HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Kamlesh Sheth Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kubal, C. Articles by Galiñanes, M. Search for Related Content PubMed PubMed Citation Articles by Kubal, C. Articles by Galiñanes, M. Related Collections Molecular biology Myocardial infarction Myocardial protection

J Thorac Cardiovasc Surg 2006;132:1112-1118
© 2006 The American Association for Thoracic Surgery

Cardiopulmonary Support and Physiology

Bone marrow cells have a potent anti-ischemic effect against myocardial cell death in humans

^a Department of Cardiovascular Sciences, Cardiac Surgery Unit, The Glenfield Hospital, University of Leicester, Leicester, United Kingdom
^b Mount Sinai Medical Center, New York, NY

Received for publication March 3, 2006; revisions received June 21, 2006; accepted for publication June 22, 2006.

^_* Address for reprints: Manuel Galiñanes, MD, PhD, FRCS, Department of Cardiovascular Sciences, Cardiac Surgery Unit, The Glenfield Hospital, University of Leicester, Leicester LE3 9QP, UK (Email: mg50{at}le.ac.uk).

	Abstract

Top Abstract Introduction Methods Results Discussion Conclusions References

 
OBJECTIVE: We sought to elucidate whether bone marrow cells ameliorate the outcomes of myocardial ischemia by reduction of cell death and to investigate whether the benefit is mediated by activation of intracellular kinases.

METHODS: Muscles from the right atrial appendage of patients were subjected to 90 minutes of normothermic simulated ischemia followed by 120 minutes of reoxygenation. Bone marrow cells from the same patients were co-incubated (10⁵ cells per milligram of tissue) with the muscles during the entire experimental period. Some groups were treated with the protein kinase C inhibitor chelerythrine (10 µmol/L) or the p38 mitogen-activated protein kinase inhibitor SB203580 (10 µmol/L). Creatine kinase released into the media during the reoxygenation period was measured (international units per milligram of wet tissue), cell death by necrosis was assessed by propidium iodide, and cell death by apoptosis was assessed by deoxyuride-5'-triphosphate biotin nick end labeling (percentage of aerobic control values).

RESULTS: Creatine kinase release was significantly reduced (from 1.30 IU/mg wet tissue ± 0.11 to 0.33 IU/mg wet tissue ± 0.06; P < .05), and cell death by necrosis and apoptosis was abolished by bone marrow cells (from 30.1% ± 7.3% and 28.1% ± 3.9% to –5.6% ± 5.1% and 3.7% ± 5.0%, respectively; P < .05), an effect that was reversed by chelerythrine (13.4% ± 4.4% and 24.6% ± 8.2%, respectively) and by SB203580 (20.1% ± 2.4% and 19.5% ± 5.7%, respectively).

CONCLUSIONS: Bone marrow cells have a potent effect against cell death of the human myocardium in the acute phase of ischemia that may explain, at least in part, the improvement in cardiac function and the reduction in infarct size seen when bone marrow cells are injected after a myocardial infarction. These findings may have important clinical implications to optimize cell therapy with bone marrow cells. In addition, the identification that the anti-ischemic effect of bone marrow cells is mediated by the kinases protein kinase C and p38 mitogen-activated protein kinase is also clinically relevant; it suggests that some of the beneficial effect of bone marrow cells can be obtained by the activation of intracellular signaling molecules, without the need for cell injection.

	Introduction

Top Abstract Introduction Methods Results Discussion Conclusions References

 
Ischemic heart disease accounts for more than 50% of the reported cases of heart failure,¹ which is the leading cause of morbidity and mortality in the Western world, affecting 4.8 million people in the United States² and at least 10 million people in countries represented by the European Society of Cardiology.³ Therapies such as thrombolysis and coronary angioplasty have improved the clinical outcomes after an acute myocardial infarction; however, the incidence of heart failure continues to increase.⁴ With the exception of heart transplantation, there is no effective treatment for heart failure, and therefore there is a need for effective new therapeutic interventions. Recently, it has been suggested that repair/regeneration of heart muscle by autologous adult stem cells may be an effective way of reversing heart failure. Bone marrow cells (BMCs) are readily available from the patient's own bone marrow, and they are inexpensive and easily prepared. Furthermore, they do not need to be expanded in culture, and their application does not require additional health resources. Because of this, BMCs can be a very attractive pool of cells for cardiac repair, and after the initial demonstration of safety use,^5-9 several randomized clinical studies are under way.

