Heart Fail Rev (2015) 20:613–619 DOI 10.1007/s10741-015-9494-7
Cardiac stem cell therapy: Have we put too much hype in which cell type to use? Jianqin Ye1 • Yerem Yeghiazarians1,2,3
Published online: 30 May 2015 Ó Springer Science+Business Media New York 2015
Abstract Injection of various stem cells has been tested with the hopes of improving cardiac function after a myocardial infarction (MI). However, there is continued controversy as to which cell type is best for repair. Due to technical differences in cell isolation, processing, delivery, and cardiac functional assessment by various investigators, it has been difficult to directly compare the results of different cells. Using same techniques to evaluate the efficacy of different cell types, we have separately delivered bone marrow cells (BMCs), cardiospheres (CSs), CS-derived Sca-1?/CD45- cells, human embryonic stem cell-derived cardiomyocytes, and BMC extract into infarcted murine myocardium and found that all of these treatments reduce infarct size and improve cardiac function post-MI similarly without one regimen being superior to another. The beneficial effects appear to be via paracrine influences. Different progenitors lead to improved cardiac function post-MI, but it is premature to hype any specific cell type at this time. Keywords Cardiac progenitor cells Bone marrow cells Cardiosphere Human embryonic stem cells Cell therapy
& Yerem Yeghiazarians [email protected] 1
Division of Cardiology, Department of Medicine, University of California, San Francisco, CA 94143, USA
2
Cardiovascular Research Institute, University of California, San Francisco, CA 94143, USA
3
Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell Research, University of California, San Francisco, CA 94143, USA
Introduction Cell therapy for the treatment of ischemic heart disease has been proposed as an attractive new method to potentially improve cardiac function after myocardial infarction (MI). Numerous preclinical and clinical studies have focused on delivering various types of stem cells into the injured myocardium with mixed clinical trial outcomes. Notably, bone marrow-derived stem cells [1–8], cardiac progenitor cells (CPCs) [9–18], and cardiomyocytes (CMs) derived from human embryonic stem cells (hESC) [19–22] have been reported. However, there is continued uncertainty as to which cell type is best for myocardial repair [23, 24]. Due to technical differences in cell isolation, processing, delivery, and cardiac functional assessment by various investigators studying a cell of interest, it has been difficult to directly compare the results using different cells to each other. We developed and published an ultrasound-guided closed-chest injection technique into the rodent heart postMI, and using this method, the injected cells are delivered to the peri-infarct regions under direct visual guidance [25]. This allows the removal of those animals with a poor injection (e.g., an injection that ends up in the left ventricular cavity rather than the peri-infarct region) from the study group, thus eliminating possible errors in the injection technique which might lead to inaccurate results [25]. Importantly, this approach also allows us to perform research at a clinically more relevant time-point by injecting cells into the heart several days post-MI without redoing thoracotomy which is associated with a higher animal mortality [8]. Using this technique [25] and keeping all other experimental methods/conditions constant (i.e., surgical induction of MI, echocardiography, and histologic analysis), we have separately delivered bone marrow cells (BMCs)
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60 Days postinjection LVEF left ventricular ejection fraction, CMs cardiomyocytes, BMCs bone marrow cells, CSs cardiospheres, hESCs human embryonic stem cells
60 Days postinjection 60 Days postinjection Yes No Human ESCs hESCderived CMs
3 Months SCID mice
106
Yes
N/A 25 Days postinjection 25 Days postinjection Yes Yes Yes blood vessels 106 9 Months C57 BL mice Sca-1? cells from CSs
2.5 Months C57BL mice
N/A N/A 25 Days postinjection Yes Yes cardiac cells 9 Months C57 BL mice CSs
2.5 Months C57BL mice
105
Yes
3 Days postinjection 3 Days postinjection Yes No 2.5 Months C57BL mice BMC extract
2.5 Months C57BL mice
106
Yes
3 Days postinjection 3 Days postinjection Yes No 106 2.5 Months C57BL mice BMCs
2.5 Months C57BL mice
Cells engraft 25 days postinjection Cell# injected/heart Recipient (mice) Origin of cells Cells
Table 1 Comparison of effects of various cells injected to murine infarcted hearts
Details of the experimental techniques have been published previously [8, 18, 22]. Briefly, BMCs, BMC extract, CSs, and CS-derived Sca-1?/CD45- cells were isolated from C57BL/6 J green fluorescent protein (GFP) transgenic mice. The H9 hESC line expressing GFP control by the ubiquitin C promoter was differentiated by human embryoid body (hEB) formation, and the hEBs were further induced to differentiate into CMs. The left anterior descending artery of mice was ligated to generate the murine MI model. At day 3 post-MI, BMCs (106), BMC extract (from 106 of BMCs), CSs (105), CS-derived Sca1?/CD45- cells (106), and hESC-derived CMs (106) were, respectively, delivered into the peri-infarct region of the left ventricle of wild-type recipient C57BL mice or SCIDBeige mice by echoguiding injection (the latter mice were used only for hESC-derived CMs to avoid immune rejection of introducing human cells into immune-competent C57BL mice) (Table 1). Cardiac function and histologic analysis were performed as previously reported [8, 18, 22]. Cardiac function was evaluated by echocardiography before MI and at days 2, 28, and 60 post-MI. On day 28 or 60 post-MI, the murine hearts were harvested and histologic analysis was performed to assess infarct size, angiogenesis, apoptosis, and proliferation of cardiomyocytes and to assess for teratoma formation (day 60 only for hESCderived CMs to rule out teratoma formation at a later timepoint with these cells). We used original data of echocardiography and histochemical and immunohistochemical staining from previous studies [8, 18, 22] and did the following comparisons—of note, the actual raw data for all measured
LVEF improved 25 days post-injection
Methods
Yes
Reduce infarct size post-injection
Induce angiogenesis postinjection
Reduce CMs apoptosis
Induce cycling CMs
[8], cardiospheres (CSs) [18], CS-derived Sca-1?/CD45cells [18], hESC-derived CMs [22], and BMC extract [8] into infarcted murine myocardium to evaluate whether one therapy is superior in regard to improving cardiac function post-MI. We have previously published the results for each of these treatment strategies, but in this review, we compare for the first time all these therapeutic regimens to each other and ask: (1) Whether each of these treatments improves cardiac function similarly? (2) How many of the delivered cells are retained in the myocardium 4 weeks after treatment? (3) Do all treatments lead to an increase in the number of endogenous blood vessel in the injured myocardium? (4) Do only CSs and CS-derived Sca-1?/ CD45- cells engraft and differentiate into blood vessels? and (5) Which cells express cardiac markers in vivo? In this review, we highlight some notable findings comparing these different treatments and discuss the clinical significance of our findings.
No at 3 days post-injection
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3 Days postinjection
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615
Fig. 2 Cardiac functional improvement by all therapies appears to be mostly due to angiogenesis. Injecting BMCs and BMC extract increased endogenous angiogenesis 3 days post-injection, but not 25 days post-injection. CSs, CS-derived Sca-1?/CD45- cells, and hESC-derived CMs increased endogenous angiogenesis 25 or 60 days post-injection with/without cell engraftment. BMCs bone marrow cells, CSs cardiospheres, hCMs human embryonic stem cell-derived cardiomyocytes
CD45- cells, hESC-derived CMs, and BMC extract (Fig. 2). Fig. 1 Different stem cells and BMC extract improve cardiac function and reduce infarct size post-MI similarly. All cell types and BMC extract injections improved the cardiac left ventricular ejection fraction (LVEF) (a) and reduced the infarct size (b) compared to the control at day 25 post-injection, but there were no significant differences between the groups in regard to these improved outcomes. BMCs bone marrow cells, Extract BMC extract, CSs cardiospheres, Sca-1 Sca-1? cells, hCMs human embryonic stem cell-derived cardiomyocytes
echocardiographic and histologic parameters have been published previously and have not been repeated in this brief communication: Change in left ventricular ejection fraction (LVEF): LVEF post-MI but pre-treatment injection was subtracted from the LVEF at study conclusion for each treatment. We compared change in LVEF of BMCs, CSs, CS-derived Sca1?/CD45- cells, hESC-derived CMs, and BMC extract (Fig. 1a). Change in infarct size: This was determined by subtracting the infarct size of the control group from the corresponding infarct size of the treatment group at day 25 or 60 post-injection. We compared change in infarct size of BMCs, CSs, CS-derived Sca-1?/CD45- cells, hESCderived CMs, and BMC extract (Fig. 1b). Change in vessel density at the peri-infarct zone: This was obtained by subtracting the vessel density (CD31 staining area) of the control group from the corresponding vessel density of the treatment group at day 25 or 60 postinjection. We compared the change in vessel density at the peri-infarct zone of BMCs, CSs, CS-derived Sca-1?/
Statistical analysis One-way ANOVA with Fisher’s post hoc test was used to analyze the differences between multiple groups. Values are expressed as mean ± SD with P \ 0.05 considered significant. SPSS 15.0 software was used to conduct all statistical analyses.
