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Affiliation(s)
- Ke Huang
- Department of Molecular Biomedical Sciences and Comparative Medicine Institute, North Carolina State University, Raleigh, NC, USA
| | - Ke Cheng
- Department of Molecular Biomedical Sciences and Comparative Medicine Institute, North Carolina State University, Raleigh, NC, USA. .,Joint Department of Biomedical Engineering, the University of North Carolina at Chapel Hill and North Carolina State University, Raleigh, NC, USA.
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Abstract
PURPOSE OF REVIEW This review presents the current state of imaging approaches that enable real-time molecular imaging in the interventional suite and discusses the potential future use of integrated nuclear imaging and fluoroscopy for intraprocedural guidance in the evaluation and treatment of both cardiovascular and oncological diseases. RECENT FINDINGS Although there are no commercially available real-time hybrid nuclear imaging devices that are approved for use in the interventional suite, prototype open gantry hybrid nuclear imaging and x-ray c-arm imaging systems and theranostic catheter for location radiotracer detection are currently undergoing development and testing by multiple groups. The integration of physiological and molecular targeted nuclear imaging for real-time delivery of targeted theranostics in the interventional laboratory may enable more personalized care for a wide variety of cardiovascular procedures and improve patient outcomes.
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Siimes S, Järveläinen N, Korpela H, Ylä-Herttuala S. Endocardial Gene Delivery Using NOGA Catheter System. Methods Mol Biol 2022; 2573:179-187. [PMID: 36040595 DOI: 10.1007/978-1-0716-2707-5_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
NOGA/MyoStar system uses low magnetic fields and endomyocardial electrical parameters, allowing precise endomyocardial injections of therapeutic agents to ischemic yet viable myocardium which is most likely to respond to the treatment. Preclinical and clinical studies have shown that NOGA/MyoStar guided intramyocardial injections are safe, feasible and a minimally invasive way to deliver gene therapy to the heart. Here we describe how to perform electroanatomical mapping and injections to hibernating myocardium in the preclinical studies.
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Affiliation(s)
- Satu Siimes
- A.I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, Kuopio, Finland
| | - Niko Järveläinen
- A.I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, Kuopio, Finland
| | - Henna Korpela
- A.I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, Kuopio, Finland
| | - Seppo Ylä-Herttuala
- A.I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, Kuopio, Finland. .,Heart Center and Gene Therapy Unit, Kuopio University Hospital, Kuopio, Finland.
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Correlation between electromechanical parameters (NOGA XP) and changes of myocardial ischemia in patients with refractory angina. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2021; 17:281-289. [PMID: 34819964 PMCID: PMC8596713 DOI: 10.5114/aic.2021.109168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 07/23/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction Cell therapy has the potential to improve symptoms and clinical outcomes in refractory angina (RFA). Further analyses are needed to evaluate factors influencing its therapeutic effectiveness. Aim Assessment of electromechanical (EM) parameters of the left ventricle (LV) and investigation of correlation between EM parameters of the myocardium and response to CD133+ cell therapy. Material and methods Thirty patients with RFA (16 active and 14 placebo individuals) enrolled in the REGENT-VSEL trial underwent EM evaluation of the LV with intracardiac mapping system. The following parameters were analyzed: unipolar voltage (UV), bipolar voltage (BV), local linear shortening (LLS). Myocardial ischemia was evaluated with single-photon emission computed tomography (SPECT). The median value of each EM parameter was used for intra-group comparisons. Results Global EM parameters (UV, BV, LLS) of LV in active and placebo groups were 11.28 mV, 3.58 mV, 11.12%, respectively; 13.00 mV, 3.81 mV, 11.32%, respectively. EM characteristics analyzed at global and segmental levels did not predict response to CD133+ cell therapy in patients with RFA (Global UV, BV and LLS at rest R = –0.06; R = 0.2; R = –0.1 and at stress: R = 0.07, R = 0.09, R = –0.1, respectively; Segmental UV, BV, LLS at rest R = –0.2, R = 0.03, R = –0.4 and at stress R = 0.02, R = 0.2, R = –0.2, respectively). Multiple linear regression of the treated segments showed that only pre-injection SPECT levels were significantly correlated with post-injection SPECT, either at rest or stress (p < 0.05). Conclusions Electromechanical characteristics of the left ventricle do not predict changes of myocardial perfusion by SPECT after cell therapy. Baseline SPECT results are only predictors of changes of myocardial ischemia observed at 4-month follow-up.
