Retinoic acid modulation guides human-induced pluripotent stem cell differentiation towards left or right ventricle-like cardiomyocytes

Retinoic acid modulation guides human-induced pluripotent stem cell differentiation towards left or right ventricle-like cardiomyocytes | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Retinoic acid modulation guides human-induced pluripotent stem cell differentiation towards left or right ventricle-like cardiomyocytes Hengliang Zhang, Payel Sen, Jules Hamers, Theresa Sittig, Brent Woestenburg, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3782805/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background. Cardiomyocytes (CMs) derived from human induced pluripotent stem cells (hiPSCs) by traditional methods are a mix of atrial and ventricular CMs and many other non-cardiomyocyte cells. Retinoic acid (RA) plays an important role in regulation of the spatiotemporal development of the embryonic heart. Methods: Engineered heart tissues (EHTs) were generated by assembling CMs derived from hiPSC (hiPSC-CM) at high cell density in a low collagen hydrogel. Different concentrations of RA (Control group without RA, LRA group with 0.05 µM and HRA group with 0.1 µM) were administered during third to sixth days of the differentiation process. Results: In the HRA group, hiPSC-CMs exhibited highest expression of maturity genes MYH7 and cTnT. The expression of TBX5, NKX2.5 and CORIN, which are the marker genes for left ventricular CMs, was also the highest in the HRA group. In terms of EHT, the HRA group displayed the highest contraction force, the lowest beating frequency, and the highest sensitivity to hypoxia and isoprenaline, which means it was more functionally similar to the left ventricle. RNAsequencing revealed that the heightened contractility of EHT within the HRA group can be attributed to the promotion of augmented extracellular matrix strength by RA. Conclusion: By interfering with the differentiation process of hiPSC with a specific concentration of RA at a specific time, we were able to successfully induce CMs and EHTs with a phenotype similar to that of the left ventricle or right ventricle. Retinoic acid hiPSC Cardiomyocyte Engineered heart tissue Left ventricle Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Background Cardiomyocytes (CMs), derived from human induced pluripotent stem cells (hiPSC-CMs), and the engineered heart tissue (EHT) derived from these hiPSC-CMs, constitute a highly advantageous in vitro experimental model for conducting personalized drug screening and advancing regenerative strategies within the realm of precision medicine[27, 37]. However, CMs induced from hiPSCs using traditional methods represent a heterogeneous population comprising both atrial and ventricular cells[29, 63]. Although, earlier studies have effectively accomplished the differentiation of hiPSC-CM into distinct atrial or ventricular phenotypes[14, 30], no prior research has achieved the successful differentiation of hiPSC-CM into EHTs with specific phenotypes corresponding to either the left ventricle (LV) or the right ventricle (RV). Retinoic acid (RA) signaling plays a pivotal role in embryonic development, as it is essential for organizing the trunk and facilitating organogenesis in diverse tissues derived from all three germ layers[16, 22]. In addition to being one of ingredients regulating embryonic development, RA also regulates cardiac development and affects the differentiation of hiPSC-CM into different subtypes, with the direction of differentiation being time- and concentration-dependent[58] (Figure 1A). Previous research has demonstrated that RA concentrations ranging from 1 µM to 5 µM appear to promote hiPSC-CM or heart embryonic differentiation toward atrial CMs [14, 30, 58], whereas a concentration of 0.05 µM appears to promote differentiation towards left ventricular CMs[25]. Other studies found that RA mainly induces epicardial cells at 1 µM to 4 µM[23], while 0.5 µM to 1 µM of RA intervenes in the mesoderm to increase the proportion of atrial CMs[14, 50]. Not only RA concentration, but also the timing of RA intervention is critical, with recent in vivo and in vitro findings showing that low RA dosage at the mesoderm induction stage is critical for left ventricular chamber specification[15, 26, 29, 31]. Numerous studies have endeavoured to uncover the regulatory relationships among transcription factors associated with heart development. RA has been shown to operate upstream of the transcription factor TBX5, indirectly modulating its expression[18, 60]. During heart development, the transcription factors TBX5, NKX2.5, and GATA4 interact with each other to regulate signal transduction pathways[7, 24, 34]. GATA4 activates the expression of NKX2-5, and both GATA4 and NKX2-5 activate the expression of TBX5[5, 38, 56]. Additionally, the proteins NKX2.5 and MEF2C have been linked to ventricular CM differentiation[6, 33, 51]. TBX5 alone or in combination with GATA4, NKX2.5 and MEF2C regulates the expression of multiple target genes that are critical to the structure and function of the heart, including MYH6, MYH7 and NPPA[11, 64]. Hence RA concentrations may govern gene and protein expression crucially involved in heart morphogenesis (Figure 1B) and modulating RA concentrations may provide a tool to direct CM-differentiation towards LV and RV phenotypes. Based on these studies, we explored a new method of left and right ventricular CM and subsequent EHT generation while optimizing concentration and timing of RA intervention during hiPSC differentiation. Specifically, the first aim of our study was to investigate whether specific concentrations of RA can guide the hiPSCs differentiation towards LV and RV phenotypes. To achieve the goal, we intervened in the differentiation process of hiPSC-CM with different concentration RA during the 3rd to 6th days, according to previously published studies[14, 25]. To verify whether the differentiated hiPSC-CMs were LV and/or RV-like, we derived LV and RV specific marker genes from single-cell RNA sequencing data available in literature, and subsequently analyzed the function and specificity of ventricular marker genes of CMs. The second aim of our study was to investigate whether the LV and RV phenotypes of the iPSC-derived CMs were preserved in EHTs, which more closely mimic functional myocardial tissue. Consequently, the contractile force of EHTs was examined and compared, alongside its responses to hypoxia, β-receptor agonists, and electrical stimulation (Figure 1C). Materials and methods 1. Ethics approval and consent to participate Human heart samples were obtained at the time of transplantation by the Clinic of Cardiac Surgery, Ludwig-Maximilians-University (LMU) Hospital, Munich, Germany. The patients provided informed consent for the scientific use of the explanted tissue and the study was approved by the Ethics Committee of the Ludwigs-Maximilians-University ("New models in cardiovascular research based on myocardial tissue culture", approved on July 4th, 2012 with the registration number 063-12), following the ethical standards of the 1964 Declaration of Helsinki and its later amendments. iPSC cells were derived from skin fibroblasts in the laboratory of Dr Moretti, after informed consent of the patient, and the study was approved by the Ethics Committee of the Medical Faculty of the Technical University of Munich ("Generation and characterization of patient-specific induced pluripotent stem cells" on June 23rd 2008, with registration number 2109/08), following the ethical standards of the 1964 Declaration of Helsinki and its later amendments. 2. Analysis of the fetal heart single-cell RNA sequencing dataset The single-cell RNA sequencing dataset GSE106118 was acquired from GEO[13]. The dataset included human fetal right and left ventricular specimens obtained from aborted fetuses aged 5 to 24 weeks with appropriate informed consent and ethical approval. Differential gene expression analysis was performed using the FindMarkers function in Seurat, and genes with an adjusted P-value 2 were considered differentially expressed. Cell-clustering analyses were performed with the FindClusters function of the “Seurat” package with proper resolutions. The t-distributed stochastic neighbor embedding (t-SNE) was used to display identified cell clusters. The data were automatically annotated through HumanPrimaryCellAtlasData (https://rdrr.io/github/LTLA/celldex/man/HumanPrimaryCellAtlasData.html). In order to increase the accuracy of annotations, the annotation results were rechecked based on highly expressed genes, uniquely expressed genes, and reported canonical cellular markers. 3. Verification of LV and RV marker genes The marker genes for LV and RV were verified in human heart tissue. Transmural sections of left and right ventricular myocardium, measuring 2 × 2 cm2, were obtained from human failing hearts. Upon retrieval, myocardial specimens were immediately placed in cold (4 °C) buffer (136 mM NaCl, 5.4 mM KCl, 1 mM MgCl2, 0.33 mM NaH2PO4, 10 mM glucose, 0.9 mM CaCl2, 30 mM 2,3-butadione-2-monoxime, 5 mM HEPES, pH 7.4)[19]. 4. Cell culture and differentiation of hiPSC-CMs Pluripotent stem cells were obtained by reprogramming somatic cell from two healthy human donors (induced two clones of hiPSC) according to the prescribed methods[39]. Clone 1 derived from skin fibroblasts in the laboratory of Dr Moretti, while clone 2 derived from erythroid progenitors (commercially available). The study participant provided written informed consent and the investigation conformed to the principles outlined in the Declaration of Helsinki. For maintenance culture, hiPSCs were cultured in matrix-coated dishes (Geltrex LDEV-Free, Gibco), using Essential 8 medium (Gibco), which was changed on a daily schedule. Cells were split at 85% confluency, using EDTA for dissociation (Versene solution; Gibco). A cutting-edge differentiation procedure for hiPSC-CMs that employs small molecules to stimulate differentiation was modified by Chen and colleagues[10]. In brief, cardiac differentiation was triggered when the cells reached around 85% confluence by utilizing chemically defined elements for 24 hours (Cardiomyocyte differentiation medium A) and subsequently Cardiomyocyte differentiation medium B (PSC Cardiomyocyte Differentiation Kit; Gibco) for 48 hours. After 72 hours, differentiation of hiPSC-CMs was sustained for 12 days using cardiomyocyte maintenance medium (PSC Cardiomyocyte Differentiation Kit; Gibco), which was refreshed every other day. The role of CM differentiation medium A is to push hiPSCs toward mesodermal commitment via BMP/activin pathway activation and glycogen kinase 3 inhibition, while CM differentiation medium B induces cardiac mesoderm via Wnt inhibition. The function of cardiomyocyte medium maintenance is to mature cardiomyocytes. During the 3rd to 6th days of differentiation, different concentrations of RA (dissolved in DMSO) were introduced into cardiomyocyte maintenance medium (Figure S1A). RA was added in two concentrations: 0.05 µM (LRA, Low concentration retinoic acid) and 0.1 µM (HRA, High concentration retinoic acid), while the control group received the same concentration of DMSO as the other groups, without RA. hiPSC-CMs began to beat spontaneously starting on the 7th or 8th day of the differentiation protocol. Hence, we recorded the beating frequency of each well in each group from day 8 onwards. 5. Primary tissue assembly Differentiated hiPSC-CMs were dissociated with TrypLE Select Enzyme (Gibco) for 8 min, followed by collagenase II (1.5 mg/mL, Sigma-Aldrich) for 7 min. Cells were dispersed in EB6 medium (Table S1) and centrifuged at 390 × g for 5 min. The cell pellet was suspended in EB6 medium to which 0.55 mg/mL bovine collagen I (Gibco), 0.08 mg/mL Geltrex (LDEV-Free, Gibco), and 1% RevitaCell supplement was added (modified from [9]), reaching a cell concentration of 1.1 × 10 5 cells/µL. Subsequently, 55 µL of the cell-matrix mixture was pipetted on a 30 mm organotypic filter (PICMORG50, Merck Millipore) to create a disc approximately 8 mm in diameter and 2 mm in thickness. Following solidification of the tissue disc for 30 minutes at 37 °C, 1 mL of EB6 medium was introduced beneath the filter and replaced every other day for a total of 5 days in culture (Figure S1B). 