Figure 3 Estimation of the effect of intracoronary injection of non-mobilized bone marrow cells on
left ventricular ejection fraction after acute myocardial infarction Meta-analysis including current
randomized controlled trials Test for heterogeneity p=068 and test for overall effect p=0002
Follow-up was 4 months in REPAIR-AMI trial and in the study by Janssens et al 6 months in ASTAMI
trial and in the study by Ge et al and 18 months in the BOOST Base = baseline EF = ejection fraction
The findings of this study indicate that intracoronary infusion of autologous MBMC after
recent myocardial infarction is safe in a multicenter setting At 4 months follow-up a modest
but significant increase in global and regional LV function was observed with a concomitant
Since the first preliminary clinical studies of cell therapy in patients after acute MI have
been published (1516) more than four hundred patients were treated with intracoronary
injection of (selected) bone marrow cells in several non-randomized and randomized
controlled trials (79-1215-23) In none of these studies complications of bone marrow
aspiration were reported In our pilot study one local dissection of the infarct-related artery
occurred during cell infusion This complication has been reported previously by others in
four patients using the same technique for cell infusion (2324) One patient in the study by
Meluzin et al developed a thrombus in the infarct-related artery in relation to cell infusion
procedure (23) We noted a mild elevation of CK or CK-MB concentration above the ULN
in five patients after cell infusion procedure corresponding to minor myocardial damageA
Chap
ter
7
110
potential arrhythmogenic effect of cell therapy has been described after autologous
transplantation of cultured skeletal myoblasts (25) After intracoronary bone marrow cell
infusion one patient developed ventricular fibrillation one day after cell infusion in the
ASTAMI trial (9) and a sustained ventricular arrhythmia occurred two days after infusion
in the study by Bartunek et al (17) In our trial one of the 26 treated patients had a non-
sustained ventricular tachycardia during follow-up We cannot exclude the possibility that
cell treatment contributed to the observed arrhythmias in the different trials However in
the randomized trials performed to date the occurrence of ventricular arrhythmias was
not different between the bone marrow and control group and the number of observed
arrhythmias in the non-randomized trials was not unexpectedly high
Concerns have been raised about safety of cell therapy on the long-term because of reports
of high rates of in-stent restenosis (172627) Kang et al reported in-stent restenosis in
7 of the 10 patients treated with granulocyte-colony stimulating factor with or without
additional intracoronary infusion (26) Bartunek et al also observed in a non-randomized
pilot trial a surprisingly high rate of 37 in-stent restenosis and 11 reocclusion in 19
patients treated with intracoronary injection of selected CD133+ bone marrow cells (17)
The injected CD133+ cells carry a high angiogenic potential and this might be an explanation
for the pro-atherogenic effect in that study (27) None of the other trials reported higher
rates of clinical or angiographic restenosis after injection of unselected bone marrow
cells In the double-blind REPAIR-AMI trial even a trend towards a reduction in target
vessel revascularization was observed at one year follow-up (28) In our study we did not
perform routine catheterization during follow-up but in only one patient a target lesion
revascularization was performed during one year follow-up In spite of these results the
possibility that specific types of cell therapy may induce progression of atherosclerosis has
been reported in preclinical studies (29) In conclusion the number of patients that have
been treated until now is only sufficient to derive preliminary data about the safety and
feasibility of intracoronary injection of bone marrow cells Large studies and long-term
follow-up are needed to definitely establish its safety profile
The treatment effect of bone marrow infusion after MI reported in the first non-randomized
trials was promising and suggested an improvement in global EF of approximately 6
However the results of the first randomized clinical trials are conflicting (79-11) Figure 3
HEB
E pi
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111
shows a summary of the change in LV EF between baseline and follow-up in the published
randomized controlled trials of intracoronary infusion of non-mobilized unselected bone
marrow cells The follow-up of these studies ranged from 4 to 18 months Compared with
control bone marrow cell therapy significantly improved global LV EF by 22 (95 CI 08 ndash
38 p=0002) None of the trials were powered to detect differences in clinical endpoints
However the REPAIR-AMI trial showed a significant reduction in the occurrence of major
adverse cardiovascular events This raises the possibility that clinical benefits may exceed
the modest improvement seen in ventricular function (28)
We observed a modest increase in LV EF of 22 This trial was not designed to test efficacy
and we did not include a control group Therefore we can not determine the role of the
additional treatment with bone marrow cells on the observed change in LV EF This modest
increase that we observed may be part of the natural course in patients treated by primary
PCI and optimized medical therapy However the change in EF in the control group in the
published randomized trials varied substantially and ranged from -19 to +70 (912)
This underscores the necessity of a randomized trial for an appropriate interpretation of the
effect of cell therapy
The most notable result of our analysis of regional function is that improvement of systolic
wall thickening in segments with 76-100 hyperenhancement is similar to segments with
less transmural infarction In the study by Janssens et al cell therapy did not augment
recovery of global LV EF however they observed enhanced recovery of regional function in
infarcted regions after cell transfer especially in the most severely injured segments (10)
When comparing trials investigating bone marrow cell infusion it is important to note
that there are differences in patient selection and study design For example there are
differences in timing of bone marrow aspiration and cell infusion (one day to few weeks
after reperfusion) cell types (nucleated cells mononuclear cells or selected bone marrow
cells) cell preparation protocol (overnight culture storage medium) and used techniques
to assess functional effects (echocardiography LV angiography gated SPECT MRI)
Although studies with intracoronary cell transplantation have used a similar technique to
infuse bone marrow cells the number of infused cells differs Remarkable is the difference
in recovery of MBMC by density gradient centrifugation from the same amount of bone
marrow (36 million cells from 40 ml bone marrow in the study by Ge et al to 236 million
Chap
ter
7
112
from 50 ml bone marrow in the REPAIR-AMI trial) As shown by Seeger et al isolation
protocols are important and can have impact on the number of isolated cells and the
functional activity of these cells (30) The number of injected MBMC and CD34+ cells in our
current study were comparable with the REPAIR-AMI trial 246 plusmn 133 x 106 versus 236 plusmn 174 x
106 and 39 plusmn 23 x 106 versus 36 plusmn 36 x 106 (11) On the other hand a recent meta-analysis
found no relation between the number of cells and functional recovery (31)
The major limitation of this pilot trial is the lack of a randomized control group which did
not receive intracoronary infusion of MBMC However this study was designed as a phase I
safety and feasibility trial Because multiple centers and stem cell laboratories are involved
this pilot study and the randomized HEBE trial allows a more general feasibility assessment
in contrast to all previous single-center studies
The aim of the HEBE trial is to include 200 patients divided over 3 treatment arms Patients
will be randomized to be treated with either intracoronary infusion MBMC mononuclear
blood cells derived from peripheral blood or standard therapy The primary end point is the
change in regional myocardial function in dysfunctional segments at 4 months relative to
baseline based on segmental analysis as measured by MRI (13)
In conclusion our results of this uncontrolled pilot study show that intracoronary infusion
of autologous MBMC in patients after acute myocardial infarction appears to be safe in
a multicenter setting At 4 months follow-up a modest increase in global and regional LV
function was observed with a concomitant decrease in infarct size
HEB
E pi
lot
113
References
(1) Bolognese L Neskovic AN Parodi G Cerisano G Buonamici P Santoro GM et al Left ventricular remodeling after primary coronary angioplasty patterns of left ventricular dilation and long-term prognostic implications Circulation 2002 Oct 29106(18)2351-7
(2) Cohn JN Ferrari R Sharpe N Cardiac remodeling--concepts and clinical implications a consensus paper from an international forum on cardiac remodeling Behalf of an International Forum on Cardiac Remodeling J Am Coll Cardiol 2000 Mar 135(3)569-82
(3) Fuchs S Baffour R Zhou YF Shou M Pierre A Tio FO et al Transendocardial delivery of autologous bone marrow enhances collateral perfusion and regional function in pigs with chronic experimental myocardial ischemia J Am Coll Cardiol 2001 May37(6)1726-32
(4) Kocher AA Schuster MD Szabolcs MJ Takuma S Burkhoff D Wang J et al Neovascularization of ischemic myocardium by human bone-marrow-derived angioblasts prevents cardiomyocyte apoptosis reduces remodeling and improves cardiac function Nat Med 2001 Apr7(4)430-6
(5) Murry CE Soonpaa MH Reinecke H Nakajima H Nakajima HO Rubart M et al Haematopoietic stem cells do not transdifferentiate into cardiac myocytes in myocardial infarcts Nature 2004 Apr 8428(6983)664-8
(6) Orlic D Kajstura J Chimenti S Jakoniuk I Anderson SM Li B et al Bone marrow cells regenerate infarcted myocardium Nature 2001 Apr 5410(6829)701-5
(7) Wollert KC Meyer GP Lotz J Ringes-Lichtenberg S Lippolt P Breidenbach C et al Intracoronary autologous bone-marrow cell transfer after myocardial infarction the BOOST randomised controlled clinical trial Lancet 2004 Jul 10364(9429)141-8
(8) Meyer GP Wollert KC Lotz J Steffens J Lippolt P Fichtner S et al Intracoronary bone marrow cell transfer after myocardial infarction eighteen monthsrsquo follow-up data from the randomized controlled BOOST (BOne marrOw transfer to enhance ST-elevation infarct regeneration) trial Circulation 2006 Mar 14113(10)1287-94
(9) Lunde K Solheim S Aakhus S Arnesen H Abdelnoor M Egeland T et al Intracoronary injection of mononuclear bone marrow cells in acute myocardial infarction N Engl J Med 2006 Sep 21355(12)1199-209
(10) Janssens S Dubois C Bogaert J Theunissen K Deroose C Desmet W et al Autologous bone marrow-derived stem-cell transfer in patients with ST-segment elevation myocardial infarction double-blind randomised controlled trial Lancet 2006 Jan 14367(9505)113-21
(11) Schachinger V Erbs S Elsasser A Haberbosch W Hambrecht R Holschermann H et al Intracoronary bone marrow-derived progenitor cells in acute myocardial infarction N Engl J Med 2006 Sep 21355(12)1210-21
(12) Ge J Li Y Qian J Shi J Wang Q Niu Y et al Efficacy of emergent transcatheter transplantation of stem cells for treatment of acute myocardial infarction (TCT-STAMI) Heart 2006 Dec92(12)1764-7
(13) Hirsch A Nijveldt R van der Vleuten PA Biemond BJ Doevendans PA van Rossum AC et al Intracoronary infusion of autologous mononuclear bone marrow cells or peripheral mononuclear blood cells after primary percutaneous coronary intervention rationale and design of the HEBE trial--a prospective multicenter randomized trial Am Heart J 2006 Sep152(3)434-41
(14) Sutherland DR Anderson L Keeney M Nayar R Chin-Yee I The ISHAGE guidelines for CD34+ cell determination by flow cytometry International Society of Hematotherapy and Graft Engineering J Hematother 1996 Jun5(3)213-26
(15) Assmus B Schachinger V Teupe C Britten M Lehmann R Dobert N et al Transplantation of Progenitor Cells and Regeneration Enhancement in Acute Myocardial Infarction (TOPCARE-AMI) Circulation 2002 Dec 10106(24)3009-17
(16) Strauer BE Brehm M Zeus T Kostering M Hernandez A Sorg RV et al Repair of infarcted myocardium by autologous intracoronary mononuclear bone marrow cell transplantation in humans Circulation 2002 Oct 8106(15)1913-8
Chap
ter
7
114
(17) Bartunek J Vanderheyden M Vandekerckhove B Mansour S De Bruyne B De Bondt P et al Intracoronary injection of CD133-positive enriched bone marrow progenitor cells promotes cardiac recovery after recent myocardial infarction - Feasibility and safety Circulation 2005 Aug 30112(9)I178-I183
(18) Chen SL Fang WW Ye F Liu YH Qian J Shan SJ et al Effect on left ventricular function of intracoronary transplantation of autologous bone marrow mesenchymal stem cell in patients with acute myocardial infarction Am J Cardiol 2004 Jul 194(1)92-5
(19) Fernandez-Aviles F San Roman JA Garcia-Frade J Fernandez ME Penarrubia MJ de la FL et al Experimental and clinical regenerative capability of human bone marrow cells after myocardial infarction Circ Res 2004 Oct 195(7)742-8
(20) Katritsis DG Sotiropoulou PA Karvouni E Karabinos I Korovesis S Perez SA et al Transcoronary transplantation of autologous mesenchymal stem cells and endothelial progenitors into infarcted human myocardium Catheter Cardiovasc Interv 2005 Jul65(3)321-9
