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Haron NA, Ishak MF, Yazid MD, Vijakumaran U, Ibrahim R, Raja Sabudin RZA, Alauddin H, Md Ali NA, Haron H, Ismail MI, Abdul Rahman MR, Sulaiman N. Exploring the Potential of Saphenous Vein Grafts Ex Vivo: A Model for Intimal Hyperplasia and Re-Endothelialization. J Clin Med 2024; 13:4774. [PMID: 39200916 PMCID: PMC11355503 DOI: 10.3390/jcm13164774] [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: 06/20/2024] [Revised: 07/31/2024] [Accepted: 08/10/2024] [Indexed: 09/02/2024] Open
Abstract
Coronary artery bypass grafting (CABG) utilizing saphenous vein grafts (SVGs) stands as a fundamental approach to surgically treating coronary artery disease. However, the long-term success of CABG is often compromised by the development of intimal hyperplasia (IH) and subsequent graft failure. Understanding the mechanisms underlying this pathophysiology is crucial for improving graft patency and patient outcomes. Objectives: This study aims to explore the potential of an ex vivo model utilizing SVG to investigate IH and re-endothelialization. Methods: A thorough histological examination of 15 surplus SVG procured from CABG procedures at Hospital Canselor Tuanku Muhriz, Malaysia, was conducted to establish their baseline characteristics. Results: SVGs exhibited a mean diameter of 2.65 ± 0.93 mm with pre-existing IH averaging 0.42 ± 0.13 mm in thickness, alongside an observable lack of luminal endothelial cell lining. Analysis of extracellular matrix components, including collagen, elastin, and glycosaminoglycans, at baseline and after 7 days of ex vivo culture revealed no significant changes in collagen but demonstrated increased percentages of elastin and glycosaminoglycans. Despite unsuccessful attempts at re-endothelialization with blood outgrowth endothelial cells, the established ex vivo SVG IH model underscores the multifaceted nature of graft functionality and patency, characterized by IH presence, endothelial impairment, and extracellular matrix alterations post-CABG. Conclusions: The optimized ex vivo IH model provides a valuable platform for delving into the underlying mechanisms of IH formation and re-endothelialization of SVG. Further refinements are warranted, yet this model holds promise for future research aimed at enhancing graft durability and outcomes for CAD patients undergoing CABG.
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Affiliation(s)
- Nur A’tiqah Haron
- Centre for Tissue Engineering and Regenerative Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur 56000, Malaysia (U.V.)
| | - Mohamad Fikeri Ishak
- Centre for Tissue Engineering and Regenerative Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur 56000, Malaysia (U.V.)
| | - Muhammad Dain Yazid
- Centre for Tissue Engineering and Regenerative Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur 56000, Malaysia (U.V.)
| | - Ubashini Vijakumaran
- Centre for Tissue Engineering and Regenerative Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur 56000, Malaysia (U.V.)
| | - Roszita Ibrahim
- Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur 56000, Malaysia
| | - Raja Zahratul Azma Raja Sabudin
- Department of Pathology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur 56000, Malaysia
- Department of Diagnostic Laboratory Services, Hospital Canselor Tuanku Muhriz, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur 56000, Malaysia
| | - Hafiza Alauddin
- Department of Pathology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur 56000, Malaysia
- Department of Diagnostic Laboratory Services, Hospital Canselor Tuanku Muhriz, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur 56000, Malaysia
| | - Nur Ayub Md Ali
- Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur 56000, Malaysia
- Heart and Lung Centre, Hospital Canselor Tuanku Muhriz, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur 56000, Malaysia
| | - Hairulfaizi Haron
- Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur 56000, Malaysia
- Heart and Lung Centre, Hospital Canselor Tuanku Muhriz, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur 56000, Malaysia
| | - Muhammad Ishamuddin Ismail
- Heart and Lung Centre, Hospital Canselor Tuanku Muhriz, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur 56000, Malaysia
| | - Mohd Ramzisham Abdul Rahman
- Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur 56000, Malaysia
- Heart and Lung Centre, Hospital Canselor Tuanku Muhriz, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur 56000, Malaysia
| | - Nadiah Sulaiman
- Centre for Tissue Engineering and Regenerative Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur 56000, Malaysia (U.V.)
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Azman SS, Yazid MD, Abdul Ghani NA, Raja Sabudin RZA, Abdul Rahman MR, Sulaiman N. Generation of a novel ex-vivo model to study re-endothelialization. ARTIFICIAL CELLS, NANOMEDICINE, AND BIOTECHNOLOGY 2023; 51:408-416. [PMID: 37584645 DOI: 10.1080/21691401.2023.2245456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/31/2023] [Accepted: 08/02/2023] [Indexed: 08/17/2023]
Abstract
Endothelial dysfunction initiates the pathogenesis of a myriad of cardiovascular diseases, yet the precise underlying mechanisms remain unclear. Current model utilises mechanical denudation of arteries resulting in an arterial-injury model with onset of intimal hyperplasia (IH). Our study shows that 5 min enzymatic denudation of human umbilical artery (hUA) lumen at 37 °C efficiently denudes hUA while maintaining vessel integrity without significantly increase intima-media thickness after 7 days in culture. This ex-vivo model will be a valuable tool in understanding the mechanism of re-endothelialization prior to smooth muscle cells (SMC) activation thus placating IH at an early stage.