6. Biomimetic culture of EHT Our team has devised a biomimetic cultivation system for the extended preservation of adult human myocardial slices, which allows precise modulation of preload and afterload, with continuous bipolar stimulation, and medium agitation [19]. This method has also been used for EHT maturation[36] as detailed below. The modified chambers used in this study were constructed using injection molded polystyrene blanks (Proto Labs,Feldkirchen, Germany). The EHTs were stimulated using bipolar, current-controlled electrical pulses with a duration of 2 × 1 ms, amplitude of 50 mA, and a frequency of 1 Hz (60 bpm). The culture system was maintained in a standard incubator (at 37 °C, 3% CO 2 , and 80% humidity) and connected to an external computer via USB, which ran custom software for stimulation control and data acquisition. Further analysis of the data was performed using LabChart Reader software (ADInstruments, Australia). The primary EHTs were transferred from organotypic filters to biomimetic culture chambers (BMCCs, InVitroSys, Gräfelfing, Germany) pre-filled with 2.4 mL of modified EHT culture medium (adapted from[52], Table S2, pre-warmed to 37 °C). The EHTs were positioned in the BMCCs by puncturing their centers with adjacent holding posts, which were then adjusted to a distance of 3 mm to create a ring-shaped EHT that was immediately subjected to electrical stimulation (1 Hz, 50 mA current) and stretch conditioning. To promote EHT maturation and minimize the risk of damage (as demonstrated in our prior work[36]), the EHTs were distended once a day by manually moving the sliding fixation hook (adjustable post) at a rate of 0.16 mm/day for three days. The medium was partially exchanged every other day (with 1.6 mL of fresh medium), which included the addition of 0.1 nmol/L 3,3′,5-triiodo-L-thyronine (Sigma-Aldrich). Eleven independent experiments from two clones were conducted, and EHTs were cultured for 7 days. On the final day of cultivation, various parameters such as contractility and spontaneous beating frequency of EHT under distinct conditions were evaluated. Systolic and diastolic forces (preload) of the EHTs were continuously assessed throughout the whole cultivation period and different stressors were introduced to assess their effect on contractile function of EHTs. Response to increasing contraction frequency: Contraction frequency was altered by modulation of the frequency of electrical stimulation in EHTs. EHTs were electrically stimulated at 1.0 Hz under baseline conditions. In the 1.5 Hz group, electrical stimulation frequency was gradually increased from 1 Hz by 0.1 Hz per minute until the frequency of 1.5 Hz was reached. In the 3.0 Hz group, electrical stimulation frequency was gradually increased from 1.0 Hz by 0.2 Hz per minute until the frequency of 3.0 Hz was reached. Hypoxia: For induction of tissue hypoxia, medium agitation was stopped for a 2-minute interval. Electrical stimulation was maintained at 1.0 Hz and contraction force recording was continued throughout. Response to beta-adrenergic stimulation: Incremental concentrations of the non-selective beta-adrenoceptor agonist isoprenaline (10 -9 to 10 -6 M in Tyrode solution) were added into the BMCC in 2 hours intervals. Contractile force was continuously recorded. Drug-induced changes in generated force, relaxation duration, and contraction duration were determined. 7. Quantitative PCR analysis RNA extraction of heart tissue, iPSC derived CMs and EHTs was carried out with the RNeasy Mini Kit (Qiagen). RNA integrity number (RIN) was determined using Simplinano Spectrophotometer (Biochrom). Equivalent amounts of RNA were reversely transcribed using the QuantiTect Reverse Transcription Kit (Qiagen), according to the manufacturer’s instructions. All qRT-PCR analyses were conducted in duplicate on a StepOnePlus Real-Time PCR System (Applied Biosystems), with the following cycling conditions: a holding stage at 95 °C for 10 min, followed by 40 cycles at 95 °C for 15 s, 60 °C for 1 min, and 72 °C for 15 s. The gene expression results were analyzed using the 2 ^−ΔΔCT method, and glyceraldehyde-3-phosphate dehydrogenase (GAPDH) was used as an endogenous control for mRNA expression. The primer list is available in table S3. 8. RNA Sequencing of EHTs Messenger RNA was purified from total RNA of 3 EHTs per group using poly-T oligo-attached magnetic beads. After fragmentation, the first strand cDNA was synthesized using random hexamer primers, followed by the second strand cDNA synthesis using either dUTP for directional library or dTTP for non-directional library. The library was checked with Qubit and real-time PCR for quantification and bioanalyzer for size distribution detection. Quantified libraries were pooled and sequenced on Illumina platforms, according to effective library concentration and data amount. Raw data (raw reads) of fastq format were first processed through in-house perl scripts. FeatureCounts[32] v1.5.0-p3 was used to count the reads numbers mapped to each gene. Then FPKM of each gene was calculated based on the length of the gene and reads count mapped to this gene. Differential expression[2] analysis was performed using the DESeq2Rpackage (1.20.0). Gene Ontology[61] (GO) enrichment analysis of differentially expressed genes was implemented by the cluster Profiler R package. GO terms with corrected P-value < 0.05 were considered significantly enriched by differential expressed genes. 9. Immunofluorescence staining After being washed with PBS three times, whole cells or tissues were prepared for fixation. Cells and EHTs were placed in 1 mL of a 30% sucrose solution in PBS at 4°C overnight. Subsequently, cells and EHTs were washed for 30 minutes with PBS and permeabilized for 60 minutes with 1% Triton X-100 in PBS. Then, incubated for 1 hour in blocking solution (3% bovine serum albumin and 1% fetal calf serum in PBS). The primary monoclonal anti-α-actinin antibody (sarcomeric, 1:100, Sigma-Aldrich) was incubated in antibody dilution buffer overnight at 4°C. On the next day, samples were incubated with goat anti-mouse IgG (H+L) and a highly cross-adsorbed secondary antibody, Alexa Fluor 546 (Invitrogen), at 1:100 in antibody dilution buffer for 2 hours. Subsequently, cells and tissues were washed with PBS three times for 10 minutes and incubated overnight at 4°C with DAPI (2 µmol/L, Invitrogen). 10. Quantitation and statistical analysis Data are shown as the mean +/- standard error of the mean (SEM). One-way ANOVA and Student's t test were used to test for treatment effects, as appropriate. All statistical analyses were performed with GraphPad Prism 7. Statistical significance was accepted at an error level of P < 0.05. The number of independent experiments performed for each data set was detailed in the figure legends. Results 1. RA signaling and determination of left and right ventricular marker genes in fetal heart In order to determine a potential role for RA signaling in LV/RV differentiation, single cell RNA sequencing data from fetuses aged 5-7 weeks (start of cardiac contraction) were extracted from the GSE106118 dataset (Figure 2A) and further analyzed, separating the LV dataset and RV datasets. Principal component analysis combined with t-distributed stochastic neighbor embedding (t-SNE) showed the distribution of various cell types in the LV and RV being noticeably different (Figures S2A, S2B and S2C). Consistent with a role for RA signalling in differentiation into LV versus RV, expression of genes involved in RA signaling (RARA, RARB and the polycomb repressor 2 subunit SUZ12) was higher in fetal CMs of the LV as compared to the RV (Figure 2B). SUZ12 is known to regulate expression of transcription factors in embryonic development[28, 35], hence, expression of transcription factors and enhancers (TBX5, TBX20, NKX2.5, MEF2C, GATA4, ISL1) was determined within the CM populations. TBX5 and NKX2.5 revealed a significantly higher expression in LV as compared to RV CMs, with very limited expression in other cell types whereas GATA4, TBX20 and ISL1 were higher expressed in the RV CMs as compared to the LV CMs. Expression of MEF2C was exhibited higher in the LV compare to the RV CMs (Figure 2C). Expression of the cardiospecific enzyme CORIN was higher in the LV CMs as compared to the RV CMs. Together with previous studies[49, 63], our data suggest that high expression of TBX5, NKX2.5 and CORIN can be used as markers of left ventricular CMs, whereas TBX20, ISL1 and GATA4 can be used to delineate RV CMs. 2. Validation of marker genes in adult human hearts Expression levels of the above mentioned genes as marker genes for LV and RV was further confirmed in adult human LV and RV. TBX5, NKX2.5 and CORIN showed a higher expression in human LV as compared to RV, while GATA4 and TBX20 showed a higher expression in RV as compared to LV (Figure 2D). Surprisingly, MEF2C has a higher expression in human adult RV, although this may be part of the RV hypertrophic and/or stress response due to LV failure[12]. ISL1, as a marker gene for right ventricular progenitor cells, was not expressed in adult hearts. 3. Effect of RA on hiPSC-CM maturation and differentiation Consistent with previous studies, iPSC culture and differentiation resulted in a network of CM monolayers (Figure S1B), that started to beat spontaneously at day 6-9 of differentiation. Expression of transcription factors TBX5, NKX2.5, MEF2C and the enzyme CORIN was highest in the HRA group (Figure 3A). Conversely, expression of TBX20 and GATA4 was highest in the control group, whereas ISL1 showed the highest expression in LRA group (Figure 3B). These data suggest that RA in a concentration of 0.1μM promoted differentiation towards a LV phenotype, whereas RA concentrations ≤ 0.05 μM promoted differentiation towards an RV like phenotype. RA also promoted maturation of the iPSC-derived CMs, with more organized α-actinin expression in the HRA group (Figure 3C) and higher mRNA expression of cTnT and MYH7 in the HRA group as compared to control, whereas expression of connexin 43 was not different (Figure 3D) at 26 days of differentiation and maturation. The LV primarily derives from the FHF, whereas the RV originates from the SHF. Within the HRA group, a high expression of the FHF marker gene, THBS4, was observed, along with notable expression of HCN4. Contrarily, the SHF marker gene, WNT5A, exhibited high expression within the control group (Figure S3A). The marker gene of ventricle, MLC2V, exhibited high expression in HRA group (Figure S3B). 4. Effect of RA on early iPSC differentiation persists in EHTs: RA improves EHT maturity through altered gene-expression related to cell-cell and cell-matrix interaction. iPSC-derived CMs were further matured into EHTs, to assess whether the differences induced by RA persisted in this maturation step. Immunofluorescence staining revealed a high expression and organization of α-actinin within the HRA-EHTs, leading to enhanced sarcomere visibility (Figure 4A). Consistent with the gene-expression in the iPSC-derived CMs, expression of TBX5, CORIN, MEF2C and NKX2.5 were highest (Figure 4B), while TBX20, GATA4 and ISL1 expression was lower in HRA-EHTs, as compared to control-EHTs (Figure 4C), after 7 days of maturation in the BMCC. Furthermore, markers of maturation and contractile function, cTnT, MYH7 and connexin43 were highest in HRA-EHTs (Figure 4D). To further investigate molecular changes underlying the improved organisation of the EHTs from CMs previously exposed to RA, RNA sequencing was performed. The HRA-EHT revealed differentially abundant genes in the HRA-EHT compared to the control-EHT. We detected 101 and 679 genes upregulated and downregulated (p-value < 0.05 and fold change ≥ 1.3) in the HRA-EHTs respectively. GO enrichment pathway analysis showed upregulation of several genes coding for the ECM remodelling (SerpinB2, F3, TGFa), intermediate filaments and cell-cell junctions (CLD7, OCLN, PPL) (Figures 5A and 5B, Table S4). Volcano plot analysis detected increased expression for several genes which play a vital role in cardiogenesis (Wnt6, BMP2, HOXA1) (Figure 5B)[58]. Furthermore, the significant downregulated genes were primarily linked to the regulation of non-cardiomyocyte differentiation (Figure 5C, Table S5). In the LRA vs Con EHT, 311 and 43 genes were upregulated and downregulated (p-value < 0.05 and fold change ≥ 1.3) in the LRA-EHTs respectively. The GO enrichment pathway analysis did not reveal any significant pathway-changes between these two groups. However, we did observe upregulation of transcription factors (FOSl1, FOSB, HOXA5) using a volcano plot analysis (Figure 5D). Thus, both the comparisons (HRA vs Con and LRA vs Con) identified that RA treatment affected expression of HOX genes. This is a significant finding as HOX genes play a critical role during heart development[46] and several of these Hox genes feature RA-response elements (RAREs) in their enhancers or proximal promoters[1]. Finally, to elucidate the connection between RA pathway and intermediate filaments, extracellular matrix genes and HOX genes, a PPI network analysis was conducted in order to provide additional insight into the RA signalling combining our RNA sequencing data and published data (Figure 5E). The network reveals PPARG as the central hub gene. Numerous groups have presented PPARG as a critical factor in cardiac development but its specific role in inducing left versus right ventricle warrants further studies[42, 65]. 