1. CV-1 Everolimus Intravascular Ultrasound (IVUS) Results of Study B253 in De Novo Heart Transplantation Jon A. Kobashigawa, MD Clinical Professor of Medicine/Cardiology Chief, Division of Clinical Faculty Medicine The David Geffen School of Medicine at UCLA Medical Director, UCLA Heart Transplant Program QC

2. CV-2 Outline of the IVUS Presentation  IVUS background  IVUS B253 study –Primary analysis results –Bias assessments –Sensitivity analysis  Summary QC

3. 3.1 mm Angiography vs Intravascular Ultrasound QC

4. CV-4 Intimal Area Intimal Area Media-adventitial area Media-adventitial area Media-adventitia (MA) Cross sectional area (mm 2 ) Maximal diameter (mm) Minimal diameter (mm) Minimal intimal thickness Minimal intimal thickness Maximal intimal thickness (MIT) Maximal intimal thickness (MIT) Intimal thickness Maximal intimal thickness (mm) Intimal area (mm 2 ) Minimal intimal thickness (mm) Lumen area Lumen Cross sectional area (mm 2 ) Maximal diameter (mm) Minimal diameter (mm) Courtesy of R. Starling, Cleveland Clinic. Intravascular Ultrasound Measurements QC

5. CV-5 Segment and Image Selection 18 17 14 12 10 8 6 4 2 16 15 13 11 9 7 5 3 1 18 mm 18 images Segments were identified: Automatic pullback (0.5 mm/sec), side branches. Frames at 1-mm intervals for measurements, minimum of 11 matched images. 102-25 QC

6. CV-6 MIT = 0 MIT > 0.5 mm Baseline (4 to 6 weeks) Year 1 Site-to-Site IVUS Analysis QC

7. CV-7 Measurement of Maximal Intimal Thickness (MIT) for Transplant Vasculopathy and Outcome  MIT accepted as standard method for CAV measurement a  Change in MIT ≥ 0.5 mm associated with b-d –Increased major adverse cardiovascular events (MACE: AMI, CHF, PCI, CABG, ICD, SD, CVA, PVD) –Reduced cardiac and overall survival e –Represents an important intermediate outcome a Mintz GS, et al. J Am Coll Cardiol. 2001;37:1478-1492. b Mehra MR, et al. J Heart Lung Transplant. 1995;4:632-639. c Kapadia SR, et al. Curr Opin Cardiol. 1999; 14:140-150. d Kobashigawa, et al. J Am Coll Cardiol. 2005;45:1532-1537. e Tuzcu EM, et al. J Am Coll Cardiol. 2005;45:1538-1542. 112-10 QC

8. CV-8 Kobashigawa J, et al. J Am Coll Cardiol. 2005;45:1532-1537. Multicenter IVUS Validation Study in Heart Transplantation (CAV: Change in MIT ≥ 0.5 mm) Without CAV at 1 year (n = 101) With CAV at 1 year (n = 24) Death Time to event (months) 01224364860 Freedom from event (%) P = 0.025 0 Time to event (months) Freedom from event (%) Nonfatal MACE/death 1224364860 0 10 20 30 40 50 60 70 80 90 100 P = 0.001 QC 0 10 20 30 40 50 60 70 80 90 100

9. CV-9 CAV at 1 year and Mortality and Myocardial Infarction (CAV: Change in MIT ≥ 0.5 mm) CAV = Cardiac allograft vasculopathy. Tuzcu EM, et al. J Am Coll Cardiol. 2005;45;1538-1542. 100 80 60 40 0 020406080100120 Time, months Death Freedom from event (%) 100 80 60 40 0 020406080100120 Time, months Nonfatal MI and death P = 0.0002 P = 0.029 Without CAV at 1 year (n = 89) With CAV at 1 year (n = 54) 155-2 Tuzcu - JACC Vol 45 No. 9 2005.pdf Figure 4 QC Freedom from event (%)

10. CV-10 IVUS Methodology B253 Heart Study  IVUS efficacy assessments performed at baseline and 12 months for patients remaining on study drug  IVUS analysis conducted centrally at an experienced core laboratory at the Cleveland Clinic Foundation by cardiologists blinded to treatment assignments QC

11. CV-11 IVUS Efficacy Assessments B253 Heart Study  Primary IVUS endpoint: change in mean maximal intimal thickness (MIT) from baseline to 1 year –Choice of vessels: Left anterior descending coronary artery (LAD) Right coronary artery if LAD not feasible –Minimum of 11 matched images  Secondary endpoints –Incidence of CAV, defined as MIT ≥ 0.5-mm increase from baseline in at least 1 matched site –Intimal area, intimal volume, and cross-sectional area of stenosis (mean and maximum change from baseline) CAV = Cardiac allograft vasculopathy. QC

