Conditions: Heart Failure Cardiomyopathy Ventricular Dysfunction
Keywords: Heart Failure Left Ventricular Assist Device Heart Transplantation Cardiomyopathy, Destination Therapy Cell Therapy Bridge to Transplant
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 159
Healthy volunteers: no

Brief summary:
The main purpose of this research is to determine whether injecting mesenchymal precursor cells (MPC) into the heart during surgery to implant a left ventricular assist device (LVAD) is safe. MPCs are normally present in human bone marrow and have been shown to increase the development of blood vessels and new heart muscle cells in the heart. In addition, this research is being done to test whether injecting the MPCs into the heart is effective in improving heart function.

Detailed description:
Intramyocardial injection of mesenchymal precursor cells (MPC) in patients with advanced heart failure who are treated with left ventricular assist device (LVAD) implantation may result in a renewable source of proliferating functional cardiomyocytes; induce development of capillaries and larger-size blood vessels to supply oxygen and nutrients to endogenous myocardium and newly-implanted cardiomyocytes; and release factors capable of paracrine signaling.

Arms:
arm 1: Intramyocardial injections of 150 million MPCs arm 2: Intramyocardial injections of 50% Alpha-MEM/42.5% ProFreeze NAO Freezing Medium/7.5% DMSO

Interventions: intervention 1: MPC Intramyocardial Injection intervention 2: Control Solution
Intervention descriptions: intervention 1: Intramyocardial injection of 150 million mesenchymal precursor cells at the time of LVAD implantation intervention 2: None

Protocol document:
Prot_SAP_000.pdf: 
Safety & Efficacy of Intramyocardial Injection of Mesenchymal Precursor Cells on 
Myocardial Function in LVAD Receipients (LVAD MPC II)
NCT02362646 
Document Date: August 2018


InCHOIR  
 
 Date Written: March 2015 
Document Number: LVAD MPC II Trial Protocol Rev 4.1  
Date Revised: October 2016 
Page 1 of 68 
 
Date Effective: 
 
CONFIDENTIAL 
 
Cardiothoracic Surgical Trials Network 
 
SAFETY & EFFICACY OF INTRAMYOCARDIAL INJECTION OF 
MESENCHYMAL PRECURSOR CELLS ON MYOCARDIAL FUNCTION 
IN LVAD RECIPIENTS (LVAD MPC II)  
 
 
Protocol 
 
 
 
 
 
 
 
 
 
 
 
Sponsored By NHLBI, NINDS, and CIHR  
CT Surgery Network Research Group 
   
 
 
Data Coordinating Center 
InCHOIR 
Icahn School of Medicine at Mount Sinai 
New York 
 
October 2016 
Revision 4.1 
 
 
CONFIDENTIAL 
 


InCHOIR  
 
 Date Written: March 2015 
Document Number: LVAD MPC II Trial Protocol Rev 4.1  
Date Revised: October 2016 
Page 2 of 68 
 
Date Effective: 
 
CONFIDENTIAL 
  
TABLE OF CONTENTS 
 
 
 
 
 
 
 
Abstract ......................................................................................................................................... 11 
Data Collection Schedule .............................................................................................................. 13 
Objectives ..................................................................................................................................... 15 
Background And Rationale ........................................................................................................... 15 
Study Design ................................................................................................................................. 23 
Endpoints ...................................................................................................................................... 23 
Study Subjects ............................................................................................................................... 24 
Eligibility Criteria ......................................................................................................................... 25 
Treatment Assignments ................................................................................................................ 26 
Randomization .............................................................................................................................. 26 
Treatment Intervention.................................................................................................................. 26 
LVAD Implant .............................................................................................................................. 27 
Definition and Measurement of Endpoints ................................................................................... 27 
Adverse Events ............................................................................................................................. 33 
Clinical Centers ............................................................................................................................. 44 
Investigators .................................................................................................................................. 45 
Site Initiation ................................................................................................................................. 46 
Data Collection ............................................................................................................................. 46 
Data Management ......................................................................................................................... 56 
Statistical Analysis and Sample Size Justification ........................................................................ 57 
Organization of the Study ............................................................................................................. 61 
References ..................................................................................................................................... 64 
 
APPENDICES  
Appendix I:  Intramyocardial Injection Procedures   
 
 
 


InCHOIR  
 
 Date Written: March 2015 
Document Number: LVAD MPC II Trial Protocol Rev 4.1  
Date Revised: October 2016 
Page 3 of 68 
 
Date Effective: 
 
CONFIDENTIAL 
TABLE OF CHANGES 
 
Version 
         Section 
Change 
Reason 
Page 
2.0 
Title Page 
Revised title page to indicate Rev 2.0 and date of 
August 2014.  
Protocol update 
1 
2.0 
Footer 
Changed footer Rev 2.0 and date of August 2014. 
Protocol update 
All 
2.0 
Definitions, Acronyms & 
Abbreviations 
Removed definitions, acronyms and abbreviations not 
found in the protocol and added Clinical Trial 
Application, Personal Information Protection and 
Electronic Documents Act and mechanical circulatory 
support to the list.  
Internal consistency 
within protocol 
6-7 
2.0 
Study Synopsis 
Added Survival as a Secondary Endpoint 
Protocol Update 
8 
2.0 
Secondary Endpoints 
Hospitalizations added as a secondary endpoint 
Protocol update 
9, 21, 29 
2.0 
Data Collection Schedule 
Updated Data Collection Schedule  
Internal consistency 
within protocol 
10-11 
2.0 
Selected Inclusion 
Criteria 
Updated Item #2 to indicate that FDA-approved 
LVADs will be utilized at US sites and Health 
Canada-approved LVADs will be utilized at Canadian 
sites. 
Regulatory clarification 
9 
2.0 
Exclusion Criteria 
Concomitant arrhythmia ablation at the time of LVAD 
implantation added as an exclusion criterion. 
Protocol Update 
9, 22 
2.0 
Study Design 
Updated to indicate that FDA-approved LVADs will 
be utilized at US sites and Health Canada-approved 
LVADs will be utilized at Canadian sites. 
Regulatory clarification 
19-20 
2.0 
Study Design 
Clarified description of patient follow-up duration 
For clarity 
20 
2.0 
Physiological 
Assessments 
Removed anti-HLA sensitization post-implant 
Internal consistency 
within protocol 
21 
2.0 
Study Subjects 
Updated to indicate that FDA-approved LVADs will 
be utilized at US sites and Health Canada-approved 
LVADs will be utilized at Canadian sites. 
Regulatory clarification 
21 
2.0 
Inclusion Criteria 
Updated Item #6 to indicate that FDA-approved 
LVADs will be utilized at US sites and Health 
Canada-approved LVADs will be utilized at Canadian 
sites. 
Regulatory clarification 
22 
2.0 
Exclusion Criteria 
Anti-HLA antibody titer exclusion criteria footer 
revised to specify type of PRA documented by the 
clinical site laboratory and type documented by the 
core laboratory.   
For clarity 
22 
2.0 
Randomization 
Revised Cohort 1 to MPCs in the first sentence of the 
section.  
Internal consistency 
within protocol 
23 
2.0 
LVAD Implant and 
Management 
 
Updated to indicate that FDA-approved LVADs will 
be utilized at US sites and Health Canada-approved 
LVADs will be utilized at Canadian sites. 
Regulatory clarification 
24 
2.0 
Secondary Endpoints 
Updated CTSN Neurocognition Committee to 
Neurocognitive Core lab.   
Internal consistency 
within protocol 
29 
2.0 
Secondary Endpoints 
Added Spanish as a language validated for the 
neurocognitive batteries.  
For consistency between 
protocol and core 
laboratory documents 
29 
2.0 
Adverse Events 
Revised second paragraph to include “in compliance 
with their institutional policies” at the end of the 
sentence. 
Protocol update 
30 
2.0 
Adverse Events 
Added Research Ethics Boards 
To reflect inclusion of 
Canadian sites in study 
 30, 31,  
38-40, 55 
2.0 
Expedited Reporting 
Added description of SAE reporting to Health Canada 
To reflect inclusion of 
Canadian sites in study 
31 
2.0 
Clinical Centers and 
Investigators 
Added additional information on and documentation 
required of Canadian sites 
To reflect inclusion of 
Canadian sites in study 
38-39 
2.0 
Conflict of Interest 
Added mention of Tri-Council Policy and removed 
“and no less than annually” from the last sentence.  
To reflect inclusion of 
Canadian sites in study 
and for consistency with 
Network procedures 
40 


InCHOIR  
 
 Date Written: March 2015 
Document Number: LVAD MPC II Trial Protocol Rev 4.1  
Date Revised: October 2016 
Page 4 of 68 
 
Date Effective: 
 
CONFIDENTIAL 
Version 
         Section 
Change 
Reason 
Page 
2.0 
Patient 
Confidentiality/HIPAA 
Certification 
Added Health Canada to list of possible reviewers of 
data and PIPEDA as governing regulation 
For clarity 
40 
2.0 
Site Initiation 
Added “and other regulatory documents” to second 
sentence of section.  
For clarity 
40 
2.0 
Data Collection 
Clarified which case report forms will capture each 
assessment.   
For consistency between 
protocol and electronic 
data capture system 
40-46 
2.0 
Pre-Screening Failure 
Form 
Renamed section to Screening Failure  
For consistency between 
protocol and electronic 
data capture system 
40 
2.0 
Pre-Screening Failure 
Form 
Clarified the HIPAA and PIPEDA compliant 
information collected.  
For consistency between 
protocol and electronic 
data capture system 
40 
2.0 
Informed Consent 
Changed description of authorization for use and 
disclosure of private information 
To reflect inclusion of 
Canadian sites in study 
41 
2.0 
Demographics 
Updated the demographic data collected. 
For consistency between 
protocol and electronic 
data capture system 
41 
2.0 
Physical Exam 
Removed BSA as it will be automatically calculated 
from height and weight in the electronic data capture 
system.  
For consistency between 
protocol and electronic 
data capture system  
40 
2.0 
Medications 
Clarified how medications will be collected and 
documented during the course of the trial. 
For consistency between 
protocol and electronic 
data capture system 
41 & 46 
2.0 
Laboratory Assessments 
Removed  HCO3 or CO2 (mM/L), total bilirubin 
(mg/dL), alkaline phosphate (IU/L), lactate 
dehydrogenase (LDH; U/L), coagulation profile, red 
blood cell (103/mL), neutrophils (%) and lymphocytes 
(%) laboratory assessments.  
Protocol update 
42 & 45 
2.0 
Immunologic Assessment 
Removed baseline immunologic assessment sample 
obtained within 24 hours prior to randomization.  
Protocol update 
43 
2.0 
Echocardiography 
Revised collection window to 14 days prior to 
randomization. 
Protocol update 
43 
2.0 
Echocardiography 
Changed the method of submitting echocardiograms 
to the Core Lab from shipping to uploading.  
For consistency between 
protocol and electronic 
data capture system 
43 
2.0 
Modified Rankin Scale 
Added Appendix VII as Modified Rankin Scale 
location.  
Protocol update 
43 & 48 
2.0 
Intervention Injection 
Verification 
Revised method for verifying and submitting injection 
verification.  
For consistency between 
protocol and electronic 
data capture system 
44 
2.0 
Post-Intervention Data 
Collection 
Removed hemodynamics data collection.   
Internal consistency 
within protocol 
46 
2.0 
Missed Visit 
Revised how missed visits will be captured.  
For consistency between 
protocol and electronic 
data capture system 
49 
2.0 
Monitoring 
Added age and removed initials and date of birth from 
the data points to be verified during a monitoring 
visit.  
For consistency between 
protocol and electronic 
data capture system 
51 
2.0 
Monitoring 
Updated close-out visit description 
For consistency between 
protocol and DCC 
procedures 
51 
2.0 
Statistical Analysis and 
Sample Size Justification 
Add analytical plan for hospitalization secondary 
endpoints.  
Protocol update 
54 
2.0 
Event Adjudication 
Committee 
Updated description of EAC membership 
For consistency between 
protocol and DCC 
procedures 
55 
2.0 
DCC, Investigator and 
Mesoblast Sections 
Updated to include Canadian documentation and 
requirements 
For clarity 
55-56 


InCHOIR  
 
 Date Written: March 2015 
Document Number: LVAD MPC II Trial Protocol Rev 4.1  
Date Revised: October 2016 
Page 5 of 68 
 
Date Effective: 
 
CONFIDENTIAL 
Version 
         Section 
Change 
Reason 
Page 
2.0 
Appendix I 
Revised to Injection Verification Case Report Form to 
Treatment Intervention Case Report Form and 
provided updated instructions for verifying injections.  
Consistency between 
protocol and electronic 
data capture system 
60-62 
2.0 
Appendix II 
Early terminations guidelines for LVAD wean 
clarified.  
Consistency within 
protocol 
64 
2.0 
Appendix VII 
Renamed Appendix from NIH Stroke Scale 
Administration Guidelines to Neurological 
Assessments. 
Consistency within 
protocol 
73 
2.0 
Appendix VII 
Inserted NIH Stroke Scale Administration Guidelines 
header.  
Internal consistency 
within protocol 
73 
2.0 
Appendix VII 
Added Modified Rankin Scale 
Internal consistency 
within protocol 
77 
3.0 
Title Page 
Revised title page to indicate Rev 3.0 and date of 
March 2015  
Protocol update 
1 
3.0 
1 Endpoints and 2 
Endpoints 
Changed wean and functional status assessments  to 
over 6 months (primary endpoint) and 12 months 
(secondary endpoint) 
To align data collection 
schedule better with 
expected time on VAD 
for BTT patients 
9, 21, 26-29 
3.0 
Weaning and Six Minute 
Walk Schedule 
Added detail on timepoints for these assessments 
Protocol clarification 
9, 21, 26, 28 
3.0 
Exclusion Criteria 
Added history of known or suspected hypercoagulable 
state as an exclusion criterion 
Consensus of clinical 
investigators 
10, 24 
3.0 
Duration, Study Design 
Changed follow-up duration from 12 to 24 months 
For collection of long 
term follow up data 
9, 21 
3.0 
Data Collection Schedule 
Changed 90 day wean and chemokine and cytokine 
assessment to 4 months ; added detail on LDH 
collection to Laboratory Assessments; added 24 
month Vital Status Follow-up 
For internal consistency 
within protocol 
11-12 
3.0 
Rationale for Selection of 
the Efficacy Endpoint   
 
Changed primary endpoint to weans conducted over 6 
months 
For internal consistency 
within protocol 
18 
3.0 
Physiological 
Assessments 
Updated WMSI assessment schedule 
Protocol update 
22, 29 
3.0 
Functional Status 
Changed scheduled to 9 and 12 months 
Protocol update 
27 
3.0 
Cytokine Quantification 
Changed assessment schedule to 120 days 
Protocol update 
31 
3.0 
Hemolysis 
Added information on assessments to be conducted in 
event of hemolysis 
Protocol update 
36 
3.0 
Laboratory Assessment 
 
Added 4 months to biospecimen collection, laboratory 
assessment, physical exam, medications and early 
stopping events schedule 
Protocol update 
46-48 
3.0 
Laboratory Assessments 
Added LDH detail to laboratory assessment 
Protocol update 
46 
3.0 
LVAD Wean and 
Functional Assessment 
 
Updated echo, 6MWT, wean and functional status 
data collection timepoints  
To align data collection 
schedule better with 
expected time on VAD 
for BTT patients 
46-48 
3.0 
Vital Status Follow-Up 
Added 24 month follow-up for check on vital status 
For collection of long 
term follow up data 
49 
3.0 
Statistical Analysis and 
Sample Size Justification   
 
Provided updated information on statistical analysis 
plan and sample size calculation 
Protocol update 
52-55 
3.0 
Peripheral Blood 
Changed collection at 90 days to 120 days 
Internal consistency 
within protocol 
72 
3.0 
Tests to be Performed 
Changed collection at 90 days to 120 days 
Internal consistency 
within protocol 
73 
4.0 
Title Page 
Revised title page to indicate short name of the trial 
(i.e., LVAD MPC II), Rev 4.0 and date of January 
2016 
Protocol Update 
1 
4.0 
Header & Footer 
Updated header and footer to standard CTSN 
document control 
Protocol Update 
ALL 


InCHOIR  
 
 Date Written: March 2015 
Document Number: LVAD MPC II Trial Protocol Rev 4.1  
Date Revised: October 2016 
Page 6 of 68 
 
Date Effective: 
 
CONFIDENTIAL 
Version 
         Section 
Change 
Reason 
Page 
4.0 
Table of Contents 
Updated to reflect changes in protocol, including 
removal of Appendices II-IX 
For consistency with all 
other CTSN protocols 
Appendices II-IX were 
moved to the appropriate 
Manual of 
Procedures/Manual 
2 
4.0 
Abstract 
Removed Anti-HLA sensitization post-transplant (for 
transplanted BTT patients) 
Internal consistency 
within protocol as this 
activity is not part of the 
protocol 
10 
4.0 
Abstract 
Revised exclusion criteria 
To clarify specific criteria 
for enrollment purposes 
and be consistent where 
possible with the industry 
partner’s heart failure 
protocol 
11 
4.0 
Data Collection Schedule 
Removed Month 9 Immunologic Assessment and 
Biospecimen Assessment  
Internal consistency 
within protocol 
12 
4.0 
Data Collection Schedule 
Added 4 Days Post RAND 
Internal consistency 
within protocol 
12-13 
 
4.0 
Data Collection Schedule, 
Cytokine Quantification, 
Laboratory Assessment, 
Biospecimen Analyses  
Revised 7 Days Post RAND window to ±2 
To align data collection 
& avoid overlap with 4 
Days post RAND 
assessment window 
12-13, 31, 47-50,  
4.0 
Data Collection Schedule 
Removed Post transplant Assessment row and 
corresponding footer for clinical biopsy and rejection 
monitoring results  
Internal consistency 
within protocol as this 
activity is not part of the 
protocol 
12-13 
4.0 
Objectives 
Added short name of trial  
For convenience and 
clarity, when referring to 
the trial or the protocol-
specific Manual of 
Procedures (MOP) 
14 
4.0 
Endpoints 
Revised the reference as to where details concerning 
the LVAD wean are found, i.e., from Appendix II to 
relevant section of protocol   
For consistency and 
clarity referred reader to 
the section within the 
protocol where this 
information is found. 
22 
4.0 
Physiological Assessment 
Removed 4 month WMSI assessment 
This assessment was 
included in Version 3.0 in 
error.  The data will not 
be used for either the 
primary or secondary 
endpoint analyses and is 
thus being removed to 
correct the error  
23, 30 
4.0 
Physiological Assessments 
Removed PTAV, TAPSE and RVIF Peak velocity and 
simplified section as Appendix V was moved to the 
LVAD MPC II MOP 
Consensus of Echo Core 
Lab Director and clinical 
investigators after gaining 
experience under Version 
3.0 and realizing that 
obtaining these values is 
burdensome for the site 
Echo labs; additionally, 
Appendix V was moved 
to the LVAD MPC II 
MOP for consistency 
with other CTSN 
protocols 
23, 30 
4.0 
Study Subjects 
Clarified monthly enrollment statement  
For consistency with 
anticipated enrollment 
period 
24 


InCHOIR  
 
 Date Written: March 2015 
Document Number: LVAD MPC II Trial Protocol Rev 4.1  
Date Revised: October 2016 
Page 7 of 68 
 
Date Effective: 
 
CONFIDENTIAL 
Version 
         Section 
Change 
Reason 
Page 
4.0 
Eligibility Criteria 
Modified Exclusion Criteria 
To clarify specific criteria 
and be consistent where 
possible with the industry 
partner’s heart failure 
protocol  
24-25 
4.0 
Treatment Intervention 
Added the relevant MOP title because there are 
multiple manuals for this protocol due to its 
complexity  
For clarification & 
consistency across trial 
documents 
26 
4.0 
Definition and 
Measurement of Endpoints 
Clarified where wean guidelines are now found and 
deleted redundant references to Appendix II.   Also 
clarified where information from Appendices III-IX 
are now found. 
For consistency with 
other CTSN protocols, 
Appendices II-IX moved 
to LVAD MPC II MOP. 
27-31 
4.0 
Definition and 
Measurement of Endpoints 
Removed specific amount of time sustained signs and 
symptoms should be noted before early termination of 
wean 
To clarify that the senior 
clinician overseeing the 
wean is to determine 
early termination of wean 
based on signs and 
symptoms; additionally, 
for consistency with 
LVAD Wean Procedure 
Guidelines 
27, 28 
4.0 
Adverse Events 
Modified Protocol-Defined Adverse Events 
For consistency with 
current INTERMACS 
registry definitions to 
enable standardization by 
current recognized and 
accepted definitions 
36-44 
4.0 
Adverse Events 
Added Pleural Effusion as a Protocol-Defined 
Adverse Event 
For consistency with 
other CTSN protocols 
37 
4.0 
Clinical Centers 
Increased the number of sites from 25 to 30 as a 
precautionary measure 
To ensure that accrual 
milestones are met 
44 
4.0 
Site Initiation 
Updated this section to explain the site initiation 
process as well as the personnel required to attend the 
pre-enrollment conference call 
For clarity and 
consistency with the 
LVAD MPC II MOP 
46 
4.0 
Screening/Pre-Implant 
Data Collection 
Revised section header to Pre-Implant (Screening and 
Baseline) Data Collection 
For consistency across 
trial documents 
46 
4.0 
Demographics 
Removed handedness  
For consistency between 
protocol and EDC 
47 
4.0 
Medications 
Clarified collection for Cardiovascular and Non-
Cardiovascular Medications 
For consistency between 
protocol and EDC 
47 
4.0 
Laboratory Assessment 
Revised collection windows based on eligibility and 
to align with standard of care 
For consistency with 
clinical practice  
47 
4.0 
Biospecimen Analyses 
Revised collection window to within 72 hours prior to 
Treatment Intervention and simplified this section 
For consistency with 
Laboratory Assessment 
Schedule and 
Biospecimen Core 
Laboratory Manual 
47-48 
4.0 
Immunologic Assessment 
Clarified collection window of anti-murine and anti-
bovine samples and simplified this section 
Clarification of protocol 
and for consistency with 
Biospecimen Core 
Laboratory Manual 
48 
4.0 
Quality of Life 
Removed reference to QoL Checklist  
For consistency between 
protocol and EDC 
49 
4.0 
Post Intervention Data 
Collection - Laboratory 
Assessment 
Added LDH collection schedule 
Consistency within 
protocol 
51 
4.0 
Biospecimen Analyses 
Simplified section 
For consistency with 
Biospecimen Core 
Laboratory Manual 
51 
4.0  
Immunologic Assessment 
Simplified section  
For consistency with 
Biospecimen Core 
Laboratory Manual and 
clarification of protocol 
51 


InCHOIR  
 
 Date Written: March 2015 
Document Number: LVAD MPC II Trial Protocol Rev 4.1  
Date Revised: October 2016 
Page 8 of 68 
 
Date Effective: 
 
CONFIDENTIAL 
Version 
         Section 
Change 
Reason 
Page 
4.0 
Medications 
Clarified collection for Cardiovascular and Non-
Cardiovascular Medications 
For consistency between 
protocol and EDC 
51 
4.0 
Wean Assessment 
Revised sentence on hypoperfusion assessment  
For consistency between 
protocol and EDC 
53 
4.0 
Quality of Life 
Removed reference to QoL Checklist  
For consistency between 
protocol and EDC 
53 
4.0 
Appendices II - IX 
Appendices II through IX were moved to the MOP 
and any references to these Appendices were updated 
throughout protocol. 
For consistency with all 
other CTSN protocols 
68-106 
4.1 
Title Page, Header & 
Footer 
Revised title page and header and footer on all pages 
to indicate Rev 4.1 and date of October 2016 
Protocol Update 
1 
4.1 
Abstract 
Changed number of subjects from 120 to 159 (Groups 
1 and 2) and treatment arms from 80 to 106 (Group 1) 
and from 40 to 53 (Group 2) 
Sample size correction  
11 
4.1 
Study Subjects 
Changed number of subjects from 120 to 159 
Sample size correction  
24 
4.1 
Treatment Assignments 
Changed treatment arm sample sizes from 80 to 106 
(Group 1) and from 40 to 53 (Group 2) 
Sample size correction 
26 
4.1 
Laboratory Assessment 
Added Day 30 collection of hematology and 
chemistry samples 
To correct internal 
inconsistency in protocol 
51 
4.1 
Statistical Analysis And 
Sample Size Justification 
 
Revised Sample Size Justification and moved figure 
to the paragraph to which it is referenced. 
Modification corrects 
original sample 
calculations and page 
formatting 
58 
 
 
 
 


InCHOIR  
 
 Date Written: March 2015 
Document Number: LVAD MPC II Trial Protocol Rev 4.1  
Date Revised: October 2016 
Page 9 of 68 
 
Date Effective: 
 
CONFIDENTIAL 
DEFINITIONS, ACRONYMS & ABBREVIATIONS 
 
 
6MWT 
 
Six Minute Walk Test  
ALT 
 
alanine aminotransferase 
AST 
 
 
 
aspartate aminotransferase 
BTT 
 
 
 
Bridge to transplant 
C 
centigrade 
CABG  
 
 
Coronary Artery Bypass Grafting 
CAD 
coronary artery disease 
CFR 
 
 
 
Code of Federal Regulations 
CHF  
 
 
congestive heart failure 
CI 
 
 
 
cardiac index 
CI 
 
 
 
confidence interval 
CO 
 
cardiac output 
CTA   
 
 
Clinical Trial Application 
CTSN  
 
 
Cardiothoracic Surgical Trials Network 
DCC 
 
Data Coordinating Center 
DMSO 
 
Dimethyl sulfoxide 
DNA 
 
deoxyribonucleic acid 
DSMB  
 
 
Data and Safety Monitoring Board 
DT 
 
 
 
Destination therapy 
eCRF 
 
Electronic case report form 
EAC 
 
Event Adjudication Committee 
EDC 
 
Electronic Data Capture System 
FDA 
 
Food and Drug Administration 
GCP 
 
Good Clinical Practice 
GMP  
 
 
Good Medical Practice 
HIPAA 
 
 
Health Insurance Portability and Accountability Act of 1996 
HLA  
 
 
Human leukocyte antigen 
ICH 
 
 
 
International Conference on Harmonization  
IDC 
 
 
 
Idiopathic dilated cardiomyopathy 
IgG 
 
 
 
Immunoglobulin G 
InCHOIR 
International Center for Health Outcomes and Innovation Research 
IND 
Investigational New Drug  
IRB 
 
 
 
Institutional Review Board 
LDH  
 
 
lactate dehydrogenase 
LV 
 
 
 
left ventricle 
LVAD  
 
 
left ventricular assist device 
LVEF  
 
 
left ventricular ejection fraction 
MCSD  
 
 
Mechanical circulatory support device 
MOP  
 
 
Manual of Procedures 
mRNA  
 
 
messenger ribonucleic acid 
MPC  
 
 
mesenchymal precursor cells 
NHLBI 
 
 
National Heart, Lung and Blood Institute 
OHT  
 
 
orthotopic heart transplantation 


InCHOIR  
 
 Date Written: March 2015 
Document Number: LVAD MPC II Trial Protocol Rev 4.1  
Date Revised: October 2016 
Page 10 of 68 
 
Date Effective: 
 
CONFIDENTIAL 
PIPEDA 
 
 
Personal Information Protection and Electronic Documents Act 
PB 
 
 
 
Peripheral blood 
PRBC  
 
 
packed red blood cells 
PTAV  
 
 
Peak tricuspid annular velocity 
REB 
 
Research Ethics Board 
REMATCH 
 
 
Randomized Evaluation of Mechanical Assistance for the 
Treatment of Congestive Heart Failure 
RNA  
 
 
ribonucleic acid 
rpm 
 
 
 
revolutions per minute 
RV 
 
 
 
right ventricle 
RVIF  
 
 
Right ventricular inflow 
RVSP  
 
 
RV systolic pressure 
SOP 
 
 
 
Standard Operating Procedures 
TAPSE 
 
 
Tricuspid annular plane systolic excursion 
TR 
 
 
 
Tricuspid regurgitation 
TTE 
 
 
 
Transthoracic echocardiogram 
UNOS  
 
 
United Network for Organ Sharing 
VAD  
 
 
ventricular assist device 
VEGF  
 
 
vascular endothelial cell growth factor 
WMSI  
 
 
Wall motion score index 
 
 
 


InCHOIR  
 
 Date Written: March 2015 
Document Number: LVAD MPC II Trial Protocol Rev 4.1  
Date Revised: October 2016 
Page 11 of 68 
 
Date Effective: 
 
CONFIDENTIAL 
ABSTRACT 
 
Objectives 
The primary objectives of this trial are to evaluate the safety and efficacy of 
injecting MPCs (150 million dose) into the native myocardium of LVAD recipients. 
 
