1. M. Valgimigli University of Ferrara Italy Autologous bone marrow stem cell mobilization Induced by G-CSF after MI Autologous bone marrow stem cell mobilization Induced by G-CSF after MI FOURTH INTERNATIONAL SYMPOSIUM ON STEM CELL THERAPY AND APPLIED CARDIOVASCULAR BIOLOGY Madrid, 26°April 2007

2. Direct Inoculation

3. The New Paradigm? The “NO TOUCH” policy

4. CD 34 + in AMI Patients *: p<0,01 vs. day 1 Valgimigli M et al.

5. Mobilized bone marrow cells repair the infarcted heart, improving survival 6 mice Splenectomized 2 wks 200 µg/kg/day SCF 50 µ g/kg/day G-CSF 5 dys 3 dys CoronaryLigation Euthanized 27 dys later Orlic D, PNAS 2001

6. G-CSF: the ideal candidate Dose-dependent BM stem cells mobilisizer Dose-dependent BM stem cells mobilisizer Safety established on healthy donors Safety established on healthy donors Reassuring long-term data available Reassuring long-term data availableHowever: Platelet activation with shortening of bleeding time* Platelet activation with shortening of bleeding time* Fibrinogen and FVIII protein C and S* Fibrinogen and FVIII protein C and S* Sporadical occurence of AMI in healthy donors Sporadical occurence of AMI in healthy donors *:Bone marrow transplantation 98; 22: 1087

7. Study Flow-chart Primary PCI if eligible if eligible G-CSF 5 µg/kg/day or placebo Single blind study Hospital admission ASA; clopidogrel, UFH GP IIb/IIIa inhibitors 4 days Deferred PCI if eligible gated-SPECT 99mTc-sestamibi (740 MBq), gated-SPECT Discharge 3 months 6 months Baseline 1°2° 3°4° 6 d 7 d 10 d 14 d CD34+; CD34-CD133-KDR+, e-CFU Hb, WBC, PLT, urate, ESR, LDH,  GT, AP, CRP

8. Estimated sample size: 60 pts (20 per group) Enrolment prematurely terminated for safety concerns about restenosis Restenosis 71% Cell infusion 66% G-CSF Lancet 2004; 363: 751

9. Study Flow-chart Primary PCI if eligible if eligible G-CSF 5 µg/kg/day or placebo Single blind study ASA; clopidogrel, UFH GP IIb/IIIa inhibitors 4 days Deferred PCI if eligible gated-SPECT 99mTc-sestamibi (740 MBq), gated-SPECT Discharge 3 months Baseline 1°2° 3°4° 6 d 7 d 10 d 14 d CD34+; CD34-CD133-KDR+, e-CFU Hb, WBC, PLT, urate, ESR, LDH,  GT, AP, CRP Angiographic Follow-up 6 months Hospital admission

10. Use of G-CSF during AMI to Enhance BMSC in Humans Clinical Safety Profile 20 pts out of 47 screened with AMI 3 pts per group not treated with 1° PCI due to late presentation, subsequently 1 pt per group underwent deferred PCI for evidence of myocardial viability in the infarcted area Syntoms Onset to G-CSG: 37±265 hours (3-265) in the whole population 16±66 hours (3-61) in those submitted to pPCI and Angiographic Valgimigli et al. EHJ 2005;26: 1838–1845

11. G-CSF administration during MI to enhance BMSC mobilisation Valgimigli et al. EHJ 2005;26: 1838–1845

12. G-CSF Impact on LV function at Gated-SPECT

13. G-CSF Safety Issues The drug was well tolerated-No complains-No arrhythmic events 1/8 in placebo group and 0/8 in G-CSF developed binary restenosis Valgimigli et al. EHJ 2005;26: 1838–1845

14. G-CSF in AMI Study Interval from AMI to PCI; h Interval from PCI to G-CSF injection, h G-CSF dosage µg/kg/d G-CSF administratio n in days MNC CD34+ max/ MNC CD34+ bl after G-CSF G-CSFControlG-CSF Control MAGIC 1464 †† 144 ** n.a.104 -- Valgimigli et al 663754151.8 Ince et al 551.5106202.1 REVIVAL-2 Within 12 Within 12 120105141 STEMMI 3429106191 Engelmann MG et al. >6 h up to 7 d 31±24 (2-107) 10 5 23 1 Takano H et al. 66152.55151.6 Ellis S et al. 6/121528/315/10529/376.8

15. G-CSF in AMI MAGIC Valgimigli et al. Ince et al. REVIVAL-2 STEMMI Engelmann MG et al. Takano H et al. Ellis S et al. P=0.71 G-CSF Group

16. G-CSF in AMI MAGIC Valgimigli et al. Ince et al. REVIVAL-2 STEMMI Engelmann MG et al. Takano H et al. Ellis S et al. +6 -4

17. G-CSF in AMI MAGIC Valgimigli et al Ince et al. REVIVAL-2 STEMMI Engelmann MG et al. Takano H et al. Ellis S et al.

18. G-CSF in AMI MAGIC Valgimigli et al. Ince et al. REVIVAL-2 STEMMI Engelmann MG et al. Takano H et al. Ellis S et al.

19. G-CSF in AMI MAGIC Valgimigli et al. Ince et al. REVIVAL-2 STEMMI Engelmann MG et al. Takano H et al. Ellis S et al. P=0.007 P=0.035 n.s.

20. G-CSF in AMI MAGIC Valgimigli et al. Ince et al. REVIVAL-2 STEMMI Engelmann MG et al. Takano H et al. Ellis S et al.

21. G-CSF in AMI MAGIC Valgimigli et al. Ince et al. REVIVAL-2 STEMMI Engelmann MG et al. Takano H et al. Ellis S et al. Change in EF at 30 days (%) Change in EF at 30 days (%) P=ns

22. G-CSF in AMI MAGIC Valgimigli et al. Ince et al. REVIVAL-2 STEMMI Engelmann MG et al. Takano H et al. Ellis S et al.

23. Timing of treatment with respect to onset of symptoms G-CSF in AMI MAGIC Valgimigli et al. Ince et al. REVIVAL-2 STEMMI Engelmann MG et al. Takano H et al. Ellis S et al.

24. Targeting the proper patient population Severe LV function impairment Anterior wall MI Suboptimal mechanical reperfusion G-CSF in AMI MAGIC Valgimigli et al. Ince et al. REVIVAL-2 STEMMI Engelmann MG et al. Takano H et al. Ellis S et al. No data beyond 30 days No data beyond 30 days 12 pts G-CSF vs. 6 controls

25. Rigenera Study 14 G-CSF vs. 27 controls Anterior MI with EF <50% after 5 days Courtesy of Leone AM. LV end diastolic volume (ml)

26. Rigenera Study 14 G-CSF vs. 27 controls Anterior MI with EF <50% after 5 days Courtesy of Leone AM.

27. G-CSF and Binary restenosis systematic review of the literature Ince et al. submitted

28. Individual patient data meta-analysis Ince et al. submitted

29. ConclusionsConclusions G-CSF administration in acute MI is feasible No REAL concern regarding clinical and ANGIOGRAPHIC safety profile The effect of this treatment on LV function improvement remains unclear The time has arrived for a multicenter RCT a multicenter RCT The time has arrived for a multicenter RCT a multicenter RCT