Governance of stem cell therapyConsequences of innovation

Prof. Dr. med. Gustav Steinhoff

Department of Cardiac Surgery

Reference and Translation Center for Cardiac Stem Cell Therapy / Cardiac Surgery University of Rostock

Bergmann, O. et al. : Turnover after the fallout: Evidence for cardiomyocyte renewal in humans. Science 2009; 324: 98–102

Exchange of cardiomyocytes

Method: Integration of carbon-14, generated by nuclear bomb tests indicates age of cardiomyocytes

Results:1% turning over annually (age dependent)

Fewer than 50% of cardiomyocytesare exchanged at the age of 75

Conclusion: “… it may be rational to work toward the development of therapeutic strategies aimed at stimulating this process in cardiac pathologies.”

2

Reference and Translation Center for Cardiac Stem Cell Therapy / Cardiac Surgery University of Rostock

LVEF Wall motion score index

5%

What are the effects of CABG surgery?

3

Knapp, M et. al.: Myocardial contractility improvement after coronary artery by-pass grafting in a 1-year observation: The role of myocardial viability assessment, Card. J., 2007, 246–251

Reference and Translation Center for Cardiac Stem Cell Therapy / Cardiac Surgery University of Rostock

mod. Dimmeler et al. JCI 2005

directapplication

mobilization

Cardiac Stem Cell Therapy

Reference and Translation Center for Cardiac Stem Cell Therapy / Cardiac Surgery University of Rostock

Cell delivery

1.Mobilization (G-GSF)2.Systemic iv injection

3.Intracoronary injection4.Endocardial injection

NOGA

Local implantation imPatch TE

Heart valve TE

Action

HomingExtravasation

Stem / Progenitor Cell

Action

SurgeryCardiology

Problems observed

2001: First clinical stem cell application in heart disease (Strauer, Steinhoff)

Strauer, DüsseldorfIntravascular application MNC BM 3/2001

Steinhoff, RostockIntramyocardial application CD133 BMSC 6/2001

IntegrationMigration

Reference and Translation Center for Cardiac Stem Cell Therapy / Cardiac Surgery University of Rostock

Reference and Translation Center for Cardiac Stem Cell Therapy / Cardiac Surgery University of Rostock

Combined Revascularization (Stent, CABG)• Acute myocardial infarction (immediately - days)• Early after myocardial infarction (< 2 weeks)• Chronic ischemia: Myocardial transition / remodeling

phase (2 weeks – several months)

Stand alone• Completed remodeling / scar postischemic

cardiomyopathy (>6 months)• Refractory angina• Chagas disease

Clinical indication – acute/chronic ischemia, post infarction

Reference and Translation Center for Cardiac Stem Cell Therapy / Cardiac Surgery University of Rostock

Stem cell “homing” and vascular activity

8

*

Kaminski A et al. (Lab Investigation 2008)

Intravital fluorescence microscopy in murine cremaster muscle

Intravascular application

Role of endothelial NOS, SDF-1 alpha and local inflammation

Reference and Translation Center for Cardiac Stem Cell Therapy / Cardiac Surgery University of Rostock

Aspects of ventricular remodeling after infarction

9

Slezak et al. 2009

Connexin 43+ gap junctions

Control Hibernation

Myocardial infarction in a mouse heart

Reference and Translation Center for Cardiac Stem Cell Therapy / Cardiac Surgery University of Rostock

In vitro differentiation of endothelial cells from CD133-positive origin

Ong LL et al, Tissue engineering Part C, 2010

020406080

100120140160

CFU

-EC

(%)

0h 24h 48h 72h

P < 0.005 P < 0.005

Biological Interaction Network Effect of hypoxia on the differentiation of CD133

CD133+ cell product from human bone marrow

10

1.5% [vol/vol] oxygen and 5% [vol/vol] carbon dioxide

Reference and Translation Center for Cardiac Stem Cell Therapy / Cardiac Surgery University of Rostock

Hypothesis

11

Intramyocardial CD133+ stem cell treatment

leads to

better recovery of hibernating myocardium

in addition to CABG surgery.

