Clinical trial NCT02933034
Conditions: ISCHEMIC CARDIOMYOPATHY
Keywords: ISCHEMIC OR CORONARY HEART DISEASE MYOCARDIAL INFARCTION MAGNETIC RESONANCE IMAGING DELAYED GADOLINIUM ENHANCEMENT MRI MANGANESE-ENHANCED MRI INFARCT VOLUME/SIZE ALL CAUSE MORTALITY VENTRICULAR ARRHYTHMIAS
Sponsor: Stanford University
Start date: 2015-04-01; Completion date: 2019-02-03
Enrollment: 33 participants; Allocation: NA; Intervention model: SINGLE_GROUP

Brief summary:
The purpose of this study is to evaluate the safety and tolerance of a new intravenous diagnostic agent, SeeMore or EVP 1001-1, in patients with Cardiovascular Disease (MEMRI scan). The initial phase of this study, NCT01989195 enrolling a total of 6 patients, has been closed. This second phase adds 10 patients in a safety cohort and 60 additional patients for a total of 70 patients.

Detailed description:
This is an open-label, baseline-controlled study to be conducted. Adult male or nonpregnant female patients who have been referred for evaluation of dilated cardiomyopathy, ischemic cardiomyopathy, non-ischemic cardiomyopathy, atrial arrhythmia and also patients who have received stem cell therapy related to both ischemic and dilated cardiomyopathy (under different trials) will be recruited. An initial cohort study of 6 patients to conduct safety evaluation was conducted before proceeding with 60 additional patients. In the initial cohort, a patient was dosed based on the Phase 1 and 2 clinical trial data evaluation completed by Eagle Vision Pharmaceutical, Inc. Subjects were excluded if they had received an investigational device within 30 days prior to administration of EVP1001-1; had a history of drug abuse or alcoholism; were taking a digitalis preparation; had a history of torsades; had New York Heart Association (NYHA) Grade IV heart failure; had abnormal liver function tests or a history of liver disease; had uncontrolled hypertension; had abnormal calcium, potassium or hemoglobin values at baseline; if they develop a cardiac arrhythmia prior to or during either of the exercise tests-- EVP1001-1 was not administered. The same parameters will apply to the new group of subjects.

Prior to entry into this study, all subjects will sign an Informed Consent and will undergo a physical examination including medical history, details regarding their cardiac history, prescription and over-the-counter drug questionnaire, vital signs, electrocardiogram (ECG), evaluation of the major organ systems, hematology, serum chemistries, and urinalysis. In addition, female subjects will undergo a serum pregnancy test.

Starting 30 minutes before the cardiac MRI scan (CMR), the subjects will take a 16 mg tablet of ondansetron by mouth. CMR imaging will subsequently take place and then EVP1001-1 will then be administered approximately 15 minutes into the scan for contrast enhanced images. EVP1001-1 will be administered intravenously over approximately one minute. The subjects will each receive 0.28 mL/kg of EVP 1001-1. All subjects will be monitored closely from before ondansetron administration until their discharge from the imaging center. Following MEMRI, delayed-enhanced MRI (DEMRI scan) is performed using 0.2 mmol/kg.

We will compare the two different contrast enhanced images (EVP1001-1 vs gadolinium (GD)) in determining the non-viable (infarct core), peri-infarct, and total infarct size of myocardial tissue.

Arms: arm 1: Participant receive 2 cardiac MRI procedures: MEMRI and DEMRI.
Interventions: intervention 1: Manganese-enhanced MRI contrast reagent intervention 2: Gadolinium-enhanced MRI contrast reagent
Intervention descriptions: intervention 1: MRI using manganese-enhanced MRI contrast reagent (manganese 0.28 mL/kg). intervention 2: MRI using gadolinium-enhanced MRI contrast reagent (gadolinium 0.2 mmol/kg).

Protocol documents:
Prot_SAP_000.pdf: 
 
Clinical Trial of Manganese-Enhanced MRI (MEMRI) to Assess Peri-
Infarct Injury 
Study Protocol and Statistical Analysis Plan 
NCT02933034 
 December 21, 2018 


 
Version 5.0, December 21, 2018 
CONFIDENTIAL 
This material is the property of Stanford University.  Do not disclose or use except as authorized in writing by the study sponsor 
CLINICAL RESEARCH PROTOCOL 
 
 
 
 
 
 
 
 
TITLE:   
 
Clinical Trial phase 1-2 of Manganese-Enhanced MRIto Assess Myocardial Injury 
and Predict Future Cardiovascular Events (MEMRI-CARE) 
 
 
 
 
 
Amendment 5. 
 
 
 
 
 
Study Product: 
EVP 1001-1 (See MoreTM) 
 
 
IND Number: 
 
 
 
 
 
 
 
 
 
 
 
Amended: 
(1) 06/30/2015 
Amended: 
(2) 10/14/2016 
Amended: 
(3) 12/19/2016 
Amended: 
(4) 03/21/2017 
Amended: 
(5) 12/21/2018 
 
 


 
 
 
List of Abbreviations 
 
 
AA 
 
 
 
 
 
 
atrial arrhythmia 
ACMA  
 
 
 
 
 
Arterial Cardiomyopathy arrhythmia 
AE 
adverse event  
AMBMC  
autologous mononuclear bone marrow cells  
BMC  
bone marrow cell  
BSC  
biologic safety cabinet  
COA  
Certificate of Analysis  
CABG  
coronary artery bypass graft  
CAD  
CCTRN 
coronary artery disease  
Cardiovascular Cell Therapy Research Network 
CFR  
Code of Federal Regulations  
CFU-F  
colony forming units – fibroblasts  
CK-MB 
CMR 
CNR  
 
 
CPL  
CPQCL  
creatinine kinase – myocardial band 
Cardiac MRI 
contrast to noise ratio  
cell processing lab  
Cell Processing Quality Control Lab  
CRO  
contract research organization  
CSCs  
CVE 
cardiac stem cells  
cardiovascular events 
DAPI  
4'-6-Diamidino-2-phenylindole  
DCM  
DEMRI 
dilated cardiomyopathy 
delayed enhanced MRI  
DMSO  
dimethyl sulfoxide  
DSMB  
EB 
Data and Safety Monitoring Board  
Evans Blue dye 
EF  
ejection fraction  
ECG  
Electrocardiogram  
EPC  
endothelial progenitor cells  
ESR  
EVP 
expedited safety report  
EVP 1001-1 injectable contrast agent 
FBS  
fetal bovine serum  
FDA  
Food and Drug Administration  
FEV1  
forced expiratory volume in 1 second  
GCP  
Good Clinical Practice  
G-CSF  
GMP  
hAMSC 
granulocyte colony stimulating factor  
Good Manufacturing Practice  
Human autologous mesenchymal stem cells 
HARP  
Harmonic Phase  
BMC 
HF  
human bone marrow cell  
heart failure 
HIPAA  
Health Insurance Portability and Accountability  
Act  
HSA  
human serum albumin  
HSC  
hematopoietic stem cell  


[MEMRI-DEMRI] 
 
Page iii 
Version:  
CONFIDENTIAL 
This material is the property of Stanford University.  Do not disclose or use except as authorized in writing by the study sponsor 
HTLV  
human T-cell lymphotropic virus  
ICAM  
intracellular adhesion molecule  
ICD  
implantable cardioverter-defibrillator 
ICF  
Informed consent form  
ICH  
International Conference on Harmonisation of 
Technical Re-quirements of Pharmaceuticals 
for Human Use  
ICM  
Ischemic Cardiomyopathy  
IDM 
IIR 
IR  
ISCI  
Infectious Disease Markers 
Intra infarct regions  
Ischemia reperfusion 
Interdisciplinary Stem Cell Institute 
 (University of Miami)  
IEC  
institutional ethics committee  
IND  
Investigational New Drug application  
IRB  
Institutional Review Board  
I.V.  
Intravenous  
KDR  
VEGF receptor-2  
LAD  
left anterior descending artery  
LV  
left ventricular  
LVAD  
left ventricular assist device  
MACE  
major adverse cardiac events  
MEM  
MEMRI 
minimum essential medium 
 Manganese enhanced MRI 
MHC  
major histocompatibility complex  
MI  
myocardial infarction  
MLHF 
MN  
Minnesota Living with Heart Failure  
manganese 
MR  
magnetic resonance  
MRI  
magnetic resonance imaging  
MSC 
NICM 
mesenchymal stem cell (human) 
 non-ischemic cardiomyopathy 
NYHA  
New York Heart Association  
PBS  
PIR 
PK 
phosphate buffered saline 
Peri-infarct region 
Pharmacokinetics  
QA  
quality assurance  
QC  
quality control  
SAE  
serious adverse event  
SCCT  
Specialized Center for Cell-Based Therapy  
SCF  
stem cell factor  
SDF-1  
stromal cell derived factor 1  
SOP 
SDCC 
SNR 
standard operating procedures  
Stanford Data Coordinating Center 
Signal to noise ratio 
SW  
TEM 
TESPI  
Stroke Work 
Tissue Electron Microscopy  
Transendocardial Study Product Injection  
TTC  
triphenyltetrazolium chloride 
TI 
Inversion time 
 
