Gene Therapy for Heart

Failure

Roger J. Hajjar, MD

Mount Sinai School of Medicine

Disclosures:

Celladon: Scientific Founder

Heart Failure - Continued Unmet Need

• Rising Patient Population

– > 5 million people in US

– Age related diagnosis; aging will

double incidence

– > 500,000 new cases per year

• Poor Prognosis

– 4-fold increased mortality at any age

– Average survival < four years

– Five-year survival rate of 25% in men

and 38% in women with NYHA

classes II to IV

Projected incidence of heart failure

Heart failure mortality with progression

Permanent loss of

myocytes

Undiseased

myocytes

Dysfunctional

myocytes

Hypertrophic Response

Pathologic Stress

Cell Therapy

Gene Therapy

Why Gene Therapy?

• Unmet needs using current therapies

• Advances in the understanding of the molecular

basis of heart failure & Arrhythmias

• Cardiomyocyte-specific targets have emerged

that are difficult to manipulate pharmacologically

• Increasingly efficient gene transfer technology

SERCA2a Deficiency is Central to Progression

of Heart Failure

• SERCA2a transfers 75% of Ca2+ from cytosol to SR lumen

• In both experimental models and human HF, SERCA2a deficiency results in

abnormal Ca2+ handling and a deficient contractile state

• In animal models, restoration of SERCA2a activity via gene transfer rescues

contractile deficit – J Am Coll Cardiol. 2008;51:1112-1119; J Mol Cell Cardiol. 2007;42:852-861; Byrne M, et.al. Gene Ther. (24 Jul 2008);[DOI:

10.1038/gt.2008.120]

Pharmacological Targeting of

SERCA2a/Phospholamban Has Failed • Search for small molecules targeting SERCA2a has not

yielded specific, non-toxic compounds

– Multiple significant efforts abandoned by large pharma & biotechnology companies

• Antibodies to phospholamban have been tried but have had no effect in vivo: intracellular protein

The Challenges

• Safe vectors

• Homogeneous transduction of the

cardiomyocytes

• Long-term expression

• Cardiac specificity

• Effective and minimally invasive techniques

of delivery

Choice of Vectors

Modes of Delivery

Immune Response

Clinical Trials

Targeting by Gene Therapy

AAV Vectors

• Safe vectors

• Long-term expression

• Cardiac specificity

• Minimal Immune

Reaction at low doses

AAV2/1.SERCA2a DNA: Vector

Genome

• AAV2 ITRs flanking expression cassette

• <300 nucleotides of non-coding AAV DNA

ITR CMV huSERCA2a ITR INTRON

4486 bp 1

BGHpA

Modes of Delivery

• Surgical Technique

– Gene Transfer During Bypass

• Catheter Based Techniques

– Extracoporeal Re-Circulating System (V-Focus™)

– Retrograde Perfusion

– Antegrade Epicardial Coronary Artery Infusion (AECAI)

Antegrade Injection

Immune Response following AAV

Gene Transfer

• Neutralizing Antibodies to specific AAV

serotype

• T cell (CD8+) response

These Patients Would

Need to be Excluded in

Clinical Trials of Gene Therapy

Especially at Low Doses of AAV

NAB in Patients with Heart Failure

0

10

20

30

40

50

60

70

80

1 2 3 4 5 6 7

% P

ati

en

ts

AAV1

AAV6

<1/4 1/8 1/16/ 1/32 1/64 1/128 1/256

Adapted from K. High

Potential for T-cell response

• Cells may transiently express AAV1 capsid protein on their cell surface.

• T-cell response could theoretically occur in any organ but highest concern for liver (MHC molecules, RES clearance) or heart (site of injection).

• In the clinical trials, to evaluate potential development of a T-cell response, a novel assay will be used: ELISPOT assay for anti-AAV1 capsid T cell responses (IFN- release when patient’s PBMCs are exposed to capsid peptide).

CLINICAL TRIALS :

AAV.SERCA2a Completed :

• CUPID Trial Phase 1 & Phase 2: Class III/IV patients with heart

failure received different doses of AAV1.SERCA2a by

percutaneous delivery. Phase 1 (12 patients), Phase 2

enrollment completed (39 patients). Phase 3, Q1 2011.

