Growth factors and cell therapy in myocardial regeneration

Retracted Article: Development of functional hydrogels for heart failure

Hydrogel-based approaches were reviewed for cardiac tissue engineering and myocardial regeneration in ischemia-induced heart failure, with an emphasis on functional studies, translational status, and clinical advancements.

Angiogenic growth factors in myocardial infarction: a critical appraisal

In the recent past, substantial advances have been made in the treatment of myocardial infarction (MI). Despite the impact of these positive developments, MI remains to be a leading cause of morbidity as well as mortality. An interesting hypothesis is that the development of new blood vessels (angiogenesis) or the remodeling of preexisting collaterals may form natural bypasses that could compensate for the occlusion of an epicardial coronary artery. A number of angiogenic factors are proven to be elicited during MI. Exogenous supplementation of these growth factors either in the form of recombinant protein or gene would enhance the collateral vessel formation and thereby improve the outcome after MI. The aim of this review is to describe the nature and potentials of different angiogenic factors, their expression, their efficacy in animal studies, and clinical trials pertaining to MI.

Postinfarction Functional Recovery Driven by a Three-Dimensional Engineered Fibrin Patch Composed of Human Umbilical Cord Blood-Derived Mesenchymal Stem Cells

Considerable research has been dedicated to restoring myocardial cell slippage and limiting ventricular remodeling after myocardial infarction (MI). We examined the ability of a three-dimensional (3D) engineered fibrin patch filled with human umbilical cord blood-derived mesenchymal stem cells (UCBMSCs) to induce recovery of cardiac function after MI. The UCBMSCs were modified to coexpress luciferase and fluorescent protein reporters, mixed with fibrin, and applied as an adhesive, viable construct (fibrin-cell patch) over the infarcted myocardium in mice (MI-UCBMSC group). The patch adhered well to the heart. Noninvasive bioluminescence imaging demonstrated early proliferation and differentiation of UCBMSCs within the construct in the postinfarct mice in the MI-UCBMSC group. The implanted cells also participated in the formation of new, functional microvasculature that connected the fibrin-cell patch to both the subjacent myocardial tissue and the host circulatory system. As revealed by echocardiography, the left ventricular ejection fraction and fractional shortening at sacrifice were improved in MI-UCBMSC mice and were markedly reduced in mice treated with fibrin alone and untreated postinfarction controls. In conclusion, a 3D engineered fibrin patch composed of UCBMSCs attenuated infarct-derived cardiac dysfunction when transplanted locally over a myocardial wound.

Sequential delivery of angiogenic growth factors improves revascularization and heart function after myocardial infarction

Treatment of ischemia through therapeutic angiogenesis faces significant challenges. Growth factor (GF)-based therapies can be more effective when concerns such as GF spatiotemporal presentation, bioactivity, bioavailability, and localization are addressed. During angiogenesis, vascular endothelial GF (VEGF) is required early to initiate neovessel formation while platelet-derived GF (PDGF-BB) is needed later to stabilize the neovessels. The spatiotemporal delivery of multiple bioactive GFs involved in angiogenesis, in a close mimic to physiological cues, holds great potential to treat ischemic diseases. To achieve sequential release of VEGF and PDGF, we embed VEGF in fibrin gel and PDGF in a heparin-based coacervate that is distributed in the same fibrin gel. In vitro, we show the benefits of this controlled delivery approach on cell proliferation, chemotaxis, and capillary formation. A rat myocardial infarction (MI) model demonstrated the effectiveness of this delivery system in improving cardiac function, ventricular wall thickness, angiogenesis, cardiac muscle survival, and reducing fibrosis and inflammation in the infarct zone compared to saline, empty vehicle, and free GFs. Collectively, our results show that this delivery approach mitigated the injury caused by MI and may serve as a new therapy to treat ischemic hearts pending further examination.

Reversal of ischemic cardiomyopathy with Sca-1+ stem cells modified with multiple growth factors

Background

We hypothesized that bone marrow derived Sca-1⁺ stem cells (BM Sca-1⁺) transduced with multiple therapeutic cytokines with diverse effects will induce faster angiomyogenic differentiation in the infarcted myocardium.

