Method for treating the cases of non-operable cardiologic patients

FIELD: medicine.

SUBSTANCE: method involves using mononuclear autologic marrow fraction containing 6-9x10⁴ mesenchyma cells per 1 ml or autologic mesenchyma trunk cells. The cells are separated from brain bioptate in the amount of 10⁶ cells/kg of patient body mass. The preparations are intracoronarily introduced in fractions at a rate of 3-5 ml/min into the right coronary artery. The introduction is also carried out in intra-arterial mode in jets or in drops.

EFFECT: higher survival rate and life quality of cardiologic patients.

1 dwg

The invention relates to medicine, more specifically to cardiology and cardiovascular surgery, and may find application in the treatment of cardiac patients.

The proposed method for the treatment of inoperable patients with ischemic heart disease and idiopathic dilated cardiomyopathy, who belong to one of the most difficult groups of cardiac patients and for which there is currently no specific treatment.

Coronary heart disease (CHD) is one of the major causes of disability and death. Treatment of disease is carried out mainly through drug therapy. Operative (surgical) treatment of coronary heart disease runs in the event of failure of medical therapy or in cases where the nature of the lesion of the coronary arteries determines a high risk of cardiac death (Recommendations by the American Heart Association and American College of Cardiology “Coronary bypass surgery” JACC, Vol.34, No. 4, October 1999:1262-1347). Inoperable patients are patients of coronary heart disease in whom the risk of surgery outweighs the expected benefit of surgical treatment in the form of elimination of symptoms that limit activity. These patients constitute the most severe category CHD patients as medical cured the e already inefficient and the severity of the condition or the nature of the lesion of vessels of the heart makes it almost impossible for surgical treatment. However, surgical treatment remains in this category of patients the only way to save lives.

Idiopathic dilated cardiomyopathy (IDCMP) - incurable genetically determined myocardial damage, inherited in an autosomal dominant or autosomal recessive principle (Towbin J, Bowie S, Ortiz-Lopez R, Wang Q. Genetic basis of dilated cardiomyopathy. Cardiomyopathies 1999; 56-65.). IDCMP is one of the most frequent reasons for the development of severe heart failure not amenable to medical therapy. Failures in drug therapy IDCMP require solving the issue of heart transplant (Olson T, Michels V., et al. Actin mutations in dilated cardiomyopathy, a heritable form of heart failure // Sciense 1998; 280) or implantation of mechanical devices (Gronda F., Vitali E. Left ventricle assist systems: a possible alternative to heart transplantation for heart failure patients? Patient selection, techniques and benefit. Eur j Heart Failure, Dec 1999; 1: 320-5.)

Specific treatment IDCMP currently there.

A known method of surgical treatment of patients with coronary artery disease, which consists in restoring blood flow and metabolism of the affected areas of the myocardium by imposing coronary artery anastomosis or perform endovascular angioplasty and testirovanie. However, the majority of patients due to the severity of their condition and this surgical the intervention is not feasible.

There is a method of medical treatment IDCMP, involving the use of inhibitors of angiotensin-converting enzyme (ACE inhibitors), diuretics drugs, drugs with positive inotropic action, etc. However, this method is symptomatic, and ineffective.

Thus, the only specific treatment for unresectable cardiac patients as CHD and IDCMP is a heart transplant is not available to the vast majority of patients, since the number of such patients exceeds the number of donors.

Closest to the proposed medication is the treatment of this category of patients (Treatment of heart failure. Recommendations of the working group for the study of heart failure of the European society of Cardiology. Eng. the honey. Journe. App. 1999.), taken as a prototype.

Because medical therapy, the purpose of which is to reduce clinical manifestations of heart failure - complications of the underlying disease, not aimed at restoring the function of the heart muscle, the quality of life of these patients is poor and the mortality remains high (more than 50% of patients die within the first year when severe heart failure). The specific honey is comentsno therapy for this category of patients is not currently exist.

The technical result of the present invention is to improve patient survival and improve their quality of life.

