Download G-CSF

4th International Symposium on Stem Cell Therapy and Applied
Cardiovascular Biology
Madrid (Spain), April 26 – 27, 2007
Preclinical session
Hüseyin Ince MD, PhD
University of Rostock
Department for Internal Medicine, Cardiology
[email protected]
What is stem cell therapy?
What is stem cell therapy?
 Stem cells in
cardiomyopathy
Antoni-Bayes Genís
Ultrastructural findings of idiopathic dilated cardiomyopathy (IDCM):
Myocyte atrophy and myofilament loss
Main epicardial coronary arteries are shorter and smaller
Microvascular density is reduced in the epicardium
Moreover, this defective vascularization is associated with reduced
myocardial expression of vascular -catenin, an important angiogenic
regulator
This study shows that both vasculogenesis and angiogenesis are
altered in IDCM
LC Guarita-Souza
Simultaneous autologous transplantation of co-cultured stem cells (SC) and
skeletal myoblasts (SM) in an experimental model of Chagas disease
Seven Wistar rats received autologous transplant of 5,4x106 and 8,0x106 cells
into the LV wall
Control group (n=8) received culture medium
After 4 weeks, cell transplantation significantly improved EF and reduced LVEDV
No change has been observed in the control group.
Conclusion: the co-transplant of SC and SM is functionally effective in Chagas
disease (at least in Wistar rats)
MiHeart
The Multicenter Randomized Cell Therapy Trial in Cardiopathies
(MiHeart) is composed of four independent clinical trials each one
dealing with a specific cardiomyopathy:
Chagasic cardiomyopathy
Dilated cardiomyopathy
Acute myocardial infarction
Chronic ischemic heart disease
MiHeart
All trials are multicenter, randomized, double-blind and placebo
controlled.
In each trial 300 patients will be enrolled.
Additionally, half of the patients will receive the autologous bone marrow
cells while the other half will receive placebo (saline with 5% autologous
serum).
The method for cell delivery is intramyocardial for the chronic ischemic
heart disease and intracoronary for all others.
Primary endpoint for all studies will be the difference in ejection fraction
six and twelve months after intervention in relation to the basal ejection
fraction.
MiHeart saftey endpoints
Incidence of arrhythmias and conduction disturbances
Number of ventricular extra systoles in six months and one year.
Number of sustained ventricular tachycardia episodes in six months and
one year.
Number of non sustained ventricular tachycardia episodes in six months
and one year.
Incidence of atrial fibrillation in six months and one year.
New-onset of atrioventricular or intraventricular conduction disturbances.
Need for artificial pacemaker implantation.
Wojciech Wojakowski
SDF-1 (ligand of CXCR4 receptor) is a crucial factor involved in progenitor cell
mobilization and homing
There is an increase of SDF-1 production and release from ischemic
myocardium generating the SDF-1 gradient towards the heart in AMI
In patients with acute myocardial infarction the absolute number of
CD34+CXCR4+, CD34+c-kit+ and c-met+ cells was significantly higher in
comparison to patients with stable angina and healthy subjects
Homing of tissue committed stem cells is also dependent
on leukemia inhibitory factor (LIF) - LIF receptor and hepatocyte growth factor
(HGF) - c-met axis
 G-CSF in AMI
Firstline-AMI
Direct effects of G-CSF on cardiac
function after ischemia reperfusion
injury
• Langendorff perfusion
model w/wo 300 ng/ml
G-CSF
• early contraction with
G-CSF in reperfusion
• improved hemodynamics
• less myocardial necrosis
Harada et al., Nature Medicine 2005;11:305-11
Firstline-AMI
