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Stem Cells in the Treatment of Heart Disease

Stefan Janssens
Division of Cardiology and Vesalius Research Center, VIB, Gasthuisberg University Hospital, University of Leuven, B-3000 Leuven, Belgium; email: Stefan.janssens@med.kuleuven.be

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Annu. Rev. Med. 2010. 61:287300 The Annual Review of Medicine is online at med.annualreviews.org This articles doi: 10.1146/annurev.med.051508.215152 Copyright c 2010 by Annual Reviews. All rights reserved 0066-4219/10/0218-0287$20.00

Key Words
cardiac stem cells, neovascularization, cardiomyogenesis, regenerative medicine (myocardial repair), transdifferentiation

Abstract
Progenitor cells residing in bone marrow, adipose tissue, and skeletal muscle or circulating in the blood are capable of improving myocardial function in preclinical models. In contrast, early clinical studies using bone marrow cells have shown mixed results and reect our incomplete understanding of underlying mechanisms. Recent identication of various cardiac precursor cells has suggested an endogenous reservoir for cell-based repair. However, confronted with massive cardiac cell loss, inventive strategies and enabling technologies are required to mobilize or deliver functionally competent progenitor cells to sites of injury or to effectively stimulate endogenous repair. We review our present knowledge in this promising and rapidly evolving development in cardiovascular medicine and highlight obstacles as well as opportunities.

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INTRODUCTION
AMI: acute myocardial infarction

The use of human stem cells is becoming pivotal for the development of new therapeutic strategies for many organ-specic diseases, which are characterized by abrupt or progressive loss of function and for which existing therapies are inadequate. Many signicant human diseases with limited options for a denitive cure are characterized by the loss or malfunction of specic cell types in the body. This is especially true for diseases associated with aging, including Alzheimers and Parkinsons disease, type II diabetes, heart failure, osteoarthritis, and autoimmune and hematopoietic disorders. The potential use of stem cells is also attractive for medical conditions resulting from acute damage to cells, e.g., infarction, trauma, and burns. In cardiology, the emerging eld of treatment called regenerative medicine or cell therapy has focused for many years on the development of methods to either induce replacement of damaged cells with stem cells to replenish the decit or (at least) use stem cells to mediate functional repair via paracrine, trophic effects (1). However, there is currently a growing understanding that in the course of evolution, the heart, like many adult solid organs, harbors a population of endogenous progenitor cells, potentially capable of regenerating the parenchymal cells of the tissue when properly activated (2). Importantly, for any cell therapy to be successful, equal efforts are required (a) to develop biomaterials, (b) to study signaling cues that will facilitate sustained cross-talk between cells and their specic microenvironment, and (c) to develop enabling technologies for successful clinical applications.

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hospitalization for heart failure is 26% (3). These sobering results are based on careful monitoring of patients included in randomized controlled trials, where implantable automatic debrillators, resynchronization devices, and pharmacological treatment with beta blockers, angiotensin converting enzyme (ACE) inhibitors, or angiotensin receptor blockers and spironolactone are optimally implemented. Most likely, clinical outcome in daily practice outside the setting of randomized trials is even more dismal. Advanced heart disease results from an abrupt or progressive loss of contractile myocytes, which in western societies is most often caused by an acute or chronic reduction of coronary blood ow. Therefore, soon after the rst promising results from mixed mononuclear bone marrow cells or selected subpopulations in small-animal models of cardiac ischemic injury (4), translational studies in patients with heart disease were initiated. In addition to these encouraging preclinical studies, the observed chimerism in the human heart (5, 6) further stimulated clinical researchers to explore autologous mononuclear bone marrow cell transfer strategies in ischemic heart disease.

EARLY CLINICAL EXPERIENCE

Initial trials of autologous bone marrow cells documented safety and feasibility both in patients with acute myocardial infarction (AMI) and in those with chronic ischemia and reported a modest, benecial effect on recuperation of LV function (7, 8, 9). By virtue of their exploratory design and emphasis on safety, these studies were not randomized, and they lacked a control population undergoing bone marrow aspiration followed by intracoronary infusion of vehicle or infusion of an irrelevant cell type. Again, the encouraging results of this rst clinical experience have accelerated subsequent introduction of larger randomized controlled trials. By 2006, four independent randomized studies using autologous bone marrowderived progenitor cells had been reported in AMI patients (Table 1). The

