Sandra Webb

Lineage and Morphogenetic Analysis of the Cardiac Valves

We used a genetic lineage-labeling system to establish the material contributions of the progeny of 3 specific cell types to the cardiac valves. Thus, we labeled irreversibly the myocardial (&agr;MHC-Cre+), endocardial (Tie2-Cre+), and neural crest (Wnt1-Cre+) cells during development and assessed their eventual contribution to the definitive valvar complexes. The leaflets and tendinous cords of the mitral and tricuspid valves, the atrioventricular fibrous continuity, and the leaflets of the outflow tract valves were all found to be generated from mesenchyme derived from the endocardium, with no substantial contribution from cells of the myocardial and neural crest lineages. Analysis of chicken-quail chimeras revealed absence of any substantial contribution from proepicardially derived cells. Molecular and morphogenetic analysis revealed several new aspects of atrioventricular valvar formation. Marked similarities are seen during the formation of the mural leaflets of the mitral and tricuspid valves. These leaflets form by protrusion and growth of a sheet of atrioventricular myocardium into the ventricular lumen, with subsequent formation of valvar mesenchyme on its surface rather than by delamination of lateral cushions from the ventricular myocardial wall. The myocardial layer is subsequently removed by the process of apoptosis. In contrast, the aortic leaflet of the mitral valve, the septal leaflet of the tricuspid valve, and the atrioventricular fibrous continuity between these valves develop from the mesenchyme of the inferior and superior atrioventricular cushions. The tricuspid septal leaflet then delaminates from the muscular ventricular septum late in development.

Development of the heart: (3) Formation of the ventricular outflow tracts, arterial valves, and intrapericardial arterial trunks

In the first part of our review of cardiac development,1 we explained the changes occurring during the transformation of the solitary primary heart tube into the primordiums of the definitive heart, describing how this involved the processes of looping, and subsequent formation from the primary tube of the components of the atriums and ventricles. In the second part of our review,2 we then accounted for the steps involved in separation of the atrial and ventricular chambers, emphasising that the processes were more complicated than the simple formation of partitions within the respective atrial and ventricular primordiums. The subject of this, our third review, is the transformation of the initially solitary outflow portion of the heart tube into the intrapericardial parts of the aorta and the pulmonary trunk, their arterial valves and sinuses, and the subarterial ventricular outflow tracts. In our first review, we summarised some of the problems that continue to plague the understanding of the development of these outflow structures. Thus, initially the entirety of the primary heart tube contained within the confines of the pericardial cavity possesses a myocardial phenotype. Yet, in the definitive heart, the walls of the intrapericardial arterial trunks, along with the sinuses of the arterial valves, and small parts of the subarterial ventricular outlets, have an arterial or fibrous phenotype. The steps involved in the changes of the walls from the myocardial to the arterial and fibrous phenotypes have yet to be clarified. And then, cushions, or ridges, of endocardial tissue initially fuse to divide the entirety of the solitary outflow segment into the presumptive systemic and pulmonary outlets. With subsequent development, these cushions lose their septal function, as the arterial valves and trunks, along with the subpulmonary muscular infundibulum, develop as free-standing structures with their own discrete walls within the pericardial …

DEVELOPMENT OF THE HEART: (1) FORMATION OF THE CARDIAC CHAMBERS AND ARTERIAL TRUNKS

Through the 20th century, knowledge of the events occurring during cardiac development was clouded by conflicting descriptions, coupled with use of notably different terminologies. Furthermore, not all accounts were based on direct study of embryonic material, instead being constructed on the basis of interpretations of previous reports, supported by inferences made from the structure of the congenitally malformed heart. Such processes, in themselves, are understandable, since it is axiomatic that proper appreciation of the events occurring during formation of the heart will aid in the analysis of the morphogenesis of cardiac malformations, this being a desirable prerequisite in the search for optimal treatment. Over the past decade, this has all changed. There has been an explosion of work, both anatomical and molecular, devoted to cardiac development. Advances in technology, coupled with the use of suitable animal models, now enable us to provide a more accurate account of the steps involved in formation and septation of the cardiac chambers. Not all of this new information is concordant with the “classical” accounts. In these reviews, therefore, we will describe, first, the steps involved in formation of the primary heart tube, and its conversion to the four cardiac chambers and the paired arterial trunks. We will then look in greater detail at the events occurring during the separation of the initial solitary heart tube into discrete systemic and pulmonary circulations. The mesodermal tissues that give rise to the heart first become evident when the embryo is undergoing the process known as gastrulation. In the human, this occurs during the third week of development, while for the mouse, at a comparable stage of development, around seven days will have elapsed from fertilisation, and the embryo will be in the presomitic stage. The embryonic plate in humans, initially possessing two layers, is ovoid, and is …

