Stem cell therapy for myocardial repair - European Medicines … · Cells for functional cardiac repair Embyronic-like stem cells (iPS) somatic cells (skin fibroblasts) 4 genes: Oct4,

Stem cell therapy for myocardial repair

Birgit Assmus

The heart is regenerating !

Undisputable Evidence from DNA Integration of C-14– generated during nuclear bomb testing during cold war -

Bergmann O et al., Science 2009; 324:98-102

expected

observed

The heart muscle is younger than the body!

Cells for functional cardiac repairCells for functional cardiac repair

Embyronic-likestem cells

(iPS)

somatic cells(skin fibroblasts)

4 genes:Oct4, Klf4, Sox2, myc

Cardiacstem cells

Modified from Dimmeler et al, JCI 2005

Phase I/II clinical trials

2001/2002

2008

Adipose tissue-derived

cells

Cardiac stem cells

c-kit+ cellsCardiospheres

Bone marrow-derived cells

2006 2009

CD34+CXCR4+Bone marrow mononuclear cells (BMC)

CD34+

CD133+

Cell enhancement,target region preconditioning

Mesenchymal Stromal Cells

2013

Phase III trials

Clinical evolution of BMC therapy for cardiovascular diseases

- Factors to enhance cardiac

differentiation

- Repeated administration

- Shock waves for enhancing cell engraftment

stopped end 2013

Cell therapy in cardiovascular diseases

Acute Myocardial InfarctionAcute Myocardial Infarction

Refractory AnginaRefractory Angina

Peripheral arterial occlusive diseasePeripheral arterial occlusive disease

Chronic postChronic post--infarction heart failureinfarction heart failure

Vascularization

Apoptosis

AcuteMyocardialInfarction

AcuteAcuteMyocardialMyocardialInfarctionInfarction

ChronicHeart Failure

ChronicChronicHeart Heart FailureFailure

chronicchronicLVLV-- dilatationdilatation

infarctinfarctexpansionexpansion

Adverse LV RemodelingAdverse LV Remodeling

Cell Therapy in Acute Myocardial Infarction: therapeutic targets

Paracrine factors

CardiacRegeneration

BMC/CPCBMC/CPC

Cytokines, e.g.

VEGF, SDF-1

Ischemia

Cell Therapy for STEMI

The patient population at risk postThe patient population at risk post--AMIAMI

Effects of cell therapy in patients at riskEffects of cell therapy in patients at risk

Derivation of the clinical benefitDerivation of the clinical benefit

Volpi et al., Circulation 1993; 88: 416-429

LV contractile recovery within 1 week after successful reperfusion determines clinical outcome in STEMI

There is no linear correlation between mortality and ejection fraction after AMI !

Enhanced contractile recovery by BMC is confined to patients with failed initial recovery

4 months data LV angiography 12 months data MRI

N Engl J Med 2006

Repair-AMI: n= 204 patients; 1:1 multicentre double-blind randomized intracoronary placebo or BMC infusion 3 -7 days after successful acute reperfusion therapy

Do beneficial effects of BMC therapy on adverse remodeling translate into clinical benefit ?

??

Therapies preventingadverse remodelling…Therapies preventingadverse remodelling…

… reduce adverse cardiovascular events… reduce adverse cardiovascular events

ACEI , ARB, ß-Blocker, Aldosteron-Ant., CRT

Jeevanantham et al, Circulation, 2012

BMC therapy post-AMI Improved clinical outcome in meta-analysis

N = 2625 patients from 50 studies

Baseline LVEF determines

5-year survival in Repair-AMI

5-year survival

Assmus et al; Eur Heart J 2014

Factors influencing function of autologous BMC

Study Number of pts.

