Significance of calcium phosphate coatings for the enhancement of new bone osteogenesis – A review

A systematic analysis of results available from in vitro, in vivo and clinical trials on the effects of biocompatible calcium phosphate (CaP) coatings is presented. An overview of the most frequently used methods to prepare CaP-based coatings was conducted. Dense, homogeneous, highly adherent and biocompatible CaP or hybrid organic/inorganic CaP coatings with tailored properties can be deposited. It has been demonstrated that CaP coatings have a significant effect on the bone regeneration process. In vitro experiments using different cells (e.g. SaOS-2, human mesenchymal stem cells and osteoblast-like cells) have revealed that CaP coatings enhance cellular adhesion, proliferation and differentiation to promote bone regeneration. However, in vivo, the exact mechanism of osteogenesis in response to CaP coatings is unclear; indeed, there are conflicting reports of the effectiveness of CaP coatings, with results ranging from highly effective to no significant or even negative effects. This review therefore highlights progress in CaP coatings for orthopaedic implants and discusses the future research and use of these devices. Currently, an exciting area of research is in bioactive hybrid composite CaP-based coatings containing both inorganic (CaP coating) and organic (collagen, bone morphogenetic proteins, arginylglycylaspartic acid etc.) components with the aim of promoting tissue ingrowth and vascularization. Further investigations are necessary to reveal the relative influences of implant design, surgical procedure, and coating characteristics (thickness, structure, topography, porosity, wettability etc.) on the long-term clinical effects of hybrid CaP coatings. In addition to commercially available plasma spraying, other effective routes for the fabrication of hybrid CaP coatings for clinical use still need to be determined and current progress is discussed.     

Controlled release properties and final macroporosity of a pectin microspheres–calcium phosphate composite bone cement

The use of calcium phosphate cements (CPC) is restricted by their lack of macroporosity and poor drug release properties. To overcome these two limitations, incorporating degradable polymer microparticles into CPC is an attractive option, as polymer microparticles could help to control drug release and induce macroporosity after degradation. Although few authors have yet tested synthetic polymers, the potentiality of polysaccharides’ assuming this role has never been explored. Low-methoxy amidated pectins (LMAP) constitute valuable candidates because of their biocompatibility and ionic and pH sensitivity. In this study, the potentiality of a LMAP with a degree of esterification (DE) of 30 and a degree of amidation (DA) of 19 was explored. The aim of this study was to explore the influence of LMAP microspheres within the composite on the cement properties, drug release ability and final macroporosity after microspheres degradation. Three LMAP incorporation ratios, 2%, 4% and 6% w/w were tested, and ibuprofen was chosen as the model drug. In comparison with the CPC reference, the resulting composites presented reduced setting times and lowered the mechanical properties, which remained acceptable for an implantation in moderate-stress-bearing locations. Sustained release of ibuprofen was obtained on at least 45 days, and release rates were found to be controlled by the LMAP ratio, which modulated drug diffusion. After 4 months of degradation study, the resulting CPC appeared macroporous, with a maximum macroporosity of nearly 30% for the highest LMAP incorporation ratio, and interconnectivity between pores could be observed. In conclusion, LMAP appear as interesting candidates to generate macroporous bone cements with tailored release properties and macroporosity by adjusting the pectin content within the composites.     

Development of a bovine collagen–apatitic calcium phosphate cement for potential fracture treatment through vertebroplasty

The aim of this study was to examine the potential of incorporating bovine fibres as a means of reinforcing a typically brittle apatite calcium phosphate cement for vertebroplasty. Type I collagen derived from bovine Achilles tendon was ground cryogenically to produce an average fibre length of 0.96 ± 0.55 mm and manually mixed into the powder phase of an apatite-based cement at 1, 3 or 5 wt.%. Fibre addition of up to 5 wt.% had a significant effect (P ? 0.001) on the fracture toughness, which was increased by 172%. Adding ?1 wt.% bovine collagen fibres did not compromise the compressive properties significantly, however, a decrease of 39–53% was demonstrated at ?3 wt.% fibre loading. Adding bovine collagen to the calcium phosphate cement reduced the initial and final setting times to satisfy the clinical requirements stated for vertebroplasty. The cement viscosity increased in a linear manner (R² = 0.975) with increased loading of collagen fibres, such that the injectability was found to be reduced by 83% at 5 wt.% collagen loading. This study suggests for the first time the potential application of a collagen-reinforced calcium phosphate cement as a viable option in the treatment of vertebral fractures, however, issues surrounding efficacious cement delivery need to be addressed.     

