Devices are So Old School: The New World of Myocardial Regeneration
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1 Devices are So Old School: The New World of Myocardial Regeneration Todd K. Rosengart, M.D. Professor and Chairman DeBakey-Bard Chair of Surgery Michael E. DeBakey Department of Surgery Professor, Texas Heart Institute
2 Disclosures XyloCor Therapeutics
3 Regenerative Therapy for Cardiac Disease Clinical Targets Ischemic Disease Therapeutic angiogenesis: The generation of new vasculature via delivery of angiogenic proteins or genes, specifically to no option patients not amenable to conventional interventions. Myocardial Infarction Cellular Reprogramming: Conversion of endogenous scar fibroblasts Click in to areas edit of subtitle myocardial style infarction into induced cardiomyocytes, thereby regenerating contractile myocardial tissue from infarcted myocardium.
4 Cellular Reprogramming: Regenerating Cardiomyocytes from Scar Fibroblasts Cardiac stem cell therapy Introduction of exogenous (stem) cells into infarcted myocardium in order to improve cardiac function. Cellular reprogramming In situ conversion of endogenous infarct fibroblasts into functional cardiomyocytes. Exogenous stem cell delivery In situ cellular reprogramming
5 Angiogenic Gene Therapy: Delivery of VEGF Induces Neovascularization Induce ischemia left circumflex 3 wk Administer AdVEGF Control 4 wk Evaluate Safety Efficacy AdVEGF121 Rosengart et al. J Thorac Cardiovasc Surg. 1998; 115;
6 Angiogenic Cardiac Gene Therapy: Proof of Principle Phase I Adenovirus Delivery of VEGF 121 to Induce Cardiac Angiogenesis 121 One-time, multi-site, direct myocardial injection Minimally invasive 15 Rosengart et al. Circulation. 1999;100: Rosengart et al. Ann Surg. 1999; 230: December 17, 1997, N.Y. Hospital: Phase I AdVEGF angiogenesis trial
7 The REVASC Trial: Phase II Multicenter AdVEGF Trial Time to 1 min ST depression: change from baseline (min) AdVEGF121 Control p = n = Wk 12 Wk Stewart et al. Gene Ther. 2006;13:
8 REVASC Histology Results: Evidence of Angiogenesis in the Human Heart Right ventricle Untreated Left ventricle AdVEGF121 (19 days post-injection) 69 year old male died 19 days post-op from an MI in the RV (AdVEGF121 administered in the LV) Stewart et al. Gene Ther. 2006;13:
9 Long-term Outcomes after Cardiac Gene Therapy Exceeded Expectations AdVEGF121 Trial 10 Year Follow Up 1 Apparent angiogenesisinduced collaterals 1 Rosengart et al, Hum Gene Ther. 2013;24:203 *Allen et al. Ann Thorac Surg. 2004; 77, *Cheng et al. Innovations. 2006; 1: 295 *Horvath et al. Circulation. 2001; 104: I81.
10 Next-Gen Angiogenic Gene Therapy Trial Subjects with diffuse moderate to severe coronary artery disease on optimal medical therapy with no other therapeutic options Multi-isoform VEGF cassette (100X greater potency) Part A (Dose escalation) Adenoviral vector Part B (randomized, double-blind, placebo controlled trial) Click Direct to myocardial edit subtitle injection style via mini-thoracotomy Assess safety and efficacy parameters up to 6 months (1 mm ST depression on ETT, PET) Treatment Group Cohort 1 AdVEGF-Minigene 3:1 Randomization Cohort 2 AdNull Placebo Group
11 Exogenous Cell Therapy and ipscs: A New Door Opens Exogenous Stem Cell Delivery Inadequate implant phenotype Inadequate delivery, survival and integration Ventricular arrhythmias Induced Pluripotent Stem Cells (ipscs) Dedifferentiated stem cell ideal basis for CM phenotype BUT: still exogenous; immunogenicity, tumorigenicity risks KLF 4 Oct 4 Sox2 cmyc Adult somatic cells Pluripotent stem cells
12 Cardiac Stem Cell Implantation Therapy: Clinical Data DAMASCENE Bone Marrow Stem Cell Meta-Analysis Cochrane Review 100+ Phase I/II trials 41 randomized controlled trials 2732 patients Non-clinically relevant increase in LVEF of 2-5% Ejection fraction effect (% change in EF) Fisher, et al. The Cochrane Database of Systematic Reviews. 2015; 9:CD Number of discrepancies per trial. Nowbar, et al. BMJ. 2014; 348:g2688.
