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Yu YS, Park SH, Choi SY, Lee HJ, Son KH, Lee JW, Kim SW. Cell-Free Biomimetic Tracheal Graft via Hybrid 3D Printing for Enhanced Tracheal Reconstruction. Adv Healthc Mater 2025; 14:e2404648. [PMID: 40223422 DOI: 10.1002/adhm.202404648] [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: 11/21/2024] [Revised: 03/31/2025] [Indexed: 04/15/2025]
Abstract
When the trachea is excessively damaged because of diseases, accidents, or surgery, it is difficult to achieve both mucosal reconstruction and structural stability using current technologies. Here, a biomimetic tracheal graft (BTG) is developed through a hybrid process of 3D printing and electrospinning using polycaprolactone (PCL)polymer. First, a flexible PCL tracheal frame with a high rotation angle is prepared using 3D printing. Second, PCL nanofibers for mucosal reconstruction are placed inside the lumen, and PCL microfibers are placed on the outside of the frame to promote blood vessel formation. Air-liquid interface cultures of human bronchial epithelial cells on the nanofibers demonstrated the generation of epithelium, goblet cells, and ciliated cells after 14 days. Chondrocyte cultures and co-cultures of chondrocytes and human umbilical vein endothelial cells confirmed higher cell attachment and survival on the BTG than on the conventional tracheal graft (CTG). In a rabbit tracheal defect model, transplantation of the BTG and CTG revealed smooth cell infiltration and proliferation in the BTG, leading to the formation of epithelial, vascular, and connective tissues after 8 weeks without tracheal obstruction. These results demonstrate that the transplantation of cell-free biomimetic grafts alone is effective for reconstructing damaged tracheal tissue.
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Affiliation(s)
- Young Su Yu
- Department of Molecular Medicine, College of Medicine, Gachon University, 155, Gaetbeol-ro, Yeonsu-ku, Incheon, 21999, Republic of Korea
| | - Sun Hwa Park
- Postech-Catholic Biomedical Engineering Institute, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Seon Young Choi
- Department of Thoracic and Cardiovascular Surgery, Gil Medical Center, College of Medicine, Gachon University, 21, Namdong-daero 774 Beon-gil, Namdong-gu, Incheon, 21565, Republic of Korea
| | - Hyun Ji Lee
- Postech-Catholic Biomedical Engineering Institute, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Kuk Hui Son
- Department of Thoracic and Cardiovascular Surgery, Gil Medical Center, College of Medicine, Gachon University, 21, Namdong-daero 774 Beon-gil, Namdong-gu, Incheon, 21565, Republic of Korea
| | - Jin Woo Lee
- Department of Molecular Medicine, College of Medicine, Gachon University, 155, Gaetbeol-ro, Yeonsu-ku, Incheon, 21999, Republic of Korea
| | - Sung Won Kim
- Postech-Catholic Biomedical Engineering Institute, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
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Kapat K, Gondane P, Kumbhakarn S, Takle S, Sable R. Challenges and Opportunities in Developing Tracheal Substitutes for the Recovery of Long-Segment Defects. Macromol Biosci 2024; 24:e2400054. [PMID: 39008817 DOI: 10.1002/mabi.202400054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 06/21/2024] [Indexed: 07/17/2024]
Abstract
Tracheal resection and reconstruction procedures are necessary when stenosis, tracheomalacia, tumors, vascular lesions, or tracheal injury cause a tracheal blockage. Replacement with a tracheal substitute is often recommended when the trauma exceeds 50% of the total length of the trachea in adults and 30% in children. Recently, tissue engineering and other advanced techniques have shown promise in fabricating biocompatible tracheal substitutes with physical, morphological, biomechanical, and biological characteristics similar to native trachea. Different polymers and biometals are explored. Even with limited success with tissue-engineered grafts in clinical settings, complete healing of tracheal defects remains a substantial challenge due to low mechanical strength and durability of the graft materials, inadequate re-epithelialization and vascularization, and restenosis. This review has covered a range of reconstructive and regenerative techniques, design criteria, the use of bioprostheses and synthetic grafts for the recovery of tracheal defects, as well as the traditional and cutting-edge methods of their fabrication, surface modification for increased immuno- or biocompatibility, and associated challenges.
