Z Kardiol 93:929937 (2004)
DOI 10.1007/s00392-004-0152-7
Y. von Kodolitsch
W. D. Ito
O. Franzen
G. K. Lund
D. H. Koschyk
T. Meinertz
Anomalien der Koronararterien
Teil I: Aktuelle Erkenntnisse
aus der Embryologie
n Zusammenfassung Angeborene
Anomalien der Koronargefe
finden sich in 0,21,2% der Be-
vlkerung und knnen mit erheb-
licher Morbiditt und Mortalitt
assoziiert sein. Diese Arbeit lie-
Received: 2 March 2004
Accepted: 15 July 1004
MD Yskert von Kodolitsch ())
MD Wulf D. Ito MD Olaf Franzen
MD Gunnar K. Lund
MD Dietmar H. Koschyk
MD Thomas Meinertz
Clinic of Internal Medicine III
University Hospital Hamburg-Eppendorf
Martinistrae 52
20246 Hamburg, Germany
Tel.: ++49 40 / 4 28 03 39 69
Fax: ++49 40 / 4 28 03 59 91
E-Mail: kodolitsch@uke.uni-hamburg.de
REVIEW
Coronary artery anomalies
Part I: Recent insights from molecular embryology
fert eine bersicht zum aktuellen
Stand aus Sicht der Embryologie
(Teil I) und zur klinischen Diag-
nostik und Therapie (Teil II).
Im vorliegenden ersten Teil der
Arbeit bieten wir eine bersicht
zur koronaren Vaskulogenese,
Angiogenese und embryonalen
Arteriogenese. Hierbei beleuchten
wir besonders die Rolle von Vor-
luferzellen wie beispielsweise der
epikardialen Vorluferzellen, der
kardialen Neuralleistenzellen und
Vorluferzellen des peripheren
Reizleitungssystems. Darber hi-
naus stellen wir die Rolle ver-
schiedener Wachstumsfaktoren
(beispielsweise FGV, HIF 1, PDGF
B, TGFb1, VEGF und VEGFR-2)
und Gene (beispielsweise FOG-2,
VCAM-1, Bves und RALDH2) bei
der Regulation einzelner Schritte
der koronaren Gefbildung dar.
Dieser Teil der bersicht
mchte die Vielzahl von Mglich-
keiten und Mechanismen zur Ent-
stehung koronarer Anomalitten
verdeutlichen. Deshalb verweisen
wir besonders auf Ergebnisse aus
Experimenten, die eine systemati-
sche Beziehung definierter St-
rungen auf molekularer Ebene
mit koronarer Anomalie erkennen
lassen. Besonders gehen wir hier-
bei auf die Rolle der Neuralleiste
bei der Entwicklung von Koronar-
anomalien und deren Assoziation
mit Anomalien der Aortenwurzel
und Aortenklappe ein.
n Schlsselwrter Angiogenese
Gefe Embryologie
Reizleitung Endotheliale
Wachstumsfaktoren Endothel
Neuralleiste Stammzellen
Koronararterien
n Summary Congenital anoma-
lies of the coronary arteries occur
in 0.21.2% of the general popu-
lation and may cause substantial
cardiovascular morbidity and
mortality. We review some of the
advances that have been made
both, in the understanding of the
embryonic development of the
coronary arteries (part I) and in
the clinical diagnosis and man-
agement of their anomalies
(part II).
In this first part of our review
we elucidate basic mechanisms of
coronary vasculogenesis, angio-
genesis and embryonic arterio-
genesis. Moreover, we review the
role of cellular progenitors such as
epicardium-derived cells, cardiac
neural crest cells and cells of the
peripheral conduction system.
Then we discuss the role of
growths factors (such as FGV, HIF
1, PDGF B, TGFb1, VEGF, and
VEGFR-2) and genes (such as
FOG-2, VCAM-1, Bves, and
RALDH2) at different states of
coronary development.
