JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
VOL. 66, NO. 18, 2015
ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
PUBLISHED BY ELSEVIER INC.
ISSN 0735-1097/$36.00
http://dx.doi.org/10.1016/j.jacc.2015.08.879
Synergistic Effects of Combined Cell
Therapy for Chronic Ischemic Cardiomyopathy
Vasileios Karantalis, MD,* Viky Y. Suncion-Loescher, MD,* Luiza Bagno, PHD,* Samuel Golpanian, MD,*
Ariel Wolf, BS,* Cristina Sanina, MD,* Courtney Premer, BS,* Anthony J. Kanelidis, BS,* Frederic McCall, BS,*
Bo Wang, MD,* Wayne Balkan, PHD,* Jose Rodriguez, BS,* Marcos Rosado, BS,* Azorides Morales, MD,y
Konstantinos Hatzistergos, PHD,* Makoto Natsumeda, MD,* Irene Margitich, BS,* Ivonne Hernandez Schulman, MD,*
Samirah A. Gomes, MD,* Muzammil Mushtaq, MD,* Darcy L. DiFede, BS,* Joel E. Fishman, MD,z
Pradip Pattany, PHD,z Juan Pablo Zambrano, MD,x Alan W. Heldman, MD,* Joshua M. Hare, MD*
ABSTRACT
BACKGROUND Both bone marrow–derived mesenchymal stem cells (MSCs) and c-kitþ cardiac stem cells (CSCs)
improve left ventricular remodeling in porcine models and clinical trials. Using xenogeneic (human) cells in immunosuppressed animals with acute ischemic heart disease, we previously showed that these 2 cell types act synergistically.
OBJECTIVES To more accurately model clinical applications for heart failure, this study tested whether the combination of autologous MSCs and CSCs produce greater improvement in cardiac performance than MSCs alone in a nonimmunosuppressed porcine model of chronic ischemic cardiomyopathy.
METHODS Three months after ischemia/reperfusion injury, Göttingen swine received transendocardial injections
with MSCs alone (n ¼ 6) or in combination with cardiac-derived CSCs (n ¼ 8), or placebo (vehicle; n ¼ 6). Cardiac
functional and anatomic parameters were assessed using cardiac magnetic resonance at baseline and before and
after therapy.
RESULTS Both groups of cell-treated animals exhibited significantly reduced scar size (MSCs 44.1 6.8%; CSC/MSC
37.2 5.4%; placebo 12.9 4.2%; p < 0.0001), increased viable tissue, and improved wall motion relative to
placebo 3 months post-injection. Ejection fraction (EF) improved (MSCs 2.9 1.6 EF units; CSC/MSC 6.9 2.8 EF units;
placebo 2.5 1.6 EF units; p ¼ 0.0009), as did stroke volume, cardiac output, and diastolic strain only in the
combination-treated animals, which also exhibited increased cardiomyocyte mitotic activity.
CONCLUSIONS These findings illustrate that interactions between MSCs and CSCs enhance cardiac performance more
than MSCs alone, establish the safety of autologous cell combination strategies, and support the development of secondgeneration cell therapeutic products. (J Am Coll Cardiol 2015;66:1990–9) © 2015 by the American College of Cardiology
Foundation.
From *The Interdisciplinary Stem Cell Institute, University of Miami Miller School of Medicine, Miami, Florida; yDepartment of
Pathology, University of Miami Miller School of Medicine, Miami, Florida; zDepartment of Radiology, University of Miami Miller
School of Medicine, Miami, Florida; and xCardiovascular Medicine, Jackson South Community Hospital, Miami, Florida. This work
was supported by National Institutes of Health grant R01HL084275 awarded to Dr. Hare. Dr. Hare is also supported by National
Institutes of Health grants R01HL107110, UM1HL113460, and R01HL110737; and grants from the Starr Foundation and the Soffer
Family Foundation. Dr. Hare has a patent for cardiac cell–based therapy; he holds equity in Vestion Inc.; and maintains a proListen to this manuscript’s
fessional relationship with Vestion as a consultant and member of the Board of Directors and Scientific Advisory Board. Vestion
audio summary by
did not play a role in the design or conduct of the study. Dr. Karantalis is funded by the American Heart Association. Dr. Morales
JACC Editor-in-Chief
has been granted >20 patents on methods, instruments, and accessories related to rapid diagnostic tissue preparation; the
Dr. Valentin Fuster.
