current concepts in therapeutic angiogenesis c. michael gibson m.s., m.d
TRANSCRIPT
Current Concepts In Therapeutic Angiogenesis
Current Concepts In Therapeutic Angiogenesis
C. Michael Gibson M.S., M.D. C. Michael Gibson M.S., M.D.
Scope of Coronary Artery DiseaseScope of Coronary Artery Disease
• ~ 15 - 20 million Americans have a history of MI, angina, or both
• Cardiovascular disease is the number one cause of death in the US
• ~ 500,000 deaths per year
• 1,500,000 new or recurrent MI’s per year
• ~ 15 - 20 million Americans have a history of MI, angina, or both
• Cardiovascular disease is the number one cause of death in the US
• ~ 500,000 deaths per year
• 1,500,000 new or recurrent MI’s per year
AHA DatabankAHA Databank
• ~ 10 million Americans have angina
• ~ 350,000 new cases of angina diagnosed each year
• ~ 1.5 million coronary angiograms per year
• ~ 500,000 PTCA per year
• ~ 500,000 CABGs per year
• ~ 10 million Americans have angina
• ~ 350,000 new cases of angina diagnosed each year
• ~ 1.5 million coronary angiograms per year
• ~ 500,000 PTCA per year
• ~ 500,000 CABGs per year
AHA DatabankAHA Databank
Scope of Coronary Artery DiseaseScope of Coronary Artery Disease
Therapeutic AngiogenesisTherapeutic Angiogenesis
Current Therapeutic OptionsCurrent Therapeutic Options
Medical• Antianginals• Antiplatelet Agents• Lipid Lowering
Agents• Anticoagulants• Vasodilators
Medical• Antianginals• Antiplatelet Agents• Lipid Lowering
Agents• Anticoagulants• Vasodilators
Interventional• PTCA• CABG• TMR/PMR• Cardiac
Transplantation• PVD: Amputation
Interventional• PTCA• CABG• TMR/PMR• Cardiac
Transplantation• PVD: Amputation
New Therapeutic OptionNew Therapeutic Option
Therapeutic Angiogenesis: DefinitionsTherapeutic Angiogenesis: Definitions
Angiogenesis• The formation of new capillary blood vessels from
existing microvessels by sprouting, i.e. cellular outgrowth
Vasculogenesis• The formation of new blood vessels of all types from
blood islands, i.e. committed stem cells, in early embryogenesis
Growth Factor • Polypeptide which acts as a regulator of cellular
function, including proliferation, migration, differentiation, and survival/apoptosis
Angiogenesis• The formation of new capillary blood vessels from
existing microvessels by sprouting, i.e. cellular outgrowth
Vasculogenesis• The formation of new blood vessels of all types from
blood islands, i.e. committed stem cells, in early embryogenesis
Growth Factor • Polypeptide which acts as a regulator of cellular
function, including proliferation, migration, differentiation, and survival/apoptosis
Angiogenic Growth FactorsAngiogenic Growth Factors
• Basic fibroblast growth factor (bFGF)
• Acidic fibroblast growth factor (aFGF)
• Angiogenin
• Angiotropin
• Insulin-like growth factor
• Interleukin-8
• Platelet activating factor (PAF)
• Basic fibroblast growth factor (bFGF)
• Acidic fibroblast growth factor (aFGF)
• Angiogenin
• Angiotropin
• Insulin-like growth factor
• Interleukin-8
• Platelet activating factor (PAF)
J. Battegay: J. Mol Med; 1995J. Battegay: J. Mol Med; 1995
• Platelet-derived growth factor
(PDGF)
• Proliferin
• Transforming growth factor-
• Transforming growth factor-
• Tumor necrosis factor-
• Vascular endothelial growth
factor (VEGF)
• Platelet-derived growth factor
(PDGF)
• Proliferin
• Transforming growth factor-
• Transforming growth factor-
• Tumor necrosis factor-
• Vascular endothelial growth
factor (VEGF)
