Barriers in Heart Failure Gene Therapy and Approaches to Overcome Them

Abstract

With the growing prevalence and incidence of heart failure worldwide, investigation and development of new therapies to address disease burden are of great urgency. Gene therapy is one promising approach for the management of heart failure, but several barriers currently exclude safe and efficient gene delivery to the human heart. These barriers include the anatomical and biological difficulty of specifically targeting cardiomyocytes, the vascular endothelium, and immunogenicity against administered vectors and the transgene. We review approaches taken to overcome these barriers with a focus on vector modification, evasion of immune responses, and heart-targeted delivery techniques. While various modifications proposed to date show promise in managing some barriers, continued investigation into improvements to existing therapies is required to address transduction efficiency, duration of transgene expression, and immune response.

Keywords: Adeno-associated virus; Adenovirus; Cardiomyocyte specificity; Heart failure; Immunogenicity; Transduction efficiency; Vector.

Figure 1 (Central Illustration)

Barriers in cardiac gene therapy. A. Genes are delivered using vectors, but anatomical, immunological, and endothelial barriers prevent efficient cardiac uptake of therapeutic genes. B. Examples of approaches to overcome these barriers. Top: Vector modification by engineering the capsid (left) and coating (right). Middle: Immune modulation by plasmapheresis to remove antibodies (left) and drugs to suppress immunity (right). Bottom: Cardiac targeted delivery with balloon occlusion to modulate mechanical factors. Parts of some Figures were adapted from https://smart.servier.com/.