This work was supported and funded under the QREN project 2013/30196, the &#34;la Caixa&#34; Banking Foundation, the Funda&#231;&#227;o para a Ci&#234;ncia e Tecnologia (FCT) project, LCF/PR/HP17/52190002. JS and EB were supported by the European Union&#39;s Horizon 2020 research and innovation program&#160;under the Marie Sklodowska-Curie grant agreement no.&#160;813716. PdCM was supported by the Stichting Life Sciences Health (LSH)-TKI project MEDIATOR (LSHM 21016).

The animal experiments were performed at the Experimental Surgery laboratory in the University of Porto, Cardiovascular Research and Development Centre (UnIC, Porto, Portugal). The institutional animal ethics committee approved the study in accordance with the National Authority for Animal Health (Direc&#231;&#227;o-Geral de Alimenta&#231;&#227;o e Veterin&#225;ria, DGAV, Ref: 2021-07-30 011706 0421/000/000/2021). The experimenters were either licensed (FELASA-equivalent Laboratory Animal Sciences authorization) or were ...

Ascending Aortic Banding for Studying Pressure-Overload Induced Heart Failure

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	<li>Savarese, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Global+burden+of+heart+failure:+a+comprehensive+and+updated+review+of+epidemiology.">Global burden of heart failure: a comprehensive and updated review of epidemiology.</a> Cardiovascular Research. 118 (17), 3272-3287 (2023).</li><li>Hartley, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Trends+in+mortality+from+aortic+stenosis+in+Europe:+2000-2017.">Trends in mortality from aortic stenosis in Europe: 2000-2017.</a> Frontiers in Cardiovascular Medicine. 8, 748137 (2021).</li><li>Silva, K. A. S., Emter, C. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Large+Animal+models+of+heart+failure:+a+translational+bridge+to+clinical+success.">Large Animal models of heart failure: a translational bridge to clinical success.</a> Journal of the American College of Cardiology: Basic to Translational Science. 5 (8), 840-856 (2020).</li><li>Brink, C. B., Lewis, D. I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+12+Rs+framework+as+a+comprehensive,+unifying+construct+for+principles+guiding+animal+research+ethics.">The 12 Rs framework as a comprehensive, unifying construct for principles guiding animal research ethics.</a> Animals (Basel). 13 (7), 1128 (2023).</li><li>Choy, J. S., Zhang, Z. D., Pitsillides, K., Sosa, M., Kassab, G. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Longitudinal+hemodynamic+measurements+in+swine+heart+failure+using+a+fully+implantable+telemetry+system.">Longitudinal hemodynamic measurements in swine heart failure using a fully implantable telemetry system.</a> PLoS One. 9 (8), 103331 (2014).</li><li>Ishikawa, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Increased+stiffness+is+the+major+early+abnormality+in+a+pig+model+of+severe+aortic+stenosis+and+predisposes+to+congestive+heart+failure+in+the+absence+of+systolic+dysfunction.">Increased stiffness is the major early abnormality in a pig model of severe aortic stenosis and predisposes to congestive heart failure in the absence of systolic dysfunction.</a> Journal of the American Heart Association. 4 (5), 001925 (2015).</li><li>Emter, C. A., Baines, C. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Low-intensity+aerobic+interval+training+attenuates+pathological+left+ventricular+remodeling+and+mitochondrial+dysfunction+in+aortic-banded+miniature+swine.">Low-intensity aerobic interval training attenuates pathological left ventricular remodeling and mitochondrial dysfunction in aortic-banded miniature swine.</a> American Journal of Physiology-Heart and Circulatory Physiology. 299 (5), H1348-H1356 (2010).</li><li>Brito, J., Raposo, L., Teles, R. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Invasive+assessment+of+aortic+stenosis+in+contemporary+practice.">Invasive assessment of aortic stenosis in contemporary practice.</a> Frontiers in Cardiovascular Medicine. 9, 1007139 (2022).</li><li>Tan, W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+Porcine+model+of+heart+failure+with+preserved+ejection+fraction+induced+by+chronic+pressure+overload+characterized+by+cardiac+fibrosis+and+remodeling.">A Porcine model of heart failure with preserved ejection fraction induced by chronic pressure overload characterized by cardiac fibrosis and remodeling.</a> Frontiers in Cardiovascular Medicine. 8, 677727 (2021).</li><li>Bikou, O., Miyashita, S., Ishikawa, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pig+model+of+increased+cardiac+afterload+induced+by+ascending+aortic+banding.">Pig model of increased cardiac afterload induced by ascending aortic banding.</a> Methods in Molecular Biology. 1816, 337-342 (2018).</li><li>Lelovas, P. P., Kostomitsopoulos, N. G., Xanthos, T. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+comparative+anatomic+and+physiologic+overview+of+the+porcine+heart.">A comparative anatomic and physiologic overview of the porcine heart.</a> Journal of the American Association for Laboratory Animal Science. 53 (5), 432-438 (2014).</li><li>Tian, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Supra-coronary+aortic+banding+improves+right+ventricular+function+in+experimental+pulmonary+arterial+hypertension+in+rats+by+increasing+systolic+right+coronary+artery+perfusion.">Supra-coronary aortic banding improves right ventricular function in experimental pulmonary arterial hypertension in rats by increasing systolic right coronary artery perfusion.</a> Acta Physiologica (Oxf). 229 (4), 13483 (2020).</li><li>Sorensen, M., Hasenkam, J. M., Jensen, H., Sloth, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Subcoronary+versus+supracoronary+aortic+stenosis.+An+experimental+evaluation.">Subcoronary versus supracoronary aortic stenosis. An experimental evaluation.</a> Journal of Cardiothoracic Surgery. 6, 100 (2011).</li><li>Lygate, C. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Serial+high+resolution+3D-MRI+after+aortic+banding+in+mice:+band+internalization+is+a+source+of+variability+in+the+hypertrophic+response.">Serial high resolution 3D-MRI after aortic banding in mice: band internalization is a source of variability in the hypertrophic response.</a> Basic Research in Cardiology. 101 (1), 8-16 (2006).</li><li>Jalal, Z., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Unexpected+Internalization+of+a+Pulmonary+Artery+Band+in+a+Porcine+Model+of+Tetralogy+of+Fallot.">Unexpected Internalization of a Pulmonary Artery Band in a Porcine Model of Tetralogy of Fallot.</a> World Journal for Pediatric and Congenital Heart Surgery. 8 (1), 48-54 (2017).</li></ol>