THE UNMET CLINICAL NEED IN HEART DISEASE

Despite state-of-the-art interventional and medical therapy for myocardial infarction (MI) and heart failure, clinical outcome remains poor in post-MI patients with reduced left ventricular (LV) function. The one-year mortality rate is 13%, and the incidence of the combined endpoint of death, recurrent infarction, or
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Table 1 Patient no. (center no.) Study design BMC vs rand control (1:1) BMC vs ic placebo (1:1) 1 Ficoll density gradient (same day) LymphoprepTM (next day) 87 Ficoll density gradient (same or next day) Ficoll-Hypaque 234 304 4.8 Gelatin polysuccinate (same day) 2460 60 (single) Transfer day after PCI Cell preparation (time of injection) Cell number ( 106 )

Randomized controlled stem cell trials in acute myocardial infarction Infarct size =

Trial

Myocardial function Global/regional (MRI) 6 mo: /18 mo: = Global/regional (MRI) 4 mo: = / Global/regional (MRI) 6 mo: = / = Global/regional (angiography) 4 mo: /

BOOST (Wollert et al.) 67 (single)

LEUVEN-AMI ( Janssens et al.) 100 (3 centers) BMC vs rand control (1:1) BMC vs ic placebo (1:1) 4 6

ASTAMI (Lunde et al.) 204 (18 centers) 80 (2 centers) BMC vs rand control (1:1) 1

REPAIR-AMI (Schachinger et al.)

NA

FINCELL (Huikuri et al.)

360

Global (angiography, 2D echocardiography) 6 mo 178 vs 1.9 Global/regional (MRI) 6 mo: = / =

NA

REGENT (Tendera et al.) 200 (8 centers) BMC vs PBC vs standard therapy (1:1:1) BMC early (36 wks) vs late (3-4 m) uncontrolled 38

200 (5 centers)

BMC vs selected CD34+ +CXCR4+ cells vs control (2:2:1)

Ficoll density gradient (same day) LymphoprepTM (same day)

NA

HEBE (Hirsch et al.) 60 (6 centers)

296 vs 287

Global/regional (MRI) 4 mo = / = 2142 vs 90120 COBE SPECTRA im 200 vs 195 ic 1300 vs 1290 Global/regional (SPECT) 9 12 mo: /

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MYSTAR (Gyongyosi et al.)

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Abbreviations: BMC, bone marrow cells; ic, intracoronary; im, intramyocardial; MRI, magnetic resonance imaging; mo, months; NA, not available; PBC, peripheral blood cells; SPECT, single photon emission computed tomography.

PCI: percutaneous coronary intervention LVEF: left ventricular ejection fraction

common objective was to investigate whether or not intracoronary infusion of autologous bone marrow cells conferred incremental benet beyond state-of-the-art reperfusion therapy and postinfarction pharmacological therapy. Inherent to the early stage of development, the studies differed in design, patient numbers, cell preparation methods, timing of cell transfer after percutaneous coronary intervention (PCI), and imaging modalities. The BOOST study was the rst randomized controlled study to report a signicant improvement in global LV function recovery after six months, expressed as a 6% incremental increase in LV ejection fraction (LVEF) evaluated using magnetic resonance imaging (MRI) in patients who had received intracoronary cell infusion after a median of 4.8 days following index PCI (10). The authors attributed the transient cell-mediated benet to enhanced regional contraction in the infarct border zones. The study was, however, not placebo-controlled; the control group did not undergo bone marrow aspiration, nor a second coronary intervention with repeated stop ow conditions. Moreover, functional recovery at six months was conned to the cell transfer group andsomewhat unexpectedlynot observed in control patients. Of note, one and ve years later, global LV function in patients who had received cell transfer was the same as that in patients who had received state-of-theart treatment (11). The relatively small number of patients, the absence of a control group undergoing repeat coronary infusions, and the relatively mild reduction in LV function after the index infarction need to be considered when interpreting these results. Two subsequent double-blind randomized placebo-controlled studies, conducted at the universities of Leuven and Frankfurt (12, 13) in a similar AMI population, addressed some of these confounding variables associated with bone marrow aspiration and a second catheterization. The increase in global LV function recovery in patients randomized to cell transfer above and beyond the increase in control patients receiving state-of-the-art therapy
Janssens