(21) Kuethe F Richartz BM Sayer HG Kasper C Werner GS Hoffken K et al Lack of regeneration of myocardium by autologous intracoronary mononuclear bone marrow cell transplantation in humans with large anterior myocardial infarctions Int J Cardiol 2004 Oct97(1)123-7
(22) Schachinger V Assmus B Britten MB Honold J Lehmann R Teupe C et al Transplantation of progenitor cells and regeneration enhancement in acute myocardial infarction final one-year results of the TOPCARE-AMI Trial J Am Coll Cardiol 2004 Oct 1944(8)1690-9
(23) Meluzin J Mayer J Groch L Janousek S Hornacek I Hlinomaz O et al Autologous transplantation of mononuclear bone marrow cells in patients with acute myocardial infarction the effect of the dose of transplanted cells on myocardial function Am Heart J 2006 Nov152(5)975-15
(24) Assmus B Honold J Schachinger V Britten MB Fischer-Rasokat U Lehmann R et al Transcoronary transplantation of progenitor cells after myocardial infarction N Engl J Med 2006 Sep 21355(12)1222-32
(25) Menasche P Hagege AA Vilquin JT Desnos M Abergel E Pouzet B et al Autologous skeletal myoblast transplantation for severe postinfarction left ventricular dysfunction J Am Coll Cardiol 2003 Apr 241(7)1078-83
(26) Kang HJ Kim HS Zhang SY Park KW Cho HJ Koo BK et al Effects of intracoronary infusion of peripheral blood stem-cells mobilised with granulocyte-colony stimulating factor on left ventricular systolic function and restenosis after coronary stenting in myocardial infarction the MAGIC cell randomised clinical trial Lancet 2004 Mar 6363(9411)751-6
(27) Mansour S Vanderheyden M De BB Vandekerckhove B Delrue L Van H I et al Intracoronary delivery of hematopoietic bone marrow stem cells and luminal loss of the infarct-related artery in patients with recent myocardial infarction J Am Coll Cardiol 2006 Apr 1847(8)1727-30
(28) Schachinger V Erbs S Elsasser A Haberbosch W Hambrecht R Holschermann H et al Improved clinical outcome after intracoronary administration of bone-marrow-derived progenitor cells in acute myocardial infarction final 1-year results of the REPAIR-AMI trial Eur Heart J 2006 Dec27(23)2775-83
(29) George J Afek A Abashidze A Shmilovich H Deutsch V Kopolovich J et al Transfer of endothelial progenitor and bone marrow cells influences atherosclerotic plaque size and composition in apolipoprotein E knockout mice Arterioscler Thromb Vasc Biol 2005 Dec25(12)2636-41
(30) Seeger FH Tonn T Krzossok N Zeiher AM Dimmeler S Cell isolation procedures matter a comparison of different isolation protocols of bone marrow mononuclear cells used for cell therapy in patients with acute myocardial infarction Eur Heart J 2007 Mar28(6)766-72
(31) Abdel-Latif A Bolli R Tleyjeh IM Montori VM Perin EC Hornung CA et al Adult Bone Marrow-Derived Cells for Cardiac Repair A Systematic Review and Meta-analysis Arch Intern Med 2007 May 28167(10)989-97
Autologous mononuclear bone marrow cells or peripheral
mononuclear blood cells aft er primary PCI
Rati onale and design of the HEBE trial ndash a prospecti ve
multi center randomized trial
Alexander Hirsch MD1 Robin Nijveldt MD2 Pieter A van der Vleuten MD3 Bart J Biemond MD
PhD4 Pieter A Doevendans MD PhD5 Albert C van Rossum MD PhD2 Jan GP Tijssen PhD1
Felix Zijlstra MD PhD3 amp Jan J Piek MD PhD1 on behalf of the HEBE investi gators
First three authors contributed equally to the manuscript and their names are provided in
alphabeti cal order
1 Department of Cardiology Academic Medical Center Amsterdam the Netherlands
2 Department of Cardiology VU University Medical Center Amsterdam the Netherlands
3 Department of Cardiology University Medical Center Groningen Groningen the Netherlands
4 Department of Haematology Academic Medical Center Amsterdam the Netherlands
5 Department of Cardiology University Medical Center Utrecht Utrecht the Netherlands
) Both authors contributed equally
Am Heart J 2006 Sep152(3)434-41
8
Chap
ter
8
116
Abstract
Background
Although mortality from acute myocardial infarction is decreasing heart failure as a result
of left ventricular remodelling remains a major cause of morbidity and mortality Recently
several preliminary reports have demonstrated that cell transplantation after acute
myocardial infarction in humans was safe and leads to better preserved left ventricular
function and improved myocardial perfusion and coronary flow reserve
Methods
This is a multicenter prospective randomized three-arm open trial with blinded evaluation
of end points Patients with acute large myocardial infarction treated with primary
PCI will undergo MRI and echocardiography A total of 200 patients are randomized to
treatment with (1) intracoronary infusion of autologous mononuclear bone marrow cells
(2) intracoronary infusion of peripheral mononuclear blood cells or (3) standard therapy
Mononuclear cells are isolated from bone marrow aspirate or venous blood by density
gradient centrifugation Within 7 days after PCI and within 24 hours after aspiration or
blood collection a catheterization for intracoronary infusion of the mononuclear cells in the
infarct-related artery is performed In all patients follow-up will be obtained at 1 4 and 12
months MRI and catheterization are repeated at 4 months The primary end point of the
study is the change of regional myocardial function based on a MRI-segmental analysis at 4
months relative to baseline
Implications
If intracoronary infusion of autologous mononuclear bone marrow cells or peripheral
mononuclear blood cells is proven to be beneficial after primary PCI it could be a valuable
tool in preventing heart failure-related morbidity and mortality after myocardial infarction
HEB
E pr
otoc
ol
117
Introduction
Numerous studies have shown that prompt reperfusion reduces early mortality and
improves late clinical outcome in patients with acute myocardial infarction However an
increasing number of patients suffers from symptoms of heart failure as a result of post-
infarct deterioration of left ventricular function
In order to challenge these ever-growing problems the concept of improving left ventricular
function after reperfusion therapy by bone marrow-derived progenitor cell infusion has
been advocated(1-4)
Background
Different mechanisms by which bone marrow-derived progenitor cells may induce a
beneficial effect have been suggested (1) enhanced neovascularization following release
of angiogenic and arteriogenic cytokines by the injected mononuclear cells (2) enhanced
scar tissue formation following the inflammatory response (3) decreased apoptosis and (4)
myocardial regeneration
Research on potential cardiac myocyte regeneration is currently ongoing and has reared
both positive(5) and negative(6-8) results However despite this ongoing dispute regarding
the regeneration hypothesis neovascularization is generally accepted to be an important
mechanism of the documented functional recovery of left ventricular function in various
in-vitro and in-vivo research(9)
Initial experience
Several preliminary reports in humans have demonstrated that local progenitor cell infusion
in patients with acute myocardial infarction is safe and may lead to better preserved left
ventricular function improved myocardial perfusion and coronary flow reserve(10-14)
In detail Schachinger et al reported that intracoronary infusion of adult progenitor cells
was associated with a significant increase in global left ventricular ejection fraction an
improvement in wall motion abnormalities in the infarct area and a significant reduction
in end systolic left ventricular volumes 4 months after acute myocardial infarction(11)
The improved left ventricular function was accompanied by complete normalization of
Chap
ter
8
118
coronary flow reserve in the infarct-related artery and by significant increases in myocardial
viability within the infarcted segments as assessed by F-18-fluorodeoxyglucose-positron
emission tomography (13) Likewise Strauer et al(10) have reported a beneficial effect on
myocardial perfusion following the infusion of bone marrow-derived progenitor cells into
the infarct-related artery of patients with an acute myocardial infarction These findings
were corroborated by the results of a small non-blinded randomized trial by Wollert(14)
A short overview of the currently available main studies in humans is provided in table 1
The principle limitation of most previously conducted studies is that these studies are small
andor non-controlled andor have not included an appropriate control group and all were
performed single center
Mononuclear cells
Progenitor cells characterized by expression of the CD 34 and CD 133 antigens are only a
small fraction of all mononuclear cells found in bone marrow Even after density gradient
centrifugation these cells remain a small fraction of the final cell suspension which is
infused Since all mononuclear cells are capable of releasing vast amounts of growth factors
and cytokines it has been suggested that the potential beneficial effects can be attributed
to the combined effects of all infused mononuclear cells rather than the progenitor cell
sub-population(15)
Current study design
These considerations constituted the rationale for a randomized controlled trial to determine
the effect of intracoronary infusion of mononuclear cells in patients with acute myocardial
infarction treated by percutaneous coronary intervention (PCI) in a multicenter design To
distinguish between the effect of progenitor cells and other mononuclear cells on cardiac
function patients will be randomized to be treated with either intracoronary infusion of
bone marrow derived mononuclear cells (including haematopoietic progenitor cells) or
mononuclear blood cells derived from peripheral blood or standard therapy
HEB
E pr
otoc
ol
119
Tabl
e 1
Ove
rvie
w o
f stu
dies
of i
ntra
-cor
onar
y in
fusi
on o
f aut
olog
ous
bone
mar
row
in p
atien
ts a
fter
acu
te m
yoca
rdia
l inf
arcti
on
Stud
yN
Des
ign
Day
s aft
er M
IFo
llow
-up
(mon
ths)
Stat
usRe
sults
Stau
er e
t al(
10)
20Se
quen
tial B
MC
(10)
than
co
ntro
l (10
) Si
ngle
cen
ter
83
Publ
ishe
dD
ecre
ased
infa
rct r
egio
n an
d ES
V on
LV-
angi
o In
crea
sed
regi
onal
con
trac
tility
on
LV-a
ngio
Impr
oved
per
fusi
on o
n sc
intig
raph
yIn
crea
sed
stro
ke v
olum
e in
dex
on R
V-ca
thet
eris
ation
Scha
chin
ger
et a
l ldquoT
OPC
ARE
-A
MIrdquo
(11)
59
Rand
omiz
ed
BMC
(29)
vs
CPC
(30)
O
pen-
labe
l Si
ngle
cen
ter
512
Publ
ishe
dD
ecre
ased
ESV
on
LV-a
ngio
In
crea
sed
LVEF
on
LV-a
ngio
and
MRI
Wol
lert
et a
l ldquoB
OO
STrdquo(
14)
60Ra
ndom
ized
BM
C (3
0) v
s C
ontr
ol (3
0)
Ope
n la
bel
Sing
le c
ente
r
56
Publ
ishe
dIn
crea
sed
LVEF
on
MRI
Fern
aacutende
z-Av
ileacutes
et a
l(16
)20
Non
-ran
dom
ized
Si
ngle
cen
ter
1411
Pu
blis
hed
Incr
ease
d LV
EF o
n M
RIIn
crea
sed
regi
onal
con
trac
tility
on
MRI
Jans
sens
et a
l66
Rand
omiz
ed
BMC
(32)
vs
con
trol
(34)
D
oubl
e bl
ind
Sin
gle
cent
er
14
Pres
ente
d at
co
ngre
ssD
ecre
ased
infa
rct s
ize
on L
CE im
ages
on
MRI
MI =
myo
card
ial i
nfar
ction
BM
C =
mon
onuc
lear
bon
e m
arro
w c
ells
ESV
= e
nd-s
ysto
lic v
olum
e L
V =
left
ven
tric
ular
RV
= ri
ght
vent
ricu
lar
CPC
= cu
ltiva
ted
circ
ulati
ng p
roge
nito
r ce
lls fr
om p
erip
hera
l blo
od L
VEF
= le
ft v
entr
icul
ar e
jecti
on fr
actio
n M
RI =
mag
netic
res
onan
ce im
agin
g L
CE =
late
co
ntra
st-e
nhan
ced
Chap
ter
8
120
Methods
Overview
The HEBE-trial is a multicenter prospective randomized open trial with blinded evaluation
of end points with participation of hospitals with coronary intervention facilities in the
Netherlands To be eligible for participation in the study patients have to meet the inclusion
and exclusion criteria listed in Tables 2 and 3 A total of 200 patients will be randomly
assigned to treatment with mononuclear bone marrow cells or peripheral mononuclear
blood cells or to standard therapy (ratio 111) A flow chart of the study design is shown
in Figure 1
Table 2 Inclusion criteriaPCI within 12 hours of onset of symptomsSuccessful treatment of a culprit lesion in the LAD RCA or RCX (segment 1 2 3 6 7 11 12 or 13
according to the CASS quantification)A stent diameter ge 30 mmAt least one CK and or CK-MB measurement 10 times higher than the local upper limit of normalHypokinesia or akinesia of ge 3 segments using a 16-segment model documented by routine resting
echocardiography at least 12 hours after primary PCI Clinically and haemodynamically stable over the previous 12 hours preceding informed consentCell infusion can be scheduled within 7 days after primary PCI
PCI = percutaneous coronary intervention LAD = left anterior descending coronary artery RCA = right coronary artery RCX = ramus circumflexus CASS = Coronary Artery Surgery Study CK = creatinin kinase
HEB
E pr
otoc
ol
121
Table 3 Exclusion criteriaAge lt30 or gt70 yearsCardiogenic shock or treatment with intra-aortic balloon pump in 12 hours preceding informed
consentThrombolytic therapy in the previous weekAdditional PCI in a vessel other than the vessel of primary PCI Anticipated percutaneous or surgical coronary intervention within the next 4 months Presence of supraventricular or ventricular arrhythmiasAn extended myocardial infarction as evidenced by a new episode of chest pain with new ST-
segment elevations and a new CK CK-MB peakHistory of myocardial infarction coronary artery bypass grafting heart failure moderate to severe
valve disease cardiomyopathy or congenital cardiac diseaseLeft ventricular ejection fraction lt 45 prior to current admission for myocardial infarctionBlood transfusion in 24 hours preceding informed consentStroke or transient ischemic attack within 24 hours preceding informed consentInability to schedule the intracoronary infusion of the mononuclear cell suspension within 24 hours
