Autologous Cardiac Stem Cell Injection in Patients With Hypoplastic Left Heart Syndrome: An Open Label Pilot Study.
Phase: PHASE1
Conditions: Hypoplastic Left Heart Syndrome
Sponsor: Joshua M Hare

Interdisciplinary Stem Cell Institute 
University of Miami/ Miller School of Medicine  
and University of Maryland 
 
Clinical Research Protocol 
 
Study Title:   
 
Autologous Cardiac Stem Cell Injection in Patients with  
HypoplastIc Left Heart SynDrome: An Open Label Pilot 
Study.  (CHILD Study) 
 
Study Product: 
 
Autologous c-kit positive cells 
 
 
Indication:  
 
Hypoplastic Left Heart Syndrome (HLHS) 
 
FDA IND No.: 
 
BB-IND #14699 
 
Sponsor: 
 
 
Joshua M. Hare, MD 
 
 
 
 
Telephone: (305) 243 – 5579  
 
 
 
 
 
 
Protocol Version:  
Version 8, dated March 23, 2021 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CONFIDENTIALITY STATEMENT 
This document is confidential and proprietary to the University of Maryland, Interdisciplinary Stem Cell 
Institute (ISCI) at the 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document constitutes agreement by the recipient that no unpublished information contained herein will be 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 the 
University of Maryland, Interdisciplinary Stem Cell Institute at the 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

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study 
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 2 
 
Investigator Signature Page 
 
Title: 
Autologous Cardiac Stem Cell Injection in 
Patients with Hypoplastic Left Heart 
Syndrome: An Open Label Pilot Study.   
 
FDA IND Number:  
14699 
 
I have read the enclosed protocol. I will ensure the safety of the study subjects 
enrolled under my supervision, and will provide the sponsor with complete, 
accurate, and timely information on this study, as outlined in this Protocol. The 
signature below constitutes approval of this protocol and the attachments, and 
provides the required assurances that this trial will be conducted according to all 
stipulations of the protocol, including local legal and regulatory requirements, 
applicable US federal regulations and (ICF E6) guidelines. I shall hold strictly 
confidential all information pertaining to the study, and that this confidentiality 
requirement applies to all study staff at the site(s) and/or under my supervision. 
 
 
__________________________________ 
 
____________________ 
Principal Investigator Signature 
 
 
Date 
 
 
 
____________________________________ 
Print Name for Principal Investigator 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 3 
 
Table of Contents 
Investigator Signature Page .............................................................................. 2 
List of Abbreviations And Definition of Terms ................................................. 5 
SECTION 1 ........................................................................................................... 8 
1. Introductory Statement ............................................................................................ 8 
2. General Investigational Plan ................................................................................ 11 
A. Background ............................................................................................................ 11 
B. Clinical Protocol ..................................................................................................... 16 
B.1. Study Design ...................................................................................................... 16 
B.1.1. Basic Design Characteristics ........................................................................ 16 
B.1.2. Sample Size..................................................................................................... 16 
B.1.3. Dosage and Administration ........................................................................... 17 
B.1.4. Premature Withdrawal ................................................................................... 17 
B.2. Criteria for Subject Enrollment ......................................................................... 17 
B.2.1. Inclusion Criteria ............................................................................................. 17 
B.2.2. Exclusion Criteria ............................................................................................ 17 
B.3 Sequence of Measurements and Evaluation .................................................. 18 
B.3.1. Subject Introduction and Informed Consent ............................................... 18 
B.3.2. Screening Phase Assessments .................................................................... 19 
B.3.3. Tissue Collection Phase ................................................................................ 19 
B.3.3.a. Tissue Collection Procedures .................................................................... 19 
B.3.3.b. Post Norwood Monitoring Phase (Standard of Care) ............................ 21 
B.3.3.c. Baseline Assessment .................................................................................. 21 
B.3.3.d. Study Product Injection .............................................................................. 22 
B.3.3.e. Investigational Final Product Preparation ................................................ 22 
B.3.3.f. Post-treatment (Stage II BDCPA operation) Assessments ................... 23 
C. Statistical Methods ................................................................................................ 26 
C.1. Statistical and Analytical Plan .......................................................................... 26 
C.2. Analysis Sets ...................................................................................................... 26 
C.3. Safety Analysis ................................................................................................... 26 
C.4. Analysis of Demographics and Other Baseline Characteristics ................. 27 
C.5. Analysis of Bioactivity ........................................................................................ 27 
C.6. Determination of Sample Size ......................................................................... 28 
C.7. Heart Tissue Analysis ....................................................................................... 29 
D.  General Procedures ............................................................................................ 29 
D.1. Adverse Events .................................................................................................. 29 
D.2. Procedures for Handling Adverse Events and Positive Microbial Post 
Product Administration .............................................................................................. 30 
D.2.1. Reporting of Serious Adverse Events ......................................................... 31 
D.2.2. Collection Period for Adverse Events .......................................................... 32 
D.2.3. Reporting Procedures .................................................................................... 32 
D.2.4. Management of Positive Microbial Post Product Administration ............ 33 
D.3. Expected Adverse Events ................................................................................ 34 
D.4. Potential Risks .................................................................................................... 34 
D.4.1. Potential Risks of Cell Selection .................................................................. 34 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 4 
 
D.4.2. Potential Risks of Cell Therapy Delivery .................................................... 35 
D.4.3. Potential Risks of MRI Study ........................................................................ 35 
D.5. Risk-Benefit Assessment .................................................................................. 36 
D.6. Data Safety Monitoring Board (DSMB) .......................................................... 36 
D.7. Stopping Guidelines .......................................................................................... 37 
D.7.1. Subject Discontinuation ................................................................................. 37 
D.8. Data Quality Assurance .................................................................................... 37 
D.9. Data Collection and Processing ...................................................................... 37 
D.10. Human Subjects .............................................................................................. 38 
D.11. Subject Confidentiality .................................................................................... 38 
E. Ethics ....................................................................................................................... 38 
E.1. Independent Ethics Committee/Institutional Review Board ........................ 38 
E.2. Ethical Conduct of the Study ............................................................................ 39 
E.3. Subject Information, Confidentiality and Consent ......................................... 39 
F. Study Administration Structure ............................................................................ 39 
F.1. Investigator Responsibilities ............................................................................. 39 
F.1.1. Investigator Agreement .................................................................................. 39 
F.1.2. Institutional Review Board (IRB) Approval .................................................. 40 
F.1.3. Informed Consent ........................................................................................... 40 
F.1.4. Records Maintenance .................................................................................... 40 
F.1.4.a. Administrative and Regulatory Files ......................................................... 40 
F.1.4.b. Investigator Information .............................................................................. 41 
F.1.4.c. Documentation of Adverse Events, Protocol Deviation, Failure to 
Obtain Informed Consent, Subject Withdrawal ..................................................... 41 
F.1.4.d. Data Corrections .......................................................................................... 41 
SECTION 2 ......................................................................................................... 42 
Literature Cited in Research Plan ............................................................................ 42 
Appendix A: Modified Ross Score for Heart Failure Classification .................... 45 
 
 
 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 5 
 
List of Abbreviations And Definition of Terms 
AE 
Adverse Event 
AST 
Aspartate Aminotransferase 
ALT 
Alanine Aminotransferase 
ANOVA 
Analysis of Variance 
ANCOVA 
Analysis of Covariance 
BDCPA  
Bidirectional Cavopulmonary Anastomosis 
BNP 
BUN 
Brain Natriuretic Peptide 
Blood Urea Nitrogen 
CBC 
Complete Blood Count 
CFR 
Code of Federal Regulations 
CHF 
Congestive Heart Failure 
CHSS 
Congenital Heart Surgeons’ Society 
CRCMP 
Clinical Research Cell Manufacturing Program 
DMSO 
Dimethyl Sulfoxide 
DSMB 
Data and Safety Monitoring Board 
ECG 
Electrocardiogram 
ECMO 
Extracorporeal membrane oxygenation 
EDV 
End-Diastolic Volume 
EF 
Ejection Fraction 
ESR 
ESV 
Expedited Safety Report 
End-Systolic Volume 
FBS 
Fetal Bovine Serum 
FDA 
Food and Drug Administration 
GCP 
Good Clinical Practice 
G-CSF 
Granulocyte Colony Stimulating Factor 
GVHD 
Graft Versus Host Disease 
HIPAA 
Health Insurance Portability and Accountability Act 
HLHS 
Hypoplastic Left Heart Syndrome 
HSA 
Human Serum Albumin 
HSC 
Hematopoietic Stem Cell 
ICD 
Implantable Cardioverter-Defibrillator 
IND 
Investigational New Drug Application 
IP 
Investigational Product 
IRB 
Institutional Review Board 
LOCF 
Last-Observation Carried-Forward 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 6 
 
LV 
LVAD 
Left Ventricle 
Left Ventricular Assist Device 
LVEDP 
LV End Diastolic Pressure 
LVEF 
Left Ventricular Ejection Fraction 
mBTS 
modified Blalock-Taussig shunt 
MMWR 
Morbidity and Mortality Weekly Report 
MRI 
Magnetic Resonance Imaging 
hMSC 
Human Mesenchymal Stem Cell 
NSF 
Nephrogenic Systemic Fibrosis 
NYHA 
New York Heart Association 
PBS 
Phosphate Buffered Saline 
PC MRI 
Phase Contrast Magnetic Resonance Imaging 
PIM 
Percutaneous Intramyocardial 
RV 
Right Ventricle 
SAE 
Serious Adverse Event 
SOP 
Standard Operating Procedures 
SW 
Stroke Work 
TTE 
Trans-thoracic echocardiogram 
U.S. 
United States 
 
 
 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 7 
 
 
Authorship Team 
 
 
The following individuals provided substantial input during protocol development: 
 
 
 
 
 
Judy Bettencourt, MPH 
 
 
University of Texas-Health  
 
Barry R. Davis, MD, PhD  
 
University of Texas- Health 
 
Michael E. Davis, MD* 
 
 
Emory University- CHOA 
 
Joshua M. Hare, MD** 
 
 
University of Miami 
 
Aisha Khan, MSc, MBA 
 
 
University of Miami  
 
Bangon Longsomboon, MA 
 
University of Miami 
 
William W. Mahle, MD* 
 
 
University of Emory- CHOA 
 
Sunjay Kaushal, MD, PhD* 
 
University of Maryland 
 
Shelly Sayre, MPH  
 
 
University of Texas- Health  
 
Kevin N. Ramdas, MD, MPH 
 
University of Miami 
 
 
 
 
*Principal investigator 
** Sponsor  
 
 
 
 
 
 
 
 
 
 
 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 8 
 
SECTION 1 
1. Introductory Statement 
 
Title: 
 
 
Autologous Cardiac Stem Cell Injection in Patients with  
HypoplastIc Left Heart SynDrome: An Open Label Pilot Study.  
(CHILD Study) 
 
Sponsor: 
Joshua M. Hare, M.D.  
 
Interdisciplinary Stem Cell Institute 
University of Miami Miller School of Medicine,  
Division of Cardiology, Miami, Florida 
 
Cell Manufacturing Center:  
 
 
 
 
Interdisciplinary Stem Cell Institute 
 
 
 
Clinical Research Cell Manufacturing (CRCMP) Program 
University of Miami Miller School of Medicine 
 
 
 
1501 NW 10th Avenue, 9th Floor 
 
 
 
Miami, Florida 33136 
 
Test Agent:  
Autologous c-kit-positive cells (c-kit+ cells) 
 
 
Population: 
Male or female neonates diagnosed with hypoplastic left heart 
syndrome (HLHS) undergoing Stage I Norwood operation. 
 
Sample Size: 
A total of 32 subjects will be enrolled for this pilot study in a 
staged enrollment.  
 
