Cardiovascular system Embryology Applied aspects

Preceptor Prof S S Kothari

 Early cardiac development Heart tube

Looping
Septation
Atrium Ventricles AV cushion

Outflow tract development .

Secondary heart field Left SVC

 In man, embryology may be defined as developmental biology from conception to the end of the second month of life

How we study human embryology ?

The Stages of Human Embryonic Development
The staging of human embryos was introduced in 1914 by Franklin P. Mall at the Department of Embryology of the Carnegie Institution of Washington.

Mall's sucessor, George L. Streeter, later refined the classification of human embryos into 23 stages, or "developmental horizons".

Each of the 23 Carnegie stages represents an arbitary point along the time-line of development

Vertebrate model systems in the study of early heart development: Xenopus and zebrafish.
The embryos are transparent, allowing observation during organogenesis; They can be obtained in large numbers;

They are readily accessible to embryologic manipulation and microinjection of RNA, DNA, or protein.
These embryos can live by diffusion for several days,

Scanning electron microscopy

Scanning electron micrograph shows the posterior half of a mouse embryo heart

Human without heart

During the first 2 weeks of life, humans have no heart and no vascular system.

The journey begins

From the cardiovascular standpoint, the main events of the third week of life, from 15 to 21 days
In humans, the mesoderm develops from the ectoderm on the 15th day of life . It is from the mesoderm that the cardiovascular system is formed.

The cardiogenic crescent of precardiac mesoderm, the immediate precursor of the heart, appears on the 18th day of life

The cardiogenic region is initially located at the anterior rim of the embryonic disc.

18d

20d

21d

26d

Day 17

Day 18

Day 21

The myocardium at this stage, however, does not completely surround the endothelial tube.
Instead, it retains, in its dorsal aspect, continuity with the splanchnic mesoderm of the developing mediastinum, through the structure known as the dorsal mesocardium

As the embryo grows, the developing heart assumes a position ventral to the forming forebrain and foregut.

DEVELOPMENT OF THE HEART TUBE

Heart is centrally positioned within the embryo
Bilaterally symmetrical

Shape of an inverted Y

Straight heart tube.

Day 23

THE FIRST BEAT

THE FIRST RED FLOW

A cut through the visceral arches, as in the image on the left, illustrates the pattern of flow as blood enters the caudal aspect of the heart tube and leaves in the region of the forming visceral arch.

Looping
WHAT IS LOOPING ? During the early phases of its development, the initially straight embryonic heart tube becomes transformed into a helically wound loop that is normally seen with a counterclockwise winding.

Why looping is important ?

Establishes the basic type of topological leftright asymmetry of the ventricular chambers

Bring the segments of the heart tube and the developing great vessels into an approximation of their definitive topographical relationships

AP dorsoventral LR

Heart defects with mirror-imaged arrangement (so-called inversion) of the ventricular chambers, were explained by leftward instead of the normal rightward looping of the embryonic heart tube

Other positional anomalies, such as left juxtaposition of the atrial appendages,were regarded as results of arrested looping

What causes looping?

The development of the morphological L-R asymmetries normally seen in the heart and other internal organs was found to be controlled by sidespecific molecular signaling cascades originating from Hensens node during the phase of gastrulation

The cardiac tube grows at a greater longitudinal rate then the rest of the embryo, causing it to fold

Looping morphogensis occurs in (1) the venous pole,

(2) the atrioventricular canal,

(3) the primitive ventricles, and (4) the outflow tract.

The AV-Canal
Its position along the original cranio-caudal axis of the heart tube is cranial to the common atrium and caudal to the primitive ventricular segment

During normal cardiac looping, the AV-canal undergoes complex positional changes together with the primitive ventricular segment (1) ventral and caudal displacement with respect to the common atrium and systemic venous sinus

AV AV

(2) leftward displacement with respect to the midline of the embryo

AV CANAL (3) A 90 degree counterclockwise rotation around its original craniocaudal axis

The Outflow Tract

The outflow tract connects the embryonic RV to the aortic sac
It consists of a proximal part (formerly called conus), which is added to the cranial end of the developing heart during the phases of dextral- and early slooping, and a distal part (formerly called truncus) which is added to the developing heart during the late phase of s-looping

Formation of atrium
The superolateral walls of the atrial component of the primary heart tube have ballooned out to either side of the outflow tract to form the atrial appendages.

It is formation of the two appendages that first differentiates the morphologically right and left sides of the primary atrium

The right appendage is extensive.

As the systemic venous sinus is incorporated within the forming right atrium, it insinuates itself between the appendage and the developing primary septum.

RAA The appendage is continuous distally with the expanding vestibule of the right atrium, formed by incorporation of the musculature of the atrioventricular canal into the developing atriums

Within the left atrium, a much larger contribution to the definitive chamber is made by the atrial component of the primary tube, from which the left appendage arises as a narrow outpouching positioned superiorly and to the left

Formation of ventricles
The ventricles are derived from the ventricular loop
As the tube bent, the primary interventricular foramen became obvious between its two components

The apical parts of the two ventricles balloon from the outer curve, with the inlet part of the primary tube giving rise to the developing apical part of the left ventricle, and the outlet part being the origin of the developing apical component of the right ventricle

When ballooning of the apical components commences, the walls of the atrioventricular canal are joined almost exclusively to the developing left ventricle, while the outlet component of the heart tube is supported almost entirely by the developing right ventricle

How RA communicate with RV

All that is required for the cavity of the right atrium to achieve direct continuity with that of the developing right ventricle, therefore, is expansion of the atrioventricular canal.

SEPTATION
WHAT IS SEPTATION ? Septation is the remodeling of the heart from a singlechannel peristaltic pump to a dual-channel, synchronously contracting device with 1-way valves In the human heart, septation occurs between 4 and 7 weeks of development Cardiac looping and chamber formation bring the contributing structures into position to engage in septation.

Cardiac septation is considered to involve the closure of direct communications between left and right atria, ventricles and subarterial channels, and the development of the right atrioventricular junction and left ventriculoarterial junction.
Myocytes that participate in the first step (chamber formation), do not materially contribute to the second step (septation).

HOW TO STUDY SEPTATION ?

In vivo labeling of cells

SEPTATION
ATRIA

OFT

AV CANAL

VENTRICLE

The left and right atria develop symmetrically up to the11th stage (22 days) The primary atrial septum grows as a muscular partition from the roof of the primary atrial component of the heart tube

This muscular shelf grows into the atrial cavity between the systemic and pulmonary venous As the primary openings

muscular septum grows from the atrial roof, it carries a mesenchymal cap on its leading edge

With continuing growth of the muscular primary atrial septum, this mesenchymal cap approaches, and then fuses with, the superior endocardial cushion of the AV canal The mass of mesenchyme entering the heart from the mediastinum, called the spina vestibuli or atrial spine

Primary septum with the mesenchymal tissues of the vestibular spine, combined with subsequent fusion with the superior and inferior atrioventricular cushions, themselves also fused by this stage, serves to fill in the gap initially seen beneath the leading edge of the primary septum and the atrioventricular endocardial cushions.

Before the primary atrial foramen is closed, however, the upper margin of the muscular primary septum breaks down to form the secondary interatrial foramen, or the ostium secundum

After fusion of the various mesenchymal structures, the primary septum itself is firmly adherent, via the tissues derived from the vestibular spine and the mesenchymal structures, to the crest of the ventricular septum

This permits the primary septum itself to function as the flap valve of the oval foramen.

Septum secudum

Septation of AV septum
AV junction is guarded by two masses of endocardial cushions, anterior/sup &posterior/inf cushion

These two masses meet in middle resulting in formation of mitral and tricuspid orifices

A deeper cut .

A V canal is positioned left of the embryo

ENDOCARDI AL CUSHION

Removal of the atrial walls and closer examination of the region around the atrioventricular canal illustrates a forming endocardial cushion.

DEEP CUT THROUGH THE VENTRICLES superior, inferior, right, and left cushions form around the atrioventricular canal.