The secondary objectives are to explore the functional and physiologic effects of 
injecting MPCs (150 million dose) into the native myocardium of LVAD recipients. 
Study Design 
Prospective, multi-center, double-blind, randomized, single dose cohort, sham 
procedure controlled trial  
Target 
Population 
Patients with end-stage heart failure, either ischemic or non-ischemic etiology, who 
are being evaluated for LVAD implantation as a bridge-to-transplant (BTT) or 
destination therapy (DT) 
Rx arms 
Patients will be enrolled in a single dose cohort randomized in a 2:1 allocation to 
intramyocardial injection of study product or control (cryoprotective media alone) at 
the time of LVAD implantation: 
o Group 1 (n=106): 150 million allogeneic MPCs (Mesoblast, Inc) 
o Group 2 (n=53): 50% Alpha-MEM/42.5% ProFreeze NAO Freezing 
Medium/7.5% DMSO (control) 
Sample Size 
159 patients 
Duration 
All patients will be followed until cardiac transplantation (for bridge to transplant 
patients) or until 24 months post randomization, whichever comes first.  
o Myocardial sample donation (at OHT or post mortem as relevant)  
1 Endpoints 
The primary safety endpoint is the incidence of study intervention-related adverse 
events (i.e., infectious myocarditis, myocardial rupture, neoplasm, hypersensitivity 
reaction, and immune sensitization). 
 
The primary efficacy endpoint is the number of temporary weans from LVAD 
support tolerated over 6 months following randomization.  
2 Endpoints 
Secondary Endpoints include: 
Safety 
o Incidence of all serious adverse events 
o Anti-HLA antibody sensitization while on LVAD support 
Survival 
o Survival  
o Survival to cardiac transplantation 
Functional Status (over 6 months) 
o Duration of ability to tolerate wean from LVAD support  
o 6 Minute walk test (6MWT) as tolerated at 20 (± 10) minutes following 
initiation of wean 
Functional Status (over 12 months) 
o Ability to tolerate each wean from LVAD support for 30 minutes  
o Duration of ability to tolerate wean from LVAD support 
o 6MWT as tolerated at 20 (± 10) minutes following initiation of wean 
Physiologic Assessments 
o Echocardiographic assessments of the myocardial size and function by 
transthoracic echocardiography with LVAD at full support, and as tolerated 
following 6MWT while weaned from LVAD support  
o Myocardial neovascularization at time of explant 
o Cardiomyocyte regeneration at explant 
o Cell Engraftment and fate at explant 


InCHOIR  
 
 Date Written: March 2015 
Document Number: LVAD MPC II Trial Protocol Rev 4.1  
Date Revised: October 2016 
Page 12 of 68 
 
Date Effective: 
 
CONFIDENTIAL 
  
Quality of Life & Neurocognition  
o Quality of Life (QoL) as assessed by SF12 and Kansas City 
Cardiomyopathy Questionnaire (KCCQ) at 6 & 12 months 
o Neurocognition at 90 days and 12 months post randomization 
Hospitalizations 
o LOS of index hospitalization 
o Frequency (<30 days and ≥30 days following index hospital discharge) and 
cause of readmissions 
o Hospital resource use (or costs) 
Weaning and 6-
minute Walk 
Schedule 
60 days, 4 mos, 6 mos, 9 mos, and 12 mos (or until transplant, whichever comes 
first) 
Selected 
Inclusion 
Criteria 
1. Admitted to the clinical center at the time of randomization 
2. Clinical indication and accepted candidate for implantation of an FDA-approved 
(US sites only) or Health Canada-approved (Canadian sites only) implantable, 
non-pulsatile LVAD as a bridge-to-transplant or for destination therapy 
Selected 
Exclusion 
Criteria 
1. 
Planned percutaneous LVAD implantation; 
2. 
Anticipated requirement for biventricular mechanical support; 
3. 
Arrhythmia ablation at the time of LVAD implantation;  
4. 
Planned aortic valve intervention for aortic insufficiency at the time of LVAD 
implantation;   
5. 
Cardiothoracic surgery within 30 days prior to randomization; 
6. 
Spontaneous myocardial infarction related to ischemia due to a primary 
coronary event such as unstable plaque rupture, erosion or dissection within 30 
days prior to randomization; 
7. 
Prior cardiac transplantation, LV reduction surgery, or cardiomyoplasty 
8. 
Acute reversible cause of heart failure (e.g. myocarditis, profound 
hypothyroidism); 
9. 
Stroke within 30 days prior to randomization; 
10. Platelet count < 100,000/mcL within 24 hours prior to randomization; 
11. Acute infectious process: acute bacterial, fungal or viral disease OR acute 
exacerbation of chronic infectious disease such as hepatitis ; 
12. Presence of >10% anti-HLA antibody titers with known specificity to MPC 
donor HLA antigens; 
13. A known hypersensitivity to dimethyl sulfoxide (DMSO), murine, and/or 
bovine products; 
14. History of a known active malignancy within the past 3 years except for 
localized prostate cancer, cervical carcinoma in situ, breast cancer in situ, or 
nonmelanoma skin cancer that has definitively been treated;  
15. Presence of human immunodeficiency virus (HIV); 
16. Received investigational intervention within 30 days of randomization; 
17. Treatment and/or an incomplete follow-up treatment of any investigational cell 
based therapy within 6 months prior to randomization;  
18. Active participation in other research therapy for cardiovascular 
repair/regeneration; 
19. Prior recipient of stem precursor cell therapy for cardiac repair; 
20. Pregnant or breastfeeding at time of randomization; 
21. History of known or suspected hypercoagulable state in the opinion of the 
investigator 
 


InCHOIR  
 
 Date Written: June 2014 
Document Number: LVAD Cell Therapy Trial II Rev 4.1  
Date Revised: October 2016 
Page 13 of 68 
 
Date Effective: 
 
 
 
 
 
 
13 
DATA COLLECTION SCHEDULE  
 
 
Assessment 
Pre-
Implant 
Randomiz-
ation 
LVAD 
Implant/ 
Inter-
vention 
(INT) 
12 hours 
post 
INT 
1 Day 
post 
INT 
4 Days 
post 
RAND 
7 Days 
post 
RAND 
30 Days 
post 
RAND 
60 Days 
post 
RAND 
90 Days 
post 
RAND 
 
 
 
Month 4 
post 
RAND 
Month 6 
post  
RAND 
Month 9 
post  
RAND 
 
 
12 
 Months 
post 
RAND‡  
 
 
24 
Months 
post 
RAND 
Event 
Driven 
Window 
 
 
 
± 4 hours 
+1 
 
± 2 
± 3 
± 7 
± 14 
± 14 
± 14  
± 14  
± 14  
± 30 
 
General 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Informed Consent 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pre-Screening Failure  
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Demographics 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical History 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical Examination 
x 
 
 
 
 x 
 
x 
 
x 
x 
x 
x 
x 
x 
 
 
Medications 
x 
 
 
 
 x 
 
x 
 
x 
x 
x 
x 
x 
x 
 
 x 
Immunotherapy Medication 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
x 
Laboratory Assessment+ 
x 
 
 
 x 
 
x+ 
x 
x 
x 
x 
x 
x 
x 
x 
 
x 
Immunologic Assessment 
x 
 
 
 
 
 
 
x 
 
x 
 
x 
 
x 
 
 
Biospecimen: Chemo and Cytokine Analyses 
x 
 
 
 
x 
 
x 
x 
x 
 
x 
x 
 
x 
 
 
Eligibility Evaluation 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Randomization & Treatment Assignment 
 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hospitalization 
 
 
x 
 
 
 
 
 
 
 
 
 
 
 
 
x 
Surgical Procedure 
 
 
x 
 
 
 
 
 
 
 
 
 
 
 
 
x 
QoL (SF12 & KCCQ) 
x 
 
 
 
 
 
 
 
 
 
 
x 
 
x 
 
 
Vital Status Follow-Up 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
x 
 
Cardiac 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hemodynamics 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Echocardiography 
x 
 
 
 
 
 
 
 
x 
 
x 
x 
x 
x 
 
 
Cardiac Histology# 
 
 
x 
 
 
 
 
 
 
 
 
 
 
 
 
x# 
Six Minute Walk Test (6MWT) 
 
 
 
 
 
 
 
 
x 
 
x 
x 
x 
x 
 
 
Intervention Injection Verification 
 
 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
Wean Assessment 
 
 
 
 
 
 
 
 
x 
 
x 
x 
x 
x 
 
 
Neurological 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
NIH Stroke Scale** 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
x 
Modified Rankin Scale** 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
x 
Neurocognitive Testing 
x 
 
 
 
 
 
 
 
 
x 
 
 
 
x 
 
 
                                                                                                                                    
 


InCHOIR  
 
 Date Written: March 2015 
Document Number: LVAD MPC II Trial Protocol Rev 4.1  
Date Revised: October 2016 
Page 14 of 68 
 
Date Effective: 
 
CONFIDENTIAL 
DATA COLLECTION SCHEDULE (continued) 
 
 
Assessment 
Pre- 
Implant 
Randomiz-
ation 
VAD 
Implant/ 
Inter-
vention 
(INT) 
12 hours 
post 
INT 
1 Day 
post 
INT 
4 Days 
post 
RAND 
7 Days 
post 
RAND 
30 Days 
post 
RAND 
60 Days 
post 
RAND 
90 Days 
post 
RAND 
 
 
 
Month 4 
post 
RAND 
Month 6 
post  
RAND 
Month 9 
post  
RAND 
 
 
12  
Months 
post 
RAND‡  
 
 
24 
Months 
post 
RAND 
Event
Driven
Window 
 
 
 
± 4 
hours 
+1 
 
± 2 
± 3 
± 7 
± 14 
± 14 
± 14 
± 14 
± 14 
± 30 
 
Event Driven Data 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Adverse Events 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
x 
Early Stopping Events 
 
 
x 
x 
 x 
 
x 
x 
x 
x 
x 
x 
x 
x 
 
x 
Mortality 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
x 
Pump Retrieval and Explant (&/or Postmortem) 
Examination 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
x 
Missed Visit 
 
 
 
 
 
 
x 
x 
x 
x 
x 
x 
x 
x 
 
x 
Study Completion/Early Termination 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
End of Study/Investigator Statement 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
‡ Final data collection 
** Event driven within 72 hours of a neurological event, and at 30 (±10) and 60 (±10) days post neurological event 
# At native heart explantation for cardiac transplantation or at autopsy (if applicable) 
+ LDH to be collected at Days 4, 7, 30, 60 and 90; at 4, 6, 9 and 12 months; and as an event-driven data point. 
 
 
 


InCHOIR  
 
 Date Written: June 2014 
Document Number: LVAD Cell Therapy Trial II Rev 4.1  
Date Revised: October 2016 
Page 15 of 68 
 
Date Effective: 
 
 
 
 
 
 
15 
OBJECTIVES 
The primary objectives of this trial are to evaluate the safety and efficacy of injecting higher dose 
allogeneic mesenchymal precursor cells (MPCs) into the native myocardium of LVAD recipients. 
 
The secondary objectives of the LVAD MPC II trial are to explore the functional and physiologic 
effects of intramyocardial injection of the higher dose MPCs in LVAD recipients. 
 
BACKGROUND AND RATIONALE   
 
LVADs and Stem Cells: a Novel Strategy for Myocardial Recovery  
Left ventricular assist devices (LVADs) have well-documented survival and quality of life benefits 
in patients with advanced heart failure both as a bridge to cardiac transplantation (BTT) and as a 
long-term therapy, so-called Destination Therapy (DT), in patients who are not transplant 
candidates.1-4  Reports of improved myocardial function have motivated investigation of the use of 
LVADs as a bridge to recovery, but while most LVAD recipients do show some indications of 
reverse remodeling of the left ventricle (LV) as evidenced by salutary changes in ventricular 
structure, myocyte contractile strength5, normalization of extracellular matrix and tissue and 
circulating neurohormones6, and programs of gene expression,7-10 these improvements are rarely 
sufficient to allow removal of the device.11  The disconnect between reverse remodeling and 
recovery of cardiac function, or “passive recovery”, have prompted our efforts to investigate 
“active recovery” to augment ventricular recovery with adjunctive therapies to LVAD support, 
such as the administration of stem cells at the time of LVAD implantation. 
 
Recent pre-clinical and clinical evidence suggests that myocardial transplantation of allogeneic 
mesenchymal stem cells, in particular, can enhance cardiac performance in settings of acute and 
chronic functional impairment.12-14 Unlike whole organ transplantation or many other allogeneic 
cell transplants, mesenchymal stem cell transplants do not appear to cause rejection and instead 
may be associated with evidence of induced tolerance to the donor. 15,16  While our ultimate goal is 
the achievement of bridging to myocardial recovery and successful LVAD explantation, 
allosensitization could adversely impact donor suitability in LVAD recipients who are transplant 
candidates.  To this end, the Cardiothoracic Surgical Trials Network (CTSN) recently conducted, 
in collaboration with the Cardiovascular Cell Therapy Research Network (CCTRN), an 
exploratory trial of a single low dose (25 million [M]) allogeneic MPCs (Mesoblast, Inc.) injected 
into the native myocardium at the time of LVAD implantation.  The objectives of this trial were to 
provide evidence of safety as well as explore the efficacy of the intervention.  If safety were 
established, the pre-specified plan was to conduct a follow-up trial with higher dose MPCs. 
 
Study Product: Mesenchymal Precursor Cells 
Mesoblast’s allogeneic, immunoselected, ex vivo expanded MPCs are derived from bone marrow 
mononuclear cells, which are obtained from the posterior iliac crest of healthy human donors. The 
allogeneic MPCs are produced in a Good Manufacturing Practice (GMP) facility and 
cryopreserved until use. The allogeneic MPCs are a STRO-3 immuno-selected, culture-expanded, 
immature sub-fraction of adult bone marrow-derived mononuclear cells.14,17  They are formulated 
and cryopreserved in 7.5% DMSO/50% Alpha Modified Eagle’s Medium (MEM) and 42.5% 
ProFreeze® and stored in the vapor phase of liquid nitrogen until use.  Cell procurement, 
processing, cryopreservation, and storage procedures are performed by a contract manufacturing 


InCHOIR  
 
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Document Number: LVAD MPC II Trial Protocol Rev 4.1  
Date Revised: October 2016 
Page 16 of 68 
 
Date Effective: 
 
CONFIDENTIAL 
facility under GMP conditions.  Donor and process testing are conducted for transmissible 
infectious diseases, karyotype, tumorigenicity, sterility, endotoxins, and mycoplasma.  The 
product is characterized by cell count, viability, surface antigen expression of STRO-1, CC-9, and 
HLA class I and II.  Cryopreserved products are shipped to clinical sites for local storage, and 
cells are thawed and injected according to study procedures.  Mesoblast, Inc. contributed its MPCs 
for the initial trial conducted and will provide them for this current trial (see section on Study 
Administration).  Further information on manufacturing and product characterization is presented 
in the Investigator’s Brochure.   
 
Pre-Clinical Studies   
An extensive nonclinical program has been conducted to explore and confirm the safety and 
efficacy of administration of allogeneic MPCs for the treatment of patients with ischemic or 
nonischemic heart disease and heart failure. Mesenchymal precursor cells have been evaluated in 
vitro as well as in vivo in nonclinical studies with rodents and sheep (acute and chronic 
myocardial ischemia and doxorubicin-induced nonischemic cardiomyopathy). 
 
Results from several in vitro studies, which included mixed lymphocyte cultures and T-cell 
proliferation assays, demonstrated that immunoselected and culture-expanded MPCs are 
nonimmunogenic in allogeneic settings and demonstrate immunosuppressive activity. 
 
In nude rat models of myocardial ischemia, implantation of allogeneic MPCs into the acutely 
ischemic myocardium was associated with arteriogenesis at 2 weeks following administration of 
MPCs and improvement in global parameters of systolic and diastolic function at both 2 and 
6 weeks after implantation.  
 
The ovine models of chronic ischemic and nonischemic cardiomyopathy (CM) demonstrated a 
dose-related improvement in left ventricular end-diastolic pressure (LVEDP) and left ventricular 
ejection fraction (LVEF) (ischemic model) and prevention of deterioration of LVEF and 
stabilization of ventricular remodeling (nonischemic model) with transendomyocardial delivery of 
allogeneic ovine MPCs. In contrast, the control groups for the chronic ischemic and nonischemic 
ovine models of CM showed time-related worsening of critical cardiac parameters. 
Cell-tracking studies have shown that less than 1% of injected human MPCs persist at 24 hours 
after being injected into ischemic rat heart tissue, yet functional cardiac recovery is observed at 
6 weeks after implantation. Arteriole proliferation in infarcted areas of the myocardium in the 
ovine model is documented at 7 days following ovine MPC implantation and is evident at the 
2-month endpoint. Improvement in vascular perfusion is seen at 4 weeks, whereas cardiac 
functional recovery is seen at 8 weeks. These observations indicate that the effects of MPCs on 
functional cardiac recovery occur shortly following administration and may result from beneficial 
and sustained effects on endogenous cells and tissues. The neovascularization observed with 
MPCs reflect protective mechanisms. These observations indicate that the protective and 
reparative mechanisms of MPCs do not require long-term MPC survival or engraftment. 
 
A total of 7 studies conducted in sheep included histopathologic evaluations for organ toxicity. 
Collectively, the results from these studies indicate that an allogeneic MPC product can be 
delivered safely by surgical epicardial injection, transendocardial injection by catheter, and 


InCHOIR  
 
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Document Number: LVAD MPC II Trial Protocol Rev 4.1  
Date Revised: October 2016 
Page 17 of 68 
 
Date Effective: 
 
CONFIDENTIAL 
intracoronary infusion. The findings from these studies also indicate that a one-time dose of MPCs 
ranging from 25 to 225 M MPCs is well tolerated. 
 
A summary of completed nonclinical studies of mesenchymal precursor cells (MPCs) in 
cardiovascular disease models is below. Further information on preclinical findings is presented in 
the Investigator’s Brochure. 
 
Summary of Completed Nonclinical Studies of Mesenchymal Precursor Cells in 
Cardiovascular Disease Models 
Study 
Number 
Indication/ 
Purpose 
Product/ 
Dose/ 
Carrier 
Time Of 
Cell 
Injection 
Following 
Myocardi
al Damage 
Control 
Route 
Method 
Species 
 # of 
animals 
Duration 
of 
Follow-Up 
(Post-
treatment) 
AB001 
Acute 
myocardial 
infarction 
Allogeneic 
ovine MPCs 
25, 75, 225 
or 450 
million 
Delivered 
to non-
ischemic 
border 
zone 
immediatel
y after MI 
Pro-
freeze 
Epicardial 
injection 
Ligation of 
LAD and 
its 2nd 
diagonal 
branch 
Sheep 
(46) 
8 weeks 
AB003 
Acute 
myocardial 
infarction 
Xenogeneic 
human 
MPCs 
0.2 or 1 
million 
 
Delivered 
to non-
ischemic 
border 
zone 
immediatel
y after MI 
Saline 
Epicardial 
injection 
Ligation of 
LAD 
Nude 
rat 
2-6 weeks 
AB004 
Acute 
myocardial 
infarction 
 
Allogeneic 
ovine MPCs 
225 million 
 
Treatment 
5 days post 
MI 
Profreeze 
Trans-
endocardi
al 
injection 
via 
NOGA 
90-min 
balloon 
occlusion 
at distal 
LAD (after 
D2) 
Sheep 
(9) 
55±4 days 
AB005 
Acute 
myocardial 
infarction 
Allogeneic 
ovine MPCs 
25 or 225 
million 
 
Treatment 
10 days 
post MI 
None 
Trans-
endocardi
al 
injection 
via 
NOGA 
90-min 
balloon 
occlusion 
at distal 
LAD (after 
D2) 
Sheep 
(4) 
7 days 
AB006 
Acute 
myocardial 
infarction 
Allogeneic 
ovine MPCs 
225 million 
 
Delivered 
to non-
ischemic 
border 
zone 
immediatel
y after MI 
Profreeze 
Epicardial 
injection 
60-min 
occlusion 
at D1 
branch of 
LAD 
Sheep 
(8) 
4 weeks 
AB010 
Acute 
myocardial 
infarction 
Allogeneic 
ovine MPCs 
225 million 
 
Treatment 
10 days 
post MI 
None 
Trans-
endocardi
al 
injection 
via 
90-min 
balloon 
occlusion 
at distal 
LAD (after 
Sheep 
(10) 
50±4 days 


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 Date Written: March 2015 
Document Number: LVAD MPC II Trial Protocol Rev 4.1  
Date Revised: October 2016 
Page 18 of 68 
 
Date Effective: 
 
CONFIDENTIAL 
Study 
Number 
Indication/ 
Purpose 
Product/ 
Dose/ 
Carrier 
Time Of 
Cell 
Injection 
Following 
Myocardi
al Damage 
Control 
Route 
Method 
Species 
 # of 
animals 
Duration 
of 
Follow-Up 
(Post-
treatment) 
NOGA 
D2) 
AB021 
Chronic 
myocardial 
infarction, 
ischemic-
reperfusion 
model 
Allogeneic 
ovine MPCs 
225 million 
 
4 weeks 
after 
infarction 
Profreeze 
Epicardial 
Injection 
90-min 
balloon 
occlusion 
of mid-
LAD 
Sheep 
(10) 
8 weeks 
AB100 
Safety of 
intracoronary 
infusion of 
MPCs in 
healthy sheep 
Allogeneic 
ovine MPCs 
25, 37.5 or 
50 million 
 
n/a 
None 
Intracoron
ary 
infusion 
Proximal 
LAD 
infusion 
(Twin Pass 
Catheter) 
Sheep 
(12) 
2 days 
AB101 
Chronic 
myocardial 
infarction, 
ischemic-
reperfusion 
model 
Allogeneic 
ovine MPCs 
25, 75 or 
225 million 
 
4 weeks 
after MI 
Profreeze 
Endocardi
al 
injection 
90-minute 
balloon 
occlusion 
of LAD 
Sheep 
(40) 
8 weeks 
AB102 
Acute 
myocardial 
infarction 
Allogeneic 
ovine MPCs 
12.5, 25 or 
37.5 million 
Ringer's 
lactate 
Immediatel
y after MI 
Vehicle 
(Ringer's 
lactate) 
Intra-
coronary 
infusion 
90-min 
balloon 
occlusion 
directly 
behind D1 
or septal 
branch of 
LAD 
Sheep 
(30) 
2 months 
D2= second diagonal branch; MPCs=mesenchymal precursor cells; MI=myocardial infarction; LAD=left anterior 
descending artery. 
 
Clinical Studies of Cell-based Myocardial Repair   
Mesoblast is conducting several clinical trials involving the administration of allogeneic MPCs by 
a number of routes and in various cardiovascular and non-cardiovascular indications. 
 
As of 19 March 2013, 291 patients have been enrolled in Mesoblast sponsored clinical trials with 
allogeneic MPCs administered to 183 subjects and a further 40 subjects enrolled in investigator-
sponsored cardiovascular clinical studies. As of August 26, 2013, MPCs have been well tolerated 
in dose ranges of up to 246 Million (M) allogeneic cells.   
 
The adverse events reported in these studies have been generally mild to moderate in severity.  
Across all indications evaluated, the most frequently reported adverse events that occurred at a 
rate of > 5% in the combined MPC treatment group and higher than controls, were chest pain 
(7.1% vs. 5.5%), fatigue (6.0% vs. 5.5%), upper respiratory tract infection (6.6% vs. 2.2%), neck 
pain (5.5% vs. 4.4%), dizziness (7.1% vs. 2.2%) and hypotension (7.7% vs. 2.2%). There has been 
no dose-limiting toxicity observed to date.  In all studies to date, antibody responses to MPC 


InCHOIR  
 
 Date Written: March 2015 
Document Number: LVAD MPC II Trial Protocol Rev 4.1  
Date Revised: October 2016 
Page 19 of 68 
 
Date Effective: 
 
CONFIDENTIAL 
donor-specific HLA have been observed in approximately 10-15% of treated patients.  No clinical 
events or adverse sequelae have been attributed to this sensitization to date.  
 
Based on review of cumulative and aggregate safety data to date the systemic safety and local 
tolerability of MPCs has been acceptable. 
 
The allogeneic MPCs used in each of the ongoing studies are identical with respect to 
manufacturing, characterization and lot release testing.  
 
Immediately below is a table listing Mesoblast’s sponsored clinical trials with allogeneic MPCs. 
 
Mesoblast, Inc. Sponsored Clinical Trials with Allogeneic MPCs 
Protocol Number 
Location 
Indication 
Route of 
Administration 
MPC 
Treated 
Control 
Treated 
Total 
Enrolled 
EMT-AB001 
 
USA 
Acute MI 
Transendocardial 
injection 
1 
1 
2 
HF-AB002 
 
USA 
Heart failure 
Transendocardial 
injection 
45 
15 
60 
MSF-0106 
 
USA 
Lumbar spinal 
fusion 
Surgical implantation 
4 
2 
6 
MSB-SF003 
 
USA 
Lumbar 
interbody fusion 
Surgical implantation 
16 
8 
24 
MSB-CAR001* 
 
Australia 
Prevention of 
osteoarthritis 
Intra-articular 
injection 
* 
* 
17 
MSB-CF001 
Australia 
Cervical fusion 
Surgical implantation 
8 
4 
12 
MSB-CF002 
USA 
Cervical fusion 
Surgical implantation 
16 
8 
24 
MSB-DR001 
USA/ 
Australia 
Disc repair 
Intra-disc injection 
60 
40 
100 
 
MSB-DM003 
USA 
Type 2 Diabetes 
IV Infusion 
30 
11 
41 
ANG-AMD002 
Singapore
/Australia 
Wet AMD 
Intravitreal Injection 
3 
2 
5 
MSB-DN001*  
 
Australia 
 
Diabetic 
nephropathy and 
Type 2 diabetes 
IV Infusion 
 
- 
- 
- 
ANG.AMI-IC001*    
Australia/
Europe 
Acute MI 
Intracoronary 
Infusion 
- 
- 
- 
MSB-RA-001*    
USA/ 
Australia 
Rheumatoid 
Arthritis 
IV Infusion 
- 
- 
- 
MSB-RA-002**     
Europe 
Rheumatoid 
Arthritis 
IV Infusion 
- 
- 
- 
CB-AB006         
 
 
USA 
Hematopoietic 
reconstitution of 
hematological 
malignancies 
Infusion^ 
 
- 
- 
- 
Total 
>183 
>91 
291 
Enrollment as of March 19, 2013      
* Blinded study, enrollment on-going      
Note: For blinded studies with ongoing enrollment allocation of subjects to active or Placebo arms is unknown 
** Planned blinded study, enrollment not yet started      


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Document Number: LVAD MPC II Trial Protocol Rev 4.1  
Date Revised: October 2016 
Page 20 of 68 
 
Date Effective: 
 
CONFIDENTIAL 
^Umbilical cord blood expanded with allogeneic MPCs co-culture 
 
The clinical trials and a detailed summary of the clinical safety outcomes to date are provided in 
more details in the Investigator’s Brochure. 
 
Safety Considerations 
In pre-clinical animal studies, it has been found that less than 5-10% of stem cells applied directly 
to the myocardium engraft and remain long-term at this site. The other cells either die through 
apoptosis or disseminate systemically through the circulation, and can be found in the spleen, 
liver, bone marrow and other organs.  Consequently, any stem cell treatment that is delivered to 
the native heart of an LVAD recipient will be expected to enter the systemic circulation, 
potentially resulting in direct exposure of the injected stem cells to biomaterials on the LVAD 
surface.   
 
No patients in the initial CTSN LVAD/MPC trial, evaluating 25 million MPCs in LVAD 
recipients, experienced any of the key safety endpoints, defined as infectious myocarditis, 
myocardial rupture, neoplasm, hypersensitivity reaction, and immune sensitization syndrome.  
While there were three deaths (30%) in the control group and none in the MPC group at 90 days, 6 
MPC patients (30%) died over the 12 months, such that the 12 month mortality rates were 
identical between groups.  The serious adverse event rates seen in the initial trial were similar 
between the MPC and control groups at both 90 days and 12 months, and the AE profiles were 
consistent with those seen in the LVAD population. 18  
 
Importantly, the initial CTSN trial (n=30) demonstrated safety with regard to allosensitization. Of 
patients randomized to the MPC group, 10% developed donor specific antibodies (DSA) 
compared to 30% of the control group, and DSA resolved by 12 months in all who survived to the 
end of the trial. As of August 26, 2013, up to 246 M cell dose of Mesoblast’s allogeneic MPCs 
manufactured under identical conditions as contemplated in the present study (150 million) have 
been safely administered although not in this particular patient population.  
 
