Download Function and form in the developing cardiovascular system

SPOTLIGHT REVIEW
Cardiovascular Research
doi:10.1093/cvr/cvr062
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Function and form in the developing
cardiovascular system
David Sedmera 1,2*
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Department of Cardiovascular Morphogenesis, Institute of Physiology, Academy of Sciences of the Czech Republic, Videnska 1083, 14220 Prague, Czech Republic; and 2Institute of
Anatomy, First Faculty of Medicine, Charles University in Prague, U nemocnice 3, 12800 Prague, Czech Republic
Received 26 November 2010; revised 23 February 2011; accepted 23 February 2011
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Abstract
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Function of the developing heart is dictated by changes in its morphology. For simplicity, we distinguish four stages
with different contraction mechanics and conduction parameters. Straight or looped tubular hearts, similar to those
of invertebrates such as Drosophila or Ciona, operate as suction pumps and are characterized by a caudally localized
pacemaker and slow, peristaltoid conduction and contraction. There is a complete occlusion of the lumen during
systole. When the atrial and ventricular chambers appear, the preseptation heart is in many functional aspects
similar to the adult heart, but the same function is achieved by different means. There are parallels in design
among the hearts of lower vertebrates, such as a spongy ventricle without coronary vasculature and a myocardial
atrioventricular canal. Even after septation, considerable maturation of cardiac morphology and function occurs
during the foetal and early postnatal period.
----------------------------------------------------------------------------------------------------------------------------------------------------------Keywords
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Myocardium † Conduction system † Embryonic heart † Ontogenesis † Phylogenesis
----------------------------------------------------------------------------------------------------------------------------------------------------------This article is part of the Spotlight Issue on: Cardiac Development
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1. Introduction
2. Tubular heart
Unlike most other organ systems, function of the cardiovascular
system is critical for embryonic survival and, as a result, the
heart has to beat in order to support circulation well before
its morphogenesis is complete. The function of the heart influences its morphology,1 and vice versa. The resulting constraints
force the hearts into very similar functional designs that are
conserved between widely divergent organisms, and make the
developmental pathway between the simple cardiac tube and
the mature four-chambered organ of homeotherm vertebrates
rather tortuous (Figure 1). In this review, I will go through different stages of morphogenesis of the mammalian heart and correlate the structure of the main pumping chamber(s), the
ventricle(s), with ventricular function, and give examples of
similar functional arrangements from ‘lower’ classes of vertebrates or invertebrates. In parallel, the sequence of activation
of different cardiac compartments will be correlated with emerging function and structure of the cardiac conduction system.
The main idea is that cardiac design is tightly dictated by
demands of life style of the particular organism. Due to evolutionary pressure, this is likely to be a very good fit. As such,
we should refrain from calling the designs of ‘lower’ vertebrates2,3 ‘primitive’, especially those of sharks4 should we
happen to meet them in their natural habitat.
The first cardiac contractions start at the straight tube stage (Figure 1),
approximately ED8.5 in the mouse5 and 22 days in humans.6 The first
heart beats are irregular and do not propel blood through the circulation,7 but activity quickly becomes coordinated and primitive blood
starts to circulate through the embryo, thus enabling its further
growth by decreasing diffusion distance for nutrients and oxygen.
Many invertebrates, such as the model organism Drosophila
melanogaster, are able to function with this tubular design. In vertebrates, the heart is consistently activated by a pacemaker situated
at the inflow part, while in invertebrates with an open circulatory
system, the direction of flow can be altered—clearly an advantage
allowing sequential perfusion of different parts of the body.8
However, the similarities end with the structure and function—at
the cellular level, these pulsatile dorsal vessels share properties of
skeletal muscle, as is the case of the ‘lymphatic hearts’.9 In the chordate Amphioxus,10 there are multiple pulsatile vessels. Of note,
although there is an epicardial layer,8 the hearts of invertebrates
supporting open circulatory systems lack endocardium11,12 (Figure 2).
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3. Cardiac looping
The next stage of cardiac morphogenesis is the transition from a
straight tube to a looped heart (Figure 1). This process is termed
* Corresponding author. Tel: +420 2 2496 5941; fax: +420 2 24596 5770, Email: [email protected]
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2011. For permissions please email: [email protected].