Animal and clinical studies have reported that the intracoronary or intramyocardial injection of BMCs after a myocardial infarction improves the recovery of cardiac function and reduces infarct size.^5-12 However, whether this effect occurs by differentiation of the BMCs into vessels and muscle has been questioned.^13,14 The observation that BMCs can spontaneously fuse with other cells and subsequently adopt the phenotype of the recipient cells^15,16 could be an alternative mechanism of tissue repair, but this phenomenon may occur at too low a rate to be meaningful¹⁷ and has been disputed by some investigators.¹⁸ Recently, we^19,20 and others^21,22 have reported that progenitor or stem cells may exist within the heart, and yet another potential explanation for the beneficial effect of BMCs on the heart could be that they promote the proliferation of resident putative stem cells. Other investigators have also shown that BMCs decrease the expression of proapoptotic proteins and reduce apoptosis,^23-25 although it is unclear from those studies whether the antiapoptotic effect is the result of increased angiogenesis and a better blood supply to the ischemic areas or is due to a direct effect of BMCs by triggering intrinsic cardioprotective mechanisms. In this connection, it has been shown that BMCs segregate growth factors and cytokines²⁶ that in turn can activate antiapoptotic intracellular signaling pathways.^27,28 These mechanisms are not necessarily exclusive, but a full clarification of the underlying cause of BMC-induced improvement in cardiac function is needed to refine their clinical application and maximize their therapeutical potential. Therefore, we sought to elucidate whether BMCs protect the human myocardium from ischemic injury by reducing cell death and to investigate whether the benefit is mediated by activation of the kinases protein kinase C (PKC) and p38 mitogen-activated protein kinase (MAPK), by using a model of simulated ischemia previously characterized in our laboratory.²⁹

	Methods

Top Abstract Introduction Methods Results Discussion Conclusions References

 
Study Patients and Experimental Preparation
The study was approved by the local ethics committee, and written consent was obtained from each patient. The right atrial appendage was obtained from patients undergoing elective heart surgery. The experimental preparation used has been previously validated in our laboratory.²⁹ Briefly, upon harvesting, samples were immediately immersed in cold (4°C) Krebs/Henseleit N-2-hydroxyethylpiperazine-N-2-ethanesulfonic acid–buffered medium (118 mmol/L NaCl, 4.8 mmol/L KCl, 27.2 mmol/L NaHCO₃, 1 mmol/L KH₂PO₄, 1.2 mmol/L MgCl₂, 1.25 mmol/L CaCl₂, 10 mmol/L glucose, and 20 mmol/L N-2-hydroxyethylpiperazine-N-2-ethanesulfonic acid) prebubbled with 95% oxygen/5% carbon dioxide (pH 7.4). Muscles were immediately sectioned manually with a skin-graft blade (Swann-Morton Ltd, Sheffield, UK) to slices 300 to 500 µm thick and weighing 30 to 50 mg. After equilibration under normothermic aerobic conditions (95% oxygen/5% carbon dioxide) for 45 minutes, muscles were subjected to 90 minutes of simulated ischemia (37°C), obtained by bubbling the media with 95% nitrogen/5% carbon dioxide in the absence of glucose and at pH 6.8, followed by 120 minutes of reoxygenation.

Aspiration of Bone Marrow and Preparation of Marrow Cells
With patients under anesthesia and immediately before the initiation of the operation, 40 mL of bone marrow was aspirated from the iliac crest of the same patients donating the atrial appendage by using a bone marrow–harvesting needle (Medical Device Technologies Inc, Gainesville, Fla). The mononuclear fraction was obtained by density gradient. Cells were washed twice and suspended in Krebs/Henseleit medium. The cells were then manually counted by using the Neubauer chamber.

Study Groups
After equilibration, the muscle slices were randomly allocated to the following groups (n = 6 per group): (1) simulated ischemia followed by reoxygenation (SI/R), (2) SI/R co-incubated with BMCs (10⁵ cells per milligram of tissue), (3) SI/R with the PKC inhibitor chelerythrine (10 µmol/L), and (4) SI/R with BMCs and the PKC inhibitor chelerythrine (10 µmol/L). Time-matched aerobic controls were used for each experiment. Similar experiments were performed by substituting chelerythrine by the p38 MAPK inhibitor SB203580 (10 µmol/L). Both chelerythrine and SB203580 were obtained from Calbiochem Ltd (Lutterworth, UK).