Development of the heart: (2) Septation of the atriums and ventricles

In the first part of our review of cardiac development,1 we discussed the initial changes involved in transformation of the heart forming regions of the embryo into the great veins, the atrial and ventricular chambers, and the arterial trunks. We showed that this first part of cardiac development could be divided into phases of formation of the primary myocardial tube, looping of the tube, during which additional parts are added that give the future compartments their definitive topography, and the assembly of these components into the cardiac chambers and arterial trunks. In this second review, we discuss the processes that complete the separation of the two sides of the definitive heart, for the most part involving septation of the parts of the primary tube not themselves directly involved in formation of the chamber-specific compartments of the atriums and ventricles. In this respect, when concluding our first review, we explained how the arterial trunks were also formed by septation within the solitary outflow tract of the primary heart tube. We also showed, however, that subsequent to formation of the two arterial trunks, there was disappearance of the cushions that initially divided them. Thus, in the definitive heart, the proximal parts of the aorta and pulmonary trunk, along with the sinuses of the arterial roots and the subpulmonary infundibulum, possess their own discrete walls, separated by extra-cardiac space. Although septation by fusion of endocardial cushions will be a topic included in this second review, septation and separation of the outflow tracts is sufficiently complicated to require special treatment. Because of this, we will devote a third review specifically to the mechanisms underscoring the remodelling of the outflow tracts. In this review, therefore, we will confine our considerations to the formation of the atrial, atrioventricular, and ventricular septal structures. As will become …

Development and structure of the atrial septum

Most cardiologists would probably consider that, during their training, they had received appropriate instruction concerning the mode of development and structure of the atrial septum. This is likely to be founded on the diagrams that exist in most standard textbooks of cardiac embryology. These illustrate the formation of primary and secondary atrial septums as overlapping muscular sheets that grow into the common atrium. This type of illustration implies that similar morphological mechanisms of development lead to the formation of these two “septums”. This is not so. To the best of our knowledge, there is no evidence existing which supports this concept of growth of a second muscular shelf into the developing atriums so as to overlap the primary atrial septum, and to provide the rims of the definitive oval fossa. On the contrary, it has long been established1,2 that the superior border of the “septum secundum”, in other words the superior rim of the oval fossa, is an infolding of the atrial roof. In this respect, case reports are to be found that describe the formation of lipomas within the supposed “septum secundum”.3 Careful study of such lipomas,4 along with scrutiny of the published images,3 reveals that the fat accumulates within the deeply infolded superior interatrial groove. All the “classical” accounts of atrial septal development have also ignored totally the contribution to atrial septation made by the “spina vestibuli”, a structure first described by His in the 19th century.5 Similarly, they take no account of the contributions made by the mesenchymal cap which clothes the leading edge of the muscular primary atrial septum.6 In reality, therefore, more structures contribute to division of the atriums than the so-called primary and secondary septums.7 It is appreciation of the roles of all these various components …

Atrial development in the human heart: an immunohistochemical study with emphasis on the role of mesenchymal tissues

The development of the atrial chambers in the human heart was investigated immunohistochemically using a set of previously described antibodies. This set included the monoclonal antibody 249‐9G9, which enabled us to discriminate the endocardial cushion‐derived mesenchymal tissues from those derived from extracardiac splanchnic mesoderm, and a monoclonal antibody recognizing the B isoform of creatine kinase, which allowed us to distinguish the right atrial myocardium from the left. The expression patterns obtained with these antibodies, combined with additional histological information derived from the serial sections, permitted us to describe in detail the morphogenetic events involved in the development of the primary atrial septum (septum primum) and the pulmonary vein in human embryos from Carnegie stage 14 onward. The level of expression of creatine kinase B (CK‐B) was found to be consistently higher in the left atrial myocardium than in the right, with a sharp boundary between high and low expression located between the primary septum and the left venous valve indicating that the primary septum is part of the left atrial gene‐expression domain. This expression pattern of CK‐B is reminiscent of that of the homeobox gene Pitx2, which has recently been shown to be important for atrial septation in the mouse. This study also demonstrates a poorly appreciated role of the dorsal mesocardium in cardiac development. From the earliest stage investigated onward, the mesenchyme of the dorsal mesocardium protrudes into the dorsal wall of the primary atrial segment. This dorsal mesenchymal protrusion is continuous with a mesenchymal cap on the leading edge of the primary atrial septum. Neither the mesenchymal tissues of the dorsal protrusion nor the mesenchymal cap on the edge of the primary septum expressed the endocardial tissue antigen recognized by 249–9G9 at any of the stages investigated. The developing pulmonary vein uses the dorsal mesocardium as a conduit to reach the primary atrial segment. Initially, the pulmonary pit, which will becomes the portal of entry for the pulmonary vein, is located along the midline, flanked by two myocardial ridges. As development progresses, tissue remodeling results in the incorporation of the portal of entry of the pulmonary vein in left atrial myocardium, which is recognized because of its high level of creatine. Closure of the primary atrial foramen by the primary atrial septum occurs as a consequence of the fusion of these mesenchymal structures. Anat Rec 259:288–300, 2000.

