Implementation of an epicardial implantable MEMS sensor for continuous and real-time postoperative assessment of left ventricular activity in adult minipigs over a short- and long-term period.

The sensing of left ventricular (LV) activity is fundamental in the diagnosis and monitoring of cardiovascular health in high-risk patients after cardiac surgery to achieve better short- and long-term outcome. Conventional approaches rely on noninvasive measurements even if, in the latest years, invasive microelectromechanical systems (MEMS) sensors have emerged as a valuable approach for precise and continuous monitoring of cardiac activity. The main challenges in designing cardiac MEMS sensors are represented by miniaturization, biocompatibility, and long-term stability. Here, we present a MEMS piezoresistive cardiac sensor capable of continuous monitoring of LV activity over time following epicardial implantation with a pericardial patch graft in adult minipigs. In acute and chronic scenarios, the sensor was able to compute heart rate with a root mean square error lower than 2 BPM. Early after up to 1 month of implantation, the device was able to record the heart activity during the most important phases of the cardiac cycle (systole and diastole peaks). The sensor signal waveform, in addition, closely reflected the typical waveforms of pressure signal obtained via intraventricular catheters, offering a safer alternative to heart catheterization. Furthermore, histological analysis of the LV implantation site following sensor retrieval revealed no evidence of myocardial fibrosis. Our results suggest that the epicardial LV implantation of an MEMS sensor is a suitable and reliable approach for direct continuous monitoring of cardiac activity. This work envisions the use of this sensor as a cardiac sensing device in closed-loop applications for patients undergoing heart surgery.

Cardiovascular response to closed-loop intraneural stimulation of the right vagus nerve: a proof-of-concept study.

Vagus nerve stimulation (VNS) is an FDA-approved technique for the neuromodulation of the autonomic nervous system. There are many therapeutic applications where VNS could be used as a therapy, such as cardiovascular diseases, epilepsy, depression, and inflammatory conditions. Cardiovascular applications are particularly relevant, since cardiovascular diseases are the top causes of death worldwide. VNS clinical trials have been performed in the last 15 years for the treatment of heart failure (HF), achieving controversial results. Typically VNS is applied with a cuff electrode placed around the nerve, in an open-loop or cardiac synchronized design. The effectiveness of this approach is hindered by the multifunctional nature of the VN, which is involved in a variety of homeostatic controls. When a high current is applied, adverse effects arise from the stimulation of undesired fibers. An alternative strategy is represented by intraneural stimulation, which can guarantee higher selectivity. Moreover, closed-loop modalities allow the delivery of electrical current inside the nerves only if needed, with a reduced risk of untargeted nerve activation and lower energy consumption. Here we propose a closed-loop intraneural stimulation of the right cervical VN in a clinically relevant animal model. The intraneural was designed according to the internal structure of the VN. A threshold-based closed-loop algorithm was developed using HR as a control variable to produce a chronotropic effect.Clinical Relevance-This work analyzes the closed-loop intraneural VNS for the treatment of cardiovascular disorders, and supports the possibility of developing fully implantable devices with a high degree of selectivity in stimulation and prolonged lifespan.

Neural Stimulation Hardware for the Selective Intrafascicular Modulation of the Vagus Nerve.

The neural stimulation of the vagus nerve is able to modulate various functions of the parasympathetic response in different organs. The stimulation of the vagus nerve is a promising approach to treating inflammatory diseases, obesity, diabetes, heart failure, and hypertension. The complexity of the vagus nerve requires highly selective stimulation, allowing the modulation of target-specific organs without side effects. Here, we address this issue by adapting a neural stimulator and developing an intraneural electrode for the particular modulation of the vagus nerve. The neurostimulator parameters such as amplitude, pulse width, and pulse shape were modulated. Single-, and multi-channel stimulation was performed at different amplitudes. For the first time, a polyimide thin-film neural electrode was designed for the specific stimulation of the vagus nerve. In vivo experiments were performed in the adult minipig to validate to elicit electrically evoked action potentials and to modulate physiological functions, validating the spatial selectivity of intraneural stimulation. Electrochemical tests of the electrode and the neurostimulator showed that the stimulation hardware was working correctly. Stimulating the porcine vagus nerve resulted in spatially selective modulation of the vagus nerve. ECAP belonging to alpha and beta fibers could be distinguished during single- and multi-channel stimulation. We have shown that the here presented system is able to activate the vagus nerve and can therefore modulate the heart rate, diastolic pressure, and systolic pressure. The here presented system may be used to restore the cardiac loop after denervation by implementing biomimetic stimulation patterns. Presented methods may be used to develop intraneural electrodes adapted for various applications.

