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NATURE|Vol 451|21 February 2008|doi:10.

1038/nature06800 INSIGHT REVIEW

Stem-cell therapy for cardiac disease


Vincent F. M. Segers1 & Richard T. Lee1

Heart failure is the leading cause of death worldwide, and current therapies only delay progression of the
disease. Laboratory experiments and recent clinical trials suggest that cell-based therapies can improve
cardiac function, and the implications of this for cardiac regeneration are causing great excitement. Bone-
marrow-derived progenitor cells and other progenitor cells can differentiate into vascular cell types, restoring
blood flow. More recently, resident cardiac stem cells have been shown to differentiate into multiple cell types
present in the heart, including cardiac muscle cells, indicating that the heart is not terminally differentiated.
These new findings have stimulated optimism that the progression of heart failure can be prevented or even
reversed with cell-based therapy.

Ischaemic heart disease — characterized by reduced blood supply such as α-myosin heavy chain and troponin T (ref. 6). Cardiac regenera-
to the heart muscle — is the primary cause of death throughout the tion in zebrafish might be initiated predominantly by undifferentiated
world, including most low-income and middle-income countries1. stem or progenitor cells from the outer (epicardial) layer of the heart8.
Obstruction of coronary arteries leads to myocardial infarction (heart Further study of newts and zebrafish will define more clearly whether
attack) with the associated death of cardiomyocytes. This overloads cardiac regeneration in these organisms requires dedifferentiation, pro-
the surviving myocardium and eventually leads to heart failure (see liferation and subsequent differentiation of existing cardiomyocytes, or
page 919). Other causes of heart failure, including chronic high blood whether regeneration is driven by the recruitment of stem cells to the
pressure, are also characterized by a gradual loss of cardiomyocytes2, injured site. By contrast, in mammalian hearts cardiomyocytes bor-
and experimental inhibition of programmed cell death can improve dering a myocardial infarction rarely divide after injury9,10, although
cardiac function3. The only standard therapy for heart failure that transgenic overexpression of specific genes in mice can increase cardio-
addresses the fundamental problem of cardiomyocyte loss is cardiac myocyte division10.
transplantation. New discoveries on the regenerative potential of stem There is strong evidence that endothelial cells are renewed by bone-
cells and progenitor cells for treating and preventing heart failure have marrow-derived progenitor cells11, but the idea that cardiomyocytes
transformed experimental research and led to an explosion in clinical are renewed by such cells is vigorously debated11. Less controversially,
investigation. The crucial point at which it is decided that laboratory many laboratories have now demonstrated that adult mammalian
evidence sufficiently supports clinical experimentation is particularly myocardium has a population of resident cardiac stem cells (CSCs) with
controversial in stem-cell therapy for heart failure, so it is timely to the potential to differentiate into cardiomyocytes and other cell types
consider the current state of this field. In this review, we discuss the such as endothelial and vascular smooth muscle cells12–15. It has been
current knowledge of regeneration in the adult mammalian heart. proposed that CSCs support basal turnover of cardiomyocytes6,11, but
We also consider the various stem-cell and progenitor-cell types that this probably occurs at a very low rate in the absence of injury16. CSCs
might regenerate the myocardium and review the major challenges have a high proliferation and differentiation potential in vitro12–15, and
to such therapy. the possibilities of expanding autologous CSCs ex vivo or stimulating
the regeneration capacity of these cells in vivo are exciting options for
Cardiac regeneration therapeutic regeneration.
Few questions in cardiac regeneration are definitively resolved. But it The realization that regenerative mechanisms do exist in mammalian
is widely agreed that the regenerative capacity of human myocardium myocardium brings into sharp focus the problem of defining the bar-
is grossly inadequate to compensate for the severe loss of heart muscle riers that could be preventing regeneration, including the ischaemia,
presented by catastrophic myocardial infarction or other myocardial inflammation and fibrosis that characterize various stages of infarcted
diseases. By contrast, skeletal muscle in mammals can regenerate effi- myocardium (Fig. 1). This hostile microenvironment might prevent the
ciently, even after widespread injury4,5. Satellite cells and other types of activation of resident CSCs and thus also reduce the success of exogenous
myoblast reside in skeletal muscle and form large numbers of new myo- cell therapies. Some components of the inflammatory response might be
tubes within days of muscle injury. However, a regenerative response essential for promoting angiogenesis and progenitor-cell recruitment, but
does occur in the hearts of some vertebrates, such as zebrafish and excessive inflammation might also prevent the recruitment and survival
newts, after injury6,7. In the normal state, newt cardiomyocytes, like of progenitor cells. Similarly, some degree of fibrosis is required to pre-
those of mice and humans, rarely divide. But after a substantial injury, vent myocardial rupture after a myocardial infarction, but dense fibrosis
remaining cardiomyocytes initiate DNA synthesis and re-enter the cell presents a formidable physical barrier to regenerating cells17. It is likely
cycle6. Division of existing cardiomyocytes seems to be the most impor- that no single factor defines the hostile microenvironment of injured
tant factor for cardiac regeneration in this animal. Dedifferentiation of myocardium. In the MRL mouse strain, multiple genetic loci contribute
cardiomyocytes near the injured zone occurs before their proliferation to increased regenerative capacity in some organs, such as faster wound
and is characterized by loss of expression of cardiac contractile proteins closure with minimal scar formation18. Several beneficial mechanisms