The superior and inferior cushions must fuse to separate the atrioventricular (AV) canal into a right and left channel

FORMATION OF THE VENTRICULAR SEPTUM

The muscular part of the ventricular septum is produced concomitant with the ballooning of the apical components of the right and left ventricles from the primary heart tube.

As these pouches grow out from the heart tube, so the muscular septum is formed between them

The additional step then required to permit closure of the embryonic interventricular foramen, separating completely the newly formed right and left ventricles, is the transfer of the subaortic outlet to the left ventricle

It is the fusion of the proximal ends of the outflow cushions with the crest of the muscular ventricular septum that walls the aorta into the left ventricle,

PROXIMAL END OF OUTLET CUSHION FUSING WITH IVS

It is the conversion of this part of the fused outflow cushions into fibrous tissue, which produces the interventricular part of the membranous septum,.

OUT FLOW TRACT

cushions form to separate the endothelially-lined outflow tract of the heart into a pulmonary and aortic trunk

Multiple cell lineages contributing to cardiovascular development.

NEURAL CREST CELLS

SHF

PHF /FHF

Secondary heart field

Not all precursors of cardiac muscle reside in the cardiac crescent and the early linear heart tube Many RV myocytes , myoctes in atria , LV cardiac inflow and outflow tracts enter the developing heart after its inital looping stages are complete

Secondary heart field is medial and ventral to primary cardiac crescent Marker is transcription factor islet 1

Staining throughout the derivatives of the primary heart field. The outflow region (arrowed) is only partly stained.

Contributio ns made to the developing heart from the secondary heart field, staining the outflow tract and developing right ventricle.

Contribution of secondary heart field

Clinical implication
The results of induced genetic pertuberations in only SHF cells of embryonic mice suggest that abnormalities in this population can cause DORV RV HYPOPLASIA PS TOF

Other right sided disorders, such as Ebsteins anomaly and some forms of ARVD are also due to abnormalities the SHF cells

Conotruncal development is dependent upon normal migration of neural crest cells

Neural crest tissue is required for formation of: conotruncus aortic arches facial structures thymus parathyroid

RA regulates SHF organization within the precise time frame in which RA deficiency affects cardiac formation in avian and mammalian models

The conotruncal cushions form from cells that are derived from the endothelium and that migrate into the cardiac jelly

In addition, neural crest cells that form at the level of the 4th and 6th aortic arches populate the forming truncal cushions

Subsequent to looping, the outflow tract possesses a characteristic dog-leg bend in its course from the right ventricle to the margins of the pericardial cavity. This bend divides the outflow tract into proximal and distal portions

The endocardial jelly concentrates itself into pairs of facing cushions that extend through the length of the outflow tract

The cushions are continuous throughout the outflow tract, spiralling round one another as they run from the distal end of the right ventricle to the aortic sac

Within the aortic sac itself, a transverse wedge of tissue is now seen separating the arteries feeding the fourth and sixth arches, respectively
The wedge of tissue that separates the fourth and sixth arches in the posterior wall of the aortic sac is the so-called aorto-pulmonary septum.

Fusion of the endocardial cushions

This starts distally, and progresses proximally. The fusion of the cushions distally divides the distal part of the outflow tract itself into the intrapericardial components of the aorta and the pulmonary trunk

Fusion of the outflow tract cushions results in separation of the blood flow; the blood exits the left ventricle through the aorta and exits the right ventricle through the pulmonary artery

Proximal to the dog-leg bend, however, it is still possible to recognise the cushions that are septating in the proximal part of the outflow tract

Two further intercalated cushions have grown in the opposite quadrants of the common outflow tract

 Formation of cavities in the fused distal parts of the proximal cushions, along with similar cavitation in the intercalated cushions, now produces the primordiums of the arterial valvar leaflets and sinuses

Distal outflow tract

Musculature of the walls of the distal outflow tract has disappeared very rapidly as the arterial trunks achieve their arterial phenotype

Distal part of proximal OFT The muscular cuff surrounding the distal part of the proximal outflow tract also disappears,but more gradually,

 But in proximal part of proximal OFT

myocardialisation The myocardial cells in the walls of the proximal outflow tract grow into the most proximal parts of the cushions as they fuse, converting the endocardial septum into a muscular partition

 As the cushions fuse and muscularise, they span the outlet from the right ventricle, which initially supports both developing outflow tracts.