Basic Fibroblast Growth Factor (bFGF)Basic Fibroblast Growth Factor (bFGF)
• 154 amino acids, MW 18 kD• Additional higher MW forms exist• Post-translational modification may yield a
shorter form• Present in almost all cells• Present from embryogenesis to adult cells• Released from extracellular sites by heparin
and various proteolytic enzymes
• 154 amino acids, MW 18 kD• Additional higher MW forms exist• Post-translational modification may yield a
shorter form• Present in almost all cells• Present from embryogenesis to adult cells• Released from extracellular sites by heparin
and various proteolytic enzymes
bFGF ReceptorsbFGF Receptors• The cell receptor is a transmembrane
tyrosine kinase
• Found on numerous cell types
• Receptor expression upregulated by injury (PTCA & ischemia)
• bFGF Binds to heparin which protects it from degradation
• Seperate binding sites for bFGF receptor and heparin
• The cell receptor is a transmembrane tyrosine kinase
• Found on numerous cell types
• Receptor expression upregulated by injury (PTCA & ischemia)
• bFGF Binds to heparin which protects it from degradation
• Seperate binding sites for bFGF receptor and heparin
Functions of Growth FactorsFunctions of Growth Factors
• Embryogenesis: Stimulates proliferation & differentiation of a variety of cells
• Wound Healing: Stimulates migration and proliferation of connective tissue
• Cytoprotection: CNS, vascular smooth muscle and endothelial cells
• Angiogenesis: Ischemic & Non-Ischemic• Active at 0.1 to 1.0 ng/ml
• Embryogenesis: Stimulates proliferation & differentiation of a variety of cells
• Wound Healing: Stimulates migration and proliferation of connective tissue
• Cytoprotection: CNS, vascular smooth muscle and endothelial cells
• Angiogenesis: Ischemic & Non-Ischemic• Active at 0.1 to 1.0 ng/ml
Augustin-Voss et al.Augustin-Voss et al.
0
200
400
600
800
1000
1200
5 15 25 35 45
Control +bFGF
0
200
400
600
800
1000
1200
5 15 25 35 45
Control +bFGF
Passage NumberPassage Number
En
doth
elia
l Cel
l Mig
ratio
n (
m 7
2 h
our
s)E
ndo
the
lial C
ell M
igra
tion
(m
72
ho
urs)
Bovine Endothelial Cell MigrationBovine Endothelial Cell Migration
0
200
400
600
800
1000
1200
Control +bFGF
0
200
400
600
800
1000
1200
Control +bFGF
Pro
life
rati
on
% /
48
hr
Pro
life
rati
on
% /
48
hr
Augustin-Voss et al.Augustin-Voss et al.
Impact of bFGF on Bovine Endothelial Cell ProliferationImpact of bFGF on Bovine Endothelial Cell Proliferation
Functions of bFGFFunctions of bFGF
Non-ischemic Angiogenesis
• Promotes endothelial cell migration and tube formation
• Stimulates the production of collagenases and plasminogen activator necessary for basement membrane remodeling
Non-ischemic Angiogenesis
• Promotes endothelial cell migration and tube formation
• Stimulates the production of collagenases and plasminogen activator necessary for basement membrane remodeling
M. Klagsbrun: Progress Growth Factor Research; 1989M. Klagsbrun: Progress Growth Factor Research; 1989
Ischemic Angiogenesis
• Endogenous bFGF production in the presence of ischemia
• Impact of exogenous bFGF on ischemic tissues
Ischemic Angiogenesis
• Endogenous bFGF production in the presence of ischemia
• Impact of exogenous bFGF on ischemic tissues
Ischemic AngiogenesisIschemic Angiogenesis
M. Cohen: J Mol Cell Cardiol; 1994M. Cohen: J Mol Cell Cardiol; 1994
Longitudinal Changes in Myocardial Basic Fibroblast Growth Factor (FGF-2) Activity
Following Coronary Artery Ligation in the Dog
Michael V. Cohen et al.