1
Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Partners Research Facility, 65 Landsdowne Street, Cambridge,
Massachusetts 02139, USA.

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INSIGHT REVIEW NATURE|Vol 451|21 February 2008

Cardiomyocyte Bone-marrow lack of efficacy22, and it is unlikely that skeletal myoblasts will be able to
proliferation stem-cell truly regenerate myocardium. Mouse skeletal muscle contains a popu-
mobilization lation of non-satellite cells that can differentiate into spontaneously
beating cells with cardiomyocyte features23, but an equivalent popula-
tion of cardiac-committed cells in human skeletal muscle has not yet
been described.

Bone-marrow-derived cells
A subset of bone-marrow-derived haematopoietic cells were the first
adult stem cells or progenitor cells reported to differentiate into cardio-

n
ra c
re
Ca ne

H o s t il e

ne ia
tio
ge

ge rd
rd rat

roenvironmen myocytes when transplanted into infarcted hearts of mice24. The first

re Ca
ia ion

i c
c

m t
Inflammation evidence that adult bone-marrow-derived progenitor cells participate
Terminal
Inadequate in the formation of cardiomyocytes in adult human hearts was based
mobilization
differentiation on reports of Y-chromosome-positive cardiomyocytes in female donor
Inefficient homing
Low proliferation hearts transplanted in male recipients25. Animal studies of bone-mar-
Inadequate
ge n e si s

capacity row transplantation with labelled haematopoietic stem cells followed by


multipotency
myocardial infarction revealed cardiomyocytes derived from the trans-
planted cells, but at an exceptionally low rate26. However, other studies
gio
Fi b

an
ro

s in animals have not demonstrated differentiation of haematopoietic


si

at
e

qu progenitor cells into cardiomyocytes24,27,28 or improvement in cardiac


Inade
function29. Currently, no consensus exists on whether bone-marrow-
regeneration

Inadequate proliferation Insufficient numbers derived progenitor cells differentiate into cardiomyocytes in vivo.
Cardiac