Angiographic and AMI related
characteristics
G-CSF group
(n = 25)
Control group
(n = 25)
13
9
3
13
8
4
293 ± 115
299 ± 123
ns
PCI plus stent, %
100
100
ns
Abciximab (adjusted dose), %
100
100
ns
Clopidogrel (300 mg loading)
100
100
ns
TIMI III flow post PCI, %
100
100
ns
Creatine kinase max, U/l
3706 ± 1818
3660 ± 2204
ns
385 ± 240
361 ± 204
ns
89 ± 35
-
na
Infarct related artery,
LAD
RCA
CFX
Onset of AMI to PCI, min
Creatine kinase MB max, U/l
Time from PCI to first G-CSF injection, min
p
AMI = acute myocardial infarction;
PCI = percutaneous coronary intervention;
Ince et al. Circulation 2005; 112:3097-3106
Functional echocardiographic
parameters
Firstline-AMI
LVEF
G-CSF (n=25)
Control (n=25)
LVEF (%)
LVEF (%)
60
p < 0.002
p < 0.001
55
60
p < 0.002
59  7
56  4
55
54  8
50
54  5
47  5
53  5
51  5
50
51  4
48  4
45
p < 0.001
51  8
45
46  4
43  5
40
40
35
35
30
30
Baseline
35 days
Rest
4 months
Baseline
35 days
4 months
Low dose Dobutamine
Ince et al. Circulation 2005; 112:3097-3106
Firstline-AMI
6 months angiographic results
Restenosis parameters (in segments)
G-CSF (n=25)
Control (n=25)
Restenosis
Late lumen loss
ns
ns
MLD
20
20
18
16
14
ns
0,64
0,62
16
0,6
12
2
0.61  0.18
0.60  0.23
1,98
0,58
10
1,96
1.96  0.50
1.95  0.38
0,56
8
1,94
6
0,54
4
1,92
0,52
2
1,9
0,5
0
6m binary restenosis rate (%)
6m late lumen loss (mm)
6m MLD (mm)
Ince et al. Circulation 2005; 112:3097-3106
G-CSF and Restenosis
 Bone marrow
mobilization
strategies after the
MAGIC trial.
Control
(n=33)
p
2.73±0.49
2.61±0.36
0.25
12.3±9.5
10.3±8.5
0.32
2.27±0.61
2.04±0.44
0.07
19.5±9.8
20.9±11.0
0.51
0.46±0.37
0.57±0.28
0.11
post PCI
MLD, (mm)
Stenosis, (%)
 No risk of
restenosis
G-CSF
(n=60)
QCA (median 6 months)
MLD, (mm)
Stenosis, (%)
LLL, (mm)
Delta-EF after G-CSF in AMI
10
8
6
4
G-CSF
Control
3D-Säule 3
2
0
G-CSF
-2
Control
-4
1
2
3
4
5
6
7
Firstline-AMI
G-CSF early after MI
• G-CSF improves cardiac
function
• Dose and time sensitive
effects
Harada et al., Nature Medicine 2005;11:305-11
 Myoblasts in CHD
Skeletal Myoblast Transplantation :
Steps of the Procedure
10 g
Biopsy
GMP Cell Expansion
Felipe Prosper
Two months after induction of myocardial infarction (MI), Goettingen
miniature pigs underwent autologous SkM transplant either by direct
surgical injection (n=6) or percutaneous access (n=6)
Control animals received media alone (n=4)
Animals received a median of 407.55±115x106 BrdU labeled autologous
SkM
Functional analysis was performed by 2D echocardiography
Myoblast transplant was associated with a significant increase in LVEF
(p<0.01), increased vasculogenesis, decreased fibrosis (p<0.05) as
compared with control animals
No differences were found between groups receiving SkM by percutaneous
or surgical access
Myoblast Tx : Phase I Surgical Trials
Author
No. Pts
No. Cells CABG
LV Function FU
+ cells Global Cell-Tx
Herreros
12
221 x 106
+
Eur Heart J 2003
Siminiak
10
EF : 35% to 53% at 3 mo.
WMSI : 2.64 to 1.64
4 x 105 -5 x 107 +
Am Heart J 2004
Dib
24
Circulation 2005
3 mo.
12 mo.
EF : 35% to 42% at 4 mo.
4/10 segments improved
1 x 107 -3 x 108
+
NA 45 mo.
EF : 28% to 36% at 2 yrs
Myoblast Tx : Phase I Interventional Trials
Author
No. Pts
No. Cells
LV Function FU
Global Cell-Tx
Smits
5
220 x 106
6 mo.
JACC 2003
EF : 36% to 41%
Ince
6
220 x 106
12 mo.
JEVT 2004
EF : 24% to 32%
Patricia Lemarchand
Possible Mechanisms of Myoblast-Related Arrhythmias
Lack of coupling between
grafted myoblasts and host
cardiomyocytes
Impulse propagation
Resting state
Peak of action potentials
Embryonic myosin
Connexin 43
of conduction,
No Slowing
action potentials
wave break & reentry
Abraham
al.PNAS,
Circ Res
2005;97:159-67.