Methods and Results

BM Sca-1⁺ were purified from transgenic male mice expressing GFP. Plasmids encoding for select quartet of growth factors, i.e., human IGF-1, VEGF, SDF-1α and HGF were prepared and used for genetic modification of Sca-1⁺ cells (^GFSca-1⁺). Scramble transfected cells (^ScSca-1⁺) were used as a control. RT-PCR and western blotting showed significantly higher expression of the growth factors in ^GFSca-1⁺. Besides the quartet of the therapeutic growth factors, PCR based growth factor array showed upregulation of multiple angiogenic and prosurvival factors such as Ang-1, Ang-2, MMP9, Cx43, BMP2, BMP5, FGF2, and NGF in ^GFSca-1⁺ (p<0.01 vs^ScSca-1⁺). LDH and TUNEL assays showed enhanced survival of ^GFSca-1⁺ under lethal anoxia (p<0.01 vs ^ScSca-1⁺). MTS assay showed significant increased cell proliferation in ^GFSca-1⁺ (p<0.05 vs^ScSca-1⁺). For in vivo study, female mice were grouped to receive the intramyocardial injection of 15 μl DMEM without cells (group-1) or containing 2.5×10^5ScSca-1⁺ (group-2) or ^GFSca-1⁺ (group-3) immediately after coronary artery ligation. As indicated by Sry gene, a higher survival of ^GFSca-1⁺ in group-3 on day4 (2.3 fold higher vs group-2) was observed with massive mobilization of stem and progenitor cells (cKit⁺, Mdr1⁺, Cxcr4⁺ cells). Heart tissue sections immunostained for actinin and Cx43 at 4 weeks post engraftment showed extensive myofiber formation and expression of gap junctions. Immunostaining for vWF showed increased blood vessel density in both peri-infarct and infarct regions in group-3. Infarct size was attenuated and the global heart function was improved in group-3 as compared to group-2.

Conclusions

Administration of BM Sca-1⁺ transduced with multiple genes is a novel approach to treat infarcted heart for its regeneration.

Repetitive myocardial ischemia promotes coronary growth in the adult mammalian heart

BACKGROUND

Coronary artery disease and ischemic cardiomyopathy represent the leading cause of heart failure and continue to grow at exponential rates. Despite widespread availability of coronary bypass surgery and percutaneous coronary intervention, subsequent ischemic events and progression to heart failure continue to be common occurrences. Previous studies have shown that a subgroup of patients develop collateral blood vessels that serve to connect patent and occluded arteries and restore perfusion to ischemic territories. The presence of coronary collaterals has been correlated with improved clinical outcomes; however, the molecular mechanisms governing this process remain largely unknown.

METHODS AND RESULTS

To date, no mouse models of coronary arterial growth have been described. Using a closed-chest model of myocardial ischemia, we have demonstrated that brief episodes of repetitive ischemia are sufficient to promote the growth of both large coronary arteries and the microvasculature. Induction of large coronary artery and microvascular growth resulted in improvements in myocardial perfusion after prolonged ischemia and protected from subsequent myocardial infarction. We further show that repetitive ischemia did not lead to increased expression of classic proangiogenic factors but instead resulted in activation of the innate immune system and recruitment of macrophages to growing blood vessels.

CONCLUSIONS

These studies describe a novel model of coronary angiogenesis and implicate the cardiac macrophage as a potential mediator of ischemia-driven coronary growth.

Natural ECM as biomaterial for scaffold based cardiac regeneration using adult bone marrow derived stem cells

Cellular therapy using stem cells for cardiac diseases has recently gained much interest in the scientific community due to its potential in regenerating damaged and even dead tissue and thereby restoring the organ function. Stem cells from various sources and origin are being currently used for regeneration studies directly or along with differentiation inducing agents. Long term survival and minimal side effects can be attained by using autologous cells and reduced use of inducing agents. Cardiomyogenic differentiation of adult derived stem cells has been previously reported using various inducing agents but the use of a potentially harmful DNA demethylating agent 5-azacytidine (5-azaC) has been found to be critical in almost all studies. Alternate inducing factors and conditions/stimulant like physical condition including electrical stimulation, chemical inducers and biological agents have been attempted by numerous groups to induce cardiac differentiation. Biomaterials were initially used as artificial scaffold in in vitro studies and later as a delivery vehicle. Natural ECM is the ideal biological scaffold since it contains all the components of the tissue from which it was derived except for the living cells. Constructive remodeling can be performed using such natural ECM scaffolds and stem cells since, the cells can be delivered to the site of infraction and once delivered the cells adhere and are not "lost". Due to the niche like conditions of ECM, stem cells tend to differentiate into tissue specific cells and attain several characteristics similar to that of functional cells even in absence of any directed differentiation using external inducers. The development of niche mimicking biomaterials and hybrid biomaterial can further advance directed differentiation without specific induction. The mechanical and electrical integration of these materials to the functional tissue is a problem to be addressed. The search for the perfect extracellular matrix for therapeutic applications including engineering cardiac tissue structures for post ischemic cardiac tissue regeneration continues.