after bone marrow aspiration or venous blood collectionContraindication for MRIChronic use of anti-inflammatory medication except for the use of non-steroidal anti-inflammatory
drugsPositive test(s) for HIV HBV or HCV infectionKnown concomitant disease with a life expectancy of less than one yearEnrolment in any other study
PCI = percutaneous coronary intervention CK = creatinin kinase MRI = magnetic resonance imaging HBV = hepatitis B virus HCV = hepatitis C virus
Patients and enrolment
Patients with an acute large myocardial infarction treated by primary PCI of one of the
pre-defined coronary artery segments are potential candidates for the study All patients
are treated with aspirin heparin and clopidogrel according to Dutch practice guidelines
Concentrations of creatinine kinase and its MB isoenzyme are measured at hospital
admission and every 6 hours for 48 hours
Before randomization at least 12 hours after PCI resting echocardiography is performed
in five standard views (parasternal long and short views and apical four- two- and three-
chamber views) If there are three or more hypokinetic akinetic or dyskinetic segments using
a 16-segment model and all inclusion and exclusion criteria are met the patient is asked for
written informed consent as required by the Institutional Review Board in accordance with
the Declaration of Helsinki
Chap
ter
8
122
Figure 1 Study design CAG = coronary angiography ETT = exercise tolerance test MI = myocardial
infarction MRI = magnetic resonance imaging PCI = percutaneous coronary intervention =
haemodynamic measurements during re-CAG are optional re-CAG for haemodynamic measurements
is optional in the control group
HEB
E pr
otoc
ol
123
Magnetic Resonance Imaging
After written informed consent Magnetic Resonance Imaging (MRI) is performed in all
patients at least 48 hours after PCI Patients are studied on a clinical 15 or 30 Tesla scanner
using a four-element phased array cardiac receiver coil For functional imaging ECG-gated
cine steady state free precession MR images are obtained during repeated breath-holds in
the three standard long axis views (four- three- and two-chamber view) Contiguous short
axis slices are acquired covering the entire left ventricle from base to apex to examine
regional and global left ventricular function Late contrast-enhanced (LCE) images are
acquired 10 minutes after administration of a gadolinium-based contrast agent (Dotarem
Guerbet 02 mmolkg) with an inversion-recovery gradient-echo pulse sequence to identify
the location and extent of myocardial infarction The data are obtained with slice locations
identical to the functional images All MRI images are sent to a core laboratory for quality
control and blinded central analysis
The MRI data are analyzed using a dedicated software package (Mass Medis Leiden
the Netherlands) On the short axis cine slices the endocardial and epicardial borders
are outlined manually in end-diastolic and end-systolic images excluding trabeculae and
papillary muscles Assessment of global left ventricular function is obtained by calculating
left ventricular volumes mass and ejection fraction using the summation of slice method
multiplied by slice distance For analysis of segmental myocardial function each short axis
slice is divided in 12 equi-angular segments starting at the posterior septal insertion of the
right ventricle Segmental wall thickening is expressed in absolute values (end-diastolic wall
thickness subtracted from end-systolic wall thickness mm) and relative values (absolute
wall thickening divided by end-diastolic wall thickness ) Areas of hyperenhancement are
outlined including central dark zones of microvascular obstruction allowing to calculate total
infarct size by summation of all slice volumes of hyperenhancement The segmental extent
of hyperenhancement is calculated by dividing the hyperenhanced area by the total area
of the predefined segment () Since both cine and LCE image acquisitions are performed
using identical slice positions within one imaging session both data sets are matched per
slice to combine functional and LCE information per segment For analysis of segmental
function and segmental extent of hyperenhancement the two most basal and two most
distal slices are excluded as segmental evaluation at these levels is not reliable due to the
Chap
ter
8
124
left ventricular outflow tract and small diameter respectively Comparison of follow-up to
baseline images is achieved by consensus of two observers using anatomic landmarks
Echocardiography
Two-dimensional echocardiography with a phased array electronic ultrasound is also
performed at least 48 hours after PCI Standard parasternal long axis and short axis views
are acquired for the assessment of global and regional left ventricular function Regional
function is calculated using regional wall motion score (1 = normal 2 = hypokinetic 3 =
akinetic 4 = dyskinetic) and wall motion score index (sum of the segment scores number
of segments scored) in a 16-segment model Left ventricular volumes are assessed using the
method of discs (Simpsonrsquos Rule)
Randomization and treatment
When MRI and echocardiography are successfully performed the investigator contacts
the randomization service by telephone Patients are randomized following a computer-
generated list to (1) intracoronary infusion of autologues mononuclear bone marrow cells
(2) intracoronary infusion of peripheral mononuclear blood cells or (3) optimal medical
treatment without infusion of cells All treatment groups are treated with aspirin clopidogrel
beta-blockers angiotensin converting enzyme inhibitors or angiotensin II receptor blockers
and aggressive lipid lowering therapy
Cell material
Collection of cells for intracoronary infusion is performed within 24 hours of the anticipated
time of cell infusion and only when tests for HIV hepatitis B virus and hepatitis C virus
infection are known to be negative Either 60 ml of bone marrow is aspirated from the
iliac crest under local anaesthesia or 150 ml of venous blood is collected after which it is
transported to the local stem cell facility Mononuclear bone marrow cells or peripheral
mononuclear blood cells are isolated by density gradient centrifugation and 15 ml of
cell suspension is transported back for intracoronary infusion The local stem cell facility
forwards a small volume of the final cell suspension to a central laboratory for further
characterization and analysis
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Intracoronary cell infusion
Intracoronary cell infusion is performed within 7 days after PCI Prior to cell infusion the
patency of the stent in the culprit lesion of the primary PCI is visually assessed by coronary
angiography of the infarct-related artery Myocardial blush grade collateral filling according
to the Rentrop classification the TIMI frame count and TIMI flow are also evaluated before
cell infusion Coronary pressure and flow measurements are performed prior to cell infusion
in the centers where this technique is available
The cell suspension is infused into the infarct-related artery through the central lumen of an
over-the-wire balloon catheter During infusion the balloon is inflated in the stented lesion
with low pressure for three minutes to stimulate adhesion of the cells in the infarcted zone
In three sessions of coronary occlusion 15 ml of cell suspension is infused with interruptions
of three minutes of reflow by deflating the balloon
Follow-up
All patients are scheduled for follow-up visits at 1 4 and 12 months after primary PCI The
visits consist of clinical evaluation blood analysis and 12-leads electrocardiogram death
myocardial re-infarction coronary artery bypass grafting PCI major arrhythmias heart
failure coronary angiography stroke and hospital admission are documented To assess
whether treatment with intracoronary infusion of cells is associated with arrhythmia
24-hours Holter registration is obtained at 1 month after PCI At 4 months MRI is repeated
and all patients are scheduled to undergo coronary angiography to assess the patency of the
infarct-related artery Echocardiography and exercise tolerance tests are performed at 4 and
12 months follow-up
End points
The primary end point of the study is the change of regional myocardial function based on
segmental analysis at 4 months relative to baseline as measured by MRI All secondary end
points are displayed in Table 4 They include clinical angiographical echocardiographical
and MRI-related parameters
Chap
ter
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Table 4 Secondary endpoints assessed at 4 and 12 monthsChange in global left ventricular ejection fraction at 4 months relative to baseline measured by MRIChange of LCE MRI infarct size at 4 months relative to baselineChange in left ventricular ejection fraction at 4 months and 12 months relative to baseline
measured by resting echocardiographyChange in global and regional wall motion score index measured by resting echocardiography at 4
months and 12 months relative to baselineOccurrence within 4 and 12 months of a major adverse cardiac event defined as cardiac death
myocardial infarction coronary bypass grafting or a repeat percutaneous intervention of the culprit lesion
Occurrence within 4 and 12 months of arrhythmiaPresence of clinically overt heart failure at 4 and 12 monthsFunctional class according to the NYHA- and CCS-Classification at 4 and 12 monthsChange of exercise capacity at 4 months relative to 12 months measured by exercise tolerance testChange in concentrations of NT-pro-BNP at 4 and 12 monthsOccurrence of clinical and angiographic binary in-stent restenosisLate luminal loss at 4 months Change in intracoronary haemodynamic parameters at 4 months
MRI = magnetic resonance imaging LCE = late contrast-enhanced NYHA = New York Heart Association CCS = Canadian Cardiovascular Society BNP = brain natriuretic peptide
Sample size and statistical analysis
The study is powered for the secondary endpoint of the change in global left ventricular
ejection fraction (LVEF) at 4 months relative to baseline measured by Magnetic Resonance
Imaging (MRI) Note this sample size calculation is based on the supposition that the power
of this study for the primary endpoint will at least match the power for the secondary
endpoint
With 60 patients in each study group the study has 90 power to detect a 6 difference
in change in ejection fraction between active treatment and control (assuming a two-sided
alpha of 005 and a standard deviation of 10 for the change in left ventricular ejection
fraction) Based on the experience in previous studies it is assumed that up to 10 of
patients will be unevaluable with respect to the ejection fraction measurements To maintain
90 power an increase to a total of 200 patients is required
The primary analysis of the study consists of separate comparisons of the change in
regional myocardial function between each of the active treatment groups and control The
comparison between the two active groups is a secondary analysis
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127
Analysis of secondary endpoints is performed using a similar strategy as outlined above
for the primary endpoint For the analysis of binary endpoints treatment comparisons will
be performed using Fisherrsquos exact probability test For continuous outcomes independent-
samples T-tests are used For clinical outcomes such as the incidence of MACE Kaplan-Meier
curves displaying the pattern of events over the 4- and 12-month follow-up period are
drawn
Study organization and monitoring
The HEBE-trial is supervised by an executive committee and coordinated by a study
coordination committee Members of both committees are listed in appendix I The steering
committee is responsible for design and conduct of the study An independent data and
safety monitoring committee monitors the patient safety as the study progresses and
reviews safety issues every three months
Prior to the start of the study an initiation visit is scheduled to ensure that all local
investigators are appropriately trained and all necessary arrangements have been made to
achieve a high degree of compliance with the study protocol Participating centers are also
required to perform at least 3 MRI scans of sufficient quality using the standardized and
uniform MRI protocol before patient enrolment can be started
Current status
The names of the 10 participating centers and their representatives are provided in the
appendix Recruitment will commence September 2005 and is expected to be completed
September 2006 Analysis and reporting is to be completed by August 2007
Discussion
The current study design as outlined above was drafted to investigate the effect of
intracoronary infusion of mononuclear cells in patients with an acute myocardial infarction
treated by PCI In previously conducted studies (Table 1) autologous mononuclear bone
marrow cells were infused intracoronary As mentioned earlier such a cell suspension consists
Chap
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of a heterogeneous cell population including only a small percentage of haematopoietic
progenitor cells Since it seems unlikely that the improved cardiac function can be totally
attributed to the formation of new cardiac myocytes or endothelial cells the positive effects
could also be a combined effect of all mononuclear cells through the release of growth