Léobon etetal.
2003;100:7808-11.
Delayed
cardiac
Stretch
activation by
repolarization
contracting myotubes
Itabayashi et al.Cardiovasc Res
2005;67:561-70.
Probability of Discharge of a First Shock
in the ICD-Implanted Patients of the PATCH Trial
Actuarial incidence of first discharges : 50% at 1 year and
57% at 2 years
Bigger et al. New Engl J Med 1997;337:1569-75.
Implantation of Skeletal Myoblasts :
Lessons from Phase I Trials
Efficacy Data
Inability to draw meaningful conclusions from early studies
because of :
The small sample sizes
The lack of control groups
The confounding effect of associated CABG
The dissociation between improved LV function and
achievement of true myocardial regeneration
Only randomized double-blind placebo-controlled
adequately powered trials will provide a meaningful
assessment of the risk-benefit ratio (In MAGIC the high
dose cell group demonstrated a significant decrease in LV
enddiastolic and endsystolic volumes)
Concept of stent-induced “Aortic Reconstruction”
Diagnosis
Occlusion of
proximal Entry
Treatment
Reconstruction of TL
before stentgraft
1 year after stentgraft
Antoine Lafont
Aortic aneurysm formation is associated with matrix metalloproteinase-9
(MMP-9) activity
Gingival healing is embryo-like in contrast to arterial healing
This could be attributed to the gingival fibroblast
Concept of using gingival fibroblast healing properties in arteries
Gingival fibroblasts reduce MMP-9 expression by increasing TIMP-1
synthesis
Vascular transfer of gingival fibroblasts could be a promising approach to
treat aortic aneurysms
Kai Pinkernell
Preclinical evaluations of adipose derived stem and regenerative cells
(ADRCs) have been carried out in acute and chronic cardiac diseases
showing an improvement of cardiac function as well as a reduction in
remodeling
The PRECISE trial in patients with chronic myocardial ischemia has been
started
The APOLLO trial in patients with AMI is scheduled to follow soon in order to
investigate the safety and feasibility of ADRC therapy in patients
Both trials are designed as prospective, double blind, randomized, dose
escalating trials
Conclusions
1. Find the best stem cell types or cytokines for repair of
cardiovascular disease.
2. Identify cardiovascular stem cells among circulating
stem cells; adipose tissue; epithelial cells; bone
marrow-derived stem cells and compare their
capabilities in cardiovascular repair in relevant
experimental animal models.
3. Identify roles of specific stem cell types or cytokines in
reparative medicine and in cardiac regeneration and
vascular repair.
Conclusions
4. Identify optimal cell numbers and methods of
administration of stem cells in cardiovascular repair.
5. Identify clinical problems most susceptible to stem cell
or cytokine treatments.
Patients
Acute
MI
Chronic
IDCM
Angina
HF
EPCs,
CD34+,
AC133+
Subsets
AGE
CM (Parenchyma) Stroma (MSCs)
Organ specific-Heart
EMBRYONIC
Fat
MNC
Gender
Mb, Fb, SP cells
BM, Blood, UCB
ADULT
STEM CELLS
Muscle
Comparison of REPAIR-AMI versus ASTAMI
Invasion activity
Healthy Controls
140
*
120
REPAIR
ASTAMI
100
80
*+
60
40
20
Invasion (x10E3) /10E6 BMC
Invasion (x10E3) /10E6 BMC
REPAIR
CAD-Patients
ASTAMI
*
80
70
60
50
40
30
+
20
10
0
0
basal
SDF-1
basal
SDF-1
basal
SDF-1
basal
SDF-1
Phase I Study Design
Phase I Trial Objectives
 To determine the safety and tolerability of 3 different
intravenous doses of Provacel compared to placebo in
subjects with AMI
 To evaluate the effect of Provacel on exploratory efficacy
endpoints
Design
 Multi center study, randomized, double-blind, placebocontrolled, dose escalation study
 48 adult subjects with AMI (powered to show safety and
preliminary efficacy)
 3 dose escalated cohorts and 1 safety cohort at the highest
tolerated dose in a 2:1 ratio of active to placebo