and differentiation of available stem cells


Endothelial progenitor cells (EPCs) are a subset of haematopoietic
Inadequate chemotaxis Loss of stem-cell function with age cells found in the bone marrow that have the potential to differenti-
ate into endothelial cells30. EPCs have not been shown to differentiate
into cardiomyocytes in vivo, but they probably have a role in promoting
angiogenesis10,30. In addition to directly contributing to the vasculature
required to deliver nutrients to new cardiomyocytes, endothelial cells
can also provide paracrine survival signals to cardiomyocytes31. EPCs are
Resident cardiac stem cells readily isolated from the blood and the bone marrow, and clinical studies
suggest that cell-based therapy with EPCs can improve myocardial func-
Figure 1 | Mechanisms of, and potential barriers to, endogenous cardiac
regeneration. Cardiomyocyte proliferation has a role in the regeneration
tion32. But definitions of EPCs vary such that different studies probably
of the heart in some vertebrates, but the proliferative capacity of these cells use different types of cell, making comparisons difficult.
is limited in the adult mammalian heart. After injection or mobilization of So far, most clinical studies have used bone-marrow mononuclear
bone-marrow-derived cells, bone-marrow-derived cardiomyocytes have cells and showed either no benefit or small (but possibly clinically
been detected at very low rates in adult hearts, indicating that bone-marrow- important) improvements in cardiac function32. The mechanisms of
derived progenitor cells may be able to migrate to the heart and differentiate these functional improvements are unknown, but it is unlikely that
into cardiomyocytes or fuse with existing cardiomyocytes. However, these the improvements result from differentiation of the injected cells into
findings are still controversial after half a decade of intensive research. cardiomyocytes. Growth factor and cytokine release by injected cells is
Resident cardiac stem cells (CSCs) with the potential to differentiate into frequently suggested as a potential mechanism of action32, and improved
multiple myocardial cell types, including cardiomyocytes, have been
microvascular function has been shown in the REPAIR-AMI study33.
isolated from myocardium. It is not completely clear what barriers prevent
endogenous CSCs from regenerating myocardium more effectively. The bone marrow also contains mesenchymal stem cells, multipotent
cells that can differentiate into osteoblasts, chondrocytes and
adipocytes34. A subset of mesenchymal stem cells can differentiate into
working together seem to contribute to the improved cardiac regenerative cardiomyocytes under specific conditions in vitro20,34. Differentiation
capacity sometimes observed in these mice, including increased vasculari- into cardiomyocytes in vivo has also been observed, but at an extremely
zation and cell proliferation as well as reduced apoptosis and fibrosis19. low rate35,36. A potential advantage of mesenchymal stem cells is that
they are less immunogenic than other stem cells, potentially allowing
Which stem cells should be used for cardiac therapy? allogeneic cell therapy36. Mesenchymal stem cells can provide paracrine
Perhaps the most stunning aspect of current progress towards cardiac growth factor support for other cells present in injured myocardium34,37,
regeneration is the wide variety of cell types that have been considered and this could be the major mechanism for the beneficial effects of these
as candidates for therapeutic delivery in humans (Fig. 2). This myriad cells. To increase the therapeutic potency of mesenchymal stem cells,
of cell types reflects the unmet medical need for treating heart dis- they have been genetically modified to overexpress prosurvival factors,
ease, and hence the large amount of experimental effort being put into angiogenic factors, growth factors, or stem-cell homing factors34. A cau-
devising cell-based therapies. It also points to the lack of mechanistic tionary note, however, was sounded by a report that found these cells dif-
understanding at many levels. The ideal cell type has not yet emerged, ferentiating into bone-forming osteoblasts — instead of cardiomyocytes
and few studies have directly compared different stem-cell types20. — in transplanted mouse hearts38. These results highlight the principle
that even if multipotent stem cells, such as mesenchymal stem cells,
Skeletal myoblasts have cardiomyocyte differentiation potential, preventing differentiation
One of the first cell-based cardiac regeneration strategies was injec- into other cell types is a crucial consideration. In addition to EPCs and
tion of autologous skeletal myoblasts into ischaemic myocardium21. mesenchymal stem cells, the bone marrow contains other populations
Myoblasts are resistant to ischaemia, can differentiate into myotubes in of putative progenitor or stem cells with the potential to differentiate
vivo (but not into cardiomyocytes11) and improve ventricular function into myocytes39.
in laboratory animal experiments21. Myotubes do not integrate electri-
cally with surviving cardiomyocytes11 and thus do not beat in synchrony Embryonic stem cells
with the surrounding myocardium. Human trials of myoblasts in heart Embryonic stem (ES) cells are the prototypical stem cells. They unambig-
failure are ongoing; however, some have been terminated because of uously fulfil all requirements of stem cells: clonality, self renewal and
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NATURE|Vol 451|21 February 2008 INSIGHT REVIEW

Figure 2 | Many cell types and


Source Cell type Potential mechanisms Potential effects
of action
mechanisms have been proposed
Direct contribution
for cardiac therapy. Stem cells and
Blastula Embryonic Differentiation to contractility progenitor cells can be isolated
stem cells into cardiomyocytes from either autologous or allogeneic
Skin Remodelling of sources. Different types of stem
fibroblasts electrical properties cell and progenitor cell have been
shown to improve cardiac function
Cardiac Remodelling of infarcts through various mechanisms,
Heart Differentiation into
stem cells
endothelial cells including the formation of new
Angiogenesis myocytes, endothelial cells and
Blood vascular smooth muscle cells, as well
Remodelling of the
as through paracrine effects.
Endothelial extracellular matrix
progenitor cells Differentiation into
Bone smooth muscle cells Contribution to
marrow mechanical properties
of the scar
Mesenchymal
Fat stem cells Paracrine effects Activation of
endogenous stem cells