 
 
 


U.S.  
United States  
  VEGF 
Peak VO2  
WBC  
 
 
  
vascular endothelial growth factor 
peak oxygen consumption 
white blood count 
 
 
 
 
 
 
 


[Insert short name of protocol here] 
 
page 1 
Version 4 
Version 5.0, December 21, 2018 
CONFIDENTIAL 
This material is the property of Stanford University.  Do not disclose or use except as authorized in writing by the study sponsor 
Study Summary 
Title 
Clinical Trial of Manganese-Enhanced MRI MEMRIto Assess Peri-Infarct 
Injury 
Short Title 
MEMRI-DEMRI 
Protocol Number 
28508   
Phase 
Clinical study phase 2 
Methodology 
Open Label 
Study Duration 
i.  Screening - approximately 1-2 hours including H&P, blood work and EKG.  
ii.  Active participation - MRI study itself is approximately 1.5 hr per exam. 
iii. Analysis of participant data takes approximately 1 hr per exam with an  
additional 0.5 hr per patient for tallying clinical outcomes and AEs. 
iv. Total time estimated 3 days per patient. We expect the study to take 
approximately 12 months. 
 
Study Center(s) 
Single 
Objectives 
This is a first-in-human clinical translation of manganese-enhanced MRI 
(MEMRI) to assess the peri-infarct injury in patients with severe ischemic 
cardiomyopathy (ICM), non-ischemic cardiomyopathy (NICM) and atrial 
fIbrillation 
Number of Subjects 
50 
Diagnosis and Main 
Inclusion Criteria 
  Patients wiith ischemic or dilated cardiomyopathy with an EF less than or 
equal to 50 or  
patients with paroxysmal or persistent atrial fibrillation  
 who are at least 18 and less than 80 years of age. Only males and non-pregnant 
females to be included. 
Study Product, Dose, 
Route, Regimen 
EVP 1001-1 (SeeMoreTM) Injectable 
Manufacturer:  University of Iowa Pharmaceuticals 
IND # 
 
Dosage:  0.28 ml/kg 
 
Duration 
of 
administration 
Intravenous injectable given slowly over approximately one (1) minute 
Reference therapy 
Gadolinium 
Statistical Methodology 
Student’s t-test to assess for significant difference between MEMRI and DEMRI; 
Pearson Correlation to assess for relationship between MEMRI and signal and 
cardiac function/clinical outcome 
 


1 Introduction 
 
This document is a protocol for a human clinical research study. This study is to be conducted according to US and 
international standards of Good Clinical Practice (FDA Title 21 part 312 and International Conference on Harmonization 
guidelines), applicable government regulations and institutional research policies and procedures.  
1.1 Background 
 This is a first-in-human clinical translation of manganese-enhanced MRI(MEMRI) to assess the peri-infarct injury in 
patients with patients wiith ischemic or dilated cardiomyopathy with an EF less than or equal to 50 or  
patients with paroxysmal or persistent atrial fibrillation  
 and those who received stem cell therapy for these indications. The PI recently obtained an approval for an 
Investigational New Drug (IND #
) to conduct a clinical trial of MEMRI contrast agent                                                           
(EVP1001-1, Eagle Vision, Downingtown, PA). Funding of this proposal will enable a clinical trial of  120 patients with 
ischemic or dilated cardiomyopathy with an EF less than or equal to 50 or  
patients with paroxysmal or persistent atrial fibrillation to evaluate the safety and efficacy of sequential acquisition of 
MEMRI and delayed-enhanced MRI (DEMRI) for precise tissue characterization of the peri-infarct region (PIR). This 
novel technique designed to integrate the biology of the viable cardiomyocytes with the anatomy of the scar will predict 
future cardiovascular events (CVE), in  this highly morbid patient population. ICM and NICM are the primary etiology of 
advanced heart failure (HF) while ACM is a frequent sequela of HF. Today, HF is the leading diagnosis of hospital 
admission in the US. Our studies have confirmed a direct association between the presence of PIR and the occurrence 
of atrial and ventricular arrhythmia and remodeling, resulting in high morbidity and mortality in advanced HF. PIR has 
been recognized as an important substrate to trigger atrial and ventricular arrhythmias and stem cells may provide an 
alternative therapy for PIR.  Studies employing DEMRI has identified atrial scar as the potential cause of atrial 
arrhythmia.   This proposal contains novel hypotheses well-grounded on the following 2 innovations: (1) MEMRI for 
management of HF. An alternative approach is to employ manganese (Mn2+), which targets the viable myocardium. 
Mn2+ is specific to the L-type calcium channels and complements the non- viable scar delineated by DEMRI. The dual 
MEMRI-DEMRI approach will, therefore, identify the viable and, potentially, salvageable cardiomyocytes outside the 
core infarct zone but inside the PIR. Our recently published study demonstrated that an overlap of DEMRI and MEMRI 
signal denoted a significant number of live cardiomyocytes (MEMRI-positive) within the non-viable (DEMRI- positive) 
region. This innovation will profoundly impact the clinical management of the advanced HF patients and AA patients 
including atrial fibrillation. EVP1001-1 allows highly effective intracellular targeting of viable cardiomyocytes with high 
level of safety and unique magnetic properties. (2) Assessment of therapeutic response using MEMRI. EVP1001-1 is 
rapidly transported, intra-cellularly, to mitochondria rich tissue such as heart, liver, and kidney, demonstrating significant 
enhancement indicative of cell metabolism and viability.  High dose clinical safety studies of SeeMoreTM with safety 
index of 45-90 correspond more favorably than the widely used clinical imaging agents (10-20 for iodinated X-ray 
products and 20-60 for gadolinium). This specific, non-perfusion dependent distribution due to active intracellular uptake 
is one of the key attributes that offers real-time assessment of therapeutic response, using cardiac cellular imaging. A 
clinical safety trial in 6 patients have demonstrated negligible uptake in the intra-infarct region (IIR), reduced uptake in 
the PIR, and significantly higher uptake in the normal tissue to generate positive signal. In this trial, the mean LVEF was 
32±?4%. The DEMRI vs. MEMRI (scar/myocardial volume) demonstrated significantly higher measurement of the scar 
by DEMRI in all patients (39±11%* vs. 16±3%, *p<0.01) These data indicate 2 important findings: 1) significant over-
estimation of the scar by DEMRI and 2) quantitative difference of the scar volume between MEMRI and DEMRI 
delineates the PIR. This precise characterization allows accurate assessment of the efficacy of novel therapeutic agents 
in restoring the PIR at both cellular and tissue levels. EVP1001-1 is a new manganese (Mn)-based intravenous imaging 
agent being developed to enhance magnetic resonance imaging (MRI). While Mn has long been known to have 
desirable magnetic and kinetic properties for MRI, use in humans was not initially possible due to cardiovascular 
depression and electrocardiogram (ECG) changes, including prolongation of PR and QTc intervals, associated with 
intravenous administration. Chelation of Mn, as had been done with gadolinium for use with MRI, provided relevant 
safety, but sacrificed desirable magnetic and kinetic properties.  EVP1001-1 provides Mn in a form that maintains the 
desired magnetic and kinetic properties while overcoming the cardiovascular toxicity of Mn. EVP1001 is taken up into 
heart cells (primarily via addition of calcium to avoid cardiotoxic effects; please refer to patent listed below). The 
potential to distinguish healthy heart tissue from unhealthy heart tissue based on a specific sustained pattern of 
enhancement provides a basis for evaluating the performance of EVP1001-1 in heart patients. MRI offers benefits over 
other imaging technologies. Relative to radioactive nuclear imaging procedures, MRI is 3- dimensional, provides good 
soft tissue discrimination, and is of high spatial and temporal resolution. These features have been reported to identify 
smaller defects (e.g., subendocardial infarcts) and match angiographic results more closely than other modalities such 
as SPECT. It may be possible to enhance the utility of MRI for heart disease further through the use of an imaging 
agent that is specifically taken up into heart cells.  EVP1001-1 is the only cardiac-specific agent being developed for this 
purpose. Unlike nuclear perfusion agents, EVP1001-1 is not radioactive and does not require special handling, 
shielding, transport or storage. In addition, the specific pattern of enhancement achieved in the heart muscle persists 


[MEMRI-DEMRI] 
 
