A Phase II, Randomized, Blinded, Study of the Safety and Efficacy of Transendocardial Injection of Allogeneic Human Mesenchymal Stem Cells (hMSCs) (20 Million or 100 Million Total MSCs) in Patients With Chronic Ischemic Left Ventricular Dysfunction Secondary to Myocardial Infarction.
Phase: PHASE2
Conditions: Chronic Ischemic Left Ventricular Dysfunction, Myocardial Infarction
Sponsor: Joshua M Hare

Interdisciplinary Stem Cell Institute 
University of Miami/Miller School of Medicine 
 
Clinical Research Protocol  
Title: 
A Phase II, Randomized, Blinded, Study of the Safety and 
Efficacy of Transendocardial Injection of Allogeneic 
Mesenchymal Stem Cells (20 Million or 100 Million Total 
MSCs) in Patients With Chronic Ischemic Left Ventricular 
Dysfunction Secondary to Myocardial Infarction. 
   
The TRansendocardial Stem Cell Injection Delivery Effects 
on Neomyogenesis STudy (The TRIDENT study) 
 
Investigational Therapy 
Names: 
Allogeneic Human Mesenchymal Stem Cells (Allo-hMSCs) 
FDA IND No.: 
Protocol No.: 
BB-IND #13568 
SCCT-08-003 (Version 2.3) – June 9, 2016 
Principal Investigator: 
Joshua M. Hare, MD                 Telephone: 305-243-1999 
Protocol Agreement Signature: 
 ggggggggggggg 
 
 
        ___________ 
Joshua M. Hare, MD  
 
 
 
 
 
 
Date 
(Sponsor – Investigator)                                              
 
 
 
CONFIDENTIALITY STATEMENT 
This document is confidential and proprietary to the Interdisciplinary Stem Cell Institute (ISCI) University of Miami 
Miller School of Medicine and its affiliates.  Acceptance of this document constitutes agreement by the recipient that 
no unpublished information contained herein will be reproduced, published, or otherwise disseminated or disclosed 
without prior written approval of  Interdisciplinary Stem Cell Institute  University of Miami Miller School of Medicine or 
its affiliates, except that this document may be disclosed in any medium to appropriate clinical investigators, 
Institutional Review Boards, and others directly involved in the clinical investigation that is the subject of this 
information under the condition that they keep the information strictly confidential.

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TABLE OF CONTENTS 
TABLE OF CONTENTS ....................................................................................... 2 
LIST OF ABBREVIATIONS AND DEFINITION OF TERMS ................................ 4 
SYNOPSIS ........................................................................................................... 7 
1. 
INTRODUCTION ..................................................................................... 10 
1.1 
Background ................................................................................... 10 
1.2 
Study Rationale ............................................................................. 20 
2. 
STUDY OBJECTIVES AND ENDPOINTS .............................................. 37 
2.1 
Study Objectives ........................................................................... 37 
2.1.1 Primary Objective ............................................................... 37 
2.1.2 Secondary Objectives ........................................................ 37 
2.2 
Study Endpoints ............................................................................ 37 
2.2.1   Primary Endpoint (Safety) ............................................................. 37 
2.2.2   Secondary Endpoints (Efficacy) ......................................... 37 
3. 
STUDY DESIGN ...................................................................................... 38 
3.1 
Inclusion Criteria ........................................................................... 40 
3.2 
Exclusion Criteria .......................................................................... 40 
4. 
TREATMENT OF PATIENTS .................................................................. 42 
4.1 
Study Therapy and Dosages ......................................................... 42 
4.1.1 Study Investigational Therapy ............................................ 42 
4.1.2 Dose Rationale ................................................................... 43 
4.1.3 Dosages and Dosing .......................................................... 43 
4.2 
Blinding and Unblinding ................................................................ 44 
4.2.1 Storage and Handling of Study Investigational Therapy ..... 44 
4.2.2 Study Investigational Therapy Accountability Procedures .. 44 
5. 
STUDY PROCEDURES .......................................................................... 44 
5.1 
Time and Events Schedule ........................................................... 44 
Time and Events Table Key: .................................................................... 46 
5.2 
Study Phases and Visits ............................................................... 47 
5.2.1 Screening Phase ................................................................ 47 
5.2.2 Baseline Phase .................................................................. 47 
5.2.3 Day 1 – Day 2 Post-Catheterization & Week 2 
Evaluations ......................................................................... 47 
5.2.4  Month 3 – Month 12 Visits ................................................. 48 
5.2.4 Biomarkers Assessment ..................................................... 48 
5.2.5 Immune Monitoring for Graft Rejection ............................... 48 
5.3 
Computed Tomography (CT) Protocol .......................................... 49 
5.4 
Echocardiogram Protocols ............................................................ 50 
Echocardiogram Protocol ......................................................................... 50 
6. 
ADVERSE EVENT MANAGEMENT........................................................ 51 

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6.1 
Definition of an Adverse Event ...................................................... 51 
6.2 
Definition of Adverse Reaction ...................................................... 52 
6.3 
Definition of Suspected Adverse Reaction .................................... 52 
6.4 
Definition of Serious ...................................................................... 52 
6.5 
Definition of Unexpected ............................................................... 53 
6.6 
Clinical Laboratory Assessments and Other Abnormal 
Assessments as Adverse Events and Serious Adverse Events .... 53 
6.7 
Recording of Adverse Events and Serious Adverse Events .......... 54 
6.8 
Intensity of Adverse Events and Serious Adverse Events ............. 54 
6.9 
Causality of Adverse Events and Serious Adverse Events ........... 54 
6.10 
Follow-Up of Adverse Events and Serious Adverse Events .......... 55 
6.11 
Timeframes for Submitting SAE Reports ...................................... 55 
6.12 
Post-Study Adverse Events and Serious Adverse Events ............ 56 
6.13 
Regulatory Aspects of Adverse Event Reporting .......................... 56 
6.14 
Monitoring of Adverse Events ....................................................... 56 
7. 
DATA COLLECTION AND STATISTICAL ISSUES................................ 57 
7.1 
Enrollment ..................................................................................... 57 
7.2 
Data Collection .............................................................................. 58 
7.3 
Study Design and Sample Size Considerations ............................ 58 
7.4 
Demographic and Baseline Characteristics .................................. 60 
7.5 
Analysis of the Primary Endpoint .................................................. 60 
7.6 
Stopping Guidelines ...................................................................... 60 
7.7 
Analysis of Secondary Endpoints .................................................. 62 
7.8 
Criteria for Dose Selection ............................................................ 63 
7.9 
Data and Safety Monitoring Board (DSMB) .................................. 63 
9. STUDY ADMINISTRATION ........................................................................... 66 
9.1   
Regulatory and Ethical Considerations ......................................... 66 
9.1.1 Regulatory Authority Approval ............................................ 66 
9.1.2 Ethics Approval .................................................................... 66 
9.1.3 Patient Informed Consent..................................................... 67 
9.2  
Confidentiality of Information ......................................................... 67 
9.3   
Payments to Patients .................................................................... 68 
10.      REFERENCES ........................................................................................ 68 
 
 
 
 

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LIST OF ABBREVIATIONS AND DEFINITION OF TERMS 
AE 
adverse event 
ALT 
AMBMC 
AMI 
Alanine aminotransferase 
autologous mononuclear bone marrow cells 
acute myocardial infarction 
BMC 
bone marrow cell 
BNP 
BSC 
Brain Natriuretic Peptide 
biologic safety cabinet 
BUN 
C of A 
Blood Urea Nitrogen 
Certificate of Analysis 
CABG 
coronary artery bypass graft 
CAD 
coronary artery disease 
CBC 
CFR 
Complete Blood Count 
Code of Federal Regulations 
CFU-F 
colony forming units – fibroblasts 
CK-MB 
creatine kinase – mb 
CMV 
CRO 
Cytomegalovirus antibody 
contract research organization 
CRP 
CT 
C-reactive Protein 
computed tomography 
CXCR4 
DAPI 
CXC Chemokine Receptor 4 
4'-6-Diamidino-2-phenylindole 
DCC 
DMSO 
Data coordinating center 
dimethyl sulfoxide 
DSMB 
Data and Safety Monitoring Board 
EF 
ejection fraction 
ECG 
Electrocardiogram 
EPC 
endothelial progenitor cells 
ESR 
expedited safety report 
ESV 
FBS 
End systolic volume 
fetal bovine serum 
FDA 
Food and Drug Administration 
FEV1 
forced expiratory volume in 1 second 
F/U 
GCP 
Follow-up 
Good Clinical Practice 
G-CSF 
granulocyte colony stimulating factor 

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HARP 
Harmonic Phase 
HBcAb 
hBMC 
Hepatitis B Core antibody 
human bone marrow cell 
HBsAg 
HCVAb 
HLA 
hMSC 
Hepatitis B surface antigen 
Hepatitis C Virus antibody 
Human Leukocyte antigen 
human mesenchymal stem cell 
HIPAA 
Health Insurance Portability and Accountability Act 
HIV 
HSA 
Human Immunodeficiency Virus 
human serum albumin 
HSC 
hematopoietic stem cell 
HTLV 
human T-cell lymphotropic virus 
ICAM 
intracellular adhesion molecule 
ICD 
implantable cardioverter-defibrillator 
ICF 
informed consent form 
ICH 
International Conference on Harmonization of Technical 
Requirements of Pharmaceuticals for Human Use 
IDM 
Infectious Disease Markers 
IEC 
institutional ethics committee 
IFN-y 
IIEF 
Interferon-y 
International Index for Erectile Dysfunction (Male) 
IM 
IND 
Intramyocardial 
Investigational New Drug application 
IRB 
Institutional Review Board 
I.V. 
Intravenous 
KDR 
VEGF receptor-2 
LAD 
left anterior descending artery 
LV 
left ventricular 
LVAD 
left ventricular assist device  
MACE 
major adverse cardiac events 
MEM 
minimum essential medium 
MHC   
major histocompatibility complex 
MI 
myocardial infarction 
MLHF 
Minnesota Living with Heart Failure 
MR 
magnetic resonance 
MRI 
magnetic resonance imaging 
MSC 
mesenchymal stem cell 

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NMDP 
National Marrow Donor Program138 
NYHA 
New York Heart Association 
PBS 
phosphate buffered saline 
QA 
quality assurance 
QC 
quality control 
RNA 
RPR 
SAE 
Ribonucleic Acid 
Rapid Plasma Reagin 
serious adverse event 
SCF 
stem cell factor 
SDF-1 
stromal cell derived factor 1 
SOP 
standard operating procedures 
SQOL-F 
Sexual Quality of Life Questionnaire-Female1  
SW 
Stroke Work 
TE-SAE 
TFN-a 
TTC 
Treatment-emergent serious adverse event 
Tumor Necrosis Factor Alpha 
triphenyltetrazolium chloride 
UMMSM 
University of Miami Miller School of Medicine 
U.S. 
United States 
VEGF 
vascular endothelial growth factor 
VT 
Peak VO2 
Ventricular tachycardia 
peak oxygen consumption 
WBC 
WMA 
WMSI 
white blood count 
Wall motion abnormalities 
Wall motion score index 
 
 
 
 
 
 
 
 
 
 
 
 

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SYNOPSIS   
Sponsor: Interdisciplinary Stem Cell Institute University of Miami Miller School of Medicine  
Name of Study Therapy: Allogeneic Human Mesenchymal Stem Cells (Allo-hMSCs) 
Title of Study: The TRansendocardial Stem Cell Injection Delivery Effects on 
Neomyogenesis STudy (The TRIDENT study) A Phase II, Randomized, Blinded 
Study of the Safety and Efficacy of Transendocardial Injection of Allogeneic Mesenchymal 
Stem Cells (20 Million or 100 Million MSCs) in Patients With Chronic Ischemic Left 
Ventricular Dysfunction Secondary to Myocardial Infarction.  
Study Center: Interdisciplinary Stem Cell Institute - 
University of Miami Miller School of Medicine 
Phase of Development: Phase II 
Objectives:   
Primary: To demonstrate the safety of allogeneic hMSCs administered by transendocardial 
injection in patients with chronic ischemic left ventricular dysfunction secondary to myocardial 
infarction (MI). 
Secondary: To demonstrate the efficacy of allogeneic hMSCs administered by transendocardial 
injection in patients with chronic ischemic left ventricular dysfunction secondary to MI. 
Design and Investigational Plan:  This is a phase II study intended to gain additional safety 
and efficacy assessments among two dose levels previously studied in a phase I setting.  In this 
study, a 20 million total hMSC dose and a 100 million total hMSC dose will be randomly 
allocated administered via the Biocardia Helical infusion system in a blinded manner.  
Randomization will occur centrally through an electronic data entry system in the following two 
treatment groups:   
 
Treatment Group 1   
Fifteen (15) patients to be treated with Allo-hMSCs: 4 million cells/ml delivered in a dose of 0.5 
ml per injection x 10 injections for a total of 0.2x 108 (20 million) Allo-hMSCs. 
Treatment Group 2 
Fifteen (15) patients to be treated with Allo-hMSCs: 20 million cells/ml delivered in a dose of 0.5 
ml per injection x 10 injections for a total of 1x 108 (100 million) Allo-hMSCs. 
The injections will be administered transendocardially during cardiac catheterization using the 
Biocardia Helical Infusion Catheter.  
The Allo-hMSCs will be supplied from an allogeneic human mesenchymal stem cell source 
manufactured by the University of Miami.  
Following cardiac catheterization and cell injections, patients will be hospitalized for a minimum 
of 2 days then followed at 2 weeks post-catheterization, and at three and six months to complete 
all safety and efficacy assessments.  Patients will also receive selected efficacy and safety 
assessments during a twelve-month follow-up visit.  
 
Patient Population:  Thirty (30) patients with chronic ischemic left ventricular dysfunction 
secondary to MI scheduled to undergo cardiac catheterization will be enrolled in the study. 
Diagnosis and Main Criteria for Inclusion/Enrollment:   
Major Inclusion Criteria 
 
Diagnosis of chronic ischemic left ventricular dysfunction secondary to MI. 
 
Be a candidate for cardiac catheterization within 5 to 10 weeks of screening. 
 
Been treated with appropriate maximal medical therapy for heart failure or post-

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infarction left ventricular dysfunction. 
 
Ejection fraction less than or equal to 50%. 
Major Exclusion Criteria 
 
Baseline glomerular filtration rate ≤35 ml/min/1.73m2. 
 
Presence of a mechanical aortic valve or heart constrictive device. 
 
Documented presence of aortic stenosis (aortic stenosis 1.5cm2 or less). 
 
Documented presence of moderate to severe aortic insufficiency (echocardiographic 
assessment of aortic insufficiency graded as ≥+2). 
 
Evidence of a life-threatening arrhythmia in the absence of a defibrillator (nonsustained 
ventricular tachycardia ≥ 20 consecutive beats or complete second or third degree heart 
block in the absence of a functioning pacemaker) or QTc interval > 550 ms on screening 
ECG.  
 
AICD firing in the past 60 days prior to study enrollment. 
 
Be eligible for or require coronary artery revascularization. 
 
Have a hematologic abnormality as evidenced by hematocrit < 25%, white blood cell < 
2,500/µl or platelet values < 100,000/µl without another explanation. 
 
Have liver dysfunction, as evidenced by enzymes (ALT and AST) greater than three 
times the ULN. 
 
Have a coagulopathy condition = (INR > 1.3) not due to a reversible cause.  
 
Known, serious radiographic contrast allergy. 
 
Known allergies to penicillin or streptomycin. 
 
Hypersensitivity to Dimethyl Sulfoxide (DMSO). 
 
Organ transplant recipient. 
 
Have a history of organ or cell transplant rejection  
 
Clinical history of malignancy within 5 years (i.e., patients with prior malignancy must be 
disease free for 5 years), except curatively treated basal cell carcinoma, squamous cell 
carcinoma, melanoma in situ or cervical carcinoma. 
 
Non-cardiac condition that limits lifespan to < 1 year. 
 
On chronic therapy with immunosuppressant medication. 
 
Serum positive for HIV, hepatitis BsAg, or viremic hepatitis C. 
 
Female patient who is pregnant, nursing, or of child-bearing potential and not using 
effective birth control. 
 
Definition of Endpoints:  
Safety (Primary): Incidence (at one month post-catheterization) of any treatment-emergent 
serious adverse events (TE-SAEs), defined as the composite of: death, non-fatal MI, stroke, 
hospitalization for worsening heart failure, cardiac perforation, pericardial tamponade, sustained 
ventricular arrhythmias (characterized by ventricular arrhythmias lasting longer than 15 seconds 
or with hemodynamic compromise). 
Definition of Endpoints (continued):  
Safety (Additional): (During the six-month follow-up period and at the month 12 visit) 

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 
Treatment emergent adverse event (AE) rates. 
 
 
24-hour ambulatory electrocardiogram (ECG) recordings. 
 
Hematology and clinical chemistry values and urinalysis results. 
 
Serial troponin I and CK-MB values (every 12 hours for first 24 hours post-cardiac 
catheterization and one set of cardiac enzymes at week 2 visit). 
 
Post-cardiac catheterization echocardiogram. 
Efficacy (Secondary): During the six-month follow-up period, at the month 12 visit. 
 
Echocardiographic measures of regional and global left ventricular function. 
 
Infarct size, regional and global left ventricular function by CT 
 
Peak VO2 (by treadmill determination). 
 
Six-minute walk test. 
 
NYHA functional class. 
 
Minnesota Living with Heart Failure (MLHF) questionnaire. 
 
Incidence of Major Adverse Cardiac Events (MACE), defined as the composite 
incidence of (1) death, (2) hospitalization for worsening HF, or (3) non-fatal recurrent MI. 
Study Therapy:  Allogeneic human mesenchymal stem cells (Allo-hMSCs) at 20 or 100 million 
total hMSCs, supplied from an allogeneic human mesenchymal stem cell source manufactured 
by the University of Miami Interdisciplinary Stem Cell Institute. 
 
Duration of Study Follow-Up: Follow-up will be at 2 weeks, 3, 6 months and 12-months. 
 

