Tissue Engineering Strategies for Myocardial Regeneration: Acellular Versus Cellular Scaffolds?

Engineering Functional Cardiac Tissues for Regenerative Medicine Applications

PURPOSE OF REVIEW

Tissue engineering has expanded into a highly versatile manufacturing landscape that holds great promise for advancing cardiovascular regenerative medicine. In this review, we provide a summary of the current state-of-the-art bioengineering technologies used to create functional cardiac tissues for a variety of applications in vitro and in vivo.

RECENT FINDINGS

Studies over the past few years have made a strong case that tissue engineering is one of the major driving forces behind the accelerating fields of patient-specific regenerative medicine, precision medicine, compound screening, and disease modeling. To date, a variety of approaches have been used to bioengineer functional cardiac constructs, including biomaterial-based, cell-based, and hybrid (using cells and biomaterials) approaches. While some major progress has been made using cellular approaches, with multiple ongoing clinical trials, cell-free cardiac tissue engineering approaches have also accomplished multiple breakthroughs, although drawbacks remain. This review summarizes the most promising methods that have been employed to generate cardiovascular tissue constructs for basic science or clinical applications. Further, we outline the strengths and challenges that are inherent to this field as a whole and for each highlighted technology.

Cardiac tissue-derived extracellular matrix scaffolds for myocardial repair: advantages and challenges

Decellularized extracellular matrix (dECM) derived from myocardium has been widely explored as a nature scaffold for cardiac tissue engineering applications. Cardiac dECM offers many unique advantages such as preservation of organ-specific ECM microstructure and composition, demonstration of tissue-mimetic mechanical properties and retention of biochemical cues in favor of subsequent recellularization. However, current processes of dECM decellularization and recellularization still face many challenges including the need for balance between cell removal and extracellular matrix preservation, efficient recellularization of dECM for obtaining homogenous cell distribution, tailoring material properties of dECM for enhancing bioactivity and prevascularization of thick dECM. This review summarizes the recent progresses of using dECM scaffold for cardiac repair and discusses its major advantages and challenges for producing biomimetic cardiac patch.

Printability and Cell Viability in Bioprinting Alginate Dialdehyde-Gelatin Scaffolds

Three-dimensional (3D) bioprinting is a promising technique used to fabricate scaffolds from hydrogels with living cells. However, the printability of hydrogels in bioprinting has not been adequately studied. The aim of this study was to quantitatively characterize the printability and cell viability of alginate dialdehyde (ADA)-gelatin (Gel) hydrogels for bioprinting. ADA-Gel hydrogels of various concentrations were synthesized and characterized using Fourier transform infrared spectroscopy, along with rheological tests for measuring storage and loss moduli. Scaffolds (with an area of 11 × 11 mm) of 1, 2, and 13 layers were fabricated from ADA-Gel hydrogels using a 3D-bioplotter under printing conditions with and without the use of cross-linker, respectively, at room temperature and at 4 °C. Scaffolds were then quantitatively assessed in terms of the minimum printing pressure, quality of strands and pores, and structural integrity, which were combined together for the characterization of ADA-Gel printability. For the assessment of cell viability, scaffolds were bioprinted from ADA-Gel hydrogels with human umbilical vein endothelial cells (HUVECs) and rat Schwann cells and were then examined at day 7 with live/dead assay. HUVECs and Schwann cells were used as models to demonstrate biocompatibility for potential angiogenesis and nerve repair applications, respectively. Our results illustrated that ADA-Gel hydrogels with a loss tangent (ratio of loss modulus over storage modulus) between 0.24 and 0.28 could be printed in cross-linker with the best printability featured by uniform strands, square pores, and good structural integrity. Additionally, our results revealed that ADA-Gel hydrogels with an appropriate printability could maintain cell viability over 7 days. Combined together, this study presents a novel method to characterize the printability of hydrogels in bioprinting and illustrates that ADA-Gel hydrogels can be synthesized and bioprinted with good printability and cell viability, thus demonstrating their suitability for bioprinting scaffolds in tissue engineering applications.

