Stamceltechnologie:
Mythe of Realiteit
Dr C. Dubois, Prof. S. Janssens
Afdeling Cardiologie
UZ-Gasthuisberg Leuven
Emeritiforum KULeuven, 26 april 2007
Cardiale Regeneration in 2007:
“the stem cell approach”
Infarct size
40 years later:
VALIANT study
(14,703 post-MI pts with
reduced EF or CHF )
(% LV mass)
60
50
40
30
20
48%
-1 y mortality: 13%
28%
- 1 y death, reMI, rehosp CHF: 26%
10
0
Shock, Death
CHF
Pfeffer et al . NEJM 2003
Caulfield et al . Circ 1976
Full Regeneration of
Myocardium in Zebrafish
Poss et al., Science 2002;298; 2188
Cardiac Regeneration in 2007:
the (stem) cell paradox?
Different cell types with uniform benefit on cardiac function:
- skeletal myoblasts (1998-2001)
- fibroblasts (2000)
- smooth muscle cells (2003)
- endothelial progenitor cells (2001)
- mesenchymal stem cells (2005)
- hematopoietic stem cells (2001-04)
- other BM-derived cells (2005)
- cardiac progenitor cells (2005)
- ES cell-derived CMC (2005)
……….
Cell Therapie voor AMI in 2007?
1. Lessen uit 4 RCT in 2006 met mononucleaire BM
cellen en 6 RCT met mobilisatie strategieën?
Is cardiale regeneratieve geneeskunde mogelijk?
2. Toekomstperspectieven?
Trial design: welke patiëntenpopulatie - eindpunten?
Endothelial
Hematopoietic SCs
Progenitor Cells Mesenchymal SCs
Hemangioblasts
SP cells
MAPC
Acuut MI
Sca-1+ cells
Myoblasts
SP cells
Mesenchymal SCs
SPcells
PLURIPOTENT
Chronisch MI:
MAGIC phase II
Stabiele Ischemie
Sca-1+ cells
c-Kit + cells
SP cells
Cel Types voor Cardiaal Herstel
(adapted from Dimmeler et al. , JCI 2005)
Sca-1+ cells
c-Kit + cells
SP cells
Cardiospheres
Future for Cardiac Resident (Stem) Cells?
Spontaneous Mobilization and
Homing in Acute - Chronic Ischemia
VEGF, FGF2
SDF-1, IL-8,….
G-CSF
Mobilization:
• CD34+/CxCR4+/CD117+, c-met+
?
(Wojakowski, Circ 2004)
• CD133+ (Ott, EHJ 2006)
• CD34+ (Crea, EHJ 2005)
• Mes SC (Kastrup, EHJ 2006)
• EPC (Shintani, Circ 2001, George EHJ 2004,
Massa, Blood 2005….)
………….
G-CSF RCT Trials in
Acuut Myocard Infarct
1.
2.
3.
4.
5.
Kuethe et al. (Am Heart J 2005;150:115)
Ince et al. (FIRSTLINE-AMI, Circ 2005;112: 3097)
Valgimigli et al. (Eur Heart J 2005;26:1838)
Ripa et al. (STEMMI, Circ 2006;113:1983)
Zohlnhofer et al. (Revival 2, JAMA 2006;295:1003)
----> geruststellend veiligheidsprofiel
-----> niet superieur tov placebo voor herstel LV functie
-----> timing, dosis, directe versus indirecte cellulaire effecten?
BOOST: LV-Ejection Fraction after 6 and 18 Months
Controls
0.7%
2.4%
BMC-Transfer
6.7%
-0.8%
(Circulation 2006;113:1287-94)
UZ-Leuven Ervaring met BMC
Transfer na AMI: design (2001)
1. Patiëntenpopulatie en Design van de Studie?
2. Cel product?
3. Timing voor Cel Transfer?
4. Primair eindpunt?
Can BMSC Transfer Improve LV Recovery
after Acute Myocardial Infarction?
