Linking cell function with perfusion: insights from the transcatheter delivery of bone marrow-derived CD133+ cells in ischemic refractory cardiomyopathy trial (RECARDIO)

Abstract

Background: Cell therapy with bone marrow (BM)-derived progenitors has emerged as a promising therapeutic for refractory angina (RA) patients. In the present study, we evaluated the safety and preliminary efficacy of transcatheter delivery of autologous BM-derived advanced therapy medicinal product CD133+ cells (ATMP-CD133) in RA patients, correlating perfusion outcome with cell function.

Methods: In the phase I "Endocavitary Injection of Bone Marrow Derived CD133+ Cells in Ischemic Refractory Cardiomyopathy" (RECARDIO) trial, a total of 10 patients with left ventricular (LV) dysfunction (ejection fraction ≤ 45%) and evidence of reversible ischemia, as assessed by single-photon emission computed tomography (SPECT), underwent BM aspiration and fluoroscopy-based percutaneous endomyocardial delivery of ATMP-CD133. Patients were evaluated at 6 and 12 months for safety and preliminary efficacy endpoints. ATMP-CD133 samples were used for in vitro correlations.

Results: Patients were treated safely with a mean number of 6.57 ± 3.45 × 106 ATMP-CD133. At 6-month follow-up, myocardial perfusion at SPECT was significantly ameliorated in terms of changes in summed stress (from 18.2 ± 8.6 to 13.8 ± 7.8, p = 0.05) and difference scores (from 12.0 ± 5.3 to 6.1 ± 4.0, p = 0.02) and number of segments with inducible ischemia (from 7.3 ± 2.2 to 4.0 ± 2.7, p = 0.003). Similarly, Canadian Cardiovascular Society and New York Heart Association classes significantly improved at follow-up vs baseline (p ≤ 0.001 and p = 0.007, respectively). Changes in summed stress score changes positively correlated with ATMP-CD133 release of proangiogenic cytokines HGF and PDGF-bb (r = 0.80, p = 0.009 and r = 0.77, p = 0.01, respectively) and negatively with the proinflammatory cytokines RANTES (r = - 0.79, p = 0.01) and IL-6 (r = - 0.76, p = 0.02).

Conclusion: Results of the RECARDIO trial suggested safety and efficacy in terms of clinical and perfusion outcomes in patients with RA and LV dysfunction. The observed link between myocardial perfusion improvements and ATMP-CD133 secretome may represent a proof of concept for further mechanistic investigations.

Trial registration: ClinicalTrials.gov, NCT02059681 . Registered 11 February 2014.

Conflict of interest statement

Ethics approval and consent to participate

The study complied with the Declaration of Helsinki and was approved by the local ethical committees (CCFM225/612 and CS/154) and the Italian Competent Authority (Istituto Superiore di Sanità, 15,934(13)PRE21-1199). The institutional review board at each center approved the protocol and all patients gave informed consent prior to participation. Patients were excluded in the case of denial and might withdraw from the study at any time, irrespective of the reason.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

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Figures

Fig. 1

Study flow chart. SPECT gated-single photon emission computed tomography, CPET cardiopulmonary exercise testing, CMR cardiac magnetic resonance, 2D two-dimensional, ECG electrocardiogram, ATMP advanced therapy medicinal product, AE adverse event, SAE serious adverse event, MACE major adverse cardiac events

Fig. 2

Schematic representation of the in vitro experimental plan. GMP good manufacturing practice, ATMP advanced therapy medicinal product, IL interleukin, SCF stem cell factor, FBS fetal bovine serum, PDGF-bb platelet-derived growth factor type bb, GRO-α growth-regulated oncogene alpha, HGF hepatocyte growth factor, VEGF vascular endothelial growth factor, RANTES regulated on activation normal T cell expressed and secreted, MIP-1b macrophage inflammatory protein-1 beta, MCP-1 monocyte chemoattractant protein-1, LIF leukemia inhibitory factor, FACS fluorescence-activated cell sorting, CFU-EC colony forming unit-endothelial cell, Ac-LDL-Dil acetylated low-density lipoprotein labeled with dioctadecyl-tetramethylindocarbocyanine perchlorate, UEA-1 Ulex europaeus agglutinin-1

Fig. 3

Myocardial perfusion at SPECT after 6-month follow-up. Changes of a summed stress score, b summed rest score, c summed difference score and d number of segments with inducible ischemia per patient. Square data markers with error bars represent mean ± SD of each SPECT parameter at baseline and 6 months (n = 9). *p ≤ 0.05, **p ≤ 0.01, ns = not significant

Fig. 4

Canadian Cardiovascular Society and New York Heart Association classes over 12-month follow-up. a Canadian Cardiovascular Society (CCS) class changes from 6 and 12 months to baseline (n = 8). b New York Heart Association (NYHA) class changes from 6 and 12 months to baseline (n = 10). Data presented as mean ± SD. **p ≤ 0.01, ***p ≤ 0.001. §§§p ≤ 0.001 vs baseline

Fig. 5

Selected secreted signature of ATMP-CD133. Pro-angiogenic (green bars), pro-inflammatory (orange bars) and anti-angiogenic (red bars) factor expression levels detected in supernatants of ATMP-CD133 (n = 10). PDGF-bb platelet derived-growth factor type bb, GRO-α growth-regulated oncogene alpha, SCF stem cell factor, HGF hepatocyte growth factor, VEGF vascular endothelial growth factor, IL interleukin, RANTES regulated on activation normal T cell expressed and secreted, MIP-1b macrophage inflammatory protein-1 beta, MCP-1 monocyte chemoattractant protein-1, LIF leukemia inhibitory factor

Fig. 6

ATMP-CD133 in vitro endothelial differentiation. Representative immunofluorescence of a clustered and (b–e) not clustered CFU-EC derived from ATMP-CD133 after 14 days in culture. Arrows indicate ATMP-CD133 committed to endothelial lineage, double-positive for Ac-LDL-Dil (red) and UEA-1 lectin (green). UEA-1 Ulex europaeus agglutinin-1, Ac-LDL-Dil acetylated low-density lipoprotein labeled with dioctadecyl-tetramethylindocarbocyanine perchlorate

Fig. 7

Correlation between ATMP-CD133 secreted factors and myocardial perfusion changes at SPECT. SSS improvements correlate (a, b) positively with measured levels of proangiogenic factors and (c, d) negatively with proinflammatory factors (n = 9). SSS summed stress score, HGF hepatocyte growth factor, PDGF-bb platelet derived-growth factor type bb, RANTES regulated on activation normal T cell expressed and secreted, IL interleukin