To Start Enrolling:

• Patients undergoing LVAD insertion as destination-therapy or bridge to

transplant will receive AAV6.SERCA2a one month after VAD

placement 5x1012 drp (8 patients) and saline (8 patients).

(Harefield/Papworth, UK)

• Class III/IV heart failure patients will receive AAV6.SERCA2a vs saline

and LV function will be followed by multi-imaging modalities (Pitie-

Salpetriere, France)

Calcium Up-Regulation by Percutaneous Administration of Gene

Therapy In Cardiac Disease (CUPID Trial)

Phase 1 & 2 Trial of Intracoronary Administration of AAV1.SERCA2a in Class III/IV Heart Failure

Phase 1: Open-Label, Sequential Dose Escalation

1.4x1011, 6x1011, 3x1012, 1x1013 drp N=12 (3:3:3:3)

Phase 2: Randomized, Double-Blind, Placebo Controlled.

6x1011, 3x1012, 1x1013 drp, & saline N=39 (8:8:9:14)

Study Schema

Long-Term

Follow-Up

Semi-Annual

Phone

Questionnaire

for 2 years

Observe 12 Months

Weeks 1, 2, 3, 4, 5 & 6

Months 2, 3, 6, 9 & 12

Placebo

MYDICAR® Low

6 X 1011 DRP

(~8.6 X 109 DRP/kg)

MYDICAR® Mid

3 X 1012 DRP

(~4.3 X 1010 DRP/kg)

MYDICAR® High

1 X 1013 DRP

(~1.4 X 1011 DRP/kg)

N=8

N=8

N=9

N=14

R

A

N

D

O

M

I

Z

E

≤30

days

S

C

R

E

E

N

Primary Analysis

at Month 6

22

Administration via Percutaneous

Intracoronary Artery Infusion

• Gene delivery to viable myocardium

– Dominance and coronary artery anatomy

from angiography determines infusion

scenario

• Antegrade epicardial coronary artery

infusion over 10 minutes

– 60 mL divided into 1, 2 or 3 infusions

depending on anatomy

– Delivered via commercially available

angiographic injection system & guide or

diagnostic catheters

Time-to-Clinical Events Analysis; Multiple Events

per Subject

• Clinical events: – Worsening Heart Failure (WHF), MI and Silent MI, HF-related

hospitalizations, All-Cause Death, LVAD, Transplant

• Observation period ends either at death or at

Month 6

• Analysis pre-specified in statistical analysis plan

(SAP)

Baseline Patient Characteristics

Characteristic All Subjects

N=39

Age, years, mean (SD) 60.5 (11.5)

Sex, n 34 Male

Race, n 34 White

HF Etiology, n (%)

Ischemic cardiomyopathy 19 (48.7)

Idiopathic cardiomyopathy 14 (35.9)

Hypertensive cardiomyopathy* 4 (10.3)

Other 3 (7.7)

Baseline Patient Characteristics

Characteristic All Subjects

N=39

Co-Morbidities, n (%)

Diabetes 13 (33.3)

Hypertension 25 (64.1)

Atrial Arrhythmia* 17 (43.6)

Coronary Artery Disease 24 (61.5)

Myocardial Infarction 21 (53.8)

HF Regimen, n (%)

ACE Inhibitor / Angiotensin Antagonist 36 (92.3%)

Aldosterone Antagonist 17 (43.6)

Beta-Blocker 35 (89.7)

Diuretic 37 (94.9)

Other Concomitant Therapy, n (%)

Digoxin Therapy 21 (53.9)

Antithrombotic Therapy** 34 (87.1)

* Includes atrial fibrillation, atrial flutter, atrial tachycardia, sick sinus syndrome and paroxysmal suptraventricular tachycardia

** Warfarin, aspirin and/or clopidogrel

Baseline Patient Characteristics

Characteristic All Subjects

N=39

6MWT, m, mean (SD) 343 (124)

VO2max*, mL/kg/min, mean (SD) 13.9 (3.9)

LVEF, %, mean (SD) 25 (7)

