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Williams K, Khan A, Lee YS, Hare JM. Cell-based therapy to boost right ventricular function and cardiovascular performance in hypoplastic left heart syndrome: Current approaches and future directions. Semin Perinatol 2023; 47:151725. [PMID: 37031035 PMCID: PMC10193409 DOI: 10.1016/j.semperi.2023.151725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/10/2023]
Abstract
Congenital heart disease remains one of the most frequently diagnosed congenital diseases of the newborn, with hypoplastic left heart syndrome (HLHS) being considered one of the most severe. This univentricular defect was uniformly fatal until the introduction, 40 years ago, of a complex surgical palliation consisting of multiple staged procedures spanning the first 4 years of the child's life. While survival has improved substantially, particularly in experienced centers, ventricular failure requiring heart transplant and a number of associated morbidities remain ongoing clinical challenges for these patients. Cell-based therapies aimed at boosting ventricular performance are under clinical evaluation as a novel intervention to decrease morbidity associated with surgical palliation. In this review, we will examine the current burden of HLHS and current modalities for treatment, discuss various cells therapies as an intervention while delineating challenges and future directions for this therapy for HLHS and other congenital heart diseases.
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Affiliation(s)
- Kevin Williams
- Department of Pediatrics, University of Miami Miller School of Medicine. Miami FL, USA; Batchelor Children's Research Institute University of Miami Miller School of Medicine. Miami FL, USA
| | - Aisha Khan
- Interdisciplinary Stem Cell Institute, University of Miami Miller School of Medicine, Miami FL, USA
| | - Yee-Shuan Lee
- Interdisciplinary Stem Cell Institute, University of Miami Miller School of Medicine, Miami FL, USA
| | - Joshua M Hare
- Interdisciplinary Stem Cell Institute, University of Miami Miller School of Medicine, Miami FL, USA; Division of Cardiology, Department of Medicine, University of Miami Miller School of Medicine. Miami FL, USA.
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Birla AK, Brimmer S, Short WD, Olutoye OO, Shar JA, Lalwani S, Sucosky P, Parthiban A, Keswani SG, Caldarone CA, Birla RK. Current state of the art in hypoplastic left heart syndrome. Front Cardiovasc Med 2022; 9:878266. [PMID: 36386362 PMCID: PMC9651920 DOI: 10.3389/fcvm.2022.878266] [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: 02/17/2022] [Accepted: 08/30/2022] [Indexed: 11/29/2022] Open
Abstract
Hypoplastic left heart syndrome (HLHS) is a complex congenital heart condition in which a neonate is born with an underdeveloped left ventricle and associated structures. Without palliative interventions, HLHS is fatal. Treatment typically includes medical management at the time of birth to maintain patency of the ductus arteriosus, followed by three palliative procedures: most commonly the Norwood procedure, bidirectional cavopulmonary shunt, and Fontan procedures. With recent advances in surgical management of HLHS patients, high survival rates are now obtained at tertiary treatment centers, though adverse neurodevelopmental outcomes remain a clinical challenge. While surgical management remains the standard of care for HLHS patients, innovative treatment strategies continue to be developing. Important for the development of new strategies for HLHS patients is an understanding of the genetic basis of this condition. Another investigational strategy being developed for HLHS patients is the injection of stem cells within the myocardium of the right ventricle. Recent innovations in tissue engineering and regenerative medicine promise to provide important tools to both understand the underlying basis of HLHS as well as provide new therapeutic strategies. In this review article, we provide an overview of HLHS, starting with a historical description and progressing through a discussion of the genetics, surgical management, post-surgical outcomes, stem cell therapy, hemodynamics and tissue engineering approaches.
