulmonary bypass (CPB), ventricular fibrillation was induced, during which 2,000 ml calcium-free cardioplegic solution LK 352 was given at the aortic root over an 8-10 min period. Precautions were taken to prevent retrograde blood flow into the coronary system via the coronary sinus. After 90 min of ischemia, ten of the dog hearts were reperfused with systemic blood for the next 30 min. Transmural biopsies were taken from the apex of the left ventricle at the following intervals: (1) before CPB, (2) immediately after the infusion of LK 352, (3) following 90 min of ischemia, (4) after 5 min, (5) after 15 min, and finally (6) after 30 min of reperfusion and were then studied ultrastructurally. The presence of NCCBC was documented by the observation of erythrocyte-filled blood vessels in the biopsies corresponding to nos. 2 and 3 of the above. To assess the degree of ischemic injury and the extent of myocardial recovery during reperfusion, a scoring system based on a semiquantitative assessment of the characteristic morphological changes was used. The average result of the separately assessed subendo- and subepicardial layers represented the score, which was plotted on the ischemic injury and the recovery scale, thus making a direct comparison of the hearts possible. All the hearts generously supplied with blood via extracoronary routes during ischemia showed minimal and reversible ischemic injuries. They recovered more quickly and more completely following reperfusion than those hearts without NCCBC. From these results we conclude that despite its warming-up effect on the myocardium and its tendency to wash out the cardioplegic solution, the NCCBC generally protects the myocardium from serious ischemic injuries and shortens the period of recuperation during the reperfusion.

Nuclear DNA of myocardial cells in the periphery of infarctions and scars

In 20 hearts the enlargement of muscle fibers and the increase in nuclear DNA is studied in the periphery of fresh and healed infarctions. The data of attack is verified by ECG records in most cases, five had passed undiagnosed. Selective cytophotometry is performed by measuring the largest nucleus in each of 50 fields of comparable density. Since significant differences in polyploidization exist between the control regions of hearts of similar weight primarily regions of the same heart are compared. No differences are observed in five hearts with infarctions about one week old. After five to six months the enlargement of the fibers is significaant (P less than 0.0005) while the increase in polyploidy is still slight (P less than 0.15). In all cases with scars one to nine years old the enlargement of fibers is significant (P less than 0.0005) while the increase in DNA is significant in most of them (5 X P less than 0.0005, 3 X P less than 0.005, 2 X P less than 0.01). In a case with two lesions, one posterior five (P less than 0.0005) and one anterior seven years old (P less than 0.0005), there is still slight increase in polyploidy with age (P less than 0.1). In the five undiagnosed cases only one has no significant increase in DNA. There is no correlation found between the enlargement of fibers and the increase in polyploidy in this limited number of cases.

Endocardial Fibroelastosis of Large Mammals

Normal hearts of a mouse, rat, man, sea lion, hippopotamus, elephant, and blue whale were shown to have different numbers of myocardial fibers, 10 7 to 10 13 , based on calculations involving their myocardial fiber diameters and nuclear density counts. These two parameters did not vary greatly in the different species. However, their heart weights ranged from 10 -1 to 10 5 g. The larger mammals have endocardial fibroelastosis of their hearts and very thick aortas. These anatomic findings were explained by employing principles of hydrostatics and proposing that elastic tissue is required to help withstand the high mural tension resulting from the long radii and the hydrostatic pressures in the heart chambers and aortic lumen.