ranged from 1.2% to 2.5% supplemental increase in LVEF. In addition, patients receiving cell transfer had a signicantly greater reduction in infarct size for a similar area at risk, as assessed using repeated MRI, and a greater recovery of regional systolic function. Importantly, these benecial effects were sustained at one-year follow-up (14, 15). Whereas bone marrow cell isolation, preparation, and characterization protocols were similar in the Leuven and Frankfurt studies, this was not the case for the Norwegian ASTAMI study (Table 1). The latter was also not placebo-controlled and concluded in 100 post-AMI patients that mononuclear bone marrowderived cell transfer did not increase global LV function recovery or reduce infarct size at six months as evaluated by MRI (16). Although the reasons for these divergent ndings are still unclear, signicant differences in trial design, isolation, and characterization of the stem cell preparation need to be considered (17). Indeed, a head-to-head comparison of the cell infusate in the Repair-AMI and the ASTAMI studies revealed important differences in bone marrow cell functionality, depending on laboratory procedures (17, 18). The Frankfurt Repair-AMI trial was a multicenter study involving 18 different sites with a central core laboratory for bone marrow cell processing (13). Cell transfer was therefore not always performed on the same day after the index PCI but ranged from three to seven days, whereas patients in the Leuven study received placebo or bone marrow cell infusion at 24 h after the rst intervention. Interestingly, when data were stratied by time of cell transfer and by severity of LV dysfunction at baseline, the benet was predominantly observed in patients receiving delayed cell transfer and in patients with a baseline LVEF below the median value of 49%. The latter observation is in agreement with our own ndings of signicantly enhanced metabolic recovery in AMI patients with large infarctions receiving cell transfer. Although the studies were not powered to primarily evaluate the effects of MI size, there was a signicant interaction between infarct severity

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and subsequent benet from cell transfer. The best results were observed in patients suffering from large infarctions with more depressed global ejection fractions (incremental increase in LVEF of 5%6%). Because of the smaller number of patients, we failed to detect a significant difference in global functional recovery but did observe signicantly greater improvement in regional contractile function in the infarct core and border zones, using both MRI and tissue Doppler analysis (19). Interestingly, strain rate and MRI-based wall-motion analysis in all infarcted segments with a >50% transmural extent of myocardial necrosis conrmed a signicant benet up to one year after cell transfer (15). We cannot exclude that by giving the cells sooner after the index infarction, we may have missed a more favorable time point for cell transfer, especially in view of the high incidence of microvascular obstruction that is observed in the early phase of reperfusion and that may limit homing, engraftment, and survival of infused cells. As highlighted in editorial comments that accompanied these pioneering studies, the best focus for future cell therapy efforts, therefore, would be in patients with severe ischemic cardiomyopathy (anterior infarctions and significant LV dysfunction) (20, 21). This focus is consistent with the unmet clinical need in this expanding population and represents the prime target in second-generation clinical trials. A major point of discussion, however, remains whether or not the absolute incremental increase in LVEF of 1.2% to 2.5% or the favorable effect on coronary ow reserve (22), infarct remodeling, and recovery of regional LV function translate into a meaningful clinical benet at longer-term follow-up and justify the additional costs of cell-based interventions. Although only adequately powered prospective clinical trials can provide the answers, the question echoes earlier discussions on the benet of changes in LVEF of similar magnitude obtained with beta blockers and ACE inhibitors in heart failure (23).

SECOND-GENERATION RANDOMIZED CLINICAL TRIALS

The common objective of the rst four landmark trials was to investigate incremental benet of autologous bone marrow cell transfer on global LV function recovery beyond stateof-the-art therapy for ST-segment elevation myocardial infarction (STEMI). In contrast, the most recent randomized studies also addressed (a) cell transfer in AMI patients receiving thrombolysis (24), (b) the added value of CD34+ CxCR4-selected hematopoietic stem cells (25), (c) selection of alternative control cells and surrogate primary end points (26), (d ) more restrictive inclusion criteria, and (e) different timing (early or late) and cell delivery routes (combined intramyocardial and intracoronary injection) (27) (Table 1). The FINCELL study is a multicenter randomized placebo-controlled trial including 80 patients with STEMI treated with thrombolysis followed by PCI and stenting 26 days after the acute coronary event (24). Patients were randomly assigned to receive intracoronary mixed bone marrow cells or placebo solution infused into the infarct-related coronary artery immediately after stenting. This study conrmed that intracoronary administration of bone marrow cells is safe in STEMI patients treated with thrombolytic therapy followed by PCI and is associated with an incremental improvement of global LVEF measured by LV angiography (7.1 vs 1.2%, p = 0.05) and 2D echocardiography (4.0 vs 1.4%, p = 0.03). In this study, however, the biological signicance of the observed changes in LVEF remains unclear as baseline values indicated virtually preserved global LV function before cell infusion. The Polish REGENT trial, in contrast, was a randomized but not placebo-controlled multicenter trial including 200 AMI patients with baseline LVEF 40% undergoing primary PCI (25). Patients were randomly assigned to selected CD34+ CXCR4+ bone marrow cell infusion, unselected mononuclear cell infusion, or control (ratio 2:2:1). The median time
STEMI: ST-segment elevation myocardial infarction