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1. 
INTRODUCTION 
1.1 
Background 
The technique of transplanting progenitor cells into a region of damaged 
myocardium, termed cellular cardiomyoplasty1, is a potentially new therapeutic 
modality designed to replace or repair necrotic, scarred, or dysfunctional 
myocardium2-4.  Ideally, graft cells should be readily available, easy to culture to 
ensure adequate quantities for transplantation, and able to survive in host 
myocardium, which is often a hostile environment of limited blood supply and 
immunorejection.  Whether effective cellular regenerative strategies require that 
administered 
cells 
differentiate 
into 
adult 
cardiomyocytes 
and 
couple 
electromechanically 
with 
the 
surrounding 
myocardium 
is 
increasingly 
controversial and recent evidence suggests that this may not be required for 
effective cardiac repair.  Most importantly, transplantation of graft cells should 
improve cardiac function and prevent adverse ventricular remodeling.  To date, a 
number of candidate cells have been transplanted in experimental models, 
including fetal and neonatal cardiomyocytes5, 6, embryonic stem cell-derived 
myocytes5, 7, 8, tissue engineered contractile grafts9, skeletal myoblasts10, 11, 
several cell types derived from adult bone marrow12-20, and cardiac precursors 
residing within the heart itself21-23. There has been substantial clinical 
development in the use of whole bone marrow and skeletal myoblast 
preparations in studies enrolling both post-infarction patients and patients with 
chronic ischemic left ventricular dysfunction and heart failure. The effects of bone 
marrow-derived mesenchymal stem cells (MSCs) have also been studied 
clinically24, 25. 
Currently, bone marrow or bone marrow-derived cells represent a highly 
promising modality for cardiac repair. The totality of evidence from trials 
investigating autologous whole bone marrow infusions into patients following 
myocardial infarction supports the safety of this approach.  In terms of efficacy, 
increases in ejection fraction are reported in the majority of the trials.  
Chronic ischemic left ventricular dysfunction is a common and problematic 
condition; definitive therapy in the form of heart transplantation is available to 
only a tiny minority of eligible patients.  Cellular cardiomyoplasty for chronic heart 
failure has been studied less than for acute MI, but represents a potentially 
important alternative for this disease.  
Cells derived from adult bone marrow   
Bone marrow harbors a variety of cells that may contribute to vasculogenesis or 
cardiomyogenesis, either directly, or by facilitating endogenous repair 
mechanisms.  Bone marrow cells have been prepared on the basis of being 1.) 
endothelial precursor cells that are CD34+, 2.) MSCs purified without an antigen 
panning technique on the basis of their fibroblast morphology, ability to divide in 
culture and to differentiate into mesodermal lineages26, and 3.) cells that express 
stem cell factor receptor, c-Kit27, 28.  Endothelial progenitor cells (EPCs) express 
the surface markers CD34, CD133, c-kit, and the vascular endothelial growth 

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factor receptor-2 (VEGFR2; KDR; Flk-1)29-34.  Hematopoietic stem cells (HSCs) 
exhibit self-renewal and differentiation.  Their cell-surface phenotype is CD34+, 
stem cell factor antigen (SCA-1)+, c-kit+, and Lin- (review35).  While there has 
been controversy regarding the ability of bone marrow-derived cells to 
transdifferentiate into cardiomyocytes36, clinical trials of bone marrow therapies 
continue to suggest potential benefit in terms of improving cardiac function or 
reducing the burden of scarred myocardium4.   
Mesenchymal Stem Cells: MSCs are a particularly promising bone marrow-
derived cell for cardiac regenerative therapy because of their availability, 
immunologic properties, and track record of safety and efficacy24, 37.  Studies of 
MSC engraftment in rodent and swine models of myocardial infarction have 
shown that administration of MSCs produces: 1) functional benefit in post-
myocardial infarction (MI) recovery of ventricular function, 2) evidence of 
neoangiogenesis at the site of the infarct, 3) decrease in collagen deposition in 
the region of the scar, and 4) some evidence of cells expressing contractile and 
sarcomeric proteins but lacking true sarcomeric functional organization38, 39.  
Moreover, MSCs are thought to be ideal candidate cells for allogeneic 
transplantation because they show minimal major histocompatibility complex 
(MHC) class II and intracellular adhesion molecule (ICAM) expression and lack 
B-7 costimulatory molecules necessary to cause a T-cell mediated immune 
response4, 37, 40.   
Although there is no agreed upon cell surface marker that characterizes MSCs, 
they appear related to c-Kit+ cells discussed next as they pass through a stage of 
cardiac differentiation in which they express this cell surface marker.  C-Kit is the 
145 KD tyrosine kinase receptor for stem cell factor41.  Some, but not all, groups 
have purified MSCs expressing c-Kit directly from bone marrow that have the 
capacity to form cardiac myocytes42.  This is of functional significance given the 
demonstration that stem cell factor stimulates cardiac repair post-MI28. 
Clinical Trials 
Several cell-based therapies have entered early studies.  As described below, 
the results continue to suggest that cellular cardiomyoplasty is a safe and 
effective strategy to improve cardiac function in patients with acute MI or chronic 
heart failure. 
Previous Human Experience with Skeletal Myoblasts 
There have been several case reports and very small phase I clinical trials 
investigating the feasibility of autologous skeletal myoblast transplantation43-45 for 
ischemic cardiomyopathy, as well as the ability of transplanted cells to survive 
and differentiate in human myocardium. Though limited by extremely small 
numbers of patients (typically fewer than 10 to 15), as well as a lack of blinding, 
control groups, and randomization, these studies suggest potential improvements 
in left ventricular ejection fraction46, 47, increased wall thickening48, and New York 
Heart Association (NYHA) functional class43, 
47. However the lack of 
electromechanical coupling between engrafted skeletal myoblasts and cardiac 
myocytes in vivo49, 50 has raised serious concerns over the likelihood of an 

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increase in ventricular tachyarrhythmia’s secondary to the formation of re-entry 
circuits43, 48, 51.  Indeed because of reports of increased arrhythmias in these 
patients, ongoing trials have mandated the use of implantable cardioverter 
defibrillator (ICD) placement for enrolled patients43.   
Recently, the Myoblast Autologous Grafting in Ischemic Cardiomyopathy 
(MAGIC) trial, a large multicenter Phase II study comparing two doses of 
autologous skeletal myoblasts to placebo in patients undergoing CABG, was 
terminated early by the DSMB on a futility basis, with virtually no chance that 
either the high-dose group or the low-dose group would demonstrate an 
improvement in the primary endpoint (survival)52.  However, although neither 
group randomized to skeletal myoblast therapy demonstrated improvement in 
survival, the high-dose group did show statistically significant reductions in both 
end diastolic volume (EDV) and end systolic volume (ESV); effects that were not 
observed in the low-dose group. 
Previous Human Experience with Autologous Mononuclear Bone Marrow 
Cells (AMBMCs)  
Clinical studies using autologous mononuclear bone marrow cells have been 
performed for a variety of indications, including peripheral vascular and cardiac 
diseases. The Therapeutic Angiogenesis using Cell Transplantation Study 
investigators53 injected bone marrow mononuclear cells into the gastrocnemius 
muscles of patients with lower extremity ischemia and demonstrated significant 
improvement in ankle-brachial pressure index, rest pain, and pain free walking 
time.  The authors concluded that the efficacy related to these implanted cells is 
due to the supply of endothelial progenitor cells. 
AMBMCs in Acute MI:  As with skeletal myoblasts, there have been several 
small studies evaluating the safety and feasibility of AMBMC cardiomyoplasty in 
patients in the peri-infarct period.  Although these studies are also limited by 
similarly small numbers of patients and lack of blinding, control groups, and 
randomization, they do offer promising insights into the potential of MSC 
transplantation.  In an early study, Strauer et al. randomized 20 patients following 
transmural MI to standard therapy plus intracoronary AMBMC injection 12 hours 
after acute MI, or to standard medical therapy alone. Intracoronary AMBMC 
decreased infarct size from 3013% to 127% and the size of perfusion defects, 
as assessed by 201thallium scintigraphy, by 26% (17499cm2 to 12871 cm2) 
compared to baseline values54.  Subsequently, Stamm et al. demonstrated 
similar improvements in perfusion, left ventricle dimensions, and ejection fraction 
(EF) in an uncontrolled, non-blinded phase I study of 12 patients with transmural 
MI and left ventricular (LV) dysfunction (EF of 39.79%).  These patients had 
infarct areas not amenable to surgical or interventional revascularization; they 
received intraoperative AMBMC injections during elective coronary artery bypass 
to non-infarct-related arteries in the first 3 months post-MI55, 56.   
In the TOPCARE-AMI57 trial, post-MI patients were randomized to receive either 
AMBMC (n=9) or peripheral blood-derived progenitor cells (n=11) infused into the 
infarct artery approximately four days after reperfusion with coronary stenting.  

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Over 90% of the cells derived from peripheral blood exhibited endothelial cell 
characteristics including KDR, von Willebrand factor, CD31, and VE-Cadherin; 
while those derived from bone marrow cells exhibited CD34 and CD133.  The 
results demonstrated a ~9% absolute increase in LVEF (from 51.69.6% at 
baseline to 60.18.6% after 4 months), as well as improvement in wall motion 
abnormalities in the infarct area and a reduction in end-systolic LV size.  There 
was also complete normalization of coronary flow reserve in the infarct artery, 
and a significant increase in myocardial viability within the infarcted segments. 
Furthermore, a sustained improvement in LV function, reduction in end-systolic 
volume, and prevention of remodeling was observed at 1-year. These findings 
were observed in both the AMBMC and peripheral blood-derived progenitor cell 
treatment groups. The recently completed 5-year follow up showed that the 
improvement in LVEF in the treated groups was sustained58. These results are 
quite promising; supporting the conduct of larger, controlled clinical trials.  
In the randomized controlled BOOST clinical trial, patients received both 
standard post-infarct medical therapy and intracoronary transfer of AMBMC 
(n=30), or standard post-infarct therapy alone, 4 to 8 days after percutaneous 
coronary intervention for their first acute ST segment elevation MI.  There was a 
6.79.5% absolute improvement in global LVEF in the cell-treated group 
(46.310.6% at baseline to 53.015.5% at 6 months), compared to 1.111.8% 
increase in the control group (47.89.7% at baseline to 48.915.2%; p=0.0026).  
Furthermore cell transplantation was associated with increased systolic wall 
motion in the MI border zone59.  Importantly, infarct size as measured by late 
enhancement magnetic resonance imaging (MRI) was not reduced compared to 
placebo in the BOOST trial.  Reports from the BOOST investigators suggest that 
the relative improvement in LVEF between placebo and AMBMC treated patients 
may wane over time, but this was due to increases in EF in the placebo patients, 
not deterioration in the AMBMC-treated patients60. The recently completed 5-year 
follow-up study showed that the 6-month improvement in LVEF in the treated 
group was not sustained61, emphasizing the importance of examining in future 
trials the long-term sustainability of cell-based therapy. 
In the REPAIR AMI study, the largest trial of bone marrow-derived cellular 
therapy to date, Schächinger et al. randomized 204 patients to intracoronary 
infusion of bone-marrow cells or placebo 3 to 7 days after successful reperfusion 
therapy.  At the four-month follow-up period, LVEF improved by 5.5% with the 
bone marrow cells versus 3% with placebo infusion (p=0.014).  Interestingly, the 
benefit was greatest in patients with the worst ejection fractions at baseline62. 
Other studies suggest relatively less benefit in EF than that reported above, 
although AMBMCs appeared to reduce infarct size63. 
AMBMCs In Chronic Ischemia:  There are several small studies investigating 
the safety and feasibility of autologous bone marrow cell transplantation for 
ischemic heart disease17, 64-68. 
Hamano and colleagues performed a non-randomized study of direct injection of 
AMBMC into ungraftable or peri-infarct myocardial segments during CABG in five 

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patients and reported improved perfusion to the treated areas up to one year 
after surgery64.  Ozbaran and colleagues injected peripheral blood stem cells 
mobilized with granulocyte colony stimulating factor (G-CSF) in the myocardium 
of 6 patients with severe ischemic cardiomyopathy (EF <25%); they found 
improvements in NYHA functional class and quality of life69.  However, it is 
important to note the difficultly in determining how much of the improved 
perfusion is secondary to the stem cells compared to surgical revascularization.  
In a randomized, crossover trial known as TOPCARE-CHD, Assmus et al. 
compared bone marrow-derived progenitor cells and progenitor cells derived 
from circulating blood to no cellular therapy in 75 patients with chronic left 
ventricular dysfunction. Results showed a modest benefit at three months in the 
group receiving the bone marrow-derived cells: EF in the patients treated with 
these had an absolute increase of 2.9% versus (1) a decrease of 0.4% in the 
patients who received injections of progenitor cells derived from circulating blood 
(P=0.003), and (2) a decrease of 1.4% in the patients who received no infusion 
(P<0.001)70. 
Several smaller (n<20) non-randomized studies have performed endocardial 
catheter injections of AMBMC into chronically ischemic myocardium and 
demonstrated improved myocardial function and perfusion, as well as reduced 
symptoms66-68.  Perin and colleagues performed a nonrandomized, open-label 
study comparing AMBMC injection (n=14) to standard therapy (n=7) in 21 
patients with severe ischemic heart failure.  They used a NOGATM endocardial-
mapping catheter to inject AMBMC into hibernating myocardial segments of 
patients with severe ischemic heart failure.  They reported a 73% reduction in the 
total reversible perfusion defect, improved mechanical function of injected 
myocardial segments as determined by electromechanical mapping, improved 
global EF (9%), and improved NYHA functional class and Canadian 
Cardiovascular Society Angina score66.   
Recently, the First Mononuclear Cells injected in the United States conducted by 
the Cardiovascular Cell Therapy Research Network (FOCUS-CCTRN) phase 2 
trial evaluated whether transendocardial delivery of AMBMCs improves LV 
performance and perfusion at 6 months in patients with chronic ischemic 
cardiomyopathy71. Although there was no improvement compared to placebo in 
LV end-systolic volume, maximal oxygen consumption, or myocardial perfusion, 
exploratory analyses showed significant improvement in LVEF and stroke 
volume. Interestingly, the improvement in EF was associated with higher bone 
marrow CD34+ and CD133+ progenitor cell counts. These results suggest that 
the cellular composition of the bone marrow may determine clinical end points, 
with certain cell populations providing a greater regenerative benefit. Together 
these results support ongoing research in AMBMC transplant for patients with 
chronic ischemic cardiomyopathy. 
Previous Human Experience with Autologous and Allogeneic Human 
Mesenchymal Stem Cells (MSCs) 

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Administration of autologous or allogeneic human MSCs to cardiovascular 
patients has been performed in several clinical studies to date. In the post-
myocardial infarction (MI) setting, previous studies have administered MSCs via 
the intracoronary route (IC) and via peripheral intravenous (IV) injection. 
In a clinical study reported by Chen et al.72, 69 patients were randomly assigned 
to receive IC infusions of autologous MSCs (average cell dose: 5.4 x 1010) or 
placebo (saline) 18 days after the onset of acute MI symptoms.  At the three-
month follow-up visit, LVEF was significantly improved in the MSC-treated group 
(from 49% ± 9% at baseline to 67% ± 11%) compared to the placebo group (from 
48% ± 10% at baseline to 53% ± 18%; P < 0.01 for the between-group 
comparison).  This improved EF was sustained at six months post-infusion.  In 
addition, significant reductions in perfusion defect, left ventricular end-diastolic 
volume (EDV) and end-systolic volume (ESV) were reported in the MSC-treated 
group.  No adverse events were reported in this study.  Although it is unclear if 
the cell preparation used was purified MSCs or whole bone marrow, even in the 
latter case, the likely range of MSC cells infused was 5 x 107 – 5 x 108 cells, 
since the MSC fraction is generally considered to be 0.1 – 1.0 % of a whole bone 
marrow aspirate.  
Katritsis et al.73  investigated the effects of IC infusions of autologous MSCs and 
endothelial progenitor cells (average cell dose: 1.5 x 106) in 11 patients 
approximately 8.6 months post-MI compared to 11 age- and sex-matched 
patients used as controls.  Statistically significant improvements in both wall 
motion score and myocardial contractility on stress echocardiography, as well as 
restoration of uptake of Tc99m sestamibi in previously nonviable myocardial scars, 
were observed at four months post-infusion.  No arrhythmias were detected on 
ambulatory ECG monitoring throughout the four-month follow-up period.  
Moreover, no ventricular arrhythmias were detected in three patients treated with 
an implantable cardioverter-defibrillator due to clinical and inducible ventricular 
tachycardia or fibrillation during the follow-up period. 
A third, multi-center, randomized, double-blinded, placebo-controlled study was 
performed in 53 patients who were treated 3-10 days post-MI74. Patients received 
one of three cell-dose levels of allogeneic MSCs (0.5, 1.6 and 5.0 M cells/kg; 
corresponding to 3.5 x 107, 1.1 x 108, and 3.5 x 108 cells per patient for a 70 kg 
body weight patient), or placebo administered via peripheral IV injection, and 
followed for six months.  There were no deaths reported in the study; no toxicity 
was observed with the administration of the allogeneic MSCs (which were found 
to be well-tolerated at all dose levels administered, with 5.3 adverse events per 
patient in the MSC-treated group vs. 7.0 in the placebo group); and no serious 
adverse events were attributed to MSC administration.  In fact, several signals 
from the trial indicate that the allogeneic MSCs were very safe, and also provided 
preliminary evidence of the following clinical benefits: 
 
 Patients in the MSC-treated group were four times less likely to 
experience an arrhythmic event compared to those receiving placebo (9% 
vs. 37%, p=0.025). 

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 Fewer patients experienced clinically significant premature ventricular 
contractions (PVCs) after receiving MSCs as compared to placebo across 
all time points (11% vs. 24%, p < 0.001). 
 The MSC-treated patients with major anterior wall myocardial infarctions 
had a statistically significant 7.0 point absolute improvement (24%) in EF 
at three months and a 7.3 point absolute improvement (25%) at six 
months over baseline (p<0.05), while similar patients receiving placebo did 
not have significant improvement. 
 Patients in the MSC-treated group had significantly improved pulmonary 
function as measured by improvement in FEV1 (% predicted), which 
increased 17% in the MSC-treated group vs. 6% in the placebo, p < 0.05. 
Significantly more patients who received the MSCs experienced improvement in 
their overall clinical status at six months as compared to those receiving placebo 
(42% vs. 11%, p=0.027). 
Previous Human Experience with Autologous Human Bone Marrow-Derived 
Mononuclear Cells 
There is substantial clinical experience with the intramyocardial delivery of 
autologous bone marrow-derived mononuclear cells (BMCs) in the clinical setting 
of chronic left ventricular dysfunction.  Table 1 lists the 11 studies in which 
intramyocardial delivery of BMCs was performed.  Cell delivery has been 
performed via either (1) direct intramyocardial (IM) injection during coronary 
artery bypass graft (CABG) surgery, or (2) catheter-based intramyocardial 
injection (including transendocardial, or TEC, delivery)24, 55, 56, 65-68, 75-80. These 
results clearly support the clinical safety of the intramyocardial injection delivery 
method. 
BMC cell doses as high as 292 ± 232 x 106 have been injected via the IM route 
without untoward effects, and have produced global improvements in ventricular 
function80.   In addition, a recent clinical study (the TABMMI trial) using the 
BioCardia Helical Infusion system (the delivery device to be used for the clinical 
study in this protocol) has been reported.  In this study, transplantation of 
autologous BMCs (86 ± 3 x 106 cells) into the peri-infarct region of patients with 
chronic ischemic heart failure79 was performed using the Biocardial Helical 
Infusion catheter to improve ease, efficiency, and safety of delivery.  The study 
demonstrated statistically significant functional improvements in transthoracic 
echocardiographic measurements at both 6 and 12 months of follow-up, with no 
adverse events associated with the catheter. 
In addition, a recent meta-analysis of all clinical trials of adult, bone marrow 
derived cell therapy (either BMCs or MSCs) for cardiac repair has been 
published81. The combined results of these studies support the clinical safety of 
administering both BMC and MSC preparations for cardiac repair. 
Previous Human Experience Using the Biocardia Helical Infusion Catheter 
The initial clinical study performed using the BioCardia Helical Infusion system 

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for intramyocardial delivery in patients with coronary artery disease undergoing 
PCI or diagnostic heart catheterization provided support that the procedure and 
device are safe and well-tolerated82. 
A recent clinical study (the TABMMI trial) using the BioCardia Helical Infusion 
system has been reported.  In this study, transplantation of autologous BMCs 
into the peri-infarct region of patients with chronic ischemic heart failure79 was 
performed using the Biocardial Helical Infusion catheter (the delivery device to be 
used for the clinical study in this protocol) to improve ease, efficiency, and safety 
of 
delivery. 
The 
study 
demonstrated 
statistically 
significant 
functional 
improvements in transthoracic echocardiographic measurements at both 6 and 
12 months of follow-up, with no adverse events associated with the catheter. 
In conclusion, the experience utilizing the BioCardia Helical Infusion system in 
these two clinical studies and in our recently published TAC-HFT clinical study24, 
described below, supports the clinical safety of the technique and provides 
preliminary evidence of patient benefit. 
 