Page 3 
Version:  
CONFIDENTIAL 
This material is the property of Stanford University.  Do not disclose or use except as authorized in writing by the study sponsor 
over time, offering potential benefits over the nonspecific extracellular agents currently available for MRI or X-ray/CT 
procedures. This feature allows full use of the high resolution of MRI, since there is not a trade-off of high spatial 
resolution for temporal (first-pass) resolution. It is anticipated that the features offered by EVP1001-1 along with the high 
resolution, three-dimensional attributes of MRI will result in higher accuracy than is available with other current 
modalities in practice, including stress echocardiograms, cardiac MRI using gadolinium contrast and nuclear studies 
such as SPECT and PET. This will be evaluated in this study and serve as the basis for pivotal registration studies.  All 
components of EVP1001-1 are USP and are approved for use as drugs in man, orally and/or intravenously. A summary 
of the Phase I safety and PK (pharmacokinetics) study are provided below.  The Phase I study evaluated the safety and 
tolerance of EVP1001-1 in humans, with special emphasis on cardiovascular safety, and assessed its PK profile.  
Overall, EVP1001-1 was found to be safe at all doses. There were no serious adverse events (SAE) or any events 
requiring medical treatment. Of special importance, no signs of cardiac depression were reported. In addition, there was 
no observation of prolongation of the QTc or PR intervals or other ECG-changes that had previously been reported in 
animals for Mn. There were no changes in hematology, serum biochemistry (including liver function tests), coagulation 
parameters nor in temperature, respiratory rate or blood oxygen levels. Transient increases in HR and BP were seen. 
These, for the most part, reflected transient changes within the normal reference range. There was no obvious dose-
relationship for these responses, although their duration and magnitude were greater for the 5-minute than for the 1- 
minute dose administrations.  Other AEs were reported, almost all which were regarded as of mild or moderate 
intensity. Almost all events occurred during or immediately after dosing and resolved within minutes.  Over 83% of the 
AEs occurred during dosing and over 93% occurred within one minute of dosing. Nearly one-third of all events resolved 
within one minute from dosing, over 80% within 5 minutes, and 94% resolved within 1 hour. The most frequent types of 
AEs were injection-associated discomforts (warmth, flushing, cold, pressure, injection site changes, increased HR/BP), 
gastrointestinal disturbances (discomforts, nausea, vomiting, diarrhea), lacrimation and headache.  Although 
gastrointestinal disturbances, such as nausea and occasional vomiting, resolved rapidly without treatment, these 
bothersome events may be avoidable through the use of a standard anti-emetic. This proved to be beneficial in humans 
and also in high-dose animal studies.  The PK profile reflected that known for Mn in humans (based on reported 
radiotracer Mn studies), with a primary blood half-life under 1 minute, and less than 1% of the dose remained in the 
blood by 30 minutes after dosing. The performance of EVP1001-1 was as expected based on information that was in 
the Investigators' Brochure.  Lastly, please refer to US Patent #5,980,863 regarding further details of EVP1001-1 
contrast ingredients. 
1.2 Investigational Agent 
 
Using aseptic technique, transfer via syringe 10 mL of 10% Calcium Gluconate, USP and 30 mL of Sterile Water for Injection 
to a vial containing EVP 103.  Shake gently to dissolve the powder.  This prepares 40 mL of Drug.  Drug should be used 
promptly (within 1 to 2 hours) following preparation.  The calculated osmolality of Drug is 0.27 (nearly isomolar), and the pH 
is slightly acidic to neutral (5.5 to 7.0). 
 
The proper dose should be specified in the protocol on a “per kilogram body weight” basis and must be given slowly over 
approximately one (1) minute intravenously.  This same administration rate applies to flushing residual drug in connecting 
tubing/injection port. 
 
Dilutents and drug project should be inspected to assure that a clear solution is present.  Should any precipitate or 
undissolved material remain in the vial, the vial should be gently warmed and shaken gently to dissolve any visible material 
prior to either dilution or administration. 
 
 
 
1.3 Preclinical Data 
A reliable porcine ischemia reperfusion (IR) injury model has been developed in our lab based on 46 swine with myocardial 
injury created by balloon occlusion of the LAD. Subsequent validation of the peri-infarct region (PIR) and intra-infarct regions 
(IIR) was performed using a novel in situ double-staining method with 1% Evans blue dye (EB) and 1% 2,3,5-
triphenyltetrazolium chloride (TTC) solution. While DEMRI is the gold-standard in identifying the non-viable myocardium, it 
does not allow direct measurement of myocardial viability. In fact, DEMRI is known to overestimate the area of non-viable 
scar due to the non-specific gadolinium distribution and the kinetics of T1 signal in vivo. MEMRI signal, on the other hand, 
is generated from the specific Mn2+ uptake by the viable, active cardiomyocytes. This recognition led to the development of 
our novel dual MEMRI-DEMRI contrast technique designed to enable rapid assessment of both the biology of viable 
myocardium and the anatomy of the nonviable scar, optimizing the evaluation of the heterogeneous PIR. In a porcine IR 


model, the injured but viable cardiomyocytes in the PIR was identified in vivo. While MEMRI and DEMRI infarct volumes 
correlated with the ex-vivo TTC stain infarct volume, MEMRI infarct (defect) volume percentage was significantly lower than 
DEMRI. The majority of the discrepancy was found in the PIR positive for both MEMRI signal (viable) and DEMRI signal 
(non-viable). These regions displayed lower SNR by MEMRI than remote zones, and lower SNR by DEMRI than core infarct 
zones, indicating heterogeneity and significant population of viable cardiomyocytes with intact Ca2+-channel function 
(MEMRI positive) surrounded by large amounts of surrounding necrotic tissue (DEMRI positive). This tissue heterogeneity 
was validated by both in situ double stain (EB/TTC) and tissue electron microscopy (TEM), which showed EB-negative/TTC-
red area of PIR in the transmural DEMRI region. In addition, TEM demonstrated preserved cellular ultrastructure in the PIR 
and the non-viable ultrastructure in the intra-infarct region (IIR). TEM exhibited significantly different scores among the cells 
in the remote region, IIR, and PIR (inter-observer agreement 0.79, p<0.05). Significant difference in the structural integrity 
of PIR generated the following score: remote (4.7±0.3), intra-infarct (1.2±0.2), and PIR (3.1±0.4*, *p<0.05).   
 
In both sub-acute and chronic porcine ischemia-reperfusion injury (IR) models, MEMRI demonstrated a consistent 
anteroseptal infarct pattern from the mid-LAD IR injury).  MEMRI of the hAMSC group revealed discrete foci of high contrast-
to-noise ratio (CNR) within infarct and peri-infarct zones, which were absent in control group. These hyperintense foci 
increased in CNR over the 3-week and 6-week time course after cell delivery in comparison to the control group. To confirm 
the specificity of the positive MEMRI signal for hAMSC engraftment, the hAMSCs for one sub-acute and one chronic IR 
swine were modified with injection of ~20% herpes simplex virus-thymidine kinase (HSV-tk) PET reporter gene (PET-RG) 
transduced hAMSCs. Serial cardiac PET-CT scans (day 0, day 7, and day 21 or 38 after injection) were then performed 
using a specific 9-[4-[F]fluoro-3-(hydroxymethyl) butyl] guanine (F-FHBG) radioisotope, which are phosphorylated and 
retained only by the viable cells expressing PET-RG. At each time point, apical PET signal co-localized with the site of cell 
injection and MEMRI signal.  Quantitative assessment of PET activity from these regions indicated significantly higher 
radiotracer uptake compared to surrounding myocardium by approximately 25-fold.  When plotted according to the AHA 16-
segment model, the integrated MEMRI and PET signal within each segment showed a significant linear correlation in both 
the sub-acute and chronic IR models. The increased MEMRI CNR tracked the survival of hAMSCs longitudinally, suggesting 
that the hAMSCs engrafted in vivo up to 6 weeks.  
 
1.4 Clinical Data to Date 
This is a clinical translation of manganese-enhanced MRI (MEMRI) to assess the peri-infarct injury in patients with severe 
ischemic cardiomyopathy (ICM). The PI recently obtained an approval for an Investigational New Drug (IND #
) to 
conduct a clinical trial of MEMRI contrast agent (SeeMoreTM, Eagle Vision, Downingtown, PA). He has already completed 
initial pilot study of safety in 6 patients and found no adverse event. Funding of this proposal will enable a clinical trial of  60 
patients with severe ICM, NICM and atrial arrhythmia (AA) and those undergoing stem cell therapy to evaluate the safety 
and efficacy of sequential acquisition of MEMRI and delayed-enhanced MRI (DEMRI) for precise tracking of stem cell 
engraftment and tissue characterization of the peri-infarct region (PIR). This novel technique designed to integrate the 
biology of the stem cells delivered into the myocardium and their regional effects on myocardia viability will elucidate the 
mechanism underlying clinical outcome in this highly morbid patient population. ICM is the primary etiology of advanced 
heart failure (HF), the leading diagnosis of hospital admission in the US. Our studies have confirmed a direct association 
between the presence of PIR and the occurrence of ventricular arrhythmia and LV remodeling, resulting in high morbidity 
and mortality in advanced HF. PIR has been recognized as an important substrate to trigger ventricular arrhythmias and 
clinical trials have demonstrated that the revascularization of the PIR result in lower incidence of CVE. In order to reliably 
evaluate the role of the PIR, we conducted 3 published clinical studies employing DEMRI, the current gold standard, to 
assess myocardial injury. These studies confirmed that the presence of ischemia, scar, and/or tissue heterogeneity in the 
PIR predicted future CVE. Although transmurality of DEMRI scar is used to predict functional recovery and improved survival 
after revascularization, DEMRI does not evaluate direct myocardial viability due to its nonspecific distribution within the 
extracellular space. The majority of the discrepancy lies within the heterogeneous PIR, resulting in overestimation of the 
non-viable infarct. To date, there is no established imaging strategy to identify the viable and, potentially, salvageable 
cardiomyocytes within the PIR. In order to address these issues, this proposal contains novel hypotheses well-grounded on 
the following 2 innovations: 1) MEMRI for management of HF. An alternative approach is to employ manganese (Mn2+), which targets 
the viable myocardium. Mn2+ is specific to the L-type calcium channels and complements the non- viable scar delineated by DEMRI. The 
dual MEMRI-DEMRI approach will, therefore, identify the viable and, potentially, salvageable cardiomyocytes outside the core infarct 
zone but inside the PIR. Our recently published study demonstrated that an overlap of DEMRI and MEMRI signal denoted a significant 
number of live cardiomyocytes (MEMRI-positive) within the non-viable (DEMRI- positive) region. This innovation will profoundly impact 
the clinical management of the advanced HF patients and AA patients including atrial fibrillation. EVP1001-1 allows highly effective 
intracellular targeting of viable cardiomyocytes with high level of safety and unique magnetic properties. 2) Assessment of therapeutic 