University of Miami licensed these patents to Sakura Finetek USA, and Dr. Morales received a percentage of the royalties gained by
the university. Dr. Hatzistergos has equity interest in Vestion. Dr. Heldman has a patent for cardiac cell–based therapy; has
received research support from BioCardia; has served as a board member and consultant for Vestion; and has equity interest in
Vestion. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Drs. Karantalis and Suncion-Loescher contributed equally to this work.
Manuscript received April 13, 2015; revised manuscript received August 12, 2015, accepted August 17, 2015.
Karantalis et al.
JACC VOL. 66, NO. 18, 2015
NOVEMBER 3, 2015:1990–9
T
1991
Combination Stem Cell Therapy for Heart Failure
here is accumulating evidence that mesen-
Illinois), counted, and total cell viability
ABBREVIATIONS
chymal stem cells (MSCs) are a safe and
determined. The cells (200 106 MSCs 1 106
AND ACRONYMS
efficacious approach to treating disorders
CSCs) were resuspended in Plasma-Lyte A
characterized by left ventricular (LV) remodeling
(total volume 6 ml) before injection. Criteria
(1–3). MSCs are antifibrotic (4,5), produce LV reverse
for release of product were cell viability $70%
remodeling (6) in both preclinical models and in
and negative results on sterility testing. The
patients (7), and improve the quality of life in pa-
placebo injection consisted of Plasma-Lyte A
tients with heart failure secondary to ischemic
alone (Online Appendix).
cardiomyopathy (1,2,8–10). It remains important,
Transendocardial stem cell injection (TESI)
however, to define strategies that enhance the ac-
was performed 3 months post-MI by using
tions of MSCs. We previously showed that transepi-
the
þ
NOGA
system
for
electroanatomical
ANOVA = analysis of variance
CMR = cardiac magnetic
resonance
CSC = c-kitD cardiac stem cell
FMD = flow-mediated dilation
IZ = infarct zone
LV = left ventricular
MI = myocardial infarction
cardiac
mapping (Biosense Webster, Inc., Diamond
MSC = mesenchymal stem cell
stem cells (CSCs) into immunosuppressed swine
Bar, California) (18). The mapping catheter
pHH3 = phospho-histone H3
2 weeks post–myocardial infarction (MI) improved
was advanced through an 8-F introducer
RZ = remote zone
LV performance and reduced myocardial scarring
sheath and positioned retrograde across the
TESI = transendocardial stem
to a greater degree than either cell type alone (11).
aortic valve into the left ventricle. A complete
cell injection
cardial injection of human MSCs plus c-kit
map of LV geometry and function was generated by
SEE PAGE 2000
collecting local position and electrocardiographic
Similarly, we showed that cell engraftment and sys-
data at >50 points in the endocardium. Cells were
tolic and diastolic recovery were superior with com-
injected
bination therapy. The goal of the present study was
(Biosense Webster, Inc.) directly into the endocar-
to determine whether transendocardial administra-
dium in approximately 0.5 ml aliquots for each of
tion of autologous MSCs plus CSCs would similarly
by
using
the
NOGA
Myostar
catheter
10 sites encompassing the infarction and its viable
produce greater therapeutic potential than MSCs
border zone (unipolar voltage $6 mV). Injection sites
alone in a swine model of chronic heart failure due
were recorded both in the electroanatomic NOGA
to post-infarct LV remodeling.
map and in 2 orthogonal radiographic projections,
and marked on a tracing of the endocardial silhouette.
METHODS
IMMUNOHISTOCHEMISTRY. Twelve slides (4 each per
All experiments were conducted in female Göttingen
infarct zone [IZ], border zone, and remote zone [RZ])
swine (12). Twenty-eight animals survived a closed-
were randomly chosen from each animal for quantifi-
chest ischemic reperfusion MI induced by inflation
cation of phospho-histone H3 (pHH3)-positive nuclei
of a coronary angioplasty balloon in the mid–left
(Online Appendix). Slides were examined by using
anterior descending artery, as previously described
fluorescence microscopy (Olympus IX81, Olympus
(12). Animals were randomized to receive trans-
Corporation, Tokyo, Japan), and the number of pHH3-
6
endocardial injections of either: 1 10 autologous
6
CSCs co-administered with 200 10 MSCs; 200 10
6
positive nuclei was quantified per slide. Representative samples were selected and stained with anti-pHH3
MSCs alone; or placebo (Plasma-Lyte, Baxter Health-
and anti–myosin light chain 2 (Novus Biologicals, Lit-
care Corporation, Deerfield, Illinois). Each animal
tleton, Colorado). Image acquisition was performed
underwent an extensive safety evaluation. Noninva-
with a Zeiss LSM-710 confocal microscope (Carl Zeiss
sive cardiac magnetic resonance (CMR) was per-
MicroImaging, Thornwood, New York).