Albert Einstein College of Medicine
Longitudinal Changes in Myocardial Basic Fibroblast Growth Factor (FGF-2) Activity
Following Coronary Artery Ligation in the Dog
Michael V. Cohen et al.
Albert Einstein College of Medicine
Demonstration of Endogenous Tissue Production of bFGF: Canine LAD Occlusion Model
Demonstration of Endogenous Tissue Production of bFGF: Canine LAD Occlusion Model
Time Following Canine LAD OcclusionTime Following Canine LAD Occlusion
Isch
emic
/No
rmal
Myo
card
ial
bF
GF
rat
ioIs
chem
ic/N
orm
al M
yoca
rdia
l b
FG
F r
atio
0
0.5
1
1.5
2
2.5
3
2 Hours 1 Week 2 Weeks 8 Weeks
0
0.5
1
1.5
2
2.5
3
2 Hours 1 Week 2 Weeks 8 Weeks
**
**
Cohen et al: J Mol Cell Cardiol; 1994Cohen et al: J Mol Cell Cardiol; 1994
Endogenous bFGF production assayed in ischemic and adjacent normal cardiac tissue bFGF production rose as early as 2 hours
Endogenous bFGF production assayed in ischemic and adjacent normal cardiac tissue bFGF production rose as early as 2 hours
Production of Growth Factors in Ischemia: Other Indirect Evidence
Production of Growth Factors in Ischemia: Other Indirect Evidence
Fujita et al measured the bFGF levels in the pericardial fluid of patients undergoing open heart surgery for unstable angina (CABG) versus those undergoing surgery for non-ischemic causes
Elevated bFGF levels found in the pericardial fluid of patients with unstable angina
Fujita et al measured the bFGF levels in the pericardial fluid of patients undergoing open heart surgery for unstable angina (CABG) versus those undergoing surgery for non-ischemic causes
Elevated bFGF levels found in the pericardial fluid of patients with unstable angina
M. Fujita et al, Circulation; 1996M. Fujita et al, Circulation; 1996
Baffour et al.• Rabbit model of hind limb ischemia (ligated main
arteries in staged procedure over 2 weeks)• Compared two weeks of IM bFGF to saline• Results:
• bFGF groups had angiographically improved collaterals
• bFGF groups had greater capillary density (per mm and per muscle fiber)
• bFGF groups had greater muscle viability
Baffour et al.• Rabbit model of hind limb ischemia (ligated main
arteries in staged procedure over 2 weeks)• Compared two weeks of IM bFGF to saline• Results:
• bFGF groups had angiographically improved collaterals
• bFGF groups had greater capillary density (per mm and per muscle fiber)
• bFGF groups had greater muscle viability
R. Baffour et al, J Vasc Surg; 1992R. Baffour et al, J Vasc Surg; 1992
Ischemic Angiogenesis & Exogenous Growth Factors : Peripheral Models
Ischemic Angiogenesis & Exogenous Growth Factors : Peripheral Models
Yang et al
• Rat model of hind limb ischemia
• Compared one to four weeks of continuous intra-
arterial bFGF (1 g/day) to heparinized saline control
• Demonstrated improvement in:
• Collateral blood flow by microspheres
• Capillary density
• Muscle performance by stimulated tension
Yang et al
• Rat model of hind limb ischemia
• Compared one to four weeks of continuous intra-
arterial bFGF (1 g/day) to heparinized saline control