5. Effect of RA on EHT function As EHT matured in BMCC, contractile force gradually increased over time in all groups, especially during the first three days when the preload was gradually increased (Figures 6A&B). Even when corrected for the increased preload using the contractility index (force/preload), the increased contractile force was evident (Figure 6C). On the fourth day in the BMCC, the supplemental preloading was discontinued, and the evaluation of EHT functionality among various groups commenced. Beating frequency was lower and contraction force was consistently higher in HRA-EHTs as compared to the LRA-EHTs and control-EHTs (Figures 6D&E), even after correction for a higher preload, using the contractility index (force/preload) (Figure 6F). The differences in gene expression induced by RA during hiPSC-CM differentiation translated into functional changes, that were persistently present. 6. Response to stress Hypoxia: The response of the EHTs to hypoxia was assessed by stopping the rocking of the BMCC system. The contractile force and beating frequency in HRA-EHTs were more sensitive to hypoxia as compared to the control-EHTs, while the LRA-EHTs showed an intermediate response (Figure 7A). These data are consistent with HRA-EHTs showing a more LV-like phenotype, as the LV has a stronger contractile force and higher oxygen consumption compared to RV[3, 47] β-adrenergic stimulation: The β-adrenoceptor agonist isoprenaline significantly increased the contractile force and beating frequency of the EHTs (Figure 7B). RT-qPCR analysis revealed high expression of the β-adrenoceptor gene, ADRB1, within the HRA-EHT (Figure 7C). The effect of β-adrenergic stimulation was most pronounced in the HRA-EHTs, consistent with observations that expression of β-adrenoceptors is highest in the LV[3]. Altogether, these data confirm a LV-like phenotype of HRA-EHTs and a RV-like phenotype of EHTs from the LRA and control groups. High-frequency electrical stimulation: It has been proposed that increasing the intensity and frequency of electrical stimulation of the EHTs may promote tissue maturation and increase contractile force[45]. The frequency of electrical stimulation of EHTs was therefore gradually increased at day 7 after culture in BMCCs. For control-EHTs, stimulation at higher frequencies damaged the EHTs to such extent that measurements were not possible. For HRA-EHTs, contractile force after 72 hours of electrical stimulation at 1.5 and 3.0 Hz was higher as compared to stimulation at 1.0 Hz, with 3.0 Hz yielding higher contractile force as compared to 1.5 Hz (Figure 7D). Although there was a slight decrease in contractile force after switching to 1.0 Hz electrical stimulation, contractile force was still significantly higher than before applying electrical stimulation (Figure 7E). Discussion In our study, reanalysis of existing single cell sequencing dataset of fetal hearts yielded the characteristics of CMs in 5-7 week fetuses and screened out highly enriched genes of LV (TBX5, NKX2.5 and CORIN) and RV (TBX20 and ISL1) as potential markers of LV and RV development, that were confirmed in human myocardium, and subsequently used to classify hiPSC derived CMs as LV or RV like. We showed that addition of RA in a concentration of 0.1 µM (HRA group) resulted in a LV-like phenotype whereas absence of RA, or RA at a concentration of 0.05 µM (LRA group) resulted in a more RV-like phenotype. iPSCs-derived CMs were subsequently used to generate EHTs. HRA-EHTs showed higher expression of LV-enriched marker genes, higher contractile force and increased sensitivity to β-adrenergic stimulation and hypoxia, whereas control- and LRA-EHTs showed higher expression of RV-marker genes. The implication of our findings will be further discussed below. Being able to control the differentiation of hiPSCs into distinct subtypes of CMs is essential for creating in vitro models of specific cardiovascular diseases and developing innovative treatments[8]. While previous studies have been largely successful, they have often utilized mixed populations of cardiovascular cells, including left ventricular-like cells, as well as small quantities of right ventricular, atrial, and pacemaker-like cells[4, 14, 20]. This approach presents a challenge, as the presence of heterogeneous cell types will significantly impact the outcomes of disease modeling in vitro . To accurately model and treat diseases that impact specific areas of the heart, it is imperative to develop precise differentiation strategies that can generate the specific CMs that belong to the LV or RV. Our results, together with results from previous studies[25, 62] suggest that RA regulates the differentiation of hiPSC into different CM subtypes in a concentration- and time dependent manner. A concentration of RA of 0.1 µM, promoted differentiation of hiPSC towards the left ventricular CMs, while concentrations of RA below 0.05 µM, promoted differentiation of hiPSC towards the right ventricular CMs. With a concentration of RA above 1µM, atrial CMs predominated over ventricular CMs[58]. Our study focused on the differentiation of hiPSCs into left and right ventricular lineages, and we have found that a precise concentration and timing of RA was necessary for left ventricular specification. The RA intervention phase aligned with the developmental stage of heart mesoderm cells and heart precursor cells in our study. Notably, the left ventricular marker genes, TBX5, NKX2.5, and CORIN, exhibited significantly increased expression in the HRA group after 20 days of differentiation. This discovery underscores the critical role of RA in driving hiPSC-CM differentiation towards a left ventricle-like phenotype. However, the precise mechanism through which RA signaling influences cardiac progenitor populations during hiPSC differentiation remains incompletely understood[17]. RA, derived from vitamin A, acts as a lipophilic molecule and serves as a ligand for nuclear RA receptors (RARs)[44], converting them from transcriptional repressors to activators. RA's impact on development and cellular differentiation is mediated through retinoid receptors, which bind to specific DNA sequences called retinoic acid response elements (RAREs), thereby influencing the transcription of target genes[59]. Although the precise methodology through which RA guides hiPSC-CM differentiation toward a right ventricle-like phenotype remains unclear. Our RNA sequencing results identified that RA treatment affected expression of HOX genes in EHTs, which is consistent with observations that HOX genes feature RA-response elements (RAREs) in their enhancers or proximal promoters[1]. As HOX genes have been shown to play a critical role during heart development[46], modulation of HOX may be a potential mechanism by which RA promotes hiPSC-CM differentiation. Furthermore, RA treatment was shown to upregulate expression of the transcription factors TBX5, NKX2.5 and MEF2C, while downregulating TBX20 and GATA4 in iPSC-CM as well as EHTs. These findings are consistent with their expression pattern in the LV and RV in the embryonic heart, and together with the specific ventricular expression pattern of the RA receptors RARA and RARB, provide a mechanism through which CMs are directed towards an LV lineage. The use of primary human CMs derived from patients in in vitro studies poses challenges due to difficulties in their acquisition, preservation, and limited availability, which constrains their broader applicability and development in experimental research[55]. EHT, a product of the marriage of biology and engineering, serves to summarize the extremely complex human physiology. It combines different matrices or scaffolds with different cell types to simulate multicellular heart tissue[41]. The BMCC system used in our study to cultivate EHT is one of the most advanced myocardial biomimetic culture systems. It provided a stable growth environment, nutrient supply, and allowed us to assess EHT functionality by manipulating environmental parameters[57]. The human LV and RV exhibit significant functional and structural differences. The LV has greater contractility, higher oxygen consumption, increased sensitivity to hypoxic environments and pressure loads, but weaker automaticity compared to the RV[43]. In our study, EHTs from the HRA group displayed enhanced contractility, increased oxygen consumption, reduced automaticity, and heightened sensitivity to β-adrenergic stimulation. These findings, coupled with the high expression of left ventricular marker genes in the HRA group, collectively indicate that the left ventricular characteristics of iPSC-CM persist during EHT development, thereby providing an in vitro model for the future study of the LV, particularly in disease modeling, drug screening, precision medicine, and potentially even regenerative medicine[48]. Our study shows that RA treatment modulates the contractile force of EHT by influencing the extracellular matrix, cell-cell junctions and intermediate filament proteins. Our sequencing and functional data underscore the importance of cellular structural components, cell-cell and cell-matrix connectivity for development of cardiac force. The mRNA sequencing results and PPI network analysis suggest that PPARG may play a crucial role in regulating the extracellular matrix of EHT in the context of RA. Indeed, it has been demonstrated that PPARG is important for myocardium development and ventricular septation[65]. Moreover, previous research has established that intermediate filament proteins can directly influence transcription of transcription factors such as NKX2.5, MEF2C thereby exerting an impact on myocardial regeneration and differentiation[40]. Furthermore, EHTs derived from patients suffering from dilated cardiomyopathy showed that the absence of intermediate filament proteins resulted in myocardial tissue dilation, mitochondrial dysfunction, and diminished contractile capabilities[54]. Our research results are in concordance with previous investigations[21, 53], emphasizing that the generation of contractile force by EHTs is governed not only by CMs contractile function, but also by CM-CM and CM- extracellular matrix-connections that may subsequently impact the expression and function of transcription factors. Although the density of the RA concentration gradient used may not fully encompass the range of potentially effective RA concentrations, and future investigations should further identify the exact differentiation pathways by which RA leads to left and right ventricular, as well as atrial CM lineages, we successfully induced hiPSC differentiation into CM and EHT exhibiting left and right ventricle-like characteristics. Our data therefore highlight the structural and functional resemblance between EHTs and myocardial tissue. Conclusion and future perspective The functional and genetic analysis of iPSC-CM and EHT has provided valuable insights in our study. Specifically, the HRA group exhibited significantly elevated expression levels of CM maturation markers, as well as left ventricular markers, while the LRA and control groups showed more pronounced expression of right ventricular markers. Moreover, the EHT derived from the HRA group demonstrated the highest contractility. These compelling findings strongly suggest that intervening in the CM differentiation process with 0.1 mM of RA can effectively facilitate the differentiation of hiPSCs into CMs closely resembling the left ventricular phenotype. The RA signaling pathway exerts intricate control over pivotal transcription factors that play a fundamental role in CM development, likely serving as the molecular mechanism behind RA's facilitation of hiPSC differentiation into left ventricular CMs and subsequent maturation of LV-like EHTs Concurrently, our study substantiated the indispensable role of the extracellular matrix in augmenting the contractile force of EHTs. These collective findings not only deepen our comprehension of cardiac differentiation but also establish a foundation for future investigations into in vitro left and right ventricular function, personalized drug screening, and the advancement of precision medicine. Abbreviations BMCC Biomimetic cultivation chamber BMP Bone morphogenetic protein CM Cardiomyocyte CORIN Corin, serine peptidase CPC Cardiac progenitor cell DMEM Dulbecco's Modified Eagle Medium DMSO Dimethyl sulfoxide E8 Essential 8 EDTA Ethylenediaminetetraacetic acid EHT Engineered heart tissue FGF Fibroblast growth factor FHF First heart field GAPDH Glyceraldehyde-3-phosphate dehydrogenase GATA4 GATA binding protein 4 HAND1 Heart and neural crest derivatives expressed 1 hESC Human embryonic stem cell hiPSC Human induced pluripotent stem cells hiPSC-CM Cardiomyocyte derived from human induced pluripotent stem cell HRA High concentration retinoic acid IGF-1 Insulin-like growth factor 1 IMDM Iscove's Modified Dulbecco's Medium ISL1 ISL LIM homeobox 1 LRA Low concentration retinoic acid LV Left Ventricle MEF2C Myocyte enhancer factor 2C MYH6 Myosin heavy chain 6 MYH7 Myosin heavy chain 7 MYL2 Myosin light chain 2 MYL7 Myosin light chain 7 NKX2.5 NK2 homeobox 5 NPPA Natriuretic peptide A NPPB Natriuretic peptide B NR2F2 Nuclear receptor subfamily 2 group F member 2 PBS Phosphate buffer saline PCR Polymerase chain reaction PFA Paraformaldehyde PPI Protein-protein interaction RA Retinoic acid RAR RA receptors RARE Retinoic acid response elements RIN RNA Integrity