Prevention of progressive heart failure

Abstract

The present disclosure relates to methods for preventing progressive heart failure in a subject with persistent left ventricular (LV) dysfunction. Such methods may also be used to treat or prevent progressive heart failure in subjects having proximal left anterior descending branch (LAD) lesions and persistent left ventricular dysfunction.

Description

[0001] This application is a divisional application of Chinese Patent Application No. 201580070480.1, filed on December 22, 2015, entitled "Prevention of Progressive Heart Failure". TECHNICAL FIELD

[0002] The present disclosure relates to methods for preventing progressive heart failure in subjects with persistent left ventricular (LV) dysfunction. Such methods can also be used to treat or prevent progressive heart failure in subjects with a proximal left anterior descending (LAD) lesion and persistent left ventricular dysfunction. BACKGROUND

[0003] Myocardial infarction (MI) remains one of the leading causes of mortality and morbidity in developed countries. A recent update of the United States Medicare records has been published that evaluated data from 350,509 acute MI hospitalizations involving patients >65 years of age who were alive at discharge after their event (Schuster et al. (2004) Physiol Heart Circa Physiol., 287(2):525-32). Within the first year after the index event, 25.9% of MI patients died and 50.5% were re-hospitalized. The likelihood of death was 21-fold higher and the likelihood of hospitalization was 12-fold higher in the month after MI than in the general Medicare age population.

[0004] Patients with larger infarcts and more post-infarction LV dysfunction after MI are at a significantly increased risk of experiencing a medium- to long-term cardiac event and death. Specifically, subjects with anterior infarction, larger infarction, and more LV dysfunction in the post-infarction period are at a significantly increased risk of experiencing a medium- to long-term cardiac event and death (Eitel et al. (2010) J Am Coll Cardiol., 55:2470-9).

[0005] Infarcts due to proximal LAD obstruction continue to be a major risk factor for progressive LV dilation, remodeling, and symptomatic progressive heart failure. The 3-year mortality rate after MI is still highest for proximal LAD lesions (10% versus 3% for distal LAD) at the late angiographic stage (Elsman et al. (2006) Am J Cardiol., 97(8): 1137-41), and this is most likely due to the large 40% infarct size associated with this anatomic lesion (Elsman et al. (2006) Am J Cardiol., 97(8): 1137-41). Since infarct size > 18.5% has been shown prospectively to result in a 30% incidence of heart failure-related major adverse cardiac events (HF-MACE, defined as heart failure hospitalization or death) within 2 years (Wu et al. (2008) Heart, 94:730-736), this indicates that the MI patient population with proximal LAD lesions, low ejection fraction, and large infarct are at highest risk for subsequent HF-MACE.

[0006] Clearly, there is a need in the art for treating or preventing progressive heart failure. SUMMARY

[0007] The present disclosure is based on the unexpected identification of a population of myocardial infarction (MI) subjects who respond well to stem cell therapy. A large number of MI subjects with elevated troponin or CK-MB (> 4x upper limit of normal (ULN)), regional cardiac wall abnormalities, and depressed global left ventricular systolic function (less than or equal to 45% and greater than or equal to 20%) (as determined on screening cardiac imaging performed within about 24 hours of MI) were administered stem cell or placebo therapy shortly after MI.

[0008] The present inventors found that global left ventricular systolic function returned to normal levels in most of these subjects about 5 days after MI. Administration of stem cell therapy did not provide a therapeutic improvement over placebo therapy in these subjects.

[0009] Surprisingly, administration of stem cell therapy provided a significant therapeutic improvement over placebo therapy in subjects with proximal left anterior descending (LAD) artery lesions. These results indicate that stem cell therapy can be used to treat or prevent progressive heart failure in a subset of MI subjects, particularly MI subjects with proximal LAD lesions.

[0010] Thus, in one example, the present disclosure provides a method of treating or preventing progressive heart failure in a myocardial infarction subject, the method comprising administering to the subject a population of mesenchymal lineage precursor cells or stem cells and / or progeny thereof and / or soluble factors derived therefrom, wherein the subject has a proximal left anterior descending (LAD) lesion. Thus, in one example, the present disclosure provides a method of treating or preventing progressive heart failure in a myocardial infarction subject, the method comprising administering to the subject a population of mesenchymal lineage precursor cells or stem cells and / or progeny thereof and / or soluble factors derived therefrom, wherein the subject has a proximal left anterior descending (LAD) lesion.

[0011] In another example, the method comprises the steps of: i) selecting a subject having a proximal left anterior descending branch (LAD) lesion, and ii) administering to the subject a population of mesenchymal lineage stem or precursor cells and / or progeny thereof and / or soluble factors derived therefrom.

[0012] The inventors have also identified that subjects with proximal LAD lesions that respond well to stem cell therapy also have persistent low ejection fraction about 5 days after MI. These results indicate that the methods of the disclosure can also be used to treat or prevent progressive heart failure in subjects with proximal LAD lesions and persistent low ejection fraction.

[0013] Thus, in another example, the disclosure provides a method of treating progressive heart failure in a myocardial infarct subject, the method comprising administering to the subject a population of mesenchymal lineage precursor cells or stem cells and / or progeny thereof and / or soluble factors derived therefrom, wherein the subject has a proximal left anterior descending branch (LAD) lesion and has persistent left ventricular dysfunction.

[0014] In one example, the subject also has an elevated left ventricular end systolic volume (LVESV) greater than 70 mL. In one example, the LVESV is greater than 80 mL, greater than 90 mL, greater than 100 mL, greater than 110 mL, or greater than 120 mL. In another example, the LVESV is greater than 80 mL / m 2 , greater than 90 mL / m 2 , greater than 100 mL / m 2 , greater than 110 mL / m 2 , or greater than 120 mL / m 2 .

[0015] In one example, the subject has a left ventricular ejection fraction (LVEF) less than about 55%. In another example, the subject has a LVEF less than about 45%. In another example, the subject has a LVEF less than about 40%. In one example, the LVEF is measured by cardiovascular magnetic resonance imaging (cMR).

[0016] The inventors have also identified that timing of administration after MI can also benefit the subject. Thus, in one example, the mesenchymal lineage precursor cells or stem cells and / or progeny thereof and / or soluble factors derived therefrom are administered about 1-7 days after myocardial infarction. In one example, the mesenchymal lineage precursor cells or stem cells and / or progeny thereof and / or soluble factors derived therefrom are administered about 2-7 days after myocardial infarction. In another example, the mesenchymal lineage precursor cells or stem cells and / or progeny thereof and / or soluble factors derived therefrom are administered about 3-5 days after myocardial infarction.

[0017] The present inventors have also characterized a population of subjects who can benefit from the methods of the disclosure based on the level of serum biomarkers relative to the upper limit of normal (ULM). In one example, the subject has greater than about 2x the upper limit of normal for creatine kinase-MB and / or troponin. In another example, the subject has greater than about 4x the upper limit of normal for creatine kinase-MB and / or troponin and / or myoglobin.

[0018] The present inventors have also characterized a population of subjects who can benefit from the methods of the disclosure based on infarct size. In one example, the subject has an infarct size of about 10-25 % left ventricle. In another example, the subject has an infarct size of greater than about 18.5 % left ventricle. In one example, infarct size is measured by cMR.

[0019] In another example, the methods of the disclosure comprise administering a population of cells enriched for mesenchymal lineage precursor cells or stem cells and / or progeny thereof and / or soluble factors derived therefrom. + In another example, the methods of the disclosure comprise administering a population of cells enriched for mesenchymal lineage precursor cells or stem cells and / or progeny thereof and / or soluble factors derived therefrom.

[0020] In another example, the methods of the disclosure comprise administering a population of cells enriched for mesenchymal lineage precursor cells or stem cells and / or progeny thereof and / or soluble factors derived therefrom. 亮 In another example, the methods of the disclosure comprise administering a population of cells enriched for mesenchymal lineage precursor cells or stem cells and / or progeny thereof and / or soluble factors derived therefrom.

