TINJAUAN PUSTAKA

The Role of Stem Cells in Degenerative Heart Diseases

Halim Semihardjo
Department of Histology, Faculty of Medicine Wijaya Kusuma University, Surabaya, Indonesia

ABSTRACT Degenerative heart diseases remains a burden both in modern or developing countries despite the advances in medical treatment. One key factor is that heart muscle (cardiomyocyte) has low capability to regenerate. Various source and type of stem cells might be potential to overcome the problem, but the results of several studies are mixed, some showed benefits, but also showed adverse effects. Further investigations are still needed. Keywords : Stem Cells, Heart, Cardiomyocyte, Heart Failure BACKGROUND Despite the advances in the management of degenerative heart diseases, including the availability of several new lines of medicine and invasive cardiology, the rate of hospitalization and mortality still remains high. In 2002, McMurray reported that people suffering from CHF is around 5 million in the US and 6,5 million in Europe with a very high mortality rate.1 It was once believed that cardiac myocyte has poor or very limited capability to regenerate and create new cells, thus unable to overcome the damage caused by degenerative diseases with high mortality and morbidity rate. Heart transplant might be the last option, but among several problems, the biggest is the avaibility of suitable donor. Other problems are the cost of the procedure, the prolonged use of immunosuppresive drugs and risk of organ rejection. In the past few years, scientist has found that heart muscles (cardiac myocyte) are actually capable of regeneration, and there are several hypotheses on the mechanism. First, it was suggested that the adult cardiac myocyte itself, triggered by injury, might reenter the cells cycle and divide.2 Second, stem cells originated from bone marrows, guided by certain cellular signal, might enter the heart via vascular route, and then differentiate into cardiomyocyte in the injured area. Third, the repair is performed by cardiac stem cells within the heart itself.2-6 Based on the hypothesis, scientist began to experiment on a different approach to treat degenerative heart diseases such as myocardial
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infarction and heart failure, using stem cells which in nature has the capability to regenerate and differentiate; early studies showed some very promising results. The still unanswered questions, among others, are : is this procedure really useful ?, what is the risk?, which is the most suitable stem cells?, and what is the best route of administration ?. INTRODUCTION Stem cells has been recognized for decades, the most widely used source of stem cell is bone marrow, used as treatment for various blood diseases, mainly leukemia. Other source of stem cell were searched; scientists isolated stem cells from animal embryo, and in 1988, stem cells were isolated from human embryo.6 The other breakthrough is perhaps the discovery of the cord blood as the potential source of stem cells. In 1988 the first cord blood transplant to Fanconi anemia patient was performed. This success has expanded the source of stem cells that can be used to treat diseases. STEM CELLS TYPE Stem cells can be classified according to sources: embryonic stem cells from human embryo, and adult stem cells from bone marrow or peripheral blood. Recently stem cells is also collected from the umbilical cord blood and placenta; expanding stem cells source, as well as its potential use in treatment. Embryonic stem cells (ES or ESC) This is the most primitive form of stem cells found in early form of embryo, called blastocyst. These cells can differentiate into any cells from the human three embryonic layer (exoderm, mesoderm, endoderm). Blastocyt has two layer

of cells; after attachment to the uterus wall, the outer layer will form the placenta, while the inner layer will form the body of fetus. The embryonic stem cells is collected from the inner layer of the blastocyst and then cultured. Since it is an undifferentiated stem cells there is a probability to develop teratoma. But the main issue is perhaps the legal and ethical aspects. Collections of the inner layer will prevent further development of blastocyt, and is considered to be unethical. Other ethical issue is regarding the source of blastocyst, which is usually obtained from the excess of IVF (invitro fertilization) process. Many countries prohibit the use of embryonic stem cells as experiment material. Adult stem cells Because of issues surrounding the use of embryonic stem cells, scientists look for other sources of stem cells in various tissue such as, bone marrow, peripheral blood, muscle, adipose, umbilical cord and even local heart tissue. a. Haemopoietic stem cells Sometimes abbreviated as HSC, these cells can be found in adult bone marrow, peripheral blood circulation and cord blood. These cells are known for their capability to reproduce and differentiate into all kind of blood cells. One cell is capable of producing up to 1015 cells.7 But although HSC has been used widely for treating blood disorder, their benefit in the treatment of heart diseases remains unclear. Markers related to this cell are CD34, CD45low, Thy-1 (CDw90), c-kit receptor (CD117), CD133,and negativity towards CD38 and lineage markers (Lin).

