Heart Disease

Coding Dimension ID: 
295
Coding Dimension path name: 
Heart Disease

Embryonic Stem Cell-Derived Therapies Targeting Cardiac Ischemic Disease

Funding Type: 
Comprehensive Grant
Grant Number: 
RC1-00124
ICOC Funds Committed: 
$2 524 617
Disease Focus: 
Heart Disease
Stem Cell Use: 
Embryonic Stem Cell
oldStatus: 
Closed
Public Abstract: 
Cardiovascular disease (CVD) is the leading cause of death in the United States. Over one million Americans will suffer from a new or recurrent heart attacks this year and over 40 percent of those will die suddenly. In addition, about two-thirds of the patients develop congestive heart failure; and in people diagnosed with CHF, sudden cardiac death occurs at 6-9 times the general population rate. Heart transplantation remains the only viable solution for severely injured hearts; however, this treatment is limited by the availability of donor hearts. Therefore, alternative strategies to treat end stage heart failure and blocked blood vessels are needed. The objective of this proposal is to determine whether human embryonic stem (hES) cell can be used for repairing the heart. Our collaborator Advanced Cell Technology (ACT) has recently succeeded in identifying conditions for the reproducible isolation of hES cells which have the characteristics of cells which form blood vessels and heart muscle. This proposal will assess whether the hES cells can form new functional blood vessels and repair injured heart muscle in a rat model of heart attacks. Results from these studies will help develop new therapies for treating patients with heart attacks.
Statement of Benefit to California: 
Cardiovascular disease (CVD) is the leading cause of death in California and the United States. Over one million Americans will suffer from a new or recurrent myocardial infarction this year and over 40 percent of those will die suddenly. In addition, about two-thirds of myocardial infarction patients develop congestive heart failure. The 5-year mortality rate for CHF is about 50%, and in people diagnosed with CHF, sudden cardiac death occurs at 6-9 times the general population rate. Heart transplantation remains the only viable solution for severely injured hearts; however, this treatment is limited by the availability of donor hearts. It is estimated that health care costs for CVD is over 18 billion dollars a year. Additionally, the morbidity associated with CVD cost California and the nation billions of dollars a year. Therefore, alternative strategies to treat end stage heart failure and ischemia are needed. (Source: American Heart Association. Heart Disease and Stroke Facts, 2004, Dallas, TX: AHA 2004; American Heart Association. Heart Disease and Stroke Statistics-2006 Update, Dallas, TX: AHA 2006). The field of regenerative medicine is important to California and the nation. Advances in the technology to find cell based therapies will be revolutionary in their impact on patient care. Human embryonic stem (hES) cells have the potential to become all of the cells in the human body, and their unique properties give researchers the hope that from these primitive cells new therapies can result that may be available in time for the looming health care crisis. This project is focused on a pre-clinical application of a specific hES cell based therapy for myocardial regeneration and an antibody targeting technology to direct stem cells to injured organs. This project will benefit California in several ways including: 1) support for UC trainees, 2) potential of developing important clinical trials in CA based on results from this proposal, and 3) enhancement of the biotechnology industry in CA which would lead to the creation of new jobs in CA and an enhanced tax base.
Progress Report: 
  • Myocardial infarction can lead to death and disability with a 5-year death rate for congestive heart failure of 50%. It is estimated that cardiovascular disease is the leading cause of mortality and morbidity and is predicted to be the leading cause of death worldwide by 2020. Currently, heart transplantation is the only successful treatment for end-stage heart failure; however, the ability to provide this treatment is limited by the availability of donor hearts. Therefore, alternative therapies for both acute and chronic myocardial ischemia need to be developed.
  • Our results demonstrate that human embryonic stem cell (hESC)-derived hemangioblasts can create new blood vessels and improve blood flow in a rodent model of myocardial infarction. We demonstrated that adult stem cells (bone marrow CD34+ cells) can be successfully targeted to injured heart tissue, thus avoiding surgery or invasive catheter based therapies. The antibody technology can be used to target hESC-derived hemangioblasts specifically to injured heart tissue.
  • Further studies are needed to confirm our initial findings, determine whether the new blood vessel formation lead to an increase in heart function and safety studies. Studies are in progress to improve the efficiency and effectiveness of hESC-derived hemangioblasts to create new blood vessels. Additionally, investigations are underway to determine if immunosuppressive drugs will be necessary to increase survival of the hESC-derived hemangioblast. Our initial finding of hES-derived hemangioblasts inducing new blood vessel formation may eventually lead to the development of an unlimited and reliable cell source for renewing blood vessels and treating myocardial infarction.
  • Coronary artery disease (CAD) remains the leading cause of morbidity and mortality worldwide and is predicted to be the leading cause of death by 2020. In the US, it is estimated that cardiovascular disease affects 60 million patients costing the healthcare system approximately $186 billion annually. Approximately two-thirds of patients sustaining a myocardial infarction do not make a complete recovery and often are left with debilitating congestive heart failure. Despite the advances in medical treatment and interventional procedures to reduce mortality in patients with CAD, the number of patients with refractory myocardial ischemia and congestive heart failure is rapidly increasing. For end-stage heart failure, heart transplantation is the only successful treatment. However, the ability to provide this treatment is limited by the availability of donor hearts. Therefore, alternative therapies in the prevention and treatment of end-stage heart failure are needed.
  • Critical to any heart repair strategy is the need to provide vessels to allow for an adequate blood supply to nourish the heart. Our results demonstrate that human embryonic stem cell (hESC)-derived hemangioblasts can create new blood vessels and improve blood flow in a rodent model of myocardial infarction. Studies are in progress to improve the efficiency and effectiveness of hESC-derived hemangioblasts to create new blood vessels. Strategies to improve efficiency and effectiveness include the use of extracellular matrix proteins (components that make up the structural aspect of the heart) to increase the survival of the cells or the use of antibodies to direct and link the cells to the damaged heart muscle. Additionally, to decrease the risk of tumor formation from the hESC-derived hemangioblasts, the hESC-derived hemangioblasts are being cultured to form more mature endothelial cells (cells that mimic the bodies natural cells that produce blood vessels). These cells are being tested to determine whether they can effectively induce blood vessels in the heart. Our initial finding of hES-derived hemangioblasts inducing new blood vessel formation may eventually lead to the development of an unlimited and reliable cell source for renewing blood vessels and treating myocardial infarction.
  • Coronary artery disease (CAD) remains the leading cause of morbidity and mortality worldwide and is predicted to be the leading cause of death by 2020. In the US, it is estimated that cardiovascular disease affects 60 million patients costing the healthcare system approximately $186 billion annually. Approximately two-thirds of patients sustaining a myocardial infarction do not make a complete recovery and often are left with debilitating congestive heart failure. Despite the advances in medical treatment and interventional procedures to reduce mortality in patients with CAD, the number of patients with refractory myocardial ischemia and congestive heart failure is rapidly increasing. For end-stage heart failure, heart transplantation is the only successful treatment. However, the ability to provide this treatment is limited by the availability of donor hearts. Therefore, alternative therapies in the prevention and treatment of end-stage heart failure are needed.
  • Critical to any heart repair strategy is the need to provide vessels to allow for an adequate blood supply to nourish the heart. Our results demonstrate that human embryonic stem cell (hESC)-derived hemangioblasts can create new blood vessels and improve blood flow in a rodent model of myocardial infarction. Subsequent studies with hESC-derived endothelial progenitor cells decreased MI size and improved LV function in a mouse model of myocardial ischemia. Studies are in progress to improve the efficiency and effectiveness of hESC-derived endothelial progenitor cells to create new blood vessels.
  • Strategies to improve efficiency and effectiveness of stem cell therapy include the use of extracellular matrix proteins (components that make up the structural aspect of the heart) to increase the survival of the cells or the use of antibodies to direct and link the cells to the damaged heart muscle. We have demonstrated that antibodies can direct stem cells to injured myocardial tissue. Continued studies are in progress to perform studies needed for the submission of an IND. The development of peptide-modified scaffolds for the treatment of chronic heart failure has produced initial proof of concept studies that a tissue engineering approach for restoration of an injured heart is possible. Additionally, we have demonstrated that extracellular matrix derived peptides can recruit endogenous cardiac stem cells. Further development of a biopolymer scaffold for the treatment of chronic heart failure is in progress.
  • Coronary artery disease (CAD) remains the leading cause of morbidity and mortality worldwide and is predicted to be the leading cause of death by 2020. In the US, it is estimated that cardiovascular disease affects 60 million patients costing the healthcare system approximately $186 billion annually. Approximately two-thirds of patients sustaining a myocardial infarction do not make a complete recovery and often are left with debilitating congestive heart failure. Despite the advances in medical treatment and interventional procedures to reduce mortality in patients with CAD, the number of patients with refractory myocardial ischemia and congestive heart failure is rapidly increasing. For end-stage heart failure, heart transplantation is the only successful treatment. However, the ability to provide this treatment is limited by the availability of donor hearts. Therefore, alternative therapies in the prevention and treatment of end-stage heart failure are needed.
  • Critical to any heart repair strategy is the need to provide vessels to allow for an adequate blood supply to nourish the heart. Our results demonstrate that human embryonic stem cell (hESC)-derived hemangioblasts can create new blood vessels and improve blood flow in a rodent model of myocardial infarction. Subsequent studies with hESC-derived endothelial progenitor cells decreased MI size and improved LV function in a mouse model of myocardial ischemia. Studies are in progress to improve the efficiency and effectiveness of hESC-derived endothelial progenitor cells to create new blood vessels.
  • Strategies to improve efficiency and effectiveness of stem cell therapy include the use of extracellular matrix proteins (components that make up the structural aspect of the heart) to increase the survival of the cells or the use of antibodies to direct and link the cells to the damaged heart muscle. We have demonstrated that antibodies can direct stem cells to injured myocardial tissue. Continued studies are in progress to perform studies needed for the submission of an IND. The development of peptide-modified scaffolds for the treatment of chronic heart failure has produced initial proof of concept studies that a tissue engineering approach for restoration of an injured heart is possible. Additionally, we have demonstrated that extracellular matrix derived peptides can recruit endogenous cardiac stem cells. Further development of a biopolymer scaffold for the treatment of chronic heart failure is in progress.

