Validating the Paradigm That Biomechanical Forces Regulate Embryonic Cardiovascular Morphogenesis and Are Fundamental in the Etiology of Congenital Heart Disease.

The goal of this review is to provide a broad overview of the biomechanical maturation and regulation of vertebrate cardiovascular (CV) morphogenesis and the evidence for mechanistic relationships between function and form relevant to the origins of congenital heart disease (CHD). The embryonic heart has been investigated for over a century, initially focusing on the chick embryo due to the opportunity to isolate and investigate myocardial electromechanical maturation, the ability to directly instrument and measure normal cardiac function, intervene to alter ventricular loading conditions, and then investigate changes in functional and structural maturation to deduce mechanism. The paradigm of "Develop and validate quantitative techniques, describe normal, perturb the system, describe abnormal, then deduce mechanisms" was taught to many young investigators by Dr. Edward B. Clark and then validated by a rapidly expanding number of teams dedicated to investigate CV morphogenesis, structure-function relationships, and pathogenic mechanisms of CHD. Pioneering studies using the chick embryo model rapidly expanded into a broad range of model systems, particularly the mouse and zebrafish, to investigate the interdependent genetic and biomechanical regulation of CV morphogenesis. Several central morphogenic themes have emerged. First, CV morphogenesis is inherently dependent upon the biomechanical forces that influence cell and tissue growth and remodeling. Second, embryonic CV systems dynamically adapt to changes in biomechanical loading conditions similar to mature systems. Third, biomechanical loading conditions dynamically impact and are regulated by genetic morphogenic systems. Fourth, advanced imaging techniques coupled with computational modeling provide novel insights to validate regulatory mechanisms. Finally, insights regarding the genetic and biomechanical regulation of CV morphogenesis and adaptation are relevant to current regenerative strategies for patients with CHD.

Cardiac myocyte diversity and a fibroblast network in the junctional region of the zebrafish heart revealed by transmission and serial block-face scanning electron microscopy.

The zebrafish has emerged as an important model of heart development and regeneration. While the structural characteristics of the developing and adult zebrafish ventricle have been previously studied, little attention has been paid to the nature of the interface between the compact and spongy myocardium. Here we describe how these two distinct layers are structurally and functionally integrated. We demonstrate by transmission electron microscopy that this interface is complex and composed primarily of a junctional region occupied by collagen, as well as a population of fibroblasts that form a highly complex network. We also describe a continuum of uniquely flattened transitional cardiac myocytes that form a circumferential plate upon which the radially-oriented luminal trabeculae are anchored. In addition, we have uncovered within the transitional ring a subpopulation of markedly electron dense cardiac myocytes. At discrete intervals the transitional cardiac myocytes form contact bridges across the junctional space that are stabilized through localized desmosomes and fascia adherentes junctions with adjacent compact cardiac myocytes. Finally using serial block-face scanning electron microscopy, segmentation and volume reconstruction, we confirm the three-dimensional nature of the junctional region as well as the presence of the sheet-like fibroblast network. These ultrastructural studies demonstrate the previously unrecognized complexity with which the compact and spongy layers are structurally integrated, and provide a new basis for understanding development and regeneration in the zebrafish heart.

Magnetic resonance imaging (MRI) assessment of ventricular remodeling after myocardial infarction in rabbits.