Incorporation of bioactive polyvinylpyrrolidone–iodine within bilayered collagen scaffolds enhances the differentiation and subchondral osteogenesis of mesenchymal stem cells

Polyvinylpyrrolidone–iodine (Povidone-iodine, PVP-I) is widely used as an antiseptic agent for lavation during joint surgery; however, the biological effects of PVP–I on cells from joint tissue are unknown. This study examined the biocompatibility and biological effects of PVP–I on cells from joint tissue, with the aim of optimizing cell-scaffold based joint repair. Cells from joint tissue, including cartilage derived progenitor cells (CPC), subchondral bone derived osteoblast and bone marrow derived mesenchymal stem cells (BM-MSC) were isolated. The concentration-dependent effects of PVP–I on cell proliferation, migration and differentiation were evaluated. Additionally, the efficacy and mechanism of a PVP–I loaded bilayer collagen scaffold for osteochondral defect repair was investigated in a rabbit model. A micromolar concentration of PVP–I was found not to affect cell proliferation, CPC migration or extracellular matrix production. Interestingly, micromolar concentrations of PVP–I promote osteogenic differentiation of BM-MSC, as evidenced by up-regulation of RUNX2 and Osteocalcin gene expression, as well as increased mineralization on the three-dimensional scaffold. PVP–I treatment of collagen scaffolds significantly increased fibronectin binding onto the scaffold surface and collagen type I protein synthesis of cultured BM-MSC. Implantation of PVP–I treated collagen scaffolds into rabbit osteochondral defect significantly enhanced subchondral bone regeneration at 6 weeks post-surgery compared with the scaffold alone (subchondral bone histological score of 8.80 ± 1.64 vs. 3.8 ± 2.19, p < 0.05). The biocompatibility and pro-osteogenic activity of PVP–I on the cells from joint tissue and the enhanced subchondral bone formation in PVP–I treated scaffolds would thus indicate the potential of PVP–I for osteochondral defect repair.     

Directing osteogenesis of stem cells with hydroxyapatite precipitated electrospun eri–tasar silk fibroin nanofibrous scaffold

Stimulating stem cell differentiation without growth factor supplement offers a potent and cost-effective scaffold for tissue regeneration. We hypothesise that surface precipitation of nano-hydroxyapatite (nHAp) over blends of non-mulberry silk fibroin with better hydrophilicity and RGD amino acid sequences can direct the stem cell towards osteogenesis. This report focuses on the fabrication of a blended eri–tasar silk fibroin nanofibrous scaffold (ET) followed by nHAp deposition by a surface precipitation (alternate soaking in calcium and phosphate solution) method. Morphology, hydrophilicity, composition, and the thermal and mechanical properties of ET/nHAp were examined by field emission scanning electron microscopy, TEM, FT-IR, X-ray diffraction, TGA and contact angle measurement and compared with ET. The composite scaffold demonstrated improved thermal stability and surface hydrophilicity with an increase in stiffness and elastic modulus (778?±?2.4?N/m and 13.1?±?0.36?MPa) as compared to ET (160.6?±?1.34?N/m and 8.3?±?0.4?MPa). Mineralisation studies revealed an enhanced and more uniform surface deposition of HAp-like crystals, while significant differences in cellular viability and attachment were observed through 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay and confocal microscopy study. The cell viability and expression of adhesion molecules (CD 44 and CD 29) are found to be optimum for subsequent stages of growth proliferation and differentiation. The rates of proliferation have been observed to decrease owing to the transition of MSC from a state of proliferation to a state of differentiation. The confirmation of improved osteogenic differentiation was finally verified through the alkaline phosphatase assay, pattern of gene expression related to osteogenic differentiation and morphological observations of differentiated cord blood human mesenchymal stem cells under fluorescence microscope. The results obtained showed the improved physicochemical and biological properties of the ET/nHAp scaffold for osteogenic differentiation without the addition of any growth factors.     

