人脐血单个核细胞移植治疗心肌梗死合并心力衰竭

doi:10.3969/j.issn.2095-4344.2014.50.012

摘要/Abstract

摘要：

背景：多项基础研究证实人脐血干细胞治疗急性心肌梗死合并心力衰竭安全有效，但目前尚未有该方法用于临床治疗的报道。
目的：观察人脐血单个核细胞移植治疗心肌梗死合并心力衰竭患者的远期疗效。
方法：入选2009年1月至2011年6月辽宁中医药大学心血管内科收治的心肌梗死合并心力衰竭患者共25例，其中12例患者冠脉造影后通过微导管将脐血单个核细胞悬液注入到冠状动脉远端，13例患者进行常规治疗。所有患者均规范应用药物治疗，急性期均行冠脉造影及经皮冠状动脉介入治疗。治疗前，治疗后12，24个月观察两组患者心功能改善情况，评价指标为左室射血分数、左室收缩末期容积及左室舒张末期容积。
结果与结论：与治疗前比较，移植组治疗后12，24个月左室射血分数显著增高，左室收缩末期容积、左室舒张末期容积显著降低(P < 0.05)。与治疗前比较，对照组治疗后12，24个月左室射血分数、左室收缩末期容积、左室舒张末期容积差异均无显著性意义(P > 0.05)。与对照组相比较，移植组各个时间点左室舒张末容积、左室收缩末容积均显著降低，左室射血分数增高(P < 0.05)。各随访期间均未发现相关不良事件发生。结果表明利用人脐血单个核细胞移植治疗心肌梗死合并心力衰竭，可显著改善患者心功能及左室重构情况。

中国组织工程研究杂志出版内容重点：干细胞；骨髓干细胞；造血干细胞；脂肪干细胞；肿瘤干细胞；胚胎干细胞；脐带脐血干细胞；干细胞诱导；干细胞分化；组织工程

全文链接：

关键词: 干细胞, 脐带脐血干细胞, 心肌梗死, 人脐血干细胞, 心力衰竭, 心功能, 左室重构

Abstract:

BACKGROUND: Increasing basic researches have confirmed that human umbilical cord blood stem cells is safe and effective to treat acute myocardial infarction complicated by heart failure, but this method is not yet available for clinical use.
OBJECTIVE: To observe the long-term effect of human umbilical cord blood mononuclear cell transplantation in the treatment of myocardial infarction combined with heart failure.
METHODS: Twenty-five patients with myocardial infarction and heart failure admitted in the Department of Cardiology, Affiliated Hospital of Liaoning University of Traditional Chinese Medicine, from January 2009 to June 2011 were randomly assigned to receive intracoronary transplantation of human umbilical cord blood mononuclear cells in addition to conventional therapy (transplantation group, n=12) or standard therapy (control group, n=13). All patients underwent standardized drug therapy, and coronary angiography and percutaneous coronary intervention were performed at acute phase. Improvement in heart function, left ventricular ejection fraction, left ventricular end-systolic volume and left ventricular end-diastolic volume at baseline and 12, 24 months after treatment were monitored.
RESULTS AND CONCLUSION: The left ventricular ejection fraction, left ventricular end-systolic volume and left ventricular end-diastolic volume were significantly improved 12, 24 months after human umbilical cord blood stem cell transplantation compared to baseline (P < 0.05), while these parameters remained unchanged in the control group (P > 0.05). Compared with the control group, the left ventricular ejection fraction was increased significantly, and the left ventricular end-systolic volume and left ventricular end-diastolic volume were reduced significantly in the transplantation group. During the follow-up, no side effects were observed. These findings indicate that human umbilical cord blood mononuclear cell transplantation leads to significant and longstanding improvements in left ventricular performance of patients with myocardial infarction and heart failure.

全文链接：

Key words: cord blood stem cell transplantation, myocardial infarction, heart failure, treatment outcome

中图分类号:

R394.2

于乐，张明. 人脐血单个核细胞移植治疗心肌梗死合并心力衰竭[J]. 中国组织工程研究, 2014, 18(50): 8103-8107.

Yu Le, Zhang Ming. Transplantation of human umbilical cord blood mononuclear cells for treatment of myocardial infarction with heart failure[J]. Chinese Journal of Tissue Engineering Research, 2014, 18(50): 8103-8107.