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between PCI and cell infusion was seven days (range 312 days), and the median number of infused CD34+ CXCR4+ cells was 1.9 106 in the selected cell group versus 1.78 106 in the unselected mononuclear cell group. At six months, the increase in LVEF observed in the cell treatment groups was not signicantly different from the increase in control patients. Of note, and consistent with the Repair-AMI study, a post hoc analysis in patients whose initial LVEF was below the median value of 37% indicated a more pronounced (5%) increase in global function recovery following cell transfer. Importantly, the design of the study did not allow evaluation of potential benets of bone marrow cell enrichment strategies, because the number of injected CD34+ CxCR4+ cells did not differ between the two cell arms of this study. Moreover, the primary endpoint analysis using repeated MRI was performed in only 60% of included patients (117 of 200 patients), which reduced the power to detect cell-mediated differences in global function recovery. The HEBE trial is also a multicenter randomized but not placebo-controlled trial including 200 STEMI patients undergoing primary PCI (26). Patients in eight medical centers in the Netherlands were randomized to intracoronary bone marrowderived mononuclear cell infusion, mononuclear peripheral blood cell infusion, or primary PCI alone (ratio 1:1:1). Cell aspiration and intracoronary infusion were performed 38 days after primary PCI. Despite promising results in the pilot trial (28, 29), intracoronary infusion of bone marrowderived cells failed to improve regional myocardial function recovery (primary endpoint) and global LV function and LV remodeling (secondary endpoints) in rst-time large-STEMI patients undergoing PCI. The reasons for these negative ndings are unclear, and although we are still awaiting data on infarct remodeling in this carefully executed study with serial MRI analysis in 189 of 200 patients, we can only speculate that the functional capacity of cells and/or their ability to home, engraft, and survive in ischemic myocardium
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is insufcient to mediate detectable biological effects. MYSTAR was a randomized multicenter open-label trial including 60 patients with LVEF <45% after AMI (27). Bone marrow derived mononuclear cells were delivered via combined intramyocardial injection and intracoronary infusion at either 36 weeks (early) or 34 months (late) after AMI. This study demonstrated feasibility, safety, and efcacy of combined delivery of a large number of autologous bone marrowderived mononuclear cells in patients after AMI with severely depressed LV function. Early and late treatment both resulted in an improvement in infarct size and global systolic function recovery, and the benet was sustained at 912 months. However, in the absence of a randomized control group, the biological signicance is unclear. Prospective randomized controlled trials will be required, including the ongoing multicenter SWISS-AMI trial in 150 STEMI patients, comparing early, late, or no cell transfer after PCI. Taken together, these recently reported trials, some of which are still ongoing, conrm that treatment with bone marrowderived cells is safe and feasible in AMI patients and in patients with ischemic cardiomyopathy. However, the use of selected bone marrow stem cells did not show an additional benet over mixed mononuclear bone marrow cells or state-ofthe-art reperfusion and pharmacological therapy, despite selection of patients with more pronounced LV dysfunction (REGENT and HEBE studies). It is difcult to reconcile the apparently discrepant results in the above studies with the earlier-stated best window of opportunity for cell therapy, but limitations in study design or conduct may account for some of the variability. Moreover, accumulating data point to reduced functionality of bone marrow cells in patients with severe and advanced ischemic heart disease (30), and these recent observations may well have affected the outcome in REGENT and HEBE, which specically targeted patients with large MIs and likely more advanced atherosclerotic disease.

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UNRESOLVED QUESTIONS ON MECHANISMS OF ACTION: CARDIOPROTECTION VERSUS CARDIOMYOGENESIS?

