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Fatehi Hassanabad A, Zarzycki AN, Fedak PWM. Cellular and molecular mechanisms driving cardiac tissue fibrosis: On the precipice of personalized and precision medicine. Cardiovasc Pathol 2024; 71:107635. [PMID: 38508436 DOI: 10.1016/j.carpath.2024.107635] [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: 01/30/2024] [Revised: 03/13/2024] [Accepted: 03/15/2024] [Indexed: 03/22/2024] Open
Abstract
Cardiac fibrosis is a significant contributor to heart failure, a condition that continues to affect a growing number of patients worldwide. Various cardiovascular comorbidities can exacerbate cardiac fibrosis. While fibroblasts are believed to be the primary cell type underlying fibrosis, recent and emerging data suggest that other cell types can also potentiate or expedite fibrotic processes. Over the past few decades, clinicians have developed therapeutics that can blunt the development and progression of cardiac fibrosis. While these strategies have yielded positive results, overall clinical outcomes for patients suffering from heart failure continue to be dire. Herein, we overview the molecular and cellular mechanisms underlying cardiac tissue fibrosis. To do so, we establish the known mechanisms that drive fibrosis in the heart, outline the diagnostic tools available, and summarize the treatment options used in contemporary clinical practice. Finally, we underscore the critical role the immune microenvironment plays in the pathogenesis of cardiac fibrosis.
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Affiliation(s)
- Ali Fatehi Hassanabad
- Section of Cardiac Surgery, Department of Cardiac Science, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Anna N Zarzycki
- Section of Cardiac Surgery, Department of Cardiac Science, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Paul W M Fedak
- Section of Cardiac Surgery, Department of Cardiac Science, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
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Lin YK, Hsiao LC, Wu MY, Chen YF, Lin YN, Chang CM, Chung WH, Chen KW, Lu CR, Chen WY, Chang SS, Shyu WC, Lee AS, Chen CH, Jeng LB, Chang KC. PD-L1 and AKT Overexpressing Adipose-Derived Mesenchymal Stem Cells Enhance Myocardial Protection by Upregulating CD25 + T Cells in Acute Myocardial Infarction Rat Model. Int J Mol Sci 2023; 25:134. [PMID: 38203304 PMCID: PMC10779305 DOI: 10.3390/ijms25010134] [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: 11/07/2023] [Revised: 12/05/2023] [Accepted: 12/14/2023] [Indexed: 01/12/2024] Open
Abstract
This study explores the synergistic impact of Programmed Death Ligand 1 (PD-L1) and Protein Kinase B (Akt) overexpression in adipose-derived mesenchymal stem cells (AdMSCs) for ameliorating cardiac dysfunction after myocardial infarction (MI). Post-MI adult Wistar rats were allocated into four groups: sham, MI, ADMSC treatment, and ADMSCs overexpressed with PD-L1 and Akt (AdMSC-PDL1-Akt) treatment. MI was induced via left anterior descending coronary artery ligation, followed by intramyocardial AdMSC injections. Over four weeks, cardiac functionality and structural integrity were assessed using pressure-volume analysis, infarct size measurement, and immunohistochemistry. AdMSC-PDL1-Akt exhibited enhanced resistance to reactive oxygen species (ROS) in vitro and ameliorated MI-induced contractile dysfunction in vivo by improving the end-systolic pressure-volume relationship and preload-recruitable stroke work, together with attenuating infarct size. Molecular analyses revealed substantial mitigation in caspase3 and nuclear factor-κB upregulation in MI hearts within the AdMSC-PDL1-Akt group. Mechanistically, AdMSC-PDL1-Akt fostered the differentiation of normal T cells into CD25+ regulatory T cells in vitro, aligning with in vivo upregulation of CD25 in AdMSC-PDL1-Akt-treated rats. Collectively, PD-L1 and Akt overexpression in AdMSCs bolsters resistance to ROS-mediated apoptosis in vitro and enhances myocardial protective efficacy against MI-induced dysfunction, potentially via T-cell modulation, underscoring a promising therapeutic strategy for myocardial ischemic injuries.
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Affiliation(s)
- Yu-Kai Lin
- Division of Cardiovascular Medicine, China Medical University Hospital, Taichung 404327, Taiwan (Y.-N.L.); (W.-H.C.); (K.-W.C.)
