The n e w e ng l a n d j o u r na l of m e dic i n e

edi t or i a l s

Illuminating the Potential of Pluripotent Stem Cells

Anthony Rosenzweig, M.D.

A classic joke often used to illustrate the nature
of scientific investigation describes a drunk search-
ing for his keys under a lamppost, even though
he dropped them some distance away, because
“that’s where the light is.” Similarly, since the time
of William Harvey, attempts to understand human
cardiac physiology have relied heavily on animal
models. Although much has been learned through
these efforts, there are important differences
among species that reinforce the intuitive prem-
ise that it would be preferable to study human
pathophysiology in human cells. In this issue of
the Journal, Moretti and colleagues1 elegantly
show the feasibility of doing just this by using a
recently developed approach to turn a patient’s
skin cells into pluripotent stem cells that can
then be differentiated into human heart muscle
cells (cardiomyocytes).
In 2006, Takahashi and Yamanaka reported
that differentiated murine fibroblasts could be re-
programmed into stem cells capable of forming
all three germ layers; they termed these cells “in-
duced pluripotent stem cells.”2 The process re-
quired expression of a small number of transcrip-
tion factors and was quickly extended to human
cells.3-5 Although much excitement has been gen-
erated by the potential for therapeutic delivery of
such cells for tissue regeneration, considerable
challenges remain to make this a practical reality.
A more immediate application of this technol-
ogy that may also have important implications
for human health lies in the development of cel-
lular models of disease genetically matched to
specific patients. Such models provide a human
context for unraveling disease pathophysiology,
validating therapeutic targets, and examining the
response to pharmacologic interventions. The fea-
sibility of this approach depends on how well such
systems recapitulate disease phenotypes. Several
groups have generated patient-specific induced
pluripotent stem cells, differentiated them into
relevant cell types, and demonstrated that the cells
produced by this process still harbor the respon-
sible mutations6,7 and manifest the morphologic
characteristics of the disease.8,9 However, whether
this system could robustly and reproducibly model
complex physiological processes such as those
seen in beating cardiomyocytes has been less
clear.
Moretti and colleagues assessed the electro-
physiological characteristics of cardiomyocytes de-
rived from induced pluripotent stem cells from
a family with the most common form of the long-
QT syndrome, long-QT syndrome type 1. Evalu-
ation of an 8-year-old boy with a prolonged QT
interval led to the identification of a missense mu-
tation in KCNQ1, a potassium channel that con-
tributes to delayed rectifying currents involved in
termination of the action potential and that has
already been implicated in long-QT syndrome
type 1. With the use of skin biopsies, induced plu-
ripotent stem cells were generated from the boy
and his father (who harbored the same mutation),
as well as from two healthy control subjects, and
were then differentiated into cardiomyocytes. Car-
diomyocytes derived from induced pluripotent
stem cells beat spontaneously in a dish or can be
paced to provide a standardized stimulus. Since
induced pluripotent stem cells can differentiate
into various cardiomyocyte lineages with distinct
characteristics, Moretti and colleagues used elec-
trophysiological measurements to categorize the
cardiomyocytes that were generated as having
“atrial,” “nodal,” or “ventricular” characteristics
and then evaluated the “ventricular” cardiomyo-
cytes at baseline and in response to pharmaco-

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 The n e w e ng l a n d j o u r na l
logic manipulation. The patient-derived cardio-
myocytes manifested slower repolarization with
prolonged action potential durations and a highly
specific defect in the particular potassium current
(Iks) encoded by KCNQ1. Adrenergic stimulation
(a recognized trigger of arrhythmia in patients
with long-QT syndrome type 1) exacerbated the
electrophysiological abnormalities in the patient-
derived cardiomyocytes, and this effect was mit-
igated by beta-blockade (a mainstay of current
therapy).
Although these results are largely confirma-
tory of similar observations in animal models,
such validation may be particularly meaningful in
the case of long-QT syndrome type 1, since rec-
tifying potassium currents are quite different in
mice,10 a species commonly used for studies of
long-QT syndrome, than in humans. Moretti and
colleagues went on to show that, although the
level of expression of KCNQ1 in cardiomyocytes de-
rived from induced pluripotent stem cells from
the patients with long-QT syndrome type 1 was
similar to that seen in cells from healthy controls,
the distribution of KCNQ1 within these cells ap-
peared to be abnormal. Additional studies in
which either the wild-type or mutant subunits
were expressed suggested that the mutation alters
membrane trafficking of the channel and may act
in a dominant negative manner when incorporat-
ed into the tetrameric channel. Ironically, these
expression studies were performed in H9c2 cells,
a rat cell line, presumably because the studies
were easier to perform in those cells, underscor-
ing the technical challenges that remain in work-
ing with cardiomyocytes derived from induced
pluripotent stem cells. Nevertheless, these stud-
ies provide important proof of concept that car-
diomyocytes derived from induced pluripotent
stem cells can be used to recapitulate complex
physiological phenotypes, probe pharmacologic
responses, and provide novel mechanistic insights.
Realizing the full potential of this approach
will itself be challenging. Working with induced
pluripotent stem cells remains technically de-
manding, and the process of differentiation into
specific cell types is incompletely understood, of-
ten inefficient, and somewhat variable. It is im-
portant to note that there are many disease phe-
notypes that simple in vitro models may not be
able to recapitulate, since the pathophysiology
1472 n engl j med 363;15  nejm.org  october 7, 2010
The New England Journal of Medicine
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of m e dic i n e
of these diseases may require multiple cell types
or interactions that are present only in vivo. In
some diseases, it even remains unclear which cell
type is most relevant. In addition, most diseases
are complex traits reflecting a mixture of multi-
ple genetic and environmental influences. In
such disorders, as compared with mendelian con-
ditions (such as long-QT syndrome type 1), the
effects of genetic variation are likely to be more
subtle and difficult to study in cells derived from
induced pluripotent stem cells.
Despite these challenges, patient-specific cellu-
lar models derived from induced pluripotent stem
cells provide an important additional tool for the
study of human disease. In the case of research
on cardiac conditions, in which the availability
and viability of human cardiomyocytes have been
limiting factors, induced pluripotent stem cells
provide an unprecedented opportunity to study
disease mechanisms and potential therapies in a
human cellular context, shining a new and pow-
erful light on some of the very processes we hope
to understand.
Disclosure forms provided by the author are available with the
full text of this article at NEJM.org.
From the Cardiovascular Division, Beth Israel Deaconess Med-
ical Center, and Harvard Medical School — both in Boston,
and the Harvard Stem Cell Institute, Cambridge, MA.
1. Moretti A, Bellin M, Welling A, et al. Patient-specific induced
pluripotent stem-cell models for long-QT syndrome. N Engl J
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from mouse embryonic and adult fibroblast cultures by defined
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Copyright © 2010 Massachusetts Medical Society.