Commercially available human umbilical vein endothelial cells and keratinocytes were purchased from Cambrex Bioscience (Berkshire, UK). The cells were grown in culture and used after a few passages. On the day of the experiment, cells were passaged and counted. A total of 10⁵ cells per milligram of tissue were incubated with endothelial cells and keratinocytes in addition to BMCs in separate groups (n = 4 per group).

Assessment of Tissue Injury
Tissue injury was assessed by measurement of creatine kinase release into the media during the 120-minute reoxygenation period. The enzyme activity was measured by a linked-enzyme kinetic assay by using a commercial assay kit (30-3060/R2; Abbott Laboratories, Diagnostic Division, Kent, UK) and a plate reader (Benchmark; Bio-Rad Laboratories, Hercules, Calif). Results were expressed as international units per milligram of wet weight after subtraction of the aerobic control values.

Assessment of Cell Death
At the end of the experimental protocol, tissues were incubated for 2 minutes on ice with 5 µg/mL propidium iodide in 0.1 mol/L trisodium citrate and 20 mmol/L phosphate-buffered saline at pH 7.4 to identify the necrotic nuclei. After this, the muscles were embedded with optical cutting temperature embedding matrix, Tissue-Tek (Agar Scientific Ltd, Essex, UK). Frozen sections were then cut at 8-µm thickness in a Bright cryotome (model OTF, Bright Instrument Co Ltd, Huntingdon, Cambridgeshire, UK) at approximately –25°C, and sections were collected on VECTABOND (Vector Laboratories Ltd, Peterborugh, UK)–treated slides. To assess apoptosis, the sections were fixed with 4% paraformaldehyde, washed with 20 mmol/L phosphate-buffered saline at pH 7.4 for 2 minutes, permeabilized in 0.02 mg/mL proteinase K for 10 minutes at 37°C in a humidity chamber, and presensitized for 1 minute in a microwave oven at 800 W in 0.1% Triton X-100 and 0.1 mol/L trisodium citrate at pH 6.0. Terminal deoxynucleotidyl transferase was then used to incorporate fluorescein isothiocyanate–labeled deoxyuridine triphosphate oligonucleotides to DNA strand breaks at the 3'-OH termini in a template-dependent manner (deoxyuride 5'-triphosphate biotin nick end labeling technique) by using a commercially available kit (Roche Diagnostics GmbH, Penzberg, Germany). Finally, to count the total number of nuclei, sections were mounted by using VECTASHIELD mounting medium (Vector Laboratories) and stained with 4',6-diamidino-2-phenylindole.

To assess necrosis, propidium iodide–labeled nuclei were excited with helium-neon laser light at 543 nm, and fluorescence was detected by using an emission range of 680 to 730 nm. For apoptosis, the fluorescein isothiocyanate fluorescence emission range used was 600 to 630 nm; it was then measured with argon ion fluorescence excitation at 488 nm and detected by laser confocal epifluorescence microscopy.

Analysis was performed with NIH Image software (Scion Corp, Frederick, Md). Fluorescent signals with areas greater than 16 µm² were counted to avoid the inclusion of artifact.

Statistical Analysis
Data were expressed as mean ± SEM and subjected to analysis of variance followed by post hoc t test comparison (Microsoft Excel analysis tool pack; Microsoft Corp, Redmond, Wash).

	Results

Top Abstract Introduction Methods Results Discussion Conclusions References

 
As shown in Figure 1, A to C, substantial ischemic injury was detected by creatine kinase release and by the degree of cell necrosis and apoptosis. The figure also shows that creatine kinase release was significantly reduced and that cell necrosis and apoptosis were abolished in the groups treated with BMCs, an effect that was reversed by the PKC blocker chelerythrine. Figure 1, D and E, shows representative photomicrographs of necrosis and apoptosis for all the study groups.