Rationale for Selection of the Efficacy Endpoint   
The field of mechanical circulatory support, particularly in the context of evaluating myocardial 
function and recovery in the setting of adjunctive interventions, remains nascent.  Standard heart 
failure efficacy endpoints such as 6-Minute Walk Test (6MWT), NYHA class or HF 
hospitalizations, are of limited use in this population because of the presence of the LVAD itself 
and the physiologic state of off-loading the left ventricle.  It is becoming increasingly accepted 
clinical practice, however, to periodically evaluate the ability of LVAD recipients to tolerate a 
temporary wean from LVAD support and to assess their functional capacity off support for 
evidence of myocardial recovery.  LVAD explantation, however, regardless of the results of the 
wean assessments, remains rare.  Whereas the initial CTSN LVAD/MPC trial was designed 
primarily to assess the safety of intramyocardial injection of MPCs in LVAD recipients, the 
secondary objectives were selected to explore a clinically meaningful effect of the intervention 
within the constraints imposed by the implanted LVAD in this unique population.  The current 
assumption remains that the most meaningful cardiac assessments in LVAD patients are those 
performed on little or no LVAD support.  Accordingly, the key efficacy outcome for initial CTSN 


InCHOIR  
 
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Document Number: LVAD MPC II Trial Protocol Rev 4.1  
Date Revised: October 2016 
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CONFIDENTIAL 
LVAD/MPC trial was defined as the ability to tolerate a wean from LVAD support for 30 minutes.  
The utility of the ability to tolerate a wean as a predictor of long-term recovery has yet to be 
established, however, it is generally accepted that those unable to tolerate a wean (in the absence 
of non-cardiac causes) have persistent and profound cardiac debilitation.   The preliminary trial 
experience, however, demonstrated that non-cardiac factors, such as intermittent bleeding which 
may prompt clinical decisions to avoid adjusting anticoagulation necessary for the safety of a 
wean, impact the ability to wean from non-cardiac causes at a particular time point.  In order to 
mitigate the impact of the inability to tolerate the wean at a single time point for non-cardiac 
causes, the primary efficacy endpoint selected for this next trial is the number of weans tolerated 
over 6 months following randomization.  This efficacy endpoint will also reflect disease burden 
over time.       
 
Additional assessments of LV performance during the temporary intervals of reduced LVAD 
support will also be performed over the one year period of observation post-implantation, to 
further assess any impact on reverse remodeling, and explore alternative predictors of myocardial 
recovery. 
 
The clinical management of the patients enrolled in the trial will be based on the judgment of the 
multidisciplinary heart failure and transplant teams, and not on the results of the study-related 
evaluations.  It is increasingly accepted, however, that the ability to tolerate a wean is influenced 
by optimal medical therapy while on LVAD support, including aggressive off-loading of the LV.  
As such, guidance for optimal medical therapy on LVAD support is included in this protocol. 
 
Rationale for Dose Selection 
Given that the initial LVAD/MPC trial did not demonstrate any safety concerns, including 
allosensitization, the Network investigators decided to proceed, as originally planned, with the 
follow-up trial in a larger cohort of patients.  Despite the low dose of cells deployed in the initial 
trial, a potential efficacy signal was observed in that a greater proportion of MPC patients 
experienced successful temporary weans at 90 days.  Moreover, the total number of temporary 
weans tolerated by MPC patients was double that of the control group.  Similarly, the significantly 
lower early mortality rate and fewer hospitalizations in MPC patients compared to control were 
promising.  However, the treatment effect was not seen at one-year.  This argues for evaluating 
higher doses in this population, especially since sensitization concerns were addressed at the lower 
dose.   
 
Preclinical studies conducted by Mesoblast found that a dose of 150 M cells was well tolerated 
and effective.  The first of the pre-clinical studies was a dose escalation study in a sheep model of 
ischemic cardiomyopathy (ICM) with progressive HF.  The results indicated that transendocardial 
delivery of allogeneic MPCs was safe.  Progressive deterioration of cardiac function and LV 
remodeling were prevented in the high-dose MPC (225 M) treatment group, but not in the lower-
dose MPC (75 M and 25 M) groups and the control group.  The second pre-clinical evaluation of 
transendocardial delivery of MPCs (mean ±SD, 109x106±5x106 cells per animal) in a sheep HF 
model demonstrated improvement in LV systolic function, stabilization of left ventricular 
remodeling, and histologic improvements in the non-ischemic cardiomyopathic left ventricle.  The 
burden of fibrosis was lower after transendocardial delivery of MPCs compared to the placebo 
arm, although it was still greater than that found in normal healthy sheep hearts. 


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In addition to the results from the animal studies, the dose of 150 M MPCs to be injected into the 
endomyocardium was selected for this study because it was shown to be safe and effective in the 
Mesoblast Phase II trial HF-AB002, and was not associated with a clinically significant immune 
response. The Mesoblast trial enrolled 60 patients with chronic systolic heart failure and 
randomized them to 25 M, 75 M, or 150 M MPCs dose cohorts (patients were randomized 3:1, 
MPC to control within each cohort). A blinded post-hoc analysis of the data was performed to 
evaluate the HF-major adverse cardiac event (HF-MACE) rate, defined as cardiac death, 
hospitalization for decompensated HF, or successful resuscitation of documented ventricular 
fibrillation. The analysis demonstrated that the 150 M dose group was statistically significantly 
superior to all other treatment groups after 36 months of follow-up. 
 
Of note, the post-hoc HF-MACE outcomes were consistent with the outcomes observed with the 
pre-specified endpoint assessments, including 6MWT, left ventricular end systolic volume 
(LVESV), and left ventricular end diastolic volumes (LVEDV).  These surrogate endpoints have 
previously been associated with clinical outcomes and have been demonstrated to correlate with 
morbidity and/or mortality in patients with chronic HF due to LV systolic dysfunction. Kramer et 
al., for example, demonstrated a significant correlation between long-term clinical outcomes and 
the shorter term changes in LVESV, LVEDV and LV ejection fraction (LVEF).19 
 
In the Phase II HF-AB002 trial, the 150 M MPC dose group demonstrated a placebo corrected 
improvement in LVESV and LVEDV of -11.5 ml and -17.7 ml, respectively.  Based on a recent 
meta-analysis by Kramer and colleagues, the magnitude of effect in LVESV and LVEDV reported 
in the 150 M MPC group would be associated with an approximate 20-30% relative risk reduction 
in HF-MACE. Changes from baseline LVESV and LVEDV observed were consistent with 
clinically meaningful reverse remodeling (improvement) in the 150M dose cohort.  No significant 
changes in LVEF were observed in any of the dose treatment groups over time.  
 
Compared with control patients, the 150 M group showed a trend toward improvement in exercise 
capacity as assessed by the 6MWT at 6 and 12 months.  The control-corrected change from 
baseline at 12 months (52.5 meters; P=0.062) exceeded the 30-meter value considered to be 
clinically important. While Opasich and colleagues concluded that “when the 6-MWT is used as 
an end-point in intervention studies, the clinical relevance of the results must be considered 
cautiously if the variation in distance is less than 10% in individuals even though the results are 
statistically significant”20, the treatment effect of 14.5% (52.5 m) observed in the Mesoblast HF-
AB002 trial surpasses the 10% threshold considered clinically relevant. 
 
In aggregate, the concordance of results observed for these three important efficacy outcomes (i.e., 
HF-MACE, LV remodelling, and exercise capacity) indicate that the 150 M MPC dose is likely to 
be an effective dose.  Consequently, the FDA recently approved a Mesoblast-sponsored Phase III 
trial evaluating a dose of 150 M MPCs in medically managed HF patients.   
 
Based on Mesoblast’s experience, the current protocol will evaluate a single dose of 150 million 
MPCs in LVAD recipients.  
 
 


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STUDY DESIGN  
This is a prospective, multi-center, double-blind, randomized (2:1), single dose cohort, sham 
procedure controlled trial to evaluate the safety and efficacy of injecting a dose of 150 M 
allogeneic MPCs into the native myocardium of LVAD recipients.  Patients with advanced heart 
failure, implanted with an LVAD as either BTT or DT may be eligible to participate in the trial.  
FDA-approved LVADs will be utilized at US sites, and Health Canada-approved LVADs will be 
utilized at Canadian sites. All patients will be followed until cardiac transplantation or 24 months 
post randomization, whichever comes first. 
 
Cardiac transplantation must not be delayed for any study related reasons when a donor organ 
becomes available for a patient participating in this trial. 
 
ENDPOINTS 
 
Primary Endpoints 
The primary safety endpoint of this study is the incidence of potential study intervention-related 
adverse events (infectious myocarditis, myocardial rupture, neoplasm, hypersensitivity reaction, 
and immune sensitization syndrome). 
 
The primary efficacy endpoint of this study is functional status, while temporarily weaned from 
LVAD support, over the 6 months post randomization.  Functional status is defined by the ability 
to tolerate wean from LVAD support to low flow for 30 minutes.  See the Definition and 
Measurement of Endpoints section below for details.  
 
Secondary Endpoints 
 
Safety 
o Incidence of all serious adverse events 
o Anti-HLA antibody sensitization while on LVAD support 
 
Survival 
o Survival 
o Survival to cardiac transplantation 
 
Functional Status (over 6 months) 
o Duration of tolerated wean from LVAD support  
o 6MWT as tolerated at 20 (± 10) minutes following initiation of wean 
 
Functional Status (over 12 months) 
o Ability to tolerate each wean from LVAD support for 30 minutes 
o Duration of ability to tolerate wean from LVAD support  
o 6MWT as tolerated at 20 (± 10) minutes following initiation of wean1 
                                                          
1  Weaning and 6-minute walk schedule: 60 days, 4 mos, 6 mos, 9 mos, and 12 mos (or until transplant, whichever 
comes first) 
 


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Physiologic Assessments   
For patients who tolerate wean from LVAD support for 30 minutes 
o Echocardiographic assessments of the myocardial size and function by transthoracic 
echocardiography with LVAD at full support, and as tolerated following 6MWT while 
weaned from LVAD support, including: 
- 
Left ventricular ejection fraction; 
- 
Left ventricular end-diastolic and end-systolic dimensions; 
- 
Left ventricular fractional shortening; 
- 
Regional wall motion score index (WMSI) (Comprehensive post 6MWT echo at 6 and 
12 months) 
- 
RV function (normal, mild, moderate, severe) by Integrative Assessment;   
- 
RVSP from tricuspid regurgitation (TR) jet; 
 
For all patients (including those unable to tolerate LVAD wean) 
o Echocardiographic assessments of the myocardial size and function by transthoracic 
echocardiography with LVAD at full support,  
− Left ventricular ejection fraction; 
− Left ventricular end-diastolic and end-systolic dimensions; 
− Left ventricular fractional shortening; 
− RV function (normal, mild, moderate, severe) by Integrative Assessment; 
o Myocardial neovascularization at time of explant 
o Cardiomyocyte regeneration at explant 
o Cell Engraftment and fate at explant 
 
Quality of Life & Neurocognition 
o Quality of Life (QoL) at 6 & 12 months post randomization 
o Neurocognition at 90 days & 12 months post randomization 
 
  
 
Hospitalizations 
o LOS of index hospitalization 
o Frequency (<30 days and ≥30 days following index hospital discharge) and cause of 
readmissions 
o Hospital resource use (or costs) 
 
Tertiary Endpoints   
The following mechanistic endpoints will be assessed:  
 
o Chemo/cytokine quantification of plasma derived from peripheral blood samples will be 
performed.  Assessments include TNF-α, IL–6,  IL–10, IL–17, TGF-β, RANTES, and 
SDF-1.   
 
STUDY SUBJECTS 
A total of 159 patients with advanced heart failure who are scheduled to be implanted with an 
LVAD as a BTT or DT will be enrolled in this trial.  FDA-approved LVADs will be utilized at US 
sites, and Health Canada-approved LVADs will be utilized at Canadian sites. We anticipate 


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recruiting approximately 6 patients/month and that enrollment will be completed within 20 
months.   
 
ELIGIBILITY CRITERIA 
Patients with end-stage heart failure, of either ischemic or non-ischemic etiology, who are being 
evaluated for LVAD implantation as a BTT or DT, are candidates for this study.  Candidates who 
meet all inclusion criteria and no exclusion criteria will be eligible for the trial regardless of 
gender, race, or ethnicity.   
 
Inclusion Criteria 
 
1. 
Signed informed consent, inclusive of release of medical information, and Health Insurance 
Portability and Accountability Act (HIPAA) documentation; 
2. 
Age 18 years or older; 
3. 
If the subject or partner is of childbearing potential, he or she must be willing to use 
adequate contraception (hormonal or barrier method or abstinence) from the time of 
screening and for a period of at least 16 weeks after procedure; 
4. 
Female subjects of childbearing potential must have a negative serum pregnancy test at 
screening; 
5. 
Admitted to the clinical center at the time of randomization;  
6. 
Clinical indication and accepted candidate for implantation of an FDA-approved (US sites 
only) or Health Canada-approved (Canadian sites only) implantable, non-pulsatile LVAD as 
a bridge to transplantation or for destination therapy. 
 
Exclusion Criteria 
 
1. 
Planned percutaneous LVAD implantation; 
2. 
Anticipated requirement for biventricular mechanical support; 
3. 
Concomitant arrhythmia ablation at time of LVAD implantation; 
4. 
Planned aortic valve intervention for aortic insufficiency at the time of LVAD implantation;   
5. 
Cardiothoracic surgery within 30 days prior to randomization; 
6. 
Spontaneous myocardial infarction related to ischemia due to a primary coronary event 
such as unstable plaque rupture, erosion or dissection within 30 days prior to 
randomization; 
7. 
Prior cardiac transplantation, LV reduction surgery, or cardiomyoplasty; 
8. 
Acute reversible cause of heart failure (e.g. myocarditis, profound hypothyroidism); 
9. 
Stroke within 30 days prior to randomization; 
10. Platelet count < 100,000/mcL within 24 hours prior to randomization; 
11. Acute infectious process: acute bacterial, fungal, or viral disease OR acute exacerbation of 
chronic infectious disease such as hepatitis; 
12. Presence of >10% anti-HLA antibody titers2 with known specificity to MPC donor HLA 
antigens3; 
                                                          
2 Documented by clinical site laboratory for sites that measure PRA.  Core Lab will assess screening PRA for all sites 
that use calculated PRA values. 
3 Documented by Core Lab 


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13. A known hypersensitivity to dimethyl sulfoxide (DMSO), murine, and/or bovine products; 
14. History of a known active malignancy within the past 3 years except for localized prostate 
cancer, cervical carcinoma in situ, breast cancer in situ, or nonmelanoma skin cancer that 
has been definitively treated; 
15. Presence of human immunodeficiency  virus (HIV); 
16. Received investigational intervention within 30 days prior to randomization; 
17. Treatment and/or an incomplete follow-up treatment of any investigational cell based 
therapy within 6 months prior to randomization;  
18. Active participation in other research therapy for cardiovascular repair/regeneration; 
19. Prior recipient of stem precursor cell therapy for cardiac repair; 
20. Pregnant or breastfeeding at time of randomization; 
21. History of known or suspected hypercoagulable state in the opinion of the investigator. 
 
TREATMENT ASSIGNMENTS 
Patients will be enrolled in a single dose cohort and randomized in a 2:1 allocation to 
intramyocardial injection of study product or control (cryoprotective media alone [sham 
procedure]) at the time of LVAD implantation: 
 
Group 1 (n= 106):  150 million allogeneic MPCs (Mesoblast, Inc)  
Group 2 (n= 53): 50% Alpha-MEM/42.5% ProFreeze NAO Freezing Medium/7.5% 
DMSO (Control) 
 
RANDOMIZATION   
Patients will be enrolled in a single dose cohort and randomized in a 2:1 allocation to receive 
either intramyocardial injection of study product (MPC) or cryoprotective media alone (Control), 
during LVAD implantation.  Randomization will take place only after it has been determined that 
all study eligibility criteria have been met.  LVAD implantation and study intervention must be 
administered within 24 hours following randomization.  
 
MASKING  
This is a double-blind, sham procedure controlled trial.  In order to maintain blinding of 
investigators, the study intervention solutions will be thawed and prepared for intramyocardial 
injection by designated personnel at the site who must have no interaction with the patients, and 
limited interaction with the study investigators and coordinators, as necessary to conduct the trial.  
The syringes, once prepared will appear identical for both groups.  Site personnel and patients, as 
well all core lab study personnel will be blinded to treatment assignment throughout the trial.    
TREATMENT INTERVENTION 
 
Treatment intervention (and LVAD implantation) must occur within 24 hours following 
randomization.  The treatment intervention will be performed in the following manner: 
 
Four 1 cc syringes will be prepared and maintained in the sterile field as detailed in Appendix I. 
Study product (MPC or Control) will be thawed and prepared as detailed in the Study Product 
Technician Manual of Procedures (MOP).  The injection process should take place within 15 
minutes, from time of first injection to last injection, and must take place no longer than 90 
minutes following thawing of the study product.  A total of 16-20 epicardial injections of 0.2 mL 


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each (not to exceed a total of 4.0 mL) will be performed as detailed in Appendix I.  Injections 
should target as much left ventricular myocardium as possible, as suggested in the diagram below 
(Figure 1). The location of each injection delivered will be documented on the Intervention 
Injection Verification Case Report Form (CRF) by the surgical team during the operation.  See the 
Study Product Technician MOP for detailed study product (MPC or Control) handling and 
preparation.  See Appendix I (Intramyocardial Injection Procedures) for the injection procedures. 
 
Of note, study product thawed longer than 90 minutes must be discarded. 
 
LVAD IMPLANT AND MANAGEMENT 
Any permanent surgically implanted non-pulsatile LVAD approved by the FDA or Health 
Canada for BTT or DT for end-stage heart failure may be implanted at the discretion of the 
surgeon for patients enrolled in this trial.  NOTE:  Only FDA-approved LVADs will be utilized at 
US sites, and only Health Canada-approved LVADs will be utilized at Canadian sites.  
Implantation and management will be performed according to the Directions for Use for the 
specific LVAD.  Long term LVAD management should include optimization of hemodynamic 
off-loading of the left ventricle to target: (1) reduction of LVEDd to 5.5-6 cm; (2) reduction of 
mitral regurgitation to, at most, mild regurgitation; and (3) reduction in mean blood pressure to < 
100 mmHg.  
 
Figure 1. 
Anterior View 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DEFINITION AND MEASUREMENT OF ENDPOINTS  
 
Primary Endpoints 
 
The Primary Safety Endpoint  
The primary safety endpoint of this study is the incidence of potential study intervention-related 
adverse events, defined as (a) infectious myocarditis, (b) myocardial rupture, (c) neoplasm, (d) 
hypersensitivity reaction, and (e) immune sensitization syndrome, will be determined.   
Posterior View 


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The Primary Efficacy Endpoint 
The primary efficacy endpoint of this study is functional status, defined by the number of 
temporary weans from LVAD support tolerated over 6 months post randomization.  A successful 
wean is the ability to tolerate temporary weaning from LVAD support for 30 minutes without 
sustained symptoms of worsening heart failure.  Wean failures are defined as follows: 
o Inability to tolerate the temporary wean for 30 minutes; 
o Death;  
o Patient too unstable, in the judgment of the primary heart failure cardiologist, to tolerate 
the wean attempt (in ICU, on inotropic support or having persistent heart failure symptoms 
despite LVAD support).   
 
LVAD weans will be performed at 60 days and at 4 and 6 months (or until transplant, whichever 
comes first).  
 
LVAD Wean 
The continuous flow LVAD wean guidance was adopted from the Harefield Hospital Protocol 
with permission of Dr. Emma Birks.   
 
Non-pulsatile LVAD (e.g., HM II, HVADTM) Weaning Guidelines: Patients with an INR < 2.0 at 
the time of wean should receive a 5,000 to 10,000 unit dose of intravenous heparin at least 5 
minutes prior to reducing the pump speed.  The LVAD flow will then be reduced as detailed in the 
CTSN LVAD MPC II Trial LVAD Wean Procedure Guidelines, which are located in the LVAD 
MPC II MOP.  Blood pressure measurements will be taken prior to wean and monitored 
throughout the wean.   
 
Early termination of LVAD Wean  
The guidelines for early termination of device turn down during echocardiography and the 6MWT 
dictate that the LVAD will be returned to full LVAD flow if the patient develops persistent signs 
or symptoms of low output or vascular congestion as determined by the senior clinician 
overseeing the wean.  Signs and symptoms may include: light headedness, dyspnea, fatigue, chest 
pain, or pulmonary edema.   
 
Based on the collective experience of its multi-center international collaborators and experience 
for the first CTSN LVAD MPC Trial, an absolute change in blood pressure alone, in the absence 
of the clinical signs and symptoms listed above, will not necessitate terminating the LVAD wean. 
 
Secondary Endpoints 
 
Safety  
The following additional secondary endpoints will be assessed for all patients (including those 
who do not tolerate LVAD wean):  
 
Serious & Study-Intervention Related Adverse Events 
The incidence of potential study intervention-related adverse events, defined as (a) infectious 
myocarditis, (b) myocardial rupture, (c) neoplasm, (d) hypersensitivity reaction, and (e) 
immune sensitization syndrome, will be determined.  In addition, the incidence and frequency 


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of all anticipated and unanticipated serious adverse events will be determined.  Moreover, the 
incidence of all adverse events classified by the clinical site investigator or independent Event 
Adjudication Committee as “possibly” or “probably” study-intervention related (to either the 
study product or to the intramyocardial injection procedure itself) will be determined.  See 
Causality and Expected Serious Adverse Event sections that follow.  The study intervention-
related events above, or mortality in excess of rates expected for the BTT and DT LVAD 
populations will trigger cessation of enrollment (see Statistical Analysis Early Stopping Rules 
section). 
 
Anti-HLA Antibody Sensitization  
The incidence of anti-HLA antibody sensitization will be measured by complement dependent 
cytotoxic assay at regular intervals post-study intervention, and will be compared among 
groups.  Immune reactivity results for % IgG Class I and IgG Class II, will be assessed.  All 
measurements will be performed by the Immunologic Core Lab (See the LVAD MPC II MOP 
for details). 
 
Overall Survival & Survival to Cardiac Transplantation 
Overall survival and survival to cardiac transplant (in the BTT patients enrolled) will be assessed 
and compared between groups. 
 
The following secondary endpoints will be assessed during the temporary LVAD wean from full 
support for patients able to tolerate the wean: 
 
Functional Status (over 6 months and over 12 months) 
Ability to Tolerate Wean from LVAD Support for 30 Minutes  
The ability to tolerate the temporary wean from full LVAD support to target low flow for 30 minutes 
will be assessed at 60 days and at 4, 6, 9 & 12  months, and will be compared between groups.  See 
LVAD MPC II MOP for LVAD Wean Procedure Guidelines.   
 
Duration of Ability to Tolerate Wean 
The duration of ability to tolerate wean from LVAD support will be measured until the patient:  
(a) Reaches 30 minutes at target low speed LVAD support, and  
(b) Completes the echo and 6MWT (if this takes longer than 30 minutes and the patient 
remains stable), or  
(c) Requires early termination of device turn down (e.g., during echocardiography and/or the 
6MWT) and resumption of LVAD at full support, for persistent signs or symptoms of low 
output or vascular congestion as determined by the senior clinician overseeing the wean.  
Signs and symptoms may include: light headedness, dyspnea, fatigue, chest pain, or 
pulmonary edema.  
 
These signs and symptoms will be assessed at each time point post intervention.   
 
 
 
 
 


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Timeline of Functional Assessments Completed During LVAD Wean:  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
The LVAD wean will continue until the patient (a) reaches 30 minutes at low target speed of 
LVAD support and completes the functional assessments, or (b) fails the wean.  The LVAD will 
then be increased to the pre-wean (baseline) full support. 
 
6 Minute Walk Test  
The total distance walked in six minutes will be assessed.  For those who tolerate the LVAD 
wean, the 6MWT will be performed immediately following the 15 minute full echo assessment 
(at 20 (± 10) minutes following initiation of wean).  The distance will be measured (in feet), 
regardless of the number of times stopped or the rate of ambulation.  The 6MWT instructions 
are detailed in the LVAD MPC II MOP. 
 
Weaning And 6-Minute Walk Schedule: 60 days, 4 mos, 6 mos, 9 mos, and 12 mos (or until 
transplant, whichever comes first). 
  
Physiologic Assessments 
 
Echocardiographic Assessments of Myocardial Function  
Echocardiographic parameters (refer to the LVAD MPC II MOP) will be assessed at each 
wean assessment time point at (a) baseline with the LVAD on full support prior to wean, (b) 
15 minutes following initiation of wean from LVAD support (while LVAD flow remains 
weaned), and (c) immediately following the 6MWT, as tolerated by the patient.    
 
Echocardiograms will be read by the Echocardiography Core Lab.  The following values will 
be calculated from the measurements: left ventricular fractional shortening, left ventricular 
mass by the formula of Devereux (only full support, comprehensive echo study).  Regional 
wall motion assessment will be performed using the American Society of Echocardiography 
scoring system, modified to exclude the 4 apical segments because of the presence of the 
LVAD cannula in the LV apex.  Therefore, 12 segments (basal and mid-ventricular segments) 
will be utilized instead of 16. 
 
LVAD Wean
Baseline
Full Support
(prior to wean)
Comprehensive 
Echo
15 Min
20 Min (±10)
6-Min Walk
Immediately 
After 6-Min Walk
Comprehensive 
Echo
Comprehensive 
Echo
Following final 
comprehensive 
echo (post 6-
min walk) 
return LVAD to 
full support
LVAD remains weaned as tolerated
 


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The following echo assessments will be recorded at each time point before and after the 
LVAD wean as per protocol:  
o Left ventricular (LV) end-diastolic and end-systolic dimensions 
o LV fractional shortening 
o LVEF by Simpson’s Rule (when possible) 
o LVEF by visual assessment 
o Regional WMSI (Comprehensive post 6MWT echo at 6 and 12 months).  WMSI 
assessment will be performed using the American Society of Echocardiography 
scoring system, modified to exclude the 4 apical segments because of the presence 
of the LVAD cannula in the LV apex.  Therefore, 12 segments (basal and mid-
ventricular segments) will be utilized instead of 16. 
o RV function (normal, mild, moderate, severe)by Integrative Assessment  
o RV systolic pressure (RVSP) from tricuspid regurgitation jet  
 
The following secondary endpoints will be assessed in ALL patients, unrelated to the ability to 
tolerate the temporary wean from LVAD support: 
 
Neovascularization and Cardiomyocyte Proliferation 
Myocardium from the apical core removed at LVAD implant and cardiac samples taken at the 
time of explant for cardiac transplantation or any other indication, if applicable, will be 
categorized with regard to region, including anterior, anterolateral, lateral, inferior, 
midventricular and basilar specimens.  All samples will be evaluated for neovascularization, 
quantification of cardiomyocyte proliferation by immunohistochemistry or molecular analyses, 
general histology, and DNA analysis (Detailed in the LVAD MPC II MOP). 
 
Cell Engraftment and Fate 
Myocardium from multiple samples taken at the time of explant for cardiac transplantation or 
any other indication, if applicable, will be evaluated for cell engraftment.  Relative number of 
donor cells in the recipient heart will be estimated by real time PCR method measuring copy 
numbers of donor HLA-DRB alleles different from the recipient in the myocardial samples. 
(Detailed in LVAD MPC II MOP). 
 
QoL and Neurocognition 
Quality of life data will be collected and evaluated as a secondary endpoint.  Quality of life will be 
assessed with the Kansas City Cardiomyopathy Questionnaire (KCCQ), a widely used tool in 
heart failure populations, and the Short Form 12 (SF12), a widely used overall health status 
measure (refer to the LVAD MPC II MOP for questionnaires).  QoL will be compared between 
treatment groups at 6 months (±14) and 12 months (±14 days) post randomization. 
 
Neurocognition will be compared between treatment groups at 90 (±14) days and 12 months (±14 
days) post randomization, but not during LVAD wean.  Cognitive performance will be assessed 
using the following battery of tests: Hopkins Verbal Learning Test; Trailmaking Tests A and B; 
MCG Complex Figures; Digit Span; Digit Symbol Substitution Test; and Controlled Oral Word 
Association (refer to the LVAD MPC II MOP).  Neurocognitive testing will be administered by 
clinical site personnel who have been trained and certified for test administration by the 


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Neurocognitive Core lab personnel.  All neurocognitive test scoring will be performed centrally by 
the Neurocognitive Core lab. 
 
The neurocognitive battery used in this trial has been validated in English, Spanish and French.  
For patients who do not speak English, Spanish or French as a first language and therefore cannot 
perform the battery, this will not preclude them from participating in the trial and completion of 
the battery for these patients will not be required.   
 
Hospitalizations 
Length of Index Hospitalization 
Overall length of stay for the index hospitalization will be measured (and broken down by 
days spent in the ICU versus days spent on telemetry/step down unit and regular floors).  In 
addition, discharge location will be captured. 
 