This result is achieved by the fact that in the treatment of inoperable patients with coronary artery disease and IDCMP use of autologous mononuclear fraction of bone marrow containing 6-9×10⁴mesenchymal cells in 1 ml or autologous mesenchymal stem cells (AMSC) in an amount of 10⁶cells/kg of body weight of the patient, which is injected intracoronary fractional volume up to 50 ml with a maximum speed of 5-10 ml/min in the left and 30 ml fractionally with a maximum speed of 3-5 ml/min in the right coronary artery, and if the patient's condition does not allow the introduction of intracoronary, perform intravenous drip or bolus intra-arterial administration.

Earlier experimental and clinical studies have shown (Zhang S et/al. Transplantation of bone marrow cells upregulated vascular endothelial growth factor and its receptor and improved ischemic myocardial function. Beijing Da Xue Xue Bao. 2003; 35(4):429-433), that the application of the mononuclear fraction of bone marrow or stem cell cultures in acute tissue damage accompanied by activation recovery (repair) processes functioning tissue and reduction in the formation of substitution scar (fibrous) tissue (Assmus Century. Et al. Transplantation of Progenitor Cells and Regeneration Enhancement in Acute Myocardial Infarction (TOPCARE-AMI). Circulation. 2002; 106(24): 009-3017). However, the reverse development is already formed fibrous tissue of the heart and the acquisition of metabolic traits characteristic of the functioning of the myocardium is impossible (Kipshidze n, Serruys P. Handbook of Cardiovascular Cell Transplantation // Martin Dunits, UK, 2004:P425). This is because the most likely stimulus for the differentiation of stem cells into specific tissue products are acute loss of the corresponding tissue.

It is known the use of stem cells in the bone marrow (as the culture of hematopoietic, mesenchymal cells, and in the composition of the mononuclear mist) during operations on the heart, treatment of acute myocardial infarction, aimed at the activation of regenerative processes functioning tissue and reduce the formation of fibrous tissue in the acute coronary insufficiency (Stamm With et al. Autologous bone-marrow stem-cell transplantation for myocardial regeneration. Lancet 2003; 361; 9351: 45-46; Tse H-F et al. Angiogenesis in ischaemic myocardium by intramyocardial autologous bone marrow mononuclear cell implantation. Lancet 2003; 361; 9351: 47-49; Assmus et al In. Transplantation of progenitor cells and regeneration enchancment in acute myocardial infarction. Circulation Circulation 2002; 106: 3009-3017; Strauer BE et al. Repair ofinfarcted myocardium by autologous intracoronary mononuclear bone marrow cell transplantation in humans. Circulation 2002; 106). However, the reverse development is already formed fibrous tissue of the heart and the acquisition of metabolic traits characteristic of the functioning of the myocardium, as said above, is impossible. Fibrous is fabric - not functional, it is not able to reduce, and a low (relative to muscle tissue) consumption of glucose. In positron emission tomography (PET) heart using Tordesillas, labeled with radioactive fluorine [18F], fibrous tissue is detected as a focus of reduced metabolism Tordesillas.

The use of stem cells in patients with no acute focal changes seemed meaningless because these patients there are no incentives for the differentiation of stem cells into specific tissue (no acute necrosis of tissue). And if attempts were made to use stem cells in patients with chronic ischemic heart disease, the introduction of intracoronary cells was accompanied by a modeling ischemia by inflating the balloon in the lumen of the coronary vessel, and intramyocardial the background was always accompanied operating injury.

Mononuclear suspension obtained by sedimentation punctate bone marrow by density gradient with hexaethyltriamido and centrifugation supernatant.

ASK is the fraction of highly purified native mesenchymal stem cells. To obtain AMSC need to fence in a patient 20-35 ml bone marrow (the procedure is performed under short-term anesthesia and continues the I within 10-15 minutes). Further from the bone marrow are highlighted in ASK that tipiloura and are grown in a special medium. After 10-12 days from the start of culturing, the number of AMSC reaches 80-100 million, which is ten times higher than the content in the bone marrow.

We have tried to introduce mesenchymal stem cells to the patient, which in the operative (surgical) treatment was denied because of the severity of vascular lesions of the heart, and the provisions of drug therapy were already exhausted. As shown by the results of this study, the patient's condition significantly improved exercise tolerance increased, which indicated the improvement of cardiac function. The results of the ultrasound and PET studies have confirmed positive changes in the heart. This fact and the basis of the present invention.

The essence of the method is illustrated by examples.

