Cardiac Muscle Cells Work as Well as Cardiac Progenitor Cells to Repair the Heart

Cell therapies for the heart after a heart attack provide some healing, but the success of these treatments in inconsistent and the majority of the improvements are modest. Whole bone marrow or even bone marrow stem cells can promote the growth of new blood vessels in the heart after a heart attack (Zhou Y, et al., Ann Thorac Surg. 2011 Apr;91(4):1206-12). The treatment of the heart after a heart attack, can also stimulate the regeneration of new heart muscle, but such new muscle comes from endogenous stem cells populations that are induced by the implanted stem cells (Hatzistergos KE, et al., Circ Res. 2010 Oct 1;107(7):913-22).

Nevertheless, the clinical trials with bone marrow cells have produced mixed results. Bone marrow implants work well in some patients and hardly at all in others. The quality of the patient’s bone marrow might be part of the reason for the disparate findings of these trials, but the fact remains, that using cells that can replace dead heart muscle can potentially treat a damaged heart better than bone marrow stem cells.

Pluripotent stem cells, either embryonic stem cells or induced pluripotent stem cells (iPSCs) can efficiently differentiate into heart muscle cells, but a debate remains as to which cell does a better job for healing the heart: Should young heart muscle cells called progenitor cells be used, or can mature heart muscle cells do the job just as well?

Charles Murray from the University of Washington, who has pioneered the use of stem cells to treat the hearts of laboratory animals, and his colleagues tested the ability of heart progenitor cells to repair the heart versus mature heart muscle cells. Both of these cell types were tested against bone marrow stem cells as a control.

Murray and his colleagues used heart muscle cells made from human embryonic stem cells and heart progenitor cells made from the same human embryonic stem cell line to treat the hearts of laboratory rats. These rats were given heart attacks and then the cells were injected directly into the walls of the heart. Injections were given four days after the heart attacks were induced. Each treatment group contained ten rats, including a control group that received injections of cells that are known to possess no healing capabilities.

Measurements of heart function four weeks after treatment showed that both heart progenitor cells and mature heart muscle cells improved the heart equally well and both cells improved heart significantly better than bone marrow stem cells.

Murray said, “There’s no reason to go back to more primitive cells, because they don’t seem to have a practical advantage over more definitive cells types in which the risk for tumor formation is lower.”

In the future, Murry would like to determine if these same cells work in a larger animal model system and then, eventually start clinical trials in human heart attack patients.

Fernandes and Chong et al., Stem Cell Reports, October 2015 DOI: 10.1016/jstemcr.2015.09.011.

Stem Cell Therapy Replaces Dead Heart Muscle in Primates

The laboratory of Charles Murry at the University of Washington has used embryonic stem cells to make heart muscle cells that were then used to regenerate damaged hearts in non-human primates. This experiment demonstrates the possibility of using heart muscle cells derived from pluripotent stem cells, but it also underscores the many challenges that still must be overcome.

When the heart undergoes a heart attack or other types of damage, heart muscle cells begin to die off and these cells are not easy to replace. Heart muscle cells, also known as cardiomyocytes, do not readily replace themselves. Even though the heart has a resident stem cell population, (cardiac progenitor cells or CPCs) these heart-specific stem cells have a limited capacity to regenerate the heart. After a heart attack, as many as one billion cardiomyocytes or more die. The loss of so many beating heart muscle cells compromises heart function and can also lead to chronic heart failure and even death.

Physicians, cardiologists, and researchers have been on the lookout for new and improved procedures and technologies to replenish damaged heart tissue. Several different types of stem cells have shown promise in animal models and in human clinical trials. Stem cells from bone marrow have the ability to secrete a cocktail of molecules that stimulate heart regeneration. Whole bone marrow or isolated stem cell populations have shown variable, but statistically significant in patients who have had a recent heart attack. Unfortunately, stem cells from bone marrow do not have the ability to differentiate into heart muscle cells, and to maximize regeneration of the heart, damaged heart muscle must be replaced.

Human embryonic stem cells have proven promising in small animal models, but the long-term effects of embryonic stem cell-mediated improvements in some cases have proven to be transient. An additional problem with embryonic stem cell-derived heart muscle cells is their tendency to cause abnormal heart rates, otherwise known as arrhythmias.

Scientists in Murry’s laboratory tried to scale-up the production of cardiomyocytes from human embryonic stem cells in order to test the regenerative ability of these cells in a large animal model – non-human primates. These experiments were published online on April 30, 2014, in the journal Nature.

Murry’s team derived cardiomyocytes from genetically-engineered human embryonic stem cells that made a fluorescent calcium indicator that glowed in the presence of high calcium ion concentrations. With this fluorescent calcium indicator, Murray and his coworkers could track the calcium waves that mark the electrical activity of a beating heart. The animal subjects for this experiment were pigtail macaques (Macaca nemestrina) that had suffered heart damage and had been treated with drugs to suppress their immune systems. Five days later, the embryonic stem cell-derived cardiomyocytes were delivered in a surgical procedure to the damaged regions and surrounding border zones of the heart.

Over a 3-month period, the implanted cells infiltrated damaged heart muscle, matured, and organized themselves into muscle fibers in all the monkeys who received the treatment. An average of 40% of the damaged tissue was replaced by these grafts. Three-dimensional imaging showed that arteries and veins integrated into the grafts. Because sick hearts often contain clogged blood vessels, oxygen delivery to the damaged heart tissue was minimal. However, because these grafts contained integrated blood vessels, they would potentially be long-lasting.

Calcium activity studies showed that the heart muscle tissue within the grafts were electrically active and coupled to activity of the host heart. The grafts beat along with host muscle at rates of up to 240 beats per minute, the highest rate tested.

Cardiac cells derived from human stem cells (green) meshed and beat along with primates’ heart cells (red). Credit: Murry Lab/University of Washington.
Cardiac cells derived from human stem cells (green) meshed and beat along with primates’ heart cells (red). Credit: Murry Lab/University of Washington.

All the macaques that received the grafts showed transient arrhythmias or irregular heart rates. However, these subsided by 4 weeks post-transplantation. The animals remained conscious and in no apparent distress during periods of arrhythmia. However, this problem will need to be addressed before this approach can be tested in humans.

“Before this study, it was not known if it is possible to produce sufficient numbers of these cells and successfully use them to remuscularize damaged hearts in a large animal whose heart size and physiology is similar to that of the human heart,” Murry says.

This article shows that despite the obstacles that remain, transplantation of human cardiomyocytes derived from pluripotent stem cells may be feasible for heart patients.

There are a few caveats I would like to mention.  First of all, these animals underwent immunosuppression.  If this procedure were to be used in a human patient, the human patient would need life-long immunosuppression, which has a wide range of side effects and tends to stop working over time.  Therefore, induced pluripotent stem cells are a better choice.  Secondly, the paper admits that the implanted cells underwent “progressive but incomplete maturation over a 3-month period.”  If the implanted cells are not maturing completely, then the risk of arrhythmias still exists, even though they may have subsided in these animals after 4 weeks.  This leads me to my third point.  These animals were watched for 3 months.  How do we know that these results were not transient?  Longer-term experiments are needed to establish that this treatment actually is long-term and not transient.  It is, however, gratifying to see an experiment that was extended to 12 weeks rather than the usual 4 weeks that is usually seen in mice.

