Research progress in autologous cardiac stem cell transplantation for treatment of ischemic cardiomyopathy

doi:10.3969/j.issn.2095-4344.2013.19.026

Abstract

Abstract:

BACKGROUND: Drugs, interventional or surgical treatment cannot fundamentally solve the loss of myocardial cells after ischemic infarction. Many studies have shown that autologous cardiac stem cells transplantation for treatment of ischemic cardiomyopathy is safe and feasible, and it can produce the neonatal cardiac myocytes, reduce the size of infarct scar, inhibit the ventricular remodeling and improve cardiac function. At present, autologous cardiac stem cells transplantation for treatment of ischemic cardiomyopathy has entered clinical trials.
OBJECTIVE: To summarize the research progress of autologous cardiac stem cells transplantation for treatment of ischemic cardiomyopathy at home and abroad in recent years.
METHODS: The first author retrieved PubMed database and China Academic Journal article from January 1998 to April 2012 using computer. The key words were “autologous, cardiac stem cells, ischemic cardiomyopathy, transplantation, treatment”. We retrieved 82 articles, and 57 articles were included in the review.
RESULTS AND CONCLUSION: Transplantation of cardiac stem cells derived from autologous heart tissue to the ischemic infarction region of the heart can differentiate and generate new cardiomyocytes as well as endothelial cells, inhibit ventricular remodeling, and improve cardiac regional systolic and diastolic function. Transplantation of autologous cardiac stem cells provides a new therapeutic approach for the treatment of ischemic cardiomyopathy. Compared to other sources of stem cells, transplantation of autologous cardiac stem cells for treatment of ischemic cardiomyopathy has higher clinical value.

Key words: stem cells, stem cell academic discussion, autologous, cardiac stem cells, transplantation, schemic cardiomyopathy, myocardial infarction, treatment, ventricular reconstruction, immunogenicity, immunological rejection, research progress

CLC Number:

R318

Hou Hong, Lü An-lin, Hou Jing, Liu Bo-wu, Da Jing, Hou Zhao-lei, Yang Na. Research progress in autologous cardiac stem cell transplantation for treatment of ischemic cardiomyopathy[J]. Chinese Journal of Tissue Engineering Research, 2013, 17(19): 3589-3595.