Isolation, Characterization, and Agent-Based Modeling of Mesenchymal Stem Cells in a Bio-construct for Myocardial Regeneration Scaffold Design

Regenerative medicine involves methods to control and modify normal tissue repair processes. Polymer and cell constructs are under research to create tissue that replaces the affected area in cardiac tissue after myocardial infarction (MI). The aim of the present study is to evaluate the behavior of differentiated and undifferentiated mesenchymal stem cells (MSCs) in vitro and in silico and to compare the results that both offer when it comes to the design process of biodevices for the treatment of infarcted myocardium in biomodels. To assess in vitro behavior, MSCs are isolated from rat bone marrow and seeded undifferentiated and differentiated in multiple scaffolds of a gelled biomaterial. Subsequently, cell behavior is evaluated by trypan blue and fluorescence microscopy, which showed that the cells presented high viability and low cell migration in the biomaterial. An agent-based model intended to reproduce as closely as possible the behavior of individual MSCs by simulating cellular-level processes was developed, where the in vitro results are used to identify parameters in the agent-based model that is developed, and which simulates cellular-level processes: Apoptosis, differentiation, proliferation, and migration. Thanks to the results obtained, suggestions for good results in the design and fabrication of the proposed scaffolds and how an agent-based model can be helpful for testing hypothesis are presented in the discussion. It is concluded that assessment of cell behavior through the observation of viability, proliferation, migration, inflammation reduction, and spatial composition in vitro and in silico, represents an appropriate strategy for scaffold engineering.

Engineered Electrospun Polyurethane Composite Patch Combined with Bi-functional Components Rendering High Strength for Cardiac Tissue Engineering

Cardiovascular application of nanomaterial's is of increasing demand and its usage is limited by its mechanical and blood compatible properties. In this work, an attempt is made to develop an electrospun novel nanocomposite loaded with basil oil and titanium dioxide (TiO2) particles. The composite material displayed increase in hydrophobic and reduced fiber diameter compared to the pristine polymer. Fourier transform infrared spectroscopy results showed the interaction of the pristine polymer with the added substances. Thermal analysis showed the increased onset degradation, whereas the mechanical testing portrayed the increased tensile strength of the composites. Finally, the composite delayed the coagulation times and also rendered safe environment for red blood cells signifying its suitability to be used in contact with blood. Strikingly, the cellular toxicity of the developed composite was lower than the pristine polymer suggesting its compatible nature with the surrounding tissues. With these promising characteristics, developed material with enhanced physicochemical properties and blood compatibility can be successfully utilized for cardiac tissue applications.

Cardiac Protective Engineering

Cardioprotective engineering is an emerging bioengineering discipline aiming to develop engineering strategies to optimize cardioprotective actions against cardiac injuries and disorders. Although there exist innate cardioprotective mechanisms capable of supporting cardiomyocyte survival in response to an insult, not all these mechanisms are optimized in promptness and effectiveness, suggesting the necessity of cardioprotective engineering. Various cardioprotective strategies have been developed and used in experimental and clinical investigations; however, few of these strategies have exerted a significant clinical impact. There are two major challenges in cardioprotective engineering - understanding the innate cardioprotective mechanisms and developing engineering strategies for precise control of the types, levels, timing, and coordination of cardioprotective actions to facilitate recovery from injuries and disorders. Understanding the innate mechanisms is the foundation for developing cardioprotective engineering strategies. Here, ischemic myocardial injury is used as an example to demonstrate the concept of cardioprotective engineering.

A review: Nanofibrous scaffold in possible prevention and treatment of coronary artery disease

Nanofibrous scaffolds have potential to improve coronary stent applications by promoting endothelial recovery on the stent surface and aids regeneration of cardiac tissues. Presently, scaffolds fabricated via electro-spinning are been widely used because of their ability to bio-mimic the precise anatomical structure of the protein fibers. Properties like convenience to spin on several components and functionalization with several bioactive molecules have signify the use of nanofibrous scaffolds for tissue engineering. This review highlights some recent applications of electrospun nanofibrous scaffolds in the treatment and management of cardiac arterial diseases and engineering new cardiac tissues.

3D printing approaches for cardiac tissue engineering and role of immune modulation in tissue regeneration

Conventional tissue engineering, cell therapy, and current medical approaches were shown to be successful in reducing mortality rate and complications caused by cardiovascular diseases (CVDs). But still they have many limitations to fully manage CVDs due to complex composition of native myocardium and microvascularization. Fabrication of fully functional construct to replace infarcted area or regeneration of progenitor cells is important to address CVDs burden. Three-dimensional (3D) printed scaffolds and 3D bioprinting technique have potential to develop fully functional heart construct that can integrate with native tissues rapidly. In this review, we presented an overview of 3D printed approaches for cardiac tissue engineering, and advances in 3D bioprinting of cardiac construct and models. We also discussed role of immune modulation to promote tissue regeneration.