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Figure 1 Four key stages in cardiac morphogenesis—tube, loop, chamber formation, completion of septation with deployment of coronary circulation. Art work by Ivan Helekal based on chick heart development studies by Manner14 and Sedmera et al.90,91
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Figure 2 Similarities in design of hearts without coronary circulation. (A) Blue Crab, transverse paraffin section stained with hematoxylin– eosin. (B)
Oyster, transverse section through ventricle stained with rhodamine – phalloidine. Scale bars 100 mm. Note that these two invertebrate hearts do not
contain endocardium (four times magnified view of trabeculae, direct interface of myocytes with haemolymph indicated by arrowheads in A). (C) Frog,
sagittal section. (D) Chick embryo, Stage 29 (embryonic day 6), transverse section through the right ventricle, scanning electron micrographs. Most of
the ventricular myocardial mass is contained in the trabeculae (Tr). Outer compact myocardium (Co) is very thin. En indicates endocardium covering
the myocytes. Partly based on studies by Sedmera et al.47,90
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Development of function and form
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cardiac looping,13,14 and for some it does not end with formation of
the loop, but continues by further ‘twisting’ well through the septation
process.15,16
Description of mechanics of the tubular heart,12 initially described
as peristaltic,17,18 is now being gradually replaced by a more precise,
albeit more complex, suction pump model.19 At this stage, there is
complete obstruction of the lumen by apposition of endocardium
reinforced by cardiac jelly, as demonstrated using high-resolution
ultrasound20 or optical coherence tomography (OCT21,22). Such
tubular hearts have 100% ejection fractions, which is never achieved
at later stages; this geometry is at the extreme end between cylindrical, optimal for generating pressure, and spherical, optimal for volume
displacement.23 In homeotherm embryos, pumping function of the
tubular heart is required from this stage on for embryonic survival.
Therefore, long-term consequences of perturbations resulting in
significant cardiac dysmorphogenesis cannot be analysed in these
model species. In contrast, during zebrafish development, the onset
of circulation precedes functional requirement by several days, allowing a rare window of opportunity to analyse various mutants with
severely dysfunctional or non-functional hearts and dissect the
effects of function or blood flow on cardiac morphogenesis.24
The conduction system at that stage has a well-defined pacemaker
at the inflow, but the general speed of conduction is slow, correlating
with the ‘peristaltoid’ mode of contraction. Gradually, conduction
remains slow in the regions of the atrioventricular canal and ventricular outflow, while there is some acceleration in the prospective
ventricular region (17,25; reviewed by Gourdie et al.26). For illustration,
see the Supplementary material online, Movie S1.
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4. Chamber formation
Soon after the beginning of looping, morphological differentiation of
myocardium along the cardiac tube becomes apparent.27 This includes
disappearance of cardiac jelly in the atria and ventricles, coinciding
with the process of development of trabeculae, and, soon afterwards,
pectinate muscles in the atria (Figure 3). The morphological differences are accompanied by changes in gene expression patterns.28,29
This process is well conserved in vertebrates, no matter whether
there is one or two atria or ventricles. Ventricular trabeculae
provide a means of increasing myocardial mass in the absence of coronary circulation30 and are also seen in the hearts of more complex
invertebrates (Figure 2). Some of these (mollusks) even have separate
atrial and ventricular chambers separated by a valve.12
Recently, a cardiac phenotype very similar to that of ErbB2 null
mice lacking ventricular trabeculae31 was described in zebrafish,32
showing conserved mechanism of ventricular trabeculation initiation
via endocardium– myocardium neuregulin-Erb signalling in vertebrates.33 In this respect, it is interesting to speculate about the
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Figure 3 Comparative morphology of adult atrial and ventricular chambers in the zebrafish and mouse. Despite considerable evolutionary distance
and dramatically different life styles, the main features of chamber myocardial design (ventricles with trabeculae carneae, Tr; atria with pectinate
muscles, pm) are conserved. Not visible is the similar ventricular activation pattern from the apex.47,92 In the zebrafish, this is achieved by trabeculae
connecting the atrioventricular canal myocardium with ventricular apex (curved arrow), while in the mouse, by His bundle and its branches contained
in the interventricular septum. The differences are in higher proportion of trabeculated ventricular myocardium and presence of a single atrial and
ventricular chamber in the fish (expertly dissected and imaged by Norman Hu, Utah). Previously published scanning electron micrograph from
Sedmera et al.91 and related to Wessels and Sedmera.70
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Figure 4 Complete activation map of ED12.5 mouse embryonic heart. Both atrial and ventricular activation maps are shown in 1 ms isochronal
intervals; delay between the chambers (due to conduction through the atrioventricular canal, invisible from the outside) was 115 ms. Those areas
first activated (intercaval region in the atria, right ventricular apex) are indicated by orange asterisks, and spread of activation is highlighted by
orange arrows. Note also slow conduction (evidenced by isochronal crowding) in the outflow tract (OT) myocardium. Scale bar 100 mm. Previously
unpublished figure related to a study by Sedmera et al.37
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molecular mechanism of trabecular formation in invertebrates
(Figure 2) that lack the endocardium.