Development of Neuro-Coupled Human Embryonic Stem Cell-Derived Cardiac Pacemaker Cells.

Funding Type: 
SEED Grant
Grant Number: 
RS1-00171
ICOC Funds Committed: 
$744 639
Disease Focus: 
Heart Disease
Stem Cell Use: 
Embryonic Stem Cell
oldStatus: 
Closed
Public Abstract: 
Optimal cardiac function depends on the properly coordinated cardiac conduction system (CCS). The CCS is a group of specialized cells responsible for generating cardiac rhythm and conducting these signals efficiently to working myocardium. This specialized CCS includes the sinoatrial node, atrioventricular node and His-Purkinje system. These specialized pacemaking /conducting cells have different properties from the surrounding myocytes responsible for the contractile force. Genetic defects or postnatal damage by diseases or aging processes of these cells would result in impaired pulse generation (sinus node dysfunction, SND) or propagation (heart block). Implantation of an electronic cardiac pacemaker is necessary for intolerant bradycardia to restore cardiac rhythm. However, the electronic implantable pacemaker has multiple associated risks (e.g. infections) and requires frequent generator changes due to limited battery life. Sinus node dysfunction is a generalized abnormality of cardiac impulse formation and accounts for >30 percent of permanent pacemaker placements in the US. A perfect therapy to SND will be to repair or replace the defective sinus node by cellular or genetic approaches. Many recent studies have demonstrated, in a proof-of-concept style, of generating a biological pacemaker by implanting various types of progenitor or stem cells into ventricular myocardium to form a pulse-generating focus. However, a perfect biological pacemaker will require good connections with the intrinsic neuronal network for proper physiological responses. Elucidation of the factors controlling the evolution of pacemaker cells and their interaction with the peripheral neuronal precursor cells (neural crest cells, NCCs) will be paramount for creating an adaptive biological pacemaker. The NCCs have been shown to be contiguous with the developing conduction system in embryonic hearts of humans. However, the influence and interaction of the NCCs with the developing cardiac pacemaker cells remains unclear. In addition, there is no simple marker for identifying the pacemaker cells and the electrophysiological (EP) recording is the only physiological method to trace the evolution of cardiac pacemaker cells from human embryonic stem cells (hESCs). We have successfully obtained the EP properties of early hESC-derived cardiomyocytes. We propose here an in vitro co-culture system to study fate of the pacemaker cells evolved from hESCs and to investigate the influence of NCCs on the early, cardiac committed myocytes derived from hESCs. Such a study will provide insight in the development of pacemaker cells and in the mechanisms of early neuro-cardiac interaction. Results from the proposed study may suggest strategies for developing efficient and neuro-coupled cardiac pacemakers from ESCs. These neuro-coupled biological pacemaker cells may one day used clinically to replace the need for implanting an electronic pacemaker for the treatment of intolerant bradycardia.
Statement of Benefit to California: 
Optimal cardiac function depends on the properly coordinated cardiac conduction system. Genetic defects or postnatal damage by diseases or aging processes of these pacemaker cells would result in impaired pulse generation (sinus node dysfunction) or propagation (heart block). The implantation of an electronic cardiac pacemaker is necessary for intolerant bradycardia to restore physiologic cardiac rhythm. However, the electronic implantable pacemaker has multiple associated risks (e.g. infections and thrombosis) and requires frequent generator changes due to limited battery life. Sinus node dysfunction (SND) is a generalized abnormality of cardiac impulse formation and accounts for 30-50 percent of permanent pacemaker placements in the US. A perfect therapy to SND will be to repair or replace the defective sinus node by cellular or genetic approaches. Most of the research work on developing biological pacemakers are performed in Columbia University at New York City, Johns Hopkins University at Baltimore, and Technion-Israel Institute of Technology at Haifa, Israel. All of their approaches produced short-lived and non-responsive biological pacemakers to physiological demands. None of human stem cell-related research in California is devoted to this highly promising field of developing biological pacemakers. The proposed research here will elucidate the factors controlling the evolution of pacemaker cells and their interaction with the peripheral neuronal precursor cells (neural crest cells). Such a study will provide insight in the development of pacemaker cells and in the mechanisms of early neuro-cardiac interaction. These factors then can be used to generate better neuro-coupled biological pacemaker cells in California. These neuro-coupled biological pacemaker cells may one day be used clinically to replace the need for implanting an electronic pacemaker for the treatment of intolerant bradycardia. Creating the neuro-coupled, adaptive biological pacemakers will make California the epicenter of the next generation of pacemaker therapy, and will benefit its citizens who have intolerant cardiac bradycardia.
Progress Report: 
  • Cardiovascular diseases remain the major cause of death in the US. Human Stem and progenitor cell-derived cardiomyocytes (SPC-CMs) hold great promise for myocardial repairs. Recent progress in cellular reprogramming of various somatic cell types into induced pluripotent stem cells opened the door for developing patient-specific, cell-based therapies. However, most SPC-CMs displayed heterogeneous and immature electrophysiological (EP) phenotypes with uncontrollable automaticity. Implanting these electrically immature and inhomogeneous CMs to the hearts would likely be arrhythmogenic and deleterious. Furthermore, as CMs mature, they undergo changes in automaticity and electrical properties. We used human embryonic stem cell-derived CMs (hESC-CMs) as the model system to study the development and maturation of CMs in the embryoid body (EB) environment. Elucidating molecular pathways governing EP maturation of early hESC-CMs in EBs would enable engineered microenvironment to create functional pacemaker cells or electrophysiologically compatible hESC-CMs for cell replacement therapies. We have established antibiotic (Abx)-resistant hESC lines conferred by lentiviral vectors under the control of a cardiac-specific promoter. With simple Abx treatment, we easily isolated >95% pure hESC-CMs at various stages of differentiation from EBs. In the first year of this grant support and using the Abx selection system, we found that hESC-CMs isolated at early stages of differentiation without further contacts with non-cardiomyocytes (non-CMs) depicted arrested electrical maturation. The intracellular Ca2+-mediated automaticity developed very early and contributed to dominant automaticity throughout hESC-CM differentiation regardless of the presence or absence of non-CMs. In contrast, sarcolemmal ion channels evolved later upon further differentiation within EBs and their maturation required the interaction with non-CMs. In the second year, we further developed an add-back co-culture system to enable adding non-CMs back to early isolated hESC-CMs, which rescued the arrest of EP maturation. We also developed techniques to isolate pure subsets of non-CMs, such as neural crest and endothelial cells, from hESC-derived EBs, which exerted influences on maturation of specific subsets of ion channel populations respectively. Therefore, our study showed for the first time that non-CMs exert significant influences on the EP maturation of hESC-CMs during differentiation. Knowledge of this study will allow us to improve functional maturation of primitive hESC-CMs or to create neuro-coupled pacemaker cells before cell transplantation.
  • Cardiovascular diseases remain the major cause of death in the US. Human Stem and progenitor cell-derived cardiomyocytes (SPC-CMs) hold great promise for myocardial repairs. Recent progress in cellular reprogramming of various somatic cell types into induced pluripotent stem cells opened the door for developing patient-specific, cell-based therapies. However, most SPC-CMs displayed heterogeneous and immature electrophysiological (EP) phenotypes with uncontrollable automaticity. Implanting these electrically immature and inhomogeneous CMs to the hearts would likely be arrhythmogenic and deleterious. Furthermore, as CMs mature, they undergo changes in automaticity and electrical properties. We used human embryonic stem cell-derived CMs (hESC-CMs) as the model system to study the development and EP maturation of CMs in the embryoid body (EB) environment. Elucidating molecular pathways governing EP maturation of early hESC-CMs in EBs would enable engineered microenvironment to create functional pacemaker cells or electrophysiologically compatible hESC-CMs for cell replacement therapies. We have established antibiotic (Abx)-resistant hESC lines conferred by lentiviral vectors under the control of a cardiac-specific promoter. With simple Abx treatment, we easily isolated >95% pure hESC-CMs at various stages of differentiation from EBs. In the first year of this grant support and using the Abx selection system, we found that hESC-CMs isolated at early stages of differentiation without further contacts with non-cardiomyocytes (non-CMs) depicted arrested electrical maturation. The intracellular Ca2+-mediated automaticity developed very early and contributed to dominant automaticity throughout hESC-CM differentiation regardless of the presence or absence of non-CMs. In contrast, sarcolemmal ion channels evolved later upon further differentiation within EBs and their maturation required the interaction with non-CMs. In the second year, we further developed an add-back co-culture system to enable adding non-CMs back to early isolated hESC-CMs, which rescued the arrest of EP maturation. In the third no-cost extension year, we further successfully established the cocultures of human neural crest cell (NCC)-derivatives and early-purified hESC-CMs. We found that peripheral neurons derived from human NCCs exerted strong influences on the development of a specific subset of ion channel populations during early hESC-CM differentiation. Therefore, our study showed for the first time that non-CMs, especially neurons derived from NCCs, exert significant influences on the EP maturation of hESC-CMs during differentiation. Knowledge of this study will allow us to improve functional maturation of primitive hESC-CMs or to create neuro-coupled pacemaker cells before cell transplantation.

