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Cell Tracking Following the Intramyocardial Injection of Mesenchymal Cells after Myocardial Infarction
S18 Journal of Cardiac Failure Vol. 12 No. 6 Suppl. 2006 057
059
Cell Tracking Following the Intramyocardial Injection of Mesenchymal Cells after Myocardial Infarction Ramesh Mazhari1, Karl H. Schuleri, Jeffrey M. Zimmet, Anastasios P. Saliaris, Luciano C. Amado, Andrew J. Boyle, Alan W. Heldman, Joshua M. Hare; 1 Department of Medicine, Cardiology Division, Institute for Cell Engineering, Broadway Research Building, Suite 651, 733 North Broadway, the Johns Hopkins University School of Medicine, Baltimore, MD
Ventilatory Response Characteristics of Heart Failure Patients with Periodic Breathing during Exercise Lyle J. Olson1, Adelaide M. Olson1, Christopher G. Scott1, Bruce D. Johnson1; 1 Cardiovascular Diseases, Mayo Clinic, Rochester, MN
Background: We have previously shown that in a swine model of myocardial infarction (MI), allogeneic MSCs delivered intramyocardially reduced the extent of necrotic myocardium and promoted the regeneration of contractile myocardium along the subendocardial surface of the infarct zone, and substantial increases in global cardiac function. Whether or not this beneficial effect involves transdifferentiation of the MSCs is not known. To further delineate the mechanism of action of MSC therapy, we analyzed the degree of cellular engraftment and survival following intramyocardial injection of MSCs. Methods: MI was induced in female Yorkshire pigs by a 60-min occlusion of the LAD. 3 days after MI, animals were randomized to receive either male allogeneic MSCs or placebo. The tissue was then examined to determine the cell retention rate, and transdifferentiation using fluorescent in-situ hybridization (FISH) to detect the Y chromosome in the injected MSCs. Results: FISH analysis of the rim region 24 hours after injection of MSCs (n 5 2) demonstrated engraftment of the injected cells (6 6 4.6 per high power field). However, there was a time-dependent reduction in the number of detectable MSCs 8 weeks post injection (n 5 6) revealing occasional Y-chromosome positive cells in only 2 of the animals (0.25 6 0.5 per high power field). There was a marked reduction in the degree of myocyte apoptosis as assessed by TUNEL assay (19.29 6 1.39 and 8.42 6 2.17 units in control and treated pigs, p ! 0.05). Conclusion: Despite the minimal persistence of the injected MSCs after 8 weeks, there was a marked reduction in the degree of apoptosis and a corresponding improvement in cardiac function. These findings argue against transdifferentiation of MSCs and support the theory of activation of endogenous repair mechanisms with MSC treatment.
058 Predictors of Chronotropic Incompetence in Heart Failure Patients Timothy E. Meyer, John D. Day, Stacia Merkel, Kira Q. Stolen, David O. Martin; Clinical Application Research Studies, Guidant Corp., St. Paul, MN; LDS Hospital, Salt Lake City, UT; Integra Clinical Trial Solutions, Brooklyn Park, MN; Clinical Application Research Studies, Guidant Corp., St. Paul, MN; Cleveland Clinic Hospital, Cleveland, OH Introduction: A common method to assess chronotropic incompetence (CI) is to use 70% of age predicted max heart rate (APHR). Very little is understood regarding possible predictors of chronotropic response (CR), especially in heart failure patients receiving cardiac resynchronization therapy (CRT). Methods: A subset of patients (N 5 119) from the Pacing Evaluation- Atrial Support Study in Cardiac Resynchronization Therapy (PEGASUS CRT) participating in an exercise sub-study were used for the current analyses. Patients meeting standard indications for a CRT defibrillator and in sinus rhythm were eligible for study participation. Patients completed a cardiopulmonary exercise test six weeks post CRT implant to determine peak oxygen consumption (VO2peak). All devices were programmed to DDD-40. CI was determined if patients achieved ! 70%APHR during the VO2peak test. Results: Baseline characteristics consisted of the following (mean 6 S.D.): age (65 6 13 years), weight (89.4 6 24.3 kg), BMI (30.1 6 7.5), and EF (24.2 6 7.2 %). According to the previously mentioned definition for CI, 30% of this general heart failure patient population had CI. In a stepwise regression model including all clinically relevant univariate predictors; history of diabetes, history of non-ischemic cardiomyopathy, history of arrhythmia and systolic blood pressure were significant predictors of CR. After adjusting for predictors of CR, VO2peak differed significantly between patients demonstrating CI (14 ml/kg/min) and chronotropic competence (CC) (16 ml/ kg/min; p ! 0.036). Conclusion: Chronotropic incompetence as defined here is common in heart failure patients. In addition, VO2peak is significantly lower in CI patients compared to CC patients. This emphasizes that many heart failure patients may not attain high enough heart rates to accommodate the demands of normal daily activities and supports the concept that atrial rate support pacing may benefit these patients.
