1

 

                DEPARTMENT OF HEALTH AND HUMAN SERVICES

 

                      FOOD AND DRUG ADMINISTRATION

 

              CENTER FOR BIOLOGICS EVALUATION AND RESEARCH

 

 

 

            BIOLOGICAL RESPONSE MODIFIERS ADVISORY COMMITTEE

 

                              MEETING #37

 

 

 

 

 

                        Thursday, March 18, 2004

 

                               8:30 a.m.

 

 

                              Hilton Hotel

                        Silver Spring, Maryland

 

                                                                 2

 

                              PARTICIPANTS

 

      Mahendra S. Rao, M.D., Ph.D., Chair

      Gail Dapolito, Executive Secretary

 

      MEMBERS

      Jonathan S. Allan, D.V.M.

      Bruce R. Blazar, M.D.

      David M. Harlan, M.D.

      Katherine A. High, M.D.

      Joanne Kurtzberg, M.D.

      Alison F. Lawton

      James J. Mul, Ph.D.

      Thomas H. Murray, Ph.D.

      Anastasios A. Tsiatis, Ph.D

 

      CONSULTANTS

 

      Jeffrey S. Borer, M.D.

      Susanna Cunningham, Ph.D.

      Jeremy N. Ruskin, M.D.

      Michael E. Schneider, M.D.

      Michael Simons, M.D.

 

      INDUSTRY REPRESENTATIVE

 

      John F. Neylan, M.D.

 

      GUEST HEALTH CANADA REPRESENTATIVE

 

      Norman Viner, M.D.

 

      GUEST SPEAKERS

 

      Stephen Epstein, M.D.

      Silviu Itescu, M.D.

      Robert J. Lederman, M.D.

      Philippe Menasch, M.D.

      Emerson C. Perin, M.D., F.A.C.C.

      Doris A. Taylor, Ph.D.

 

      NIH PARTICIPANTS

 

      Richard O. Cannon, M.D.

      Stephen M. Rose, Ph.D.

 

      FDA PARTICIPANTS

 

      Jesse L. Goodman, M.D., M.P.H.

      Philip Noguchi, M.D.

      Dwaine Rieves, M.D

      Stephen Grant, M.D.

      Richard McFarland, Ph.D., M.D.

      Donald Nick Jensen, D.V.M., M.S.E.E.

 

                                                                 3

 

                            C O N T E N T S

                                                              PAGE

 

      Call to Order

        Mahendra Rao, M.D., Ph.D., Chair                         5

 

      Conflict of Interest Statement

        Gail Dapolito, Executive Secretary                       5

 

      Introduction of Committee                                  9

 

      FDA Opening Remarks

         Presentation of Certificate of Appreciation

         to Retiring Member

         Jesse Goodman, M.D., M.P.H.                            14

         Philip Noguchi, M.D.                                   16

 

                        Open Committee Discussion

                 Cellular Therapies for Cardiac Disease

 

      FDA Introduction and Perspectives

        Dwaine Rieves, M.D.                                     18

 

      Guest Presentations

 

        Overview Cardiomyopathy and Ischemic Heart

           Disease

        Emerson Perin, M.D., Ph.D.                              35

        Q&A                                                     65

 

        Clinical Experience of Autologous Myoblast

        Transplantation

        Philippe Menasch, M.D.                                 85

        Q&A                                                    115

 

        Bone Marrow Cell Therapy for Angiogenesis:

        Present and Future

        Steven Epstein, M.D.                                   128

        Q&A                                                    148

 

      Cellular Therapies for Cardiac Disease

      Richard McFarland, Ph.D., M.D.                           159

 

      Guest Presentations

 

        Myoblasts:  The First Generation Cells for

        Cardiac Repair: What Have We Learned?

        Doris Taylor, Ph.D.                                    169

        Q&A                                                    202

 

        Preclinical Models  - Hematopoietic and

        Mesenchymal Cell Therapies for Cardiac Diseases

        Silviu Itescu, M.D.                                    219

        Q&A                                                    245

 

                                                                 4

 

                      C O N T E N T S (Continued)

 

        From Mouse to Man:  Is it a Logical Step for

        Cardiac Repair?

        Doris Taylor, Ph.D.                                    257

        Q&A                                                    275

 

        Cardiac Catheters for Delivery of Cell Suspension

        Donald Nick Jensen, D.V.M., M.S.E.E.                   292

 

        Transcatheter Myocardial Cell Delivery: Questions

        and Considerations from the Trenches

        Robert Lederman, M.D.                                  307

        Q&A                                                    333

 

      Open Public Hearing                                      343

 

                                                                 5

 

  1                      P R O C E E D I N G S

 

  2                          Call to Order

 

  3             DR. RAO:  Good morning.  Welcome to the

 

  4   37th meeting of the Biological Response Modifiers

 

  5   Advisory Committee.

 

  6             Today's topic, as you all know, is related

 

  7   to use of cells in cardiovascular disorders, and we

 

  8   have a pretty full schedule for the next couple of

 

  9   days, but before we can start the meeting, we have

 

 10   to have a few sort of committee stuff that needs to

 

 11   be gotten through, so I will turn the mike over to

 

 12   Gail, so that she can make the mandatory

 

 13   announcements.

 

 14                  Conflict of Interest Statement

 

 15             MS. DAPOLITO:  Good morning.

 

 16             The following announcement addresses

 

 17   conflict of interest issues associated with this

 

 18   meeting of the Biological Response Modifiers

 

 19   Advisory Committee on March 18 and 19, 2004.

 

 20             Pursuant to the authority granted under

 

 21   the Committee Charter, the Associate Commissioner

 

 22   for External Relations, FDA, appointed Drs. Jeffrey

 

 23   Borer and Susanna Cunningham as temporary voting

 

 24   members.

 

 25             In addition, the Director of FDA's Center

 

                                                                 6

 

  1   for Biologics Evaluation and Research, appointed

 

  2   Drs. Jeremy Ruskin, Michael Schneider, and Michael

 

  3   Simons as temporary voting members.

 

  4             Based on the agenda, it was determined

 

  5   that there are no specific products considered for

 

  6   approval at this meeting.  The committee

 

  7   participants were screened for their financial

 

  8   interests.  To determine if any conflicts of

 

  9   interest existed, the agency reviewed the agenda

 

 10   and all relevant financial interests reported by

 

 11   the meeting participants.

 

 12             The Food and Drug Administration prepared

 

 13   general matters waivers for participants who

 

 14   required a waiver under 18 U.S.C. 208.  Because

 

 15   general topics impact on many entities, it is not

 

 16   prudent to recite all potential conflicts of

 

 17   interest as they apply to each member.

 

 18             FDA acknowledges that there may be

 

 19   potential conflicts of interest, but because of the

 

 20   general nature of the discussions before the

 

 21   committee, these potential conflicts are mitigated.

 

 22             We note for the record that Dr. John

 

 23   Neylan is participating in this meeting as a

 

 24   non-voting industry representative acting on behalf

 

 25   of regulated industry.  Dr. Neylan's appointment is

 

                                                                 7

 

  1   not subject to 18 U.S.C. 208.  He is employed by

 

  2   Wyeth Research and thus has a financial interest in

 

  3   his employer.

 

  4             With regards to FDA's invited guest

 

  5   speakers and guests, the agency determined that

 

  6   their services are essential.  The following

 

  7   disclosures will assist the public in objectively

 

  8   evaluating presentations and/or comments made by

 

  9   the participants.

 

 10             Dr. Stephen Epstein is the Executive

 

 11   Director, Cardiovascular Research Institute,

 

 12   Washington Hospital Center.  He receives research

 

 13   support, is a consultant to and has financial

 

 14   interests with, firms that could be affected by the

 

 15   committee discussions.

 

 16             Dr. Philippe Menasch is employed at the

 

 17   George Pompidou Hospital in Paris, France.  He has

 

 18   an association with a firm that could be affected

 

 19   by the committee discussions.

 

 20             Dr. Emerson Perin is employed by the Texas

 

 21   Heart Institute.  He receives consultant fees from,

 

 22   and is a scientific advisor to, firms that could be

 

 23   affected by the committee discussions.

 

 24             Dr. Doris Taylor is employed by the

 

 25   University of Minnesota, Center for Cardiovascular

 

                                                                 8

 

  1   Repair.  She receives consultant fees from a firm

 

  2   that could be affected by the committee

 

  3   discussions.

 

  4             Dr. Norman Viner is employed by the

 

  5   Biologics and Radiopharmaceuticals Evaluation

 

  6   Centre, Biologics and Genetic Therapies

 

  7   Directorate, Health Canada, in Ottawa, Canada.

 

  8             FDA participants are aware of the need to

 

  9   exclude themselves from the discussions involving

 

 10   specific products or firms for which they have not

 

 11   been screened for conflicts of interest.  Their

 

 12   exclusion will be noted for the public record.

 

 13             With respect to all other meeting

 

 14   participants, we ask in the interest of fairness

 

 15   that you state your name, affiliation, and address

 

 16   any current or financial involvement with any firm

 

 17   whose product you wish to comment upon.

 

 18             Waivers are available by written request

 

 19   under the Freedom of Information Act.

 

 20             Thank you, Dr. Rao.

 

 21             DR. RAO:  Now you know why I always have

 

 22   Gail read that statement.

 

 23             Before we start any committee work, I

 

 24   would like to welcome two new members to the

 

 25   committee, Dr. Murray and Dr. James Mul.  We

 

                                                                 9

 

  1   generally introduce everyone on the committee

 

  2   first, and we generally go in alphabetical order,

 

  3   but this time I will try and start with the new

 

  4   members, so that they can tell us a little bit

 

  5   about themselves before we have the others

 

  6   introduce themselves.

 

  7                    Introduction of Committee

 

  8             DR. MULE:  I am Dr. Jim Mul.  I am

 

  9   currently the Associate Center Director for the H.

 

 10   Lee Moffitt Cancer Center in Tampa.  I oversee all

 

 11   translational research at the Center including all

 

 12   cell-based therapies for the treatment of cancer as

 

 13   it applies to the clinical treatment of patients

 

 14   with advance tumors.

 

 15             Prior to being in Tampa since September of

 

 16   last year, I was at the University of Michigan

 

 17   Cancer Center for 10 years, and prior to that, the

 

 18   NCI for another 10 years, and I am delighted to be

 

 19   here.

 

 20             DR. MURRAY:  Good morning.  I am Tom

 

 21   Murray.  I am President of the Hastings Center,

 

 22   which is celebrating its 35th years as the world's

 

 23   first research institute devoted to ethics in

 

 24   medicine and the life sciences.

 

 25             I spent 15 years as professor at medical

 

                                                                10

 

  1   schools including 12 at Case Western Reserve

 

  2   University School of Medicine.  My interests are

 

  3   fairly broad.  I write a lot about ethics and

 

  4   ethics in the life science and science policy.

 

  5             Thank you.  I am delighted also to be

 

  6   here.

 

  7             DR. RAO:  If we can go down the table, Dr.

 

  8   Tsiatis.

 

  9             DR. TSIATIS:  Hi.  I am Butch Tsiatis.  I

 

 10   am from the Department of Statistics at North

 

 11   Carolina State University.

 

 12             DR. BORER:  My name is Jeff Borer.  I am a

 

 13   cardiologist.  I work at Weill Medical College of

 

 14   Cornell University in New York City.  I run a

 

 15   division and an institute at Cornell and, relevant

 

 16   to this meeting, I am the Chairman of the

 

 17   Cardiorenal Drugs Advisory Committee of the FDA.

 

 18             DR. CUNNINGHAM:  Good morning.  My name is

 

 19   Susanna Cunningham.  I am a professor in the School

 

 20   of Nursing at the University of Washington in

 

 21   Seattle, and I am the consumer representative for

 

 22   the Cardiovascular Renal Advisory Committee.

 

 23             DR. SCHNEIDER:  I am Michael Schneider.  I

 

 24   co-direct the Center for Cardiovascular Development

 

 25   at Baylor College of Medicine, and our interests

 

                                                                11

 

  1   are in the molecular genetics of cardiac muscle

 

  2   formation, cardiac growth, cardiac cell apoptosis

 

  3   and its relation to heart failure, and, relevant to

 

  4   this meeting, cardiac progenitor cells of different

 

  5   kinds.

 

  6             DR. SIMONS:  Hi.  I am Michael Simons.  I

 

  7   am Chief of Cardiology at Dartmouth Medical School.

 

  8   I work in the area of vascular biology, gene and

 

  9   cell therapy.

 

 10             DR. RUSKIN:  Good morning.  I am Jeremy

 

 11   Ruskin.  I am a cardiologist and

 

 12   electrophysiologist, and I direct the  Cardiac

 

 13   Arrhythmia Service at Massachusetts General

 

 14   Hospital.

 

 15             DR. NEYLAN:  Good morning.  I am John

 

 16   Neylan.  I am a nephrologist and an organ

 

 17   transplanter by training. Currently, I am Vice

 

 18   President of Clinical Research and Development at

 

 19   Wyeth, and I serve as a industry representative to

 

 20   the committee.

 

 21             DR. KURTZBERG:  Hi.  I am Joanne

 

 22   Kurtzberg.  I am a pediatric oncologist.  I direct

 

 23   the Pediatric Bone Marrow and Stem Cell Transplant

 

 24   Program at Duke University and the Carolinas Cord

 

 25   Blood Bank at Duke.

 

                                                                12

 

  1             DR. ALLAN:  Hi.  I am Jon Allan.  I am a

 

  2   virologist at the Southwest Foundation for

 

  3   Biomedical Research.  My area is nonhuman primate

 

  4   models for AIDS pathogenesis.

 

  5             DR. CANNON:  Good morning.  I am Richard

 

  6   Cannon.  I am at the National Heart, Lung, and

 

  7   Blood Institute.  I am Clinical Director of NHLBI,

 

  8   and I am representing NHLBI at this meeting.

 

  9             DR. ROSE:  Good morning.  I am Stephen

 

 10   Rose.  I am Deputy Director for the Recombinant DNA

 

 11   Program in the Office of Biotechnology Activities

 

 12   in the NIH.

 

 13             DR. JENSEN:  Good morning.  My name is

 

 14   Nick Jensen.  I am a reviewer in the Center for

 

 15   Devices and Radiological Health.  I am a

 

 16   veterinarian and an engineer.

 

 17             DR. McFARLAND:  Good morning.  I am

 

 18   Richard McFarland.  I am a reviewer in the

 

 19   Pharm/Tox Branch in the Center for Biologics in the

 

 20   Office of Cellular, Tissue and Gene Therapies.

 

 21             DR. RIEVES:  Good morning.  My name is

 

 22   Dwaine Rieves.  I am a medical officer in FDA's

 

 23   Center for Biologics Evaluation and Research.

 

 24             DR. GOODMAN:  Good morning.  I am Jesse

 

 25   Goodman.  I am the Center Director of the Center

 

                                                                13

 

  1   for Biologics.  I would just like to join in

 

  2   welcoming especially the new members.  My

 

  3   background is as an infectious disease physician in

 

  4   academic medicine for many years.

 

  5             DR. NOGUCHI:  I am Phil Noguchi, Acting

 

  6   Director of the Office of Cellular, Tissue and Gene

 

  7   Therapies in CBER.

 

  8             DR. RAO:  Thank you, everyone.

 

  9             We are very fortunate in having some

 

 10   really leaders in the field come and present some

 

 11   of the data which will be the basis of where we can

 

 12   address some of the questions that have been raised

 

 13   by the FDA.

 

 14             I am going to ask them to just briefly

 

 15   introduce themselves, as well.

 

 16             DR. EPSTEIN:  I am Steve Epstein, a

 

 17   cardiologist.  I am head of the Cardiovascular

 

 18   Research Institute at the Washington Hospital

 

 19   Center.  We are involved in vascular biology, gene,

 

 20   and cell therapy.

