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Nasoalveolar molding (NAM) is an accepted treatment strategy in presurgical cleft therapy. The major drawbacks of the treatment listed in the literature relate to the time of the treatment and the coordination of the required interdisciplinary team of therapists, parents, and patients. To overcome these limitations, we present the automated RapidNAM concept that facilitates the design and manufacturing process of NAM devices, and that allows the virtual modification and subsequent manufacture of the devices in advance, with a growth prediction factor adapted to the patient's natural growth. The RapidNAM concept involves (i) the prediction of three trajectories that envelope the fragmented alveolar segments with the goal to mimic a harmonic arch, (ii) the extrusion from the larger toward the smaller alveolar segment along the envelope curves toward the harmonic upper alveolar arch, and (iii) the generation of the NAM device with a ventilation hole, fixation pin, and fixation points for the nasal stents. A feasibility study for a vector-based approach was successfully conducted for unilateral and bilateral cleft lip and palate (CLP) patients. A comparison of the modified target models with the reference target models showed similar results. For further improvement, the number of landmarks used to modify the models was increased by a curve-based approach.

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Bone disorders are the most common cause of severe long term pain and physical disability, and affect millions of people around the world. In the present study, we report bio-inspired preparation of bone-like composite structures by electrospinning of collagen containing catecholamines and Ca(2+). The presence of divalent cation induces simultaneous partial oxidative polymerization of catecholamines and crosslinking of collagen nanofibers, thus producing mats that are mechanically robust and confer photoluminescence properties. Subsequent mineralization of the mats by ammonium carbonate leads to complete oxidative polymerization of catecholamines and precipitation of amorphous CaCO3. The collagen composite scaffolds display outstanding mechanical properties with Young's modulus approaching the limits of cancellous bone. Biological studies demonstrate that human fetal osteoblasts seeded on to the composite scaffolds display enhanced cell adhesion, penetration, proliferation, differentiation and osteogenic expression of osteocalcin, osteopontin and bone matrix protein when compared to pristine collagen or tissue culture plates. Among the two catecholamines, mats containing norepinephrine displayed superior mechanical, photoluminescence and biological properties than mats loaded with dopamine. These smart multifunctional scaffolds could potentially be utilized to repair and regenerate bone defects and injuries.

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Transcatheter aortic valve implantation (TAVI) is a fast-growing, exciting field of invasive therapy. During the last years many innovations significantly improved this technique. However, the prostheses are still associated with drawbacks. The aim of this study was to create cell-seeded biohybrid aortic valves (BAVs) as an ideal implant by combination of assets of biological and artificial materials. Furthermore, the influence of TAVI procedure on tissue-engineered BAV was investigated. BAV (n=6) were designed with decellularized homograft cusps and polyurethane walls. They were seeded with fibroblasts and endothelial cells isolated from saphenous veins. Consecutively, BAV were conditioned under low pulsatile flow (500 mL/min) for 5 days in a specialized bioreactor. After conditioning, TAVI-simulation was performed. The procedure was concluded with re-perfusion of the BAV for 2 days at an increased pulsatile flow (1100 mL/min). Functionality was assessed by video-documentation. Samples were taken after each processing step and evaluated by scanning electron microscopy (SEM), immunohistochemical staining (IHC), and Live/Dead-assays. The designed BAV were fully functioning and displayed physiologic behavior. After cell seeding, static cultivation and first conditioning, confluent cell layers were observed in SEM. Additionally, IHC indicated the presence of endothelial cells and fibroblasts. A significant construction of extracellular matrix was detected after the conditioning phase. However, a large number of lethal cells were observed after crimping by Live/Dead staining. Analysis revealed that the cells while still being present directly after crimping were removed in subsequent perfusion. Extensive regions of damaged cell-layers were detected by SEM-analysis substantiating these findings. Furthermore, increased ICAM expression was detected after re-perfusion as manifestation of inflammatory reaction. The approach to generate biohybrid valves is promising. However, damages inflicted during the crimping process seem not to be immediately detectable. Due to severe impacts on seeded cells, the strategy of living TE valves for TAVI should be reconsidered.

