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Zakeri Z, Salehi R, Rahbarghazi R, Taghipour YD, Mahkam M, Sokullu E. Electrospun polyhedral oligomeric silsequioxane-poly(carbonate-urea) urethane for fabrication of hemocompatible small-diameter vascular grafts with angiogenesis capacity. Int J Biol Macromol 2024; 277:134064. [PMID: 39048012 DOI: 10.1016/j.ijbiomac.2024.134064] [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: 06/04/2024] [Revised: 07/12/2024] [Accepted: 07/19/2024] [Indexed: 07/27/2024]
Abstract
The clinical utility of small-diameter vascular grafts (SDVGs) is limited due to the possibility of thrombosis and intimal hyperplasia. These features can delay the development of a functional endothelial cell (EC) monolayer on the luminal surface of grafts. Therefore, the development and fabrication of vascular grafts (VGs) with comparable extracellular matrix (ECM) functions are mandatory to elicit hemocompatible confluent EC monolayers, and angiogenesis behavior inside the body. To promote the interactions between ECs and the surface of electrospun polyacrylic acid-grafted polyhedral oligomeric silsesquioxane-poly(carbonate-urea)-urethane (PAAc-POSS-PCUU), in this research, the surface of nanofibers was modified by covalently immobilizing extracted soluble proteins from aorta (ESPA) using EDC/NHS chemistry. The ATR-FTIR spectroscopy, WCA, and SEM microscopy confirmed the binding of acrylic acid and soluble vascular proteins on the surface of electrospun fibers. The PAAc-POSS-PCUU nanofibers and engineered biomimetic Pro-PAAc-POSS-PCUU nanofibers exhibited excellent biocompatibility indicated by increased survival rate (p < 0.05). Western blotting revealed the increase of VE-cadherin, Tie-2, vWF, and VEGFR-2 in HUVECs after being plated on PAAc-POSS-PCUU and Pro-PAAc-POSS-PCUU scaffolds, indicating appropriate angiogenesis behavior (p < 0.05). Besides, the antioxidant capacity was induced by the increase of SOD and GPx activity (p < 0.05). Additionally, blood compatibility tests revealed that Pro-PAAc-POSS-PCUU nanofibers accelerate the formation of a single EC layer without hemolysis and platelet adhesion. Taken together, Pro-PAAc-POSS-PCUU nanofibers exhibited excellent blood compatibility, and angiogenesis behavior, making them a promising candidate for clinical applications.
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Affiliation(s)
- Ziba Zakeri
- Chemistry Department, Science Faculty, Azarbaijan Shahid Madani University, Tabriz, Iran; Drug Applied Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Roya Salehi
- Department of Medical Nanotechnology, Faculty of Advanced Medical Sciences, Tabriz University of Medical Sciences, Tabriz, Iran; Clinical Research Development Unite of Tabriz Valiasr Hospital, Tabriz University of Medical Sciences, Tabriz, Iran.
| | - Reza Rahbarghazi
- Stem Cell Research Center, Tabriz University of Medical Sciences, Tabriz, Iran; Department of Applied Cell Sciences, Faculty of Advanced Medical Sciences, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Yasamin Davatgaran Taghipour
- Department of Medical Nanotechnology, Faculty of Advanced Medical Sciences, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mehrdad Mahkam
- Chemistry Department, Science Faculty, Azarbaijan Shahid Madani University, Tabriz, Iran
| | - Emel Sokullu
- Koç University Research Centre for Translational Medicine (KUTTAM), Koç University School of Medicine, Rumeli Feneri, 34450, Sariyer, Istanbul, Turkey; Biophysics Department, Koç University School of Medicine, Rumeli Feneri, 34450, Sariyer, Istanbul, Turkey
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Jiang S, Yang N, Tan RP, Moh ESX, Fu L, Packer NH, Whitelock JM, Wise SG, Rnjak-Kovacina J, Lord MS. Tuning Recombinant Perlecan Domain V to Regulate Angiogenic Growth Factors and Enhance Endothelialization of Electrospun Silk Vascular Grafts. Adv Healthc Mater 2024; 13:e2400855. [PMID: 38780418 DOI: 10.1002/adhm.202400855] [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: 03/06/2024] [Revised: 05/21/2024] [Indexed: 05/25/2024]
Abstract
Synthetic vascular grafts are used to bypass significant arterial blockage when native blood vessels are unsuitable, yet their propensity to fail due to poor blood compatibility and progressive graft stenosis remains an intractable challenge. Perlecan is the major heparan sulfate (HS) proteoglycan in the blood vessel wall with an inherent ability to regulate vascular cell activities associated with these major graft failure modes. Here the ability of the engineered form of perlecan domain V (rDV) to bind angiogenic growth factors is tuned and endothelial cell proliferation via the composition of its glycosaminoglycan (GAG) chain is supported. It is shown that the HS on rDV supports angiogenic growth factor signaling, including fibroblast growth factor (FGF) 2 and vascular endothelial growth factor (VEGF)165, while both HS and chondroitin sulfate on rDV are involved in VEGF189 signaling. It is also shown that physisorption of rDV on emerging electrospun silk fibroin vascular grafts promotes endothelialization and patency in a murine arterial interposition model, compared to the silk grafts alone. Together, this study demonstrates the potential of rDV as a tunable, angiogenic biomaterial coating that both potentiates growth factors and regulates endothelial cells.
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Affiliation(s)
- Shouyuan Jiang
- Graduate School of Biomedical Engineering, University of New South Wales, Sydney, NSW, 2052, Australia
| | - Nanji Yang
- School of Medical Sciences, Faculty of Health and Medicine, University of Sydney, Sydney, NSW, 2006, Australia
- Charles Perkins Centre, University of Sydney, Sydney, NSW, 2006, Australia
- The University of Sydney Nano Institute, University of Sydney, Sydney, NSW, 2006, Australia
| | - Richard P Tan
- School of Medical Sciences, Faculty of Health and Medicine, University of Sydney, Sydney, NSW, 2006, Australia
- Charles Perkins Centre, University of Sydney, Sydney, NSW, 2006, Australia
- The University of Sydney Nano Institute, University of Sydney, Sydney, NSW, 2006, Australia
| | - Edward S X Moh
- ARC Centre of Excellence in Synthetic Biology, Macquarie University, Sydney, New South Wales, 2109, Australia
- School of Natural Science, Faculty of Science and Engineering, Macquarie University, Sydney, New South Wales, 2109, Australia
| | - Lu Fu
- Graduate School of Biomedical Engineering, University of New South Wales, Sydney, NSW, 2052, Australia
| | - Nicolle H Packer
- ARC Centre of Excellence in Synthetic Biology, Macquarie University, Sydney, New South Wales, 2109, Australia
- School of Natural Science, Faculty of Science and Engineering, Macquarie University, Sydney, New South Wales, 2109, Australia
| | - John M Whitelock
- Graduate School of Biomedical Engineering, University of New South Wales, Sydney, NSW, 2052, Australia
| | - Steven G Wise
- School of Medical Sciences, Faculty of Health and Medicine, University of Sydney, Sydney, NSW, 2006, Australia
- Charles Perkins Centre, University of Sydney, Sydney, NSW, 2006, Australia
- The University of Sydney Nano Institute, University of Sydney, Sydney, NSW, 2006, Australia
| | - Jelena Rnjak-Kovacina
- Graduate School of Biomedical Engineering, University of New South Wales, Sydney, NSW, 2052, Australia
| | - Megan S Lord
- Graduate School of Biomedical Engineering, University of New South Wales, Sydney, NSW, 2052, Australia
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Jiang S, Wise SG, Kovacic JC, Rnjak-Kovacina J, Lord MS. Biomaterials containing extracellular matrix molecules as biomimetic next-generation vascular grafts. Trends Biotechnol 2024; 42:369-381. [PMID: 37852854 DOI: 10.1016/j.tibtech.2023.09.009] [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: 08/07/2023] [Revised: 09/18/2023] [Accepted: 09/19/2023] [Indexed: 10/20/2023]
Abstract
The performance of synthetic biomaterial vascular grafts for the bypass of stenotic and dysfunctional blood vessels remains an intractable challenge in small-diameter applications. The functionalization of biomaterials with extracellular matrix (ECM) molecules is a promising approach because these molecules can regulate multiple biological processes in vascular tissues. In this review, we critically examine emerging approaches to ECM-containing vascular graft biomaterials and explore opportunities for future research and development toward clinical use.
