ognizant Communication Corporation

The Regenerative Medicine Journal

VOLUME 18, NUMBER 3, 2009

Cell Transplantation, Vol. 18, pp. 245-254, 2009
0963-6897/09 $90.00 + 00
E-ISSN 1555-3892
Copyright © 2009 Cognizant Comm. Corp.
Printed in the USA. All rights reserved.

Early Translation of Adipose-Derived Cell Therapy for Cardiovascular Disease

Ricardo Sanz-Ruiz,1 Eugenia Fernández-Santos,1 Marta Domínguez-Muñoa,1 Radoslaw Parma,2 Adolfo Villa,1 Lucía Fernández,1 Pedro L. Sánchez,1 and Francisco Fernández-Avilés1

1Cardiology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
2Third Division of Cardiology, Medical University of Silesia, Katowice, Poland

Over the past decade, cell therapy has emerged as a new approach to reversing myocardial ischemia. Several types of adult stem cells have been studied in both preclinical and clinical conditions for this purpose: bone marrow cells, circulating cells, and myoblasts. Nevertheless, the quest for the ideal "anti-ischemic" cell is still ongoing. Recently, the existence of a population of stem cells located in adipose tissue (adipose-derived stem cells) has been observed. These are able to differentiate into multiple cell lineages including cardiomyocytic differentiation. In this review we discuss the basic principles of adipose-derived stem cells (types and characteristics, harvesting, and expansion), the initial experimental studies, and the currently ongoing clinical trials.

Key words: Stem cells; Cardiovascular repair; Adipose-derived stem cells; Adipose tissue; APOLLO trial; PRECISE trial

Address correspondence to Prof. Francisco Fernández-Avilés, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, 28007, Madrid, Spain. Tel: 91 426 5880; Fax: 91 586 8276; E-mail: faviles@secardiologia.es

Cell Transplantation, Vol. 18, pp. 255-259, 2009
0963-6897/09 $90.00 + 00
E-ISSN 1555-3892
Copyright © 2009 Cognizant Comm. Corp.
Printed in the USA. All rights reserved.

Function and Mode of Regulation of Endothelial Major Histocompatibility Complex Class II

Irina Alexander,1,2 Elazer R. Edelman,1,3 and Heiko Methe1,4

1Harvard-MIT Division of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA, USA
2Institute of Cell Biology, ETH Hoenggerberg, Zurich, Switzerland
3Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
4Department of Internal Medicine/Cardiology, University Hospital Grosshadern, Ludwig-Maximilians University, Munich, Germany

Tissue engineering is a promising approach to implement endothelial cells as a cellular delivery therapy for vascular disease. We and others previously demonstrated that endothelial cells embedded in three-dimensional collagen-based matrices retain their full biosecretory spectrum, enabling them to serve as powerful regulators of vascular diseases. Fascinatingly, matrix embedding of endothelial cells not only allows for their implantation but also seems to provide protection from allo- and xenogeneic-triggered host immune responses. This is not an effect of simple physical shielding but a more fundamental influence of cell-matrix interconnectivity on the cellular immune phenotype. Reduced cytokine-induced levels of costimulatory and adhesion molecules associated with significantly lower expression levels of major histocompatibility class II expression on matrix-embedded human aortic endothelial cells when compared to the same cells cultured on two-dimensional polystyrene coated-tissue culture plates. Strikingly, the entire interferon-g-dependent signaling cascade resulting in MHC class II molecule expression is markedly suppressed in endothelial cells grown to confluence within three-dimensional scaffolds. These findings might be of pivotal importance for designing endothelial cell-based therapies in general and might enhance our understanding of the underlying pathophysiology in a broad range of cardiovascular diseases (e.g., atherosclerosis, vasculitis, chronic allograft vasculopathy).

Key words: Endothelial cell; Matrix; MHC class II molecule

Address correspondence to Heiko Methe, Department of Internal Medicine/Cardiology, University Hospital Grosshadern, Ludwig-Maximilians University, Marchioninistrasse 15, 81377 Munich, Germany. Tel: +49-89-70953164; Fax: +49-89-70956164; E-mail: heiko.methe@med.uni-muenchen.de

Cell Transplantation, Vol. 18, pp. 261-273, 2009
0963-6897/09 $90.00 + 00
E-ISSN 1555-3892
Copyright © 2009 Cognizant Comm. Corp.
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NF-kB Activity in Endothelial Cells Is Modulated by Cell Substratum Interactions and Influences Chemokine-Mediated Adhesion of Natural Killer Cells

