Heart Failure Clin 1 (2005) 303 312

Cell Therapy in Heart Failure

Otmar Pfister, MDa, Mohit Jain, MD, PhDb, Ronglih Liao, PhDa,*
a

Whitaker Cardiovascular Institute, Boston, MA, USA

b
Brigham and Womens Hospital, Boston, MA, USA

Loss of cardiomyocytes, a result of either ischemia

and necrosis after MI or programmed cell death (apoptosis) in hearts subjected to chronic hemodynamic
overload, remains central to the pathophysiology of
HF [1 3]. In contrast to other muscle tissue, such as
smooth muscle and skeletal muscle, the mitotic or
regenerative capacity of adult myocardial tissue is
limited, and therefore inadequate to compensate for
cell loss in acute and chronic cardiac injury.
Recent advances in stem cell research, notably the
discovery of stem cell populations with myogenic
and angiogenic potential, have prompted attempts to
regenerate lost myocardium and vasculature by stem
cell-based therapies [4 6]. This concept of cellular transplantation, or cellular cardiomyoplasty,
specifically addresses the underlying issue of cardiomyocyte loss, and therefore has the potential to
evolve into a promising new treatment strategy for
HF. This article discusses advantages and limitations of specific cell types proposed for cell therapy and gives an overview of the first clinical trials
using this novel therapeutic approach in patients who
have HF.

The nature of stem cells

Stem cell populations are defined by their potential for self-renewal, proliferation, and differentia-

This work was supported in part through National Institutes of Health Grants HL71775, HL67297, and HL73756.
* Corresponding author. Cardiac Muscle Research
Laboratory, Whitaker Cardiovascular Institute, Department
of Medicine, Boston University School of Medicine,
650 Albany Street, X-726, Boston, MA 02118.
E-mail address: rliao@bu.edu (R. Liao).

tion into functionally mature cells. Ideally, stem cells

should be capable of reconstituting a damaged organ,
as is the case for hematopoietic stem cells, which
have been used to reconstitute bone marrow function
after high-dose chemotherapies and radiation in leukemia patients. The flexibility of stem cells to differentiate into more than one specific type of mature
cell is termed plasticity.
A clear distinction exists between stem cells isolated from the embryo, known as embryonic stem
cells (ESCs), and stem cells isolated from adult somatic tissue, or adult stem cells. Within these two
groups, stem cells can be categorized further according to their tissue of origin and their plasticity. Totipotent stem cells are ESCs derived from the first
two cell divisions of the zygote. They have the potential to generate the full spectrum of differentiated
cell types in an organism, including trophoblastic
cells of the placenta. Cells derived from the inner cell
layer of the embryonic blastocyst have the potential
to give rise to cells of the three primary cell layers
(endoderm, ectoderm, and mesoderm) and are therefore considered pluripotent. Depending on their external milieu, adult stem cells produce a restricted
spectrum of tissue-specific progenies and thus are
termed multipotent. Stem cells are further subclassified according to cell surface marker expression or
immunophenotype, as described below.

Embryonic stem cells

ESCs are harvested from the inner cell mass of
the blastocyst [7]. To maintain ESCs in a prolonged
undifferentiated state, they must be kept on a feeder
layer usually consisting of embryonic or fetal fibroblasts. Removal of ESCs from the feeder layer ini-

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tiates the aggregation of embryoid bodies formed by