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PURPOSE: Computer-assisted design and computer-aided manufacturing (CAD/CAM) technology in nasoalveolar molding (NAM) should save time and manpower and reduce family input in cases of cleft lip and palate. MATERIAL AND METHODS: Intraoral casts from 12 infants with complete unilateral cleft lip and palate were taken immediately after birth (T1) and after (T2) NAM treatment, digitalized, and transformed into STL data. The infants were randomized into Group 1 (n = 6) receiving conventional NAM treatment or Group 2 receiving CAD/CAM NAM (n = 6). We analyzed the following variables by using Geomagic software: intersegmental alveolar distance (ISAD); intersegmental lip distance (ISLD); nostril height cleft/noncleft (NHc/nc); nasal width cleft/noncleft (NWn/nc); and columella deviation angle (CDA). RESULTS: In both groups, all variables except NHnc and NWnc were changed significantly between T1 and T2. The analysis of the mean differences of the variables in Group 1 and 2 showed no significant differences, with a comparable incidence of clinical alterations such as skin or mucosal irritations. CONCLUSION: NAM plates can be produced virtually by using CAD/CAM technology. The CAD/CAM NAM results show no significant differences from the conventional technique. We present our clinically usable virtual CAD/CAM workflow for producing a basic NAM plate.

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BACKGROUND AND STUDY AIMS: Endoscopic submucosal dissection (ESD) is a recognized method for the curative treatment of superficial neoplasia, but its use is limited by lengthy procedures and the lack of versatility of existing knives. We developed a prototype ESD device with the ability to work as a needle, hook, or "scythe." This new device was compared to regular ESD knives in a randomized animal study. PATIENTS AND METHODS: Eight pigs underwent two gastric ESD procedures each, similar in size and difficulty, one with a regular ESD device and the other with the new device. The order and location of each ESD, as well as the performing operator, were randomized. Primary judgment criterion was safety of procedures. Overall and submucosal dissection procedure times were measured. Time-to-surface ratios were measured and estimated for ESDs larger than those performed. Histopathology of the resected tissue and remaining stomach was done after each experiment. RESULTS: No complications were observed throughout the study and all resections were completed en-bloc and uneventfully. The submucosal extension of resections was similar with both the standard and the new devices. A comparison of time-consumption between groups did not show statistically significant differences, but a dramatic reduction of procedure duration was observed in some procedures with the new device; based on observed data, a potential time-saving of up to 66 % was anticipated, with a relatively short learning curve. CONCLUSIONS: This new versatile device proved to be as safe as regular ESD knives, and seems likely to help reduce the duration of the procedure.

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A cardiac patch is a construct devised in regenerative medicine to replace necrotic heart tissue after myocardial infarctions. The cardiac patch consists of a scaffold seeded with stem cells. To identify the best scaffold for cardiac patch construction we compared polyurethane, Collagen Cell Carriers, ePTFE, and ePTFE SSP1-RGD regarding their receptiveness to seeding with mesenchymal stem cells isolated from umbilical cord tissue. Seeding was tested at an array of cell seeding densities. The bioartificial patches were cultured for up to 35 days and evaluated by scanning electron microscopy, microscopy of histological stains, fluorescence microscopy, and mitochondrial assays. Polyurethane was the only biomaterial which resulted in an organized multilayer (seeding density: 0.750 × 10(6) cells/cm(2)). Cultured over 35 days at this seeding density the mitochondrial activity of the cells on polyurethane patches continually increased. There was no decrease in the E Modulus of polyurethane once seeded with cells. Seeding of CCC could only be realized at a low seeding density and both ePTFE and ePTFE SSP1-RGD were found to be unreceptive to seeding. Of the tested scaffolds polyurethane thus crystallized as the most appropriate for seeding with mesenchymal stem cells in the framework of myocardial tissue engineering.

