Efficacy and Safety of Targeted Intramyocardial Delivery of Auto CD34+ Stem Cells for Improving Exercise Capacity in Subjects With Refractory Angina (RENEW)

• Angina Frequency (Episodes Per Week) at the 12 Month Follow-up Visit [ Time Frame: Baseline and 12 month visit ]
  Participants self-reported angina episodes utilizing an electronic diary for 4 weeks at baseline (screening period) and in the 4 weeks before the 3, 6 and 12 month follow-up visits.
• Change From Baseline in Total Exercise Time on Exercise Tolerance Test (ETT) at the 6 Month Follow-up Visit [ Time Frame: Baseline and 6 month visit ]
  Baseline (BL) is the average of the two total exercise times measured during the screening period.
• Angina Frequency (Episodes Per Week) at the 6 Month Follow-up Visit [ Time Frame: 6 month visit ]
• Percentage of Participants With Incidences of MACE From Randomization Until the End of the 24 Month Follow-up Period [ Time Frame: From randomization until the end of the 24 month follow-up period ]

  Major adverse cardiac events (MACE) defined as death, cardiac hospitalization, non-fatal myocardial infarction and stroke, as adjudicated by an independent clinical endpoint classification (CEC) committee.

  The category Total MACE includes death, cardiovascular hospitalization, myocardial infarction or stroke.

• Percentage of Participants With at Least One Serious Adverse Event (SAE) From Randomization Until the End of the 24 Month Follow-up Period [ Time Frame: From randomization until the end of the 24 month follow-up period ]

• Angina frequency (episodes per week) [ Time Frame: 12 months ]
  Subjects will self-report angina episodes utilizing an electronic diary for 4 weeks at baseline and before the 3, 6 and 12 month follow-up visit.
• Change from baseline in total exercise time on ETT at the 6 month follow-up timepoint [ Time Frame: 6 months ]
• Angina frequency (episodes per week) at the 6 month follow-up timepoint [ Time Frame: 6 months ]
• Incidence of major adverse cardiac events and other serious adverse events in all subjects [ Time Frame: 24 months ]

• Chronic Myocardial Ischemia
• Refractory Angina Pectoris
• Advanced Coronary Heart Disease

• Biological: Auto-CD34+ cells
  10 intramyocardial injections of 0.2 mL per injection site of Auto-CD34+ cells
• Biological: Placebo: Diluent used to suspend Auto-CD34+ cells
  10 intramyocardial injections of 0.2 mL per injection site of placebo
• Other: Standard of care
  Standard of care for refractory angina

• Experimental: Treatment Arm
  Targeted intramyocardial delivery of 1 x 10^5 Auto-CD34+ cells after granulocyte-colony stimulating factor (G-CSF) mobilization and apheresis
  Intervention: Biological: Auto-CD34+ cells
• Placebo Comparator: Active Control Arm
  Targeted intramyocardial delivery of placebo after G-CSF mobilization and apheresis
  Intervention: Biological: Placebo: Diluent used to suspend Auto-CD34+ cells
• Unblinded Standard of Care (SOC) Arm
  No study-related procedures will be performed.
  Intervention: Other: Standard of care

• Povsic TJ, Henry TD, Traverse JH, Fortuin FD, Schaer GL, Kereiakes DJ, Schatz RA, Zeiher AM, White CJ, Stewart DJ, Jolicoeur EM, Bass T, Henderson DA, Dignacco P, Gu Z, Al-Khalidi HR, Junge C, Nada A, Hunt AS, Losordo DW; RENEW Investigators. The RENEW Trial: Efficacy and Safety of Intramyocardial Autologous CD34(+) Cell Administration in Patients With Refractory Angina. JACC Cardiovasc Interv. 2016 Aug 8;9(15):1576-85. doi: 10.1016/j.jcin.2016.05.003.
• Povsic TJ, Junge C, Nada A, Schatz RA, Harrington RA, Davidson CJ, Fortuin FD, Kereiakes DJ, Mendelsohn FO, Sherman W, Schaer GL, White CJ, Stewart D, Story K, Losordo DW, Henry TD. A phase 3, randomized, double-blinded, active-controlled, unblinded standard of care study assessing the efficacy and safety of intramyocardial autologous CD34+ cell administration in patients with refractory angina: design of the RENEW study. Am Heart J. 2013 Jun;165(6):854-861.e2. doi: 10.1016/j.ahj.2013.03.003. Epub 2013 Apr 19.

