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Nägele F, Pölzl L, Graber M, Hirsch J, Mayr A, Pamminger M, Troger F, Theurl M, Schreinlechner M, Sappler N, Dorfmüller C, Mitrovic M, Ulmer H, Grimm M, Gollmann-Tepeköylü C, Holfeld J. Safety and efficacy of direct cardiac shockwave therapy in patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting (the CAST-HF trial): study protocol for a randomized controlled trial-an update. Trials 2022; 23:988. [PMID: 36494706 PMCID: PMC9733047 DOI: 10.1186/s13063-022-06931-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 11/12/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Coronary artery disease (CAD) remains a severe socio-economic burden in the Western world. Coronary obstruction and subsequent myocardial ischemia result in the progressive replacement of contractile myocardium with dysfunctional, fibrotic scar tissue. Post-infarctional remodelling is causal for the concomitant decline of left-ventricular function and the fatal syndrome of heart failure. Available neurohumoral treatment strategies aim at the improvement of symptoms. Despite extensive research, therapeutic options for myocardial regeneration, including (stem)-cell therapy, gene therapy, cellular reprogramming or tissue engineering, remain purely experimental. Thus, there is an urgent clinical need for novel treatment options for inducing myocardial regeneration and improving left-ventricular function in ischemic cardiomyopathy. Shockwave therapy (SWT) is a well-established regenerative tool that is effective for the treatment of chronic tendonitis, long-bone non-union and wound-healing disorders. In preclinical trials, SWT regenerated ischemic myocardium via the induction of angiogenesis and the reduction of fibrotic scar tissue, resulting in improved left-ventricular function. METHODS In this prospective, randomized controlled, single-blind, monocentric study, 80 patients with reduced left-ventricular ejection fraction (LVEF≤ 40%) are subjected to coronary-artery bypass-graft surgery (CABG) surgery and randomized in a 1:1 ratio to receive additional cardiac SWT (intervention group; 40 patients) or CABG surgery with sham treatment (control group; 40 patients). This study aims to evaluate (1) the safety and (2) the efficacy of cardiac SWT as adjunctive treatment during CABG surgery for the regeneration of ischemic myocardium. The primary endpoints of the study represent (1) major cardiac events and (2) changes in left-ventricular function 12 months after treatment. Secondary endpoints include 6-min walk test distance, improvement of symptoms and assessment of quality of life. DISCUSSION This study aims to investigate the safety and efficacy of cardiac SWT during CABG surgery for myocardial regeneration. The induction of angiogenesis, decrease of fibrotic scar tissue formation and, thus, improvement of left-ventricular function could lead to improved quality of life and prognosis for patients with ischemic heart failure. Thus, it could become the first clinically available treatment strategy for the regeneration of ischemic myocardium alleviating the socio-economic burden of heart failure. TRIAL REGISTRATION ClinicalTrials.gov NCT03859466. Registered on 1 March 2019.
