 to hearing about stem cell therapy, or is it ready for clinical use? Thank you, Jim, it's really humbled by the introduction. So I'm a little behind the eight ball because of the vagaries of broadcasting. But here we go, it's nice to be able to broadcast this. And so let's talk about this, cell therapy, something that's rather more controversial of late than it used to be. If you think that the word there yet, you can buy some stem cell products, but I'm not sure this is the kind of cell therapy that we were talking about. And there's a lot of shysterism in things going on, and you can fly to Cancun and get your fat cells injected for $60,000 to cure almost anything, but I'm not sure that's cell therapy either. I wish our brochures were as nice as these guys at CellTex. So I like to kind of always start with a broad perspective. And this is from a company called Gartner that evaluates new technologies. They're a public-traded company, Cymbal IT. And basically they look at really new technical developments and advising on investments on things. And pretty much all new fantastic technologies go through this cycle of the discovery of it, and all of a sudden it's the greatest thing since sliced bread. But then it takes a while sometimes for things to really start working. Think about 3D printers. There's lots of things that, you know, they have this super hyped up beginning, and then things kind of fall down a little bit. And gradually as data comes in and things start happening, we start learning more about it, and that's when you really get to integrate that technology into the mainstream. So talking about cells, here's a car, it's four wheels, gets you from point A to point B. Here's another car, four wheels, gets you from point A to point B. So, and it is my car actually. And so the point is when we talk about cell therapy, cell therapy, there are many, many different kinds of cells. So it's not just one, oh, we're just gonna give cell therapy. It's a very hundreds of different kind of treatments if you wanna think of it that way. So one thing to address as well, so just gives you a broad idea of how cells work. And we've really gone through quite an evolution on the understanding of cell therapy. In the beginning, seriously, in the late 90s, we had this sort of naive idea that it was kind of like magic, and you would put cells in and it grows the heart muscle and blood vessels and it's amazing, you know? And with research, a lot of pre-clinical studies and clinical studies and going backward from bench to bedside, we've come to a much better understanding today of how cell therapy works as opposed to how we did before. And so here's some different mechanisms that are involved. And definitely, I mean, we can build blood vessels with stem cells, that's easy to do. And we know that angiogenesis is well known and easy to achieve actually with gene therapy, with cell therapy. Tissue regeneration, not so much, and that's part of the naive beginning, but there's a little bit of that that can happen. We know that certain kinds of cells can have a great effect on healing, and most of that effect is through signaling, local signaling that we call peregrine signaling, because these cells, actually, and I'm gonna show you just a little bit, kinda react to their environment and put out signs for things to happen. They can do things like prevent apoptosis, which is very important, depending on the disease state. And one thing that we've learned quite a lot, again, depending on the cell type, is immune modulation. So immunomodulatory therapy is very important when you're dealing with inflammation. And if you've been around medicine for a while at the end of the day, if you sit here in Grand Rounds week after week, you learn that inflammation is basically, everything is inflammation, right? So I don't have to tell you that. So if we can modulate inflammation, that may go a long way towards helping things. So I just put up a slide here. This is, it's kinda complicated, but just to get down to the role, and I'm really talking, I just jumped to NPCs, which are mesenchymal cells, they're part of the stroma, and in this case, they're derived from picking out like a cell in a million out of the bone marrow. So this is a bone marrow derived cell that we've done this large trial with. And it's important to understand the concept that heart failure, and I'm not the one saying this, is when you get to the advanced stages of heart failure, it is a global inflammatory disease. The heart failure is inflammation. And so a lot of that inflammation and a lot of the bad things are driven by the macrophages that are in the myocardium. And they're in this phenotype called M1 that produces, for example, TNF alpha, which is a major player in heart failure. IL1 beta, IL6, all these things that we know that drive heart failure. And M1's actually drive remodeling and drive worsening of systolic function. So this is a big deal. And so to give you an example of mechanism, when you put one of these NPCs in the tissue, and by the way, that's one of the reasons that we really push the idea of delivering cells into the myocardial space, because if you give them IV or in some other way, you need to stick them in the middle of the fire. They react to the signaling locally. And what they do, a very important thing to do, for example, is polarize M1 towards M2. Now M2s are very different. They promote healing. They're