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Maes L, Vervenne T, Hendrickx A, Estrada AC, Van Hoof L, Verbrugghe P, Rega F, Jones EAV, Humphrey JD, Famaey N. Cell signaling and tissue remodeling in the pulmonary autograft after the Ross procedure: A computational study. J Biomech 2024; 171:112180. [PMID: 38906711 DOI: 10.1016/j.jbiomech.2024.112180] [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: 01/02/2024] [Revised: 03/20/2024] [Accepted: 05/31/2024] [Indexed: 06/23/2024]
Abstract
In the Ross procedure, a patient's pulmonary valve is transplanted in the aortic position. Despite advantages of this surgery, reoperation is still needed in many cases due to excessive dilatation of the pulmonary autograft. To further understand the failure mechanisms, we propose a multiscale model predicting adaptive processes in the autograft at the cell and tissue scale. The cell-scale model consists of a network model, that includes important signaling pathways and relations between relevant transcription factors and their target genes. The resulting gene activity leads to changes in the mechanical properties of the tissue, modeled as a constrained mixture of collagen, elastin and smooth muscle. The multiscale model is calibrated with findings from experiments in which seven sheep underwent the Ross procedure. The model is then validated against a different set of sheep experiments, for which a qualitative agreement between model and experiment is found. Model outcomes at the cell scale, including the activity of genes and transcription factors, also match experimentally obtained transcriptomics data.
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Affiliation(s)
- Lauranne Maes
- BioMechanics, Department of Mechanical Engineering, KU Leuven, Leuven, Belgium.
| | - Thibault Vervenne
- BioMechanics, Department of Mechanical Engineering, KU Leuven, Leuven, Belgium
| | - Amber Hendrickx
- Cardiac Surgery, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Ana C Estrada
- Department of Biomedical Engineering, Yale University, New Haven CT, USA
| | - Lucas Van Hoof
- Cardiac Surgery, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Peter Verbrugghe
- Cardiac Surgery, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Filip Rega
- Cardiac Surgery, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Elizabeth A V Jones
- Centre for Molecular and Vascular Biology, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium; CARIM School for Cardiovascular Diseases, Department of Cardiology, Maastricht University, Maastricht, Netherlands
| | - Jay D Humphrey
- Department of Biomedical Engineering, Yale University, New Haven CT, USA
| | - Nele Famaey
- BioMechanics, Department of Mechanical Engineering, KU Leuven, Leuven, Belgium
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Costa D, Andreucci M, Ielapi N, Serraino GF, Mastroroberto P, Bracale UM, Serra R. Vascular Biology of arterial aneurysms. Ann Vasc Surg 2023:S0890-5096(23)00225-X. [PMID: 37068624 DOI: 10.1016/j.avsg.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/06/2023] [Accepted: 04/07/2023] [Indexed: 04/19/2023]
Abstract
OBJECTIVE This review aims to analyze biomolecular and cellular events responsible for arterial aneurysm formation with particular attention to vascular remodeling that determines the initiation and the progression of arterial aneurysm, till rupture. METHODS This review was conducted searching libraries such as Web of Science, Scopus, ScienceDirect and Medline. Used keywords with various combinations were: "arterial aneurysms", "biology", "genetics", "proteomics", "molecular", "pathophysiology" and extracellular matrix" RESULTS: There are several genetic alterations responsible of syndromic and non-syndromic disease that predispose to aneurysm formation. ECM imbalance, mainly due to the alteration of vascular smooth muscle cells (VSMCs) homeostasis, overexpression of metalloproteinases (MPs) and cytokines activation, determines weakness of the arterial wall that dilates thus causing aneurysmal disease. Altered mechanotransduction in the ECM may also trigger and sustain anomalous cellular and biochemical signaling. Different cell population such as VSMCs, macrophages, perivascular adipose tissue (PVAT) cells, vascular wall resident stem cells (VWRSCs) are all involved at different levels CONCLUSIONS: Improving knowledge in vascular biology may help researchers and physicians in better targeting aneurysmal disease in order to better prevent and better treat such important disease.
