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Reichart B, Cooper DKC, Längin M, Tönjes RR, Pierson RN, Wolf E. Cardiac xenotransplantation: from concept to clinic. Cardiovasc Res 2023; 118:3499-3516. [PMID: 36461918 PMCID: PMC9897693 DOI: 10.1093/cvr/cvac180] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 10/17/2022] [Accepted: 10/21/2022] [Indexed: 12/05/2022] Open
Abstract
For many patients with terminal/advanced cardiac failure, heart transplantation is the most effective, durable treatment option, and offers the best prospects for a high quality of life. The number of potentially life-saving donated human organs is far fewer than the population who could benefit from a new heart, resulting in increasing numbers of patients awaiting replacement of their failing heart, high waitlist mortality, and frequent reliance on interim mechanical support for many of those deemed among the best candidates but who are deteriorating as they wait. Currently, mechanical assist devices supporting left ventricular or biventricular heart function are the only alternative to heart transplant that is in clinical use. Unfortunately, the complication rate with mechanical assistance remains high despite advances in device design and patient selection and management, and the quality of life of the patients even with good outcomes is only moderately improved. Cardiac xenotransplantation from genetically multi-modified (GM) organ-source pigs is an emerging new option as demonstrated by the consistent long-term success of heterotopic (non-life-supporting) abdominal and life-supporting orthotopic porcine heart transplantation in baboons, and by a recent 'compassionate use' transplant of the heart from a GM pig with 10 modifications into a terminally ill patient who survived for 2 months. In this review, we discuss pig heart xenotransplantation as a concept, including pathobiological aspects related to immune rejection, coagulation dysregulation, and detrimental overgrowth of the heart, as well as GM strategies in pigs to prevent or minimize these problems. Additional topics discussed include relevant results of heterotopic and orthotopic heart transplantation experiments in the pig-to-baboon model, microbiological and virologic safety concepts, and efficacy requirements for initiating formal clinical trials. An adequate regulatory and ethical framework as well as stringent criteria for the selection of patients will be critical for the safe clinical development of cardiac xenotransplantation, which we expect will be clinically tested during the next few years.
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Affiliation(s)
- Bruno Reichart
- Walter Brendel Centre for Experimental Medicine, Ludwig-Maximilians-Universität München, Munich 81377, Germany
| | - David K C Cooper
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MA 02129, USA
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA 02114, USA
| | - Matthias Längin
- Department of Anaesthesiology, University Hospital, Ludwig-Maximilians-Universität München, Munich 81377, Germany
| | - Ralf R Tönjes
- Division of Medical Biotechnology, Paul-Ehrlich-Institute, Langen 63225, Germany
| | - Richard N Pierson
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MA 02129, USA
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA 02114, USA
| | - Eckhard Wolf
- Gene Centre and Centre for Innovative Medical Models (CiMM), Ludwig-Maximilians-Universität München, Munich 81377, Germany
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Hansen-Estruch C, Porrett PM, Kumar V, Locke JE. The science of xenotransplantation for nephrologists. Curr Opin Nephrol Hypertens 2022; 31:387-393. [PMID: 35703221 DOI: 10.1097/mnh.0000000000000800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
PURPOSE OF REVIEW The field of xenotransplantation has seen remarkable progress since its inception with recent preclinical trials in human recipients pushing kidney xenotransplantation one-step closer to clinical reality. In this review, we update practicing clinicians on recent advances in kidney xenotransplantation given the proximity of clinical trials in humans. RECENT FINDINGS Early studies in the field established the physiologic basis of xenotransplantation and suggested that the pig kidney will support human physiology. Genetic engineering of source pigs has greatly reduced the immunogenicity of kidney grafts, and studies in nonhuman primates have demonstrated the viability of kidney xenotransplants for months after transplantation. Finally, a recent study in a novel preclinical human model demonstrated that key findings in NHP experiments are generalizable to humans, namely, the absence of hyperacute rejection. SUMMARY Overall, it appears that critical physiologic, immunologic and technical barriers to implementation of clinical trials in humans have been overcome.
