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”

Caulfield et al . Circ 1976

0

10

20

30

40

50

60

Infarct size(% LV mass)

48% 28%

Shock, Death CHFPfeffer et al . NEJM 2003

40 years later:VALIANT study (14,703 post-MI pts with reduced EF or CHF )

-1 y mortality: 13%

- 1 y death, reMI, rehosp CHF: 26%

Full Regeneration of Myocardium in Zebrafish

Poss et al., Science 2002;298; 2188Poss et al., Science 2002;298; 2188

Cardiac Regeneration in 2007: the (stem) cell paradox?

- 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) ……….

Different cell types with uniform benefit on cardiac function:

Cell Therapie voor AMI in 2007?

2. Toekomstperspectieven?Trial design: welke patiëntenpopulatie - eindpunten?

1. Lessen uit 4 RCT in 2006 met mononucleaire BM cellen en 6 RCT met mobilisatie strategieën?

Is cardiale regeneratieve geneeskunde mogelijk?

Sca-1+ cellsc-Kit + cells

SP cells

Endothelial Progenitor Cells

Hematopoietic SCsMesenchymal SCs

HemangioblastsSP cellsMAPC

Sca-1+ cellsMyoblastsSP cells

Mesenchymal SCsSPcells

PLURIPOTENT

Cel Types voor Cardiaal Herstel(adapted from Dimmeler et al. , JCI 2005)

Chronisch MI:MAGIC phase II

Acuut MI

Stabiele Ischemie

Sca-1+ cellsc-Kit + cells

SP cellsCardiospheres

Future for Cardiac Resident (Stem) Cells?

Spontaneous Mobilization and Homing in Acute - Chronic Ischemia

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….)………….

?

VEGF, FGF2SDF-1, IL-8,…. G-CSF

1. Kuethe et al. (Am Heart J 2005;150:115)

2. Ince et al. (FIRSTLINE-AMI, Circ 2005;112: 3097)

3. Valgimigli et al. (Eur Heart J 2005;26:1838)

4. Ripa et al. (STEMMI, Circ 2006;113:1983)

5. 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?

G-CSF RCT Trials in Acuut Myocard Infarct

BOOST: LV-Ejection Fraction after 6 and 18 Months

(Circulation 2006;113:1287-94)

BMC-TransferControls

LV

EF

[%

]

0.7% 6.7%2.4% -0.8%

UZ-Leuven Ervaring met BMC Transfer na AMI: design (2001)

2. Cel product?

1. Patiëntenpopulatie en Design van de Studie?

3. Timing voor Cel Transfer?

4. Primair eindpunt?

AMI+ documented LV dysfunction post PCI

Can BMSC Transfer Improve LV Recovery after Acute Myocardial Infarction?

BMSC or placebo transfer in open IRA

• Informed consent• TTE• Acetate-PET scan• Bone marrow aspiration

+ randomization

24 hours

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)

44

45

46

47

48

49

50

51

52

LVEF - MRI (%)

BMSCCON

Leuven AMI (n=67)

+ 2.2% + 3.4%

= +1.2% (P=NS)

4-mo 4-mo

(Lancet 2006; 367:113-121)

51

52

53

54

55

56

57

58

42

44

46

48

50

52

54

LVEF - MRI (%)

REPAIR-AMI (n=187) ASTAMI (n=87)

+ 3.0% + 5.5%

= +2.5% (P<0.05)

+ 4.2% + 1.2%

= -3% (P=NS)

CON CON BMSCBMSC

4-mo 4-mo 6-mo 6-mo

LVEF - angio (%)

(NEJM 2006; 355:1199-1221)

Bone Marrow Cell Transfer Post-AMIDoes infarct size matter?

BMCPlac

20

-20

10

-10

0

Change EF(%)

NEJM 2006; 355:1210-21

Baseline EF <48.9% Baseline EF >48.9%

P=0.002

P=0.81

(52) (41) (40) (54)

Bone Marrow Cell Transfer Post-AMIDoes timing matter?

20

-20

10

-10

0

LV-EF (%)

Time after PCI (days)

46 (8) 47 (9)

(n=36)LV-EF (%)

P=NS

3-4 d 4 moLV-EDV

(mL)

P=0.014162 (33) 175 (43)

3-4 d 4 mo

>4 d <4 d

Coronary occlusion

20 min. 60 min. 3hrs. >3-6hrs.

Reversible injury Irreversible injury

Reperfusion

LV

Paracrine or autocrine effects of transferred cells?

??

MRI and TDI Analysis Post-AMI: Infarct Transmurality & Segmental Contraction

BMSC Treatment Effect* on Infarct Size

0

5

10

15

20

25

30

CONTROL BMSC

BASELINE4 Months

Infarct size (g)

P=0.036

* Expressed as ratio’s of adjusted squares means (ANCOVA) with 95% CI.

28% treatment effect*

**

**

Lancet 2006; 367:113-121

BMSC Treatment Effect* on Infarct Size

0

5

10

15

20

25

30

CONTROL BMSC

BASELINE4 Months1 Year

Infarct size (g)

P=0.036

* Expressed as ratio’s of adjusted squares means (ANCOVA) with 95% CI.

