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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
Circulation. Author manuscript; available in PMC 2013 October 9.
Published in final edited form as:
PMCID: PMC3477474

This article has been retractedRetraction in: Circulation. 2015 March 20; 129(16): e466    See also: PMC Retraction Policy

Cardiomyogenesis in the Aging and Failing Human Heart



Two opposite views of cardiac growth are currently held: one views the heart as a static organ, characterized by a large number of cardiomyocytes, which are present at birth and live as long as the organism; and the other views the heart a highly plastic organ in which the myocyte compartment is restored several times during the course of life.

Methods and Results

The average age of cardiomyocytes, vascular endothelial cells (ECs), and fibroblasts and their turnover rates were measured by retrospective 14C birth dating of cells in 19 normal hearts, 2 to 78 years of age, and in 17 explanted failing hearts, 22 to 70 years of age. We report that the human heart is characterized by a significant turnover of ventricular myocytes, ECs, and fibroblasts, physiologically and pathologically. Myocyte, EC, and fibroblast renewal is very high shortly after birth, decreases during postnatal maturation, remains relatively constant in the adult organ, and increases dramatically with age. From 20 to 78 years of age, the adult human heart replaces entirely its myocyte, EC, and fibroblast compartment ~8, ~6, and ~8 times, respectively. Myocyte, EC, and fibroblast regeneration is further enhanced with chronic heart failure (CHF).


The human heart is a highly dynamic organ that retains a remarkable degree of plasticity throughout life and in the presence of CHF. However, the ability to regenerate cardiomyocytes, vascular ECs, and fibroblasts cannot prevent the manifestations of myocardial aging or oppose the negative effects of ischemic and idiopathic dilated cardiomyopathy.

Keywords: 14C birth dating, cardiac cell turnover, myocyte cytokinesis

Three cellular processes regulate the postnatal development of the heart, the steady state of the adult organ, myocardial aging, and chronic heart failure (CHF): myocyte regeneration, hypertrophy, and death.1,2 The balance between cell growth and cell death characterizes tissue homeostasis in which cell loss is counteracted by a corresponding rate of cell renewal. Myocyte hypertrophy occurs with maturation and in response to a hemodynamic challenge in the adult heart; post-mitotic myocytes increase in size being unable to reenter the cell cycle and divide. Although there is no controversy on the role of myocyte hypertrophy in the expansion of the cardiac mass, a debate persists on the extent of myocyte formation occurring physiologically after birth, in adulthood, and in the presence of pathological stimuli.3,4

The integration of atmospheric 14C into the nuclear DNA has been used to define the turnover rate of cardiomyocytes in the human heart.3 The [14C] in the atmosphere is constantly monitored and the birth date of cells can be defined by tracing back the year in which an equivalent atmospheric 14C was detected. Based on [14C], the claim has been made that myocyte turnover involves at most 1% of cells annually in individuals at 25 years of age; by 75 years of age, it decreases to 0.45%. By this premise, only ~50% of myocytes are replaced once during the course of life in humans, while an equal number lives as long as the organ and organism.3

The low degree of myocyte renewal reported by this work is inconsistent with the extent of myocyte death present in the human heart with aging alone and together with cardiac diseases.48 The magnitude of myocyte turnover measured by other methodologies suggests that myocyte regeneration is significantly higher than 0.45–1%, and increases with age and CHF.4,912 Therefore, retrospective 14C birth dating of myocytes, endothelial cells (ECs), and fibroblasts was measured in 19 normal donor hearts, not used for transplantation, obtained from individuals 2 to 78 years of age. Moreover, the renewal of myocytes, ECs, and fibroblasts was determined in 17 explanted hearts collected from patients, 22 to 70 years of age, suffering from CHF.


An expanded Materials and Methods section is provided in the online-only Data Supplement.


Donor hearts declined for transplantation and explanted hearts were utilized in this study. Collectively, 19 donor and 17 explanted hearts were obtained. Extensive histological analysis was conducted in each donor heart to exclude cardiac pathologies. Explanted hearts were collected from 13 patients affected by post-infarction ischemic cardiomyopathy and 4 by idiopathic dilated cardiomyopathy.

Isolation of Myocardial Cells

Large samples of the left ventricle (LV) were digested by collagenase and cardiomyocytes were purified by differential centrifugation. These sampled areas were associated with a predominantly intact coronary artery branch to allow appropriate perfusion of the tissue. This approach excluded that large foci of scarring were present in the myocardium. Non-myocytes were incubated with anti-von Willebrand factor and anti-CD146 for the identification of ECs, and fibroblasts, respectively. Cell sorting was performed by FACSAria. The purity of each cell preparation in each heart was determined by immunolabeling and confocal microscopy. Mononucleated and multinucleated cells were measured together with the level of DNA ploidy for the appropriate interpretation of [14C] data.

Accelerator Mass Spectrometry (AMS)

The analyses by AMS were done blindly in DNA samples obtained from each cell preparation. Background contamination was accounted for by following the procedure of Brown and Southon. The [14C] data are reported as decay-corrected Δ14C.

Immunocytochemistry and Quantitative Analysis

Replicating cells were identified by Ki67, phospho-H3, and aurora B kinase labeling. Myocytes, ECs, and fibroblasts were recognized by α-SA, vWf, and procollagen, respectively. The number and volume of myocytes, ECs, and fibroblasts were measured morphometrically.