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Affiliation(s)
- Siti Sarah Azman
- Centre for Tissue Engineering and Regenerative Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Malaysia
- Faculty of Applied Sciences, Universiti Teknologi MARA, Perak Branch, Tapah Campus, Perak, Malaysia
| | - Muhammad Dain Yazid
- Centre for Tissue Engineering and Regenerative Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Malaysia
| | - Nur Azurah Abdul Ghani
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Malaysia
- Hospital Canselor Tuanku Mukhriz, Jalan Yaacob Latif, Bandar Tun Razak, Cheras, Kuala Lumpur, Malaysia
| | - Raja Zahratul Azma Raja Sabudin
- Hospital Canselor Tuanku Mukhriz, Jalan Yaacob Latif, Bandar Tun Razak, Cheras, Kuala Lumpur, Malaysia
- Department of Pathology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Malaysia
| | - Mohd Ramzisham Abdul Rahman
- Hospital Canselor Tuanku Mukhriz, Jalan Yaacob Latif, Bandar Tun Razak, Cheras, Kuala Lumpur, Malaysia
- Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Malaysia
| | - Nadiah Sulaiman
- Centre for Tissue Engineering and Regenerative Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Malaysia
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3
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Yeo M, Sarkar A, Singh YP, Derman ID, Datta P, Ozbolat IT. Synergistic coupling between 3D bioprinting and vascularization strategies. Biofabrication 2023; 16:012003. [PMID: 37944186 PMCID: PMC10658349 DOI: 10.1088/1758-5090/ad0b3f] [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: 01/19/2023] [Revised: 09/27/2023] [Accepted: 11/09/2023] [Indexed: 11/12/2023]
Abstract
Three-dimensional (3D) bioprinting offers promising solutions to the complex challenge of vascularization in biofabrication, thereby enhancing the prospects for clinical translation of engineered tissues and organs. While existing reviews have touched upon 3D bioprinting in vascularized tissue contexts, the current review offers a more holistic perspective, encompassing recent technical advancements and spanning the entire multistage bioprinting process, with a particular emphasis on vascularization. The synergy between 3D bioprinting and vascularization strategies is crucial, as 3D bioprinting can enable the creation of personalized, tissue-specific vascular network while the vascularization enhances tissue viability and function. The review starts by providing a comprehensive overview of the entire bioprinting process, spanning from pre-bioprinting stages to post-printing processing, including perfusion and maturation. Next, recent advancements in vascularization strategies that can be seamlessly integrated with bioprinting are discussed. Further, tissue-specific examples illustrating how these vascularization approaches are customized for diverse anatomical tissues towards enhancing clinical relevance are discussed. Finally, the underexplored intraoperative bioprinting (IOB) was highlighted, which enables the direct reconstruction of tissues within defect sites, stressing on the possible synergy shaped by combining IOB with vascularization strategies for improved regeneration.
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Affiliation(s)
- Miji Yeo
- The Huck Institutes of the Life Sciences, Penn State University, University Park, PA 16802, United States of America
- Engineering Science and Mechanics Department, Penn State University, University Park, PA 16802, United States of America
| | - Anwita Sarkar
- Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research, Kolkata, West Bengal 700054, India
| | - Yogendra Pratap Singh
- The Huck Institutes of the Life Sciences, Penn State University, University Park, PA 16802, United States of America
- Engineering Science and Mechanics Department, Penn State University, University Park, PA 16802, United States of America
| | - Irem Deniz Derman
- The Huck Institutes of the Life Sciences, Penn State University, University Park, PA 16802, United States of America
- Engineering Science and Mechanics Department, Penn State University, University Park, PA 16802, United States of America
| | - Pallab Datta
- Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research, Kolkata, West Bengal 700054, India
| | - Ibrahim T Ozbolat
- The Huck Institutes of the Life Sciences, Penn State University, University Park, PA 16802, United States of America
- Engineering Science and Mechanics Department, Penn State University, University Park, PA 16802, United States of America
- Department of Biomedical Engineering, Penn State University, University Park, PA 16802, United States of America
- Materials Research Institute, Penn State University, University Park, PA 16802, United States of America
- Department of Neurosurgery, Penn State College of Medicine, Hershey, PA 17033, United States of America
- Penn State Cancer Institute, Penn State University, Hershey, PA 17033, United States of America
- Biotechnology Research and Application Center, Cukurova University, Adana 01130, Turkey
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Li Y, Zhou Y, Qiao W, Shi J, Qiu X, Dong N. Application of decellularized vascular matrix in small-diameter vascular grafts. Front Bioeng Biotechnol 2023; 10:1081233. [PMID: 36686240 PMCID: PMC9852870 DOI: 10.3389/fbioe.2022.1081233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 12/13/2022] [Indexed: 01/09/2023] Open
Abstract
Coronary artery bypass grafting (CABG) remains the most common procedure used in cardiovascular surgery for the treatment of severe coronary atherosclerotic heart disease. In coronary artery bypass grafting, small-diameter vascular grafts can potentially replace the vessels of the patient. The complete retention of the extracellular matrix, superior biocompatibility, and non-immunogenicity of the decellularized vascular matrix are unique advantages of small-diameter tissue-engineered vascular grafts. However, after vascular implantation, the decellularized vascular matrix is also subject to thrombosis and neoplastic endothelial hyperplasia, the two major problems that hinder its clinical application. The keys to improving the long-term patency of the decellularized matrix as vascular grafts include facilitating early endothelialization and avoiding intravascular thrombosis. This review article sequentially introduces six aspects of the decellularized vascular matrix as follows: design criteria of vascular grafts, components of the decellularized vascular matrix, the changing sources of the decellularized vascular matrix, the advantages and shortcomings of decellularization technologies, modification methods and the commercialization progress as well as the application prospects in small-diameter vascular grafts.