 

 21             DR. MENASCHE:  I am Philippe Menasch.  I

 

 22   am cardiac surgeon at the Hospital European George

 

 23   Pompidou in Paris, France.

 

 24             DR. PERIN:  Good morning.  I am Emerson

 

 25   Perin.  I am an interventional cardiologist and

 

                                                                14

 

  1   Director of Interventional Cardiology at Texas

 

  2   Heart Institute in Houston.

 

  3             DR. TAYLOR:  Hi.  I am Doris Taylor.  I am

 

  4   a scientist.  I just moved from Duke University to

 

  5   the University of Minnesota to head the Center for

 

  6   Cardiovascular Repair.

 

  7             DR. ITESCU:  Hi.  I am Silviu Itescu.  I

 

  8   am Director of Transplantation Immunology at

 

  9   Columbia Presbyterian, New York.

 

 10             DR. RAO:  I would also like to welcome Dr.

 

 11   Viner who is from Health Canada.  Health Canada has

 

 12   been following a lot of what the FDA has been doing

 

 13   and it is nice to have them there.

 

 14             I would like to invite Dr. Goodman to make

 

 15   a statement.

 

 16                       FDA Opening Remarks

 

 17           Presentation of Certificate of Appreciation

 

 18                        to Retiring Member

 

 19             DR. GOODMAN:  My main purpose is to thank

 

 20   Joanne Kurtzberg for I guess about four years of

 

 21   service to the BRMAC.  We really appreciate that

 

 22   tremendously.  She has also interacted with CBER

 

 23   before that.

 

 24             One of the reasons I really wanted to come

 

 25   by this morning.  Joanne is rotating off this

 

                                                                15

 

  1   committee.  I know from interactions both within

 

  2   this committee and outside, and from all the

 

  3   leadership and staff within CBER, just what a

 

  4   tremendous advisor and asset Joanne has been for

 

  5   FDA and for your various fields here.

 

  6             Of course, she has mostly contributed very

 

  7   extensively in her areas of hematopoietic stem

 

  8   cells, et cetera, but she has also been a very

 

  9   important thinker and discussant and contributor on

 

 10   the whole range of other cellular therapies and

 

 11   even gene therapy.

 

 12             Please join me in thanking Joanne for her

 

 13   service over these years.  Also, we like to say,

 

 14   particularly CBER, that we are a family and that

 

 15   nobody ever leaves it, and that we, just like a

 

 16   family, we will keep asking for favors in the

 

 17   future and probably causing grief in return.

 

 18             Thanks so much, Joanne.  We have a plaque

 

 19   for her, of course.

 

 20             [Applause.]

 

 21             DR. GOODMAN:  I guess I will just turn it

 

 22   over to Phil to just give a brief introduction for

 

 23   the meeting, but just to say that, as I mentioned a

 

 24   little while back about the islet cell therapies,

 

 25   we, at FDA, are extremely excited about cellular

 

                                                                16

 

  1   therapies and their potential, and I think nowhere

 

  2   is some of that potential clearer, but also perhaps

 

  3   more difficult to evaluate and help move forward

 

  4   than in the area of cardiovascular disease whether

 

  5   it is for ischemic disease or heart muscle disease

 

  6   or trauma, et cetera, some of the uses where there

 

  7   have been some very promising reports.

 

  8             So, we think this is a very timely

 

  9   meeting.  It is very important to get input about

 

 10   how to go forward with efficient development of

 

 11   those products, how to address some of the clinical

 

 12   and safety issues, and how to hopefully make this

 

 13   field positioned to realize its successes in the

 

 14   most efficient manner and also help FDA get that

 

 15   right to the extent that we all can based on

 

 16   incomplete information.

 

 17             Again, we really look forward to this.  I

 

 18   apologize, my usual schedule means I will be in and

 

 19   out,  but I really appreciate it.

 

 20             Phil.

 

 21             DR. NOGUCHI:  Thank you, Jesse, and, of

 

 22   course, Dr. Kurtzberg, our sincere thanks for the

 

 23   many years of service.  Jesse is absolutely right,

 

 24   don't be surprised if the next meeting, you get a

 

 25   funny call early in the morning.

 

                                                                17

 

  1             This is one of our, in a way, continuing

 

  2   series of dealing with things that seem really

 

  3   wonderful and amazing when they come up, where

 

  4   there is a lot of hope and there is perhaps a

 

  5   little bit of hype, but what we have always found

 

  6   over the years, and here I would like to just

 

  7   acknowledge Dr. Rose in the Office of Biotechnology

 

  8   Activities and the Recombinant DNA Committee, what

 

  9   we have learned from them is that one of the best

 

 10   ways that we have of really dealing with things

 

 11   controversial and where there is both hope and

 

 12   there is some trepidation about whether or not this

 

 13   is actually going to work or not, is to bring

 

 14   everyone together, put them in the same room.

 

 15             Our continuing--and this really goes back

 

 16   at least 25 years through the RAC and many years

 

 17   for the BRMAC--is that when you get reasonable

 

 18   people together who may have differing opinions

 

 19   about things, but are presented the facts and the

 

 20   realities, as well as the unknowns, we all

 

 21   basically pretty much come out with the same

 

 22   conclusion, and then we can make significant

 

 23   progress in making these therapies not just

 

 24   experimental, but a reality.

 

 25              With that, what I would really like to

 

                                                                18

 

  1   do, because we have such a full schedule, is now

 

  2   turn it over to Dr. Rieves for the introduction.

 

  3             DR. RAO:  As Dr. Rieves comes up to the

 

  4   mike, I just want to remind people of a few simple

 

  5   rules.  Remember that when you want to ask a

 

  6   question, make sure that you are recognized.  Use

 

  7   the button.  You will see that the light comes on.

 

  8   When you are done, just hit the button again to

 

  9   switch it off, because otherwise, there is sort of

 

 10   a feedback loop and noise.  Make sure you identify

 

 11   yourself when you ask questions.

 

 12              Cellular Therapies for Cardiac Disease

 

 13                FDA Introduction and Perspectives

 

 14             DR. RIEVES:  Good morning.  My name is

 

 15   Dwaine Rieves.  I am a medical officer within FDA's

 

 16   Center for Biologics Evaluation and Research.  This

 

 17   morning I am going to present a brief overview of

 

 18   FDA's perspective on cellular products used in the

 

 19   treatment of cardiac diseases.

 

 20             As will be covered in a subsequent

 

 21   presentation, certain cellular products, when

 

 22   either perfused into the heart or directly injected

 

 23   into heart muscle, are thought to be capable of

 

 24   regenerating heart tissue and/or augmenting heart

 

 25   function.

 

                                                                19

 

  1             Consequently, these products may have

 

  2   special utility in the treatment of heart failure

 

  3   and certain other cardiac diseases.  Today and

 

  4   tomorrow, we will discuss issues in the early

 

  5   clinical development of these products.

 

  6             [Slide.]

 

  7             This talk is divided into three major

 

  8   sections. First, I will cite the purpose in

 

  9   convening this advisory committee.  Secondly, I

 

 10   will provide a regulatory background on FDA's

 

 11   understanding and activities within the realm of

 

 12   clinical development of these products.  Finally, I

 

 13   will introduce the major questions we have proposed

 

 14   for discussion.

 

 15             [Slide.]

 

 16             Unlike many advisory committees where the

 

 17   topics center around assessment of data associated

 

 18   with a specific product or data related to a

 

 19   specific regulatory concern, our purpose in

 

 20   convening this committee is not to obtain

 

 21   definitive regulatory advice, instead, FDA has

 

 22   convened this committee to listen to, and learn

 

 23   from, the voiced thoughts and perspectives with the

 

 24   understanding that this information will enhance

 

 25   our ability to promote the safe clinical

 

                                                                20

 

  1   development of these products.

 

  2             As you are aware, the clinical development

 

  3   of cellular products is in its infancy and many

 

  4   questions surround the very early stages of product

 

  5   development. Consequently, our purpose today and

 

  6   tomorrow is to stimulate a solid scientific

 

  7   discussion of the major facets associated with the

 

  8   very early clinical development of these products.

 

  9             As noted here, we will focus upon three

 

 10   major areas:  manufacturing aspects of the cellular

 

 11   product, preclinical testing of the products, and

 

 12   finally, items related to the early clinical

 

 13   studies.

 

 14             [Slide.]

 

 15             What are the cellular products we will be

 

 16   discussing?  These products may be broadly grouped

 

 17   into two categories.

 

 18             Firstly, those manufactured without

 

 19   ex-vivo culture methodology, that is, the cells are

 

 20   harvested from humans, processed, and then

 

 21   delivered to a recipient without maintaining the

 

 22   cells in culture for a period of time.

 

 23             In general, these cells consist of bone

 

 24   marrow mononuclear cells and certain peripheral

 

 25   blood mononuclear cells, hematopoietic progenitor

 

                                                                21

 

  1   cells that are variously referred to as stem cells,

 

  2   cells thought to be capable of assuming phenotypic

 

  3   characteristics of non-hematopoietic cells.

 

  4             The second category consists of cells

 

  5   that, following harvesting, are maintained in ex

 

  6   vivo culture for a period of time before final

 

  7   processing and administration.

 

  8             In general, these cells consist of those

 

  9   derived from skeletal muscle tissue, cells

 

 10   frequently referred to as myoblasts, and certain

 

 11   bone marrow stromal cells, cells also referred to

 

 12   as mesenchymal cells.  Whether these cultured cells

 

 13   should be regarded as forms of stem cells is more

 

 14   questionable than that for the hematopoietic

 

 15   progenitor cells.

 

 16             Lastly, as the slide notes, most of the

 

 17   cellular products we will be discussing today and

 

 18   tomorrow are of autologous origin.

 

 19             [Slide.]

 

 20             The many questions surrounding the

 

 21   scientific basis for cellular product development

 

 22   illustrate the very nascent nature of the field.

 

 23   As we are probably all aware, there is almost no

 

 24   precedent for the clinical development of products

 

 25   intended to regenerate and/or augment disease

 

                                                                22

 

  1   tissue.

 

  2             The scientific data surrounding this field

 

  3   are relatively new, such that the data are limited

 

  4   in depth and the extent of replication.  Hence we

 

  5   come to the table of clinical development with many

 

  6   hypothetical considerations and some, but

 

  7   relatively limited background supportive data.

 

  8             [Slide.]

 

  9             Given these limitations, our discussions

 

 10   today and tomorrow assume a scientific focus in

 

 11   which certain insights and perspectives are

 

 12   presented, and you, the committee members, will be

 

 13   asked to share your thoughts.  Three points are

 

 14   cited here.

 

 15             First, we acknowledge that these thoughts

 

 16   are all tentative and susceptible to revision based

 

 17   on accumulating data.

 

 18             Secondly, we are not requesting any

 

 19   definitive assessment of data, and we note that the

 

 20   data presented here today are within the public

 

 21   arena, and have not undergone FDA vetting.

 

 22             Finally, I reiterate an earlier comment,

 

 23   that no specific cellular product discussed here is

 

 24   under review with respect to regulatory

 

 25   decisionmaking.

 

                                                                23

 

  1             [Slide.]

 

  2             This slide illustrates the

 

  3   interconnectedness of clinical research and

 

  4   regulatory paradigms.  The connecting link between

 

  5   the two fields is the science.  Clinical research

 

  6   generates the scientific background for clinical

 

  7   development of cellular products and the scientific

 

  8   background forms the major basis for our regulatory

 

  9   paradigms.

 

 10             [Slide.]

 

 11             FDA is charged with many responsibilities,

 

 12   but as cited here, two are especially relevant to

 

 13   this discussion. Specifically, FDA's mission is to

 

 14   promote and protect the public health by optimizing

 

 15   pre-market product development and ensuring

 

 16   sufficient post-marketing product monitoring.

 

 17             The key word in these two statements is

 

 18   "product." A notation that whereas we frequently

 

 19   hear the terms transplant, graft, and procedure, we

 

 20   need to think in terms of a cellular product, a

 

 21   product that is manufactured, labeled, and

 

 22   potentially marketed.

 

 23             [Slide.]

 

 24             A little over 10 years ago, FDA clarified

 

 25   the regulatory basis for oversight of clinical

 

                                                                24

 

  1   development programs for cellular products.  In

 

  2   general, this regulatory framework is the same as

 

  3   that for the drugs and biologic products we

 

  4   commonly recognize as marketed products.

 

  5             Hence, the commonly cited biologic

 

  6   product, drug, and device regulations applied to

 

  7   the clinical development of these cellular

 

  8   products, and the clinical studies must be

 

  9   conducted under the purview of submission of a

 

 10   investigational new drug application.

 

 11             The last bullet on this slide reminds us

 

 12   that clinical development programs may be divided

 

 13   into early and late stages, with the late stages

 

 14   focused upon the ascertainment of data definitive

 

 15   to safety and efficacy, and the early stage, what

 

 16   we are talking about today and tomorrow, focused

 

 17   upon the ascertainment of exploratory safety and

 

 18   bioactivity data.

 

 19             That is, we hope to examine the nature and

 

 20   extent of background data necessary to introduce

 

 21   the cellular products into small, sample size,

 

 22   Phase I clinical studies.

 

 23             [Slide.]

 

 24             As previously noted, the keystone

 

 25   consideration in early clinical development is

 

                                                                25

 

  1   safety.  Specifically, we need to ensure that the

 

  2   tripod of product development is solid. That tripod

 

  3   consists of manufacturing control and testing

 

  4   information, sufficient preclinical testing

 

  5   information, especially information that may inform

 

  6   the design of a clinical study, and finally, the

 

  7   clinical study itself.

 

  8             The next few slides will cite each of

 

  9   these three components.

 

 10             [Slide.]

 

 11             Cellular products must be manufactured in

 

 12   some manner, that is, the cells must be harvested

 

 13   and processed prior to administration to a

 

 14   recipient.  Manufacturing aspects may be divided

 

 15   among four major areas, three being shown on this

 

 16   slide.

 

 17             The top bullet notes that documents should

 

 18   describe the cell source and reagents used in the

 

 19   manufacturing process, such as growth factors,

 

 20   sera, salt solutions and additives.  We need to be

 

 21   confident that all the reagents used in the

 

 22   manufacturing are of clinical or pharmaceutical

 

 23   grade, or that if they are not pharmaceutical

 

 24   grade, they are sufficient for human use.

 

 25             One may envision many potential concerns

 

                                                                26

 

  1   with these materials, such as the use of sera that

 

  2   may contain infections agents, or the use of only

 

  3   partially purified reagents that contain harmful

 

  4   excipients.

 

  5             Secondly, documents should describe the

 

  6   procedures used in manufacturing, specifically

 

  7   describing how cells are aseptically harvested,

 

  8   isolated, and potentially selected.

 

  9             For example, a distinct population of

 

 10   cells may be selected based upon the presence of

 

 11   certain cell surface markers, such as the CD34

 

 12   antigen with the selection process involving

 

 13   incubation with an antibody to CD34.

 

 14             As we know, many investigational

 

 15   antibodies have been developed to target cell

 

 16   surface antigens, and we need to be confident that

 

 17   these selection techniques are performed in a

 

 18   reproducible and safe manner.

 

 19             Additionally, documents should describe

 

 20   the storage and tracking of the cellular products,

 

 21   this being of special concern because certain

 

 22   cellular products may be patient-specific products.

 

 23             For example, measures must be in place to

 

 24   ensure that for autologous products, the cellular

 

 25   product is returned to the correct donor.  Of

 

                                                                27

 

  1   course, the cellular product needs to be labeled as

 

  2   one for investigational use only.

 

  3             The bullet at the bottom of this slide

 

  4   emphasizes the importance of testing the cellular

 

  5   product, an especially important concern since

 

  6   cellular products cannot be sterilized in the same

 

  7   manner as one might sterilize a drug product or a

 

  8   device.  Notable aspects of testing include tests

 

  9   for sterility, endotoxin, viability, enumeration,

 

 10   or cell counting.

