Electrical and Mechanical Strategies to Enable Cardiac Repair and Regeneration

Skin-inspired, sensory robots for electronic implants

Drawing inspiration from cohesive integration of skeletal muscles and sensory skins in vertebrate animals, we present a design strategy of soft robots, primarily consisting of an electronic skin (e-skin) and an artificial muscle. These robots integrate multifunctional sensing and on-demand actuation into a biocompatible platform using an in-situ solution-based method. They feature biomimetic designs that enable adaptive motions and stress-free contact with tissues, supported by a battery-free wireless module for untethered operation. Demonstrations range from a robotic cuff for detecting blood pressure, to a robotic gripper for tracking bladder volume, an ingestible robot for pH sensing and on-site drug delivery, and a robotic patch for quantifying cardiac function and delivering electrotherapy, highlighting the application versatilities and potentials of the bio-inspired soft robots. Our designs establish a universal strategy with a broad range of sensing and responsive materials, to form integrated soft robots for medical technology and beyond.

Progress and promise of cell sheet assisted cardiac tissue engineering in regenerative medicine

Cardiovascular diseases (CVDs) are the most common leading causes of premature deaths in all countries. To control the harmful side effects of CVDs on public health, it is necessary to understand the current and prospective strategies in prevention, management, and monitoring CVDs.In vitro,recapitulating of cardiac complex structure with its various cell types is a challenging topic in tissue engineering. Cardiac tissue engineering (CTE) is a multi-disciplinary strategy that has been considered as a novel alternative approach for cardiac regenerative medicine and replacement therapies. In this review, we overview various cell types and approaches in cardiac regenerative medicine. Then, the applications of cell-sheet-assisted CTE in cardiac diseases were discussed. Finally, we described how this technology can improve cardiac regeneration and function in preclinical and clinical models.

Application of Nanomaterials in Stem Cell-Based Therapeutics for Cardiac Repair and Regeneration

Cardiovascular disease is a leading cause of disability and death worldwide. Although the survival rate of patients with heart diseases can be improved with contemporary pharmacological treatments and surgical procedures, none of these therapies provide a significant improvement in cardiac repair and regeneration. Stem cell-based therapies are a promising approach for functional recovery of damaged myocardium. However, the available stem cells are difficult to differentiate into cardiomyocytes, which result in the extremely low transplantation efficiency. Nanomaterials are widely used to regulate the myocardial differentiation of stem cells, and play a very important role in cardiac tissue engineering. This study discusses the current status and limitations of stem cells and cell-derived exosomes/micro RNAs based cardiac therapy, describes the cardiac repair mechanism of nanomaterials, summarizes the recent advances in nanomaterials used in cardiac repair and regeneration, and evaluates the advantages and disadvantages of the relevant nanomaterials. Besides discussing the potential clinical applications of nanomaterials in cardiac therapy, the perspectives and challenges of nanomaterials used in stem cell-based cardiac repair and regeneration are also considered. Finally, new research directions in this field are proposed, and future research trends are highlighted.

Irisin Regulates Cardiac Responses to Exercise in Health and Diseases: a Narrative Review

Exercise has been recognized as an important non-pharmacological approach for the prevention, treatment, and rehabilitation of cardiovascular diseases, but the mechanisms of exercise in promoting cardiovascular health remain unclear. Exercise generates cardiac benefits via stimulating muscle to secret hundreds of myokines that directly enter circulation and target heart tissue. Therefore, inter-organ communication between skeletal muscle and heart may be one important regulating pattern, and such communication can occur through secretion of molecules, frequently known as myokines. Irisin, a newly identified myokine, is cleaved from fibronectin type III domain-containing protein 5 (FNDC5) and secreted by the stimulation of exercise. Recently, accumulating evidence focusing on the interaction between irisin and cardiac function has been reported. This review highlights the molecular signaling by which irisin regulates the benefits of exercise on cardiac function both in physiological and pathological process, and discusses the clinical potential of irisin in treating heart diseases. Exercise generates various cardiovascular benefits through stimulating skeletal muscle to secrete irisin. The exercise "hormone" irisin, both produced by exercise or recombinant form, exerts therapeutic effects in a group of cardiovascular disorders including heart failure, myocardial infarction, atherosclerosis and hypertension. However, the molecular mechanisms involved remain ambiguous.This review highlights the most up-to-date findings to bridge the gap between exercise, irisin and cardiovascular diseases, and discusses the potential clinical prospect of irisin.

