Translating Molecular Insights Into New Cellular Therapies For Cardiovascular Disease

Transcription

1 Ottawa Hospital Research Institute Institute de recherche de l Hopital d Ottawa Translating Molecular Insights Into New Cellular Therapies For Cardiovascular Disease ACC Rockies March 11-14, 2012 Dr. Duncan J. Stewart, CEO and Scientific Director, Ottawa Hospital Research Institute, VP Research, The Ottawa Hospital, Professor of Medicine, uottawa

2 Learning objectives Why we need cardiac stem cell therapies Discuss current cell therapy products that are under clinical evaluation Review the effects of host factors on autologous progenitor/stem cells Introduce the next generation of cell therapy Enhanced cell therapy Resident cardiac stem cells

3 Why are stem cell therapies needed? CODE STEMI 24 X patients/year 40 % anterior MIs 21% LVEF <40% Le May et al., NEJM 2009 Increased mortality Peterson et al., Ann Int Med 1997 Kasama et al., Heart 2011

4 Cardiac injury Sprott Stem Cell Centre Modified from: Armstrong PW. Tex Heart Inst J. 2009;36(4): Acute myocardial infarction Door-to-balloon Time is muscle!

5 Cardiac injury Sprott Stem Cell Centre Modified from: Armstrong PW. Tex Heart Inst J. 2009;36(4): Acute myocardial infarction Door-to-balloon

6 Cardiac Cell Therapy Menu Now serving fresh stem and progenitor cells! (approximate prices in CAN $) EPCs (circulating or bone marrow) CD34+/VEGFR2+... $30K Early growth EPCs. $25K Late outgrowth EPCs...$50K Unbilical cord EPCs when available! MSCs (bone marrow or fat) Allogenic... $25K Autologous.. $150K Myoblasts (served with a defibrillator!) Freshly harvested.$27k Cardiac resident stem cells Bring your own!... $??? CSCs Embryonic stem cells Special permission required! ES/iPS

7 Selection methods for progenitor cell enrichment Bone marrow or blood sample Ficoll gradient centrifugation Mononuclear cells (MNCs) % EPCs Culture specification of MNCs early growth EPCs or circulating angiogenic cells MNCs cultured on matrix (fibronectin) with endothelial growth factors (VEGF, IGF, etc,) for 3-10 days Unselected MNCs ~ M cells Selection by surface markers: CD34, CD M cells (TOPCARE-AMI) Intracoronary delivery post AMI DJ Stewart 2011,Taljard AHJ 2010

8 Circulating angiogenic cells - CAC Culture-Derived EPCs Early growth cells 3-7 days -CD14+, CD45+ -express EC markers -Nonproliferative -Highly angiogenic 1-2 weeks cell clusters Late outgrowth EPCs >2 wks - CD14, CD45 negative - Strong EC phenotype - Highly proliferative Arterioscler Thromb Vasc Biol. 2008;28:

9 Delivery approaches for cardiac cell therapy Stauer and Steinhoff JACC Vol. 58, No. 11, 2011

10 Strauer and Steinhoff JACC Vol. 58, No. 11, 2011:

11 Martin-Rendon et al. European Heart Journal (2008) 29, Systematic Review of Bone Marrow Cell Therapy for AMI Improvement in global LVEF REPAIR-AMI ~3% in LVEF P= Favors control Favors BMCs

12 Stem cell treatment for acute myocardial infarction: Cochrane review Thirty-three RCTs (1765 participants) were eligible for inclusion. In short-term follow up, stem cell treatment was observed to improve left ventricular ejection fraction (LVEF) significantly (WMD 2.87, 95% CI 2.00 to 3.73) This improvement in LVEF was maintained over longterm follow up of 12 to 61 months (WMD 3.75, 95% CI 2.57 to 4.93) Stem cell treatment for acute myocardial infarction (Review) Copyright 2012 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.

13 Stem cell treatment for acute myocardial infarction: Cochrane review Thirty-three RCTs (1765 participants) were eligible for inclusion. In short-term follow up, stem cell treatment was observed to improve left ventricular ejection fraction (LVEF) significantly (WMD 2.87, 95% CI 2.00 to 3.73) This improvement in LVEF was maintained over longterm follow up of 12 to 61 months (WMD 3.75, 95% CI 2.57 to 4.93) 2-3% increase in global EF is this good enough? - Effect size greater in patients with reduced EF (REPAIR-AMI 6% with EF <49% - Effect of host factors? Stem cell treatment for acute myocardial infarction (Review) Copyright 2012 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.

14 Autologous Progenitor Cell Dysfunction CAD and CAD risk factors impair the number and function of EPCs CAD Diabetes Advanced age Smoking Hypertension Hypercholesterolemia EPC homing/migration Dysfunction From: Kutryk and Stewart, 2004

15 Fadini G P et al. Circulation Research 2012;110:

16 Fadini G P et al. Circulation Research 2012;110:

17 Reduced neovascularization capacity in immune-deficient xeno-transplant mouse model Day Ratio of I/NI limb DPBS n=6 hepcs - high risk n=9 hepcs - low risk n=8 p<0.05 * Day x10 5 cells per animal 0 post Days Mike Ward, MD/PhD candidate, AHA 2006

18 Cell-enhancement strategies for the treatment of ischemic heart disease Angiogenic activity

19 modifies from Templin et al. Int. J. Dev. Biol. 55: Cell enhancement strategies Jet-PEI transfection enos plasma DNA

