Intracoronary Sarcoplasmic Reticulum Calcium-ATPase Gene Therapy in Advanced Heart Failure Patients with reduced Ejection Fraction: A Prospective Cohort Study

Abstract

OBJECTIVE:

Heart failure is a progressive and debilitating disease. Intracoronary sarcoplasmic reticulum calcium-ATPase gene therapy may improve the function of cardiac muscle cells. This study aimed to test the hypothesis that intracoronary sarcoplasmic reticulum calcium-ATPase gene therapy can improve outcomes and reduce the number of recurrent and terminal events in advanced heart failure patients with reduced ejection fraction.

METHODS:

A total of 768 heart failure patients with reduced ejection fraction and New York Heart Association classification II to IV were included in this prospective cohort study. Patients either underwent intracoronary sarcoplasmic reticulum calcium-ATPase gene therapy (CA group, n=384) or received oral placebo (PA group; n=384). Data regarding recurrent and terminal event(s), treatment-emergent adverse effects, and outcome measures were collected and analyzed.

RESULTS:

After a follow-up period of 18 months, intracoronary sarcoplasmic reticulum calcium-ATPase gene therapy reduced the number of hospital admissions (p=0.001), ambulatory treatments (p=0.0004), and deaths (p=0.024). Additionally, intracoronary sarcoplasmic reticulum calcium-ATPase gene therapy improved the left ventricular ejection fraction (p<0.0001) and Kansas City Cardiomyopathy Questionnaire score (p<0.0001). The number of recurrent and terminal events/patients were higher in the PA group than in the CA group after the follow-up period of 18 months (p=0.015). The effect of the intracoronary sarcoplasmic reticulum calcium-ATPase gene therapy was independent of the confounding variables. No new arrhythmias were reported in the CA group.

CONCLUSIONS:

Intracoronary sarcoplasmic reticulum calcium-ATPase gene therapy reduces the number of recurrent and terminal events and improves the clinical course of advanced heart failure patients with reduced ejection fraction.

Cardiac Events; Ejection Fraction; Heart Failure; Intracoronary Delivery; Sarcoplasmic Reticulum calcium-ATPase Gene Therapy


INTRODUCTION

Heart failure is a progressive and debilitating disease (11. Martinez-Fernandez A. MicroRNA therapy for the failing heart. Circ Cardiovasc Genet. 2014;7(3):393-4. https://doi.org/10.1161/CIRCGENETICS.114.000687.
https://doi.org/10.1161/CIRCGENETICS.114...
). It is associated with inadequate contractility of the heart (22. Zouein FA, Booz GW. AAV-mediated gene therapy for heart failure: enhancing contractility and calcium handling. F1000Prime Rep. 2013;5:27. https://doi.org/10.12703/P5-27.
https://doi.org/10.12703/P5-27...
) due to abnormal calcium cycling (33. Zsebo K, Yaroshinsky A, Rudy JJ, Wagner K, Greenberg B, Jessup M, et al. Long-term effects of AAV1/SERCA2a gene transfer in patients with severe heart failure: analysis of recurrent cardiovascular events and mortality. Circ Res. 2014;114(1):101-8. https://doi.org/10.1161/CIRCRESAHA.113.302421.
https://doi.org/10.1161/CIRCRESAHA.113.3...
). Morbidity and mortality in heart failure patients are high (44. Bradley EH, Curry L, Horwitz LI, Sipsma H, Thompson JW, Elma M, et al. Contemporary evidence about hospital strategies for reducing 30-day readmissions: a national study. J Am Coll Cardiol. 2012;60(7):607-14. https://doi.org/10.1016/j.jacc.2012.03.067.
https://doi.org/10.1016/j.jacc.2012.03.0...
,55. Tsai CT, Wu CK, Lee JK, Chang SN, Kuo YM, Wang YC, et al. TNF-α down-regulates sarcoplasmic reticulum Ca2? ATPase expression and leads to left ventricular diastolic dysfunction through binding of NF-κB to promoter response element. Cardiovasc Res. 2015;105(3):318-29. https://doi.org/10.1093/cvr/cvv008.
https://doi.org/10.1093/cvr/cvv008...
). Drugs for heart failure only slow down the progression of the disease but do not cure the disease (66. Greenberg B, Yaroshinsky A, Zsebo KM, Butler J, Felker GM, Voors AA, et al. Design of a phase 2b trial of intracoronary administration of AAV1/SERCA2a in patients with advanced heart failure: the CUPID 2 trial (calcium up-regulation by percutaneous administration of gene therapy in cardiac disease phase 2b). JACC Heart Fail. 2014;2(1):84-92. https://doi.org/10.1016/j.jchf.2013.09.008.
https://doi.org/10.1016/j.jchf.2013.09.0...
). Calcium-ATPase deficiency is generally associated with the progression of heart failure (77. Kho C, Lee A, Hajjar RJ. Altered sarcoplasmic reticulum calcium cycling--targets for heart failure therapy. Nat Rev Cardiol. 2012;9(12):717-33. https://doi.org/10.1038/nrcardio.2012.145.
https://doi.org/10.1038/nrcardio.2012.14...
,88. Eisner D, Caldwell J, Trafford A. Sarcoplasmic reticulum Ca-ATPase and heart failure 20 years later. Circ Res. 2013;113(8):958-61. https://doi.org/10.1161/CIRCRESAHA.113.302187.
https://doi.org/10.1161/CIRCRESAHA.113.3...
). During diastole, the sarcoplasmic reticulum calcium-ATPase regulates contraction and relaxation of cardiac muscle cells by transporting calcium from the cytosol into the sarcoplasmic reticulum (99. Greenberg B, Butler J, Felker GM, Ponikowski P, Voors AA, Desai AS, et al. Calcium upregulation by percutaneous administration of gene therapy in patients with cardiac disease (CUPID 2): a randomised, multinational, double-blind, placebo-controlled, phase 2b trial. Lancet. 2016;387(10024):1178-86. https://doi.org/10.1016/S0140-6736(16)00082-9.
https://doi.org/10.1016/S0140-6736(16)00...
). Gene therapy restores the function of the heart as a pump (22. Zouein FA, Booz GW. AAV-mediated gene therapy for heart failure: enhancing contractility and calcium handling. F1000Prime Rep. 2013;5:27. https://doi.org/10.12703/P5-27.
https://doi.org/10.12703/P5-27...
). If calcium-ATPase deficiency is corrected, the function of the cardiac muscle cells may be improved in heart failure patients (77. Kho C, Lee A, Hajjar RJ. Altered sarcoplasmic reticulum calcium cycling--targets for heart failure therapy. Nat Rev Cardiol. 2012;9(12):717-33. https://doi.org/10.1038/nrcardio.2012.145.
https://doi.org/10.1038/nrcardio.2012.14...
).