Effects of nanostructuration on the electrochemical performance of metallic bioelectrodes

The use of metallic nanostructures in the fabrication of bioelectrodes (e.g., neural implants) is gaining attention nowadays. Nanostructures provide increased surface area that might benefit the performance of bioelectrodes. However, there is a need for comprehensive studies that assess electrochemical performance of nanostructured surfaces in physiological and relevant working conditions. Here, we introduce a versatile scalable fabrication method based on magnetron sputtering to develop analogous metallic nanocolumnar structures (NCs) and thin films (TFs) from Ti, Au, and Pt. We show that NCs contribute significantly to reduce the impedance of metallic surfaces. Charge storage capacity of Pt NCs is remarkably higher than that of Pt TFs and that of the other metals in both morphologies. Circuit simulations of the electrode/electrolyte interface show that the signal delivered in voltage-controlled systems is less filtered when nanocolumns are used. In a current-controlled system, simulation shows that NCs provide safer stimulation conditions compared to TFs. We have assessed the durability of NCs and TFs for potential use in vivo by reactive accelerated aging test, mimicking one-year in vivo implantation. Although each metal/morphology reveals a unique response to aging, NCs show overall more stable electrochemical properties compared to TFs in spite of their porous structure.

Conductive Polymer PEDOT:PSS-Based Platform for Embryonic Stem-Cell Differentiation

Organic semiconductors are constantly gaining interest in regenerative medicine. Their tunable physico-chemical properties, including electrical conductivity, are very promising for the control of stem-cell differentiation. However, their use for combined material-based and electrical stimulation remains largely underexplored. Therefore, we carried out a study on whether a platform based on the conductive polymer poly(3,4-ethylenedioxythiophene):polystyrene sulfonate (PEDOT:PSS) can be beneficial to the differentiation of mouse embryonic stem cells (mESCs). The platform was prepared using the layout of a standard 24-well cell-culture plate. Polyethylene naphthalate foil served as the substrate for the preparation of interdigitated gold electrodes by physical vapor deposition. The PEDOT:PSS pattern was fabricated by precise screen printing over the gold electrodes. The PEDOT:PSS platform was able to produce higher electrical current with the pulsed-direct-current (DC) electrostimulation mode (1 Hz, 200 mV/mm, 100 ms pulse duration) compared to plain gold electrodes. There was a dominant capacitive component. In proof-of-concept experiments, mESCs were able to respond to such electrostimulation by membrane depolarization and elevation of cytosolic calcium. Further, the PEDOT:PSS platform was able to upregulate cardiomyogenesis and potentially inhibit early neurogenesis per se with minor contribution of electrostimulation. Hence, the present work highlights the large potential of PEDOT:PSS in regenerative medicine.

Mimicking cardiac tissue complexity through physical cues: A review on cardiac tissue engineering approaches

Cardiovascular diseases are the number one killer in the world.^1,2 Currently, there are no clinical treatments to regenerate damaged cardiac tissue, leaving patients to develop further life-threatening cardiac complications. Cardiac tissue has multiple functional demands including vascularization, contraction, and conduction that require many synergic components to properly work. Most of these functions are a direct result of the cardiac tissue structure and composition, and, for this reason, tissue engineering strongly proposed to develop substitute engineered heart tissues (EHTs). EHTs usually have combined pluripotent stem cells and supporting scaffolds with the final aim to repair or replace the damaged native tissue. However, as simple as this idea is, indeed, it resulted, after many attempts in the field, to be very challenging. Without design complexity, EHTs remain unable to mature fully and integrate into surrounding heart tissue resulting in minimal in vivo effects.³ Lately, there has been a growing body of evidence that a complex, multifunctional approach through implementing scaffold designs, cellularization, and molecular release appears to be essential in the development of a functional cardiac EHTs.^4-6 This review covers the advancements in EHTs developments focusing on how to integrate contraction, conduction, and vascularization mimics and how combinations have resulted in improved designs thus warranting further investigation to develop a clinically applicable treatment.

When Stiffness Matters: Mechanosensing in Heart Development and Disease

During embryonic morphogenesis, the heart undergoes a complex series of cellular phenotypic maturations (e.g., transition of myocytes from proliferative to quiescent or maturation of the contractile apparatus), and this involves stiffening of the extracellular matrix (ECM) acting in concert with morphogenetic signals. The maladaptive remodeling of the myocardium, one of the processes involved in determination of heart failure, also involves mechanical cues, with a progressive stiffening of the tissue that produces cellular mechanical damage, inflammation, and ultimately myocardial fibrosis. The assessment of the biomechanical dependence of the molecular machinery (in myocardial and non-myocardial cells) is therefore essential to contextualize the maturation of the cardiac tissue at early stages and understand its pathologic evolution in aging. Because systems to perform multiscale modeling of cellular and tissue mechanics have been developed, it appears particularly novel to design integrated mechano-molecular models of heart development and disease to be tested in ex vivo reconstituted cells/tissue-mimicking conditions. In the present contribution, we will discuss the latest implication of mechanosensing in heart development and pathology, describe the most recent models of cell/tissue mechanics, and delineate novel strategies to target the consequences of heart failure with personalized approaches based on tissue engineering and induced pluripotent stem cell (iPSC) technologies.

