Extracellular Matrix-based Biomaterials Research Articles

Fibrin-Polycaprolactone Scaffolds for the Differentiation of Human Neural Progenitor Cells into Dopaminergic Neurons.

Parkinson's disease (PD), a progressive central nervous system disorder marked by involuntary movements, poses a significant challenge in neurodegenerative research due to the gradual degeneration of dopaminergic (DA) neurons. Early diagnosis and understanding of PD's pathogenesis could slow disease progression and improve patient management. In vitro modeling with DA neurons derived from human-induced pluripotent stem cell-derived neural progenitor cells (NPCs) offers a promising approach. These neurons can be cultured on electrospun (ES) nanofibrous polycaprolactone (PCL) scaffolds, but PCL's hydrophobic nature limits cell adhesion. We investigated the ability of ES PCL scaffolds coated with hydrophilic extracellular matrix-based biomaterials, including cell basement membrane proteins, Matrigel, and Fibrin, to enhance NPC differentiation into DA neurons. We hypothesized that fibrin-coated scaffolds would maximize differentiation based on fibrin's known benefits in neuronal tissue engineering. The scaffolds both coated and uncoated were characterized using scanning electron microscopy (SEM), transmission electron microscopy, Fourier transform infrared spectroscopy-attenuated total reflectance, and dynamic mechanical analysis to assess their properties. NPCs were seeded on the coated scaffolds, differentiated, and matured into DA neurons. Immunocytochemistry targeting tyrosine hydroxylase (TH) and SEM confirmed DA neuronal differentiation and morphological changes. Electrophysiology via microelectrode array recorded their neuronal firing. Results showed enhanced neurite extension, increased TH expression, and active electrical activity in cells on fibrin-coated scaffolds. Diluted fibrin coatings particularly promoted more pronounced neuronal differentiation and maturation. This study introduces a novel tissue-on-a-chip platform for neurodegenerative disease research using DA neurons.

Applications of Extracellular Matrix Biomaterial in Tongue Reconstruction.

Tongue neoplasms are common in the head and neck region and are primarily treated through surgical interventions. Various reconstruction techniques, such as primary closure, skin grafts, skin substitute biomaterials, and free tissue transfer, are used to address the resulting defects. This study provides an overview of our experience utilizing extracellular matrix-based biomaterials (ECM) for the reconstruction of tongue defects and evaluates the mean volumetric size of postsurgical tongue. This retrospective case series evaluated subjects with tongue defects secondary to benign or malignant resections who underwent reconstruction with ECM-based biomaterials at Ascension Hospital from July 2022 to May 2023. Descriptive variables were collected, and descriptive statistical analyses were conducted. The primary outcome was the volume of postsurgical defect reconstructed. Twenty-five subjects were included: 10 had benign pathology and 15 had malignancy. The mean reconstructed defect volume was 12.65cm 3 , ranging between 2 and 35cm 3 . Postoperative bleeding, mainly linked to anticoagulation medication, occurred in 20% (n=5) of the cases, and the rate of need for additional procedures was 8%. In conclusion, ECM-based biomaterials are suitable for reconstructing varying sizes of postsurgical tongue defects with no donor-site morbidity. Carefully considering patient factors, including anticoagulation medication use and defect volume, is essential in optimizing outcomes.

Co-administration of extracellular matrix-based biomaterials with neural stem cell transplantation for treatment of central nervous system injury.

