review article mesenchymal stem cells for cardiac...

Review ArticleMesenchymal Stem Cells for Cardiac Regenerative TherapyOptimization of Cell Differentiation Strategy

Han Shen Ying Wang Zhiwei Zhang Junjie Yang Shijun Hu and Zhenya Shen

Department of Cardiovascular Surgery and Institute of Cardiovascular Science First Affiliated Hospital of Soochow UniversitySuzhou Jiangsu 215006 China

Correspondence should be addressed to Shijun Hu shijunhusudaeducn and Zhenya Shen uuzyshenaliyuncom

Received 16 December 2014 Revised 28 February 2015 Accepted 11 March 2015

Academic Editor Matthew S Alexander

Copyright copy 2015 Han Shen et alThis is an open access article distributed under theCreativeCommonsAttribution License whichpermits unrestricted use distribution and reproduction in any medium provided the original work is properly cited

With the high mortality rate coronary heart disease (CHD) has currently become a major life-threatening disease The mainpathological change of myocardial infarction (MI) is the induction of myocardial necrosis in infarction area which finally causesheart failure Conventional treatments cannot regenerate the functional cell efficiently Recent researches suggest that mesenchymalstem cells (MSCs) are able to differentiate into multiple lineages including cardiomyocyte-like cells in vitro and in vivo and theyhave been used for the treatment of MI to repair the injured myocardium and improve cardiac function In this review we willfocus on the recent progress on MSCs derived cardiomyocytes for cardiac regeneration after MI

1 Introduction

As the leading cause of mortality cardiovascular disease is amajor problemof global public health Among cardiovasculardiseases coronary heart disease (CHD) is the main diseasetype causing the majority of deaths At present the treatmentof CHD mainly includes medicine percutaneous coronaryintervention (PCI) and operation To some extent thesetreatments could improve myocardial ischemia and heartfailure symptoms Although the surgery operations make theocclusion artery unobstructed again the damage to myocar-dial wall is irreversible The current pharmacological andsurgical measures are limited to palliative effects Shortagein donor hearts and high cost are hindering the prevalenceof heart transplantation In 2001 Orlic et al [1] transplantedautologous bone marrow mesenchymal stem cells (BMSCs)into mouse damaged heart and found these stem cells mostlydifferentiated into cardiomyocytes This important discoveryguided the scientists and clinicians to engage in plenty ofresearches on stem cells transplantation to treat myocardialinfarction (MI) Significant progress has been made in theMSC research field such as cell culture condition and tech-nique of inducing differentiation in vitro [2 3] The differen-tiated myocardial cells from stem cells provide a promisingperspective to cell treatment on cardiac diseases [4ndash6]

Stem cells include embryonic stem cells (ESCs) and adultstem cells (ASCs) commonly holding two major capabilitiesof self-renewal and differentiation ASCs can be isolatedfrom different adult tissues and can be differentiated into avariety of cell types [7] As a kind of ASCs mesenchymalstem cells (MSCs) have been described in nearly all postnataltissues or organs including umbilical cord blood [8 9]placenta [10ndash12] and bonemarrow [13] among others MSCsrepresent an infrequent progenitor population with multipledifferentiation potentials [14ndash19] They are able to differen-tiate into several mesenchymal lineages such as cartilagemuscle vascular endothelial cells and epidermic cells [2021] With the advantage of autologous transplantation whichavoids the immune rejection and ethical concerns MSCshave great application prospect in personalized treatment ofcardiovascular diseases [22ndash24]

2 The Induction Approaches of CellDifferentiation In Vitro and In Vivo

Currently the major methods to induce myocardial cellfrom BMSCs include biochemistry induction myocardialmicroenvironment induction and genetic modification (Fig-ure 1)

Hindawi Publishing CorporationStem Cells InternationalVolume 2015 Article ID 524756 10 pageshttpdxdoiorg1011552015524756

2 Stem Cells International

Markers

5-Aza DMSOBMP-2 Ang-II

and Chinesemedicine

MSCs + medium + FBS

MSCs + medium + FBS

MSCs + cardiomyocyte + medium + FBS

Induced 24h

Induced 2w

Induced 7d

Cardiomyocyte-like cells

myotube-like structures andcellular junction in cellsqPCRNKx 25 GATA-4 early genesImmunohistochemistry specificprotein such as actin cTnT

CLMmyocardialcell broth

Electron microscope

desmin and Cx43

Figure 1The diagram for the induction and identification of cardiomyocyte-like cells MSCs cultured in medium supplemented with 5-AzaDMSO and BMP-2 will be induced to cardiomyocyte-like cells 24 h later MSCs incubated in CLMmyocardial cell broth will differentiateto cardiomyocyte-like cells after 2w MSCs cocultured with cardiomyocyte will differentiated to cardiomyocyte-like cells 7 d later Theidentification methods consist of morphology detection and molecular marker analysis

21 Biochemical Substance

211 5-Azacytidine (5-Aza) 5-Aza a chemical analogue ofcytidine is generally known as a demethylation pharmaceuti-cal that can induceMSCs differentiation into cardiomyocyte-like cells by activating some dormant genes through demeth-ylation [37] In 1995 Wakitani et al [25] first reported thesuccessful isolation and culture of MSCs in vitro After a 24-hour incubation with 5-Aza they could observe myotube-like structures and cardiac-specific proteins expression in 7ndash10 dThese results showed that BMSCs could differentiate intocardiomyocyte-like cells with 5-Aza supplement laying thefoundation for BMSCs differentiation into cardiomyocyte-like cells In 1999 Makino et al [26] and others inducedthe immortalized BMSCs differentiation with 5-Aza Theyobserved myotube-like structures after 1 week spontaneousbeating after 2 weeks and synchronous contraction after 3weeksThe differentiated BMSCs not only expressed cardiac-specific proteins but also exhibited biological and electro-physiological characteristics of myocardial cells Fukuda [38]found that the myocardial cells induced by 5-Aza had twokinds of action potentials One comes from sinus nodal cellsand the other one might come from ventricular myocytesJaquet et al [39] first separated human MSCs (hMSCs) forin vitro culture and incubated these hMSCs with 10 120583molL5-Aza The immunocytochemistry showed that 80 hMSCsexpressed smooth muscle actin in two weeks indicatingthese hMSCs might be differentiated into other musclecells Although 5-aza is the most commonly used chemicalinducer the differentiation efficiency is lowmainly due to thepotential toxicity of 5-Aza and fat deposit in the cytoplasmwhich induce cell death All the inducer applied in BMSCsdifferentiation are listed in Table 1

212 Bone Morphogenetic Protein-2 (BMP-2) As a multifunc-tional glycoprotein BMP-2 contributes to regulating of awide

variety of cell functions including cell growth differentiationand apoptosis among others [40] Several studies haveshown that the BMP-2 expression is initiated in early embry-onic development [41] BMP-2 plays a fundamental role indirected differentiation of cardiac stem cells and the develop-ment of embryonic heart through regulating the expressing ofsome cardiac transcription factors [42] He Qizhi and Haijie[27] found that BMP-2 could also induce BMSCs differen-tiation into cardiomyocyte-like cells in vitro Recent studieshave shown that the roles of BMP-2 in gene expression ofcardiogenic factors and cardiac differentiation from BMSCswere mediated by three molecular pathways Smads P38-MAPK and PI-3KAkt [43ndash45]

213 Angiotensin-II (Ang-II) Ang-II is capable of stimulat-ing the proliferation of vascular smooth muscle cells [46]and fibroblast [47] By regulating the signal of MAPK [48]and tumor growth factor (TGF) [49ndash51] and their consequentpathways Ang-II can induce BMSCs to differentiate intocardiomyocyte-like cells Xing et al [28] induced BMSCsdifferentiation with Ang-II in vitro After 4-week inductionthe cells exhibited morphological characteristics of myocar-dial cells with cTnI expression and showed muscle wire-likestructure under the electron microscope

