Scholarly article on topic 'Stem cells and heart disease - Brake or accelerator?'

Stem cells and heart disease - Brake or accelerator? Academic research paper on "Basic medicine"

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{"Stem cell" / "Cardiac disease" / "Tissue repair" / HSC / EPC / MSC / SH2B3 / "Quality management" / "Systems medicine"}

Abstract of research paper on Basic medicine, author of scientific article — Gustav Steinhoff, Julia Nesteruk, Markus Wolfien, Jana Große, Ulrike Ruch, et al.

Abstract After two decades of intensive research and attempts of clinical translation, stem cell based therapies for cardiac diseases are not getting closer to clinical success. This review tries to unravel the obstacles and focuses on underlying mechanisms as the target for regenerative therapies. At present, the principal outcome in clinical therapy does not reflect experimental evidence. It seems that the scientific obstacle is a lack of integration of knowledge from tissue repair and disease mechanisms. Recent insights from clinical trials delineate mechanisms of stem cell dysfunction and gene defects in repair mechanisms as cause of atherosclerosis and heart disease. These findings require a redirection of current practice of stem cell therapy and a reset using more detailed analysis of stem cell function interfering with disease mechanisms. To accelerate scientific development the authors suggest intensifying unified computational data analysis and shared data knowledge by using open-access data platforms.

Academic research paper on topic "Stem cells and heart disease - Brake or accelerator?"

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Gustav Steinhoff, Julia Nesteruk, Markus Wolfien, Jana Große, Ulrike Ruch, Praveen Vasudevan, Paula Müller

Accepted Manuscript

Stem cells and heart disease - brake or accelerator?

S0169-409X(17)30231-4 doi:10.1016/j.addr.2017.10.007 ADR 13200

To appear in: Advanced Drug Delivery Reviews

Received date: 28 July 2017 Revised date: 12 October 2017

Accepted date: 13 October 2017

Please cite this article as: Gustav Steinhoff, Julia Nesteruk, Markus Wolfien, Jana Große, Ulrike Ruch, Praveen Vasudevan, Paula Müller, Stem cells and heart disease - brake or accelerator?, Advanced Drug Delivery Reviews (2017), doi:10.1016/j.addr.2017.10.007

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STEM CELLS AND HEART DISEASE - BRAKE OR ACCELERATOR?

Gustav Steinhoff, MD1, Julia Nesteruk, MD1, Markus Wolfien2, Jana Große, PhD1, Ulrike Ruch, PhD1, Praveen Vasudevan1, Paula Müller1

Correspondence to:

Gustav Steinhoff, MD Professor of Cardiac Surgery Department of Cardiac Surgery

Reference and Translation Center for Cardiac Stem Cell Therapy

University Medical Center Rostock

Schillingallee 35

18055 Rostock

Germany

Mobile +49 179 39 39 344

Phone: +49 (381) 494-6100

Fax: +49 (381) 494-6102

E-mail: gustav.steinhoff@med.uni-rostock.de

Affiliations:

1 University Medicine Rostock

Department of Cardiac Surgery

Reference and Translation Center for Cardiac Stem Cell Therapy

University Medical Center Rostock

Schillingallee 35

18055 Rostock

Germany

Phone: +49 (381) 494-6100 Fax: +49 (381) 494-6102 E-mail: gustav.steinhoff@med.uni-rostock.de E-mail: iuliia.nesteruk@med.uni-rostock.de E-mail: jana.grosse@med.uni-rostock.de E-mail: ulrike.ruch@med.uni-rostock.de E-mail: praveen.vasudevan@med.uni-rostock.de E-mail: paula.mueller@med.uni-rostock.de

2 University Rostock

Institute of Computer Science

Department of Systems Biology and Bioinformatics

Ulmenstraße 69

18057 Rostock, Germany

Phone: +49 (381) 498-7570

Fax: +49 (381) 498-7572

E-mail: markus.wolfien@uni-rostock.de

Abstract

After two decades of intensive research and attempts of clinical translation, stem cell based therapies for cardiac diseases are not getting closer to clinical success. This review tries to unravel the obstacles and focuses on underlying mechanisms as the target for regenerative therapies. At present, the principal outcome in clinical therapy does not reflect experimental evidence. It seems that the scientific obstacle is a lack of integration of knowledge from tissue repair and disease mechanisms. Recent insights from clinical trials delineate mechanisms of stem cell dysfunction and gene defects in repair mechanisms as cause of atherosclerosis and heart disease. These findings require a redirection of current practice of stem cell therapy and a reset using more detailed analysis of stem cell function interfering with disease mechanisms. To accelerate scientific development the authors suggest intensifying unified computational data analysis and shared data knowledge by using open-access data platforms

Keywords

Stem cell, cardiac disease, tissue repair, HSC, EPC, MSC, SH2B3, quality management, systems medicine

Abbreviations

ACC = American College of Cardiology acLDL = acetylated-low density lipoprotein AHA = American Heart Association ALL = acute lymphoblastic leukemia ANG1 = angiopoietin 1

ATMP = Advanced Therapy Medicinal Product BM = bone marrow

BMSC = bone marrow-derived stem cell

B-reg = regulatory B-cells

CABG = coronary artery bypass graft

CDC = cardiosphere-derived cell

CCL2 = C-C motif chemokine ligand 2

CCTRN = Cardiovascular Cell Therapy Research Network

CPC = cardiac progenitor cell

CSC = cardiac stem cell

CEC = circulating endothelial cell

CFU = colony-forming unit

CSF-1 = colony-stimulating factor 1

CVD = cardiovascular disease

CXCL12 = C-X-C motif chemokine 12

CXCR4 = C-X-C chemokine receptor 4

EMA = European Medicines Agency

EPC = endothelial progenitor cell

EPO = erythropoietin

ESC = embryonic stem cell

FAIR = findable, accessible, interoperable and reusable

FDA = US Food and Drug Administration

GCP = Good Clinical Practice

GLP = Good Laboratory Practice

GMP = Good Manufacturing Practice

G-CSF = granulocyte-colony stimulating factor

GSP = Good Scientific Practice

GVP = Good Vigilance Practice

GWAS = genome-wide association studies

GxP = good practice

HGF = hepatocyte growth factor

HIF-1 alpha = hypoxia-inducible factor 1 alpha

HLA-G5 = human leukocyte antigen class I molecule G5

HSC = hematopoietic stem cell

IDO = indoleamine 2,3-dioxygenase

IFN = interferon

IGF = insulin-like growth factor

IGFBP = insulin-like growth factor-binding protein

IgM = immunoglobulin M

IL = interleukin

iPSC = induced pluripotent stem cell IVUS = intravascular ultrasound lncRNAs = long non-coding RNAs

IP-10/CXCL10= interferon gamma-induced protein 10/C-X-C motif chemokine 10 LVEF = left ventricular ejection fraction LVESV = left ventricular end-systolic volume MI = myocardial infarction ML = machine learning

MACE = major adverse cardiac events

MMP = matrix metalloproteinase

MNC = mononuclear cell

MRI = magnetic resonance imaging

MSC = mesenchymal stem cell

mTOR = mechanistic target of rapamycin kinase

mTORC 1 = mechanistic target of rapamycin kinase complex 1

NGS = Next Generation Sequencing

NK cells = natural killer cells

NO = nitric oxide

NOS = nitric oxide synthase

NR = non-responder

OCTGT = Office of Cellular, Tissue and Gene Therapeutics

PB = peripheral blood

PEI = Paul-Ehrlich Institute

PGE2 = prostaglandin E2

QC = quality control

R = responder

RCV = retrograde coronary sinus ROS = reactive oxygen species SAE = serious adverse event SC = stem cell SCF = stem cell factor

SDF-1 alpha = stromal cell-derived factor 1 alpha SH2 = Src homology region 2

SH2B3/LNK = SH2B adapter protein 3/lymphocyte adaptor protein

SNP = single nucleotide polymorphism

TBX5 = T-box transcription factor 5

TGF-pi = transforming growth factor beta 1

TLR = toll like receptor

TNF alpha = tumor necrosis factor alpha

T-reg = regulatory T-cells

t-SNE = t-distributed stochastic neighboring embedding VE-cadherin = vascular endothelial cadherin VEGF = vascular endothelial growth factor VEGFR = vascular endothelial growth factor receptor WGCNA = Weighted Gene Co-expression Network Analysis

Introduction

This review addresses the current state of development of cardiac stem cell (SC) therapy. Although the first clinical cardiac SC phase I trials having started in 2001 [1] still licensed and standardized therapies are not realized after 16 years of clinical development. This requires a critical analysis of scientific evidence for diagnosis, genetic control, clinical indication, and treatment approach. The review comprises knowledge on SC function for cardiac homeostasis and repair as well as strategies for treatment and diagnostic development deducted from the recently published results of the phase III PERFECT trial [2]. The five main topics in this review listed in table 1 are focusing on (1) SC function and delivery, (2) disease pathomechanism, treatment options and biomarkers, (3) standardization and quality control (QC) for best practice, (4) data analysis and (5) comprehensive treatment centers.

1 Stem cell function and delivery in heart disease Function

The evolving detection of SC functions in tissue development, regeneration and repair have advanced medical sciences in the last two decades leading to the understanding of tissue development and regeneration during aging as well as repair. The observation that an injury in different organs, such as muscle, liver, and brain, triggers bone marrow (BM)-derived cells to the area of damage where they contribute to regenerative processes has provided the basis for bone marrow-derived stem cell (BMSC) therapy[3-6]. In human heart transplants, the immigration and differentiation of recipient myofibroblast was observed in 1989 as well as different kinetics of cell replacement [7,8]. In animal models of myocardial infarction (MI), intramyocardial injections of BMSCs preserved left ventricular contractile function and reduced fibrosis formation [9,10].

