Due to the need for improved assessment and prediction of cardiotoxicity during drug development and testing, we have developed a novel 2D/3D hybrid organoid model which uses optical imaging techniques to study drug effects via calcium transients, contractility, and, most distinctly, signal propagation. We found that our novel 2D/3D hybrid organoid model accurately assessed the known cardiotoxic effects of Dox, and thus, presents a feasible method for evaluating drug cardiotoxicity on a cellular level in a high-throughput manner. To first validate our model, we assessed Dox cardiotoxicity and confirmed its known effects. Calcium transient data demonstrated prolonged total peak durations, extended release and reuptake phases, reduced frequency, and decreased maximum rate of rise. These results align with case studies of patients arrythmias, such as QT interval prolongation, extrasystoles, atrial fibrillation, and ventricular arrythmias, all of which can in part be attributed to defects in calcium handling.16–19 Previous studies in animal models and in 2D and 3D iPSC cultures have also demonstrated decreased heart rate, prolonged QT interval, and irregular beating pattern, as well as altered calcium dynamics, including decreased reuptake and increased concentration, providing further validation to our results using calcium transients as a surrogate marker of cardiotoxicity.12–14,20
Each of these previously used models, however, have drawbacks, namely related to consistency and feasibility. Our novel 2D/3D hybrid organoid model provides a more robust and optimal platform by optimally balancing the advantages and disadvantages of each. For example, results found in 2D cell culture have yielded contradictory effects, with some studies finding reduced beating rate and prolonged action potential duration, while others have reported increased frequency, no acute effects on beating, or a complete cessation of contractile motion.14,20,21 Additionally, studies have shown that 2D cultured cells lack the complexity seen in real tissues and have divergent transcriptomes and electromechanical properties, which offers explanation to different toxicity responses observed in 2D versus 3D cell culture.9,10,22–25 Our model circumvents these discrepancies because the isolated single “2D” cells in our hybrid model are developed as part of the organoid, and not as monolayers, thus preserving properties of true cardiomyocytes and cell-cell interactions, while still allowing for easy optical analysis without interfering adjacent signal. Overall, our hybrid model overcomes the challenges of other systems by presenting reliable, easy-to-interpret results in human cells that display the complexity and structure of cardiomyocytes.
Furthermore, what distinguishes our hybrid model from others is the dispersion of cells around the beating organoid, which allows us to study signal propagation and how the signal changes from its origin on a per cell basis. This is important because a major contributor to arrhythmias is conduction velocity, which is hypothesized to be impaired in Dox cardiotoxicity.11,26 Our results demonstrated diastole prolongation with increased distance from the beating organoid, suggesting that Dox cardiotoxicity amplifies across a signal. This can contribute to arrhythmias due to calcium overload impacting the initiation of the next action potential, which can predispose cells to altered signals and arrhythmias. Correlative findings have also been previously reported in human patients, 2D and 3D cell culture, and in animal models, which have shown increased QT dispersion, increased field potential duration, increased dispersion of repolarization, and reduced and heterogenous conduction velocity.14,27–31 Although these findings report different metrics, they converge on the underlying observation that signal propagation is not uniform throughout, and such signal dispersion and electrical heterogeneity with nonuniform repolarization and refractoriness can induce arrhythmias. Mechanistic investigations have supported these conclusions, demonstrating Dox and calcium overload impact connexin-43, the main gap junction protein found in cardiac tissue.32–35 Specifically, Dox has been found to impair expression and function of connexin-43, which can lead to conduction velocity slowing and heterogeneity, while calcium overload has been shown to exacerbate conduction slowing through down-regulated gap junction communication and electrical uncoupling.33–39 Thus, there are several mechanisms that contribute to cell-cell communication and offer explanation to the impaired signal propagation demonstrated in our model.
