Overview: 1) Current scenario of cardiac fibrosis research 2) Understanding of available technologies 3) Current progress and challenges in the cardiac fibrosis research

1. Rugmani Iyer, Ph.D
Senior Scientist
Merck Research Laboratories
Cardiac Fibrosis
A comprehensive
overview of
mechanisms, tools and
potential targets

2. Audience Poll

3. Cardiac Fibrosis
A comprehensive
overview of
mechanisms, tools and
potential targets
Rugmani Iyer
May 27th, 2020

4. Fibrosis: Well-recognized cause of morbidity & mortality
Zhao et. Al., Nature Reviews Drug Discovery volume 19, pages57–75(2020)

5. Gourdie, R. et.al. Nat Rev Drug Discov 15, 620–638 (2016)
This illustrates the pronounced and above-average
increase in attention paid to cardiac fibroblasts in the past
Cardiac Fibrosis - History of Research

6. Cardiac Fibrosis
Reilly K.., US Pharmacist. 2015;Feb 18, Hinderer S et al. Adv Drug Deliv Rev. 2019;146:77‐82, Gourdie, R. et.al. Nat Rev Drug Discov 15, 620–638 (2016)
Pathological extracellular matrix (ECM)
remodeling leading to abnormalities in
matrix composition and quality
Occurs after myocardial infarction,
hypertensive heart disease, diabetic
hypertrophic cardiomyopathy and
idiopathic dilated cardiomyopathy

7. Cardiac Fibrosis Types
Diffused distribution within
the interstitium and perivascular
region
Progressive onset
Hypertension, diabetes mellitus,
non-ischemic dilated
cardiomyopathy, pressure-overload
and volume-overload states, aging
heart
Precedes irreversible replacement
fibrosis
Mewton et al, Volume 57, Issue 8, 22 February 2011, Pages 891-903
Reactive Interstitial Fibrosis

8. Cardiac Fibrosis Types
Mewton et al, Volume 57, Issue 8, 22 February 2011, Pages 891-903
Progressive deposit of insoluble
proteins or glycosphingolipids in the
cardiac interstitium
Progressive onset
Amyloidosis, Anderson-Fabry disease
Infiltrative Interstitial Fibrosis

9. Cardiac Fibrosis Types
Mewton et al, Volume 57, Issue 8, 22 February 2011, Pages 891-903
Replacement of myocytes by plexiform
fibrosis, mainly type I collagen
Localized distribution (MI, ischemic
cardiomyopathy, myocarditis)
Diffused distribution (chronic renal
insufficiency, toxic cardiomyopathies,
miscellaneous inflammatory disease)
Replacement/Scarring Fibrosis
.

10. Fibroblast, ECM,
MMPs
Feng et. al., J. Cardiovasc. Dev. Dis. 2019, 6(4), 34

11. Fibroblast/Myofibroblast
Fan et al, Fibrogenesis Tissue Repair. 2012;5:15, Tallquist et.al. Nature Reviews Cardiology volume 14, pages484–491(2017), Hinderer S et al. Adv Drug Deliv Rev. 2019;146:77‐82, Gourdie,
R. et.al. Nat Rev Drug Discov 15, 620–638 (2016), Liu et. al., Front Physiol. . 2017 Apr 24;8:238
Fibroblasts have central roles in cardiac
homeostasis
Fibroblasts are found within the heart’s
connective tissue and account for
approximately two-thirds of cardiac cells
Collagen synthesis and turnover
.

12. .
Fibroblast/Myofibroblast Phenotypes
Ma Y, Iyer RP et. al Trends Pharmacol Sci . 2017 May;38(5):448-458
Activated fibroblasts are a common component of granulation tissue throughout the body, typically
peaking in density at 4–6 days post-injury

13. Fibroblast Markers
Ma Y, Iyer RP et. al. Trends Pharmacol Sci . 2017 May;38(5):448-458

14. Sources of Fibroblasts
Tallquist et.al. Nature Reviews Cardiology volume 14, pages484–491(2017
Lineage tracing and chimeric mouse
models post-injury identified sources
of transdifferentiated fibroblasts
Cell populations that contribute to
fibrosis:
Resident fibroblasts
Bone Marrow derived
EMT
EndoMT
.

15. Myofibroblast Origin and Activation – A Puzzle
Gourdie, R. et.al. Nat Rev Drug Discov 15, 620–638 (2016)

16. Cardiac Extracellular matrix (ECM)
 The ECM is a highly durable, mechanically stable fiber-containing structure that serves as a scaffold for cells
 Cell-ECM interactions influence cellular behaviors
 The cardiac ECM is a complex meshwork of structural and non structural proteins and sugars that are further
subdivided into glycoproteins, proteoglycans, and glycosaminoglycans
 The major component of the adult human cardiac muscle is fibrillar collagen type I (approximately 85%) and
collagen type III (approximately 11%)
Hinderer S et al. Adv Drug Deliv Rev. 2019;146:77‐82, Rienks et. al. Circulation Research. 2014;114:872–888, Gourdie, R. et.al. Nat Rev Drug Discov 15, 620–638 (2016)

17. Balance Is Important for Optimal Healing
Zamilpa et. al, JMCC. 2010;48(3):558-563, Liu et. al., Front Physiol. . 2017 Apr 24;8:238
Matrix Metalloproteinases
(MMPs)
MMPs play pivotal roles in the
development of fibrosis by
controlling ECM degradation

18. One MMP Can Wear Many Hats
Iyer RP et. al, AJP: Heart and Circ. Physiol. 2012;303 (8), Iyer RP et. al, Int. J. Cardiol. 2015;185:195-208, Mouton et. al., Pharmacological Research, 2018; 137:252-258

19. Effect of MMPs on Fibroblasts
Iyer RP, Circ Res. 2014;114(5):860‐871

20. Signaling
Pathways
Joshua G. Travers. Circulation Research.
Cardiac Fibrosis, 2016, 118(6), 1021-1040

21. Transforming Growth Factor (TGF)- β
Smad-dependent and Smad-
independent
Travers et. al., Circulation Research. 2016;118:1021–1040
Ma ZG et. al., Int J Biol Sci 2018; 14(12):1645-1657,
Frangogiannis, N.;Molecular Aspects of Medicine, 2019, 65, 70-99
Perhaps the most extensively studied mediator of
fibroblast activation

22. Wnt Signaling
Fu W et. al., Acta Pharmacologica Sinica volume 40, pages9–12(2019), Tao et. al., Metabolism, Volume 65, Issue 2, February 2016, Pages 30-40

23. Hippo Signaling
Delaunay et. al., Cells 2020, 9, 69

24. Transient Receptor Potential Channels (TRPC)
Travers et. al., Circulation Research. 2016;118:1021–1040, Prabhu et. al., Circulation Research. 2016;119:91-112, Falcon et. al., Front Physiol. 2019; 10: 159

25. Fibroblast Signaling Module
Ma Y, Iyer RP, Trends Pharmacol Sci . 2017 May;38(5):448-458

26. Diagnostic Tools for
Fibrosis Detection
Listed Tools
Endomyocardial
Biopsies
Biomarkers
Echocardiography
CMRI
Doppler Flow Velocity

27. Diagnostic Tools For Fibrosis Detection
Endomyocardial Biopsies
Iyer RP, JMCC. 2016;100:109-117, Iyer RP, Circ Res. 2014;114(5):860‐871

28. Diagnostic Tools For Fibrosis Detection
Biochemical Assays/Biomarkers Criteria
de Jong, et. al. J. Cardiovasc. Pharmac.57(5):522-535, 2011.

29. Diagnostic Tools For Fibrosis Detection
Hinderer S et al. Adv Drug Deliv Rev. 2019;146:77‐82. Tallquist et.al. Nature Reviews Cardiology volume 14, pages484–491(2017)
Biochemical Assays/Biomarkers
Jordan, JIM. 2007;262(3):385-392 Mansour et. al. J Card Fail. 2016 Sep; 22(9): 692–699.