differentiated and undifferentiated cells of all three
primary germ layers. Further culture leads to differentiation into embryonic cell lines, including spontaneously beating cardiomyocytes and endothelial cells
[8]. Extensive studies of ESC-derived cardiomyocytes
have demonstrated the development of adult cardiomyocyte morphology, including properly organized
myofibrils and expression of gap junctions and
desmosomes [9,10]. Moreover, thorough electrophysiologic studies have identified distinct subpopulations among ESC-derived cardiomyocytes with
atrial-, ventricular-, and purkinje-like action potential
profiles [11].
Transplantation studies injecting mouse ESCderived cardiomyocytes into the infarct border zone
in mice and rats have shown consistently high engraftment rates, and a significant augmentation in
cardiac function and capillary density [12,13]. Nevertheless, the pluripotency of ESCs and the heterogeneity of ESC-derived cardiomyocytes also may have
undesirable effects, because tumorigenicity and local
teratoma formation have been reported after ESC
injection [14]. Additionally, ESCs are allogenic, thus
requiring the use of immunosuppressive agents to
prevent graft rejection. Therapeutic cloning, or the
transfer of a somatic cell nucleus obtained from a
patient into an enucleated oocyte, may circumvent
this problem [15]. ESCs then may be harvested
from the resulting blastocyst. Such ESCs would be
syngenic, and as such, immunosuppressive therapy
would not be required upon transplantation. Issues of
ESC transplantation and therapeutic cloning involve
enormous ethical concerns hindering the application
of such techniques in human trials to date.

Adult stem cells

Because the life span of most human cells is considerably shorter than the life span of the organism,
postnatal life is accompanied by continuous cell loss.
To maintain physiologic cell homeostasis, adult stem
cells can replenish lost cells throughout the lifetime
of an organism. Although bone marrow contains
the greatest population of adult stem cells, these cells
also have been identified in many adult tissues
and organs, including liver (oval cells), kidney, lung,
brain (neural stem cells), and skeletal muscle (satellite
cells) [16 20]. Recently, several groups, including
the authors, have identified and characterized stem
cell populations within the adult heart [21 26]. Most
progress in stem cell based therapies for HF has
been achieved with transplantation of adult stem

cells, including skeletal muscle precursor cells (myoblasts), bone marrow derived stem cells (BMSC),
and recently with cardiac stem cells.

Skeletal myoblasts
Postnatal skeletal muscle contains a musclespecific stem cell population termed satellite cells.
Satellite cells typically are located on the surface of
mature myofibers, and with muscle injury undergo
proliferation and give rise to myoblasts, which subsequently differentiate into myotubes and new muscle
fibers [27]. Myoblasts are isolated easily from muscle
biopsies and expanded in vitro [28]. Although myoblasts do not fit the stem cell classification per se,
high resistance to ischemia, high mitogenic activity,
and the commitment to a myogenic lineage make
myoblasts an appealing candidate for cellular cardiomyoplasty [29]. Transplantation studies in animals
have demonstrated that implanted skeletal myoblasts
differentiate into myotubes and form viable grafts in
infarcted myocardium, resulting in favorable ventricular remodeling and improvement of left ventricular
function [4,30,31]. Engrafted skeletal myoblasts,
however, have proved electrically isolated from host
cardiomyocytes and maintained a skeletal muscle
phenotype [32]. Many initial studies investigating
cell therapy in HF patients have focused upon the use
of skeletal myoblasts, as described below.

Bone marrow derived stem cells

The bone marrow represents a well-established
source of adult stem cells, and BMSC have been used
routinely to treat hematologic disorders successfully.
Recent reports suggested that BMSC can surmount
cell lineage boundaries and transdifferentiate into skeletal muscle, hepatocytes, neurons, endothelial cells, and
cardiomyocytes if properly stimulated [3335]. This
unexpected plasticity has prompted attempts to use
BMSC to promote cardiovascular regeneration after
myocardial injury. Much of the recent progress in
cardiovascular research has been achieved through
the study of bone marrow derived stem/progenitor
cell populations, including hematopoietic stem cells
(HSCs), endothelial progenitor cells (EPCs), and
mesenchymal stem cells (MSCs).
Hematopoietic stem cells
HSCs represent the prototypic adult stem cell
population. HSCs can be isolated from other bone