Results Different stem cells and BMC extract improve cardiac function and reduce infarct size post-MI similarly After the induction of MI, murine BMCs [8], CS cells, CSderived Sca-1?/CD45- cells [18], hESC-derived CMs, and the BMC extract [8] were each injected into the murine infarcted myocardium at day 3 post-MI by echoguided injection, respectively. All cell types and BMC extract injections improved cardiac function and reduced infarct size compared to the control group in follow-up at either day 25 or day 60 after treatment (Table 1). LVEF was improved 7.5 ± 2.8 % by BMCs, 7.7 ± 5.1 % by CSs, 8.7 ± 5.8 % by CS-derived Sca-1?/CD45- cells, 6.1 ± 4.3 % by hESC-derived CMs, and 6.1 ± 2.6 % by BMC extract compared to their respective controls 25 days post-injection (Fig. 1a). There were no significant differences between the groups in regard to these improved outcomes.
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The infarct size with each treatment was significantly smaller compared to its control, but there were no statistical differences in the infarct sizes between treatment groups (Fig. 1b). Cardiac functional improvement by all therapies appears to be mostly due to a paracrine effect, especially via an angiogenic mechanism Except for the CSs and CS-derived Sca-1?/CD45- cells, none of the other cells injected into the injured myocardium were present 1–2 weeks post-injection by immunohistochemical analysis and qualitative (q) RT-PCR [8, 18, 22]. Even the CSs and CS-derived Sca-1?/CD45cells that appear to be present are there in very low numbers (*3 % of injected cells retained). Upon histologic analysis, treatment with BMCs and BMC extract showed increased endogenous angiogenesis and reduced apoptosis of native CMs (BMCs also had an increase in native CM proliferation) 3 days post-injection, but not 25 days postinjection (Table 1) [8]. CSs, CS-derived Sca-1?/CD45- cells, and hESCderived CMs also increased endogenous angiogenesis and reduced apoptosis of native CMs 25 or 60 days post-injection with or without cell engraftment (Fig. 2; Table 1) [22]. These results, especially in light of our findings with the BMC extract injection, suggest that the main mechanism of action after all these cell treatments in regard to limiting infarct size and improving cardiac function is paracrine in nature. Injection of these cells into the host myocardium appears to secrete/release growth factors and cytokines which induce endogenous angiogenesis at early stages post-injection. This leads to preservation of cardiomyocytes which we have reported occurs by a decrease in early CM apoptosis and increased CM proliferation with BMCs or BMC extract treatments [8]. More recent reports also show that injected bone marrow (BM)-derived mesenchymal stem cells (MSCs) [26] or BM stem cells [27] could induce the proliferation of native CPCs. These effects of cell therapy may limit the area of ischemic myocardium, reduce LV remodeling, and preserve cardiac function post-MI. Only CS cells engraft in injured myocardium and express cardiac markers in vivo As opposed to the BMCs and hESC-derived CMs, CSs can differentiate into Troponin I? CM, CD31? endothelial cells, and a-smooth muscle actin? smooth muscle cells in the peri-infarct zone 25 days post-injection in vivo [18]. CS-derived Sca-1?/CD45- cells engraft in the peri-infarct zone 25 days post-injection and differentiate into endothelial and smooth muscle cells to form new vascular
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structures after day 75 post-injection, but we could not find evidence that they express cardiac markers in vivo [18]. These results suggest that CS cells not only appear to survive and differentiate into cardiac cells and blood vessels, but also induce paracrine effects in vivo as the low degree of cell retention (*3 %), and differentiation is not adequate to explain the functional improvements and the degree of new blood vessel formation post-MI [28].
Discussion In this review, while keeping experimental methods/conditions constant (i.e., surgical induction of MI, echocardiography, and histologic analysis), we show that post-MI treatment with BMCs, CSs, CS-derived Sca-1?/CD45cells, hESC-derived CMs, and BMC extract, all improve cardiac function and decrease infarct scar. No one therapy is superior to others with regard to improving cardiac function post-MI compared to control. CSs and CS-derived Sca-1?/CD45- cells appear to be the best cells in regard to their retention in the myocardium 4 weeks after treatment, but even this occurs at a very low level. All treatments lead to an increase in the number of endogenous blood vessels in the injured myocardium, and only CSs and CS-derived Sca-1?/CD45- cells engraft and differentiate into blood vessels. Lastly, only CSs express cardiac markers in vivo. Given the very low or nonexistent retention rate of the cells after delivery post-MI and the notable findings of more blood vessels with all the treatments, in light of similar findings when BMC extract is used as therapy (in the absence of any live cells), it can be concluded that the primary mechanism of benefit with the cells used in our studies is primarily via paracrine effect(s) (for example, due to angiogenesis and/or reduction in cardiomyocyte apoptosis leading to reduction in scar size and smaller infarcts [8] rather than direct myocardial regeneration). Research is ongoing to identify the paracrine factor(s) that might play a beneficial role post-MI, but no one factor or combination of factors has yet been isolated [8, 28, 29] that can be translated to clinical use. It is also not clear whether differences in the secreted factors between the different stem cells would result in significant differences in clinical outcome after treatment. Additionally, since adult-derived stem cells are known to ‘‘age’’ and are impacted negatively by cardiovascular risk factors and the fact that most of the subjects in clinical trials after a myocardial infarction are older individuals, it is plausible that the paracrine factors secreted from these ‘‘aged’’ adult-derived stem cells are less optimal [30]. Of course, this hypothesis will need to be tested in the future. It has been proposed that if safe methods with biodegradable matrices are developed (i.e., alginate and
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other compounds) that can be injected in combination with cells to increase cell retention locally in the myocardium after delivery [31, 32], theoretically it might be possible for the retained stem cells to continue to secrete growth factors and cytokines in the host myocardium and induce their beneficial effects for a longer period [33]. One of the limitations for such combination matrix–cell treatment would be that intra-coronary injections cannot be performed in patients, and cell-based treatments would then have to be performed via direct myocardial injection (either at the time of open heart surgery or via catheter-based myocardial injection methods) [31]. Selection of an optimal stem cell(s) for clinical use will greatly depend on the ease of isolation, number of cells needed, and safety. Embryonic or induced pluripotentderived stem cell-derived cardiomyocytes have the potential risk of teratoma formation and are not ready for prime time use at this time. Despite this risk, progress is being made and we [22] and other [34] have demonstrated that CMs derived from hESCs can safely be injected into infarcted murine hearts and at 60 days, there was no evidence for teratoma formation. Skeletal myoblasts have been used clinically in patients, but given the pro-arrhythmia risks of these cells, it is unlikely that they will become a preferred cell for routine clinical use [35, 36]. BM-derived cells (as either a heterogeneous combination of cells or specifically isolated cells such as CD34, CD133, MSCs, or others) are being investigated clinically. However, recent BM stem cell trials in patients with post-MI have all been disappointing and negative [5–7, 37]. Ongoing clinical trials will clarify whether these cells have any future for routine clinical use [23]. MSCs are intriguing cells for clinical use, given that they do not express major histocompatibility class II antigens or the B7 and CD40 ligand costimulatory molecules and have been safely used in allogeneic transplantation [38–40]. Ongoing studies with these cells will help define their role for treatment post-MI. Based on numerous preclinical [12, 16] and clinical reports [17] and our findings [18] as presented here, CS cells and native cardiac progenitor cells [23, 24] have recently generated considerable excitement as ideal cell types for post-MI treatment. These cells can easily be obtained and isolated by heart biopsy with very low risk, amplified in number, and safely and effectively used clinically [14, 15, 17]. Larger multicenter ongoing clinical trials will determine the role of these cells for clinical use post-MI. There are a number of limitations to our report. First, to perform all these studies simultaneously with the different stem cells listed would be nearly impossible technically. As such, we have had to perform these studies at different times, but included a control arm in each study to test the efficacy of a given treatment versus its own simultaneous control group. Second, to test the efficacy of hESC-derived
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CMs, we had to utilize SCID mice versus wild-type C57BL mice which were used for all the other groups to avoid rejection issues in the immunocompetent animals with the injection of hESC-derived CMs. Whether the results of these cells can be directly compared to the other cells in this setting is a potential issue, but given the appropriate control group for each treatment arm, we believe the results should be comparable among the groups. Third, research is ongoing in our laboratory and others to identify the potential paracrine factors/signals secreted from all these different cell types, but at this time, there are no firm conclusions in this regard. Last, all this work was performed in the same laboratory. In summary, despite over a decade of preclinical and clinical trials, it is still not known which cell type (or combination of cells [23]) is optimal for treatment post-MI to improve cardiac function. Paracrine effects clearly appear to play a significant role with all cell types used. Improvement of cell retention locally using cell–matrix combination in the myocardium after cell delivery is likely to improve outcome, but this remains to be investigated. Ongoing clinical trials using BM-derived cells, MSCs, and native cardiac stem cells will demonstrate the efficacy of these cell therapies post-MI. In conclusion, different stem cells lead to improvement of heart function post-MI, but it is premature to hype any specific cell type at this time. Acknowledgments We thank Dr. Joel Karliner for his input and assistance in preparation of this manuscript. The authors gratefully acknowledge the generous support of the Wayne and Gladys Valley Foundation, the UCSF Cardiac Stem Cell Foundation, the Torian Foundation, the Leone-Perkins Foundation, the Vadasz Foundation, and the Harold Castle Foundation to Y.Y. and a Comprehensive Research Grant from California Institute for Regenerative Medicine (RC1-00104) to HSB and YY. Conflict of interest
None.