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Affiliation(s)
| | - Paige M Porrett
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Vineeta Kumar
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jayme E Locke
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Hansen-Estruch C, Cooper DK, Judd E. Physiological aspects of pig kidney xenotransplantation and implications for management following transplant. Xenotransplantation 2022; 29:e12743. [PMID: 35297098 PMCID: PMC9232961 DOI: 10.1111/xen.12743] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 02/19/2022] [Accepted: 03/03/2022] [Indexed: 12/16/2022]
Abstract
Successful organ transplantation between species is now possible, using genetic modifications. This article aims to provide a comprehensive overview of the differences and similarities in kidney function between humans, primates, and pigs, in preparation for pig-allograft to human xenotransplantation. The kidney, as the principal defender of body homeostasis, acts as a sensor, effector, and regulator of physiologic feedback systems. Considerations are made for anticipated effects on each system when a pig kidney is placed into a human recipient. Discussion topics include anatomy, global kidney function, sodium and water handling, kidney hormone production and response to circulating hormones, acid-base balance, and calcium and phosphorus handling. Based on available data, pig kidneys are anticipated to be compatible with human physiology, despite a few barriers.
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Affiliation(s)
- Christophe Hansen-Estruch
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David K.C. Cooper
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Eric Judd
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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Ross CJ, Zheng J, Ma L, Wu Y, Lee CH. Mechanics and Microstructure of the Atrioventricular Heart Valve Chordae Tendineae: A Review. Bioengineering (Basel) 2020; 7:E25. [PMID: 32178262 PMCID: PMC7148526 DOI: 10.3390/bioengineering7010025] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 03/09/2020] [Accepted: 03/10/2020] [Indexed: 11/16/2022] Open
Abstract
The atrioventricular heart valves (AHVs) are responsible for directing unidirectional blood flow through the heart by properly opening and closing the valve leaflets, which are supported in their function by the chordae tendineae and the papillary muscles. Specifically, the chordae tendineae are critical to distributing forces during systolic closure from the leaflets to the papillary muscles, preventing leaflet prolapse and consequent regurgitation. Current therapies for chordae failure have issues of disease recurrence or suboptimal treatment outcomes. To improve those therapies, researchers have sought to better understand the mechanics and microstructure of the chordae tendineae of the AHVs. The intricate structures of the chordae tendineae have become of increasing interest in recent literature, and there are several key findings that have not been comprehensively summarized in one review. Therefore, in this review paper, we will provide a summary of the current state of biomechanical and microstructural characterizations of the chordae tendineae, and also discuss perspectives for future studies that will aid in a better understanding of the tissue mechanics-microstructure linking of the AHVs' chordae tendineae, and thereby improve the therapeutics for heart valve diseases caused by chordae failures.
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Affiliation(s)
- Colton J. Ross
- Biomechanics and Biomaterials Design Laboratory, School of Aerospace and Mechanical Engineering, The University of Oklahoma, Norman, OK 73019, USA; (C.J.R.); (Y.W.)
| | - Junnan Zheng
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Zhejiang University, Hangzhou 310058, China; (J.Z.); (L.M.)
| | - Liang Ma
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Zhejiang University, Hangzhou 310058, China; (J.Z.); (L.M.)
| | - Yi Wu
- Biomechanics and Biomaterials Design Laboratory, School of Aerospace and Mechanical Engineering, The University of Oklahoma, Norman, OK 73019, USA; (C.J.R.); (Y.W.)
| | - Chung-Hao Lee
- Biomechanics and Biomaterials Design Laboratory, School of Aerospace and Mechanical Engineering, The University of Oklahoma, Norman, OK 73019, USA; (C.J.R.); (Y.W.)
