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Monreal G, Koenig SC, Huang J, Slaughter MS. Anatomical and Hemodynamic Characterization of Totally Artificial Hearts. ASAIO J 2024; 70:338-347. [PMID: 38557701 DOI: 10.1097/mat.0000000000002209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
We characterize the anatomy and function of never before studied total artificial hearts (TAHs) using established methods for testing mechanical circulatory support (MCS) devices. A historical review of TAHs is also presented to aid in benchmarking performance metrics. Six TAHs, ranging from spooky Halloween beating hearts to a cute colorful plush heart, were imaged, instrumented (mock flow loops) to measure their pressure, volume, and flow, and qualitatively evaluated by 3rd party cardiac surgeons for anatomical accuracy and surgical considerations. Imaging of Claw, Beating, and Frankenstein TAHs revealed internal motors, circuit boards, and speakers. Gummy TAH was ranked favorite TAH for tactile realism, while Frankenstein TAH had the most favorable audible/visual indicators, including an illuminated Jacob's Ladder. Beating TAH demonstrated superior pulsatile hemodynamic performance compared to Claw TAH (16mL vs 1.3mL stroke volume). Light Up TAH and Gummy TAH functioned only as passive compliance chambers. Cute TAH rapidly exsanguinated due to its porosity (-3.0 L/min flow). These TAHs demonstrated a wide range of anatomical accuracy, surgeon appeal, unique features, and hemodynamic performance. While Claw TAH and Beating TAH successfully generated a modicum of pulsatility, we recommend the clinical community continue to support pre-clinical development of emerging or use of clinically-approved TAHs.
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Affiliation(s)
- Gretel Monreal
- From the Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, Kentucky
| | - Steven C Koenig
- From the Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, Kentucky
- Department of Bioengineering, University of Louisville, Louisville, Kentucky
| | - Jiapeng Huang
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, Kentucky
| | - Mark S Slaughter
- From the Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, Kentucky
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Lee J, Oh J, Kang SM. Another, A Few Good Device for End Stage Heart Failure. INTERNATIONAL JOURNAL OF HEART FAILURE 2024; 6:82-83. [PMID: 38694930 PMCID: PMC11058437 DOI: 10.36628/ijhf.2024.0023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 04/18/2024] [Indexed: 05/04/2024]
Affiliation(s)
- Jooyeon Lee
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jaewon Oh
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seok-Min Kang
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
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Walther CP. Cardiac Devices and Kidney Disease. Semin Nephrol 2024; 44:151513. [PMID: 38760291 DOI: 10.1016/j.semnephrol.2024.151513] [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] [Indexed: 05/19/2024]
Abstract
A growing variety of cardiac devices are available to monitor or support cardiovascular function. The entwined nature of cardiovascular disease and kidney disease makes the relationship of these devices with kidney disease a multifaceted question relating to the use of these devices in individuals with kidney disease and to the effects of the devices and device placement on kidney health. Cardiac devices can be categorized broadly into cardiac implantable electronic devices, structural devices, and circulatory assist devices. Cardiac implantable electronic devices include devices for monitoring and managing cardiac electrical activity and devices for monitoring hemodynamics. Structural devices modify cardiac structure and include valve prostheses, valve repair clips, devices for treating atrial septal abnormalities, left atrial appendage closure devices, and interatrial shunt devices. Circulatory assist devices support the failing heart or support cardiac function during high-risk cardiac procedures. Evidence for the use of these devices in individuals with kidney disease, effects of the devices on kidney health and function, specific considerations with devices in kidney disease, and important knowledge gaps are surveyed in this article. With the growing prevalence of combined cardiorenal disease and the increasing variety of cardiac devices, kidney disease considerations are an important aspect of device therapy.
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Affiliation(s)
- Carl P Walther
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX.
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Bounader K, Flécher E. End-stage heart failure: The future of heart transplant and artificial heart. Presse Med 2024; 53:104191. [PMID: 37898310 DOI: 10.1016/j.lpm.2023.104191] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 08/10/2023] [Accepted: 10/02/2023] [Indexed: 10/30/2023] Open
Abstract
In the last decades, outcomes significantly improved for both heart transplantation and LVAD. Heart transplantation remains the gold standard for the treatment of end stage heart failure and will remain for many years to come. The most relevant limitations are the lack of grafts and the effects of long-term immunosuppressive therapy that involve infectious, cancerous and metabolic complications despite advances in immunosuppression management. Mechanical circulatory support has an irreplaceable role in the treatment of end-staged heart failure, as bridge to transplant or as definitive implantation in non-transplant candidates. Although clinical results do not overcome those of HTx, improvement in the new generation of devices may help to reach the equipoise between the two therapies. This review will go through the evolution, current status and perspectives of both therapeutics.
