From Bench to Bedside Step 1:First-time application of DESWT in a rodent model of ischemic HF (pilot trial); redesign of device Step 2:In-vitro validation Step 3: Reproduction of results of pilot trial in a rodent large scale trial (320 rodents); human fitting studies Step 4: Reproduction of the results of the rodent large scale trial in a large animal (pig) model; human fitting studies Step 5: Phase I clinical trial with external data monitoring

Pilot Trials Trials show promising results, exceeding com- parable stem cell trials. Main problem: size of the applicator

8 Weeks Later: Cardiac Shock Wave Applicator CardioGold ® CG050 CRT – Cardiac Regeneration Technologies, Woodstock, USA (manufactured by MTS-Europe GmbH, Konstanz, Germany) Electro-hydraulic, focused, ECG-triggering facility EFD: 0.38 mJ/mm 2 Frequency: 1-5 Hz 35mm

In-vitro Experiments heater adapter temp. sensor distance bar appl. fixation Shock Wave Devices Water bath – prototype Degassed water, temperature 37°C DermaGold ® CP155 (TRT, USA) 300 impulses at 0.15 mJ/mm 2, 5 Hz

In-vitro Experiments Mean cell duplication time Connexine 43 = cell contact, communication Cardiomyocytes (= heart muscle cells) Endothelial cells (= vessel cells) Fibroblasts (= cells of connective tissue)

Rodent Large Scale Trial – Results from 320 rats! ___ SWT ___ Controls * p<.05 to pre MI † p<.05 to post MI ‡ p<.05 SWT Group vs. Controls * * * * * * † † ‡ ‡

Next Step: Large Animal Trial 25 Domestic pigs: Myocardial infarction by LAD ligation 3 Groups: Sham = healthy subjects SWT = LAD ligation with SWT Control = LAD ligation without SWT Timeline: d0 week 4 week 8 ▼ _______________ ▼ _______________ ▼ LAD lig./sham OP SWT/sham OP Termination

LV ejection fraction % * p<.05 vs. pre MI + p<.05 vs. 4 weeks post MI d0week 4 week 8 controlSWT ** Ventricular Function LVEF * + 68 ± 0.7% 43 ± 2.5% 62 ± 9.1% 46 ± 5%

First Human Application – Study Design Title: DESWT - Safety of Myocardial Regeneration by Direct Epicardial Shock Wave Therapy in Combination with Coronary Artery Bypass Grafting Design: Prospective, Phase I Enrollment: Commenced September 2008, 10 Patients – last patient enrolled June 2009 Primary Endpoint: Safety Secondary Endpoint: Efficacy Study outline: CABG+DESWT 8-week FUP 6-month FUP ▼_______________▼______________▼

First Human Application (Sep. 23, 2008)

First Human Application (Sep. 23, 2008)

 Death  Myocardial infarction  Bleeding, including pericardial tamponade  Ventricular arrhythmias  Bacteriaemia / sepsis  Respiratory failure  CPR  Lesions related to DESWT (cardiac, intrathoracic)  Renal failure  Liver failure  Low cardiac output syndrome  CVA (Stroke/Bleeding/TIA)  Re-hospitalization  Other non-anticipated events fulfilling the definition for AEs/SAEs Primary Endpoint - Safety

 Myocardial contractility  Cardiac MRI  Symptoms of heart failure  Minnesota Heart Failure Questionnaire  Six-minute walk test  Serum levels of proBNP  Device failures and malfunctions Secondary Endpoint - Efficacy

Primary Endpoint AE/SAE´s Perioperative 1 Pat. ventricular arrhytmia 1st. to 3rd p.o. day 1 Pat. prolonged ICU stay, mediastinitis 1 Pat. post-op bleeding (no surgical revision) Follow-Up Follow-Up 3 Pat. rehospitalization (embolism, pneumonia, pacemaker implant) None of the complications device related!

* P < 0.05 to baseline Left Ventricular Ejection Fraction * Gavira JJ JTCVS 2006 * LVEF % less late enhancement in all patients Improvement of wall motion in all patients

Left Ventricular Wall Motion Global Treated areas = infarct * P < 0.05 to baseline ** **

Left Ventricular Volumes * P < 0.05 to baseline ** End Diastolic Volume End Systolic Volume **

6-Minute Walk Test * P < 0.05 to baseline *

Minnesota Heart Failure Questionnaire * P < 0.05 to baseline *

Conclusion  DESWT is SAFE  Neo – Angiogenesis  VEGF, PIGF, Flt-1  Endogenous angiogenetic pathway activation ?  Stem cell homing ?  Improvement of LV function  Global and regional LV function  proBNP surrogate for heart failure  Improvement of Symptoms  6-MWT gold standard of symtom assessment in heart failure  Patients feel the difference – Minesota Heart Failure Questionnaire

Conclusion  Safe and simple method for myocardial regeneration  Bench to bedside completed  Next logical step – prospective randomized trial  Continuation of basic research (working mechanism)  Continuation of human trials (histology, stem cells)  Continuation of animal trials (dose-reaction, working mechanism)  Customized device, disposable therapy head  Cell cultivation, cell seeding on scaffolds ………