Cell Transplantation for the failing myocardium: A UK perspective Tony Gershlick U.H. Leicester BCIS meeting Bristol Sept 2005 Therapy for AMI – • Lysis v PPC • Impact of time/treatment Heart failure -strategies- Medical treatment Biventricular pacing 1 million UK heart failure 5% all admissions 1-2% health budget Surgical cardiomyoplasty Left ventricular assist device Artificial hearts Heart transplantation Cell transplantation ? Stem cells for myocardial dysfunction Questions that (should) concern us in the UK Question 1 Is the science sound ? Endothelial progenitor cells Intra myocardial primitive satellite cells Primative BM stem cells Skeletal muscle satellite cells Volume 50(5): 589–610, 2002 The Journal of Histochemistry & Cytochemistry Bone marrow transplantation –plenty of pre-clinical data Transplanted adult bone marrow cells repair myocardial infarcts in mice. Orlic D, Kajstura J, Chimenti S, Bodine DM, Leri A, Anversa P. The left coronary artery was ligated and 5 hours later Lin- c-kit+ bone marrow cells obtained from transgenic male mice expressing enhanced green fluorescent protein - injected into the healthy myocardium adjacent to the site of the infarct. 9 days the damaged hearts were examined for regenerating myocardium. A band of new myocardium was observed in 12 surviving mice. The developing myocytes were small and resembled fetal and neonatal myocytes. - positive for EGFP, Y chromosome, and several myocyte-specific proteins including cardiac myosin, and the transcription factors GATA-4, MEF2, and Csx/Nkx2.5. The cells were also positive for connexin 43, acells gap junction/intercalated disc component Primative BM stem Primitive cardiomyogenic cells from bone marrow Clin Invest, March 1999, Volume 103, Number 5, 697-70 Shinji Makino1, ball-like or stick-like appearance spontaneously beating Fibroblast like 5-azacytidine 2/52 form myotube-like structures beating cells were connected and formed myotube-like structures Peripheral blood mononuclear cells Endothelial progenitor cells 1. Heamopoietic markers CD 34 + CD 133 + 2. Endothelial markers EGF -2 A EPC transdifferentiate in-vitro into cardiomyocytes Intracellular gap junctional coupling between rat cardiomyocytes and human EPCs was demonstrated Badorff et al, Circulation 2003;107:1024-1032 B Human EPCs transplanted into rat infarct model day 7 Therapeutic Potential of Ex Vivo Expanded Endothelial Progenitor Cells for Myocardial Ischemia Atsuhiko Kawamoto Circulation. 2001;103:634 Angiogenic potential / neo-vascularisation Myoblasts are satellite cells and exist in a quiescent state. They have built in resistance to ischemia Vol ume 50(5): 589–610, 2002 The Journal of Histochemistry & Cytochemistry Myotubes with prominent normal Z bands in myofilaments and peripheral multiple nuclei in myotubes grafted skeletal myotubes replacing scar fibrosis Myoblast grafts can survive and show a switch to slowtwitch fibres . Do not become myocytes Hagege et al, Lancet 2003;361:491-92 Science :Good In-vitro, ex-vivo, animal data for BMC, EPC , Myoblast all have potential Which will be clinically applicable ? What is actually happening ? Autologous bone marrow cells Circulating progenitor cells Ischaemia (AMI) Skeletal myoblasts Chronic Heart Failure Manipulation of in-vivo cells Questions that (should) concern us in the UK Is the basic science sound Are the trials of sufficient quality to provide the answers to the questions being asked ? Are the trials relevant to our current practice ? MNC MNC v CPC MNC MNC Circulation, December 10, 2002 •20 patients with reperfused acute myocardial infarction received bone marrow-derived stem cells (n=9) CPC (n=11)250mls •Non-randomized matched reference group •Trial end-point: LVEF assessed by Echo and PET-Scan @ 4 months follow-up and at one year TOPCARE-AMI LVEF 51.3% 8.2% 59.5% Would they have got better 2 nd to PCI anyway? Improved myocardial viability in the stem cells group The Lancet, July 10, 2004 •First randomized clinical trial •after successful percutaneous coronary intervention (PCI): 30 patients control group, 30 patients bone-marrow cell group •Primary endpoint: global