Univariate Predictors of Chronotropic Response
History of Diabetes; N (%) History of Non-ischemic Cardiomyopathy; N (%) History of Arrhythmia; N (%) Systolic Blood Pressure mean 6 S.D.
CI (N 5 36)
CC (N 5 83)
Univariate p-value
17 (47%) 19 (28%)
23 (28%) 41 (49%)
0.04 0.03
21 (58%) 122.6 6 21.0
34 (41%) 129.7 6 17.1
0.08 0.10
Periodic breathing (PB) in patients with congestive heart failure (CHF) may include Cheyne-Stokes respiration at rest, central sleep apnea and oscillatory ventilation during exercise (EOV). EOV has been associated with adverse prognosis, worse symptoms and decreased functional capacity. Traditionally, EOV has been associated with low left ventricular ejection fraction (LVEF); however, we have observed EOV in CHF patients with preserved LVEF. The aim of this study was to compare ventilatory response characteristics of CHF patients with EOV to controls with no EOV matched for LVEF. Methods: Inclusion in the study group required demonstration of EOV by cardiopulmonary exercise testing (CPET) defined as O 25% breath by breath variation of minute ventilation (VE) persisting O 60% exercise duration. Contemporaneous controls matched for LVEF with no EOV were identified. All subjects were clinically stable and on optimal medical therapy. Ventilatory response parameters including oxygen uptake (VO2), ventilatory efficiency (VE/VCO2), carbon dioxide production (VCO2), end-tidal CO2 (ETCO2), tidal volume (VT) and breathing frequency (fb) were measured at rest (r) and peak (p) exercise. Mean values were compared for the two groups by unpaired t-test. Results: See Table. Conclusion: CHF patients with EOV had worse symptoms, reduced functional capacity, more tachypneic ventilatory pattern and reduced ventilatory efficiency and greater hyperventilation both at rest and during exercise. These findings suggest that EOV is associated with more severe CHF, independent of LVEF.
Age (years) LVEF (%) Male gender N (%) NYHA Class rfb rVT rETCO2 rVE/VCO2 pVO2 pfb pVT pETCO2 pVE/VCO2
Controls (N 5 47)
PB (N 5 47)
p value
54.7 6 12.8 34.8 6 13.5 33 (70%) 2.1 6 0.9 16.5 6 4.7 0.79 6 0.51 33.0 6 3.3 40.2 6 4.7 20.4 6 7.5 32.0 6 5.5 1.94 6 0.7 34.2 6 5.3 33.8 6 6.6
60.7 6 13.9 36.6 6 17.3 34 (72%) 2.6 6 0.8 19.5 6 4.4 0.72 6 0.29 30.9 6 4.3 44.5 6 7.5 15.7 6 5.2 34.6 6 7.1 1.65 6 0.6 29.6 6 5.0 40.2 6 7.8
0.03 0.77 0.82 0.006 !0.001 0.84 0.02 0.002 0.01 0.08 0.08 !0.001 !0.001
060 Early Recovery of Venous Endothelial Dysfunction in Decompensated Congestive Heart Failure Karen B. Ruschel1, Eneida R. Rabelo1,2, Anelise O. Brun2, Nadine Clausell1,2, Maria C. Irigoyen3, Luis E. Rohde1,2; 1Pos Graduation Program, Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil; 2Cardiology Division, Hospital de Clinicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil; 3 Heart Institute, University of Sao Paulo, Sao Paulo, Sao Paulo, Brazil Background: Since more than 70% of total circulating volume lies in the venous vascular bed, it is conceivable that small changes in venous tone may substantially affect filling pressures, making the assessment of venous endothelial function an attractive new parameter of vascular homeostasis in congestive heart failure (CHF). Objective: To evaluate the effect of in-hospital clinical compensation on endothelium venous function in CHF patients. Methods: Patients admitted with decompensated CHF were eligible to this protocol. Subjects underwent a venous endothelial evaluation, a 6-minute walk test and BNP measurement at baseline and immediately before discharge. Venous endothelium function was evaluated by the dorsal hand vein technique using a tripod holding a linear variable differential transformer, that contains a movable metal core 10 mm downstream from a needle tip. Dose-response curves were constructed to assess the endothelium-dependent vasodilator (after acetylcholine Ach administration) and endothelium-independent vasodilator (after sodium nitropruside SNP) into a pre-constricted vein (after phenylephrine use). Results: 15 patients with decompensated CHF (80% males, 61 6 14 years-old and left ventricular ejection fraction of 27 6 10%) were studied. During hospital stay, we observed a significant improvement in NYHA functional class (P ! 