factors and cytokines In order to test this hypothesis the current study design includes
a separate arm in which patients are treated with peripheral mononuclear blood cells
following the same density gradient centrifugation and infusion protocols
In the field of cardiac cell treatment intracoronary infusion is generally accepted to
be the optimal mode of delivery since it ensures that the cells reach the infarcted area
without being locally invasive and thus avoiding the arrhytmogenic effects associated with
intracardiac injection In contrast the time window for cell delivery is widely disputed The
rationale for choosing the time window in the current study design was that infusion within
48 hours of the index myocardial infarction as performed in the study by Janssens et al (as
presented at the 2005 American College of Cardiology congress in Orlando) could lead to
a sub-optimal treatment effect since the inflammatory response peaks in the first 48 hours
after myocardial infarction This leads to increased debridement and formation of a fibrin-
based provisional matrix It was also contemplated that after 7 days scar tissue formation
would limit the effects of cell infusion However it needs to be stressed that the optimal
time of cell delivery is not elucidated
The study design incorporates a control group to verify that any measured effect can not
be attributed to the natural course of disease after optimal standard care for myocardial
infarction The design of the study is not double-blind because the impact of implementing
such a design is that all patients would have to undergo bone marrow aspiration peripheral
blood collection and repetitive coronary occlusion Since there is no evidence in the current
literature that suggests that either bone marrow aspiration infusion of the cell medium or
repetitive occlusion by balloon inflation 3 to 7 days after primary PCI has a positive effect on
left ventricular functional recovery the decision was made not to expose the participating
patients to more procedures than was considered necessary for both executing the
treatment to which the patient is randomized and obtaining a proper follow-up To avoid
bias in data analysis the blinded evaluation of the primary end point is performed by an
independent MRI core laboratory Additionally randomization is performed after baseline
HEB
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129
MRI assessment However the open-label study design compromises the validity of any
quality of life or other self-assessment questionnaires
The aim of the study in terms of inclusion is 200 patients divided over three treatment
arms This number of patients exceeds any current study on the subject To achieve these
patient numbers within the pre-defined time-constraints a multicenter study design is
implemented Since multiple centers and stem cell facilities are involved this study design
also allows a more general feasibility assessment in contrast to all previous single center
studies The results from the current study will either further strengthen or weaken the
growing body of evidence concerning intracoronary cell therapy
Implications
If intracoronary infusion of autologous mononuclear bone marrow cells or peripheral
mononuclear blood cells is proven to be beneficial after primary PCI it could be a valuable
tool in preventing heart failure-related morbidity and mortality after myocardial infarction
Appendix
Executive committee
JJ Piek MD PhD Academic Medical Center Amsterdam (principal investigator) F Zijlstra
MD PhD University Medical Center Groningen Groningen (principal investigator) BJ
Biemond MD PhD Academic Medical Center Amsterdam AC van Rossum MD PhD
VU University Medical Center Amsterdam JGP Tijssen PhD Academic Medical Center
Amsterdam PA Doevendans MD PhD University Medical Center Utrecht Utrecht
Participating centers
Academic Medical Center Amsterdam ndash JJ Piek MD PhD Catharina Hospital Eindhoven ndash
JJ Koolen MD PhD Erasmus Medical Center Rotterdam ndash WJ van der Giessen MD PhD
Medical Center Alkmaar Alkmaar ndash JOJ Peels MD St Antonius Hospital Nieuwegein ndash JM
ten Berg MD PhD University Hospital Maastricht Maastricht ndash J Waltenberger MD PhD
University Medical Center Groningen Groningen ndash RA Tio MD PhD University Medical
Center St Radboud Nijmegen ndash W Aengevaeren MD PhD University Medical Center
Utrecht Utrecht ndash PA Doevendans MD PhD VU University Medical Center Amsterdam ndash
K Marques MD All centres are in the Netherlands
Chap
ter
8
130
Study coordination committee
Clinical study A Hirsch MD Academic Medical Center Amsterdam R Nijveldt MD VU
University Medical Center Amsterdam PA van der Vleuten MD University Medical Center
Groningen Groningen In vitro studies on cell material JJ Zwaginga MD PhD Sanquin
Research at CLB Amsterdam
The HEBE-trial is initiated by the Interuniversity Institute of Cardiology of the Netherlands
(ICIN) Utrecht The Netherlands ndash WH van Gilst PhD University Medical Center Groningen
Groningen and CA Visser MD PhD VU University Medical Center Amsterdam
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References
(1) Orlic D Kajstura J Chimenti S Jakoniuk I Anderson SM Li B et al Bone marrow cells regenerate infarcted myocardium Nature 2001 Apr 5410(6829)701-5
(2) Kocher AA Schuster MD Szabolcs MJ Takuma S Burkhoff D Wang J et al Neovascularization of ischemic myocardium by human bone-marrow-derived angioblasts prevents cardiomyocyte apoptosis reduces remodeling and improves cardiac function Nat Med 2001 Apr7(4)430-6
(3) Orlic D Kajstura J Chimenti S Limana F Jakoniuk I Quaini F et al Mobilized bone marrow cells repair the infarcted heart improving function and survival Proc Natl Acad Sci U S A 2001 Aug 2898(18)10344-9
(4) Tomita S Mickle DA Weisel RD Jia ZQ Tumiati LC Allidina Y et al Improved heart function with myogenesis and angiogenesis after autologous porcine bone marrow stromal cell transplantation J Thorac Cardiovasc Surg 2002 Jun123(6)1132-40
(5) Kajstura J Rota M Whang B Cascapera S Hosoda T Bearzi C et al Bone marrow cells differentiate in cardiac cell lineages after infarction independently of cell fusion Circ Res 2005 Jan 796(1)127-37
(6) Balsam LB Wagers AJ Christensen JL Kofidis T Weissman IL Robbins RC Haematopoietic stem cells adopt mature haematopoietic fates in ischaemic myocardium Nature 2004 Apr 8428(6983)668-73
(7) Bel A Messas E Agbulut O Richard P Samuel JL Bruneval P et al Transplantation of autologous fresh bone marrow into infarcted myocardium a word of caution Circulation 2003 Sep 9108 Suppl 1II247-II252
(8) Murry CE Soonpaa MH Reinecke H Nakajima H Nakajima HO Rubart M et al Haematopoietic stem cells do not transdifferentiate into cardiac myocytes in myocardial infarcts Nature 2004 Apr 8428(6983)664-8
(9) Wollert KC Drexler H Clinical applications of stem cells for the heart Circ Res 2005 Feb 496(2)151-63
(10) Strauer BE Brehm M Zeus T Kostering M Hernandez A Sorg RV et al Repair of infarcted myocardium by autologous intracoronary mononuclear bone marrow cell transplantation in humans Circulation 2002 Oct 8106(15)1913-8
(11) Schachinger V Assmus B Britten MB Honold J Lehmann R Teupe C et al Transplantation of progenitor cells and regeneration enhancement in acute myocardial infarction final one-year results of the TOPCARE-AMI Trial J Am Coll Cardiol 2004 Oct 1944(8)1690-9
(12) Britten MB Abolmaali ND Assmus B Lehmann R Honold J Schmitt J et al Infarct remodeling after intracoronary progenitor cell treatment in patients with acute myocardial infarction (TOPCARE-AMI) mechanistic insights from serial contrast-enhanced magnetic resonance imaging Circulation 2003 Nov 4108(18)2212-8
(13) Assmus B Schachinger V Teupe C Britten M Lehmann R Dobert N et al Transplantation of Progenitor Cells and Regeneration Enhancement in Acute Myocardial Infarction (TOPCARE-AMI) Circulation 2002 Dec 10106(24)3009-17
(14) Wollert KC Meyer GP Lotz J Ringes-Lichtenberg S Lippolt P Breidenbach C et al Intracoronary autologous bone-marrow cell transfer after myocardial infarction the BOOST randomised controlled clinical trial Lancet 2004 Jul 10364(9429)141-8
(15) Yoshioka T Ageyama N Shibata H Yasu T Misawa Y Takeuchi K et al Repair of infarcted myocardium mediated by transplanted bone marrow-derived CD34+ stem cells in a nonhuman primate model Stem Cells 2005 Mar23(3)355-64
(16) Fernandez-Aviles F San Roman JA Garcia-Frade J Fernandez ME Penarrubia MJ de la FL et al Experimental and clinical regenerative capability of human bone marrow cells after myocardial infarction Circ Res 2004 Oct 195(7)742-8
Chap
ter
8
132
Intracoronary infusion of mononuclear cells from bone
marrow or peripheral blood aft er primary percutaneous
coronary interventi on
Alexander Hirsch MD1 Robin Nijveldt MD PhD2 Pieter A van der Vleuten MD3 Jan GP Tijssen PhD1 Willem
J van der Giessen MD PhD4 Reneacute A Tio MD PhD3 Johannes Waltenberger MD PhD5 Jurrien M ten Berg MD
PhD6 Pieter A Doevendans MD PhD7 Wim RM Aengevaeren MD PhD8 Jaap Jan Zwaginga MD PhD9 Bart J
Biemond MD PhD10 Albert C van Rossum MD PhD2 Jan J Piek MD PhD1 Felix Zijlstra MD PhD3 on behalf of
the HEBE investi gatorsdagger
1 Department of Cardiology Academic Medical Center University of Amsterdam Amsterdam The Netherlands
2 Department of Cardiology VU University Medical Center Amsterdam The Netherlands
3 Thorax Center University Medical Center Groningen Un iversity of Groningen The Netherlands
4 Thorax Center Department of Cardiology Erasmus University Medical Center Rott erdam The Netherlands
5 Department of Cardiology University Hospital Maastricht Maastricht The Netherlands
6 Department of Cardiology St Antonius Hospital Nieuwegein The Netherlands
7 Department of Cardiology University Medical Center Utrecht Utrecht The Netherlands
8 Department of Cardiology University Medical Center St Radboud Nijmegen The Netherlands
9 Department of Experimental Immunohaematology Sanquin Research Amsterdam and Department of
Immunohaematology and Blood transfusion Leiden University Medical Center The Netherlands
10 Department of Haematology Academic Medical Center University of Amsterdam Amsterdam The
Netherlands
Drs Hirsch Dr Nijveldt and Drs van der Vleuten contributed equally to this arti cle
dagger Investi gators of the HEBE trial are listed in the appendix
Submitt ed
9
Chap
ter
9
134
Abstract
Background
Previous randomized trials that investigated the effect of intracoronary infusion of bone
marrow cells after acute myocardial infarction (AMI) on myocardial function have shown
conflicting results
Methods
In a multicenter trial 200 patients with large first AMI treated with primary percutaneous
coronary intervention were randomly assigned to either intracoronary infusion of
mononuclear bone marrow cells (n=69) mononuclear peripheral blood cells (n=66) or
standard therapy (without placebo infusion)(n=65) Mononuclear cells were delivered
intracoronary between 3 and 8 days after AMI Regional and global left ventricular
myocardial function and volumes were assessed by magnetic resonance imaging before
randomization and at 4 months and clinical events were reported The primary endpoint
was the percentage of dysfunctional left ventricular segments at baseline with improved
segmental wall thickening at 4 months
Results
The percentage of dysfunctional left ventricular segments that improved during follow-up
did not differ significantly between either of the treatment groups and control 386plusmn247
in the bone marrow group 368plusmn209 in the peripheral blood group and 424plusmn187 in
the control group (P=033 and P=014) Improvement of left ventricular ejection fraction was
38plusmn74 in the bone marrow group 42plusmn62 in the peripheral blood group as compared
with 40plusmn58 in the control group (P=094 and P=090) Furthermore the 3 groups did
not differ significantly in changes in left ventricular volumes mass and infarct size and had
similar rates of clinical events
Conclusions
Intracoronary infusion of mononuclear cells from bone marrow or peripheral blood following
AMI does not improve regional or global systolic myocardial function (Netherlands Trial
Register number NTR166 and Current Controlled Trials number ISRCTN95796863)
HEB
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Introduction
Major advances in treatment for acute myocardial infarction over the past decades have
translated into a considerable decline in mortality(1) However an increasing number
of patients suffers from symptoms of heart failure as a result of post-infarct ventricular
remodeling(2) In an attempt to address these problems the use of cell therapy as an
adjunctive therapy has been advocated(34) Recent randomized trials that investigated the
effect of intracoronary infusion of (selected) bone marrow cells after primary percutaneous
coronary intervention (PCI) for acute myocardial infarction have shown conflicting results
(5-8) This may in part be explained by differences in cell isolation protocols timing of cell
infusion patient selection and the imaging modalities used to measure the treatment effect
(Although mononuclear bone marrow cells and in particular hematopoietic progenitor cells
have been suggested to improve cardiac function by myocardial and vascular regeneration
the positive effect could also be induced by other mononuclear cells capable of releasing
growth factors and cytokines(1213) We designed a randomized controlled trial to
determine the effect of intracoronary infusion of mononuclear cells in patients with large
acute myocardial infarction treated by primary PCI To distinguish between the effect of
progenitor cells and other mononuclear cells on cardiac function patients were randomized
