Regeneration of ischemic cardiac muscle and vascular endothelium by adult stem cells

Distinct progenitor populations in skeletal muscle are bone marrow derived and exhibit different cell fates during vascular regeneration

Vascular progenitors were previously isolated from blood and bone marrow; herein, we define the presence, phenotype, potential, and origin of vascular progenitors resident within adult skeletal muscle. Two distinct populations of cells were simultaneously isolated from hindlimb muscle: the side population (SP) of highly purified hematopoietic stem cells and non-SP cells, which do not reconstitute blood. Muscle SP cells were found to be derived from, and replenished by, bone marrow SP cells; however, within the muscle environment, they were phenotypically distinct from marrow SP cells. Non-SP cells were also derived from marrow stem cells and contained progenitors with a mesenchymal phenotype. Muscle SP and non-SP cells were isolated from Rosa26 mice and directly injected into injured muscle of genetically matched recipients. SP cells engrafted into endothelium during vascular regeneration, and non-SP cells engrafted into smooth muscle. Thus, distinct populations of vascular progenitors are resident within skeletal muscle, are derived from bone marrow, and exhibit different cell fates during injury-induced vascular regeneration.

Stem cells for myocardial regeneration

Stem cells are being investigated for their potential use in regenerative medicine. A series of remarkable studies suggested that adult stem cells undergo novel patterns of development by a process referred to as transdifferentiation or plasticity. These observations fueled an exciting period of discovery and high expectations followed by controversy that emerged from data suggesting cell-cell fusion as an alternate interpretation for transdifferentiation. However, data supporting stem cell plasticity are extensive and cannot be easily dismissed. Myocardial regeneration is perhaps the most widely studied and debated example of stem cell plasticity. Early reports from animal and clinical investigations disagree on the extent of myocardial renewal in adults, but evidence indicates that cardiomyocytes are generated in what was previously considered a postmitotic organ. On the basis of postmortem microscopic analysis, it is proposed that renewal is achieved by stem cells that infiltrate normal and infarcted myocardium. To further understand the role of stem cells in regeneration, it is incumbent on us to develop instrumentation and technologies to monitor myocardial repair over time in large animal models. This may be achieved by tracking labeled stem cells as they migrate into myocardial infarctions. In addition, we must begin to identify the environmental cues that are needed for stem cell trafficking and we must define the genetic and cellular mechanisms that initiate transdifferentiation. Only then will we be able to regulate this process and begin to realize the full potential of stem cells in regenerative medicine.

Transplantation of Progenitor Cells and Regeneration Enhancement in Acute Myocardial Infarction (TOPCARE-AMI)

BACKGROUND

Experimental studies suggest that transplantation of blood-derived or bone marrow-derived progenitor cells beneficially affects postinfarction remodeling. The safety and feasibility of autologous progenitor cell transplantation in patients with ischemic heart disease is unknown.

METHODS AND RESULTS

We randomly allocated 20 patients with reperfused acute myocardial infarction (AMI) to receive intracoronary infusion of either bone marrow-derived (n=9) or circulating blood-derived progenitor cells (n=11) into the infarct artery 4.3+/-1.5 days after AMI. Transplantation of progenitor cells was associated with a significant increase in global left ventricular ejection fraction from 51.6+/-9.6% to 60.1+/-8.6% (P=0.003), improved regional wall motion in the infarct zone (-1.5+/-0.2 to -0.5+/-0.7 SD/chord; P<0.001), and profoundly reduced end-systolic left ventricular volumes (56.1+/-20 mL to 42.2+/-15.1 mL; P=0.01) at 4-month follow-up. In contrast, in a nonrandomized matched reference group, left ventricular ejection fraction only slightly increased from 51+/-10% to 53.5+/-7.9%, and end-systolic volumes remained unchanged. Echocardiography revealed a profound enhancement of regional contractile function (wall motion score index 1.4+/-0.2 at baseline versus 1.19+/-0.2 at follow-up; P<0.001). At 4 months, coronary blood flow reserve was significantly (P<0.001) increased in the infarct artery. Quantitative F-18-fluorodeoxyglucose-positron emission tomography analysis revealed a significant (P<0.01) increase in myocardial viability in the infarct zone. There were no differences for any measured parameter between blood-derived or bone marrow-derived progenitor cells. No signs of an inflammatory response or malignant arrhythmias were observed.

CONCLUSIONS

In patients with AMI, intracoronary infusion of autologous progenitor cells appears to be feasible and safe and may beneficially affect postinfarction remodeling processes.

Plasticity revisited

Despite some recent setbacks, it remains clear that adult stem cells under appropriate experimental conditions can at some frequency exhibit a wider range of differentiation potentials than previously appreciated. This is underscored by the recent demonstration of the extensive differentiation potential of mesenchymal stem cells. In terms of mechanism, it remains unclear in many cases to what extent plasticity reflects in vitro adaptation, transdifferentiation/cell-type switching or the persistence in adult tissues of stem cells with extensive endogenous or bona fide developmental potentials. These issues will need to be resolved before the full therapeutic potential of adult-derived stem cells can be realised.

Differentiative potential of human metanephric mesenchymal cells

OBJECTIVE

To evaluate the ability of mesenchymal cells derived from nonhematopoietic organs to form blood and other tissues in vitro and in vivo.

MATERIALS AND METHODS

Because of its mesodermic derivation, human fetal kidney was used as a source of mesenchymal cells. Two populations of kidney cells were studied at a nonclonal level: a crude preparation, and an adherent fraction that was derived from the first by propagation in vitro (MNMC). Both populations were transplanted into sheep fetuses and analyzed at intervals for the presence of human cells in different organs by flow cytometry, PCR, immunohistochemistry, and in situ hybridization. Secondary transplantation studies were performed using human hematopoietic cells obtained from the bone marrow (BM) of primary recipients.

RESULTS

MNMC were Thy-1(+), CD51(+), CD44(+), CD45(-), and vimentin(+), a phenotype consistent with that of metanephric mesenchyme. The crude population displayed the same phenotype but was contaminated with 0.4% CD34(+)CD45(+) cells. Cells with hepatocyte-like morphology and phenotype were obtained from the MNMC after culture in specific inducing media. After transplantation, both populations of cells produced multilineage hematopoietic engraftment and gave rise to CD34(+) cells. Successful hematopoietic engraftment in secondary recipients demonstrated the generation of long-term engrafting hematopoietic stem cells from MNMC. PCR analysis confirmed human hematopoietic engraftment and revealed that human cells were also present within other organs. Liver sections of transplanted animals contained human albumin-producing hepatocyte-like cells.