LVESV, mL, mean (SD) 202 (91)

NYHA Class III, n (%) 39 (100)

MLWHFQ, mean (SD) 46 (22)

NT-proBNP, pg/mL, mean (SD) 2932 (3028)

Creatinine, mg/dL, mean (SD) 1.34 (0.53)

0 30 60 90 120 150 180

Pro

po

rtio

n W

ith

ou

t C

lin

ica

l E

ve

nt

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

Placebo (N=14)

MYDICAR Low Dose (N=8)

MYDICAR Mid-Dose (N=8)

MYDICAR High Dose (N=9)

Time to Multiple Clinical Events

by Treatment Group at 6 Months

p=0.048

p=0.040

p=0.13

Hazard Ratio (CI) vs Placebo

High 0.50 (0.026, 0.497) Risk Reduction 50%

Mid 0.65 (0.38, 1.13) Risk Reduction 35%

Low 0.14 (0.02, 0.98) Risk Reduction 86%

Days of Observation

Placebo

Time to Multiple Clinical Events

HF LVAD Transplant Chronic Inotrope

Months 2 4 6 8 10 12

Death

AAV1.SERCA2a Mid

MI

//

AAV1.SERCA2a Low

// //

AAV1.SERCA2a High

Placebo

//

NAb+

Cumulative Clinical Event Rates Adjusted for Competing Risk of

Terminal Events

AAV1.SERCA2a Low Dose

AAV1.SERCA2a Mid Dose

AAV1.SERCA2a High Dose

Days of CV-related Hospitalization

* 0.05 < p <0.1 (High vs Placebo)

Months

6 9 12

Mea

n (

SE

) D

ays

in

Ho

sp

ital

0

2

4

6

8

10

12

14

16

P (N=14) L (N=8) M (N=8) H (N=9)

* *

NT-ProBNP

Biomarker Domain

Low Mid High Placebo

Me

an

(S

E)

Ch

an

ge

Fro

m B

as

eli

ne

(p

g/m

L)

-2000

0

2000

4000

6000

8000

10000

12000

14000

16000

1 1 1

1

2 2 2

2 3

3 3

3

6

6 6

6

9

9

9

9

12

12

12

12

P (N=14) L (N=8) M (N=8) H (N=9)

6 Minute Walk Test Functional Domain

Low Mid High Placebo

Me

an

(S

E)

Ch

an

ge

Fro

m B

as

eli

ne

(m

)

-250

-200

-150

-100

-50

0

50

100

3 3 3 3

6

6 6

6 9 9

9

9 12

12

12

12

* 0.05 < p < 0.1 (High vs Placebo)

*!

P (N=14) L (N=8) M (N=8) H (N=9)

Quality of Life: MLWHFQ Symptomatic Domain

Low Mid High Placebo

Me

an

(S

E)

Ch

an

ge

Fro

m B

as

eli

ne

-20

-10

0

10

20

30

40

1

1 1 1 3

3 3

3 6

6

6 6

9 9

9

9 12

12

12 12

P (N=14) L (N=8) M (N=8) H (N=9)

Left Ventricular Ejection Fraction Remodeling Domain

Low Mid High Placebo

Me

an

(S

E)

Ch

an

ge

Fro

m B

as

eli

ne

(%

)

-10

-8

-6

-4

-2

0

2

4

6

12

12

12

12

9 9

9

9

6 6

6

6

3

3

3

3 1 1

1

1

* 0.05 < p < 0.1 (High vs Placebo)

*!

P (N=14) L (N=8) M (N=8) H (N=9)

Left Ventricular End Systolic Volume Remodeling Domain

Low Mid High PlaceboMe

an

(S

E)

Ch

an

ge

Fro

m B

ase

lin

e (

mL

)

-40

-20

0

20

40

60

80

100

120

1

1 1 1

3

3 3 3

6

6

6

6 9

9

9

9 12

12

12

12

* *

* 0.05 < p < 0.1 (High vs Placebo)

P (N=14) L (N=8) M (N=8) H (N=9)

AAV1.SERCA2a

Clinical and Safety Results Support Phase 3

As of 5/17/11 (Including Long-term Follow-up)