Reference and Translation Center for Cardiac Stem Cell Therapy / Cardiac Surgery University of Rostock

CD133+ stem cell preparation and transplantation

12

Reference and Translation Center for Cardiac Stem Cell Therapy / Cardiac Surgery University of Rostock

CD133+ stem cell preparation and transplantation

13

Clinical setting: CD133+ Isolation with CliniMACS-unit Miltenyi Biotec

Direct injectioninto myocardium

150–200ml

Reference and Translation Center for Cardiac Stem Cell Therapy / Cardiac Surgery University of Rostock

LAD

Posteriorinterventricular

Lateral LV

viability / stress induced ischemia / reduced wall thickening

Target area for intramyocardial transepicardial injection

14

Reference and Translation Center for Cardiac Stem Cell Therapy / Cardiac Surgery University of Rostock

A

C

B

Analysis of stem cell related effects during CABG

Clinical case reports (CD133+, n= …)

Clinical trials Rostock Phase I (CABG + CD133+, n=15)

Rostock Phase II (CABG + CD133+, n=20)

Meta Analysis (CABG + stem cells, n=94)

Phase III Trial PERFECT

Clinical real world Rostock REGISTRY (CABG + CD133+, n=99)

15

Reference and Translation Center for Cardiac Stem Cell Therapy / Cardiac Surgery University of Rostock

74 y.o. ♂Stand-alonestem cell therapy2 monthsafter stentedLAD-infarction

EF 32% EF 47%

pre op 1 year

Case report stand alone CD133+ therapy

16

A

Reference and Translation Center for Cardiac Stem Cell Therapy / Cardiac Surgery University of Rostock

-10

-5

0

5

10

15

20

25

30

diffe

renc

e in

LVEF

(%)

CABG & CD133+ cells CABG

9.7%

3.4%

p=0.0009

10

20

30

40

50

60

70

preop discharge 6 months 18 months

LVEF

(%)

39±947±6* 50±8*

48±6*

Phase I Trial / 18 months (n=15) Phase II Trial / 6months (n=20 vs. control)

25-35 25-40 25-45 >25

Abso

lute

LVE

F Im

prov

emen

t in

%

0

5

10

15

20

25

30Stem cell groupControl group

subgroup analysisn=35 vs. controln=20 at 6 months

Increase in myocardial

perfusionat 6 months

Rostock phase I/II study early follow-up

17

B

Stamm et al. J Thorac Cardiov Surg, 133(3):717-25; 2007

Reference and Translation Center for Cardiac Stem Cell Therapy / Cardiac Surgery University of Rostock

Myocardial perfusion after CD133 + CABG – 3years

0

0,2

0,4

0,6

0,8

1

1,2

1,4

1 year 3 years

CABG+Stem cell Control

*

*p

Reference and Translation Center for Cardiac Stem Cell Therapy / Cardiac Surgery University of Rostock

CT-Scan B

19

No cardiac malformation in all analyzed hearts! (MRI/CT)

One slight myocardial calcification without functional relevance in treatment group:

Reference and Translation Center for Cardiac Stem Cell Therapy / Cardiac Surgery University of Rostock

Study No. of patientsTreatment Control

Age Treatment Control

Sex, male Treatment Control

Baseline LVEF Treatment Control

Follow-up LVEF Treatment Control

Change of LVEF Treatment Control

Stamm et al2007, Germany

20 20 62.0±10.2 63.5±8.4 75 80 37.4±8.4 37.9±10.3 47.1±8.3 41.3±9.1 9.7±8.8 3.4±5.5

Hendrikx et al2006, Belgium

10 10 63.2±8.5 66±9.2 100 70 42.9±10.3 39.5±5.5 48.9±9.5 43.1±10.9 6.1±8.6 3.6±9.1

Ahmadi et al2007, Iran

18 9 48.6±9.8 50.9±4.7 91.6 57.1 34.3±6.4 29.2±7.8 38.0±5.5 34.3±8.4 3.7±6.3 5.1±4.5

Mocini et al2005, Italy

18 18 64.4±8.6 66.9±4.5 94.4 94.4 46.0±6 48.0±8 51.0±9 49.0±9 5.0±8.3 1.0±4.8

Patel et al2005, USA

10 10 64.8±3.9 63.6±4.9 80 80 29.4±3.6 30.7±2.5 46.9±1.9 37.2±3.4 16.7±3.2 6.5±1.8