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Affiliation(s)
- Felix Nägele
- grid.5361.10000 0000 8853 2677Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Leo Pölzl
- grid.5361.10000 0000 8853 2677Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Graber
- grid.5361.10000 0000 8853 2677Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Jakob Hirsch
- grid.5361.10000 0000 8853 2677Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Agnes Mayr
- grid.5361.10000 0000 8853 2677Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Mathias Pamminger
- grid.5361.10000 0000 8853 2677Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Felix Troger
- grid.5361.10000 0000 8853 2677Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Markus Theurl
- grid.5361.10000 0000 8853 2677Department of Internal Medicine III, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Schreinlechner
- grid.5361.10000 0000 8853 2677Department of Internal Medicine III, Medical University of Innsbruck, Innsbruck, Austria
| | - Nikolay Sappler
- grid.5361.10000 0000 8853 2677Department of Internal Medicine III, Medical University of Innsbruck, Innsbruck, Austria
| | | | | | - Hanno Ulmer
- Department of Medical Statistics, Informatics and Health Economics, Innsbruck, Austria
| | - Michael Grimm
- grid.5361.10000 0000 8853 2677Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Can Gollmann-Tepeköylü
- grid.5361.10000 0000 8853 2677Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Johannes Holfeld
- grid.5361.10000 0000 8853 2677Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
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Graber M, Nägele F, Hirsch J, Pölzl L, Schweiger V, Lechner S, Grimm M, Cooke JP, Gollmann-Tepeköylü C, Holfeld J. Cardiac Shockwave Therapy – A Novel Therapy for Ischemic Cardiomyopathy? Front Cardiovasc Med 2022; 9:875965. [PMID: 35647069 PMCID: PMC9133452 DOI: 10.3389/fcvm.2022.875965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 04/12/2022] [Indexed: 11/14/2022] Open
Abstract
Over the past decades, shockwave therapy (SWT) has gained increasing interest as a therapeutic approach for regenerative medicine applications, such as healing of bone fractures and wounds. More recently, pre-clinical studies have elucidated potential mechanisms for the regenerative effects of SWT in myocardial ischemia. The mechanical stimulus of SWT may induce regenerative effects in ischemic tissue via growth factor release, modulation of inflammatory response, and angiogenesis. Activation of the innate immune system and stimulation of purinergic receptors by SWT appears to enhance vascularization and regeneration of injured tissue with functional improvement. Intriguingly, small single center studies suggest that SWT may improve angina, exercise tolerance, and hemodynamics in patients with ischemic heart disease. Thus, SWT may represent a promising technology to induce cardiac protection or repair in patients with ischemic heart disease.
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Affiliation(s)
- Michael Graber
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
- Department of Cardiovascular Sciences, Center for Cardiovascular Regeneration, Houston Methodist Research Institute, Houston, TX, United States
| | - Felix Nägele
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Jakob Hirsch
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Leo Pölzl
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
- Division of Clinical and Functional Anatomy, Medical University of Innsbruck, Innsbruck, Austria
| | - Victor Schweiger
- Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Sophia Lechner
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Grimm
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - John P. Cooke
- Department of Cardiovascular Sciences, Center for Cardiovascular Regeneration, Houston Methodist Research Institute, Houston, TX, United States
| | | | - Johannes Holfeld
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
- *Correspondence: Johannes Holfeld,
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Gollmann-Tepeköylü C, Pölzl L, Graber M, Hirsch J, Nägele F, Lobenwein D, Hess MW, Blumer MJ, Kirchmair E, Zipperle J, Hromada C, Mühleder S, Hackl H, Hermann M, Al Khamisi H, Förster M, Lichtenauer M, Mittermayr R, Paulus P, Fritsch H, Bonaros N, Kirchmair R, Sluijter JPG, Davidson S, Grimm M, Holfeld J. miR-19a-3p containing exosomes improve function of ischaemic myocardium upon shock wave therapy. Cardiovasc Res 2021; 116:1226-1236. [PMID: 31410448 DOI: 10.1093/cvr/cvz209] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 06/28/2019] [Accepted: 08/12/2009] [Indexed: 12/27/2022] Open
Abstract
AIMS As many current approaches for heart regeneration exert unfavourable side effects, the induction of endogenous repair mechanisms in ischaemic heart disease is of particular interest. Recently, exosomes carrying angiogenic miRNAs have been described to improve heart function. However, it remains challenging to stimulate specific release of reparative exosomes in ischaemic myocardium. In the present study, we sought to test the hypothesis that the physical stimulus of shock wave therapy (SWT) causes the release of exosomes. We aimed to substantiate the pro-angiogenic impact of the released factors, to identify the nature of their cargo, and to test their efficacy in vivo supporting regeneration and recovery after myocardial ischaemia. METHODS AND RESULTS Mechanical stimulation of ischaemic muscle via SWT caused extracellular vesicle (EV) release from endothelial cells both in vitro and in vivo. Characterization of EVs via electron microscopy, nanoparticle tracking analysis and flow cytometry revealed specific exosome morphology and size with the presence of exosome markers CD9, CD81, and CD63. Exosomes exhibited angiogenic properties activating protein kinase b (Akt) and extracellular-signal regulated kinase (ERK) resulting in enhanced endothelial tube formation and proliferation. A miRNA array and transcriptome analysis via next-generation sequencing were performed to specify exosome content. miR-19a-3p was identified as responsible cargo, antimir-19a-3p antagonized angiogenic exosome effects. Exosomes and target miRNA were injected intramyocardially in mice after left anterior descending artery ligation. Exosomes resulted in improved vascularization, decreased myocardial fibrosis, and increased left ventricular ejection fraction as shown by transthoracic echocardiography. CONCLUSION The mechanical stimulus of SWT causes release of angiogenic exosomes. miR-19a-3p is the vesicular cargo responsible for the observed effects. Released exosomes induce angiogenesis, decrease myocardial fibrosis, and improve left ventricular function after myocardial ischaemia. Exosome release via SWT could develop an innovative approach for the regeneration of ischaemic myocardium.
