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New horizons in cardiovascular research are opened by using 3D printing for biodegradable implants. This additive manufacturing approach allows the design and fabrication of complex structures according to the patient's imaging data in an accurate, reproducible, cost-effective, and quick manner. Acellular cardiovascular implants produced from biodegradable materials have the potential to provide enough support for in situ tissue regeneration while gradually being replaced by neo-autologous tissue. Subsequently, they have the potential to prevent long-term complications. In this Review, we discuss the current status of 3D printing applications in the development of biodegradable cardiovascular implants with a focus on design, biomaterial selection, fabrication methods, and advantages of implantable controlled release systems. Moreover, we delve into the intricate challenges that accompany the clinical translation of these groundbreaking innovations, presenting a glimpse of potential solutions poised to enable the realization of these technologies in the realm of cardiovascular medicine.

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Small diameter vascular grafts (SDVGs) are associated with a high failure rate due to poor endothelialization. The incorporation of a nitric oxide (NO) releasing system improves biocompatibility by using the NO effect to promote endothelial cell (EC) migration and proliferation while preventing bacterial infection. To circumvent the instability of NO donors and to prolong NO releasing, S-nitroso-N-acetyl-D-penicillamine (SNAP) as a NO donor was loaded in multi-walled carbon nanotubes (MWCNTs). Successful loading was confirmed with a maximum SNAP amount of ~ 5% (w/w) by TEM, CHNS analysis and FTIR spectra. SDVGs were 3D printed from polycaprolactone (PCL) and coated with a 1:1 ratio of polyethylene glycol and PCL dopped with different concentrations of SNAP-loaded matrix and combinations of MWCNTs-OH. Coating with 10% (w/w) SNAP-matrix-10% (w/w) SNAP-MWCNT-OH showed a diminished burst release and 18 days of NO release in the range of 0.5-4 × 10-10 mol cm-2 min-1 similar to the NO release from healthy endothelium. NO-releasing SDVGs were cytocompatible, significantly enhanced EC proliferation and migration and diminished bacterial viability. The newly developed SNAP-loaded MWCNT-OH has a great potential to develop NO releasing biomaterials with a prolonged, controlled NO release promoting in-situ endothelialization and tissue integration in vivo, even as an approach towards personalized medicine.

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Smart materials are able to react to different stimuli and adapt their shape to the environment. Although the development of 3D printing technology increased the reproducibility and accuracy of scaffold fabrication, 3D printed scaffolds can still be further improved to resemble the native anatomy. 4D printing is an innovative fabrication approach combining 3D printing and smart materials, also known as stimuli-responsive materials. Especially for cardiovascular implants, 4D printing can promisingly create programmable, adaptable prostheses, which facilitates implantation and/or create the topology of the target tissue post implantation. In this review, the principles of 4D printing with a focus on the applied stimuli are explained and the underlying 3D printing technologies are presented. Then, according to the type of stimulus, recent applications of 4D printing in constructing smart cardiovascular implants and future perspectives are discussed.

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Decellularization aims to remove cells from tissue ultrastructure while preserving the mechanical and biological properties, which makes the decellularized extracellular matrix (dECM) an appropriate scaffold for tissue engineering applications. Three-dimensional (3D) bioprinting technology as a reproducible and accurate method can print the combination of ECM and autologous cells layer by layer to fabricate patient based cell-laden structures representing the intrinsic cues of natural ECM. This review defines ECM, classifies decellularization agents and techniques, and explains different sources of ECM. Then, bioprinting techniques, bioink concept, applications of dECM bioinks, and finally the future perspectives of 3d bioprinting technology are discussed.

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The vascular network has a complex architecture such as branches, curvatures, and bifurcations which is even more complicated in view of individual patients' defect anatomy requiring custom-specifically designed vascular implants. In this work, 3D printing is used to overcome these challenges and a new shorter impregnation method was developed to incorporate S-nitroso-N-acetyl-d-penicillamine (SNAP) as a nitric oxide (NO) donor to printed grafts. The 3D-printed small-diameter vascular grafts (SDVGs) were impregnated with SNAP solution during SNAP synthesis (S1) or with SNAP dissolved in methanol (S2). The advantage of the newly developed S1 impregnation method is the elimination of the synthesis step by direct impregnation inside the S1 solution. Scanning electron microscopy imaging reveals the successful crystal formation in both methods. The results demonstrate that both S1- and S2-impregnated grafts, after covering with polycaprolactone topcoat, can release NO in a controlled manner and in the physiological range (0.5-4.0 × 10-10 mol cm-2 min-1 ) over a 15 days period. The created grafts with a NO-releasing surface have also shown bactericidal effect while the healing properties of the implant were improved by promoting migration and proliferation of endothelial cells (ECs). These results suggest that incorporation of 3D printing technology with the newly developed S1 impregnation of SNAP can optimize and shorten the manufacturing process of the next generation of patient-based antibacterial SDVGs with a higher attraction for ECs.