- Cardiovascular Research Laboratory, China Medical University Hospital, Taichung 404327, Taiwan; (C.-M.C.); (A.-S.L.)
- School of Medicine, China Medical University, Taichung 404328, Taiwan
| | - Lien-Cheng Hsiao
- Division of Cardiovascular Medicine, China Medical University Hospital, Taichung 404327, Taiwan (Y.-N.L.); (W.-H.C.); (K.-W.C.)
- Cardiovascular Research Laboratory, China Medical University Hospital, Taichung 404327, Taiwan; (C.-M.C.); (A.-S.L.)
- School of Medicine, China Medical University, Taichung 404328, Taiwan
| | - Mei-Yao Wu
- School of Post-Baccalaureate Chinese Medicine, China Medical University, Taichung 404328, Taiwan;
- Department of Chinese Medicine, China Medical University Hospital, Taichung 404327, Taiwan
| | - Yun-Fang Chen
- Department of Medicine, Mackay Medical College, New Taipei City 25245, Taiwan; (Y.-F.C.); (W.-Y.C.)
| | - Yen-Nien Lin
- Division of Cardiovascular Medicine, China Medical University Hospital, Taichung 404327, Taiwan (Y.-N.L.); (W.-H.C.); (K.-W.C.)
- School of Medicine, China Medical University, Taichung 404328, Taiwan
| | - Chia-Ming Chang
- Cardiovascular Research Laboratory, China Medical University Hospital, Taichung 404327, Taiwan; (C.-M.C.); (A.-S.L.)
| | - Wei-Hsin Chung
- Division of Cardiovascular Medicine, China Medical University Hospital, Taichung 404327, Taiwan (Y.-N.L.); (W.-H.C.); (K.-W.C.)
| | - Ke-Wei Chen
- Division of Cardiovascular Medicine, China Medical University Hospital, Taichung 404327, Taiwan (Y.-N.L.); (W.-H.C.); (K.-W.C.)
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung 404328, Taiwan;
| | - Chiung-Ray Lu
- Division of Cardiovascular Medicine, China Medical University Hospital, Taichung 404327, Taiwan (Y.-N.L.); (W.-H.C.); (K.-W.C.)
| | - Wei-Yu Chen
- Department of Medicine, Mackay Medical College, New Taipei City 25245, Taiwan; (Y.-F.C.); (W.-Y.C.)
| | - Shih-Sheng Chang
- Division of Cardiovascular Medicine, China Medical University Hospital, Taichung 404327, Taiwan (Y.-N.L.); (W.-H.C.); (K.-W.C.)
- School of Medicine, China Medical University, Taichung 404328, Taiwan
| | - Woei-Cheang Shyu
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung 404328, Taiwan;
- Translational Medicine Research Center, China Medical University Hospital, Taichung 404327, Taiwan
- Neuroscience and Brain Disease Center, New Drug Development Center, China Medical University, Taichung 404328, Taiwan
- Department of Neurology, China Medical University, Taichung 404328, Taiwan
- Department of Occupational Therapy, Asia University, Taichung 413305, Taiwan
| | - An-Sheng Lee
- Cardiovascular Research Laboratory, China Medical University Hospital, Taichung 404327, Taiwan; (C.-M.C.); (A.-S.L.)
- Department of Medicine, Mackay Medical College, New Taipei City 25245, Taiwan; (Y.-F.C.); (W.-Y.C.)
| | - Chu-Huang Chen
- Vascular and Medicinal Research, Texas Heart Institute, Houston, TX 77030, USA;
- New York Heart Research Foundation, Mineola, NY 11514, USA
| | - Long-Bin Jeng
- Cell Therapy Center, China Medical University Hospital, Taichung 404327, Taiwan;
- Organ Transplantation Center, China Medical University Hospital, Taichung 404327, Taiwan
| | - Kuan-Cheng Chang
- Division of Cardiovascular Medicine, China Medical University Hospital, Taichung 404327, Taiwan (Y.-N.L.); (W.-H.C.); (K.-W.C.)
- Cardiovascular Research Laboratory, China Medical University Hospital, Taichung 404327, Taiwan; (C.-M.C.); (A.-S.L.)