Finally, tucked away in the extended data is the statement: “The cell-treated animals showed variable responses, with some having increased function and some having decreased function. Because of small group size, no statistical effects of hESC-CM therapy can be discerned.”  In other words, the treatments worked swimmingly in some animals and not at all in others.  This was a small animal trial and better numbers will be needed if this technology is to come to the clinic.

Transplanted Human Umbilical Cord Blood Cells Improved Long-Term Heart Muscle Structure and Function in Rats After a Heart Attack

Jianyi Zhang, from the University of Minnesota Health Science Center, in Minneapolis, Minnesota and his co-workers have shown that the transplantation of human umbilical cord blood cells into the rat hearts after a heart attack experience long-term effects that are not observed in the control animals that did not receive the stem cells. Furthermore, none of these laboratory animals required immunosuppressive therapy. The study is scheduled to be published in the journal Cell Transplantation.

“Myocardial infarction induced by coronary artery disease is one of the major causes of heart attack,” said Dr. Zhang. “Because of the loss of viable myocardium after an MI, the heart works under elevated wall stress, which results in progressive myocardial hypertrophy and left ventricular dilation that leads to heart failure. We investigated the long-term effects of stem cell therapy using human non-hematopoietic umbilical cord blood stem cells (nh-UCBCs). These cells have previously exhibited neuro-restorative effects in a rodent model of ischemic brain injury in terms of improved LV function and myocardial fiber structure, the three-dimensional architecture of which make the heart an efficient pump.”

According to Zhang and his co-authors, stem cell researchers have intently examined the ability of stem cells to regenerate and heal damaged heart tissue. Many laboratories all over the world have employed different types of stem cells, different animal models, and distinct modes of stem cell delivery into the heart tissue, and different stem cell doses. All of these studies have produced varying levels of improvement of left ventricular function. Zhang and others also note that, for the most part, the underlying mechanisms by which implanted stem cells improve heart function are “poorly understood and that the overall regeneration of heart muscle cells is modest at best.

In order to investigate the heart’s remodeling processes and to characterize the alterations in cardiac fiber architecture, Zhang’s team used diffusion tensor MRI (DTMRI), which has been previously used to study heart muscle fiber structure in both humans and animals. Most previous studies have concentrated on the short-term effects of umbilical cord blood cells (UCBCs) on damaged heart muscles. Fortunately, this study, which examined the long-term effects of UCBCs, not only demonstrated evidence of significantly improved heart function in treated rats, but also showed evidence of delay and prevention of myocardial fiber structural remodeling. Keep in mind that such alterations in heart muscle fiber structure could have resulted in heart failure.

When compared to the age-matched but untreated rat hearts that had suffered a heart attack, the regional heart muscle function of non-hematopoietic UCBC-treated hearts was significantly improved and the preserved myocardial fiber structure seems to have served as an “underlying mechanism for the observed function improvements.”

“Our data demonstrate that nh-UCBC treatment preserves myocardial fiber structure that supports the improved LV regional and chamber function,” concluded the researchers.

“This study provides evidence that UCBCs could be a potential therapy with long-term benefits for MI” said Dr. Amit N. Patel, director of cardiovascular regenerative medicine at the University of Utah and section editor for Cell Transplantation. “Preservation of the myocardial fiber structure is an important step towards finding an effective therapy for MIs”

See: Chen, Y.; Ye, L.; Zhong, J.; Li, X.; Yan, C.; Chandler, M. P.; Calvin, S.; Xiao, F.; Negia, M.; Low, W. C.; Zhang, J.; Yu, X. The Structural Basis of Functional Improvement in Response to Human Umbilical Cord Blood Stem Cell Transplantation . Cell Transplant. Appeared or available online: December 10, 2013.

Pure Heart Muscle Cells from Induced Pluripotent Stem Cells With Molecular Beacons

Using induced pluripotent stem cells to have heart muscle cells is one of the goals of regenerative medicine. Successful cultivation of heart muscle cells from a patient’s own cells would provide material to replace dead heart muscle, and could potentially extend the life of a heart-sick patient.

Unfortunately, induced pluripotent stem cells, which are made by applying genetic engineering techniques to a patient’s own adult cells, like embryonic stem cells, will cause tumors when implanted into a living organism. To beat the problem of tumor formation, scientists must be able to efficiently isolate the cells that have properly differentiated from those cells that have not differentiated.

A new paper from a laboratory the Emory University School of Medicine in Atlanta, Georgia, have used “molecular beacons” to purify heart muscle cells from induced pluripotent stem cells, thus bringing us one step closer to a protocol that isolates pure heart muscle cells from induced pluripotent stem cells made from a patient’s own cells.

Molecular beacons are nanoscale probes that fluoresce when they bind to a cell-specific messenger RNA molecule. Because heart muscle cells express several genes that are only found in heart muscle cells, Kiwon Ban in the laboratory of Young-Sup Yoon designed heart muscle-specific molecular beacons and used them to purify heart muscle cells from cultured induced pluripotent stem cells from both mice and humans.

The molecular beacons made by this team successfully isolated heart muscle cells from an established heart muscle cell line called HL-1. Then Ban and co-workers applied these heart-specific molecular beacons to successfully isolate heart muscle cells that were made from human embryonic stem cells and human induced pluripotent stem cells. The purity of their isolated heart muscle cells topped 99% purity.

Finally, Ban and others implanted these heart muscle cells into the hearts of laboratory mice that had suffered heart attacks. When heart muscle cells that had not been purified were used, tumors resulted. However, when heart muscle cells that had been purified with their molecular beacons were transplanted, no tumors were observed and the heart function of the mice that received them steadily increased.

Because the molecular beacons are not toxic to the cells, they are an ideal way to isolate cells that have fully differentiated to the desired cell fate away from potentially tumor-causing undifferentiated cells. in the words of Ban and his colleagues, “This purification technique in combination with cardiomyocytes (heart muscle cells) generated from patient-specific hiPSCs will be of great value for drug screening and disease modeling, as well as cell therapy.”

Heart Regeneration and the Heart’s Own Stem Cell Population

For years scientists were sure that the heart virtually never regenerated.

Today this view has changed, and researchers at the Max Plank Institute for Heart and Lung Research have identified a stem cell population that is responsible for heart regeneration. Human hearts, as it turns out, do constantly regenerate, but at a very slow rate.

This finding brings the possibility that it might be possible to stimulate and augment this self-healing process, especially in patients with diseases or disorders of the heart, with new treatments.

Some vertebrates have the ability to regenerate large portions of their heart. For example zebrafish and several species of amphibians have the ability to self-heal and constantly maintain the heart at maximum capacity. This situation is quite different for mammals that have a low capacity for heart regeneration. Heart muscle cells in mammals stop dividing soon after birth.

However, mammalian hearts do have a resident stem cell population these cells replace heart muscle cells throughout the life of the organism, In humans, between 1-4% of all heart muscle cells are replaced every year.

Experiments with laboratory mice have identified at heart stem cells called Sca-1 cells that replace adult heart muscle cells and are activated when the heart is damaged. Under such conditions, Sca-1 cells produce significantly more heart muscle.

Unfortunately, the proportion of Sca-1 cells in the heart is very low, and finding them has been likened to searching for a diamond at the bottom of the Pacific Ocean.