left-ventricular ejection fraction (LVEF) change from baseline to 6 months’ follow-up, determined by cardiac MRI BOOST Mean in-stent restenosis in the infarct-related artery, expressed as a percentage of luminal diameter, was 32% (SD 20) in the control group and 33% (23) in the bone-marrow-cell group (p=0·88). Four patients from the control group and seven from the bonemarrow-cell group presented with an in-stent restenosis of at least 50% (p=0·28). Problems with the acute ischaemic trials Unanswered clinical trial questions Trials don’t tell us which cells Variable numbers of cells transplanted – both CPC and BMC 3-5% : (Stem cell selection~ 200 mls BM) Retention 3% Benefit did not correlate with absolute numbers of CD 34 cells Unselected and selected cell populations not compared No dose ranging studies Timing ? Early environment cyto-toxic 3- 7 days Engraftment ? longer Problems with the acute clinical trials No clear messages re type cells, nos. and delivery All P PCI Small number subjects -pilot studies (Mortality/ morbidity end point “REPAIR AMI” AHA (1000 s patients) No adequate controls (Bone marrow acquisition?, coronary manipulation ?) Mode of Delivery EF increases small Who is likely to benefit ? BOOST Appropriate trials ? Who most likely to benefit ? Cell type ? o Which of these questions can be answered ? o What is the UK involvement o Can we add to the Clinical science? UK Centres Involved in Stem Cell Therapy UHL/ St Barts/ The London Anthony Mather Martin Rothman John Martin Eric Alton Kings College Hospital Jonathan Hill AJ Shah St Marys/ Brompton Nic Peters Philip Poole-wilson UH Leicester Jan Kovac Manual Galinanes Nilesh Samani Tony Gershlick Single Centre Trial @ UHL Failure of thrombolysis Successful R-PCI Echo d 3 EF < 45% Baseline MRI SC or Heparinised plasma d 4-5 P EP 4 mo MRI Poor LV Setting lysis + RESCUE-PCI Late phase Clinical ‘stem cell’ trials - Barts and the London NHS Trust/UCLH • Randomised control trials using autologous bone marrow derived mononuclear cells in patients with: – Heart failure 2o IHD - commenced 8/05 - 300 patients – Dilated cardiomyopathy - recruiting - 200 patients – AMI tx with primary angioplasty - funding sort - 200 patients • PIs: A Mathur, M Rothman, J Martin Which of these questions can be answered, What is the UK involvement Appropriate trials ? Who most likely to benefit ? Cell type ? Muscular Biopsy •Myoblast cells liberated through Enzymatic Digestion intercellular matrices Alternative Therapies For the Treatment of Ischemic Cardiomyopathy 40% LVEF/NYHA IMPROVEMENT AT SIX MONTHS 35% LVEF % Change 30% NYHA 37% 25% 20% 15% 10% 24% 25% 14% 5% 0% Bi-V Pacing MyoCell Bi-V Pacing MyoCell Journal of the American College of Cardiology, Vol. 42, No. 12, 2003, Smits, Serruys et al. Patient Study. Study sponsored by Bioheart, Inc. 3 month, P=0.009, n=5; 6 month, P= 0.23, n=5. SAFETY: Multi center phase 1 trial 6 pts No ICD at Baseline #102: VT at 1mfup; resolved #201: NSVT 3.5mfup; ICD implanted 15 pts enrolled 3 pts event free 9 pts with ICD in place 5 pts event free #105: arrhythmias at 2mfup: ICD pacing #107: tachycardia during 6min-walk: firing ICD #204: NSVT/VT 1 week post proc. Slow VT, Elec storm: firing ICD; patient died #4003:died 9 days post proc #207: slow VTs 1 week post proc: manual termination Bioheart Percutaneously Delivered Myoblasts EU Phase II Trial (SEISMIC™) Screening: 46 ICD patients Baseline Evaluation Visit 1 (Week -6) ICD EF > 20% < 40 % 8 European Centres 3 UK : Glenfield, (AHG,JK) Leicester St Marys (Nic Peters) Royal Brompton (Philip Poole-Wilson Randomization : ICD patients: 30 MyoCell ™, 16 Standard medical therapy Treatment Arm (Myocell TM 150-800 x 10 6) Control Arm (Standard Medical Therapy) 30 ICD patients - 16 ICD patients Enrollment Began June 2005. SEISMIC Safety Endpoints Primary: – Defined Serious Adverse Events (SAEs) Secondary: – – – – Routine Clinical laboratory test results Holter monitoring, 12-lead ECG data Overall patient survival Assessment of the safety of the use of the MyoCath™, by Adverse Event assessment SEISMIC Efficacy Endpoints Primary: – Change in LVEF at 3 and 6 months by MUGA