• Demonstrated improvement in:
• Collateral blood flow by microspheres
• Capillary density
• Muscle performance by stimulated tension
H. Yang et al, Circ. Res 1996H. Yang et al, Circ. Res 1996
Ischemic Angiogenesis & Exogenous Growth Factors : Peripheral Models
Ischemic Angiogenesis & Exogenous Growth Factors : Peripheral Models
0
10
20
30
40
50
60
Base 1 Week 2 Weeks 4 Weeks
Control
bFGF
0
10
20
30
40
50
60
Base 1 Week 2 Weeks 4 Weeks
Control
bFGF
Time Following Hind Limb Arterial OcclusionTime Following Hind Limb Arterial Occlusion
Co
llat
eral
Flo
w (
ml
/ m
in /
100
g)
Co
llat
eral
Flo
w (
ml
/ m
in /
100
g) ** **
H. Yang et al, Circ. Res.; 1996H. Yang et al, Circ. Res.; 1996
Ischemic Angiogenesis & Exogenous Growth Factors : Peripheral Models
Ischemic Angiogenesis & Exogenous Growth Factors : Peripheral Models
Uchida et al
• Occluded canine LAD model
• Compared intrapericardial bFGF, heparin, or both to
saline control (drug given 30 minutes after occlusion)
• Measured:
• Ejection fraction
• Capillary density
• Infarct size
Uchida et al
• Occluded canine LAD model
• Compared intrapericardial bFGF, heparin, or both to
saline control (drug given 30 minutes after occlusion)
• Measured:
• Ejection fraction
• Capillary density
• Infarct size Y. Uchida et al, Am Heart J; 1995Y. Uchida et al, Am Heart J; 1995
Ischemic Angiogenesis & Exogenous Growth Factors : Cardiac Models
Ischemic Angiogenesis & Exogenous Growth Factors : Cardiac Models
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
Base 30 min. 1 month
Saline
Heparin
bFGF
Hep+bFGF
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
Base 30 min. 1 month
Saline
Heparin
bFGF
Hep+bFGF
Time Following Arterial OcclusionTime Following Arterial Occlusion
Eje
ctio
n F
ract
ion
Eje
ctio
n F
ract
ion
****
Y. Uchida: Am Heart J; 1995Y. Uchida: Am Heart J; 1995
Ischemic Angiogenesis & Exogenous Growth Factors : Cardiac Models
Ischemic Angiogenesis & Exogenous Growth Factors : Cardiac Models
0
5
10
15
20
25
30
Saline Heparin bFGF Hep +bFGF
0
5
10
15
20
25
30
Saline Heparin bFGF Hep +bFGF
Infa
rcte
d W
eig
ht
(% o
f L
V)
Infa
rcte
d W
eig
ht
(% o
f L
V)
‡‡
**
Y. Uchida et al, Am Heart J; 1995Y. Uchida et al, Am Heart J; 1995
Ischemic Angiogenesis & Exogenous Growth Factors : Cardiac Models
Ischemic Angiogenesis & Exogenous Growth Factors : Cardiac Models
0
1
2
3
4
5
6
7
8
9
Saline Heparin bFGF Hep+bFGF
Noninfarct Zone
Infarct Zone
0
1
2
3
4
5
6
7
8
9
Saline Heparin bFGF Hep+bFGF
Noninfarct Zone
Infarct Zone
Cap
illa
ry N
um
ber
per
200
m
Cap
illa
ry N
um
ber
per
200
m ‡‡
Y. Uchida et al, Am Heart J; 1995Y. Uchida et al, Am Heart J; 1995
**
Ischemic Angiogenesis & Exogenous Growth Factors : Cardiac Models
Ischemic Angiogenesis & Exogenous Growth Factors : Cardiac Models
Ameroid constriction of porcine circumflex• Compared intrapericardial bFGF and/or heparin to
saline control
• Measured:
• Angiographic collaterals
• Microsphere blood flow
• MRI Cardiac function
• MRI collateral flow
Ameroid constriction of porcine circumflex• Compared intrapericardial bFGF and/or heparin to