[0021] In one example, the population of mesenchymal lineage precursor cells or stem cells express tissue non-specific alkaline phosphatase (TNAP) and / or the progeny cells and / or soluble factors are derived from mesenchymal lineage precursor cells or stem cells that express TNAP.

[0022] In one example, the population of mesenchymal lineage precursor cells or stem cells express angiopoietin-1 (Ang1) in an amount of at least 0.1 pg / 10 6 In one example, the population of mesenchymal lineage precursor cells or stem cells express Ang1 in an amount of at least 0.5 pg / 10 6 In one example, the population of mesenchymal lineage precursor cells or stem cells express Ang1 in an amount of at least 0.7 pg / 10 6 In one example, the population of mesenchymal lineage precursor cells or stem cells express Ang1 in an amount of at least 0.7 pg / 10 6 In one example, the population of mesenchymal lineage precursor cells or stem cells express Ang1 in an amount of at least 0.7 pg / 10 6 In one example, the population of mesenchymal lineage precursor cells or stem cells express Ang1 in an amount of at least 0.7 pg / 10

[0023] In one example, the population of mesenchymal lineage precursor cells or stem cells expresses VEGF in an amount less than about 0.05 pg / 10 6 In one example, the population of mesenchymal lineage precursor cells or stem cells expresses VEGF in an amount less than about 0.05 pg / 10 6 In one example, the population of mesenchymal lineage precursor cells or stem cells expresses VEGF in an amount less than about 0.05 pg / 10 6 In one example, the population of mesenchymal lineage precursor cells or stem cells expresses VEGF in an amount less than about 0.05 pg / 10

[0024] In one example, the population of mesenchymal lineage precursor cells or stem cells expresses Ang1 :VEGF in a ratio of at least about 2: 1 and / or the progeny cells and / or soluble factors are derived from mesenchymal lineage precursor cells or stem cells that express Ang1 :VEGF in a ratio of at least about 2: 1. In one example, the population of mesenchymal lineage precursor cells or stem cells expresses Ang1 :VEGF in a ratio of at least about 10: 1. In one example, the population of mesenchymal lineage precursor cells or stem cells expresses Ang1 :VEGF in a ratio of at least about 20: 1. In one example, the population of mesenchymal lineage precursor cells or stem cells expresses Ang1 :VEGF in a ratio of at least about 30: 1.

[0025] In one example, the population of mesenchymal lineage precursor cells or stem cells and / or progeny cells thereof and / or soluble factors derived therefrom are administered systemically. In one example, the population of mesenchymal lineage precursor cells or stem cells and / or progeny cells thereof and / or soluble factors derived therefrom are administered intravenously, intramuscularly, or intranasally. For example, the population of mesenchymal lineage precursor cells or stem cells and / or progeny cells thereof and / or soluble factors derived therefrom can be administered intravenously.

[0026] In one example, a plurality of doses of the population of mesenchymal lineage precursor cells or stem cells and / or progeny cells thereof and / or soluble factors derived therefrom are administered.

[0027] In one example, the methods of the present disclosure comprise administering 1 x 10 6 to 8 x 10 8 In one example, the methods of the present disclosure comprise administering 1.2 x 10 8 to 4 x 10 8 In one example, the methods of the present disclosure comprise administering at least about 1.5 x 10 8 In one example, the methods of the present disclosure comprise administering at least about 1.5 x 10

[0028] In one example, the population of cells and / or progeny cells are autologous or allogeneic and / or the soluble factors are derived from autologous or allogeneic cells.

[0029] In one example, the population of mesenchymal lineage precursor cells or stem cells and / or progeny thereof and / or soluble factors derived therefrom have been cultured prior to administration and / or prior to obtaining the soluble factors.

[0030] In one example, the mesenchymal lineage precursor cells or stem cells and / or progeny thereof and / or soluble factors derived therefrom are administered in the form of a composition comprising the mesenchymal lineage precursor cells or stem cells and / or progeny thereof and / or soluble factors derived therefrom and a carrier and / or excipient. For example, the composition can comprise a cryoprotectant.

[0031] Thus, in one example, the disclosure relates to a population of mesenchymal lineage precursor cells or stem cells and / or progeny thereof and / or soluble factors derived therefrom for use in treating or preventing progressive heart failure in a subject with myocardial infarction (MI), wherein the subject has a proximal left anterior descending (LAD) artery lesion. In another example, the disclosure relates to use of a population of mesenchymal lineage precursor cells or stem cells and / or progeny thereof and / or soluble factors derived therefrom in the manufacture of a medicament for treating or preventing progressive heart failure in a subject with myocardial infarction (MI), wherein the subject has a proximal left anterior descending (LAD) artery lesion. In these examples, the subject can have persistent left ventricular dysfunction. For example, the subject can have an LVEF of less than about 55%. In another example, the subject has an LVEF of less than about 45%. In another example, the subject has an LVEF of less than about 40%. In these examples, the mesenchymal lineage precursor cells or stem cells and / or progeny thereof and / or soluble factors derived therefrom can be administered about 1-7 days after myocardial infarction. For example, the mesenchymal lineage precursor cells or stem cells and / or progeny thereof and / or soluble factors derived therefrom are administered about 3-5 days after myocardial infarction. In these examples, the subject can have greater than about 2x upper limit of normal for creatine kinase-MB and / or troponin. In another example, the subject has greater than about 4x upper limit of normal for creatine kinase-MB and / or troponin and / or myoglobin. In these examples, the subject can have an infarct size of about 10-25 % left ventricle. In another example, the subject can have an infarct size of greater than about 18.5 % left ventricle. In these examples, LVEF or infarct size can be measured by cMR. SUMMARY

[0032] Figure 1 : Comparison of placebo and remestemcel-L treatment groups - Baseline.

[0033] Figure 2 : Comparison of placebo and remestemcel-L treatment groups - Change from baseline at Month 6.

[0034] Figure 3 : Comparison of placebo and remestemcel-L treatment groups - patients with less than -10 ml change in left ventricular end diastolic volume after 6 months. Change from baseline measured.

[0035] Figure 4 : Change in LVESV values at 6 months in placebo (control) and subjects administered MPC (150 million cells) stratified according to LVESV greater than 70 mL.

[0036] Figure 5 : Change in LVESV values at 6 months in placebo (control) and subjects administered MPC (150 million cells) stratified according to LVESV greater than 80 mL.

[0037] Figure 6 : Change in LVESV values at 6 months in placebo (control) and subjects administered MPC (150 million cells) stratified according to LVESV greater than 90 mL.

[0038] Figure 7 : Change in LVESV values at 6 months in placebo (control) and subjects administered MPC (150 million cells) stratified according to LVESV greater than 100 mL.

[0039] Figure 8 : Change in LVESV values at 6 months in placebo (control) and subjects administered MPC (150 million cells) stratified according to LVESV greater than 110 mL.

[0040] Figure 9 : Change in LVESV values at 6 months in placebo (control) and subjects administered MPC (150 million cells) stratified according to LVESV greater than 120 mL. DETAILED DESCRIPTION

[0041] General techniques and definitions

[0042] Unless specifically defined otherwise, all technical and scientific terms used herein shall be taken to have the same meaning as commonly understood by one of ordinary skill in the art (e.g., in molecular genetics, molecular biology, cell culture, stem cell differentiation, immunology, immunohistochemistry, protein chemistry, and biochemistry).

[0043] The stem cell, cell culture, and surgical techniques used in the present disclosure are standard procedures known to those of skill in the art unless otherwise indicated. These techniques are described and explained throughout the literature in sources such as J. Perbal, A Practical Guide to Molecular Cloning, John Wiley and Sons (1984); J. Sambrook et al., Molecular Cloning: A Laboratory Manual, Cold Spring Harbour Laboratory Press (1989); T.A. Brown (ed.), Essential Molecular Biology: A Practical Approach, Volumes 1 and 2, IRL Press (1991); D.M. Glover and B.D. Hames (eds), and F.M. Ausubel et al. (eds.), Current Protocols in Molecular Biology, Greene Pub. Associates and Wiley-Interscience (1988 including all updates until present); Ed Harlow and David Lane (eds), Antibodies: A Laboratory Manual, Cold Spring Harbour Laboratory, (1988); and J.E. Coligan et al. (eds), Current Protocols in Immunology, John Wiley & Sons (including all updates until present).

