Cardiac Regeneration in the Human Left Ventricle After CorMatrix Implantation Alice Ferng, PhD, Alana Connell, MD, Martha Nunez, BS, Kitsie Johnson, BS,

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Cardiac Regeneration in the Human Left Ventricle After CorMatrix Implantation Alice Ferng, PhD, Alana Connell, MD, Martha Nunez, BS, Kitsie Johnson, BS, Beth Braunhut, MD, Scott Lick, MD, Ankit Desai, MD, Toshinobu Kazui, MD, Ray Runyan, PhD, Zain Khalpey, MD, PhD The Annals of Thoracic Surgery Volume 104, Issue 3, Pages e239-e241 (September 2017) DOI: 10.1016/j.athoracsur.2017.03.044 Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Intraoperative images showing position of left ventricular apical CorMatrix patch after explantation of HeartMate II. (A) Heart before removal of CorMatrix. After patient had HeartMate II left ventricular assist device (LVAD) explanted, CorMatrix was placed on heart for closure of defects in (B) the left ventricular apex and aorta. After 3 months, the patient required a HeartWare LVAD implant as destination therapy, and during this procedure CorMatrix biopsy specimens were taken for analysis. White arrows denote where the CorMatrix patch is visible. (C and D) CorMatrix biopsy samples were specifically taken from the aorta and the rim of the device. The Annals of Thoracic Surgery 2017 104, e239-e241DOI: (10.1016/j.athoracsur.2017.03.044) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Excised 3-month-old CorMatrix from left ventricular apex. (A) H&E-stained sections show mature cardiac myocytes in a background of dense fibrotic stroma (×100). The myocytes have conspicuous cross-striations and frequent vacuolar cytoplasmic change. No coagulative necrosis or wavy fibers are seen; however, hypereosinophilic fibers are apparent on the right. Myocyte nuclei are readily apparent throughout, and size is normal to slightly enlarged. In area of hypereosinophilic change, myocyte nuclei are hyperchromatic. Blood vessels are regularly distributed within interstitium. (B) On higher power (×200), myocyte cross-striations are readily apparent, as is cytoplasmic vacuolization. Cardiomyocytes are present within dense fibrotic stroma, shown by black arrows. Blood vessels are regularly distributed and appear normal. Biopsy specimens of the aorta CorMatrix stained with hematoxylin and eosin (C) and trichrome (D) show elastin and collagen growth patterns comparable to those found in normal aortic histologic patterns. The Annals of Thoracic Surgery 2017 104, e239-e241DOI: (10.1016/j.athoracsur.2017.03.044) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 CorMatrix sections from the apex, but not from the aorta, stained positive for anti-HOPX antibodies, suggestive of cardiomyoblastic growth in regenerating cardiac tissue. Hoechst staining was used to stain for DNA of fixed cells (left panel), while anti-HOPX staining was used to identify which of those cells were new cardiomyoblasts (middle panel). Samples from the aorta were negative for anti-HOPX staining (data not shown). The right panel shows the overlay of both stains, which demonstrates in vivo cardiac tissue regeneration within the left ventricular apical CorMatrix patch. The Annals of Thoracic Surgery 2017 104, e239-e241DOI: (10.1016/j.athoracsur.2017.03.044) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions