European Heart Journal Advance Access published online on December 11, 2007
European Heart Journal, doi:10.1093/eurheartj/ehm559
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A placebo controlled, dose-ranging, safety study of allogenic mesenchymal stem cells injected by endomyocardial delivery after an acute myocardial infarction
1 Cardiovascular Division, Hospital of the University of Pennsylvania, 3400 Spruce Street, 9 Gates, Philadelphia, PA 19104, USA
2 Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
3 CV Path, Gaithersburg, MD, USA
4 Osiris Therapeutics Inc., Baltimore, MD, USA
Received 16 July 2007; revised 8 October 2007; accepted 31 October 2007.
* Corresponding author. Tel: +1 215 615 3060, Fax: +1 215 615 3073. Email: robert.wilensky{at}uphs.upenn.edu
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Abstract |
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Aims: Although mesenchymal stem cells (MSCs) show promising signs in reducing myocardial infarct (MI) size, the safety of endomyocardial delivery and the most efficacious dose is unknown.
Methods and results: Three days after MI, female Yorkshire swine (25–32 kg, age 2 months, n = 32) were randomized to endomyocardial delivery of one of three MSC doses (2.4 x 107, 2.4 x 108, 4.4 x 108 cells) or vehicle control. Animals were sacrificed at 12 weeks. There were no safety issues related to cell delivery and all animals tolerated the procedure. By magnetic resonance imaging infarct size (g) was decreased in the experimental groups and increased in the control group; 2.4 x 107: 
–2.5 ± 2.5 g, 2.4 x 108: –0.9 ± 2.71 g, 4.4 x 108: –1.6 ± 5.8 g, and control +3.6 ± 3.4 g (P = 0.002, P = 0.016, and P = 0.055 compared with control, respectively). There was no effect on ejection fraction or left ventricular volumes. By histology there were no toxic effects of MSC delivery, however, few engrafted MSCs were observed.
Conclusion: Direct MSC delivery into infarcted myocardium was safe and produced a local but not a functional effect. There was no dose-dependent effect. The effect of MSCs on infarct reduction may result from transient residence and subsequent paracrine effects.
Key Words: Catheterization • Magnetic resonance imaging • Myocardium • Stem cells • Regeneration
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Introduction |
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Mesenchymal stem cells (MSCs) derived from bone marrow have demonstrated potential for myocardial regeneration.1–3 In culture, MSCs are able to maintain an undifferentiated stable phenotype over many generations4,5 and avoid detection by the host immune system. MSCs are capable of differentiating into osteoblasts, chondroblasts, adipocytes, and cardiomyocytes. Given their allogenicity MSCs can be provided to the patient without the need for bone marrow harvesting or immunosuppression and are available for immediate use. As such, administration of allogenic MSCs is a potential therapeutic approach to repair myocardial damage following an acute myocardial infarction (MI).
There are several methods for stem cell delivery including endomyocardial, intravenous, intra-coronary, or retrograde coronary sinus.2,6–8 The endomyocardial route is the most direct approach and is not dependent on ‘homing’ to the infarcted region as is intravenous delivery. Efficiency and retention at 2 weeks is greater following endomyocardial delivery than intravenous delivery and there is less likelihood of distal microvascular plugging compared with intracoronary delivery.7,8 However, little is known about the safety of endomyocardial delivery in the setting of an MI, given the potential risk of perforation or arrhythmogenesis and no consensus has emerged on the effective MSC dose. Hence, we evaluated the safety and dose-dependent response of 3 MSC doses delivered into swine infarcted myocardium 3 days after an acute MI.
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Methods |
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The study endpoints of this randomized, placebo controlled safety and dose ranging study were (i) short and long-term mortality and morbidity related to endomyocardial injection and (ii) functional improvement following MSC delivery, defined as a reduction in infarct size or an improvement in ejection fraction as assessed by magnetic resonance imaging (MRI). The study was approved by the Institutional Animal Care and Use Committee of the University of Pennsylvania.
Mesenchymal stem cell preparation
Using a standardized protocol allogenic, male MSCs were cultured from porcine iliac crest bone marrow. Aspirates were passed through a density gradient to remove undesired cells. MSCs were uniformly positive for SH2, SH3, CD29, CD44, CD71, CD90, CD106, CD120a, and CD124 markers.1 All cultured cells were harvested when they reached 80–90% confluence at the third passage. MSCs were then placed in a cryopreservation solution consisting of 10% DMSO, 5% porcine serum albumin, and 85% plasmalyte-A, labelled with DAPI/DiI and cryopreserved as individual doses at –110°C. On the day of the procedure, thawed cells were centrifuged and re-suspended in saline. The viability of all thawed MSC lots was verified to be >85% immediately before injection using trypan blue staining. Four injection doses were tested: (i) 2.4 x 107 cells, (ii) 2.4 x 108 cells, (iii) 4.4 x 108 cells, and (iv) the plasmalyte-A control solution. These doses were chosen to represent a range of potentially deliverable clinical doses. Previous studies have shown the presence of labelled MSCs in infarcted myocardium following endocardial delivery of 5 x 107 cells.7 For the current study we chose a dose 
50% lower, a dose one log higher and one representing the highest concentration of cells which can safely be delivered via the Stilletto catheter without damage to the cells. MSC viability following passage through the Stiletto catheter at these concentrations is >90% (data on file at Boston Scientific Corp., Natick, MA, USA).
Infarct procedure
In female Yorkshire swine weighing 27–32 kg, (age 2 months) an anterior MI was produced by an 1 h balloon occlusion in the mid-left anterior descending coronary artery. This results in a predictable infarct involving the distal half of the septum and anterolateral walls.7 The animals were premedicated with aspirin 325 mg, atenolol 25 mg, lisinopril 5 mg, and IV amiodarone 3 mg/kg, and the first three were continued throughout the entire study period. Heparin 300 units/kg was administered initially and additional heparin was administered as needed to maintain an activated clotting time >300 s during all procedures. Continuous blood pressure, oximetry and electrocardiographic changes were monitored throughout the procedure.
Magnetic resonance imaging
Cardiac MRI was performed 3 days and at 8 and 12 weeks after the MI to measure the resulting infarct size, using a 1.5 Tesla system (Siemens Sonata) with anterior and posterior phased-array coils. Free-breathing ECG-gated segmented k-space SSFP (TrueFISP) cine images were acquired in short and long-axis planes with three signal averages, allowing calculation of left ventricular (LV) ejection fraction (LVEF) and LV end systolic volume (LVESV) and LV end diastolic volume (LVEDV). Inversion recovery-prepped gradient echo (turboFLASH) delayed enhancement (DE) images were then acquired in multiple planes 15 min after IV administration of 0.2 mmol/kg Gd-DTPA (Omniscan, GE Healthcare).9 The inversion time (TI) was chosen from a TI-scout sequence as the value gave optimal nulling of the signal from myocardium remote to the infarct area. Infarct area was measured by manual planimetry of the hyper-enhancing zone on short-axis DE images; any subendocardial hypoenhancing no-reflow zone related to microvascular obstruction was included as part of the infarct size. Infarct mass was calculated as total infarct area x slice thickness (0.8 cm) x the density of myocardial tissue (1.05 g/dL). Given the rapid growth of the animals during the 12-week follow-up period (from 30 to 97 kg) the percentage of infarct to total myocardial area was not calculated, since any potential improvement is exaggerated. LVESV and LVEDV are normalized to the animal’s weight in order to more adequately present the data over time, as both volumes naturally increase with growth of the animal. Infarct thickness was measured manually in the short axis plane at a location two slices apical to the first basal slice in which hyper-enhancement appeared; the no-reflow zone was again included as part of the infarction. Intra and interpersonal variability was excellent with r > 0.9 as determined on pilot infarct animals.
Mesenchymal stem cell delivery
MSCs were delivered 3 days after the infarction to minimize the effect of myocardial stunning on baseline measurements of regional and global LV function. Following the baseline MRI, MSCs were delivered by endomyocardial injection using a Stiletto® catheter (Boston Scientific Corp., Natick, MA, USA) in those animals in which the infarcted myocardium was at least 15% of the LV. Animals were randomly assigned to either placebo or one of the MSC doses. Each animal received the solution in 19 ± 2 injections of 0.5 cc, in and around the infarcted region under fluoroscopic guidance using a previously published protocol.7 Briefly, left ventriculography was performed in two views separated by 90° in order to visualize the septum in parallel and perpendicular views. This configuration enabled selective targeting of injections in the infarcted area. The infarct area was recorded on a mylar sheet which, in turn, is overlaid on the fluoroscopic image. The Stilletto needle catheter was directed to the infarct and border zone using a 7 Fr steering guide placed within a 9 Fr long sheath. Contact of the Stilletto needle with the myocardium was determined when concurrent movement of the injecting catheter with the cardiac systolic motion was noted and premature ventricular beats on the electrocardiogram were observed.
Necropsy and tissue processing
Following the 12-week MRI all animals underwent a full necropsy by a veterinary pathologist blinded to the study group. Samples of all tissues were immersion-fixed in 10% neutral buffered formalin. Histologic evaluation was performed by another blinded pathologist. Hearts were serially sliced (bread-loafed) at 1 cm intervals parallel to the posterior atrio-ventricular sulcus starting near the apex and continuing to the base of the heart. Slices from the mid and distal portion of the ventricle were sectioned circumferentially at 2 cm length intervals to include the whole circumference of the LV. These sections were paraffin embedded.
One radial slice from the scar area was used for assessment of DAPI/DiI-labelled MSCs. A section from the infarct zone was transferred to 15% sucrose overnight at 4°C and embedded in OCT (optimum cutting tissue medium, TBS, NC) for cryosectioning. Thin sections were cut at 8 µm and mounted on charged slides. Cut sections were examined with a reflected light fluorescence microscope (Olympus BX51, Olympus, USA) at magnification (x400) using a triple filter (Olympus, D/F/TR UM61002), which is able to detect fluorescence in the UV (DAPI) and red (DiI) range.
Immunohistochemistry
Immunohistochemistry for identification of capillaries included anti-von Willebrand factor (vWf, dilution, 1:4000, Strategic Biosolutions, Newark, DE, USA) and lectin (Dolichos biflorus, DBA, Sigma). The latter was mainly used to reveal normal capillaries around myocytes in non-infarcted zones, which stained inconsistently with vWf. In contrast, capillary staining with vWf in the infarct and border areas was intense. The monoclonal antibody against actin clone 1A4 (Sigma, dilution 1:2000) was used for the identification of smooth muscle cells. Heating the sections with steam for 20 min was done for antigen recovery for macrophages while prior incubation with protease VIII (Sigma) was used for vWf antigen. The sections were pre-incubated with 0.3% hydrogen peroxide and Protein Block Serum-Free (X0909, Dako Corp., CA, USA) and incubated overnight at 4°C with the primary antibodies. Primary antibody labelling was performed using a biotinylated-linked antibody, directed against mouse, using a peroxidase based LSAB kit (Dako). Positive staining was visualized using a 3-amino-9-ethylcarbazole substrate–chromogen system. After immunostaining, the sections were counterstained with Gill’s haematoxylin, washed and mounted in aqueous media.
Statistical analysis
Data are presented as mean ± standard deviation. Analysis was performed using site-licensed SPSS statistical software (SPSS, Chicago, IL, USA). Initial comparisons were made among the three dose levels using one-way ANOVA or Dunnett’s multiple range test. Individual comparisons between dose levels and controls were made using Student’s t-tests for independent variables, as well as paired analyses within subjects. Schieffe correction was used to control for multiple comparisons. Statistical significance was set at the 0.05 level.
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Safety of endomyocardial mesenchymal stem cell delivery
Thirty-three animals underwent the MI procedure and the baseline MRI. One animal had an infarct which did not meet entry criteria and was excluded from further study and one control animal died 4 weeks after the procedure due to bleeding from the groin puncture site. Thirty-one animals completed the study. Although transient ventricular arrhythmias were common during contact of the guiding catheter or Stilletto catheter with the myocardium, ventricular tachycardia or fatal arrhythmias did not occur. All the animals tolerated the allogenic cells well and had no clinical immunological reactions defined as skin rash, anorexia, nausea or vomiting.