Hematopoeitic stem cells (HSCs) have been well characterized by membrane markers like CD133+ as well as distinct progenitor subtypes differentiating into blood and immune lineages [11]. In 1997, endothelial progenitor cells (EPCs) were first described by Asahara et al. [12] as a main component of cardiovascular and tissue regeneration [13,14]. Cardiovascular lineage EPCs can be generally identified by their capability to express endothelial phenotypical markers like CD133, CD34, CD117, CD184, vascular endothelial growth factor receptor 2 (VEGFR2, KDR, Flk1), and vascular endothelial cadherin (VE-cadherin). They also possess some endothelial cell functional characteristics in vitro and in vivo, like acetylated-low density lipoprotein (acLDL) uptake and the formation of endothelial colony-forming units (CFUs). Under steady state conditions, the concentration of CD34+ EPCs in

peripheral blood (PB) is much lower than in BM [15]. Interestingly, it was shown in clinical studies that the number of circulating EPCs significantly increased during the early phase of acute MI, suggesting that these cells may contribute to healing processes [16-19].

Mesenchymal stem cells (MSCs) are part of the BMSC pool [20] as well as a basic component for perivascular tissue throughout all tissues and organs [21]. MSCs are characterized by fibroblast clonal potency and multicellular differentiation into osteocytes, adipocytes and chondrocytes. Furthermore, their role for induction and down-regulation of T-lymphocyte response has been observed in graft-versus-host disease [22]. Intramyocardial or intravenous application of MSCs has been reported to reduce post MI damage in animal studies and clinical trials [23,24].

Cardiac stem cells (CSC) were described for the first time in 2003 by Beltrami et al. with the presence of self-renewing c-kit+ cells in the adult heart, which differentiated into cardiomyocytes, smooth muscle cells as well as endothelial cells and regenerated functional myocardium [25-27]. To date, various additional populations of putative endogenous cardiac stem and progenitor cells have been identified in the heart, including Isl-1+ cells [28-30], Sca-1+ cells [31-33], cardiosphere-derived cells (CDCs) [34-37] and cardiac side population cells [38-40]. Recent evidence from genetic fate mapping studies further confirmed that in addition to proliferating pre-existing cardiomyocytes also differentiating resident cardiac stem and progenitor cells can contribute to post-natal cardiomyogenesis [41-43].

Embryonic stem cells (ESCs) have the ability to differentiate into derivatives of all three germ layers [44]. Several protocols have been successfully developed to induce cardiomyocytes from ESCs in vitro [45]. Although the generation of fully mature cardiomyocytes in large yields and with high purity is still unfeasible [46], these studies demonstrated a strong cardiogenic potential of ESCs. However, clinical translation of these cells has been hampered by significant obstacles, including ethical concerns [47], the risk of immune rejection [48,49], genetic instability [50,51] and tumorigenic potential [44]. In fact, some early studies hypothesize that the cardiac environment is sufficient to induce the differentiation of ESCs into cardiomyocytes [52,53]. Nevertheless, this suggestion has been refuted, since the formation of teratomas was detected after intramyocardial injection of undifferentiated ESC [48,54,55]. Consequently, more attention has been given to the identification, generation and purification of ESC-derived cardiac progenitor cells. Numerous preclinical studies demonstrated stable electromechanical integration of ESC-derived cardiomyocytes into the host myocardium leading to reduced scar size, decreased cardiac remodeling and improved cardiac function without teratoma formation in small [54,56-61] and large [55,62,63] animal models. These encouraging data have paved the way for the first phase I clinical trial by Menasche in 2013 (ESCORT) using human ESC-derived cardiac progenitors (Isl-1+ and SSEA-1+) embedded in a fibrin

scaffold in six patients with severely impaired cardiac function scheduled for CABG. Although initial results from the first patient are promising [64], it is still too early to assess the safety as well as the therapeutic benefit of these cells in humans.

Induced pluripotent stem cells (iPSCs) are pluripotent SCs generated directly from somatic cells through a reprogramming process. In 2006, Takahashi and Yamanaka published for the first time the generation of iPSCs from mouse fibroblasts by retroviral transduction of four different transcription factors (Oct3/4, Sox2, c-Myc, and Klf4) [65]. One year later, the same group could transfer this technology to human fibroblasts [66]. It was shown that generated iPSCs not only express ESC markers and exhibit morphology, proliferation as well as tumorigenic properties similar to ESCs, but also bear comparable cardiogenic potential [65,67]. Although terminal differentiation of iPSCs into fully mature cardiomyocytes in vitro is still an unreached goal [68-72], functional cardiomyocytes have been generated from both mouse [73-75] and human [76-79] iPSCs. Moreover, promising in vivo experiments in MI models showed the engraftment as well as improved cardiac performance, reduced infarction size and attenuated cardiac remodeling after iPSC-derived cardiomyocyte transplantation [80-86]. Importantly, the iPSC-generation technology enables the creation of patient-specific pluripotent stem cells [87] that can be used for genetic repair. However, first enthusiasm has been tempered by the investigation that syngeneic mouse iPSCs were immunogenic and rejected following transplantation [88,89]. This observation was contrary to the initial suggestion that autologous iPSCs would not cause immune response in the host due to the so-called "self-tolerance" [90]. Since then, significant genomic instabilities in iPSC lines including epigenetic memory, aberrant methylation patterns and mutations have been reported resulting from variations in parenteral somatic cells or occurring during the reprogramming process and culturing time [91-95]. Recently, new protocols have been developed improving the efficiency and safety for the generating of iPSCs by using virus-free and non-integrative approaches e.g. proteins [96,97], mRNAs [98], microRNAs [99,100], and small molecules [101-103]. Nevertheless, iPSC-derived cardiomyocytes did not reach clinical grade, yet.

Delivery techniques

Delivery techniques could be conventionally divided into three categories: intracoronary delivery, intramyocardial application (including endoventricular, transepicardial and transvascular injections) and intavenous delivery (including retrograde coronary sinus (RCV) and peripheral intravenous infusions). The choice of techniques is not regulated and depends on preferences of SC centres, their equipment opportunities and experience. The delivery routes and techniques are summarized in figure 1 (reprinted from: [104]).

Intracoronary application

Selective intracoronary delivery route was used with the intention to minimize shedding to non-targeted organs [105]. To facilitate transendothelial passage and migration into the infarcted zone, an angioplasty balloon was inflated in the proximal segment of coronary arteries and cells were infused in the culprit vessel (stop-flow technique). The transmigration process is facilitated in injured and ischaemic viable tissue [106], as local myocardial ischemia is a potent stimulus for chemokinesis of SCs due to stromal cell-derived factor 1 (SDF-1) and C-X-C chemokine receptor 4 (CXCR4) signalling [107-109]. Therefore, the ischemia-producing stimulus may actually promote the cell adhesion and extravasation into the myocardial tissue [110,111]. Delivery of SCs to the injured or failing myocardium by a simple intracoronary administration seemed to be sufficient to promote myocardial repair [112,113]. The intracoronary approach, however, should be reserved for the smaller, mononuclear BMSCs, since intracoronary application of cultured cell types, like MSCs or skeletal myoblasts, was associated with microembolisation and significant microvascular obstruction [114].

Intramyocardial application

Endoventricular intramyocardial injection

The intramyocardial injection of SCs results in the direct delivery into the myocardial target area, without dependence on vascular access or sufficient cell migration across the endothelial barrier. Percutaneous endoventricular injection of cell preparations are generally guided using routine fluoroscopic ventriculography or by electromechanical mapping using the NogaStar mapping catheter (Biologics Delivery Systems, Diamond Bar, CA). The percutaneous transendocardial delivery catheters Helix® and C-Cath® use direct fluoroscopic imaging [115-117]. The myocardial cell retention of these catheters typically varies between the 20-35%. The Myostar® injection catheter is interfaced with the NOGA© 3-dimensional electromechanical endoventricular mapping system. Based on the structural reconstruction of unipolar voltage mapping in combination with the mapping of linear local shortening, the operator can distinguish in real time viable myocardium from non-viable, hibernating or scar tissue. Clinical studies have established safety and feasibility of the transendocardial intramyocardial injection in the setting of chronic heart failure [118], refractory angina [119], as well as in subacute MI [120]. However, cell loss and shedding to non-targeted organs is still considerable for all percutaneous injection catheters.

Transepicardial application

SC implantation during open heart surgery is generally performed into well exposed epicardial ischaemic areas allowing for multiple injections within, and principally, around the infarct area with a thin needle [120,121]. This procedure is limited to certain areas of the left ventricle, and cannot be used for the septal myocardial segments. Moreover, the therapeutic effect of intramyocardial SC therapy is difficult to be unequivocally interpreted when performed together with a revascularisation

procedure. Therefore, recent reports about surgical "stand alone" SC therapy are of particular interest [122,123].

Epicardial delivery of bioengineered composite sheets harboring SCs is a new method of SC delivery. SC sheets adhere to the epicardial surface spontaneously, or as collagen-based patches [124,125]. Adipose-derived stromal cell sheets resulted in significant improved survival and left ventricular remodeling in an infarct model in rats compared to intramyocardial injections [126].

Transvascular delivery

The transvascular delivery of SCs occurs via transvenous or transarterial delivery under intravascular ultrasound (IVUS) imaging. The success transvenous intramyocardial delivery of a cell-hydrogel by the TransAccess® delivery catheter (Medtronic Vascular, Santa Rosa, CA, USA) was described [127,128]. The Mercator Cricket® and Bullfrog® perpendicular-positioned microneedles (Mercator MedSystems, Emeryville, CA) penetrate the coronary artery wall and allows the user to inject SCs directly into the perivascular space (tunica adventitia of the coronary artery) [129-131].

Intravenous delivery

Retrograde coronary sinus infusion

RCV infusion is performed by femoral venous access and the positioning of a conventional angioplasty balloon into the mid portion of the coronary sinus followed by SC infusion. Clinical and preclinical studies demonstrated safety, efficacy and high cell retention of delivering via the coronary sinus [132-134]. Coronary sinus delivery could be recommended in cases of severe aortic stenosis, severe peripheral artery disease or intraventricular thrombus formations which precludes percutaneous endoventricular injection. The method is also possible for patients with a resynchronization device. Potential complications are coronary sinus rupture and embolisation [135,136].

