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Traxler D, Krotka P, Reichardt B, Copic D, Veraar C, Mildner M, Wendt R, Auer J, Mascherbauer J, Ankersmit HJ, Graf A. Revisiting aortic valve prosthesis choice in patients younger than 50 years: 10 years results of the AUTHEARTVISIT study. Eur J Cardiothorac Surg 2024; 65:ezad308. [PMID: 37756697 PMCID: PMC10761203 DOI: 10.1093/ejcts/ezad308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 08/22/2023] [Accepted: 09/22/2023] [Indexed: 09/29/2023] Open
Abstract
OBJECTIVES This population-based cohort study investigated mid-term outcome after surgical aortic valve replacement with a bioprosthetic or mechanical valve prosthesis in patients aged <50 years in a European social welfare state. METHODS We analysed patient data from the main social insurance carriers in Austria (2010-2020). Subsequent patient-level record linkage with national health data provided patient characteristics and clinical outcome. Survival, reoperation, myocardial infarction, heart failure, embolic stroke or intracerebral haemorrhage, bleeding other than intracerebral haemorrhage and major adverse cardiac events were evaluated as outcomes. RESULTS A total of 991 patients were analysed. Regarding demographics, no major differences between groups were observed. Multivariable Cox regression revealed no significant difference in overall survival (P = 0.352) with a median follow-up time of 6.2 years. Reoperation-free survival was decreased (hazard ratio = 1.560 [95% CI: 1.076-2.262], P = 0.019) and the risk for reoperation was increased (hazard ratio = 2.770 [95% CI: 1.402-5.472], P = 0.003) in patients who received bioprostheses. Estimated probability of death after reoperation was 0.23 (CL: 0.08-0.35) after 2 years and 0.34 (CL: 0.06-0.53) after 10 years over both groups. Regarding further outcomes, no significant differences between the two groups were observed. CONCLUSIONS In patients below 50 years of age receiving aortic valve replacement, implantation of bioprostheses when compared to mechanical heart valve prostheses was associated with a significantly higher rate of reoperations and reduced reoperation-free survival. Nevertheless, we could not observe a difference in overall survival. However, long-term follow-up has to evaluate that a significantly lower rate of reoperations may translate in consistently improved long-term survival.
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Affiliation(s)
- Denise Traxler
- Clinic of Thoracic Surgery, Medical University of Vienna, Austria
- Laboratory for Cardiac and Thoracic Diagnosis, Regeneration and Applied Immunology, Austria
- Department of Oral and Maxillofacial Surgery, Medical University of Vienna, Austria
| | - Pavla Krotka
- Center for Medical Data Science, Medical University of Vienna, Austria
| | | | - Dragan Copic
- Clinic of Thoracic Surgery, Medical University of Vienna, Austria
- Laboratory for Cardiac and Thoracic Diagnosis, Regeneration and Applied Immunology, Austria
- Division of Nephrology and Dialysis, Medical University of Vienna, Austria
| | - Cecilia Veraar
- Laboratory for Cardiac and Thoracic Diagnosis, Regeneration and Applied Immunology, Austria
- Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Medical University of Vienna, Austria
| | - Michael Mildner
- Department of Dermatology, Medical University of Vienna, Austria
| | - Ralph Wendt
- Department of Nephrology, St. Georg Hospital, Leipzig, Germany
| | - Johann Auer
- Department of Internal Medicine I with Cardiology and Intensive Care, St. Josef Hospital Braunau, Braunau am Inn, Austria
| | - Julia Mascherbauer
- Department of Internal Medicine 3, University Hospital St. Poelten, Austria
| | - Hendrik Jan Ankersmit
- Clinic of Thoracic Surgery, Medical University of Vienna, Austria
- Laboratory for Cardiac and Thoracic Diagnosis, Regeneration and Applied Immunology, Austria
| | - Alexandra Graf
- Center for Medical Data Science, Medical University of Vienna, Austria
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Galloway AC, Dorsey MP. Commentary: Incremental improvement is better than no improvement! J Thorac Cardiovasc Surg 2023:S0022-5223(23)01000-0. [PMID: 37890661 DOI: 10.1016/j.jtcvs.2023.10.043] [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: 10/19/2023] [Accepted: 10/20/2023] [Indexed: 10/29/2023]
Affiliation(s)
- Aubrey C Galloway
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, NY.