28% treatment effect*

**

**

23%

-20

-15

-10

-5

0

Baseline 5 d 2 mo 4 mo 1 yr

(n=232)

Infarcted segments

* *

ES Strain(%) BMSC

Control

* p < 0.001

Treatment Effect

Time Profile

Regional Function AnalysisTDI: End-systolic Strain

Adverse Events during 1-year Follow-up

BMSC Tx (n=31)

Control group (n=34)

Ventricular tachycardia (Holter) - 1

Life threatening arrhythmia’s - 1 (ICD)

Death 1 (suicide) -

Myocardial reinfarction 1 1

Recurrent ischemia, PCI 2 4

Congestive Heart Failure - 1

Others: depression

PAD (claudication)

11

1-

Schachinger, V. et al. Eur Heart J 2006 27:2775-2783

Kaplan-Meier event-free survival analysis

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.

• Grote, multicenter studie in ernstig AMI - klinisch eindpunt- Centraal hematologie core faciltieit

- SOPs cel bereiding

- Q-control, financiele ondersteuning,….

Toekomstperspectieven: Optimaliseren van Stam Cel Transfer?

• Gefocuseerde klinische studies en parallele preklinische studies

- Boost 2

- NL interuniversity study - Poland (cell comparison)

- Leuven/Frankfurt meta-analysis

- Leuven homing studies

Sca-1+ cellsMyoblastsSP cells

Cell Sources for Cardiac Repair(adapted from Dimmeler et al. , JCI 2005)

Ischemic Cardiomyopathy

(EF<35%)MAGIC phase II

MAGIC Phase 1 Study

To assess the feasibility and safety of autologous skeletal myoblasts in pts with

ischemic heart failure.

Single center (F): n=10Suggestion of efficacy (EF, NYHA, WMSI)

Cave: arrhythmogenicity

MAGIC Phase 2: Studie Procedures

BiopsieBiopsie

GMP Cell ProcessingGMP Cell Processing Cel suspensieCel suspensie

10 g10 g

The MAGIC Trial

Safety - MACE : All deaths, MI, congestive HF, resuscitated sudden death & stroke- Ventricular arrhythmias (ICD implanted in all patients before hospital discharge)

End Points

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

X X X X XX X X X XX X X X XX X X X XX X X X X

Infarct Zone(Scar)

Peri-InfarctZone

High dose groupLow dose groupPlacebo group

Summary of Time to First MACE

12

0 1 6 12 18 2420

30

40

50

60

70

80

90

100

Months from CABG

MA

CE-f

rees

urv

ival(%

)

30 24 24 20 16 333 29 20 14 5 334 32 27 20 17 8#

at

risk

p = 0.09 p = 0.43 Low dose vs placebo

p = 0.87 p = 0.12 High dose vs placebo

6 months30 days

High dose groupLow dose groupPlacebo group

13

200 1 6 12 18 24

30

40

50

60

70

80

90

100

Ve

ntr

icu

lar

arr

hyth

mia

-fre

e su

rviv

al (%

)

Months from CABG

30 25 22 19 16 533 27 24 18 7 534 33 31 21 14 6#

at

ris

k

High dose groupLow dose groupPlacebo group

p = 0.23 p = 0.20 Low dose vs placebo

p = 0.12 p = 0.30 High dose vs placebo

6 months30 days

Death treated as censored event

Summary of Time to First Ventricular Arrhythmia

The MAGIC Trial

Regional Wall MotionPatients with Qualitative Echo Data at Baseline

and Month 6

Number of patients 26 28 31

Recovery in at least one segment

Yes (%) 12 (46) 13 (46) 18 (58)

No (%) 14 (54) 15 (54) 13 (42)

Recovery in at least two segments

Yes (%) 8 (31) 10 (36) 12 (39)No (%) 18 (69) 18 (64) 19 (61)

High dose Low dose Placebo

LV End-Diastolic Volume

Data are given as median (interquartile range)

High dose Low dose Placebo-50

-40

-30

-20

-10

0

10

20

30

ED

V a

bs

olu

te c

ha

ng

e

n=26-23.0

(-42.0;0.0)

n=27-9.0

(-33.0;25.0)

n=30+9.0

(-21.0;28.0)

p=0.006

p=0.62

mL

Sca-1+ cellsc-Kit + cells

SP cellsCardiospheres

10

010

110

210

310

40

150

pos isotype PE

Isotype control

Sca-1

Sca-1+ cells60,000 - 100,000

Total %Sca-1+

3500 89.97

Future for Cardiac Resident (Stem) Cells?

Smith, R. R. et al. Circulation 2007;115:896-908

Regenerative Potential of Biopsy-derived Human Cardiospheres

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)

- Departments of Cardiology, Hematology, Radiology, Nuclear Medicine, Radiopharmacy, Biostatistics- Leuven Coordinating Center (LCC) - Referring Cardiology Sites

AcknowledgmentsGasthuisberg University Hospital & CTG, VIB-3

University of Leuven, Belgium