During continued development

Space beneath the free proximal edge of the fused cushions becomes increasingly smaller

 Eventually the entire leading edge of the fused outflow cushions becomes attached to the right ventricular surface of the crest of the muscular ventricular septum,

PA COMMITTED TO RV & AORTA COMMITTED TO LV

 Later this muscular tissue converted into fibrous tissue

Producing the area of fibrous continuity between the leaflets of the aortic and mitral valves & Severing the electrical continuity at this site between the atrial and ventricular muscle masses

 the muscularised partition becomes converted into the free-standing infundibulum of the pulmonary valve, and part of the supraventricular crest of the right ventricle

Is septation defects alone explain conotruncal anomalies?

 Observations of 96-16 transgene expression in Splotch mice with PTA or DORV reveal an arrest of OFT rotation associated with a septation defect.

 Rotation of the myocardium at the base of the OFT is probably essential to achieve normal positioning of the great arteries with respect to each other at the ventriculo-arterial junction. The spiraling movement of the aortico-pulmonary septum, which generates specific ventriculoarterial connections, may result from the rotation of the myocardial wall of the OFT

Importance of pathogenetic mechanism

Classification of Cardiovascular Malformations by Pathogenetic Mechanisms

I. Ectomesenchymal tissue migration abnormalities (neural crest defects) Conotruncal septation defects Increased mitralaortic separation Subarterial ventricular septal defect Double-outlet right ventricle Tetralogy of Fallot with or without pulmonary atresia

Aorticopulmonary window Truncus arteriosus Branchial arch defects Double aortic arch Right aortic arch with mirror image branching

Abnormal conotruncal cushion position

D-transposition of the great arteries

 II. Abnormalities of intracardiac blood flow

Left heart defects Bicuspid aortic valve Aortic valve stenosis Coarctation of the aorta Interrupted aortic arch, Hypoplastic left heart, aortic atresia, and mitral atresia Right heart defects Secundum atrial septal defect Bicuspid pulmonary valve Pulmonary valve stenosis Pulmonary valve atresia with intact ventricular septum

 III. Cell death abnormalities Ebstein malformation of the tricuspid valve Muscular ventricular septal defect IV. Extracellular matrix abnormalities Endocardial cushion defects Ostium primum atrial septal defect Atrioventricular canal type ventricular septal defect (inflow) Complete atrioventricular canal defect Dysplastic pulmonary or aortic valve

 V. Abnormal targeted growth Anomalous pulmonary venous connection Partially anomalous pulmonary venous connection Totally anomalous pulmonary venous connection Cor triatriatum

 VI. Abnormal situs and looping Situs inversus totalis Isolated Immotile cilia syndrome, Kartagener syndrome Heterotaxy Asplenia syndrome, right isomerism, bilateral rightsidedness Polysplenia syndrome, left isomerism, bilateral leftsidedness Looping abnormalities L-transposition of the great arteries Ventricular inversion

 Persistent left superior vena cava is the most common form of anomalous venous drainage involving the SVC Seen in 0.3%0.5% of the normal population and 1.5%10% of patients with CHD

 First organ to form in the body

Newer research methods are emerging to improve our knowledge of developmental biology Not all parts of the heart is formed from primary heart field

SHF & neural crest cells also contribute to heart development

SHF contributes to RV development and research is throwing light into its involvement in diseases involving RV

 Neural crest cells are assuming importance in OFT development & its disorders Teratogens like Vit A acts through SHF & neural crest cell migration.

Looping & septation anomalies are the causes for major CHDs
Rotation abnormalities are assuming pathogenic significance Developmental biology helps in better understanding of the pathogentic classification of CHDs

Understanding this much is difficult

Thank you ..

Tetralogy of Fallot
Anterior deviation of the outlet ventricular septum is the cause of all four abnormalities seen in tetralogy of Fallot.