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Affiliation(s)
| | | | | | | | - Xuefeng Qiu
- *Correspondence: Xuefeng Qiu, ; Nianguo Dong,
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5
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Mitchell TC, Feng NL, Lam YT, Michael P, Santos M, Wise SG. Engineering vascular bioreactor systems to closely mimic physiological forces in vitro. TISSUE ENGINEERING PART B: REVIEWS 2022. [DOI: 10.1089/ten.teb.2022.0158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Timothy C Mitchell
- The University of Sydney, 4334, School of Medical Sciences, Sydney, New South Wales, Australia,
| | - Nicolas L Feng
- The University of Sydney, 4334, School of Medical Sciences, Sydney, New South Wales, Australia,
| | - Yuen Ting Lam
- The University of Sydney, 4334, School of Medical Sciences, Sydney, New South Wales, Australia,
| | - Praveesuda Michael
- The University of Sydney, 4334, School of Medical Sciences, Sydney, New South Wales, Australia,
| | - Miguel Santos
- The University of Sydney, 4334, School of Medical Sciences, Sydney, New South Wales, Australia,
| | - Steven G Wise
- The University of Sydney, 4334, School of Medical Sciences, Sydney, New South Wales, Australia,
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6
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Engineering Smooth Muscle to Understand Extracellular Matrix Remodeling and Vascular Disease. Bioengineering (Basel) 2022; 9:bioengineering9090449. [PMID: 36134994 PMCID: PMC9495899 DOI: 10.3390/bioengineering9090449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 08/31/2022] [Accepted: 09/02/2022] [Indexed: 11/29/2022] Open
Abstract
The vascular smooth muscle is vital for regulating blood pressure and maintaining cardiovascular health, and the resident smooth muscle cells (SMCs) in blood vessel walls rely on specific mechanical and biochemical signals to carry out these functions. Any slight change in their surrounding environment causes swift changes in their phenotype and secretory profile, leading to changes in the structure and functionality of vessel walls that cause pathological conditions. To adequately treat vascular diseases, it is essential to understand how SMCs crosstalk with their surrounding extracellular matrix (ECM). Here, we summarize in vivo and traditional in vitro studies of pathological vessel wall remodeling due to the SMC phenotype and, conversely, the SMC behavior in response to key ECM properties. We then analyze how three-dimensional tissue engineering approaches provide opportunities to model SMCs’ response to specific stimuli in the human body. Additionally, we review how applying biomechanical forces and biochemical stimulation, such as pulsatile fluid flow and secreted factors from other cell types, allows us to study disease mechanisms. Overall, we propose that in vitro tissue engineering of human vascular smooth muscle can facilitate a better understanding of relevant cardiovascular diseases using high throughput experiments, thus potentially leading to therapeutics or treatments to be tested in the future.
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7
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Xie Y, Hu J, Lei W, Qian S. Prediction of vascular injury by cavitation microbubbles in a focused ultrasound field. ULTRASONICS SONOCHEMISTRY 2022; 88:106103. [PMID: 35908343 PMCID: PMC9340509 DOI: 10.1016/j.ultsonch.2022.106103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 07/10/2022] [Accepted: 07/22/2022] [Indexed: 06/15/2023]
Abstract
Many studies have shown that microbubble cavitation is one mechanism for vascular injury under ultrasonic excitation. Previous work has attributed vascular damage to vessel expansions and invaginations due to the expansion and contraction of microbubbles. However, the mechanisms of vascular damage are not fully understood. In this paper, we investigate, theoretically and experimentally, the vessel injury due to stress induced by ultrasound-induced cavitation (UIC). A bubble-fluid-vessel coupling model is constructed to investigate the interactions of the coupling system. The dynamics process of vessel damage due to UIC is theoretically simulated with a finite element method, and a focused ultrasound (FU) setup is carried out and used to assess the vessel damage. The results show that shear stress contributes to vessel injury by cell detachment while normal stress mainly causes distention injury. Similar changes in cell detachment in a vessel over time can be observed with the experimental setup. The severity of vascular injury is correlated to acoustic parameters, bubble-wall distance, and microbubble sizes, and the duration of insonation..
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Affiliation(s)
- Yaqian Xie
- College of Mathematics and Physics, University of South China, Hengyang 421001, China
| | - Jiwen Hu
- College of Mathematics and Physics, University of South China, Hengyang 421001, China.