AMI
+ documented LV dysfunction post PCI
•
•
•
•
Informed consent
TTE
Acetate-PET scan
Bone marrow aspiration
+ randomization
24 hours
BMSC or placebo transfer in open IRA
-
Admission (7 d)
cine MRI - LE
Echo / TDI
Follow-up (4 mo)
- cine MRI - LE
- Acetate-PET scan
- Echo / TDI
Follow-up (1 y)
- cine MRI - LE
- Echo TDI
Bone Marrow Cell Transfer Post-AMI
(randomized controlled trials 2006)
ASTAMI (n=87)
REPAIR-AMI (n=187)
Leuven AMI (n=67)
(Lancet 2006; 367:113-121)
(NEJM 2006; 355:1199-1221)
LVEF - MRI (%)
LVEF - angio (%)
LVEF - MRI (%)
54
58
52
57
52
51
50
56
50
49
55
48
48
47
46
54
53
46
44
45
44
4-mo
4-mo
CON
+ 2.2%
4-mo
4-mo
42
BMSC
+ 3.4%
 = +1.2%
(P=NS)
52
6-mo
6-mo
51
CON
+ 3.0%
BMSC
+ 5.5%
 = +2.5%
(P<0.05)
CON
BMSC
+ 4.2%
+ 1.2%
 = -3%
(P=NS)
Bone Marrow Cell Transfer Post-AMI
Does infarct size matter?
Change EF
(%)
P=0.002
20
Plac
BMC
P=0.81
10
0
-10
-20
(52)
(41)
Baseline EF <48.9%
(40)
(54)
Baseline EF >48.9%
NEJM 2006; 355:1210-21
Bone Marrow Cell Transfer Post-AMI
Does timing matter?
(n=36)
LV-EF
(%)
 LV-EF
(%)
20
46 (8)
P=NS
3-4 d
10
47 (9)
4 mo
LV-EDV
(mL)
0
-10
-20
162 (33)
>4 d
P=0.014
<4 d
Time after PCI (days)
175 (43)
3-4 d
4 mo
MRI and TDI Analysis Post-AMI:
Infarct Transmurality & Segmental Contraction
LV
?
?
Coronary
occlusion
20 min.
60 min.
3hrs.
Reperfusion
Reversible injury
Irreversible injury
Paracrine or autocrine effects
of transferred cells?
>3-6hrs.
BMSC Treatment Effect* on Infarct Size
Infarct size 30
(g)
28% treatment effect*
P=0.036
BASELINE
4 Months
25
20
**
15
**
10
5
0
CONTROL
BMSC
* Expressed as ratio’s of adjusted squares means (ANCOVA) with 95% CI.
Lancet 2006; 367:113-121
BMSC Treatment Effect* on Infarct Size
28% treatment effect*
Infarct size 30
(g)
P=0.036
23%
25
20
**
15
**
10
5
0
CONTROL
BMSC
* Expressed as ratio’s of adjusted squares means (ANCOVA) with 95% CI.
BASELINE
4 Months
1 Year
Regional Function Analysis
TDI: End-systolic Strain
Time Profile
ES Strain
(%)
Control
Infarcted segments
BMSC
(n=232)
-20
*
-15
*
-10
Treatment Effect
* p < 0.001
-5
0
Baseline
5d
2 mo
4 mo
1 yr
Adverse Events during 1-year Follow-up
BMSC Tx
(n=31)
Control group
(n=34)
-
1
1 (ICD)
1 (suicide)
1
1
Recurrent ischemia, PCI
Congestive Heart Failure
2
-
4
1
Others: depression
PAD (claudication)
1
1
1
-
Ventricular tachycardia (Holter)
Life threatening arrhythmia’s
Death
Myocardial reinfarction
Kaplan-Meier event-free
survival analysis
Schachinger, V. et al.
Eur Heart J 2006 27:2775-2783
Conclusies
• IC transfer van autologe BMSCs is veilig en leidt niet tot laattijdige
significante nevenwerkingen.
• Na tijdige reperfusie van een myocardinfarct met een matige graad
van ventrikel schade hebben BMSCs variabele effecten op herstel
van globale LV functie, doch verbeteren ze op significante wijze de
regionale functie (waar schade is opgetreden).
• De uitdaging voor de toekomst bestaat erin om na te gaan hoe de
geobserveerde paracriene effecten van BMSC kunnen vertaald
worden tot een klinische meerwaarde voor AMI patienten met een
ernstigere initiele linker ventrikel beschadiging.
Toekomstperspectieven:
Optimaliseren van Stam Cel Transfer?
• Grote, multicenter studie in ernstig AMI - klinisch eindpunt
- Centraal hematologie core faciltieit
- SOPs cel bereiding
- Q-control, financiele ondersteuning,….
• Gefocuseerde klinische studies en parallele preklinische
studies
- Boost 2
- NL interuniversity study - Poland (cell comparison)
- Leuven/Frankfurt meta-analysis
- Leuven homing studies
Sca-1+ cells
Myoblasts
SP cells
Ischemic
Cardiomyopathy
(EF<35%)
MAGIC phase II
Cell Sources for Cardiac Repair
(adapted from Dimmeler et al. , JCI 2005)
MAGIC Phase 1 Study
To assess the feasibility and safety of
autologous skeletal myoblasts in pts with
ischemic heart failure.