[MEMRI-DEMRI] 
 
Page 5 
Version:  
CONFIDENTIAL 
This material is the property of Stanford University.  Do not disclose or use except as authorized in writing by the study sponsor 
response using MEMRI. EVP1001-1 is rapidly transported, intra-cellularly, to mitochondria rich tissue such as heart, liver, and kidney, 
demonstrating significant enhancement indicative of cell metabolism and viability.  High dose clinical safety studies of SeeMoreTM with 
safety index of 45-90 correspond more favorably than the widely used clinical imaging agents (10-20 for iodinated X-ray products and 20-
60 for gadolinium). This specific, non-perfusion dependent distribution due to active intracellular uptake is one of the key attributes that 
offers real-time assessment of therapeutic response, using cardiac cellular imaging. A clinical safety trial in 6 patients have demonstrated 
negligible uptake in the intra-infarct region (IIR), reduced uptake in the PIR, and significantly higher uptake in the normal tissue to generate 
positive signal. In this trial, the mean LVEF was 32±?4%. The DEMRI vs. MEMRI (scar/myocardial volume) demonstrated significantly 
higher measurement of the scar by DEMRI in all patients (39±11%* vs. 16±3%, *p<0.01). 
 
EVP is novel manganese (Mn)-based intravenous imaging agent being developed to enhance magnetic resonance imaging 
(MRI). While Mn has long been known to have desirable magnetic and kinetic properties for MRI, use in humans was not 
initially possible due to cardiovascular depression and electrocardiogram (ECG) changes, including prolongation of PR and 
QTc intervals, associated with intravenous administration. Chelation of Mn, as had been done with gadolinium for use with 
MRI, provided relevant safety, but sacrificed desirable magnetic and kinetic properties. EVP provides Mn in a form that 
maintains the desired magnetic and kinetic properties while overcoming the cardiovascular toxicity of Mn. EVP is taken up 
into heart cells (primarily via addition of calcium to avoid cardiotoxic effects; please refer to patent listed below). The potential 
to distinguish healthy heart tissue from unhealthy heart tissue based on a specific sustained pattern of enhancement 
provides a basis for evaluating the performance of EVP in heart patients. MRI offers benefits over other imaging 
technologies. Relative to radioactive nuclear imaging procedures, MRI is 3-dimensional, provides good soft tissue 
discrimination, and is of high spatial and temporal resolution. These features have been reported to identify smaller defects 
(e.g., sub-endocardial infarcts) and match angiographic results more closely than other modalities such as SPECT. It may 
be possible to enhance the utility of MRI for heart disease further through the use of an imaging agent that is specifically 
taken up into heart cells. EVP is the only cardiac-specific agent being developed for this purpose. Unlike nuclear perfusion 
agents, EVP is not radioactive and does not require special handling, shielding, transport or storage. In addition, the specific 
pattern of enhancement achieved in the heart muscle persists over time, offering potential benefits over the nonspecific 
extracellular agents currently available for MRI or X-ray/CT procedures. This feature allows full use of the high resolution of 
MRI since there is no trade-off of high spatial resolution for temporal (first-pass) resolution. It is anticipated that the features 
offered by EVP along with the high resolution, three dimensional attributes of MRI will result in higher accuracy than is 
available with other current modalities in practice, including stress echocardiograms, cardiac MRI using gadolinium contrast 
and nuclear studies such as SPECT and PET. This will be evaluated in this study and serve as the basis for pivotal studies 
for routine clinical application.  
 
All components of EVP are USP and are approved for use as drugs in man, orally and/or intravenously. A summary of the 
Phase I safety and PK (pharmacokinetics) study are provided below. 
  
The Phase I study evaluated the safety and tolerance of EVP in humans, with special emphasis on cardiovascular safety, 
and assessed its PK profile. Overall, EVP was found to be safe at all doses. There were no serious adverse events (SAE) 
or any events requiring medical treatment. Of special importance, no signs of cardiac depression were reported. In addition, 
there was no observation of prolongation of the QTc or PR intervals or other ECG-changes that had previously been reported 
in animals for Mn. There were no changes in hematology, serum biochemistry (including liver function tests), coagulation 
parameters nor in temperature, respiratory rate or blood oxygen levels.   
 
Transient increases in HR and BP were seen. These, for the most part, reflected transient changes within the normal 
reference range. There was no obvious dose-relationship for these responses, although their duration and magnitude were 
greater for the 5-minute than for the 1-minute dose administrations.  
   
Other AEs were reported, almost all which were regarded as of mild or moderate intensity. Almost all events occurred during 
or immediately after dosing and resolved within minutes. Over 83% of the AEs occurred during dosing and over 93% 
occurred within one minute of dosing. Nearly one-third of all events resolved within one minute from dosing, over 80% within 
5 minutes, and 94% resolved within ½ hour. The most frequent types of AEs were injection-associated discomforts (warmth, 
flushing, cold, pressure, injection site changes), increased HR/BP, gastrointestinal disturbances (discomforts, nausea, 
vomiting, diarrhea), lacrimation and headache. Although gastrointestinal disturbances, such as nausea and occasional 
vomiting, resolved rapidly without treatment, these bothersome events may be avoidable through the use of a standard anti-
emetic. This proved to be beneficial in humans and also in high-dose animal studies.  
 
The PK profile reflected what was known for Mn in humans (based on reported radiotracer Mn studies), with a primary blood 
half-life under 1 minute, and less than 1% of the dose remained in the blood by 30 minutes after dosing. The performance 


of EVP was as expected based on information that was in the Investigators' Brochure. Lastly, please refer to US Patent 
#5,980,863 regarding further details of EVP contrast ingredients.  
1.5 Dose Rationale and Risk/Benefits 
The safety and tolerance of EVP1001-1 has been evaluated in healthy volunteers, in various preclinical 
models and in patients with a known myocardial infarction. The doses to be tested in this study 
demonstrated high safety factors in animal studies and were well tolerated in human studies to date. There 
have been no life-threatening or other unexpected AEs. There have been no clinically meaningful changes 
in hematology, clinical chemistry or coagulation profile, including liver function tests. Regarding the ECG, 
there were no consistent drug-related changes in QT or ST segment or prolongation of the PR interval. 
Importantly, no cardiac depression has been observed. Results in heart patients to date were similar to 
those in normal volunteers with no meaningful changes in blood or urine parameters and AEs that occur at 
the time of dosing and resolve in less than 5 minutes whose nature is that of discomforts, transient vital sign 
changes. 
2 Study Objectives 
This is a first-in-human clinical trial of combined manganese-enhanced MRI(MEMRI) and delayed-
enhanced MRI(DEMRI) to determine reliable detection and clinical significance of peri-infarct injury in both 
the ventricles and atria. An IND approval was obtained to utilize EVP1001-1 to assess peri-infarct injury in 
patients with ischemic or dilated cardiomyopathy atrial fibrillation  and those who undergo stem cell therapy 
for these indications. In preparation for a Phase I/II clinical trial, an initial safety study of 6 patients has 
been completed and no adverse events were observed. This proposal will enable a clinical trial of 50 
patients to evaluate the safety and efficacy of MEMRI-DEMRI to characterize peri-infarct injury. 
 
Primary Objective 
Specific Aim 1 evaluates the efficacy of MEMRI-DEMRI to characterize the peri-infarct injury in the 
ventricles and atria. 
 