Development of the Murine Pulmonary Vein and Its Relationship to the Embryonic Venous Sinus

Arguments concerning the development of the pulmonary vein, and its relationship to the embryonic venous sinus (sinus venosus) have continued for well over a century. Recently, attention has again been focused on the origin of the pulmonary vein. It has been suggested that, whereas the pulmonary vein originates from the left atrium in humans, in all other vertebrates it originates from the venous sinus, with subsequent transfer to the left atrium. The nature of this transfer has not, however, been elucidated, although there is speculation that the pulmonary vein is “pinched off” from the left side of the embryonic venous sinus.

Septation and separation within the outflow tract of the developing heart

The developmental anatomy of the ventricular outlets and intrapericardial arterial trunks is a source of considerable confusion. First, major problems exist because of the multiple names and definitions used to describe this region of the heart as it develops. Second, there is no agreement on the boundaries of the described components, nor on the number of ridges or cushions to be found dividing the outflow tract, and the pattern of their fusion. Evidence is also lacking concerning the role of the fused cushions relative to that of the so‐called aortopulmonary septum in separating the intrapericardial components of the great arterial trunks. In this review, we discuss the existing problems, as we see them, in the context of developmental and postnatal morphology. We concentrate, in particular, on the changes in the nature of the wall of the outflow tract, which is initially myocardial throughout its length. Key features that, thus far, do not seem to have received appropriate attention are the origin, and mode of separation, of the intrapericardial portions of the arterial trunks, and the formation of the walls of the aortic and pulmonary valvar sinuses. Also as yet undetermined is the formation of the free‐standing muscular subpulmonary infundibulum, the mechanism of its separation from the aortic valvar sinuses, and its differentiation, if any, from the muscular ventricular outlet septum.

Reconstruction of the Patterns of Gene Expression in the Developing Mouse Heart Reveals an Architectural Arrangement That Facilitates the Understanding of Atrial Malformations and Arrhythmias

Firm knowledge about the formation of the atrial components and of the variations seen in congenital cardiac malformations and abnormal atrial rhythms is fundamental to our understanding of the normal structure of the definitive atrial chambers. The atrial region is relatively inaccessible and has continued to be the source of disagreement. Seeking to resolve these controversies, we made three-dimensional reconstructions of the myocardial components of the developing atrium, identifying domains on the basis of differential expression of myocardial markers, connexin40, and natriuretic precursor peptide A. These reconstructions, made from serial sections of mouse embryos, show that from the outset of atrial development, the systemic and pulmonary veins are directly connected to the atrium. Relative to the systemic junctions, however, the pulmonary venous junction appears later. Our experience shows that three-dimensional reconstructions have three advantages. First, they provide clear access to the combined morphological and molecular data, allowing clarification and verification of morphogenetic concepts for nonmorphological experts and setting the scene for further discussion. Second, they demonstrate that, from the outset, the myocardium surrounding the pulmonary veins is distinct from that clothing the systemic venoatrial junctions. Third, they reveal an anatomical and molecular continuity between the entrance of the systemic venous tributaries, the internodal atrial myocardium, and the atrioventricular region. All these regions are derived from primary myocardium, providing a molecular basis for the observed nonrandom distribution of focal right atrial tachycardias.

Clinical anatomy of the atrial septum with reference to its developmental components.

Knowledge of development is of crucial importance and can help clarify mechanisms of maldevelopment, but it must be properly validated. Concepts of development must be consistent with the anatomy seen in postnatal life. Such consistency is not always achieved. We have reviewed new and old accounts of cardiac embryology with regard to the definitive structure of the atrial septum. The key to understanding is to distinguish between folds of the atrial wall and true interatrial partitions. The flap valve of the oval foramen, and its inferior rim, are true septal structures, whereas the other rims, particularly the antero‐superior rim, are infoldings enclosing extracardiac fat. During embryonic life, the systemic venous tributaries must achieve entrance only to the right side of the primary atrium. Development of the pulmonary venous component is a late event, with the canalizing vein using the dorsal mesocardium to gain access to the left side of the atrium. Once the systemic venous tributaries have achieved their rightward shift, the primary septum, together with the mesenchymal cap, grows between the systemic and pulmonary venous orifices. Closure of the primary foramen is achieved by fusion of the mesenchymal cap of the primary septum with the atrioventricular endocardial cushions and the vestibular spine (an additional mesenchymal structure carried on the right side of the pulmonary venous orifice). The superior margin of the newly formed secondary foramen is produced by an infolding of the atrial walls. Historically these mechanisms received appropriate recognition, but not all receive their proper due in current writings. Clin. Anat. 12:362–374, 1999.