Cardiovascular cell therapy: next step is a custom work?

Transcription

1 Cardiovascular cell therapy: next step is a custom work? Giulio Pompilio MD PhD UNITA DI RICERCA CLINICA E PRECLINICA DI TERAPIA RIGENERATIVA CARDIOVASCOLARE CENTRO CARDIOLOGICO MONZINO IRRCS UNIVERSITA DEGLI STUDI DI MILANO

2 BM- c-kit+

3 Stem cell transplantation for cardiac regeneration TRANSPLANTED STEM CELLS Proliferation Vessels Muscle Cells Cell fusion Differentiation Paracrine effects: Recruitment of resident stem cells Cell Apoptosis Cell Proliferation Perfusion Function

4 Reduction of infarct size/ thicker and cellularized infarct Improvement in vascularization acute chronic

5 Key Issues in Cell Therapy of Cardiovascular Diseases 1) Which Cell Type 2) Strategies for Cell transplantation 3) Which diseases could be treated 1) How to overcome cell impairment 2) The search for tissue-specific (cardiac) progenitor cells 3) Drug therapy to activate resident cardiac stem cells

6 Bone Marrow Cells Peripheral Blood - derived (after mobilization with G-CSF) Adipose tissue derived cells Umbilical cord blood cells Cardiac stem cells Embryonic SC ips cells Which Cell Type Unfractionated Fractioned EPC c-kit+ Mesenchymal Endotelial Progenitor Cells (EPC): CD34 +, AC133 + CD34 + AC133 + Skeletal myoblasts Cells used in clinical studies

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8 Which diseases could be treated Acute myocardial infarction (STEMI) Chronic myocardial ischemia Heart failure Post-ischemic Chemotherapy Post-infection Unknown etiology Ventricular arrhythmias

9 Cell Therapy for STEMI

10 Adult bone marrow cells for cardiac repair: a meta-analysis LVESV was significantly reduced by 4.74 ml in BMSC treated hearts There is a trend showing LVEDV reduction in BMSC treated hearts Martin-Rendon et al. Eur. Heart J. 2008

11 Adult bone marrow cells for cardiac repair: a meta-analysis LVEF was improved by 2.99% in BMSC treated hearts Martin-Rendon et al. Eur. Heart J. 2008

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13 Cell Therapy for STEMI For whom: large infarcts with reduced EF (<45%) after PCI. When: 6-10 days after MI.

14 Cell Therapy for ICM

15 Aim of the study Bone marrow AC133 + cell transplantation in patients with class III/IV angina on maximal medical therapy and unsuitable for conventional revascularization

16 Endothelial progenitor cells Bone Marrow Peripheral circulation Homing to ischemic tissue c-kit CD34 AC133 KDR CD34 AC133 KDR CD34 low AC133 - Endothelial markers +

17 Study design Procedure 3 months p.o months p.o. AC133 isolation 4-12x Dobutamine-echo Thallium SPECT - Electrophysiologic studies - Dobutamine-echo Thallium SPECT - Coronary angiography - Electrophysiologic studies Pompilio G et al. Thorac. Cariov. Surg. 2007

18 Patients Ineligible for conventional mechanical revascularization Full medical therapy Canadian Class III/IV Evidence of distinct ischemia in viable territory No co-morbidities affecting survival No history of malignant disease Not older that 75 years Good compliance Pompilio G et al. Thorac. Cariov. Surg. 2007

19 PATIENT Selected characteristics of treated patients Site of Ischemia Approach Number CD Lateral MiTh 9 x % None EF Prior Procedures 2 Inferior SubDiaphr 12 x % CAB, SCS 3 Anterior MiTh 8 x % CAB, PCI, TMR 4 Anterior MiTh 5 x % CAB, PCI, SCS 5 Posterolateral MiTh 4 x % CAB, PCI, SCS 6 Anteroapical MiTh 5 x % CAB, PCI 7 Anterolateral MiTh 8 x % CAB, PCI 8 Lateral MiTh 12 x % CAB, PCI 9 Anterior MiTh 6 x % PCI