| | - Michael P Dorsey
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, NY
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Chabry Y, Dhayni K, Kamel S, Caus T, Bennis Y. Prevention by the CXCR2 antagonist SCH527123 of the calcification of porcine heart valve cusps implanted subcutaneously in rats. Front Cardiovasc Med 2023; 10:1227589. [PMID: 37781314 PMCID: PMC10540224 DOI: 10.3389/fcvm.2023.1227589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 09/08/2023] [Indexed: 10/03/2023] Open
Abstract
Introduction Calcification is a main cause of bioprosthetic heart valves failure. It may be promoted by the inflammation developed in the glutaraldehyde (GA)-fixed cusps of the bioprosthesis. We tested the hypothesis that antagonizing the C-X-C chemokines receptor 2 (CXCR2) may prevent the calcification of GA-fixed porcine aortic valves. Materiel and methods Four-week-old Sprague Dawley males were transplanted with 2 aortic valve cusps isolated from independent pigs and implanted into the dorsal wall. Four groups of 6 rats were compared: rats transplanted with GA-free or GA-fixed cusps and rats transplanted with GA-fixed cusps and treated with 1 mg/kg/day SCH5217123 (a CXCR2 antagonist) intraperitoneally (IP) or subcutaneously (SC) around the xenograft, for 14 days. Then, rats underwent blood count before xenografts have been explanted for histology and biochemistry analyses. Results A strong calcification of the xenografts was induced by GA pre-incubation. However, we observed a significant decrease in this effect in rats treated with SCH527123 IP or SC. Implantation of GA-fixed cusps was associated with a significant increase in the white blood cell count, an effect that was significantly prevented by SCH527123. In addition, the expression of the CD3, CD68 and CXCR2 markers was reduced in the GA-fixed cusps explanted from rats treated with SCH527123 as compared to those explanted from non-treated rats. Conclusion The calcification of GA-fixed porcine aortic valve cusps implanted subcutaneously in rats was significantly prevented by antagonizing CXCR2 with SCH527123. This effect may partly result from an inhibition of the GA-induced infiltration of T-cells and macrophages into the xenograft.
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Affiliation(s)
- Yuthiline Chabry
- MP3CV Laboratory, UR UPJV 7517, Amiens, France
- Department of Cardiac Surgery, Bichat Hospital, Paris, France
- LVTS unit, INSERM, Paris, France
| | | | - Saïd Kamel
- MP3CV Laboratory, UR UPJV 7517, Amiens, France
- Department of Clinical Biochemistry, CHU Amiens-Picardie, Amiens, France
| | - Thierry Caus
- MP3CV Laboratory, UR UPJV 7517, Amiens, France
- Department of Cardiac Surgery, CHU Amiens-Picardie, Amiens, France
| | - Youssef Bennis
- MP3CV Laboratory, UR UPJV 7517, Amiens, France
- Department of Clinical Pharmacology, CHU Amiens-Picardie, Amiens, France
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Zvyagina AI, Minaychev VV, Kobyakova MI, Lomovskaya YV, Senotov AS, Pyatina KV, Akatov VS, Fadeev RS, Fadeeva IS. Soft Biomimetic Approach for the Development of Calcinosis-Resistant Glutaraldehyde-Fixed Biomaterials for Cardiovascular Surgery. Biomimetics (Basel) 2023; 8:357. [PMID: 37622962 PMCID: PMC10452421 DOI: 10.3390/biomimetics8040357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 08/01/2023] [Accepted: 08/06/2023] [Indexed: 08/26/2023] Open
Abstract
Pathological aseptic calcification is the most common form of structural valvular degeneration (SVD), leading to premature failure of heart valve bioprostheses (BHVs). The processing methods used to obtain GA-fixed pericardium-based biomaterials determine the hemodynamic characteristics and durability of BHVs. This article presents a comparative study of the effects of several processing methods on the degree of damage to the ECM of GA-fixed pericardium-based biomaterials as well as on their biostability, biocompatibility, and resistance to calcification. Based on the assumption that preservation of the native ECM structure will enable the creation of calcinosis-resistant materials, this study provides a soft biomimetic approach for the manufacture of GA-fixed biomaterials using gentle decellularization and washing methods. It has been shown that the use of soft methods for preimplantation processing of materials, ensuring maximum preservation of the intactness of the pericardial ECM, radically increases the resistance of biomaterials to calcification. These obtained data are of interest for the development of new calcinosis-resistant biomaterials for the manufacture of BHVs.
