Collagenase for CTO: An update Bradley H Collagenase for CTO: An update Bradley H. Strauss MD, PhD Chief, Schulich Heart Program Reichmann Chair in Cardiovascular Research Sunnybrook Health Sciences Centre University of Toronto Toronto, Canada

Bradley H. Strauss, MD, PhD Stocks, Stock Options, other ownership interest: Matrizyme Pharmaceuticals Off Label: Collagenase for facilitating guidewire crossing in total occlusions

Collagen: An important CTO target Increased fibrocalcific plaques with age Srivatsa et al, J Am Coll Cardiol 1997:29:955-63

Collagenase Preclinical Studies % Guidewire crossing success * Collagenase 450 µg Placebo Rabbit femoral artery CTO model Circulation 2003; 108:1259-62 * p=0.028 In preclinical CTO models, local delivery of collagenase directly into the CTO significantly increasd guide wire crossing rates, without damaging deeper structures in the arterial wall

CTO-1 FIM Study

Collagenase Total Occlusion (CTO)-1 Trial Phase I safety and feasibility study Two Toronto centers, 28 patients All patients had previously failed CTO attempts Dose range 300 – 1,200 µg CTO-1: Four increasing dose cohorts (5 patients/dose) CTO-1A: Additional 8 patients at highest dose Two stage procedure Day #1: Intracoronary collagenase injection Day #2: PCI Follow up 3 month Coronary CT Angiogram This is the Bulleted List slide. To create this particular slide, click the NEW SLIDE button on your toolbar and choose the BULLETED LIST format. (Top row, second from left) The Sub-Heading and footnote will not appear when you insert a new slide. If you need either one, copy and paste it from the sample slide. If you choose not to use a Sub-Heading, let us know when you hand in your presentation for clean-up and we’ll adjust where the bullets begin on your master page. Also, be sure to insert the presentation title onto the BULLETED LIST MASTER as follows: Choose View / Master / Slide Master from your menu. Select the text at the bottom of the slide and type in a short version of your presentation title. Click the SLIDE VIEW button in the lower left hand part of your screen to return to the slide show. (Small white rectangle) Strauss BH et al, Circulation 2012:125(3):522-8 7

MZ-004 Collagenase Formulation GMP Biologic made by Fermentation Clostridium histolyticum Initiates collagen degradation Bacterial collagenase more effective than human collagenase at degradation of human collagen Collagenase enzyme present as several isoforms Molecular weight range: 68,000 to 130,000 Da Minimal amount of additional proteases Formulation’s activity and dosage are optimized active enough to degrade collagen limited effect on artery wall Strauss BH et al, Circulation 2012:125(3):522-8

Strauss BH et al, Circulation 2012:125(3):522-8 Local Delivery of MZ-004 Over-the-wire balloon catheter (proximal to CTO) n=8 FineCrossTM Microcatheter(directly into CTO) n=20 Strauss BH et al, Circulation 2012:125(3):522-8

Patient Characteristics # Patients 28 Age median (range) 60 (40 - 79) Male % 100 Hypertension % 75 Hyperlipidemia % Diabetes mellitus % 32 Previous MI % 25 CCS Class I/II/III/IV 2/16/9/1 LV EF 55% ± 10% Q wave in territory %

Lesion Characteristics 28 pts LAD/LCx/RCA 36% / 25% / 39% Lesion Length (median) 18 mm (Q1 = 15, Q3 = 28 mm) Lesion Length > 20 mm 40% Reference Diameter 2.87 mm (Q1=2.54, Q3=3.22) Blunt Entry 55% Side Branch at Occlusion 57% Occlusion Age (median) 12.5 mths (Q1 = 7, Q3 = 32)

CTO-1 Procedural Outcomes 21/28 CTO successfully crossed and stented 22nd successful case at 4 month reattempt: initially subintimal balloon dilation in LAD CTO Mean stent length 67 mm ± 21 (range 23 - 102 mm) 82% crossed with soft guidewires (Fielder XT/Pilot 50 - tip loads 1-1.5 g) 14/22 (64%) entire CTO 4/22 (18%) up to distal cap where stiff wire used 4/22 (18%) mainly stiff guidewires (Confianza PRO 9/12) This is the Bulleted List slide. To create this particular slide, click the NEW SLIDE button on your toolbar and choose the BULLETED LIST format. (Top row, second from left) The Sub-Heading and footnote will not appear when you insert a new slide. If you need either one, copy and paste it from the sample slide. If you choose not to use a Sub-Heading, let us know when you hand in your presentation for clean-up and we’ll adjust where the bullets begin on your master page. Also, be sure to insert the presentation title onto the BULLETED LIST MASTER as follows: Choose View / Master / Slide Master from your menu. Select the text at the bottom of the slide and type in a short version of your presentation title. Click the SLIDE VIEW button in the lower left hand part of your screen to return to the slide show. (Small white rectangle) 12