References 1. ‘Tomita S, Li RK, Weisel RD, Mickle DA, Kim EJ, Sakai T, Jia ZQ (1999) Autologous transplantation of bone marrow cells improves damaged heart function. Circulation 100(19 Suppl):II247–II256 2. Orlic D, Kajstura J, Chimenti S, Jakoniuk I, Anderson SM, Li B, Pickel J, McKay R, Nadal-Ginard B, Bodine DM, Leri A, Anversa P (2001) Bone marrow cells regenerate infarcted myocardium. Nature 410(6829):701–705 3. Strauer BE, Brehm M, Zeus T, Kostering M, Hernandez A, Sorg RV, Kogler G, Wernet P (2002) Repair of infarcted myocardium by autologous intracoronary mononuclear bone marrow cell transplantation in humans. Circulation 106(15):1913–1918 4. Assmus B, Schachinger V, Teupe C, Britten M, Lehmann R, Dobert N, Grunwald F, Aicher A, Urbich C, Martin H, Hoelzer D, Dimmeler S, Zeiher AM (2002) Transplantation of progenitor cells and regeneration enhancement in acute myocardial infarction (TOPCARE-AMI). Circulation 106(24):3009–3017
123
618 5. Traverse JH, Henry TD, Pepine CJ, Willerson JT, Zhao DX, Ellis SG, Forder JR, Anderson RD, Hatzopoulos AK, Penn MS, Perin EC, Chambers J, Baran KW, Raveendran G, Lambert C, Lerman A, Simon DI, Vaughan DE, Lai D, Gee AP, Taylor DA, Cogle CR, Thomas JD, Olson RE, Bowman S, Francescon J, Geither C, Handberg E, Kappenman C, Westbrook L, Piller LB, Simpson LM, Baraniuk S, Loghin C, Aguilar D, Richman S, Zierold C, Spoon DB, Bettencourt J, Sayre SL, Vojvodic RW, Skarlatos SI, Gordon DJ, Ebert RF, Kwak M, Moye LA, Simari RD (2012) Effect of the use and timing of bone marrow mononuclear cell delivery on left ventricular function after acute myocardial infarction: the TIME randomized trial. JAMA 308(22):2380–2389 6. Traverse JH, Henry TD, Vaughan DE, Ellis SG, Pepine CJ, Willerson JT, Zhao DX, Simpson LM, Penn MS, Byrne BJ, Perin EC, Gee AP, Hatzopoulos AK, McKenna DH, Forder JR, Taylor DA, Cogle CR, Baraniuk S, Olson RE, Jorgenson BC, Sayre SL, Vojvodic RW, Gordon DJ, Skarlatos SI, Moye LA, Simari RD (2012) LateTIME: a phase-II, randomized, double-blinded, placebo-controlled, pilot trial evaluating the safety and effect of administration of bone marrow mononuclear cells 2 to 3 weeks after acute myocardial infarction. Tex Heart Inst J 37(4):412–420 7. Perin EC, Willerson JT, Pepine CJ, Henry TD, Ellis SG, Zhao DX, Silva GV, Lai D, Thomas JD, Kronenberg MW, Martin AD, Anderson RD, Traverse JH, Penn MS, Anwaruddin S, Hatzopoulos AK, Gee AP, Taylor DA, Cogle CR, Smith D, Westbrook L, Chen J, Handberg E, Olson RE, Geither C, Bowman S, Francescon J, Baraniuk S, Piller LB, Simpson LM, Loghin C, Aguilar D, Richman S, Zierold C, Bettencourt J, Sayre SL, Vojvodic RW, Skarlatos SI, Gordon DJ, Ebert RF, Kwak M, Moye LA, Simari RD (2012) Effect of transendocardial delivery of autologous bone marrow mononuclear cells on functional capacity, left ventricular function, and perfusion in chronic heart failure: the FOCUS-CCTRN trial. JAMA 307(16):1717–1726 8. Yeghiazarians Y, Zhang Y, Prasad M, Shih H, Saini SA, Takagawa J, Sievers RE, Wong ML, Kapasi NK, Mirsky R, Koskenvuo J, Minasi P, Ye J, Viswanathan MN, Angeli FS, Boyle AJ, Springer ML, Grossman W (2009) Injection of bone marrow cell extract into infarcted hearts results in functional improvement comparable to intact cell therapy. Mol Ther 17(7):1250–1256 9. Oyama T, Nagai T, Wada H, Naito AT, Matsuura K, Iwanaga K, Takahashi T, Goto M, Mikami Y, Yasuda N, Akazawa H, Uezumi A, Takeda S, Komuro I (2007) Cardiac side population cells have a potential to migrate and differentiate into cardiomyocytes in vitro and in vivo. J Cell Biol 176(3):329–341 10. Beltrami AP, Barlucchi L, Torella D, Baker M, Limana F, Chimenti S, Kasahara H, Rota M, Musso E, Urbanek K, Leri A, Kajstura J, Nadal-Ginard B, Anversa P (2003) Adult cardiac stem cells are multipotent and support myocardial regeneration. Cell 114(6):763–776 11. Wang X, Hu Q, Nakamura Y, Lee J, Zhang G, From AH, Zhang J (2006) The role of the sca-1?/CD31- cardiac progenitor cell population in postinfarction left ventricular remodeling. Stem Cells 24(7):1779–1788 12. Messina E, De Angelis L, Frati G, Morrone S, Chimenti S, Fiordaliso F, Salio M, Battaglia M, Latronico MV, Coletta M, Vivarelli E, Frati L, Cossu G, Giacomello A (2004) Isolation and expansion of adult cardiac stem cells from human and murine heart. Circ Res 95(9):911–921 13. Bearzi C, Rota M, Hosoda T, Tillmanns J, Nascimbene A, De Angelis A, Yasuzawa-Amano S, Trofimova I, Siggins RW, Lecapitaine N, Cascapera S, Beltrami AP, D’Alessandro DA, Zias E, Quaini F, Urbanek K, Michler RE, Bolli R, Kajstura J, Leri A, Anversa P (2007) Human cardiac stem cells. Proc Natl Acad Sci USA 104(35):14068–14073 14. Bolli R, Chugh AR, D’Amario D, Loughran JH, Stoddard MF, Ikram S, Beache GM, Wagner SG, Leri A, Hosoda T, Sanada F,
123
Heart Fail Rev (2015) 20:613–619
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