CONCLUSION

A human metanephric mesenchymal cell population simultaneously gave rise to human blood and liver-like cells, suggesting that mesenchymal cells may represent a broad population of putative stem cells in multiple adult organs.

Stem cells: a minireview

The identification of adult-derived stem cells which maintain plasticity throughout the course of a lifetime, has transformed the field of stem cell biology. Bone marrow derived hematopoietic stem cells (HSC) are the most well-characterized population of these multipotential cells. First identified for their ability to reconstitute blood lineages and rescue lethally irradiated hosts, these cells have also been shown to differentiate and integrate into skeletal muscle, cardiac myocytes, vascular endothelium, liver, and brain tissue. Various populations of HSC are being studied, exploiting cell surface marker expression, such as Sca-1, c-kit, CD34, and lin; as well as the abilityto efflux the vital dye Hoecsht 33342. Detection of engrafted donor derived cells into various tissue types in vivo is a laborious process and may involve detection of beta-galactosidase via colorimetric reaction or antibody labeling or green fluorescent protein (GFP) via fluorescence microscopy, as well as in situ hybridization to detect the Y-chromosome. Using these techniques, the search has begun for tissue specific stem cells capable of host tissue regeneration, self renewal, and transdifferentiation. Caution is urged when interpreting these types of experiments because although they are stimulating, limitations of the technologies may provide misleading results.

Stem cell plasticity and blood and marrow transplantation: a clinical strategy

The newly described phenomenon of stem cell plasticity raises interesting biological questions and offers exciting opportunities in clinical application. This review uses the well-established practice of blood and marrow transplantation as a paradigm to explore the clinical consequences of this finding. Recently proposed non-myeloablative conditioning regimens have shown that mixed donor-host hematolymphoid chimerism can be established with relatively low toxicity in both animal studies and human trials. Hematopoietic growth factor treatment of transplanted patients can mobilize a large number of donor stem cells to migrate from marrow to non-hematopoietic organs. We propose that these advances, in conjunction with the developmental plasticity of stem cells, can constitute components of a clinical strategy to use blood and marrow transplantation as a platform to treat systemic diseases involving non-hematopoietic tissues.

Adult bone marrow stem cells for cell and gene therapies: implications for greater use

There is excitement generated almost daily about the possible uses of stem cells to treat human disease. Much of the interest of late is generated by embryonic stem cells (ESCs). As exciting as ESCs may be, they are quite controversial for moral reasons, given their source. They are also scientifically controversial since they are much less well understood than the original, long-standing, and clinically successful hematopoietic stem cell (HSC). HSCs have the distinct advantage of being reasonably well characterized and have been proven in the clinic. They can be isolated by simple procedures directly from the bone marrow or from peripheral blood after being stimulated (mobilized). They can then be manipulated and delivered to a patient, often producing a cure. Their biology provides the paradigm by which all other stem cells are judged, and they have little in the way of moral controversy surrounding them given they are isolated from adults who have consented to the procedure. Another putative stem cell has gained momentum in the last few years; the mesenchymal stem cell (MSC). MSCs appear to have much in common with HSCs. They were originally characterized from bone marrow, are capable of differentiating along multiple lineages and, at least in vitro, have significant expansion capability. Unlike HSCs, they have not yet been definitively shown to function as stem cells, despite their ability to differentiate into various mesenchymal cell types under the right culture conditions. Still, there is mounting evidence these cells may be useful, if not as true stem cells then at least as vehicles for emerging cell and gene therapies, especially in the field of tissue engineering. While this is an important endpoint, it is more important to thoroughly understand stem cell biology. That understanding can then be applied toward the ultimate goal of using these cells not just for various forms of therapy, but rather as a tool to discover the mechanisms and means to bring about directed repair and regeneration of damaged or diseased tissues and organs. The excitement of HSCs and MSCs has been muted somewhat by the excitement surrounding ESCs, primarily due to the fact HSCs and MSCs are viewed as limited to specific cell types while ESCs could potentially be applied to any cell type. Recent information indicates HSCs, MSCs, and other cells in general may have more universal differentiation abilities than previously thought.

Biological progression from adult bone marrow to mononucleate muscle stem cell to multinucleate muscle fiber in response to injury

Adult bone marrow-derived cells (BMDC) are shown to contribute to muscle tissue in a step-wise biological progression. Following irradiation-induced damage, transplanted GFP-labeled BMDC become satellite cells: membrane-ensheathed mononucleate muscle stem cells. Following a subsequent exercise-induced damage, GFP-labeled multinucleate myofibers are detected. Isolated GFP-labeled satellite cells are heritably myogenic. They express three characteristic muscle markers, are karyotypically diploid, and form clones that can fuse into multinucleate cells in culture or into myofibers after injection into mouse muscles. These results suggest that two temporally distinct injury-related signals first induce BMDC to occupy the muscle stem cell niche and then to help regenerate mature muscle fibers. The stress-induced progression of BMDC to muscle satellite cell to muscle fiber results in a contribution to as many as 3.5% of muscle fibers and is due to developmental plasticity in response to environmental cues.

Platelet-endothelial cell adhesion molecule-1 (CD31) expression on donor endothelial cells attenuates the development of transplant arteriosclerosis

BACKGROUND

Platelet-endothelial cell adhesion molecule(PECAM)-1 (CD31) is expressed on the surface of endothelial cells, platelets, monocytes, neutrophils, and certain T-cell subsets. Treatment of endothelial cells with anti-PECAM-1 antibody inhibits leukocyte transmigration. This study was designed to test the hypothesis that, in transplantation, the absence of PECAM-1 expression on donor endothelial cells would reduce the number of leukocytes transmigrating into the allograft, thereby attenuating the development of transplant arteriosclerosis.

METHODS

PECAM-1 and PECAM (C57BL/6/H2 ) abdominal aortic allografts were transplanted into BALB/c (H2 ) recipients; syngeneic grafts were used as controls. Aortic grafts were analyzed by performing morphometry, immunohistochemistry, and quantitative reverse transcriptase-polymerase chain reaction for the detection of intragraft cytokine mRNA production.

RESULTS

Intimal proliferation was exacerbated in PECAM-1 grafts (57+/-5% for PECAM-1 vs. 36+/-6% for PECAM-1; <0.005; n=6). The absence of PECAM-1 expression on donor endothelial cells did not reduce the overall number of graft-infiltrating cells significantly but instead resulted in a significant increase in infiltration by macrophages (F4/80 cells), leading to significantly elevated intragraft mRNA expression of inducible nitric oxide synthase. During the development of transplant arteriosclerosis, PECAM-1 donor endothelial cells were replaced by recipient PECAM-1 endothelial cells, a process that occurred only in the allogeneic situation. Endothelial replacement commenced 14 days after transplantation and was complete by day 30.