| | - Weirui Lei
- College of Mathematics and Physics, University of South China, Hengyang 421001, China
| | - Shengyou Qian
- College of Physics and Electronics, Hunan Normal University, Changsha 410081, China
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8
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Matos RS, Maselli D, McVey JH, Heiss C, Campagnolo P. 3D Printed Bioreactor Enabling the Pulsatile Culture of Native and Angioplastied Large Arteries. Front Cardiovasc Med 2022; 9:864580. [PMID: 35800166 PMCID: PMC9253513 DOI: 10.3389/fcvm.2022.864580] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 05/13/2022] [Indexed: 12/30/2022] Open
Abstract
Routine interventions such as balloon angioplasty, result in vascular activation and remodeling, often requiring re-intervention. 2D in vitro models and small animal experiments have enabled the discovery of important mechanisms involved in this process, however the clinical translation is often underwhelming. There is a critical need for an ex vivo model representative of the human vascular physiology and encompassing the complexity of the vascular wall and the physical forces regulating its function. Vascular bioreactors for ex vivo culture of large vessels are viable alternatives, but their custom-made design and insufficient characterization often hinders the reproducibility of the experiments. The objective of the study was to design and validate a novel 3D printed cost-efficient and versatile perfusion system, capable of sustaining the viability and functionality of large porcine arteries for 7 days and enabling early post-injury evaluations. MultiJet Fusion 3D printing was used to engineer the EasyFlow insert, converting a conventional 50 ml centrifuge tube into a mini bioreactor. Porcine carotid arteries either left untreated or injured with an angioplasty balloon, were cultured under pulsatile flow for up to 7 days. Pressure, heart rate, medium viscosity and shear conditions were adjusted to resemble arterial in vivo hemodynamics. Tissue viability, cell activation and matrix remodeling were analyzed by immunohistochemistry, and vascular function was monitored by duplex ultrasound. Culture conditions in the EasyFlow bioreactor preserved endothelial coverage and smooth muscle organization and extracellular matrix structure in the vessel wall, as compared to static culture. Injured arteries presented hallmarks of early remodeling, such as intimal denudation, smooth muscle cell disarray and media/adventitia activation in flow culture. Duplex ultrasound confirmed continuous pulsatile blood flow conditions, dose-dependent vasodilator response to nitroglycerin in untreated vessels and impaired dilator response in angioplastied vessels. The scope of this work is to validate a low-cost, robust and reproducible system to explore the culture of native and injured large arteries under pulsatile flow. While the study of vascular pathology is beyond the scope of the present paper, our system enables future investigations and provides a platform to test novel therapies and devices ex vivo, in a patient relevant system.
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Affiliation(s)
- Rolando S. Matos
- Cardiovascular Section, Department of Biochemical Sciences, Guildford, United Kingdom
| | - Davide Maselli
- Cardiovascular Section, Department of Biochemical Sciences, Guildford, United Kingdom
| | - John H. McVey
- Cardiovascular Section, Department of Biochemical Sciences, Guildford, United Kingdom
| | - Christian Heiss
- Cardiovascular Section, Department of Biochemical Sciences, Guildford, United Kingdom,Clinical Medicine Section, Department of Clinical and Experimental Medicine, University of Surrey, Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - Paola Campagnolo
- Cardiovascular Section, Department of Biochemical Sciences, Guildford, United Kingdom,*Correspondence: Paola Campagnolo
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Marei I, Abu Samaan T, Al-Quradaghi MA, Farah AA, Mahmud SH, Ding H, Triggle CR. 3D Tissue-Engineered Vascular Drug Screening Platforms: Promise and Considerations. Front Cardiovasc Med 2022; 9:847554. [PMID: 35310996 PMCID: PMC8931492 DOI: 10.3389/fcvm.2022.847554] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 02/03/2022] [Indexed: 12/12/2022] Open
Abstract
Despite the efforts devoted to drug discovery and development, the number of new drug approvals have been decreasing. Specifically, cardiovascular developments have been showing amongst the lowest levels of approvals. In addition, concerns over the adverse effects of drugs to the cardiovascular system have been increasing and resulting in failure at the preclinical level as well as withdrawal of drugs post-marketing. Besides factors such as the increased cost of clinical trials and increases in the requirements and the complexity of the regulatory processes, there is also a gap between the currently existing pre-clinical screening methods and the clinical studies in humans. This gap is mainly caused by the lack of complexity in the currently used 2D cell culture-based screening systems, which do not accurately reflect human physiological conditions. Cell-based drug screening is widely accepted and extensively used and can provide an initial indication of the drugs' therapeutic efficacy and potential cytotoxicity. However, in vitro cell-based evaluation could in many instances provide contradictory findings to the in vivo testing in animal models and clinical trials. This drawback is related to the failure of these 2D cell culture systems to recapitulate the human physiological microenvironment in which the cells reside. In the body, cells reside within a complex physiological setting, where they interact with and respond to neighboring cells, extracellular matrix, mechanical stress, blood shear stress, and many other factors. These factors in sum affect the cellular response and the specific pathways that regulate variable vital functions such as proliferation, apoptosis, and differentiation. Although pre-clinical in vivo animal models provide this level of complexity, cross species differences can also cause contradictory results from that seen when the drug enters clinical trials. Thus, there is a need to better mimic human physiological conditions in pre-clinical studies to improve the efficiency of drug screening. A novel approach is to develop 3D tissue engineered miniaturized constructs in vitro that are based on human cells. In this review, we discuss the factors that should be considered to produce a successful vascular construct that is derived from human cells and is both reliable and reproducible.