This part of the article is de-
ZFK 0152
signed to review major determi-
nants of coronary vascular devel-
930 Zeitschrift fr Kardiologie, Band 93, Heft 12 (2004)
Steinkopff Verlag 2004

opment to provide a better under- in mechanisms of coronary mal- n Key words Angiogenesis
standing of the multiplicity of op- formation and we discuss the role Vessels Embryology
tions and mechanisms that may of the cardiac neural crest in the Conduction Endothelial growth
give rise to coronary anomaly. To concurrence of coronary anoma- factors Endothelium
this end, we highlight results from lies with aortic root malforma- Neural crest Stem cells
experiments that provide insight tions. Coronary arteries

As the human heart grows during embryonal devel- Abbreviations

opment, it reaches a size that does not permit sim-
ple diffusion to supply sufficient nutrients and oxy- Ang-Tie Angiopoietin-Tie
gen. At the earliest embryonic stages, a coronary cir- bFGF Basic fibroblast growth factor
culation does not yet exist, and the blood flowing bHLH Basic helix-loop-helix
Bves Blood vessel epicardial substance
through the lumen of the heart tube nourishes the CNC Cardiac neural crest
endocardium and myocardium. However, by begin- ET-1 Cytokine endothelin-1
ning of the third week as the heart wall increases in EPDCs Epicardium-derived cells
thickness, a dedicated vascular system is required to EMT Epithelial-mesenchymal transformation
FGVs Fibroblast growth factors
form over the surface of the myocardium [2]. FOG-2 Friend of GATA-2
Although formation of the coronary arteries consists PCS Peripheral conduction system
of a precisely orchestrated series of molecular and PDGF Platelet derived growth factor
morphogenetic events, even subtle perturbations of PEO Proepicardial organ
these processes may lead to congenital coronary ar- SMC Smooth muscle cells
PPF Periarterial Purkinje fibers
terial abnormality with catastrophic outcome. SPF Subendocardial Purkinje fibers
Previously, the coronary arteries were considered VCAM-1 Vascular cell adhesion molecule 1
outgrowths of the aortic root. In the late eighties, how- VEGF Vascular endothelial growth factor
ever, the Leiden group provided evidence that coro-
nary endothelial precursors self-organize in the sub-
epicardial space and form a vascular plexus that only
in later stages connects to the aorta [4] (Fig. 1). The in as angiogenesis [6, 20, 45]. Vasculogenesis and in par-
situ self-organisation of a vascular plexus from ticular angiogenesis appear to be driven by hypoxia
mesenchymal precursor cells is called vasculogenesis gradients [12, 41]. Only very late during embryonic
and early coronary development is currently consider- development this network gains access to the aortic
ed a paradigm of this process [45]. After formation of rout. The drastic hemodynamic changes caused by
the primary plexus in the subepicardial space a com- the sudden perfusion of this plexus with pulsatile high
plex vascular network grows throughout the myocar- pressures launch the arterialization of this vascular
dium via sprouting from the primary vascular plexus network; this process is referred to as embryonal ar-
and via intussusception by forming new septa and pil- teriogenesis [47]. Arteriogenesis includes the migra-
lars within the vascular lumen; this process is known tion of smooth muscle cells and pericytes from the

Fig. 1 Development of the coronary arteries. Movement of the PEO to and over
the heart is shown in the top panel, and mesenchymal migration and differ-
entiation are shown in the bottom panel. The PEO (blue) is seen as an outgrowth
from the dorsal body wall that moves to the looping heart (red). Next, migrating
epithelium is seen spreading over the heart. In cross section, the epithelium is
seen as a single cell layer. Epithelial/mesenchymal transition provides cells that
migrate into the myocardium. Vasculogenetic cells differentiate and link to form
plexi that induce other mesenchymal cells to become smooth muscle. These
plexi are remodeled into definitive arteries, and the most proximal points of the
major coronaries finally link up with the aorta. (From: [42] with permission)
 Y. von Kodolitsch et al.
Coronary artery anomalies
epicardium and the aortic rout, the assembly of these
cells with the primitive vascular structures to form
stable vessels, radial growth and regression of vessels.
Interestingly, at this stage apoptosis is essential to
form a proper coronary vasculature [6].
Thus, distinct vascular provinces are formed very
late during embryonal life and in rats this process
even proceeds into the neonatal period. However, the
distinction between venous and arterial vasculature
occurs very early during vascular development
although the coronary vessels remain morphologically
indistinguishable and only connect to the sinus veno-
sus during the last stage of coronary development [6].
A defect at any stage of coronary development can
lead to coronary anomaly. First, we will glance over
the different cell types that contribute to the develop-
ment of the coronary arteries. Then we will highlight
the close link between the development of the coro-
nary vasculature and development of the aortic root
and the conduction system. Finally we will review ma-
jor molecular mechanisms that drive coronary devel-
opment. This article is designed to review major
determinants of coronary vascular development to
provide a better understanding of the multiplicity of
options and mechanisms that may give rise to coro-
nary abnormality. To this end, we highlight results
from experiments that provide insight in mechanisms
of coronary malformation [33, 39].
