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Vogel AD, Kwon JH, Mitta A, Sherard C, Brockbank KGM, Rajab TK. Immunogenicity of Homologous Heart Valves: Mechanisms and Future Considerations. Cardiol Rev 2024; 32:385-391. [PMID: 36688843 PMCID: PMC10363244 DOI: 10.1097/crd.0000000000000519] [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] [Indexed: 01/24/2023]
Abstract
Pediatric valvar heart disease continues to be a topic of interest due to the common and severe clinical manifestations. Problems with heart valve replacement, including lack of adaptive valve growth and accelerated structural valve degeneration, mandate morbid reoperations to serially replace valve implants. Homologous or homograft heart valves are a compelling option for valve replacement in the pediatric population but are susceptible to structural valve degeneration. The immunogenicity of homologous heart valves is not fully understood, and mechanisms explaining how implanted heart valves are attacked are unclear. It has been demonstrated that preservation methods determine homograft cell viability and there may be a direct correlation between increased cellular viability and a higher immune response. This consists of an early increase in human leukocyte antigen (HLA)-class I and II antibodies over days to months posthomograft implantation, followed by the sustained increase in HLA-class II antibodies for years after implantation. Cytotoxic T lymphocytes and T-helper lymphocytes specific to both HLA classes can infiltrate tissue almost immediately after implantation. Furthermore, increased HLA-class II mismatches result in an increased cell-mediated response and an accelerated rate of structural valve degeneration especially in younger patients. Further long-term clinical studies should be completed investigating the immunological mechanisms of heart valve rejection and their relation to structural valve degeneration as well as testing of immunosuppressant therapies to determine the needed immunosuppression for homologous heart valve implantation.
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Affiliation(s)
- Andrew D Vogel
- From the Department of Surgery, Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
- Department of Surgery, Alabama College of Osteopathic Medicine, Dothan, AL
| | - Jennie H Kwon
- From the Department of Surgery, Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
| | - Alekhya Mitta
- From the Department of Surgery, Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
- Department of Surgery, School of Medicine, University of South Carolina, Columbia, SC
| | - Curry Sherard
- From the Department of Surgery, Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
- Department of Surgery, College of Medicine, Medical University of South Carolina, Charleston, SC
| | - Kelvin G M Brockbank
- Department of Surgery, Tissue Testing Technologies LLC, North Charleston, SC
- Department of Bioengineering, Clemson University, Charleston, SC
| | - Taufiek Konrad Rajab
- From the Department of Surgery, Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
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Andreeva A, Werner P, Coti I, Kocher A, Laufer G, Ehrlich M, Zimpfer D, Andreas M. Decellularized aortic homografts versus mechanical composite grafts for aortic root replacement. Eur J Cardiothorac Surg 2024; 66:ezae314. [PMID: 39178014 PMCID: PMC11361793 DOI: 10.1093/ejcts/ezae314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 07/23/2024] [Accepted: 08/21/2024] [Indexed: 08/24/2024] Open
Abstract
OBJECTIVES Mechanical composite valve grafts (MCVGs) are the first-line therapy for aortic root replacement in young adults. Decellularized aortic homografts (DAH) present a promising novel alternative due to their lower thrombogenicity. We aimed to compare both treatment options regarding survival and valve-related adverse events. METHODS This study was designed as a single-centre retrospective cohort study including patients who underwent root replacement with MCVG or DAH between 2000 and 2022. Urgent or emergent procedures were excluded. RESULTS The study cohort included 289 patients (MCVG n = 216, DAH n = 73) with a mean age of 48.5 ± 12 years (MCVG 49 ± 12 years vs DAH 47 ± 11 years; P = 0.23) and a median EuroScore II of 1.7% (1.2, 2.6). The 30-day mortality was 1% (n = 3). Cumulative survival at 3 years was 99% for DAH and 94% for MCVG, respectively (P = 0.15). Mean follow-up was 98.9 ± 72.7 months. Bleeding events (n = 14, 6.5%) and thromboembolism (n = 14, 6.5%) were only observed in the MCVG group (P = 0.19 and 0.09, respectively). Four cases (5%) of moderate structural valve deterioration occurred, all in the DAH group (P ≤ 0.001). The cumulative incidence of a composite end point of valve-related adverse events was significantly higher in the MCVG group (P = 0.0295). CONCLUSIONS Aortic root replacement with MCVGs and decellularized aortic homografts showed low mortality in an elective setting. Patients in the homograft cohort demonstrated significantly higher freedom from valve-related adverse events. DAH present a promising treatment option for young patients requiring root replacement; however, data on long-term durability are needed.