Secondary Objective 
Specific Aim 2 is a clinical follow-up to determine the occurrence of cardiovascular events..  To evaluate the 
safety and efficacy of MEMRI-DEMRI to characterize peri-infarct injury, in the ventricles and atria, through an 
innovative approach, integrating direct biological evaluation of myocardial viability and anatomical delineation 
of scar. 
 
3 Study Design 
3.1 
General Design 
Prior to entry into this study, all subjects will sign an Informed Consent and will then  
undergo a  physical assessment  including medical history, details regarding their cardiac 
history, prescription and over-the-counter drug review,, vital signs, electrocardiogram 
(ECG), evaluation of the major organ systems, hematology, serum chemistries. In addition, 
female subjects will undergo a serum pregnancy test. 
 
Starting 30 minutes before the cardiac MRI scan (CMR), the subjects will take  16 mgs of 
ondansetron by mouth. CMR imaging will subsequently take place and then EVP1001-1 will 
then be administered approximately 15 minutes into the scan for contrast enhanced images. 
EVP1001-1 will be administered intravenously over approximately one minute. The subjects 
will each receive 0.28 mL/kg of EVP 1001-1.  All subjects will be monitored closely from before 
ondansetron administration until their discharge from the imaging center. Following MEMRI, 
delayed-enhanced MRI(DEMRI)is performed using 0.2mmol/kg gandolinium. We will compare 
the two different contrast enhanced images (EVP1001-1 vs Gadolinium) in determining the 
viable, peri-infarct, and intra-infarct myocardial tissue. 
 
To ensure a high-quality image, if the participant heart rate is greater than 65 bpm and regular 
rhythm, metoprolol will be given.  If the HR is 65 and irregular, metopolol will be given if there 


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are no contraindications (see table 1 below) 
 
Beta Blocker Administration Protocol 
 
PROTOCOL 
PARAMETER(s) 
ACTION(s) 
Assess whether -blockers are necessary 
If pulse is < 65 bpm and regular or if pulse 
is < 60 
bpm and irregular 
 
If pulse is > 65 bpm or if pulse is > 60 bpm 
and 
irregular 
 
A -blocker is not given 
 
 
 
Screen for contraindications for giving -
blocker 
Screen 
for 
contraindications 
for 
-
blockers 
If any of the following conditions exist: 
Heart rate, < 60 bpm 
Systolic blood pressure, < 100 mm Hg 
Decompensated cardiac failure 
Allergy to -blocker 
Asthma or COPD on 2-agonist inhaler 
Active bronchospasm 
Second- or third-degree atrioventricular 
block 
 
If the above conditions are absent 
A -blocker is not given 
 
 
 
 
 
 
Oral metoprolol is given 
Administer metoprolol 
If giving oral metoprolol, 
One 50-mg dose of metoprolol is given 
orally and patient is 
monitored over 1 hr, during which heart 
rate is checked every 
15 min. If heart rate remains elevated, 
perform practice 
breath-hold If heart rate still remains 
elevated, give IV 
metoprolol 
 
If giving IV metoprolol 
Two 2.5-mg doses of metoprolol are given 
5 min apart; then, two 
doses of 5 mg each are given 5 min apart. 
Total maximum dose, 
15 mg. Blood pressure and heart rate are 
checked before each 
IV dose 
Administer postprocedure care 
If only one dose of oral metoprolol is given 
No monitoring necessary, patient can 
leave department after 
study 
 
If IV metoprolol is given 
The patient is observed for 30 min 
 
If heart rate drops to < 45 bpm 
Consideration is given to administering 
atropine 
 
If bronchospasm occurs 
A -agonist inhaler is given 
Note—bpm = beats per minute, COPD = chronic obstructive pulmonary disease. 
 
 
Parameters to be Measured: 
 
A standard physical assessment  will be performed on the day of imaging (approximately 1- 
hour post dosing). Body temperature and respiration rate will be measured within 24 hours 
prior to dosing and at approximately 1- and 2-hours post dose. A standard 12-lead EKG will be 
performed both before and after the MR study to assure no significant EKG changes have 
occurred. Patient's hemodynamics will also be serially monitored. A baseline BP and HR will 
be performed before beginning the study. After EVP1001-1 contrast infusion, BP and HR will 
be measured every 2 minutes until 10 minutes post EVP1001-1 contrast infusion after which 
point a BP and HR will be measured every 5 minutes until the conclusion of the MEMRI and 
every 10 minutes until the conclusion of DEMRI study. There will be a 5-minute post 
administration observation interval outside the scanner. The patient will also have continuous 
EKG monitoring during this time. After the study, the patient will have another standard 12-lead 
EKG performed to compare with the pre-MRI 12-lead EKG. The patient's symptoms will be 


reassessed 1 hour after infusion of the EVP1001-1 contrast. A differential and serum chemistry 
profile (with liver function test) will be performed within a month prior to administration of 
EVP1001-1 and within 24 hours post EVP1001-1.  Adverse events (AEs) and discomforts will 
be recorded until discharge from the imaging center. At the 24 hour follow-up, the subject will 
be evaluated by telephone to determine if any AEs occurred from the time the subject left the 
imaging center. The subjects will have a contact number to report any AEs or to ask questions. 
Any clinically relevant changes from baseline in vital signs, ECG rhythm, clinical chemistries or 
physical condition and all AEs will be followed until resolution or until the outcome is known. 
Injection-associated discomforts will be recorded during administration and until imaging is 
completed. Primary efficacy will be based on determining whether the heart is normal or 
abnormal and if abnormal whether there is an infarction, ischemia or both. This provides the 
basis for calculating sensitivity, specificity, accuracy and predictive values. In addition, the 
location, size, conspicuity and associated confidence for any disease will be recorded. 
 
The study will be stopped for any significant adverse cardiovascular event including 
cardiovascular death, myocardial infarction, ventricular arrhythmia, ICD firing, congestive heart 
failure, hospitalization, or syncope. All serious adverse events that require medical 
intervention and/or withdrawal of a patient will be reported to the IRB within 24 hours if it 
meets the unanticipated problem reporting criteria. 
 
3.2 Primary Study Endpoints 
The key endpoints of this study include the assessment of safety, tolerance and efficacy of EVP1001-1. 
Safety and tolerance will be evaluated based on the nature and extent of AEs and injection-associated 
discomforts and changes in laboratory parameters, vital signs and ECG after administration of EVP1001-
1.  Effects, if any, of EVP1001-1 on QT/QTc intervals will be determined by comparing the intervals before 
and after EVP1001-1 across the full HR range for each patient, including use of individual correction of 
QT by RR. All subjects who receive EVP1001-1 will be included in the analyses. Pre- and post-dose results 
will be compared for vital signs, clinical laboratory parameters, ECG parameters and hemodynamic 
parameters to identify individual changes from baseline and potential systematic shifts. The presence or 
absence of infarcts and/or ischemic areas relative to the current clinical standard (by echo and gadolinium-
based cardiac MRI) along with comparison to patient outcomes will determine efficacy.  
3.3 Secondary Study Endpoints 
In addition, location, size, conspicuity, confidence, wall motion deficits and related diagnostic information will be assessed. 
. 
4 Subject Selection and Withdrawal 
4.1 Inclusion Criteria 
All subjects to be entered must: 
 
 be at least 18 years of age and less than 80 years 
 if female, be non-pregnant as evidenced by a serum pregnancy test and using a medically-approved method of birth 
control, or post-menopausal or surgically sterile 
 provide written informed consent after having received oral and written information about the study 
 patients with ischemic or dilated cardiomyopathy with an EF less than or equal to 50 or  
patients with paroxysmal or persistent atrial fibrillation  
 Have completed the MRI checklist and do not have exclusions to having an MRI 
  
 
4.2 Exclusion Criteria 
 have a positive pregnancy test (females) 
 received an investigational drug or device within 30 days prior to administration of EVP1001-1 


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 have known hypersensitivity to ondansetron or other selective serotonin 5HT3 receptor blockers 
 are taking a digitalis preparation or calcium channel blocker within 30 days to MRI 
 Contraindication to receiving metoprolol 
 have a history of torsades or prolonged QT/QTc interval (QTc > 470 msecs) 
 have NYHA Grade IV heart failure or EF less than 25 
 have abnormal liver function tests or a history of liver disease (2 times upper limits of normal) 
 have stage 11 hypertension (Systolic Blood Pressure > 140 or Diastolic BP > 90 consistently at baseline) 
 have abnormal baseline potassium or calcium (outside normal reference ranges) 
  hemoglobin less than 10 g/dl 
 
 Have a history of ventricular arrhythmia per stress test or monitoring 
 No recent cardiac intervention within 90 days (CABG, Valve, PTCA) 
 No recent CHF, MI or Angina within 60 days 
 Conduction disease (QRSd >120 msec or Sick Sinus Syndrome.) 
 No cardiac implantable device 
 Weight not to exceed 300 kgs and/or   chest circumference .36cms 
  
 
4.3 Subject Recruitment and Screening 
This is an open-label, baseline-controlled study to be conducted. Adult male or non-pregnant female 
patients who have been referred for evaluation of cardiomyopathy and atrial fibrillationand patients who 
have received stem cell therapy related to these indications will be recruited. An initial cohort study of 6 
patients to conduct safety evaluation was conducted before proceeding with  120 additional patients. In the 
initial cohort, a patient was dosed based on the Phase 1 and 2 clinical trial data evaluation completed by 
Eagle Vision Pharmaceutical, Inc. Subjects were excluded if they had received an investigational device 
within 30 days prior to administration of EVP1001-1; had a history of drug abuse or alcoholism; were taking 
a digitalis preparation; had a history of torsades; had NYHA Grade IV heart failure; had abnormal liver 
function tests or a history of liver disease; had uncontrolled hypertension; had abnormal calcium, potassium 
or hemoglobin values at baseline; if they develop a cardiac arrhythmia prior to or during either of the 
exercise tests-- EVP1001-1 was not administered. The same parameters will apply to the new group of 
subjects. 
 
