1、缺血性心脏病的基因治疗,南京医科大学第一附属医院 心内科 杨志健,现有治疗,药物治疗 PCI CABG,具有局限性！ 无法血运重建 细胞丧失,生物学治疗,基因治疗、细胞成形术 优化现有的治疗 为终末期患者提供新的治疗途径,基因治疗的目的在于修复、替代体内突变、缺失的基因或加强某些被不良抑制基因的功能，或抑制某些不当过强表达基因的功能，以达到使机体异常的功能、代谢得以改善、恢复的目的。,Angiogenesis Status,Since 1999 a massive wave of angiogenesis-stimulating drugs in clinical trials: 5 drug
2、s for coronary artery disease; 6 5 drugs for peripheral vascular disease; 2 drugs for stroke; 10 drugs for wound healing;,Laser Doppler blood flow in ischemic hindlimb model,血管内皮生长因子（ VEGF）：形成最初的血管丛血管生成细小，有渗漏,基因治疗：,VEGF-121进行了人下肢缺血性治疗的二期临床试验(863),血管生成素（Ang）：稳定新生血管壁血管口径增大,VEGF165和Ang1基因 促血管生成和抗缺血研究,研
3、究内容,构建Ad5-VEGF165和Ad5-Ang1 联合转染促血管生成作用研究 联合转染抗心肌缺血作用研究 机制探讨,研究结果,更强的促血管生成作用,进一步减少心肌梗死面积,Ang1组和联合组与对照组均有显著性差异，但VEGF组无显著性差异； Ang1组和联合组与VEGF组均有显著性差异,高调心肌Bcl-2，抗凋亡,单独转染组以及联合组PI3K活性均比对照组显著性增高；联合组比VEGF单独转染组显著升高，但与Ang1组无差异。,进一步活化心肌PI3K信号,腺病毒介导肝细胞生长因子治疗缺血性心脏病(863,973),HGF在心血管方向的研究现状,抗心肌细胞凋亡，促进血管新生，抗心肌组织纤维化,
4、促梗死周遍区心肌肥厚可能改善梗死后室壁扩张，有待进一步研究,体外实验中发现HGF诱导骨髓干细胞分化成心肌细胞以及能诱导特异的前体细胞沿浓度梯度定向迁移至梗死区,通过阻NFkappaB旁路，起到抗炎作用,研究目的,考察经非梗死相关动脉转染Ad5-HGF对梗死后心衰 的改善作用,研究转染Ad5-HGF后，局部心肌中CD117+干细胞动员情况,对比经非梗死相关动脉移植骨髓间充质干细胞（BM-MSCs）或转染Ad5-HGF对心梗死后心衰治疗作用,实验技术方法,对照组,急性心梗模型建立,MSCs培养,移植（4周后）,门控心肌显像，冠状动脉造影,处死，免疫组织化学,Ad5-HGF组,BM-MSCs组,3周
5、后,再次,心肌显像，冠脉造影,开胸结扎前降支，建立模型,门控心肌核素显像,A:对照组4周和7周对比,B:Ad5-HGF 组4周和7周对比,心 功 能,冠状动脉造影：侧支循环分析,A:对照组4周和7周对比,B:Ad5-HGF 组4周和7周对比,免疫组化,ELISA法检测心肌组织中HGF蛋白表达,因子阳性血管,A: BM-MSCs治疗组,B: Ad5-HGF治疗组,SMA阳性血管,A: BM-MSCs治疗组,B: Ad5-HGF治疗组,CD117+细胞结果,A:对照组,B：Ad5-HGF 组,连续切片CD117和C-Met抗体免疫组织化学检测,A：显示细胞呈CD117+,B：显示细胞也呈C-Met
6、+,结 论,经冠脉转染Ad5-HGF能使心肌高度表达HGF蛋白， HGF对心肌梗死慢性期的侧枝循环形成，心肌灌注及心功能均有改善作用,经非梗死相关动脉移植BM-MSCs或肝细胞生长因子均能促进梗死心脏心功能改善和促进血管再生；BM-MSCs移植或Ad5-HGF转导，未显示何者更具优势。,HGF能增加动员至缺血区的CD117+骨髓干细胞，并且该类细胞表达c-Met+；HGF改善心功能及心肌灌注的作用不仅仅是血管新生，可能还涉及到对干细胞的动员召集作用。,文章被引用,VEGF165 and angiopoietin-1 decreased myocardium infarct size throu
7、gh phosphatidylinositol-3 kinase and Bcl-2 pathways . 2005 Gene Therapy,Ad-HGF Clinical Trial Phasein China,23 CHD patients, divided into 3 groups by different dose of Ad-HGF 5109pfu Ad-HGF 11010pfu Ad-HGF 21010pfu Ad-HGF,Low dose group:6 cases Middle dose group:6 cases High dose group:11cases11 pat
8、ients only received HGF therapy,Safety,2 patients have transient fever(38.0-38.5 0C) within one week after gene therapy，and recovered after 2-3 days All subjects have routine examination of blood, biochemical index, and tumor marker, all of them have no significant change,Efficiency,Evaluate the eff
9、iciency in patients received HGF therapy only,Code H-01 Name LYNA Sex Male Age 72 Birth date 1934.03.25 Diagnosis1.Coronary artery disease；2.unstable angina Angina grading (Canada） Angiography：1.LAD proximal segment 90% stenosis；2.LCX proximal middle segment 80%，middle segment:total occluded ；3.RCA