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Affiliation(s)
- Davide Costa
- Department of Law, Economics and Sociology, University "Magna Graecia" of Catanzaro, 88100 Catanzaro, Italy; Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology. University "Magna Graecia" of Catanzaro, 88100 Catanzaro, Italy
| | - Michele Andreucci
- Department of Health Sciences. University "Magna Graecia" of Catanzaro. 88100, Catanzaro, Italy
| | - Nicola Ielapi
- Department of Public Health and Infectious Disease, "Sapienza" University of Rome, 00185, Rome, Italy
| | - Giuseppe Filiberto Serraino
- Department of Experimental and Clinical Medicine. University "Magna Graecia" of Catanzaro. 88100, Catanzaro, Italy
| | - Pasquale Mastroroberto
- Department of Experimental and Clinical Medicine. University "Magna Graecia" of Catanzaro. 88100, Catanzaro, Italy
| | | | - Raffaele Serra
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology. University "Magna Graecia" of Catanzaro, 88100 Catanzaro, Italy; Department of Medical and Surgical Sciences. University "Magna Graecia" of Catanzaro. 88100, Catanzaro, Italy.
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Biomechanics of Pulmonary Autograft as Living Tissue: A Systematic Review. Bioengineering (Basel) 2022; 9:bioengineering9090456. [PMID: 36135002 PMCID: PMC9495771 DOI: 10.3390/bioengineering9090456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/01/2022] [Accepted: 09/04/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction: The choice of valve substitute for aortic valve surgery is tailored to the patient with specific indications and contraindications to consider. The use of an autologous pulmonary artery (PA) with a simultaneous homograft in the pulmonary position is called a Ross procedure. It permits somatic growth and the avoidance of lifelong anticoagulation. Concerns remain on the functionality of a pulmonary autograft in the aortic position when exposed to systemic pressure. Methods: A literature review was performed incorporating the following databases: Pub Med (1996 to present), Ovid Medline (1958 to present), and Ovid Embase (1982 to present), which was run on 1 January 2022 with the following targeted words: biomechanics of pulmonary autograft, biomechanics of Ross operation, aortic valve replacement and pulmonary autograph, aortic valve replacement and Ross procedure. To address the issues with heterogeneity, studies involving the pediatric cohort were also analyzed separately. The outcomes measured were early- and late-graft failure alongside mortality. Results: a total of 8468 patients were included based on 40 studies (7796 in pediatric cohort and young adult series and 672 in pediatric series). There was considerable experience accumulated by various institutions around the world. Late rates of biomechanical failure and mortality were low and comparable to the general population. The biomechanical properties of the PA were superior to other valve substitutes. Mathematical and finite element analysis studies have shown the potential stress-shielding effects of the PA root. Conclusion: The Ross procedure has excellent durability and longevity in clinical and biomechanical studies. The use of external reinforcements such as semi-resorbable scaffolds may further extend their longevity.
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Nappi F. The role of the extracellular matrix in the development of heart valve disease: Underestimation or undercomprehension? J Card Surg 2022; 37:1623-1626. [PMID: 35352851 DOI: 10.1111/jocs.16445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 03/15/2022] [Indexed: 11/26/2022]
Abstract
The function of metalloproteinases of the extracellular matrix and their inhibitors has emerged with a crucial role in valve diseases. Both the expression of matrix metalloproteinases and their inhibitors are susceptible to modification in patients with severe mitral insufficiency. This process is due to substantial changes in the collagen structure during mechanical stress on the mitral valve leaflets. Several studies have measured the level of deformation of the mitral leaflets with the use of the finite element analysis method by establishing the stiffness of the cellular and extracellular elements of the mitral valve leaflets. Evidence suggested the possible underestimation of the stiffness of the leaflets. This implies greater stress on the components of the extracellular matrix in the circumferential and radial strains that involve the mitral leaflets during chronic regurgitation. The remodeling process during mechanical stress phenomena involves both the cellular compartment and the extracellular matrix and can be adaptive or maladaptive as showed in patients who receive a pulmonary autograft to replace the diseased aortic valve. However, adaptive remodeling can be driven using resorbable polymers that interfere with the extracellular matrix. Further investigation is required for the understanding of the mechanisms that determine the structural changes of the extracellular matrix and to prevent them.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord, Saint-Denis, France
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DeCampli WM. Will we work out the Ross dilemma in 30 minutes?-Or 30 years? World J Pediatr Congenit Heart Surg 2022; 13:175-177. [PMID: 35238699 DOI: 10.1177/21501351221075839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- William M DeCampli
- Division of Cardiovascular Surgery, Arnold Palmer Hospital for Children, Orlando, FL, USA; Department of Clinical Sciences, University of Central Florida College of Medicine, Orlando, FL, USA
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Cao Y, Asai H, Niwano H, Ikarashi J, Tachibana T. Surgical Angioplasty for a Single Coronary Artery With Myocardial Bridging. Ann Thorac Surg 2022; 114:e347-e350. [PMID: 35216995 DOI: 10.1016/j.athoracsur.2022.01.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 01/15/2022] [Accepted: 01/23/2022] [Indexed: 11/26/2022]
Abstract
Single coronary artery (SCA) with myocardial bridging (MB) is rare but associated with the risk of sudden cardiac death in children, yet there is no standardized treatment approach. We report a 6-year-old girl with chest pain having an SCA with complete MB of the left main coronary artery (LMCA) (modified Lipton type RII-S) branching from the right coronary artery at an acute angle. Coronary angioplasty using an in-situ aortic flap and an autologous pulmonary arterial patch combined with myocardial unroofing was successfully performed for the LMCA. The patient remains healthy for over 3 years without any exercise restriction.