In recent years, several studies have utilized surgical aortic banding as a model for left ventricular pressure overload and heart failure (descending9 to the ascending aorta10), allowing researchers to obtain various phenotypes tailored to their specific needs. Although using such models requires costly equipment and specialized knowledge, the information they provide is invaluable. Swine, due to its size and similarity to the human heart, serves as an ideal model<sup clas...

Heart failure (HF) is a life-threatening disease that affects millions of people worldwide, causing major social and economic impacts1. One of its significant etiologies is aortic valve disease or aortic stenosis (AS). Aortic stenosis is more prevalent in advanced age and ranks as the second most common valvular lesion in the United States. AS-related mortality has also increased in Europe, particularly in countries without access to recent interventional procedures2. Given the complexity of HF and the scarcity of therapeutic innovations, there is a pressing need for reliable animal models that can replicate the human condition and facilitate the testing of new interventions3. While rodent models outnumber large animal models, the latter offers several advantages due to their size and physiological similarities, allowing the testing of drug doses and medical devices intended for human use.
The aim of this method is to establish a reproducible model of ascending aortic banding (AAB) applicable to most large animal species used in biomedical research. In this study, the procedure is demonstrated in swine using a minimally invasive approach, adhering to the 3Rs principles (replacement, reduction, and refinement4). This approach ensures the creation of an accurate pressure gradient, resulting in high reproducibility (potentially reducing the number of required animals). Additionally, the small surgical incision (2-3 cm) minimizes surgical insult, improving animal well-being compared to more aggressive approaches like sternotomy and larger thoracotomies5 (refinement). Furthermore, providing a video demonstration of the method, along with detailed descriptions in the literature, could potentially reduce the need for animals used solely for training purposes (replacement), further decreasing animal usage. This model can be adapted for different swine strains/breeds with distinct growth rates and induces sustained pressure overload, leading to significant hypertrophy after 1 or 2 months of follow-up.
Current methods employ fixed stenosis6, disregarding animal size variability, or calculate gradient using fluid-filled pressure readings7, which are less reliable than high-fidelity pressure sensors and are susceptible to signal damping8. Another approach uses a single pressure measurement distal to the stenosis5. However, calibrating the stenosis through simultaneous proximal and distal pressure signals using percutaneously delivered high-fidelity pressure sensors represents a substantial optimization of the protocol, resulting in improved group homogeneity. By visually demonstrating this method, other researchers should be able to replicate it without significant obstacles, increasing the availability of this model while promoting the application of the 3Rs principles.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>3-0 PDS II suture</td>