View larger version (69K): [in this window] [in a new window]   Figure 1. Creatine kinase (CK) release (A) and cell death by necrosis (B) and apoptosis (C) of human right atrium myocardium (n = 6 specimens per group) subjected to 90 minutes of simulated ischemia and 120 minutes of reoxygenation in the presence and absence of autologous BMCs and the effect of PKC blockade with chelerythrine (10 pmol/L). *P < .05 versus the bone marrow (BM) group. Representative photomicrographs showing necrosis (D) by staining with propidium iodide dye (red) and apoptosis (e) by the deoxyuride-5'-triphosphate biotin nick end labeling technique (green). Necrotic nuclei were determined as a percentage of 4',6-diamidino-2-phenylindole–stained nuclei and subtraction of the percentage of necrotic nuclei from control aerobic sections.

View larger version (75K): [in this window] [in a new window]   Figure 2. Creatine kinase (CK) release (A) and cell death by necrosis (B) and apoptosis (C) of human right atrium myocardium (n = 6 specimens per group) subjected to 90 minutes of simulated ischemia and 120 minutes of reoxygenation in the presence and absence of autologous BMCs and the effect of p38 MAPK blockade with SB203580 (10 pmol/L). *P < .05 versus the bone marrow (BM) group. Representative photomicrographs showing necrosis (D) by staining with propidium iodide dye (red) and apoptosis (E) by the deoxyuride-5'-triphosphate biotin nick end labeling technique (green). Necrotic nuclei were determined as a percentage of 4',6-diamidino-2-phenylindole–stained nuclei and subtraction of the percentage of necrotic nuclei from control aerobic sections.

View larger version (51K): [in this window] [in a new window]   Figure 3. Creatine kinase (CK) release from human right atrial myocardium (n = 4 specimens per group) subjected to 90 minutes of simulated ischemia and 120 minutes of reoxygenation in the absence and in the presence of autologous BMCs, human umbilical vein endothelial cells, and human keratinocytes. *P < .05 versus the other groups. IU, International units.

	Discussion

Top Abstract Introduction Methods Results Discussion Conclusions References

There is experimental evidence that injection of BMCs into the infarcted myocardium improves cardiac function and reduces infarct size.^10,11 More recently, there is indication that BMCs also ameliorate cardiac contractility in humans.^5-9,12 However, it is not clear whether the mechanism of these beneficial effects from the BMCs involves proliferation and differentiation of the injected cells, stimulation of proliferation of putative resident stem cells, or a reduction of myocardial cell death. Animal^11,30 and clinical^6-9,12 studies have suggested that BMCs can differentiate into cardiomyocytes, although the capacity of hematopoietic linage cells to differentiate into heart muscle has been disputed.^13,14 Although this mechanism could still play a role in tissue repair, the capacity of BMCs to differentiate into cardiomyocytes may occur at a low frequency,³¹ and it might not be sufficient to fully explain the time course and the degree of the benefit observed. Furthermore, few BMCs remain in the heart after injection,³² which also questions the importance of proliferation and differentiation of BMCs into cardiomyocytes. Stimulation of putative resident stem cells by BMCs may also play a role in the regeneration of cardiac tissue, but, again, cells would require some time to proliferate and fully differentiate into cardiomyocytes. Here we have demonstrated for the first time that in humans, autologous BMCs almost completely abolish myocardial apoptosis and necrosis induced by ischemia. Therefore, the rescue of cardiac tissue from dying may be a plausible explanation for the rapid improvement in function after the administration of BMCs. Our results seem to be specific for BMCs, because other cell types failed to afford cardioprotection. The findings in human myocardium are supported by animal studies in which injection of fractionated BMCs also reduced apoptosis and decreased the production of proapoptotic proteins.^23-25 However, in these animal investigations, it was not possible to separate whether the antiapoptotic effect was caused by a direct action of the BMCs or was the result of an improvement in blood supply to the ischemic areas by angiogenesis.

A second important finding of our study is that the cardioprotection of BMCs can be reversed by blockade of PKC and p38 MAPK, thus suggesting that these kinases are essential factors in mediating the beneficial effect of these cells. In a rat model, Gnecchi and colleagues²⁵ have also suggested that Akt-modified mesenchymal stem cells improve protection of the ischemic heart. It is worth noting that this intracellular signaling pathway of protection by BMCs is also shared by ischemic preconditioning in humans,^33,34 another potent cardioprotective intervention that per se may induce the recruitment of bone marrow–derived endothelial progenitor cells to the ischemic myocardium.³⁵