Until recently, the major premise in preclinical tests was that circulating or bone marrow derived progenitor cells could potentially repopulate the injured myocardium and undergo milieu-dependent differentiation to form vascular cells and cells with a cardiomyocyte-like phenotype (31). Improvements in cardiac function following adult mononuclear stem or progenitor cell injection in preclinical models were initially ascribed to cardiac and vascular regeneration via such autocrine transdifferentiation mechanisms (4). However, the plasticity of adult stem cells remains debatable, with more recent data questioning the validity of the cardiomyogenic potential of these cells (32). Based on observations in genetically engineered mice allowing unambiguous tracking of both donor lineage and cardiac phenotype with a single molecular marker, the prevailing view among stem cell scientists and developmental biologists is that cardiac transdifferentiation after direct injection of hematopoietic stem cells is very limited (33, 34). Moreover, limited retention, engraftment, and survival of transferred cells in clinical and preclinical studies alike favor paracrine effects via secreted trophic factors that may stimulate nutrient blood supply, reduce apoptotic cardiomyocyte death, or activate residual cardiac resident stem cells (Figure 1) (35, 36). Differentiation into cardiomyocytes has only been clearly demonstrated in embryonic stem cells (37) and cardiac resident stem cells (38, 39). More recent preclinical studies in mice have likewise suggested that intracardiac injection of in vitro expanded adult mesenchymal stem cells exerted a benecial effect on the infarcted myocardium by enhancing neoangiogenesis rather than via true cardiac regeneration (40). Thus, despite initial reports of cardiomyogenic potential, many subsequent studies in mice, rats, and pigs have concluded that bone marrowderived or circulating

progenitor cells may improve cardiac function indirectly via release of trophic factors that enhance angiogenesis and rescue cardiomyocytes at risk in the infarct border zone (35, 41, 42). Similarly, the limited improvement in global systolic function recovery in clinical studies with adult mononuclear bone marrow cells has traditionally been ascribed to insufcient homing, engraftment, and survival of transplanted cells into the ischemic and hostile milieu. To a certain extent, this may relate to faulty extrapolation of the data from small animals to the human, failure to properly account for the difference in size between rodent and human, and the unknown nature, functionality, and number of true stem cells administered (43). In addition, most of the cell transplantation based therapeutic approaches used so far are predicated on the concept that the adult human myocardium does not have intrinsic regenerative capacity because the working myocytes are terminally differentiated cells with no regenerative capacity. Recently, however, the adult myocardium has been found to harbor a population of resident pluripotent cells with the characteristics of true cardiac stem cells, i.e., self-renewing, clonogenic, and multipotent. Several groups have identied cardiac stem cells possessing growth factorreceptor systems and reported different membrane markers or transport proteins. These endogenous cardiac stem cells (CSCs) are able to regenerate the contractile myocytes and endothelial and smooth muscle cells of the microvasculature, but their numbers vary substantially between species, and it is unclear whether they constitute phenotypic variations of a unique cell type (38, 44). The very recent demonstration that human ISL1 heart progenitors, isolated from second-heart-eld-derived structures in embryonic life, are capable of selfrenewal, expansion, and differentiation into the major cell types in the heart provides another important model system for ES-cell-derived cardiomyogenesis (55). All these discoveries

CSC: cardiac stem cell

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Ischemia

Necrosis

Remodeling

Myocardial injury/damage
PCI (CABG-MedR/)

Functional repair

Cardioprotection
CMC apoptosis CMC oxidative stress CMC metabolism Neovascularization Fibrosis/matrix remodeling
Trophic eects

Cardiac regeneration
Stimulation/maturation of cardiac stem cells Transdierentiation?

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Stem cell transfer

Cardiac muscle

Skeletal muscle

Bone marrow

Adipose tissue

Figure 1 Cell-based myocardial functional repair. Abbreviations: PCI, percutaneous coronary intervention; CABG, coronary artery bypass grafting; CMC, cardiomyocyte.

have opened novel therapeutic avenues for physiologically meaningful regeneration of the myocardium damaged by ischemic or inammatory events or by congenital defects (1, 45, 46). The problem is that these reservoirs of cells are usually overridden in patients with AMI, advanced coronary artery disease, and chronic heart failure. Despite this limited capacity for regeneration of myocardium, the existence of these repair mechanisms suggests that cardiac repair may be achieved therapeutically in these clinical settings, given the appropriate stimulation (in situ activation, multiplication and differentiation of the eCSCs) and/or adoptive transfer of (stem) cells involved in these processes (47, 48). Cardiac repair via endogenous CSCs represents a major target for translational research in the years to come.
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THE QUEST FOR THE OPTIMAL CELL SOURCE: AUTOLOGOUS VERSUS ALLOGENEIC, EXOGENOUS VERSUS ENDOGENOUS PROGENITOR CELLS?
Autologous cell therapies, even if their clinical efcacy were markedly superior, suffer from relative complexity and face signicant cost constraints posed by the need to make the treatment affordable to large numbers of candidate patients. Moreover, the clinical requirement for a readily available (off-the-shelf ) treatment that can be prepared and administered in the majority of catheterization laboratories during the acute phase of the disease remains a major challenge (Table 2). To circumvent some of these obstacles, a rapid

Table 2

Cell types and modalities for myocardial repair

Progenitor cell transfer Allogeneic versus autologous cells Autocrine versus paracrine, trophic effects Purication/expansion/manipulation of cells under GMP conditions required Autologous cell function affected by disease severity Limited cell engraftment or survival upon transplantation in injured heart Stimulation endogenous cardiac stem cells Tissue-specic with slow regenerative response Express receptors for growth factors/cytokines produced by injured/stressed cardiomyocytes Activation requires knowledge of differentiation and maturation signals Reservoir depleted after extensive myocardial injury

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and relatively simple purication procedure has been proposed to isolate a mixed mononuclear progenitor cell population from adipose tissue, with a promising prole in preclinical testing (49). However, inclusions in two earlyphase clinical protocolsthe APOLLO trial in AMI (50) and the PRECISE trial in patients with chronic ischemic cardiomyopathyhave recently been halted (H.J. Duckers, personal communication), and the yield of progenitor cells processed by the Celution system (Cytori Therapeutics) from liposuction tissue in patients on concomitant antiplatelet and/or anticoagulant therapies is unclear. Similarly, other potential candidate autologous cell types, including early outgrowth endothelial progenitor cells and skeletal musclederived myoblasts, require time-consuming and expensive cultureexpansion steps in GMP-certied laboratories, adding to the cost and complexity and introducing potential risk for inadvertent contamination. Moreover, these cells failed to confer signicant benet in patients with chronic ischemic cardiomyopathy (51, 52), which has been largely attributed to poor engraftment and survival of transplanted cells. In contrast, allogeneic cells offer in principle distinct advantages with respect to practical clinical application, as an offthe-shelf advanced medicinal product. For a long time, mesenchymal stem cells were thought to fulll the criteria for a clinically suitable allogeneic cell product because of their low immunogenicity and their repair capacityboth in

terms of secretory prole and transdifferentiation capacity. Again despite successful preclinical testing, the rst clinical applications in post-MI patients failed to show a signicant improvement in global or regional systolic function. Alternatively, in vitro predifferentiation into a cardiomyogenic lineage or use of more lineage-committed progenitor cells (e.g., mesangioblasts) may also enhance integration and coupling of transferred cells and stimulate functional recovery. These novel concepts are currently under investigation in prospective clinical studies of patients with chronic ischemic cardiomopathy and reduced LV function. In addition, clinical trials have thus far not been able to capitalize on the intrinsic regenerative capacity of the heart and the potential role of endogenous CSCs in cardiac cellular homeostasis. Insufcient knowledge of biological mechanisms to activate this dormant reservoir remains a major obstacle for clinical studies and a high priority for translational research.

LIMITATIONS AND FUTURE OUTLOOK

Although we have witnessed remarkable progress in this exciting era of translational cell-based therapies for cardiovascular disorders, many outstanding questions remain. Most importantly, we have recognized that insufcient homing and survival of transplanted cells into the ischemic milieu (53) and
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GMP: good manufacturing practice

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Enabling technologies: Tissue generation:

Tissue organization Biomarkers Imaging technologies High-throughput technologies Model systems Bioreactors

Regenerative therapies:
Clinical validation

Interaction:

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Cells, microenvironment, and biomaterials

Basic research:
Stem/progenitor cell dierentiation and maturation

Figure 2 Regenerative medicine: a stepwise investigational approach.