			<td>Ethicon</td>
			<td>Z683G</td>
			<td>Aorta banding</td>
		</tr>
		<tr>
			<td>5-0 prolene</td>
			<td>Ethicon</td>
			<td>7472H</td>
			<td>Aorta banding</td>
		</tr>
		<tr>
			<td>ACUSON NX2 Ultrasound System</td>
			<td>Siemens</td>
			<td>(240)11284381</td>
			<td>Vascular Access and Echocardiography</td>
		</tr>
		<tr>
			<td>Arterial Extension 200 cm</td>
			<td>PMH</td>
			<td>303.0666</td>
			<td>Anesthesia Maintenance</td>
		</tr>
		<tr>
			<td>Atlan A300 Ventilator</td>
			<td>Draeger</td>
			<td>8621300</td>
			<td>Ventilation</td>
		</tr>
		<tr>
			<td>Bone cutters</td>
			<td>Fehling</td>
			<td>AMP 367.00</td>
			<td>Aorta banding</td>
		</tr>
		<tr>
			<td>Cefazolin 1000 mg</td>
			<td>Labesfal</td>
			<td>100063</td>
			<td>Antibiotic</td>
		</tr>
		<tr>
			<td>Chlorhexidine 4% Wash Solution</td>
			<td>AGA</td>
			<td>19110008</td>
			<td>Cleaning</td>
		</tr>
		<tr>
			<td>Doyen Intestinal Forceps</td>
			<td>Aesculap</td>
			<td>EA121R</td>
			<td>Intubation</td>
		</tr>
		<tr>
			<td>Echogenic Introducer Needle</td>
			<td>Teleflex</td>
			<td>AN-04318</td>
			<td>Vascular Access</td>
		</tr>
		<tr>
			<td>Endotracheal tube</td>
			<td>Intersurgical</td>
			<td>8040070</td>
			<td>Intubation</td>
		</tr>
		<tr>
			<td>ePTFE vascular graft (5 mm x 40 cm)</td>
			<td>GORE-TEX</td>
			<td>S0504</td>
			<td>Aorta banding</td>
		</tr>
		<tr>
			<td>Extension line 100 cm</td>
			<td>PMH</td>
			<td>303.0394</td>
			<td>Anesthesia Induction</td>
		</tr>
		<tr>
			<td>F.O. Laryngoscope</td>
			<td>Luxamed</td>
			<td>E1.317.012</td>
			<td>Intubation</td>
		</tr>
		<tr>
			<td>F.O. Miller Blade 4 204 x 17 mm</td>
			<td>Luxamed</td>
			<td>3</td>
			<td>Intubation</td>
		</tr>
		<tr>
			<td>Fenestrated Sterile Drape</td>
			<td>Bastos Viegas</td>
			<td>4882-256</td>
			<td>Aseptic Technique</td>
		</tr>
		<tr>
			<td>Fentanyl 0.5 mg/10 mL</td>
			<td>B.Braun</td>
			<td>5758883</td>
			<td>Anesthesia / Analgesia</td>
		</tr>
		<tr>
			<td>Guidewire 260 cm J-tip</td>
			<td>B.Braun</td>
			<td>J3 FC-FS 260-035</td>
			<td>Left Ventricle catheterization</td>
		</tr>
		<tr>
			<td>Infusomat Space Infusion Pump</td>
			<td>B.Braun</td>
			<td>24101800</td>
			<td>Fluids / Drug administration</td>
		</tr>
		<tr>
			<td>Intercostal retractor</td>
			<td>Fehling Surgical</td>
			<td>MRP-1</td>
			<td>Thoracotomy</td>
		</tr>
		<tr>
			<td>Introcan Certo IV Catheter 20G</td>
			<td>B.Braun</td>
			<td>4251326</td>
			<td>Fluids / Drug administration</td>
		</tr>
		<tr>
			<td>Isotonic Saline Solution 0.9%</td>
			<td>B.Braun</td>
			<td>5/44929/1/0918</td>
			<td>Fluids / Drug administration</td>
		</tr>
		<tr>
			<td>Ketamidor 100 mg/mL</td>
			<td>Richter pharma</td>
			<td>1121908AB</td>
			<td>Anesthesia Induction</td>
		</tr>
		<tr>
			<td>L10-5v Linear Transducer</td>
			<td>Siemens</td>
			<td>11284481</td>
			<td>Vascular Access</td>
		</tr>
		<tr>
			<td>Midazolam 15 mg/3 mL</td>
			<td>Labesfal</td>
			<td>PLB762-POR/2</td>
			<td>Anesthesia Induction</td>
		</tr>
		<tr>
			<td>Mikro-cath</td>