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Zoppo F, Gagno G, Perazza L, Cocciolo A, Mugnai G, Vaccari D, Calzolari V. Electroanatomic voltage mapping for tissue characterization beyond arrhythmia definition: A systematic review. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:1432-1448. [PMID: 34096635 DOI: 10.1111/pace.14288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 05/17/2021] [Accepted: 05/30/2021] [Indexed: 11/28/2022]
Abstract
Three-dimensional (3D) reconstruction by means of electroanatomic mapping (EAM) systems, allows for the understanding of the mechanism of focal or re-entrant arrhythmic circuits, which can be identified by means of dynamic (activation and propagation) and static (voltage) color-coded maps. However, besides this conventional use, EAM may offer helpful anatomical and functional information for tissue characterisation in several clinical settings. Today, data regarding electromechanical myocardial viability, scar detection in ischaemic and nonischaemic cardiomyopathy and arrhythmogenic right ventricle dysplasia (ARVC/D) definition are mostly consolidated, while emerging results are becoming available in contexts such as Brugada syndrome and cardiac resynchronisation therapy (CRT) implant procedures. As part of an invasive procedure, EAM has not yet been widely adopted as a stand-alone tool in the diagnostic path. We aim to review the data in the current literature regarding the use of 3D EAM systems beyond the definition of arrhythmia.
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Affiliation(s)
- Franco Zoppo
- Elettrofisiologia, U.O.C. di Cardiologia, Ospedale Civile Gorizia, Gorizia, Italy
| | - Giulia Gagno
- Dipartimento di Cardiologia, Azienda Sanitaria Universitaria Giuliano Isontina, ed Università degli Studi di Trieste, Trieste, Italy
| | - Luca Perazza
- Elettrofisiologia, U.O.C. di Cardiologia, Ospedale Civile Gorizia, Gorizia, Italy
| | - Andrea Cocciolo
- Elettrofisiologia, U.O.C. di Cardiologia, Ospedale Civile Gorizia, Gorizia, Italy
| | - Giacomo Mugnai
- Elettrofisiologia, U.O.C di Cardiologia, Ospedale Civile Arzignano, Vicenza, Italy
| | - Diego Vaccari
- Elettrofisiologia, U.O.C di Cardiologia, Ospedale Civile Feltre, Belluno, Italy
| | - Vittorio Calzolari
- Elettrofisiologia, U.O.C di Cardiologia, Ospedale Civile Treviso, Treviso, Italy
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Zoppo F, Gagno G, Perazza L, Cocciolo A, Mugnai G, Vaccari D, Calzolari V. Electroanatomic voltage mapping and characterisation imaging for "right ventricle arrhythmic syndromes" beyond the arrhythmia definition: a comprehensive review. Int J Cardiovasc Imaging 2021; 37:2347-2357. [PMID: 33761057 DOI: 10.1007/s10554-021-02221-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 03/08/2021] [Indexed: 11/30/2022]
Abstract
Three-dimensional (3D) reconstruction by means of electroanatomic mapping (EAM) systems, allows for the understanding of the mechanism of focal or re-entrant arrhythmic circuits along with pacing techniques. However, besides this conventional use, EAM may offer helpful anatomical and functional information. Data regarding electromechanical scar detection in ischaemic (and nonischaemic) cardiomyopathy are mostly consolidated, while emerging results are becoming available in contexts such as arrhythmogenic right ventricular dysplasia (ARVC/D) definition and Brugada syndrome. As part of an invasive procedure, EAM has not yet been widely adopted as a stand-alone tool in the diagnostic path. We aim to review the current literature regarding the use of 3D EAM systems for right ventricle (RV) functional characterisation beyond the definition of arrhythmia.
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Affiliation(s)
- Franco Zoppo
- Elettrofisiologia, U.O.C. Di Cardiologia, Ospedale Civile Gorizia, Gorizia, Italy.
| | - Giulia Gagno
- Azienda Sanitaria Universitaria Giuliano Isontina - Dipartimento di Cardiologia Trieste, Trieste, Italy
| | - Luca Perazza
- Elettrofisiologia, U.O.C. Di Cardiologia, Ospedale Civile Gorizia, Gorizia, Italy
| | - Andrea Cocciolo
- Elettrofisiologia, U.O.C. Di Cardiologia, Ospedale Civile Gorizia, Gorizia, Italy
| | - Giacomo Mugnai
- Elettrofisiologia, U.O.C Di Cardiologia, Ospedale Civile Arzignano, Vicenza, Italy
| | - Diego Vaccari
- Elettrofisiologia, U.O.C Di Cardiologia, Ospedale Civile Feltre, Belluno, Italy
| | - Vittorio Calzolari
- Elettrofisiologia, U.O.C Di Cardiologia, Ospedale Civile Treviso, Treviso, Italy
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Validation of a novel stand-alone software tool for image guided cardiac catheter therapy. Int J Cardiovasc Imaging 2019; 35:225-235. [PMID: 30689193 PMCID: PMC6428788 DOI: 10.1007/s10554-019-01541-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 01/18/2019] [Indexed: 01/07/2023]
Abstract
Comparison of the targeting accuracy of a new software method for MRI-fluoroscopy guided endomyocardial interventions with a clinically available 3D endocardial electromechanical mapping system. The new CARTBox2 software enables therapy target selection based on infarction transmurality and local myocardial wall thickness deduced from preoperative MRI scans. The selected targets are stored in standard DICOM datasets. Fusion of these datasets with live fluoroscopy enables real-time visualization of MRI defined targets during fluoroscopy guided interventions without the need for external hardware. In ten pigs (60–75 kg), late gadolinium enhanced (LGE) MRI scans were performed 4 weeks after a 90-min LAD occlusion. Subsequently, 10–16 targeted fluorescent biomaterial injections were delivered in the infarct border zone (IBZ) using either the NOGA 3D-mapping system or CARTBox2. The primary endpoint was the distance of the injections to the IBZ on histology. Secondary endpoints were total procedure time, fluoroscopy time and dose, and the number of ventricular arrhythmias. The average distance of the injections to the IBZ was similar for CARTBox2 (0.5 ± 3.2 mm) and NOGA (− 0.7 ± 2.2 mm; p = 0.52). Injection procedures with CARTBox2 and NOGA required 69 ± 12 and 60 ± 17 min, respectively (p = 0.36). The required endocardial mapping procedure with NOGA prior to injections, leads to a significantly longer total procedure time (p < 0.001) with NOGA. Fluoroscopy time with NOGA (18.7 ± 11.0 min) was significantly lower than with CARTBox2 (43.4 ± 6.5 min; p = 0.0003). Procedures with CARTBox2 show a trend towards less ventricular arrhythmias compared to NOGA. CARTBox2 is an accurate and fast software-only system to facilitate cardiac catheter therapy based on gold standard MRI imaging and live fluoroscopy.