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PURPOSE: X-ray fluoroscopy guidance is frequently used in medical interventions. Image-guided interventional procedures that employ localization for registration require accurate information about the C-arm's rotation angle that provides the data externally in real time. Optical, electromagnetic, and image-based pose tracking systems have limited convenience and accuracy. An alternative method to recover C-arm orientation was developed using an accelerometer as tilt sensor. METHODS: The fluoroscopic C-arm's orientation was estimated using a tri-axial acceleration sensor mounted on the X-ray detector as a tilt sensor. When the C-arm is stationary, the measured acceleration direction corresponds to the gravitational force direction. The accelerometer was calibrated with respect to the C-arm's rotation along its two axes, using a high-accuracy optical tracker as a reference. The scaling and offset error of the sensor was compensated using polynomial fitting. The system was evaluated on a GE OEC 9800 C-arm. Results obtained by accelerometer, built-in sensor, and image-based tracking were compared, using optical tracking as ground truth data. RESULTS: The accelerometer-based orientation measurement error for primary angle rotation was -0.1 ± 0.0° and for secondary angle rotation it was 0.1 ± 0.0°. The built-in sensor orientation measurement error for primary angle rotation was -0.1 ± 0.2°, and for secondary angle rotation it was 0.1 ± 0.2°. The image-based orientation measurement error for primary angle rotation was -0.1 ± 1.3°, and for secondary angle rotation it was -1.3 ± 0.3°. CONCLUSION: The accelerometer provided better results than the built-in sensor and image-based tracking. The accelerometer sensor is small, inexpensive, covers the full rotation range of the C-arm, does not require line of sight, and can be easily installed to any mobile X-ray machine. Therefore, accelerometer tilt sensing is a very promising applicant for orientation angle tracking of C-arm fluoroscopes.

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AIM: Myocardial infarction is caused after impairment of heart wall muscle following an immense cell loss and also when the myocardial tissue is lacking the inherent capacity to regenerate for normal functioning of myocardium. An immediate challenge in cardiac regeneration is to devise a strategy that leads to a reproducible degree of cardiac differentiation. We have speculated that ex vivo pretreatment of adipose-derived stem cells (ADSCs) using 5-azacytidine and a suitable patterned nanofibrous construct could lead to cardiomyogenic differentiation and results in superior biological and functional effects on cardiac regeneration of infarcted myocardium. MATERIALS & METHODS: Polyglycerol sebacate/gelatin fibers were fabricated by core/shell electrospinning with polyglycerol sebacate as the core material and gelatin as the shell material. Patterning of the core/shell fibers to form orthogonal and looped buckled nanostructures was achieved. RESULTS: Results demonstrated that the buckled fibers showing an orthogonal orientation and looped pattern had a Young's modulus of approximately 3.59 ± 1.58 MPa and 2.07 ± 0.44 MPa, respectively, which was comparable to that of native myocardium. The ADSCs cultured on these scaffolds demonstrated greater expression of the cardiac-specific marker proteins actinin, troponin and connexin 43, as well as characteristic multinucleation as shown by immunocytochemical and morphological analysis, indicating complete cardiogenic differentiation of ADSCs. CONCLUSION: In the natural milieu, cardiomyogenic differentiation probably involves multiple signaling pathways and we have postulated that a buckled structure combination of chemical treatment and environment-driven strategy induces cardiogenic differentiation of ADSCs. The combination of patterned buckled fibrous structures with stem cell biology may prove to be a productive device for myocardial infarction.

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Dental implant alloys made from titanium and zirconium are known for their high mechanical strength, fracture toughness and corrosion resistance in comparison with commercially pure titanium. The aim of the study was to investigate possible differences in the surface chemistry and/or surface topography of titanium and titanium-zirconium surfaces after sand blasting and acid etching. The two surfaces were compared by X-ray photoelectron spectroscopy, secondary ion mass spectroscopy, scanning electron microscopy and profilometry. The 1.9 times greater surface hydrogen concentration of titanium zirconium compared to titanium was found to be the major difference between the two materials. Zirconium appeared to enhance hydride formation on titanium alloys when etched in acid. Surface topography revealed significant differences on the micro and nanoscale. Surface roughness was increased significantly (p<0.01) on the titanium-zirconium alloy. High-resolution images showed nanostructures only present on titanium zirconium.