Zhao et al2008, China

18 18 60.3±10.4 59.1±15.7 83.3 83.3 35.8±7.3 36.7±9.2 49.1±9.7 40.6±8.4 13.3±9.2 3.9±4.9

Stamm et al. 2007

Hendrikx et al. 2006

Ahmadi et al. 2006

Moccini et al.2005

Patel et al. 2005

Zhao et al. 2006

Peter Donndorf et al., in review

B Meta analysis Intramyocardial bone marrow stem cell therapy during CABG

20

Reference and Translation Center for Cardiac Stem Cell Therapy / Cardiac Surgery University of Rostock

RR Cardiovascular Events.1 1 10

Combined

Zhao et al. 2008

Patel et al. 2005

Mocini et al. 2005

Ahmadi et al. 2006

Hendrikx et al. 2006

Stamm et al. 2007

Forrest Plot Fixed Effects

Major adverse cardiovascular eventsComposite of cardiac death, recurrent MI, revascularisation procedure and stroke

Favours BMSC Favours control

Combined

(95% CI)

Study

Stamm et al. 2007

Hendrikx et al. 2006

Ahmadi et al. 2006

Moccini et al.2005

Patel et al. 2005

Zhao et al. 2006

n=179

Meta analysis Intramyocardial bone marrow stem cell therapy during CABG

21

B

Reference and Translation Center for Cardiac Stem Cell Therapy / Cardiac Surgery University of Rostock

Overall (I-squared = 81.7%, p = 0.000)

Ahmadi et al. 2006

Zhao et al. 2008

Hendrikx et al. 2006

ID

Study

Mocini et al. 2005

Patel et al. 2005

Stamm et al. 2007

6.94 (5.38, 8.51)

-1.40 (-5.57, 2.77)

9.40 (4.58, 14.22)

2.50 (-5.26, 10.26)

WMD (95% CI)

4.00 (-0.43, 8.43)

10.20 (7.92, 12.48)

6.30 (1.75, 10.85)

100.00

14.04

10.53

4.05

Weight

%

12.44

47.14

11.80

6.94 (5.38, 8.51)

-1.40 (-5.57, 2.77)

9.40 (4.58, 14.22)

2.50 (-5.26, 10.26)

WMD (95% CI)

4.00 (-0.43, 8.43)

10.20 (7.92, 12.48)

6.30 (1.75, 10.85)

100.00

14.04

10.53

4.05

Weight

%

12.44

47.14

11.80

Favours Control Favours BMSC

0-5.57 6.94 14.2

Forest Plot Fixed Effects

LVEF change (95%CI)

p=0,001)

Meta analysis Intramyocardial bone marrow stem cell therapy during CABG

22

B

Reference and Translation Center for Cardiac Stem Cell Therapy / Cardiac Surgery University of Rostock

Overall ( I-squared = 0.0%, p = 0.715)

Stamm et al. 2007

ID

Patel et al. 2005

Study

Ahmadi et al. 2006

-14.28 (-28.87, 0.32)

-6.50 (-30.46, 17.46)

WMD (95% CI)

-18.00 (-39.11, 3.11)

-21.60 (-59.18, 15.98)

100.00

37.11

Weight

47.81

%

15.09

-14.28 (-28.87, 0.32)

-6.50 (-30.46, 17.46)

WMD (95% CI)

-18.00 (-39.11, 3.11)

-21.60 (-59.18, 15.98)

100.00

37.11

Weight

47.81

%

15.09

Favours BMSC Favours Control

0-59.2 -14.3 17.5

Forest Plot Fixed Effects

LVEDV follow-up (95%CI)

Stamm et al. 2007

Ahmadi et al. 2006

Patel et al. 2005

Overall (I-squared= 0.0%,p=0.715)

-6.50(-30.46,17.46) 37.11

-21.60(-59.18,15.99) 15.09

-18.00(-39.11,3.11) 47.81

-14.28(-28.87,0.32) 100.00

Study

WMD(95% CI)

%

Weight

-59,2 -14.3 0 17.5

Meta analysis Intramyocardial bone marrow stem cell therapy during CABG

23

B

Reference and Translation Center for Cardiac Stem Cell Therapy / Cardiac Surgery University of Rostock

Conclusion and plans

A Phase-I clinical feasibility and safety study in 15 CABG patients showed that intramyocardial injection of autologous CD133+ bone marrow cells was not associated with cell-related complications in longterm analysis 1,2.

