Heart Disease

Coding Dimension ID: 
295
Coding Dimension path name: 
Heart Disease
Funding Type: 
Basic Biology IV
Grant Number: 
RB4-05901
Investigator: 
Institution: 
Type: 
PI
ICOC Funds Committed: 
$1 708 560
Disease Focus: 
Heart Disease
Stem Cell Use: 
Embryonic Stem Cell
iPS Cell
oldStatus: 
Active
Public Abstract: 

Each cell type in our body has its own identity. This identity allows a heart cell to contract repetitively, and a brain cell to conduct nerve impulses. Each cell type gains its identity by turning on or off thousands of genes that together give the cell its identity. Understanding how these sets of genes are regulated together as a cell gains its identity is important to be able to generate new cells in disease. For example, after a heart attack, heart muscle dies, leaving scar tissue and a poorly functioning heart. It would be very useful to be able to make new heart muscle by introducing the right set of instructions into other cells in the heart, and turn them into new heart muscle cells. One way that many genes are turned on or off together is by a cellular mechanism called epigenetic regulation. This global regulation coordinates thousands of genes. We plan to understand the epigenetic regulatory mechanisms that give a human heart muscle cell its identity. Understanding their epigenetic blueprint of cardiac muscle cells will help develop strategies for cardiac regeneration, and for a deeper understanding of how cells in our body acquire their individual identities and function.

Statement of Benefit to California: 

This research will benefit the state of California and its citizens by helping develop new approaches to cardiac regeneration that will be more efficient than current approaches, and amenable to drug-based approaches. In addition, the knowledge acquired in these studies will be important not only for heart disease, but for any other disease where reprogramming to regenerate new cells is desirable. The mechanisms revealed by this research will also lead to new understanding of the basis for congenital heart defects, which affect several thousand Californian children every year, and for which we understand very little.

Progress Report: 
  • We have made considerable progress on this project, which is aimed at understanding how genes are controlled during the conversion of human stem cells into heart cells. We have been able to use advanced techniques that allow us to make millions of human heart cells in a dish from "Induced Pluripotent Stem Cells" (known as iPS cells), which are cells derived from skin cells that have properties of embryonic stem cells. We are now using genome engineering techniques to insert a mutation that is associated with human congenital heart defects. We are now starting to map the chromatin marks that will tell us how heart genes are turned on, while genes belonging to other cell types are kept off. This "blueprint" of a heart cell will help us understand how to make better heart cells to repair injured hearts, and will allow us to model human congenital heart disease in a human experimental system.
  • We have made considerable progress on this project, which is aimed at understanding how genes are controlled during the conversion of human stem cells into heart cells. We have been able to use advanced techniques that allow us to make millions of human heart cells in a dish from "Induced Pluripotent Stem Cells" (known as iPS cells), which are cells derived from skin cells that have properties of embryonic stem cells. We are now using genome engineering techniques to insert a mutation that is associated with human congenital heart defects. We are now starting to map the chromatin marks that will tell us how heart genes are turned on, while genes belonging to other cell types are kept off. This "blueprint" of a heart cell will help us understand how to make better heart cells to repair injured hearts, and will allow us to model human congenital heart disease in a human experimental system.
Funding Type: 
Basic Biology IV
Grant Number: 
RB4-06276
Investigator: 
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.
  • 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 heart rhythms or heart failure. We made significant breakthrough and successfully modeled sick ARVD/C heart muscles in cell cultures using versatile stem cells derived from ARVD/C patients’ skin cells with genetic mutations in desmosomal (a specific type of cell-cell junctions in hearts) proteins, e.g. plakophilin-2 (Pkp2). These disease-specific stem cells can give rise to heart cells, which allow us to discover specific abnormalities in energy consumption of ARVD/C heart muscles that lead to their dysfunction and death. In Year 2, we continued to create and characterize additional stem cells lines from ARVD/C patients with different desmosomal mutations. As we had published previously, we have confirmed that the same metabolic deregulation occurs in heart muscles derived from new ARVD/C patient-specific stem cells with different mutations from Pkp2. We further explored new microRNA-based pathogenic mechanisms and identified new classes of therapeutic agents to suppress ARVD/C pathologies in culture. We also started to establish a known ARVD/C mouse model for future preclinical drug testing.
Funding Type: 
Early Translational III
Grant Number: 
TR3-05559
Investigator: 
Name: 
Type: 
PI
ICOC Funds Committed: 
$1 857 600
Disease Focus: 
Heart Disease
Stem Cell Use: 
Embryonic Stem Cell
oldStatus: 
Active
Public Abstract: 

Heart failure is a major and ever-growing health problem affecting an estimated 5.8 million Americans with about half a million new cases every year. There are limited therapeutic options for heart failure. Heart transplantation is effective but has limited impact due to scarcity of donor organs and eventual immune rejection even under chronic immune suppression. Therefore, there is a clear unmet medical need to develop new effective therapies to treat heart failure. Human ES cell based cell therapy could provide a cure for heart diseases by providing renewable source of human cardiomyocytes (CMs) to restore lost cardiomyocytes and cardiac functions. In support of this notion, hESC-derived cardiomyocytes (hESC-CMs) can repopulate lost cardiac muscle and improve heart function in preclinical animal models of advanced heart failure. However, one key bottleneck hindering such clinic development is that hESC-CMs will be rejected by allogenic immune system of the recipients, and the typical immunosuppressant regimen is especially toxic for patients with heart diseases and leads to increased risk of cancer and infection. To resolve this bottleneck, I propose to develop a novel approach to protect the hESC-CMs from allogenic immune system. If successful, our approach will not only greatly improve the feasibility of developing hESC-CMs to treat heart failure but also has broad application in other hESC-based cell therapies for which allogenic immune rejection remains a major hurdle.