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Affiliation(s)
- Isra Marei
- Department of Pharmacology, Weill Cornell Medicine-Qatar, Doha, Qatar
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- *Correspondence: Isra Marei
| | - Tala Abu Samaan
- Department of Pharmacology, Weill Cornell Medicine-Qatar, Doha, Qatar
| | | | - Asmaa A. Farah
- Department of Pharmacology, Weill Cornell Medicine-Qatar, Doha, Qatar
| | | | - Hong Ding
- Department of Pharmacology, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Chris R. Triggle
- Department of Pharmacology, Weill Cornell Medicine-Qatar, Doha, Qatar
- Chris R. Triggle
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Fodor M, Fodor L, Bota O. The role of nanomaterials and nanostructured surfaces for improvement of biomaterial peculiarities in vascular surgery: a review. PARTICULATE SCIENCE AND TECHNOLOGY 2021. [DOI: 10.1080/02726351.2021.1871692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Marius Fodor
- Department of Vascular Surgery, First Surgical Clinic, Emergency District Hospital, Cluj-Napoca, Romania, Cluj-Napoca, Romania
| | - Lucian Fodor
- Department of Plastic Surgery, First Surgical Clinic, Emergency District Hospital, Cluj-Napoca, Romania, Cluj-Napoca, Romania
| | - Olimpiu Bota
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
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11
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Devillard CD, Marquette CA. Vascular Tissue Engineering: Challenges and Requirements for an Ideal Large Scale Blood Vessel. Front Bioeng Biotechnol 2021; 9:721843. [PMID: 34671597 PMCID: PMC8522984 DOI: 10.3389/fbioe.2021.721843] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 09/20/2021] [Indexed: 01/05/2023] Open
Abstract
Since the emergence of regenerative medicine and tissue engineering more than half a century ago, one obstacle has persisted: the in vitro creation of large-scale vascular tissue (>1 cm3) to meet the clinical needs of viable tissue grafts but also for biological research applications. Considerable advancements in biofabrication have been made since Weinberg and Bell, in 1986, created the first blood vessel from collagen, endothelial cells, smooth muscle cells and fibroblasts. The synergistic combination of advances in fabrication methods, availability of cell source, biomaterials formulation and vascular tissue development, promises new strategies for the creation of autologous blood vessels, recapitulating biological functions, structural functions, but also the mechanical functions of a native blood vessel. In this review, the main technological advancements in bio-fabrication are discussed with a particular highlights on 3D bioprinting technologies. The choice of the main biomaterials and cell sources, the use of dynamic maturation systems such as bioreactors and the associated clinical trials will be detailed. The remaining challenges in this complex engineering field will finally be discussed.
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Affiliation(s)
- Chloé D Devillard
- 3d.FAB, CNRS, INSA, Univ Lyon, CPE-Lyon, UMR5246, ICBMS, Université Lyon 1, Villeurbanne Cedex, France
| | - Christophe A Marquette
- 3d.FAB, CNRS, INSA, Univ Lyon, CPE-Lyon, UMR5246, ICBMS, Université Lyon 1, Villeurbanne Cedex, France
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12
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Wang J, Kural MH, Wu J, Leiby KL, Mishra V, Lysyy T, Li G, Luo J, Greaney A, Tellides G, Qyang Y, Huang N, Niklason LE. An ex vivo physiologic and hyperplastic vessel culture model to study intra-arterial stent therapies. Biomaterials 2021; 275:120911. [PMID: 34087584 DOI: 10.1016/j.biomaterials.2021.120911] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 05/17/2021] [Accepted: 05/19/2021] [Indexed: 11/19/2022]
Abstract
Conventional in vitro methods for biological evaluation of intra-arterial devices such as stents fail to accurately predict cytotoxicity and remodeling events. An ex vivo flow-tunable vascular bioreactor system (VesselBRx), comprising intra- and extra-luminal monitoring capabilities, addresses these limitations. VesselBRx mimics the in vivo physiological, hyperplastic, and cytocompatibility events of absorbable magnesium (Mg)-based stents in ex vivo stent-treated porcine and human coronary arteries, with in-situ and real-time monitoring of local stent degradation effects. Unlike conventional, static cell culture, the VesselBRx perfusion system eliminates unphysiologically high intracellular Mg2+ concentrations and localized O2 consumption resulting from stent degradation. Whereas static stented arteries exhibited only 20.1% cell viability and upregulated apoptosis, necrosis, metallic ion, and hypoxia-related gene signatures, stented arteries in VesselBRx showed almost identical cell viability to in vivo rabbit models (~94.0%). Hyperplastic intimal remodeling developed in unstented arteries subjected to low shear stress, but was inhibited by Mg-based stents in VesselBRx, similarly to in vivo. VesselBRx represents a critical advance from the current static culture standard of testing absorbable vascular implants.
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Affiliation(s)
- Juan Wang
- Department of Anesthesiology, School of Medicine, Yale University, New Haven, CT, 06519, USA
| | - Mehmet H Kural
- Department of Anesthesiology, School of Medicine, Yale University, New Haven, CT, 06519, USA
| | - Jonathan Wu
- Department of Biomedical Engineering, School of Medicine, Yale University, New Haven, CT, 06519, USA
| | - Katherine L Leiby
- Department of Biomedical Engineering, School of Medicine, Yale University, New Haven, CT, 06519, USA
| | - Vinayak Mishra
- Department of Molecular and Cell Biology, University of Connecticut, Storrs, CT, 06269, USA
| | - Taras Lysyy
- Department of Surgery, School of Medicine, Yale University, New Haven, CT, 06519, USA
| | - Guangxin Li
- Department of Surgery, School of Medicine, Yale University, New Haven, CT, 06519, USA
| | - Jiesi Luo
- Yale Cardiovascular Research Center, Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT06519, USA
| | - Allison Greaney
- Department of Biomedical Engineering, School of Medicine, Yale University, New Haven, CT, 06519, USA
| | - George Tellides
- Department of Surgery, School of Medicine, Yale University, New Haven, CT, 06519, USA
| | - Yibing Qyang
- Yale Cardiovascular Research Center, Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT06519, USA
| | - Nan Huang
- School of Material Science and Engineering, Southwest Jiaotong University, Chengdu, Sichuan, 610031, China
| | - Laura E Niklason
- Department of Anesthesiology, School of Medicine, Yale University, New Haven, CT, 06519, USA; Department of Biomedical Engineering, School of Medicine, Yale University, New Haven, CT, 06519, USA.