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Affiliation(s)
- Alexandra Andreeva
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Paul Werner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Iuliana Coti
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Alfred Kocher
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Guenther Laufer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Marek Ehrlich
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Martin Andreas
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
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3
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Wang Z, Ma K, Li S. Clinical Outcomes and Predictors of Valved Homograft Conduits Used for Right Ventricular Outflow Tract Reconstruction. Pediatr Cardiol 2024:10.1007/s00246-024-03582-x. [PMID: 39042329 DOI: 10.1007/s00246-024-03582-x] [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: 04/18/2024] [Accepted: 07/08/2024] [Indexed: 07/24/2024]
Abstract
We conducted a retrospective review of patients who underwent valved homograft conduits (VHC) for right ventricular outflow tract (RVOT) reconstruction at our center. Long-term outcomes were analyzed, and risk factors affecting the long-term durability of VHC were explored. Kaplan-Meier survival curves were used to evaluate survival, freedom from VHC reintervention, and freedom from VHC dysfunction. Multivariate Cox proportional hazards regression model was used to analyze the risk factors for late VHC dysfunction. A total of 290 patients who underwent VHC for RVOT reconstruction in our center were enrolled. Seven patients occurred early death, all of which were in the non-Ross group. Two hundred and sixty-five patients were followed up for 85 (0.3-176.0) months. Six patients occurred late death, all in the non-Ross group. Six patients underwent VHC reintervention. During the follow-up period, 52 patients developed VHC dysfunction. Freedom from VHC dysfunction was higher in the Ross group than in the non-Ross group in the whole cohort. Multivariate Cox regression analysis showed that age < 6 years and non-Ross operation were independent risk factors for VHC dysfunction. Freedom from VHC dysfunction was higher in the Ross group than in the non-Ross group in patients younger than 6 years of age at surgery. However, there was no significant difference in freedom from VHC dysfunction between the two groups in patients older than 6 years. Long-term outcomes of VHC for RVOT reconstruction are satisfactory. Age < 6 years and non-Ross operation are independent risk factors for VHC dysfunction. The long-term survival rate and durability of VHC in Ross group were better than those in non-Ross group. The advantage of long-term durability of VHC in the Ross group was mainly reflected in patients aged < 6 years at operation.
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Affiliation(s)
- Zhangwei Wang
- Department of Cardiovascular Surgery, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Fuwai Hospital, No.167 Beilishi Road, Xicheng District, Beijing, China
| | - Kai Ma
- Department of Cardiovascular Surgery, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Fuwai Hospital, No.167 Beilishi Road, Xicheng District, Beijing, China
| | - Shoujun Li
- Department of Cardiovascular Surgery, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases, Fuwai Hospital, No.167 Beilishi Road, Xicheng District, Beijing, China.
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Snyder Y, Jana S. Innovative Substrate Design with Basement Membrane Components for Enhanced Endothelial Cell Function and Endothelization. Adv Healthc Mater 2024:e2401150. [PMID: 39021293 DOI: 10.1002/adhm.202401150] [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: 03/27/2024] [Revised: 06/28/2024] [Indexed: 07/20/2024]
Abstract
Enhancing endothelial cell growth on small-diameter vascular grafts produced from decellularized tissues or synthetic substrates is pivotal for preventing thrombosis. While optimized decellularization protocols can preserve the structure and many components of the extracellular matrix (ECM), the process can still lead to the loss of crucial basement membrane proteins, such as laminin, collagen IV, and perlecan, which are pivotal for endothelial cell adherence and functional growth. This loss can result in poor endothelialization and endothelial cell activation causing thrombosis and intimal hyperplasia. To address this, the basement membrane's ECM is emulated on fiber substrates, providing a more physiological environment for endothelial cells. Thus, fibroblasts are cultured on fiber substrates to produce an ECM membrane substrate (EMMS) with basement membrane proteins. The EMMS then underwent antigen removal (AR) treatment to eliminate antigens from the membrane while preserving essential proteins and producing an AR-treated membrane substrate (AMS). Subsequently, human endothelial cells cultured on the AMS exhibited superior proliferation, nitric oxide production, and increased expression of endothelial markers of quiescence/homeostasis, along with autophagy and antithrombotic factors, compared to those on the decellularized aortic tissue. This strategy showed the potential of pre-endowing fiber substrates with a basement membrane to enable better endothelization.