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Affiliation(s)
- Alyona I. Zvyagina
- Institute of Theoretical and Experimental Biophysics, Russian Academy of Sciences, 142290 Pushchino, Russia (V.S.A.); (R.S.F.)
| | - Vladislav V. Minaychev
- Institute of Theoretical and Experimental Biophysics, Russian Academy of Sciences, 142290 Pushchino, Russia (V.S.A.); (R.S.F.)
| | - Margarita I. Kobyakova
- Institute of Theoretical and Experimental Biophysics, Russian Academy of Sciences, 142290 Pushchino, Russia (V.S.A.); (R.S.F.)
| | - Yana V. Lomovskaya
- Institute of Theoretical and Experimental Biophysics, Russian Academy of Sciences, 142290 Pushchino, Russia (V.S.A.); (R.S.F.)
| | - Anatoliy S. Senotov
- Institute of Theoretical and Experimental Biophysics, Russian Academy of Sciences, 142290 Pushchino, Russia (V.S.A.); (R.S.F.)
| | - Kira V. Pyatina
- Institute of Theoretical and Experimental Biophysics, Russian Academy of Sciences, 142290 Pushchino, Russia (V.S.A.); (R.S.F.)
- Pushchino State Institute of Natural Science, 142290 Pushchino, Russia
| | - Vladimir S. Akatov
- Institute of Theoretical and Experimental Biophysics, Russian Academy of Sciences, 142290 Pushchino, Russia (V.S.A.); (R.S.F.)
- Pushchino State Institute of Natural Science, 142290 Pushchino, Russia
| | - Roman S. Fadeev
- Institute of Theoretical and Experimental Biophysics, Russian Academy of Sciences, 142290 Pushchino, Russia (V.S.A.); (R.S.F.)
- Pushchino State Institute of Natural Science, 142290 Pushchino, Russia
| | - Irina S. Fadeeva
- Institute of Theoretical and Experimental Biophysics, Russian Academy of Sciences, 142290 Pushchino, Russia (V.S.A.); (R.S.F.)
- Pushchino State Institute of Natural Science, 142290 Pushchino, Russia
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Kobayashi Y, Okuyama K, Kuwata S, Koga M, Izumo M, Akashi YJ. Bioprosthetic valve failure of the Inspiris Resilia valve during transcatheter valve implantation. Cardiovasc Interv Ther 2023:10.1007/s12928-023-00923-0. [PMID: 36920742 DOI: 10.1007/s12928-023-00923-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 02/27/2023] [Indexed: 03/16/2023]
Affiliation(s)
- Yoshikuni Kobayashi
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-Ku, Kawasaki, 216-8511, Japan.
| | - Kazuaki Okuyama
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-Ku, Kawasaki, 216-8511, Japan
| | - Shingo Kuwata
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-Ku, Kawasaki, 216-8511, Japan
| | - Masashi Koga
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-Ku, Kawasaki, 216-8511, Japan
| | - Masaki Izumo
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-Ku, Kawasaki, 216-8511, Japan
| | - Yoshihiro Johnny Akashi
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-Ku, Kawasaki, 216-8511, Japan
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El-Andari R, Bozso SJ, Jh Kang J, Fialka NM, Al-Adra D, Meyer SR, Moon MC, Freed DH, Nagendran J, Nagendran J. Quantifying the immune response to a tissue-engineered porcine extracellular matrix. Regen Med 2023; 18:229-237. [PMID: 36691822 DOI: 10.2217/rme-2022-0172] [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: 01/25/2023] Open
Abstract
Aim: Structural valvular deterioration of xenogenic heart valve replacements is thought to be due to a chronic immune response. We sought to engineer porcine extracellular matrix that elicits minimal inflammatory immune response. Materials & methods: Whole blood, bone marrow and pericardium were collected from patients undergoing elective cardiac surgery. Porcine extracellular matrix was decellularized, reseeded with homologous mesenchymal stem cells and exposed to whole blood. Results: DAPI stain confirmed the absence of cells after decellularization, and presence of mesenchymal stem cells after recellularization. There was a significant reduction in IL-1β and TNF-α production in the recellularized matrix. Conclusion: Recellularization of porcine matrix is successful at attenuating the xenogenic immune response and may provide a suitable scaffold to address the current limitations of prosthetic heart valve replacements.