to either intracoronary infusion of bone marrow-derived mononuclear cells (including
hematopoietic progenitor cells) or mononuclear cells derived from peripheral blood or no
intracoronary infusion
Methods
The HEBE trial was a multicenter randomized open trial with blinded evaluation of end
points Between August 2005 and April 2008 200 patients with first ST-segment elevation
myocardial infarction treated with primary PCI and stent implantation were enrolled in 8
hospitals in The Netherlands The design of the study has previously been published(14)
and prior to participation all centers had to participate in a pilot trial(15) In summary
patients 30 to 75 years of age were eligible for inclusion if they met the following inclusion
Chap
ter
9
136
criteria successful PCI within 12 hours after onset of symptoms three or more hypokinetic
or akinetic left ventricular (LV) segments observed on echocardiography performed at least
12 hours after PCI and an elevation of creatine kinase (CK) or CK-MB more than 10 times
the local upper limit of normal (ULN) Main exclusion criteria were hemodynamic instability
anticipated additional PCI or coronary-artery bypass grafting within the next 4 months
severe comorbidity and contraindications for magnetic resonance imaging (MRI)
The study complied with the principles set out in the Declaration of Helsinki All patients
gave informed consent The study protocol was approved by the Institutional Review Boards
of the participating centers
Randomization and treatment
Baseline MRI was performed at least 2 days after PCI After MRI on day 2 to 7 patients
were randomly assigned in a 111 ratio to either intracoronary infusion of autologous
mononuclear bone marrow cells intracoronary infusion of mononuclear peripheral blood
cells or standard therapy (without placebo infusion) Permuted-block randomization was
performed with stratification according to site with the use of a computerized voice-
response system After randomization study processes were not blinded
In the bone marrow and peripheral blood group cell harvesting was performed within 8
days after primary PCI Either 60 ml of bone marrow was aspirated from the iliac crest under
local anesthesia or 150 to 200 ml of venous blood was taken Bone marrow or peripheral
blood was collected in a sterile container with heparin and send to one of the 6 participating
cell-processing laboratories In both groups mononuclear cells were isolated by density
gradient centrifugation using LymphoprepTM After two washing steps mononuclear cells
were resuspended in 15 to 20 ml saline supplemented with 4 human serum albumin and 20
IEml sodium heparin(1115) The number of nucleated blood cells was measured and the
number of CD34+ cells and CD14+ cells were determined according to the ISHAGE protocol
(16) All participating laboratories are accredited stem cell laboratories We validated our
isolation protocol with regard to the quantity and quality of isolated cells by comparing it
with processing protocols used in other clinical trials for cell therapy(11)
Cell infusion was performed at the same day of harvesting in all but one patient in whom
infusion was done the following day Cells were infused into the infarct-related artery
HEB
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137
through the central lumen of an over-the-wire balloon catheter in 3 sessions of 3 minutes of
coronary occlusion interrupted by 3 minutes of coronary flow The level of CK-MB andor CK
was measured at 6-hour intervals during the first 24 hours after cell infusion
Magnetic resonance imaging
MRI was performed at baseline and repeated after 4 months Patients were studied on
a clinical 15 or 30 Tesla scanner (193 and 7 patients respectively) MRI acquisition and
analyses involved a standardized protocol published previously(1415) MRI analyses were
performed by two blinded core laboratories Bio-Imaging Technologies BV (Leiden) for
functional analysis and VU University medical center (Amsterdam) for infarct size analysis
In short contiguous short axis slices were acquired every 10 mm covering the whole left
ventricle using a segmented steady state free precession pulse sequence Late gadolinium
enhancement (LGE) images were obtained 10 to 15 minutes after administration of a
gadolinium-based contrast agent (Dotarem Guerbet 02 mmolkg) using a 2D segmented
inversion recovery gradient-echo pulse sequence with slice position identical to the cine
images
LV volumes and mass were measured on the cine images and indexed for body-surface
area LV ejection fraction was calculated Infarct size was determined on the LGE images as
previously described using a standardized and predefined definition of hyperenhancement
(1417) For analysis of regional myocardial function each short axis slice was divided in 12
equi-angular segments to calculate wall thickening (in mm) of each segment by subtracting
end-diastolic from end-systolic wall thickness Myocardial segments were considered
dysfunctional if segmental wall thickening was lt3 mm(18) Improved wall thickening of a
segment at follow-up was defined as gt15 mm improvement in segmental wall thickening
between baseline and follow-up
End point measures
The primary end point was the change in regional myocardial function in dysfunctional
segments at baseline defined as the percentage of dysfunctional segments with improved
segmental wall thickening at 4 months Secondary end points included changes in absolute
segmental wall thickening in dysfunctional segments and changes in global LV ejection
Chap
ter
9
138
fraction volumes mass and infarct size To assess clinical status and adverse events patients
were seen at the outpatient clinic at 1 and 4 months after randomization Recurrent
myocardial infarction associated with cell delivery was defined as an increase of CK-MB
levels of at least 3 times the ULN within 24 hours after delivery A clinical event committee
independently adjudicated all potential clinical events
Statistical analysis
We estimated enrolment of 60 patients in each study group to achieve a power of 90
with a two-sided significance level of 005 to detect a 6 difference in change in global
LV ejection fraction between active treatment and control assuming a standard deviation
of 10 It was assumed that up to 10 of patients would not have paired MRI studies and
therefore a total of 200 patients was required The decision about the sample size was
based upon the consideration that the power of this study for the primary end point would
at least match the power for the secondary end point of the change in global LV ejection
fraction(14)
All analyses were performed on the basis of the intention-to-treat principle Categorical data
are presented as frequencies (percentage) and continuous data as meanplusmnSD (unless stated
otherwise) The prespecified primary analysis consisted of separate comparisons of the end
points between the two active treatment groups and control For the comparison of changes
in MRI variables between groups analysis of covariance was used including treatment group
as the main factor and each baseline variable as a covariate Paired Studentrsquos t test was used
to compare baseline and follow-up values within each study group Because the study was
not powered for clinical outcomes the event rates are presented for descriptive purposes
only and no statistical comparisons were done All P values are two-sided and statistical
significance was set at Plt005
HEB
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Results
Enrolment and baseline characteristics
A total of 200 patients were enrolled in the study and underwent baseline MRI at a median
time of 3 days after primary PCI (interquartile range 2 to 4) After MRI 69 patients were
assigned to the bone marrow group 66 to the peripheral blood group and 65 to the control
group Intracoronary infusion was not performed in 3 patients assigned to the bone marrow
group One patient withdrew consent in one the bone marrow aspiration was unsuccessful
and in one the infarct-related artery was occluded on control angiography prior to cell
delivery In the peripheral blood group intracoronary delivery was performed in all but one
patient who refused cell delivery (Figure 1) The 3 groups were well matched with respect
to baseline and procedural characteristics (Table 1) Overall the mean age was 56plusmn9 years
85 of the patients were men median time from onset of symptoms to reperfusion was
33 hours (interquartile range 23 to 45) and 90 had TIMI flow grade 3 after primary PCI
Cell harvesting and intracoronary infusion
Intracoronary cell infusion was performed between 3 and 8 days after PCI with a median
of 6 days in the bone marrow group and 5 days in the peripheral blood group The median
time from cell harvesting to cell infusion was 63 hours (interquartile range 57 to 69) in the
bone marrow group and 63 (interquartile range 58 to 70) in the peripheral blood group
The total number of cells was comparable in the bone marrow and peripheral blood group
(296plusmn164 x106 vs 287plusmn137 x106) see also Table 1 No complications of cell harvesting were
noted in either group
The adverse events related to the catheterization for cell delivery are summarized in Table
2 Three patients in the peripheral blood group developed a recurrent myocardial infarction
related to the cell delivery procedure in one patient this was due to coronary spasm after
cell infusion in one an occlusion of a small side branch occurred and in the third patient no
cause was identified
Chap
ter
9
140
Table 1 Baseline characteristicsCharacteristic Bone Marrow
Group
(N = 69)
Peripheral Blood Group
(N = 66)
Control Group
(N = 65)
Age ndash yr 56 plusmn 9 57 plusmn 9 55 plusmn 10Male gender ndash no () 58 (84) 56 (85) 56 (86)Body mass index dagger 26 plusmn 3 26 plusmn 4 27 plusmn 3Risk factors ndash no () Diabetes mellitus 3 (4) 7 (11) 2 (3) Known hypertension 27 (39) 13 (20) 17 (26) Family history of coronary heart disease 33 (48) 30 (45) 33 (51) Hypercholesterolemia 17 (25) 14 (21) 15 (23) Current cigarette smoking 37 (54) 31 (47) 37 (57)Angiography and infarct treatment Time from symptom onset to PCI ndash hours Median 35 30 34 Interquartile range 24ndash51 21ndash48 23ndash42 Infarct-related artery ndash no () Left anterior descending artery 42 (61) 46 (70) 40 (62) Left circumflex artery 14 (20) 5 (8) 5 (8) Right coronary artery 13 (19) 15 (23) 20 (31) Multivessel disease ndash no () 12 (17) 21 (32) 16 (25) TIMI flow grade post-PCI ndash no () Grade 1 1 (1) 1 (2) 0 Grade 2 8 (12) 5 (8) 6 (9) Grade 3 60 (87) 60 (91) 59 (91) Type of stent(s) used ndash no () Bare metal 62 (90) 60 (91) 57 (88) Drug eluting 7 (10) 6 (9) 8 (12) Number of stents Median 1 1 1 Range 1ndash2 1ndash3 1ndash4 Size of stent ndash mm 34 plusmn 04 34 plusmn 04 35 plusmn 04 Length of stent ndash mm Median 18 20 23 Interquartile range 15ndash28 18ndash28 18ndash28 Platelet glycoprotein IIbIIIa inhibitors ndash no () 49 (71) 47 (71) 43 (66) Intra-aortic balloon pump ndash no () 3 (4) 4 (6) 4 (6) Maximum serum creatine kinase MB or creatine kinase ndash xULN
Median 37 38 42 Interquartile range 22ndash63 26ndash64 24ndash67Cell infusion Dagger Days after primary PCI Median 6 5 ndash Interquartile range 4ndash7 4ndash6 ndash Number of injected cells ndash x106 296 plusmn 164 287 plusmn 137 ndash
HEB
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141
Table 1 continued CD34+ cells Absolute no ndash x106 48 plusmn 40 03 plusmn 02 ndash Percentage 16 plusmn 09 01 plusmn 007 ndash CD14+ cells Absolute no ndash x106 246 plusmn 142 613 plusmn 327 ndash Percentage 96 plusmn 61 221 plusmn 79 ndashMedication at discharge ndash no () int Aspirin 65 (96) 62 (94) 65 (100) Clopidogrel 68 (100) 66 (100) 65 (100) Coumarin derivate 6 (9) 15 (23) 11 (17) Beta-blockers 64 (94) 63 (95) 62 (95) ACE inhibitor or AT IIndashreceptor blocker 63 (93) 58 (88) 65 (100) Statins 68 (100) 65 (98) 65 (100)Medication at 4 months follow-up ndash no () para Aspirin 65 (96) 53 (82) 61 (94) Clopidogrel 58 (85) 52 (80) 62 (95) Coumarin derivate 7 (10) 19 (29) 10 (15) Beta-blockers 63 (93) 60 (92) 60 (92) ACE inhibitor or AT IIndashreceptor blocker 66 (97) 54 (83) 63 (97) Statins 67 (99) 63 (97) 63 (97)
Plus-minus values are means plusmn SD TIMI denotes thrombolysis in myocardial infarction PCI percutaneous coronary intervention MB myocardial band ULN upper limit of normal ACE angiotensin-converting-enzyme and AT angiotensin
dagger The body-mass index is the weight in kilograms divided by the square of the heights in meters
Dagger This analysis included only patients in whom cell infusion was performed 66 patients in the bone marrow group and 65 in the peripheral blood group There was no difference between the total number of injected cells between the bone marrow and peripheral blood group P=079 by nonparametric testing
int The analysis included 68 patients in the bone marrow group 66 in the peripheral blood group and 65 in the control group
para The analysis included 68 patients in the bone marrow group 65 in the peripheral blood group and 65 in the control group
Chap
ter
9
142
Figure 1 Trial profile
STEMI denotes ST-segment elevation myocardial infarction and MRI magnetic resonance imaging
HEB
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143
Table 2 Adverse events and clinical outcome from randomization to 4 months follow-upEvent Bone Marrow
Group
(N = 69)
Peripheral Blood Group
(N = 66)
Control Group
(N = 65)
No of patientsCatheterization for cell deliveryAdverse events during cell delivery Coronary spasm 1 3 ndash Transient bradycardia 1 0 ndash Thrombus in infarct-related artery dagger 1 0 ndash Occlusion of small side branch of infarct-related artery