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TABLE 1 
CLINICAL STUDIES: AUTOLOGOUS BONE MARROW-DERIVED MONONUCLEAR CELLS (BMCs) ADMINISTERED VIA 
INTRAMYOCARDIAL (IM) INJECTION IN PATIENTS WITH CHRONIC LEFT VENTRICULAR DYSFUNCTION 
 
Study 
 
N 
Cell Delivery (Injection) 
Method 
 
Cell Source & Type 
Cell Dose 
(x 106) 
Safety 
Results 
Efficacy 
Results 
Stamm 
6 
Direct IM during CABG surgery 
Autologous, AC133+ BMCs 
1.2 - 3.4 
No arrhythmias; no neoplasia 
↑ global contractility (EF) 
 
 
 
 
 
 
 
Tse 
8 
Catheter-based IM 
Autologous BMCs 
2.6 - 21.2 
No arrhythmias 
↑ wall motion & thickening 
 
 
 
 
 
 
 
Fuchs 
10 
Catheter-based IM 
Autologous BMCs 
32.6 + 27.5 
No arrhythmias or other SAEs 
↓ angina score; ↓ ischemia 
 
 
 
 
 
 
 
Perin 
14 
Catheter-based IM 
Autologous CD34+  BMCs 
25.5 + 6.3 
No arrhythmias at 6-mo. F/U 
↑ global contractility (EF); ↓ ESV 
 
 
 
 
 
 
 
Beeres 
25 
Catheter-based IM 
Autologous BMCs 
84.1 + 28.7 
No arrhythmias or pericardial 
effusion 
↑ global contractility (EF); ↓ ESV 
 
 
 
 
 
 
 
Briguori 
10 
Catheter-based IM 
Autologous CD34+  BMCs 
4.6 + 1.5 
No arrhythmias or AMI 
↑ quality of life; ↑ perfusion 
 
 
 
 
 
 
 
de La Fuente 
10 
Catheter-based IM 
Autologous CD34+  BMCs 
86 + 3 
No arrhythmias at 12-mo. F/U 
↑ global contractility (EF) 
 
 
 
 
 
 
 
Mocini 
36 
Direct IM during CABG surgery 
Autologous CD34+  BMCs 
292 + 232 
No SAEs 
↑ global contractility (EF) 
 
 
 
 
 
 
 
Hendrikx 
20 
Direct IM during CABG surgery 
Autologous BMCs 
60.1 + 31.1 
Possible inducible VT 
↑ global contractility (EF) 
 
 
 
 
 
 
 
Stamm 
55 
Direct IM during CABG surgery 
Autologous, CD133+ BMCs 
3.85 - 103.0 
No arrhythmias 
↑ global contractility (EF) 
 
 
 
 
 
 
 
Li 
6 
Direct IM during CABG surgery 
Autologous BMCs 
50 – 100 
No arrhythmias; no neoplasia 
Not assessed 
 
 
 
 
 
 
 
AMI: acute myocardial infarction; IM: intramyocardial; CABG: coronary artery bypass graft; BMC: bone marrow-derived mononuclear cells; EF: Ejection Fraction; ESV: end systolic 
volume; F/U: follow-up; SAE: serious adverse event; VT: ventricular tachycardia. 

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Potential mechanisms for MSC mediated improvements in cardiac function 
 
As noted above, prior studies have shown that a variety of cellular sources are 
capable of differentiating into phenotypes that strongly resemble the three 
principal cell types of myocardium; cardiomyocytes, smooth muscle and vascular 
endothelium.  Our preliminary data and reports from other labs cited above 
suggest that MSCs, the cells employed in our model of cellular cardiomyoplasty, 
have the potential to form all three cell types within infarcted myocardium in 
vivo16. Nevertheless, it is important to consider that MSCs may exert other 
favorable effects on cardiac repair above and beyond differentiation4, 37.  For 
example, these cells may also participate in the recruitment and/or stimulation of 
other cells to differentiate into a cardiac phenotype83.   
There is a wealth of evidence suggesting that stem cell homing to injured 
myocardium is directed by injury signal(s) emanating from the area within or 
surrounding the infarct.  For example, stromal-cell-derived factor 1 (SDF-1), a 
chemokine that is a natural ligand for the CXCR4 receptor, is crucial for bone 
marrow retention of hematopoietic stem cells84, 85, cardiogenesis86, recruitment of 
endothelial progenitor cells to sites of ischemic tissue87 and, potentially, migration 
of tissue-committed stem/progenitor cells88.  Interestingly, it was recently shown 
that the CXCR4 receptor is strongly expressed by a proportion of MSCs and it 
plays an important role in MSC mobilization89.  Expression of SDF-1 dramatically 
increased over the first week following infarction, and exogenous expression of 
SDF-1 increased the numbers of mobilized bone marrow cells (BMCs) homing to 
the heart at time periods remote from infarction90.  These findings suggest that 
MSCs participate in the complex autocatalytic cascade of cytokines and growth 
factors that is activated following MI.  Indeed, human MSCs are capable of 
secreting several cytokines, including stem cell factor (SCF) and G-CSF91, and 
intramyocardial administration of MSCs is associated with increases in vascular 
endothelium growth factor (VEGF) levels19.  Furthermore, it has been shown that 
MSCs participate in angiogenesis and arteriogenesis, differentiating into 
endothelium and vascular smooth muscle in a VEGF-dependent manner92. 
 
Once cells successfully home and engraft in the heart, they must survive in a 
hostile environment if they are to effect successful cardiac repair.  It is thought 
that apoptosis within the infarct region is responsible for the fact that only a 
fraction of cells injected directly into the heart will engraft and survive, and that 
such cell death reduces the efficacy of cellular cardiomyoplasty.  In a dramatic 
proof of principle study, Mangi et al. genetically engineered rat MSCs using ex 
vivo retroviral transduction to overexpress the anti-apoptotic protein Akt1, a 
serine-threonine kinase39.  Transplantation of 5x106 cells overexpressing Akt into 
the ischemic rat myocardium led to dramatic improvements in structure and 
function that far exceeded those seen with injection of control MSCs transduced 
with Lac-Z.  MSCs reduced inflammation, collagen deposition and cardiomyocyte 
hypertrophy, regenerated 80-90% of lost myocardium, and completely 
normalized systolic and diastolic cardiac function in a dose-dependent fashion.  

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1.2 
Study Rationale 
Introduction 
The field of stem cell mediated myocardial repair has advanced rapidly over the 
past few years, and early studies have been performed in humans (including new 
studies in the USA).  At present, several types of adult stem cells (possibly 
enhanced by concomitant strategies aimed at enhancing trafficking or survival) 
hold great promise to improve recovery following MI.  This clinical study will 
utilize allogeneic bone marrow-derived hMSCs as a therapy for chronic ischemic 
left ventricular dysfunction and heart failure.   Allogeneic MSCs have been 
chosen because they have shown effectiveness in small and large animal 
models as well as safety and effectiveness in clinical trials4, 74, and offer the 
substantial advantage of already having approval from the FDA for use in 
humans.   
Preliminary Studies 
A 
porcine 
model 
of 
anterior 
myocardial infarction was used to 
characterize the impact of cellular 
cardiomyoplasty 
on 
cardiac 
structure 
and 
function 
using 
hemodynamic, 
imaging, 
and 
histological analyses.  A pig model 
was 
selected 
because 
of 
its 
anatomic similarity to the human 
heart. 
 
The 
following 
sections 
describe the safety and efficacy 
results obtained with this model93.   
Two distinct sets of studies were 
conducted, representing the early 
treatment 
of 
acute 
myocardial 
infarction, as well as the treatment 
of chronic ischemic cardiomyopathy. 
 
Allogeneic 
mesenchymal 
stem 
cell 
transplantation 
improves 
global cardiac function in a swine 
model 
of 
acute 
myocardial 
infarction: 
Previously 
published 
work demonstrated that autologous 
MSC transplantation in post-MI pigs 
improved 
cardiac 
function, 
with 
histological 
evidence 
of 
robust 
engraftment at 8 weeks, and differentiation to a myocyte-like phenotype38.  
Based on in vitro observations that MSCs lack the B-7 costimulatory molecule 
and may therefore be immune-privileged, the impact of allogeneic MSC 
transplantation in porcine MI was assessed.  A 14 pig randomized, placebo-
Figure 1.  MSC engraftment and differentiation.  MSC engraftment 
and muscle-specific protein-expression. DAPI and Di-I labeled MSCs 
(blue staining nuclei and red staining membranes, respectively) and 
fluorescent muscle protein-specific antibodies (green).  (A) 
Hematoxylin and eosin (H&E)–stained section and corresponding 
fluorescent detection of cellular labels (B) depicts a cluster of MSCs in 
proximity to host myocardium.  Several muscle-specific proteins are 
detected by immunofluorescence including 
-actinin (C), phospho- 
lamban (D), tropomyosin (E) and troponin T (F).  Yellow fluorescence 
indicates colocalization of immunofluorescent antibodies and DiI. (G) 
H&E stained sections of vascular structures at the border of the 
infarcted myocardium.  Corresponding sections depict DAPI stained 
MSC nuclei (H) with immunofluorescent detection of factor 8 (I).  
C 
D 
E 
F 
B 
A 
G 
H 
I 

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controlled study (MSCs vs. placebo) using the BioCardia Helical Infusion 
Catheter was performed to assess safety and efficacy of allogeneic 
transendocardial injections93. Farm pigs were chronically instrumented to 
measure left-ventricular pressure, dimension, and oxygen consumption, and 
were randomized to active treatment or placebo groups. Three days following MI, 
placebo (n=7) or 2X108 allogeneic MSCs (n=7) labeled with Di-I and DAPI (both 
fluorescent dyes to aid histochemical identification) were injected percutaneously 
into infarcted myocardium of the 
left ventricular cavity using a 
helical injection needle catheter 
inserted through a steerable 
guide catheter (BioCardia, Inc.).  
All 
animals 
tolerated 
the 
catheter-based injections well.  
Animals were then studied on a 
weekly basis for 8 weeks to 
assess hemodynamics and to 
examine ventricular architecture.  
In 
treated 
animals, 
MSCs 
engrafted within the MI (Figure 1 
a, b) and expressed several 
myocyte proteins, including α-
actinin, 
phospholamban, 
tropomyosin, and troponin T 
(Figure 1 c, d, e, f).  In addition, 
there was evidence of stem-cell 
differentiation or incorporation 
into vascular structures within 
the infarct area (Figure 1 g, h, i).  
MSCs were detected in vascular 
structures as they expressed 
VEGF 
and 
von 
Willebrand 
Factor, suggesting that they are 
capable of differentiating into 
vascular smooth muscle and/or 
endothelium.  That the cells did 
not elicit rejection, despite the 
absence of immunosuppressive 
drug therapy, was supported by 
the 
lack 
of 
a 
significant 
inflammatory response.  (Note 
that cells surrounding vessel in 
Figure 1g and 1i are of MSC 
origin, as indicated by DAPI 
positivity in Figure 1h). The 
number of MSCs persisting in 
0
2
4
-50
0
50
100
150
0
2
4
6
8
-40
0
40
80
120
0
2
4
6
8
-30
-20
-10
0
10
0
10
20
30
40
50
*
Dimension (mm)
28
32
36
40
44
48
52
28
32
36
40
44
48
52
20
24
28
32
36
40
44
20
24
28
32
36
40
44
Dimension (mm)
Left ventricle Pressure
            mmHg
0
40
80
120
Ees
LVEDP
*† 
 Weeks
SW/ MVO2
 Ees
 MSC
 Placebo
E
D
C
B
A
*†
*†
 tau
 
 Day 3
 Week 8
 LVEDP 
MSC
Control
Figure 2.  Physiologic impact of MSCs delivered with the BioCardia 
Catheter following anterior myocardial infarction (MI) in pigs.  (A)
Pressure-dimension (PD) data from placebo (left) and an MSC-treated 
(right) pig obtained 3 days (black loops) and 8 weeks (red loops) 
following MI.  Placebo animals exhibit an increase in left-ventricular 
end-diastolic pressure (LVEDP) and dimension.  Both myocardial 
contractility, measured by the slope of the end systolic pressure-
dimension relationship (ventricular elastance, Ees), and ventricular 
stroke work, pressure-dimension loop area, decline in controls.  In 
MSC-treated animals, Ees and stroke work increase to normal. (B-E) 
Average hemodynamic responses over 8 weeks showing divergent 
responses in cardiac function in MSC vs. placebo treated animals.  (B)
Ees declines in placebo-treated pigs but increases in the MSC group. 
(C) Isovolemic ventricular relaxation (τ), reduces to normal in MSC pigs 
but remains unchanged in placebo.  (D) LVEDP increases in placebo 
but remains unchanged in MSC pigs. (E) Stroke work declines in 
placebo-treated animals while myocardial oxygen consumption 
(MVO2) increases (81±10.4%), leading to reduced SW/MVO2.  In 
contrast, in MSC-treated pigs, stroke work increases 89.8±15.3%, 
MVO2 decreases 48.9±16.7%, resulting in augmented SW/MVO2 and
restoration of mechanoenergetic coupling toward normal.  *p<0.05 vs. 
placebo and †P<0.05 vs. 3-day following MI, by ANOVA. 

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the myocardium decreased over time.  Nonetheless, MSC injection produced a 
wide range of benefits, including improved regional and global ventricular 
function, reduced myocyte apoptosis, and improved tissue perfusion. 
 
In terms of functional responses, anterior MI caused dramatic deterioration of 
systolic and diastolic ventricular function, and impaired cardiac energy 
metabolism (p<0.05 vs. pre-MI values).  Compared with injection of placebo, 
MSC cardiomyoplasty resulted in profound improvements in myocardial function 
and efficiency (Figure 2).  Figure 2a depicts representative examples of 
pressure-dimension data from animals in either group.  As shown, MSC 
treatment led to a pattern of LV recovery over a 2-3 month period marked by a 
substantial increase in stroke work (SW, the area within the loops).  In the 
placebo-treated group, impaired cardiac function evident 3 days post infarction 
either persisted or worsened over 8 weeks of follow-up: indices of myocardial 
contraction fell and end-diastolic pressure rose (Figure 2 a,b,c,d).  In marked 
contrast, LV end diastolic pressure increased to normal 8 weeks after MSC 
treatment (*p<0.05 vs. placebo).  MSCs caused myocardial performance to 
recover to normal, both in systolic (Ees rose to 13.9±2.7 mmHg/mm and peak 
+dP/dt to 2465±575 mmHg/sec) and diastolic function (Tau fell to 373.8 msec). 
Heart failure is characterized by mechanoenergetic uncoupling: decreased 
efficiency of work per unit oxygen consumption.  In placebo-treated animals, SW 
decreased substantially during the 8-weeks following infarction, and there was a 
paradoxical increase in myocardial oxygen consumption, resulting in decreased 
ratio of SW/MVO2.    Conversely, MSC-injected animals’ follow-up was marked 
by improving myocardial efficiency, both because of increasing SW (from 
374.4±59.3 to 654.4±129.9 mmHg.mm at 8 weeks) and because of decreasing 
MVO2 (from 10.3±2 to 3.7±1.8 J/beat), both toward normal (Figure 2 e).  Thus, 
MSC therapy exerts favorable effects on the damaged heart that extend to 
improvements in cellular energy metabolism.  The SW/MVO2 ratio increased from 
2.5±0.6 at 3 days post-MI to a normal ratio of 10±5.6 (p<0.05 vs. placebo) at 4 
weeks.  This improvement in mechanoenergetics was the earliest observable 
benefit of MSC treatment, preceding changes in global cardiac function.  
Improved mechanoenergetic coupling in the MSC group is consistent with 
several possible mechanisms, including reduced native tissue death94, new 
tissue formation39, 95, or stimulation of endogenous repair mechanisms83, 96. 
 

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Besides these metabolic effects, MSC treatment also reduced infarct size. At 8 
weeks following treatment, the percentage of LV mass made up by infarcted 
myocardium was 16±7.2% in placebo-treated and 3.3±1.2% of MSC-treated 
hearts; p<0.05) (Figure 3).  This finding resulted from reduced scarring within 
ventricles of similar mass. Placebo-treated animals had transmural myocardial 
infarctions, while those injected with MSCs had mid-myocardial infarcts, with 
viable non-scar myocardium surrounding the infarct on both the endo- and 
epicardial sides. In order to identify the mechanism behind these findings, we 
tracked the fate of MSCs in the swine myocardium using noninvasive imaging 
techniques.  
 
As described in detail below, magnetically labeled MSCs can be detected in vivo 
using MRI.  Using this technique, the site of injection of Feridex-labeled stem 
cells can be identified for up to 8 weeks (Figure 4).  The Feridex signal fades 
over time, suggesting either death of the MSCs or loss of Feridex from their 
cytoplasm, possibly during differentiation.  Restoration of contractile function was 
observed in areas of MSC injection; supporting the notion that MSCs persist in 
the myocardium and differentiate into contractile cells. Other potential 
mechanisms are not excluded by this finding, and the profound decreases in 
infarct size and improvements in cardiac function suggest the possibility of other 
concomitant repair mechanisms, for example recruitment and stimulation of 
endogenous cardiac progenitor cells83. 
0
6
12
18
24
*
 8 weeks Post-MI
MI size (% of LV mass)
 Placebo
 MSC
Figure 3. Myocardial infarct size 8 weeks following transient left anterior descending coronary artery 
occlusion.  A.  Representative example of scar formation due to myocardial infarction in placebo (top) and MSC 
treated animal (bottom).  In placebo-treated animals the area of scar formation is transmural (arrow), while in 
the MSC group the scar area is barely visible and surrounded by non-scar tissue on both endo- and epicardial 
sides.  B.  Bar graph depicting scar formation as a percentage of LV mass.  *P=0.008. 
MSC 
Placebo 
A 
B 

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To further investigate the mechanisms of MSC-mediated cardiac repair, both MRI  
and computed tomography (CT) were used to image and quantify myocardial 
infarcts in MSC- and placebo-injected swine. Infarct size measurement in vivo by 
MRI and CT correlated tightly to that determined by triphenyl tetrazolium chloride 
(TTC) staining post-mortem.  Furthermore, using a 32 slice multidetector CT, the 
same endocardial rim of viable, non-infarcted myocardium observed in the first 
series of post-mortem hearts (Figure 3, Figure 5) was identified by in vivo 
imaging. These data not only speak to the therapeutic potential of MSC 
cardiomyoplasty, but also establish that noninvasive imaging techniques can be 
used to measure the effects of cardiomyoplasty, and to study the mechanisms 
underlying these effects.  These results in this pig model provide strong rationale 
for the development of MSC-based cellular cardiomyoplasty strategies and 
suggest that human studies are warranted. 
 