Injuries and disorders of the central nervous system (CNS) present a particularly difficult challenge for modern medicine to address, given the complex nature of the tissues, obstacles in researching and implementing therapies, and barriers to translating efficacious treatments into human patients. Recent advancements in neural stem cell (NSC) transplantation, endogenous neurogenesis, and in vivo reprogramming of non-neural cells into the neuronal lineage represent multiple approaches to resolving CNS injury. However, we propose that one practice that must be incorporated universally in neuroregeneration studies is the use of extracellular matrix (ECM)-mimicking biomaterials to supply the architectural support and cellular microenvironment necessary for partial or complete restoration of function. Through consideration of developmental processes including neurogenesis, cellular migration, and establishment of functional connectivity, as well as evaluation of process-specific interactions between cells and ECM components, insights can be gained to harness and modulate native and induced neurobiological processes to promote CNS tissue repair. Further, evaluation of the current landscape of regenerative medicine and tissue engineering techniques external to the neurosciences provides key perspectives into the role of the ECM in the use of stem cell-based therapies, and the potential directions future neuroregenerative approaches may take. If the most successful of these approaches achieve wide-spread adoption, innovative paired NSC-ECM strategies for neuroregeneration may become prominent in the near future, and with the rapid advances these techniques are poised to herald, a new era of treatment for CNS injury may dawn.

Tissue Engineering Neovagina for Vaginoplasty in Mayer-Rokitansky-Küster-Hauser Syndrome and Gender Dysphoria Patients: A Systematic Review.

Background: Vaginoplasty is a surgical solution to multiple disorders, including Mayer-Rokitansky-Küster-Hauser syndrome and male-to-female gender dysphoria. Using nonvaginal tissues for these reconstructions is associated with many complications, and autologous vaginal tissue may not be sufficient. The potential of tissue engineering for vaginoplasty was studied through a systematic bibliography search. Cell types, biomaterials, and signaling factors were analyzed by investigating advantages, disadvantages, complications, and research quantity. Search Methods: A systematic search was performed in Medline, EMBASE, Web of Science, and Scopus until March 8, 2022. Term combinations for tissue engineering, guided tissue regeneration, regenerative medicine, and tissue scaffold were applied, together with vaginoplasty and neovagina. The snowball method was performed on references and a Google Scholar search on the first 200 hits. Original research articles on human and/or animal subjects that met the inclusion (reconstruction of vaginal tissue and tissue engineering method) and no exclusion criteria (not available as full text; written in foreign language; nonoriginal study article; genital surgery other than neovaginal reconstruction; and vaginal reconstruction with autologous or allogenic tissue without tissue engineering or scaffold) were assessed. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist, the Newcastle-Ottawa Scale, and the Gold Standard Publication Checklist were used to evaluate article quality and bias. Outcomes: A total of 31 out of 1569 articles were included. Data extraction was based on cell origin and type, biomaterial nature and composition, host species, number of hosts and controls, neovaginal size, replacement fraction, and signaling factors. An overview of used tissue engineering methods for neovaginal formation was created, showing high variance of cell types, biomaterials, and signaling factors and the same topics were rarely covered multiple times. Autologous vaginal cells and extracellular matrix-based biomaterials showed preferential properties, and stem cells carry potential. However, quality confirmation of orthotopic cell-seeded acellular vaginal matrix by clinical trials is needed as well as exploration of signaling factors for vaginoplasty. Impact statement General article quality was weak to sufficient due to unreported cofounders and incomplete animal study descriptions. Article quality and heterogenicity made identification of optimal cell types, biomaterials, or signaling factors unreliable. However, trends showed that autologous cells prevent complications and compatibility issues such as healthy cell destruction, whereas stem cells prevent cross talk (interference of signaling pathways by signals from other cell types) and rejection (but need confirmation testing beyond animal trials). Natural (orthotopic) extracellular matrix biomaterials have great preferential properties that encourage future research, and signaling factors for vascularization are important for tissue engineering of full-sized neovagina.

Advancements in Extracellular Matrix-Based Biomaterials and Biofabrication of 3D Organotypic Skin Models.

