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CELL-BASED MYOGENIC AND ANGIOGENIC THERAPY FOR MYOCARDIAL REGENERATION

CELL-BASED MYOGENIC AND ANGIOGENIC THERAPY FOR MYOCARDIAL REGENERATION. J.C. CHACHQUES, MD, PhD POMPIDOU HOSPITAL PARIS - FRANCE. René Magritte Surrealist painter 1898-1967. EUROPEAN HOSPITAL GEORGES POMPIDOU. CARDIAC BIOASSIST PROCEDURES. MOLECULAR BASIS OF CONGESTIVE HEART FAILURE.

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CELL-BASED MYOGENIC AND ANGIOGENIC THERAPY FOR MYOCARDIAL REGENERATION

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  1. CELL-BASED MYOGENIC AND ANGIOGENIC THERAPY FOR MYOCARDIAL REGENERATION J.C. CHACHQUES, MD, PhD POMPIDOU HOSPITAL PARIS - FRANCE

  2. René MagritteSurrealist painter 1898-1967

  3. EUROPEAN HOSPITAL GEORGES POMPIDOU

  4. CARDIAC BIOASSIST PROCEDURES

  5. MOLECULAR BASIS OF CONGESTIVE HEART FAILURE • LACK OF MYOCARDIAL STEM CELLS • UNABILITY OF THE DAMAGED CELLS TO • UNDERGO SUFFICIENT REPAIR

  6. HEART FAILURE THERAPY • PHARMACOLOGICAL THERAPY • CARDIAC PACING FOR RESYNCHRONIZATION • VENTRICULAR RESTORATION, LV REDUCTION • CARDIOMYOPLASTY, AORTOMYOPLASTY • VENTRICULAR CONTAINMENT, MITRAL VALVULOPLASTY • HEART TRANSPLANTATION • MECHANICAL ASSIST DEVICES - ARTIFICIAL HEART • CELLULAR CARDIOMYOPLASTY

  7. CELL TRANSPLANTATION THERAPY • VASCULAR SURGERY: CRITICAL LEG ISCHEMIA • HEMATOLOGY : LEUKEMIA • DERMATOLOGY : EPIDERMAL CELLS • OPHTHALMOLOGY: CORNEAL REGENERATION • ORTHOPEDICS : CHONDROCYTES • MYOLOGY : DUCHENNE DYSTROPHY • NEUROLOGY : PARKINSON DISEASE • HEPATOLOGY : HEPATOCYTES • DIABETES : LANGERHANS ISLETS

  8. NOVEL EMERGING TREATMENTS IN ISCHEMIC HEART FAILURE • CELL-BASED MYOGENIC THERAPY • CELL-BASED ANGIOGENIC THERAPY

  9. LIMITATIONS OF ANGIOGENIC GROWTH FACTORS AND GENE THERAPY • GROWTH FACTOR PROTEINS • Systemic effects: angiogenesis in the retina. • Intimal arterial hyperplasia and development of • atheromatous plaque. • Potentiation of growth and metastasis of occult tumors • GENE THERAPY • Instability and adverse response to transfection vectors

  10. ANGIOGENIC CELLS • BONE MARROW DERIVED ANGIOBLASTS Hematopoietic stem cells (HSC): CD34+ • Progenitor endothelial cells (PEC): CD 133+ • VASCULAR ENDOTHELIAL CELLS • collected from the intima of arteries or veins

  11. CliniMACS instrument for immuno-magnetic cell selection (microbeads)Miltenyi Biotec Germany

  12. MYOGENIC CELLS • SKELETAL MYOBLASTS ( satellite cells ) • SMOOTH MUSCLE CELLS • BONE MARROW CELLS : • Multipotent adult progenitor cells (MAPC) • CARDIOMYOCYTES : fetal, neonatal

  13. SKELETAL MUSCLE BIOPSY

  14. MYOBLAST CULTURE TECHNIQUE • Manipulations in a laminar flow hood • REMOVAL OF FIBROUS AND ADIPOSE TISSUE FROM MUSCLE BIOPSY • MUSCLE MINCING WITH SCISSORS • ENZYMATIC (collagenase + trypsin) & MECHANICAL DIGESTION • MULTIPLE CENTRIFUGATIONS

  15. MYOBLAST CULTURE TECHNIQUE • ISOLATION OF MYOBLASTS, EXCLUSION OF FIBROBLASTS • IN VITRO MYOBLASTS CULTURE : 3 WEEKS, 37°C, 5% CO2 • ASSESSMENT OF % CELL VIABILITY : TRYPAN BLUE • ASSESMENT OF % MYOBLASTS / FIBROBLASTS : • CD 56 and DESMIN ANTIBODIES • STERILITY TESTS : BACTERIAL, VIRAL, FUNGIAL • CELL SUSPENSION IN 0.5 % HUMAN ALBUMIN FOR • MYOCARDIAL INJECTION

  16. CELL CULTURES with AUTOLOGOUS-HUMAN-SERUM - obtained from plasmapheresis or blood sample - • AVOIDS THE FIXATION OF ANIMAL PROTEINS (FBS) ON THE CELL SURFACE • AVOIDS IMMUNOLOGICAL AND INFLAMMATORY ADVERSE EVENTS LEADING TO FIBROSIS AND MICRO-REENTRY CIRCUITS • REDUCE THE RISK OF ARRHYTHMIA AND THE NEED OF A DEFIBRILLATOR • AVOIDS THE RISK OF PRION, VIRAL, OR ZOONOSES CONTAMINATION

  17. TRANSPLANTED SKELETAL MYOBLASTSINTRAMYOCARDIAL ORGANIZATION • ISOLATED MYOBLASTS • MULTINUCLEATED MYOTUBES • MYOFIBRES