MSCs 
injected 
intravenously 
home 
to 
and 
engraft 
in 
infarcted 
myocardium 
conferring functional benefit: 
Preliminary 
studies 
were 
conducted on the efficacy of 
MSCs administered intravenously 
(I.V.) in a rat model of permanent 
left anterior descending (LAD) 
artery 
occlusion.  
Echocardiography was used to 
assess LV function at baseline, in 
the peri-infarct period, and four 
weeks after MI.  MSC injection in 
Wistar 
rats 
led 
to 
dramatic 
improvement in LV function, with 
increased myocardial thickening and contractility in treated animals (Figure 6A 
Figure 5. Comparison of infarct size using MRI (A), CT (B), and 
TTC (C). Images were obtained 8 weeks after closed-chest 
infarction in a pig and demonstrate subendocardial myocardial 
infarction 
as 
hyperenhancing 
region 
(~7-11 
o’clock). 
TTC 
nonstaining areas (e.g., lack of brick red staining) in post-mortem 
slices (bottom) demonstrate concordance of infarct location and size 
with MRI and CT.  Infarct region is notable for rim of noninfarcted 
myocardium along the endocardial border seen with CT and TTC 
staining. (arrows) 
A. 
 
     B. 
 
           C. 
Figure 4. MRI image of swine myocardium obtained after myocardial infarction and injection of Feridex labeled 
mesenchymal stem cells.  Feridex labeled cells can be seen as dark hypoenhancing regions in the epicardium (arrows)
using an ECG-gated, fast gradient echo (fgre) pulse sequence.  As shown, Feridex labeling remains evident for up to 
eight weeks after stem cell injection. 
Baseline 
 
 
Week 1  
 
Week 4  

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and 6B).  Labeled cells were identified within the infarct (Figure 7a), and were 
shaped like fibroblasts but expressed the cardiac protein, α-actinin, albeit at 
lower levels than native cardiomyocytes (Figure 7b). These labeled cells were 
most evident at the endocardial rim of the infarct, a finding similar to that seen in 
the porcine studies above.   
MSCs delivered intravenously (I.V.) distributed to the heart in response to 
an injury signal: MSCs injected I.V. at the time of coronary reperfusion homed 
to the myocardium, while cells injected I.V. two weeks after reperfusion were 
more likely to engraft in the bone marrow (Figure 8). Determination of SDF-1 and 
CXCR4 levels revealed not only that both are expressed by MSCs, but also that 
serum levels are upregulated immediately post infarct and remain elevated for at 
least 2 weeks (Figure 9). 
Myocardial Function can be Determined in vivo by MRI 
The clinical research team has extensive experience using tagged MRI scanning 
to detect and quantify alterations in regional myocardial mechanics in animal 
models of ischemic heart disease97, 98.  The team has also developed non-
surgical, MRI-compatible animal models for studying cardiac mechanics, 
perfusion, and interventional procedures99-102. The team has recently developed 
new MR imaging and analysis methods that enable the rapid determination of 
myocardial function in infarction and ischemia103, 104. This new technique, 
Harmonic Phase (HARP) MRI104-106 is based on tagged MRI techniques.  
Computationally, the analysis of HARP MRI can be performed much more rapidly 
than traditional tag tracking in tagged MRI. “Real-time” HARP imaging exploits 
the concept that only one of the spectral peaks must be acquired for motion in 
one direction; this in turn accelerates the image acquisition in addition to the 
rapid analysis already available in HARP. An example of the use of real-time 
HARP to monitor the onset of ischemia in a canine model of coronary artery 
stenosis is depicted (Figure 10)104. Using this technique, we can identify 
abnormal regional myocardial contraction after the onset of ischemia 20 seconds 
earlier than can be done using conventional cine wall motion studies and one 
minute earlier than ECG changes. HARP MRI, similar to tagged MRI, yields 
quantitative motion and strain parameters on a regional basis that can be used 
for comparison across patients or at serial time points after intervention.  Thus, 
HARP MRI and analysis represents a rapid and repeatable method to assess left 
ventricular function serially in a quantitative manner.  HARP provides fast, 
accurate assessment of myocardial strains in humans with and without coronary 
artery disease107.  Similar techniques have been used to assess structural and 
functional changes after myocardial infarction in rats108, 109. 
 
Noninvasive Determination of Infarct Size 
Using an intravenous injection of Gd-DTPA, the study team is able to determine 
infarct size non-invasively with T1-weighted contrast-enhanced MRI (i.e., 
“Delayed Contrast-Enhanced MRI”).  Short-axis image slices, which span the 
entire left ventricle, can be obtained using multiple breath-holds to yield images 
with the highest spatial resolution. The size of the area of hyperenhancement 

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measured on such images has been shown to be within 10% of the infarct size 
measured by post-mortem TTC staining (Figure 11).  Alternately, using new 
imaging techniques, one can obtain the entire 3D left ventricular volume in a 
single breath hold (~16 heartbeats).  It was recently shown that the 3D technique 
is in concordance with infarct size as measured by traditional 2D multi-slice 
techniques (Figure 11)110, 111.  Thus, infarct size and location can be accurately 
determined in less than one minute of scanning time, in order to determine the 
size of an infarct prior to therapy and over time. 

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Pre-Infarct
Day-7
Pre-Infarct
Day-7
 
 
SDF
*
*
 
Arbitrary units
CXCR4
B 1 
Figure 6. A: Two-dimensional echocardiography showing end 
diastole (left column) and end systole (right column) in a treated 
rat 1) before infarction 2) after infarction and prior to treatment and 
3) 4 weeks after treatment with MSCs. B: M-Mode from same 
animal showing fractional shortening at the papillary level at the 
same time points as in A. 
 1 
A
2 
3 
2 
3 
Figure 8. Confocal images of 
infarcted myocardium (top row) 
and bone marrow (bottom row) 
illustrating 
the 
degree 
of 
allogeneic 
MSC 
engraftment 
observed when 5 million MSCs 
were delivered via tail vein at 
reperfusion (left columns) or 2 
weeks 
post-reperfusion 
(right
column). 
 
As 
shown, 
at 
reperfusion cells home to the 
heart and not bone marrow;  two 
weeks later, trafficking to the 
heart is reduced, and cells now 
migrate and engraft in the bone 
marrow.  All  tissues were 
harvested 
4 
weeks 
post-
implantation. A FITC-conjugated 
antibody directed against desmin 
(green) was used to assess the 
myogenic differentiation. 
Bone 
Marrow 
Infarcted 
Myocardium 
Reperfusion 
2-weeks post-MI 
Figure 7: A: β-galactosidase positive (blue) cells are visible at 
20X magnification within the infarct in young rats.  These cells 
form a band along the endocardial surface.  B:  These cells show 
evidence of α-actinin expression on immunofluorescence, also at 
20X magnification (bright appearing cells, B&W image).  C:
Quantification demonstrates 10-fold higher engraftment in young 
relative to old (p<0.001). 
↑ 
endocardium 
A
B
Figure 9: Both SDF-1 and CXCR4 levels are 
elevated 
following 
myocardial 
infarction. 
P<0.05 vs. pre infarct 
Figure 11. 2D delayed CE MRI in 
short axis plane (top) acquired 
within the first 24 hrs after closed-
chest infarction demonstrating 
subendocardial myocardial 
infarction as hyperenhancing 
region (~11-1 o’clock) in a dog.  
TTC nonstaining areas (e.g., lack 
of brick red staining) in post-
mortem slices (bottom) 
demonstrate concordance of infarct 
location and size with MRI. 
Figure 10: Real-time HARP images in the short-axis plane at different time points (10 sec prior to ischemia and 0, 6, and 20 heartbeats after 
the onset of ischemia from left to right) in a canine closed-chest model of acute LAD coronary artery occlusion.  Overlaid on the tagged 
images is a pseudo-color map of circumferential shortening where green is uniform shortening, red is decreased shortening or stretching,
and blue is increased shortening.  At 6 heartbeats after ischemic insult, stretching of the ischemic myocardium is observed in the LAD bed
whereas wall motion abnormalities by cine MRI could not be appreciated until 30 sec post-occlusion. 

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Autologous Mesenchymal Stem Cells Produce Reverse Remodeling in 
Chronic Ischemic Cardiomyopathy:   In addition to the studies outlined above 
using models of acute MI in the pig, we have also developed a model of chronic 
MI in the Gottingen mini-swine.  We have used both autologous and allogeneic 
MSCs, with surgical and catheter delivery strategies, and have developed 
sufficient experience to translate the therapy from the laboratory bench to clinical 
trials.  Together our results indicate that bone marrow derived MSCs stimulate 
cardiac recovery by engrafting, forming new blood vessels that increase tissue 
perfusion in hypoperfused areas, forming new cardiac myocytes, and importantly 
interacting with endogenous precursor cells to also contribute to new cardiac 
myocyte formation. From an immunologic perspective, MSCs may be safely used 
as an allogeneic graft, and have been done so extensively in clinical trials112-114. 
Our experience with a 53 patient, 10-center, phase I study under the sponsorship 
of Osiris therapeutics, which demonstrated safety and provisional efficacy of 
allogeneic MSC therapy in patients with acute infarction is outlined below74. In 
animal studies conducted in mini-swine, MSC injection via catheter into infarcted 
tissue reduces myocardial infarct size (Figs. 12 and 13), improves global and 
regional LV function, normalizes cardiac energetics, and restores tissue 
perfusion93, 115.  These results form the basis for our approval to conduct the 
TRIDENT study. 
 
 
 
 
Our work in large animal models with fully healed scars after MI showed that 
MSC administration can significantly improve left ventricular structure and 
functional indices, indicating meaningful repair. Through exploitation of our 
experience with imaging techniques we were able to track phenotypic 
improvements triggered by implantation of MSCs in our porcine model of chronic 
ischemic cardiomyopathy, and to quantify these changes morphometrically.  MI 
was created in swine; after 12 weeks, the infarct segment had thinned, leaving a 
transmural scar (Figure 12). Autologous MSCs were expanded from each 
Figure 13. Infarct circumferential extent of the LV before and 12 
weeks after injection in swine.  Infarct size was significantly 
reduced by MSC treatment.  p<0.05 MSC vs. placebo, p<0.05 
MSC week 12 vs. week 24. [n=10] 
Week 12 
Week 24 
Placebo 
MSC 
Figure 12. Myocardial regeneration in our porcine model of 
MI.  Delayed gadolinium-enhanced MRI images depicting 
chronic (week 12 post MI) myocardial scar before treatment 
and (week 24) 12 weeks following injection of MSCs or 
placebo. Infarct tissue appears bright white, and healthy 
myocardium appears black.  Comparable gross heart sections 
are shown adjacent to the MR images.  Infarct size is reduced 
by MSC treatment, and cardiac performance improves. 

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animal116, and these cells or placebo were delivered to the infarct and 
surrounding border zone at this time.  During a further 12-week follow up period, 
cardiac MRI revealed that intramyocardial injections of MSCs not only reduced 
the scar burden (as a percentage of LV mass) by 21.8+3.9% (p<0.05 vs. placebo 
and week 12 vs. week 24) (Figure 12, 13), but also significantly improved 
regional contractility, global LV function, ejection fraction, and myocardial blood 
flow.  Importantly, the therapy produced reverse remodeling and reduced the 
circumferential extent of the infarct scar (Figure 13).  This constellation of effects 
suggests highly effective repair of ischemic cardiomyopathy.  We subsequently 
confirmed reverse remodeling in a pilot study of 8 patients with ischemic 
cardiomyopathy (Figure 15)24.   
   
 
Figure 14. Engraftment of MSCs in chronic myocardial infarction. (A) Colocalization Y chromosome and 
troponin, indicative of an MSC differentiated into a cardiomyocyte.  (B) Evidence of cardiac commitment in 
the transplanted cardiomyocyte by the colocalization of cardiac transcription factor Nkx2.5 (green, arrow). 
(C) Ypos cells also reside in the interstitial compartment (arrows) of border myocardium in a non-
differentiated stage. (D) Ypos cells that colocalize with smooth muscle actinin (arrowheads) and factor viii-
related antigen (white, arrows) demonstrating vascular smooth muscle and endothelial commitment, 
respectively. (E) Confirmation of Ypos cells commitment into vascular structures as depicted by co-
localization with SM22-alpha (F) The functional outcomes (i.e. infarct size reduction, increase in contractility 
and increase in tissue perfusion) showed related interaction with the magnitude of transplanted cells 
detected. 
 
Allogeneic Mesenchymal Stem Cells Restore Cardiac Function in Chronic 
Ischemic Cardiomyopathy Via Trilineage Differentiating Capacity: 
We tested the hypothesis that MSC based cardiac repair regenerates the heart 
via mechanisms comprising long-term engraftment and by differentiation into 
both myocardial and vascular elements. We generated allogeneic MSCs from a 
male swine donor, and administered sex mismatched cells by transendocardial 
injection into female swine 12 weeks post-MI.  Animals were followed with serial 
MRI, and 12 weeks later the hearts were collected for immunohistological 
evaluation. The fate of the male donor cells was determined by co-localization of 
Y-chromosome (Ypos) cells with markers of cardiac, vascular, and endothelial 
lineages.  MSCs engrafted in infarct and border zones and differentiated into 

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cardiomyocytes (Figure 14) as ascertained by co-localization with GATA-4, 
Nkx2.5, and α-sarcomeric actin markers. In addition, Ypos MSCs exhibited 
vascular smooth muscle and endothelial cell differentiation, contributing to large 
and small vessel formation.  The number of cells engrafting correlated with the 
functional changes that occurred (Figure 14F).  Thus, MSCs could engraft and 
repair hearts in chronic ischemic cardiomyopathy16. 
 
Preliminary Results from the Transendocardial Autologous Cells in 
Ischemic Heart Failure Trial (TAC-HFT): We enrolled 8 patients in an open-
label run-in phase of the TAC-HFT trial to assess the safety and preliminary 
efficacy of bone marrow mononuclear cells (MNCs) and MSCs in patients with 
ischemic cardiomyopathy24, 25. At baseline each patient underwent a bone 
marrow aspiration and transendocardial injection (Helix Infusion Catheter; 
Biocardia, Inc., CA) of bone marrow derived MNCs or MSCs to the infarct and 
border zone using biplane fluoroscopic guidance.  All 8 patients tolerated the 
procedure well and have been followed-up with serial cardiac MRI at 3, 6, and 12 
months post injection (Figure 15).  The injection of bone marrow derived cells 
into the hearts of these patients produced reverse remodeling, with reductions in 
EDV of ~12% and improved regional function as measured by –Ecc, a cardiac 
MRI derived index (Figure 15).  We have also treated patients with Allogeneic 
MSCs in the POSEIDON trial and have demonstrated an acceptable safety 
profile, as per the interim analysis of the NIH DSMB. 
 
A. 
 
 
 
 
 
B. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
C. 
 
 
 
 
 
 
 

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D. 
 
 
       E.  
 
               
 
 
          
 
F. 
 
 
 
G. 
 
Figure 15.  Cardiac MRI follow-up data of (A) end-diastolic volume, (B) end-systolic volume, and (C) peak 
Eulerian circumferential strain (Ecc) of the infarct zone from tagged imaging.  Example cardiac MRI images 
of change in EDV from (D) baseline to (E) 1 year, and change in ESV from (F) baseline to (G) 1 year after 
stem cell injection.  As depicted, EDV and ESV are reduced by 6 months following injection, and do not 
return towards baseline by 12 months.  Peak Ecc is dramatically reduced by 3 months following injection 
(the more negative Ecc corresponds to improving regional LV function). *p<0.05 in post-hoc analysis 
compared to baseline.  Yellow Arrow:  Note improved systolic thickening in lateral wall, the site of cell 
therapy in this example. 
Preliminary Results from the Percutaneous Stem Cell Injection Delivery 
Effects on Neomyogenesis Pilot Study (POSEIDON): We randomized 30 
patients in an open-label study of either allogeneic or autologous hMSCs at 3 
doses; 20, 100, or 200 million total hMSCs.  The study was designed as a pilot 
study to compare the safety and efficacy of allogeneic versus autologous hMSCs 
in patients with chronic ischemic left ventricular dysfunction secondary to 
myocardial infarction.  Autologous MSCs were derived from a sample of the 
patient’s bone marrow approximately 4-6 weeks prior to cardiac catheterization.  
Allogeneic MSCs were supplied from a human MSC source manufactured by the 
University of Miami.  All 30 patients tolerated the procedure well and have been 
followed-up with serial cardiac CT at 13 months post injection.  The serious 
adverse event rate (SAE) was lower among patients treated with allogeneic 
MSCs as compared to autologous MSCs (6-months: 20%-allogeneic MSCs and 
40%-autologous MSCs).  The injection of MSCs into the hearts of these patients 
produced reverse remodeling, with reductions in EDV of ~23 ml and reduction in 
spherecity index of 0.8.    

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Together, these preliminary data support our hypothesis that allogeneic MSC 
administration is a safe and successful option for cellular cardiomyoplasty.  We 
have demonstrated long-term MSC survival, engraftment, and differentiation into 
myocardial, vascular, and endothelial lineages following transplantation into 
chronically 
scarred 
porcine 
myocardium. 
These 
cells’ 
capacity 
for 
cardiomyogenesis and vasculogenesis both likely contribute to their ability to 
repair chronically scarred myocardium.    
 
Animal Pharmacology and Toxicology Studies of MSCs Delivered Via 
Intramyocardial Injection 
 
Seven preclinical studies (Table 2) and 2 clinical studies (described above) have 
been performed using autologous or allogeneic MSCs delivered to ischemic 
myocardium via intramyocardial injection.  The cell doses administered in these 
studies cover the proposed dose (1.0 x 108 MSCs) for the clinical study in this 
IND application. 
Shake et al.38 investigated the engraftment and functional effects of transplanted 
autologous MSCs (cell dose = 60 x 106, administered via direct intramyocardial 
injection with a 30-gauge needle) 14 days after MI in a porcine animal model.  No 
ectopic tissue formation was observed.  Furthermore, there was no evidence of 
MSC differentiation to tissues other than cardiac muscle, and no significant 
inflammatory infiltrates at the MSC implantation sites.  Microscopic analysis 
showed robust engraftment of MSCs in all treated animals.  Expression of 
muscle-specific proteins was seen as early as 2 weeks and could be identified in 
all animals at sacrifice. The degree of contractile dysfunction was significantly 
attenuated at 4 weeks in animals transplanted with MSCs (+5.4% ± 2.2% versus 
-3.37% ± 2.7% in control).  In addition, the extent of wall thinning after MI117 was 
markedly reduced in treated animals. 
In a porcine animal model, Cattaneo et al.96 transplanted allogeneic MSCs (cell 
dose = 200 x 106, administered via direct intramyocardial injection with a 27-
gauge needle) shortly (1 day) after MI.  No ectopic tissue formation, significant 
inflammatory responses, or other adverse events were observed. Robust 
engraftment of allogeneic MSCs was seen in all treated animals. Furthermore, 
engrafted MSCs were found to express numerous muscle specific proteins and 
exhibited morphological changes consistent with cardiomyogenesis.  A marked 
improvement in both ejection fraction and global wall motion score was observed 
in treated animals at 10 weeks post-MSC implantation.  Systolic wall thickening 
and diastolic wall thickness were also augmented in MSC-treated animals. Since 
no significant differences in infarct size or cardiac loading were noted between 
groups (MSC-treated of placebo), improvements in cardiac function were likely 
attributable to MSC implantation. 
The two porcine animal model studies by Amado et al.93, 118 investigated the 
intramyocardial injection of allogeneic porcine MSCs (cell dose = 200 x 106) via 
transendocardial catheter delivery 3 days after MI.  One of the studies, a 

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randomized, placebo-controlled study of 14 pigs using the BioCardia Helical 
Infusion Catheter found93:   
1. MSC and placebo transendocardial injections were safe and well-
tolerated. 
2. At the 8-week follow-up assessment, MSC injections resulted in profound 
improvements in LV end diastolic pressure (LVEDP) and dimension.  
3. MSC-treated pigs showed improved LV recovery, as demonstrated by a 
substantial increase in stroke work. 
4. MSC treatment resulted in myocardial performance recovery to normal, 
both in systolic and diastolic function.  
Additionally, several important findings emerged from both Amado and 
investigators’ transendocardial porcine animal studies93, 118, including: 
1. MSCs were safely injected via the transendocardial catheter delivery route 
using two different catheter-needle systems.  
2. Cellular transplantation of MSCs resulted in long-term engraftment and 
profound reduction in scar formation.  
3. Transplanted MSCs were prepared from an allogeneic donor and were not 
rejected; a major practical advance for the potential widespread 
application of this therapy.  
Schuleri et al115 used a porcine animal model and injected autologous MSCs (low 
cell dose= 20 x 106 and high cell dose= 200 x 106, administered via direct 
intramyocardial injection using a 1.0 ml syringe with a 29-guage needle) 12 
weeks (90 days) after MI. Between groups there was no difference in mortality, 
systemic inflammatory responses, or post-injection arrhythmias. No ectopic 
tissue formation was observed in the treatment groups. A trend towards 
reduction was noted in the low dose group, whereas the high dose MSC 
treatment group saw a significant reduction in infarct size. Additionally this 
therapy produced new tissue that is contractile and perfused, and an overall 
increase in LVEF following a single administration of MSCs.  
A study by Quevedo, et al16 sought to test the ability of allogeneic MSCs to 
engraft and differentiate in chronically infarcted myocardium. Female porcine 
animals were injected transendocardially with allogeneic MSCs using a catheter 
(cell dose= 200 x 106) 12 weeks after MI. The study saw the presence of viable 
MSCs in infarct and border zones 12 weeks after transplantation into a chronic 
ischemic scar. The MSCs differentiated into cardiomyocytes and blood vessel 
elements that integrated into host myocardium, formed gap junctions, and 
contributed to the restoration of cardiac function and tissue perfusion. The 
decrease in infarct size together with increased contractility and perfusion 
resulted in improved global LV function. Also a significant increase in ejection 
fraction was seen in the MSC-treated group. This study was able to document 
MSC engraftment and differentiation into cardiac cell constituents in an infarcted 
heart.  