0 1 ndash
Recurrent myocardial infarction Dagger 0 3 ndashAdditional revascularization int Target lesion revascularization 3 3 ndash Target vessel nontarget lesion revascularization
1 2 ndash
At 4 months follow-up (cumulative)Death 0 1 0Recurrent myocardial infarction 0 4 1 Related to cell infusion procedure 0 3 ndash Spontaneous 0 1 1Revascularization 4 6 6 Target lesion revascularization 3 3 4 Target vessel nontarget lesion revascularization
1 3 0
Nontarget vessel revascularization 0 0 3Documented ventricular arrhythmia treated by ICD 0 1 1Hospitalization for heart failure 0 1 1Stroke 0 0 0Cancer 0 1 0Composite of death recurrent myocardial infarction or target lesion revascularization
3 6 4
Composite of death recurrent myocardial infarction or any revascularization
4 9 6
Composite of death recurrent myocardial infarction or hospitalization for heart failure
0 5 2
ICD denotes implantable cardioverter-defibrillator
dagger The occlusion was treated with a glycoprotein IIbIIIa inhibitor thrombosuction and balloon inflation resulting in TIMI grade 3 flow This event did not result in a procedural related myocardial infarctionDagger Causes of myocardial infarctions related to cell delivery were an occlusion of a small side branch in one patient coronary spasm in another and in one patient no cause was identified
int This included an additional PCI in a patient in the bone marrow group who did not undergo cell delivery due to a total occlusion of the infarct-related artery The attempt to reopen the vessel failed In the peripheral blood group one patient was treated by stent implantation for a local dissection of the infarct-related artery caused by an intracoronary flow wire and one patient was treated by balloon inflation for a thrombus in the infarct-related artery during cell delivery as described above All other patients were treated before cell infusion without complications
Chap
ter
9
144
Left ventricular function volumes and infarct size
Paired cine MRI images for functional analysis were available for 67 patients in the bone
marrow group 62 in the peripheral blood group and 60 in the control group Paired images
for infarct analysis were available for 58 57 and 52 patients respectively (Figure 1) There
were no differences in MRI parameters between the three groups at baseline Among all
patients baseline LV end-diastolic volume was 984plusmn154 mlm2 and LV end-systolic volume
was 570plusmn151 mlm2 This resulted in a mean LV ejection fraction of 426plusmn88
The mean percentage of dysfunctional segments at baseline was 533plusmn196 in the bone
marrow group 575plusmn196 in the peripheral blood group and 562plusmn184 in the control
group At 4 months 386plusmn247 of the dysfunctional segments showed improved segmental
wall thickening in patients treated with mononuclear bone marrow cells compared with
368plusmn209 in the peripheral blood group and 424plusmn187 in the control group This
resulted in nonsignificant differences between either of the treatment groups and control
(P=033 and P=014 Table 3) Improvement of LV ejection fraction was 38plusmn74 in the bone
marrow group 42plusmn62 in the peripheral blood group as compared with 40plusmn58 in the
control group (p=094 and p=090 Figure 2) There were also no significant differences in the
changes in absolute segmental wall thickening in dysfunctional segments and changes in
LV volumes mass and infarct size between the bone marrow peripheral blood and control
group (Table 3)
Clinical outcome
During follow-up one patient assigned to the peripheral blood group died of ventricular
fibrillation at 18 days after randomization (13 days after cell delivery) Autopsy revealed
thrombus in the infarct-related artery Ventricular fibrillation occurred in another patient
in the peripheral blood group one day after randomization (within a few hours after cell
infusion) and in one patient in the control group 3 days after randomization Both patients
survived without sequelae after resuscitation and received an implantable cardioverter-
defibrillator Table 2 summarizes all clinical events from randomization to 4 months follow-
up With regard to clinical symptoms at 4 months 19 (1368) of the patients in the bone
marrow group were in New York Heart Association class II or higher compared to 20
(1365) and 18 (1265) in the peripheral blood and control group
HEB
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145
Figu
re 2
Esti
mati
on o
f the
effe
ct o
f int
raco
rona
ry in
jecti
on o
f mon
onuc
lear
cel
ls fr
om b
one
mar
row
or
peri
pher
al b
lood
on
left
ven
tric
ular
eje
ction
fr
actio
nLV
den
otes
left
ven
tric
ular
In
the
left
pan
el th
e lin
es re
pres
ent t
he c
hang
e ob
serv
ed in
indi
vidu
al p
atien
ts a
nd th
e sq
uare
s re
pres
ent t
he m
ean
with
th
e st
anda
rd d
evia
tion
In th
e ri
ght p
anel
the
mea
n ch
ange
bet
wee
n ba
selin
e an
d fo
llow
-up
at 4
mon
ths
is p
rese
nted
with
the
stan
dard
err
or
Chap
ter
9
146
Tabl
e 3
Qua
ntita
tive
mea
sure
s of
regi
onal
and
glo
bal l
eft v
entr
icul
ar fu
nctio
n v
olum
es m
ass
and
infa
rct s
ize
by m
agne
tic re
sona
nce
imag
ing
Bo
ne M
arro
w
Gro
upPe
riph
eral
Blo
od
Gro
upCo
ntro
l
Gro
upBo
ne M
arro
w v
s C
ontr
olPe
riph
eral
Blo
od v
s C
ontr
ol
(N =
67)
(N =
62)
(N =
60)
Trea
tmen
t eff
ect dagger
Estim
ate
(95
CI)
P va
lue
Trea
tmen
t eff
ect dagger
Estim
ate
(95
CI)
P va
lue
Prim
ary
end
poin
t ndash
D
ysfu
nctio
nal s
egm
ents
at
b
asel
ine
533
plusmn 1
96
575
plusmn 1
96
562
plusmn 1
84
D
ysfu
nctio
nal s
egm
ents
that
im
prov
ed d
urin
g fo
llow
-up
386
plusmn 2
47
368
plusmn 2
09
424
plusmn 1
87
ndash39
(ndash11
7 to
40
)0
33ndash5
3 (ndash
123
to 1
7)
014
Segm
enta
l wal
l thi
cken
ing
in
dysf
uncti
onal
seg
men
ts ndash
mm
B
asel
ine
119
plusmn 0
55
118
plusmn 0
49
114
plusmn 0
52
F
ollo
w-u
p2
31 plusmn
13
22
21 plusmn
12
12
31 plusmn
09
7
Cha
nge
112
plusmn 1
20
103
plusmn 0
99
118
plusmn 0
80
ndash00
6 (ndash
043
to 0
30)
073
ndash01
5 (ndash
048
to 0
17)
035
P
val
ue (b
asel
ine
vs 4
mon
ths)
lt00
01lt0
001
lt00
01LV
eje
ction
frac
tion
ndash
B
asel
ine
437
plusmn 9
041
7 plusmn
91
424
plusmn 8
3
Fol
low
-up
475
plusmn 9
946
0 plusmn
93
464
plusmn 9
2
Cha
nge
38
plusmn 7
44
2 plusmn
62
40
plusmn 5
80
1 (ndash
22
to 2
4)
094
01
(ndash2
0 to
22
)0
90
P v
alue
(bas
elin
e vs
4 m
onth
s)lt0
001
lt00
01lt0
001
LV e
nd-d
iast
olic
vol
ume
ndash m
lm
2
B
asel
ine
973
plusmn 1
40
980
plusmn 1
54
100
0 plusmn
169
F
ollo
w-u
p10
26
plusmn 19
110
34
plusmn 22
610
82
plusmn 24
6
Cha
nge
54
plusmn 13
45
3 plusmn
163
82
plusmn 13
5ndash2
5 (ndash
72
to 2
2)
029
ndash26
(ndash8
0 to
27
)0
33
P v
alue
(bas
elin
e vs
4 m
onth
s)0
002
001
lt00
01LV
end
-sys
tolic
vol
ume
ndash m
lm
2
B
asel
ine
554
plusmn 1
45
578
plusmn 1
59
581
plusmn 1
51
F
ollo
w-u
p54
9 plusmn
19
557
1 plusmn
21
659
3 plusmn
21
7
Cha
nge
ndash05
plusmn 1
34
ndash07
plusmn 1
44
12
plusmn 11
7ndash1
5 (ndash
59
to 3
0)
052
ndash19
(ndash6
6 to
28
)0
43
P v
alue
(bas
elin
e vs
4 m
onth
s)0
750
710
42
HEB
E st
udy
147
LV m
ass
ndash gr
m2
B
asel
ine
598
plusmn 1
22
596
plusmn 1
14
591
plusmn 1
19
F
ollo
w-u
p51
7 plusmn
10
551
3 plusmn
10
251
4 plusmn
10
6
Cha
nge
ndash80
plusmn 9
6ndash8
3 plusmn
79
ndash78
plusmn 7
6ndash0
03
(ndash2
6 to
26
)0
98ndash0
4 (ndash
28
to 2
0)
074
P
val
ue (b
asel
ine
vs 4
mon
ths)
lt00
01lt0
001
lt00
01In
farc
t siz
e ndash
gr Dagger
B
asel
ine
229
plusmn 1
26
211
plusmn 1
12
236
plusmn 1
38
F
ollo
w-u
p15
2 plusmn
82
132
plusmn 7
314
2 plusmn
89
C
hang
endash7
7 plusmn
85
ndash79
plusmn 6
5ndash9
4 plusmn
71
13
(ndash0
5 to
32
)0
160
4 (ndash
11
to 1
9)
062
P
val
ue (b
asel
ine
vs 4
mon
ths)
lt00
01lt0
001
lt00
01
Pl
us-m
inus
val
ues
are
mea
ns plusmn
SD
LV
deno
tes
left
ven
tric
ular
P v
alue
s fo
r th
e ch
ange
bet
wee
n ba
selin
e an
d fo
llow
-up
with
in e
ach
stud
y gr
oup
wer
e ca
lcul
ated
with
pai
red
Stud
entrsquos
t te
st
dagger Tr
eatm
ent e
ffect
and
P v
alue
s w
ere
dete
rmin
ed b
y an
alys
is o
f cov
aria
nce
Dagger Th
e an
alys
is in
clud
ed 5
8 pa
tient
s in
the
bone
mar
row
gro
up 5
7 in
the
peri
pher
al b
lood
gro
up a
nd 5
2 in
the
cont
rol g
roup
Chap
ter
9
148
Discussion
We evaluated the potential benefit of intracoronary infusion of mononuclear cells from
bone marrow or peripheral blood in the subacute phase after acute myocardial infarction
in patients treated with primary PCI There were no significant differences between the
treatment groups and standard therapy in the efficacy end points that were evaluated
including the primary end point of percentage of dysfunctional segments at baseline with
improved segmental wall thickening at 4 months and the secondary end points of change in
LV ejection fraction volumes mass and infarct size
To date intracoronary injection of bone marrow-derived cells as an adjunctive therapy in
patients with acute myocardial infarction has been tested in several small and medium-sized
trials with various results The results of the ASTAMI trial and the study by Janssens et al did
not indicate an improvement of LV function whereas the data from the BOOST and REPAIR-
AMI trial showed a significant 60 and 25 absolute increase in LV ejection fraction
respectively (56819) Our study differed from the aforementioned studies in several ways
MRI was used for assessment of the primary end point of change in regional myocardial
function patients with relatively large first myocardial infarctions and short total ischemic
time were included cell infusion was performed at the same day of cell harvesting and a
second treatment group with infusion of mononuclear peripheral blood cells was included
We have chosen the change in regional systolic myocardial function measured by MRI as our
primary end point based on the assumption that regional function is more sensitive than
global LV function for the evaluation of cell therapy(20) Several mechanisms of action by
which cell therapy may enhance functional cardiac recovery have been suggested including
cardiac and vascular regeneration Alternatively paracrine activities of the transplanted
mononuclear cells may responsible for the functional recovery(1221) Detailed MRI analysis
in the BOOST trial demonstrated enhanced recovery of regional systolic wall motion mostly
in the border zone of the infarct whereas Janssens et al noted improvement especially in the
most severely infarcted segments(519) Restoration of microvascular function determined
by intracoronary flow measurements in patients in the REPAIR-AMI trial provided first
clinical proof of concept of vascular repair by intracoronary cell therapy(22) However
these measurements were secondary end points and in part post-hoc analyses Our study is
HEB
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149
the largest study so far that used a highly accurate and quantitative imaging technique for
assessment of regional systolic function in a multicenter setting
Compared to other cell therapy studies after acute myocardial infarction we included
relatively large infarcts This resulted in a population with a markedly depressed LV ejection
fraction (426plusmn88) despite a relatively short symptom onset to PCI time and contemporary
post-infarct treatment(23) While subgroup analyses of the REPAIR-AMI trial demonstrated
an interaction between the baseline LV ejection fraction and the improvement seen after
bone marrow cell therapy with cell therapy being most effective in patients with a lower LV
ejection fraction (lt49) we observed no improvement in our study(8)
Most clinical studies have used the stop-flow technique with an over-the-wire balloon
catheter for cell infusion after acute myocardial infarction However isolation protocols
and numbers of injected cells have differed substantially As shown by Seeger et al the
isolation protocol and incubation period are important and can have a major impact on the
number of isolated cells and the functional activity of these cells(10) It has been suggested
that differences in cell isolation procedures between the REPAIR-AMI and ASTAMI trial
are responsible for the contrasting outcomes(6810) In agreement we have previously
demonstrated that particular composition of the washing medium and centrifugation speed
influence cell recovery and functional activity of the isolated cells(11) In this light we
showed that our choice of density gradient solution (LymphoprepTM) did not have an effect
on cell recovery as compared to Ficoll Moreover in this study cell infusion was performed at
the day of harvesting thus avoiding overnight storage a procedure that may have a negative
impact on functional activity of isolated cells(10) Finally our isolation method was shown
to result in a cell fraction with quantities at least comparable to the REPAIR-AMI trial
(11) In fact the number of isolated cells and CD34+ cell fraction in the present study was
comparable with the REPAIR-AMI trial 296plusmn164 x106 and 236plusmn174 x106 cells with 16plusmn09
and 15plusmn07 CD34+ cells respectively Considering these data we believe that the lack of
beneficial effect in our trial is not explained by the cell isolation protocol
Our trial has several limitations First for ethical reasons the HEBE trial was not a double-
blind placebo controlled study Bone marrow aspiration and venous blood collection was not
performed in all patients and the control group did not undergo sham infusion However
there was a blind evaluation of end points using a core laboratory for MRI analysis Second
Chap
ter
9
150
