Date post: | 30-Dec-2015 |
Category: |
Documents |
Upload: | penelope-pickett |
View: | 33 times |
Download: | 1 times |
Jozef Bartunek
Cardiovascular Center, Aalst, Belgium
Faculty of Biomedical Engineering, TU Eindhoven, NL
What’s New?
On Adult Stem Cells?
JB is a member of an institution which is a founding member of Cardio3 Biosciences
5th International Symposium on Stem Cell Therapy & Applied Biotechnology Madrid, April 2008
STEM CELLSTEM CELL
THERAPY THERAPY
“MECHANISMS AT WORK”• Target organ – heart• Remote Homing• Arrhythmias• Coronary vasculature
CELL PRODUCT• Type• Processing• Function and number
CELL DELIVERY
PATIENT• Disease • Risk Profile • Bone Marrow
Adult Stem Cells for Cardiac RepairFramework towards the optimization
Two Clinically Applied Cell Types
2000 2006
MenaschéAHA
AnversaNature
StrauerCirculation
GalinanesAHA
DiacrinDib
MagicMenasche
ZeiherCirculation
SteinhoffLancet
Steinhoff
SiminiakEHJ
TseLancet
TX-Brazil/HoustonPerin
MacLellanUCLA
BioheartSerruys
Myoblast
Bone Marrow Stem Cells
BoostLancet
Repair-AMI,ASTAMIJanssens
SeismicSerruys
2000 2008
Navarra
Abdel-Latif, Arch Intern Med 2007
Adult Stem Cells Therapy for Cardiac Repair
Overall clinical safety demonstrated over 1 to 2 years period
Adult Stem Cells for Cardiac RepairCell Type
Cardiac RepairCardiac Repair
Endothelial progenitor cellsCD34+, CD133+, CD31+, VEGFR 2+, VE-cadherin+
Hematopoetic stem cells C-kit+, CD34+, CD133+
CD31+
Mesenchymal stem cellsCD34-, CD45-,
Adherent, CD90+
Mononuclear BM cellsCD45+, CD14+
~ 1-2% CD34/CD133+
Skeletal Myoblasts
Stem Cell Type and Therapeutic Effect
• BM mononuclear fraction delivers functional response – No cell type omitted– Effect ~ cellular cross
talk between multiple cell types
Cell type
Potential of enriched Potential of enriched (hematopoietic) (hematopoietic)
cell populations should be cell populations should be InvestigatedInvestigated
-2.0
-1.5
-1.0
-0.5
0.0
CPC BMC
Regional Wall Motion
SD
/ch
ord
* *
Follow-up
Baseline
Shachinger V, JACC 2004
Similar functional effectsEPC vs MNC
Kawamoto A, Circulation 2006
CD34+ superior to MNC
Selected/Enriched Adult Stem Cells for Cardiac Repair
Coronary
Myocardial
Function PlannedCardio-myogenic
Autologous
Limited?