Elmore JB, Goichberg P, Cappetta D, Solankhi NK, Fahsah I, Rokosh DG, Slaughter MS, Kajstura J, Anversa P (2011) Cardiac stem cells in patients with ischaemic cardiomyopathy (SCIPIO): initial results of a randomised phase 1 trial. Lancet 378(9806): 1847–1857 Chugh AR, Beache GM, Loughran JH, Mewton N, Elmore JB, Kajstura J, Pappas P, Tatooles A, Stoddard MF, Lima JA, Slaughter MS, Anversa P, Bolli R (2012) Administration of cardiac stem cells in patients with ischemic cardiomyopathy: the SCIPIO trial: surgical aspects and interim analysis of myocardial function and viability by magnetic resonance. Circulation 126(11 Suppl 1):S54–S64 Smith RR, Barile L, Cho HC, Leppo MK, Hare JM, Messina E, Giacomello A, Abraham MR, Marban E (2007) Regenerative potential of cardiosphere-derived cells expanded from percutaneous endomyocardial biopsy specimens. Circulation 115(7): 896–908 Makkar RR, Smith RR, Cheng K, Malliaras K, Thomson LE, Berman D, Czer LS, Marban L, Mendizabal A, Johnston PV, Russell SD, Schuleri KH, Lardo AC, Gerstenblith G, Marban E (2012) Intracoronary cardiosphere-derived cells for heart regeneration after myocardial infarction (CADUCEUS): a prospective, randomised phase 1 trial. Lancet 379(9819):895–904 Ye J, Boyle A, Shih H, Sievers RE, Zhang Y, Prasad M, Su H, Zhou Y, Grossman W, Bernstein HS, Yeghiazarians Y (2012) Sca-1 ? cardiosphere-derived cells are enriched for Isl1-expressing cardiac precursors and improve cardiac function after myocardial injury. PLoS One 7(1):e30329 Min JY, Yang Y, Converso KL, Liu L, Huang Q, Morgan JP, Xiao YF (2002) Transplantation of embryonic stem cells improves cardiac function in postinfarcted rats. J Appl Physiol 92(1):288–296 Menard C, Hagege AA, Agbulut O, Barro M, Morichetti MC, Brasselet C, Bel A, Messas E, Bissery A, Bruneval P, Desnos M, Puceat M, Menasche P (2005) Transplantation of cardiac-committed mouse embryonic stem cells to infarcted sheep myocardium: a preclinical study. Lancet 366(9490):1005–1012 Laflamme MA, Chen KY, Naumova AV, Muskheli V, Fugate JA, Dupras SK, Reinecke H, Xu C, Hassanipour M, Police S, O’Sullivan C, Collins L, Chen Y, Minami E, Gill EA, Ueno S, Yuan C, Gold J, Murry CE (2007) Cardiomyocytes derived from human embryonic stem cells in pro-survival factors enhance function of infarcted rat hearts. Nat Biotechnol 25(9):1015–1024 Yeghiazarians Y, Gaur M, Zhang Y, Sievers RE, Ritner C, Prasad M, Boyle A, Bernstein HS (2012) Myocardial improvement with human embryonic stem cell-derived cardiomyocytes enriched by p38MAPK inhibition. Cytotherapy 14(2):223–231 Telukuntla KS, Suncion VY, Schulman IH, Hare JM (2013) The advancing field of cell-based therapy: insights and lessons from clinical trials. J Am Heart Assoc 2(5):e000338 Sanganalmath SK, Bolli R (2013) Cell therapy for heart failure: a comprehensive overview of experimental and clinical studies, current challenges, and future directions. Circ Res 113(6): 810–834 Springer ML, Sievers RE, Viswanathan MN, Yee MS, Foster E, Grossman W, Yeghiazarians Y (2005) Closed-chest cell injections into mouse myocardium guided by high-resolution echocardiography. Am J Physiol Heart Circ Physiol 289(3):H1307–H1314 Hatzistergos KE, Quevedo H, Oskouei BN, Hu Q, Feigenbaum GS, Margitich IS, Mazhari R, Boyle AJ, Zambrano JP, Rodriguez JE, Dulce R, Pattany PM, Valdes D, Revilla C, Heldman AW, McNiece I, Hare JM (2010) Bone marrow mesenchymal stem cells stimulate cardiac stem cell proliferation and differentiation. Circ Res 107(7):913–922 Loffredo FS, Steinhauser ML, Gannon J, Lee RT (2011) Bone marrow-derived cell therapy stimulates endogenous cardiomyocyte
Heart Fail Rev (2015) 20:613–619
28.
29.
30.
31.
32.
33.
34.
35.
36.
progenitors and promotes cardiac repair. Cell Stem Cell 8(4):389–398 Chimenti I, Smith RR, Li TS, Gerstenblith G, Messina E, Giacomello A, Marban E (2010) Relative roles of direct regeneration versus paracrine effects of human cardiosphere-derived cells transplanted into infarcted mice. Circ Res 106(5):971–980 Mirotsou M, Jayawardena TM, Schmeckpeper J, Gnecchi M, Dzau VJ (2011) Paracrine mechanisms of stem cell reparative and regenerative actions in the heart. J Mol Cell Cardiol 50(2): 280–289 Wang X, Takagawa J, Haddad DJ, Pinnamaneni K, Zhang Y, Sievers RE, Grossman W, Yeghiazarians Y, Springer ML (2011) Advanced Donor age impairs bone marrow cell therapeutic efficacy for cardiac disease. J Tissue Sci Eng. doi:10.4172/21577552.S3-002 Venugopal JR, Prabhakaran MP, Mukherjee S, Ravichandran R, Dan K, Ramakrishna S (2012) Biomaterial strategies for alleviation of myocardial infarction. J R Soc Interface 9(66):1–19. doi:10.1098/rsif.2011.0301 Sui R, Liao X, Zhou X, Tan Q (2011) The current status of engineering myocardial tissue. Stem Cell Rev 7(1):172–180. doi:10.1007/s12015-010-9131-8 Levit RD, Landazuri N, Phelps EA, Brown ME, Garcia AJ, Davis ME, Joseph G, Long R, Safley SA, Suever JD, Lyle AN, Weber CJ, Taylor WR (2013) Cellular encapsulation enhances cardiac repair. J Am Heart Assoc 2(5):e000367 Caspi O, Huber I, Kehat I, Habib M, Arbel G, Gepstein A, Yankelson L, Aronson D, Beyar R, Gepstein L (2007) Transplantation of human embryonic stem cell-derived cardiomyocytes improves myocardial performance in infarcted rat hearts. J Am Coll Cardiol 50(19):1884–1893 Menasche P, Hagege AA, Vilquin JT, Desnos M, Abergel E, Pouzet B, Bel A, Sarateanu S, Scorsin M, Schwartz K, Bruneval P, Benbunan M, Marolleau JP, Duboc D (2003) Autologous skeletal myoblast transplantation for severe postinfarction left ventricular dysfunction. J Am Coll Cardiol 41(7):1078–1083 Menasche P, Alfieri O, Janssens S, McKenna W, Reichenspurner H, Trinquart L, Vilquin JT, Marolleau JP, Seymour B, Larghero
619
37.
38.
39.
40.