			<td>Millar</td>
			<td>63405(1)</td>
			<td>Pressure recording</td>
		</tr>
		<tr>
			<td>MP1 guide catheter 6 Fr</td>
			<td>Cordis</td>
			<td>67027000</td>
			<td>Left Ventricle catheterization</td>
		</tr>
		<tr>
			<td>Needle Holder</td>
			<td>Fehling Surgical</td>
			<td>ZYY-5</td>
			<td>Aorta banding</td>
		</tr>
		<tr>
			<td>Non-woven adhesive</td>
			<td>Bastos Viegas</td>
			<td>442-002</td>
			<td>Fluids / Drug administration</td>
		</tr>
		<tr>
			<td>P4-2 Phased Array Transducer</td>
			<td>Siemens</td>
			<td>11284467</td>
			<td>Echocardiography</td>
		</tr>
		<tr>
			<td>Perfusor Compact Syringe Perfusion Pump</td>
			<td>B.Braun</td>
			<td>8717030</td>
			<td>Fluids / Drug administration</td>
		</tr>
		<tr>
			<td>Pressure Signal Conditioner</td>
			<td>ADinstruments</td>
			<td>PCU-2000</td>
			<td>Pressure recording</td>
		</tr>
		<tr>
			<td>Propofol Lipuro 2%</td>
			<td>B.Braun</td>
			<td>357410&#160;</td>
			<td>Anesthesia Maintenance</td>
		</tr>
		<tr>
			<td>Radifocus Introducer II Standard Kit B - Introducer Sheath</td>
			<td>Terumo</td>
			<td>RS+B60K10MQ</td>
			<td>Vascular Access</td>
		</tr>
		<tr>
			<td>Radiopaque marker</td>
			<td>Scanlan</td>
			<td>1001-83</td>
			<td>Aorta banding</td>
		</tr>
		<tr>
			<td>Scissors</td>
			<td>Fehling Surgical</td>
			<td></td>
			<td>Thoracotomy</td>
		</tr>
		<tr>
			<td>Skinprep (Chlorhexidine 2% / 70% Isopropyl alcohol)</td>
			<td>Vygon</td>
			<td>SKPC015ES</td>
			<td>Disinfection</td>
		</tr>
		<tr>
			<td>Stopcock manifold (3 ports)</td>
			<td>PMH</td>
			<td>310.0489</td>
			<td>Fluids / Drug administration</td>
		</tr>
		<tr>
			<td>Straight forceps</td>
			<td>Fehling Surgical</td>
			<td>ZYY-1</td>
			<td>Thoracotomy</td>
		</tr>
		<tr>
			<td>Stresnil 40 mg/mL</td>
			<td>ecuphar</td>
			<td>572184.2</td>
			<td>Anesthesia Induction</td>
		</tr>
		<tr>
			<td>Syringe Luer Lock 20 cc</td>
			<td>Omnifix B.Braun</td>
			<td>4617207V</td>
			<td>Anesthesia Induction</td>
		</tr>
		<tr>
			<td>Syringe Luer Lock 50 cc</td>
			<td>Omnifix B.Braun</td>
			<td>4617509F</td>
			<td>Anesthesia Maintenance</td>
		</tr>
		<tr>
			<td>Transdermal fentanyl Patch 50 mcg/h</td>
			<td>Mylan</td>
			<td>5022153</td>
			<td>Analgesia</td>
		</tr>
		<tr>
			<td>Ultravist</td>
			<td>Bayer</td>
			<td>KT0B019</td>
			<td>Angiography</td>
		</tr>
		<tr>
			<td>Universal Hemostasis Valve Adapter</td>
			<td>Merit Medical</td>
			<td>UHVA08</td>
			<td>Left Ventricle catheterization</td>
		</tr>
		<tr>
			<td>Velcro Limb Immobilizer</td>
			<td>PMH</td>
			<td>SU-211</td>
			<td>Animal stabilization</td>
		</tr>
		<tr>
			<td>Venofix A, 21 G</td>
			<td>B.Braun</td>
			<td>4056337</td>
			<td>Anesthesia Induction</td>
		</tr>
		<tr>
			<td>Vista 120S Patient Monitor</td>
			<td>Draeger</td>
			<td>MS32997</td>
			<td>Monitoring</td>
		</tr>
		<tr>
			<td>Weck titanium clip</td>
			<td>Teleflex</td>
			<td>523760</td>
			<td>Aorta banding</td>
		</tr>
		<tr>
			<td>Weck titanium clip applier</td>
			<td>Teleflex</td>
			<td>523166</td>
			<td>Aorta banding</td>
		</tr>
		<tr>
			<td>Zhiem Vision</td>
			<td>Iberdata</td>
			<td>N/A</td>
			<td>Fluoroscopy</td>
		</tr>
	</tbody>
</table>