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Van den Broek HT, De Jong L, Doevendans PA, Chamuleau SAJ, Van Slochteren FJ, Van Es R. 3D Whole-heart Myocardial Tissue Analysis. J Vis Exp 2017:54974. [PMID: 28447974 PMCID: PMC5564696 DOI: 10.3791/54974] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Cardiac regenerative therapies aim to protect and repair the injured heart in patients with ischemic heart disease. By injecting stem cells or other biologicals that enhance angio- or vasculogenesis into the infarct border zone (IBZ), tissue perfusion is improved, and the myocardium can be protected from further damage. For maximum therapeutic effect, it is hypothesized that the regenerative substance is best delivered to the IBZ. This requires accurate injections and has led to the development of new injection techniques. To validate these new techniques, we have designed a validation protocol based on myocardial tissue analysis. This protocol includes whole-heart myocardial tissue processing that enables detailed two-dimensional (2D) and three-dimensional (3D) analysis of the cardiac anatomy and intramyocardial injections. In a pig, myocardial infarction was created by a 90-min occlusion of the left anterior descending coronary artery. Four weeks later, a mixture of a hydrogel with superparamagnetic iron oxide particles (SPIOs) and fluorescent beads was injected in the IBZ using a minimally-invasive endocardial approach. 1 h after the injection procedure, the pig was euthanized, and the heart was excised and embedded in agarose (agar). After the solidification of the agar, magnetic resonance imaging (MRI), slicing of the heart, and fluorescence imaging were performed. After image post-processing, 3D analysis was performed to assess the IBZ targeting accuracy. This protocol provides a structured and reproducible method for the assessment of the targeting accuracy of intramyocardial injections into the IBZ. The protocol can be easily used when the processing of scar tissue and/or validation of the injection accuracy of the whole heart is desired.
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Affiliation(s)
| | - Leon De Jong
- Department of Cardiology, Division Heart and Lungs, University Medical Center Utrecht; MIRA Institute, University Twente
| | - Pieter A Doevendans
- Department of Cardiology, Division Heart and Lungs, University Medical Center Utrecht
| | - Steven A J Chamuleau
- Department of Cardiology, Division Heart and Lungs, University Medical Center Utrecht;
| | | | - René Van Es
- Department of Cardiology, Division Heart and Lungs, University Medical Center Utrecht
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Nigro P, Bassetti B, Cavallotti L, Catto V, Carbucicchio C, Pompilio G. Cell therapy for heart disease after 15 years: Unmet expectations. Pharmacol Res 2017; 127:77-91. [PMID: 28235633 DOI: 10.1016/j.phrs.2017.02.015] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 02/07/2017] [Accepted: 02/16/2017] [Indexed: 12/17/2022]
Abstract
Over the past two decades cardiac cell therapy (CCT) has emerged as a promising new strategy to cure heart diseases at high unmet need. Thousands of patients have entered clinical trials for acute or chronic heart conditions testing different cell types, including autologous or allogeneic bone marrow (BM)-derived mononuclear or selected cells, BM- or adipose tissue-derived mesenchymal cells, or cardiac resident progenitors based on their potential ability to regenerate scarred or dysfunctional myocardium. Nowadays, the original enthusiasm surrounding the regenerative medicine field has been cushioned by a cumulative body of evidence indicating an inefficient or modest efficacy of CCT in improving cardiac function, along with the continued lack of indisputable proof for long-term prognostic benefit. In this review, we have firstly comprehensively outlined the positive and negative results of cell therapy studies in patients with acute myocardial infarction, refractory angina and chronic heart failure. Next, we have discussed cell therapy- and patient-related variables (e.g. cell intrinsic and extrinsic characteristics as well as criteria of patient selection and proposed methodologies) that might have dampened the efficacy of past cell therapy trials. Finally, we have addressed critical factors to be considered before embarking on further clinical trials.
