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Cell Combination Therapy

Joshua M. Hare, M.D.

Louis Lemberg Professor

Senior Associate Dean

Chief Science Officer

Interdisciplinary Stem Cell Institute

The Miller School of Medicine, University of Miami

PACT WEBINARJune 19, 2018

Disclosures• Research Grants – Biocardia, Osiris

• UM Patent

• Consultant – Kardia, Vestion

• Equity – Kardia, Vestion, Heart Genomics, Biscayne Pharma, Longeveron

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Background on the Development of Cell Combination Therapy (CCT) for HF 

• Bone marrow MSCs lead to reverse remodeling in chronic ischemic cardiomyopathy and possible clinical benefits (being tested in phase 3 RCT)

• Mechanism of action– Neovascularization ‐ Reduction of fibrosis

– Immunomodulation ‐ Stimulation of myogenesis

• Enhancement of effect

Endocardial Length

Scar Thickness

Epicardial Cap

0

10

20

30

40

Baseline 18 months

Endocardial Length

0

2

4

6

Baseline 18 months

Scar Thickness

0

2

4

6

Baseline 18 months

Epicardial Cap

P=0.002P=0.005 P<0.001

Impact of MSCs on Scar Morphology

Baseline 18 monthsKarantalis Circ Res 2014

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TAC-HFT Trial – Scar Reduction and Regional Function

Pre 3M 6M 12M

Time Post-TESI

-40

-30

-20

-10

0

%C

ha

ng

e fr

om

Bas

elin

e

PlaceboBMCsMSCs

*p<0.05, **p<0.01, ***p<0.001Heldman et al. JAMA 2014

*

****

**

**

**

Pre 3M 6M 12M

Time Post-TESI

-20

-15

-10

-5

0

Ec

c in

th

e In

jec

ted

Zo

ne

PlaceboBMCsMSCs

*p<0.05, **p<0.01

*

**

Trial name Δ 6MWT ∆MLHFQ  ∆MI SIZE  ∆EF

Williams  et al. (n=8) … … ‐18±8.3% …

SCIPIO (n=21)  … ‐19.8  ‐9.8±3.5g (‐30%)  +8‐12.3%

MESOBLAST (n=60) +52.5 m* … … +5.2±9.3%*§

CADUCEUS (n=25)  +33.0 m  ‐10.8†  ‐12.9g (‐42%) †

POSEIDON (n=30)  +43.5 m  ‐7.6 ‐33.21 % g  +2.0%*†

C‐CURE (n=33)  +62.0 m  ±10*† … +7.0%

TAC‐HFT (n=59)  +32.6 m† ‐6.3  −12.6 g (−32.9%) †

MSC‐HF‡ (n=59) … … −4.4±5.1 g +5.5±3.8%

*Not significant vs control. †Not significant within‐group.

‡EHJ 2015. §25 million mesenchymal precursor cell group.

Sanina C. et al. Mesenchymal Stem Cells as a Biological Drug for Heart Disease: Where Are We With Cardiac Cell‐Based Therapy?Circ Res 2015 Jul 17;117(3):229‐33. doi: 10.1161/CIRCRESAHA.117.306306.

Results of Trials of Cell‐Based Therapy in Chronic Heart Failure:Emerging evidence for clinical efficacy

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• Major dilemma that has plagued the field: Long-term engraftment is minimal to absent

• Endogenous repair

Mechanism of action:  C‐Kit+ Cells and cell cycle activity in MSC treated hearts

Hatzistergos et al. Circ Res 2010

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Ex vivo co-culture enhances CSC proliferation and lineage commitment

Hatzistergos. Circ Res 2010

Targeting Endogenous Regeneration

• Cardiomyocyterenewal rates are 0.5 to 2% per year in adult humans

• Renewal rates increase following injury

Olaf Bergmann et al. Science 2009;324:98-102

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Interventions that Stimulate Endogenous Regeneration

• Injury

• Exercise

• Ventricular Geometry

• Cell-therapy

21.6% 15.3%

ckit+ hCSC

Impact of human ckit+ cardiac stem cell (hCSC) and bone marrow mesenchymal stem cells (hMSC) therapy on delayed enhancement cMRI scar size – Acute

Myocarial Infarction4 week post-injectionPre-injection Pre-injection 4 week post-injection

20.9% 16.6%

hMSC

20.7% 13.5%

ckit+ hCSC and hMSC

18.4% 17.5%

Placebo

(*p<0.05 within group ANOVA; †p<0.05 vs. placebo at 4 weeks post-injection and ╪p<0.05 vs. hCSC alone and hMSC alone at 4 weeks post-injection)

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Pressure Volume Loop HemodynamicsImproved diastolic function after combination hMSC and hCSC therapy

Placebo

ComboMSC/CSCTherapy

Pre-injection Post-injection

Williams et al. Circulation 2013. (*p<0.05 within group and **p<0.05 between groups)