To understand the structure-function relationship in the postinfarcted myocardium in rabbits, we induced cardiac ischemia by ligating the left circumflex coronary artery. Sham controls underwent thoracotomy only. At 7 and 30 d after ligation, cardiac MRI was conducted by using pulse-oxymetry-gated cine acquisition to provide complete phases of the heartbeat. The rabbits were anesthetized under 1.5% isoflurane ventilation, and ultrafast techniques made breath-hold 3D coverage in different cardiac axes feasible. Viability imaging was performed after intravenous injection of 0.15 mmol/kg gadolinium to assess the extent of infarction. Data (n ≥ 6) are presented as mean ± SEM and analyzed by ANOVA and ANCOVA. In postligation rabbits, end-systolic (mean ± SEM, 2.3 ± 0.3 mL) and end-diastolic (4.2 ± 0.4 mL) volumes were increased compared with preligation values (end-systolic, 1.1 ± 0.1 mL; end-diastolic, 2.98 ± 0.2 mL). Ejection fraction was influenced adversely by the presence of scar tissue at both 7 and 30 d after ligation and apparently nonlinear with the heart rate. Cardiac force was increased in the basal region in both end-systole and end-diastole in postligation hearts but progressively decreased toward the apex. Late gadolinium enhancement delineated 15.2 ± 5.8% myocardial infarction at 7 d after ligation and 14.5 ± 5.8% at 30 d, with limited wall motion and wall thinness. Compensatory wall thickening was present in the basal region when compared with that in preligation hearts. MRI offers detailed spatial resolution and tissue characterization after myocardial infarction.

Bioreducible polymer-transfected skeletal myoblasts for VEGF delivery to acutely ischemic myocardium.

Implantation of skeletal myoblasts to the heart has been investigated as a means to regenerate and protect the myocardium from damage after myocardial infarction. While several animal studies utilizing skeletal myoblasts have reported positive findings, results from clinical studies have been mixed. In this study we utilize a newly developed bioreducible polymer system to transfect skeletal myoblasts with a plasmid encoding vascular endothelial growth factor (VEGF) prior to implantation into acutely ischemic myocardium. VEGF has been demonstrated to promote revascularization of the myocardium following myocardial infarction. We report that implanting VEGF expressing skeletal myoblasts into acutely ischemic myocardium produces superior results compared to implantation of untransfected skeletal myoblasts. Skeletal myoblasts expressing secreted VEGF were able to restore cardiac function to non-diseased levels as measured by ejection fraction, to limit remodeling of the heart chamber as measured by end systolic and diastolic volumes, and to prevent myocardial wall thinning. Additionally, arteriole and capillary formation, retention of viable cardiomyocytes, and prevention of apoptosis was significantly improved by VEGF expressing skeletal myoblasts compared to untransfected myoblasts. This work demonstrates the feasibility of using bioreducible cationic polymers to create engineered skeletal myoblasts to treat acutely ischemic myocardium.

Ligation of the left circumflex coronary artery with subsequent MRI and histopathology in rabbits.

Provided is the surgical procedure for ligating the left circumflex coronary artery to simulate heart ischemia by using a rabbit model. Heart rate monitored by electrocardiogram was increased at 5 min after ligation (mean ± SEM, 205 ± 13 bpm) when compared with that before ligation (170 ± 12 bpm), but returned to baseline at 25 min after ligation (183 ± 11 bpm). A marked elevation in the ST segment and reduction of the QRS wave of the electrocardiogram indicated the evolving myocardial infarct. The ejection fraction derived from MRI was decreased by 20% in the infarcted heart. The extent of necrosis and fibrosis in the myocardium due to ischemia led to decreased compliance and efficiency of the left ventricle. Masson trichrome staining showed blue-stained fibrils with the appearance of loose, threadlike scar tissue dispersed transmurally in the left ventricle and extending toward the apex. This study demonstrates the feasibility of MRI analysis of myocardial infarction in a rabbit model. The myocardial architecture, including the geometry of the myofibers which determines the contractile function of the heart, is clearly demonstrated by using cardiac MRI. Understanding the 3-dimensional arrangement of the myocardial microstructure and how remodeling of the infarcted myocardium affects cardiac function in an animal model has important implications for the study of heart disease in humans.

Dependence of aortic arch morphogenesis on intracardiac blood flow in the left atrial ligated chick embryo.