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Affiliation(s)
- Yuriy Snyder
- Department of Chemical and Biomedical Engineering, University of Missouri, 1406 Rollins Street, Columbia, MO, 65211, USA
| | - Soumen Jana
- Department of Chemical and Biomedical Engineering, University of Missouri, 1406 Rollins Street, Columbia, MO, 65211, USA
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5
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Van Hoof L, Rooyackers B, Schuermans A, Duponselle J, Van De Bruaene A, De Meester P, Troost E, Meuris B, Budts W, Gewillig M, Flameng W, Daenen W, Meyns B, Verbrugghe P, Rega F. Long-term outcome after the Ross procedure in 173 adults with up to 25 years of follow-up. Eur J Cardiothorac Surg 2024; 66:ezae267. [PMID: 38991839 DOI: 10.1093/ejcts/ezae267] [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: 03/20/2024] [Revised: 06/09/2024] [Accepted: 07/10/2024] [Indexed: 07/13/2024] Open
Abstract
OBJECTIVES The potential risk of autograft dilatation and homograft stenosis after the Ross procedure mandates lifelong follow-up. This retrospective cohort study aimed to determine long-term outcome of the Ross procedure, investigating autograft and homograft failure patterns leading to reintervention. METHODS All adults who underwent the Ross procedure between 1991 and 2018 at the University Hospitals Leuven were included, with follow-up data collected retrospectively. Autograft implantation was performed using the full root replacement technique. The primary end-point was long-term survival. Secondary end-points were survival free from any reintervention, autograft or homograft reintervention-free survival, and evolution of autograft diameter, homograft gradient and aortic regurgitation grade over time. RESULTS A total of 173 adult patients (66% male) with a median age of 32 years (range 18-58 years) were included. External support at both the annulus and sinotubular junction was used in 38.7% (67/173). Median follow-up duration was 11.1 years (IQR, 6.4-15.9; 2065 patient-years) with 95% follow-up completeness. There was one (0.6%) perioperative death. Kaplan-Meier estimate for 15-year survival was 91.1% and Ross-related reintervention-free survival was 75.7% (autograft: 83.5%, homograft: 85%). Regression analyses demonstrated progressive neoaortic root dilatation (0.56 mm/year) and increase in homograft gradient (0.72 mmHg/year). CONCLUSIONS The Ross procedure has the potential to offer excellent long-term survival and reintervention-free survival. These long-term data further confirm that the Ross procedure is a suitable option in young adults with aortic valve disease which should be considered on an individual basis.
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Affiliation(s)
- Lucas Van Hoof
- Department of Cardiac Surgery, UZ Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Bert Rooyackers
- Department of Cardiac Surgery, UZ Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Art Schuermans
- Department of Cardiac Surgery, UZ Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Jolien Duponselle
- Department of Cardiac Surgery, UZ Leuven, Herestraat 49, 3000 Leuven, Belgium
| | | | - Pieter De Meester
- Department of Cardiovascular Diseases, UZ Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Els Troost
- Department of Cardiovascular Diseases, UZ Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Bart Meuris
- Department of Cardiac Surgery, UZ Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Werner Budts
- Department of Cardiovascular Diseases, UZ Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Marc Gewillig
- Department of Pediatric Cardiology, UZ Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Willem Flameng
- Department of Cardiac Surgery, UZ Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Willem Daenen
- Department of Cardiac Surgery, UZ Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Bart Meyns
- Department of Cardiac Surgery, UZ Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Peter Verbrugghe
- Department of Cardiac Surgery, UZ Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Filip Rega
- Department of Cardiac Surgery, UZ Leuven, Herestraat 49, 3000 Leuven, Belgium
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6
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Sengupta PP, Kluin J, Lee SP, Oh JK, Smits AIPM. The future of valvular heart disease assessment and therapy. Lancet 2024; 403:1590-1602. [PMID: 38554727 DOI: 10.1016/s0140-6736(23)02754-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 08/15/2023] [Accepted: 12/06/2023] [Indexed: 04/02/2024]
Abstract
Valvular heart disease (VHD) is becoming more prevalent in an ageing population, leading to challenges in diagnosis and management. This two-part Series offers a comprehensive review of changing concepts in VHD, covering diagnosis, intervention timing, novel management strategies, and the current state of research. The first paper highlights the remarkable progress made in imaging and transcatheter techniques, effectively addressing the treatment paradox wherein populations at the highest risk of VHD often receive the least treatment. These advances have attracted the attention of clinicians, researchers, engineers, device manufacturers, and investors, leading to the exploration and proposal of treatment approaches grounded in pathophysiology and multidisciplinary strategies for VHD management. This Series paper focuses on innovations involving computational, pharmacological, and bioengineering approaches that are transforming the diagnosis and management of patients with VHD. Artificial intelligence and digital methods are enhancing screening, diagnosis, and planning procedures, and the integration of imaging and clinical data is improving the classification of VHD severity. The emergence of artificial intelligence techniques, including so-called digital twins-eg, computer-generated replicas of the heart-is aiding the development of new strategies for enhanced risk stratification, prognostication, and individualised therapeutic targeting. Various new molecular targets and novel pharmacological strategies are being developed, including multiomics-ie, analytical methods used to integrate complex biological big data to find novel pathways to halt the progression of VHD. In addition, efforts have been undertaken to engineer heart valve tissue and provide a living valve conduit capable of growth and biological integration. Overall, these advances emphasise the importance of early detection, personalised management, and cutting-edge interventions to optimise outcomes amid the evolving landscape of VHD. Although several challenges must be overcome, these breakthroughs represent opportunities to advance patient-centred investigations.
