Induced Pluripotent Stem Cell Transplantation in the Treatment of Porcine Chronic Myocardial Ischemia Yifu Zhou, MD, Suna Wang, MD, Zuxi Yu, MD, PhD,

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Induced Pluripotent Stem Cell Transplantation in the Treatment of Porcine Chronic Myocardial Ischemia Yifu Zhou, MD, Suna Wang, MD, Zuxi Yu, MD, PhD, Robert F. Hoyt, DVM, Timothy Hunt, BS, Bogdan Kindzelski, BS, David Shou, BS, Wen Xie, MD, Yubin Du, PhD, Chengyu Liu, PhD, Keith A. Horvath, MD The Annals of Thoracic Surgery Volume 98, Issue 6, Pages 2130-2137 (December 2014) DOI: 10.1016/j.athoracsur.2014.07.008 Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Top panel shows tissue explant method to obtain myocardial fibroblasts: (A) Arrow indicating a tissue clump attached to the culture plate; (B) arrow indicating cells migrating out from tissue clump after 3 days in culture; (C) migrated cells starting to proliferate to localized confluence; (D) cells derived from the myocardial tissue clump showing homogeneous fibroblast morphology after splitting and subculturing. Bottom panel shows reprogramming of myocardial fibroblasts; (E) and (F) arrows indicating preliminary colonies 5 days after transfection; (G) a mature induced pluripotent stem cell colony at passage 5 at day 44; (H) higher magnification of (G). Magnifications: (A)–(G) = ×100; H = ×200. The Annals of Thoracic Surgery 2014 98, 2130-2137DOI: (10.1016/j.athoracsur.2014.07.008) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Pluripotency tests for myocardial fibroblast-derived induced pluripotent stem cells. (A) Positive alkaline phosphatase staining; (B) Tra-1-60; (C) Tra-1-80; (D) Nanog; (E) SSEA4; (F) Sox2; (G) OCT4; (H) phase contrast image shows neural differentiation; (I) positive Tuj-1 staining. Magnifications: (A)–(C) = ×100; (D)–(G) = ×200; (H) and (I) = ×100. The Annals of Thoracic Surgery 2014 98, 2130-2137DOI: (10.1016/j.athoracsur.2014.07.008) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Allogeneic transplantation of myocardial fibroblast-derived induced pluripotent stem cells (iPSCs). (A) Arrow indicating an area with 3 spherical shaped tumors at 4 weeks after injection (×12.5); (B) and (C) higher magnification of (A) (×100 and × 200); (D) arrow indicating an area with 3 irregular shaped tumors at 6 weeks after injection (×12.5); (E) and (F) higher magnification of (D) (×100); (G) and (H) positive stage-specific embryonic antigen-4 staining (red) of the tumor-like cell clumps at 6 weeks (×400); (I) arrowhead indicating positive OCT 4 (green) and arrow indicating smooth muscle actin staining (red) (×400); (J)–(L) arrows indicating cell clumps were also found in lung (J and K) and spleen (L) at 6 weeks similar to those found in ischemic heart area (×100); (M) arrow indicating a normal splenic nodule with a central artery in the center which was not found in iPSC formed tumors (×400); (N)–(R) arrows indicating two sets of photos showing similar spherical-shaped small tumors from 2 different animals at 8 weeks. (N) and (P) = ×12.5; (O), (Q), and (R) = ×100. The Annals of Thoracic Surgery 2014 98, 2130-2137DOI: (10.1016/j.athoracsur.2014.07.008) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 (A) Smooth muscle actin (red) and von Willebrand Factor (green) staining at 8 weeks; arrow indicating a cell clump; (B) negative control of (A); (C) staining of (A) at 4 weeks; arrow indicating a cell clump; (D) staining of (A) at noninjected area at 4 weeks after injection. Magnifications (A)–(D) = ×100. The Annals of Thoracic Surgery 2014 98, 2130-2137DOI: (10.1016/j.athoracsur.2014.07.008) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Expression of vascular endothelial growth factor (VEGF), fibroblast growth factor (FGF), and aryl hydrocarbon receptor nuclear translocator (ANRT) by reverse real-time polymerase chain reaction were significantly higher in the injected myocardium compared with none injected both in 4-week samples (left panel) and 3-month samples after myocardial-derived induced pluripotent stem cell transplantation. The Annals of Thoracic Surgery 2014 98, 2130-2137DOI: (10.1016/j.athoracsur.2014.07.008) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

Fig 6 Histologic analysis of the animals that received cell transplantation with the induced pluripotent stem cell strain provided by Michael Robert’s lab. (A) Arrow indicating a group of irregular small tumors at 8 weeks (×12.5); (B) higher magnification of the boxed area in (A) (×100); arrow indicating capsule found around the small tumors; (C) OCT4 staining (×400); (D) SSEA4 staining (×400); (E) arrow indicating cell clumps at 3 months after injection (×50); (F) higher magnification of (E) (×200); (G) and (H) showing images from 2 separate animals at 3 months (×50 and ×200). The Annals of Thoracic Surgery 2014 98, 2130-2137DOI: (10.1016/j.athoracsur.2014.07.008) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions