Name:Jether Marc P.
Gardose
Course:BSE-Biology III-A
INTRODUCTION
Through the 20th century, knowledge of the events occurring during cardiac
development was clouded by conflicting descriptions, coupled with use of notably
different terminologies. Furthermore, not all accounts were based on direct study of
embryonic material, instead being constructed on the basis of interpretations of previous
reports, supported by inferences made from the structure of the congenitally malformed
heart. Such processes, in themselves, are understandable, since it is axiomatic that
proper appreciation of the events occurring during formation of the heart will aid in the
analysis of the morphogenesis of cardiac malformations, this being a desirable
prerequisite in the search for optimal treatment.
Over the past decade, this has all changed. There has been an explosion of work, both
anatomical and molecular, devoted to cardiac development. Advances in technology,
coupled with the use of suitable animal models, now enable us to provide a more
accurate account of the steps involved in formation and septation of the cardiac
chambers. Not all of this new information is concordant with the “classical” accounts. In
these reviews, therefore, we will describe, first, the steps involved in formation of the
primary heart tube, and its conversion to the four cardiac chambers and the paired
arterial trunks. We will then look in greater detail at the events occurring during the
separation of the initial solitary heart tube into discrete systemic and pulmonary
circulations.
DISCUSSION
FORMATION OF THE HEART TUBE
The mesodermal tissues that give rise to the heart first become evident when the
embryo is undergoing the process known as gastrulation. In the human, this occurs
during the third week of development, while for the mouse, at a comparable stage of
development, around seven days will have elapsed from fertilisation, and the embryo
will be in the presomitic stage. The embryonic plate in humans, initially possessing two
layers, is ovoid, and is formed at the union between the yolk sac and the amniotic
cavity. In the midline of the long axis of the oval disc is found the primitive streak, with
the node at its cranial end. Through this streak, cells migrate from the upper layer by the
process called gastrulation to form the three germ layers of the embryo proper: the
ectoderm, the endoderm, and the mesoderm. The mesoderm insinuates between the
ectodermal and endodermal layers, which themselves are continuous with the amnion
and yolk sac, respectively. Having insinuated, the mesoderm spreads laterally and
cranially within the embryonic disc, ultimately giving rise to a variety of structures, such
as the somites, which will produce the axial structures, and the lateral plate mesoderm,
which will form the parietal body wall. The cells that are destined to form the heart are
also derived from this mesodermal layer. They form a crescent virtually at the cranial
border of the disc. As this heart forming region achieves its crescentic shape, the
central region of the ectoderm transforms into the neural plate. This folds to become the
neural tube, with the developing brain at its cranial end. In the human, the developing
heart is initially cranial within the disc relative to the neural folds.
Ventral views of mouse embryos having four, six, and eight somites, respectively
(panels A–C), representing the period from 7 ½12 to 8 days after fertilisation, in which
the myocardium has been labelled blue using a reporter transgene ...
At this stage, the developing heart itself consists of a plate of promyocardial cells,
intermingled with a plexus of endothelial strands, also derived from the cardiac
crescent. The cardiac plate is positioned inferior to the presumptive pericardial cavity,
which has arisen as a space within the mesoderm. With continuing folding of the disc,
this heart forming region is moved into the developing neck of the embryo. The folding
inverts the orientation of the developing heart relative to the neural structures and the
gut. Initially the cardiac plate was inferior to the pericardial cavity but, subsequent to
folding, it also folds into a tube between the pericardial space and the newly formed
foregut that then becomes surrounded by the pericardial space. The process of folding
is driven by the massive growth of the cranial end of the neural tube as it forms the
brain, coupled with invagination of the endoderm to produce the foregut.
These events can now be visualised in animals such as the mouse, with the cardiac
structures demonstrated by the genes and proteins they contain. The location of the
promyocardial cells can be determined from the outset by the expression of NKX 2.5, a
master gene controlling cardiac development.1 The cells can be then be shown by
staining for sarcomeric proteins as they acquire a myocardial phenotype, revealing their
location within the cardiac crescent. The arrangement is somewhat different in mouse
compared to human, since the murine embryonic plate is cup-shaped rather than
discoid, with the endoderm on the outside and the ectoderm on the inside of the cup.