- Institute for Biomedical Engineering, Science and Technology (IBEST), The University of Oklahoma, Norman, OK 73019, USA
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Längin M, Konrad M, Reichart B, Mayr T, Vandewiele S, Postrach J, Mokelke M, Radan J, Brenner P, Bauer A, Abicht J. Hemodynamic evaluation of anesthetized baboons and piglets by transpulmonary thermodilution: Normal values and interspecies differences with respect to xenotransplantation. Xenotransplantation 2019; 27:e12576. [DOI: 10.1111/xen.12576] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 11/04/2019] [Accepted: 11/29/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Matthias Längin
- Department of Anaesthesiology University Hospital LMU Munich Munich Germany
| | | | - Bruno Reichart
- Transregional Collaborative Research Center 127 Walter Brendel Centre of Experimental Medicine LMU Munich Munich Germany
| | - Tanja Mayr
- Department of Anaesthesiology University Hospital LMU Munich Munich Germany
| | - Stephanie Vandewiele
- Transregional Collaborative Research Center 127 Walter Brendel Centre of Experimental Medicine LMU Munich Munich Germany
- Dr. von Haunersches Kinderspital Kinderklinik und Kinderpoliklinik der LMU München Munich Germany
| | - Johannes Postrach
- Transregional Collaborative Research Center 127 Walter Brendel Centre of Experimental Medicine LMU Munich Munich Germany
- Privatklinik Dr. Robert Schindlbeck GmbH &Co KG Department of Medicine Herrsching am Ammersee Germany
| | - Maren Mokelke
- Transregional Collaborative Research Center 127 Walter Brendel Centre of Experimental Medicine LMU Munich Munich Germany
| | - Julia Radan
- Transregional Collaborative Research Center 127 Walter Brendel Centre of Experimental Medicine LMU Munich Munich Germany
| | - Paolo Brenner
- Department of Cardiac Surgery University Hospital LMU Munich Munich Germany
| | - Andreas Bauer
- Department of Anaesthesiology and Intensive Care RoMed Klinikum Rosenheim Rosenheim Germany
| | - Jan‐Michael Abicht
- Department of Anaesthesiology University Hospital LMU Munich Munich Germany
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Abstract
Duchenne muscular dystrophy is a progressive, fatal, X-linked disease caused by a failure to accumulate the cytoskeletal protein dystrophin. This disease has been studied using a variety of animal models including fish, mice, rats, and dogs. While these models have contributed substantially to our mechanistic understanding of the disease and disease progression, limitations inherent to each model have slowed the clinical advancement of therapies, which necessitates the development of novel large-animal models. Several porcine dystrophin-deficient models have been identified, although disease severity may be so severe as to limit their potential contributions to the field. We have recently identified and completed the initial characterization of a natural porcine model of dystrophin insufficiency. Muscles from these animals display characteristic focal necrosis concomitant with decreased abundance and localization of dystrophin-glycoprotein complex components. These pigs recapitulate many of the cardinal features of muscular dystrophy, have elevated serum creatine kinase activity, and preliminarily appear to display altered locomotion. They also suffer from sudden death preceded by EKG abnormalities. Pig dystrophinopathy models could allow refinement of dosing strategies in human-sized animals in preparation for clinical trials. From an animal handling perspective, these pigs can generally be treated normally, with the understanding that acute stress can lead to sudden death. In summary, the ability to create genetically modified pig models and the serendipitous discovery of genetic disease in the swine industry has resulted in the emergence of new animal tools to facilitate the critical objective of improving the quality and length of life for boys afflicted with such a devastating disease.
