Infusion Of Cardiosphere-derived Cells Research Articles

Eight-year follow-up of cardiosphere-derived cell transplantation in patients with single ventricle congenital heart disease

Abstract Background Although transcoronary infusion of cardiosphere-derived cells (CDCs) in patients with single ventricles provides short-term improvement in cardiac function, the long-term efficacy is still unknown. Purpose: We tested the hypothesis that CDC infusion is associated with improved long-term clinical outcome in patients with single ventricles and heart failure. Methods: Patients were enrolled in the TICAP phase 1 (Transcoronary Infusion of Cardiac Progenitor Cells in Patients With Single Ventricle Physiology) and PERSEUS phase 2 (Cardiac Progenitor Cell Infusion to Treat Univentricular Heart Disease) trials between January 5, 2011, and January 30, 2015. The inclusion criteria were that patients were aged <6 years who were diagnosed with single ventricle lesions undergoing stage 2 (bidirectional Glenn: BDG) or stage 3 (total cavopulmonary connection: TCPC) palliation. Ventricular ejection fraction should be <60% during the initial screening through the final enrollment. Medical records of patients with single ventricles were obtained and analyzed as a control group who were eligible but were treated by staged palliation alone. We evaluated the effectiveness of CDCs using an integrated cohort study in 93 patients with single ventricles, including 41 patients who received CDC infusion and 52 controls. Results: At the time of this study, 36 patients with CDC infusion and 42 controls were alive without cardiac transplantation, with mean follow-up of 9.7±1.2 years. Survival rate did not differ between the 2 groups (log-rank P = 0.351), whereas overall patients treated by CDCs had lower incidents of late failure defined as late death, protein-losing enteropathy, plastic bronchitis, BDG or TCPC take down, disqualified TCPC candidate, Ross classification 3 or 4, or rehospitalization for heart failure (P = 0.048) compared with controls. Adverse events defined as unplanned cardiac operation, arrhythmia, thromboembolic events, cerebral hemorrhage, or tumor formation (P = 0.057) and unplanned catheter intervention (P = 0.094) did not differ between 2 groups. Conclusions: Intracoronary delivery of CDCs in patients with single ventricles did not improve all-cause mortality rate but significantly reduced the incidence of late failure at 8 years of follow-up.

Abstract 13241: Long-Term Clinical Outcome After Transcoronary Cardiosphere-Derived Cell Infusion in Patients With Single Ventricle Congenital Heart Disease

Introduction: Although transcoronary infusion of cardiosphere-derived cells (CDCs) in patients with single ventricles provides short-term improvement in cardiac function, the long-term efficacy is still unknown. Hypothesis: We tested the hypothesis that CDC infusion is associated with improved long-term clinical outcome in patients with single ventricles and heart failure. Methods: Patients were enrolled in the TICAP phase 1 (Transcoronary Infusion of Cardiac Progenitor Cells in Patients With Single Ventricle Physiology) and PERSEUS phase 2 (Cardiac Progenitor Cell Infusion to Treat Univentricular Heart Disease) trials between January 5, 2011, and January 30, 2015. The inclusion criteria were that patients were aged <6 years who were diagnosed with single ventricle lesions undergoing stage 2 (bidirectional Glenn) or stage 3 (total cavopulmonary connection) palliation. Medical records of patients with single ventricles were obtained and analyzed as a control group who were eligible but were treated by staged palliation alone. We evaluated the effectiveness of CDCs using an integrated cohort study in 93 patients with single ventricles, including 40 patients who received CDC infusion and 53 controls. Results: At the time of this study, 35 patients with CDC infusion and 43 controls were alive without cardiac transplantation, with mean follow-up of 10.0±1.2 years. The absolute changes in brain natriuretic peptide ( P = 0.015), atrioventricular regurgitation grade ( P = 0.018), and weight for age ( P < 0.001) from baseline to last follow-up showed significant improvements in CDC-treated patients compared with controls. Survival rate did not differ between the 2 groups (log-rank P = 0.351), whereas overall patients treated by CDCs had lower incidents of late failure ( P = 0.043) and adverse events ( P = 0.036) compared with controls. Multivariate proportional hazard regression analyses showed that CDC infusion was associated with lower risks of late failure ( P = 0.003) and adverse events ( P = 0.013). Conclusions: Intracoronary delivery of CDCs in patients with single ventricles did not improve all-cause mortality rate but significantly reduced the incidence of late failure and adverse events at 8 years of follow-up.

Effect of cardiosphere-derived cells on segmental myocardial function after myocardial infarction: ALLSTAR randomised clinical trial

BackgroundMost cell therapy trials failed to show an improvement in global left ventricular (LV) function measures after myocardial infarction (MI). Myocardial segments are heterogeneously impacted by MI. Global LV function...

Cardiosphere-derived exosomal microRNAs for myocardial repair in pediatric dilated cardiomyopathy.

