1. Intracoronary injection of mononuclear bone marrow cells after acute myocardial infarction Lessons from the ASTAMI trial Ketil Lunde, Rikshospitalet University Hospital, Oslo, Norway The 4th Symposium on Stem Cell Therapy and Cardiovascular Biology, Madrid, 26 th April 2007 Presenter disclosure information : No conflicts of interest

2. Nature 2001;410:701-705 Circulation 2002;106:1913-1918 Background

3. Study power Primary end-point: LVEF 5 % difference between groups of the ∆ LVEF (Baseline – 6 months) by SPECT 80 % power, significance level 5 %

4. Day 0: Acute Anterior Wall Myocardial Infarction PCI with stent on LAD culprit lesion Day 3-5: Randomization 2-3 weeks: MRI, bicycle exercise tests, SF-36 mBMC group n=50 Control group n=50 Day 4-8: Bone marrow aspiration and intracoronary mBMC injection 6 months follow-up: 99mTc-MIBI SPECT, Echocardiography, MRI, Coronary angiography, SF-36 Study design 12 months follow up: Echocardiography 3 months follow up: Echocardiography Day 4-7: Baseline recordings, 99mTc-MIBI SPECT, Echocardiography

5. Cell harvesting and preparation Local anesthesia Aspirated volume: 50 ml Density gradient centrifugation on ficoll-hypaque mBMC: 68 x 10 6 cells CD34 + cells: 0.7 x 10 6 Viability: 95 % GMP accredited laboratory Values are median

6. Cell preparation in ASTAMI The ASTAMI Study protocol for –Isolation of mononuclear cells –Overnight storage –Viability testing Proven successful for treatment of patients with hematological diseases Egeland et al, Eur Heart J 2007;letter to editor (in press)

7. Intracoronary mBMC injection Time point  6.0 (1.3) days after PCI Total volume injected  10 ml mBMC suspension Procedure  Over-the-wire balloon  balloon inflation for 1.5 min with no- flow and distal injection of apprx 3.3ml mBMC suspension  injections repeated twice with 5 min re-flow between balloon inflations

8. Baseline characteristics mBMC group (n=50)Control group (n=50)p Age (years)58 (8)57 (10)0.42 Diabetes mellitus (%)1080.73 Smokers (%)40480.72 Symptom start to PCI (min)262 (142)274 (135)0.66 *CK-MB mass max (µg/L)400 (223-444)357 (220-400)0.50 Values are mean (SD), proportion (%) or *median (interquartile range)

9. Medication at discharge mBMC group (n=50)Control group (n=50) ASA100% Clopidogrel100% ACE inhibitor/ATII-blocker100% Beta-blockers98%100% Statins100%

10. Change in LVEF Baseline6 monthsChange mBMCControlmBMCControlmBMCControl SPECT41.342.649.3 8.17.0 Echocardiography45.746.948.849.03.12.1 MRI54.853.656.258.11.24.3 Values are mean with SEM error bars, p = ANCOVA N Engl J Med 2006;355:1199-1209 EchocardiographySPECTMRI

11. Dose-response

12. Change in Infarct Size Baseline6 monthsChange mBMCControlmBMCControlmBMCControl SPECT43.838.332.830.5-11.0-7.8 MRI22.022.220.919.6-0.7-2.6 Values are mean with SEM error bars, p = ANCOVA Lunde et al, N Engl J Med 2006;355:1199-1209 SPECTMRI

13. Change in exercise capacity Baseline6 monthsChange mBMCControlmBMCControlmBMCControl Exercise time (minutes)8.68.810.69.92.11.2 Peak V O 2 (ml/kg/min)19.818.822.420.92.82.4 Values are mean with SEM error bars, p = ANCOVA Lunde et al, Eur Heart J 2006;27(Suppl 1):280[abstract#1680)

14. mBMC Control 12 months follow-up *p = SPSS mixed models for difference between groups over time Baseline3 months6 months12 months mBMC45.748.948.848.7 Control46.949.349.048.5 Lunde et al, AHA Scientific Sessions 2006; Abstract#2717

15. Moller et al. Am Heart J 2006;151:419-425

16. mBMC Control 12 months follow-up *p = SPSS mixed models for difference between groups over time Baseline3 months6 months12 months mBMC1.781.551.591.56 Control1.741.521.551.51 Lunde et al, AHA Scientific Sessions 2006; Abstract#2717

17. 12 months clinical follow-up Values are number of patients mBMC (n=50)Control (n=50)p Mortality 00 1.00 Reinfarction 10 1.00 Revascularisation 1311 0.81

18. BaselineDay 1p mBMC6.68.2 Control8.04.9 < 0.01 Interleukin 6 Values are median (picog/L), p=ANCOVA for the change between groups Solheim et al, JACC 2007;49(Suppl 1):189[abstract#1001-132]

19. Conclusion I In this randomized trial investigating effects of intracoronary injections of autologous bone marrow cells after acute MI - There was a similar improvement in LV function - The clinical outcome was excellent - Adverse event rates were similar and low In both groups during 12 months follow-up

20. Results on LVEF in randomized BMC trials NFollow-up (months) Primary Imaging modality Change in control group Change in BMC group p BOOST6018MRI3.1±9.65.9±8.90.27 Janssens et al674MRI2.2±7.33.4±6.90.36 ASTAMI1006SPECT7.0±9.68.1±11.20.77 REPAIR-AMI2044LV angio3.0±6.55.5±7.30.01

21. Clinical follow-up in BMC trials BOOST (N=60) 18 mo Janssens et al (N=67) 4 mo ASTAMI (N=100) 12 mo REPAIR-AMI (N=204) 12 mo BMC Mortality03 %02 % Reinfarction3 %02 %0 Revascularization17 %6 %26 %22 % Control / Placebo Mortality3 %006 % Reinfarction03 %06 % Revascularization13 %3 %22 %36 %

22. Conclusion II Intracoronary administration of BMC after AMI seems to be safe Efficacy is not established Results of ongoing adequately powered studies with accurate assessment of LV function are awaited

23. ASTAMI investigators Steering committee K Forfang (chair), S Aakhus, H Arnesen, T Egeland, K Endresen, A Ilebekk, A Mangschau Study investigators S Aakhus, M Abdelnoor, H Arnesen, P Aukrust, R Bjørnerheim, M Brekke, L Brinch, JE Brinchmann, T Egeland, K Endresen, JG Fjeld, K Forfang, HK Grøgaard, E Hopp, A Ilebekk, TO Kjellevand, NE Kløw, K Lunde, A Mangschau, C Mϋller, A Ragnarsson, I Seljeflot, HJ Smith, S Solheim, E Taraldsrud Data and safety monitoring board K Rasmussen, L Wallentin, R Wiseth Acknowledgements K Lunde and S Solheim are recipients of research fellowships from the Norwegian Council on Cardiovascular diseases

26. TOPCARE-AMI Britten et al, Circulation 2003;108:2212-2218