Example 1. Patient M born in 1948, and a/b No. 3323 was admitted to the hospital 16.12.2003 with a diagnosis of CHD. Angina III-IV voltage and peace. Atherosclerosis and myocardial infarction (myocardial infarction in 1999, 2003).

Ventricular fibrillation 14.03.2003. NC - III (NYHA)

Upon receipt worried about the pain with minimal exertion, night pain at rest shortness of breath with minimal physical activity.

When echocardiographies the MD study areas of akinesia in the anterior-apical segment and hypokinesia in the rear-lower segments of the left ventricle. Contractility of the left ventricle is reduced (EF=44%).

Performed coronary angiography No. 974 from 18.12. 2003:

Local anesthesia Sol. Novocaini 0.25%-30.0. Puncture and catheterization a.femoralis dextra. Selective coronary angiography LCA and RCA (contrast “Ultravist”).

Type of blood: mixed

Selective coronary angiography LCA:

The trunk of LCA: without stenotic changes. The left descending artery (LAD): Diffuse changed. Occlusion after discharge major diagonal branch. Collateral filling no. Envelope artery (LCX): Diffuse changed from the mouth throughout with a maximum stenosis of 80% in the proximal segment. The right coronary artery (RCA). Occlusion of the proximal segment. Retrograde filling of the LCA system.

Given the nature of the coronary lesion and the patient's condition, surgical revascularization was denied.

The patient after signing the informed consent produced by the puncture of the iliac crest, received ~ 180 ml of bone marrow from which the selected mononuclear fraction containing 6.0×10⁴mesenchymal cells in 1 ml, and injected intracoronary fractional volume of 40 ml at a rate of 10 ml/min in the left and 30 ml of fractional speeds of 3-5 ml/min in the right crowns the RNA artery. When you try to increase the speed of the left coronary artery is almost instant increase of ischemic changes on EKG (pain was not).

Introduction mononuclear mist patient satisfactorily and 22.12.2003 was discharged from the hospital.

With repeated follow-up at 3 months (drawing B) after injection of mononuclear mist - the disappearance of pain alone. In re PET study, normalization of metabolism in the scar area after myocardial infarction (in segments with baseline hypometabolism of glucose (drawing) there is an increase in capture of the radiopharmaceutical at 46-127%). Load exercise test revealed a significant increase in tolerance to physical load (110 watts). Cardiac contractile force increased during the observation period from 44% to 53%, including regional contractility in areas with original Hypo-akinesia.

Subsequent dynamic observation in April 2004 and July 2004 confirmed the positive effect of the treatment.

Example 2. Patient B. 1950 birth, and/b 949, was admitted to the hospital 26.03.2004. the invalid of I group. The diagnosis of CHD. Angina III-IV functional class and rest. Atherosclerosis and myocardial infarction (re-myocardial infarction in 2001, 2002). Chronic heart is Naya failure Art. IV

Admission: koronarograficheskie study (clinic, military medical Academy, Kirov, small - diameter coronary vessels, tresolution defeat). Consulted in the cardiac branches of the Kirov military medical Academy, research Institute of cardiology of Russian Federation Ministry of health. Surgical revascularization is denied. Ultrasonic examination of the presence of pericardial effusion, the fraction of exile 22%, mitral and tricuspid insufficiency. Objectively a serious condition, heart rate 120 in 1 min, NPV 26 in 1 min. Indurativnyy edema of the lower extremities up to the level of the lower third of the thigh, refractory to ongoing diuretic therapy. Cachexia.

Daily attacks of cardiac asthma. Given the bad condition of the patient and high risk of death, it was decided to intravenous him ASK.

Analogously to example No. 1 was punctured bone marrow derived sampling, from which were selected AMSC, then typed and grown in a special medium. After 10-12 days from the start of culturing, the number of AMSC reached 70 million AMSC were introduced intravenously. The insertion procedure was carried to the sick satisfactory and the patient was discharged from the hospital. Through 1 month after the introduction of the gradual improvement of health, reduction of signs of heart failure.

3 months after the introduction of the culture of mesenchymal cells distinct wedge the economic improvement - the disappearance of refractoriness to ongoing diuretic therapy. Reduction of swelling of the lower extremities to pastoznost legs. The disappearance of the attacks of cardiac asthma. The possibility to sleep at night. Increases in motor activity. Fraction of exile - 28%. In re PET study distinct improvement of metabolism in the scar area after suffering a myocardial infarction (in segments with initial glucose hypometabolism observed increase in the capture of the radiopharmaceutical). Subsequent dynamic observation in July 2004 confirmed confirmed positive effect of the treatment.

