1. ON HEART TISSUE REENGINEERING ? JC Chachques, MD PhD Georges Pompidou European Hospital Paris, France Stem cell therapy and CV innovations What’s new ?

2. Cardiac Bioassist - Cooperative Work Teams : Olivier Schussler. Ottawa Heart Institut, Canada Carlos Semino. MIT + Barcelona Bioengineering Center Jorge Genovese. Pittsburgh University, USA Jorge Trainini. Avellaneda Hospital, Argentina

3. HEART FAILURE IN EUROPE Heart failure is the single biggest reason for acute hospital admission. Around 30 million people in Europe have heart failure and its incidence is increasing. More people are living to an old age, and more are surviving a heart attack but with damage to the heart.

4. PREVALENCE of HEART FAILURE in USA (total population: 305 millions)

5. Evidence for cardiomyocyte renewal in humans Science 2009; 324: 98-102 Frisen J. et al, Karolinska Institut, Stockholm, Sweden Cardiomyocytes are generated also later in life ? Carbon-14, generated by nuclear bomb tests during the Cold War, integrated into DNA allows to establish the age of cardiomyocytes in humans Results: cardiomyocytes renew, with a gradual decrease from 1% turning over annually at age of 25, to 0.45% at age of 75 Fewer than 50% of cardiomyocytes are exchanged during a normal life span Perspectives: development of therapeutic strategies aimed at stimulating this process in cardiac pathologies

6. STEM CELL THERAPY and BIOARTIFICIAL MYOCARDIUM

7. CARDIAC BIO-ASSIST

8. CELLS FOR MYOCARDIAL REGENERATION Skeletal myoblasts Bone marrow mononuclear cells Bone marrow mesenchymal cells Umbilical cord cells Adipose tissue stroma cells Mesothelial cells (from epiploon) Menstrual blood endometrial cells Stem cells from the testis Embryonic cells (pluripotents)

9. BONE MARROW ASPIRATION

10. DEVELOPMENT OF BIO-ARTIFICIAL MYOCARDIUM

11. BACKGROUND Limitations of Cellular Cardiomyoplasty Cell bio-retention and engraftment within scar tissue is low Mortality of implanted cells in ischemic myocardium is high In ischemic heart disease the extracellular matrix is pathologically modified

12. BACKGROUND 2 Limitations of Cellular Cardiomyoplasty Implanted cells lack both mechanical synchronization and electrical integration, forming « islands of tissue » Questions and risks: Excitation-contraction coupling? Additional excitable cells? Proarrhythmic?

13. RATIONALE FOR 3D CARDIAC TISSUE ENGINEERING The efficacy and arrhythmia occurrence of stem cell therapy depends on the surviving cell number as well as the delivery route of cells A cell-seeded epicardial scaffolds should offert additional niches for cell homing without the risk of a proarrhythmogenic substrate Allogeneic cells should be better tolerated in a matrix « niche environment »

14. Heart extracellular matrix Cell niche + cell homing ml : muscular lacunae cl : capillary lacunae

15. COMPONENTS OF EXTRACELLULAR MATRIX IN HUMAN HEART Collagen Type I (80%) : Ventricular chamber geometry, structural support Collagen Type III (10%): Role in transduction of myocyte shortening during systole

16. EXTRACELLULAR MATRIX IN ISCHEMIC HEART DISEASE Collagen Type I : Decreases from 80% to 40% Collagen Type III : Increases from 10% to 35% RESULTS : Ventricular dilatation, systolic + diastolic dysfunctions

17. COLLAGEN TYPE I MATRIX (Pangen 2, France) lyophilised, bovine collagen, 5 x 7 x 0.6 cm

18. DEVELOPMENT OF ARTIFICIAL MYOCARDIUM Collagen matrix (type I) 3D and Biodegradable Seeded with stem cells

19. Collagen Matrix without cells seeded with cells

20. Confocal Microscop y 3D matrix + cells

21. MATRIX MATRIX GRAFTED ON EPICARDIUM

22. PRECLINICAL STUDIES Published in Tissue Engineering 2007; 13:2681-7 Cell-seeded collagen matrix - 2 Mo Follow-up

23. BIOARTIFICIAL MYOCARDIUM « MAGNUM » Clinical Trial M yocardial A ssistance by G rafting a N ew bioartificial U pgraded M yocardium

24. Rationale Associate a procedure for myocardial and extracellular matrix regeneration, i.e. Cellular cardiomyoplasty + Collagen scaffold grafting

25. Cellular CMP + Cell Seeded Matrix

26. Clinical Collagen Matrix Implantation

27. MAGNUM Clinical Trial RESULTS

28. Functional Outcomes: 1 year follow-up BaselineEnd FU p =0.005 NYHA Class

29. p = 0.04 LV Ejection Fraction (%) Echocardiographic Study

30. p = 0.03 LV End Diastolic Volume (mL) Echocardiographic Study

31. LV FILLING Doppler-derived mitral deceleration time (ms) p = 0.01 DIASTOLIC FUNCTION

32. Scar Area Thickness (mm) p = 0.005 Echocardiographic Study

33. Cellular CMP + Matrix Radioisotopic SPECT sestamibi studies Preop12 Months

34. MAGNUM CLINICAL TRIAL CONCLUSIONS REDUCES THE SIZE AND FIBROSIS OF INFARCT SCARS MINIMIZES GLOBAL VENTRICULAR DILATATION IMPROVES DIASTOLIC FUNCTION INCREASES MYOCARDIAL WALL THICKNESS INDUCES MODULATION OF EXTRACELLULAR MATRIX

35. MAGNUM CLINICAL TRIAL CONCLUSIONS The implanted matrix contributed to generate the “adequate niche” for native, transplanted and migrating stem cells

37. FUTURE MATRIX IMPROVEMENTS Crosslinking angiogenic growth factors Prolong absorption delay by nanotechnologies and additional chemical - physical crosslinking Stem cell preconditioning : hypoxic conditions (5%) during cultures in-vitro electrostimulation

38. Nature Clin Pract Cardiovasc Med 2009; 6: 240-9 Use of arginine-glycine-aspartic (RGD) acid adhesion peptides coupled with a new collagen scaffold to engineer a myocardium-like tissue graft Schussler O, Coirault C, Louis-Tisserand M, Chachques JC, Carpentier A, Lecarpentier Y

39. Frontiers in Bioscience. 2009; 14: 2996-3002 Cardiac pre-differentiation of human mesenchymal stem cells by electrostimulation Genovese J, Spadaccio C, Schussler O, Carpentier A, Chachques JC, Patel AN

40. Biomaterials. 2009; 30: 1156-65 The effect of self-assembling peptide nanofiber scaffolds on mouse embryonic fibroblast implantation and proliferation Degano IR, Quintana L, Semino C, et al.

41. A prototypic synthetic extracellular matrix Molecular designed material Chemically defined Synthetic process Highly similarity to natural ECMs structure: nano-scale fibers self-assembling process biologically permissive non-competition with natural ECM biodegradable Mechanical properties for soft tissues Modification control Building up properties Transient scaffold Injecting biological material

42. A generic peptide scaffold network Peptide nanofibers = 10-20 nm Scaffold pore size = 50-200 nm

43. RECATABI PROJECT - European Union

46. CARMAT ( Carpentier - Matra ) Artificial Heart