干細(xì)胞移植治療AMI臨床研究進(jìn)展.ppt

干細(xì)胞移植治療AMI臨床研究進(jìn)展,哈爾濱醫(yī)科大學(xué)第一臨床醫(yī)學(xué)院,李 悅,Despite advances in reperfusion strategies and medical treatment, MI and subsequent HF remain major causes of morbidity and mortality. The use of cell therapy to promote myocardial repair has gained profound scientific and public interest.,干細(xì)胞移植（stem cell transplantation) 亦稱(chēng)為 細(xì)胞心肌成形術(shù)（cellular cardiomyoplasty, CCMP),胚胎干細(xì)胞 倫理問(wèn)題、來(lái)源有限、免疫排斥、發(fā)生腫瘤風(fēng)險(xiǎn)，研究受到很大限制。 成體干細(xì)胞 橫向分化 (transdifferentiation),臨床角度，成體干細(xì)胞優(yōu)于胚胎干細(xì)胞，自體干細(xì)胞優(yōu)于同種干細(xì)胞。 骨髓間質(zhì)干細(xì)胞（mesenchymal stem cells，MSC） 從骨髓中分離，可使用G-CSF動(dòng)員或在體外擴(kuò)增。 內(nèi)皮祖細(xì)胞（endothelial progenitor cells，EPC） 數(shù)量往往不足，特別是從外周血采集時(shí)，需要分離、純化并在體外培養(yǎng)擴(kuò)增EPC。 成骨骼肌細(xì)胞（skeletal myoblasts，SM） 為獲得足夠數(shù)量SM， 需要大塊肌肉組織。體外培養(yǎng)、擴(kuò)增衛(wèi)星細(xì)胞周期較長(zhǎng)。,可供移植干細(xì)胞,Experimental studies have shown that bone marrow cells (BMCs) are capable of inducing myogenesis and angiogenesis; this leads in turn to amelioration of cardiac function in mice and pigs.,Nature. 2001;410:701705 Nat Med. 2001;7:430436 Proc Natl Acad Sci U S A. 2001;98:1034410349. J Thorac Cardiovasc Surg. 2002;123:11321135.,The first study on intracoronary mBMC therapy shortly after AMI in humans was reported in 2002.,Circulation 2002;15:19138.,10 patients were transplanted with autologous mononuclear BMCs via a balloon catheter placed into the infarct-related artery during balloon dilatation。,From bench to bedside,Conclusions： Demonstrate for the first time that selective intracoronary transplantation of autologous, mononuclear BMCs is safe and seems to be effective under clinical conditions.,However, the efficacy results vary between studies. Possible explanations for these differences are small study samples, different imaging techniques and differences in timing of treatment, cell dose, placebo treatment or cell processing protocols. Concerns have been raised about accelerated atherosclerosis, intramyocardial calcifications and risk for arrhythmias. Long-term data on safety and efficacy of this treatment are needed.,20042005年，黃禹錫在科學(xué)雜志發(fā)表偽造的干細(xì)胞論文，夸張干細(xì)胞治療絕癥的可能性，并由此從農(nóng)協(xié)和SK領(lǐng)取20億韓元研究費(fèi)、政府支援的研究費(fèi)(特定經(jīng)濟(jì)犯罪加重處罰法的詐騙及工作上的貪污)。并且還涉嫌非法買(mǎi)賣(mài)卵子(違反生命倫理法)，因而于2006年5月被拘留立案。,REPAIR-AMI trial （randomized, double-blind, placebo controlled, multicenter),N Engl J Med.2006;355:12101221,204 AMI patients receive intracoronary infusion of progenitor cells derived from bone marrow (BMC) or placebo medium into the infarct artery 3 to 7 days after successful reperfusion therapy.,RESULTS: At 4 months, the absolute improvement in the global LVEF was significantly greater in the BMC group than in the placebo group ( 5.5+/-7.3% vs. 3.0+/-6.5%; P=0.01) . Baseline LVEF at or below the median value of 48.9% derived the most benefit. At 1 year, intracoronary infusion of BMC was associated with a reduction in clinical end point of death, recurrence of MI and any revascularization procedure (P=0.01).,Extended clinical follow-up in the REPAIR-AMI trial, to assess long-term safety and durability of the observed beneficial effects on cardiovascular event rate and cardiac function at 2 years.,精讀（1）,Circ Heart Fail. 2010;3:89-96,Study flow diagram (17 centers),EF45% by visual estimate,OTW balloon,There were no significant differences in baseline characteristics. Medication did not significantly differ between placebo and BMC at hospital discharge and up to 2 years follow-up, with the exception of aldosterone antagonists, which were significantly less frequently used in the BMC group at hospital discharge and at 12 months follow-up.,End Points,The primary end point： The absolute improvement in global LVEF from baseline to 4 months. Combined clinical end points: Death, repeated MI or any revascularization procedurereflecting progression of vascular disease. Death, MI, or rehospitalization for heart failure, reflecting progression of disease toward HF.,MRI,In a subgroup of 59 patients, MRI imaging at 2-year follow-up was available. preformed by blinded investigators.,Only 27 patients had baseline MRI.,Clinical Events at 2-Year Follow-Up,Clinical Events at 2-Year Follow-Up,Predictors of Combined End Point (Death, MI, or Rehospitalization for HF),Multivariable Cox regression analysis revealed that randomization to the BMC group (P=0.032) and age (P=0.045) remained the only significant independent predictors of an improved clinical outcome as assessed by the combined end point.,Cardiac Function After 2 Y (59 cases BMC,26; Con,33),梗死節(jié)段室壁增厚率,梗死面積,射血分?jǐn)?shù),Conclusion,The 2-year follow-up demonstrates： No late hazards associated with BMC therapy,Restenosis/ athersclerotic disease progression,?,Revascularization rates were significantly reduced in the BMC group within the first year, still tend to be lower in the BMC group compared to placebo at 2 years follow-up.,Adverse: inflammatory Beneficial: enhanced reendothelialization, vascular repair,Malignant ventricular arrhythmia,?,No evidence of malignant ventricular arrhythmias or syncopes within 2 years after intracoronary infusion of BMC.,Neoplasms,?,Although 