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The aim of the study was to compare the behavior of seeded cells on synthetic and natural aortic valve scaffolds during a low-flow conditioning period. Polyurethane (group A) and aortic homograft valves (group B) were consecutively seeded with human fibroblasts (FB), and endothelial cells (EC) using a rotating seeding device. Each seeding procedure was followed by an exposure to low pulsatile flow in a dynamic bioreactor for 5 days. For further analysis, samples were taken before and after conditioning. Scanning electron microscopy showed confluent cell layers in both groups. Immunohistochemical analysis showed the presence of EC and FB before and after conditioning as well as the establishment of an extracellular matrix (ECM) during conditioning. A higher expression of ECM was observed on the scaffolds' inner surface. Real-time polymerase chain reaction showed higher inflammatory response during the conditioning of homografts. Endothelialization caused a decrease in inflammatory gene expression. The efficient colonization, the establishment of an ECM, and the comparable inflammatory cell reaction to the scaffolds in both groups proved the biocompatibility of the synthetic scaffold. The newly developed bioreactor permits conditioning and cell adaption to shear stress. Therefore, polyurethane valve scaffolds may offer a new option for aortic valve replacement.

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BACKGROUND: Duchenne muscular dystrophy is an inherited degenerative neuromuscular disease characterised by rapidly progressive muscle weakness. Currently, curative treatment is not available. Approaches for new treatments that improve muscle strength and quality of life depend on preclinical testing in animal models. The mdx mouse model is the most frequently used animal model for preclinical studies in muscular dystrophy research. Standardised pathology-relevant parameters of dystrophic muscle in mdx mice for histological analysis have been developed in international, collaborative efforts, but automation has not been accessible to most research groups. A standardised and mainly automated quantitative assessment of histopathological parameters in the mdx mouse model is desirable to allow an objective comparison between laboratories. METHODS: Immunological and histochemical reactions were used to obtain a double staining for fast and slow myosin. Additionally, fluorescence staining of the myofibre membranes allows defining the minimal Feret's diameter. The staining of myonuclei with the fluorescence dye bisbenzimide H was utilised to identify nuclei located internally within myofibres. Relevant structures were extracted from the image as single objects and assigned to different object classes using web-based image analysis (MyoScan). Quantitative and morphometric data were analysed, e.g. the number of nuclei per fibre and minimal Feret's diameter in 6 month old wild-type C57BL/10 mice and mdx mice. RESULTS: In the current version of the module "MyoScan", essential parameters for histologic analysis of muscle sections were implemented including the minimal Feret's diameter of the myofibres and the automated calculation of the percentage of internally nucleated myofibres. Morphometric data obtained in the present study were in good agreement with previously reported data in the literature and with data obtained from manual analysis. CONCLUSIONS: A standardised and mainly automated quantitative assessment of histopathological parameters in the mdx mouse model is now available. Automated analysis of histological parameters is more rapid and less time-consuming. Moreover, results are unbiased and more reliable. Efficacy of therapeutic interventions, e.g. within the scope of a drug screening or therapeutic exon skipping, can be monitored. The automatic analysis system MyoScan used in this study is not limited exclusively to dystrophin-deficient mice but also represents a useful tool for applications in the research of other dystrophic pathologies, various other skeletal muscle diseases and degenerative neuromuscular disorders.

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A functional scaffold fabricated is developed from natural polymers, favoring regeneration of the ischemic myocardium. Hemoglobin/gelatin/fibrinogen (Hb/gel/fib) nanofibers are fabricated by electrospinning and are characterized for morphology, scaffold composition, functional groups and hydrophilicity. It is hypothesized that ex vivo pretreatment of mesenchymal stem cells (MSCs) using 5-azacytidine and such a functional nanofibrous construct having a high oxygen-carrying potential could lead to enhanced cardiomyogenic differentiation of MSCs and result in superior biological and functional effects. The combination of a functional nanofibrous scaffold composed of natural polymers and crosslinked with a natural crosslinking agent, phytic acid, and stem cell biology may prove to be a novel therapeutic device for treatment of myocardial infarction.

