experimental & clinical cardiology

EXPERIMENTAL & CLINICAL CARDIOLOGY

Volume 20, Issue 8, 2014

Title: "Cardiac Tissue Engineering As an Alternative to Current Therapies: Economical and Technical Challenges"

Authors: Nohra E. Beltran, Angelica Reyes and Alvaro R. Lara

How to reference: Cardiac Tissue Engineering As an Alternative to Current Therapies: Economical and Technical Challenges/Nohra E. Beltran, Angelica Reyes and Alvaro R. Lara/Exp Clin Cardiol Vol 20 Issue8 pages 3375-3388 / 2014

Cardiac Tissue Engineering As an Alternative to Current Therapies: Economical and Technical Cha...

Experimental & Clinical Cardiology

Cardiac tissue engineering as an alternative to current therapies: economical and technical challenges Review Article

Nohra E. Beltran, Angélica Reyes, Alvaro R. Lara Departamento de Procesos y Tecnología, Universidad Autónoma Metropolitana-Cuajimalpa Av. Vasco de Quiroga 4871, Col. Santa Fe, Del. Cuajimalpa, México, D.F., C.P. 05348, México. *Corresponding autor. E-mail: [email protected]

Abstract Cardiovascular disease is the most common cause of mortality worldwide, and ischemic heart disease with an episode of acute myocardial infarction is the most common cause of left-‐‑sided cardiac failure. Current therapies for cardiac failure in general provide limited improvements in cardiac output and related symptoms, and cardiac transplantation is restricted by the lack of donor organs available and the high risk of tissue rejection. In this paper we evaluate the cost-‐‑effectiveness of total artificial heart, organ transplant, cellular therapy, and cardiac tissue therapy. To obtain a functional cardiac tissue, regeneration of 3D tissue using bioreactors is crucial to provide the right mechanical and physiological properties to grow constructs of myocardial tissue. We reviewed current advances in cardiac tissue generation using bioreactors, and analyze the technical challenges for cardiomyocytes cultivation for tissue engineering. Such

information is illustrated in the layout of the basic requirements that needed for a suitable bioreactor for cardiomyocytes culture. A market analysis of current therapies showed the viability of cardiac tissue engineering as a treatment strategy for myocardial infarction. Keyword Cardiomyocytes culture, cardiovascular disease, heart failure, heart transplantation, market analysis Need of cardiomyocytes cultivation for tissue engineering Cardiovascular disease (CVD) is the most common cause of mortality in the developed world [1], and the leading cause of death and disability in both industrialized nations and the developing world, with approximately 40% of deaths by heart failures and congenital cardiovascular defects [2], [3]. In 2008, 17 million deaths were associated with CVDs [WHO]. The

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Exp Clin Cardiol, Volume 20, Issue 8, 2014 - Page 3375


vast majority of studies concerning CVDs are carried out in “developed” regions such as the United States and Western Europe; however, 13 million of these CVD deaths occurred in low-‐‑ income and middle-‐‑income countries, compared with 3 million in high-‐‑income countries [4]. Diseases of the heart are currently the leading cause of death across the entire American population, accounting for a third of all deaths [5].Indeed, by 2020, CVDs are predicted to be the major causes of morbidity and mortality in most developing nations around the world [6]. Most CVDs in the world are due to aterosclerosis (coronary heart disease, and ischemic strokes). Mexico, a developing country with a landmass of almost 2 million km2, the 14th larger country in the world, and 5th larger country in America, has a population of more than 112 million. In 2012, Mexico had 109,309 deaths associated with CVDs (first cause of mortality), and 67% of them were due to ischemic strokes [7]. Many pathological states of the heart are associated with cardiac myocyte cell death and apoptosis [8],especially by abrupt occlusion of one or more of the blood vessels (coronary arteries) supplying blood to heart (myocardial infarction). Patients who survive the acute event may eventually develop heart failure (HF), which is a condition reflecting impairment of the pumping efficiency of the heart, and it is caused by a variety of underlying diseases, including ischemic heart disease with or without an episode of acute myocardial infarction, hypertensive heart disease, valvular heart disease, and primary myocardial disease [9]. The most common cause of left-‐‑sided cardiac failure is ischemic heart disease or coronary artery disease, with an episode of acute myocardial infarction[9].