Image Processing

Images were assembled with Adobe Photoshop software according to the standard protocol detailed in the Nature guidelines for digital images. Processing included changes in brightness and was applied uniformly across the entire image; it was used exclusively to equalize the appearance of multiple panels in a single figure.

Spectral Analysis

Spectral analysis was performed to validate the specificity of all immunolabeled signals. This technique was performed with a Zeiss LSM510 Meta confocal microscope. The emission spectra were normalized by dividing the intensity of each wavelength by the peak signal. The spectrum from each actual signal exhibited a well-defined peak while the spectrum of autofluorescence was spread across the range of wavelengths and did not show a clearly defined peak.

Statistical Analysis

Results are shown as mean±SD. Significance was determined by Student’s t test and Bonferroni method. Non-linear regressions, confidence intervals, and covariance were calculated utilizing the Prism software. All P values are two-sided and values <0.05 were considered significant. Sampling error for each quantitative measurement was determined assuming a Poisson distribution.


Cardiac Cells for Retrospective 14C Birth Dating

The earlier report on 14C birth dating of cardiomyocytes and non-cardiomyocytes employed mathematical modeling to define the average age of these cells.3 This approach was required because the variables needed for the direct measurement of [14C] in cardiac cells and the several correction factors necessary for an accurate assessment of atmospheric [14C] in the DNA could not be ascertained from the samples of frozen myocardium available to the authors.

In this study, the 19 donor and 17 explanted hearts were obtained within 24 hours of organism death or organ explant, allowing the acquisition of all the data involved in 14C determinations (online-only Data Supplement Tables 1 and 2). In each case, myocytes, ECs, and fibroblasts were isolated from a large portion of the left ventricle (LV) free of areas of scarring. Moreover, the purity of each cell preparation was determined (Figure 1) and the values of [14C] in each cell class of each heart were corrected for the contribution of the other cell categories. Another aspect relevant to the analysis of [14C] in myocytes concerned the proportion of mononucleated, binucleated, and multinucleated cells. The availability of isolated cells allowed us to measure this parameter and introduce it in the evaluation of [14C] (Figure 2A through 2F) by Accelerator Mass Spectrometry (AMS). At 2, 3 and 7 years after birth myocytes were almost exclusively mononucleated; binucleated myocytes became apparent at 16 and 20 years of age and later in life. Trinucleated myocytes were only occasionally seen and tetranucleated cardiomyocytes were not found. As shown by non-linear exponential fitting, from 2 to 78 years of age, mononucleated myocytes decreased and binucleated myocytes increased up to 25 years of age and remained constant thereafter. An average of 77% mononucleated and 23% binucleated myocytes was found in the adult human heart, and these values were not affected by myocardial aging or CHF. Mononucleated myocytes constituted the large majority of cells with aging and CHF; however, the [14C] in myocyte nuclei was corrected in each heart for the relative contribution of mononucleated and binucleated myocytes. This adjustment was not needed for ECs and fibroblasts; we never found a binucleated EC or fibroblast.

Figure 1
Cell preparation
Figure 2Figure 2Figure 2Figure 2
Myocyte classes and cell ploidy

To establish whether the enzymatic digestion protocol affected the proportion of mononucleated and binucleated myocytes, 20–25 µm thick sections from normal (n=5) and failing (n=5) hearts were stained by α-sarcomeric actin and connexin 43 and the percentage of these two cell classes was determined in situ by confocal microscopy. The collected data were consistent with the results obtained in dissociated myocytes (Figure 2G through 2I), confirming the efficiency of the cell isolation protocol.

Polyploidy Affects a Small Fraction of Myocyte Nuclei

A critical parameter for the interpretation of [14C] in the DNA involves the analysis of ploidy in cardiomyocyte, EC, and fibroblast nuclei. Polyploidy, i.e., 4n, 8n, and 16n, would mimic cell replication resulting in an overestimation of the rate of cell turnover. Thus far, there is little or no information on this critical process of DNA endoreplication in the human heart, and frequently cited results3,13 were collected nearly 4 decades ago.14 These old studies were based on the measurement of DNA content per nucleus by Feulgen staining and cytophotometry. Labeling of nuclear DNA by the Feulgen reaction15 was developed in 1924 and was combined with cytophotometry in 1964.16 Unfortunately, this protocol continues to be used, despite significant limitations, which include type and duration of fixation,17 extent of DNA hydrolysis required for the Schiff reaction,18,19 and the chromatin structure. The latter is critical for the accessibility of the DNA by this technique.20 These inherent problems are avoided by the use of flow-cytometry that has become the gold standard for measurement of nuclear ploidy in various organs, including liver,21 brain,22 intestine,23 skin,24 kidney,25 and cancer cells.26,27

The analysis of ploidy in cardiac cell preparations by flow-cytometry showed that the majority of myocyte, EC, and fibroblast nuclei had 2n diploid DNA content (Figure 2J, online-only Data Supplement Figure 1A through 1F). Tetraploid and octaploid myocyte nuclei were rare and hexadecaploid myocyte nuclei were not detected, confirming previous results.12 The fraction of myocyte, EC, and fibroblast nuclei with DNA content higher than 2n and lower than 4n reflected dividing cells positive for Ki67 (online-only Data Supplement Figure 1G). Myocyte nuclei with 4n DNA content were, in part, Ki67-positive, while octaploid myocyte nuclei were negative for Ki67, excluding that they represented cycling cells in G2 (online-only Data Supplement Figure 1H). Additionally, polyploid EC and fibroblast nuclei were negligible (online-only Data Supplement Figure 2A). As shown by non-linear exponential fitting (Figure 2K), polyploid myocyte nuclei increased during postnatal myocardial growth, reaching a plateau at ~25 years of age. Organ age and the duration of CHF did not affect the fraction of polyploid myocyte, EC, or fibroblast nuclei (Figure 2K, online-only Data Supplement Figure 2B). The value of polyploidy for each cell type in each heart was introduced in the analysis of [14C].