Shizuka Uchida, the project leader of this research, said, “We also faced the problem that Sca-1 is no longer available in the cells as a marker protein for stem cells after they have been changed into heart muscle cells. To prove this, we had to be inventive.”

This inventiveness came in the form of a visible protein that was made all the time in the Sca-1 cells that would continue being made even if the cells differentiated into heart muscle.

Uchida put it this way: “In this way, we were able to establish that the proportion of the heart muscle cells originating from Sca-1 stem cells increased continuously in healthy mice. Around five percent of the heart muscle cells regenerated themselves within 18 months.”

When the same measurements were taken in mice with heart disease, the number of heart muscle cells made from Sca-1 stem cells increased three-fold.

“The data show that in principle the mammalian heart is able to trigger regeneration and renewal processes. Under normal circumstances, however, these processes are not enough to ultimately repair cardiac damage,” said Thomas Braun, the principal investigator in whose laboratory this work was done.

The aim is to devise and test strategies to improve the activity and number of these stem cells and, ultimately, to strengthen and augment the heart’s self-healing powers.

A More Efficient Way to Grow Heart Muscle from Stem Cells Could Yield New Regenerative Therapies

An improved method to produce heart muscle from embryonic stem cells or induced pluripotent stem cells could potentially fulfill the demand for heart disease treatments and models of testing new heart drugs. The challenging part of making heart muscle in the laboratory is the production of cells that are all the same. Otherwise their response to drugs or their transplantation into a damaged heart will be unpredictable and unreliable. Fortunately a new study published in the journal STEM CELLS Translational Medicine may provide a way to make large, homogeneous batches of heart muscle cells.

By mixing some small molecules and growth factors together, an international research team led by investigators at the Cardiovascular Research Center at Icahn School of Medicine at Mount Sinai developed a two-step system that induced embryonic stem cells (ESCs) and induced pluripotent stem cells (iPSCs) to efficiently differentiate into ventricular heart muscle cells. This protocol was not only highly efficient but also very reproducible. It also seemed to nicely recapitulate the developmental steps of normal heart development.

“These chemically induced, ventricular-like cardiomyocytes (termed ciVCMs) exhibited the expected cardiac electrophysiological and calcium handling properties as well as the appropriate heart rate responses,” said lead investigator Ioannis Karakikes, Ph.D., of the Stanford University School Of Medicine, Cardiovascular Institute. Other members of this research team consisted of scientists from the Icahn School of Medicine at Mount Sinai, New York, and the Stem Cell & Regenerative Medicine Consortium at the University of Hong Kong.

One of the unusual aspects of this research project was the integrated approach it took. This research group combined computational and experimental systems and by using these techniques, they showed that the use of particular small molecules modulated the Wnt pathway. Signals from the Wnt pathway pass from cell to cell and play a key role in determining whether cells differentiate into an atrial or ventricular muscle cell.

“The further clarification of the molecular mechanism(s) that underlie this kind of subtype specification is essential to improving our understanding of cardiovascular development. We may be able to regulate the commitment, proliferation and differentiation of pluripotent stem cells into heart muscle cells and then harness them for therapeutic purposes,” Dr. Karakikes said.

“Most cases of heart failure are related to a deficiency of heart muscle cells in the lower chambers of the heart,” said Anthony Atala, MD, editor of STEM CELLS Translational Medicine and director of the Wake Forest Institute for Regenerative Medicine. “An efficient, cost-effective and reproducible system for generating ventricular cardiomyocytes would be a valuable resource for cell therapies as well as drug screening.”

Grafted Stem Cell Derivatives Restore Normal Heart Rhythms in Mice

American researchers, in collaboration with technicians from Fujifilm VisualSonics, Inc., have used advanced ultrasonic software to document microscopic, regenerative improvements to heart muscle that has suffered from previous damage.

High-frequency ultrasound and special cardiac-assessment software was developed by FujiFilm VisualSonics, Inc of Toronto, Canada. Scientists from Mayo Clinic implanted engineered cells into the damaged hearts of mice and then used the special software and ultrasound imaging to observe the regeneration of the heart so that it began to contract with normal cardiac rhythms.

After a heart attack, dead heart tissue is replaced with a cardiac scar that consists of scar tissue that neither contracts nor conducts the signals to contract. Depending of the size of the heart scar, the heart can beat abnormally. An abnormal heart beat is known as arrhythmia. Arrhthymias come in three different categories: a heart that beats too fast (tachycardia), a heart that beats too slowly (bradycardia), and a heart that beats erratically. Arrhythmias after a heart attack can be life-threatening, and restoring normal heart rhythm to the heart after a heart attack is very important.

In this experiment, mice were given heart attacks, and then undifferentiated induced pluripotent stem cells (iPSCs) were implanted into these hearts. Those mice that received induced pluripotent stem cells gradually normalized, their heart beat. The resynchronization of the heart beat of these mice was imaged with high-resolution ultrasound.

Satsuki Yamada, first author of this paper, said, “A high-resolution ultrasound revealed harmonized pumping [of the heart] where iPS cells were introduced to be the previously damaged heart tissue.” Yamada also noted that Induced pluripotent stem cell intervention rescues ventricular wall motion disparity, and achieves resynchronization of the heart beat after a heart attack.

This experiment shows, for the first time that undifferentiated iPSCs have the potential to stabilize a patient’s heart after a heart attack. The healing of the heart was documented by ultrasound imaging and by “speckle-tracking echocardiogram.,” Speckle-tracking echocardiography was designed by VevoStrain Advanced Cardiac Analysis Software, which was manufactured by VisualSonics.

This software package provides advanced imaging and quantification capabilities for studying sensitive movements in heart muscles and it is also the only commercial cardiac-strain package optimized for assessing cardiovascular function preclinical rodent studies.

Yamada and her co-researchers utilized this software during the implantation and observation of the iPSCs within the hearts of mice. This software package the motion of the heart wall both at the regional and global levels and from several different perspectives, measurements of these movements, the changes in dimension in the left ventricle during the heart cycle.

The software definitely showed that homogeneous wall movement was restored in those mice that had received implants of iPSCs.

When iPSCs were implanted into mice that had dysfunctional immune systems, they produced tumors, but in mice with normal immune systems, the implanted iPSCs did not produce tumors. What became of those cells is uncertain, but they clearly helped heal the heart and did not cause tumors.

Immunocompetent status defines cell growth outcome  Immunocompetent infarcted hearts were free from uncontrolled growth following iPS cell implantation as documented in vivo (echocardiography; A and B) and on autopsy (A and C) during the 60-week-long follow-up, in contrast to teratoma formation observed in immunodeficient hosts. In A: M, mass; LV, left ventricle; S, suture for coronary ligation. In B, data represent means ± SEM (n = 8 immunocompetent hearts: n = 7 immunodeficient hosts); *P < 0.05 versus immunocompetent.
Immunocompetent status defines cell growth outcome  Immunocompetent infarcted hearts were free from uncontrolled growth following iPS cell implantation as documented in vivo (echocardiography; A and B) and on autopsy (A and C) during the 60-week-long follow-up, in contrast to teratoma formation observed in immunodeficient hosts. In A: M, mass; LV, left ventricle; S, suture for coronary ligation. In B, data represent means ± SEM (n = 8 immunocompetent hearts: n = 7 immunodeficient hosts); *P < 0.05 versus immunocompetent.