Hospital Readmissions 
Readmission rates will be calculated for hospitalizations within the first 30 days following 
index hospitalization discharge, and for the duration of follow-up thereafter.  All readmissions 
will be classified by the investigator and adjudicated by the Event Adjudication Committee 
(EAC). 
 
Hospital Resource Use 
Inpatient resource utilization and costs will be measured through UB-92 forms and hospital 
billing forms for clinical sites located in the United States. Transfusion requirements will be 
calculated from the medical record.  In addition to index hospitalization costs, costs associated 
with subsequent readmissions will also be included in the study. Patients will also be asked at 
each follow-up visit if they have been hospitalized at another hospital and if yes for how long. 
Costs related to hospitalization at non-Network institutions will be imputed based on the 
average per day cost of hospitalization of study patients at Network hospitals. Outpatient costs 
incurred at non-Network and non-US hospitals will not be captured. 
 
Tertiary Endpoints 
The following tertiary endpoints will be assessed for all patients (including those who do not 
tolerate LVAD wean):  
 
Cytokine Quantification 
Plasma samples will be processed at the site at baseline (prior to study intervention), at day 1 (+1) 
post intervention, and at days 7 (±2), 30 (±3), 60 (±7), and 120 (± 14) days post randomization, and 
at 6 and 12 months (± 14 days) post randomization.  Chemo/cytokine quantification of plasma 
derived from peripheral blood samples will be performed by Luminex multiplex assay and include 
TNF-α, IL–6,  IL–10, IL–17, TGF-β, RANTES, SCF and SDF-1.   
 


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ADVERSE EVENTS   
An adverse event is any unfavorable, harmful or pathological change in the health of a research 
subject.  It may be indicated by physical signs, symptoms, clinically significant laboratory 
abnormalities, and/or disease temporally associated with the use of a medical (investigational) 
treatment, procedure, or product, whether or not related to the medical (investigational) treatment, 
procedure, or product.  This definition includes inter-current illnesses, injuries, exacerbations of 
pre-existing conditions and events occurring as a result of product abuse or overdose.  Stable pre-
existing conditions and elective procedures to address such conditions are not adverse events.  A 
change in a laboratory variable is considered an adverse event if it leads to a change in the 
patient’s functional status, or is considered by the attending physician to be clinically significant 
or if it caused (or may have caused) the investigator to reduce or discontinue the use of the product 
or to institute therapy.  
 
All investigators conducting clinical studies supported by the NHLBI must report both expected 
and unexpected serious adverse events to the Data Coordinating Center (DCC) and their individual 
Institutional Review Boards (IRBs)/Research Ethics Boards (REBs) in compliance with their 
institutional policies.   
 
All protocol-defined and serious adverse events will be collected from the time of randomization 
into this trial until induction of anesthesia for cardiac transplant or 12 months, whichever occurs 
first.  Any condition that was pre-existing is not an adverse event unless there is a change in the 
nature, severity or degree of the condition.  In addition, information regarding the occurrence of 
the events that trigger the Early Stopping Rules will also be collected as they occur, and their 
absence will be confirmed at each study visit.   
 
Early Stopping Rules 
An early stopping event is an event that results in a halt to enrollment. These events include: 
infectious myocarditis, myocardial rupture, neoplasm, hypersensitivity reaction, and immune 
sensitization syndrome.   (See Statistical Analysis Section, Early Stopping Rules). 
 
Copies of source documentation related to reported adverse events will be collected.  All patient 
identifiers will be removed from the source documents, and will be replaced with the patient’s 
study identification number. 
 
Serious Adverse Events 
Serious adverse events are defined as any experience that results in a fatality or is life threatening; 
results in significant or persistent disability; requires or prolongs a hospitalization; results in a 
congenital anomaly/birth defect; or represents other significant hazards or potentially serious harm 
to research subjects or others, in the opinion of the investigators. Important medical events that 
may not result in death, be life-threatening, or require hospitalization may be considered a serious 
adverse event when, based upon appropriate medical judgment, they may jeopardize the patient 
and may require medical or surgical intervention to prevent one of the outcomes listed in this 
definition.  Examples of such medical events include bronchospasm requiring intensive treatment 
in an emergency room or at home, blood dyscrasias, or convulsions that do not result in inpatient 
hospitalization.  
 


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CONFIDENTIAL 
Unexpected serious adverse events are defined as any experience that has not been described in 
the package insert for a given product/device or investigator’s brochure, protocol, or the informed 
consent document.  Expedited reporting is required for serious adverse events that are unexpected.  
  
Expedited Reporting (Procedure for Reporting Serious Adverse Events) 
Protocol defined (expected) and unexpected serious adverse events, as well as all events that 
trigger the Early Stopping Rules, must be reported to the DCC and entered into the electronic data 
capture (EDC) system within 24 hours of discovery of the event. All serious adverse events must 
be reported to the respective IRB/REB in accordance with the clinical center’s policies.  The DCC 
will notify the NHLBI program officials of any unexpected serious adverse events (including 
death), and events that trigger the Early Stopping Rules, via e-mail within 24 hours of receipt of 
the event.  The DCC will report all expected deaths (regardless of relationship to intervention), as 
well as all adverse events that are unexpected, serious and intervention-related to the NHLBI 
program officials within 72 hours of notification.  The NHLBI program officials, in turn, will 
notify the DSMB chair of these events.  All serious adverse events will be reported to the DSMB 
at least semi-annually at the discretion of the DCC medical monitor.  The IND Sponsor will 
promptly upon discovery, report serious and unexpected adverse events for which there is a 
reasonable possibility that the cell therapy (i.e., study product and/or injection procedure) caused 
the events, to the FDA in accordance with 21 CFR 312.32 regulations and ICH E2A guidelines.  
The Clinical Trial Application (CTA) Sponsor will also inform Health Canada, in an expedited 
manner, of any serious unexpected adverse drug reaction that has occurred inside or outside 
Canada in accordance with Canadian Food and Drug Regulations Division 5, Section C.05.014. 
 
Causality  
The investigator will assess the relationship of an adverse event to the treatment intervention.  If 
possible, the investigator should distinguish the relationship between the event and (a) the LVAD 
implant and (b) the investigational intervention.  Causality will be defined as follows:  
 
Probable 
Adverse events that, after careful medical evaluation, are considered with a high degree of 
certainty to be related to the LVAD implant or investigational intervention.  The following 
characteristics will apply: 
o A reasonable temporal relationship exists between the event and the LVAD implant or 
investigational intervention, and  
o The event is a known reaction to the LVAD implant or investigational intervention, which 
cannot be explained by an alternative etiology commonly occurring in the 
population/individual. 
 
Possible 
Adverse events that, after careful medical evaluation, do not meet the criteria for a probable 
relationship to the LVAD implant or investigational intervention, but for which a connection has 
reasonable certainty. The following characteristics will apply: 
 
o The event occurs after exposure to the LVAD implant or investigational intervention, and 
o The event is not a known reaction to the LVAD implant or investigational intervention but 
cannot be explained by a commonly occurring alternative etiology, or 


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CONFIDENTIAL 
o In the absence of a temporal relationship, the event cannot reasonably be explained by an 
alternative etiology. 
 
Unlikely 
 
Adverse events that, after careful medical evaluation, do not meet the criteria for a possible or 
probable relationship to the LVAD implant or investigational intervention and for which a 
connection is unlikely but cannot be ruled out. The following characteristics will apply: 
o The event does not follow a reasonable temporal sequence from administration of the LVAD 
implant or investigational intervention, or 
o May be explained by a commonly occurring alternative etiology in the population/individual, 
or 
o May have been produced by environmental factors, and there is no apparent pattern of 
response to the LVAD implant or investigational intervention. 
 
Expected Serious Adverse Events 
There are certain known and expected risks associated with products that are used in the 
production of MPCs.  These risks include: 
 
Reaction to Fetal Calf Serum or Murine Mouse Antibody 
For immunoselection of the allogeneic MPCs, the technology incorporates an antibody 
based sorting process using murine derived antihuman antibody. In the cell expansion 
process, fetal calf serum is used. The risk of sensitization from this formulation is 
unknown, but expected to be extremely rare.  
 
Reaction to Dimethyl Sulfoxide 
Dimethyl sulfoxide 7.5% is used as part of the MPCs cryopreservation process. The 
therapeutic and toxic effects of DMSO include its own rapid penetration and enhanced 
penetration of other substances across biologic membranes, free radical scavenging, and 
effects on coagulation, anticholinesterase activity, and DMSO-induced histamine release 
by mast cells. The systemic toxicity of DMSO is considered to be low. The DMSO 
exposure in this therapy is minimal and is locally applied.  
 
Potential Cell Contamination 
MPCs are an allogeneic, immunoselected, ex vivo expanded cell product, which has the 
potential to become contaminated and subsequently cause infection in the study patient at 
the time of surgical implantation. This risk is greatly minimized by the use of a Good 
Manufacturing Practice (GMP)-compliant production facility. As with any blood or 
marrow-derived biological agent, infectious risks from unknown pathogens are possible. 
 
Potential Inflammatory Responses 
The addition of allogeneic MPCs may exacerbate local inflammatory responses resulting 
from the allogeneic exposure to the MPC donor.  The risks of exposure are unknown but 
will be monitored throughout the study duration. If sensitivity occurs, persistent expression 
of anti-HLA antibodies could limit subsequent allogeneic transplant donor selection. 
Subjects will be monitored for these responses by performing inflammatory marker tests at 
follow-up visits. 


InCHOIR  
 
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CONFIDENTIAL 
 
Possible Effects of Cells on Fetus 
Because of potential or unknown side effects of the study on the fetus, if the patient is a 
female of childbearing potential, the patient must have a negative serum pregnancy test 
prior to study entry. In the event that the study patient is confirmed to be pregnant during 
the study, the Principal Investigator must immediately notify the DCC and the DCC’s 
Medical Monitor about the pregnancy and record it on the Adverse Event CRF. In 
addition, the Principal Investigator must report to the DCC follow-up information 
regarding the course of the pregnancy, including perinatal and neonatal outcome. Infants 
should be observed and monitored through the first year of life.  
 
LVAD-related adverse events in this study will collect data using updated definitions consistent 
with the INTERMACS registry definitions to enable standardization by currently recognized and 
accepted definitions. 
 
Protocol-Defined Adverse Events 
 
Neoplasm 
Any new uncontrolled growth of aberrant cells. 
 
Major Bleeding (Non-Intra-operative) 
An episode of suspected internal or external bleeding that results in one or more of the following: 
(a) death, (b) re-operation, (c) hospitalization; or (d) transfusion of red blood cells as follows: 
o ≥ 50 kg: ≥ 4U packed red blood cells (PRBC) within any 24 hour period during the 
first 7 days post-implant (once the patient has left the operating room) 
o < 50 kg: ≥ 20 cc/kg packed red blood cells (PRBC) within any 24 hour period during 
the first 7 days post-implant (once the patient has left the operating room) 
o Any transfusion of PRBC after 7 days following implant. (The number of units 
received/24 hour period will be recorded). 
Note: Hemorrhagic stroke is considered a neurological event and not a separate bleeding event. 
 
Intra-operative Bleeding 
Bleeding that results in death, re-operation, or transfusion of more than 4 units of packed red 
blood cells during an operative event (while the patient remains in the operating room).  
 
Cardiac Arrhythmias  
Any documented arrhythmia that results in clinical compromise (e.g., abnormal VAD function 
[e.g., diminished LVAD flow or suction events], oliguria, pre-syncope or syncope, angina, 
dyspnea), or requires hospitalization or treatment (drug therapy, defibrillation, cardioversion, ICD 
therapy (e.g., shock or anti-tachycardia pacing) or arrhythmia ablation procedure).  
 
Cardiac arrhythmias are classified as follows:  


InCHOIR  
 
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CONFIDENTIAL 
o Sustained ventricular arrhythmia resulting in clinical compromise, or requiring 
hospitalization or drug treatment, defibrillation or cardioversion, ICD therapy, or 
arrhythmia ablation procedure. 
o Sustained supraventricular arrhythmia resulting in clinical compromise, or requiring 
hospitalization or drug treatment, cardioversion, ICD therapy or arrhythmia ablation 
procedure.  
 
Pericardial Fluid Collection 
Accumulation of fluid or clot in the pericardial space that requires surgical intervention or 
percutaneous catheter drainage.  This event will be subdivided into those with clinical signs of 
tamponade (e.g. increased central venous pressure and decreased cardiac/LVAD output) and those 
without signs of tamponade. 
 
Pleural Effusion 
Accumulation of fluid or clot in the pleural space documented by chest radiogram or chest CT that 
requires evacuation with surgical intervention or chest tube placement. 
 
Vasodilatory State 
Episode of vasodilation documented by hemodynamic evidence, without obvious underlying cause 
such as, but not limited to, sepsis or pharmacotherapy, lasting ≥ 24 hours. 
 
Inflammatory Reaction  
Two types of inflammatory reactions will be identified as follows: 
 
Hypersensitivity Reaction 
Clinical syndrome including but not limited to fever, leukocytosis, or rash with onset ≤ 2 
hours post treatment intervention and lasting < 24 hours, in the absence of clinical signs of 
concomitant infection.   
 
Immune Sensitization Syndrome 
Clinical syndrome including but not limited to fever, leukocytosis, rash or arthralgias with 
onset ≥ 7 days post treatment intervention and subsequent detection of anti-HLA 
antibodies against the donor cells detected ≤ 30 days following onset of syndrome, in the 
absence of clinical signs of concomitant infection.   
 
Device Malfunction 
Device malfunction occurs when any component of the mechanical circulatory support device 
(MCSD) system ceases to operate to its designed performance specifications or otherwise fails to 
perform as intended. Performance specifications include all claims made in the Instructions for 
Use for the device.  
 
Device malfunctions are defined as major or minor: 
 
1. Major device malfunction, otherwise known as failure, occurs when one or more of the 
components of the MCSD system either directly causes or could potentially induce a state 
of inadequate circulatory support (low cardiac output state) or death. A failure that was 
iatrogenic or recipient-induced will be classified as an Iatrogenic/Recipient-Inducted 


InCHOIR  
 
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Document Number: LVAD MPC II Trial Protocol Rev 4.1  
Date Revised: October 2016 
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Date Effective: 
 
CONFIDENTIAL 
Failure. A device malfunction or failure is considered major when one of the following 
conditions occurs:  
a. Suspected or Confirmed Pump Thrombus (see below)  
b. Urgent Transplantation (immediate 1A listing for transplant) 
c. Pump Replacement 
d. Pump Explant 
e. Breach of Integrity of Drive Line Requiring Repair 
f. Death 
 
2. Minor device malfunction includes inadequately functioning external components which 
require repair or replacement but do not result in 1a-f under major device malfunction.  It 
does not apply to “routine” maintenance which includes repair/replacement of external 
controller, pneumatic drive unit, electric power supply unit, batteries, interconnect cable. 
 
Pump Thrombus represents a special case of major device malfunction and will be classified as 
“Suspected” based upon clinical, biochemical, or hemodynamic findings or “Confirmed” based 
upon device inspection or incontrovertible radiologic studies or absence of appropriate Doppler 
flow signals that confirms thrombus within the device or its conduits that results in or could 
potentially induce circulatory failure.  
 
o Suspected pump thrombus is a pump-related malfunction in which clinical MCSD 
parameters suggest thrombus on the blood contacting components of the pump, 
cannulae, or grafts. Signs and symptoms should include at least 2 of the 3 following 
criteria: 
 Presence of hemolysis 
 Presence of heart failure not explained by structural heart disease 
 Abnormal pump parameters 
Suspected pump thrombus should be accompanied by 1 or more of the following 
events or interventions: 
 Treatment with intravenous anticoagulation (e.g., heparin), intravenous 
thrombolytics (e.g., tPA) or intravenous antiplatelet therapy (e.g., eptifibatide, 
tirofiban) 
 Pump replacement 
 Pump explantation 
 Urgent transplantation (UNOS 1A) 
 Stroke 
 Arterial non-CNS thromboembolism 
 Death 
o Confirmed pump thrombus is a major pump-related malfunction in which thrombus 
is confirmed within blood contacting surfaces of the device inflow cannula or outflow 
conduit or grafts. This can be reported via direct visual inspection or by 
incontrovertible radiologic studies or absence of appropriate Doppler flow signals that 
results in or could potentially induce circulatory failure or result in thromboembolism. 
 
Hemolysis 


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CONFIDENTIAL 
Minor Hemolysis: A plasma-free hemoglobin value greater than 20 mg/dL or serum lactate 
dehydrogenase (LDH) level greater than two and one-half time (2.5x) the upper limits of normal 
range at the implanting center occurring after the first 72 hours post-transplant in the absence of 
clinical symptoms or findings of hemolysis or abnormal pump function.  
 
Major Hemolysis: 
A plasma-free hemoglobin value that is greater than 20 mg/dL or serum lactate dehydrogenase 
(LDH) level greater than two and one-half times (2.5x) the upper limits of the normal range at the 
implanting center occurring after the first 72 hours post-implant and associated with clinical 
symptoms or findings of hemolysis or abnormal pump function. Major Hemolysis requires the 
presence of one or more of the following conditions: 
 Hemoglobinuria (“tea-colored urine”) 
 Anemia (decrease in hematocrit or hemoglobin level that is out of proportion to levels 
explainable by chronic illness or usual post-VAD state) 
 Hyperbilirubinemia (total bilirubin above 2 mg/dL, with predominately indirect component) 
 Pump malfunction and/or abnormal pump parameters 
 
Subjects will undergo routine surveillance for hemolysis using serum lactate dehydrogenase 
(LDH). LDH to be collected at Days 4, 7, 30, 60 and 90; at 4, 6, 9 and 12 months; and as an event-
driven data point. 
 
Hepatic Dysfunction 
An increase in any two of the following hepatic laboratory values (total bilirubin, aspartate 
aminotransferase/AST and alanine aminotransferase/ALT) to a level greater than three times the 
upper limit of normal for the hospital, for 14 consecutive days post-implant (or if hepatic 
dysfunction is the primary cause of death). 
 
Hypertension 
New onset BP elevation greater than or equal to 140 mmHg systolic or 90 mmHg diastolic 
(pulsatile pump) or 110 mmHg mean pressure (rotary pump).   
 
Major Infection 
A clinical infection accompanied by pain, fever, drainage and/or leukocytosis that is treated by 
anti-microbial agents (non-prophylactic).  A positive culture from the infected site or organ should 
be present unless strong clinical evidence indicates the need for treatment despite negative 
cultures.   
 
The general categories of infection are listed below: 
 
Localized Non-Device Infection 
Infection localized to any organ system or region (e.g. mediastinitis) without evidence of 
systemic involvement (see sepsis definition below), ascertained by standard clinical 
methods and either associated with evidence of bacterial, viral, fungal or protozoal 
infection, and/or requiring empirical treatment. 
 


InCHOIR  
 
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Document Number: LVAD MPC II Trial Protocol Rev 4.1  
Date Revised: October 2016 
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Date Effective: 
 
CONFIDENTIAL 
Percutaneous Site Infection 
A positive culture from the skin and/or tissue surrounding the drive line or from the tissue 
surrounding the external housing of a pump implanted within the body, coupled with the 
need to treat with antimicrobial therapy when there is clinical evidence of infection such as 
pain, fever, drainage, and/or leukocytosis. 
 
Internal Pump Component, Inflow or Outflow Tract Infection 
Infection of blood-contacting surfaces of the LVAD documented by positive site culture, 
including valve endocarditis and pump housing infection. 
 
Sepsis 
Evidence of systemic involvement by infection, manifested by positive blood cultures 
and/or hypotension. 
 
Myocardial Infarction (MI) 
Two categories of myocardial infarction will be identified: 
 
Peri-operative Myocardial Infarction 
The clinical suspicion of myocardial infarction, together with CK-MB or Troponin >10 
times the local hospital’s upper limits of normal, found within 7 days following LVAD 
implant, together with ECG findings consistent with acute myocardial infarction.  (This 
definition uses the higher suggested limit for serum markers due to apical coring at the 
time of LVAD placement and does not use wall motion changes because the apical sewing 
ring inherently creates new wall motion abnormalities). 
 
Non-Perioperative Myocardial Infarction 
The presence >7 days post-implant, of 2 of the following 3 criteria: 
o Chest pain which is characteristic of myocardial ischemia; 
o ECG with a pattern or changes consistent with a myocardial infarction; 
o Troponin or CK (measured by standard clinical pathology/laboratory medicine  
methods) greater than the normal range for the local hospital with positive MB 
fraction (≥3% total CK).  This should be accompanied by a new regional LV or RV 
wall motion abnormality on a myocardial imaging study. 
 
Myocardial Rupture 
The presence of myocardial rupture as evidenced by direct visualization (intra-operative or at 
autopsy) or by standard diagnostic modalities including, but not limited to echocardiography or 
ventriculography, with or without hemodynamic instability. 
 
 
Neurological Dysfunction 
Any new, temporary or permanent, focal or global neurological deficit ascertained by a standard 
neurological examination (administered by a neurologist or other qualified physician and 
documented with appropriate diagnostic tests and consultation note); or an abnormality identified 
by surveillance neuroimaging.  The examining physician will classify the event as a 
cerebrovascular event as defined below or as a non-vascular acute neurologic event. A neurologic 
event may be recognized by a clinically evident sign or symptom, or by clinically-silent 


InCHOIR  
 
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Document Number: LVAD MPC II Trial Protocol Rev 4.1  
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CONFIDENTIAL 
electrographic seizure activity, or as a clinically silent lesion detected by surveillance 
neuroimaging. Each neurologic event should be classified by the clinical provider following 
complete neurologic assessment as one of the following event types: 
 
o Transient Ischemic Attack: Acute transient neurologic deficit conforming anatomically to 
arterial distribution cerebral ischemia that resolves completely within 24 hours with no 
evidence of infarction on brain imaging. 
 
o Ischemic Stroke: Acute neurologic deficit (or acute encephalopathy) of any duration 
associated with acute infarction on imaging corresponding anatomically to the clinical 
deficit. Classified as due to arterial-distribution ischemia or due to venous thrombosis. 
 
o Acute Symptomatic Intracranial Hemorrhage: New acute neurologic deficit (or acute 
encephalopathy) attributable to Intracranial hemorrhage (ICH). ICH subtype are specified 
as one or a combination of the following types: subarachnoid, intraventricular, 
parenchymal, subdural. 
 
o Clinically Covert Ischemic Stroke or ICH: infarction or ICH seen by surveillance imaging, 
without clinical findings or stroke or ICH at the time of event recognition. 
 
o Hypoxic-Ischemic Encephalopathy: Acute new encephalopathy due to hypoxic-ischemic 
injury (HIE), manifest as clinically-evident signs and symptoms, or subclinical 
electrographic seizures found by complete neurological diagnostic evaluation to be 
attributable to acute global or focal hypoxic or ischemic brain injury not meeting one of the 
ischemic stroke or ICH events as defined above.  
 
o Other: Acute new encephalopathy due to other causes, manifested as clinically-evident 
signs and symptoms or subclinical electrographic seizures found by complete neurological 
diagnostic evaluation to be attributable causes other than stroke, ICH or HIE as defined 
above.  
 
The anticoagulation and antiplatelet medication regimen at the time of the neurological event will 
be recorded.  In addition, the NIH Stroke Scale and the Modified Rankin Scale must be 
administered at the time of event (within 72 hours following the event), and at 30 days (±10 days) 
and 60 days (±10 days) post neurological event to document the presence and severity of 
neurological deficits.  Each neurological event must be subcategorized as: 
 
Psychiatric Episode 
Disturbance in thinking, emotion or behavior that causes substantial impairment in functioning or 
marked subjective distress requiring intervention.  Intervention is the addition of new psychiatric 
medication, hospitalization, or referral to a mental health professional for treatment.  Suicide is 
included in this definition.   
 
Renal Dysfunction 
Two categories of renal dysfunction will be identified: 
 
Acute Renal Dysfunction 


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CONFIDENTIAL 
Abnormal kidney function requiring dialysis (including hemofiltration) in patients who did 
not require this procedure prior to implant, or a rise in serum creatinine of greater than 3 
times baseline or greater than 5mg/dL sustained for over 48 hours. 
 
Chronic Renal Dysfunction 
An increase in serum creatinine of 2 mg/dL or greater above baseline or requirement for 
hemodialysis, either of which is sustained for at least 90 days. 
 
Respiratory Failure 
Impairment of respiratory function requiring intubation or tracheostomy, or the inability to 
discontinue ventilatory support within 6 days (144 hours) post-LVAD implant.  This excludes 
intubation for re-operation or temporary intubation for diagnostic or therapeutic procedures.   
 
Right Heart Failure 
Symptoms and signs of persistent right ventricular failure characterized by both of the following: 
 Documentation of elevated central venous pressure (CVP) by: 
o Direct measurement (e.g., right heart catheterization) with evidence of a CVP or 
right atrial pressure > 16 mmHg. 
or 
o Findings of significantly dilated inferior cava with absence of inspiratory variation 
by echocardiography. 
or 
o Clinical findings of elevated jugular distension at least half way up the neck in an 
upright position. 
 Manifestation of elevated CVP characterized by: 
o Clinical findings of peripheral edema (≥ 2+ either new or unresolved),  
or 
o Presence of ascites or palpable hepatomegaly on physical examination (unmistaken 
abdominal contour) or by diagnostic imaging,  
or 
o Laboratory evidence of worsening hepatic (total bilirubin > 2.0 mg/dL) or renal 
dysfunction (creatinine > 2.0 mg/dL) 
 
The severity of right heart failure will be graded according to the below scale. Direct 
measurement of CVP or right arterial pressure must be one of the criteria to grade the 
severity as severe or severe acute.  
 
Right Heart Failure Severity Grade 
Severity 
Definitions 
VAD Implant Admission 
Surveillance Period* 
Moderate 
Post-implant inotropes, inhaled 
nitric oxide or intravenous 
vasodilators continued beyond 
post-op day 7 and up to post-
op day 14 following VAD 
implant  
Limited to 1 readmission for 
intravenous 
diuretics/vasodilators to treat 
RHF since last surveillance 
visit  
AND 


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CONFIDENTIAL 
Right Heart Failure Severity Grade 
Severity 
Definitions 
VAD Implant Admission 
Surveillance Period* 
No inotropes since last 
surveillance visit 
Severe 
CVP and right arterial pressure 
greater than 16mmHg 
AND 
Prolonged post-implant 
inotropes, inhaled nitric oxide 
or intravenous vasodilators 
continued beyond post-op day 
14 following VAD implant 
Need for inotropes at any time 
since last surveillance period 
OR 
2 or more readmissions for 
intravenous 
diuretics/vasodilators to treat 
RHF since last surveillance 
period 
OR 
Requiring RVAD support at 
any time after hospital 
discharge 
OR 
Death any time following 
discharge from the LVAD 
implant hospitalization with 
RHF as the primary cause  
Severe-Acute 
CVP or right arterial pressure 
greater than 16 mmHg 
AND 
Need for RVAD at any time 
following LVAD implant 
OR 
Death during LVAD implant 
hospitalization with RHF as 
primary cause 
Not applicable 
 
Arterial Non-CNS Thromboembolism 
An acute systemic arterial perfusion deficit in any non-cerebrovascular organ system due to 
thromboembolism confirmed by one or more of the following:   
o Standard clinical and laboratory testing 
o Operative findings 
o Autopsy findings 
 
This definition excludes neurological events. 
 
Venous Thromboembolism  


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CONFIDENTIAL 
Evidence of venous thromboembolic event (e.g. deep vein thrombosis, pulmonary embolism) by 
standard clinical and laboratory testing. 
 
Wound Dehiscence 
Disruption of the apposed surfaces of surgical incision, excluding infectious etiology, and 
requiring surgical repair. 
 
Unexpected (Other) Serious Adverse Events 
Other Serious Adverse Event 
An event that causes clinically relevant changes in the patient’s health or any event that is life-
threatening, results in a fatality, results in permanent disability, requires hospitalization, or 
prolongs an existing hospital stay. 
 
CLINICAL CENTERS 
The trial will be conducted in up to 30 clinical centers that have been selected in conjunction with 
the NHLBI. The selected centers are all highly experienced LVAD and heart failure centers with a 
proven track record of conducting clinical trials in this area.  
 
Each clinical center will be required to obtain IRB/REB approval for the protocol and consent 
revisions in a timely fashion, to recruit patients, to collect data and enter it accurately into the 
electronic data capture (EDC) system, to faithfully follow the protocol and adhere to the standards 
of Good Clinical Practice (GCP) and HIPAA regulations (US sites) or the Personal Information 
Protection and Electronic Documents Act (PIPEDA) regulations (Canadian sites). In addition, 
centers will be required to provide the DCC the information necessary for interim, annual, and 
final reports, to provide source documents, data and regulatory documents to study monitors, to 
respond promptly to DCC inquiries, and, to participate in analyses and reporting of study results. 
 