Shmuel Hess,1,2* Heiko Methe,1,3* Jong-Oh Kim,3 and Elazer R. Edelman1,2

1Harvard-MIT Division of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, MA, USA
2Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
3Department of Cardiology, University Hospital Grosshadern, Ludwig-Maximilians-University, Munich, Germany

Because changes in subendothelial matrix composition are associated with alterations of the endothelial immune phenotype, we sought to understand if cytokine-induced NF-kB activity and downstream effects depend on substrate adherence of endothelial cells (EC). We compared the upstream phosphorylation cascade, activation of NF-kB, and expression/secretion of downstream effects of EC grown on tissue culture polystyrene plates (TCPS) with EC embedded within collagen-based matrices (MEEC). Adhesion of natural killer (NK) cells was quantified in vitro and in vivo. NF-kB subunit p65 nuclear levels were significantly lower and p50 significantly higher in cytokine-stimulated MEEC than in EC-TCPS. Despite similar surface expression of TNF-a receptors, MEEC had significantly decreased secretion and expression of IL-6, IL-8, MCP-1, VCAM-1, and ICAM-1. Attenuated fractalkine expression and secretion in MEEC (two to threefold lower than in EC-TCPS; p < 0.0002) correlated with 3.7-fold lower NK cell adhesion to EC (6,335 ± 420 vs. 1,735 ± 135 cpm; p < 0.0002). Furthermore, NK cell infiltration into sites of EC implantation in vivo was significantly reduced when EC were embedded within matrix. Matrix embedding enables control of EC substratum interaction. This in turn regulates chemokine and surface molecule expression and secretion, in particular of those compounds within NF-kB pathways, chemoattraction of NK cells, local inflammation, and tissue repair.

Key words: Endothelial cell; Extracellular matrix; NF-kB; Natural killer cell

Address correspondence to Shmuel Hess, Ph.D., Harvard-MIT Division of Health Sciences and Technology, Massachusetts Institute of Technology, 77 Massachusetts Avenue, Bldg E25-449, Cambridge, MA 02139, USA. Tel: 617-253-8146; Fax: 617-253-2514; E-mail: shess@mit.edu

*Shmuel Hess and Heiko Methe contributed equally to this article.

Cell Transplantation, Vol. 18, pp. 275-282, 2009
0963-6897/09 $90.00 + 00
E-ISSN 1555-3892
Copyright © 2009 Cognizant Comm. Corp.
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Evaluation of a Peritoneal-Generated Cardiac Patch in a Rat Model of Heterotopic Heart Transplantation

Gabriel Amir,1 Liron Miller,1 Michal Shachar,2 Micha S. Feinberg,1 Radka Holbova,1 Smadar Cohen,2 and Jonathan Leor1

1Neufeld Cardiac Research Institute, Sheba Medical Center, Tel-Aviv University, Tel-Hashomer, Israel
2Department of Biotechnology Engineering, Ben-Gurion University of the Negev, Beer Sheva, Israel

Tissue engineering holds the promise of providing new solutions for heart transplant shortages and pediatric heart transplantation. The aim of this study was to evaluate the ability of a peritoneal-generated, tissue-engineered cardiac patch to replace damaged myocardium in a heterotopic heart transplant model. Fetal cardiac cells (1 × 106/scaffold) from syngeneic Lewis rats were seeded into highly porous alginate scaffolds. The cell constructs were cultured in vitro for 4 days and then they were implanted into the rat peritoneal cavity for 1 week. During this time the peritoneal-implanted patches were vascularized and populated with myofibroblasts. They were harvested and their performance in an infrarenal heterotopic abdominal heart transplantation model was examined (n = 15). After transplantation and before reperfusion of the donor heart, a 5-mm left (n = 6) or right (n = 9) ventriculotomy was performed and the patch was sutured onto the donor heart to repair the defect. Echocardiographical studies carried out 1-2 weeks after transplantation showed normal LV function in seven of the eight hearts studied. After 1 month, visual examination of the grafted patch revealed no aneurysmal dilatation. Microscopic examination revealed, in most of the cardiac patches, a complete disappearance of the scaffold and its replacement by a consistent tissue composed of myofibroblasts embedded in collagen bundles. The cardiac patch was enriched with a relatively large number of infiltrating blood vessels. In conclusion, cardiac patches generated in the peritoneum were developed into consistent tissue patches with properties to seal and correct myocardial defects. Our study also offers a viable rat model for screening and evaluating new concepts in cardiac reconstruction and engineering.