anti-inflammatory. So if you can make the M1s go to an M2 phenotype, now you have secretion of IL10, which is very beneficial. And this will have effects to the tissue, to the cellular level. You have improvement of smooth muscle, so you can see the different growth factors you kind of shift what's happening inside the myocardium. So this is the real magic of cell therapy. And we're starting to understand it a little better. It's not the naive magic that we thought in the beginning. Like I said, we've kind of come a long way. So this is what we're trying to fight. Remodeling is the problem. An initial event gives rise to remodeling of the heart. The heart thinks that by being a big ball, it can work better. It doesn't, and that leads to a bad spiral that gets a lot of people in trouble. And heart failure is the number one problem and very, very prevalent here in the US. So this is what we're trying to find. And it's very hard. And people think, you know, you're crazy. They think you can inject some cells and reverse this process. It's very hard to achieve something beneficial in that. So that Dr. Wielicz alluded to this, we've been at this a long time. These are trials that we've done and led here. These are our trials from the Heart Institute. And you can see this is a good time because there's three trials on the bottom here that are completed that we're waiting on results on. And you can see here on the cell type, as we've gone over time, you can see how we've evolved. At the beginning, ABNN and C stands for autologous bone marrow. When we first started, the very first patient, we needed something really simple and intuitive. And it was like, well, take some bone marrow, spin it down, in there are some stem cells, there's some other cells too. And we'll see how that works. And it worked a little bit. I'll show you very briefly, but it wasn't the greatest thing. It was a weak effect, but we saw enough of a signal that we knew that something was going on. And so then we pursued different cell types. Till we got to what I'm showing you here, where I was just showing you the actions of this cell called the NPC, which we think is a very potent cell, at least in 2019 terms, I'm sure in 2040 terms, that will be a very different story. These are other cell trials in heart failure, which we've been part of. And it's a very tight group of maybe about 150 people throughout the world that really work on this. And we've had a couple of meetings here in this auditorium with all our colleagues. We have a group called Tactics that is transatlantic to the European colleagues, our colleagues, along with the FDA as well. And there is going to be later this year, we've put together a think tank in Washington with industry, FDA and investigators. So we're really making progress because we want to kind of lay the groundwork because we're getting there for the approval of cell therapy. So that's real important. So very quickly, because my time's kind of gone, I'm not going to get into this very much. You can deliver cells a great many ways. Basically, you can go from broad to more specific. We've really helped develop some of these systems that deliver cells in the myocardium from inside the heart. This is a Noga catheter delivery system. This is a Noga map, which is a real-time 3D representation of the endocardial. So we create this 3D live map that we can then navigate inside of. We can distinguish different kinds of tissue and we can have a strategy. You see the black dots there to inject the cells where we want them. And so this has been validated, we've done this work. Here's the map showing, here's the front. So this is the apex, that's the base. This is looking from the bottom. You can see red is dead. Red is a big old scar in the base. And if you look at the MR images, and so this is part of the validation, we've validated with delayed hyper-enhancing MR, there is a very strong correlation to where we've developed this concept of voltage being viability. So I'm just as good as an MR to tell you how viable a ventricle is. And that helps me have a strategy to place the cells where they need to be. This is one of the prettiest RLC curves. I couldn't even believe it when the statisticians gave me this back. So this has been published, like I said, and validated. And we know the numbers to use to be able to inject these cells, not in a dead area where the cells can't respond anything, but in an area of tissue where the cells get that signaling and then can put the anti-signaling out and have an effect on what's going on in the heart. So in general, I'm gonna go through some trials quickly. These are kind of the kind of patients that we started. We started with sicker and we progressed a little less sicker, but in the beginnings, they're very symptomatic, heart failure. In the beginning, only ischemic cardiomyopathy and people that really had no other options and like anything that you're starting, they can't have any other option for therapy. That's now changed a little bit. So I'm from Brazil and the very first trial we did was back in, you started in the year 2000 in Rio. I get to go there a lot to inject cells. That was a really hard thing to do. And, but it turned out to be worthwhile. This is the second patient we ever injected and these are these NOGA maps that you can see in these black dots of the injections. And so this is the map of the time of the procedure and we never see