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Affiliation(s)
- Patrizia Nigro
- Vascular Biology and Regenerative Medicine Unit, Centro Cardiologico Monzino-IRCCS, via Carlo Parea 4, 20138, Milan, Italy
| | - Beatrice Bassetti
- Vascular Biology and Regenerative Medicine Unit, Centro Cardiologico Monzino-IRCCS, via Carlo Parea 4, 20138, Milan, Italy
| | - Laura Cavallotti
- Department of Cardiovascular Surgery, Centro Cardiologico Monzino-IRCCS, via Carlo Parea 4, 20138, Milan, Italy
| | - Valentina Catto
- Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino-IRCCS, via Carlo Parea 4, 20138, Milan, Italy
| | - Corrado Carbucicchio
- Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino-IRCCS, via Carlo Parea 4, 20138, Milan, Italy
| | - Giulio Pompilio
- Vascular Biology and Regenerative Medicine Unit, Centro Cardiologico Monzino-IRCCS, via Carlo Parea 4, 20138, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, via Festa del Perdono 7, 20122, Milan, Italy.
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Psaltis PJ, Schwarz N, Toledo-Flores D, Nicholls SJ. Cellular Therapy for Heart Failure. Curr Cardiol Rev 2016; 12:195-215. [PMID: 27280304 PMCID: PMC5011188 DOI: 10.2174/1573403x12666160606121858] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 12/18/2015] [Accepted: 12/31/1969] [Indexed: 12/12/2022] Open
Abstract
The pathogenesis of cardiomyopathy and heart failure (HF) is underpinned by complex changes at subcellular, cellular and extracellular levels in the ventricular myocardium. For all of the gains that conventional treatments for HF have brought to mortality and morbidity, they do not adequately address the loss of cardiomyocyte numbers in the remodeling ventricle. Originally conceived to address this problem, cellular transplantation for HF has already gone through several stages of evolution over the past two decades. Various cell types and delivery routes have been implemented to positive effect in preclinical models of ischemic and nonischemic cardiomyopathy, with pleiotropic benefits observed in terms of myocardial remodeling, systolic and diastolic performance, perfusion, fibrosis, inflammation, metabolism and electrophysiology. To a large extent, these salubrious effects are now attributed to the indirect, paracrine capacity of transplanted stem cells to facilitate endogenous cardiac repair processes. Promising results have also followed in early phase human studies, although these have been relatively modest and somewhat inconsistent. This review details the preclinical and clinical evidence currently available regarding the use of pluripotent stem cells and adult-derived progenitor cells for cardiomyopathy and HF. It outlines the important lessons that have been learned to this point in time, and balances the promise of this exciting field against the key challenges and questions that still need to be addressed at all levels of research, to ensure that cell therapy realizes its full potential by adding to the armamentarium of HF management.
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Affiliation(s)
- Peter J Psaltis
- Co-Director of Vascular Research Centre, Heart Health Theme, South Australian Health and Medical Research Institute, North Terrace, Adelaide, South Australia, Australia 5000.
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van Slochteren FJ, van Es R, Gyöngyösi M, van der Spoel TIG, Koudstaal S, Leiner T, Doevendans PA, Chamuleau SAJ. Three dimensional fusion of electromechanical mapping and magnetic resonance imaging for real-time navigation of intramyocardial cell injections in a porcine model of chronic myocardial infarction. Int J Cardiovasc Imaging 2016; 32:833-43. [PMID: 26883433 PMCID: PMC4853462 DOI: 10.1007/s10554-016-0852-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 02/07/2016] [Indexed: 11/15/2022]
Abstract
For cardiac regenerative therapy intramyocardial catheter guided cell transplantations are targeted to the infarct border zone (IBZ) i.e. the closest region of viable myocardium in the vicinity of the infarct area. For optimal therapeutic effect this area should be accurately identified. However late gadolinium enhanced magnetic resonance imaging (LGE-MRI) is the gold standard technique to determine the infarct size and location, electromechanical mapping (EMM) is used to guide percutaneous intramyocardial injections to the IBZ. Since EMM has a low spatial resolution, we aim to develop a practical and accurate technique to fuse EMM with LGE-MRI to guide intramyocardial injections. LGE-MRI and EMM were obtained in 17 pigs with chronic myocardial infarction created by balloon occlusion of LCX and LAD coronary arteries. LGE-MRI and EMM datasets were registered using our in-house developed 3D CartBox image registration software toolbox to assess: (1) the feasibility of the 3D CartBox toolbox, (2) the EMM values measured in the areas with a distinct infarct transmurality (IT), and (3) the highest sensitivity and specificity of the EMM to assess IT and define the IBZ. Registration of LGE-MRI and EMM resulted in a mean error of 3.01 ± 1.94 mm between the LGE-MRI mesh and EMM points. The highest sensitivity and specificity were found for UV <9.4 mV and bipolar voltage <1.2 mV to respectively identify IT of ≥5 and ≥97.5 %. The 3D CartBox image registration toolbox enables registration of EMM data on pre-acquired MRI during the EMM guided procedure and allows physicians to easily guide injections to the most optimal injection location for cardiac regenerative therapy and harness the full therapeutic effect of the therapy.