Over the last decades, three-dimensional (3D) organotypic skin models have received enormous attention as alternative models to in vivo animal models and in vitro two-dimensional assays. To date, most organotypic skin models have an epidermal layer of keratinocytes and a dermal layer of fibroblasts embedded in an extracellular matrix (ECM)-based biomaterial. The ECM provides mechanical support and biochemical signals to the cells. Without advancements in ECM-based biomaterials and biofabrication technologies, it would have been impossible to create organotypic skin models that mimic native human skin. In this review, the use of ECM-based biomaterials in the reconstruction of skin models, as well as the study of complete ECM-based biomaterials, such as fibroblasts-derived ECM and decellularized ECM as a better biomaterial, will be highlighted. We also discuss the benefits and drawbacks of several biofabrication processes used in the fabrication of ECM-based biomaterials, such as conventional static culture, electrospinning, 3D bioprinting, and skin-on-a-chip. Advancements and future possibilities in modifying ECM-based biomaterials to recreate disease-like skin models will also be highlighted, given the importance of organotypic skin models in disease modeling. Overall, this review provides an overview of the present variety of ECM-based biomaterials and biofabrication technologies available. An enhanced organotypic skin model is expected to be produced in the near future by combining knowledge from previous experiences and current research.

Xenogeneic Decellularized Extracellular Matrix-based Biomaterials For Peripheral Nerve Repair and Regeneration.

Peripheral nerve injury could lead to either impairment or a complete loss of function for affected patients, and a variety of nerve repair materials have been developed for surgical approaches to repair it. Although autologous or autologous tissue-derived biomaterials remain preferred treatment for peripheral nerve injury, the lack of donor sources has led biomedical researchers to explore more other biomaterials. As a reliable alternative, xenogeneic decellularized extracellular matrix (dECM)-based biomaterials have been widely employed for surgical nerve repair. The dECM derived from animal donors is an attractive and unlimited source for xenotransplantation. Meanwhile, as an increasingly popular technique, decellularization could retain a variety of bioactive components in native ECM, such as polysaccharides, proteins, and growth factors. The resulting dECM-based biomaterials preserve a tissue's native microenvironment, promote Schwann cells proliferation and differentiation, and provide cues for nerve regeneration. Although the potential of dECM-based biomaterials as a therapeutic agent is rising, there are many limitations of this material restricting its use. Herein, this review discusses the decellularization techniques that have been applied to create dECM-based biomaterials, the main components of nerve ECM, and the recent progress in the utilization of xenogeneic dECM-based biomaterials through applications as a hydrogel, wrap, and guidance conduit in nerve tissue engineering. In the end, the existing bottlenecks of xenogeneic dECM-based biomaterials and developing technologies that could be eliminated to be helpful for utilization in the future have been elaborated.

Extracellular Matrix-Based Biomaterials for Cardiovascular Tissue Engineering.

Regenerative medicine and tissue engineering strategies have made remarkable progress in remodeling, replacing, and regenerating damaged cardiovascular tissues. The design of three-dimensional (3D) scaffolds with appropriate biochemical and mechanical characteristics is critical for engineering tissue-engineered replacements. The extracellular matrix (ECM) is a dynamic scaffolding structure characterized by tissue-specific biochemical, biophysical, and mechanical properties that modulates cellular behavior and activates highly regulated signaling pathways. In light of technological advancements, biomaterial-based scaffolds have been developed that better mimic physiological ECM properties, provide signaling cues that modulate cellular behavior, and form functional tissues and organs. In this review, we summarize the in vitro, pre-clinical, and clinical research models that have been employed in the design of ECM-based biomaterials for cardiovascular regenerative medicine. We highlight the research advancements in the incorporation of ECM components into biomaterial-based scaffolds, the engineering of increasingly complex structures using biofabrication and spatial patterning techniques, the regulation of ECMs on vascular differentiation and function, and the translation of ECM-based scaffolds for vascular graft applications. Finally, we discuss the challenges, future perspectives, and directions in the design of next-generation ECM-based biomaterials for cardiovascular tissue engineering and clinical translation.

Decellularised extracellular matrix-based biomaterials for repair and regeneration of central nervous system.