COVID-19-associated cardiovascular morbidity in older adults: a position paper from the Italian Society of Cardiovascular Researches.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infects host cells following binding with the cell surface ACE2 receptors, thereby leading to coronavirus disease 2019 (COVID-19). SARS-CoV-2 causes viral pneumonia with additional extrapulmonary manifestations and major complications, including acute myocardial injury, arrhythmia, and shock mainly in elderly patients. Furthermore, patients with existing cardiovascular comorbidities, such as hypertension and coronary heart disease, have a worse clinical outcome following contraction of the viral illness. A striking feature of COVID-19 pandemics is the high incidence of fatalities in advanced aged patients: this might be due to the prevalence of frailty and cardiovascular disease increase with age due to endothelial dysfunction and loss of endogenous cardioprotective mechanisms. Although experimental evidence on this topic is still at its infancy, the aim of this position paper is to hypothesize and discuss more suggestive cellular and molecular mechanisms whereby SARS-CoV-2 may lead to detrimental consequences to the cardiovascular system. We will focus on aging, cytokine storm, NLRP3/inflammasome, hypoxemia, and air pollution, which is an emerging cardiovascular risk factor associated with rapid urbanization and globalization. We will finally discuss the impact of clinically available CV drugs on the clinical course of COVID-19 patients. Understanding the role played by SARS-CoV2 on the CV system is indeed mandatory to get further insights into COVID-19 pathogenesis and to design a therapeutic strategy of cardio-protection for frail patients.

Tuscany Sangiovese grape juice imparts cardioprotection by regulating gene expression of cardioprotective C-type natriuretic peptide.

PURPOSE: A regular intake of red grape juice has cardioprotective properties, but its role on the modulation of natriuretic peptides (NPs), in particular of C-type NP (CNP), has not yet been proven. The aims were to evaluate: (1) in vivo the effects of long-term intake of Tuscany Sangiovese grape juice (SGJ) on the NPs system in a mouse model of myocardial infarction (MI); (2) in vitro the response to SGJ small RNAs of murine MCEC-1 under physiological and ischemic condition; (3) the activation of CNP/NPR-B/NPR-C in healthy human subjects after 7 days' SGJ regular intake. METHODS: (1) C57BL/6J male and female mice (n = 33) were randomly subdivided into: SHAM (n = 7), MI (n = 15) and MI fed for 4 weeks with a normal chow supplemented with Tuscany SGJ (25% vol/vol, 200 µl/per day) (MI + SGJ, n = 11). Echocardiography and histological analyses were performed. Myocardial NPs transcriptional profile was investigated by Real-Time PCR. (2) MCEC-1 were treated for 24 h with a pool of SGJ small RNAs and cell viability under 24 h exposure to H2O2 was evaluated by MTT assay. (3) Human blood samples were collected from seven subjects before and after the 7 days' intake of Tuscany SGJ. NPs and miRNA transcriptional profile were investigated by Real-Time PCR in MCEC-1 and human blood. RESULTS: Our experimental data, obtained in a multimodal pipeline, suggest that the long-term intake of SGJ promotes an adaptive response of the myocardium to the ischemic microenvironment through the modulation of the cardiac CNP/NPR-B/NPR-C system. CONCLUSIONS: Our results open new avenue in the development of functional foods aimed at enhancing cardioprotection of infarcted hearts through action on the myocardial epigenome.

High concentration of C-type natriuretic peptide promotes VEGF-dependent vasculogenesis in the remodeled region of infarcted swine heart with preserved left ventricular ejection fraction.