Autologous cardiac-derived cells for advanced ischemic cardiomyopathy

Funding Type: 
Disease Team Research I
Grant Number: 
DR1-01461
ICOC Funds Committed: 
$5 560 232
Disease Focus: 
Heart Disease
Stem Cell Use: 
Adult Stem Cell
Cell Line Generation: 
Adult Stem Cell
oldStatus: 
Closed
Public Abstract: 
The adult human heart contains small numbers of cardiac stem cells that are able to partially repair the heart following a heart attack or throughout the course of progressive heart failure. We have developed a method to isolate these cells and grow them to large numbers in the lab. Isolation begins with a minimally-invasive biopsy taken from a patient’s heart. Our method can be used to then generate clusters of cells (termed “cardiospheres [CSps]”) or individual cells (termed “cardiosphere-derived cells [CDCs]”), each with their own advantages and disadvantages. When delivered to animals after a heart attack or in the midst of heart failure, these cells can better repair the heart, form new heart muscle and new blood vessels. CDCs are currently being given to patients after a recent heart attack, using a catheter to deliver the single cells into a blood vessel supplying the heart, as part of an ongoing clinical trial. The proposed research aims to test both CSps and CDCs in large animals in the midst of heart failure, using a catheter to deliver the cells directly into the heart muscle, in preparation for another clinical trial. Preliminary data shows that CSps may be a more potent cell therapeutic when compared to their single cell counterparts. Direct injection into the muscle not only allows for safe delivery of the cell clusters, but also increases the effective dose of the cells. Patients with heart failure also stand to benefit more from such a cell-based therapeutic when compared to those victims of a recent heart attack. As such, this research will involve not only animal studies, but also cell manufacturing studies, and the preparation and filing of an IND in order to begin a clinical trial. The first study will test both cell products along with the direct-injection catheter in a large scale animal model in order to determine the optimum cell dose. The second study will determine the optimum number of injections to perform during the procedure. These results will be available by the end of the first year, and will allow for a final pivotal study to be conducted during the course of the second year. This pivotal study will examine both the safety and efficacy of cell delivery in the large scale animal model, utilizing a group of control animals, and will serve as key preclinical data when filing an IND. During the course of the first two years, cell manufacturing studies will be conducted in parallel. These studies will enable us to develop procedures to reproducibly generate, store, ship, and deliver the cell therapeutic in the manner that will be adopted during the clinical trial. During the third year, the preclinical and manufacturing data will be combined with a clinical protocol formulated during the course of the pivotal animal study, to constitute the bulk of an IND. Following pre-IND discussions and IND review, we will begin conducting a clinical trial in patients with heart failure in the hope of halting disease progression for these individuals.
Statement of Benefit to California: 
Few families in California are not impacted by heart disease. Cardiovascular disease remains the leading cause of death and disability in Americans- on average, cardiovascular disease kills one American every 37 seconds. The death toll from cardiovascular disease is greater than that for cancer, chronic respiratory diseases, accidents, and diabetes combined. Death rates have improved, but new treatments are urgently needed. Aside from the human costs, cardiovascular disease exacts a tremendous fiscal toll: the American Heart Association estimates that the total costs of cardiovascular disease in the United States approached one-half trillion dollars in 2008. All taxpayers must bear the economic burden of resulting death and disability. Clearly, virtually all Californians stand to benefit, directly or indirectly, from the development of more effective treatments of cardiovascular disease. Heart disease is a particularly good target not just because of the magnitude of the public health problem, but also because heart muscle does not ordinarily regenerate once it has been destroyed by heart attacks and other types of damage. We seek to tap into the innate repair mechanisms of the heart by harvesting adult cardiac stem cells. The present work seeks to provide the scientific basis for regulatory filings that would allow us to reintroduce cardiac stem cells into patients with advanced heart failure. The treatment would be “autologous”, in that cells from any given patient would be used to treat that same patient. Thus, the cells are a perfect genetic match, obviating the risk of rejection. If our studies are successful, we may offer a cost-effective way to reduce the tremendous damage to Californians inflicted by major types of cardiovascular disease. This in turn may also reduce the economic burden presently borne by taxpayers who support the health care systems in California. In addition to the public health benefits, spinoff technology developed by this disease team will benefit existing California-based biotechnology companies, leading to fuller employment and an enhanced tax base.
Progress Report: 
  • Disease Team Award DR1-01461, Autologous cardiac-derived cells for advanced ischemic cardiomyopathy, is targeted at developing novel therapies for the treatment of heart failure, a condition which afflicts 7 million Americans. Heart failure, when symptomatic, has a mortality exceeding that of many malignant tumors; new therapies are desperately needed. In the first year of CIRM support, we have developed and validated a development candidate, cardiospheres, which are three-dimensional (3D) functional microtissues engineered in culture and suitable for implantation in the hearts of patients via minimally-invasive catheter-based methods. Cardiospheres, derived from heart biopsies using methods developed by the Principal Investigator, have now been successfuly delivered via magnetically-navigated injection catheters into healthy heart tissue surrounding zones of myocardial damage in preclinical models. The 3D microtissues engraft efficiently in preclinical models of heart failure, as expected from prior work indicating their complex multi-layer nature combining cardiac progenitors, supporting cells and derivatives into the cardiomyocyte and endothelial lineages. We have also developed standard operating procedures for cardiosphere manufacturing, and are in the process of developing release criteria for the 3D microtissue development candidate. Next steps include efficacy studies, with a view to an approved IND by mid-2012.
  • Disease Team Award DR1-01461, autologous cardiac-derived cells for advanced ischemic cardiomyopathy, is targeted at developing novel therapies for the treatment of heart failure, a condition which afflicts 7 million Americans. Heart failure, when symptomatic, has a mortality exceeding that of many malignant tumors; new therapies are desperately needed. In the second year of CIRM support, pivotal pre-clinical studies have been completed. We have found that dose-optimized injection of CSps preserves systolic function, attenuates remodeling, decreases scar size and increases viable myocardium in a porcine model of ischemic cardiomyopathy. The 3D microtissues engraft efficiently in preclinical models of heart failure, as expected from prior work indicating their complex multi-layer nature combining cardiac progenitors, supporting cells and derivatives into the cardiomyocyte and endothelial lineages. Analysis of the MRI data continues. We have developed standard operating procedures for cardiosphere manufacturing and release criteria, product and freezing/thawing stability testing have been completed for the 3D microtissue development candidate. We have identified two candidate potency assays for future development. The disease team will evaluate the results of the safety study (immunology, histology, and markers of ischemic injury) and complete the pivotal pig study in Q1 2012. With data in hand, full efforts will be placed on preparation of the IND for Q2 2012 submission.

Studying Arrhythmogenic Right Ventricular Dysplasia with patient-specific iPS cells

Funding Type: 
Basic Biology IV
Grant Number: 
RB4-06276
ICOC Funds Committed: 
$1 582 606
Disease Focus: 
Heart Disease
Pediatrics
Stem Cell Use: 
iPS Cell
Cell Line Generation: 
iPS Cell
oldStatus: 
Active
Public Abstract: 
Most heart conditions leading to sudden death or impaired pumping heart functions in the young people (<35 years old) are the results of genetic mutations inherited from parents. It is very difficult to find curative therapy for these inherited heart diseases due to late diagnosis and lack of understanding in how genetic mutations cause these diseases. Using versatile stem cells derived from patients’ skin cells with genetic mutations in cell-cell junctional proteins, we have made a significant breakthrough and successfully modeled one of these inherited heart diseases within a few months in cell cultures. These disease-specific stem cells can give rise to heart cells, which allow us to discover novel abnormalities in heart energy consumption that causes dysfunction and death of these diseased heart cells. Currently, there is no disease-slowing therapy to these inherited heart diseases except implanting a shocking device to prevent sudden death. We propose here to generate more patient-specific stem cell lines in a dish from skin cells of patients with similar clinical presentations but with different mutations. With these new patient-specific stem cell lines, we will be able to understand more about the malfunctioned networks and elucidate common disease-causing mechanisms as well as to develop better and safer therapies for treating these diseases. We will also test our new therapeutic agents in a mouse model for their efficacy and safety before applying to human patients.
Statement of Benefit to California: 
Heart conditions leading to sudden death or impaired pumping functions in the young people (<35 years old) frequently are the results of genetic mutations inherited from parents. Currently, there is no disease-slowing therapy to these diseases. It is difficult to find curative therapy for these diseases due to late diagnosis. Many cell culture and animal models of human inherited heart diseases have been established but with significant limitation in their application to invent novel therapy for human patients. Recent progress in cellular reprogramming of skin cells to patient-specific induced pluripotent stem cells (iPSCs) enables modeling human genetic disorders in cell cultures. We have successfully modeled one of the inherited heart diseases within a few months in cell cultures using iPSCs derived from patients’ skin cells with genetic mutations in cell-cell junctional proteins. Heart cells derived from these disease-specific iPSCs enable us to discover novel disease-causing abnormalities and develop new therapeutic strategies. We plan to generate more iPSCs with the same disease to find common pathogenic pathways, identify new therapeutic strategies and conduct preclinical testing in a mouse model of this disease. Successful accomplishment of proposed research will make California the epicenter of heart disease modeling in vitro, which very likely will lead to human clinical trials and benefit its young citizens who have inherited heart diseases.
Progress Report: 
  • Most heart conditions leading to sudden death or impaired cardiac pumping functions in the young people (<35 years old) are the results of genetic mutations inherited from parents. It is very difficult to find curative therapy for these inherited heart diseases due to late diagnosis and lack of understanding in how genetic mutations cause these diseases. One of these inherited heart diseases is named arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C). The signature features of sick ARVD/C hearts are progressive heart muscle loss and their replacement by fat and scare tissues, which can lead to lethal irregular heart rhythms and/or heart failure. We have made a significant breakthrough and successfully modeled the sick ARVD/C heart muscles within two months in cell cultures using versatile stem cells derived from ARVD/C patients’ skin cells with genetic mutations in one of the desmosomal (a specific type of cell-cell junctions in hearts) proteins, named plakophilin-2. These disease-specific stem cells can give rise to heart cells, which allow us to discover specific abnormalities in heart energy consumption of ARVD/C heart muscles that causes dysfunction and death of these diseased heart cells. In the Year 1 of this grant support, we have made and characterized additional stem cells lines from ARVD/C patients with different desmosomal mutations. We are in the process to determine if heart muscles derived from these new ARVD/C patient-specific stem cells have common disease-causing mechanisms as we had published. We found two proposed therapeutic agents are ineffective in suppressing ARVD/C disease in culture but we have identified one potential drug that suppressed the loss of ARVD/C heart cells in culture. We also started to establish a known ARVD/C mouse model for future preclinical drug testing.

Heart Repair with Human Tissue Engineered Myocardium

Funding Type: 
Early Translational III
Grant Number: 
TR3-05556
ICOC Funds Committed: 
$4 766 231
Disease Focus: 
Heart Disease
Stem Cell Use: 
Embryonic Stem Cell
oldStatus: 
Active
Public Abstract: 
Heart disease is the number one cause of morbidity and mortality in the US. With an estimated 1.5 million new or recurrent myocardial infarctions, the total economic burden on our health care system is enormous. Although conventional pharmacotherapy and surgical interventions often improve cardiac function and quality of life, many patients continue to develop refractory symptoms. Thus, the development of new therapies is urgently needed. “Tissue engineering” can be broadly defined as the application of novel bioengineering methods to understand complex structure-function relationships in normal or pathological conditions and the development of biological substitutes to restore, maintain, or improve function. It is different from “cell therapy”, which is designed to improve the function of an injured tissue by simply injecting suspensions of isolated cells into the injury site. To date, two main limitations of cell therapy are (1) acute donor cell death due to unfavorable seeding environment and (2) the lack of suitable cell type that genuinely resembles human cardiac cells. Our proposal seeks to use engineered tissue patches seeded with human embryonic stem cell-derived cardiomyocytes for treatment of ischemic heart disease in small and large animal models. It represents a significant development of novel techniques to address both of the main limitations of cell therapy, and will provide a new catalyst for the entire field of stem cell-based tissue engineering.
Statement of Benefit to California: 
Patients with end-stage heart failure have a 2-year survival rate of 25% by conventional medical therapy. Not commonly known to the public is that this dismal survival rate is actually worse when compared to patients with AIDS, liver cirrhosis, or stroke. Following a heart failure, the endogenous repair process is not sufficient to compensate for cardiomyocyte death. Thus, novel therapies with stem cells in combination with supportive scaffolds to form engineered cardiac tissue grafts is emerging as a promising therapeutic avenue. Engineered tissues have now been used to make new bladders for patients needing cystoplasty, bioarticial heart patches seeded with bone marrow cells, and more recently new trachea for patient with late stage tracheal cancer. Our multi-disciplinary team intends to push the therapeutic envelop by developing human tissue engineered myocardium for treatment of post-myocardial infarction heart failure. We will first test our engineered cardiac tissue in small and large animal models. We will perform extensive quality control measures to define morphological, molecular, and functional properties. At the end of 3 years, we are confident we will be able to derive a lead candidate that can move into IND-enabling preclinical development. These discoveries will benefit the millions of patients with heart failure in California and globally.
Progress Report: 
  • Despite advances in medical and device therapies, patients with end-stage heart failure have a survival rate of only 25% during the first 2 years following their diagnosis. Heart failure typically follows from damage induced by severe myocardial infarction (MI; heart attack). After a severe MI, the human heart may lose up to 1 billion heart muscle cells (cardiomyocytes). For most of these patients, heart transplantation is the only useful therapy, but there is a severe shortage of donor hearts. Recently, left ventricular assist devices (LVADs) have become available to take over the pumping function of the crucial left ventricle chamber of the heart. These devices were originally used as “bridge to transplant” (a temporary measure to keep patients alive until a new heart became available); recently some patients have received LVADs as “destination therapies” (permanent substitutes for transplanted hearts). The problems associated with these mechanical implants, however, include increased risk of stroke (blood clots that form due to the devices) and infection (the LVADs are powered from batteries that are carried outside the body and require wires to pierce the skin).
  • We are working to develop cardiac regenerative medicine using Engineered Heart Muscle (EHM). We are using human embryonic stem cells (hESCs) because they can be grown in very large quantities and, with the appropriate methods, can be triggered to differentiate into the cardiomyocytes, fibroblasts and smooth muscle that are lost after MI. Because these cells can be produced in essentially unlimited quantities, we could theoretically treat a very large number of patients who currently have no options.
  • During the first year of this project, we have a) established methods for producing the multi-billion quantities of hESC-derived cells needed to address this problem; b) developed methods to freeze and ship these cells to our collaborator in Germany for EHM assembly, and c) used these cells to generate 2 different forms of EHMs to compare their survival and function both in vitro (composition, force generated) and in vivo (after transplantation into rats that have been given MIs). We are now refining the EHM design with the goal of moving forward to testing them in animals with more human-like hearts (based on size and heart rate); this step will be essential to evaluate their safety and function before any clinical trial.