cannot pump a sufficient amount of blood to meet body’s metabolic requirements [12]. Current therapies for cardiac failure (with the exception of cardiac transplantation) in general provide limited improvements in cardiac output and related symptoms [13]. Pharmacological therapy focuses on work load reduction and toxic humoral factors protection, which are over activated in HF [14]. The best interventional therapy for cardiac failure (cardiac transplant) is restricted by the lack of donor organs available for transplantation and the high risk of tissue rejection due to complications associated with immune suppressive treatments [10]. Implantation of total artificial heart (or ventricular assist devices) for work load reduction and cardiac output increase are a high cost interventional alternative, with complications associated with immune suppressive treatments. Both pharmacological and interventional therapies cannot adequately control disease progression to the end stage [15]. Recently, tissue-‐‑based and cell-‐‑based strategies have come as viable alternatives for the treatment of heart disease. In the cell-‐‑ based therapy isolated cells are injected to the infarct region via the pericardium, endocardium or coronary arteries. The main feasibility of cell transplantation in the heart was confirmed almost 13 years ago [16]. Even if most studies support the notion that cell engraftment in animal models of myocardial infarction can improve contractile function, the efficacy of cell engraftment is very low, as more than 90% of the cell suspension injected is lost and does not engraft [17].Embryonic stem cells emerged in the late 1990s as promising candidates for cardiac repair. However, there is a technical difficulty of growing them and keeping undifferentiated, low efficiency of spontaneous cardiac differentiation, and difficulty of cardiomyocytes purification from other cell types that form during spontaneous differentiation [18]. Stem cells seem to be the only meaningful cell source to allocate enough cardiomyocytes for clinical applications [19]. Some other studies showed that fetal and neonatal cardiomyocytes developed massive cell death, coupled with only limited cell proliferation after transplantation, and only replace a tiny fraction of an infarct [20].It is important to remember that 1 gram of adult myocardium contains approximately 20-‐‑40 million myocytes [21], and a typical myocardial

The adult human heart is unable to self-‐‑ regenerate to a significant degree. Myocardial infarction typically results in fibrotic scar formation and permanent cardiac failure because, after a massive cell loss due to ischemia, the myocardial tissue lacks significant intrinsic regenerative capability to replace the lost cells [10]. Also an impairment of the heart wall muscle occurs as a consequence of collagen extracellular matrix weakening, with wall thinning and ventricular dilation. The increase in ventricular volume leads to progressive structural and functional changes in association with mechanical pumping inefficiency, predisposing towards the end stage of congestive HF [11]; condition in which the heart

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infarction generates a loss of around 50 g of heart muscle [22]. In order to compensate that loss 1-‐‑2 billion myocytes will be necessary. For this reason, much effort is now conveyed to the development of tissue-‐‑engineering strategies to generate constructs to engraft successfully new cells into the cardiac muscle.

transported to the cells by molecular diffusion, which provided enough oxygen for an approximately 100 µμm thick outer layer of functional tissue but not to the construct interior which remained relatively acellular [31], [32], [28]. Bioreactors may provide the right mechanical and physiological properties to grow constructs of myocardial tissue [3]. Viability of the cultivation of cardiomyocytes for tissue engineering The incidence and prevalence of HF has increased during recent decades as a result of an aging population and improvements in treatment and survival of cardiovascular disease [33]. Morbidity and mortality for HF are substantial, with more than 1.1 million hospital discharges in 2006 and almost 3.5 million out patient visits in 2007. The estimated direct and indirect costs related to HF increased from $22.5 billion in 2001 [34] to almost $40 billion in 2010 [35].It has been reported that HF is an expensive disease, and still the most costly cardiovascular illness in the United States [36], [37], [38]. Cardiovascular diseases accounted for 34% of all deaths in the United States (US) with an associated cost of $503.2 billion in 2010 alone [35]. It is estimated that 5 million Americans, 1.8 million Britons, and 25 million people worldwide suffer from HF, with approximately 700,000 and 120,000 new cases diagnosed each year in the US and the United Kingdom (UK), respectively [39], [9]. Prognosis is poor with 40% mortality within 12 months of diagnosis, and a 10% annual mortality rate thereafter [40]. In 2013, HF cost health-‐‑care system over $32 billion and is expected to double by 2030 [41].