20% of the intracoronary infused cells actually retained in the heart, with the remaining cells distributing throughout the body including lung, liver, and spleen, No signal of an increased rate of neoplasms within 2 years.,The 2-year follow-up demonstrates： The beneficial effects of BMC therapy on cardiovascular outcome are preserved beyond the first months up to the end of the present observation period. Moreover, the better regional recovery of LV function in the BMC group is maintained for at least 2 years.,Neovascularization,Neovascularization induced by intracoronary infusion of BMC may be a key mechanism leading to recovery of contractile function and subsequent reduction of clinical event rate.,心臟功能及預(yù)后改善機(jī)制,A substudy of REPAIR-AMI assessing the effect of intracoronary BMC administration on coronary flow dynamics using intracoronary Doppler flow velocity measurements at baseline and at 4 month follow-up: Significant greater recovery of coronary blood flow reserve (CFR) in the BMC-treated infarct artery compared with infarct vessels receiving placebo infusion.,Circulation. 2007; 116:366374,Paracrine effects,Various studies confirmed that progenitor cells release paracrine factors (cytokines and growth factors) that modulate angiogenesis, cardiomyocyte apoptosis, fibrosis, and inflammation.,Fibrogenesis Tissue Repair. 2008 Oct 13;1(1):4,J Cardiovasc Transl Res. 2010 Feb 26. Epub ahead of print,Swine subjected to AMI by temporary balloon occlusion of the LAD using percutaneous techniques received intracoronary injection of either concentrated MSC-derived growth factors or control medium. MSC-derived factors significantly reduced cardiac troponin-T elevation and improved echocardiographic parameters, decreased the fibrotic area, reduced myocardial damage and prevented cardiomyocyte apoptosis.,旁分泌因子作用,Strategies designed to augment MSC paracrine function have been employed in an attempt to improve their therapeutic efficacy. It has been demonstrated that treating MSCs with transforming growth factor- (TGF-) can stimulate VEGF production in vitro.,擴(kuò)大旁分泌作用,Am J Physiol Regul Integr Comp Physiol. 2010;299(1):R371-8,Using a model of isolated heart perfusion, MSCs pretreated with TGF- was associated with decreased myocardial injury and increased myocardial function after global ischemia/ reperfusion when compared to infusion of untreated MSCs.,Circulation. 2010;121:2001-2011,Methods and Results: Vectors that encoded inducible suicide genes under the control of endothelium (endothelial nitric oxide synthase)-, smooth muscle (SM22)-, and cardiomyocyte (-MHC)-specific promoters, thereby allowing selective depletion of the individual cell lineage acquired by the transplanted undifferentiated bone marrowderived cells.,Depletion of eNOS-expressing cells (內(nèi)皮細(xì)胞） was associated with a reduction of capillary and arteriole density and induced a deterioration of regional and global LVEF. The depletion of cells that expressed SM22-（平滑肌細(xì)胞） induced a deterioration in contractile function. The elimination of cells that expressed the cardiac myocyte marker-MHC（心肌細(xì)胞） did not significantly affect cardiac function.,移植途徑,Intracoronary injection,However, traditional reperfusion strategies fail to open the artery in some patients, making effective delivery impossible. The study demonstrated a safe and efficient approach to delivering bone marrow stem cells via a noninfarcted artery in an animal myocardial infarction model.,Cardiovasc Ther. 2010 Mar 10. Epub ahead of print,NOGA system,支持文獻(xiàn),Clinical implications,The sample size of the REPAIR-AMI trial was not powered to definitely answer the question whether BMC administration is capable to modify mortality and morbidity after AMI. Therefore, this analysis should be viewed as hypothesis generating. As such, this analysis provides the rationale to design a larger clinical outcome trial addressing the clinical end.,精讀（2）,Patients from the Autologous Stem cell Transplantation in Acute Myocardial Infarction (ASTAMI) study were re-assessed 3 years after inclusion.,Heart 2009 95: 1983-1989,Randomised, controlled trial Two university hospitals in Oslo, Norway,The primary endpoint: The change in LVEF from baseline to 6 months measured by SPECT. Echocardiography and MRI were used for serial assessment of LV function. Secondary endpoints: Changes in exercise capacity and quality-of-life (QoL).,End Points,Results: The rates of adverse clinical events in the groups were low and equal. There were no significant differences between groups in change of global LV systolic function by echocardiography or MRI during the follow-up.,On exercise testing, the mBMC-treated patients had larger improvement in exercise time from 23 weeks to 3 years (1.5 minutes vs 0.6 minutes, p=0.05), but the change in peak oxygen consumption did not differ (3.0 ml/kg/min vs 3.1 ml/kg/min, p=0.75).,Conclusion: Intracoronary mBMC injection after AMI did not improve global LV function or clinical outcome during the 3 years of observation. A moderately larger increase in exercise time is observed in mBMC-treated patients. The treatment appears safe, with no adverse effect