The challenges for cardiac vascular precursor cell therapy: lessons from a very elusive precursor

There is compelling evidence that cardiovascular disorders arise and/or progress due mainly to endothelial dysfunction. Novel therapeutic strategies aim to generate new myocardial tissue using cells with regenerative potential, either alone or in combination with biomaterials, cytokines and advanced monitoring devices. Among the human adult progenitor cells used in such methods, those historically termed 'endothelial progenitor cells' show promise for vascular growth and repair. Asahara et al. [Science 1997;275:964-967] initially described putative endothelial cell precursors in 1997. Subsequently, distinct cell populations termed endothelial colony-forming units-Hill, circulating angiogenic cells and endothelial colony-forming cells were identified that varied in terms of phenotype, vascular homeostasis contribution and purity. Notably, most of these cells are not genuine vascular precursor cells belonging to the endothelial lineage. This review provides a broad overview of the main properties of the endothelium, focusing on the basis governing its growth and repair. We discuss efforts to identify true vascular precursors, a matter of debate for the past 15 years, as well as recent methodological advances in identifying new hierarchies of more homogeneous, clonogenic and proliferative vascular endothelial-lineage precursors. Consideration of these issues provides insights that may help develop more effective therapies against human diseases that involve vascular deficits.

Enhanced cardiomyogenic lineage differentiation of adult bone-marrow-derived stem cells grown on cardiogel

The extracellular matrix (ECM) and its components are known to promote growth and cellular differentiation in vitro. Cardiogel, a three-dimensional extracellular matrix derived from cardiac fibroblasts, is evaluated for its cardiomyogenic-differentiation-inducing potential on bone-marrow-derived stem cells (BMSC). BMSC from adult mice were grown on cardiogel and induced to differentiate into specific lineages that were validated by morphological, phenotypic and molecular assays. The data revealed that the cardiogel enhanced cardiomyogenic and adipogenic differentiation and relegated osteogenic differentiation following specific induction. More importantly, increased cardiomyogenic differentiation was also observed following BMSC growth on cardiogel without specific chemical (5-azacytidine) induction. This is the first report of an attempt to use cardiogel as a biomaterial on which to achieve cardiomyogenic differentiation of BMSC without chemical induction. Our study suggests that cardiogel is an efficient extracellular matrix that enhances the cardiomyogenic differentiation of BMSC and that it can therefore be used as a scaffold for cardiac tissue regeneration.

Human umbilical cord blood-derived mesenchymal stem cells promote vascular growth in vivo

Stem cell therapies are promising strategies to regenerate human injured tissues, including ischemic myocardium. Here, we examined the acquisition of properties associated with vascular growth by human umbilical cord blood-derived mesenchymal stem cells (UCBMSCs), and whether they promoted vascular growth in vivo. UCBMSCs were induced in endothelial cell-specific growth medium (EGM-2) acquiring new cell markers, increased Ac-LDL uptake, and migratory capacity as assessed by qRT-PCR, Western blotting, indirect immunofluorescence, and invasion assays. Angiogenic and vasculogenic potentials could be anticipated by in vitro experiments showing self organization into Matrigel-mediated cell networks, and activation of circulating angiogenic-supportive myeloid cells. In mice, following subcutaneous co-injection with Matrigel, UCBMSCs modified to co-express bioluminescent (luciferases) and fluorescent proteins were demonstrated to participate in the formation of new microvasculature connected with the host circulatory system. Response of UCBMSCs to ischemia was explored in a mouse model of acute myocardial infarction (MI). UCBMSCs transplanted using a fibrin patch survived 4 weeks post-implantation and organized into CD31⁺network structures above the infarcted myocardium. MI-treated animals showed a reduced infarct scar and a larger vessel-occupied area in comparison with MI-control animals. Taken together, the presented results show that UCBMSCs can be induced in vitro to acquire angiogenic and vasculogenic properties and contribute to vascular growth in vivo.