 

 11             [Slide.]

 

 12             The fourth component of manufacturing

 

 13   information is product characterization as

 

 14   highlighted here.  When one speaks of product

 

 15   characterization, we are generally talking about

 

 16   cellular phenotype and/or functional

 

 17   characterization and the characteristics of the

 

 18   product's final formulation.

 

 19             For example, a product containing solely

 

 20   CD34 positive cells in saline with no preservatives

 

 21   or media. Product characterization is especially

 

 22   important from a clinical perspective, because

 

 23   failure to consistently manufacture a product makes

 

 24   the clinical data virtually uninterpretable.

 

 25             As noted here, the major aspects of

 

                                                                28

 

  1   product characterization consist of a description

 

  2   of identity, purity, and potency of the final

 

  3   cellular product.

 

  4             [Slide.]

 

  5             Pre-clinical testing is the second major

 

  6   component of product development, and the major

 

  7   aspects of this testing are cited here.  The top

 

  8   bullet notes that consistent with the science, the

 

  9   extent and depth of preclinical testing necessary

 

 10   to support a clinical study is an evolving paradigm

 

 11   and is a major topic for discussion at this

 

 12   meeting.  However, we generally take the stance

 

 13   that this preclinical testing paradigm should be

 

 14   consistent with that used for other biological

 

 15   products.

 

 16             The last bullet notes another important

 

 17   aspect of preclinical testing, the testing of the

 

 18   product administration procedure.

 

 19             This is especially important because many

 

 20   cellular products involve injection directly into

 

 21   heart muscle either through the epicardial surface

 

 22   or the endocardial surface.  These techniques

 

 23   represent inherent safety concerns that may be best

 

 24   evaluated in animals prior to their use in humans.

 

 25             As noted, all available catheters, whether

 

                                                                29

 

  1   marketed or not, are regarded as investigational

 

  2   with respect to administration of cellular

 

  3   products.

 

  4             [Slide.]

 

  5             This slide highlights three aspects of

 

  6   preclinical testing that will be the focus of the

 

  7   preclinical questions tomorrow.

 

  8             Firstly, the choice of the relevant

 

  9   species is central to designing preclinical studies

 

 10   with the major choices being between large animals,

 

 11   such as pigs, versus small animals, such as mice,

 

 12   as well as the choice between immunocompetent

 

 13   animals where, for autologous products, the

 

 14   cellular products would be the animal cells, not

 

 15   human cells, or immunocompromised animals, where

 

 16   the actual human cellular product may be tested.

 

 17             Secondly, designing preclinical studies

 

 18   raise questions of the choice of model, that is, a

 

 19   disease model, such as ischemic heart disease

 

 20   induced in the pig versus a healthy animal.

 

 21             Lastly, preclinical concerns relate to

 

 22   testing of the administration procedure itself,

 

 23   such items as the impact of the catheter materials

 

 24   upon cells, the potential for occlusion of

 

 25   catheters by the cellular product, and the safety

 

                                                                30

 

  1   concerns associated with manipulation of the

 

  2   catheters in the heart.

 

  3             [Slide.]

 

  4             The third component of the clinical

 

  5   development program for cellular products is the

 

  6   clinical study.  There are many aspects of clinical

 

  7   study design that could be discussed, but at this

 

  8   meeting, we are focusing upon two, the first shown

 

  9   here, that is, adverse event detection.

 

 10             This slide highlights two aspects of

 

 11   clinical study design that are frequently

 

 12   engineered to optimize adverse event detection, the

 

 13   evaluation plan with attention to the duration of

 

 14   clinical follow-up, the frequency of evaluations,

 

 15   and the extent or nature of these evaluations.

 

 16             Secondly, the clinical study safety

 

 17   monitoring plan may be optimized through the use of

 

 18   close scrutiny of each study subject based upon the

 

 19   sequential, not simultaneous, enrollment and

 

 20   treatment of the subjects, as well as the

 

 21   prespecifications of the types and numbers of

 

 22   adverse events that should prompt interruption of

 

 23   the study, that is, the study stopping rules.

 

 24             Tomorrow, the committee will be asked to

 

 25   discuss potential adverse events in these early

 

                                                                31

 

  1   clinical studies, both the nature of the events and

 

  2   ways to optimize the safety of the studies.

 

  3             [Slide.]

 

  4             This slide illustrates an additional

 

  5   clinical study design item that we will bring to

 

  6   the committee, that is, a discussion of the

 

  7   analysis of adverse events.

 

  8             Exploratory clinical studies are, by their

 

  9   nature, small sample size studies in which it is

 

 10   often difficult or impossible to distinguish

 

 11   treatment-related events from adverse events that

 

 12   might occur in the natural history of the disease,

 

 13   potential study design mechanisms that might help,

 

 14   but certainly not resolve this issue are cited in

 

 15   the bullets, design features that incorporate

 

 16   randomization of subjects among groups, such that

 

 17   comparisons may be made, the use of controls,

 

 18   especially placebo controls, to make comparisons,

 

 19   the use of masking or blinding to help lessen the

 

 20   bias associated with concomitant therapies or

 

 21   clinical care.

 

 22             Tomorrow, the committee will be asked to

 

 23   discuss mechanisms that might aid in adverse event

 

 24   attribution.

 

 25             [Slide.]

 

                                                                32

 

  1             In this presentation, we have covered

 

  2   three major topics.  Firstly, we have noted that

 

  3   the focus of this meeting is upon a discussion of

 

  4   the scientific aspects of early cellular product

 

  5   development.

 

  6             Secondly, we have noted the regulatory

 

  7   precedent for the cellular products.

 

  8             Finally, we come to the questions.

 

  9             [Slide.]

 

 10             This slide highlights the four major areas

 

 11   of tomorrow's questions.  Specifically, questions

 

 12   related to manufacturing, we will request a

 

 13   discussion of the extent of safety testing and

 

 14   characterization that should be performed prior to

 

 15   the release of a cellular product for

 

 16   administration to humans.

 

 17             The second and third discussion areas are

 

 18   especially critical and may consume the bulk of our

 

 19   time, that is, the extent and nature of preclinical

 

 20   testing necessary to support the introduction of a

 

 21   cellular product into humans, testing that involves

 

 22   questions related to the product itself, as well as

 

 23   the delivery mechanism, the catheter.

 

 24             Finally, we will pose clinical questions

 

 25   centered around adverse event detection and

 

                                                                33

 

  1   analysis with a discussion of the pros and cons

 

  2   associated with the use of controls in these

 

  3   studies.

 

  4             [Slide.]

 

  5             Our agenda is summarized on this slide.

 

  6   As you can see, today, we have a series of invited

 

  7   presentations by FDA staff and leading

 

  8   investigators in the field, as well as the

 

  9   opportunity for public presentations.

 

 10             Tomorrow, we will have another opportunity

 

 11   for public presentations followed by a discussion

 

 12   of the questions.

 

 13             [Slide.]

 

 14             In closing, listed here are some documents

 

 15   that are especially pertinent to our discussions.

 

 16   All these documents are available at www.fda.gov

 

 17   under the CBER sites, specifically the guidance

 

 18   section.

 

 19             The first document is entitled "Draft

 

 20   Guidance for CMC Reviewers: Human Somatic Cell

 

 21   Therapy Investigational New Drug Applications."

 

 22   This document describes the types of information

 

 23   FDA reviewers will examine following the submission

 

 24   of an IND.  Consequently, it provides a very clear

 

 25   description of the types of manufacturing

 

                                                                34

 

  1   information that needs to be submitted with an IND

 

  2   application.

 

  3             The second document is from the

 

  4   International Conference on Harmonization of

 

  5   Regulatory Practices, and it is entitled "

 

  6   Preclinical Safety Evaluation of

 

  7   Biotechnology-derived Pharmaceutics," the S6

 

  8   document.

 

  9             This document is cited because it contains

 

 10   a paradigm that one may apply to cellular products.

 

 11             Finally, the last bullet cites one of the

 

 12   most useful guidances to sponsors and

 

 13   investigators, the ICH Guideline on Good Clinical

 

 14   Practice.

 

 15             This guideline provides detailed

 

 16   information on how to design and conduct a clinical

 

 17   study, information presented in a simple to read,

 

 18   yet relatively comprehensive format.

 

 19             This concludes my presentation and I thank

 

 20   you for your attention.

 

 21             [Applause.]

 

 22             DR. RAO:  Before we continue with the rest

 

 23   of the presentations, I would like to just welcome

 

 24   Dr. Harlan and ask him to introduce himself.

 

 25             DR. HARLAN:  I apologize for being late,

 

                                                                35

 

  1   but I am David Harlan, NIDDK.  I study

 

  2   transplantation of islets and immunotherapies.

 

  3             DR. RAO:  Our first speaker will be Dr.

 

  4   Perin, whom you already were introduced to.

 

  5                        Guest Presentations

 

  6        Overview Cardiomyopathy and Ischemic Heart Disease

 

  7             DR. PERIN:  I want to thank you for the

 

  8   invitation to be here to present to you today,

 

  9   especially Dr. Grant, who has helped me put this

 

 10   together in a way.

 

 11             So, what I want to do here this morning,

 

 12   the task that has been laid before me is that of in

 

 13   a way setting the stage or giving you a general

 

 14   idea of the kinds of patients that we are treating.

 

 15             Obviously, this is fundamental if we are

 

 16   thinking about doing clinical trials.  It is very

 

 17   important to understand the nature of the disease

 

 18   in which these kind of therapies will frequently be

 

 19   applied.

 

 20             What I plan to do is talk about the

 

 21   following topics.  First, we will start from the

 

 22   beginning, define what heart failure is, look at

 

 23   the scope of heart failure, talk a little bit about

 

 24   the pathophysiology, look at some prognostic

 

 25   markers, talk about the treatment to some extent 

 

                                                                36

 

  1   and that is important in terms of monitoring, and

 

  2   then really work our way towards end stage heart

 

  3   failure because that is where I think the focus of

 

  4   most of the future clinical trials will likely be

 

  5   initially, and finally, talk about adverse events,

 

  6   which I think is a major concern, and the

 

  7   monitoring of there adverse events.

 

  8             Now, I know many of you are not

 

  9   cardiologists, so hopefully, I can go from a level

 

 10   where we are not getting too complicated, but not

 

 11   too simple.

 

 12             Starting with the definition of what heart

 

 13   failure is.  Firstly, heart failure is a clinical

 

 14   syndrome very simply defined by certain symptoms

 

 15   and certain signs that come together.  These

 

 16   symptoms are fatigue, shortness of breath, and

 

 17   congestion, and these are translated on a physical

 

 18   exam by being able to hear a third heart sound, the

 

 19   patient manifesting peripheral edema, and jugular

 

 20   venous distention.

 

 21              If we start looking at this problem and

 

 22   have a broad overview of this, first, I want to

 

 23   show you a graph from the HOPE trial.  This is a

 

 24   trial that was conducted in thousands of patients,

 

 25   as you can see here, over 9,000 patients.  It was a

 

                                                                37

 

  1   study primarily of ramipril and vitamin E in

 

  2   patients with hypertension over a long period of

 

  3   time, involved a five-year follow-up.

 

  4             But it is just very interesting, as we

 

  5   start out looking at heart failure, to look at this

 

  6   patient population, and here we have over 500 days,

 

  7   so here is about a year out, and if we look at this

 

  8   population, who is not primarily designated as

 

  9   particularly sick or harboring heart failure, that

 

 10   identified the patients that did have heart failure

 

 11   and we look at their survival, you will see the

 

 12   mortality.

 

 13             It separates from the beginning, and when

 

 14   we get out to about a year, you have got a 10

 

 15   percent mortality in the group that has heart

 

 16   failure compared to less than 4 percent mortality

 

 17   in the general population.  So, you can see that

 

 18   the problem that we are dealing with seems to be

 

 19   very serious.

 

 20             If we go here and let's just look at the

 

 21   placebo arms of some very large heart failure

 

 22   trials, these are trials pretty much aimed at

 

 23   evaluating different forms of therapy now in heart

 

 24   failure patients, and looking at different severity

 

 25   of heart failure patients, for example, in the

 

                                                                38

 

  1   V-HeFT trial, inclusion criteria might be an

 

  2   ejection fraction less than 40 percent.

 

  3             If we look at PRAISE, which evaluated

 

  4   amlodipine in more severe heart failure, an

 

  5   ejection fraction was less than 30 percent,

 

  6   comparing this with Class III and Class IV

 

  7   patients, very sick patients.

 

  8             So, you can see here if we look at just

 

  9   the placebo arms of all these trials, a very

 

 10   striking mortality as we go along.  If we look at 1

 

 11   year here, this will vary from 10 percent down to

 

 12   around 30 percent.

 

 13             If we go out to 2 years in the very sick

 

 14   patients, we see that half of the patients are

 

 15   dead.  So, heart failure, depending on the

 

 16   presentation, carries a very ominous prognosis.

 

 17             It is a very broad problem, 5 million

 

 18   Americans are living with heart failure now,

 

 19   550,000 new cases are diagnosed each year.

 

 20             From 1979 to 2000, heart failure deaths

 

 21   increased by 148 percent.  Now, what is

 

 22   interesting, over this period of time, we have

 

 23   actually gotten a lot better at treating heart

 

 24   failure, and we do treat it. I will get into this a

 

 25   little later, and I will show you the modern treat

 

                                                                39

 

  1   of heart failure and how much better we are doing,

 

  2   but at the same time that we are treating heart

 

  3   failure better, we are also treating the patients

 

  4   that have coronary disease, which is a very

 

  5   dominant problem in this country and around the

 

  6   world,  we are treating those patients better, too,

 

  7   so what happens is we are getting more patients

 

  8   with heart disease that normally would have died

 

  9   earlier, to live longer, and as we are able to

 

 10   bypass and stent and do all these revascularization

 

 11   procedures and come up with better treatments, we

 

 12   are getting people that go further down the road,

 

 13   that otherwise would have succumbed a long time

 

 14   ago.

 

 15             So, despite our improvements in treatment

 

 16   of coronary disease, we are dealing with an

 

 17   increasing amount of heart failure deaths.

 

 18             In individuals diagnosed with heart

 

 19   failure, cardiac death occurs at 6 to 9 times the

 

 20   rate in the general population.  If you are more

 

 21   than 40 years old, you have a 1 in 5 chance of

 

 22   developing heart failure, and 22 percent of men and

 

 23   46 percent of women that have heart attacks will be

 

 24   disabled within 6 years with heart failure.

 

 25             So, as you can imagine, the high

 

                                                                40

 

  1   prevalence and multiple complications have an

 

  2   implication in terms of health costs.  If we look

 

  3   at the costs, and these numbers vary, and it

 

  4   depends on what you are looking at and what year

 

  5   you are looking at, but this is a very significant

 

  6   financial burden on the country, over 5 percent of

 

  7   the total health care costs.

 

  8             You can see that most of the cost involved

 

  9   is really involved in inpatient care, and as I will

 

 10   show you hopefully, that really translates to the

 

 11   sickest portions of these patients, that as you get

 

 12   sicker with heart failure, you start coming into

 

 13   the hospital more, and that is what runs up the

 

 14   cost of treating these patients.  It is interesting

 

 15   that transplant is just a little sliver out of the

 

 16   pie here.

 

 17             So, let's look at the causes of heart

 

 18   failure, and I am not going to get into all the

 

 19   little minor details, but let's look at the major

 

 20   causes of what brings on heart failure.

 

 21             Seventy-five percent of people that go on

 

 22   to develop heart failure had hypertension

 

 23   previously.  Valvular heart disease is a big

 

 24   contributor and also heart failure engenders

 

 25   valvular heart disease, mitral regurgitation

 

                                                                41

 

  1   further contributes to the problem.