An experimental model (77. Kho C, Lee A, Hajjar RJ. Altered sarcoplasmic reticulum calcium cycling--targets for heart failure therapy. Nat Rev Cardiol. 2012;9(12):717-33. https://doi.org/10.1038/nrcardio.2012.145.
https://doi.org/10.1038/nrcardio.2012.14...
,88. Eisner D, Caldwell J, Trafford A. Sarcoplasmic reticulum Ca-ATPase and heart failure 20 years later. Circ Res. 2013;113(8):958-61. https://doi.org/10.1161/CIRCRESAHA.113.302187.
https://doi.org/10.1161/CIRCRESAHA.113.3...
), a phase 2 trial involving a high-dose of sarcoplasmic reticulum calcium-ATPase gene therapy in advanced heart failure patients (1010. Jessup M, Greenberg B, Mancini D, Cappola T, Pauly DF, Jaski B, et al. Calcium Upregulation by Percutaneous Administration of Gene Therapy in Cardiac Disease (CUPID): a phase 2 trial of intracoronary gene therapy of sarcoplasmic reticulum Ca2+-ATPase in patients with advanced heart failure. Circulation. 2011;124(3):304-13. https://doi.org/10.1161/CIRCULATIONAHA.111.022889.
https://doi.org/10.1161/CIRCULATIONAHA.1...
), and a randomized trial (33. Zsebo K, Yaroshinsky A, Rudy JJ, Wagner K, Greenberg B, Jessup M, et al. Long-term effects of AAV1/SERCA2a gene transfer in patients with severe heart failure: analysis of recurrent cardiovascular events and mortality. Circ Res. 2014;114(1):101-8. https://doi.org/10.1161/CIRCRESAHA.113.302421.
https://doi.org/10.1161/CIRCRESAHA.113.3...
) involving the use of gene therapy for the treatment of cardiac disease have confirmed the hypothesis that sarcoplasmic reticulum calcium-ATPase gene transfer improves survival and the performance of cardiac muscle cells in heart failure conditions. However, a phase 2b trial involving high-risk ambulatory patients with heart failure (99. Greenberg B, Butler J, Felker GM, Ponikowski P, Voors AA, Desai AS, et al. Calcium upregulation by percutaneous administration of gene therapy in patients with cardiac disease (CUPID 2): a randomised, multinational, double-blind, placebo-controlled, phase 2b trial. Lancet. 2016;387(10024):1178-86. https://doi.org/10.1016/S0140-6736(16)00082-9.
https://doi.org/10.1016/S0140-6736(16)00...
) revealed that high-dose intracoronary sarcoplasmic reticulum calcium-ATPase gene therapy does not improve cardiac muscle cell performance in heart failure patients. Thus, the favorable effect of targeted intracoronary sarcoplasmic reticulum calcium-ATPase gene therapy in heart failure patients has not been thoroughly investigated.

The aim of this study is to test the hypothesis that intracoronary sarcoplasmic reticulum calcium-ATPase gene therapy can improve outcomes and reduce the number of recurrent and terminal events in advanced heart failure patients with reduced ejection fraction.