compared with baseline Secondary: – QOL Assessments (6-min. walk, NYHA class) – Hospitalization, readmissions or the need for medical treatment outside of hospitalizations – Echocardiography (global contractility, wall thickness and coronary perfusion improvements) ? UK Infra structure British Collaborative on Stem Cell Research and the Heart Objective: To form a collaborative group of basic scientists and clinicians involved in research in stem cells and the heart, in order to perform joint research. • Four meetings held in UCL, average attendance 50 people. • Three groups formed: stem cells and vectors animal models clinical trials British Collaborative on Stem Cell Research and the Heart • A “writing group” has met to define what clinical and basic research needs to be done. Joint grants will be applied for. A document will be circulated shortly. • The clinical group will peer review protocols with an emphasis on safety and necessity of studies. • The group has a close connection to the European Society of Cardiology Task Force on Stem Cells and the Heart General Summary and Conclusions Too soon to draw any conclusions Studies small, all PPCI, ? Safety concerns (restenosis) Promising Bone-marrow stem cell Post AMI patient Advantages •Pluripotent stem cells can develop into cardiomyocytes •Easy to isolate and grow well in culture Limitations •New program of cell differentiation program is required •Efficiency of differentiation into adult cardiomyocytes may be limited •Some studies difficult to replicate •Neovascularization can also occur at the site of the scar •Small trials •Can improve myocardial function •UK PPCI makes applicability difficult •LV improves anyway Trials to date uncontrolled small numbers un-blinded Skeletal myoblasts Chronic HF AMI patient Advantages •Cells proliferate in vitro •Ischemia resistant •Transplanted cells can differentiate into slow-twitch myocytes, enabling cellular cardiomyoplasty •Reduce dilatation and improve cardiac function •Can use adult cells Limitations •Likely do not develop new cardiomyocytes in vivo •Electrical coupling to surrounding myocardial cells is probable but not definite •Long-term stability of differentiated phenotype is unknown •Arrhythmic potential Transplantation of progenitor Cells AMI patients •Intracoronary infusions are safe and feasible •Increase in global LVEF •Improvement in wall motion abnormalities •Reduction in LVESV •Complete normalization of CFR(< so in BMC) •Increases in myocardial viability May need cytokines like G–CSF and this may be a problem Stem Cell Tx appears to “work” Issues and questions 1 How long will the transplanted cells survive? Can they be safely delivered PCI/endocardially Are they able to integrate? Modified ? Do they have the ability to differentiate? Will the cell transplant influence LV function? Can we augment/enhance grafting, proliferation and function of stem cell implants? Is it safe ? Issues and questions 2 How many cells do we need to transplant? Which is the best way for delivery? Should the donor cell chosen depend on the cause of heart failure/ ventricular dysfunction ? Which is the optimal time for cell transplantation? What trials are needed to provide definitive answers ? UK is involved, central organisation, ▓ Funding, Regulatory bodies (MHRA,COREC) collaboration, need for multi discipline are all challenges Cell transplantation is an exciting development Many questions “EPC > Bone marrow > myoblasts “ NEED SUFFICIENTLY POWERED RANDOMISED CONTROLLED TRIALS 1. True quantity of effect 2. That it is the SCT that is having any effect 3. Safe Something (UK) interventional cardiologists need to be involved in Watch this space - new era for interventional cardiology The Future of Stem Cells and the Heart Need for double blind randomised trials in myocardial infarction and heart failure of autologous bone marrow cells. These should be agreed nationally to avoid duplication. The procedure should not be given as a treatment to individual patients before results of above trials. A second wave of trials will follow using other sources of cells, particular engineered. UK Stem Cell Foundation