cell therapy in heart failure

marrow cells through selective sorting for a particular

immunophenotype (eg, Lineage , c-kit+, Sca-1+,
CD34lo, and CD38hi) [36,37]. The ability of HSCs
to reconstitute the hematopoietic system of a myeloablated host led to the first clinical application
of adult stem cells more than 35 years ago [38].
Although studies have failed to demonstrate differentiation of HSCs into cardiomyogenic lineages in
vitro, several studies in mice have demonstrated the
potential of HSCs to differentiate into cardiomyocytes and vascular structures after myocardial injury
in vivo [5,6,39]. Direct injection of HSCs into periinfarcted myocardium in mice resulted in the formation of new cardiomyocytes and capillaries, as well
as improved ventricular function and survival [6].
Additionally, given the capacity of HSCs to home to
sites of injury, it has been suggested that mobilization
of bone marrow HSCs through systemically delivered
cytokine stimulants may represent a less invasive
strategy to deliver HSCs after MI. Indeed, administration of stem cell factor (SCF) and granulocyte
colony stimulating factor (G-CSF) in infarcted mice
resulted in significant myocardial regeneration and
capillary formation as well as improved hemodynamics [39]. Importantly, however, cytokinemediated HSC mobilization in nonhuman primates
failed to improve post-MI cardiac function. Although
a significant increase in capillary density and coronary flow was demonstrated in this model, no
myocardial regeneration was observed [40]. Recent
studies also have raised questions regarding the
differentiation capacity of HSCs, suggesting in
particular that cellular fusion between HSCs and
cardiomyocytes rather than true transdifferentiation
may be responsible for previously reported findings
[41 43]. To date, it is unknown whether cellular
fusion represents a naturally occurring random event
or a mechanism involved in tissue repair.
Endothelial progenitor cells
In addition to the capacity for myocardial regeneration, BMSCs also have a vasculogenic potential.
Hematopoietic progenitor cells can attain an endothelial phenotype in vitro [44 47]. These EPCs
characteristically express the hematopoietic stem cell
markers CD133 and CD34 and the endothelial
marker Flk-1 (VEGFR-2) [46]. EPCs can be isolated
directly from the bone marrow or from the peripheral
circulation and expanded in vitro. Mobilization of
EPCs through cytokine stimulants increases EPC
concentration in the peripheral circulation substantially [48]. In addition to the classical HSC mobilization agents such as G-CSF and SCF, vascular

305

endothelial growth factor (VEGF), erythropoietin

(EPO), and statins promote EPC recruitment [48 51].
In vivo, bone marrow derived EPCs participate
in postnatal vasculogenesis and reendothelialization,
and thus play a role in the maintenance of vascular
homeostasis [47,52]. Moreover, by secreting various
angiogenic cytokines such as VEGF, they exert a
paracrine effect to enhance the generation of new
vessels from existing ones. The ability of EPCs to
home and promote neovascularization in sites of
ischemic injury prompted their use for therapeutic
vasculogenesis [53]. In animal models of hind limb
ischemia, the infusion of ex vivo expanded EPCs
improved blood flow and capillary density [54,55].
Similarly, ex vivo expanded or mobilized EPCs incorporated into foci of myocardial neovascularization and improved cardiac function after MI [56,57].
Although EPCs differentiate into functional cardiomyocytes in vitro [58], their contribution to new
myocardium in vivo is under scrutiny. These encouraging observations have led to the initiation of
human clinical studies of EPC transplantation in
patients who have acute MI and chronic ischemic
HF [59].

Mesenchymal stem cells

Within the bone marrow stroma resides a subset
of nonhematopoietic cells that have the potential to
differentiate into cells of mesenchymal origin [60,61].
These MSCs represent approximately 0.001% to
0.01% of the total nucleated marrow cell population,
a concentration 10-fold lower than their hematopoietic counterparts. MSCs are self-renewing and
expandable in vitro using standard cell culture techniques. Immunophenotypically, MSCs lack the typical hematopoietic antigens (CD45, CD34, CD14) but
express specific antigens (SH2/SH3/SH4/STRO-1)
and adhesion molecules (ALCAM/CD44) [62,63].
Initially, MSCs were believed to contribute solely to
the formation of the stromal microenvironment in the
bone marrow and maintain HSC survival and function. Subsequent studies have demonstrated, however, that MSCs are capable of multipotency, with
differentiation into chondrocytes, osteoblasts, astrocytes, neurons, skeletal muscle, and, notably, cardiomyocytes [33,64 66].
Several groups have demonstrated the cardiomyogenic differentiation potential of MSCs convincingly
in in vitro and in vivo systems [66 68]. Makino
and colleagues [66] generated a cardiomyogenic cell
line by treating isolated murine MSCs with the
DNA-methylating agent 5-azacytidine. This cardio-