Peripheral intravenous infusion

Intravenous infusion is the most safe and cost-effective SC delivery method. Its safety and feasibility has been shown in swine model of MI [137] and later in a phase I clinical study after delivery of allogeneic MSCs [138]. The study resulted in a significant improvement of the ejection fraction in the treated group versus placebo at 12 month follow-up, although the myocardial retention following intravenous injections is mere 0.5% [139].

2 Disease pathomechanism, therapeutic options, diagnostic biomarkers Disease pathomechanism

Ischemia

The contractile workload of heart tissue is dependent on sufficient oxygen supply to maintain homeostasis of viability and function. The aerobic metabolism of the heart at rest needs about 8-15mL 02/min/100g tissue - more than double the consumption of brain tissue with 3ml 02/min/100g tissue [140]. With exercise and increased hypertensive workload this need for oxygen can increase up to more than 70mL 02/min/100g. Unrestricted blood supply and oxygen delivery from capillaries to cardiomyocyte cell membrane are crucial factors for maintaining sufficient pump function. The surveillance relies mainly on the capillary density surrounding and in contact to cardiomyocyte fibrils [140]. Oxygen shortage leads to activation of hypoxia-inducible factor 1 alpha (HIF-1 alpha) by cardiomyocytes, which induces local vascular endothelial growth factor (VEGF) release to the circulation by endothelial cells as well as induced endothelial expression of VEGFR2 (CD309) and induce SDF1 alpha as a ligand for circulating EPCs. Circulating angiogenetic capacity of EPCs is enhanced by combined release of VEGF and erythropoeitin (EPO) by endothelial cells, pericytes, and MSCs in tissue. By this pathway the hypoxic state of every single cardiomyocyte can activate local angiogenesis of capillary sprouting on demand [141]. This mechanism is dependent on the co-activation of neighboring endothelial cells, pericytes, macrophages, and MSCs for systemic proliferation/release of EPCs and circulating endothelial cell (CECs) as well as expression of local homing receptors for targeted angiogenesis sprouting.

Cardiomyocyte crosstalk with the regulatory BMSC niche for vascularization

Tissue hypoxia mediators are released by ischemic cardiomyocytes and are directly activating local endothelial cells and BM-derived EPCs. By this mechanism, they induce blood driven angiogenesis at the ischemic endothelial spot by targeting circulating EPCs and VEGF, SDF-1 or Vitronectin receptors to the endothelial surface [142]. For the local angiogenesis induction, at least local endothelial expression of VEGFR2 is required for the induction of sprouting from blood vessels by local adherent EPCs [143,144]. In the BMSC niche, angiogenic chemokine stimulation enhances EPC or HSC proliferation and release, but precise stimulatory pathways have to be unraveled [142,145]. EPC proliferation is influenced by insulin-like growth factor (IGF)-1 and VEGF [146]. EPO production is attributed to kidney tissue interstitial cells, most likely pericytes [147]. However, also pericytes in brain and liver are producing EPO upon local ischemic activation by HIF-1 alpha [143]. It is conceivable that pericytes in other cardiovascular tissues and heart may be inducible to produce EPO upon hypoxia.

Progenitor cell trafficking is regulated by hypoxic gradients through HIF-1 alpha induction of C-X-C motif chemokine 12 (CXCL12)/SDF-1 [148]. Moreover, in vitro hypoxia induced HIF-1 alpha induces mTOR complex 1 (mTORC1) axis in human umbilical cord blood MSCs leading to cell-cycle and F-actin modulation with increased proliferation and migration [149]. The mTOR pathway leading to proliferation is also induced by hypoxia mediator in BM niche cells [150]. This local process involves tissue macrophages capable to influence the cell cycle of vascular endothelial cells through the

paracrine wnt ligand WNT7b [151] and in conjunction with pericytes, which secrete angiopoietin 1 (ANG1) to regulate angiogenesis leading to AKT-mTOR activation [152]. At the same time, monocyte derived dendritic cells seem to regulate angiogenesis during development through the production of VEGF and transforming growth factor beta 1 (TGF-pi) [153]. VEGF recruited numerous BM-derived macrophages to the tissue through signaling by CXCR4, the ligand being expressed by pericytes [154]. A similar mechanism involving CXCL12 was shown to guide these BM-derived progenitor cells to sites of vascular expansion in the embryo. In addition, CXCR4 and CXCL12/SDF-1 were up-regulated in response to hypoxia in ischemic tissue, which resulted in the recruitment of similar myeloid cells [148]. In conclusion, hypoxic cardiomyocyte are able to induce a local and systemic SC proliferation response for adaptive capillary angiogenesis.

Early and late inflammation

The cell-cell interactions between immune cells, such as macrophages and T-cells, with CD34+ SCs and MSCs are critically important for the development of the further inflammatory repair process. Enhancing factors for repair are IGF-1 and activin. The shortage of oxygen supply to the cardiac tissue leads to necrosis, apoptosis [155] and release of various factors like interleukin (IL)-1, reactive oxygen species (ROS), nitric oxide (NO) and immunoglobulin M (IgM) by the stressed cells. Toll like receptors (TLRs) are of essential importance in the activation of the immune response after MI [156]. The primary response to these paracrine signals is mounted by the cardiac resident macrophages. They have different functions and roles in comparison to the peripheral BM-derived macrophages [157] whose development is regulated by colony-stimulating factor 1 (CSF-1) [158]. These activated tissue resident macrophages secrete high levels of pro-inflammatory molecules like IL-1, IL-6, IL-8, NO and TNF alpha [159,160]. TLR3 has been identified as a polarizing signaling effect on pro- or anti-inflammatory activation of MSCs and immune cells. Down-regulation mechanisms of MSCs and macrophages at the site of injury can aid cardiac repair quality [161]. In this context the role of TLRs as modulator of MSC expression remains remarkable and may need further investigation [162].

In recent years, immune modulation into pro- or anti-inflammatory states have received major attention for interventional immune therapy. While the mentioned early inflammatory process is mediated mostly by components of the innate immune system, the chronic inflammatory phase is effected mainly by the adaptive immune system. The lymphocytes are activated by antigen presenting cells [163] and lead to destruction of cells bearing these antigens by cytotoxic T-cells while B-cells amplify this response by producing antibodies. However, an important component of the whole inflammatory process and its successful resolution depends on a particular subset of T-helper cells called regulatory T-cells (T-reg) and regulatory B-cells (B-reg) [164-166].

Inflammatory cells and SC interaction

The early inflammatory phase that occurs after the onset of ischemia and mediated by the host immune cells and SCs is mostly complete by the time SCs or cardiomyocytes are transplanted in a clinical setting. Therefore, it is important to understand the interaction of these cells with the host immune and SC pools in the ischemic heart at certain/different time points to improve the efficacy and timing of cell therapy as well as their ability to replace the cardiomyocytes lost during ischemia. This would help in deciding the best outcome expected from these cells and their appropriate interactions with the host repair response. It could also help in selecting suitable response signatures to a particular cell type. The ideal scenario where a particular cell type induces cardiomyocyte proliferation would necessitate for these cells to eventually resolve the inflammatory process and not induce further long-term secretion of anti-inflammatory molecules that could increase scar formation.

Currently, there are no studies available on the interaction of transplanted HSCs, EPCs or cardiomyocytes with the inflammatory pathway under ischemic conditions. This is a fundamental gap in SC therapy studies considering the importance of inflammation on the overall outcome. However, the relationship between these SCs and the inflammatory components is not exactly known. HSC proliferation and differentiation is regulated by pro-inflammatory cytokines such as TNF, IL-1, IL-6, IL-8 and interferons (IFNs) [167]. Long-term stimulation of TLR4 leads to impaired long-term self-renewal of HSCs [168]. Also, BM-resident macrophages govern the retention of HSCs within the BM [169]. It would be interesting to speculate the proliferation and retention of HSCs in the cardiac tissue where the macrophages are recruited. The mechanism of interaction of EPCs directly with the immune cells is not yet clear, but, EPCs have been shown to secrete endothelial nitric oxide synthase (NOS), inducible NOS, VEGF-A, SDF-1, IGF-1 and hepatocyte growth factor (HGF) under ischemic conditions [170]. NOS has been shown to be a versatile player in the immune system, being able to alter the functions of macrophages, T-cells, eosinophils and neutrophils [171]. SDF-1 has been shown to play a role in the recruitment of lymphocytes, monocytes and driving macrophage differentiation [172,173].

The immunomodulatory functions of MSCs have thus far been more broadly investigated than other SCs. MSCs have been shown to inhibit T-cell proliferation by the release of TGF-P [174]. This activity is however mediated by prostaglandin E2 (PGE2) [175] and dependent on levels of inducible NOS in mice and indoleamine 2,3-dioxygenase (IDO), and soluble human leukocyte antigen class I molecule G5 (HLA-G5) in humans [176,177]. MSCs modulate B-cells [178] through soluble factors like C-C motif chemokine ligand 2 (CCL2) [179]. Similar to T-cell inhibition, inflammatory stimulation of MSCs is required for their B-cell inhibitory activity [180]. MSCs also modify dendritic cells with the addition of PGE2 [181] and IL-6 [182]. They have been also shown to inhibit natural killer cells (NK cells), but only at high MSC/NK cell ratios [183] and in the presence of IDO or PGE2 [184]. Recently, TLR3 or TLR4 pathways were identified to induce MSC suppression and T-reg

induction [185]. TLR3 displays a protective role in mouse models of atherosclerosis [186], and activation of TLR3 signaling is associated with ischemic preconditioning-induced protection against brain ischemia and attenuation of reactive astrogliosis [187,188]. In addition, TLR3 activators show effects on human vascular cells [186]. Unlike their inhibitory effects on the other immune cells, BM-derived MSCs shifted the macrophages to a more anti-inflammatory phenotype through the release of PGE2 and cell-contact mediated signaling [189].