Key words: Alginate; Cardiac patch; Myocardial infarction; Tissue engineering; Vascularization

Address correspondence to Prof. Jonathan Leor, M.D., Neufeld Cardiac Research Institute, Sheba Medical Center, Tel-Hashomer 52621, Israel. Tel: 972-3-530-2614; Fax: 972-3-535-1139; E-mail: leorj@post.tau.ac.il or Prof. Smadar Cohen, Ph.D., Department of Biotechnology Engineering, Marcus Family Campus, Bldg. 39, Room 222, Ben-Gurion University of the Negev, Beer Sheva, 84105 Israel. Tel: 972-8-646-1798; Fax: 972-8-647-2915; E-mail: scohen@bgu.ac.il

Cell Transplantation, Vol. 18, pp. 283-295, 2009
0963-6897/09 $90.00 + 00
E-ISSN 1555-3892
Copyright © 2009 Cognizant Comm. Corp.
Printed in the USA. All rights reserved.

Implantation of a Three-Dimensional Fibroblast Matrix Improves Left Ventricular Function and Blood Flow After Acute Myocardial Infarction

Hoang M. Thai,1 Elizabeth Juneman,1 Jordan Lancaster,1 Tracy Hagerty,1 Rose Do,1 Lisa Castellano,1 Robert Kellar,2 Stuart Williams,3 Gulshan Sethi,1 Monika Schmelz,1 Mohamed Gaballa,1,4 and Steven Goldman1

1Section of Cardiology, Department of Medicine and Pathology, Southern Arizona VA Health Care System, Sarver Heart Center, University of Arizona, Tucson, AZ, USA
2Northern Arizona University, Flagstaff, AZ, USA
3Jewish Hospital, Louisville, KY, USA
4Theregen Inc., San Francisco, CA, USA

This study was designed to determine if a viable biodegradable three-dimensional fibroblast construct (3DFC) patch implanted on the left ventricle after myocardial infarction (MI) improves left ventricular (LV) function and blood flow. We ligated the left coronary artery of adult male Sprague-Dawley rats and implanted the 3DFC at the time of the infarct. Three weeks after MI, the 3DFC improved LV systolic function by increasing (p < 0.05) ejection fraction (37 ± 3% to 62 ± 5%), increasing regional systolic displacement of the infarcted wall (0.04 ± 0.02 to 0.11 ± 0.03 cm), and shifting the passive LV diastolic pressure volume relationship toward the pressure axis. The 3FDC improved LV remodeling by decreasing (p < 0.05) LV end-systolic and end-diastolic diameters with no change in LV systolic pressure. The 3DFC did not change LV end-diastolic pressure (LV EDP; 25 ± 2 vs. 23 ± 2 mmHg) but the addition of captopril (2mg/L drinking water) lowered (p < 0.05) LV EDP to 12.9 ± 2.5 mmHg and shifted the pressure-volume relationship toward the pressure axis and decreased (p < 0.05) the LV operating end-diastolic volume from 0.49 ± 0.02 to 0.34 ± 0.03 ml. The 3DFC increased myocardial blood flow to the infarcted anterior wall after MI over threefold (p < 0.05). This biodegradable 3DFC patch improves LV function and myocardial blood flow 3 weeks after MI. This is a potentially new approach to cell-based therapy for heart failure after MI.

Key words: Acute myocardial infarct; Fibroblasts; Growth factors; Angiogenesis; Extracellular matrix; Bioabsorbable scaffold

Address correspondence to Steven Goldman, M.D., Cardiology Section, 1-111C, Southern Arizona VA Health Care System, 3601 S. 6th Avenue, Tucson, AZ 85723, USA. Tel: (520) 792-1450, ext. 5081; Fax: (520) 629-4636; E-mail: steven.goldman@va.gov

Cell Transplantation, Vol. 18, pp. 297-304, 2009
0963-6897/09 $90.00 + 00
E-ISSN 1555-3892
Copyright © 2009 Cognizant Comm. Corp.
Printed in the USA. All rights reserved.

Percutaneous Cell Delivery Into the Heart Using Hydrogels Polymerizing In Situ

Timothy P. Martens,1,2 Amandine F. G. Godier,1 Jonathan J. Parks,1 Leo Q. Wan,1 Michael S. Koeckert,1 George M. Eng,1 Barry I. Hudson,2 Warren Sherman,3 and Gordana Vunjak-Novakovic1

1Department of Biomedical Engineering, Columbia University, New York, NY, USA
2Department of Surgery, Columbia University Medical Center, New York, NY, USA
3Center for Interventional Vascular Therapy, Columbia University Medical Center, New York, NY, USA