Partial left atrial ligation before cardiac septation redistributes intracardiac blood flow and produces left ventricular hypoplasia in the chick. We hypothesized that redistributed intracardiac blood flow adversely alters aortic arch development. We ligated the left atrial appendage with a 10-0 nylon suture at stage 21 chick embryos, then reincubated up to stage 34. Sham embryos had a suture tied adjacent to the atrial wall, and normal controls were unoperated. We measured simultaneous atrioventricular (AV) and dorsal aortic (DAo) blood velocities from stage 24 embryos with an ultrasound pulsed-Doppler flow meter; and the left and right third and fourth aortic arch blood flow with a laser-Doppler flow meter. Ventricular and atrial cross-sectional areas were measured from sequential video fields for planimetry. Intracardiac flow patterns were imaged on video by injecting India ink into the vitelline vein. In separate embryos, radiopaque microfil was injected into the cardiovascular system for micro-CT scanning. We analyzed the morphologic characteristics of the heart at stage 34. Active AV and DAo stroke volume (mm(3)), right third and fourth aortic arch blood flow (mm(3)/s) were all decreased in ligated embryos (P < 0.05) when compared with normal and sham embryos. Ventricular end-diastolic volume versus normal and sham embryos decreased by 45% and 46%, respectively (P < 0.05). India ink injection revealed altered right aortic arch flow patterns in the ligated embryos compared with normal embryos. micro-CT imaging confirmed altered arch morphogenesis. Alterations in intracardiac blood flow disrupt both early cardiac morphogenesis and aortic arch selection.

Cardiogenic effects of trichloroethylene and trichloroacetic acid following exposure during heart specification of avian development.

Trichloroethylene (TCE) and its metabolite trichloroacetic acid (TCA) are common drinking water contaminants in the United States. Both chemicals have been implicated in causing congenital heart defects (CHD) in human epidemiological and animal model studies. However, the latter studies have primarily focused on assessment of cardiac morphology at late embryonic stages. Here, we tested whether treating avian embryos with TCE or TCA during an exposure window encompassing cardiac specification (Hamburger-Hamilton [HH] 3+) until the onset of chambering (HH 17) informs the etiology of CHD at later stages of development. Embryos were exposed to TCE or TCA via direct injection into the yolk, over a range of doses that included each compound's maximum contaminant level as established by the U.S. Environmental Protection Agency. A modified TUNEL (Terminal deoxynucleotide transferase mediated dUTP-biotin Nick-End Labeling) assay indicated that neither compound induced apoptotic cell death in ventricular myocytes or endocardiocytes at HH 18. However, mid-range dosages of TCE increased myocyte and endocardiocyte proliferation by this time, as determined by monitoring BrdU incorporation; in contrast, an intermediate dose of TCA inhibited proliferation in endocardiocytes. These cellular changes had no apparent functional consequences because all measured hemodynamic parameters were normal for TCE- and TCA-exposed embryos at HH 18, HH 21, and HH 23. In summary, TCE or TCA exposure during the cardiac specification window has only minimal effects on the developing avian heart. These results sharply contrast with our previously reported observations following administration of equivalent doses during a window of valvuloseptal morphogenesis. Taken together, these findings indicate that, as for other teratogens, sensitivity is dictated by the embryo's stage of development.

Trichloroethylene exposure during cardiac valvuloseptal morphogenesis alters cushion formation and cardiac hemodynamics in the avian embryo.