multipotentiality40. ES cells can differentiate into any cell present in proportion of stem cells that express the cell-surface markers Kit12
the adult organism and have the potential to completely regenerate the or Sca1 (ref. 48). Side-population cells, identified by their ability to
myocardium. Two of the obstacles that stand in the way of the thera- exclude Hoechst dye, were first described in the bone marrow as being
peutic use of ES cells are immunological rejection and the propensity enriched in haematopoietic stem cells, but they are also found in other
of ES cells to form teratomas when injected in vivo11,41. As knowl- organs, including the heart14. Some side-population cells express Kit
edge of pathways for ES-cell differentiation and for heart embryonic and/or Sca1, and like Kit+ CSCs and Sca1+ CSCs, side-population cells
development increases, ES-cell differentiation might become more can generate cardiomyocytes in vitro and in vivo49. In addition to Kit+
controllable. Methods to limit teratoma formation include genetic CSCs, Sca1+ CSCs and side-population cells, a fourth population of
selection of differentiated ES cells42, or differentiation of ES cells in CSCs expresses the transcription factor Isl1 (ref. 13). Lineage-tracing
vitro into cardiomyocytes or endothelial cells before injection43,44; for experiments have shown that Isl1-expressing cells can differentiate into
example, tumour-necrosis factor promotes the differentiation of ES endothelial, endocardial, smooth muscle, conduction system, right ven-
cells into cardiomyocytes45. Differentiated ES cells can survive and tricular and atrial myogenic lineages during the development of the
improve myocardial function if delivered to the myocardium in a rich embryonic heart50. Isl1-expressing cells are also present in the adult
prosurvival cocktail43. An inherent difficulty in controlling the growth mammalian heart, but they are limited to the right atrium, are found
and differentiation of ES cells and other pluripotent stem cells is that in smaller numbers than in embryonic hearts13 and have an unknown
the timing with which specific signalling pathways are activated might physiological role. Recently, epicardium-derived progenitor cells have
be crucial. For example, recent studies on mouse and zebrafish embryos been described that show angiogenic potential51,52.
reveal that the role of the Wnt–β-catenin pathway in cardiac develop- CSCs can be isolated and expanded from human myocardial sam-
ment varies depending on the developmental stage46. ples obtained using a minimally invasive biopsy procedure53,54. Thus,
from autologous CSCs, it might be possible to generate enough cells
Endogenous cardiac stem cells to transplant into patients with heart failure, a procedure that would
Because allogeneic cells face immunological challenges that would have minimal risk of immune rejection or teratoma formation. But no
probably require immunosuppression, the isolation of endogenous clinical data using CSCs are available yet, and many important ques-
adult mammalian CSCs on the basis of cell-surface markers has gener- tions about CSCs remain unanswered. Can their in vitro proliferative
ated great enthusiasm47. However, a definitive marker for CSCs has and differentiation potential translate to long-term in vivo function? Do
not yet been identified. Mammalian myocardium includes a small they retain their cardiogenic potential in disease states, or with advanced
Isolation Delivery Survival and proliferation Electromechanical Stability and safety
integration
• Blood • Intravenous
Choices

• Bone marrow • Intracoronary


• Muscle biopsy • Intramyocardial
• Cardiac biopsy
• Embryonic stem cells
Challenges

• Purity of isolated cells • Safety • Ischaemic environment • Differentiation into • Long-term engraftment
• Sufficient number of cells • Cell retention • Inflammation mature cardiomyocytes • Arrythmogenicity
• Differentiation into • Spatial distribution • Immune response • Electrical integration
cardiomyocytes • Fibrosis • Mechanical coupling
before transplantation • Growth and adhesion signals
• Formation of functional
blood vessels
Figure 3 | Challenges to stem-cell therapy for cardiac disease. True cardiac regeneration with stem-cell therapy will require careful consideration at each
step, from isolation of the cells to their stable and safe long-term integration.