J, Lake S, Chatellier G, Solomon S, Desnos M, Hagege AA (2008) The myoblast autologous grafting in ischemic cardiomyopathy (MAGIC) trial: first randomized placebo-controlled study of myoblast transplantation. Circulation 117(9):1189–1200 Traverse JH, Henry TD, Ellis SG, Pepine CJ, Willerson JT, Zhao DX, Forder JR, Byrne BJ, Hatzopoulos AK, Penn MS, Perin EC, Baran KW, Chambers J, Lambert C, Raveendran G, Simon DI, Vaughan DE, Simpson LM, Gee AP, Taylor DA, Cogle CR, Thomas JD, Silva GV, Jorgenson BC, Olson RE, Bowman S, Francescon J, Geither C, Handberg E, Smith DX, Baraniuk S, Piller LB, Loghin C, Aguilar D, Richman S, Zierold C, Bettencourt J, Sayre SL, Vojvodic RW, Skarlatos SI, Gordon DJ, Ebert RF, Kwak M, Moye LA, Simari RD (2011) Effect of intracoronary delivery of autologous bone marrow mononuclear cells 2 to 3 weeks following acute myocardial infarction on left ventricular function: the LateTIME randomized trial. JAMA 306(19): 2110–2119 Le Blanc K, Tammik C, Rosendahl K, Zetterberg E, Ringden O (2003) HLA expression and immunologic properties of differentiated and undifferentiated mesenchymal stem cells. Exp Hematol 31(10):890–896 Klyushnenkova E, Mosca JD, Zernetkina V, Majumdar MK, Beggs KJ, Simonetti DW, Deans RJ, McIntosh KR (2005) T cell responses to allogeneic human mesenchymal stem cells: immunogenicity, tolerance, and suppression. J Biomed Sci 12(1): 47–57 Hare JM, Fishman JE, Gerstenblith G, DiFede Velazquez DL, Zambrano JP, Suncion VY, Tracy M, Ghersin E, Johnston PV, Brinker JA, Breton E, Davis-Sproul J, Schulman IH, Byrnes J, Mendizabal AM, Lowery MH, Rouy D, Altman P, Wong Po Foo C, Ruiz P, Amador A, Da Silva J, McNiece IK, Heldman AW (2012) Comparison of allogeneic vs autologous bone marrowderived mesenchymal stem cells delivered by transendocardial injection in patients with ischemic cardiomyopathy: the POSEIDON randomized trial. JAMA 308(22):2369–2379
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Cardiac stem cell therapy: Have we put too much hype in which cell type to use? Jianqin Ye1 • Yerem Yeghiazarians1,2,3
Published online: 30 May 2015 Ó Springer Science+Business Media New York 2015
Abstract Injection of various stem cells has been tested with the hopes of improving cardiac function after a myocardial infarction (MI). However, there is continued controversy as to which cell type is best for repair. Due to technical differences in cell isolation, processing, delivery, and cardiac functional assessment by various investigators, it has been difficult to directly compare the results of different cells. Using same techniques to evaluate the efficacy of different cell types, we have separately delivered bone marrow cells (BMCs), cardiospheres (CSs), CS-derived Sca-1?/CD45- cells, human embryonic stem cell-derived cardiomyocytes, and BMC extract into infarcted murine myocardium and found that all of these treatments reduce infarct size and improve cardiac function post-MI similarly without one regimen being superior to another. The beneficial effects appear to be via paracrine influences. Different progenitors lead to improved cardiac function post-MI, but it is premature to hype any specific cell type at this time. Keywords Cardiac progenitor cells Bone marrow cells Cardiosphere Human embryonic stem cells Cell therapy
& Yerem Yeghiazarians [email protected] 1
Division of Cardiology, Department of Medicine, University of California, San Francisco, CA 94143, USA
2
Cardiovascular Research Institute, University of California, San Francisco, CA 94143, USA
3
Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell Research, University of California, San Francisco, CA 94143, USA
Introduction Cell therapy for the treatment of ischemic heart disease has been proposed as an attractive new method to potentially improve cardiac function after myocardial infarction (MI). Numerous preclinical and clinical studies have focused on delivering various types of stem cells into the injured myocardium with mixed clinical trial outcomes. Notably, bone marrow-derived stem cells [1–8], cardiac progenitor cells (CPCs) [9–18], and cardiomyocytes (CMs) derived from human embryonic stem cells (hESC) [19–22] have been reported. However, there is continued uncertainty as to which cell type is best for myocardial repair [23, 24]. Due to technical differences in cell isolation, processing, delivery, and cardiac functional assessment by various investigators studying a cell of interest, it has been difficult to directly compare the results using different cells to each other. We developed and published an ultrasound-guided closed-chest injection technique into the rodent heart postMI, and using this method, the injected cells are delivered to the peri-infarct regions under direct visual guidance [25]. This allows the removal of those animals with a poor injection (e.g., an injection that ends up in the left ventricular cavity rather than the peri-infarct region) from the study group, thus eliminating possible errors in the injection technique which might lead to inaccurate results [25]. Importantly, this approach also allows us to perform research at a clinically more relevant time-point by injecting cells into the heart several days post-MI without redoing thoracotomy which is associated with a higher animal mortality [8]. Using this technique [25] and keeping all other experimental methods/conditions constant (i.e., surgical induction of MI, echocardiography, and histologic analysis), we have separately delivered bone marrow cells (BMCs)
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60 Days postinjection LVEF left ventricular ejection fraction, CMs cardiomyocytes, BMCs bone marrow cells, CSs cardiospheres, hESCs human embryonic stem cells
60 Days postinjection 60 Days postinjection Yes No Human ESCs hESCderived CMs
3 Months SCID mice
106
Yes
N/A 25 Days postinjection 25 Days postinjection Yes Yes Yes blood vessels 106 9 Months C57 BL mice Sca-1? cells from CSs
2.5 Months C57BL mice
N/A N/A 25 Days postinjection Yes Yes cardiac cells 9 Months C57 BL mice CSs
2.5 Months C57BL mice
105
Yes
3 Days postinjection 3 Days postinjection Yes No 2.5 Months C57BL mice BMC extract
2.5 Months C57BL mice
106
Yes
3 Days postinjection 3 Days postinjection Yes No 106 2.5 Months C57BL mice BMCs
2.5 Months C57BL mice
Cells engraft 25 days postinjection Cell# injected/heart Recipient (mice) Origin of cells Cells
Table 1 Comparison of effects of various cells injected to murine infarcted hearts
Details of the experimental techniques have been published previously [8, 18, 22]. Briefly, BMCs, BMC extract, CSs, and CS-derived Sca-1?/CD45- cells were isolated from C57BL/6 J green fluorescent protein (GFP) transgenic mice. The H9 hESC line expressing GFP control by the ubiquitin C promoter was differentiated by human embryoid body (hEB) formation, and the hEBs were further induced to differentiate into CMs. The left anterior descending artery of mice was ligated to generate the murine MI model. At day 3 post-MI, BMCs (106), BMC extract (from 106 of BMCs), CSs (105), CS-derived Sca1?/CD45- cells (106), and hESC-derived CMs (106) were, respectively, delivered into the peri-infarct region of the left ventricle of wild-type recipient C57BL mice or SCIDBeige mice by echoguiding injection (the latter mice were used only for hESC-derived CMs to avoid immune rejection of introducing human cells into immune-competent C57BL mice) (Table 1). Cardiac function and histologic analysis were performed as previously reported [8, 18, 22]. Cardiac function was evaluated by echocardiography before MI and at days 2, 28, and 60 post-MI. On day 28 or 60 post-MI, the murine hearts were harvested and histologic analysis was performed to assess infarct size, angiogenesis, apoptosis, and proliferation of cardiomyocytes and to assess for teratoma formation (day 60 only for hESCderived CMs to rule out teratoma formation at a later timepoint with these cells). We used original data of echocardiography and histochemical and immunohistochemical staining from previous studies [8, 18, 22] and did the following comparisons—of note, the actual raw data for all measured
LVEF improved 25 days post-injection
Methods
Yes
Reduce infarct size post-injection
Induce angiogenesis postinjection
Reduce CMs apoptosis
Induce cycling CMs
[8], cardiospheres (CSs) [18], CS-derived Sca-1?/CD45cells [18], hESC-derived CMs [22], and BMC extract [8] into infarcted murine myocardium to evaluate whether one therapy is superior in regard to improving cardiac function post-MI. We have previously published the results for each of these treatment strategies, but in this review, we compare for the first time all these therapeutic regimens to each other and ask: (1) Whether each of these treatments improves cardiac function similarly? (2) How many of the delivered cells are retained in the myocardium 4 weeks after treatment? (3) Do all treatments lead to an increase in the number of endogenous blood vessel in the injured myocardium? (4) Do only CSs and CS-derived Sca-1?/ CD45- cells engraft and differentiate into blood vessels? and (5) Which cells express cardiac markers in vivo? In this review, we highlight some notable findings comparing these different treatments and discuss the clinical significance of our findings.
No at 3 days post-injection
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3 Days postinjection
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615
Fig. 2 Cardiac functional improvement by all therapies appears to be mostly due to angiogenesis. Injecting BMCs and BMC extract increased endogenous angiogenesis 3 days post-injection, but not 25 days post-injection. CSs, CS-derived Sca-1?/CD45- cells, and hESC-derived CMs increased endogenous angiogenesis 25 or 60 days post-injection with/without cell engraftment. BMCs bone marrow cells, CSs cardiospheres, hCMs human embryonic stem cell-derived cardiomyocytes
CD45- cells, hESC-derived CMs, and BMC extract (Fig. 2). Fig. 1 Different stem cells and BMC extract improve cardiac function and reduce infarct size post-MI similarly. All cell types and BMC extract injections improved the cardiac left ventricular ejection fraction (LVEF) (a) and reduced the infarct size (b) compared to the control at day 25 post-injection, but there were no significant differences between the groups in regard to these improved outcomes. BMCs bone marrow cells, Extract BMC extract, CSs cardiospheres, Sca-1 Sca-1? cells, hCMs human embryonic stem cell-derived cardiomyocytes
echocardiographic and histologic parameters have been published previously and have not been repeated in this brief communication: Change in left ventricular ejection fraction (LVEF): LVEF post-MI but pre-treatment injection was subtracted from the LVEF at study conclusion for each treatment. We compared change in LVEF of BMCs, CSs, CS-derived Sca1?/CD45- cells, hESC-derived CMs, and BMC extract (Fig. 1a). Change in infarct size: This was determined by subtracting the infarct size of the control group from the corresponding infarct size of the treatment group at day 25 or 60 post-injection. We compared change in infarct size of BMCs, CSs, CS-derived Sca-1?/CD45- cells, hESCderived CMs, and BMC extract (Fig. 1b). Change in vessel density at the peri-infarct zone: This was obtained by subtracting the vessel density (CD31 staining area) of the control group from the corresponding vessel density of the treatment group at day 25 or 60 postinjection. We compared the change in vessel density at the peri-infarct zone of BMCs, CSs, CS-derived Sca-1?/
Statistical analysis One-way ANOVA with Fisher’s post hoc test was used to analyze the differences between multiple groups. Values are expressed as mean ± SD with P \ 0.05 considered significant. SPSS 15.0 software was used to conduct all statistical analyses.