Direct Cardiac Reprogramming for Heart Regeneration

Funding Type: 
Early Translational III
Grant Number: 
TR3-05593
ICOC Funds Committed: 
$6 319 110
Disease Focus: 
Heart Disease
Stem Cell Use: 
Directly Reprogrammed Cell
oldStatus: 
Active
Public Abstract: 
Heart disease is a leading cause of mortality. The underlying pathology is typically loss of heart muscle cells that leads to heart failure. Because heart muscle has little or no regenerative capacity after birth, current therapeutic approaches are limited for the over 5 million Americans who suffer from heart failure. Our recent findings regarding direct reprogramming of a type of structural cell of the heart, called fibroblasts, into cardiac muscle-like cells using just three genes offers a novel approach to achieving cardiac regeneration. 50% of cells in the human heart are cardiac fibroblasts, providing a potential source of new heart muscle cells for regenerative therapy. We simulated a heart attack in mice by blocking the coronary artery, and have been able to reprogram existing mouse cardiac fibroblasts in to new muscle by delivering the three genes into the heart. We found a significant reduction in scar size and an improvement in cardiac function that persists after injury. The reprogramming of cells in the intact organ was more complete than in cells in a dish. We now propose to develop the optimal gene therapy approach to introduce cardiac reprogramming genes into the heart, to establish the optimal delivery approach to administer virus encoding cardiac reprogramming factors that results in improvement in cardiac function in a preclinical model of cardiac injury, and to establish the safety profile of in vivo cardiac reprogramming in a preclinical model.
Statement of Benefit to California: 
This research will benefit the state of California and its citizens by helping develop a new therapeutic approach to cardiac regeneration. Heart disease is a leading cause of death in adults and children in California, but there is no current treatment that can promote cardiac regeneration. This proposal will lay the groundwork for a clinical trial that could result in generation of new heart muscle cells from within the heart. If successful, there is potential economic benefit in terms of productive lives saved and in the commercialization of this technology.
Progress Report: 
  • Heart disease is a leading cause of mortality. The underlying pathology is typically loss of heart muscle cells that leads to heart failure. Because heart muscle has little or no regenerative capacity after birth, current therapeutic approaches are limited for the over 5 million Americans who suffer from heart failure. Our recent findings regarding direct reprogramming of a type of structural cell of the heart, called fibroblasts, into cardiac muscle-like cells using just three genes offers a novel approach to achieving cardiac regeneration. 50% of cells in the human heart are cardiac fibroblasts, providing a potential source of new heart muscle cells for regenerative therapy. We simulated a heart attack in mice by blocking the coronary artery, and have been able to reprogram existing mouse cardiac fibroblasts into new muscle by delivering the three genes into the heart. We found a significant reduction in scar size and an improvement in cardiac function that persists after injury. The reprogramming of cells in the intact organ was more complete than in cells in a dish. We now identified a combination of factors that reprogram human and pig cardiac fibroblasts and are optimizing a gene therapy approach to introduce cardiac reprogramming genes into the heart of pigs. In a pig model of cardiac injury, these factors were able to convert non-muscle cells into new muscle in the area of injury. We also found a viral vector that can preferentially infect the fibroblasts compare to the muscle cells. We are now in a position to test for functional improvement in pigs.
  • Heart disease is a leading cause of mortality. The underlying pathology is typically loss of heart muscle cells that leads to heart failure. Because heart muscle has little or no regenerative capacity after birth, current therapeutic approaches are limited for the over 5 million Americans who suffer from heart failure. Our recent findings regarding direct reprogramming of a type of structural cell of the heart, called fibroblasts, into cardiac muscle-like cells using just three genes offers a novel approach to achieving cardiac regeneration. We simulated a heart attack in mice by blocking the coronary artery, and have regenerated damaged hearts by converting existing mouse cardiac fibroblasts into new muscle by delivering the three genes into the heart. We have found that a combination of the three genes used in mice plus two additional factors were sufficient to identified to reprogram human and pig cardiac fibroblasts and are optimizing a gene therapy approach to introduce cardiac reprogramming genes into the heart of pigs. In a pig model of cardiac injury, we identified the optimal combination of factors that was able to convert non-muscle cells into new muscle in the area of injury. We have completed a pilot study of these five factors for functional improvement using MRI to measure cardiac output 3 days after injury and 2 months after treatment with the reprogramming factors. We also found a viral vector that can preferentially infect the fibroblasts compare to the muscle cells and have confirmed this activity. We are now testing for functional improvement in pigs using various viral vectors.

Human Embryonic Stem Cell-Derived Cardiomyocytes for Patients with End Stage Heart Failure

Funding Type: 
Disease Team Therapy Planning I
Grant Number: 
DR2-05394
ICOC Funds Committed: 
$108 895
Disease Focus: 
Heart Disease
oldStatus: 
Closed
Public Abstract: 
Patients with end-stage heart failure (ESHF) have a 2-year survival rate of 50% with conventional medical therapy. This dismal survival rate is actually significantly worse than patients with AIDS, liver cirrhosis, stroke, and other debilitating diseases. Stem cell therapy may be a promising strategy for inducing myocardial regeneration via paracrine activation, prevention of cardiac apoptosis, and other mechanisms. Several studies have convincingly shown that human embryonic stem cells can be differentiated into cardiomyocytes (hESC-CMs) and that these cells can be used to effectively improve cardiac function following myocardial infarction (MI). The objectives of this CIRM Disease Team Therapy proposal are two-fold: (1) to perform IND enabling studies involving hESC-CM for subsequent FDA approval and (2) to complete a Phase I trial with ESHF patients undergoing the left ventricular assist device (LVAD) procedure whereby hESC-CMs will be injected at the same time.
Statement of Benefit to California: 
Coronary artery disease (CAD) is the number one cause of mortality and morbidity in the US. Following myocardial infarction (MI), the limited ability of the surviving cardiac cells to proliferate thereafter renders the damaged heart susceptible to dangerous consequences such as heart failure. In recent years, stem cell therapy has emerged as a promising candidate for treating ischemic heart disease. In contrast to adult stem cells, human embryonic stem cells (hESCs) have the advantage of being pluripotent, which endows them with the ability to differentiate into virtually every cell type. Numerous studies have demonstrated that hESC-derived cardiomyocytes (hESC-CMs) can improve cardiac function in small and large animal models. In addition, the FDA has approved hESC-derived oligodendrocyte progenitor cells for patients with acute spinal cord injury and hESC-derived retinal pigment epithelial cells for patients with Stargardt’s macular dystrophy. Hence the conventional controversies and regulatory hurdles related to hESC-based trials are no longer major barriers to the field. In this proposal, we seek to extend and translate the robust pre-clinical data into clinical reality by demonstrating the safety and feasibility of hESC-CM transplantation. We will perform careful IND-enabling research in the first 3 years. Afterwards, our medical teams will initiate a phase 1 clinical trial involving 10 patients with end stage heart failure (ESHF). We will perform direct intramyocardial injection of hESC-CMs in ESHF patients undergoing left ventricular assist device (LVAD) implantation as a bridge toward orthotopic heart transplantation (OHT). After the patients have received matching donor hearts, the native recipient hearts will be explanted. This will provide us an opportunity to carefully assess the fate of these cells and to ensure safety before we can embark on a larger clinical trial in Years 5-10.
Progress Report: 
  • Patients with end-stage heart failure (ESHF) have a 2-year survival rate of 50% with conventional medical therapy. This dismal survival rate is actually significantly worse than patients with AIDS, liver cirrhosis, stroke, and other debilitating diseases. Stem cell therapy may be a promising strategy for inducing myocardial regeneration via paracrine activation, prevention of cardiac apoptosis, and other mechanisms. Several studies have convincingly shown that human embryonic stem cells can be differentiated into cardiomyocytes (hESC-CMs) and that these cells can be used to effectively improve cardiac function following myocardial infarction (MI). Over the past year, we have assembled a strong multi-disciplinary team and applied for the CIRM Disease Team Therapy proposal.

Phase I study of IM Injection of VEGF Producing MSC for the Treatment of Critical Limb Ischemia