Cellular mechanisms
of coronary artery development
In the primitive streak stage embryo, precursors of
the cardiomyocytes are located in the bilateral plate
mesoderm of the cardiogenic fields, which after
midline fusion form the myocardial tube. The tube
heart comprises the sinus venosus, the atrium, the
ventricle, the bulbus arteriosus, and the truncus ar-
teriosus. Looping of this tubular structure results in
the final four-chambered heart. The early tubular
heart is a bilaminar structure that consists of an in-
ternal layer, the endocardium, and a surrounding
outer layer, the myocardium. The epicardium forms
later during development as a third external layer.
Cells of different origin contribute in the formation
of the coronary vasculature [9, 15].
Epicardium-derived cells (EPDCs): The work of
Manner has documented the requirement of epicar-
dium for development of the myocardium [29, 30].
After looping of the heart tube the epicardium forms
from an extracardiac aggregation of cells located on
the coelomic wall between the sinus venosus and the
developing liver. This cell population is known as
the proepicardial organ (PEO), which is a transient
931
Fig. 2 The pro-epicardial organ (arrow) in a stage 16 quail embryo, which
has been stained with the HNK1 antibody and cleared for transparency. This
antibody will also stain the atrioventricular and outflow tract cushions and
the developing nervous system. (From: [38]; Copyright 2002 Texas Heart
Institute)
structure that decreases in size as the developing
epicardium envelops the heart. During several waves
of invasion, a process of epithelial-mesenchymal
transformation (EMT) generates migratory cells
from the epicardium, which penetrate heart tissues
and provide progenitor populations that differentiate
into interstitial fibroblasts, coronary smooth muscle
cells, adventitial fibroblasts and, most likely, coro-
nary endothelial cells [14, 15, 56]. The function of
the PEO can be described in five consecutive steps:
1) migration as a layer of cells over the myocardial
surface, 2) epithelial-mesenchymal transformation,
3) invasion of the cardiac tube, 4) differentiation
into endothelial cells, smooth muscle cells and fibro-
blasts and 5) interaction with myocardial cells that
subsequently differentiate into Purkinje cells (PCS).
Thus EPDCs play a pivotal role for vasculogenesis
and arteriogenesis (Fig. 2).
Cells of the peripheral conduction system (PCS): In
chicken, the PCS is formed by the periarterial Pur-
kinje fibers (PPF) and the subendocardial Purkinje fi-
bers (SPF). Retrovirus lineage tracing experiments re-
vealed that PPFs differentiate from cardiomyogenic
cells in the tubular heart with the developing arterial
tree establishing a directional framework over which
the PCS is recruited. Interestingly, coronary-artery-
derived cytokine endothelin-1 (ET-1) has been found
to play a role in the terminal differentiation of PPFs. It
should be mentioned, however, that although chick
PPFs serve as an important model for the differentia-
tion of specialized cardiac lineages no relationship be-
tween arteries and specialized myocardial cells has
been found in mammals so far [7, 15] (Fig. 3).
932 Zeitschrift fr Kardiologie, Band 93, Heft 12 (2004)
Steinkopff Verlag 2004
Fig. 3 Induction of periarterial Purkinje fiber conduction cells. The left-hand
panel shows a cluster of red nuclei delineating a clone of lacZ-expressing
cells infected with a defective retrovirus. The clone contains both working
myocytes and an sMHC+ (green) Purkinje fiber a pattern consistent with
the occurrence of localized recruitment of a multipotent progenitor cell to
Fig. 4 Two sections of the base of a 15.5-day transgenic mouse heart at
the level of the aortic semilunar valve. The Wnt1-Cre-lacZ neural crest report-
er is visualized (dark cells) after staining for the presence of b-galactosidase.
Neural crest cells are present in the outflow tract myocardium and in the
Cardiac neural crest (CNC) cells: The CNC cells
migrate from the caudal hindbrain to the base of the
cardiac outflow tract. Although cellular elements of
the coronary arteries are not derived from CNC,
parasympathetic ganglia associated with coronary
vasculature were found to originate from these cells.