The conduction system starts to show mature characteristics once
the chambers are formed, i.e. activation from a well-defined pacemaker,34 spreading through the atrial tissues using preferential pathways,35 and atrioventricular delay based upon slow conduction
through the myocardium of the atrioventricular canal.5,17,36
The outflow valve function is exercised, rather efficiently,20 by a combination of close apposition of the outflow tract cushions and contraction of the slowly conducting myocardium of the outflow
tract17,25,37 (Figure 4, Supplementary material online, Movie S2).
At this stage, the embryonic heart is big enough for imaging and
acquisition of functional parameters. It was shown that many functional aspects of the trabeculated heart are comparable with the
adult heart, and the same parameters can be meaningfully determined
after some modification of the equipment. Video recordings (Supplementary material online, Movie S3) of chick hearts,38 together
with direct servo-null pressure measurements and Doppler flow
waveforms,39 have taught us that the trabeculated embryonic heart
observes the Frank –Starling relationship, dorsal aortic blood flow
scales with embryo weight, and that the increase in heart rate
results in decreased cardiac output.40 Video recordings in mice
followed shortly,41 and ultrasound studies even allowed longitudinal
follow-up of individual embryos42 and provided functional insights
into the demise of some prenatally lethal mouse mutants, such as
NFATc1 mutants that lack outflow valves.43 Likewise, insufficient
valve function of the cushions in the outflow tract in ED11.5 mouse
embryos leads to diastolic flow reversal and death at ED12.5.44
Recently, results from early human embryos have been reported
using advances in gynecological ultrasound.45
5. Maturation of ventricular impulse
conduction
The heart with formed cardiac chambers is from the conduction
system point of view directly comparable with the matured one.
The pacemaking activity is localized to the sino-atrial node, which
starts to acquire its autonomic innervation pattern for neural modulation.46 The function of delay generation between the activation of
atria and ventricles begins to shift from the slowly conducting myocardium of the atrioventricular canal5,17,36 that is similar to arrangement
in the adult hearts of lower vertebrates47 to the atrioventricular
node.48 The transition from primitive base-to-apex activation of the
ventricles to mature apex-to-base sequence correlates with ventricular septation.49 This is rather logical, as the proximal part of the fast
component of the ventricular conduction system, His bundle and
bundle branches, is located in the interventricular septum.50,51
However, the actual transition occurs before the completion of septation, and is structurally supported by trabecular sheets connected
directly to the atrioventricular canal myocardium.52 This is similar
to situation in the lower vertebrates where apex-to-base activation
is achieved by trabeculae connecting the ventricular apex and atrioventricular canal myocardium (Figure 3), which is insulated from the
ventricular compact zone by a fibrous wedge of subepicardial
tissue.47 The first precursor of the ventricular conduction system is
the primary ring, described first by immunohistochemistry53,54 and
later shown to mediate early ventricular activation in the mouse,55
chick,52,56 and rat.57 Interestingly, the apex to base activation of the
ventricle is first heralded by an epicardial breakthrough localized to
the right of the interventricular septum, near the apex of the
forming right ventricle. This was documented in the mouse,58
chick,25 rat,57 and rabbit59 and is indicative of earlier right bundle
branch functionality. This precocious functionality suggests that geometry of this bundle—narrow with fewer side branches compared
with left bundle branch—plays an important role in conduction
speed. Earlier functionality of the right bundle is conserved among
species despite molecularly more advanced differentiation of the
left ventricle evidenced by earlier and higher level expression of
connexin40, shown both in the chick60,61 and mouse.51 Examples
of our interpretation of ventricular activation patterns, from the
least mature to most, are shown in Figure 5. Conservation and
potential utility of this arrangement could be explained by the
close proximity of the ventricular inflow and outflow at the base
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Development of function and form
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Figure 5 Maturation of ventricular activation sequence in birds. (A) Activation through primary ring (along the forming interventricular septum).