• 8 Deaths in Phase 2 trial (No clinical holds)

– 4 in Placebo

– 3 in Low Dose

– 1 in Mid Dose

Through 12 months on study:

• No findings for changes over time between groups for:

– Symptomatic CTL response against AAV1 capsid proteins via

ELISPOT

– Cardiac enzymes

– Serum Chemistries and Hematology

– Vitals

– Heart Rate

• No new findings compared to baseline for interrogation of ICDs and ECG

Reduction in Heart Failure Clinical Events in High Dose

Group Sustained Through Month 18 (LTFU Events Were not Adjudicated )

WHF LVAD Transplant Chronic Inotrope Death

MYDICAR Mid

MI

//

MYDICAR Low

MYDICAR High

Placebo

NAb+

Months

1 6 12 18 24 30 36

011007

011009

011011

011013

041007

051001

081011

141001

151001

161001

211001

241006

241008

251002

131002

091009

081012

031005

121001

081010

041002

011006

031004

041003

041004

051002

081006

081007

151003

241001

011008

011010

091010

161003

181001

181003

201002

241004

251004

All Patients through Mo 18 in LTFU

as of May 18

CUPID SUMMARY

• In this phase 2 study of patients with advanced HF,

AAV1.SERCA2a was found to be safe and

associated with benefit in the following:

– Clinical outcomes

– Symptoms

– Functional Status

– Biomarkers

– Cardiac Structure

• These encouraging results support phase 3 studies

to advance AAV1.SERCA2a towards registration for

advanced HF.

Pre-Clinical

Efficacy Dose

AAV1.SERCA2a

Cohort 1

Dose of

CUPID

Phase 1

AAV1.LPL

ELISPOT+

No CPK elevation High Dose of

AAV1.SERCA2a

in CUPID

AAV1.LPL

ELISPOT+

+ CPK elevation

Loss of

Transgene

AAV2.FIX

ELISPOT+

+ LFTs elevation

AAV2.FIX

ELISPOT+

Intrahepatic + LFTs

Loss of Transgene

AA

V D

ose v

g

1014

1013

1012

1011

1010

Should Higher

Doses of

AAV1.SERCA2a

be Used?

CUPID Pre-Screen Anti-AAV1 Antibody Results

≈50% Heart Failure Patients Qualify

N=509

<1:2

n=244

≥1:16

n=160

1:2

n=36

1:4

n=30

1:8 n=36

Percent by NAb Titer

49%

7%

6%

7%

31%

<1:2

1:2

1:4

1:8

≥ 1:16

Plasmapharesis to Remove NAbs Prior to

AAV1.SERCA2a Infusion

• Plasmapharesis for anti-AAV1

NAb

• Plasma is continuously prepared

under appropriate anticoagulation

and is pumped alternating through

the adsorbers, where the

antibodies are bound by the

ligands.

• The plasma volume to be treated

depends on the indication

• Potentially can reduce antibody

titers 15-20 fold

Designer AAV Vectors

• Highly Tropic for Cardiac Muscle

• Highly Efficient in Primate & Human Cardiac Myocytes

• Has very little/no tropism to liver, lungs, spleen, kidneys.

• NO Antecedent Neutralizing Antibodies

Novel Vectors:

DNA Shuffling and Directed Evolution

AAVMUT111 Resistant to Antecedent

NABs

0

10

20

30

40

50

60

70

80

1 2 3 4 5 6 7

% P

ati

en

ts

AAVMUT 111

AAV1

<1/4 1/8 1/16/ 1/32 1/64 1/128 1/256

90

100

FDA

RAC

DSMB

Discovery

Target

Identification

Target

Validation

Lead

Optimization

Preclinical

Studies

Biology of

Heart Failure

Vector

Development

Gene/Cell

Delivery

Imaging

Modalities

Animal

Models

Genomics/

Proteomics

Translation of SERCA2a as a Target to Clinical Trials

Other Indications for SERCA2a

Gene Transfer

• Diastolic Dysfunction

• Pulmonary Hypertension

• AV Fistula closure

• Muscular Dystrophy

Thank you for your attention