A new approach in biomimetic synthesis of calcium phosphate coatings using lactic acid–Na lactate buffered body fluid solution

The main objective of this study was to investigate calcium phosphate (CaP) coatings on Ti6Al4V substrates by using the biomimetic technique. To this purpose, a new solution was developed to coat CaP on Ti6Al4V alloy substrates. The newly formulated body fluid (Lac-SBF) contained appropriate amounts of sodium lactate (NaL) and lactic acid (HL), as well as all the other ionic constituents of the human blood plasma. The inorganic ion concentrations of the Lac-SBF solutions were identical with those of human blood plasma. The new Lac-SBF solution of this study eliminated the need for using Tris/HCl or Hepes/NaOH buffers. Prior to coating, Ti6Al4V substrates were chemically treated in NaOH and/or NaOH + H₂O₂ solutions as an alternative route and then heated at 600 °C for 1 h in air. In the previous applications, the Cl^? ion concentration was found to be higher than blood plasma 103 mM, which exists in human blood plasma as a result of Tris/HCl which are used to prevent precipitation and to keep the pH level at certain values. In this study, instead of using Tris/HCl, HL/NaL which are generated by human body and do not show any toxic behavior, are used and Cl^? concentration was kept at 103 mM value for the first time. The prepared Lac-SBF was shown to have similar concentration to human blood plasma in terms of all inorganic ions for the first time. Solution properties were evaluated by using turbidimeter, pH meter and rheometer. The coatings were characterized using Fourier-transform infrared spectroscopy (FTIR), X-ray diffraction (XRD), scanning electron microscopy (SEM), and a scratch tester. The obtained results are presented and discussed.     

Computational modelling of phonological dyslexia: how does the DRC model fare?

This paper investigates the patterns of reading impairment in phonological dyslexia using computational modelling with the dual-route cascaded model of reading (DRC, Coltheart, Rastle, Perry, Langdon, & Ziegler, 2001). Systematic lesioning of nonlexical and phonological processes in DRC demonstrates that different lesions and severity of those lesions can reproduce features of phonological dyslexia including impaired reading of nonwords, relatively spared reading of words, an advantage for reading pseudohomophones. Using the same stimuli for model and for patients, lesions to DRC were also used to simulate the reading accuracy shown by three individuals with acquired phonological dyslexia. No single lesion could replicate the reading performance of all three individuals. In order to simulate reading accuracy for one individual a phonological impairment was necessary (addition of noise to the phoneme units), and for the remaining two individuals an impairment to nonlexical reading procedures (increasing the time interval between each new letter being processed) was necessary. We argue that no single locus of impairment (neither phonological nor nonlexical) can account for the reading impairments of all individuals with phonological dyslexia. Instead, different individuals have different impairments (and combinations of impairments) that together provide the spectrum of patterns found in phonological dyslexia.     

Bioactive silica–collagen composite xerogels modified by calcium phosphate phases with adjustable mechanical properties for bone replacement

The development of composites has been recognized as a promising strategy to fulfil the complex requirements of biomaterials. The present study reports on the modification of a novel silica–collagen composite material by varying the inorganic/organic mass ratio and introducing calcium phosphate cement (CPC) as a third component. The sol–gel technique is used for processing, followed by xerogel formation under specific temperature and relative humidity conditions. Cylindrical monolithic samples up to 400 mm³ were obtained without any sintering processes. Various hierarchical phases of the organic component were applied, ranging from tropocollagen and collagen fibrils up to collagen fibers, each characterized by atomic force microscopy. Focusing on the application of fibrils, various inorganic/organic mass ratios were used: 100/0, 85/15 and 70/30; their influence on the structure of the composite material was demonstrated by scanning electron microscopy. The composition was extended by the addition of 25 wt.% CPC which led to increased bioactivity by accelerating the formation of bone apatite layers in simulated body fluid. Synchrotron microcomputed tomography demonstrated the homogeneous distribution of the cement particles in the silica–collagen matrix. Compressive strength tests showed that the mechanical properties of the brittle pure silica gel are changed significantly due to collagen addition. The highest ultimate strength of about 115 MPa at about 18% total strain was registered for the 70/30 silica–collagen composite xerogels. Incorporation of CPC lowered the gel’s strength. By demonstrating differentiation of human monocytes into osteoclast-like cells, an important feature of the composite material regarding successful bone remodeling is fulfilled.     