BACKGROUND: Vasculogenesis is a hallmark of myocardial restoration. Post-ischemic late remodeling is associated with pathology and function worsening. At the same time, neo-vasculogenesis helps function improving and requires the release of vascular endothelial growth factor type A (VEGF-A). The vasculogenic role of C-type natriuretic peptide (CNP), a cardiac paracrine hormone, is unknown in infarcted hearts with preserved left ventricular (LV) ejection fraction (EF). We explored whether myocardial VEGF-dependent vasculogenesis is affected by CNP. METHODS AND RESULTS: To this end, infarcted swine hearts were investigated by magnetic resonance imaging (MRI), histological and molecular assays. At the fourth week, MRI showed that transmural myocardial infarction (MI) affected approximately 13% of the LV wall mass without impairing global function (LVEF>50%, n=9). Increased fibrosis, metalloproteases and capillary density were localized to the infarct border zone (BZ), and were associated with increased expression of CNP (p=0.03 vs. remote zone (RZ)), VEGF-A (p<0.001 vs. RZ), BNP, a marker of myocardial dysfunction (p<0.01 vs. RZ) and the endothelial marker, factor VIII-related antigen (p<0.01 vs. RZ). In vitro, CNP 1000 nM promoted VEGF-dependent vasculogenesis without affecting the cell growth and survival, although CNP 100 nM or a high concentration of VEGF-A halted vascular growth. CONCLUSIONS: CNP expression is locally increased in infarct remodeled myocardium in the presence of dense capillary network. The vasculogenic response requires the co-exposure to high concentration of CNP and VEGF-A. Our data will be helpful to develop combined myocardial delivery of CNP and VEGF-A genes in order to reverse the remodeling process.

NPR-B, the C-type natriuretic peptide specific receptor, is the predominant biological receptor in mouse and pig myocardial tissue.

AIM: The increased myocardial production and the elevated plasma concentrations of C-type natriuretic peptide (CNP) in heart failure patients suggest its involvement in pathophysiological cardiac remodeling. The cardiovascular action of CNP seems to be mainly mediated by natriuretic peptide receptor (NPR)-B but the importance of CNP/NPR-B signaling in heart is not yet well characterized. The aim of this study was to assess the cardiac mRNA expression of CNP and NPR-B together with those of BNP and NPR-A in order to evaluate the relative importance of these peptides and of their receptors in cardiovascular system. METHODS: The expression of mRNA coding for CNP, NPR-B, BNP and NPR-A was investigated in myocardial tissue (BALB/c mice, N=5) by use of RT-PCR. NPR-A and NPR-B expression were also evaluated in left ventricle of male adult minipigs without (N=5) and with pacing-induced heart failure (HF, N=5). RESULTS: The proposed method allowed to detect the expression of mRNA coding for CNP and NPR-B in myocardial tissue confirming the presence of these effectors in the heart. These data also indicate that CNP mRNA expression is lower with respect to that of BNP (CNP/GAPDH= 0.117+/-0.035 vs. BNP/GAPDH=0.247+/-0.066) and that NPR-B is the predominant subtype receptor in the heart (Mouse: NPR-A/GAPDH=0.244+/- 0.028; NPR-B/GAPDH=0.657+/-0.022; p=0.0008; Pig: NPR-A/GAPDH=3.06+/-1.75, NPR-B/GAPDH= 14.3+/-3.6, p=0.0028; HF Pig: NPR-A/GAPDH= 4.29+/-0.93, NPR-B/GAPDH=7.9+/-1.1, p=0.0043). CONCLUSION: In the present study, we provided the first evidence of a higher mRNA expression in cardiac tissue of NPR-B with respect to NPR-A indicating that CNP specific receptor (NPR-B) is the predominant biological receptor in mouse and pig myocardial tissue.

Animal models of dilated cardiomyopathy for translational research.

Animal models of cardiovascular disease have proved critically important for the discovery of pathophysiological mechanisms and for the advancement of diagnosis and therapy. They offer a number of advantages, principally the availability of adequate healthy controls and the absence of confounding factors such as marked differences in age, concomitant pathologies and pharmacological treatments. Dilated cardiomyopathy (DCM) is the third cause of heart failure (HF) and is characterized by progressive ventricular dilation and functional impairment in the absence of coronary lesions and/or hypertension. Over the past thirty years, investigators have developed numerous small and large animal models to study this very complex syndrome. Genetically modified mice are the most widely and intensively utilized research animals and allow high throughput studies on DCM. However, to translate discoveries from basic science into medical applications, research in large animal models becomes a necessary step. An accurate large animal model of DCM is pacing-induced HF. It is obtained by continuous cardiac pacing at a frequency three- to fourfold higher than the spontaneous heart rate and is mostly applied to dogs, but also to pigs, sheep and monkeys. To date, this model can still be considered a gold standard in HF research.