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Affiliation(s)
- Partho P Sengupta
- Division of Cardiovascular Diseases and Hypertension, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA; Cardiovascular Services, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA.
| | - Jolanda Kluin
- Department of Cardiothoracic Surgery, Erasmus MC Rotterdam, Thorax Center, Rotterdam, Netherlands
| | - Seung-Pyo Lee
- Department of Internal Medicine, Seoul National University Hospital and Seoul National University College of Medicine, Seoul, South Korea
| | - Jae K Oh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Anthal I P M Smits
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands; Institute for Complex Molecular Systems, Eindhoven University of Technology, Eindhoven, Netherlands
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7
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Glomb C, Wilhelmi M, Strauß S, Zippusch S, Klingenberg M, Aper T, Vogt PM, Ruhparwar A, Helms F. Fabrication and biomechanical characterization of a spider silk reinforced fibrin-based vascular prosthesis. J Mech Behav Biomed Mater 2024; 152:106433. [PMID: 38316085 DOI: 10.1016/j.jmbbm.2024.106433] [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: 12/03/2023] [Revised: 01/15/2024] [Accepted: 01/25/2024] [Indexed: 02/07/2024]
Abstract
With fibrin-based vascular prostheses, vascular tissue engineering offers a promising approach for the fabrication of biologically active regenerative vascular grafts. As a potentially autologous biomaterial, fibrin exhibits excellent hemo- and biocompatibility. However, the major problem in the use of fibrin constructs in vascular tissue engineering, which has so far prevented their widespread clinical application, is the insufficient biomechanical stability of unprocessed fibrin matrices. In this proof-of-concept study, we investigated to what extent the addition of a spider silk network into the wall structure of fibrin-based vascular prostheses leads to an increase in biomechanical stability and an improvement in the biomimetic elastic behavior of the grafts. For the fabrication of hybrid prostheses composed of fibrin and spider silk, a statically cast tubular fibrin matrix was surrounded with an envelope layer of Trichonephila edulis silk using a custom built coiling machine. The fibrin matrix was then compacted and pressed into the spider silk network by transluminal balloon compression. This manufacturing process resulted in a hybrid prosthesis with a luminal diameter of 4 mm. Biomechanical characterization revealed a significant increase in biomechanical stability of spider silk reinforced grafts compared to exclusively compacted fibrin segments with a mean burst pressure of 362 ± 74 mmHg vs. 213 ± 14 mmHg (p < 0.05). Dynamic elastic behavior of the spider silk reinforced grafts was similar to native arteries. In addition, the coiling with spider silk allowed a significant increase in suture retention strength and resistance to external compression without compromising the endothelialization capacity of the grafts. Thus, spider silk reinforcement using the abluminal coiling technique represents an efficient and reproducible technique to optimize the biomechanical behavior of small-diameter fibrin-based vascular grafts.
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Affiliation(s)
- Clara Glomb
- Lower Saxony Centre for Biomedical Engineering, Implant Research and Development (NIFE), Hannover Medical School, Stadtfelddamm 34, 30625, Hannover, Germany
| | - Mathias Wilhelmi
- Lower Saxony Centre for Biomedical Engineering, Implant Research and Development (NIFE), Hannover Medical School, Stadtfelddamm 34, 30625, Hannover, Germany; Department of Vascular- and Endovascular Surgery, St. Bernward Hospital, Hildesheim, Germany
| | - Sarah Strauß
- Department of Plastic, Hand and Reconstructive Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Sarah Zippusch
- Lower Saxony Centre for Biomedical Engineering, Implant Research and Development (NIFE), Hannover Medical School, Stadtfelddamm 34, 30625, Hannover, Germany; Division for Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Melanie Klingenberg
- Lower Saxony Centre for Biomedical Engineering, Implant Research and Development (NIFE), Hannover Medical School, Stadtfelddamm 34, 30625, Hannover, Germany; Division for Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Thomas Aper
- Lower Saxony Centre for Biomedical Engineering, Implant Research and Development (NIFE), Hannover Medical School, Stadtfelddamm 34, 30625, Hannover, Germany; Division for Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Peter M Vogt
- Department of Plastic, Hand and Reconstructive Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Arjang Ruhparwar
- Lower Saxony Centre for Biomedical Engineering, Implant Research and Development (NIFE), Hannover Medical School, Stadtfelddamm 34, 30625, Hannover, Germany; Division for Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Florian Helms
- Lower Saxony Centre for Biomedical Engineering, Implant Research and Development (NIFE), Hannover Medical School, Stadtfelddamm 34, 30625, Hannover, Germany; Division for Cardiothoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Hannover, Germany.