214 DMSO DMSO was proved to induce mouse P19 cellsto differentiate into beating myocardial cells [29 52ndash55]DMSO plays a critical role in increasing the expression ofprodynorphin and dynorphin B at the transcriptional levelIt turns on both GATA4 and Nkx25 expressions and then itrecruits 120572-MHC and ventricle-specific cardiac myosin lightchain-2 (MLC-2v) to form a functional compound [56]Another study also showed that DMSO could mediate thereleasing of calcium from intracellular stores in sarcoplasmicreticulum Elevation of calcium concentration may play animportant role in the induction of cell differentiation [57]

Stem Cells International 3

Table 1 The inducer for BMSC differentiation

Inducing condition Year Researcher Culturing durationafter induction Detection marker

5-Aza 1995 Wakitani et al [25] 24 h7ndash10 days observing myotube-likestructuresand expressing cardiac-specific protein

1999 Makino et al [26] 24 h

1 week myotube-like structures2 weeks spontaneous beating and3 weeks synchronous contractionexpressing cardiac-specific protein andexhibiting biological andelectrophysiological characteristics ofmyocardial cells

BMP-2 2005 He Qizhi and Haijie [27] 24 h The expression of Nkx25 GATA-4 cTnTand CX43 increasing

Ang-II 2012 Xing et al [28] 24 h

Expressing cTnI after 4 weeks exhibitingmorphological characteristics ofmyocardial cells and being seen asmuscle wire-like structures under theelectron microscope

DMSO 1999 Skerjanc [29] gt6 d Spontaneously beating cardiac myocytesafter 6 days

Panax notoginsengsaponins 2006 Yang et al [30] 24 h 2 weeks beginning to express MHC and

more apparent after 4 weeks

Sal B 2007 Chen et al [31] 24 hExpression of NKX25 GATA-4 mRNAenhanced and peaked at 7 days theexpression of 120572-actin appeared at 14 days

Icariin 2008 Shao-Ying [32] 24 h28 days weakly expressing GATA-4Nkx2-5 combining with 5-Aza enhanceits induction

Astragaloside 2007 Xian et al [33] 24 h 48 h and 72 h

4 weeks detecting cardiac-specific proteindesmin cTnI 120572-MHC and 120573-MHCno significant difference in induction ratewith different length

Microenvironment invivo 2002 Toma et al [34]

hMSCs could differentiate intomyocardium and express myocardiumspecific protein in left ventricularmicroenvironment of SCID micemdashcTnTand phosphoprotein regulating Ca-ATPactivity at sarcoplasmic reticulum

CLM 2005 Yuan et al [35] 7 d 7 days the cells growing well expressing120572-actin and cTnT

Coculturing withcardiomyocytes 2003 Rangappa et al [36] 48 h

hMSCs coculturing with cardiomyocytesat a 1 1 ratio expressing contractileproteins and cardiac specific genesMHC and beta-actin

215 Traditional Chinese Herb Traditional Chinese herb caneffectively induce stem cells differentiation into myocardialcells without any toxic or side effect [58] Several studies [3059 60] indicated that MSCs supplemented with by notogin-senoside in vitro could differentiate into cardiomyocyte-likecells The morphologic features and characteristic markersof these cells were consistent with cardiomyocytes Addi-tional research [61] claimed that glucocorticoids releasedfrom myocardial tissue could induce BMSCs to migrate anddifferentiate into endothelial cells There are several othertraditional Chinese medicine inducers which also can drive

MSCs to myocardial cells such as Dan phenolic acid B [31]icariin [32] and astragaloside [33 62]

22 Myocardial Microenvironment

221 Myocardial Microenvironment In Vivo Derived fromthe embryonic mesoderm MSCs exhibit multiple differ-entiation potentials into mesoderm groups such as bonescartilages and myocardium under suitable conditions Tomaand his colleagues [34] reported that the transplanted hMSCscould successfully differentiate into myocardium and express


myocardium specific proteins after cell transplantation intoleft ventricle of SCIDmiceThemyocardium specific proteinscTnT and phosphoprotein could regulate Ca-ATP activity insarcoplasmic reticulum

222 Myocardial Microenvironment In Vitro

(1) Cardiomyocyte Lysis Medium (CLM) Yuan et al [35] suc-cessfully initiated MSCs differentiation into cardiomyocyte-like cells using cardiac specific cell lysate generated fromprimary myocardial cells Cao et al [63] induced hMSCsdifferentiation into cardiac myocytes with the minipigrsquos car-diomyocyte lysate These derived cardiomyocytes expressedcTnT Cx43 and CD31They also induced hMSCs differentia-tion with 5-Aza and differentiated cardiomyocytes expressedcTnT and Cx43 but not CD31 It is indicated that somecompositions of CLM could also promote the differentiationfromMSCs to endothelial cells which might help create basicconditions for revascularization

(2) The Supernatants of Cultured Cardiomyocytes Multipleevidence showed that BMSCs cultured in the media sup-plemented with myocardial cell culture supernatants coulddifferentiate into cardiomyocyte-like cells [64] Wang et al[65] found that 10 20 30 40 and 50 supernatantsof the cardiomyocytes groups were used in induction ofBMSCs without morphological change The expressions ofa-SMA 120573-actin and troponin-T were significantly higher in10 20 30 40 and 50 supernatant of cardiomyocytesgroups than those in control group and the most significantpercentage was 30 Li et al [66] found that the concentra-tions of insulin-like growth factor-1 (IGF-1) platelet-derivedgrowth factor (PDGF) and fibroblast growth factor (FGF) inthe supernatant of cardiomyocytes culture were significantlyhigher than that in BMSCs culture Their results indicatedthat IGF-1 PDGF and FGF in the supernatant of cardiomy-ocytes may have capability to induce BMSCs to differentiateinto cardiomyocyte-like cells and insulin-like growth factormay serve as the main cytokine

(3) Coculture with Myocardial Cells After coculturing GFPlabeled rat MSCs with the cardiomyocytes in different pro-portions for 7 days He et al [67] successfully detected thecardiac specific proteins expression and action potentialRangappa [36] and others indicated that the induction effi-ciency of MSCs cocultured with myocardial cells is obviouslyhigher than those cultured alone Through investigation onthe structure of the gap conjunction between cardiomyocytesPlotnikov and his colleagues claimed that direct contractionof cells was very important during the differentiation proce-dure [68ndash70]

23 Genetic Modification In recent years genetic modifica-tion has become a novel induction strategy which can con-verse BMSCs into myocardial cells in the molecular level Byinducing one or several key genes to activate cardiac genenetworks BMSCs could obtain cardiac differentiation Sev-eral key transcription factors including Nkx25 GATA4 andTBX5 are expressed in the early cardiac development and

regulate the expression of many cardiac structural proteinswhich are irreplaceable to the development of heart [71ndash75] Recently Jamali et al found that exogenous Nkx25gene expression could induce P19 cells to differentiateinto cardiomyocyte-like cells alone [76] Furthermore withexogenous expression of Nkx25 the P19CL6 could differen-tiate into myocardial cells earlier and more efficiently whensupplied with DMSO [77]

3 Identification of Successful CardiacDifferentiation from MSCs

BMSCs can differentiate into cardiomyocytes through theinduction of chemicals cytokine and simulated cardiacmicroenvironment The differentiated cells were polygonalor star-shape under the microscope The ultrastructure andfilament in the cytoplasm were observed by transmissionmicroscope and cardiac specific cellular junction existingbetween cells

First we can detect the expression of cardiac markergenes Nkx 25 and GATA-4 by qPCR Tissue-specific tran-scription factor GATA-4 and homologous nucleoproteinNkx25 are two earlymarkers of cardiac precursor cells whichplay an important role in early cardiac development [78]