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Affiliation(s)
- Kausik Kapat
- Department of Medical Devices, National Institute of Pharmaceutical Education and Research Kolkata, 168, Maniktala Main Road, Kankurgachi, Kolkata, West Bengal, 700054, India
| | - Prashil Gondane
- Department of Medical Devices, National Institute of Pharmaceutical Education and Research Kolkata, 168, Maniktala Main Road, Kankurgachi, Kolkata, West Bengal, 700054, India
| | - Sakshi Kumbhakarn
- Department of Medical Devices, National Institute of Pharmaceutical Education and Research Kolkata, 168, Maniktala Main Road, Kankurgachi, Kolkata, West Bengal, 700054, India
| | - Shruti Takle
- Department of Medical Devices, National Institute of Pharmaceutical Education and Research Kolkata, 168, Maniktala Main Road, Kankurgachi, Kolkata, West Bengal, 700054, India
| | - Rahul Sable
- Department of Medical Devices, National Institute of Pharmaceutical Education and Research Kolkata, 168, Maniktala Main Road, Kankurgachi, Kolkata, West Bengal, 700054, India
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Martins RS, Weber J, Drake L, Latif MJ, Poulikidis K, Razi SS, Luo J, Bhora FY. Improved Composite Hydrogel for Bioengineered Tracheal Graft Demonstrates Effective Early Angiogenesis. J Clin Med 2024; 13:5148. [PMID: 39274364 PMCID: PMC11396371 DOI: 10.3390/jcm13175148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 08/19/2024] [Accepted: 08/26/2024] [Indexed: 09/16/2024] Open
Abstract
Background/Objectives: Collagen-agarose hydrogel blends currently used in tracheal graft bioengineering contain relatively high concentrations of collagen to withstand mechanical stresses associated with native trachea function (e.g., breathing). Unfortunately, the high collagen content restricts effective cell infiltration into the hydrogel. In this study, we created an improved hydrogel blend with lower concentrations of collagen (<5 mg/mL) and characterized its capacity for fibroblast invasion and angiogenesis. Methods: Four collagen-agarose hydrogel blends were created: 1 mg/mL type 1 collagen (T1C) and 0.25% agarose, 1 mg/mL T1C and 0.125% agarose, 2 mg/mL T1C and 0.25% agarose, and 2 mg/mL T1C and 0.125% agarose. The hydrogel surface was seeded with fibroblasts, while both endothelial cells and fibroblasts (3:1 ratio) were mixed within the hydrogel matrix. We assessed early angiogenesis by observing fibroblast migration and endothelial cell morphology (elongation and branching) at 7 days. In addition, we performed immunostaining for alpha-smooth muscle actin (aSMA) and explored the gene expression of various angiogenic markers (including vascular endothelial growth factor; VEGF). Results: Gels with lower agarose concentrations (0.125%) with 1 or 2 mg/mL T1C were more effective in allowing early attachment and migration of surface-applied fibroblasts compared to gels with higher (0.25%) agarose concentrations. The low-agarose gels also allowed cells to quickly adopt a spread morphology and self-assemble into elongated structures indicative of early angiogenesis, while demonstrating positive immunostaining for aSMA and increased gene expression of VEGF by day 7. Conclusions: Hydrogel blends with collagen and low agarose concentrations may be effective in allowing early cellular infiltration and angiogenesis, making such gels a suitable cell substrate for use in the development of composite bioengineered tracheal grafts. The collagen-agarose hydrogel blend is meant to be cast around a three-dimensional (3D) printed polycaprolactone support structure and wrapped in porcine small intestine submucosa ECM to create an off-the-shelf bioengineered tracheal implant.
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Affiliation(s)
- Russell Seth Martins
- Division of Thoracic Surgery, Department of Surgery, Hackensack Meridian School of Medicine, Hackensack Meridian Health (HMH) Network, Edison, NJ 08820, USA
| | - Joanna Weber
- Division of Thoracic Surgery, Department of Surgery, Hackensack Meridian School of Medicine, Hackensack Meridian Health (HMH) Network, Edison, NJ 08820, USA
| | - Lauren Drake
- Department of Surgery, Nuvance Health, Danbury, CT 06810, USA
| | - M Jawad Latif
- Division of Thoracic Surgery, Department of Surgery, Hackensack Meridian School of Medicine, Hackensack Meridian Health (HMH) Network, Edison, NJ 08820, USA
| | - Kostantinos Poulikidis
- Division of Thoracic Surgery, Department of Surgery, Hackensack Meridian School of Medicine, Hackensack Meridian Health (HMH) Network, Edison, NJ 08820, USA
| | - Syed Shahzad Razi
- Division of Thoracic Surgery, Department of Surgery, Hackensack Meridian School of Medicine, Hackensack Meridian Health (HMH) Network, Edison, NJ 08820, USA
| | - Jeffrey Luo
- Division of Thoracic Surgery, Department of Surgery, Hackensack Meridian School of Medicine, Hackensack Meridian Health (HMH) Network, Edison, NJ 08820, USA
| | - Faiz Y Bhora
- Division of Thoracic Surgery, Department of Surgery, Hackensack Meridian School of Medicine, Hackensack Meridian Health (HMH) Network, Edison, NJ 08820, USA
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Martins RS, Weber J, Johnson B, Luo J, Poulikidis K, Latif MJ, Razi SS, Al Shetawi AH, Lebovics RS, Bhora FY. Identifying Molecular Pathophysiology and Potential Therapeutic Options in Iatrogenic Tracheal Stenosis. Biomedicines 2024; 12:1323. [PMID: 38927530 PMCID: PMC11201234 DOI: 10.3390/biomedicines12061323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 06/07/2024] [Accepted: 06/11/2024] [Indexed: 06/28/2024] Open
Abstract
INTRODUCTION While most patients with iatrogenic tracheal stenosis (ITS) respond to endoscopic ablative procedures, approximately 15% experience a recalcitrant, recurring disease course that is resistant to conventional management. We aimed to explore genetic profiles of patients with recalcitrant ITS to understand underlying pathophysiology and identify novel therapeutic options. METHODS We collected 11 samples of granulation tissue from patients with ITS and performed RNA sequencing. We identified the top 10 most highly up- and down-regulated genes and cellular processes that these genes corresponded to. For the most highly dysregulated genes, we identified potential therapeutic options that favorably regulate their expression. RESULTS The dysregulations in gene expression corresponded to hyperkeratinization (upregulation of genes involved in keratin production and keratinocyte differentiation) and cellular proliferation (downregulation of cell cycle regulating and pro-apoptotic genes). Genes involved in retinoic acid (RA) metabolism and signaling were dysregulated in a pattern suggesting local cellular RA deficiency. Consequently, RA also emerged as the most promising potential therapeutic option for ITS, as it favorably regulated seven of the ten most highly dysregulated genes. CONCLUSION This is the first study to characterize the role of hyperkeratinization and dysregulations in RA metabolism and signaling in the disease pathophysiology. Given the ability of RA to favorably regulate key genes involved in ITS, future studies must explore its efficacy as a potential therapeutic option for patients with recalcitrant ITS.