formed (12–14). The study design is outlined in Online
STUDY ENDPOINTS AND ASSESSMENTS. Specified
Figure 1, and the timeline for serial measurements of
safety endpoints were assessed, including survival,
cardiac function are shown in Online Table 1.
body weights, and continuous cardiac rhythm moni-
CELL MANUFACTURING AND DELIVERY. CSCs were
toring for ventricular or supraventricular arrhythmias
isolated from 5 to 8 endomyocardial biopsy specimens
post-injection by using implanted monitoring devices
(1 to 2 mm) obtained from the septal wall of the right
(Reveal DX 9528 and Reveal XT 9529 [Medtronic,
ventricle immediately after MI/reperfusion; they were
Minneapolis, Minnesota]), as described elsewhere (6).
then expanded, harvested, and cryopreserved as pre-
Laboratory values included hematology, chemistry,
viously described (15–17). MSCs were isolated from
and markers of cardiac injury (i.e., creatine phos-
bone marrow obtained from the tibial cavity, as re-
phokinase, creatine kinase-myocardial band isozyme,
ported elsewhere (11). On the morning of stem cell in-
troponin I) (Online Figure 2). After the animals were
jection, the cells were thawed, washed, re-suspended
killed, gross and microscopic tissue samples were
in Plasma-Lyte A (Abbott Laboratories, North Chicago,
obtained from the brain, liver, spleen, kidney, lung,
Karantalis et al.
JACC VOL. 66, NO. 18, 2015
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Combination Stem Cell Therapy for Heart Failure
F I G U R E 1 Antifibrotic Effects Post-TESI
A
B
After TESI
D
E
G
H
J
%Δ Scar Mass as % LV Mass
Before TESI
10
-10
F
I
*
-20
-30
-40
-50
-60
C
TESI
0
K
60
%Δ Viable Tissue Mass
1992
50
40
Placebo
MSCs
CSC/MSC
3m post MI
**
*
†
*
1m post TESI 2m post TESI 3m post TESI
Placebo
MSCs
CSC/MSC
*
†
**
*
30
20
10
0
TESI
3m post MI
1m post TESI 2m post TESI 3m post TESI
Short-axis sections of delayed enhancement cardiac magnetic resonance depict the infarct extension (scar ¼ red with white arrows) before (A to C) and
3-months after (D to F) treatment and, as seen in comparable gross pathology sections (G to J), 3 months after transendocardial stem cell injection (TESI).
(A, D) In this representative example, scar size changed from (A, D) 7.2 to 9.0 g for the placebo, (B, E) 9.7 to 5.9 g for autologous mesenchymal stem
cells (MSCs) and (C, F) 8.9 to 5.8 g for c-kitþ cardiac stem cells (CSCs)/MSCs. (G) Cell-treated groups had similar scar size reduction (between-group
comparison, 2-way analysis of variance [ANOVA] p < 0.0001) and (K) increased viable tissue (between-group comparison, 2-way ANOVA p ¼ 0.0002).
Graphs ¼ mean SEM. *p < 0.05 within-group repeated measures 1-way ANOVA; 2-way ANOVA between-group comparison and Tukey’s multicomparison
test; **p < 0.05 CSC/MSC versus placebo at 1, 2, and 3 months post-TESI; and †p < 0.05 MSC versus placebo at 1, 2, and 3 months post-TESI. LV ¼ left
ventricular; MI ¼ myocardial infarction.
and ileum to determine the presence of neoplastic
ANOVA were applied with Tukey’s multiple compari-
tissue at necropsy. CMR was performed by using a
son test when applicable. A p value <0.05 was
3.0-T clinical scanner (Magnetom, Siemens AG,
considered statistically significant.
Munich, Germany).