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Hatzistergos et al.83 investigated the ability of bone marrow derived MSCs to 
stimulate the proliferation and differentiation of endogenous cardiac stem cells 
(CSCs). The study had a 2 phase porcine model. In phase 1, eight pigs were 
transendocardially injected with 75 x 106 GFP labeled MSCs, eight more pigs 
received placebo, and three pigs were part of a no injection comparison group. 
The injections occurred at 3-days post MI. The animals were euthanized at 
varying points after transplantation. The second phase of the study contained 12 
pigs, which were equally randomized to one of two groups. Six pigs were treated 
with 100 x 106 male GFP-labeled MSCs and six pigs were treated with their 10x 
concentrated conditioned medium (CCM). The animals from phase 2 were 
followed by MRI analyses at several time-points post-injection to assess the 
amount of functional recovery; the animals were euthanized at varying points.   
The absolute size of the myocardial infarct was reduced in the animals treated 
with MSCs as early as 4 days post-procedure while no change was seen in those 
treated with CCM. By two weeks, the MSC group also had a significant 
improvement in ejection fraction compared to post-MI, and this result persisted 
through the 8-week follow-up period. Two weeks after injection MSC-treated 
hearts exhibited chimeric clusters containing both immature MSCs of exogenous 
origin and endogenous CSCs. The bone marrow derived MSCs injected post-MI 
facilitated engraftment, differentiation, and substantial cardiac recovery involving 
host cell-based repair.  
The results of these preclinical studies, and the ongoing clinical trials TAC-HFT 
and POSEIDON, support the safety and potential efficacy of the dose (1.0 X 108 
MSCs) for the proposed clinical study in this IND application. 
 
 
 
 
 

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TABLE 2 
PRECLINICAL STUDIES: AUTOLOGOUS AND ALLOGENEIC MESENCHYMAL STEM CELLS (MSCs) 
ADMINISTERED VIA INTRAMYOCARDIAL INJECTION 
 
Study 
 
Model 
 
N 
Cell 
Delivery 
Cell Source 
& Type 
Cell Doses 
(x 106) 
Safety 
Results 
Efficacy 
Results 
Shake 
 
14-Day 
Post-MI Pig 
 
14 
Surgical 
(needle) IM 
injection 
Autologous, 
porcine MSCs 
 
60.0 
- No ectopic tissue formation 
- No MSC differentiation to non-cardiac tissue 
- No significant inflammatory infiltrates at site 
of MSC implantation 
- MSC engraftment 
- ↑regional contractile 
function 
 
 
 
 
 
 
 
 
Cattaneo  
1-Day 
Post-MI Pig 
 
13 
Surgical 
(needle) IM 
injection 
Allogeneic, 
porcine MSCs 
 
200.0 
- No ectopic tissue formation 
- No significant inflammatory response 
- MSC engraftment 
- ↑EF and global wall 
motion score 
 
 
 
 
 
 
 
 
Amado  
3-Day 
Post-MI Pig 
 
14 
PIM 
(catheter) 
injection 
Allogeneic, 
porcine MSCs 
 
200.0 
- No deaths; no malignant arrhythmias 
- No evidence of cardiac perforation during 
injection 
- MSC engraftment 
- ↓infarct scar 
- Improved systolic and 
diastolic function 
 
 
 
 
 
 
 
 
Amado  
3-Day 
Post-MI Pig 
 
22 
PIM 
(catheter) 
injection 
Allogeneic, 
porcine MSCs 
 
200.0 
- No difference in deaths between treated/placebo 
 
- MSC engraftment 
- ↑Viable myocardium 
- ↓infarct scar 
 
 
 
 
 
 
 
 
Schuleri 
90-Day 
Post-MI Pig 
 
9 
Surgical 
(needle) IM 
injection 
Autologous 
porcine MSCs 
20.0 (Low) 
200.0 (High) 
-No difference in deaths between groups 
-No evidence of post-injection arrhythmias 
-No ectopic tissue formation 
- ↓infarct scar at High 
Dose 
-↑EF 
 
 
 
 
 
 
 
 
 
Quevedo 
90-Day 
Post-MI Pig 
 
6 
PIM 
(catheter 
injection) 
Allogeneic, 
porcine MSCs 
 
200.00 
 
-MSC engraftment & 
differentiation 
-↓infarct scar 
-↑global LV function and 
EF 
 
 
 
 
 
 
 
 
Hatzisterg
os 
3-Day 
 Post-MI Pig 
 
12 
PIM 
(catheter 
injection) 
Allogeneic 
porcine MSCs 
& 
Concentrated 
Condition 
Medium 
75 
100 & 
10 x 
concentrated 
condition 
medium 
 
-MSC engraftment & 
differentiation 
-↑EF 
 
 
 
 
 
 
 
 
 
EF: Ejection Fraction; IM: intramyocardial; MSC: Mesenchymal Stem Cell; PIM: percutaneous intramyocardial; VT: ventricular tachycardia 

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Rationale for Proposed Mesenchymal Stem Cell (MSC) Dose 
The clinical experience with the administration of MSCs in the three clinical 
studies performed to date (two utilizing the IC route, and one via peripheral IV 
injection) as well as our experience on the POSEIDON study provide substantial 
evidence of clinical safety at the cell doses administered as well as preliminary 
support of clinical efficacy.  Although none of the studies employed the delivery 
method planned in this IND application’s proposed clinical study, two of the three 
studies utilized cell doses that were over 50% greater72 and as much as two 
hundred-fold greater70 than the two MSC cell doses proposed herein (0.2 x 108 
and 1.0 x 108). 
Summary  
Preliminary data strongly support the hypothesis that MSCs may improve heart 
function and prevent the development of heart failure following myocardial 
infarction. The study team has extensive experience using mouse, rat, and swine 
models of myocardial infarction and assessing left ventricular function in vivo with 
imaging techniques in small and large animals.  
Given the experience and encouraging preliminary results with stem cell 
therapies and tracking, the University of Miami Miller School of Medicine 
(UMMSM) team is conducting this clinical study.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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2. 
STUDY OBJECTIVES AND ENDPOINTS 
2.1 
Study Objectives 
2.1.1 
Primary Objective 
To 
demonstrate 
the 
safety 
of 
allogeneic 
hMSCs 
administered 
by 
transendocardial injection in patients with chronic ischemic left ventricular 
dysfunction secondary to myocardial infarction (MI). 
2.1.2 
Secondary Objectives 
To evaluate the safety of allogeneic hMSCs administered by transendocardial 
injection in patients with chronic ischemic left ventricular dysfunction secondary 
to MI. To demonstrate the efficacy of allogeneic hMSCs administered by 
transendocardial injection in patients with chronic ischemic left ventricular 
dysfunction secondary to MI.  
2.2 
Study Endpoints 
2.2.1   Primary Endpoint (Safety) 
Incidence (at one month post-catheterization) of any treatment-
emergent serious adverse events (TE-SAEs), defined as the 
composite of: death, non-fatal MI, stroke, hospitalization for 
worsening heart failure, cardiac perforation, pericardial tamponade, 
sustained ventricular arrhythmias (characterized by ventricular 
arrhythmias lasting longer than 15 seconds or with hemodynamic 
compromise) or any other potential late effects  detected and 
corroborated by clinical presentation, laboratory investigations, 
image analysis and when necessary with biopsy from suspected 
target sites in the body.  
2.2.2   Secondary Endpoints (Efficacy) 
The following efficacy endpoints will be evaluated in this trial (during the six-
month follow-up period, at the month 12 visit): 
 CT and Echocardiographic-derived measures of left ventricular function: 
1. Difference between the baseline and 12-month infarct scar size 
(ISS) as determined by delayed contrast-enhanced CT 
2. Difference between the baseline and 12-month regional left 
ventricular function (at the site of allogeneic cell injections) as 
determined by CT.  
3. Difference between the baseline and 12-month regional left 
ventricular wall thickening as determined by CT.  

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4. Difference between the baseline, 6-month (echocardiogram only), 
and 12-month left ventricular end diastolic wall thickness as 
determined by CT and echocardiogram. 
5. Difference between the baseline, 6-month (echocardiogram only), 
and 12-month left ventricular ejection fraction, end diastolic and end 
systolic volumes, as determined by CT and echocardiogram. 
6. Difference between the baseline and 12-month left ventricular 
regional myocardial perfusion as determined by CT. 
Note: If the 6-month observations for echocardiogram are not 
available, the 3-month observations will be used. 
 Tissue perfusion measured by CT. 
 Peak VO2 (by treadmill determination).  
 Six-minute walk test.  
 NYHA functional class. 
 Minnesota Living with Heart Failure (MLHF) Questionnaire. 
 Incidence of the Major Adverse Cardiac Events (MACE) endpoint, defined 
as the composite incidence of (1) death, (2) hospitalization for worsening 
heart failure, or (3) non-fatal recurrent MI. 
 
2.2.3     Secondary Endpoints (Safety)  
 
The following safety endpoints will be evaluated in this trial (during the six-month 
follow-up period, at the month 12 visit: 
 
 Treatment emergent adverse event (AE) rates. 
 24-hour ambulatory electrocardiogram (ECG) recordings. 
 Hematology and clinical chemistry values and urinalysis results. 
 Serial Troponin I and CK-MB values (every 12 hours for the first 24 
hours post-cardiac catheterization). 
 Post-cardiac catheterization echocardiogram. 
 
3. 
STUDY DESIGN 
This is a Phase II, randomized, blinded study, intended to further evaluate the 20 
million and 100 million dose levels of allogeneic MSCs.  A total of 30 patients will 
be randomized and receive the study injection via the Biocardia Helical infusion 
system: 

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Treatment Group 1 (15 patients) 
Fifteen (15) patients will be treated with Allo hMSCs: 4 million cells/ml delivered 
in a dose of 0.5 ml per injection x 10 injections for a total of 0.2 x 108 (20 million) 
Allo-hMSCs.  
Treatment Group 2 (15 patients) 
Fifteen (15) patients will be treated with Allo hMSCs: 20 million cells/ml delivered 
in a dose of 0.5 ml per injection x 10 injections for a total of 1 x 108 (100 million) 
Allo-hMSCs.  
The Study Team will record and maintain a detailed record of injection locations.  
The 
injections 
will 
be 
administered 
transendocardially 
during 
cardiac 
catheterization using the Biocardia Helical Infusion Catheter.   
The Allo-hMSCs will be supplied from an allogeneic human mesenchymal stem 
cell source isolated from bone marrow cells from normal human donors and 
manufactured by the University of Miami.   
Following cardiac catheterization and cell injections, patients will be hospitalized 
for a minimum of 2 days then followed at 2 weeks post-catheterization, and at 
three and six months to complete all safety and efficacy assessments.  Patients 
will also receive selected efficacy and safety assessments during a 12 month 
follow-up visit.   
* Definition of Myocardial Infarction: 
Myocardial infarction (MI) will be defined by an adaptation of the diagnostic 
criteria for myocardial infarction with coronary bypass graft (CABG) surgery, as 
outlined in the recent consensus document from the ACC/AHA/ESC/WHF that 
has become the authoritative standard for the definition of MI (Thygesen K, 
Alpert JS, White HD et al, J Am Coll Cardiol, 2007; 50:2173-2195).  This 
definition for post-CABG MI is most applicable because it recognizes that 
cardiopulmonary bypass is associated with myocyte death, even when 
successful, and that at low biomarker levels, patient prognosis is not adversely 
affected. 
The administration of cells requires a transendocardial injection, thus an 
elevation of cardiac biomarkers is expected concurrent with successful cell 
delivery (please see documentation of 7-fold elevation in the clinical study 
reported in Section 3, Attachment 1 of the IND). Accordingly the above MI criteria 
require modification of the troponin I elevation threshold.  Although an average 
7.7-fold elevation in troponin I is documented as associated with this procedure, 
we will use troponin l values more than 5 times the 99th percentile of the normal 
reference range as our guideline to define a procedure-related MI, as used in the 
consensus document.  Thus, the definition for procedure-related MI will be more 
sensitive than specific. 
In summary, a procedure-related MI will be defined within the first 48 hours after 
cell product delivery if at least 2 of the following 3 criteria are met: 
 

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1. There is typical ischemic cardiac pain lasting at least 30 minutes. 
2. There are Troponin I values more than 5 times the 99th percentile of the 
normal reference range or CPK-MB levels more than 5 times the 99th 
percentile of the normal reference range during the first 48 h following 
intramyocardial cell delivery. 
3. There are new pathological Q-waves or new LBBB in conjunction with 
echocardiographic evidence of new loss of viable myocardium. 
 
** Definition of myocardial perforation: 
Myocardial perforation will be considered to have occurred if a) a new pericardial 
effusion >1cm thick is detected by transthoracic echocardiography immediately 
post, 4-6 hours post, or on day 2 post catheter injection; or b) a new ventricular 
septal defect is detected by Doppler echocardiography immediately post, 4-6 
hours post, or on day 2 post catheter injection.  
3.1 
Inclusion Criteria 
In order to participate in this study, a patient MUST: 
1. Be ≥ 21 and < 90 years of age. 
2. Provide written informed consent. 
3. Have a diagnosis of chronic ischemic left ventricular dysfunction 
secondary to myocardial infarction (MI) as defined by previous 
myocardial 
infarction 
documented 
by 
an 
imaging 
study 
demonstrating coronary artery disease with corresponding areas of 
akinesis, dyskinesis, or severe hypokinesis.  
4.  Been treated with appropriate maximal medical therapy for heart failure or 
 
post-infarction left ventricular dysfunction.  For beta-blockade, the patient 
 
must have been on a stable dose of a clinically appropriate beta-blocker 
 
for 3 months.  For angiotensin-converting enzyme inhibition, the patient 
 
must have been on a stable dose of a clinically appropriate agent for 1 
 
month. 
5. Be a candidate for cardiac catheterization within 5 to 10 weeks of 
 
screening as determined by doctors. 
6.  Have an ejection fraction of less than or equal to 50% by gated blood pool 
scan, two-dimensional echocardiogram, CT, or left ventriculogram within 
the prior six months and not in the setting of a recent ischemic event. 
3.2 
Exclusion Criteria 
In order to participate in this study, a patient MUST NOT: 
1. Have a baseline glomerular filtration rate ≤ 35 ml/min/1.73m2. 
2. Have a known, serious radiographic contrast allergy. 
3. Have a Mechanical aortic valve or heart constrictive device. 

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4. Have a documented presence of aortic stenosis (aortic stenosis graded as 
1.5cm2 or less). 
5. Have a documented presence of moderate to severe aortic insufficiency 
(echocardiographic assessment of aortic insufficiency graded as ≥+2). 
6. Require coronary artery revascularization.  Patients who require or 
undergo revascularization procedures should undergo these procedures a 
minimum of 3 months in advance of treatment in this study. In addition, 
patients who develop a need for revascularization following enrollment will 
be submitted for this therapy without delay. 
7. Have evidence of a life-threatening arrhythmia in the absence of a 
defibrillator (non-sustained ventricular tachycardia ≥ 20 consecutive beats 
or complete second or third degree heart block in the absence of a 
functioning pacemaker) or QTc interval > 550 ms on screening ECG 
8. AICD firing in the past 60 days prior to enrollment. 
9. Have a hematologic abnormality as evidenced by hematocrit < 25%, white 
blood cell < 2,500/µl or platelet values < 100,000/µl without another 
explanation. 
10. Have liver dysfunction, as evidenced by enzymes (AST and ALT) greater 
than three times the ULN. 
11. Have a coagulopathy = (INR > 1.3) not due to a reversible cause (i.e., 
Coumadin).  Patients on Coumadin will be withdrawn 5 days before the 
procedure and confirmed to have an INR < 1.3.  Patients who cannot be 
withdrawn from Coumadin will be excluded from enrollment  
12. Have known allergies to penicillin or streptomycin. 
13. Hypersensitivity to Dimethyl Sulfoxide (DMSO). 
14. Be an organ transplant recipient. 
15. Have a history of organ or cell transplant rejection  
16. Have a clinical history of malignancy within 5 years (i.e., patients with prior 
malignancy must be disease free for 5 years), except curatively-treated 
basal cell carcinoma, squamous cell carcinoma, melanoma in situ or 
cervical carcinoma. 
17. Have a non-cardiac condition that limits lifespan to < 1 year. 
18. Have a history of drug or alcohol abuse within the past 24 months.   
19. Be on chronic therapy with immunosuppressant medication, such as 
corticosteroids or TNFα antagonists. 
20. Be serum positive for HIV, hepatitis BsAg or viremic hepatitis C. 
21. Be currently participating (or participated within the previous 30 days) in 
an investigational therapeutic or device trial. 

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22. Be a female who is pregnant, nursing, or of childbearing potential while 
not practicing effective contraceptive methods. Female patients must 
undergo a blood or urine pregnancy test at screening and within 36 hours 
prior to injection. 
 