10、mild stenosis LAD、LCX with HGF,After 5 weeks Angino grading（Canada） ECT ：after treatment, the perfusion of inferior wall improved, LV diameter diminished,Pre post Pre post Pre post Pre post,Perfusion LVd,M-02 Name:SXBA Sex Female Name 74 Birth Date 1932.08.14 Diagnosis 1.CHD；2. unstable angina Angin
11、a grading（Canada） Angiography 1.LAD proximal segment total occluded ；2.LCX middle and distal segment 90% stenosis；3.RCA proximal segment 70% stenosis LAD、LCX with HGF,After 5 weeks Angina grading (Canada) ECT：anterior and posterior wall perfusion improved,Pre post Pre post Pre post Pre post,Perfusio
12、n,M-03 Name GSBI Sex male Age 52 Birth date 1954.04.25 Diagnosis 1. CHD；2. Stable angina Angina grading（Canada） Angiography 1.LAD proximal segment 50% stenosis ，middle segment 30stenosis；2.LCX stenosis in stent ，distal segment mild irregular 3.RCA restenosis in stent ，proximal segment of stent 30-50
13、% stenosis，distal 30% LAD,LCX with HGF,After 5 weeks Angina grading (Canada) ECT：LV anterior, IVS, inferior wall perfusion significantly improved。LV diameter diminished.,Pre post Pre post Pre post Pre post,Perfusion LVd,M-05 Name LGSH Sex male Age 76 Birth date 1930.07.06 Diagnosis 1.CHD ；2.unstable
14、 angina Angina grading（Canada ） Angiography: LAD proximal and middle segment 70-80% stenosis ，LCX 70%，middle segment 80% stenosis，OM1proximal segment 80% stenosis，RCA proximal segment 70%，distal segment 90% LAD、LCX、RCA with HGF,After 5 weeks Angina grading (Canada) ECT：anterior and posterior wall pe
15、rfusion significant improved 。,Pre post Pre post Pre post Pre post,Perfusion,B-01 name XJLI Sex M Age 69 Diagnosis CHD, AMI，Myocardial dysfunction，Hypertension，DM type 2 Angina grading（Canada）III Angiography: LM 90%，LAD、LCX 75-90% stenosis，RCA long stenosis，occluded in distal segment LAD、LCX、RCA wit
16、h HGF,Treatment for 5 week Angina grading（Canada）III ECT：No significant improvment,Pre post Pre post Pre post,B-03 name TZHE Sex M Age 71 Diagnosis CHD、AMI，Hypertension、DM Angina grading （Canada）2 Angiography LAD proximal segment 90%，middle segment total occlusion ，LCX distal segment 80% stenosis，RC
17、A distal segment 60% stenosis LAD with HGF,Treatment for 5 weeks Angina grading (Canada): 1 ECT：Perfusion of anterior wall ,inferior wall and lateral wall significantly improved, cardiac chamber also diminished。,Pre post Pre post Pre post Pre post,Perfusion LVd,Conclusion,In all 11 patients 7 patien
18、ts clinical syndrome improved 5 patients myocardium perfusion improved(5of 6) Common medical therapy for all patients(ASA, statin, ACEI, -blocker, etc) Ad-HGF therapy safe, effective,冠心病患者冠状动脉内注射给药，对受试者的生命体征、血液生化等均无影响 冠心病患者冠状动脉内注射给药受试者的中、大剂量组心肌供血改善，显示Ad-HGF对弥漫性病变,药物治疗很难奏效,又不能承受外科手术或血管成型术的患者提供了一种新的有效的方法。,II期临床试验即将批准!,谢 谢,