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Affiliation(s)
- Shouyuan Jiang
- Graduate School of Biomedical Engineering, University of New South Wales, Sydney, NSW 2052, Australia
| | - Steven G Wise
- School of Medical Sciences, Faculty of Health and Medicine, University of Sydney, Sydney, NSW 2006, Australia; Charles Perkins Centre, University of Sydney, Sydney, NSW 2006, Australia; The University of Sydney Nano Institute, University of Sydney, Sydney, NSW 2006, Australia
| | - Jason C Kovacic
- Victor Chang Cardiac Research Institute, Darlinghurst, NSW 2010, Australia; St Vincent's Clinical School, University of New South Wales, Darlinghurst, NSW 2010, Australia; Cardiovascular Research Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jelena Rnjak-Kovacina
- Graduate School of Biomedical Engineering, University of New South Wales, Sydney, NSW 2052, Australia
| | - Megan S Lord
- Graduate School of Biomedical Engineering, University of New South Wales, Sydney, NSW 2052, Australia.
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Xiang Y, Yan J, Bao X, Gleadall A, Sun T. Investigation of cell infiltration and colonization in 3D porous scaffolds via integrated experimental and computational strategies. J Biotechnol 2024; 382:78-87. [PMID: 38307299 DOI: 10.1016/j.jbiotec.2024.01.015] [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: 06/29/2023] [Accepted: 01/29/2024] [Indexed: 02/04/2024]
Abstract
This study aimed to integrate experimental and computational methods to systematically investigate cell infiltration and colonization within porous scaffolds. Poly(lactic acid) discs (Diameter: 6 mm; Thickness: 500 µm) with open pores (Diameter: 400-1100 µm), corners (Angle: 30-120°) and gaps (Distance: 100-500 µm), and cellulosic scaffolds with irregular pores (Diameter: 50-300 µm) were situated in tissue culture plates and cultured with human dermal fibroblasts (HDFs). Both phase contrast and scanning electron microscopy revealed that HDFs initially proliferated on scaffold surfaces, then infiltrated into the porous structures via cell bridging and stacking strategies, which was affected by the initial cell seeding densities, porous structures and culture times. Based on the density-dependent cell growths in two-dimensional cell cultures, power law models were developed to quantitatively simulate cell growths on scaffold surfaces. Model analysis predicted the effect of cell seeding efficiency on cell infiltrations into the porous scaffolds, which was further validated via series cell seeding experiments. The novelty of this research lies in the incorporation of multiple experimental and computational strategies, which enables the mechanistic insights of cell invasion and colonization in porous scaffolds, also facilitates the development of suitable bioprocesses for cell seeding and tissue manufacturing in Tissue Engineering and Regenerative Medicine.
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Affiliation(s)
- Yu Xiang
- Department of Materials, Loughborough University, Epinal Way, Loughborough LE11 3TU, UK
| | - Jiongyi Yan
- Wolfson School of Mechanical, Electrical and Manufacturing Engineering, Loughborough University, Epinal Way, Loughborough LE11 3TU, UK
| | - Xujin Bao
- Department of Materials, Loughborough University, Epinal Way, Loughborough LE11 3TU, UK
| | - Andrew Gleadall
- Wolfson School of Mechanical, Electrical and Manufacturing Engineering, Loughborough University, Epinal Way, Loughborough LE11 3TU, UK
| | - Tao Sun
- Department of Chemical Engineering, Loughborough University, Epinal Way, Loughborough LE11 3TU, UK.
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Notenboom ML, Schuermans A, Etnel JRG, Veen KM, van de Woestijne PC, Rega FR, Helbing WA, Bogers AJJC, Takkenberg JJM. Paediatric aortic valve replacement: a meta-analysis and microsimulation study. Eur Heart J 2023; 44:3231-3246. [PMID: 37366156 PMCID: PMC10482570 DOI: 10.1093/eurheartj/ehad370] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 04/21/2023] [Accepted: 05/24/2023] [Indexed: 06/28/2023] Open
Abstract
AIMS To support decision-making in children undergoing aortic valve replacement (AVR), by providing a comprehensive overview of published outcomes after paediatric AVR, and microsimulation-based age-specific estimates of outcome with different valve substitutes. METHODS AND RESULTS A systematic review of published literature reporting clinical outcome after paediatric AVR (mean age <18 years) published between 1/1/1990 and 11/08/2021 was conducted. Publications reporting outcome after paediatric Ross procedure, mechanical AVR (mAVR), homograft AVR (hAVR), and/or bioprosthetic AVR were considered for inclusion. Early risks (<30d), late event rates (>30d) and time-to-event data were pooled and entered into a microsimulation model. Sixty-eight studies, of which one prospective and 67 retrospective cohort studies, were included, encompassing a total of 5259 patients (37 435 patient-years; median follow-up: 5.9 years; range 1-21 years). Pooled mean age for the Ross procedure, mAVR, and hAVR was 9.2 ± 5.6, 13.0 ± 3.4, and 8.4 ± 5.4 years, respectively. Pooled early mortality for the Ross procedure, mAVR, and hAVR was 3.7% (95% CI, 3.0%-4.7%), 7.0% (5.1%-9.6%), and 10.6% (6.6%-17.0%), respectively, and late mortality rate was 0.5%/year (0.4%-0.7%/year), 1.0%/year (0.6%-1.5%/year), and 1.4%/year (0.8%-2.5%/year), respectively. Microsimulation-based mean life-expectancy in the first 20 years was 18.9 years (18.6-19.1 years) after Ross (relative life-expectancy: 94.8%) and 17.0 years (16.5-17.6 years) after mAVR (relative life-expectancy: 86.3%). Microsimulation-based 20-year risk of aortic valve reintervention was 42.0% (95% CI: 39.6%-44.6%) after Ross and 17.8% (95% CI: 17.0%-19.4%) after mAVR. CONCLUSION Results of paediatric AVR are currently suboptimal with substantial mortality especially in the very young with considerable reintervention hazards for all valve substitutes, but the Ross procedure provides a survival benefit over mAVR. Pros and cons of substitutes should be carefully weighed during paediatric valve selection.