Figures/Tables 1

2.1 影响心脏干细胞数量的因素从心脏获得治疗量的心脏干细胞是实现自体心脏干细胞移植治疗的关键。动物实验和临床试验结果均显示急、慢性心肌梗死、终末期心力衰竭的心脏和健康心脏一样都含有心脏干细胞[23-24]。但疾病的类型与心脏干细胞数量关系没有统一的认识。一种观点认为冠状动脉疾病和慢性缺血性疾病不会影响心脏中心脏干细胞的数量[25]；另一种观点支持慢性缺血性心肌病患者的心脏干细胞的数量会减少[26]。Itzhaki-Alfia等[27]的研究提示23-80岁心脏病患者的心脏都存在c-kit+/Lin-心脏干细胞。Mishra等[28]的实验显示随着年龄增加心脏干细胞的数量会逐步减少，再生能力降低。但是Kajstura等[29]的研究却提出：年龄不是心脏干细胞量和功能的主要决定因素，这可能与心脏干细胞在心脏中的特殊存在环境——心肌巢相关[30]。Itzhaki-Alfia等[27]和Kajstura等[31]的研究显示，女性心脏较男性心脏拥有更多的心脏干细胞。大量实验均显示从不同年龄段缺血性心肌病患者心脏均能有效的分离培养出治疗量的心脏干细胞。 2.2 心脏干细胞的来源与分布关于心脏干细胞的来源，Quaini等[32]通过性别错配心脏移植的实验研究，认为心脏干细胞来源于骨髓。但是随着研究的进一步深入，大量的实验结果显示心脏干细胞来自心脏，心脏干细胞巢是心脏干细胞来自心脏有力的证据[21]。心脏干细胞存在于在心房、心室、房室沟[33]、心耳[10]、心外膜[34]。但分布不均匀，分布位置与组织所受压力成反比[35]，心房多于心室[36]。Itzhaki-Alfia等[27]的研究显示从患病右心耳分离出来的c-kit+心脏干细胞多于心脏其他部位。 2.3 心脏干细胞的分离、培养、纯化、扩增心脏干细胞的分离：如何安全获取用于分离、培养心脏干细胞的心脏组织是临床应用主要难题。目前主要包括外科手术法和经皮心内膜心肌活检法。外科手术方法是心脏手术时获取心脏组织，最常获取的是右心耳组织，因右心耳组织容易获得，相对安全，c-kit+/Lin-心脏干细胞含量较多[27]。但是，开胸创伤较大，仅限于必须手术的患者，适应性有限。经皮心内膜心肌活检法技术在临床已广泛应用[24]，其创伤性小，安全性高，易于患者接受，不易受疾病类型的影响。不足之处是获得取的组织量相对比较少，但是随着分离、培养技术的改进，即使很少的组织量也能有效分离扩增获得治疗量的心脏干细胞[24]。心脏干细胞的培养、纯化：获取的心肌组织通过单细胞培养法、组织块培养法等均可培养出心脏干细胞[10，37]，但是获取的心脏干细胞数量都比较少，同时还混含有其他类型的细胞，必须经过进一步纯化、扩增才能满足临床治疗。传统的纯化方法有传代法，通过多次传代去除杂质细胞，达到纯化、增殖目的，但是这种方法获得的纯度有限，一般可把心脏干细胞纯度提高到10%-40%[10]。目前临床常用的纯化方法有：通过用流式细胞分析仪分选纯化法和免疫磁珠分选纯化法，SCIPIO试验中经过免疫磁珠分选法[27，38-39]，c-kit+心脏干细胞纯化达75%-98%。心脏干细胞的扩增：心脏干细胞快速扩增到治疗量也是临床应用的一大难题。目前有许多的方法可以使心脏干细胞快速增殖，例如，在培养基中加入各种细胞因子，如碱性成纤维细胞生长因子、胰岛素样生长因子1；通过改变培养条件，如低氧(体积分数5%的O2)条件下培养(常规的细胞培养条件均为体积分数20%的O2)[25]；通过特定的培养过程，如“心肌球”的培养过程[40]，即可在短时间内获得大量纯度较高的心脏干细胞等等。 2.4 自体心脏干细胞的移植自体心脏干细胞的移植方法：目前，自体心脏干细胞移植的方法有2种，分别为经皮冠状动脉内输入移植法和开胸心肌层内注射移植法。经皮冠状动脉输入移植法操作相对比较简单，创伤小，适应性广，移植数量相对较多，移植后分布较均匀，但有发生栓塞的危险。已广泛应用于骨髓源性干细胞移植的动物和临床试验中[41]，是目前应用较多，移植效果较好的移植方法[42]，也是心脏干细胞最常用的移植方法[43]。开胸心肌层内注射移植法[44-45]。适用用于需要开胸手术的患者，创伤大，临床应用局限。但是可以直视下多点注射，避免血管输入发生栓塞的危险。可只在梗死周边区注射心脏干细胞，提高移植效率。