CELL-BASED MYOGENIC AND ANGIOGENIC THERAPY FOR MYOCARDIAL REGENERATION J.C. CHACHQUES, MD, PhD POMPIDOU HOSPITAL PARIS - FRANCE.

CELL-BASED MYOGENIC AND

ANGIOGENIC THERAPY FOR

MYOCARDIAL REGENERATION

J.C. CHACHQUES, MD, PhD

POMPIDOU HOSPITAL

PARIS - FRANCE

René Magritte

Surrealist painter

1898-1967

EUROPEAN HOSPITAL GEORGES POMPIDOU

CARDIAC BIOASSIST PROCEDURES

MOLECULAR BASIS OF CONGESTIVE HEART FAILURE

• LACK OF MYOCARDIAL STEM CELLS

• UNABILITY OF THE DAMAGED CELLS TO

UNDERGO SUFFICIENT REPAIR

HEART FAILURE THERAPY

• PHARMACOLOGICAL THERAPY

• CARDIAC PACING FOR RESYNCHRONIZATION

• VENTRICULAR RESTORATION, LV REDUCTION

• CARDIOMYOPLASTY, AORTOMYOPLASTY

• VENTRICULAR CONTAINMENT, MITRAL VALVULOPLASTY

• HEART TRANSPLANTATION

• MECHANICAL ASSIST DEVICES - ARTIFICIAL HEART

• CELLULAR CARDIOMYOPLASTY

CELL TRANSPLANTATION THERAPY

• VASCULAR SURGERY: CRITICAL LEG ISCHEMIA

• HEMATOLOGY : LEUKEMIA

• DERMATOLOGY : EPIDERMAL CELLS

• OPHTHALMOLOGY: CORNEAL REGENERATION

• ORTHOPEDICS : CHONDROCYTES

• MYOLOGY : DUCHENNE DYSTROPHY

• NEUROLOGY : PARKINSON DISEASE

• HEPATOLOGY : HEPATOCYTES

• DIABETES : LANGERHANS ISLETS

NOVEL EMERGING TREATMENTS

IN ISCHEMIC HEART FAILURE

• CELL-BASED MYOGENIC THERAPY

• CELL-BASED ANGIOGENIC THERAPY

LIMITATIONS OF ANGIOGENIC GROWTH

FACTORS AND GENE THERAPY

• GROWTH FACTOR PROTEINS

Systemic effects: angiogenesis in the retina.

Intimal arterial hyperplasia and development of

atheromatous plaque.

Potentiation of growth and metastasis of occult tumors

• GENE THERAPYInstability and adverse response to transfection vectors

ANGIOGENIC CELLS

• BONE MARROW DERIVED ANGIOBLASTS

Hematopoietic stem cells (HSC): CD34+

Progenitor endothelial cells (PEC): CD 133+

• VASCULAR ENDOTHELIAL CELLScollected from the intima of arteries or veins

CliniMACS

instrument

for immuno-

magnetic cell

selection

(microbeads)

Miltenyi Biotec

Germany

MYOGENIC CELLS

• SKELETAL MYOBLASTS ( satellite cells )

• SMOOTH MUSCLE CELLS

• BONE MARROW CELLS :

Multipotent adult progenitor cells (MAPC)

• CARDIOMYOCYTES : fetal, neonatal

SKELETAL MUSCLE BIOPSY

MYOBLAST CULTURE TECHNIQUE

Manipulations in a laminar flow hood

• REMOVAL OF FIBROUS AND ADIPOSE TISSUE FROM

MUSCLE BIOPSY

• MUSCLE MINCING WITH SCISSORS

• ENZYMATIC (collagenase + trypsin) & MECHANICAL

DIGESTION

• MULTIPLE CENTRIFUGATIONS

MYOBLAST CULTURE TECHNIQUE

• ISOLATION OF MYOBLASTS, EXCLUSION OF FIBROBLASTS

• IN VITRO MYOBLASTS CULTURE : 3 WEEKS, 37°C, 5% CO2

• ASSESSMENT OF % CELL VIABILITY : TRYPAN BLUE

• ASSESMENT OF % MYOBLASTS / FIBROBLASTS :

CD 56 and DESMIN ANTIBODIES

• STERILITY TESTS : BACTERIAL, VIRAL, FUNGIAL

• CELL SUSPENSION IN 0.5 % HUMAN ALBUMIN FOR

MYOCARDIAL INJECTION

CELL CULTURES with AUTOLOGOUS-HUMAN-SERUM

- obtained from plasmapheresis or blood sample -

• AVOIDS THE FIXATION OF ANIMAL PROTEINS (FBS) ON THE CELL

SURFACE

• AVOIDS IMMUNOLOGICAL AND INFLAMMATORY ADVERSE

EVENTS LEADING TO FIBROSIS AND MICRO-REENTRY CIRCUITS

• REDUCE THE RISK OF ARRHYTHMIA AND THE NEED OF A

DEFIBRILLATOR

• AVOIDS THE RISK OF PRION, VIRAL, OR ZOONOSES

CONTAMINATION

TRANSPLANTED SKELETAL MYOBLASTS

INTRAMYOCARDIAL ORGANIZATION

• ISOLATED MYOBLASTS

• MULTINUCLEATED MYOTUBES

• MYOFIBRES

IN VIVO MYOBLAST ORGANIZATION

CELL IMPLANTATION TECHNOLOGIES

EPICARDIAL APPROACH

• SURGICAL : CLASSIC OR MINIMALLY INVASIVE

• THORASCOCOPIC

ENDOVENTRICULAR : CATHETER BASED

• ASSISTED BY 3D ELECTROMECHANICAL MAPPING

• ASSISTED BY ECHO & FLUOROSCOPY, MRI

INTRAVASCULAR

• CATHETER BASED INTRACORONARY

• CORONARY VENOUS ROUTE or INTRAVENOUS SYSTEMIC

ELECTROMAGNETIC 3D CARDIAC MAPPING

PRE / POSTOPERATIVE EVALUATION

MYOCARDIAL VIABILITY

• POSITRON EMISSION TOMOGRAPHY : 2 fluoro

deoxyglucose.