saline control
• Measured:
• Angiographic collaterals
• Microsphere blood flow
• MRI Cardiac function
• MRI collateral flow
M. Simmons, personal communication; 1997M. Simmons, personal communication; 1997
Ischemic Angiogenesis & Exogenous Growth Factors : Cardiac Models
Ischemic Angiogenesis & Exogenous Growth Factors : Cardiac Models
0
0.2
0.4
0.6
0.8
1
1.2
1.4
0 Weeks 4 Weeks
Saline
Heparin
bFGF 30
bFGF 200
bFGF 2000
0
0.2
0.4
0.6
0.8
1
1.2
1.4
0 Weeks 4 Weeks
Saline
Heparin
bFGF 30
bFGF 200
bFGF 2000
Cir
cum
flex
F
low
(m
l /
min
/ g
)C
ircu
mfl
ex
Flo
w
(ml
/ m
in /
g)
*
**
Time Post Drug AdministrationTime Post Drug Administration
M. Simmons, personal communication; 1997M. Simmons, personal communication; 1997
Ischemic Angiogenesis & Exogenous Growth Factors : Cardiac Models
Ischemic Angiogenesis & Exogenous Growth Factors : Cardiac Models
0
5
10
15
20
25
30
Saline Heparin bFGF 30
bFGF200
bFGF2000
0
5
10
15
20
25
30
Saline Heparin bFGF 30
bFGF200
bFGF2000
Del
ayed
Co
ntr
ast
Arr
ival
Ext
ent
(%)
Del
ayed
Co
ntr
ast
Arr
ival
Ext
ent
(%)
**
M. Simmons, personal communication; 1997M. Simmons, personal communication; 1997
**
**
Ischemic Angiogenesis & Exogenous Growth Factors : Cardiac Models
Ischemic Angiogenesis & Exogenous Growth Factors : Cardiac Models
Lazarous et al.
• Ameroid constriction of porcine circumflex
• Daily systemic bFGF (4 to 9 weeks) vs saline control
• Measured microsphere determinations of collateral blood flow
Lazarous et al.
• Ameroid constriction of porcine circumflex
• Daily systemic bFGF (4 to 9 weeks) vs saline control
• Measured microsphere determinations of collateral blood flow
D. Lazarous et al, Circulation; 1995D. Lazarous et al, Circulation; 1995
Ischemic Angiogenesis & Exogenous Growth Factors : Cardiac Models
Ischemic Angiogenesis & Exogenous Growth Factors : Cardiac Models
D. Lazarous et al, Circulation; 1995D. Lazarous et al, Circulation; 1995
Ischemic Angiogenesis & Exogenous Growth Factors : Cardiac Models
Ischemic Angiogenesis & Exogenous Growth Factors : Cardiac Models
Lazarous et al. Short Infusion Model
• Ameroid constriction of porcine circumflex
• Shorter duration of systemic bFGF (7 days) or VEGF to saline control
• Measured microsphere determinations of collateral blood flow
Lazarous et al. Short Infusion Model
• Ameroid constriction of porcine circumflex
• Shorter duration of systemic bFGF (7 days) or VEGF to saline control
• Measured microsphere determinations of collateral blood flow
D. Lazarous et al, Circulation; 1996D. Lazarous et al, Circulation; 1996
Ischemic Angiogenesis & Exogenous Growth Factors : Cardiac Models
Ischemic Angiogenesis & Exogenous Growth Factors : Cardiac Models
D. Lazarous: Circulation; 1996D. Lazarous: Circulation; 1996
Lazarous et al: Data Following 7 Day Infusions
Yanagisawa-Miwa et al.
• Acute occlusion of canine LAD
• Compared two bolus circumflex injections of bFGF vs saline
• Measured:• LV Function• Infarct size• Histologic assessment of collateral growth
Yanagisawa-Miwa et al.