4. 
TREATMENT OF PATIENTS 
4.1 
Study Therapy and Dosages 
4.1.1 
Study Investigational Therapy 
 
Harvesting for Allo-hMSCs 
Bone marrow (BM) will be harvested from normal healthy donors with 30 to 120 
ml aspirated from the posterior iliac crest, which is the thickened superior margin 
of the ilium terminating in the iliac spine. The patient will lay on his/her side to 
enable the physician to have optimal access to the posterior iliac crest of the hip 
area. This area will be cleaned with a germ-killing cleanser followed by the 
application of local anesthetic. The BM aspiration will be done with a special 
needle attached to the heparinized syringes. The mononuclear fraction (MNC) 
will be isolated using a density gradient with Lymphocyte Separation Medium 
(LSM; specific gravity 1.077).  The low density cells will be collected from the 
gradient and washed with Plasma-Lyte A containing 1% human serum albumin 
(HSA).  The washed cells will be sampled and viable cell counts performed to 
determine the total number of viable cells. 
The required dose of Allo-hMSC will be generated using standard hMSC culture 
conditions.  Preclinical validation studies have demonstrated the reproducible 
generation of more than 200 million hMSCs in 21 days of culture. The BM MNC 
are seeded into 225 cm2 tissue culture flasks in alpha MEM containing 20% FBS.  
After 14 days of culture passage, zero (P0) cells are harvested by trypsin 
treatment and expanded into 30 flasks.  These flasks are incubated for a further 
7 days and the hMSCs are harvested by trypsin treatment (P1 cells).  The P1 
cells are washed and total viable cell counts determined.  
The Allo-hMSCs will be resuspended in cryoprotectant consisting of Pentaspan 
(10% pentastarch in 0.9% sodium chloride) supplemented with 2% HSA and 5% 
DMSO.  The cells are transferred to cryo-bags and frozen using a control rate 
freezer.  The frozen cells will be stored in a liquid nitrogen freezer until issue. 
 
Allo-hMSC Preparation for Administration 
The required dose of Allo-hMSC will be generated using standard human MSC 
culture conditions. Preclinical validation studies have demonstrated the 
reproducible generation of more than 200 million hMSCs in 21 days of culture. 
The bone marrow mononuclear cells are seeded into 225 cm2 tissue culture 
flasks in alpha MEM containing 20% FBS.  After 14 days of culture passage, zero 

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(P0) cells are harvested by trypsin treatment and expanded into 30 flasks.  These 
flasks are incubated for a further 7 days and the MSCs are harvested by trypsin 
treatment (P1 cells). The P1 cells are washed and total viable cell counts 
determined.  
The Allo-hMSCs will be resuspended in cryoprotectant consisting of Pentaspan 
(10% pentastarch in 0.9% sodium chloride) supplemented with 2% HSA and 5% 
DMSO.  The cells are transferred to cryo-bags and frozen using a control rate 
freezer.  The frozen cells will be stored in a liquid nitrogen freezer until issue. 
Upon request, the frozen bags will be thawed in a 370C water bath.  In a BSC, 
the cell suspension will be transferred to conical tubes and slowly diluted with a 
PBS buffer supplemented with 1% HSA or Plasma-Lyte A supplemented with 1% 
HSA.  The suspension will be centrifuged and the cell pellet re-suspended in the 
dilution buffer.  The cells will be counted to determine the total viable cells.  After 
release, the cells will be placed in a labeled conical tube and delivered to the 
appropriate medical staff.  
 
Technique for Administration 
Please see Addendum A, which specifies the technique for percutaneous 
endocardial administration of Allo-hMSCs. Addendum B provides a detailed 
training program for the Biocardia Helical Catheter System. 
4.1.2 
Dose Rationale 
In preclinical studies in a porcine model16, 93, 115, MSC therapy was safely 
administered via intramyocardial injection at doses of up to 2 x 108 cells.  Results 
of the POSEIDON study support the use of 0.2 x 108 Allo-MSCs and 1.0 x 108 
Allo-MSCs in this clinical study.  
 
4.1.3 
Dosages and Dosing 
The Study Team will record and maintain a detailed record of the locations and 
actual number of injections in the study.  
 
Fifteen (15) patients will be treated with Allo hMSCs: 4 million cells / ml delivered 
in a dose of 0.5 ml per injection x 10 injections for a total of 0.2 x 108 (20 million) 
Allo-hMSCs and fifteen (15) patients will be treated with Allo hMSCs: 20 million 
cells / ml delivered in a dose of 0.5 ml per injection x 10 injections for a total of 1 
x 108 (100 million) Allo-hMSCs.  
 
The 
injections 
will 
be 
administered 
transendocardially 
during 
cardiac 
catheterization using a Biocardia Helical Infusion Catheter. Intramyocardial 
injections will be discontinued during the procedure if one or more of the 
following occur: 

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a. Sustained drop in blood pressure exceeding 20mm/Hg not responsive to 
fluid administration. 
b. Clinical signs and symptoms indicating acute coronary syndrome 
c. Clinical signs and symptoms indicating a cerebrovascular accident 
d. Two episodes of sustained ventricular tachycardia / ventricular     
fibrillation requiring cardioversion 
The cells will be supplied from an allogeneic human mesenchymal stem cell 
source manufactured by the University of Miami.  Cardiac catheterization will be 
scheduled following successful enrollment.     
4.2 
Blinding and Unblinding 
The administration of either dose of allo-MSCs will be performed in a double-
blind manner; the study investigators and patients will not be made aware of the 
assigned treatment regimen.  If for important medical reasons unblinding is 
thought to be necessary, the Investigator may identify the treatment assignment 
by obtaining the randomization assignment by contacting the Director of 
Experimental and Clinical Cell Based Therapies who is responsible for 
maintaining randomization records for all patients. Standard Operating 
Procedures (SOPs) will be in place at the center outlining the emergency 
unblinding procedures.   
4.2.1 
Storage and Handling of Study Investigational Therapy 
Study therapy (Allo-hMSCs) should only be dispensed once a patient has (1) 
provided written informed consent, (2) met all eligibility criteria for entry into the 
study, and (3) completed all baseline evaluations.   
Before dispensing the investigational product, Cell Therapy Lab staff will confirm 
the CMV status of eligible recipient. This information will be used to select Allo- 
MSC product. CMV status of the recipient and donor of the Allo-MSC product will 
be matched. CMV positive Allo-MSC product will only be infused to a CMV 
positive recipient. All CMV negative recipients will receive CMV negative Allo-
MSC product125. 
 
4.2.2 
Study Investigational Therapy Accountability Procedures 
The Investigator is responsible for study investigational therapy accountability, 
reconciliation, and record maintenance. In accordance with all applicable 
regulatory requirements, the Investigator or designated study center personnel 
must maintain accountability records throughout the study.   
 
5. 
STUDY PROCEDURES 
5.1 
Time and Events Schedule 
The Time and Events Schedule for the conduct of this study is shown in Table 3.  

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Study Procedure 
Screening 
 
 
(Weeks  
-10 to -5) 
Baseline
#  
 
 
(Weeks 
-10 to -2) 
Day 1 
 
 
 
Day 2 
 
 
 
Day 14 
±3 days 
 
(Week 2)  
Month 3 
±10 days 
 
(Week 12) 
Month 6 
±10 days 
 
(Week 24) 
Month 12 
±21 days 
 
(Week 52)  
Informed Consent 
X 
 
 
 
 
 
 
 
History and Physical 
X 
 
X 
X 
X 
X 
X 
X 
Vital Signs 
X 
 
X 
X 
X 
X 
X 
X 
12-lead ECG 
X  
 
X 
X 
X 
X 
X 
X 
Concomitant Medications 
X 
 
X 
X 
X 
X 
X 
X 
Eligibility for Enrollment 
 
X 
 
 
 
 
 
 
Catheterization 
 
 
X 
 
 
 
 
 
Investigational agent 
 
 
X 
 
 
 
 
 
Standard Post-Procedural Care 
 
 
X 
X 
 
 
 
 
CT 
Assessment 
of 
Heart 
/complete chest, abdomen and 
pelvis CT ‡ 
X 
 
 
 
 
 
 
X 
Echocardiogram $ 
X 
 
X ₤ 
X 
 
X 
X 
X 
Treadmill Determination. of Peak 
VO2 
 
X 
 
 
 
 
X 
X 
Six-Minute Walk Test 
 
X 
 
 
 
X 
X 
X 
NYHA Functional Class 
X 
 
 
 
 
X 
X 
X 
Questionnaires 
MLHF, 
IIEF 
(male), SQOL-F(female) 
X 
 
 
 
 
X 
X 
X 
Pulmonary function (FEV1) 
 
X 
 
X*** 
X 
 
X 
X 
 24 Hour Ambulatory ECG* 
X  
 
X * 
 
X 
X 
X 
X 
Serum Troponin I & CK-MB ** 
 
 
X 
 
X 
 
 
 
Hematology & Clinical Chem. % 
Pro-BNP, Uric acid, and CRP 
Immune monitoring (XX) 
X 
 
X, XX 
X,XX 
 
 
X 
X, XX 
X 
Urinalysis 
X 
 
X 
X 
 
X 
X 
X 
Serum or urine pregnancy test 
X 
 
X $$ 
 
 
X 
X 
 
HIV 1, HIV 2, Hepatitis B & C, and 
CMV  
X 
 
 
 
 
 
 
 
Donor Screening Tests 
X 
 
 
 
 
 
 
 
Biomarkers Assessment %% 
 
 
X 
 
 
 
X 
 
Adverse Events 
 
 
X 
X 
X 
X 
X 
X 

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Time and Events Table Key: 
# -  
All Baseline Visit tests will occur 2 to 10 weeks prior to the cardiac 
catheterization. 
‡ - 
Cardiac CT and whole body scan (CT of chest, abdomen and pelvis) will 
occur at screening and final month 12 visit  
* -    24 hour Holter will capture day one and day two of hospitalization post 
injection. 
** -  
Serial Troponin I and CK-MB laboratory assays will be performed every 12 
hours for the first 24 hours post-cardiac catheterization and one time assay at 
week 2 visit.         
*** -     Unless the patient is not capable, then 48 hours prior to discharge. 
% -  
The minimal laboratory requirements for hematological, liver function and 
renal function include:  
Hematology Tests: white blood cell count, platelet count, hemoglobin and 
hematocrit. 
Liver 
Function 
Tests: 
Albumin, 
alkaline 
phosphatase, 
alanine 
transaminase, aspartate aminotransferase, prothrombin time / activated 
partial thromboplastin time, and bilirubin. 
Renal Function Tests: creatinine, blood urea nitrogen (BUN), creatinine 
clearance, glomerular filtration rate, sodium, potassium, chloride, 
bicarbonate, and glucose. 
Serum Uric Acid, Pro-BNP, and C-reactive protein (CRP) 
%% - The following biomarkers will be analyzed:  
 Cell-surface markers: CXCR4, C-Kit, & Connexin 43 
 Transcriptomic/Proteome: RNA, miRNA, protein samples, and 
telomerase, akt 
 Growth factors: Sdf-1, notch,  
 Functional Assays: VEGF, cell growth rate, and CFU assay 
 
$ -   All subjects will undergo transthoracic echocardiographic assessment of 
overall and regional LV systolic function at baseline, day 2, and months 3, 6, and 
12.  
₤ -  
All subjects will undergo a limited transthoracic echocardiographic 
assessment pre-catheterization, immediately following the catheterization 
procedure, and 4-6 hours later.  
$$ -    A serum or urine pregnancy test will be completed within 36 hours prior to 
injection for females of childbearing potential.  
XX -    Immune monitoring for graft rejection.  The following markers will be used 
for analysis to assess for activated T-cells based upon a CD3+CD25+ or 
CD3+CD69+ phenotype: 

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 CD3, CD25, CD69 
5.2 
Study Phases and Visits  
5.2.1 
Screening Phase 
See Table 3 for the procedures and assessments to be performed during this 
phase of the study.  Any patient who has a life-threatening arrhythmia in the 
absence of a defibrillator (sustained or short run > 20 consecutive beats of 
ventricular tachycardia or complete second or third degree heart block in the 
absence of a functioning pacemaker) on ECG or 24-hour Ambulatory ECG 
performed during the screening phase will be removed from the study. The donor 
screening blood work is specific to each cell manufacturing facility and may 
include hepatitis A, West Nile Virus, human T-cell lymphotropic virus (HTLV) I/II, 
CMV and syphilis.  All screening visit tests and procedures will occur within five 
weeks of the signed informed consent (IC) and 5 to 10 weeks prior to cardiac 
catheterization. No screening exams will take place until the patient is fully 
informed of the research and signs the consent form.  
5.2.2 
Baseline Phase 
See Table 3 for the procedures and assessments to be performed during this 
phase of the study.  After all screening exams, patients will be enrolled into the 
study to receive allogeneic hMSCs.   
The Baseline Phase will take place 2 to 10 weeks prior to the cardiac 
catheterization. The Baseline Visit will occur once the screening tests are 
completed and it has been determined that the patient remains eligible for the 
study. Upon successful enrollment of the patients, they will be scheduled for 
catheterization as soon as possible. 
5.2.3 
Day 1 – Day 2 Post-Catheterization & Week 2 Evaluations  
See Table 3 for the procedures and assessments to be performed during these 
evaluations. The listed procedures (other than catheterization and Investigational 
Agent administration) should all be performed as soon as practicable after the 
catheterization procedure.  All patients will have Troponin I and CK-MB 
laboratory work completed prior to catheterization, and every 12 hours post 
catheterization for the first 24 hours, as well as an echocardiogram prior to 
catheterization, immediately following the procedure, 4-6 hours later and 24 
hours post-cardiac catheterization.  Additionally, an FEV1 assessment will be 
completed during day 2, unless the patient is unable, then 48 hours prior to 
discharge. 
During Week 2 (Day 14 ± 3), patients will return to the clinic for a 12-lead ECG, 
24-hour ambulatory ECG, one time assay of Troponin I and CK-MB and an FEV1 
assessment. 

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  5.2.4  
Month 3 – Month 12 Visits 
See Table 3 for the procedures and assessments to be performed during these 
follow-up visits.  Outpatient visits should be completed as close to the scheduled 
visit dates as possible. For visits months 3 and 6, the visit window is ± 10 days 
from the intended date of the visit. For visits during month 12, the visit window is 
± 21 days. If required, outpatient visit procedures may take place over more than 
one day. If procedures are performed on more than one day, the date of the 
history and physical will be considered the visit day.   Every attempt will be made 
to have the visit close to the target date.  
5.2.4 
Biomarkers Assessment 
A separate 7 mL blood sample for gene expression profiling of WBC RNA will be 
obtained at day 1 and at 6 months if the patient consents. All samples will be 
identified so that they can be linked to individual patients. These samples may be 
stored indefinitely.  Individual results will not be returned to the patient or the 
study physician.  Data presented in publications will not contain individual 
patient’s gene expression or clinical characteristics or outcomes; only aggregate 
data from the entire study will be disclosed.   
5.2.5 
Immune Monitoring for Graft Rejection 
The studies planned in the TRIDENT protocol will utilize allogeneic mesenchymal 
stem cells (MSC) in patients with heart disease. The use of an allogeneic graft 
raises the potential of graft rejection through immune cells resulting in failure of 
the therapy. MSCs are ideal candidates for allogeneic transplantation because 
they show minimal MHC class II and ICAM expression and lack B-7 co-
stimulatory molecules necessary for T-cell mediated immune responses119, 120. 
Indeed MSCs do not stimulate a proliferative response from alloreactive T-cells 
even when the MSCs have differentiated into other lineages or are exposed to 
proinflammatory cytokines. Previous studies have demonstrated that MSCs have 
significant immunomodulatory effects, inhibiting T-cell proliferation, prolonging 
skin allograft survival, and decreasing graft-versus-host disease (GVHD). 
Recently human MSCs were shown to alter the cytokine secretion profile of 
dendritic cells, T cells, and natural killer cells in vitro, inhibiting secretion of 
proinflammatory cytokines (e.g. TNF-a, IFN-γ) and increasing expression of 
suppressive cytokines (e.g.IL-10), possibly via a prostaglandin E2 mediated 
pathway.  
In vivo studies of the fate of MSCs have shown that, when transplanted into fetal 
sheep, human MSCs engraft, undergo site-specific differentiation into various cell 
types, including myocytes and cardiomyocytes and persist in multiple tissues for 
as long as 13 months after transplantation in non-immunosuppressed 
immunocompetent hosts.  Further, in vivo studies using rodents, dogs, goats, 
and baboons demonstrate that allogeneic MSCs can be engrafted into these 
species without stimulating systemic alloantibody production or eliciting a 
proliferative response from recipient lymphocytes. These findings, coupled with 

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our demonstration of efficacy of these cells for cardiac repair, solidify the notion 
of using MSCs as an allograft for successful tissue regeneration. 
As part of the Trident protocol we will obtain peripheral blood samples 
from all patients to evaluate the presence of activated T cells. Two heparinized 
(green top) vacutainer tubes (approx. 15 cc total blood) will be collected at 
different time points during the study: at day one prior to infusion of MSC, within 
24 hours (day 2) of injection (post infusion of MSC), and at 6 months.  Peripheral 
blood mononuclear cells (PBMC) will be isolated from heparinized blood by ficoll 
sedimentation and will be viably cryopreserved for planned assessments of T cell 
activation. 
Two of the best-accepted markers of T cell activation are CD69 and CD25 
(IL-2 receptor ).  We will monitor the activation of T cells by flow cytometric 
analysis of CD3+CD25+CD69+ cells in thawed PBMC. CD69 is an 
immediate/early marker of CD3+ T cell activation while CD25 expression 
increases within 1-2 days of activation and remains sustained over the 
intermediate-long term during chronic immune activation. Given the differences in 
the kinetics of CD69 and CD25 upregulation, assessment of both activation 
phenotypes (CD3+CD69+ and CD3+CD25+) will maximize the sensitivity of 
detection of T cell activation following autologous or allogeneic MSC infusion. 
 
5.2.7              Enrollment Contingency Plans 
The following list will be followed to take into account certain unexpected events 
that can disrupt the planned study schedule: 
1. Any patient whose catheterization is delayed will be allowed to 
remain in the study and receive the study product for up to 6 
months from the date of the signed informed consent; as long as 
the patient remains eligible based upon a successful repeat 
screening exam. 
2. Enrolled patients who unexpectedly die prior to catheterization, or 
otherwise withdraw from the study after the screening period but 
before surgery, may be replaced without limit. 
3. Patients who are in the middle of the cardiac catheterization and 
additional therapy is given may be withdrawn from the study and 
replaced by newly enrolled subjects without limit.   
 