- School of Medicine, China Medical University, Taichung 404328, Taiwan
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Amirzadeh Gougheri K, Ahmadi A, Ahmadabadi MG, Babajani A, Yazdanpanah G, Bahrami S, Hassani M, Niknejad H. Exosomal Cargo: Pro-angiogeneic, anti-inflammatory, and regenerative effects in ischemic and non-ischemic heart diseases - A comprehensive review. Biomed Pharmacother 2023; 168:115801. [PMID: 37918257 DOI: 10.1016/j.biopha.2023.115801] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 10/17/2023] [Accepted: 10/26/2023] [Indexed: 11/04/2023] Open
Abstract
Heart diseases are the primary cause of mortality and morbidity worldwide which inflict a heavy social and economic burden. Among heart diseases, most deaths are due to myocardial infarction (MI) or heart attack, which occurs when a decrement in blood flow to the heart causes injury to cardiac tissue. Despite several available diagnostic, therapeutic, and prognostic approaches, heart disease remains a significant concern. Exosomes are a kind of small extracellular vesicles released by different types of cells that play a part in intercellular communication by transferring bioactive molecules important in regenerative medicine. Many studies have reported the diagnostic, therapeutic, and prognostic role of exosomes in various heart diseases. Herein, we reviewed the roles of exosomes as new emerging agents in various types of heart diseases, including ischemic heart disease, cardiomyopathy, arrhythmia, and valvular disease, focusing on pathogenesis, therapeutic, diagnostic, and prognostic roles in different areas. We have also mentioned different routes of exosome delivery to target tissues, the effects of preconditioning and modification on exosome's capability, exosome production in compliance with good manufacturing practice (GMP), and their ongoing clinical applications in various medical contexts to shed light on possible clinical translation.
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Affiliation(s)
- Kowsar Amirzadeh Gougheri
- Department of Pharmacology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Armin Ahmadi
- Department of Pharmacology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Amirhesam Babajani
- Department of Pharmacology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ghasem Yazdanpanah
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, 1855 W. Taylor Street, MC 648, Chicago, IL 60612, USA
| | - Soheyl Bahrami
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology in AUVA Research Center, Vienna, Austria
| | - Mohammad Hassani
- Department of Vascular and Endovascular Surgery, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hassan Niknejad
- Department of Pharmacology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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Attar A, Farjoud Kouhanjani M, Hessami K, Vosough M, Kojuri J, Ramzi M, Hosseini SA, Faghih M, Monabati A. Effect of once versus twice intracoronary injection of allogeneic-derived mesenchymal stromal cells after acute myocardial infarction: BOOSTER-TAHA7 randomized clinical trial. Stem Cell Res Ther 2023; 14:264. [PMID: 37740221 PMCID: PMC10517503 DOI: 10.1186/s13287-023-03495-1] [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: 04/09/2023] [Accepted: 09/12/2023] [Indexed: 09/24/2023] Open
Abstract
BACKGROUND Mesenchymal stromal cell (MSC) transplantation can improve the left ventricular ejection fraction (LVEF) after an acute myocardial infarction (AMI). Transplanted MSCs exert a paracrine effect, which might be augmented if repeated doses are administered. This study aimed to compare the effects of single versus double transplantation of Wharton's jelly MSCs (WJ-MSCs) on LVEF post-AMI. METHODS We conducted a single-blind, randomized, multicenter trial. After 3-7 days of an AMI treated successfully by primary PCI, 70 patients younger than 65 with LVEF < 40% on baseline echocardiography were randomized to receive conventional care, a single intracoronary infusion of WJ-MSCs, or a repeated infusion 10 days later. The primary endpoint was the 6-month LVEF improvement as per cardiac magnetic resonance (CMR) imaging. RESULTS The mean baseline EF measured by CMR was similar (~ 40%) in all three groups. By the end of the trial, while all patients experienced a rise in EF, the most significant change was seen in the repeated intervention group. Compared to the control group (n = 25), single MSC transplantation (n = 20) improved the EF by 4.54 ± 2%, and repeated intervention (n = 20) did so by 7.45 ± 2% when measured by CMR imaging (P < 0.001); when evaluated by echocardiography, these values were 6.71 ± 2.4 and 10.71 ± 2.5%, respectively (P < 0.001). CONCLUSIONS Intracoronary transplantation of WJ-MSCs 3-7 days after AMI in selected patients significantly improves LVEF, with the infusion of a booster dose 10 days later augmenting this effect. TRIAL REGISTRATION Trial registration: Iranian Registry of Clinical Trials, IRCT20201116049408N1. Retrospectively Registered 20 Nov. 2020, https://en.irct.ir/trial/52357.