MATERIALS AND METHODS

Ethics consideration and consent to participate

The designed protocol (SRHS/CL/12/15 dated December 5th 2015) of the established study was approved by the review board of Second Rehabilitation Hospital of Shanghai. The study was reported according to the laws of China, strengthening the reporting of observational studies in epidemiology (STROBE) statement, and the 2008 Helsinki Declaration. An informed consent form was signed by all enrolled patients regarding the publication of data on pathology and interventions, including personal data and images (if any), in all formats (hard and/or electronic).

Inclusion criteria

Patients aged 18 to 80 years, who had experienced chronic heart failure as per the 2016 European Society of Cardiology (ESC) Guidelines (1111. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2016;37(27):2129-200. https://doi.org/10.1093/eurheartj/ehw128.
https://doi.org/10.1093/eurheartj/ehw128...
) (confirmed by left ventricular angiography for ejection fraction), and had been undergoing medical treatment for at least one month in the Second Rehabilitation Hospital of Shanghai, Shanghai, China, were considered for the study. Among these patients, only those with the New York Heart Association (NYHA) heart functional classification II to IV (for ischemic or non-ischemic etiology) and a left ventricular ejection fraction 35% or less were included in the analysis. Heart failure patients with undetectable neutralizing antibodies who could not block vector entry of adeno-associated viruses 1 into the target cells were only included in the study.

Exclusion criteria

Patients aged above 80 years, pregnant females, those who had undergone cardiac surgery, and those who had undergone either percutaneous coronary intervention, acute heart failure treatment (positive inotropes, intravenous vasodilators, or diuretics), or valvuloplasty were excluded from the study. Restrictive cardiomyopathic patients, obstructive cardiomyopathic patients, and patients who had amyloidosis (confirmed by blood and urine tests, biopsies of belly fat, and imaging methods), acute myocarditis, infiltrative cardiomyopathy, pericardial disease, thyroid disease, abnormal liver function, anemia, thrombocytopenia, carcinoma, sarcoma, and/or cancer were also excluded from the study.

Sample size calculation

The sample size was calculated using OpenEpi (Epidemiologic Statistics for Public Health, USA) at a power of 80%. The sample size for both cohorts was calculated as 384.

Cohorts

Patients who received intracoronary 1×1013 DNase-resistant particles of adeno-associated virus 1 sarcoplasmic reticulum calcium-ATPase (CA) (Luxturna; Sparks Therapeutics, Philadelphia, PA, USA) were assigned to the CA group (n=384) and patients who received oral placebo (Cebocap, Forte Pharmaceutical, Hyderabad, India) were assigned to the PA (placebo group; n=384) (99. Greenberg B, Butler J, Felker GM, Ponikowski P, Voors AA, Desai AS, et al. Calcium upregulation by percutaneous administration of gene therapy in patients with cardiac disease (CUPID 2): a randomised, multinational, double-blind, placebo-controlled, phase 2b trial. Lancet. 2016;387(10024):1178-86. https://doi.org/10.1016/S0140-6736(16)00082-9.
https://doi.org/10.1016/S0140-6736(16)00...
). Data on the function of the liver, kidney, and other vital organs were reviewed before the administration of calcium-ATPase.

Recurrent and terminal events during a follow-up period of 18 months

The number of hospital admissions due to heart failure and the number of ambulatory treatments for worsening conditions were acquired. Information regarding all causes of death, heart transplantations performed, and the use of a mechanical ventilation system were also collected (66. Greenberg B, Yaroshinsky A, Zsebo KM, Butler J, Felker GM, Voors AA, et al. Design of a phase 2b trial of intracoronary administration of AAV1/SERCA2a in patients with advanced heart failure: the CUPID 2 trial (calcium up-regulation by percutaneous administration of gene therapy in cardiac disease phase 2b). JACC Heart Fail. 2014;2(1):84-92. https://doi.org/10.1016/j.jchf.2013.09.008.
https://doi.org/10.1016/j.jchf.2013.09.0...
). Additionally, data on the incidences and severity of interventions-emergent adverse events and the number of deaths (cardiovascular-related) were collected (99. Greenberg B, Butler J, Felker GM, Ponikowski P, Voors AA, Desai AS, et al. Calcium upregulation by percutaneous administration of gene therapy in patients with cardiac disease (CUPID 2): a randomised, multinational, double-blind, placebo-controlled, phase 2b trial. Lancet. 2016;387(10024):1178-86. https://doi.org/10.1016/S0140-6736(16)00082-9.
https://doi.org/10.1016/S0140-6736(16)00...
).

