1. Bone Marrow Stem Cells in Cardiac Repair

2. 2 Dimmeler S et al. Arterioscler Thromb Vasc Biol. 2007;Oct. 19 epub. EC differentiation SMC differentiation Paracrine Effects Cardiac differentiation fusion Angiogenesis Attraction/ Activation of CSC Arteriogenesis Cardiomyocyte proliferation  Cardiomyocyte apoptosis Scar remodeling Modulation of inflammation FUNCTIONAL IMPROVEMENT Vasculo- genesis Cardio- myogenesis Cell homing and tissue integration Stem cells in cardiac repair: Proposed mechanisms of action

3. 3 Bone marrow cells promote myocardial regeneration: Postulated mechanism Orlic D et al. Nature. 2001;410:701-5. Transplanted Cells Infarcted myocardium Cell migration to damaged area Proliferation and differentiation Cytoplasmic proteinsNuclear proteins Functional competence Unknown molecular signal(s) Cardian myosin α-Sarcomeric actin Connexin 43 Csx/Nkx2.5 MEF2 GATA-4

4. 4 Deb A et al. Circulation. 2003;107:1247-9. Blue, green arrow = Y chromosome–positive true nucleus of BM Red = Derived cardiomyocyte cytoplasm (sarcomeric actin) surrounded by basement membrane laminin (green, arrowhead) Post-mortem analysis of 4 hearts of female recipients of male BM transplants Demonstration of Y-chromosomes in up to 23% of cardiomyocytes Cardiac stem cells are derived, in part, from bone marrow

5. 5 Communication between heart and bone marrow signals in repair Courtesy of Carl J. Pepine, MD SDF-1 SDF-1 transport CXCR4 Cell Recruitment Stem/progenitor cell Maturing leukocyte Heart Blood vessel endothelium Bone Bone marrow endosteum Blood vessel endothelium

6. 6 Orlic D et al. Nature. 2001;410:701-5. mm Hg 40 30 20 10 0 * * † LVEDP mm Hg 120 100 80 60 40 20 0 * * † LVDP mm Hg s -1 12000 8000 4000 0 * * † LV +dP/dt * * † LV –dP/dt mm Hg s -1 12000 8000 4000 0 SOMI + BMMISOMI + BMMI Ventricular function BMCs regenerate infarcted myocardium in mice

7. 7 Kamihata H et al. Circulation. 2001;104:1046-52. BMCs reduce perfusion defect in ischemic pig hearts

8. 8 Kamihata H et al. Circulation. 2001;104:1046-52. LAD LigationBM-MNC after 3 weeks BMCs enhance collaterals to infarct region

9. 9 BMC therapy increases angiogenesis in ischemic pig hearts In part via enhanced synthesis of angiogenic factors in the infarcted region (ie, VEGF) Kamihata H et al. Circulation. 2001;104:1046-52. BM-MNC (Factor-VII) Control Medium (Factor-VIII)

10. 10 Infarcted myocardium repair via autologous intracoronary mononuclear BMC transplantation Strauer BE, et al. Circulation. 2002;106:1913-8. Human model

11. 11 BMCs minimize infarcted myocardium region At 3 months: SV index 49  56, P = 0.01 Left ventricular end-systolic volume 82  67, P = 0.01 Thallium scintigraphy, cm 2 174  128 Strauer BE et al. Circulation. 2002;106:1913-8. Cell therapyStandard therapy 25 20 15 10 5 0 Infarct region (%) * P = 0.04

12. 12 Assessment of intracoronary cell therapy in AMI StudyDesign N enrolled (follow-up)Cell type Follow-up (months)Primary endpoint Strauer, 2002Non-RCT20(20)BMC3LVEF Bartunek, 2005Non-RCT35 (35)BMC4Safety, LVEF Jannsens, 2006RCT67 (66)BMC4LVEF BOOST, 2006RCT60 (60)BMC18LVEF, safety Zhan-Quang, 2006Non-RCT70 (58)PMC6LVEF, LV vol, WMSI MAGIC CELL-3- DES, 2006 RCT56 (50)PMC6LVEF TCT-STAMI, 2006RCT20 (20)BMC6LVEF ASTAMI, 2006RCT100 (97)BMC6LVEF, EDV, infarct size REPAIR-AMI, 2006RCT204 (197)BMC12LVEF Meluzin, 2006RCT66 (66)BMC3Infarct zone systolic function Lipinsky MJ et al. J Am Coll Cardiol. 2007;50:1761-7. PMC = peripheral mononuclear cells; RCT= randomized controlled trial; WMSI = wall motion score index.

13. 13 Effects of intracoronary cell therapy on LVEF Lipinsky MJ et al. J Am Coll Cardiol. 2007;50:1761-7. Test for heterogenicity, Chi 2 = 33.62,  f = 9 (P = 0.0001), P = 73.2% Test for overall effect: Z = 5.35 (P = 0.00001) StudyEF change % (random)EF change % or sub-category95% CI95% CI ASTAMI, 2005-1.49 (-2.81, 0.01) Bartunek, 2005-1.10 (-9.14, 2.94) BOOST, 2004-2.83 (-3.00, -0.60) Jannsens, 2004-1.10 (-2.68, 0.68) MAGIC-3, 2006-2.20 (-7.18, 1.23) Meluzin, 2006-2.03 (-2.94, -1.04) REPAIR-AM, 2006-2.59 (-1.54, -1.44) Strauer, 2002-1.03 (-4.06, 2.04) TCT-STAMI, 2006-6.70 (-1.89, -3.51) Zhan-Quan, 2006-5.50 (-3.19, -2.83) Total-2.97 (-1.04, -1.22) Favors cell therapyFavors control -10-50510

14. 14 Autologous CD34 + cells for intractable angina N = 24 patients with CCS class 3/4 angina G-CSF 5 μg/kg/day x 5 days Leukapheresis performed on Day 5 CD34 + cell selection NOGA-guided transplantation to zones of myocardial ischemia Phase I/IIa double-blind, 3:1 randomization, with crossover of placebo patients using frozen cells Losordo DW et al. Circulation. 2007;115:3165-72.

15. 15 Decrease in angina frequency with CD34 + cell therapy Months Losordo DW et al. Circulation. 2007;115:3165-72. 36