Cardiac tissue engineering is an emerging field for the development of innovative treatment strategies for heart diseases that offers the promise of creating functional tissue replacements for use in the failing heart [23]. A great progress in this field has occurred in the last decade, with new advances in interdisciplinary areas such as developmental biology, genetic engineering, biomaterials, polymer science, bioreactor engineering, and stem cell biology [23]. Most of the cardiac tissues engineering approaches have been focused on the use of synthetic or biological matrix materials and heart cells to generate constructs that might be utilized for replacement of diseased myocardium in vivo. However, in the absence of true vascularization, in vitro engineering approaches face the problem of critical thickness because mass transportation into tissue is difficult beyond a thin peripheral layer of an engineered tissue constructs with nutrients and oxygen supply [24]. It has been widely recognized that bioreactors are essential for the research in tissue engineering. Cells into the body are always stimulated by mechanical, electrical and chemical signals that influence their biological behavior [3]. If the signals are not present or inadequate, cells may die. In fact, biological tissues adapt their composition and structure to surrounding functional demands [25]. To obtain a functional cardiac tissue, regeneration of complex 3D tissue using bioreactors is crucial.

The cost of a heart transplant, including preliminary testing (30 days pre-‐‑transplant), surgery (procurement, hospital transplant admission, physician during transplant) and 180 days post-‐‑operative recovery, estimated in U.S in 2011 is around $997,700 [42]. In 2008 the estimated cost was $787,700 [43]. The cost in 2011 was almost twice the cost in 2005 ($478,900) [44]. From these numbers we can calculate an annual increment cost of $86,467 for heart transplant. Moreover, long-‐‑term costs of post-‐‑ transplant care can be around $70,000 a year [1].The US cost of hospitalizations alone for orthotopic heart transplantation and Left-‐‑

Three-‐‑dimensional tissue constructs that express structural and physiological features characteristic of native myocardium have been engineered using collagen gels [26], [27], [28], collagen fibers [29],or collagen sponges [30] in conjunction with fetal or neonatal rat cardiac myocytes. In all cases cells were seeded on scaffolds and cultivated in dishes [30], [31], spinner flasks [31], [32], or rotating vessels [29],[31], [32]. Oxygen dissolved in medium was

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Ventricular Assist Device (LVAD) implantation approached $1 billion in 2009 [45]. Although around 1,800 LVADs were implanted in the U.S. in 2012; patients who undergo implantation as a bridge to transplant obtain only 1-‐‑year survival rates [1]. In the UK, CVD causes approximately 200,000 deaths per year. Across Europe, 1.9 million people die from CVDs, about half of all deaths. Moreover, CVDs are estimated to cost the European Union economy €196 billion annually in informal patient care, direct healthcare and productivity losses. In the US, 83 million adults, more than a third of the population, live with a CVD. Diseases of the heart in American population cost the economy over $400 billion per year [5]. LVADs have an initial hospitalization cost of $198,000 with a first year survival of 51.6% [46].

because the life-‐‑years gained and the patient utility of those years are low compared to the alternatives. The QALY is lower for heart transplantation ($35,290/year) compared to total artificial heart ($113,750/year) [49]. Any new treatment that reduces cost without compromising efficacy is cost-‐‑effective. Goldman et al have suggested that an incremental cost-‐‑effectiveness ratio of less than $20,000 per QALY is very attractive, a ratio of $20,000 to $60,000 per QALY is acceptable, and over $100,000 per QALY is unattractive [38]. The number of heart donors has reached a plateau despite an increasing number of potential recipients. More than 5,000 cardiac transplants occur each year around the world, although it is estimated that up to 50,000 people are candidates for transplantation [50]. Approximately 85 to 90 % of heart transplant patients are living one year after their surgery, with an annual death rate of approximately 4 % thereafter. The three-‐‑year survival approaches 75 % [51]. Cardiac transplant recipients have an average of one to three episodes of rejection in the first year after transplantation. Between 50 and 80 % of people experience at least one rejection episode. Acute rejection is most likely to occur in the first three to six months, with the incidence declining significantly after this time [52]. In the first year, most deaths are due either to acute rejection (18 %) or infections (22 %). Infections often develop as a result of the anti-‐‑ rejection medications and weakened immune system that are required to prevent rejection.