Evaluating the efficacy of tissue-engineered human amniotic membrane in the treatment of myocardial infarction

AIM

The aim of this study was to evaluate the efficacy of tissue-engineered amniotic membrane (AM) in the treatment of myocardial infarction lesions.

MATERIALS & METHODS

20 rats were subjected to coronary arterial ligation in order to induce myocardial infarction injury. Decellularized human AMs were seeded with 2 × 10⁵ adipose-derived mesenchymal stem cells and were implanted in the infarcted hearts.

RESULTS & CONCLUSION

Histological and immunohistochemical evaluations indicated the regeneration of cardiomyocytes and reduction of inflammation and fibrosis in the patch-implanted group compared with a control group, 14 days after the surgery. Terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate biotin nick-end labeling assay was suggestive for apoptosis reduction in the patch-implanted specimens. This study suggested that human AM can be developed into a novel treatment for treating postmyocardial infarction.

Bioactive scaffolds in stem-cell-based therapies for cardiac repair: protocol for a meta-analysis of randomized controlled preclinical trials in animal myocardial infarction models

BACKGROUND

Acute myocardial infarction (MI) remains one of the leading causes of death worldwide with no curative therapy available. Stem cell therapies have been gaining interest as a means to repair the cardiac tissue after MI and prevent the onset of heart failure. Many in vivo reports suggest that the use of stem cells is promising, yet clinical trials suggest that the cells fail to integrate into the native tissue, resulting in limited improvements in cardiac function and repair. To battle this limitation, the combination of using stem cells embedded in a bioactive scaffold that promotes cell retention is growing in interest. Yet, a systematic review of the literature on the use of stem cells embedded in bioactive scaffolds for cardiac repair has not yet been performed. In this protocol, we outline a systematic review and meta-analysis of preclinical trials in animal MI models that utilize stem cell-embedded scaffolds for cardiac repair and compare their effects to stem cell-treated animals without the use of a scaffold.

METHODS/DESIGN

We will search the following electronic databases: Cochrane Library, MEDLINE, Embase, PubMed, Scopus and Web of Science, and gray literature: Canadian Agency for Drugs and Technologies in Health and Google Scholar. We will only include randomly controlled preclinical trials that have directly investigated the effects of stem cells embedded in a scaffold for cardiac repair in an animal MI model. Two investigators will independently review each article included in the final analysis. The primary endpoint that will be investigated is left ventricular ejection fraction. Secondary endpoints will include infarct size, end systolic volume, end diastolic volume, fractional shortening and left ventricular wall thickness. Pooled analyses will be conducted using the DerSimonian-Laird random effects and Mantel-Haenszel fixed-effect models. Between-studies heterogeneity will be quantified and determined using the Tau2 and I2 statistics. Publication bias will be assessed using visual inspection of funnel plots and complemented by Begg's and Egger's statistical tests. Possible sources of heterogeneity will be assessed using subgroup-meta analysis and meta-regression.

DISCUSSION

To date, the use of scaffolds in myocardial repair has not yet been systematically reviewed. The results of this meta-analysis will aid in determining the efficacy of stem cell-embedded scaffolds for cardiac repair and help bring this therapy to the clinic.

Transplantation of Cardiac Mesenchymal Stem Cell-Derived Exosomes for Angiogenesis

We demonstrated the effects of exosomes secreted by cardiac mesenchymal stem cells (C-MSC-Exo) in protecting acute ischemic myocardium from reperfusion injury. To investigate the effect of exosomes from C-MSC on angiogenesis, we injected C-MSC-Exo or PBS intramuscularly into ischemic hind limb. Blood perfusion of limb was evaluated by laser Doppler Imaging. We observed that ischemic limb treated with C-MSC-Exo exhibits improved blood perfusion compared to ischemic limb treated with PBS at 2 weeks and 1 month after induction of limb ischemia. To explore the potential mechanisms underlying C-MSC-Exo's angiogenetic effect, we performed microRNA array analysis and identify mmu-miR-7116-5p as the most abundant enriched miRNA detected in C-MSC-Exo. Bioinformatics' analysis shows that miR-7116-5p negatively regulates protein polyubiquitination. In conclusion, our study demonstrated that intramuscular delivery of C-MSC-Exo after limb ischemia improves blood perfusion, and we identified the most abundant miRNAs that are preferentially enriched in C-MSC-Exo.

