M. Valgimigli University of Ferrara Italy

1. FOURTH INTERNATIONAL SYMPOSIUM ON STEM CELL THERAPY AND APPLIED CARDIOVASCULAR BIOLOGY Autologous bone marrow stem cell mobilization Induced by G-CSF after MI M. Valgimigli University of Ferrara Italy 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. 200 µg/kg/day SCF 50 µg/kg/dayG-CSF 6 mice Splenectomized Euthanized 27 dys later 3 dys 2 wks 5 dys Coronary Ligation Mobilized bone marrow cells repair the infarcted heart, improving survival Orlic D, PNAS 2001

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

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

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

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

10. and Angiographic Use of G-CSF during AMI to Enhance BMSC in HumansClinical 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 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

15. G-CSF in AMI G-CSF Group P=0.71

16. G-CSF in AMI -4 +6

17. G-CSF in AMI

18. G-CSF in AMI

19. G-CSF in AMI P=0.035 P=0.007 n.s.

20. G-CSF in AMI

21. G-CSF in AMI P=ns Change in EF at 30 days (%)

22. G-CSF in AMI

23. G-CSF in AMI • Timing of treatment with respect to onset of symptoms

24. G-CSF in AMI • Targeting the proper patient population • Severe LV function impairment • Anterior wall MI • Suboptimal mechanical reperfusion No data beyond 30 days 12 pts G-CSF vs. 6 controls

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

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

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

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

29. Conclusions • 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