number RV Right Ventricle SEM Standard error of the mean SHF Second heart field TBX20 T-box transcription factor 20 TBX5 T-box transcription factor 5 TGF-ß1 Transforming growth factor-β1 transcription factor (TF) t-SNE t-distributed stochastic neighbor embedding VEGF165 Vascular endothelial growth factor isoform 165 WGA Wheat germ agglutinin Declarations Author contributions Daphne Merkus, Payel Sen and Hengliang Zhang conceived the study. Hengliang Zhang and Jules Hamers performed data analysis. Payel Sen and Theresa Sittig performed immunofluorescence experiments. Alessandra Moretti and Andreas Dendorfer provided technical support for hiPSC differentiation. Hengliang Zhang, Payel Sen and Brent Woestenburg performed cell culture and PCR expreiments. Hengliang Zhang and Daphne Merkus wrote the manuscript. All authors read and approved the final version of the manuscript. Funding This work was supported by German Center for Cardiovascular Research (DZHK81Z0600207 to D.M. and P.S.) China Scholarship Council (CSC202108410141) and Henan Provincial Medical Science and Technology Research Project, as well as the Dutch CardioVascular Alliance: An initiative with support of the Dutch Heart Foundation (2020B008 RECONNEXT). Ethical standards All human and animal studies have been approved by the appropriate ethics committee and have therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. All persons gave their informed consent prior to their inclusion in the study. Data Availability Statement All data generated or analyzed during this study are included in this published article and its supplementary information files. The sequencing data of EHT were deposited into the Gene Expression Omnibus (GEO) database under accession number GSE245954 Acknowledgements The authors would like to thank Zhengwu Sun and Claudia Fahney for their support in preparing EHT and cell culture. Conflicts of Interest The authors have no relevant financial or non-financial interests to disclose. References Alexander T, Nolte C, Krumlauf R (2009) Hox genes and segmentation of the hindbrain and axial skeleton. 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Curr Med Sci 40:313-319 doi:10.1007/s11596-020-2184-2 Supplementary Files Supplementary231110.docx TableS4HivsControldegup.xls TableS5HivsControldegdown.xls Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Major Revision 03 Jan, 2024 Reviewers agreed at journal 27 Dec, 2023 Reviewers invited by journal 27 Dec, 2023 Editor assigned by journal 25 Dec, 2023 First submitted to journal 21 Dec, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Merkus","email":"data:image/png;base64,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","orcid":"https://orcid.org/0000-0002-4852-831X","institution":"University Hospital Munich Walter Brendel Centre of Experimental Medicine: LMU Klinikum Walter Brendel Zentrum","correspondingAuthor":true,"prefix":"","firstName":"Daphne","middleName":"","lastName":"Merkus","suffix":""}],"badges":[],"createdAt":"2023-12-20 16:30:51","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3782805/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3782805/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":49022970,"identity":"d8775338-21e4-434b-90d9-6ace35987891","added_by":"auto","created_at":"2024-01-01 10:29:33","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":94351,"visible":true,"origin":"","legend":"\u003cp\u003eRetinoic acid (RA) signaling plays a pivotal role in iPSC differentiation.\u003c/p\u003e\n\u003cp\u003eA RA regulates the differentiation direction of CMs in a concentration dependent manner.\u003c/p\u003e\n\u003cp\u003eB RA regulates hiPSC-CM differentiation direction through left ventricular-specific transcription factors.\u003c/p\u003e\n\u003cp\u003eC Schematic presentation of this study. Gene names with a red colour represent marker genes or/and transcription factor genes. hiPSC: human induced pluripotent stem cell. RA: Retinoic acid. LRA, low concentration RA-- 0.05 µM. HRA, high concentration RA-- 0.1 µM. LV: Left ventricle. RV: Right ventricle. EHT: Engineered heart tissue. CM: Cardiomyocyte.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3782805/v1/b2d536f371c66536b868ecec.png"},{"id":49022969,"identity":"c6e8a9cc-11c5-4b00-951c-be86d8d16577","added_by":"auto","created_at":"2024-01-01 10:29:33","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":106674,"visible":true,"origin":"","legend":"\u003cp\u003eRA signaling and determination of left and right ventricular marker genes.\u003c/p\u003e\n\u003cp\u003eA Introduction to the GSE106118 single cell RNA sequencing dataset.\u003c/p\u003e\n\u003cp\u003eB The genes involved in the RA signalling pathway shows high expression in left ventricular CMs.\u003c/p\u003e\n\u003cp\u003eC The marker genes exhibited different expression between left and right ventricular CMs. B and C: Unpaired t-test between LV and RV. *p \u0026lt; 0.05, **p \u0026lt; 0.05, ***p \u0026lt; 0.001. Exclude the samples which gene expression is 0 in the original data, and all values are converted by log10.\u003c/p\u003e\n\u003cp\u003eD Expression of marker genes in adult humans. Unpaired t-test between RV and LV. *p \u0026lt; 0.05, **p \u0026lt; 0.01.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-3782805/v1/b2784b5fd21b44c39607fd45.png"},{"id":49022972,"identity":"02d215a8-0435-4bc3-815b-3cd8c693611c","added_by":"auto","created_at":"2024-01-01 10:29:33","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":156343,"visible":true,"origin":"","legend":"\u003cp\u003eEffect of RA on hiPSC-CM maturation and differentiation.\u003c/p\u003e\n\u003cp\u003eA. Left ventricular marker genes expressed in hiPSC-CMs.\u003c/p\u003e\n\u003cp\u003eB. Right ventricular marker genes expressed in hiPSC-CMs.\u003c/p\u003e\n\u003cp\u003eC. α-actinin expression in hiPSC-CM. Left: control. Middle: LRA. Right: HRA. Immunofluorescent images of hiPSC-CM cultured for 26 days. Red: α-actinin. Blue: DNA. Scale bar: 200 µm.\u003c/p\u003e\n\u003cp\u003eD. Relative mRNA expression of marker genes of CM maturation.\u003c/p\u003e\n\u003cp\u003eA, B and D: One-way ANOVA, Tukey’s multiple comparison test. *p \u0026lt; 0.05, **p \u0026lt; 0.01, ***p \u0026lt; 0.001, ****p \u0026lt; 0.0001.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-3782805/v1/179b90247a48df0be30f53a4.png"},{"id":49022971,"identity":"ff07cb86-28ce-42cc-a700-dc91e046f94e","added_by":"auto","created_at":"2024-01-01 10:29:33","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":231885,"visible":true,"origin":"","legend":"\u003cp\u003eEffect of RA on early iPSC differentiation persists in EHTs.\u003c/p\u003e\n\u003cp\u003eA. Immunofluorescence images of EHT across various experimental groups are presented. Upper Panel: The spatial distribution of α-actinin exhibits variability across distinct EHT groups. Red: α-actinin. Blue: DNA. Scale bar = 30 µm. Lower Panel: A localized magnification reveals variations in sarcomere quantity and quality within the different experimental groups. Red: α-actinin. Blue: DNA. Scale bar = 10 µm.\u003c/p\u003e\n\u003cp\u003eB. Marker genes of LV expressed in different groups of EHT.\u003c/p\u003e\n\u003cp\u003eC. Marker genes of RV expressed in different groups of EHT.\u003c/p\u003e\n\u003cp\u003eD. Marker genes of CM maturation expressed in different groups of EHT.\u003c/p\u003e\n\u003cp\u003eB-D: One-way ANOVA, Tukey’s multiple comparison test. *p \u0026lt; 0.05, **p \u0026lt; 0.01, ***p \u0026lt; 0.001, ****p \u0026lt; 0.0001.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-3782805/v1/178a819cb1f225283dec5c24.png"},{"id":49022977,"identity":"f0fc39a7-2449-4f6d-b76f-ee71923be91e","added_by":"auto","created_at":"2024-01-01 10:29:33","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":162300,"visible":true,"origin":"","legend":"\u003cp\u003eThe extracellular matrix plays a crucial role in contributing to the contractile force of EHT.\u003c/p\u003e\n\u003cp\u003eA. GO terms illustrating the functional enrichment of upregulated DEGs between the HRA and control group.\u003c/p\u003e\n\u003cp\u003eB. Volcano plot displaying DEGs between HRA and control group.\u003c/p\u003e\n\u003cp\u003eC. GO terms illustrating the functional enrichment of down regulated DEGs between the HRA and control groups.\u003c/p\u003e\n\u003cp\u003eD. Volcano plot displaying DEGs between LRA and control group.\u003c/p\u003e\n\u003cp\u003eE. PPI network illustrating the relationship between RA signaling pathway, transcription factors and the extracellular matrix. The red circle represents protein relevant to the RA signaling pathway. The yellow circle represents transcription factors relevant to ventricular differentiation. The blue circle represents proteins related to the extracellular matrix.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-3782805/v1/e5e0489e65db60bdaef46f02.png"},{"id":49023194,"identity":"02d6740e-298b-4a66-84e3-e98aeffe823a","added_by":"auto","created_at":"2024-01-01 10:37:33","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":69351,"visible":true,"origin":"","legend":"\u003cp\u003eEffect of RA on EHT function\u003c/p\u003e\n\u003cp\u003eA. The contractile force of EHT over time. N = 11.\u003c/p\u003e\n\u003cp\u003eB. The preload force of EHT over time. N = 11.\u003c/p\u003e\n\u003cp\u003eC. The contractile force/preload of EHT over time. N = 11.\u003c/p\u003e\n\u003cp\u003eD. The beating frequency of EHTs on fourth day.\u003c/p\u003e\n\u003cp\u003eE. The contractile force of EHTs on fourth day.\u003c/p\u003e\n\u003cp\u003eF. The preload force and contractile force/preload on fourth day.\u003c/p\u003e\n\u003cp\u003eD-F: One-way ANOVA, Tukey’s multiple comparison test. *p \u0026lt; 0.05, **p \u0026lt; 0.01, ***p \u0026lt; 0.001, ****p \u0026lt; 0.0001.\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-3782805/v1/170bdcf035233c29007c802f.png"},{"id":49023193,"identity":"dfa884dc-1e59-471f-abca-471a56f186c2","added_by":"auto","created_at":"2024-01-01 10:37:33","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":98504,"visible":true,"origin":"","legend":"\u003cp\u003eEHT response to stress.\u003c/p\u003e\n\u003cp\u003eA. The relative change of contractile force and beating frequency after hypoxia in different groups\u003c/p\u003e\n\u003cp\u003eB. The response of EHTs to different concentrations of isoproterenol (Left). N = 11.\u003c/p\u003e\n\u003cp\u003eC. β-adrenoceptor gene expressed in different groups of EHT.\u003c/p\u003e\n\u003cp\u003eD. The contractile force after different electrical stimulation frequencies.\u003c/p\u003e\n\u003cp\u003eE. The contractile force in different electrical stimulation groups over time. N = 8.\u003c/p\u003e\n\u003cp\u003eA, C and D: One-way ANOVA, Tukey’s multiple comparison test. *p \u0026lt; 0.05, **p \u0026lt; 0.01.\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-3782805/v1/0afcf9c06fda5b6b771208dd.png"},{"id":49023298,"identity":"97ab05fc-92a8-40da-a648-d6c28342daa7","added_by":"auto","created_at":"2024-01-01 10:45:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1307917,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3782805/v1/32cfdd6f-d2ca-46be-9059-f7924bc28ee4.pdf"},{"id":49022973,"identity":"4d2bac7f-6c37-4d5e-bcc7-51159d89d219","added_by":"auto","created_at":"2024-01-01 10:29:33","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":2108412,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementary231110.docx","url":"https://assets-eu.researchsquare.com/files/rs-3782805/v1/0ba211c049f15ece36485a43.docx"},{"id":49022978,"identity":"aefdf2f0-2764-448b-99c8-fa4fc2c32f1c","added_by":"auto","created_at":"2024-01-01 10:29:33","extension":"xls","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":48518,"visible":true,"origin":"","legend":"","description":"","filename":"TableS4HivsControldegup.xls","url":"https://assets-eu.researchsquare.com/files/rs-3782805/v1/3113f84d7ef088f7d5fac333.xls"},{"id":49022976,"identity":"2df1ce42-a899-4712-966f-d3012f2318fa","added_by":"auto","created_at":"2024-01-01 10:29:33","extension":"xls","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":252785,"visible":true,"origin":"","legend":"","description":"","filename":"TableS5HivsControldegdown.xls","url":"https://assets-eu.researchsquare.com/files/rs-3782805/v1/93e75627b5a230063c140a73.xls"}],"financialInterests":"","formattedTitle":"Retinoic acid modulation guides human-induced pluripotent stem cell differentiation towards left or right ventricle-like cardiomyocytes","fulltext":[{"header":"Background","content":"\u003cp\u003eCardiomyocytes (CMs), derived from human induced pluripotent stem cells (hiPSC-CMs), and the engineered heart tissue (EHT) derived from these hiPSC-CMs, constitute a highly advantageous \u003cem\u003ein vitro\u003c/em\u003e experimental model for conducting personalized drug screening and advancing regenerative strategies within the realm of precision medicine[27, 37]. However, CMs induced from hiPSCs using traditional methods represent a heterogeneous population comprising both atrial and ventricular cells[29, 63]. Although, earlier studies have effectively accomplished the differentiation of hiPSC-CM into distinct atrial or ventricular phenotypes[14, 30], no prior research has achieved the successful differentiation of hiPSC-CM into EHTs with specific phenotypes corresponding to either the left ventricle (LV) or the right ventricle (RV).