CONCLUSIONS

These data suggest that PECAM-1 expression by donor endothelial cells attenuates the development of transplant arteriosclerosis, possibly by affecting macrophage infiltration.

Characterization and enrichment of cardiomyocytes derived from human embryonic stem cells

Cell replacement therapy is a promising approach for the treatment of cardiac diseases, but is challenged by a limited supply of appropriate cells. We have investigated whether functional cardiomyocytes can be efficiently generated from human embryonic stem (hES) cells. Cardiomyocyte differentiation was evaluated using 3 parent (H1, H7, and H9) hES cell lines and 2 clonal (H9.1 and H9.2) hES cell lines. All cell lines examined differentiated into cardiomyocytes, even after long-term culture (50 passages or approximately 260 population doublings). Upon differentiation, beating cells were observed after one week in differentiation conditions, increased in numbers with time, and could retain contractility for over 70 days. The beating cells expressed markers characteristic of cardiomyocytes, such as cardiac alpha-myosin heavy chain, cardiac troponin I and T, atrial natriuretic factor, and cardiac transcription factors GATA-4, Nkx2.5, and MEF-2. In addition, cardiomyocyte differentiation could be enhanced by treatment of cells with 5-aza-2'-deoxycytidine but not DMSO or retinoic acid. Furthermore, the differentiated cultures could be dissociated and enriched by Percoll density centrifugation to give a population containing 70% cardiomyocytes. The enriched population was proliferative and showed appropriate expression of cardiomyocyte markers. The extended replicative capacity of hES cells and the ability to differentiate and enrich for functional human cardiomyocytes warrant further development of these cells for clinical application in heart diseases.

Identification of the hemangioblast in postnatal life

Postnatal CD34(+) cells expressing vascular endothelial growth factor receptor 2 (KDR) generate hematopoietic or endothelial progeny in different in vitro and in vivo assays. Hypothetically, CD34(+)KDR(+) cells may comprise hemangioblasts bipotent for both lineages. This hypothesis is consistent with 2 series of experiments. In the first series, in clonogenic culture permissive for hematopoietic and endothelial cell growth, CD34(+)KDR(+) cells generate large hemato-endothelial (Hem-End) colonies (5% of seeded cells), whereas CD34(+)KDR(-) cells do not. Limiting-dilution analysis indicates that Hem-End colonies are clonally generated by single hemangioblasts. Sibling cells generated by a hemangioblast, replated in unicellular culture, produce either hematopoietic or Hem-End colonies, depending on the specific culture conditions. Identification of endothelial cells was based on the expression of VE-cadherin and endothelial markers and with lack of CD45 and hematopoietic molecules, as evaluated by immunofluorescence, immunocytochemistry, and reverse transcription-polymerase chain reaction. Furthermore, endothelial cells were functionally identified using low-density lipoprotein (LDL) uptake and tube-formation assays. In the second series, to evaluate the self-renewal capacity of hemangioblasts, single CD34(+)KDR(+) cells were grown in 3-month extended long-term culture (ELTC) through 3 serial culture rounds-that is, blast cells generated in unicellular ELTC were reseeded for a subsequent round of unicellular ELTC. After 9 months, 10% blasts from tertiary ELTC functioned as hemangioblasts and generated macroscopic Hem-End colonies in clonogenic culture. These studies identified postnatal hemangioblasts in a CD34(+)KDR(+) cell subset, endowed with long-term proliferative potential and bilineage differentiation capacity. Although exceedingly rare, hemangioblasts may represent the lifetime source/reservoir for primitive hematopoietic and endothelial progenitors.

Adult stem cells: assessing the case for pluripotency

It has been known for decades that stem cells with limited differentiation potential are present in post-natal tissues of mammals, and adult stem cells are already used clinically. For instance, hematopoietic stem cells can reestablish the hematopoietic system following myeloablation, and stem cells are being used to regenerate corneal and skin tissue. But recent studies report that adult tissues might contain cells with pluripotent characteristics. These have evoked significant excitement, given the medical implications, but have also met with much skepticism. Indeed, most studies still await independent confirmation, there is a low frequency with which the apparent lineage switching occurs, and importantly such lineage switching defies established developmental biology and stem cell principles. Here, I critically review the published data indicating that postnatal stem cells persist that have greater differentiation potential than previously thought.

Side population cells from diverse adult tissues are capable of in vitro hematopoietic differentiation

OBJECTIVE

Pluripotent hematopoietic stem cells and muscle-derived hematopoietic potential cells isolated by Hoechst 33342 dye-mediated fluorescein-activated cell sorting (FACS) as side population (SP) cells, give rise to hematopoietic cells as well as skeletal muscle cells following intravenous transplantation. However, besides bone marrow and skeletal muscle, it has remained unclear whether other adult tissues also contain SP cells that are enriched for cells that exhibit hematopoietic potential.

METHODS

To test whether adult tissues contain SP cells with hematopoietic potential, Hoechst-FACS analysis and hematopoietic colony formation assays were performed with cells isolated from a variety of adult tissues, skeletal muscle, heart, brain, spleen, liver, kidney, lung, and small intestine and compared with peripheral blood and bone marrow cells.

RESULTS

In addition to hematopoietic tissues, cell preparations from nonhematopoietic tissues, such as skeletal muscle, kidney, lung, and small intestine, displayed markedly higher hematopoietic colony formation activity compared to peripheral blood cells. Moreover, the hematopoietic progenitors in these adult tissues expressed the hematopoietic cell marker CD45. Hoechst-FACS analysis demonstrated that all adult tissues examined contained SP cells. In addition, these SP fractions were enriched for cells that efficiently formed hematopoietic colonies in vitro.

CONCLUSION

These results indicate that hematopoietic progenitors are present in significant numbers in all adult tissues examined.

New directions in bioabsorbable technology

Generating replacement tissues requires an interdisciplinary approach that combines developmental, cell, and molecular biology with biochemistry, immunology, engineering, medicine, and the material sciences. Because basic cues for tissue engineering may be derived from endogenous models, investigators are learning how to imitate nature. Endogenous models may provide the biological blueprints for tissue restoration, but there is still much to learn. Interdisciplinary barriers must be overcome to create composite, vascularized, patient-specific tissue constructs for replacement and repair. Although multistep, multicomponent tissue fabrication requires an amalgamation of ideas, the following review is limited to the new directions in bioabsorbable technology. The review highlights novel bioabsorbable design and therapeutic (gene, protein, and cell-based) strategies currently being developed to solve common spine-related problems.