13 Cardiac Stem Cell Implantation Therapy: Angina Outcomes Data IMPACT-CABG RCT (JTCVS 2016): Autologous intramyocardial CD133 + (n=40) endothelial progenitor cells as adjunct to CABG: No difference in improvement in angina RENEW RCT (JACC 2016): Autologous intramyocardial CD34 + cells (n=112) Angina frequency was improved at 6 months (p = 0.05) Exercise time difference Click 61 s to at 3edit months title 36 s at style 12 months (p = 0.43) Study terminated REGENT-VSEL RCT (Circ Res 2016): Autologous intramyocardial CD133 + (n=31) No change in ischemia by SPECT No difference in improvement in angina
14 Obstacles to Exogenous Cell Therapy Segers, et al. Stem Cell Therapy for Cardiac Disease. Nature. 2009
15 and If You had Any Doubt:
16 A New Era: Cardiac Cellular Reprogramming Yamanaka (Oct4, Sox2, Kfl4, c-myc) Srivastava (Gata4, Mef2c, Tbx5) David et al. Physiology 2012
17 Induced Cardiomyocyte Generation Cardiac fibroblasts Reprogramming Genes Gata 4 Mef2C Tbx5 Gene Transfer Vectors Induced cardiomyocytes GMT DAPI GFP Cardiac Troponin T Merge GFP Control Spontaneous icm Contractility Mathison et. al. J Am Heart Assoc. 2013
18 Myocardial Regeneration via In Situ Cellular Reprogramming Fibroblasts Cellular Reprogramming Factors Induced cardiomyocytes
19 Cellular Reprogramming In Situ: Experimental Studies Create Infarct + Revascularization 3 wk 4 wk Assessment Reprogramming Fischer 344 rats LAD ligation AdVEGF or AdNull Gata 4, Mef2c, and Tbx5 Lentivirus vectors Immunohistochemistry Echocardiography
20 Cellular Reprogramming In Situ: Evidence of Myocardial Regeneration Control Treated (VEGF / GMT) MYH7 + cardiac myocytes Fibrosis (trichrome) Echocardiography
21 Cellular Reprogramming: Improved Ventricular Function in Post-Infarct Model 80 Ejection fraction (%) VEGF/GMT Null/GMT VEGF/GFP Null/GFP p = 0.05 Control Days after coronary ligation Mathison et. al. J Am Heart Assoc VEGF/GMT
22 Triplet Vectors Enhance Reprogramming Efficacy Compared to Singlet Vectors Lentivirus Singlet Vectors Lentivirus GMT Triplet Change in Ejection Fraction from Baseline 40% 30% 20% 10% 0% -10% -20% Mathison et al. J Thorac Cardiovasc Surg 2014 *p < 0.01 Pre-injection 2 weeks 4 weeks VEGF/Triplet GMT* VEGF/Singlet GMT Double Control
23 Clinical Barriers to Reprogramming Therapy: Human Resistance to Cellular Plasticity Human Cellular Reprogramming Cellular senescence Lack of stemness Cell cycle arrest Differentiation/anti-plasticity Chromatin based epigenetic modulation of genetic activation
24 Strategy to Overcome Human Resistance More Factors in the Cocktail! Tbx5 Gata4 Mef2c Mef2 c Mesp1 Gata4 Tbx5 Mef2c Hand 2 ESSRG Myocardin mir-1 mir-133
25 Overcoming Higher Order Species Cellular Plasticity Barrier GMT-treated porcine fibroblasts (GFP/actinin) GMT(HM)-treated porcine fibroblasts (GFP/actinin) GMT(HM)-treated porcine fibroblasts
26 Myocardial Regeneration: Lessons from the Tadpole
27 The p53 Family: The Guardians of the Genome Key to Overcoming Barriers to Reprogramming? p53/p63 Regulation Cellular senescence Stemness Cell cycle arrest Differentiation/plasticity Loss of p53/p63 Interferes with chromatin deacetylation Unlocks gene activation/promoter sites Enhanced ips formation Confers increased cell plasticity Chakravati et al. PNAS. 2014
28 p63 Silencing Induces Cell Plasticity and Cardiac Cell Reprogramming Murine Cardiac fibroblasts Epigenetic Transdifferentiation p63 Knockdown Hand2 Myocardin Murine Induced cardiomyocytes Contractility Contractility Cell length (µm) µ Cell length (µm) µ 4 2 Ca 2+ Transient Ca Transient (Fura2 ratio) Ca Transient (Fura2 ratio)
29 Conclusions Gene therapy cardiac applications including angiogenesis trials have reappeared in the clinical arena Angiogenic pretreatment of infarcted myocardium improves outcomes of cell therapy Although formidable barriers remain, cardiac cellular reprogramming represents an exciting new potential treatment for individuals with end stage heart disease and heart failure
30 Cardiac Regenerative Therapy A New Paradigm for Treating Heart Disease
31 Thank you! Michael E. DeBakey Department of Surgery Laboratory for Cardiac Regeneration Todd Rosengart, MD; Austin Cooney, PhD; Megumi Mathison, MD, PhD; Lisa Mullany, PhD; Mustafa Naguib; BS, Jackie Olive; BS, Vivek Patel, MD; D. Sanagasetti, Vivek Singh, PhD; Lina Yang, BS; Hongran Wang, MD; PhD, Jerry Yang, PhD
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