Magnetic resonance imaging assessment of infarct size over time
The groups were evenly matched with regard to weight, LV myocardial mass, and baseline infarct size (Table 1). Comparison of the mean change in infarct size between the control and experimental groups demonstrated a significant improvement in the experimental group (P = 0.005). By ANOVA the change in MI mass was significant (P = 0.027) with the 2.4 x 107 and 2.4 x 108 MSC groups demonstrating a significant improvement in MI size (P = 0.002, P = 0.016, respectively) compared with control while the 4.4 x 108 MSC group approached statistical significance (P = 0.055, Table 2). In this group one of the eight animals demonstrated a 103% increase in the infarct size, while six animals had a decrease in infarct size (Figure 1). There was no dose-dependent effect of MSCs on infarct size reduction (Table 2). When evaluating the percentage change in MI size the percentage improvement In the 2.4 x 107 group was 19.7% (P = 0.004 vs. control) while the 2.4 x 108 MSC group had a 6.1% improvement (P = 0.02) and the 4.4 x 108 cell group improved by 5.9% (P = 0.103). The infarct size in controls increased by 31.1%.
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Change in infarct thickness
Wall thickness at the maximal infarct site was decreased in all groups indicating wall thinning and fibrosis (Table 2). The greatest decrease was in the control group while the highest dose group demonstrated the least change. The differences were not significant and there was no dose-dependent effect (ANOVA P = 0.54).
Change in left ventricular volumes
All groups demonstrated a decrease in the normalized LVEDV and LVESV; the 4.4 x 108 cells group demonstrated the greatest decrease in both parameters (Table 2). These changes were not statistically significant (ANOVA P = 0.20 for LVEDV and P = 0.29 for LVESV) and no dose-dependent effect of MSC delivery was observed.
Change in left ventricular ejection fraction
The mean ejection fraction decreased slightly in all groups (Table 2). There was neither a statistically significant difference nor a dose dependent effect (ANOVA P = 0.84).
Effects of mesenchymal stem cell on myocardium as assessed by pathology
No animals had evidence of pericardial effusion, pericardial haemorrhage, constrictive pericarditis or pericardial adhesions at necropsy. All organs appeared grossly normal without abnormalities thought to result from either injection or treatment. One animal in the 2.4 x 108 MSC group demonstrated an area of healed fibrosis and haemorrhage (Figure 2).
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Localized areas of inflammation within the myocardium were present in 24 of 31 animals. The extent of inflammatory infiltrate generally consisted of one or two foci of chronic inflammatory cells although one animal in the 2.4 x 107 MSC group showed two large foci of >100 cells/40x high power field (Figure 3). Of the hearts showing inflammation 11 of 42 slides (26%) among seven (of the eight) animals in the 2.4 x 107 MSC group showed inflammatory foci; nine of 36 slides (25%) from six (of eight) animals in the 2.4 x 108 MSC group, 13 of 42 slides (25%) among seven (of eight) animals of the MSC group and seven of 24 slides (29%) from four (of seven) animals of the control animals showed inflammatory foci (P = 0.69).
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Evidence of mineralization within the infarct region was noted in three of 31 hearts (10%, Figure 4). The surrounding cells were fibroblasts and not osteoblastic in appearance with little inflammation, although a few multinucleated giant cells were observed. Small granulomas with birefringent material were noted from one of the six animals in the 2.4 x 108 MSC group and two of seven animals in the 4.4 x 108 MSC group. Infarcts of both MSC-injected and control animals appeared similar consisting of abundant collagen fibres and fibroblasts and many small vessels including capillaries, arterioles, and muscular arteries. In some sections, islands or sheets of extravascular smooth muscle actin-positive cells (myofibroblasts) were also noted. Picrosirius red staining with polarization microscopy in the infarct region showed a predominance of collagen types I and III, with no discernable differences between control and MSC-treated animals. Scars contained more type I than type III collagen. By fluorescent microscopy, myocardial sections showed high intrinsic auto-fluorescence from resident myocardial leukocytes and infarcted tissue. There was only rare evidence of selective nuclear fluorescence attributed to DAPI and cytoplasmic DiI fluorescence.
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Effects of mesenchymal stem cell on myocyte and capillary number
A non-significant trend towards greater capillary density was observed in the MSC delivery groups in both the border and infarct zones (Table 3). Arteriole and artery densities were similar. The number of myocytes/mm3 was significantly greater in control hearts from both non-infarcted and border zones compared with the 2.4 x 108 and 4.4 x 108 MSC groups (Table 4). The infarct zone was not measured since measuring capillary/myocyte densities in a 12-week scar is difficult as the composition is rich in collagen fibres with little cellularity. Also, divergent staining intensities and section orientation (cross-sections) may produce spurious results. The capillaries/myocyte ratios were increased in the non-infarcted and border zone sections of the 2.4 x 108 MSC group compared with control.