reduced functional capacity, along with absence of cardiomyogenesis, limit bone marrow cell based cardiac repair (Figure 2). We also lack a proper understanding of the vital cues in the microenvironment to which cells are exposed and of the more complex signals for tissue organization. Several potential priming strategies of adult progenitor cells with PPAR-gamma modulators, eNOS enhancers, integrin activators, and statins are being applied to improve homing, engraftment, and other critical progenitor cell functions (54). Some have already shown promising results in experimental models (30) and will undergo clinical testing. Meanwhile, priming of the ischemic target milieu with shockwave treatment and targeted investigations to identify optimal cell dose, delivery methods, cell type, and timing of transfer are ongoing (54). Importantly, innovative tissue engineering protocols that combine cells with articial or natural scaffolds may further enhance cell-mediated benet. All of these conditions need to be and will be tested in properly designed and focused preclinical large-animal
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models and in properly sized mechanistic clinical trials. In contrast, it is not known whether in vitro cardiomyogenic differentiation enhances integration and coupling of transferred cells and accelerates functional recovery, and these questions represent a much greater challenge. Only when successful cardiac prespecication protocols have been established in vitro will we be able to test this treatment paradigm in experimental models. Rapidly growing insights in cardiopoietic programming from induced pluripotent patient-specic cells or in stimulation and amplication mechanisms of endogenous CSCs offer signicant potential for cardiomyogenesis in the years to come without prohibitive ethical or immunological obstacles. Finally, we should realize that none of the above obstacles will be overcome without concomitant efforts to develop critically needed enabling technologies. These include characterization of biomarkers (monitoring biological activity and efcacy of implanted cells and biomaterials), validation of appropriate

imaging modalities (molecular imaging tools), high-throughput techniques (screens of small molecules capable of specifying and guiding differentiation processes), model systems (mimicking interactions between stem cells and local environment), and bioreactors (cell amplication procedures under GMP conditions).

CONCLUSIONS
Many of the cell-based treatment protocols have proven modestly effective at best. Although they are interesting from the point of view of advancing a new paradigm for the treatment of ischemic heart disease and heart failure, none is poised to solve the severe public health problem of advanced cardiac disease yet. So far, most bone marrow cell transfer is safe and might constitute a valuable treatment option for patients with large MI and signicantly impaired LV function. The absolute incremental increase in global function recovery following cell transfer is modest, and at least

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three randomized trials failed to show significant changes in surrogate endpoints. Under these circumstances, judicious clinical development of cell-based cardiac repair requires stepwise investigations of the critical limitations to functional recovery, as we understand it today. At an early stage, this will best be accomplished through collaborative studies on cell-enhancement strategies involving expert centers and will benet from standardized operational procedures for progenitor cell procurement, processing, and functional evaluation. At the same time, cross-talk between clinicians, basic scientists, and developmental stem cell biologists will be indispensable in this rapidly progressing eld of medicine. Preclinical studies in relevant large-animal models are needed to dene our best options. It is very likely that new and better progenitor cell populations will be identied in the near future and that cardiac prespecication or endogenous CSC activation will become a realistic treatment option.

DISCLOSURE STATEMENT
Dr. Janssens is a group leader at VIB and holds a named chair nanced by AstraZeneca at KU-Leuven, Belgium.

ACKNOWLEDGMENTS
Dr. Janssens is supported by a research grant from the Flemish Institute for Scientic Research, FWO and the University of Leuven, Belgium (GOA). LITERATURE CITED
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51. Assmus B, Honold J, Schachinger V, et al. 2006. Transcoronary transplantation of progenitor cells after myocardial infarction. N. Engl. J. Med. 355(12):122232 52. Menasche P, Aleri O, Janssens S, et al. 2008. The Myoblast Autologous Grafting in Ischemic Cardiomyopathy (MAGIC) trial: rst randomized placebo-controlled study of myoblast transplantation. Circulation 117(9):1189200 53. Hofmann M, Wollert KC, Meyer GP, et al. 2005. Monitoring of bone marrow cell homing into the infarcted human myocardium. Circulation 111(17):2198202 54. Dimmeler S, Burcheld J, Zeiher AM. 2008. Cell-based therapy of myocardial infarction. Arterioscler. Thromb. Vasc. Biol. 28(2):20816 55. Bu L, Jiang X, Martin-Puig S, et al. 2009. Human ISL1 heart progenitors generate diverse multipotent cardiovascular cell lineages. Nature 460:11317

