improvement of cardiac function by intracoronary … j. (2011).pdfmailing address: ramazan gökmen...

Circulation Journal Vol.75, March 2011

Circulation JournalOfficial Journal of the Japanese Circulation Societyhttp://www.j-circ.or.jp

espite widespread use of primary percutaneous coro-nary intervention for prompt reperfusion of the infarcted myocardium, acute myocardial infarction

(AMI) is a major cause of chronic heart failure (HF). HF is a leading public health problem resulting in increased risk of cardiovascular complications and mortality. Despite advances in medical therapy, the prevalence of HF is still increasing. Conventional medical strategies as well as an increase of chronic rejection after heart transplantation1,2 for the treat-ment of HF due to myocardial infarction (MI) do not attempt to correct the underlying cause (ie, loss of viable or func-tional myocardial tissue), raising a need for strategies aimed at myocardial regeneration and repair.3,4 Autologous bone marrow cell transplantation (BMCs-Tx) is a promising novel option for treatment of cardiovascular disease.5 In animal models, bone marrow-derived stem/progenitor cell infusion improves cardiac function and neovascularization after MI.6–13 Additionally, recent clinical studies provide further

evidence for a promising improvement of cardiac function after intracoronary infusion of BMCs in patients with AMI.14–19 However, it is unknown whether freshly isolated BMCs transplantation have beneficial affects postinfarction remodeling. In this prospective nonrandomized control trial, we analyzed the influence of intracoronary freshly isolated cell therapy by use of point of care system on cardiac function in patients with AMI.

Editorial p 546

MethodsPatients’ CharacteristicsIn a prospective nonrandomized controlled trial, 32 patients between 18 and 80 years of age were eligible for inclusion in this study if they had had an acute ST-elevation MI on the

Received August 17, 2010; revised manuscript received October 10, 2010; accepted November 8, 2010; released online January 24, 2011 Time for primary review: 20 days

Department of Internal Medicine, Division of Cardiology, Rostock-University, Rostock (R.G.T., I.B.-T., J.O., I.A., S.K., H.S., T.C.R., C.H.T., M.R., T.K., T.C., C.A.N., H.I.); Institute for Clinical Research and Statistics, Cologne (K.S.), Germany

Mailing address: Ramazan Gökmen Turan, MD, Department of Internal Medicine, Division of Cardiology, Rostock-University, Ernst Hydemann Str 6, 18055 Rostock, Germany. E-mail: [email protected]

ISSN-1346-9843 doi: 10.1253/circj.CJ-10-0817All rights are reserved to the Japanese Circulation Society. For permissions, please e-mail: [email protected]

Improvement of Cardiac Function by Intracoronary Freshly Isolated Bone Marrow Cells Transplantation in Patients

With Acute Myocardial InfarctionRamazan Gökmen Turan, MD; Ilkay Bozdag-Turan, MD; Jasmin Ortak, MD;

Ibrahim Akin, MD; Stephan Kische, MD; Henrik Schneider, MD; Tim Christopher Rehders, MD; Cem Hakan Turan, MD; Mathias Rauchhaus, MD; Tilo Kleinfeldt, MD; Tuschar Chatterjee, MD;

Kurtulus Sahin, PhD; Christoph A. Nienaber, MD; Hüseyin Ince, MD

Background: We analyzed in the present study the influence of intracoronary autologous freshly isolated bone marrow cells transplantation (BMCs-Tx) on cardiac function in patients with acute myocardial infarction (AMI).

Methods and Results: The 32 patients with AMI were enrolled in this prospective nonrandomized study to either freshly isolated BMC-Tx or to a control group without cell therapy. Global left ventricular ejection fraction (LVEF) and the size of infarct area were determined by left ventriculography. We observed in patients with autolo-gous freshly isolated BMCs-Tx at 6 months follow up a significant reduction of infarct size as compared to control group. Moreover, we found a significant increase of LVEF as well as infarct wall movement velocity at 6 months follow up in cell therapy group as compared to control group. In the control group there was no significant differ-ence of LVEF, infarct size and infarct wall movement velocity between baseline and 6 months after AMI.