C-kit, Sca1, MDR1, Isl1,
Resident cardiac stem cells
Coronary
Myocardial
Perfusion Rand-DB
Ongoing
Pluripotency
Angiogenic
AutologousCD49D, Stro-1, CD166, CD44
Adipose-derived stem cells
Rand-DB Ongoing
Function
Perfusion
Multipotency
Paracrine
“Off-shelf” use
Myocardial
Systemic
Allogeneic
Autologous
CD166, Stro-1, CD44, CD106
BM mesenchymal stem cells
Coronary
Myocardial
Delivery
Perfusion
Function
Pre-clinical experience
Rand-DB Ongoing
Angiogenic
Paracrine
Autologous
Allogeneic (umbilical cord)
CD133, CD34
CD31
Hematopoietic stem cells
Clinical Studies
PotentialSourceMarkers
• Double-blinded, placebo controlled, randomized study
• Direct comparison of autologous BM MNC and autologous culture expanded BM MSCs in the canine model of the chronic myocardial infarction
• Multimodality functional and morphological assessment including, echocardiography, MRI and invasive pressure-volume loops
• Histology and gene expression analyses
Week - 2
Week +8
9 weeks
16 weeksWeek +16 : (-) Echocardiography
(-) MRI
Week +9 : (-) Echocardiography
(-) Pressure-volume loops
(-) MRI
Week +17 : (-) Sacrifice
(-) Histopathology
(-) Macro-morphometry
Week 0 : (-) Bone-marrow collection (BMNC)
(-) Cells injection
(-) Echocardiography
Week -11 : (-) Bone-marrow collection
(-) Coronary ligation
Baseline
(-) Echocardiography
Week -1 : (-) Echocardiography
(-) Pressure-volume loops
(-) MRI
Stem Cell Type and Therapeutic EffectDirect Comparison MSCs vs BMNCs
Mathieu M, McEntee K, Erasmus, ULB Brussels, ACC 2008
Mathieu M, Mc Entee K, Erasmus, ULB Brussels, ACC 2008
Stem Cell Type and Therapeutic EffectMSCs vs BMNCs
Superior effects of MNC vs MSCs in chronic MI:Superior effects of MNC vs MSCs in chronic MI:- Model specific?Model specific?- Disease/remodelling specific?Disease/remodelling specific?- Implications for the clinical trials?Implications for the clinical trials?
• Mice model of the myocardial infarction (cryoinjury, coronary ligation)• Injection of 2x105 MSCs (passage 3) or total BM from EGFP+ transgenic mice• Follow up from 29 to 268 days.
Stem Cell Type and Therapeutic EffectWord of Caution on Safety?
Breitbach M et al, Blood 2007Osteocalcin, Cy3 EGFP labeled stem cells
Damaged adult heart may not be able to recapitulate Damaged adult heart may not be able to recapitulate necessary millieu to stimulate myocardial specification resulting necessary millieu to stimulate myocardial specification resulting
in the limited efficacy or unwanted signalling/differentiation in the limited efficacy or unwanted signalling/differentiation of “naive” or plastic stem cells of “naive” or plastic stem cells
Adult Stem Cell Therapy
Olson, Nat Medicine 2004; Chien, Nature 2004; Wang, J Thorac Cardiovasc Surg 2001, Yoon, Circulation 2004, Breitbach, Blood 2007
Goals:- to improve cell function- to increase engraftment- to increase integration - to increase cell survival- to guarantee safety
From Non-modified Adult Stem Cells to“Second Generation Stem Cell Products”
Strategies:- Pharmacological
pretreatment- Genetic engineering- Tissue engineering- …..
“Second Generation Stem Cell Products” Increased efficacy after pretreatment with eNOS Enhancer
Sasaki et al, PNAS 2006
Improved Cell Function Enhanced Neovascularization
“Second Generation Stem Cell Products” SDF 1-engineered Skeletal Myoblasts
Enhanced neovascularization and functional improvementAskari et al., JACC 2004
SKMB AdSDF-1
+-
++
Vasc
ular
Den
sity
(ves
sels
/mm
2 )
0
10
20
30
40
50
“Second Generation Stem Cell Products” SCF-engineered MSCs
• Stem cell factor binds to c-kit and leads to bone marrow stem cells activation and mobilization• SCF is upregulated in the myocardial tissue after the infarction • Hypothesis: Upregulation of SCF in MSCs leads to more efficient myocardial repair
Fazel S et al, AHA 2007
“Second Generation Stem Cell Products” SCF-engineered MSCs - Word of Caution?
Stem cell therapy with engineered stem cells may enhance functional effects. However, outcome may be hindered by uncontrolled effect on proliferation
and growth with risk of tumor formation if both techniques are combined in “plastic” cells.
Fazel S et al, AHA 2007
““clues” from embryonic development?clues” from embryonic development?
“Second Generation Stem Cell Products” Cardiomyogenic Specification?
Selected Cardiomyogenic Growth Factors Pretreatment
“Second Generation Stem Cell Products” Cardiomyogenic Specification?
