Clinical Trial Objectives To determine the safety and efficacy of intracoronary injection of autologous Angiogenic Cell Precursors (ACPs) in relieving symptoms of angina pectoris in patients on maximal medical therapy. Background Significant progress has been made in establishing therapeutic strategies to treat a vatiety of cardiovascular disorders by using Endothelial Progenitor Cells (EPC). Initial results from these trials are promising, showing that the therapy is safe and thatitimproves the patients’ condition, Angiogenic Cell Precursors (ACPs) contribute to the generation of all constituents of a blood vessel. VesCell ™, a product containing of autologous ACPs, was used in a pilot clinical trial assessing the safety and efficacy of intracoronary injection for the treatment of non-option patients suffering from severe angina pectoris. Methods Patient Selectio “Twenty four patients with chronic table angina pectoris on masimal drug therapy were prospectively enlled and treatec with ACPs Ineusion Criteria fxcusion citer Stable angina on maimal medical weatment Ml dung last 3 months Not candidates for CABG or not wiling to undergo CABG ‘Slood transfusions during lst 4weeks Not candidates for angioplasty tothe ichemia related coronary iP heart transplantation artery and the coronary artery suitable for ACP injection Severe valvular disease or replacement Ejection faction > 354% Cardiomyopathy Reversible ischemia proven by MII scan (exercise) Anemia Informed consent signed Severe organ fue (ena ver) Severe concurrent cisease infectious SLE MS) Malignancy or stroke during the last 3 years High fever Generation of Angiogenic Cell Precursors (ACPs): a. For in vitro studie: Blood samples from healthy donors were obtained from the Israeli Blood Bank. Cells were isolated based on their density and cultured at a concentration of 1.5-3x10° cells/m! in X-vivo 15 medium supplemented with 2-20% autologous serum, 1-10ng/ml VEGF and 5-25 IU/ml heparin. Resulting, enriched ACP cultures were tested for their morphology, expression of cellular markers, in vitro physiological activity of cytokine secretion and formation of tube-like structures. b. For administration to patients Individual patients’ blood samples of 250m! were used in order to generate VesCell™ as described above. Cell administration to the patients: Theadiministration ofthe therapy was basecl upon entifying ischemic but viable myocardium (SPECT-MIBI scan) in the distribution of occluded coronary arteries. ACPs were injected via a catheter with proximal balloon occlusion of the coronary artery,UR Co fer ee Ure pasa eed co — cos eee gee re Eee et eos . Invitro vascular tube formation assay for evaluation of cell angiogenic potency. Harvested ACPs were seeded on extracellular matrix (ECM).Semi-closed and closed polygons of capillaries and complex mesh-lke capillary structures are observed (indicated by arrows). Harvested, slide-tixed ACPs positively stained with: Oe Enea ee oe) Peeuroeraa aos ee eater een ee cc @ Sees Re ed CE Re ACEO TOE) (10.1%) Specific markers of Progenitor and Mature Endothelial / Angiogenic Cells KOR (10.2%), Tie-2 (32.7496), CD144 eM ae Lee EL) Specific uptake of Low-Density Lipoprotein Dieraten ee) Cee eee uc TC ee eRe ee a IL scrtion by VEGF sretion by Anglogenin sretion by Pngiogenie Cel Precursor Angiogenic Cel Precursor Angiogenic Cel PrecisClinical Results Safety Safety results were analyzed and relation to cell administration was determined by the principal investigator leading the study. The therapy showed a high safety profile. One patient died from myocardial infarction one month after the administration of cell therapy. Coronary catheterization determined that the infarction occurred in a region of the heart supplied by another coronary artery than the one in which the cells were injected. The principal investigator of the study therefore concluded that the death was not related to the administration of the cell therapy. There were no other deaths among the study population. ‘Three patients developed transient ventricular fibrillation. One occurred during the catheterization procedure which was continued successfully and two during angiography six months after the procedure. All three patients recovered. The Pl determined that these ‘events were unrelated to the cell administration. Seven patients developed minor transient adverse events (elevated ESR, chest pain, Hypoglycemia, URI, oral paresthesia, urticaria, hematoma at puncture site and leg pain), these findings subsided after a short period without affecting the patient's clinical condition. Adverse Events PatientNo, | Preoperative morbidity ‘Complications and side effects 2 DM.HTHL CHE increas in Erythrocyte Sedimentation Rate 4 weeks alter intervention 6 HL Short episode of VentecularFiilation during procedure, spontaneously resolved MLOM HT HL ypoalyeemia Upper Respiratory Infection ated Erythrocyte Sedimentation Rate MLOM AT HL ‘ral paresthesias Chest gain during coronary catheterization, History of Transient Ischemic Attack spontaneously resolved atthe end of procedure. DM. HT HLPAD,CABG Unicaria developed 3 weeks following the procedure HTL “wo weeks fllowing procedure Mi due to thrombosis at crcumtfox coronary artery (not atthe sit of cl injection) which had angioplasty and stent insertion during the catheterization for cllinjecton. Unicatis MLOMAT HE Shor episode of Ventricular Fibilation at Visit 8 (6 months post, injection) during balloon angioplasty ofan unrelated artery. Leg pain OMT HL Hematoma at puncture ste OMT HL Shor episode of Ventricular Fibilation at Visit (6 months post Injection) during balloon angioplasty ofan urveated artery, required defibriatorsnock, Efficacy Changes in objective and subjective clinical parameters at 3 and 6 months follow-up All patients showed significantly improved symptoms at 3 months vs. baseline, with the improvement persisting to 6 months. Six minute walking distance increased from 338.04+27.47 to 409.7425 82 (N=23, P=0.0018) meters at 3 months and to 422.82+26.47 meters at 6 months (N=22, P<0.001);exercise performance, measured by metabolic equivalents (METS), increased from 5.49+0.49 to 6.56:0.60 METs at 3 months (N=20, P<0,001) and to 6.77+0.59 METS at 6 months (N=20,P=0.0015); perfusion defect decreased from 39.3745,65% to 24.3845.41% at 3 months (N=23, P=0.0016) and to 24.915.57% at 6 months (N=23, P=0.0011);and mean CCS grade decreased from 2.1740.18 to 1.04:0.04 at 3 months (N=23, P<0.001) and to 1.130.10 at 6 months (N=23, P<0,001), Statistical analysis comparing 3 and 6 month results forall parameters showed no significant differences.