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b. Endothelial progenitor cells Sometimes abbreviated as EPC; EPCs have the capability to enter circulation, proliferate,and differentiate into mature endothelial cells.7 Thus might be a reasonable treatment for endothelial disorder.This cell is also proven to be involved in the neovascularization process when injected into animal models with ischemia 8,9. EPCs can be found in bone marrow, scarcely in the peripheral blood, and is abundant in cord blood, EPCs from umbilical cord blood also seems to have greater proliferation capability and lower apoptosis. 4, and therefore might be a better option in vasculogenesis and heart tissue therapies. 4,7 A strong correlation is found between the number of circulating endothelial progenitor cells and the subjects combined Framingham risk factor score - lower EPCs are related to higher risk of cardiovascular event, or higher score8. Another report also showed similar result.10 These findings suggested that endothelial damage is actually a balance between injury and repair capacity, and EPCs are thought to be an important part of the process. It might be difficult to distinguish the EPCs from the HSCs, since they share several similarity due to their same origin, which is the hemangioblast , common markers associated with these cells are CD34+ CD133+, and KDR. 7,10 c. Mesenchymal stem cells These cells have the capability to proliferate and differentiate into various mesenchymal tissue, depending on the location, such as osteogenic adipogenic, chondrogenic, myogenic, cardiomyogenic and others.7 Bone marrow is still the most common source of these cells, but their capability to proliferate and differentiate decrease at increasing age. There is also concern on the invasive procedure needed to collect the cells from the bone marrow. Recently, it has been shown that umbilical cord blood (UCB) also contain this type of stem cells, it is also suggested that umbilical cord/ placental stroma contain the MSCs as well. 4,7 Markers for MSCs are still controversial; some research showed expression of certain markers, while others showed the absence of the same marker. The widely accepted phenotyping is perhaps the absence of the haematopoietic marker, CD34 and CD45. 7,11,
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Recently, it has been shown that umbilical cord blood (UCB) also contain this type of stem cells, it is also suggested that umbilical cord/ placental stroma contain the MSCs as well. 4,7 Markers for MSCs are still controversial; some research showed expression of certain markers, while others showed the absence of the same marker. The widely accepted phenotyping is perhaps the absence of the haematopoietic marker, CD34 and CD45. 7,11 d. Cardiac stem cells It was once believed that heart muscles as well as neurons, are a static object in term of regeneration, which mean they cannot proliferate. But recent data shows that there are stem cells in human heart, cardiac myocytes can undergo both hyperthorphy and hyperplasia.This cell, also known as hCSCs,5 have the capability to reproduce itself and differentiate into several type of cells mainly cardiac myocyte, also capable of forming smooth muscle and endothelial cells. 5,12,13 The activity of hCSCs are increased in acute pathologic state, but in prolonged ventricular decompensation and end-stage cardiac failure their ability is decreased.12,14 Markers related to these stem cells are c-kit, MDR1, or Sca-1-reactive protein and negativity towards the antigens of hemopoietic markers. 4, 5, 12-14 hCSCs are naturally involved in the regeneration of the heart, and will mostly differentiate into cardiac myocyte. This fact made hCSC the ideal stem cells for repairing damaged heart.4,13,14. hSCSs studies and trial on human have been performed; but the main obstacles are that adult cardiac stem cells are scarce in nature, and hard to be identified.3 e. Muscle-derived stem cells Also known as myoblast or satellite cells, these cells are more suitable to be classified as precursor cell rather than stem cell, and can be found in the basal membrane of skeletal muscle fibre. 4,15 After injection into the damaged myocardium, these cells can proliferate and differentiate into striated muscle within the heart, which will improve cardiac function; but problems of arrythmias may occur as there is action potential property difference between heart muscle and striated muscle.4,15