0.01), reduction in weight (mean difference of 3.8 Kg, p ! 0.01), increment in the distance walked over 6 minutes (mean difference of 107 meters, p ! 0.01) and a non-significant reduction in BNP levels, p 5 0.17. Maximum vasodilator response to Ach, was significantly lower at baseline compared to the pre-discharge response (40 6 28% versus 86 6 52%, respectively, p ! 0.01). The response evaluated after SNP was similar in both timepoints (180 6 111% versus 167 6 93%, respectively, p 5 0.2). No significant changes in the percentage of use of angiotensin converting enzyme inhibitors (ACEi) and beta-blockers were observed between baseline and discharge. Conclusions: Decompensated CHF patients experience marked endothelium-dependent venous dysfunction that recovers partially during hospital treatment. This recovery ran in parallel to improvements in other markers of clinical congestion, but was not associated with ACEi and beta-blockers administration.
059
Cell Tracking Following the Intramyocardial Injection of Mesenchymal Cells after Myocardial Infarction Ramesh Mazhari1, Karl H. Schuleri, Jeffrey M. Zimmet, Anastasios P. Saliaris, Luciano C. Amado, Andrew J. Boyle, Alan W. Heldman, Joshua M. Hare; 1 Department of Medicine, Cardiology Division, Institute for Cell Engineering, Broadway Research Building, Suite 651, 733 North Broadway, the Johns Hopkins University School of Medicine, Baltimore, MD
Ventilatory Response Characteristics of Heart Failure Patients with Periodic Breathing during Exercise Lyle J. Olson1, Adelaide M. Olson1, Christopher G. Scott1, Bruce D. Johnson1; 1 Cardiovascular Diseases, Mayo Clinic, Rochester, MN
Background: We have previously shown that in a swine model of myocardial infarction (MI), allogeneic MSCs delivered intramyocardially reduced the extent of necrotic myocardium and promoted the regeneration of contractile myocardium along the subendocardial surface of the infarct zone, and substantial increases in global cardiac function. Whether or not this beneficial effect involves transdifferentiation of the MSCs is not known. To further delineate the mechanism of action of MSC therapy, we analyzed the degree of cellular engraftment and survival following intramyocardial injection of MSCs. Methods: MI was induced in female Yorkshire pigs by a 60-min occlusion of the LAD. 3 days after MI, animals were randomized to receive either male allogeneic MSCs or placebo. The tissue was then examined to determine the cell retention rate, and transdifferentiation using fluorescent in-situ hybridization (FISH) to detect the Y chromosome in the injected MSCs. Results: FISH analysis of the rim region 24 hours after injection of MSCs (n 5 2) demonstrated engraftment of the injected cells (6 6 4.6 per high power field). However, there was a time-dependent reduction in the number of detectable MSCs 8 weeks post injection (n 5 6) revealing occasional Y-chromosome positive cells in only 2 of the animals (0.25 6 0.5 per high power field). There was a marked reduction in the degree of myocyte apoptosis as assessed by TUNEL assay (19.29 6 1.39 and 8.42 6 2.17 units in control and treated pigs, p ! 0.05). Conclusion: Despite the minimal persistence of the injected MSCs after 8 weeks, there was a marked reduction in the degree of apoptosis and a corresponding improvement in cardiac function. These findings argue against transdifferentiation of MSCs and support the theory of activation of endogenous repair mechanisms with MSC treatment.