Although cardiosphere-derived cells (CDCs) improve cardiac function and outcomes in patients with single ventricle physiology, little is known about their safety and therapeutic benefit in children with dilated cardiomyopathy (DCM). We aimed to determine the safety and efficacy of CDCs in a porcine model of DCM and translate the preclinical results into this patient population. A swine model of DCM using intracoronary injection of microspheres created cardiac dysfunction. Forty pigs were randomized as preclinical validation of the delivery method and CDC doses, and CDC-secreted exosome (CDCex)-mediated cardiac repair was analyzed. A phase 1 safety cohort enrolled five pediatric patients with DCM and reduced ejection fraction to receive CDC infusion. The primary endpoint was to assess safety, and the secondary outcome measure was change in cardiac function. Improved cardiac function and reduced myocardial fibrosis were noted in animals treated with CDCs compared with placebo. These functional benefits were mediated via CDCex that were highly enriched with proangiogenic and cardioprotective microRNAs (miRNAs), whereas isolated CDCex did not recapitulate these reparative effects. One-year follow-up of safety lead-in stage was completed with favorable profile and preliminary efficacy outcomes. Increased CDCex-derived miR-146a-5p expression was associated with the reduction in myocardial fibrosis via suppression of proinflammatory cytokines and transcripts. Collectively, intracoronary CDC administration is safe and improves cardiac function through CDCex in a porcine model of DCM. The safety lead-in results in patients provide a translational framework for further studies of randomized trials and CDCex-derived miRNAs as potential paracrine mediators underlying this therapeutic strategy.

Abstract 12730: Cardiosphere-derived Cells Improve Segmental Myocardial Circumferential Strain by Magnetic Resonance Imaging: Results From the Allogeneic Heart Stem Cells to Achieve Myocardial Regeneration Study

Introduction: Cell therapy failed to improve global LV ejection fraction (LVEF) in most trials of post-MI LV dysfunction. LVEF does not consider the effect of cell therapy on different segments of the myocardium, which may be heterogeneous across different myocardial regions in patients with regional MI. Hypothesis: Allogeneic cardiosphere-derived cells (CDCs) improve segmental (but not global) myocardial function indexed as circumferential strain by MRI. Methods: In this randomized double-blind trial, 142 post-MI patients with LVEF<45% and 15% or greater LV scar size were randomized in 2:1 ratio to receive intracoronary infusion of allogenic CDCs or placebo, respectively. Change in segmental myocardial circumferential strain (Ecc) by MRI from baseline to 6-month was compared between CDCs and placebo groups. Results: In total, 124 patients completed the 6-month follow-up (mean (SD) age 54.3(10.8) and 108 (87.1%) males). Segmental Ecc improvement was significantly greater in patients receiving CDC (-0.5%(4.0)) compared to placebo (0.2%(3.7), p=0.05). The greatest benefit for improvement in segmental Ecc was observed in segments containing scar tissue (change in segmental Ecc of -0.7% (3.5) in patients receiving CDC vs. 0.04% (3.7) in the placebo group, p=0.04). The beneficial effect of CDCs for improving segmental Ecc was greater in patients with LV ejection fraction<41%, LV scar size>18.8% or LV end-diastolic volume index>100 [mixed effect regression coefficients of -0.92(p=0.02),-0.78(p=0.03), and -1.16(p=0.004) respectively versus -0.58(p=0.05) for the entire cohort]. Conclusions: In patients with post-MI LV dysfunction, allogeneic CDC administration resulted in improved segmental myocardial function. This CDC induced improvement in segmental myocardial function was greater in patients with severe LV dysfunction, dilated LV and greater infarct size. (clinicaltrials.gov Identifier: NCT01458405).

Cardiosphere-derived exosomal microRNAs for cardiac repair in pediatric dilated cardiomyopathy: preclinical and safety lead-in phase 1 clinical studies