\u003c/p\u003e\n\u003cp\u003eRetinoic acid (RA) signaling plays a pivotal role in embryonic development, as it is essential for organizing the trunk and facilitating organogenesis in diverse tissues derived from all three germ layers[16, 22]. In addition to being one of ingredients regulating embryonic development, RA also regulates cardiac development and affects the differentiation of hiPSC-CM into different subtypes, with the direction of differentiation being time- and concentration-dependent[58]\u0026nbsp;(Figure 1A). Previous research has demonstrated that RA concentrations ranging from 1 \u0026micro;M to 5 \u0026micro;M appear to promote hiPSC-CM or heart embryonic differentiation toward atrial CMs\u0026nbsp;[14, 30, 58], whereas a concentration of 0.05 \u0026micro;M appears to promote differentiation towards left ventricular CMs[25]. Other studies found that RA mainly induces epicardial cells at 1 \u0026micro;M to 4 \u0026micro;M[23], while 0.5 \u0026micro;M to 1 \u0026micro;M of RA intervenes in the mesoderm to increase the proportion of atrial CMs[14, 50]. Not only RA concentration, but also the timing of RA intervention is critical, with recent \u003cem\u003ein vivo\u0026nbsp;\u003c/em\u003eand \u003cem\u003ein vitro\u003c/em\u003e findings showing that low RA dosage at the mesoderm induction stage is critical for left ventricular chamber specification[15, 26, 29, 31].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNumerous studies have endeavoured to uncover the regulatory relationships among transcription factors associated with heart development. RA has been shown to operate upstream of the transcription factor TBX5, indirectly modulating its expression[18, 60]. During heart development, the transcription factors TBX5, NKX2.5, and GATA4 interact with each other to regulate signal transduction pathways[7, 24, 34]. GATA4 activates the expression of NKX2-5, and both GATA4 and NKX2-5 activate the expression of TBX5[5, 38, 56]. Additionally, the proteins NKX2.5 and MEF2C have been linked to ventricular CM differentiation[6, 33, 51]. TBX5 alone or in combination with GATA4, NKX2.5 and MEF2C regulates the expression of multiple target genes that are critical to the structure and function of the heart, including MYH6, MYH7 and NPPA[11, 64]. Hence RA concentrations may govern gene and protein expression crucially involved in heart morphogenesis (Figure 1B) and modulating RA concentrations may provide a tool to direct CM-differentiation towards LV and RV phenotypes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBased on these studies, we explored a new method of left and right ventricular CM and subsequent EHT generation while optimizing concentration and timing of RA intervention during hiPSC differentiation. Specifically, the first aim of our study was to investigate whether specific concentrations of RA can guide the hiPSCs differentiation towards LV and RV phenotypes. To achieve the goal, we intervened in the differentiation process of hiPSC-CM with different concentration RA during the 3rd to 6th days, according to previously published studies[14, 25]. To verify whether the differentiated hiPSC-CMs were LV and/or RV-like, we derived LV and RV specific marker genes from single-cell RNA sequencing data available in literature, and subsequently analyzed the function and specificity of ventricular marker genes of CMs. The second aim of our study was to investigate whether the LV and RV phenotypes of the iPSC-derived CMs were preserved in EHTs, which more closely mimic functional myocardial tissue. Consequently, the contractile force of EHTs was examined and compared, alongside its responses to hypoxia, \u0026beta;-receptor agonists, and electrical stimulation (Figure 1C).\u0026nbsp;\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003e\u003cstrong\u003e1. Ethics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHuman heart samples were obtained at the time of transplantation by the Clinic of Cardiac Surgery, Ludwig-Maximilians-University (LMU) \u0026nbsp; Hospital, Munich, Germany. The patients provided informed consent for the scientific use of the explanted tissue \u0026nbsp; and the study was approved by the Ethics Committee of the Ludwigs-Maximilians-University (\u0026quot;New models in cardiovascular research based on myocardial tissue culture\u0026quot;, \u0026nbsp;approved on July 4th, 2012 with the registration number 063-12), following the ethical standards of the 1964 Declaration of Helsinki and its later amendments.\u003c/p\u003e\n\u003cp\u003eiPSC cells were derived from skin fibroblasts in the laboratory of Dr Moretti, after informed consent of the patient, and the study was approved by the Ethics Committee of the Medical Faculty of the Technical University of Munich (\u0026quot;Generation and characterization of patient-specific induced pluripotent stem cells\u0026quot; on June 23rd 2008, with registration number \u0026nbsp; 2109/08), following the ethical standards of the 1964 Declaration of Helsinki and its later amendments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2. Analysis of the fetal heart single-cell RNA sequencing dataset\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe single-cell RNA sequencing dataset GSE106118 was acquired from GEO[13]. The dataset included human fetal right and left ventricular specimens obtained from aborted fetuses aged 5 to 24 weeks with appropriate informed consent and ethical approval. Differential gene expression analysis was performed using the FindMarkers function in Seurat, and genes with an adjusted P-value \u0026lt; 0.05 and a |log-fold change| \u0026gt; 2 were considered differentially expressed. Cell-clustering analyses were performed with the FindClusters function of the \u0026ldquo;Seurat\u0026rdquo; package with proper resolutions. The t-distributed stochastic neighbor embedding (t-SNE) was used to display identified cell clusters. The data were automatically annotated through HumanPrimaryCellAtlasData (https://rdrr.io/github/LTLA/celldex/man/HumanPrimaryCellAtlasData.html). In order to increase the accuracy of annotations, the annotation results were rechecked based on highly expressed genes, uniquely expressed genes, and reported canonical cellular markers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3. Verification of LV and RV marker genes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe marker genes for LV and RV were verified in human heart tissue. Transmural sections of left and right ventricular myocardium, measuring 2\u0026thinsp;\u0026times;\u0026thinsp;2\u0026thinsp;cm2, were obtained from human failing hearts. Upon retrieval, myocardial specimens were immediately placed in cold (4\u0026thinsp;\u0026deg;C) buffer (136\u0026thinsp;mM NaCl, 5.4\u0026thinsp;mM KCl, 1\u0026thinsp;mM MgCl2, 0.33\u0026thinsp;mM NaH2PO4, 10\u0026thinsp;mM glucose, 0.9\u0026thinsp;mM CaCl2, 30\u0026thinsp;mM 2,3-butadione-2-monoxime, 5\u0026thinsp;mM HEPES, pH 7.4)[19].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4. Cell culture and differentiation of hiPSC-CMs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePluripotent stem cells were obtained by reprogramming somatic cell from two healthy human donors (induced two clones of hiPSC) according to the prescribed methods[39]. Clone 1 derived from skin fibroblasts in the laboratory of Dr Moretti, while clone 2 derived from erythroid progenitors (commercially available).\u0026nbsp;The study participant provided written informed consent and the investigation conformed to the principles outlined in the Declaration of Helsinki. For maintenance culture, hiPSCs were cultured in matrix-coated dishes (Geltrex LDEV-Free, Gibco), using Essential 8 medium (Gibco), which was changed on a daily schedule. Cells were split at 85% confluency, using EDTA for dissociation (Versene solution; Gibco). A cutting-edge differentiation procedure for hiPSC-CMs that employs small molecules to stimulate differentiation was modified by Chen and colleagues[10]. In brief, cardiac differentiation was triggered when the cells reached around 85% confluence by utilizing chemically defined elements for 24 hours (Cardiomyocyte differentiation medium A) and subsequently Cardiomyocyte differentiation medium B (PSC Cardiomyocyte Differentiation Kit; Gibco) for 48 hours. After 72 hours, differentiation of hiPSC-CMs was sustained for 12 days using cardiomyocyte maintenance medium (PSC Cardiomyocyte Differentiation Kit; Gibco), which was refreshed every other day. The role of CM differentiation medium A is to push hiPSCs toward mesodermal commitment via BMP/activin pathway activation and glycogen kinase 3 inhibition, while CM differentiation medium B induces cardiac mesoderm via Wnt inhibition. The function of cardiomyocyte medium maintenance is to mature cardiomyocytes. During the 3rd to 6th days of differentiation, different concentrations of RA (dissolved in DMSO) were introduced into cardiomyocyte maintenance medium (Figure S1A). RA was added in two concentrations: 0.05 \u0026micro;M (LRA, Low concentration retinoic acid) and 0.1 \u0026micro;M (HRA, High concentration retinoic acid), while the control group received the same concentration of DMSO as the other groups, without RA. hiPSC-CMs began to beat spontaneously starting on the 7th or 8th day of the differentiation protocol. Hence, we recorded the beating frequency of each well in each group from day 8 onwards.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e5. Primary tissue assembly\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; Differentiated hiPSC-CMs were dissociated with TrypLE Select Enzyme (Gibco) for 8 min, followed by collagenase II (1.5 mg/mL, Sigma-Aldrich) for 7 min. Cells were dispersed in EB6 medium (Table S1) and centrifuged at 390 \u0026times; g for 5 min. The cell pellet was suspended in EB6 medium to which 0.55 mg/mL bovine collagen I (Gibco), 0.08 mg/mL Geltrex (LDEV-Free, Gibco), and 1% RevitaCell supplement was added (modified from\u0026nbsp;[9]), reaching a cell concentration of 1.1 \u0026times; 10\u003csup\u003e5\u003c/sup\u003e cells/\u0026micro;L. Subsequently, 55 \u0026micro;L of the cell-matrix mixture was pipetted on a 30 mm organotypic filter (PICMORG50, Merck Millipore) to create a disc approximately 8 mm in diameter and 2 mm in thickness. Following solidification of the tissue disc for 30 minutes at 37 \u0026deg;C, 1 mL of EB6 medium was introduced beneath the filter and replaced every other day for a total of 5 days in culture (Figure S1B).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6. Biomimetic culture of EHT\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur team has devised a biomimetic cultivation system for the extended preservation of adult human myocardial slices, which allows precise modulation of preload and afterload, with continuous bipolar stimulation, and medium agitation\u0026nbsp;[19]. This method has also been used for EHT maturation[36]\u0026nbsp;as detailed below.\u0026nbsp;The modified chambers used in this study were constructed using injection molded polystyrene blanks (Proto Labs,Feldkirchen, Germany). The EHTs were stimulated using bipolar, current-controlled electrical pulses with a duration of 2 \u0026times; 1 ms, amplitude of 50 mA, and a frequency of 1 Hz (60 bpm). \u0026nbsp;The culture system was maintained in a standard incubator (at 37 \u0026deg;C, 3% CO\u003csub\u003e2\u003c/sub\u003e, and 80% humidity) and connected to an external computer via USB, which ran custom software for stimulation control and data acquisition. Further analysis of the data was performed using LabChart Reader software (ADInstruments, Australia).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; The primary EHTs were transferred from organotypic filters to biomimetic culture chambers (BMCCs, InVitroSys, Gr\u0026auml;felfing, Germany) pre-filled with 2.4 mL of modified EHT culture medium (adapted from[52], Table S2, pre-warmed to 37 \u0026deg;C). The EHTs were positioned in the BMCCs by puncturing their centers with adjacent holding posts, which were then adjusted to a distance of 3 mm to create a ring-shaped EHT that was immediately subjected to electrical stimulation (1 Hz, 50 mA current) and stretch conditioning. To promote EHT maturation and minimize the risk of damage (as demonstrated in our prior work[36]), the EHTs were distended once a day by manually moving the sliding fixation hook (adjustable post) at a rate of 0.16 mm/day for three days. The medium was partially exchanged every other day (with 1.6 mL of fresh medium), which included the addition of 0.1 nmol/L 3,3\u0026prime;,5-triiodo-L-thyronine (Sigma-Aldrich). Eleven independent experiments from two clones were conducted, and EHTs were cultured for 7 days. On the final day of cultivation, various parameters such as contractility and spontaneous beating frequency of EHT under distinct conditions were evaluated.