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Affiliation(s)
- F J van Slochteren
- Department of Cardiology, University Medical Center Utrecht, E03.511, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands.
| | - R van Es
- Department of Cardiology, University Medical Center Utrecht, E03.511, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - M Gyöngyösi
- Department of Cardiology, Medical University of Vienna, Vienna, Austria
| | - T I G van der Spoel
- Department of Cardiology, University Medical Center Utrecht, E03.511, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - S Koudstaal
- Department of Cardiology, University Medical Center Utrecht, E03.511, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands
| | - T Leiner
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - P A Doevendans
- Department of Cardiology, University Medical Center Utrecht, E03.511, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands.,Interuniversity Cardiology Institute of the Netherlands (ICIN), Utrecht, The Netherlands
| | - S A J Chamuleau
- Department of Cardiology, University Medical Center Utrecht, E03.511, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands.,Interuniversity Cardiology Institute of the Netherlands (ICIN), Utrecht, The Netherlands
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Vela D, Gahremanpour A, Buja LM. Method for sectioning and sampling hearts for histologic evaluation after delivery of biological agents by transendocardial injection. Cardiovasc Pathol 2015; 24:304-9. [DOI: 10.1016/j.carpath.2015.04.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 02/20/2015] [Accepted: 04/13/2015] [Indexed: 11/26/2022] Open
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Pavo N, Jakab A, Emmert MY, Strebinger G, Wolint P, Zimmermann M, Ankersmit HJ, Hoerstrup SP, Maurer G, Gyöngyösi M. Comparison of NOGA endocardial mapping and cardiac magnetic resonance imaging for determining infarct size and infarct transmurality for intramyocardial injection therapy using experimental data. PLoS One 2014; 9:e113245. [PMID: 25409528 PMCID: PMC4237404 DOI: 10.1371/journal.pone.0113245] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 10/21/2014] [Indexed: 01/16/2023] Open
Abstract
Objectives We compared the accuracy of NOGA endocardial mapping for delineating transmural and non-transmural infarction to the results of cardiac magnetic resonance imaging (cMRI) with late gadolinium enhancement (LE) for guiding intramyocardial reparative substance delivery using data from experimental myocardial infarction studies. Methods Sixty domestic pigs underwent diagnostic NOGA endocardial mapping and cMRI-LE 60 days after induction of closed-chest reperfused myocardial infarction. The infarct size was determined by LE of cMRI and by delineation of the infarct core on the unipolar voltage polar map. The sizes of the transmural and non-transmural infarctions were calculated from the cMRI transmurality map using signal intensity (SI) cut-offs of>75% and>25% and from NOGA bipolar maps using bipolar voltage cut-off values of <0.8 mV and <1.9 mV. Linear regression analysis and Bland-Altman plots were used to determine correlations and systematic differences between the two images. The overlapping ratios of the transmural and non-transmural infarcted areas were calculated. Results Infarct size as determined by 2D NOGA unipolar voltage polar mapping correlated with the 3D cMRI-LE findings (r = 0.504, p<0.001) with a mean difference of 2.82% in the left ventricular (LV) surface between the two images. Polar maps of transmural cMRI and bipolar maps of NOGA showed significant association for determining of the extent of transmural infarction (r = 0.727, p<0.001, overlap ratio of 81.6±11.1%) and non-transmural infarction (r = 0.555, p<0.001, overlap ratio of 70.6±18.5%). NOGA overestimated the transmural scar size (6.81% of the LV surface) but slightly underestimated the size of the non-transmural infarction (−3.04% of the LV surface). Conclusions By combining unipolar and bipolar voltage maps, NOGA endocardial mapping is useful for accurate delineation of the targeted zone for intramyocardial therapy and is comparable to cMRI-LE. This may be useful in patients with contraindications for cMRI who require targeted intramyocardial regenerative therapy.