Fibrosis

The failure of the terminally differentiated cardiac myocytes to proliferate for repair of the infarct myocardium leads to impaired wound healing and ultimately, the formation of a scar. The initial inflammatory phase as described above involving cells such as monocytes and macrophages are responsible for the migration of local fibroblasts and their subsequent conversion to myofibroblasts in order to stabilize the heart after infarction. The origin of these cells is however contentious since both cardiac MSCs [190] and circulating monocytes [191] have been shown to contribute to fibrosis. The clinically relevant problem is the formation of a mature scar where type III collagen is replaced by type I collagen due to the secretion of various matrix metalloproteinases (MMPs). This can also have major effects over time since distal regions of the heart undergo gradual fibrosis leading to increased global cardiac function deterioration and arrhythmogenesis [192]. Therefore, SC therapies should also be determined based on their ability to replace these myofibroblasts, thereby resolving the scar. However, this capability is often deemphasized when choosing a particular cell type for transplantation over other competencies like angiogenic potential.

Cell renewal

Starting with initial transplantation studies of HSCs into cardiac tissue in 2001 and 2002, BMSCs were thought to contribute to the functional recovery of damaged myocardial tissue by coupling electromechanically with the recipient myocardium after acquiring a cardiomyogenic fate [9,193]. However, the trans-differentiation of these cells into cardiomyocytes within the heart tissue remains inconclusive up to date, with studies both supporting [194-197] and refuting [198-200] this notion. Others indicated fusion of BM-derived SCs with endogenous cardiomyocytes as a predominant mechanism for the transformation of BM-derived SCs into cardiomyocytes [201-203]. Similarly, both of these potential mechanisms have been attributed to the generation of cardiomyocytes from PB- and adipose tissue-derived stem and progenitor cells [204-207]. Interestingly, it was demonstrated that adult cardiomyocytes re-enter the cell cycle after fusion with hematopoietic and mesenchymal stem and progenitor cells in vitro and in vivo [208,209]. However, the detected fractions of grafted cells converting along the cardiac lineage were very small [201,210,211]. The main functions of tissue immigrating or transplanted HSCs, which are CD117+ (c-kit or SCF-receptor) and/or CD34+, as well as resident or migrating MSC, which are CD105+ (endoglin) and/or CD271+, still have to be defined

depending on tissue specific homeostasis and disease mechanism. Altogether, adult MSCs/CSCs and HSCs may potentially be transformed into cardiomyocytes through (trans)differentiation and/or fusion with pre-existing cardiomyocytes. This, however, can be considered only as a rare event in cardiac tissue regeneration response. This is reflected in low survival and engraftment [34,211-214] as well as limited generation of cardiomyocytes from injected SCs implying that direct re-muscularization has only a limited contribution to beneficial SC effects.

Conflicting results have been obtained with respect to the cardiomyogenic differentiation potential of cardiac stem and progenitor cells. On the one hand, in vitro studies observed the expression of cardiac markers and structural proteins several days after cell cultivation under certain conditions [25,26,37,38,40] and in co-culture with neonatal or adult cardiomyocytes [28,32,38,39,215]. In line with these findings, various in vivo experiments demonstrated that transplanted cardiac stem and progenitor cells give rise to newly generated cardiomyocyte-like cells through direct differentiation [25-27,216-219]. On the other hand, it was shown that fusion of injected cells with pre-existing cardiomyocytes contributes equally to the generation of cardiomyocytes from injected cells [33]. Moreover, the maturity of engrafted cardiac stem and progenitor cells remains highly controversial, with studies reporting the contractile function [25] and the full maturation of newly-formed cardiomyocytes within two months [27], whereas others did not observe the phenotype of mature cardiomyocytes one year after cell transplantation [212]. Likewise, quantified fractions of engrafted cells acquiring a cardiomyogenic lineage vary considerably from modest to substantial [32,40,212,220]. Some lineage tracing studies also refuted the significant myocardial potential of putative resident cardiac progenitor cells after injury [221-223], while others indicated their intrinsic regenerative capacity by replacing lost cardiomyocytes [27]. Only limited cardiomyocyte turnover occurs in vivo [224,225]. In a meta-analysis, including 80 animal studies, cardiac derived precursor cell therapy was shown to significantly improve LVEF by 10.7% compared with placebo controls [226]. This was not different from results of extracardiac precursor and SCs [227]. Interestingly, CSCs had a significantly greater beneficial effect in small animal models compared with large animal models (~12% vs. 5% improved LVEF), while cell source, comorbidities, use of immunosuppression and disease models did not influence the effects on cardiac function. In 2011, Bolli et al. published the first report of cardiac SC therapy in humans [228]. In this phase I clinical study (SCIPIO) no mortality or CSC-related adverse events were observed following the intracoronary infusion of autologous c-kit+ cardiac SC in patients with ischemic cardiomyopathy. In addition, cardiac magnetic resonance results in an improved global as well as regional left ventricular function, a reduced infarct size as well as an increase in viable tissue four and twelve months after SC application [229]. In 2012, the CADUCEUS trial demonstrated the safety and feasibility of intracoronary infused CDCs grown from endomyocardial biopsy specimens in patients with left ventricular dysfunction after MI [144]. After CSC transplantation, analyses demonstrated significant reduction in the size of the infarct as well as an

increase in the amount of viable myocardium, regional contractility and regional systolic wall thickening compared with controls, whereas left ventricular function and volumes did not differ between groups [144,230]. However, as these early phase I clinical studies should show the safety of the therapy they were not powered to determine the efficacy of CSCs.

Therapeutic options

Enhancing the circulating EPC pool

BM-derived mononuclear cells (MNCs) can be isolated from BM aspirates through density gradient centrifugation. Notably, the overall composition of BM-derived MNCs is primarily that of predominantly differentiated blood cells with a low percentage of early committed cells at various maturation stages, with only little amounts comprising HSCs, EPCs and MSCs [231]. In 2001, Strauer et al. demonstrated for the first time that intracoronary application of autologous BM-derived MNCs is feasible under clinical conditions and results in modified cardiac tissue response (e.g. scar regeneration) after MI [232]. In the first controlled study, the application of BM-MNCs in patients with acute MI significantly improved local contractility and perfusion, reduced left ventricular end-systolic volume (LVESV), and decreased infarction site compared with the standard therapy group [105]. Furthermore, the authors postulated that therapeutic effects were associated with myocardial regeneration and neovascularization. Since then, large numbers of clinical trials investigated the potential of BM-derived MNCs for the treatment of ischemic and non-ischemic heart diseases. However, therapeutic benefits continued to remain controversial. In fact, several randomized, controlled studies demonstrated a significantly improved cardiac function after intravenous or intracoronary BM-derived MNC transplantation [233-241], while others could not prove cell-based benefits [242-251]. This heterogeneity is also reflected by recent meta-analyses revealing not only an overall mild (2-5%) improvement of the global heart performance and a possible attenuation of adverse cardiac remodeling [252-256], but also failed to detected therapeutic effects of BM-derived MNC on left ventricular function [257].

To date, similar findings have been made in trials employing the systemic administration of granulocyte-colony stimulating factor (G-CSF) used to stimulate the mobilization of stem and progenitor cells from BM [258]. However, meta-analyses demonstrated that the G-CSF treatment as a stand-alone therapy has no beneficial effects on myocardial regeneration [259-261]. The intramyocardial and intracoronary transplantation of G-CSF mobilized HSCs/EPCs also yielded controversial results. In particular, various clinical studies demonstrated the safety and an improved cardiac performance following the injection of PB-derived MNCs [262-265] and CD34+ cells

[119,266-274], while some failed to detect additional reliable and significant therapeutic effects compared to control groups [248,275,276].

Notwithstanding, the feasibility and safety of intravascular BM-derived MNC transfusion was demonstrated in all of the clinical trials while disease treatment efficacy has not been proven in pivotal phase III trials. In fact, several randomized, controlled phase II studies demonstrated a significantly improved cardiac function after intramyocardial or intracoronary BM-derived MNC transplantation [242-249], while others could not prove cell-based benefits [250-259].

Based on these inconclusive clinical results, the strategy may have to be reset to understand the underlying disease mechanism. This can be seen in the recently intensifying interest in clinical research programs on the mechanism of action of angiogenetic or immune response modulation by the US - Cardiovascular Cell Therapy Research Network (CCTRN) [277] and the TACTICS EU-network [278].

Intramyocardial application

The initial observation in the first-in-man phase I trial for intramyocardial transplantation of purified CD133+ BMSCs performed by our group in Rostock in June 2001 revealed promising results with induction of cardiac regeneration by more than 10% left ventricular ejection fraction (LVEF) increase [1]. The phase II trial confirmed the finding in BMSC treated patients vs. coronary artery bypass graft (CABG) controls [121]. Similar findings were reported by Patel et al. [279]. However, in placebo controlled trials the BMSC induced improvement in heart function was not different from placebo controls [280]. Recently, in the randomized double blinded placebo controlled multicenter phase III trial - PERFECT; an improvement in the heart function (LVEF >5%) was observed in 60% of placebo as well as SC treated patients [2]. Interestingly, the large gain in LVEF was not different in the SC and placebo CABG treatment groups: ALVEF (Placebo +8.8% vs. CD133+ BMSCs +10-4%, ACD133+ vs. placebo +2.58%, p=0.414). In fact, the LVEF increase in placebo-treated patients undergoing BM harvest was remarkable (+8.8% vs. +3.5%) in comparison with earlier results [121]. This finding of 60% LVEF improvement (categorized as 'responders') was also reported in CABG surgery for patients with reduced pump function [281]. In the clinical setup of chronic ischemic heart failure of the PERFECT trial, 40% of patients were 'non-responders' to induction of cardiac regeneration irrespective their treatment with placebo or CD133+ BMSCs. Induction of circulating EPCs as well as angiogenesis and heart function improvement was significantly reduced in non-responders [2]. Cardiac function improvement by purified intramyocardial BMSCs was effective only in patients with angiogenesis response by circulating EPCs [2].