Therapeutic strategies based on polymeric microparticles

The development of the field of materials science, the ability to perform multidisciplinary scientific work, and the need for novel administration technologies that maximize therapeutic effects and minimize adverse reactions to readily available drugs have led to the development of delivery systems based on microencapsulation, which has taken one step closer to the target of personalized medicine. Drug delivery systems based on polymeric microparticles are generating a strong impact on preclinical and clinical drug development and have reached a broad development in different fields supporting a critical role in the near future of medical practice. This paper presents the foundations of polymeric microparticles based on their formulation, mechanisms of drug release and some of their innovative therapeutic strategies to board multiple diseases.

Post-infarction scar coverage using a pericardial-derived vascular adipose flap. Pre-clinical results

BACKGROUND

Myocardial salvage after coverage with a fat flap was recently demonstrated in acute coronary occlusion. The effect of this novel therapeutic strategy on a chronic myocardial scar is unknown.

METHODS

Myocardial infarction (MI) was induced by coil deployment in the mid circumflex artery in the swine model. Two weeks after infarction, a pericardial-derived adipose flap was transposed, fully covering the scar, in the treated group. Infarct size and histopathology were analyzed on post mortem sections. To assess cell migration, adenoviral eGFP vectors were injected in the adipose flap and expression was evaluated upon sacrifice both at the flap and myocardium. Magnetic resonance imaging (MRI) was used to measure left ventricular (LV) ejection fraction and ventricular volumes at baseline, 2 weeks post-MI, and at 6 weeks.

RESULTS

One month after flap transposition, histopathology confirmed a 34% reduction in infarct size (8.7% vs. 5.7%; P=0.04) and the presence of vascular connections at the flap-myocardium interface. High eGFP expression was detected at the infarct core both at the gene and protein level (negligible signal was detected at the flap on sacrifice). At the functional level, changes in LV ejection fraction and volumes (end-systolic and end-diastolic) were not significantly different between groups (all P values>0.1).

CONCLUSIONS

Our data support the use of post-infarction scar coverage with a pericardial-derived fat flap to reduce infarct size, due partly to neovascular connections and cell trafficking at the flap-myocardium interface. Further studies are needed to validate the functional and clinical relevance of this intervention.

Adult stem cells: from new cell sources to changes in methodology

Cardiovascular diseases constitute the first cause of mortality and morbidity worldwide. Alternative treatments like transplantation of (stem) cell populations derived from several adult tissue sources, like the bone marrow, skeletal muscle, or even adipose tissue, have been already employed in diverse clinical trials. Results from these studies and previous animal studies have reached to the conclusion that stem cells induce a benefit in the treated hearts, which is exerted mainly through paracrine mechanisms and not through direct differentiation as it was initially expected. However, a strong technical limitation for the stem cell therapy, which is the low level of cell survival and engraftment, diminishes their potential. Thus, new strategies like combination of the cells with bioengineering techniques have been developed and are being subject of intense research, suggesting that new strategies may improve the efficacy of these therapies. In this review, we will discuss the different therapeutic approaches, drawbacks, and future expectations of new regenerative therapies for cardiovascular diseases.

Therapeutic angiogenesis by implantation of a capillary structure constituted of human adipose tissue microvascular endothelial cells

OBJECTIVE

We previously reported a novel technology for the engineering of a capillary network using an optical lithographic technique. To apply this technology to the therapy of ischemic diseases, we tested human omental microvascular endothelial cells (HOMECs) as an autologous cell source and decellularized human amniotic membranes (DC-AMs) as a pathogen-free and low immunogenic transplantation scaffold.