 
5.3 
 
Computed Tomography (CT) Protocol 
CT Protocol  

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Patients will undergo contrast-enhanced CT at screening and at the 12 month 
follow-up visit.  In addition to screening the chest, abdomen, and pelvis for 
ectopic tissue formation, cardiac CT will be used to measure global left 
ventricular function, regional wall motion, and volumetric parameters; rest 
perfusion; and infarct scar size. 
Imaging will be performed using a 128 slice CT scanning system (Siemens AS+, 
Siemens Medical Solutions).  Patients will lie supine on the scanner table and be 
attached to the scanner’s electrocardiographic monitor.  Baseline heart rate will 
be recorded.  Beta-blockers will not be given, except for the patient’s normally 
prescribed dose (if applicable).  Scout images will be obtained for determining 
scan range.  
Cardiac CT Function and Rest Perfusion Imaging 
Cardiac CT function and rest perfusion imaging will be performed with a temporal 
resolution of 100-150 msec.  Rest perfusion imaging will be acquired at peak 
tube current and an optimal diastolic phase of the R-R interval.  Dose modulation 
and low tube voltage (100 kV) will be used to minimize the radiation dose.  
Contrast dose will be 140 ml.  The estimated radiation dose for function and rest 
perfusion imaging is estimated to not exceed 10 mSv. 
Functional images will be reconstructed using segmental reconstruction every 
5% of the R-R interval.  Global left ventricular systolic function, regional wall 
motion and wall thickening, end-systolic and end-diastolic volumes will be 
measured. 
Rest perfusion images will be reconstructed in mid-diastole using myoperfusion 
convolution kernels with beam hardening correction.  Custom myocardial 
perfusion software will be used to measure segmental and regional perfusion. 
Chest / Abdomen / Pelvic CT 
The chest, abdominal, and pelvic CT will be performed according to standard 
clinical protocol, immediately following the function and rest perfusion scan.  Oral 
gastrografin will be used for bowel opacification. No additional intravenous 
contrast will be administered. The estimated radiation dose will be 17 mSv.   
Delayed Enhanced CT Infarct Scar Imaging 
Five minutes following contrast injection, delayed enhanced viability imaging will 
be performed using a prospective ECG-gated protocol.  No additional contrast 
will be administered. Prospective ECG-gating will limit X-ray exposure to 70-90% 
of the R-R interval.  Tube voltage will remain low (100 kV) to minimize radiation 
dose.  The estimated radiation dose for delayed enhanced imaging is estimated 
to not exceed 5 mSv.  
5.4 
Echocardiogram Protocols 
Echocardiogram Protocol 
All subjects will undergo transthoracic echocardiographic assessment of overall 
and regional LV systolic function at screening. A limited 2D echocardiogram 

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assessment will be performed prior to catheterization, immediately following the 
catheterization procedure, and 4-6 hours later on Day 1. On day 2, months 3, 6, 
and 12 a complete 3D echo will be performed. 
The echocardiograms will be performed using commercially available ultrasound 
machines.  Images will be recorded for off-line analysis.  Multiple views will be 
recorded, including the parasternal long and short axis views, the apical two and 
four chamber views and the subcostal views. The parasternal short-axis views 
will be recorded at the basal (mitral valve level), mid (papillary muscle level), and 
apical positions. Subject angulation and transducer position will be recorded for 
serial examinations.  
End-diastolic wall thickness will be measured from the parasternal long- and 
short-axis views. Wall motion analysis will be performed using the 16-segment 
model proposed by the American Society of Echocardiography.  Each wall 
segment will be scored using a visual grading system (1=normal, 2=hypokinetic, 
3=akinetic, 4=dyskinetic, 5=aneurysmal). A wall motion score index (WMSI) will 
be defined as the average wall motion score for all segments divided by the 
number of segments analyzable. A percentage of wall motion abnormalities 
(%WMA) will be obtained by dividing the number of akinetic, dyskinetic, and 
aneurysmal segments by the total number of segments evaluated.   
Left ventricular volumes will be determined at end-diastole and end-systole. 
Endocardial borders will be manually traced from apical four-chamber and two-
chamber views and the volumes obtained will be used to calculate ejection 
fraction using the biplane summation-of-disks method recommended by the 
American Society of Echocardiography. 
In addition, the 3D echocardiography performed can simultaneously integrate the 
effects of radial, circumferential and longitudinal contraction of all 17 myocardial 
segments on cardiac dysynchrony.  A semi-automated detection process, 
through endocardial traces of 2D subsections of the full volume data, can be 
used to generate a mathematically based “cast” of the LV cavity that provides 
time volume data for the entire cardiac cycle. These time volume data are 
subsequently divided into time volume estimates for each of the 17 standard 
segments. The echocardiogram procedures are described in detail in Appendix C 
(Transthoracic Echocardiogram SOP).   
 
6. 
ADVERSE EVENT MANAGEMENT 
6.1 
Definition of an Adverse Event  
An Adverse Event (AE) is any untoward medical occurrence in a patient or 
clinical investigation subject temporally associated with the use of a medicinal 
product, whether or not considered related to the medicinal product.  The 
occurrence does not necessarily have to have a causal relationship with this 
treatment.  An AE can therefore be any unfavorable and unintended sign 
(including an abnormal laboratory finding, for example), symptom, or disease 

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(new or exacerbated) temporally associated with the use of a medicinal product, 
whether or not considered related to the medicinal product. 
Examples of an AE include: 
 Exacerbation of a chronic or intermittent pre-existing condition including 
either an increase in frequency or intensity of the condition. 
 Significant 
or 
unexpected 
worsening 
or 
exacerbation 
of 
the 
condition/indication under study. 
 A new condition detected or diagnosed after study therapy administration 
even though it may have been present prior to the start of the study. 
 Pre- or post-treatment events that occur as a result of protocol-mandated 
procedures (e.g., invasive protocol-defined procedures, modification of a 
patient’s previous treatment regimen). 
An AE does not include: 
 Medical or surgical procedures (e.g., colonoscopy, biopsy).  The medical 
condition that leads to the procedure is an AE. 
 Social or convenience hospital admissions where an untoward medical 
occurrence did not occur. 
 Day to day fluctuations of pre-existing disease or conditions present or 
detected at the start of the study that do not worsen. 
 The disease/disorder being studied or expected progression, signs, or 
symptoms of the disease/disorder being studied unless more severe than 
expected for the patient’s condition. 
6.2 
Definition of Adverse Reaction 
An adverse reaction is any adverse event caused by a drug.  Adverse reactions 
are a subset of all suspected adverse reactions for which there is reason to 
conclude that the drug caused the event. 
6.3 
Definition of Suspected Adverse Reaction 
Suspected adverse reaction means any adverse event for which there is a 
reasonable possibility that the drug caused the adverse event.  For the purposes 
of IND safety reporting, ‘reasonable possibility’ means there is evidence to 
suggest a causal relationship between the drug and the adverse event.  A 
suspected adverse reaction implies a lesser degree of certainty about causality 
than adverse reaction, which means any adverse event caused by a drug. 
6.4 
Definition of Serious  
An adverse event (AE) or suspected adverse reaction is considered “serious” if it: 
1. results in death 
2. is life-threatening (at risk of death at the time of the event) 

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3. requires 
in 
inpatient 
hospitalization 
or 
prolongation 
of 
existing 
hospitalization 
NOTE:  Complications that occur during hospitalization are AEs.  If a 
complication prolongs hospitalization or fulfills any other serious criteria, 
the event is serious.  Hospitalization for elective treatment of a pre-existing 
condition that did not worsen from baseline is not considered to be an AE. 
4. results in disability/incapacity 
NOTE:  The term disability means a substantial disruption of a person’s 
ability to conduct normal life functions.  This definition is not intended to 
include experiences of relatively minor medical significance such as 
uncomplicated 
headache, 
nausea, 
vomiting, 
diarrhea, 
influenza, 
accidental trauma (i.e., sprained ankle) that may interfere or prevent 
everyday life functions but do not constitute a substantial disruption.  
5. is a congenital anomaly/birth defect.   
Important medical events that may not result in death, be life-threatening, or 
require hospitalization may be considered an SAE when, based upon appropriate 
medical judgment, they may jeopardize the patient or subject and may require 
medical or surgical intervention to prevent one of the outcomes listed in the 
above definition. 
6.5 
Definition of Unexpected 
An adverse event or suspected adverse reaction is considered “unexpected” if it 
is not listed in the investigator brochure or is not listed at the specificity or 
severity that has been observed; or, if an investigator brochure is note required 
or available, is not consistent with the risk information described in the general 
investigational plan or elsewhere in the current application. 
6.6 
Clinical 
Laboratory 
Assessments 
and 
Other 
Abnormal 
Assessments as Adverse Events and Serious Adverse Events 
Abnormal laboratory findings (e.g. clinical chemistry, hematology, urinalysis) or 
other abnormal assessments (e.g., ECGs, vital signs) that are judged by the 
Investigator as clinically significant will be recorded as AEs or SAEs if they meet 
the definition of an AE as defined in Section 6.1 (“Definition of an Adverse 
Event”) or SAE, as defined in Section 6.2 (“Definition of a Serious Adverse 
Event”).  Clinically significant abnormal laboratory findings or other abnormal 
assessments that are detected during the study or are present at screening and 
significantly worsen following the start of the study will be reported as AEs or 
SAEs.  However, clinically significant abnormal laboratory findings or other 
abnormal assessments that are associated with the disease being studied, 
unless judged by the Investigator as more severe than expected for the patient’s 
condition, or that are present or detected at the start of the study but do not 
worsen, will not be reported as AEs or SAEs. 
The Investigator will exercise medical judgment in deciding whether abnormal 
laboratory values are clinically significant. 

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6.7 
Recording of Adverse Events and Serious Adverse Events 
The Investigator should review all documentation (e.g., hospital progress notes, 
laboratory, or diagnostic reports) relative to the event being reported.  The 
Investigator will then record all relevant information regarding an AE/SAE into the 
electronic data system.  It is not acceptable for the Investigator to send 
photocopies of the patients’ medical records in lieu of completion of the 
appropriate AE/SAE pages.   
The Investigator will attempt to establish a diagnosis of the event based on signs, 
symptoms, and/or other clinical information.  In such cases, the diagnosis should 
be documented as the AE/SAE and not the individual signs and symptoms. 
Pregnancies 
Patient pregnancy must be reported to the Principal Investigator within 1 working 
day of knowledge of the event.  Any patient who becomes pregnant during the 
study must be promptly withdrawn from the study.  Follow-up information 
regarding the outcome of the pregnancy and any postnatal sequelae in the infant 
will be required.  
6.8 
Intensity of Adverse Events and Serious Adverse Events 
The Investigator will make an assessment of intensity for each AE and SAE 
reported during the study.  The assessment will be based on the Investigator’s 
clinical judgment.  The intensity of each AE and SAE should be assigned to one 
of the following categories: 
Mild:  
An event that is easily tolerated by the patient, causing 
minimal discomfort and not interfering with everyday 
activities. 
Moderate:  An event that is sufficiently discomforting to interfere with 
normal everyday activities. 
Severe:  
An event that prevents normal everyday activities. 
An AE that is assessed as severe should not be confused with an SAE.  Severity 
is a category utilized for rating the intensity of an event; and both AEs and SAEs 
can be assessed as severe.  An event is described as ‘serious’ when it meets 
one of the pre-defined outcomes as described in Section 6.4, “Definition of 
Serious.” 
6.9 
Causality of Adverse Events and Serious Adverse Events  
The Investigator is obligated to assess the causality between study therapy and 
the occurrence of each AE/SAE.  The Investigator will use clinical judgment to 
determine if there is a reasonable possibility that the biological action of the study 
therapy was responsible for AE/SAE being reported.  Alternative causes such as 
natural history of the underlying diseases, concomitant therapy, other risk factors, 
and the temporal relationship of the event to the study therapy will be considered 
and investigated.  The Investigator will also consult the Clinical Investigator’s 

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Brochure and/or Product Information, for marketed products, in the determination 
of his/her assessment. 
The Investigator will use the following questions when assessing causality of an 
adverse event to study therapy.  
Is there a reasonable possibility that the study therapy caused the event? 
Reasonable possibility implies that there is evidence that the vent was caused by 
the study product.  
An affirmative answer designates the event as a suspected adverse reaction.  
There may be situations when an SAE has occurred and the Investigator has 
minimal information to include in the initial report.  However, it is very important 
that the Investigator always make an assessment of causality. 
6.10 
Follow-Up of Adverse Events and Serious Adverse Events 
After the initial AE/SAE report, the Investigator is required to proactively follow 
each patient and provide further information on the patient’s condition.  All AEs 
and SAEs documented at a previous visit/contact that are designated as ongoing 
will be reviewed at subsequent visits/contacts.   
Adverse events and SAEs will be followed until resolution, until no further 
changes in the event are expected (i.e. the point at which a patient experiencing 
a critical adverse event is treated successfully and stabilized even though they 
may continue to experience lingering sequelae that may never resolve), until the 
patient is lost to follow-up, or until it is agreed that further follow-up of the event is 
not warranted (e.g. non-serious, study therapy unrelated, mild or moderate 
adverse events ongoing at a patient’s final study visit).  If a patient dies during 
participation in the study or during a recognized follow-up period, the Investigator 
will provide a copy of any post-mortem findings, including histopathology. 
New or updated information will be recorded by modifying the AE forms in the 
electronic data system 
6.11 
Timeframes for Submitting SAE Reports 
Once an Investigator becomes aware that an SAE has occurred in a study 
patient, he/she will record the information in the electronic data record within 48 
hours.  Any fatal or life-threatening event must be reported within 24 hours.  If the 
Investigator does not have all information regarding an SAE, he/she will not wait 
to receive additional information before recording the event in the data system 
and completing as much information known at the time of the submission.  The 
reporting timeframes for any SAE occurring during the study are summarized in 
Table 4.  
 
 
TABLE 4 

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Serious Adverse Event Reporting Requirements 
 
Initial Reports 
Follow-Up 
Reports 
Type of SAE 
Fatal 
or  
Life-Threatening 
Other SAEs 
Any SAE 
Reporting 
Timeframes 
24 hours 
48 hours 
48 hours 
Documents 
Required 
 
24 hours: 
Complete as much 
information in the electronic 
data system that is known. 
 
48 hours: 
Fully complete all AE forms 
Fully 
completed 
AE forms  
 
Updated AE Forms 
 
. 
6.12 
Post-Study Adverse Events and Serious Adverse Events 
The Investigator should report any death or SAE occurring at any time after a 
patient has completed or terminated a clinical trial, when such death or SAE may 
reasonably be related to the study therapy used in an investigational trial.  
Investigators are not obligated to actively seek AEs from former study 
participants. 
6.13 
Regulatory Aspects of Adverse Event Reporting 
The Investigator will promptly report all SAEs within the timeframes specified in 
Section 6.8.  Prompt notification of SAEs by the Investigator is essential so that 
UMMSM can meet legal obligations and fulfill ethical responsibilities towards the 
safety of all patients participating in UMMSM-sponsored investigational trials. 
The Investigator will comply with the applicable local regulatory requirements 
related to reporting of SAEs to his or her Institutional Review Board (IRB) or 
Independent Ethics Committee (IEC). 
This protocol has been filed under an Investigational New Drug (IND) application 
with the FDA.  A given SAE may qualify as an Expedited Safety Report (ESR) if 
the SAE is both at least possibly attributable to study therapy and unexpected.  In 
this case, all Investigators participating in an IND study will receive an ESR.   
The ESRs are prepared according to UMMSM policy and are forwarded to the 
Investigator as necessary.  The purpose of the ESR is to fulfill specific regulatory 
and Good Clinical Practice (GCP) requirements regarding the product under 
investigation.   
6.14 
Monitoring of Adverse Events 
The following list summarizes the Contract Research Organization’s (CRO’s) role 
in monitoring AE/SAEs: 

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 All serious suspected adverse reactions will be reviewed by the Medical 
Monitor at the CRO within 2 business days of the site entering the 
information into the EDC.  
 If the Medical Monitor requires additional information to make his/her 
assessment, the clinical centers will have 2 business days to respond to 
the request for additional information.  
 The CRO is responsible for initial notification of the DSMB immediately of 
all unexpected, serious suspected adverse reactions, regardless of 
attribution, and of any concerns regarding the frequency or type of SAE(s) 
on a study or treatment arm according to the DSMB charter. 
 The attribution, as assessed by the clinical center and the CRO Medical 
Monitor, will be provided to the DSMB within 2 business days of receiving 
the clinical center report and available data supporting the attribution if the 
event is both unexpected and a serious suspected adverse reaction. 
 
The CRO will prepare semi-annual summary reports of all AEs/SAEs for the 
DSMB.  Semi-annual reports will be made available on a secure website; the 
DSMB Chair will be notified by e-mail when the materials are posted.  
 
7. 
DATA COLLECTION AND STATISTICAL ISSUES 
This section describes methods for enrollment, data collection, sample size 
determination, analysis populations, and planned analyses for safety and efficacy 
endpoints.   
7.1 
Enrollment  
Patients will be registered using the following procedures: 
1. An authorized user completes the initial screening by entering patient 
demographics and inclusion/exclusion criteria on the Enrollment Form.  The 
enrollment screen includes a question confirming that the patient signed the 
informed consent form.   
2. If the patient is eligible as determined by the electronic data entry system, a 
unique patient study number is generated as well as a blinded study product 
number.  The blinded study product number will allow the cell therapy lab to 
know what dose to prepare.  Only the unblinded statistician and cell lab will 
be aware of the treatment assignment.    
3. The study coordinator informs the Cell Therapy Laboratory of the blinded 
study number and will prepare the study product based on an unblinded 
treatment assignment table.   
4. The study coordinator will inform the Cell Therapy Laboratory of the blinded 
study number and prepare the study product based on an unblinded 
treatment assignment table. 