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Affiliation(s)
- Maximiliaan L Notenboom
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Erasmus MC, Doctor Molewaterplein 40, 3015 GD, Rotterdam, Zuid-Holland, The Netherlands
| | - Art Schuermans
- Department of Cardiac Surgery, University Hospitals Leuven, UZ Leuven Gasthuisberg, Herestraat 49, 3000, Leuven, Flanders, Belgium
- Cardiovascular Research Center, Massachusetts General Hospital, 149 13th Street, 4th floor, Boston, MA 02129, USA
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Merkin Building, 415 Main St., Cambridge, MA 02142, USA
| | - Jonathan R G Etnel
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Erasmus MC, Doctor Molewaterplein 40, 3015 GD, Rotterdam, Zuid-Holland, The Netherlands
| | - Kevin M Veen
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Erasmus MC, Doctor Molewaterplein 40, 3015 GD, Rotterdam, Zuid-Holland, The Netherlands
| | - Pieter C van de Woestijne
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Erasmus MC, Doctor Molewaterplein 40, 3015 GD, Rotterdam, Zuid-Holland, The Netherlands
| | - Filip R Rega
- Department of Cardiac Surgery, University Hospitals Leuven, UZ Leuven Gasthuisberg, Herestraat 49, 3000, Leuven, Flanders, Belgium
| | - Willem A Helbing
- Department of Paediatrics, Division of Paediatric Cardiology, Erasmus MC-Sophia Children's Hospital, Wytemaweg 80, 3015 CN, Rotterdam, Zuid-Holland, The Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Erasmus MC, Doctor Molewaterplein 40, 3015 GD, Rotterdam, Zuid-Holland, The Netherlands
| | - Johanna J M Takkenberg
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Erasmus MC, Doctor Molewaterplein 40, 3015 GD, Rotterdam, Zuid-Holland, The Netherlands
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Crago M, Winlaw DS, Farajikhah S, Dehghani F, Naficy S. Pediatric pulmonary valve replacements: Clinical challenges and emerging technologies. Bioeng Transl Med 2023; 8:e10501. [PMID: 37476058 PMCID: PMC10354783 DOI: 10.1002/btm2.10501] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 01/17/2023] [Accepted: 01/29/2023] [Indexed: 03/06/2023] Open
Abstract
Congenital heart diseases (CHDs) frequently impact the right ventricular outflow tract, resulting in a significant incidence of pulmonary valve replacement in the pediatric population. While contemporary pediatric pulmonary valve replacements (PPVRs) allow satisfactory patient survival, their biocompatibility and durability remain suboptimal and repeat operations are commonplace, especially for very young patients. This places enormous physical, financial, and psychological burdens on patients and their parents, highlighting an urgent clinical need for better PPVRs. An important reason for the clinical failure of PPVRs is biofouling, which instigates various adverse biological responses such as thrombosis and infection, promoting research into various antifouling chemistries that may find utility in PPVR materials. Another significant contributor is the inevitability of somatic growth in pediatric patients, causing structural discrepancies between the patient and PPVR, stimulating the development of various growth-accommodating heart valve prototypes. This review offers an interdisciplinary perspective on these challenges by exploring clinical experiences, physiological understandings, and bioengineering technologies that may contribute to device development. It thus aims to provide an insight into the design requirements of next-generation PPVRs to advance clinical outcomes and promote patient quality of life.
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Affiliation(s)
- Matthew Crago
- School of Chemical and Biomolecular EngineeringThe University of SydneySydneyAustralia
| | - David S. Winlaw
- Department of Cardiothoracic SurgeryHeart Institute, Cincinnati Children's HospitalCincinnatiOHUSA
| | - Syamak Farajikhah
- School of Chemical and Biomolecular EngineeringThe University of SydneySydneyAustralia
| | - Fariba Dehghani
- School of Chemical and Biomolecular EngineeringThe University of SydneySydneyAustralia
| | - Sina Naficy
- School of Chemical and Biomolecular EngineeringThe University of SydneySydneyAustralia
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Cordoves EM, Vunjak-Novakovic G, Kalfa DM. Designing Biocompatible Tissue Engineered Heart Valves In Situ: JACC Review Topic of the Week. J Am Coll Cardiol 2023; 81:994-1003. [PMID: 36889879 PMCID: PMC10666973 DOI: 10.1016/j.jacc.2022.12.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 12/19/2022] [Indexed: 03/08/2023]
Abstract
Valvular heart disease is a globally prevalent cause of morbidity and mortality, with both congenital and acquired clinical presentations. Tissue engineered heart valves (TEHVs) have the potential to radically shift the treatment landscape for valvular disease by functioning as life-long valve replacements that overcome the current limitations of bioprosthetic and mechanical valves. TEHVs are envisioned to meet these goals by functioning as bioinstructive scaffolds that guide the in situ generation of autologous valves capable of growth, repair, and remodeling within the patient. Despite their promise, clinical translation of in situ TEHVs has proven challenging largely because of the unpredictable and patient-specific nature of the TEHV and host interaction following implantation. In light of this challenge, we propose a framework for the development and clinical translation of biocompatible TEHVs, wherein the native valvular environment actively informs the valve's design parameters and sets the benchmarks by which it is functionally evaluated.
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Affiliation(s)
- Elizabeth M Cordoves
- Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA; Department of Biomedical Engineering, Columbia University, New York, New York, USA
| | - Gordana Vunjak-Novakovic
- Department of Biomedical Engineering, Columbia University, New York, New York, USA; Department of Medicine, Columbia University, New York, New York, USA.
| | - David M Kalfa
- Division of Cardiac, Thoracic and Vascular Surgery, Section of Pediatric and Congenital Cardiac Surgery, New-York Presbyterian-Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, New York, USA.
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Biological Scaffolds for Congenital Heart Disease. BIOENGINEERING (BASEL, SWITZERLAND) 2023; 10:bioengineering10010057. [PMID: 36671629 PMCID: PMC9854830 DOI: 10.3390/bioengineering10010057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 12/20/2022] [Accepted: 12/26/2022] [Indexed: 01/05/2023]
Abstract
Congenital heart disease (CHD) is the most predominant birth defect and can require several invasive surgeries throughout childhood. The absence of materials with growth and remodelling potential is a limitation of currently used prosthetics in cardiovascular surgery, as well as their susceptibility to calcification. The field of tissue engineering has emerged as a regenerative medicine approach aiming to develop durable scaffolds possessing the ability to grow and remodel upon implantation into the defective hearts of babies and children with CHD. Though tissue engineering has produced several synthetic scaffolds, most of them failed to be successfully translated in this life-endangering clinical scenario, and currently, biological scaffolds are the most extensively used. This review aims to thoroughly summarise the existing biological scaffolds for the treatment of paediatric CHD, categorised as homografts and xenografts, and present the preclinical and clinical studies. Fixation as well as techniques of decellularisation will be reported, highlighting the importance of these approaches for the successful implantation of biological scaffolds that avoid prosthetic rejection. Additionally, cardiac scaffolds for paediatric CHD can be implanted as acellular prostheses, or recellularised before implantation, and cellularisation techniques will be extensively discussed.
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Blum KM, Mirhaidari G, Breuer CK. Tissue engineering: Relevance to neonatal congenital heart disease. Semin Fetal Neonatal Med 2022; 27:101225. [PMID: 33674254 PMCID: PMC8390581 DOI: 10.1016/j.siny.2021.101225] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Congenital heart disease (CHD) represents a large clinical burden, representing the most common cause of birth defect-related death in the newborn. The mainstay of treatment for CHD remains palliative surgery using prosthetic vascular grafts and valves. These devices have limited effectiveness in pediatric patients due to thrombosis, infection, limited endothelialization, and a lack of growth potential. Tissue engineering has shown promise in providing new solutions for pediatric CHD patients through the development of tissue engineered vascular grafts, heart patches, and heart valves. In this review, we examine the current surgical treatments for congenital heart disease and the research being conducted to create tissue engineered products for these patients. While much research remains to be done before tissue engineering becomes a mainstay of clinical treatment for CHD patients, developments have been progressing rapidly towards translation of tissue engineering devices to the clinic.
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Affiliation(s)
- Kevin M Blum
- Center for Regenerative Medicine, The Abigail Wexner Research Institute, Nationwide Childrens Hospital, Columbus, OH, USA; Department of Biomedical Engineering, The Ohio State University, Columbus, OH, USA.
| | - Gabriel Mirhaidari
- Center for Regenerative Medicine, The Abigail Wexner Research Institute, Nationwide Childrens Hospital, Columbus OH, USA,Biomedical Sciences Graduate Program, The Ohio State University College of Medicine, Columbus OH, USA
| | - Christopher K Breuer
- Center for Regenerative Medicine, The Abigail Wexner Research Institute, Nationwide Childrens Hospital, Columbus, OH, USA.