Site Approval  
The following documents are required for all sites approved to participate in the trial: 
o Clinical Study Agreement with the CTSN DCC: InCHOIR, Department of Health Policy, 
Icahn School of Medicine at Mount Sinai 
o Signed Conflict of Interest Statements 
o Completed Form FDA 1572  
o Signed and dated CVs for all staff on Delegation of Authority Log 
o Completed Delegation of Authority Log 
o Privacy training (HIPAA or PIPEDA) and Human Subjects training documentation (as 
required by local institutional guidelines) for all staff on Delegation of Authority Log 
o Current licenses for all staff on Delegation of Authority Log 
o IRB/REB roster 
o IRB/REB approval for protocol, informed consent document, HIPAA authorization 
o Clinical Center Laboratory Certification 
o Dangerous Goods Certification Training for appropriate staff 
o NIH Stroke Scale and Modified Rankin Scale Training Certification for appropriate staff 
o Laboratory Normal Ranges  
o Certification forms for Surgeons, Investigators, Unblinded Staff members 
o Signed Document Approval Form for protocol 


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Document Number: LVAD MPC II Trial Protocol Rev 4.1  
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CONFIDENTIAL 
o Study-specific training documents 
 
Canadian sites must provide:  
o Health Canada Clinical Trial Site Information Form 
o Qualified Investigator Undertaking Form 
o Research Ethics Board Attestation Form 
 
INVESTIGATORS 
All surgeons, cardiologists, coordinators and other investigators involved in the trial must 
complete the Investigator Contact Form with their hospital affiliation, address, contact numbers 
(phone, fax, cell, pager), and email address.  All investigators must send their CV, Clinical Study 
Agreement/Conflict of Interest Statement, completed Form FDA 1572, Qualified Investigator 
Undertaking Form (Canadian sites only), Good Clinical Practice Certificates, and HIPAA or other 
Privacy Protection certification as required by the local institution to the DCC. 
 
Qualifications and Training  
Clinical investigators will be cardiothoracic surgeons with expertise in cardiac transplant surgery 
and heart failure/transplant cardiologists.  To qualify as a participating surgeon, the surgical 
investigators must have performed at least 10 LVAD implantation procedures annually (averaged 
over a 2 year period) and a minimum of 25 LVAD implants to date.  The clinical center must 
perform a minimum of 10 LVAD implants annually.  The heart failure/transplant cardiology 
investigator must have a minimum of 5 years of experience as an attending physician caring for 
critically ill cardiac patients and patients on LVAD support.  Surgical and cardiology 
qualifications for all participating investigators will be collected on the Certification Form and 
faxed to the DCC prior to accreditation.  The clinical site Principal Investigator will be responsible 
for overseeing the ongoing performance of the other participating surgical and cardiology 
investigators at that site over the course of the study.  In addition, each investigator will participate 
in at least one of the bi-annual meetings of the Clinical Management Committee. 
 
Each clinical site echocardiography lab involved in image acquisition for this trial will be certified 
by the Echocardiography Core Lab. 
 
All clinical site investigators and coordinators will be trained by the DCC in the specifics of the 
protocol and the intramyocardial injection procedure at a site initiation visit in advance of patient 
enrollment.  The study coordinators will be trained by the Neurocognition Core lab to administer 
the neurocognitive testing.  In addition, the investigators and coordinators will undergo a separate 
training session to gain familiarity with the electronic data capture system. 
  
Good Clinical Practices (GCP) Certificate 
All investigators and coordinators who are involved in care of study patients, and/or research data 
collection must provide certification that they have successfully completed their institutionally 
required GCP or other Human Subjects Protection courses.  
 
Conflict of Interest  
A conflict of interest statement will be collected from all study investigators to ensure that no 
investigator may exert undue influence that may bias the trial.  Any conflict of interest identified 


InCHOIR  
 
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Document Number: LVAD MPC II Trial Protocol Rev 4.1  
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CONFIDENTIAL 
will be reviewed by the NIH and managed in compliance with 21 CFR 54 and 42 CFR 50(f) and 
the Tri-Council Policy Statement on Ethical Conduct for Research Involving Humans. Conflict of 
interest statements will be updated as changes occur. 
 
Patient Confidentiality 
Confidentiality of all patient records will be maintained according to HIPAA and PIPEDA 
guidelines.  Study Investigators, site IRBs, REBs, the DCC (InCHOIR), the Event Adjudication 
Committee (EAC), the NHLBI, Mesoblast, Inc., Health Canada and the FDA may review source 
documentation for enrolled patients as necessary, but all unique patient and hospital identifiers 
will be removed prior to review. If the results of this study are published, the data will be 
presented in aggregate, with all patient identifiers removed.   
 
HIPAA or other Privacy Training Certification 
All investigators and coordinators must provide documentation that they have successfully 
completed the institutional requirements to ensure patient rights, privacy and security under 
HIPAA or PIPEDA.   
 
SITE INITIATION 
Site initiation involves multiple trainings, which will occur in-person, via teleconference, webinar, 
video and/or through on-line training courses, depending on one’s role and responsibilities in the 
study, and culminates with a pre-enrollment teleconference for key study personnel. IRB/REB 
approval and the clinical study agreement between the clinical site and the DCC must be signed 
and executed prior to the completion of the site initiation process.  Additionally, the completed 
Form FDA 1572, applicable CVs and other regulatory documents must be on file with the DCC 
prior to completing site initiation.  Representatives from the DCC will conduct a pre-enrollment 
teleconference prior to site activation and enrollment of the first patient.  The PI, lead heart failure 
cardiologist, study coordinator, LVAD coordinator, and  study product technicians will be 
required to attend the pre-enrollment teleconference.  All other health care professionals who may 
be involved in the trial (e.g. echocardiographers, neuropsychologists, engineers, social workers, 
in-patient staff) will be encouraged to attend. 
 
DATA COLLECTION 
 
Pre-Implant (Screening & Baseline) Data Collection  
 
Screening Failure  
Prior to informed consent 
Prior to approaching a patient to begin the informed consent process, the study personnel will 
review data on prospective patients to determine eligibility for inclusion in the trial.  All pre-
screened patients (patients who are not consented) who are not enrolled are recorded as pre-
screening failures on the Screening Registration form in the EDC.  The data collected is HIPAA 
and PIPEDA compliant and does not include patient identifiers but does include screening quarter, 
screening year, age, sex, racial category, and reason not eligible or not enrolled.  
 
Informed Consent  
Prior to screening data collection and all protocol defined procedures 


InCHOIR  
 
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CONFIDENTIAL 
The investigator is responsible for ensuring that the informed consent process is conducted and 
documented appropriately by trained study staff.  A signed informed consent form, which has 
been approved by the DCC and the individual IRBs/REBs, is required.  The consent form must 
incorporate a clinical research authorization for use and disclosure of private health information 
and Release of Medical Information that authorizes release of medical records to the trial 
investigators, monitors, sponsors (NIH, NINDS, CIHR), Mesoblast, Inc. (the MPC manufacturer) 
and the DCC.  The investigators or a designated and qualified individual, will provide a thorough 
explanation of the objectives, patient responsibilities, risks and benefits of the study, and will fully 
address all concerns raised by the patient and/or family.  After all issues have been adequately 
resolved, and the investigator has confirmed that the patient has been fully consented, the patient 
will be asked to sign the informed consent.  The consent process must be documented in the 
medical chart, and a signed copy of the consent must be given to the patient.   
 
For the purpose of primary analysis, patients meeting the eligibility criteria are considered enrolled 
in the study at time of randomization. 
 
Demographics 
During screening, following informed consent 
For all patients screened, age, racial category, sex, and education  will be captured on the 
Screening Registration form.   
 
Medical History  
Within 7 days prior to randomization 
This form captures information pertaining to the etiology of heart failure, the history of 
cardiovascular disease and other co-morbidities. 
 
Physical Examination  
Within 7 days prior to randomization 
This form documents a physical examination including anthropometrics (height andweight), vital 
signs including temperature, and a cardiovascular, pulmonary, abdominal, and extremity exam.  
 
Medications 
Within 7 days prior to randomization 
All cardiovascular medications that the patient receives during the pre-implant period (within 7 
days prior to randomization) through study completion will be captured on the Medication Log in 
the electronic data capture (EDC) system. All non-cardiovascular medications will be captured on 
the Concomitant Medication CRF in the EDC. 
 
Immunotherapy Medication 
Within 30 days prior to randomization 
This form captures all immunosuppressive medications/procedures that the patient received within 
30 days prior to randomization.  
 
Laboratory Assessment  
Within 24 hours prior to randomization 
o Urine or serum beta HCG (IU/L) for women who have the potential to become pregnant  


InCHOIR  
 
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o Platelet count (103/mL) 
 
Within 72 hours prior to treatment intervention 
o Blood Type and Cross  
o Chemistry Panel to include: 
Sodium (mM/L), Potassium (mM/L), Blood Urea Nitrogen (mg/dL), Creatinine (mg/dL), 
Alanine Aminotransferase (ALT; U/L), Aspartate Aminotransferase (AST; U/L) 
o Hematology: 
White blood cell count (103/mL), Hemoglobin (g/dL), Hematocrit (%) 
 
Biospecimen Analyses  
Within 72 hours prior to treatment intervention  
A baseline peripheral blood sample will be obtained  for chemo- and cytokine quantification 
(detailed in the Biospecimen Core Laboratory Manual). Isolated plasma will be stored frozen at 
the clinical site and shipped to the Biospecimen Core Lab as directed in the Manual. 
   
Immunologic Assessment  
Screening PRA will be obtained within 6 months prior to randomization (must be at least 2 weeks 
following receipt of PRBC or platelet administration, if applicable).   
A screening anti-HLA antibody serum sample will be obtained and analyzed as described in the 
Biospecimen Core Laboratory Manual.  Immune reactivity results for % IgG Class I and IgG 
Class II will be recorded.  Presence of > 10% anti-HLA antibody titers triggers a comparison of 
recipient antibodies to the MPC donor HLA antigen profiles performed by the Immunologic Core 
Laboratory.  Known specificity to the MPC donor HLA antigens will exclude participation in 
this trial (See Eligibility Criteria section).   
 
Within 72 hours prior to treatment intervention 
A baseline peripheral blood sample will be obtained to measure anti-murine and anti-bovine 
antibodies (detailed in the Biospecimen Core Laboratory Manual).  The sample will be processed, 
frozen and stored at the clinical site and shipped to the Biospecimen Core Lab as directed in the 
Manual. 
 
Hemodynamics 
Within 7 days prior to randomization 
Right heart catheterization should be performed within 7 days prior to randomization, if clinically 
indicated.  In the absence of clinical indication, the hemodynamics must be obtained in the 
operating room prior to treatment intervention and LVAD implantation.  Hemodynamics 
including central venous pressure (CVP), pulmonary artery pressures including systolic, diastolic 
and mean pulmonary artery pressures (PAS, PAD, PAM), pulmonary capillary wedge pressure 
(PCWP), transpulmonary gradient, cardiac output (CO), cardiac index (CI), pulmonary artery 
oxygen saturation (PAO2 sat), and pulmonary vascular resistance (PVR measured in Wood Units) 
will be assessed by right heart catheterization.   
 
Echocardiography  
Within 14 days prior to randomization  


InCHOIR  
 
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Document Number: LVAD MPC II Trial Protocol Rev 4.1  
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CONFIDENTIAL 
A complete echocardiogram will be performed prior to LVAD implantation to assess ventricular 
size, function and regional wall motion (See the LVAD MPC II MOP for details). The echo will 
be analyzed by the Echocardiography Core Lab. The form also captures information pertaining to 
echocardiography image acquisition including the date and time of the study, and date uploaded to 
the Echocardiography Core Lab. If an image was not performed, a protocol deviation will be 
documented.  
 
NIH Stroke Scale  
Within 7 days prior to randomization 
The NIH Stroke Scale will be performed prior to LVAD implant for baseline neurological 
assessment ( ) by a certified staff member (See the LVAD MPC II MOP). 
 
Modified Rankin Scale  
Within 7 days prior to randomization  
The Modified Rankin Scale will be performed prior to LVAD implant for baseline neurological 
assessment ( ) by a certified staff member (See the LVAD MPC II MOP).  
 
Neurocognitive Testing  
Within 7 days prior to randomization  
Cognitive performance prior to LVAD implant will be assessed using the following battery of 
tests: Hopkins Verbal Learning Test; Trailmaking Form A and B; Digit Span; Digit Symbol; MCG 
Complex Figures; Controlled Oral Word Association. The testing will take a total of 45 minutes, 
will involve a trained technician but will not require a neurologist or neuro-psychologist and can 
be performed with a minimal amount of special equipment. Results from these tests will be 
independently scored by investigators from the CTSN Neurocognitive Core Lab.  All 
neurocognitive batteries will be tape recorded and the de-identified recordings sent to the Duke 
University neurocognitive core lab for quality assurance evaluation.  (See the LVAD MPC II 
MOP) 
 
Quality of Life  
Within 7 days prior to randomization  
QoL will be assessed by the KCCQ and SF12, which will be completed by the patient.    (See the 
LVAD MPC II MOP for questionnaires) 
 
Eligibility Evaluation 
Prior to randomization 
This checklist of inclusion and exclusion criteria will be completed and signed by the investigator 
to verify that the patient meets all eligibility requirements for this trial.  
 
Randomization Procedure 
A DCC representative will be available to discuss any questions regarding patient eligibility.  
Once the site investigator has confirmed that the patient meets all eligibility criteria for 
participation in the trial, and has completed the eligibility forms in the EDC, randomization will be 
performed electronically.  Only a research staff member trained on the protocol and designated by 
the PI to do so may perform the randomization. 


InCHOIR  
 
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CONFIDENTIAL 
 
Randomization  
Must be completed within 24 hours prior to planned LVAD implantation and treatment 
intervention  
The randomization procedure will be performed within 24 hours prior to the LVAD 
implantation and treatment intervention.  Randomization to the study assignment will be 
generated by the Electronic Data Capture (EDC) system once the checklist of inclusion and 
exclusion criteria has been completed and verified. For the purpose of the primary analysis, 
patients are considered enrolled in the study once they are randomized and an identification code 
is generated.   
 
Treatment Intervention  
LVAD implantation with the assigned treatment intervention must be administered within 24 
hours following randomization (See Randomization section). 
 
Post Intervention Data Collection 
In the following section of post intervention data collection, “post intervention” is defined as the 
time of LVAD implantation and intramyocardial study product injection. 
 
Intervention Injection Verification  
Must be completed within 24 hours following myocardial injection procedure  
Immediately following the treatment intervention, the operating surgeon will verify the number 
and location of injection sites as well as the total volume implanted.  The diagram will be signed 
by the surgeon and uploaded into the EDC.  This form also captures the date and time of 
intramyocardial injections.  
 
Hospitalization 
At index hospitalization for LVAD implant  
Information pertaining to the baseline hospital admission will be collected including date of 
hospitalization, date of hospital discharge, number of cumulative days in an intensive care unit 
setting following LVAD implant (i.e., OHRR, CCU, MICU, SICU) throughout the hospitalization, 
and disposition at time of discharge (home, skilled nursing facility, rehabilitation facility, death). 
 
Surgical Procedure 
Must be completed within 24 hours of initial LVAD implant procedure 
Data associated with the initial LVAD surgery and type of LVAD implanted will be captured on 
this form.   
 
Cardiac Histology  
At LVAD implantation, at native heart explant for cardiac transplantation, and at autopsy (if 
applicable) 
Histologic samples will be forwarded to the Immunohistochemistry Core Laboratory for analyses, 
according to the specifications outlined in the LVAD MPC II MOP and Biospecimen Core 
Laboratory Manual. The form also records whether specimens for cardiac histology analyses were 
obtained and shipped to the Core Laboratory. If specimens were not collected or able to be 
analyzed, reasons for failure will be documented. 


InCHOIR  
 
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CONFIDENTIAL 
 
Laboratory Assessment 
12 (±4) hours post intervention; days 7(±2), 30 (±3), 60 (±7), and 90 (± 14) post randomization, 
and at 4, 6, 9 and 12 months (± 14) post randomization, or until cardiac transplantation, 
whichever comes first 
o Hematology:  
White blood cell count (103/mL), Hemoglobin (g/dL), Hematocrit (%), Platelet count (103/mL)  
o Chemistry Panel to include:  
Sodium (mM/L), Potassium (mM/L), Blood Urea Nitrogen (mg/dL), Creatinine (mg/dL), 
Alanine Aminotransferase (ALT; U/L), Aspartate Aminotransferase (AST; U/L)  
 
Days 4, 7 (±2), 30 (±3), 60 (±7), and 120 (± 14) days, and 6, 9 and 12 months (± 14 days) post 
randomization, or until cardiac transplantation, whichever comes first 
o Lactate dehydrogenase (LDH; U/L)4 
 
Biospecimen Analyses  
Day 1 (+1) post intervention, days 7 (±2), 30 (±3), 60 (±7), and 120 (± 14), and 6 and 12 months 
(± 14 days) post randomization 
A peripheral blood sample will be obtained for chemo-and cytokine quantification (detailed in the 
Biospecimen Core Laboratory Manual). Isolated plasma will be stored frozen at the clinical site 
and shipped to the Biospecimen Core Lab as directed in the Manual. 
 
If the specimen was not collected, prepared, shipped, or able to be analyzed the reason for the 
failure will be specified (e.g. reason specimen not obtained, issue with shipping, etc). 
 
Immunologic Assessment  
At days 30 (±3) and 90 (± 14), and at months 6 (± 14 days) and 12 (± 14 days) months post 
randomization, or until cardiac transplantation, whichever comes first 
o Anti-HLA antibody serum sample 
o Anti-murine and anti-bovine antibodies sample 
 
Serum sample will be collected, processed and shipped as outlined in the Biospecimen Core 
Laboratory Manual. These samples will be stored frozen at the clinical site and shipped to the 
Biospecimen Core Laboratory as directed in the Manual.   
 
If the specimen was not obtained or is unable to be analyzed, the reason for the failure will be 
specified (e.g. reason specimen not obtained, issue with shipping, etc) on the Specimen Checklist 
CRF in the EDC. 
 
Physical Examination  
At day 1(+1) post intervention; days 7 (±2), 60 (±7), and 90 (± 14) post randomization, and at 4, 
6, 9 and 12 months (± 14) post randomization, or until cardiac transplantation, whichever comes 
first  
                                                          
4 LDH to be collected also as an event-driven data point. 
 


InCHOIR  
 
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Document Number: LVAD MPC II Trial Protocol Rev 4.1  
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Date Effective: 
 
CONFIDENTIAL 
This form documents a physical examination including anthropometrics (height, weight and BSA), 
vital signs including temperature, and a cardiovascular, pulmonary, abdominal, extremity exam.  
A research clinician trained on the protocol and designated by the PI to do so will conduct all 
follow-up physical examinations. 
 
Medications  
At day 1(+1) post intervention; days 7(±2), 60 (±7), and 90 (± 14) post randomization, and at 4, 6, 
9 and 12 months (± 14) post randomization, or until cardiac transplantation, whichever comes 
first  
All cardiovascular medications the patient receives from the  pre-implant period (within 7 days 
prior to randomization) through study completion will be captured on the Medication Log in the 
EDC. Modifications to the cardiovascular medication regimen will be confirmed at a minimum for 
each time point defined above.  
 
All non-cardiovascular medications will be captured on the Concomitant Medication CRF in the 
EDC at each of the listed study visits.  
 
Early Stopping Events   
At LVAD implantation, 12 (±4) hours and days 1(+1) post intervention; days 7 (±2), 30 (±3), 60 
(±7), and 90 (± 14), and at 4, 6, 9 and 12 months (± 14) post randomization, or until cardiac 
transplantation, whichever comes first 
Information regarding the occurrence of any event that triggers the early stopping rule, regardless 
of the seriousness of the event, will be collected as they occur (event driven), and will be 
confirmed at each study visit.  These events include:  infectious myocarditis, myocardial rupture, 
neoplasm, hypersensitivity reaction, and immune sensitization syndrome.  Only research 
physicians listed on the delegation of duties log may evaluate early stopping events. 
 
LVAD Wean and Functional Assessment 
 
Echocardiography  
At 60 days (±7) and at 4, 6, 9 and 12 months (± 14) post randomization, or until cardiac 
transplantation, whichever comes first 
An echocardiogram to assess myocardial function will be performed at each time point with 
LVAD at full support and again following LVAD wean as tolerated (See the LVAD MPC II 
MOP).  The tests will be forwarded to the Echocardiography Core Lab for analysis as outlined in 
the Echo Core Lab Operation Manual for the LVAD MPC II Trial. Only the baseline (pre-wean) 
echocardiogram will be performed for patients who do not tolerate LVAD wean.  
 
The Echocardiography & Collection form also captures information pertaining to 
echocardiography image acquisition including the date and time of the study, and date shipped to 
the CTSN Echocardiography Core Lab.  If an image was not performed, a protocol deviation will 
be documented. 
 


InCHOIR  
 
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CONFIDENTIAL 
Six Minute Walk Test 
At 60 days (±7) and at 4, 6, 9 and 12 months (± 14) post randomization, or until cardiac 
transplantation, whichever comes first  
The 6MWT will be performed at 20 (± 10) minutes following initiation of wean (immediately 
following the 15 minute echocardiogram), if the patient remains clinically stable (See the LVAD 
Wean Procedure Guidelines in the LVAD MPC II MOP).  This form captures the distance in feet 
walked on a level hallway in six minutes (See the LVAD MPC II MOP for further details).  A 
research clinician trained on the protocol and designated by the PI will oversee the 6MWT. 
 
Wean Assessment 
At 60 days (±7) and at 4, 6, 9 and 12 months (± 14) post randomization, or until cardiac transplantation, 
whichever comes first 
The duration of ability to tolerate wean from LVAD support will be assessed.  Signs or symptoms 
of hypoperfusion including, but not limited to, symptoms of low output (e.g., light headedness, 
dyspnea, fatigue) or signs of vascular congestion (e.g. pulmonary edema) will be assessed during 
the wean (See the LVAD MPC II MOP for LVAD Wean Procedure Guidelines).  A research 
physician trained on the protocol and delegated by the PI will oversee the wean assessment. 
 
The LVAD wean will continue until the patient: 
(a) Reaches 30 minutes off LVAD support, and  
(b) Completes the echo and 6MWT (if this takes longer than 30 minutes and the patient 
remains stable), or  
(c) Fails the wean  
 
Following the wean, the LVAD will be restarted at the previous baseline mode and rate.   
 
The functional assessments (echocardiography, 6MWT, and ability to tolerate wean) will be 
performed at 60 days (±7) and at 4, 6, 9 and 12 months (± 14) post randomization, or until cardiac 
transplantation, whichever comes first.   
 
Neurocognitive Testing 
At 90 days (± 14) and 12 months (± 14 days) post randomization 
Cognitive performance prior to LVAD implant will be assessed using the following battery of 
tests: Hopkins Verbal Learning Test; Trailmaking Form A and B; Digit Span; Digit Symbol; MCG 
Complex Figures; Controlled Oral Word Association. Study personnel, trained in accordance with 
the respective neurocognitive tool, must conduct these tests and document the results on the 
appropriate forms The testing will take a total of 45 minutes, will involve a trained technician but 
will not require a neurologist or neuro-psychologist and can be performed with a minimal amount 
of special equipment. Results from these tests will be independently scored by investigators from 
the CTSN Neurocognitive Core Lab.  The neurocognitive battery will be tape recorded and the de-
identified recordings sent to the Duke University neurocognitive core lab for quality assurance 
evaluation.  (Seethe LVAD MPC II MOP) 
 
Quality of Life  
At 6 months (± 14 days) and 12 months (± 14 days) post randomization 


InCHOIR  
 
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CONFIDENTIAL 
QoL will be assessed by the KCCQ and SF12, which will be completed by the patient.  Data 
regarding completeness of QOL data collection and reasons for missing responses to 
questionnaires will be collected on the the KCCQ and SF12 CRFs.  (See the LVAD MPC II MOP) 
 
Vital Status Follow-Up 
24 months (±30 days) post randomization 
A vital status follow-up assessment will be conducted via telephone (or via medical record review 
if necessary) by investigative site personnel to document that the patient is alive and to determine 
if the patient has undergone transplant or explant.   
 
Event Driven Data Collection 
 
Adverse Events 
 
Event Driven within 24 hours of knowledge of event 
The event classification, as well as detailed information regarding the event will be recorded.  
Information regarding all adverse events, including study-intervention specific adverse events will 
be collected on this form.  Research staff trained on the protocol and delegated by the PI may 
identify and collect information on adverse events.  The PI will evaluate all adverse events for 
expectedness, seriousness and relatedness. 
 
Early Stopping Events  
At every study visit and event driven 
Information regarding the occurrence of any event that triggers the early stopping rule, regardless 
of the seriousness of the event, will be collected as they occur (event driven), and will be 
confirmed at each study visit.  These events include:  infectious myocarditis, myocardial rupture, 
neoplasm, hypersensitivity reaction, and immune sensitization syndrome.  Only research 
physicians listed on the delegation of duties log may evaluate early stopping events. 
 
NIH Stroke Scale   
Event driven within 72 hours of a neurological event, and at 30 (±10) days and 60 (±10 days) post 
neurological event 
The NIH Stroke Scale will be performed by a certified staff member in the case of a neurological 
adverse event (See the LVAD MPC II MOP). 
 
Modified Rankin Scale  
Event driven within 72 hours of a neurological event, and at 30 (±10) days and 60 (±10 days) post 
neurological event 
The Modified Rankin Scale will be performed by a certified staff member in the case of a 
neurological adverse event. (See LVAD MPC II MOP)  
 
Hospitalization 
Event driven for any hospitalization following the initial LVAD implant  
Information pertaining to any hospital admission following the initial LVAD implant 
hospitalization will be collected including date of hospitalization, date of hospital discharge, 
number of cumulative days in an intensive care unit setting (i.e., OHRR, CCU, MICU, SICU) 


InCHOIR  
 
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Document Number: LVAD MPC II Trial Protocol Rev 4.1  
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CONFIDENTIAL 
throughout the hospitalization, and disposition at time of discharge (home, skilled nursing facility, 
rehabilitation facility, death). 
 
Surgical Procedure 
Event driven within 24 hours of procedure 
Data associated with an operation for any reason, including the initial LVAD implantation and 
treatment intervention surgery, all re-implants, cardiac transplantation, and re-operations, will be 
captured on this form.   
 
Medication 
Event driven with the report of one of the following adverse events: Right heart failure, Bleeding, 
Pump Thrombus, Stroke, Arterial Non-CNS Thromboembolism, and Venous Thromboembolism 
Event 
All prescribed anticoagulation, antiplatelet and other medications as indicated that the patient is 
receiving at the time of the adverse event will be captured. 
 
Immunotherapy Medication 
Event driven 
All prescribed immunosuppressive medications that the patient receives following LVAD 
implantation must be documented on this form.  
 
Mortality 
Event Driven within 24 hours of knowledge of event   
The investigator will record the date of death, immediate cause of death, primary underlying cause 
of death, notation of autopsy being performed, and clinical narrative of the event. 
 
Pump Retrieval and Explant (and/or Postmortem) Examination 
Event Driven  
All attempts to obtain permission for a full body autopsy should be made.  At a minimum, 
autopsies will be requested of patients who participated in the study in order to evaluate the 
device, heart and other major organs. Photographs will be taken of the pump and all related 
components in situ before removal, and of all areas of evident pathology suspected to be device 
related.  The LVAD should be opened upon removal and inspected.  Histologic samples of the 
myocardium will also be obtained and forwarded to the Biospecimen Core Laboratory for 
analyses, according to the specifications outlined in the Biospecimen Core Lab Manual.  
 
Missed Visit 
Event Driven 
If a patient is unable to return for follow-up before closure of a study visit window, a missed visit 
will be documented and reason why the visit was not conducted will be collected. 
 
End of Study 
 
Study Completion/Early Termination 
Event Driven 
This form records the date and reason for study completion or early termination.   


InCHOIR  
 
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CONFIDENTIAL 
 
Investigator Statement 
At the end of study after eCRF data completion and review 
After a complete review of the eCRFs and patient summaries, the investigator will sign this form 
to attest to the accuracy and completeness of the data collected. 
 
DATA MANAGEMENT 
In order to capture the highest quality data, we will use a web-based system with electronic 
validation.  In addition, we will cross-validate the data for complex errors.  Ongoing review of 
data collection by the DCC will ensure that the quality and completeness of the data will be 
reflective of the state of the art in clinical trials. 
 