Results Different stem cells and BMC extract improve cardiac function and reduce infarct size post-MI similarly After the induction of MI, murine BMCs [8], CS cells, CSderived Sca-1?/CD45- cells [18], hESC-derived CMs, and the BMC extract [8] were each injected into the murine infarcted myocardium at day 3 post-MI by echoguided injection, respectively. All cell types and BMC extract injections improved cardiac function and reduced infarct size compared to the control group in follow-up at either day 25 or day 60 after treatment (Table 1). LVEF was improved 7.5 ± 2.8 % by BMCs, 7.7 ± 5.1 % by CSs, 8.7 ± 5.8 % by CS-derived Sca-1?/CD45- cells, 6.1 ± 4.3 % by hESC-derived CMs, and 6.1 ± 2.6 % by BMC extract compared to their respective controls 25 days post-injection (Fig. 1a). There were no significant differences between the groups in regard to these improved outcomes.
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The infarct size with each treatment was significantly smaller compared to its control, but there were no statistical differences in the infarct sizes between treatment groups (Fig. 1b). Cardiac functional improvement by all therapies appears to be mostly due to a paracrine effect, especially via an angiogenic mechanism Except for the CSs and CS-derived Sca-1?/CD45- cells, none of the other cells injected into the injured myocardium were present 1–2 weeks post-injection by immunohistochemical analysis and qualitative (q) RT-PCR [8, 18, 22]. Even the CSs and CS-derived Sca-1?/CD45cells that appear to be present are there in very low numbers (*3 % of injected cells retained). Upon histologic analysis, treatment with BMCs and BMC extract showed increased endogenous angiogenesis and reduced apoptosis of native CMs (BMCs also had an increase in native CM proliferation) 3 days post-injection, but not 25 days postinjection (Table 1) [8]. CSs, CS-derived Sca-1?/CD45- cells, and hESCderived CMs also increased endogenous angiogenesis and reduced apoptosis of native CMs 25 or 60 days post-injection with or without cell engraftment (Fig. 2; Table 1) [22]. These results, especially in light of our findings with the BMC extract injection, suggest that the main mechanism of action after all these cell treatments in regard to limiting infarct size and improving cardiac function is paracrine in nature. Injection of these cells into the host myocardium appears to secrete/release growth factors and cytokines which induce endogenous angiogenesis at early stages post-injection. This leads to preservation of cardiomyocytes which we have reported occurs by a decrease in early CM apoptosis and increased CM proliferation with BMCs or BMC extract treatments [8]. More recent reports also show that injected bone marrow (BM)-derived mesenchymal stem cells (MSCs) [26] or BM stem cells [27] could induce the proliferation of native CPCs. These effects of cell therapy may limit the area of ischemic myocardium, reduce LV remodeling, and preserve cardiac function post-MI. Only CS cells engraft in injured myocardium and express cardiac markers in vivo As opposed to the BMCs and hESC-derived CMs, CSs can differentiate into Troponin I? CM, CD31? endothelial cells, and a-smooth muscle actin? smooth muscle cells in the peri-infarct zone 25 days post-injection in vivo [18]. CS-derived Sca-1?/CD45- cells engraft in the peri-infarct zone 25 days post-injection and differentiate into endothelial and smooth muscle cells to form new vascular
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structures after day 75 post-injection, but we could not find evidence that they express cardiac markers in vivo [18]. These results suggest that CS cells not only appear to survive and differentiate into cardiac cells and blood vessels, but also induce paracrine effects in vivo as the low degree of cell retention (*3 %), and differentiation is not adequate to explain the functional improvements and the degree of new blood vessel formation post-MI [28].
Discussion In this review, while keeping experimental methods/conditions constant (i.e., surgical induction of MI, echocardiography, and histologic analysis), we show that post-MI treatment with BMCs, CSs, CS-derived Sca-1?/CD45cells, hESC-derived CMs, and BMC extract, all improve cardiac function and decrease infarct scar. No one therapy is superior to others with regard to improving cardiac function post-MI compared to control. CSs and CS-derived Sca-1?/CD45- cells appear to be the best cells in regard to their retention in the myocardium 4 weeks after treatment, but even this occurs at a very low level. All treatments lead to an increase in the number of endogenous blood vessels in the injured myocardium, and only CSs and CS-derived Sca-1?/CD45- cells engraft and differentiate into blood vessels. Lastly, only CSs express cardiac markers in vivo. Given the very low or nonexistent retention rate of the cells after delivery post-MI and the notable findings of more blood vessels with all the treatments, in light of similar findings when BMC extract is used as therapy (in the absence of any live cells), it can be concluded that the primary mechanism of benefit with the cells used in our studies is primarily via paracrine effect(s) (for example, due to angiogenesis and/or reduction in cardiomyocyte apoptosis leading to reduction in scar size and smaller infarcts [8] rather than direct myocardial regeneration). Research is ongoing to identify the paracrine factor(s) that might play a beneficial role post-MI, but no one factor or combination of factors has yet been isolated [8, 28, 29] that can be translated to clinical use. It is also not clear whether differences in the secreted factors between the different stem cells would result in significant differences in clinical outcome after treatment. Additionally, since adult-derived stem cells are known to ‘‘age’’ and are impacted negatively by cardiovascular risk factors and the fact that most of the subjects in clinical trials after a myocardial infarction are older individuals, it is plausible that the paracrine factors secreted from these ‘‘aged’’ adult-derived stem cells are less optimal [30]. Of course, this hypothesis will need to be tested in the future. It has been proposed that if safe methods with biodegradable matrices are developed (i.e., alginate and
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other compounds) that can be injected in combination with cells to increase cell retention locally in the myocardium after delivery [31, 32], theoretically it might be possible for the retained stem cells to continue to secrete growth factors and cytokines in the host myocardium and induce their beneficial effects for a longer period [33]. One of the limitations for such combination matrix–cell treatment would be that intra-coronary injections cannot be performed in patients, and cell-based treatments would then have to be performed via direct myocardial injection (either at the time of open heart surgery or via catheter-based myocardial injection methods) [31]. Selection of an optimal stem cell(s) for clinical use will greatly depend on the ease of isolation, number of cells needed, and safety. Embryonic or induced pluripotentderived stem cell-derived cardiomyocytes have the potential risk of teratoma formation and are not ready for prime time use at this time. Despite this risk, progress is being made and we [22] and other [34] have demonstrated that CMs derived from hESCs can safely be injected into infarcted murine hearts and at 60 days, there was no evidence for teratoma formation. Skeletal myoblasts have been used clinically in patients, but given the pro-arrhythmia risks of these cells, it is unlikely that they will become a preferred cell for routine clinical use [35, 36]. BM-derived cells (as either a heterogeneous combination of cells or specifically isolated cells such as CD34, CD133, MSCs, or others) are being investigated clinically. However, recent BM stem cell trials in patients with post-MI have all been disappointing and negative [5–7, 37]. Ongoing clinical trials will clarify whether these cells have any future for routine clinical use [23]. MSCs are intriguing cells for clinical use, given that they do not express major histocompatibility class II antigens or the B7 and CD40 ligand costimulatory molecules and have been safely used in allogeneic transplantation [38–40]. Ongoing studies with these cells will help define their role for treatment post-MI. Based on numerous preclinical [12, 16] and clinical reports [17] and our findings [18] as presented here, CS cells and native cardiac progenitor cells [23, 24] have recently generated considerable excitement as ideal cell types for post-MI treatment. These cells can easily be obtained and isolated by heart biopsy with very low risk, amplified in number, and safely and effectively used clinically [14, 15, 17]. Larger multicenter ongoing clinical trials will determine the role of these cells for clinical use post-MI. There are a number of limitations to our report. First, to perform all these studies simultaneously with the different stem cells listed would be nearly impossible technically. As such, we have had to perform these studies at different times, but included a control arm in each study to test the efficacy of a given treatment versus its own simultaneous control group. Second, to test the efficacy of hESC-derived
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CMs, we had to utilize SCID mice versus wild-type C57BL mice which were used for all the other groups to avoid rejection issues in the immunocompetent animals with the injection of hESC-derived CMs. Whether the results of these cells can be directly compared to the other cells in this setting is a potential issue, but given the appropriate control group for each treatment arm, we believe the results should be comparable among the groups. Third, research is ongoing in our laboratory and others to identify the potential paracrine factors/signals secreted from all these different cell types, but at this time, there are no firm conclusions in this regard. Last, all this work was performed in the same laboratory. In summary, despite over a decade of preclinical and clinical trials, it is still not known which cell type (or combination of cells [23]) is optimal for treatment post-MI to improve cardiac function. Paracrine effects clearly appear to play a significant role with all cell types used. Improvement of cell retention locally using cell–matrix combination in the myocardium after cell delivery is likely to improve outcome, but this remains to be investigated. Ongoing clinical trials using BM-derived cells, MSCs, and native cardiac stem cells will demonstrate the efficacy of these cell therapies post-MI. In conclusion, different stem cells lead to improvement of heart function post-MI, but it is premature to hype any specific cell type at this time. Acknowledgments We thank Dr. Joel Karliner for his input and assistance in preparation of this manuscript. The authors gratefully acknowledge the generous support of the Wayne and Gladys Valley Foundation, the UCSF Cardiac Stem Cell Foundation, the Torian Foundation, the Leone-Perkins Foundation, the Vadasz Foundation, and the Harold Castle Foundation to Y.Y. and a Comprehensive Research Grant from California Institute for Regenerative Medicine (RC1-00104) to HSB and YY. Conflict of interest
None.