 

  2             Coronary artery disease, you are all

 

  3   familiar with this, the number one problem in this

 

  4   country, and this is really what we are going to

 

  5   focus majorly on in terms of causing heart failure

 

  6   and the specific kind of heart failure that this

 

  7   engenders.

 

  8             In cardiomyopathy, there is many different

 

  9   kinds of things that get a heart to perform poorly,

 

 10   all the way from an idiopathic cardiomyopathy to

 

 11   such things as iron overload, et cetera, which are

 

 12   not as common.

 

 13             Now, what I want to talk about here is

 

 14   really systolic heart failure.  There is something

 

 15   called diastolic heart failure, and that really has

 

 16   a lot to do with compliance problems of the

 

 17   ventricle, and in these patients, we are going to

 

 18   see a normal ejection fraction.

 

 19             So, this is really a different animal and

 

 20   it is really not what we are focusing on, so what I

 

 21   am going to be talking about today is systolic

 

 22   heart failure, and as I will show you, with the

 

 23   hallmark being a low left ventricular ejection

 

 24   fraction.

 

 25             This is just to give you a practical

 

                                                                42

 

  1   example.  This is an angiogram from one of the

 

  2   patients that we treated with stem cell therapy in

 

  3   Brazil, who all had an ejection fraction that

 

  4   averaged about 20 percent.  This patient has an

 

  5   ejection fraction of 10 percent.

 

  6             You can see the coronaries are calcified.

 

  7   This is a catheter in the left ventricle.  This

 

  8   heart is supposed to be pumping this contrast we

 

  9   just put into the aorta.  As you can see, it is not

 

 10   doing that very well at all.  Only 10 percent of

 

 11   what is in here gets out with each beat.

 

 12             So, you can tell this is a dilated big

 

 13   heart that just doesn't contract well.  That is the

 

 14   picture of severe heart failure right there, and

 

 15   this is what I want to talk about.

 

 16             Now, when we talk about heart failure, I

 

 17   think everybody is aware of the classification.

 

 18   There is Class I, II, III, IV, which are commonly

 

 19   used, but it is important to acknowledge this.

 

 20   Class I involves no limitation of physical

 

 21   activity, Class II slight limitations, Class III

 

 22   marked limitations, you can't walk up a flight of

 

 23   stairs without getting short of breath, and Class

 

 24   IV, you have symptoms at rest.

 

 25             If we look at this, if we put Class III

 

                                                                43

 

  1   and Class IV together, you see the division is

 

  2   about a third for each of these pieces of the pie

 

  3   here.

 

  4             Now, if somebody comes in with Class IV

 

  5   heart failure, they are very short of breath at

 

  6   rest, you can give them some diuretics and they

 

  7   will feel better.  They are not Class IV anymore,

 

  8   they are Class III.

 

  9             So, it is interesting, there has been a

 

 10   want in development of a little different way of

 

 11   looking at heart failure, and a staging or

 

 12   classification put out by joint AHA and ACC shows

 

 13   four different stages, and really looks at heart

 

 14   failure more like a disease like cancer.

 

 15             So, where we can identify patients that

 

 16   are at high risk of developing it, we can screen

 

 17   patients, and then we can start treating patients

 

 18   before they really manifest symptoms of the

 

 19   disease.

 

 20             Again, this is a progressive disease and

 

 21   we are going to end up with people that are

 

 22   refractory even to all kinds of treatment.  I am

 

 23   going to go over this a little bit more in detail a

 

 24   little later.

 

 25             So, in defining what heart failure is, I

 

                                                                44

 

  1   hope I have given you a general idea of the scope

 

  2   of the problem, just talk a little bit about what

 

  3   causes it because it is important to understand

 

  4   that to be able to know how we treat it and how we

 

  5   monitor these patients.

 

  6             Usually, we are talking about ischemic

 

  7   heart disease and we are dealing with a myocardial

 

  8   insult, which is usually a heart attack, so that

 

  9   heart attack causes damage to the heart muscle, and

 

 10   that is going to result in dysfunction of that

 

 11   heart muscle.

 

 12             Well, the body is going to try to

 

 13   compensate this dysfunction and especially in two

 

 14   major ways.  One is neurohumoral activation, so we

 

 15   will talk a little bit about this in more detail,

 

 16   but essentially, these compensatory mechanisms are

 

 17   going to make the heart change its shape and its

 

 18   size.  It is something we call remodeling.  It

 

 19   involves hypertrophy of the myocytes and then it

 

 20   involves fibrosis and dilatation.

 

 21             So, these mechanisms that the body helps,

 

 22   to try to help to reverse what is going on,

 

 23   actually wind up causing toxicity, hemodynamic

 

 24   alterations that all lead to remodeling, and

 

 25   remodeling really is the hallmark.

 

                                                                45

 

  1             You saw that big heart.  Well, remodeling

 

  2   is how you get from a normal small heart, which you

 

  3   have, to a big boggy heart that doesn't contract.

 

  4   That is the problem of heart failure.

 

  5             This was very simply put by Doug Mann in a

 

  6   nice editorial a few years ago.  Basically, here is

 

  7   the heart over time, as we have an index event, and

 

  8   basically, remodeling occurs, the heart gets

 

  9   bigger, the ejection fraction goes down as time

 

 10   goes by and symptoms occur as time progresses, as

 

 11   well.

 

 12             So, I have told you we have a myocardial

 

 13   insult. This leads to LV dysfunction and

 

 14   remodeling, and this really instigates a

 

 15   neurohumoral response.  In return, this is going to

 

 16   have an impact on remodeling again.

 

 17             So, what are these neurohumoral things

 

 18   that happen?  Well, first of all, most importantly,

 

 19   is the renin- angiotensin-aldosterone system, and

 

 20   there are several points in which the body

 

 21   upregulates the system and ultimately, it acts on

 

 22   the AT-1 receptor, which will cause

 

 23   vasoconstriction, proteinuria, again LV remodeling.

 

 24             As you can identify, here are several

 

 25   sites in which medications, the mainstay of some of

 

                                                                46

 

  1   the therapy for heart failure works, namely ACE

 

  2   inhibitors that work at this point, ARBs that work

 

  3   at this point, beta blockers have a role in

 

  4   inhibiting renin, as well.  So, some of the

 

  5   mainstay of therapy is actually directed at one of

 

  6   these mechanisms of compensation.

 

  7             On the other side, we have sympathetic

 

  8   activation. We have increased sympathetic activity

 

  9   that again leads to myocardial toxicity and

 

 10   arrhythmias, and then on the other side, with the

 

 11   sympathetic outflow, we get vasoconstriction. This

 

 12   impacts negatively on the kidney, sodium retention,

 

 13   more vasoconstriction, and progression of the

 

 14   disease.

 

 15             Just to get a slightly little bit more

 

 16   complicated, just to mention that it is really not

 

 17   all that simple, there are other things involved,

 

 18   and we have cytokines, TNF-alpha, IL-6,

 

 19   inflammation that actually progresses with the

 

 20   progression of heart failure.

 

 21             Endothelin is a potent vasoconstrictor.

 

 22   All these things lead to apoptosis and unfavorable

 

 23   effects upon the myocyte, but then lead to LV

 

 24   remodeling, which I have told you is one of the

 

 25   mainstays of reasons for heart failure.

 

                                                                47

 

  1              Now, natruretic peptides are important,

 

  2   as well. It's another compensatory mechanism that

 

  3   the body has.  I am sure you are familiar with

 

  4   these BNP, it's a B-type natruretic protein that

 

  5   actually comes from the ventricle, the A types

 

  6   comes from the atrium.  We will just focus on the B

 

  7   type.

 

  8             What this does, basically, in response to

 

  9   elevated pressure inside the heart, we secrete BNP.

 

 10   This suppresses the renin-angiotensin-aldosterone

 

 11   system and suppresses endothelin.  It helps with

 

 12   peripheral vascular resistances, decreases

 

 13   vasodilatation, and it increases natruresis.

 

 14             So, if we go on to understand now that

 

 15   there is an interplay between LV dysfunction and

 

 16   remodeling, and that basically, this will lead to

 

 17   low ejection fraction, and that is what we see in

 

 18   the patients.

 

 19             On the other hand, as a result of this, we

 

 20   will start getting a constellation of symptoms, and

 

 21   it is the combination of having a low ejection

 

 22   fraction and symptoms that defines heart failure.

 

 23             Let's look a little bit at the prognostic

 

 24   markers. I just talked a little bit about BNP.

 

 25   Well, it is very interesting.  If we divide BNP in

 

                                                                48

 

  1   quartiles here, depending on the amount of BNP that

 

  2   you have circulating, your survival will go down.

 

  3   It is a prognostic marker, as well as a treatment.

 

  4   Norepinephrine, the same way.  So, these are

 

  5   markers of prognosis.

 

  6             It is very interesting.  These are levels

 

  7   of BNP, and if you can decrease them, decrease to a

 

  8   less degree, or here, we have an increase.  So,

 

  9   depending on which direction your BNP goes, your

 

 10   survival varies as well, and that is an important

 

 11   concept.

 

 12             Let's look at another different kind of

 

 13   marker. Exercise capacity, peak oxygen consumption.

 

 14   In the transplant world, this is very important.

 

 15   Here you see the number 14, so a peak oxygen

 

 16   consumption greater than 14 or less than 14 has

 

 17   very different prognostic indicators and in many

 

 18   centers, this serves as a marker threshold for one

 

 19   of the criteria for entering the patient into a

 

 20   transplant program.

 

 21             You can see here a difference in mortality

 

 22   from 53 percent mortality over two years in

 

 23   patients that have an NVO2 of less than 14, to that

 

 24   of 11 with greater than 14, so this is another

 

 25   important number in patients with heart failure.

 

                                                                49

 

  1             Then, if we look overall and look at

 

  2   symptoms and hospitalizations, here is a New York

 

  3   Heart Class I to IV, and this is fairly intuitive,

 

  4   but as we get more symptomatic, we have an impact

 

  5   on survival, and as we are getting more

 

  6   symptomatic, we have an increase in

 

  7   rehospitalization.

 

  8             What about ejection fraction?  I just

 

  9   talked about ejection fraction, and you can see

 

 10   here, similarly to NVO2, ejection fraction can

 

 11   divide prognostically how patients will do.  Here

 

 12   we see more than 20 percent, less than 20 percent.

 

 13   Here you see a two-year survival, 54 percent, so

 

 14   half the people dying that have an ejection

 

 15   fraction less than 20 percent.  At one year, that

 

 16   is a little over 20 percent.

 

 17             The same thing, this is a large randomized

 

 18   clinical trial, ejection fraction less than 40

 

 19   percent.  Over time, people die more frequently.

 

 20             Now, let's add a little arrhythmia to

 

 21   this.  Looking at different levels, the first two

 

 22   are greater than 30 percent ejection fraction, here

 

 23   less than 30 percent, so that stratifies that out,

 

 24   but then if we just add the amount of extra

 

 25   ventricular beats to this, and if we have less than

 

                                                                50

 

  1   10 per hour, more than 10 per hour, and then with a

 

  2   poorly contractile ventricle, your survival goes

 

  3   down as we add extra ventricular beats.

 

  4             One attempt that has been made to sort of

 

  5   graph this problem, because now I have shown you

 

  6   many different prognostic markers and different

 

  7   things we can use to classify these patients to

 

  8   decide what to do and how to follow them.

 

  9             One of them is a heart failure survival

 

 10   score.  There is an invasive model, there is a

 

 11   non-invasive model.  So, things like cause of heart

 

 12   failure, resting heart rate, EF, mean blood

 

 13   pressure, if there is a conduction delay

 

 14   electrically in the heart, oxygen consumption, and

 

 15   serum sodium can enter into a risk classification.

 

 16             Here, you just basically have a graph that

 

 17   shows according to low, medium, and high, your

 

 18   survival will vary according to the risk.

 

 19             In our little schema here, that leads

 

 20   symptoms and low ejection fraction to heart

 

 21   failure, what are really the things, though, that

 

 22   are driving mortality?  They are going to be pump

 

 23   failure, on the one hand, and arrhythmia, on the

 

 24   other, because sudden death, as I talked to you

 

 25   about before, is a very prominent problem in people

 

                                                                51

 

  1   that have heart failure.

 

  2             So, it is the combination of these three

 

  3   things that will pretty much drive patients to a

 

  4   lethal exit.

 

  5             Let's talk a little bit about treatment

 

  6   now.  What are the goals of treatment of heart

 

  7   failure?  You want to delay the progression or

 

  8   reverse remodeling, which you can do in some

 

  9   patients, and delay the progression and reverse

 

 10   myocardial dysfunction.

 

 11             You want to reduce mortality, relieve the

 

 12   symptoms, improve functional capacity, and reduce

 

 13   disability, also decrease the intensity of medical

 

 14   care and hopefully reduce economic cost.

 

 15             I have shown you we go from initial

 

 16   injury, initial infarct, we suffer remodeling, we

 

 17   get a remodeled heart that now has a low ejection

 

 18   fraction, and over this course of time, we have a

 

 19   worsening of symptoms, so how are we going to

 

 20   impact this in terms of treatment?

 

 21             Well, the two mainstays are neurohumoral

 

 22   blockade, we have kind of gone over some of the

 

 23   things that we can do, and we will look at those,

 

 24   and the other is revascularization.  So, many times

 

 25   with the use of medication or with the use of

 

                                                                52

 

  1   revascularization, we can reverse some of this

 

  2   remodeling in some patients, and in some patients

 

  3   we don't.

 

  4             One thing that is very important in terms

 

  5   of being able to recover patients that have

 

  6   remodeled hearts, and that are in this road of

 

  7   heart failure, is identification of viable

 

  8   myocardium.

 

  9             Myocardial viability has clearly been

 

 10   shown to influence the prognosis of people that are

 

 11   undergoing revascularization procedures, so if you

 

 12   have a viable myocardium, you are going to do

 

 13   better.  You have a chance of improving more than

 

 14   someone who doesn't.

 

 15             Just to shift gears for just a second

 

 16   here, these are electromechanical maps.  These are

 

 17   representations of the left ventricle.  This is

 

 18   from a patient in our Brazil stem cell study.

 

 19             This is an electrical map, this is a

 

 20   mechanical map.  Let's just look at the electrical

 

 21   map because I just talked to you about viability.

 

 22   Very simply, if your cells are alive, they have an

 

 23   electrical signal that is high.  If you have a big

 

 24   scar with no cells, you have no electricity, you

 

 25   have a low electrical signal.

 

                                                                53

 

  1             We put it on a little color scale.  Red is

 

  2   dead or red is very little voltage.  Purple is

 

  3   high.  Here, you see on this electromechanical map,

 

  4   an area of myocardial viability.  Again, just as it

 

  5   is important to understand viability when you are

 

  6   vascularizing patients that have heart failure,

 

  7   that have coronary disease, it is also going to be

 

  8   important, in my view, to understand myocardial

 

  9   viability when we are applying some of these

 

 10   therapies, and I think there will be differences in

 

 11   bone marrow therapies and myoblast therapy, but

 

 12   that is something to keep in mind.

 

 13             I just wanted to show you an example of

 

 14   the very common things that we deal with, so this

 

 15   is not some esoteric difficult patient to find.  We

 

 16   come across people like this all the time in the

 

 17   hospital every day.

 

 18             This is a patient who was 41 years old, he

 

 19   had bypass, he stopped up all his vein grafts and

 

 20   his memory artery, and he had ejection fraction of

 

 21   20 percent, very similar to the one that I showed

 

 22   you, and Class IV congestive heart failure.

 

 23             This gentleman was really delightful.  He

 

 24   was actually a pilot for a major airline, and

 

 25   because of his bypass, he had to be put off the

 

                                                                54

 

  1   flying, and he was actually in charge of all the

 

  2   simulators, and he was the guy that graded all the

 

  3   pilots when they had to come in and do the

 

  4   simulation testing.