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13
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Iop L. Toward the Effective Bioengineering of a Pathological Tissue for Cardiovascular Disease Modeling: Old Strategies and New Frontiers for Prevention, Diagnosis, and Therapy. Front Cardiovasc Med 2021; 7:591583. [PMID: 33748193 PMCID: PMC7969521 DOI: 10.3389/fcvm.2020.591583] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 12/08/2020] [Indexed: 12/18/2022] Open
Abstract
Cardiovascular diseases (CVDs) still represent the primary cause of mortality worldwide. Preclinical modeling by recapitulating human pathophysiology is fundamental to advance the comprehension of these diseases and propose effective strategies for their prevention, diagnosis, and treatment. In silico, in vivo, and in vitro models have been applied to dissect many cardiovascular pathologies. Computational and bioinformatic simulations allow developing algorithmic disease models considering all known variables and severity degrees of disease. In vivo studies based on small or large animals have a long tradition and largely contribute to the current treatment and management of CVDs. In vitro investigation with two-dimensional cell culture demonstrates its suitability to analyze the behavior of single, diseased cellular types. The introduction of induced pluripotent stem cell technology and the application of bioengineering principles raised the bar toward in vitro three-dimensional modeling by enabling the development of pathological tissue equivalents. This review article intends to describe the advantages and disadvantages of past and present modeling approaches applied to provide insights on some of the most relevant congenital and acquired CVDs, such as rhythm disturbances, bicuspid aortic valve, cardiac infections and autoimmunity, cardiovascular fibrosis, atherosclerosis, and calcific aortic valve stenosis.
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Affiliation(s)
- Laura Iop
- Department of Cardiac Thoracic Vascular Sciences, and Public Health, University of Padua Medical School, Padua, Italy
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14
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Luo J, Shi X, Lin Y, Yuan Y, Kural MH, Wang J, Ellis MW, Anderson CW, Zhang SM, Riaz M, Niklason LE, Qyang Y. Efficient Differentiation of Human Induced Pluripotent Stem Cells into Endothelial Cells under Xenogeneic-free Conditions for Vascular Tissue Engineering. Acta Biomater 2021; 119:184-196. [PMID: 33166710 PMCID: PMC8133308 DOI: 10.1016/j.actbio.2020.11.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 10/12/2020] [Accepted: 11/03/2020] [Indexed: 12/31/2022]
Abstract
Tissue engineered vascular grafts (TEVGs) represent a promising therapeutic option for emergency vascular intervention. Although the application of small-diameter TEVGs using patient-specific primary endothelial cells (ECs) to prevent thrombosis and occlusion prior to implantation could be hindered by the long time course required for in vitro endothelialization, human induced pluripotent stem cells (hiPSCs) provide a robust source to derive immunocompatible ECs (hiPSC-ECs) for immediate TEVG endothelialization. To achieve clinical application, hiPSC-ECs should be derived under culture conditions without the use of animal-derived reagents (xenogeneic-free conditions), to avoid unwanted host immune responses from xenogeneic reagents. However, a completely xenogeneic-free method of hiPSC-EC generation has not previously been established. Herein, we substituted animal-derived reagents used in a standard method of xenogeneic hiPSC-EC differentiation with functional counterparts of human origin. As a result, we generated xenogeneic-free hiPSC-ECs (XF-hiPSC-ECs) with similar marker expression and function to those of human primary ECs. Furthermore, XF-hiPSC-ECs functionally responded to shear stress with typical cell alignment and gene expression. Finally, we successfully endothelialized decellularized human vessels with XF-hiPSC-ECs in a dynamic bioreactor system. In conclusion, we developed xenogeneic-free conditions for generating functional hiPSC-ECs suitable for vascular tissue engineering, which will further move TEVG therapy toward clinical application.