The central nervous system (CNS), consisting of the brain and spinal cord, regulates the mind and functions of the organs. CNS diseases, leading to changes in neurological functions in corresponding sites and causing long-term disability, represent one of the major public health issues with significant clinical and economic burdens worldwide. In particular, the abnormal changes in the extracellular matrix under various disease conditions have been demonstrated as one of the main factors that can alter normal cell function and reduce the neuroregeneration potential in damaged tissue. Decellularised extracellular matrix (dECM)-based biomaterials have been recently utilised for CNS applications, closely mimicking the native tissue. dECM retains tissue-specific components, including proteoglycan as well as structural and functional proteins. Due to their unique composition, these biomaterials can stimulate sensitive repair mechanisms associated with CNS damages. Herein, we discuss the decellularisation of the brain and spinal cord as well as recellularisation of acellular matrix and the recent progress in the utilisation of brain and spinal cord dECM.

Extracellular matrix-based biomaterials as adipose-derived stem cell delivery vehicles in wound healing: a comparative study between a collagen scaffold and two xenografts

BackgroundStem cell therapies represent a promising tool in regenerative medicine. Considering the drawbacks of direct stem cell injections (e.g. poor cell localisation), extracellular matrix-based biomaterials (e.g. scaffolds and tissue grafts), due to their compositional biofunctionality and cytocompatibility, are under investigation as potential stem cell carriers.MethodsThe present study assessed the potential of three commercially available extracellular matrix-based biomaterials [a collagen/glycosaminoglycan scaffold (Integra™ Matrix Wound Dressing), a decellularised porcine peritoneum (XenoMEM™) and a porcine urinary bladder (MatriStem™)] as human adipose-derived stem cell delivery vehicles.ResultsBoth tissue grafts induced significantly (p < 0.01) higher human adipose-derived stem cell proliferation in vitro over the collagen scaffold, especially when the cells were seeded on the basement membrane side. Human adipose-derived stem cell phenotype and trilineage differentiation potential was preserved in all biomaterials. In a splinted wound healing nude mouse model, in comparison to sham, biomaterials alone and cells alone groups, all biomaterials seeded with human adipose-derived stem cells showed a moderate improvement of wound closure, a significantly (p < 0.05) lower wound gap and scar index and a significantly (p < 0.05) higher proportion of mature collagen deposition and angiogenesis (the highest, p < 0.01, was observed for the cell loaded at the basement membrane XenoMEM™ group). All cell-loaded biomaterial groups retained more cells at the implantation side than the direct injection group, even though they were loaded with half of the cells than the cell injection group.ConclusionsThis study further advocates the use of extracellular matrix-based biomaterials (in particular porcine peritoneum) as human adipose-derived stem cell delivery vehicles.Graphical abstractComparative analysis of a collagen scaffold (Integra™ Matrix Wound Dressing) and two tissue grafts [decellularised porcine peritoneum (XenoMEM™) and porcine urinary bladder (MatriStem™)] as human adipose-derived stem cells carriers

A method for simultaneously crosslinking and functionalizing extracellular matrix-based biomaterials as bioprosthetic heart valves with enhanced endothelialization and reduced inflammation

With the coming of an aging society and the emergence of transcatheter valve technology, the implantation of bioprosthetic heart valves (BHVs) in patients with valvular disease has significantly increased worldwide. Currently, most clinically available BHVs are crosslinked with glutaraldehyde (GLUT). However, the GLUT treated BHV is less durable due to the combined effect of multiple factors such as cytotoxicity, immune responses, and calcification. In this study, the in-situ polymerization of sulfonic monomers with a decellularized extracellular matrix (ECM) was performed to simultaneously achieve the crosslinking and functionalization of ECM. Subsequently, the feasibility of the hybrid ECM used as leaflet material of BHV was evaluated. In in-vitro tests, the results indicated that the hybrid ECM fixed collagen efficiently and the introduction of sulfonic polymer promoted the proliferation and migration of human umbilical vein endothelial cells (HUVECs). In in-vivo tests, after being implanted in SD rats and mice, the hybrid ECM significantly inhibited immune response and calcification compared with the non-hybrid counterpart and GLUT crosslinked tissue. These results indicated that the hybrid ECM exhibited more competitive stability and better biocompatibility compared to these features in GLUT-crosslinked valve. Therefore, the sulfonic polymer hybrid ECM provides a potential material for more durable BHV and the in-situ polymerization strategy can serve as a general treatment method for tissue crosslinking as well as tailoring the biophysical properties of ECM.