Cells Heparin in Final Cell Product

Primary Endpoint

Effects

ASTAMI 100 i.c.; BM-MNC vs. standard therapy

5 U/ml LVEF (SPECT) (-) after 6 / 12 months

BONAMI 101 i.c.; BM-MNC vs. standard therapy

No heparin Vitality (SPECT)

(+) vitality after 3 months

(-) LVEF

FINCELL 80 i.c.; BM-MNC vs. medium

heparinized serum LVEF (QLVA, echo)

(+) LVEF after months

HEBE 200 i.c.; BM-MNC vs. peripheral MNC vs. standard therapy

20 U/ml reg. LV-function (MRI)

(-) after 4 months

Janssens-Trial 67 i.c.; BM-MNC vs. NaCl + serum

No heparin LVEF (MRI) (+) reduction infarct size

(+) regional LV function

Plewka et al 60 i.c.; BM-MNC vs. standard therapy

? LVEF (echo) (+) LVEF after 6 months

REGENT 200 i.c.; BM-MNC vs. CXCR4+ BM-MNC vs. standard therapy

No heparin LVEF (MRI) ((+)) LVEF after 6 months in cell treated groups

REPAIR-AMI 204 i.c.; BM-MNC vs. medium

No heparin LVEF (QLVA) (+) LVEF after 4 months

(+) after 12 & 24 months

Selection of clinical BMC Trials in AMIEU- Ficoll isolated BMC trials

Migratory / Invasion Capacity of BMC: Effects of Heparin

BMC/CPCBMC/CPC

Cytokines, e.g.

VEGF, SDF-1

Ischemia

24 hours

SDF-1

in-vitro migration assay

MigrationHoming of BMC inear wound model

Functional capacity of the applied BMC predicts clinical outcome at 5 years

Eur Heart J 2014

BAMI Clinical Trial Design (ESC Cell Therapy Trial Consortium)

‚The effect of intracoronary reinfusion of bone marrow-derived mononuclear cells

on all-cause mortality in STEMI‘

- 1:1 randomized, controlled, no placebo group- intracoronary BMC administration vs. standard care- approx. 3000 patients, event-driven trial design- primary endpoint: all-cause mortality- Inclusion criterion: LVEF < 45% 3-6 days after successful

reperfusion by quantitative echo core lab analysis- Aim: to reduce 2-year mortality by 25%- anticipated mortality in control group: 11.5% at 2 years- 11 participating European countries- 6 core cell processing facilities across Europe- first patient in: Q3 / 2013

Visit planPatients with acute myocardial infarction post primary PCI

Randomisation 1:1

N = 3000 eligible AMI patients 3-6 days post primary PCICentral reading of echocardiography (EF ≤ 45%)

Intracoronary infusion of BMCs 4-8 days post PCI

Day 30 ± 7 days: Site visit follow-up

Month 3: Telephone follow-up

Every 3 months: Telephone follow-up

Following observation of full no. of events:End of study visit (on site)

Group 1: Control, n= 1500No intervention

Group 2: BM-MNC, n= 1500Bone marrow aspiration

Day 30 ± 7 days: Site visit follow-up

Month 3: Telephone follow-up

Every 3 months: Telephone follow-up

Following observation of full no. of events:End of study visit (on site)

Study flowchart

Cell processing centers and patient distribution

- The Royal London Hospital,London, UK- Hospital Gregorio Maranon,Madrid, Spain- Rigshospitalet University Hospital, Copenhagen, Denmark- Universitaire Ziekenhuizen,Leuven, Belgium- BSD, Institute for Transfusion Medicine, Frankfurt, Germany

potentially eligible patients@ day 4-5 post AMI (EF≤45)

Start Sept 2013, 8 Sept 2014: n = 51 patients

Cell therapy in cardiovascular diseases

Acute Myocardial InfarctionAcute Myocardial Infarction

Refractory AnginaRefractory Angina

Peripheral arterial occlusive diseasePeripheral arterial occlusive disease

Chronic postChronic post--infarction heart failureinfarction heart failure

Acute Infarction

LV- Dilatation

ChronicHeart Failure

Challenges in Cell Therapy of Chronic Heart Failure

-- ‘‘healedhealed‘‘ infarctioninfarction-- established scarestablished scar-- lack of inflammationlack of inflammation-- remodeled LVremodeled LV-- chronically ill patientchronically ill patient

Reverse LV RemodelingReverse LV Remodeling

?