Statement of Benefit to California: 

Heart disease is a leading cause of death and disability among Californians with an above average rate of mortality. It costs the State tremendous expenditure for the treatment and loss of productivity. There are limited therapeutic options for advanced heart diseases. In this context, heart transplantation is effective but limited by the shortage of donors. Therefore, there is clearly an urgent unmet medical need for new and effective therapies to treat heart failure. Human ES cell based cell therapy approach offers the unique potential to provide renewable source of cardiomyocytes to treat heart failure by restoring lost cardiomyocytes and cardiac function. However, one key bottleneck is that the allogenic hESC-derived cardiomyocytes will be immune rejected by recipients, and the typical immunosuppression regimen is especially toxic for fragile patients with heart diseases. In addition, chronic immune suppression greatly increases the risk of cancer and infection. Our proposed research is aimed to develop novel strategies to prevent allogenic immune rejection of hESC-derived cardiomyocytes without inducing systemic immune suppression. If successful, our approach will greatly facilitate the development of hESC-derived cardiomyocytes for treating heart disease and also has broad application in other hESC-based therapy for which allogenic immune rejection remains a bottleneck.

Progress Report: 
  • Heart failure affects an estimated 5.8 million Americans with about half a million new cases every year. It is also one of the leading causes of death and loss of productivity in California. There is a clear unmet medical need to develop new therapies to treat patients with heart failure. Human embryonic stem cells (hESCs) can undergo unlimited self-renewal and retain the pluripotency to differentiate into all cell types in the body. Therefore, as a renewable source of various cell types in the body, hESCs hold great promise for the cell replacement therapy of many human diseases. In this context, significant progress has been made in the differentiation of hESCs into functional cardiomyocytes (CMs), providing the potential of cell replacement therapy to cure heart diseases through the restoration of lost cardiac function. However, one key bottleneck hindering the clinic development of hESC-derived CMs is that hESC-derived CMs will be rejected by allogenic immune system of the recipients, and the typical immunosuppressant regimen can be highly toxic for patients with heart diseases. To resolve this bottleneck and improve the feasibility of the hESC-based therapy of heart failure, we developed and validated a novel approach to protect the hESC-derived CMs from the allogenic human immune system in vivo.
  • Heart failure is a major disease in California with limited therapeutic options. It costs the State tremendous expenditure in treatment and loss in productivity. While heart transplant is effective in treating the disease, this option is limited by the scarcity of heart donors and the modest graft survival rate (50%) ten years after transplantation. With their unlimited self-renewal capability and pluripotency to differentiate into all cell types in the body, human ES cells (hESCs) hold great promise for human cell therapy. Therefore, cell therapy approaches with hESC-derived CMs have the unique potential for a cure by restoring lost CMs and cardiac function. Despite significant progress in differentiating hESCs into CMs that are capable of partially restoring heart functions in myocardia infarction (MI) animal models, one key bottleneck remaining is that the allogenic hESC-derived CMs will be immune rejected by the recipients, and the typical immunosuppression regimen is especially toxic for patients with advanced heart diseases. By developing a novel approach to prevent allogenic immune rejection of hESC-derived CMs without the typical immunosuppression, we showed that genetically modified hESCs can be efficiently differentiated into cardiomyocytes, which exhibit characteristic electric physiological properties and are protected from allogenic immune rejection.
Funding Type: 
Early Translational III
Grant Number: 
TR3-05687
Investigator: 
Name: 
Type: 
PI
ICOC Funds Committed: 
$1 701 575
Disease Focus: 
Heart Disease
Pediatrics
Stem Cell Use: 
iPS Cell
Cell Line Generation: 
iPS Cell
oldStatus: 
Active
Public Abstract: 

Autophagy is the cells mechanism for breaking down and recycling proteins. Danon disease is an inherited disorder of autophagy. Patients with this disease have major abnormalities in heart and skeletal muscle and generally die by the time they are in their 20s. Recently we used a new technology to turn skin cells from two patients with this disease into stem cells. The objective of our work is to use these cells to find new medications. To achieve this objective we will use techniques we helped develop to make Danon disease stem cells into heart cells. We will then screen hundreds of thousands of different drugs on these heart cells, to find drugs that make these cells work better. The most promising drugs will be tested on mice with a genetic defect that is similar to those found in patients with Danon disease. When complete, the proposed research will result in the development of a drug suitable for clinical trials of patients with Danon disease. As impaired autophagy is associated with may other diseases, including heart failure, cancer and Parkinson's disease, it is possible that the drug identified will be suitable for treatment of a variety of ailments. Furthermore, the studies will serve as proof of concept for other stem cell based drug discovery systems.