Transparent support media for high resolution 3D printing of volumetric cell-containing ECM structures

3D bioprinting may revolutionize the field of tissue engineering by allowing fabrication of bio-structures with a high degree of complexity, fine architecture and heterogeneous composition. The printing substances in these processes are mostly based on biomaterials and living cells. As such, they generally possess weak mechanical properties and thus must be supported during fabrication in order to prevent the collapse of large, volumetric multi-layered printouts. In this work, we characterize a uniquely formulated media used to support printing of extracellular matrix-based biomaterials. We show that a hybrid material, comprised of calcium-alginate nanoparticles and xanthan gum, presents superb qualities that enable printing at high resolution of down to 10 microns, allowing fabrication of complex constructs and cellular structures. This hybrid also presents an exclusive combination of desirable properties such as biocompatibility, high transparency, stability at a wide range of temperatures and amenability to delicate extraction procedures. Moreover, as fabrication of large, volumetric biological structures may require hours and even days to accomplish, we have demonstrated that the hybrid medium can support prolonged, precise printing for at least 18 h. All these qualities make it a promising support medium for 3D printing of tissues and organs.

Extracellular matrix-based biomaterials for cardiac regeneration and repair.

The spectrum of ischemic heart diseases, encompassing acute myocardial infarction to heart failure, represents the leading cause of death worldwide. Although extensive progress in cardiovascular diagnoses and therapy has been made, the prevalence of the disease continues to increase. Cardiac regeneration has a promising perspective for the therapy of heart failure. Recently, extracellular matrix (ECM) has been shown to play an important role in cardiac regeneration and repair after cardiac injury. There is also evidence that the ECM could be directly used as a drug to promote cardiomyocyte proliferation and cardiac regeneration. Increasing evidence supports that applying ECM biomaterials to maintain heart function recovery is an important approach to apply the concept of cardiac regenerative medicine to clinical practice in the future. Here, we will introduce the essential role of cardiac ECM in cardiac regeneration and summarize the approaches of delivering ECM biomaterials to promote cardiac repair in this review.

A Review of Decellularized Extracellular Matrix Biomaterials for Regenerative Engineering Applications

Biomaterials are a cornerstone technology of the biomedical device, tissue engineering, and regenerative medicine industries. While traditional biomaterials are fully defined synthetics, growing evidence supports the use of extracellular matrix-based biomaterials produced through the decellularization of organs, tissues, or cell cultures. These materials are particularly advantageous as they largely retain the structure and the biochemical nature of the original tissue, properties that are often difficult to reproduce with synthetics. Indeed, there are many FDA-approved and clinically used extracellular matrix-based materials that are generated through decellularization processes. In this review, we first describe methods of decellularization used to produce these materials and their associated advantages and limitations, discuss the current use of extracellular matrix-based materials in regenerative engineering applications, describe the areas where current research is occurring, and forecast areas where impactful research may appear. The regeneration of tissues often requires a scaffold material to support and guide the cells that are performing the repair. Often, these materials are manmade and lack many of the key features present in native tissue. However, a tissue can be processed to remove its cells (a process called decellularization), leaving behind a scaffold of proteins and polysaccharides known as the extracellular matrix. These decellularized matrices are attractive scaffolds for use in regenerative medicine applications, and they are the subject of this review.

Evaluation of xenogeneic extracellular matrix fabricated from CuCl2-conditioned mesenchymal stem cell sheets as a bioactive wound dressing material.

