1. 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

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

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

4. Collagenase Preclinical Studies%
Guidewire
crossing success *
Collagenase 450 µg
Placebo
Rabbit femoral artery CTO model
Circulation 2003; 108:
* 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

5. CTO-1 FIM Study

7. 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
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Strauss BH et al, Circulation 2012:125(3):522-8 7

8. 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

9. 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

10. Patient Characteristics
# Patients 28
Age median (range)
60 ( )
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 %

11. 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)

12. 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 mm)
82% crossed with soft guidewires (Fielder XT/Pilot 50 - tip loads 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)
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13. 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%)

14. 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 < )
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
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16. 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

17. Prior to Collagenase injection

18. Positioning of Finecross using Confienza Pro 9 GW for collagenase injection

19. Finecross microcatheter in position for collagenase injection

20. Initial attempt with Fielder XT guide wire

21. Pilot 50 guide wire, initial attempt

22. Crossing with Pilot 50 Guide wire

23. Post stenting: 3 DES, 74 mm length

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

25. 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
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26. 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)

27. CTO-2 Study Protocol

28. 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 or
US Principal Investigator, Dr. Aaron Grantham at
Dr. Bradley Strauss at