Outcome measures

We collected data on blood pressure, changes in the NYHA functional class of the heart, Kansas City Cardiomyopathy Questionnaire (KCCQ; 23-item questionnaire; the score ranged from 0 to 100) score (1212. Joseph SM, Novak E, Arnold SV, Jones PG, Khattak H, Platts AE, et al. Comparable performance of the Kansas City Cardiomyopathy Questionnaire in patients with heart failure with preserved and reduced ejection fraction. Circ Heart Fail. 2013;6(6):1139-46. https://doi.org/10.1161/CIRCHEARTFAILURE.113.000359.
https://doi.org/10.1161/CIRCHEARTFAILURE...
), exercise ability (6-min walk test; comparison was made with patients who had no neuromuscular, orthopedic, or rheumatologic abnormality, and were able to walk 300–400 m in 6 min (66. Greenberg B, Yaroshinsky A, Zsebo KM, Butler J, Felker GM, Voors AA, et al. Design of a phase 2b trial of intracoronary administration of AAV1/SERCA2a in patients with advanced heart failure: the CUPID 2 trial (calcium up-regulation by percutaneous administration of gene therapy in cardiac disease phase 2b). JACC Heart Fail. 2014;2(1):84-92. https://doi.org/10.1016/j.jchf.2013.09.008.
https://doi.org/10.1016/j.jchf.2013.09.0...
)), creatinine level (1010. Jessup M, Greenberg B, Mancini D, Cappola T, Pauly DF, Jaski B, et al. Calcium Upregulation by Percutaneous Administration of Gene Therapy in Cardiac Disease (CUPID): a phase 2 trial of intracoronary gene therapy of sarcoplasmic reticulum Ca2+-ATPase in patients with advanced heart failure. Circulation. 2011;124(3):304-13. https://doi.org/10.1161/CIRCULATIONAHA.111.022889.
https://doi.org/10.1161/CIRCULATIONAHA.1...
), and N-terminal pro-B-type natriuretic peptide (NT-proBNP) at baseline and at 1, 3, 6, 10, and 18 months after interventions. Endomyocardial biopsy was performed after 18 months of intervention to evaluate the development of new heart failure and/or arrhythmias (1313. Cooper LT, Baughman KL, Feldman AM, Frustaci A, Jessup M, Kuhl U, et al. The role of endomyocardial biopsy in the management of cardiovascular disease: a scientific statement from the American Heart Association, the American College of Cardiology, and the European Society of Cardiology. Endorsed by the Heart Failure Society of America and the Heart Failure Association of the European Society of Cardiology. J Am Coll Cardiol. 2007;50(19):1914-31. https://doi.org/10.1016/j.jacc.2007.09.008.
https://doi.org/10.1016/j.jacc.2007.09.0...
).

Outcome measures were collected by physicians and the nursing staff of the institute(s) (all personnel had a minimum of three years of experience). For patients who died during the follow-up period, the last reported data were used for analysis.

Safety

All new arrhythmias found during the 18-month follow-up period were recorded.

Statistical analysis

For statistical analysis, InStat, 3.1 Window, GraphPad, San Diego, CA, USA was used. For ordinal data, the Chi-square Independence test (44. Bradley EH, Curry L, Horwitz LI, Sipsma H, Thompson JW, Elma M, et al. Contemporary evidence about hospital strategies for reducing 30-day readmissions: a national study. J Am Coll Cardiol. 2012;60(7):607-14. https://doi.org/10.1016/j.jacc.2012.03.067.
https://doi.org/10.1016/j.jacc.2012.03.0...
) was used for statistical analysis while the one-way analysis of variance (ANOVA) (1414. Ashara KC, Shah KV. The Study of Chloramphenicol for Ophthalmic Formulation. IJSRR. 2018;7(Suppl 1):173-81.) was used to analyze continuous variables. Logistic regression analysis was performed to evaluate the risk factors for recurrent and terminal events during the 18-month follow-up period. All results were considered significant at a 95% confidence level.

RESULTS

Clinical characteristics

Among the enrolled patients, 80% were males and 99% were Han Chinese. Additionally, most of the patients had NYHA heart functional class III. The other clinical characteristics of the patients are presented in Table 1. At baseline, both groups had the same demographical and clinical characteristics (p>0.05 for all).

Table 1
Demographic and clinical characteristics of the enrolled patients.

Recurrent and terminal events

After a follow-up period of 18 months, intracoronary sarcoplasmic reticulum calcium-ATPase gene therapy reduced the number of hospital admissions (p=0.001), ambulatory treatments (p=0.0004), and deaths (p=0.024) but was not successful in reducing the number of heart transplantations (p=0.576) and mechanical ventilation incidences (p=0.864, Figure 1).

Figure 1
Recurrent and terminal events after a follow-up period of 18 months. The chi-square test of independence was performed between the two groups. A p-value <0.05 was considered significant. *A significant fewer values reported than the placebo group.