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INSIGHT REVIEW NATURE|Vol 451|21 February 2008

Box 1 | Fundamental questions in CSC therapy stem cells to the injured myocardium. For example, local myocardial
Is the optimal opportunity for CSC therapy early after myocardial
delivery of the chemoattractant cytokine CXCL12 can improve hom-
infarction or in chronic cardiomyopathy? ing of EPCs to the heart56. Furthermore, mesenchymal stem cells can
• The advantages of therapy immediately after myocardial infarction be found in small numbers in peripheral blood57, indicating that non-
include preservation of myocardial architecture. Fibrosis is minimal and haematopoietic stem cells or progenitor cells circulate and might have
cardiac remodelling of the remaining viable myocardium has not yet the capability to home to injured tissues. Like stem cells or progenitor
occurred. Paracrine mechanisms that promote cell survival or promote cells in other tissues, CSCs reside in clusters consistent with the exist-
angiogenesis might be a good strategy for this early period. ence of cardiac niches53. The factors that attract these cells out of their
• The advantages of therapy in chronic cardiomyopathy include putative niches to an injury site remain to be defined. The question
clinical stability and a larger target patient population. The stable scar also remains whether CSCs stably reside in the heart or are derived
tissue has less intense inflammation. Contractile cells or cells that from other tissues such as the bone marrow, as has been suggested for
can differentiate into contractile cells might be the best choice in this Kit+ cells58.
situation.
Strategies and challenges
Can allogeneic cells be used? Some of the challenges facing stem-cell therapy for cardiac disease
• Allogeneic cells that are ‘off the shelf’ can be generated with a high are outlined in Fig. 3. The most obvious question to be answered by
degree of homogeneity and quality control. Therapy immediately after preclinical studies is which type of stem cell or progenitor cell is the best
myocardial infarction is possible at a potentially lower cost. candidate for therapy20. Bone-marrow-derived progenitor cell therapy
• Allogeneic cells will be more prone to rejection than autologous cells, has thus far proven safe and beneficial under defined circumstances
and the need for chronic immunosuppression could increase the risk
(acute myocardial infarction), but the cells’ regeneration potential is
over the benefit.
controversial. CSCs have the potential to be patient specific, but isola-
How much mechanistic understanding is needed before clinical trials?
tion and culture procedures are in the early development stages53,54. ES
• The fundamental mechanisms of cardiac regeneration in humans are cells have the greatest differentiation potential, but face ethical barriers
incompletely defined, and the degree of experimental evidence needed and also have the greatest risk for teratoma formation41. Whether ES-cell
to justify clinical trials is controversial. derivatives will be rejected by the host immune response is still under
• Although current enthusiasm for translating CSC therapy into humans debate; in principle, however, rejection can be avoided by using cells
seems appropriate, patient safety and clinical trials that adequately test from a bank of only 150 donors with different HLA types59. If the new
defined hypotheses are key considerations. technology that reprogrammes human and mouse fibroblasts to ES-like
• At this early stage, clinical trials should maximize the potential for cells can be harnessed60–63, the use of patient-specific reprogrammed
obtaining rigorous mechanistic information. cells could reduce or even eliminate immune rejection. A crucial issue
in designing more rational cell-based therapy approaches for cardiac
What are the primary mechanism by which different types of stem cell disease is understanding the mechanisms by which each of the stem-cell
or progenitor cell improve myocardial performance? or progenitor-cell types can affect myocardial performance11,55 (Fig. 2
• Different cell types might be capable of improving cardiac function by and Box 1). Also, different cardiac pathologies — for example, acute