Swine underwent serial CMR at baseline, 1 and
RESULTS
3 months post-MI, and 1, 2, and 3 months postTESI. Global and regional function were assessed
Baseline and post-MI conditions for all animals were
through the measurement of end-diastolic volume,
assessed (Online Table 2). There were no differences
end-systolic volume, stroke volume, EF, scar size,
between groups for body weight or age at baseline or at
viable tissue, Eulerian circumferential strain, dia-
scheduled time points (Online Tables 1 and 2). Serum
stolic strain rate, and perfusion. Endothelial function
hematology, chemistry, and cardiac enzyme values
was measured by the brachial artery flow-mediated
were measured at several time points throughout the
dilation (FMD) (19) (Online Appendix).
study. There was no evidence of clinically relevant
STATISTICS. All data are presented as mean SEM.
laboratory abnormalities after TESI (Online Figure 2) in
All data points were analyzed by using GraphPad
any of the groups. TESI was tolerated; there were no
Prism version 4.03 (GraphPad Software Inc., La Jolla,
sustained arrhythmias and no evidence of ectopic
California). For within-group changes, 1-way analysis
tissue formation (Online Tables 3 and 4).
of variance (ANOVA) was applied with Tukey’s multiple
All study groups had similar infarct sizes, whether
comparison test. For between-group comparisons, an
evaluated as a percentage of LV mass or absolute
unpaired 2-tailed Student t test and 1- and 2-way
scar size 3 months after infarction (Online Table 5).
Karantalis et al.
JACC VOL. 66, NO. 18, 2015
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Combination Stem Cell Therapy for Heart Failure
Stem cell treatment, but not placebo, produced sub-
CSC/MSC vs. MSC and CSC/MSC vs. placebo, each
stantially reduced scar size (CSC/MSC 37.2 5.4%;
p < 0.05). EF as a percent change from post-MI
MSCs 44.1 6.8%; placebo 12.9 4.2%; p < 0.0001)
improved only in the CSC/MSC group: 20.61 2.11%,
and increased viable tissue (CSC/MSC 30.9 7%; MSCs
14.37 3.64%, and 13.9 6.2% at 1, 2, and 3 months
43.7 13.3%; placebo 13.5 5.9%; p ¼ 0.0002) relative
post-TESI, respectively (between-group p ¼ 0.0004;
to placebo (Figure 1). Scar size reduction was evident
3 months post-MI vs. 1, 2, and 3 months post-TESI, each
1 month post-TESI and persisted for 3 months. There
p < 0.05) but was unchanged in the MSC and placebo
was a strong correlation between scar size measured by
groups (each p ¼ NS) (Figure 2B). EF restoration was
using delayed-enhancement CMR and scar size
accompanied by a substantial improvement in stroke
measured according to gross pathology sections:
volume in the CSC/MSC group, exceeding that of MSCs
r ¼ 0.93; 95% confidence interval: 0.80 to 0.98;
or placebo (CSC/MSC 47.2 11.1% vs. MSCs 21.2 4.7%
p < 0.0001 (Online Figure 3).
vs. placebo 22.4 12.0%; between-group p ¼ 0.008;
All animals had similar depression of ejection frac-
CSC/MSC vs. MSC, MSC vs. placebo, each p < 0.05)
tion (EF) due to MI (Figure 2A, Online Table 6). EF
(Figure 2C). Furthermore, cardiac output increased only
increased 3 months post-TESI in the combination
in the CSC/MSC group: 50.5 11.3%, p ¼ 0.007; MSCs
group by 6.9 2.8 EF units (p ¼ 0.0003), in MSCs
27.8 13.6%, p ¼ 0.2; placebo: 15.5 9.5%, p ¼ 0.02;
by 2.9 1.6 EF units (p ¼ NS), and with placebo by
between-group comparison p ¼ 0.008) (Figure 2D,
2.5 1.6 EF units (p ¼ NS; between-group p ¼ 0.0009;
Online Table 6).
F I G U R E 2 EF Improvement Post-TESI
B
60
TESI
TESI
TESI
40
20
Placebo
MSCs
CSC/MSC
p=NS
0
C
p=NS
*
** †
40
30
TESI
10
0
-20
Placebo
MSCs
CSC/MSC
3m Post MI
1m Post TESI
20
15
*
** †
10
TESI
5
3m Post MI
D
-10
Placebo
MSCs
CSC/MSC
0
3m Post MI 3m Post TESI 3m Post MI 3m Post TESI 3m Post MI 3m Post TESI
60
20
25
p=0.05
50
%Δ Stroke Volume (SV)
%Δ Ejection Fraction (EF)
80
2m Post TESI
3m Post TESI
1m Post TESI
2m Post TESI
3m Post TESI
70
60
%Δ Cardiac Output (CO)
Ejection Fraction (%)
A
Placebo
MSCs
CSC/MSC
*
50
40
30
20
TESI
10
0
-10
3m Post MI
1m Post TESI
2m Post TESI
3m Post TESI
Change in ejection fraction (EF) for individual animals for (A) EF units and (B) as a percent change (p ¼ 0.01) post-TESI. Accompanying this EF restoration
was a substantial improvement in the CSC/MSC group in (C) stroke volume (p ¼ 0.008) and (D) cardiac output, which increased only in the CSC/MSC
group (p ¼ 0.007). Graphs represent mean SEM. *p < 0.05 1-way ANOVA, 3 months post-MI vs. 1, 2, and 3 months post TESI with CSC/MSC; **p < 0.05
CSC/MSC vs. placebo; †p < 0.05 CSC/MSC vs. MSCs. Abbreviations as in Figure 1.