Irrespective of the differences between species, the endothelial plexus, as described
above, is formed at the same time within the cardiac region and within the embryo,
ensuring the presence of a circulatory system. In the cardiac region, this creates the
primary endocardial tube of the heart. The endocardial cells forming the tube come from
both sides of the developing embryo and, as they form a lumen, are enveloped by
myocardial cells, all this occurring within the newly formed pericardial cavity. The
myocardium at this stage, however, does not completely surround the endothelial tube.
Instead, it retains, in its dorsal aspect, continuity with the splanchnic mesoderm of the
developing mediastinum, through the structure known as the dorsal mesocardium.
DEVELOPMENT OF THE HEART TUBE
At this stage, the forming heart is centrally positioned within the embryo, and is
bilaterally symmetrical, taking the shape of an inverted Y. The two arms of the Y,
positioned inferiorly, are continuous with the developing venous tributaries of the
embryo, yolk sac, and placenta. Marking studies, however, have shown that the arms of
the initial primary tube are fated to become the precursors of the atrial chambers, with
the stem of the Y itself becoming the definitive left ventricle. There is no evidence to
support the notion that, from the outset, the “straight heart tube” contains all
components of the definitive cardiac chambers.It is only as the symmetrical arms of the
tube are incorporated caudally into the heart to form the primary atrial component that
there is formation also of a prominent junctional component, the atrioventricular canal.
Subsequent to these changes, the venous tributaries then drain to either side of the
newly formed atrium through the right and left sinus horns. This occurs in symmetrical
fashion in the mouse but, when first seen in the human, the venous tributaries are
already asymmetrical. At the stage when the systemic venous tributaries are already
seen draining to the newly incorporated primary atrium, there is no formation of either
the lungs or the pulmonary vein. Establishment of the pulmonary circulation, and its
connection with the heart, is a later event in development.
By this time, nonetheless, other important changes have been occurring at the cranial
end of the heart tube. Cells from a second cardiogenic area, located posterior to the
dorsal wall of the developing pericardial cavity migrate into the cardiac region, where
they make significant contributions to the developing cranial pole of the heart tube. The
cells from this secondary heart field, first identified as a second crescent within the
embryonic disc, lying contiguous with, but medial to, the primary cardiac crescent, will
populate the outflow tract and the primordium of the right ventricle .
These embryos are photographed in left lateral view. The embryo shown in panel A
carries a transgenic marker for myosin light chain, and shows staining throughout the
derivatives of the primary heart field. Note that the outflow region (arrowed) is only ...
In this embryo, the cells from the secondary heart field, shown in fig 4B4B,, are labelled
with a reporter transgene for fibroblast growth factor 10. As can be seen, the cells from
the secondary field populate the pharyngeal arches, the outflow ...
LOOPING OF THE HEART TUBE
These caudal and cranial additions to the tube produce a pronounced elongation of the
primary heart tube. Associated with this elongation, the dorsal mesocardium, initially
tethering the developing left ventricle to the mediastinum, undergoes disruption and
liberates the larger part of the tube. Once liberated, the tube itself bends to the right as
the start of the process known as looping Looping of the heart tube is usually held to be
the first visual evidence of asymmetry within the embryo, although the atrioventricular
canal is itself formed in asymmetric fashion, with a bulge to the left The signalling
pathway that ensured that the loop bent to the right, however, is established earlier,
during the stage of gastrulation. At this earlier stage, a leftward flow of secreted proteins
across the node is the start of at least two separable pathways. One of these, of which
we currently know very little, ensures that the loop turns in rightward direction. The other
ensures that some organs in the body, including parts of the heart, develop with
morphologically left sided or right sided features. The pathways involve genes including
lefty, nodal, and Pitx2.
Once formed, the ventricular loop itself has inlet and outlet components, with the outlet
part supporting the outflow tract. The outflow tract, in turn, feeds the arteries that arise
from the aortic sac and extend into the increasing number of pharyngeal arches. This
arrangement is seen at around the 25th day in the human, the comparable situation
being the 11th day in the mouse, when there has been formation of about 40 somites.
The stage is now set for formation of the definitive cardiac chambers, along with the
arterial trunks.