Additionally, our results reflect what has been elucidated from molecular studies of Dox cardiotoxicity and abnormal calcium handling. Firstly, Dox is known to cause a pro-apoptotic environment and decrease cell viability, which explains why we have overall fewer cells in our Dox-treated models.14,15,34 The prolonged time for calcium reuptake and overall increased levels of calcium found in our study are reflective of previous work identifying dysfunctional SERCA2a proteins as a cause for impaired calcium release and reuptake in Dox cardiotoxicity.12,35,40,41 In addition to direct effects seen on SERCA2a expression, Dox has also been shown to increase reactive oxygen species, which are known to alter SERCA2a activity and cause diastolic calcium leak causing contractile dysfunction and impaired cardiomyocyte relaxation, which we have also observed in our model.15,42,43 Impaired SERCA2a expression and function is a proposed mechanism for abnormal contractility and has also been seen in heart failure, arrhythmias, and ischemic heart disease, and therefore is a likely contributor to Dox cardiotoxicity.44–46
Considering the tight control of excitation-contraction coupling, it is not surprising that our Dox treated cells also display impaired contractility that is reflective of the effects seen on calcium transients. Previous studies have elucidated that calcium transients decay rate closely mirrors myocyte contraction, implicating that decreased calcium reuptake and subsequent elevated intracellular calcium levels during diastole play a significant role in impaired and delayed relaxation.47 Specifically in Dox models, depressed contractility and impaired relaxation have been attributed to altered sarcoplasmic reticulum calcium release and uptake.48,49 Furthermore, Dox and its associated calcium overload have been shown to reduce contractile structures and impair their function due to sarcomeric disarray and myofibril deterioration.50–53 This provides explanation for why some of our cells with dysfunctional contractility did not have calcium abnormalities. On the other hand, studies have shown that calcium transients become abnormal significantly earlier than contractility defects arise, explaining why not all cells with abnormal calcium had abnormal beating.54 Therefore, our model provides additional insight into excitation-contraction coupling impairment in Dox cardiotoxicity and can clarify if its attributable to calcium, cellular architecture, or both.
Given that many of the detrimental effects caused by Dox can be attributed to abnormal calcium handling, this study emphasizes the need to correctly detect normal versus abnormal calcium transients. When done manually, this process is burdensome, inefficient, and prone to human error due to borderline signal, output noise, subjectivity, and expertise. Therefore, we additionally developed a machine learning classifier for assessing normality. Previous studies have shown the ability of various machine learning methods, including SVM, to successfully classify cells based on calcium transient data. This has been done to assess impaired relaxation, predict mechanistic action of cardioactive drugs, classify different cardiac diseases, and categorize normal versus abnormal calcium transients.55–58 These models have all had impressive accuracy ranging from 80–88%, and our model’s had comparable results with an accuracy improved to 92.6%. Because irregularities may relate to not solely to transient morphology but also to signal phase and because cells may occasionally have a singular abnormal signal amongst normal transients and vice-versa, we classified calcium transients on a whole cell basis, based on averaged parameters, rather than a single peak basis to obtain the most accurate classification for a cell to assess overall cardiotoxic burden. Additionally, since both control and Dox-treated cells had calcium transients of normal and abnormal morphology, we trained and tested our model to classify calcium transients regardless of drug-treatment status to capture underlying patterns of calcium abnormality in an unbiased manner to ensure it was not solely classifying based on drug-status. This improves its generalizability among cardiomyocytes with different cardiotoxicities, which will enhance its ability to screen a variety of drugs in a high-throughput manner.
Despite overcoming the challenges of previously utilized model systems for assessing drug cardiotoxicity, our study is subject to the following limitations. We assessed one drug at one concentration at one timepoint. Future studies employing our model with numerous drugs at a variety of concentrations at different time points will provide further validation and proof of utility. Given its ability to screen drugs in a high-throughput manner, this can easily be achieved. Additionally, we imaged calcium transients and contractility consecutively as opposed to simultaneously. Assessment of these two parameters in conjunction can be done with this model with the proper equipment and would shed further light on a drug’s impact on excitation-contraction coupling.
In conclusion, our 2D/3D hybrid organoid model has potential to offer a novel, high throughput, low cost, and effective drug screening tool that can be utilized to assess several factors impacting cardiac health, such as calcium transients, contractility, and signal propagation. Given that most cardiotoxic effects relate to pro-arrhythmia, our model is well-suited to study most drugs. It additionally allows for studying contractility in association with electrical effects. The isolation of single cells can also allow for staining and assessment of other structures impacted in drug-related cardiotoxicity such as mitochondria, cellular architecture, and alpha actinin. Furthermore, it has potential to provide personalized, precision medicine by utilizing iPSCs directly from patients to study how they may uniquely react to potential drug candidates.