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Affiliation(s)
- Russell Seth Martins
- Division of Thoracic Surgery, Department of Surgery, Hackensack Meridian School of Medicine, Hackensack Meridian Health (HMH) Network, Edison, NJ 08820, USA; (R.S.M.); (J.W.); (J.L.); (K.P.); (M.J.L.); (S.S.R.)
| | - Joanna Weber
- Division of Thoracic Surgery, Department of Surgery, Hackensack Meridian School of Medicine, Hackensack Meridian Health (HMH) Network, Edison, NJ 08820, USA; (R.S.M.); (J.W.); (J.L.); (K.P.); (M.J.L.); (S.S.R.)
| | - Bryan Johnson
- Department of Surgery, Mount Carmel Health System, Columbus, OH 43213, USA;
| | - Jeffrey Luo
- Division of Thoracic Surgery, Department of Surgery, Hackensack Meridian School of Medicine, Hackensack Meridian Health (HMH) Network, Edison, NJ 08820, USA; (R.S.M.); (J.W.); (J.L.); (K.P.); (M.J.L.); (S.S.R.)
| | - Kostantinos Poulikidis
- Division of Thoracic Surgery, Department of Surgery, Hackensack Meridian School of Medicine, Hackensack Meridian Health (HMH) Network, Edison, NJ 08820, USA; (R.S.M.); (J.W.); (J.L.); (K.P.); (M.J.L.); (S.S.R.)
| | - Mohammed Jawad Latif
- Division of Thoracic Surgery, Department of Surgery, Hackensack Meridian School of Medicine, Hackensack Meridian Health (HMH) Network, Edison, NJ 08820, USA; (R.S.M.); (J.W.); (J.L.); (K.P.); (M.J.L.); (S.S.R.)
| | - Syed Shahzad Razi
- Division of Thoracic Surgery, Department of Surgery, Hackensack Meridian School of Medicine, Hackensack Meridian Health (HMH) Network, Edison, NJ 08820, USA; (R.S.M.); (J.W.); (J.L.); (K.P.); (M.J.L.); (S.S.R.)
| | - Al Haitham Al Shetawi
- Division of Surgical Oncology, Department of Surgery, Vassar Brothers Medical Center, Nuvance Health, Dyson Center for Cancer Care, Poughkeepsie, NY 12601, USA;
- Division of Oral and Maxillofacial Surgery, Department of Surgery, Vassar Brothers Medical Center, Nuvance Health, Poughkeepsie, NY 12601, USA
| | - Robert S. Lebovics
- Division of Otolaryngology, Department of Surgery, Hackensack Meridian School of Medicine, Hackensack Meridian Health (HMH) Network, Edison, NJ 08820, USA;
| | - Faiz Y. Bhora
- Division of Thoracic Surgery, Department of Surgery, Hackensack Meridian School of Medicine, Hackensack Meridian Health (HMH) Network, Edison, NJ 08820, USA; (R.S.M.); (J.W.); (J.L.); (K.P.); (M.J.L.); (S.S.R.)
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Weber J, Martins RS, Muslim Z, Baig MZ, Poulikidis K, Al Shetawi AH, Bhora FY. Anastomotic stenosis of bioengineered trachea grafts is driven by transforming growth factor β1-induced signaling, proinflammatory macrophages, and delayed epithelialization. JTCVS OPEN 2023; 15:489-496. [PMID: 37808012 PMCID: PMC10556948 DOI: 10.1016/j.xjon.2023.07.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 06/30/2023] [Accepted: 07/13/2023] [Indexed: 10/10/2023]
Abstract
Objective Anastomotic stenosis caused by hypertrophic granulation tissue often develops in response to orthotopically implanted bioengineered tracheal grafts. To determine mechanisms responsible for the development and persistence of this granulation tissue, we looked for changes in gene expression from tissue specimens from the graft-native interface. Methods RNA was isolated from paraffin-embedded tissue samples of the anastomotic sites of orthotopically implanted bioengineered tracheal grafts of 9 animals. Tissue samples were binned into 3 groups based on degree of stenosis: no stenosis (<5%), mild stenosis (25%-50%), and moderate and severe stenosis (≥75%). Sections of healthy trachea tissue were used as control. The expression levels of ∼200 genes related to wound healing, plus several endogenous controls, were measured with a pathway-focused predesigned primer array. Results Expression of ARG2, IL4, RPL13 A, TGFBR3, and EGFR decreased, whereas expression of RUNX2 was increased in stenotic wounds compared with nonstenotic tissue. Based on the cell types present in the trachea and wound healing, this expression profile indicates a lack of M2 anti-inflammatory macrophages, absent epithelial cells, and transforming growth factor β1-induced signaling. Conclusions These findings represent a significant step for tracheal tissue engineering by identifying several key mechanisms present in stenotic granulation tissue. Further research must be conducted to determine what modifications of the graft substrate and which coadministered therapeutics can be used to prevent the development of hypertrophic granulation tissue.