Second we can test myocardial cell specific proteinsincluding actin cTnT desmin and Cx43 by immunoflu-orescence technique Actin is the cytoskeletal proteins ofthe muscle cells which is expressed in skeletal and cardiacmuscle and plays an important role in maintaining myofib-rillar morphology and signal transmission in the sarcomere[79ndash81] Cardiac troponin-T (cTnT) is only expressed in themyocardium thus being a specific protein in the identifica-tion of myocardial cells [82 83] Desmin is the intermediatefilament protein in muscle with 476 amino acids It not onlyconnects the adjacent myofibrils but also connects myofi-brils nucleus cytoskeleton and organelle Furthermoredesmin plays important roles in signal transduction [84]Additional research [85] showed that desmin was involved incell signal transduction and gene expression regulationwhichare closely related to left ventricular remodeling Cx43mainlyexists in the atrial and ventricular muscle and participatesin the formation of gap junctions It composes three kindsof special structure of intercalated disc with intermediatejunction and desmosome Gap junctions mediate electricaland chemical coupling between adjacent cardiomyocytesthrough forming the cell-to-cell pathways for orderly spreadof thewave of electrical excitation responsible for a functionalsyncytium [86] The expression of Cx43 in MSCs afterinduction indicates that myocardial cells own the morpho-logical basis of the intercalated disc structure formationIt provides the material basis for the rhythmic systolicand diastolic motion Cx43 maintains electrical activity andsynchronization of systolic and diastolic functions which arevery important to keep on myocardial function

Adult cardiomyocytes show complicated electrophysio-logical characteristics It has been shown that ion-channelproteins are expressed differently during differentiation Twokinds of ion-channel proteins are expressed in early phaseof sustained calcium current (Ica-L) and transient outward


potassium current (Ito) butmyocardial cells in later period ofdifferentiation express all ion current voltage dependent Nacurrent (INa) delayed rectifierK current (Ik) inward rectifierK current (Ik1) muscarinic receptor agonist inward rectifierK current (IKAch) and the pacemaker current (If)

Additional research [2 87ndash90] suggested that actionpotential consists of sinus node-like action potential atrialmuscle-like action potential and ventricular-like actionpotential These cells have the longer action potential dura-tion and platform period the smaller resting potentialand a pacemaker current slowly depolarizing in late dias-tole The early cardiomyocytes express pacemaker-like cellsaction potential derived from two ion currents (Ica-L Ik-to) whereas the late cardiomyocytes such as the atrial andventricular muscle cells express three action potentials-a75mV resting potential maximum action potential and theovershoot rate [87]

4 MSCs-Based Clinical Therapy for MI

The most important aim of the basic researches of the MSCsis to serve the clinical treatmentMSCs which have the abilityto differentiate into cardiomyocyte-like cells endothelialcells and smooth muscle cells become one of the most pop-ular cells in MI treatment area The cardiomyocyte-like cellscan be differentiated from theMSCs in vitrowith inducementof several external induction factors These cardiomyocyte-like cells can be transplanted into MI patient and directcontact myocardial cells which provide a microenvironmentof the induction of theMSCs intomyocardial cells As a resultit can help to repair the infracted heart muscles better

41 Safety and Efficacy Evaluation of Stem-Cell BasedTherapyIn 2001 the first case of the autologous stem cell trans-plantation for acute MI in clinical trials was carried out byDr Strauer who is a medical scientist from Dusseldorf ofGermany [91] A total of 1 times 107 autologous stem cells weretransplanted into infracted artery by catheter during percu-taneous coronary angioplasty After 10 weeks it was shownthat the intracoronary autologous stem cell transplantationfor acute MI was safe and feasible through myocardial singlephoton emission computed tomography echocardiogramand nuclein ventriculography At present it is also verifiedthat stem cell transplantation for ischemic heart diseasetreatment is safe and preliminary effective via clinical trialsof REPAIR-AMI [92]MAGICCell-3-DES [93] BOOST [94]PROTECT-CAD [95] and so on

42 The Suitable Transplant Time after MI After MI severalfactors are unfavorable for the survival of transplanted cellssuch as a large number of inflammatory cell infiltrationischemical reperfusion injury and microcirculatory distur-bance Meanwhile a series of cell factors including stromalcell derived factor vascular endothelial growth factor andhepatocyte growth factor are upregulated which is good forthe aggregation proliferation and differentiation of trans-planted cells toward the infarction area Therefore when totransplant is an important factor which affects the survival oftransplanted cells and curative effect If the transplantation

is too early a lot of transplanted cells will die due to theadverse local microenvironment On the contrary if it is toolate the transplanted effect is limited because of irreversiblemyocardial injury and formed ventricular remodeling

There are several clinical trials carrying out the stemcell transplantation in different points of time Comparingwith the transplantation 1 hour after MI the amount ofsurvival cells are much less than that after 1-2 weeks andthe improvement of left ventricular function and reductionof the scar area is also lower [96] The transplantation in 24hours is not able to improve cardiac systolic function but canreduce the infarction area [97]The research of REPAIR-AMIdemonstrated that the BMSCs treatment in 4 days after MIis not beneficial but can improve cardiac systolic function in4ndash8 days after infarction

In 2009 MYSTAR trial first adopted the injection ofautologous MNCs via both myocardial and coronary arteriesto treat the MI patient The LVEF of these patients was lessthan 45 The transplant curative effect is measured by thedifferences between LVEF of early stage of AIM (3ndash6 weeks)and that of advanced stage (3-4 months)

43The Dose of Transplant Cells afterMI Thedosage of stemcells used to treat MI varied enormously between differentinvestigations In 2002 Ghostine et al [98] injected 5 times 104cells by intramyocardial delivery system Fukushima et al[99] injected 5 times 106 GFP-expressing skeletal myoblasts byeither retrograde intracoronary or intramyocardial routes Asan urgent problem researchers are pitching great effort inexploring the optimal transplanted cell dosage

44 Delivery Route of Transplant Cells

441 Intracoronary (IC) Artery Injection MSCs are infusedto injured sites by percutaneous artery injection into coronaryarteryThis approach ensures the higher dose of transplantedMSCs to infarction and its surrounding region at the firsttime [100] In post-AMI study this ldquohomingrdquo phenomenonabout migration of cells into cardiomyocytes is only foundin intracoronary injection instead of intravenous injectionThis method is a common clinically practiced approach[101] but there are security issues In patients with coronaryartery obstructions MSCs need to be infused by retrogradecoronary venous (RCV) delivery system Vicario et al [102]and Yokoyama et al [103] also provide correlated data in thisarea

442 Surgical Intramyocardial (IM) Injection At presentmost studies recommend transplanting stem cells by epicar-dial puncture under open-heart surgeries like CABG [104ndash106] or thoracoscopic Intramyocardial injection has been themost accurate and direct approach for injecting stem cellsto MI region of the heart For its advantage of targetinglocalized myocardium this method avoids many complexissues such as homing of the transplanted cells The biggestdrawback of IM injection is the invasive procedures andthe injection site is likely to cause cardiac arrhythmia andsystemic embolization [107]


443 Intravenous (IV) Infusion Without heart surgery andcatheterization intravenous injection of stem cells is a simpleand least invasive delivery route In an experimental modelof acute MI heart function was improved significantly byperipheral intravenous injection of EPCs or BMSCs [108]but a lot of transplanted cells remained outside of themyocardium [109] This limited the clinical application

444 Tissue Engineering Technology Tissue engineeringtechnology is a novel strategy to improve the efficacy of cellengraftment MSCs are cultured on biological materials suchas a hydrogel 3D scaffold to formmonolayer cells with bettercell-to-cell adhesion This enables direct tissue transplantsandminimizes loss of cells [110]The engrafted sheet survivedon ischemic myocardium and grew to a thick stratum includ-ing some newly formed vessels and cardiomyocytes [111]Thetechnology creates an excellent environmentwhich is suitablefor MSCs survival proliferation and differentiation