Treatment: All subjects with the diagnosis of hypoplastic left heart syndrome 
(HLHS) undergo a palliative reconstructive surgery performed in the first two 
weeks of life, termed the Norwood procedure. The Norwood procedure involves 
reconstruction of the aortic arch, resection of the atrial septum, and establishment 
of pulmonary blood flow through either a modified Blalock-Taussig shunt (mBTS) 
(a Gore-Tex tube from the innominate artery to the right pulmonary artery) or a 
Sano shunt (a Gore-Tex tube from the right ventricle to the right pulmonary artery). 
To initiate cardiopulmonary bypass for this surgery, the right atrial appendage is 
cannulated. Typically, the appendage is excised and discarded during this step. 
However, in our study, this excised right atrial appendage will be harvested and c-
kit+ cells will be isolated. The process and manufacturing of the c-kit+ cells will be 
exactly as specified in the TAC-HFT II Study (IND# 14647, NCT00768066). TAC-
HFT II  was a Phase I/II, Randomized, Placebo-Controlled Study of the Safety and 
Efficacy of Transendocardial Injection of Autologous Human Cells (Mesenchymal 
or the combination of MSC and ckit+ in Patients with Chronic Ischemic Left 
Ventricular Dysfunction and Heart Failure Secondary to Myocardial Infarction trial 
of University of Miami under IND #14647. The patients will then proceed with the 
typical postoperative care. The second stage in the palliation of HLHS is a 
scheduled bidirectional cavopulmonary anastomosis, BDCPA) operation that 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 9 
 
occurs between 4 to 6 months of age. The BDCPA operation is an anastomosis 
between the superior vena cava and the right pulmonary artery and removes the 
pulmonary shunt (the previously placed mBT or Sano shunt). The BDCPA 
operation can utilize the GLENN or Hemi-Fontan procedure. During this surgery 
when the patient is on cardiopulmonary bypass, we will deliver the entire dose of 
cells of 600 microliters previously harvested, isolated, and expanded autologous 
c-kit+ cells in 6-10 intramyocardial injections. The intramyocardial injection of cells 
will take approximately 5-10 minutes, which is insignificant to the total bypass time. 
The remaining part of the BDCPA operation will proceed as anticipated. In this 
way, we will replicate the same administration route and cell dosing of these cells 
as the ELPIS trial, which is cross-referenced (IND# 16045, NCT02398604).  ELPIS 
was a phase I, randomized, open label study of Allogeneic Human MEsenchymal 
Stem Cell (MSC) Injection in Patients with Hypoplastic Left Heart Syndrome: A 
Phase I/II Study (ELPIS). 
 
 
In summary, we aim to overlay a novel cell therapeutic strategy on the two-stage 
surgical procedures that HLHS patients typically undergo in the first year of life: 
Stage I Norwood operation in the neonatal period and Stage II BDPCA operation 
at approximately 4-6 months of age.  We will harvest endogenous c-kit+ cells from 
right atrial appendage (RAA) tissue typically discarded during the patient’s Stage I 
Norwood operation and then grow them under the exact conditions specified by 
the cross-referenced IND #14647. During the Stage II operation, the c-kit cells will 
be injected intramyocardially into the heart muscle. The c-kit+ cells have already 
been tested for their feasibility, safety, efficacy in adult humans with ischemic 
disease (cross-referenced IND #14647).   
 
Duration: All subjects will be followed for 12 months post-treatment. 
 
Objective: The objectives of this pilot study are to: 
a. evaluate the feasibility and safety of intramyocardial injection of 
autologous c-kit+ cells during the Stage II BDCPA operation 
b. observe effects on clinical outcome including right ventricular 
myocardial function, severity of tricuspid regurgitation, incidence of 
serious adverse events, re-hospitalizations, changes in health 
status, the need for transplantation, or mortality. 
 
Endpoints: 
 
Primary: Consistent with the nature of this study, multiple assessments will be 
performed to evaluate the safety, feasibility, and efficacy of intramyocardial 
delivery of c-kit+ cells in subjects with HLHS: 
 
1. Safety will be assessed by monitoring the following major adverse 
cardiac events during the first 30 days post Stage II BDCPA operation: 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 10 
 
• Greater than 30 seconds of sustained/symptomatic ventricular 
tachycardia requiring intervention with inotropic support or anti-
arrhythmics 
• Cardiogenic shock (i.e. tissue hypoperfusion presented by 
hypotension due to decreased cardiac output, determined by 
rising lactate levels (5x normal levels in first 24 hours, 2.5x 
normal levels in first 30 days) 
• Unplanned cardiovascular operation due to right ventricular 
intramyocardial injection site bleeding in the first 5 days after 
Stage II BDCPA operation 
• Need for new permanent pacemaker 
• Stroke or embolic event to the brain determined by CT scan 
• Death  
 
2. Feasibility will be assessed by monitoring how many c-kit+ products can 
be manufactured and delivered to subjects and how many subjects can 
get baseline, 6-month and 12-month MRIs. 
 
3. Efficacy will be assessed at 12 months post-Stage II BDPCA operation  
by change from baseline in right ventricular ejection fraction, right 
ventricular end-diastolic volume, right ventricular end-systolic volume, 
and tricuspid regurgitation measured by serial echocardiograms and 
MRI scans (baseline, 6 months and 12 months). 
 
Secondary: 
 
1. Incidence of mortality or need for transplantation after the Stage II 
BDCPA operation up to 12-month follow-up. 
 
2. Incidence of the following after the Stage II BDCPA operation up to 12-
month follow-up: 
 
i. All-cause mortality  
 
ii. Cardiovascular mortality 
 
iii. Need for transplantation  
 
iv. Hospitalization for heart failure 
 
v. Cardiovascular morbidity, including myocardial infarction, stroke, 
heart failure, or sustained/symptomatic arrythmias  
 
3. Changes 
in 
somatic 
growth 
velocity 
(weight, 
length, 
head 
circumference) over 12 month follow-up. 
 
4. Change in quality of life measured by the Infant Toddler Quality of Life 
Survey (ITQOL) at baseline, 6 and 12 months after Stage II BDCPA 
operation. 
 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 11 
 
2. General Investigational Plan 
A. Background 
 
Surgical and Clinical Outcomes for HLHS 
The epidemic of congestive heart failure (CHF) is a growing, worldwide concern 
and is expected to become worse.  In adults, there are approximately 15 million 
people worldwide and 5 million patients in the United States who have CHF, with 
400,000 new cases per year in the U.S. alone. In children, there is an equal trend 
of CHF with an increase in prevalence in the last decade. There were almost 3000 
more CHF-related hospitalizations in children in 2006 than in 2000 with an increase 
in total hospital charges of over 1 billion dollars (1). This cost in children with CHF 
is less than but on the same scale as the monies spent for all cancer-related 
diagnoses ($2.24 billion) and myocardial infarction ($3.18 billion) combined.  
These numbers in children will only increase during the next decade as patients 
with congenital heart disease are now living longer than the number of congenital 
heart patients being born with congenital heart disease.  
 
We have focused our efforts in a selected, homogenous population of children 
diagnosed with hypoplastic left heart syndrome. Prior to the development of 
palliative approaches for HLHS the lesion was universally lethal in infancy. With 
development over the last few decades of staged surgical treatments, outcomes 
of surgical palliation for HLHS have steadily improved. According to reports in the 
MMWR approximately 949 infants are estimated to be born each year with HLHS, 
and 318 die during the neonatal period for a death rate of approximately 33% (2). 
The cost of managing these patients is very high with typical hospitalizations for 
the neonatal first-stage surgery of $199,597 (2003 dollars). Despite surgical 
improvements the overall 5-year survival rate remains limited with reported 
survivals over 50%-60%, with cardiac transplantation remaining as the only 
alternative for patients with failing circulations (3;4).   
 
As an increasing number of these patients survive the neonatal period there is a 
growing population of patients who present later in life with failure of the single 
ventricle. Maintenance of ventricular function for these patients is therefore very 
important for long term survival. All patients who require cardiac transplantation 
have a waiting list mortality of over 20%. In addition, even after cardiac 
transplantation, HLHS patients have a decreased survival rate when compared to 
other transplanted patients for other causes (5;6). Although the expenditure for 
heart transplantation exceeds that for other operations that are required for these 
HLHS patients, patients who fail these other operations for HLHS (see the 
following) due to ventricular dysfunction prove to be ultimately even more costly 
and have increased postoperative morbidity than heart transplantation by itself (7). 
Estimated charges for heart transplant in 2008 are $787,700 according to the 
Millman Reports. While this applies to all heart transplantations, the patients who 
undergo transplantation for HLHS are at an even higher risk, and constitute a 
costlier group. For the last three patients who underwent cardiac transplantation 
after surgical operations for HLHS at our institution the average hospital costs was 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 12 
 
over $1,000,000. Interventions that improve ventricular function and avoid or defer 
transplantation in patients with HLHS are therefore urgently needed. 
 
Patients with advanced heart failure represent about 10% of the total heart 
population, have a high short-term mortality, and consume tremendous resources. 
The cost of one year of care for a patient with advanced CHF is approximately 
$20,000; admission for cardiac transplantation including postoperative care 
averages $1,000,000 for HLHS patients; implantation of a left ventricular assist 
device (LVAD) averages $175,000. Expensive as these solutions are, they are in 
fact not available in sufficient supply. Cardiac transplantation is highly constrained 
by the donor shortage so that only approximately 1000 heart transplants per year 
are performed for the approximately 30,000 to 60,000 children and adults with end-
stage CHF who might potentially benefit from this scarce resource.   
 
Before consideration for transplant, patients with CHF are optimized with medical 
treatment. CHF in infants with HLHS is not related to typical coronary ischemia and 
thus revascularization is not applicable. Treatment such as extracorporeal 
membrane oxygenation (ECMO) or left ventricular assist device (LVAD) therapy 
are limited by the size of the patient and the duration of support on these devices. 
Furthermore, support of HLHS patients with these devices is technically 
challenging because they have only one ventricle.  
 
Our hypothesis is that endogenous ckit+ cells can improve long-term performance 
in the right ventricle builds on surgical advances of the past thirty years, and is 
intended to address remaining obstacles to long-term cardiac function in HLHS 
patients. Since the early 1980s, a series of surgical interventions has been used 
to create a viable circulation in these infants, allowing the right ventricle to serve 
as the sole pump for systemic circulation. Currently, the strategy consists of three 
palliative operations: Stage I is the Norwood operation, Stage II is the BDCPA  
operation, and Stage III is the Fontan operation (4). The overall objective is to rely 
on the right ventricle to eject blood into the systemic circulation and for the systemic 
venous return to passively flow through the pulmonary circulation in the absence 
of a ventricular pumping chamber. 
 
The goals of the Stage I Norwood operation are to reconstruct the aortic arch, 
create an atrial septal defect, and establish reliable pulmonary blood flow. With 
these modifications to the anatomy, the single right ventricle becomes responsible 
for pumping blood to both the body and lungs. Typically, pulmonary blood flow is 
achieved by either a modified Blalock-Taussig shunt (mBTS) which uses a 
polytetrafluoroethylene conduit to connect the subclavian artery to the pulmonary 
artery, or a Sano shunt which connects the right ventricle to the pulmonary artery 
using a similar polytetrafluoroethylene conduit. A prospective randomized study 
has been performed to compare the outcomes of the two shunt types (8). This 
study reported that the Sano shunt had better survival in the first year, but 
intermediate-term outcomes were not different for the two shunt types. 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 13 
 
Cardiovascular surgeons continue to use both shunt variations pending long-term 
findings on whether one method is superior to the other. 
 
Sometimes in high-risk HLHS patients who may have severe tricuspid regurgitation 
or severe right ventricle dysfunction, the Stage I Norwood operation is not 
recommended. Instead, the Stage I Hybrid operation is preferred which uses a 
median sternotomy approach for pulmonary artery banding, patent ductus 
arteriosus stenting, and an atrial septostomy. With these Hybrid patients, the Stage 
II operation occurs at 4-6 months of age and involves the BDCPA operation and 
the Norwood operation.  
 