distinct mechanisms. myocardial infarction and chronic ischaemic cardiomyopathy — might
• ES cells and resident CSCs might have true mechanical potential, as require different types of stem cell or progenitor cell (Box 1).
they can differentiate into mature cardiomyocytes. Another issue for cell-based therapy is determining the optimal
• Mesenchymal stem cells might improve angiogenesis by paracrine route of delivery. Cells can be injected intravenously, into coronary
factors, but other mechanisms are plausible. arteries or directly into the myocardium. Myocardial stem-cell and
• EPCs have the greatest potential for angiogenesis.
progenitor-cell delivery with these approaches in numerous phase I
clinical trials has thus far revealed few serious adverse effects32. Recent
Will cells be necessary?
• The greatest potential of stem-cell therapy is true cardiac regeneration
trials that include a control group are listed in Table 1. Retention of
through differentiation into cardiomyocytes. However, studies so far cells immediately after delivery is highly dependent on the delivery
suggest that the differentiation of bone-marrow progenitor cells into strategy: if cells are injected intramyocardially during open-chest sur-
cardiomyocytes is a rare event, and the positive effects of cell-based gery, many cells are lost through the vasculature21, and few cells infused
therapy could be due to cell-derived paracrine factors. into coronary arteries ultimately engraft20. Survival in the inflamma-
• Transplantation of stem cells or progenitor cells for their paracrine tory environment of infarcted myocardium is a challenge common to
effects remains a reasonable strategy because the beneficial paracrine all types of transplanted cell, as typically 90% of the cells die within a
factors remain unidentified and because multiple factors might be week11. A sufficiently large cell graft with appropriate structural and
functioning synergistically. functional properties will be needed. Because persistent ischaemia also
• If paracrine cell-derived factors that improve cardiac function are limits cell survival, revascularization and improving angiogenesis could
identified, then protein-based therapy might be more easily translated be essential components of cell-based therapy. Survival and integration
into clinical benefits than cell-based therapy. of transplanted cells can also be improved by embedding them in matri-
ces such as collagen21 or Matrigel43, by implanting cells as monolayer
sheets35 or by simultaneously delivering growth factors43,64. Long-term
age? To what extent are the different types of CSC that have been identi- electromechanical stability and appropriate structural and functional
fied really different cell types? Or are they the same cell type at varying electromechanical integration65 with host tissue will be essential for
stages of differentiation47? Are all the CSCs that have been isolated so cardiac regeneration.
far truly capable of self renewal in vivo, and is their plasticity real or just
a laboratory artefact? Future directions
The identification of various cell types with cardiogenic potential In many studies, the number of differentiated and functionally inte-
has also stimulated interest in improving cardiac function by mobi- grated myocytes derived from transplanted stem cells is too small to
lizing endogenous stem cells and progenitor cells without removing explain the observed improvements in cardiac function37,47. Improved
and expanding the cells ex vivo. Proangiogenic factors either produced cardiac function in these studies might be driven by paracrine mecha-
by ischaemic tissues or administered exogenously can mobilize EPCs nisms, and identification of these cell-derived paracrine factors could
and improve vascular function47,55. In addition to mobilizing stem cells lead to effective therapies without delivery of the cells themselves. Local
from the bone marrow, homing signals can be important for guiding intramyocardial delivery of cytokines or growth factors could be more
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NATURE|Vol 451|21 February 2008 INSIGHT REVIEW