Abstract Introduction Stem cell therapies have been shown to improve cardiac function; however, therapeutic potential of cardiosphere-derived cells (CDCs) in dilated cardiomyopathy (DCM) and the underlying mechanisms of paracrine effectors include CDC-secreted exosomes (CDCex) mediating cardiac repair remain unknown. Purpose- We aimed to evaluate the safety and therapeutic efficacy of CDCs in swine model of DCM and translate the preclinical results into children with DCM. Methods As a preclinical study, female Yorkshire pigs (n=15) were treated by intracoronary administration of microspheres (1.0×104 particles) to develop diffuse cardiac dysfunction and animals were randomly assigned to receive placebo or 9.0×106 CDC injection pretreated by DMSO or exosome inhibitor (EI; GW4869). CDCex-derived microRNAs (miRs) profile was assessed and ventricular ejection fraction (EF) was evaluated before and 1 month after cell infusion. In safety lead-in clinical trial, 5 patients with DCM (<18 years) with reduced EF (<40%) were prospectively enrolled to receive CDC infusion. The primary endpoint was to assess safety, and the secondary outcome measure was change in cardiac function over 12 months. Results Compared with placebo control, DMSO-treated CDC infusion resulted in improved cardiac function with decrease in myocardial fibrosis (18.2±4.1% versus; 9.5±3.6%; P<0.001) and enhanced cardiomyocyte cycling (Ki67: 27.2±3.6/106 myocytes versus 43.9±6.0/106 myocytes; P=0.002) and neovascularization (von Willebrand factor: 644.8±84.3/mm2 versus 820.7±159.7/mm2; P=0.01) at 1 month. miR expression analysis showed that CDCex were highly enriched with miR-126, miR-132, miR-146a, miR-181b, miR-210, and miR-451. Inhibition of CDCex-derived miRs production by EI pretreatment did not affect CDC viability but rendered CDC ineffective in functional improvement (ΔEF: +5.4%±2.0% versus −1.0%±2.1%; P=0.002). One-year follow-up of clinical trial was completed in 5 patients with favorable profile and preliminary efficacy outcomes. Echocardiographic measurements revealed that CDC infusion increased EF from baseline to 12 months of follow up (28.5±10.7% versus 33.0±11.1%; P=0.038) in accordance with reduced native T1 mapping (1041.6±60.4 ms versus 984.8±39.3 ms; P=0.025). CDCex-derived miRs profiles from patients demonstrated that several miRs were exclusively enriched in CDCs but human cardiac fibroblasts included miR-126, miR-132, miR-146a, miR-181b, and miR-210. Notably, miR-146a expression levels were positively correlated with the reduction in myocardial fibrosis 12 months after CDC infusion (Δnative T1: r=0.896, P=0.040). Conclusions Intracoronary delivery of CDCs is safe and improves cardiac function through CDCex-derived miRs secretion in swine model of DCM. The safety lead-in results in patients warrant further assessment of clinical benefits and highlight miR-146a as a major paracrine mediator of CDC's antifibrotic function for clinical therapeutics. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Research Project for Practical Application of Regenerative Medicine (16bk0104052h0001, 17bk0104052h0002, 18bk0104052h0003) by the Japan Agency for Medical Research and Development

DMD – ANIMAL MODELS & PRECLINICAL TREATMENT: P.209 Repeated administration of cardiosphere-derived cells preserves exercise capacity and muscle function for at least one year in mdx mice

Cardiosphere-derived cells (CDCs) are cardiac progenitor/stromal cells with immunomodulatory, anti-fibrotic, and pro-regenerative properties. These therapeutic actions antagonize crucial pathways central to the pathology of Duchenne muscular dystrophy (DMD). We have previously demonstrated that CDCs are therapeutic in Duchenne muscular dystrophy (DMD) patients and in mdx mice. Our earlier preclinical work centered on the infusion of a single dose of CDCs to aged mdx mice. Due to the progressive nature of DMD, we questioned whether repeated CDC infusion to mdx mice, beginning in youth, could prevent disease progression into adulthood. Therefore, we intravenously infused CDCs monthly into 8-week-old mdx mice during a 12-month study period. Maximal exercise capacity was measured at baseline and bimonthly thereafter, and skeletal muscle function of the solei and diaphragm was measured in subsets of mice euthanized quarterly. CDCs preserved maximal exercise capacity during the entire study duration. In contrast, maximal exercise capacity in vehicle-infused mdx mice declined with age. Further, muscle function of the solei was also maintained with CDCs – in contrast to vehicle. CDCs also improved diaphragm muscle function relative to vehicle. However, force-producing capacity declined in both groups with age. Histology showed CDCs dramatically improved dystrophic features of the diaphragm and reduced fibrosis as early as 3 months following treatment, which remained evident after 12 months of treatment. The deterioration in mdx mouse physiology resulting from natural aging is consistent with DMD. To date, CDCs have been administered to DMD patients only in advanced stages of the illness. The present finding, that early and repeated CDC treatments delay disease progression, motivate reconsideration of this paradigm.

Allogeneic cardiosphere-derived cells for the treatment of heart failure with reduced ejection fraction: the Dilated cardiomYopathy iNtervention with Allogeneic MyocardIally-regenerative Cells (DYNAMIC) trial.