Diagnostic biomarkers

Monitoring of angiogenesis response in the PERFECT trial

The interest in diagnostic use of angiogenesis factors and cytokines in blood is rising, since different levels of biomarkers across a spectrum of pathophysiological processes of different diseases were revealed. Monitoring of biomarker concentrations in blood can not only provide the clinician information about the diagnosis, but can improve prognostication and treatment strategies at the same time [282,283].

The advantage of the PERFECT phase III trial was a study design that included blood harvesting and storage before, 24 and 72 hours as well as 10 days after CABG with or without SC application [2]. Resulting from this, the dynamics of 13 angiogenesis factors and cytokines (VEGF, stem cell factor (SCF), SDF-1, IGF-1, insulin-like growth factor-binding protein (IGFBP)-2 and -3, interferon gamma-induced protein 10 (IP-10), tumor necrosis factor alpha (TNF alpha), IL-6,8,10, EPO, vitronectin) were obtained in time. The study revealed that responder and non-responder but not CD133+ SC and control groups differed in angiogenesis factors before operation. Responders were defined as having a ALVEF at 6 months versus baseline higher than 5%. It was shown, that non-responders display basically elevated angiogenesis stimulating factors as VEGF and EPO, as well as pro-inflammatory factor IP-10 and decreased level of IGFBP-3 accompanied by reduced amount of EPCs in PB. The VEGF level did not change in time, in contrast, a low baseline level of VEGF in the responder group doubled in 10 days after CABG procedure [2].

Ischemia and angiogenesis - a failure of stem cells?

The non-responders in the PERFECT trial show typically lowered CD133+/CD34+/CD117+ EPC and thrombocyte counts and elevated angiogenesis stimulating factors such as VEGF and EPO in the PB [2]. In contrast, responders display basically elevated EPCs and thrombocytes also in the absence of angiogenesis stimulating factors. The underlying mechanism for a lack of response to induction of cardiac regeneration may be a failure of vascular repair by reduced circulating EPCs. This mechanism has been observed already twelve years ago to be associated with progression in atherosclerosis and coronary artery disease [284] as well as in-stent restenosis [285-288]. Low EPC titers were correlated to untreated hypercholesterolemia, whereas HMGcoA reductase (statin) therapy has been associated with EPC recruitment, activation and improved survival, and improved vascular repair following injury. The e-HEALING, a post-marketing registry of 5000 'all-comers' coronary artery disease patients indeed suggested that the EPC capturing Genous stent was associated with reduced clinical major adverse cardiac events (MACE) and late stent thrombosis [289].

Recent clinical findings on the association of BM failure and cardiovascular disease are setting the spotlight on BMSC function as the main disease pathomechanism. Altered BM subpopulations have been associated with response to SC therapy in CCTRN trial analysis [277,290]. Recently, Jaiswal et al. have found the association of BM-derived EPCs or altered clonal hematopoiesis and atherosclerotic cardiovascular disease [291,292]. Reduction in hematopoietic clonal capacity have been shown to be

relevant for post MI heart failure in mouse models with increased HSC apoptosis [293]. Recent research results from cardiac SC therapy trial PERFECT show the impact of BMSC failure on cardiac regeneration as well as a pivotal role of a defined responder or non-responder status for the induction of cardiac tissue regeneration [2]. Genetic control of cardiovascular disease on SC level may be associated with gene dysfunction of SH2B adaptor protein 3 (SH2B3) [2]. First results assume that an increased SH2B3 expression in PB is associated with non-response to cardiac function improvement [2]. Moreover, this pattern of heart failure is associated with reduced EPCs, non-response to angiogenic stimulation, and reduced angiogenesis in the heart [2].

SH2B3 adaptor protein regulates EPC and SC response in cardiovascular disease

SH2B3, also known as lymphocyte adaptor protein (LNK), is a frequent cause of diseases resulting from genetic variations, acquired or inherited in nonmalignant and malignant hematological diseases [294,295]. Susceptibility to celiac disease type 13, rheumatism, insulin-dependent diabetes mellitus, and other autoimmune diseases have been demonstrated. Most interesting is the association with hypertensive, arteriosclerotic and coronary disease that has been recently described [296-298]. It can be envisaged that increased inflammatory activation in atherosclerosis and hypertension are associated with lowered SH2B3 expression levels [297,298]. This may also be the basis of increased cancer inflammation associated with SH2B3 [299,300].

The SH2B3 adaptor protein was first described in lymphocytes [301]. Alternatively spliced transcript variants encoding different isoforms have been identified for this gene. Transcription produces seven different mRNAs, six alternatively spliced variants and one unspliced form [302]. The encoded protein is a key negative regulator for cell proliferation and cell activation in the blood, immune, and cardiovascular system [303]. Intracellular pathway modification involves cytokine signaling like IL-7 and IL-11 in B-cell progenitors [304] and control of hematopoiesis by abrogation of growth factor signaling [305].

The protein is expressed mainly in blood cells and immune cells [298]. The tissue expression on endothelia is of importance with respect to regulation of immune activation [298]. As an example the gene transfer of SH2B3 does prevent endothelial cell activation and apoptosis [306]. Recently, in mouse models the relevance SH2B3 gene expression for EPC proliferation, release and restitution of angiogenetic and wound healing capacity has been demonstrated [307].

Mutations in this gene have been associated with hematological disease based on HSC dysfunction in myelodysplasia, erythrocytosis, anemia or myeloproliferative neoplasms including leukemia and lymphoma [305]. Furthermore, mutations have been found to be associated with a variety of autoimmune, cancer and cardiovascular diseases (table 2). The lessons learned from altered gene function by inherited mutational variants can enable us to associate genotype and phenotype of altered

function in patients with the corresponding disease. This further allows the establishment of novel diagnostic and therapeutic strategies in treating these diseases.

The initial description in the PERFECT outcome analysis of assumed SH2B3 gene expression enhancement in the PB of non-responders suggests a potential regulatory role of SH2B3 with respect to suppression of the BM response [2]. Moreover, association with hematological traits, coronary artery disease [296], and arteriosclerosis have been found for point mutations of SH2B3 promotor regions as well as influence of SH2B3 single nucleotide polymorphism (SNP) on human longevity [308].

Enhanced proliferation in T-cell leukemia has been demonstrated to be driven by Notch1 stimulated mTOR1/PId signaling. Loss of SH2B3 activity has been found to induce acute lymphoblastic leukemia (ALL) proliferation in Notch1-transgenic mice and was also found in a subpopulation of ALL patients in acute leukemic cells [309]. Homozygous loss of SH2B3 expression was found to be associated with induced Notch1 driven proliferation in relapsing T-ALL [310,311]. The alterations included nonsense and missense mutations affecting the pleckstrin homology and/or the Src homology region 2 (SH2) domains. Mutations in SH2B3 have also been identified in lymphoid malignancies including ALL as both germline and somatic events [312,313].

It has been shown in mouse models that the SH2B3 interference induces EPC proliferation, peripheral EPC release and enhanced angiogenesis [307,314,315]. However, further clinical evaluations of SH2B3 expression are needed to unravel the precise mechanism in humans [2,316]. These may lead to clarification on proposed pivotal regulation of HSCs, EPCs, and MSCs by SH2B3 (figure 3). The authors pose this observation as a "stem cell switch hypothesis" to define the role and interplay of SH2B3 vs. Notch/mTOR for homeostatic function and/or dysregulation equilibrium of SCs (HSCs, EPCs, MSCs) in disease (figure 3). Further studies have to unravel this question in clinical and experimental setups.

3 Definition of quality standard and best practice

It is conceivable that the continuous presence of all scientific expertise and critical analysis has to be implied in every step of development as well as the decision for reaching milestones to exit to the following step. To avoid risks of failure scientifically based quality management is mandatory. The obvious obstacles in development require a new approach to achieve best practice. The advance of scientific knowledge to molecular disease diagnosis is not yet a solid basis for molecular and cellular interventions in disease pathways. Therefore, to the author's opinion, it is mandatory to change the

quality management approach in general. The identification of obstacles for the development and treatment of heart disease as well as new technical solutions have to be discussed.

Good practice - a classical quality standard is not enough

The development of medicinal products is structured from historical experience by a stepwise interval development divided in basic research, preclinical development and clinical studies. The basic research approach (according to Good Scientific Practice (GSP)) has been drawn from pharmaceutical chemistry and is aiming for a therapeutical substance. For cell products this very often has limited applicability because of complex reactions and tissue products. Moreover, the use of autologous and allogenic cells is more similar to regulation in transfusion or transplantation medicine and interferes with patient dependent rights and ethical aspects.

Scientific verification is needed in each step of the development. The outcome of preclinical experiments (safety, quality and efficacy) is a crucial point and determines whether clinical studies are reasonable. It depends on the clinical result if the (investigational) product will be approved by a national or international authority and thereby will enter the market to be administered routinely to patients (figure 4). Only in some cases (e.g. for Advanced Therapy Medicinal Products (ATMPs)) structured and lifelong patient vigilance monitoring after the approval of the medical SC product are performed to observe its long-term-behavior.

Besides the scientific and clinical development it is important to take early considerations in account which are dealing with aspects such as the social view on the new product, the medical need, the accessibility for patients and the mode of payment/reimbursement. A suspended marketing authorization of an implant to repair cartilage (MACI®; EMA/282918/2013, EMEA/H/C/002522) [317], that was not profitable, illustrates the importance of economically issues: e.g. an economically viable manufacturing process or suitable distribution concepts are besides the proven safety and efficacy of the new product also worth to consider. This current developmental chain concept, which has been applied in the initial phase of SC therapies has to be considered as inefficient and contains high risks of failure in the developmental process (figure 4).