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8
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Schmiady MO, Jashari R, Lenherr R, Regenscheit S, Hitendu D, Wendt M, Schiess S, Schweiger M, Hofmann M, Sromicki J, Flammer A, Wilhelm MJ, Cesnjevar R, Carrel T, Vogt PR, Mestres CA. How to counteract the lack of donor tissue in cardiac surgery? Initial experiences with a newly established homograft procurement program. Cell Tissue Bank 2024; 25:1-10. [PMID: 37097383 PMCID: PMC10126547 DOI: 10.1007/s10561-023-10087-z] [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: 10/17/2022] [Accepted: 03/28/2023] [Indexed: 04/26/2023]
Abstract
Homograft heart valves may have significant advantages and are preferred for the repair of congenital valve malformations, especially in young women of childbearing age, athletes and in patients with active endocarditis. A growing problem, however, is the mismatch between tissue donation and the increasing demand. The aim of this paper is to describe the initiation process of a homograft procurement program to attenuate the shortage of organs. A comprehensive description of the infrastructure and procedural steps required to initiate a cardiac and vascular tissue donation program combined with a prospective follow-up of all homografts explanted at our institution. Between January 2020 and May 2022, 28 hearts and 12 pulmonary bifurcations were harvested at our institution and delivered to the European homograft bank. Twenty-seven valves (19 pulmonary valves, 8 aortic valves) were processed and allocated for implantation. The reasons for discarding a graft were either contamination (n = 14), or morphology (n = 13) or leaflet damage (n = 2). Five homografts (3 PV, 2 AV) have been cryopreserved and stored while awaiting allocation. One pulmonary homograft with a leaflet cut was retrieved by bicuspidization technique and awaits allocation, as a highly requested small diameter graft. The implementation of a tissue donation program in cooperation with a homograft bank can be achieved with reasonable additional efforts at a transplant center with an in-house cardiac surgery department. Challenging situations with a potential risk of tissue injury during procurement include re-operation, harvesting by a non-specialist surgeon and prior central cannulation for mechanical circulatory support.
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Affiliation(s)
- Martin O Schmiady
- Clinic for Cardiac Surgery, University Heart Center, University Hospital Zurich, Rämistrasse 100, CH-8091, Zurich, Switzerland.
- Department of Congenital Cardiovascular Surgery, University Children's Hospital Zurich, Zurich, Switzerland.
- Children's Research Center, University Children's Hospital Zurich, University Zurich, Zurich, Switzerland.