20 Filmato

21 AC133 + transplantation improves Canadian Cardiovascular Society Score from 3.8 to 1.8 after 6 months CANADIAN CLASS I II III IV PRE 6-months 1-year The improvement of angina been observed after a mean of 3,8 weeks from cell injection (range 2-9)

22 Pre Post Injected segments (rest) 1.0 Pre Post G Pompilio et al, Thorac Cardiovasc Surg Injected segments (stress)

23 Pre-op Post-op (6 months) Pompilio G et al. Thorac. Cariov. Surg. 2007

24 Conclusions AC133 + transplantation for refractory myocardial ischemia results in long-term clinical and perfusion improvement in the absence of adverse events.

25 Selected References and Design (Pts) Perin et al Series (14) + control (7). Pathologic Substrate Chronic ischemic cardiomyopathy Therapeutic Approach NOGA-guided intramyocardial BMCs inoculation. Cellrelated Adverse Events None Results (primary Main endpoints) Quantification Method perfusion and exercise capacity (MvO 2 in pts. < 60y). SPECT; Ramp treadmill Beeres et al. Refractory RCT, double blind, ischemia placebocontrolled NOGA-guided None intramyocardial BMCs inoculation. perfusion and EF (3%) MR; SPECT Losordo Refractory RCT, double blind, ischemia placebocontrolled NOGA-guided None intramyocardial BMCs inoculation. perfusion and exercise time SPECT; treadmill

26 EPC number and function impairment Aging Diabetes Hypercholesterolemia Heart failure Uremia

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29 Key Issues in Cell Therapy of Cardiovascular Diseases 1) Which Cell Type 2) Strategies for Cell transplantation 3) Which diseases could be treated 1) How to overcome cell impairment 1) The search for tissue-specific (cardiac) progenitor cells 2) Drug therapy to activate resident cardiac stem cells

30 Diabetic BM derived c-kit + cells exhibit impaired SDF-1 directed differentiation toward the endothelial phenotype Normoglycemic c-kit + Diabetic ckit + De Falco ed al. JCMM 2009

31 How to overcome Stem Cell impairment? Cell treatment with molecules may increase homing, survival and differentiation Statins Erythropoietin Estrogene p38 inhibitors enos enhancers Histone deacetylases inhibitors HMGB1 Hypoxic/Acidotic culture conditions AKT gene transfer

32 Acidosis enhances CXCR4 expression Acidic preconditioning enhances cell chemotaxis and transendothelial migration toward SDF-1 Fold increase CXCR4 mrna ph 7.4 ph 7.0 * Migration index ph 7.4 ph 7.0 * SDF-1

33 Acidic preconditioning enhances cell differentiation toward the endothelial lineage DiI-Ac-LDL + cells ph 7.4 ph 7.0 * 20% FCS ph 7.4 ph 7.0 vwf + cells ph 7.4 ph 7.0 * 0

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35 Conclusions It is possible to treat cells ex vivo to enhance their therapeutic potential

36 Key Issues in Cell Therapy of Cardiovascular Diseases 1) Which Cell Type 2) Strategies for cell transplantation 3) Which diseases could be treated 4) How to overcome cell impairment 1) The search for tissue-specific (cardiac) progenitor cells 1) Drug therapy to activate resident cardiac stem cells

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38 Differentiation: cardiogenesis Gene expression analysis ATRA/Phenyl-Bur based medium mrna expression DCt CM ATRA/PB GATA NS SMA ** Troponin-I * * NS Sarc ** MHC * MLC-2a * NS CMSC BMMSC CMSC BMMSC * IF after treatment CMSC BMMSC -sarcomeric actin DAPI 40x

39 In vivo injection in a rat model of chronic MI QDot labelled cell tracking CMSC Phase Contrast UV Light QD 585 QD 585 (CMSC) 1 mm BMMSC QD 705 QD 705 (BMMSC) % of QDot Area /Analysed Area CMSC * BMMSC m

40 In vivo injection in a rat model of chronic MI Only CMSC-derived -Sarc POS cells located within the scar border presented evident sarcomeres CMSC border BMMSC CMSC infarct border 20 m -sarc GFP DAPI

41 CONCLUSIONS Cardiac Mesenchimal Stem Cells: In vitro revealed a higher efficiency in the acquisition of a cardiovascular phenotype In vivo, following injection in a rat model of chronic MI: - persisted within the tissue - differentiated into cardiomyocytes - improved cardiac function and remodeling more efficiently than their bone marrow counterpart. Therefore CMSC may represent a suitable source of cells for myocardial repair.