Statement of Benefit to California: 

Heart failure is among the most common reasons Californians are hospitalized, and one of the greatest expenses for the health care system. Danon disease is a type of heart failure that patients inherit. It is rare but almost always fatal. Patients who suffer from Danon disease cannot correctly perform autophagy, which is a way that cells recycle proteins. We believe that our work will help in the development of new drugs to treat Danon disease. It is also possible that the drugs we discover will be useful for the treatment of other types of heart failure. As other disease such as cancer and Parkinson's disease are associated with impaired autophagy, these drugs may help them as well. From a public health perspective, the development of new drugs for heart failure would be of great benefit to Californians. Furthermore, the work could lead to additional grants from federal agency's, as well as larger studies on patients done in partnership with industry. Such studies have the potential of creating jobs and revenue for the state.

Progress Report: 
  • The goal of our project was to use stem cells to help identify new drugs for the treatment of Danon Disease, a rare, inherited disease that causes severe heart disease. Patients with Danon disease generally die in the second and third decade of life of heart failure. We have been working on this project for roughly one year. Since starting we have developed multiple stem cell lines from patients with Danon Disease. We have used these stem cells to make heart cells and have begun testing medicines on these heart cells to see if we can get them to work better. We plan in the future to identify new medicines to test any new medicines we identify on mice that have been made to mimic the disease. We are very hopeful that by the end of this project we will have come up with new ways for helping patients with this deadly disease.
  • The goal of our project is use stem cells to help identify new drugs for the treatment of Danon Disease, a rare, inherited disease that causes severe heart disease. Patients with Danon disease generally die in the second and third decade of life of heart failure. We have been working on this project for roughly two yeara. Since starting we have developed over 7 stem cell lines from patients with Danon Disease. We have used these stem cells to make heart cells and have screened hundreds of drugs on these cells. We have identified several drugs using this system that show some promise and are undergoing more rigorous testing. We have also begun working with mice that have been genetically engineered to model Danon disease. We hope that these mice can be used to test out the new drugs we have identified using our stem cell screens.
Funding Type: 
Early Translational III
Grant Number: 
TR3-05626
Investigator: 
Type: 
PI
ICOC Funds Committed: 
$4 939 140
Disease Focus: 
Heart Disease
Stem Cell Use: 
Adult Stem Cell
oldStatus: 
Active
Public Abstract: 

An estimated 16.3 million Americans suffer from coronary heart disease. Every 25 seconds, someone has a coronary event and every minute, someone dies from one. Treatment for coronary heart disease has improved greatly in recent years, yet 1 in 6 deaths in the US in 2007 was still caused by this terrible disease. Stem cells have been used as an supplemental form of treatment but they have been most effective for patients treated immediately after their first heart attack. Unfortunately, stem cell therapy for chronic heart disease and heart failure has been less successful. With current delivery methods for stem cells into the heart, most are washed away quickly, whereas our device will hold them in the area that needs repair. With this project we are testing a novel approach to improve the benefits of stem cell therapy for patients suffering from chronic heart disease. By applying a type of bone marrow stem cells known to enhance tissue repair (mesenchymal stem cells) to a biological scaffold, we hope to greatly amplify the beneficial properties of both the stem cells and the biological scaffold. This device will be implanted onto an appropriate preclinical model that have been treated so as to mirror the chronic heart disease seen in humans. We predict that this novel device will heal the damaged heart and improve its function to pave the way for a superior treatment option for the thousands of Americans for whom the unlikely prospect of a heart transplant is currently the only hope.

Statement of Benefit to California: 

Heart disease is the number one cause of death and disability in California and in the US as a whole. An estimated 16.3 million Americans over the age of 20 suffer from coronary heart disease (CHD) with an estimated associated cost of $177.5 billion and CHD accounted for 1 in 6 deaths in the US in 2007. Advances in treatment have decreased early mortality but consequently lead to an increase in the incidences of heart failure (HF). Patients with HF have a 50 percent readmission rate within six months, which is a heavy cost both in terms of quality of life and finances. The high cost of caring for patients with HF results primarily from frequent hospital readmissions for exacerbations. The need for efficient treatment strategies that address the underlying cause, massive loss of functional myocardium, is yet to be met. We believe that present project proposal, development of a combined mesenchymal stem cell and extra cellular matrix scaffold device, will lead to improved standards of care for patients suffering from chronic myocardial infarction who are thus at risk of developing HF. By not only retarding disease progression but by actually restoring cardiac function, we believe that the proposed project will have a tremendous impact on both the cost of care as well as the quality of life for large groups of Californians and patients worldwide for whom the improbable prospect of heart transplantation is the only curative treatment option available.