baseline MRI was not performed on a fixed time point after myocardial infarction and this
may influence the measured changes in LV parameters However in all patients MRI was
performed before randomization and no differences between the 3 groups were observed
Finally we performed follow-up MRI at 4 months after cell therapy Due to this relative short
follow-up period long-term effects on LV function and remodeling may have been missed
This should be further investigated and therefore repeat MRI will be performed at 2 years
In conclusion we did not show a beneficial effect of intracoronary delivery of mononuclear
cells from bone marrow or peripheral blood on regional and global systolic myocardial
function at 4 months follow-up in patients with a first acute myocardial infarction treated
with primary PCI
Funding
The HEBE trial has been initiated by the Interuniversity Cardiology Institute of The
Netherlands (ICIN) Utrecht The Netherlands (directors WH van Gilst University Medical
Center Groningen Groningen and EE van der Wall Leiden University Medical Center
Leiden) The study is financially supported by funds provided by the ICIN the Netherlands
Heart Foundation (grant 2005T101) and by unrestricted grants from Biotronik Boston
Scientific Guerbet Guidant Medtronic Novartis Pfizer and Sanofi-Aventis Dr Robin
Nijveldt was supported by the Netherlands Heart Foundation grant 2003B126
Appendix
In addition to the authors the following investigators and committee members all in The
Netherlands participated in the HEBE trial (numbers in parentheses are the numbers of
patients enrolled) University Medical Center Groningen Groningen (87) W Nieuwland
M Oudkerk LH Piers JT de Wolf Academic Medical Center Amsterdam (58) JD Haeck
MI Klees AM van der Laan AM Spijkerboer VU University Medical Center Amsterdam
(18) F Afsharzada AM Beek PC Huijgens KMJ Marques Erasmus University Medical
Center Rotterdam (16) PAW te Boekhorst E Braakman RJ van Geuns University
Medical Center Utrecht Utrecht (8) MJM Cramer ICM Slaper-Cortenbach EJVonken
University Hospital Maastricht Maastricht (6) M Grommeacute HC Schouten G Snoep St
Antonius Hospital Nieuwegein (5) D Biesma MAR Bosschaert B Rensing University
HEB
E st
udy
151
Medical Center St Radboud Nijmegen (2) FWMB Preijers FWA Verheugt MJ van
der Vlugt Sanquin Research at CLB Amsterdam (core laboratory for in vitro studies on
cell material) RT van Beem S Dohmen IM Lommerse E van der Schoot C Voermans
Trial Management and Executive Committee JJ Piek (cochair) F Zijlstra (cochair) AC van
Rossum JGP Tijssen BJ Biemond PA Doevendans A Hirsch R Nijveldt PA van der
Vleuten Data and Safety Monitoring Committee M van den Brand H Wellens AW van
rsquot Hof Adjudication Committee AF van den Heuvel IC van der Horst Data Center and
Monitoring JL Hillege Trial Coordination Center University Medical Center Groningen
Groningen Core laboratories for MRI Bio-Imaging Technologies BV Leiden (for functional
analysis) and VU University medical center Amsterdam (for infarct size analysis)
Chap
ter
9
152
References
(1) Van de Werf F Bax J Betriu A Blomstrom-Lundqvist C Crea F Falk V et al Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation the Task Force on the Management of ST-Segment Elevation Acute Myocardial Infarction of the European Society of Cardiology Eur Heart J 2008 Dec29(23)2909-45
(2) Velagaleti RS Pencina MJ Murabito JM Wang TJ Parikh NI DrsquoAgostino RB et al Long-term trends in the incidence of heart failure after myocardial infarction Circulation 2008 Nov 11118(20)2057-62
(3) Assmus B Schachinger V Teupe C Britten M Lehmann R Dobert N et al Transplantation of Progenitor Cells and Regeneration Enhancement in Acute Myocardial Infarction (TOPCARE-AMI) Circulation 2002 Dec 10106(24)3009-17
(4) Strauer BE Brehm M Zeus T Kostering M Hernandez A Sorg RV et al Repair of infarcted myocardium by autologous intracoronary mononuclear bone marrow cell transplantation in humans Circulation 2002 Oct 8106(15)1913-8
(5) Janssens S Dubois C Bogaert J Theunissen K Deroose C Desmet W et al Autologous bone marrow-derived stem-cell transfer in patients with ST-segment elevation myocardial infarction double-blind randomised controlled trial Lancet 2006 Jan 14367(9505)113-21
(6) Lunde K Solheim S Aakhus S Arnesen H Abdelnoor M Egeland T et al Intracoronary injection of mononuclear bone marrow cells in acute myocardial infarction N Engl J Med 2006 Sep 21355(12)1199-209
(7) Meyer GP Wollert KC Lotz J Steffens J Lippolt P Fichtner S et al Intracoronary bone marrow cell transfer after myocardial infarction eighteen monthsrsquo follow-up data from the randomized controlled BOOST (BOne marrOw transfer to enhance ST-elevation infarct regeneration) trial Circulation 2006 Mar 14113(10)1287-94
(8) Schachinger V Erbs S Elsasser A Haberbosch W Hambrecht R Holschermann H et al Intracoronary bone marrow-derived progenitor cells in acute myocardial infarction N Engl J Med 2006 Sep 21355(12)1210-21
(9) Arnesen H Lunde K Aakhus S Forfang K Cell therapy in myocardial infarction Lancet 2007 Jun 30369(9580)2142-3
(10) Seeger FH Tonn T Krzossok N Zeiher AM Dimmeler S Cell isolation procedures matter a comparison of different isolation protocols of bone marrow mononuclear cells used for cell therapy in patients with acute myocardial infarction Eur Heart J 2007 Mar28(6)766-72
(11) van Beem RT Hirsch A Lommerse IM Zwaginga JJ Noort WA Biemond BJ et al Recovery and functional activity of mononuclear bone marrow and peripheral blood cells after different cell isolation protocols used in clinical trials for cell therapy after acute myocardial infarction Eurointervention 2008 May4(1)133-8
(12) Gnecchi M Zhang Z Ni A Dzau VJ Paracrine mechanisms in adult stem cell signaling and therapy Circ Res 2008 Nov 21103(11)1204-19
(13) Kamihata H Matsubara H Nishiue T Fujiyama S Amano K Iba O et al Improvement of collateral perfusion and regional function by implantation of peripheral blood mononuclear cells into ischemic hibernating myocardium Arterioscler Thromb Vasc Biol 2002 Nov 122(11)1804-10
(14) Hirsch A Nijveldt R van der Vleuten PA Biemond BJ Doevendans PA van Rossum AC et al Intracoronary infusion of autologous mononuclear bone marrow cells or peripheral mononuclear blood cells after primary percutaneous coronary intervention rationale and design of the HEBE trial--a prospective multicenter randomized trial Am Heart J 2006 Sep152(3)434-41
(15) Hirsch A Nijveldt R van der Vleuten PA Tio RA van der Giessen WJ Marques KM et al Intracoronary infusion of autologous mononuclear bone marrow cells in patients with acute myocardial infarction treated with primary PCI Pilot study of the multicenter HEBE trial Catheter Cardiovasc Interv 2008 Feb 1571(3)273-81
HEB
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(16) Sutherland DR Anderson L Keeney M Nayar R Chin-Yee I The ISHAGE guidelines for CD34+ cell determination by flow cytometry International Society of Hematotherapy and Graft Engineering J Hematother 1996 Jun5(3)213-26
(17) Bondarenko O Beek AM Hofman MB Kuhl HP Twisk JW van Dockum WG et al Standardizing the definition of hyperenhancement in the quantitative assessment of infarct size and myocardial viability using delayed contrast-enhanced CMR J Cardiovasc Magn Reson 20057(2)481-5
(18) Nijveldt R Beek AM Hirsch A Stoel MG Hofman MB Umans VA et al Functional recovery after acute myocardial infarction comparison between angiography electrocardiography and cardiovascular magnetic resonance measures of microvascular injury J Am Coll Cardiol 2008 Jul 1552(3)181-9
(19) Wollert KC Meyer GP Lotz J Ringes-Lichtenberg S Lippolt P Breidenbach C et al Intracoronary autologous bone-marrow cell transfer after myocardial infarction the BOOST randomised controlled clinical trial Lancet 2004 Jul 10364(9429)141-8
(20) Herbots L Drsquohooge J Eroglu E Thijs D Ganame J Claus P et al Improved regional function after autologous bone marrow-derived stem cell transfer in patients with acute myocardial infarction a randomized double-blind strain rate imaging study Eur Heart J 2008 Dec 23doi101093eurheartjehn532
(21) Dimmeler S Zeiher AM Schneider MD Unchain my heart the scientific foundations of cardiac repair J Clin Invest 2005 Mar115(3)572-83
(22) Erbs S Linke A Schachinger V Assmus B Thiele H Diederich KW et al Restoration of microvascular function in the infarct-related artery by intracoronary transplantation of bone marrow progenitor cells in patients with acute myocardial infarction the Doppler Substudy of the Reinfusion of Enriched Progenitor Cells and Infarct Remodeling in Acute Myocardial Infarction (REPAIR-AMI) trial Circulation 2007 Jul 24116(4)366-74
(23) Martin-Rendon E Brunskill SJ Hyde CJ Stanworth SJ Mathur A Watt SM Autologous bone marrow stem cells to treat acute myocardial infarction a systematic review Eur Heart J 2008 Aug29(15)1807-18
Chap
ter
9
154
10Summary and conclusions
Chap
ter
10
156
Sum
mar
y an
d co
nclu
sion
s
157
Earlier studies mostly designed to establish the value of various pharmacologic interventions
after myocardial infarction have shown the prognostic value of global left ventricular function
measured as left ventricular ejection fraction (LVEF) in terms of mortality and re-admission
rates for heart failure(1-3) In chapter 2 we showed that LVEF assessed shortly after primary
percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) is a
powerful predictor of long term survival However the post-procedural ECG is available even
sooner In chapter 3 it was shown that an increasing number of Q-waves on the first 12-lead
ECG after PPCI is strongly associated with the extent of myocardial damage measured as
area under the curve of creatin kinase and its myocardial isoenzyme and adverse long-term
prognosis This easy and low-cost method of clinical assessment after PPCI could lead to
more focused use of advanced and expensive additional diagnostics or therapeutics
In chapter 4 the relationship between ST-segment resolution residual ST-segment elevation
and Q waves in relation to left ventricular function size and extent of infarction and
microvascular injury in acute myocardial infarction measured by MRI was explored
In chapter 5 we compared electromechanical endocardial mapping (EEM) with MRI
and we found that EEM-derived global left ventricular functional parameters showed a
significant underestimation compared to MRI However regional parameters appeared to
be useful indicators of dysfunctional myocardial segments Although there were substantial
differences in global left ventricular functional parameters between EEM and MRI a good
correlation was found between the surface-area of the EEM-map with a unipolar voltage
below 69 mV and MRI infarct-size(4) Segmental analyses showed that EEM can be used to
determine both regional function and extent of infarction in patients with a large myocardial
infarction Although regional data showed good correlation with MRI convincing cut-off
values for EEM-parameters could not be established Exact pinpointing of myocardial areas
benefiting from direct injection of therapeutics remains difficult
Since residual left ventricular function was shown to be one of the most powerful predictors
of prognosis after primary PCI for STEMI every effort should be made to conserve and
possibly even improve left ventricular function after STEMI Cell therapy has been a
promising new modality in the field of post-STEMI care which has rendered mixed results
so far(5-10) (chapter 6) In order to assess the full potential of cell therapy in a national
Chap
ter
10
158
multicenter trial a pilot-study was conducted to establish the safety and feasibility of all
study related procedures (chapter 7) This study indicated that intracoronary infusion of
autologous bone marrow derived mononuclear cells after recent myocardial infarction is
safe in a multicenter setting At 4 months follow-up a modest but significant increase in
global and regional LV function was observed with a concomitant decrease in infarct-size
After successfully completing the pilot-study the multicenter HEBE trial could be initiated
(chapter 8 and 9) The rationale behind the three arm-armed study design is to test the
hypothesis that the beneficial effects of cell-therapy on left ventricular function cannot be
completely attributed to the formation of new cardiac myocytes or endothelial cells but
that these positive effects could also be a combined effect of all mononuclear cells through
the release of growth factors and cytokines Intracoronary infusion was chosen as mode
of delivery since the benefits of avoiding local injection were considered to outweigh the
obvious drawback of decreased local cell-retention(11) The rationale behind the choice for
MRI as imaging modality for the primary end-point of the study is its ability to combine left
ventricular function analysis with infarct-size analyses
The HEBE trial showed no benefit of infusion of autologous bone marrow derived progenitor
cells after STEMI Research in this field will most likely continue since cell therapy remains
a very appealing concept In the future trials with other cell types or pre-treatment of cells
may be conducted However since the procedures involved in cell therapy are relatively
invasive and time-consuming great care should be taken to identify those patients in which
the potential of success is the highest and clearly outweighs the procedural risk costs and
patient discomfort
Sum
mar
y an
d co
nclu
sion
s
159
References
(1) Mehta RH Orsquoneill WW Harjai KJ Cox DA Brodie BR Boura J et al Prediction of one-year mortality among 30-day survivors after primary percutaneous coronary interventions Am J Cardiol 2006 Mar 1597(6)817-22