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Iwaki R, Shoji T, Matsuzaki Y, Ulziibayar A, Shinoka T. Current status of developing tissue engineering vascular technologies. Expert Opin Biol Ther 2021; 22:433-440. [PMID: 34427482 DOI: 10.1080/14712598.2021.1960976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Cardiovascular disease (CVD) is the leading cause of death in western countries. Although surgical outcomes for CVD are dramatically improving with the development of surgical techniques, medications, and perioperative management strategies, adverse postoperative events related to the use of artificial prosthetic materials are still problematic. Moreover, in pediatric patients, using these artificial materials make future re-intervention inevitable due to their lack of growth potential. AREAS COVERED This review focuses on the most current tissue-engineering (TE) technologies to treat cardiovascular diseases and discusses their limitations through reports ranging from animal studies to clinical trials. EXPERT OPINION Tissue-engineered structures, derived from a patient's own autologous cells/tissues and biodegradable polymer scaffolds, can provide mechanical function similar to non-diseased tissue. However, unlike prosthetic materials, tissue-engineered structures are hypothetically more biocompatible and provide growth potential, saving patients from additional or repetitive interventions. While there are many methods being investigated to develop TE technologies in the hopes of finding better options to tackle CVD, most of these approaches are not ready for clinical use or trials. However, tissue engineering has great promise to potentially provide better treatment options to vastly improve cardiovascular surgical outcomes.
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Affiliation(s)
- Ryuma Iwaki
- Center for Regenerative Medicine, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Toshihiro Shoji
- Center for Regenerative Medicine, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Yuichi Matsuzaki
- Center for Regenerative Medicine, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Anudari Ulziibayar
- Center for Regenerative Medicine, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Toshiharu Shinoka
- Center for Regenerative Medicine, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
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Ebken J, Mester N, Smart I, Ramm R, Goecke T, Jashari R, Böthig D, Horke A, Cebotari S, Tudorache I, Avsar M, Bobylev D, Haverich A, Sarikouch S, Hilfiker A. Residual immune response towards decellularized homografts may be highly individual. Eur J Cardiothorac Surg 2021; 59:773-782. [PMID: 33544830 PMCID: PMC8083949 DOI: 10.1093/ejcts/ezaa393] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 09/17/2020] [Accepted: 09/24/2020] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES Decellularized homograft valves (DHVs) have shown promising clinical results, particularly in the treatment of congenital heart disease. However, DHV appears to elicit an immune response in a subset of young patients, indicated by early valve degeneration. As the decellularization process is quality controlled for each DHV, we hypothesized that there may be residual immunogenicity within the extracellular matrix of DHV. METHODS A semi-quantitative dot blot analysis was established to screen for preformed recipient antibodies using secondary anti-human antibodies. Fifteen DHV samples (7 aortic, 8 pulmonary) were solubilized and exposed to serum from 20 healthy controls. RESULTS The sera from young controls (n = 10, 18–25 years) showed significantly stronger binding of preformed antibodies than sera from older individuals (n = 10, 48–73 years). The difference between the means of arbitrary units was 15.1 ± 6.5 (P = 0.0315). There was high intraindividual variance in the mean amounts of arbitrary units of antibody binding with some healthy controls showing >10 times higher antibody binding towards 2 different DHV. The amount of preformed antibodies bound to DHVs was higher in aortic than in pulmonary DHVs. The mean number of antibody binding (in arbitrary units) was 17.2 ± 4.5 in aortic and 14.5 ± 4.7 in pulmonary DHV (P = 0.27). The amount of preformed antibodies bound to pulmonary DHVs was statistically significantly higher in the sera of healthy males (n = 10) than in the sera of healthy females (n = 10). The mean number of arbitrary units was 17.2 ± 4.2 in male and 11.7 ± 5.3 in female sera (P = 0.036). Antibody binding to aortic DHV was also higher in males, but not significant (18.8 ± 5.0 vs 15.6 ± 4.0). Blood group (ABO) incompatibility between the serum from controls and DHV showed no impact on antibody binding, and there was no age-related impact among DHV donors. CONCLUSIONS Residual immunogenicity of decellularized homografts appears to exist despite almost complete cell removal. The established dot blot method allows a semi-quantitative assessment of the individual immune response towards extracellular DHV components and potentially the possibility of preoperative homograft matching.
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Affiliation(s)
- Johannes Ebken
- Leibniz Research Laboratories for Biotechnology and Artificial Organs (LEBAO), Hannover Medical School, Hannover, Germany
| | - Nils Mester
- Leibniz Research Laboratories for Biotechnology and Artificial Organs (LEBAO), Hannover Medical School, Hannover, Germany
| | - Isabel Smart
- Leibniz Research Laboratories for Biotechnology and Artificial Organs (LEBAO), Hannover Medical School, Hannover, Germany
| | - Robert Ramm
- Leibniz Research Laboratories for Biotechnology and Artificial Organs (LEBAO), Hannover Medical School, Hannover, Germany
| | - Tobias Goecke
- Leibniz Research Laboratories for Biotechnology and Artificial Organs (LEBAO), Hannover Medical School, Hannover, Germany.,Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Ramadan Jashari
- European Homograft Bank, Clinique Saint-Jean, Brussels, Belgium
| | - Dietmar Böthig
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Alexander Horke
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Serghei Cebotari
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Igor Tudorache
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Murat Avsar
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Dmitry Bobylev
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Leibniz Research Laboratories for Biotechnology and Artificial Organs (LEBAO), Hannover Medical School, Hannover, Germany.,Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Samir Sarikouch
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Andres Hilfiker
- Leibniz Research Laboratories for Biotechnology and Artificial Organs (LEBAO), Hannover Medical School, Hannover, Germany
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12
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Gähwiler EKN, Motta SE, Martin M, Nugraha B, Hoerstrup SP, Emmert MY. Human iPSCs and Genome Editing Technologies for Precision Cardiovascular Tissue Engineering. Front Cell Dev Biol 2021; 9:639699. [PMID: 34262897 PMCID: PMC8273765 DOI: 10.3389/fcell.2021.639699] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 03/31/2021] [Indexed: 12/12/2022] Open
Abstract
Induced pluripotent stem cells (iPSCs) originate from the reprogramming of adult somatic cells using four Yamanaka transcription factors. Since their discovery, the stem cell (SC) field achieved significant milestones and opened several gateways in the area of disease modeling, drug discovery, and regenerative medicine. In parallel, the emergence of clustered regularly interspaced short palindromic repeats (CRISPR)-associated protein 9 (CRISPR-Cas9) revolutionized the field of genome engineering, allowing the generation of genetically modified cell lines and achieving a precise genome recombination or random insertions/deletions, usefully translated for wider applications. Cardiovascular diseases represent a constantly increasing societal concern, with limited understanding of the underlying cellular and molecular mechanisms. The ability of iPSCs to differentiate into multiple cell types combined with CRISPR-Cas9 technology could enable the systematic investigation of pathophysiological mechanisms or drug screening for potential therapeutics. Furthermore, these technologies can provide a cellular platform for cardiovascular tissue engineering (TE) approaches by modulating the expression or inhibition of targeted proteins, thereby creating the possibility to engineer new cell lines and/or fine-tune biomimetic scaffolds. This review will focus on the application of iPSCs, CRISPR-Cas9, and a combination thereof to the field of cardiovascular TE. In particular, the clinical translatability of such technologies will be discussed ranging from disease modeling to drug screening and TE applications.