Heart disease is the leading cause of death in the US. Following an acute myocardial infarction, a fibrous, noncontractile scar develops, and results in congestive heart failure in more than 500,000 patients in the US each year. Muscle regeneration and the induction of new vascular growth to treat ischemic disorders of the heart can have significant therapeutic implications. Early studies in patients with chronic ischemic systolic left ventricular dysfunction (SLVD) using skeletal myoblasts or bone marrow-derived cells report improvement in left ventricular ejection function (LVEF) and clinical status, without notable safety issues. Nonetheless, the efficacy of cell transfer for cardiovascular disease is not established, in part due to a lack of control over cell retention, survival, and function following delivery. We studied the use of biocompatible hydrogels polymerizable in situ as a cell delivery vehicle, to improve cell retention, survival, and function following delivery into the ischemic myocardium. The study was conducted using human bone marrow-derived mesenchymal stem cells and fibrin glue, but the methods are applicable to any human stem cells (adult or embryonic) and a wide range of hydrogels. We first evaluated the utility of several commercially available percutaneous catheters for delivery of viscous cell/hydrogel suspensions. Next we characterized the polymerization kinetics of fibrin glue solutions to define the ranges of concentrations compatible with catheter delivery. We then demonstrate the in vivo effectiveness of this preparation and its ability to increase cell retention and survival in a nude rat model of myocardial infarction.

Key words: Hydrogel; Human stem cells; Heart repair

Address correspondence to Timothy P. Martens, M.D., Department of Surgery, Columbia University Medical Center, 177 Fort Washington Ave., MHB 7-435, New York, NY 10032, USA. Tel: (212) 305-5755; Fax: (212) 305-533; E-mail: tpm2102@columbia.edu or Gordana Vunjak-Novakovic, Ph.D., Professor, Department of Biomedical Engineering, Columbia University, Vanderbilt Clinic 12th floor, Room 12-234, 622 West 168th Street, New York, NY 10032, USA. Tel: (212) 305-2304, Fax: (212) 305-4692; E-mail: gv2131@columbia.edu

Cell Transplantation, Vol. 18, pp. 305-318, 2009
0963-6897/09 $90.00 + 00
E-ISSN 1555-3892
Copyright © 2009 Cognizant Comm. Corp.
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Ex Vivo Nanofiber Expansion and Genetic Modification of Human Cord Blood-Derived Progenitor/Stem Cells Enhances Vasculogenesis

Hiranmoy Das,1 Nasreen Abdulhameed,2 Matthew Joseph,1 Ramasamy Sakthivel,3 Hai-Quan Mao,4 and Vincent J. Pompili1

1Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH, USA
2Cardiovascular Research Institute, Case Western Reserve University, Cleveland, OH, USA
3Arteriocyte, Inc., Cleveland, OH, USA
4Department of Materials Science and Engineering & Whitaker Biomedical Engineering Institute, Johns Hopkins University, Baltimore, MD, USA

The stem cell therapy for treating ischemic diseases is promising; however, the limited availability and compromised quality of progenitor cells in aged and diseased patients limit its therapeutic use. Here we report a nanofiber-based ex vivo stem cell expansion technology and proangiogenic growth factors overexpression of human umbilical cord blood (UCB)-derived progenitor cells to enhance angiogenic potential of therapeutic stem cells. The progenitor cells were expanded ~225-fold on nanofiber-based serum-free ex vivo expansion culture technique without inducing differentiation. The expanded cells express high levels of stem cell homing receptor, CXCR4, and adhesion molecule, LFA-1. The nanofiber-expanded stem cells uptake AcLDL effectively, and migrate efficiently in an in vitro transmigration assay. These expanded cells can also differentiate into endothelial and smooth muscle cells in vitro. In a NOD/SCID mouse hind limb vascular injury model, nanofiber-expanded cells were more effective in blood flow restoration and this effect was further augmented by VEGF164 and PDGF-BB, growth factor overexpression. The data indicate that nanofiber-based ex vivo expansion technology can provide an essential number of therapeutic stem cells. Additionally, proangiogenic growth factors overexpression in progenitor cells can potentially improve autologous or allogeneic stem cell therapy for ischemic diseases.

Key words: Human umbilical cord blood; Hematopoietic progenitor stem cells; Proangiogenic growth factors; Nanofibers; Limb ischemia

Address correspondence to Hiranmoy Das, Ph.D., Associate Professor of Internal Medicine, Director, Cardiovascular Stem Cell Laboratories, The Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Medical Center, 460 W. 12th Avenue, BRT 382, Columbus, OH 43210, USA. Tel: (614) 688-8711; Fax: (614) 293-5614; E-mail: hiranmoy.das@osumc.edu or Vincent J. Pompili, M.D., FACC, Professor of Internal Medicine, Section Director, Interventional Cardiology, Director, Cardiovascular Cell-Based Therapies, The Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Medical Center, 460 W. 12th Avenue, Columbus, OH 43210, USA. Tel: (614) 293-4967; Fax: (614) 292-1518; E-mail: vincent.pompili@osumc.edu

Cell Transplantation, Vol. 18, pp. 319-331, 2009
0963-6897/09 $90.00 + 00
E-ISSN 1555-3892
Copyright © 2009 Cognizant Comm. Corp.
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A Transformed Cell Population Derived From Cultured Mesenchymal Stem Cells Has no Functional Effect After Transplantation Into the Injured Heart

Dario Furlani,1* Wenzhong Li,1* Erik Pittermann,1 Christian Klopsch,1 Liang Wang,1 Agnes Knopp,2 Philipp Jungebluth,3 Elke Thedinga,4 Carolin Havenstein,1 Ingeborg Westien,1 Murat Ugurlucan,1 Ren-Ke Li,5 Nan Ma,1* and Gustav Steinhoff1*

1Department of Cardiac Surgery, University Rostock, Rostock, Germany
2Division of Hematology and Oncology, University Rostock, Rostock, Germany
3Department of General Thoracic Surgery, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
4Bionas GmbH, Rostock, Germany
5Division of Cardiovascular Surgery, Toronto General Hospital and the University of Toronto, Toronto, Canada

Bone marrow-derived mesenchymal stem cells (MSCs) are multipotent cells characterized by their self-renewal and differentiation potential. Accumulating clinical and preclinical evidence indicate MSCs are a promising cell source for regenerative medical therapies. However, undesirable immortalization, spontaneous transformation, and tumorigenic potential from long-term cultured MSCs have been reported in human and mouse. We report rat MSCs isolated from young donors could undergo transformation in early passage culture. We aimed to characterize the transformed population and determine their therapeutic effects after intracardiac transplantation in the infarcted myocardium. MSCs were isolated from bone marrow of Lewis rats according to standard protocols and cultured under standard conditions. Phenotype of growing cells was assessed by flow cytometry. Following acute myocardial infarction in rats, cells were delivered by intracardiac injection. Cardiac functions were assessed by pressure-volume loops. Infarction size and pathologic effects were evaluated after 6 weeks. The abnormal colonies were detected in culture as early at passage 3. They were noted to appear as distinctly different morphology from typical MSCs, which changed from a normal elongated spindle shape to a compact abnormal morphology. They exhibited rapid cell proliferation. Some subclones lost contact inhibition of cell division and formed multilayer aggregates. Chromosomal instability was detected. They were devoid of surface markers CD29, CD44, CD90, and CD117. Furthermore, there was no significant improvement on infarction size and cardiac function 6 weeks after cell transplantation. Our study highlights the need for establishment of biosafety criteria in regulating culture-expanded MSCs to achieve the full clinical therapeutic benefits.

Key words: Mesenchymal stem cells; Transplantation; Transformation; Regeneration

Address correspondence to Nan Ma, FKGO, Department of Cardiac Surgery, University Rostock, Schillingallee 69, 18057 Rostock, Germany. Tel: +49-381-494 6105; Fax: +49-381-494 6214; E-mail: nan.ma@med.uni-rostock.de

*Authors contributed equally to this work.

Cell Transplantation, Vol. 18, pp. 333-341, 2009
0963-6897/09 $90.00 + 00
E-ISSN 1555-3892
Copyright © 2009 Cognizant Comm. Corp.
Printed in the USA. All rights reserved.

Myoblast Transfer in Ischemic Heart Failure: Effects on Rhythm Stability

Warren Sherman,1 Kun-Lun He,2 Geng-Hua Yi,2 Jie Wang,2 Jack Harvey,3 Myung J. Lee,2 Howard Haimes,3 Paul Lee,4 Emma Miranda,1 Sunil Kanwal,1 and Daniel Burkhoff2

1Division of Cardiology, College of Physicians & Surgeons, Columbia University, New York, NY, USA
2Division of Circulatory Physiology, College of Physicians & Surgeons, Columbia University, New York, NY, USA
3Bioheart Inc., Weston, FL, USA
4The Cardiovascular Institute, Mount Sinai School of Medicine, New York, NY, USA