Impaired homing of progenitor cells in chronic heart failure

Effects of i.c. administration of progenitor cells in CHF

Acute MI MI > 1 year0

2

4

6

8

10

Mean

In

diu

m a

cti

vit

y(%

; A

UC

/tim

e)

Schächinger et al, Circ 2008

Assmus et al, NEJM 2006Kang et al, Circ 2006

0

1

2

3

4

5

6

7

Ab

s. d

elt

a L

VE

F(b

aselin

e –

FU

; %

)

Pooled analysis (N=70)

Need for novel cell sources or enhancement strategies for cell therapy in chronic heart failure

Bone marrow

BloodSkeletal muscle

Adipose tissue

Cardiac stem cells

genes small molecules

Pretreatment of progenitor cells

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*

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Celltherapy

Pretreatment of the target region

Recruitmentin target tissue

Seeger et al, Nat Clin Pract Cardiovasc Med, 2007

shock wave pretreatmentshock wave pretreatmentnanofibernanofiber--based deliverybased delivery

Repetitiveapplications

http://medizinus.de/img/medizin/pic/muskelaufbau.jpg

Vrtovec B,…,Wu JC; Circ Res 2013

Shock Wave Application may Improve Cell Homing to Target Area

Shock WavePretreatment

1.

(Aicher et al, Circulation 2006)

Injection of cells3.

Homing 0

200

400

600

800

Untreatedlimb

500 1000 2000

6876N =

P<0.05

Nu

mb

er o

f C

ells

(% o

f co

ntr

ol)

Number of pulses

0.05 mJ/mm2

Release of chemoattractant factorsin target tissue

after 24 h

VEGF & SDF-1 (attraction & retention of BMC)

2.GAPDH

0 500 1000 2000 HLI H20

SDF-1

SDF-1 SDF-1

VEGF VEGF

Target tissue

Flat coil

Membrane

Acoustic lens

Bellow

Shockwave path

Shockwave Source

Shockwave generator

• Coil High Voltage pulse

• Membrane (Magnetic field)

• Rapid membrane movement

• Shock wave produced in water bellow

• Shockwave focused by acoustic lens

Live 2D integratedUltrasound Imaging

ECG Trigger

Patient

SW target area

Power generator with Energy level control unit and ECG synchronization

2-D-Echo-guided cardiac shockwave application

Custom build byDornier Med Tech Systems

Wessling, GermanyAssmus et al., JAMA 2013

p=0.01

0

1

2

3

4

SW & PlaceboN=33

SW & BMCN=37

- pooled groups -

Primary endpoint:absolute change in LVEF at 4 months

Assmus et al., JAMA 2013

5

4

3

2

1

0

SW & Placebo

SW & BMC

Placebo-SW & BMC

N=11 N=7 N=15

P for trend =0.01

7.5

5.0

2.5

0

-2.5

SW & Placebo

SW & BMC

Placebo-SW & BMC

N=12 N=6 N=13

P for trend =0.002

Mechanistic Insights by MRI substudy

Increased infarct wall thickening Decreased infarct size

Abs

olut

e D

elta

Wal

l Thi

cken

ing

Infa

rct (

%)

Abs

olut

e D

elta

Infa

rct S

ize

(% L

V m

ass)


SW & Placebo betterSW & BMC better

Cardiac death and rehospitalisationfor heart failure

Cardiac Death

Re-MI

Rehospitalization for CHF

Ventricular Tachycardia

All-cause death

Cardiac death, rehospitalisationfor heart failure, and re-AMI

Cardiac death, rehospitalisationfor heart failure, re-AMI and VT

Hazard ratios for MACE at 3-year follow-up

0.2 10.5 2 5


Conclusions

Cell therapy with autologous BMC is a realistic option in

patients with large acute myocardial infarction

EU-sponsored mortality trial

Cell therapy with autologous BMC in patients with chronic post-infarction heart

failure: application and single therapy are safe, but have minor efficacy ;

Enhancement stragies are under way

- different cell types (cardiomyocyte progenitor cells)

- pretreatment of target tissue (shockwave)

- repeated applications (Repeat trial)

Support:

DFG (SFB 834, TR-SFB23)Excellence Cluster ECCPSLOEWE Leducq Foundation: Transatlantik Network of ExcellenceEuropean Union: ERC Advanced Grant, Endostem

Institute of Cardiovascular RegenerationCentre for molecular medicine

Med. Klinik III, Kardiologie, Goethe University

Andreas Zeiher & Stefanie DimmelerFlorian Seeger, Stephan Fichtlscherer, Jörg Honold, Brigitte Luu

Cardiology Studies Coordinating Centre (CSCC): Stephanie Estel, Daniela Höhl, Carmelo Smorta, Anne Krämer, Marga Müller-Ardogan

Former contributers:Volker Schächinger, Salvatore de Rosa,David Leistner, Ulrich Fischer-RasokatRalf Lehmann


Bone marrow


Adipose tissue

Other sources



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*

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*

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Celltherapy




shock wave pretreatmentshock wave pretreatmentnanofibernanofiber--based deliverybased delivery



Comparison of observed and model-predicted * mortality in 297 consecutive patients treated with intracoronary BMC infusion.

