Natural myocardial ECM patch drives cardiac progenitor based restoration even after scarring

Objective To evaluate the regenerative capacity of non-supplemented and bioactive patches made of decellularized porcine cardiac extracellular matrix (pcECM) and characterize the biological key factors involved in possible cardiac function (CF) restoration following acute and 8 weeks chronic MI. Background pcECM is a key natural biomaterial that can affect cardiac regeneration following myocardial infarction (MI), through mechanisms, which are still not clearly understood. Methods Wistar rats underwent MI and received pcECM patch (pcECM-P) treatment in either acute or chronic inflammatory phases. Treated, sham operated (no MI), and control (MI without treatment) animals, were compared through echocardiography, hemodynamics, pathological evaluation and analyses of various mRNA and protein level markers. Results Our results show that in both acute and long-term chronic MI models, pcECM promotes significant cardiac function improvement, which is correlated to progenitor (GATA4⁺, c-kit⁺) and myocyte (MYLC⁺, TRPI⁺) recruitment. Interestingly, recruited progenitors, isolated using laser capture microdissection (LCM), expressed both early and late cardiomyocyte (CM) differentiation markers, suggesting differentiation towards the CM lineage. Recruited CM-like cells organized in a partially striated and immature muscle fiber arrangement that presented connexin43 —a crucial mediator of cardiac electrical conductivity. Concomitantly, pcECM was rapidly vascularized, and induced a constructive remodeling process as indicated by increased M2/M1 macrophage phenotypic ratio and pathological evaluation. Conclusions Acellular pcECM patch implants alone, i.e., without added biologics, are bioactive, and exert potent efficacy, stimulating biological regenerative processes that cooperatively lead to a cardiac progenitor-based restoration of function, even after scar tissue had already formed. Statement of Significance MI (‘heart attack’) remains the leading cause of heart failure and death in developed-countries. Restoration of cardiac function requires active turnover of damaged heart contracting cells (CM), however, CM endogenous regeneration is not efficient and is a matter of controversy. We show that a bioactive biomaterial alone—decellularized heart tissue (pcECM)—without added cells or growth factors, can elicit a complex regenerative response even after irreversible scarring. The pcECM patch induces macrophage polarization towards constructive remodeling and cardiomyocyte progenitor cell (GATA4⁺, c-kit⁺) recruitment (evidenced at both mRNA and protein levels) resulting in de novo immature striated-like muscle patterns (MLC⁺, TrpI⁺, connexin43⁺). We, therefore, suggest this bioactive pcECM can model cardiac regeneration, and serve as a candidate for fast-track clinical application.