Stage 24 (embryonic day 4) chick embryonic heart (from Sankova et al.56). (B) Single epicardial breakthrough near the right ventricular apex indicates
functionality of the right bundle branch. (C) The presence of two epicardial breakthrough sites near left and right ventricular apices signifies that both
right and left bundle branch are functional. Both are unpublished maps of Stage 34 (embryonic day 8) quail embryonic hearts related to study by Nanka
et al.71 Scale bar 1 mm.
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of the heart, which favours beginning of contraction from the opposite end—the apex.
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6. Remodelling of atrioventricular
myocardium
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The myocardium of the atrioventricular canal initially mediates, together
with the atrioventricular cushions, valve function in the preseptation
heart. In higher vertebrates, atrioventricular canal myocardium gradually
regresses, at least in part through apoptosis,62 and is replaced by fibrous
insulating tissue derived from the epicardium.63 The function of delay
generator between the atrium and ventricle is then localized to the
atrioventricular node.48,64 This structure is prominent and well recognized in mammals, and has recently been characterized at the molecular
level as a rather complex structure with several functional subdomains
with differential gene expression.29 It is well recognized that the adult
node is derived from a slowly conducting embryonic myocardial
segment expressing, among other genes, Tbx265 that is down-regulated
in the developing chambers. A molecular model of conduction system
differentiation was recently presented by the Amsterdam group.66
Detailed understanding of the normal development of atrioventricular
canal myocardium is essential for our ability to explain the developmental origins of cardiac arrhythmias such as ventricular pre-excitation,
characterized by the presence of rapidly conducting anomalous
myocardial connections between the atria and ventricles. Abnormal
atrioventricular canal remodelling in the quail model of epicardial
ablation can lead to persistence of accessory pathways that can lead
in turn to ventricular pre-excitation63 or form a substrate of atrioventricular reentry circuit resulting in reciprocating tachycardia. This
situation is observed in the early embryonic mouse heart,67 where
these connections are still normally present and functional.
Problems can arise also from the opposite situation, where conduction from the atrioventricular node is slowed or even completely
blocked. The atrioventricular node is one of the targets of the autoantibodies present in mothers with lupus. These patients stand up to
5% chance68 of having a child with congenital heart block. Third-degree
atrioventricular block results often in profound bradycardia, leading to
circulatory failure with accumulation of fluid in foetal tissues and cavities
(hydrops) and rapid demise. Fortunately, diagnosis is nowadays possible
in utero, so serial monitoring of at-risk pregnancies is possible69 and
treatment can be initiated as soon as the condition develops;
however, no firm therapeutic guidelines are currently established.
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7. Foetal circulation
While the interest of developmental biologists wanes after completion of septation, in the clinical settings, this is when it just starts,
since the earliest stages under 12 weeks are seldom studied apart
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from confirming the presence of a beating heart. Many interesting
things happen between septation and birth, especially in humans
where this period lasts 6 months rather than 6 days for the mouse.