CNC are subjected to a high degree of apoptosis and
appear to play an important role for the patterning
of the coronary vasculature as well as for the remod-
elling process of coronary artery development. Using
Wnt1-Cre-lacZ neural crest reporter the fate of CNC
cells can be detected and visualized, as demonstrated
in Figure 4. Experimental ablation of the CNC re-
sulted in various cardiac abnormalities including
systemic rearrangements of the coronary arteries
and reduced density of intramural arterial branches
[15, 24].
specialized myocardial lineages in the avian heart. The right-hand panel
shows a model in which hemodynamically induced factors (for example, en-
dothelin-1) from arterial tissues locally mediate this divergence into either
working myocytes or Purkinje fiber conduction cells within a cardiomyogenic
lineage. (From: [15]; Copyright 2002 Texas Heart Institute)
subendocardium of the right ventricle, but more specifically in the semilunar
valve leaflets, in the aortopulmonary septum (arrow), and surrounding the
coronary arteries (arrowheads). Ao = aorta; RV = right ventricular outflow.
(From: [38]; Copyright 2002 Texas Heart Institute)
Molecular mechanisms
of coronary artery development
Growth factors are essential for regulating the pro-
cesses of epithelial-mesenchymal transformation,
proliferation, migration, tube formation, sprouting
and further assembly of the vascular wall of the de-
veloping coronary arteries (Fig. 5).
Vasculogenesis: At the earliest stage of vasculari-
zation endothelial precursor cells migrate into the
myocardium and assemble into primitive vascular
tubes; in the myocardium, these precursor cells de-
velop an epicardial-to-endocardial vascular gradient,
which is closely related to the deposition of specific
components of the extracellular matrix such as fi-
bronectin with its receptor alpha5beta1 and collagen
I with its receptors a1b1 and a2b1. Proteins of the
transforming growth factor family like bone mor-
phogenic protein (BMP) and TGFb1 play an impor-
tant role during these initial steps of endothelial cell
migration and proliferation [6, 20]. The function of
TGFb1 is tightly regulated and only at low concen-
 Y. von Kodolitsch et al.
Coronary artery anomalies
Fig. 5 Molecular mechanisms of coronary artery
development. For abbreviation see text
trations TGFb1 promotes endothelial migration and
proliferation via the TGFb1-ALK1 pathway, whereas
at higher concentrations TGFb1 accounts for vessel
maturation; TGFb1-stimulated vessel maturation is
mediated by TGFb1-ALK5 during later stages of vas-
cular development. The TGFb1 response is likely to
be regulated by endoglin. The growth factors vascu-
lar endothelial growth factor A (VEGF A) and basic
fibroblast growth factor (bFGF) are also important
for the initial steps of precursor cell migration, dif-
ferentiation, proliferation and primary tube forma-
tion [44, 45]. The extent of vascularization relates to
the rate of myocardial growth and hypoxia and
physical stretch act as major stimuli of vasculariza-
tion [26, 47]. Low oxygen saturation is transmitted
into growth factor expression via the Hypoxia Indu-
cible Factor 1 alpha (HIF 1 alpha) [12, 41]. HIF 1 is
an a /b heterodimer and HIF a units are inducible by
hypoxia interacting with hypoxia response elements
(HREs) of different genes (VEGF, erythropoietin) to
induce transcriptional activity [5153].
Angiogenesis: Hypoxia-regulated VEGF A expres-
sion also plays an important role during the second
step of vascular development. Vascular sprouting
from the primary plexus is guided by hypoxic gradi-
ents and promoted by VEGF A and the VEGF recep-
tor FLK 1 [6, 45]. The Angiopoietin-Tie (Ang-Tie)
system is also essential for coronary angiogenesis.
VEGF A and Ang 2 act on the receptor Tie 2 to in-
duce vascular sprouting by loosening intercellular
contacts. Conversely, Ang 1 leads to vascular stabili-
933
sation and thus is an important factor for vessel ma-
turation [6, 20]. bFGF also plays a pivotal role for
vascular sprouting. Studies on explanted quail hearts
reveal that the effect of these different growth factors
is interdependent [52, 53].
Arteriogenesis: Stabilization of the vascular net-
work is accomplished by attracting pericytes and
smooth muscle cells from the pericardium [47]. This
process is primarily regulated by platelet derived
growth factor B (PDGF B) and the receptor PDGFR
b, that is expressed on SMC progenitors [6, 20]. Vas-
cular maturation is likely to be initiated by the sud-
den hemodynamic changes after the coronary vascu-
lar network is connected to the aortic rout. Interest-
ingly, a shear stress response element has been
cloned for the PDGF gene [43, 47]. Moreover, by ac-
tivating Tie 2 Ang 1 stabilizes contacts between both
endothelial cells and endothelial cells and smooth
muscle cells. TGFb1 inhibits endothelial cell growth,
promotes basement membrane formation and stimu-
lates SMC differentiation and recruitment [6, 20].