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Affiliation(s)
- Joanna Weber
- Division of Thoracic Surgery, Department of Surgery, Hackensack Meridian School of Medicine, Hackensack Meridian Health Network, Edison, NJ
| | - Russell Seth Martins
- Division of Thoracic Surgery, Department of Surgery, Hackensack Meridian School of Medicine, Hackensack Meridian Health Network, Edison, NJ
| | - Zaid Muslim
- Department of Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Kostantinos Poulikidis
- Division of Thoracic Surgery, Department of Surgery, Hackensack Meridian School of Medicine, Hackensack Meridian Health Network, Edison, NJ
| | - Al Haitham Al Shetawi
- Divisions of Surgical Oncology and Oral & Maxillofacial Surgery, Department of Surgery, Vassar Brothers Medical Center, Nuvance Health, Dyson Center for Cancer Care, Poughkeepsie, NY
| | - Faiz Y. Bhora
- Division of Thoracic Surgery, Department of Surgery, Hackensack Meridian School of Medicine, Hackensack Meridian Health Network, Edison, NJ
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Lee HY, Lee JW. Current Status and Future Outlook of Additive Manufacturing Technologies for the Reconstruction of the Trachea. J Funct Biomater 2023; 14:jfb14040196. [PMID: 37103286 PMCID: PMC10141199 DOI: 10.3390/jfb14040196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 03/27/2023] [Accepted: 03/31/2023] [Indexed: 04/05/2023] Open
Abstract
Tracheal stenosis and defects occur congenitally and in patients who have undergone tracheal intubation and tracheostomy due to long-term intensive care. Such issues may also be observed during tracheal removal during malignant head and neck tumor resection. However, to date, no treatment method has been identified that can simultaneously restore the appearance of the tracheal skeleton while maintaining respiratory function in patients with tracheal defects. Therefore, there is an urgent need to develop a method that can maintain tracheal function while simultaneously reconstructing the skeletal structure of the trachea. Under such circumstances, the advent of additive manufacturing technology that can create customized structures using patient medical image data provides new possibilities for tracheal reconstruction surgery. In this study, the three-dimensional (3D) printing and bioprinting technologies used in tracheal reconstruction are summarized, and various research results related to the reconstruction of mucous membranes, cartilage, blood vessels, and muscle tissue, which are tissues required for tracheal reconstruction, are classified. The prospects for 3D-printed tracheas in clinical studies are also described. This review serves as a guide for the development of artificial tracheas and clinical trials using 3D printing and bioprinting.
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Affiliation(s)
- Hwa-Yong Lee
- Division of Science Education, Kangwon National University, Chuncheon 24341, Republic of Korea
| | - Jin Woo Lee
- Department of Molecular Medicine, College of Medicine, Gachon University, Incheon 21999, Republic of Korea
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Greaney AM, Niklason LE. The History of Engineered Tracheal Replacements: Interpreting the Past and Guiding the Future. TISSUE ENGINEERING. PART B, REVIEWS 2021; 27:341-352. [PMID: 33045942 PMCID: PMC8390779 DOI: 10.1089/ten.teb.2020.0238] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 09/30/2020] [Indexed: 12/16/2022]
Abstract
The development of a tracheal graft to replace long-segment defects has thwarted clinicians and engineers alike for over 100 years. To better understand the challenges facing this field today, we have consolidated all published reports of engineered tracheal grafts used to repair long-segment circumferential defects in humans, from the first in 1898 to the most recent in 2018, totaling 290 clinical cases. Distinct trends emerge in the types of grafts used over time, including repair using autologous fascia, rigid tubes of various inert materials, and pretreated cadaveric allografts. Our analysis of maximum clinical follow-up, as a proxy for graft performance, revealed that the Leuven protocol has a significantly longer clinical follow-up time than all other methods of airway reconstruction. This method involves transplanting a cadaveric tracheal allograft that is first prevascularized heterotopically in the recipient. We further quantified graft-related causes of mortality, revealing failure modes that have been resolved, and those that remain a hurdle, such as graft mechanics. Finally, we briefly summarize recent preclinical work in tracheal graft development. In conclusion, we synthesized top clinical care priorities and design criteria to inform and inspire collaboration between engineers and clinicians toward the development of a functional tracheal replacement graft. Impact statement The field of tracheal engineering has floundered in recent years due to multiple article retractions. However, with recent advances in biofabrication and tissue analysis techniques, the field remains ripe for advancement through collaboration between engineers and clinicians. With a long history of clinical application of tracheal replacements, engineered tracheas are arguably the regenerative technology with the greatest potential for translation. This work describes the many phases of engineered tracheal replacements that have been applied in human patients over the past 100 years with the goal of carrying forward critical lessons into development of the next generation of engineered tracheal graft.
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Affiliation(s)
- Allison M. Greaney
- Department of Biomedical Engineering, Yale University, New Haven, Connecticut, USA
| | - Laura E. Niklason
- Department of Biomedical Engineering, Yale University, New Haven, Connecticut, USA
- Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut, USA
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Motility Improvement of Biomimetic Trachea Scaffold via Hybrid 3D-Bioprinting Technology. Polymers (Basel) 2021; 13:polym13060971. [PMID: 33810007 PMCID: PMC8004939 DOI: 10.3390/polym13060971] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/17/2021] [Accepted: 03/18/2021] [Indexed: 11/16/2022] Open
Abstract
A trachea has a structure capable of responding to various movements such as rotation of the neck and relaxation/contraction of the conduit due to the mucous membrane and cartilage tissue. However, current reported tubular implanting structures are difficult to impelement as replacements for original trachea movements. Therefore, in this study, we developed a new trachea implant with similar anatomical structure and mechanical properties to native tissue using 3D printing technology and evaluated its performance. A 250 µm-thick layer composed of polycaprolactone (PCL) nanofibers was fabricated on a rotating beam using electrospinning technology, and a scaffold with C-shaped cartilage grooves that mimics the human airway structure was printed to enable reconstruction of cartilage outside the airway. A cartilage type scaffold had a highest rotational angle (254°) among them and it showed up to 2.8 times compared to human average neck rotation angle. The cartilage type showed a maximum elongation of 8 times higher than that of the bellows type and it showed the elongation of 3 times higher than that of cylinder type. In cartilage type scaffold, gelatin hydrogel printed on the outside of the scaffold was remain 22.2% under the condition where no hydrogel was left in other type scaffolds. In addition, after 2 days of breathing test, the amount of gelatin remaining inside the scaffold was more than twice that of other scaffolds. This novel trachea scaffold with hydrogel inside and outside of the structure was well-preserved under external flow and is expected to be advantageous for soft tissue reconstruction of the trachea.