Improved conditions to induce hepatocytes from rat bone marrow cells in culture

Recent studies have revealed that bone marrow cells can develop into hepatocytes by in vivo transplantation under certain circumstances. However, little is known about the mechanism of bone marrow cell differentiation into hepatocytes. It is important to determine suitable culture conditions in which bone marrow cells will be differentiated into hepatocytes not only for understanding differentiation mechanisms but also for efficient amplification of hepatocyte-progenitor cells of bone marrow origin, this being a prerequisite for potential therapeutic use. In the present study, we found that hepatocyte growth factor (HGF) receptor (c-Met)- and alpha-fetoprotein-expressing cells were present in adult rat bone marrow. We also found that these cells also express hematopoietic stem cell markers, such as CD34, Thy-1, and c-Kit. Using an HGM medium with HGF and EGF, we succeeded in propagating hepatocyte-like cells induced from adult rat bone marrow in culture. These cells were immunocytochemically stained for albumin. By RT-PCR analysis of cultures containing the hepatocyte-like cells, we detected mRNAs of tryptophan-2,3-dioxygenase and tyrosine aminotransferase, markers of hepatocytes at a terminal differentiation stage. The present culture therefore can be a useful resource for cell transplantation therapy for liver diseases.

Myogenic specification of side population cells in skeletal muscle

Skeletal muscle contains myogenic progenitors called satellite cells and muscle-derived stem cells that have been suggested to be pluripotent. We further investigated the differentiation potential of muscle-derived stem cells and satellite cells to elucidate relationships between these two populations of cells. FACS(R) analysis of muscle side population (SP) cells, a fraction of muscle-derived stem cells, revealed expression of hematopoietic stem cell marker Sca-1 but did not reveal expression of any satellite cell markers. Muscle SP cells were greatly enriched for cells competent to form hematopoietic colonies. Moreover, muscle SP cells with hematopoietic potential were CD45 positive. However, muscle SP cells did not differentiate into myocytes in vitro. By contrast, satellite cells gave rise to myocytes but did not express Sca-1 or CD45 and never formed hematopoietic colonies. Importantly, muscle SP cells exhibited the potential to give rise to both myocytes and satellite cells after intramuscular transplantation. In addition, muscle SP cells underwent myogenic specification after co-culture with myoblasts. Co-culture with myoblasts or forced expression of MyoD also induced muscle differentiation of muscle SP cells prepared from mice lacking Pax7 gene, an essential gene for satellite cell development. Therefore, these data document that satellite cells and muscle-derived stem cells represent distinct populations and demonstrate that muscle-derived stem cells have the potential to give rise to myogenic cells via a myocyte-mediated inductive interaction.

Isolation and characterization of size-sieved stem cells from human bone marrow

Bone marrow mesenchymal stem cells (MSCs) have the capacity for renewal and the potential to differentiate into multiple lineages of mesenchymal tissues. In the laboratory, MSCs have the tendency to adhere to culture dish plastic and are characterized by fibroblastic morphology, but possess no specific markers to select them. To isolate and purify MSCs from bone marrow, we use a culture device-a plastic culture dish comprising a plate with 3-microm pores-to sieve out a homogeneous population of cells (termed size-sieved [SS] cells) from bone marrow aspirates. SS cells that adhered to the upper porous plate surface were a relatively homogeneous population as indicated by morphology and other criteria, such as surface markers. They had the capacity for self-renewal and the multilineage potential to form bone, fat, and cartilage, and satisfy the characteristics of MSCs. In addition, if all the cells from each passage had been plated and cultured in our defined conditions, over 10(14) SS cells would have been obtained from each 10-ml aspirate in 15 additional weeks of culture. This technically simple method leads to an efficient isolation and purification of cells with the characteristics of MSCs.

A role for extrarenal cells in the regeneration following acute renal failure

BACKGROUND

Recovery of renal function following acute tubular necrosis (ATN) is dependent on the replacement of necrotic tubular cells with functional tubular epithelium. The source of these new tubular cells is thought to be resident renal tubular cells. The discovery of pluripotent bone marrow-derived stem cells has led to a reexamination of the cellular source and processes involved in the recovery from organ injury.

METHODS

To test the hypothesis in humans that extrarenal cells participate in the recovery following ATN, we examined the origin of tubular cells in male patients with resolving ATN who had received a kidney transplant from a female donor. Immunohistochmistry of kidney biopsies was performed to identify renal tubular epithelial cells (cytokeratin positive) and leukocytes (CD45 positive). Fluorescent in-situ hybridization was used to detect Y chromosome containing cells with DAPI serving as a nuclear stain. All staining was performed on the same section.

RESULTS

The Y chromosome was detected in approximately 40% of tubular cell nuclei in male kidneys (positive control) and in no nuclei of female kidneys (negative control). In male recipients of female kidneys who developed ATN, 1% of tubules contained Y chromosome cells defined by their morphology, positive staining for cytokeratin, and negative staining for CD45. When present, multiple cells in a positive tubule stained for the Y chromosome. No Y chromosome containing tubular cells were seen in similar sex mismatched transplants in male recipients who did not develop ATN, suggesting that recipient derived cells do not routinely repopulate the transplanted kidney.

CONCLUSIONS

This proof-of-principle clinical observation demonstrates that extrarenal cells can participate in the regenerative response following ATN. These findings provide rationale for the cellular therapy of acute renal failure.

The scarless heart

Over the past several years many mechanisms by which myocardial replacement could be achieved have been described. These include resident cardiac stem cells or circulating stem cells that can either differentiate into, or fuse to cardiomyocytes, or mature cells that can transdifferentiate into cardiomyocytes. However, the fact remains that after injury to the heart, the overriding response is scar formation with little myocardial replacement. One exception to this response is the MRL mouse, which heals with little scarring and shows nearly full myocardial replacement after injury. Results obtained with this model will be discussed.