[0044] Throughout this specification, unless specifically stated otherwise or the context requires otherwise, reference to a single step, composition of matter, group of steps or group of compositions of matter shall be taken to encompass one and a plurality (i.e. one or more) of those steps, compositions of matter, groups of steps or group of compositions of matter.

[0045] The scope of the present disclosure is not limited to the specific embodiments described herein, which are intended only for exemplification purposes. Functionally equivalent products, compositions and methods as described herein are obviously within the scope of the present disclosure.

[0046] Unless specifically stated otherwise, any of the examples disclosed herein shall be considered to be applicable as necessary modifications to any other example.

[0047] The term "and / or", e.g., "A and / or B" shall be understood to mean either "A and B" or "A or B" and is to be taken in its broadest context with support from both claims interpretation and grammatical guidelines.

[0048] As used herein, unless otherwise indicated, the term "about" means + / - 10%, more preferably + / - 5% of the indicated value.

[0049] Throughout this specification, the word "comprise", or variations such as "comprises" or "comprising", will be understood to imply the inclusion of a stated element, integer or step, or group of elements, integers or steps, but not the exclusion of any other element, integer or step, or group of elements, integers or steps.

[0050] Mesenchymal lineage precursor cells

[0051] As used herein, the term "mesenchymal lineage precursor cell or stem cell" refers to an undifferentiated pluripotent cell that has the capacity for self-renewal while maintaining the capacity to differentiate into multiple cell types of mesenchymal origin (e.g., osteoblasts, chondrocytes, adipocytes, stromal cells, fibroblasts, and tendons), or non-mesodermal origin (e.g., hepatocytes, neural cells, and epithelial cells). For the avoidance of doubt, a "mesenchymal lineage precursor cell" refers to a cell that can differentiate into mesenchymal cells such as bone, cartilage, muscle and fat cells, and fibrous connective tissue.

[0052] The term "mesenchymal lineage precursor cell or stem cell" includes both the parent cell and its undifferentiated progeny. The term also includes mesenchymal precursor cells, multipotent stromal cells, mesenchymal stem cells (MSCs), perivascular mesenchymal precursor cells, and their undifferentiated progeny.

[0053] Mesenchymal lineage precursor cells or stem cells can be autologous, xenogeneic, syngeneic, or isogenic. Autologous cells are isolated from the same individual into which they will be reimplanted. Allogeneic cells are isolated from a donor of the same species. Xenogeneic cells are isolated from a donor of another species. Syngeneic or isogenic cells are isolated from genetically identical organisms (e.g., twins, clones, or highly inbred research animal models).

[0054] Mesenchymal lineage precursor cells or stem cells reside primarily in bone marrow, but also appear to be present in different host tissues, including, for example, umbilical cord blood and umbilical cord, adult peripheral blood, adipose tissue, trabecular bone, and dental pulp.

[0055] In one example, the mesenchymal lineage precursor cell or stem cell is a STRO-1+ mesenchymal precursor cell. As used herein, the phrase "STRO-1+ multipotent cell" shall be taken to mean a STRO-1+ and / or TNAP+ progenitor cell capable of forming a multipotent cell colony.

[0056] STRO-1+ multipotent cells are found in bone marrow, blood, dental pulp cells, adipose tissue, skin, spleen, pancreas, brain, kidney, liver, heart, retina, brain, hair follicle, intestine, lung, lymph node, thymus, bone, ligament, tendon, skeletal muscle, dermis, and periosteum; and are capable of differentiating into lineages such as mesoderm and / or endoderm and / or ectoderm cells. Thus, STRO-1+ multipotent cells are capable of differentiating into a large number of cell types, including but not limited to adipose tissue, bone tissue, cartilage tissue, elastic tissue, muscle tissue, and fibrous connective tissue. The specific lineage commitment and differentiation pathway that these cells enter depends on various influences from institutional effects and / or endogenous bioactive factors, such as growth factors, cytokines, and / or local microenvironmental conditions established by the host tissue.

[0057] Mesenchymal lineage precursor cells or stem cells can be isolated from host tissue and enriched by selecting for STRO-1+ cells. For example, a bone marrow aspirate from a subject can be further treated with antibodies against STRO-1 or TNAP to enable selection of mesenchymal lineage precursor cells or stem cells. In one example, mesenchymal lineage precursor cells or stem cells can be enriched by using the STRO-1 antibody described in (Simmons & Torok-Storb, 1991).

[0058] The term "enriched" or variations thereof is used herein to describe a population of cells in which the proportion of a particular cell type or the proportion of a plurality of particular cell types is increased when compared to an untreated population of cells (e.g., cells in their native environment). In one example, a population enriched for STRO-1+ cells comprises at least about 0.1% or 0.5% or 1% or 2% or 5% or 10% or 15% or 20% or 25% or 30% or 50% or 75% STRO-1+ cells. In this regard, the term "a population of cells enriched for STRO-1+ cells" shall be considered to provide explicit support for the term "a population of cells comprising X% STRO-1+ cells," where X% is the percentage as described herein. In some examples, STRO-1+ cells can form clonogenic colonies, e.g., CFU-F (fibroblast) or a subset thereof (e.g., 50% or 60% or 70% or 70% or 90% or 95%) can have this activity.

[0059] In one example, the cell population is enriched from a cell preparation comprising STRO-1+ cells in a selectable form. In this regard, the term "selectable form" will be understood to mean that the cells express a marker (e.g., a cell surface marker) that allows for selection of STRO-1+ cells. The marker can be STRO-1, but need not be. For example, cells (e.g., mesenchymal precursor cells) that express STRO-2 and / or STRO-3 (TNAP) and / or STRO-4 and / or VCAM-1 and / or CD146 and / or 3G5 also express STRO-1 (and can be STRO-1bright). Thus, the indication that the cells are STRO-1+ does not mean that the cells are selected by STRO-1 expression. In one example, the cells are selected based on at least STRO-3 expression, e.g., they are STRO-3+ (TNAP+).

[0060] Reference to selection of cells or populations thereof does not necessarily require selection from a particular tissue source. As described herein, STRO-1+ cells can be selected or isolated or enriched from a very wide variety of sources. That is, in some examples, these terms provide support for selection from a tissue or vascularized tissue comprising STRO-1+ cells (e.g., mesenchymal precursor cells) or pericytes (e.g., STRO-1+ pericytes) or any one or more of the tissues described herein.

[0061] In one example, the mesenchymal lineage precursor cells or stem cells used in the present disclosure express one or more markers selected from the group consisting of TNAP+, VCAM-1+, THY-1+, STRO-2+, STRO-4+ (HSP-90β), CD45+, CD146+, 3G5+, or any combination thereof, alone or in combination.

[0062] The use of the term "alone" means that the disclosure encompasses the recited marker or group of markers alone, and although the individual marker or group of markers can not be listed individually herein, the appended claims can define such markers or groups of markers separately and divisibly from one another.

[0063] The use of the term "in combination" means that the disclosure encompasses any number or combination of the recited markers or groups of markers, and although such number or combination of markers or groups of markers can not be explicitly listed herein, the appended claims can define such combinations or subcombinations separately and divisibly from any other combination of markers or groups of markers.

[0064] In one example, the STRO-1+ cells are STRO-1 亮 (synonym STRO-1 bri ). In another example, the STRO-1+ cells are STRO-1 暗 or STRO-1中间 Cells preferentially enriched for STRO-1 bri Cells. In another example, the STRO-1 bri Cells are additionally one or more of TNAP+, VCAM-1+, THY-1+, STRO-2+, STRO-4+ (HSP-90β) and / or CD146+. For example, the cells are selected for and / or shown to express one or more of the foregoing markers. In this regard, cells shown to express a marker need not be explicitly tested, but rather cells previously enriched or isolated can be reasonably assumed to also express the same marker, subsequent uses, isolations or enrichments.