图/表（结果） 2

参考文献

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引言

INTRODUCTION

Heart failure is a common complication after myocardial infarction, mainly leading to high mortality in myocardial infarction. Myocardial infarction complicated by heart failure is at the end stage of heart disease, and it often indicates poor quality of life and prognosis of patients, which has increasingly become a major hazard to human health. Epidemiological surveys show that China has gradually entered the aging society, and the incidence of myocardial infarction has been increased year by year, which has become a heavy burden of social health resources. In recent years, stem cell therapy for myocardial infarction with clinical heart failure provides a new therapeutic strategy^[1-3]. Autologous bone marrow stem cells that are the most widely used for clinical studies have been confirmed to be safe and effective in clinical treatment. After treatment with autologous bone marrow stem cells, the left ventricular ejection fraction is increased by 5% to 8% on average, and during the treatment there are no significant adverse events. However, this therapy is limited clinically in the following aspects: there are fewer stem cells; the clinical results vary greatly; cell extraction and separation is difficult. Cord blood stem cells provide a new choice for stem cell transplantation. Compared with peripheral blood and bone marrow stem cells, incidences of acute and chronic graft-versus-host disease, mortality rate related to transplantation, and relapse rate are lower after cord blood stem cell transplantation. Cord blood stem cells that are easy to acquire

and have immune tolerance attach more and more attentions. This study investigated the long-term effect and safety of umbilical cord blood mononuclear cells in the treatment of myocardial infarction with heart failure.

中国组织工程研究杂志出版内容重点：干细胞；骨髓干细胞；造血干细胞；脂肪干细胞；肿瘤干细胞；胚胎干细胞；脐带脐血干细胞；干细胞诱导；干细胞分化；组织工程
全文链接：

材料方法

SUBJECTS AND METHODS

Design

A perspective, non-randomized, and controlled study.

Time and setting

The study was completed at the Department of Cardiology, Affiliated Hospital of Liaoning University of Traditional Chinese Medicine, from January 2009 to June 2011.

Subjects

Totally 25 patients with myocardial infarction accompanied by heart failure were enrolled at the Department of Cardiology, Affiliated Hospital of Liaoning University of Traditional Chinese Medicine, from January 2009 to June 2011. There were 10 cases of acute myocardial infarction and 15 cases of old myocardial infarction.

Diagnostic criteria for myocardial infarction

Acute myocardial infarction: When the levels of cardiac biomarkers (troponin I or creatine kinase) are greater than the upper limit of 99%, patients meet at least one of the following criteria: (1) two or more adjacent ST-segment elevation; (2) typical ischemic symptoms; (3) new left bundle branch block; (4) new pathological Q waves; (5) poor ventricular wall motion or activity loss shown on imaging studies.

Old myocardial infarction: Patients have been previously diagnosed with acute myocardial infarction, and the time of myocardial infarction is longer than 60 days.

Diagnostic criteria for heart failure

(1) Clinical symptoms of heart failure; (2) ejection fraction ≤ 40% on echocardiography.

Inclusive criteria

(1) Acute myocardial infarction or old myocardial infarction; (2) heart failure; (3) patients signed the informed consent.

Exclusion criteria

(1) Active infection; (2) previous or current history of cancer or other fatal diseases that can influence the short-term survival; (3) anemia (hemoglobin < 100 g/L) and coagulopathy; (4) unable to perform coronary angiography; (5) primary hemolytic disease; (6) the patient is determined to be at risk by an investigator in any case; (7) patients refuse to receive stem cell transplantation.

Methods

Grouping: All patients were divided into transplantation group (stem cell therapy, n=12) and control group (conventional therapy, n=13).

Conventional therapy: Patients in the two groups were subjected to antiplatelet, anticoagulant, β-blockers, ACEI or ARB, diuretics. These drugs had no impact on the results and conclusions.

Intervention: All patients were subjected to emergent coronary intervention with 12 hours of onset, for infarct-related revascularization.

Mononuclear cell extraction and collection method: All cord blood samples were collected from healthy pregnant women with term delivery at (38.5±1.57) weeks. The mean body weight of newborns was (3.82±0.26) kg. Cord blood samples were donated voluntarily, in line with medical ethics standards. Cord blood samples of 100-

200 mL were collected, and using cord blood stem cells/progenitor cells in vitro separation reagent developed by Walson, Canada and made in Ningxia Zhonglianda Company, the supernatant was separated after precipitation of red blood cells in cord blood to harvest umbilical cord blood mononuclear cells that were not cultured. The in vitro operating time of separation was about 2 hours. Flow cytometry was used for immunofluorescence detection, and the purity of mononuclear cells was ≥ 98%. Finally, there was 10-15 (12.5±1.78) mL of cord blood stem cell suspension.

Transplantation: Under sterile conditions, the radial artery or femoral artery access was established in the patients of transplantation group, which reached to the target vessels (infarct-related vessels) via guiding catheters. Then, the microcatheter was placed into the guiding catheter, and (1.72±0.84)×10⁸/L cord blood mononuclear cell suspension was infused via the microcatheter into the distal end of the coronary arteries.

Cardiac function assessment: Echocardiography was recorded at baseline, and at 12, 24 months after transplantation, and the cardiac function was assessed by the following indicators: left ventricular end-systolic volume, left ventricular end-diastolic volume and left ventricular ejection fraction.