12. CV-12 Patient Disposition for IVUS Analysis Study B253 All randomized n = 634 Baseline IVUS performed n = 419 12-month IVUS performed n = 262 Matched at 12 months n = 211 another CV slide.ppt 205-11 QC

13. CV-13 Reported Reasons for IVUS Data Loss at 12 months Study B253 DRT1962.ppt 205-2 Everolimus AZA1.5 mg3.0 mgTotal No baseline assessment626865195 Technical issues 7 9 521 D/C study, death, AEs28253083 Due to renal problems 4161232 IVUS tape not analyzable26 81751 Administrative problems10 8 624 No consent 1 4 611 Unknown 4 1 1 6 Total142139142423 QC

14. CV-14 Baseline Demographics Study B253—ITT Population vs IVUS Population ITT population (N = 634)12-month IVUS population (N = 211) Recipients AZA n = 214 AZA n = 72 Age, yr (mean ± SD) 50.5 ± 11.550.4 ±10.71 Male, n (%)182 (85.0)63 (87.5) Race, n (%) White193 (90.2)63 (87.5) Black13 (6.1)6 (8.3) Diabetes, n (%) at baseline 36 (16.8)14 (19.4) CAD, n (%) at baseline 68 (31.8)27 (37.5) GFR < 29 mL/min/1.73m 2 at baseline 6 (2.8)1 (1.4) QC 10 (14.3) 27 (38.6) 4 (5.7) 5 (7.1) 62 (88.6) 57 (81.4) 51.2 ±10.16 1.5 mg n = 70 Everolimus 49 (23.2) 84 (39.8) 7 (3.3) 11 (5.2) 192 (91.0) 171 (81.0) 52.1 ± 10.8 3.0 mg n = 211 35 (16.7) 78 (37.3) 14 (6.7) Everolimus 21 (10.0) 181 (86.6) 166 (79.4) 51.2 ± 11.1 1.5 mg n = 209 24 (34.8)* 30 (43.5) 3 (4.3) 4 (5.8) 62 (89.9) 54 (78.3) 51.9 ± 10.90 3.0 mg n = 69 PTT 3.1-4 *P = 0.057 vs AZA

15. CV-15 *P < 0.05 vs AZA; **P = 0.014 vs AZA; ***P < 0.01 vs AZA; ****P < 0.003 vs AZA 143-53 Everolimus IVUS measurement: Change from baseline AZA n = 72 1.5 mg n = 70 3.0 mg n = 69 Mean maximal intimal thickness (MIT) (mm) 0.10 0.04** 0.03**** Mean intimal area (mm 2 ) 0.93 0.41*** 0.22*** Mean cross-sectional area of stenosis (%) 5.562.07*1.46* Mean intimal volume (mm 3 )16.56 9.70*** 8.24*** Incidence of vasculopathy (%) (MIT increase ≥ 0.5 mm) 52.835.7*30.4* 12-month IVUS Endpoints Study B253 (Baseline to 1 year) QC

16. CV-16 Treatment Comparisons of IVUS Variables at 12 months 95% CI for Everolimus Minus AZA Mean Intimal area (mm 2 ) Mean change in MIT (mm) a Everolimus 1.5 mg vs AZAEverolimus 3.0 mg vs AZA –0.06 –0.07 –0.52 –0.71 -0.9-0.8-0.7-0.6-0.5-0.4-0.3-0.2-0.10 Difference (95% CI) Everolimus betterAZA better a Primary IVUS endpoint. QC

17. CV-17 Treatment Comparisons of IVUS Variables at 12 months 95% CI for Everolimus Minus AZA -14-12-10-8-6-4-20 Difference (95% CI) Intimal volume (mm 3 ) Cross-sectional area of stenosis: mean % change Cross-sectional area of stenosis: max % change Everolimus 1.5 mg vs AZAEverolimus 3.0 mg vs AZA IVUS back-up - Aug 10 th.ppt 205-12 –7.15 –8.8 –3.4 –4.1 –3.71 –5.4 Everolimus betterAZA better QC

