M. ValgimigliM. ValgimigliUniversity of University of

FerraraFerrara

ItalyItaly

Autologous bone marrow stem cell mobilization

Induced by G-CSF after MI

Autologous bone marrow stem cell mobilization

Induced by G-CSF after MI

FOURTH INTERNATIONAL SYMPOSIUM ON STEM CELL THERAPY AND APPLIED CARDIOVASCULAR BIOLOGY

FOURTH INTERNATIONAL SYMPOSIUM ON STEM CELL THERAPY AND APPLIED CARDIOVASCULAR BIOLOGY

Madrid, 26°April 2007Madrid, 26°April 2007Madrid, 26°April 2007Madrid, 26°April 2007

Direct InoculationDirect Inoculation

The New Paradigm?The New Paradigm?The “NO TOUCH” policy

CD 34CD 34++ in AMI Patients in AMI Patients

0

2

4

6

8

10

12

1 3 5 7 10 14

*

Time after Onset (Days)

CD

34+ c

ells

(cel

l/

l)

*: p<0,01 vs. day 1Valgimigli M et al.Valgimigli M et al.

Mobilized bone marrow cells repair the infarcted heart,

improving survival

Mobilized bone marrow cells repair the infarcted heart,

improving survival

6 mice6 mice

SplenectomizedSplenectomized

2 wks2 wks

200 µg/kg/day SCF50 µg/kg/day G-CSF

5 dys5 dys 3 dys3 dys

CoronarCoronaryy

LigationLigation

EuthanizedEuthanized

27 dys later27 dys later

Orlic D, PNAS 2001Orlic D, PNAS 2001

G-CSF: the ideal G-CSF: the ideal candidatecandidate

G-CSF: the ideal G-CSF: the ideal candidatecandidate

Dose-dependent BM stem cells Dose-dependent BM stem cells mobilisizermobilisizer

Safety established on healthy donorsSafety established on healthy donors

Reassuring long-term data availableReassuring long-term data available

However:However:

Platelet activation with shortening of bleeding Platelet activation with shortening of bleeding time*time*

Fibrinogen and FVIII protein C and S*Fibrinogen and FVIII protein C and S*

Sporadical occurence of AMI in healthy donors Sporadical occurence of AMI in healthy donors *:Bone marrow transplantation 98; 22: 1087*:Bone marrow transplantation 98; 22: 1087

Study Flow-chartStudy Flow-chartStudy Flow-chartStudy Flow-chart

Primary PCIPrimary PCI

if eligibleif eligible

G-CSF 5 µg/kg/day or placebo Single blind study

Hospita

l admiss

ion

Hospita

l admiss

ion

ASA; clopidogrel, UFHASA; clopidogrel, UFH

GP IIb/IIIa inhibitorsGP IIb/IIIa inhibitors4 days4 days

Deferred PCI Deferred PCI

if eligibleif eligible

99mTc-sestamibi (740 MBq), gated-gated-SPECTSPECT

Disch

arge

Disch

arge

3 month

s

3 month

s

6 month

s

6 month

s

BaselineBaseline1°1° 2°2° 3°3° 4°4° 6 d6 d 7 d7 d 10 d10 d 14 d14 d

CD34+; CD34-CD133-KDR+, e-CFUCD34+; CD34-CD133-KDR+, e-CFUHb, WBC, PLT, urate, ESR, LDH, Hb, WBC, PLT, urate, ESR, LDH, GT, AP, CRPGT, AP, CRP

Estimated sample size: 60 pts (20 per group)

Enrolment prematurely terminated for safety concerns about restenosis

Restenosis71% Cell infusion66% G-CSF

Lancet 2004; 363: 751

Study Flow-chartStudy Flow-chartStudy Flow-chartStudy Flow-chart

Primary PCIPrimary PCI

if eligibleif eligible

G-CSF 5 µg/kg/day or placebo Single blind study

ASA; clopidogrel, UFHASA; clopidogrel, UFH

GP IIb/IIIa inhibitorsGP IIb/IIIa inhibitors4 days4 days

Deferred PCI Deferred PCI

if eligibleif eligible

99mTc-sestamibi (740 MBq), gated-gated-SPECTSPECT

Disch

arge

Disch

arge

3 month

s

3 month

s

BaselineBaseline1°1° 2°2° 3°3° 4°4° 6 d6 d 7 d7 d 10 d10 d 14 d14 d

CD34+; CD34-CD133-KDR+, e-CFUCD34+; CD34-CD133-KDR+, e-CFUHb, WBC, PLT, urate, ESR, LDH, Hb, WBC, PLT, urate, ESR, LDH, GT, AP, CRPGT, AP, CRP

Angiographic Follow-upAngiographic Follow-up

6 month

s

6 month

s

Hospita

l admiss

ion

Hospita

l admiss

ion

Use of G-CSF during AMI to Use of G-CSF during AMI to Enhance BMSC in HumansEnhance BMSC in Humans

  Clinical Safety ProfileClinical Safety Profile

20 pts out of 47 screened with AMI 20 pts out of 47 screened with AMI

3 pts per group not treated with 1° PCI due 3 pts per group not treated with 1° PCI due to late presentation, subsequently 1 pt per to late presentation, subsequently 1 pt per group underwent deferred PCI for evidence group underwent deferred PCI for evidence of myocardial viability in the infarcted areaof myocardial viability in the infarcted area

Syntoms Onset to G-CSG: Syntoms Onset to G-CSG: 3737±265 hours (3-265) in the whole population±265 hours (3-265) in the whole population

16±66 hours (3-61) in those submitted to pPCI16±66 hours (3-61) in those submitted to pPCI

and and AngiographicAngiographic

Valgimigli et al. EHJ 2005;26: 1838–1845

G-CSF administration during G-CSF administration during MI to enhance BMSC MI to enhance BMSC

mobilisationmobilisation

0 1 2 3 4 5 6 7 8 9 1011121314 0

10

20

30

40

50

Placebo

G-CSF

1°2°3°4°

*

*

*

Days

CD

34

+ c

ells

/ul

0

1

2

Placebo G-CSF

6 Day Day

*

†

CD

34

+A

C1

33

+V

EG

FR2

+

(ce

lls/

ul)

0

10

20

30 Placebo G-CSF

Day6 Day

e-CFU

Valgimigli et al. EHJ 2005;26: 1838–1845

G-CSF Impact on LV G-CSF Impact on LV function at Gated-function at Gated-

SPECTSPECT

0 Entry 3 ms 6 ms 0

10

20

30 Placebo G-CSF

**

Sum

med

Res

t Sco

re

0 Entry 3 ms 6 ms 50

100

150

200

250

300Placebo G-CSF

ED

V(m

l/m

3)

0 Entry 3 ms 6 ms 15

25

35

45

55

65

75 Placebo G-CSF

* *

EF

0

10

20

30

40G-CSF Placebo

3 Months 6 Months

EF

rela

tive

Incr

ease

(%)

p=0.09

G-CSF Safety IssuesG-CSF Safety Issues

0

1

2 G-CSF Placebo

0.30 0.35Late

Lo

ss (

mm

)

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

G-CSF in AMI G-CSF in AMI

StudyInterval from AMI to PCI; h

Interval from PCI to G-CSF injection, h

G-CSF dosageµg/kg/d

G-CSF administratio

n in days

MNCCD34+max/MNCCD34+bl after G-CSF

G-CSF Control G-CSF G-CSF G-CSF G-CSF Control

MAGIC 1464†† 144** n.a. 10 4 - -

Valgimigli et al 6 6 37 5 4 15 1.8

Ince et al 5 5 1.5 10 6 20 2.1

REVIVAL-2Within

12Within

12120 10 5 14 1

STEMMI 3 4 29 10 6 19 1

Engelmann MGet al.

>6 h up to 7 d

>6 h up to 7 d

31±24(2-107)

10 5 23 1

Takano Het al. 6 6 15 2.5 5 15 1.6

Ellis S et al. 6/12 15 28/31 5/10 5 29/37 6.8

G-CSF in AMI G-CSF in AMI

MAGIC

Valgimigli et al.

Ince et al.

REVIVAL-2

STEMMI

Engelmann MGet al.

Takano Het al.

Ellis S et al.

0

25

50

75

Baseline 6 months

LVEF (

%)

P=0.71P=0.71

G-CSF GroupG-CSF Group

G-CSF in AMI G-CSF in AMI

MAGIC

Valgimigli et al.

Ince et al.

REVIVAL-2

STEMMI

Engelmann MGet al.

Takano Het al.

Ellis S et al.

+6+6 -4-4

G-CSF in AMI G-CSF in AMI

MAGIC

Valgimigli et al

Ince et al.

REVIVAL-2

STEMMI

Engelmann MGet al.

Takano Het al.

Ellis S et al.

G-CSF in AMI G-CSF in AMI

MAGIC

Valgimigli et al.