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Affiliation(s)
- Karl Bounader
- Department of Cardiac Surgery, La Pitié Sâlpétrière Charles Foix Hospital, Paris, France
| | - Erwan Flécher
- Department of Vascular and Cardio-Thoracic Surgery, Rennes University Hospital, Rennes, France.
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Bierewirtz T, Narayanaswamy K, Giuffrida R, Rese T, Bortis D, Zimpfer D, Kolar JW, Kertzscher U, Granegger M. A Novel Pumping Principle for a Total Artificial Heart. IEEE Trans Biomed Eng 2024; 71:446-455. [PMID: 37603484 DOI: 10.1109/tbme.2023.3306888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
Abstract
OBJECTIVE Total artificial hearts (TAH) serve as a temporary treatment for severe biventricular heart failure. The limited durability and complication rates of current devices hamper long-term cardiac replacement. The aim of this study was to assess the feasibility of a novel valveless pumping principle for a durable pulsatile TAH (ShuttlePump). METHODS The pump features a rotating and linearly shuttling piston within a cylindrical housing with two in- and outlets. With a single moving piston, the ShuttlePump delivers pulsatile flow to both systemic and pulmonary circulation. The pump and actuation system were designed iteratively based on analytical and in silico methods, utilizing finite element methods (FEM) and computational fluid dynamics (CFD). Pump characteristics were evaluated experimentally in a mock circulation loop mimicking the cardiovascular system, while hemocompatibility-related parameters were calculated numerically. RESULTS Pump characteristics cover the entire required operating range for a TAH, providing 2.5-9 L/min of flow rate against 50-160 mmHg arterial pressures at stroke frequencies of 1.5-5 Hz while balancing left and right atrial pressures. FEM analysis showed mean overall copper losses of 8.84 W, resulting in a local maximum blood temperature rise of <2 K. The CFD results of the normalized index of hemolysis were 3.57 mg/100 L, and 95% of the pump's blood volume was exchanged after 1.42 s. CONCLUSION AND SIGNIFICANCE This study indicates the feasibility of a novel pumping system for a TAH with numerical and experimental results substantiating further development of the ShuttlePump.
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Lee S, Lee WS, Enomoto T, Akimoto AM, Yoshida R. Anisotropically self-oscillating gels by spatially patterned interpenetrating polymer network. SOFT MATTER 2024; 20:796-803. [PMID: 38168689 DOI: 10.1039/d3sm01237a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Here we introduce sub-millimeter self-oscillating gels that undergo the Belousov-Zhabotinsky (BZ) reaction and can anisotropically oscillate like cardiomyocytes. The anisotropically self-oscillating gels in this study were realized by spatially patterning an acrylic acid-based interpenetrating network (AA-IPN). We found that the patterned AA-IPN regions, locally introduced at both ends of the gels through UV photolithography, can constrain the horizontal gel shape deformation during the BZ reaction. In other words, the two AA-IPN regions could act as a physical barrier to prevent isotropic deformation. Furthermore, we controlled the anisotropic deformation behavior during the BZ reaction by varying the concentration of acrylic acid used in the patterning process of the AA-IPN. As a result, a specific directional deformation behavior (66% horizontal/vertical amplitude ratio) was fulfilled, similar to that of cardiomyocytes. Our study can provide a promising insight to fabricating robust gel systems for cardiomyocyte modeling or designing novel autonomous microscale soft actuators.
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Affiliation(s)
- Suwen Lee
- Department of Materials Engineering, School of Engineering, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8656, Japan.
| | - Won Seok Lee
- Department of Materials Engineering, School of Engineering, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8656, Japan.
| | - Takafumi Enomoto
- Department of Materials Engineering, School of Engineering, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8656, Japan.
| | - Aya Mizutani Akimoto
- Department of Materials Engineering, School of Engineering, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8656, Japan.
| | - Ryo Yoshida
- Department of Materials Engineering, School of Engineering, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8656, Japan.
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Gülcher OJ, Vis A, Peirlinck M, Kluin J. Balancing the ventricular outputs of pulsatile total artificial hearts. Artif Organs 2023; 47:1809-1817. [PMID: 37702086 DOI: 10.1111/aor.14641] [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: 06/19/2023] [Revised: 08/15/2023] [Accepted: 08/28/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND Maintaining balanced left and right cardiac outputs in a total artificial heart (TAH) is challenging due to the need for continuous adaptation to changing hemodynamic conditions. Proper balance in ventricular outputs of the left and right ventricles requires a preload-sensitive response and mechanisms to address the higher volumetric efficiency of the right ventricle. METHODS This review provides a comprehensive overview of various methods used to balance left and right ventricular outputs in pulsatile total artificial hearts, categorized based on their actuation mechanism. RESULTS Reported strategies include incorporating compliant materials and/or air cushions inside the ventricles, employing active control mechanisms to regulate ventricular filling state, and utilizing various shunts (such as hydraulic or intra-atrial shunts). Furthermore, reducing right ventricular stroke volume compared to the left often serves to balance the ventricular outputs. Individually controlled actuation of both ventricles in a pulsatile TAH seems to be the simplest and most effective way to achieve proper preload sensitivity and left-right output balance. Pneumatically actuated TAHs have the advantage to respond passively to preload changes. CONCLUSION Therefore, a pneumatic TAH that comprises two individually actuated ventricles appears to be a more desirable option-both in terms of simplicity and efficacy-to respond to changing hemodynamic conditions.