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Affiliation(s)
- Eric K. N. Gähwiler
- Institute for Regenerative Medicine (IREM), University of Zurich, Zurich, Switzerland
| | - Sarah E. Motta
- Institute for Regenerative Medicine (IREM), University of Zurich, Zurich, Switzerland
- Wyss Zurich, University and ETH Zurich, Zurich, Switzerland
| | - Marcy Martin
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford School of Medicine, Stanford, CA, United States
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford School of Medicine, Stanford, CA, United States
- Stanford Cardiovascular Institute, Stanford School of Medicine, Stanford, CA, United States
| | - Bramasta Nugraha
- Molecular Parasitology Lab, Institute of Parasitology, University of Zurich, Zurich, Switzerland
- Bioscience Cardiovascular, Research and Early Development, Cardiovascular, Renal and Metabolism, R&D BioPharmaceuticals, AstraZeneca, Gothenburg, Sweden
| | - Simon P. Hoerstrup
- Institute for Regenerative Medicine (IREM), University of Zurich, Zurich, Switzerland
- Wyss Zurich, University and ETH Zurich, Zurich, Switzerland
| | - Maximilian Y. Emmert
- Institute for Regenerative Medicine (IREM), University of Zurich, Zurich, Switzerland
- Wyss Zurich, University and ETH Zurich, Zurich, Switzerland
- Department of Cardiovascular Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
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13
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Thottappillil N, Nair PD. Dual source co-electrospun tubular scaffold generated from gelatin-vinyl acetate and poly-ɛ-caprolactone for smooth muscle cell mediated blood vessel engineering. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2020; 114:111030. [PMID: 32994010 DOI: 10.1016/j.msec.2020.111030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 04/09/2020] [Accepted: 04/27/2020] [Indexed: 01/01/2023]
Affiliation(s)
- Neelima Thottappillil
- Division of Tissue Engineering and Regeneration Technologies, Biomedical Technology Wing, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram 695012, India
| | - Prabha D Nair
- Division of Tissue Engineering and Regeneration Technologies, Biomedical Technology Wing, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram 695012, India.
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14
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Next-generation tissue-engineered heart valves with repair, remodelling and regeneration capacity. Nat Rev Cardiol 2020; 18:92-116. [PMID: 32908285 DOI: 10.1038/s41569-020-0422-8] [Citation(s) in RCA: 111] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/09/2020] [Indexed: 02/06/2023]
Abstract
Valvular heart disease is a major cause of morbidity and mortality worldwide. Surgical valve repair or replacement has been the standard of care for patients with valvular heart disease for many decades, but transcatheter heart valve therapy has revolutionized the field in the past 15 years. However, despite the tremendous technical evolution of transcatheter heart valves, to date, the clinically available heart valve prostheses for surgical and transcatheter replacement have considerable limitations. The design of next-generation tissue-engineered heart valves (TEHVs) with repair, remodelling and regenerative capacity can address these limitations, and TEHVs could become a promising therapeutic alternative for patients with valvular disease. In this Review, we present a comprehensive overview of current clinically adopted heart valve replacement options, with a focus on transcatheter prostheses. We discuss the various concepts of heart valve tissue engineering underlying the design of next-generation TEHVs, focusing on off-the-shelf technologies. We also summarize the latest preclinical and clinical evidence for the use of these TEHVs and describe the current scientific, regulatory and clinical challenges associated with the safe and broad clinical translation of this technology.
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15
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Durko AP, Yacoub MH, Kluin J. Tissue Engineered Materials in Cardiovascular Surgery: The Surgeon's Perspective. Front Cardiovasc Med 2020; 7:55. [PMID: 32351975 PMCID: PMC7174659 DOI: 10.3389/fcvm.2020.00055] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 03/20/2020] [Indexed: 12/13/2022] Open
Abstract
In cardiovascular surgery, reconstruction and replacement of cardiac and vascular structures are routinely performed. Prosthetic or biological materials traditionally used for this purpose cannot be considered ideal substitutes as they have limited durability and no growth or regeneration potential. Tissue engineering aims to create materials having normal tissue function including capacity for growth and self-repair. These advanced materials can potentially overcome the shortcomings of conventionally used materials, and, if successfully passing all phases of product development, they might provide a better option for both the pediatric and adult patient population requiring cardiovascular interventions. This short review article overviews the most important cardiovascular pathologies where tissue engineered materials could be used, briefly summarizes the main directions of development of these materials, and discusses the hurdles in their clinical translation. At its beginnings in the 1980s, tissue engineering (TE) was defined as “an interdisciplinary field that applies the principles of engineering and the life sciences toward the development of biological substitutes that restore, maintain, or improve tissue function” (1). Currently, the utility of TE products and materials are being investigated in several fields of human medicine, ranging from orthopedics to cardiovascular surgery (2–5). In cardiovascular surgery, reconstruction and replacement of cardiac and vascular structures are routinely performed. Considering the shortcomings of traditionally used materials, the need for advanced materials that can “restore, maintain or improve tissue function” are evident. Tissue engineered substitutes, having growth and regenerative capacity, could fundamentally change the specialty (6). This article overviews the most important cardiovascular pathologies where TE materials could be used, briefly summarizes the main directions of development of TE materials along with their advantages and shortcomings, and discusses the hurdles in their clinical translation.
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Affiliation(s)
- Andras P Durko
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Magdi H Yacoub
- Imperial College London, National Heart and Lung Institute, London, United Kingdom
| | - Jolanda Kluin
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center, Amsterdam, Netherlands
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16
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Lin C, Han G, Ning H, Song J, Ran N, Yi X, Seow Y, Yin H. Glycine Enhances Satellite Cell Proliferation, Cell Transplantation, and Oligonucleotide Efficacy in Dystrophic Muscle. Mol Ther 2020; 28:1339-1358. [PMID: 32209436 DOI: 10.1016/j.ymthe.2020.03.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 02/10/2020] [Accepted: 03/05/2020] [Indexed: 12/25/2022] Open
Abstract
The need to distribute therapy evenly systemically throughout the large muscle volume within the body makes Duchenne muscular dystrophy (DMD) therapy a challenge. Cell and exon-skipping therapies are promising but have limited effects, and thus enhancing their therapeutic potency is of paramount importance to increase the accessibility of these therapies to DMD patients. In this study, we demonstrate that co-administered glycine improves phosphorodiamidate morpholino oligomer (PMO) potency in mdx mice with marked functional improvement and an up to 50-fold increase of dystrophin in abdominal muscles compared to PMO in saline. Glycine boosts satellite cell proliferation and muscle regeneration by increasing activation of mammalian target of rapamycin complex 1 (mTORC1) and replenishing the one-carbon unit pool. The expanded regenerating myofiber population then results in increased PMO uptake. Glycine also augments the transplantation efficiency of exogenous satellite cells and primary myoblasts in mdx mice. Our data provide evidence that glycine enhances satellite cell proliferation, cell transplantation, and oligonucleotide efficacy in mdx mice, and thus it has therapeutic utility for cell therapy and drug delivery in muscle-wasting diseases.
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Affiliation(s)
- Caorui Lin
- Tianjin Key Laboratory of Cellular Homeostasis and Human Diseases, Department of Cell Biology, Tianjin Medical University, Qixiangtai Road, Heping District, Tianjin 300070, China
| | - Gang Han
- School of Medical Laboratory, Tianjin Medical University, Guangdong Road, Tianjin 300203, China
| | - Hanhan Ning
- Tianjin Key Laboratory of Cellular Homeostasis and Human Diseases, Department of Cell Biology, Tianjin Medical University, Qixiangtai Road, Heping District, Tianjin 300070, China
| | - Jun Song
- Tianjin Key Laboratory of Cellular Homeostasis and Human Diseases, Department of Cell Biology, Tianjin Medical University, Qixiangtai Road, Heping District, Tianjin 300070, China
| | - Ning Ran
- Tianjin Key Laboratory of Cellular Homeostasis and Human Diseases, Department of Cell Biology, Tianjin Medical University, Qixiangtai Road, Heping District, Tianjin 300070, China
| | - Xianfu Yi
- School of Biomedical Engineering, Tianjin Medical University, Tianjin, China
| | - Yiqi Seow
- Molecular Engineering Laboratory, Biomedical Sciences Institutes, Agency for Science Technology and Research, 61 Biopolis Way, Singapore 138668, Singapore
| | - HaiFang Yin
- Tianjin Key Laboratory of Cellular Homeostasis and Human Diseases, Department of Cell Biology, Tianjin Medical University, Qixiangtai Road, Heping District, Tianjin 300070, China.