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Small-diameter vascular grafts (SDVGs) are associated with a high incidence of failure due to infection and obstruction. Although several vascular grafts are commercially available, specific anatomical differences of defect sites require patient-based design and fabrication. Design and fabrication of such custom-tailored grafts are possible with 3d-printing technology. The aim of this study is to develop 3d-printed SDVGs with a nitric oxide (NO)-releasing coating to improve the success rate of implantation. The SDVGs were printed from polylactic acid and coated with blending of 10 wt% S-nitroso-N-acetyl-D-penicillamine into the polymeric substrate consisting of poly (ethylene glycol) and polycaprolactone. Our results show that NO is released in the physiological range (0.5-4 × 10-10 mol·cm-2·min-1) for 14 days and NO-releasing coating showed significant antibacterial potential against Gram-positive and Gram-negative strains. It was shown that both NO-releasing and control grafts are biocompatible in-vitro and in-vivo. Interestingly, the NO-releasing SDVGs dramatically enhanced ECs proliferation and significantly enhanced ECs migration in-vitro compared to control grafts. In addition, the NO-releasing SDVGs showed angiogenic potential in-vivo which can further prove the results of our in-vitro study. These findings are expected to facilitate tissue regeneration and integration of custom-made vascular implants with enhanced clinical success. STATEMENT OF SIGNIFICANCE: A series of 3d-printed small-diameter vascular grafts (SDVGs, <6 mm) with controlled release of nitric oxide (NO) were prepared to combine the advantages of 3D printing technology and NO-releasing systems. The resulting NO-releasing grafts were promisingly showing sustained NO release in the physiological range over a two weeks period. In addition to the evaluation of endothelial cell migration in-vitro, we implanted for the first time the NO-releasing vascular grafts in a chick chorioallantoic membrane (CAM) to investigate the effect of the prepared grafts on the angiogenesis in-vivo. The fabricated grafts also exhibited bactericidal properties which prevent the formation of a biofilm layer and can thereby enhance the chance of endothelialization on the surface. Taken together, the innovative combination of rapid and highly accurate 3d-printing technology as a patient-specific fabrication method with NO-releasing coating represents a promising approach to develop bactericidal SDVGs with improved endothelialization.

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Thrombogenicity and bacterial infectiveness are the most common complications for foreign blood contacting surfaces associated with functional failure of small-diameter vascular grafts (SDVGs). In this work, novel bactericidal and nonthrombogenic SDVGs were manufactured via 3D-printing technology, thus producing a controlled nitric oxide (NO) release coating. S-Nitroso-N-acetyl-D-penicillamine (SNAP) was synthesized as an NO-donor, and three biomedical grade composite matrixes of poly(ethylene glycol) (PEG)-SNAP, polycaprolactone (PCL)-SNAP, and PEG-PCL-SNAP were validated for water uptake and NO-release kinetics. To optimize and extend the NO releasing profile, a PCL top-coat (tc) was deposited over the NO-releasing layer. The PEG-PCL-SNAP-tc was selected for biological tests as its NO-release profile was prolonged and well-controlled. Coating the 3D-printed SDVG with PEG-PCL-SNAP-tc resulted in quantitative antibacterial features against both Gram-positive and Gram-negative bacteria and in NO-mediated inhibition of platelet activation and aggregation. Antibacterial and antithrombogenic properties in plasma are expected to be as effective as in PBS, since NO release in plasma was not significantly different from that in PBS. Overall, application of the inexpensive, rapid, and reproducible 3D-printing technology as a custom-based production method, in combination with a well-controlled NO release system, is promising for the production of innovative bactericidal and hemocompatible SDVGs.

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Current vascular grafts have a high incidence of failure, especially in the grafts less than 6 mm in diameter, due to thrombus formation. Nitric oxide (NO) is released by endothelium and has some beneficial influences such as an antithrombotic effect. We hypothesized that applying different shear stress regiments and low temperature or aspirin would result in an increase in the amount of NO release from human umbilical vein endothelial cells (HUVECs) and decrease in platelet aggregation in the same manner as expected in vivo. HUVECs were cultured into the intraluminal surface of silicone tubes. HUVECs were subjected for 60 min to different parameters of shear stress, temperature, aspirin, and platelets or a combination in a perfusion bioreactor by monitoring NO secretion. We found that shear stress leads to an elevation of NO production in HUVECS, independent of the shear stress magnitude (0.9 or 1.8 dyne/cm(2)). The magnitude of this response increased with a decrease in temperature. Our results also show that by addition of platelets in combination with aspirin to media circulation, no thrombus formation occurred during the test time. Presence of aspirin resulted in marked increase in NO levels. In conclusion, shear stresses, temperature lowering, and aspirin increase the amount of NO release from HUVECs. Also no thrombus formation was detected in our experimental setting.

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