Cell Number Is Required for 14C Birth Dating

Myocyte number per unit volume of myocardium was determined by measuring myocyte cell volume and the volume fraction of myocytes within the tissue. Myocyte cell volume was obtained in isolated myocytes by optical section reconstruction (online-only Data Supplement Figure 3A), and the volume fraction of cardiomyocytes was determined morphometrically in samples collected from the same hearts for histological analysis. Based on these two parameters, the number of cardiomyocytes per 10 cm3 of myocardium was computed. An identical protocol was employed for ECs and fibroblasts (online-only Data Supplement Figure 3B through 3F).

The volume fraction of cardiomyocytes and ECs was higher in the aging heart than in CHF, while the volume fraction of fibroblasts was larger in the decompensated heart. These changes were dictated by a dramatic increase in interstitial and replacement fibrosis with CHF (online-only Data Supplement Figure 3B, 3D 3F, and 3G). The reduction in the myocyte compartment, together with the increase in myocyte cell volume, led to a significant decrease in the number of cardiomyocytes per 10 cm3 of myocardium with CHF.

The Interpretation of [14C] Is Dependent on Organ Birth Date

The multi-valued curve of [14C] in the atmosphere creates problems in terms of the accuracy in deriving the average age of a cell population (online-only Data Supplement Figure 4A). The atmospheric 14C curve shows the dependent variable, i.e., [14C], as a function of time, which represents the independent variable. This curve has the characteristics of a proper function: one independent variable yields one unique dependent variable. However, in retrospective 14C birth dating of cells, [14C] is used as the independent variable and time as the dependent variable. This transformation produces a degenerate function, i.e., one independent variable yields more than one dependent variable (online-only Data Supplement Figure 4B).

The 9 donor hearts, from 2 to 46 years of age, collected from individuals born after the 1963 peak in [14C] in the atmosphere can all be analyzed by employing the descending limb of the 14C curve (online-only Data Supplement Figure 4C). However, for the 10 donor hearts born before the 14C peak, two separate values can be obtained in each case. If the ascending limb of the 14C curve is arbitrarily selected, average myocyte age in this group of hearts would be 53 years. Conversely, if the descending limb of the 14C curve is arbitrarily chosen, average myocyte age would be 5 years (online-only Data Supplement Figure 4D).

Let us consider the myocyte DNA samples collected from 4 individuals born in 1958 (52 year-old), 1960 (50 year-old), March 1962 and September 1962 (49 year-old), a time close to the peak of the 14C curve; the only biologically possible average myocyte age can be derived from the descending limb of the curve, since the values on the ascending limb would reflect a myocyte birth date that precedes the birth date of these individuals (online-only Data Supplement Figure 4E). For the next 5 subjects, born in 1941 (69 year-old), 1942 (68 year-old), 1947 (63 year-old), 1952 (58 year-old), and 1955 (55 year-old), the information on binucleation and polyploidy becomes important to define the actual birth date of myocytes. Binucleation of myocytes reaches its average adult value of 23% at 25 years of age (see Figure 2B). The fraction of binucleated myocytes was, respectively, 23%, 25%, 28%, 27%, and 25% in these 69, 68, 63, 58, and 55 year-old hearts, indicating that a significant amount of DNA synthesis had to occur during the first 25 years of life. Moreover, tetraploid and octaploid myocyte nuclei accounted together for ~12% of cells in these 5 hearts implying that an additional level of DNA synthesis took place early in life (see Figure 2K).

In the first 25 years of life of the 69 year-old man, from 1941 to 1966, the weighted average atmospheric [14C] was 182; this was derived from the yearly [14C], comprising the interval before the rise in [14C], its peak, and part of the descending limb of the 14C curve (Figure 3A). The calculated 182 value was significantly higher than the measured 54 value. An identical analysis was performed for the 68, 63, 58, and 55 year-old hearts and similar conclusions were reached (Figure 3A). Based on these data, only the values on the descending limb of the 14C curve were considered valid for the measurement of average myocyte age. This argument could not be applied to the 78 year-old individual born in 1933. In this case, the weighted average atmospheric [14C] in the first 25 years of life was extremely low, 16, and less than the measured value, 67; however, the results in the other 18 hearts indicated that the descending limb of the 14C curve was appropriate for the evaluation of average myocyte age.

Figure 3Figure 3
[14C] in myocytes from patients born before 1956

An identical approach was introduced in the analysis of the 17 explanted hearts: 3 hearts were collected from patients born after the [14C] peak; 3 hearts were obtained from patients born shortly before 1963 when the [14C] in the atmosphere was almost at its maximum; and 11 hearts were acquired from patients born before the rise or during the initial phase of the increase in atmospheric [14C] (online-only Data Supplement Figure 5A). In the first 3 cases, the descending limb of the 14C curve was used to measure average myocyte age. In the second group of 3 cases, the levels of atmospheric 14C at the time of birth were already higher than those measured by AMS, indicating that only the values on the descending limb were biologically valid for the assessment of myocyte age (online-only Data Supplement Figure 5B). In the third group of 11 hearts, the weighted average atmospheric [14C] during the initial 25 years of life was in each case higher than that measured by AMS, designating the descending limb of the 14C curve appropriate for the evaluation of myocyte age (Figure 3B).