The DYNAMIC trial assessed the safety and explored the efficacy of multivessel intracoronary infusion of allogeneic cardiosphere-derived cells (CDCs) in patients with heart failure and reduced ejection fraction (HFrEF). Here we report the results of the DYNAMIC trial. We enrolled 14 patients with EF ≤35% and NYHA Class III-IV despite maximal medical and device-based therapy in this single-centre, open-label trial. Intracoronary catheterisation delivered four escalating doses (totalling 37.5-75 million cells) by sequential non-occlusive technique to all three major coronary arteries. The primary safety endpoint was a composite of post-infusion TIMI flow, ventricular tachycardia/fibrillation, sudden death, major adverse cardiac events or acute myocarditis within 72 hours. Twelve patients were male and EF averaged 23.0% (±4.5%). No primary safety endpoints were observed. Two patients died of HFrEF progression nine and 12 months following infusion. Compared to baseline, there was an improvement in EF (26.8% vs 22.9%, p=0.023) and left ventricular end-systolic volume (139.5 vs 177.8 cm3, p=0.03) at six months. Quality of life (QoL) scores and NYHA class (p=0.006) improved at six months. At 12 months, the improvement in EF and QoL remained significant. Global intracoronary infusion of allogeneic CDCs is safe and feasible. The efficacy of allogeneic CDCs in HFrEF needs to be tested in larger randomised trials.

Stem Cell Therapies and Treatment Advances for Heart Failure with Preserved Ejection Fraction

Heart failure with preserved ejection fraction (HFpEF) is characterized by a left ventricular ejection fraction of 50% or greater. While heart failure with reduced ejection fraction (HFrEF) is well-characterized and has numerous treatment options, HFpEF remains poorly understood. HFpEF has long been termed diastolic dysfunction, because it was thought that fibrosis and impaired relaxation of the left ventricle could alone explain the underlying pathophysiology. However, recent research has identified additional mechanisms that influence HFpEF, specifically metabolic disorders and proinflammatory conditions. Despite this recent progress in elucidating the pathophysiology, there are still no approved treatment options that increase survival in patients with HFpEF. In the context of limited pharmacological options, stem cell therapy and cardiac biomarkers have emerged as potential breakthroughs in the treatment of HFpEF, but there has not yet been a review of their potential. This review evaluates the potential of cardiosphere-derived cells (CDCs), mesenchymal stromal cells (MSCs), and endothelial progenitor cells (EPCs) in the treatment of HFpEF. CDCs have shown promise, with a placebo-controlled animal trial demonstrating an increase in survival and a marked improvement in left ventricular end diastolic filling among the group treated with intracoronary infusion of CDCs. Additionally, with the newfound understanding of HFpEF pathophysiology, studies have also investigated the role MSCs and EPCs play in the inflammation associated with HFpEF, as well as the potential benefit these stem cells would bring to the treatment of HFpEF. While clinical trials are needed to confirm the safety and efficacy of these therapies, we offer insight into their potential, as well as a comprehensive summary of the pertinent clinical studies that are currently in progress. Embase, Ovid Medline, and PubMed were used to search all relevant literature for this review.

P318Exosomes mediate myocardial regeneration of cardiac progenitor cells in a swine model of dilated cardiomyopathy

Abstract Introduction Stem cell therapy has been shown to improve cardiac function. The mechanisms of therapeutic efficacy are considered the secretion of paracrine factors but the details are still unknown. Hypothesis Exosomes are extracellular vesicles containing bioactive substances such as proteins, messenger RNAs and micro RNAs. We hypothesized that exosomes may be the main paracrine factors to mediate therapeutic efficacy of cardiosphere-derived cells (CDCs). Methods Farm pigs (30 kg, n=10) were treated by intracoronary administration of 10,000 microspheres (100–300 μm) into three vessels. Two weeks later, 9.0×106 CDCs pretreated by exosome inhibitor (EI; 20μM of GW4869) or DMSO as controls were selectively infused into three coronary arteries. Evaluation of ejection fraction (EF) was performed before cell infusion and 1 month after protocol treatment. Results Pigs developed diffuse hypokinetic heart failure (baseline EF 37.1%±2.1%) and randomly assigned into two groups (CDCs with EI: n=5, CDCs with DMSO: n=5). No serious adverse events were found during the CDCs infusion. Significant improvement of EF was observed in CDCs with DMSO group (37.1%±2.1% to 42.5%±3.0%; P=0.01), whereas no change was found in CDCs with EI group (37.1%±2.4% to 36.2%±2.9%; P=0.58). Myocardial fibrosis stained by picrosirius red was significantly reduced in CDCs with DMSO group compared with CDCs with EI group (9.5±3.6% versus 17.3±5.3%; P<0.01). Conclusions We confirmed the therapeutic efficacy of CDCs and these effects were mainly mediated by exosomes.

Cardiosphere-Derived Cells Attenuate Inflammation, Preserve Systolic Function, and Prevent Adverse Remodeling in Rat Hearts With Experimental Autoimmune Myocarditis.