  18. IN VIVO MYOBLAST ORGANIZATION

  19. CELL IMPLANTATION TECHNOLOGIES • EPICARDIAL APPROACH • SURGICAL : CLASSIC OR MINIMALLY INVASIVE • THORASCOCOPIC • ENDOVENTRICULAR : CATHETER BASED • ASSISTED BY 3D ELECTROMECHANICAL MAPPING • ASSISTED BY ECHO & FLUOROSCOPY, MRI • INTRAVASCULAR • CATHETER BASED INTRACORONARY • CORONARY VENOUS ROUTE or INTRAVENOUS SYSTEMIC

  20. ELECTROMAGNETIC 3D CARDIAC MAPPING

  21. PRE / POSTOPERATIVE EVALUATION • MYOCARDIAL VIABILITY • POSITRON EMISSION TOMOGRAPHY : 2 fluoro deoxyglucose. • MAGNETIC RESONANCE IMAGING : uptake of gadolinium. • SCINTIGRAPHY: stress-redistribution-reinjection • 201 thallium scintigraphy.

  22. PRE / POSTOPERATIVE EVALUATION • VENTRICULAR FUNCTION • BASAL AND DOBUTAMINE STRESS ECHOCARDIOGRAPHY • RADIONUCLIDE VENTRICULOGRAPHY • CARDIAC CATHETERIZATION + CORONAROGRAPHY • COLOR KINESIS AND DOPPLER TISSUE ECHOGRAPHY • NEUROHORMONAL ACTIVATION(BNP)

  23. CELLULAR CMP - INCLUSION CRITERIA • MYOCARDIAL INFARCT • DILATED CARDIOMYOPATHIES • NYHA FUNCTIONAL CLASS 2 - 3 • LV WALL THICKNESS > 4 mm • LV EJECTION FRACTION : 20 to 40% • VIRUS-FREE TESTS • FREE OF UNCONTROLABLE ARRHYTHMIAS

  24. CELLULAR CMP MECHANISMS OF BENEFICIAL EFFECTS • VENTRICULAR REMODELING • REDUCES THE SIZE AND FIBROSIS OF INFARCT SCARS • MINIMIZES GLOBAL VENTRICULAR DILATATION • INCREASES MYOCARDIAL WALL THICKNESS • INDUCES MODULATION OF EXTRACELLULAR MATRIX

  25. CELLULAR CMP - PET 18 FDG 3 MONTHS PREOP

  26. CELLULAR CMP MECHANISMS OF BENEFICIAL EFFECTS • DIASTOLIC FUNCTION • IMPROVES MYOCARDIAL WALL TENSION AND ELASTICITY • IMPROVES STRAIN AND DYNAMIC STIFFNESS • REVERSES DIASTOLIC CREEP

  27. CELLULAR CMP MECHANISMS OF BENEFICIAL EFFECTS SYSTOLIC FUNCTION • IMPROVES REGIONAL VENTRICULAR WALL MOTION • INCREASES DEVELOPED PRESSURES • IMPROVES GLOBAL VENTRICULAR CONTRACTION ?

  28. CLINICAL TRIALS • > 150 ischemic patients (Europe, America, Asia) • Skeletal Myoblasts <=> Bone Marrow Cell Implants • Surgical <=> Interventional Cardiology Procedures • Defibrillators only implanted in myoblast approach • (when cultivated with bovine serum)

  29. CLINICAL DIFFICULTIES TO BE SOLVED • CHOICE OF CELL TYPE AND DOSE • CELL ENGRAFTMENT AFTER IMPLANTATION need of prevascularization ? • DIFFERENTIATION OF STEM CELLS IN FIBROBLASTS • HOST-CELL INTERACTIONS mechanical and electrical coupling ? • ELECTRICAL INSTABILITY >>ARRHYTHMIAS

  30. CONCLUSIONS CURRENT EXPERIMENTAL AND CLINICAL RESULTS SUGGEST THAT CELLULAR CRDIOMYOPLASTY FOR MYOCARDIAL REGENERATION MAY BE EFFICIENT TO AVOID PROGRESSION OF VENTRICULAR REMODELING AND SUBSEQUENT HEART FAILURE IN PATIENTS WITH MODERATE CARDIAC INSUFFICIENCY RESULTING FROM ISCHEMIC HEART DISEASE

  31. NEW DEVELOPMENTS • ASSOCIATION OF ANGIOGENIC AND MYOGENIC CELLS • PRE-CONDITIONING OF STEM CELLS • COMBINATION WITH CARDIAC PACING : DYNAMIC SUPPORT • NEW INDICATIONS FOR CELLULAR CMP : ISCHEMIC MITRAL REGURGITATION NON ISCHEMIC CARDIOMYOPATHIES

  32. PRE-CONDITIONING OF STEM CELLS • Treatment with 5-azacytidine : toxic • Co-culture with cardiomyocytes : limited expansion • In-vitro electrostimulation

  33. ELECTROSTIMULATION OF STEM CELL CULTURES

  34. Scientific Basis of Myocardial Differentiation - ANALOGY - Embryon and fetus Cardiac conduction tissue 120 impulses min Mesoderm Myocardium Cell cultures Pacemaker (rate 120 min) Stem cell cultures Cardiomyocytes ?

  35. Human CD34+ cell cultures at 3 weeks Without Stimulation Electrostimulated

  36. Human CD34+ cell cultures at 3 weeks Desmin antibody Without Stimulation Electrostimulated

  37. CONCLUSION • Positive effect of electrostimulation over human stem cell cultures have been detected • Myogenic differentiation was observed in electrostimulated CD34+ cells

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