Progress Report: 
  • Heart disease is a major cause of death and disability in the US, accounting for 1 in every 4 deaths and costing more than 100 billion annually. While significant improvements have been made towards treating and managing heart disease, we are still not able to effectively return the heart to a healthy state and cure the patients. With our project we have set out to develop a novel strategy for not only halting the disease progression but to reverse the devastating effect on the function of the heart. By combining bone marrow mesenchymal stromal cells with a biological scaffold material, we hope to create a patch for the heart that will support and regenerate the diseased tissue to the point where the patient will be relieved of the burden of their disease and have a markedly improve quality of life. We have in the past year made significant advances toward establishing an animal disease model in which we can study novel ways of treating heart disease. We have in the same time isolated and characterized cells that reside in the bone marrow and that have the potential to heal the diseased tissue by improving blood flow, minimize scarring and generally promoting recovery of the heart function. We have studies these cells under when grown under different conditions and found their ability to mediate tissue regeneration to be highly dependent on their local environments. We are currently trying to identify the optimal combination of cells and microenvironment that may achieve maximal regenerative effect in our disease model and ultimately help our patient combat their heart disease.
  • Cardiovascular diseases remain the leading cause of death and disability in the United States. Even with optimal intervention, patients that suffer from an initial coronary event are prone to development of ischemic heart disease (IHD). Current therapies for IHD such medication, percutaneous coronary intervention, anticoagulants, and coronary artery bypass grafting are incapable of rescuing necrotic tissue and recovering normal cardiac function. The only current curative therapy is heart transplantation; however donor organ supply is severely limited and the vast majority of patients die from congestive heart failure while on the transplant waiting list.
  • Cellular therapies are being explored as a potential cure for IHD. In the majority of these trials, cells are injected in suspension into either vasculature or directly into the ischemic myocardium. Clinical outcomes have clearly demonstrated the safety of these cell based therapies. However, clinical improvements have been modest at best, ostensibly due to poor long term donor cells survival and retention.
  • Mesenchymal stem cells (MSCs) are an attractive allogeneic stem cell source for cardiac regenerative therapies. MSCs are considered to be immunoprivileged in that they modulate and evade the host immune microenvironment, thus making them ideal candidates for allogeneic transplantation. MSCs also facilitate regeneration by secreting angiogenic and chemotactic factors that facilitate new blood vessel formation and recruitment of host stem and progenitor cells.
  • Porcine small intestinal submucosa extracellular matrix (SIS-ECM) is a bioscaffold produced from the small intestine of pigs. It has been found to exert a variety of beneficial pro-regenerative functions, hereunder modulating the chemotactic and immune response and releasing large amounts of pro-angiogenic factors. SIS-ECM is ideal in surgical applications as a replacement for synthetic materials in that it facilitates site specific regeneration and resorbs into native tissue without a need for later removal.
  • The overall goal of this project is to generate a MSC seeded SIS-ECM device for the treatment of IHD. The hypothesis is that the combination of MSCs and SIS-ECM will produce a device with regenerative properties that exceed either component alone. We will with this project develop a porcine myocardial infarct (MI) model that mimics the hallmarks of the human disease. We will then test the proposed device in this model and monitor functional improvement as compared to control animals and animals receiving cells or SIS-ECM alone. We will also verify in vitro that human and porcine MSCs are phenotypically and functionally equivalent to confirm that the results obtained in our porcine model are relevant for the human setting with a high probability. Finally, we will explore mechanisms of action in vitro in relevant assay and in vivo in rat myocardial infarct models.
  • Major accomplishments in this reporting period:
  • 1. We successfully established a reproducible porcine chronic MI model (CMI) and an acute myocardial infarct (AMI) model. We tested two routes of delivery, epicardial patch and intramyocardial injection. We also optimized orientation and seeding density of the device as well as telemetry implantation in a non-injury porcine sternotomy model. We conclude that the CMI model is well suited for the upcoming studies where we will transplantation our device as an epicardial patch with the MSC seeded side facing the epicardium and seeded below maximal capacity to be the favored approach.
  • 2. We found that MSCs from human and porcine bone marrow samples can readily be isolated, expanded and banked using identical methodology. We created master cell banks from three donors for each species. We additionally generated working cell banks of eGFP and Luciferase overexpressing MSCs for both species. We furthermore confirmed, again using identical methodology that both human and porcine MSCs are analogous with respect to tri-lineage potential, cells surface marker expression and karyotype. Moreover, these major MSC hallmarks are not altered in response to seeding onto SIS-ECM. Finally, we are completing similar studies for rat MSCs
  • 3. We have confirmed that human and porcine MSCs are analogous in the expression pattern of angiogenic factors. We also found that the migratory effect of culture supernatants from human or porcine MSCs seeded onto plastic or SIS-ECM is comparable. Additionally, we found that secretion levels of inflammatory cytokines and in vitro tube formation from culture supernatant was comparable for human MSCs seeded on plastic or SIS-ECM. We furthermore established an AMI model in both immune competent and immune deficient rats. Using these models we have demonstrated significant disease modifying effects of the rat DC analogue as compared to SIS-ECM or MSCs alone. Finally we found improved cell retention at the site of implant for our human DC in the immune deficient SCID rat AMI model.
Funding Type: 
Disease Team Therapy Planning I
Grant Number: 
DR2-05394
Investigator: 
Institution: 
Type: 
PI
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.
Funding Type: 
Disease Team Therapy Planning I
Grant Number: 
DR2-05434
Investigator: 
Institution: 
Type: 
PI
ICOC Funds Committed: 
$106 239
Disease Focus: 
Heart Disease
oldStatus: 
Closed
Public Abstract: 

This application seeks to bring to the clinic a new treatment for myocardial disease based on human embryonic stem cell (hESC) derived cardiomyocytes. hESC-cardiomyocytes have the unique potential to address the underlying cause of heart disease by repopulating areas of damaged myocardium (heart tissue) with viable cardiac cells. This therapeutic approach represents a potential breakthrough in heart disease treatment, serving one of the most intractable, largest, and most costly unmet clinical needs in the U.S.