Cardiosphere-derived cells (CDCs) have yielded promising efficacy signals in early-phase clinical trials of ischemic and nonischemic cardiomyopathy. The potential efficacy of CDCs in acute myocarditis, an inflammatory cardiomyopathy without effective therapy, remains unexplored. Given that CDCs produce regenerative, cardioprotective, anti-inflammatory, and anti-fibrotic effects (all of which could be beneficial in acute myocarditis), we investigated the efficacy of intracoronary delivery of CDCs in a rat model of experimental autoimmune myocarditis. Lewis rats underwent induction of experimental autoimmune myocarditis by subcutaneous footpad injection of purified porcine cardiac myosin supplemented with Mycobacterium tuberculosis on days 1 and 7. On day 10, rats were randomly assigned to receive global intracoronary delivery of 500 000 CDCs or vehicle. Global intracoronary delivery was performed by injection of cells or vehicle into the left ventricular (LV) cavity during transient occlusion of the aortic root. Rats were euthanized 18 days after infusion. Cardiac volumes and systolic function were assessed by serial echocardiography, performed on days 1, 10, and 28. Myocardial inflammation, T-cell infiltration, and cardiac fibrosis were evaluated by histology. Experimental autoimmune myocarditis was successfully induced in 14/14 rats that completed follow-up. Left ventricular ejection fraction (LVEF) and volumes were comparable on days 1 and 10 between groups. CDC infusion resulted in increased LVEF (81.5% ± 3% vs 65.4% ± 8%, P < .001) and decreased LV end-systolic volume (43 ± 15 vs 100 ± 24 μL, P < .001) compared to placebo administration at 18 days post-infusion. Cardiosphere-derived cell infusion decreased myocardial inflammation (7.4% ± 7% vs 20.7% ± 4% of myocardium, P = .007), cardiac fibrosis (16.6% ± 13% vs 38.1% ± 3% of myocardium, P = .008), and myocardial T-cell infiltration (30.4 ± 29 vs 125.8 ± 49 cells per field, P = .005) at 18 days post-infusion compared to placebo administration. Intracoronary delivery of CDCs attenuates myocardial inflammation, T-cell infiltration, and fibrosis while preventing myocarditis-induced systolic dysfunction and adverse remodeling in rats with experimental autoimmune myocarditis.

Therapeutic benefits of intravenous cardiosphere-derived cell therapy in rats with pulmonary hypertension.

Pulmonary arterial hypertension (PAH) is a progressive condition characterized by occlusive pulmonary arteriopathy, in which survival remains poor despite pharmacologic advances. The aim of this study was to evaluate the ability of cardiosphere-derived cells (CDCs), cardiac progenitor cells with potent anti-inflammatory and immunomodulatory properties, to attenuate hemodynamic and morphometric remodeling of the right ventricle (RV) and pulmonary arterioles in rats with established monocrotaline (MCT)-induced PAH. Animals were divided into 3 groups: 1) Control (CTL), 2) PAH in which CDCs were centrally infused (CDC) and 3) PAH in which saline was given (Sham). Significant increments in RV systolic pressure (RVSP) and RV hypertrophy were noted in Sham animals compared to CTL. In CDC rats at day 35, RSVP fell (- 38%; p< 0.001) and RV hypertrophy decreased (-26%; p< 0.01). TAPSE and cardiac output were preserved in all 3 groups at day 35. Pulmonary arteriolar wall thickness was greater in Sham rats compared to CTL, and reduced in CDC animals for vessels 20–50 μm (P<0.01; back to CTL levels) and 50–80μm (P<0.01) in diameter. The macrophage population was increased in Sham animals compared to CTL (P< 0.001), but markedly reduced in CDC rats. In conclusion, infusion of CDCs markedly attenuated several key pathophysiologic features of PAH. As adjunctive therapy to PAH-specific agents, CDCs have the potential to impact on the pathobiology of adverse pulmonary arteriolar remodeling, by acting on multiple mechanisms simultaneously.

Effect and mechanism of cardiosphere-derived cells in the treatment of rats with acute myocardial infarction after reperfusion

Objective To investigate whether cardiosphere-derived cells (CDCs) can protect ischemia-reperfusion in acute myocardial infarction, and to explore its mechanism. Methods 7-10 week-old female Wistar-Kyoto (WKY) rats were used for all in vivo experiment.Ischemia was induced for 45 min to allow reperfusion.Twenty minutes (or two hours) later, CDCs (or PBS control) were injected into the LV cavity with an aortic cross-clamp.After 48 hours and 2 weeks, representative echocardiography long-axis images of the left ventricular (LV) systolic and diastolic dimensions, the protein level of activated caspase-3 were observed, the apoptosis rate of myocardial cells and the infarct area of the heart were determined in those groups. Results Rats underwent 45 minutes of ischemia, followed by either 20 minutes or 120 minutes (delayed injection) of reperfusion prior to infusion of CDCs (cells per 100μL) or PBS control (100μL) into the LV cavity during aortic cross-clamp.Ejection fraction, as measured by echocardiography, was significantly preserved in CDCs-treated animals at 48 hours with a 20-minute, but not a 120-minute, delay of infusion(28.0% vs 38.0%, χ2=7.340, P=0.008). CDCs-treated animals reduced percentage of infarct mass(6.2% vs 13.4%, χ2=4.226, P=0.002; 6.2% vs 13.5%, χ2=1.853, P=0.003), infarct mass(6.2% vs 13.4%, χ2=2.220, P=0.002; 6.2% vs 13.5%, χ2=3.119, P=0.003) treated with PBS control.CDC-treated animals reduced infarct size, relative to those of animals treated with PBS control(45.0% vs 24.0%, χ2=4.825, P=0.008), less thinning of the LV anterior wall(1.96mm vs 1.45mm, t=0.897, P=0.028). Protein expressions of MMP-8 and CXGL7 were elevated in the infarct zone of hearts treated with CDCs(MMP-8: 0.74 vs 0.56, t=0.657, P=0.014; CXGL7: 0.44 vs 0.81, t=0.791, P=0.010). Conclusion CDCs is suggested to be a promising cell source to repair acute myocardial infarction through inhibiting apoptosis and reduce proinflammatory cytokine expression. Key words: Myocardial infarction; Ischemia reperfusion; Cardiosphere-derived cells