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Affiliation(s)
- Joshua T Selsby
- Joshua T. Selsby, PhD, and Jason W. Ross, PhD are associate professors of Animal Science at Iowa State University, Ames, IA 50011. Dan Nonneman, PhD, is a research molecular biologist at the USDA, ARS, U.S. Meat Animal Research Center, Clay Center, NE 68933. Katrin Hollinger, PhD, was a graduate student in Genetics at Iowa State University, Ames, IA 50011
| | - Jason W Ross
- Joshua T. Selsby, PhD, and Jason W. Ross, PhD are associate professors of Animal Science at Iowa State University, Ames, IA 50011. Dan Nonneman, PhD, is a research molecular biologist at the USDA, ARS, U.S. Meat Animal Research Center, Clay Center, NE 68933. Katrin Hollinger, PhD, was a graduate student in Genetics at Iowa State University, Ames, IA 50011
| | - Dan Nonneman
- Joshua T. Selsby, PhD, and Jason W. Ross, PhD are associate professors of Animal Science at Iowa State University, Ames, IA 50011. Dan Nonneman, PhD, is a research molecular biologist at the USDA, ARS, U.S. Meat Animal Research Center, Clay Center, NE 68933. Katrin Hollinger, PhD, was a graduate student in Genetics at Iowa State University, Ames, IA 50011
| | - Katrin Hollinger
- Joshua T. Selsby, PhD, and Jason W. Ross, PhD are associate professors of Animal Science at Iowa State University, Ames, IA 50011. Dan Nonneman, PhD, is a research molecular biologist at the USDA, ARS, U.S. Meat Animal Research Center, Clay Center, NE 68933. Katrin Hollinger, PhD, was a graduate student in Genetics at Iowa State University, Ames, IA 50011
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Gallo M, Naso F, Poser H, Rossi A, Franci P, Bianco R, Micciolo M, Zanella F, Cucchini U, Aresu L, Buratto E, Busetto R, Spina M, Gandaglia A, Gerosa G. Physiological performance of a detergent decellularized heart valve implanted for 15 months in Vietnamese pigs: surgical procedure, follow-up, and explant inspection. Artif Organs 2012; 36:E138-50. [PMID: 22512408 DOI: 10.1111/j.1525-1594.2012.01447.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
This study features the longest experimental follow-up for decellularized heart valves implanted in an animal model. Porcine aortic heart valves were decellularized according to a disclosed standardized method in which TRITON X-100 and sodium cholate (TRICOL) are used in succession, followed by a further treatment with the endonuclease Benzonase to completely remove the nucleic acid remnants. Experimental animals (n = 17), represented by Vietnamese pigs (VPs), received a decellularized aortic allograft as a substitute for the replacement of their right ventricular outflow tract. The surgical implantation of the TRICOL-treated aortic valve conduit was successful in 11 VPs, while perioperative or postoperative complications occurred in the remaining six animals. In the sham-operated group (n = 4), the native pulmonary root was excised and immediately reimplanted orthotopically in the same animal. Echocardiography demonstrated a satisfactory hemodynamic performance of the TRICOL-treated valves during follow-up as well as the absence of relevant leaflet alterations concerning thickness and motility or valve insufficiency. At explantation, macroscopic inspection of tissue-engineered heart valve conduits did not evidence calcifications and showed a decreased wall thickness, comparable to that of the reimplanted native pulmonary roots. Noteworthy, extended functional performance, recovery of DNA content, and active extracellular matrix precursor incorporation are apparently compatible with the properties of a living self-supporting substitute.
