• McGregorChristopher G ACGADepartment of Surgery, University of Minnesota Twin Cities, Minneapolis, Minn; Institute of Cardiovascular Sciences, University College London, London, United Kingdom. Electronic address: mcgregor.christopher@mayo.edu., Guerard W Byrne, Zhiqiang Fan, Christopher J Davies, and Irina A Polejaeva.
• Department of Surgery, University of Minnesota Twin Cities, Minneapolis, Minn; Institute of Cardiovascular Sciences, University College London, London, United Kingdom. Electronic address: mcgregor.christopher@mayo.edu.
• J. Thorac. Cardiovasc. Surg. 2023 Oct 1; 166 (4): e142e152e142-e152.

BackgroundHeart valve implantation in juvenile sheep to demonstrate biocompatibility and physiologic performance is the accepted model for regulatory approval of new biological heart valves (BHVs). However, this standard model does not detect the immunologic incompatibility between the major xenogeneic antigen, galactose-α-1,3-galactose (Gal), which is present in all current commercial BHVs, and patients who universally produce anti-Gal antibody. This clinical discordance leads to induced anti-Gal antibody in BHV recipients, promoting tissue calcification and premature structural valve degeneration, especially in young patients. The objective of the present study was to develop genetically engineered sheep that, like humans, produce anti-Gal antibody and mirror current clinical immune discordance.MethodsGuide RNA for CRISPR Cas9 nuclease was transfected into sheep fetal fibroblasts, creating a biallelic frame shift mutation in exon 4 of the ovine α-galactosyltransferase gene (GGTA1). Somatic cell nuclear transfer was performed, and cloned embryos were transferred to synchronized recipients. Cloned offspring were analyzed for expression of Gal antigen and spontaneous production of anti-Gal antibody.ResultsTwo of 4 surviving sheep survived long-term. One of the 2 was devoid of the Gal antigen (GalKO) and expressed cytotoxic anti-Gal antibody by age 2 to 3 months, which increased to clinically relevant levels by 6 months.ConclusionsGalKO sheep represent a new, clinically relevant advanced standard for preclinical testing of BHVs (surgical or transcatheter) by accounting for the first time for human immune responses to residual Gal antigen that persists after current BHV tissue processing. This will identify the consequences of immune disparity preclinically and avoid unexpected past clinical sequelae.Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

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