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Affiliation(s)
- Ryaan El-Andari
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, T6G 2B7, Canada
| | - Sabin J Bozso
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, T6G 2B7, Canada
| | - Jimmy Jh Kang
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, T6G 2B7, Canada
| | - Nicholas M Fialka
- Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, T6G 2R7, Canada
| | - David Al-Adra
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine & Public Health, Madison, WI 53705, USA
| | - Steven R Meyer
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, T6G 2B7, Canada
| | - Michael C Moon
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, T6G 2B7, Canada
| | - Darren H Freed
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, T6G 2B7, Canada
| | - Jayan Nagendran
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, T6G 2B7, Canada
| | - Jeevan Nagendran
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, T6G 2B7, Canada
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Bozso SJ, Kang JJH, El-Andari R, Boe D, Hedtke H, Moon MC, Freed DH, Nagendran J, Nagendran J. Recellularized bovine pericardium with autologous mesenchymal stem cells reduces immune activation. Xenotransplantation 2022; 29:e12774. [PMID: 36098060 DOI: 10.1111/xen.12774] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 08/11/2022] [Accepted: 08/24/2022] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Current bioprosthetic heart valve replacement options are limited by structural valvular deterioration (SVD) due to an immune response to the xenogenic scaffold. Autologous mesenchymal stem cell (MSC) recellularization is a method of concealing xenogenic scaffolds, preventing recipient immune recognition of xenogenic tissue heart valves, and potentially leading to reduction in SVD incidence. The purpose of this study is to examine the effects of autologous MSC recellularized tissue on the immune response of human whole blood to bovine pericardium (BP). We hypothesized that autologous MSC recellularization of BP will result in reduced pro-inflammatory cytokine production equivalent to autologous human pericardium. METHODS Bone marrow, human pericardium, and whole blood were collected from adult patients undergoing elective cardiac surgery. Decellularized BP underwent recellularization with autologous MSCs, followed by co-incubation with autologous whole blood. Immunohistochemical, microscopic, and quantitative immune analysis approaches were used. RESULTS We demonstrated that native BP, exposed to human whole blood, results in significant TNF-α and IL1β production. When decellularized BP is recellularized with autologous MSCs and exposed to whole blood, there is a significant reduction in TNF-α and IL1β production. Importantly, recellularized BP exposed to whole blood had similar production of TNF-α and IL1β when compared to autologous human pericardium exposed to human whole blood. CONCLUSION Our results suggest that preventing initial immune activation with autologous MSC recellularization may be an effective approach to decrease the recipient immune response, preventing recipient immune recognition of xenogeneic tissue engineered heart valves, and potentially leading to reduction in SVD incidence.