• MAGNETIC RESONANCE IMAGING : uptake of

gadolinium.

• SCINTIGRAPHY: stress-redistribution-reinjection

201 thallium scintigraphy.

PRE / POSTOPERATIVE EVALUATION

VENTRICULAR FUNCTION

• BASAL AND DOBUTAMINE STRESS ECHOCARDIOGRAPHY

• RADIONUCLIDE VENTRICULOGRAPHY

• CARDIAC CATHETERIZATION + CORONAROGRAPHY

• COLOR KINESIS AND DOPPLER TISSUE ECHOGRAPHY

NEUROHORMONAL ACTIVATION (BNP)

CELLULAR CMP - INCLUSION CRITERIA

• MYOCARDIAL INFARCT

• DILATED CARDIOMYOPATHIES

• NYHA FUNCTIONAL CLASS 2 - 3

• LV WALL THICKNESS > 4 mm

• LV EJECTION FRACTION : 20 to 40%

• VIRUS-FREE TESTS

• FREE OF UNCONTROLABLE ARRHYTHMIAS

CELLULAR CMP MECHANISMS OF BENEFICIAL EFFECTS

VENTRICULAR REMODELING

• REDUCES THE SIZE AND FIBROSIS OF INFARCT SCARS

• MINIMIZES GLOBAL VENTRICULAR DILATATION

• INCREASES MYOCARDIAL WALL THICKNESS

• INDUCES MODULATION OF EXTRACELLULAR MATRIX

PREOP 3 MONTHS

CELLULAR CMP - PET 18 FDG

CELLULAR CMP MECHANISMS OF BENEFICIAL EFFECTS

DIASTOLIC FUNCTION

• IMPROVES MYOCARDIAL WALL TENSION AND ELASTICITY

• IMPROVES STRAIN AND DYNAMIC STIFFNESS

• REVERSES DIASTOLIC CREEP

CELLULAR CMP MECHANISMS OF BENEFICIAL EFFECTS

SYSTOLIC FUNCTION

• IMPROVES REGIONAL VENTRICULAR WALL MOTION

• INCREASES DEVELOPED PRESSURES

• IMPROVES GLOBAL VENTRICULAR CONTRACTION ?

CLINICAL TRIALS

• > 150 ischemic patients (Europe, America, Asia)

• Skeletal Myoblasts <=> Bone Marrow Cell Implants

• Surgical <=> Interventional Cardiology Procedures

• Defibrillators only implanted in myoblast approach

(when cultivated with bovine serum)

CLINICAL DIFFICULTIES TO BE SOLVED

• CHOICE OF CELL TYPE AND DOSE

• CELL ENGRAFTMENT AFTER IMPLANTATION

need of prevascularization ?

• DIFFERENTIATION OF STEM CELLS IN FIBROBLASTS

• HOST-CELL INTERACTIONS

mechanical and electrical coupling ?

• ELECTRICAL INSTABILITY >>ARRHYTHMIAS

CONCLUSIONS

CURRENT EXPERIMENTAL AND CLINICAL RESULTS

SUGGEST THAT CELLULAR CRDIOMYOPLASTY FOR

MYOCARDIAL REGENERATION MAY BE EFFICIENT TO

AVOID PROGRESSION OF VENTRICULAR REMODELING

AND SUBSEQUENT HEART FAILURE IN PATIENTS WITH

MODERATE CARDIAC INSUFFICIENCY RESULTING

FROM ISCHEMIC HEART DISEASE

NEW DEVELOPMENTS

• ASSOCIATION OF ANGIOGENIC AND MYOGENIC CELLS

• PRE-CONDITIONING OF STEM CELLS

• COMBINATION WITH CARDIAC PACING :

DYNAMIC SUPPORT

• NEW INDICATIONS FOR CELLULAR CMP :

ISCHEMIC MITRAL REGURGITATION

NON ISCHEMIC CARDIOMYOPATHIES

PRE-CONDITIONING OF STEM CELLS

• Treatment with 5-azacytidine : toxic

• Co-culture with cardiomyocytes : limited expansion

• In-vitro electrostimulation

ELECTROSTIMULATION OF STEM CELL CULTURES

Scientific Basis of Myocardial Differentiation

- ANALOGY -

Embryon and fetus

Cardiac conduction tissue 120 impulses min

Mesoderm

Myocardium

Cell cultures

Pacemaker (rate 120 min)

Stem cell cultures

Cardiomyocytes ?

Human CD34+ cell cultures at 3 weeks

Without Stimulation Electrostimulated

Human CD34+ cell cultures at 3 weeksDesmin antibody

Without Stimulation Electrostimulated

CONCLUSION

• Positive effect of electrostimulation

over human stem cell cultures have been

detected

• Myogenic differentiation was observed

in electrostimulated CD34+ cells