ACCEPTED MANUSCRIPT. In situ heart valve tissue engineering: Employing the innate immune response to do the

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1 Accepted Manuscript In situ heart valve tissue engineering: Employing the innate immune response to do the hard work F. Zafar, MD, D.L.S. Morales, MD PII: S (18) DOI: /j.jtcvs Reference: YMTC To appear in: The Journal of Thoracic and Cardiovascular Surgery Received Date: 9 March 2018 Accepted Date: 15 March 2018 Please cite this article as: Zafar F, Morales D, In situ heart valve tissue engineering: Employing the innate immune response to do the hard work, The Journal of Thoracic and Cardiovascular Surgery (2018), doi: /j.jtcvs This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

2 In situ heart valve tissue engineering: Employing the innate immune response to do the hard work. Zafar F, MD, Morales DLS, MD The Heart Institute, Cincinnati Children s Hospital Medical Center, Cincinnati, OH Corresponding Author Information: David L.S. Morales, MD Cincinnati Children s Hospital Medical Center Department of Cardiovascular Surgery 333 Burnet Avenue, MLC 2013 Cincinnati, OH david.morales@cchmc.org Conflict of interest: Morales is a consultant for Berlin Heart, HeartWare, Azyio, CorMatrix, and SynCardia. Morales is member of Adverse Events Committee for Xeltis Xplore2 FDA trial. Zafar has nothing to disclose. Word count: 547

3 Central Message: In situ heart valve tissue engineering, which utilizes induced regenerative process to recapitulate native tissue, demonstrates a potential alternative approach for heart valve replacement. Character count (with spaces): 190 (limit 200)

4 Bennink and colleagues present an investigation comparing the use of a synthetic bioabsorbable, polymer-based, pulmonary valved conduit to a Hancock aortic valved dacron conduit for pulmonary valve replacement in sheep. [1] It demonstrates functional and morphologic changes in the polymer-based valves at 2, 6 and 12 months. While this is a limited preliminary study and present some concerning findings at 12 months, there are several positive take-home points. There was acceptable valve function, neointima formation (nonthrombogenic), degradation of polymers which may represent remodeling, deposition of native matrix and lack of calcification up to 12 months. This study promotes the tissue engineering approach towards using scaffolds (biologic or non-biologic), allowing the native cells to populate it and lay down their own extracellular matrix (ECM) along with resorption of the exogenous scaffold. This approach a.k.a. in situ tissue engineering, relies on the host response to the exogenous scaffold and interplay between the immune and progenitor cells in the microenvironment provided by the scaffold with the additional influence by the hemodynamic environment. [2] Although it is logistically (cost, availability) superior to the traditional tissue engineering approaches (cell based), in situ tissue engineering is still in its infancy and is fraught with occasional unexpected failures. Bennink et. al. showed tears and fragmentation of valve leaflets at 12 months coinciding with shrinkage of the leaflet, rolling of free edge and associated progressive increase in regurgitation. The hemodynamic performance in these sheep appeared worse in all categories than the Hancock conduit (limited to 24wks) with the XPV having greater than mild insufficiency after 40 weeks. They demonstrated neointimal hyperplasia and thickening of the conduit wall and leaflet in some cases. [1] These problems have also been noted in other studies examining in situ tissue engineering of heart valves [3-5] and are commonly attributed to three broad factors: a) scaffold design (porosity, rate of degradation, etc.), b) hemodynamic environment (low vs high pressure, flow, shear stress, etc.) and c) cellular response (pro-inflammatory vs

5 pro-regenerative, cell adhesion molecules, cell polarization and chemo-attractive cytokines, etc.). It is not a static tissue formation, but a functional tissue regeneration in continuously changing biomechanical microenvironments ranging from initial acellular scaffold to degrading scaffold with variable matrix and cell infiltration. Therefore, it is extremely important to understand the fundamental reasons of failure in these devices and make adaptations to continue to make progress in this promising approach. Bennink et. al., used a novel Polycarpolactone- and Polycarbonate-based, supramolecular, ureido-pyrimidinone (UPy) polymers. [1] UPy is a unique polymer with high dimerization constant and hydrogen-binding motifs resulting in tunable morphologies. [6] Similar design changes, such as reducing fiber diameters to minimize blood activation, increase pore size to promote cell infiltration, and modulating degradation rates to be compatible with ECM resorption, have been proposed by others. [2] Changing fiber arrangements in the arterial vs ventricular side to account for flow and shear stress differences, supplementing scaffolds with VEGF (promoting angiogenesis) and IL- 10 (promoting macrophage polarization to M2) are some other considerations being investigated. While we are far from a robust clinically applicable device that we can claim will remodel into native tissue, in situ tissue engineering of heart valves appears promising and appealing since it is based on us only creating the environment in which nature can do the hard work = valve creation.

6 References: 1. Bennink G, Tossii S, Brugmans M, et. al. A novel restorative pulmonary valved conduit in a chronic sheep model: mid-term haemodynamic function and histological assessment. J Thorac Cardiovasc Surg. XXXX 2. Wissing TB, Bonito V, Bouten CVC, Smits AIPM. Biomaterial-driven in situ cardiovascular tissue engineering a multi-disciplinary perspective. NPJ Regen Med.2017;2:18 3. Driessen-Mol A, Emmert MY, Dijkman PE, et. al. Transcatheter implantation of homologous Off-the-Shelf tissue engineered heart valves with self-repair capacity: Long-term functionality and rapid in vivo remodeling in sheep. 4. Reimer J, Syedian Z, Haynie B, Lahti M, Berry J, Tranquillo R. Implantation of a tissueengineered tubular heart valve in growing lambs. Ann Biomed Eng. 2017;45: Kluin J, Talacua H, Smits AIPM, et. al. In situ heart valve tissue engineering using a bioabsorbable elastomeric implant from material design to 12 months follow-up in sheep. Biomaterial. 2017;125: Appel WPJ, Portale G, Wisse E, Danker PYW, Meijer EW. Aggregation of ureidopyrimidinone supramolecular thermoplastic elastomers into nanofibers: A kinetic analysis. Macromolecules. 2011;44:

7 Central Figure: Figure adapted from Wissing et.al.; [2] Induced regenerative response comprised of inflammatory, proliferative and remodeling phases with a potential to go astray (chronic inflammation and fibrosis).

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