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Affiliation(s)
- Michele Gallo
- Department of Cardiac, Thoracic, and Vascular Science, University of Padova, 2 via Giustiniani, Padua, Italy
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Denner J, Tönjes RR. Infection barriers to successful xenotransplantation focusing on porcine endogenous retroviruses. Clin Microbiol Rev 2012; 25:318-43. [PMID: 22491774 PMCID: PMC3346299 DOI: 10.1128/cmr.05011-11] [Citation(s) in RCA: 136] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Xenotransplantation may be a solution to overcome the shortage of organs for the treatment of patients with organ failure, but it may be associated with the transmission of porcine microorganisms and the development of xenozoonoses. Whereas most microorganisms may be eliminated by pathogen-free breeding of the donor animals, porcine endogenous retroviruses (PERVs) cannot be eliminated, since these are integrated into the genomes of all pigs. Human-tropic PERV-A and -B are present in all pigs and are able to infect human cells. Infection of ecotropic PERV-C is limited to pig cells. PERVs may adapt to host cells by varying the number of LTR-binding transcription factor binding sites. Like all retroviruses, they may induce tumors and/or immunodeficiencies. To date, all experimental, preclinical, and clinical xenotransplantations using pig cells, tissues, and organs have not shown transmission of PERV. Highly sensitive and specific methods have been developed to analyze the PERV status of donor pigs and to monitor recipients for PERV infection. Strategies have been developed to prevent PERV transmission, including selection of PERV-C-negative, low-producer pigs, generation of an effective vaccine, selection of effective antiretrovirals, and generation of animals transgenic for a PERV-specific short hairpin RNA inhibiting PERV expression by RNA interference.
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Verma N, Rettenmeier AW, Schmitz-Spanke S. Recent advances in the use of Sus scrofa
(pig) as a model system for proteomic studies. Proteomics 2011; 11:776-93. [DOI: 10.1002/pmic.201000320] [Citation(s) in RCA: 130] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2010] [Revised: 08/30/2010] [Accepted: 09/06/2010] [Indexed: 12/11/2022]
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Vongvatcharanon S, Vongvatcharanon U, Boonyoung P. Immunohistochemical localization of parvalbumin calcium-binding protein in the heart tissues of various species. Acta Histochem 2007; 110:26-33. [PMID: 17706751 DOI: 10.1016/j.acthis.2007.05.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2007] [Revised: 05/16/2007] [Accepted: 05/22/2007] [Indexed: 11/17/2022]
Abstract
Parvalbumin (PV), a cytoplasmic high-affinity Ca(2+)-binding protein, was recently identified in rat heart tissue and has been implicated in mediating relaxation in cardiac myocytes. The presence of PV in the heart of mouse, chicken, rabbit and pig was studied using immunohistochemistry. PV immunoreactivity (PV-ir) was identified in the heart of all four species. All cardiac myocytes of each species had an identical pattern of PV-ir in their cytoplasm. The highest intensity of PV-ir was observed in mouse and chicken cardiac myocytes. The intensity of PV-ir was lower in rabbit cardiac myocytes and lowest in pig cardiac myocytes compared to those of chicken and mouse. PV-ir was observed in the walls of all four cardiac chambers (left and right atria and left and right ventricles), with the left ventricle, in general, having the highest labeling intensity. The intensity of PV-ir may be correlated with the physical activity of the heart of each species. Some potential applications of these data for treatment of human diastolic heart dysfunctions are discussed.
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Affiliation(s)
- Surapong Vongvatcharanon
- Department of Oral Surgery, Anesthesiology Section, Faculty of Dentistry, Prince of Songkla University, Hat-Yai 90112, Thailand.
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Ibrahim Z, Busch J, Awwad M, Wagner R, Wells K, Cooper DKC. Selected physiologic compatibilities and incompatibilities between human and porcine organ systems. Xenotransplantation 2006; 13:488-99. [PMID: 17059572 DOI: 10.1111/j.1399-3089.2006.00346.x] [Citation(s) in RCA: 144] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The shortage of donor organs is a major barrier to clinical organ transplantation. Although xenotransplantation is considered one of the alternatives to human organ transplantation, there are immunologic and physiologic incompatibilities between humans and pigs. With the exception of coagulation, the major potential physiologic incompatibilities relating to function of the kidney, heart, liver, lungs, pancreatic islets, and hormones are reviewed. Some of these physiologic differences can be overcome by producing genetically altered pigs to improve compatibility with humans. The possibility of producing such pigs for organ transplantation is considered.
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Affiliation(s)
- Zuhaib Ibrahim
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA 15261, USA
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