References 1. ‘Tomita S, Li RK, Weisel RD, Mickle DA, Kim EJ, Sakai T, Jia ZQ (1999) Autologous transplantation of bone marrow cells improves damaged heart function. Circulation 100(19 Suppl):II247–II256 2. Orlic D, Kajstura J, Chimenti S, Jakoniuk I, Anderson SM, Li B, Pickel J, McKay R, Nadal-Ginard B, Bodine DM, Leri A, Anversa P (2001) Bone marrow cells regenerate infarcted myocardium. Nature 410(6829):701–705 3. Strauer BE, Brehm M, Zeus T, Kostering M, Hernandez A, Sorg RV, Kogler G, Wernet P (2002) Repair of infarcted myocardium by autologous intracoronary mononuclear bone marrow cell transplantation in humans. Circulation 106(15):1913–1918 4. Assmus B, Schachinger V, Teupe C, Britten M, Lehmann R, Dobert N, Grunwald F, Aicher A, Urbich C, Martin H, Hoelzer D, Dimmeler S, Zeiher AM (2002) Transplantation of progenitor cells and regeneration enhancement in acute myocardial infarction (TOPCARE-AMI). Circulation 106(24):3009–3017
123
618 5. Traverse JH, Henry TD, Pepine CJ, Willerson JT, Zhao DX, Ellis SG, Forder JR, Anderson RD, Hatzopoulos AK, Penn MS, Perin EC, Chambers J, Baran KW, Raveendran G, Lambert C, Lerman A, Simon DI, Vaughan DE, Lai D, Gee AP, Taylor DA, Cogle CR, Thomas JD, Olson RE, Bowman S, Francescon J, Geither C, Handberg E, Kappenman C, Westbrook L, Piller LB, Simpson LM, Baraniuk S, Loghin C, Aguilar D, Richman S, Zierold C, Spoon DB, Bettencourt J, Sayre SL, Vojvodic RW, Skarlatos SI, Gordon DJ, Ebert RF, Kwak M, Moye LA, Simari RD (2012) Effect of the use and timing of bone marrow mononuclear cell delivery on left ventricular function after acute myocardial infarction: the TIME randomized trial. JAMA 308(22):2380–2389 6. Traverse JH, Henry TD, Vaughan DE, Ellis SG, Pepine CJ, Willerson JT, Zhao DX, Simpson LM, Penn MS, Byrne BJ, Perin EC, Gee AP, Hatzopoulos AK, McKenna DH, Forder JR, Taylor DA, Cogle CR, Baraniuk S, Olson RE, Jorgenson BC, Sayre SL, Vojvodic RW, Gordon DJ, Skarlatos SI, Moye LA, Simari RD (2012) LateTIME: a phase-II, randomized, double-blinded, placebo-controlled, pilot trial evaluating the safety and effect of administration of bone marrow mononuclear cells 2 to 3 weeks after acute myocardial infarction. Tex Heart Inst J 37(4):412–420 7. Perin EC, Willerson JT, Pepine CJ, Henry TD, Ellis SG, Zhao DX, Silva GV, Lai D, Thomas JD, Kronenberg MW, Martin AD, Anderson RD, Traverse JH, Penn MS, Anwaruddin S, Hatzopoulos AK, Gee AP, Taylor DA, Cogle CR, Smith D, Westbrook L, Chen J, Handberg E, Olson RE, Geither C, Bowman S, Francescon J, Baraniuk S, Piller LB, Simpson LM, Loghin C, Aguilar D, Richman S, Zierold C, Bettencourt J, Sayre SL, Vojvodic RW, Skarlatos SI, Gordon DJ, Ebert RF, Kwak M, Moye LA, Simari RD (2012) Effect of transendocardial delivery of autologous bone marrow mononuclear cells on functional capacity, left ventricular function, and perfusion in chronic heart failure: the FOCUS-CCTRN trial. JAMA 307(16):1717–1726 8. Yeghiazarians Y, Zhang Y, Prasad M, Shih H, Saini SA, Takagawa J, Sievers RE, Wong ML, Kapasi NK, Mirsky R, Koskenvuo J, Minasi P, Ye J, Viswanathan MN, Angeli FS, Boyle AJ, Springer ML, Grossman W (2009) Injection of bone marrow cell extract into infarcted hearts results in functional improvement comparable to intact cell therapy. Mol Ther 17(7):1250–1256 9. Oyama T, Nagai T, Wada H, Naito AT, Matsuura K, Iwanaga K, Takahashi T, Goto M, Mikami Y, Yasuda N, Akazawa H, Uezumi A, Takeda S, Komuro I (2007) Cardiac side population cells have a potential to migrate and differentiate into cardiomyocytes in vitro and in vivo. J Cell Biol 176(3):329–341 10. Beltrami AP, Barlucchi L, Torella D, Baker M, Limana F, Chimenti S, Kasahara H, Rota M, Musso E, Urbanek K, Leri A, Kajstura J, Nadal-Ginard B, Anversa P (2003) Adult cardiac stem cells are multipotent and support myocardial regeneration. Cell 114(6):763–776 11. Wang X, Hu Q, Nakamura Y, Lee J, Zhang G, From AH, Zhang J (2006) The role of the sca-1?/CD31- cardiac progenitor cell population in postinfarction left ventricular remodeling. Stem Cells 24(7):1779–1788 12. Messina E, De Angelis L, Frati G, Morrone S, Chimenti S, Fiordaliso F, Salio M, Battaglia M, Latronico MV, Coletta M, Vivarelli E, Frati L, Cossu G, Giacomello A (2004) Isolation and expansion of adult cardiac stem cells from human and murine heart. Circ Res 95(9):911–921 13. Bearzi C, Rota M, Hosoda T, Tillmanns J, Nascimbene A, De Angelis A, Yasuzawa-Amano S, Trofimova I, Siggins RW, Lecapitaine N, Cascapera S, Beltrami AP, D’Alessandro DA, Zias E, Quaini F, Urbanek K, Michler RE, Bolli R, Kajstura J, Leri A, Anversa P (2007) Human cardiac stem cells. Proc Natl Acad Sci USA 104(35):14068–14073 14. Bolli R, Chugh AR, D’Amario D, Loughran JH, Stoddard MF, Ikram S, Beache GM, Wagner SG, Leri A, Hosoda T, Sanada F,
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15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
Elmore JB, Goichberg P, Cappetta D, Solankhi NK, Fahsah I, Rokosh DG, Slaughter MS, Kajstura J, Anversa P (2011) Cardiac stem cells in patients with ischaemic cardiomyopathy (SCIPIO): initial results of a randomised phase 1 trial. Lancet 378(9806): 1847–1857 Chugh AR, Beache GM, Loughran JH, Mewton N, Elmore JB, Kajstura J, Pappas P, Tatooles A, Stoddard MF, Lima JA, Slaughter MS, Anversa P, Bolli R (2012) Administration of cardiac stem cells in patients with ischemic cardiomyopathy: the SCIPIO trial: surgical aspects and interim analysis of myocardial function and viability by magnetic resonance. Circulation 126(11 Suppl 1):S54–S64 Smith RR, Barile L, Cho HC, Leppo MK, Hare JM, Messina E, Giacomello A, Abraham MR, Marban E (2007) Regenerative potential of cardiosphere-derived cells expanded from percutaneous endomyocardial biopsy specimens. Circulation 115(7): 896–908 Makkar RR, Smith RR, Cheng K, Malliaras K, Thomson LE, Berman D, Czer LS, Marban L, Mendizabal A, Johnston PV, Russell SD, Schuleri KH, Lardo AC, Gerstenblith G, Marban E (2012) Intracoronary cardiosphere-derived cells for heart regeneration after myocardial infarction (CADUCEUS): a prospective, randomised phase 1 trial. Lancet 379(9819):895–904 Ye J, Boyle A, Shih H, Sievers RE, Zhang Y, Prasad M, Su H, Zhou Y, Grossman W, Bernstein HS, Yeghiazarians Y (2012) Sca-1 ? cardiosphere-derived cells are enriched for