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5. Cell Therapy Lab will also be provided with the CMV test results of eligible 
recipient. 
6. This information will be used to select Allo- MSC product for eligible recipient. 
7. CMV status of the recipient and donor of the Allo-MSC product will be 
matched. 
8. CMV positive Allo-MSC product will only be infused to a CMV positive 
recipient. 
9. All CMV negative recipients will receive CMV negative Allo-MSC product. 
10. Upon the user saving the injection date on the Injection Form in Advantage 
EDC, a visit schedule based on the study product injection date is available 
for printing and is referred to as “Segment A Follow-up.” 
7.2 
Data Collection 
A description of each of the forms and the procedures required for forms 
completion and submission can be found in the Data Management Handbook 
and User’s Guide. The Investigator or designee must record all required patient 
data, and an explanation must be documented for any missing data. 
Follow-up Assessments: The timing of follow-up visits is based on the date of 
the cardiac catheterization procedure.  Following catheterization, a Patient Visit 
Schedule listing target dates for assessments will be prepared.   
7.3 
Study Design and Sample Size Considerations 
The primary focus of this study is to assess the 30-day post-cardiac 
catheterization SAE proportion as defined in Section 2.  Thirty patients will be 
enrolled over a 12-18 month accrual period.  Fifteen patients will receive allo-
hMSCs at each dose level in a blinded fashion.   
The total sample size is 30 patients for the trial equally distributed between the 
20 million and 100 million dose levels. As a result, the sample size and power 
considerations will be based on the 15 subjects who received the injection in 
each treatment group. Exact binomial ninety-five percent confidence intervals 
were calculated for varying number of events based on the sample size.  Table 5 
provides confidence intervals for a variety of true underlying number of events.  
Of particular interest, is the anticipated 30 day proportion of treatment-emergent 
serious adverse events (TE-SAE) as defined in 2.2.1.  The underlying rate of 30-
day TE-SAE is 20%, which translates into 3 patients with events out of 15 
patients.  For the setting of 3 events, the confidence interval is 0.04-0.48.  The 
probabilities above and below 3 represent other plausible scenarios.   
Exact power computations based on the binomial distribution were conducted 
using the SAS system version 9.1.  The precision of the estimates could be 
viewed as a lower bound on the number of events reported.  The probability to 
rule out the number of patients experiencing a TE-SAE of a certain size can be 
interpreted as “power.”  Table 4 provides the probability (or power) that the lower 

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bound of a 95% two-sided confidence interval for the primary endpoint will be 
greater than thresholds of 1, 2, 3, 4, 5, 6, and 7 events.  When the true number of 
events is 3, there is 65% power to rule out a number of patients experiencing the 
primary endpoint of 8 or higher.   
Table 5.  Exact Binomial 95% Confidence 
Intervals for Various Sample Sizes and Proportion 
of Patients Experiencing the Primary Endpoint 
Patients 
randomized 
to 
each 
treatment 
group 
 
Number 
of 
patients 
experiencing 
the 
primary 
endpoint 
Exact 95% Confidence 
Intervals 
15 
 
1 
0.002, 
0.32 
2 
0.02, 
0.40 
3 
0.04, 
0.48 
4 
0.08, 
0.55 
5 
0.12, 
0.62 
6 
0.16, 
0.68 
7 
0.21, 
0.73 
 
Table 6. Probability of Ruling Out a Threshold of Size T or larger for Various 
Sample Sizes and True Underlying SAE Proportion of Patients Experiencing 
the Primary Endpoint 
N 
 
True 
Number of 
Events 
Probability of Ruling Out Events of Size T or Larger 
1 
 
2 
 
3 
 
4 
 
5 
6 
7 
8 
15 
 
1 
 
<0.01 
<0.01 
0.35 
0.73 
0.73 0.93 
0.99 
2 
0.12 
 
<0.01 
0.12 
0.40 
0.40 0.69 
0.88 
3 
0.35 
0.06 
 
0.04 
0.17 
0.17 0.40 
0.65 
4 
0.60 
0.19 
0.08 
 
0.06 
0.06 0.19 
0.40 
5 
0.78 
0.37 
0.20 
0.03 
 
0.02 0.08 
0.22 
6 
0.91 
0.60 
0.39 
0.10 
0.04 
 
0.03 
0.09 
7 
0.97 
0.79 
0.61 
0.23 
0.10 
0.04  
0.03 
8 
0.99 
0.90 
0.77 
0.39 
0.21 
0.09 0.03 
 
 

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7.4 
Demographic and Baseline Characteristics 
Demographics and baseline characteristics will be summarized for all patients.  
Characteristics to be examined are: age, gender, race/ethnicity, ejection fraction, 
six-minute walk test performance, peak VO2, etc. 
7.5 
Analysis of the Primary Endpoint 
Descriptive analyses of the primary endpoint will be performed.  Point estimates 
and confidence intervals of TE-SAE proportion will be computed.  Fisher Exact 
Test will be used to compare the two dose levels.   
7.6 
 Stopping Guidelines 
The proportion of patients experiencing TE-SAE as defined in 2.2.1 will be 
monitored within 30 days of injection.  This guideline is to be used to indicate 
boundaries requiring discussion by the Data and Safety Monitoring Board 
(DSMB) and is designed to assist the independent DSMB in overseeing the 
study. The DSMB may also request additional interim analyses and develop 
other criteria including provision for monitoring of potential late effects to 
determine when to intervene in the enrollment or treatment of patients in the 
study.  
Monitoring of key safety endpoints will be conducted. If rates significantly exceed 
the pre-set threshold, then the DSMB will be advised.  
A Bayesian motivated safety stopping guideline will be used for this trial123, 124.  
The expected underlying TE-SAE at 30 days post-catheterization probability is 
assumed to be 20% and that a probability of greater than 40% is unacceptable.  
A Beta distribution can be used as the prior distribution of ; where  is the 
proportion of patients who experience a TE-SAE.  The stopping rule is based on 
the beta-binomial methodology and assumes a prior expected failure rate.  This 
leads to prior Beta parameters where a=2.5 and b=10.0.  The Beta distribution 
will have a prior mean of 0.20 and a prior probability of <0.05 of exceeding 0.40.  
The guideline is derived such that there is strong evidence (posterior probability 
>0.95) that the probability of the event is greater than 40%, the trial will be 
stopped. The resulting boundaries tabulated in table 7 were rounded to be 
conservative with the stopping guideline and is considered after 5 patients are 
enrolled on the study. 
 
 
 
 
 
TABLE 7 
Bayesian Stopping Guideline for Event Rate of 20% * 

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# Events 
#  Patients in 
Study 
4 
5-8 
5 
9-12 
6 
13-15 
 
* The stopping guidelines serve as a trigger for consultation with the DSMB for 
additional review, and are not formal “stopping rules” that would mandate 
automatic closure of study enrollment. 
 
A simulation study was conducted to evaluate the operating characteristics of this 
stopping rule.  Data were generated from the binomial distribution with varying 
probabilities of failure () and assuming a sample size of 15 patients.  Table 8 
shows the probability of stopping the trial early and the average sample size (N), 
conditional on stopping early, at which the boundary is crossed for each value of 
.  The unconditional average sample size of the trials for each value of  is 
displayed.  
 
Table 8 
Operating Characteristics for Bayesian Motivated Stopping 
Guideline 
Mean 
of 
Prior 
Distribution 
 
Probability 
of stopping 
Conditional 
Average  
Sample Size 
(N) 
Unconditional 
Average 
Sample 
Size 
of Trials (N) 
0.20 
0.20 
0.11 
9.5 
14.4 
 
0.25 
0.22 
9.4 
13.8 
 
0.30 
0.36 
9.4 
13.0 
 
0.35 
0.52 
9.1 
11.9 
 
0.40 
0.67 
8.8 
10.9 
 
0.45 
0.79 
8.4 
9.8 
 
0.50 
0.88 
7.9 
8.8 
 
0.55 
0.94 
7.4 
7.8 
 

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Although the motivation for the boundary is Bayesian, the operating 
characteristics can be evaluated from a frequentist perspective of Type I error 
and power.  The stopping rule for a 20% event rate has a 11% chance (“Type I 
error”) of suggesting early termination when the true rate is 0.20, and a 67% 
chance (“power”) when the true rate is 0.40, rising to 88% when the true rate is 
50%. 
7.7 
Analysis of Secondary Endpoints 
A number of secondary endpoints as noted in chapter 2 will be examined to 
compare the safety and efficacy of each of the allo-MSC dose levels.  The 
analysis of the secondary endpoints that are planned is included below. 
 Adverse Events: Fisher exact tests will be used to compare groups on the 
incidence of adverse events (including percentages of patients with > 1 
adverse events, possibly-related MSC adverse events, possibly-related to 
the catheter adverse events, and serious adverse events.  All adverse 
events will be coded according to the Medical Dictionary for Regulatory 
Activities (MedDRA).  MedDRA coded events will be displayed by system 
organ class and preferred term.  The time periods would be within 30-
days, 6 and 12-months post-injection.   
 MACE: Fisher exact tests will be used to compare groups on the incidence 
of major adverse cardiac events (MACE) as defined in section 2.2.3.  The 
time periods would be within 30-days, 6 and 12-months post-injection.   
 TE-SAE: Fisher exact tests will be used to compare groups on the 
incidence of treatment emergent adverse events (TE-SAE) as defined in 
section 2.2.2.  The time periods would be within 30-days, 6 and 12-months 
post-injection.   
 Ectopic Tissue Formation: The incidence of ectopic tissue formation will 
be described between groups and compared using Fishers exact test.  
The time periods would be within 30-days, 6 and 12-months post-injection.   
 Cardiac Enzymes: CK-MB and serum troponin will be monitored at 
baseline and every 12-hours for the first 48 hours post-injection.  
Generalized linear models will be employed to model the effects of 
treatment on cardiac enzymes. 
 Hospitalizations will be described based on adjudicated readmissions.  
o The rate of any hospitalization and hospitalization for worsening 
heart failure will be compared using Fishers Exact test.   
o The probability of hospitalization-free survival will be estimated 
using a binomial proportion at 1-year as well as using the Kaplan-
Meier method if the number of events permits.     
o The time to hospitalization will be estimated using the cumulative 
incidence method treating death as a competing risk and censoring 

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at the last date of follow-up.  The time periods would be 6 and 12-
months post-injection 
 Deaths will be described by treatment arm and evaluated using the 
Kaplan-Meier method if the number of events permits.   
 Changes from baseline will be evaluated for the 6-minute walk test, peak 
Vo2, forced expiratory volume in 1-second (FEV1), echocardiographic 
measures, and CT parameters.  General linear models will be used to 
model the effects of treatment on the change from baseline. 
 New York Heart Association class will be analyzed as either improvement, 
no change or worsening of class at 6 and 12-months post-injection as 
compared to pre-injection and will be analyzed using a chi-square test.   
 Quality of Life 
o The Minnesota Living with Heart Failure Questionnaire will be 
administered at 6 and 12-months post-injection.  The total score, 
emotional score and physical dimension score will be calculated 
and compared using general linear models.   
o Sexual Quality of Life Questionnaire (Female) will be administered 
at 3, 6 and 12-months post-injection.  The score will be calculated 
and compared using general linear models.   
o International Index for Erectile Dysfunction (Male) will be 
administered at 3, 6 and 12-months post-injection.  The score will 
be calculated and compared using general linear models.   
 Composite Score will be computed based on death, hospitalization, 
Minnesota Living with Heart Failure Total Score, change in 6-minute walk 
test, ejection fraction and change in NYHA class.  Groups will be 
compared at 3, 6, and 12-months using general linear models.  
7.8 
Criteria for Dose Selection 
The criteria for moving to the next phase of the study will be based on the totality 
of evidence including the safety and efficacy endpoints previously described. 
7.9 
Data and Safety Monitoring Board (DSMB) 
Interim analyses will be conducted at times coincident with regularly scheduled 
meetings of the Data and Safety Monitoring Board (DSMB) at approximately six-
month intervals.  The DSMB Chair will be notified each time an unexpected, 
serious suspected adverse reaction occurs.  The DSMB will evaluate AE data 
(including SAEs) at the following pre-specified intervals: (1) when 5 patients are 
enrolled and completed 1 month of follow-up.  Other safety data, such as 24-hour 
ambulatory ECGs and laboratory data will also be evaluated by the DSMB as 
appropriate.  Monitoring of key safety endpoints will be conducted as described 
above, and if rates significantly exceed pre-set thresholds, the DSMB Chair will 
be notified and information will be supplied to the DSMB.  Policies of the DSMB 

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will be described in the DSMB Charter, which will be prepared by the DSMB prior 
to study initiation.  The stopping guidelines serve as a trigger for consultation with 
the DSMB for additional review, and are not formal “stopping rules” that would 
mandate automatic closure of study enrollment.   
 
8.   
NORMAL DONORS FOR GENERATION OF ALLOGENEIC MSC 
 
The availability of allogeneic MSC (allo-MSC) offers the potential for an “off the 
shelf” product for patients. Significant data has been generated (see Background 
Section 2) to demonstrate that the allo-MSCs are immunosuppressive. In 
addition, allo-MSCs are immunoprivileged and can be infused without immune 
rejection despite disparate HLA phenotypes.  BM aspirates will be obtained from 
maximum of 15 normal individuals and MSC isolated and expanded. 
 
The recipient screening blood work is specific to each cell manufacturing facility 
and may include hepatitis A, West Nile Virus, human T-cell lymphotropic virus 
(HTLV) I/II, CMV and syphilis.” 
 
8.1   
Bone Marrow Aspiration for Generation of Allo-MSC  
BM will be obtained from normal volunteers with 120 ml aspirated from the 
posterior iliac crest. The BM will be aspirated into heparinized syringes. The 
MNC fraction will be isolated using a density gradient with Lymphocyte 
Separation Media (specific gravity 1.077). The low-density cells will be collected 
and washed with Plasma-Lyte A containing 1% HSA. The washed cells will be 
samples and viable cell numbers determined. The BM MNC will be seeded into 
225 cm2 tissue culture flasks in alpha MEM containing 20% FBS. After 14 days of 
culture, passage zero (P0) cells will be harvested by trypsin treatment and 
expanded into 60 flasks. These flasks are incubated for a further 7 to 10 days 
and the MSC harvested by trypsin treatment (P1 cells). 
 
8.2   
Normal Donor Eligibility 
Donors (male or female) between the ages of 20 to 45 will be screened as 
potential BM donors (maximum of 15) and shall be evaluated by history and 
physical examination, as well as, completion of the National Marrow Donor 
Program (NMDP) questionnaire138. The history shall include the following: 
- 
History of malignancy 
- 
Bleeding abnormalities 
- 
Deep venous thrombosis 
- 
Cardio/pulmonary conditions 
- 
Blood transfusions 
- 
Vaccinations 
- 
Questions to identify persons at risks of infectious disease 
transmission 

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- 
Questions to identify persons at risk of transmitting hematological or 
immunological disease 
 
The physical examination shall be completed and include evaluation for potential 
risk of the BM aspiration procedure. 
Prospective donors shall have infectious Disease Testing including: 
- 
Hepatitis B surface antigen (HBsAg) 
- 
Anti-Hepatitis B core antibody (HBcAb) 
- 
Anti-Hepatitis C virus antibody (HCV Ab) 
- 
Anti-Human Immunodeficiency Virus (HIV) antibody (HIV 1/2 ) 
- 
Cytomegalovirus antibody (CMV) 
- 
HCV/HIV Nucleic Acid test 
- 
West Nile Virus Nucleic Acid test 
- 
Rapid Plasma Reagin (RPR) 
- 
Human T-lymphotropic Virus I/II (HTLV I/II) 
- 
T. cruzi ELISA test (Chagas disease) 
 
Prospective donors shall have the following blood tests: 
- 
CBC, differential, platelet count 
- 
Creatinine, ALT, bilirubin, alkaline phosphatase, glucose, Pro-BNP and 
uric acid 
- 
Na, K, Cl, Mg, calcium 
 
Eligibility Criteria for Normal Donors 
- 
Male and female gender 
- 
No history of malignancy  
- 
No active coagulopathy and/or hypocoagulable state 
- 
No history of cardio/pulmonary conditions 
- 
Negative tests for Hepatitis B, Hepatitis C, RPR, Chagas, HIV ½, HTLV 
I/II and NAT for HCV, HIV, and WNV 
- 
Hemoglobin > 13.0 g/dL 
- 
Platelet count 140,000 to 440,000/µl 
- 
WBC 3.0 to 11.0 K/µl 
- 
No anomalies on the CBC and differential suggestive of a 
hematopoietic disorder 
- 
Creatinine <1.5 mg/dL 
- 
ALT< 112 IU/L 
- 
Bilirubin < 1.5 mg/dL 
- 
No diabetes 
- 
Systolic blood pressure < 170 
- 
Diastolic blood pressure < 90 
- 
No history of autoimmune disorders 
- 
Negative serum or urine pregnancy test for female donors 

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Female donors would need to be screened for pregnancy as the procedure may 
be an added risk to a fetus. 
8.3  
Donor Consent 
Informed consent shall be obtained and documented. The procedure shall be 
explained in terms the donor can understand, and shall include information about 
the significant risks of the procedure. The donor shall have the right to review the 
results of tests. 
The donor shall have the opportunity to ask questions and the right to refuse to 
donate.   
8.4  
Follow-up Schedule for Donors  
After discharge from the hospital, the bone marrow donor will be contacted by the 
study team with 24 hours post BMA follow-up telephone calls to determine the 
well-being and health status of the donor. The donor will be provided with contact 
telephone numbers in the consent form for any questions or comments.  
 
9. STUDY ADMINISTRATION 
9.1   
Regulatory and Ethical Considerations 
9.1.1 Regulatory Authority Approval 
This study will be conducted in accordance with Good Clinical Practice (GCP) 
requirements described in the current revision of International Conference on 
Harmonization of Technical Requirements of Pharmaceuticals for Human Use 
(ICH) Guidelines and all applicable regulations, including current United States 
Code of Federal Regulations (CFR), Title 21, Parts 11, 50, 54, 56, and 312 and 
Title 45, Part 164.  Compliance with these regulations and guidelines also 
constitutes compliance with the ethical principles described in the current revision 
of the Declaration of Helsinki.  This study will also be carried out in accordance 
with local legal requirements. 
9.1.2 Ethics Approval 
It is the Investigator’s responsibility to ensure, that prior to initiating this study, 
this protocol is reviewed and approved by the appropriate local IRB.  The 
composition and conduct of this committee must conform to the United States 
CFR.   
The IRB/IEC must also review and approve the site’s informed consent form 
(ICF), other written information provided to the patient and all advertisements that 
may be used for patient recruitment.   
If it is necessary to amend the protocol or the ICF during the study, the 
Investigator will be responsible for ensuring that the IRB/IEC reviews and 
approves these amended documents. An IRB/IEC approval of the amended 
protocol and/or ICF must be obtained in writing before implementation of the 

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amended procedures and before new patients are consented to participate in the 
study using the amended version of the ICF. 
9.1.3 Patient Informed Consent 
Before being admitted to the clinical study, all patients must consent in writing to 
participate.  An ICF will be given to each patient, which will contain all United 
States federally required elements, all ICH-required elements, and Health 
Insurance Portability and Accountability Act Authorization (HIPAA) information in 
language that is understandable to the patient.  
The process of obtaining the informed consent will be in compliance with all 
federal regulations, ICH requirements, and local laws.   
The Investigator will review the study with each patient.  The review will include 
the nature, scope, procedures, and possible consequences of the patient's 
participation in the study.  The ICF and review must be in a form understandable 
to the patient.  The Investigator or designee and the patient must both sign and 
date the ICF after review and before the patient can participate in the study.  The 
patient will receive a copy of the signed and dated form, and the original will be 
retained in the site study files.  The Investigator or his/her designee must 
emphasize to the patient that study participation is entirely voluntary and that 
consent regarding study participation may be withdrawn at any time without 
penalty or loss of benefits to which the patient is otherwise entitled. 
If the ICF is amended during the study, the Investigator must follow all applicable 
regulatory requirements pertaining to approval of the amended ICF by the 
IRB/IEC.  The site must use the amended consent form for all new patients and 
repeat the consent process with the amended ICF for any ongoing patients. 
9.2  
Confidentiality of Information  
Patients’ names will remain confidential and will not be included in the database.  
Only patient number, patient initials, and birth date will be recorded in the data 
system.  If the patient name appears on any other document collected (e.g., 
hospital discharge summary), the name must be obliterated before the document 
is transmitted.  All study findings will be stored in electronic databases.  The 
patients will give explicit permission for representatives of regulatory authorities 
and the IRB/IEC to inspect their medical records to verify the information 
collected.   
Patients will be informed that all personal information made available for 
inspection will be handled in the strictest confidence and in accordance with all 
state, local, and federal data protection/privacy laws, including, without limitation, 
the HIPAA. 
All participants in the United States will provide written authorization to disclose 
private health information either as a part of the written ICF or as a separate 
authorization form.  The authorization will contain all required elements specified 
by 45 CFR 164, and will contain a waiver of patient access to study-related 
private health information until the conclusion of the clinical study.  The 

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authorization will remain valid and in full force and effect until the first to occur of 
(1) the expiration of 2 years after the study therapy is approved for the indication 
being studied, or (2) the expiration of 2 years after the research program is 
discontinued.  Individual patient medical information obtained during this study is 
confidential and its disclosure to third parties (other than those mentioned in this 
Section 9.7) is strictly prohibited.  In addition, medical information obtained during 
this study may be provided to the patient's personal physician or to other 
appropriate medical personnel when required in connection with the patient's 
continued health and welfare. 
The Investigator will maintain a personal patient identification list (patient and 
treatment numbers with the corresponding patient names) to enable records to 
be identified.   
9.3   
Payments to Patients 
Patients will be reimbursed $50 at the end of each follow-up visit (months 3, 6, 
and 12) for a total remuneration of $150).  These disbursements are meant to 
cover the time required to complete these study visits and all necessary travel 
and parking expenses.  
Normal donors for generation of allo-MSC will be reimbursed $350 at the end of 
BM aspiration. This payment will compensate donors for lost time, parking and 
travel expenses.  
 
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