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Affiliation(s)
- Sabin J Bozso
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Jimmy J H Kang
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Ryaan El-Andari
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Dana Boe
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Hannah Hedtke
- Faculty of Graduate Studies and Research, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Michael C Moon
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Darren H Freed
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Jayan Nagendran
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Jeevan Nagendran
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
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Wen S, Zhou Y, Yim WY, Wang S, Xu L, Shi J, Qiao W, Dong N. Mechanisms and Drug Therapies of Bioprosthetic Heart Valve Calcification. Front Pharmacol 2022; 13:909801. [PMID: 35721165 PMCID: PMC9204043 DOI: 10.3389/fphar.2022.909801] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 04/26/2022] [Indexed: 11/13/2022] Open
Abstract
Valve replacement is the main therapy for valvular heart disease, in which a diseased valve is replaced by mechanical heart valve (MHV) or bioprosthetic heart valve (BHV). Since the 2000s, BHV surpassed MHV as the leading option of prosthetic valve substitute because of its excellent hemocompatible and hemodynamic properties. However, BHV is apt to structural valve degeneration (SVD), resulting in limited durability. Calcification is the most frequent presentation and the core pathophysiological process of SVD. Understanding the basic mechanisms of BHV calcification is an essential prerequisite to address the limited-durability issues. In this narrative review, we provide a comprehensive summary about the mechanisms of BHV calcification on 1) composition and site of calcifications; 2) material-associated mechanisms; 3) host-associated mechanisms, including immune response and foreign body reaction, oxidative stress, metabolic disorder, and thrombosis. Strategies that target these mechanisms may be explored for novel drug therapy to prevent or delay BHV calcification.
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Affiliation(s)
| | | | | | | | | | | | - Weihua Qiao
- *Correspondence: Weihua Qiao, ; Nianguo Dong,
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Bozso SJ, Kang JJH, El-Andari R, Fialka N, Zhu LF, Meyer SR, Freed DH, Nagendran J, Nagendran J. Recellularization of xenograft heart valves reduces the xenoreactive immune response in an in vivo rat model. Eur J Cardiothorac Surg 2021; 61:427-436. [PMID: 34633028 DOI: 10.1093/ejcts/ezab439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 08/20/2021] [Accepted: 09/10/2021] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Our aim was to address the role of autologous mesenchymal stem cell recellularization of xenogenic valves on the activation of the xenoreactive immune response in an in vivo rat model. METHODS Explanted aortic valve constructs from female Hartley guinea pigs were procured and decellularized, followed by recellularization with autologous Sprague-Dawley rat mesenchymal stem cells. Aortic valve xenografts were then implanted into the infrarenal aorta of recipient rats. Grafts were implanted as either autologous grafts, non-decellularized (NGP), decellularized and recellularized xenografts (RGP). Rats were euthanized after 7 and 21 days and exsanguinated and the grafts were explanted. RESULTS The NGP grafts demonstrated significant burden of granulocytes (14.3 cells/HPF) and CD3+ T cells (3.9 cells/HPF) compared to the autologous grafts (2.1 granulocytes/HPF and 0.72 CD3+ T cells/HPF) after 7 days. A lower absolute number of infiltrating granulocytes (NGP vs autologous, 6.4 vs 2.4 cells/HPF) and CD3+ T cells (NGP vs autologous, 2.8 vs 0.8 cells/HPF) was seen after 21 days. Equivalent granulocyte cell infiltration in the RGP grafts (2.4 cells/HPF) compared to the autologous grafts (2.1 cells/HPF) after 7 and 21 days (2.8 vs 2.4 cells/HPF) was observed. Equivalent CD3+ T-cell infiltration in the RGP grafts (0.63 cells/HPF) compared to the autologous grafts (0.72 cells/HPF) after 7 and 21 days (0.7 vs 0.8 cells/HPF) was observed. Immunoglobulin production was significantly greater in the NGP grafts compared to the autologous grafts at 7 (123.3 vs 52.7 mg/mL) and 21 days (93.3 vs 71.6 mg/mL), with a similar decreasing trend in absolute production. Equivalent immunoglobulin production was observed in the RGP grafts compared to the autologous grafts at 7 (40.8 vs 52.7 mg/mL) and 21 days (29.5 vs 71.6 mg/mL). CONCLUSIONS Autologous mesenchymal stem cell recellularization of xenogenic valves reduces the xenoreactive immune response in an in vivo rat model and may be an effective approach to decrease the progression of xenograft valve dysfunction.
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Affiliation(s)
- Sabin J Bozso
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Jimmy J H Kang
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Ryaan El-Andari
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Nicholas Fialka
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Lin Fu Zhu
- Department of Surgery, Surgical Medical Research Institute, University of Alberta, Edmonton, AB, Canada
| | - Steven R Meyer
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Darren H Freed
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Jayan Nagendran
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Jeevan Nagendran
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
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