1993
Karantalis et al.
1994
JACC VOL. 66, NO. 18, 2015
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Combination Stem Cell Therapy for Heart Failure
F I G U R E 3 Contractility and Diastolic Strain
0
B 0.6
TESI
Placebo
MSCs
CSC/MSC
-5
*
-10
**
End Diastolic Strain
TESI
*
0.4
0.3
0.2
-15
0.1
Placebo
MSCs
CSC/MSC
I
st
T
ES
po
3m
st
T
po
2m
ES
I
I
ES
I
st
T
po
3m
1m
1m
po
lin
se
Ba
po
st
M
I
I
ES
st
T
ES
3m
2m
po
st
T
st
T
1m
po
po
3m
I
I
ES
I
st
M
e
lin
se
Ba
e
0.0
-20
po
Infarct Zone Peak Ecc
0.5
st
M
A
(A) Circumferential strain rate (peak Eulerian circumferential shortening strain [Ecc]) in the infarct zone improved in both cell-treated animal groups but not in
the placebo group (*MSC p ¼ 0.04; **CSC/MSC p < 0.004; between-group comparison p ¼ 0.1). (B) Diastolic strain increased only in the combination-treated
animals (*p ¼ 0.04), remaining unchanged in the MSC (p ¼ NS) and placebo (p ¼ NS) groups (between-group comparison p ¼ 0.9). Abbreviations as in Figure 1.
Circumferential strain rate (peak Eulerian circumferential shortening strain), a measure of regional
function in the border zone compared with placebo
(data not shown).
contractility calculated from tagged CMR, exhibited
CMR tagging was used to evaluate diastolic per-
improved regional function (greater negative delta) of
formance. Diastolic strain increased only in the
the IZ only in the cell-treated groups (CSC/MSC 3.2 combination-treated animals (0.44 0.07; p ¼ 0.04)
1.2, p ¼ 0.004; MSCs 1.1 0.9, p ¼ 0.04; placebo
and remained unchanged in the MSC (0.38 0.11;
delta 0.2 0.9, p ¼ NS; between-group comparison
p ¼ NS) and placebo (0.25 0.08; p ¼ NS) groups
p ¼ 0.1) (Figure 3A). TESI did not improve regional
(between-group comparison p ¼ 0.9) (Figure 3B).
The impact of cell therapy on peripheral vascular
function was also explored by measuring FMD of the
F I G U R E 4 Endothelial Function
brachial artery, which improved similarly in both celltreated groups but worsened in the placebo group
400
(CSC/MSC 147.6 74.5%, 1-way ANOVA p < 0.0001;
MSCs 142.5 135.4%, 1-way ANOVA p ¼ 0.04;
%Δ Flow Mediated Dilation
300
placebo 102.4 106.5%, 1-way ANOVA p ¼ NS;
200
**
†
TESI
100
between-group comparison p ¼ 0.01; Tukey’s multiple comparison test p < 0.05, CSC/MSC vs. placebo
and p < 0.05 MSCs vs. placebo) (Figure 4).
0
We analyzed 11 to 12 slides (3-4/zone) from each of
20 pigs for PHH3 and Myosin Light Chain 2 staining
-100
-200
-300
(Figures 5A and 5B) and found a greater number of
pHH3 þ cardiomyocytes in the border zone (TESI site)
Placebo
MSCs
CSC/MSC
in the CSC/MSC group (1.0 0.3) compared to the
placebo group (0.2 0.1; p ¼ 0.05) but no differences
in the infarct or remote zones (Figures 5C to 5E).
3m Post MI
1m Post TESI
2m Post TESI
3m Post TESI
Similarly in the combination group there were
significantly
more
mitotic
pHH3-positive
nuclei
Flow-mediated dilation improved endothelial function in both cell-treated groups. CSC/
found within the myocardium in the infarct zone
MSC vs. Placebo **p < 0.05; MSCs vs. placebo †p < 0.05. Abbreviations as in Figure 1.