Myocyte Age Decreases and Turnover Increases with Aging

Donor hearts, 2, 3, and 7 year-old, showed similar values of myocyte age, averaging 8 months (Figure 4A). From 2 to 20 years, myocyte age averaged 2.8 years, and from 33 to 46 years, 7.9 years. From 49 to 63, and from 68 to 78 years, myocyte age was 6.5 and 2.6 years, respectively. Thus, myocyte age increased postnatally, remained relatively constant in adulthood, and decreased in the old heart (Figure 4B).

Figure 4Figure 4
Cell age and turnover rate with organ aging

Myocyte turnover was computed in a similar manner (Figure 4C). From 2 to 20 years, annual myocyte renewal comprised 23% of cells, and from 20 to 40 years, 7% of cells. Subsequently, myocyte replacement increased with age; at 50, 60, 70, and 80 years, myocyte formation involved annually 8%, 10%, 14%, and 19% of cells, respectively. From 2 to 20 years, the number of cardiomyocytes doubled, and myocyte cell volume increased 4.5-fold (Figure 4D), indicating that myocyte formation and cellular hypertrophy contributed to the increase in myocardial mass with maturation. Consistent with previous results,5 the adult value of ~8 × 109 myocytes was reached at 20 years of age. Thus, the ability of the human heart to renew its myocyte compartment in adulthood from 20 and 78 years was calculated; the myocyte class was replaced ~8 times during this interval (online-only Data Supplement Figure 6A).

EC and Fibroblast Age and Turnover Vary with Aging

The [14C] measured by AMS in each EC and fibroblast preparation are listed in online-only Data Supplement Table 3. These values were employed to compute average cell age. The age of ECs averaged 1 year up to 7 years of organ age; however, it increased to 8 years in hearts from 16 to 33 years and remained essentially constant up to 78 years (Figure 4E and 4F). Annual EC turnover was 31%, from 2 to 7 years, but decreased to 9% at 16 years, and 6% at 20 years. EC renewal did not change further with age (Figure 4G). Fibroblasts mimicked myocyte and EC behavior up to ~40 years of age. In older hearts, fibroblast age was similar to that of myocytes, but younger than ECs (Figure 4H and 4I). Annual fibroblast turnover decreased from 33% at 2 years to 6% at 20 years (Figure 4J), and remained rather constant from 20 to 40 years. Fibroblast renewal increased progressively at 50, 60, 70, and 80 years of age: a turnover rate of 7%, 9%, 12%, and 15% per year was found, respectively. From 20 to 78 years of age, ECs were renewed ~6 times and fibroblasts ~8 times (online-only Data Supplement Figure 6B and 6C). Thus, the growth and death of cardiomyocytes and fibroblasts are comparable in the adult and aging heart, exceeding the growth and death of ECs (Figure 4K).

Cardiac Cell Age Decreases and Turnover Increases with CHF

The myocyte compartment in failing hearts was composed of cells 40% younger than in physiological aging (Figure 5A and 5B). Similarly, myocyte turnover was higher with CHF; the highest value was found in a 22 year-old patient in whom myocyte regeneration was 750% per year (Figure 5C). Even if we exclude this unique case, CHF in patients 23 to 70 year-old resulted in a nearly 2-fold higher level of myocyte renewal than in normal hearts 20 to 78 years of age (Figure 5D).

Figure 5Figure 5Figure 5
Cell age and turnover rate with CHF

In failing hearts 22 to 70 year-old, ECs and fibroblasts were, respectively, 42% and 49% younger than in normal hearts of similar age. Fibroblasts retained a younger phenotype than ECs (Figure 5E and 5F), while myocytes showed characteristics similar to ECs (see Figure 5B). With CHF, the annual renewal of ECs varied from 12% to 75%. Fibroblast turnover was higher ranging from 16% to 91% (Figure 5G and 5H).

Myocyte Generation at Organ Death

The cardiomyocyte [14C] gives a measurement of the average age of this cell population; if one myocyte is 40 year-old and another is 1 year-old, a value of 20.5 years is obtained. To determine the degree of myocyte regeneration at organ death, three markers of the cell cycle were employed: Ki67,4,1012 phospho-H3,4 and aurora B kinase.4,28 Ki67 is expressed in late G1, S, G2 and early mitosis and is not implicated in DNA repair or ploidy formation. Phospho-H3 is upregulated in late G2 and mitosis; it is highly phosphorylated at Ser10 during chromatin condensation and remains phosphorylated up to the end of telophase. Aurora B kinase ensures accurate segregation of the duplicated chromosomes and controls proper cytoplasmic division, preventing polyploidization.28 Myocyte nuclei labeled by Ki67 were found in the LV of all hearts with aging and CHF (Figure 6A). The expression of Ki67 allowed us to measure the number of myocytes being formed at the time of sample acquisition (Figure 6B). The Ki67 data in aging hearts yielded a curve (Figure 6C) that mimicked the results by [14C]. Similarly, myocyte growth was enhanced with CHF (Figure 6D), paralleling the 14C data. To validate the data collected in tissue sections, the fraction of Ki67-positive myocytes was measured in isolated cells from normal (n=5) and failing (n=5) hearts (Figure 6E). The two approaches yielded essentially identical values, confirming the reliability of the measurements obtained and the proper efficiency of the cell isolation protocol. In comparison with aging hearts 20 to 78 year-old, an average 4.5-fold higher number of cycling myocytes was found with CHF (Figure 6E and 6F). The high degree of covariance between the Ki67 curve and the 14C curve with aging (Figure 6G) provided strong evidence in favor of the interpretation of the 14C data.