The Stage II operation, the BDCPA operation, is typically performed when the 
HLHS patient is 4 to 6 months of age. The procedure connects the superior vena 
cava to the right pulmonary artery to bypass the right ventricle and allow systemic 
blood to flow directly to the pulmonary circulation. The second part of the BDCPA 
operation includes ligation of the pulmonary shunt placed during the Norwood 
procedure. Finally, the Stage III Fontan operation, performed when the child is 
between 18 months to 3 years of age, directs inferior vena caval flow into the 
pulmonary artery, thus bypassing the heart. 
 
The largest and most comprehensive outcome analysis of patients undergoing a 
Stage I Norwood operation was reported by the Congenital Heart Surgeons’ 
Society in 2003 (9). Between 1994 and 2000 twenty-nine institutional members of 
CHSS enrolled 985 neonates who had either critical aortic stenosis or atresia. A 
total of 710 of the 985 patients underwent a Stage I Norwood operation. The 
survival was 76% at 1 month, 60% at 1 year, and 54% at 5 years. Numerous 
studies have determined the physiologic risk factors for poor perioperative 
outcome after Stage I, with conflicting results (10-14). Surprisingly in these studies, 
right ventricular (RV) function was not reported as a predictor of survival. This is 
an unexpected finding since in other congenital heart surgeries for other 
malformations poor ventricular function has been associated with adverse 
outcome after operative procedures (15). Two possible explanations may exist to 
explain these results: 1) previous analyses of RV function in the setting of HLHS 
have been limited to qualitative assessment of the right ventricle, and 2) other 
perioperative factors in the initial unstable hemodynamic state may overshadow 
the impact of RV function in the early post-stage I Norwood period. 
 
A more accurate quantitative evaluation of the right ventricle has now been 
reported using the biplane pyramidal approximation method by echocardiography 
(ECHO) and phase contrast magnetic resonance imaging (PC MRI) (16-18). These 
newer imaging methods have demonstrated that the systemic right ventricle, 
working against the high-pressure systemic circulation, becomes dysfunctional, 
which may correlate with decreased survival. In fact, Altman and colleagues 
reported that a new qualitative assessment of the right ventricle using biplane 
pyramidal approximation method by ECHO was an operative predicator of survival 
after Norwood stage I (16;17). Their study revealed that patients with decreased 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 14 
 
right ventricular function had a 35% survival rate when compared with 70% survival 
rate in patients with normal RV function during short-term follow-up. This study 
emphasizes the importance of RV function as it correlates with survival rates. 
Other studies using PC MRI have reported similar findings of decreased function 
of the right ventricle in HLHS. These studies suggest a critical need to improve RV 
function in HLHS patients. In fact, many HLHS survivors are now living longer and 
if they have right ventricular function, they may eventually require heart 
transplantation, the only remaining treatment option (19).Other HLHS patients die 
suddenly due to complications that rely on a systemic right ventricle (19). We 
propose that a cell-based therapy for HLHS patients may prevent RV dysfunction 
and therefore improve outcomes, reducing both mortality and the need for 
transplantation. 
 
c-kit+ cells 
 
Preclinical Work 
 
To verify the findings derived from a previously reported rat model on c-kit+ cells, 
experiments were conducted on pigs in a large model (21).  In this study, 
myocardial ischemia was induced in Yorkshire pigs (n=21) by a 90 min coronary 
occlusion of the left anterior descending artery followed by reperfusion.  At the 
same time of occlusion, the right atrial appendage was harvested for isolation and 
expansion of c-kit+ cells.  After four months, autologous ckit+ cells (n=11) or vehicle 
(n=10) were injected into the chronic infarct zone using a balloon catheter. At the 
time of treatment, left ventricle ejection fraction and LVEDP and LV dP/dt (Millar 
catheter) were similar in the two groups that implied the infarction zone was similar 
among the two groups. After one month, the ckit+ treated pigs demonstrated an 
increase in LV ejection fraction (51.7 +2.0% vs. 42.9 +2.3%. P<0.01) and an 
improvement in systolic thickening fraction in the infarcted LV wall relative to 
control pigs (31.7 +2.4% vs. 21.1+2.4% in controls, P<0.01).  At the microscopic 
level, confocal microscopy showed clusters of small alpha-sacromeric actin 
positive cells expressing Ki67 were present in the scar of treated pigs, consistent 
with cardiac regeneration.  This study showed that in a large animal model the 
ckit+ cells promoted cardiac regeneration in a chronic model of ischemia. 
Furthermore, these findings lay the groundwork for clinical trials of ckit+ cells in 
human patients requiring cardiac regeneration.  
 
 
Most of the small animal or large animal studies have used direct intracoronary 
injection of the ckit+ cells.  However, recently, a large animal study using cardiac 
stem cells demonstrated the feasibility, safety, and benefit of direct intramyocardial 
injection of cardiac stem cells into ischemic hearts (22). In these experiments, the 
cardiac stem cells used were a different type but very closely related to the c-kit+ 
cells, called cardiosphere derived cells. These cardiosphere derived cells are 
similarly derived from the heart tissue and have similar regenerative abilities as the 
c-kit+ cells. In fact, a phase I-II clinical study with these cardiosphere derived cells 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 15 
 
is underway called the CADUCEUS (CArdiosphere-Derived aUtologous stem 
CElls to reverse ventricUlar dysfunction) study.  In this intramyocardial injection 
study, myocardial infarction was induced in female Yuctan mini-pigs by inflation of 
an angioplasty balloon in the mid-left anterior descending artery for two hours. 
After 4 weeks after infarction, c-kit+ cells derived from endomyocardial biopsies 
were injected at a cell dose of (0.5 million cells/ site) into 20 peri-infarcted sites of 
the ischemic myocardium through a thoracotomy incision. The results showed that 
the ejection fraction was equivalent at baseline, but at 8 weeks was higher than 
the placebo in the stem cell treated group (placebo vs CDC, p=0.01). More 
importantly, the direct myocardial injection was extremely safe with only one 
reported (out of 660 injections) catheter related ventricular tachycardia, which was 
treated with electrical conversion. In the postoperative period, no morbidity or 
mortality was associated with the injection. This large animal study provides the 
necessary pre-clinical data to demonstrate the feasibility, dosage, and safety of 
injecting c-kit+ cells directly into the myocardium using a 25-27gauge needle.   
  
Clinical Work 
 
All of the previous (and ongoing) stem cell studies have been performed with adult 
ckit+ cells with ischemic coronary artery disease. Cardiomyopathy in children, 
however, are usually non-ischemic and therefore do not usually involve coronary 
artery disease. We have recently reported the largest and most systematic series, 
which characterized and tested the functionality of cardiac stem cells in congenital 
heart patients (23).  In this study, 140 myocardial samples were collected from 
congenital heart patients, which included 10 HLHS patients. The major findings of 
our study are that resident ckit+ cells are present in the maturing postnatal human 
heart and are most abundant during the neonatal period with a steady decline with 
advancing age (neonates=9% versus children=3%). Regardless of age-dependent 
variations in resident ckit+ cells numbers or congenital cardiac diagnoses, we 
demonstrated the validity of our method to reproducibly isolate and expand 
cardiosphere derived cells from right atrial tissues. Finally, we showed that 
intramyocardial delivery of these cells into a nude rat triggered myocardial 
regeneration by differentiating into mature cardiomyocytes, smooth muscle cells, 
and endothelial cells. This histological evidence correlated with functional 
improvement by ECHO in the treated group with these cells by 15 percent in 
comparison with controls that received fibroblasts or media when measuring 
ventricular ejection function. More importantly, the neonatal derived cardiac stem 
cells from HLHS patients had the highest ability to regenerate the ischemic 
myocardium when compared to infant or adult derived cardiac stem cells. These 
data provide the important preclinical evidence of the existence and strong 
regenerative abilities of ckit+ cells within the hearts of HLHS patients. This study 
shows the feasibility of harvesting and expanding from HLHS patient’s right atrial 
appendage tissue and the regenerative efficacy of these cells.    
 
 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 16 
 
B. Clinical Protocol 
B.1. Study Design 
B.1.1. Basic Design Characteristics 
 
We plan to enroll thirty-two patients with HLHS in a two staged enrollment process. 
In this study, a maximum of 21 patients will receive intramyocardial injection of c-
kit+ cells and 11 standard of care control patients with no injection. The enrollment 
of the patients will occur in two staged groups: Group A and Group B. Initially in 
Group A, 10 consecutive HLHS patients will be enrolled in the c-kit+ cell treatment 
arm to determine feasibility and safety. Six months after the last patient is enrolled 
in Group A, the DSMB will conduct a review of all Group A patients in order to 
determine whether the methodology is feasible and safe, including the harvesting, 
processing, and administering of the c-kit+ cells. Thereafter, Group B will enroll a 
total of 22 HLHS patients which will be randomized, double-blinded to the 
treatment and standard of care control arms in a 1:1 ratio, respectively, in order to 
have 11 c-kit+ cell-treated patients and 11 control patients. Randomization will 
occur post-Norwood operation upon receipt of viable tissue sample at University 
of Miami Clinical Research Cell Manufacturing Program (CRCMP).  The rationale 
underlying this two-staged enrollment is to initially test the feasibility and safety of 
this methodology of obtaining the c-kit + cells from the right atrial appendage with 
the Group A patients. The second Group B patients may provide the required 
numbers to potentially validate the efficacy of the trial. Eventually, a Phase II trial 
will provide the necessary numbers to provide an accurate assessment of efficacy 
of the c-kit+ cells in HLHS patients.  
 
 
 
 
 
 
 
 
 
 
 
B.1.2. Sample Size 
 
Twenty-one (21) subjects will be enrolled in the treatment group and eleven (11) 
in the standard of care control group. The 10 Group A subjects are part of an open-
label safety and feasibility analysis. The 22 Group B subjects will be randomized 
1:1 to cell treatment and control to detect a difference of 6 RVEF units, given a 
standard deviation of 4, 89% power and type 1 error of 0.05. Twenty patients are 
needed with 10% added for possible lost to follow-up. 
12-month 
Randomized 
Endpoint 
Collection 
Group A: 
Open-label 
10 treated 
HLHS Patients 
(n = 32) 
6-month 
Open-label 
Feasibility 
Analysis 
12-month 
Open-label 
Follow-up 
Group B: 
Double-blind, 
Randomized 
11 treated 
11 control 
6-month 
Randomized 
Endpoint 
Collection 
End of Study 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 17 
 
B.1.3. Dosage and Administration 
 
The treated HLHS patients will receive up to 12,500 cells/kg. The terminology “up 
to” a certain dose indicates that if the number of the c-kit+ cells is not sufficiently 
attainable from the cardiac specimen to the specified dose then the achievable 
dose will be delivered. A secondary analysis of subjects who achieve ≥80% of the 
assigned dose will be performed as part of the overall analysis plan.  The decision 
to weight-adjust the dose of cells was made based on preclinical studies. The cells 
will be delivered through 6-10 intramyocardial injections of approximately 100uL 
per injection for total volume of 0.6 mL 
B.1.4. Premature Withdrawal 
 
For subjects withdrawn after receiving study product injection, all efforts will be 
made to encourage return for all assessments through the end of the study 
period, so that safety can continue to be monitored.  
 