[0065] In one example, mesenchymal precursor cells are perivascular mesenchymal precursor cells as defined in WO 2004 / 85630, characterised by the presence of the perivascular marker 3G5.

[0066] Cells referred to as "positive" for a given marker can express the marker at a low (lo or dim) or high (bright, bri) level depending on the extent to which the marker is present on the cell surface, with the terms relating to the fluorescence intensity or other marker used in the cell sorting process. The distinction between lo (or dim or dull) and bri will be understood in the context of the marker used on the particular cell population being sorted. Cells referred to as "negative" for a given marker do not necessarily completely lack the marker from the cell. The term means that the marker is expressed by the cell at a relatively very low level and it produces a very low signal when detectably labelled or is not detectable above background levels, for example detected using an isotype control antibody.

[0067] As used herein, the term "bright" or "bri" refers to a marker on the surface of a cell that produces a relatively high signal when detectably labelled. While not wishing to be limited by theory, it is proposed that "bright" cells express more of the target marker protein (e.g. the antigen recognised by STRO-1) than other cells in the sample. For example, as determined by fluorescence activated cell sorting (FACS) analysis, STRO-1 暗淡 / 暗 ) compared to non-bright cells (STRO-1 bri ) when labelled with a FITC-conjugated STRO-1 antibody. In one example, "bright" cells constitute at least about 0.1% of the most brightly labelled bone marrow mononuclear cells contained in the starting sample. In other examples, "bright" cells constitute at least about 0.5%, at least about 1%, at least about 1.5% or at least about 2% of the most brightly labelled bone marrow mononuclear cells contained in the starting sample. In one example, STRO-1 亮Cells have high 2 orders of magnitude greater expression of STRO-1 surface expression relative to "background", i.e., STRO-1"cells. In contrast, STRO-1 暗淡 and / or STRO-1 中间 Cells have less than 2 orders of magnitude greater expression of STRO-1 surface expression relative to "background", typically about 1 order of magnitude or less.

[0068] As used herein, the term "TNAP" is intended to encompass all isoforms of tissue non-specific alkaline phosphatase. For example, the term encompasses the liver isoform (LAP), the bone isoform (BAP), and the kidney isoform (KAP). In one example, TNAP is BAP. In one example, as used herein, TNAP refers to a molecule that can bind to a STRO-3 antibody produced by the hybridoma cell line deposited under Accession No. PTA-7282 with the ATCC on December 19, 2005, pursuant to the terms of the Budapest Treaty.

[0069] Further, in one example, STRO-1+ cells are capable of generating clonogenic CFU-F.

[0070] In one example, a substantial proportion of STRO-1+ multipotent cells are capable of differentiating into at least two different lineages. Non-limiting examples of lineages to which the multipotent cells can be directed include bone precursor cells; liver progenitor cells that are multipotent for bile duct epithelial cells and hepatocytes; neural restricted cells that can generate glial cell precursors that progress to oligodendrocytes and astrocytes; neuronal precursors that progress to neurons; precursors of cardiac muscle and cardiomyocytes, glucose-responsive insulin secreting pancreatic beta cell lineage. Other lineages include, but are not limited to, odontoblasts, dentin-producing cells and chondrocytes, and precursor cells for retinal pigment epithelial cells, fibroblasts, skin cells such as keratinocytes, dendritic cells, hair follicle cells, kidney tubular epithelial cells, smooth and skeletal muscle cells, testis progenitor cells, vascular endothelial cells, tendon, ligament, cartilage, adipose cells, fibroblasts, bone marrow stroma, cardiac muscle, smooth muscle, skeletal muscle, pericytes, blood vessels, epithelial, glial, neuronal, astrocyte and oligodendrocyte cells.

[0071] In one aspect of the disclosure, the mesenchymal lineage precursor cells or stem cells presently described are MSCs. The MSCs can be a homogenous composition or can be a mixed cell population enriched for MSCs. Homogenous MSC cell compositions can be obtained by culturing adherent bone marrow or periosteum cells, and MSCs can be identified by specific cell surface markers identified with unique monoclonal antibodies. Methods for obtaining cell populations enriched for MSCs are described, for example, in U.S. Patent No. 5,486,359. Alternative sources of MSCs include, but are not limited to, blood, skin, umbilical cord blood, muscle, fat, bone, and periosteum.

[0072] In another example, the mesenchymal lineage precursor cells or stem cells are CD29+, CD54+, CD73+, CD90+, CD102+, CD105+, CD106+, CD166+, MHC1+ MSCs (e.g., remestemcel-L).

[0073] The isolated or enriched mesenchymal lineage precursor cells or stem cells can be expanded in vitro by culturing. The isolated or enriched mesenchymal lineage precursor cells or stem cells can be cryopreserved, thawed, and subsequently expanded in vitro by culturing.

[0074] In one example, the isolated or enriched mesenchymal lineage precursor cells or stem cells are seeded at 50,000 viable cells / cm2 2 Seeded in culture medium (serum-free or serum-supplemented), such as alpha minimal essential medium (aMEM) supplemented with 5% fetal bovine serum (FBS) and glutamine, and allowed to adhere to the culture vessel overnight at 37°C, 20% O2. The medium is then changed and / or modified as needed, and the cells are cultured for an additional 68 to 72 hours at 37°C, 5% O2.

[0075] As will be appreciated by one of skill in the art, cultured mesenchymal lineage precursor cells or stem cells differ from in vivo cell phenotypes. For example, in one embodiment, they express one or more of the following markers: CD44, NG2, DC146, and CD140b. Cultured mesenchymal lineage precursor cells or stem cells differ biologically from in vivo cells, having a higher rate of proliferation compared to the majority of non-circulating (quiescent) cells in vivo.

[0076] The mesenchymal lineage precursor cells or stem cells can also be cryopreserved prior to administration to a subject.

[0077] Expression of Angl and / or VEGF

[0078] The mesenchymal lineage precursor cells or stem cells of the disclosure can be genetically modified or unmodified and express high levels of Angl. For example, the mesenchymal lineage precursor cells or stem cells can express at least 0.1 pg / 106 The cells express Ang1 in an amount of at least 0.2 pg / 10 6 cells, 0.3 pg / 10 6 cells, 0.4 pg / 10 6 cells, 0.5 pg / 10 6 cells, 0.6 pg / 10 6 cells, 0.7 pg / 10 6 cells, 0.8 pg / 10 6 cells, 0.9 pg / 10 6 cells, 1 pg / 10 6 cells, 1.1 pg / 10 6 cells, 1.2 pg / 10 6 cells, 1.3 pg / 10 6 cells, 1.4 pg / 10 6 cells, 1.5 pg / 10 6 cells.

[0079] In another example, the mesenchymal lineage precursor cells or stem cells express VEGF in an amount of less than about 0.05 pg / 10 6 cells. In other examples, the cells express VEGF in an amount of less than about 0.05 pg / 10 6 cells, 0.04 pg / 10 6 cells, 0.03 pg / 10 6 cells, 0.02 pg / 10 6 cells, 0.01 pg / 10 6 cells, 0.009 pg / 10 6 cells, 0.008 pg / 10 6 cells, 0.007 pg / 10 6 cells, 0.006 pg / 10 6 cells, 0.005 pg / 10 6 cells, 0.004 pg / 10 6 cells, 0.003 pg / 10 6 cells, 0.002 pg / 10 6 cells, 0.001 pg / 10 6 cells.

[0080] In another example, the mesenchymal lineage precursor cells or stem cells express Angl :VEGF at a ratio of at least about 2: 1. In other examples, the cells express Angl :VEGF at a ratio of at least about 10: 1, 15: 1, 20: 1, 21: 1, 22: 1, 23: 1, 24: 1, 25: 1, 26: 1, 27: 1, 28: 1, 29: 1, 30: 1, 31: 1, 32: 1.