30. Diagnostic Tools For Fibrosis Detection
Echocardiography
Macedo et. al., Int J Cardiol Heart Vasc. 2015 Sep 1; 8: 75–80.

31. Diagnostic Tools For Fibrosis Detection
Cardiac Magnetic Resonance Imaging (CMRI)
Late Gadolinium Enhancement (LGE)
Mewton et al, Volume 57, Issue 8, 22 February 2011, Pages 891-903

32. Diagnostic Tools For Fibrosis Detection
Doppler Flow Velocity
Fibrosis by LGE was directly and significantly correlated
with E/E’
Moreo et.al., Circ Cardiovasc Imaging. 2009 Nov 1; 2(6): 437–443.

33. Audience Poll

34. Current
Therapeutic
Approaches
Approach Examples
Growth Factors PDGF, CTGF
Cytokines MCP-1, Cxcl10
miRNAs miR-21,miR-29
Biomaterials Ventrigel, Alginate
Cell Therapy FAP, Sca-1
Reprogramming SeV-GFP
Proteins Serelaxin, Periostin
Electric Communication Cx43, Gap26

35. Current Therapeutic Approaches
Pamrevlumab (FG-3019)
PPMD Conférence, 2019, Tandon et. al., J Am Heart Assoc. 2015 Apr; 4(4)
Fully human monoclonal antibody (mAb)
against CTGF
DMD patients, IPF, and pancreatic cancer
Patients showed improvement in LVEF and
reduction in cardiac fibrosis

36. Current Therapeutic Approaches
miR-21
Yang et. al., Cell Death & Disease, 2018, 9 (769)

37. VentriGel, an ECM
hydrogel derived
from decellularized
porcine
myocardium
Improvements in
left ventricular
remodeling
observed in
patients treated
>1-year post–MI vs
<1 year
Biomaterial Assisted Therapies
Franco et. al., J Thorac Dis. 2018 Jul; 10(Suppl 20). Traverse et. al., J Am Coll Cardiol Basic Trans Science, 2019, 4(6), 659-69
Current Therapeutic Approaches

38. Current Therapeutic Approaches
FAP CAR T Cells
Aghajanian et.al. Nature. 2019 Sep; 573(7774): 430–433.
• Possibility of targeting cardiac fibrosis in mice with
engineered T cells and immunotherapy

39. Current
Therapeutic
Approaches
Fibroblast Reprogramming
Miyamoto et. al., Cell Stem Cell, 2018, 22 (1) , 91-103
• SeV vectors expressing
cardiac reprogramming
factors efficiently reprogram
both mouse and human
fibroblasts into integration-
free iCMs in vitro.
• Gene transfer of SeV-GMT
into mouse infarct hearts
enhanced in vivo cardiac
reprogramming and improved
cardiac function after MI.

40. Knowledge Gaps

41.  Fibroblast: Are the only relevant source of collagen and ECM production in the heart?
How activated fibroblasts perform in vivo?
What is the entire molecular circuitry that regulates fibroblast activation?
 Scar: Are all cardiac scars are created equal?
Is the scar composition and quality similar or different between fibrotic diseases?
What is process of cardiac scar formation?
 Signaling Pathways: Which factors exactly trigger healing processes?
Is there one factor that rules all?
 Diagnostic Tools: How do we improve tools and techniques for early, reliable and non-invasive detection?
 Therapeutic Targets: Can all mediators be blocked in same phase?
Can blocking certain mediators in a wrong phase impact cellular responses that are
mandatory for cardiac repair?

42. Inflammation’s Role in Fibroblast Activation
Ma Y, Iyer RP, Pflugers Arch. 2014; 466(6): 1113–1127

44. Audience Poll

45. Rugmani Iyer, PhD
Senior Scientist
Merck Research Laboratories
Please contact Scintica Instrumentation for
additional product information:
Phone: +1 (519) 914 5495
info@scintica.com
Q&A
SESSION:
To ask a question, click the Q&A Button,
type your question and click send. Any
questions that are not addressed during
the live webinar will be answered
following the event.
Thank you for participating!