FORMATION OF THE CARDIAC CHAMBERS
By the stage of looping, the primary heart tube within the pericardial cavity can be
divided into atrial and ventricular components along with an outflow tract. The atrial and
ventricular components are separated by the atrioventricular canal, which at this stage
has significant length .The systemic venous tributaries, embedded in the substance of
the posterior mediastinum, drain into the unseptated primary atrium. The blood flowing
through the atrial component of the tube must, perforce, traverse the entirety of the
ventricular loop so as to reach the outflow tract. This developing outflow component is
supported by the distal, or outlet, component of the ventricular loop. By this stage, a
constriction, which marks the site of the primary interventricular foramen, has developed
between the inlet and outlet parts of the ventricular loop, which will become the left and
right ventricles, respectively. The myocardial walls of the heart tube at this stage are
formed of so-called primary myocardium. With further development, pronounced
changes occur in all parts of the tube so as to produce separate left and right
components. These changes occur over the same period of time but, for convenience,
we will describe them sequentially.
This sagittal section is from a human embryo at Carnegie stage 14. It shows the
developing left ventricle in communication with the atrial component of the primary heart
tube through the atrioventricular canal, which at this stage has considerable length. ...
FORMATION OF THE ATRIUMS
Completion of the development of the left atrium requires formation of the lungs and the
pulmonary vasculature. The lungs themselves develop as outpouchings from the
trachea. As the lung buds form, a plexus of vessels develops around them. The plexus
establishes a connection with the primary atrial component of the heart tube via the
pulmonary vein. Initially seen as an endothelial strand within the mediastinum, the
initially solitary vein makes contact with the heart through the dorsal mesocardium .By
this time, the asymmetry of the systemic venous tributaries has become exaggerated,
with the left sinus horn, cradling the developing pulmonary vein, becoming incorporated
in the left side of the atrioventricular junction but opening into the right side of the
primary atrium. The left horn always maintains its own walls within the left
atrioventricular junction, separate from those of the primary atrium. When viewed
internally, the junction between the systemic venous tributaries and the primary atrium
can now be recognised because of the formation of the venous valves. The opening of
the solitary pulmonary vein is now seen in the left and inferior part of the primary atrium,
positioned between the folds that mark the site of the persisting dorsal mesocardium
.Concomitant with these changes, the superolateral walls of the atrial component of the
primary heart tube have ballooned out to either side of the outflow tract to form the atrial
appendages. It is formation of the two appendages that first differentiates the
morphologically right and left sides of the primary atrium. This morphological sidedness
is under the control of the pathways discussed above, mediated finally by Pitx2. The
right appendage is extensive. As the systemic venous sinus is incorporated within the
forming right atrium, it insinuates itself between the appendage and the developing
primary septum. The appendage is continuous distally with the expanding vestibule of
the right atrium, formed by incorporation of the musculature of the atrioventricular canal
into the developing atriums. Within the left atrium, a much larger contribution to the
definitive chamber is made by the atrial component of the primary tube, from which the
left appendage arises as a narrow outpouching positioned superiorly and to the left . As
with the developing right atrium, part of the initial atrioventricular canal becomes
incorporated into the definitive left atrium as the vestibule of the mitral valve. The
pulmonary venous component, when first formed in the human, is relatively insignificant,
since a solitary vein opens inferiorly . Only subsequent to septation does the venous
component expand to form the roof of the left atrium, eventually producing the definitive
arrangement with four venous orifices.
FORMATION OF THE VENTRICLES
The ventricles are derived from the ventricular loop. Initially, the ventricular part of the
primary tube was formed by the stem of the Y shaped heart tube, derived from the
primary cardiac crescent, and by a distal part that received significant contributions from
the secondary heart field. At this stage, all the blood from the atrial segment was
required to pass through these two parts of the primary tube so as to reach the outflow
tract. As the tube bent, the primary interventricular foramen became obvious between
its two components. After looping, the tube itself has an inner and an outer curvature.
Pronounced changes occur in both of these curves. The apical parts of the two
ventricles balloon from the outer curve, with the inlet part of the primary tube giving rise
to the developing apical part of the left ventricle, and the outlet part being the origin of
the developing apical component of the right ventricle. The beginnings of formation of
the apical part of the left ventricle are seen even before looping. Once formed, the new
myocardium can readily be distinguished from the primary myocardium by its
expression of atrial natriuretic factor. The apical part of the right ventricle appears
subsequently, ballooning from the outlet limb of the primary tube .It is the trabeculations
of these outpouchings that eventually give the definitive ventricles their characteristic
morphology. Unlike the atrial chambers, the morphological differences between the two
ventricles are not a reflection of left–right asymmetry. It is more likely that they reflect
the spatio-temporal development of the ventricles in series within the ventricular
component of the primary heart tube.
The changes that occur within the inner curve ensure that each apical part achieves its
own inlet and outlet component. When ballooning of the apical components
commences, the walls of the atrioventricular canal are joined almost exclusively to the
developing left ventricle, while the outlet component of the heart tube is supported
almost entirely by the developing right ventricle . At this stage, the myocardium
surrounding the interventricular foramen itself, the so-called primary ring can be
distinguished within the primary myocardium by its expression of the GlN epitope.
Tracing this primary ring over a period of time demonstrated the remodelling of the
ventricular segment of the inner heart curvature, along with its junction with the
atrioventricular canal proximally and the outlet component distally. This remodelling
permits the separating atriums, and the dividing outflow tract, to be shared between the
developing apical components of the left and right ventricles. Sharing of the atriums
between the ventricles requires expansion of the atrioventricular canal. From the outset,
the wall of the developing right atrium is continuous in the inner curvature, via the
primary fold, with the wall of the outflow tract. All that is required for the cavity of the
right atrium to achieve direct continuity with that of the developing right ventricle,
therefore, is expansion of the atrioventricular canal. Subsequent to expansion, and
concomitant with the development of the insulating plane between the atrial and
ventricular chambers, the musculature of the right side of the atrioventricular canal itself
then becomes incorporated into the right atrium as the vestibule of the tricuspid valve.
The inlet of the right ventricle, contiguous with the vestibule of the tricuspid valve,
develops within the ventricular component of the primary heart tube, specifically in the
part delineated as the primary ring by its expression of GlN. The leaflets of the tricuspid
valve delaminate from the myocardial walls of the primary tube, incorporating the
endocardial cushions in their substance . The cavity of the left atrium is continuous with
that of the developing left ventricle from the outset. As with the right side, the
musculature of the atrioventricular canal becomes sequestrated within the atrium
subsequent to formation of the atrioventricular plane of insulation, the leaflets of the
mitral valve delaminating within the inlet component of the left ventricle in a fashion
comparable to the formation of the tricuspid valve . Completion of left ventricular
development requires that half of the proximal part of the initial outflow tract be
transferred from its initial location above the developing right ventricle to form the aortic
vestibule, leaving the remainder of the outflow tract as the subpulmonary infundibulum.
This change, obviously, requires that significant changes occur also within the outflow
tract itself.
FORMATION OF THE ARTERIAL TRUNKS
The outlet component of the primary heart tube, extending from the distal part of the
ventricular loop to the distal extent of the pericardial cavity where it joins the aortic sac,
is initially a structure with exclusively myocardial walls, and with distal and proximal
parts separated by a characteristic bend . Due to processes as yet undetermined, the
walls of the distal outflow change rapidly from this myocardial phenotype to an arterial
one . Concomitant with the changes, the initially solitary tube seen distally is replaced
by the intrapericardial portions of the ascending aorta and the pulmonary trunk. The
proximal part also separates into two components, again losing its myocardial
phenotype, with the arterial valvar leaflets and their supporting arterial sinuses formed
just proximal to the bend, which marks the site of formation of the definitive sinutubular
junctions . The most proximal part of the outflow tract is then itself separated by fusion
of the cushions within it, new myocardium forming within the cushions to produce the
medial part of the subpulmonary infundibulum, which retains its origin from the right
ventricle. At the same time, the subaortic part of the outflow segment is partitioned to
the left ventricle by the fusion of the cushions to the crest of the muscular ventricular
septum, the myocardium of the initial inner heart curvature eventually disappearing to
permit fibrous continuity between the leaflets of the aortic and mitral valves in the
ventricular roof.