something this red. So this is voltage, which is basically, think of it as viability with red being low and purple being high. So all the colors in between. So there's this island of viability in the posterior lateral wall here, but this guy had an ejection fraction of 11%. And this is a big red ball. We thought the guy was some, we did this procedure in the middle of it. We gave the guy a 20 at Lasix because we didn't think he would make it through the whole procedure. So that's the kind of patient we started in back in the beginning. But lo and behold, doing VO2 maxes on these patients and this first trial was very small, but we saw an objective signal. These guys could do better. So something was going on and enough, this is, we've changed to this movie is not gonna play, but enough to have that guy that I just showed you the map on running on the beach in Copacabana, which is incredible. Not everybody responded like that, but this guy did and a couple of other guys did. And that told me that this is real. This is not a figment of my imagination. When you put in then objective data and you verify that in some patients, you go like, okay, I got something. I just need to figure it out and probably take quite a long time to be able to do that. And we've been doing that for the last 20 years. Okay, so then the second trial came to the US, talked to the FDA, actually they called me at home one day because they saw the first publication of the Brazilian trial. They thought I had done it in the US and they were calling me to say, what in the world are you doing? You have, this has not been approved by regulatory. And I said, well, if you read the trial, you'll see that it was done in Rio. And they're like, okay, I said, but since I got you on the phone, let me just talk up what we wanna do a trial here in the US. And I should have started in the US. I thought it'd be easier in Brazil, but it wasn't. Took several years there to get it approved the regulatory as it did here. So first trial in the US, let's do the same thing. Boom, curves right there, one on top of each other. What happened? So, you know, and that's a good thing for the fellows is that whenever you do science and you do trials, you're never gonna get what you expect to get, just get ready. That's the challenge of it. You're gonna not get the things that you need to get and then you need to figure it out. So in this case, we went back and tried to figure it out. These are, so these are CFU. So if you put a little cell in a Petri dish, it'll grow and a stem cell, that's what it do. The definition of a stem cell is that it's self-renews, right? So it grows like crazy, basically. So if you put the cell in a Petri dish, it develops colonies and you can count those colonies. So if you see here, these are the patients that actually receive treatment in the trial. And so when we grew their colonies, they're all supposed to be up here. They're supposed to grow at least 30 colonies. But in these guys, we've plated their cells and they grew nothing. Well, if you put something that doesn't work into somebody, you're not gonna get an effect. So the light went off and we said, oh, when you think about this is autologous, everybody's their own treatment. So autologous therapy is kind of challenging and people that smoke and have diabetes and are old and this and that and the other, their cells that we're using to treat their own heart may not be as good as somebody who's very healthy and young. We thought age would be an important thing and we looked at this data according to age and bingo, you can separate out. Here's the growth of the colonies, significantly different. If you just divide the population in the younger half, older half, there's a difference. You look at that same curve, now they separate out. So this told us, okay, Houston, we have a problem because this is autologous therapy. So then we did the next trial and this was with an NIH consortium. At the time, very big trial, 92 patients. I presented this in front of 8,000 people and this is basically a negative trial. No change in it. Instalic volume in VO2 reversible defect. I picked in these new things in these exploratory phase two trials where you don't know what you're gonna get. If you pick the wrong end points, you're done. Had I picked ejection fraction, I'd be sitting on a positive trial. Although as you can tell from all the noise on this stuff, it's not a very big difference but it improved significantly, okay? So that's just sort of the BS of science. I could have had a beautiful positive trial, but I didn't. So back to the drawing board. We were ready and we knew about the age thing and we knew about the problem with autologous cells in older people being bad. So we already respectively put in an analysis to separate out those groups and if you look at the ejection fraction, you see all of the benefit is in the younger half of the population. And actually if I told you I got a, near 5% increase in ejection fraction, boy, that's better than a lot of things that we use today for heart failure. So that kind of confirms some of the things you were thinking about. We saw some correlation with different cell types that are actually now being used in different trials. Here's an example of, you play this, it doesn't grow. Here's cells that are healthy and they're growing and we could correlate that growth of colonies also with the MVO2, which didn't change