Stem cell differentiation requires a paracrine pathway in the heart

Members of the transforming growth factor beta1 (TGF-beta) superfamily--namely, TGF-beta and BMP2--applied to undifferentiated murine embryonic stem cells up-regulated mRNA of mesodermal (Brachyury) and cardiac specific transcription factors (Nkx2.5, MEF2C). Embryoid bodies generated from stem cells primed with these growth factors demonstrated an increased potential for cardiac differentiation with a significant increase in beating areas and enhanced myofibrillogenesis. In an environment of postmitotic cardiomyocytes, stem cells engineered to express a fluorescent protein under the control of a cardiac promoter differentiated into fluorescent ventricular myocytes beating in synchrony with host cells, a process significantly enhanced by TGF-beta or BMP2. In vitro, disruption of the TGF-beta/BMP signaling pathways by latency-associated peptide and/or noggin prevented differentiation of stem cells. In fact, only host cells that secrete a TGF-beta family member induced a cardiac phenotype in stem cells. In vivo, transplantation of stem cells into heart also resulted in cardiac differentiation provided that TGF-beta/BMP2 signaling was intact. In infarcted myocardium, grafted stem cells differentiated into functional cardiomyocytes integrated with surrounding tissue, improving contractile performance. Thus, embryonic stem cells are directed to differentiate into cardiomyocytes by signaling mediated through TGF-beta/BMP2, a cardiac paracrine pathway required for therapeutic benefit of stem cell transplantation in diseased heart.

Bone marrow-derived progenitor cells modulate vascular reendothelialization and neointimal formation: effect of 3-hydroxy-3-methylglutaryl coenzyme a reductase inhibition

OBJECTIVE

Atherosclerosis and restenosis after vascular injury are both characterized by endothelial dysfunction, apoptosis, inappropriate endothelialization, and neointimal formation. Bone marrow-derived endothelial progenitor cells have been implicated in neovascularization, resulting in adult blood vessel formation. Despite the anticipated stem cell plasticity, the role of bone marrow-derived endothelial progenitor cells has not been clarified in vascular lesion development.

METHODS AND RESULTS

We investigated vascular lesion formation in mice after transplantation of bone marrow transfected by means of retrovirus with enhanced green fluorescent protein. Carotid artery injury was induced, resulting in neointimal formation. Fluorescence microscopy and immunohistological analysis revealed that bone marrow-derived progenitor cells are involved in reendothelialization of the vascular lesions. Treatment with rosuvastatin (20 mg/kg body wt per day), a 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor, enhanced the circulating pool of endothelial progenitor cells, propagated the advent of bone marrow-derived endothelial cells in the injured vessel wall, and, thereby, accelerated reendothelialization and significantly decreased neointimal formation.

CONCLUSIONS

Vascular lesion development initiated by endothelial cell damage is moderated by bone marrow-derived progenitor cells. 3-Hydroxy-3-methylglutaryl coenzyme A reductase inhibition promotes bone marrow-dependent reendothelialization and diminishes vascular lesion development. These findings may help to establish novel pathophysiological concepts and therapeutic strategies in the treatment of various cardiovascular diseases.

New directions in bioabsorbable technology

Generating replacement tissues requires an interdisciplinary approach that combines developmental, cell, and molecular biology with biochemistry, immunology, engineering, medicine, and the material sciences. Since the basic cues for tissue engineering may be derived from endogenous models, investigators are learning how to imitate nature. Endogenous models may provide the biologic blueprints for tissue restoration, but there is still much to learn. Interdisciplinary barriers must be overcome to create composite, vascularized, patient-specific tissue constructs for replacement and repair. Although multistep, multicomponent tissue fabrication requires an amalgamation of ideas, the following review is limited to the new directions in bioabsorbable technology. The review highlights novel bioabsorbable design and therapeutic (gene, protein, and cell-based) strategies that are currently being developed to solve common spinal problems.

Little evidence for developmental plasticity of adult hematopoietic stem cells

To rigorously test the in vivo cell fate specificity of bone marrow (BM) hematopoietic stem cells (HSCs), we generated chimeric animals by transplantation of a single green fluorescent protein (GFP)-marked HSC into lethally irradiated nontransgenic recipients. Single HSCs robustly reconstituted peripheral blood leukocytes in these animals, but did not contribute appreciably to nonhematopoietic tissues, including brain, kidney, gut, liver, and muscle. Similarly, in GFP+:GFP- parabiotic mice, we found substantial chimerism of hematopoietic but not nonhematopoietic cells. These data indicate that "transdifferentiation" of circulating HSCs and/or their progeny is an extremely rare event, if it occurs at all.

Neural cells derived from adult bone marrow and umbilical cord blood

Under experimental conditions, tissue-specific stem cells have been shown to give rise to cell lineages not normally found in the organ or tissue of residence. Neural stem cells from fetal brain have been shown to give rise to blood cell lines and conversely, bone marrow stromal cells have been reported to generate skeletal and cardiac muscle, oval hepatocytes, as well as glia and neuron-like cells. This article reviews studies in which cells from postnatal bone marrow or umbilical cord blood were induced to proliferate and differentiate into glia and neurons, cellular lineages that are not their normal destiny. The review encompasses in vitro and in vivo studies with focus on experimental variables, such as the source and characterization of cells, cell-tracking methods, and markers of neural differentiation. The existence of stem/progenitor cells with previously unappreciated proliferation and differentiation potential in postnatal bone marrow and in umbilical cord blood opens up the possibility of using stem cells found in these tissues to treat degenerative, post-traumatic and hereditary diseases of the central nervous system.

Auto Repair on the Aging Stem Cell Superhighway

Adult bone marrow stem cells offer the potential for rejuvenation of diseased or damaged tissues and organs. The greatest need for such a treatment in older individuals is to counter age-associated predisposition to cardiovascular diseases. Unfortunately, changes in senescent vascular function might limit the recruitment of bone marrow-derived precursor cells. In order to provide the patient with the conduits required to deliver bone marrow cells to damaged tissues, it is essential to develop strategies to overcome these limitations. This effort will require novel approaches to reverse aging-associated vascular dysfunction, including reharnessing the potential of stem cells from the aging bone marrow for vascular repair.

VEGF enhances functional improvement of postinfarcted hearts by transplantation of ESC-differentiated cells

Despite considerable advances in medicine, the incidence of heart failure remains high in patients after myocardial infarction (MI). This study investigated the effects of engrafted early-differentiated cells (EDCs) from mouse embryonic stem cells, with or without transfection of vascular endothelial growth factor (VEGF) cDNA (phVEGF(165)), on cardiac function in postinfarcted mice. EDCs were transfected with green fluorescent protein (GFP) cDNA and transplanted into infarcted myocardium. Compared with the MI mice receiving cell-free medium, cardiac function was significantly improved in the MI mice 6 wk after transplantation of EDCs. Moreover, improvement of heart function was significantly greater in the mice implanted with EDCs overexpressing VEGF (EDCs-VEGF) than with EDCs alone. Frozen sections of infarcted myocardium with EDCs or EDCs-VEGF transplantation showed GFP-positive tissue. The area with positive immunostaining for cardiac troponin I and alpha-myosin heavy chain was larger in injured myocardium with EDCs or EDCs-VEGF transplantation than with medium injection. Transplantation of EDCs or EDCs-VEGF significantly increased the number of blood vessels in the MI area. However, the density of capillaries was significantly higher in the EDCs-VEGF animals than in the EDC mice. Double staining for GFP and connexin-43 was positive in injured myocardium with EDC transplantation. Our data demonstrate that engrafted EDCs or EDCs-VEGF regenerated cardiac tissue and significantly improved cardiac function in postinfarcted hearts. The novel EDCs-VEGF synergistic approach may have an important impact on future cell therapy for patients experiencing MI or heart failure.