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Affiliation(s)
- Jiesi Luo
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine Yale School of Medicine, New Haven, CT 06511, USA; Yale Stem Cell Center, New Haven, CT 06520, USA
| | - Xiangyu Shi
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine Yale School of Medicine, New Haven, CT 06511, USA; Yale Stem Cell Center, New Haven, CT 06520, USA; Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, 410011, China
| | - Yuyao Lin
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine Yale School of Medicine, New Haven, CT 06511, USA; Yale Stem Cell Center, New Haven, CT 06520, USA; Department of Cardiovascular Medicine, First Affiliated Hospital of Xi'an Jiaotong University, No. 277 West Yanta Road, Xi'an, Shaanxi, 710061, China
| | - Yifan Yuan
- Vascular Biology and Therapeutics Program, Yale University School of Medicine, New Haven, CT 06520, USA; Department of Anesthesiology, Yale University, New Haven, CT 06519, USA
| | - Mehmet H Kural
- Vascular Biology and Therapeutics Program, Yale University School of Medicine, New Haven, CT 06520, USA; Department of Anesthesiology, Yale University, New Haven, CT 06519, USA
| | - Juan Wang
- Vascular Biology and Therapeutics Program, Yale University School of Medicine, New Haven, CT 06520, USA; Department of Anesthesiology, Yale University, New Haven, CT 06519, USA
| | - Matthew W Ellis
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine Yale School of Medicine, New Haven, CT 06511, USA; Yale Stem Cell Center, New Haven, CT 06520, USA; Department of Cellular and Molecular Physiology, Yale University, New Haven, CT 06519, USA
| | - Christopher W Anderson
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine Yale School of Medicine, New Haven, CT 06511, USA; Yale Stem Cell Center, New Haven, CT 06520, USA; Department of Pathology, Yale School of Medicine, New Haven, CT, 06520 USA
| | - Shang-Min Zhang
- Department of Pathology, Yale School of Medicine, New Haven, CT, 06520 USA
| | - Muhammad Riaz
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine Yale School of Medicine, New Haven, CT 06511, USA; Yale Stem Cell Center, New Haven, CT 06520, USA
| | - Laura E Niklason
- Yale Stem Cell Center, New Haven, CT 06520, USA; Vascular Biology and Therapeutics Program, Yale University School of Medicine, New Haven, CT 06520, USA; Department of Anesthesiology, Yale University, New Haven, CT 06519, USA; Department of Biomedical Engineering, Yale University, New Haven, CT 06519, USA
| | - Yibing Qyang
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine Yale School of Medicine, New Haven, CT 06511, USA; Yale Stem Cell Center, New Haven, CT 06520, USA; Vascular Biology and Therapeutics Program, Yale University School of Medicine, New Haven, CT 06520, USA; Department of Pathology, Yale School of Medicine, New Haven, CT, 06520 USA.
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15
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Kingsley DM, Roberge CL, Rudkouskaya A, Faulkner DE, Barroso M, Intes X, Corr DT. Laser-based 3D bioprinting for spatial and size control of tumor spheroids and embryoid bodies. Acta Biomater 2019; 95:357-370. [PMID: 30776506 PMCID: PMC7171976 DOI: 10.1016/j.actbio.2019.02.014] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 02/08/2019] [Accepted: 02/12/2019] [Indexed: 12/17/2022]
Abstract
3D multicellular aggregates, and more advanced organotypic systems, have become central tools in recent years to study a wide variety of complex biological processes. Most notably, these model systems have become mainstream within oncology (multicellular tumor spheroids) and regenerative medicine (embryoid bodies) research. However, the biological behavior of these in vitro tissue surrogates is extremely sensitive to their aggregate size and geometry. Indeed, both of these geometrical parameters are key in producing pathophysiological gradients responsible for cellular and structural heterogeneity, replicating in vivo observations. Moreover, the fabrication techniques most widely used for producing these models lack the ability to accurately control cellular spatial location, an essential component for regulating homotypic and heterotypic cell signaling. Herein, we report on a 3D bioprinting technique, laser direct-write (LDW), that enables precise control of both spatial patterning and size of cell-encapsulating microbeads. The generated cell-laden beads are further processed into core-shelled structures, allowing for the growth and formation of self-contained, self-aggregating cells (e.g., breast cancer cells, embryonic stem cells). Within these structures we demonstrate our ability to produce multicellular tumor spheroids (MCTSs) and embryoid bodies (EBs) with well-controlled overall size and shape, that can be designed on demand. Furthermore, we investigated the impact of aggregate size on the uptake of a commonly employed ligand for receptor-mediated drug delivery, Transferrin, indicating that larger tumor spheroids exhibit greater spatial heterogeneity in ligand uptake. Taken together, these findings establish LDW as a versatile biomanufacturing platform for bioprinting and patterning core-shelled structures to generate size-controlled 3D multicellular aggregates. STATEMENT OF SIGNIFICANCE: Multicellular 3D aggregates are powerful in vitro models used to study a wide variety of complex biological processes, particularly within oncology and regenerative medicine. These tissue surrogates are fabricated using environments that encourage cellular self-assembly. However, specific applications require control of aggregate size and position to recapitulate key in vivo parameters (e.g., pathophysiological gradients and homotypic/heterotypic cell signaling). Herein, we demonstrate the ability to create and spatially pattern size-controlled embryoid bodies and tumor spheroids, using laser-based 3D bioprinting. Furthermore, we investigated the effect of tumor spheroid size on internalization of Transferrin, a common ligand for targeted therapy, finding greater spatial heterogeneity in our large aggregates. Overall, this technique offers incredible promise and flexibility for fabricating idealized 3D in vitro models.
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Affiliation(s)
- David M Kingsley
- Department of Biomedical Engineering, Rensselaer Polytechnic Institute, 110 Eighth St., Troy, NY 12180, USA.
| | - Cassandra L Roberge
- Department of Biomedical Engineering, Rensselaer Polytechnic Institute, 110 Eighth St., Troy, NY 12180, USA.
| | - Alena Rudkouskaya
- Department of Molecular and Cellular Physiology, Albany Medical College, Albany, NY 12208, USA.
| | - Denzel E Faulkner
- Department of Biomedical Engineering, Rensselaer Polytechnic Institute, 110 Eighth St., Troy, NY 12180, USA.
| | - Margarida Barroso
- Department of Molecular and Cellular Physiology, Albany Medical College, Albany, NY 12208, USA.
| | - Xavier Intes
- Department of Biomedical Engineering, Rensselaer Polytechnic Institute, 110 Eighth St., Troy, NY 12180, USA.
| | - David T Corr
- Department of Biomedical Engineering, Rensselaer Polytechnic Institute, 110 Eighth St., Troy, NY 12180, USA.