For nearly two decades cell therapeutics to treat heart diseases are developed and several clinical trials were done. Nevertheless, no approved cell therapy is available for heart failure patients so far (approx. 200 clinical trials (phase I-III)); and there is no product legally in the market [318]. A slightly more optimistic situation exists for cell therapies of other indications (e.g. cartilage repair Spherox® [319] or cornea repair Holoclar® [320]) or other types of ATMPs (gene therapeutics: Glybera® [321], Imlygic® [322], Strimvelis® [323], Zalmoxis® [324]). A discussion about reasons for these low numbers of legally available regenerative therapies recently accelerates in the scientific community. A

well-known point is their novelty as a new class of medicinal products with a high complexity regarding their development, manufacturing, characterization and especially in cardiac therapies their administration [325]. Indeed regulators and developers are now in a process of adapting the regulatory framework related to cellular therapies to possible and proven risks and opportunities [326]. Due to the continually growing progress in cell therapy knowledge and experience, there are numerous ways of support provided by the authorities (e.g. European Medicines Agency (EMA), US Food and Drug Administration (FDA)). They created some tools such as ATMP classification, certification, scientific advice, adoptive pathways pilot program and classification of ATMPs. Moreover, all involved parties are invited to profit from concentrated knowledge at EMA's Academia or FDA's Office of Cellular, Tissue and Gene Therapeutics (OCTGT). The most important move, however, came from Japan introducing a new regulatory Regenerative Medicine Act in 2014 aiming to achieve both intensified scientific quality control as well as earlier translation to clinical trials [327].

These recently enhanced regulatory adaptions combined with increasing political awareness raise some hope for reduced obstacles on the way to market authorization for more cell therapies [328]. Although improvement is still needed at this point it is not only the restrictive regulations that impede or even prevent innovations.

As basic research and pre-clinical development mostly take place in academically environment, it is important for researchers to know, that dealing with critical aspects of cell therapy development at an early stage is essential [329]. As mentioned above, authorities are willing to support and collaborate. So every research team/developer has the chance to find its own particular way due of the uniqueness of their new product. General guidance cannot easily be translated in specific requirements for a certain cell product [325]. Based on the author's experience, it is very helpful to be early, continuing and actively in contact with the relevant authorities and equally important patient organizations to develop cell therapies successfully. Additional to the frequently complained regulatory hurdles, the attitude of scientific community itself has a major impact on the successful development of all new medicinal products. The competition factor that could cause intratransparency regarding data access and quality is just one example.

Collaboration and sharing of knowledge of publicity-funded research and pharmaceutical industry, in turn, could be the key to enhanced development of cell therapies [328]. Furthermore, Foley and Whitaker suggested in 2012 that at least cell therapies, which demand therapeutic procedures like all currently known cell therapy approaches for heart failure, would benefit from an early collaboration of developers and clinicians [330], because a suitable way of distribution, preparation or administration is also an important issue to widespread a therapy.

Besides all regulatory or economic issues there is apparently a discrepancy between the large amount of preclinical data on the one hand and the outcome of clinical trials with cell therapies for ischemic heart diseases on the other [331]. Because of their role of being responsible for public/patient safety no agency would have agreed to test a particular cell product in humans without promising in vivo results. According to published data, early as well as late stage clinical trials with heart failure related products could show their safety and feasibility during the observation period [278,332]. These are important and valuable results but verification of safety is only the first part of the developmental process for medicinal products. Clinical trials also need to address the question of efficacy: the new cell or another medicinal product must benefit the patient in a measurable way (endpoints), which could not be confirmed for any cardiac cell therapy so far. For all interested parties - patients as well as authorities and developers - it is a frustrating situation when enormous scientific and monetary research efforts as well as patient's involvement (e.g. frequent consultations, follow-up interviews and treatment with poorly conceived therapies) lead to no advantageous cell products [333]. Following consequences from this are intentions to spend resources (money and time) for more promising and "fancy" approaches. The worst effect will be a further growing grey market of unproven therapies (e.g. SC tourism) in under-regulated countries as well as in Europe or the U.S. [334] where no regulations are given to protect patients from poor investigated products.

It is obvious that the current approach of medicinal product translation from academic basic science to commercial SC product development lacks large scale knowledge integration and has a high risk of failure to reach standard therapy. Attempts have been made in US and recently in Europe to form large scale task force projects like CCTRN [277], TACTICS [278] or PERFECT [2] with longterm setup to face the challenge of complex continuous diagnostic and therapy development. The uncertain situation of the whole endeavor of development of a regenerative cardiovascular medicine based on SCs at the moment requires an international consensus program lead by governmental research councils in collaboration with regulatory authorities. For this shortcomings program based approaches to improve development (table 3) have to be defined and tested.

The role of good practice

What is the reason for this disappointing setting in cell therapies although the developmental process should be performed according to good practice (GxP)? GxP in particularly with regard to medicinal products includes the regulated international quality standards Good Laboratory Practice (GLP) for preclinical research, Good Manufacturing Practice (GMP) for the manufacturing of the investigational product and Good Clinical Practice (GCP) for clinical research (figure 4). In the author's opinion, there is a massive misunderstanding in expecting a certain quality per se from these standards, but in contrast GxP includes only formal specifications on how data in preclinical and clinical settings are recorded (and stored). GxP does not assure the usage of appropriate (= scientifically relevant)

methods, thus in general GxP alone cannot guarantee a scientific significance of analyses or examinations.

In order to ensure only reproducibility and correctness of data, preclinical investigations should be performed according to GLP, a worldwide accepted standard that determines the way how non-clinical test results are generated and documented. In health and environmental relevant safety testing of industrial chemicals well established and approved test methods (e.g. in vivo skin irritation and corrosion data (OECD TG404 for toxicity testing) already exist. But especially for new approaches like cell products GLP does not state, if certain tests are scientifically suitable to address specific questions. This way still needs to be gone for cellular products and their characterization. Therefore, the development, testing and definition of specific outcome parameters for efficacy and safety testing are mandatory for the field of SC therapy.

GMP is a second standard, which is the prerequisite in manufacturing cell or other medicinal products intended for (pre)clinical testing or routine care. For one part of GMP, QC of the medicinal product, there are special pharmaceutical rules for quality and analytics (methods) that are officially recognized and under permanent revision (pharmacopoeia), which have verifiable to be validated on every QC-site by the holder of a manufacturing permissi

on. Because of the novelty of cellular therapies, there are only few quality related methods for testing cellular therapeutic agents (cell number, sterility). Like in GLP there is also a need for significant tests in GMP that prove efficacy (in terms of stable and effective quality) and safety of a certain cell product in relation to heart failure or other medical indication. This lack of functional characterization of cell products beyond cell numbers, few extracellular markers and sterility has to be removed by scientific investigations (basic and pre-clinical research) that have to be peer reviewed and discussed by the scientific community to establish common accepted standards for relevant markers, parameters and analytical procedures (comparable to Pharmacopoeia) in this field.

An example for this standardization process is the longstanding development of the cluster determinant membrane epitope characterization or the genecard database (e.g. https://www.ncbi.nlm.nih.gov/gene). A similar profiling has to be requested for an international SC molecular sequencing profile register. This could be used to characterize genetic or disease variations in the phenotype and genotype of SC.

GCP is an ethic and scientific standard, used only how to plan and perform clinical trials in humans and to document and report the outcome. Also GCP is characterized through specialized formal documents (e.g. Declaration of Helsinki, ICH guideline, etc.), which aim to protect human rights and quality of the produced data. But, as mentioned above, the main focus of attention of GCP is again just on documentation of data. However, this is only one side of the coin - the explanatory power of data,

on the other side, depends on applicability of the performed method in terms of validation. Biological or technical variance or inconsistence of diagnostic findings can lead to non-evaluation of endpoints and can either be caused by methodical differences - which become even more relevant in multicenter trials - or due to using simply inappropriate methods. The first issue can easily be solved by the validation of a method (e.g. magnetic resonance imaging (MRI) assessment) for every study site. The second issue needs more commitment, because a comprehensive evaluation of safety and efficacy for cell products in clinical studies needs at first the definition of relevant parameters by intense research and an open discussion in the scientific community.

4 International standard of data analysis

Systems medicine emerged as an inevitable tool to investigate complex diseases by the integration of multidimensional datasets and numerous mathematical approaches with data from pre-clinical and clinical studies. The iterative cycle of data-driven modeling and model-driven experimentation, in which alternative hypotheses are postulated and refined until they are validated, helps in identifying new mechanistic details of cell-biological processes and previously unidentified regulatory interactions in the system [335]. However, systems approaches are widely perceived as basic research, so that a main current challenge is to shift from the "need" of translating basic finding into clinical research toward the integration between non-clinical and clinical data. Cardiovascular diseases (CVDs), being multifactorial, may be a potential field test for Systems Medicine [336]. Moreover, it has been shown that current CVD risk scores could be improved in accuracy by computational approaches that identify disease risk and predict the maximum personalized treatment benefit [337]. In this section, we highlight the opportunities and hurdles of data mining, novel sequencing approaches, network methodologies and machine learning (ML) for cardiac research (figure 5).

Data mining and management

Accessing and retrieving high quality omics datasets is the first great challenge to overcome while working in the field of cardiac diseases. Analysis of high-throughput experimental data together with patient phenotypic information has led to the identification of sets of candidate genes, proteins and pathways that may be implicated in many disease conditions. In order to build a higher level picture of the underlying processes involved in the disease pathology, it is necessary to integrate various classes of heterogeneous information and to explore the complex relationships between entities such as diseases, candidate genes, proteins, interactions and pathways [338]. In contrast to monolithic databases, graph databases provide a powerful framework for a combined storage, querying and envisioning of such complex biological datasets. For example the graph database platform Bio4j integrates popular databases like GO, RefSeq, NCBI Taxonamy and Expasy Enzyme DB and allows for intrinsic and extrinsic semantic feature implementation to enhance their respective relationships

and importance towards a common biological perspective [339]. Another aspect is the need for an environment that allows the management and sharing of generated heterogeneous datasets and computational models in the context of the experiments, which created them. The FAIRDOMHub is a framework for publishing FAIR (findable, accessible, interoperable and reusable) Data, operating procedures and models for the Systems Biology community that enables researchers to organize, share and publish data, models and protocols for an enhanced reproducibility and reusability of research results [340] (figure 5).