45 Assessment of Various Cell Delivery Methods In order todetect the cell viability and repair effect of BMSCs deliveredvia different route tracing technology and cardiac ultrasoundare applied Hou et al [112] traced cells via radioactivelylabelling to evaluate the efficacy of cell engraftment Theyreported 11 (surgical injection) 26 (coronary artery) and32 (coronary venous) of them being retained respectivelyLee et al [113] dual labeled the stem cells with HSVttkreporter gene and iron oxide particles for PET imagingof cell viability and MR imaging of cell location Theyapplied cardiac ultrasound and electrocardiogram to validateits therapeutic potential for MI The improved ventricularfunction was measured via ejection fraction and strokevolumeWith increases in advanced technology on stem-cellsbased therapy the evaluation of efficacy ofMSCs engraftmentwill be more perfect and powerful

5 Conclusion

In summary the methods to induce BMSCs differentia-tion into cardiomyocyte-like cells include biochemical druginduction in vitro such as 5-aza BMP-2 AngII DMSOand various herbs Chemical inducers are known to havethe possible toxicity Even under the best concentrations andoptimal inducing time chemical inducers may lead to celldeath Due to their toxicity and undesirable effect chemicalinducers are not able to be used in clinical translationFurthermore myocardial microenvironment could affectBMSCs differentiationThus creating culture conditions thatmore closely mimic cardiac environment is a good ideasuch as cardiomyocyte lysate culture medium of myocardialcells Therefore differentiation methods with the myocardialmicroenvironment will be more prospective A study [114]has shown that the inducing rate of culture medium ofmyocardial cells is not as good as CLM The evidenceindicated that some soluble substances contributing to induc-ing BMSCs differentiation could be released by cardiomy-ocytes However these substances could not be released untilmyocardial cells are broken [114 115] Because MSCs interactwith cardiomyocytes by paracrine and autocrine after directly

coculturing with cardiomyocytes there are physical stim-ulations such as electrical activity and mechanical tractionbetween MSCs and cardiomyocytes [68ndash70] Thus amongvarious inductionmethods CLM and direct coculturingwithmyocardial cells may bemore feasible It will be expected thatapplication of both CLM and coculturing will further boostthe MSCs differentiation into cardiomyocytes

Human bone marrow mesenchymal stem cells have wideapplication prospect because it can be obtained autologouslyand have no immune rejection Furthermore it is easy toculture in vitro and can be induced to differentiate intomyocardial cells through many ways However there arestill several problems needed to be addressed The specificpathways and the regulation mechanism of hMSCs differen-tiation into cardiomyocyte-like cells are still not clear Morestudies are needed to determine optimal infusion dosagetimingwith different inductionmethod To satisfy the clinicalusage it needs to ameliorate the conditions of induction andto further improve the differentiation efficiency Howeverthe clinical translation of stem-cell based therapy is a morecomplex process and its efficacy needs to be fully investigatedin a larger sample size and evaluated in a great quantity ofpreclinical experiments

Therefore what is needed in the stem cell research is theinvestigation of the bestsafest cell type and improvementafter clinical treatment for MI The convincing researchesneed more considerations well-conceived plan and rigorousexperiments It is convinced that with the deepen of theresearch and the improvement of technology the applicationperspective of BMSCs transplantation to treat MI will beextremely bright

Conflict of Interests

The authors declare no conflict of interests

Authorsrsquo Contribution

Han Shen and Ying Wang contributed equally to this work

Acknowledgments

This work is supported by the Jiangsu Provincersquos KeyMedicalCenter (no BL2014051) and the National Natural ScienceFoundation of China (nos 81402090 and 81400199)

References

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[2] A J Friedenstein R K Chailakhyan and U V GerasimovldquoBone marrow osteogenic stem cells in vitro cultivation andtransplantation in diffusion chambersrdquo Cell and Tissue Kineticsvol 20 no 3 pp 263ndash272 1987

[3] M F Pittenger A M Mackay S C Beck et al ldquoMultilineagepotential of adult human mesenchymal stem cellsrdquo Science vol284 no 5411 pp 143ndash147 1999


[4] M H Soonpaa G Y Koh M G Klug and L J Field ldquoForma-tion of nascent intercalated disks between grafted fetal cardio-myocytes and host myocardiumrdquo Science vol 264 no 5155 pp98ndash101 1994

[5] T Asahara T Murohara A Sullivan et al ldquoIsolation of putativeprogenitor endothelial cells for angiogenesisrdquo Science vol 275no 5302 pp 964ndash967 1997

[6] A P Beltrami L Barlucchi D Torella et al ldquoAdult cardiac stemcells are multipotent and support myocardial regenerationrdquoCell vol 114 no 6 pp 763ndash776 2003

[7] Z-B Hu R Zeng W-T Guo and H Lin ldquoInduction and dif-ferentiation of bone marrow mesenchymal stem cellsrdquo Journalof Clinical Rehabilitative Tissue Engineering Research vol 12 no43 pp 8561ndash8566 2008

[8] A Erices P Conget and J J Minguell ldquoMesenchymal progen-itor cells in human umbilical cord bloodrdquo British Journal ofHaematology vol 109 no 1 pp 235ndash242 2000

[9] O K Lee T K Kuo W-M Chen K-D Lee S-L Hsieh andT-H Chen ldquoIsolation of multipotent mesenchymal stem cellsfrom umbilical cord bloodrdquo Blood vol 103 no 5 pp 1669ndash16752004

[10] P S Inrsquot Anker S A Scherjon C Kleijburg-Van Der Keur et alldquoIsolation of mesenchymal stem cells of fetal or maternal originfrom human placentardquo Stem Cells vol 22 no 7 pp 1338ndash13452004

[11] B L Yen H-I Huang C-C Chien et al ldquoIsolation of multi-potent cells from human term placentardquo Stem Cells vol 23 no1 pp 3ndash9 2005

[12] S Kern H Eichler J Stoeve H Kluter and K Bieback ldquoCom-parative analysis of mesenchymal stem cells from bonemarrowumbilical cord blood or adipose tissuerdquo Stem Cells vol 24 no5 pp 1294ndash1301 2006

[13] P Tropel D Noel N Platet P Legrand A-L Benabid and FBerger ldquoIsolation and characterisation of mesenchymal stemcells from adult mouse bone marrowrdquo Experimental CellResearch vol 295 no 2 pp 395ndash406 2004

[14] M Dominici K le Blanc I Mueller et al ldquoMinimal criteriafor defining multipotent mesenchymal stromal cells The Inter-national Society for Cellular Therapy position statementrdquoCytotherapy vol 8 no 4 pp 315ndash317 2006

[15] A Tocci and L Forte ldquoMesenchymal stem cell use and perspec-tiverdquo Hematology Journal vol 4 no 2 pp 92ndash96 2003

[16] H Dayoub R J Dumont J Z Li et al ldquoHuman mesenchymalstem cells transduced with recombinant bone morphogeneticprotein-9 adenovirus promote osteogenesis in rodentsrdquo TissueEngineering vol 9 no 2 pp 347ndash356 2003

[17] C Jorgensen F Djouad F Apparailly and D Noel ldquoEngineer-ingmesenchymal stem cells for immunotherapyrdquoGeneTherapyvol 10 no 10 pp 928ndash931 2003

[18] D L Kraitchman A W Heldman E Atalar et al ldquoIn vivomagnetic resonance imaging of mesenchymal stem cells inmyocardial infarctionrdquo Circulation vol 107 no 18 pp 2290ndash2293 2003

[19] R S Tuan G Boland and R Tuli ldquoAdult mesenchymal stemcells and cell-based tissue engineeringrdquo Arthritis Research ampTherapy vol 5 no 1 pp 32ndash45 2003

[20] K A Jackson S M Majka H Wang et al ldquoRegeneration ofischemic cardiac muscle and vascular endothelium by adultstem cellsrdquo The Journal of Clinical Investigation vol 107 no 11pp 1395ndash1402 2001