METHODS AND RESULTS

Human umbilical vein endothelial cells were aligned on a patterned glass substrate and formed a capillary structure when transferred onto an amniotic membrane (AM). In contrast, HOMECs were scattered and did not form a capillary structure on AMs. Treatment of HOMECs with sphingosine 1-phosphate (S1P) inhibited HOMEC migration and enabled HOMEC formation of a capillary structure on AMs. Using quantitative RT-PCR and Western blot analyses, we demonstrated that the main S1P receptor in HOMECs is S1P(2), which is lacking in human umbilical vein endothelial cells, and that inhibition of cell migration by S1P is mediated through an S1P(2)-Rho-Rho-associated kinase signaling pathway. Implantation of capillaries engineered on DC-AMs into a hindlimb ischemic nude mouse model significantly increased blood perfusion compared with controls.

CONCLUSIONS

A capillary network consisting of HOMECs on DC-AMs can be engineered ex vivo using printing technology and S1P treatment. This method for regeneration of a capillary network may have therapeutic potential for ischemic diseases.

Tumor angiogenesis: insights and innovations

Angiogenesis is a vital process resulting in the formation of new blood vessels. It is normally a highly regulated process that occurs during human development, reproduction, and wound repair. However, angiogenesis can also become a fundamental pathogenic process found in cancer and several other diseases. To date, the inhibition of angiogenesis has been researched at both the bench and the bedside. While several studies have found moderate improvements when treating with angiogenesis inhibitors, greater success is being seen when the inhibition of angiogenesis is combined with other traditional forms of available therapy. This review summarizes several important angiogenic factors, examines new research and ongoing clinical trials for such factors, and attempts to explain how this new knowledge may be applied in the fight against cancer and other angiogenic-related diseases.

Transient hypoxia induces ERK-dependent anti-apoptotic cell survival in endothelial cells

Ischemia-induced apoptosis of endothelial cells may contribute to tissue injury, organ failure, and transplantation rejection. However, little is known about survival mechanisms capable to counteract endothelial apoptosis. This study investigated the potential role of an endogenous anti-apoptotic response elicited by transient hypoxia, capable to avert ongoing apoptosis in endothelial cells. Experiments were carried out in three different types of cultured endothelial cells (human umbilical vein, pig aorta, and from rat coronary microvasculature). As a pro-apoptotic challenge endothelial cells were cultured in serum-free medium and subjected to hypoxia for 2 h. We found that transient hypoxia reduced caspase 3 activation within 1 h of hypoxia. Accordingly, the number of apoptotic cells was reduced after 24 h of reoxygenation. This was true for all three cell types analyzed. Analysis of Akt and mitogen-activated protein kinase kinase (MEK)/extracellular signal-regulated kinase (ERK) pathways revealed that hypoxia induced a transient activation of ERK 2 but not of Akt. ERK 2 phosphorylation preceded the phosphorylation of pro-apoptotic molecule Bad at Ser112, an inhibitory phosphorylation site specific for ERK. The protective effects of hypoxia regarding Bad phosphorylation, caspase 3 activation, and apoptosis were abolished by MEK 1/2 inhibitors, PD98059 or UO126, as well as by antisense oligonucleotides directed against ERK 1/2. Furthermore, inhibition of this pathway inhibited hypoxia-induced increase in mitochondrial membrane potential. The present study demonstrates that transient hypoxia induces a novel survival mechanism that protects endothelial cells against apoptosis. This endogenous process involves MEK/ERK-mediated inhibition of the pro-apoptotic molecule Bad and caspase 3.

Angiomyogenesis for myocardial repair

The conventional therapeutic modalities for myocardial infarction have limited success in preventing the progression of left ventricular remodeling and congestive heart failure. The heart cell therapy and therapeutic angiogenesis are two promising strategies for the treatment of ischemic heart disease. After extensive assessment of safety and effectiveness in vitro and in experimental animal studies, both of these approaches have accomplished the stage of clinical utility, albeit with limited success due to the inherent limitations and problems of each approach. Neomyogenesis without restoration of regional blood flow may be less meaningful. A combined stem-cell and gene-therapy approach of angiomyogenesis is expected to yield better results as compared with either of the approaches as a monotherapy. The combined therapy approach will help to restore the mechanical contractile function of the weakened myocardium and alleviate ischemic condition by restoration of regional blood flow. In providing an overview of both stem cell therapy and gene therapy, this article is an in-depth and critical appreciation of combined cell and gene therapy approach for myocardial repair.