(2) Ottervanger JP Ramdat Misier AR Dambrink JH de Boer MJ Hoorntje JC Gosselink AT et al Mortality in patients with left ventricular ejection fraction lt=30 after primary percutaneous coronary intervention for ST-elevation myocardial infarction Am J Cardiol 2007 Sep 1100(5)793-7
(3) Ndrepepa G Mehilli J Martinoff S Schwaiger M Schomig A Kastrati A Evolution of left ventricular ejection fraction and its relationship to infarct size after acute myocardial infarction J Am Coll Cardiol 2007 Jul 1050(2)149-56
(4) Perin EC Silva GV Sarmento-Leite R Sousa AL Howell M Muthupillai R et al Assessing myocardial viability and infarct transmurality with left ventricular electromechanical mapping in patients with stable coronary artery disease validation by delayed-enhancement magnetic resonance imaging Circulation 2002 Aug20106(8)957-61
(5) Lunde K Solheim S Forfang K Arnesen H Brinch L Bjornerheim R et al Anterior myocardial infarction with acute percutaneous coronary intervention and intracoronary injection of autologous mononuclear bone marrow cells safety clinical outcome and serial changes in left ventricular function during 12-monthsrsquo follow-up J Am Coll Cardiol 2008 Feb 1251(6)674-6
(6) Lunde K Solheim S Aakhus S Arnesen H Abdelnoor M Egeland T et al Intracoronary injection of mononuclear bone marrow cells in acute myocardial infarction N Engl J Med 2006 Sep 21355(12)1199-209
(7) Britten MB Abolmaali ND Assmus B Lehmann R Honold J Schmitt J et al Infarct remodeling after intracoronary progenitor cell treatment in patients with acute myocardial infarction (TOPCARE-AMI) mechanistic insights from serial contrast-enhanced magnetic resonance imaging Circulation 2003 Nov 4108(18)2212-8
(8) Assmus B Schachinger V Teupe C Britten M Lehmann R Dobert N et al Transplantation of Progenitor Cells and Regeneration Enhancement in Acute Myocardial Infarction (TOPCARE-AMI) Circulation 2002 Dec 10106(24)3009-17
(9) Schachinger V Erbs S Elsasser A Haberbosch W Hambrecht R Holschermann H et al Intracoronary bone marrow-derived progenitor cells in acute myocardial infarction N Engl J Med 2006 Sep 21355(12)1210-21
(10) Schachinger V Erbs S Elsasser A Haberbosch W Hambrecht R Holschermann H et al Improved clinical outcome after intracoronary administration of bone-marrow-derived progenitor cells in acute myocardial infarction final 1-year results of the REPAIR-AMI trial Eur Heart J 2006 Dec27(23)2775-83
(11) Penicka M Lang O Widimsky P Kobylka P Kozak T Vanek T et al One-day kinetics of myocardial engraftment after intracoronary injection of bone marrow mononuclear cells in patients with acute and chronic myocardial infarction Heart 2007 Jul93(7)837-41
Chap
ter
10
160
Summary in Dutch
(Nederlandse samenvatting)
Sam
enva
tting
162
Sam
enva
tting
163
Het acute ST-elevatie myocardinfarct (STEMI) gaat vrijwel altijd gepaard met schade aan
de hartspier Het is lastig gebleken om deze schade betrouwbaar in maat en getal weer te
geven Wat uiteindelijk voor de patieumlnt het belangrijkste is zijn de overlevingskansen en
het vermogen om zonder beperkende klachten deel te nemen aan het dagelijkse leven In
het eerste deel van dit proefschrift wordt in ingegaan op een aantal ontwikkelingen op het
gebied van het beoordelen van de schade na een infarct
Tegenwoordig wordt de schade bij veel patieumlnten voor een deel beperkt doordat het
afgesloten bloedvat dat het infarct veroorzaakt zo snel mogelijk wordt opengemaakt
door een directe percutane coronaire interventie (PCI ofwel dotterbehandeling) Bij
sommige patieumlnten ontstaat desondanks veel schade aan de hartspier Uit veelbelovend
dierexperimenteel onderzoek is naar voren gekomen dat een behandeling met uit beenmerg
of bloed afkomstige cellen kort na een hartinfarct zou kunnen bijdragen aan het herstel van
de schade van een hartinfarct Deel twee van dit proefschrift gaat dieper in op de toepassing
van deze therapie bij patieumlnten
In grote onderzoeken veelal verricht om het effect van verschillende medicijnen bij
patieumlnten met stabiel hartfalen te onderzoeken is al eerder het verband aangetoond
tussen de pompfunctie uitgedrukt in de linkerventrikelejectiefractie (LVEF) en overleving
In hoofdstuk 2 tonen wij aan dat er een duidelijk verband is tussen de LVEF gemeten in
de weken na het infarct en de overleving op lange termijn Opvallend is daarbij dat een
kleine achteruitgang in LVEF gepaard gaat met een beperkte toename in mortaliteit maar
een afname tot onder de 35 (normaalwaarde gt 55) grote gevolgen heeft wat betreft
overlevingskansen
Om de prognose kort na een PCI voor STEMI te kunnen schatten hebben we gekeken naar de
waarde van het tellen van Q-golven op het eerste beschikbare 12-kanaals elektrocardiogram
(ECG) na de PCI bij een groot aantal STEMI patieumlnten (hoofdstuk 3) Daarbij hebben we
gezien dat bij een toenemend aantal Q-golven op het ECG het infarct biochemisch groter is
en de 1-jaarsmortaliteit hoger Dit effect bleek nog aanwezig te zijn als er werd gecorrigeerd
voor andere bekende voorspellers van infarctgrootte en prognose
In hoofdstuk 4 tonen we aan dat het aantal Q-golven op het eerste ECG na de PCI en de
normalisatie van het ST-segment gerelateerd is aan linkerkamerfunctie en infarctgrootte
gemeten met magnetische resonantie (MRI)
Sam
enva
tting
164
Endocardiale elektromechanische mapping (ook wel NOGA genoemd naar de naam van
het hierbij gebruikte systeem) is een techniek om in het linker ventrikel van het hart de
regionale (en globale) wandbeweging en elektrische activiteit van de hartspier evenals de
mate van infarcering te beoordelen Deze techniek wordt tegenwoordig veel toegepast bij
elektrofysiologische interventies (bijvoorbeeld bij boezemfibrilleren) In het licht van de
mogelijke toepassing bij celtherapie (deel 2 van dit proefschrift) hebben wij de met NOGA
gemeten globale en regionale karakteristieken van het myocard vergeleken met de gegevens
van de MRI In hoofdstuk 5 beschrijven we dat er een goede overeenkomst is maar dat het
niettemin moeilijk blijft om exact de begrenzing van het door de STEMI aangetaste gedeelte
van het myocard te bepalen
Ondanks grote vooruitgang in het beperken van de schade van een hartinfarct is er
vooralsnog geen werkzame manier gevonden om de eenmaal ontstane schade aan
de hartspier te repareren Uit dierexpirimenteel onderzoek en enkele onderzoeken bij
patieumlnten is naar voren gekomen dat het gunstig zou kunnen zijn om kort na een hartinfarct
mononucleaire cellen uit het beenmerg (met daaronder de voorloper- of stamcellen) te
isoleren en in de kransslagader te infunderen In hoofdstuk 6 worden alle beschikbare data
uit gerandomiseerd klinisch onderzoek op een rij gezet Om de veiligheid van alle (deels
invasieve) procedures te waarborgen is eerst een veiligheidsonderzoek verricht (hoofdstuk
7)
In het multicenter gerandomiseerde onderzoek dat daarna is uitgevoerd onder auspicieumln
van het Interuniversitair Cardiologisch Instituut Nederland (ICIN) (hoofdstuk 8 en 9) is
onderzocht of het intracoronair infunderen van uit het beenmerg of uit perifeer bloed
afkomstige mononucleaire cellen kan bijdragen aan het herstel van linker ventrikel
functie na een STEMI Er werden 200 patieumlnten geiumlncludeerd die een primaire PCI hadden
ondergaan binnen 12 uur na het ontstaan van klachten Er werd geloot of deze mensen
in de ldquobeenmergrdquo-groep de ldquobloedrdquo-groep of de ldquocontrolerdquo-groep terecht kwamen Bij de
patieumlnten in de ldquobeenmergrdquo-groep werd 60 milliliter beenmerg uit de rand van het bekkenbot
geaspireerd Uit dit beenmerg werd vervolgens de mononucleaire celfractie geiumlsoleerd
Deze celsuspensie werd vervolgens via een procedure die lijkt op een PCI geiumlnfundeerd in de
bij het infarct betrokken coronairarterie Bij de patieumlnten in de ldquobloedrdquo-groep werd in plaats
Sam
enva
tting
165
van beenmerg 200 ml perifeer bloed gebruikt om de mononucleaire celfractie uit te isoleren
Ook deze celsuspensie werd toegediend in de bij het infarct betrokken coronairarterie
Bij de patieumlnten in de ldquocontrolerdquo-groep werd een dergelijke behandeling niet uitgevoerd
Daarnaast werden alle patieumlnten in het onderzoek behandeld zoals normaal gebruikelijk is
na een STEMI Bij alle patieumlnten werd binnen een week na de primaire PCI een MRI-scan van
het hart gemaakt
Na 4 maanden werd opnieuw een MRI verricht om het effect van de behandeling te
evalueren Hierbij bleek dat in alle drie de groepen de linkerventrikelfunctie zowel globaal
als regionaal licht was verbeterd ten opzichte van de situatie kort na het hartinfarct De
resultaten in de ldquobeenmergrdquo- en de ldquobloedrdquo-groep waren echter niet beter dan de resultaten
in de ldquocontrolerdquo-groep De behandelingen zoals die zijn uitgevoerd in ons onderzoek zijn dus
in de praktijk veilig toepasbaar maar leiden niet tot verbetering van de linkerventrikelfunctie
na een STEMI Nieuwe inzichten en aanvullend onderzoek zullen de brug moeten slaan van
het veelbelovende dierexperimenteel onderzoek naar de dagelijkse cardiologische praktijk
om na een infarct kamerfunctieherstel mogelijk te maken
Sam
enva
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166
Dankwoord
Dan
kwoo
rd
168
Dan
kwoo
rd
169
De totstandkoming van dit proefschrift zou nooit een feit zijn geworden zonder de directe
en indirecte hulp van een groot aantal mensen Hoewel ik me besef dat het onmogelijk is
om iedereen met naam en toenaam te noemen wil ik toch graag een aantal mensen in het
bijzonder bedanken
Allereerst mijn promotor prof dr F Zijlstra Beste Felix je weet in je rol als promotor op
onnavolgbare wijze twee uitersten te combineren Enerzijds houd je voldoende afstand
zodat je promovendi zelfstandig kunnen werken Anderzijds heb je een grote inhoudelijke
betrokkenheid bij alle projecten en ben je desgevraagd altijd bereid je handen uit de
mouwen te steken Daarnaast heb je een fascinerend vermogen om nooit lang stil te staan
bij een probleem maar direct te zoeken naar een oplossing Bedankt voor de kans om dit
proefschrift te schrijven en ik hoop dat we in de toekomst nog veel onderzoek blijven doen
op en rond de HC
Mijn co-promotor dr RA Tio Beste Reneacute op het moment van het verschijnen van dit
boekje kennen we elkaar alweer ruim 8 jaar Zonder jou was ik nooit aan dit proefschrift
begonnen en je onverstoorbare positiviteit hebben mij menig maal de dagelijkse obstakels
van het onderzoek doen relativeren
Mijn officieuze ldquotweede co-promotorrdquo dr Gillian Jessurun is slechts zijdelings betrokken
geweest bij de directe inhoud van dit proefschrift Echter je onorthodoxe persoonlijkheid
en enthousiasme voor een niet nader te noemen Duits automerk hebben mijn dagen als
onderzoeker absoluut opgefleurd
Ook met de overige interventiecardiologen (dr Yung Tan dr Bart de Smet dr Rutger
Anthonio en dr Ad van den Heuvel) was en is het erg prettig samenwerken
Uiteraard wil ik ook de beoordelingscommissie bestaande uit prof dr ROB Gans prof dr
JJ Piek en prof dr DJ van Veldhuisen danken voor het kritisch lezen en becommentarieumlren
van dit proefschrift
Dan
kwoo
rd
170
Daarnaast ben ik de opleiders van de afdeling cardiologie (dr MP van den Berg en prof
dr DJ van Veldhuisen) en de afdeling interne geneeskunde (prof dr ROB Gans dr CA
Stegeman en dr JTM van Leeuwen) zeer erkentelijk voor de mogelijkheid om mijn opleiding
tot cardioloog en mijn interne vooropleiding te doorlopen in het UMCG
Door de HEBE-studie heb ik naast de afdeling cardiologie ook veel te maken gehad met
andere afdelingen binnen en buiten het UMCG
De afdeling radiologie (in het bijzonder dr Tineke Willems Peter Kappert Danieumll Lubbers
en Gonda de Jonge) heeft mij de kans gegeven om mijn horizon te verbreden richting de
cardiale imaging
De afdeling hematologie (in het bijzonder dr Joost de Wolf Jenne Kits en Marchienus
Weggemans) heeft mij en een groot aantal patieumlnten ervan overtuigd dat een crista-
punctie mits technisch goed uitgevoerd lang niet zo belastend is als wordt verondersteld
door veel mensen binnen en buiten de gezondheidszorg
Daarnaast was de ondersteuning door Cardio Research (Margriet Couperus en Trienke
Steenhuis in het bijzonder) ldquode dames van C2rdquo (Anja en Trudie) en de verpleging van de
diverse afdelingen essentieel voor het slagen van de studie Tevens wil ik ook dr Wiebe
Nieuwland bedanken voor zijn continue waakzaamheid op de CCU
Buiten het UMCG heb ik zeer intensief samengewerkt met mijn ldquoHEBE-maatjesrdquo Robin
Nijveldt Alexander Hirsch Farshid Afsharzada en Anja van der Laan Ik verheug me op het
verder uitwerken van de studie en hoop dat dit zal leiden tot een aantal mooie publicaties
In dat kader wil ik ook Lieuwe Piers bedanken voor het waarnemen van de HEBE-taken
tijdens het begin van mijn vooropleiding Ik hoop van harte dat je in de Randstad letterlijk
en figuurlijk je plek vindt
Dan
kwoo
rd
171
Een goede werksfeer begint met gezellige collegarsquos Gelukkig heb ik met mijn collegarsquos (onder
andere Daan Kevin Mathijs Tone Jessica Marieke Pieter-Jan Christiane Yulan Marthe
Sheba Marcelle Sandra Hessel Ali Anne Jan-Pieter Tom Martin Michiel Pim Peter
Suzan Bart Willem-Peter Jardi Liza Jasper en Rik) zowel in als buiten ldquode Greenhouserdquo
een mooie tijd gehad Ik hoop dat we die lijn kunnen voortzetten in de kliniek
Niels van Minnen en Michiel Kuijpers wil hartelijk bedanken voor het feit dat zij de taak van
paranimf op zich hebben genomen Ik hoop met jullie beiden nog lang ldquoin het Noorden te
blijven plakkenrdquo
Als laatste bedank ik Saskia Tideman voor allerlei dingen die stuk voor stuk niets met
onderzoek te maken hebben