42 Key Issues in Cell Therapy of Cardiovascular Diseases 1) Which Cell Type 2) Strategies for cell transplantation 3) Which diseases could be treated 4) How to overcome cell impairment 5) The search for tissue-specific (cardiac) progenitor cells 1) Drug therapy to activate resident cardiac stem cells

43 Resident Cardiac Stem Cells Cardiac stem cells Epicardial stem cells Mesothelial layer Adipose Tissue Epicardium c-kit Myocardium 50 m Limana et al. Circ Res 2007

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45 Growth factor modulation of resident Cardiac Stem Cells HGF, IGF-1 High Mobility Group Box 1 DNA binding domain Cardiac tissue regeneration and improvement of cardiac function 1 BOX A BOX B Acidic tail 215 aa RAGE binding domain Urbanek et al. PNAS 2005 Linke et al. PNAS 2005

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47 HMGB1 promotes cardiac c-kit + cell proliferation c-kit Ki-67 -sarcomeric actin nuclei 24 hr after MI Limana et al. Circ Res 2005

48 HMGB1 improves myocardial function: Echocardiography Hemodynamic M-Mode Echocardiography Before MI 25 LVEDP After MI 20 Control Ejection Fraction HMGB1 mm Hg SO C HMGB1 SO C HMGB1 SO C HMGB1 % MI MI MI 30 1w 2w 4w 0 SO C HMGB1 SO C HMGB1 SO C HMGB1 MI MI MI 1w 2w 4w Limana et al. Circ Res 2005

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50 4 weeks after HMGB1 treatment: HMGB1 induces cardiac tissue regeneration in cronic ischemic hearts Ctrl HMGB1 -sarcomeric actin connexin 43 Ki67

51 4 weeks after HMGB1 treatment: Volume and number of newly formed myocytes mm * 30 * * 25 Regenerated volume fraction (%) Myocyte number (x10 6 ) Ctrl HMGB1 Ctrl HMGB1 Ctrl HMGB

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53 4 weeks after HMGB1 treatment: Collagen expression 40X HMGB1 % collagen Ctrl P<0.005 HMGB1 green collagen pink muscle

54 CONCLUSIONS Exogenous HMGB1 enhances c-kit + cell activation after MI Exogenous HMGB1 induces myocardial and vascular regeneration after MI Exogenous HMGB1 improves LV remodelling after MI Exogenous HMGB1 improves LV function after MI

55 INFERENCES Cardiovascular cell therapy has the potential to expand the armentarium of cardiovascular therapy. We need to better understand biology but biology needs to be clinically-driven (traslational). A custom-work is anticipated for our patients: a single cell for a single disease.

56 MONZINO Maurizio Pesce Ombretta Pozzoli Federica Limana Claudia Colussi Barbara Illi Giuliana DiRocco Alessandra Rossini Yuri D Alessandra Elisa Gambini Marco De Simone Valeria Parente Manuela Tilenni Alessandro Scopece Ilaria Burba Paolo Devanna Matteo Vecelio Pietro Vella Beatrice Bassetti Prof. Paolo Biglioli Maurizio C Capogrossi IDI Carlo Gaetano Antonia Germani SAN DIEGO STATE UNIV. Mark Sussmann TEXAS HEART INSTITUTE UNIVERSITY OF ROSTOCK Emerson Perin Gustav Steinhoff Marlos Fernandez Andreas Liebold HARVARD UNIVERSITY NIA Piero Anversa Ed Lakatta Annarosa Leri