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17
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Fioretta ES, Lintas V, Mallone A, Motta SE, von Boehmer L, Dijkman PE, Cesarovic N, Caliskan E, Rodriguez Cetina Biefer H, Lipiski M, Sauer M, Putti M, Janssen HM, Söntjens SH, Smits AI, Bouten CV, Emmert MY, Hoerstrup SP. Differential Leaflet Remodeling of Bone Marrow Cell Pre-Seeded Versus Nonseeded Bioresorbable Transcatheter Pulmonary Valve Replacements. JACC Basic Transl Sci 2019; 5:15-31. [PMID: 32043018 PMCID: PMC7000873 DOI: 10.1016/j.jacbts.2019.09.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 09/16/2019] [Accepted: 09/16/2019] [Indexed: 01/01/2023]
Abstract
Bone marrow mononuclear cell pre-seeding of polycarbonate bisurea–based tissue-engineered heart valves has detrimental effects on long-term performance and in situ remodeling and, therefore, should be avoided. Leaflet-specific analysis revealed pronounced remodeling differences with regard to cell infiltration, scaffold resorption, and extracellular matrix deposition within the same valve explant. The heterogeneity in remodeling of polycarbonate bisurea–based tissue-engineered heart valves may have important safety implications in terms of clinical translation. An in-depth understanding of the mechanobiological mechanisms involved in the in situ remodeling is required to limit the risk of unpredictable (maladaptive) remodeling.
This study showed that bone marrow mononuclear cell pre-seeding had detrimental effects on functionality and in situ remodeling of bioresorbable bisurea-modified polycarbonate (PC-BU)-based tissue-engineered heart valves (TEHVs) used as transcatheter pulmonary valve replacement in sheep. We also showed heterogeneous valve and leaflet remodeling, which affects PC-BU TEHV safety, challenging their potential for clinical translation. We suggest that bone marrow mononuclear cell pre-seeding should not be used in combination with PC-BU TEHVs. A better understanding of cell–scaffold interaction and in situ remodeling processes is needed to improve transcatheter valve design and polymer absorption rates for a safe and clinically relevant translation of this approach.
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Key Words
- B-GLAP, bone gamma-carboxyglutamate
- BMMNC, bone marrow mononuclear cells
- BVG, bioresorbable vascular graft
- CXCL12, stromal cell-derived factor-1α (SDF1α)
- ECM, extracellular matrix
- IL, interleukin
- MCP, monocyte chemoattractant protein
- MMP, matrix metalloproteinase
- PC-BU, polycarbonate bisurea
- SMA, smooth muscle actin
- TEE, transesophageal echocardiography
- TEHV, tissue-engineered heart valve
- TGF, transforming growth factor
- TVR, transcatheter valve replacement
- cardiovascular regenerative medicine
- endogenous tissue regeneration
- in situ tissue engineering
- supramolecular polymer
- tissue-engineered heart valve
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Affiliation(s)
| | - Valentina Lintas
- Institute for Regenerative Medicine, University of Zürich, Zürich, Switzerland
- Wyss Translational Center Zürich, University of Zürich and ETH Zürich, Zürich, Switzerland
| | - Anna Mallone
- Institute for Regenerative Medicine, University of Zürich, Zürich, Switzerland
| | - Sarah E. Motta
- Institute for Regenerative Medicine, University of Zürich, Zürich, Switzerland
| | - Lisa von Boehmer
- Institute for Regenerative Medicine, University of Zürich, Zürich, Switzerland
| | - Petra E. Dijkman
- Institute for Regenerative Medicine, University of Zürich, Zürich, Switzerland
| | - Nikola Cesarovic
- Division of Surgical Research, University of Zürich, Zürich, Switzerland
- Department of Cardiovascular Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Etem Caliskan
- Department of Cardiovascular Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | | | - Miriam Lipiski
- Division of Surgical Research, University of Zürich, Zürich, Switzerland
| | - Mareike Sauer
- Division of Surgical Research, University of Zürich, Zürich, Switzerland
| | - Matilde Putti
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
- Institute for Complex Molecular Systems, Eindhoven University of Technology, Eindhoven, the Netherlands
| | | | | | - Anthal I.P.M. Smits
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
- Institute for Complex Molecular Systems, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Carlijn V.C. Bouten
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
- Institute for Complex Molecular Systems, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Maximilian Y. Emmert
- Institute for Regenerative Medicine, University of Zürich, Zürich, Switzerland
- Wyss Translational Center Zürich, University of Zürich and ETH Zürich, Zürich, Switzerland
- Department of Cardiovascular Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
- Address for correspondence: Dr. Maximilian Y. Emmert, Institute for Regenerative Medicine, Moussonstrasse 13, 8044 Zürich, Switzerland.
| | - Simon P. Hoerstrup
- Institute for Regenerative Medicine, University of Zürich, Zürich, Switzerland
- Wyss Translational Center Zürich, University of Zürich and ETH Zürich, Zürich, Switzerland
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
- Dr. Simon P. Hoerstrup, Institute for Regenerative Medicine, Moussonstrasse 13, 8044 Zürich, Switzerland.
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18
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Si MS. Commentary: Promise of personalized tissue-engineered vascular grafts for congenital heart surgery. J Thorac Cardiovasc Surg 2019; 159:1984-1985. [PMID: 31727349 DOI: 10.1016/j.jtcvs.2019.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 10/08/2019] [Accepted: 10/08/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Ming-Sing Si
- Section of Pediatric Cardiovascular Surgery, Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich.
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19
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Emmert MY, Schmitt BA, Loerakker S, Sanders B, Spriestersbach H, Fioretta ES, Bruder L, Brakmann K, Motta SE, Lintas V, Dijkman PE, Frese L, Berger F, Baaijens FPT, Hoerstrup SP. Computational modeling guides tissue-engineered heart valve design for long-term in vivo performance in a translational sheep model. Sci Transl Med 2019; 10:10/440/eaan4587. [PMID: 29743347 DOI: 10.1126/scitranslmed.aan4587] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 09/20/2017] [Accepted: 04/09/2018] [Indexed: 12/14/2022]
Abstract
Valvular heart disease is a major cause of morbidity and mortality worldwide. Current heart valve prostheses have considerable clinical limitations due to their artificial, nonliving nature without regenerative capacity. To overcome these limitations, heart valve tissue engineering (TE) aiming to develop living, native-like heart valves with self-repair, remodeling, and regeneration capacity has been suggested as next-generation technology. A major roadblock to clinically relevant, safe, and robust TE solutions has been the high complexity and variability inherent to bioengineering approaches that rely on cell-driven tissue remodeling. For heart valve TE, this has limited long-term performance in vivo because of uncontrolled tissue remodeling phenomena, such as valve leaflet shortening, which often translates into valve failure regardless of the bioengineering methodology used to develop the implant. We tested the hypothesis that integration of a computationally inspired heart valve design into our TE methodologies could guide tissue remodeling toward long-term functionality in tissue-engineered heart valves (TEHVs). In a clinically and regulatory relevant sheep model, TEHVs implanted as pulmonary valve replacements using minimally invasive techniques were monitored for 1 year via multimodal in vivo imaging and comprehensive tissue remodeling assessments. TEHVs exhibited good preserved long-term in vivo performance and remodeling comparable to native heart valves, as predicted by and consistent with computational modeling. TEHV failure could be predicted for nonphysiological pressure loading. Beyond previous studies, this work suggests the relevance of an integrated in silico, in vitro, and in vivo bioengineering approach as a basis for the safe and efficient clinical translation of TEHVs.