Skeletal myoblast (SM) implantation promotes recovery of myocardial function after ischemic injury. Clinical observations suggest an association of SM implantation and ventricular arrhythmias. Support for this link has been sought in animal studies, but none employing models of congestive heart failure. In a canine model of postinfarction congestive heart failure (CHF) we compared the frequency of rhythm disturbances using ambulatory electrocardiography monitoring following skeletal myoblast or saline (SAL) implantation. In 19 mongrel dogs ischemic injury and CHF were induced by intracoronary microsphere infusions. Direct intramyocardial injection of autologous skeletal myoblasts (ASM) (2.7-8.3 × 108 cells) or SAL controls was administered to 11 and 8 dogs, respectively. Serial echocardiography and 24-h ambulatory electrocardiography were recorded at baseline (after CHF induction) and at 4 weeks and at 8-10 weeks after injection. Comparisons between groups of left ventricular ejection fraction (LVEF) and the frequency of ventricular arrhythmias, supraventricular arrhythmias, and measures of heart rate variability (HRV) were made at each of the three time points. LVEF increased from 41 ± 6% to 47 ± 2% (p < 0.03) in the ASM group, and did not change (42 ± 6% to 40 ± 2%, p = ns) in SAL. After injection, no differences were seen in the number of dogs demonstrating ventricular tachycardia (n = 3 vs. n = 2, p = ns) or frequent PVCs (n = 3 vs. n = 3, p = ns) in the ASM versus SAL groups, respectively. Significant changes were observed in a time-domain measure of HRV, standard deviation of normal-to-normal RR interval (in ms: 4 weeks 174 ± 95 vs. 242 ± 19; 8 weeks 174 ± 78 vs. 276 ± 78, ASM vs. SAL), but not in other time domain parameters. In this canine model of ischemic CHF, ASM implantation did not result in a significant increase in ventricular arrhythmias compared to controls animals. The potential for ASM implantation to affect time-domain parameters of HRV merits further study.

Key words: Congestive heart failure; Skeletal myoblasts; Canine model; Ventricular arrhythmia; Heart rate variability

Address correspondence to Warren Sherman, M.D., Center for Interventional Vascular Therapies, Columbia University Medical Center, 161 Ft. Washington Avenue, New York, NY 10032, USA. E-mail: ws2157@columbia.edu

Cell Transplantation, Vol. 18, pp. 343-352, 2009
0963-6897/09 $90.00 + 00
E-ISSN 1555-3892
Copyright © 2009 Cognizant Comm. Corp.
Printed in the USA. All rights reserved.

Autologous Bone-Marrow Mononuclear Cell Transplantation After Acute Myocardial Infarction: Comparison of Two Delivery Techniques

Suzana A. Silva,1* André L. S. Sousa,2* Andrea F. Haddad,1 Jader C. Azevedo,2 Vinicio E. Soares,3 Cíntia M. Peixoto,1 Ana J. S. Soares,3 Aurora F. C. Issa,3 Luis Renato V. Felipe,2 Rodrigo V. C. Branco,2 João A. Addad,2 Rodrigo C. Moreira,1 Fabio A. A. Tuche,1 Cláudio T. Mesquita,2 Cristina C. O. Drumond,2 Amarino O. Junior,2 Carlos E. Rochitte,2 José H. M. Luz,2 Arnaldo Rabischoffisky,2 Fernanda B. Nogueira,2 Rosana B. C. Vieira,4 Hamilton S. Junior,5 Radovan Borojevic,4 and Hans F. R. Dohmann1

1Teaching and Research Center of Pró-Cardíaco/PROCEP, Rio de Janeiro, Brazil
2Pró-Cardíaco Hospital, Rio de Janeiro, Brazil
3Miguel Couto Municipal Hospital, Rio de Janeiro, Brazil
4Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
5Excellion Servic¸os Biomédicos S/A, Petrópolis, Brazil

The objective of this study was to investigate safety and feasibility of autologous bone marrow mononuclear cells (BMMNC) transplantation in ST elevation myocardial infarction (STEMI), comparing anterograde intracoronary artery (ICA) delivery with retrograde intracoronary vein (ICV) approach. An open labeled, randomized controlled trial of 30 patients admitted with STEMI was used. Patients were enrolled if they 1) were successfully reperfused within 24 h from symptoms onset and 2) had infarct size larger than 10% of the left ventricle (LV). One hundred million BMMNC were injected in the infarct-related artery (intra-arterial group) or vein (intravenous group), 1% of which was labeled with Tc99m-hexamethylpropylenamineoxime. Cell distribution was evaluated 4 and 24 h after injection. Baseline MRI was performed in order to evaluate microbstruction pattern. Baseline radionuclide ventriculography was performed before cell transfer and after 3 and 6 months. All the treated patients were submitted to repeat coronary angiography after 3 months. Thirty patients (57 ± 11 years, 70% males) were randomly assigned to ICA (n = 14), ICV (n = 10), or control (n = 6) groups. No serious adverse events related to the procedure were observed. Early and late retention of radiolabeled cells was higher in the ICA than in the ICV group, independently of microcirculation obstruction. An increase of EF was observed in the ICA group (p = 0.02) compared to baseline. Injection procedures through anterograde and retrograde approaches seem to be feasible and safe. BMMNC retention by damaged heart tissue was apparently higher when the anterograde approach was used. Further studies are required to confirm these initial data.