Main outcome measures

Left ventricular end-systolic volume, left ventricular end-diastolic volume and left ventricular ejection fraction

Statistical analysis

The data were expressed as mean±SD and analyzed by SPSS 13.0 software. Intergroup and intragroup comparison was performed by t-test, and enumeration data were tested by chi-square test. A value of P < 0.05 was considered significant.

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讨论

DISCUSSION

It has been demonstrated that although the mechanism is not entirely clear, stem cell transplantation therapy can significantly improve cardiac function of patients with acute myocardial infarction complicated by heart failure. Therefore, stem cell transplantation still becomes one of the most promising therapeutic methods in this century^[1-5]. Howe to select the appropriate type of stem cells has always been one of the important topics to explore. Currently, multiple stem cell types are used in clinical studies, and autologous bone marrow stem cells are the most widely used in clinic^[5-10], but this type of stem cells is limited clinically because of the invasive collection method and lower stem cell content. Recently, new types of stem cells have been gradually used clinically. C-CURE study has shown that cardiac-derived stem cells for treatment of heart failure can significantly improve patient’s cardiac function^[11]. In addition, cord blood stem cells as a new type of stem cells have attracted and more clinical attentions. The cord blood is characterized as extensive source, easy to harvest, and no harm to maternal and child, which contains many stem cell populations expressing CD34⁺ and CD133⁺ surface antigens and has a high content of early stem cells that are undifferentiated. Because of primitive lymphocytes, many immature phenotypes, and relatively immature function, and low incidence of graft-versus-host disease incidence, umbilical cord blood stem cells become an ideal type of transplanted cells^[12-14].

Several basic studies have confirmed that umbilical cord blood stem cell transplantation may exert a role of myocardial regeneration and revascularization, thereby further reducing infarct size, improving ventricular remodeling and improving cardiac function^[15-22]. Rabald et al ^[18]infused umbilical cord blood mononuclear cells into myocardial infarction rats, and then these scholars found that new blood vessels formed in the infarcted myocardium and cardiac function was significantly improved after cell transplantation. After transplantation of cord blood CD34⁺ cells into rabbit’s infracted myocardial tissue, Hirata and co-workers discovered the new vessels in the infracted myocardium, and cord blood CD34⁺ cells were increased in number and differentiated into cardiomyocytes, thereby improving rabbit’s cardiac function. Leor et al ^[19] found that human umbilical cord blood mononuclear cells and CD133⁺ cells could survive in the rat heart, and promoted angiogenesis, which could improve heart function of myocardial infarction rats. Henning et al ^[20] isolated human unrestricted so-matic stem cells from the umbilical cord blood and then transplanted these cells into a porcine model of myocardial infarction. Researchers found that after transplantation, there were regenerated cardiac cells and new blood vessels, and local cardiac function and the whole left ventricular function were improved; moreover, there was no arrhythmia, tumor and rejection. These findings have confirmed the safety and effectiveness of transplantation of human unrestricted so-matic stem cells from the umbilical cord blood, and up to now, this study is the only pre-clinical study of cord blood stem cell transplantation in the treatment of myocardial infarction. Stem cell transplantation can promote angiogenesis, but the exact mechanism is not consistent. Various cytokines secreted from stem cells are thought to play an important role.

Currently, bone marrow stem cells and peripheral blood stem cells as transplanted cells are mostly used in clinic, but a low level of stem cells leads to varied therapeutic outcomes. At present, a variety of new stem cells are used clinically, such as cardiac-derived stem cells, adipose stem cells and umbilical cord blood stem cells. Our previous clinical studies have confirmed that umbilical cord blood stem cell transplantation exhibits good safety^[20], based on which, we further observe the clinical efficacy of umbilical cord blood stem cell transplantation. In the present study, the left ventricular ejection fraction was increased significantly, and the left ventricular end-systolic volume and left ventricular end-diastolic volume were significantly reduced in the transplantation at 12, 24 months after cell transplantation compared to the baseline (P < 0.05). However, there was no significant different in the above-mentioned indicators in the control group before and after treatment. Compared with the control group, the left ventricular ejection fraction was increased significantly by 7%-8%, and the left ventricular end-systolic volume and left ventricular end-diastolic volume were reduced significantly in the transplantation group at 12, 24 months after treatment (P < 0.05). No severe adverse effects were found during the transplantation and follow-up. These findings initially confirmed that human umbilical cord blood mononuclear cell transplantation in the treatment of myocardial infarction with heart failure is effective and safe, and the therapeutic effect may last for a long time.

Currently, there are still many problems about clinical application of human umbilical cord blood stem cells to be solved, such as the mechanism of action, the proper time of transplantation, specification of stem cell sources, suitable separation and extraction methods and migration pathways. In addition to the small sample size of this study, large-size samples are required to further confirm the efficacy and safety of human umbilical cord blood stem cell transplantation.