Ince et al.

REVIVAL-2

STEMMI

Engelmann MGet al.

Takano Het al.

Ellis S et al.

G-CSF in AMI G-CSF in AMI

MAGIC

Valgimigli et al.

Ince et al.

REVIVAL-2

STEMMI

Engelmann MGet al.

Takano Het al.

Ellis S et al.

0

25

50

75G-CSFPlacebo

Baseline 3 months

LVEF (

%)

P=0.007P=0.007

P=0.035P=0.035

n.s.n.s.

G-CSF in AMI G-CSF in AMI

MAGIC

Valgimigli et al.

Ince et al.

REVIVAL-2

STEMMI

Engelmann MGet al.

Takano Het al.

Ellis S et al.

G-CSF in AMI G-CSF in AMI

MAGIC

Valgimigli et al.

Ince et al.

REVIVAL-2

STEMMI

Engelmann MGet al.

Takano Het al.

Ellis S et al.

0

1

2

3

4

5

6

7

8

Control

5 ug/kg

10 ug/kg

Ch

an

ge in

EF a

t 30 d

ays (

%)

Ch

an

ge in

EF a

t 30 d

ays (

%)

P=nsP=ns

G-CSF in AMI G-CSF in AMI

MAGIC

Valgimigli et al.

Ince et al.

REVIVAL-2

STEMMI

Engelmann MGet al.

Takano Het al.

Ellis S et al.

Timing of treatment with Timing of treatment with respect to onset of symptomsrespect to onset of symptoms

G-CSF in AMI G-CSF in AMI

MAGIC

Valgimigli et al.

Ince et al.

REVIVAL-2

STEMMI

Engelmann MGet al.

Takano Het al.

Ellis S et al.

Y = 876 .87 - 129 .7 * XCo rrelat io n : r = - .8476

-4 -2 0 2 4 6 8 10

Delt a Eject io n Fract ion (% )

-200

0

200

400

600

800

1000

1200

1400

1600

Tim

e f

rom

sym

pto

m o

nse

t to

tre

atm

ent

(hs)

9 5% co nfidence

M A GIC

Y = 122 .33 - 6 .020 * XCo rrelat io n : r = - .0978

3 4 5 6 7 8 9 10

Delt a Eject io n Fract ion (% )

-50

0

50

100

150

200

250

300

350

Tim

e f

rom

sym

pto

m o

nse

t to

tre

atm

ent

(hs)

9 5 % con fid e n ce

Targeting the proper patient Targeting the proper patient populationpopulation

Severe LV function impairmentSevere LV function impairment

Anterior wall MIAnterior wall MI

Suboptimal mechanical reperfusionSuboptimal mechanical reperfusion

G-CSF in AMI G-CSF in AMI

MAGIC

Valgimigli et al.

Ince et al.

REVIVAL-2

STEMMI

Engelmann MGet al.

Takano Het al.

Ellis S et al.

No data beyond 30 daysNo data beyond 30 days

12 pts G-CSF vs. 6 controls12 pts G-CSF vs. 6 controls

Rigenera StudyRigenera StudyRigenera StudyRigenera Study

14 G-CSF vs. 27 controls14 G-CSF vs. 27 controls Anterior MI with EF <50% after 5 Anterior MI with EF <50% after 5

daysdays

Courtesy of Leone AM.Courtesy of Leone AM.

50

100

150

200

250

300

50

100

150

200

250

300

LV

ED

V (

ml)

Baseline BaselineFollow up Follow up

147+32 144+45 141+35 168+41

G-CSF Control group

p=0.002p=0.77

2-way ANOVAp=0.03

LV

en

d d

iasto

lic v

olu

me (

ml)

Rigenera StudyRigenera StudyRigenera StudyRigenera Study

14 G-CSF vs. 27 controls14 G-CSF vs. 27 controls Anterior MI with EF <50% after 5 Anterior MI with EF <50% after 5

daysdays

Courtesy of Leone AM.Courtesy of Leone AM.