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Novel composite trachea grafts using 3-dimensional printing. JTCVS OPEN 2021; 5:152-160. [PMID: 36003188 PMCID: PMC9390405 DOI: 10.1016/j.xjon.2020.11.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 11/05/2020] [Indexed: 11/29/2022]
Abstract
Objective Porcine-derived small intestine submucosa (SIS) extracellular matrix (ECM) surgical patches claim to have greater regenerative properties compared with dermal extracellular matrices. We hypothesized that using SIS-ECM in a bioengineered composite tracheal graft would allow better incorporation into the native tissue. Methods Two types of size-matched polycaprolactone support scaffolds were designed: rigid and flexible. The SIS-ECM was wrapped around the polycaprolactone supports lining the inside and outside of the graft. The grafts were implanted in 4 Yorkshire pigs, replacing an ∼2 cm segment of native trachea. Airway patency was evaluated with computed tomography scans and explanted grafts were examined grossly and histologically. Results All animals survived through the immediate postoperative period. Generally, extraluminal examination showed a smooth transition between native and graft without significant volumetric loss. Animals that received the flexible design survived ∼10 days longer than those that received the rigid design; however, severe perianastomotic intraluminal granulation tissue was observed. The rigid design had less significant intraluminal granulation tissue development at the distal anastomosis, but partial dehiscence had occurred at the proximal anastomosis interrupting graft incorporation. Conclusions The generally good extraluminal graft incorporation in our composite tracheal graft highlights some increased regenerative capabilities of SIS-ECM. However, the presence of intraluminal granulation tissue indicates that its use as an off-the-shelf, unaltered substrate in an airway graft is still not ideal. Further research must be conducted to determine whether a modification of the substrate is possible to enhance luminal airway incorporation and to exert control over the mechanisms responsible for granulation tissue development.
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Weber JF, Rehmani SS, Baig MZ, Jadoon Y, Bhora FY. Successes and Failures in Tracheal Bioengineering: Lessons Learned. Ann Thorac Surg 2020; 112:1089-1094. [PMID: 33186605 DOI: 10.1016/j.athoracsur.2020.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 07/30/2020] [Accepted: 10/12/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Controversy in tracheal reconstruction using grafts and bioengineered constructs highlights the importance of animal studies before human application. Small animal models help to refine designs but do not adequately model sizes relevant to human anatomy. We have conducted extensive large animal studies and summarize our findings in 26 consecutive transplants. METHODS We pooled 26 large animal studies together to investigate common elements related to successes and failures. In general the engineered tracheal graft consisted of a decellularized extracellular matrix surgical patch supported by a 3-dimensional-printed plastic polymer scaffold. Circumferential graft coverage ranged from 50% to 100%, spanning the length of 4 to 6 tracheal rings. Some grafts included embedded stem cells. Control grafts were fabricated without the support scaffold. At death grafts were harvested and examined grossly and through histology. RESULTS The support scaffold prevented graft malacia and collapse. Luminal epithelialization was most extensive in grafts with smaller circumferential coverage. Smaller circumferential coverage was also associated with longest animal survival. Chondrogenesis was only observed in grafts with embedded stem cells. Survival time was shortest in 100% circumferential grafts. Granulation tissue was an issue for all graft designs. CONCLUSIONS Large animal models capture challenges and complexities relevant to human anatomy. Development of granulation tissue remains a challenge, especially in circumferential grafts. Significant additional research is needed to investigate granulation tissue formation and to provide actionable insight into its management.
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Affiliation(s)
- Joanna F Weber
- Department of Surgical Oncology, Nuvance Health, Rudy L. Ruggles Biomedical Research Institute, Danbury, Connecticut
| | - Sadiq S Rehmani
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Mirza Zain Baig
- Department of Surgical Oncology, Nuvance Health, Rudy L. Ruggles Biomedical Research Institute, Danbury, Connecticut
| | - Yamna Jadoon
- Medical College, Aga Khan University Hospital, Karachi, Pakistan
| | - Faiz Y Bhora
- Department of Surgical Oncology, Nuvance Health, Vassar Brother's Medical Center, Poughkeepsie, New York.
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Niermeyer WL, Rodman C, Li MM, Chiang T. Tissue engineering applications in otolaryngology-The state of translation. Laryngoscope Investig Otolaryngol 2020; 5:630-648. [PMID: 32864434 PMCID: PMC7444782 DOI: 10.1002/lio2.416] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 04/06/2020] [Accepted: 05/11/2020] [Indexed: 12/14/2022] Open
Abstract
While tissue engineering holds significant potential to address current limitations in reconstructive surgery of the head and neck, few constructs have made their way into routine clinical use. In this review, we aim to appraise the state of head and neck tissue engineering over the past five years, with a specific focus on otologic, nasal, craniofacial bone, and laryngotracheal applications. A comprehensive scoping search of the PubMed database was performed and over 2000 article hits were returned with 290 articles included in the final review. These publications have addressed the hallmark characteristics of tissue engineering (cellular source, scaffold, and growth signaling) for head and neck anatomical sites. While there have been promising reports of effective tissue engineered interventions in small groups of human patients, the majority of research remains constrained to in vitro and in vivo studies aimed at furthering the understanding of the biological processes involved in tissue engineering. Further, differences in functional and cosmetic properties of the ear, nose, airway, and craniofacial bone affect the emphasis of investigation at each site. While otolaryngologists currently play a role in tissue engineering translational research, continued multidisciplinary efforts will likely be required to push the state of translation towards tissue-engineered constructs available for routine clinical use. LEVEL OF EVIDENCE NA.