CD34(+) or CD34(-): which is the more primitive?

Remarkable progress has been achieved in the characterization and isolation of primitive hematopoietic stem cells (HSC). HSC represent a very small subset of hematopoietic cells and provide self-renewal, possess differentiation capacity and allow a constant supply of the entire hematopoietic cell spectrum. Until recently, CD34 has been used as a convenient marker for HSC, since CD34(+) cells have been shown to possess colony-forming potential in short-term assays, maintain long-term colony-forming potential in in vitro cultures and allow the expression and differentiation of blood cells from different hematopoietic lineages in in vivo models. Clinical and experimental protocols have targeted CD34(+) cells enriched by a variety of selection models and have readily used these for transplantation, purging and gene therapies and targets for future organ replacement. Recent studies in murine and human models, however, have indicated that CD34(-) HSC exist as well, which possess engraftment potential and distinct HSC characteristics. These studies challenge the dogma that HSC are uniformly found in the CD34(+) subset, and question whether primitive HSC are CD34(+) or CD34(-). In this review, results on murine and human CD34(+) and CD34(-) HSC, differences between them and their possible interactions are examined.

Damaged epithelia regenerated by bone marrow-derived cells in the human gastrointestinal tract

Studies have shown that bone marrow cells have the potential to differentiate into a variety of cell types. Here we show that bone marrow cells can repopulate the epithelia of the human gastrointestinal tract. Epithelial cells of male donor origin were distributed in every part of the gastrointestinal tract of female bone marrow transplant recipients. Donor-derived epithelial cells substantially repopulated the gastrointestinal tract during epithelial regeneration after graft-versus-host disease or ulcer formation. Regeneration of gastrointestinal epithelia with donor-derived cells in humans shows a potential clinical application of bone marrow-derived cells for repairing severely damaged epithelia, not only in the gastrointestinal tract but also in other tissues.

Transdifferentiation and nuclear reprogramming in hematopoietic development and neoplasia

Cell transplantation and tissue regeneration studies indicate a surprisingly broad developmental potential for lineage-committed hematopoietic stem cells (HSCs). Under these conditions HSCs transition into myocytes, neurons, hepatocytes or other types of nonhematopoietic effector cells. Equally impressive is the progression of committed neuronal stem cells (NSCs) to functional blood elements. Although critical cell-of-origin issues remain unresolved, the possibility of lineage switching is strengthened by a few well-controlled examples of cell-type conversion. At the molecular level, switching probably initiates from environmental signals that induce epigenetic modifications, resulting in changes in chromatin configuration. In turn, these changes affect patterns of gene expression that mediate divergent developmental programs. This review examines recent findings in nuclear reprogramming and cell fusion as potential causative mechanisms for transdifferentiation during normal and malignant hematopoiesis.

Gene therapy for cardiac cachexia?

The prevention or attenuation of disease-related skeletal muscle degeneration has been a common goal in the treatment of cardiac cachexia. Cell-based therapies are complicated by insufficient numbers of autologous myoblasts and by ineffective incorporation into host muscle. Pharmacological administration of growth hormone in a variety of clinical conditions characterized by an increase in catabolic rate have been associated with increases in mortality and morbidity, resulting in a decrease in the clinical use of growth hormone and its downstream effector, insulin-like growth factor-1 and a decline in general research into anabolic treatment strategies. In mouse models, however, the selective expression of a muscle-specific transgene encoding a locally acting IGF-1 isoform induces muscle hypertrophy, prevents age- or disease-related atrophy, by increasing stem cell recruitment to injured or degenerating tissue. This gene-based approach avoids hypertrophic effects on distal organs such as the heart, and eliminates risk of possible neoplasms induced by inappropriate high expression levels of circulating IGF-1. The potential therapeutic role of locally expressed IGF-1 is discussed in the context of current strategies for the attenuation of cardiac cachexia.

Stem cells on the way to restorative medicine

Stem cells are defined by their unique properties of self-renewal and multilineage differentiation. Several decades ago, cells with such developmental plasticity have been identified in the embryo and in the bone marrow of the adult; in other organs, such cells could not be demonstrated. Here, recent findings are briefly summarized indicating that the elementary stem cell capabilities are retained by a limited number of cells present in many organs of the adult. Other data suggest that, on response to another microenvironment, "organ-specific" stem cells are able to acquire different fates. If confirmed these findings will have considerable impact on the future of clinical stem cell therapy.

Bone marrow stromal cells contract synchronously with cardiomyocytes in a coculture system

OBJECTIVES

Cell transplantation is a promising therapy for improving damaged heart function. Cardiac environmental factors are thought to be powerful differentiation inducers, but their effects are not well understood because of their in vivo nature. We simulated the cardiac environment using coculture and evaluated cardiomyogenic differentiation in bone marrow stromal cells and synchronous contraction with other cardiomyocytes.

METHODS

Experiment 1. We evaluated the labeling efficiency, intensity, and pattern of green fluorescence in the transgenic mouse expressing green fluorescent protein-derived bone marrow stromal cells (GFP-BMCs) from initial plating through 8 weeks under fluorescent microscopy. Experiment 2. GFP-BMCs (10(5) cells) were cocultured with neonatal rat cardiomyocytes (10(5) cells). We also evaluated the incorporation, myogenic differentiation, and synchronous contraction of GFP-BMCs for 1 week under the same microscopy with a digital video camera.

RESULTS

Experiment 1. All GFP-BMCs but red blood cells maintained green fluorescence from initial plating through 8 weeks. Experiment 2. Some GFP-BMCs were incorporated in parallel with cardiomyocytes and showed myotube-like formation on day 1. On day 2, GFP-BMCs started to contract synchronously with cardiomyocytes. GFP-BMCs formed colonies and maintained synchronous contraction on day 7.

CONCLUSIONS

Direct cell-to-cell interaction with cardiomyocytes is essential for myogenic differentiation and synchronous contraction of bone marrow cells. This coculture is a simple tool for simulating the cardiac environment and evaluating phenotypic changes in vitro.