 

  5             Basically, here, we have a 41-year-old

 

  6   guy, very active man who has gone bypass, he has

 

  7   lost his graft, he obviously has very aggressive

 

  8   disease, and why I hear the talk about why some

 

  9   people have more aggressive coronary disease than

 

 10   others.

 

 11             You see this is his right coronary, it is

 

 12   completely blocked up, X's mean that you can't see

 

 13   anything on angiography, so this kind of fills from

 

 14   the other side by collaterals, see these little

 

 15   twigs down here.

 

 16             Then, the circumflex is completely

 

 17   occluded.  This is a floating marginal branch.

 

 18   This is supposed to be connected, but this is

 

 19   totally occluded, as well.  The only artery he has

 

 20   got left is the one down the front of his heart,

 

 21   but this is very much infarcted, and has a very

 

 22   significant blockage here, as well as the takeoff

 

 23   of this.

 

 24             So, this patient, there is really nothing

 

 25   to do, and we are faced with this a lot every day. 

 

                                                                55

 

  1   This patient, as I have shown you these curves of

 

  2   mortality, this patient at our hospital wound up

 

  3   going for an LVAD type procedure and died, and that

 

  4   is what we see again and again, so this is a very

 

  5   serious problem.

 

  6             So, looking of an overview of treatment of

 

  7   heart failure, let's see, we have medical-based

 

  8   therapy, on one hand, we have device-based therapy,

 

  9   on the other.

 

 10             On the medical side, we need neurohumoral

 

 11   blockade, we can have a hemodynamic approach and

 

 12   also antiarrhythmic approach, so we are going to

 

 13   use these drugs, ACE inhibitors, aldosterones,

 

 14   diuretics, beta blockers, and then antiarrhythmics,

 

 15   such as amiodarone, and then we are going to use

 

 16   more potent i.v. inotropes that improve

 

 17   hemodynamics, and asaratide [ph], which is

 

 18   basically similar to BNP, it is like giving the

 

 19   patient BNP.

 

 20             On the other hand, we are going to have a

 

 21   device-based approach using resynchronization

 

 22   therapy.  It really hasn't shown a benefit in

 

 23   survival, but in combined endpoints.  We are going

 

 24   to put defibrillators into people, and I will show

 

 25   you how that has improved survival.

 

                                                                56

 

  1             Then, we will have ventricular assist

 

  2   devices, and when all this fails, we have an option

 

  3   of heart transplant, that is very little available

 

  4   actually, and as you saw, it is a very little

 

  5   sliver of what we are able to do.

 

  6             But as you cumulatively add these

 

  7   therapies, you are able to impact on survival and

 

  8   make patients live longer.  Here, you see sort of

 

  9   adding digoxin and diuretic, adding an ACE

 

 10   inhibitor, and then adding a beta blocker, we get

 

 11   progressive improvement.  So, this is pretty well

 

 12   established in terms of medical therapy.

 

 13             When we look at defibrillators, here is a

 

 14   curve. This is from the MADA-2.  This is primary

 

 15   prevention, defibrillator in patients, previous MI,

 

 16   LVF less than 30 percent, a very significant

 

 17   survival difference in the patients that get a

 

 18   defibrillator, so treating the arrhythmias is also

 

 19   important.

 

 20             Back to our schema of the different

 

 21   classification of stages of heart failure.  You see

 

 22   that we can gradually, we start with ACE inhibitors

 

 23   and gradually add different medications, but

 

 24   everybody kind of goes up these stairs and ends up

 

 25   here at the top, and that is why we have increasing

 

                                                                57

 

  1   mortality from heart failure, because we are

 

  2   getting people to get to this point where before

 

  3   they really didn't reach that stage.

 

  4             Then, we get to a stage of basically

 

  5   refractory symptoms, so they have been bypassed,

 

  6   they have had stents, everything has been done for

 

  7   them, and they have that bad heart, it doesn't pump

 

  8   well, they have a lot of symptoms, they can't

 

  9   breathe very well.  Many of them have angina.  I

 

 10   want to want to give you a little bit of my own

 

 11   perspective on that.

 

 12             If we look at current trends, this was

 

 13   published last week in JACC, very interesting.

 

 14   Heart failure treatment--this is the survival

 

 15   curves--heart failure treatment in 1994 to 1997.

 

 16   Here is a survival curve.  We have improved the

 

 17   treatment of heart failure.

 

 18             1999 to 2001, gee, we are doing a lot

 

 19   better, and this is comparable actually to

 

 20   transplant from 1993 to 2000, and it really raises

 

 21   the question if transplant, with the modern

 

 22   management in medical management of heart failure,

 

 23   how important is it and what the role of transplant

 

 24   really is.

 

 25             Really, there is a gap between a very

 

                                                                58

 

  1   invasive transplant or LVAD and the medical

 

  2   therapy, there really is, and we are here to talk

 

  3   about stem cell therapy.  There is a gap of

 

  4   something that could be done that is not quite as

 

  5   invasive and traumatic as an LVAD or transplant,

 

  6   and that can improve the patient significantly

 

  7   since we are doing so well with medical therapy.

 

  8             I want to talk to you a little bit about

 

  9   my perspective on end-stage ischemic heart disease.

 

 10   Basically, as I have told you, we have improved the

 

 11   medical management, so we have longer survival, we

 

 12   have improved the vascularization treatments of

 

 13   coronary disease, we have improved the survival

 

 14   following a heart attack, and that is why we have

 

 15   more patients, and now we are using widely

 

 16   defibrillators, and that is why people are living

 

 17   longer.

 

 18             So, this is sort of my understanding of

 

 19   this end-stage patient.  You progress with coronary

 

 20   disease until you get to the Stage III and Stage

 

 21   IV, Class III/Class IV heart failure.

 

 22             If we look at these patients, sometimes

 

 23   there will be a little surprise, because some

 

 24   patients really just have shortness of breath, so

 

 25   this is a variable.  This may occupy the whole

 

                                                                59

 

  1   square or angina may occupy the whole square.

 

  2             So, some patients predominantly have heart

 

  3   failure, and these patients that predominantly have

 

  4   heart failure probably weren't very good at forming

 

  5   collaterals when they had heart attacks and

 

  6   developed a lot of scar tissue, and have a very low

 

  7   ejection fraction.  These are the sickest patients

 

  8   and the patients that are going to have a very high

 

  9   mortality.

 

 10             On the other hand, but also in the Class

 

 11   III or Class IV, and sometimes we pool these people

 

 12   together in trials and that is why I am making this

 

 13   distinction, some people have angina more than they

 

 14   have heart failure.  These probably have a much

 

 15   better collateral formation when they had these

 

 16   events, so their ejection fraction is a little more

 

 17   preserved.

 

 18             I have had many patients that have lived

 

 19   on one artery.  Their whole heart is beating okay.

 

 20   That one artery feeds everything by collaterals,

 

 21   but they are in really bad shape.  I mean it's an

 

 22   illusion that they are doing okay, but they do have

 

 23   a preserved ejection fraction, and their

 

 24   manifestation is a lot of chest pain.

 

 25             So, symptoms can vary from one side to the

 

                                                                60

 

  1   other and some patients have a balance here, and I

 

  2   think we need to keep this in mind when we are

 

  3   designing these trials.

 

  4             So, there is a predominant angina, and

 

  5   this is the kind of patient that got, let's say,

 

  6   these TMR type procedures.  That is the kind of

 

  7   population you are dealing with.  The predominant

 

  8   aspect is disabling angina, preserved EF, 100- to

 

  9   200,000 new cases per year, and constitute about 5

 

 10   percent of the patients undergoing angiography at

 

 11   tertiary referral centers.  This has been studied

 

 12   in this particular case at the Cleveland Clinic.

 

 13             One year mortality is still very high.

 

 14   Then, that other group, predominantly heart failure

 

 15   symptoms, very low EF, myocardial ischemia, though,

 

 16   is still present, but with more scar.  No option

 

 17   really for any kind of revascularization.  One year

 

 18   mortality, 20 to 50 percent.  I have shown you one

 

 19   curve where it is up to 80 percent, I mean it can

 

 20   be really bad.

 

 21             Here, we have ICD therapy trials.  If we

 

 22   look at secondary prevention trials, very sick

 

 23   patients in this study, treated with amiodarone,

 

 24   you see here one year mortality 44 percent.  I mean

 

 25   heart failure can be worse than cancer.

 

                                                                61

 

  1             Here is the REMATCH trial.  This is an

 

  2   LVAD.  This is the impact of LVAD, and there is an

 

  3   impact of survival, but again you are dealing, in

 

  4   this case, with Class IV patients that are

 

  5   unresponsive to medical therapy, so these very sick

 

  6   patients, but again an invasive, costly, not widely

 

  7   available kind of therapy, but it does have an

 

  8   impact on failure.

 

  9             I want to finish now talking a little bit

 

 10   then, hopefully, I have given you an overview of

 

 11   the problems with heart failure, and how are we

 

 12   going to look at adverse events.

 

 13             Well, what are the things that are going

 

 14   to drive the adverse events here, are going to be

 

 15   arrhythmia, ejection fraction, and symptoms, and I

 

 16   think if we focus here, we can pretty much decide

 

 17   what we need to look at in these patients over time

 

 18   as we use new therapy towards these patients.

 

 19             Let's look at low ejection fraction, how

 

 20   are we going to monitor that?  Well, we need to

 

 21   look at cardiac function, cardiac size, and the

 

 22   perfusion status of the ventricle.  We can do that

 

 23   very simply, if you take a simplistic approach,

 

 24   with echocardiography.

 

 25              I empirically have placed this here based

 

                                                                62

 

  1   on my own limited experience here, but I read in

 

  2   the document that you wanted some more practical

 

  3   advice, so I will give you my own sort of practical

 

  4   feel for what I would do.

 

  5             If we did echocardiogram on these

 

  6   patients, we could do it monthly for the first

 

  7   three months and then at six months follow-up.  We

 

  8   can do SPECT, we know that we don't need it too

 

  9   early, and that is a very simple way of doing it,

 

 10   three to six months.  Clinical visits, which will

 

 11   be very frequent, and I will talk about that, and

 

 12   BNP can be done for that, as well.

 

 13             Now, we can get fancy and use alternative

 

 14   imaging strategies, we can use MRI,

 

 15   electromechanical mapping, PET, depending on the

 

 16   institution, and depending on what we are really

 

 17   looking for and want to find.

 

 18             Cardiac arrhythmias, it is important to

 

 19   monitor cardiac rhythm.  Holter monitoring is very

 

 20   simple, probably should be done after the

 

 21   procedure, one, three, six months later.  Q-T

 

 22   interval when the patient comes in for his clinic

 

 23   visit is a strong predictor of survival, just a

 

 24   plain-old, good-old 12-lead EKG, and that should

 

 25   always be looked at.

 

                                                                63

 

  1             In the patients I guess that are getting

 

  2   myoblast therapy, there may be a little bit more

 

  3   concern about this, and this is really not my area

 

  4   of expertise, but these patients, many of them

 

  5   already entering with an AICD, that have sort of a

 

  6   built-in little computer that is already monitoring

 

  7   their rhythm as it is.  If they don't, you might

 

  8   want to consider event monitoring.

 

  9             For symptoms, well, clinical visits

 

 10   biweekly for 8 weeks, monthly up to 6 months.  We

 

 11   are going to look at heart class, we are going to

 

 12   look at EKG, CBC, CRP, look for inflammation.

 

 13   Exercise capacity, ramp treadmills, as you know, if

 

 14   you put a patient that has end-stage heart failure

 

 15   on a graded treadmill test, every time the

 

 16   treadmill bumps up and goes a little faster, he

 

 17   just may not be able to exercise at that point.

 

 18             So, the advantage of a ramp treadmill

 

 19   protocol is that you have a gradual continuous

 

 20   increase, so these people that really can't do very

 

 21   much at all, they will be able to tolerate the

 

 22   exercise and probably get further than they could

 

 23   in any other kind of exercise test.

 

 24             There is a very simple way of evaluating

 

 25   an exercise test, a 6-minute walk test.  You just

 

                                                                64

 

  1   define a distance, walk the patient walk for 6

 

  2   minutes, see how fast he can go.  You can do that

 

  3   at a clinic visit, and it is very simple to do.

 

  4   So, you can do something like this at one, three,

 

  5   and six months.

 

  6             Rehospitalization.  We look at the

 

  7   rehospitalization rates.  It is important to look

 

  8   at the use of i.v. medications that are used to

 

  9   control symptoms, because this is, as you saw, the

 

 10   biggest part of the pie in terms of costs, and is a

 

 11   real problem in the end-stage patients.

 

 12             Quality of life, it is important to assess

 

 13   quality of life, for example, SF36, Minnesota

 

 14   Questionnaire.

 

 15             Just some suggestions.  I want to wrap

 

 16   this up and saying I hope I have given you a

 

 17   general idea and scope of this problem.  We deal

 

 18   with a very, very serious problem, which is heart

 

 19   failure, specifically, that which is ischemic heart

 

 20   failure and specifically, end-stage ischemic heart

 

 21   failure.

 

 22             I hope I have given you a flavor of this

 

 23   and set the stage for the discussions.

 

 24             Thank you very much.

 

 25             [Applause.]

 

                                                                65

 

  1             DR. RAO:  Thank you, Dr. Perin.

 

  2             There is time for questions, and we can

 

  3   open it up to the committee.

 

  4                               Q&A

 

  5             DR. SCHNEIDER:  Emerson, one of the things

 

  6   that you did very nicely was lay out the clinical

 

  7   spectrum for people who may not be familiar with it

 

  8   in this context.

 

  9             I wanted to follow up on that point

 

 10   because work presented at international meetings

 

 11   recently by the Frankfurt group of Andreas Sire and

 

 12   Stephanie Dimler suggests that bone marrow derived

 

 13   cells and circulating progenitor cells from

 

 14   patients with established heart failure may be

 

 15   deficient relative to the performance of bone

 

 16   marrow derived and circulating progenitor cells

 

 17   from patients with an acute infarct.

 

 18             So, while it is not quite an apples and

 

 19   oranges comparison to envision cardiac cell

 

 20   grafting immediately post infarction or in the

 

 21   first week post infarction in patients without

 

 22   severe ventricular dysfunction versus patients,

 

 23   let's say, two to four months out with mild or no

 

 24   ventricular dysfunction versus the end-stage heart

 

 25   failure patients who have been a focus in your talk

 

                                                                66

 

  1   this morning, it does seem to me that that clinical

 

  2   heterogeneity introduces a couple of problems.

 

  3             I am curious to know how you have worked

 

  4   those through in your own work.  One of them is

 

  5   because what we are discussing today and tomorrow,

 

  6   is autologous cell therapy, I believe that there is

 

  7   a serious issue of patient-to-patient cell

 

  8   heterogeneity which has been relatively little

 

  9   discussed in the field except in these still

 

 10   unpublished or perhaps one paper has come out in a

 

 11   secondary journal from Stephanie and Andreas about

 

 12   the defects.

 

 13             So, one question is what kinds of

 

 14   standards should a proposed production center be

 

 15   required to meet in terms of their ability to

 

 16   generate cells that perform in accordance with some

 

 17   standard when there is patient-to-patient variation

 

 18   of this kind.

 

 19             Secondly, if you are envisioning putting

 

 20   cells of different kinds into a so severely an

 

 21   ischemic background as the 41-year-old former pilot

 

 22   that you mentioned, doesn't it become important to

 

 23   clearly distinguish, as the prefatory remarks did,

 

 24   between mechanisms of action for proposed donor

 

 25   cells that are aimed at regeneration specifically

 

                                                                67

 

  1   versus benefits that are achieved through entire

 

  2   different mechanisms, such as angiogenesis?