Example 3. Patient M., born in 1956, the patient with severe right-left ventricular failure (Chronic heart failure (CHF) IV functional class)due to idiopathic DC.

From the anamnesis: About the disease learned after the first clinical manifestations of heart failure and follow-up examinations. Simpaticheskaja therapy ineffective.

The growth of liver failure.

Admission: State of moderate severity. Shortness of breath when talking. HR - 110 in 1 min Interesest sclera. Edema of the lower extremities. Cardiac cirrhosis. Contractility of the heart is sharply reduced (EF=32%). Mitral, tricuspid regurgitation.

PA is Ianto after signing the informed consent produced by the puncture of the iliac crest, received ~180 ml of bone marrow from which the selected mononuclear fraction containing 9.0×10⁴mesenchymal cells in 1 ml Estimated volume survey included coronary angiography and intracoronary introduction mononuclear mist.

However, for technical reason, intracoronary introduction mononuclear suspension failed, the suspension was introduced intraarterially jet (descending aorta).

3 days after injection of mononuclear mist patient was discharged.

After 3 months at follow-up - change in the functional class of CHF to II-III (article). The increase in contractility to 39%. In re PET study: reducing the size of the area of hypometabolism of glucose in the apical segment of the lower wall of the left ventricle, the disappearance of the area of hypometabolism in the middle segment of the interventricular septum.

Subsequent dynamic observation over 6 months, 9 months. and 1 year confirmed achieved clinical effect.

Example 4. Patient B. 54 years, patients with idiopathic DC.

Chronic heart failure IV functional class (NYHA classification).

Admission: State of moderate severity. Sleep half-sitting. Sinus tachycardia with a heart rate of 96 beats per 1 minute of Hepatomegaly. Edema of the lower extremities. Contractile ability is ü heart dramatically reduced (EF=37%). Mitral, tricuspid regurgitation.

Analogously to example No. 1 was punctured bone marrow derived sampling, from which were selected AMSC, then typed and grown in a special medium. Two weeks from the beginning of cultivation, the number of AMSC reached 80 million AMSC were introduced intravenously. The insertion procedure was carried to the sick satisfactory and the patient was discharged from the hospital.

3 months after intravenous culture of mesenchymal stem cells - the change in the functional class of CHF to II-III (article). When re-PET study in segments with initial glucose hypometabolism observed increase in the capture of the radiopharmaceutical. Cardiac contractile force increased to 45%.

Follow-up for 9 months achieved confirmed the positive effect of the treatment.

To date, the proposed method of treatment more than 30 unresectable patients who injected mesenchymal stem cells in mononuclear suspension or tissue culture. None of the patients to date is not lost. The proposed method is compared with the prototype has a number of advantages:

1. Provides a higher survival rate in the most severe group of cardiac patients. When medical therapy, as you specified is e, more than 50% of patients die within the first year when severe heart failure. Transplantation of hearts is not available for the vast majority of patients, since the number of such patients exceeds the number of donors.

2. Quality of life invalidizirovannyh patients who were treated in the above manner, was significantly higher. All patients increased exercise tolerance. This made it possible not only to maintain themselves in everyday life, but also to increase the level of social adaptation (easy work).

The method developed in the clinic cnerry MZ the Russian Federation (St. Petersburg) together with the staff of the city hospital # 2, St.-Petersburg state medical University named after academician I.P. Pavlov and was clinically tested in 30 patients with a positive result.

A method for the treatment of unresectable cardiac patients by injecting the patient a therapeutic agent, characterized in that as a remedy using autologous mononuclear fraction of bone marrow containing 6-9×10⁴mesenchymal cells in 1 ml of autologous mesenchymal stem cells in an amount of 10⁶cells/kg of body weight of the patient, which is injected or intracoronary fractional volume up to 50 ml with a maximum speed of 5-10 is l/min in the left and 30 ml fractionally with a maximum speed of 3-5 ml/min in the right coronary artery, or intraarterially inkjet, or intravenous drip.