(Figure 5F) per slide compared to the placebo group
(CSC/MSC: 1.2 0.2; MSCs: 0.7 0.3; placebo:
Karantalis et al.
JACC VOL. 66, NO. 18, 2015
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1995
Combination Stem Cell Therapy for Heart Failure
F I G U R E 5 Treatment-Enhanced Myocardial Mitotic Activity
1
0
Placebo
MSCs
CSC/MSC
G
Infarct zone
3
*
2
1
0
Placebo
MSCs
CSC/MSC
E
Border zone
3
2
*
1
0
Placebo
MSCs
CSC/MSC
H
Border zone
4
3
2
1
0
pHH3+ Cardiomyocytes per Slide
2
pHH3+ Cardiomyocytes per Slide
3
4
pHH3+ Cells/Slide
D
Infarct zone
pHH3+ Cells/Slide
F
B
pHH3+ Cells/Slide
C
pHH3+ Cardiomyocytes per Slide
A
Placebo
MSCs
CSC/MSC
Remote zone
3
2
1
0
4
Placebo
MSCs
CSC/MSC
Remote zone
3
2
1
0
Placebo
MSCs
CSC/MSC
Confocal microscopy depicts increased mitotic activity of endogenous cardiomyocytes (phospho-histone H3–positive [pHH3þ ] nuclei) in (A) border and (B) remote zones
in cell-treated hearts at 3 months post-TESI. Based on the average number of pHH3þ mitotic cardiomyocytes per slide per group in the (C) infarct, (D) border, and (E)
remote zones, combination cell therapy significantly increased mitotic activity in the border zone compared with placebo (*p ¼ 0.05). According to the average number
of pHH3þ mitotic cells within the myocardium per slide per group in the (F) infarct, (G) border, and (H) remote zones, combination therapy produced significant increases
in mitotic cells in the infarct zone compared with placebo (*p ¼ 0.05). DAPI ¼ 4’,6-diamidino-2-phenylindole; other abbreviations as in Figure 1.
0.2 0.1; p ¼ 0.05) but not in the border or remote
Vascular density was similar in all 3 groups (Online
zones (Figures 5G and 5H).
Figure 4).
Perfusion was assessed in all 3 zones (IZ, border,
and remote ). In the IZ, there was a borderline trend
DISCUSSION
toward progressively deteriorating tissue perfusion
(15.0 9.9%, p ¼ 0.07), which was offset by each cell
This preclinical animal study was designed to provide a
therapy group (MSC 6.4 12.2%, p ¼ 0.32; CSC/MSC
rigorous placebo-controlled and blinded safety and
23.7 22.5%, p ¼ 0.72) when comparing 3 months
efficacy assessment using autologous MSCs alone or in
post-MI and 3 months post-TESI (Figure 6). Heart
combination with autologous CSCs in a chronic MI/
sections from each zone were stained with von Wil-
reperfusion model. There are 3 major findings. First,
lebrand reagent, and blood vessels were counted.
we established that coinjection of autologous MSCs
Karantalis et al.
JACC VOL. 66, NO. 18, 2015
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Combination Stem Cell Therapy for Heart Failure
F I G U R E 6 Infarct Zone Perfusion
reduction in scar size with combination therapy
compared with either cell administered alone in the
setting of acute MI and xenogeneic (human) cells
50
Relative Upslope (%)
1996
Placebo
4 weeks post-injection (11). Coadministration of
MSCs
human CSCs and MSCs also significantly increased
CSC/MSC
(7-fold) retention and engraftment compared with
30
either cell type administered alone, suggesting direct
cell contribution to myocardial regeneration. One
mechanism underlying the beneficial effects of stem
10
cell therapy is endogenous tissue regeneration,
including CSC activation and myocyte division (25).
