Università e Azienda Ospedaliera di Perugia C ardiologia e Fisiopatologia Cardiovascolare

1. Università e Azienda Ospedaliera di PerugiaCardiologiaeFisiopatologia Cardiovascolare Terapia Cellulare in Cardiologia Giuseppe Ambrosio

2. MINISTERO DELL'ISTRUZIONE, DELL'UNIVERSITÀ E DELLA RICERCADipartimento per la Programmazione il Coordinamento e gli Affari Economici Servizio per lo sviluppo e il Potenziamento delle Attività di ricerca (SSPAR) PNR 2001 (FIRB art.8) D.M. 199 Ric. del 8 marzo 2001 Protocollo: RBNE01HLAK_005 Il trapianto cellulare come alternativa al trapianto d'organo: studio dei processi di crescita e differenziamento delle cellule staminali orientate verso fenotipi cardiovascolari Responsabile Scientifico dell'Unità operativa AMBROSIO Giuseppe Perugia

3. Circulation, November 2005

5. Therapeutic Angiogenesis • Is it feasible? • Does it work? • Is it safe? • Will it have an impact on clinical practice?

8. Angiogenesi Terapeutica:Possibili Approcci a) Aumento delle concentrazioni locali di fattori angiogenetici • Proteina • “Naked” DNA • Trasfezione chimica o fisica • Trasfezione virale b) Incremento delle Cellule Progenitrici • Iniezione diretta • Mobilizzazione

9. Therapeutic Angiogenesis • Is it feasible? • Does it work? • Is it safe? • Will it have an impact on clinical practice?

10. Adenovirus-Mediated Acidic Fibroblast Growth Factor Gene Transfer Induces Angiogenesis in the Nonischemic Rabbit Heart (Safi J et al, Microvascular Research 1999)

13. Therapeutic Angiogenesis • Is it feasible? • Does it work? • Is it safe? • Will it have an impact on clinical practice?

14. Adenovirus-Mediated Acidic Fibroblast Growth Factor Gene Transfer Induces Angiogenesis in the Nonischemic Rabbit Heart Capillary Density Arteriolar Density (Safi J et al, Microvascular Research 1999)

15. Adenovirus-Mediated Acidic Fibroblast Growth Factor Gene Transfer Induces Angiogenesis in the Nonischemic Rabbit Heart Confocal microscopic localization of endothelial constitutive nitric oxide synthase (ecNOS; red fluorescence), and -smooth muscle actin (green fluorescence) in the vascular wall of coronary arterioles from a rabbit injected with aFGF1-154 (Safi J et al, Microvascular Research 1999)

16. Adenovirus-Mediated Acidic Fibroblast Growth Factor Gene Transfer Induces Angiogenesis in the Nonischemic Rabbit Heart (Safi J et al, Microvascular Research 1999)

18. Therapeutic Angiogenesis • Is it feasible? • Does it work in patients? • Is it safe? • Will it have an impact on clinical practice?

19. Safety and Feasibility of Catheter-Based Local Intracoronary Vascular Endothelial Growth Factor Gene Transfer in the Prevention of Postangioplasty and In-Stent Restenosis and in the Treatment of Chronic Myocardial Ischemia Hedman et al, Circulation 2003

20. Therapeutic Angiogenesis • Is it feasible? • Does it work? • Is it safe? • Will it have an impact on clinical practice?

21. Jun 18, 2002 Wrongful death lawsuit filed against gene therapy group led by Jeffrey Isner The suit alleges that Isner and his colleagues“took advantage of patients’ desperation”and"all too human desire for a miracle cure"to get them to agree to the procedure Jul 15, 2003 Medical tribunal rejects wrongful-death suit against late Jeffrey Isner

22. Therapeutic Angiogenesis:Potential Risks • Genomic incorporation • Inflammatory reaction • Unwanted vascular proliferation • Growth/spread of tumors • Paradoxical worsening of Ischemic Heart Disease

24. Therapeutic Angiogenesis • Is it feasible? • Does it work? • Is it safe? • Will it have an impact on clinical practice?

25. Actually, they’re the same! The reason is an optical illusion called the Ponzo Illusion, after Italian physicist Mario Ponzo, who first demonstrated it in 1913. In determining the size of an object our mind is influenced by the background

26. The Ponzo Effect:Endothelial Progenitor Cells Appear on the Horizon The Ponzo effect (i.e., difficultyof assessing the size of an object as it appears over the horizon) is an apt metaphor for new therapeutic ideas, such as theclinical application of EPCs It is too soon to know whetherEPCs will rise up to assume their place in the therapeutic armamentariumof cardiologists and other physicians who treatpatients with vascular disease Cam Patterson

29. Cell Therapy for Acute Myocardial Infarction: Curb Your Enthusiasm? Welt and Losordo, Circulation 2006 (Editoriale di commento a BOOST) We remain optimistic regarding the future of cell therapy for cardiac disease. However, the field requires a recommitment to preclinical investigation as a means of better understanding basic mechanisms, and to clinical trial design based on such preclinical data

31. Three Stages in the Movement of Endothelial Progenitor Cells from Bone Marrow to Vascular Endothelium Rosenzweig, A. N Engl J Med 2003

35. So far, a flurry of small, mostly uncontrolled clinical studies exploring the safety and feasibility of stem cell therapy have been conducted. These studies have used a myriad of different cell types and preparations, each in a small number of patients, with different disease states • This preliminary clinical evidence suggests that stem cell therapy might work. However, we should take into account the lessons learned from therapeutic angiogenesis studies, where great expectations raised by open studies have not been confirmed by subsequent randomized trials • We advocate to no longer perform small open studies, but to conduct intermediate-size, double-blind, randomized-controlled clinical trials to establish the effects of stem cell therapy on surrogate markers, like LVEF, myocardial perfusion, or exercise capacity (Wollert et al, Circulation 2005)

36. Adenovirus-Mediated Acidic Fibroblast Growth Factor Gene Transfer Induces Angiogenesis in the Nonischemic Rabbit Heart (Safi J et al, Microvascular Research 1999)

37. Adenovirus-Mediated Acidic Fibroblast Growth Factor Gene Transfer Induces Angiogenesis in the Nonischemic Rabbit Heart (Safi J et al, Microvascular Research 1999)

38. Effect of Intramyocardial Transplantation of Autologous Endothelial Progenitor Cellsin Nude Mice Subjected to Myocardial Ischemia (Kawamoto et al, Circulation 2003)

39. The VIVA Trial: Vascular Endothelial Growth Factor in Ischemia for Vascular Angiogenesis (Henry et al, Circulation 2003)

40. Angiogenic Gene Therapy (AGENT) Trial in Patients With Stable Angina Pectoris (Grines CL, Circulation 2002)

42. Aicher A, et al Circulation 2003