Abstract 11909: Transcoronary Infusion of Cardiac Progenitor Cells in Hypoplastic Left Heart Syndrome: 3-year Results of the TICAP Trial

Backgrounds: Hypoplastic left heart syndrome (HLHS) is still one of the severe congenital heart defects. The first results of the TICAP trial (NCT01273857) conducted in our hospital have shown that intracoronary infusion of cardiosphere-derived cells (CDCs) in children with HLHS was feasible and safe; however, the mid-term safety and efficacy of CDCs infusion in these patients remain unsolved. The aim of this study is to evaluate the safety and efficacy of CDCs injection during mid-term period and to determine the factors that may be related to the beneficial effects of cardiac function after cell injection. Methods and Design: This phase 1 trial is a prospective controlled study. Fourteen patients with HLHS undergoing staged-2 or -3 palliations were enrolled between January 2011, and January 2012. Seven patients assigned to receive intracoronary CDCs infusion 1 month after the cardiac surgery followed by 7 patients allocated to a control with standard care alone. The primary endpoint was to assess the safety and the secondary endpoint was to evaluate the cardiac function and heart failure status. Results: No complications including tumor formation were reported within 3 years after CDC infusion. Echocardiogram showed a significantly greater improvement in right ventricular ejection fraction (RVEF) in children receiving CDCs than in controls at 3 years (+8.0 ± 4.7% vs. +2.2 ± 4.3%, P=0.03). In cardiac MRI study, improvement of RVEF at 3 years was significantly greater in the CDC-treated group than in controls (+5.7 ± 4.9 vs. -1.0 ± 4.6%, P=0.04). These cardiac function improvements resulted in reduced brain natriuretic peptide levels (P=0.04), lower incidence of unplanned catheter interventions (P=0.04), and higher weight-for-age Z score (WAZ) (P=0.02) at 3 years compared with those of controls. As independent predictors of treatment responsiveness, absolute changes in RVEF at 3 years were negatively correlated with age, WAZ, and RVEF at CDC infusion (age: r=-0.91, P=0.005; WAZ: r=-0.88, P=0.009; EF: r=-0.90, P=0.006). Conclusions: Intracoronary CDC infusion in patients with HLHS was safe and improved RVEF during 3 years of follow-up. This therapeutic strategy may merit somatic growth enhancement and reduce the incidence of heart failure.

Abstract 11714: Allogeneic Cardiosphere-Derived Cells Administered at the Time of Reperfusion Only Improve Ejection Fraction When Infused to Ischemic as well as Remote Myocardial Regions in Swine With Acute Myocardial Infarction

Introduction: While intracoronary infusion of cardiosphere-derived cells (CDCs) to myocardial infarcts using the stop-flow technique reduces scar volume, ejection fraction (EF) remains unchanged. Hypothesis: We hypothesized that this may relate to ineffective treatment of myocyte loss in normally-perfused remote regions which could negatively impact EF. We therefore compared CDC infusion to the entire heart with conventional regional infusion to the infarct-related artery. Methods: Swine (n=24) chronically treated with cyclosporine (100 mg/day) underwent a 1-hour LAD occlusion and EF decreased from 60 ± 2% at baseline to 46 ± 2% after reperfusion (p&lt;0.05 vs. baseline). We infused either 10x10^6 intracoronary allogeneic CDCs via stop-flow infusion (regional LAD infusion), 20x10^6 intracoronary allogeneic CDCs to the entire heart under flow (global infusion) or vehicle 30 minutes after reperfusion. Four weeks later we assessed left ventricular function (echo), myocyte proliferation (Ki67), infarct size (TTC), myocyte nuclear density and cell size. Data were compared to vehicle. Results: Regional LAD infusion increased wall thickening and reduced scar volume but did not affect EF (Table). In contrast, global infusion increased EF despite an insignificant reduction in infarct volume. This was accompanied by 2-fold increases in myocyte proliferation (Ki67) in border and remote regions which did not change with regional LAD infusion. Global infusion increased myocyte nuclear density by 12% and decreased cell size by 9% while there were no significant changes after regional LAD infusion. Conclusion: Although regional LAD infusion reduces scar size and improves regional function, only global infusion improves EF since it effectively stimulates endogenous myocyte regeneration throughout the entire left ventricle. Thus, global infusion may more effectively prevent deleterious post-infarction remodeling than regional administration alone.