| | - Ramadan Jashari
- European Homograft Bank (EHB), University Hospital St. Luc, Brussels, Belgium
| | - Renato Lenherr
- Donor Care Association, University Hospital Zurich, Zurich, Switzerland
| | | | - Dave Hitendu
- Department of Congenital Cardiovascular Surgery, University Children's Hospital Zurich, Zurich, Switzerland
- Children's Research Center, University Children's Hospital Zurich, University Zurich, Zurich, Switzerland
| | - Martin Wendt
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Zurich, Switzerland
| | - Stefanie Schiess
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Zurich, Switzerland
| | - Martin Schweiger
- Department of Congenital Cardiovascular Surgery, University Children's Hospital Zurich, Zurich, Switzerland
- Children's Research Center, University Children's Hospital Zurich, University Zurich, Zurich, Switzerland
| | - Michael Hofmann
- Clinic for Cardiac Surgery, University Heart Center, University Hospital Zurich, Rämistrasse 100, CH-8091, Zurich, Switzerland
| | - Juri Sromicki
- Clinic for Cardiac Surgery, University Heart Center, University Hospital Zurich, Rämistrasse 100, CH-8091, Zurich, Switzerland
| | - Andreas Flammer
- Clinic for Cardiology, University Heart Centre, University Hospital Zurich, Zurich, Switzerland
| | - Markus J Wilhelm
- Clinic for Cardiac Surgery, University Heart Center, University Hospital Zurich, Rämistrasse 100, CH-8091, Zurich, Switzerland
| | - Robert Cesnjevar
- Department of Congenital Cardiovascular Surgery, University Children's Hospital Zurich, Zurich, Switzerland
- Children's Research Center, University Children's Hospital Zurich, University Zurich, Zurich, Switzerland
| | - Thierry Carrel
- Clinic for Cardiac Surgery, University Heart Center, University Hospital Zurich, Rämistrasse 100, CH-8091, Zurich, Switzerland
| | - Paul R Vogt
- Clinic for Cardiac Surgery, University Heart Center, University Hospital Zurich, Rämistrasse 100, CH-8091, Zurich, Switzerland
| | - Carlos A Mestres
- Clinic for Cardiac Surgery, University Heart Center, University Hospital Zurich, Rämistrasse 100, CH-8091, Zurich, Switzerland
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9
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Bobylev D, Horke A, Avsar M, Cvitkovic T, Boethig D, Hazekamp M, Meyns B, Rega F, Dave H, Schmiady M, Ciubotaru A, Cheptanaru E, Vida V, Padalino M, Tsang V, Jashari R, Laufer G, Andreas M, Andreeva A, Tudorache I, Cebotari S, Haverich A, Sarikouch S. Matched comparison of decellularized homografts and bovine jugular vein conduits for pulmonary valve replacement in congenital heart disease. Cell Tissue Bank 2024; 25:55-66. [PMID: 36917328 PMCID: PMC10901942 DOI: 10.1007/s10561-023-10082-4] [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: 10/13/2022] [Accepted: 02/23/2023] [Indexed: 03/16/2023]
Abstract
For decades, bovine jugular vein conduits (BJV) and classic cryopreserved homografts have been the two most widely used options for pulmonary valve replacement (PVR) in congenital heart disease. More recently, decellularized pulmonary homografts (DPH) have provided an alternative avenue for PVR. Matched comparison of patients who received DPH for PVR with patients who received bovine jugular vein conduits (BJV) considering patient age group, type of heart defect, and previous procedures. 319 DPH patients were matched to 319 BJV patients; the mean age of BJV patients was 15.3 (SD 9.5) years versus 19.1 (12.4) years in DPH patients (p = 0.001). The mean conduit diameter was 24.5 (3.5) mm for DPH and 20.3 (2.5) mm for BJV (p < 0.001). There was no difference in survival rates between the two groups after 10 years (97.0 vs. 98.1%, p = 0.45). The rate of freedom from endocarditis was significantly lower for BJV patients (87.1 vs. 96.5%, p = 0.006). Freedom from explantation was significantly lower for BJV at 10 years (81.7 vs. 95.5%, p = 0.001) as well as freedom from any significant degeneration at 10 years (39.6 vs. 65.4%, p < 0.001). 140 Patients, matched for age, heart defect type, prior procedures, and conduit sizes of 20-22 mm (± 2 mm), were compared separately; mean age BJV 8.7 (4.9) and DPH 9.5 (7.3) years (p = n.s.). DPH showed 20% higher freedom from explantation and degeneration in this subgroup (p = 0.232). Decellularized pulmonary homografts exhibit superior 10-year results to bovine jugular vein conduits in PVR.
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Affiliation(s)
- Dmitry Bobylev
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Alexander Horke
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Murat Avsar
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Tomislav Cvitkovic
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Dietmar Boethig
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Mark Hazekamp
- Department of Congenital Cardiac Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Bart Meyns
- Department of Cardiac Surgery, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Filip Rega
- Department of Cardiac Surgery, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Hitendu Dave
- Division of Congenital Cardiovascular Surgery, University Children's Hospital, Zurich, Switzerland
| | - Martin Schmiady
- Division of Congenital Cardiovascular Surgery, University Children's Hospital, Zurich, Switzerland
- Cardiac Surgery Center, State Medical and Pharmaceutical University, Chisinau, Moldova
| | - Anatol Ciubotaru
- Cardiac Surgery Center, State Medical and Pharmaceutical University, Chisinau, Moldova
| | - Eduard Cheptanaru
- Cardiac Surgery Center, State Medical and Pharmaceutical University, Chisinau, Moldova
| | - Vladimiro Vida
- Pediatric and Congenital Cardiac Surgery Unit, Azienda Ospedaliera di Padova, University of Padua Medical School, Padua, Italy
| | - Massimo Padalino
- Pediatric and Congenital Cardiac Surgery Unit, Azienda Ospedaliera di Padova, University of Padua Medical School, Padua, Italy
| | - Victor Tsang
- Department of Cardiothoracic Surgery, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Ramadan Jashari
- European Homograft Bank, Clinique Saint-Jean, Brussels, Belgium
| | - Günther Laufer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Martin Andreas
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Alexandra Andreeva
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Igor Tudorache
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Serghei Cebotari
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Samir Sarikouch
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany.