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Affiliation(s)
- Maximilian Y Emmert
- Institute for Regenerative Medicine, University of Zurich, Zurich, Switzerland.,University Heart Center Zurich, University Hospital Zurich, Zurich, Switzerland.,Wyss Translational Center Zurich, University of Zurich and ETH Zurich, Zurich, Switzerland
| | - Boris A Schmitt
- German Heart Center Berlin and Charité-Universitätsmedizin Berlin, Department of Congenital Heart Disease, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Sandra Loerakker
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands.,Institute for Complex Molecular Systems, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Bart Sanders
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands.,Institute for Complex Molecular Systems, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Hendrik Spriestersbach
- German Heart Center Berlin and Charité-Universitätsmedizin Berlin, Department of Congenital Heart Disease, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Emanuela S Fioretta
- Institute for Regenerative Medicine, University of Zurich, Zurich, Switzerland
| | - Leon Bruder
- German Heart Center Berlin and Charité-Universitätsmedizin Berlin, Department of Congenital Heart Disease, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Kerstin Brakmann
- German Heart Center Berlin and Charité-Universitätsmedizin Berlin, Department of Congenital Heart Disease, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Sarah E Motta
- Institute for Regenerative Medicine, University of Zurich, Zurich, Switzerland
| | - Valentina Lintas
- Institute for Regenerative Medicine, University of Zurich, Zurich, Switzerland
| | - Petra E Dijkman
- Institute for Regenerative Medicine, University of Zurich, Zurich, Switzerland
| | - Laura Frese
- Institute for Regenerative Medicine, University of Zurich, Zurich, Switzerland
| | - Felix Berger
- German Heart Center Berlin and Charité-Universitätsmedizin Berlin, Department of Congenital Heart Disease, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Frank P T Baaijens
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands.,Institute for Complex Molecular Systems, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Simon P Hoerstrup
- Institute for Regenerative Medicine, University of Zurich, Zurich, Switzerland. .,Wyss Translational Center Zurich, University of Zurich and ETH Zurich, Zurich, Switzerland
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20
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D'Amore A, Luketich SK, Hoff R, Ye SH, Wagner WR. Blending Polymer Labile Elements at Differing Scales to Affect Degradation Profiles in Heart Valve Scaffolds. Biomacromolecules 2019; 20:2494-2505. [PMID: 31083976 DOI: 10.1021/acs.biomac.9b00189] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
After more than 22 years of research challenges and innovation, the heart valve tissue engineering paradigm still attracts attention as an approach to overcome limitations which exist with clinically utilized mechanical or bioprosthetic heart valves. Despite encouraging results, delayed translation can be attributed to limited knowledge on the concurrent mechanisms of biomaterial degradation in vivo, host inflammatory response, cell recruitment, and de novo tissue elaboration. This study aimed to reduce this gap by evaluating three alternative levels at which lability could be incorporated into candidate polyurethane materials electroprocessed into a valve scaffold. Specifically, polyester and polycarbonate labile soft segment diols were reacted into thermoplastic elastomeric polyurethane ureas that formed scaffolds where (1) a single polyurethane containing both of the two diols in the polymer backbone was synthesized and processed, (2) two polyurethanes were physically blended, one with exclusively polycarbonate and one with exclusively polyester diols, followed by processing of the blend, and (3) the two polyurethane types were concurrently processed to form individual fiber populations in a valve scaffold. The resulting valve scaffolds were characterized in terms of their mechanics before and after exposure to varying periods of pulsatile flow in an enzymatic (lipase) buffer solution. The results showed that valve scaffolds made from the first type of polymer and processing combination experienced more extensive degradation. This approach, although demonstrated with polyurethane scaffolds, can generally be translated to investigate biomaterial approaches where labile elements are introduced at different structural levels to alter degradation properties while largely preserving the overall chemical composition and initial mechanical behavior.
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21
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Zhang BL, Bianco RW, Schoen FJ. Preclinical Assessment of Cardiac Valve Substitutes: Current Status and Considerations for Engineered Tissue Heart Valves. Front Cardiovasc Med 2019; 6:72. [PMID: 31231661 PMCID: PMC6566127 DOI: 10.3389/fcvm.2019.00072] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 05/13/2019] [Indexed: 12/14/2022] Open
Abstract
Tissue engineered heart valve (TEHV) technology may overcome deficiencies of existing available heart valve substitutes. The pathway by which TEHVs will undergo development and regulatory approval has several challenges. In this communication, we review: (1) the regulatory framework for regulation of medical devices in general and substitute heart valves in particular; (2) the special challenges of preclinical testing using animal models for TEHV, emphasizing the International Standards Organization (ISO) guidelines in document 5840; and (3) considerations that suggest a translational roadmap to move TEHV forward from pre-clinical to clinical studies and clinical implementation.
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Affiliation(s)
- Benjamin L Zhang
- Department of Surgery, University of Minnesota, Minneapolis, MN, United States
| | - Richard W Bianco
- Department of Surgery, University of Minnesota, Minneapolis, MN, United States
| | - Frederick J Schoen
- Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
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22
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Boyd R, Parisi F, Kalfa D. State of the Art: Tissue Engineering in Congenital Heart Surgery. Semin Thorac Cardiovasc Surg 2019; 31:807-817. [PMID: 31176798 DOI: 10.1053/j.semtcvs.2019.05.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 05/28/2019] [Indexed: 12/17/2022]
Abstract
Congenital heart disease is the leading cause of death secondary to congenital abnormalities in the United States and the incidence has increased significantly over the last 50 years. For those defects requiring surgical repair, bioprosthetic xenografts, allografts, and synthetic materials have traditionally been used. However, none of these modalities offer the potential for growth and accommodation within the pediatric population. Tissue engineering has been an area of great interest in a variety of cardiac applications as an innovative solution to create a product that can grow and regenerate within the body over time. Over the last 30 years, the original tissue engineering paradigm of a scaffold seeded with cells and cultured in a bioreactor has been expanded upon to include innovative methods of decellularization and production of "off-the-shelf" tissue-engineered products capable of in situ host cell repopulation. Despite progress in conceptual design and promising clinical results, widespread use of tissue-engineered products remains limited due to both regulatory and ongoing scientific challenges. Here, we describe the current state of the art with regards to in vitro, in vivo, and in situ tissue engineering as applicable within the field of congenital heart surgery and provide a brief overview of challenges and future directions.
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Affiliation(s)
- Rebekah Boyd
- Division of Cardiac, Thoracic and Vascular Surgery, Section of Pediatric and Congenital Cardiac Surgery, New-York Presbyterian Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, New York
| | - Frank Parisi
- Division of Cardiac, Thoracic and Vascular Surgery, Section of Pediatric and Congenital Cardiac Surgery, New-York Presbyterian Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, New York
| | - David Kalfa
- Division of Cardiac, Thoracic and Vascular Surgery, Section of Pediatric and Congenital Cardiac Surgery, New-York Presbyterian Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, New York.
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Abstract
Biomaterials as we know them today had their origins in the late 1940s with off-the-shelf commercial polymers and metals. The evolution of materials for medical applications from these simple origins has been rapid and impactful. This review relates some of the early history; addresses concerns after two decades of development in the twenty-first century; and discusses how advanced technologies in both materials science and biology will address concerns, advance materials used at the biointerface, and improve outcomes for patients.
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Affiliation(s)
- Buddy D. Ratner
- Departments of Bioengineering and Chemical Engineering, University of Washington, Seattle, Washington 98195, USA
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Hutcheson JD, Goergen CJ, Schoen FJ, Aikawa M, Zilla P, Aikawa E, Gaudette GR. After 50 Years of Heart Transplants: What Does the Next 50 Years Hold for Cardiovascular Medicine? A Perspective From the International Society for Applied Cardiovascular Biology. Front Cardiovasc Med 2019; 6:8. [PMID: 30838213 PMCID: PMC6382669 DOI: 10.3389/fcvm.2019.00008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 01/24/2019] [Indexed: 12/24/2022] Open
Abstract
The first successful heart transplant 50 years ago by Dr.Christiaan Barnard in Cape Town, South Africa revolutionized cardiovascular medicine and research. Following this procedure, numerous other advances have reduced many contributors to cardiovascular morbidity and mortality; yet, cardiovascular disease remains the leading cause of death globally. Various unmet needs in cardiovascular medicine affect developing and underserved communities, where access to state-of-the-art advances remain out of reach. Addressing the remaining challenges in cardiovascular medicine in both developed and developing nations will require collaborative efforts from basic science researchers, engineers, industry, and clinicians. In this perspective, we discuss the advancements made in cardiovascular medicine since Dr. Barnard's groundbreaking procedure and ongoing research efforts to address these medical issues. Particular focus is given to the mission of the International Society for Applied Cardiovascular Biology (ISACB), which was founded in Cape Town during the 20th celebration of the first heart transplant in order to promote collaborative and translational research in the field of cardiovascular medicine.