Because the data from the proposed trial may be used to design future phases of 
clinical trials, we put a high priority on collecting data that is complete and 
accurately describes the safety and efficacy of the intervention as 
described.  Therefore, the goal is to have final MRI  and other efficacy endpoint 
measurements on at least 20 Group B subjects during the randomized portion of 
trial. As such, Group B study treatment subjects who do not undergo the stem 
cell injection or do not get the Stage II BDCPA operation can diminish the goal 
sample size of 20. A maximum of six additional subjects can be randomized to 
replace this potential loss to achieve the target sample size of 20 evaluable 
subjects.  
B.2. Criteria for Subject Enrollment 
B.2.1. Inclusion Criteria 
 
For inclusion in the study, subjects must meet all of the inclusion criteria: 
 
1. Subjects with hypoplastic left heart syndrome (all types) requiring Stage I 
Norwood operation. 
B.2.2. Exclusion Criteria 
 
Candidates will be excluded from the study if any of the following conditions are 
met: 
 
1. Subjects undergoing the Stage I Norwood operation who do not have 
HLHS.  
2. Subjects requiring mechanical circulatory support  immediately prior to 
Stage II BDCPA operation (within 5 days). 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 18 
 
3. Parent or guardian unwilling or unable to comply with necessary follow-
up(s). 
4. Mother is serum positive for HIV 1/2, hepatitis BsAg or viremic hepatitis 
C and Treponema pallidum. 
5. Subjects who are unsuitable for inclusion in the study in the opinion of 
the investigator(s). 
B.3 Sequence of Measurements and Evaluation 
B.3.1. Subject Introduction and Informed Consent 
 
Prior to the Stage I Norwood operation, the subject’s guardians will be given a 
complete explanation of the purpose of the study and evaluations to be performed 
which are in addition to those of standard of care. The Institutional Review Board 
(IRB) approved informed consent document will be reviewed with the guardians 
and any questions answered at that time.   
 
The consent document (and the discussion with the guardians) will clearly outline 
the following:  
1) the subject’s guardians do not have to consent to this research for their 
child to receive the planned surgeries,  
2) if the guardians want the subject to participate, there is a need for tissue 
sample collection to take place at the time of the Stage I Norwood operation 
(to enable study product to be manufactured) and consent is needed for 
this, if the subject is randomized to the standard of care group (i.e. no cells 
to be delivered) then the tissue will be discarded at the manufacturing 
facility. 
3) there is a potential that the subject could be deemed ineligible for study 
participation prior to the Stage II BDCPA operation; for example, due to 
changes in health status, and  
4) what a change in participation status would mean for any acquired tissue 
if the subject is discontinued from the protocol prior to the Stage II BDCPA 
operation.   
 
Should the guardians consent to the study, a copy of the signed consent form will 
be provided to them at that time.    
 
Prior to the Stage II BDCPA operation, the subject’s guardians will be contacted to 
schedule appointments for research-related testing needed for determining 
continued eligibility.  Before any testing is initiated, the consent form will be re-
reviewed with the guardians to affirm their continued willingness to allow their child 
to participate.  This re-review will be documented in the subject’s chart.  If the 
guardians are no longer interested in participation, the subject will be withdrawn 
from the study, and this will be noted in the subject’s chart.   
 
 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 19 
 
B.3.2. Screening Phase Assessments 
 
The Screening Phase starts at enrollment and completes at the initiation of the 
harvest during the Stage I Norwood operation. The screening phase may last 
between 2 – 3 weeks, and will not alter the patient’s pre-surgical duration. 
 
 
The following evaluations will be performed 21 days or less before Stage I 
Norwood operation (including right atrial tissue collection). These evaluations will 
include the following, which are routinely obtained for Stage I Norwood HLHS 
patients: 
a. Demographic data, including date of birth, gestational age, length, 
weight, gender, and race.  
b. Physical exam with vitals (length, weight, head circumference, oxygen 
saturation, heart rate, respiratory rate and blood pressure). 
c. Laboratory Assessments: 
1. Clinical chemistry: BUN, creatinine, sodium, potassium, chloride, 
glucose, calcium, bilirubin (total), total protein, albumin alanine 
aminotransferase (ALT), aspartate aminotransferase (AST), B-type 
Natriuretic Peptide (BNP). 
2. Hematology: complete blood count (CBC) with differential and platelet 
count 
d. Assessment of mother’s infectious disease status for HIV 1/2, hepatitis 
BsAg or viremic hepatitis C and syphilis (Treponema pallidum). 
e. 12-lead electrocardiogram (ECG) 
f. Concomitant medication history  
 
The investigator may use clinical judgment when determining the clinical 
significance of laboratory parameter findings throughout the study. 
 
During the screening phase, and prior to the tissue collection phase, the 
condition of the subject will be verified and key safety parameters will be 
assessed by the PI and study team to confirm feasibility of operation, including:  
• Physical Examination 
• Standard of Care pre-procedural labs 
• ECHO results to determine valve status 
• Tricuspid insufficiency 
• Restrictive septum 
• Poor RV function.  
B.3.3. Tissue Collection Phase 
B.3.3.a. Tissue Collection Procedures 
 
The cell processing and manufacturing will be performed exactly as specified 
in the TAC-HFT II (A Phase I/II, Randomized, Placebo-Controlled Study of the 
Safety and Efficacy of Transendocardial Injection of Autologous Human Cells 
(Mesenchymal or the combination of MSC and Cardiac Stem Cells) in Patients 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 20 
 
With Chronic Ischemic Left Ventricular Dysfunction and Heart Failure 
Secondary to Myocardial Infarction) trial of University of Miami (IND #14647). 
As specified, the tissues will be sent and processed at the University of Miami 
Clinical Research Cell Manufacturing Program (CRCMP), Interdisciplinary 
Stem Cell Institute. 
 
Prior to tissue collection the investigators must confirm that Mother is serum 
negative for HIV 1/2, hepatitis BsAg and negative for viremia of hepatitis C and 
Treponema pallidum and transmit that information to the CRCMP. 
 
All HLHS patients will undergo the Stage 1 Norwood operation, which is the 
standard operation for all HLHS patients. If the HLHS patients are considered high 
risk for the Norwood operation, which includes moderate or more tricuspid 
regurgitation, moderate or more right ventricular function, or a significant 
neurological complication, then we would not proceed with the Norwood operation 
but would proceed with the Hybrid operation. The Hybrid operation consists of 
pulmonary artery banding, ductus arteriosus stenting, and atrial septostomy, which 
is approached through a median sternotomy. 
 
During the Norwood operation, the HLHS patient will be placed on 
cardiopulmonary bypass in the usual standard fashion, which involves cannulating 
the right atrium. The right atrial tissue is then discarded. However, in our study this 
excised tissue will be harvested. If the Hybrid operation is performed, the right atrial 
appendage will be harvested during the open heart procedure. The ELPIS protocol 
IND # 16045 will be cross-referenced to this protocol and will follow what is 
described below: 
 
• Right atrial tissue (averaging 1 g or less in weight) will be harvested 
under sterile conditions in the operating room at  the participating clinical 
centers from patients undergoing HLHS surgery procedures. 
• Each time a right atrial sample is taken, the patient’s study 
ID/ACROSTIC will be used for identification at the University of Miami 
CRCMP, Interdisciplinary Stem Cell Institute and participating clinical 
centersto refer to a given sample. These data will be kept and recorded 
in the electronic data capture system. The culture medium and all 
medium used during RAA and ckit+ cells ex-vivo processing is devoid of 
any antimicrobials or antifungals. 
• Within the sterile field, the right arterial tissue samples will be placed into 
sterile cryovials containing Ham’s F-12 medium supplemented with 10% 
Fetal Bovine Serum (FBS), 100 ng/ml recombinant human basic 
fibroblastic factor, L-glutathione, and 5 mU/ml human erythropoietin, 
which has been tested for sterility using aerobic, anaerobic, and fungal 
cultures. This media will be provided by CRCMP.  
• Shipping Procedures - Tissue will be enclosed in a rigid shipping 
container with temperature insulating properties. Cold temperature 
packs will be used to maintain the shipping temperature between 2°C to 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 21 
 
10°C. The rigid shipping container will include a document on the inside 
of the container and a label on the outside of the container according to 
Health Resources and Services Administration (HRSA) guidelines for 
organ transport policies and procedures. Shipping container will be 
accompanied by appropriate documentation including the “Chain of 
Custody form” with subject and sample unique identifiers, and a 
temperature logger. The vials containing the tissue will be shipped 
overnight using FEDEX to CRCMP (see cell processing manual for more 
detail). 
B.3.3.b. Post Norwood Monitoring Phase (Standard of Care) 
 
Following the completion of the Stage I Norwood operation and up to the Stage II 
BDCPA operation, all patients will be followed by both parent(s) and faculty per 
institutional standard of care. There will be no research-related procedures or 
data collected during this phase until the baseline visit and eligibility assessment.  
B.3.3.c. Baseline Assessment 
 
Prior to admission for the Stage II BDCPA operation, all subjects will undergo 
baseline testing and study eligibility determination as described below: 
a. Complete medical history including any co-morbidities such as central 
nervous system, renal, gastrointestinal and genetic abnormalities,  
b. Physical exam and vital signs (length, weight, head circumference, 
oxygen saturation heart rate, respiratory rate, blood pressure, and 
Modified Ross Score for heart failure classification (see Appendix A)) 
c. 12 lead Electrocardiogram (ECG) 
d. Complete Trans-thoracic echocardiogram (TTE) 
e.  Cardiac Magnetic Resonance Imaging (cMRI) 
f. A complete right and left cardiac catheterization, which is routinely 
performed before the Stage II BDCPA operation, if clinically indicated.  
g. Laboratory Assessments: 
1. Clinical chemistry: BUN, creatinine, sodium, potassium, chloride, 
glucose, calcium, bilirubin (total), total protein, albumin alanine 
aminotransferase (ALT), aspartate aminotransferase (AST), B-type 
Natriuretic Peptide (BNP). 
2. Hematology: complete blood count (CBC) with differential and platelet 
count 
h. Infant and Toddler Quality of Life (ITQOL) survey 
i. Collection of Blood for Biomarker analysis of circulating pro-inflammatory 
markers (see MOP for blood collection and shipping instructions to 
CRCMP) 
 
The research-only assessments listed above are the cMRI, ITQOL survey, and 
biomarker blood sample tests thus AE monitoring will begin when the first of these 
is performed. 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 22 
 
B.3.3.d. Study Product Injection 
 
The Stage II BDCPA operation occurs between 4 to 6 months of age. For Group 
B subjects randomized to study treatment, during this surgery when the patient is 
on cardiopulmonary bypass, the previously harvested c-kit+ cells will be injected 
into the right ventricle directly intramyocardially using a 25-27gauge needle syringe 
at the completion of the repair but before separating from cardiopulmonary bypass. 
The entire dose of the cells, up to 12,500/kg patient weight in 600 microliters, will 
be divided and delivered in 6-10 intramyocardial injections. The intramyocardial 
injection of cells will take approximately 5-10 minutes, which is insignificant to the 
total bypass time. The remaining part of the operation will proceed as anticipated. 
 
B.3.3.e. Investigational Final Product Preparation 
 
The harvested c-kit+ cells will undergo quality control testing and review by  
CRCMP laboratory director and quality assurance manager prior to release for 
clinical use.  When the Stage II BDCPA operation is scheduled for subjects 
randomized to receive study product, upon request from the clinical site, product 
is shipped cryopreserved from CRCMP to the local cell processing laboratory in a 
validated vapor phase cryoshipper maintained at temperatures < -120 oC with a 
temperature monitoring device.  Upon arrival, product is inspected to ensure that 
product is in good condition and the temperature data will be verified before 
transferring to the secured vapor phase storage freezer at the site.  In the event 
that the temperature deviates from the specified shipping temperature, the product 
will not be used.  Local cell processing laboratory notify CRCMP.  The incident will 
be investigated with corrective and preventive actions implemented following the 
CRCMP standard operating procedures.  CRCMP will prepare a new shipment of 
the product. 
 
Days prior to the product injection, the principal investigator will send a request for 
product with date, time and location of the operation to local cell processing 
laboratory.  On the day of the operation, local cell processing laboratory will 
prepare the product and perform quality control testing. The endotoxin assay is 
done according to the standard operating procedures (SOPs) provided by 
CRCMP.  The gram stain and sterility tests are performed following the local cell 
processing laboratory protocols.   
 
