Novel Approaches for
Regenerative Therapies
Marc S. Penn, MD, PhD, FACC
Director of Research
Director of Cardiovascular Medicine Fellowship
Summa Cardiovascular Institute
Summa Health System
Professor of Medicine and Integrative Medical Sciences Director,
Skirball Laboratory for Cardiovascular Cellular Therapeutics
Northeast Ohio Medical University
Founder and CMO
Juventas Therapeutics, Inc.
Disclosures
Company Name
Juventas Therapeutics
BOD
SironRx Therapeutics
Cleveland Heart Lab, LLC
Current Relationship
Founder, CM/SO, Equity, Inventor,
Oakwood Medical Ventures
Venture Partner
Athersys, Inc.
SDG, Inc.
Sponsored Research
SAB, Sponsored Research
MPI Research
Consultant
NIH, Heart Failure Network
BIOMET, Inc.
VBL, Inc.
DSMB Member
DSMB Member
DSMB Member
CardioVIP, Inc.
Member BOD
Founder, CMO, Equity, Inventor
Founder, CMO, Equity, Inventor
Stem Cell Based Tissue Repair
• We proposed several years ago that:
– Stem cell based repair of ischemic tissue in
mammals is a natural process but clinically
inefficient due to dysregulation or short term
expression of key molecular signals
Conceptual Evolution of CV
Regenerative Medicine
Cell Therapy
Paracrine Factors
SKMB, MSC, MAPC
with or without Cells
Embryonic Stem Cells
or
Adult-derived ES like
Cells
Homing Signal
Characteristics of Putative Myocardial
Stem Cell Homing Factor
< 5 hours
MI
Time
> 2 days
Cell Tx
8 wks post MI
Orlic, et al. Nature 2001;410:701-705; Kocher, et al. Nat Med 2001;7:430-436.
SDF-1 Mediates Stem Cell
Homing following MI
Stromal Cell-Derived Factor –1
Time after MI:
Transplantation:
Hours
0
1
-
-
24
-
Days
7 30
- +
30
-
SDF-1
GAPDH
RT-PCR of 500 ng of total RNA for 40 cycles
Aksari et al. Lancet 362: 697, 2003
Stromal Cell-Derived Factor-1
(SDF-1)
• Chemokine – receptor CXCR4/CXCR7
• Induces stem cell homing to bone marrow
• Lethal knockout secondary to abnormal
hematopoietic trafficking
• SDF-1:CXCR4 blocks apoptotic cell death
Effects of transient expression of
SDF-1 in ischemic cardiomyopathy
Animal and Human studies have shown:
• Recruitment of bone marrow derived and
organ specific stem cells
• Microvascular growth and resolution of periinfarct ischemia
• Prevention of cell death
• Long-term down-regulation of cardiac
myocyte CXCR4 expression
• Remodeling of scar
Expression
Hypothesis: Cell Therapy Induces
Myocardial Repair by Temporally Aligning
the SDF-1: CXCR4 axis
SDF-1
CXCR4
Time after Ischemic Injury
Expression
Hypothesis: Adult Cell Therapy
Temporally Aligns the SDF-1: CXCR4
Axis
SDF-1 with MSC delivery
CXCR4
Time after Ischemic Injury
CXCR4 is not required for Cardiac
Myocyte Development or Function
MCM-Cre: CXCR4f/f
MLC-2v: CXCR4f/f
•No VSD
•No differences in EF,
radial strain or
circumferential
strain compared to
littermates lacking
MLC-2v
Hypothesis: MSC Engraftment Temporally
Aligns the SDF-1: CXCR4 Axis
SDF-1
Expression