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16
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Fernández-Colino A, Iop L, Ventura Ferreira MS, Mela P. Fibrosis in tissue engineering and regenerative medicine: treat or trigger? Adv Drug Deliv Rev 2019; 146:17-36. [PMID: 31295523 DOI: 10.1016/j.addr.2019.07.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Revised: 05/11/2019] [Accepted: 07/04/2019] [Indexed: 02/07/2023]
Abstract
Fibrosis is a life-threatening pathological condition resulting from a dysfunctional tissue repair process. There is no efficient treatment and organ transplantation is in many cases the only therapeutic option. Here we review tissue engineering and regenerative medicine (TERM) approaches to address fibrosis in the cardiovascular system, the kidney, the lung and the liver. These strategies have great potential to achieve repair or replacement of diseased organs by cell- and material-based therapies. However, paradoxically, they might also trigger fibrosis. Cases of TERM interventions with adverse outcome are also included in this review. Furthermore, we emphasize the fact that, although organ engineering is still in its infancy, the advances in the field are leading to biomedically relevant in vitro models with tremendous potential for disease recapitulation and development of therapies. These human tissue models might have increased predictive power for human drug responses thereby reducing the need for animal testing.
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17
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Kural MH, Wang J, Gui L, Yuan Y, Li G, Leiby KL, Quijano E, Tellides G, Saltzman WM, Niklason LE. Fas ligand and nitric oxide combination to control smooth muscle growth while sparing endothelium. Biomaterials 2019; 212:28-38. [PMID: 31102854 DOI: 10.1016/j.biomaterials.2019.05.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 04/21/2019] [Accepted: 05/06/2019] [Indexed: 01/08/2023]
Abstract
Metallic stents cause vascular wall damage with subsequent smooth muscle cell (SMC) proliferation, neointimal hyperplasia, and treatment failure. To combat in-stent restenosis, drug-eluting stents (DES) delivering mTOR inhibitors such as sirolimus or everolimus have become standard for coronary stenting. However, the relatively non-specific action of mTOR inhibitors prevents efficient endothelium recovery and mandates dual antiplatelet therapy to prevent thrombosis. Unfortunately, long-term dual antiplatelet therapy leads to increased risk of bleeding/stroke and, paradoxically, myocardial infarction. Here, we took advantage of the fact that nitric oxide (NO) increases Fas receptors on the SMC surface. Fas forms a death-inducing complex upon binding to Fas ligand (FasL), while endothelial cells (ECs) are relatively resistant to this pathway. Selected doses of FasL and NO donor synergistically increased SMC apoptosis and inhibited SMC growth more potently than did everolimus or sirolimus, while having no significant effect on EC viability and proliferation. This differential effect was corroborated in ex vivo pig coronaries, where the neointimal formation was inhibited by the drug combination, but endothelial viability was retained. We also deployed FasL-NO donor-releasing ethylene-vinyl acetate copolymer (EVAc)-coated stents into pig coronary arteries, and cultured them in perfusion bioreactors for one week. FasL and NO donor, released from the stent coating, killed SMCs close to the stent struts, even in the presence of flow rates mimicking those of native arteries. Thus, the FasL-NO donor-combination has a potential to prevent intimal hyperplasia and in-stent restenosis, without harming endothelial restoration, and hence may be a superior drug delivery strategy for DES.
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Affiliation(s)
- Mehmet H Kural
- Vascular Biology and Therapeutics Program, Yale University School of Medicine, New Haven, CT 06520, USA; Department of Anesthesiology, Yale University, New Haven, CT 06519, USA.
| | - Juan Wang
- Vascular Biology and Therapeutics Program, Yale University School of Medicine, New Haven, CT 06520, USA; Department of Anesthesiology, Yale University, New Haven, CT 06519, USA
| | - Liqiong Gui
- Vascular Biology and Therapeutics Program, Yale University School of Medicine, New Haven, CT 06520, USA; Department of Anesthesiology, Yale University, New Haven, CT 06519, USA
| | - Yifan Yuan
- Vascular Biology and Therapeutics Program, Yale University School of Medicine, New Haven, CT 06520, USA; Department of Anesthesiology, Yale University, New Haven, CT 06519, USA
| | - Guangxin Li
- Vascular Biology and Therapeutics Program, Yale University School of Medicine, New Haven, CT 06520, USA; Department of Surgery, Yale University, New Haven, CT 06519, USA
| | - Katherine L Leiby
- Department of Biomedical Engineering, Yale University, New Haven, CT 06519, USA
| | - Elias Quijano
- Department of Biomedical Engineering, Yale University, New Haven, CT 06519, USA
| | - George Tellides
- Vascular Biology and Therapeutics Program, Yale University School of Medicine, New Haven, CT 06520, USA; Department of Surgery, Yale University, New Haven, CT 06519, USA
| | - W Mark Saltzman
- Vascular Biology and Therapeutics Program, Yale University School of Medicine, New Haven, CT 06520, USA; Department of Biomedical Engineering, Yale University, New Haven, CT 06519, USA
| | - Laura E Niklason
- Vascular Biology and Therapeutics Program, Yale University School of Medicine, New Haven, CT 06520, USA; Department of Anesthesiology, Yale University, New Haven, CT 06519, USA; Department of Biomedical Engineering, Yale University, New Haven, CT 06519, USA; Yale Stem Cell Center, New Haven, CT 06520, USA
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