	Conclusions

Top Abstract Introduction Methods Results Discussion Conclusions References

 
The results of this study may have important clinical implications for the treatment of ischemic heart disease and the progression to heart failure. They suggest that the administration of BMCs may prevent myocardial injury and the death of tissue in the acute phase of a myocardial infarction, at a time when massive myocardial necrosis and apoptosis occur.³⁶ Previously it has been suggested that a high expression of inflammatory factors in the early period of a myocardial infarction may reduce the engraftment of BMCs,³⁷ and, because of this, clinical trials have been designed to administer the BMCs 4 to 9 days after the infarction.^6,7 Therefore, if BMCs act through a dual mechanism, then it seems logical that they should be applied at more than one time point, initially to reduce the loss of tissue and later to initiate the repair/regeneration of the defective heart muscle.

Our demonstration that the cardioprotection by BMCs during acute myocardial ischemia is mediated by PKC and p38 MAPK is also of clinical relevance because the same beneficial effect could be obtained by selective pharmacologic activation of this signaling pathway without the need for BMC administration. This is of special importance because during the first few hours of a myocardial infarction, the aspiration of the marrow and the separation and injection of the cells may be logistically difficult and unpractical. Although these findings need to be confirmed in a clinical setting, it is clear that this approach may reduce the myocardial injury induced by ischemia in acute coronary syndromes and during cardiac surgery. However, it is worth noting that we do not possess the means for the selective manipulation of the kinase-mediated signaling cascades and that, at present, the safest clinical application may be the use of autologous BMCs.

	Acknowledgments

 
We thank the British Heart Foundation (PG/04/050) and Take Heart Leicester for their support and Nicola Harris for help with the preparation of the manuscript. We are also grateful to Dr. Nick Taub (Trent RDSU) for statistical advice.

	Footnotes

 
The first two authors contributed equally to this work.

This work was partly funded by a grant from the British Heart Foundation (PG/04/050) and by Take Heart Leicester.

	References

Top Abstract Introduction Methods Results Discussion Conclusions References

 

1. Fox KF, Cowie MR, Wood DA, Coats AJ, Gibbs JS, Underwood SR, et al. Coronary artery disease as the cause of incident heart failure in the population. Eur Heart J 2001;22:228-236.[Abstract/Free Full Text]
   
2. American Heart Association Heart disease and stroke—update 2005. Dallas, Tex: American Heart Association; 2005.
   
3. Swedberg K, Cleland J, Dargie H, Drexler H, Follath F, Komajda M, et al. Guidelines for the diagnosis and treatment of chronic heart failure: executive summary (update 2005): the Task Force for the Diagnosis and Treatment of Chronic Heart Failure of the European Society of Cardiology. Eur Heart J 2005;26:1115-1140.[Free Full Text]
   
4. Kamalesh M, Nair G. Disproportionate increase in prevalence of diabetes among patients with congestive heart failure due to systolic dysfunction. Int J Cardiol 2005;99:125-127.[Medline]
   
5. Hamano K, Nishida M, Hirata K, Mikamo A, Li TS, Harada M, et al. Local implantation of autologous bone marrow cells for therapeutic angiogenesis in patients with ischemic heart disease: clinical trial and preliminary results. Jpn Circ J 2001;65:845-847.[Medline]
   
6. Strauer BE, Brehm M, Zeus T, Kostering M, Hernandez A, Sorg RV, et al. Repair of infarcted myocardium by autologous intracoronary mononuclear bone marrow cell transplantation in humans. Circulation 2002;106:1913-1918.[Abstract/Free Full Text]
   
7. Assmus B, Schachinger V, Teupe C, Britten M, Lehman R, Dobert N, et al. Transplantation of Progenitor Cells and Regeneration Enhancement in Acute Myocardial Infarction (TOPCARE-AMI). Circulation 2002;106:3009-3017.[Abstract/Free Full Text]
   
8. Stamm C, Westphal B, Kleine HD, Petzsch M, Kittner C, Klinge H, et al. Autologous bone-marrow stem-cell transplantation for myocardial regeneration. Lancet 2003;361:45-46.[Medline]
   
9. Galiñanes M, Loubani M, Davies J, Chin D, Pasi J, Bell PR. Safety and efficacy of transplantation of autologous bone marrow into scarred myocardium for the enhancement of cardiac function in man. Cell Transpl 2004;13:7-13.[Medline]
   
10. Tomita S, Li RK, Weisel RD, Mickle DA, Kim EJ, Sakai T, et al. Autologous transplantation of bone marrow cells improves damaged heart function. Circulation 1999;100(suppl):II247-II256.
    