Cost-‐‑effectiveness analysis is important to make a decision of which therapy will make a patient live longer and/or live better. The most commonly used metric is “quality-‐‑adjusted life years” (QALY), a composite of the extra years of life gained with a treatment and the quality of that life as measured by utility [47]. The utility is a scale of 0 to 1, where 0 represents death and 1 represents ideal health. This utility number is then multiplied by the additional survival to obtain QALY. The utility score is an empiric measurement obtained from patients (interviews or quality of life questions). Although QALY is the most commonly used metric to compare cost-‐‑effectiveness, it is subjective and may not always match the wishes of individual patients [48]. According to Goodman (2004), QALY provide the ability to estimate the overall burden of disease; compare the relevant impact of specific diseases, condition, and syndromes as they relate to medical technology intervention; and conceive economic correlations, such as cost effectiveness and cost utility of different medical technologies [49]. Survival is generally discounted, which means that patients value a year of survival at the present time more than a year of survival in the future. Although the true discount rate for survival is unknown, 3% is the most popular [34]. The cost of conventional treatment for CVDs is the lowest ($28,500) compared with the cost of heart transplantation ($298,200) and total artificial heart ($327,600). However, the cost per QALY is the highest in conventional medical treatment ($950,000/year)

In Mexico, according to Cenatra (National Center of Transplants) during this year, 55 patients are waiting for a heart transplant, and only 4 (7%) have been occurred this year [53]. Figure 1 shows historical data of number of heart transplants from 1988 to 2014 in Mexico, with a waitlist time of 30 months approximately. According with National Health Secretary, in 2001 the cost of a heart transplant was between $40,000 and $50,000. But there is not information about total hospitalization cost or QALYs. It is well know that post-‐‑implant treatment is more expensive than the transplant itself because immunosuppressive therapy, rejection, morbidity or mortality. Specifically, tissue engineering of heart muscle may be used to restore or enhance contractile function of failing

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myocardium in vivo, must develop systolic force, withstand diastolic load with appropriate

compliance, forming an electrical and functional syncytium [19].

Figure 1. Historical data of number of heart transplants in Mexico. Because the costs per QALY in conventional have not approved more new cellular therapies medical treatment, heart transplantation and than Europe [56]. The National Institutes of total artificial heart are greater than $20,000 per Health (NIH) support regenerative medicine QALY, and some of the are over$100,000 per research to translate science into clinical QALY which is unattractive; a new treatment for practice, and invested approximately 1 billion heart failure is based on cellular therapy has dollars a year into stem cell research [57]. The been proposed. However, there is only little global cell therapy industry is a billion dollar information about total cost of this alternative. It global business with unlimited potential [58]. has been reported an estimation cost of cellular This is an emerging field, but more clinical trials production for cardiac regeneration after and regulation will be necessary in order to get infarction is around $10,000 [54]. Recently, some more cost-‐‑ effective strategies for clinical reports showed the potential of regenerative practice. medicine to treat and cure diseases in UK, A critical issue with cell transplantation to improving the quality of live and also cardiovascular tissue is the decision of which demonstrate the significant economic benefits cell type to use. Human embryonic stem cells or [55]. It has been estimated that between 2004 fetal cardiomyocytes are impractical for clinical and 2010, 318 regenerative medicine clinical use because of ethical concerns and trials were initiated in Europe, 78 % of which are inmunorejection [59]. Future studies of stem cell relative to cell-‐‑based medicinal products; transplantation to cardiac muscle will need to however, only two regenerative medicine focus on differentiation of the stem cell into a products obtained marketing authorization as functional cardiomyocyte lineage, as well as advanced therapy medicinal products [56]. gene therapy techniques for improving Other countries such as US, Canada, and Japan

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regeneration and limiting fibrotic scar formation [60].

using a volume/mass ratio of 0.8 mL/g determined at the end of diastole [71]. Therefore, approximately 13.64 cm3 of cardiac tissue will be necessary after heart infarction, with an estimated cost of $1243. If we include the transplant surgery cost of $53,492, the total cost for an infarct treatment will be less than $55,000. Optimizing cell growth, enhancing cardiomyocyte production, and improving cost-‐‑ effectiveness of tissue engineering treatment, this strategy might be utilized for replacement of diseased myocardium in vivo if we consider the market size and the potential profitability. Bioreactor systems in tissue engineering Cultivation of cells for tissue engineering require strict control of environmental conditions in order to mimic the physiological characteristics needed for the development of the desired cellular functions. The bioreactors used for tissue cultivation are diverse, ranging from simple petri dishes and spinner flasks to perfusion bioreactors and bioreactor systems that can apply well defined mechanical forces [72]. The bioreactor should provide means for proper nutrients supply and also the physical stimulus required to achieve a defined phenotype. Moreover, the hydrodynamics characteristics created during the operation should cause any damage to the cells. Therefore, each bioreactor is designed taking into account the particular characteristics of the cells or tissue to be cultivated. The design is not straightforward, since the exact influence of physical factors on the tissue development is not always well described, and there is a frequent lack of detailed kinetic characteristics of the cells during in vitro growth. Furthermore, the small bioreactor size and the need for scaffolds often difficult the mass (oxygen) transfer and the instrumentation of the bioreactor, which should be non-‐‑invasive. There are several options for the cultivation of cardiomyocytes for laboratory studies. However, for therapeutic purposes, the cultivation system should provide sufficient amounts of cardiomyocytes with the proper contractile activity. Furthermore, the bioreactor system should be suitable for scaling-‐‑up to clinical scales while allowing predictable and reproducible results. Factors like cost-‐‑effective

The mean total cost for the initial hospitalization and 1 year of follow up after transplantation for peripheral blood stem cell therapy was around $430,000 during 2008 and $436,000 for bone marrow transplantation [61]. Some studies found that stem cell therapy for bone marrow transplantation was cost-‐‑effective, with the intervention cost less than $50,000 per QALY [62]. Tissue engineering techniques are being employed with aims of repopulating a diseased tissue for improving clinical outcomes. Tissue engineering broadly involves the use of three components: cell source, biomaterial/membranes, and/or growth stimulators, either alone or in any combination. There have been reported the cost-‐‑effectiveness analysis of bladder and urethra based on tissue engineering [63]; however, current literature fails to support a clinical benefit of cardiac tissue engineering over other techniques such as heart transplant, conventional treatment for CVDs, or ventricular assist devices. Moreover, many of the advancements in tissue engineering have yet to be applied in a clinical setting. While basic science (studies in rodents, large animals, and even humans) has demonstrated successful cell transplantation to diseased heart tissue [64], [65], [66], available evidence does not conclude the superiority of modern tissue engineering methods over other techniques in improving clinical symptoms or restoring native heart muscle. There is not information about cardiac tissue cost; however, we made an estimation based on some epithelial commercial tissues. In Mexico, 8 cm3 of epithelial tissue cost $729 [67]. Cardiac tissue development should be more difficult and complex than epithelial tissue, because we need to be stimulated by mechanical, electrical and chemical signals that influence their biological behavior; also we need more efficient nutrients and oxygen supply. We estimated an increment of 50% over epithelial tissue cost approximately. Using a cell density between 0.16X108 to 24.6X108 to heart infarction treatment, it has been reported a 6% LVEF increase [68]. In terms of cost/benefit ratio, a 6% improvement in the LVEF will cost $19,000 [69]. It we consider a median infarct size around 11% of LV mass [70], the volume will be 124 cm3,

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manufacturing and the capability to complain with Good Manufacturing Practice (GMP) and robust quality control are key for the successful application of cardiomyocytes in order to compete with other medical treatments [73] like transplants, which have been discussed above. The specific requirements for the cultivation of cardiomyocytes intended for clinical applications are addressed below. Technical challenges for cardiomyocytes cultivation for tissue engineering The goal of bioreactor culture of cardiomyocytes for clinical application is to obtain sufficient amounts of cells that retain the desired function. This goal define the main constrains for bioreactor design and operation. The amount of cells to be obtained is relatively large, being 108cells/cm3 (similar to the cell density found in heart) a frequently mentioned target [74],[75],[76]. This is a central challenge, since the growth capacity of cardiomyocytes during in vitro culture has been very limited [77]. Another feature is that the size of the cardiac patch area such be as large as 50 cm2 and have a thickness of several mm [76]. All these factors point to the

possibility of oxygen limitations, which is highly undesirable. The oxygen uptake rate of cardiomyocytes can be high (see Table 1) and since air bubbles for oxygen transfer are not an option, high enough oxygen transfer rates to the medium are difficult to achieve. This also limits the achievable thickness of the cell film. The most effective bioreactor operation mode for cardiomyocytes cultivation is perfusion [19], [74]. This provides means to overcome mass transfer limitations and to continuously provide nutrients to the cells [78]. Since the culture medium is continuously circulated to a chamber where cells are attached to a scaffold, an external bubble-‐‑free mass transfer device can be installed previous to medium delivery to the culture chamber. This would allow to saturate the medium with oxygen and thus avoid any limitation to the cells. Nevertheless, the scaffold material also plays a role for the transport of oxygen (and other nutrients) to the cells that are not in contact with the medium [79]. A variety of materials have been used as scaffold in cardiomyocytes cultures, including hyaluronic acid [80], collagen [19], poly-‐‑lactate and [32] and polylactones [81].