Experiments using neutralizing antibodies to either
bFGF or VEGF provide evidence that the hierarchical
development of the arteriolar vasculature is influ-
enced by these growth factors [52, 53] (Fig. 5).
The arterio-venous fate of endothelial cells is de-
termined very early during development and may
even take place before the primary plexus is formed
[6]. The Notch pathway that includes its ligands
(Delta-like-4, Jagged-1 and Jagged-2) and receptors
(Notch-1, Notch-3 and Notch-4) promotes the ar-
934 Zeitschrift fr Kardiologie, Band 93, Heft 12 (2004)
Steinkopff Verlag 2004

terial fate of endothelial cells by suppressing venous

differentiation. Sonic Hedgehog and VEGF act up-
stream, whereas Gridlock probably acts downstream
of Notch to determine arterial fate. Later during
development Notch 3 receptor on SMCs appears to
be crucial for the anchorage and survival of SMCs.
EphrinB2-EphB4 signaling is important to demarcate
arterial and venous boundaries. EphrinB2 is ex-
pressed in arterial endothelium but not in venous
endothelium whereas the receptor EphB4 is ex-
clusively expressed on venous endothelium; inter-
estingly both EphrinB2 and EphB4 are already
present when the primary plexus endothelium devel-
ops.
The complexity of the molecular mechanisms that
regulate the development of the coronary arteries of-
fers multiple potential sites at which vascular malfor-
mations may occur. Targeted deletion of genes that
express most of the factors that are mentioned above
result in severe disturbance of coronary vascular de-
velopment that is usually lethal. It is likely that mi-
nor changes in the mechanisms or the balance of
growth factors causes coronary anomalies. However,
little is known about the genetic background of
coronary anomalies and thus we will review some of
the genes known to be involved in coronary vascular
development.
The role of genes in coronary artery development
The molecular basis of the regulation of coronary ar-
tery development is currently evolving. For instance,
the zinc finger protein friend of GATA-2 (FOG-2) is
modulating transcriptional activities of GATA factors
through physical interaction. In mice, disruption of
the FOG-2 gene is lethal at midgestation with cardi-
ac malformations comprising a thin ventricular myo-
cardium, common atrioventricular canal, and the
tetralogy of Fallot malformation. Most notably, both
coronary vasculature and markers of cardiac vessel
development are absent in FOG-2-deficient hearts
despite an intact epicardial layer. Thus, loss of FOG-
2 is likely to prevent epithelial-to-mesenchymal tran-
sition of epicardial cells suggesting an essential
FOG-2-dependent role for myocardium in the pro-
gram of coronary vessel development. Interestingly,
mice harboring a single amino acid replacement in
GATA-4 selectively impairing its physical interaction
with FOG-2 exhibited a similar heart phenotype as
FOG-2-deficient mice (Fig. 6) [8, 31, 40, 50].
Knockout of the cell adhesion molecules a4 inte-
grin in the epicardium and vascular cell adhesion
molecule 1 (VCAM-1) in the myocardium result in
lack of the epicardial layer over large portions of the
Fig. 6 Coronary vasculature abnormality despite intact epicardium in hearts
of mice with inactivation of the FOG-2 gene (Fog-2/) as compared to wild-
type control hearts (FOG-2+/+). Immunostaining of isolated E12.5 mouse
hearts with a-PECAM-1 antibody, a cell adhesion molecule expressed in en-
dothelium (top: ventral view; bottom: dorsal view) shows the presence of
the endocardial cell network in the ventricles and endothelial cells lining the
great vessels and the atria in the wild-type (a and c) and in the mutant (b
and d). Capillary vasculature in the control heart (arrow) is absent in the
mutant. Staining illustrates stenosis of the pulmonary trunk (PT) in FOG-2/
heart (arrowhead). (Reprinted from [50]; Copyright 2000 with permission
from Elsevier)
heart leading to absence of coronary vessels with se-
vere hemorrhage. Interestingly, these genes are still
expressed in hearts of FOG-2-deficient mice with
their defects occurring prior to EMT [50]. The tran-
scription factor capsulin and the cell adhesion mole-
cule blood vessel epicardial substance (Bves) may
have roles in both migration and differentiation of
epicardial and coronary cell progenitors. Capsulin,
also known as epicardin and Pod1, is a member of
the basic helix-loop-helix (bHLH) transcription fac-
tor family associated with the epithelial-mesenchy-
mal transformation process in lung, gut and kidney.