The product thawing process is performed asepticaly under sterile condition of the 
biolocical safety cabinet (BSC).  Product is thawed in a waterbath at 37 oC.   After 
the product is thawed, in the BSC, the product is transferred from a vial to a sterile 
conical containing 5-10 mL.  The product vial is rinsed with thaw media containing 
Plasma-Lyte A supplemented with 1% of 25% Human Serum Albumin (HSA) and 
transferred to the same sterile conical and the media volume brought up to 45mL. 
The conical containing the product is centrifuged at 500g for 5 minutes at 4 oC, 
break set at low. This is the first wash.  Supernatant is removed and leaves 
approximately 2mL to resuspend the pellet.  A 60 microliter x 2 for cell count using 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 23 
 
crystal violet and viability using trypan blue. The media volume is brought up to 
45mL and the tube is centrifuged at 500g for 5 minutes at 4 oC, break set at low.  
This is the second wash.   Sterility and endotoxin samples are collected from 
supernatant and small drops of supernatant are used to prepare glass slides for 
gram stain.  Sample tubes and slides are labelled with product unique ID, patient 
acrostic and ID, type of test to be performed and date.  Cell dose adjustment is 
calculated and prepared to obtain 12,500/kg in 0.6mL total volume concentration.  
Sterile field is set up in the BSC to prepare final product.  Cell dose is loaded in a 
sterile cryovial and place in a sterile plastic bag, seal and place in another sterile 
plastic  bag before removing from the BSC.   Product is transport in a validated 
vessel that maintains the temperature at 1-15 oC.  A temperature monitoring device 
is used to monitor transport temperature. 
 
B.3.3.f. Post-treatment (Stage II BDCPA operation) Assessments 
 
All subjects will be cared for according to institutional standard postoperative 
protocols, which included standard of care post-surgery assessments. Research-
related study visits will occur at Day 5 (± 3 days), Week 4 (30 days ± 7 days), 
Month 6 (180 days ± 30 days) and Month 12 (365 days ± 30 days) (see Table 1). 
Data from standard of care visits can be used for study visits if collected within visit 
window. If a patient remains hospitalized at the planned visit date, the assessment 
will be performed as an inpatient. 
 
The following assessments will be collected post-Stage II BDCPA operation (Day 
0) visits as part of standard of care: 
 
a. Physical exam and vital signs (length, weight, head circumference, 
oxygen saturation, heart rate, respiratory rate, blood pressure, and 
Modified Ross Score for heart failure classification (see Appendix A)) 
b. 12 lead electrocardiogram 
c. Complete TTE (Day 5, Month 6, and Month 12) 
d. Laboratory assessments at 5 days, 6 months, and 12 months: 
1. Clinical chemistry: BUN, creatinine, sodium, potassium, chloride, 
glucose, calcium, bilirubin (total), total protein, albumin alanine 
aminotransferase (ALT), aspartate aminotransferase (AST), B-type 
Natriuretic Peptide (BNP).  
2. Hematology: complete blood count (CBC) with differential and 
platelet count 
e. 24-hour Telemetry (Day 5) 
f. AE monitoring 
 
The following research-related assessments will be collected post-Stage II 
BDCPA operation (Day 0):  
a. cMRI scan (Month 6 and Month 12)  
b. ITQOL survey (Month 6 and Month 12) 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 24 
 
c. Biomarker blood collection (Day 5, Month 6, and Month 12) (See MOP 
for collection and shipping instructions) 
 
 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 25 
 
 
Table 1 
Test/Procedure  
Pre-
Norwood 
Pre-BDCPA  BDCPA  
Post-BDCPA  
Baseline1 
Day 0 
 Day 5 
± 3 days 
Week 4 
30 days ± 
7 days 
Month 6 
180 days ± 
30 days 
Month 12 
365 days ± 
30 days 
Informed Consent 
X 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
Medical History 
 
X 
 
 
 
 
 
Physical Exam2 
X 
X 
 
X 
X 
X 
X 
Lab Assessments3 
X 
X 
 
X 
 
X 
X 
Infectious disease 
testing4  
X  
 
 
 
 
 
 
ECG 
X 
X 
 
X 
X 
X 
X 
ITQOL survey 
 
X 
 
 
 
X 
X 
Trans-thoracic Echo 
(TTE)5 
 
X 
 
X 
 
X 
X 
MRI5 
 
X 
 
 
 
X 
X 
Cardiac Cath6 
 
X 
 
 
 
 
 
Randomization7 
X 
 
 
 
 
 
 
Study Product Injection 
(SPI) 
 
 
X 
 
 
 
 
Telemetry 
 
 
 
X 
 
 
 
Biomarker blood 
collection  
 
X 
 
X 
 
X 
X 
Adverse Event 
Monitoring 
 
X 
X 
X 
X 
X 
X 
 
1 – Baseline testing should preferably occur within 30 days of Stage II BDCPA operation 
(Day 0), however can occur up to 90 days before  
2 – Physical exams to include: vitals, Modified Ross score for heart failure classification 
and current medication usage  
3 –Labs to include: CBC with differential BUN, creatinine, electrolytes,  alanine 
aminotransferase (ALT), aspartate aminotransferase (AST), bilirubin (total), albumin, 
glucose, calcium, total protein, B-type natriuretic peptide (BNP). 
4 – Infectious disease assessment will be conducted through mother’s testing during 
pregnancy or through blood tests during screening phase for HIV, hepatitis BsAg or 
viremic hepatitis C and syphilis (Treponema pallidum).  
5 – Will be analyzed by CHoA MRI Core lab and Lurie Children’s Hospital Echo Core lab 
6 – If clinically indicated 
7 – Randomization will occur post-Norwood operation upon receipt of viable tissue sample 
at University of Miami Clinical Research Cell Manufacturing Program (CRCMP) 
 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 26 
 
C. Statistical Methods 
C.1. Statistical and Analytical Plan 
 
A statistical analysis plan (SAP) will be prepared and finalized prior to database 
lock.  This document will provide further details regarding the definition of analysis 
variables and analysis methodology to address all study objectives. 
 
A data review will be conducted prior to database lock.  This review will assess the 
accuracy and completeness of the study database and appropriateness of the 
planned statistical methods. 
C.2. Analysis Sets 
 
Analysis populations are defined as the following: 
 
Safety Analysis Set (SAS): All subjects in the Group A lead-in group and the 
Group B randomized group. The primary and secondary safety/feasibility 
analyses will be performed on the SAS population. 
 
Efficacy Analysis Set (EAS): All subjects who are randomized and will be 
analyzed for intention-to-treat according to the treatment group to which they 
were assigned. Primary efficacy and secondary safety and efficacy analyses 
will be performed on the EAS population. 
 
Safety and feasibility analysis will be based on the Safety Analysis Set (SAS). 
The analyses of bioactivity will be based on the Efficacy Analysis Set (EAS), also 
known as the intention-to-treat population. 
C.3. Safety Analysis 
 
Safety will be evaluated based on the adverse events (AE) profile of the subjects.  
AEs will be classified with regard to severity, duration and frequency of the event.  
AE data will be listed individually, and described by body system, and preferred 
terms within a body system. 
 
Each occurrence of an AE (based on preferred terminology) will be reported 
separately for a given subject, and its relationship to the study drug will be 
assessed independent of whether the event occurred previously.  If two or more 
AE’s are reported as a unit, the individual terms will be reported as separate 
events.  If a subject experiences more than one episode of a particular coded 
adverse event, the subject will be counted only once by the maximum intensity of 
the episode (i.e. once per unique preferred term per subject). 
 
A Data Safety Monitoring Board (DSMB) will review all safety data in a timely 
fashion.  The DSMB will consist of an independent group of clinicians (a minimum 
of three). A pediatric cardiologist specializing in heart failure will chair the DSMB, 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 27 
 
which will include an additional pediatric specialist, and a biostatistician. Serious 
adverse events will be reviewed by the DSMB as the events occur. Semi-annual 
meetings of the DSMB will focus on a review of frequency and severity of all 
adverse events as well as demographic and bioactivity data. The DSMB will closely 
monitor the safety of the subjects participating in this study, and they will make a 
decision to stop the study if, in their judgment, safety concerns arise.  
C.4. Analysis of Demographics and Other Baseline Characteristics 
 
Baseline characteristics collected and selective data will be summarized for each 
subject.  Such variables include: 1) demographic variables, 2) type of HLHS, 3) 
physical examination, 4) laboratory data, 5) echocardiography variables, 6) cardiac 
magnetic resonance imaging variables.  Descriptive statistics (e.g., number of 
subjects, mean, SD, median, minimum, and maximum) will be generated for 
continuous demographic variables and baseline variables (e.g., age, length, 
weight, head circumference and BMI) for all subjects. The number and percentage 
of subjects in each class of categorical demographic variables and baseline 
variables (e.g., gender, ethnicity, and race) will be tabulated. Chi-square test (for 
categorical variables) and student t-test (for continuous variable) will be used to 
evaluate the difference between the treated and non-treated subjects. Individual 
subject demographic and baseline characteristic data will be listed. 
C.5. Analysis of Bioactivity 
 
Analyses of bioactivity will be exploratory in nature in order to aid in endpoints, 
time points, and sample size determination for subsequent larger trials, if 
appropriate. We will need to look at the totality of data at the end of this study 
and use best clinical/statistical judgment in developing a larger study design. As 
an example, we may see improvement in right ventricular function in treated 
subjects. Given the objective and predictive nature of this endpoint, and in the 
absence of safety concerns we could make a decision to proceed with a larger 
study based on this finding alone. Alternatively, if treated subjects exhibited 
improved tricuspid regurgitation associated with reductions in symptoms or 
pleural effusion, this constellation of findings might justify proceeding with 
additional studies. Regarding the primary endpoint for a Phase I/II study, we will 
need to look at the outcomes from the proposed study as well as the outcomes 
from similar studies and the evolving consensus of the research community 
regarding the importance and predictive nature of specific endpoints in this 
patient population. To account for patient body surface area, RVESV and 
RVEDV indices are reported. 
 
Bioactivity endpoints are changes from baseline in: 
 
1. RVEF - continuous variable, with improvement indicated by an increase;  
2. RVESVI and RVEDVI - continuous, with improvement indicated by a 
decrease; 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 28 
 
3. Tricuspid regurgitation- continuous, with improvement indicated by a 
decrease 
 
Every effort will be made to obtain all the data from all the enrolled patients in the 
study. If not, two analytical approaches will be used to account for missing data: 
multiple imputations and available data. The primary analysis will be based on the 
available data. Multiple imputations will be used as a sensitivity analysis.  
 
All endpoints will be summarized by treatment group. Summary on continuous 
variables will include the following descriptive statistics: mean, median, maximum, 
minimum, standard deviation, and the 95% confidence interval. 
 
For each bioactivity endpoint, the difference (in change from baseline) between 
treatment arms will be estimated with the 95% confidence interval. The main 
bioactivity endpoints of interests will be the changes from baseline at 12 months.  
 
Analysis of bioactivity endpoints 
 
1. Student t-test will be used to assess the difference between the treatments 
in the change from baseline for continuous outcomes; also, analysis of 
covariance (ANCOVA) with adjustment for baseline values will be used to 
assess treatment effect.  
2. Wilcoxon rank sum test will be used to assess the difference in treatment 
effect in the change from baseline for continuous outcomes if normality 
assumption does not hold. 
3. Chi-square test or Fisher’s exact test will be used to assess difference 
between treatments in incidence of categorical outcomes.  
4. Logistic regression with baseline covariates will be used to assess 
treatment effect for categorical outcomes with adjustment for baseline 
covariates if appropriate. 
5. No adjustment will be made for multiple comparisons. 
C.6. Determination of Sample Size 
 
A total of twenty-two subjects will be randomized to two groups (eleven control and 
eleven treated). In our statistical plan we have allowed for a 10% attrition rate, with 
one subject per group for the bioactivity analysis.  
 