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Affiliation(s)
- Yuchen Cao
- Division of Cardiovascular Surgery, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Hidetsugu Asai
- Division of Cardiovascular Surgery, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Haruki Niwano
- Division of Cardiovascular Surgery, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Jin Ikarashi
- Division of Cardiovascular Surgery, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Tsuyoshi Tachibana
- Division of Cardiovascular Surgery, Kanagawa Children's Medical Center, Yokohama, Japan.
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Van Hoof L, Verbrugghe P, Jones EAV, Humphrey JD, Janssens S, Famaey N, Rega F. Understanding Pulmonary Autograft Remodeling After the Ross Procedure: Stick to the Facts. Front Cardiovasc Med 2022; 9:829120. [PMID: 35224059 PMCID: PMC8865563 DOI: 10.3389/fcvm.2022.829120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 01/17/2022] [Indexed: 12/12/2022] Open
Abstract
The Ross, or pulmonary autograft, procedure presents a fascinating mechanobiological scenario. Due to the common embryological origin of the aortic and pulmonary root, the conotruncus, several authors have hypothesized that a pulmonary autograft has the innate potential to remodel into an aortic phenotype once exposed to systemic conditions. Most of our understanding of pulmonary autograft mechanobiology stems from the remodeling observed in the arterial wall, rather than the valve, simply because there have been many opportunities to study the walls of dilated autografts explanted at reoperation. While previous histological studies provided important clues on autograft adaptation, a comprehensive understanding of its determinants and underlying mechanisms is needed so that the Ross procedure can become a widely accepted aortic valve substitute in select patients. It is clear that protecting the autograft during the early adaptation phase is crucial to avoid initiating a sequence of pathological remodeling. External support in the freestanding Ross procedure should aim to prevent dilatation while simultaneously promoting remodeling, rather than preventing dilatation at the cost of vascular atrophy. To define the optimal mechanical properties and geometry for external support, the ideal conditions for autograft remodeling and the timeline of mechanical adaptation must be determined. We aimed to rigorously review pulmonary autograft remodeling after the Ross procedure. Starting from the developmental, microstructural and biomechanical differences between the pulmonary artery and aorta, we review autograft mechanobiology in relation to distinct clinical failure mechanisms while aiming to identify unmet clinical needs, gaps in current knowledge and areas for further research. By correlating clinical and experimental observations of autograft remodeling with established principles in cardiovascular mechanobiology, we aim to present an up-to-date overview of all factors involved in extracellular matrix remodeling, their interactions and potential underlying molecular mechanisms.