[0081] In one example, the mesenchymal lineage precursor cells or stem cells are not genetically modified and express a reference level of Ang-1 or VEGF or the Angl :VEGF ratios mentioned above. As used herein, the term "not genetically modified" refers to cells that have not been modified by transfection with a nucleic acid. For the avoidance of doubt, mesenchymal lineage precursor cells or stem cells that have been transfected with a nucleic acid encoding Angl would be considered to be genetically modified in the context of the present disclosure.

[0082] The amount of Angl and / or VEGF expressed in culture or present in cells of a composition of mesenchymal lineage precursor cells or stem cells can be determined by various methods known to those of skill in the art. Such methods include, but are not limited to, Western blot, enzyme-linked immunosorbent assay (ELISA), fluorescence-linked immunosorbent assay (FLISA), competitive assay, radioimmunoassay, lateral flow immunoassay, flow-through immunoassay, electrochemiluminescence assay, nephelometric-based assay, turbidometric-based assay, fluorescence-activated cell sorting (FACS)-based assay (for detecting Ang-1 or VEGF in culture medium for culturing mesenchymal lineage precursor cells or stem cells), and surface plasmon resonance (SPR or Biacore).

[0083] In one example, the level of Angl and / or VEGF expressed by a culture or present in a composition of mesenchymal lineage precursor cells or stem cells is determined by an ELISA assay. For example, a cell lysate from a culture of mesenchymal lineage precursor cells or stem cells is added to a well of an ELISA plate. The well can be coated with a primary antibody (monoclonal or polyclonal) directed against Angl or VEGF. The well is washed and then contacted with a secondary antibody (monoclonal or polyclonal) directed against the primary antibody. For example, the secondary antibody is conjugated to an appropriate enzyme, such as horseradish peroxidase. After an appropriate incubation period, the well is washed and then contacted with a suitable substrate for the enzyme conjugated to the secondary antibody, such as one or more chromogens. Chromogens that can be used include, but are not limited to, hydrogen peroxide and tetramethylbenzidine. After the substrate is added, the well is incubated for an appropriate period of time. After incubation is complete, a "stop" solution is added to the well in order to stop the reaction of the enzyme with the substrate. The optical density (OD) of the sample is then measured. The optical density of the sample is correlated to the optical density of a sample containing a known amount of Angl or VEGF in order to determine the amount of Angl or VEGF expressed by the culture of mesenchymal lineage precursor cells or stem cells being tested. Methods of determining the Angl :VEGF expression ratio will also be apparent to those of skill in the art. For example, after the levels of Angl and VEGF are quantified, the ratio based on the quantified levels of Angl and VEGF can be expressed as: (level of Angl / level of VEGF) = Angl :VEGF ratio.

[0084] Methods of treating progressive heart failure

[0085] Heart failure occurs when the heart is not pumping sufficiently to maintain blood flow to meet the needs of the body. One cause of heart failure following myocardial infarction (MI) is systolic dysfunction. An MI occurs when blood flow to a portion of the heart is stopped. The lack of blood supply results in a region of local myocardial necrosis known as an infarct or infarction. The infarcted heart is not pumping sufficiently to maintain blood flow to meet the needs of the body, resulting in a variety of pathophysiological responses and ultimately in heart failure. Following an MI, a series of compensatory mechanisms are initiated to mitigate the decrease in cardiac output and assist in maintaining adequate blood pressure to perfuse vital organs. Thus, a heart failure patient can be asymptomatic for a long period of time. However, the compensatory mechanisms eventually fail to compensate for the damaged heart, resulting in a gradual decrease in cardiac output, known as "progressive heart failure." In the context of the present disclosure, the terms chronic heart failure, congestive heart failure, congestive cardiac failure, systolic dysfunction, and end-stage heart failure can be used interchangeably with "progressive heart failure."

[0086] The methods of the present disclosure relate to the treatment of the progressive decline in cardiac output characteristic of heart failure. Accordingly, in the context of the present disclosure, "treat" and "treatment" refer to therapeutic treatment and prophylactic or preventative measures.

[0087] In one example, the treatment reduces the probability or risk of heart failure-related major adverse cardiac events (HF-MACE), defined as a composite of cardiac-related death or resuscitated cardiac death or non-fatal decompensated heart failure event. In one example, the probability or risk of HF-MACE is reduced for at least 6 months, at least 12 months, at least 24 months, at least 36 months. For example, the treatment reduces the probability or risk of all-cause mortality.

[0088] Myocardial infarction subjects

[0089] The term "myocardial infarction (MI) subject" is used to define a subject who has had a myocardial infarction. The methods of the present disclosure can be used to treat progressive heart failure in a particular population of MI subjects. Subjects in need of treatment include those who already have progressive heart failure as well as those who are to be prevented, delayed, or stopped from developing progressive heart failure.

[0090] MI subjects treated with the methods of the present disclosure have a proximal left anterior descending (LAD) artery lesion. As will be appreciated by those skilled in the art, the LAD artery runs within the anterior interventricular groove separating the right atrium and the left ventricle anteriorly in the heart. The diagonal (Dx) branch diverges from the LAD and runs diagonally across the anterior wall towards its outer or lateral portion. Thus, the Dx supplies blood to the anterolateral portion of the left ventricle. A subject can have one or several Dx branches. The first Dx branch acts as a boundary between the proximal and intermediate portions of the LAD. Thus, the arterial portion before the Dx origin is referred to as the "proximal LAD", while this segment is proximal to the first major side of the branch. The distal segment of the LAD is the terminal third of the artery.

[0091] In the context of the present disclosure, the term "artery lesion" encompasses an obstructive lesion that occludes the LAD of the heart; or an artery lesion of the LAD that was previously occluded has been treated, for example, by percutaneous coronary intervention (PCI), also known as angioplasty.

[0092] In one example, the subject treated with the methods of the disclosure receives PCI within about 1 hour of the ischemic symptoms. In other examples, the subject receives PCI within about 2 hours, about 3 hours, about 4 hours, about 5 hours, about 6 hours, about 7 hours, about 8 hours, about 9 hours, about 10 hours, about 11 hours of the ischemic symptoms. In one example, the subject receives PCI within about 12 hours of the ischemic symptoms. In other examples, the subject receives PCI within about 13 hours, about 14 hours, about 15 hours, about 16 hours, about 17 hours, about 18 hours, about 19 hours, about 20 hours, about 21 hours, about 22 hours, about 23 hours, or more of the ischemic symptoms. Subjects treated with thrombolytic therapy who have recurrent chest pain and / or ECG changes can not be transferred for PCI until at least 24 hours after the ischemic symptoms occurred. Thus, in other examples, the subject receives PCI within about 24 hours, about 25 hours, about 26 hours, about 27 hours, about 28 hours, about 29 hours, about 30 hours, about 35 hours, about 40 hours, about 48 hours of the ischemic symptoms.

[0093] The subject with MI can have an elevated left ventricular end systolic volume (LVESV). In one example, the subject with MI treated using the methods of the disclosure has an elevated LVESV greater than 70 mL. In one example, the subject has an elevated LVESV greater than 80 mL, greater than 90 mL, greater than 100 mL, greater than 110 mL, or greater than 120 mL. In another example, the subject has an elevated LVESV greater than 80 mL / m 2 , greater than 90 mL / m 2 , greater than 100 mL / m 2 , greater than 110 mL / m 2 , or greater than 120 mL / m 2 .

[0094] MI can cause persistent left ventricular dysfunction. Thus, in another example, the subject with MI has a proximal LAD artery lesion and persistent left ventricular dysfunction. Left ventricular dysfunction is characterized by a reduction in myocardial contractility. When myocardial contractility is reduced within the left ventricle, it results in a reduction in left ventricular ejection fraction (LVEF). Thus, LVEF provides a way to determine left ventricular dysfunction.

[0095] LVEF and LVESV can be measured by a variety of methods known in the art, such as echocardiography, single photon emission computed tomography (SPECT), or cardiac magnetic resonance imaging (cMRI).

