What‘s New: On classical and new adult cells?

Marc S. Penn, MD, PhD, FACCSkirball Laboratory for

Cardiovascular Cellular Therapeutics

Director, Center for Cardiovascular Cell TherapyDirector, Bakken Heart-Brain InstituteDepartments of Cardiovascular Medicine,

Biomedical Engineering and Stem Cell BiologySenior Medical Director, Emerging Businesses

Company Name Current RelationshipJuventas Therapeutics CSO, Equity, InventorIntellect, Inc. Equity, InventorCour Pharmaceuticals CMO, EquityPrognostix, Inc. CMO, Equity, InventorCardionomic, Inc. Equity, Inventor

BioHeart, Inc., SAB Member, Licensee

Oakwood Medical Ventures Venture Partner

Cardax Pharmaceuticals SAB Member

Athersys, Inc. Sponsored ResearchSDG, Inc. Sponsored ResearchCCO Technologies Sponsored ResearchCell Targeting Sponsored Research

Southwest Michigan Fund ConsultantMPI Research Consultant

DisclosuresDisclosures

03/2009

Clinical Strategies for Stem Clinical Strategies for Stem Cell TherapyCell Therapy

Cell Types of InterestCell Types of Interest

Embryonic Stem CellsTotipotent

Pluripotent

Hematopoietic SCCD117+, CD34+

Mesenchymal SCCD117-, CD34-, SH-1+

Monocytes, Neutrophils, . . . .Endothelial Cells, Hepatocytes

Cardiac Myocytes, Neurons

Umbilical Cord Stem CellsMAPCs

Skeletal Myoblasts

Cell Types of InterestCell Types of Interest

Embryonic Stem CellsTotipotent

Pluripotent

Hematopoietic SCCD117+, CD34+

Mesenchymal SCCD117-, CD34-, SH-1+

Monocytes, Neutrophils, . . . .Endothelial Cells, Hepatocytes

Cardiac Myocytes, Neurons

Umbilical Cord Stem CellsMAPCs

Skeletal Myoblasts

Direct Comparison of the Effects of Direct Comparison of the Effects of Allogeneic and Syngeneic MAPCAllogeneic and Syngeneic MAPC

• LAD ligation in Lewis Rat

• Genetically marked MAPC from– Lewis Rat (syngeneic)– SD Rat (allogeneic)

Vascular Effects of MAPCVascular Effects of MAPC

PBSPBS

LewisLewis

SDSD

vWFvWF SMASMA OverlayOverlay

MAPC into Lewis Rat at Time MAPC into Lewis Rat at Time of Acute MIof Acute MI

0

5

10

15

20

25

PBS Lewis SD

Sh

ort

en

ing

Fra

cti

on

(%

)

Source of MAPCSource of MAPC6 weeks after Acute MI6 weeks after Acute MI10 million MAPC or Saline at time of MI10 million MAPC or Saline at time of MI

75%51%

Summary of PreclinicalSummary of PreclinicalMAPC StudiesMAPC Studies

• Administration of MAPC to the heart at the time of AMI results in decreased inflammation and improved cardiac function

• Improvement is despite– Loss of viable MAPC over time– No evidence of myocardial regeneration

• Suggests improvement due to paracrine effects of MAPC

Clinical StrategyClinical Strategy

• Off the shelf cell product for allogeneic use

• Wanted easy to implement cell delivery strategy so that cells can be delivered at time of primary PCI

Adventitial Delivery Catheters

2.5 – 3.0 mm treatment range

Cricket

Micro-Infusion Catheter™

Both 510(k) cleared for delivery to vessel wall or perivascular area

Bullfrog™

Micro-Infusion Catheter

3.0 – 6.0 mm treatment range

Adventitial Micro-Infusion Adventitial Micro-Infusion Catheter OperationCatheter Operation

Adventitial Micro-Infusion Adventitial Micro-Infusion Catheter OperationCatheter Operation

Balloon shieldsmicroneedle

Needle is deployedwith inflation

Needle reachesadventitia for infusion

Porcine ModelPorcine Model

• Anterior wall MI induced by 90 min balloon occlusion of LAD

• MAPC delivery 2 days post AMI to animals with EF < 40%

Biodistribution Following Biodistribution Following Transarterial DeliveryTransarterial Delivery

Biodistribution Following Biodistribution Following Transarterial DeliveryTransarterial Delivery

Circumferential Distribution of gal positive cells

Radial Distribution of -gal positive cells

20

30

40

50

60

Baseline 1 Wk post-MI 4 Wk post MI

Eje

ctio

n F

ract

ion

%

***

MAPC 50MSaline

Acute MI Catheter-Based Acute MI Catheter-Based Delivery of MAPC Delivery of MAPC

Improvements in Functional Improvements in Functional Performance in GLP StudyPerformance in GLP Study

At Risk Territory

Non-Risk Territory

Summary of PreclinicalSummary of PreclinicalMAPC StudiesMAPC Studies

• Administration of MAPC to the heart at the time or 2 days after of AMI results in improved cardiac function

• Improvement is despite– Loss of viable MAPC over time– No evidence of myocardial regeneration

• Suggests improvement due to paracrine effects of MAPC

• Trans-arterial delivery of MAPC into infarcted myocardium is feasible

MultiStem® in Patients With Acute Myocardial Infarction

• PI – Marc Penn, MD, PhD• Co-PI - Warren Sherman, MD

• Sponsors – Athersys/Angiotech

Clinical StudyClinical Study

• Phase I study, open label, dose escalation– STEMI, LVEF between 30-45%

– Administration of MultiStem in coronary artery (via transarterial catheter) delivered on day 2-5 after Acute MI