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Affiliation(s)
- Can Gollmann-Tepeköylü
- Department of Cardiac Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.,Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - Leo Pölzl
- Department of Cardiac Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.,Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - Michael Graber
- Department of Cardiac Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.,Division of Clinical and Functional Anatomy, Medical University of Innsbruck, Innsbruck, Austria
| | - Jakob Hirsch
- Department of Cardiac Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.,Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - Felix Nägele
- Department of Cardiac Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.,Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - Daniela Lobenwein
- Department of Cardiac Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.,Division of Clinical and Functional Anatomy, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael W Hess
- Division of Histology and Embryology, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael J Blumer
- Division of Clinical and Functional Anatomy, Medical University of Innsbruck, Innsbruck, Austria
| | - Elke Kirchmair
- Department of Cardiac Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.,Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - Johannes Zipperle
- Austrian Cluster for Tissue Regeneration, Vienna, Austria.,Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Center, Vienna, Austria
| | - Carina Hromada
- Austrian Cluster for Tissue Regeneration, Vienna, Austria.,Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Center, Vienna, Austria
| | - Severin Mühleder
- Austrian Cluster for Tissue Regeneration, Vienna, Austria.,Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Center, Vienna, Austria
| | - Hubert Hackl
- Division of Bioinformatics, Medical University of Innsbruck, Innsbruck, Austria
| | - Martin Hermann
- Department of Anesthesiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Hemse Al Khamisi
- Laboratory of Experimental Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Martin Förster
- Department of Cardiology, Pneumology and Angiology, Friedrich-Schiller-University Jena, Jena, Germany
| | - Michael Lichtenauer
- Department of Cardiology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Rainer Mittermayr
- Austrian Cluster for Tissue Regeneration, Vienna, Austria.,AUVA Trauma Center Meidling, Vienna, Austria
| | - Patrick Paulus
- Department of Anesthesiology and Operative Intensive Care Medicine, Kepler University Hospital Linz, Linz, Austria
| | - Helga Fritsch
- Division of Histology and Embryology, Medical University of Innsbruck, Innsbruck, Austria
| | - Nikolaos Bonaros
- Department of Cardiac Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Rudolf Kirchmair
- Department of Internal Medicine III, Medical University of Innsbruck, Innsbruck, Austria
| | - Joost P G Sluijter
- Laboratory of Experimental Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Sean Davidson
- Hatter Cardiovascular Institute, University College London, London, UK
| | - Michael Grimm
- Department of Cardiac Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Johannes Holfeld
- Department of Cardiac Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.,Austrian Cluster for Tissue Regeneration, Vienna, Austria
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Shah SGS, Shah SFH, Farrow A. Invited commentary on "Extracorporeal shockwave therapy improves pain and function in subjects with knee osteoarthritis: A systematic review and meta-analysis of randomized clinical trials". Int J Surg 2020; 84:136-137. [PMID: 33188926 DOI: 10.1016/j.ijsu.2020.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 11/08/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Syed Ghulam Sarwar Shah
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Headington Way, Headington, Oxford, OX3 9DU, England, UK.