This paper is interesting and suggests that undifferentiated cells can also exert healing effects on the heart.

Inhibition of a Heart-Specific Enzyme After a Heart Attack Decreases Heart Damage and Prevents Remodeling

Cardiac Troponin I-interacting Kinase or TNNI3K is an enzyme that was initially identified in fetal and adult heart tissue, but was undetectable in other tissues. The function of this enzyme remains unknown, but Chinese scientists showed that overexpression of TNNI3K in cultured heart muscle cells causes them to blow up and get large (hypertrophy). Earlier this year, a research team from Peking Union Medical College showed that overexpression of TNNI3K in mice caused enlargement of the heart (Tang H., et al., J Mol Cell Cardiol 54 (2013): 101-111). These results suggested that TNNI3K is a potential therapeutic target for heart attack patients.

To that end, Ronald Vagnozzi and his colleagues in the laboratory of Thomas Force at Temple University School of Medicine and their collaborators designed small molecules that can inhibit TNNI3K activity, and these small molecules decrease cardiac remodeling after a heart attack in rodents. Large animal trials are planned next.

In the first experiments of this paper, Vagnozzi and others showed that the levels of TNNI3K in the heart increase after a heart attack. Measurements of TNNI3K protein levels failed to detect it in all tissue other than the heart. Furthermore, it was present throughout the heart, and mainly in heart muscle and not in blood vessels, fibroblasts, and other types of non-muscle heart tissues.

Next, Vagnozzi and others measured TNNI3K protein levels in heart transplant patients. The heart tissues of these patients, who had badly dysfunctional hearts showed higher than usual levels of TNNI3K protein. Thus, TNNI3K is associated with heart tissue and is up-regulated in response to heart dysfunction.

The next experiment examined the effects of overexpressing the human TNNI3K gene in mice. While the overexpression of TNNI3K did not affect heart function of structure under normal circumstances, under pathological conditions, however, this is not he case. If mice that overexpressed TNNI3K where given heart attacks and then “reperfused,” means that the blood vessel that was tied off to cause the heart attack was opened and blood flowed back into the infarcted area. In these cases, mice that overexpressed TNNI3K had a larger area of cell death in their hearts than their counterparts that did not overexpress TNNI3K. The reason for this increased cell death had to do with the compartment in the cell that generated most of the energy – the mitochondrion. TNNI3K causes the mitochondria in heart muscle cells to go haywire and kick out all kinds of reactive oxygen-containing molecules that damage cells.

Cell damage as a result of reactive oxygen-containing molecules (known as reactive oxygen species or ROS) activates a pathway in heart cells called the “p38” pathway, which leads to programmed cell death.

p38 signaling

Once Vagnozzi and his colleagues nailed down the function of TNNI3K in heart muscle cells after a heart attack, they deleted the gene that encodes TNNI3K and gave those TNNI3K-deficient mice heart attacks. Interestingly enough, after a heart attack, TNNI3K-deficient mice showed much small dead areas than normal mice. Also, the levels of the other mediators of TNNI3K-induced cell death (e.g., oxygen-containing molecules, p38, ect.) were quite low. This confirms the earlier observations that TNNI3K mediates the death of heart muscle cells after a heart attack, and inhibiting TNNI3K activity decreases the deleterious effects of a heart attack.

And now for the pièce de résistance – Vagnozzi and his crew synthesized small molecules that inhibited TNNI3K in the test tube. Then they gave mice heart attacks and injected these molecules into the bellies of the mice. Not only were the infarcts, or areas of dead heart muscle cells small in the mice injected with these TNNI3K inhibitors, but the heart of these same mice did not undergo remodeling and did not enlarge, showed reduced scarring, and better ventricular function. This is a proof-of-principle that inhibiting TNNI3K can reduce the pathological effects of a heart attack.

This strategy must be tested in large animals before it can move to human trials, but the strategy seems sound at this point, and it may revolutionize the treatment of heart attack patients.

The Use of Synthetic Messenger RNAs Augment Heart Regeneration and Healing After a Heart Attack

A collaborative effect between researchers at Harvard University and Karolinska Institutet has shown that the application of particular factors to the heart after a heart attack can heal the heart and induce the production of new heart muscle.

Kenneth Chien, who has a dual appointment at the medical university Karolinska Institutet and Harvard University, led this research teams said this about this work: “This is the beginning of using the heart as a factory to produce growth factors for specific families of cardiovascular stem cells, and suggests that it may be possible to generate new heart parts without delivering any new cells to the heart itself.”

This study builds upon previous work by Chien and his colleagues in which the growth factor VEGFA, which is known to activate the growth of endothelial cells in the adult heart (endothelial cells line blood vessels), also serves as a switch that converts heart stem cells away from making heart muscle to forming coronary vessels in the fetal heart.

To drive the expression of VEGFA in the heart, Chien and others made synthetic messenger RNAs that encoded VEGFA and injected them into the heart cells. Injections of these synthetic VEGFA messenger RNAs produced a short burst of VEGFA.

Chien induced a heart attack in mice and then administered the synthetic VEGFA messenger RNAs to some mice and buffer to others 48 hours after the heart attacks. Chien and his crew was sure to inject the synthetic VEGFA mRNAs into the regions of the heart known to harbor the resident cardiac stem cell populations.

Not only did the VEGFA-mRNA-injected mice survive better than the other mice, but their hearts had smaller heart scars, and had clear signs of the growth of new heart muscle that had been made by the resident cardiac stem cell populations. One pulse of VEGFA had long-term benefits and those cells that would have normally made the heart scar ended up making heart muscle instead as a result of one pulse of VEGFA.

Chien said of this experiment, “This moves us very close to clinical studies to regenerate cardiovascular tissue with a single chemical agent without the need for injecting any additional cells into the heart.”

At the same time, Chien also noted that this technology is in the early stages of development. Even though these mice had their chests cracked open and their hearts injected, for human patients, the challenge is to adapt heart catheter technologies to the delivery of synthetic messenger RNAs. Also, to demonstrate the safety and efficacy of this technology to humans, Chien and others will need to repeat these experiments in larger animals that serve as a better model system for the human heart than rodents. Chien’s laboratory is presently in the process of doing that.

To adapt catheter technology to deliver these reagents, Chien had co-founded a company called Moderna Therapeutics to research this problem and develop the proper platform technology for clinical use. Chien is also collaborating with the biotechnology company AstraZeneca to help expedite moving the synthetic RNA technology into a clinical setting.

Do Stem Cells from Bone Outdo Those from the Heart in Regenerating Cardiac Tissue?

Scientists at Tulane University in New Orleans, La. (US) have completed a study that suggests that stem cells derived from cortical, or compact bone do a better job of regenerating heart tissue than do the heart’s own stem cells.

The study, led by Steven R. Houser, Ph.D., FAHA, director of Tulane’s School of Medicine’s Cardiovascular Research Center (CVRC), could potentially lead to an “off the rack” source of stem cells for regenerating cardiac tissue following a heart attack.