Conclusions: These results demonstrate for the first time that intracoronary transplantation of autologous freshly isolated BMCs by use of a point of care system is safe, and may lead to improvement of cardiac function in patients with AMI. (Circ J 2011; 75: 683 – 691)

Key Words: Acute myocardial infarction; Freshly isolated bone marrow cell transplantation; Global left ventricu-lar ejection fraction; Infarct size

D

ORIGINAL ARTICLERegenerative Medicine


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electrocardiogram. None of the patients had a history of a previous AMI or HF. Exclusion criteria were the presence of acutely decompensated HF with a New York Heart Associa-tion (NYHA) class of IV, infectious or inflammatory disease, active bleeding, surgery or trauma within 2 months, renal or liver dysfunction, thrombocytopenia, or anemia, a severe comorbidity and alcohol or drug dependency, a history of other severe chronic diseases or cancer, or unwillingness to participate. The study conforms to the principles outlined in the Declaration of Helsinki and was approved by the local ethics committee. Written informed consent was obtained from each patient. All AMI patients were discharged with standard medication consisting of acetylsalicylic acid and clopidogrel, an angiotensin-converting enzyme inhibitor or AT-II blocker, a β-blocker and a statin.

Study ProtocolIn this prospective nonrandomized study, 32 patients with AMI were enrolled to either receive intracoronary autolo-gous freshly isolated BMCs-Tx, or to a control group with no stem cell therapy after successful coronary revascularization. All AMI patients were treated with heparin, a GIIb/IIIa antag-onist, and acetylsalicylic acid, and they underwent coronary angiography as well as left ventriculography. Coronary revascularization of the infarct-related artery was initiated by balloon angioplasty with subsequent stent implantation. The 17 patients of the intervention group underwent intracoro-nary autologous freshly isolated BMCs-Tx on day 7 after AMI, and the 15 patients of the second group served as a control group without stem cell therapy. The primary end-point of the study was the change in left ventricular ejection fraction (LVEF) as well as the size of infarcted area mea-

sured by left ventriculography after 6 months. The secondary endpoint was the functional status by NYHA classification in both groups. All data were obtained by blinded expert read-ers unaware of patient group assignment.

Coronary Angiography and Left VentriculographyAll patients in both groups underwent left heart catheteriza-tion, left ventriculography and coronary angiography. Car-diac function and infarct size were determined by left ven-triculography. Cardiac function was evaluated by LVEF and by auxotonic myocardial contractility index, evaluated by the wall movement velocity of the infarcted area. LVEF was measured with Quantcor software (Siemens, Erlangen/Germany). To quantify the size of infarct area we used the centerline method according to Sheehan et al20 by plotting 5 axes perpendicular to the long axis of the heart in the main akinetic or dyskinetic segment of ventricular wall. Systolic and diastolic lengths were then measured by 2 independent observers, and the mean difference was divided by systolic duration in seconds. The follow-up was 6 months after the treatment. All hemodynamic investigations were obtained by 2 independent observers. All data were obtained by blinded expert readers unaware of patient group assignment.

Preparation and Administrations of BMCSeven days after AMI, a total of 120 ml bone marrow was taken from the iliac crest after local anesthesia and mononu-clear cells were isolated and identified including CD34+ and CD133+. The cell suspension concentration consisted of a heterogeneous cell population including hematopoietic, mes-enchymal and other progenitor cells and processed according to manufactures instructions (using Bone Marrow Aspirate

Table 1. Baseline Clinical Characteristics of the Study Population

AMI with BMCs-Tx (n=17)

AMI without BMCs-Tx (n=15) P value

Age (years) 61±5　　 60±8　　 NS

Sex (M/F) 11/6　　 11/4　　 NS

Cardiovascular risk factors (%)