A sample of 20 participants (10 in the treatment group and 10 in the control) 
provides 89% power with an alpha of 0.05 to detect a 6 unit change in RVEF (with 
a SD of 4 units) between the stage II operation (baseline) and 12 months later as 
measured by cMRI 
 
We performed a power analysis based on our pilot study and the PERSEUS trial 
published in the administration of cardiosphere derived cells in HLHS patients. The 
sample size for comparing means from two independent samples of a continuous 
variable is as follows: 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 29 
 
 
𝑛𝐶= 2 ∗(𝑍1−∝/2 + 𝑍1−𝛽)
2𝜎2
𝛿2
 
 
In a 1:1 randomization, nA = nC, where nA = number in the active groups and nC = 
number in the control group δ = μ1 – μ2 (difference of 2 means) and σ2 is common 
variance. Total sample size is 2nC.  
 
Z1-α/2 for an α of .05 for a 2-sided test is 1.96, Z1-β for power of .89 is 1.21. The 
primary analysis will consist of one comparison – cKit versus control. We assume 
that will have a 6 unit change in RVEF with a SD of 4 units based on data from the 
PERSEUS trial.1 
 
Analyses of bioactivity will be exploratory in nature in order to aid in selection of 
dosage, endpoints, time points, and sample size determination for subsequent 
larger trials. 
C.7. Heart Tissue Analysis 
 
In the event of a heart transplant or left-ventricular device insertion during the 
post-treatment phase, the heart or tissue will be retrieved and analyzed. 
Parents/guardians of participants will give/deny permission for this process at 
time of enrollment in trial.  Consent to this analysis is optional and does not 
impact the participant’s ability to take part in the trial if the parents/guardians 
decline to consent to tissue donation.  If tissue is collected, the sites of cell 
injection will be studied, along with a detailed gross and light microscopic cardiac 
examination.   
D.  General Procedures 
D.1. Adverse Events 
 
AEs will be classified with regard to severity, relationship to study, duration, and 
seriousness.   
 
AE data will be listed individually and described by system organ class (SOC) and 
preferred terms using the MedDRA hierarchy.  Each occurrence of an AE will be 
reported separately for a given subject, and its relationship to the study therapy 
will be assessed independent of whether the event occurred previously.  If two or 
more AEs are reported as a unit, the individual terms will be reported as separate 
events. 
 
AEs will be listed by subject and summarized by and within SOC.  Listings and 
tables will be provided for study-emergent adverse events (defined for an individual 
subject as an event not present prior to beginning study therapy, or, if present prior 
to beginning study therapy, an event which increases in intensity, is considered 
related to the study therapy, or becomes serious during the treatment of follow-up 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 30 
 
phases of the study).  Separate listings and/or tables will also be provided for 
adverse events by maximum intensity, drug-related adverse events, serious 
adverse events, and adverse events resulting in discontinuation of study drug and 
deaths. 
D.2. Procedures for Handling Adverse Events and Positive Microbial Post 
Product Administration 
 
The following definition of adverse event will be used for this study: Any untoward 
medical occurrence in a subject for whom investigational product (IP) was 
administered, and not necessarily appearing to have a causal relationship to the 
IP.  An adverse event can therefore be any unfavorable and unintended sign 
(including abnormal laboratory finding), symptom or disease temporally associated 
with the use of an investigational product, whether or not related to the 
investigational product. 
 
It is the responsibility of the investigator or co-investigator(s) to perform periodic 
and special assessments for AEs.  The investigator and clinical staff will note all 
AEs from time of consent re-review at baseline testing, when research-related 
procedures begin.  
 
The Common Terminology Criteria for Adverse Events (CTCAE), version 5.0, is 
used for detailed descriptions of Severity Grades.  The CTCAE schema is 
classified by body system and event using the MedDRA hierarchy and provides 
descriptions of events that qualifies under each severity rating. The following table 
contains general descriptions of Adverse Event Severity Grades. 
 
Please note: Grade 1 (Mild) AE/SARs are not entered in the electronic CRF in 
the database.  
 
Severity Grade   Description 
1 
Mild. Asymptomatic or mild symptoms; clinical or diagnostic observations 
only; intervention is not indicated.  
2 
Moderate. Minimal, local, or non-invasive intervention indicated or limiting 
age-appropriate instrumental activities of daily living (i.e. preparing 
meals, shopping for groceries/clothes, managing money, using 
3 
Severe or medically significant but not immediately life-threatening. 
Hospitalization or prolongation of hospitalization indicated OR disabling 
OR limiting self-care (e.g. bathing, dressing, feeding self, using toilet, 
taking medications, and not bedridden etc.) 
4 
Life-threatening consequences; urgent intervention indicated. 
5 
Death. Death related to adverse event. 
 
All clinical complaints volunteered by, or elicited from, the subject’s 
parents/guardians during the study period will be recorded on the appropriate page 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 31 
 
of the eCRF for the study phase indicated.  If any AE occurs, the subject will 
receive appropriate treatment and medical supervision.  In addition, the 
investigator will record the AE on the appropriate page of the eCRF.  All AEs 
judged to be clinically significant will be followed until resolution.  Serious AEs will 
require special reporting. 
 
D.2.1. Reporting of Serious Adverse Events 
 
Serious Adverse Event (SAE) is an untoward medical occurrence that may occur. 
The following regulatory criteria qualify as an adverse event as serious: 
 
Death of a subject:  
An event resulting in the death of a subject. 
 
Life-threatening: 
 
In the opinion of the investigator, an event that would  
have resulted in immediate death if medical 
intervention had not been initiated.  This does not 
include an event that would have been fatal if it had 
occurred in a more severe form. 
 
Hospitalization: 
An event resulting in formal inpatient admission of the 
subject to the hospital.  Visits to the emergency room 
or outpatient facility do not constitute hospitalization for 
the purpose of this definition. 
 
Prolongation of  
An event that prolongs the subject’s stay in the 
hospital. 
Hospitalization: 
By definition, this is a different event from the event that 
resulted in the hospitalization. 
 
Persistent or Significant 
An event that substantially interferes with the subject’s  
Disability/Incapacity: 
usual daily activities of living.  This category is not 
intended to include events of relatively minor medical 
significance such as minor trauma, diarrhea, nausea, 
etc. 
 
Important Medical Event: Although not resulting in death or hospitalization, an 
important medical event should be considered a 
serious adverse event if, based on medical judgment, 
it significantly jeopardizes the subject and/or requires 
medical or surgical intervention to prevent one of the 
other serious outcomes from occurring. 
 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 32 
 
D.2.2. Collection Period for Adverse Events 
 
 
 
 
 
 
 
  
The causality category chosen for an AE or SAE that occurs during the time interval 
between the signing of the informed consent and study product injection should 
reflect whether the event was thought to be “possibly related” or “not related” to 
any protocol mandated procedures during this interval. 
 
Medical and scientific judgment should be exercised in deciding whether expedited 
reporting is appropriate in other situations, such as important medical events that 
may not be immediately life-threatening or result in death or hospitalization but 
may jeopardize the subject or may require intervention to prevent one of the other 
outcomes listed in the definition described previously.  These should also usually 
be considered serious.  Examples of such events are intensive treatment in an 
emergency room or at home for allergic bronchospasm; blood dyscrasias or 
convulsions that do not result in hospitalization; or development of drug 
dependency or drug abuse. 
 
The term “severe” is often used to describe the intensity (severity) of a specific 
event (as in mild, moderate, or severe myocardial infarction).  The event itself, 
however, may be of relatively minor medical significance.  This is not the same as 
“serious,” which is based on subject/event outcome or action criteria usually 
associated with events that pose a threat to a subject’s life or functioning.  
Seriousness (not severity) serves as a guide for defining regulatory reporting 
obligations. 
 
The terms “serious,” “unexpected,” and “expected” are regulatory definitions.  
Therefore, if a subject experiences any of the reactions described as expected, the 
only way this reaction can be unexpected is if it is either more severe than usually 
seen, or if the incidence of an event (e.g., hypertension) at a specific center is 
higher than usually expected. Similarly, if a subject with a concomitant heart 
condition suffers a myocardial infarction, this must be noted as unexpected, even 
if it is recognized as an expected event for that subject. 
D.2.3. Reporting Procedures 
 
The DCC medical monitor will assess each serious adverse event (SAE) to 
determine if the SAE qualifies as an expedited report according to FDA regulations 
and ICH GCP guidelines. Expedited reports will be submitted to the appropriate 
regulatory authorities including the governing IRB.   
 
 
 
 
 
  SAEs and Non-Serious AEs 
Informed 
Tissue 
Consent Re-review/ Baseline visit  
 
12 Months  
Consent 
Harvested 
 
 
Signed 
 
 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 33 
 
D.2.4. Management of Positive Microbial Post Product Administration 
 
In the event that microbial test results become positive following injection of the 
cellular product the following actions will be taken: 
 
a. All positive microbial test results will be reported immediately to local cell 
processing laboratory director, the principal investigator, laboratory 
medical director, study sponsor and the attending physician (if not the 
same as principal investigator).  .  
b. The subject’s parents or legal guardian is notified immediately by 
telephone to inform him/her of the result. Three attempts at telephone 
contact will be made. If unsuccessful, a registered letter will be sent to 
the subject’s home, with instructions to contact the principal investigator 
or study coordinator for additional follow up requirements.   
c. Each subject’s parents or legal guardian will be interviewed about 
symptoms of infection, including; lassitude, cough, coryza, conjunctivitis, 
rash, dysuria, and diarrhea. All subjects will be instructed to report to the 
hospital immediately for blood work, sputum and urine cultures, throat 
and nasal swab, and a complete examination and consultation with an 
infectious disease specialist. Subject is monitored by his/her physician 
based on the patient's symptomology (fever, chills or other indicators 
suggestive of infection) and started on broad spectrum antibiotics if the 
organism identification results are not yet available. The subject will 
remain in the study and be monitored for clinical signs of infection.  The 
local research team will report in the EDC any resultant adverse events 
per protocol.  When organism ID is available, the antibiotics are selected 
based on these results.  The subject will remain in the study and be 
continuously monitored for clinical signs of infection. 
d. Additional microbiological testing will be performed to identify the 
microbial organism, once available, those results will be reported to local 
cell processing laboratory director, laboratory medical director, study 
sponsor and the attending physician (if not the same as principal 
investigator). Results of organism identified  will be reviewed by the 
principal investigator in consultation with an infectious disease specialist 
and decisions regarding treatment and repeat testing will be based on 
these consultations. A decision regarding the use of antimicrobial agents 
will be based on the recommendations of the infectious disease 
consultant and the clinical judgment of the investigator. 
e. A full investigation of the incident will be performed to determine the 
potential root cause of contamination following the cell processing 
laboratory protocols (CPL).  Corrective actions and preventive plan will 
be implemented to prevent a recurrence of the event. 
f. The clinical research program to report the incident related to 
administration of positive microorganism to the IRB regardless of patient 
adverse event. Upon IRB review, the incident will be reported to the FDA 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 34 
 
if recommended.  Reporting of the incident will follow 21 CFR 312. 31 
and 312.32. 
g.   In the event that subject exhibits the symptom in association with the 
microbial contamination that falls into the serious adverse event (SAE) 
grade 4 or 5 (life threatening or fatal), the event will be reported through 
Medwatch form and information be submitted in an IND safety report 
within 7 calendar days of learning of the event, under SAE grade 3 (non-
life threatening or non-fatal) report will be submitted through Medwatch 
form and information be submitted in an IND safety report within 15 
days of learning of the event.  Local cell processing laboratory will 
provide the investigation of the root cause and corrective/preventive 
actions will be reported to the study sponsor to be submitted to the FDA 
as soon as it becomes available.   
       In the event of no adverse event, the positive sterility test results, the 
investigation of the cause and corrective/preventive actions will be 
reported, in an information amendment and will be submitted to the 
FDA within 30 calendar days. 
D.3. Expected Adverse Events 
 
Because the subjects in this study have, by definition, a serious congenital heart 
defect, they may experience adverse events that are related to the natural history 
or standard of surgical care of their defect including death.  These subjects also 
frequently have other cardiovascular disease involving the cerebrovascular, renal, 
and coronary arteries; all of which may become clinically active at any time in such 
subject. 
 
