2. Regeneration and stem cells Definition 1) Self-renewing capability  Clonal expansion 2) Differentiation into various types of cells, multipotent = self renewal

3. Why stem cell research in CV medicine? Rising Mortality from cardiovascular diseases TNF-α Poor prognosis of cardiovascular diseases 824 6 0 20 40 60 80 100 Survival curve of heart failure Survival curve of advanced gastric cancer Ischemic heart disease mortality per 100,000 198619881990199219941996199820002002 0 5 10 15 20 25 30 Mortality in Korea due to ischemic heart disease (Korea National Statistical Office, 2003)

4. Mechanism of Action Effects on Loss of myocardiumInadequate blood supply Medical Treatment Inhibit neurohumoral response May prevent further loss+ Cardiac resynchronization therapy Resynchronize contraction - +/- Surgical ventricular restoration Restoring geometry - +/- Ventricular assist deviceUnloading cardiac load - +/- Artificial heart New mechanical contractile apparatus +++Not indicated Heart TransplantationNew heart+++ Stem cell therapy Regeneration of myocardium and blood vessels ++ Why stem cell research in CV medicine?

5. NMethod of delivery (Underling disease)LVEFFollow-up PeriodDonor cellComplications Hamano et al5Myocardial injection during CABG (OMI)NAUp to 1 yBone marrow cellsNone Strauer et al10Intracoronary infusion after PCI (AMI)57%3 moBone marrow cellsNone Assmus et al20Intracoronary infusion after PCI (AMI)51%4 moBone marrow cells/ Progenitor cells None Menasché et al10Myocardial injection during CABG (OMI)24%10.9 moSkeletal myoblastsDeath, VT Stamm et al12Myocardial injection during CABG (OMI)36%3-9 moBone marrow cellsSVT Pagani et al5Myocardial injection during LVAD (OM)NA68-191 dSkeletal myoblastsArrhythmia, LVAD death Tse et al8Myocardial injection during catheterization (angina) 58%3 moBone marrow cellsNone Perin et al14Myocardial injection during catheterization (OMI)30%4 moBone marrow cellsDeath Galinaes et al21Myocardial injection during CABG (OMI)NA10 moBone marrow cellsNone BOOSTl65Intracoronary infusion after PCI (AMI)50%6 moBone marrow cellsNone Smits et al5Myocardial injection during catheterization36%6 moSkeletal myoblastsVT MAGIC 1,242Intracoronary infusion after PCI (AMI+OMI)49%1 yPeripheral blood cells Restenosis Aviles et al5Intracoronary infusion after PCI (AMI)53%6 moBone marrow cellsHeart attack Chen et al34Intracoronary infusion after PCI (AMI)49%6 moBone marrow cellsNone Earlier Clinical Trials of Cell Therapy for IHD in recent 10 yrs

6. NameNUnderling disease Method of delivery Change of LVEF Follow-up Period Donor cellComplication REPAIR217AMIIC2.5%4MBMnone MAGIC-3-DES150AMI/OMIIC5.9% (AMI)6MPBSCnone TOPCARE-DCM20DCMICLAD2.8%3MBMnone TOPCARE-CHD109OMIIC4.8% vs. 2.8% 4MBM,CPCnone TOPCARE- Crossover 48ICMPIC2% vs. 0%2MBM/CPCnone ASTAMI100Ant. AMIICNone6MBMnone Hendrikx et al20OMICABGNone4MBMnone Herbots et al67AMIICNone4MBMnone Hambrecht et al26OMI CTOIC8%3MCPCnone IACT/Strauer18OMIIC7%3MBMrestenosis (6%) Erbs et al26OMI CTOIC7.1%3MCPCnone Zbinden et a14Anginanone-2wkGMCSF only2 ACS Hill et al16Anginanone-1MGCSF only 2MI Later Clinical Trials of Cell Therapy for IHD in recent 10 yrs