5 Study Drug  
5.1 Description 
The active ingredient is EVP 103 and is provided as a sterile, non-pyrogenic powder in 50 ml vials. Please see 5.4 for 
preparation instructions 
5.2 Treatment Regimen 
The proper dose should be specified in the protocol on a "per kilogram body weight" (0.28 ml/kg) basis and must be given 
slowly over approximated one (1) minute intravenously. This same administration rate applies to flushing residual drug in 
connecting tubing/injection port. 
5.3 Method for Assigning Subjects to Treatment Groups 
Not Applicable 
5.4 Preparation and Administration of Study Drug 
The active ingredient is EVP 103 and is provided as a sterile, non-pyrogenic powder in 50 ml vials. Prior to 
administration, Drug will be prepared as follows: Using aseptic technique, transfer via syringe 10 ml of 10% Calcium 
Gluconate, USP and 30 ml of Sterile Water for Injection to a vial containing EVP 103. Shake gently to dissolve the 
powder. This prepares 40 ml of Drug. Drug should be used promptly (within 1 to 2 hours) following preparation. The 
calculated osmolality of Drug is 0.27 (nearly isomolar) and the pH is slightly acidic to neutral (5.5 to 7.0). 


 
Dilutents and drug product should be inspected to assure that a clear solution is present.  Should any precipitate or 
undissolved material remain in the vial, the vial should be gently warmed an shaken gently to dissolve any visible material 
prior to either dilution or administration 
5.5 Packaging 
Drug will be supplied as a non-pyrogenic powder in 50 ml vials. 
• Shipped in boxes of 30 vials each 
• Labeling: 
EVP 103: Sterile Lot No: 11211114 
CAUTION; FOR INVESTIGATIONAL USE ONLY 
Contents: 1161umol of EVP 103 
Store at room temperature 
Stanford University Medical Center 
269 Campus Drive, Stanford, CA 94305 
Expiration: 0612019 Vial #'s: 0001 - 0030 
5.6 Blinding of Study Drug 
Not Applicable 
5.7 Receiving, Storage, Dispensing and Return 
5.7.1 Receipt of Drug Supplies 
Drug to be delivered via Federal Express 
 
Upon receipt of the of the study treatment supplies, an inventory must be performed and a drug receipt log filled out and 
signed by the person accepting the shipment.  It is important that the designated study staff counts and verifies that the 
shipment contains all the items noted in the shipment inventory.  Any damaged or unusable study drug in a given shipment 
(active drug or comparator) will be documented in the study files.  The investigator must notify study sponsor of any damaged 
or unusable study treatments that were supplied to the investigator’s site. 
5.7.2 Storage 
The investigational drug will be in our locked cabinet and only the necessary vials will be withdrawn at the time of the 
study.  They will be mixed by the administering physician in a sterile fashion. 
 
5.7.3 Dispensing of Study Drug 
Regular study drug reconciliation will be performed to document drug assigned, drug consumed, and drug remaining. 
This reconciliation will be logged on the drug reconciliation form, and signed and dated by the study team. 
5.7.4 Return or Destruction of Study Drug 
At the completion of the study, there will be a final reconciliation of drug shipped, drug consumed, and drug remaining.  This 
reconciliation will be logged on the drug reconciliation form, signed and dated.  Any discrepancies noted will be investigated, 
resolved, and documented. 
6 Study Procedures 
 
Please refer to #3 above 


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7 Statistical Plan 
7.1 Sample Size Determination 
The total number of 0 patients will power this study adequately, however as we have extended the protocol to include the 
atrial fibrillation participants (and extra 60 pts) the difficulty in imaging the atria, coupled with the thin atrial walls, means that 
we expect a difference in DEMRI volume  of 40 (+ or – 20) in participants with early disease and 60 (+ or – 20) in participants 
with advanced disease.  Accordingly, 60 participants will be needed for the additional cohort. Our published pre-clinical 
study in 13 swine demonstrated the infarct volume percentage difference of 9% between MEMRI and DEMRI (p<0.001)17. 
This difference will enable significant delineation of the changes in the peri-infarct viability between the cell therapy and 
control arms. The preliminary porcine data presented above demonstrated a mean of 100% increase in the CNR of the peri-
infarct region and a mean of 50% decrease in the scar volume, suggesting robust MEMRI signal detection of stem cell 
engraftment and increased peri-infarct viability17,98,99. Furthermore, the clinical trial in 6 ICM patients demonstrated 
significant difference in the infarct volume between MEMRI defect and DEMRI enhancement. This difference between 
MEMRI and DEMRI represents PIR assuring reliable detection of the PIR. Employing these data, in order to detect a mean 
difference of 20% in MEMRI signal of stem cell engraftment and MEMRI-DEMRI signal of peri-infarct viability with a standard 
deviation of 5%, the t-test sample size calculation in this study has 90% power at the alpha 0.05 significance level, assuming 
an equal variance between the two distributions. 
7.2 Statistical Methods 
Student’s t-test to compare MEMRI and DEMRI measurement of the infarct and viable myocardium. Pearson’s correlation 
to generate any association between stem cell engraftment/peri-infarct viability and functional restoration and/or clinical 
outcome. 
 
7.3 Subject Population(s) for Analysis 
We expect to enroll 60 patients with various cardiomyopathies including NICM, ICM, and ACM (dilated cardiomyopathy, 
ischemic cardiomyopathy, and atrial cardiomyopathy). Our goal is to demonstrate improved sensitivity and specificity 
of identifying viable myocardium and PIR in the ventricles and atria in various cardiac patients to help improve clinical 
management 
8 Safety and Adverse Events 
8.1 Definitions 
Unanticipated Problems Involving Risk to Subjects or Others 
Any incident, experience, or outcome that meets all of the following criteria:  
 Unexpected in nature, severity, or frequency  (i.e. not described in study-related documents such as the IRB-
approved protocol or consent form, the investigators brochure, etc) 
 Related or possibly related to participation in the research (i.e. possibly related means there is a reasonable 
possibility that the incident experience, or outcome may have been caused by the procedures involved in the 
research) 
 Suggests that the research places subjects or others at greater risk of harm (including physical, psychological, 
economic, or social harm). 
 
Adverse Event 
An adverse event (AE) is any symptom, sign, illness or experience that develops or worsens in severity during the course 
of the study.  Inter-current illnesses or injuries should be regarded as adverse events.  Abnormal results of diagnostic 
procedures are considered to be adverse events if the abnormality: 
 results in study withdrawal 
 is associated with a serious adverse event 
 is associated with clinical signs or symptoms 
 leads to additional treatment or to further diagnostic tests 


 is considered by the investigator to be of clinical significance 
 
Serious Adverse Event 
Adverse events are classified as serious or non-serious.  A serious adverse event is any AE that is:  
 fatal 
 life-threatening 
 requires or prolongs hospital stay 
 results in persistent or significant disability or incapacity 
 a congenital anomaly or birth defect 
 an important medical event 
 
Important medical events are those that may not be immediately life threatening, but are clearly of major clinical significance. 
They may jeopardize the subject, and may require intervention to prevent one of the other serious outcomes noted above.  
For example, drug overdose or abuse, a seizure that did not result in in-patient hospitalization, or intensive treatment of 
bronchospasm in an emergency department would typically be considered serious.  
 
All adverse events that do not meet any of the criteria for serious should be regarded as non-serious adverse events.  
 
Adverse Event Reporting Period 
The study period during which adverse events must be reported is normally defined as the period from the initiation of any 
study procedures to the end of the study treatment follow-up.  For this study, the study treatment follow-up is defined as 30 
days following the last administration of study treatment.  
 
Pre-existing Condition 
A preexisting condition is one that is present at the start of the study.  A preexisting condition should be recorded as an 
adverse event if the frequency, intensity, or the character of the condition worsens during the study period. 
 
General Physical Examination Findings 
At screening, any clinically significant abnormality should be recorded as a preexisting condition.  At the end of the study, 
any new clinically significant findings/abnormalities that meet the definition of an adverse event must also be recorded and 
documented as an adverse event.  
 