It is controversial whether trichloroethylene (TCE) is a cardiac teratogen. We exposed chick embryos to 0, 0.4, 8, or 400 ppb TCE/egg during the period of cardiac valvuloseptal morphogenesis (2-3.3 days' incubation) . Embryo survival, valvuloseptal cellularity, and cardiac hemodynamics were evaluated at times thereafter. TCE at 8 and 400 ppb/egg reduced embryo survival to day 6.25 incubation by 40-50%. At day 4.25, increased proliferation and hypercellularity were observed within the atrioventricular and outflow tract primordia after 8 and 400 ppb TCE. Doppler ultrasound revealed that the dorsal aortic and atrioventricular blood flows were reduced by 23% and 30%, respectively, after exposure to 8 ppb TCE. Equimolar trichloroacetic acid (TCA) was more potent than TCE with respect to increasing mortality and causing valvuloseptal hypercellularity. These results independently confirm that TCE disrupts cardiac development of the chick embryo and identifies valvuloseptal development as a period of sensitivity. The hypercellular valvuloseptal profile is consistent with valvuloseptal heart defects associated with TCE exposure. This is the first report that TCA is a cardioteratogen for the chick and the first report that TCE exposure depresses cardiac function. Valvuloseptal hypercellularity may narrow the cardiac orifices, which reduces blood flow through the heart, thereby compromising cardiac output and contributing to increased mortality. The altered valvuloseptal formation and reduced hemodynamics seen here are consistent with such an outcome. Notably, these effects were observed at a TCE exposure (8 ppb) that is only slightly higher than the U.S. Environmental Protection Agency maximum containment level for drinking water (5 ppb) .

Ventricular diastolic filling characteristics in stage-24 chick embryos after extra-embryonic venous obstruction.

Alteration of extra-embryonic venous blood flow in stage-17 chick embryos results in well-defined cardiovascular malformations. We hypothesize that the decreased dorsal aortic blood volume flow observed after venous obstruction results in altered ventricular diastolic function in stage-24 chick embryos. A microclip was placed at the right lateral vitelline vein in a stage-17 (52-64 h of incubation) chick embryo. At stage 24 (4.5 days of incubation), we measured simultaneously dorsal aortic and atrioventricular blood flow velocities with a 20-MHz pulsed-Doppler velocity meter. The fraction of passive and active filling was integrated and multiplied by dorsal aortic blood flow to obtain the relative passive and active ventricular filling volumes. Data were summarized as means +/- S.E.M. and analyzed by t-test. At similar cycle lengths ranging from 557 ms to 635 ms (P>0.60), dorsal aortic blood flow and stroke volume measured in the dorsal aorta were similar in stage-24 clipped and normal embryos. Passive filling volume (0.07+/-0.01 mm(3)) was decreased, and active filling volume (0.40+/-0.02 mm(3)) was increased in the clipped embryo when compared with the normal embryo (0.15+/-0.01 mm(3), 0.30+/-0.01 mm(3), respectively) (P<0.003). In the clipped embryos, the passive/active ratio was decreased compared with that in normal embryos (P<0.001). Ventricular filling components changed after partially obstructing the extra-embryonic venous circulation. These results suggest that material properties of the embryonic ventricle are modified after temporarily reduced hemodynamic load.

Cellular changes in experimental left heart hypoplasia.

Hypoplastic left heart syndrome (HLHS) is a rare but deadly congenital malformation, which can be created experimentally in the chick embryo by left atrial ligation (LAL). The goal of this study was to examine the cellular changes leading to the profound remodeling of ventricular myocardial architecture that occurs in this model. Hypoplasia of left heart structures was produced after 3H-thymidine prelabeling by partial LAL at stage 24, thereby reducing its volume, and redistributing blood preferentially to the developing right ventricle (RV). Controls included both sham-operated and intact stage-matched embryos. Survivors were studied 4 days after the ligation, when the heart organogenesis was essentially complete. Paraffin sections of the hearts were subjected to autoradiography and immunohistochemistry to detect changes in history of cell proliferation and expression of myosin, and growth factors implicated in cardiomyocyte proliferation. Sampling for apoptosis detection using TUNEL assay was done at stages 29 and 34. LAL resulted in decreased levels of proliferation in the left ventricular compact layer and trabeculae. The right ventricular compact layer also showed a slight decrease, but the trabeculae showed no differences. Anti-myosin staining was significantly reduced in all compartments. The expression levels of growth factors were altered as well. Apoptosis was increased in the right atrioventricular mesenchyme, with no changes in the working myocardium. These data suggest that changes in cardiomyocyte proliferation play a significant role in the pathogenesis of HLHS.