| | - Sayed Fida Hussain Shah
- Department of Surgery, Minimal Invasive Surgical Centre, Bilawal Medical College, Liaquat University of Medical and Health Sciences, Jamshoro, 76090, Sindh, Pakistan
| | - Alexandra Farrow
- School of Health and Life Sciences, Brunel University London, Uxbridge, Middlesex, UB8 3PH, England, UK
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Pölzl L, Nägele F, Graber M, Hirsch J, Lobenwein D, Mitrovic M, Mayr A, Theurl M, Schreinlechner M, Pamminger M, Dorfmüller C, Grimm M, Gollmann-Tepeköylü C, Holfeld J. Safety and efficacy of direct Cardiac Shockwave Therapy in patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting (the CAST-HF trial): study protocol for a randomized controlled trial. Trials 2020; 21:447. [PMID: 32473644 PMCID: PMC7260800 DOI: 10.1186/s13063-020-04369-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 05/05/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Coronary artery diseases (CAD) remains a severe socio-economic burden in the Western world. Coronary obstruction and subsequent myocardial ischemia result in progressive replacement of contractile myocardium with dysfunctional, fibrotic scar tissue. Post-infarctional remodeling is causal for the concomitant decline of left-ventricular function and the fatal syndrome of heart failure. Available neurohumoral treatment strategies aim at the improvement of symptoms. Despite extensive research, therapeutic options for myocardial regeneration, including (stem)-cell therapy, gene therapy, cellular reprogramming or tissue engineering, remain purely experimental. Thus, there is an urgent clinical need for novel treatment options for inducing myocardial regeneration and improving left-ventricular function in ischemic cardiomyopathy. Shockwave Therapy (SWT) is a well-established regenerative tool that is effective for the treatment of chronic tendonitis, long-bone non-union and wound-healing disorders. In preclinical trials, SWT regenerated ischemic myocardium via the induction of angiogenesis and the reduction of fibrotic scar tissue, resulting in improved left-ventricular function. METHODS/DESIGN In this prospective, randomized controlled, single-blind, monocentric study, 80 patients with reduced left-ventricular ejection fraction (LVEF≤ 40%) are subjected to coronary-artery bypass-graft surgery (CABG) surgery and randomized in a 1:1 ratio to receive additional cardiac SWT (intervention group; 40 patients) or CABG surgery with sham treatment (control group; 40 patients). This study aims to evaluate (1) the safety and (2) the efficacy of cardiac SWT as adjunctive treatment during CABG surgery for the regeneration of ischemic myocardium. The primary endpoints of the study represent (1) major cardiac events and (2) changes in left-ventricular function 12 months after treatment. Secondary endpoints include 6-min Walk Test distance, improvement of symptoms and assessment of quality of life. DISCUSSION This study aims to investigate the safety and efficacy of cardiac SWT during CABG surgery for myocardial regeneration. The induction of angiogenesis, decrease of fibrotic scar tissue formation and, thus, improvement of left-ventricular function could lead to improved quality of life and prognosis for patients with ischemic heart failure. Thus, it could become the first clinically available treatment strategy for the regeneration of ischemic myocardium alleviating the socio-economic burden of heart failure. TRIAL REGISTRATION ClinicalTrials.gov, ID: NCT03859466. Registered on 1 March 2019.
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Affiliation(s)
- Leo Pölzl
- University Clinic of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Felix Nägele
- University Clinic of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Graber
- University Clinic of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Jakob Hirsch
- University Clinic of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Daniela Lobenwein
- University Clinic of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Martina Mitrovic
- Clinical Trial Center, Medical University of Innsbruck, Innrain 52, 6020, Innsbruck, Austria
| | - Agnes Mayr
- University Clinic of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Markus Theurl
- University Clinic of Internal Medicine III, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Schreinlechner
- University Clinic of Internal Medicine III, Medical University of Innsbruck, Innsbruck, Austria
| | - Matthias Pamminger
- University Clinic of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Michael Grimm
- University Clinic of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Can Gollmann-Tepeköylü
- University Clinic of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Johannes Holfeld
- University Clinic of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria.
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