Transcoronary infusion of cardiac progenitor cells in hypoplastic left heart syndrome: Three-year follow-up of the Transcoronary Infusion of Cardiac Progenitor Cells in Patients With Single-Ventricle Physiology (TICAP) trial

ObjectivesOur aim was to assess midterm safety and clinical outcomes of intracoronary infusion of cardiosphere-derived cells (CDCs) after staged palliation in patients with hypoplastic left heart syndrome (HLHS). MethodsIn this prospective, controlled study, 14 consecutive patients with HLHS who were undergoing 2- or 3-stage surgical palliations were assigned to receive intracoronary CDC infusion 1 month after cardiac surgery (n = 7), followed by 7 patients allocated to a control group with standard care alone. The primary end point was to assess procedural feasibility and safety; the secondary end point was to evaluate cardiac function and heart failure status through 36-month follow-up. ResultsNo complications, including tumor formation, were reported within 36 months after CDC infusion. Echocardiography showed significantly greater improvement in right ventricular ejection fraction (RVEF) in infants receiving CDCs than in controls at 36 months (+8.0% ± 4.7% vs +2.2% ± 4.3%; P = .03). These cardiac function improvements resulted in reduced brain natriuretic peptide levels (P = .04), lower incidence of unplanned catheter interventions (P = .04), and higher weight-for-age z score (P = .02) at 36 months relative to controls. As independent predictors of treatment responsiveness, absolute changes in RVEF at 36 months were negatively correlated with age, weight-for-age z score, and RVEF at CDC infusion. ConclusionsIntracoronary CDC infusion after staged procedure in patients with HLHS is safe and improves RVEF, which persists during 36-month follow-up. This therapeutic strategy may enhance somatic growth and reduce incidence of heart failure.

Cardiac regenerative potential of cardiosphere-derived cells from adult dog hearts.

The regenerative potential of cardiosphere-derived cells (CDCs) for ischaemic heart disease has been demonstrated in mice, rats, pigs and a recently completed clinical trial. The regenerative potential of CDCs from dog hearts has yet to be tested. Here, we show that canine CDCs can be produced from adult dog hearts. These cells display similar phenotypes in comparison to previously studied CDCs derived from rodents and human beings. Canine CDCs can differentiate into cardiomyocytes, smooth muscle cells and endothelial cells in vitro. In addition, conditioned media from canine CDCs promote angiogenesis but inhibit cardiomyocyte death. In a doxorubicin-induced mouse model of dilated cardiomyopathy (DCM), intravenous infusion of canine CDCs improves cardiac function and decreases cardiac fibrosis. Histology revealed that injected canine CDCs engraft in the mouse heart and increase capillary density. Out study demonstrates the regenerative potential of canine CDCs in a mouse model of DCM.

Cellular postconditioning: allogeneic cardiosphere-derived cells reduce infarct size and attenuate microvascular obstruction when administered after reperfusion in pigs with acute myocardial infarction.

Intracoronary delivery of cardiosphere-derived cells (CDCs) has been demonstrated to be safe and effective in porcine and human chronic myocardial infarction. However, intracoronary delivery of CDCs after reperfusion in acute myocardial infarction has never been assessed in a clinically-relevant large animal model. We tested CDCs as adjunctive therapy to reperfusion in a porcine model of myocardial infarction. First, escalating doses (5, 7.5, and 10 million cells) of allogeneic CDCs were administered intracoronary 30 minutes after reperfusion. Forty-eight hours later, left ventriculography was performed and animals euthanized to measure area at risk, infarct size (IS), and microvascular obstruction. Second, identical end points were measured in a pivotal study of minipigs (n=14) that received 8.5 to 9 million allogeneic CDCs, placebo solution, or sham. Multiple indicators of cardioprotection were observed with 7.5 and 10 million allogeneic CDCs, but not 5 million CDCs, relative to control. In the pivotal study, IS, microvascular obstruction, cardiomyocyte apoptosis, and adverse left ventricular remodeling were all smaller in the CDC group than in sham or placebo groups. In addition, serum troponin I level at 24 hours was lower after CDC infusion than that in the placebo or sham groups, consistent with the histologically-demonstrated reduction in IS. Intracoronary delivery of allogeneic CDCs is safe, feasible, and effective in cardioprotection, reducing IS, preventing microvascular obstruction, and attenuating adverse acute remodeling. This novel cardioprotective effect, which we call cellular postconditioning, differs from previous strategies to reduce IS in that it works even when initiated with significant delay after reflow.