Dog model of chronic myocardial infarction- Injection of culture expanded MSCs- Injection of modified MSCs (coctail of growth factors including
BMP2, IGF-1 and bFGF) - Follow-up up to 12 weeks including histology
Non-modified vs Modified BMSCs in a Chronic Dog MI Model
Regional LV function and Cell Retention
0
1
2
3
4
5
% DiI + myosin+ cells/mm2
ModifiedBMSCs(n=5)
Non-modifiedBMSCs(n=3)
p=0.037
Bartunek et al, AJP 2007
% LV Wall Thickening
BL 2 4 wks 8 wks 12 wksBL 110
20
30
40
50%
*
Non-modified MSC, n=4Non-modified MSC, n=4Modified MSC, n=7Modified MSC, n=7
20October 2006Confidential
Problems encountered:
• Only cytoplasmic expression, but no nuclear translocation
of cardiac markers
• “Terminal’ cardiac commitment (functional excitation-
contraction coupling) in vitro was not achieved
• Suboptimal reproducibility when treatment applied to
mesenchymal stem cells from cardiac patients
“Second Generation Stem Cell ProductsSelected Cardiomyogenic Growth Factors Pretreatment
“Second Generation Stem Cell ProductsHigh Throughput Genomic and Proteomic Technology
A. Behfar & A. Terzic
Behfar A et al , J Exp Med 2007; Arell et al Stem Cells 2008; Nelson TJ et al, Stem Cells 2008; Faustino RS et al , Genome Biol 2008; Behfar A et al, Nat Clin Pract Cardiovasc Med 2006
Candidate effectors of cardiac differentiation were Candidate effectors of cardiac differentiation were identified using the comparative proteomics and genomics identified using the comparative proteomics and genomics
on the secretome of murine visceral endoderm-like cellson the secretome of murine visceral endoderm-like cells in response to TNF-in response to TNF-αα
Behfar et al, J Exp Med 2007; Arell et al , Stem Cells 2008
“Second Generation Stem Cell ProductsHigh Throughput Genomic and Proteomic Technology
The cardiogenic coctail secured guided differentiation of mouse embyronic stem The cardiogenic coctail secured guided differentiation of mouse embyronic stem cells into cardiopoietic cellscells into cardiopoietic cells
Mouse ESCs Guided mouse ESCs
Cardiogenic Cocktail
Behfar et al, 2007, J Exp Med 204: 405-420
“Second Generation Stem Cell ProductsHigh Throughput Genomic and Proteomic Technology
Guided cardiopoietic BM mesenchymal stem cellsGuided cardiopoietic BM mesenchymal stem cells: : - upregulation and nuclear translocation of cardiac transcription factors, upregulation and nuclear translocation of cardiac transcription factors, - sarcomeric organization and expression of the gap junction protein connexin 43sarcomeric organization and expression of the gap junction protein connexin 43- rhythmic calcium transients. rhythmic calcium transients.