SDF-1
CXCR4
Time after Ischemic Injury
Expression
Hypothesis: MSC Engraftment Temporally
Aligns the SDF-1: CXCR4 Axis
SDF-1
with MSC
SDF-1
with MSC
CXCR4
Time after Ischemic Injury
CM-CXCR4 and MSC Cardiac Repair
Mechanism
Neovascularization
CSC Recruitment
Cardiac Myocyte Survival
Improved Function
Effect of CXCR4

Required
Required
Required
Ejection Fraction (%)
CM-CXCR4 is Required for CM Preservation
and Functional Response to Mesenchymal
Stem Cells
100
CTRL
CTRL+ MSC
CM-CXCR4 Null
CM-CXCR4 Null +MSC
80
*#
60
40
20
0
Baseline
21 d after AMI
Cardiac Myocyte CXCR4 Expression
Negative inotrope due to
• Abnormal calcium handling
• Down-regulates B2 adrenergic stimulation of
cardiac myocyte contractility
Findings are consistent with end-organ Cell CXCR4
expression is a marker of cellular hibernation
Pyo, RT et al. J Mol Cell Cardiol 41:834, 2006
LaRocca, TJ et al. J Cardiovasc Pharmacol 56: 548, 2010
LaRocca, TJ et al. J Mol Cell Cardiol 53:223, 2012
SDF-1 Down-Regulates Cardiac
Myocyte CXCR4 Expression
12 weeks post AMI – 8 weeks after transient SDF-1
SDF-1
Control
Clinical Translation
SDF-1 Plasmids Generated
Cellular
Expression
Plasmid
Promoter
Expression Profile
p3CB-SDF1
CMV
5-7 day expression; Mid-level peak
All cells
pKCB-SDF1
CMV
15-20 day expression; High-level peak
All cells
pBMB-SDF1
aMHC
20-30 day expression; No peak
3.00E+07
2.50E+07
pKCB-SDF1
2.00E+07
p3CB-SDF1
pBMB-SDF1
1.50E+07
1.00E+07
5.00E+06
0.00E+00
0
5
10
15
20
Time Post-injection (Days)
25
myocytes
100
90
80
70
60
50
40
30
20
10
0
pKCB-SDF1
p3CB-SDF1
pBMB-SDF1
0
5
10
15
20
Time Post-injection (Days)
25
There is a SDF-1 Dose Response
Protein Expression (A450-540)
0.7
90X
0.6
0.5
0.4
0.3
25X
0.2
0.1
X
0
pBMH p3CB pKCB
There is a SDF-1 Dose Response
90X
30
*
Saline
0.6
0.5
0.4
0.3
25X
0.2
0.1
Vascular Density (/mm2)
Protein Expression (A450-540)
0.7
25
20
p3CB
*
pKCB
15
10
5
X
0
0
pBMH p3CB pKCB
Saline
p3CB
pKCB
10 weeks after SDF-1 Plasmid
There is a SDF-1 Dose Response
90X
50.00
0.6
0.5
0.4
0.3
25X
0.2
0.1
X
0
pBMH p3CB pKCB
% Change Shortening Fraction
Protein Expression (A450-540)
0.7
30.00
10.00
-10.00
Baseline
2 Week
-30.00
-50.00
-70.00
p3CB-SDF1 (n=10)
pKCB-SDF1 (n=9)
pBMH-SDF1 (n=9)
Saline (n=10)
4 Week
JVS-100 (hSDF-1 plasmid)
• Non-viral DNA plasmid
• Encodes for hSDF-1 (CXCL12)
• Driven by CMV promoter with enhancer
elements (RU5)
BioCardia Helical Infusion
Catheter
• Delivers therapeutics via endomyocardial injection
• Used to deliver biologics in over 100 clinical cases1,2
• CE marked
1 Williams AR. Circ Res. 2011;108:792-796;
2 de la Fuente LM. Am Heart J. 2007 Jul;154(1):79.e1-7.
AWMI model in Pig
90 min Balloon occlusion of LAD
EF ~35%, LVESV > 55 ml
Saline or control plasmid
delivered 1 month after AMI
Endoventricular injection using
Biocardia Catheter
Pivotal Porcine Preclinical
Study Summary
DOSE SCHEDULE
# sites
Conc.