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pfister et al

myogenic (CMG) cell line exhibited spontaneous

contraction, organized sarcomeric structure, ventricular cardiomyocyte-like action potentials, and functional adrenergic and muscarinic receptors [66,69].
Subsequent studies have confirmed the cardiomyogenic differentiation of human MSCs in vitro
using similar treatment with 5-azacytidine [70].
Moreover, labeled human MSCs engraft and express cardiomyocyte-specific contractile proteins and
calcium handling proteins when implanted into the
adult murine heart in vivo [67]. Furthermore, transplantation of MSCs in swine following MI resulted
in stable engraftment over 6 months and was associated with attenuation of deleterious ventricular
remodeling [68]. Notably, treated swine exhibited
an attenuation of pathologic wall thinning and a reduction in left ventricular end-diastolic pressure by
approximately 50%, suggesting that implantation
of MSCs after MI improved ventricular compliance and preserved diastolic function. These functional improvements are caused presumably by
favorable alterations in tissue cellularity and extracellular matrix remodeling.
The lack of improvement in systolic function,
however, calls the active contractile contribution of
implanted MSCs into question. Recent reports also
suggest that MSCs express a broad spectrum of
cardioprotective cytokines, including VEGF, insulinlike growth factor (IGF), and hepatocyte growth
factor (HGF), which enhance neovascularization and
prevent apoptosis [71,72]. Thus, paracrine mechanisms may contribute substantially to the favorable
remodeling seen after MSC implantation. This limited functional benefit may suggest that implanted
MSCs undergo histologic cardiomyogenic differentiation in the absence of functional differentiation.
In addition to cardiomyogenic differentiation, MSCs
may exhibit the potential to differentiate into endothelial cells as demonstrated in a rat MI model [73].
In contrast to HSCs and EPCs, MSCs exhibit a
cell surface phenotype of low immunogenicity that
allows for allogenic transplantation without immunosuppressive therapy [63,68]. These unique properties with the encouraging results obtained from
animal studies make MSCs an appealing cell type
for cell therapy.

Cardiac stem cells

Until recently, the postnatal heart was believed to
be composed of terminally differentiated cardiomyocytes with limited regenerative or mitotic potential.

Increasing evidence, however, suggests that a resident

cardiac stem/progenitor cell population may exist in
the adult heart and be responsible for regulating
cardiac cell homeostasis [21 24]. These cardiac stem
cells express various cell surface markers, including
the stem cell markers c-kit and Sca-1, as well as
the ATP-binding cassette transporters ABCG2 and
MDR1 [21,24,74]. The latter are involved in the
efflux of specific drugs and cell toxins, but also
provide the characteristic side population (SP) phenotype during fluorescent-activated cell sorting analysis after incubation with the Hoechst dye [75,76].
Cardiac cells expressing c-kit in the absence of
lineage markers (Lin ) are self-renewing, clonogenic,
and multipotent, giving rise to cardiomyocytes,
smooth muscle cells, and endothelial cells [21]. If
injected into ischemic myocardium or administered
intravenously after cardiac injury, cardiac stem cells
home to areas of injury, reconstitute myocardium and
capillaries, and improve cardiac function [21,22].
Results from the authors laboratory suggest that
cardiac progenitor cells exhibiting the SP phenotype
have the potential to differentiate into functional
cardiomyocytes in vitro and are activated after MI in
vivo [25,26].
Recently, Messina and colleagues [77] developed
a culture method enabling the harvest and expansion
of stem cell like cells from human heart biopsy specimens. Using this methodology, a log-phase expansion of cells was obtained from one biopsy within a
short period of time. Importantly, ex vivo expanded
cells retained their differentiation capacity and gave
rise to cardiomyocytes and vascular cells following
implantation into mice. These exciting new findings
provide the rationale for using resident cardiac stem
cells for myocardial repair. Further understanding
of the mechanisms regulating recruitment and expansion of cardiac stem cells may lead to new concepts in the prevention and the treatment of HF.