• Acute occlusion of canine LAD
• Compared two bolus circumflex injections of bFGF vs saline
• Measured:• LV Function• Infarct size• Histologic assessment of collateral growth
A. Yanagisawa-Miwa et al, Science; 1992A. Yanagisawa-Miwa et al, Science; 1992
Ischemic Angiogenesis & Exogenous Growth Factors : Cardiac Models
Ischemic Angiogenesis & Exogenous Growth Factors : Cardiac Models
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
Baseline 30 Min. 1 Week
Saline
bFGF
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
Baseline 30 Min. 1 Week
Saline
bFGF
Eje
ctio
n F
ract
ion
Eje
ctio
n F
ract
ion **
A. Yanagisawa-Miwa: Science; 1992A. Yanagisawa-Miwa: Science; 1992
Time post InfarctionTime post Infarction
Ischemic Angiogenesis & Exogenous Growth Factors : Cardiac Models
Ischemic Angiogenesis & Exogenous Growth Factors : Cardiac Models
0
5
10
15
20
25
bFGF Saline
0
5
10
15
20
25
bFGF Saline
Infa
rct
wei
gh
t / L
V w
eig
ht
(%)
Infa
rct
wei
gh
t / L
V w
eig
ht
(%)
**
A. Yanagisawa-Miwa et al, Science; 1992A. Yanagisawa-Miwa et al, Science; 1992
Ischemic Angiogenesis & Exogenous Growth Factors : Cardiac Models
Ischemic Angiogenesis & Exogenous Growth Factors : Cardiac Models
0
10
20
30
40
50
60
70
80
90
100
0
10
20
30
40
50
60
70
80
90
100C
apill
ary
Nu
mb
er /
Un
it A
rea
Cap
illar
y N
um
ber
/ U
nit
Are
a**
A. Yanagisawa-Miwa et al, Science; 1992A. Yanagisawa-Miwa et al, Science; 1992
0
2
4
6
8
10
12
14
16
Control bFGF
0
2
4
6
8
10
12
14
16
Control bFGF
**
Art
erio
le N
um
ber
/ U
nit
Are
aA
rter
iole
Nu
mb
er /
Un
it A
rea
Ischemic Angiogenesis & Exogenous Growth Factors : Cardiac Models
Ischemic Angiogenesis & Exogenous Growth Factors : Cardiac Models
ControlControl bFGFbFGF
Horrigan et al.
• Four hour balloon occlusion of canine LAD
• Compared two bolus LM injections of bFGF or vehicle
• Measured:
• Infarct size
• Histologic assessment of collateral growth
Horrigan et al.
• Four hour balloon occlusion of canine LAD
• Compared two bolus LM injections of bFGF or vehicle
• Measured:
• Infarct size
• Histologic assessment of collateral growth
M. Horrigan et al, Circulation; 1996M. Horrigan et al, Circulation; 1996
Ischemic Angiogenesis & Exogenous Growth Factors : Cardiac Models
Ischemic Angiogenesis & Exogenous Growth Factors : Cardiac Models
0
5
10
15
20
25
30
Vehicle bFGF
0
5
10
15
20
25
30
Vehicle bFGF
Infa
rct
Siz
e (%
are
a at
ris
k)In
farc
t S
ize
(% a
rea
at r
isk)
**
M. Horrigan et al, Circulation; 1996M. Horrigan et al, Circulation; 1996
Ischemic Angiogenesis & Exogenous Growth Factors : Cardiac Models
Ischemic Angiogenesis & Exogenous Growth Factors : Cardiac Models
Chiron StudyChiron Study
Multi-Center, Single-Blind, Dose
Escalation, Safety and Tolerability Study
of Recombinant Fibroblast Growth
Factor-2 (rFGF-2) in Subjects with
Advanced Coronary Artery Disease
Multi-Center, Single-Blind, Dose
Escalation, Safety and Tolerability Study
of Recombinant Fibroblast Growth
Factor-2 (rFGF-2) in Subjects with
Advanced Coronary Artery Disease
Study ObjectivesStudy Objectives
• Evaluate safety, tolerability and
pharmacokinetics of short-term (20 min)
intracoronary (IC) and intravenous (IV) single
infusions of ascending doses of rFGF-2
• Determine maximum tolerated IC and IV doses
• Measure preliminary efficacy data using
nuclear stress imaging and cardiac MRI
• Evaluate safety, tolerability and
pharmacokinetics of short-term (20 min)