Abstract 15656: Global Intracoronary Infusion of Allogeneic Cardiosphere-Derived Cells (CDCs) Immediately After Reperfusion Stimulates Myocyte Regeneration in Remote Viable Myocardium in Swine With Acute Myocardial Infarction

Introduction: Previous studies evaluating regenerative strategies have focused on administering stem cells to the infarct related artery. Unfortunately, this does not stimulate cardiac regeneration nor prevent myocyte loss in viable remote myocardium that becomes dysfunctional due to LV remodeling. Hypothesis: We hypothesized that administrating allogeneic CDCs to the entire heart (global CDC infusion) at the time of reperfusion could improve function, stimulate myocyte regeneration and prevent myocyte loss throughout the LV. Methods: Yorkshire swine (n=12) underwent a one hour LAD occlusion. Ejection fraction (EF) decreased from 63 ± 2% at baseline to 44 ± 2% after infarction (p&lt;0.05 vs. baseline). Immediately after reperfusion animals were randomized to allogeneic intracoronary CDCs or vehicle in a blinded fashion (n=6 each). Allogeneic CDCs (20 x 10^6 CDCs, cyclosporine 100 mg/day) were infused into the 3 major coronary distributions without interrupting flow. Four weeks later we assessed myocardial function (echo), myocyte proliferation (Ki67), infarct size (TTC), myocyte nuclear density and cell size in comparison to vehicle. Results: After 4 weeks, global CDC infusion increased wall thickening and ejection fraction despite the fact that infarct volume was not different (Table). CDCs stimulated myocyte proliferation (Ki67) in border and remote regions by 3-fold. As a result, myocyte number (nuclear density) increased by 34 % and cell size decreased by 7% in viable infarct border and remote regions. Conclusion: Global infusion of allogeneic CDCs immediately after reperfusion 1.) stimulates myocyte regeneration in viable myocardium remote from the infarct and 2.) improves regional and global LV function without altering infarct size. Thus, treating viable remote myocardium as well as the infarct related artery with allogeneic CDCs may afford a widely available approach to reverse LV dysfunction in patients with acute myocardial infarction.

Abstract 15884: Cardiosphere-Derived Cells Confer Acute Cardioprotection Following Ischemia-Reperfusion Injury in Rats: Role of Macrophage Polarization

Introduction: Cardiosphere-derived cells (CDCs) confer both cardioprotection and regeneration in acute myocardial infarction (MI). However, only long-term (&gt;3 wks) post-MI endpoints have been studied, making it impossible to investigate the cardioprotective effects in isolation. Macrophages (MF) concentrate within the heart following ischemic injury as part of the inflammatory response to injury. Here we test the hypothesis that CDCs are cardioprotective by modifying MF within the myocardium post-MI. Methods &amp; Results: Wistar-Kyoto rats (aged 8-12 wks) underwent 45 min of ischemia followed by 20 min of reperfusion, then intracoronary (i.c.) infusion of either saline or CDCs (5x10 5 ). The use of a 48 hr endpoint enabled the selective study of cardioprotection. CDC-treated animals had preserved ejection fraction (59.2% vs. 47.4%; p&lt;0.001) and reduced infarct size (TTC; 6.3% vs. 13.6%; p&lt;0.01). The finding that CDC-treated hearts contained fewer CD68 + MF (p&lt;0.05) suggested a mechanistic role for MF, a conjecture which we tested in detail. MF isolated from CDC-treated hearts secreted lower amounts of proinflammatory cytokines ( Nos2, Tnf, Il1b ; p&lt;0.05). Systemic depletion of MF with clodronate liposomes attenuated the benefits of CDC therapy post-MI (p&lt;0.05). In vitro , MF conditioned by transwell exposure to CDCs (M CDC ) exhibited distinct gene profiles relative to proinflammatory M 1 or “healing” M 2 polarization states (M CDC : Il10 ; M 1 : Nos2 ; M 2 : Arg1, Pparg ). Adoptive transfer of selective MF populations into the heart (i.c.; 20 min post-reflow) revealed that M CDC , but not M 1 or M 2 MF, could recapitulate the reduction in infarct size (M CDC : 4.5%; M 1 : 14.0%; M 2 : 10.8%; p&lt;0.05). In vitro co-culture shows that M CDC selectively reduce cardiomyocyte apoptosis following oxidant stress (M CDC : 9.9%; M 1 : 39.4%; M 2 : 37.4%; p&lt;0.001). Conclusions: CDCs are cardioprotective when administered 20 min after reflow; the timing distinguishes this form of cardioprotection from preconditioning or ischemic postconditioning. Various lines of evidence indicate that CDCs work by polarizing MF toward a cardioprotective phenotype. The findings motivate further translational development of the adjunctive use of CDCs post-MI to limit infarct size.