11. Orlic D, Kajstura J, Chimenti S, Jakoniuk I, Anderson SM, Li B, et al. Bone marrow cells regenerate infarcted myocardium. Nature 2001;410:701-705.[Medline]
    
12. Fernandez-Aviles F, San Roman JA, Garcia-Frade J, Fernandez ME, Penarrubia MJ, de la Fuente L, et al. Experimental and clinical regenerative capability of human bone marrow cells after myocardial infarction. Circ Res 2004;95:742-748.[Abstract/Free Full Text]
    
13. Murry CE, Soonpaa MH, Reinecke H, Nakajima H, Nakajima HO, Rubart M, et al. Haematopoietic stem cells do not transdifferentiate into cardiac myocytes in myocardial infarcts. Nature 2004;428:664-668.[Medline]
    
14. Balsam LB, Wagers AJ, Christensen JL, Kofidis T, Weissman IL, Robbins RC. Haematopoietic stem cells adopt mature haematopoietic fates in ischaemic myocardium. Nature 2004;428:668-673.[Medline]
    
15. Terada N, Hamazaki T, Oka M, Hoki M, Mastalerz DM, Nakano Y, et al. Bone marrow cells adopt the phenotype of other cells by spontaneous cell fusion. Nature 2002;416:542-545.[Medline]
    
16. Alvarez-Dolado M, Pardal R, Garcia-Verdugo JM, Fike JR, Lee HO, Pfeffer K, et al. Fusion of bone-marrow-derived cells with Purkinje neurons, cardiomyocytes and hepatocytes. Nature 2003;425:968-973.[Medline]
    
17. Nygren JM, Jovinge S, Breitbach M, Sawen P, Roll W, Hescheler J, et al. Bone marrow-derived hematopoietic cells generate cardiomyocytes at a low frequency through cell fusion, but not transdifferentiation. Nat Med 2004;10:494-501.[Medline]
    
18. Kajstura J, Rota M, Whang B, Cascapera S, Hosoda T, Bearzi C, et al. Bone marrow cells differentiate in cardiac cell lineages after infarction independently of cell fusion. Circ Res 2005;96:127-137.[Abstract/Free Full Text]
    
19. Beltrami AP, Barlucchi L, Torella D, Baker M, Limana F, Chimenti S, et al. Adult cardiac stem cells are multipotent and support myocardial regeneration. Cell 2003;114:763-776.[Medline]
    
20. Shenje LT, Matata BM, Galiñanes M. Uncovering human cardiac myocyte progenitor cells for myocardial regeneration [abstract]. J Am Coll Cardiol 2004;43(suppl A):263A.
    
21. Oh H, Bradfute SB, Gallardo TD, Nakamura T, Gaussin V, Mishina Y, et al. Cardiac progenitor cells from adult myocardium: homing, differentiation, and fusion after infarction. Proc Natl Acad Sci U S A 2003;100:12313-12318.[Abstract/Free Full Text]
    
22. Matsuura K, Nagain T, Nishigaki N, Oyama T, Nishi J, Wada H, et al. Adult cardiac Sca-1-positive cells differentiate into beating cardiomyocytes. J Biol Chem 2004;279:11384-11391.[Abstract/Free Full Text]
    
23. Yoon YS, Wecker A, Heyd L, Park JS, Tkebuchava T, Kusano K, et al. Clonally expanded novel multipotent stem cells from human bone marrow regenerate myocardium after myocardial infarction. J Clin Invest 2005;115:326-338.[Medline]
    
24. Tang YL, Zhao Q, Qin X, Shen L, Cheng L, Ge J, et al. Paracrine action enhances the effects of autologous mesenchymal stem cell transplantation on vascular regeneration in rat model of myocardial infarction. Ann Thorac Surg 2005;80:229-237.[Abstract/Free Full Text]
    
25. Gnecchi M, He H, Liang OD, Melo LG, Morello F, Mu H, et al. Paracrine action accounts for marked protection of ischemic heart by Akt-modified mesenchymal stem cells. Nat Med 2005;11:367-368.[Medline]
    
