Comparison of transendocardial and intracoronary CD34+ cell transplantation in patients with nonischemic dilated cardiomyopathy

BACKGROUND - In an open-label blinded study, we compared intracoronary and transendocardial CD34 cell transplantation in patients with nonischemic dilated cardiomyopathy. METHODS AND RESULTS - Of the 40 patients with dilated cardiomyopathy, 20 were randomized to receive intracoronary injection and 20 received transendocardial CD34 cell delivery. In both groups, CD34 cells were mobilized by filgrastim, collected via apheresis, and labeled with technetium-99m radioisotope for single-photon emission computed tomographic imaging. In the intracoronary group, cells were injected intracoronarily in the artery supplying segments of greater perfusion defect on myocardial perfusion scintigraphy. In the transendocardial group, electroanatomic mapping was used to identify viable but dysfunctional myocardium, and transendocardial cell injections were performed. Nuclear single-photon emission computed tomographic imaging for quantification of myocardial retention was performed 18 hours thereafter. At baseline, groups did not differ in age, sex, left ventricular ejection fraction, or N-terminal pro-brain natriuretic peptide levels. The number of CD34 cells was also comparable (105±31×10 in the transendocardial group versus 103±27×10 in the intracoronary group, P=0.62). At 18 hours after procedure, myocardial retention was higher in the transendocardial group (19.2±4.8%) than in the intracoronary group (4.4±1.2%, P<0.01). At 6 months, left ventricular ejection fraction improved more in the transendocardial group (+8.1±4.3%) than in the intracoronary group (+4.2±2.3%, P=0.03). The same pattern was observed for the 6-minute walk test distance (+125±33 m in the transendocardial group versus +86±13 m in the intracoronary group, P=0.03) and N-terminal pro-brain natriuretic peptide (-628±211 versus -315±133 pg/mL, P=0.04). CONCLUSIONS - In patients with dilated cardiomyopathy, transendocardial CD34 cell transplantation is associated with higher myocardial retention rates and greater improvement in ventricular function, N-terminal pro-brain natriuretic peptide, and exercise capacity compared with intracoronary route. CLINICAL TRIAL REGISTRATION - URL: http://www.clinicaltrials.gov. Unique identifier: NCT01350310.