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSystolic and diastolic forces (preload) of the EHTs were continuously assessed throughout the whole cultivation period and different stressors were introduced to assess their effect on contractile function of EHTs.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eResponse to increasing contraction frequency:\u003c/u\u003e Contraction frequency was altered by modulation of the frequency of electrical stimulation in EHTs. EHTs were electrically stimulated at 1.0 Hz under baseline conditions. In the 1.5 Hz group, electrical stimulation frequency was gradually increased from 1 Hz by 0.1 Hz per minute until the frequency of 1.5 Hz was reached. In the 3.0 Hz group, electrical stimulation frequency was gradually increased from 1.0 Hz by 0.2 Hz per minute until the frequency of 3.0 Hz was reached.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eHypoxia:\u003c/u\u003e For induction of tissue hypoxia, medium agitation was stopped for a 2-minute interval. Electrical stimulation was maintained at 1.0 Hz and contraction force recording was continued throughout.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eResponse to beta-adrenergic stimulation:\u003c/u\u003e\u0026nbsp; Incremental concentrations of the non-selective beta-adrenoceptor agonist isoprenaline (10\u003csup\u003e-9\u003c/sup\u003e to 10\u003csup\u003e-6\u0026nbsp;\u003c/sup\u003eM in Tyrode solution) were added into the BMCC in 2 hours intervals. Contractile force was continuously recorded. Drug-induced changes in generated force, relaxation duration, and contraction duration were determined.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e7. Quantitative PCR analysis\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRNA extraction of heart tissue, iPSC derived CMs and EHTs was carried out with the RNeasy Mini Kit (Qiagen). RNA integrity number (RIN) was determined using Simplinano Spectrophotometer (Biochrom). Equivalent amounts of RNA were reversely transcribed using the QuantiTect Reverse Transcription Kit (Qiagen), according to the manufacturer\u0026rsquo;s instructions. All qRT-PCR analyses were conducted in duplicate on a StepOnePlus Real-Time PCR System (Applied Biosystems), with the following cycling conditions: a holding stage at 95 \u0026deg;C for 10 min, followed by 40 cycles at 95 \u0026deg;C for 15 s, 60 \u0026deg;C for 1 min, and 72 \u0026deg;C for 15 s. The gene expression results were analyzed using the 2\u003csup\u003e^\u0026minus;\u0026Delta;\u0026Delta;CT\u003c/sup\u003e method, and glyceraldehyde-3-phosphate dehydrogenase (GAPDH) was used as an endogenous control for mRNA expression. The primer list is available in table S3.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e8. RNA Sequencing of EHTs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; Messenger RNA was purified from total RNA of 3 EHTs per group using poly-T oligo-attached magnetic beads. After fragmentation, the first strand cDNA was synthesized using random hexamer primers, followed by the second strand cDNA synthesis using either dUTP for directional library or dTTP for non-directional library. The library was checked with Qubit and real-time PCR for quantification and bioanalyzer for size distribution detection. Quantified libraries were pooled and sequenced on Illumina platforms, according to effective library concentration and data amount. Raw data (raw reads) of fastq format were first processed through in-house perl scripts. FeatureCounts[32]\u0026nbsp;v1.5.0-p3 was used to count the reads numbers mapped to each gene. Then FPKM of each gene was calculated based on the length of the gene and reads count mapped to this gene. Differential expression[2]\u0026nbsp;analysis was performed using the DESeq2Rpackage (1.20.0). Gene Ontology[61]\u0026nbsp;(GO) enrichment analysis of differentially expressed genes was implemented by the cluster Profiler R package. GO terms with corrected P-value \u0026lt; 0.05 were considered significantly enriched by differential expressed genes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e9. Immunofluorescence staining\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;After being washed with PBS three times, whole cells or tissues were prepared for fixation. Cells and EHTs were placed in 1 mL of a 30% sucrose solution in PBS at 4\u0026deg;C overnight. Subsequently, cells and EHTs were washed for 30 minutes with PBS and permeabilized for 60 minutes with 1% Triton X-100 in PBS. Then, incubated for 1 hour in blocking solution (3% bovine serum albumin and 1% fetal calf serum in PBS). The primary monoclonal anti-\u0026alpha;-actinin antibody (sarcomeric, 1:100, Sigma-Aldrich) was incubated in antibody dilution buffer overnight at 4\u0026deg;C. On the next day, samples were incubated with goat anti-mouse IgG (H+L) and a highly cross-adsorbed secondary antibody, Alexa Fluor 546 (Invitrogen), at 1:100 in antibody dilution buffer for 2 hours. Subsequently, cells and tissues were washed with PBS three times for 10 minutes and incubated overnight at 4\u0026deg;C with DAPI (2 \u0026micro;mol/L, Invitrogen).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e10. Quantitation and statistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; Data are shown as the mean +/- standard error of the mean (SEM). One-way ANOVA and Student\u0026apos;s t test were used to test for treatment effects, as appropriate. All statistical analyses were performed with GraphPad Prism 7. Statistical significance was accepted at an error level of P \u0026lt; 0.05. The number of independent experiments performed for each data set was detailed in the figure legends.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003e1. RA signaling and determination of left and right ventricular marker genes in fetal heart\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn order to determine a potential role for RA signaling in LV/RV differentiation, single cell RNA sequencing data from fetuses aged 5-7 weeks (start of cardiac contraction) were extracted from the GSE106118 dataset (Figure 2A) and further analyzed, separating the LV dataset and RV datasets. Principal component analysis combined with t-distributed stochastic neighbor embedding (t-SNE) showed the distribution of various cell types in the LV and RV being noticeably different (Figures S2A, S2B and S2C). Consistent with a role for RA signalling in differentiation into LV versus RV, expression of genes involved in RA signaling (RARA, RARB and the polycomb repressor 2 subunit SUZ12) was higher in fetal CMs of the LV as compared to the RV (Figure 2B).\u003c/p\u003e\n\u003cp\u003eSUZ12 is known to regulate expression of transcription factors in embryonic development[28, 35], hence, expression of transcription factors and enhancers (TBX5, TBX20, NKX2.5, MEF2C, GATA4, ISL1) was determined within the CM populations. TBX5 and NKX2.5 revealed a significantly higher expression in LV as compared to RV CMs, with very limited expression in other cell types whereas GATA4, TBX20 and ISL1 were higher expressed in the RV CMs as compared to the LV CMs. Expression of MEF2C was exhibited higher in the LV compare to the RV CMs (Figure 2C). Expression of the cardiospecific enzyme CORIN was higher in the LV CMs as compared to the RV CMs. Together with previous studies[49, 63], our data suggest that high expression of TBX5, NKX2.5 and CORIN can be used as markers of left ventricular CMs, whereas TBX20, ISL1 and GATA4 can be used to delineate RV CMs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2. Validation of marker genes in adult human hearts\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eExpression levels of the above mentioned genes as marker genes for LV and RV was further confirmed in adult human LV and RV. TBX5, NKX2.5 and CORIN showed a higher expression in human LV as compared to RV, while GATA4 and TBX20 showed a higher expression in RV as compared to LV (Figure 2D). Surprisingly, MEF2C has a higher expression in human adult RV, although this may be part of the RV hypertrophic and/or stress response due to LV failure[12]. ISL1, as a marker gene for right ventricular progenitor cells, was not expressed in adult hearts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3. Effect of RA on hiPSC-CM maturation and differentiation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; Consistent with previous studies, iPSC culture and differentiation resulted in a network of CM monolayers (Figure S1B), that started to beat spontaneously at day 6-9 of differentiation. Expression of transcription factors TBX5, NKX2.5, MEF2C and the enzyme CORIN was highest in the HRA group (Figure 3A). Conversely, expression of TBX20 and GATA4 was highest in the control group, whereas ISL1 showed the highest expression in LRA group (Figure 3B). These data suggest that RA in a concentration of 0.1\u0026mu;M promoted differentiation towards a LV phenotype, whereas RA concentrations \u0026le; 0.05 \u0026mu;M promoted differentiation towards an RV like phenotype. RA also promoted maturation of the iPSC-derived CMs, with more organized \u0026alpha;-actinin expression in the HRA group (Figure 3C) and higher mRNA expression of cTnT and MYH7 in the HRA group as compared to control, whereas expression of connexin 43 was not different (Figure 3D) at 26 days of differentiation and maturation. The LV primarily derives from the FHF, whereas the RV originates from the SHF. Within the HRA group, a high expression of the FHF marker gene, THBS4, was observed, along with notable expression of HCN4. Contrarily, the SHF marker gene, WNT5A, exhibited high expression within the control group (Figure S3A). The marker gene of ventricle, MLC2V, exhibited high expression in HRA group (Figure S3B).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4. Effect of RA on early iPSC differentiation persists in EHTs: RA improves EHT maturity through altered gene-expression related to cell-cell and cell-matrix interaction.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eiPSC-derived CMs were further matured into EHTs, to assess whether the differences induced by RA persisted in this maturation step. Immunofluorescence staining revealed a high expression and organization of \u0026alpha;-actinin within the HRA-EHTs, leading to enhanced sarcomere visibility (Figure 4A).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Consistent with the gene-expression in the iPSC-derived CMs, expression of TBX5, CORIN, MEF2C and NKX2.5 were highest (Figure 4B), while TBX20, GATA4 and ISL1 expression was lower in HRA-EHTs, as compared to control-EHTs (Figure 4C), after 7 days of maturation in the BMCC. Furthermore, markers of maturation and contractile function, cTnT, MYH7 and connexin43 were highest in HRA-EHTs (Figure 4D).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo further investigate molecular changes underlying the improved organisation of the EHTs from CMs previously exposed to RA, RNA sequencing was performed. The HRA-EHT revealed differentially abundant genes in the HRA-EHT compared to the control-EHT. We detected 101 and 679 genes upregulated and downregulated (p-value \u0026lt; 0.05 and fold change\u0026nbsp;\u0026ge;\u0026nbsp;1.3) in the HRA-EHTs respectively. GO enrichment pathway analysis showed upregulation of several genes coding for the ECM remodelling (SerpinB2, F3, TGFa), intermediate filaments and cell-cell junctions (CLD7, OCLN, PPL) (Figures 5A and 5B, Table S4). Volcano plot analysis detected increased expression for several genes which play a vital role in cardiogenesis (Wnt6, BMP2, HOXA1) (Figure 5B)[58]. \u0026nbsp;Furthermore, the significant downregulated genes were primarily linked to the regulation of non-cardiomyocyte differentiation (Figure 5C, Table S5).\u003c/p\u003e\n\u003cp\u003eIn the LRA vs Con EHT, 311 and 43 genes were upregulated and downregulated (p-value \u0026lt; 0.05 and fold change \u0026ge; 1.3) in the LRA-EHTs respectively. The GO enrichment pathway analysis did not reveal any significant pathway-changes between these two groups. However, we did observe upregulation of transcription factors (FOSl1, FOSB, HOXA5) using a volcano plot analysis (Figure 5D). Thus, both the comparisons (HRA vs Con and LRA vs Con) identified that RA treatment affected expression of HOX genes. This is a significant finding as HOX genes play a critical role during heart development[46] and \u0026nbsp;several of these Hox genes feature RA-response elements (RAREs) in their enhancers or proximal promoters[1].\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; Finally, to elucidate the connection between RA pathway and intermediate filaments, extracellular matrix genes and HOX genes, a PPI network analysis was conducted in order to provide additional insight into the RA signalling combining our RNA sequencing data and published data (Figure 5E). \u0026nbsp; The network reveals PPARG as the central hub gene. Numerous groups have presented PPARG as a critical factor in cardiac development but its specific role in inducing left versus right ventricle warrants further studies[42, 65].