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Contents
Using Genetic Diagnosis to Determine Individual Therapeutic Utility C. Thomas Caskey p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 1 Emotion Recollected in Tranquility: Lessons Learned from the COX-2 Saga Tilo Grosser, Ying Yu, and Garret A. FitzGerald p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p17 Progressive Multifocal Leukoencephalopathy in Patients on Immunomodulatory Therapies Eugene O. Major p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p35 The Future of Antiplatelet Therapy in Cardiovascular Disease Carlo Patrono and Bianca Rocca p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p49 Pharmacogenetics of Warfarin Farhad Kamali and Hilary Wynne p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p63 Heparin-Induced Thrombocytopenia Gowthami M. Arepally and Thomas L. Ortel p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p77 Regulation of Phosphate Homeostasis by PTH, Vitamin D, and FGF23 Clemens Bergwitz and Harald Juppner p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p91 Alveolar Surfactant Homeostasis and the Pathogenesis of Pulmonary Disease Jeffrey A. Whitsett, Susan E. Wert, and Timothy E. Weaver p p p p p p p p p p p p p p p p p p p p p p p p p p p p 105 Diagnosis and Treatment of Neuropsychiatric Disorders Katherine H. Taber, Robin A. Hurley, and Stuart C. Yudofsky p p p p p p p p p p p p p p p p p p p p p p p p p p p 121 Toward an Antibody-Based HIV-1 Vaccine James A. Hoxie p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 135 HIV-1 Vaccine Development After STEP Dan H. Barouch and Bette Korber p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 153 Growing Up with HIV: Children, Adolescents, and Young Adults with Perinatally Acquired HIV Infection Rohan Hazra, George K. Siberry, and Lynne M. Mofenson p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 169

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H5N1 Avian Inuenza: Preventive and Therapeutic Strategies Against a Pandemic Suryaprakash Sambhara and Gregory A. Poland p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 187 Revascularization for Coronary Artery Disease: Stents Versus Bypass Surgery Spencer B. King III, John Jeffrey Marshall, and Pradyumna E. Tummala p p p p p p p p p p p p p 199 Controversies in the Use of Drug-Eluting Stents for Acute Myocardial Infarction: A Critical Appraisal of the Data Rahul Sakhuja and Laura Mauri p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 215
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Arrythmogenic Cardiomyopathy: Etiology, Diagnosis, and Treatment Srijita Sen-Chowdhry, Robert D. Morgan, John C. Chambers, and William J. McKenna p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 233 Contemporary Use of Ventricular Assist Devices Cesare M. Terracciano, Leslie W. Miller, and Magdi H. Yacoub p p p p p p p p p p p p p p p p p p p p p p p p p p 255 Stress Cardiomyopathy Yoshihiro J. Akashi, Holger M. Nef, Helge M llmann, and Takashi Ueyama p p p p p p p p p p p 271 o Stem Cells in the Treatment of Heart Disease Stefan Janssens p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 287 Biological Mechanisms Linking Obesity and Cancer Risk: New Perspectives Darren L. Roberts, Caroline Dive, and Andrew G. Renehan p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 301 Hepatocellular Carcinoma: Novel Molecular Approaches for Diagnosis, Prognosis, and Therapy Augusto Villanueva, Beatriz Minguez, Alejandro Forner, Maria Reig, and Josep M. Llovet p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 317 Molecular Diagnosis and Therapy of Kidney Cancer W. Marston Linehan, Gennady Bratslavsky, Peter A. Pinto, Laura S. Schmidt, Len Neckers, Donald P. Bottaro, and Ramaprasad Srinivasan p p p p p p p p p p p p p p p p p p p p p p p p p p 329 Myelodysplastic Syndromes Bart L. Scott and H. Joachim Deeg p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 345 Nanotechnology Applications in Surgical Oncology Sunil Singhal, Shuming Nie, and May D. Wang p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 359 Emerging Molecular Targets for the Treatment of Nonalcoholic Fatty Liver Disease Giovanni Musso, Roberto Gambino, and Maurizio Cassader p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 375 Metabolic Surgery to Treat Type 2 Diabetes: Clinical Outcomes and Mechanisms of Action Francesco Rubino, Philip R. Schauer, Lee M. Kaplan, and David E. Cummings p p p p p p p p 393
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Genetic Aspects of Pancreatitis David C. Whitcomb p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 413 Anorexia Nervosa: Current Status and Future Directions Evelyn Attia p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 425 Structural Variation in the Human Genome and its Role in Disease Pawel Stankiewicz and James R. Lupski p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 437 Surgical Innovations Arising from the Iraq and Afghanistan Wars Geoffrey S.F. Ling, Peter Rhee, and James M. Ecklund p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 457 Medicare Part D: Ongoing Challenges for Doctors and Patients Gretchen Jacobson and Gerard Anderson p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 469 Indexes Cumulative Index of Contributing Authors, Volumes 5761 p p p p p p p p p p p p p p p p p p p p p p p p p p p 477 Cumulative Index of Chapter Titles, Volumes 5761 p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 481 Errata An online log of corrections to Annual Review of Medicine articles may be found at http://med.annualreviews.org/errata.shtml

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