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Discussion |
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The current study addresses two unresolved issues regarding cellular regeneration using MSCs, namely the safety of endomyocardial delivery into a recently infarcted milieu and the dose-response of MSCs in improving myocardial function. The results show: (i) endomyocardial delivery of MSCs significantly reduced MI size, but not LVEF, (ii) the effect of MSCs on regional or functional MRI parameters was not dose-dependent, (iii) endomyocardial delivery of MSCs or vehicle control solution 3 days after an AMI was not associated with untoward peri-procedural or long-term clinical events or pathologic effects and (iv) evaluation by an independent laboratory revealed no histopathologic differences between control and experimental groups. Few labelled MSCs could be detected 12 weeks after cell transplantation, indicating a potential paracrine effect of MSCs on MI repair.
Safety of endocardial delivery
In the days following MI the myocardium undergoes necrosis with interstitial oedema and neutrophil accumulation. Hence, direct intramyocardial injection within this weakened myocardium may result in perforation or additional myocardial damage. Since the optimal time of stem cell delivery has not been established, and may be as soon as possible after the infarct, determination of the safety of delivery is of paramount importance. In the current study, safety of the endocardial approach was ascertained. No animal suffered acute or delayed damage attributable to the injection procedure. No animal sustained fatal arrhythmias, myocardial perforation, pericardial tamponade or other untoward effects of delivery into and around the infarcted myocardium. Furthermore, no animal suffered sudden death, which has been associated with ventricular arrhythmogenesis caused by myoblast transplantation.10 Histologic evaluation, at 12 weeks, demonstrated no damage attributable to intramyocardial injection. However, inflammatory foci were observed in all groups and may reflect a response to endomyocardial injection since such foci were also observed in control animals.
There was no indication of severe calcifications as has been noted following intramyocardial delivery of bone marrow cells in rats.11 Focal calcifications were observed, in both the control and treated groups, and were attributed to cell necrosis and/or calcification of extracellular matrix proteins. Histologic evidence to support this assumption includes the lack of osteoblasts in the vicinity of the calcification, suggesting that the mechanism of calcification is unrelated to active bone synthesis by differentiated MSCs. Moreover, calcifications were also present in a control heart, which received vehicle only. Recently, it has been shown that 85% of control animals not receiving cell therapy demonstrated findings of dystrophic cardiac calcinosis of scar tissue post-MI arguing against an effect caused by MSC injection.12 The precise origin of calcification in myocardial scar tissue is not clear but experimental ultrastructural studies suggest that calcified mitochondria may serve as the nidus for further calcium precipitation once the local calcium phosphate solubility product is exceeded.13 Further, dystrophic calcification is becoming recognized as a tightly regulated process involving the presence of non-collagenous matrix proteins such as osteopontin, matrix GLa protein, osteocalcin, SPARC (osteonectin), and bone morphogenetic proteins.14
Effect of mesenchymal stem cell delivery on myocardial recovery
The results indicate that the primary effect of MSCs was a reduction in infarct mass with minimal effect on global function. As such the results are similar to those of Amado et al.2 in which they injected identical cells using a similar protocol. They demonstrated a reduction of the percentage of necrotic myocardium as determined by MRI, from 20.7 ± 3.5% to 9.9 ± 1.3% of the LV after endomyocardial injection of 2.0 x 108 MSCs while the control group was unchanged. Although we presented our data as absolute infarct size the reduction in percentage of necrotic myocardium is similar. However, they also demonstrated an improvement in the ejection fraction, histologic evidence of improvement in infarct thickness and observed MSCs within the ischaemic myocardium at 8 weeks. We could not demonstrate a significant improvement in infarct thickness and we did not demonstrate the unequivocal presence of large numbers of MSCs within the ischaemic myocardium at a 12 week time point. The potential differences between the two studies may be a result of different parameters: histology vs. MRI evaluation, as histologic thickness of the MI was an endpoint in the Amado et al. study while we used MRI to determine infarct size, thickness and EF. In addition, the current endpoint was obtained at 12 weeks following MSC delivery while they used an 8 week follow-up and so the lack of MSCs on histology may reflect the longer study duration.