Subgroups Success by Vessel Success by Lesion Length LAD 8/10 (80%)- 2 early cases, technical issues LCx 7/7 (100%) RCA 6/11 (55%)- long CTO >30 mm Success by Lesion Length <25 mm: 14/18 (78%) ≥ 25 mm: 7/10 (70%) ≥ 30 mm: 4/6 (67%)

Follow Up: In-Hospital and 6 months Procedural complications: Small (< 1 cm) pericardial effusion in 1 patient post PCI 3 Non STEMI due to side branch ischemia total CK/CK-MB: 411/16, 493/54, 330/80 Clinical follow-up: Anginal improvement at 1 month CCS Class 2.3  0.7 to 0.9  1.0 (p < 0.001) For PCI success group: CCS Class 2.3  0.7 to 0.4  0.7 (p < 0.0001) CTA/Cath at 3-6 months in all patients All stented arteries patent No myocardial / pericardial changes 2 peri-stent restenoses at CTA with subsequent TVR This is the Bulleted List slide. To create this particular slide, click the NEW SLIDE button on your toolbar and choose the BULLETED LIST format. (Top row, second from left) The Sub-Heading and footnote will not appear when you insert a new slide. If you need either one, copy and paste it from the sample slide. If you choose not to use a Sub-Heading, let us know when you hand in your presentation for clean-up and we’ll adjust where the bullets begin on your master page. Also, be sure to insert the presentation title onto the BULLETED LIST MASTER as follows: Choose View / Master / Slide Master from your menu. Select the text at the bottom of the slide and type in a short version of your presentation title. Click the SLIDE VIEW button in the lower left hand part of your screen to return to the slide show. (Small white rectangle) 14

Case History 50 year old truck driver, type II diabetic Positive GXT at second stage in February 2011 Cath: 100% RCA, 100% LCx- no known MI PET showed posterior and lateral wall viability 1st attempt June 2011: Fielder XT, MB12, pilot 200 without any penetration into CTO

Prior to Collagenase injection

Positioning of Finecross using Confienza Pro 9 GW for collagenase injection

Finecross microcatheter in position for collagenase injection

Initial attempt with Fielder XT guide wire

Pilot 50 guide wire, initial attempt

Crossing with Pilot 50 Guide wire

Post stenting: 3 DES, 74 mm length

Does Collagenase Soften CTO? 2.5 hrs 5 hrs Thind A et al, submitted

CTO-2 Study Overview Principal Investigator Overall: Dr. Christopher Buller (Toronto) US: Dr. Aaron Grantham (Kansas City) Objectives to assess efficacy (anginal relief and physical limitations based on SAQ and guidewire crossing) and safety of 1,200 μg intra- lesional MZ-004 in symptomatic CTO patients FDA phase-3 Design Overview open label training phase (up to 3 patients/site) prospective, multi-center, placebo controlled, double-blinded up to 50 centers in Canada and USA At least 415 patients with CCS class II / III This is the Bulleted List slide. To create this particular slide, click the NEW SLIDE button on your toolbar and choose the BULLETED LIST format. (Top row, second from left) The Sub-Heading and footnote will not appear when you insert a new slide. If you need either one, copy and paste it from the sample slide. If you choose not to use a Sub-Heading, let us know when you hand in your presentation for clean-up and we’ll adjust where the bullets begin on your master page. Also, be sure to insert the presentation title onto the BULLETED LIST MASTER as follows: Choose View / Master / Slide Master from your menu. Select the text at the bottom of the slide and type in a short version of your presentation title. Click the SLIDE VIEW button in the lower left hand part of your screen to return to the slide show. (Small white rectangle) 25

CTO-2 Lesion Eligibility Non-Yielding Lesion Criteria – Antegrade Either (1) history of unsuccessful PCI at index occlusion with documentation of above non-yielding criteria during that attempt Or (2) estimated visual lesion length ≤ 25 mm 10 minutes flouroscopy time from cap contact at least 1 CTO guide (any MB, any Progress, any Confianza, Pilot 150 or 200)

CTO-2 Study Protocol

Collagenase Total Occlusion-2 (CTO-2) Randomized Trial Collagenase versus Placebo in CTO For more information related to CTO-2 please contact: Principal Investigator, Dr. Christopher Buller at BullerC@smh.ca or US Principal Investigator, Dr. Aaron Grantham at jgrantham@saint-lukes.org Dr. Bradley Strauss at Bradley.Strauss@sunnybrook.ca