in the overall group. But if we looked at the people that had growing cells, 2.5 is enough to take somebody off the transplant list. If you have a 2.0 improvement in MVO2, you have an actual survival that, again, you're off the transplant list. So very important. But back to our problem. Our problem is that we figured out that autologous therapy is not the greatest. We gotta do something different. So think about it. If you give people aspirin, it's the same aspirin for everybody. But if you give people cells, you're giving, everybody's getting a different medicine. And some people are getting a really lousy medicine and some people are getting a medium medicine as we're getting a really good medicine. So that's the issue. So different solutions. And so I'll just touch on some of these. Now, this is not cell therapy. I just make a little parentheses. This is gene therapy. In the future, I predict that the solution to all of this is gonna be a combination of cell and gene therapy. Gene therapy took some hits, but it's fine and well. And obviously is a big part of the future of therapeutics in medicine in general, right? And so this is work that's getting done in THI. Jim Martin is the guy that's pursued all this and discovered a lot of things. And basically my cardio cells, when they're in embryo, they're growing and they grow fantastically well. When you're born, things get kind of shut off. So there's program sort of turn off the signal for proliferation of cardiomyocytes when you're born. So he's figured out a way to turn that back on. Okay, so we can turn that on and off. Can you imagine injecting genes into a heart that turns on, uninhibits the stimulation for cardiomyocytes to regenerate? Hey, that's a pretty good treatment, right? So Jim Martin has shown this in pigs. I'm shown it in mice. And we've got about 30 pigs that we're finishing. This is one of those pigs. You can see these are new myocytes with yellow nuclei. And so this is a big thing and it's something we're pursuing. As you can tell, this is complicated. I need to go to the FDA. I gotta say, oh, okay, I got a new treatment. You gotta let me do this in people. This hasn't been done, obviously, ever been done in people, but we're gonna do it. But like I said, this is a complicated route to follow. But it will be for sure, it's the future. The other thing is, well, we can select out other cells in the bone marrow. We've done that with other kinds of cells and I don't wanna move forward. So this is a trial of a specific kind of bone marrow cell that was a pilot trial that we then used in peripheral arterial disease that was very angiogenic. And you can see, here's a polar map and you can see this is lack of perfusion. This is good perfusion up here. So this big scar, when you look at it black is sort of non-reversible and white is reversible, okay? And so you can see that we injected, and this map for same kind of display, the dots where we injected the cells right in this area, you can see that the reversibility is significantly lower and there's a lot more of perfusion in this heart compared to the baseline. So these cells are very angiogenic. We wanna use them more in PAD. Okay, then you can go to alternative sources, fat. And I'm not gonna talk a lot about that either, but we've done a whole trial in Madrid. Fat is super interesting, but that's talked for another day. If you take fat and you take all the actual fat away, there's, it's a network of blood vessels and around these blood vessels are parasites and every parasite is a mesenchymal cell. It's a different kind of mesenchymal cell but it's a wonderful cell type to deal with and it heals like crazy. So this is the trial we did in Madrid. We saw basically arresting of progression to transplant levels of MVO2. We saw a decrease in infarct size and this is what I talk about healing. Cell therapy, cell therapy, Lindsay Vaughn, I mean, so we did this trial in Spain and in Spain we had a hand in this. It's approved for ACL surgery, these cells, okay? So, you know, the FDA is a little slower but there's definitely different, and remember the two cars I showed you in the beginning, different cells have different characteristics and can do different things. Now this is interesting, I'm putting this up here, the Cipio trial, this trial was retracted from Lancet. So I told you there's some controversy in cell therapy, right? So this guy, Ann Versa, who's a scientist, he falsified some slides on animal work and, you know, like the coloring of this turned into that and okay, well, it turned out that it was falsified and they made him retract the study. The problem is, and you can, when you read the retraction from Lancet, what they wrote, all of the, you know, Dr. Bowley, who's in Louisville, built a clinical trial and basically Dr. Ann Versa's lab supplied the cells. But all the clinical work and everything that happened, Lancet is very clear, so no, we don't have any, no, any problems at all with that. Our problems are with the cell, but because of that, they took away the whole thing. But you can see, this is, I talked about different sources. These are cardiac stem cells and that's the big controversy is that people are, you know, a lot of the basic scientists are really committed and worried about the notion of is there a real cardiac progenitor cell? Is it a real cardiac stem cell? Or it really doesn't exist? I was gonna say who cares. It's not who can, we all care. It's important. But if we can benefit patients and I can decrease scar in a heart, I actually really don't care. I want to use treatment that works. And that's why we, when we started 20 years ago, we didn't have any idea of how this worked. I have a little better idea now. So you can see how the scar tissue really decreased over time on MR. So, and we have a trial that's pending right now. Two cells, one of them is a cardiac stem cell. Texas Heart is part of this, waiting for the results. Another different trial, also part of this CCTRN NIH Consortium and Adria-Marcin cardiomyopathy, new application of pilot study also completed. We're about to find out in October now what the results are of that. So we've got a couple of things in the pipeline. But this is where I wanted to get to an end at. Allogenic cell source. So again, I said, Houston, we have a problem with the autologous thing. I thought, man, allogenic is great if you could do it. Now, if you put heart cells in, I got a bit of a problem because it's rejection, right? You can have rejection with a big heart transplant. You can have a rejection and cell at a time. And so, immunology is a problem. But there's certain cells that kind of fly under that immunological radar, not to say that we can't really use different cell types, but in certain cell types, it may be more beneficial. So really quickly, this is kind of complicated, but all of you know that, and I'm looking at some of the trends, the heart failure guys, you know that continuous flow pumps where Texas Heart are associated with GI bleeding. And how does that happen? Well, hypoxia, you get all this extra production of angiopeptin-2 and good old inflammation contributes to it. And you get all this angiogenesis and basically proliferation of vascular tissue that's not functional. And you get GI bleeding and that's pretty well known. Well, this was not very well presented actually. They didn't, I don't think they quite understood what they had in their hands, but that's okay. So this was presented at the last AHA meeting in November in this trial in which they injected NPCs into patients with LVAD, and this was led by Columbia in the CTSN, which is a surgical NIH network. They missed the point really, because they were using weaning from the LVAD as the endpoint. That's really hard. That's a very complicated and a hard thing to do. But look at this. There is a 70% reduction in GI bleeding in the patients that got the cells. Now, do you think that's an accident? Or do you think that's a paracrine effect from the cells that got exposed to the inflammation? We know they secrete angiopeptin one. That's one of the release criteria to get the cells out. And angiopeptin one would have an effect to counterbalance the angiopeptin two, decrease the bleeding. These curves separate out. So this is not a paracrine effect that I'm talking about in the heart. This is like a endocrine effect. It's at a distance. So looks like this is the first sign that cell therapy really works. And actually the company that produces, they're actually pursuing this. And they did talk to the FDA about it ahead of time. They're trying to prove the cells based on this as a treatment in continuous flow pumps for GI bleeds. But let's go a little further and let's do heart failure, right? So these same cells, we did a phase two trial at six centers. It was a dosing center. You gotta remember when we did this, it was an allergenic cell. And that was a problem. We don't usually give allergenic cells into the heart. So we had to do a dosing study. We had to be very careful in terms of regulatory. And it's a small trial, but it's an extremely well done trial. And you can see the different dates where we had to go to the FDA to show them there really wasn't an immunological problem. Each group consisted of 15 treatments and five controls. And let's look at some of the results. So endpoint, six month imaging with ECHO. And you can see, so here's the baseline. At six months, and this is low dose, medium dose, 150 million, okay? So compared to placebo, we have a dose dependent decrease in volume. Now this is actually negative volume. Remember the remodeling I was talking about? And a nice significant change in six months. And actually in 12 months, this wasn't the endpoint, but also it's not significant because of the numbers, but it also goes in the right direction. Okay, I'll tell you, I've done several cell trials and endostolic volume you can kind of get. What's really hard to get is endostolic volume to go down. Here we go, six months, significant change, negative change in the volumes. This is remodeling. This is making the heart smaller, okay? With 150 million dose, again, a dose dependent, a significant, and we can see this out to 12 months. It's pretty consistent. If you have a proportional decrease in your endostolic and endostolic volumes, that's what the F is not gonna change. So for the guys that look at, oh, you're reupting, you go down, or didn't go up, it doesn't matter if you have a smaller heart, that is much better, right? So if you know anything about the formula of ejection freshener, it has a negative sign up there that kind of screws things up a bit, and that's something to discuss later. But anyway, no change in ejection freshener, which is very good. But this is the main thing. People die over time that have heart failure many times and despite all the stuff