We showed that the CSC/MSC combination led to
-10
increased cardiomyocyte mitosis 3 months post-TESI
and was associated with sustained improvement of
-30
*
cardiac performance and scar size reduction (Central
Illustration). Scar size reduction in all cell-treated
pigs was accompanied by substantial recovery in
According to the contrast-enhanced cardiac magnetic resonance perfusion
analysis in the resting state, there was a trend toward deterioration of
tissue perfusion in the infarct zone with placebo (15.0 9.9%; *p ¼ 0.07).
cardiac function but was less robust when MSCs were
administered alone. Interestingly, significant im-
This decline did not occur in the cell treatment groups (MSC 6.4 12.2%,
provement in cardiac function was shown only in the
p ¼ 0.32; c kitþ CSC/MSC 23.7 22.5%, p ¼ 0.72). Bar graphs depict change
combination group, as measured by EF, stroke vol-
in tissue perfusion from 3 months post-MI and 3 months post-TESI as
ume, cardiac output, regional diastolic strain rate, and
measured according to upslope analyses. Abbreviations as in Figure 1.
endothelial function. This discrepancy relative to our
earlier study may be due to differences in the 2 models:
autologous versus xenogeneic cells (porcine vs. hu-
and CSCs is safe and not associated with an increased
man), timing (chronic vs. subacute), delivery methods
risk of adverse effects. Second, both cell treatments
(transendocardial vs. direct via thoracotomy), and
produced similar antifibrotic effects. Third, only the
immunosuppression (absence vs. presence).
coadministration of cells improved myocardial con-
The interactions of immunosuppressant drugs with
tractile performance. These findings are the first
MSCs remain controversial. Buron et al. (32) showed
demonstration that autologous cell combination ther-
that cyclosporine and other immunosuppressant
apy is superior to MSCs alone in a model of chronic
drugs reduce the ability of MSCs to suppress lym-
ischemic cardiomyopathy, and they therefore have
phocyte proliferation. In contrast, other studies
important implications for future clinical trial design.
found that cyclosporine promotes the lymphocyte-
The efficacy of autologous MSCs alone has been
suppressing effects of MSCs (33,34). The longer
established pre-clinically and clinically (3,4). MSCs
follow-up time may also play a role, suggesting that
are thought to act primarily via a combination of
the combination of stem cells may help sustain the
paracrine signaling (20–22), proangiogenic effects
beneficial effects over a longer period of time.
(23,24), and stimulation of endogenous CSC prolif-
Recently, the POSEIDON (Percutaneous Stem Cell
eration, differentiation (25–28), and recruitment (29).
Injection Delivery Effects on Neomyogenesis) (1) and
For the combination of the 2 cell types, efficacy was
TAC-HFT
demonstrated by improvement in both structural and
Ischemic Heart Failure Trial) (2) clinical trials reported
functional parameters. CSCs are located in niches
that injections of autologous MSCs did not improve EF
within the heart, and they exert important regulatory
12 months post-delivery; there was, however, signifi-
and regenerative roles (30) that can be augmented by
cant improvement in the clinical status of patients, as
cell therapy (31). Together, these results suggest that
measured by using the 6-min walk test and Minnesota
TESI, with a combination of MSCs plus CSCs, pro-
Living with Heart Failure questionnaire score.
(Transendocardial
Autologous
Cells
in
vides an advantage by overcoming factors that
Our regional analysis of contractility revealed
inhibit or counteract the efficacy of the current sin-
improved peak diastolic strain rate in the targeted
gle cell–type therapy (25).
areas in the combination-treated animals. Peak dia-
The present study illustrates that autologous MSCs
stolic strain rate (35) is a measure of diastolic function
alone or in combination with CSCs similarly reduce
that, in impaired myocardial regions, can remain
infarct size and increase viable tissue compared with
persistently compromised despite complete systolic
placebo. We previously showed a 2-fold greater
functional recovery after reperfusion post-MI. FMD,
Karantalis et al.
JACC VOL. 66, NO. 18, 2015
NOVEMBER 3, 2015:1990–9
CENTRAL I LLU ST RAT ION
Combination Stem Cell Therapy for Heart Failure
Combination Stem Cell Therapy for Heart Failure
A
B
Karantalis, V. et al. J Am Coll Cardiol. 2015; 66(18):1990–9.
Tagged harmonic phase cardiac magnetic resonance strain maps show significantly depressed regional function according to peak Eulerian circumferential
shortening strain (Ecc) at (A) 3 months post–myocardial infarction (white arrows). Red/white indicates weak contractility (more positive Ecc) and
green/blue indicates vigorous contractility (more negative Ecc) in harmonic phase strain maps. (B) At 3 months after cell injection, infarct zone
contractility has improved (less, red/white; more, green/blue). TESI ¼ transendocardial stem cell injection.