Cortical bone stem cells (CBSCs) are considered some of the most pluripotent cells in the adult body. These cells are naïve and ready to differentiate into just about any cell type. However, even though CBSCs and similar pluripotent stem cells retain the ability to develop into any cell type required by the body, they have the potential to wander off course and land in unintended tissues. Cardiac stem cells, on the other hand, are more likely to stay in their resident tissue.

Bone cross-section

To determine how CBSCs might behave in the heart, Houser’s team, led by Temple graduate student Jason Duran, collected the cells from mouse tibias (shin bones), expanded them in the lab and then injected them into back the mice after they had undergone a heart attack.

The cells triggered the growth of new blood vessels in the injured tissue and six weeks after injection had differentiated into heart muscle cells. While generally smaller than native heart cells, the new cells had the same functional capabilities and overall improved survival and heart function.

Similar improvements were not observed in mice treated with cardiac stem cells, nor did those cells show evidence of differentiation.

“What we did generates as many questions as it does answers,” Dr. Houser said. “Cell therapy attempts to repopulate the heart with new heart cells. But which cells should be used, and when they should be put into the heart are among many unanswered questions.”

The next step will be to test the cells in larger animal models. The current study was published in the Aug. 16 issue of Circulation Research.

Transformation of Non-Beating Human Cells into Heart Muscle Cells Lays Foundation for Regenerating Damaged Hearts

After a heart attack, the cells within the damaged part of the heart stop beating and become ensconced in scar tissue. Not only does this region not beat, it does not conduct the signal to beat either and that can not only lead to a slow, sluggish heartbeat, it can also cause irregular heart rates or arrhythmias.

Now, however, scientists have demonstrated that this damage to the heart muscle need not be permanent. Instead there is a way to transform those cells that form the human scar tissue into cells that closely resemble beating heart cells.

Last year, researchers from the laboratory of Deepak Srivastava, MD, the director of Cardiovascular and Stem Cell Research at the Gladstone Institute, transformed scar-forming heart cells (fibroblasts) into beating heart-muscle cells in live mice. Now they report doing the same to human cells in a culture dishes.

“Fibroblasts make up about 50 percent of all cells in the heart and therefore represent a vast pool of cells that could one day be harnessed and reprogrammed to create new muscle,” said Dr. Srivastava, who is also a professor at the University of California, San Francisco. “Our findings here serve as a proof of concept that human fibroblasts can be reprogrammed successfully into beating heart cells.”

In 2012, Srivastava and his team reported that fibroblasts could be reprogrammed into beating heart cells by injecting just three genes (collectively known as GMT, which is short for Gata4, Mef2c, and Tbx5), into the hearts of live mice that had been damaged by a heart attack (Qian L, et al., Nature. 2012 31;485(7400):593-8). From this work, they reasonably concluded that the same three genes could have the same effect on human cells.

“When we injected GMT into each of the three types of human fibroblasts (fetal heart cells, embryonic stem cells and neonatal skin cells) nothing happened—they never transformed—so we went back to the drawing board to look for additional genes that would help initiate the transformation,” said Gladstone staff scientist Ji-dong Fu, Ph.D., the study’s lead author. “We narrowed our search to just 16 potential genes, which we then screened alongside GMT, in the hopes that we could find the right combination.”

The research team began by injecting all candidate genes into the human fibroblasts. They then systematically removed each one to see which were necessary for reprogramming and which were dispensable. In the end, they found that injecting a cocktail of five genes—the 3-gene GMT mix plus the genes ESRRG and MESP1—were sufficient to reprogram the fibroblasts into heart-like cells. They then found that with the addition of two more genes, called MYOCD and ZFPM2, the transformation was even more complete.

To help things along, the team used a growth factor known as Transforming Growth Factor-Beta (TGF-Beta) to induce a signaling pathway during the early stages of reprogramming that further improved reprogramming success rates.

“While almost all the cells in our study exhibited at least a partial transformation, about 20 percent of them were capable of transmitting electrical signals—a key feature of beating heart cells,” said Dr. Fu. “Clearly, there are some yet-to-be-determined barriers preventing a more complete transformation for many of the cells. For example, success rates might be improved by transforming the fibroblasts within living hearts rather than in a dish—something we also observed during our initial experiments in mice.”

The immediate next steps are to test the five-gene cocktail in hearts of larger mammals. Eventually, the team hopes that a combination of small, drug-like molecules could be developed to replace the cocktail, which would offer a safer and easier method of delivery.

This latest study was published online August 22 in Stem Cell Reports.

Overexpression of a Potassium Channel in Heart Muscle Cells Made From Embryonic Stem Cells Decreases Their Arrhythmia Risk

Embryonic stem cells have the capacity to differentiate into every cell in the adult body. One cell type into which embryonic stem cells (ESCs) can be differentiated rather efficiently is cardiomyocytes, which is a fancy term for heart muscle cells. The protocol for making heart muscle cells from ESCs is well worked out, and the conversion is rather efficient and the purification schemes that have been developed are also rather effective (for example, see Cao N, et al., Highly efficient induction and long-term maintenance of multipotent cardiovascular progenitors from human pluripotent stem cells under defined conditions. Cell Res. 2013 Sep;23(9):1119-32. doi: 10.1038/cr.2013.102 and Mummery CL et al., Differentiation of human embryonic stem cells and induced pluripotent stem cells to cardiomyocytes: a methods overview. Circ Res. 2012 Jul 20;111(3):344-58).

Using these cells in a clinical setting has two large challenges. The first is that embryonic stem cell derivatives are rejected by the immune system of the recipient, thus setting up the patient for a graft versus host response to the implanted tissue, thus making the patient even sicker than when they started. The second problem is that heart muscle cells made from ESCs are immature and cause the heart to beat abnormally fast thus causing “tachyarrythmias” and died within the first two weeks after the transplant (see Liao SY, et al., Heart Rhythm 2010 7:1852-1859).

Both of these problems are large problems, but the laboratory of Ronald Li at the University of Hong Kong at used a genetic engineering trick to make heart muscle cells from mouse embryonic stem cells to seemingly fix this problem.

Li and his colleagues engineered mouse ESCs with a gene for a potassium rectifier channel that could be induced with drugs. Then they differentiated these genetically ESCs into heart muscle cells. This potassium rectifier channel (Kir2.1) is not present in immature heart muscle cells and putting it into these cells might cause them to beat at a slower rate.

These engineered ESC-derived heart muscle cells were tested for their electrophysiological properties first. Without the drug that induces KIR2.1, the heart muscle cells showed very abnormal electrical properties. However, once the drug was added, their electrical properties looked much more normal.

Then they induced heart attacks in laboratory animals and implanted their engineered ESC-derived heart muscle cells 1 hour after the heart attacks were induced. Animals not given the drug to induce the expression of Kir2.1 faired very poorly and had episodes of tachyarrythmia (really fast heart beat) and over half of them died by 5 weeks after the implantation. Essentially the implanted animals did worse than those animals that had had a heart attack that were not treated. However, those animals that were given the drug that induces the expression of Kir2.1 in heart muscle cells did much better. The survival rate of these animals was higher than the untreated animals after about 7 weeks after the procedure. Survival rates increased by only a little, but the increase was significant. Also, the animals that died did not die of tachyarrythmias. In fact the rate of tachyarrythmias in the animals given the inducing drug (which was doxycycline by the way) had significantly lower levels of tachyarrythmia than the other two groups.