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Affiliation(s)
- Oskar J Gülcher
- Department of Cardiothoracic Surgery, Amsterdam University Medical Centers, Location University of Amsterdam, Amsterdam, The Netherlands
- Department of Biomechanical Engineering, Delft University of Technology, Delft, The Netherlands
| | - Annemijn Vis
- Department of Cardiothoracic Surgery, Amsterdam University Medical Centers, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Mathias Peirlinck
- Department of Biomechanical Engineering, Delft University of Technology, Delft, The Netherlands
| | - Jolanda Kluin
- Department of Cardiothoracic Surgery, Amsterdam University Medical Centers, Location University of Amsterdam, Amsterdam, The Netherlands
- Department of Cardiothoracic Surgery, Thorax Center, Erasmus MC, Rotterdam, The Netherlands
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Zhang Y, McCurdy MT, Ludmir J. Sepsis Management in the Cardiac Intensive Care Unit. J Cardiovasc Dev Dis 2023; 10:429. [PMID: 37887876 PMCID: PMC10606987 DOI: 10.3390/jcdd10100429] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/11/2023] [Accepted: 10/13/2023] [Indexed: 10/28/2023] Open
Abstract
Septic shock management in the cardiac intensive care unit (CICU) is challenging due to the complex interaction of pathophysiology between vasodilatory and cardiogenic shock, complicating how to optimally deploy fluid resuscitation, vasopressors, and mechanical circulatory support devices. Because mixed shock portends high mortality and morbidity, familiarity with quality, contemporary clinical evidence surrounding available therapeutic tools is needed to address the resultant wide range of complications that can arise. This review integrates pathophysiology principles and clinical recommendations to provide an organized, topic-based review of the nuanced intricacies of managing sepsis in the CICU.
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Affiliation(s)
- Yichi Zhang
- Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA;
| | - Michael T. McCurdy
- Division of Pulmonary & Critical Care, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA;
| | - Jonathan Ludmir
- Corrigan Minehan Heart Center, Cardiology Division, Massachusetts General Hospital, Boston, MA 02114, USA
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Garcia LP, Walther CP. Kidney health and function with left ventricular assist devices. Curr Opin Nephrol Hypertens 2023; 32:439-444. [PMID: 37195244 PMCID: PMC10524584 DOI: 10.1097/mnh.0000000000000896] [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] [Indexed: 05/18/2023]
Abstract
PURPOSE OF REVIEW Mechanical circulatory support (MCS) is a group of evolving therapies used for indications ranging from temporary support during a cardiac procedure to permanent treatment of advanced heart failure. MCS is primarily used to support left ventricle function, in which case the devices are termed left ventricular assist devices (LVADs). Kidney dysfunction is common in patients requiring these devices, yet the impact of MCS itself on kidney health in many settings remains uncertain. RECENT FINDINGS Kidney dysfunction can manifest in many different forms in patients requiring MCS. It can be because of preexisting systemic disorders, acute illness, procedural complications, device complications, and long-term LVAD support. After durable LVAD implantation, most persons have improvement in kidney function; however, individuals can have markedly different kidney outcomes, and novel phenotypes of kidney outcomes have been identified. SUMMARY MCS is a rapidly evolving field. Kidney health and function before, during, and after MCS is relevant to outcomes from an epidemiologic perspective, yet the pathophysiology underlying this is uncertain. Improved understanding of the relationship between MCS use and kidney health is important to improving patient outcomes.