a minimally invasive model of aortic stenosis in swine

Large animal models of heart failure play an essential role in the development of new therapeutic interventions due to their size and physiological similarities to humans. Efforts have been dedicated to creating a model of pressure-overload induced heart failure, and ascending aortic banding while still supra-coronary and not a perfect mimic of aortic stenosis in humans, closely resembling the human condition.
The purpose of this study is to demonstrate a minimally invasive approach to induce left ventricular pressure overload by placing an aortic band, precisely calibrated with percutaneously introduced high-fidelity pressure sensors. This method represents a refinement of the surgical procedure (3Rs), resulting in homogenous trans-stenotic gradients and reduced intragroup variability. Additionally, it enables swift and uneventful animal recovery, leading to minimal mortality rates. Throughout the study, animals were followed for up to 2 months after surgery, employing transthoracic echocardiography and pressure-volume loop analysis. However, longer follow-up periods can be achieved if desired. This large animal model proves valuable for testing new drugs, particularly those targeting hypertrophy and the structural and functional alterations associated with left ventricular pressure overload.

Author Spotlight: Development of a Minimally Invasive Large-Animal Model for Reliable and Reproducible Cardiovascular Research 

A Minimally Invasive Model of Aortic Stenosis in Swine

Most preclinical cardiovascular research is conducted on rodents and other small animal models. From a logistical, economic, reproducibility, and throughput perspective, it has obvious advantages. However, their phylogenetics, pathophysiological, and pharmacological responses are different from humans, and this may preclude the reliable translation to clinical use.Taking advantage of our highly specialized surgical and endovascular skillset, we have focused on developing surgical and they breed large animal models of common cardiac pathologies. This protocol is one good example of a simple, minimally invasive procedure that provides a good balance between reliability, reproducibility, and animal welfare. By monitoring the gradient in real time using high fidelity pressure sensors, we are able to accurately titrate the pressure gradient across the stenosis, resulting in a very homogeneous degree of severity between animals.Furthermore, the minimally invasive approach results in a much lower complication rate and better animal recovery. The development of large animal models, in this case swine, is promising for human-like pharmacological and device testing. This is particularly true for very sensitive areas where anatomophysiological similarities to humans are key, like anesthesia, cardiopulmonary bypass, ECMO, LVAS, percutaneous interest catheter therapies, and minimally invasive and robotic surgery.

During the initial development of the model, the mortality rate was approximately 30%, with animals dying from acute heart failure after banding and surgical complications. However, after the model was established, surgical complications became less common, and the mortality rate dropped to around 15%. The two deaths that occurred were due to aortic rupture during dissection.
The use of high-fidelity pressure sensors enables obtaining high-quality pressure signals (Figure ...

Watch this Scientific Journal Video about Development of a Minimally Invasive Large-Animal Model for Reliable and Reproducible Cardiovascular Research at JoVE.com

This protocol describes a minimally invasive surgical procedure for ascending aortic banding in swine.

Large animal models of heart failure play an essential role in the development of new therapeutic interventions due to their size and physiological ...