Solving Heart Failure 3345C 1

The Galloheart

Abstract

Currently, heart failure (HF) has no cure and affects almost 6 million Americans annually. Myocardial

infarction (MI), more commonly known as a heart attack, causes heart failure by preventing oxygenated

blood flow and killing cardiomyocytes, the muscle cells that cause the heart to pump. Because

cardiomyocytes dont replicate, this tissue damage is irreparable naturally and permanently impairs heart

function. In order to restore normal heart functions to a patient post-MI, we propose this future

technology: a three dimensional (3D) bioprinter capable of creating extracellular matrixes (ECM). The

ECMs printed will then be grafted with stem cells that differentiate into the appropriate cell type. This

will effectively allow us to create fully functional, transplantable organs.

Solving Heart Failure 3345C 2

II. Description

Present Technology.

Currently, patients who experience heart failure currently have mechanical devices, such as the

left ventricular assist device (LVAD), implanted into them. The LVAD pumps blood from the hearts left

ventricle into the aorta, supplying the rest of the body with oxygenated blood (Stanford Health Care,

2016); it effectively acts as a heart. While the LVAD is helpful, it only helps the patient cope with HF. It

does not actually repair the hearts damage. Additionally, the LVAD requires its user to carry an attached

battery and control pack at all times, making it susceptible to physical damage and infection of the line

outside of the body (Nucleus Medical Media, 2015).

The actual tissue damage that results from a myocardial infarction can be repaired through cell

therapy. Cell therapy is a form of regenerative medicine that relies on introducing new cells into damaged

tissue for repair. Stem cells are introduced, as they are not rejected by the immune system, can

differentiate into any tissue, and can replicate indefinitely. This therapy has potential to reverse the

damage caused by a myocardial infarction, since it directly replaces the cardiomyocytes (muscle cells)

that died post-MI. Stem cell therapy as a treatment option is theoretically sound, but it is currently in need

of more clinical trials if it is to become an approved, standard treatment (Flynn & OBrien, 2011).

Most commonly, Infusion delivery is used to bring stem cells to damaged tissues. Infusion

delivery involves injecting stem cells into the vasculature near the heart (Davies, Goetsch, Ngoepe, Franz,

& Lecour, 2016). Typically, the stem cells are injected in an artery near the heart in order to prevent the

stem cells from engrafting elsewhere, and a balloon is inflated prior to the injection site in order to

prevent the stem cells from back flowing out (Davies et al., 2016). Even though patients do show signs of

improvement after these therapy techniques, engraftment rates are poor; less than 3% of stem cells

injected remain in the heart. This is likely because the patients heart is still beating while the stem cells

are injected. This would cause the injected stem cells to be pumped out of the heart, preventing them from

grafting themselves onto the damaged tissue.

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Alternatively, intramyocardial injection can be used to deliver the stem cells. Instead of pumping

stem cells into the bloodstream, stem cells are injected directly into the hearts muscle. Epicardial

injections - ones on the outer tissues of the heart - require open-heart surgery, making it impractical for

weaker patients. However, endocardial injections - ones on the inside tissues - are much more practical

for weaker patients, as they require only the insertion of a catheter into the heart (Davies 2016).

Engraftment rates for certain methods of epicardial injection, such as transvenous delivery, are higher

than infusion methods, but they have only been tested for pigs and havent been approved for use in

humans (George J., et al 2008). In short, current stem cell treatments suffer from poor engraftment rates.

Currently, 3D printing can not fully model the complexity of biomaterials (Murphy & Atala,

2014). Some researchers have created analogues to ECMs by extruding a powderized ECM with cells, but

the efficacy of these analogues as organs is unknown. They are able to sustain cells, however (Pati, Jang,

Ha, Kim, Rhie, Shim, Kim, & Cho 2014).

History.

The publication Clinical Trials to Date with MSCs: Heart Failure describes five clinical trials

attempt to cure heart failure through mesenchymal stem cells (MSCs). In the C-CURE experiment,

50x10^6 allogenic bone MSCs were injected into patients with ischemic cardiomyopathy. Out of the

patients treated, 75% responded with positive results, showing that MSCs were able to safely aid with the

disease.

Then with allogenic mesenchymal precursor cells (MPCs), patients with ischemic and

nonischemic heart failure, two analyses were done to determine the best amount of MPCs to inject. The

first analysis proved safety in use with lower doses, and the second analysis provided significantly more

benefits to those that got higher doses. After three years worth of post-trial checkups, all groups with

high doses of MPCs did not require hospitalization or die cardiac-related deaths. As a result, the

experiments foreshadow the possibility of reversing heart failure through the use of MSCs. These two

studies are considered breakthroughs because they prove that healing the heart through the use of stem

cells is feasible.
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In addition to stem cells, decellularization of a cadaveric tissue is another breakthrough in

regenerative medicine and tissue engineering. In a tour of Texas Heart Institute (THI), Dr. Doris Taylor

explained the base of the decellularization process. However, during the tour, Dr. Taylor explained that

whole organ decellularization was not always available. Scientists have decellularized other organs

including, kidney, liver, and lungs (Lyons et al, 1995). At the THI, researches used a series of solutions

and detergents to decellularize the heart. They placed a heart in a glass container, connected tubes to the

heart, and circulated a detergent. Over four to eight days, the heart was flushed of its cells, and only the

ECM of the organ remained

The history of 3D printing is not as interesting. 3D printers were initially used to rapidly create

prototypes for industry, but, currently, 3D printers are used for either rapid prototyping or for the

production of highly specialized, detailed parts (3D printing industry, n.d.). Our 3D printer falls into the

latter. 3D printers function by arranging some material into a pattern defined by a file, but the exact

method the printer uses varies, as each method has certain strengths and drawbacks (Chia & Wu 2014).