Other heart functions were also significantly affected. The ejection fraction in the animals that ha received the Kir2.1-expression heart muscle cells was 10-20% higher than the control animals. Also the density of blood vessels was substantially higher in both sets of animals treated with ESC-derived heart muscle cells. The echocardiogram of the hearts implanted with the Kir2.1-expressing heart muscle cells was altogether more normal than that of the others.

This paper is a significant contribution to the use of ESC-derived cells to treat heart patients. The induction of heart arrhythmias by ESC-derived heart muscle cells is a documented risk of their use. Li and his colleagues have effectively eliminated that risk in this paper by forcing the expression of a potassium rectifier channel in the ESC-derived heart muscle cells. Also, because these cells were completely differentiated and did not have any interloping pluripotent cells in their culture, tumor formation was not observed.

There are a few caveats I would like to point out. First of all, the increase in survival rate above the control is not that impressive. The improvement in heart function parameters is certainly encouraging, but because the survival rates are not that higher than the control mice that received no treatment, it appears that these benefits were only conferred to those mice who survived in the first place.

Secondly, even though the heart attacks were induced in the ventricles of the heart, Li and his colleagues injected a mixture of heart muscle cells that included atrial, ventricular, nodal and heart fibroblasts. This provides an opportunity for beat mismatches and a “substrate for ventricular tachycardia” as Li puts it. In the future, the transplantation of just ventricular heart muscle cells would be cleaner experiment. Since these mice were not observed long enough to observe potential arrythmias that might have arisen from the presence of a mixed population in the ventricle.

Finally, in adapting this to humans might be difficult, since the hearts of mice beat so much faster than those of humans. It is possible that even if human cardiomyocytes were engineered with Kir2.1-type channels, that arrythmias might still be a potential problem.

Despite all that, Li’s publication is a large step forward.

Reducing the Heart Scar After a Heart Attack

After a heart attack, inflammation in the heart kills off heart muscle cells and fibroblasts in the heart make a protein called collagen, which forms a heart scar. The heart scar does not contract and does not conduct electrochemical signals. The scar will contract over time, but its presence can lead to abnormal heart rhythms, also known as arrhythmias. Arrythmias can be fatal, since they can cause a heart attack. To prevent a heart attack, physicians will treat heart attack patients with a group of drugs called beta-blockers that slow down the heart rate and protect the heart from the deleterious effects of norepinephrine (secreted by the sympathetic nerve inputs to the heart). An alternative treatment is digoxin or digitalis, which is a chemical found in foxglove. Digitalis inhibits ion pumps in heart muscle cells and slows the heart and the force of its contractions. Digitalis, however, interacts with a whole shoe box fill of drugs, has a very long half-life, and is hard to dose. Therefore it is not the first choice.

Given all this, helping the heart to make a smaller heart scar is a better strategy for treating a heart after a heart attack. To accomplish this, you need to inhibit the heart fibroblasts that make the heart scar in the first place. Secondly, you must move something into the place of the dead cells. Otherwise, the heart could burst or scar tissue will move into the area anyway.

To that end, Yigang Wang and his colleagues at the University of Cincinnati Medical Center in Ohio have published an ingenious paper in which they tried two different strategies to reduce the size of the heart scar, which concomitantly increased the colonization of the heart by induced pluripotent stem cells engineered to express a sodium-calcium exchange pump.

Previously, Wang and his colleagues used a patch to heal the heart after a heart attack. The patch consisted of endothelial cells, which make blood vessels, induced pluripotent stem cells engineered to make a sodium-calcium exchange pump called NCX1, and embryonic fibroblasts. This so-called tri-cell patch makes new blood vessels, establishes new heart muscle, and the foundational matrix molecules to form a platform for beating heart muscle.

In order to get these cells to spread throughout the injured heart, Wang and others used a reagent that specifically inhibits heart fibroblasts. They used a small non-coding RNA molecule. A group of microRNAs called miR-29 family are downregulated after a heart attack. As it turns out, these microRNAs inhibit a group of genes that involved in collagen deposition. Therefore, by overexpressing miR-29 microRNAs, they could prevent collagen deposition and reduce scar formation.

The experimental design in this paper is rather complex. Therefore, I will go through it slowly. First, they tried to overexpress miR-29 microRNAs in cultured heart fibroblasts and sure enough, they inhibited collagen synthesis. Cells overexpressing miR-29 made less than a third of the collagen of their normal counterparts. When they placed these fibroblasts into the heart and induced heart attacks, again, they made significantly less collagen when they were expressing miR-29.

Then they used their miR-29 RNAs by injecting them directly into the heart before inducing a heart attack, and then after the heart attack, they applied the tri-patch. Their results were significant. The scar size was smaller (almost one-third the size of the controls), and the density of blood vessels was much higher in the tri-patched hearts treated with miR-29. The induced pluripotent stem cells differentiated into heart muscle cells and spread throughout the heart. Heart function measures also consistently went up too.  The echiocardiograph before more normal, the ejection fraction went up, the % shortening of the heart muscle fibers was increased, and the relaxation phase of the heart (diastole) also was not so puffy (see graphs and figures below).

(A): M-mode echocardiograph data in three groups. (B): Quantification analysis for heart function. Quantitative data for LVDd (B-1), LVDs (B-2), EF (B-3), and FS (B-4) 4 weeks after Tri-P implantation. *p,0.05 vs. Ctrl+MI+Tri-P group; {p,0.05 vs. Anti-29b+MI+Tri-P group. LVDd, left ventricular enddiastolic diameters; LVDs, left ventricular end-systolic diameters; EF, ejection fraction index; FS, fractional shortening. All values expressed as mean 6 SEM. n = 6 for each group. (C): Two-D mode echocardiograph data in three groups, analyzed by long-axis and short-axis views. *p,0.05 vs. Ctrl+MI+Tri-P group; {p,0.05 vs. miR-29b+MI+Tri-P group. Ctrl, control mimic pretreatd rat with Tri-cell patch graft; miR-29b, miR- 29b mimic pretreated rat with Tri-cell patch graft; Anti-29b, miR-29b inhibitor pretreated rat with Tri-cell patch graft. White dotted lines indicate endocardium and epicardium.
(A): M-mode echocardiograph data in three groups. (B): Quantification analysis for heart function. Quantitative data for LVDd (B-1), LVDs (B-2), EF (B-3), and FS (B-4) 4 weeks after Tri-P implantation. *p,0.05 vs. Ctrl+MI+Tri-P group; {p,0.05 vs. Anti-29b+MI+Tri-P group. LVDd, left ventricular enddiastolic diameters; LVDs, left ventricular end-systolic diameters; EF, ejection fraction index; FS, fractional shortening. All values expressed as mean 6 SEM. n = 6 for each group. (C): Two-D mode echocardiograph data in three groups, analyzed by long-axis and short-axis views. *p,0.05 vs. Ctrl+MI+Tri-P group; {p,0.05 vs. miR-29b+MI+Tri-P group. Ctrl, control mimic pretreatd rat with Tri-cell patch graft; miR-29b, miR-29b mimic pretreated rat with Tri-cell patch graft; Anti-29b, miR-29b inhibitor pretreated rat with Tri-cell patch graft. White dotted lines indicate endocardium and epicardium.