as a measure of endothelial function that can be
tested in early-stage clinical trials. Admixtures of cell
imaged and quantified as an index of vasomotor
types that complement each other’s capabilities seem
function (36), is an attractive technique because it
to provide synergistic benefits that enhance the
is noninvasive and allows for repeated measure-
short-term (11) and long-term therapeutic outcomes
ments throughout the study. Both cell-treated groups
compared with 1 type of cell alone.
demonstrated improved FMD, suggesting that stem
STUDY LIMITATIONS. The present study was rigor-
cell treatment promotes nitric oxide release by the
ously designed but lacked a CSC-alone group. How-
endothelium with subsequent vasodilation. The
ever, in early-phase clinical trials (40), autologous
improvement in endothelial function due to cell
CSCs had a successful safety profile, including
therapy in this study is important in the context
increased EF, regional wall motion, New York Heart
of our finding that tissue perfusion was improved
Association functional class, and quality-of-life scores
in the IZ of cell-treated pigs in the absence of in-
on the Minnesota Living with Heart Failure question-
creased vascular density. Recently, we found that
naire. Although in vitro and rodent studies show that
MSCs increase endothelial function and release of
CSCs are necessary and sufficient for functional cardiac
endothelial progenitor cells in patients with heart
regeneration and repair (41), others have found that
failure (37).
endogenous CSCs may produce new cardiomyocytes at
Finally, this study suggests that combining cell
low levels (42). There is growing consensus (43) that
types can have clinical benefits, including enhancing
CSCs alone may be insufficient to repair the failing
improvements in myocardial contractile performance
myocardium, and strategies are being developed to
(38,39). The strategy tested here supports the fea-
address this issue (44,45). Adding MSCs may overcome
sibility of clinical trials, as both cell types have been
these shortfalls by providing the needed paracrine
1997
1998
Karantalis et al.
JACC VOL. 66, NO. 18, 2015
NOVEMBER 3, 2015:1990–9
Combination Stem Cell Therapy for Heart Failure
factors, stromal support, and cell-to-cell contact that
ACKNOWLEDGMENTS The
contribute to cardiac niche reconstitution. Interest-
Martin and Doug Suehr from Biosense Webster, Inc.,
authors
thank
Mark
ingly, Konfino et al. (46) showed that the type of injury,
for their assistance with the NOGA system; neither
resection, or infarction dictates the mode of repair in
received compensation for their contribution. The
the neonatal and adult murine heart. They suggested
authors also thank David Valdes, Krystalenia Valasaki
that MI and subsequent inflammation might inhibit
and Dr. Jose Da Silva for valuable technical assistance.
complete regeneration. Thus, the immunomodulatory
properties of MSCs render this cell type an indispens-
REPRINT
able component for effective cell combinations.
Dr. Joshua M. Hare, Interdisciplinary Stem Cell
REQUESTS
AND
CORRESPONDENCE:
Another limitation is that the present study lacked
Institute, University of Miami Miller School of Medi-
dose escalations of each stem cell therapy. However,
cine, Biomedical Research Building, Room 824, P.O.
there are many contradictory reports relating thera-
Box 016960 (R125), 1501 N.W. 10th Avenue, Miami,
peutic efficacy with higher (6) or lower (1) doses of
Florida 33101. E-mail: [email protected].
MSCs, and there is still no defined efficacious dose
range for CSCs. In addition, using autologous cells
PERSPECTIVES
precluded quantification of engraftment.
CONCLUSIONS
COMPETENCY IN MEDICAL KNOWLEDGE:
Transendocardial injection of autologous MSCs plus
autologous
CSCs
produced
scar
size
reduction,
increased viable tissue, and restored contractile performance 3 months post-MI. These findings showed,
for the first time, that important interactions between
these stem cells produce substantial enhancement in
cell-based therapy for at least 3 months after treatment. The current and previous cell combination
studies have produced excellent safety and highly
encouraging efficacy profiles, supporting the conduct
Chronic heart failure due to ischemic heart disease
involves deleterious myocardial remodeling that impairs patients’ functional capacity. Combination therapy with MSCs and CSCs reduces scar size and
improves LV contractility.
TRANSLATIONAL OUTLOOK: Clinical trials are
needed to assess the effectiveness and safety of
combination cell therapy in patients with heart failure
due to ischemic cardiomyopathy.
of clinical trials.
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A PP END IX For an expanded Methods section
athy via trilineage differentiating capacity. Proc
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coronary artery disease. J Am Coll Cardiol 2009;
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as well as supplemental tables and figures,
please see the online version of this article.
KEY WORDS cardiac, combination therapy,
heart failure, mesenchymal stem cell
1999