Future Technology.

While artificial hearts that are derived from decellularized hearts and stem cells are theoretically

able to act as transplants, they still require a donor heart to be decellularized. This limits our supply of

artificial hearts. If we were to design a 3D printer capable of printing ECMs, we could create an unlimited

amount of functional, transplantable, synthetic organs.

We envision a 3D printer capable of producing an organs extracellular matrix. This 3D printer

would extrude a bioink, and a plastic that could easily be dissolved. The bioink would contain stem

cells, differentiated cells, nutrients, and the proteins that make up the ECM. The plastic would be

extruded to create a rough mold of the organ to support the bioink. The cells in the bioink would create

the ECM itself, since it is too complex of a tissue to model. Once the cells are finished creating a layer of

the ECM, another layer of plastic will be extruded to support the matrixs further development. When the

matrix is done, the plastic will be dissolved and the matrix decellularized. This leaves a final product

ready to be grafted with stem cells. Because this 3D printer can be used to create any ECM, it can
Solving Heart Failure 3345C 5

theoretically make any organ for transplant, assuming that engineers know how to graft and differentiate

the appropriate cells unto it.

This technology, ultimately, will involve machine learning, tissue engineering, cellular biology,

and, of course, 3D printing for reasons we will soon discuss.

Breakthroughs.

A number of breakthroughs are needed for us to print ECMs. Firstly, while the chemical

composition of an ECM is known (Alberts, Johnson, Lewis, Raff, Roberts, & Walter 2002), designing the

matrix by hand on an atom-by-atom basis is impractical due to its size. Secondly, the actual construction

of the matrix --how it is created during organogenesis-- is not thoroughly understood.

These problems are solvable. Instead of designing the heart by hand chemically, it can be

designed by a machine cellularly. Machine learning is a method of data analysis where an algorithm finds

pattern in a data set and is able to predict and classify future data. Even though machine learning reduces

the labor it takes to design an ECM, doing so on a chemical level is impractical due to the sheer size of

the matrix. Not to mention, it is possible for the machine to make errors while modelling the heart. If the

machine does not arrange the ECM perfectly, it may be inhospitable to life, because both the three-

dimensional structure of the matrix and its chemical composition determine its functionality (Czirok,

Zamir, Filla, Litttle, & Rongish, 2006). So, the program designing the ECM itself would only design the

matrixs macroscopic structure by creating a mold to support the cells actually making the matrix.

Machine learning requires a data set to extrapolate from. When training a machine to recognize

images, each image is fed as a matrix (a 2-tensor), and the value of each element in the matrix

corresponds to the color of a pixel (Tensorflow, 2016). Likewise, we can abstract the heart by reducing it

to a three-dimensional array (a 3-tensor), as it is a 3D object. However, what the value of each element

represents is not so clear. Further research that elucidates how the ECM is formed is necessary in order to

determine what to represent with the value of each element. Research that correlates the composition of a

bioink and the final structure of the ECM would be the most useful. While the ECMs role in cell

differentiation is well understood, little is known about how it is formed during organogenesis (Czirok et
Solving Heart Failure 3345C 6

al. 2006). This research would help us understand how to simplify the design of the organ, and it would

also help us further determine the composition of our bioink.

Current bioinks, such as those in Pati et. al (2014), involve extruding a powderized decellularized

ECM as a solution with cells encapsulated within the matrix. This solution soon hardens and functions as

a pseudo ECM. Our 3D printer will require further development of this technology. Instead of containing

a decellularized matrix, our bioink will contain the matrixs constituent biochemicals, nutrients, and cells.

Again however, there is no in depth understanding of the ECM is actually formed during organogenesis

(Czirok et al. 2006), so the precise composition of our bioink cannot currently be determined.

To surmise, our 3D printer, the Galloheart, chiefly needs a breakthrough in the understanding

how the ECM is formed, both on a chemical and physical level. Data that correlates the composition of

certain bioinks some property of the final ECM would allow us to use machine learning to design the

ECM macroscopically. Data that elucidates how the ECM is formed during organogenesis, both

physically and chemically, would enable superior formulations of bioink that can be correlated to some

property of the ECM. Czirok et al.s paper (2006) explicitly calls for, ...a vast spectrum of studies

ranging from determining protein conformations to computer modeling of embryonic tissue movements

during organogenesis, for further understanding of ECM development.

Design Process.