Bioreactor mode

Cell type

O2 conc. (µμmol/L)

O2 uptake rate nmol/(min*106cell)

Reference

Perfusion

Neonatal rat cardiomyocyte

100

2.2 ± 0.2

[82]

Closed-‐‑cell chamber


100

1.5±0.1

[82]

Perfusion


220

3.6

[75]

Table 1. O2 uptake rates of cardiomyocytes under different dissolved O2 concentrations and bioreactor operation modes. The flow rate in a perfusion system should be determined taken into account the demand of nutrients by the cells and the possibility of damage by shear stresses. Nevertheless, metabolic and kinetic information is scarce and often very variable. For instance, Table 2 shows the glucose uptake rates reported for neonatal cardiomyocytes under different experimental conditions. The uptake values are 300 % different. Therefore, a precise and informed

perfusion design based on metabolic information is not yet doable. Progress in the study of the metabolism of cardiomyocytes in perfusion cultures using for instance, isotopomer analysis and network modelling [83] will be useful not only for perfusion and culture media design. Recent developments on the non-‐‑ invasive monitoring of metabolic activity of the constructs [84] represent a potential improvement toward perfusion culture control

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and scaling-‐‑up. Regarding the hydrodynamics effects, a practical limit for perfusion rate can be estimated by the shear rate at which apoptosis is Bioreactor mode

Cell type

O2 conc. (µμmol/L)

triggered in cardiomyocytes, which has been reported to be equal to 2.4 din/cm2 [85].

Glucose conc. (µμmol/L)

Glucose uptake rate (nmol/min*106cell)

Reference

Closed-‐‑cell chamber


100

5,500

2.1 ± 1.3

[82]

Perfusion


220

25,000

0.7 ± 0.4

[75]

Table 2. Glucose uptake rates of cardiomyocytes under different glucose concentrations and bioreactor operation modes. Cultured cardiomyocytes should display some physiological functions in order to be used in clinical treatments, mainly contractile activity. To enhance the contractile capacity of the cultured cardiomyocytes, physical stimulation is frequently used in the form of electrical pulses [86],[87] or mechanical stretch [88]. Both methods have yielded positive results, but are not directly comparable due to different experimental settings. Electrical pulses using carbon electrodes is probably the most widely applied stimulation. It has been reported that for neonatal cardiomyocytes, the optimal setting of electrical pulses at 3 V/cm amplitude and 3 Hz frequency resulted in the highest tissue density and the best contractile behavior under the conditions used [87]. This information is valuable for the design and start-‐‑up of the bioreactor for cardiomyocytes cultivation. Nevertheless, similar studies should have to be performed using human cells.

In principle, as shown in Figure 2A, the bioreactor should meet essential requirements for the cardiomyocytes culture, like the efficient supply of oxygen and other nutrients and removal of by-‐‑products without generating hydrodynamic conditions negative to the cells. Also, the culture system should provide adequate electrical stimulation in order to produce contractile cells suitable for clinical applications. For such application, perfusion mode has proven to be the best option (Figure 2B), in which mass transfer can be performed outside the perfusion chamber, preferably without bubbles using bubbles. The perfusion chamber contains the construct and the carbon electrodes for pulsatile stimulation. The culture medium could be recirculated or discarded, depending on the nutrients consumption or by-‐‑ products accumulation. Recent advances in construct monitoring represent an important step towards the highly needed process control and documentation as well as improved operation.

The above mentioned information serves as basis for the conceptual design of the bioreactor.

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Figure 2. A) Essential requirements for the cardiomyocytes culture. B) Conceptual design of a perfusion bioreactor. Conclusions approach will strongly depend on the technological advances focused on the The estimation of costs for cardiomyocytes reproducible and informed operation of the culture presented in this work is yet bioprocess. As the knowledge about the preliminary, since it is based on the scarce cardiomyocytes (quantitave) physiology information of other tissues. However, the advances, particularly for human cardiomyocyte calculations allow to predict that cardiac tissue culture, more robust and reproducible processes engineering is potentially a viable alternative for will be implemented. heart failure treatment. The success of this References 1. Williams ML, Trivedi JR, McCants KC, et al. assist device in heart transplant-‐‑eligible Heart transplant vs left ventricular patients. Ann Thorac Surg

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