20 Dr. Howard Leong Poi, St Michael s Hospital Contrast ultrasound perfusion imaging of ischemic mouse hindlimb Normal Ischemic 20 Non-transfected EPCs Normal Ischemic enos-transfected EPCs

21 Perfusion Ratio (Ischemic/Nonischemic limb) Sprott Stem Cell Centre Effect of enos gene transfer on perfusion recovery: nonviral transfection with Jet- PEI (Polyplus) Ratio of I/NI : Echo contrast perfusion (day 28) P< control saline Non Tx EPCs enos Tx EPCs N = 6 patients; 3 mice for each data point Dr. Howard Leong Poi, St Michael s Hospital

22 The Enhanced Angiogenic CellTherapy Acute Myocardial Infarction (EnACT- AMI) Phase IIA/B (100 patients) Multicentre randomized double blind controlled trial 3 cities in eastern Canada 5 sites Ottawa University of Ottawa Heart Institute (Chris Glover) Toronto St. Michael s Hospital (Mike Kutryk) Sunnybrook HSC (Sandy Dick MRI core) Montreal Jewish General Hospital (Dominique Joyal) Montreal Heart Institute (Hung Ly Qroc) Am Heart J Mar;159(3):354-60

23 EnACT- AMI -Design 3 treatment groups Group 1: placebo (Plasma-Lyte A) coronary injection to the infarct related artery Group 2: autologous Non transfected EPCs Group 3: autologous EPCs transfected with henos (Jet-PEI) I o Endpoint: Change in global LVEF by cardiac MRI (baseline to 6 month follow-up) a) between patients treated with EPCs (both enos transfected and non-transfected groups) vs. placebo b) between patients treated with henos-transfected vs. nontransfected EPCs Planned statistical analysis: ANCOVA, controlling for baseline LVEF. Multiple comparisons between the three groups will be based on Tukey s studentized range test.

24 EF<45% <41% for the first 12 pts Yes No PCI of IRA? No Angio: > TIMI 1; 70% No Yes Apheresis Minimization scheme Early (5-15 days) Late (16-30 days) Randomization Saline EPCs enos/epcs 3-5 days for cell processing LVEF -MRI Cell/Placebo injection +/- PCI* 6 months FU * PCI if angiogram criteria met and have not had PCI post MI

25 EnACT-AMI Timelines Funding: Canadian Institutes for Health Research (2008) Canadian Stem Cell Network (2008) Regulatory approval Nov 2011 Research ethics approval Q Trial initiation Q

26 Blood and bone marrow stem cell mechanisms of benefit Blood and bone marrow stem cells Immunomodulatory Segers and Li Nature 2008

27 Ott et al., Nat. Med Sprott Stem Cell Centre The adult heart contains small reservoirs of cardiac progenitor cells Stem cell niche in the adult a-sarc actin human c-kit atrium: procollagen fibronectin nuclei N-cadherin Cx43 Leri et al. Physiol Rev 2005 Bearzi et. al. PNAS 2007.

28 How are cardiac stem cells obtained? Whole heart or atrial appendage, Digest with enzymes Limitations: Tissue limited, time, technically complex, cost and phenotypic drift. Select cells that express surface molecules of cardiac stem cells c-kit+ sca-1+ SSEA-1+ abcg2+ On-going culture to expand to clinical doses (months)

29 Biopsy culture process Biopsy (1) Explants (2) Cardiosphere -forming cells (3) Cardiospheres (4) Cardiospherederived cells (CDCs, 5) mm 100 mm 200 mm 100 mm Smith et al. Circulation 2007; Davis PLoS ONE 2010

30 Clinical trials using resident cardiac stem cells Inclusion criteria: MI + PCI.25 EF.45 Inclusion criteria: History of MI EF.45 scheduled for CABG CArdiosphere-Derived autologous Stem CElls to reverse ventricular dysfunction (CADUCEUS) Marban Biopsy Atrial appendage 25 patients (8 controls) 1-4 months culture AHA Scientific Sessions 2011 Cardiospherederived cells (CDCs) million c-kit+ Stem Cells 1 million Mean EF: 38% MRI scar: Mass 24% MeanEF: 31±2% NYHA 2±.02 Cardiac Stem Cell Infusion in Patients with Ischemic cardiomyopathy (SCIPIO) Bolli/Anversa 23 patients (7 controls) IC injection 1 st patient May 27, 2009 IC injection 1 st patient July 17, 2009

31 Main results CADUSEUS - Makkar et al., Lancet Scar mass, viable mass (MRI) - No improvement in EF (MRI) SCIPIO - Bolli et al., Lancet Decreased infarct size (MRI) - Increase in LVEF (Echo) 3 months post MI 6 months post cell Rx

32 Conclusions Stem/progenitor cell therapy for cardiac disease represents a potentially important adjunctive therapy for patients with cardiac dysfunction post MI Bone morrow or blood-derived cell therapies have demonstrated promise however enhancement strategies are likely needed to improve efficacy ENACT AMI is a logical next step by using enhanced progenitor cells for cardiac repair Resident cardiac stem cell therapy is also promising but larger phase 2 trials are needed to assess relative benefits compared to BM and blood-derived progenitors

33 Cell therapy for management of LV dysfunction post MI. Pivotal trail confirming even modest effects of bone marrow cells will change practice New technology and advances in cell selection, processing and enhancement will result in robust and predictable improvement in cardiac function

34 Thank you!