18. CV-18 Incidence of CAV (Change in MIT ≥ 0.5 mm) at 12 months P = 0.010 P = 0.045 122-34 MIT = Maximal intimal thickness; CAV = Cardiac allograft vasculopathy. Pairwise comparison with Fisher’s exact test. Eisen H, et al. N Engl J Med. 2003;349:847-858. Everolimus 1.5 mg n = 70 Everolimus 3.0 mg n = 69 AZA n = 72 Keep % in numbers QC

19. CV-19 Strengths and Limitations of the IVUS Study Strengths  Prospective, blinded study  Met planned sample size (n = 234)  Blinded central core lab  Blinded baseline and 12 months IVUS  Centers –48/52 at baseline –39/52 at 1 year  IVUS population characteristics similar to ITT Limitations  Not an ITT analysis –Patient participation determined by investigator –Only 12-month survivors –Only patients on therapy at 1 year DRT1962.ppt 205-1 QC

20. CV-20 Assessment of Potential Selection Bias in the IVUS Subpopulation  Purpose –Identify selection bias favoring everolimus Demographic and clinical characteristics  Plan –Identify patterns of bias in favor of everolimus arms –Sensitivity analyses to investigate the impact of potential biases DRT1962.ppt 205-3 QC

21. CV-21 Potential Sources of Selection Bias Investigated IVUS at 1 year Demographic characteristics  Recipient age  Recipient gender  Recipient race  Donor age  Donor gender  GFR < 29 (mL/min/1.73 m 2 )  Coronary artery disease  Diabetes history*  BMI > 33  LVAD  Hypertension  CMV Clinical characteristics  BPAR ≥ 3A  BPAR + HDC  Treated AR  Total cholesterol  LDL cholesterol  CsA trough levels  Posttransplant diabetes  Mean GFR at 12 months**  Triglyceride  ACE inhibitor  Statin use *Favors AZA and everolimus 1.5 mg over everolimus 3.0 mg. **Favors AZA over everolimus. QC

22. CV-22 Sensitivity Analyses Performed to Assess Impact of Missing IVUS Data  Imputation methods used for missing 12-month values –Assigned with age-matched AZA patients outcome –Assigned a CAV outcome (MIT > 0.5 mm)  Imputations were done for two sets of missing values –Patients with no IVUS due to reported renal dysfunction –Patients with no 12-month IVUS DRT1962.ppt 205-9 QC

23. CV-23 Sensitivity Analysis for Missing Data for CAV (MIT ≥ 0.5 mm) Difference in CAV (%) Everolimus 1.5 mg vs AZA Everolimus 3.0 mg vs AZA DRT1962.ppt 205-10 -40-30-20-10010 Assigning age-matched AZA MIT Assigning CAV No imputation for CAV (n = 211) 12-month IVUS population –8.5 –9.5 –9.1 –11.3 –17.0 –22.0 Assigning age-matched AZA MIT Assigning CAV Missing due to renal dysfunction (n = 243) All missing 12 month values (n = 419) –12.8 –19.4 –8.2 –14.5 Everolimus betterAZA better QC

24. CV-24 Kaplan-Meier Analysis of Time to First Graft-Related MACE From Month 1 to Month 48 Excluding Patients Who Died Within 30 Days of First Dose TreatmentPatients at risk/censored AZA (n = 211)186/7168/1898/80 Everolimus 1.5 mg (n = 202)184/8172/15106/78 Everolimus 3.0 mg (n = 206)175/14163/2396/85 email 10/11/05 excel datasets P = 0.052, 1.5 mg vs AZA P = 0.356, 3.0 mg vs AZA QC 1.5 mg 3.0 mg AZA

25. CV-25 MACE Summary Study B253—Month 1 to 48 Patients, n (%) a Everolimus AZA n = 214 1.5 mg n = 209 3.0 mg n = 211 MACE (total) 43 (22.8)32 (19.3)32 (17.5) Graft-related 33 (17.4) 19 (10.4)*25 (13.6) Non–graft-related14 (7.8)15 (10.2)8 (4.4) Fatal10 (5.2)6 (3.7)7 (4.2) Nonfatal 39 (21.1)27 (16.6)26 (14.0) A patient may be counted in more than one row. a Percent based on Kaplan-Meier rate. *P = 0.052 based on log-rank test QC

26. CV-26 IVUS 12-month Summary  Everolimus demonstrated significant benefit in all IVUS measures of allograft vasculopathy vs AZA –Smaller increases in maximal intimal thickness –Lower incidence of CAV –Smaller increase in intimal area and volume, percent stenosis, and others  Sensitivity analyses support the primary IVUS CAV results  No bias favoring everolimus was detected  48-month MACE data suggest potential for long-term benefit 110-13 QC