A thin carbon-fiber web as a scaffold for bone-tissue regeneration

Due to the rapid progress being made in tissue regeneration therapy, biomaterials used as scaffolds are expected to play an important role in future clinical application. We report the development of a 3D web (sheet) consisting of high-purity carbon fibers in a nanoscale structure. When the thin carbon-fiber web (TCFW) and recombinant human bone morphogenetic protein 2 (rhBMP-2) composite is implanted in the murine back muscle, new ectopic bone is formed, and the values of the bone mineral content and bone mineral density are significantly higher than those obtained with a collagen sheet. Observation of the interface between the carbon fibers and bone matrix reveal that the fibers are directly integrated into the bone matrix, indicating high bone-tissue compatibility. Further, the rhBMP-2/TCFW composite repairs a critical-size bone defect within a short time period. These results suggest that the TCFW functions as an effective scaffold material and will play an important role in tissue regeneration in the future.

A role of myocardial stiffness in cell-based cardiac repair: a hypothesis

Determining which time point is optimal for bone marrow-derived cell (BMC) transplantation for acute myocardial infarction (AMI) has attracted a great deal of attention. Studies have verified the interaction between cell treatment effect and transfer timing and have suggested that the optimal time frame for BMC therapy is day 4 to day 7 after AMI. However, the potential mechanism underlying the time-dependent therapeutic response remains unclear. Recently, a growing body of in vitro evidence has suggested that stem cells are able to feel and respond to the stiffness of their microenvironment to commit to a relevant lineage, indicating that soft matrices that mimic brain are neurogenic, stiffer matrices that mimic muscle are myogenic and comparatively rigid matrices that mimic collagenous bone prove osteogenic. Simultaneously, considering the fact that the myocardium post-infarction experiences a time-dependent stiffness change from flexible to rigid as a result of myocardial remodelling following tissue necrosis and massive extracellular matrix deposition, we presume that the myocardial stiffness within a certain time frame (possibly day 4–7) post-AMI might provide a more favourable physical microenvironment for the phenotypic plasticity and functional specification of engrafted BMCs committed to some cell lineages, such as endothelial cells, vascular smooth muscle cells or cardiomyocytes. The beneficial effect facilitates angiogenesis and myocardiogenesis in the infarcted heart, and subsequently leads to more amelioration of cardiac functions. If the present hypothesis were true, it would be of great help to understand the mechanism underlying the optimal timing for BMC transplantation and to establish a direction for the time selection of cell therapy.

Development of targeted angiogenic medicine

Strategies to alter angiogenesis have been successfully translated from the bench to bedside. With an estimated number of more than 500 million patients worldwide potentially benefiting from it, it is a prime example of targeted therapy that is increasingly changing the face of clinical medicine. Most efforts to stimulate or inhibit angiogenesis in the past were focused on the key angiogenic factor vascular endothelial growth factor (VEGF), resulting in the approval by the Food and Drug Administration of several drugs for the treatment of cancer and ocular disease. However, mounting clinical evidence reveals that inhibition of VEGF causes resistance and class-specific side effects, while therapeutic angiogenesis by delivering VEGF protein is more challenging than anticipated in human patients. Hence, alternatives are needed, and modulation of oxygen-sensitive enzymes (prolyl hydroxylase domain proteins) and of hypoxia induced transcription factors has recently emerged as a potential novel strategy to treat cancer and ischemic diseases. Furthermore, placental growth factor is a disease-specific angiogenic target, whose inhibition reduces cancer growth without causing major side effects, while its delivery induces revascularization of ischemic tissues. In this review, we summarize recent developments and discuss questions that arise in the exciting, rapidly developing field of angiogenic medicine, including a brief description of its possible implications in neurodegenerative diseases.

Myocardial repair: from salvage to tissue reconstruction

Cardiac tissue reconstruction following myocardial infarction represents a major challenge in cardiovascular therapy, as current clinical approaches are limited in their ability to regenerate or replace damaged myocardium. Thus, different novel treatments have been introduced aimed at myocardial salvage and repair. Here, we present a review of recent advancements in cardiac cell, gene-based and tissue engineering therapies. Selected strategies in cell therapy and new tools for myocardial gene transfer are summarized. Finally, we consider novel approaches to myocardial tissue engineering as a platform for the integration of various modalities in an attempt to rejuvenate infarcted tissue in vivo.