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10
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Lux M, Haller R, Giere B, Lindner B, Harder M, Mastrobuoni S, Jashari R. Advantages and challenges in processing and quality control of decellularized heart valves. Cell Tissue Bank 2024; 25:43-53. [PMID: 37138137 DOI: 10.1007/s10561-023-10092-2] [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: 10/18/2022] [Accepted: 04/12/2023] [Indexed: 05/05/2023]
Abstract
More than 1000 donated aortic and pulmonary valves from predominantly European tissue banks were centrally decellularized and delivered to hospitals in Europe and Japan. Here, we report on the processing and quality controls before, during and after the decellularization of these allografts. Our experiences show that all tissue establishments, which provide native cardiovascular allografts for decellularization, meet comparably high-quality standards, regardless of their national origin. A total of 84% of all received allografts could be released as cell-free allografts. By far the most frequent reasons for rejection were non-release of the donor by the tissue establishment or severe contaminations of the native tissue donation. Only in 2% of all cases the specification for freedom from cells was not fulfilled, indicating that decellularization of human heart valves is a safe process with a very low discard ratio. In clinical use, cell-free cardiovascular allografts have been shown to be advantageous over conventional heart valve replacements, at least in young adults. These results open the discussion on the future gold standard and funding of this innovative therapeutic option for heart valve replacement.
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Affiliation(s)
- Marco Lux
- Corlife oHG, Feodor-Lynen-Str. 23, 30625, Hannover, Germany.
| | - Ralf Haller
- Corlife oHG, Feodor-Lynen-Str. 23, 30625, Hannover, Germany
| | - Bettina Giere
- Corlife oHG, Feodor-Lynen-Str. 23, 30625, Hannover, Germany
| | - Bianca Lindner
- Corlife oHG, Feodor-Lynen-Str. 23, 30625, Hannover, Germany
| | - Michael Harder
- Corlife oHG, Feodor-Lynen-Str. 23, 30625, Hannover, Germany
| | - Stefano Mastrobuoni
- Cliniques Universitaires Saint-Luc, European Homograft Bank, Brussels, Belgium
| | - Ramadan Jashari
- Cliniques Universitaires Saint-Luc, European Homograft Bank, Brussels, Belgium
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11
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Andreeva A, Coti I, Werner P, Scherzer S, Kocher A, Laufer G, Andreas M. Aortic Valve Replacement in Adult Patients with Decellularized Homografts: A Single-Center Experience. J Clin Med 2023; 12:6713. [PMID: 37959179 PMCID: PMC10650916 DOI: 10.3390/jcm12216713] [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: 09/01/2023] [Revised: 10/16/2023] [Accepted: 10/17/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND decellularized aortic homografts (DAH) represent a promising alternative for aortic valve replacement in young adults due to their low immunogenicity and thrombogenicity. Herein, we report our midterm, single-center experience in adult patients with non-frozen DAH from corlife. METHODS safety, durability, and hemodynamic performance were evaluated according to current guidelines in all consecutive patients who had received a DAH at our center since 03/2016. RESULTS seventy-three (mean age 47 ± 11 years, 68.4% (n = 50) male) patients were enrolled. The mean diameter of the implanted DAH was 24 ± 2 mm. Mean follow-up was 36 ± 27 months, with a maximum follow-up of 85 months and cumulative follow-up of 215 years. No cases of stenosis were observed, in four (5.5%) cases moderate aortic regurgitation occurred, but no reintervention was required. No cases of early mortality, non-structural dysfunction, reoperation, valve endocarditis, or thrombosis were observed. Freedom from bleeding and thromboembolic events was 100%; freedom from re-intervention was 100%; survival was 98.6% (n = 72). CONCLUSIONS early and mid-term results showed low mortality and 100% freedom from reoperation, thromboembolic events, and bleeding at our center. However, in order for this novel approach to be established as a valid alternative to aortic valve replacement in young patients, long-term data are required.
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Affiliation(s)
- Alexandra Andreeva
- Department of Cardiac Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria; (I.C.); (P.W.); (S.S.); (A.K.); (G.L.); (M.A.)