Unlike cardiomyocytes,skeletal myocytes are more resistant to apoptosis, more easily cultured and require shorter period, enabling to collect sufficient number of cells for transplantation.3 But some experiments showed that myoblasts might induce ventricular arrythmias in model rat.15 f. Other stem cells Other stem cells include adipose-derived stem cells, neural stem cells, hepatic stem cells, pancreatic stem cells, stem cells of the skin, lung epithelial stem cells, intestinal stem cells.4,16 Other stem cells are also being searched within bone marrow or cord blood, but their presence and usage still require further studies. 7 DELIVERY METHOD Currently, there are three known methods of delivering stem cells into the heart : the peripheral intravenous, stem cell mobilization and direct injection into cardiac muscle. No study shows the superiority of certain technique over the other. The peripheral intravenous administration and cell mobilization are the easiest and minimally invasive way, it is based on the thought that injured area in the heart can attract and activate stem cells by certain homing signal via the cytokines and other cellular mediator, and after reaching the injured muscle, the stem cells will then proliferate and differentiate into cardiac muscle. However, scientist must find the correct signal so the regeneration process is accurately perform in the heart and not in other organ. 19 To accurately deliver the stem cells into the injured area, several techniques have been used, including direct epicardial myocard injection, usually performed during a surgical intervention (e.g. coronary artery bypass grafting, arrythmia surgery, mechanical assist device implantation, and valve repair).19 Other delivery method using catheter to deliver the stem cells had also been used. THE REPAIR MECHANISM There is still ongoing debate on the mechanism of repair, but there is evidence that stem cells injection has resulted in formation of new cardiac myocyte, vascularization and and improvement in ventricular remodelling2-5,19. Both angiogenesis and vasculogenesis plays a crucial role, not only by improving perfusion to the