Key words: Bone marrow cell transplantation; Angiogenesis; Stem cells; Myocardial infarction; Myocardial ischemia

Address correspondence to Hans Dohmann, Hospital Pró-Cardíaco, Rua Dona Mariana 219, Botafogo, Rio de Janeiro. Brasil. CEP: 22280-000. Tel: (55)21-21311584; Fax: (55)21-21311523; E-mail: diretoria.cientifica@procardiaco.com.br

*Drs. Silva and Sousa are co-principal investigators.

Cell Transplantation, Vol. 18, pp. 353-359, 2009
0963-6897/09 $90.00 + 00
E-ISSN 1555-3892
Copyright © 2009 Cognizant Comm. Corp.
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Intramyocardial Injection of Autologous Platelet-Rich Plasma Combined With Transmyocardial Revascularization

K. E. Wehberg,1 G. Answini,2 D. Wood,1 J. Todd,1 J. Julian,1 N. Ogburn,1 and K. B. Allen3

1Peninsula Regional Medical Center, Salisbury, MD, USA
2Christ Hospital, Cincinatti, OH, USA
3Mid America Heart and Lung Surgeons, Kansas City, MO, USA

Transmyocardial revascularization (TMR) can improve refractory angina but does not consistently demonstrate an effect on myocardial function. Recent studies suggest a synergistic effect between TMR and exogenously supplied growth factors. We evaluated the clinical role of intramyocardial injection of autologous platelet-rich plasma (PRP) in conjunction with TMR. Twenty-five nonrevascularizable patients with class III/IV angina underwent minimally invasive sole therapy TMR during a 5-year period at a single institution. Group 1 (14 patients) underwent TMR alone while group 2 (11 patients) underwent TMR plus injection of PRP (Magellan plasma separator) between TMR channels. Blinded angina assessment and ejection fraction (EF) were measured preoperatively and at 6 months postoperatively. Baseline EF (57 ± 10% vs. 50 ± 7%), angina class (3.7 ± 0.5 vs. 3.7 ± 0.5), and the number of channels (48 ± 5 vs. 48 ± 4) were statistically similar in both groups. At 6 months, two class angina relief was similar in both groups (92% vs. 100%, p = 0.4); however, the TMR + PRP group had a lower average angina score (1.3 vs. 0.4, p = 0.07) and more were angina free (23% vs. 78%, p = 0.04) than the TMR-alone group. EF improved in the TMR + PRP group (-2.0% vs. +9.0%, p = 0.07) compared to the TMR-alone group. Two 30-day morbidities occurred in the TMR-alone group (atrial fibrillation and left pleural effusion) and one mortality occurred in the TMR + PRP group. Intramyocardial injection of autologous PRP combined with TMR may be more efficacious at relieving angina and improving myocardial function than TMR alone.

Key words: Transmyocardial revascularization (TMR); Platelet-rich plasma (PRP); Growth factors; Angiogenesis; Stem cells; Angina

Address correspondence to Kurt E. Wehberg, M.D., Peninsula Regional Medical Center, CV Surgical PA, 201 Pine Bluff Road, Salisbury, MD 21801, USA. Tel: 1-410-546-1353; Fax: 1-410-543-8360; E-mail: kwehberg@msn.com

Cell Transplantation, Vol. 18, pp. 361-370, 2009
0963-6897/09 $90.00 + 00
E-ISSN 1555-3892
Copyright © 2009 Cognizant Comm. Corp.
Printed in the USA. All rights reserved.

Two-Dimensional Speckle Tracking Strain Analysis for Efficacy Assessment of Myocardial Cell Therapy

Boris A. Nasseri,1* Marian Kukucka,2* Michael Dandel,1 Christoph Knosalla,1 Yeong-Hoon Choi,4 Wolfram Ebell,3 Roland Hetzer,1,5 and Christof Stamm1,5

1Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
2Department of Anaesthesiology, Deutsches Herzzentrum Berlin, Berlin, Germany
3Pediatric Bone Marrow Transplant Program, Charité, Universita¨tsmedizin Berlin, Berlin, Germany
4Cardiothoracic Surgery, University of Cologne, Cologne, Germany
5BCRT-Berlin-Brandenburg Center for Regenerative Therapies, Berlin, Germany