 

  3             If you put new cells into an ischemic

 

  4   background, they will surely die, and if the goal

 

  5   is to achieve angiogenesis in a background where

 

  6   the native coronary circulation has failed and the

 

  7   graft has failed, then, it seems to me we need a

 

  8   clearer resolution of the problem of which cells do

 

  9   which things well, and really fine-tune much better

 

 10   than the field has to date, you know, which are the

 

 11   cells that we want where the spectrum is normal

 

 12   vasculature, insufficient muscle cells versus the

 

 13   hypothetical ischemic patient that you described

 

 14   where revascularization is the major goal.

 

 15             DR. PERIN:  Well, that's fantastic.

 

 16             [Laughter.]

 

 17             DR. PERIN:  I think the basic answer to

 

 18   your question is I don't know, but, you know, these

 

 19   are all very good points, starting with the cell

 

 20   type, we really don't know.

 

 21             Actually, we have submitted a manuscript

 

 22   in which we have had the pathology of one or our

 

 23   patients in our study in Brazil who received

 

 24   autologous bone marrow, died 11 months later, and I

 

 25   really can't preempt I guess our publication, but I

 

                                                                68

 

  1   think we will be seeing some evidence of myogenesis

 

  2   and angiogenesis from autologous bone marrow cells,

 

  3   but we really don't know what we are getting when

 

  4   we are putting, let's say, autologous bone marrow,

 

  5   and even in that patient that has, let's say he has

 

  6   predominantly ischemia, if we want to

 

  7   revascularize, can we get a predominantly

 

  8   angiogenic effect, so we really don't know, and we

 

  9   need to define that.

 

 10             Mononuclear fraction of the bone marrow is

 

 11   a very simple approach, the one that we have taken,

 

 12   and it seems to initially, and we haven't really

 

 13   done efficacy studies and we are continuing on, but

 

 14   there is a suggestion that it does, so I think that

 

 15   we need to take every step that we take should be

 

 16   put one foot in front of the other, and if  the

 

 17   mononuclear cell fraction works, I think we can go

 

 18   from there and keep investigating that.

 

 19             Now, the average age in our trial was

 

 20   about 58, and you mentioned the problem--

 

 21             DR. RAO:  Can I interrupt?  These are

 

 22   really important questions, but they discuss data

 

 23   which was not presented in the talk right now.  I

 

 24   would like to at least focus the questions

 

 25   initially on the issues that relate to the

 

                                                                69

 

  1   presentation right now.

 

  2             We should really come back to these

 

  3   questions tomorrow when we discuss exactly these

 

  4   sorts of issues.

 

  5             Do you think that that would be okay with

 

  6   you, Dr. Schneider?

 

  7             DR. SCHNEIDER:  We will certainly return

 

  8   to them tomorrow, but I was discussing issues that

 

  9   were raised in this talk, which was clinical

 

 10   heterogeneity.

 

 11             DR. RAO:  Let's then focus, not on the

 

 12   cells per se, and the choice of cells, because none

 

 13   of the presentation was related to the production

 

 14   facility or how the cells would be, or the quality

 

 15   would be, or how you would choose the mechanism,

 

 16   but maybe how do you choose patients for a trial or

 

 17   is there some reasonable way of selecting patients,

 

 18   that there would be consensus on.

 

 19             DR. PERIN:  Okay.  So, we will get back to

 

 20   your first question and really, that is something

 

 21   that actually, we are working on trying to

 

 22   understand, is there a thumbprint or is there a

 

 23   profile in the study by Dimler and their colleagues

 

 24   looking at the characteristics of cells in certain

 

 25   patients, and obviously, they may not be the same

 

                                                                70

 

  1   in a diabetic, in a severe heart failure, we don't

 

  2   know, so there is another important we don't know.

 

  3             Age obviously is a very important thing,

 

  4   so harvesting cells from a 75-year-old may be very

 

  5   different than doing that in a 55-year-old, so

 

  6   these are all questions that need to be answered.

 

  7             DR. RAO:  Dr. Mul.

 

  8             DR. MULE:  Given the slides you showed of

 

  9   the steps toward progression of heart failure, and

 

 10   given the current interventions along that pathway,

 

 11   from your perspective, where would you see

 

 12   cell-based therapy intervention falling into that

 

 13   step toward complete heart failure?

 

 14             DR. PERIN:  Right now, at close to the

 

 15   last few steps, I think ethically, we are propelled

 

 16   to really study the problem in the patients that

 

 17   really don't have a proven conventional option for

 

 18   treatment.  In brief, I would say in the patients

 

 19   who can't be revascularized, because really medical

 

 20   therapy, we are going to apply to everyone, so then

 

 21   we are left with revascularization.

 

 22             Well, can we revascularize?  Well, we do,

 

 23   and we do it again and again, and there is a point

 

 24   where you are out of revascularization options, and

 

 25   I think that is one  place we are initially now,

 

                                                                71

 

  1   then, you could think about applying this kind of

 

  2   treatment.

 

  3             DR. HARLAN:  Building upon what Dr. Rieves

 

  4   mentioned when he gave his introductory comments, I

 

  5   want to just congratulate you on, it seems like our

 

  6   task is to weigh the risk-benefit, and you have

 

  7   outlined very clearly the risk, and I accept that

 

  8   it is severe, and I also want to congratulate you

 

  9   on mentioning the JACC paper that was just

 

 10   published, that showed how dangerous it is to look

 

 11   at historical controls, because we are making such

 

 12   rapid progress.

 

 13             My question is along those lines, not in

 

 14   this field, I just read in the journal, the

 

 15   Washington Post, about the great advance that has

 

 16   been made in super-high statin therapies, and I

 

 17   wonder if you could comment on that study, that

 

 18   these super-physiologic statin doses seem to have a

 

 19   major impact on mortality.

 

 20             DR. PERIN:  I really don't have an

 

 21   expertise in a lot of things, and that is not one

 

 22   of them, so it is really hard for me to comment on

 

 23   that.  I know that it looks like giving people HDL

 

 24   in the future may be a very exciting thing, and we

 

 25   may be able to finally find our liquid plumber kind

 

                                                                72

 

  1   of solution for people.

 

  2             Then, again, statins are just--more and

 

  3   more if you study statins, you have probably come

 

  4   to the conclusion it should be in the water pretty

 

  5   soon, I mean the patient benefit is on every single

 

  6   aspect of cardiovascular disease.

 

  7             DR. RAO:  Dr. Kurtzberg.

 

  8             DR. KURTZBERG:  You mentioned some

 

  9   practice-based methods to evaluate outcomes and

 

 10   function in these patients, but I think the

 

 11   challenge is to determine what the cells are doing,

 

 12   you know, are they differentiating into other kinds

 

 13   of cells, are they mediating inflammation, are they

 

 14   mediating angiogenesis, and I don't see how you can

 

 15   sort that out by clinical-based study.

 

 16             Do you know of other technologies that are

 

 17   on the  horizon that may help with that, that are

 

 18   non-invasive, or would you consider serial biopsies

 

 19   in patients like this to answer those questions?

 

 20             DR. PERIN:  That is a good question.  I

 

 21   don't know that serial biopsies would be a very

 

 22   efficient way of evaluating that.  You would have

 

 23   to have a very precise way of being able to

 

 24   identify where you put the cells and be able to go

 

 25   exactly to that same spot.

 

                                                                73

 

  1             We do have that technology.  Dr. Lederman

 

  2   is going to follow me eventually here.  The MRI

 

  3   field, I think is very promising in that regard in

 

  4   terms of labeling and following cells.

 

  5             Now, I really don't know that even

 

  6   labeling a cell, even if it died, if the label

 

  7   stays there,  you still see the label, so I think

 

  8   that we have to even go a step further and be able

 

  9   to prove the functionality of the cell that is

 

 10   alive and was implanted.

 

 11             That can be done on an experimental basis,

 

 12   so we figure ways out to do that, but this is a

 

 13   very intriguing problem and a very difficult

 

 14   problem to evaluate.  I think  you have put your

 

 15   finger on something that is going to be hard to

 

 16   know.

 

 17             DR. DINSMORE:  Jonathan Dinsmore from

 

 18   GenVec.

 

 19             I just had a question on your angina heart

 

 20   failure continuum.  I was confused because most

 

 21   heart failure patients present without angina, with

 

 22   symptoms of fatigue, so what percentage of heart

 

 23   failure patients actually experience angina?

 

 24             DR. PERIN:  If we are talking about

 

 25   ischemic heart failure, we are not talking about

 

                                                                74

 

  1   other kinds of heart failure, actually, idiopathic

 

  2   heart failure, you kind of get the same remodeling

 

  3   and everything except you didn't have that infarct

 

  4   in the beginning, but you go through the same sort

 

  5   of pathophysiologic processes.

 

  6             So, we are talking about ischemic heart

 

  7   failure. People that have ischemic heart failure

 

  8   have coronary disease.  Coronary disease is

 

  9   narrowing of your coronary arteries.

 

 10             Depending on what your response is, you

 

 11   will or will not have angina, but angina is one of

 

 12   the manifestations of coronary disease, and it is

 

 13   really not a good thing to base a lot on, because

 

 14   the expression of angina is very variable.

 

 15             It depends on your pain threshold.  I mean

 

 16   if you are a diabetic, you may not have as much

 

 17   pain.  It is a subjective thing subject to

 

 18   interpretation by the actual patient, so it is

 

 19   something that is very difficult to evaluate, and

 

 20   that is why I put the continuum, because it is all

 

 21   there and you really shouldn't take a patient

 

 22   population based on angina or based on shortness of

 

 23   breath.

 

 24             I think you have got to bring both of

 

 25   these things together to understand they are sort

 

                                                                75

 

  1   of in the spectrum of a similar underlying

 

  2   pathophysiologic process.

 

  3              DR. SIMONS:  I would like to come back to

 

  4   the issues of the differences among the patients

 

  5   having these kind of therapies.  We have learned

 

  6   from a number of trials of growth factor therapies

 

  7   that there is a very large difference in how the

 

  8   patients respond.

 

  9             This issue that there are different

 

 10   subgroups that we are not defining is fairly

 

 11   critical to the field.  You mentioned one or two

 

 12   biomarkers, but there seemed to be a general

 

 13   association of markers as opposed to really

 

 14   identifying which patients respond in which manner.

 

 15             What would you suggest as a way of trying

 

 16   to sort of stratify these patient groups?  Not

 

 17   suggest ejection fraction, that is probably in a

 

 18   way sort of crude measure, but in terms of

 

 19   biological responses.

 

 20             DR. PERIN:  If we look at the trials of

 

 21   devices, I think that probably a common way to look

 

 22   at these patients is exercise capacity.

 

 23             I think that probably is one of the

 

 24   unifying parameters that we cannot only use at

 

 25   entry, but also you are able to follow as a patient

 

                                                                76

 

  1   goes along, and if he has a response to therapy, he

 

  2   will have a positive response in terms of what he

 

  3   is able to do in terms of function.

 

  4             That has a very practical translation into

 

  5   quality of life and people feeling better.  I would

 

  6   say in a broad sense, that exercise capacity, peak

 

  7   oxygen consumption might be something that I might

 

  8   consider an important thing to follow in these

 

  9   patients, and not just ejection fraction, which is

 

 10   dependent on a lot of things, how much loading the

 

 11   ventricle has that day, the amount of mitral

 

 12   regurgitation, et cetera, so there is a lot of

 

 13   things that will make that extremely variable.

 

 14             DR. RAO:  As an extension of that, it's a

 

 15   very general question.  Is there any problem with

 

 16   many of these studies which are in high-risk

 

 17   patients enrolling people for the placebo arm of

 

 18   the trial?  Not in cell therapy, but maybe when you

 

 19   do devices or you do assists, has this been

 

 20   historically a problem for the cardiovascular

 

 21   field?

 

 22             DR. PERIN:  Well, it has been done as you

 

 23   can see, so I have showed you a bunch of studies

 

 24   where it has been done, and it can be done.

 

 25             Personally, the way I like to see it is I

 

                                                                77

 

  1   want to offer patients that get in the placebo arm

 

  2   some kind of a treatment, so in our future upcoming

 

  3   study, what I am going to do is I will tell a

 

  4   patient you are going to get randomized to maybe

 

  5   not getting treatment, but if you don't get that

 

  6   treatment at an X period of time, six months, you

 

  7   will cross over to get the treatment.

 

  8             I think that is a humane way of doing it,

 

  9   in which these patients are very ill and desperate

 

 10   to get something to help, so again, if you can

 

 11   cross over, sometimes these placebo patients at

 

 12   some point after you have achieved your assessment,

 

 13   then that makes it a more palatable or fair way to

 

 14   do things maybe.

 

 15             DR. RAO:  Dr. Cunningham.

 

 16             DR. CUNNINGHAM:  I just wonder, in your

 

 17   data, if  you see any difference by either

 

 18   socioeconomic status or by gender, or by any way of

 

 19   culture, dividing populations, whether it would be

 

 20   race or ethnicity or any other factor like that?

 

 21             DR. PERIN:  You mean in our own--

 

 22             DR. CUNNINGHAM:  Yes, reading the JACC

 

 23   data, was there anything by gender, for instance,

 

 24   or by subpopulation?

 

 25             DR. PERIN:  Females, there are some

 

                                                                78

 

  1   differences in the female population in which there

 

  2   are some differences. There is the catch-up

 

  3   phenomenon in the end, but socioeconomic

 

  4   differences, I am not aware that it would have an

 

  5   impact on that, as well, but maybe gender

 

  6   differences, yes.

 

  7             DR. RAO:  One question to sort of follow

 

  8   on Dr. Simons' question, in at least the way I

 

  9   understood it, it is really kind of difficult to

 

 10   stratify patients or to extrapolate from one class

 

 11   of patients to the other.  Historically, that has

 

 12   always been a problem.

 

 13             Again, it's a general feeling when one

 

 14   conducts studies in the cardiovascular field, is

 

 15   there some consensus  that everybody says that,

 

 16   well, if you measure by ejection fraction, and we

 

 17   take patients, which is what it seemed like a lot

 

 18   of studies have done, that that is a reasonable

 

 19   criteria that you can extrapolate from one

 

 20   classification of that kind to the next, or one

 

 21   cannot?  Just as a general statement.

 

 22             DR. PERIN:   It has been done, and it is a

 

 23   general way of separating--there is definitely a

 

 24   correlation with your ejection fraction and your

 

 25   survival, so it is probably not the most refined

 

                                                                79

 

  1   way of dividing patients, and it depends where you

 

  2   make the cutoff, so if you make a fairly high

 

  3   cutoff, let's say, patients that had ejection

 

  4   fraction less than 40 percent, then, you are

 

  5   including most of the population of patients that

 

  6   have heart failure, so it's a general way to divide

 

  7   things.

 

  8             If you start decreasing that number of

 

  9   that cutoff, then, you are really selecting out

 

 10   more I think subpopulations we were talking about,

 

 11   maybe some different kind of subpopulations of

 

 12   patients with heart failure.

 

 13             DR. RAO:  Dr. Borer.

 

 14             DR. BORER:  Dr. Rao, a few minutes ago you

 

 15   made a point, and I would like to restate it in

 

 16   another way, because what Dr. Perin did, as I see

 

 17   it, is very well present an overview as an outline,

 

 18   was a scaffold upon which we can conduct subsequent

 

 19   more specific discussions.

 

 20             I think that right now we are getting into

 

 21   a series of questions that are way beyond the data

 

 22   that exist, and you couldn't expect Dr. Perin to

 

 23   respond to them in a meaningful way because the

 

 24   data don't exist.