[0096] In one example, a subject with an LVEF of less than about 60% has left ventricular dysfunction. In other examples, a subject with an LVEF of less than about 55%, 54%, 53%, 52%, 51%, 50%, 49%, 48%, 47%, 46% has left ventricular dysfunction. In another example, a subject with an LVEF of less than about 45% has left ventricular dysfunction. In other examples, a subject with an LVEF of less than about 44%, 43%, 42%, 41% has left ventricular dysfunction. In another example, a subject with an LVEF of less than about 40% has left ventricular dysfunction. In other examples, a subject with an LVEF of less than about 39%, 38%, 37%, 36%, 35%, 34%, 33%, 32%, 31%, 30% has left ventricular dysfunction.

[0097] In the context of the present disclosure, the term "persistent left ventricular dysfunction" is used to define left ventricular dysfunction that persists over a period of time or over a series of measurements. For example, "persistent left ventricular dysfunction" can include left ventricular dysfunction that persists between about 1 and about 14 days or more after MI. For example, persistent left ventricular dysfunction can include left ventricular dysfunction that persists between about 1 and about 10 days, between about 1 and about 9 days, about 2 to about 8 days, about 2 to about 7 days after MI. In another example, "persistent left ventricular dysfunction" can include left ventricular dysfunction that persists over about 1 to 10 or more measurements.

[0098] The size or amount of myocardial necrosis after MI is clinically referred to as infarct size. The methods of the present disclosure involve treating subjects with MI who have a large infarct size. For example, subjects treated using the methods of the present disclosure can have an infarct size of greater than about 10-35% of the left ventricle. In other examples, subjects have an infarct size of greater than about 11-34%, about 12-33%, about 13-32%, about 14-31%, about 15-30%, about 16-29%, about 17-28% of the left ventricle. In another example, subjects have an infarct size of greater than about 18.5% of the left ventricle. In other examples, subjects have an infarct size of greater than about 19-27%, about 20-26%, about 21-25%, about 22-24%, about 23% of the left ventricle.

[0099] Infarct size can be measured by a variety of methods known in the art. Examples of these methods include the use of serum markers such as creatine kinase (CK), CK-MB, troponin I, and brain natriuretic peptide troponin.

[0100] In one example, a subject treated with the methods of the present disclosure has a troponin level of at least about 2x upper limit of normal (ULN) 2x. In another example, a subject has a troponin level of at least about 3x, about 4x, about 5x, about 6x ULN.

[0101] In one example, the subject treated with the methods of the disclosure has a creatine kinase-MB level of at least about 2 x ULM. In another example, the subject has a creatine kinase-MB level of at least about 3x, about 4x, about 5x, about 6x ULM.

[0102] Other examples of measuring infarct size include Sestamibi single photon emission computed tomography (SPECT) myocardial perfusion imaging, magnetic resonance imaging. In one example, infarct size is measured using cMRI. Several cMRI techniques can be used to diagnose infarct size. One of the most accurate and effective techniques is delayed enhancement cardiac magnetic resonance imaging (DE-CMR). Thus, in one example, the cMRI comprises DE-CMR.

[0103] When using appropriate settings for DE-CMR, normal myocardium appears black or null, while non-viable regions appear bright or hyperenhanced. Thus, in one example, infarct size can be determined by visual assessment of bright and hyperenhanced regions. Other examples of determining infarct size are known in the art (Sievers et al. (2007), Circulation, 115, 236-244; Kim et al. (2000), N Engl J Med, 343, 1445-1453). Briefly, hyperenhancement is scored on a 5-point scale for each segment on a 17-segment model (0 = no hyperenhancement, 1 = 1% to 25%, 2 = 26% to 50%, 3 = 51% to 75%, 4 = 76% to 100%). Black regions completely contained within hyperenhanced myocardium are interpreted as regions of microvascular injury (no reflow) and are included as part of the infarct. Infarct size is calculated as a percentage of LV myocardium by summing the regional scores, each weighted by the midpoint of the hyperenhanced range (i.e. 1 = 13%, 2 = 38%, 3 = 63%, 4 = 88%), and dividing by 17. In another example, infarct size can be quantified by planimetry of hyperenhanced regions on short-axis image stacks.

[0104] In one example, infarct size is measured between about 1 day and 40 days after MI. In other examples, infarct size is measured between about 1 to 40 days, between about 2 to 35 days, between about 3 to 30 days, between about 4 to 25 days, between about 5 to 20 days, between about 6 to 15 days after MI. For example, infarct size can be measured about 30 days after MI.

[0105] In the context of the disclosure, "infarct size" refers to left ventricular infarct size. In other words, left ventricular infarct size refers to the amount of left ventricle that is infarcted.

[0106] The methods of the disclosure can be used to treat progressive heart failure in MI subjects having various stages or classifications of heart failure. For example, the subject can have Stage A, B, C, or D heart failure. In one example, the subject has Stage B or C heart failure. In these examples, the heart failure stage is based on the American College of Cardiology (ACC) and American Heart Association (AHA) staging criteria.

[0107] In another example, the subject can have Class I, II, III, or IV heart failure. In one example, the subject has Class II or III heart failure. In these examples, the heart failure classification is based on the New York Heart Association (NYHA) classification scale.

[0108] Cell compositions

[0109] In carrying out the methods of the disclosure, mesenchymal lineage precursor cells or stem cells can be administered in the form of a composition. In one example, such a composition comprises a pharmaceutically acceptable carrier and / or excipient.

[0110] The terms "carrier" and "excipient" refer to compositions of matter conventionally used in the art to facilitate storage, administration, and / or bioactivity of active compounds (see, e.g., Remington's Pharmaceutical Sciences, 16th Ed., Mac Publishing Company (1980). Carriers can also reduce any undesirable side effects of the active compound. Suitable carriers are, for example, stable, e.g., do not react with other ingredients in the carrier. In one example, the carrier does not produce significant local or systemic adverse reactions in the recipient at the doses and concentrations used for treatment.

[0111] Suitable carriers for use in the disclosure include those conventionally used, such as, for example, water, saline, aqueous dextrose, lactose, Ringer's solutions, buffered solutions, hyaluronic acid and glycols are exemplary liquid carriers, particularly (when isotonic) for use in solutions. Suitable pharmaceutical carriers and excipients include starch, cellulose, glucose, lactose, sucrose, gelatin, malt, rice, flour, chalk, silica gel, magnesium stearate, sodium stearate, glycerol monostearate, sodium chloride, glycerol, propylene glycol, water, ethanol, and the like.

[0112] In another example, the carrier is a culture medium composition, such as in which the cells are grown or suspended. Such culture medium compositions do not induce any adverse effects in the subject to which they are administered.

[0113] Exemplary carriers and excipients do not adversely affect the viability of the cells and / or the ability of the cells to prevent or delay progressive heart failure.

[0114] In one example, the carrier or excipient provides a buffering activity to maintain the cells and / or soluble factors at a suitable pH to exert a biological activity, e.g., the carrier or excipient is phosphate buffered saline (PBS). PBS represents an attractive carrier or excipient because it minimally interacts with the cells and factors and allows for rapid release of the cells and factors, in which case the compositions of the present disclosure can be produced as a liquid for direct application to the bloodstream or to a tissue or area surrounding or adjacent to a tissue, e.g., by injection.

[0115] Stem cells and / or progeny cells thereof can also be incorporated or embedded within a scaffold that is compatible with the recipient and degrades into products that are not harmful to the recipient. These scaffolds provide support and protection for the cells to be transplanted into the recipient subject. Natural and / or synthetic biodegradable scaffolds are examples of such scaffolds.

[0116] A variety of different scaffolds can be successfully used in the practice of the present disclosure. Exemplary scaffolds include, but are not limited to, biological, biodegradable scaffolds. Natural biodegradable scaffolds include collagen, fibronectin, and laminin scaffolds. Suitable synthetic materials for cell transplantation scaffolds should be able to support a wide range of cell growth and cell function. Such scaffolds can also be resorbable. Suitable scaffolds include polyglycolic acid scaffolds (e.g., as described in Vacanti et al. J. Ped. Surg. 23:3-9 1988; Cima et al. Biotechnol. Bioeng. 38:145 1991; Vacanti et al. Plast. Reconstr. Surg. 88:753-9 1991); or synthetic polymers such as polyanhydrides, polyorthoesters, and polylactic acid.