Electronic Data Capture 
All study data will be entered in the electronic data capture (EDC) system. Study personnel 
requiring access will have their own Login/Password. Access to clinical study information will be 
based on individuals' roles and responsibilities.  The application employs fine-grained role-based 
access control for data entry, viewing, and reporting options. All study data will be transmitted 
over an encrypted SSL (Secure Sockets Layer) connection that requires user authentication.  This 
application is designed to be in full compliance with the International Conference on 
Harmonization and Good Clinical Practices (ICH-GCP), the FDA’s Code of Federal Regulations 
(CFR) 21 Part 11 Electronic Record and Electronic Signatures, the FDA's "Guidance: 
Computerized Systems Used in Clinical Trials,” and the Privacy Rule of the Health Insurance 
Portability and Accountability Act of 1996 (HIPAA).  
 
EDC supports efficient data collection and management and facilitates rapid data closure. A strong 
advantage of web-based design is that the DCC has immediate and ongoing access to the data 
from all clinical centers so that queries can be generated and distributed to the sites in real-time, 
the frequency of missing data can be reduced by two mechanisms, the coordinators will receive a 
list of queries generated by the study monitors upon logging into the system, and any data required 
during a visit is immediately evident through the system and can be collected before closure of the 
visit window.  The EDC will be a vital part of the centralized monitoring planned for this study. 
 
Monitoring   
The DCC will employ a risk-based approach to monitoring for this study.  This will be 
accomplished via centralized or remote monitoring of data via the EDC with a focus on safety, 
study endpoints, data completion and data outliers.  Clinical centers will provide source 
documentation (with patient-identifying information redacted) to the DCC for remote monitoring 
via upload to the EDC or remote access to electronic medical records.  The DCC will also 
centrally monitor study logs including the Informed Consent Log, the Protocol 
Violation/Deviation Log and the Serious Adverse Event/IND Safety Report Log periodically to 
ensure that the sites are adhering to the study protocol and procedures. The DCC will generate 
performance metrics to analyze site characteristics such as recruitment rates and timeliness of data 
entry.  This will allow the DCC to identify trends across sites and to address low-performing sites 
appropriately.  
 


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Document Number: LVAD MPC II Trial Protocol Rev 4.1  
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CONFIDENTIAL 
The DCC will also perform on-site monitoring visits at each study site at least once a year.   The 
monitoring visits will be an opportunity to verify a minimum of the following data points for all 
patients:  age, sex, signed informed consent, eligibility criteria, medical history, date of 
enrollment, protocol-defined serious adverse events (SAEs) and mortalities.  The monitors will 
also conduct a review of the regulatory documents for the study. 
 
The frequency of site visits will be based on the following considerations:  
o The first monitoring visit will be scheduled soon after the first patient has been enrolled. 
o Routine visits will be scheduled based upon enrollment rate, site experience, previous 
performance and information collected via centralized monitoring.  
o Additional visits are scheduled as needed to resolve study-related problems including 
query resolution. 
o The DCC will conduct close-out activities with each site as an on-site visit or via 
teleconference. 
 
The primary objectives of the DCC are to educate, support, identify and resolve issues related to 
the clinical trial.  The monitors will discuss the protocol in detail, and clarify any areas of 
uncertainty.  At initiation of the study, the monitors will conduct a tutorial on the EDC system.  
The coordinators will practice entering data so that the monitors can confirm that the coordinators 
are proficient in all aspects of data entry, query response, and communication with the data 
management team.  
 
Through the combination of centralized and on-site monitoring, the EDC system, instantaneous 
electronic validation, and visual cross-validation by the DCC to detect complex errors, it is 
anticipated that the best possible quality and most complete data will be collected.  
 
STATISTICAL ANALYSIS AND SAMPLE SIZE JUSTIFICATION   
The primary aims of this trial are determining safety and potential efficacy of MPC therapy at the 
studied dose. Safety will be based on the absence of all of the following: infectious myocarditis, 
myocardial rupture, neoplasm, hypersensitivity reaction, and immune sensitization; and on 
mortality.  Efficacy will be based on measuring functional status; the number of successful 
temporary weans achieved out of three planned over the first six months of follow-up.  Patients 
who expire prior to being assessed, or whose morbidity precludes assessment, will be considered 
weaning failures.  Few patients are expected to undergo cardiac transplantation prior to the 
primary endpoint assessment, but if they do, they will be censored at the time of transplant.  For 
patients who undergo cardiac transplantation, the incidence rate of successful weans will be 
calculated as the number of successful weans out of the number of weans performed over the time 
of follow-up until transplantation. The information fraction contributed by these patients to the 
primary outcome will be adjusted for the amount of follow-up time until transplantation.   
 
A Bayesian approach based on the posterior distribution that active therapy is superior to control 
will be used to assess the strength of potential efficacy, should safety continue to be demonstrated.  
The procedure will be carried out as follows.   
 


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A binomial likelihood is specified for the 
primary efficacy outcome, the number of 
successful weans out of the three planned 
(or the number attempted).  The reasons to 
have fewer than the planned number of 
weans include cardiac transplantation, 
patient refusal, or missed visit due to 
logistical obstacles.  All patients considered 
too unstable to tolerate the wean attempt 
(e.g., patient in the ICU or on inotropic 
support) in the judgment of the primary 
heart failure cardiologist are considered a 
wean failure.  The prior distribution for the 
success probability of the binomial 
likelihood is based on data from the control 
patients in the previous trial, where the rate 
of successful wean was found to be 
approximately 0.18. Independent gamma 
priors with this mean and standard deviation of 0.10 are assumed for each group. The induced 
prior for the relative rate of success for active versus control therapy is shown in the figure.  The 
prior is centered at one (consistent with no difference) with nearly all mass between 0.5 and 2. 
 
Prior to any data collection, equipoise implies that the probability that active therapy is superior to 
control is 50%.  Based on observed data, an increase in this probability to 80% or more, without 
safety concerns, will be considered a positive signal of efficacy for MPC therapy.  Simulations 
indicate that our sample size of 159 patients provides a probability of 80% to detect such an 
efficacy signal if the true rate ratio is 1.5, with a false positive rate of 15%.  These values are 
based on the estimated posterior distribution for the rate ratio, to be determined by simulation. 
 
As enrollment is expected to be completed within 20 months, a formal interim analysis of efficacy 
is not planned (see below for continuous monitoring of safety). NHLBI will determine whether 
and how future development of MPC therapy continues within the NHLBI funded Network 
infrastructure based upon all efficacy results, safety outcomes, feasibility, and the state of the field 
as it relates to the scientific validity and integrity of a proposed future trial.   
 
Analysis of secondary endpoints 
Duration of time weaning is tolerated. The duration of time weaning is tolerated will be examined 
at each time point post randomization.  Random effects models will be used to characterize 
changes over time in the duration that a patient tolerates weaning.  Orthogonal contrasts with the 
Tukey’s HSD correction will be used to compare the two groups at each point in time. An 
interaction term of time*treatment group will be used to determine the difference in the 
longitudinal course of duration of weaning between the two treatment groups.  We will use an 
additional approach that separates the data into strata defined by the time of death or dropout.  We 
will then estimate a separate linear model, including a treatment effect, for the data in each 
stratum.  This method, known as pattern-mixture modeling is not sensitive to un-testable 
 
 
 
 
 
 
Prior distribution for rate ratio 
Risk Ratio 


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assumptions about the dropout mechanism because it models the data directly in strata defined by 
dropout time.  The method of Wu and Bailey is an instance of pattern-mixture modeling.21 
 
Pattern of successful weans over time.  The pattern of successful weans over both the 6 and 12 
month follow-up periods will be explored using logistic regression with parameter estimation 
using generalized estimating equations.   
 
Echocardiographic assessments. All of the echocardiographic measures (left and right ventricular 
dimensions, LVEF, regional wall motion score) will be described using both graphical and 
numerical summaries. Analysis of covariance will be used to estimate and assess differences 
between treatment arms in the change from baseline (defined as 30 day post randomization) to 12 
months post randomization.  Analyses incorporating all available follow-up data will be performed 
using random effects regression models. The primary aims of the random effects models will be to 
characterize the changes over time in the echocardiographic measures in each treatment group.  
 
Six minute walk test. The 6MWT will be analyzed similarly to the duration of time weaning is 
tolerated. 
 
Mortality.  Time to death will be described by Kaplan-Meier curves and differences between 
randomization groups will also be assessed via the log-rank test.  Patients who undergo 
transplantation will be censored at the time of transplant. 
 
Safety and Adverse Events. Differences in the incidence of individual adverse events among 
randomization arms will be assessed using Poisson regression. Exact 95% confidence intervals 
(based on the Poisson distribution) for the risk ratios for individual adverse events will be 
computed.  In addition, the proportion of patients who exhibit anti-murine and anti-bovine 
antibodies following study product administration will be compared among randomization arms 
by a chi-squared test of the equality of proportions. 
 
Anti-HLA antibody sensitivity.  The proportion of patients with anti-HLA antibody sensitivity 
while on LVAD support will be compared among randomization arms by a chi-squared test of the 
equality of proportions. 
 
In addition to the analyses of clinical outcomes described above, explanted native hearts will be 
examined to quantify the extent of neovascularization, MPC cell engraftment, as well as histologic 
and gene regulation responses to cell implantation as detailed in the LVAD MPC II MOP. 
Confidence intervals will be used to compare treatment groups on these histological measures. 
Differences between groups in the prevalence of these measures will be quantified using relative 
risks and associated 95% confidence intervals.  
 
Quality of life. Quality of life will be measured using the KCCQ and SF-12. We will employ two 
approaches to the analysis of quality of life. The first will be to base the analysis on longitudinal 
mixed effects models.  These models would predict outcome from treatment group and time. The 
mixed modeling approach requires an assumption that patient dropout is ignorable in that the 
probability of dropping out at any time is related only to previously observed data items.  Of 
course, this assumption may not hold, and moreover it is impossible to test robustly from the data 


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at hand.  An alternative approach we will also use, not subject to this criticism, will be to separate 
the data into strata defined by the time of death or dropout.  We will then estimate a separate linear 
model, including a treatment effect, for the data in each stratum.  This method, known as pattern-
mixture modeling is not sensitive to un-testable assumptions about the dropout mechanism 
because it models the data directly in strata defined by dropout time.  The method of Wu and 
Bailey is an instance of pattern-mixture modeling. 19  
 
Neurocognitive Outcomes. Neurocognitive outcomes for each test will be standardized using the 
means and standard deviations observed in the overall sample and combined within cognitive 
domains using weights, which are being defined by the Neurocognitive Committee.  Differences 
in the scores for each domain at 90 days and 12 months post-randomization will be compared 
between randomization arms based on an analysis of covariance that adjusts for important baseline 
values.  
 
Hospitalization Length of Stay and Days in ICU. We will compare hospital length of stay and days 
spent in ICU between treatment groups using a Wilcoxon Rank-Sum Test.  
 
Readmission. We will use Poisson regression models to compare the frequency of readmissions 
between groups at both 30 days and 12 months for any cause.  
 
Hospital Readmission. Rates of all-cause hospitalizations, and rate of cardiovascular-and heart 
failure-specific hospitalizations, both within 30 days and within 12 months, will be compared 
between treatment groups using chi-square tests.  
  
Tertiary Endpoints. Mixed effects models will be used to characterize levels of cytokines and 
chemokines over time.  The association of cytokine and chemokine levels with engraftment of 
cells in native explanted hearts will be described graphically, and quantified by regression and 
correlation analysis.   
 
Early Stopping Rules 
Safety will be continuously monitored. The DCC will report all deaths and unexpected, as well as 
rare but expected serious adverse events to the NHLBI, who, in turn, will report to the DSMB 
chair.  There are two components to the safety monitoring plan. The first focuses on rare events 
that are very likely to be related to the experimental treatment and not to the underlying heart 
failure.  The second focuses on mortality which is not a rare event in this patient population.  With 
respect to the rare events likely associated with experimental treatment, enrollment will be halted 
should any of the pre-specified events (infectious myocarditis, myocardial rupture, neoplasm, 
hypersensitivity reaction, or immune sensitization syndrome) be observed.  Stopping guidelines 
for mortality will use the same approach as that described to assess the presence of an efficacy 
signal using a very diffuse beta (2,8) prior for mortality for both groups, and will be initiated 
following the randomization of the 10th patient. We would propose to halt randomization if the 
probability that mortality on active therapy is increased compared to control exceeds 80%.  The 
probability will be determined sequentially, after each mortality event. NHLBI, in conjunction 
with the DSMB’s recommendations, will determine whether enrollment should be continued, 
suspended or terminated should any of the proposed stopping criteria be met. 
 


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Missing Data 
Patients who require an LVAD are a highly dependent patient population and are extremely 
compliant with their care and follow-up. They receive extensive training in adverse event and 
alarm recognition prior to discharge, and they are called at least once a week when at home. Due 
to diligent patient and site monitoring, we anticipate that there will be few missing data points in 
this study.  Imputation procedures will be used as appropriate.     
 
 
ORGANIZATION OF THE STUDY 
This section describes the overall study organization.  The study is conducted by the 
Cardiothoracic Surgical Trials Network Core and Consortium clinical sites.  The following 
committees and institutions will be involved in the administration of the study.     
 
Event Adjudication Committee 
The charge of the Event Adjudication Committee (EAC) is to review source documents and to 
adjudicate all adverse events, the severity and causality of the adverse events, and the causes of 
mortality. The individuals who will serve on the committee will be appointed by the DCC, and 
will be independent of the study intervention manufacturer (Mesoblast, Inc.) and the DCC.  EAC 
members may be affiliated with the clinical centers but refrain from evaluating AEs at their site. 
The committee will consist of, at least, a cardiothoracic surgeon with LVAD experience, a heart 
failure cardiologist, a neurologist and an infectious disease expert. Additional experts in transplant 
immunology and cardiac pathology will be consultants to the committee as necessary. The EAC 
will meet every 6 months or as needed to adjudicate adverse events and outcomes data for each 
subject enrolled.    
 
Data and Safety Monitoring Board (DSMB)  
To meet the study's ethical responsibility to its subjects, an independent data safety monitoring 
board (DSMB) will monitor results during the study.  The board consists of physicians, 
biostatisticians, ethicists and bioengineers, who have no formal involvement or conflict of interest 
with the subjects, manufacturer (Mesoblast, Inc.), investigators, the DCC or the clinical sites, and 
will be appointed by the NHLBI. The DSMB will act in a senior advisory capacity to the DCC and 
the NHLBI regarding data and safety matters throughout the duration of the study. In addition, the 
DSMB will review interim summary results of the accumulating data from the Event Adjudication 
Committee every 6 months.  These data include adverse events (e.g., infection, bleeding, right 
heart failure) and mortality.  They will communicate their findings directly with the DCC and the 
NHLBI.  The clinical centers will have no contact with the members of DSMB and no voting 
member of the committee may participate in the study as an investigator. 
 
Data Coordinating Center (DCC)   
The university-based CTSN DCC (InCHOIR) will monitor interim data, and analyze the study's 
results in conjunction with the investigators and the sponsors.  The CTSN DCC will also 
administrate the DSMB and EAC.   The DCC holds the study-specific IND with the FDA and the 
study-specific CTA with Health Canada and will be responsible for reporting serious and 
unexpected adverse events due to the study product to the FDA according to 21 CFR 312.32 and 
ICH E2A guidelines and to Health Canada according to C.05.012(3)(c) and C.05.014.  In addition, 
the DCC will be responsible for submitting the required progress reports to the FDA and Health 


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Canada.  The DCC will provide Mesoblast with abridged versions of these reports to ensure 
Mesoblast remains blinded to the trial results and aggregate data for the duration of the trial.   
 
Clinical Sites and Investigators 
The roles and responsibilities of the Investigators and Clinical Sites include, but are not limited to 
(a) assuring that the trial is conducted according to the Protocol and Operations Manual; (b) 
identifying, recruiting, and enrolling subjects; (c) obtaining informed consent from each subject 
and protecting their rights; (d) collecting and entering study data into the EDC, and following 
subjects through study completion; (e) collecting and filing source documentation; (f) ensuring 
that Form FDA 1572 or a Qualified Investigator Undertaking Form (for Canadian sites) is accurate 
and securely maintained with other essential clinical trial documents at the site with provided to 
the DCC; (g) assuring regular IRB/REB review; (h) maintaining communication with the DCC. 
 
Core Labs 
Echocardiography (Echo) Core Lab 
All echocardiograms will be performed according to a standardized protocol (found in the LVAD 
MPC II MOP and Echo Core Lab Operation Manual for LVAD MPC II Trial) and will be 
centrally analyzed by the CTSN Echo Core Lab directed by Judy W. Hung, MD, located at the 
Massachusetts General Hospital, Boston, MA. 
 
Biorepository Core Lab  
The Biospecimen Core Laboratory will be responsible for storage of critical biomaterials (i.e., 
tissue samples, blood, and blood products); long-term integrity of these specimens (up to 10 
years); management of immunologic, immunohistochemical, cellular, and molecular analyses of 
tissue and serum samples.  The Biospecimen Core Lab will address an unmet clinical need in 
cardiovascular research to develop mechanistic understandings of the impact of cell therapy and 
will be located at the Texas Heart Institute and directed by Doris Taylor, PhD.   
 
Neurocognitive Core Lab 
The Neurocognitive Core Lab, located at Duke University is directed by Joseph Mathew, MD.  
The core lab will be responsible for training the clinical site personnel in administration of the 
specific tests.  All neurocognitive tests will be scored centrally by the core lab. 
 
Executive Steering Committee 
The Network Steering Committee (with the assistance of the protocol development committee) 
will provide the overall scientific direction for the study.  The responsibilities of the Steering 
Committee are to: (a) maintain contact with study investigators to ensure high quality data 
collection; (b) approve and implement major protocol changes in response to advice from the 
DSMB; (c) collaborate in data analysis, interpretation, and publication; (d) establish criteria for 
authorship on all manuscripts, publications and presentations that arise from the study.  
 
Mesoblast, Inc. 
Mesoblast, Inc. holds the IND for mesenchymal precursor cells and has provided a cross-reference 
letter allowing the FDA to review their IND files for the DCC-held study specific IND.  Mesoblast 
has also filed a Drug Master File with Health Canada and provided a letter of access for the DCC 
CTA.  Mesoblast will be responsible for labeling and supplying the study product/cryoprotective 


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media control to all participating sites.  Mesoblast will receive regular reports from the DCC 
regarding adverse events for the study product group but will be blinded to all other data 
throughout the trial.   
 
NIH 
This trial is funded by the National Heart, Lung, and Blood Institute (NHLBI), National Institute 
of Neurologic Disorders and Stroke (NINDS), and the Canadian Institutes of Health Research 
(CIHR).  The NHLBI has appointed an independent DSMB to provide oversight of this trial.  
NHLBI program officials will serve as members of the Steering Committee.  


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REFERENCES 
 
1. Rose EA, Gelijns AC, Moskowitz AJ, Heitjan DF, Stevenson LW, Dembitsky W, Long JW, Ascheim DD, 
Tierney AR, Levitan RG, Watson JT, Meier P, Ronan NS, Shapiro PA, Lazar RM, Miller LW, Gupta L, Frazier 
OH, Desvigne-Nickens P, Oz MC, Poirier VL; Randomized Evaluation of Mechanical Assistance for the 
Treatment of Congestive Heart Failure (REMATCH) Study Group. Long-term use of a left ventricular assist 
device for end-stage heart failure. N Engl J Med. 2001;345:1435-43. 
2. Slaughter MS, Rogers JG, Milano CA, Russell SD, Conte JV, Feldman D, Sun B, Tatooles AJ, Delgado RM 3rd, 
Long JW, Wozniak TC, Ghumman W, Farrar DJ, Frazier OH; HeartMate II Investigators. Advanced heart failure 
treated with continuous-flow left ventricular assist device. N Engl J Med. 2009;361:2241-51.   
3. Russo MJ, Hong KN, Davies RR, Chen JM, Sorabella RA, Ascheim DD, Williams MR, Gelijns AC, Stewart AS, 
Argenziano M, Naka Y. Posttransplant survival is not diminished in heart transplant recipients bridged with 
implantable left ventricular assist devices.  J Thorac Cardiovasc Surg. 2009;138:1425-32.e1-3. 
4. Miller LW, Pagani FD, Russell SD, John R, Boyle AJ, Aaronson KD, Conte JV, Naka Y, Mancini D, Delgado 
RM, MacGillivray TE, Farrar DJ, Frazier OH; HeartMate II Clinical Investigators. Use of continuous-flow device 
in patients awaiting heart transplantation. N Engl J Med 2007;357:885-96. 
5. Ogletree-Hughes ML, Stull LB, Sweet WE, Smedira NG, McCarthy PM, Moravec CS. Mechanical unloading 
restores beta-adrenergic responsiveness and reverses receptor downregulation in the failing human heart. 
Circulation. 2001;104:881-6. 
6. Thompson LO, Skrabal CA, Loebe M, Lafuente JA, Roberts RR, Akgul A, Jones V, Bruckner BA, Thohan V, 
Noon GP, Youker KA. Plasma neurohormone levels correlate with left ventricular functional and morphological 
improvement in LVAD patients.  J Surg Res 2005:123:25-32.  
7. Felkin LE, Lara-Pezzi EA, Hall JL, Birks EJ, Barton PJ. Reverse remodeling and recovery from heart failure are 
associated with complex patterns of gene expression. J Cardiovasc Transl Res. 2011;4:321-31.   
8. Hall JL, Fermin DR, Birks EJ, Barton PJ, Slaughter M, Eckman P, Baba HA, Wohlschlaeger J, Miller LW. 
Clinical, molecular, and genomic changes in response to a left ventricular assist device. J Am Coll Cardiol. 
2011;57;641-52. 
9. Heerdt PM, Klotz S, Burkhoff D. Cardiomyopathic etiology and SERCA2a reverse remodeling during 
mechanical support of the failing human heart. Anesth Analg. 2006;102:32-7. 
10. Birks EJ. Molecular changes after left ventricular assist device support for heart failure. Circ Res. 2013;113:777-
91. 
11. Birks EJ, George RS, Firouzi A, Wright G, Bahrami T, Yacoub MH, Khaghani A.  Long-term outcomes of 
patients bridged to recovery versus patients bridged to transplantation. J Thorac Cardiovasc Surg. 2012;144:190-
6. 
12. Houtgraaf JH, de Jong R, Kazemi K, de Groot D, van der Spoel TI, Arslan F, Hoefer I, Pasterkamp G, Itescu S, 
Zijlstra F, Geleijnse ML, Serruys PW, Duckers HJ. Intracoronary infusion of allogeneic mesenchymal precursor 
cells directly after experimental acute myocardial infarction reduces infarct size, abrogates adverse remodeling, 
and improves cardiac function. Circ Res. 2013;113:153-66. 
13. Hare JM, Traverse JH, Henry TD, Dib N, Strumpf RK, Schulman SP, Gerstenblith G, DeMaria AN, Denktas AE, 
Gammon RS, Hermiller JB Jr, Reisman MA, Schaer GL, Sherman W. A randomized, double-blind, placebo-
controlled, dose-escalation study of intravenous adult human mesenchymal stem cells (prochymal) after acute 
myocardial infarction. J Am Coll Cardiol. 2009;54:2277–2286. 
14. See F, Seki T, Psaltis PJ, Sondermeijer HP, Gronthos S, Zannettino AC, Govaert KM, Schuster MD, Kurlansky 
PA, Kelly DJ, Krum H, Itescu S. Therapeutic effects of human STRO-3-selected mesenchymal precursor cells 
and their soluble factors in experimental myocardial ischemia. J Cell Mol Med. 2011;15:2117-29.  
15. Jellema RK, Wolfs TG, Lima Passos V, Zwanenburg A, Ophelders DR, Kuypers E, Hopman AH, Dudink J, 
Steinbusch HW, Andriessen P, Germeraad WT, Vanderlocht J, Kramer BW. Mesenchymal stem cells induce T-
cell tolerance and protect the preterm brain after global hypoxia-ischemia. PLoS One. 2013;8:e73031. 
16. Wang Y, Liu J, Xu C, Zhang W, Bai L, Li N, Liu Y, Wang Y, Su Y, Hu D. Bone marrow transplantation 
combined with mesenchymal stem cells induces immune tolerance without cytotoxic conditioning. J Surg Res. 
2011;171:e123-31. 
17. Bartholomew A, Sturgeon C, Siatskas M, et al. Mesenchymal stem cells suppress lymphocyte proliferation in 
vitro and prolong skin graft survival in vivo. Exp Hematol 2002;30(1):42-8. 
18. Ascheim DD, Gelijns AC, Goldstein D, et. al. Mesenchymal Precursor Cells as Adjunctive Therapy in Recipients 
of Contemporary LVADs.  Circulation  (Conditionally accepted for publication) 


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19. Kramer DG, Trikalinos TA, Kent DM, Antonopoulos GV, Konstam MA, Udelson JE.Quantitative evaluation of 
drug or device effects on ventricular remodeling as predictors of therapeutic effects on mortality in patients with 
heart failure and reduced ejection fraction: a meta-analytic approach. J Am Coll Cardiol. 2010 Jul 27;56(5):392-
406. doi: 10.1016/j.jacc.2010.05.011. 
20. Opasich C, Pinna GD, Mazza A, Febo O, Riccardi PG, Capomolla S, Cobelli F, Tavazzi L. Reproducibility of the 
six-minute walking test in patients with chronic congestive heart failure: practical implications. Am J 
Cardiol.1998 Jun 15;81(12):1497-500. 
21. Wu MC, Bailey K. Analysing changes in the presence of informative right censoring caused by death and 
withdrawal. Statistics in Medicine. 1988;7:337–346. 
 


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66 
APPENDIX I:  Intramyocardial Injection Procedures 
 
See the Study Product Technician Manual of Procedures for the list of supplies needed as well as 
detailed instructions on the procedures for preparing the study product for injection.  
 
PREPARATION OF SYRINGES FOR STUDY PRODUCT INJECTION 
 
Study Drug Injection Procedure 
 
1. Four (4) sterile 1cc syringes must be prepared under sterile technique (see MOP), and labeled 
numbers 1-4.   
 
2. Wrap the lower portion of the syringe with a wide steri-strip to obscure the lower barrel of the 
syringe and blind the operator to the nature of the contents (cell or placebo).  Mark the plunger at 
least 1 cc above the top of the steri-strip with a nick or marker and thus allow tracking of amount 
injected. 
 
3. Fill each syringe with 1ml of study product. 
 
4. Note:  During any downtime or delay, each syringe should be gently hand rocked in order to 
prevent clumping 
 
5. The injection process should take place within 15 minutes and must take place no longer than 90 
minutes following thawing of the MPCs. 
 
6. A total of 16-20 intramyocardial injections of 0.2 mL (not to exceed a total of 4.0 mL) each will 
be performed.  Note:  Cells thawed longer than 90 minutes will be discarded and the process 
will be continued with a new vial. 
 
 
INTRAMYOCARDIAL INJECTION PROCEDURE/DOCUMENTATION 
 
Consider injecting cells during or around the time of LV apical cannula guide implantation as the 
heart is positioned for maximal access to the entire left ventricle. 
 
1. The intent is to inject study product intramyocardially, across as much of the left ventricular 
myocardium as possible. 
 
2. Twenty (20) suggested locations are identified in the diagram below.  
 
3.  Injections should be made from an oblique angle into the mid-myocardium, with particular 
attention to avoid injection into the LV cavity.  
 
4. Each 0.2ml should be injected slowly, over 5 seconds into each epicardial location, and the 
needle should then be held in place for an additional 5 seconds before removing. 


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5. A total volume of 4.0ml will be delivered into the myocardium. 
 
Suggested locations for intramyocardial injections: 
 
 
 
 
 
 
 
 
 
 
 
6. Immediately following the treatment intervention the operating surgeon will document date and 
time of the intramyocardial injections, the number and locations of injection sites as well as the 
total volume implanted on the Treatment Intervention Case Report Form (CRF). 
 
The intramyocardial injection sites will be documented using the following table: 
Posterior View 
Anterior View 


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7. The completed Injection Verification section of the Treatment Intervention CRF must be signed 
by the surgeon and uploaded into the EDC within 24 hours following treatment intervention. The 
original copy should be kept in the patient’s source document binder. 
 