The extracellular matrix has drawn considerable interest in tissue engineering not only acts as a bioactive three-dimensional scaffold but also regulates cell behaviors through providing biochemical signals. Extracellular matrix-based biomaterials, mainly derived from xenogeneic tissues, have shown positive outcomes in promoting cutaneous wound healing. However, such extracellular matrices only contain low doses of growth factors, which limit their therapeutic efficiency. Recent reports demonstrated that cell sheets made from mesenchymal stem cell can accelerate wound repair through enhanced re-epithelialization and angiogenesis, but its clinical translation is hindered by several limitations, such as the risk of aberrant immune responses and cost implications. In this study, acellular extracellular matrices were prepared from CuCl2-conditioned mesenchymal stem cell sheets and their invivo wound healing properties were evaluated in a mouse model of full-thickness skin defect. We found that extracellular matrices derived from CuCl2-conditioned mesenchymal stem cell sheets have a compact surface with thick solid-like cross-sectional structure. Moreover, CuCl2 dramatically enriched the extracellular matrices with collagen I, collagen III, transforming growth factor-β1, vascular endothelial growth factor, and basic fibroblast growth factor via hypoxia-inducible factor-1α activation. And as a consequence, the resulting extracellular matrices showed markedly improved invivo wound healing potency through early adipocyte mobilization, enhanced granulation tissues formation, rapid re-epithelialization, and augmented angiogenesis. Therefore, we consider that the extracellular matrix derived from CuCl2-conditioned mesenchymal stem cell sheets has the potential for clinical translation and may lead to a novel strategy for wound management.

Enhanced neuroprotection with decellularized brain extracellular matrix containing bFGF after intracerebral transplantation in Parkinson’s disease rat model

Extracellular matrix-based biomaterials have many advantages over synthetic polymer materials for regenerative medicine applications. In central nervous system (CNS), basic fibroblast growth factor (bFGF) is widely studied as a potential agent for Parkinson’s disease (PD). However, the poor stability of bFGF hampered its clinical use. In this study, CNS-derived biologic scaffold containing bFGF was used to enhance and extend the neuroprotective effect of bFGF on PD targeted therapy. Decellularized brain extracellular matrix (dcBECM) was prepared by chemical extraction. The biocompatibility of dcBECM was evaluated using CCK-8 assay and magnetic resonance imaging (MRI). The controlled-release behavior of dcBECM containing bFGF (bFGF+dcBECM) was confirmed by ELISA assay. Furthermore, the cytocompatibility and neuroprotective effect of bFGF+dcBECM was evaluated in vitro and in vivo. From results, dcBECM showed a three-dimensional network structure with high biocompatibility. MRI of dcBECM implanted rats showed nearly seamless fusion of dcBECM with the adjoining tissues. The cumulative release rate of bFGF+dcBECM in vitro reached to 75.88% at 10h and maintained sustained release trend during the observation. ELISA results in vivo further confirmed the sustained-release behavior (from 12h to 3d) of bFGF+dcBECM in brain tissues. Among the experimental groups, bFGF+dcBECM group showed the highest cell survival rate of PD model cells, improved behavioral recovery and positive expressions of neurotrophic proteins in PD recovered rats. In conclusion, sustained neuroprotection in PD rats was achieved by using bFGF+dcBECM. The combination of dcBECM and bFGF would be a promising therapeutic strategy to realize an effective and safe alternative for CNS disease treatment.