[0117] In another example, the cells can be administered in a gel scaffold, such as Gelfoam from Upjohn Company.

[0118] The cell compositions described herein can be administered alone or as a mixture with other cells. Different types of cells can be mixed with the compositions of the present disclosure immediately or shortly before administration or they can be co-cultured together for a period of time prior to administration.

[0119] In one example, the composition comprises an effective amount or a therapeutically or prophylactically effective amount of cells. For example, the composition comprises about 1 x 10 5 cells to about 1 x 10 9 cells or about 1.25 x 10 3 cells to about 1.25 x 10 7 cells. The exact amount of cells to be administered depends on a variety of factors, including the age, weight, and sex of the subject and the extent and severity of the condition being treated.

[0120] An exemplary dose includes at least about 1.2 x 10 8 to about 8 x 10 10 cells, such as about 1.3 x 10 8 to about 8 x 10 9 cells, about 1.4 x 10 8 to about 8 x 10 8 cells, about 1.5 x 10 8 to about 7.2 x 10 8 cells, about 1.6 x 10 8 to about 6.4 x 10 8 cells, about 1.7 x 10 8 to about 5.6 x 10 8 cells, about 1.8 x 10 8 to about 4.8 x 10 8 cells, about 1.9 x 10 8 to about 4.0 x 10 8 cells, about 2.0 x 10 8 to about 3.2 x 10 8 cells, about 2.1 x 10 8 to about 2.4 x 10 8 cells. For example, a dose can include at least about 1.5 x 10 8 cells. For example, a dose can include at least about 2.0 x 10 8 cells.

[0121] In other words, an exemplary dose includes at least about 1.5 x 10 6 cells / kg (an 80 kg subject). In one example, a dose can include at least about 2.5 x 10 6 cells / kg. In other examples, a dose can include about 1.5 x 10 6 to about 1 x 10 9 cells / kg, about 1.6 x 10 6 to about 1 x 10 8 cells / kg, about 1.8 x 10 6 to about 1 x 10 7 cells / kg, about 1.9 x 10 6 to about 9 x 10 6 cells / kg, about 2.0 x 10 6 to about 8 x 10 6 cells / kg, about 2.1 x 10 6 to about 7 x 10 6about 2.3 x 10 6 about 2.4 x 10 6 about 2.5 x 10 6 about 2.6 x 10 6 about 2.7 x 10 6 about 2.8 x 10 6 about 2.9 x 10 6 about 3 x 10 6 about 3 x 10

[0122] In one example, mesenchymal lineage precursor cells or stem cells comprise at least about 5%, at least about 10%, at least about 15%, at least about 20%, at least about 25%, at least about 30%, at least about 35%, at least about 40%, at least about 45%, at least about 50%, at least about 55%, at least about 60%, at least about 65%, at least about 70%, at least about 75%, at least about 80%, at least about 85%, at least about 90%, at least about 95%, at least about 99% of the cell population of the composition.

[0123] The compositions of the disclosure can be cryopreserved. Cryopreservation of mesenchymal lineage precursor cells or stem cells can be performed using slow-cooling methods or "rapid" freezing protocols known in the art. Preferably, the method of cryopreservation maintains similar phenotype, cell surface markers, and growth rate of the cryopreserved cells compared to non-cryopreserved cells.

[0124] Cryopreserved compositions can include a cryopreservation solution. The pH of the cryopreservation solution is typically 6.5 to 8, preferably 7.4.

[0125] The cryopreservation solution can include a sterile, non-pyrogenic, isotonic solution, such as PlasmaLyte A TM 100 mL of PlasmaLyte A TM contains 526 mg sodium chloride, USP (NaCl); 502 mg sodium gluconate (C6H 11 NaO7); 368 mg sodium acetate trihydrate, USP (C2H3NaO2•3H2O); 37 mg potassium chloride, USP (KCl); and 30 mg magnesium chloride, USP (MgCl2•6H2O). It does not contain an antimicrobial agent. The pH is adjusted with sodium hydroxide. The pH is 7.4 (6.5 to 8.0).

[0126] The cryopreservation solution can include Profreeze TM The cryopreservation solution can additionally or alternatively include a culture medium, such as aMEM.

[0127] To facilitate freezing, a cryoprotective agent, such as, for example, dimethyl sulfoxide (DMSO), is typically added to the cryopreservation solution. Ideally, the cryoprotective agent should be non-toxic, non-antigenic, chemically inert to cells and patients, provide high survival rates upon thawing, and allow for transplantation without washing. However, the most commonly used cryoprotective agent, DMSO, exhibits some cytotoxicity. Hydroxyethyl starch (HES) can be used as a substitute or in combination with DMSO to reduce the cytotoxicity of the cryopreservation solution.

[0128] The cryopreservation solution can include one or more of DMSO, hydroxyethyl starch, human serum component, and other protein fillers. In one example, the cryopreserved solution includes about 5% human serum albumin (HSA) and about 10% DMSO. The cryopreservation solution can also include one or more of methylcellulose, polyvinylpyrrolidone (PVP), and trehalose.

[0129] In one embodiment, the cells are suspended in 42.5% Profreeze TM / 50% aMEM / 7.5% DMSO and cooled in a controlled rate freezer.

[0130] The cryopreserved composition can be thawed and administered directly to the subject, or added to another solution (e.g., including HA). Alternatively, the cryopreserved composition can be thawed, and the mesenchymal lineage precursor cells or stem cells resuspended in an alternative carrier prior to administration.

[0131] In one example, the cell composition described herein can be administered about 1 to about 10 days after MI. In other examples, the cell composition described herein can be administered about 1 to 9 days, about 1 to 8 days, about 2 to 7 days, about 2 to 6 days, about 3 to 5 days after MI. For example, the cell composition described herein can be administered about 5 days after MI.

[0132] In one example, the cell composition described herein can be administered about 1 to about 10 days after PCI. In other examples, the cell composition described herein can be administered about 1 to 9 days, about 1 to 8 days, about 2 to 7 days, about 2 to 6 days, about 3 to 5 days after PCI. For example, the cell composition described herein can be administered about 5 days after PCI.

[0133] In one example, the cell composition described herein can be administered in a single dose. In one example, the cell composition is administered in multiple doses. For example, at least 2, at least 3, at least 4, at least 5, at least 6, at least 7, at least 8, at least 9, at least 10 doses.

[0134] In one example, the expanded mesenchymal lineage precursor cells or stem cells can be cultured prior to administration. Various methods of culturing mesenchymal lineage precursor cells or stem cells are known in the art. In one example, the expanded mesenchymal lineage precursor cells or stem cells are cultured in serum-free media prior to administration.

[0135] The mesenchymal lineage precursor cells or stem cells can be administered systemically, such as, for example, by intravenous, intra-arterial, or intraperitoneal administration. The mesenchymal lineage precursor cells or stem cells can also be administered by intranasal, intramuscular, or intracardiac administration. In one example, the mesenchymal lineage precursor cells or stem cells are administered directly to the myocardium. For example, the mesenchymal lineage precursor cells or stem cells can be administered directly into the myocardium of the left ventricle. In one example, the mesenchymal lineage precursor cells or stem cells are administered via an endocardial catheter, such as a J&J Myostar™ injection catheter.

[0136] In one example, the mesenchymal lineage precursor cells or stem cells are administered to viable myocardium. In one example, the mesenchymal lineage precursor cells or stem cells are administered to hibernating myocardium. Those skilled in the art will be able to identify viable myocardium and / or hibernating myocardium using methods known in the art. For example, viable myocardium and / or hibernating myocardium can be identified using a mapping catheter system such as the NOGASTAR® mapping catheter system. TM In one example, the mesenchymal lineage precursor cells or stem cells are administered to viable myocardium. In one example, the mesenchymal lineage precursor cells or stem cells are administered to hibernating myocardium. Those skilled in the art will be able to identify viable myocardium and / or hibernating myocardium using methods known in the art. For example, viable myocardium and / or hibernating myocardium can be identified using a mapping catheter system such as the NOGASTAR® mapping catheter system.