 

 25                In specific response to your question,

 

                                                                80

 

  1   which was a very fundamental one, I think we are at

 

  2   a point now with this form of therapy where if we

 

  3   could define any group in which we saw a response

 

  4   which seemed credible, which was statistically

 

  5   valid, we would then have a series of hypotheses

 

  6   that would have been generated that would allow one

 

  7   to move further, but I think that is the level we

 

  8   are at.

 

  9             The idea of defining a general population

 

 10   in which to test therapy the way we do with drugs,

 

 11   we are not there yet, so I think the specific

 

 12   questions have to come a little later in this

 

 13   forum.

 

 14             DR. RAO:  I just wanted to get it clear to

 

 15   people that that was the case, but your point is

 

 16   very well taken.

 

 17             Dr. Neylan.

 

 18             DR. NEYLAN:  Thank you.

 

 19             That was a very nice clinical overview,

 

 20   and I wanted to ask you from your perspective as a

 

 21   clinician, there are obviously many parameters

 

 22   whose relief or improvement would be significant in

 

 23   terms of the lives of individual patients, and many

 

 24   of these could be utilized as endpoints for proof

 

 25   of concept.

 

                                                                81

 

  1             But ultimately, what do you believe is the

 

  2   most relevant clinical endpoint for defining

 

  3   registration criteria for this form of therapy, is

 

  4   it patient mortality or something else?

 

  5             DR. PERIN:  I don't know if we are going

 

  6   to be impacting patient mortality.  That is a very

 

  7   difficult question.  I would go back and what I had

 

  8   said earlier, and use an endpoint, I would use

 

  9   something like the LV02 as an endpoint.

 

 10             I think that is a little bit more

 

 11   palpable, and obviously, looking at mortality, this

 

 12   is such an initial incipient field in which we have

 

 13   barely treated any patient, so to think about

 

 14   looking at mortality, which involves a much larger

 

 15   number of patients, I think that is probably

 

 16   getting ahead of ourselves a little bit.

 

 17             We need to first verify if this is

 

 18   efficacious and if there is some objective

 

 19   improvement in these patients, and one of those

 

 20   objective ways of doing that would be something

 

 21   like exercise capacity, like I mentioned.

 

 22             DR. RAO:  Dr. Ruskin.

 

 23             DR. RUSKIN:  Just two quick comments on

 

 24   Dr. Perin's very nice presentation.

 

 25             One is that we have learned from drug and

 

                                                                82

 

  1   device trials that both ejection fraction and heart

 

  2   failure classification are critically important

 

  3   predictors, but that they are not necessarily fully

 

  4   interactive, that is, they are independent, so

 

  5   using both, I think in any classification with

 

  6   regard to these kinds of interventions would be

 

  7   critical because the outcomes are very, very

 

  8   different in Class III and IV even with the same

 

  9   EF.

 

 10             The other relates to a question that Dr.

 

 11   Rao raised about recruitment and controls.  I think

 

 12   that given the excitement in this area, but the

 

 13   unknown issues that have already been raised, doing

 

 14   trials that have adequate controls perhaps is more

 

 15   important here than anywhere else one can imagine

 

 16   given the severity of the illness that we are

 

 17   dealing with and the kinds of outcomes that Dr.

 

 18   Perin has described.

 

 19             As someone who recruits for device trials,

 

 20   though, I can tell you that it is not easy, and

 

 21   randomizing patients to acceptable controls in this

 

 22   kind of illness is going to be a huge challenge,

 

 23   but I think it is important for this group to

 

 24   emphasize that there is no place where this could

 

 25   be more important, otherwise, we will never get an

 

                                                                83

 

  1   answer, and I think that mortality ultimately will

 

  2   have to be a critical part of any trial that is

 

  3   done.

 

  4             DR. RAO:  Go ahead, Dr. Borer.

 

  5             DR. BORER:  I agree completely with Jeremy

 

  6   that controls are essential in this kind of

 

  7   research and really in any clinical research, but I

 

  8   think again to put this whole area in context, and

 

  9   in response to Dr. Neylan's point and question, we

 

 10   are at the point now of looking at physiological

 

 11   variables and what we would call in drug

 

 12   development "surrogates," to see whether cardiac

 

 13   performance, cardiac perfusion, this, that, and the

 

 14   other thing, is affected in one way or another, so

 

 15   that one could extrapolate to the point where it

 

 16   would be legitimate to define hypotheses about

 

 17   clinical outcome.

 

 18             We are not there yet, and the clinical

 

 19   outcome, just to put it in context from the drug

 

 20   world, is perfectly legitimate in the view of most

 

 21   people who deal with this area and these agents to

 

 22   think of a therapy as being approvable if it makes

 

 23   people feel better, but doesn't make them live

 

 24   longer.

 

 25             If it makes people feel better, even if it

 

                                                                84

 

  1   makes them live a little bit shorter, as long as

 

  2   you know how much shorter that is, and if it makes

 

  3   people live longer while not making them feel too

 

  4   much worse.

 

  5             I don't think we are at a point yet again

 

  6   to define what the outcomes variables should be.  I

 

  7   think we are at the point of defining physiological

 

  8   and pathophysiological surrogates, and that is what

 

  9   is being done in the studies to date, and then we

 

 10   can decide what the outcomes are, clinically

 

 11   important for registration.

 

 12             DR. RAO:  I guess that leads us to the

 

 13   fact that many of these things should be discussed

 

 14   tomorrow, just like  you pointed out.

 

 15             If there are no critical questions

 

 16   remaining, I will thank Dr. Perin.

 

 17             [Applause.]

 

 18             DR. RAO:  We are going to take a short

 

 19   break.

 

 20             [Break.]

 

 21             DR. RAO:  We are really extremely

 

 22   fortunate in having Dr. Menasch here to present

 

 23   his findings, and I look forward to a really

 

 24   interesting talk.

 

 25                Clinical Experience of Autologous

 

                                                                85

 

  1                     Myoblast Transplantation

 

  2             DR. MENASCHE:  Good morning.  First of

 

  3   all, I would like really to thank you for the

 

  4   privilege of this invitation and this unique

 

  5   opportunity of sharing some data on the clinical

 

  6   myoblast transplantation.

 

  7             What I would like to do in this talk is

 

  8   first to briefly touch on the preclinical data

 

  9   which have paved the way for these early clinical

 

 10   trials, and then, as requested by Dr. Grant, to

 

 11   focus on the various aspects of the clinical

 

 12   experience which has accumulated so far before

 

 13   drawing some perspectives which may have clinical

 

 14   relevance in the near future.

 

 15             Now, I think just to make things clear,

 

 16   that the basic assumption is fairly

 

 17   straightforward, and the objective of this therapy

 

 18   is really to try to repopulate areas of dead

 

 19   myocardium with new contractile cells with the hope

 

 20   that these areas can regain some function, and

 

 21   given the close relationship between function and

 

 22   survival, which has been already mentioned, the

 

 23   ultimate hope is obviously that it can have a

 

 24   significant impact on clinical outcomes.

 

 25             The reason why we initially started with

 

                                                                86

 

  1   the skeletal myoblasts are actually listed here.

 

  2   These cells are not really stem cells, they are

 

  3   better termed precursor cells for muscular fibers

 

  4   in that they are very committed to their skeletal

 

  5   muscle phenotype as you will see.

 

  6              The first advantage of the myoblasts is

 

  7   that they can be very easily retrieved from the

 

  8   patient himself, thus overcoming any problem

 

  9   associated with rejection and immunosuppressive

 

 10   therapies.

 

 11             These cells feature a very great expansion

 

 12   potential which is important given the relationship

 

 13   which exists between the number of cells which are

 

 14   injected and the ultimate functional outcome.

 

 15              As I have just said, they are pretty well

 

 16   committed to their myogenic lineage, and the risk

 

 17   of tumor development is virtually negligible.

 

 18   Finally, they are pretty resistant to ischemia, and

 

 19   although unfortunately, many of them die shortly

 

 20   after the injections, fortunately, some of them

 

 21   will survive and may positively affect function.

 

 22             So, this is type of animal model which has

 

 23   been used initially in rodents.  You see here the

 

 24   heart and the needle injecting the cells.  I just

 

 25   would like to mention that it took us seven years,

 

                                                                87

 

  1   seven years of preclinical work before I did

 

  2   operate on the first patient June 15, 2000.

 

  3             During the seven years, we moved from the

 

  4   rodent models to the large animal models, which I

 

  5   think is absolutely necessary before arriving to

 

  6   clinical trials.

 

  7             Just to summarize the bulk of this data,

 

  8   we can say, number one, that when you inject

 

  9   skeletal myoblasts into an infarcted area, they

 

 10   retain the possibility of differentiating into

 

 11   typical myotubes.  Here is a typical myotube,

 

 12   elongated structure, and this is a sheep heart and

 

 13   this is a human heart.

 

 14             This is an autopsy specimen.  One patient

 

 15   of our Phase I trial died 18 months after his

 

 16   surgery from stroke, and we had permission for the

 

 17   autopsy.  You will appreciate the striking

 

 18   similarity of these two slides.  Here you find in

 

 19   this human heart, a typical myotube embedded in

 

 20   scar tissue.

 

 21             At closer magnification, you can

 

 22   appreciate the typical cross-striations, and I

 

 23   think two observations are important to be made at

 

 24   this point.  Number one, these cells really remain

 

 25   committed to their skeletal muscle phenotype. In

 

                                                                88

 

  1   other words, there is virtually no evidence that

 

  2   they can ever turn to cardiomyocytes.  They will

 

  3   not become cardiac cells.

 

  4             Number two, they remain electrically

 

  5   insulated from the surrounding myocardium, which

 

  6   obviously raises major mechanistic questions

 

  7   regarding the underlying mechanisms by which they

 

  8   can improve function, but the fact is that there is

 

  9   no real evidence that they develop connections with

 

 10   the neighboring cardiomyocytes.

 

 11             Nevertheless, when you subject them to

 

 12   strong depolarizing currents, they show excitable

 

 13   properties, and you see here, this is a fluorescent

 

 14   myotube which has been grafted in a myocardial

 

 15   scar.  This is an in vivo study and definitely they

 

 16   can respond to currents by generating action

 

 17   potentials followed by contractions.

 

 18             This translates into an improvement in

 

 19   function, both regional function here in the sheep

 

 20   model, and global function, the LV ejection

 

 21   fraction.  This improvement, as you can see, seems

 

 22   to be sustained over time until one year in our rat

 

 23   studies, and basically, these kinds of observations

 

 24   have been made by several other investigators

 

 25   already past 10 years.

 

                                                                89

 

  1             So, there is a fairly good consistency

 

  2   showing that these myoblasts can, to some extent,

 

  3   improve function at least in animal models, and

 

  4   obviously, the gap with the humans is a wide one.

 

  5             So, if we now move to the clinical

 

  6   experience, so far there are 44 patients who have

 

  7   been included in early Phase I trials, and 34

 

  8   patients currently included in our ongoing

 

  9   randomized, multi-centered Phase II study .

 

 10             This list is by far not exhaustive.  I

 

 11   have not tabulated anecdotal case or me-too cases.

 

 12   I have just kept those studies which have been

 

 13   published in peer-reviewed journals.

 

 14             Basically, the inclusion criteria have

 

 15   been fairly straightforward across all these

 

 16   studies.  Patients with low ejection fractions,

 

 17   usually below 35 percent, patients with a history

 

 18   of myocardial infarct, and obviously, patients

 

 19   requiring concomitant coronary bypass surgery since

 

 20   for ethical reasons, it is difficult to open the

 

 21   chest just for injecting a product we don't really

 

 22   know whether it is effective or not.

 

 23             If we try to summarize the main results,

 

 24   we can say, number one, that multiple epicardial

 

 25   injections look to be safe.  I have never seen any

 

                                                                90

 

  1   bleeding from the needle holes, and overall, this

 

  2   experience has been shared by the other surgeons

 

  3   who have practiced the operation.

 

  4             Number two, it is possible--and we will

 

  5   come back on that--that the procedure increases the

 

  6   risk of arrhythmia postoperatively, at least in the

 

  7   early post-op period.

 

  8             Number three, I will be extremely careful

 

  9   and cautious about that, there are some data

 

 10   suggesting that maybe function can improve, but it

 

 11   is clear that until we have the results of the

 

 12   ongoing randomized, placebo-controlled study, we

 

 13   cannot make any meaningful conclusion.

 

 14             This is the list of the studies and of the

 

 15   patients.  I have just added the last one a few

 

 16   days ago. Professor Siminiak presented at the

 

 17   American College of Cardiology another series of 10

 

 18   patients who got the cells through a percutaneous

 

 19   catheter using the coronary sinus route.  I will

 

 20   come back on that catheter in a few minutes, but I

 

 21   will rather concentrate on the surgical

 

 22   implantations listed here.

 

 23             Dr. Smits also injected cells through a

 

 24   catheter using the interventricular approach

 

 25   similar to the one alluded to by Dr. Perin.

 

                                                                91

 

  1              This goes back to the inclusion criteria

 

  2   which have previously been mentioned.  I think it

 

  3   is important to look at all words, because as you

 

  4   will see, differences in definition may really be

 

  5   confounders in the interpretation of the results.

 

  6             It is important to look at akinetic areas

 

  7   that is really dead myocardium, not simply

 

  8   ipokinetic or dyskinetic, really akinetic

 

  9   myocardium, which are not amenable to

 

 10   revascularization and obviously, it is also

 

 11   important that the bypass surgery be done in other

 

 12   areas.

 

 13             For example, you will see that in one

 

 14   study, the area which was transplanted with cells

 

 15   was also revascularized, so when the authors

 

 16   conclude that cell therapy improves function, it is

 

 17   clearly meaningless since the same area has got

 

 18   simultaneous revascularization.

 

 19             For those of you who are not familiar with

 

 20   the procedure, I just would like briefly to show

 

 21   you this three-step operation.  It starts with a

 

 22   muscular biopsy.  We take it at the thigh.  It is a

 

 23   very simple procedure under local anesthesia.

 

 24             We remove a chunk of muscle, which is then

 

 25   cut into small pieces, put in this sheeping medium

 

                                                                92

 

  1   and sent to the cell culture lab where a multiple

 

  2   tri-cell factory is being designed to allow for

 

  3   large-scale cell production.

 

  4             Then, there are regular morphological

 

  5   controls. Obviously, the key point is to inject the

 

  6   cells before they reach confluence.  What you would

 

  7   like to do is that confluence occurs in vivo

 

  8   following the engraftment, not before, so it is

 

  9   important to check the morphological state of the

 

 10   cells on a regular basis.

 

 11             This is how human myoblasts look like

 

 12   during the cell culture process, and this is how

 

 13   the cells look like when they are back in the

 

 14   operating room.

 

 15             Then, with the curved needle, we inject

 

 16   the cells all across the infarcted area including

 

 17   the borders.  It's a time-consuming, I would say

 

 18   10, 12, 15 minute procedure, rather tedious and

 

 19   boring procedure, by the way, where you have to

 

 20   mentally construct the grids and then go with the

 

 21   needle from side to side, so we are working on the

 

 22   multiple shot device, but it is more tricky than we

 

 23   initially thought.

 

 24             So, right now we have the requirement for

 

 25   these multiple injections all across.  This is

 

                                                                93

 

  1   another view of the injections.

 

  2             So, if we start by feasibility, I think it

 

  3   is quite well established that this technique is

 

  4   perfectly feasible.  In other words, it does

 

  5   demonstrate that provided  you have the appropriate

 

  6   techniques, you can take a small piece of muscle

 

  7   which contains, say, 3- 4 million skeletal

 

  8   myoblasts initially and expand it over two to three

 

  9   weeks until approximately 1 billion cells.

 

 10             These are the results of our cultures

 

 11   during the Phase I trial, during which the target

 

 12   numbers which have been prespecified have

 

 13   consistently been obtained and even overshoot it.