Outcome measures

After a follow-up period of 18 months, intracoronary sarcoplasmic reticulum calcium-ATPase gene therapy improved the heart function (p=0.009), left ventricular ejection fraction (p<0.0001), KCCQ score (p<0.0001), systolic blood pressure (p<0.0001), and performance in the 6-min walk test (p=0.047). However, intracoronary sarcoplasmic reticulum calcium-ATPase gene therapy failed to reduce the NT-proBNP (p=0.482) and serum creatinine (p=0.822, Table 2) levels.

Table 2
Outcome measures for cardiac function reported after a follow-up period of 18 months.

Age (p=0.048), NT-proBNP (p=0.046), and placebo treatment (p=0.021) were associated with recurrent and terminal events during the 18-month follow-up period and the effect of the intracoronary sarcoplasmic reticulum calcium-ATPase gene therapy was independent of the confounding variables (Table 3). Moreover, cumulative recurrent and terminal events/patients were higher in the PA group than in the CA group during the 18-month follow-up period (p=0.015, Figure 2).

Table 3
The influence of risk factors on recurrent and terminal events after a follow-up period of 18 months.
Figure 2
Recurrent and terminal events after a follow-up period of 18 months.

Safety

In the CA group, endomyocardial biopsies performed after the 18-month follow-up period, revealed no new arrhythmias or treatment-emergent adverse effects.

