Stem Cell Injection to Treat Heart Damage During Open Heart Surgery

Background:

Many investigators now believe that bone marrow-derived stem cells or endothelial progenitor
cells can be recruited to and incorporated into tissues undergoing neovascularization,
including cardiac tissue.

Stem cells which include hematopoietic stem cells (HSCs), endothelial progenitor cells
(EPCs), mesenchymal stem cells / stromal stem cells (MSCs), myoblasts, and undifferentiated
side population cells have been used as an alternative therapeutic strategy for ischemic
cardiovascular diseases that cannot be treated by routine interventional approaches.

In a porcine pre-clinical study we found that cells survived after intramyocardial injection
and differentiated into vascular cells, smooth muscle or endothelial cells. Functional
analysis of regional wall motion and ejection fraction demonstrated statistically significant
improvement in function in cell treated animals after six weeks compared with baseline and
sham controls.

A variety of studies have been conducted in subjects with coronary artery disease using
different cell types and routes of administration. This study will be the first of its kind
to administer autologous BMSC via direct intramyocardial injection in a rigorous clinical
trial in the U.S.

Objectives:

To evaluate the safety and feasibility of direct intra-myocardial injection of autologous
bone marrow stromal cells (BMSCs) in adult subjects undergoing coronary artery bypass graft
(CABG) or transmyocardial revascularization (TMR).

A secondary objective is to assess whether direct intra-myocardial injection of autologous
bone marrow stromal cells (BMSCs) improves the patient s cardiac function, quality of life,
and reduces cardiac events compared with historical controls at three and six months after
intervention.

Eligibility:

Adult subjects with three-vessel coronary artery disease who plan to undergo CABG or TMR at
the NIH Heart Center at Suburban Hospital and are willing to participate, who have stable
angina, LV EF less than or equal to 50%, and who have evidence of hypokinetic segments.

Subjects will be excluded if they have had a recent myocardial infarction (MI), bleeding
disorder, infection, HIV or who are unable to wait 3 weeks for surgery while cells are being
expanded prior to injection.

Design:

Bone marrow aspiration will be performed on subjects who suffer from ischemic heart disease
with depressed left ventricular function three weeks before their admission to have CABG or
TMR in the NIH Clinical Center Outpatient Clinic.

Data will be presented based on the subject s treatment regimen:

Group 1 CABG+Cells (total of 10 evaluable subjects)

Group 2 TMR + Cells (total of 10 evaluable subjects)

The autologous MSCs will be isolated from the marrow aspirate, cultured and expanded in vitro
for 3 passages (approximately 21 days (+/- 4 days)) in the Clinical Center Cell Processing
Laboratory (CPS), located in the Department of Transfusion Medicine (DTM), Clinical Center,
NIH.

During the surgery at Suburban Hospital, the MSCs will be injected directly into the ischemic
area after CABG or TMR. Patients will be assessed for functional improvements pre, 3, 6, 12
and 60 months after the surgery by transthoracic echocardiography and/or by MRI at pre, 3 and
6 months after surgery. Toxicity data will be reported from time of surgery to 6 months after
surgery, unless later toxicities occur that are related to cell injection.

- INCLUSION CRITERIA

- Consenting adult patients (male or female, aged above 18 and less than or equal to
85), and

- Plans to undergo CABG or TMR at the NIH Heart Center at Suburban Hospital and are
willing to participate.

- Must meet indications for CABG or TMR:

- Indications for CABG (31)

1. Significant left main coronary artery stenosis (> 50% reduction in lumen
diameter).

2. Left main equivalent: significant (greater than or equal to70%) stenosis of
proximal LAD and proximal left circumflex artery.

3. Three-vessel disease (stenosis of 50% or more in all 3 major coronary
territories). (Survival benefit is greater when LVEF is

<0.50.)

4. Two-vessel disease with significant proximal LAD stenosis and either EF <0.50 or
demonstrable ischemia on noninvasive

testing.