058 Predictors of Chronotropic Incompetence in Heart Failure Patients Timothy E. Meyer, John D. Day, Stacia Merkel, Kira Q. Stolen, David O. Martin; Clinical Application Research Studies, Guidant Corp., St. Paul, MN; LDS Hospital, Salt Lake City, UT; Integra Clinical Trial Solutions, Brooklyn Park, MN; Clinical Application Research Studies, Guidant Corp., St. Paul, MN; Cleveland Clinic Hospital, Cleveland, OH Introduction: A common method to assess chronotropic incompetence (CI) is to use 70% of age predicted max heart rate (APHR). Very little is understood regarding possible predictors of chronotropic response (CR), especially in heart failure patients receiving cardiac resynchronization therapy (CRT). Methods: A subset of patients (N 5 119) from the Pacing Evaluation- Atrial Support Study in Cardiac Resynchronization Therapy (PEGASUS CRT) participating in an exercise sub-study were used for the current analyses. Patients meeting standard indications for a CRT defibrillator and in sinus rhythm were eligible for study participation. Patients completed a cardiopulmonary exercise test six weeks post CRT implant to determine peak oxygen consumption (VO2peak). All devices were programmed to DDD-40. CI was determined if patients achieved ! 70%APHR during the VO2peak test. Results: Baseline characteristics consisted of the following (mean 6 S.D.): age (65 6 13 years), weight (89.4 6 24.3 kg), BMI (30.1 6 7.5), and EF (24.2 6 7.2 %). According to the previously mentioned definition for CI, 30% of this general heart failure patient population had CI. In a stepwise regression model including all clinically relevant univariate predictors; history of diabetes, history of non-ischemic cardiomyopathy, history of arrhythmia and systolic blood pressure were significant predictors of CR. After adjusting for predictors of CR, VO2peak differed significantly between patients demonstrating CI (14 ml/kg/min) and chronotropic competence (CC) (16 ml/ kg/min; p ! 0.036). Conclusion: Chronotropic incompetence as defined here is common in heart failure patients. In addition, VO2peak is significantly lower in CI patients compared to CC patients. This emphasizes that many heart failure patients may not attain high enough heart rates to accommodate the demands of normal daily activities and supports the concept that atrial rate support pacing may benefit these patients.
Univariate Predictors of Chronotropic Response
History of Diabetes; N (%) History of Non-ischemic Cardiomyopathy; N (%) History of Arrhythmia; N (%) Systolic Blood Pressure mean 6 S.D.
CI (N 5 36)
CC (N 5 83)
Univariate p-value
17 (47%) 19 (28%)
23 (28%) 41 (49%)
0.04 0.03
21 (58%) 122.6 6 21.0
34 (41%) 129.7 6 17.1
0.08 0.10
Periodic breathing (PB) in patients with congestive heart failure (CHF) may include Cheyne-Stokes respiration at rest, central sleep apnea and oscillatory ventilation during exercise (EOV). EOV has been associated with adverse prognosis, worse symptoms and decreased functional capacity. Traditionally, EOV has been associated with low left ventricular ejection fraction (LVEF); however, we have observed EOV in CHF patients with preserved LVEF. The aim of this study was to compare ventilatory response characteristics of CHF patients with EOV to controls with no EOV matched for LVEF. Methods: Inclusion in the study group required demonstration of EOV by cardiopulmonary exercise testing (CPET) defined as O 25% breath by breath variation of minute ventilation (VE) persisting O 60% exercise duration. Contemporaneous controls matched for LVEF with no EOV were identified. All subjects were clinically stable and on optimal medical therapy. Ventilatory response parameters including oxygen uptake (VO2), ventilatory efficiency (VE/VCO2), carbon dioxide production (VCO2), end-tidal CO2 (ETCO2), tidal volume (VT) and breathing frequency (fb) were measured at rest (r) and peak (p) exercise. Mean values were compared for the two groups by unpaired t-test. Results: See Table. Conclusion: CHF patients with EOV had worse symptoms, reduced functional capacity, more tachypneic ventilatory pattern and reduced ventilatory efficiency and greater hyperventilation both at rest and during exercise. These findings suggest that EOV is associated with more severe CHF, independent of LVEF.