Adult cell therapy in heart failure: from bench

to bedside
Skeletal myoblasts
The first clinical cardiac cell therapy trial using
skeletal myoblasts was initiated in 2000 and completed in 2003 by Menasche and colleagues [78]. In
this phase-1 trial, the feasibility and safety of skeletal
myoblast transplantation was assessed in patients
who had ischemic cardiomyopathy. Ten patients with
severe left ventricular dysfunction (ejection fraction
less than 35%) were injected successfully with au-

Table 1
Major clinical trials using autologous cell therapy
Population

Enrolled LVEF

Control group

Method of injection

Time after MI

Follow-up (mo)

Skeletal myoblast (N = 10)

ICM

24 1

No

During CABG

3 mo 19 y

BMCs (enriched for CD34; N = 12)

AMI

39 9

No

During CABG

>10 d

BMCs (N = 11)

ICM

26 6

Yes (N = 9)

Endomyocardial

ND

BMCs (BOOST; N = 30)

AMI

50 10

Yes (N = 30)

Intracoronary

5.7 d

BMCs (N = 10)

AMI

51 14

Yes (N = 10)

Intracoronary

59 d

BMCs (N = 29) or circulating EPCs

(N = 30); (TOCARE-AMI)

AMI

50 10

No

Intracoronary

37 d

12

10.9

>12

12

Results

Ref.

LVEF: improved
LVEDV: NS
NYHA: improved
Caveat: arrhythmias
LVEF: improved
LVEDV: improved
NYHA: improved
Exercise capacity: improved
LVEF: NS
NYHA: improved
Exercise capacity: improved
LVEF: improved
LVEDV: NS
LVESV: NS
Infarct region: reduced
LVEDV: NS
LVESV: improved
LVEF: improved
LVESV: improved
LVEDV: NS

[78]

[88]

[86]

[83]

[84]

cell therapy in heart failure

Cell type

[85]

Abbreviations: AMI, acute myocardial infarction; BMCs, bone marrow cells; ICM, ischemic cardiomyopathy; LVEDV, left ventricular end-diastolic volume; LVESV, left ventricular
end-systolic volume; ND, not determined; NS, nonsignificant; NYHA, New York Heart Association Class.

307

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pfister et al

tologous skeletal myoblasts across the scar at the time

of coronary artery bypass graft surgery. Following
myoblast implantation, significant improvement of
New York Heart Association functional class and left
ventricular ejection fraction (LVEF) was documented.
Importantly, however, in patients receiving skeletal
myoblasts implantation, a high occurrence of sustained ventricular tachycardias was noted, warranting
placement of an internal defibrillator in four patients.
Additional randomized trials currently are assessing
the benefits and risks of autologous skeletal myoblast
cell therapy.
Bone marrow derived stem cells
Initial clinical trials of BMSCs largely have used
the mononuclear cell fraction isolated from whole
bone marrow aspirates. This fraction contains the full
array of BMSCs, including HSCs, EPCs, and MSCs,
and stands in contrast to most animal studies, in
which specific populations of BMSCs have been
investigated. Similar as with skeletal myoblasts,
human studies of autologous mononuclear bone
marrow cells have used direct implantation of cells
into the postinfarction scar and peri-infarct border
zone during coronary artery bypass graft surgery
[79,80]. Subsequently, less-invasive cell delivery
strategies, including direct coronary injection through
an inflated over-the-wire balloon catheter and transendocardial injection using a NOGA injection catheter (Biosense Webster, Markham, Ontario) also have
been applied successfully [81,82]. To date, only a few
patients have been enrolled in mostly open-labeled
studies with limited control groups, as summarized in
Table 1. The body of available data consistently
indicates, however, that BMSC transplantation is
feasible and safe in patients who have severe, chronic
ischemic HF and in patients after acute MI [82 85].
In contrast to the implantation of skeletal myoblast,
BMSC transplantation was not associated with
malignant ventricular arrhythmias within a 12-month
follow-up [82,85]. Additionally, direct intracoronary
BMSC injection was not associated with systemic
proinflammatory response, an increase in thromboembolic events, or stent restenosis. Also, there was no
evidence for cell therapy induced myocardial damage or major bleeding complications associated with
implantation of cells, despite anticoagulant and antiplatelet therapy [82,85].
The largest clinical cell therapy studies have
examined cardiac function in patients after acute
MI in a population with predominantly preserved
left ventricular function (LVEF greater than 50%)
[83 85]. Therefore, these findings do not translate