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BACKGROUND: Tissue engineering represents a promising new method for treating heart valve diseases. The aim of this study was evaluate the importance of conditioning procedures of tissue engineered polyurethane heart valve prostheses by the comparison of static and dynamic cultivation methods. METHODS: Human vascular endothelial cells (ECs) and fibroblasts (FBs) were obtained from saphenous vein segments. Polyurethane scaffolds (n = 10) were primarily seeded with FBs and subsequently with ECs, followed by different cultivation methods of cell layers (A: static, B: dynamic). Group A was statically cultivated for 6 days. Group B was exposed to low flow conditions (t1=3 days at 750 ml/min, t2=2 days at 1100 ml/min) in a newly developed conditioning bioreactor. Samples were taken after static and dynamic cultivation and were analyzed by scanning electron microscopy (SEM), immunohistochemistry (IHC), and real time polymerase chain reaction (RT-PCR). RESULTS: SEM results showed a high density of adherent cells on the surface valves from both groups. However, better cell distribution and cell behavior was detected in Group B. IHC staining against CD31 and TE-7 revealed a positive reaction in both groups. Higher expression of extracellular matrix (ICAM, Collagen IV) was observed in Group B. RT- PCR demonstrated a higher expression of inflammatory Cytokines in Group B. CONCLUSION: While conventional cultivation method can be used for the development of tissue engineered heart valves. Better results can be obtained by performing a conditioning step that may improve the tolerance of cells to shear stress. The novel pulsatile bioreactor offers an adequate tool for in vitro improvement of mechanical properties of tissue engineered cardiovascular prostheses.

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Hydrogel-based biomaterial systems have great potential for tissue reconstruction by serving as temporary scaffolds and cell delivery vehicles for tissue engineering (TE). Hydrogels have poor mechanical properties and their rapid degradation limits the development and application of hydrogels in TE. In this study, nanofiber reinforced composite hydrogels were fabricated by incorporating electrospun poly(ε-caprolactone) (PCL)/gelatin 'blend' or 'coaxial' nanofibers into gelatin hydrogels. The morphological, mechanical, swelling and biodegradation properties of the nanocomposite hydrogels were evaluated and the results indicated that the moduli and compressive strengths of the nanofiber reinforced hydrogels were remarkably higher than those of pure gelatin hydrogels. By increasing the amount of incorporated nanofibers into the hydrogel, the Young's modulus of the composite hydrogels increased from 3.29 ± 1.02 kPa to 20.30 ± 1.79 kPa, while the strain at break decreased from 66.0 ± 1.1% to 52.0 ± 3.0%. Compared to composite hydrogels with coaxial nanofibers, those with blend nanofibers showed higher compressive strength and strain at break, but with lower modulus and energy dissipation properties. Biocompatibility evaluations of the nanofiber reinforced hydrogels were carried out using bone marrow mesenchymal stem cells (BM-MSCs) by cell proliferation assay and immunostaining analysis. The nanocomposite hydrogel with 25 mg ml(-1) PCL/gelatin 'blend' nanofibers (PGB25) was found to enhance cell proliferation, indicating that the 'nanocomposite hydrogels' might provide the necessary mechanical support and could be promising cell delivery systems for tissue regeneration.

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OBJECTIVE: Malpositioning is one of the major problems in transcatheter aortic valve implantation. To evaluate the influence of mechanical balloon inflation on aortic valve stent positioning, the expansion process and the impact on the valve leaflet's structure were investigated. METHODS: Custom-made stents were laser cut from a 22-mm diameter stainless steel tube and mounted with a glutaraldehyde-treated bovine pericardial valve. The valved stents were crimped onto a standard balloon catheter and expanded by inflation of the balloon with 2 bar for 3 seconds. Expansion was studied using a high-speed camera, and the histology of the pericardial tissue was analyzed. RESULTS: The valved stents were fully expanded within 3 seconds. Balloon inflation was observed to be asymmetric starting proximally. At the beginning of expansion, the valved stents were pulled proximally. During further inflation, the stents slipped distally on the balloon and experienced a total displacement of 13.5 mm. Macroscopic examination showed severe imprinting of the stent struts into the pericardial tissue. Histology revealed disrupted tissue layers and collagen fibers. CONCLUSIONS: Analysis of valved stent expansion showed a displacement of the stent on the catheter during balloon inflation. Therefore, precise placement of the valved stent cannot be accomplished. Histologic analysis of the expanded pericardial tissue revealed disruption of collagen fibers. Disruption of pericardial tissue structures due to balloon expansion may result in early functional valve failure.