In a subsequent Phase-II randomized, controlled, and prospective clinical trial in 40 patients, CABG & intramyocardial injection of CD133+ bone marrow cells resulted in better LV ejection fraction and perfusion than CABG only 3. Longterm safety of the treatment couldbe confirmed 4.

Phase-III clinical study investigation (multicentre double-blindedrandomized trial) is planned to finish in 2012 for definitive clinicalintroduction in the treatment of chronic ischemia after myocardialinfarction.

1 Stamm et al. Autologous bone marrow stem-cell transplantation for myocardial regeneration. Lancet, 361(9351);45-6; 20032 Stamm et al. CABG and bone marrow stem cell transplantation after myocardial infarction. Thorac Cardiov Surg, 52(3):152-8; 20043 Stamm et al. Intramyocardial delivery of CD133+ bone marrow cells and coronary artery bypass grafting for chronic ischemic heart

disease: safety and efficacy sturdies. J Thorac Cardiov Surg, 133(3):717-25; 20074 Yerebakan et al. Safety of intramyocardial stem cell therapy for the ischemic myocardium: Results of the Rostock trial after five year

follow-up. Cell transplantation 2007; 16(9): 935-40.

B

Reference and Translation Center for Cardiac Stem Cell Therapy / Cardiac Surgery University of Rostock

PERFECT Phase III Studya controlled, prospective, randomized, double blinded multicenter

trial

PERFECTINTRAMYOCARDIAL TRANSPLANTATION OF BONE MARROW STEM CELLS FOR IMPROVEMENT OF POST-INFARCT MYOCARDIAL REGENERATION IN ADDITION TO

CABG SURGERY

Principal investigator: Prof. Dr. G. SteinhoffSponsor: Miltenyi-Biotec GmbH

German study centers: Berlin Heart CenterMedical School Hannover

University of Rostock

Approved (Phase III clinical trial) by Paul Ehrlich Institute June 2009First patient: October 2009

Recruitment: 24 monthsPlanned final evaluation: 2012

CLINICAL OUTCOME STUDY

B

Reference and Translation Center for Cardiac Stem Cell Therapy / Cardiac Surgery University of Rostock

Inclusion:

Postinfarction (2w-6m), reduced LVEF (25-40%MRI), regional hibernation (MRI), indication CABG, 18-79y

Objectives:

Primary objective: To determine whether injection of autologously-derived bone marrow stem cells yields a functional benefit in addition to the coronary artery bypass graft (CABG) operation as determined by left ventricular heart function (LVEF-MRI).

Secondary objectives: To determine the effects of an injection of autologously-derived bone marrow stem cells on physical exercise capacity, cardiac function, safety and quality of life (QoL).

PERFECT Phase III Studya controlled, prospective, randomized, double blinded multicenter

trial

B

Reference and Translation Center for Cardiac Stem Cell Therapy / Cardiac Surgery University of Rostock

PERFECT Phase III Studya controlled, prospective, randomized, double blinded multicenter

trial 142 Patientsestimated drop-out rate

15%, randomized in an 1:1 ratio, bone marrow

aspiration prior to CABG surgery

71 Patientsto provide 60 evaluable

patientsfor stem cell group200 ml BM harvest

5ml CD133+ cells (1-10x106) suspended in

physiological saline + 10% autologous serumintramyocardially

71 Patientsto provide 60 evaluable

patientsfor placebo group200 ml BM harvest

5ml physiological saline + 10% autologous serum

intramyocardially

B

Reference and Translation Center for Cardiac Stem Cell Therapy / Cardiac Surgery University of Rostock

PERFECT study (pocket cards)

28

Inclusion criteria Previous MI (2w–6m) CABG indicated LVEF 25–40%

Exclusion criteria Mitral regurgitation Emergency Cancer Claustrophobia Chronic Hepatitis

Secondary endpoints physical exercise capacity cardiac function safety and quality of life (QoL).