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Affiliation(s)
- Lucas Van Hoof
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Peter Verbrugghe
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | - Jay D. Humphrey
- Department of Biomedical Engineering, Yale University, New Haven, CT, United States
| | - Stefan Janssens
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Nele Famaey
- Biomechanics Section, KU Leuven, Leuven, Belgium
| | - Filip Rega
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
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Nappi F, Iervolino A, Avtaar Singh SS. The effectiveness and safety of pulmonary autograft as living tissue in Ross procedure: a systematic review. Transl Pediatr 2022; 11:280-297. [PMID: 35282027 PMCID: PMC8905099 DOI: 10.21037/tp-21-351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 01/14/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Reports on effectiveness and safety after the implant of pulmonary autograft (PA) living tissue in Ross procedure, to treat both congenital and acquired disease of the aortic valve and left ventricular outflow tract (LVOT), show variable durability results. We undertake a quantitative systematic review of evidence on outcome after the Ross procedure with the aim to improve insight into outcome and potential determinants. METHODS A systematic search of reports published from October 1979 to January 2021 was conducted (PubMed, Ovid Medline, Ovid Embase and Cochrane library) reporting outcomes after the Ross procedure in patients with diseased aortic valve with or without LVOT. Inclusion criteria were observational studies reporting on mortality and/or morbidity after autograft aortic valve or root replacement, completeness of follow-up >90%, and study size n≥30. Forty articles meeting the inclusion criteria were allocated to two categories: pediatric patient series and young adult patient series. Results were tabulated for a clearer presentation. RESULTS A total of 342 studies were evaluated of which forty studies were included in the final analysis as per the eligibility criteria. A total of 8,468 patients were included (7,796 in pediatric cohort and young adult series and 672 in pediatric series). Late mortality rates were remarkably low alongside similar age-matched mortality with the general population in young adults. There were differences in implantation techniques as regard the variability in stress and the somatic growth that recorded conflicting outcomes regarding the miniroot vs the subcoronary approach. DISCUSSION The adaptability of lung autograft to allow for both stress variability and somatic growth make it an ideal conduit for Ross's operation. The use of the miniroot technique over subcoronary implantation for better adaptability to withstand varying degrees of stress is perhaps more applicable to different patient subgroups.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France
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Starnes VA, Bowdish ME, Cohen RG, Baker CJ, Elsayed RS. The Ross procedure utilizing the pulmonary autograft inclusion technique in adults. JTCVS Tech 2021; 10:372-376. [PMID: 34977756 PMCID: PMC8690298 DOI: 10.1016/j.xjtc.2021.05.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 05/24/2021] [Indexed: 11/25/2022] Open
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10
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Buratto E, Konstantinov IE. Valve-sparing aortic root surgery in children and adults with congenital heart disease. J Thorac Cardiovasc Surg 2021; 162:955-962. [DOI: 10.1016/j.jtcvs.2020.08.116] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 08/04/2020] [Accepted: 08/11/2020] [Indexed: 12/12/2022]
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Highlights in congenital cardiothoracic surgery: 2020-2021. J Thorac Cardiovasc Surg 2021; 162:349-352. [PMID: 34045057 DOI: 10.1016/j.jtcvs.2021.04.066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 04/18/2021] [Accepted: 04/19/2021] [Indexed: 12/15/2022]
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Mechano-biological adaptation of the pulmonary artery exposed to systemic conditions. Sci Rep 2020; 10:2724. [PMID: 32066803 PMCID: PMC7026065 DOI: 10.1038/s41598-020-59554-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 01/29/2020] [Indexed: 12/30/2022] Open
Abstract
Cardiac surgeries may expose pulmonary arterial tissue to systemic conditions, potentially resulting in failure of that tissue. Our goal was to quantitatively assess pulmonary artery adaptation due to changes in mechanical environment. In 17 sheep, we placed a pulmonary autograft in aortic position, with or without macroporous mesh reinforcement. It was exposed to systemic conditions for 6 months. All sheep underwent 3 ECG-gated MRI’s. Explanted tissue was subjected to mechanical and histological analysis. Results showed progressive dilatation of the unreinforced autograft, while reinforced autografts stabilized after two months. Some unreinforced pulmonary autograft samples displayed more aorta-like mechanical behavior with increased collagen deposition. The mechanical behavior of reinforced autografts was dominated by the mesh. The decrease in media thickness and loss of vascular smooth muscle cells was more pronounced in reinforced than in unreinforced autografts. In conclusion, altering the mechanical environment of a pulmonary artery causes changes in its mechano-biological properties.
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Konstantinov IE, Caldaroni F, Ivanov Y. Commentary: Prediction of pulmonary root dilatation after Ross operation—The power of protein shake? J Thorac Cardiovasc Surg 2020; 159:635-636. [DOI: 10.1016/j.jtcvs.2019.08.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 08/02/2019] [Indexed: 12/15/2022]
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Ibrahim M, Spelde AE, Augoustides JG. Commentary: Toward a biologic understanding of autograft dilatation in the Ross procedure-creating opportunities to rescue the neoaortic root. J Thorac Cardiovasc Surg 2019; 159:633-634. [PMID: 31604643 DOI: 10.1016/j.jtcvs.2019.08.019] [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: 08/01/2019] [Accepted: 08/01/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Michael Ibrahim
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine University of Pennsylvania, Philadelphia, Pa
| | - Audrey E Spelde
- Cardiovascular and Critical Care Divisions, Perelman School of Medicine University of Pennsylvania, Philadelphia, Pa
| | - John G Augoustides
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine University of Pennsylvania, Philadelphia, Pa.
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