Remodeling an infarcted heart: novel hybrid treatment with transmyocardial revascularization and stem cell therapy

Long-term results of isolated transmyocardial laser revascularization in combination with the intramyocardial autologous bone marrow stem cells injection

To evaluate the long-term results of TMLR using a CO² laser in combination with intramyocardial injection of ABMSC as an isolated procedure in patients with the end-stage coronary artery disease, the study included 20 patients (90% male), with a mean age of 58.4 ± 8.7 years. To assess the long-term results, patients were examined in a hospital. The Minnesota Living with Heart Failure Questionnaire (MLHFQ) and the Seattle Angina Questionnaire (SAQ) were used. The evolution of laboratory and instrumental indices, as well as medical therapy, was assessed. The end points of the study were death, acute myocardial infarction (AMI), repeated myocardial revascularization, recurrent hospitalizations due to coronary artery disease, and stroke. The changes in angina functional class were also evaluated. The median of follow-up period was 54 (36; 83) months, that is, 4.5 years. The analysis of the evolution of echocardiographic data showed the absence of statistically significant changes in the following parameters: left ventricular end-diastolic diameter (EDD) (p = 0.967), end-systolic diameter (ESD) (p = 0.204), end-diastolic volume (EDV) (p = 0.852), end-systolic volume (ESV) (p = 0.125), and left ventricular ejection fraction (LVEF) (p = 0.120). The patients continued to regularly take the main groups of medications. Nitrate consumption was significantly reduced (p < 0.001). Significant positive dynamics were observed in the changes in angina functional class. At the baseline, all patients had angina III FC, in the long term, 3 patients had II FC, 11 patients had I FC, and 6 patients had no angina. Clinical outcomes (mortality, recurrent myocardial infarction, stroke) were absent during the follow-up period. There were two cases of repeated myocardial revascularization. Regression analysis revealed that SYNTAX score was associated with the clinical outcome "repeated revascularization." TMLR in combination with intramyocardial injection of ABMSC is a safe method to achieve a statistically significant antianginal effect and reduce the need for "nitrates," which in turn improves the quality of life and reduces the frequency of hospitalizations due to coronary artery disease. These results can be achieved with strict adherence to the certain indications for the intervention.

Remodeling Failing Human Myocardium With Hybrid Cell/Matrix and Transmyocardial Revascularization

Given the limited treatment options for advanced heart failure, the intrinsic regenerative properties of stem cells have been evaluated for myocardial remodeling. Previous stem cells techniques for myocardiocyte remodeling have been limited by the low cellular retention. Presented is a hybrid approach for remodeling infarcted myocardium through implantation of allogeneic human amniotic fluid-derived mesenchymal stem cells within micronized human allograft-derived liquid matrix during the performance of transmyocardial revascularization (TMR). Given the induced increase in vascular density from TMR, we hypothesize that it may serve as a therapeutic delivery system for stem cell placement into damaged myocardium. We present a patient with ischemic cardiomyopathy and refractory angina, who clinically improved after this hybrid therapy of intraoperative TMR and placement of amniotic fluid-derived mesenchymal stem cells and liquid matrix within the TMR channels. Noninvasive testing of myocardial viability biomarkers utilizing both cardiac magnetic resonance imaging and thallium imaging supported the clinical improvement in cardiac symptom may be related to ventricular remodeling in a region of infarct with subsequent functional improvement.