Post-study Adverse Event 
All unresolved adverse events should be followed by the investigator until the events are resolved, the subject is lost to 
follow-up, or the adverse event is otherwise explained.  At the last scheduled visit, the investigator should instruct each 
subject to report any subsequent event(s) that the subject, or the subject’s personal physician, believes might reasonably 
be related to participation in this study.  The investigator should notify the study sponsor of any death or adverse event 
occurring at any time after a subject has discontinued or terminated study participation that may reasonably be related to 
this study.  The sponsor should also be notified if the investigator should become aware of the development of cancer or of 
a congenital anomaly in a subsequently conceived offspring of a subject that has participated in this study.  
 
Abnormal Laboratory Values 
A clinical laboratory abnormality should be documented as an adverse event if any one of the following conditions is met:  
 The laboratory abnormality is not otherwise refuted by a repeat test to confirm the abnormality 
 The abnormality suggests a disease and/or organ toxicity 
 The abnormality is of a degree that requires active management; e.g. change of dose, discontinuation of the drug, 
more frequent follow-up assessments, further diagnostic investigation, etc. 
 
Hospitalization, Prolonged Hospitalization or Surgery 
Any adverse event that results in hospitalization or prolonged hospitalization should be documented and reported as a 
serious adverse event unless specifically instructed otherwise in this protocol.  Any condition responsible for surgery should 
be documented as an adverse event if the condition meets the criteria for and adverse event.  
 
Neither the condition, hospitalization, prolonged hospitalization, nor surgery are reported as an adverse event in the 
following circumstances: 


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 Hospitalization or prolonged hospitalization for diagnostic or elective surgical procedures for a preexisting condition.  
Surgery should not be reported as an outcome of an adverse event if the purpose of the surgery was elective or 
diagnostic and the outcome was uneventful. 
 Hospitalization or prolonged hospitalization required to allow efficacy measurement for the study. 
 Hospitalization or prolonged hospitalization for therapy of the target disease of the study, unless it is a worsening or 
increase in frequency of hospital admissions as judged by the clinical investigator. 
8.2 Recording of Adverse Events 
At each contact with the subject, the investigator must seek information on adverse events by specific questioning and, as 
appropriate, by examination.  Information on all adverse events should be recorded immediately in the source document, 
and also in the appropriate adverse event module of the case report form (CRF).  All clearly related signs, symptoms, and 
abnormal diagnostic procedures results should recorded in the source document, though should be grouped under one 
diagnosis. 
 
All adverse events occurring during the study period must be recorded.  The clinical course of each event should be followed 
until resolution, stabilization, or until it has been determined that the study treatment or participation is not the cause.  Serious 
adverse events that are still ongoing at the end of the study period must be followed up to determine the final outcome.  Any 
serious adverse event that occurs after the study period and is considered to be possibly related to the study treatment or 
study participation should be recorded and reported immediately. 
 
As for intravenous injection of any investigational drug, competent personnel and emergency facilities must be available to 
address severe and possibly delayed reactions after administration of EVP1001-1 or severe responses to the stress prior 
to EVP1001-1 administration. Subjects will be observed for AEs starting with the pre-treatment (with ondansetron), during 
and for at least 1 hour after EVP1001-1 administration during which time emergency equipment will be readily available. 
AEs will be recorded until discharge from the imaging center. At the 24-hour follow-up, the subject will be evaluated by 
telephone to determine if any AE occurred from the time the subject left the imaging center. In addition, the subjects will 
have a contact number to report any AE or to ask questions. Any clinically relevant changes from baseline in vital signs, 
ECG rhythm, clinical chemistries or physical condition and all AEs will be followed until resolution or until the outcome is 
known. AEs, if any, will be recorded on the CRF (case report form) along with the action(s) required, time of onset, duration, 
intensity, and outcome. A judgment will be made by the investigator as to the causality of each event. If a subject has more 
than one incidence of a given AE, that AE with the greatest severity will be used for analyses. If a cluster of AEs are related, 
a term describing the syndrome or overall adverse experience should be captured. 
 
8.3 Reporting of Serious Adverse Events and Unanticipated Problems 
Investigators and the protocol sponsor must conform to the adverse event reporting timelines, formats and requirements of 
the various entities to which they are responsible, but at a minimum those events that must be reported are those that are: 
 related to study participation, 
 unexpected, and  
 serious or involve risks to subjects or others  
(see definitions, section 8.1).   
If the report is supplied as a narrative, the minimum necessary information to be provided at the time of the initial report 
includes: 
 
Study identifier 
 
Study Center 
 
Subject number 
 
A description of the event 
 
Date of onset 
 
Current status 
 
Whether study treatment was discontinued 
 
The reason why the event is classified as serious 
 
Investigator 
assessment 
of 
the 
association 
between the event and study treatment 
 
8.3.1 Investigator reporting: notifying the Stanford IRB and Study Sponsor 
An initial cohort study of 6 patients was conducted under protocol #24224. The safety evaluations were conducted with no 
adverse events before proceeding with the remaining  120 patients. In this initial cohort, a patient will be dosed based on 


the Phase 1 and 2 clinical trial data evaluation completed by Eagle Vision Pharmaceutical, Inc. The stopping rule will include 
any significant adverse cardiovascular event including cardiovascular death, myocardial infarction, ventricular arrhythmia, , 
congestive heart failure, hospitalization, or syncope. All serious adverse events that require medical intervention and/or 
withdrawal of a patient will be reported to the IRB within 24 hours. Any unexpected fatal or life-threatening suspected 
adverse reactions will be reported to the FDA no later than 7 calendar days after initial receipt of the information. Any 
serious, unexpected suspected adverse reactions, findings from other clinical, animal, or in-vitro studies that suggest 
significant human risk, and a clinically important increase in the rate of a serious suspected adverse reaction will be reported 
to the FDA and all investigators no later than 15 calendar days after determining that the information qualifies for reporting 
[21 CFR 312.32(c)(1)]. An annual progress report will be submitted to the FDA as required within 60 days of the anniversary 
of the date the IND went into effect. 
 
Copies of each report and documentation of IRB notification and receipt will be kept in the Clinical Investigator’s study file. 
 
Reporting Deaths:  more rapid reporting requirements 
Concerning deaths that occur during the course of a research study, the following describes the more rapid reporting 
requirement of the Stanford IRB for specific situations: 
 Report the event within 24 hours when the death is unforeseen (unexpected) and indicates participants or others 
are at increased risk of harm. 
 Report the event within 72 hours, for all other deaths, regardless of whether the death is related to study participation. 
 
 
Other Reportable events: 
For clinical drug trials, the following events are also reportable to the Stanford IRB: 
 Any adverse experience that, even without detailed analysis, represents a serious unexpected adverse event that is 
rare in the absence of drug exposure (such as agranulocytosis, hepatic necrosis, Stevens-Johnson syndrome). 
 Any adverse event that would cause the sponsor to modify the investigators brochure, protocol or informed consent 
form, or would prompt other action by the IRB to assure protection of human subjects. 
 Information that indicates a change to the risks or potential benefits of the research, in terms of severity or frequency. 
For example:  
– An interim analysis indicates that participants have a lower rate of response to treatment than initially expected. 
– Safety monitoring indicates that a particular side effect is more severe, or more frequent than initially expected. 
– A paper is published from another study that shows that an arm of your research study is of no therapeutic value. 
 Change in FDA safety labeling or withdrawal from marketing of a drug, device, or biologic used in a research protocol. 
 Breach of confidentiality 
 Change to the protocol taken without prior IRB review to eliminate apparent immediate hazard to a research 
participant. 
 Incarceration of a participant when the research was not previously approved under Subpart C and the investigator 
believes it is in the best interest of the subject to remain on the study. 
 Complaint of a participant when the complaint indicates unexpected risks or the complaint cannot be resolved by 
the research team. 
 Protocol violation (meaning an accidental or unintentional deviation from the IRB approved protocol) that in the 
opinion of the investigator placed one or more participants at increased risk, or affects the rights or welfare of 
subjects. 
 