Seattle Heart Failure Model (SHFM):Seattle Heart Failure Model (SHFM):

•• multivariable risk model that predicts allmultivariable risk model that predicts all--cause and causecause and cause--specific mortality in CHFspecific mortality in CHF

• age, gender, etiology of cardiomyopathy, hemodynamics, LVEF, treatment incl. devices, lab values

•• validated in 9942 patients from large validated in 9942 patients from large clinical trials: ELITE2, Valclinical trials: ELITE2, Val--HeFT, UW, HeFT, UW, RENAISSANCE, INRENAISSANCE, IN--CHF)CHF)

RE

PE

AT

BMC therapy in CHF – effects on mortality?

Small but significant effects on LV function

• initiation of an ongoing registry in 2005 • open to all patients presenting with CHF

at our centre• patients were offered repeated treatment

at 4 months at time of first treatment (not to long-distance travellers)

Only repeated intracoronary BMC treatment is associated with lower mortality than SHFM-model predicted mortality

0.85

0.90

0.95

1.00

0

0 1 2 3

P=0.048

Years of Follow Up

Esti

mate

d c

um

ula

tive s

urv

ival [%

]

Single BMC administration

Repeated BMC administration

observed

Model-predicted

RE

PE

AT


De Rosa, … Zeiher, Assmusunder revision

N = 297 patients; repeated treatment offered at 4 months FUSingle BMC Administration (n=186)

Repeated BMC Administration (n=111)

RE

PE

AT


repeated BMC administration

single BMC administration

Es

tim

ate

d c

um

ula

tiv

e s

urv

iva

l

MortalityTotal cohort analysis Landmark analysis

P=0.02 P=0.07

Es

tim

ate

d e

ve

nt-

fre

e s

urv

iva

l

Death and rehospitalizationTotal cohort analysis Landmark analysis

repeated BMC administration

single BMC administration

P=0.02 P=0.06

Design REPEAT trial

RE

PE

AT

N = 668 patients with post-infarction heart failureOpen infarct vessel / bypass

1. intracoronary infusion of BMCN=334

1. intracoronary infusion of BMCN=334

2. intracoronary infusion of BMC4 monthsVisit

Randomisation 1:1

8 months

24 months; primary endpoint

Visit

Visit

Group 1 Group 2

60 months; end of studyVisit

Visit

Visit

Visit

Trial Flowchart

Primary endpoint: Mortality at 2 years

Secondary endpoint: Rehospitalization for CHF, cardiac death,

HTX/LVAD

Started Dec. 2013


Bone marrow


Adipose tissue

Other sources



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Celltherapy




- shock wave pretreatment- nanofiber-based delivery



Beltrami et al, Cell 114(6):763-76, 2003

•c-kit (mouse, dog, human)

•Sca-1 (mouse)Sca-1-like (dog, human)

•Cardiospheres (murine, human)

•Islet (postnatal mouse, human)

(Beltrami, Cell 2003)

(Oh et al, PNAS 2003)

(Laugwitz et al, Nature 2005)

(Messina et al, Circ Res 2004)

Cardiac stem cells: the heart´s little helperCardiac stem cells: the heart´s little helper

Cell therapy with cardiac stem cellsCell therapy with cardiac stem cells

Cardiospheres (Caduceus trial)

Ejection Fraction at 4 Months After CSCs

N=17N=17 N=8

• No difference in EF or volumes

2009 2011First patient

treatedPhase I data: presented AHA 2011

c-kit+ CSC (Scipio trial)(Makkar et al Lancet 2012)(Bolli et al Lancet 2011)

Infarct size reduction at 6 and 12 months after Cardiospheres

Cells expanded from endomyocardial biopsiesCells expanded from atrial samples obtained during CABG

Stem cell therapy for myocardial repair - European Medicines … · Cells for functional cardiac repair Embyronic-like stem cells (iPS) somatic cells (skin fibroblasts) 4 genes: Oct4,

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