Primate skeletal muscle contains cells capable of sustaining in vitro hematopoiesis

OBJECTIVE

Several investigators recently reported that adult murine skeletal muscle cells possess a remarkable capacity to differentiate into hematopoietic cells. We further examined this biologic process by studying the phenotype and in vitro functional behavior of primate skeletal muscle cells.

MATERIALS AND METHODS

Muscles from human abortuses as well as fetal and adult baboons were digested enzymatically and mononuclear cell fractions were isolated. Muscle tissue-derived mononuclear cells (mu-TDMNC) were phenotypically characterized. Both short-term and long-term hematopoietic progenitors were assayed from mu-TDMNC using standard techniques. Gene expression patterns characteristic of hematopoietic and endothelial cells were examined in primary and cultured muscle cells.

RESULTS

Primate muscle cells were shown to express the CD34 antigen. Such CD34(+) cells were shown to be CD45(-) and desmin(+), indicating they were not of hematopoietic origin. Fetal but not adult muscle cells contained assayable hematopoietic progenitors. In addition, muscles contained an additional class of progenitors that formed colonies composed of blast cells after prolonged incubation (3-4 weeks). A two-step culture system was established that permitted muscle cells to continue to proliferate when exposed to a hematopoietic environment for 8 months. During this prolonged period of time, the generation of CD34(+), CD56(+), CD11b(+), and CD31(+) as well as von Willebrand factor (vWF)(+) cells were observed.

CONCLUSIONS

Our studies indicate that although primate muscle cells contain a significant number of CD34(+) cells, they are likely not of hematopoietic origin. Important ontogenic differences in the hematopoietic potential of primate muscle cells were documented. When exposed to appropriate microenvironmental stimuli, mu-TDMNC displayed an extensive proliferative capacity and contained primitive progenitors with the capacity to generate cells in vitro with phenotypic and genetic properties of hematopoietic and endothelial cells for sustained periods of time. Whether this observation can be accounted for by true transdifferentiation of muscle cells or proliferation of reservoirs of hematopoietic and endothelial progenitor cells residing within skeletal muscle remains unresolved.

Multipotent progenitor cells can be isolated from postnatal murine bone marrow, muscle, and brain

OBJECTIVE

Recent studies have shown that cells from bone marrow (BM), muscle, and brain may have greater plasticity than previously known. We have identified multipotent adult progenitor cells (MAPC) in postnatal human and rodent BM that copurify with mesenchymal stem cells (MSC). BM MAPC proliferate without senescence and differentiate into mesodermal, neuroectodermal, and endodermal cell types. We hypothesized that cells with characteristics similar to BM MAPC can be selected and cultured from tissues other than BM.

MATERIALS AND METHODS

BM, whole brain, and whole muscle tissue was obtained from mice. Cells were plated on Dulbecco modified Eagle medium supplemented with 2% fetal calf serum and 10 ng/mL epidermal growth factor (EGF), 10 ng/mL platelet-derived growth factor (PDGF-BB), and 1000 units/mL leukemia inhibitory factor (LIF) for more than 6 months. Cells were maintained between 0.5 and 1.5 x 10(3) cells/cm(2). At variable time points, we tested cell phenotype by FACS and evaluated their differentiation into endothelial cells, neuroectodermal cells, and endodermal cells in vitro. We also compared the expressed gene profile in BM, muscle, and brain MAPC by Affimetrix gene array analysis.

RESULTS

Cells could be cultured from BM, muscle, and brain that proliferated for more than 70 population doublings (PDs) and were negative for CD44, CD45, major histocompatibility complex class I and II, and c-kit. Cells from the three tissues differentiated to cells with morphologic and phenotypic characteristics of endothelium, neurons, glia, and hepatocytes. The expressed gene profile of cells derived from the three tissues was identical (r(2) > 0.975).

CONCLUSIONS

This study shows that cells with MAPC characteristics can be isolated not only from BM, but also from brain and muscle tissue. Whether MAPC originally derived from BM are circulating or all organs contain stem cells with MAPC characteristics currently is being studied. Presence of MAPC in multiple tissues may help explain the "plasticity" found in multiple adult tissues.

Oxytocin induces differentiation of P19 embryonic stem cells to cardiomyocytes

We recently discovered the existence of the oxytocin/oxytocin receptor (OT/OTR) system in the heart. Activation of cardiac OTR stimulates the release of atrial natriuretic peptide (ANP), which is involved in regulation of blood pressure and cell growth. Having observed elevated OT levels in the fetal and newborn heart at a stage of intense cardiomyocyte hyperplasia, we hypothesized a role for OT in cardiomyocyte differentiation. We used mouse P19 embryonic stem cells to substantiate this potential role. P19 cells give rise to the formation of cell derivatives of all germ layers. Treatment of P19 cell aggregates with dimethyl sulfoxide (DMSO) induces differentiation to cardiomyocytes. In this work, P19 cells were allowed to aggregate from day 0 to day 4 in the presence of 0.5% DMSO, 10(-7) M OT and/or 10(-7) M OT antagonist (OTA), and then cultured in the absence of these factors until day 14. OT alone stimulated the production of beating cell colonies in all 24 independently growing cultures by day 8 of the differentiation protocol, whereas the same result was obtained in cells induced by DMSO only after 12 days. Cells induced with OT exhibited increased ANP mRNA, had abundant mitochondria (i.e., they strongly absorbed rhodamine 123), and expressed sarcomeric myosin heavy chain and dihydropyridine receptor-alpha 1, confirming a cardiomyocyte phenotype. In addition, OT as well as DMSO increased OTR protein and OTR mRNA, and OTA completely inhibited the formation of cardiomyocytes in OT- and DMSO-supplemented cultures. These results suggest that the OT/OTR system plays an important role in cardiogenesis by promoting cardiomyocyte differentiation.

Pluripotency of mesenchymal stem cells derived from adult marrow

We report here that cells co-purifying with mesenchymal stem cells--termed here multipotent adult progenitor cells or MAPCs--differentiate, at the single cell level, not only into mesenchymal cells, but also cells with visceral mesoderm, neuroectoderm and endoderm characteristics in vitro. When injected into an early blastocyst, single MAPCs contribute to most, if not all, somatic cell types. On transplantation into a non-irradiated host, MAPCs engraft and differentiate to the haematopoietic lineage, in addition to the epithelium of liver, lung and gut. Engraftment in the haematopoietic system as well as the gastrointestinal tract is increased when MAPCs are transplanted in a minimally irradiated host. As MAPCs proliferate extensively without obvious senescence or loss of differentiation potential, they may be an ideal cell source for therapy of inherited or degenerative diseases.