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Affiliation(s)
- Noemi Pavo
- Department of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Andras Jakab
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Maximilian Y. Emmert
- Swiss Centre for Regenerative Medicine, University of Zürich, Zürich, Switzerland
- Division of Surgical Research, University Hospital of Zürich, Zürich, Switzerland
- Clinic for Cardiovascular Surgery, University Hospital of Zürich, Zürich, Switzerland
| | - Georg Strebinger
- Department of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Petra Wolint
- Swiss Centre for Regenerative Medicine, University of Zürich, Zürich, Switzerland
- Division of Surgical Research, University Hospital of Zürich, Zürich, Switzerland
- Clinic for Cardiovascular Surgery, University Hospital of Zürich, Zürich, Switzerland
| | - Matthias Zimmermann
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Hendrik Jan Ankersmit
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
- Christian Doppler Laboratory for Cardiac and Thoracic Diagnosis and Regeneration, Vienna, Austria
| | - Simon P. Hoerstrup
- Swiss Centre for Regenerative Medicine, University of Zürich, Zürich, Switzerland
- Division of Surgical Research, University Hospital of Zürich, Zürich, Switzerland
- Clinic for Cardiovascular Surgery, University Hospital of Zürich, Zürich, Switzerland
| | - Gerald Maurer
- Department of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Mariann Gyöngyösi
- Department of Cardiology, Medical University of Vienna, Vienna, Austria
- * E-mail:
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Richardson JD, Psaltis PJ, Frost L, Paton S, Carbone A, Bertaso AG, Nelson AJ, Wong DT, Worthley MI, Gronthos S, Zannettino AC, Worthley SG. Incremental benefits of repeated mesenchymal stromal cell administration compared with solitary intervention after myocardial infarction. Cytotherapy 2014; 16:460-70. [DOI: 10.1016/j.jcyt.2013.07.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Revised: 07/16/2013] [Accepted: 07/29/2013] [Indexed: 12/11/2022]
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15
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Richardson JD, Nelson AJ, Zannettino ACW, Gronthos S, Worthley SG, Psaltis PJ. Optimization of the cardiovascular therapeutic properties of mesenchymal stromal/stem cells-taking the next step. Stem Cell Rev Rep 2014; 9:281-302. [PMID: 22529015 DOI: 10.1007/s12015-012-9366-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Despite current treatment options, cardiac failure is associated with significant morbidity and mortality highlighting a compelling clinical need for novel therapeutic approaches. Based on promising pre-clinical data, stem cell therapy has been suggested as a possible therapeutic strategy. Of the candidate cell types evaluated, mesenchymal stromal/stem cells (MSCs) have been widely evaluated due to their ease of isolation and ex vivo expansion, potential allogeneic utility and capacity to promote neo-angiogenesis and endogenous cardiac repair. However, the clinical application of MSCs for mainstream cardiovascular use is currently hindered by several important limitations, including suboptimal retention and engraftment and restricted capacity for bona fide cardiomyocyte regeneration. Consequently, this has prompted intense efforts to advance the therapeutic properties of MSCs for cardiovascular disease. In this review, we consider the scope of benefit from traditional plastic adherence-isolated MSCs and the lessons learned from their conventional use in preclinical and clinical studies. Focus is then given to the evolving strategies aimed at optimizing MSC therapy, including discussion of cell-targeted techniques that encompass the preparation, pre-conditioning and manipulation of these cells ex vivo, methods to improve their delivery to the heart and innovative substrate-directed strategies to support their interaction with the host myocardium.
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Affiliation(s)
- James D Richardson
- Cardiovascular Research Centre, Royal Adelaide Hospital and Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia
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Porras AR, Piella G, Berruezo A, Fernández-Armenta J, Frangi AF. Pre to Intraoperative Data Fusion Framework for Multimodal Characterization of Myocardial Scar Tissue. IEEE JOURNAL OF TRANSLATIONAL ENGINEERING IN HEALTH AND MEDICINE-JTEHM 2014; 2:1900211. [PMID: 27170873 PMCID: PMC4848079 DOI: 10.1109/jtehm.2014.2354332] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Revised: 07/11/2014] [Accepted: 08/16/2014] [Indexed: 11/16/2022]
Abstract
Merging multimodal information about myocardial scar tissue can help electrophysiologists to find the most appropriate target during catheter ablation of ventricular arrhythmias. A framework is presented to analyze and combine information from delayed enhancement magnetic resonance imaging (DE-MRI) and electro-anatomical mapping data. Using this information, electrical, mechanical, and image-based characterization of the myocardium are performed. The presented framework allows the left ventricle to be segmented by DE-MRI and the scar to be characterized prior to the intervention based on image information. It allows the electro-anatomical maps obtained during the intervention from a navigation system to be merged together with the anatomy and scar information extracted from DE-MRI. It also allows for the estimation of endocardial motion and deformation to assess cardiac mechanics. Therefore, electrical, mechanical, and image-based characterization of the myocardium can be performed. The feasibility of this approach was demonstrated on three patients with ventricular tachycardia associated to ischemic cardiomyopathy by integrating images from DE-MRI and electro-anatomical maps data in a common framework for intraoperative myocardial tissue characterization. The proposed framework has the potential to guide and monitor delivery of radio frequency ablation of ventricular tachycardia. It is also helpful for research purposes, facilitating the study of the relationship between electrical and mechanical properties of the tissue, as well as with tissue viability from DE-MRI.