Reporting Process: 
Any study-related unanticipated problem posing risk of harm to subjects or others, and any type of serious adverse event, 
must be reported to the study sponsor by telephone within 24 hours of the event.  To report such events, a Serious Adverse 
Event (SAE) form must be completed by the investigator and faxed to the study sponsor within 24 hours.  The investigator 
will keep a copy of this SAE form on file at the study site.  Report serious adverse events by phone and facsimile to: 
 
Phillip C. Yang, MD 


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Stanford University Medical Center 
Center for Clinical Science Research (CCSR), 3115C 
650-498-8008 (phone) 
650-724-4034 (facsimile) 
 
Within the following 48 hours, the investigator must provide further information on the serious adverse event or the 
unanticipated problem in the form of a written narrative.  This should include a copy of the completed Serious Adverse Event 
form, and any other diagnostic information that will assist the understanding of the event.  Significant new information on 
ongoing serious adverse events should be provided promptly to the study sponsor 
 
8.3.2 Sponsor reporting: Notifying the FDA 
The study sponsor is required to report certain study events in an expedited fashion to the FDA.  These written notifications 
of adverse events are referred to as IND safety reports. The following describes the safety reporting requirements by timeline 
for reporting and associated type of event: 
 
 Within 7 calendar days 
Any study event that is: 
– associated with the use of the study drug 
– unexpected,  
– fatal or life-threatening, and  
 
 Within 15 calendar days 
Any study event that is: 
– associated with the use of the study drug, 
– unexpected, and 
– serious, but not fatal or life-threatening 
-or- 
– a previous adverse event that was not initially deemed reportable but is later found to fit the criteria for reporting 
(reporting within 15 calendar days from when event was deemed reportable). 
Any finding from tests in laboratory animals that:  
– suggest a significant risk for human subjects including reports of mutagenicity, teratogenicity, or carcinogenicity. 
 
Additional reporting requirements 
Sponsors are also required to identify in IND safety reports all previous reports concerning similar adverse events and to 
analyze the significance of the current event in light of the previous reports. 
 
Reporting Process 
Adverse events may be submitted on FDA Form 3500A or in a narrative format. If supplied as in a narrative format, the 
minimum information to be supplied is noted above at the beginning of section 8.3. The contact information for submitting 
IND safety reports is noted below: 
 
, M.S., MSDRA: Regulatory Health Project Manager: Division of Medical Imaging Products Office of Drug 
Evaluation IV : Center for Drug Evaluation and Research : Food and Drug Administration 
10903 New Hampshire Avenue, 
 : Silver Spring, MD 20993 
Phone: 
 ·Fax: 
: 
@fda.hhs.gov 
8.4 Stopping Rules 
Those patients meeting the exclusion criteria or those patients wishing to withdraw will be terminated from the study. This 
will not prohibit the patient from receiving standard medical care outside the study. Should a serious adverse event 
occur, we will first and foremost stabilize the patient. Further administration of our contrast study will be stopped. 
Depending on the severity of the adverse event, standard medical care will be provided including inpatient hospitalization 
if deemed necessary. Patient will be overseen directly by a physician at all times during the imaging exam to ensure 
appropriate medical care is always provided. Emergency medications will be present and up to date at all times.  


8.5 Medical Monitoring 
It is the responsibility of the Principal Investigator to oversee the safety of the study at his/her site.  This safety monitoring 
will include careful assessment and appropriate reporting of adverse events as noted above, as well as the construction 
and implementation of a site data and safety-monitoring plan (see section 9 Auditing, Monitoring and Inspecting).  Medical 
monitoring will include a regular assessment of the number and type of serious adverse events. 
 
Relevant clinical data will be linked only to the unique code. Our data will be maintained in an electronic spreadsheet. 
The spreadsheet has a unique identifier for each participant. The computer which the spreadsheet is maintained on is 
encrypted. This computer is located in a locked office in the Department of Cardiovascular Medicine at Stanford 
University. De-identification of data and specimen will be handled by the study personnel responsible for collection of 
the specimen. Only the Protocol director has the key to the code. That is also on an electronic spreadsheet that is on an 
encrypted computer. The only data that is transferred is the coded data. This is transferred through secure email 
according to the Stanford Computing guidelines. 
9 Data Handling and Record Keeping 
9.1 Confidentiality 
Information about study subjects will be kept confidential and managed according to the requirements of the Health 
Insurance Portability and Accountability Act of 1996 (HIPAA).  Those regulations require a signed subject authorization 
informing the subject of the following:  
 What protected health information (PHI) will be collected from subjects in this study 
 Who will have access to that information and why 
 Who will use or disclose that information 
 The rights of a research subject to revoke their authorization for use of their PHI.  
 
In the event that a subject revokes authorization to collect or use PHI, the investigator, by regulation, retains the ability to 
use all information collected prior to the revocation of subject authorization.  For subjects that have revoked authorization 
to collect or use PHI, attempts should be made to obtain permission to collect at least vital status (i.e. that the subject is 
alive) at the end of their scheduled study period. 
9.2 Source Documents 
Source data is all information, original records of clinical findings, observations, or other activities in a clinical trial necessary 
for the reconstruction and evaluation of the trial.  Source data are contained in source documents.  Examples of these 
original documents, and data records include: hospital records, clinical and office charts, laboratory notes, memoranda, 
subjects’ diaries or evaluation checklists, pharmacy dispensing records, recorded data from automated instruments, copies 
or transcriptions certified after verification as being accurate and complete, microfiches, photographic negatives, microfilm 
or magnetic media, x-rays, subject files, and records kept at the pharmacy, at the laboratories, and at medico-technical 
departments involved in the clinical trial. 
9.3 Case Report Forms 
The study case report form (CRF) is the primary data collection instrument for the study.  All data requested on the CRF 
must be recorded.  All missing data must be explained.  If a space on the CRF is left blank because the procedure was not 
done or the question was not asked, write “N/D”.  If the item is not applicable to the individual case, write “N/A”.  All entries 
should be printed legibly in black ink.  If any entry error has been made, to correct such an error, draw a single straight line 
through the incorrect entry and enter the correct data above it.  All such changes must be initialed and dated.  DO NOT 
ERASE OR WHITE OUT ERRORS.  For clarification of illegible or uncertain entries, print the clarification above the item, 
then initial and date it. 
9.4 Records Retention 
 
It is the investigator’s responsibility to retain study essential documents for at least 2 years after the last approval of a 
marketing application in their country and until there are no pending or contemplated marketing applications in their country 
or at least 2 years have elapsed since the formal discontinuation of clinical development of the investigational product.  


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These documents should be retained for a longer period if required by an agreement with the sponsor.  In such an instance, 
it is the responsibility of the sponsor to inform the investigator/institution as to when these documents no longer need to be 
retained.  
 
10 Study Monitoring, Auditing, and Inspecting 
10.1 Study Monitoring Plan 
The investigator will allocate adequate time for such monitoring activities.  The Investigator will also ensure that the monitor 
or other compliance or quality assurance reviewer is given access to all the above noted study-related documents and study 
related facilities (e.g. pharmacy, diagnostic laboratory, etc.), and has adequate space to conduct the monitoring visit. 
10.2 Auditing and Inspecting 
The investigator will permit study-related monitoring, audits, and inspections by the EC/IRB, the sponsor, government 
regulatory bodies, and University compliance and quality assurance groups of all study related documents (e.g. source 
documents, regulatory documents, data collection instruments, study data etc.).  The investigator will ensure the capability 
for inspections of applicable study-related facilities (e.g. pharmacy, diagnostic laboratory, etc.). 
 
Participation as an investigator in this study implies acceptance of potential inspection by government regulatory authorities 
and applicable University compliance and quality assurance offices. 
11 Ethical Considerations 
This study is to be conducted according to US and international standards of Good Clinical Practice (FDA Title 21 part 312 
and International Conference on Harmonization guidelines), applicable government regulations and Institutional research 
policies and procedures. 
 
This protocol and any amendments will be submitted to a properly constituted independent Ethics Committee (EC) or 
Institutional Review Board (IRB), in agreement with local legal prescriptions, for formal approval of the study conduct.  The 
decision of the EC/IRB concerning the conduct of the study will be made in writing to the investigator and a copy of this 
decision will be provided to the sponsor before commencement of this study.  The investigator should provide a list of 
EC/IRB members and their affiliate to the sponsor. 
 
All subjects for this study will be provided a consent form describing this study and providing sufficient information for 
subjects to make an informed decision about their participation in this study.  See Attachment 1 for a copy of the Subject 
Informed Consent Form.  This consent form will be submitted with the protocol for review and approval by the EC/IRB for 
the study.  The formal consent of a subject, using the EC/IRB-approved consent form, must be obtained before that subject 
undergoes any study procedure.  The consent form must be signed by the subject or legally acceptable surrogate, and the 
investigator-designated research professional obtaining the consent.  
12 Study Finances 
12.1 Funding Source 
Pending at this time 
12.2 Conflict of Interest 
Any investigator who has a conflict of interest with this study (patent ownership, royalties, or financial gain greater than the 
minimum allowable by their institution, etc.) must have the conflict reviewed by a properly constituted Conflict of Interest 
Committee with a Committee-sanctioned conflict management plan that has been reviewed and approved by the study 
sponsor prior to participation in this study.  All Stanford University investigators will follow the University conflict of interest 
policy. 


13 Publication Plan 
Neither the complete nor any part of the results of the study carried out under this protocol, nor any of the information 
provided by the sponsor for the purposes of performing the study, will be published or passed on to any third party without 
the consent of the study sponsor.  Any investigator involved with this study is obligated to provide the sponsor with complete 
test results and all data derived from the study. 
14 Attachments 
 Sample Consent Form 
 Study Procedures Flowchart/Table 
 Investigational New Drugs Pharmacy Policy 
 Specimen Preparation And Handling