Atrial myxomas arise from multipotent cardiac stem cells

Aims Cardiac myxomas usually develop in the atria and consist of an acid-mucopolysaccharide-rich myxoid matrix with polygonal stromal cells scattered throughout. These human benign tumours are a valuable research model because of the rarity of cardiac tumours, their clinical presentation and uncertain origin. Here, we assessed whether multipotent cardiac stem/progenitor cells (CSCs) give rise to atrial myxoma tissue. Methods and results Twenty-three myxomas were collected and analysed for the presence of multipotent CSCs. We detected myxoma cells positive for c-kit (c-kit(pos)) but very rare Isl-1 positive cells. Most of the c-kit(pos) cells were blood lineage-committed CD45(pos)/CD31(pos) cells. However, c-kit(pos)/CD45(neg)/CD31(neg) cardiac myxoma cells expressed sternness and cardiac progenitor cell transcription factors. Approximately <= 10% of the c-kit(pos)/CD45(neg)/CD31(neg) myxoma cells also expressed calretinin, a characteristic of myxoma stromal cells. In vitro, the c-kit(pos)/CD45(neg)/CD31g myxoma cells secrete chondroitin-6-sulfate and hyaluronic acid, which are the main components of gelatinous myxoma matrix in vivo. In vitro, c-kit(pos)/CD45(neg)/CD31(neg) myxoma cells have stem cell properties being clonogenic, selfrenewing, and sphere forming while exhibiting an abortive cardiac differentiation potential. Myxoma-derived CSCs possess a mRNA and microRNA transcriptome overall similar to normal myocardium-derived c-kit(pos)/CD45(neg)/CD31(neg)CSCs , yet showing a relatively small and relevant fraction of dysregulated mRNA/miRNAs (miR-126-3p and miR-335-5p, in particular). Importantly, myxoma-derived CSCs but not normal myocardium-derived CSCs, seed human myxoma tumours in xenograft's in immunodeficient NOD/SCID mice. Conclusion Myxoma-derived c-kit(pos)/CD45(n)(eg)/CD31(n)(eg) CSCs fulfill the criteria expected of atrial myxoma-initiating stem cells. The transcriptome of these cells indicates that they belong to or are derived from the same lineage as the atrial multipotent c-kit(pos)/CD45(neg)/CD31(n)(eg) CSCs. Taken together the data presented here suggest that human myxomas could be the first-described CSC-related human heart disease.