Funding Type: 
Disease Team Therapy Planning I
Grant Number: 
DR2-05423
ICOC Funds Committed: 
$76 861
Disease Focus: 
Heart Disease
oldStatus: 
Closed
Public Abstract: 
Critical limb ischemia (CLI) represents a significant unmet medical need without any approved medical therapies for patients who fail surgical or angioplasty procedures to restore blood flow to the lower leg. CLI affects 2 million people in the U.S. and is associated with an increased risk of leg amputation and death. Amputation rates in patients not suitable for surgery or angioplasty are reported to be up to 30-50% after 1 year. Patients who are not eligible for revascularization procedures are managed with palliative care, but would be candidates for the proposed phase I clinical trial. In an effort to combat CLI, prior and ongoing clinical trials that our group and others have conducted have evaluated direct injection of purified growth factors into the limb that has low blood flow. Some trials have tested plasmids that would produce the blood vessel growth factors for a short period of time. These therapies did show benefit in early stage clinical trials but were not significantly better than controls in Phase III (late stage) trials, probably due to the short duration of presence of the growth factors and their inability to spread to the areas most needed. Other clinical trials ongoing in our vascular center and others are testing the patient’s own stem cells, moved from the bone marrow to the damaged limb, and those studies are showing some benefit, although the final assessments are not yet completed. Stem cells can have benefit in limb ischemia because they can actively seek out areas of low oxygen and will produce some growth factors to try to encourage blood vessel growth. But in cases where the circulation needs very high levels of rescue, this strategy might not be enough. As an improved strategy we are combining the stem cell and growth factor approaches to make a more potent therapy. We have engineered human Mesenchymal Stem Cells (MSCs) to produce high levels of the strong angiogenic agent VEGF for this novel approach (MSC/VEGF). We and others have documented over the past 20+ years that MSC are capable of sustained expression of growth factors, migrate into the areas of lowest oxygen in the tissues after injection, and wrap around the damaged or tiny blood vessels to secrete their factors where they are needed most. These MSC/VEGF cells are highly potent, safe and effective in our preclinical studies. These human stem cells designed to produce VEGF as “paramedic delivery vehicles armed with growth factor to administer” rapidly restored blood flow to the limbs of rodents who had zero circulation in one leg. With funding that could be potentially obtained through the proposed application we will follow the detailed steps to move this candidate therapy into clinical trials, and will initiate and complete an early phase clinical trial to test safety and potential efficacy of this product that is designed to save limbs from amputation.
Statement of Benefit to California: 
Critical Limb Ischemia (CLI) represents a significant unmet medical need without any curative therapies in its end stages, after even the best revascularization attempts using sophisticated catheters, stents, and bypass surgeries have failed. CLI affects over 2 million people in the US and the prevalence is increasing due to the aging of our population and the diabetes epidemic. In 2007, the treatment of diabetes and its complications in the USA generated $116 billion in direct costs; at least 33% of these costs were linked to the treatment of ischemic foot ulcers, associated with CLI. Once a patient develops CLI in a limb, the risk of needing amputation of the other limb is 50% after 6 years, with devastating consequences. Treatment costs are immense and lives are significantly shortened by this morbid disease. The symptoms associated with this very severe form of lower extremity peripheral artery disease (PAD) are pain in the foot at rest, non- healing ulcers, limb/digital gangrene and delayed wound healing. The quality of life for those with CLI is extremely poor and reported to be similar to that of patients with end stage malignancy. Most patients with CLI will undergo repeat hospitalizations and surgical/endovascular procedures in an effort to preserve the limb, progress to immobility and need constant care. Unfortunately, the limb salvage efforts are often not effective enough, and despite multiple attempts at revascularization, the wounds still fail to heal. The final stage in 25% of cases is limb amputation, which is associated with a high mortality rate within 6 months. Amputation rates in patients not suitable for revascularization are reported to be up to 30-50% after 1 year. Fewer than half of all CLI patients achieve full mobility after an amputation and only one in four above-the-knee amputees will ever wear a prosthesis. Between 199– 1999, over 28,000 first time lower extremity bypass procedures were performed in California for CLI, and 29% of patients were admitted to the hospital for at least one subsequent bypass operation or revision procedure. The 5-year amputation free survival rate for this group of CLI patients from California was only 51.1%. The direct costs to California for the treatment of CLI and diabetic ischemic ulcers are substantial. The lost ability of no-option CLI patients to remain in the CA workforce, to support their families, and to pay taxes causes additional financial strain on the state’s economy. The goal of the proposed study is to develop and apply a safe and effective stem cell therapy to save limbs from amputation due to disorders of the vasculature that currently cannot be cured. The successful implementation of our planned therapies will significantly reduce the cost of healthcare in California and could bring people currently unable to work due to immobility back to the workforce and active lifestyles, with a significantly improved quality of life.
Progress Report: 
  • A) Pre-clinical: The remainder of the IND-enabling studies for the development candidate MSC/VEGF were designed in consultation with Biologics Consulting Group (BCG). The project will begin with the IND-enabling phase and transition through regulatory approvals and through the Phase I clinical trial. The project has a Preclinical unit under the leadership of co-PI Dr. Jan Nolta, and a Clinical unit under the leadership of PI Dr. John Laird. The two units are well integrated, since the team has been meeting frequently since 2008 to plan the testing of the current and prior development candidates. The team is currently performing a Phase I stem cell therapy to test a medical device, as the result of those interactions. During the planning phase we met weekly, and worked continually on the MSC/VEGF project.
  • Co-PI Jan Nolta, Ph.D. is Scientific Director of the UC Davis/CIRM GMP Facility. Dr. Nolta’s team is expert in translational applications of gene-modified MSC at the level of GLP. The Pre-Clinical team is performing all IND-enabling studies for MSC/VEGF, and will manufacture and qualify the MSC and MSC/VEGF products in the GMP facility at UC Davis that is directed by Dr. Bauer (CMC lead). These studies are ongoing and we have been advised by BCG consulting lead Andra Miller, who was formerly Gene Therapy Group Leader at the FDA, CBER, Division of Cell and Gene Therapies. BCG is assisting with preIND preparation, through the planning grant period funding for this project.
  • B) Clinical: The Clinical team is led by PI John Laird MD, Medical Director of the UCD Vascular Center, who is an internationally recognized leader in the field of peripheral vascular interventions. He is the PI for multicenter and multinational trials to evaluate novel treatments for peripheral arterial disease. He has led clinical trials investigating the use of FGF-1, Hif, and VEGF to treat claudication and CLI. Christy Pifer is the experienced Project Manager who will guide the entire process. She is the Vascular Center’s clinical trials manager and orchestrates accrual of patients to all trials, including one ongoing Phase I stem cell clinical trial and another pending, as well as a Phase III gene transfer clinical trial. Ms. Pifer has coordinated over 100 Phase I, II and III clinical trials over the past 12 years. The planning grant allowed Ms. Pifer to contribute significant amounts of time to conducting meetings and designing the clinical study with Dr. Laird and other Vascular Center faculty. We had weekly meetings with the clinical and translational team members to finalize the CIRM Disease Team Grant Application.
  • C) Consultant meetings conducted through the Planning Grant Mechanism:
  • - Paragon was chosen as our CRO for the proposed trial. We had on-site meetings and conference calls with Paragon during the planning phase.
  • - Our consultant Dr. Andy Balber, was a Founder, and for ten years served as the CSO of Aldagen, Inc. At Aldagen since 2000, he helped the Company establish and maintain a clinical program during which patients were treated with stem cell products under seven cleared INDs. Dr. Balber has assisted our team with preparation of the preIND application, and will assist with further dialog with the FDA. We met frequently through conference call and email, and he edited our Disease Teams Grant proposal.
  • - Andra Miller, Director, Cell and Gene Therapy, Biologics Consulting Group, Inc, is a consultant for the development of regulatory strategies to facilitate rapid development of our cell and gene based therap. She and her team are providing support for CMC submission, pre-IND, RAC and IND preparation, Phase I product development strategies and assessment of cGLP compliance. Dr. Miller was Gene Therapy Group Leader for the Division of Cellular and Gene Therapies, Office of Therapeutics of FDA's Center for Biologics Evaluation and Research, for ten years. We met through conference call and email during the Planning Grant period and she edited our Disease Teams grant application.
  • Partner PI group: Dr. Herrera from the Reina Sofia Hospital, Cordoba University, Andalucia, is our partner, identified through the planning grant phase. Her team is currently performing clinical trials of MSC injections for CLI using intra-arterial administration. Now, using the strong development candidate MSC/VEGF, the two teams will each embark upon parallel clinical trials in their respective countries, each capitalizing on their own team’s stem cell delivery strengths to patients at the same stage of no option CLI. The two teams will use similar inclusion and exclusion criteria and will work closely together, if funded, to develop Phase I trials that are highly similar except for the route of injection. We had Skype and conference call meetings with interpreters, and frequent email contact during the Planning Grant phase. This partnership would not have been possible without the CIRM Planning Award.

Optimization in the Identification, Selection and Induction of Maturation of Subtypes of Cardiomyocytes derived from Human Embryonic Stem Cells