Cardiac tissue engineering: state-of-the-art methods and outlook

The purpose of this review is to assess the state-of-the-art fabrication methods, advances in genome editing, and the use of machine learning to shape the prospective growth in cardiac tissue engineering. Those interdisciplinary emerging innovations would move forward basic research in this field and their clinical applications. The long-entrenched challenges in this field could be addressed by novel 3-dimensional (3D) scaffold substrates for cardiomyocyte (CM) growth and maturation. Stem cell-based therapy through genome editing techniques can repair gene mutation, control better maturation of CMs or even reveal its molecular clock. Finally, machine learning and precision control for improvements of the construct fabrication process and optimization in tissue-specific clonal selections with an outlook of cardiac tissue engineering are also presented.

Acquisition, Processing and Analysis of Electrocardiogram in Awake Zebrafish

Long-term monitoring of intrinsic electrocardiogram (ECG) in zebrafish plays a crucial role in heart disease studies as well as drug screening. In this work, we developed a polymer-based apparatus with embedded flexible thin-film electrodes to acquire ECG signals of awake zebrafish. The apparatus was made of polydimethylsiloxane (PDMS) using the molding technique with molds formed by 3D printing. A graphical user interface (GUI) was built in National Instruments LabView platform for real-time recording, processing and analysis. The program provided important features, such as signal de-noising, characteristic wave detection and anomaly detection. Further, it could operate on both real-time coming signals as well as previously-saved data, facilitating analysis and interpretation. We demonstrated the use of our system to investigate the effects of the anesthetic drug, namely Tricaine (MS-222), on cardiac electrophysiology of zebrafish, revealing promising findings. We speculate that our novel system may contribute to a host of studies in various disciplines using the zebrafish model.

Naturally Engineered Maturation of Cardiomyocytes

Ischemic heart disease remains one of the most prominent causes of mortalities worldwide with heart transplantation being the gold-standard treatment option. However, due to the major limitations associated with heart transplants, such as an inadequate supply and heart rejection, there remains a significant clinical need for a viable cardiac regenerative therapy to restore native myocardial function. Over the course of the previous several decades, researchers have made prominent advances in the field of cardiac regeneration with the creation of in vitro human pluripotent stem cell-derived cardiomyocyte tissue engineered constructs. However, these engineered constructs exhibit a functionally immature, disorganized, fetal-like phenotype that is not equivalent physiologically to native adult cardiac tissue. Due to this major limitation, many recent studies have investigated approaches to improve pluripotent stem cell-derived cardiomyocyte maturation to close this large functionality gap between engineered and native cardiac tissue. This review integrates the natural developmental mechanisms of cardiomyocyte structural and functional maturation. The variety of ways researchers have attempted to improve cardiomyocyte maturation in vitro by mimicking natural development, known as natural engineering, is readily discussed. The main focus of this review involves the synergistic role of electrical and mechanical stimulation, extracellular matrix interactions, and non-cardiomyocyte interactions in facilitating cardiomyocyte maturation. Overall, even with these current natural engineering approaches, pluripotent stem cell-derived cardiomyocytes within three-dimensional engineered heart tissue still remain mostly within the early to late fetal stages of cardiomyocyte maturity. Therefore, although the end goal is to achieve adult phenotypic maturity, more emphasis must be placed on elucidating how the in vivo fetal microenvironment drives cardiomyocyte maturation. This information can then be utilized to develop natural engineering approaches that can emulate this fetal microenvironment and thus make prominent progress in pluripotent stem cell-derived maturity toward a more clinically relevant model for cardiac regeneration.

In vivo Electrophysiological Study of Induced Ventricular Tachycardia in Intact Rat Model of Chronic Ischemic Heart Failure

OBJECTIVE

The objective of this study was to define the clinical relevance of in vivo electrophysiologic (EP) studies in a rat model of chronic ischemic heart failure (CHF).

METHODS

Electrical activation sequences, voltage amplitudes, and monophasic action potentials (MAPs) were recorded from adult male Sprague-Dawley rats six weeks after left coronary artery ligation. Programmed electrical stimulation (PES) sequences were developed to induce sustained ventricular tachycardia (VT). The inducibility of sustained VT was defined by PES and the recorded tissue MAPs.