Currently available heart disease treatments have demonstrated ability to slow progression of the disease, but to date none can restore the key underlying defect in heart failure, a loss of contractile function. Cell therapy approaches have generated excitement for their unique potential to play a curative role in myocardial disease through the restoration of lost contractile and/or circulatory function. hESC-cardiomyocytes are unique amongst the cell therapy approaches in that they are a human cardiomyocyte (heart muscle cell) product; replacing damaged myocardium with viable heart cells which can integrate and form fully functional cardiac tissue. This approach has the potential to significantly halt or reverse cardiac functional decline. These benefits can significantly impact patient medication requirements and hospitalizations associated with ongoing cardiac decline, key drivers of the enormous health care costs associated with heart failure.

The proposed scope of this project includes activities leading up to and including a regulatory filing with the FDA to initiate clinical testing of hESC-cardiomyocytes for the treatment of heart failure, as well as the enrollment and initial follow-up of a small cohort of patients in a first-in-human trial. The proposed product has completed extensive process development, product characterization, and preclinical (animal model studies) proof-of-concept studies to date. The scope of the proposed research includes: (i) performance of key preclinical safety and efficacy studies to enable entry to clinical testing (ii) manufacture of material for use in preclinical studies, development work, and clinical testing (iii) development and qualification of assays for product characterization, and (iv) preparation for and execution of initial clinical studies.

Statement of Benefit to California: 

The proposed project has the potential to benefit the state of California through 1) providing improved medical outcomes for patients with heart disease, 2) increasing California’s leadership in the emerging field of stem cell research, and 3) preserving and creating high quality, high paying jobs for Californians.

Heart disease is one of the most intractable, wide-spread, and fatal diseases in the U.S. More than 5.8 million Americans currently suffer from heart failure; close to 60% of heart failure patients die within 5 years of diagnosis. Although specific statistics are not available for California, they are likely similar to those nationwide, with incidence of more than 10 in 1000 individuals >65 years of age (AHA, 2010). Currently available heart disease therapies have demonstrated the ability to slow disease progression, but to date none can restore the key underlying defect leading to heart failure, a loss of cardiac contractile function. Cell therapy, an approach to regenerate or repair the damaged heart with new cells, addresses this fundamental need, and is considered one of the most important and promising frontiers for the treatment of heart disease. Although multiple other cell therapy products are currently being evaluated for the treatment of heart disease, human embryonic stem cell derived cardiomyocytes have unique potential to address the underlying defect of loss of contractile activity in heart failure, by replacing scarred or damaged heart tissue with new, functional human heart cells to restore cardiac function.

California has a history of leadership in biotechnology, and is emerging as a leader in the development of stem cell therapeutics. Cutting edge stem cell research, in many cases funded by CIRM, is already underway in academic research laboratories and biotechnology companies throughout the state. The proposed project has the potential to further increase California’s leadership in the field of stem cell therapeutics through the performance of the first clinical testing of an hESC-derived cardiac cell therapy.

The applicant has been located in California since its inception, and currently employs nearly 200 full-time employees at its California headquarters with more than 50% of employees holding an advanced degree. These positions are highly skilled positions, offering competitive salaries and comprehensive benefits. The successful performance of the proposed project would enable significant additional jobs creation as the program progresses through more advanced clinical testing.

Funding Type: 
Disease Team Therapy Planning I
Grant Number: 
DR2-05423
Investigator: 
Name: 
Type: 
PI
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.
Funding Type: 
Basic Biology III
Grant Number: 
RB3-05129
Investigator: 
Name: 
Institution: 
Type: 
PI
ICOC Funds Committed: 
$1 425 600
Disease Focus: 
Heart Disease
Stem Cell Use: 
iPS Cell
Cell Line Generation: 
iPS Cell
oldStatus: 
Active
Public Abstract: 

Familial hypertrophic cardiomyopathy (HCM) is the leading cause of sudden cardiac death in young people, including trained athletes, and is the most common inherited heart defect. Until now, studies in humans with HCM have been limited by a variety of factors, including variable environmental stimuli which may differ between individuals (e.g., diet, exercise, and lifestyle), the relative difficulty in obtaining human cardiac samples, and inadequate methods of maintaining human heart tissue in cell culture systems. Cellular reprogramming methods that enable derivation of human induced pluripotent stem cells (hiPSCs) from adult cells, which can then be differentiated into cardiomyocytes (hiPSC-CMs), are a revolutionary tool for creating disease-specific cell lines that may lead to effective targeted therapies.

In this proposal, we will derive hiPSC-CMs from patients with HCM and healthy controls, then perform a battery of functional and molecular tests to determine the presence of cardiomyopathic disease and associated abnormal molecular programs. With these preliminary studies, we believe hiPSC-CMs with HCM phenotype will dramatically enhance the ability to perform future high-throughput drug screens, evaluate gene and cell therapies, and assess novel electrophysiologic interventions for potential new therapies of HCM. Because HCM is not a rare disease but rather the leading cause of inherited heart defects, we believe the findings here should have broad clinical and scientific impact toward understanding the molecular and cellular basis of HCM.