Next generation sequencing

The actual generation of Next Generation Sequencing (NGS) data is steadily increasing, especially the numerous data being generated for genome-wide association studies (GWAS) have uncovered numerous genetic variants (SNPs) and alternative splicing forms that are associated with blood pressure [341] as well as human heart development [342,343]. Especially SH2B3 emerged as a powerful switch for the influence on blood pressure by using GWAS, meta- and network analyses [344,345]. An extended identification and characterization of additional T-box transcription factor 5 (TBX5) mutations and SNPs was also achieved, which hold promise for a therapeutic strategy targeting TBX5 associated developmental abnormalities and diseases [346]. These novel sequencing technologies have also resulted in the discovery of previously unannotated long non-coding RNAs (lncRNAs), which are under further investigation for the amelioration of CVDs [347]. Furthermore, it has been reported that the interplay of chromatin modifications and non-coding RNAs in the heart also plays a bigger role than previously expected [348]. The list of examples for sequencing success stories could be continued, but we want to put more emphasize on the current bottleneck of this emerging technology - transparent, reproducible and proper data analysis strategies [349]. With respect to the number of data analysis steps, the complexity of decisions on tool selection is increasing likewise, hence calling for systematic workflow development and management frameworks [350]. For this reason, Galaxy [351] and the Galaxy-RNA-Workbench [352] are providing a general framework that makes advanced computational tools accessible without the need of prior extensive training. Galaxy seeks to make data-intensive research more accessible, transparent and reproducible by providing a web-based environment in which users can perform computational analyses and have all of the details automatically tracked for later inspection, publication, or reuse. Data analysis pipelines within such data analysis platforms can be easily used for the QC, complete data processing and advanced predictive analyses and evaluations, as it has been recently shown for RNA sequencing datasets [353]. Increasing the ease of use and comprehensiveness of tools and computational methodologies an interactive environment framework for Galaxy was designed to combine Galaxy's tools and workflows with popular advanced computational environments such as Jupyter [354]. This development tremendously simplifies the daily routine of tool developers and non-computational end users. Taken

together, tailor-made and expert-driven scientifically developed computational workflows instead of rigid data analyses are mandatory for an appropriate preclinical and clinical data analysis [349].

Network approaches

Network approaches are another central concept in Systems Medicine, because they combine the existing knowledge about classic linear pathways with experimental data. Biological networks occur on many different levels such as genes, transcripts, proteins, metabolites, organelles, cells, organs, organisms, and social systems. In general, they appear to exhibit an architecture described mathematically as "scale free," in which most nodes have few links but a small fraction of nodes (called hubs) are highly interconnected [355]. Those hub-genes are assumed to be biologically relevant, because they represent mediators to interconnect and regulate different processes that might play a critical key role within the underlying network of involved pathways. In addition to broadly applied single pathway analyses, differential network detection provides enhanced explanatory insights while taking into account the changing interplay of pathways, e.g. during disease progression [356]. Nowadays, predicting molecular commonalities between phenotypically related diseases, even if they do not share primary disease genes is possible and it can be assumed that network-based approaches, relying on an increasingly accurate interactome, are poised to become unavoidable in interpreting disease-associated genome variations [357]. Furthermore, gene co-expression network based approaches such as Weighted Gene Co-expression Network Analysis (WGCNA), which is one of the most powerful approaches, have been widely used in analyzing microarray and RNA sequencing data, especially for identifying functional modules and hub-like genes [358]. However, it has to be taken into consideration that there might be major topological difference between RNA-seq and microarray co-expression in the form of low overlaps between hub-like genes from each network due to changes in the correlation of expression noise within different technologies [359]. Disease maps are another novel expert-approved pathway-based reconstruction of a network customizing a particular disease or being used as a graphical review on the molecular mechanisms of a disease. It is a collection of interconnected signalling, metabolic and gene regulatory pathways stored in standard Systems Biology formats (e.g. SBGN, SBML, BioPAX) [338]. As interdisciplinary projects continue to generate large amounts of heterogeneous datasets, the network approaches presented here, may offer useful solutions for knowledge integration.

Artificial intelligence and machine learning

As previously described, established approaches to CVD risk assessment, such as the recommendations by the American Heart Association/American College of Cardiology (AHA/ACC), predict the prognostic risk of CVD based on common risk factors like cholesterol, age, smoking, and diabetes [360]. However, there are numerous patients remaining that fail to be identified by these classical linear prediction models and some patients are unnecessarily treated [361]. These models

may thus oversimplify complex high-dimensional datasets by using too few parameters and not considering non-linear interactions among the measured parameters. With the rise of highly efficient ML algorithms, alternative approaches to classical linear prediction models have been developed that have the potential to use available "Big data" for better prognosis and diagnosis [362]. The artificial intelligence relies on algorithms to learn in a supervised or unsupervised manner the provided input data by minimizing the error between predicted and observed outcomes (supervised) and, finally, unravelling the complex and non-linear interactions between the parameters [363]. ML significantly improves the accuracy of cardiovascular risk prediction, increases the number of patients identified who could benefit from a preventive treatment and likewise avoides unnecessary treatment of others [361]. Our group recently used clinical and advanced subgroup measurements in the phase III clinical trial to enable a therapy responsive patient classification for a potential intervention with an applied ML model and obtained a prediction accuracy of above 90% [2]. In addition to pure classification of disease and healthy states, supervised ML can be used to uncover unexpected parameters to be important for the choice between these states that can be subsequently used to further investigate the underlying mechanism or a particular molecule. In addition to supervised ML, unsupervised ML approaches need no specific ground truth for training the actual model, but are based on their non-linearity dimension reduction less effective to identify a specific set of important parameters. These unsupervised statistical learning analyses assume that there are naturally occurring subclasses within patients that behave differently yet reproducibly across a number of populations and varying scenarios (e.g. treatments, ethnologies, environments). Thus, the first part of a study emphasizes finding intrinsic structure within patient phenotypic data, which can then be evaluated retrospectively and prospectively for predicting treatment outcomes and guiding clinical trial design [364]. By applying non-linear approaches like t-distributed stochastic neighbor embedding (t-SNE) for dimensional reduction, our group identified two distinct groups, respectively with responder and non-responder characteristics, within the data and, thus, could independently confirm our response biomarker signature hypothesis [2]. The results obtained can subsequently be used for supervised learning, e.g. for an estimation and prediction of distinct classification groups as well as the underlying important features. Taken together, ML is becoming an invaluable asset to test and evaluate novel classification hypotheses of a disease or clinical syndrome and should be a mandatory analysis for a robust and independent validation strate

Comprehensive centers for R&D integrated disease treatment

The current health care concept experiences an economic dominance of business models based on medicinal products and health care service to be purchased by patients for gaining health. Principally, this system needs supervision for outcome control and should be integrated in society priority to improve disease burden. The unique chance of SC based therapies, however, is to realize a basic repair of disease. This enormous task can only be realized by supervised quality management in the developmental process of therapies as well as in standard care. The model of comprehensive treatment centers integrating research, development, licensing, clinical development and highest quality lifelong patient care could be the masterfile for the development of cardiac stem cell therapies in the context of adequately specialized heart disease centers.

As initially described, the classical flow of information leads in one direction: from basic and preclinical research via clinical analysis to authorization and in best case beyond (vigilance; figure 4). This one-sidedness limits the generation and multiplication of knowledge because unexpected results from pre- and clinical research are apparently blocking continuous improvement. Recently, in a white paper of TACTICS-members a new translational axis from basic research via preclinical research involving several different stages of animal models to clinical trials with feedback to all previous stages was suggested [278].

In contrast to this proposal, the authors state that translation includes not only a directed process with backwards oriented feedback (figure 4), but has to be routed in an integrative process management, where the complete interdisciplinary team (scientists, clinicians, engineers, etc.) is involved in each and every step of the development to maintain complex analyses. The road picture as depicted in figure 6 will be a circling knowledge process like a circling road fitting solutions to basic, preclinical and clinical exits. Especially the availability of special diagnostic and imaging technology has to bridge over all developmental steps. In some cases there is a chance for products failed in clinical trials to be reinvestigated in basic research considering the actual state-of-the-art. Apparently, the first licensed heart related regenerative and cell therapy has to pass this developmental circle repetitively before reaching the status of a highly standardized therapy. All clinical results need to be investigated again in preclinical settings in more detail to clarify the affected disease mechanisms. Moreover, granting of the marketing authorization is not the end, but the beginning of cell therapy standardization.

Given a continuous vigilance under GCP the possibility for conditioned early approval of therapy would have a safer prospect. The authors postulate that all ATMP therapies should be monitored lifelong like in comprehensive cancer center concept for tumor therapy or organ transplantation

medicine according to Good Vigilance Practice (GVP). IT-based concepts have been suggested for improved patient care in diabetes [365].

Only a limited amount of specialized patients (defined by age, sex, comorbidities, etc.) can be analyzed before regulatory approval. The most important stage to demonstrate safety and long-term behavior of new products is therefore after approval and market authorization (= pharmacovigilance). Because of this pharmacovigilance needs to be obligatory for every treating, clinic and manufacturer must be specified and controlled by competent authorities. Possible long-time effects or other outcome can be taken into consideration for the risk-benefit-balance evaluation that is performed annually by EMA. In Germany, the competent authority (Paul-Ehrlich-Institute (PEI)) coordinates and supervises pharmacovigilance systems for four product classes (ATMP, in vitro-diagnostics, tissues, blood components) where side effects and severe events are reported and evaluated. These systems must serve as an accessible database for every patient and physician.

The authors assume further, that an intensive monitoring of patients including bio-banking should be employed to give access for later analysis e.g. marker analysis [2]. The current situation would benefit from a standardized approach to gather preclinical and clinical data as well as biological samples. Therefore, all information related to a certain therapy/cell product can be made available for the scientific and clinical community. Recently a first step was done by EMA with its freely available "clinical data" website (www.clinicaltrialsregister.eu). As a result theoretical simulations ("high-dimensional data analysis") and experimental setups could be adapted more easily. This also includes the characterization of patient conditions compared to healthy individuals. Another example for pattern recognition and thereof arising possibilities is the work of Sengupta et al. [366] where a cognitive ML algorithm could be generated for cardiac imaging. Another Systems Medicinal approach was used to detect differential connections between diseases associated networks [357]. In summary this new way of large scale analyzing methods require harmonized and standardized datasets for research and clinical treatment.