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Affiliation(s)
- Armin Attar
- Department of Cardiovascular Medicine, TAHA Clinical Trial Group, School of Medicine, Shiraz University of Medical Sciences, Zand Street, Shiraz, 71344-1864, Iran.
| | | | - Kamran Hessami
- School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Massoud Vosough
- Department of Regenerative Medicine, Cell Science Research Center, Royan Institute for Stem Cell Biology and Technology, ACECR, Tehran, Iran
| | - Javad Kojuri
- Department of Cardiovascular Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mani Ramzi
- Hematopathology and Molecular Pathology Service, Department of Pathology, Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, 71344-1864, Iran
| | | | - Marjan Faghih
- Department of Biostatistics, School of Medicine, Arak University of Medical Sciences, Arak, Iran
| | - Ahmad Monabati
- Hematopathology and Molecular Pathology Service, Department of Pathology, Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, 71344-1864, Iran.
- Department of Pathology, Shiraz University of Medical Sciences, Shiraz, Iran.
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Whole-Heart Tissue Engineering and Cardiac Patches: Challenges and Promises. BIOENGINEERING (BASEL, SWITZERLAND) 2023; 10:bioengineering10010106. [PMID: 36671678 PMCID: PMC9855348 DOI: 10.3390/bioengineering10010106] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/02/2023] [Accepted: 01/05/2023] [Indexed: 01/15/2023]
Abstract
Despite all the advances in preventing, diagnosing, and treating cardiovascular disorders, they still account for a significant part of mortality and morbidity worldwide. The advent of tissue engineering and regenerative medicine has provided novel therapeutic approaches for the treatment of various diseases. Tissue engineering relies on three pillars: scaffolds, stem cells, and growth factors. Gene and cell therapy methods have been introduced as primary approaches to cardiac tissue engineering. Although the application of gene and cell therapy has resulted in improved regeneration of damaged cardiac tissue, further studies are needed to resolve their limitations, enhance their effectiveness, and translate them into the clinical setting. Scaffolds from synthetic, natural, or decellularized sources have provided desirable characteristics for the repair of cardiac tissue. Decellularized scaffolds are widely studied in heart regeneration, either as cell-free constructs or cell-seeded platforms. The application of human- or animal-derived decellularized heart patches has promoted the regeneration of heart tissue through in vivo and in vitro studies. Due to the complexity of cardiac tissue engineering, there is still a long way to go before cardiac patches or decellularized whole-heart scaffolds can be routinely used in clinical practice. This paper aims to review the decellularized whole-heart scaffolds and cardiac patches utilized in the regeneration of damaged cardiac tissue. Moreover, various decellularization methods related to these scaffolds will be discussed.
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Abdolmohammadi K, Mahmoudi T, Alimohammadi M, Tahmasebi S, Zavvar M, Hashemi SM. Mesenchymal stem cell-based therapy as a new therapeutic approach for acute inflammation. Life Sci 2022; 312:121206. [PMID: 36403645 DOI: 10.1016/j.lfs.2022.121206] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 11/12/2022] [Accepted: 11/15/2022] [Indexed: 11/19/2022]
Abstract
Acute inflammatory diseases such as acute colitis, kidney injury, liver failure, lung injury, myocardial infarction, pancreatitis, septic shock, and spinal cord injury are significant causes of death worldwide. Despite advances in the understanding of its pathophysiology, there are many restrictions in the treatment of these diseases, and new therapeutic approaches are required. Mesenchymal stem cell-based therapy due to immunomodulatory and regenerative properties is a promising candidate for acute inflammatory disease management. Based on preclinical results, mesenchymal stem cells and their-derived secretome improved immunological and clinical parameters. Furthermore, many clinical trials of acute kidney, liver, lung, myocardial, and spinal cord injury have yielded promising results. In this review, we try to provide a comprehensive view of mesenchymal stem cell-based therapy in acute inflammatory diseases as a new treatment approach.