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Affiliation(s)
| | - Cole Rodman
- The Ohio State University College of MedicineColumbusOhioUSA
| | - Michael M. Li
- Department of Otolaryngology—Head and Neck SurgeryThe Ohio State University Wexner Medical CenterColumbusOhioUSA
| | - Tendy Chiang
- Department of OtolaryngologyNationwide Children's HospitalColumbusOhioUSA
- Department of Otolaryngology—Head and Neck SurgeryThe Ohio State University Wexner Medical CenterColumbusOhioUSA
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Stramiello JA, Saddawi-Konefka R, Ryan J, Brigger MT. The role of 3D printing in pediatric airway obstruction: A systematic review. Int J Pediatr Otorhinolaryngol 2020; 132:109923. [PMID: 32035351 DOI: 10.1016/j.ijporl.2020.109923] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 01/30/2020] [Accepted: 01/30/2020] [Indexed: 02/09/2023]
Abstract
BACKGROUND Tracheomalacia and tracheal stenosis are complicated, patient-specific diseases that require a multidisciplinary approach to diagnose and treat. Surgical interventions such as aortopexy, slide tracheoplasty, and stents potentially have high rates of morbidity. Given the emergence of three-dimensional (3D) printing as a versatile adjunct in managing complex pathology, there is a growing body of evidence that there is a strong role for 3D printing in both surgical planning and implant creation for pediatric airway obstruction. METHODS A structured PubMed.gov literature search was utilized, and a two-researcher systematic review was performed following the PRISMA criteria. The following search query was utilized: (((((3D printing) OR three-dimensional printing) OR 3D printed) OR three-dimensional printed) AND trachea) OR airway. RESULTS Over 23,000 publications were screened. Eight literature reviews and thirty-seven original papers met inclusion criteria. Of the thirty-seven original papers, eleven discussed 3D printing for surgical planning and twenty-six discussed 3D printing implants for interventions. CONCLUSION The reported application of 3D printing for management of pediatric airway obstruction is emerging with positive and broad applications. 3D printing for surgical planning not only improves pre-operative assessment of surgical approach and stent customization, but also helps facilitate patient/family education. 3D printing for custom implantable interventions is focused on bioresorbable external airway splints and biological grafts, with both animal studies and human case reports showing good results in improving symptoms.
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Affiliation(s)
- Joshua A Stramiello
- Division of Otolaryngology-Head & Neck Surgery, Department of Surgery, University of California San Diego, 200 W Arbor Dr. MC8895, San Diego, CA 92103, USA.
| | - Robert Saddawi-Konefka
- Division of Otolaryngology-Head & Neck Surgery, Department of Surgery, University of California San Diego, 200 W Arbor Dr. MC8895, San Diego, CA 92103, USA
| | - Justin Ryan
- 3D Innovations Lab, Rady Children's Hospital, 3020 Children's Way MC5166, San Diego, CA, 92123, USA
| | - Matthew T Brigger
- Division of Otolaryngology-Head & Neck Surgery, Department of Surgery, University of California San Diego, 200 W Arbor Dr. MC8895, San Diego, CA 92103, USA; Division of Pediatric Otolaryngology, Department of Surgery, Rady Children's Hospital, 3020 Children's Way, San Diego, CA, 92123, USA
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Gao B, Jing H, Gao M, Wang S, Fu W, Zhang X, He X, Zheng J. Long-segmental tracheal reconstruction in rabbits with pedicled Tissue-engineered trachea based on a 3D-printed scaffold. Acta Biomater 2019; 97:177-186. [PMID: 31352107 DOI: 10.1016/j.actbio.2019.07.043] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 07/20/2019] [Accepted: 07/24/2019] [Indexed: 12/13/2022]
Abstract
Long-segmental tracheal defects constitute an intractable clinical problem, due to the lack of satisfactory tracheal substitutes for surgical reconstruction. Tissue engineered artificial substitutes could represent a promising approach to tackle this challenge. In our current study, tissue-engineered trachea, based on a 3D-printed poly (l-lactic acid) (PLLA) scaffold with similar morphology to the native trachea of rabbits, was used for segmental tracheal reconstruction. The 3D-printed scaffolds were seeded with chondrocytes obtained from autologous auricula, dynamically pre-cultured in vitro for 2 weeks, and pre-vascularized in vivo for another 2 weeks to generate an integrated segmental trachea organoid unit. Then, segmental tracheal defects in rabbits were restored by transplanting the engineered tracheal substitute with pedicled muscular flaps. We found that the combination of in vitro pre-culture and in vivo pre-vascularization successfully generated a segmental tracheal substitute with bionic structure and mechanical properties similar to the native trachea of rabbits. Moreover, the stable blood supply provided by the pedicled muscular flaps facilitated the survival of chondrocytes and accelerated epithelialization, thereby improving the survival rate. The segmental trachea substitute engineered by a 3D-printed scaffold, in vitro pre-culture, and in vivo pre-vascularization enhanced survival in an early stage post-operation, presenting a promising approach for surgical reconstruction of long segmental tracheal defects. STATEMENT OF SIGNIFICANCE: We found that the combination of in vitro pre-culture and in vivo pre-vascularization successfully generated a segmental tracheal substitute with bionic structure and mechanical properties similar to the native trachea of rabbits. Moreover, the stable blood supply provided by the pedicled muscular flaps facilitated the survival of chondrocytes and accelerated epithelialization, thereby improving the survival rate of the rabbits. The segmental trachea substitute engineered by a 3D-printed scaffold, in vitro pre-culture, and in vivo pre-vascularization enhanced survival in an early stage post-operation, presenting a promising approach for surgical reconstruction of long segmental tracheal defects.