5. One- or 2-vessel coronary artery disease without significant proximal LAD
stenosis, but with a large area of viable

myocardium and high-risk criteria on noninvasive testing.

- Indications for TMR (32, 33).

1. Canadian Cardiovascular Class III or IV angina that is refractory to maximal medical
therapy.

2. Reversible ischemia of the left ventricular free wall and coronary artery disease
corresponding to the regions of myocardial

ischemia.

3. In all regions of the myocardium, the coronary disease must not be amenable to
coronary artery bypass graft (CABG) or

percutaneous transluminal coronary angioplasty (PTCA), due to:

i. severe diffuse disease,

ii. lack of suitable targets for complete revascularization,

iii. lack of suitable conduits for complete revascularization

- Stable Angina. Patient?s clinical state has to be stable to receive surgical treatment.
Patients must have received or currently receiving standard of care medical therapy(33) for
at least 4 weeks prior to enrollment, to include:

1. Aspirin in the absence of contraindications in patients with prior MI

2. Beta-blockers as initial therapy in the absence of contraindications in patients with
prior MI.

3. Lipid-lowering therapy in patients with documented CAD and LDL cholesterol greater
than 130 mg/dL, with a target LDL of less

than 100 mg/dL

4. ACE inhibitor in patients with CAD (considered significant by angiography or previous
MI) who also have diabetes and/or left

ventricular systolic dysfunction.

- Three-vessel CAD. Multi-vessel diffuse coronary artery disease not amenable to
percutaneous coronary intervention.

- LV EF less than or equal to 50% by by MRI or Echocardiogram. The left ventricle
ejection fraction less than 50% evidenced the diagnosis of heart failure indicating
global weakness of myocardial contractility and leaves space for functional
improvement.

- Evidence of hypokinetic segment. Regional wall motion abnormality which includes
regional low/no motion, or motion in opposite direction, is a good indication for
invasive intervention and can be well-compared before and after treatment.

- Laboratory tests showed no evidence of major organ dysfunction, bleeding disorder, or
infectious diseases. Patients must have organ and marrow function as defined below:

i. Leukocytes greater than or equal to 2,500/mcL

ii. Lymphocytes greater than or equal to 800/mcL

iii. Platelets greater than or equal to 100,000/mcL

iv. Total Bilirubin less than or equal to 2mg/dL

v. AST (SGOT)/ALT (SGPT) less than or equal 1.5 times

institutional upper limit of normal (ULN)

vi. Creatinine less than or equal to institutional upper limit of

normal (ULN)

- Must be willing to participate in 10-CC-0053 to obtain autologous bone marrow.

- Patients must understand and sign an informed consent document that explains the
nature of his/her cardiac disease, the procedures to be followed, the experimental
nature of the treatment, alternative treatments, and potential risks and toxicities.

EXCLUSION CRITERIA

- Patients who have the following conditions will be excluded from the study:

- Acute MI. Less than three months after recent acute myocardial infarction.

- Unstable angina. Excluded due to the propensity to deteriorate into AMI.

- Bleeding disorder, including history of familial hemophilia, signs and symptoms of
easy bruising, petechiae, or platelet count < 80,000 cells/mcL. This disorder may
unnecessarily complicate the operative procedure and postoperative recovery.

- Severe respiratory disorder, including acute asthma, chronic bronchitis, severe
chronic obstructive lung disease. A disorder that would complicate the operative
procedure and postoperative recovery.

- Unable to provide informed consent on this study or on 10-CC-0053.

- Unable to wait 3 weeks for surgery, which is the waiting period for ex-vivo cell
expansion.

- Reactive for anti-HIV, Hepatitis B surface antigen, anti-HCV or nucleic acid testing
for HIV, Hepatitis B and C. An investigational component accompanying this major
surgical procedure in the presence of infection has the potential to increase risk of
complications, and manufacturing contaminated products risks contaminating other
cellular products in CPS.

- Pregnant or lactating females, due to the highly investigational nature of this study
and its unknown effects on a developing fetus.

- Allergic to Gentamicin.