[21] A A Kocher M D Schuster M J Szabolcs et al ldquoNeovascu-larization of ischemic myocardium by human bone-marrow-derived angioblasts prevents cardiomyocyte apoptosis reducesremodeling and improves cardiac functionrdquo Nature Medicinevol 7 no 4 pp 430ndash436 2001

[22] T A Lodie C E Blickarz T J Devarakonda et al ldquoSystematicanalysis of reportedly distinct populations of multipotent bonemarrow-derived stem cells reveals a lack of distinctionrdquo TissueEngineering vol 8 no 5 pp 739ndash751 2002

[23] S Gronthos A CW Zannettino S J Hay et al ldquoMolecular andcellular characterisation of highly purified stromal stem cellsderived from human bone marrowrdquo Journal of Cell Science vol116 no 9 pp 1827ndash1835 2003

[24] Y-J Geng ldquoMolecular mechanisms for cardiovascular stemcell apoptosis and growth in the hearts with atheroscleroticcoronary disease and ischemic heart failurerdquo Annals of the NewYork Academy of Sciences vol 1010 pp 687ndash697 2003

[25] S Wakitani T Saito and A I Caplan ldquoMyogenic cells derivedfrom rat bone marrow mesenchymal stem cells exposed to 5-azacytidinerdquoMuscle ampNerve vol 18 no 12 pp 1417ndash1426 1995

[26] S Makino K Fukuda S Miyoshi et al ldquoCardiomyocytes canbe generated frommarrow stromal cells in vitrordquoThe Journal ofClinical Investigation vol 103 no 5 pp 697ndash705 1999

[27] T Y He Qizhi and W Haijie ldquoEffects of BMP-2 on differenti-ation of marrow-derived cardiac stem cells towards cardiomy-ocytesrdquoActa Anatomica Sinica vol 36 no 5 pp 498ndash502 2005

[28] Y Xing A Lv L Wang and X Yan ldquoThe combination ofangiotensin II and 5-azacytidine promotes cardiomyocyte dif-ferentiation of rat bone marrow mesenchymal stem cellsrdquoMolecular and Cellular Biochemistry vol 360 no 1-2 pp 279ndash287 2012

[29] I S Skerjanc ldquoCardiac and skeletal muscle development in P19embryonal carcinoma cellsrdquoTrends in CardiovascularMedicinevol 9 no 5 pp 139ndash143 1999

[30] Z Q Yang S X Xian C H Wang N Y Nan and L C ZhaoldquoEffects of panax notoginseng saponins on the differentiation ofmarrowmesenchymal stem cells into cardiomyocyte-like cellsrdquoTraditional ChineseDrugResearchampClinical Pharmacology vol17 no 4 pp 239ndash242 2006

[31] J Chen J-C Sun and Y-H Zou ldquoDifferentiation of marrowmesenchymal stem cells into cardiomyocyte-like cells inducedby salvianolic acid Brdquo Journal of the Fourth Military MedicalUniversity vol 28 no 23 pp 2152ndash2155 2007

[32] L Shao-Ying ldquoEffects of icariin on bone marrow mesenchymalstem cell proliferation and differentiation into cardiomyocytesrdquoJournal of Beijing University of Traditional Chinese Medicine2008

[33] S X Xian Z Q Yang C H Wang N Y Li and L C ZhaoldquoAn experimental study on astragaloside inducing bonemarrowmesenchymal stem cells to differentiate into cardiomyogeniccells in vitrordquo Jouranl of Guangzhou Uiversity of TraditionalChinese Medicine vol 24 no 1 pp 37ndash40 2007

[34] C Toma M F Pittenger K S Cahill B J Byrne and P DKessler ldquoHuman mesenchymal stem cells differentiate to a car-diomyocyte phenotype in the adult murine heartrdquo Circulationvol 105 no 1 pp 93ndash98 2002

[35] Y Yuan L-F Chen S-Y Zhang W Wu H Chen and X-W Yan ldquoDifferentiation of mesenchymal stem cells into car-dio myogenic cells under the induction of myocardial celllysaterdquo Chinese Journal of Cardiology vol 33 no 2 pp 170ndash1732005


[36] S Rangappa J W C Entwistle A S Wechsler and J Y KreshldquoCardiomyocyte-mediated contact programs human mesen-chymal stem cells to express cardiogenic phenotyperdquo Journal ofThoracic and Cardiovascular Surgery vol 126 no 1 pp 124ndash1322003

[37] S M Taylor ldquo5-aza-21015840-deoxycytidine cell differentiation andDNA methylationrdquo Leukemia vol 7 supplement 1 pp 3ndash81993

[38] K Fukuda ldquoDevelopment of regenerative cardiomyocytes frommesenchymal stem cells for cardiovascular tissue engineeringrdquoArtificial Organs vol 25 no 3 pp 187ndash193 2001

[39] K Jaquet K Krause N Stuts A Zander and K-H Kuck ldquoAza-cytidine stimulated bonemarrow derived humanmesenchymalstem cells percutaneous intramyocardial deliveryrdquo Journal ofthe American College of Cardiology vol 39 supplement 1 p 752002

[40] S Huques ldquoCardiac stem cellsrdquo The Journal of Pathology vol197 no 4 pp 468ndash478 2002

[41] X Cai A Nomura-Kitabayashi W Cai J Yan V M Christ-offels and C-L Cai ldquoMyocardial Tbx20 regulates early atri-oventricular canal formation and endocardial epithelial-mesenchymal transition via Bmp2rdquoDevelopmental Biology vol360 no 2 pp 381ndash390 2011

[42] E de Pater M Ciampricotti F Priller et al ldquoBmp signalingexerts opposite effects on cardiac differentiationrdquo CirculationResearch vol 110 no 4 pp 578ndash587 2012

[43] K-H Lee S Evans T Y Ruan and A B Lassar ldquoSMAD-mediated modulation of YY1 activity regulates the BMPresponse and cardiac-specific expression of a GATA456-dependent chick Nkx25 enhancerrdquo Development vol 131 no19 pp 4709ndash4723 2004

[44] R W Stottmann M Choi Y Mishina E N Meyers and JKlingensmith ldquoBMP receptor IA is required in mammalianneural crest cells for development of the cardiac outflow tractand ventricular myocardiumrdquo Development vol 131 no 9 pp2205ndash2218 2004

[45] M D Schneider V Gaussin and K M Lyons ldquoTempting fateBMP signals for cardiac morphogenesisrdquo Cytokine and GrowthFactor Reviews vol 14 no 1 pp 1ndash4 2003

[46] C Endtmann T Ebrahimian T Czech et al ldquoAngiotensinII impairs endothelial progenitor cell number and functionin vitro and in vivo implications for vascular regenerationrdquoHypertension vol 58 no 3 pp 394ndash403 2011

[47] J Xu S C Lin J Chen et al ldquoCCR2 mediates the uptake ofbone marrow-derived fibroblast precursors in angiotensin II-induced cardiac fibrosisrdquoThe American Journal of PhysiologymdashHeart and Circulatory Physiology vol 301 no 2 pp H538ndashH547 2011

[48] L Li D Fan C Wang et al ldquoAngiotensin II increases periostinexpression via Rasp38 MAPKCREB and ERK12TGF-beta1pathways in cardiac fibroblastsrdquo Cardiovascular Research vol91 no 1 pp 80ndash89 2011

[49] Y M Kim E S Jeon M R Kim S K Jho S W Ryu and J HKim ldquoAngiotensin II-induced differentiation of adipose tissue-derived mesenchymal stem cells to smooth muscle-like cellsrdquoInternational Journal of Biochemistry and Cell Biology vol 40no 11 pp 2482ndash2491 2008

[50] J-G He S-L Chen Y-Y Huang Y-L Chen Y-G Dong andHMa ldquoThenonpeptide AVE0991 attenuatesmyocardial hyper-trophy as induced by angiotensin II through downregulation oftransforming growth factor-1205731Smad2 expressionrdquo Heart andVessels vol 25 no 5 pp 438ndash443 2010

[51] NWang G-D Ren Z Zhou et al ldquoCooperation of myocardinand smad2 in inducing differentiation of mesenchymal stemcells into smooth muscle cellsrdquo IUBMB Life vol 64 no 4 pp331ndash339 2012

[52] M W McBurney E M V Jones-Villeneuve M K S Edwardsand P J Anderson ldquoControl of muscle and neuronal differenti-ation in a cultured embryonal carcinoma cell linerdquo Nature vol299 no 5879 pp 165ndash167 1982

[53] M A G van der Heyden M J A van Kempen Y Tsuji M BRook H J Jongsma and T Opthof ldquoP19 embryonal carcinomacells a suitable model system for cardiac electrophysiologicaldifferentiation at the molecular and functional levelrdquo Cardio-vascular Research vol 58 no 2 pp 410ndash422 2003

[54] C Ventura and M Maioli ldquoOpioid peptide gene expressionprimes cardiogenesis in embryonal pluripotent stem cellsrdquoCirculation Research vol 87 no 3 pp 189ndash194 2000

[55] I S Skerjanc H Petropoulos A G Ridgeway and S WiltonldquoMyocyte enhancer factor 2C and Nkx2-5 up-regulate eachotherrsquos expression and initiate cardiomyogenesis in P19 cellsrdquoThe Journal of Biological Chemistry vol 273 no 52 pp 34904ndash34910 1998

[56] J Paquin B A Danalache M Jankowski S M McCann andJ Gutkowska ldquoOxytocin induces differentiation of P19 embry-onic stem cells to cardiomyocytesrdquo Proceedings of the NationalAcademy of Sciences of the United States of America vol 99 no14 pp 9550ndash9555 2002

[57] A Rephaeli A Aviram E Rabizadeh T Englender and MShaklai ldquoThe role of calcium in differentiation of leukemic celllinesrdquo Cancer Biochemistry Biophysics vol 11 no 2 pp 119ndash1251990

[58] J-H X-Y Sun W-X Huang and Z-Q Yang ldquoAdvances inbone marrow mesenchymal stem cells induced to differentiateinto cardiomyocytes under Chinese medicine interventionrdquoTraditional ChineseDrugResearchampClinical Pharmacology vol23 no 1 pp 115ndash118 2002

[59] Z X S Li and Z Wang ldquoEffect of panax notoginseng saponinson proliferation of bone marrow mesenchymal stem cellsand their differentiation into cardiomyogenic cellsrdquo Journal ofGuangzhou University of Traditional Chinese Medicine vol 24no 6 pp 470ndash475 2007

[60] X D Kong P Qiu and Y Wang ldquoDifferentiation of porcinemarrow stromal cells into myocardium-like cells induced byPanax notoginosides in vitrordquoChinese Journal of CardiovascularReview vol 3 no 7 pp 528ndash531 2005

[61] N-Y Wang C-J Lu and X-H Chen ldquoStudy on effect ofginsenoside Rg1 in promoting myocardiac vascular endothelialcell regeneration through induction on bonemarrow stem cellrsquosmigration and differentiation in rabbits of myocardial infarc-tionrdquo Chinese Journal of Integrated Traditional and WesternMedicine vol 25 no 10 pp 916ndash919 2005

[62] Q-Y Yang S-X Xian H-R Sun L-C Zhao and C-HWang ldquoExperimental study on marrowmesenchyma stem cellsdifferentiated into the cardic muscle type cells inducted bythe medicine blood serum with Huangqirdquo Liaoning Journal ofTraditional Chinese Medicine vol 35 no 6 pp 832ndash834 2008

[63] X-X Cao Y-H Dai S-Y Zhang et al ldquoDifferentiation ofhuman mesenchymal stem cells into cardiomyocyte-like cellsrdquoBasic amp Clinical Medicine vol 27 no 2 pp 157ndash160 2007

[64] X Jue E B S Gong and D Qing ldquoEffect of microenvironmentin vitro on the differentiation of bone marrow mesenchymalstem cells into cardiomyogenic cellsrdquoChinese Journal of ClinicalRehabilitation vol 8 no 12 pp 2250ndash2252 2006


[65] X-L Wang J Wang and H-B Gong ldquoEffects of myocar-dial microenvironment on BMSCs differentiating into cardio-myocyte-like cellsrdquo Progress in Modern Biomedicine vol 8 no12 pp 2419ndash2422 2008

[66] C-M Li X-L Wang H-L Zhu J Wang and H-B GongldquoSupernatant of myocardiocyte induces differentiation of bonemarrow-derived mesenchymal stem cellsrdquo Chinese Journal ofTissue Engineering Research vol 17 no 36 pp 6417ndash6422 2013

[67] X-Q He M-S Chen S-H Li et al ldquoCo-culture with car-diomyocytes enhanced the myogenic conversion of mesenchy-mal stromal cells in a dose-dependent mannerrdquo Molecular andCellular Biochemistry vol 339 no 1-2 pp 89ndash98 2010

[68] MXuMWani Y-SDai et al ldquoDifferentiation of bonemarrowstromal cells into the cardiac phenotype requires intercellularcommunication with myocytesrdquo Circulation vol 110 no 17 pp2658ndash2665 2004

[69] E Y Plotnikov T G Khryapenkova A K Vasileva et al ldquoCell-to-cell cross-talk between mesenchymal stem cells and cardi-omyocytes in co-culturerdquo Journal of Cellular and MolecularMedicine vol 12 no 5 pp 1622ndash1631 2008

[70] A Cselenyak E Pankotai E M Horvath L Kiss and Z LaczaldquoMesenchymal stem cells rescue cardiomyoblasts from celldeath in an in vitro ischemia model via direct cell-to-cellconnectionsrdquo BMC Cell Biology vol 11 article 29 2010

[71] R Bodmer ldquoThe gene tinman is required for specification of theheart and visceral muscles inDrosophilardquoDevelopment vol 118no 3 pp 719ndash729 1993

[72] M Tanaka Z Chen S Bartunkova N Yamasaki and SIzumo ldquoThe cardiac homeobox gene CsxNkx25 lies geneti-cally upstream of multiple genes essential for heart develop-mentrdquo Development vol 126 no 6 pp 1269ndash1280 1999

[73] W T Pu T Ishiwata A L Juraszek Q Ma and S IzumoldquoGATA4 is a dosage-sensitive regulator of cardiac morphogen-esisrdquo Developmental Biology vol 275 no 1 pp 235ndash244 2004

[74] K Gajewski N Fossett J D Molkentin and R A Schulz ldquoThezinc finger proteins pannier and GATA4 function as cardio-genic factors in Drosophilardquo Development vol 126 no 24 pp5679ndash5688 1999

[75] M E Horb and G H Thomsen ldquoTbx5 is essential for heartdevelopmentrdquo Development vol 126 no 8 pp 1739ndash1751 1999

[76] M Jamali P J Rogerson S Wilton and I S Skerjanc ldquoNkx2-5 activity is essential for cardiomyogenesisrdquo The Journal ofBiological Chemistry vol 276 no 45 pp 42252ndash42258 2001

[77] K Monzen W Zhu H Kasai et al ldquoDual effects of the home-obox transcription factor CsxNkx2-5 on cardiomyocytesrdquo Bio-chemical and Biophysical Research Communications vol 298no 4 pp 493ndash500 2002

[78] F A Stennard M W Costa D A Elliott et al ldquoCardiac T-box factor Tbx20 directly interacts with Nkx2-5 GATA4 andGATA5 in regulation of gene expression in the developingheartrdquoDevelopmental Biology vol 262 no 2 pp 206ndash224 2003