Figure 6Figure 6
Replicating myocytes with aging and CHF

A myocyte mitotic index was measured by phospho-H3 expression in tissue sections (Figure 7A) and isolated myocytes (Figure 7B). As expected, this parameter was higher in failing hearts (Figure 7B through 7F). The phospho-H3 curve with aging was superimposable on those of Ki67 and [14C] (Figure 7G), supporting our conclusions on retrospective 14C birth dating of cardiomyocytes. Additionally, to provide unequivocal evidence of myocyte cytokinesis, several examples of aurora B kinase localization at the cleavage furrow of dividing myocytes were obtained in normal and failing hearts (Figure 8, online-only Data Supplement Figure 7).

Figure 7Figure 7
Myocyte mitotic index with aging and CHF
Figure 8
Myocyte cytokinesis


Collectively, our findings indicate that the human heart is a dynamic organ characterized by high turnover of myocytes, ECs, and fibroblasts. This conclusion was reached by applying an analysis that: a) is independent from a potential bias; b) excludes the human factor in the collection of the data; c) uses a non-modified, unperturbed biological system, i.e., physiological myocardial aging; d) introduces an established condition, CHF, known to affect the myocardium structurally and functionally; and e) is redundant, from the point of view of information theory, reducing the amount of noise in the data, i.e., misinformation, as defined by Shannon’s law.29 Thus, we have used AMS for the measurement of [14C] in myocytes to define the average age and turnover of this cell population. Additionally, FACS analysis was employed to evaluate polyploidy in myocyte nuclei, a critical determinant of average myocyte age and turnover. These operator-independent findings were combined with 3 operator-dependent measurements, Ki67, phospho-H3, and aurora B kinase localization in replicating myocyte nuclei and dividing cells.

A certain degree of skepticism may exist concerning these observations, since previous results utilizing only retrospective 14C birth dating have suggested that myocyte turnover in the human heart is minimal and decreases with age.3 In contrast to this early work, several confounding factors were considered here in the analysis of 14C incorporation into the nuclear DNA of cardiomyocytes;2,8 they included unbiased collection of cardiomyocytes, purity of the cell preparation, proportion of mononucleated and multinucleated cells, fraction of polyploid nuclei, and number of cardiomyocytes. These variables have profound consequences on the quantitative evaluation of cardiomyocyte renewal in the aging heart by 14C birth dating of cells.

Data in our study are consistent with the necessary balance between myocyte death and myocyte regeneration present during an individual’s lifespan. Myocyte apoptosis and necrosis occur physiologically,57,30 and cell death has to be accompanied by cell formation for the heart to continue to exist. The simple concept of a requisite equilibrium between myocyte death and renewal has often been ignored. Myocyte apoptosis in the normal human heart involves at least 10/106 cells,5 and since apoptosis lasts at most 4 hours,31 0.006% myocytes are lost per day; this accounts for a decrease of 2.2% myocytes per year. Myocyte apoptosis increases linearly with age so that over a period of 30 years, ~95% of the original ventricular myocytes are lost as a result of wear and tear of the organ.4 This magnitude of cell death does not include cell necrosis,30,32 which has recently been documented independently by the presence of cardiac troponin in the circulation of apparently healthy individuals.6,7 Thus, a significantly higher level of myocyte regeneration than that purported in the previous study on 14C birth dating of cells3 has to occur in order to preserve cardiac mass and function in humans.

Myocardial aging and CHF are characterized by activation of resident cardiac stem cells (CSCs) with decreased telomere length, generating an old progeny that contributes to the manifestations of the aging myopathy4,32 and ventricular decompensation.33 CSCs with shortened telomeres are preferentially activated, rather than CSCs with long telomeres, which can experience a larger number of divisions,4,34 before replicative senescence and growth arrest is reached.35 Apparently, the latter class of CSCs remains quiescent and their growth reserve is intact late in life, reflecting a pool of young CSCs in the old or failing heart.4,34 The length of telomeres in stem cells is largely controlled by telomerase activity that restores partly the telomeric DNA lost during each round of division.36 Telomere attrition may upregulate telomerase that, in turn, stimulate the cell cycle. This interaction is found in highly proliferating cancer cells that have dramatically shortened telomeres, but possess high telomerase activity.37

A relevant issue addressed here, with significant effects on the evaluation of [14C] in the nuclear DNA, concerns the polyploidization of myocyte nuclei with aging and CHF. Polyploidy is characterized by an exponential increase in DNA content dictated by the number of doublings of the entire genome. This exponential increase in amount of DNA is reflected by a parallel increase in nuclear volume, a phenomenon that only occasionally occurs with myocardial aging and pathology, as shown previously5,38,39 and in the current study. However, based on the Feulgen reaction and cytophotometry, the number of polyploid myocyte nuclei has been claimed to comprise 50% of myocytes at 10 years of age and nearly 100% in the adult, old, or hypertrophied heart.40 Importantly, the latter value was introduced in the previous interpretation of [14C] in myocyte nuclei.3 Moreover, in the original report by Bergmann and colleagues,3 the selection of myocyte nuclei, the mathematical model used, and the interpretation of [14C] to arbitrarily construct an exponential curve pointing to a decline in myocyte renewal with age, may all have contributed to yield the unusual low rates of myocyte turnover.2,8,12