Interfacial tissue engineering of heart regenerative medicine based on soft cell-porous scaffolds

Myocardial infarction (MI), occurs when the coronary artery is occluded resulting in the hypoxia of areas in heart tissue, is increasing in recent years because of the population ageing and lifestyle changes. Currently, there is no ideal therapeutic scheme because of the limitation of MI therapeutic strategies due to the lack of regenerative ability of the heart cells in adult humans. Recent advances in tissue engineering and regenerative medicine brings hope to the MI therapy and current studies are focusing on restoring the function and structure of damaged tissue by delivering exogenous cells or stimulating endogenous heart cells. However, attempts to directly inject stem cells or cardiomyocytes to the infract zone often lead to rapid cell death and abundant cell loss. To address this challenge, various soft repair cells and porous scaffold materials have been integrated to improve cell retention and engraftment and preventing left ventricle (LV) dilatation. In this article, we will review the current method for heart regeneration based on soft cell-porous scaffold interfacial tissue engineering including common stem cell types, biomaterials, and cardiac patch and will discuss potential future directions in this area.

Strategies for directing cells into building functional hearts and parts

The increasing population of patients with heart disease and the limited availability of organs for transplantation have encouraged multiple strategies to fabricate healthy implantable cardiac tissues. One of the main challenges in cardiac tissue engineering is to direct cell behaviors to form functional three-dimensional (3D) biomimetic constructs. This article provides a brief review on various cell sources used in cardiac tissue engineering and highlights the effect of scaffold-based signals such as topographical and biochemical cues and stiffness. Then, conventional and novel micro-engineered bioreactors for the development of functional cardiac tissues will be explained. Bioreactor-based signals including mechanical and electrical cues to control cardiac cell behavior will also be elaborated in detail. Finally, the application of computational fluid dynamics to design suitable bioreactors will be discussed. This review presents the current state-of-the-art, emerging directions and future trends that critically appraise the concepts involved in various approaches to direct cells for building functional hearts and heart parts.

Mesenchymal Stem Cell-Based Therapy for Cardiovascular Disease: Progress and Challenges

Administration of mesenchymal stem cells (MSCs) to diseased hearts improves cardiac function and reduces scar size. These effects occur via the stimulation of endogenous repair mechanisms, including regulation of immune responses, tissue perfusion, inhibition of fibrosis, and proliferation of resident cardiac cells, although rare events of transdifferentiation into cardiomyocytes and vascular components are also described in animal models. While these improvements demonstrate the potential of stem cell therapy, the goal of full cardiac recovery has yet to be realized in either preclinical or clinical studies. To reach this goal, novel cell-based therapeutic approaches are needed. Ongoing studies include cell combinations, incorporation of MSCs into biomaterials, or pre-conditioning or genetic manipulation of MSCs to boost their release of paracrine factors, such as exosomes, growth factors, microRNAs, etc. All of these approaches can augment therapeutic efficacy. Further study of the optimal route of administration, the correct dose, the best cell population(s), and timing for treatment are parameters that still need to be addressed in order to achieve the goal of complete cardiac regeneration. Despite significant progress, many challenges remain.

Macrophages' Role in Tissue Disease and Regeneration

Inflammation is an essential component of the normal mammalian host tissue response and plays an important role during cardiovascular and musculoskeletal diseases. Given the important role of inflammation on the host tissue response after injury, understanding this process represents essential aspects of biomedical research, tissue engineering, and regenerative medicine. Macrophages are central players during the inflammatory response with an extensive role during wound healing. These cells exhibit a spectrum of activation states that span from pro-inflammatory to pro-healing phenotypes. The phenotype of the macrophages can have profound influences on the progression of disease or injury. As such, understanding and subsequent modulation of macrophage phenotype represents an exciting target area for regenerative medicine therapies. In this chapter, we describe the role of macrophages in specific cases of injury and disease. After myocardial infarction, a biphasic response of pro- and anti-inflammatory macrophages are involved in the remodeling process. In volumetric muscle loss, there is an intricate communication between inflammatory cells and progenitor cells affecting repair processes. Osteoarthritis is characterized by increased levels of pro-inflammatory macrophages over an extended period of time with significant impact on the progression of the disease. By harnessing the complex role of macrophages, enhanced therapeutic treatments can be developed that enhance the normal healing response as well as help the survival of therapeutic cells delivered to the site of injury.