Cell-based Therapies for Cardiovascular Repair How small things matter Hendrik Jacob Houtgraaf ISBN: 978-90-9028238-1 Printed by: Ridderprint BV Cover: These six patients, who suffered from a large acute myocardial infarction, were among the first in the world to receive intracoronary infusion of adipose tissue-derived regenerative cells. Photography: Danny Cotino Design: Jasper Spronk Layout: Ton Everaers © 2014 Hendrik Jacob Houtgraaf Thesis Erasmus University Medical Center, Rotterdam, The Netherlands. All rights reserved. No part of this thesis may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without prior written permission from the copyright owner. Financial support by the Dutch Heart Foundation for the publication of this thesis is gratefully acknowledged. Cell-based Therapies for Cardiovascular Repair How small things matter Celtherapie voor ziekten van hart en bloedvaten Proefschrift ter verkrijging van de graad van doctor aan de Erasmus Universteit Rotterdam op gezag van de rector magnificus Prof.dr. H.A.P. Pols en volgens besluit van het College voor Promoties. De openbare verdediging zal plaatsvinden op woensdag 4 juni 2014 om 9.30 uur door Hendrik Jacob Houtgraaf geboren te Rotterdam Promotiecommissie Promotoren: Prof.dr. F. Zijlstra Prof.dr. P.W.J.C. Serruys Overige leden: Prof.dr. P.P.T. de Jaegere Prof.dr. J. Laman Prof.dr. J.J. Piek Co-promotor: Dr. H.J. Duckers The greatest glory in living lies not in never falling, but in rising every time we fall. Nelson Mandela Contents Part I. Introduction 11 Chapter 1 13 General introduction Chapter 2 17 A concise review on cell-based therapies for cardiovascular repair: What the clinician needs to know Part II. First generation stem cells in ischemic heart disease patients 53 Bone marrow-derived mononuclear cells and skeletal myoblasts Chapter 3. 55 Intracoronary stem cell infusion following acute myocardial infarction modestly improves LVEF, but does not affect clinical outcomes: a meta-analysis and update on clinical trials Chapter 4. 97 Bone marrow mononuclear cell therapy in ischemic heart disease: a review and meta-analysis Chapter 5. 127 Final results of a phase IIa, randomised, open-label trial to evaluate the percutaneous intramyocardial transplantation of autologous skeletal myoblasts in congestive heart failure patients: the SEISMIC trial Part III. Second generation stem cells in acute 145 myocardial infarction patients Adipose tissue-derived regenerative cells Chapter 6. 147 First experience in humans using adipose tissue-derived regenerative cells in the treatment of patients with ST-segment elevation myocardial infarction Chapter 7. Long-term patient follow up after intracoronary infusion of adipose 153 tissue-derived regenerative cells in patients with ST-segment elevation myocardial infarction: first and final results of the APOLLO trial Part IV. Third generation stem cells in acute myocardial infarction 173 Allogeneic mesenchymal stem cells Chapter 8. 175 Intracoronary Infusion of Allogeneic Mesenchymal Precursor Cells Directly Following Experimental Acute Myocardial Infarction Reduces Infarct Size, Abrogates Adverse Remodeling and Improves Cardiac Function. Chapter 9. 213 Feasibility of intracoronary GLP-1 eluting CellBead™ infusion in acute myocardial infarction. Chapter 10. 231 Efficacy and dose-finding study of intracoronary GLP-1 eluting CellBead™ infusion in acute myocardial infarction Part V. Second generation stem cells in stent design 261 Endothelial progenitor cell capturing stent Chapter 11. 263 Endothelial progenitor cell (EPC) capture to aid vascular repair following coronary stenting: a new frontier in stent technology? Chapter 12. 275 Capture of circulatory endothelial progenitor cells and accelerated re-endothelialization of a bioengineered stent in human ex vivo shunt and rabbit denudation model Chapter 13. 299 Final results of the HEALING IIB trial to evaluate a bio-engineered CD34 antibody coated stent (Genous™Stent) designed to promote vascular healing by capture of circulating endothelial progenitor cells in CAD patients. Chapter 14. 317 Efficiency of statin treatment on EPC recruitment depends on baseline EPC titer, and does not improve angiographic outcome in coronary artery disease patients treated with the Genous™ stent. Part VI. Discussion and summary 333 Chapter 15. 