Main Inclusion Criteria:

• Male or female participants who are 21 to 80 years of age at the time of signing the informed consent.
• Participants with Canadian Cardiovascular Society (CCS) class III or IV chronic refractory angina.
• Participants without control of their angina symptoms in spite of maximal tolerated doses of anti-angina drugs. Participants must be on optimal therapy for their angina and must have been on a stable anti-anginal medication regimen for at least 4 weeks before signing the informed consent form.
• Participants with obstructive coronary disease unsuitable for conventional revascularization due to unsuitable anatomy or comorbidity as determined at the site and confirmed by an independent adjudication committee.
• Participants must have evidence of inducible myocardial ischemia.
• Participants must experience angina episodes.
• Participants must be able to complete 2 exercise tolerance tests on the treadmill within 3 weeks of randomization.
• If female of childbearing potential, subject must not be pregnant and agree to employ adequate birth control measures for the duration of the study.

Main Exclusion Criteria:

• Cardiovascular hospitalization within 60 days prior to potential study enrollment. Participant has had a successful or partially successful coronary artery bypass graft (CABG) within 6 months or PCTA within 60 days of potential study enrollment.
• Participant has had a placement of a bi-ventricular pacemaker for cardiac resynchronization therapy (CRT) for heart failure within 180 days of potential study enrollment.
• Participant has documented stroke or transient ischemic attacks (TIAs) within 60 days of potential study enrollment.
• Participant has a history of moderate to severe aortic stenosis; or severe aortic insufficiency; or severe mitral stenosis; or severe mitral insufficiency.
• Participant has a prosthetic aortic valve or a mechanical mitral valve replacement.
• Participant has severe co-morbidity associated with a reduction in life expectancy to less than 3 years as a result of chronic medical illnesses.

• Participants with cancer are excluded with the following exceptions:

  • Subjects with in-situ non-melanoma skin cancer or in-situ cervical cancer are not excluded.
  • Participants that have been cancer free for >= 5 years as determined by their oncologist are not excluded. Subjects with a prior history of stem cell transplant for cancer are excluded no matter how long they have been cancer-free.
• Participants with a history of leukemia or other bone marrow disease.
• Participant has sickle cell disease or sickle cell trait.
• Participants with proliferative retinopathy.
• Participants with Hb A1c > 9%.
• Participant has platelet counts >10% above the upper limit of normal (ULN) or platelet counts < 70,000.
• Participant has a hematocrit < 30% prior to potential study enrollment.
• Participant has a serum creatinine > 2.5 mg/dL prior to potential study enrollment.
• Participant tests positive for HIV, hepatitis B, or hepatitis C, or is on chronic immunosuppressive medications, or has had a previous stem cell transplant.
• Participant has a known contraindication to Neupogen (filgrastim) or G-CSF.
• Participant was previously enrolled in an active treatment group of cell therapy trials for cardiovascular disease including any phase of CD34+ stem cell trials.
• Left ventricular (LV) thickness of < 7 mm in the target areas of injection as measured by during a 2-D echocardiogram (ECHO).
• Atrial fibrillation, atrial flutter, or other uncontrolled arrhythmias that would prohibit accurate electromechanical mapping and NOGA-guided intramyocardial injection.
• Bleeding diathesis with an INR > 1.8 when not receiving anti-thrombotic therapy.
• Hepatic dysfunction as evidenced by elevated AST or ALT levels > 2.5 x ULN.
• Any previous transplant requiring immunosuppression.
• Disease state requiring chronic immunosuppression.