[79] B Kinner JM Zaleskas andM Spector ldquoRegulation of smoothmuscle actin expression and contraction in adult human mes-enchymal stem cellsrdquo Experimental Cell Research vol 278 no1 pp 72ndash83 2002

[80] K S Chang K N Rothblum and R J Schwartz ldquoThe com-plete sequence of the chicken 120572-cardiac actin gene a highlyconserved vertebrate generdquo Nucleic Acids Research vol 13 no4 pp 1223ndash1237 1985

[81] Y Mayer H Czosnek P E Zeelon D Yaffe and U NudelldquoExpression of the genes coding for the skeletal muscle andcardiac actins in the heartrdquo Nucleic Acids Research vol 12 no2 pp 1087ndash1100 1984

[82] M Panteghini ldquoPresent issues in the determination of tro-ponins and othermarkers of cardiac damagerdquoClinical Biochem-istry vol 33 no 3 pp 161ndash166 2000

[83] IMoscoso A Centeno E Lopez et al ldquoDifferentiation lsquoin vitrorsquoof primary and immortalized porcine mesenchymal stem cellsinto cardiomyocytes for cell transplantationrdquo TransplantationProceedings vol 37 no 1 pp 481ndash482 2005

[84] L Qing-An ldquoEffect of ouabain on the expression of cellmembraneNa+k+minusATPaserdquo Journal of XiaimingUniversity vol25 no 1 pp 16ndash19 2011

[85] R Saunders and G Scheiner-Bobis ldquoOuabain stimulatesendothelin release and expression in human endothelial cellswithout inhibiting the sodium pumprdquo European Journal ofBiochemistry vol 271 no 5 pp 1054ndash1062 2004

[86] K Boengler R Schulz and G Heusch ldquoConnexin 43 signallingand cardioprotectionrdquoHeart vol 92 no 12 pp 1724ndash1727 2006

[87] V A Maltsev A M Wobus J Rohwedel M Bader and J Hes-cheler ldquoCardiomyocytes differentiated in vitro from embryonicstem cells developmentally express cardiac-specific genes andionic currentsrdquo Circulation Research vol 75 no 2 pp 233ndash2441994

[88] Y M Zhang C Hartzell M Narlow and S C Dudley JrldquoStem cell-derived cardiomyocytes demonstrate arrhythmicpotentialrdquo Circulation vol 106 no 10 pp 1294ndash1299 2002

[89] S Viatchenko-Karpinski B K Fleischmann Q Liu et alldquoIntracellular Ca2+ oscillations drive spontaneous contractionsin cardiomyocytes during early developmentrdquoProceedings of theNational Academy of Sciences of theUnited States of America vol96 no 14 pp 8259ndash8264 1999

[90] V A Maltsev J Rohwedel J Hescheler and A M WobusldquoEmbryonic stem cells differentiate in vitro into cardiomyocytesrepresenting sinusnodal atrial and ventricular cell typesrdquoMech-anisms of Development vol 44 no 1 pp 41ndash50 1993

[91] B E Strauer M Brehm T Zeus et al ldquoIntracoronary humanautologous stem cell transplantation for myocardial regener-ation following myocardial infarctionrdquo Deutsche MedizinischeWochenschrift vol 126 no 34-35 pp 932ndash938 2001

[92] V Schachinger S Erbs A Elsasser et al ldquoIntracoronary bonemarrow-derived progenitor cells in acute myocardial infarc-tionrdquoThe New England Journal of Medicine vol 355 no 12 pp1210ndash1221 2006

[93] H-J Kang H-Y Lee S-H Na et al ldquoDifferential effect ofintracoronary infusion of mobilized peripheral blood stem cellsby granulocyte colony-stimulating factor on left ventricularfunction and remodeling in patients with acute myocardialinfarction versus old myocardial infarction the MAGIC cell-3-DES randomized controlled trialrdquo Circulation vol 114 no 1pp I145ndashI151 2006

[94] G P Meyer K C Wollert J Lotz et al ldquoIntracoronary bonemarrow cell transfer after myocardial infarction eighteenmonthsrsquo follow-up data from the randomized controlledBOOST (Bonemarrow transfer to enhance ST-elevation infarctregeneration) trialrdquo Circulation vol 113 no 10 pp 1287ndash12942006

[95] H F Tse K H Yiu and C P Lau ldquoBone marrow stem celltherapy for myocardial angiogenesisrdquo Current Vascular Phar-macology vol 5 no 2 pp 103ndash112 2007


[96] X Hu J Wang J Chen et al ldquoOptimal temporal delivery ofbone marrow mesenchymal stem cells in rats with myocardialinfarctionrdquo European Journal of Cardio-Thoracic Surgery vol 31no 3 pp 438ndash443 2007

[97] S Janssens C Dubois J Bogaert et al ldquoAutologous bonemarrow-derived stem-cell transfer in patients with ST-segmentelevation myocardial infarction double-blind randomisedcontrolled trialrdquoTheLancet vol 367 no 9505 pp 113ndash121 2006

[98] S Ghostine C Carrion L C G Souza et al ldquoLong-termefficacy of myoblast transplantation on regional structure andfunction after myocardial infarctionrdquo Circulation vol 106 no12 supplement 1 pp I131ndashI136 2002

[99] S Fukushima S R Coppen J Lee et al ldquoChoice of cell-deliveryroute for skeletal myoblast transplantation for treating post-infarction chronic heart failure in ratrdquo PLoS ONE vol 3 no 8Article ID e3071 2008

[100] P Widimsky M Penicka O Lang et al ldquoIntracoronary trans-plantation of bone marrow stem cells background techniquesand limitationsrdquoEuropeanHeart Journal Supplements vol 8 ppH16ndashH22 2006

[101] A M Mozid S Arnous E C Sammut and A Mathur ldquoStemcell therapy for heart diseasesrdquo British Medical Bulletin vol 98no 1 pp 143ndash159 2011

[102] J Vicario J Piva A Pierini et al ldquoTranscoronary sinus deliveryof autologous bonemarrow and angiogenesis in pigmodelswithmyocardial injuryrdquo Cardiovascular Radiation Medicine vol 3no 2 pp 91ndash94 2002

[103] S-I Yokoyama N Fukuda Y Li et al ldquoA strategy of retro-grade injection of bone marrow mononuclear cells into themyocardium for the treatment of ischemic heart diseaserdquo Jour-nal of Molecular and Cellular Cardiology vol 40 no 1 pp 24ndash34 2006

[104] N Dib P Menasche J J Bartunek et al ldquoRecommendationsfor successful training on methods of delivery of biologics forcardiac regeneration a report of the International Society forCardiovascular Translational Researchrdquo JACC CardiovascularInterventions vol 3 no 3 pp 265ndash275 2010

[105] A N Patel L Geffner R F Vina et al ldquoSurgical treatmentfor congestive heart failure with autologous adult stem celltransplantation a prospective randomized studyrdquo The JournalofThoracic and Cardiovascular Surgery vol 130 no 6 pp 1631ndash1638 2005

[106] K Hamano M Nishida K Hirata et al ldquoLocal implantationof autologous bone marrow cells for therapeutic angiogenesisin patients with ischemic heart diseasemdashclinical trial andpreliminary resultsrdquo Japanese Circulation Journal vol 65 no 9pp 845ndash847 2001

[107] A A Hagege J-P Marolleau J-T Vilquin et al ldquoSkeletalmyoblast transplantation in ischemic heart failure Long-termfollow-up of the first phase I cohort of patientsrdquoCirculation vol114 no 1 pp I108ndashI113 2006

[108] M E Halkos Z-Q Zhao F Kerendi et al ldquoIntravenous infu-sion of mesenchymal stem cells enhances regional perfusionand improves ventricular function in a porcine model of myo-cardial infarctionrdquo Basic Research in Cardiology vol 103 no 6pp 525ndash536 2008