RESULTS

Rats in CHF were defined ( 0.05) by elevated left ventricular (LV) end-diastolic pressure (5 ± 1 versus 18 ± 2 mmHg), decreased LV + d P/dt (7496 ± 225 versus 5502 [Formula: see text] s), LV - dP/dt (7723 ± 208 versus 3819 [Formula: see text]), LV ejection fraction (79 ± 3 versus [Formula: see text]), peak developed pressure (176 ± 4 versus 145 ± 9 mmHg), and prolonged time constant of LV relaxation Tau (18 ± 1 versus 29 ± 2 ms). The EP data showed decreased ( 0.05) electrogram amplitude in border and infarct zones (Healthy zone (H): 8.7 ± 2.1 mV, Border zone (B): 5.3 ± 1.6 mV, and Infarct zone (I): 2.3 ± 1.2 mV), decreased MAP amplitude in the border zone (H: [Formula: see text] 1.0 mV, B: 9.7 ± 0.5 mV), and increased repolarization heterogeneity in the border zone (H: 8.1 ± 1.5 ms, B: 20.2 ± 3.1 ms). With PES we induced sustained VT (>15 consecutive PVCs) in rats with CHF (10/14) versus Sham (0/8).

CONCLUSIONS

These EP studies establish a clinically relevant protocol for studying genesis of VT in CHF.

SIGNIFICANCE

The in vivo rat model of CHF combined with EP analysis could be used to determine the arrhythmogenic potential of new treatments for CHF.

Echocardiographic evaluation of cardiac dyssynchrony in patients with congestive heart failure

The present study investigated the application of echocardiography to evaluation of cardiac dyssynchrony in patients with congestive heart failure (CHF). A total of 348 consecutive CHF patients who were admitted for cardiac resynchronization (CRT) and presented with low ejection fraction (EF) and wide QRS duration were enrolled in this study, along with 388 healthy individuals. Dyssynchrony was assessed based on filling time ratio (FT/RR), left ventricular pre-ejection delay (PED), interventricular mechanical delay (IVMD), longitudinal opposing wall delay (LOWD) and radial septal to posterior wall delay (RSPWD). Response to CRT was defined as a ≥15% increase in EF. The results showed that FT/RR was decreased while PED, IVMD, LOWD and RSPWD were increased in the CHF group compared with the control group (P<0.01). In the CHF group, FT/RR was negatively correlated with the QRS duration, LV end-diastolic diameter (LVESd), LV end-diastolic volume (LVEDV) and LV end-systolic volume (LVESV) (P<0.01), but positively with the LVEF (P<0.01). Additionally, PED, IVMD, LOWD and RSPWD were positively correlated with the QRS duration, LVESd, LVEDV and LVESV (P<0.01), but negatively with the LVEF (P<0.01). The CHF group was divided into three subgroups according to the varying degrees of LVEF. FT/RR decreased successively from the LVEF-1 group to the LVEF-2 group to the LVEF-3 group, while the PED, IVMD, LOWD and RSPWD successively increased in the same order (P<0.01). The CHF group was divided into three subgroups according to the varying degrees of QRS duration, and FT/RR decreased successively in a sequence from the QRS-1 group to the QRS-2 group to the QRS-3 group, while the PED, IVMD, LOWD and RSPWD successively increased in the same order (P<0.01). Speckle tracking radial dyssynchrony ≥130 ms was predictive of an EF response in patients in QRS-1 group (78% sensitivity, 83% specificity), those in QRS-2 group (83% sensitivity, 77% specificity) and in QRS-3 group (89% sensitivity, 79% specificity). In conclusion, echocardiography is a convenient and sensitive method for evaluating cardiac dyssynchrony in patients with CHF.

Cardiomyocytes from human pluripotent stem cells: From laboratory curiosity to industrial biomedical platform

Cardiomyocytes from human pluripotent stem cells (hPSCs-CMs) could revolutionise biomedicine. Global burden of heart failure will soon reach USD $90bn, while unexpected cardiotoxicity underlies 28% of drug withdrawals. Advances in hPSC isolation, Cas9/CRISPR genome engineering and hPSC-CM differentiation have improved patient care, progressed drugs to clinic and opened a new era in safety pharmacology. Nevertheless, predictive cardiotoxicity using hPSC-CMs contrasts from failure to almost total success. Since this likely relates to cell immaturity, efforts are underway to use biochemical and biophysical cues to improve many of the ~30 structural and functional properties of hPSC-CMs towards those seen in adult CMs. Other developments needed for widespread hPSC-CM utility include subtype specification, cost reduction of large scale differentiation and elimination of the phenotyping bottleneck. This review will consider these factors in the evolution of hPSC-CM technologies, as well as their integration into high content industrial platforms that assess structure, mitochondrial function, electrophysiology, calcium transients and contractility. This article is part of a Special Issue entitled: Cardiomyocyte Biology: Integration of Developmental and Environmental Cues in the Heart edited by Marcus Schaub and Hughes Abriel.