A few comments have to be made regarding the potential confounding variables present in the evaluation of [14C] in myocyte nuclei; they include DNA repair of damaged or mutated DNA, turnover of mitochondrial DNA, and nucleotide salvage pathways triggered by cell death. The first two possibilities would yield younger myocytes and higher turnover rates, while the third would lead to opposite effects; however, these processes do not significantly alter the measurements of [14C] in the nuclear DNA by AMS. Nearly 2,000 to 10,000 nucleotide bases are replaced per day in the human genome as a result of DNA damage.41 Diploid human cells contain 6 × 109 base pairs, i.e., 12 × 109 nucleotide bases.42 When the highest value of 10,000 bases being repaired per day is considered, it would require 1.2 × 106 days or 3,288 years to restore the entire genomic DNA. Over 80 years of life, only 2.4% of 14C in the genomic DNA would be derived by this mechanism. The mitochondrial genome contains 1.6 × 104 base pairs, i.e., 3.2 × 104 nucleotide bases.43 Even if we assume that 3,000 mitochondria are present in adult human cardiomyocytes, aggregate mitochondrial DNA would be composed of 9.6 × 106 nucleotide bases. This value is equivalent to 0.1% of the DNA, making its contribution to the measurement of 14C in the genomic DNA essentially negligible. Finally, incorporation of 14C-labeled nucleotides released from dying myocytes during DNA degradation would be minimal. In a model of irradiated cells in vitro it was demonstrated that less than 0.05% metabolites originating from the degraded DNA is re-used for new DNA synthesis.44 This value is significantly below the level of accuracy of AMS. Importantly, 14C was found to be undetectable in human neurons of individuals born prior to the raise in 14C in the atmosphere resulting from above ground nuclear testing,45 further questioning the relevance of these biological events in the evaluation of average myocyte age and turnover rate by this methodology. Importantly, the data obtained by 14C birth dating of cardiomyocytes are consistent with previous results collected by IdU incorporation in replicating myocytes12 and following the implementation of a hierarchical model of cardiac growth in the aging heart.4

In summary, the human heart is a highly dynamic organ that retains a significant degree of plasticity throughout life and in the presence of CHF. However, the ability to regenerate cardiomyocytes, ECs, and fibroblasts cannot prevent the manifestations of myocardial aging4,32 or oppose the negative effects of ischemic and idiopathic dilated cardiomyopathy.2 Recently, the clinical implementation of autologous cardiac stem cells and cardiospheres in patients with CHF of ischemic origin has provided encouraging results,46,47 suggesting that cell therapy may interfere with the devastating consequences of the myocardial disease.

Clinical Summary

Cardiomyogenesis in the Aging and Failing Human Heart

For the last 70 years, the possibility that the adult heart retains after birth a significant capacity for myocyte regeneration has been opposed strongly. Similarly, the notion that stem cells reside within the myocardium and regulate tissue homeostasis physiologically, and the repair process following injury has been challenged. Different approaches have provided contrasting results, which have divided the scientific community in supporters of an extremely low myocyte renewal in the mammalian heart, and proponents of a relatively high myocyte replacement at all stages of life. Essentially, two opposite views are currently being purported: one that sees the heart as a static organ, characterized by a large number of myocytes, which are present at birth and live as long as the organ and organism, and the other that considers the heart a highly dynamic organ in which the myocyte compartment is restored several times during the course of life. By employing retrospective 14C birth dating of cells, it has been possible to demonstrate that the human heart retains a significant degree of myocyte regeneration throughout life and in the presence of chronic heart failure (CHF). Although the ability to regenerate cardiomyocytes, and vascular structures cannot prevent the manifestations of myocardial aging or oppose the negative effects of ischemic and idiopathic dilated cardiomyopathy, understanding the complex mechanisms of tissue repair may identify novel strategies for the management of CHF and prolong health span and life span in the elderly.

Supplementary Material



This work was supported by NIH grants and by grant NCRR RR13461. This work was performed in part under the auspices of the U.S. Department of Energy by Lawrence Livermore National Laboratory under Contract DE-AC52-07NA27344.