Hypertension 65 65 NS

Hyperlipidemia 65 65 NS

Smoking 90 85 NS

Diabetes 25 25 NS

Positive family history of CAD 20 20 NS

No. of diseased vessels (1/2/3) 12/5/0 10/5/0 NS

Infarct-related vessel (LAD/LCX/RCA) 11/1/5 9/0/6 NS

PTCA/stent at the time of AMI 17/17 15/15 NS

Time from symptom onset to first reperfusion therapy (h) 7±5 6±3 NS

Primary reperfusion therapy (%) 100 100 NS

Medication at discharge (%)

Aspirin 100 100 NS

Clopidogrel 100 100 NS

ACEI or AT-II blocker 100 100 NS

β-blocker 100 100 NS

Aldosterone antagonist 25 25 NS

Statin 100 100 NS

Laboratory parameters

CK U/L 2,294±530　　　 2,500±755　　　 NS

AMI, acute myocardial infarction; BMCs-Tx, bone marrow cell transplantation; NS, not significant; LAD, left anterior descending coronary artery; LCX, left circumflex artery; RCA, right coronary artery; PTCA, percutaneous transluminal coronary angioplasty; ACEI, angiotensin-converting enzyme inhibitor; CK, creatine kinase.


685Freshly Isolated BM Cells Transplantation in AMI

Concentrate BMAC™, Harvest Technologies GmbH, Munich, Germany).

After undergoing arterial puncture, all patients received 7,500–10,000 Units of heparin. Cell transplantation was per-formed via intracoronary administration21 of 4–6 fractional infusions of 3–5 ml of cell suspension. All cells were infused directly into the infarcted zone through the infarct-related artery via an angioplasty balloon catheter, which was inflated at low pressure (2–4 atm) and was located within the previ-ously stented coronary segment. This prevented back flow of cells and produced stop flow beyond the site of balloon infla-tion to facilitate high-pressure infiltration of cells into the infarcted zone with prolonged contact time for cellular migration. Six months after catheter-guided cell transplanta-tion, all functional tests were repeated, including coronary angiography and left ventriculography. There were no pro-cedural or cell-induced complications and there were no side effects in any patients.

Safety ParametersTo assess any inflammatory response and myocardial reac-tion after cell therapy, white blood cell count, and the serum levels of both C-reactive protein (CRP) and creatine kinase (CK) were determined immediately before as well as after treatment. Additional analysis was done directly after trans-plantation and 3 months later: BNP level in PB, ECG at rest, 24-h Holter ECG and echocardiography.

Statistical AnalysisQuantitative data are presented with mean ± SD and qualita-

tive data are tabulated using absolute frequencies and/or per-centages. Differences between therapy groups for qualitative variables are tested using Fisher’s-Exact-Test due to the small number of patients in each therapy group. Within differences of quantitative variables in each therapy group were com-pared using the Wilcoxon-Test for depending samples, and differences between therapy groups of quantitative variables were compared with the Wilcoxon-Test (Mann-Whitney-Test) for independent samples. Both of the nonparametric Wilcoxon-Tests are preferred due to the more likely expected non-normal distribution of the data. For all statistical tests, the result was seen as statistically significant if the corre-sponding 2-sided P-value was smaller or equal to 0.05. Sta-tistical analysis was performed with SPSS for Windows (Version 15.0). Analysis of the intra- and interobserver vari-abilities of endpoint measurements was performed using cor-relation analysis and the Spearman correlation coefficient (Statistical software package SAS Version 9.2) as well as the method of Bland-Altman assessment of agreement. More than 95% of inter- or intra-rater difference was within the “limits of agreement” defined as mean ± 2SD, if plotted against the mean differences of a patient’s individual data.22

ResultsBaseline Characteristics of the PatientsWe enrolled 32 patients with AMI after acute coronary revascularization in the study. Of these, 17 patients in the first group received autologous freshly isolated BMCs-Tx into the infarct-related coronary artery, and 15 patients in the

Table 2. Cardiac Function, Clinical Function Status Parameters at Baseline and 6 Months After AMI in the BMCs-Tx Group