“Second Generation Stem Cell ProductsCardiogenic Coctail in Adult BM-MSCs from Cardiac Patients
Behfar & Terizc, personnal communication
“Second Generation Stem Cell ProductsGuided Cardiopoietic BM-MSCs in the Mice Model of the Chronic MI
Guided cardiopoietic BM mesenchymal stem cells:Guided cardiopoietic BM mesenchymal stem cells: - superior effects on functional improvement in the chronically infarcted myocardium superior effects on functional improvement in the chronically infarcted myocardium as compared to nonmodified MSCsas compared to nonmodified MSCs- paralleled by the superior effects on neovascularization and cardiac differentiationparalleled by the superior effects on neovascularization and cardiac differentiation- no toxicity observedno toxicity observed Behfar & Terzic, personnal communication
Cardio³ BioSciences C-Cure™ I Clinical TrialProtocol Number: C3BS-C-07-02
EudraCT Number: 2007-007699-40
Sponsor: Cardio3 Biosciences, Braine L’alleud, Belgium
Goal:
To test the safety and efficacy of guided, autologous bone marrow-derived cardiopoietic mesenchymal stem cells
in ischemic cardiomyopathy
Stage B(n = 195)
Stage A(n = 45)
• A multicenter, prospective, open-label, sequential design with 2 parallel arms• Blinded core lab analyses• 2:1 randomization
Guided cellsn = 30
Control groupn = 15
Guided cellsn =130
Ischemic Heart Failure
2
1
~12 sites ~ 25-30 sites
Control groupn = 65
Cardio³ BioSciences C-Cure™ I Clinical Trial
Primary and Secondary Endpoints
Baseline 1-mo 3-mo 6-mo 9-mo 1-yr 18-mo 2-yrs
LVEF (Muga)LVEF (Muga) LVEF and volumes (Echo)
6-min walking distance Quality of Life Humoral Markers Spiroergometry Clinical events Arrhythmias Resource utilization
Major inclusion criteria
• Patient has history of previous myocardial infarction
• Patient on optimal and stable medical management
(state-of-the-art treatment conform the guidelines)
• Patient has congestive heart failure
NYHA class II or III and LV ejection fraction ≥ 15% and ≤ 40%
Treatment Procedure
• All patients (Phase A) will receive an ICD
• All patients under optimal medical management (CRT allowed if implanted > 6 months before randomization)
• Mesenchymal stem cells culture expanded and treated with the cardiogenic coctail
• Cardiomyogenic specification confirmed by the presence of the cardiac specific markers according to the release criteria
• NOGA-guided cells injection into the dysfunctional and viable myocardium
Trial Management
• Prinicipal Investigators: J. Bartunek, A. Terzic
• Steering Committee: J. Bartunek, A. Terzic, W. Wijns, M. Tendera, S. Henry
• Clinical Event Committee: W. Shen, M. Bertrand, G. Breithardt, H. Klein
• DSMB: S. Waldman, D. Meldrum, J. Thijssen
• Trial monitoring: Cardio3Biosciences, Belgium
• Independent core lab analyses: MUGA, Echocardiography, ECG/ICD
Trial Sites/Investigators – Phase A
Country Site Local PI MEC Status Regulatory Status/Country
Belgium Liege V.Legrand Approved Revision Pending
UZ Antwerpen C. Vrints Submitted
Genk M. Vrolix Submitted
Aalst M. Vanderheyden Approved
Germany Munchen W. Franz Submitted Submitted
Hamburg K-H. Kuck Submitted
Aachen R. Hoffmann Submitted
Switzerland Zurich F. Eberli Approved Submitted
Lugano T. Moccetti Submitted
Lausanne E. Eeckhout Planned
Netherlands Maastricht J. Waltenberger Submitted Planned 05/08
India Ahmedabad K. Parikh Planned Planned 05/08
Interplay between BM and heart after injury Multipotency of BM stem cells Variety of stem cell types Promising functional effects on cardiac repair in experimental setting
Limited effects of naive stem cells Fate of cells: survival, transdifferentiation and integration Optimal cell type? Mechanism? Timing? Delivery? Homing? What Patient?
“New age” in cardiac interventions: “The” fundamental solution for the myocyte loss Heart failure treatment and prevention
“Hype” effect Large scale randomized trials could be negative Intellectual conflict of interest Unforeseen safety problems Proliferation of uncontrolled small trials
Adult Stem Cells Therapy SWOT 2008
Cardiovascular Center, Aalst
Jozef Bartunek*, Marc Vanderheyden, William Wijns, Guy Heyndrickx,
King’s College London, UK
Jonathan Hill
Mayo Clinic, Rochester, MN
Andre Terzic
Atta Behfar
Cardio3 Biosciences, Brussel
Vincienne Gaussin
Sophie Henry
Christian Homsy
Aurrore de Lavareille
Naima Mazouz
Phillipe Willemsen
*Biomedical Engineering, TU Eindhoven, NL Birgit Faber Carlijn Van Bouten Anthal Smits Mark Post
ULB Brussels, Belgium Kathleen McEntee Myreille Mathieu
University of Gent, Belgium Bart Vandekerkhove Frank Timmermans
Ike W. Lee