335 Discussion and future directions Summary 354 Samenvatting 358 List of publications 362 About the author 364 Dankwoord 366 PART I Introduction Chapter 1 General introduction and outline of the thesis General introduction and outline of the thesis Cardiovascular disease accounts for almost half of the deaths in the Western world and 25% in devel- oping countries, despite significant therapeutic and interventional advances. It is estimated that by the year 2020, cardiovascular disease will surpass infectious disease, to become the world’s leading cause of mortality and morbidity. Approximately half of the cardiovascular mortality is due to acute myocardial infarction, whereas subsequent heart failure and stable coronary artery disease account for the majority of morbidity. Stem cell therapy to reduce the burden of cardiovascular disease has been the topic of extensive research over the past decade. The assumption that multipotent cells can graft to the injured heart and incorporate into the host’s myocardium, thereby contributing to contractility and improving cardiac function, is considered to be the holy grail for cardiac cell therapy. Hence, the first attempt of cardiac cell therapy more than a decade ago was with skeletal myoblasts (SkM) in end-stage heart failure patients. These progenitor cells are derived from striated skeletal muscle, and are destined to become contracting myofibers. It was hypothesized that, once injected into myocardial scars, these SkM would differentiate into con- tractile units in vivo, and actually contribute to the contractile apparatus. Unfortunately, clinical reality turned out to be less manipulable, and subsequent research has indicated that the road towards the holy grail is still long and comprises many obstacles on the way. More specifically, injected SkM did not actually incorporate into scars, but rather formed re-entry cir- Chapter 1 Chapter cuits for ventricular arrhythmias, whereas cardiac function was not enhanced following SkM injection. In the clinical arena, these disappointing results were rather generalized into the notion that cardio- vascular cell therapy did not work. However, as there are several different cardiovascular pathologies and even more different stem cell types, cell therapy is not a single entity. Therefore, the last decade has been devoted to unraveling numerous questions, as 1) what is the ideal stem cell type and dose; 2) what cardiovascular disease types qualify for stem cell therapy; 3) when should stem cell therapy be initiated; 4) how should cells be administered; 5) what is the best surrogate end point to evaluate the effect of cell therapy; etcetera. This thesis aims to clarify some of these questions, and summarizes our current knowledge about car- diovascular cell therapy. The latter is described and discussed in part I, in which a systematic review covers most relevant pre-clinical and clinical experience. Moreover, in two meta-analyses, the clinical efficacy of the first generation of stem cells is assessed in both myocardial infarction and heart failure patients. This thesis also aims to elaborate on various cell types, as well as the cardiovascular diseases these cells aim to heal. More specifically, safety and efficacy of first generation stem cells in both heart failure and acute myocardial infarction (AMI) patients is depicted in part II. In part III, first-in-man clin- ical experience with intracoronary infusion of adipose tissue-derived cells (second generation stem cells) is described in AMI patients. These initial results formed the basis for a larger phase II/III study. Part IV covers third generation stem cells for the adjunctive treatment of AMI, which comprise alloge- neic mesenchymal stem cells (MSC). Safety and efficacy of both single cell suspensions of MSC, as well as encapsulated MSC, were investigated in large animal models of AMI. In contrast to previous reports, 14 it was found that intracoronary infusion of these cells is both safe and effective when infused briefly following AMI. This finding resulted in the design of a phase I/II clinical study that is currently enrolling AMI patients. Part V encompasses studies with the Genous™ stent, which is designed to attract endo- thelial progenitor cells (second generation stem cells). This stent is hypothesized to promote vascular healing post stent implantation, and theoretically reduces thrombogeneity and in-stent restenosis. Part VI summarizes the current findings and touches upon future steps that should be taken to ac- commodate stem cell therapy as a clinical entity in the future of cardiovascular medicine. 15 Chapter 2 A concise review of cell-based therapies for cardiovascular repair What the clinician needs to know Jaco H. Houtgraaf Renate de Jong Shin Takashima Patrick W. Serruys Henricus J. Duckers Provisionally accepted in EuroIntervention 2014 Introduction Stem cell therapy to heal scarred myocardium or abrogate adverse remodeling following acute myocardial infarction (AMI) has raised high hopes over the past decades. As stem cells are by defini- tion multipotent cells, in theory