DISCUSSION

In the present study, intracoronary sarcoplasmic reticulum calcium-ATPase gene therapy reduced the number of recurrent and terminal events. In heart failure patients, a decrease in sarcoplasmic reticulum calcium-ATPase activity results in reduced calcium uptake during relaxation (66. Greenberg B, Yaroshinsky A, Zsebo KM, Butler J, Felker GM, Voors AA, et al. Design of a phase 2b trial of intracoronary administration of AAV1/SERCA2a in patients with advanced heart failure: the CUPID 2 trial (calcium up-regulation by percutaneous administration of gene therapy in cardiac disease phase 2b). JACC Heart Fail. 2014;2(1):84-92. https://doi.org/10.1016/j.jchf.2013.09.008.
https://doi.org/10.1016/j.jchf.2013.09.0...
), which is associated with depressed calcium homeostasis and reduced cardiomyocyte function (99. Greenberg B, Butler J, Felker GM, Ponikowski P, Voors AA, Desai AS, et al. Calcium upregulation by percutaneous administration of gene therapy in patients with cardiac disease (CUPID 2): a randomised, multinational, double-blind, placebo-controlled, phase 2b trial. Lancet. 2016;387(10024):1178-86. https://doi.org/10.1016/S0140-6736(16)00082-9.
https://doi.org/10.1016/S0140-6736(16)00...
) due to the reduction in the contractile function of the heart (55. Tsai CT, Wu CK, Lee JK, Chang SN, Kuo YM, Wang YC, et al. TNF-α down-regulates sarcoplasmic reticulum Ca2? ATPase expression and leads to left ventricular diastolic dysfunction through binding of NF-κB to promoter response element. Cardiovasc Res. 2015;105(3):318-29. https://doi.org/10.1093/cvr/cvv008.
https://doi.org/10.1093/cvr/cvv008...
). Recurrent and terminal events are frequent during the clinical course of patients with cardiac disease (1515. Butler J, Kalogeropoulos A. Hospital strategies to reduce heart failure readmissions: where is the evidence? J Am Coll Cardiol. 2012;60(7):615-7. https://doi.org/10.1016/j.jacc.2012.03.066.
https://doi.org/10.1016/j.jacc.2012.03.0...
) due to disturbance of the immune pathway and the short duration of transgene expression (1616. Mariani JA, Smolic A, Preovolos A, Byrne MJ, Power JM, Kaye DM. Augmentation of left ventricular mechanics by recirculation-mediated AAV2/1-SERCA2a gene delivery in experimental heart failure. Eur J Heart Fail. 2011;13(3):247-53. https://doi.org/10.1093/eurjhf/hfq234.
https://doi.org/10.1093/eurjhf/hfq234...
), which leads to increases in the financial burden of patients (1717. Dunlay SM, Shah ND, Shi Q, Morlan B, VanHouten H, Long KH, et al. Lifetime costs of medical care after heart failure diagnosis. Circ Cardiovasc Qual Outcomes. 2011;4(1):68-75. https://doi.org/10.1161/CIRCOUTCOMES.110.957225.
https://doi.org/10.1161/CIRCOUTCOMES.110...
). The correction of these abnormalities using intracoronary DNase-resistant particles of adeno-associated virus 1 can improve cardiac function and the survival rate (88. Eisner D, Caldwell J, Trafford A. Sarcoplasmic reticulum Ca-ATPase and heart failure 20 years later. Circ Res. 2013;113(8):958-61. https://doi.org/10.1161/CIRCRESAHA.113.302187.
https://doi.org/10.1161/CIRCRESAHA.113.3...
,1818. Mattila M, Koskenvuo J, Soderstrom M, Eerola K, Savontaus M. Intramyocardial injection of SERCA2a-expressing lentivirus improves myocardial function in doxorubicin-induced heart failure. J Gene Med. 2016;18(7):124-33. https://doi.org/10.1002/jgm.2885.
https://doi.org/10.1002/jgm.2885...
) by improving vascular reactivity and coronary flow (1919. Hadri L, Bobe R, Kawase Y, Ladage D, Ishikawa K, Atassi F, et al. SERCA2a gene transfer enhances eNOS expression and activity in endothelial cells. Mol Ther. 2010;18(7):1284-92. https://doi.org/10.1038/mt.2010.77.
https://doi.org/10.1038/mt.2010.77...
). Additionally, intracoronary calcium-ATPase transfer decreases the number of ventricular arrhythmias and improves the arrhythmogenic substrate and the factors that trigger it by entering the cardiac cells, where high transduction efficiency is necessary. Moreover, entering of the adeno-associated viruses 1 in cardiac cells tropism provides homogeneous cardiac myocyte transduction (33. Zsebo K, Yaroshinsky A, Rudy JJ, Wagner K, Greenberg B, Jessup M, et al. Long-term effects of AAV1/SERCA2a gene transfer in patients with severe heart failure: analysis of recurrent cardiovascular events and mortality. Circ Res. 2014;114(1):101-8. https://doi.org/10.1161/CIRCRESAHA.113.302421.
https://doi.org/10.1161/CIRCRESAHA.113.3...
). The results of the analysis were consistent with the results of previous experimental studies (1616. Mariani JA, Smolic A, Preovolos A, Byrne MJ, Power JM, Kaye DM. Augmentation of left ventricular mechanics by recirculation-mediated AAV2/1-SERCA2a gene delivery in experimental heart failure. Eur J Heart Fail. 2011;13(3):247-53. https://doi.org/10.1093/eurjhf/hfq234.
https://doi.org/10.1093/eurjhf/hfq234...
,1818. Mattila M, Koskenvuo J, Soderstrom M, Eerola K, Savontaus M. Intramyocardial injection of SERCA2a-expressing lentivirus improves myocardial function in doxorubicin-induced heart failure. J Gene Med. 2016;18(7):124-33. https://doi.org/10.1002/jgm.2885.
https://doi.org/10.1002/jgm.2885...
), pilot studies (33. Zsebo K, Yaroshinsky A, Rudy JJ, Wagner K, Greenberg B, Jessup M, et al. Long-term effects of AAV1/SERCA2a gene transfer in patients with severe heart failure: analysis of recurrent cardiovascular events and mortality. Circ Res. 2014;114(1):101-8. https://doi.org/10.1161/CIRCRESAHA.113.302421.
https://doi.org/10.1161/CIRCRESAHA.113.3...
,99. Greenberg B, Butler J, Felker GM, Ponikowski P, Voors AA, Desai AS, et al. Calcium upregulation by percutaneous administration of gene therapy in patients with cardiac disease (CUPID 2): a randomised, multinational, double-blind, placebo-controlled, phase 2b trial. Lancet. 2016;387(10024):1178-86. https://doi.org/10.1016/S0140-6736(16)00082-9.
https://doi.org/10.1016/S0140-6736(16)00...
), and a phase 2 trial (1010. Jessup M, Greenberg B, Mancini D, Cappola T, Pauly DF, Jaski B, et al. Calcium Upregulation by Percutaneous Administration of Gene Therapy in Cardiac Disease (CUPID): a phase 2 trial of intracoronary gene therapy of sarcoplasmic reticulum Ca2+-ATPase in patients with advanced heart failure. Circulation. 2011;124(3):304-13. https://doi.org/10.1161/CIRCULATIONAHA.111.022889.
https://doi.org/10.1161/CIRCULATIONAHA.1...
), but were not consistent with the results of the phase 2b trial (99. Greenberg B, Butler J, Felker GM, Ponikowski P, Voors AA, Desai AS, et al. Calcium upregulation by percutaneous administration of gene therapy in patients with cardiac disease (CUPID 2): a randomised, multinational, double-blind, placebo-controlled, phase 2b trial. Lancet. 2016;387(10024):1178-86. https://doi.org/10.1016/S0140-6736(16)00082-9.
https://doi.org/10.1016/S0140-6736(16)00...
). The results of the current study showed that the intracoronary DNase-resistant particles of adeno-associated virus 1 sarcoplasmic reticulum calcium-ATPase may improve the clinical course of heart failure patients with reduced ejection fraction.