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Affiliation(s)
- Leonardo Pozo Garcia
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Carl P. Walther
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX
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Duan M, Xia S, Liu Y, Pu X, Chen Y, Zhou Y, Huang M, Pi C, Zhang D, Xie J. Stiffened fibre-like microenvironment based on patterned equidistant micropillars directs chondrocyte hypertrophy. Mater Today Bio 2023; 20:100682. [PMID: 37304578 PMCID: PMC10251154 DOI: 10.1016/j.mtbio.2023.100682] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 05/04/2023] [Accepted: 05/23/2023] [Indexed: 06/13/2023] Open
Abstract
Articular cartilage, composed of collagen type II as a major extracellular matrix and chondrocyte as a unique cell type, is a specialized connective tissue without blood vessels, lymphatic vessels and nerves. This distinctive characteristic of articular cartilage determines its very limited ability to repair when damaged. It is well known that physical microenvironmental signals regulate many cell behaviors such as cell morphology, adhesion, proliferation and cell communication even determine chondrocyte fate. Interestingly, with increasing age or progression of joint diseases such as osteoarthritis (OA), the major collagen fibrils in the extracellular matrix of articular cartilage become larger in diameter, leading to stiffening of articular tissue and reducing its resistance to external tension, which in turn aggravates joint damage or progression of joint diseases. Therefore, designing a physical microenvironment closer to the real tissue and thus obtaining data closer to the real cellular behaviour, and then revealing the biological mechanisms of chondrocytes in pathological states is of crucial importance for the treatment of OA disease. Here we fabricated micropillar substrates with the same topology but different stiffnesses to mimic the matrix stiffening that occurs in the transition from normal to diseased cartilage. It was first found that chondrocytes responded to stiffened micropillar substrates by showing a larger cell spreading area, a stronger enhancement of cytoskeleton rearrangement and more stability of focal adhesion plaques. The activation of Erk/MAPK signalling in chondrocytes was detected in response to the stiffened micropillar substrate. Interestingly, a larger nuclear spreading area of chondrocytes at the interface layer between the cells and top surfaces of micropillars was observed in response to the stiffened micropillar substrate. Finally, it was found that the stiffened micropillar substrate promoted chondrocyte hypertrophy. Taken together, these results revealed the cell responses of chondrocytes in terms of cell morphology, cytoskeleton, focal adhesion, nuclei and cell hypertrophy, and may be beneficial for understanding the cellular functional changes affected by the matrix stiffening that occurs during the transition from a normal state to a state of osteoarthritis.
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Affiliation(s)
- Mengmeng Duan
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
- National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, 610041, China
| | - Shuang Xia
- State Key Laboratory of Polymer Materials Engineering, Polymer Research Institute of Sichuan University, Chengdu, 610065, China
| | - Yang Liu
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Xiaohua Pu
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Yukun Chen
- State Key Laboratory of Polymer Materials Engineering, Polymer Research Institute of Sichuan University, Chengdu, 610065, China
| | - Yilin Zhou
- State Key Laboratory of Polymer Materials Engineering, Polymer Research Institute of Sichuan University, Chengdu, 610065, China
| | - Minglei Huang
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Caixia Pi
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Demao Zhang
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
- Institute of Biomedical Engineering, West China School of Basic Medical Sciences & Forensic Medicine, Sichuan University, Chengdu, China
| | - Jing Xie
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
- National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, 610041, China
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Arfaee M, Vis A, Kluin J. Future technologies in total artificial heart development: can a robot become as good as a donor heart? Eur Heart J 2022; 43:4970-4972. [PMID: 36171689 DOI: 10.1093/eurheartj/ehac512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Affiliation(s)
- Maziar Arfaee
- Cardiothoracic Surgery, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, 1105AZ Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands.,Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Amsterdam, The Netherlands
| | - Annemijn Vis
- Cardiothoracic Surgery, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, 1105AZ Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands.,Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Amsterdam, The Netherlands
| | - Jolanda Kluin
- Cardiothoracic Surgery, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, 1105AZ Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands.,Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Amsterdam, The Netherlands
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Smadja DM. Stem Cell Therapy, Artificial Heart or Xenotransplantation: What will be New “Regenerative” Strategies in Heart Failure during the Next Decade? Stem Cell Rev Rep 2022; 19:694-699. [PMID: 36383298 DOI: 10.1007/s12015-022-10476-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2022] [Indexed: 11/17/2022]
Abstract
The main limitation of allotransplantation and in particular heart transplantation is the insufficient supply of donor organs. As alternative strategies to heart transplantation, stem cells opened the way of regenerative medicine in early 2000. While new biotechnologies tried to minimize side effects due to hemocompatibility in artificial hearts, progress in xenotransplantation allowed in 2022 to realize the first pig-to-human heart transplant on a compassionate use basis. This xenotransplantation has been successful thanks to genetically modified pigs using the CRISPR-Cas9 technology. Indeed, gene editing allowed modifications of immune responses and thrombotic potential to modulate graft and systemic reaction. Academic research and preclinical studies of xenogeneic tissues already used in clinic such as bioprosthesis valve and of new xenotransplantation options will be necessary to evaluate immune-thrombosis and organ/vascular damages more deeply to make this hope of xenotransplantation a clinical reality. Stem cells, artificial heart and xenotransplantation are all in line to overcome the lack of donor hearts. Combination of stem cell approaches and/or xenogeneic tissue and/or artificial organs are probably part of the research objectives to make these projects real in the short term.
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