Baseline 6 months after BMCs-Tx P value

LVEF (%) 42±8　　 55±8　　 <0.001

The size of infarct area (%) 34±8　　 15±10 <0.001

Infarct wall movement velocity (cm/s) 1.73±0.65 3.98±0.60 <0.001

LVEDV (ml) 130±41　　 139±54　　 NS

LVESV (ml) 75±28 62±20 <0.01　　

SVI (ml/m2) 33±10 43±11 <0.01　　

NYHA classification 2.8±0.5 1.5±0.3 <0.001

Values are mean ± SD.There were no significant differences in baseline cardiac function, clinical function status parameters between 2 groups.LVEDV, left ventricular end-diastolic volume; LVESV, left ventricular end-systolic volume; SVI, stroke volume index; NYHA, New York Heart Association. Other abbreviations see in Table 1.

Table 3. Cardiac Function, Clinical Function Status Parameters at Baseline and 6 Months After AMI in Control Group Without BMCs-Tx

Baseline 6 months after AMI P value

LVEF (%) 43±10 46±7　　 NS

The size of infarct area (%) 35±8　　 30±8　　 NS

Infarct wall movement velocity (cm/s) 1.70±0.66 2.00±1.00 NS

LVEDV (ml) 129±32　　 132±42　　 NS

LVESV (ml) 73±25 71±24 NS

SVI (ml/m2) 34±11 33±13 NS

NYHA classification 2.9±0.8 2.5±0.9 NS

Values are mean ± SD.There were no significant differences in baseline cardiac function, clinical function status parameters between 2 groups.Abbreviations see in Tables 1,2.


686 TURAN RG et al.

second group received no intracoronary BMCs transplanta-tion. There were no significant differences between the base-line characteristics and demographics of patients in both groups (Table 1).

Cellular Composition of Point of Care System From BMCsTable 4 shows the cellular composition of the bone marrow aspirate (120 ml) and bone marrow concentrate (20 ml) as well as the viability of cells by use of point of care system. The number of total nucleated cells, CD34+, CD133+ and platelet counts increased significantly post separation in the

bone marrow concentrate compared to pre-separation in the bone marrow aspirate (P<0.001).

Effect of Freshly Isolated BMCs TransplantationLeft Ventricular (LV) Function, Infarct Size and Infarct

Wall Movement Velocity LVEF, LV end-diastolic and end-systolic volumes (LVEDV, LVESV, respectively), stroke volume index (SVI), infarct size and the wall movement velocity of the infarcted area were measured by left ventric-ulography in the first group at baseline and 6 months after BMCs-Tx as well as in the second group without BMCs-Tx

Figure 1. (A,B) LVEF were measured by left ventriculography immediately before and 6 months after procedure in both groups. There were no significant baseline differences in global EF between the 2 groups. LVEF significantly increased 6 months after cell therapy as compared to the control group. Furthermore, no significant changes were observed in the control group at fol-low-up. Additionally, Panel B shows the increase of single values of LVEF after BMCs-Tx for each patient in the cell therapy group. AMI, acute myocardial infarction; BMCs-Tx, bone marrow cells transplantation; LVEF, left ventricular ejection fraction.



at baseline and 6 months after acute coronary revasculariza-tion. There were no significant baseline differences in LVEF, infarct size or infarct wall movement velocity between the 2 groups. At 6 months after cell therapy, we observed a sig-nificant increase of LVEF and infarct wall movement veloc-ity whereas there was no significant difference in the control group. Furthermore, there was a significant decrease of infarct size after 6 months. Moreover, we found a significant increase of SVI and decrease of LVESV whereas no signifi-cant change was observed in LVEDV in cell therapy group. In the control group there were no significant changes in

infarct size, LVEF, LVEDV, LVESV, SVI and wall move-ment velocity of the infarcted area 6 months after coronary angiography (Tables 2,3). Moreover, we observed that the LVEF and the wall movement velocity of the infarcted area significantly increased 6 months after cell therapy compared to control group (Figures 1,3). Infarct size significantly decreased 6 months after BMCs-Tx as compared to control group without cell therapy (Figure 2). An analysis of the intra- and inter-rater reliability of global EF (Spearman cor-relation coefficient was 0.997 for intra-rater and 0.996 for inter-rater) and the size of the infarct area (Spearman corre-