intracoronary (IC) and intravenous (IV) single
infusions of ascending doses of rFGF-2
• Determine maximum tolerated IC and IV doses
• Measure preliminary efficacy data using
nuclear stress imaging and cardiac MRI
• Study Agent• Recombinant protein produced in yeast• Differs from native human bFGF by only two amino
acids• Essentially identical angiogenic properties
• Enrollment• Screening physical exam and labs• Exercise or dipyridamole stress test with dual isotope
imaging• Cardiac MRI with cardiac function and collateral flow
determinations• Ophthalmologic exam• Quality of Life questionnaire
• Study Agent• Recombinant protein produced in yeast• Differs from native human bFGF by only two amino
acids• Essentially identical angiogenic properties
• Enrollment• Screening physical exam and labs• Exercise or dipyridamole stress test with dual isotope
imaging• Cardiac MRI with cardiac function and collateral flow
determinations• Ophthalmologic exam• Quality of Life questionnaire
Study DesignStudy Design
Inclusion CriteriaInclusion Criteria
• Severe CAD with inducible ischemia on stress test
• No optimal revascularization option
• Normal routine laboratory screening
• Willingness and ability to complete all components of the study and its follow-up
• Signed informed consent
• Severe CAD with inducible ischemia on stress test
• No optimal revascularization option
• Normal routine laboratory screening
• Willingness and ability to complete all components of the study and its follow-up
• Signed informed consent
• Class IV CHF or EF < 20%
• MI < 3 months
• New or unstable angina < 3 wks
• CABG < 6 months
• PTCA or TMR < 6 months
• Significant arrhythmias
• Pacemaker or AICD
• LBBB
• Class IV CHF or EF < 20%
• MI < 3 months
• New or unstable angina < 3 wks
• CABG < 6 months
• PTCA or TMR < 6 months
• Significant arrhythmias
• Pacemaker or AICD
• LBBB
• Severe valvular heart disease
• Restrictive or hypertrophic cardiomyopathy
• Known AVMs• TIA or CVA < 6 mths• DM with end-organ
damage• Cr Cl < 80 ml/min or
proteinuria• Cancer within 10 years
• Severe valvular heart disease
• Restrictive or hypertrophic cardiomyopathy
• Known AVMs• TIA or CVA < 6 mths• DM with end-organ
damage• Cr Cl < 80 ml/min or
proteinuria• Cancer within 10 years
Exclusion CriteriaExclusion Criteria
Drug AdministrationDrug Administration
• Intracoronary Infusion• Left and Right heart catheterizations• 10 minute infusions of bFGF into the RCA and
LM (or the major supplying bypass graft)• Intravenous Infusion
• Left heart catheterization (if not done within 6 mths)
• 10 minute infusion into a peripheral vein
• Intracoronary Infusion• Left and Right heart catheterizations• 10 minute infusions of bFGF into the RCA and
LM (or the major supplying bypass graft)• Intravenous Infusion
• Left heart catheterization (if not done within 6 mths)
• 10 minute infusion into a peripheral vein
Follow-Up ProtocolFollow-Up Protocol
• Clinic visits with routine blood tests at day 6,
day 14 and at 1, 2, 6 and 12 months
• Repeat stress test and MRI scans at 1 month
• Subsequent exams only if indicated
• Repeat Eye exams at 2 and 12 months
• Repeat Quality of Life questionnaire at 2
months
• Clinic visits with routine blood tests at day 6,
day 14 and at 1, 2, 6 and 12 months
• Repeat stress test and MRI scans at 1 month
• Subsequent exams only if indicated
• Repeat Eye exams at 2 and 12 months
• Repeat Quality of Life questionnaire at 2
months