7. Scheme of Clinical Trials for CardioVascular Regeneration Therapy Surgical Ecto-Myo injection Trans-catheter Endo-Myo injection Intracoronary Infusion Skeletal Myoblast (Genetic Engineering) Bone Marrow Stem Cells Peripheral Blood Stem Cells Adipose Tissue Stem Cells In-situ Cardiac Stem Cells Umbilical Cord Blood Stem Cells Delivery StrategySource of Stem Cells X

8. Skeletal myoblast: MyoCell TM Skeletal myoblast: MyoCell TM program in SNUH cell selection & expansion final 50 million cells/cc patient muscle biopsy intramyocardial cell injection ICD injection catheter xxx xxx xxx x 25 million cells/site x 10 sites

9. Bone marrow-derived stem cell NIH Stem Cell Book 2006, Cho et al 2006 Regenerative Medicine

10. Adipose-derived stem cell: ASC Gimble et al, Circ Res 2004 Gimble et al, Circulation 2007

11. Cardiac stem/progenitor cell Beltrami A et al Cell 2003, Barile L et al NCPC 2007 nucleus c-kit Nkx2.5 α-sarcomeric actin

12. Umbilical cord blood-derived stem cell Separation of MNCs UCB Harvest Seeding & Incubation Monolayer of cultured cells - Prolonged proliferation - Multi-potential differentiation - Immunological privilege (allogeneic source)  HLA II 음성  T cell co-stimulatory molecules 음성 (B7-1, B7-2, CD40, CD40L 음성 )  MLR inhibition  fail to induce allogenic T cell response in vivo

13. MAGIC cell program: Myocardial Regeneration and Angiogenesis in Patient with Myocardial Infarction using G-CSF mobilization and Intra-Coronary Stem Cell Infusion G-CSF injection for 3days Intracoronary infusion of stem cells Apheresis Mob PBSCs Kang HJ, Kim HS, et al. Lancet 2004Kang HJ, Kim HS, et al. Can Med Asso J 2004 Kang HJ,,,, Kim HS. Circulation 2006Kang HJ,,,, Kim HS. Am Heart J 2007 Kang HJ,,,, Kim HS. Heart 2007Kang JH & Kim HS. Exp Rev Card Thr 2008 Chang SA,,,, Kang HJ, Kim HS. Heart 2008Kang HJ & Kim HS. EHJ Supp 2008 Park KW,,,, Kim HS. JMCC 2008Kim YJ,,,, Kim HS. Heart 2009 Chang SA, Kang HJ,,,, Kim HS. Heart 2009Kang HJ,,,, Kim HS. Trials 2011 Kang HJ,,, Kim HS. Cell Transplantation 2012Kang HJ,,, Kim HS. Euro Heart J 2012

14. MAGIC Cell program in SNUH [Seoul National University Hospital, Korea] MAGIC Cell-1 MAGIC Cell-2 MAGIC Cell-3-DES MAGIC Cell-4-ICMP G-CSF and endothelial function Effect of Cell infusion on LV dyssynchrony G-CSF and Restenosis, coronary remodeling MAGIC Cell-5 : G-CSF vs. Cell infusion vs. control in elective PCI : G-CSF vs. control in AMI who underwent primary PCI : Cell infusion vs. control in AMI and OMI with DES : Cell infusion in ischemic CMP without PCI 2003 2004 2005 2006 2007 2008 2009 2010 1st generation stem cell therapy 1.5th generation stem cell therapy 2nd generation stem cell therapy : cell infusion with combicytokine vs. G-CSF MAGIC Cell-6 : waiting for agent development

15. MAGIC Cell-3-DES & 4-ICMP trial from Feb 2004 DES solved restenosis problem of G-CSF. Additional cell infusion is better than control in AMI rather than OMI MAGIC Cell-5-CombiCyto trial from April 2007 To enhance homing rate and therapeutic efficacy MAGIC Cell-1,2 trial from Dec 2002 Additional cell infusion is better than G-CSF alone. NIH may be a concern of G-CSF. SNUH MAGIC Cell Program