Intracoronary sarcoplasmic reticulum calcium-ATPase gene therapy improved the NYHA class, performance during the 6-min walk test, left ventricular ejection fraction, KCCQ score, and systolic blood pressure. The improvement in the KCCQ score and 6-min walk test would result in an increase in the ability of patients to perform physical activities, which would result in the improvement of the NYHA class (2020. Yap J, Lim FY, Gao F, Teo LL, Lam CS, Yeo KK. Correlation of the New York Heart Association Classification and the 6-Minute Walk Distance: A Systematic Review. Clin Cardiol. 2015;38(10):621-8. https://doi.org/10.1002/clc.22468.
https://doi.org/10.1002/clc.22468...
). Intracoronary sarcoplasmic reticulum calcium-ATPase gene therapy significantly inhibits left ventricular dilation, which restores systolic functions of the heart (2121. Periasamy M, Kalyanasundaram A. SERCA2a gene therapy for heart failure: ready for primetime? Mol Ther. 2008;16(6):1002-4. https://doi.org/10.1038/mt.2008.89.
https://doi.org/10.1038/mt.2008.89...
). The results of the analysis were consistent with the results of the phase 2 trial (1010. Jessup M, Greenberg B, Mancini D, Cappola T, Pauly DF, Jaski B, et al. Calcium Upregulation by Percutaneous Administration of Gene Therapy in Cardiac Disease (CUPID): a phase 2 trial of intracoronary gene therapy of sarcoplasmic reticulum Ca2+-ATPase in patients with advanced heart failure. Circulation. 2011;124(3):304-13. https://doi.org/10.1161/CIRCULATIONAHA.111.022889.
https://doi.org/10.1161/CIRCULATIONAHA.1...
) and experimental studies (1616. Mariani JA, Smolic A, Preovolos A, Byrne MJ, Power JM, Kaye DM. Augmentation of left ventricular mechanics by recirculation-mediated AAV2/1-SERCA2a gene delivery in experimental heart failure. Eur J Heart Fail. 2011;13(3):247-53. https://doi.org/10.1093/eurjhf/hfq234.
https://doi.org/10.1093/eurjhf/hfq234...
,2222. Kawase Y, Ly HQ, Prunier F, Lebeche D, Shi Y, Jin H, et al. Reversal of cardiac dysfunction after long-term expression of SERCA2a by gene transfer in a pre-clinical model of heart failure. J Am Coll Cardiol. 2008;51(11):1112-9, doi: https://doi.org/10.1016/j.jacc.2007.12.014.
https://doi.org/10.1016/j.jacc.2007.12.0...
). The positive results regarding outcome measures showed that intracoronary sarcoplasmic reticulum calcium-ATPase gene therapy may be beneficial to heart failure patients with reduced ejection fraction.

Intracoronary sarcoplasmic reticulum calcium-ATPase gene therapy failed to reduce the NT-proBNP (p=0.482) and creatinine (p=0.822) levels. An NT-proBNP level higher than 1600 pg/mL is responsible for recurrent events (66. Greenberg B, Yaroshinsky A, Zsebo KM, Butler J, Felker GM, Voors AA, et al. Design of a phase 2b trial of intracoronary administration of AAV1/SERCA2a in patients with advanced heart failure: the CUPID 2 trial (calcium up-regulation by percutaneous administration of gene therapy in cardiac disease phase 2b). JACC Heart Fail. 2014;2(1):84-92. https://doi.org/10.1016/j.jchf.2013.09.008.
https://doi.org/10.1016/j.jchf.2013.09.0...
). The results of the analysis were consistent with the results of another study (99. Greenberg B, Butler J, Felker GM, Ponikowski P, Voors AA, Desai AS, et al. Calcium upregulation by percutaneous administration of gene therapy in patients with cardiac disease (CUPID 2): a randomised, multinational, double-blind, placebo-controlled, phase 2b trial. Lancet. 2016;387(10024):1178-86. https://doi.org/10.1016/S0140-6736(16)00082-9.
https://doi.org/10.1016/S0140-6736(16)00...
). NT-proBNP released as a result of targets not achieved by intracoronary sarcoplasmic reticulum calcium-ATPase gene therapy (2323. Cortés R, Roselló-Lletí E, Rivera M, Martinez-Dolz L, Salvador A, Sirera R, et al. Expression of B-type natriuretic peptide forms in ischemic human hearts. Int J Cardiol. 2012;158(2):199-204. https://doi.org/10.1016/j.ijcard.2011.01.014.
https://doi.org/10.1016/j.ijcard.2011.01...
). In addition, it is well known that the hydrosaline retention state present during heart failure is related not only to the hemodynamic phenomenon due to the heart pumping failure but also as a result of various neurohumoral mechanisms that maintain a reduced glomerular filtration rate, which would remain constant regardless of the improvement in pump function after intracoronary sarcoplasmic reticulum calcium-ATPase gene therapy (2424. Xia WJ, Huang YY, Chen YL, Chen SL, He JG. Acute myocardial ischemia directly modulates the expression of brain natriuretic peptide at the transcriptional and translational levels via inflammatory cytokines. Eur J Pharmacol. 2011;670(1):7-12. https://doi.org/10.1016/j.ejphar.2011.09.012.
https://doi.org/10.1016/j.ejphar.2011.09...
). A negative outcome may slow down, but not deter, further research. These negative results need to be addressed in future randomized trials.

