Catálogo de publicaciones - libros

This special issue gives an overview of the current state-of-the-art of creating a bioengineered pacemaker. The subject has potential clinical interest. Indeed, electronic pacemakers currently available have several limitations, among which inadequate rate adaptation to physiological needs, problems related to the stimulating and sensing leads and infection of the pacemaker pocket, which might be overcome by a bio-pacemaker. Generation of a bio-pacemaker has also scientific interest, because it may answer the longstanding question of whether the complex structure of the sinus node is indeed a prerequisite for reliable pacemaking, or simpler structures might work as well.

The sinus node is an inhomogeneous structure. In the embryonic heart all myocytes have sinus node type pacemaker channels () in their sarcolemma. Shortly before birth, these channels disappear from the ventricular myocytes. The response of the adult sinus node to changes in the interstitium, in particular to (neuro)transmitters, results from the interplay between the responses of all of its constituent cells. The response of the whole sinus node cannot be simply deduced from these cellular responses, because all cells have different responses to specific agonists. A biological pacemaker will be more homogeneous. Therefore it can be anticipated that tuning of cycle length may be problematic. It is discussed that efforts to create a biological pacemaker responsive to vagal stimulation, may be counterproductive, because it may have the potential risk of’ standstill’ of the biological pacemaker. A normal sinus node remains spontaneously active at high concentrations of acetylcholine, because it has areas that are unresponsive to acetylcholine. The same is pertinent to other substances with a negative chronotropic effect. Such functional inhomogeneity is lacking in biological pacemakers.

Cardiac rhythm-associated disorders are caused by malfunctions of impulse generation and conduction. Present therapies for the impulse generation span a wide array of approaches but remain largely palliative. The progress in the understanding of the biology of the diseases with related biological tools beckons for new approaches to provide better alternatives to the present routine. Here, we review the current state of the art in gene and cell-based approaches to correct cardiac rhythm disturbances. These include genetic suppression of an ionic current, stem cell therapies, adult somatic cell-fusion approach, novel synthetic pacemaker channel, and creating a self-contained pacemaker activity in non-excitable cells. We then conclude by discussing advantages and disadvantages of the new possibilities.

While electronic cardiac pacing in its various modalities represents standard of care for treatment of symptomatic bradyarrhythmias and heart failure, it has limitations ranging from absent or rudimentary autonomic modulation to severe complications. This has prompted experimental studies to design and validate a biological pacemaker that could supplement or replace electronic pacemakers. Advances in cardiac gene therapy have resulted in a number of strategies focused on -adrenergic receptors as well as specific ion currents that contribute to pacemaker function. This article reviews basic pacemaker physiology, as well as studies in which gene transfer approaches to develop a biological pacemaker have been designed and validated in vivo. Additional requirements and refinements necessary for successful biopacemaker function by gene transfer are discussed.

Biological pacemaking as a replacement for or adjunct to electronic pacemakers has been a subject of interest since the 1990s. In the following pages, we discuss the rational for and progress made using a hyperpolarization activated, cyclic nucleotide gated channel isoform to carry the pacemaker current in gene and cell therapy approaches. Both strategies have resulted in effective biological pacemaker function over a period of weeks in intact animals. Moreover, the use of adult human mesenchymal stem cells as a platform for carrying pacemaker genes has resulted in the formation of functional gap junctions with cardiac myocytes in situ leading to effective and persistent propagation of pacemaker current. The approaches described are encouraging, suggesting that biological pacemakers based on this strategy can be brought to clinical testing.

Old age and a variety of cardiovascular disorders may disrupt normal sinus node function. Currently, this is successfully treated with electronic pacemakers, which, however, leave room for improvement. During the past decade, different strategies to initiate pacemaker function by gene therapy were developed. In the search for a biological pacemaker, various approaches were explored, including -adrenergic receptor overexpression, down regulation of the inward rectifier current, and overexpression of the pacemaker current. The most recent advances include overexpression of bioengineered ion channels and genetically modified stem cells. This review considers the strengths and the weaknesses of the different approaches and discusses some of the different viral vectors currently used.

A biological pacemaker might be created by generation of a cellular construct consisting of cardiac cells that display spontaneous membrane depolarization, and that are electrotonically coupled to surrounding myocardial cells by means of gap junctions. Depending on the frequency of the spontaneously beating cells, frequency regulation might be required. We hypothesized that application of Kir2.1 expressing non-cardiac cells, which provide to spontaneously active neonatal cardiomyocytes (NCMs) by electrotonic coupling in such a cellular construct, would generate an opportunity for pacemaker frequency control. Non-cardiac Kir2.1 expressing cells were co-cultured with spontaneously active rat NCMs. Electrotonic coupling between the two cell types resulted in hyperpolarization of the cardiomyocyte membrane potential and silencing of spontaneous activity. Either blocking of gap-junctional communication by halothane or inhibition of by BaCl restored the original membrane potential and spontaneous activity of the NCMs. Our results demonstrate the power of electrotonic coupling for the application of specific ion currents into an engineered cellular construct such as a biological pacemaker.

Spontaneous activity of specific regions (e.g., the Sinoatrial node, SAN) is essential for the normal activation sequence of the heart and also serve as a primary means of modulating cardiac rate by sympathetic tone and circulating catecholamines. The mechanisms of how a small SAN region can electrically drive a much larger atrium, or how a small ectopic focus can drive surrounding ventricular or atrial tissue are complex, and involve the membrane properties and electrical coupling within the SAN or focus region as well as the membrane properties, coupling conductance magnitudes and also regional distribution within the surrounding tissue. We review here studies over the past few decades in which mathematical models and experimental studies have been used to determine some of the design principles of successful propagation from a pacemaking focus. These principles can be briefly summarized as (1) central relative uncoupling to protect the spontaneously firing cells from too much electrotonic inhibition, (2) a transitional region in which the cell type and electrical coupling change from the central SAN region to the peripheral atrial region, and (3) a distributed anisotropy to facilitate focal activity.

Over the past decades patch-clamp experiments have provided us with detailed information on the different types of ion channels that are present in the cardiac cell membrane. Sophisticated cardiac cell models based on these data can help us understand how the different types of ion channels act together to produce the cardiac action potential. In the field of biological pacemaker engineering, such models provide important instruments for the assessment of the functional implications of changes in density of specific ion channels aimed at producing stable pacemaker activity. In this review, an overview is given of the progress made in cardiac cell modelling, with particular emphasis on the development of sinoatrial (SA) nodal cell models. Also, attention is given to the increasing number of publicly available tools for non-experts in computer modelling to run cardiac cell models.

Bone marrow mesenchymal stem cells (CMG cells) are multipotent and can be induced by 5-azacytidine to differentiate into cardiomyocytes. We characterized the electrophysiological properties of these cardiomyocytes and investigated their potential for use as transplantable bio-pacemakers. After differentiation, action potentials in spontaneously beating cardiomyocytes were initially sinus node-like, but subsequently became ventricular cardiomyocyte-like. RT-PCR established that ion channels mediating and were expressed before differentiation. After differentiation, ion channels underlying and were expressed first, followed by ion channels mediating and . Differentiated CMG cells expressed -adrenergic receptors and increased their beat rate in response to isoproterenol. CMG cardiomyocytes were purified using GFP fluorescence and transplanted into the free walls of the left ventricles of mice. The transplanted cardiomyocytes survived and connected to surrounding recipient cardiomyocytes via intercalated discs. Although further innovation is required, the present findings provide evidence of the potential for bone marrow-derived cardiomyocytes to be used as bio-pacemakers.