B

Reference and Translation Center for Cardiac Stem Cell Therapy / Cardiac Surgery University of Rostock

screening

6h 24h

discharge 6 month

72h

1. Cell-/Blood analysis: time points

post OPpre OP OP

BMaspiration

Concomitant research to PERFECT

29

B

Reference and Translation Center for Cardiac Stem Cell Therapy / Cardiac Surgery University of Rostock

max 10%of aspired bone marrow

2. Cell analysis

Isolation of CD133+ cells

miRNA profile Characterization (sub-populations, FACS) Parvo-Virus Vitality and proliferation (FACS, CFU-Assay) Angiogenesis in vitro und in vivo

Concomitant research to PERFECT

30

B

Reference and Translation Center for Cardiac Stem Cell Therapy / Cardiac Surgery University of Rostock

3. Blood analysis

All patients (Rostock, Hannover, Berlin): Angiogenesis (VEGF, FGF) Stem cell factors (SCF, SDF-1, GCSF) Heart failure (myoglobin) Inflammation reaction (IL-6, IL-8, TNFα) Immune suppression (IL-10) Endothelial activation (sE-Selectin) Monitoring (CMV, EBV, Parvo, HAMA, AFP) Identification of diagnostic markers

(miRNA, protein patterns)

ca 60 ml

Add. Rostock patients: ca. 90 ml blood

additional time points Angiogenesis in vivo Mobiliziation of endothelial

progenitor cells (FACS, CFU-Hill)

Concomitant research to PERFECT

31

B

Reference and Translation Center for Cardiac Stem Cell Therapy / Cardiac Surgery University of Rostock

Clinical real world – the REGISTRY program

32

REGISTRY-program treatment of additional cardiovascular indications

long time FU

documentation at Rostock University since 2001

inclusion of further SC-therapy-centers in Germany

start national SC-register for cardiac application

C

Reference and Translation Center for Cardiac Stem Cell Therapy / Cardiac Surgery University of Rostock

Content of the REGISTRY-Database

33

Database

Patient data

Follow-Up‘s(Laboratory, MRT, Scintigraphy, ECG)

Information about surgery / product

Indication

Screening (Laboratory, MRT, Scintigraphy, ECG)

Check lists, printed forms

C

Reference and Translation Center for Cardiac Stem Cell Therapy / Cardiac Surgery University of Rostock

34,1279069836,60869565

38,58461538

0

10

20

30

40

50

60

preop discharge 6 months

LVEF

Linear (LVEF)

REGISTRY / LVEF in CABG + CD133+

34

Improvement in LVEF 6 months after CD133 + CABG treatment: (n = 56)

mean 3.4±10.1 (50% change LVEF > 5%)

*

*p=0.005 vs. preop.

C

Reference and Translation Center for Cardiac Stem Cell Therapy / Cardiac Surgery University of Rostock

REGISTRY / Arrhythmia in CABG + CD133+

-10

-8

-6

-4

-2

0

2

4

6

8

preop postop follow-up

Mean change in VES / all beat percentage: -0.8%

CMedian change in number of ventricular ES / h

35

Reference and Translation Center for Cardiac Stem Cell Therapy / Cardiac Surgery University of Rostock

REGISTRY / Survival

Survival 93% in CABG + CD133+(93 out of 99)

vs. 88% in Control Phase II

patient 1 – 10 months (Phase II)patient 2 – 02 months (Registry)patient 3 – 74 months (Phase I)patient 4 – 07 months stroke (Phase I)patient 5 – 81 months (Phase I)patient 6 – 62 months (Registry)

36

C

Reference and Translation Center for Cardiac Stem Cell Therapy / Cardiac Surgery University of Rostock

1988 - 2009 Animal models, mechanism and safety research

2001: worldwide first application and phase I study of intramyocardialinjection of purified CD133+ bone marrow stem cells in coronary bypasspatients

2001 – 2006: Safety and efficacy approval in Phase I (2001-2003) andPhase II (2003-2005) clinical trials

Since 2006 Reimbursement by German health insurance companies(sDRG)

2008 Establishment of national reference center for cardiac stem celltherapy (RTC, Rostock)

2001-2009 Clinical safety and efficacy approval in longterm vigilancestudies

9/2009 Start of Phase III clinical outcome study (Sponsor: Miltenyi-BiotecGmbH)

37

Update 2010

Reference and Translation Center for Cardiac Stem Cell Therapy / Cardiac Surgery University of Rostock

Intramyocardial CD133+ Bone Marrow Stem Cell Therapy,

38

Clinical research(I) (II) (III)

EMEA license

Preclinicalresearch

Standard therapy

2009200320011988

!

