The intricate process of formation of the heart relies on the spatiotemporal regulation of differentiation and growth of its different parts. Errors in these processes can result in hypoplasia of the chambers and incorrect alignment of the atria and great arteries with the ventricles, with such abnormalities producing the worst forms of congenital heart disease.1 Although recent advances in molecular embryology have greatly improved our understanding of normal cardiac development, our insights into the pathogenesis of human cardiac malformations remain limited.2 With the current lack of data on gene expression in humans, inferences concerning morphogenesis rely on classic studies of human cardiac development or on extrapolation of experimental data from animal studies. Most textbooks on human embryology describe the embryonic heart tube as already possessing a linear array of the definitive components, despite this so-called segmental concept being disproved some time ago by fate-mapping experiments in chickens,3,4 which are now endorsed by recent molecular lineage analyses in mice.5 Proliferation studies in chickens revealed that the primary heart tube proliferates minimally and that its growth occurs through addition of differentiating cells from visceral mesoderm at the venous and arterial poles.6 These findings underscore previous lineage studies performed in mice, which have shown that transcription factors Islet1 and Tbx1 play a crucial role in the intricate balance between the cardiac precursor state and differentiation.7,8 Subsequent to its formation, the heart tube elongates and loops, producing its inner and outer curvatures and providing the general building plan for formation of the chambers and conduction system.9 The chambers themselves form by local proliferation and differentiation at the outer curvature.10,11 At the same time, the differentiating chamber myocardium remains flanked by primary myocardium, which is prevented from further differentiation by the …
Read full abstract