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12
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Oripov F, Ramm R, Falk C, Goecke T, Ebken J, Jashari R, Böthig D, Horke A, Avsar M, Bobylev D, Haverich A, Hilfiker A, Sarikouch S. Serial assessment of early antibody binding to decellularized valved allografts. Front Cardiovasc Med 2022; 9:895943. [PMID: 36017105 PMCID: PMC9395941 DOI: 10.3389/fcvm.2022.895943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 07/13/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectivesDecellularized homograft valves (DHV) appear to elicit an immune response despite efficient donor cell removal.Materials and methodsA semiquantitative Dot-Blot analysis for preformed and new recipient antibodies was carried out in 20 patients following DHV implantation on days 0, 1, 7, and 28 using secondary antihuman antibodies. Immune reactions were tested against the implanted DHV as well as against the stored samples of 5 non-implanted decellularized aortic (DAH) and 6 pulmonary homografts (DPH).ResultsIn this study, 20 patients (3 female and 17 male patients) were prospectively included, with a median age of 18 years and an IQR of 12–30 years. Six patients received DPH and 14 received DAH. The amount of antibody binding, averaged for all patients, decreased on post-operative days 1 and 7 compared to pre-operative values; and on day 28, antibody binding reached close to pre-operative levels (16.8 ± 2.5 on day 0, 3.7 ± 1.9 on day 1, 2.3 ± 2.7 on day 7, and 13.2 ± 3.7 on day 28). In comparison with the results in healthy controls, there was a higher amount of antibody binding to DAH than to DPH. The mean number of arbitrary units was 18.4 ± 3.1 in aortic and 12.9 ± 4.5 in pulmonary DHV (p = 0.140). Male patients exhibited higher antibody binding to aortic DHV than female patients (19.5 ± 2.1 vs. 1.6 ± 6.7). The p-value calculation was limited, as only two female patients received DAH. There was no correlation between the amount of overall antibody binding to DHV with respect to donor age (Kruskal–Wallis test p = 0.550). DHV recipients with a sex mismatch to the donor showed significantly less antibody binding (6.5 ± 1.8 vs. 13.7 ± 1.8; p = 0.003). Our main finding was an increase in antibody binding in younger patients receiving decellularized aortic allografts. This increase was higher in patients with early degeneration signs but was not specific to the individual DHV implanted nor previous DHV implantation. Antibody binding toward explanted DHV was significantly increased in implicating antibody-mediated DHV degeneration.ConclusionSerial assessment of tissue-specific antibody binding revealed an increase in some patients within 4 weeks after surgery, who subsequently developed early signs of allograft degeneration. Further studies with larger sample sizes are needed to confirm the prognostic relevance of increased antibody activity in addition to targeted research efforts to identify the molecular agents triggering this type of antibody response.
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Affiliation(s)
- Firdavs Oripov
- Leibniz Research Laboratories for Biotechnology and Artificial Organs (LEBAO), Hannover Medical School, Hanover, Germany
| | - Robert Ramm
- Leibniz Research Laboratories for Biotechnology and Artificial Organs (LEBAO), Hannover Medical School, Hanover, Germany
| | - Christine Falk
- Institute of Transplant Immunology, Hannover Medical School, Hanover, Germany
| | - Tobias Goecke
- Institute of Transplant Immunology, Hannover Medical School, Hanover, Germany
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hanover, Germany
| | - Johannes Ebken
- Leibniz Research Laboratories for Biotechnology and Artificial Organs (LEBAO), Hannover Medical School, Hanover, Germany
| | - Ramadan Jashari
- European Homograft Bank, Clinique Saint-Jean, Brussels, Belgium
| | - Dietmar Böthig
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hanover, Germany
| | - Alexander Horke
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hanover, Germany
| | - Murat Avsar
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hanover, Germany
| | - Dmitry Bobylev
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hanover, Germany
| | - Axel Haverich
- Leibniz Research Laboratories for Biotechnology and Artificial Organs (LEBAO), Hannover Medical School, Hanover, Germany
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hanover, Germany
| | - Andres Hilfiker
- Leibniz Research Laboratories for Biotechnology and Artificial Organs (LEBAO), Hannover Medical School, Hanover, Germany
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hanover, Germany
| | - Samir Sarikouch
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hanover, Germany
- *Correspondence: Samir Sarikouch,
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13
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Strategies for development of decellularized heart valve scaffolds for tissue engineering. Biomaterials 2022; 288:121675. [DOI: 10.1016/j.biomaterials.2022.121675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 07/02/2022] [Accepted: 07/06/2022] [Indexed: 01/01/2023]
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