(mg/ml)
Vol./ site
(ml)
TOTAL
DNA (mg)
Control
(n=12)
20
0
1
0
Low
(n=15)
15
0.5
1
7.5
Mid
(n=15)
15
2
1
30
High
(n=15)
20
5
1
100
Mean % Improvement SDF-1 Treated (Relative to Control)
Combined Low and Mid Dose
40
35
30
25
20
15
10
5
0
-5
-10
30 Days
AWMI model in Pig
LVESV
LVEF
WMSI
40
35
30
25
20
15
10
5
0
-5
-10
LVEDV
60 Days
90 min Balloon occlusion of LAD
EF ~35%, LVESV > 55 ml
Saline or control plasmid
delivered 1 month after AMI
LVESV
LVEF
WMSI
40
35
30
25
20
15
10
5
0
-5
-10
LVEDV
90 Days
LVESV
LVEF
WMSI
LVEDV
Endoventricular injection using
Biocardia Catheter
SDF-1 Treatment Increases Vascular
Density
% increase in vessel density
(Relative to Control)
50
*
*
40
30
20
10
0
Low (n=4)
*p<0.05 vs. control
Mid (n=5)
High (n=2)
Pivotal Porcine Preclinical
Study Summary
• Low and Mid Dose
provided:
– Improvement in LVESV,
LVEF
– Significant increase in
vasculogenesis
– No safety issues
• High Dose provided:
– No improvement in LVESV,
LVEF
– Slight increase in
vasculogenesis
– No safety issues
DOSE SCHEDULE
# sites
Conc.
(mg/ml)
Vol./ site
(ml)
TOTAL
DNA (mg)
Control
(n=12)
20
0
1
0
Low
(n=15)
15
0.5
1
7.5
Mid
(n=15)
15
2
1
30
High
(n=15)
20
5
1
100
SDF-1 Plasmid for NYHA Class III CHF
– Phase I trial
Sponsor: Juventas Therapeutics, Inc.
Northwestern University
Columbia University
Princeton Baptist
Rush Memorial
Open Label Dose Escalation Study
PI – Doug Losordo
JVS-100 (hSDF-1 plasmid)
• Non-viral DNA plasmid
• Encodes for hSDF-1 (CXCL12)
• Driven by CMV promoter with enhancer
elements (RU5)
• Goal of vector design was to achieve
sufficient SDF-1 expression to reach a
threshold for at least 12 days.
JVS-100 (hSDF-1 plasmid)
• Non-viral DNA plasmid
• Encodes for hSDF-1 (CXCL12)
• Driven by CMV promoter with enhancer
elements (RU5)
• Phase I open label dose escalation study in
patients with CHF demonstrated safety and
preliminary signs of efficacy in 17 patients
Penn et al. Circ Res 112:816, 2013
SDF-1 plasmid Treatment Of Patients Heart Failure (STOP-HF)
• Exploratory Phase II Randomized Blinded Placebo
Controlled Trial at 15 centers in the US over 18
months
• Powered based on 2x 6MWD and MLWHF QoL
changes observed in Phase I
• Target population: Patients with HF due to prior MI
with: 6MWD≤400m, LVEF ≤40%, MLHFQ≥20
• Delivery via 15 x 1 ml injections using the Biocardia
Helical Infusion Catheter
• 4 and 12 month follow-ups
• Independent DSMB and Clinical Events Committee
STOP-HF Trial
National Co-PIs:
•
•
•
Warren Sherman, MD (Columbia University)
Leslie Miller, MD (Pepin Heart)
Eugene Chung, MD (Lindner Center)
Site Name
Cardiology PC
Columbia Medical Center
MHIF at Abbott Northwestern Hospital
University of Utah
Lindner Center at the Christ Hospital
USF
Pepin
Montefiore Medical Center
Summa (NEOCS)
Hospital at the University of Penn
University of Florida
MCVI
Johns Hopkins
Spectrum Health
Iowa Heart
Washington University
Site PI
Farrell Mendelsohn
Jane Farr
Jay Traverse
Amit Patel
Gene Chung
Les Miller
Charles Lambert
Julia Shin
Kevin Silver
Saif Anwarruddin
Dave Anderson
Safwan Kassas
Peter Johnston
Michael Dickinson
Mark Tannenbaum
Greg Ewald
93 Subjects Enrolled
Cohort 1
(n = 31)
Control
Cohort 2
(n = 32)
15 mg
Cohort 3
(n = 30)
30 mg
STOP-HF Baseline Characteristics
Characteristic
Demographics Patients (n)
Sex (% male)
NYHA Class III (%)
Years since Last MI
Comorbidities Diabetic (%)
Age
BMI
LV Structure LVESV (ml)
LVEDV (ml)
LVEF (%)
Clinical Status NTproBNP (pg/ml)
6MWD (meters)
MLWHFQ
Baseline Therapy ACE-I/b-blocker/MRA(%)
Bi-V pacemaker (%)
Placebo
15 mg
30 mg
31
90
69
13 + 11
48.3
67 + 9
30 + 5
158 + 64
219 + 68
30 + 7
32
88
61.3
10 + 7
35.5
64 + 11
29 + 4
161 + 63
228 + 75
28 + 8
30
90
70
10 + 9
46.7
64 + 7
32 + 7
183 + 71
222 + 76
26 + 8
1259 + 1373
284 + 98
56 + 17
84/94/48
54.8
1144 + 1005
295 + 96
49 + 18
78/91/62
53.1
952 + 802
308 + 73
47 + 22
80/93/63
43.3
STOP-HF Baseline Characteristics
STOP-HF patients
represent symptomatic,
ischemic cardiomyopathy
heart failure population
STOP-HF patients are on
average approximately 11
years post their first
myocardial infarction and
have chronically
remodeled hearts
Patient Profiles
Parameter
Phase I
(n=17)
STOP-HF
(n=93)
Age (yr)
66 ± 9
65 ± 9
Previous MI (yr)
7±7
11 ± 9
Gender (% Male)
71%
89%
NYHA Class III
94%
66%
6 Min. Walk (m)
290 ± 91
296 ± 89
QoL Score
54 ± 21
51 ± 19
LVESV (ml)
109 ± 35
168 ± 67
LVEF (%)
32.5±5.5
28.5 ± 7.6
NTpro
2851±408
5
1120 ±
1083
GAL-3
NA
12.9 ± 6.0
Enrollment Consort for STOP-HF
Effect of JVS-100 on Total Population
Change in Cardiac Structure by
Baseline EF
High Risk Population Analyses
Baseline Characteristics
Effect of Baseline EF on Response
to JVS-100
Change in Stroke Volume by
Dose of JVS-100
Summary
• The delivery of JVS-100 to patients with chronic heart
failure is safe, no SAE or AE due to drug.
• SDF-1 over-expression induces significant ventricular
remodeling in high risk heart failure patients
• 30 mg is a more effective dose than 15 mg
Other Delivery Strategies
Retrograde Delivery
• Balloon catheter
advanced into the
coronary sinus
• Balloon is inflated to
occlude CS and JVS-100
infused cardiac venous
system
Ladage et al, 2012 Gene Therapy
• Balloon remains occluded
for ten minutes to allow
for diffusion of JVS-100
into surrounding tissue
Retrograde Delivery
• Provides delivery flexibility, without concerns for wall
thickness
• Ease of delivery (15 - 20 minute procedure)
• Broader physician base capable of delivering via
retrograde.
• General cardiologists and EP physicians as well as
interventionalists are comfortable on right side of heart
• Several device companies currently market and sell
balloons and catheters for retrograde delivery
Retrograde Delivery distributes
JVS-100 to the heart
Results: Retrograde delivery of JVS100 Provides Cardiac Benefit
Retrograde delivery of JVS-100
Provides Cardiac Benefit
RETRO-HF Phase I/II Trial
• Target Population
• Symptomatic HF due to
ischemic cardiomyopathy
• EF≤40%
• 6MWd≤400 m
• QOL≥20 points
• Treatment delivered at day 0
• Infusion of 40 mls of JVS100 or placebo
• Follow up
• Day 3, 1, 4, 12 months
Phase I – 12 Subjects
Open Label
Cohort 1
(n = 6)
30 mg
Cohort 2
(n = 6)
45 mg
Phase II – 60 Subjects
Randomized
Group 1
(n = 20)
Placebo
Group 2
(n = 20)
30 mg
Group 3
(n = 20)
45 mg
RETRO-HF Phase II Baseline
Characteristics
RETRO-HF 4-month results
2
LVESV
LVEF
5
D LVEF (%)
D LVESV (mL)
10
0
-5
-10
0
-1
-2
Placebo
200
30 mg
45 mg
5
NTproBNP
100
0
-100
-200
Placebo
30 mg
Placebo
D Composite Score
D NTproBNP (pg/mL)
1
45 mg
30 mg
45 mg
Composite Score
4
3
2
1
0
Placebo
30 mg
45 mg
Noted differences between
RETRO-HF and STOP-HF
RETRO-HF patients represent a
healthier population than STOPHF patients across all parameters.
• ICD (100% STOP-HF; 77%
RETRO-HF)
• Biventricular pacing (50%
STOP-HF; 0% RETRO-HF)
Bio-distribution for retrograde is
different than endo-myocardial
injection
Parameter
STOP-HF
RETRO-HF
Age
65 ± 9.4
63± 9.8
NTPro
1121 ± 1083
941 ± 1486
6MW
296 ± 89
321 ± 63
QoL
50 ± 19
48 ± 23
NYHA III
67%
36%
EF
28 ± 7.7
28 ± 7.1
ESV
167 ± 66
141 ± 53
EDV
228 ± 75
195 ± 64
RETRO-HF Considerations
A Single Endocardial Administration of JVS100 Provides Significant Benefit at 1 year
Pre-Clinical Translation of
JVS-100
•
•
•
•
•
Muscle defect regeneration
Fecal and urinary incontinence
Nerve sparing in prostatectomy
Stroke
Diabetic Nephropathy
Clinical Translation of JVS100
• Cosmetic wound healing
• Critical limb ischemia
Red Duroc Porcine Hyperplastic Scar
Model
Control
28 days
Red Duroc Porcine Hyperplastic Scar
Model
Control
SDF-1
28 days
Current JVS-100 Wound Repair
Clinical Study: Phase 1
• Randomized, double-blind, placebo
controlled, dose escalation
• Evaluate safety and efficacy in adults
receiving surgical sternotomy incisions
• Twenty-four subjects in 3 cohorts
receive localized drug injections
Sternotomy wound
• 5 centers with follow-up on Days 7, 21, 42, months 3
and 6
–
–
–
–
–
Montefiore-Einstein Medical Center (Dr. Robert Michler, Co-PI)
University of Utah Health Sciences Center (Dr. Amit Patel, Co-PI)
Summa Health System (Dr. Eric Espinal)
Northwestern Memorial Hospital (Dr. Patrick McCarthy)
Sentara Norfolk General Hospital (Dr. Michael McGrath)
Sternotomy Injection Protocol
Volume Wound Defect
at 6 months
Volume Defect
(Cubic millimeters)
12000
Absolute Vol
Negative Vol
Positive Vol
8000
4000
0
-4000
-8000
Placebo
1 Inj/1 mg/ml
1 Inj/2 mg/ml
2 Inj/2 mg/ml
2-Dimensional Wound Defect
at 6 months
35
2D Width
Max Height
2D Defect
(millimeters)
30
25
0.04
20
0.02
0.06
15
10
5
0
Placebo
1 Inj/1 mg/ml
1 Inj/2 mg/ml
2 Inj/2 mg/ml
Change in 2-Dimensional Wound Defect
From BL to 6 months
Change in 2D Defect
5.0
0.0
-5.0
0.09
0.04
-10.0
-15.0
0.03
2D Width
Placebo
1 Inj/1 mg/ml
1 Inj/2 mg/ml
2 Inj/2 mg/ml
Max Height
Change in 2-Dimensional Wound Defect
From BL to 6 months
5
Placebo
1 Inj/1 mg/ml
1 Inj/2 mg/ml
2 Inj/2 mg/ml
Change in Cosmesis
0
-5
-10
-15
0.14
-20
0.09
-25
0.17
-30
0.15
-35
VAS
POSAS Pt
POSAS Dr
MSS Tot
Acknowledgements
Skirball Foundation, New York, NY
Corbin Foundation, Akron, OH
Juventas Therapeutics, Inc.
Acknowledgements
Maritza Mayorga, PhD Feng Dong, MD, PhD
Indu Deglurkar, MD
Niladri Mal, MD
Samuel Unzek, MD
Jing Bian, PhD
Soren Schenk, MD
Nikolai Vasilyev, MD
Ming Zhang, MD, PhD Mazen Khalil, MD
Yu Peng, MD
Dominik Wiktor, MD
Udit Agarwal, PhD
Amanda Finan
Nikolai Sopko, PhD
Peter Lee, PhD
Srividia Sundararaman, PhD
Zoran Popovic, MD
Farhad Forudi, BS
Matthew Kiedrowski, BS
Kristal Weber, BS
Juventas Therapeutics
MPI Research
Summary
• Stem cells are offering insight into endogenous
tissue repair
• Over-expression of SDF-1 appears to cause
structural remodeling in chronic ischemic
cardiomyopathy
• Defining the molecular mechanisms activated by
exogenous stem cell therapy offers the
opportunity to define
– Novel Biology
– Novel targets for therapeutic development