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Affiliation(s)
- Joshua D Hutcheson
- Department of Biomedical Engineering, Florida International University, Miami, FL, United States
| | - Craig J Goergen
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, United States
| | - Frederick J Schoen
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Masanori Aikawa
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Peter Zilla
- Chris Barnard Division of Cardiothoracic Surgery, University of Cape Town, Cape Town, South Africa
| | - Elena Aikawa
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
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25
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Hu JB, Tomov ML, Buikema JW, Chen C, Mahmoudi M, Wu SM, Serpooshan V. Cardiovascular tissue bioprinting: Physical and chemical processes. APPLIED PHYSICS REVIEWS 2018; 5:041106. [PMID: 32550960 PMCID: PMC7187889 DOI: 10.1063/1.5048807] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 09/24/2018] [Indexed: 05/08/2023]
Abstract
Three-dimensional (3D) cardiac tissue bioprinting occupies a critical crossroads position between the fields of materials engineering, cardiovascular biology, 3D printing, and rational organ replacement design. This complex area of research therefore requires expertise from all those disciplines and it poses some unique considerations that must be accounted for. One of the chief hurdles is that there is a relatively limited systematic organization of the physical and chemical characteristics of bioinks that would make them applicable to cardiac bioprinting. This is of great significance, as heart tissue is functionally complex and the in vivo extracellular niche is under stringent controls with little room for variability before a cardiomyopathy manifests. This review explores the critical parameters that are necessary for biologically relevant bioinks to successfully be leveraged for functional cardiac tissue engineering, which can have applications in in vitro heart tissue models, cardiotoxicity studies, and implantable constructs that can be used to treat a range of cardiomyopathies, or in regenerative medicine.
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Affiliation(s)
- James B. Hu
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California 94305, USA
| | | | | | - Caressa Chen
- Department of General Surgery, Loyola University Medical Center, Maywood, Illinois 60153, USA
| | | | | | - Vahid Serpooshan
- Author to whom correspondence should be addressed: . Present address: 1760 Haygood Dr. NE, HSRB Bldg., Suite E480, Atlanta, Georgia 30322, USA. Telephone: 404-712-9717. Fax: 404-727-9873
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26
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Cardiovascular tissue engineering: From basic science to clinical application. Exp Gerontol 2018; 117:1-12. [PMID: 29604404 DOI: 10.1016/j.exger.2018.03.022] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 03/26/2018] [Indexed: 12/20/2022]
Abstract
Valvular heart disease is an increasing population health problem and, especially in the elderly, a significant cause of morbidity and mortality. The current treatment options, such as mechanical and bioprosthetic heart valve replacements, have significant restrictions and limitations. Considering the increased life expectancy of our aging population, there is an urgent need for novel heart valve concepts that remain functional throughout life to prevent the need for reoperation. Heart valve tissue engineering aims to overcome these constraints by creating regenerative, self-repairing valve substitutes with life-long durability. In this review, we give an overview of advances in the development of tissue engineered heart valves, and describe the steps required to design and validate a novel valve prosthesis before reaching first-in-men clinical trials. In-silico and in-vitro models are proposed as tools for the assessment of valve design, functionality and compatibility, while in-vivo preclinical models are required to confirm the remodeling and growth potential of the tissue engineered heart valves. An overview of the tissue engineered heart valve studies that have reached clinical translation is also presented. Final remarks highlight the possibilities as well as the obstacles to overcome in translating heart valve prostheses into clinical application.
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Soynov IA, Zhuravleva IY, Kulyabin YY, Nichay NR, Afanasyev AV, Aleshkevich NP, Bogachev-Prokofiev AV, Karaskov AM. [Valved conduits in pediatric cardiac surgery]. Khirurgiia (Mosk) 2018:75-81. [PMID: 29376963 DOI: 10.17116/hirurgia2018175-81] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- I A Soynov
- Meshalkin Siberian Federal Biomedical Research Center of Healthcare Ministry of the Russian Federation, Novosibirsk, Russia
| | - I Yu Zhuravleva
- Meshalkin Siberian Federal Biomedical Research Center of Healthcare Ministry of the Russian Federation, Novosibirsk, Russia
| | - Yu Yu Kulyabin
- Meshalkin Siberian Federal Biomedical Research Center of Healthcare Ministry of the Russian Federation, Novosibirsk, Russia
| | - N R Nichay
- Meshalkin Siberian Federal Biomedical Research Center of Healthcare Ministry of the Russian Federation, Novosibirsk, Russia
| | - A V Afanasyev
- Meshalkin Siberian Federal Biomedical Research Center of Healthcare Ministry of the Russian Federation, Novosibirsk, Russia
| | - N P Aleshkevich
- Meshalkin Siberian Federal Biomedical Research Center of Healthcare Ministry of the Russian Federation, Novosibirsk, Russia
| | - A V Bogachev-Prokofiev
- Meshalkin Siberian Federal Biomedical Research Center of Healthcare Ministry of the Russian Federation, Novosibirsk, Russia
| | - A M Karaskov
- Meshalkin Siberian Federal Biomedical Research Center of Healthcare Ministry of the Russian Federation, Novosibirsk, Russia
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28
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Motta SE, Lintas V, Fioretta ES, Hoerstrup SP, Emmert MY. Off-the-shelf tissue engineered heart valves for in situ regeneration: current state, challenges and future directions. Expert Rev Med Devices 2017; 15:35-45. [PMID: 29257706 DOI: 10.1080/17434440.2018.1419865] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Transcatheter aortic valve replacement (TAVR) is continuously evolving and is expected to surpass surgical valve implantation in the near future. Combining durable valve substitutes with minimally invasive implantation techniques might increase the clinical relevance of this therapeutic option for younger patient populations. Tissue engineering offers the possibility to create tissue engineered heart valves (TEHVs) with regenerative and self-repair capacities which may overcome the pitfalls of current TAVR prostheses. AREAS COVERED This review focuses on off-the-shelf TEHVs which rely on a clinically-relevant in situ tissue engineering approach and which have already advanced into preclinical or first-in-human investigation. EXPERT COMMENTARY Among the off-the-shelf in situ TEHVs reported in literature, the vast majority covers pulmonary valve substitutes, and only few are combined with transcatheter implantation technologies. Hence, further innovations should include the development of transcatheter tissue engineered aortic valve substitutes, which would considerably increase the clinical relevance of such prostheses.
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Affiliation(s)
- Sarah E Motta
- a Institute for Regenerative Medicine (IREM) , University of Zurich , Zurich , Switzerland
| | - Valentina Lintas
- a Institute for Regenerative Medicine (IREM) , University of Zurich , Zurich , Switzerland
| | - Emanuela S Fioretta
- a Institute for Regenerative Medicine (IREM) , University of Zurich , Zurich , Switzerland
| | - Simon P Hoerstrup
- a Institute for Regenerative Medicine (IREM) , University of Zurich , Zurich , Switzerland.,b Wyss Translational Center Zurich , University and ETH Zurich , Zurich , Switzerland
| | - Maximilian Y Emmert
- a Institute for Regenerative Medicine (IREM) , University of Zurich , Zurich , Switzerland.,b Wyss Translational Center Zurich , University and ETH Zurich , Zurich , Switzerland.,c Heart Center Zurich , University Hospital Zurich , Zurich , Switzerland
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