Figure 2. (A,B) Infarct size measured by left ventriculography immediately before and 6 months after procedure in both groups. There were no significant baseline differences in infarct size between the 2 groups. There was a significant decrease of infarct size 6 months after cell transplantation compared to control group without cell therapy. Moreover, no significant changes were observed in the control group at follow-up. Additionally, Panel B shows the decrease of single values of infarct size after BMCs-Tx for each patient in cell therapy group. AMI, acute myocardial infarction; BMCs-Tx, bone marrow cells transplantation.


688 TURAN RG et al.

lation coefficient was 0.998 for intra-rater and 0.990 for inter-rater) showed good agreement between 2 raters as well as between 2 different ratings of the same rater.

Functional Status and Clinical Safety Parameters To determine the functional status we assessed NYHA classifi-cation in both groups by 2 independent and blinded physi-cians. There were no significant differences of baseline NYHA classification between both groups. We observed a significant improvement in NYHA classification 6 months after intracoronary cell therapy, whereas there was no sig-

nificant difference in control group 6 months after coronary angiography (Tables 2,3). The NYHA classification signifi-cantly decreased 6 months after cell therapy compared to the control group (Figure 4). An analysis of intra- and inter-rater reliability of NYHA (Spearman correlation coefficient was 0.999 for intra-rater and 0.998 for inter-rater) showed good agreement between 2 raters as well as between 2 dif-ferent ratings of the same rater.

ECG at rest, on exercise and 24-h Holter ECG revealed no rhythm disturbances at any time point. There was no inflam-

Figure 3. (A,B) Infarct wall movement velocity were measured by left ventriculography immediately before and 6 months after procedure in both groups. There were no significant baseline differences in infarct wall movement velocity between the 2 groups. infarct wall movement velocity significantly increased 6 months after cell therapy as compared to control group. Fur-thermore, no significant changes were observed in the control group at follow-up. Additionally, Panel B shows the increase of single values of Infarct wall movement velocity after BMCs-Tx for each patient in cell therapy group. AMI, acute myocardial in-farction; BMCs-Tx, bone marrow cells transplantation.



matory response or myocardial reaction (white blood cell count, CRP, CK) after cell therapy.

DiscussionIn this prospective nonrandomized controlled study we examined the influence of autologous freshly isolated intra-coronary BMCs-Tx on the LV function in patients with AMI after 6 months.

Despite widespread use of primary percutaneous coronary intervention for prompt reperfusion of the infarcted myocar-dium, AMI is a major cause of chronic HF. The risk of chronic HF as well as mortality and morbidity are signifi-cantly increased in patients with reduced LVEF after AMI. The use of stem cell-based therapy is becoming increasingly recognized as having the potential to salvage damaged myo-cardium and to promote endogenous repair of cardiac tis-sue,23 thus having the potential for the treatment of HF. In animal models autologous infusion or injection of stem/pro-genitor cells derived from various sources was shown to enhance blood flow and neovascularization and improve heart function after MI.24,25 Moreover, clinical pilot and ran-domized studies suggested, that the intracoronary infusion of autologous BMCs is safe and feasible in patients with AMI.14–19 While initial pilot studies by Strauer et al15 and Fernandez-Avilez et al16 as well as the TOPCARE-AMI14 and BOOST17 trials reported an improvement in LVEF and improved perfusion in the infarcted area 4–6 months after cell transplantation, a randomized controlled trial by Janssens et al18 did not reveal a significant effect on LVEF, but showed an improvement in regional EF and a reduction of the infarct size in the BMC group. The beneficial effects observed in most phase I/II studies were confirmed in the so far largest double-blind, randomized multicenter REPAIR-AMI trial.19 Only one larger study, the ASTAMI trial,26 did