The team used the following decision matrix to think through three alternative ideas considering

the solution to heart failure. Our final decision on which idea to pursue is based on the following criteria:

Readily available technology: Is there technology that already exists that we could use for this

idea?

Ethics: Would doing this idea be controversial? Would it be against any religions or moral values

people hold?

Longevity: How long would it take to implement the idea? Hypothetically speaking, could it

work fast enough for a patient who is on the verge of death? How long would the solution work?
Solving Heart Failure 3345C 7

Safety to patient: How safe is this idea? How much harm would need to be done to the patient in

order for the idea to work? Do the positive effects on the patient outweigh the negatives?

Readily Ethics Longevity Safety to patient Total

available

technology

Idea 1: Make a 5 --Easy 5 --All of the 1 --Unsure if 1 --The body could 12/20

patch out of access to components would patch would easily reject the

ECM, stem cells, ECM and be taken from work; our patch if not created

and growth other factors donors. limited specifically.

factors. needed to research

make the prevents our

patch. knowing.

Idea 2: Take 5 --Easy to 1 --Taking stem 1 --Unsure if 1 --Human body 8/20

allogenic (bone extract, cells from the bone the animal could easily reject

marrow) stem procedures marrow of animals marrow would stem cells of

cells from for extraction would not be work on animals or the stem

organisms other and transplant considered humans for cells would be too

than humans, already exist. completely ethical however long. unnatural for the

such as cows. to religious and human body to

The cells would those protecting work with.

then differentiate animal lives from

into heart cells experiments.

for the patient.

Solving Heart Failure 3345C 8

Idea 3: Amplify 1 --None 1 --Regenerative 1 --Developing 1 --Overgrowth or 4/20

or modify hearts are the technology overexpression of

oncogenes and controversial in would take a oncogenes could

tumor suppressor religious aspects lot of time and cause creation of

genes to help research. cancerous tumor.

regenerate parts

of the heart as it

deteriorates.

Idea 4: 3D print 5 --Already 1 --Controversial 5 --3D printing 3 --If made 14/20

an ECM to grow have multi- to all-natural takes less than correctly, the ECM

healthy heart material 3D people who a week (three could support the

cells and make an printers; believe the body days human heart

entire new heart. already know should not be maximum); our indefinitely.

what ECM is synthetic. technology

made of. would have to

work in less

than a week.

As shown in the above decision matrix, the team decided to pick our fourth idea - 3D printing the

ECM - because there are already existing technology that could be developed into our technology. As

shown in the Future Technology section of this report, 3D printers have transformed from using one

material, such as polyethylene, into others, such as soft metals. Current 3D printers require a maximum of

seventy-two hours to create objects the size of a heart with any kind of materials. Medical tools, including

heart valves, have been made through tissue-producing 3D printers (Crawford, 2013). It is safe to assume

that, within the two decades or so, it will be feasible to print an ECM for the heart.
Solving Heart Failure 3345C 9

In terms of ethics, printing the ECM could be controversial due to its artificial nature. However,

if made correctly, the ECM could function indefinitely without mechanical aid. The patient would not

require cyclical heart transplants or an LVAD. This would increase the rate of survival as the patient

evades surgery and possibility of infection with the LVAD.

Our first proposed idea of a patch requires the ECM of a donated heart, which our chosen

technology does not need. During the brainstorming process we realized that, since the goal of our 3D

printer is to create ECMes, it could help the first idea. The second proposal was to extract stem cells from

an animal, such as a cow, and inject them into a patient, thereby negating donation from another human or

the patient themself. However, the ethics of were too complicated, we saw no marketability of the

product. Additionally, there is already technology available to conduct this idea that we would not need to

invent anything else for. For the third idea, we thought of making a regenerative heart that would utilize

oncogenes and tumor suppressors. The oncogenes would stimulate growth while the tumor suppressors

would stop it. However, we deemed the idea too risky, as there is a lack of scientific research that would

prove our hypothesis.

Consequences.

In recognition of all the benefits and negatives that new technology can affect on society, the

team came up with potential positive and negative consequences for our 3D printer.

3D printing an ECM eradicates the need of a donor heart and, consequently, any need for organ

donors. Theoretically, the ECM produced by the printer could function indefinitely until the patient died

of natural causes unrelated to heart failure. This 3D printer could also create the ECMs of other organs,

such as the kidneys. That would be a significant development in the field of tissue engineering.

Additionally, developing the printer would create many jobs for researchers, scientists, and doctors across

a plethora of fields.

However, our invention also has potential negative effects. Developing this 3D printer requires a

lot of time and resources. The proteins, growth factors, and other materials of the ECM are not dispersed

evenly throughout the ECM, and the creation of the ECM itself is poorly understood. A thorough
Solving Heart Failure 3345C 10

understanding of both these processes is necessary for our 3D printer. Thus, it would take years of

research and development to perfect the bioink for our printer. We would also need to test the efficacy

and safety of the printed matrixes during a clinical trial, which would also require additional resources.

During these clinical trials, the body might even reject the heart, costing money, and, more importantly

the life of the patient.

Solving Heart Failure 3345C 11

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