Funding Type: 
Tools and Technologies I
Grant Number: 
RT1-01143
ICOC Funds Committed: 
$906 629
Disease Focus: 
Heart Disease
Stem Cell Use: 
Embryonic Stem Cell
Cell Line Generation: 
Embryonic Stem Cell
oldStatus: 
Closed
Public Abstract: 
Cardiovascular diseases remain the major cause of death in the western world. Stem and progenitor cell-derived cardiomyocytes (SPC-CMs) hold great promise for the myocardial repair. However, most of SPC-CMs displayed heterogeneous and immature electrophysiological phenotypes with substantial automaticity. Implanting these electrically immature and inhomogeneous CMs to the hearts would be arrhythmogenic and deleterious. Further optimization in identification, selection and inducing maturation of subtypes of CMs from primitive SPC-CMs are paramount for developing a safe and effective cell-based therapy. Commonly used CM isolation techniques are microdissection, density sedimentation or promoter-driven, fluorescence-activated cell sorting (FACS). Microdissection and density sedimentation are labor intensive and lack of purity. Promoter-driven FACS may compromise cell viability and which promoter is proficient for selection remains unclear. We have established several antibiotics (Abx)-resistant human embryonic stem cell (hESC) lines conferred by lentiviral vectors under the control of various cardiac-specific promoters. With simple Abx treatment, we have easily isolated >95% pure hESC-CMs at various stages of differentiation from embryoid bodies (EBs). Using this Abx selection system, we also found that electrical maturation and differentiation of primitive hESC-CMs depended heavily on developmental cues from extracardiac cells in the EBs. This Abx selection system therefore could be used easily to purify CMs for mechanistic studies and future cell-based therapies. However, the subtype specification of atrial, ventricular and pacemaking CMs appears to occur at very early stages of differentiation because early EBs possess all three types of cells. Furthermore, various cardio-specific promoters have been shown to select preferentially certain subtypes of CMs. In order to use these promoters and Abx resistance to sub-select particular types of CMs at early stages of differentiation, we need to know the timing and sequence of expressions of various cardiac promoters during the EB development. For this later purpose, we will generate hESC lines expressing different colors of fluorescent proteins under the control of various cardiac-specific promoters respectively to determine the timing of expressions of these promoters in the EBs. Based on the sequence of expression, we will generate the Abx-resistant hESC lines under the control of these promoters to sub-select CMs. We will then study the EP properties of these sub-selected hESC-CMs and their interactions with extra-cardiac cells. The overall goal of this proposal is to establish an In Vitro system to track the sequence of expressions of various promoters in order to sub-select particular phenotypes of CMs by the Abx-resistance method. As a result, we will be able to optimize the selection and induction of a population of mature and homogeneous hESC-CMs for a safe and effective cell-based therapy.
Statement of Benefit to California: 
Cardiovascular diseases remain the major cause of death in the western world. Stem and progenitor cell (SPC)-based cell therapies in animal and human studies suggest promising therapeutic potentials. However, most SPC-derived cardiomyocytes (SPC-CMs) displayed heterogeneous and immature electrophysiological (EP) phenotypes with substantial automaticity. Implanting these electrically immature and inhomogeneous CMs to the hearts would be arrhythmogenic and deleterious. Further optimization in identification, selection and inducing maturation of subtypes of CMs from these primitive SPC-CMs are badly needed. Most frequently used isolation techniques are microdissection, density sedimentation or promoter-driven, fluorescence-activated cell sorting (FACS). Microdissection and density sedimentation are labor intensive and lack of purity. Promoter-driven FACS may compromise cell viability and which promoter is proficient for the cardiomyocyte selection remains to be determined. None of the laboratories in the world has success in developing an easy and efficient way to isolate the SPC-CMs. As a result, no method has been developed to induce the maturation of SPC-CMs. We already have the technology to efficiently isolate pure populations of human embryonic stem cell-derived CMs (hESC-CMs) from the embryoid bodies. The proposed research will further determine which type of promoter is best to properly sub-select a specific phenotype of hESC-CMs for future cell-based therapies in California. Most importantly, using this antibiotics-based selection method, we have started investigating the methods for inducing maturation of these sub-selected and primitive CMs. With both goals achieved, we will make California the first state to have a safe and effective cell-based therapy for myocardial repair with a mature and homogeneous population of hESC-CMs. None of stem cell-related research in California is devoted to optimize the selection, identification and induction of maturation of a specific phenotype of hESC-CMs in order to develop a safe cell-based therapy. The proposed research will be the first to achieve this goal proposed by CIRM Tools and Technologies Award. The success of this proposal will also make California the epicenter of the next generation of cell therapies and will benefit its citizens who have significant cardiovascular diseases.
Progress Report: 
  • The goal of our project is to develop methods to induce stem cells to differentiate into heart cells. Importantly, there are three major types of heart cells, which correspond to the ventricle (the major chambers that pump blood to the body), the atria (the smaller chambers that pump blood to the ventricles), and the nodes (these are the regions within the heart where the "pacemaker" cells are found, which control the heart rate). If we can produce pure populations of ventricular, atrial, or nodal cells, we can potentially use these cells for "replacement therapy" for patients which have had heart attacks or who have developed arrhythmias. During the first year of the research, we succeeded in producing cells that correspond to the ventricle. Furthermore, we have developed novel culturing techiques that improve the differentiation of the cells into atrial and nodal type myocytes, and the new strategies look very promising for the future research of this project.
  • The goal of our project is to develop methods to induce stem cells to differentiate into heart cells. Importantly, there are three major types of heart cells, which correspond to the ventricle (the major chambers that pump blood to the body), the atria (the smaller chambers that pump blood to the ventricles), and the nodes (these are the regions within the heart where the "pacemaker" cells are found, which control the heart rate). If we can produce pure populations of ventricular, atrial, or nodal cells, we can potentially use these cells for "replacement therapy" for patients which have had heart attacks or who have developed arrhythmias. During the first year of the research, we succeeded in producing cells that correspond to the ventricle. Furthermore, we have developed novel culturing techiques that improve the differentiation of the cells into atrial and nodal type myocytes, and the new strategies look very promising for the future research of this project.