Determinants of the voltage dependence of G protein modulation within calcium channel β subunits

Ca_Vβ subunits of voltage-gated calcium channels contain two conserved domains, a src-homology-3 (SH3) domain and a guanylate kinase-like (GK) domain with an intervening HOOK domain. We have shown in a previous study that, although Gβγ-mediated inhibitory modulation of Ca_V2.2 channels did not require the interaction of a Ca_Vβ subunit with the Ca_Vα1 subunit, when such interaction was prevented by a mutation in the α1 subunit, G protein modulation could not be removed by a large depolarization and showed voltage-independent properties (Leroy et al., J Neurosci 25:6984–6996, 2005). In this study, we have investigated the ability of mutant and truncated Ca_Vβ subunits to support voltage-dependent G protein modulation in order to determine the minimal domain of the Ca_Vβ subunit that is required for this process. We have coexpressed the Ca_Vβ subunit constructs with Ca_V2.2 and α₂δ-2, studied modulation by the activation of the dopamine D2 receptor, and also examined basal tonic modulation. Our main finding is that the Ca_Vβ subunit GK domains, from either β1b or β2, are sufficient to restore voltage dependence to G protein modulation. We also found that the removal of the variable HOOK region from β2a promotes tonic voltage-dependent G protein modulation. We propose that the absence of the HOOK region enhances Gβγ binding affinity, leading to greater tonic modulation by basal levels of Gβγ. This tonic modulation requires the presence of an SH3 domain, as tonic modulation is not supported by any of the Ca_Vβ subunit GK domains alone. Andriy V. Dresviannikov and Karen M. Page contributed equally to this work.     

Adenosine deaminase–acid phosphatase association and the environment: A study in a continental Italian population

Three hundred fifty newborns from Rome and 351 from Penne were studied in continental Italy. Medium high altitude above sea level and cold winters characterize the area of Penne, while low altitude and very mild winters characterize the area of Rome. An effect of environmental conditions on the association between adenosine deaminase (ADA) and acid phosphatase (ACP1), previously shown in Sardinia, has been confirmed in continental Italy. When compared with expected independent assortment, the proportion of ACP1*A/*A carrying the ADA*2 allele is lower than expected in the lowlands and higher than expected in highlands. In continental Italy there is an interaction among ACP1–ADA genotype, season of conception, and locality. The excess of *A/*A newborns carrying the ADA*2 allele is present only among those conceived in the first half of the year (January–June). Among newborns in Penne conceived in the Spring, the proportion of those with *A/*A genotype is increased and these infants show decreased intrauterine growth. The present data suggest that ADA and ACP1 interact during intrauterine life with effects on development and survival and that such effects are dependent on local environment and season of conception. Am. J. Hum. Biol. 12:214–220, 2000. © 2000 Wiley-Liss, Inc.     

Lipid–calcium phosphate nanoparticles for delivery to the lymphatic system and SPECT/CT imaging of lymph node metastases

A lipid/calcium/phosphate (LCP) nanoparticle (NP) formulation (particle diameter ∼25 nm) with superior siRNA delivery efficiency was developed and reported previously. Here, we describe the successful formulation of ¹¹¹In into LCP for SPECT/CT imaging. Imaging and biodistribution studies showed that, polyethylene glycol grafted ¹¹¹In-LCP preferentially accumulated in the lymph nodes at ∼70% ID/g in both C57BL/6 and nude mice when the improved surface coating method was used. Both the liver and spleen accumulated only ∼25% ID/g. Larger LCP (diameter ∼67 nm) was less lymphotropic. These results indicate that 25 nm LCP was able to penetrate into tissues, enter the lymphatic system, and accumulate in the lymph nodes via lymphatic drainage due to 1) small size, 2) a well-PEGylated lipid surface, and 3) a slightly negative surface charge. The capability of intravenously injected ¹¹¹In-LCP to visualize an enlarged, tumor-loaded sentinel lymph node was demonstrated using a 4T1 breast cancer lymph node metastasis model. Systemic gene delivery to the lymph nodes after IV injection was demonstrated by the expression of red fluorescent protein cDNA. The potential of using LCP for lymphatic drug delivery is discussed.     

Substrate stiffness and contractile behaviour modulate the functional maturation of osteoblasts on a collagen–GAG scaffold