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Affiliation(s)
- Botao Gao
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, 1678 Dongfang Road, Shanghai 200127, People's Republic of China
| | - Hui Jing
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, 1678 Dongfang Road, Shanghai 200127, People's Republic of China
| | - Manchen Gao
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, 1678 Dongfang Road, Shanghai 200127, People's Republic of China; Department of Pediatric Cardiac Surgery, National Center for Cardiovascular Disease and Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, 167 Beilishi Road, Xicheng, Beijing 100037, People's Republic of China
| | - Shoubao Wang
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, 1678 Dongfang Road, Shanghai 200127, People's Republic of China; Department of Plastic and Reconstrucive Surgery, Shanghai 9th People's Hospital, 639 Zhi Zao Ju Road, Shanghai 200011, People's Republic of China
| | - Wei Fu
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, 1678 Dongfang Road, Shanghai 200127, People's Republic of China; Institute of Pediatric Translational Medicine, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, 1678 Dong Fang Road, Shanghai 200127, People's Republic of China
| | - Xiaoyang Zhang
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, 1678 Dongfang Road, Shanghai 200127, People's Republic of China
| | - Xiaomin He
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, 1678 Dongfang Road, Shanghai 200127, People's Republic of China
| | - Jinghao Zheng
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, 1678 Dongfang Road, Shanghai 200127, People's Republic of China.
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Chan DS, Fnais N, Ibrahim I, Daniel SJ, Manoukian J. Exploring polycaprolactone in tracheal surgery: A scoping review of in-vivo studies. Int J Pediatr Otorhinolaryngol 2019; 123:38-42. [PMID: 31059931 DOI: 10.1016/j.ijporl.2019.04.039] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 04/25/2019] [Accepted: 04/25/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Tracheal pathology can be life-threatening if not managed appropriately. There are still some surgical limitations today for certain pathologies, such as in severe tracheomalacia, or when long segments of trachea need to be resected. Poly(ε-caprolactone) (PCL) is a polymer that has recently gained popularity for its use in tracheal surgeries in animal models and in certain human pediatric cases in hopes of addressing these difficult situations. PCL can be 3D printed or manufactured through molds to create tracheal stents, splints, patches and even to reconstruct full circumferential tracheal defects. OBJECTIVE To perform a scoping review, and explore insights into the applications of PCL for tracheal surgeries in-vivo. METHODS A literature search in Embase, MEDLINE, and BIOSIS was performed to include all articles available prior to December 21, 2018 without any language restrictions. We included all original research that investigated the use of a PCL implant, stent, splint, scaffold, or graft in tracheal surgeries in-vivo. Assessment of all articles were performed by two independent authors prior to inclusion for analysis. RESULTS A total of 27 articles were included in the study. All articles were original research studies, primarily consisting of interventional studies (92.4%), there was also 2 case reports (7.4%). Articles were published in the last decade, publications range from 2009 to 2019. The most common animal model used for the tracheal surgeries were the New Zealand rabbits (n = 19, 70%). Two studies (7%) also described the use PCL in a total of 4 human cases. To investigate the PCL reconstructed airways, histology and bronchoscopy were the most commonly implemented methods of analysis in 88.9% and 70.4% respectively. Airway analysis was also done using imaging modalities including CT scan (n = 9, 33.3%), MRI (n = 2, 7.4%), X-ray (n = 1, 3.7%). 17 (62.9%) of the studies used 3D printing processes to create their PCL implants. CONCLUSIONS Overall, this review demonstrates the feasibility of PCL in tracheal reconstruction and tracheal stenting/splinting. It highlights common trends and the limitations of the literature thus far on this topic.
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Affiliation(s)
- David S Chan
- Department of Otolaryngology Head and Neck Surgery, McGill University, Montreal, Canada.
| | - Naif Fnais
- Department of Otolaryngology Head and Neck Surgery, McGill University, Montreal, Canada
| | - Iman Ibrahim
- Department of Otolaryngology Head and Neck Surgery, McGill University, Montreal, Canada
| | - Sam J Daniel
- Department of Otolaryngology Head and Neck Surgery, Montreal Children's Hospital, McGill University, Montreal, Canada
| | - John Manoukian
- Department of Otolaryngology Head and Neck Surgery, Montreal Children's Hospital, McGill University, Montreal, Canada
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Ahn CB, Son KH, Yu YS, Kim TH, Lee JI, Lee JW. Development of a flexible 3D printed scaffold with a cell-adhesive surface for artificial trachea. Biomed Mater 2019; 14:055001. [DOI: 10.1088/1748-605x/ab2a6c] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Abstract
Tracheobronchial tumors with involvement of the carina represent a challenging problem in the pulmonary surgery. Carinal resection is referred to removal and reconstruction of the airway itself, whereas concomitant removal of the lung parenchyma (usually a whole lung) is termed as carinal pneumonectomy. Thorough preoperative workup of these patients is mandatory. Meticulous surgical technique and aggressive postoperative management is required for the best outcomes in these difficult cases. In the paper authors review surgical technique, evaluation and management of this challenging patient population.