not show any benefit on left ventricular functional parame-ters. The reason for the failure of the ASTAMI trial to show a benefit of cell therapy may have been the different cell iso-lation and storage protocol, which significantly affected the functional capacity of the cells.27 Whereas in the REPAIR-AMI trial Ficoll gradient centrifugation was used for cell isolation, the negative clinical ASTAMI trial used a differ-ent, not yet validated, technique (LymphoPrep). Strikingly, the yield in total nucleated cells out of the same volume of 50 ml bone marrow aspirate was quite different. While the Ficoll-based protocol, which was used for the isolation pro-cedure in the REPAIR-AMI trial, provided 3-fold higher number of cells as compared to ASTAMI trial. Even more importantly, recent data also suggest that the number of hematopoietic colony-forming units and the SDF-1-induced migratory activity of recovered BMCs based on the ASTAMI protocol are significantly lower compared to the Ficoll pro-tocol.27 These data suggest that, although similar techniques were used, the functional activity and/or cellular composi-tion of the obtained cellular product were quite different. Because most of the previous clinical trials involved BMCs isolated by Ficoll,14–19 this technique is currently viewed as the gold standard. Our findings that the infarct size reduced, whereas the LVEF and regional infarct wall movement velocity increased, 6 months after intracoronary cell therapy in patients with AMI, are in line with the data of previous published pilot14–16 and randomized clinical trials.17–19 Addi-tionally, we observed improvement of the functional status (NYHA classification) 6 months after cell therapy. Cell iso-lation procedures are crucial for the functional activity of the administered cellular product. In our trial we chose to use a point of care system for the preparation of the treating cell composition. We demonstrated the same results for the first time with intracoronary freshly isolated BMCs-Tx using a point of care system with Harvest BMAC-system for the

Figure 4. NYHA classification in both groups. There were no significant differences of baseline NYHA classification between the 2 groups. At 6 months after cell therapy there were a significant decrease of NYHA classification compared to control group without cell therapy. Moreover, no significant changes were observed in the control group at follow up. BMCs-Tx, bone marrow cells transplantation; NYHA, New York Heart Association.


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preparation of the treating cell composition, unlike many previously conducted trials that employed Ficoll gradient separation as the method of cell collection, which produces a very limited cell linage spectrum. Harvest BMAC system is a point of care system for the concentration of BMCs. The cellular composition of the concentrate, which was prepared by the Harvest BMAC system, differs from that prepared using the Ficoll method. The Ficoll composition contains predominantly mononuclear cells (lymphocytes, erythro-blasts and monocytes) and very few granulocytes. The Har-vest BMAC system concentrates the entire nucleated cell population with mononuclear cells and specific stem cell populations (CD34+ and CD133+) from the marrow aspirate as well as the platelets (Table 4). Importantly, however, the Harvest device provided an advantage of producing a sig-nificantly higher yield of isolated BMCs compared to the Ficoll protocol. Thus, if the number of infused cells in the in vivo neovascularization model was adjusted for this higher yield of BMCs, the treatment effect was significantly greater compared to Ficoll BMCs, as assessed by limb perfusion measurement.28 One obvious difference in the 2 compositions is the presence of significant numbers of granulocytes and platelets in the Harvest BMAC composition. Platelets and granulocytes have been shown to have a positive effect on the neovascular potential of the resulting concentrate. The pres-ence of platelets within the composition could be important because it has been shown that these platelet-derived media-tors also potently enhance postnatal angiogenesis. Iba et al demonstrated that implantation of mononuclear cells together with platelets into ischemic limbs more effectively augments collateral vessel formation by supplying various angiogenic factors, in which VEGF played a key role.29 Indeed, Massberg et al provided compelling evidence that platelets generate the critical signal that recruits CD34+ BMCs and c-Kit+ Sca-1+ Lin- bone marrow-derived progenitor cells to sites of injury.30 Therefore, these findings strongly support the notion that implanted platelets play a pivotal role in stem and progenitor recruitment, and provide a rationale for the fact that Harvest BMAC produced functional in vivo results similar to or better than Ficoll. In our study, despite higher number of platelets, we observed no immediate periprocedural or post-procedural adverse complications. In addition, unlike Ficoll isolation where cells are resuspended in a serum free medium, Harvest BMAC is always resuspended in the patient’s own plasma. Thus, the isolated cells are not removed from their natural plasma microenvironment, which may be help to sustain the functionality of the cells. This has been further supported by experimental study of Hermann et al,28 who showed that the BMAC composition to be significantly more bioactive than the Ficoll composition. Intriguingly, however, due to the greater yield of cells generated by the Harvest device, the cellular product isolated from a given bone mar-