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infarcted region and preventing further lost of myocyte and cardiac degeneration, but also by preventing cell apoptosis in surrounding area (peri-infarct area).4,19 Remodelling of the extracellular matrix (ECM) play an important role in the development of ventricular dilatation and ultimately lead to heart failure. Stabile matrix is essential to prevent cell lost and improving heart function. Stem cells have the capability to increase the matrix stability by preventing ECM degradation or restoring damaged ECM. 16,19 Clinical Trial Different trials, using various source of stem cells, delivery method, patients diagnosis, follow up period, and result have been done in the past few years. The reported trials show promising results, such as improvement in cardiac function,
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1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. Mc Murray JJV, Stewart S. The burden of heart failure. Eur Heart J 2002; 4 (Suppl D): D50-D58. Parmacek MS, Epstein JA. Cardiomyocyte renewal. NEJM 2009; 361:86-88. Garca JM, Goldenthal MJ. Application of Stem Cells in Cardiology: Where we are and where we are Going. Curr Stem Cell Res Ther. 2006 Jan;1(1):1-11. Wu KH, Liu YL, Zhou B, Han ZC. Therapeutic Potential of Human Umbilical Cord Derived Stem Cells in a Rat Myocardial Infarction Model. Ann. Thorac. Surg. 2007; 83(4): 1491 - 1498. Bearzi C, Rota M, Hosoda T,Tillmanns J, Nascimbene A, De Angelis A, et al. Human cardiac stem cells. Proc. Natl. Acad. Sci. USA 2007 104:14068-14073 The National Academies. Understanding stem cells. USA 2009:2. Mehta A, Cetrulo C, Stubblefield P, Cetrulo K. Placental and Pregnancy Stem Cells. In : Bhattacharya N, Stubblefield P eds. Frontiers of Cord Blood Sciences. London : Springer-Verlag. 2009 : 3-18. Hill JM, Zalos G, Halcox JPJ, Schenke WH, Waclawiw MA, Quyyumi AA, et al. Circulating Endothelial Progenitor Cells,Vascular Function, and Cardiovascular Risk. NEJM 2003;348 : 593-600. Urbich C, Dimmeler S. Endothelial Progenitor Cells: Characterization and Role in Vascular Biology. Circ. Res. 2004;95:343-353 Werner N, Kosiol S, Schiegl T, Ahlers P, Walenta K, Link A, Circulating Endothelial Progenitor Cells and Cardiovascular Outcomes. NEJM 2005;353:999-1007. Bhatia R, Hare JM, Mesenchymal Stem Cells: Future Source for Reparative Medicine. Division of Cardiology and Institute for Cell Engineering (ICE), Johns Hopkins University School of Medicine. http://www.medscape.com/viewarticle/ 504431_print. 2005 Urbanek K, Quaini F, Tasca G, Torella D, Castaldo C, Nadal-Ginard B, et al. Intense myocyte formation from cardiac stem cells in human cardiac hypertrophy. Proc. Natl. Acad. Sci. USA. 2003 100: 1044010445 Urbanek K, Torella D, Sheikh F, De Angelis A, Nurzynska D, Silvestri F, et al. Myocardial regeneration by activation of multipotent cardiac stem cells in ischemic heart failure. Proc. Natl. Acad. Sci. USA 2005 102: 86928697 Kubo H, Jaleel N, Kumarapeli A, Berretta RM, Bratinov G, Shan X, et al. Increased Cardiac Myocyte Progenitors in Failing Human Hearts. Circulation 2008;118:649-657 Fernandes S, Amirault JC, Lande G, Nguyen JM, Forest V, Bignolais O, et al. Autologous myoblast transplantation after myocardial infarction increases the inducibility of ventricular arrhythmias. Cardiol Res. 2006;69: 348 358 Krbling M, Estrov Z. Adult Stem Cells for Tissue Repair - A New Therapeutic Concept?. NEJM 2003;349:570-82 Edmunds MW. Advances in Stem Cell Technology. Johns Hopkins University School of Nursing, Baltimore. http://cme. medscape. com/viewarticle/551442_print. 2007 Asahara T, Takahashi T, Masuda H, Kalka C, Chen D, Iwaguro H, at al. VEGF contributes to postnatal neovascularization by mobilizing bone marrow-derived endothelial progenitor cells. EMBO J. 1999; 18 : 39643972. Gallegos R P, Bolman R M III . Stem CellInduced Regeneration of Myocardium. In : Cohn LH, ed. Cardiac Surgery in the Adult. New York: McGraw-Hill. 2008:1657-1668. Herreros J, Prosper F, Perez A, Gavira JJ, Garcia-Velloso MJ, Barba J, et al. Autologous intramyocardial injection of cultured skeletal muscle-derived stem cells in patients with non-acute myocardial infarction. Eur. Heart J. 2003;24: 20122020 Menasch P, Hagge AA, Vilquin JT, Desnos M, Abergel E, Pouzet B, et al. Autologous Skeletal Myoblast Transplantation forSevere Postinfarction Left Ventricular Dysfunction. J. Am. Coll. Cardiol. 2003;41;1078-1083 Fox M, Embryonic stem cells made without embryos. Thomson Reuters USA. http://www.reuters.com/articlePrint? articleId=USN2058175020071121. 2007

improvement in perfusion, differentiation of myoblasts, increase in vessel numbers, improvement in LVEF and viability in infarct area, restoration of wall viability, increase in life quality and NYHA class, improvement in haemodynamic parameter, survival and engraftment of myoblasts and reduced anginal symptoms. 4,20,21 Several studies have shown adverse reaction: tachycardia was the most commonly seen, ventricular arrythmias was reported in model rats injected with myoblast. 4,15,19 Conclusion Degenerative heart diseases present serious problem both in modern or developing country despite the advances in medical, interventional and surgical therapy.

This condition poses a challenge to find a new method of treatment. Since the heart is considered having very low capability to regenerate, the use of stem cells is attractive; various trials have shown promising results. But some adverse effects might need to be investigated. Each stem cell type has their own advantage and disadvantages, MSCs and hCSCs are perhaps the most suitable for the heart, but larger trials are needed to confirm, as well as to find the best delivery method, dose and other issues.

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