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Heart valve disease (HVD) is a globally increasing problem and accounts for thousands of deaths yearly. Currently end-stage HVD can only be treated by total valve replacement, however with major drawbacks. To overcome the limitations of conventional substitutes, a new clinical approach based on cell colonization of artificially manufactured heart valves has been developed. Even though this attempt seems promising, a confluent and stable cell layer has not yet been achieved due to the high stresses present in this area of the human heart. This study describes a bioreactor with a new approach to cell conditioning of tissue engineered heart valves. The bioreactor provides a low pulsatile flow that grants the correct opening and closing of the valve without high shear stresses. The flow rate can be regulated allowing a steady and sensitive conditioning process. Furthermore, the correct functioning of the valve can be monitored by endoscope surveillance in real-time. The tubeless and modular design allows an accurate, simple and faultless assembly of the reactor in a laminar flow chamber. It can be concluded that the bioreactor provides a strong tool for dynamic pre-conditioning and monitoring of colonized heart valve prostheses physiologically exposed to shear stress.

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INTRODUCTION: Animal studies are an essential method to evaluate implants for the middle ear prior to clinical studies. New Zealand rabbits, guinea pigs and chinchillas are, among other small mammals, well established animal models, but their auditory system is significantly smaller compared to human. Hence, the suitability of the domestic pig (sus scrofa domesticus) as a new animal model for research on the middle ear (ME), that would match the human in size, was investigated. METHODS: Thirty halved pig heads were obtained from the butcher and each middle ear was dissected. Using a digital light microscope, several anatomical magnitudes were determined for 24 specimens, namely the planar projected area of the tympanic membrane (TM), in relation to the stapes footplate as well as the dimensions and weight of the ossicles, in order to determine the effective lever ratios. Using normal and micro computed tomography (CT), six porcine temporal bones were scanned and the geometric data obtained were transferred into a finite element model (FEM) simulation of the porcine middle ear. The transfer function was determined and compared to those from humans determined by measurements and simulations, respectively. RESULTS: The anatomy investigated presented itself as highly comparable to that of the human. Differing from literature, no fourth ossicle could be found. The porcine dimensions and lever ratios determined match the humans far better than those of all established animal models. The obtained transfer function was congruent to the human one. This underlines the suitability of the pig as an animal model for middle ear implants.

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The aim of this project was to investigate the fundamental idea of the possibility of anastomosing small blood vessels in microvascular transplant procedures by an individualized stent known from coronary angioplasty. We investigated the influence of length, dilation and differences in fabrication of the newly developed balloon-expandable stent on the tensile force of stented anastomoses. Various gripping devices were tested and validated to investigate how the length, dilatation and differences in fabrication of the newly developed stent influence the tensile force of the stented anastomosis. Overall, 66 arteries of thiel-fixed human cadavers were investigated, divided into 11 groups. The median tensile force in sutured anastomoses was 2.96 N. The stented anastomoses with 24 mm stents and Ø 3.5 mm dilation attained approximately two-thirds of F(max)-values compared with conventional sutured anastomoses. If the stent was less dilated or had a shorter length, the maximum tensile force of the anastomosis was lower. Recent developments with an inversely oriented stent structure are expected to achieve even higher tensile force values. Further research in stent design to reduce leakage is necessary. A reduction of stent and catheter dimension is also needed to enhance the implantation method.

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After myocardial infarction, the implantation of stem cell seeded scaffolds on the ischemic zone represents a promising strategy for restoration of heart function. However, mechanical integrity and functionality of tissue engineered constructs need to be determined prior to implantation. Therefore, in this study a novel pulsatile bioreactor mimicking the myocardial contraction was developed to analyze the behavior of mesenchymal stem cells derived from umbilical cord tissue (UCMSC) colonized on titanium-coated polytetrafluorethylene scaffolds to friction stress. The design of the bioreactor enables a simple handling and defined mechanical forces on three seeded scaffolds at physiological conditions. The compact system made of acrylic glass, Teflon®, silicone, and stainless steel allows the comparison of different media, cells and scaffolds. The bioreactor can be gas sterilized and actuated in a standard incubator. Macroscopic observations and pressure-measurements showed a uniformly sinusoidal pulsation, indicating that the bioreactor performed well. Preliminary experiments to determine the adherence rate and morphology of UCMSC after mechanical loadings showed an almost confluent cellular coating without damage on the cell surface. In summary, the bioreactor is an adequate tool for the mechanical stress of seeded scaffolds and offers dynamic stimuli for pre-conditioning of cardiac tissue engineered constructs in vitro.