 
 


 
 
 
STATISTICAL ANALYSIS PLAN 
 
 
SAFETY & EFFICACY OF INTRAMYOCARDIAL INJECTION OF 
MESENCHYMAL PRECURSOR CELLS ON MYOCARDIAL FUNCTION IN 
LVAD RECIPIENTS (LVAD MPC II)  
 
 
 
 
 
Sponsored By NHLBI, NINDS, and CIHR  
CT Surgery Network Research Group 
   
 
 
Data Coordinating Center 
InCHOIR 
Icahn School of Medicine at Mount Sinai 
New York 
 
August 2018 
  
 
 
CONFIDENTIAL 
 
Version 2 
 
 
 
 
 
 
 
 
 
 


 
Table of Contents 
LIST OF ABBREVIATIONS AND DEFINITION OF TERMS ........................................................... 3 
PURPOSE OF STATISTICAL ANALYTICAL PLAN (SAP) ............................................................ 4 
1. 
INTRODUCTION ................................................................................................................... 5 
1.1 
Study Objectives ..................................................................................................................... 5 
1.1.1 
Primary Objective ................................................................................................................... 5 
1.1.2 
Secondary Objectives .............................................................................................................. 5 
1.2 
Study Design ........................................................................................................................... 6 
1.3 
Study Duration and Time Points ............................................................................................. 6 
1.4 
Randomization and Masking................................................................................................... 6 
2. 
STUDY POPULATIONS ....................................................................................................... 6 
3. 
DEFINITIONS AND VARIABLES ....................................................................................... 7 
3.1 
Baseline Characteristics .......................................................................................................... 7 
4. 
EFFICACY ENDPOINTS ...................................................................................................... 8 
4.1 
Primary Efficacy Endpoint ...................................................................................................... 8 
4.2 
Secondary Efficacy Endpoints ................................................................................................ 9 
4.2.1 
Overall Survival and Survival to Cardiac Transplantation .................................................... 10 
4.2.2 
Functional Status over 6 Months and over 12 Months Post Randomization ......................... 10 
4.2.3 
Physiologic Assessments ...................................................................................................... 11 
4.2.4 
Quality of Life and Neurocognition ...................................................................................... 13 
4.2.5 
Index Hospitalization and Readmissions ............................................................................... 13 
4.3 
Tertiary Endpoints ................................................................................................................. 14 
4.3.1 
Cytokine Quantification ........................................................................................................ 14 
4.3.2 
Angiopoietin-1 and Angiopoietin-2 Quantification .............................................................. 14 
5. 
SAFETY ENDPOINTS ........................................................................................................ 14 
5.1 
Primary Safety Endpoint ....................................................................................................... 14 
5.2 
Secondary Safety Endpoints ................................................................................................. 15 
5.2.1 
Incidence and Rate of Non-Surgical GI Bleeding Events and/or Epistaxis by 6 Months Post 
Randomization ...................................................................................................................... 15 
5.2.2 
Serious & Study-Intervention Related Adverse Events ........................................................ 15 
5.2.3 
Anti-HLA Antibody Sensitization ........................................................................................ 16 
6.   
STATISTICAL METHODOLOGY ..................................................................................... 16 
6.1 
Statistical and Analytical Issues ............................................................................................ 16 
6.1.1 
Statistical Methods ................................................................................................................ 16 
6.1.2 
Handling of Dropouts and Missing Data ............................................................................... 17 
6.2 
Patients Characteristics ......................................................................................................... 18 
6.2.1 
Patients Disposition ............................................................................................................... 18 
6.2.2 
Protocol Deviations and Violations ...................................................................................... 18 
6.2.3 
Demographic Characteristics ................................................................................................ 19 
6.2.4 
Prior and Concomitant Medication ....................................................................................... 19 
6.2.5 
Medical History .................................................................................................................... 19 
6.2.6 
Pre-Implant Echocardiographic Parameters .......................................................................... 19 
6.3 
Efficacy Analysis .................................................................................................................. 19 
6.3.1 
Analysis of the Primary Efficacy Endpoint and Determination of Sample Size ................... 19 
6.3.2 
Analysis of Secondary Efficacy Endpoints ........................................................................... 20 
6.4 
Tertiary Endpoints................................................................................................................. 23 
6.5 
Subgroup Analyses ............................................................................................................... 23 
6.6 
Safety Analysis ...................................................................................................................... 23 
6.6.1 
Incidence and Rate of Non-Surgical GI Bleeding Events and/or Epistaxis by 6 Months Post 
Randomization ...................................................................................................................... 23 
6.6.2 
Treatment-emergent Adverse Events (TEAEs) ..................................................................... 24 
6.6.2   
Anti-HLA Antibody Sensitivity, Anti-Murine and Anti-Bovine Antibodies ........................ 24 
6.7  
Early Stopping Rules ............................................................................................................ 24 
6.8 
Interim Analysis .................................................................................................................... 25 
7. 
REFERENCES ...................................................................................................................... 26 
 
2 
 


 
LIST OF ABBREVIATIONS AND DEFINITION OF TERMS 
 
6MWT 
Six Minute Walk Test  
ALT 
 
Alanine Aminotransferase 
AST 
 
Aspartate Aminotransferase 
BTT 
 
Bridge to transplant 
CI 
 
Cardiac Index or Confidence Interval 
CIHR  
Canadian Institutes of Health Research 
CMS  
Centers for Medicare and Medicaid Services 
CO 
 
Cardiac Output 
CRF 
 
Case report form 
CTSN  
Cardiothoracic Surgical Trials Network 
DCC  
Data Coordinating Center 
DNA  
Deoxyribonucleic Acid 
DSMB  
Data and Safety Monitoring Board 
DT 
 
Destination Therapy 
EAC  
Event Adjudication Committee 
EDC  
Electronic Data Capture System 
FDA  
Food and Drug Administration 
HLA  
Human Leukocyte Antigen 
IgG 
 
Immunoglobulin G 
InCHOIR 
International Center for Health Outcomes and Innovation Research 
ITT 
 
Intention To Treat 
LDH  
Lactate Dehydrogenase 
LV 
 
Left Ventricle 
LVAD  
Left Ventricular Assist Device 
LVEDD 
Left ventricular end-diastolic dimension(s) 
LVEF  
Left Ventricular Ejection Fraction 
M 
 
Million 
MAR  
Missing At Random 
MNAR 
Missing Not At Random 
MCG  
Medical College of Georgia 
MPC  
Mesenchymal Precursor Cells 
NHLBI 
National Heart, Lung and Blood Institute 
NINDS 
National Institute of Neurological Disorders and Stroke 
QoL 
 
Quality of Life 
rpm 
 
Revolutions Per Minute 
RV 
 
Right Ventricle 
SAP 
 
Statistical Analytical Plan 
TEAE  
Treatment-emergent Adverse Event 
VAD  
Ventricular Assist Device 
WMSI  
Wall Motion Score Index 
 
 
3 
 


 
PURPOSE OF STATISTICAL ANALYTICAL PLAN (SAP) 
The purpose of this SAP is to outline the planned analyses to be completed for the LVAD 
MPC II trial.  The analyses identified in this SAP will be included in abstracts and 
manuscripts reporting the results of the trial.  Exploratory analyses not necessarily 
identified in this SAP may also be performed. Any post hoc, or unplanned, analyses not 
explicitly identified in this SAP will be clearly identified as such in any published papers 
from this study. 
 
This SAP may be updated in response to additional developments, either within or 
outside the trial. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
4 
 


 
1. 
INTRODUCTION 
Left ventricular assist devices (LVADs) have well-documented survival and quality of 
life benefits in patients with advanced heart failure both as a bridge to cardiac 
transplantation (BTT) and as a long-term therapy, so-called Destination Therapy (DT), in 
patients who are not transplant candidates.1-4  Reports of improved myocardial function 
have motivated investigation of the use of LVADs as a bridge to recovery, but while 
most LVAD recipients do show some indications of reverse remodeling of the left 
ventricle (LV) as evidenced by salutary changes in ventricular structure, myocyte 
contractile strength5, normalization of extracellular matrix and tissue and circulating 
neurohormones6, and programs of gene expression,7-10 these improvements are rarely 
sufficient to allow removal of the device.11  The disconnect between reverse remodeling 
and recovery of cardiac function, or “passive recovery”, have prompted our efforts to 
investigate “active recovery” to augment ventricular recovery with adjunctive therapies 
to LVAD support, such as the administration of stem cells at the time of LVAD 
implantation. 
 
 
Recent pre-clinical and clinical evidence suggests that myocardial transplantation of 
allogeneic mesenchymal lineage cells, in particular, can enhance cardiac performance in 
settings of acute and chronic functional impairment.12-14 Unlike whole organ 
transplantation or many other allogeneic cell transplants, mesenchymal lineage cell 
transplants do not appear to cause rejection and instead may be associated with evidence 
of induced tolerance to the donor. 15, 16  Since our ultimate goal is the achievement of 
bridging to myocardial recovery and successful LVAD explantation, allosensitization,  if 
it should occur, could adversely impact donor suitability in LVAD recipients who are 
transplant candidates.   
 
To this end, the Cardiothoracic Surgical Trials Network (CTSN) recently conducted, in 
collaboration with the Cardiovascular Cell Therapy Research Network (CCTRN), an 
exploratory trial of a single low dose (25 million [M]) allogeneic mesenchymal precursor 
cells (MPCs; Mesoblast, Inc.) injected into the native myocardium at the time of LVAD 
implantation.  The objectives of this trial were to provide evidence of immunological 
safety, provide preliminary data on clinically important serious adverse events, and 
explore the efficacy of the intervention.  If safety were established, the pre-specified plan 
was to conduct a follow-up trial with a higher MPC dose administered in the same 
manner and timing as the pilot study. 
 
Given that the exploratory trial did not demonstrate any safety concerns, the Network 
investigators decided to proceed with the current follow-up trial (LVAD MPC II) using 
the MPC dose of 150M in LVAD recipients.  This document serves as the SAP for the 
LVAD MPC II trial.  
 
1.1 
Study Objectives 
 
1.1.1 Primary Objective 
The primary objective of this trial is to evaluate the safety and efficacy of injecting 
approximately 150 million allogeneic mesenchymal precursor cells (MPCs) into the 
native myocardium of LVAD recipients at the time of device implantation. 
 
1.1.2 Secondary Objectives 
The secondary objective of the trial is to explore the functional and physiologic effects of 
5 
 


 
intramyocardial injection of the 150M dose of MPCs in LVAD recipients at the time of 
device implantation. 
 
1.2 
Study Design 
This is a prospective, multi-center, double-blind, randomized (2:1), single dose cohort, 
sham procedure-controlled trial to evaluate the safety and efficacy of injecting a dose of 
150 M allogeneic MPCs into the native myocardium of LVAD recipients at the time of 
device implantation.  A total of 159 patients with advanced heart failure who are 
scheduled to be implanted with an LVAD as a BTT or DT will be enrolled in this trial.   
FDA-approved LVADs will be utilized at US sites, and Health Canada-approved LVADs 
will be utilized at Canadian sites.  
 
1.3 
Study Duration and Time Points   
All patients will be followed until cardiac transplantation (for bridge to transplant 
patients) or until 24 months post randomization, whichever comes first. Assessment 
of the study outcomes will be performed at 1 day, 7 days, 30 days, 60 days, 90 days, 4 
months, 6 months, 9 months, and 12 months post randomization (or until transplant, 
whichever comes first).  Safety will be assessed continuously throughout the 12-
month follow-up period.  A vital status follow-up assessment will be conducted at 24 
months to document whether the patient is alive and to determine if the patient has 
undergone a cardiac transplant, LVAD explant, and/or LVAD replacement.   
 
 
1.4 
Randomization and Masking 
Patients will be enrolled in a single dose cohort and randomized in a 2:1 allocation to 
receive either epicardial injection of study product (MPC) or cryoprotective media 
alone (Control) into the mid LV myocardial wall as add-on therapy, during LVAD 
implantation.  Randomization will take place only after it has been determined that all 
study eligibility criteria have been met.  LVAD implantation and study intervention 
must be administered within 24 hours following randomization.  
 
This is a double-blind, sham procedure controlled trial.  Site personnel and patients, as 
well as all core lab study personnel will be blinded to treatment assignment 
throughout the trial. 
 
2. 
STUDY POPULATIONS 
Two populations will be used for all summaries and analyses.  Subgroup analyses will 
also be performed. 
 
Intent-to-Treat (ITT) Population 
The ITT population is defined as all randomized subjects, regardless of when they 
withdrew from the study or received the assigned treatment.  The ITT population will be 
used to present all efficacy data (including the primary efficacy endpoint) by randomized 
treatment group.  Subjects will be analyzed according to the treatment to which they 
were randomized, regardless of the treatment they actually received.  Subjects with at 
least one assessment of the primary efficacy endpoint will be included in the ITT 
population. 
 
 
Safety Population 
The safety population, defined as all randomized subjects who received the study 
6 
 


 
treatment, will be used to present the safety summaries by actual treatment received.  The 
Safety population will therefore be identical to the ITT population if all randomized 
subjects receive the assigned treatment.  
  
Population Subgroups 
Population subgroups will be defined for analysis purposes. These subgroups include 
patients who, at the time of LVAD implantation were categorized as Destination Therapy 
(DT) or Bridge to Transplant (BTT); patients who receive the HVAD or HeartMate II 
LVAD; and subgroups based on demographic variables (e.g. gender and age). 
 
3. 
DEFINITIONS AND VARIABLES 
 
3.1 
Baseline Characteristics 
 
Demographics 
For all patients screened demographic variables will include age, racial category, sex, and 
education.   
 
Medical History  
Include information pertaining to the etiology of heart failure, the history of 
cardiovascular disease and other co-morbidities. 
 
Physical Examination  
Include anthropometric measures (height and weight), vital signs including temperature, 
and a cardiovascular, pulmonary, abdominal, and extremity exam.  
 
Medications 
All cardiovascular medications that the patient receives during the pre-implant period 
(within 7 days prior to randomization) through month 12 post randomization will be 
captured on the Medication Log in the electronic data capture (EDC) system.  All non-
cardiovascular medications will be captured on the Concomitant Medication case report 
form (CRF) in the EDC. 
 
Immunotherapy Medication 
All immunosuppressive medications/procedures that the patient received within 30 days 
prior to randomization will be recorded.  
 
Laboratory Assessment  
o 
Urine or serum beta HCG (IU/L) for women who have the potential to  
            become pregnant  
o 
Platelet count (103/mL) 
o 
Blood Type and Cross  
o 
Chemistry Panel to include: Sodium (mM/L), Potassium (mM/L), Blood Urea 
Nitrogen (mg/dL), Creatinine (mg/dL), Alanine Aminotransferase (ALT; U/L), 
Aspartate Aminotransferase (AST; U/L) 
o 
Hematology: White blood cell count (103/mL), Hemoglobin (g/dL),  
            Hematocrit (%) 
 
 
Biospecimen Analyses  
7 
 


 
Peripheral blood chemokine and cytokine quantification. 
   
Immunologic Assessment  
Immune reactivity results for % IgG Class I and IgG Class II will be recorded.  Presence 
of  > 10% anti-HLA antibody titers triggers a comparison of recipient antibodies to the 
MPC donor HLA antigen profiles performed by the Immunologic Core Laboratory.   
A baseline peripheral blood sample will be obtained to measure anti-murine and anti-
bovine antibodies. 
 
Hemodynamics  
Hemodynamics include central venous pressure (CVP), pulmonary artery pressures 
including systolic, diastolic and mean pulmonary artery pressures (PAS, PAD, PAM), 
pulmonary capillary wedge pressure (PCWP), transpulmonary gradient, cardiac output 
(CO), cardiac index (CI), pulmonary artery oxygen saturation (PAO2 sat), and pulmonary 
vascular resistance (PVR measured in Wood Units) will be assessed by right heart 
catheterization.   
 
Echocardiography  
Echocardiogram will assess ventricular size, function and regional wall motion. 
 
NIH Stroke Scale  
The NIH Stroke Scale (NIHSS) is made up of 11 different elements each evaluating a 
specific ability. The score for each ability ranges between 0 and 4, 0 being normal 
functioning and 4 being completely impaired. The NIHSS score is calculated by adding 
the scores for each element. The total score ranges between 0 and 42 with the higher the 
score indicating more impairment. 
 
Modified Rankin Scale  
The Modified Rankin Scale ranges from 0 to 6, running from perfect health without 
symptoms to death. 
 
Neurocognitive Testing  
Cognitive performance prior to LVAD implant includes following battery of tests: 
Hopkins Verbal Learning Test; Trail making Form A and B; Digit Span; Digit Symbol; 
Medical College of Georgia (MCG) Complex Figures; Controlled Oral Word 
Association.  
 
Quality of Life  
Quality of life measures include the Kansas City Cardiomyopathy Questionnaire 
(KCCQ) and the Short Form 12 (SF12), which will be completed by the patient.    
 
4. 
EFFICACY ENDPOINTS 
 
4.1 
Primary Efficacy Endpoint 
The primary efficacy endpoint of this study is clinical functional status, defined by the 
number of successful temporary weans from LVAD support out of 3 planned 
assessments over the first 6 months post randomization.  LVAD weans will be performed 
at 60 (±7) days and at 4 and 6 months (±14 days) (or until transplant, whichever comes 
first). 
 
8 
 


 
The wean begins when the patient reaches his/her low-speed LVAD flow (rpm) threshold 
(also called minimal support/time 0).  Low-speed is defined as the lowest possible LVAD 
flow (rpm) the patient will tolerate for the wean assessment.  The protocol recommends a 
target low-speed of 6,000 rpm for the HeartMate II and 1,800 rpm for the HVAD.  Based 
on the patient, the cardiology investigators will use their discretion for the target low-
speed for the wean assessment.  A wean may terminate early if the cardiologist 
overseeing the wean determines that the patient has developed persistent signs and 
symptoms of low cardiac output and vascular congestion, in which case the LVAD will 
be returned to full LVAD flow.  Signs and symptoms may include: light headedness, 
dyspnea, fatigue, chest pain, or pulmonary edema.  A complete weaning assessment ends 
when measurements for the mean arterial pressure and heart rate are taken after the final 
comprehensive echocardiographic exam following the 6MWT.  This occurs prior to 
increasing the pump speed back to the original pre-wean settings. 
 
If, for any reason, the end of wean time is unknown, the time at the start of the weaning 
echocardiograms recorded on the CRF or the time recorded by the local core lab at the 
site closest to device turn up will be used. If that time is not available, the end of wean 
time may be extrapolated from sources for the 6MWT and times to when the mean 
arterial pressure and heart rate measurements were taken throughout the weaning. 
 
A successful wean is defined as the ability to tolerate temporary weaning from LVAD 
support for 30 minutes without sustained symptoms of worsening heart failure.  Patients 
whose LVAD is explanted for myocardial recovery and not replaced will be considered 
to have successful weans for all the assessments following pump explantation.   
 
 Wean failures are defined as follows: 
o Inability to tolerate the temporary wean for 30 minutes; this includes patients who 
attempted the wean but were unable to reach minimal support and patients who 
achieved minimal support but were unable to tolerate the wean for 30 minutes; 
o Death.  Patients who die will be considered weaning failures for all assessments 
following their death;  
o Patient too unstable, in the judgment of the primary heart failure cardiologist, to 
tolerate the wean attempt (e.g., in ICU, on inotropic support, having persistent heart 
failure symptoms despite LVAD support, suspicion or evidence of thrombus on 
baseline echo, aortic valve intervention, stroke within 30 days, evidence of hemolysis 
defined as LDH > 2.5x the upper limits of normal).   
 
Missing weans due to other reasons (besides death) including cardiac transplantation, 
patient refusal, missed visit, or study dropout (withdrawal, lost to follow-up) will not be 
counted as a failure and will not be imputed.  Details on how missing values on the 
primary and secondary endpoints will be handled and the sensitivity analyses for missing 
data that will be performed are provided in Section 6.1.2 
 
This endpoint will be analyzed using a binary goal attainment variable (30 minute wean 
achieved [yes/no]) at each time point. 
 
4.2 
Secondary Efficacy Endpoints 
Secondary efficacy endpoints are measured by 6 and 12 months post randomization. The 
following secondary endpoints will be analyzed. 
 
9 
 


 
 
4.2.1 Overall Survival and Survival to Cardiac Transplantation 
Overall survival and survival to cardiac transplant from randomization will be assessed 
over 12 months.  For the overall survival analysis, the endpoint is death from any cause 
at 12 months (+14 days).  Patients who receive a transplant will be censored at the time 
of transplant.  Patients who withdraw consent or are lost to follow-up will be censored at 
the date of early termination. For patients who are lost to follow-up, the early termination 
date will be the date of last known proof of life defined as whichever chronological date 
that is last of any available dates such as: contact documented in the medical record, 
including encounters with other services, correspondence with study team, or in-person 
visit. Patients who are alive at 12 months and have not exited the study early for any 
reason will be censored at the time the 12 month window closes.   
 
A second mortality endpoint is death from any cause at 24 months (+30 days).  Patients 
who are alive at 24 months and have not exited the study early for any reason will be 
censored at the time of last data collection for the 24 months vital status assessment. 
 
For survival to cardiac transplant, the endpoint of interest is cardiac transplantation at 12 
months (+14 days) and 24 months (+30 days). Follow-up time for patients who withdraw 
consent, drop out of study, or are alive without experiencing cardiac transplant and death 
will be defined similarly as the overall survival endpoint. 
 
4.2.2 Functional Status over 6 Months and over 12 Months Post Randomization 
Weaning and 6-Minute Walk will be assessed at 60 (±7) days, 4, 6 months (±14 days) (or 
until transplant, whichever comes first).   
 
• Ability to Tolerate Wean from LVAD Support for 30 Minutes  
The ability to tolerate the temporary wean from full LVAD support to target low flow for 
at least 30 minutes will be assessed at 60 days and at 4, 6 and 12 months.  Wean 
successes and failures are defined similarly as the primary efficacy endpoint and will be 
analyzed using a binary goal attainment variable (30 minute wean achieved [yes/no]) at 
each time point. 
 
• Duration of Ability to Tolerate Wean 
(a) The duration of ability to tolerate wean from LVAD support will begin at the time the 
patient reaches his/her low-speed LVAD flow (rpm) threshold and will be measured 
until resumption of LVAD at full support. The duration of ability to tolerate the wean 
will be measured for all patients who attempt the wean regardless of whether they 
successfully complete the wean. 
  
10 
 


 
 
 
 
 
Patients will receive a value of 0 for their duration of time weaning if they meet any of 
the following criteria: 
• Wean attempted but minimal support not reached 
• Wean not attempted because patient too unstable in the judgment of the primary 
heart failure cardiologist to tolerate wean attempt 
 
• Six Minute Walk Test  
 
The total distance walked in six minutes will be assessed.  After maintaining the 
patient at minimal support for 15 minutes, the patient will undergo a comprehensive 
echocardiogram if stable and asymptomatic.  For those patients stable and 
asymptomatic at the completion of the echo, the 6MWT will be performed (about 20 
minutes into the wean) while the patient is at his/her low-speed LVAD flow 
threshold.  The distance is measured (in feet), regardless of the number of times 
stopped or the rate of ambulation. 
 
In most cases, patients who tolerate the wean for 30 minutes will undergo the 6MWT.  
However, since the 6MWT begins immediately after the 15 minute comprehensive echo, 
it may be performed by patients who are weaned for less than 30 minutes.  The distance 
walked for these patients will still be included in the 6MWT endpoint. 
 
Patients will receive a value of 0 for the total distance walked in six minutes if they meet 
any of the following criteria: 
• Wean attempted, minimal support reached, and 6MWT not performed 
• Wean attempted, minimal support not reached, and 6MWT not performed 
• Wean not attempted because patient too unstable in the judgment of the primary 
heart failure cardiologist to tolerate wean attempt 
 
4.2.3 Physiologic Assessments 
 
• Echocardiographic Assessments of Myocardial Function   
Echocardiographic parameters will be assessed at each wean assessment time point at (a) 
LVAD on full support prior to wean, (b) 15 minutes following initiation of wean from 
LVAD Wean
Baseline
Full Support
(prior to wean)
Comprehensive 
Echo
15 Min
20 Min (±10)
6-Min Walk
Immediately 
After 6-Min Walk
Comprehensive 
Echo
Comprehensive 
Echo
Following final 
comprehensive 
echo (post 6-
min walk) 
return LVAD to 
full support
LVAD remains weaned as tolerated
11 
 


 
LVAD support (while LVAD flow remains weaned), and (c) immediately following the 
6MWT, as tolerated by the patient.    
The following echo assessments will be recorded and/or calculated at each time point 
before and after the LVAD wean as per protocol:  
• 
Left ventricular end-diastolic dimensions (LVEDD) and left ventricular 
end-systolic dimensions (LVESD) 
• 
LV fractional shortening 
• 
LVEF by Simpson’s Rule (when possible).  
• 
LVEF by visual assessment 
• 
LV regional wall motion score index (WMSI; comprehensive post 6MWT 
echo at 6 and 12 months).  WMSI assessment will be performed using the 
American Society of Echocardiography scoring system, modified to 
exclude the 4 apical segments because of the presence of the LVAD 
cannula in the LV apex.  Therefore, 12 segments (basal and mid-ventricular 
segments) will be utilized instead of 16. 
• 
LV mass by the formula of Devereux (only full support, comprehensive 
echo study) 
• 
RV function (normal, mild, moderate, severe)by Integrative Assessment 
• 
RV chamber size (normal, dilated [mild, moderate, severe])  
 
• LV Chamber Remodeling 
Echocardiographic assessments of LV chamber remodeling will be performed while 
the LVAD is at full support. The baseline echocardiographic evaluation will be 
defined as the LVEDD minor axis assessment prior to LVAD implantation. The 
percent change from baseline in LV end-diastolic minor axis dimension (LVEDD) 
will be determined. 
 
The following secondary endpoints will be assessed in ALL patients, regardless of the 
ability to tolerate the temporary wean from LVAD support: 
 
• Neovascularization and Cardiomyocyte Proliferation 
Myocardium from the apical core removed at LVAD implant and cardiac samples taken 
at the time of explant for cardiac transplantation or any other indication, if applicable, 
will be categorized with regard to region, including anterior, anterolateral, lateral, 
inferior, midventricular and basilar specimens.  All samples will be evaluated for 
neovascularization, quantification of cardiomyocyte proliferation by 
immunohistochemistry or molecular analyses, general histology, and DNA analysis. 
 
• Cell Engraftment and Fate 
Myocardium from multiple samples taken at the time of explant for cardiac 
transplantation or any other indication, if applicable, will be evaluated for cell 
engraftment.  Relative number of donor cells in the recipient heart will be estimated by 
real time PCR method measuring copy numbers of donor HLA-DRB alleles different 
from the recipient in the myocardial samples.   
 
• Immunologic Assessment  
Immune reactivity results for % IgG Class I and IgG Class II will be recorded.  Presence 
of >10% anti-HLA antibody titers triggers a comparison of recipient antibodies to the 
MPC donor HLA antigen profiles performed by the Immunologic Core Laboratory.   
12 
 


 
A peripheral blood sample will be obtained to measure anti-murine and anti-bovine 
antibodies. 
 
4.2.4 Quality of Life and Neurocognition 
Quality of life (QoL) data will be collected and evaluated as a secondary endpoint.  
Quality of life will be assessed with the KCCQ, a widely used tool in heart failure 
populations, and the SF12, a widely used overall health status measure.  QoL will be 
compared between treatment groups at baseline, 6 and 12 months (±14 days) post 
randomization. 
 
The KCCQ is a 15-item questionnaire that assesses how heart failure affects a 
patient’s life.  Ten summary scores can be calculated within the KCCQ including but 
not limited to the Overall Summary score, Clinical Summary score, and Total 
Symptom score.  These 3 scores range from 0 to 100, with high higher scores 
indicating better quality of life, fewer symptoms, and physical limitations associated 
with heart failure.  
 
The SF 12 is a 12-item survey that assesses a patient’s view about their health. The 
Physical and Mental Health Composite Scale scores can be derived from the SF-12.  
These composite scores are normed as T-scores (mean=50, SD=10) where a higher score 
indicates a better health state. 
 
A neurocognition battery will be administered at baseline and at 90 (±14) days and 12 
months (±14 days) post randomization, but not during LVAD wean.  Cognitive 
performance will be assessed using the following battery of tests: Hopkins Verbal 
Learning Test; Trailmaking Tests A and B; MCG Complex Figures; Digit Span; Digit 
Symbol Substitution Test; and Controlled Oral Word Association.  Neurocognitive 
testing will be administered by clinical site personnel who have been trained and certified 
for test administration by the Neurocognitive Core lab personnel.   
 
4.2.5 Index Hospitalization and Readmissions 
All readmissions ≥ 24 hours will be considered. Readmissions due to heart 
transplantation or LVAD explantation for myocardial recovery will be excluded. 
 
• Total Number of Days Alive and out of the Hospital 
Total number of days alive out of the hospital will be calculated as the total number of 
days, from the day of randomization to 12 months (+14 days) post randomization during 
which the patient is not in the hospital.  For patients who die, receive a heart transplant, 
or drop out of study (withdrawal, lost to follow-up) before month 12, the total number of 
days alive out of the hospital will be calculated as the total number of days, from the day 
of randomization to death, transplant, or study discontinuation during which the patient is 
not in the hospital.   
 