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1. Hill JA, Olson EN. Cardiac plasticity. N Engl J Med. 2008;358:1370–1380. [PubMed]
2. Leri A, Kajstura J, Anversa P. Role of cardiac stem cells in cardiac pathophysiology: a paradigm shift in human myocardial biology. Circ Res. 2011;109:941–961. [PMC free article] [PubMed]
3. Bergmann O, Bhardwaj RD, Bernard S, Zdunek S, Barnabé-Heider F, Walsh S, Zupicich J, Alkass K, Buchholz BA, Druid H, Jovinge S, Frisén J. Evidence for cardiomyocyte renewal in humans. Science. 2009;324:98–102. [PMC free article] [PubMed]
4. Kajstura J, Gurusamy N, Ogórek B, Goichberg P, Clavo-Rondon C, Hosoda T, D'Amario D, Bardelli S, Beltrami AP, Cesselli D, Bussani R, del Monte F, Quaini F, Rota M, Beltrami CA, Buchholz BA, Leri A, Anversa P. Myocyte turnover in the aging human heart. Circ Res. 2010;107:1374–1386. [PubMed]
5. Olivetti G, Abbi R, Quaini F, Kajstura J, Cheng W, Nitahara JA, Quaini E, Di Loreto C, Beltrami CA, Krajewski S, Reed JC, Anversa P. Apoptosis in the failing human heart. N Engl J Med. 1997;336:1131–1141. [PubMed]
6. Omland T, de Lemos JA, Sabatine MS, Christophi CA, Rice MM, Jablonski KA, Tjora S, Domanski MJ, Gersh BJ, Rouleau JL, Pfeffer MA, Braunwald E. Prevention of Events with Angiotensin Converting Enzyme Inhibition (PEACE) Trial Investigators. A sensitive cardiac troponin T assay in stable coronary artery disease. N Engl J Med. 2009;361:2538–2547. [PMC free article] [PubMed]
7. Mahajan VS, Jarolim P. How to interpret elevated cardiac troponin levels. Circulation. 2011;124:2350–2354. [PubMed]
8. Kajstura J, Rota M, Hosoda T, Anversa P, Leri A. Carbon 14 birth dating of human cardiomyocytes. Circ. Res. 2012;110:e19–e21. [PMC free article] [PubMed]
9. Astorri E, Bolognesi R, Colla B, Chizzola A, Visioli O. Left ventricular hypertrophy: a cytometric study on 42 human hearts. J Mol Cell Cardiol. 1977;9:763–775. [PubMed]
10. Beltrami AP, Urbanek K, Kajstura J, Yan SM, Finato N, Bussani R, Nadal-Ginard B, Silvestri F, Leri A, Beltrami CA, Anversa P. Evidence that human cardiac myocytes divide after myocardial infarction. N Engl J Med. 2001;344:1750–1757. [PubMed]
11. Urbanek K, Quaini F, Tasca G, Torella D, Castaldo C, Nadal-Ginard B, Leri A, Kajstura J, Quaini E, Anversa P. Intense myocyte formation from cardiac stem cells in human cardiac hypertrophy. Proc Natl Acad Sci USA. 2003;100:10440–10445. [PubMed]
12. Kajstura J, Urbanek K, Perl S, Hosoda T, Zheng H, Ogórek B, Ferreira-Martins J, Goichberg P, Rondon-Clavo C, Sanada F, D'Amario D, Rota M, Del Monte F, Orlic D, Tisdale J, Leri A, Anversa P. Cardiomyogenesis in the adult human heart. Circ Res. 2010;107:305–315. [PMC free article] [PubMed]
13. Laflamme MA, Murry CE. Heart regeneration. Nature. 2011;473:326–335. [PMC free article] [PubMed]
14. Adler CP. Relationship between deoxyribonucleic acid content and nucleoli in human heart muscle cells and estimation of cell number during cardiac growth and hyperfunction. Recent Adv Stud Cardiac Struct Metab. 1975;8:373–386. [PubMed]
15. Feulgen R, Rossenbeck H. Mikroskopisch-chemischer Nachweis einer Nucleinsaure von Typus der Thymonukleinsaure und die darauf beruhende elektive Farbung von Zellkernen in mikroskopischen Praparaten. Hoppe-Seyler’s Z Physiol Chem. 1924;135:203–248.
16. Sandritter W, Scomazzoni G. Deoxyribonucleic acid content (feulgen photometry) and dry weight (interference microscopy) of normal and hypertrophic heart muscle fibers. Nature. 1964;202:100–101. [PubMed]
17. Kiss R, Salmon I, Camby I, Gras S, Pasteels JL. Characterization of factors in routine laboratory protocols that significantly influence the Feulgen reaction. J Histochem Cytochem. 1993;41:935–945. [PubMed]
18. Greilhuber J. Cytochemistry and C-values: the less-well-known world of nuclear DNA amounts. Ann Bot. 2008;101:791–804. [PMC free article] [PubMed]
19. Dolezel J, Greilhuber J, Suda J. Estimation of nuclear DNA content in plants using flow cytometry. Nat Protoc. 2007;2:2233–2244. [PubMed]
20. Darzynkiewicz Z, Traganos F, Kapuscinski J, Staiano-Coico L, Melamed MR. Accessibility of DNA in situ to various fluorochromes: relationship to chromatin changes during erythroid differentiation of Friend leukemia cells. Cytometry. 1984;5:355–363. [PubMed]
21. Si-Tayeb K, Lemaigre FP, Duncan SA. Organogenesis and development of the liver. Dev Cell. 2010;18:175–189. [PubMed]
22. Westra JW, Barral S, Chun J. A reevaluation of tetraploidy in the Alzheimer's disease brain. Neurodegener Dis. 2009;6:221–229. [PMC free article] [PubMed]
23. Barletta A, Marzullo F, Pellecchia A, Montemurro S, Labriola A, Lomonaco R, Grammatica L, Paradiso A. DNA flow cytometry, p53 levels and proliferative cell nuclear antigen in human colon dysplastic, precancerous and cancerous tissues. Anticancer Res. 1998;18:1677–1682. [PubMed]