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Porras AR, Piella G, Berruezo A, Hoogendoorn C, Andreu D, Fernandez-Armenta J, Sitges M, Frangi AF. Interventional endocardial motion estimation from electroanatomical mapping data: application to scar characterization. IEEE Trans Biomed Eng 2012. [PMID: 23204274 DOI: 10.1109/tbme.2012.2230327] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Scar presence and its characteristics play a fundamental role in several cardiac pathologies. To accurately define the extent and location of the scar is essential for a successful ventricular tachycardia ablation procedure. Nowadays, a set of widely accepted electrical voltage thresholds applied to local electrograms recorded are used intraoperatively to locate the scar. Information about cardiac mechanics could be considered to characterize tissues with different viability properties. We propose a novel method to estimate endocardial motion from data obtained with an electroanatomical mapping system together with the endocardial geometry segmented from preoperative 3-D magnetic resonance images, using a statistical atlas constructed with bilinear models. The method was validated using synthetic data generated from ultrasound images of nine volunteers and was then applied to seven ventricular tachycardia patients. Maximum bipolar voltages, commonly used to intraoperatively locate scar tissue, were compared to endocardial wall displacement and strain for all the patients. The results show that the proposed method allows endocardial motion and strain estimation and that areas with low-voltage electrograms also present low strain values.
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Affiliation(s)
- Antonio R Porras
- Center for Computational Imaging and Simulation Technologies in Biomedicine, Universitat Pompeu Fabra, Barcelona 08018, Spain.
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Psaltis PJ, Simari RD, Rodriguez-Porcel M. Emerging roles for integrated imaging modalities in cardiovascular cell-based therapeutics: a clinical perspective. Eur J Nucl Med Mol Imaging 2011; 39:165-81. [PMID: 21901381 DOI: 10.1007/s00259-011-1925-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2011] [Accepted: 08/18/2011] [Indexed: 12/20/2022]
Abstract
Despite preclinical promise, the progress of cell-based therapy to clinical cardiovascular practice has been slowed by several challenges and uncertainties that have been highlighted by the conflicting results of human trials. Most telling has been the revelation that current strategies fall short of achieving sufficient retention and engraftment of cells to meet the ambitious objective of myocardial regeneration. This has sparked novel research into the refinement of cell biology and delivery to overcome these shortcomings. Within this context, molecular imaging has emerged as a valuable tool for providing noninvasive surveillance of cell fate in vivo. Direct and indirect labelling of cells can be coupled with clinically relevant imaging modalities, such as radionuclide single photon emission computed tomography and positron emission tomography, and magnetic resonance imaging, to assess their short- and long-term distributions, along with their viability, proliferation and functional interaction with the host myocardium. This review details the strengths and limitations of the different cell labelling and imaging techniques and their potential application to the clinical realm. We also consider the broader, multifaceted utility of imaging throughout the cell therapy process, providing a discussion of its considerable value during cell delivery and its importance during the evaluation of cardiac outcomes in clinical studies.
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Affiliation(s)
- Peter J Psaltis
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Gyöngyösi M, Dib N. Diagnostic and prognostic value of 3D NOGA mapping in ischemic heart disease. Nat Rev Cardiol 2011; 8:393-404. [DOI: 10.1038/nrcardio.2011.64] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Kastrup J, Jørgensen E, Fuchs S, Nikol S, Bøtker HE, Gyöngyösi M, Glogar D, Kornowski R. A randomised, double-blind, placebo-controlled, multicentre study of the safety and efficacy of BIOBYPASS (AdGVVEGF121.10NH) gene therapy in patients with refractory advanced coronary artery disease: the NOVA trial. EUROINTERVENTION 2011; 6:813-8. [PMID: 21252014 DOI: 10.4244/eijv6i7a140] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
AIMS Genes encoding vascular endothelial growth factor (VEGF) can potentially augment myocardial perfusion in patients with coronary artery disease (CAD). We conducted a randomised, double-blind, placebo-controlled gene therapy study with the adenovirus carrying VEGF121 (BIOBYPASS [AdGVVEGF121.10NH]). METHODS AND RESULTS Seventeen patients with severe CAD were 2:1 randomised to BIOBYPASS (n=12; 61 years) or placebo (n=5; 64) as 12 intra-myocardial injections into the ischaemic area using the NOGA XP® system. The study was terminated prematurely due to a company product portfolio decision. Mean change in total exercise duration from baseline to 12, 26 and 52 weeks was 20.2, 21.4 and 16.4 sec in BIOBYPASS treated and 46.2, 31.4 and 12.4 sec in placebo (NS). Change from baseline to at least 1 mm ST depression during exercise at 12, 26 and 52 weeks did not differ between BIOBYPASS and placebo. Change in stress-induced ischaemia score was similar in the BIOBYPASS (3.4%) and placebo (2.0%) groups. An improvement in symptoms was seen in patients treated with BIOBYPASS, but no difference between the groups. CONCLUSIONS Direct intramyocardial injection of BIOBYPASS (AdGVVEGF121.10NH) was safe but did not improve exercise capacity, time to ischaemic threshold or myocardial perfusion compared to sham injection in patients with refractory myocardial ischaemia.