Cardiomyocytes of noncardiac origin in myocardial biopsies of human transplanted hearts

BACKGROUND

Cell replacement therapy with stem cells able to differentiate into cardiomyocytes has been discussed as a method for remodeling damaged myocardium. A physiological or pathophysiological situation in which this phenomenon might be relevant is not known. We studied the origin of cardiomyocytes in myocardial biopsies of male patients that had undergone sex-mismatched cardiac transplantation to determine whether cells containing a Y chromosome (and therefore being of recipient origin) are able to differentiate into cardiomyocytes.

METHODS AND RESULTS

Myocardial biopsies (n=21) were obtained from the right ventricles of male patients (n=13) who had undergone sex-mismatched heart transplantation. Tissue from 1 nontransplanted male and myocardial biopsies from sex-matched heart-transplanted patients served as controls. Cells from donor and recipient origins were identified by fluorescence in situ hybridization with the use of specific probes for X and Y chromosomes on paraffin sections of the biopsies. Cell types were identified by using immunostaining procedures on the same tissue sections. Cardiomyocytes of recipient origin were detected in 8 of 13 male recipients of female hearts. They were connected by gap junctions with adjacent myocytes. Of the cardiomyocyte nuclei, 0.16+/-0.04% (mean+/-SEM, median 0.09%) contained the Y-chromosomal marker. There was no detectable correlation with the extent or number of rejection episodes, time of transplantation, or medical treatment regimen.

CONCLUSIONS

These results show that regeneration by cells of noncardiac origin (differentiated into cardiomyocytes and physiologically linked to neighboring myocytes) can be detected even in small myocardial biopsies. This may lead to new diagnostic and therapeutic strategies in the treatment of myocardial infarction, inflammatory heart disease, and/or heart failure.

Autologous cell transplantation for the treatment of damaged myocardium

Autologous cell transplantation for the treatment of damaged myocardium after myocardial infarction is becoming an increasingly promising strategy. This form of treatment can be divided into 2 treatment strategies: The first uses differentiated cell types to replace the scarred tissue with living cells, while the second strategy uses stem cells in an attempt to regenerate myocardium. Over the past decade, multiple cell types have been used in animal studies, and clinical trials to determine the safety of injecting and engrafting skeletal myoblasts into damaged myocardium are presently being conducted. Animals studies focused on using stem cells to regenerate damaged myocardium have shown a naturally occurring reparative process that consists of up-regulation of progenitor cell release from the bone marrow after myocardial infarction, homing of these cells to the injured tissue, and differentiation of these progenitor cells into vascular cells and cardiac myocytes within the infarcted tissue. Unfortunately, this process occurs with great infrequency. Strategies to regenerate myocardium with stem cells either extract stem cells from the bone marrow and inject these cells into the damaged area or they attempt to increase the efficiency of the natural reparative process by increasing the mobilization of bone marrow-derived stem cells after myocardial infarction. This review summarizes the field of cell transplantation over the past decade, discusses areas of controversy, and proposes an outline of advancements that need to be made in both the clinical and scientific arenas for autologous cell transplantation to fully reach its clinical potential.

Adult stem cell plasticity

Observations made in the last few years support the existence of pathways, in adult humans and rodents, that allow adult stem cells to be surprisingly flexible in their differentiation repertoires. Termed plasticity, this property allows adult stem cells, assumed, until now, to be committed to generating a fixed range of progeny, to switch, when they have been relocated, to make other specialized sets of cells appropriate to their new niche. Reprogramming of some adult stem cells can occur in vivo; the stem cells normally resident in bone marrow appear particularly flexible and are able to contribute usefully to multiple recipient organs. This process produces cells with specialized structural and metabolic adaptations commensurate with their new locations. In a few examples, the degree of support is sufficient to assist or even rescue recipient mice from genetic defects. Some studies provide evidence for the expansion of the reprogrammed cells locally, but in most it remains possible that cells arrive and redifferentiate, but are no longer stem cells. Nevertheless, the fact that appropriately differentiated cells are delivered deep within organs simply by injection of bone marrow cells should make us think differently about the way that organs regenerate and repair. Migratory pathways for stem cells in adult organisms may exist that could be exploited to effect repairs using an individual's own stem cells, perhaps after gene therapy. Logical extensions of this concept are that a transplanted organ would become affected by the genetic susceptibilities of the recipient, alleles that re-express themselves via marrow-derived stem cells, and that plasticity after bone marrow transplantation would also transfer different phenotypes, affecting important parameters such as susceptibility to long-term complications of diabetes, or the ability to metabolize drugs in the liver. This article reviews some of the evidence for stem cell plasticity in rodents and man.

Plasticity and hematopoiesis: Circe's transforming potion?

It has long been believed that mammalian stem cells are irreversibly committed to the individual tissue in which they reside; however, several recent studies have challenged this assertion and suggest a remarkable plasticity of stem cells derived from various adult tissues. Hematopoietic stem cells have been central to this paradigm shift, and in this review, the authors discuss the recent advances in this rapidly growing field. Although several exciting findings in rodents have already led to clinical trials in humans, true stem cell plasticity has not rigorously been established in most, if not all, studies to date, and a number of issues remain unresolved. Large animal models should prove invaluable to the progress of the field.

Cardiac stem cells

Augmentation of myocardial performance in experimental models of therapeutic infarction and heart failure has been achieved by the transplantation of exogenous cells into damaged myocardium, a procedure known as cellular cardiomyoplasty (CCM). Historically, a wide range of cell types have been used for CCM, including rat and human fetal ventricular myocytes, but the availability of human fetal donor cells for clinical purposes is limited. The quest for suitable alternative donor cells has prompted research into the use of both embryonic stem (ES) cells and adult somatic stem cells, but the optimal choice of donor cell source is not yet known. Recently, there has been a growing body of evidence that multipotent somatic stem cells in adult bone marrow exhibit tremendous functional plasticity and can reprogramme in a new environmental tissue niche to give rise to cell lineages specific for the new organ site. This phenomenon has made a huge impact on myocardial biology and has captured the imagination of scientists who have recently discovered that multipotent adult bone marrow haematopoeitic stem cells and mesenchymal stem cells can repopulate infarcted rodent myocardium and differentiate into both cardiomyocytes and new blood vessels. These data, coupled with the identification of a putative primitive cardiac stem cell population in the adult human heart, may pave the way for novel therapeutic modalities for enhancing myocardial performance and treating end-stage cardiac disease.