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Affiliation(s)
- Aditya K. Birla
- Laboratory for Regenerative Tissue Repair, Texas Children's Hospital, Houston, TX, United States
- Center for Congenital Cardiac Research, Texas Children's Hospital, Houston, TX, United States
| | - Sunita Brimmer
- Laboratory for Regenerative Tissue Repair, Texas Children's Hospital, Houston, TX, United States
- Center for Congenital Cardiac Research, Texas Children's Hospital, Houston, TX, United States
- Division of Congenital Heart Surgery, Texas Children's Hospital, Houston, TX, United States
| | - Walker D. Short
- Laboratory for Regenerative Tissue Repair, Texas Children's Hospital, Houston, TX, United States
- Department of Surgery, Baylor College of Medicine, Houston, TX, United States
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, United States
| | - Oluyinka O. Olutoye
- Laboratory for Regenerative Tissue Repair, Texas Children's Hospital, Houston, TX, United States
- Department of Surgery, Baylor College of Medicine, Houston, TX, United States
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, United States
| | - Jason A. Shar
- Department of Mechanical Engineering, Kennesaw State University, Marietta, GA, United States
| | - Suriya Lalwani
- Laboratory for Regenerative Tissue Repair, Texas Children's Hospital, Houston, TX, United States
- Center for Congenital Cardiac Research, Texas Children's Hospital, Houston, TX, United States
| | - Philippe Sucosky
- Department of Mechanical Engineering, Kennesaw State University, Marietta, GA, United States
| | - Anitha Parthiban
- Department of Surgery, Baylor College of Medicine, Houston, TX, United States
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, United States
- Division of Pediatric Cardiology, Texas Children's Hospital, Houston, TX, United States
| | - Sundeep G. Keswani
- Laboratory for Regenerative Tissue Repair, Texas Children's Hospital, Houston, TX, United States
- Center for Congenital Cardiac Research, Texas Children's Hospital, Houston, TX, United States
- Department of Surgery, Baylor College of Medicine, Houston, TX, United States
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, United States
| | - Christopher A. Caldarone
- Center for Congenital Cardiac Research, Texas Children's Hospital, Houston, TX, United States
- Division of Congenital Heart Surgery, Texas Children's Hospital, Houston, TX, United States
- Department of Surgery, Baylor College of Medicine, Houston, TX, United States
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, United States
| | - Ravi K. Birla
- Laboratory for Regenerative Tissue Repair, Texas Children's Hospital, Houston, TX, United States
- Center for Congenital Cardiac Research, Texas Children's Hospital, Houston, TX, United States
- Division of Congenital Heart Surgery, Texas Children's Hospital, Houston, TX, United States
- Department of Surgery, Baylor College of Medicine, Houston, TX, United States
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, United States
- *Correspondence: Ravi K. Birla
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Holst KA, Dearani JA, Qureshi MY, Wackel P, Cannon BC, O'Leary PW, Olson TM, Seisler DK, Nelson TJ. From Safety to Benefit in Cell Delivery During Surgical Repair of Ebstein Anomaly: Initial Results. Ann Thorac Surg 2021; 113:890-895. [PMID: 33539782 DOI: 10.1016/j.athoracsur.2020.11.065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 10/26/2020] [Accepted: 11/09/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND The objective of this study is to assess the safety and early impact of intramyocardial delivery of autologous bone marrow-derived mononuclear cells (BM-MNC) at time of surgical Ebstein repair. METHODS Patients with Ebstein anomaly (ages 6 months to 30 years) scheduled to undergo repair of the tricuspid valve were eligible to participate in this open-label, non-randomized phase I clinical trial. BM-MNC target dose was 1-3 million cells/kg. Ten patients have undergone surgical intervention and cell delivery to the right ventricle (RV) and completed 6-month follow-up. RESULTS All patients underwent surgical tricuspid valve repair and uneventful BM-MNC delivery; there were no ventricular arrhythmias and no adverse events related to study product or delivery. Echocardiographic RV myocardial performance index improved and RV fractional area change showed an initial decline and then through study follow-up. There was no evidence of delayed myocardial enhancement or regional wall motion abnormalities at injection sites on 6-month follow-up magnetic resonance imaging. CONCLUSIONS Intramyocardial delivery of BM-MNC after surgical repair in Ebstein anomaly can be performed safely. Echocardiography variables suggest a positive impact of cell delivery on the RV myocardium with improvements in both RV size and wall motion over time. Additional follow-up and comparison to control groups are required to better characterize the impact of cell therapy on the myopathic RV in Ebstein anomaly.