Table 1 | Overview of clinical trials of stem-cell or progenitor-cell delivery to the heart


Cell type Study design Number of Mean follow-up Number of cells Route of injection Ejection fraction Source‡
patients* duration (months) injected versus control (%)†
BMMNC R-SB 60 12 108 Intracoronary +7.0 (P = 0.03) Meluzin et al.67 (2007)
R-SB 51 3 2 × 108 Intracoronary +4.1 (P = 0.001) Assmus et al.32 (2006)
R-SB 66 3 108 Intracoronary +3 (P = 0.04) Meluzin et al.68 (2006)
R-SB 204 12 2.4 × 108 Intracoronary Decreased mortality Schächinger et al.69 (2006)
7
R-SB 20 6 4 ×1 0 Intracoronary +6.7 (NS) Ge et al.32 (2006)
7
R-SB 20 4 6 × 10 TEIM +2.5 (NS) Hendrikx et al.32 (2006)
8
R-DB 67 4 1.7 × 10 Intracoronary +1.2 (NS) Janssens et al.32 (2006)
7
R-SB 100 6 8.7 × 10 Intracoronary –3.0 (P = 0.05) Lunde et al.32 (2006)
9
R-SB 60 18 2.5 × 10 Intracoronary +2.8 (NS) Meyer et al.32 (2006)
8
Cohort§ 36 3 3 × 10 TEIM +4.0 (NS) Mocini et al.32 (2006)
8
R-SB 204 4 2.4 × 10 Intracoronary +2.5 (P = 0.01) Schächinger et al.32 (2006)
7
Cohort§ 36 3 9 × 10 Intracoronary +7.0 (P = 0.02) Strauer et al.32 (2005)
Cohort§ 20 12 2.6 × 107 TEIM +8.1 (NS) Perin et al.32 (2004)
Cohort§ 20 3 2.8 × 107 Intracoronary +1.0 (NS) Strauer et al.32 (2002)
CPC Cohort§ 54 6 5 × 109 Intracoronary +6.0 (P = 0.04) Tatsumi et al.70 (2007)
Cohort§ 73 6 2 × 109 Intracoronary +2.8 (NS) Choi et al.71 (2007)
7
R-SB 47 3 2 × 10 Intracoronary +0.8 (NS) Assmus et al.32 (2006)
9
R 82 6 1.4 × 10 Intracoronary –0.2 (NS) Kang et al.32 (2006)
7
Cohort§ 70 6 7.3 × 10 Intracoronary +5.5 (P = 0.04) Li et al.32 (2006)
7
SB 26 3 7 × 10 Intracoronary +7.2 (NS) Erbs et al.32 (2005)
+
CD133 Cohort§ 27 6 NA Intramyocardial || NA Ahmadi et al.72 (2007)
6
Cohort§ 55 6 6 × 10 Intramyocardial || +6.3 (P = 0.02) Stamm et al.73 (2007)
7
Cohort§ 35 4 1.3 × 10 Intracoronary +2.8 (NS) Bartunek et al.32 (2005)
+ 7
CD34 R-DB 24 6 3.5 × 10 TEIM NA Losordo et al.74 (2007)
SMB R-DB 97 6 NA Intramyocardial || +3 (P < 0.04) MAGIC22 (2007)
8
Cohort§ 26 12 2.5 × 10 Intramyocardial || +14.5 (P < 0.01) Gavira et al.75 (2006)
8
Cohort§ 12 12 2.1 × 10 TEIM +11.6 (P < 0.05 ) Ince et al.76 (2004)
6
MSC R 48 12 5 × 10 Intracoronary –3 (NS) Chen et al.77 (2006)
10
R-SB 69 6 6 × 10 Intracoronary +12.0 (P = 0.01) Chen et al.32 (2004)
6
MSC + EPC Cohort§ 22 4 3 × 10 Intracoronary +0.3 (NS) Katritsis et al.32 (2005)
BMC R-DB 20 6 NA Intracoronary +9.2 (P < 0.05) Ruan et al.32 (2005)
BMC, bone-marrow-derived cells (unspecified); BMMNC, bone-marrow mononuclear cell; CPC, circulating progenitor cell; DB, double blinded; EPC, endothelial progenitor cell; MSC, mesenchymal stem
cell; NA, not available; NS, not significant; R, randomized; SB, single blinded; SMB, skeletal myoblast; TEIM, transendocardial intramyocardial injection. *The number of patients is the sum of individuals in the
control and treatment groups; almost all studies have equal numbers in each group. †Ejection fraction is the proportion of blood in the left ventricle that is ejected into the aorta during each heartbeat; this
is a measure of cardiac function. ‡The author names refer to the original report, and the reference number cited indicates either the original report or a meta-analysis (or review) in which the original report is
discussed. §Cohort denotes a non-randomized and non-blinded study. ||Intramyocardial indicates injection through the epicardial side of the heart.

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Defining the factors present in the hostile microenvironment of injured This comprehensive review discusses the cardiac regeneration potential of different
myocardium that limit the survival and functional integration of trans- stem cells and the possible experimental artefacts.
planted cells is also crucial. As the barriers that prevent human cardiac 12. Beltrami, A. P. et al. Adult cardiac stem cells are multipotent and support myocardial
regeneration. Cell 114, 763–776 (2003).
regeneration are further defined, clinical trials should proceed with cau- 13. Laugwitz, K. L. et al. Postnatal isl1+ cardioblasts enter fully differentiated cardiomyocyte
tion and with a paramount concern for patient safety. ■ lineages. Nature 433, 647–653 (2005).
14. Martin, C. M. et al. Persistent expression of the ATP-binding cassette transporter, Abcg2,
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comments.
self-proliferation and selective homing of bone marrow-derived stem cells. Circ. Res. 97,
1090–1092 (2005). Author Information Reprints and permissions information is available at
50. Moretti, A. et al. Multipotent embryonic isl1+ progenitor cells lead to cardiac, smooth npg.nature.com/reprints. The authors declare no competing financial interests.
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