One important step in myocardial morphogenesis and maturation is
deployment of the coronary supply to the ventricular myocardium,
occurring in all higher vertebrates and some (but not all) lower vertebrates. While the evolutionary necessity of ventricular compaction
is debated,12 its importance for homeotherms is clearly shown by
lethality of mouse mutants with impaired compaction (reviewed by
Wessels and Sedmera70) or hypoxic quail embryos with absent coronary arteries and thin compact myocardium.71 The foetal heart
not only grows in size, but further develops spiralling myocardial
architecture of the compact layer.72 This development was shown
to depend on haemodynamic loading, being accelerated by increased
pressure load and delayed by decreased preload.73 Abnormal haemodynamics can lead to development of some forms of severe congenital
heart disease, such as aortic atresia in hearts that were perfectly
normal at the routine scan at 19 weeks of human gestation.74 From
clinical perspective, the period between 20 and 28 weeks of gestation
is the time when foetal intervention can be attempted for some
severe lesions with predictably devastating consequences such as
severe aortic stenosis.75 Recently, a rare valvar anomaly (mitral
fibrous arcade) was linked to volume overload in the recipient twin
in the settings of twin–twin transfusion syndrome,76 confirming the
role of haemodynamic loading not only in myocardial changes, but
also valve maturation. Impaired performance of malformed hearts
also affects the other foetal systems, most critically the central
nervous system.77 It is thus likely that foetal interventions improving
cardiac output, such as balloon dilation of the stenotic aortic78 or pulmonary valve,79 could have potential benefits exceeding the simple
restoration of normal cardiac anatomy and circulation. Several foetal
models were developed to test the effects of prenatal interventions80
or to study the growth response of the foetal heart to haemodynamic
challenge.81,82 It is important to know the limits of adaptation of the
foetal circulatory system, since some procedures that might work
well in theory may not be tolerated by the whole organism
(e.g. requirement of three-stage palliation of the hypoplastic left
heart syndrome ending up in Fontan circulation rather than ‘all at
once’ procedure; reviewed by Sedmera et al.83). Interventions in prenatal life have the potential to take advantage of the growth capacity
of foetal myocardium based upon myocyte proliferation rather than
hypertrophy. Such restoration of myocardial mass with appropriate
vascularization might also result in superior performance in the
long term.
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8. Adaptation to postnatal
circulation
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Changes in circulatory patterns after birth are well known from
embryology and obstetrics textbooks. The early postnatal period
differs from subsequent growth in childhood, as there is a timewindow during which cardiomyocytes are still capable of proliferation.
In rodents, this privileged period lasts for about 3 days after birth,84
while in humans, it is believed to last about 6 months, and surgical
interventions85 such as biventricular repair for hypoplastic left heart
syndrome are most successful during this window.85,86
The ability of the adult mammalian myocardium to regenerate is
limited. Nevertheless, because of the potential significance of
D. Sedmera
regeneration to counter the current human plague of infarction and
resulting chronic heart failure in survivors, exploration of regenerative
potential is a subject of intensive research. The identification of resident cardiac stem cells87 generated much hope as well as much controversy, and the current state of the field is nicely summarized by
Rosenthal and Harvey.88 Proliferative activity of adult cardiac myocytes has recently been documented in the normal human heart.89
However, it appears to be more related to homeostatic renewal
than further growth of myocardium or regeneration after ischaemic
attack. Myocardial infarction is healed by scar tissue, thus sacrificing
long-term output for immediate strength and decreased risk of
rupture. A further insight into normal developmental processes is
necessary to define optimal therapeutic strategies for regeneration
and repair of the diseased adult heart.
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9. Concluding remarks
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During heart morphogenesis, cardiac performance increases dramatically and a sequence of different functional designs (tubular heart,
spongy ventricles), tested successfully during the course of evolution,
meld smoothly into each other. Each morphological stage has a developmentally appropriate pacemaking and conduction system. A better
understanding of the links between cardiac structure and function is
important for devising treatment strategies for the developing heart
and new in vivo imaging technologies, such as high-resolution ultrasound and OCT, are changing the way we look at the structure –
function relationship in cardiac morphogenesis and dysmorphogenesis.
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Supplementary material
Supplementary material is available at Cardiovascular Research online.
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Acknowledgements
I would like to thank to all my past and present collaborators who
were instrumental in generating results discussed in this paper and
helped to shape my thinking about the developing heart. Ivan
Helekal is acknowledged for generating the Figure 2. Norman Hu
(Salt Lake City, UT) prepared the zebrafish heart specimen shown
in Figure 3. I would also like to thank Robert Kelly for final critical
reading of the manuscript and linguistic corrections.
Conflict of interest: none declared.
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Funding
Supported by Ministry of Education VZ 0021620806, Academy of
Sciences Purkinje Fellowship to D.S., and AV0Z50110509, Grant Agency
695
of the Czech Republic 304/08/0615 and P302/11/1308.
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