There is a cautionary note to this study. Inhibiting collagen formation after a heart attack could create soft fragile regions of the heart that are subject to rupture should the vascular systolic pressure increase. While that threat was not observed in this study, human hearts, which are much larger, would be much more susceptible to such a mishap. Therefore, while this study is interesting and suggest a strategy in humans, it requires more testing and refinement before anyone can even think about applying it to humans.

A Living Patch for Damaged Hearts

Duke University scientists have constructed a three-dimensional human heart muscle patch that behaves much like natural heart muscle tissue. This advance could be used to either treat heart attack patients or to test new heart medicines.

This “heart patch” was grown in the laboratory from human cells, and the procedures used in this research overcame two large roadblocks. First the patch conducts electrochemical impulses at the same speed as normal adult human heart tissue and it contracts to the same degree as normal human heart tissue. In the past, heart tissue patches have conducted electrochemical impulses too slowly and contracted weakly.

The cell source used by the Duke University team were human embryonic stem cells. Thus, the heart patch would not be appropriate for human patients, since it would be rejected by the patient’s immune system. However, the procedures used in this research could also be applied to heart muscle cells made from induced pluripotent stem cells.

Nenad Bursac, associate professor of biomedical engineering at Pratt Engineering, said, “The structural and functional properties of these 3-D tissue patches surpass all previous reports for engineered human heart muscle. This is the closest man-made approximately of native human heart tissue to date.” Bursac also said that the approach does not involve genetic manipulation of the cells.

Bursac continued: “In past studies, human stem cell-derived cardiomyocytes (that is, heart muscle cells) were not able to both rapidly conduct electrical activity and strongly contract as well as normal cardiomyocytes. Through optimization of a three-dimensional environment for cell growth, we were able to ‘push’ cardiomyocytes to reach unprecedented levels of electrical and mechanical maturation.”

The rate of functional maturation is a procedural issue that has very practical implications. If clinicians want to make a heart patch for a patient, the time required to make the heart patch is important, since a heart patch that takes too long to make is of no clinical use to heart patients. In the developing human, it takes about nine months for the newborn heart to develop and an additional five years to reach adult levels of function. These heart patches, however, were grown in about 1 month. And, according to Brusac, further work should shorten the time required to make such a heart patch.

Bursac commented: “It would take us about five to six weeks starting from pluripotent stem cells to grow a highly functional heart patch. When someone has a heart attack, a portion of the heart muscle dies. Our goal would be to implant a patch of new and functional heart tissue at the site of the injury as rapidly after heart attack as possible. Using a patient’s own cells to generate pluripotent stem cells would add further advantage in that there would likely be no immune system reaction, since the cells in the patch would be recognized by the body as self.”

Bursac added that besides using these heart patches in patients, the patches could also be used in the laboratory to test new heart medicines and to model heart pathologies.

“Tests of trials of new drugs can be expensive and time-consuming.  Instead of, or along with testing drugs on animals, the ability to test on actual, functioning human tissue may be more predictive of the drugs’ effects and help determine which drugs should go into further studies.”

Some drug tests are conducted on two-dimensional sheets of heart cells, but according to Bursac, the three-dimensional culture of heart muscle cells provides a more realistic model system for drug testing.  Engineered heart tissues from patients who suffer from cardiac diseases could be used as a model to study that disease and test and explore potential therapies.

Even though Bursac used a particular embryonic stem cell line, but his co-workers also were able to replicate these results with two other embryonic stem cell lines.  Bursac also wants to test his heart muscle patches in animals to determine how well they integrate into the host heart tissue and how well they conduct electrical signals.

Sheets of Heart Muscle Cells Made from Induced Pluripotent Stem Cells Increases Blood Vessel Density in Infarcted Heart

Induced pluripotent stem cells (iPSCs) are made from adult cells by means of genetic engineering techniques that introduce specific genes into adult cells. These genes express their proteins and they push the adult cell to de-differentiate into cells that, in many ways, resemble embryonic stem cells. These de-differentiated cells can form all the cell types, and they can potentially be used for regenerative medicine.

In particular, the heart can experience the death of heart muscle cells after a heart attack, and replacement of dead heart muscle cells can return the heart to its full potential. To this end, iPSCs and embryonic stem cells (ESCs) can be differentiated into heart muscle cells and transplanted into the damaged heart. Such experiments have been done and they do improve heart function, but what is the best way to apply the heart muscle cells? Should they be injected into the heart wall? Should they be applied on sheets?

Hidetoshi Matsumoto and colleagues in the laboratory of Jun Yamashita at Kyoto University has made mouse iPSCs, and differentiated them into heart muscle cells that were grown in sheets. These sheets were laid over the heart of athymic rats that had suffered a heart attack (athymic mice do not have a thymus gland and therefore are unable to reject transplanted, foreign tissue). The results were telling not for what they did to the heart, but how they did it.

Matsumoto made sheets of heart muscle, sheets of endothelial cells, which make blood vessels, and sheets of mural cells, which are the smooth muscle cells that control the diameter of blood vessels. He also made sheets that contained combinations of cells and sheets with all three cell types.

The sheets that contained all three cell types improved heart function, but after four weeks, no transplanted cells could be detected. How then did these sheets improve heart function? The answer was in a vast increase in the density of blood vessels. When the sheets were applied, they quickly showed a vast increase in the expression of those genes that induce the formation of blood vessels. Thus, even though the cells did not survive, the blood vessels they induced endured and improved heart function.

When cell sheets consisting only of endothelial cells or endothelial cells and mural cells were applied, only slight improvements in heart function were observed and the vast increase in blood vessel density did not ensue. Therefore, heart muscle cells are necessary to induce the formation of new blood vessels.

These results are very similar to those of Yoon et al, who used genetically engineered bone marrow cells to treat rodent hearts that had experienced a heart attack. When Yoon and others depleted these populations of either endothelial or mural cells, the implanted cells failed to improve heart function (Yoon et al., Circulation 2010 121: 2001-11).

Thus. iPSC-derived heart muscle sheets might very improve heart function after a heart attack, but they might do so without actually integrating into the heart.

On a closing note, it seems to me that preconditioning these cells to survive in the hostile environment of the infarcted heart might improve the survival of these cells, and therefore, and their ability to improve heart function. This might be an experiment for future researchers.

See Matsumoto et al, Stem Cells 2012 30:1196-1205.

Stem Cell Fixes for the Heart

Two recent papers have provided very good evidence that pluripotent stem cells can help heal a heart that has experienced a heart attack. One of these papers used induced pluripotent stem cells from rats, and the other used embryonic stem cells.

The first paper comes from the laboratory of Yoshiki Sawa, who is a professor in the Department of Surgery at the Osaka University Graduate School of Medicine in Osaka, Japan. In this paper, Sawa’s group made induced pluripotent stem cells (iPSCs) from mice and cultured them under conditions known to induce differentiation into heart muscle cells. Beating cells were detected and grown on gelatin-coated plates with Delbecco’s medium. When these cells were tested for gene expression, they made all the same genes as those found in a mouse heart.

To get the cells to form sheets of heart muscle cells, Sawa and his team plated his iPSCs on UpCell plates that are coated with a chemical that causes the cells to adhere to it at normal temperatures, but when the temperature is dropped, the cells detach from the plate. Sawa used another innovation with this culture system; he grew cell without any sugar. This caused all the non-heart cells to die off. The result was a sheet of heart muscle cells that contracted in unison.