[109] M B Britten N D Abolmaali B Assmus et al ldquoInfarctremodeling after intracoronary progenitor cell treatment inpatients with acute myocardial infarction (TOPCARE-AMI)mechanistic insights from serial contrast-enhanced magneticresonance imagingrdquo Circulation vol 108 no 18 pp 2212ndash22182003

[110] A Bel V Planat-Bernard A Saito et al ldquoComposite cell sheetsa further step toward safe and effective myocardial regenerationby cardiac progenitors derived from embryonic stem cellsrdquoCirculation vol 122 no 11 supplement pp S118ndashS123 2010

[111] Y Miyahara N Nagaya M Kataoka et al ldquoMonolayered mes-enchymal stem cells repair scarred myocardium after myocar-dial infarctionrdquo Nature Medicine vol 12 no 4 pp 459ndash4652006

[112] D Hou E A-S Youssef T J Brinton et al ldquoRadiolabeled celldistribution after intramyocardial intracoronary and intersti-tial retrograde coronary venous delivery implications for cur-rent clinical trialsrdquo Circulation vol 112 no 9 supplement ppI150ndashI156 2005

[113] A S Lee D Xu J R Plews et al ldquoPreclinical derivation andimaging of autologously transplanted canine induced pluripo-tent stem cellsrdquoThe Journal of Biological Chemistry vol 286 no37 pp 32697ndash32704 2011

[114] J SWang D Shum-Tim J Galipeau E Chedrawy N Eliopou-los and R C-J Chiu ldquoMarrow stromal cells for cellular cardio-myoplasty feasibility and potential clinical advantagesrdquo Journalof Thoracic and Cardiovascular Surgery vol 120 no 5 pp 999ndash1006 2000

[115] C E Murry M H Soonpaa H Reinecke et al ldquoHaematopoi-etic stem cells do not transdifferentiate into cardiac myocytesin myocardial infarctsrdquoNature vol 428 no 6983 pp 664ndash6682004

Submit your manuscripts athttpwwwhindawicom

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Anatomy Research International

PeptidesInternational Journal of


Hindawi Publishing Corporation httpwwwhindawicom

International Journal of

Volume 2014

Zoology


Molecular Biology International

GenomicsInternational Journal of


The Scientific World JournalHindawi Publishing Corporation httpwwwhindawicom Volume 2014


BioinformaticsAdvances in

Marine BiologyJournal of



Signal TransductionJournal of


BioMed Research International

Evolutionary BiologyInternational Journal of



Biochemistry Research International

ArchaeaHindawi Publishing Corporationhttpwwwhindawicom Volume 2014


Genetics Research International


Advances in

Virolog y

Hindawi Publishing Corporationhttpwwwhindawicom

Nucleic AcidsJournal of

Volume 2014

Stem CellsInternational



Enzyme Research



Microbiology


Markers

5-Aza DMSOBMP-2 Ang-II

and Chinesemedicine

MSCs + medium + FBS

MSCs + medium + FBS

MSCs + cardiomyocyte + medium + FBS

Induced 24h

Induced 2w

Induced 7d

Cardiomyocyte-like cells

myotube-like structures andcellular junction in cellsqPCRNKx 25 GATA-4 early genesImmunohistochemistry specificprotein such as actin cTnT

CLMmyocardialcell broth

Electron microscope

desmin and Cx43

Figure 1The diagram for the induction and identification of cardiomyocyte-like cells MSCs cultured in medium supplemented with 5-AzaDMSO and BMP-2 will be induced to cardiomyocyte-like cells 24 h later MSCs incubated in CLMmyocardial cell broth will differentiateto cardiomyocyte-like cells after 2w MSCs cocultured with cardiomyocyte will differentiated to cardiomyocyte-like cells 7 d later Theidentification methods consist of morphology detection and molecular marker analysis

21 Biochemical Substance

211 5-Azacytidine (5-Aza) 5-Aza a chemical analogue ofcytidine is generally known as a demethylation pharmaceuti-cal that can induceMSCs differentiation into cardiomyocyte-like cells by activating some dormant genes through demeth-ylation [37] In 1995 Wakitani et al [25] first reported thesuccessful isolation and culture of MSCs in vitro After a 24-hour incubation with 5-Aza they could observe myotube-like structures and cardiac-specific proteins expression in 7ndash10 dThese results showed that BMSCs could differentiate intocardiomyocyte-like cells with 5-Aza supplement laying thefoundation for BMSCs differentiation into cardiomyocyte-like cells In 1999 Makino et al [26] and others inducedthe immortalized BMSCs differentiation with 5-Aza Theyobserved myotube-like structures after 1 week spontaneousbeating after 2 weeks and synchronous contraction after 3weeksThe differentiated BMSCs not only expressed cardiac-specific proteins but also exhibited biological and electro-physiological characteristics of myocardial cells Fukuda [38]found that the myocardial cells induced by 5-Aza had twokinds of action potentials One comes from sinus nodal cellsand the other one might come from ventricular myocytesJaquet et al [39] first separated human MSCs (hMSCs) forin vitro culture and incubated these hMSCs with 10 120583molL5-Aza The immunocytochemistry showed that 80 hMSCsexpressed smooth muscle actin in two weeks indicatingthese hMSCs might be differentiated into other musclecells Although 5-aza is the most commonly used chemicalinducer the differentiation efficiency is lowmainly due to thepotential toxicity of 5-Aza and fat deposit in the cytoplasmwhich induce cell death All the inducer applied in BMSCsdifferentiation are listed in Table 1

212 Bone Morphogenetic Protein-2 (BMP-2) As a multifunc-tional glycoprotein BMP-2 contributes to regulating of awide

variety of cell functions including cell growth differentiationand apoptosis among others [40] Several studies haveshown that the BMP-2 expression is initiated in early embry-onic development [41] BMP-2 plays a fundamental role indirected differentiation of cardiac stem cells and the develop-ment of embryonic heart through regulating the expressing ofsome cardiac transcription factors [42] He Qizhi and Haijie[27] found that BMP-2 could also induce BMSCs differen-tiation into cardiomyocyte-like cells in vitro Recent studieshave shown that the roles of BMP-2 in gene expression ofcardiogenic factors and cardiac differentiation from BMSCswere mediated by three molecular pathways Smads P38-MAPK and PI-3KAkt [43ndash45]

213 Angiotensin-II (Ang-II) Ang-II is capable of stimulat-ing the proliferation of vascular smooth muscle cells [46]and fibroblast [47] By regulating the signal of MAPK [48]and tumor growth factor (TGF) [49ndash51] and their consequentpathways Ang-II can induce BMSCs to differentiate intocardiomyocyte-like cells Xing et al [28] induced BMSCsdifferentiation with Ang-II in vitro After 4-week inductionthe cells exhibited morphological characteristics of myocar-dial cells with cTnI expression and showed muscle wire-likestructure under the electron microscope

214 DMSO DMSO was proved to induce mouse P19 cellsto differentiate into beating myocardial cells [29 52ndash55]DMSO plays a critical role in increasing the expression ofprodynorphin and dynorphin B at the transcriptional levelIt turns on both GATA4 and Nkx25 expressions and then itrecruits 120572-MHC and ventricle-specific cardiac myosin lightchain-2 (MLC-2v) to form a functional compound [56]Another study also showed that DMSO could mediate thereleasing of calcium from intracellular stores in sarcoplasmicreticulum Elevation of calcium concentration may play animportant role in the induction of cell differentiation [57]

























































5 Conclusion









Acknowledgments


References































































































































Volume 2014

Zoology






















Advances in

Virolog y



Volume 2014




Enzyme Research



Microbiology

























































5 Conclusion









Acknowledgments


References































































































































Volume 2014

Zoology






















Advances in

Virolog y



Volume 2014




Enzyme Research



Microbiology




























































































































Volume 2014

Zoology






















Advances in

Virolog y



Volume 2014




Enzyme Research



Microbiology

review article mesenchymal stem cells for cardiac...

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