Isl1-expressing cardiac precursors and improve cardiac function after myocardial injury. PLoS One 7(1):e30329 Min JY, Yang Y, Converso KL, Liu L, Huang Q, Morgan JP, Xiao YF (2002) Transplantation of embryonic stem cells improves cardiac function in postinfarcted rats. J Appl Physiol 92(1):288–296 Menard C, Hagege AA, Agbulut O, Barro M, Morichetti MC, Brasselet C, Bel A, Messas E, Bissery A, Bruneval P, Desnos M, Puceat M, Menasche P (2005) Transplantation of cardiac-committed mouse embryonic stem cells to infarcted sheep myocardium: a preclinical study. Lancet 366(9490):1005–1012 Laflamme MA, Chen KY, Naumova AV, Muskheli V, Fugate JA, Dupras SK, Reinecke H, Xu C, Hassanipour M, Police S, O’Sullivan C, Collins L, Chen Y, Minami E, Gill EA, Ueno S, Yuan C, Gold J, Murry CE (2007) Cardiomyocytes derived from human embryonic stem cells in pro-survival factors enhance function of infarcted rat hearts. Nat Biotechnol 25(9):1015–1024 Yeghiazarians Y, Gaur M, Zhang Y, Sievers RE, Ritner C, Prasad M, Boyle A, Bernstein HS (2012) Myocardial improvement with human embryonic stem cell-derived cardiomyocytes enriched by p38MAPK inhibition. Cytotherapy 14(2):223–231 Telukuntla KS, Suncion VY, Schulman IH, Hare JM (2013) The advancing field of cell-based therapy: insights and lessons from clinical trials. J Am Heart Assoc 2(5):e000338 Sanganalmath SK, Bolli R (2013) Cell therapy for heart failure: a comprehensive overview of experimental and clinical studies, current challenges, and future directions. Circ Res 113(6): 810–834 Springer ML, Sievers RE, Viswanathan MN, Yee MS, Foster E, Grossman W, Yeghiazarians Y (2005) Closed-chest cell injections into mouse myocardium guided by high-resolution echocardiography. Am J Physiol Heart Circ Physiol 289(3):H1307–H1314 Hatzistergos KE, Quevedo H, Oskouei BN, Hu Q, Feigenbaum GS, Margitich IS, Mazhari R, Boyle AJ, Zambrano JP, Rodriguez JE, Dulce R, Pattany PM, Valdes D, Revilla C, Heldman AW, McNiece I, Hare JM (2010) Bone marrow mesenchymal stem cells stimulate cardiac stem cell proliferation and differentiation. Circ Res 107(7):913–922 Loffredo FS, Steinhauser ML, Gannon J, Lee RT (2011) Bone marrow-derived cell therapy stimulates endogenous cardiomyocyte
Heart Fail Rev (2015) 20:613–619
28.
29.
30.
31.
32.
33.
34.
35.
36.
progenitors and promotes cardiac repair. Cell Stem Cell 8(4):389–398 Chimenti I, Smith RR, Li TS, Gerstenblith G, Messina E, Giacomello A, Marban E (2010) Relative roles of direct regeneration versus paracrine effects of human cardiosphere-derived cells transplanted into infarcted mice. Circ Res 106(5):971–980 Mirotsou M, Jayawardena TM, Schmeckpeper J, Gnecchi M, Dzau VJ (2011) Paracrine mechanisms of stem cell reparative and regenerative actions in the heart. J Mol Cell Cardiol 50(2): 280–289 Wang X, Takagawa J, Haddad DJ, Pinnamaneni K, Zhang Y, Sievers RE, Grossman W, Yeghiazarians Y, Springer ML (2011) Advanced Donor age impairs bone marrow cell therapeutic efficacy for cardiac disease. J Tissue Sci Eng. doi:10.4172/21577552.S3-002 Venugopal JR, Prabhakaran MP, Mukherjee S, Ravichandran R, Dan K, Ramakrishna S (2012) Biomaterial strategies for alleviation of myocardial infarction. J R Soc Interface 9(66):1–19. doi:10.1098/rsif.2011.0301 Sui R, Liao X, Zhou X, Tan Q (2011) The current status of engineering myocardial tissue. Stem Cell Rev 7(1):172–180. doi:10.1007/s12015-010-9131-8 Levit RD, Landazuri N, Phelps EA, Brown ME, Garcia AJ, Davis ME, Joseph G, Long R, Safley SA, Suever JD, Lyle AN, Weber CJ, Taylor WR (2013) Cellular encapsulation enhances cardiac repair. J Am Heart Assoc 2(5):e000367 Caspi O, Huber I, Kehat I, Habib M, Arbel G, Gepstein A, Yankelson L, Aronson D, Beyar R, Gepstein L (2007) Transplantation of human embryonic stem cell-derived cardiomyocytes improves myocardial performance in infarcted rat hearts. J Am Coll Cardiol 50(19):1884–1893 Menasche P, Hagege AA, Vilquin JT, Desnos M, Abergel E, Pouzet B, Bel A, Sarateanu S, Scorsin M, Schwartz K, Bruneval P, Benbunan M, Marolleau JP, Duboc D (2003) Autologous skeletal myoblast transplantation for severe postinfarction left ventricular dysfunction. J Am Coll Cardiol 41(7):1078–1083 Menasche P, Alfieri O, Janssens S, McKenna W, Reichenspurner H, Trinquart L, Vilquin JT, Marolleau JP, Seymour B, Larghero
619
37.
38.
39.
40.
J, Lake S, Chatellier G, Solomon S, Desnos M, Hagege AA (2008) The myoblast autologous grafting in ischemic cardiomyopathy (MAGIC) trial: first randomized placebo-controlled study of myoblast transplantation. Circulation 117(9):1189–1200 Traverse JH, Henry TD, Ellis SG, Pepine CJ, Willerson JT, Zhao DX, Forder JR, Byrne BJ, Hatzopoulos AK, Penn MS, Perin EC, Baran KW, Chambers J, Lambert C, Raveendran G, Simon DI, Vaughan DE, Simpson LM, Gee AP, Taylor DA, Cogle CR, Thomas JD, Silva GV, Jorgenson BC, Olson RE, Bowman S, Francescon J, Geither C, Handberg E, Smith DX, Baraniuk S, Piller LB, Loghin C, Aguilar D, Richman S, Zierold C, Bettencourt J, Sayre SL, Vojvodic RW, Skarlatos SI, Gordon DJ, Ebert RF, Kwak M, Moye LA, Simari RD (2011) Effect of intracoronary delivery of autologous bone marrow mononuclear cells 2 to 3 weeks following acute myocardial infarction on left ventricular function: the LateTIME randomized trial. JAMA 306(19): 2110–2119 Le Blanc K, Tammik C, Rosendahl K, Zetterberg E, Ringden O (2003) HLA expression and immunologic properties of differentiated and undifferentiated mesenchymal stem cells. Exp Hematol 31(10):890–896 Klyushnenkova E, Mosca JD, Zernetkina V, Majumdar MK, Beggs KJ, Simonetti DW, Deans RJ, McIntosh KR (2005) T cell responses to allogeneic human mesenchymal stem cells: immunogenicity, tolerance, and suppression. J Biomed Sci 12(1): 47–57 Hare JM, Fishman JE, Gerstenblith G, DiFede Velazquez DL, Zambrano JP, Suncion VY, Tracy M, Ghersin E, Johnston PV, Brinker JA, Breton E, Davis-Sproul J, Schulman IH, Byrnes J, Mendizabal AM, Lowery MH, Rouy D, Altman P, Wong Po Foo C, Ruiz P, Amador A, Da Silva J, McNiece IK, Heldman AW (2012) Comparison of allogeneic vs autologous bone marrowderived mesenchymal stem cells delivered by transendocardial injection in patients with ischemic cardiomyopathy: the POSEIDON randomized trial. JAMA 308(22):2369–2379
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