Reference and Translation Center for Cardiac Stem Cell Therapy / Cardiac Surgery University of Rostock

Standardization of cardiac stem cell therapy

•Indication (ischemia/postinfarction/cardiomyopathy/Htx)•Safety (arrhythmia, tumor, calcification)•Dosage/Toxicity•Standardization of cell preparation•Efficacy (longterm, quality of life)•Biodistribution of cells (migration, survival)•Tumorogenicity•Mechanism of action (paracrine, cellular)•Comparison of different stem cell types

•CLINICAL OUTCOME (PE,MACE,QoL)

Reference and Translation Center for Cardiac Stem Cell Therapy / Cardiac Surgery University of Rostock

Department of Cardiac Surgery, University of Rostock

40

This work was supported by the Helmholtz Gemeinschaft, Mecklenburg-Vorpommern (Nachwuchsgruppe Regenerative Medizin Regulation der Stammzellmigration 0402710), BMBF BioChance PLUS (0313191), Miltenyi Biotec, Sonderforschungs-bereich/Transregio 37, B5, B2 and A4; and BMBF Reference andTranslation Center of Cardiac Stem Cell Therapy (2008–2011).

www.cardiac-surgery-rostock.comwww.cardiac-stemcell-therapy.com Cardiac SurgeryA. Liebold / B. Westphal /

A. Kaminski / P. Donndorf /C. Nesselmann / C. Klopsch

Research Partners (RTC)N. Ma / P. Mark / W. Li / D. Furlani /R. Gäbel / W. Wang , C. Lux

Intenational PartnersNU Singapur, Beijing/Hefei/Nankai, ChinaAsahara, CDB/RIKEN, Kobe, JapanRenkeLiToronto, Kanada; Capogrossi, IDI, Rome, ItalyPompilio, Milano, Italy

R&D Partners:Miltenyi Biotec GmbHD-Trust GmbH, BerlinATP GmbH, RostockHelmholtz (GKSS/Teltow)

Clinical Development Partners:A. Haverich, MH HannoverR. Hetzer/C. Stamm, DHZ Berlin

Translation Management G. Tiedemann / J. Große / A. Wagner / J. Gabriel / B.E. Strauer

Governance of stem cell therapy�Consequences of innovationExchange of cardiomyocytesWhat are the effects of CABG surgery?Foliennummer 42001: First clinical stem cell application in heart disease (Strauer, Steinhoff)Foliennummer 6Foliennummer 7Stem cell “homing” and vascular activityAspects of ventricular remodeling after infarction CD133+ cell product from human bone marrow HypothesisCD133+ stem cell preparation and transplantationCD133+ stem cell preparation and transplantationTarget area for intramyocardial transepicardial injectionAnalysis of stem cell related effects during CABGCase report stand alone CD133+ therapyRostock phase I/II studyearly follow-upMyocardial perfusion after CD133 + CABG – 3years CT-Scan Meta analysis Intramyocardial bone marrow stem cell therapy during CABGMeta analysis Intramyocardial bone marrow stem cell therapy during CABGMeta analysis Intramyocardial bone marrow stem cell therapy during CABGMeta analysis Intramyocardial bone marrow stem cell therapy during CABGConclusion and plans�PERFECT Phase III Study�a controlled, prospective, randomized, double blinded multicenter trial PERFECT Phase III Study�a controlled, prospective, randomized, double blinded multicenter trial PERFECT Phase III Study�a controlled, prospective, randomized, double blinded multicenter trial PERFECT study (pocket cards)Concomitant research to PERFECT Concomitant research to PERFECT Concomitant research to PERFECT Clinical real world – the REGISTRY programContent of the REGISTRY-DatabaseREGISTRY / LVEF in CABG + CD133+REGISTRY / Arrhythmia in CABG + CD133+REGISTRY / SurvivalFoliennummer 37Intramyocardial CD133+ Bone Marrow Stem Cell Therapy, Foliennummer 39Foliennummer 40