Anchorage-dependent cells respond to the mechanical and physical properties of biomaterials. One such cue is the mechanical stiffness of a material. We compared the osteogenic potential of collagen–glycosaminoglycan (CG) scaffolds with varying stiffness for up to 6 weeks in culture. The mechanical stiffness of CG scaffolds were varied by cross-linking by physical (dehydrothermal (DHT)) and chemical (1-ethyl-3-(3-dimethyl aminopropyl) carbodiimide (EDAC) and glutaraldehyde (GLUT)) methods. The results showed that all CG substrates allowed cellular attachment, infiltration and osteogenic differentiation. CG scaffolds treated with EDAC and GLUT were mechanically stiffer, retained their original scaffold structure and resisted cellular contraction. Consequently, they facilitated a 2-fold greater cell number, probably due to the pore architecture being maintained, allowing improved diffusion of nutrients. On the other hand, the less stiff substrates cross-linked with DHT allowed increased cell-mediated scaffold contraction, contracting by 70% following 6 weeks (P < 0.01) of culture. This reduction in scaffold area resulted in cells reaching the centre of the scaffold quicker up to 4 weeks; however, at 6 weeks all scaffolds showed similar levels of cellular infiltration, with higher cell numbers found on the stiffer EDAC- and GLUT-treated scaffolds. Analysis of osteogenesis showed that scaffolds cross-linked with DHT expressed higher levels of the late stage bone formation markers osteopontin and osteocalcin (P < 0.01) and increased levels of mineralisation. In conclusion, the more compliant CG scaffolds allowed cell-mediated contraction and supported a greater level of osteogenic maturation of MC3T3 cells, while the stiffer, non-contractible scaffolds resulted in lower levels of cell maturation, but higher cell numbers on the scaffold. Therefore, we found scaffold stiffness had different effects on differentiation and cell number whereby the increased cell-mediated contraction facilitated by the less stiff scaffolds positively modulated osteoblast differentiation while reducing cell numbers.     

Computational modelling of motion at the bone–implant interface after total knee arthroplasty: The role of implant design and surgical fit

Background

Aseptic loosening, osteolysis, and infection are the most commonly reported reasons for revision total knee arthroplasty (TKA). This study examined the role of implant design features (e.g. condylar box, pegs) and stems in resisting loosening, and also explored the sensitivity of the implants to a loose surgical fit due to saw blade oscillation.

Mathematical modelling of the acid–base chemistry and oxygenation of blood: a mass balance, mass action approach including plasma and red blood cells

Mathematical models of the acid–base chemistry of blood based upon mass action and mass balance equations have become popular as diagnostic tools in intensive care. The reference models using this approach are those based on the strong ion approach, but these models do not currently take into account the effects of oxygen on the buffering characteristics of haemoglobin. As such these models are limited in their ability to simulate physiological situations involving simultaneous changes of O₂ and CO₂ levels in the blood. This paper describes a model of acid–base chemistry of blood based on mass action and mass balance equations and including the effects of oxygen. The model is used to simulate the mixing of venous blood with the same blood at elevated O₂ and reduced CO₂ levels, and the results compared with the mixing of blood sampled from 21 healthy subjects. Simulated values of pH, PCO₂, PO₂ and SO₂ in the mixed blood compare well with measured values with small bias (i.e. 0.000 pH, −0.06 kPa PCO₂, −0.1% SO₂, −0.02 kPa PO₂), and values of standard deviations (i.e. 0.006 pH, 0.11 kPa PCO₂, 0.8% SO₂, 0.13 kPa PO₂) comparable to the precision seen in direct measurement of these variables in clinical practice. These results indicate that the model can reliably simulate the mixing of blood and has potential for application in describing physiological situations involving the mixing of blood at different O₂ and CO₂ levels such as occurs in the mixing of lung capillary and shunted pulmonary blood.     

Evaluation of host inflammatory responses of β-tricalcium phosphate bioceramics caused by calcium pyrophosphate impurity using a subcutaneous model

Implantation of synthetic materials into body elicits inflammatory host responses that limit medical device integration and biological performance. Since the effective use of biomaterials in vivo requires good biocompatibility and bio-functionality, it is vital that we assess the inflammatory reactions provoked by various implanted biomaterials. In chemical precipitation of β-tricalcium phosphate [β-Ca?(PO?)?, β-TCP], the impurity of calcium pyrophosphate (Ca?P?O?, CPP) will easily appear if the preparation conditions are not well controlled. To test the influences of CCP-impurity on the biocompatibility of the material, four groups of β-TCP ceramic samples doped with 0.5-10 wt % of CCP impurity, and pure β-TCP and CCP samples were fabricated and implanted in rat subcutaneous site for one, two, and four weeks. The host tissue responses to the ceramics were evaluated by histomorphometric analysis, and the results were compared with pure β-TCPbioceramics. The results show that the CPP impurity can elicit and stimulate the inflammatory responses at the tissue/implant interface. Moreover, with the increase of CPP doping amount, the inflammation increases apparently. However, the pure β-TCP bioceramics only present slight post-implantation inflammatory responses. The influence of the CPP doping on the inflammatory responses is mainly related to a microparticles release because of an insufficient sintering of β-TCP by CPP doping. The microparticle release could be at the origin of local inflammation and cell/tissue damages. Therefore, to obtain perfect biocompatibility and high quality β-TCP bioceramics, it is important to avoid and control the CPP impurity in the preparation of β-TCP powders and bioceramics.     