Next, the Sawa team took induced heart attacks in a Japanese rat strain. 2 weeks after suffering the heart attack, the sheet of heart muscle cells were placed on the heart scar in half of the rats and the other half received no implants.

Four weeks after implantation of the heart muscle sheet, the differences in heart function were stark. The ejection fraction in the hearts of the animals that had received the iPSC-derived heart muscle sheets increased almost 10%. The fractional shortening, which is the degree to which the heart muscle shortens when it contracts, also increased more than 5%. Also, the amount of stretching during pumping decreased, which indicates that the heart is pumping more efficiently.

When the heart muscle from the implants were examined, they were also filled with molecules associated with the production of new blood vessels. Thus the implanted heart muscle sheets also helped heal the heart by inducing the formation of new blood vessels.

A danger of using iPSC-derived heart muscle cells is the tendency to miss undifferentiated cells and have undifferentiated cells that cause tumors. In this experiment, they noticed tumors if they only grew the cells in the sugar-free medium for a little while. However, if they grew the iPSC-heart muscle cells in sugar-free media for at least three days, all the tumor-causing cells died and implants from these sheets never formed any tumors.

This paper demonstrated the efficacy and plausibility of using patient-specific iPSCs to treat a heart that has had a heart attack some time ago.

The second paper comes from the laboratory of Marisa Jaconi in Geneva, Switzerland. In this paper, Jaconi and her gang of stem cell scientists at the Geneva University Hospitals and the Ecole Polytechnique Fédérale de Lausanne used a “cardiopatch” seeded with cardiac-committed embryonic stem cells to treat a heart attack in rats.

Because the injection of stem cells can induce arrhythmias (irregular heart beats), narrowing of blood vessels, blood vessel obstruction, and other types of damage, these two papers tried to use sheets of cells or cells embedded in biodegradable patches to treat the heart. In this paper, Jacobi and others used a hydrogel made from fibrin, which is the same material found in blood clots. Into that fibrin hydrogel, they placed mouse embryonic stem cells that had been treated with a protein called BMP-2, which drives pluripotent stem cells toward a heart cell fate.

To use these cardiopatches, Jacobi and her group induced heart attacks in a French rat strain and then applied the patch to the heart. They had two groups of rats; those that had been given heart attacks and those that had not. The sham group received either a patch with cells, a patch with iron particles (for detection with MRI) or not patch. The heart attack group received the same.

The results are a little hard to interpret, but the patch + cells definitely improved heart function. First, the hearts that had received patches with cells showed in increase in small blood vessels and blood vessel-making (CD31+) cells. Therefore the patches + cells improved heart circulation. Second, the hearts with the patch + cells showed the presence of new heart muscle cells and much mess thinning of the walls of the heart. Third, the heart functional parameters were better preserved in the patch + cells hearts. The ejection fraction decreased substantially in the hearts that did not receive cells, but in the hearts that received patch + cells, the amount of blood left in the heart after pumping and at rest did not increase nearly as much as in the other groups. These parameters are in indication of the efficiency with which the heart is pumping. The fact that the heart + cells hearts did not decrease in efficiency nearly as precipitously as the others shows that the stem cells are healing the heart.

While these results may not seem terribly robust, we must remember that the cardiopatch was only placed over a small portion of the heart. Therefore, we would not expect to see large increased in function. The fact that we do see new heart muscle cells, new blood vessels, and an arrest in the functional free fall of the heart is significant, given the small area of the heart that was cover with the cells.

The cardiopatch is a new technology and this experiment showed that the patch biodegrades quickly and without incident. It also showed that embedding cells in the patch is feasible, and that the patch is a plausible vehicle to deliver cells to the heart. This procedure also induced the formation of new heart muscle cells in the heart scar and new blood vessels too. Perhaps even more encouraging is the absence of tumors reported in this paper. Even though the ESCs were not differentiated completely into heart muscle cells, the cardiac-directed cells were differentiated enough to form either blood vessels, smooth muscle, or heart muscle. This seems to be enough to prevent the cells from forming tumors. Also, the fibrin scaffold was not deleterious to the heart, even though some studies have used other scaffolds that are damaging to the heart.

Thus cardiopatches and cardiac muscle sheets are perfectly good strategies for treating heart with stem cells. More work needs to be done, but the results are encouraging.

Mesenchymal stem cells form heart muscle

On August 3rd, 2009, the University of Miami Miller School of Medicine released a press piece that reported the results on a study by Joshua M. Hare, who is the director of the Interdisciplinary Stem Cell Institute at the Miller School. This study examined the ability of mesenchymal stem cells to fix ailing hearts.

Mesenchymal stem cells are found in lots of different places in our bodies. They are found in bone marrow stroma, fat, connective tissue, blood vessels, umbilical cord, and lots of other places too. These cells might come from “perivascular” cells, which are cells that hang around blood vessels. Nevertheless, mesenchymal stem cells have the ability to form bone, cartilage, fat, and muscle. They also have a fascinating capacity to hide from the immune system. They have groups of surface proteins that prevent cells from the immune systems from recognizing them as foreign, and therefore, mesenchymal stem cells from one person can be transferred into an unrelated person without fear of transplantation rejection.

Several experiments have shown that mesenchymal stem cells (MSCs) can differentiate into heart muscle if treated with the right chemicals (S. Tomita, et al., Circulation 1999;100:II-247–II-256; Also see H. Okura, et al., Tissue Eng Part C Methods, 2009). Transplanting MSCs into the hearts of laboratory animals that have had heart attacks can also help the fix the heart (D. Wolf, et al., J Am Soc Echocardiogr 2007;20:512-20). However, there is a raging debate over how MSCs help broken hearts get better.

Even though MSCs can form heart muscle in culture, they seem to do so rather poorly (Y. Zhang, et al., Interact Cardiovasc Thorac Surg. 2009 Dec;9(6):943-6). Also, several studies suggest that once MSCs are transplanted into ailing hearts, they do not differentiate into heart muscle with any efficiency worth bragging about and seem to help the heart by means of the chemicals they produce (Ryota Uemura, et al., Circulation Res 98 (2006): 1414-21).

There are, however, some reasons to suspect that this is not the end of the story. Engineering MSCs with various genes or administering MSCs with certain chemicals can push then to form heart muscle at higher rates (Yigang Wang, et al. Am J Physiol Heart Circ Physiol (nov 6, 2009, doi:10.1152/ajpheart.00765.2009). Also, in particular experiments, MSCs clearly form heart muscle (J. Tang, et al., Eur J Cardiothorac Surg 30 (2006): 353-61).

Clinical studies with MSCs for heart problems have been conducted but the data are limited. Initial studies were very encouraging (S. Chen, et al., Am J Cardiol 94 (2004): 92-5 and S. Chen, et al., J. Invasive Cardiol 18 (2006): 552-6). Now a new study has shown that MSCs not only help people who have had a recent heart attack, but that they turn into heart muscle and other heart tissues.  MSCs can also help form blood vessels and the increase of blood flow to the heart also helps an ailing heart.  This seems to be one of the main ways that bone marrow-based stem cells help hearts after a heart attack.  Therefore MSCs might be one of the best ways to treat bum hearts, but certainly more work needs to be done.