Statement of Benefit to California: 

Familial hypertrophic cardiomyopathy (HCM) is the leading cause of sudden cardiac death in young people and is the most common inherited heart defect. In this study, we will generate hiPSC-derived cardiomyocytes from patients with HCM, then perform a number of functional, molecular, bioinformatic, and imaging analyses to determine the extent and nature of cardiomyopathic disease. We believe hiPSC-CMs with HCM phenotype will dramatically enhance the ability to perform future high-throughput drug screens, evaluate gene and cell therapies, and assess electrophysiologic interventions for potential novel therapies of HCM. The experiments outlined are pertinent and central to the overall mission of CIRM, which seeks to explore the use of stem cell platforms to yield novel mechanistic insights into the molecular and cellular basis of disease. Because HCM is not an orphan disease, but rather the leading cause of sudden cardiac death in young people, we believe the research findings will benefit the state of California and its citizens.

Progress Report: 
  • Familial hypertrophic cardiomyopathy (HCM) is the leading cause of sudden cardiac death in young people, including trained athletes, and is the most common inherited heart defect. In this proposal, we will generate human induced pluripotent stem cell-derived cardiomyocytes (iPSC-CMs) from patients with HCM. The specific aims are as follow:
  • Specific Aim 1: Generate iPSCs from patients with HCM and healthy controls.
  • Specific Aim 2: Determine the extent of disease by performing molecular and functional analyses of hiPSC-CMs.
  • Specific Aim 3: Rescue the molecular and functional phenotypes using zinc finger nuclease (ZFN) technology.
  • Over the past year, we have now derived iPSCs from a 10-patient family cohort with the MYH7 mutation. Established iPSC lines from all subjects were differentiated into cardiomyocyte lineages (iPSC-CMs) using standard 3D EB differentiation protocols. We found hypertrophic iPSC-CMs exhibited features of HCM such as cellular enlargement and multi-nucleation beginning in the sixth week following induction of cardiac differentiation. We also found hypertrophic iPSC-CMs demonstrated other hallmarks of HCM including expression of atrial natriuretic factor (ANF), elevation of β-myosin/α-myosin ratio, calcineurin activation, and nuclear translocation of nuclear factor of activated T-cells (NFAT) as detected by immunostaining. Blockade of calcineurin-NFAT interaction in HCM iPSC-CMs by cyclosporin A (CsA) and FK506 reduced hypertrophy by over 40%. In the absence of inhibition, NFAT-activated mediators of hypertrophy such as GATA4 and MEF2C were found to be significantly upregulated in HCM iPSC-CMs beginning day 40 post-induction of cardiac differentiation, but not prior to this point. Taken together, these results indicate that calcineurin-NFAT signaling plays a central role in the development of the HCM phenotype as caused by the Arg663His mutation.
  • Familial hypertrophic cardiomyopathy (HCM) is the leading cause of sudden cardiac death in young people, including trained athletes, and is the most common
  • inherited heart defect. In this proposal, we will generate and characterize human induced pluripotent stem cell-derived cardiomyocytes (iPSC-CMs) from patients with HCM. The
  • specific aims are as follow:
  • Specific Aim 1: Generate iPSCs from patients with HCM and healthy controls.
  • Specific Aim 2: Determine the extent of disease by performing molecular and functional analyses of hiPSC-CMs.
  • Specific Aim 3: Rescue the molecular and functional phenotypes using zinc finger nuclease (ZFN) technology.
  • Over the past year, we have characterized the pathological phenotypes from iPSCs derived from a 10-patient family cohort with the MYH7 mutation.
  • We've differentiated all stablished iPSC lines from all subjects into cardiomyocyte using a modified protocol from that published by Palacek in PNAS 2011. This protocol increased the yield of cardiomyocytes significantly to consistently greater than 70% beating cardiomyocytes. We then tested the electrophysiological properties of iPSC-CMs from control and patients with HCM and found that both control and patient iPSC-CM display atrial, ventricular and nodal-like electrical waveforms by whole cell patch clamping. However, by day 30, a large subfraction (~40%) of the HCM iPSC-CM exhibit arrhythmic waveforms including delayed after-depolarizations (DADs) compared with control (~5.1%). In addition we found that treatment of HCM hiPSC-CM with positive inotropic agents (beta-adrenergic agonist - isoproterenal) for 5 days caused an earlier increase in cell size by 1.7 fold as compared to controls and significant increase in irregular calcium transients. Furthermore, we found that HCM iPSC-CMs exhibited frequent arrhythmia due to their increased intracellular calcium level by 30% at baseline. These HCM iPSC-CM also exhibited decreased calcium release by the sarcoplasmic reticulum. These findings emphasize the role of irregular calcium recycling in the pathogenesis of HCM. To confirm that the regulation of myocyte calcium is the key to HCM pathogenesis, we treated several lines from multiple HCM patients with calcium channel blocker (verapamil/diltiazem) and found that this treatment significantly ameliorated all aspects of the HCM phenotype including myocyte hypertrophy, calcium handling abnormalities, and arrhythmia. These finding supports the use of calcium channel blockers in patients with HCM and encourages further clinical studies in HCM patients using these agents.
  • Familial hypertrophic cardiomyopathy (HCM) is the leading cause of sudden cardiac death in young people, including trained athletes, and is the most common
  • inherited heart defect. In this proposal, we will generate human induced pluripotent stem cell-derived cardiomyocytes (iPSC-CMs) from patients with HCM. The
  • specific aims are as follow:
  • Specific Aim 1: Generate iPSCs from patients with HCM and healthy controls.
  • Specific Aim 2: Determine the extent of disease by performing molecular and functional analyses of hiPSC-CMs.
  • Specific Aim 3: Rescue the molecular and functional phenotypes using zinc finger nuclease (ZFN) technology.
  • Over the past year, we have characterized iPSC-CMs from a 10-patient family cohort with the MYH7 mutation using standard 3D EB differentiation protocols.
  • We found normal and hypertrophic iPSC-CMs were predictive as in vitro model for arrhythmia screening using microelectroarrays and single cell patch-clamping
  • analysis. For example, we found that administration of catecholamine drug norepinephrine causes the formation of torsade de point which is a lethan arrhythmia.
  • This recapitulates the phenotype in patients with HCM receiving catecholamine drugs. We also found increase in torsade formation when the iPSC-CMs are treated
  • with hERG blockers that are also known to cause increases in arrhythmia in HCM patients. We believe the use of hiPSC-CM from healthy individuals and patients with
  • genetic heart disease can help predict the potential arrhythmic risk in existing or new drug agents that are undergoing FDA evaluation.
  • We have also generated HCM mutations in lines of normal iPSC to determine whether these mutant lines will exhibit HCM phenotype. This would satisfy the Koch's postulate
  • with regards to the role of the mutant DNA sequence on HCM manifestation. We found, using TALEN and piggyBac transposon technologies that genome edited can be generated
  • to carry R663H mutation in the MYH7 gene and that these genome edited iPSC-CM recapitulated the HCM phenotype associated with the R663H mutation such as sarcomere
  • disassembly and intracellular calcium abnormalities as well as contractile arrhythmias. We have also corrected mutant HCM human iPSC from patients with MYH7 R663H mutation
  • and show that these corrected iPSC-CM exhibit normal sarcomeric phenotype with smaller cell size and reduced calcium transient irregularities.
Funding Type: 
Basic Biology III
Grant Number: 
RB3-05103
Investigator: 
Type: 
PI
ICOC Funds Committed: 
$1 341 955
Disease Focus: 
Heart Disease
Pediatrics
Stem Cell Use: 
iPS Cell
Cell Line Generation: 
iPS Cell
oldStatus: 
Active
Public Abstract: 