25

30

35

40

45

50

55

60

25

30

35

40

45

50

55

60

LV

EF

(%

)

Baseline BaselineFollow up Follow up

40+6 45+6 38+6 38+8

G-CSF Control group

p=0.95p=0.068

2-way ANOVAp=0.04

G-CSF and Binary restenosisG-CSF and Binary restenosissystematic review of the literaturesystematic review of the literatureG-CSF and Binary restenosisG-CSF and Binary restenosissystematic review of the literaturesystematic review of the literature

G-CSF Control OR (fixed) Weight OR (fixed)n/N n/N 95% CI % 95% CI Year

G-CSF aloneMAGIC 2/3 0/1 1.20 5.00 [0.11, 220.62] Ince 4/25 5/25 20.22 0.76 [0.18, 3.25] Valgimigli 0/8 1/8 6.82 0.29 [0.01, 8.37] REVIVAL-2 19/54 17/55 52.55 1.21 [0.55, 2.70] STEMMI 3/32 4/30 18.01 0.67 [0.14, 3.29]

Subtotal (95% CI) 122 119 98.80 1.01 [0.55, 1.85]Total events: 28 (G-CSF), 27 (Control)Test for heterogeneity: Chi² = 1.81, df = 4 (P = 0.77), I² = 0%Test for overall effect: Z = 0.02 (P = 0.99)

G-CSF and blood stem cellsMAGIC 5/7 0/1 1.20 6.60 [0.19, 225.79] 2004

Subtotal (95% CI) 7 1 1.20 6.60 [0.19, 225.79]Total events: 5 (G-CSF), 0 (Control)Test for heterogeneity: not applicableTest for overall effect: Z = 1.05 (P = 0.30)

Total (95% CI) 129 120 100.00 1.07 [0.59, 1.95]Total events: 33 (G-CSF), 27 (Control)Test for heterogeneity: Chi² = 2.86, df = 5 (P = 0.72), I² = 0%Test for overall effect: Z = 0.23 (P = 0.82)

0.001 0.01 0.1 1 10 100 1000

Favours G-CSF Favours control

2004 (15)2005 (14)2005 (17)2006 (21)2006 (20)

G-CSF Control OR (fixed) Weight OR (fixed)n/N n/N 95% CI % 95% CI Year

G-CSF aloneMAGIC 2/3 0/1 1.20 5.00 [0.11, 220.62] Ince 4/25 5/25 20.22 0.76 [0.18, 3.25] Valgimigli 0/8 1/8 6.82 0.29 [0.01, 8.37] REVIVAL-2 19/54 17/55 52.55 1.21 [0.55, 2.70] STEMMI 3/32 4/30 18.01 0.67 [0.14, 3.29]

Subtotal (95% CI) 122 119 98.80 1.01 [0.55, 1.85]Total events: 28 (G-CSF), 27 (Control)Test for heterogeneity: Chi² = 1.81, df = 4 (P = 0.77), I² = 0%Test for overall effect: Z = 0.02 (P = 0.99)

G-CSF and blood stem cellsMAGIC 5/7 0/1 1.20 6.60 [0.19, 225.79] 2004

Subtotal (95% CI) 7 1 1.20 6.60 [0.19, 225.79]Total events: 5 (G-CSF), 0 (Control)Test for heterogeneity: not applicableTest for overall effect: Z = 1.05 (P = 0.30)

Total (95% CI) 129 120 100.00 1.07 [0.59, 1.95]Total events: 33 (G-CSF), 27 (Control)Test for heterogeneity: Chi² = 2.86, df = 5 (P = 0.72), I² = 0%Test for overall effect: Z = 0.23 (P = 0.82)

0.001 0.01 0.1 1 10 100 1000

Favours G-CSF Favours control

2004 (15)2005 (14)2005 (17)2006 (21)2006 (20)

2004 (15)2005 (14)2005 (17)2006 (21)2006 (20)

Ince et al. submittedInce et al. submitted

Individual patient data Individual patient data meta-analysismeta-analysisIndividual patient data Individual patient data meta-analysismeta-analysis

G-CSF vs Control

0

20

40

60

80

100

-0,25 0,25 0,75 1,25 1,75

LLL (mm)

Cu

mu

lati

ve %

Control

G-CSF

G-CSF vs Control

0

20

40

60

80

100

-0,25 0,25 0,75 1,25 1,75

LLL (mm)

Cu

mu

lati

ve %

Control

G-CSF

Ince et al. submittedInce et al. submitted

ConclusionsConclusionsConclusionsConclusions

G-CSF administration in acute MI is G-CSF administration in acute MI is feasiblefeasible

No No REALREAL concern regarding clinical concern regarding clinical and ANGIOGRAPHIC safety profileand ANGIOGRAPHIC safety profile

The effect of this treatment on LV The effect of this treatment on LV function improvement remains function improvement remains unclearunclear

The time has arrived for The time has arrived for

a multicenter RCT a multicenter RCT

The time has arrived for The time has arrived for

a multicenter RCT a multicenter RCT