Age (years) LVEF (%) Male gender N (%) NYHA Class rfb rVT rETCO2 rVE/VCO2 pVO2 pfb pVT pETCO2 pVE/VCO2
Controls (N 5 47)
PB (N 5 47)
p value
54.7 6 12.8 34.8 6 13.5 33 (70%) 2.1 6 0.9 16.5 6 4.7 0.79 6 0.51 33.0 6 3.3 40.2 6 4.7 20.4 6 7.5 32.0 6 5.5 1.94 6 0.7 34.2 6 5.3 33.8 6 6.6
60.7 6 13.9 36.6 6 17.3 34 (72%) 2.6 6 0.8 19.5 6 4.4 0.72 6 0.29 30.9 6 4.3 44.5 6 7.5 15.7 6 5.2 34.6 6 7.1 1.65 6 0.6 29.6 6 5.0 40.2 6 7.8
0.03 0.77 0.82 0.006 !0.001 0.84 0.02 0.002 0.01 0.08 0.08 !0.001 !0.001
060 Early Recovery of Venous Endothelial Dysfunction in Decompensated Congestive Heart Failure Karen B. Ruschel1, Eneida R. Rabelo1,2, Anelise O. Brun2, Nadine Clausell1,2, Maria C. Irigoyen3, Luis E. Rohde1,2; 1Pos Graduation Program, Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil; 2Cardiology Division, Hospital de Clinicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil; 3 Heart Institute, University of Sao Paulo, Sao Paulo, Sao Paulo, Brazil Background: Since more than 70% of total circulating volume lies in the venous vascular bed, it is conceivable that small changes in venous tone may substantially affect filling pressures, making the assessment of venous endothelial function an attractive new parameter of vascular homeostasis in congestive heart failure (CHF). Objective: To evaluate the effect of in-hospital clinical compensation on endothelium venous function in CHF patients. Methods: Patients admitted with decompensated CHF were eligible to this protocol. Subjects underwent a venous endothelial evaluation, a 6-minute walk test and BNP measurement at baseline and immediately before discharge. Venous endothelium function was evaluated by the dorsal hand vein technique using a tripod holding a linear variable differential transformer, that contains a movable metal core 10 mm downstream from a needle tip. Dose-response curves were constructed to assess the endothelium-dependent vasodilator (after acetylcholine Ach administration) and endothelium-independent vasodilator (after sodium nitropruside SNP) into a pre-constricted vein (after phenylephrine use). Results: 15 patients with decompensated CHF (80% males, 61 6 14 years-old and left ventricular ejection fraction of 27 6 10%) were studied. During hospital stay, we observed a significant improvement in NYHA functional class (P ! 0.01), reduction in weight (mean difference of 3.8 Kg, p ! 0.01), increment in the distance walked over 6 minutes (mean difference of 107 meters, p ! 0.01) and a non-significant reduction in BNP levels, p 5 0.17. Maximum vasodilator response to Ach, was significantly lower at baseline compared to the pre-discharge response (40 6 28% versus 86 6 52%, respectively, p ! 0.01). The response evaluated after SNP was similar in both timepoints (180 6 111% versus 167 6 93%, respectively, p 5 0.2). No significant changes in the percentage of use of angiotensin converting enzyme inhibitors (ACEi) and beta-blockers were observed between baseline and discharge. Conclusions: Decompensated CHF patients experience marked endothelium-dependent venous dysfunction that recovers partially during hospital treatment. This recovery ran in parallel to improvements in other markers of clinical congestion, but was not associated with ACEi and beta-blockers administration.