that we do. And so this is sort of the spiral of our current events that we're trying to fight. And this is the, if we look at the events, the people that got the 150 million for some miracle, there wasn't one death, this is three years out. And the other two doses that weren't significantly better in terms of anatomical changes, tracked with control. This is amazing. This is enough to take to the FDA and say, okay, guys, I'd like to do a phase three trial with these cells. I think I might have something for heart failure here. And that is the case. So the trial is called DreamHF. It's completely enrolled now. We use that 150 million dose. And based on the date of the phase two trial, we've completed this trial now in 52 sites in the US and Canada. It's an event driven trial. We need to get to 531. We are actually a little ahead of track on that, which is fantastic. And the endpoint, I'm talking about it, just a little bit has changed over time. So we've actually used something called adaptive design. We've actually enriched the population at different stages. We've changed how we've done the trial together with the FDA. So this is, I think, and so I'll show you something that's coming out about this, because this is very important, I think. And obviously the trials has a DSMB committee, endpoints committee, everything's been reviewed. And we passed a futility analysis back in April of 2017. And all you have to do is go to clinic to see the patients to know that this is a one-to-one ramization. There's something going on. So we just got this approved. So this will be published on July 19 in CERC Research. And it's about what we did with the trial design, okay? And so you can see the title there. But basically explaining, we need to introduce to people that this really, to tell you the truth is, and I fought it a little bit, but this is immunotherapy, okay? This is inflammation therapy for heart failure. And you can read there the things that it does. I already touched on those things. But the important things are how we changed, we're able to enrich the trial based on data from outside and from within the trial. And also how we also adjusted our endpoint. We went from a time to first event to a current recurrent non-fatal events and we changed the statistical modeling for that, the joint frailty model. So here's how that works. And I'm almost at the end, I promise. But this is kind of interesting. When you look at events and they show you all these Kaplan-Meijer curves, most of the time, that's a time to first event. So somebody has an event, boom, they're out of the analysis. You can't count that guy anymore, it's over. So if you can see here, this patient, let's say, he's gonna have a non-fatal, heart failure decompensation. That's what people do, they decompensate. Then he's gonna have a VT and it's gonna get resuscitated. Then he's gonna come back in the house and then he's gonna die. Well, with this first bout of non-compensated heart failure, he's out of the analysis. Now, is that really a smart thing to do? Is this kind of population that they come back in, they're gonna have different things. All the people that die, as sick as the people that don't die, and there's a relationship between these events. So we ought to be a little bit more sophisticated in capturing how we analyze events down the road. And this is kind of what we've done. And so, for example, and I'm not a statistician, but there's some really smart guys that has helped us out. But you can see here, taking into it out of the correlation between recurrent heart failure events and between the recurrent heart failure events and terminal events. So these different modeling schemes don't take that necessary into account where the joint-fail-to model takes all that relationship between all these events into account. And we look at all of them and we've made the endpoint recurrent events. Okay, so this is something that I think is, and we're able to actually reduce the size of the trial because you can imagine how many hundreds of millions of dollars from 1200 patients to 600 patients. And that was, so it was also helped economically a great deal. So if you look, here's some examples. Charm, added, Valheft, emphasis, HF. So these are populations that are kind of similar to DreamHF and you can look, if you look at the traditional versus the joint-fail-to model and you can see that if we analyze those data, they actually would be significantly more positive with a joint-fail-to model, meaning you need less people, which is brilliant. We need to spend less money doing these huge trials but do things smartly. So this is coming out and we're proud of it. So to summarize, long time ago, wrong ideas, autologous bone marrow, focused trial, back in the US, confirmation, kind of a weak therapy. Let's try other cell types, other applications. We use them in peripheral disease. We use them in arthritis. Then really pursuing them as ankylomal cells is gone to multiple trials. Going from initial talk to the FDA when we published our first trial back in 2003 to, you know, that's what we need is a cell treatment for heart failure and it is coming. So that's kind of where we are on the high perv. I think we're in a new era in cell therapy and the first phase three trials is about to come out and approval is very close. Thank you very much. These are some of the folks here in the room that help us out. Thank you very much.