VEGF signaling in adventitial stem cells in vascular physiology and disease

Funding Type: 
New Faculty II
Grant Number: 
RN2-00909
ICOC Funds Committed: 
$3 155 931
Disease Focus: 
Heart Disease
Stem Cell Use: 
Adult Stem Cell
oldStatus: 
Active
Public Abstract: 
Coronary heart disease is the leading cause of death in the developed world. This disease results from atherosclerosis or fatty deposits in the vessel wall that causes blockage of coronary arteries. Blockage of these arteries cut off supplies of nutrients and oxygen to the heart muscle, causing heart attacks, heart failure or sudden death. To restore coronary blood supply, physicians use guide-wires to position an inflatable balloon at the blockage site of the artery, where the balloon is inflated to open up the artery. This procedure is called percutaneous transluminal coronary angioplasty or PTCA, which is usually accompanied by the placement of a metal tube (or stent) at the diseased site to maintain vessel opening. PTCA is the dominant procedure to restore blood flow in coronary arteries- in the United States alone nearly 1.3 million PTCA procedures were performed in 2004. However, as a response to PTCA-related vessel wall damage, cells from the vessel wall are activated to divide and grow into the vessel lumen, causing re-narrowing or restenosis of the artery. Restenosis of the vessel lumen is the major hurdle limiting the success of PTCA. It occurs in 20-50% of cases within six months of the initial PTCA procedure and requires repeated PTCA to open up the re-narrowed artery, leading to tremendous human and social expenses. Stents which contain drug inhibitors of cell growth (drug eluting stents, or DES) reduce restenosis; however, considerable concerns have emerged regarding the safety of DES due to an increased risk of sudden stent occlusion by platelet aggregates (or thrombosis). This sudden occlusion is caused by a concomitant drug inhibition of cells that cover the raw surface of metal stents to prevent platelet aggregation. This complication is frequently lethal, resulting in death or heart attack in 85% of cases. The safety concerns over DES have created an urgent need to define the mechanisms underlying the biology of restenosis. A population of cells resident in the vessel wall consists of progenitor cells that divide and grow into the vessel lumen when vessels are injured. The repair process mediated by these cells directly contributes to vessel restenosis. Our goal is to understand the biology of these stem cells in the repair of injured arteries- how vessel injury signals these cells to divide and invade the vessel lumen, what molecular effectors control the cellular responses, and how to intercept these signals and effectors to prevent vessel restenosis. This will provide a solid scientific basis for new therapeutic targets and strategies for vessel restenosis after PTCA. The proposal is a targeted response to CIRM New Faculty Awards II. It seeks to extend my research expertise into the field of stem cell biology related to clinically important vascular diseases. We are confident that our proposed studies will generate significant progress in this field, in both scientific knowledge and useful therapies.
Statement of Benefit to California: 
Coronary heart disease is the leading cause of death in California. This disease results from atherosclerosis or fatty deposits in the vessel wall that causes blockage of coronary arteries of the heart, causing heart attacks, heart failure or sudden death. Physicians use wires and balloons to open up the blocked artery (angioplasty) and a metal tube (stent) to keep the artery open and restore blood flow. Although effective, angioplasty and stenting cause some damages to the blood vessel, which leads to a recurrent blockage (or restenosis) of the vessel in 20-50% of patients within 6 months of the procedure. This vessel restenosis requires repeated angioplasties and stenting for restoration of blood flow. Given the large number of patients with coronary heart disease in California, the need for repeated surgical procedures has resulted in tremendous human, social and economic costs in our state. An attempt to reduce vessel restenosis is the placement of drug-eluting stents (or DES) in angioplastied vessels. Although drugs released from the stents reduce vessel restenosis, this approach creates a new and frequently fatal complication- sudden occlusion of the stented arteries. This complication is because drugs in the stents delay the repair of inner lining of the artery, whose function is to prevent platelet aggregation within the lumen of the artery. Sudden platelet aggregation (or thrombosis) within the vessel lumen causes instantaneous obstruction of the artery, leading to acute heart attacks or death. Thus, the safety concerns over DES have created an urgent need to define the mechanisms underlying the biology of restenosis. A population of cells present at the vessel wall possess stem cell characteristics. After vessel injury, these cells increase in number and turn into different kinds of cells, which then migrate from the vessel wall into the lumen, causing blockage of the vessel. Thus, understanding how these cells behave will inspire new ideas for treating recurrent vessel blockage or restenosis. We propose to study how and what molecular signals activate these cells when vessels are injured. Our goal is to provide a scientific strategy of intercepting these signals for the treatment of vessel restenosis. We believe that understanding the biology of vascular stem cells will lead to significant advances in the research and novel therapies of vessel injury and restenosis. Given the scope of this problem , an improved therapy of vessel restenosis will have a significant economic and social impact. We have proposed to use modern methods in genetics, cell biology, and molecular biology to attack the challenges of this project. At the same time, we will train a new generation of bright students and junior scientists in the areas of stem cell biology highly relevant to human disease. This ensures that an essential knowledge base will be preserved, passed on and expanded in California for the foreseeable future.
Progress Report: 
  • Coronary heart disease is the leading cause of death in the developed world. This disease results from atherosclerosis or fatty deposits in the vessel wall that causes blockage of coronary arteries. Blockage of these arteries cut off supplies of nutrients and oxygen to the heart muscle, causing heart attacks, heart failure or sudden death. To restore coronary blood supply, physicians use guide-wires to position an inflatable balloon at the blockage site of the artery, where the balloon is inflated to open up the artery. This procedure is called percutaneous transluminal coronary angioplasty or PTCA, which is usually accompanied by the placement of a metal tube (or stent) at the diseased site to maintain vessel opening. However, as a response to PTCA, cells from the vessel wall are mobilized to divide and grow into the vessel lumen, causing re-narrowing of the artery. Renarrowing of the vessel lumen is the major hurdle limiting the success of PTCA. Mental stents which contain drug inhibitors of cell growth (drug eluting stents, or DES) reduce re-narrowing; however, considerable concerns have emerged regarding the safety of DES due to an increased risk of sudden stent occlusion by platelet aggregates (or thrombosis). This sudden occlusion is caused by a concomitant drug inhibition of cells that cover the raw surface of metal stents to prevent platelet aggregation. This complication is frequently lethal, resulting in death or heart attack in 85% of cases. The safety concerns over DES have created an urgent need to define the mechanisms underlying the biology of vascular re-narrowing.
  • A population of cells resident in the vessel wall consists of stem cells that divide and grow into the vessel lumen when vessels are injured. The repair process mediated by these cells directly contributes to vessel re-narrowing. Our goal is to understand the biology of these stem cells in the repair of injured arteries- how vessel injury signals these cells to divide and invade the vessel lumen, what molecular effectors control the cellular responses, and how to intercept these signals and effectors to prevent vessel re-narrowing. This will provide a solid scientific basis for new therapeutic targets and strategies for vessel re-narrowing after PTCA.
  • In the past year, we have successfully developed in the laboratory a more efficient method of isolating the vessel wall stem cells (or adventitial stem cells) and growing these cells in test tubes. The ability to isolate and grow these stem cells has allowed us to study the effects of many biologically active molecules on these cells critical for vascular repair and re-narrowing. We are now using this method to study molecular pathways that can modify the biological behavior of the vessel wall stem cells. Furthermore, we have developed a different method of injuring the blood vessels to study how the vessel wall stem cells respond to different types of vessel injury. This method allows us to track the mobilization of vessel wall stem cells more precisely in the vascular repair process. We are using this method to study the activity of vessel wall stem cells following injury.
  • Coronary heart disease is the leading cause of death in the developed world. This disease results from atherosclerosis or fatty deposits in the vessel wall that causes blockage of coronary arteries, causing shortage of blood supply with consequent heart attacks, sudden death, or heart failure. To restore coronary blood supply, physicians use guide-wires to position an inflatable balloon at the blockage site of the artery, where the balloon is inflated to open the artery. This angioplasty procedure is usually accompanied by the placement of a metal stent at the diseased site to maintain vessel opening. Such percutaneous coronary intervention (PCI) with angioplasty and stenting is the dominant procedure for opening obstructed coronary arteries. However, PCI activates a population of cells in the vessel wall to grow into the vessel lumen, causing re-narrowing of the artery. This vessel re-narrowing (restenosis) is the major hurdle limiting the success of PCI. Mental stents coated with drug inhibitors of cell growth (drug eluting stents, or DES) reduce re-narrowing; however, considerable concerns have emerged regarding the safety of DES due to an increased risk of sudden stent occlusion by platelet aggregates (or thrombosis) and the need for prolonged anti-platelet therapy, which poses bleeding risks especially to older patients or patients who need surgery. These concerns call for defining mechanisms that control re-narrowing of injured arteries.
  • A population of cells resident in the vessel wall consists of stem cells that are activated when vessels are injured. Activation of these cells directly contributes to vessel re-narrowing. Our goal is to understand how these cells are activated by vessel injury, how injury signals these cells to divide and invade the vessel lumen, what molecular effectors control the cellular responses, and how to intercept these signals and effectors to prevent vessel re-narrowing. In the past year, we successfully developed new methods for isolating and growing these vascular stem cells in test tubes. These new methods allowed us to determine how these stem cells turn into other types of vessel cells after injury and how they contribute to re-narrowing of injured vessels. We are using this method to define molecular pathways that control vessel wall stem cells to respond to vessel injury.
  • Coronary heart disease is a leading cause of morbidity and mortality. This disease results from blockage of coronary arteries that supply blood to the heart muscle. To restore blood supply, physicians use angioplasty to open the obstructed artery and apply stenting to maintain the arterial patency. Approximately 1.3 million angioplasty and stenting procedures are performed every year in the US to relieve coronary obstruction. However, these procedures activate a population of vascular cells to grow into the arterial lumen, causing re-narrowing of the artery. This re-narrowing (restenosis) is the major hurdle limiting the success of angioplasty and stenting. Mental stents coated with drug inhibitors of cell growth (drug eluting stents, or DES) reduce re-narrowing; however, considerable concerns have emerged regarding the safety of DES due to an increased risk of sudden stent occlusion by platelet aggregates (or thrombosis) and the need for prolonged anti-platelet therapy, which poses bleeding risks. These concerns call for defining mechanisms that control re-narrowing of injured arteries.
  • A population of stem cells resides in the arterial wall. These cells are activated when arteries are injured by mechanical stress such as angioplasty and stenting. Activation of these cells directly contributes to arterial re-narrowing. Our goal is to understand how these stem cells are activated by vessel injury, how injury signals these cells to divide and invade the vessel lumen, what molecular effectors control the cellular responses, and how to intercept these signals and effectors to prevent vessel re-narrowing. We developed new methods for isolating and growing these vascular stem cells in test tubes. In the past year, we successfully used these methods to determine how arterial injury or mechanical stress signals the stem cells to produce different types of cells which grow into the arterial lumen, causing narrowing of the artery. We are using these methods and also developing new methods to define molecular pathways that control the reaction of stem cells to arterial injury. This will help identify drug targets for therapeutic intervention.
  • Coronary heart disease, the major cause of morbidity and mortality in our society, results from blockage of the coronary arteries that supply blood to the heart muscle. Blockage of the coronary arteries causes heart attack. Angioplasty and stenting are used to open the obstructed coronary artery and maintain the arterial patency. ~1.3 million angioplasty and stenting procedures are performed in the US every year to treat coronary artery disease. However, these procedures activate a population of vascular cells to grow into the arterial lumen, causing re-narrowing of the artery. This re-narrowing (restenosis) is the major hurdle limiting the success of angioplasty and stenting. Mental stents coated with drug inhibitors of cell growth (drug eluting stents, or DES) reduce re-narrowing; however, considerable concerns have emerged regarding the safety of DES due to an increased risk of sudden stent occlusion by platelet aggregates (or thrombosis) and the need for prolonged anti-platelet therapy, which poses bleeding risks. Defining the mechanisms that control re-narrowing of injured arteries is therefore important for treating coronary artery disease.
  • The arterial wall contains a population of stem cells. These stem cells are activated when arteries are injured by mechanical stress such as angioplasty and stenting. Activation of these cells directly contributes to arterial re-narrowing. Our goal is to understand how these stem cells are activated by vessel injury, how injury signals these cells to divide and invade the vessel lumen, what molecular effectors control the cellular responses, and how to intercept these signals and effectors to prevent vessel re-narrowing. We developed new methods for isolating and growing these vascular stem cells in test tubes, and we have successfully used these methods to determine how arterial injury or mechanical stress signals the stem cells to produce different types of cells which grow into the arterial lumen, causing narrowing of the artery. In the past year, we developed new genetic tools to further understand the mechanism of vascular injury and repair. We are using the new genetic tool to define molecular and cellular pathways that control the reaction of stem cells to arterial injury.
  • Blockage of coronary arteries that supply blood to the heart muscle is the major cause of morbidity and mortality in our society. Angioplasty and stenting are used to open the obstructed coronary artery and maintain the arterial patency. In US, ~1.3 million angioplasty and stenting procedures are performed every year to treat coronary artery disease. Although effective in restoring the blood flow, these procedures activate a population of vascular cells resident in the arterial wall to grow into the vesslel lumen, causing re-narrowing (restenosis) of the treated artery months or years later. This arterial re-narrowing is a major hurdle limiting the success of angioplasty and stenting. Mental stents coated with drug inhibitors of cell growth (drug eluting stents, or DES) reduce re-narrowing; however, the safety of DES has raised considerable concerns due to an increased risk of sudden stent occlusion by platelet aggregates (or thrombosis) as well as the need for prolonged anti-platelet therapy, which poses bleeding risks, especially in the elderly population. It is therefore important to define the underlying mechanisms of re-narrowing of injured arteries in order to design new therapies for coronary artery disease.
  • A population of stem cells resides in the arterial wall. These stem cells are activated when arteries are injured by angioplasty and stenting. Once activated, these cells grow and differentiate into cells that invade the vascular luman and contribute to arterial re-narrowing. We developed new genetic tools to further understand the mechanism of vascular injury and repair. We are using the new genetic tool to define molecular and cellular pathways that control the reaction of stem cells to arterial injury. The goal is to understand how these stem cells are activated by vessel injury, how injury signals these cells to divide and invade the vessel lumen, what molecular effectors control the cellular responses, and how to intercept these signals and effectors to prevent vessel re-narrowing.

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