– Multiple sites

• Objectives– Primary endpoints: safety: arrhythmias, acute toxicity,

hospitalization, death, mechanical complication

– Secondary endpoints: functionality measure

Clinical SynopsisClinical Synopsis

Delivery of MultiStem in Post-AMI Delivery of MultiStem in Post-AMI PatientPatient

5 sec 30 sec 60 sec

Advantage of the System Advantage of the System Approach Approach

• We have developed a clinically translatable system that allows for delivery of cell therapy to the myocardium at any time post primary PCI

MAPC Reduces Inflammation MAPC Reduces Inflammation

PBS

MAPC

Elastase staining in infarcted hearts

Neutrophil count in infarcted hearts

Rat AMI Model•LAD ligation and direct MAPC injection in infarct zone

•Sacrifice after 3 days

0

10

20

30

40

50

PBS MAPC

**

UpdateUpdate

• Cohort 1 with 20 million cells completed

• Cohort 2 with 50 million cells is enrolling

• Cohort 3 with 100 million cells is pending

Where next?Where next?

Stem Cell Based Tissue Stem Cell Based Tissue RepairRepair

• We proposed several years ago that:– Stem cell based repair of ischemic tissue in

mammals is a natural process but clinically inefficient due to dysregulation or short term expression of key molecular signals

Stromal Cell-Derived Factor-1Stromal Cell-Derived Factor-1(SDF-1)(SDF-1)

• Chemokine – receptor CXCR4/CXCR7

• Induces stem cell homing to bone marrow

• Lethal knockout secondary to abnormal hematopoietic trafficking

• SDF-1:CXCR4 blocks apoptotic cell death

Hypothesis: Hypothesis: Cell Therapy Induces Cell Therapy Induces Myocardial Repair by Temporally Aligning Myocardial Repair by Temporally Aligning

the SDF-1: CXCR4 axisthe SDF-1: CXCR4 axis

Time after Ischemic Injury

SDF-1

CXCR4

Exp

ress

ion

Time after Ischemic Injury

SDF-1

CXCR4

Exp

ress

ion

Ischemic PreconditioningPretreat MSC with hypoxiaOver-express CXCR4Growth Factors: IGF-1 & FGF2Exogenous CD34+

SDF-1 DeliveryMSC EngraftmentBMMNC Infusion

MSC Over-expressing SDF-1MSC Over-expressing SDF-1

0

200

400

600

0 6 12 18 24

T ime (h)

SD

F-1

Co

nce

ntr

atio

n in

Med

ia (

pg

/ml)

MSC

MSC:SDF-1

SDF-1 Leads to Preservation of SDF-1 Leads to Preservation of Cardiac MyocytesCardiac Myocytes

MSC:SDF-1Saline MSC

Cardiac Myosin

5 weeks after AMI5 weeks after AMI

SDF-1 Over-expression SDF-1 Over-expression Improves Cardiac FunctionImproves Cardiac Function

Eje

ctio

n F

ract

ion

(%

)

0

10

20

30

40

50

60

70

W eeks after AM I

0 1 2 3 4 5

S aline

MS C

MS C :S D F -1

78%

228%

SDF-1 Efficacy in PigsSDF-1 Efficacy in Pigs

Saline or control plasmid delivered 3 month after AMI

Endoventricular injection using Biocardia Catheter

Echo 30 day after injection

AWMI model in Pig

90 min Balloon occlusion of LAD

EF ~35%

SDF-1 Efficacy in PigsSDF-1 Efficacy in Pigs

-20

-10

0

10

20

30

% C

ha

ng

e in

EF

-30

-20

-10

0

10

20

30

40

PBS SDF-1 PBS SDF-1

SDF-1 Efficacy in PigsSDF-1 Efficacy in Pigs

% C

ha

ng

e in

EF

30 d 60 dTime after Treatment

30 d 60 dTime after Treatment

•SDF-1 Delivery 1 month after MI

•Baseline EF 31.2%

•N = 3-5 animals per dose

Can we test this hypothesis?Can we test this hypothesis?

CXCR4 is not required for Cardiac CXCR4 is not required for Cardiac Myocyte Development or FunctionMyocyte Development or Function

MCM-Cre: CXCR4f/f MLC-2v: CXCR4f/f

•No VSD

•No differences in EF, radial strain or circumferential strain compared to littermates lacking MLC-2v

SummarySummary

• “Classical” bone marrow derived mononuclear cells are progressing through clinical trials

• Novel cell types and delivery systems are offering the flexibility to deliver cell therapy at any time after reperfusion– Testing of hypotheses directly in clinical populations

• Defining mechanisms of action may allow for the development of novel therapeutic targets

Funding SourcesAmerican Heart AssociationNIHShalom FoundationSkirball FoundationState of OhioWilson Foundation

Commecial CollaborationsAthersys - MAPC studies

Bioheart Inc-SKMB:SDF-1 Preclinical and Clinical trials

Juventas Therapeutics- SDF-1 Clinical Development

AcknowledgementsAcknowledgements

Maritza Mayorga, PhD Jing Bian, PhDIndu Deglurkar, MD Niladri Mal, MDArman Askari, MD Samuel Unzek, MDZoran Popovic, MD Soren Schenk, MDNikolai Vasilyev, MD Kai Wang, MD, PhDMing Zhang, MD, PhD Xiaorong Zhou, MDMazen Khalil, MD Dominik Wiktor, MDYu Peng, MD

Udit Agarwal Srividia SundararamanAmanda Finan Nikolai Sopko

Farhad Forudi, BSMatthew Kiedrowski, BSKristal Weber, BS

CCFStephen Ellis, MDRavi Nair, MDPhil Howe, PhDJames Thomas, MD

CWRUStan Gerson, MD

AcknowledgementsAcknowledgements