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e5. Effect of RA on EHT function\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs EHT matured in BMCC, contractile force gradually increased over time in all groups, especially during the first three days when the preload was gradually increased (Figures 6A\u0026amp;B). Even when corrected for the increased preload using the contractility index (force/preload), the increased contractile force was evident (Figure 6C). On the fourth day in the BMCC, the supplemental preloading was discontinued, and the evaluation of EHT functionality among various groups commenced. Beating frequency was lower and contraction force was consistently higher in HRA-EHTs as compared to the LRA-EHTs and control-EHTs (Figures 6D\u0026amp;E), even after correction for a higher preload, using the contractility index (force/preload) (Figure 6F). The differences in gene expression induced by RA during hiPSC-CM differentiation translated into functional changes, that were persistently present.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6. Response to stress\u003c/strong\u003e\u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eHypoxia:\u003c/em\u003e The response of the EHTs to hypoxia was assessed by stopping the rocking of the BMCC system. The contractile force and beating frequency in HRA-EHTs were more sensitive to hypoxia as compared to the control-EHTs, while the LRA-EHTs showed an intermediate response (Figure 7A). These data are consistent with HRA-EHTs showing a more LV-like phenotype, as the LV has a stronger contractile force and higher oxygen consumption compared to RV[3, 47]\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026beta;-adrenergic stimulation:\u0026nbsp;\u003c/em\u003eThe \u0026beta;-adrenoceptor agonist isoprenaline significantly increased the contractile force and beating frequency of the EHTs (Figure 7B). RT-qPCR analysis revealed high expression of the \u0026beta;-adrenoceptor gene, ADRB1, within the HRA-EHT (Figure 7C). The effect of \u0026beta;-adrenergic stimulation was most pronounced in the HRA-EHTs, consistent with observations that expression of \u0026beta;-adrenoceptors is highest in the LV[3].\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; Altogether, these data confirm a LV-like phenotype of HRA-EHTs and a RV-like phenotype of EHTs from the LRA and control groups.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp; \u0026nbsp; High-frequency electrical stimulation:\u003c/em\u003e It has been proposed that increasing the intensity and frequency of electrical stimulation of the EHTs may promote tissue maturation and increase contractile force[45]. The frequency of electrical stimulation of EHTs was therefore gradually increased at day 7 after culture in BMCCs. For control-EHTs, stimulation at higher frequencies damaged the EHTs to such extent that measurements were not possible. For HRA-EHTs, contractile force after 72 hours of electrical stimulation at 1.5 and 3.0 Hz was higher as compared to stimulation at 1.0 Hz, with 3.0 Hz yielding higher contractile force as compared to 1.5 Hz (Figure 7D). Although there was a slight decrease in contractile force after switching to 1.0 Hz electrical stimulation, contractile force was still significantly higher than before applying electrical stimulation (Figure 7E).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn our study, reanalysis of existing single cell sequencing dataset of fetal hearts yielded the characteristics of CMs in 5-7 week fetuses and screened out highly enriched genes of LV (TBX5, NKX2.5 and CORIN) and RV (TBX20 and ISL1) as potential markers of LV and RV development, that were confirmed in human myocardium, and subsequently used to classify hiPSC derived CMs as LV or RV like. We showed that addition of RA in a concentration of 0.1 µM (HRA group) resulted in a LV-like phenotype whereas absence of RA, or RA at a concentration of 0.05 µM (LRA group) resulted in a more RV-like phenotype. iPSCs-derived CMs were subsequently used to generate EHTs. HRA-EHTs showed higher expression of LV-enriched marker genes, higher contractile force and increased sensitivity to β-adrenergic stimulation and hypoxia, whereas control- and LRA-EHTs showed higher expression of RV-marker genes. The implication of our findings will be further discussed below.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; Being able to control the differentiation of hiPSCs into distinct subtypes of CMs is essential for creating \u003cem\u003ein vitro\u003c/em\u003e models of specific cardiovascular diseases and developing innovative treatments[8]. While previous studies have been largely successful, they have often utilized mixed populations of cardiovascular cells, including left ventricular-like cells, as well as small quantities of right ventricular, atrial, and pacemaker-like cells[4, 14, 20]. This approach presents a challenge, as the presence of heterogeneous cell types will significantly impact the outcomes of disease modeling \u003cem\u003ein vitro\u003c/em\u003e. To accurately model and treat diseases that impact specific areas of the heart, it is imperative to develop precise differentiation strategies that can generate the specific CMs that belong to the LV or RV. Our results, together with results from previous studies[25, 62]\u0026nbsp;suggest that RA regulates the differentiation of hiPSC into different CM subtypes in a concentration- and time dependent manner. A concentration of RA of 0.1 µM, promoted differentiation of hiPSC towards the left ventricular CMs, while concentrations of RA below 0.05 µM, promoted differentiation of hiPSC towards the right ventricular CMs. With a concentration of RA above 1µM, atrial CMs predominated over ventricular CMs[58].\u003c/p\u003e\n\u003cp\u003eOur study focused on the differentiation of hiPSCs into left and right ventricular lineages, and we have found that a precise concentration and timing of RA was necessary for left ventricular specification. The RA intervention phase aligned with the developmental stage of heart mesoderm cells and heart precursor cells in our study. Notably, the left ventricular marker genes, TBX5, NKX2.5, and CORIN, exhibited significantly increased expression in the HRA group after 20 days of differentiation. This discovery underscores the critical role of RA in driving hiPSC-CM differentiation towards a left ventricle-like phenotype. However, the precise mechanism through which RA signaling influences cardiac progenitor populations during hiPSC differentiation remains incompletely understood[17]. RA, derived from vitamin A, acts as a lipophilic molecule and serves as a ligand for nuclear RA receptors (RARs)[44], converting them from transcriptional repressors to activators. RA's impact on development and cellular differentiation is mediated through retinoid receptors, which bind to specific DNA sequences called retinoic acid response elements (RAREs), thereby influencing the transcription of target genes[59].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAlthough the precise methodology through which RA guides hiPSC-CM differentiation toward a right ventricle-like phenotype remains unclear. Our RNA sequencing results identified that RA treatment affected expression of HOX genes in EHTs, which \u0026nbsp;is consistent with observations that HOX genes feature RA-response elements (RAREs) in their enhancers or proximal promoters[1]. As HOX genes have been shown to play a critical role during heart development[46], modulation of HOX may be a potential mechanism by which RA promotes hiPSC-CM differentiation. Furthermore, RA treatment was shown to upregulate expression of the transcription factors TBX5, NKX2.5 and MEF2C, while downregulating TBX20 and GATA4 in iPSC-CM as well as EHTs. These findings are consistent with their expression pattern in the LV and RV in the embryonic heart, and together with the specific ventricular expression pattern of the RA receptors RARA and RARB, provide a mechanism through which CMs are directed towards an LV lineage.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe use of primary human CMs derived from patients in \u003cem\u003ein vitro\u003c/em\u003e studies poses challenges due to difficulties in their acquisition, preservation, and limited availability, which constrains their broader applicability and development in experimental research[55]. EHT, a product of the marriage of biology and engineering, serves to summarize the extremely complex human physiology. It combines different matrices or scaffolds with different cell types to simulate multicellular heart tissue[41]. The BMCC system used in our study to cultivate EHT is one of the most advanced myocardial biomimetic culture systems. It provided a stable growth environment, nutrient supply, and allowed us to assess EHT functionality by manipulating environmental parameters[57]. The human LV and RV exhibit significant functional and structural differences. The LV has greater contractility, higher oxygen consumption, increased sensitivity to hypoxic environments and pressure loads, but weaker automaticity compared to the RV[43]. In our study, EHTs from the HRA group displayed enhanced contractility, increased oxygen consumption, reduced automaticity, and heightened sensitivity to β-adrenergic stimulation. These findings, coupled with the high expression of left ventricular marker genes in the HRA group, collectively indicate that the left ventricular characteristics of iPSC-CM persist during EHT development, thereby providing an \u003cem\u003ein vitro\u003c/em\u003e model for the future study of the LV, particularly in disease modeling, drug screening, precision medicine, and potentially even regenerative medicine[48].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur study shows that RA treatment modulates the contractile force of EHT by influencing the extracellular matrix, cell-cell junctions and intermediate filament proteins. Our sequencing and functional data underscore the importance of cellular structural components, cell-cell and cell-matrix connectivity for development of cardiac force. The mRNA sequencing results and PPI network analysis suggest that PPARG may play a crucial role in regulating the extracellular matrix of EHT in the context of RA. Indeed, it has been demonstrated that PPARG is important for myocardium development and ventricular septation[65]. Moreover, previous research has established that intermediate filament proteins can directly influence transcription of transcription factors such as NKX2.5, MEF2C thereby exerting an impact on myocardial regeneration and differentiation[40]. \u0026nbsp;Furthermore, EHTs derived from patients suffering from dilated cardiomyopathy showed that the absence of intermediate filament proteins resulted in myocardial tissue dilation, mitochondrial dysfunction, and diminished contractile capabilities[54]. Our research results are in concordance with previous investigations[21, 53], emphasizing that the generation of contractile force by EHTs is governed not only by CMs contractile function, but also by CM-CM and CM- extracellular matrix-connections that may subsequently impact the expression and function of transcription factors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAlthough the density of the RA concentration gradient used may not fully encompass the range of potentially effective RA concentrations, and future investigations should further identify the exact differentiation pathways by which RA leads to left and right ventricular, as well as atrial CM lineages, we successfully induced hiPSC differentiation into CM and EHT exhibiting left and right ventricle-like characteristics. Our data therefore highlight the structural and functional resemblance between EHTs and myocardial tissue.\u003c/p\u003e"},{"header":"Conclusion and future perspective","content":"\u003cp\u003eThe functional and genetic analysis of iPSC-CM and EHT has provided valuable insights in our study. Specifically, the HRA group exhibited significantly elevated expression levels of CM maturation markers, as well as left ventricular markers, while the LRA and control groups showed more pronounced expression of right ventricular markers. Moreover, the EHT derived from the HRA group demonstrated the highest contractility. These compelling findings strongly suggest that intervening in the CM differentiation process with 0.1 mM of RA can effectively facilitate the differentiation of hiPSCs into CMs closely resembling the left ventricular phenotype. The RA signaling pathway exerts intricate control over pivotal transcription factors that play a fundamental role in CM development, likely serving as the molecular mechanism behind RA's facilitation of hiPSC differentiation into left ventricular CMs and subsequent maturation of LV-like EHTs Concurrently, our study substantiated the indispensable role of the extracellular matrix in augmenting the contractile force of EHTs. These collective findings not only deepen our comprehension of cardiac differentiation but also establish a foundation for future investigations into \u003cem\u003ein vitro\u003c/em\u003e left and right ventricular function, personalized drug screening, and the advancement of precision medicine.