因为Lee等[45]在猪的前临床实验中证实，开胸直视下心肌层内注射心脏干细胞24 h后，在梗死区内注射的细胞无存活，在梗死周边区和边远的正常心肌区注射的细胞存活率为8%-9%。此外，已经在临床中用于骨髓源性干细胞的移植的经皮心内膜穿刺移植法[46-47]，有待成为另一种安全、有效的自体心脏干细胞移植方法。同时人们也在尝试不同的移植方法，如通过其他的介质把心脏干细胞移植到受损的心脏区[48]。心脏干细胞自体移植的时机：自体心脏干细胞移植的时机也是备受关注的问题，大量动物实验显示：早期移植，干细胞易于迁移，移植后治疗效果好。但是从心脏组织中分离出心脏干细胞至少需要3周才能培养扩增到治疗量[49]。在前临床的动物实验中多选择在梗死后4周进行心脏干细胞移植[43]，因为此时心脏因缺血梗死后的自身修复基本结束，心脏结构功能趋于稳定。临床试验中一般选择在心脏干细胞增殖到治疗量后进行移植[39，50]。自体心脏干细胞的移植数量：因移植方法不同自体心脏干细胞的移植的数量也不同。Johnston等[43]动物实验显示CDCs经冠脉移植安全有效的输入剂量是1×107-2.5×107，临床合适输入剂量为3×105/kg，不能高于6.5×105/kg(-2.5×107)。SCIPIO和CADUCEUS临床试验均选用此范围剂量[39-50]；Lee等[45]开胸心肌内注射移植试验结果显示合适的CDCs注射剂量为0.5×107/注射点，总量不超过1×107。 2.5 心脏干细胞修复心脏的机制心脏干细胞修复心脏的机制主要有心脏干细胞直接分化机制和心脏干细胞旁分泌机制[43，51]。直接分化机制支持心脏干细胞移植到受损心脏后可以分化成心肌细胞、内皮细胞和平滑肌细胞，通过增加心脏功能细胞的数量，从而改善心脏功能。但是，许多的实验结果显示心脏干细胞分化的心肌细胞数量不足以替补心脏受损死亡的细胞数量，心脏功能的改善不能用心脏干细胞分化来解释，从而引出了心脏干细胞的旁分泌机制，此观点认为心脏干细胞移植到受损的心脏后除了能分化生成新的心脏细胞外，还能分泌出许多的细胞因子，如血管内皮生长因子、肝细胞生长因子、胰岛素样生长因子1、基质细胞衍生因子1、血管细胞黏附分子1等[52-54]，这些细胞因子有促进干细胞生存、分化、血管新生、抗凋亡的作用，同时能促进受损细胞的修复生存。多数实验结果显示心脏干细胞的旁分泌作用大于心脏干细胞的直接分化作用[55]。 2.6 自体心脏干细胞心脏干细胞移植治疗缺血性心肌病心脏干细胞具有定向心脏细胞分化趋势，致瘤率低；自体移植心脏干细胞不存在移植后免疫排斥反应和伦理问题；而且可以冻存，重复多次使用。这些特点使心脏干细胞更适合临床治疗。大量动物实验显示，无论是经冠状动脉移植或开胸直接心肌内注射治疗缺血性心肌病均能明显促进心肌细胞新生，使左心室质量增加，瘢痕减少，改善心脏收、舒张末期的容积，抑制心室重构、改善血流动力学和左室射血分数[17，56]。同时能够改善心室纤颤阈值，调节心脏电生理失常[57]。自体心脏干细胞移植治疗缺血性心肌病的Ⅰ期临床试验(SCIPIO和CADUCEUS)显示通过冠脉内移植自体心脏干细胞治疗缺血性心肌病是可行、安全的，并取得一定的临床疗效[39，50]。在SCIPIO试验中，冠状动脉内输入自体心脏干细胞的治疗组患者的左室射血分数显著提高，4个月后左室射血分数值从移植前的30.3%增加到38.5%(P=0.001)，1年后增加到42.5%，比基础值增加了12.2个单位[39]。对照组相同时间段左室射血分数从30.1%到30.20%(P=0.899)，无改变；同时4个月时间梗死面积较少24%。CADUCEUS临床试验显示，治疗组治疗6，12个月后瘢痕质量占左室质量从基础值24%分别减少7.7%(组内P < 0.000 1)、12.3%(组内P=0.001)，瘢痕减少可达50%以上[50]。对照组仅减少0.3%(组内P=0.89)，2.2%(组内P=0.452)，均无明显变化。自体心脏干细胞移植治疗缺血性心肌病的临床试验中都有心肌细胞生成，局部心脏收缩功能改善，这种改善甚至可以长达1年。但是左室射血分数增加和左室心腔大小变化并不一致，这有待于进一步的试验研究。"

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