Heart disease is the number one cause of death and disability in California and in the United States. Especially devastating is Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC), an inherited form of heart disease associated with a high frequency of arrhythmias and sudden cardiac death in young people, including young athletes, who despite their appearance of health are struck down by this type of heart disease. Even though it is inherited, early detection is hindered because people carrying the genetic code have highly variable clinical symptoms, making ARVC and catastrophic cardiac events very hard to predict and avoid. Evidence suggests that this heart disease is caused by mistakes in the genetic code essential for holding the mechanical integrity of heart muscle cells together or cell junctions. What is missing is an understanding of the basic biology of these heart muscle cell junctions in humans and appropriate human model systems to study their dynamics in heart disease, which is important since other heart diseases also share some of these same heart cell defects. Our goal is to understand the basic biology of how human heart muscle cell junctions mature and what happens in disease, by studying ARVC. Human iPS cells are a unique population of stem cells from our own tissues, such as skin, that have the same genetic information as the rest of our bodies. Thus, hiPS from people who carry the ARVC heart disease mistakes can be used in our laboratory to provide a true human model of that disease. We will generate heart muscle cells from hiPS from normal and ARVC donors that carry mistakes in the genetic code for cell junction components. We have identified new pathways that may be important causes of ARVC, thus we will also use our hiPS lines, to confirm whether these new pathways are truly important in human ARVC disease progression and if our approaches reverse disease progression. Characterization of our hiPS derived heart cells can also be exploited for translational medicine to predict an individual's heart cell response to drug treatment and provides a promising platform to identify new drugs for heart diseases, such as ARVC, which are currently lacking in the field. Recent advances in stem cell biology have highlighted the unique potential of hiPS to be used in the future as a source of cells for cell-based therapies for heart disease. However, prior to clinical application, a detailed understanding of the basic biology and maturation of these hiPS into heart muscle cells is required. Our studies seek to advance our understanding of how cell-cell junctions mature in hiPS and highlight tools that influence the microenvironment of the hiPS in a dish, to accelerate this process. This knowledge can also be exploited in regenerative medicine to achieve proper electromechanical integration of cardiac stem cells when using stem cells for heart repair, to improve longterm successful clinical outcomes of cardiac stem cell therapies.

Statement of Benefit to California: 

Heart disease is the number one cause of death and disability within the United States and the rates are calculated to be even higher for citizens of the State of California when compared to the rest of the nation. These diseases place tremendous financial burdens on the people and communities of California, which highlights an urgency to understand the underlying molecular basis of heart diseases as well as find more effective therapies to alleviate these growing burdens. Our goal is to improve heart health and quality of life of Californians by generating human stem cell models from people with an especially devastating form of genetic heart disease that affects young people and results in sudden cardiac death, to improve our molecular and medical understanding of how cardiac cells go wrong in the early stages of heart disease in humans. We will also test current drugs used to treat heart disease and new candidate pathways, that we have uncovered, to determine if and how they reverse and intervene with these defects. We believe that our model systems have tremendous potential in being used to diagnose, test an individual's heart cell's response to drug treatment, as well as predict severity of symptoms in heart diseases at an early stage, to monitor drug treatment strategies for the heart. We believe our studies also have a direct impact on regenerative medicine as a therapy for Californians suffering from heart disease, since data from our studies can identify ways to improve cardiac stem cell integration into the diseased heart when used for repair, as a way to improve long-term successful clinical outcomes of cardiac stem cell therapies. We also believe that our development of multiple human heart disease stem cells lines with unique genetic characteristics could be of tremendous value to biotechnology companies and academic researchers interested in large scale drug screening strategies to identify more effective compounds to rescue defects and treat Californians with heart disease, as well as provide important economic revenue and resources to California, which is stimulated by the development of businesses interested in developing these therapies further.