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eBMCC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eBiomimetic cultivation chamber\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eBMP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eBone morphogenetic protein\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eCM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eCardiomyocyte\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eCORIN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eCorin, serine peptidase\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eCPC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eCardiac progenitor cell\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eDMEM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eDulbecco\u0026apos;s Modified Eagle Medium\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eDMSO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eDimethyl sulfoxide\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eE8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eEssential 8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eEDTA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eEthylenediaminetetraacetic acid\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eEHT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eEngineered heart tissue\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eFGF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eFibroblast growth factor\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eFHF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eFirst heart field\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eGAPDH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eGlyceraldehyde-3-phosphate dehydrogenase\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eGATA4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eGATA binding protein 4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eHAND1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eHeart and neural crest derivatives expressed 1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003ehESC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eHuman embryonic stem cell\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003ehiPSC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eHuman induced pluripotent stem cells\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003ehiPSC-CM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eCardiomyocyte derived from human induced pluripotent stem cell\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eHRA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eHigh concentration retinoic acid\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eIGF-1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eInsulin-like growth factor 1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eIMDM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eIscove\u0026apos;s Modified Dulbecco\u0026apos;s Medium\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eISL1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eISL LIM homeobox 1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eLRA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eLow concentration retinoic acid\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eLV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eLeft Ventricle\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eMEF2C \u0026ensp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eMyocyte enhancer factor 2C\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eMYH6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eMyosin heavy chain 6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eMYH7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eMyosin heavy chain 7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eMYL2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eMyosin light chain 2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eMYL7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eMyosin light chain 7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eNKX2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eNK2 homeobox 5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eNPPA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eNatriuretic peptide A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eNPPB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eNatriuretic peptide B\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eNR2F2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eNuclear receptor subfamily 2 group F member 2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003ePBS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003ePhosphate buffer saline\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003ePCR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003ePolymerase chain reaction\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003ePFA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eParaformaldehyde\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003ePPI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eProtein-protein interaction\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eRA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eRetinoic acid\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eRAR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eRA receptors\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eRARE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eRetinoic acid response elements\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eRIN \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eRNA Integrity number\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eRV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eRight Ventricle\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eSEM\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eStandard error of the mean\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eSHF\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eSecond heart field\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eTBX20\u0026ensp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eT-box transcription factor 20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eTBX5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eT-box transcription factor 5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eTGF-\u0026szlig;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eTransforming growth factor-\u0026beta;1 transcription factor (TF)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003et-SNE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003et-distributed stochastic neighbor embedding\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eVEGF165\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eVascular endothelial growth factor isoform 165\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eWGA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.91166077738517%\" valign=\"top\"\u003e\n \u003cp\u003eWheat germ agglutinin\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDaphne Merkus, Payel Sen and Hengliang Zhang conceived the study. Hengliang Zhang and Jules Hamers performed data analysis. Payel Sen and Theresa Sittig performed immunofluorescence experiments. Alessandra Moretti and Andreas Dendorfer provided technical support for hiPSC differentiation. Hengliang Zhang, Payel Sen and Brent Woestenburg performed cell culture and PCR expreiments. Hengliang Zhang and Daphne Merkus wrote the manuscript. All authors read and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by German Center for Cardiovascular Research (DZHK81Z0600207 to D.M. and P.S.) China Scholarship Council (CSC202108410141) and Henan Provincial Medical Science and Technology Research Project, as well as the Dutch CardioVascular Alliance: An initiative with support of the Dutch Heart Foundation (2020B008 RECONNEXT).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical standards\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll human and animal studies have been approved by the appropriate ethics committee and have therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll persons gave their informed consent prior to their inclusion in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article and its supplementary information files. The sequencing data of EHT were deposited into the Gene Expression Omnibus (GEO) database under accession number GSE245954\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank Zhengwu Sun and Claudia Fahney for their support in preparing EHT and cell culture.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAlexander T, Nolte C, Krumlauf R (2009) Hox genes and segmentation of the hindbrain and axial skeleton. Annu Rev Cell Dev Biol 25:431-456 doi:10.1146/annurev.cellbio.042308.113423\u003c/li\u003e\n \u003cli\u003eAnders S, Huber W (2010) Differential expression analysis for sequence count data. 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Curr Med Sci 40:313-319 doi:10.1007/s11596-020-2184-2\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"stem-cell-research-and-therapy","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scrt","sideBox":"Learn more about [Stem Cell Research \u0026 Therapy](http://stemcellres.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/scrt/default.aspx","title":"Stem Cell Research \u0026 Therapy","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Retinoic acid, hiPSC, Cardiomyocyte, Engineered heart tissue, Left ventricle","lastPublishedDoi":"10.21203/rs.3.rs-3782805/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3782805/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground.\u003c/strong\u003e Cardiomyocytes (CMs) derived from human induced pluripotent stem cells (hiPSCs) by traditional methods are a mix of atrial and ventricular CMs and many other non-cardiomyocyte cells. Retinoic acid (RA) plays an important role in regulation of the spatiotemporal development of the embryonic heart.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e Engineered heart tissues (EHTs) were generated by assembling CMs derived from hiPSC (hiPSC-CM) at high cell density in a low collagen hydrogel. Different concentrations of RA (Control group without RA, LRA group with 0.05 µM and HRA group with 0.1 µM) were administered during third to sixth days of the differentiation process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e In the HRA group, hiPSC-CMs exhibited highest expression of maturity genes MYH7 and cTnT. The expression of TBX5, NKX2.5 and CORIN, which are the marker genes for left ventricular CMs, was also the highest in the HRA group. In terms of EHT, the HRA group displayed the highest contraction force, the lowest beating frequency, and the highest sensitivity to hypoxia and isoprenaline, which means it was more functionally similar to the left ventricle. RNAsequencing revealed that the heightened contractility of EHT within the HRA group can be attributed to the promotion of augmented extracellular matrix strength by RA.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e By interfering with the differentiation process of hiPSC with a specific concentration of RA at a specific time, we were able to successfully induce CMs and EHTs with a phenotype similar to that of the left ventricle or right ventricle.\u003c/p\u003e","manuscriptTitle":"Retinoic acid modulation guides human-induced pluripotent stem cell differentiation towards left or right ventricle-like cardiomyocytes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-01 10:29:28","doi":"10.21203/rs.3.rs-3782805/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major Revision","date":"2024-01-04T02:48:45+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2023-12-27T10:16:48+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-12-27T09:38:33+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-12-26T00:15:57+00:00","index":"","fulltext":""},{"type":"submitted","content":"Stem Cell Research \u0026 Therapy","date":"2023-12-22T03:54:54+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"stem-cell-research-and-therapy","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scrt","sideBox":"Learn more about [Stem Cell Research \u0026 Therapy](http://stemcellres.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/scrt/default.aspx","title":"Stem Cell Research \u0026 Therapy","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6896341c-7f1e-4e44-89d4-ea93e8984d26","owner":[],"postedDate":"January 1st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-04-23T22:36:44+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-01 10:29:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3782805","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3782805","identity":"rs-3782805","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}