In addition, adverse events that are specified in the labeling of the various 
components of this intervention, in this protocol, investigator’s brochure, or in the 
informed consent are deemed anticipated for the purpose of reporting 
requirements. 
D.4. Potential Risks 
 
During the Stage I Norwood operation, there is no additional risk to the HLHS 
patient in conjunction with collection of the right atrial appendage tissue. To initiate 
cardiopulmonary bypass for this surgery, the right atrial appendage is cannulated. 
Typically, the right atrial appendage is excised and discarded during this step of 
the operation. However, in our study, this excised right atrial appendage will be 
collected and c-kit+ cells will be isolated. So, no additional tissue from the heart will 
be required and thus no potential risks to the function of the heart or to the patient 
will occur.  
D.4.1. Potential Risks of Cell Selection 
 
Potential risks related to cell processing include the risk of infusion of bacterially 
contaminated cells that may cause infection. There is the potential for infusion of 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 35 
 
foreign proteins that are residual process components, which may evoke an 
immune response. 
D.4.2. Potential Risks of Cell Therapy Delivery 
 
As with any new drug, an allergic reaction could occur.  This could result in hives, 
rash, difficulty breathing or collapse of the lung and breathing systems.  These 
reactions are usually reversible but could lead to permanent disability or death. 
Other rare but possible risks include infection, respiratory distress or failure, 
pulmonary edema, renal or hepatic failure. As with any investigational drug, 
administration of autologous c-kit-positive cells could cause currently unknown 
side effects that might be permanently disabling or fatal, including tumor formation 
or arrhythmias. 
 
The c-kit+ cells will be delivered through intramyocardial injection.  Risks 
associated with intramyocardial injection into cardiac tissue include possible 
sustained rapid heart rates and ventricular arrhythmias, ectopic tissue formation, 
cardiac perforation, infections and abnormal laboratory values. Additional risks 
associated with the delivery are minimized due to the nature of the study agent, 
namely autologous stem cells.  It is possible that a small amount of cells will enter 
the systemic circulation of the heart rather than the myocardium, although since 
these are autologous cells there should be no sequelae of such an event.   
D.4.3. Potential Risks of MRI Study 
 
The risks associated with the MRI study with gadolinium include anesthetic risks, 
anaphylactoid reaction, arrhythmia, vasodilation, and nephrogenic systemic 
fibrosis. At Children’s Memorial Hospital, the University of Maryland, a study was 
conducted that has shown no complications with the MRI study in congenital heart 
patients during the last nine years. This protocol is mentioned below.  
 
The most serious complication is nephrogenic systemic fibrosis, or NSF, with 
administration of gadolinium in adult patients with decreased renal function. In a 
study by Prince, et al., none of 74,124 adult patients developed NSF after 
administration of single dose of gadolinium (0.1 mmol/kg), but 15 of 8997 (0.017%) 
patients developed NSF after the administration of high dose (≥ 0.2 mmol/kg) (24). 
Of 265 patients undergoing chronic hemodialysis, 1 (0.4%) developed NSF (all 
received high-dose gadolinium); and of 131 patients in acute renal failure, 11 
(8.4%) developed NSF (24).  Therefore, NSF results from a high dose of the 
gadolinium administered or if the patient has decreased renal function.  At 
Children’s Memorial Hospital, we use Gadavist: Gadopentetate dimeglumine 
469.01 mg/ml for our gadolinium-based contrast agent at a dose of 0.2mmol/kg 
that is required for delayed enhancement to assess for myocardial fibrosis. To 
assess for renal toxicity, patients are screened by creatinine if they are less than 
one year of age and Glomerular Filtration Rate (GFR) if greater than one year of 
age. If the creatinine level is <0.64 mg/dl for infants less than one year of age, we 
use Gadavist at a dose of 0.2 mmol/ kg. If the creatinine level is >0.64 mg./dl, then 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 36 
 
Gadavist is contraindicated and not given. In patients greater than one year of age, 
if the GFR is > 60 ml/min/1.73 m2, the patient is cleared to receive the normal dose. 
Between 30-60 will need consent from the parents and a half dose of gadolinium 
(0.05 mmol/kg) was used, which is not ideal and the quality of images are 
sometimes not conclusive. If the GFR is < 30, then gadolinium administration is 
contraindicated. By basing the administration of gadolinium on these strict criteria, 
we have not had any complications with the MRI study at Children’s Memorial 
Hospital. 
 
The basis of these criteria for dosing gadolinium is due to several reasons. We 
now base it on the creatinine level, which is due to several reasons for infants less 
than one year of age. First, we have had no complications with the 0.2 mmol/kg 
dosing for GBCA. Secondly, the creatinine levels are more stable after 2 months 
of age up to one year of age. The creatinine levels reflect more of the intrinsic 
function and does not reflect muscle mass.  Finally, GFR calculated values for 
patients less than one year of age may not reflect the actual kidney function but in 
fact the immaturity of the nephrons, which may in fact be normal and have no 
intrinsic disease processes.  Furthermore, GFR may be given a true estimate of 
kidney function in this very young patient population. Taken together, we will base 
the GBCA dosing at 0.2 mmol/kg up to creatinine level of 0.64 mg/dl for patients 
less than one year of age and GFR for patients greater than one year of age. 
 
Other complications are mostly theoretical and have not been seen in our practice. 
The mortality of MRI is directly related to whether a metallic object is within the 
body of the patient. Every patient will undergo routine screening for metallic 
implants. Since we will be operating on and following these patients, we will be 
aware of metallic objects in the patients.  Another risk is general anesthesia, which 
is less than < 0.1%.  Safety efficacy of gadolinium have not been established in 
children < 2 years of age or for use in magnetic resonance angiography. Side 
effects include anaphylactoid reaction, arrhythmia, vasodilation, and wheezing and 
are reported as less than < 1%. 
D.5. Risk-Benefit Assessment 
 
The potential benefit in this clinical study is augmentation of right ventricular 
function that is of sufficient magnitude to reduce tricuspid regurgitation, improve 
symptoms, and decrease pleural effusions. Since the right atrial tissue used in this 
study is typically discarded, there will be no consequence to the heart function.  In 
the absence of cell therapy, deleterious consequences, which may occur as part 
of the natural history of the subject’s cardiac disease, might include persistent 
cardiac dysfunction, progressive loss of tissue integrity, and/or death.  
D.6. Data Safety Monitoring Board (DSMB) 
 
A Data Safety Monitoring Board (DSMB) will review all safety data in a timely 
fashion.  The DSMB will consist of an independent group of clinicians (a minimum 
of three) including two pediatric cardiologists or surgeons and statistician that are 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 37 
 
not actively recruiting subjects for this trial. Serious adverse events will be 
reviewed by the DSMB as the events occur. Semi-annual meetings of the DSMB 
will focus on a unblinded review of frequency and severity of all adverse events as 
well as demographic and bioactivity data. Ad hoc meetings also may be held for 
any safety concerns during the study. Based upon review of the data, the DSMB 
will make recommendations to continue, modify, or stop the study if it appears that 
the subject’s safety is at risk. Further responsibilities and details of the DSMB will 
be included in the DSMB Charter. 
D.7. Stopping Guidelines 
 
The sponsor will review all SAE reports.  If conditions arise during the study 
indicating that the enrollment should be halted, this action may be taken by the 
sponsor and the DSMB.   
The IRB and FDA will be notified of any cessation of enrollment.  The IRB and FDA 
will review the safety data that led to the suspension of enrollment and make a 
determination regarding continuation of the study. 
D.7.1. Subject Discontinuation 
 
Individual subjects may withdraw from the study at any time, however, all efforts 
will be made to encourage return for all assessments through the end of the study 
period, so that safety can continue to be monitored. The investigator will provide a 
written report on the appropriate eCRF page describing the reason for 
discontinuation.  If a subject withdraws or is discontinued from the study before 
completion, every effort will be made to complete the assessments scheduled 
during the post-treatment phase to monitor safety. 
 
D.8. Data Quality Assurance 
 
CRF workbook data will be entered into a validated electronic clinical database 
using the physical source copies of the study documents.  Computerized data 
checks and manual review checks will be implemented to check for discrepancies.  
An electronic audit trail system will be used to track all changes in the database 
subsequent to the reconciliation of the data.  
D.9. Data Collection and Processing 
 
Case report forms (CRFs) will be completed for each study visit, and adverse 
events.  All CRFs will then be entered into the electronic data capture (EDC) 
system managed by the DCC. Errors on CRFs will be corrected by making a single 
strike-out through the erroneous data and writing the correct data legibly above, 
beside, or below the erroneous data so that the original entry is not obscured.  
Each correction must be initialed and dated by the person making the correction. 
Errors on eCRFs will be made through the correction process in the EDC system. 
 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 38 
 
The completed, original CRF will be retained in the investigator’s study files.  A 
copy of the original CRF will be reviewed by the clinical monitor and a copy may 
be requested to be sent to the sponsor and/or monitor for review.  
 
Before the CRFs are finalized, the clinical monitor may request copies of the CRFs 
for preliminary medical review.  Electronic data queries will then be generated and 
provided to the study personnel.  The study personnel will take appropriate action 
based on the queries, after which the clinical monitor will collect the original, 
completed CRFs. 
D.10. Human Subjects 
 
The data and records from the conduct of this trial will be obtained from the 
individual subject’s guardians who will voluntarily agree to enroll in this study.  We 
will obtain informed consent for study participation prior to study enrollment and 
administration of intervention.  In all cases the guidelines of the governing 
Institutional Review Board (IRB) will be followed.  The principal investigator or 
his/her designee will explain the study’s purpose, methods, risks, and potential 
benefits to each subject’s guardian.  Reviewing the written Informed Parent 
Consent Form and answering any questions will be part of the informed consent 
process. This process includes describing all of the testing, including laboratory 
and diagnostics pre-treatment to the follow-up evaluations that are required for 
each enrollee.   
 
Recruitment of subjects will be entirely voluntary.  Guardians of all eligible subjects 
will be invited to participate in this study.  The principal investigator or his/her 
designee will obtain consent after a complete description of the study.  Consent 
will be documented in writing by having the subject’s legal guardian sign a written 
informed parent consent form approved by the Institutional Review Board. 
 
In the event of an adverse event, subjects will have ready access to the study 
coordinator and principal investigator for the appropriate intervention.  All adverse 
events will be reported in accordance with existing guidelines of IRBs and the FDA. 
D.11. Subject Confidentiality 
 
Assigning each subject a study number and acrostic will protect subject 
confidentiality.  This number will be the only identification used in any 
communication or report.  Accordingly, subject confidentiality and anonymity will 
be protected at all times according to institutional policies, IRB and HIPAA 
regulations. 
E. Ethics 
E.1. Independent Ethics Committee/Institutional Review Board 
 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 39 
 
The investigator must submit this protocol, informed parent consent form, and 
subject information to an Institutional Review Board (IRB).  Prior to the beginning 
of the study, the investigator must obtain written IRB approval of the protocol, 
consent form, and subject information.  The investigator may not initiate the study 
until IRB approval has been obtained.  The Investigator has the responsibility to 
notify the IRB if the study is either amended or terminated.  Emergency changes 
to protect the life of the subject do not require prior approval, but must be reported 
to the IRB immediately. 
 
Written informed consent must be obtained from the participant’s legal guardian 
prior to their participation in the study after the IRB approval of the study protocol 
and parent consent form. 
E.2. Ethical Conduct of the Study 
 
The study will be conducted under the following conditions: 
1.  Declaration of Helsinki  
2.  ICH Guidelines for Good Clinical Practice (GCP) 
3.  GCP/International Conference on Harmonization (ICH) guidelines 
E.3. Subject Information, Confidentiality and Consent 
 
All subject information, medical records, and laboratory data will be kept 
confidential.  Information and data may be discussed, analyzed, and reported.  
However, ID numbers will identify the subject on the case report forms and the 
subject’s identity will be kept confidential.   
 