 

 14             You will note that you can get up to 90

 

 15   percent of skeletal myoblasts in that--and this is

 

 16   an important point--you really end up with a pretty

 

 17   well defined cell therapy product.  You really know

 

 18   what you are injecting.

 

 19             Importantly, what we have seen is that

 

 20   heart failure does not prevent skeletal myoblasts

 

 21   to differentiate  into myotubes, and this was a

 

 22   question because when we did preclinical rounds, I

 

 23   got pieces of tissue from orthopedic colleagues,

 

 24   but often these patient were young, and the

 

 25   question was are the myoblasts from this Class

 

                                                                94

 

  1   III/IV heart failure patients going to

 

  2   differentiate normally, and the answer is yes, so

 

  3   far we have had no failure.

 

  4             The only thing is that it may take a

 

  5   little bit more time for some patients until we get

 

  6   the target number of cells, but at the end of the

 

  7   day, it has always been possible to achieve the

 

  8   prespecified target number of cells in myoblasts.

 

  9             What about safety now?  These are the

 

 10   different adverse events we were concerned with by

 

 11   the time we started the trial, and fortunately, I

 

 12   must say that none of them has occurred except--and

 

 13   we are going to discuss that--possibly the

 

 14   arrhythmias, but it is important to emphasize that,

 

 15   for example, there was never any particular

 

 16   bleeding from these multiple puncture sites.

 

 17             There was no unusual complication in the

 

 18   postoperative course of these patients, and when

 

 19   the cells were injected in newt immunocompromised

 

 20   mice, there was never any evidence for tumor

 

 21   formation.

 

 22             Obviously, before we started the study, we

 

 23   had to go through a lot of regulatory constraints,

 

 24   indeed, what I did is to discuss with the French

 

 25   FDA and ask them what was approved or not, and the

 

                                                                95

 

  1   game was not so easy because as previously

 

  2   mentioned, there was no precedent.

 

  3             So, they told us, well, this is what you

 

  4   are allowed to do.  This is the kind of culture

 

  5   medium, ancillary product additives which are

 

  6   permitted for human use, so we immediately from the

 

  7   onset designed our cell culture in accordance to

 

  8   the prespecified instructions, and obviously, it

 

  9   was timesaving because when we came back with the

 

 10   process, there was nothing else than to accept it.

 

 11             Well, what about the V-tachs?  In the

 

 12   initial series we had 4 patients with sustained

 

 13   episodes of ventricular tachycardia.

 

 14             All of them occurred during the early

 

 15   post-op period, the early three first week,

 

 16   postoperative weeks, and there was virtually no

 

 17   recurrence later on because these patients had a

 

 18   defibrillator put on and only one of them

 

 19   experienced firing of the defibrillator one year

 

 20   later, so it really appears to be a relatively

 

 21   early post-op event.

 

 22             Now, there are different mechanisms which

 

 23   could account for these arrhythmias, in particular,

 

 24   the differences in electrical membrane properties

 

 25   between the grafted cells and the neighboring

 

                                                                96

 

  1   cardiomyocytes.  Obviously, other mechanisms can

 

  2   also be considered, but we really favor the first

 

  3   one because we did an EP study in which we looked

 

  4   at the different membrane properties of the cells.

 

  5             Here, you see a typical action potential

 

  6   of a muscular fiber and here of a cardiomyocyte.

 

  7   Now, if you graft skeletal myoblasts back into a

 

  8   muscle, these cells retain a typical skeletal

 

  9   muscle phenotype, and this is also true for

 

 10   myotubes which grow in culture.

 

 11             The question is how does it look like when

 

 12   you graft the skeletal myoblasts into the heart.

 

 13   Well, definitely it remains very similar to what it

 

 14   was initially and different from the action

 

 15   potential of the cardiomyocyte.

 

 16             If you expressed it graphically, you would

 

 17   see that the action potential duration is quite

 

 18   different between the cardiomyocyte and the

 

 19   myotube, and this heterogeneity might account for

 

 20   some of these arrhythmias.

 

 21             Now, having said that, the picture is

 

 22   probably more complex and the reason, as you know,

 

 23   and it has been mentioned by Dr. Perin in his talk,

 

 24   is that heart failure by itself predisposes

 

 25   patients to arrhythmias.

 

                                                                97

 

  1             So, I think that as long as we don't have

 

  2   the results of the randomized trial in which all

 

  3   patients have been instrumented with a

 

  4   defibrillator, it will be difficult to conclusively

 

  5   establish a causal relationship between grafting of

 

  6   cells and the occurrence of arrhythmia.

 

  7             I can also tell you that we currently have

 

  8   randomized 34 patients in the Phase II trial and

 

  9   the incidence of arrhythmia has been strikingly

 

 10   low, much lower than in the initial study we had

 

 11   done, so things are probably less clear than they

 

 12   were initially, and once again we have to wait for

 

 13   the results of the randomized trial before we can

 

 14   definitely say yes, there is no relationship

 

 15   between myoblast transplantation and arrhythmia.

 

 16             Anyway, these patients or most of them

 

 17   would require at one point a defibrillator, so it

 

 18   was not a big issue for us to implant those

 

 19   defibrillators in all the Phase II patients.

 

 20             Now, what about efficacy?  Now, we have to

 

 21   be extremely careful in the interpretation of the

 

 22   results which are presented because of the

 

 23   multiplicity of the confounding factors.

 

 24             The culture conditions, for example, the

 

 25   Spanish group has used a culture medium which

 

                                                                98

 

  1   contains the patient's own serum, and the

 

  2   conclusion is we had no arrhythmia, so if you use

 

  3   the patient's own serum instead of fetal calf

 

  4   serum, you prevent arrhythmia.

 

  5             I think it is really a simplistic

 

  6   conclusion based on 12 patients, but it can

 

  7   introduce an additional bias.  There is currently

 

  8   no evidence that fetal calf serum is really

 

  9   responsible for the arrhythmias.

 

 10             Dosing has been extremely different and

 

 11   variable from one study to the other, as well as

 

 12   the kinetics of the  grafted area.

 

 13             Once again, any kinetic area is different

 

 14   from a dyskinetic area, which features a

 

 15   paradoxical motion, and, for example, in the U.S.

 

 16   trial, some patients were included who had

 

 17   hypokinesia, which we know can improve just because

 

 18   of the revascularization even if revascularization

 

 19   is not targeted at this particular area.

 

 20             The same for bypasses.  In the Spanish

 

 21   study, for example, the cell grafted areas were

 

 22   also bypassed, which makes the interpretation of

 

 23   results impossible.

 

 24             Type of surgery has also been different.

 

 25   In the U.S. study, for example, some patients had

 

                                                                99

 

  1   additional reconstructions of the left ventricle in

 

  2   addition to the bypass surgery, which make things

 

  3   still more complicated.

 

  4             Finally, the method of outcome assessment,

 

  5   in some studies, the assessment has been

 

  6   centralized at one side, in others, each center has

 

  7   made its own assessment, which obviously makes big

 

  8   differences.

 

  9             This is just to illustrate the variability

 

 10   in the number of cells which have been injected.  I

 

 11   don't have the figures for the initial surgical

 

 12   study from Professor Siminiak, but as you can see,

 

 13   there is a wide variability.

 

 14             The U.S. study of Dr. Dib was, as you

 

 15   know, was a dose escalating study accounting for

 

 16   this variability in the numbers.  Dosing is

 

 17   probably important.  This is one study among others

 

 18   showing that there seems to be a tight relationship

 

 19   between the number of injected cells and the

 

 20   functional outcomes.

 

 21             This is the reason why, in our early Phase

 

 22   I trial, we have targeted a high number of cells,

 

 23   800 million. In the Phase II, we have two arms with

 

 24   two different doses of cells, but the number

 

 25   probably makes a big difference given the high rate

 

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  1   of early cell death.

 

  2             The characteristics of the grafted

 

  3   segments, as I previously mentioned, have also been

 

  4   different from one study to the other, as well as

 

  5   the method for assessing viability, usually,

 

  6   dobutamine echocardiography, occasionally MRI or

 

  7   PET scan.

 

  8              Same variability in the characteristics

 

  9   of injections, but you see that you can go up to

 

 10   almost 60 injections without any concern related to

 

 11   bleeding, and obviously, the number of injections

 

 12   depends on the extent of the area of infarction.

 

 13             It is also important to look at the cell

 

 14   concentration.  We extensively studied that before

 

 15   I started doing patients.  You have to find a

 

 16   tradeoff because if you use a large needle, then,

 

 17   you can have large holes and some bleeding

 

 18   problems.

 

 19             If you use a too small needle, you will

 

 20   eliminate the bleeding problems, but the cells may

 

 21   be packed and damaged through their passage, so we

 

 22   ended with a 27-gauge needle which gave an

 

 23   acceptable rate of cell viability.

 

 24             The concentration of cells is important,

 

 25   and probably still more important when you are

 

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  1   using a long catheter.  We are using a short needle

 

  2   with directly the serum hooked to the needle, but

 

  3   if you are using a long catheter, concentration may

 

  4   make a big difference.

 

  5             Finally, revascularization is occasionally

 

  6   being done in the same area as the area where cells

 

  7   were put in, which completely confuses the results.

 

  8             This is, for example, the Spanish study,

 

  9   what you see is that, what they call the untreated

 

 10   segments, that it is segments which had just

 

 11   bypassed, the wall motion score went from 1.2 to

 

 12   1.1 and 1, but really, this is almost normal

 

 13   motion, so obviously, it makes it easier to

 

 14   demonstrate that in the other segments which have

 

 15   bypass surgery and cells, the improvement was

 

 16   greater.

 

 17             This is a summary of our data from the

 

 18   Phase I trial.  We had an improvement in the

 

 19   functional status and an increase in ejection

 

 20   fraction.  These results are meaningless because

 

 21   these patients had associated bypass surgery.

 

 22             So, we rather looked at the number of

 

 23   scarred segments, and I remind you these were

 

 24   akinetic segments without viability on dobutaminic

 

 25   echocardiography without any possibility for

 

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  1   revascularization.  So, we looked at the changes in

 

  2   the contractions of these segments which have been

 

  3   grafted with cells.

 

  4             So, initially, obviously, there was no

 

  5   motion since it was one of the inclusion criteria,

 

  6   and afterwards we had, at two different time

 

  7   points, approximately 60 percent of segments

 

  8   regaining some function.

 

  9             I am not saying that these segments were

 

 10   normally contracting, they were not.  There was a

 

 11   slight and modest improvement.  This was a blinded

 

 12   assessment, in other words, we blinded the dates of

 

 13   the echo tapes and asked independent

 

 14   echocardiographers to review them and to grade

 

 15   them.  There was a modest improvement, not normal

 

 16   contraction, but it was sufficient to push us to

 

 17   move forward to the Phase II study.

 

 18             I just show you a couple of examples.

 

 19   This is a flat exterior wall, no motion at all, and

 

 20   this is the same wall with the systolic thickening

 

 21   following myoblast transplantation.  This is the

 

 22   MRI study which does not project on the screen.  I

 

 23   have it on the computer, but not on the screen.

 

 24             You see here the interior infarct which

 

 25   has been grafted, and you can appreciate an

 

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  1   improvement in wall motion in the postoperative

 

  2   period.  This is an exterior infarct.  You see the

 

  3   thin wall here, which has been grafted, and this is

 

  4   the post-op pattern with a thickening of the wall.

 

  5             I add intentionally that these patients

 

  6   also had bypasses in the left system.  I don't like

 

  7   the slides where you see pre-transplantation,

 

  8   post-transplantation, just omitting that in

 

  9   addition, there was either bypass surgery or

 

 10   balloon angioplasty.

 

 11             This is another example of an interior

 

 12   infarct pre-transplantation and bypass to the

 

 13   posterior descending coronary artery and the

 

 14   post-op, with an improvement in the wall motion.

 

 15             So, now, can it be due to the

 

 16   revascularization of the PDA?  It is unlikely, but

 

 17   it cannot be eliminated.

 

 18             So, basically, this is the design of the

 

 19   MAGIC, the Phase II trial which has been initiated

 

 20   now in Europe, in different countries in Europe.

 

 21   It is targeted to include 300 patients in different

 

 22   countries, and to emphasize what Dr. Ruskin was

 

 23   mentioning earlier, it is a placebo-controlled

 

 24   study.  In other words, patients following

 

 25   randomization have a muscular biopsy and they have

 

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  1   eventually injection of a placebo solution in

 

  2   addition to their bypass surgery.

 

  3             There are three arms, one control and two

 

  4   treated groups, one having 400 million, the other

 

  5   having 800 million cells.  The production of cells,

 

  6   and this is probably important, has been

 

  7   centralized in two sites, one in Paris and one in

 

  8   Boston, and it is exactly the same technology which

 

  9   is used in the two sites.

 

 10             The primary endpoint is the improvement in

 

 11   the contractility of the segments which have been

 

 12   grafted with cells in the core lab and in a blinded

 

 13   fashion.  In addition to that, we are obviously

 

 14   looking at major adverse cardiovascular events at

 

 15   the one-year follow-up time.

 

 16             I would like to move on now before

 

 17   finishing to some clinically relevant perspectives

 

 18   which may have really clinical implications in the

 

 19   near future.

 

 20             First of all, so far we have been talking

 

 21   primarily of ischemia cardiomyopathy, but as

 

 22   mentioned by Dr. Perin, there are other causes of

 

 23   heart failure in particular non-ischemic, globally

 

 24   dilated cardiomyopathy.

 

 25             So, we have been interested in assessing

 

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  1   myoblast transplantation in this particular

 

  2   context, and use a particular genetic strain of

 

  3   hamsters which develop a non-ischemic dilated

 

  4   cardiomyopathy, and randomize the animals to

 

  5   receive either autologous skeletal myoblasts,

 

  6   because phenotypically, these myoblasts are free

 

  7   from the disease, or culture medium.

 

  8             To make a long story short, you see that

 

  9   there is a definite improvement in function which

 

 10   correlates with a major engraftment of cells in

 

 11   this non-ischemic myocardium. I think it just

 

 12   brings another piece of evidence that maybe

 

 13   something good is occurring.

 

 14             The second problem is cell death.

 

 15   Regardless of the cell type, cell death is

 

 16   extremely high, 80, 90 percent of cells are dying

 

 17   shortly after the injections for a variety of

 

 18   causes, in particular, apoptosis, but also

 

 19   ischemia.  It makes sense since we are injecting

 

 20   cells in scar areas which receive very little

 

 21   vascularization.  So, even if myoblasts are fairly

 

 22   resistant, they die nevertheless.

 

 23             So, now there are several studies

 

 24   suggesting that the co-induction of angiogenesis

 

 25   may be an effective means of improving survival of

 

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  1   the cells, and ultimately, of improving function of

 

  2   the animals.

 

  3             This is a study comparing transplantation

 

  4   of fetal cardiomyocytes, injection of fibroblast

 

  5   growth factor, or a combination of both.  As you

 

  6   can see, function is improved when you combine the

 

  7   two therapies.

 

  8             Recently, we have duplicated this study

 

  9   except that we used myoblasts and another growth

 

 10   factor, and we found exactly similar results.

 

 11             So, there are different ways of inducing

 

 12   angiogenesis, and I know Dr. Epstein is going to

 

 13   discuss that, but the point I wanted to make, this

 

 14   is, you know, the difference in cell survival

 

 15   between myoblasts alone and myoblasts plus an

 

 16   angiogenic growth factor.

 

 17             The point I would like to make is that

 

 18   probably in the future, you will have to deal with

 

 19   proposal of studies trying to combine cell

 

 20   transplantation with some form of angiogenesis just

 

 21   to optimize cell survival and potentiate the

 

 22   benefits of the intervention.

 

 23             A third point regards cycling.  This is

 

 24   the muscular biopsy of the patient who died.  I

 

 25   previously talked about this patient who died from

 

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  1   a stroke.  Initially, in this biopsy, and this is