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Affiliation(s)
- Roman V Petrov
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Charles T Bakhos
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Abbas E Abbas
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
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Park JH, Park JY, Nam IC, Ahn M, Lee JY, Choi SH, Kim SW, Cho DW. A rational tissue engineering strategy based on three-dimensional (3D) printing for extensive circumferential tracheal reconstruction. Biomaterials 2018; 185:276-283. [PMID: 30261427 DOI: 10.1016/j.biomaterials.2018.09.031] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 09/17/2018] [Indexed: 01/12/2023]
Abstract
Extensive circumferential tracheal defects remain a major challenging problem in the field of tracheal reconstruction. In this study, a tissue-engineered tracheal graft based on three-dimensional (3D) printing was developed for extensive circumferential tracheal reconstruction. A native trachea-mimetic bellows scaffold, a framework for a tissue-engineered tracheal graft, was indirectly 3D printed and reinforced with ring-shaped bands made from medical grade silicone rubber. A tissue-engineered tracheal graft was then created by stratifying tracheal mucosa decellularized extracellular matrix (tmdECM) hydrogel on the luminal surface of the scaffold and transferring human inferior turbinate mesenchymal stromal cell (hTMSC) sheets onto the tmdECM hydrogel layer. The tissue-engineered tracheal graft with critical length was anastomosed end-to-end to the native trachea and complete re-epithelialization was achieved on the entire luminal surface within 2 months in a rabbit model with no post-operative complications. With this successful result, the present study reports the preliminary potential of the tissue-engineered tracheal graft as a rational tissue engineering strategy for extensive circumferential tracheal reconstruction.
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Affiliation(s)
- Jeong Hun Park
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
| | - Ju Young Park
- Department of Mechanical Engineering, Pohang University of Science and Technology (POSTECH), Pohang, South Korea
| | - Inn-Chul Nam
- Department of Otolaryngology and HNS, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Minjun Ahn
- Department of Mechanical Engineering, Pohang University of Science and Technology (POSTECH), Pohang, South Korea
| | - Jae Yeon Lee
- Department of Mechanical Engineering, Pohang University of Science and Technology (POSTECH), Pohang, South Korea
| | - Seok Hwa Choi
- Veterinary Medical Center, Chungbuk National University, Cheongju, South Korea
| | - Sung Won Kim
- Department of Otolaryngology and HNS, College of Medicine, The Catholic University of Korea, Seoul, South Korea; Department of Biomedical Science, College of Medicine, The Catholic University of Korea, Seoul, South Korea.
| | - Dong-Woo Cho
- Department of Mechanical Engineering, Pohang University of Science and Technology (POSTECH), Pohang, South Korea.
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Engineering a 3D-Bioprinted Model of Human Heart Valve Disease Using Nanoindentation-Based Biomechanics. NANOMATERIALS 2018; 8:nano8050296. [PMID: 29751516 PMCID: PMC5977310 DOI: 10.3390/nano8050296] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 04/18/2018] [Accepted: 04/24/2018] [Indexed: 01/18/2023]
Abstract
In calcific aortic valve disease (CAVD), microcalcifications originating from nanoscale calcifying vesicles disrupt the aortic valve (AV) leaflets, which consist of three (biomechanically) distinct layers: the fibrosa, spongiosa, and ventricularis. CAVD has no pharmacotherapy and lacks in vitro models as a result of complex valvular biomechanical features surrounding resident mechanosensitive valvular interstitial cells (VICs). We measured layer-specific mechanical properties of the human AV and engineered a three-dimensional (3D)-bioprinted CAVD model that recapitulates leaflet layer biomechanics for the first time. Human AV leaflet layers were separated by microdissection, and nanoindentation determined layer-specific Young’s moduli. Methacrylated gelatin (GelMA)/methacrylated hyaluronic acid (HAMA) hydrogels were tuned to duplicate layer-specific mechanical characteristics, followed by 3D-printing with encapsulated human VICs. Hydrogels were exposed to osteogenic media (OM) to induce microcalcification, and VIC pathogenesis was assessed by near infrared or immunofluorescence microscopy. Median Young’s moduli of the AV layers were 37.1, 15.4, and 26.9 kPa (fibrosa/spongiosa/ventricularis, respectively). The fibrosa and spongiosa Young’s moduli matched the 3D 5% GelMa/1% HAMA UV-crosslinked hydrogels. OM stimulation of VIC-laden bioprinted hydrogels induced microcalcification without apoptosis. We report the first layer-specific measurements of human AV moduli and a novel 3D-bioprinted CAVD model that potentiates microcalcification by mimicking the native AV mechanical environment. This work sheds light on valvular mechanobiology and could facilitate high-throughput drug-screening in CAVD.
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Lazar JF. Confronting the fundamental challenges of airway surgery: a paradigm shift is practically upon us. J Thorac Dis 2017; 9:3670-3671. [PMID: 29268371 DOI: 10.21037/jtd.2017.09.52] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- John F Lazar
- Thoracic Surgery, Medical Director PinnacleHealth Robotic Institute, UPMC PinnacleHealth, Harrisburg, PA 17104, USA
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Patel V, Burt BM. The printed trachea. J Thorac Dis 2017; 9:3672-3673. [PMID: 29268372 DOI: 10.21037/jtd.2017.09.49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Vivekkumar Patel
- Division of Thoracic Surgery, The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Bryan M Burt
- Division of Thoracic Surgery, The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
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