Decellularization method influences early remodeling of an allogenic tissue scaffold

Extracellular matrix-based biomaterials are currently pursued as an alternative to autologous transplants for the treatment of gingival recession and periodontal disease. These grafts offer improved tissue regeneration without the need for a second operative procedure used in current treatments to remove nonresorbable synthetic biomaterials. However, while decellularization is necessary to minimize the potential immunological impact, it can significantly modify the materials architectural and biochemical properties. By understanding cellular responses, it is possible to more specifically target varying clinical situations. These investigations assess a novel allogenic scaffold derived from the human umbilical vein and determine the effects of two decellularization approaches (osmotic lysis and the surfactant Triton X-100) on the biological and mechanical properties during early remodeling events. Results show Triton X-100 to be significantly more effective at extracting lipids, while the extraction of the scaffolds bulk protein, GAG and DNA similar between the two treatments. Once seeded, scaffolds prepared with osmotic lysis displayed increased cellular proliferation and reduced metabolic activity compared to scaffolds treated with surfactant. Biomechanical properties were largely preserved and similar between the two treatments. These results suggest that by optimizing scaffold processing conditions, biological events associated with remodeling can be modulated to tailor scaffold function for specific clinical applications.

An Injectable Adipose Matrix for Soft-Tissue Reconstruction

Soft-tissue repair is currently limited by the availability of autologous tissue sources and the absence of an ideal soft-tissue replacement comparable to native adipose tissue. Extracellular matrix-based biomaterials have demonstrated great potential as instructive scaffolds for regenerative medicine, mechanically and biochemically defined by the tissue of origin. As such, the distinctive high lipid content of adipose tissue requires unique processing conditions to generate a biocompatible scaffold for soft-tissue repair. Human adipose tissue was decellularized to obtain a matrix devoid of lipids and cells while preserving extracellular matrix architecture and bioactivity. To control degradation and volume persistence, the scaffold was cross-linked using hexamethylene diisocyanate and 1-ethyl-3-(3-dimethylaminopropyl) carbodiimide. In vitro studies with human adipose-derived stem cells were used to assess cell viability and adipogenic differentiation on the biomaterial. In vivo biocompatibility and volume persistence were evaluated by subcutaneous implantation over 12 weeks in a small-animal model. The scaffold provided a biocompatible matrix supporting the growth and differentiation of adipose-derived stem cells in vitro. Cross-linking the matrix increased its resistance to enzymatic degradation. Subcutaneous implantation of the acellular adipose matrix in Sprague-Dawley rats showed minimal inflammatory reaction. Adipose tissue development and vascularization were observed in the implant, with host cells migrating into the matrix indicating the instructive potential of the matrix for guiding tissue remodeling and regeneration. With its unique biological and mechanical properties, decellularized adipose extracellular matrix is a promising biomaterial scaffold that can potentially be used allogenically for the correction of soft-tissue defects.

Establishing Pediatric Cardiovascular Services in the Developing World

There is increasing realization that the lack of facilities for sustainable pediatric cardiac services in the developing world results in a massive number of preventable deaths and suffering. It is estimated that 15 million children die or are crippled annually by potentially treatable or preventable cardiac diseases. Ignored for a long time, this issue is starting to be a cause of major concern to individuals, governments, and, most importantly, cardiovascular specialists who can appreciate the gravity of the problem and that the current situation is unacceptable. What then can be done to alleviate the problem, by whom, and how? In this issue of Circulation , Larrazabal et al describe the pioneering efforts of Castenada and his colleagues in Guatemala.1 This should act as a model and a source of inspiration in this field. This editorial is an attempt to outline some of the issues that relate to the problem, such as estimates of its size, and explores potential, long-lasting solutions. Article p 1882 The pediatric population constitutes a larger proportion of the community in developing countries, with ≈40% of individuals <18 years old in some countries. Children in developing countries have a significantly higher incidence and prevalence of serious cardiac diseases.2 This is contributed to by a variety of factors that include a lack of early correction of congenital cardiac abnormalities that results in accumulation of a large number of children with uncorrected anomalies who survive the neonatal period. In addition, many of these children develop more rapid deterioration in their clinical condition as a result of accelerated forms of secondary changes in the heart and other organs, such as pulmonary hypertension. Some of these changes could be the result of genetic and/or environmental factors such as pollution or infection. Furthermore, endemic “neglected” cardiac diseases such as rheumatic …