Antifibrotic Effects of Cell Therapy: Chronic Ischemic CardiomyopathyPost MI 3m post  TESI

Scar size(DE): 7.4g Scar size (DE): 8.9g

MSCs MSCs

Scar size(DE): 9.7g Scar size (DE): 5.9g

Combo Combo

Scar size(DE): 8.9g Scar size (DE): 5.8g

Placebo Placebo

*P<0.05 1‐way ANOVA, **P<0.05 2‐way ANOVA multicomparisontest combo vs placebo,  + P<0.05 multicomparison test MSCs vs placebo    JACC 2015

P<0.0001

P<0.0001

3m post MI 1m 2m 3m -50

-40

-30

-20

-10

0

10

20

** ****

**

TESI

% S

car

Mas

s a

s %

LV

Mas

s

% V

iab

le T

issu

e M

ass

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Combined engraftment enhances repair in an autologous model of

chronic ischemic cardiomyopathy

Karantalis et al. JACC, 2015

Combination Of c-kit cells and mesenchymal cells: a Novel, dual Cell study Evaluating Regenerative properties for Treatment in

Chronic Heart Failure

Study Chair: Roberto Bolli, MD

Professor, Director of Cardiology

University of Louisville, Louisville, KY

The Cardiovascular Cell Therapy Research Network

The CONCERT-CHF Trial:

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Sample Size and Treatment Groups

• 144 subjects will be randomized 1:1:1:1

• 36 subjects/group to 1 of 4 treatment groups:

1. Combo: Target dose is a mixture of 150 million MSCs and 5 million CSCs

2. MSCs: Target dose is 150 million MSCs

3. CSCs: Target dose is 5 million CSCs

4. Placebo: Cell‐free PlasmaLyte‐A medium

• Run in phase (n=16)

• Each subject will receive 15 injections, each of 0.4 ml volume (cells or placebo)

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Organizational Structure: NHLBI Cardiovascular Cell Therapy Research Network (CCTRN)

Data Coordinating CenterUTSPHMoyé

NHLBIEbert

Texas Heart Texas Heart Institute

Steering Committee

ChairSimari

Cell Processing QC Lab

Univ of Miami

Biorepository & Core Labs

DSMBDSMBPRC

PDCs

U Florida MinneapolisMinneapolisHeart Inst.

U Louisville U Miami Stanford Indiana U

MDCore

MDCore

RCCore

RCCore

P & P

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A cKit+ myocardial lineage emerges on ~E9.5

A B C D

E F

Tam E9.5‐11.5 :: Analysis E18.5

cKitCreERT2/IRG

EGFPDsRedDapi

Hatzistergos et al. Circulation Research 2016

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C-Kit Cell Expansion Endomyocardial Biopsy Digestion

Cell Expansion

CD117+ Cell Sorting

Further Cell Expansion

Adherence to surface of cell culture flasks

Expansion Expansion

Sorting

ExpansionC-kit+ Cells C-kit+ Cells

P0

P1-P2P2-P3

Cell Growth

1.0E+03

4.0E+03

1.6E+04

6.4E+04

2.6E+05

1.0E+06

4.1E+06

1.6E+07

6.6E+07

2.6E+08

0 10 20 30 40 50 60 70 80

Cell Count

Days in culture

DCM 033

DCM 035

DCM 036

DCM 037

*DCM 037

*DCM 037, only 5million cells were Plated at P2, if 20million Plated, recovery 80million

Khan and Hare, Unpublished, 2015

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Cell Characterization

ckit ab 5506 98.91Ckit APC(eBioscience 17‐1171‐82) 

98.85

Ckit APC (eBioscience 17‐1179‐42) 

98.94DCM 037

ckit ab 5506 99.56Ckit APC (eBioscience17‐1171‐82) 

97.12

Ckit APC (eBioscience17‐1179‐42) 

94.53

DCM 035

DCM 036

ckit  ab 5506 99.65Ckit APC (Abcam ab130410) 

99.19

Ckit APC (eBioscience 17‐1171‐82) 

99.84

Khan and Hare, Unpublished, 2015

New Ongoing Efforts:Staged surgical palliation for patients with

hypoplastic left heart syndrome.

Brody Wehman, and Sunjay Kaushal Circulation Research. 2015;116:566-569

Copyright © American Heart Association, Inc. All rights reserved.

I Norwood II bidirectional III total cavopulmonary (Fontan)

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Conclusions and Implications• MSCs reduce scar tissue tissue by 30‐50%

• The replaced tissue is unequivocally contractile  

• Regeneration in the human heart, likely due to increased abundance of endogenous c‐kit cells and cell‐cycle activity 

• Lineage tracing studies show that MSCs activate myocardial c‐kit cells

• Three studies show unequivocal evidence of c‐kit differentiation into cardiac myocytes (BMP regulation)

• The interaction of MSCs and c‐kit cells forms the basis for a novel therapeutic principle – cell combination therapy – which is in clinical trial

Soffer Family Foundation,Starr, Marcus