necessarily into a HF population. The sustained improvement in left ventricular function documented in
treated patients compared with controls, however,
suggests a favorable left ventricular remodeling process that interferes with the development of post-MI
HF. Notably, patients with the most severe impairment in left ventricular function demonstrated the
largest absolute improvement [85]. In conjunction
with these initial observations, Perin and colleagues
[82] evaluated the therapeutic benefit of autologous
BMSC implantation in patients who had end-stage
ischemic HF. Using electromechanical mapping,
BMSCs were injected transendocardially into areas
of viable, hibernating myocardium. In accordance
with prior animal studies, BMSC treatment resulted
in enhanced neovascularization, with a significant
reduction in reversible stress defects on single-photon
emission CT analysis up to 12 months after implantation [86]. These functional improvements were
paralleled by significant improvements in exercise
capacity and HF symptoms.
Despite the promising results provided by these
clinical trials, it is important to remember that their
primary intention was to assess the safety and feasibility of cell-based therapies, and given the relatively low patient numbers and the lack of proper
placebo-treated control groups, the treatment-related
functional benefits must be interpreted with caution.
Larger, randomized, double-blind, placebo-controlled
trials, including the continuing Reinfusion of Enriched Progenitor Cells And Infarct Remodeling in
Acute Myocardial Infarction (REPAIR-AMI) multicenter trial, will provide much-needed data regarding
the efficacy of myocardial cell therapy.

Summary
Over the last decade, a surge of experimental data
has emerged, providing the rationale for the therapeutic potential of stem cells in the treatment of left
ventricular dysfunction and HF. Early clinical trials in
humans not only have demonstrated the safety and
feasibility of this novel therapy, but also have provided the first evidence for the beneficial effects on
myocardial remodeling and cardiac function.
Many basic scientific and clinical questions remain to be answered, however. It remains unclear
which cell typeskeletal myoblasts, BMSCs, or endogenous cardiac stem cellsis best suited and most
efficacious for the treatment of HF. Additionally,
although stem cell implantation with almost any cell
type is associated with favorable myocardial remod-

cell therapy in heart failure

eling, the underlying biologic mechanisms leading to

this functional benefit are poorly understood. Moreover, the poor survival of implanted cells limits regeneration of large areas of myocardium [67].
Therefore, strategies to enhance peritransplantation cell survival may further improve the efficacy
of cell transplantation. Recently, Mangi and colleagues [87] elegantly demonstrated in a rat infarction
model that transplantation of genetically modified
MSCs that overexpressed the prosurvival gene Akt1
drastically improved cardiac regeneration and function relative to nonmodified MSCs. This combination
of gene therapy and cell therapy therefore may be
promising, but has yet to be translated into the clinical setting.
The identification and characterization of resident
cardiac stem cells also has changed the classic view
of the heart as a postmitotic organ and opens new opportunities to intervene in the homeostatic processes
of the myocardium. Treatment strategies aiming
to inhibit growth arrest and promote activation of
cardiac stem cells may prevent the onset of HF or
improve cardiac regeneration after injury. Finally, for
stem cell based therapies to become an established
treatment for HF, it is of utmost importance that the
beneficial effects observed in pilot trials are substantiated in larger, placebo-controlled, randomized
trials. With a greater understanding of adult stem cell
biology and its responsible translation into clinical
trials we may harness the therapeutic potential of
these cells in the years to come [88].

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