• Length of Index Hospitalization 
Overall post-operative length of stay for the index hospitalization will be measured (and 
broken down by days spent in the ICU versus days spent on telemetry/step down unit and 
regular floors).  In addition, discharge location will be captured. 
 
• Time to First Readmission 
13 
 


 
The timing of the first hospital readmission over the 12 months of study will be 
calculated as the time from index hospitalization discharge to the date of the first hospital 
readmission for all patients who were discharged alive.  
 
• Readmission Rates 
The rate of hospital readmissions post index hospitalization as well as the total number of 
days alive and out of the hospital will be considered over the 12 months (+14 days) study 
period. Readmissions due to heart transplantation or LVAD explantation for myocardial 
recovery will be excluded.  Readmission rates will be calculated as the ratio of number of 
hospital readmissions over the number of days alive out of hospital. 
 
• Hospital Resource Use 
Inpatient claims will be obtained through UB-04/92 hospital billing data for clinical 
sites located in the United States. Cost data will be obtained from Vizient or from the 
site directly. Hospital costs will be calculated by converting the reported charges to 
costs using institution and cost-center specific Cost-to-Charge Ratios (CCRs) 
obtained from annual CMS cost reports. In addition to index hospitalization costs, 
costs associated with subsequent readmissions will be included in the study. Patients 
will also be asked at each follow-up visit if they have been hospitalized at another 
hospital and if yes for how long. Outpatient costs incurred at non-Network and non-
US hospitals will not be captured. 
 
4.3 
Tertiary Endpoints 
 
4.3.1 Cytokine Quantification 
Plasma samples will be processed at the site at baseline (prior to study intervention), 
at day 1 (+1) post intervention, and at days 7 (±2), 30 (±3), 60 (±7), and 120 (± 14) 
days post randomization, and at 6 and 12 months (± 14 days) post randomization.  
Chemo/cytokine quantification of plasma derived from peripheral blood samples will 
be performed by Luminex multiplex assay and include TNF-α, IL-1, IL–6,  IL–10, 
IL–17, TGF-β, RANTES, SCF and SDF-1.  
 
4.3.2 Angiopoietin-1 and Angiopoietin-2 Quantification 
Because angiopoietin-1 and -2 play important roles in vascular development and 
maturation of normal stable angiogenesis, these analytes will also be measured in 
peripheral blood plasma collected at the following timepoints:  at baseline (prior to 
study intervention), at day 1 (+1) post intervention, and at days 7 (±2), 30 (±3), 60 
(±7), and 120 (± 14) days post randomization, and at 6 and 12 months (± 14 days) 
post randomization.     
 
5. 
SAFETY ENDPOINTS 
The following additional endpoints will be assessed for all patients (including those who 
do not tolerate LVAD wean):  
 
5.1 
Primary Safety Endpoint 
The primary safety endpoint of this study is the incidence of potential study intervention-
related adverse events, defined as  
(a) infectious myocarditis,  
(b) myocardial rupture,  
14 
 


 
(c) neoplasm,  
(d) hypersensitivity reaction, and  
(e) immune sensitization syndrome  
 
Infectious Myocarditis: Evidence of myocardial infection manifest by positive 
myocardial gram stain and/or cultures, with or without signs or symptoms of systemic 
infection.  May be accompanied by new acute inflammatory process on histological 
examination (if absent on histological examination of the apical core at the time of 
LVAD implantation). 
 
Myocardial Rupture: The presence of myocardial rupture as evidenced by direct 
visualization (intra-operative or at autopsy) or by standard diagnostic modalities 
including, but not limited to echocardiography or ventriculography, with or without 
hemodynamic instability. 
 
Neoplasm: Any new uncontrolled growth of aberrant cells. 
 
Hypersensitivity reaction: Clinical syndrome including but not limited to fever, 
leukocytosis, or rash with onset ≤ 2 hours post treatment intervention and lasting < 24 
hours, in the absence of clinical signs of concomitant infection. 
 
Immune sensitization syndrome: Clinical syndrome including but not limited to fever, 
leukocytosis, rash or arthralgias with onset ≥ 7 days post treatment intervention and 
subsequent detection of anti-HLA antibodies against the donor cells detected ≤ 30 days 
following onset of syndrome, in the absence of clinical signs of concomitant infection. 
 
5.2 
Secondary Safety Endpoints 
 
5.2.1 Incidence and Rate of Non-Surgical GI Bleeding Events and/or Epistaxis by 
6 Months Post Randomization  
Evidence from the LVAD I study involving 30 patients suggests that treatment with 
MPC may reduce GI bleeding events and/or epistaxis by 6 months after 
randomization. Therefore, particular emphasis will be placed on the analysis of these 
events. 
 
Serious GI bleeding and/or epistaxis events whose source is documented as either 
suspected or confirmed and occur prior to 6 months (+14 days) will be defined using 
the INTERMACS definition for mucosal bleeding. Based on the INTERMACS 
criteria, a non-surgical major mucosal bleeding event that occurs >7 days after initial 
LVAD implantation is defined as a bleeding event that results in death, re-operation, 
re-hospitalization or prolonged hospitalization and/or transfusion of red blood cells.  
The latter is quantified as the number of units given per 24 hour period. Bleeding due 
to trauma (e.g. falls) will be excluded. 
 
5.2.2 Serious & Study-Intervention Related Adverse Events  
The incidence and frequency of all anticipated and unanticipated serious adverse events 
that occur prior to 12 months (+14 days) post injection of MPC or cryoprotective media 
alone, will be determined.  Moreover, the incidence of all adverse events classified by the 
clinical site investigator or independent Event Adjudication Committee as “possibly” or 
“probably” study-intervention related (to either the study product or to the 
15 
 


 
intramyocardial injection procedure itself) will be determined.   
 
5.2.3 Anti-HLA Antibody Sensitization 
Anti-HLA antibody serum sample will be collected at days 30 (±3) and 90 (± 14), and at 
months 6 and 12 (± 14 days). Immune reactivity results for % IgG Class I and IgG Class 
II, will be assessed.  If the PRA (percent reactive antigens) of either class I or class II 
HLA antibodies are >10 %, specificity analysis will be performed. The specificity test is 
to measure the presence of antibodies to HLA antigens including MPC donor specific 
HLA antigens.  
 
 
6.   
STATISTICAL METHODOLOGY 
 
6.1 
Statistical and Analytical Issues 
 
6.1.1 Statistical Methods 
All data will be presented by treatment group as well as for the whole sample.  Subgroup 
analyses will be performed as described in section 6.5. 
 
For all baseline, demographic and efficacy variables, data will be summarized and 
analyzed by randomized treatment group as per ITT.  Safety variables will be 
summarized by actual treatment received. 
 
In summary tables of continuous variables, the following descriptive statistics will be 
used: minimum and maximum, mean, median, 95% confidence interval (CI), standard 
deviation (SD) and standard error (SE). 
 
In summary tables of non-normally distributed variables data will be presented using the 
minimum, maximum, median and lower and upper quartiles. 
 
In summary tables of categorical variables, counts and percentages will be used. The 
denominator for each percentage will be the number of patients within the randomization 
group unless otherwise specified. 
 
Rates of events will be calculated as the ratio of the total number of events recorded over 
a period of time over the total patient/time (months or days). Total patient/time will be 
calculated by summing the time (in months or days) that patients were at risk for a 
specific event from the time they were randomized in the study. For patients who die, are 
transplanted, or drop out of study (withdrawal, lost to follow-up) before they experience 
an event, their patient/time will be calculated as the time from randomization to death, 
transplant, or study discontinuation.  Rates and 95% confidence intervals will be 
reported.  
 
For any variable measured at different points in time, change from baseline will be 
calculated as the difference between the value of the variable at a specific point in time 
(e.g. 90 days) minus the baseline value. 
 
Relative change from baseline will be calculated as the value of a parameter at a specific 
point in time minus the baseline value of the parameter divided by the baseline value of 
16 
 


 
the parameter. 
 
Percent change will be calculated as the relative change multiplied by 100. 
 
All hypothesis testing will be carried out at the 0.05 (2-sided) significance level, unless 
otherwise specified.  There will be no formal correction of the Type I error rate for 
multiple testing of statistical hypotheses.  
 
P-values will be rounded to three decimal places.  P-values less than 0.001 will be 
reported as <0.001 in tables.  P-values greater than 0.999 will be reported as >0.999.  
 
Should any of the statistical methods proposed prove unsuitable during data analysis, 
more appropriate methods will be used. These include data transformation (for example 
to a logarithmic scale) to satisfy model assumptions such as normally distributed 
residuals with constant variance, or the application of non-parametric techniques. 
 
Additional ad-hoc analyses may be conducted as deemed appropriate. 
 
All statistical analysis will be performed using SAS V9.4 and R V3.4.3 or higher. 
 
6.1.2 Handling of Dropouts and Missing Data 
 
Missing baseline values that are needed to compute absolute, relative, or percent change 
from baseline will be imputed using mean imputation.17 The missing values of a variable 
will be replaced with the observed sample mean of that variable.  Mean imputation is 
appropriate because baseline variables are independent of randomization assignment. 
 
Patients who require an LVAD are a highly dependent patient population and are 
extremely compliant with their care and follow-up. They receive extensive training in 
adverse event and alarm recognition prior to discharge, and they are called at least once a 
week when at home. Due to diligent patient and site monitoring, we anticipate that there 
will be few missing data points in this study.   
 
• Missing Values for the Primary Outcome 
Missing outcome values on the primary endpoint will not be imputed. For the primary 
efficacy endpoint, missing data can be the result of patient receiving cardiac 
transplantation, patient refusal, missed visit, or study dropout (withdrawal, lost to follow-
up).  Patients who receive a heart transplant will be censored at the time of transplant and 
the number of successful weans out of the number of possible wean assessments up to the 
time of transplant will be considered in the analysis.  Intermittent missing data due to 
patient refusal or missed visits are assumed to be missing at random (MAR) and the 
number of successful weans out of the number of possible wean assessments will be used 
for analysis. Study dropout is also assumed to be MAR and the number of successful 
weans out of the number of possible wean assessments up to the time of dropout will be 
computed.  As described in Section 4.1 patients who do not attempt the wean because of 
death or physician contraindication will be considered as failures. 
 
• Missing Values for the Secondary Efficacy Outcomes 
Missing outcome values on secondary endpoints will not be imputed.  Analytic rules 
17 
 


 
have been developed in Section 4.2.2 for missing wean duration and/or 6MWT due to 
patient’s morbidity that precludes evaluation or patient’s inability to complete the entire 
wean assessment. Echo parameters related to LVEDD chamber remodeling are measured 
while the LVAD is at full support and therefore, do not depend on the ability to perform 
the wean.  Since longitudinal models will be used for the analysis of wean duration, 
6MWT, and echo parameters over time (see Section 6.3.2), intermittent missing data 
under MAR are allowed.  To accommodate for missingness due to death, transplant or 
study drop-out (withdrawal, loss to follow-up) pattern-mixture analyses will be used for 
longitudinal models.  Values of the duration of weaning that are missing because the 
patient was not able to reach minimal support or did not perform the wean because of 
cardiology discretion will be assigned a value of zero. 
 
• Missing Values for All Other Outcomes 
Consideration for missing data for secondary and tertiary outcomes will be handled 
similarly to what described above. 
 
• Sensitivity Analysis 
Sensitivity analysis will be conducted to investigate possible violations of 
the missing at random assumption. Using a pattern-mixture model approach for 
MNAR18 (missing not at random), we will impute the missing data under several 
MNAR scenarios.  Specifically, we will use delta adjustments after several 
multiple imputation models in which the imputed values will be modified (e.g. 
shifted by a constant) to reflect a better or worse score for specific patients (e.g. 
patients who do not perform the 6MWT because of refusal or withdrawal of 
consent will receive a worse score). The consistency of results across these 
different models will indicate the robustness of the assumptions. 
 
6.2 
Patients Characteristics 
 
6.2.1 Patients Disposition 
The subject disposition table will summarize patients’ characteristics by randomization 
group and overall. 
• 
The number (%) of patients randomized 
• 
The number (%) of patients withdrawn or lost to follow-up by month 12 
• 
The number (%) of patients who received a transplant by month 12 
• 
The number (%) of patients who completed the study at month 24 
• 
The number (%) of patients in the ITT population 
• 
The number (%) of patients in the Safety population 
 
The number (%) of subjects who complete and withdraw/lost to follow-up from the study 
and the primary reason for withdrawal will be summarized by randomization group and 
overall for all subjects. 
The percentages will be calculated based on the total number of patients randomized in 
each randomization group. 
 
6.2.2 Protocol Deviations and Violations 
Protocol deviations and violations are defined as deviations from the procedures outlined 
in the protocol. There is no “Per Protocol” population defined for this study. All 
statistical analyses and summaries will be conducted on an intent-to-treat basis for the 
18 
 


 
efficacy endpoints and on an as-treated basis for the safety endpoints. 
 
6.2.3  Demographic Characteristics 
Demographic and baseline characteristics data including age, gender, race, ethnicity, 
indication for LVAD (DT, BTT), device type (HeartMate II, HVAD) will be summarized 
using summary statistics for continuous variables or by group frequencies and 
percentages for categorical variables, as appropriate.   
 
6.2.4 Prior and Concomitant Medication 
The number (%) of patients receiving cardiovascular medications prior to or at the time 
of randomization will be reported and categorized by treatment group and medication 
type. 
 
6.2.5 Medical History 
Information pertaining to the etiology of heart failure, NYHA and Intermacs 
classification, the history of cardiovascular disease and other co-morbidities, and 
cardiovascular procedures will be summarized. 
The number of patient with specific conditions in their medical history will be 
summarized using frequencies and percentages. 
 
6.2.6 Pre-Implant Echocardiographic Parameters 
Pre-implant echocardiographic parameters such as left ventricular ejection fraction will 
be presented with summary statistics for continuous variables. 
 
6.3 
Efficacy Analysis 
 
6.3.1 Analysis of the Primary Efficacy Endpoint and Determination of Sample Size  
A Bayesian approach based on the probability that active therapy is superior to control will 
be used to assess the strength of potential efficacy, should safety continue to be 
demonstrated.  Simulations will be conducted to estimate this probability. The procedure 
will be carried out as follows: a binomial likelihood is specified for the primary efficacy 
outcome of the number of successful weans out of the three planned. The prior distribution 
for the success probability of the binomial likelihood is based on data from the control 
patients in the LVAD MPC I trial, where the rate of successful wean was found to be 
approximately 0.18.  Independent gamma priors with this mean and standard deviation of 
0.10 are assumed for each group.  Under the null hypothesis of no difference between the 
two groups, the simulated prior distribution of the success rate ratio is centered at one with 
nearly all mass between 0.5 and 2.  Before any data collection, equipoise implies that the 
probability that active therapy is superior to control is 50%.  Based on observed data, an 
increase in this probability to 80% or more, without safety concerns, will be considered a 
positive signal of efficacy for MPC therapy.  Simulations indicate that a sample size of 159 
patients provides a probability of 80% to detect such an efficacy signal if the true rate ratio 
is 1.5, with a false positive rate of 15%.   
 
An additional analysis based on a frequentist approach will also be conducted on the 
primary outcome as a sensitivity analysis. Negative binomial regression will be used to 
compare the number of successful weans in the first 6 months after randomization 
between the MPC and the control group and will include an offset term to adjust for the 
total number of possible wean assessments.  The model accounts for between-subject 
heterogeneity, and accommodates over-dispersed data.  If there are excess zeros due to 
19 
 


 
failure to wean that cannot be satisfactorily accounted for in the negative binomial 
model, a zero-inflated negative binomial regression will be considered. 
 
6.3.2 Analysis of Secondary Efficacy Endpoints 
All secondary efficacy analyses will be performed using the ITT population, unless 
otherwise specified.  
 
• 
Overall Survival and Survival to Cardiac Transplantation 
Time to death will be calculated as the number of days between randomization and death 
due to any cause at 12 (+14 days) and 24 (+30 days) months. Patients who are alive at the 
respective time points will be censored. Patients who undergo cardiac transplantation will 
be censored at the time of transplant. Patients who drop out (withdraw, lost to follow-up) 
will be censored at the time of study discontinuation. 
 
Survival at 12 and 24 months will be described by Kaplan-Meier curves and differences 
between randomization groups will be assessed via the log-rank test.   
If the number of events permits, additional analyses will be performed for cardiovascular 
and non-cardiovascular cause of death and for LVAD related and non-LVAD related 
cause of death. 
 
Time to cardiac transplantation by 12 or 24 months post randomization will be calculated 
as the number of days between randomization and transplant. Patients who do not receive 
a transplant by month 12 or month 24 will be censored. Patients who drop out (withdraw, 
lost to follow-up) will be censored at the time of study discontinuation.  Death before 
transplant will be considered a competing risk in the calculation of the cumulative 
incidence curves of time to cardiac transplantation.  
 
Time to cardiac transplantation by 12 and 24 months will be described by cumulative 
incidence curves and differences between randomization groups will be assessed via 
Gray’s test.19  
 
• Functional Status by 6 Months and 12 Months Post Randomization 
Ability to Tolerate Wean from LVAD Support for 30 Minutes   
The pattern of successful weans over 6 months and 12 months follow-up will be explored 
using logistic regression with parameter estimation using generalized estimating 
equations.  
 
Duration of Ability to Tolerate Wean  
The duration of time weaning is tolerated will be examined at each time point post 
randomization.  Random effects pattern mixture models will be used to characterize 
changes over time in the duration that a patient tolerates weaning.   
 
This approach is not sensitive to untestable assumptions about missing data 
mechanism because it separates the data into strata based on the missing patterns and 
estimates a separate linear model, including a treatment effect, for data in each 
stratum. An interaction term of treatment-by-time will be used to determine the 
difference in the longitudinal course of duration of weaning between the two 
randomization groups in each stratum. The model will, at a minimum, include a 
random subject effect.  If a random slope on time is needed, an unstructured 
20 
 


 
covariance matrix among the random effects will be used and independence among 
the residuals will be assumed.  The model makes assumptions regarding the 
distribution (mean and correlation structure) of the random effects and the residuals 
which will all require checking.   
 
The method of Wu and Bailey20 is an instance of pattern-mixture modeling.   
 
If there are excess zeros, a two-part mixed effects pattern-mixture model will be 
considered.  A pattern-mixture binary mixed model will be used to analyze the zero part 
of weaning duration and a pattern-mixture Gaussian (or other appropriate link function) 
mixed model for the non-zero response. 
 
Six Minute Walk Test  
The 6MWT will be analyzed similarly to the duration of time weaning is tolerated using 
random effects pattern mixture models.  An interaction term of treatment-by-time will be 
used to determine the difference in the longitudinal course of the 6MWT between the two 
randomization groups.   
 
• Physiological Assessments 
At each wean assessment, echo parameters are measured 3 times – prior to wean, 15 
minutes after wean started, and after the 6MWT. Separate analyses will be conducted for 
each of these endpoints.  All of the echocardiographic measures will be described using 
both graphical and numerical summaries.  We will use random effect models similar to 
the ones described for the analysis of the secondary efficacy endpoints to analyze the 
echo parameters collected before the wean. The primary aims of the random effects 
models will be to characterize the changes over 12 months in the echocardiographic 
measures in each treatment group. For the echo parameters collected during and at the 
end of the weaning we will restrict the analysis to descriptive measures and their 95% 
confidence intervals. 
 
LV performance and LV chamber remodeling  
The percent change from baseline in LV end-diastolic minor axis dimension (LVEDD) 
will be measured from the echocardiogram performed when the LVAD is at full support 
before the wean. Similar to the duration of wean and 6MWT endpoints, changes in echo 
parameters over time will be analyzed using random effects pattern mixture models with 
an interaction term of treatment-by-time group to determine the difference in the 
longitudinal course of LVEDD between the two randomization groups.   
    
• Index Hospitalization and Readmissions 
Total Number of Days Alive and out of the Hospital 
Total number of days alive and out of the hospital during the first 6 months (+14 days) 
post randomization will be analyzed using negative binomial regression models in which 
the randomization arm will be the independent variable of interest and the total days alive 
as an offset. 
 
Hospitalization Length of Stay and Days in ICU of the Index Hospitalization 
We will compare post-operative hospital length of stay and days spent in ICU of the 
index hospitalization between randomization groups using a Wilcoxon Rank-Sum 
Test. Patients who die in the hospital before discharge will be assigned the worst rank 
21 
 


 
according to the time of death (with patients dying earlier having the worse rank). 
 
Time to First Readmission 
Time to first readmission by 12 months post randomization will be calculated as the 
number of days between time of discharge from index hospitalization and first 
readmission. Patients who are not re-admitted by month 12 will be censored. Patients 
who drop out (withdraw, lost to follow-up) or are transplanted without being re-
admitted will be censored at the time of study discontinuation.  Death post discharge 
from the index hospitalization will be considered a competing risk in the calculation of 
the cumulative incidence curves of time to cardiac transplantation. Time to cardiac 
first readmission by 12 months will be described by cumulative incidence curves and 
differences between randomization groups will be assessed via Gray’s test.  
 
Readmission Rates 
Rates of all-cause hospitalizations, and rate of cardiovascular-specific hospitalizations, 
both within 30 days and 12 months (+14 days), will be compared between 
randomization groups using negative binomial regression models.  
 
Hospital Resource Use 
Hospital resource utilization or hospital costs will be calculated by converting charges 
to costs using institution specific Ratio-of-Cost-to-Charges (RCCs).   Costs associated 
with the index hospitalization and readmissions at 12 months will be totaled for each 
patient and compared between treatment groups  by Students t-test after log 
transformation.  Independent predictors of total cost, including randomization group, 
baseline factors, operative factors and postoperative events occurring during the index 
hospitalization, will be determined by multivariate regression analysis with the 
appropriate distribution and link function based on the modified Park test. 
 
• Quality of Life and Neurocognition 
Quality of Life 
Quality of life will be measured using the KCCQ and SF-12 at baseline and at 6 and 
12 months post randomization.  These patient-reported outcomes will be analyzed 
using random effect pattern mixture models.   
 
Neurocognitive Outcomes 
 Neurocognitive outcomes for each test will be standardized using the means and 
standard deviations observed in the overall sample and combined within cognitive 
domains using weights.  Differences in the scores for each domain at 90 days and 12 
months post-randomization will be compared between randomization arms based on 
an analysis of covariance that adjusts for important baseline values.  
 
Results from each test will be normalized to a Z-score based on the baseline means 
and standard deviations for the whole sample.  Function of 4 cognitive domains 
(verbal learning and memory, visual learning and memory, executive functioning, and 
visuospatial/constructional functioning) will be measured by averaging the Z-scores 
of tests that correspond to each domain.   
 
The impact of MPC treatment over time will be assessed using linear mixed effects 
models with random intercepts.  In these models, the standardized neurocognitive 
scores assessed at each time point will be used as the dependent variable, treatment, 
22 
 


 
assessment time and their interaction will be the primary predictors of interest. 
Models will also be adjusted for age and education level.  We will also analyze the 
proportion of patients with neurocognitive decline defined as a change from baseline 
to the 1-year assessment of 0.5, or greater, SD in 2 or more domains.  For this analysis 
we will use logistic models with the proportion of patients with neurocognitive 
decline at 1 year as the outcome and treatment assignment as the primary predictor.   
Models will also be adjusted for age and education level. 
 
6.4 
Tertiary Endpoints 
Mixed effects models will be used to characterize levels of cytokines and chemokines 
over time.  The association of cytokine and chemokine levels with engraftment of 
cells in native explanted hearts will be described graphically, and quantified by 
regression and correlation analysis.   
 
6.5 
Subgroup Analyses 
Stratified analyses will be conducted, if the sample size permits, to explore the effect 
of the MPC treatment in particular subgroups of patients. These analyses will be 
stratified by LVAD indication (DT or BTT). Since the randomization was not 
stratified according to this factor, there is no assurance that the randomization groups 
will be balanced within these strata. An assessment of the available sample size within 
each stratum and reasonable balance of the treatment assignment will be conducted 
before performing the subgroup analyses. Strata that contain less than 20% of the 
sample size and/or in which the number of patients assigned to a specific group is less 
than 10 will not be considered. 
 
6.6 
Safety Analysis 
6.6.1 Incidence and Rate of Non-Surgical GI Bleeding Events and/or Epistaxis by 6 
Months Post Randomization  
Evidence from the LVAD I study involving 30 patients suggest that treatment with 
MPC may reduce GI bleeding events and/or epistaxis by 6 months after 
randomization. Therefore, particular emphasis will be placed on the analysis of these 
events. 
 
A time to first serious GI bleeding and/or epistaxis analysis will be conducted to 
compare the two randomization groups. Time to first bleeding event over 6 months 
(+14 days) will be calculated as the time from randomization to the first episode of 
bleeding.  Time to first bleeding event will be described by cumulative incidence 
curves and differences between randomization groups will be assessed via Gray’s 
test.18   Death before bleeding will be considered a competing risk in the calculation of 
the cumulative incidence curves of time to first bleeding event.  Patients who do not 
experience bleeding by the end of the 6 months period will be censored. For patients 
who undergo cardiac transplantation prior to a bleeding event, censoring will be at the 
time of transplant.  Similarly, patients who drop out without having a bleeding event 
will be censored at the time of study discontinuation.   
 
The rate of serious GI bleeding events and/or epistaxis in each group will be 
calculated as the ratio of the total number of bleeding events and the total 
patient/months. A negative binomial model will be used to compare the rate of 
bleeding between the MPC and the control group. 
 
23 
 


 
Should the two groups be different with respect of baseline factors, such as type of LVAD 
implanted (Heartmate II or HVAD), the LVAD indication (DT or BTT), or history of GI 
bleeding, negative binomial models will be fitted to examine the effect of these factors on 
bleeding. Interaction terms may also be added to these models depending on the 
frequency of the outcome variable in the subgroups. 
 
6.6.2 Treatment-emergent Adverse Events (TEAEs) 
All adverse events in this study will be analyzed from the time of injection. All safety 
analysis will be based on the safety population. Subjects who were randomized, but 
never been administrated with the study drug (either MPC or control) will be 
excluded from the safety analysis. 
 
AEs will be mapped to the MedDRA coding system.  The incidence of TEAEs and 
serious TEAEs will be summarized by System Organ Class, MedDRA Preferred Term 
and treatment.   
 
Separate tables will be presented for all TEAEs, TEAEs by severity, serious TEAEs, 
study intervention-related TEAEs, LVAD related TEAEs and TEAEs leading to 
death. 
 
The number and percentage of patients with a TEAE or serious TEAE will be 
presented.  A patient will be counted only once in the incidence count for a specific 
MedDRA Preferred Term, although a MedDRA Preferred Term might be recorded 
more than once for a particular patient. 
 
The number and rate of each TEAE will be presented.  Differences in the incidence of 
individual TEAEs s will be assessed using negative binomial regression with the 
treatment groups  as the predictor.  
 
6.6.2   Anti-HLA Antibody Sensitivity, Anti-Murine and Anti-Bovine Antibodies 
The proportion of patients with anti-HLA antibody sensitivity while on LVAD support 
will be reported along with 95% confidence intervals by treatment group.  In addition, 
the proportion of patients who exhibit anti-murine and anti-bovine antibodies following 
study product administration will be reported similarly. The analysis will be based on all 
available samples at each time point. Missing data will not be imputed. In addition to the 
analyses of clinical outcomes described above, explanted native hearts will be examined 
to quantify the extent of neovascularization, MPC cell engraftment, as well as histologic 
and gene regulation responses to cell implantation. Confidence intervals will be 
constructed and differences between treatment groups in the prevalence of these 
measures will be summarized. 
 
6.7  
Early Stopping Rules 
Safety will be continuously monitored. The DCC will report all deaths and 
unexpected adverse events, as well as rare but expected serious adverse events to the 
NHLBI, who, in turn, will report to the DSMB chair.  There are two components to 
the safety monitoring plan. The first focuses on rare events that are very likely to be 
related to the experimental treatment and not to the underlying heart failure.  The 
second focuses on mortality which is not a rare event in this patient population.  With 
respect to the rare events likely associated with experimental treatment, enrollment 
will be halted should any of the pre-specified events (infectious myocarditis, 
24 
 


 
myocardial rupture, neoplasm, hypersensitivity reaction, or immune sensitization 
syndrome) be observed.  Stopping guidelines for mortality will use the same approach 
as that described to assess the presence of an efficacy signal using a very diffuse beta 
(2, 8) prior for mortality for both groups, and will be initiated following the 
randomization of the 10th patient. We would propose to halt randomization if the 
probability that mortality on active therapy is increased compared to control exceeds 
80%.  The probability will be determined sequentially, after each mortality event. 
NHLBI, in conjunction with the DSMB’s recommendations, will determine whether 
enrollment should be continued, suspended or terminated should any of the proposed 
stopping criteria be met. 
 
6.8   Interim Analysis 
There is no planned interim analysis for this study. 
 
 
25 
 


 
7. 
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