row aspirate by the Harvest BMAC device may actually translate into even greater therapeutic effects. Additionally, practical aspects may also deserve consideration. Importantly, a major limitation of the Ficoll isolation procedure for clini-cal applications is that it is strongly investigator dependent, immensely time consuming and requires a good manufac-turing practice (GMP) facility. In this study, we were able to demonstrate that such complex methods are not necessary to achieve established results. As the concentration process by use of s point of care system is completed with a 15-min period, everything can be accomplished in one session with-out adding excessive time to the overall procedure, circum-venting the previously mentioned disadvantages of the Ficoll isolation process. The Harvest device not only provides a much shorter turnaround time, but it also does not require an expensive GMP facility for the cell isolation procedure. Therefore, this device represents a cost-effective and time-efficient stand-alone technique for the isolation of autologous BMCs suitable for cell therapy regimens in the rapidly grow-ing field of regenerative medicine.

Several hypotheses have been proposed about how intra-coronary cell therapy improves myocardial function. Experi-mental studies addressing the capacity of transplanted bone marrow-derived stem cells to differentiate into the cardio-myogenic lineage yielded conflicting results.12,31 Recent well-conducted studies suggest that the BMCs do not trans-differentiate into cardiomyocytes but adopt mature hemato-poietic characteristics. In contrast to embryonic stem cells, most adult stem or progenitor cells do not spontaneously dif-ferentiate into cardiomyocytes, but rather require an ade-quate stimulus to do so. Another proposed mechanism is that cell therapy may increase angiogenesis and improve blood supply to ischemic regions, potentially aiding in the revascu-larization of hibernating myocardium and preventing cardio-myocyte apoptosis. Additionally or alternatively, the local microenvironment plays an important role to induce cell fate changes by physical cell-to-cell interaction or by providing paracrine factors promoting tissue repair.32–34

Cell-based therapy is a promising option for treatment of ischemic disease. However, cell therapy is in its early stages, and various questions remain. For example, the mechanisms of action by which cells exhibit beneficial effects. Currently, a variety of autologous adult progenitor cells are undergoing preclinical evaluation. BMCs are, at present, the most fre-quent source used clinically for cardiac repair.35 BMC frac-tions includes a heterogeneous mixture of cells with varying percentages of hematopoietic stem cells, BM-CPCs, mesen-chymal stem cells, and side population cells.36,37

In the present study, we could demonstrate that intracoro-nary transplantation of autologous freshly isolated BMCs by use of a point of care system improved LVEF and reduced infarct size significantly in patients with AMI after 6 months.

Table 4. Cellular Composition of Bone Marrow Aspirate and Bone Marrow Concentrate by Use of Point of Care System in the Group With BMCs-Tx

Bone marrow aspirate (pre separation, 120 cc)

Bone marrow concentrate (post separation, 20 cc)

Total nucleated cells (×106 ml) 24±8　　 101±20　　

CD34+ cells (×106 ml) 0.18±0.06 0.88±0.16

CD133+ cells (×106 ml) 0.08±0.002 0.28±0.01

Platelet count (×103/μl) 124±29　　 678±205

Viability of cells (%) 98±1.5

Abbreviation see in Table 1.



Moreover, we observed a significant enhancement of NYHA classification, even 6 months after cell transplantation. This interesting observation could be implemented in future large-scale randomized studies.

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