Until now, there is at least in the field of heart failure treatment no consensus about which kind of clinical endpoints are crucial and accepted by the scientific community. This leads to a non-defined clinical outcome (figure 7). Among other aspects this point was also already addressed by Fernandez-Aviles et al. who additionally assumed that multidisciplinary collaborations being aware of these limitations could not overcome them until now [278]. Therefore, the knowledge has to become even broader: proving efficacy goes along with understanding the underlying mechanisms. Thus the scientific discussion of the before mentioned topics needs to be forced and would also benefit from an open-minded culture of publishing "negative" results to reduce repetition of failed approaches. Such publication bias could lead to unjustified transition or stop of approaches in the developmental process [367]. Likewise, also successful approaches have to be questioned, as Nowbar et al. showed discrepancies in the enhancement of ejection fraction in trials investigating autologous BMSCs [368].

Finally the debate should end in accepted scientific standards that will elevate GxP to a higher level for cell therapies comparable to the area of chemical medicinal products (small molecules). The knowledge-driven discourse is the essential part during the development of cell therapies: ideally as long as knowledge grows, standards need to be adapted to present circumstances.

Considering the findings of the PERFECT trial [2] - every patient has a responder (or a non-responder) biomarker signature - it is worth to analyze recently published clinical data with no significant outcome again. Concomitant research programs, additionally to the clinical trial protocols, could benefit a detailed and comprehensive analysis. With a more nuanced view supposed negative results could turn out to be more specific than initially assumed. Furthermore, the scientific strategy in planning future investigations in terms of suitable tests and animal models need to be optimized. Like exemplified in part 3.1 using Systems Medicine approaches and accurate data analysis settings, the outcome of preclinical and clinical studies can be enhanced.

Linked to all previously discussed issues are the questions regarding regulatory hurdles and the financing of research for small and middle sized companies as well as for universities. Well performed research takes well skilled scientists and money over a long period of time. Just the concerted efforts of all involved parties (authorities, industry, patient organizations, researchers, scientific publication machinery, etc.) can result in an increased input-output-ratio for cell therapy products. Based on this knowledge, it will be mandatory to intensify data exchange and establish interdisciplinary standards of cooperation. There is a great need for a central clinical database for CVD mechanisms and regenerative approaches, unanimous quality management, classification of SC products by gene regulation, cluster determinant platforms for (stem) cell differentiation, diagnostic fostering of biomarker and imaging applications (table 3). Ultimately, applying artificial intelligence by means of ML methodologies may be a crucial step towards deeper insights into the complex mechanisms of cardiovascular regeneration.

FUNDING:

This work was supported by the Federal Ministry of Education and Research Germany (FKZ 0312138A and FKZ 316159), the State Mecklenburg-Western Pomerania with EU Structural Funds (ESF/IVWM-B34-0030/10 and ESF/IVBM-B35-0010/12).

DECLARATION OF INTERESTS All authors declare no competing interests.

CONTRIBUTORS

GS performed the conception, design, drafting, and writing supervision of the manuscript. JN, MW, JG, UR, PV, PM performed extensive literature search and wrote the manuscript. All authors read and approved the final version for submission.

List of tables and figures

Table 1: Main topics of the review

1. Stem cell function and delivery in heart disease

2. Disease pathomechanism, therapeutic options, diagnostic biomarkers

3. Definition of quality standard and best practice

4. International standard of data analysis

5. Comprehensive centers for R&D integrated disease treatment

Table 2: Functions of SH2B3 in hematopoietic, vascular and interstitial cells

Cellular Pathway Downregulation References

cytokine pathways: IL-7, IL-11 [304,369]

growth factors in HSC and MSC: EpoR, SCR, Jaggedl [370]

integrin and actin signaling [306]

VCAM-1 [371]

PDGF Rec [372]

Inhibition of cellular function

stem cell proliferation (HSC, EPC, MSC?) [373,374]

lymphocyte proliferation (B-Lymphocytes) [309]

endothelial activation [306]

blood MNC and thrombocyte proliferation [303,375]

Systemic Inhibitory Effect

blood, immune and cardiovascular proliferation [315]

angiogenesis and vascular repair [307,314,376]

endothelial activation [298,316] immune cell

Table 3: Proposals for improved development

1. Diagnose disease mechanism and pathway signature

2. Classify (CD, Rseq) and standardize (stem) cell product

3. Establish specific molecular and/or biopsy imaging

4. Monitor treatment effect by biomarkers

5. Use disease specific model validation

6. Establish lifelong quality management for all clinical diagnostics and procedures

7. Establish biobank for tissue, blood, and cell product

8. Use machine learning / Systems medicine for data analysis validation

9. Individualize therapy to target disease and tissue repair mechanism

10. Integrate expert knowledge, but validate by computational approaches like machine learning

Harmonized qualitycontrol

^ "iec/,anisms

V\at*6e

Kno-.vn factors Missingfactors

Graphical abstract: Missing parts in the puzzle of stem cell based treatments in cardiovascular disease

SC: stem cell; HSC: hematopoietic stem cell; NR/R: non-responder/responder; MSC: mesenchymal stem cell

Figure 1: Intravascular (A) and intramyocardial (B) delivery techniques of stem cells for cardiac disease treatment (reprint from: [104])

O Pathomechanism O Stem cell repair O Homeostasis

Figure 2: Stem cell functions adapting to tissue homeostasis, repair, and dysfunction

Figure 3: Stem cell switch hypothesis: Homeostasis and stem cell mediated disease. Stem cell and bone marrow dysfunction in cardiovascular disease (red area). Proliferation and functional control of HSCs/EPCs/MSCs by SH2B3 vs. Notch/mTOR in homeostasis (green), repair (yellow) and disease pathomechanism (red).

Basic Preclinical Clinical MA /

Research Research Research Market

(GSP) (GLP; GMP) (GMP; GCP) / (GMP; GVP)

Figure 4: Development of a medicinal product. The scheme illustrates the old developmental process (fragmented). Feedback and quality testing are incomplete. (GCP - Good Clinical Practice, GLP - Good Laboratory Practice, GMP - Good Manufacturing Practice, GVP - Good Vigilance Practice).

Unexplained symptoms

A CA G101000111 AG G101010101 111 CA AAOOOllOU AAGCA1010011

Scalable data processing, e.g. RNA-Galaxy Workbench

-.Galaxy

Machine learning

Data classification and prediction

Improved diagnosis, prognosis and therapy

101000111A CA G 101010101111 CA AA 00011011AAGCA 1010011 AG G

Data management, e.g. FAIRDOM

•HUB*

FAIRDOM

New insights

% f * y

Transparent evaluation of omics data, e.g. TRAPIINE

logz(foldchange)

miRNAl mRNAl mRNA3

Data integration and prediction, e.g. TriplexRNA

" Up regulated □ Disease associated GO » Down regulated term

Figure 5: Integration of a Systems Medicine approach within a stem cell therapy development scenario.

Figure 6: Development of a regenerative medicine therapy as an integrated process. Every stage of research is a component of a circular process that is based on four central approaches and spins in both directions. Each result, if positive or negative, affects other parts of the development. This approach leads to enhanced knowledge about the (cell) product as well as the affected and underlying mechanisms in humans. Quality standards and risk-benefit-evaluation are the main elements of this approach. GCP - Good Clinical Practice, GLP - Good Laboratory Practice, GMP - Good Manufacturing Practice, GSP - Good Scientific Practice, GVP - Good Vigilance Practice, MA -Market authorization.

Validated treatment result

Efficacy

Safety

Quality

Treatment result?

Disease burden

Health Industry

Scientists

Health Care

Treatment development

Figure 7: Disease burden and treatment development: Who benefits?

At least three hurdles need to be passed during the development of new cell therapies for patients: quality, efficacy and safety have to be proven for market authorization. Nevertheless there are ways to bypass these steps to reach patients. Here in the grey market zone, patients get treated and the outcome can be very dangerous (in red). Reasons for the grey market are diverse: scientific prestige, sales volume etc. But also „over-regulation" by laws - not adapted to current situations - could result in a decelerated development.

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Table 1-3

Table 1: Main topics of the review

6. Stem cell function and delivery in heart disease

7. Disease pathomechanism, therapeutic options, diagnostic biomarkers

8. Definition of quality standard and best practice

9. International standard of data analysis

10. Comprehensive centers for R&D integrated treatment

Table 2:

Functions of SH2B3 in hematopoietic, vascular and interstitial cells

Cellular Pathway Downregulation

cytokine pathways: IL-7, IL-11

growth factors in HSC and MSC: EpoR, SCR, Jagged1

integrin and actin signaling

VCAM-1

PDGF Rec

Inhibition of cellular function

stem cell proliferation (HSC, EPC, MSC?)

lymphocyte proliferation (B-Lymphocytes)

endothelial activation

blood MNC and thrombocyte proliferation

Systemic Inhibitory Effect

blood, immune and cardiovascular proliferation

angiogenesis and vascular repair

endothelial activation

immune cell

References

[145,301]

[302] [147]

[305.306] [150] [147]

[144.307]

[148,155,156] [140,158]

Table 3:

Proposals for improved development

11. Diagnose disease mechanism and pathway signature

12. Classify (CD, Rseq) and standardize (stem) cell product

13. Establish specific molecular and/or biopsy imaging

14. Monitor treatment effect by biomarkers

15. Use disease specific model validation

16. Establish lifelong quality management for all clinical diagnostics and procedures

17. Establish biobank for tissue, blood, and cell product

18. Use machine learning / Systems medicine for data analysis validation

19. Individualize therapy to target disease and tissue repair mechanism

20. Integrate expert knowledge, but validate by computational approaches like machine learning

Clinical

Vascular

Ischemia

HSCrole

signature

Fibrosis

Irïïlammat.

Regulation

Animal

models

Market

Harmonized qualitycontrol

Known factors

Missingfactors

Graphical abstract