24. Mommers JM, Goossen JW, van De Kerkhof PC, van Erp PE. Novel functional multiparameter flow cytometric assay to characterize proliferation in skin. Cytometry. 2000;42:43–49. [PubMed]
25. Ikeda R, Tanaka T, Moriyama MT, Kawamura K, Miyazawa K, Suzuki K. Proliferative activity of renal cell carcinoma associated with acquired cystic disease of the kidney: comparison with typical renal cell carcinoma. Hum Pathol. 2002;33:230–235. [PubMed]
26. Navin N, Kendall J, Troge J, Andrews P, Rodgers L, McIndoo J, Cook K, Stepansky A, Levy D, Esposito D, Muthuswamy L, Krasnitz A, McCombie WR, Hicks J, Wigler M. Tumour evolution inferred by single-cell sequencing. Nature. 2011;472:90–94. [PMC free article] [PubMed]
27. Golebiewska A, Brons NH, Bjerkvig R, Niclou SP. Critical appraisal of the side population assay in stem cell and cancer stem cell research. Cell Stem Cell. 2011;8:136–147. [PubMed]
28. Bersell K, Arab S, Haring B, K hn B. Neuregulin1/ErbB4 signaling induces cardiomyocyte proliferation and repair of heart injury. Cell. 2009;138:257–270. [PubMed]
29. Mclellan MR, Ryan MD, Breneman CM. Rank order entropy: why one metric is not enough. J Chem Inf Model. 2011;51:2302–2319. [PMC free article] [PubMed]
30. Frustaci A, Kajstura J, Chimenti C, Jakoniuk I, Leri A, Maseri A, Nadal-Ginard B, Anversa P. Myocardial cell death in human diabetes. Circ Res. 2000;87:1123–1132. [PubMed]
31. De Saint-Hubert M, Prinsen K, Mortelmans L, Verbruggen A, Mottaghy FM. Molecular imaging of cell death. Methods. 2009;48:178–187. [PubMed]
32. Chimenti C, Kajstura J, Torella D, Urbanek K, Heleniak H, Colussi C, Di Meglio F, Nadal-Ginard B, Frustaci A, Leri A, Maseri A, Anversa P. Senescence and death of primitive cells and myocytes lead to premature cardiac aging and heart failure. Circ Res. 2003;93:604–613. [PubMed]
33. Urbanek K, Torella D, Sheikh F, De Angelis A, Nurzynska D, Silvestri F, Beltrami CA, Bussani R, Beltrami AP, Quaini F, Bolli R, Leri A, Kajstura J, Anversa P. Myocardial regeneration by activation of multipotent cardiac stem cells in ischemic heart failure. Proc Natl Acad Sci USA. 2005;102:8692–8697. [PubMed]
34. Cesselli D, Beltrami AP, D'Aurizio F, Marcon P, Bergamin N, Toffoletto B, Pandolfi M, Puppato E, Marino L, Signore S, Livi U, Verardo R, Piazza S, Marchionni L, Fiorini C, Schneider C, Hosoda T, Rota M, Kajstura J, Anversa P, Beltrami CA, Leri A. Effects of age and heart failure on human cardiac stem cell function. Am J Pathol. 2011;179:349–366. [PubMed]
35. Aubert G, Lansdorp PM. Telomeres and aging. Physiol Rev. 2008;88:557–579. [PubMed]
36. Martinez P, Blasco MA. Telomeric and extra-telomeric roles for telomerase and the telomere-binding proteins. Nat Rev Cancer. 2011;11:161–176. [PubMed]
37. Xu L, Blackburn EH. Human cancer cells harbor t-stumps, a distinct class of extremely short telomeres. Mol Cell. 2007;28:315–327. [PMC free article] [PubMed]
38. Olivetti G, Melissari M, Capasso JM, Anversa P. Cardiomyopathy of the aging human heart. Myocyte loss and reactive cellular hypertrophy. Circ Res. 1991;68:1560–1568. [PubMed]
39. Olivetti G, Giordano G, Corradi D, Melissari M, Lagrasta C, Gambert SR, Anversa P. Gender differences and aging: effects on the human heart. J Am Coll Cardiol. 1995;26:1068–1079. [PubMed]
40. Oberpriller JO, Oberpriller JC, Mauro A. The development and regenerative potential of cardiac muscle. New York: Hardwood Accademic Publishers; 1991. pp. 227–252.
41. Lindahl T. Instability and decay of the primary structure of DNA. Nature. 1993;362:709–715. [PubMed]
42. International Human Genome Sequencing Consortium. Initial sequencing and analysis of the human genome. Nature. 2001;409:860–921. [PubMed]
43. Tsutsui H, Kinugawa S, Matsushima S. Mitochondrial oxidative stress and dysfunction in myocardial remodelling. Cardiovasc Res. 2009;81:449–456. [PubMed]
44. Cleaver JE, Trosko JE. DNA-degradation products from mammalian cells irradiated with ultra-violet light. Int J Radiat Biol Relat Stud Phys Chem Med. 1969;15:411–424. [PubMed]
45. Spalding KL, Bhardwaj RD, Buchholz BA, Druid H, Fris n J. Retrospective birth dating of cells in humans. Cell. 2005;122:133–143. [PubMed]
46. Bolli R, Chugh AR, D'Amario D, Loughran JH, Stoddard MF, Ikram S, Beache GM, Wagner SG, Leri A, Hosoda T, Sanada F, Elmore JB, Goichberg P, Cappetta D, Solankhi NK, Fahsah I, Rokosh DG, Slaughter MS, Kajstura J, Anversa P. Cardiac stem cells in patients with ischaemic cardiomyopathy (SCIPIO): initial results of a randomised phase 1 trial. Lancet. 2011;378:1847–1857. [PMC free article] [PubMed]
47. Makkar RR, Smith RR, Cheng K, Malliaras K, Thomson LE, Berman D, Czer LS, Marbán L, Mendizabal A, Johnston PV, Russell SD, Schuleri KH, Lardo AC, Gerstenblith G, Marbán ER. Intracoronary cardiosphere-derived cells for heart regeneration after myocardial infarction (CADUCEUS): a prospective, randomised phase 1 trial. Lancet. 2012;379:895–904. [PMC free article] [PubMed]