Progress Report: 
  • Heart disease is the number one cause of death and disability in California and in the United States. Especially devastating is Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC), an inherited form of heart disease associated with a high frequency of arrhythmias and sudden cardiac death in young people, including young athletes, who despite their appearance of health are struck down by this type of heart disease. Even though it is inherited, early detection is hindered because people carrying the genetic code have highly variable clinical symptoms, making ARVC and catastrophic cardiac events very hard to predict and avoid. Evidence suggests that this heart disease is caused by mistakes in the genetic code essential for holding the mechanical integrity of heart muscle cells together or cell junctions. What is missing is an understanding of the basic biology of these heart muscle cell junctions in humans and appropriate human model systems to study their dynamics in heart disease, which is important since other heart diseases also share some of these same heart cell defects. Our goal is to understand the basic biology of how human heart muscle cell junctions mature and what happens in disease, by studying ARVC. Human iPS cells are a unique population of stem cells from our own tissues, such as skin, that have the same genetic information as the rest of our bodies. Thus, hiPS from people who carry the ARVC heart disease mistakes can be used in our laboratory to provide a true human model of that disease. During the first year of our grant, we have enrolled sufficient numbers of normal and ARVC donors into our study. We have collected skin biopsy tissues from donors as means to generate hiPS cells. Our results show that hiPS cell lines can be efficiently generated from both normal and ARVC donors and we have extensively characterized their profiles, such that we know they are bona fide stem cell lines and can be used as a model system to dissect defects in cardiac cell junction biology between these various different hiPS lines. We have also developed efficient and robust methodologies to generate heart muscle cells from hiPS from normal and ARVC donors that carry mistakes in the genetic code for cell junction components and are now in the midst of characterizing their molecular, genetic, biochemical and functional profiles to identify features in these cells that are unique for ARVC. Through our previous studies, we identified new pathways that may be important causes of ARVC, thus we will also use our hiPS lines, to confirm whether these new pathways are truly important in human ARVC disease progression and if our approaches reverse disease progression. Towards this goal, we have generated novel tools to increase and decrease a component of this pathway in order to test these approaches and have preliminary data to show that these tools are efficient in altering levels of this component in heart muscle cells, which we are now applying towards understanding these pathways in hiPS derived heart muscle cells and reversing defects in heart muscle cells from ARVC hiPS derived lines. Based on our progress, we have met all of the milestones stated in our grant proposal and in some cases, surpassed some milestones. We believe progress over the next year, will allow us to define some of the key cellular defects in ARVC and advance our understanding of how cell-cell junctions mature in hiPS and highlight tools that influence the microenvironment of the hiPS in a dish, to accelerate this process.
  • Overall, we have been able to achieve the milestones proposed for Year 2 of the grant. We have generated a panel of control and ARVC hiPSC lines using integration-free based methods. We provide evidence of our method to generate robust numbers of hiPSC-derived cardiac cells that express desmosomal cell-cell junction proteins. We show ARVC lines that display disease symptom-specific features (adipogenic or arrhythmic), which phenocopy the striking and differential symptoms found in respective individual ARVC-patients as tools to study human ARVC. We also uncover desmosomal defects in hiPSC-derived cardiac muscle cells that underlie the disease features found in ARVC cells. We have also published two reviews in the field of cell-cell junctional remodeling and stem cell approaches that helps to further our understanding of this field in cardiomyocytes, that is relevant to human disease and our research using hiPS.
  • Overall, we have been able to complete the milestones proposed for our grant. We have generated a unique panel of control and ARVC hiPSC lines using integration-free methods. We provide evidence of our method to generate robust numbers of hiPSC derived cardiac cells that express key components of the cardiac muscle cell-cell junction include mechanical junctions and electrical junctions. We show that our ARVC hiPSC lines display disease symptom-specific features (adipogenic and arrhythmic), which phenocopy the striking and differential diagnosis observed in our ARVC donor hearts and provide a platform to study the varying disease features underlying ARVC. We uncover novel and classic molecular and ultrastructural defects underlying the arrhythmogenic defects in our ARVC hiPSC lines that mimic the gradation in disease severity observed in ARVC donor hearts. We exploit conventional ARVC drugs to determine their impact on arrhythmogenic behavior and reversibility of phenotypes in our cells. We have published 4 articles in the field of cell-cell junction remodeling, protein turnover and stem cell approaches that further our understanding of this field in cardiac muscle cells as well as filed a provisional patent application on the use of a novel drug discovery system for fat arrhythmogenic disorders that exploit the genetic diversity and clinical features observed in our ARVC lines.

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