26. Fuchs S, Baffour R, Zhou YF, Shou M, Pierre A, Tio FO, et al. Transendocardial delivery of autologous bone marrow enhances collateral perfusion and regional function in pigs with chronic experimental myocardial ischemia. J Am Coll Cardiol 2001;37:1726-1732.[Abstract/Free Full Text]
    
27. Lotem J, Sachs L. Cytokines as suppressors of apoptosis. Apoptosis 1999;4:187-196.[Medline]
    
28. Tehranchi R, Fadeel B, Schmidt-Mende J, Forsblom AM, Emanuelsson E, Jadersten M, et al. Antiapoptotic role of growth factors in the myelodysplastic syndromes: concordance between in vitro and in vivo observations. Clin Cancer Res 2005;11:6291-6299.[Abstract/Free Full Text]
    
29. Zhang JG, Ghosh S, Ockelford C, Galiñanes M. Characterization of an in vitro model for the study of the short and prolonged effects of myocardial ischaemia and reperfusion in man. Clin Sci 2000;99:443-453.
    
30. Makino S, Fukuda K, Miyoshi S, Konishi F, Kodama H, Pan J, et al. Cardiomyocytes can be generated from marrow stromal cells in vitro. J Clin Invest 1999;103:697-705.[Medline]
    
31. Misao Y, Takemura G, Arai M, Sato S, Suzuki K, Miyata S, et al. Bone marrow-derived myocyte-like cells and regulation of repair-related cytokines after bone marrow cell transplantation. Cardiovasc Res 2006;69:476-490.[Abstract/Free Full Text]
    
32. Hofmann M, Wollert KC, Meyer GP, Menke A, Arseniev L, Hertenstein B, et al. Monitoring of bone marrow cell homing into the infarcted human myocardium. Circulation 2005;111:2198-2202.[Abstract/Free Full Text]
    
33. Loubani M, Galiñanes M. Pharmacological and ischemic preconditioning of the human myocardium: mitoKatp channels are upstream and p38 MAPK is downstream of PKC. BMC Physiol 2002;2:10.[Medline]
    
34. Hassouna A, Matata BM, Galiñanes M. PKC-epsilon is upstream and PKC-alpha is downstream of mitoKATP channels in the signal transduction pathway of ischemic preconditioning of human myocardium. Am J Physiol Cell Physiol 2004;287:C1418-C1425.[Abstract/Free Full Text]
    
35. Ii M, Nishimura H, Iwakura A, Wecker A, Eaton E, Asahara T, et al. Endothelial progenitor cells are rapidly recruited to myocardium and mediate protective effect of ischemic preconditioning via "imported" nitric oxide synthase activity. Circulation 2005;111:1114-1120.[Abstract/Free Full Text]
    
36. Vohra HA, Galiñanes M. Effect of the degree of ischaemic injury and reoxygenation time on the type of myocardial cell death in man: role of caspases. BMC Physiol 2005;5:14.[Medline]
    
37. Frangogiannis NG, Smith CW, Entman ML. The inflammatory response in myocardial infarction. Cardiovasc Res 2002;53:31-47.[Abstract/Free Full Text]
    

This article has been cited by other articles:

				V. K. Lai, K.-L. Ang, W. Rathbone, N. J. Harvey, and M. Galinanes Randomized controlled trial on the cardioprotective effect of bone marrow cells in patients undergoing coronary bypass graft surgery Eur. Heart J., October 1, 2009; 30(19): 2354 - 2359. [Abstract] [Full Text] [PDF]

				M. Gnecchi, Z. Zhang, A. Ni, and V. J. Dzau Paracrine Mechanisms in Adult Stem Cell Signaling and Therapy Circ. Res., November 21, 2008; 103(11): 1204 - 1219. [Abstract] [Full Text] [PDF]

				J. C. Chachques, J. C. Trainini, N. Lago, M. Cortes-Morichetti, O. Schussler, and A. Carpentier Myocardial Assistance by Grafting a New Bioartificial Upgraded Myocardium (MAGNUM Trial): Clinical Feasibility Study Ann. Thorac. Surg., March 1, 2008; 85(3): 901 - 908. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Kamlesh Sheth Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kubal, C. Articles by Galiñanes, M. Search for Related Content PubMed PubMed Citation Articles by Kubal, C. Articles by Galiñanes, M. Related Collections Molecular biology Myocardial infarction Myocardial protection