Single center (F): n=10
Suggestion of efficacy (EF, NYHA, WMSI)
Cave: arrhythmogenicity
MAGIC Phase 2: Studie Procedures
10 g
Biopsie
GMP Cell Processing
Cel suspensie
The MAGIC Trial
End Points
Safety
- MACE : All deaths, MI, congestive HF, resuscitated sudden death
& stroke
- Ventricular arrhythmias (ICD implanted in all patients before
hospital discharge)
Efficacy
- Primary : Recovery of contractility of previously akinetic
segments & change from baseline to month 6 in LVEF as assessed
by echocardiography (Core Labs) ± MUGA
- Secondary : LV volumes
Skeletal Myoblast Transplantation
• Total of 30-35 injections
• Injections in a grid with
 5 mm between injections
•  equally divide in scar and
in peri-infarct zone
• Injection volume 200 uL from
1 mL syringe
• Total injection volume 6 mL
• Total injection time: 15-20 min
Infarct Zone
(Scar)
X X X X X
X X X X X
X X X X X
X X X X X
X X X X X
Peri-Infarct
Zone
Summary of Time to First MACE
High dose group
Low dose group
Placebo group
100
MACE-free survival (%)
90
80
70
60
6 months
40
High dose vs placebo
p = 0.12
p = 0.87
30
Low dose vs placebo
p = 0.43
p = 0.09
20
# at risk
30 days
50
0
30
33
34
1
24
29
32
6
24
20
27
12
20
14
20
18
16
5
17
Months from CABG
24
3
3
8
12
Summary of Time to First Ventricular Arrhythmia
High dose group
Low dose group
Placebo group
# at risk Ventricular arrhythmia-free surv ival (%)
100
90
80
70
60
30 days
6 months
50
40
30
20
0
30
33
34
1
25
27
33
High dose vs placebo
p = 0.30
p = 0.12
Low dose vs placebo
p = 0.20
p = 0.23
6
22
24
31
12
19
18
21
18
16
7
14
Months from CABG
Death treated as censored event
24
5
5
6
13
The MAGIC Trial
Regional Wall Motion
Patients with Qualitative Echo Data at Baseline
and Month 6
High dose
Number of patients
26
Low dose
Placebo
28
31
Recovery in at least one segment
Yes (%)
12 (46)
No (%)
14 (54)
13 (46)
15 (54)
18 (58)
13 (42)
Recovery in at least two segments
Yes (%)
8 (31)
No (%)
18 (69)
10 (36)
18 (64)
12 (39)
19 (61)
LV End-Diastolic Volume
mL
30
p=0.006
20
p=0.62
EDV absolute change
10
0
-10
-20
n=26
-23.0
(-42.0;0.0)
n=27
-9.0
(-33.0;25.0)
n=30
+9.0
(-21.0;28.0)
Low dose
Placebo
-30
-40
-50
High dose
Data are given as median (interquartile range)
Sca-1+ cells
60,000 - 100,000
150
Isotype control
Sca-1+ cells
c-Kit + cells
SP cells
Cardiospheres
Sca-1
0 0
10
1
2
3
10
10
Total10 %Sca-1+
pos isotype PE
3500 89.97
Future for Cardiac Resident (Stem) Cells?
4
10
Regenerative Potential of Biopsy-derived Human Cardiospheres
Smith, R. R. et al. Circulation 2007;115:896-908
Cel Therapie voor Ischemische
Dysfunctie in 2007: Droom of Realiteit?
• Isolatie, amplificatie en intramyocardiale administratie van
Sca-1 positieve CSC (muis) en c-kit positieve CSC (rat, varken)
en humane cardiospheren (RV biopsie)
• Intramyocardiale administratie van CSCs in geinfarceerd myocard
verbetert regionale systolische functie (TTE)
• First in men (veiligheid, haalbaarheid per CABG): Q3 2007 (US)
Stamcelbehandeling:
Fontein van de Eeuwige Jeugd?
Lucas Cranach (olie op canvas 1546)
Acknowledgments
Gasthuisberg University Hospital & CTG, VIB-3
University of Leuven, Belgium
- Departments of Cardiology, Hematology, Radiology, Nuclear
Medicine, Radiopharmacy, Biostatistics
- Leuven Coordinating Center (LCC)
- Referring Cardiology Sites