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Affiliation(s)
- Jens Kastrup
- The Heart Center, University Hospital Rigshospitalet, Copenhagen, Denmark.
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Psaltis PJ, Carbone A, Nelson AJ, Lau DH, Jantzen T, Manavis J, Williams K, Itescu S, Sanders P, Gronthos S, Zannettino ACW, Worthley SG. Reparative effects of allogeneic mesenchymal precursor cells delivered transendocardially in experimental nonischemic cardiomyopathy. JACC Cardiovasc Interv 2011; 3:974-83. [PMID: 20850099 DOI: 10.1016/j.jcin.2010.05.016] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2010] [Revised: 05/03/2010] [Accepted: 05/15/2010] [Indexed: 12/29/2022]
Abstract
OBJECTIVES This study set out to evaluate the safety and efficacy of allogeneic bone marrow mesenchymal precursor cells (MPC) delivered by multisegmental, transendocardial implantation in the setting of nonischemic cardiomyopathy (NICM). BACKGROUND Prospectively isolated MPC have shown capacity to mediate cardiovascular repair in myocardial ischemia. However, their efficacy in NICM remains undetermined. METHODS Mesenchymal precursor cells were prepared from ovine bone marrow by immunoselection using the tissue nonspecific alkaline phosphatase, or STRO-3, monoclonal antibody. Fifteen sheep with anthracycline-induced NICM were assigned to catheter-based, transendocardial injections of allogeneic MPC (n = 7) or placebo (n = 8), under electromechanical mapping guidance. Follow-up was for 8 weeks, with end points assessed by cardiac magnetic resonance, echocardiography, and histology. RESULTS Intramyocardial injections were distributed similarly throughout the left ventricle in both groups. Cell transplantation was associated with 1 death late in follow-up, compared with 3 early deaths among placebo animals. Left ventricular end-diastolic size increased in both cohorts, but MPC therapy attenuated end-systolic dilation and stabilized ejection fraction, with a nonsignificant increase (37.3 ± 2.8% before, 39.2 ± 1.4% after) compared with progressive deterioration after placebo (38.8 ± 4.4% before, 32.5 ± 4.9% after, p < 0.05). Histological outcomes of cell therapy included less fibrosis burden than in the placebo group and an increased density of karyokinetic cardiomyocytes and myocardial arterioles (p < 0.05 for each). These changes occurred in the presence of modest cellular engraftment after transplantation. CONCLUSIONS Multisegmental, transendocardial delivery of cell therapy can be achieved effectively in NICM using electromechanical navigation. The pleiotropic properties of immunoselected MPC confer benefit to nonischemic cardiac disease, extending their therapeutic potential beyond the setting of myocardial ischemia.
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Affiliation(s)
- Peter J Psaltis
- Cardiovascular Research Centre, Royal Adelaide Hospital and Department of Medicine, University of Adelaide, Adelaide, Australia.
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Abstract
INTRODUCTION Stem cell therapy has emerged as a promising strategy for the treatment of ischemic cardiomyopathy. SOURCES OF DATA Multiple candidate cell types have been used in preclinical animal models and in clinical trials to repair or regenerate the injured heart either directly (through formation of new transplanted tissue) or indirectly (through paracrine effects activating endogenous regeneration). AREAS OF AGREEMENT (i) Clinical trials examining the safety and efficacy of bone marrow derived cells in patients with heart disease are promising, but results leave much room for improvement. (ii) The safety profile has been quite favorable. (iii) Efficacy has been inconsistent and, overall, modest. (iv) Tissue retention of cells after delivery into the heart is disappointingly low. (v) The beneficial effects of adult stem cell therapy are predominantly mediated by indirect paracrine mechanisms. AREAS OF CONTROVERSY The cardiogenic potential of bone marrow-derived cells, the mechanism whereby small numbers of poorly-retained cells translate to measurable clinical benefit, and the overall impact on clinical outcomes are hotly debated. GROWING POINTS/AREAS TIMELY FOR DEVELOPING RESEARCH: This overview of the field leaves us with cautious optimism, while motivating a search for more effective delivery methods, better strategies to boost cell engraftment, more apt patient populations, safe and effective 'off the shelf' cell products and more potent cell types.
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Assessment of myocardial fibrosis by endoventricular electromechanical mapping in experimental nonischemic cardiomyopathy. Int J Cardiovasc Imaging 2010; 27:25-37. [DOI: 10.1007/s10554-010-9657-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2010] [Accepted: 06/11/2010] [Indexed: 01/02/2023]
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Psaltis PJ, Zannettino ACW, Gronthos S, Worthley SG. Intramyocardial Navigation and Mapping for Stem Cell Delivery. J Cardiovasc Transl Res 2009; 3:135-46. [DOI: 10.1007/s12265-009-9138-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2009] [Accepted: 09/28/2009] [Indexed: 01/16/2023]
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