The subtle effects of transplanted bone marrow cells (BMC) on regional myocardial behavior in patients with ischemic heart disease are difficult to assess. Novel echocardiographic techniques can quantify regional myocardial deformation (strain) and distinguish between passive and active wall motion. We hypothesized that this technique may help delineate cell therapy-induced changes in regional LV contractility that escape clinical routine studies. Twelve patients with coronary artery disease and impaired LV function (LVEF &<35%) underwent CABG surgery plus intramyocardial injection of autologous bone marrow mononuclear cells. Between two and five predefined segments of ischemic myocardium per patient received BMCs, and untreated ischemic segments served as internal controls. Segmental echocardiographic analysis of peak systolic strain by speckle tracking was performed before and 1 year after surgery and compared with standard wall motion analysis. Two patients died during the follow-up period. In the remaining 10 patients, mean LVEF increased from 24.5 ± 10% to 32.1 ± 11% (p = 0.02). A moderate improvement of systolic function was noted in ischemic control segments by both wall motion score (WMS) and 2D strain echocardiography (2DSE). In BMC-treated segments, WMS improved slightly, but the data failed to reach statistical significance. As assessed by 2DSE, however, systolic function of BMC-treated segments improved by nearly 100%. 2DSE proved to detect BMC-induced change with 30-fold higher sensitivity than WMS, and the Receiver Operating Characteristic curve (ROC) confirmed the diagnostic precision of 2DSE (area-under-the-ROC = 0.87). We conclude that echocardiographic speckle tracking two-dimensional strain analysis can detect cell therapy-induced changes in regional contractile function that may escape detection by standard wall motion assessment. Thus, 2DSE may be a useful tool for the further development of clinical cardiac cell therapy.

Key words: Speckle tracking; Myocardial cell therapy; Two-dimensional strain analysis

Address correspondence to Boris A. Nasseri, M.D., Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Augustenburger Platz 1, 13353 Berlin, Germany. Tel: +49-30 4593 9238; E-mail: nasseri@dhzb.de

*Both authors contributed equally to this study.

Cell Transplantation, Vol. 18, pp. 371-380, 2009
0963-6897/09 $90.00 + 00
E-ISSN 1555-3892
Copyright © 2009 Cognizant Comm. Corp.
Printed in the USA. All rights reserved.

Autologous Bone Marrow Cell Transplantation Increases Leg Perfusion and Reduces Amputations in Patients With Advanced Critical Limb Ischemia Due to Peripheral Artery Disease

Berthold Amann,1 Claas Luedemann,1 Richard Ratei,2 and J. André Schmidt-Lucke1

1Department of Medicine, Franziskuskrankenhaus, Berlin Vascular Center, Berlin, Germany
2Cell Marker Laboratory, HELIOS Klinikum Berlin-Buch, Berlin, Germany

Bone marrow cell transplantation has been shown to induce angiogenesis and thus improve ischemic artery disease. This study evaluates the effects of intramuscular bone marrow cell transplantation in patients with limb-threatening critical limb ischemia with a very high risk for major amputation. After failed or impossible operative and/or interventional revascularization and after unsuccessful maximum conservative therapy, 51 patients with impending major amputation due to severe critical limb ischemia had autologous bone marrow cells (BMC) transplanted into the ischemic leg. Patients 1-12 received Ficoll-isolated bone marrow mononuclear cells (total cell number 1.1 ± 1.1 × 109), patients 13-51 received point of care isolated bone marrow total nucleated cells (3.0 ± 1.7 × 109). Limb salvage was 59% at 6 months and 53% at last follow-up (mean 411 ± 261 days, range 175-1186). Perfusion measured with ankle-brachial index (ABI) and transcutaneous oxygen tension (tcpO2) at baseline and after 6 months increased in patients with consecutive limb salvage (ABI 0.33 ± 0.18 to 0.46 ± 0.15, tcpO2 12 ± 12 to 25 ± 15 mmHg) and did not change in patients eventually undergoing major amputation. No difference in clinical outcome between the isolation methods were seen. Clinically most important, patients with limb salvage improved from a mean Rutherford category of 4.9 at baseline to 3.3 at 6 months (p = 0.0001). Analgesics consumption was reduced by 62%. Total walking distance improved in nonamputees from zero to 40 m. Three severe periprocedural adverse events resolved without sequelae, and no unexpected long-term adverse events occurred. In no-option patients with endstage critical limb ischemia due to peripheral artery disease, bone marrow cell transplantation is a safe procedure that can improve leg perfusion sufficiently to reduce major amputations and permit durable limb salvage.

Key words: Bone marrow cell therapy; Critical limb ischemia; Peripheral vascular disease; Point of care

Address correspondence to Berthold Amann, M.D., Department of Internal Medicine, Franziskuskrankenhaus, Berlin Vascular Center, Budapester Strasse 15-19, D 10787 Berlin, Germany. Tel: +49-30-2638-3601; Fax: +49-30-2638-3609; E-mail: amann@franziskus-berlin.de