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Affiliation(s)
- Kamal Abdolmohammadi
- Department of Immunology, School of Medicine, Iranshahr University of Medical Sciences, Iranshahr, Iran
| | - Tayebeh Mahmoudi
- 17 Shahrivar Hospital, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mina Alimohammadi
- Department of Immunology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Safa Tahmasebi
- Department of Immunology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahdi Zavvar
- Department of Medical Laboratory Sciences, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Mahmoud Hashemi
- Department of Immunology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Medical Nanothechnology and Tissue Engineering Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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Chen KH, Lin HS, Li YC, Sung PH, Chen YL, Yin TC, Yip HK. Synergic Effect of Early Administration of Probiotics and Adipose-Derived Mesenchymal Stem Cells on Alleviating Inflammation-Induced Chronic Neuropathic Pain in Rodents. Int J Mol Sci 2022; 23:ijms231911974. [PMID: 36233275 PMCID: PMC9570240 DOI: 10.3390/ijms231911974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 10/05/2022] [Accepted: 10/06/2022] [Indexed: 11/05/2022] Open
Abstract
This study investigated the hypothesis that probiotics enhanced the therapeutic effect of adipose-derived mesenchymal stem cells (ADMSCs) on alleviating neuropathic pain (NP) due to chronic constriction injury (CCI) mainly through regulating the microbiota in rats. SD rats (n = 50) were categorized into group 1 (sham-control), group 2 (NP), group 3 (NP + probiotics (i.e., 1.5 billion C.F.U./day/rat, orally 3 h after NP procedure, followed by QOD 30 times)), group 4 (NP + ADMSCs (3.0 × 105 cells) 3 h after CCI procedure, followed by QOD six times (i.e., seven times in total, i.e., mimic a clinical setting of drug use) and group 5 (NP + probiotics + ADMSCs (3.0 × 105 cells)) and euthanized by day 60 after NP induction. By day 28 after NP induction, flow-cytometric analysis showed circulating levels of early (AN-V+/PI−) and late (AN-V+/PI+) apoptotic, and three inflammatory (CD11b-c+, Ly6G+ and MPO+) cells were lowest in group 1 and significantly progressively reduced in groups 2 to 5 (all p < 0.0001). By days 7, 14, 21, 28, and 60 after CCI, the thresholds of thermal paw withdrawal latency (PWL) and mechanical paw withdrawal threshold (PWT) were highest in group 1 and significantly progressively increased in groups 2 to 5 (all p < 0.0001). Numbers of pain-connived cells (Nav1.8+/peripherin+, p-ERK+/peripherin+, p-p38+/peripherin+ and p-p38+/NF200+) and protein expressions of inflammatory (p-NF-κB, IL-1ß, TNF-α and MMP-9), apoptotic (cleaved-caspase-3, cleaved-PARP), oxidative-stress (NOX-1, NOX-2), DNA-damaged (γ-H2AX) and MAPK-family (p-P38, p-JNK, p-ERK1/2) biomarkers as well as the protein levels of Nav.1.3, Nav.1.8, and Nav.1.9 in L4-L5 in dorsal root ganglia displayed an opposite pattern of mechanical PWT among the groups (all p < 0.0001). In conclusion, combined probiotic and ADMSC therapy was superior to merely one for alleviating CCI-induced NP mainly through suppressing inflammation and oxidative stress.
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Affiliation(s)
- Kuan-Hung Chen
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
| | - Hung-Sheng Lin
- Division of Neurology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
| | - Yi-Chen Li
- Center of Cell Therapy, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan
| | - Pei-Hsun Sung
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
| | - Yi-Ling Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
| | - Tsung-Cheng Yin
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
- Correspondence: (T.-C.Y.); (H.-K.Y.)
| | - Hon-Kan Yip
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
- Institute for Translational Research in Biomedicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan
- Center for Shockwave Medicine and Tissue Engineering, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Department of Medical Research, China Medical University Hospital, China Medical University, Taichung 40402, Taiwan
- Department of Nursing, Asia University, Taichung 41354, Taiwan
- Division of Cardiology, Department of Internal Medicine, Xiamen Chang Gung Hospital, Xiamen 361028, China
- Correspondence: (T.-C.Y.); (H.-K.Y.)
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