Other investigators have also shown conflicting results. Guarita-Souza et al.15 demonstrated no significant cardiac functional effect following direct injection of stem cells in rats. However, Shake et al.16 showed a significant improvement in wall thickness over a 4 week period following direct delivery of 6 x 107 MSC 2 weeks after infarction. Makkar et al.17 demonstrated an improvement in ejection fraction 1 and 2 months after direct surgical stem cell injection 1 month after an occlusive MI as determined by left ventriculography and echocardiography, methods less sensitive than MRI. No data was reported on infarct size and the EF was 55% at the time of injection, substantially better than the baseline EF in the current study. In contradistinction to other studies we chronically administered aspirin, angiotensin-converting enzyme inhibitors and beta-blockers; therapeutic manoeuvres clinically demonstrated to improve cardiac function after AMI. It is possible that MSC delivery in the setting of optimal medical therapy contributed little to global functional recovery.
The presented data, however, support recent clinical studies. Janssens et al.18 reported in 67 patients with an ST elevation MI that infarct volume by MRI was decreased in the stem cell group. Little effect on LVEF was observed. Strauer et al.19 demonstrated no effect on LVEF at 3 months after bone marrow stem cell transplantation while there was a significant increase in regional functional recovery. In the BOOST study20 there was no significant difference in LVEF at 18 months between control and experiment groups and the ASTAMI21 trial demonstrated no effect on LVEF at 6 months. These studies as well as the current one imply that the positive effect of MSC cell injection on regional infarct size does not translate to improved LV function. It should be noted that these data are in variance with other recent trials22,23 which have demonstrated a positive effect on EF. Nonetheless the current data suggests that the improvement in infarct size was insufficient to affect global LV function.
Effect of mesenchymal stem cell delivery on capillary growth
A trend in increased capillary density was observed in the experimental hearts both in the border and infarct zones. The increased capillary/myocyte ratio was observed in the border zone and may reflect myocyte hypertrophy. Recent studies have demonstrated that transplanted MSCs may play a role in capillary growth. In a rat model of MI MSCs have been shown to increase capillary density, an effect not observed following skeletal muscle transplantation15,24 In a pig model of chronic MI, delivery of donor bone-marrow derived MSCs via a non-infarct related artery resulted in improved cardiac perfusion, but not angiographic collateral formation, 4 weeks after delivery (8 weeks after infarction). Vessel densities, by histology, were significantly increased in the infarct and border zone areas.25
Lack of dose dependent response
This study, the first evaluating the dose-response of any bone derived stem cells on myocardial function, indicate little effect of dose on MI size, or normalized LVEF or LVEDV. Previous studies demonstrated that 3% of injected cells were present 2 weeks after endomyocardial delivery7 and so it was surprising that an increased dose did not translate into an improved functional effect. The time of injection may be relevant in this regard, since injection into a necrotic, inflamed milieu may have resulted in significant MSC loss in all groups. Injection at a later time point may demonstrate a more robust effect. The effect of MSC transplantation and lack of a dose response could be explained by a paracrine mechanism in which the effect of MSCs on neighbouring cells has a threshold which was reached in the lowest dose group. The inability to detect a large number of Dapi/ DiI labelled cells at necropsy and the lack of a dose-response make it is unlikely that the mechanism of infarct size reduction was related to long-term engraftment. MSCs may transiently reside within the infarct area, interacting with neighbouring cells thereby promoting cardiomyocyte repair prior to subsequent MSC apoptosis. Hence, the 12 week time point may be a point in which the MSC effect is observed although cells are not. One could speculate that the presence of, rather than the absolute number of injected MSCs, may affect native cell viability through an undefined signalling mechanism resulting in decreased infarct size.
Furthermore, a lack of early neovascularization may have resulted in inadequate delivery of nutrients to the newly injected cells so that all doses were relatively ineffective.
Summary
Delivery of all three doses of MSC reduced infarct size but had little effect on cardiac function. There was no dose-dependent response in the decrease in infarct size or the return of myocardial function. Direct delivery of allogenic MSC into the acutely infarcted myocardium was safe and well tolerated.
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Funded in part by a grant from Osiris Corp. to the University of Pennsylvania, CV Pathology (Drs Wilensky, Rippy, and Virmani were recipients of grant funding from Osiris Therapeutics, manufacturers of mesenchymal stem cells).
Conflict of interest: Dr Wilensky has served on scientific advisory boards of Boston Scientific Corp., maker of the Stilletto® catheters. Dr Young is an employee of Osiris Therapeutics. There are no other potential conflicts of interest.
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