Intracoronary sarcoplasmic reticulum calcium-ATPase gene therapy improved the clinical course of the enrolled patients without any treatment-emergent adverse effects. Our results are consistent with those of published studies (33. Zsebo K, Yaroshinsky A, Rudy JJ, Wagner K, Greenberg B, Jessup M, et al. Long-term effects of AAV1/SERCA2a gene transfer in patients with severe heart failure: analysis of recurrent cardiovascular events and mortality. Circ Res. 2014;114(1):101-8. https://doi.org/10.1161/CIRCRESAHA.113.302421.
https://doi.org/10.1161/CIRCRESAHA.113.3...
,99. Greenberg B, Butler J, Felker GM, Ponikowski P, Voors AA, Desai AS, et al. Calcium upregulation by percutaneous administration of gene therapy in patients with cardiac disease (CUPID 2): a randomised, multinational, double-blind, placebo-controlled, phase 2b trial. Lancet. 2016;387(10024):1178-86. https://doi.org/10.1016/S0140-6736(16)00082-9.
https://doi.org/10.1016/S0140-6736(16)00...
,1010. Jessup M, Greenberg B, Mancini D, Cappola T, Pauly DF, Jaski B, et al. Calcium Upregulation by Percutaneous Administration of Gene Therapy in Cardiac Disease (CUPID): a phase 2 trial of intracoronary gene therapy of sarcoplasmic reticulum Ca2+-ATPase in patients with advanced heart failure. Circulation. 2011;124(3):304-13. https://doi.org/10.1161/CIRCULATIONAHA.111.022889.
https://doi.org/10.1161/CIRCULATIONAHA.1...
). Our positive results show that intracoronary sarcoplasmic reticulum calcium-ATPase gene therapy is safe and promising.

In this study, gene therapy was performed via intracoronary delivery. The percutaneous, cardiac-perfusion circuit enhances the uptake of the gene by cardiomyocytes (1616. Mariani JA, Smolic A, Preovolos A, Byrne MJ, Power JM, Kaye DM. Augmentation of left ventricular mechanics by recirculation-mediated AAV2/1-SERCA2a gene delivery in experimental heart failure. Eur J Heart Fail. 2011;13(3):247-53. https://doi.org/10.1093/eurjhf/hfq234.
https://doi.org/10.1093/eurjhf/hfq234...
). However, intracoronary delivery is simple, practical, and also enhances uptake of the gene (55. Tsai CT, Wu CK, Lee JK, Chang SN, Kuo YM, Wang YC, et al. TNF-α down-regulates sarcoplasmic reticulum Ca2? ATPase expression and leads to left ventricular diastolic dysfunction through binding of NF-κB to promoter response element. Cardiovasc Res. 2015;105(3):318-29. https://doi.org/10.1093/cvr/cvv008.
https://doi.org/10.1093/cvr/cvv008...
). We recommend intracoronary delivery for gene therapy for optimal effect.

In this study, we reported recurrent and terminal events simultaneously. Each recurrent event in patients increases the risk of additional recurrent and terminal events (2525. Feldman AG, Beaty BL, Curtis D, Juarez-Colunga E, Kempe A. Incidence of Hospitalization for Vaccine-Preventable Infections in Children Following Solid Organ Transplant and Associated Morbidity, Mortality, and Costs. JAMA Pediatr. 2019;173(3):260-8. https://doi.org/10.1001/jamapediatrics.2018.4954.
https://doi.org/10.1001/jamapediatrics.2...
). For example, the mortality rate is higher after the fourth hospitalization compared to that after the first hospitalization (66. Greenberg B, Yaroshinsky A, Zsebo KM, Butler J, Felker GM, Voors AA, et al. Design of a phase 2b trial of intracoronary administration of AAV1/SERCA2a in patients with advanced heart failure: the CUPID 2 trial (calcium up-regulation by percutaneous administration of gene therapy in cardiac disease phase 2b). JACC Heart Fail. 2014;2(1):84-92. https://doi.org/10.1016/j.jchf.2013.09.008.
https://doi.org/10.1016/j.jchf.2013.09.0...
). Thus, to avoid bias, we evaluated recurrent and terminal events simultaneously.

One limitation of the study is its prospective nature and the lack of a randomized trial. If a patient died during the follow-up period, the last reported data were used for analysis. This increases the possibility of the occurrence of bias. We did not evaluate the bias between coronary intervention and oral administration.

CONCLUSION

Intracoronary sarcoplasmic reticulum calcium-ATPase gene therapy reduces the number of recurrent and terminal events and improves the clinical course of advanced heart failure patients with reduced ejection fraction.

ACKNOWLEDGMENTS

The authors would like to thank the medical and non-medical staffs of the Second Rehabilitation Hospital of Shanghai, Shanghai, China.

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Publication Dates

  • Publication in this collection
    13 Mar 2020
  • Date of issue
    2020

History

  • Received
    7 Sept 2019
  • Accepted
    7 Jan 2020
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