Capsulin is expressed in the PEO of mice and con-
tinues into the developing coronary vasculature [15,
17]. Bves is a prototype of a novel class of cell-adhe-
sion molecules that is expressed in a subset of cells
within the PEO in chicken and in cells of the epicar-
dium and subepicardium in mice. Later during de-
velopment, Bves is found in cells in the subendocar-
dium and in arterial vascular channels, where it lo-
calizes to smooth muscle cells of mature coronary
arteries [57].
The RhoA-RhoK GTPase signaling system also
plays a role in EMT and PEO cell migration and par-
 Y. von Kodolitsch et al. 935
Coronary artery anomalies

ticipates in actin reorganization; interestingly, per-
turbation experiments prevent PEO cells from mi-
grating into the myocardium [28]. RALDH2 (retinoic
acid-synthetic enzyme) responsible for retinoic acid
production is another gene product of the epicar-
dium giving rise to potent signaling molecules for
heart development [27, 32, 58].
Role of the aortic root
Anomalies of coronary arteries involve varying de-
grees of aortic root abnormality such as asymmetry
of the aortic sinuses, bicuspid and quadricuspid aor-
tic valves in about 26% of cases [1]. With a bicuspid
aortic valve, the left coronary artery supplies the
crux of the heart in 29 to 57% of the cases [18, 19]
and 90% of cases the left main stem is less than 5
mm in length [34]. Moreover, anomalous origins of
the right and left coronary arteries have been noted
in patients with bicuspid aortic valves [10, 37] and
such anomalies require the surgeons awareness to
avoid coronary injury during valve replacement [11,
34]. Similarly, Syrian hamsters belonging to an
inbred laboratory colony with high incidence of con-
genitally bicuspid aortic valves exhibited abnormal
coronary pattern in 48% of cases [5, 46]. The CNC
gives rise to ectomesenchyme, which supports the
development of the aortic arch arteries, the aortico-
pulmonary septum that divides the cardiac outflow
tract into the aortic and pulmonary tracts and the
coronary arteries [13, 15, 22]. In addition, CNC co-
lonize the aortic and pulmonary valve primordia
and thus may participate in the developmental pro-
cess of the semilunar heart valve cushions [48, 49].
Thus, CNC defects may account for the clustering of
numerous cardiac abnormalities and in humans bi-
cuspid aortic valves are also associated with malfor-
mation of other neural crest-derived systems such as
aortic arch hypoplasia, aortic coarctation and Di-
George syndrome [21, 54, 55].
Experimental ablation of the cardiac neural crest
results in definite phenotypes comprising persistent
truncus arteriosus, overriding aorta, tetralogy of Fal-
lot and double outlet right ventricle, all of which are
invariantly associated with patterning anomalies of
the great arteries [3, 35]. However, CNC have a re-
gional specification that occurs prior to migration
and provides these cells with a unique ability to sup-
port cardiovascular development in specific regions
of the heart and the great arteries [23, 36]. As might
have been expected from these insights, specific tar-
geting of paralogous groups of Hox messages with
their anterior expression domains in pharyngeal ar-
ches 3, 4 and 6 was associated with abnormal pat-
terning of the aortic arch but did not evoke cardiac
malformations. Thus, the concurrence of cardiac
outflow tract defects with abnormal development of
the aortic arch may not be obligatory in individuals
with inborn defects of the CNC [25].
Final considerations
Epicardium-derived cells play an important role in
coronary artery development and differentiation,
and specific genes such as FOG-2, VCAM-1, Bves,
and RALDH2 give rise to potent signaling molecules
responsible for vascular growth. The epicardium-de-
rived cells and genes appear to have potential as a
resource to repair ischemic and failing hearts and to
deliver endothelial cells, SMC, and fibroblasts to sites
of heart injury [38]. Moreover, knowledge of distinct
gene defects may be instrumental both for early
identification of patients at risk for coronary malfor-
mation and for gene therapy of specific anomalies.
On the other hand, pharmacologic interventions that
activate genes or growth factors in the myocardium
may obviate the need of invasively delivering genes
or growth factors to the coronary arteries. Moreover,
mechanical factors such as shear stress may be used
as therapeutic agents to activate growth factors and,
consequently, coronary angiogenesis [16, 53].
n Acknowledgement The authors wish to express their grateful-
ness to Claudia Hottendorff and Heidi Schning for helping us to
prepare the figures to the manuscript.

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