Once the entire study has been explained and understood, the subject’s legal 
guardian will sign and date the IRB approved informed parent consent form. 
F. Study Administration Structure 
F.1. Investigator Responsibilities 
F.1.1. Investigator Agreement 
 
The investigator must sign FDA Form 1572, the Investigator Agreement, certifying 
that he/she will conduct the investigation in accordance with U.S. Federal 
Investigational New Drug regulations (21 CFR 312).  The investigator is 
responsible for ensuring that the investigation is conducted in accordance with the 
investigational plan, and all IND and relevant FDA regulations for the protection of 
subjects’ rights, safety, and welfare while under the investigator’s care. 
 
The investigator must notify the sponsor and the reviewing IRB of any deviation 
from the investigational plan to protect the life or physical well-being of a subject 
in an emergency.  This notice shall be given as soon as possible but no later than 
five working days after such deviation occurred. 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 40 
 
F.1.2. Institutional Review Board (IRB) Approval 
 
Under the Code of Federal Regulations, 21 CFR §50, an appropriate Institutional 
Review Board, or like assembly, must review this protocol, the Informed Consent 
Form, and any other supporting study documents which impact subject safety, 
prior to study initiation.   
 
The Institutional Review Board must review the protocol, and any amendments or 
revisions, and the Informed Consent Form at least annually over the course of this 
study.  The study cannot continue until the IRB has given written renewal approval, 
signed by the board chairperson or authorized personnel, and the sponsor has on 
file a copy of the renewal approval letter and the approved Informed Consent Form. 
F.1.3. Informed Consent 
 
The investigator is required to obtain in writing a legally effective informed consent 
from the study subject’s parents/guardian prior to the subject's participation in the 
investigation. No human being as a subject can participate in this study without 
such consent.  The Informed Consent Form must be approved by the site’s 
Institutional Review Board (IRB).  The investigator shall seek such consent only 
under circumstances that provide the prospective subject’s guardian sufficient 
opportunity to consider whether or not to participate and that minimize the 
possibility of coercion or undue influence.  The information that is given to the 
subject’s parents/guardian shall be in language understandable to the subject’s 
parents/guardian.  Sufficient time must be available for the subject’s guardian to 
have all questions answered. 
 
In addition to the written explanation in the Informed Consent Form, a verbal 
explanation will be given by the investigator or his/her designee.  The investigator 
or his/her designee will further explain the reason for the study, the risk to the 
subject of participating in the study as well as the potential benefits and alternative 
treatments the subject would receive should he/she choose not to participate in 
the study. The consent process will also be documented in the subject’s research 
chart. 
F.1.4. Records Maintenance 
F.1.4.a. Administrative and Regulatory Files 
 
The administrative and regulatory files include the following: 
• IRB membership list / address; 
• Original application to IRB, original approval letter - signed and dated; 
• Additional submissions with amendments or changes and all approval 
letters 
• Informed Consent original approval letter, signed and dated; 
• All subsequent renewal application, and renewal approvals; 
• Reports, at least annually, to the IRB. 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 41 
 
F.1.4.b. Investigator Information 
 
Including but not limited to the following:  
• Investigator Curriculum Vitae; 
• FDA Form 1571 
• FDA Form 1572 - Investigator Agreement(s) - signed / dated; 
• Monitoring records - including a sign-in log listing date, duration, and 
purpose of visit 
F.1.4.c. Documentation of Adverse Events, Protocol Deviation, Failure to 
Obtain Informed Consent, Subject Withdrawal 
 
Documentation regarding any of the following: 
• Adverse events or drug complications; 
• Deviations from the protocol; 
• Failure to obtain informed consent prior to subject participation; 
• Subject withdrawal from the study. 
F.1.4.d. Data Corrections 
 
All corrections to the data, either on a case report form or the medical record, will 
be: 
• lined through so that the original entry can still be viewed 
• initialed and dated by the individual making the correction 
• corrected legibly 
• reason for the correction will be noted only in the event that it is a 
“subjective” change (e.g., change from mild to moderate); otherwise 
changes should be supported by source document  
 
Please note that whiteout or other corrective fluids will not be used at any time on 
the forms. 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 42 
 
SECTION 2  
Literature Cited in Research Plan 
 
(1)  Rossano, J.W., Kim, J.J.,  Decker. J.A.,  Price, J.F., Zafar, F., Graves, 
D.E.,Morales, D.L.,  Heinle, J.S., Bozkurt, B., Denfield, S.W.,  Dreyer, 
D.W., Jefferies, J.L. Increasing Prevalence and Hospital Charges in 
Pediatric Heart Failure Related Hospitalizations in the United States: A 
Population-Based Study. Circulation; AHA 2010:122:A13740. 
 
 (2)  MMWR. Centers for Disease Control and Prevention, Hospital Stays, 
Hospital Charges, and In-Hospital Deaths Among Infants with Selected 
Birth Defects—United States, 2003, MMWR 2007;56(5-29).  
 (3)  Williams DL, Gelijns AC, Moskowitz AJ, Weinberg AD, Ng JH, Crawford E, 
et al. Hypoplastic left heart syndrome: valuing the survival. J Thorac 
Cardiovasc Surg 2000 Apr;119(4 Pt 1):720-31. 
 (4)  Bove EL. Current status of staged reconstruction for hypoplastic left heart 
syndrome. Pediatr Cardiol 1998 Jul;19(4):308-15. 
 (5)  Bernstein D, Naftel D, Chin C, Addonizio LJ, Gamberg P, Blume ED, et al. 
Outcome of listing for cardiac transplantation for failed Fontan: a multi-
institutional study. Circulation 2006 Jul 25;114(4):273-80. 
 (6)  Morrow WR, Naftel D, Chinnock R, Canter C, Boucek M, Zales V, et al. 
Outcome of listing for heart transplantation in infants younger than six 
months: predictors of death and interval to transplantation. The Pediatric 
Heart Transplantation Study Group. J Heart Lung Transplant 1997 
Dec;16(12):1255-66. 
 (7)  Gajarski RJ, Towbin JA, Garson A, Jr. Fontan palliation versus heart 
transplantation: a comparison of charges. Am Heart J 1996 
Jun;131(6):1169-74. 
 (8)  Ohye RG, Sleeper LA, Mahony L, Newburger JW, Pearson GD, Lu M, et 
al. Comparison of shunt types in the Norwood procedure for single-
ventricle lesions. N Engl J Med 2010 May 27;362(21):1980-92. 
 (9)  Ashburn DA, McCrindle BW, Tchervenkov CI, Jacobs ML, Lofland GK, 
Bove EL, et al. Outcomes after the Norwood operation in neonates with 
critical aortic stenosis or aortic valve atresia. J Thorac Cardiovasc Surg 
2003 May;125(5):1070-82. 
 (10)  Bando K, Turrentine MW, Sun K, Sharp TG, Caldwell RL, Darragh RK, et 
al. Surgical management of hypoplastic left heart syndrome. Ann Thorac 
Surg 1996 Jul;62(1):70-6. 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 43 
 
 (11)  Forbess JM, Cook N, Roth SJ, Serraf A, Mayer JE, Jr., Jonas RA. Ten-
year institutional experience with palliative surgery for hypoplastic left 
heart syndrome. Risk factors related to stage I mortality. Circulation 1995 
Nov 1;92(9 Suppl):II262-II266. 
 (12)  Murdison KA, Baffa JM, Farrell PE, Jr., Chang AC, Barber G, Norwood 
WI, et al. Hypoplastic left heart syndrome. Outcome after initial 
reconstruction and before modified Fontan procedure. Circulation 1990 
Nov;82(5 Suppl):IV199-IV207. 
 (13)  Tweddell JS, Hoffman GM, Mussatto KA, Fedderly RT, Berger S, Jaquiss 
RD, et al. Improved survival of patients undergoing palliation of 
hypoplastic left heart syndrome: lessons learned from 115 consecutive 
patients. Circulation 2002 Sep 24;106(12 Suppl 1):I82-I89. 
 (14)  Weldner PW, Myers JL, Gleason MM, Cyran SE, Weber HS, White MG, et 
al. The Norwood operation and subsequent Fontan operation in infants 
with complex congenital heart disease. J Thorac Cardiovasc Surg 1995 
Apr;109(4):654-62. 
 (15)  Cohen AJ, Cleveland DC, Dyck J, Poppe D, Smallhorn J, Freedom RM, et 
al. Results of the Fontan procedure for patients with univentricular heart. 
Ann Thorac Surg 1991 Dec;52(6):1266-70. 
 (16)  Altmann K, Printz BF, Solowiejczky DE, Gersony WM, Quaegebeur J, 
Apfel HD. Two-dimensional echocardiographic assessment of right 
ventricular function as a predictor of outcome in hypoplastic left heart 
syndrome. Am J Cardiol 2000 Nov 1;86(9):964-8. 
 (17)  Muthurangu V, Taylor AM, Hegde SR, Johnson R, Tulloh R, Simpson JM, 
et al. Cardiac magnetic resonance imaging after stage I Norwood 
operation for hypoplastic left heart syndrome. Circulation 2005 Nov 
22;112(21):3256-63. 
 (18)  Sundareswaran KS, Kanter KR, Kitajima HD, Krishnankutty R, Sabatier 
JF, Parks WJ, et al. Impaired power output and cardiac index with 
hypoplastic left heart syndrome: a magnetic resonance imaging study. 
Ann Thorac Surg 2006 Oct;82(4):1267-75. 
 (19)  Rychik J. Hypoplastic left heart syndrome: from in-utero diagnosis to 
school age. Semin Fetal Neonatal Med 2005 Dec;10(6):553-66. 
 (20)  Beltrami AP, Barlucchi L, Torella D, Baker M, Limana F, Chimenti S, et al. 
Adult cardiac stem cells are multipotent and support myocardial 
regeneration. Cell 2003 Sep 19;114(6):763-76. 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 44 
 
 (21)  Bolli, R., Jneid, H., Tang, X.L., Dawn, B., Rimoldi, O., Mosna, F., et al. 
Intracoronary administration of cardiac cells improves cardiac functrion in 
pigs with  old infarction. Circulation 2006; 114(suppl II):II-239 (abstract). 
 (22)  Lee ST, White AJ, Matsushita S, Malliaras K, Steenbergen C, Zhang Y, et 
al. Intramyocardial injection of autologous cardiospheres or cardiosphere-
derived cells preserves function and minimizes adverse ventricular 
remodeling in pigs with heart failure post-myocardial infarction. J Am Coll 
Cardiol 2011 Jan 25;57(4):455-65. 
 (23)  Mishra R, Vijayan K, Colletti EJ, Harrington DA, Matthiesen TS, Simpson 
D, et al. Characterization and functionality of cardiac progenitor cells in 
congenital heart patients. Circulation 2011 Feb 1;123(4):364-73. 
 (24)  Prince MR, Zhang HL, Prowda JC, Grossman ME, Silvers DN. 
Nephrogenic systemic fibrosis and its impact on abdominal imaging. 
Radiographics 2009 Oct;29(6):1565-74. 
(25)  Laer S, Mir TS, Behn F, Eiselt M, Scholz H, Venzke A, et al. Carvedilol 
therapy in pediatric patients with congestive heart failure: A study 
investigating clincial and pharmacokinetic parameters. Am Heart J 2002; 
143:916-22. 
 
 

Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome: An Open Label Pilot Study  
Clinical Protocol; Version 8,  March 23, 2021 
***CONFIDENTIAL AND PROPRIETARY*** 
 
Page 45 
 
Appendix A: Modified Ross Score for Heart Failure Classification  
 
The Modified Ross Score for heart failure classification (25) will be used to 
assess heart failure during physical exams in the CHILD trial. It will be assessed 
at baseline and follow-up visits (Day 5, Week 4, Month 6, Month 12)