Comparison of seven modelling algorithms for γ-aminobutyric acid–edited proton magnetic resonance spectroscopy

Edited MRS sequences are widely used for studying γ-aminobutyric acid (GABA) in the human brain. Several algorithms are available for modelling these data, deriving metabolite concentration estimates through peak fitting or a linear combination of basis spectra. The present study compares seven such algorithms, using data obtained in a large multisite study. GABA-edited (GABA+, TE = 68 ms MEGA-PRESS) data from 222 subjects at 20 sites were processed via a standardised pipeline, before modelling with FSL-MRS, Gannet, AMARES, QUEST, LCModel, Osprey and Tarquin, using standardised vendor-specific basis sets (for GE, Philips and Siemens) where appropriate. After referencing metabolite estimates (to water or creatine), systematic differences in scale were observed between datasets acquired on different vendors' hardware, presenting across algorithms. Scale differences across algorithms were also observed. Using the correlation between metabolite estimates and voxel tissue fraction as a benchmark, most algorithms were found to be similarly effective in detecting differences in GABA+. An interclass correlation across all algorithms showed single-rater consistency for GABA+ estimates of around 0.38, indicating moderate agreement. Upon inclusion of a basis set component explicitly modelling the macromolecule signal underlying the observed 3.0 ppm GABA peaks, single-rater consistency improved to 0.44. Correlation between discrete pairs of algorithms varied, and was concerningly weak in some cases. Our findings highlight the need for consensus on appropriate modelling parameters across different algorithms, and for detailed reporting of the parameters adopted in individual studies to ensure reproducibility and meaningful comparison of outcomes between different studies.     

Genome–environment interactions in the molecular pathogenesis of dilated cardiomyopathy

Dilated cardiomyopathy (DCM) is a heart muscle disease characterized by impaired contractility and dilation of the ventricles. In a subset of DCM patients, classical inheritance patterns occur (familial DCM), which have led to the identification of specific genomic loci and gene defects causing monogenic DCM subtypes. In the majority of DCM patients, however, there is no evidence for a monogenic etiology of the disorder (sporadic DCM), and in the absence of other recognizable etiological factors, these cases were classified as idiopathic. Recent research suggests that cardiotropic viruses are important environmental factors in the pathogenesis of idiopathic cases and that DCM commonly results from interactions between genetic and environmental factors, whereas pure genetic forms are rather rare. Regarding genetics, the clinical cardiomyopathic phenotype associated with single gene defects may be highly variable for unknown reasons. Furthermore, a novel class of genetic defects was identified recently which provide a molecular basis for abnormal reactions of cardiomyocytes to environmental stress. These defects are paradigms of specific molecular links between genome and environment during the pathogenesis of DCM. Regarding environmental factors, a recent molecular virological study based on myocardial biopsies in a large series of sporadic DCM patients has detected cardiac viral infections in the majority of patients, with a broad spectrum of virus species being involved. Apparently, DCM does not only occur as a late sequela of acute viral myocarditis, but also in patients without clinical history of cardiac viral disease. Cardiotropic viruses thus emerge as prevalent environmental factors which may cause or influence the course of DCM in a large fraction of cases. Synopsis of current data suggests that a comprehensive picture of DCM pathogenesis can only be drawn if both genetic and environmental pathogenetic factors are considered. The course of cardiac viral infections depends strongly on genetic host factors and may range from rapid and complete virus elimination or silencing without clinical symptoms, to rapidly progressive or fatal disease. Viruses interact not only with genetically heterogenous host systems of virus uptake, migration, and antiviral immunity, but, due to their prevalence in DCM hearts, are also likely to encounter multiple structural proteins of cardiac cells known to be defective in familial DCM. The combined knowledge on DCM-associated gene defects and viruses therefore suggests in-depth studies on genome–environment interactions in DCM pathogenesis which may underlie the high clinical variability observed both in monogenic and virus-associated DCM and have implications for the clinical management of DCM patients.