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Affiliation(s)
- Kimberly A Holst
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - M Yasir Qureshi
- Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota.
| | - Philip Wackel
- Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota
| | - Bryan C Cannon
- Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota
| | | | - Timothy M Olson
- Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota
| | - Drew K Seisler
- Wanek HLHS Consortium Clinical Pipeline, Mayo Clinic, Rochester, Minnesota
| | - Timothy J Nelson
- Wanek HLHS Consortium Clinical Pipeline, Mayo Clinic, Rochester, Minnesota
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Martinez J, Zoretic S, Moreira A, Moreira A. Safety and efficacy of cell therapies in pediatric heart disease: a systematic review and meta-analysis. Stem Cell Res Ther 2020; 11:272. [PMID: 32641168 PMCID: PMC7341627 DOI: 10.1186/s13287-020-01764-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 06/04/2020] [Accepted: 06/08/2020] [Indexed: 12/09/2022] Open
Abstract
BACKGROUND Adult clinical trials have reported safety and the therapeutic potential of stem cells for cardiac disease. These observations have now translated to the pediatric arena. We conducted a meta-analysis to assess safety and efficacy of cell-based therapies in animal and human studies of pediatric heart disease. METHODS AND RESULTS A literature search was conducted to examine the effects of cell-based therapies on: (i) safety and (ii) cardiac function. In total, 18 pre-clinical and 13 human studies were included. Pre-clinical: right ventricular dysfunction was the most common animal model (80%). Cardiac-derived (28%) and umbilical cord blood (24%) cells were delivered intravenously (36%) or intramyocardially (35%). Mortality was similar between cell-based and control groups (OR 0.94; 95% CI 0.05, 17.41). Cell-based treatments preserved ejection fraction by 6.9% (p < 0.01), while intramyocardial at a dose of 1-10 M cells/kg optimized ejection fraction. Clinical: single ventricle physiology was the most common cardiac disease (n = 9). Cardiac tissue was a frequent cell source, dosed from 3.0 × 105 to 2.4 × 107 cells/kg. A decrease in adverse events occurred in the cell-based cohort (OR 0.17, p < 0.01). Administration of cell-based therapies improved ejection fraction (MD 4.84; 95% CI 1.62, 8.07; p < 0.01). CONCLUSIONS In this meta-analysis, cell-based therapies were safe and improved specific measures of cardiac function. Implications from this review may provide methodologic recommendations (source, dose, route, timing) for future clinical trials. Of note, many of the results described in this study pattern those seen in adult stem cell reviews and meta-analyses.
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Affiliation(s)
- John Martinez
- Department of Pediatrics, University of Texas Health San Antonio, San Antonio, TX, 77229, USA
| | - Sarah Zoretic
- Department of Pediatrics, University of Texas Health San Antonio, San Antonio, TX, 77229, USA
| | - Axel Moreira
- Department of Pediatrics, University of Texas Health San Antonio, San Antonio, TX, 77229, USA
- Department of Pediatrics, Texas Children's Hospital, Houston, TX, 77030, USA
| | - Alvaro Moreira
- Department of Pediatrics, University of Texas Health San Antonio, San Antonio, TX, 77229, USA.
- Department of Pediatrics, UT Health San Antonio, 7703 Floyd Curl Drive, MC 7812, San Antonio, TX, 78229, USA.
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Ferrari MR, Di Maria MV, Jacot JG. Review on Mechanical Support and Cell-Based Therapies for the Prevention and Recovery of the Failed Fontan-Kreutzer Circulation. Front Pediatr 2020; 8:627660. [PMID: 33575233 PMCID: PMC7870783 DOI: 10.3389/fped.2020.627660] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 12/31/2020] [Indexed: 12/13/2022] Open
Abstract
Though the current staged surgical strategy for palliation of single ventricle heart disease, culminating in a Fontan circulation, has increased short-term survival, mounting evidence has shown that the single ventricle, especially a morphologic right ventricle (RV), is inadequate for long-term circulatory support. In addition to high rates of ventricular failure, high central venous pressures (CVP) lead to liver fibrosis or cirrhosis, lymphatic dysfunction, kidney failure, and other comorbidities. In this review, we discuss the complications seen with Fontan physiology, including causes of ventricular and multi-organ failure. We then evaluate the clinical use, results, and limitations of long-term mechanical assist devices intended to reduce RV work and high CVP, as well as biological therapies for failed Fontan circulations. Finally, we discuss experimental tissue engineering solutions designed to prevent Fontan circulation failure and evaluate knowledge gaps and needed technology development to realize a more robust single ventricle therapy.
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Affiliation(s)
- Margaret R Ferrari
- Department of Bioengineering, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Michael V Di Maria
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Jeffrey G Jacot
- Department of Bioengineering, University of Colorado Anschutz Medical Campus, Aurora, CO, United States.,Department of Pediatrics, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
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