[0137] In another example, the mesenchymal lineage precursor cells or stem cells are administered by intracoronary infusion. For example, the mesenchymal lineage precursor cells or stem cells can be administered to the left anterior descending (LAD) artery. In one example, the mesenchymal lineage precursor cells or stem cells are administered into the LAD artery immediately following revascularization of the LAD by PCI.

[0138] In one example, the cells are contained within a chamber that does not allow the cells to exit the circulation of the subject, however, does allow factors secreted by the cells to enter the circulation. In this way, soluble factors can be administered to the subject by allowing the cells to secrete the factors into the circulation of the subject. Such a chamber can likewise be implanted at a site in the subject to increase local levels of soluble factors, for example, in or near the heart.

[0139] Those skilled in the art will appreciate that numerous variations and / or modifications can be made to the present application as shown in the specific embodiments without departing from the spirit or scope of the application as broadly described. The present embodiments are, therefore, to be considered in all respects as illustrative and not restrictive.

[0140] All publications discussed and / or referenced herein are incorporated herein in their entirety.

[0141] Any discussion of documents, acts, materials, devices, articles or the like which has been included in the present specification is solely for the purpose of providing a context for the present application. It is not to be taken as an admission that any or all of these matters actually or

[0142] This application claims priority from AU 2014905240 filed 23 December 2014, the disclosure of which is incorporated herein by reference.

[0143] EMBODIMENTS

[0144] EMBODIMENT 1

[0145] Clinical stage 2a / 2b IV MSCs in AMI

[0146] A randomized placebo-controlled Phase 2a / 2b trial was initiated to evaluate a single intravenous (IV) dose of 200 million mesenchymal stem cells (MSCs) administered at 2-7 days in patients with ST-elevation MI (STEMI) or non-ST-elevation myocardial infarction (NSTEMI) and reduced cardiac ejection fraction.

[0147] A Phase IIa / IIb, multicenter, randomized, double-blind, placebo-controlled study was designed to evaluate the safety and efficacy of remestemcel-L (ex vivo cultured adult mesenchymal stem cells) intravenous infusion following acute myocardial infarction.

[0148] The study was a Phase II, multicenter, randomized, double-blind, placebo-controlled study in 220 subjects who recently experienced an acute myocardial infarction (MI). Eligible acute MI patients for this study included those with any acute coronary syndrome that resulted in:

[0149] 1) a positive biomarker (troponin or CK-MB > 4x ULN);

[0150] 2) regional wall motion abnormalities;

[0151] 3) suppressed global left ventricular systolic function of < 45% and > 20% as determined by screening cardiac imaging within approximately 24 hours of the initial onset of acute event.

[0152] Subjects were evaluated for safety and efficacy until the occurrence of death, withdrawal of consent, or 60 months after IA infusion, whichever occurred first. The treatment window was 2 to 7 days after the initial onset of acute MI.

[0153] Subjects were randomized to placebo or treatment (remestemcel-L 200 x 10 6 Approximately equal numbers of subjects in each cohort were assigned to each of the 2 groups (1 : 1 randomization).

[0154] Overall study data at 24 months

[0155] Overall, intravenous mesenchymal stem cell (MSC) therapy is well-tolerated, and studies have shown that IV MSCs are safe to use at the time of acute myocardial infarction. There was no significant difference between remestemcel-L and placebo in the overall adverse events (90.9% vs. 90.9%) and serious adverse events (32.7% vs. 33.6%) in acute MI subjects. There were 5 deaths in the study: 2 in the remestemcel-L group and 3 in the placebo group. Only 1 subject death was considered possibly related to study treatment, and that subject received placebo.

[0156] Although the primary inclusion criteria for study entry in the original study design was LVEF < 45% as determined by cardiac imaging approximately 24 hours after the acute event, it was actually found that over 70% of the eligible subjects at the time of screening had LVEF > 45% by cMR shortly before intravenous injection of the study product, which was administered at a mean time point of 5.4 days after the MI. This is most likely due to the natural process of myocardial recovery after MI and angioplasty procedures. Thus, less than 30% of enrolled patients actually met the study design criteria for persistent left ventricular (LV) dysfunction at the time of remestemcel-L infusion, and therefore most patients in this study actually had normal LV function at the time they received treatment.

[0157] 66 patients had left anterior descending (LAD) lesions and low ejection fraction at the time of screening. For the primary efficacy variable of cMR-derived change in left ventricular end systolic volume at 3 months, subjects in the remestemcel-L group exhibited a numerically, but not statistically significant, change (+3.31 mL vs. -0.35, p = 0.17). Similar non-significant numerical changes were evident in the 6-month change in ESV, as well as mean infarct size and ejection fraction.

[0158] The effect of remestemcel-L therapy was then evaluated in a subset of patients with persistent LV dysfunction and proximal LAD lesions, as measured by cMR prior to infusion.

[0159] Post-hoc efficacy analysis

[0160] The central rationale of this study was that remestemcel-L would be effective in post-MI patients with persistent LV dysfunction. However, in the overall patient population, over 70% had their ejection fraction standardized between the choice of trial inclusion at 24 hours post-MI and treatment infusion at days 2-7 (mean treatment administration at day 5.4). This can reflect early recovery of stunned myocardium within days after reperfusion by PCI, leading to improved LV systolic function prior to treatment administration. The difference in LVEF data between study entry and treatment administration clearly negates the ability of the original trial to adequately test the underlying hypothesis.

[0161] Accordingly, a post-hoc analysis was designed and aimed to further investigate the potential impact of remestemcel-L on a subset of patients expected to have the most extensive post-MI disease, in particular subjects with a proximal LAD culprit lesion and cMR LVEF < 45% at the time of treatment administration.

[0162] The post-hoc analysis was designed to answer whether a single dose (200 x 10 6 intravenous administration of MSCs would be more effective than placebo in reversing left ventricular heart failure and preventing progressive adverse LV remodeling at 6 months post- index AMI in patients with the highest risk of progressive heart failure. The highest risk patients were selected for study entry as follows:

[0163] • first anterior acute myocardial infarction due to a proximal LAD culprit lesion;

[0164] • successful treatment of the culprit coronary lesion with a PCI procedure within 12 hours of onset of ischemic symptoms;

[0165] • persistent LV systolic dysfunction present at 2-7 days post-index AMI (i.e. post-PCI LVEF < 45% by cMR).

[0166] Out of the 220 patients randomized into the overall trial, a total of 25 subjects met the criteria consisting of MI localized to the proximal LAD, ischemic time < 12 hours, successful percutaneous coronary intervention (PCI), baseline cMR LVEF < 45%, and treatment with the study product within 2 to 7 days post-index AMI.

[0167] These 25 subjects constituted the evaluation population for the post-hoc analysis and were assigned to 10 subjects in the remestemcel-L group and 15 subjects in the placebo group. In the post-hoc analysis of the Phase 2 remestemcel-L AMI trial, the responder index method was used to assess the impact of cell therapy on adverse LV remodeling. This method was used to assess the primary endpoint of the post-hoc study, where the change in LVESV from baseline was assessed to determine if there was a clinically meaningful difference between patients treated with remestemcel-L compared to placebo 6 months after AMI.

[0168] It has been previously shown that LVESV is a strong predictor of long-term survival after recovery from acute myocardial infarction among commonly assessed measures of LV systolic function (White et al. (1987) Circulation, 76:44-51).

[0169] Indeed, LVESV is now recognized as a useful surrogate efficacy endpoint of biologic and clinical significance, as it correlates with adverse LV remodeling and related MACE formation in patients at risk for development / progression of LV systolic dysfunction heart failure. This analytical model has been shown to correlate well with MACE outcomes in Phase 2 gene therapy trials (Hajjar et al. (2008) J Card Fail., 14(5):355-67; Jaski et al. (2009) Card Fail., 15(3): 171-81; Jessup et al. (2011) Circulation, 124:304-313).

[0170] In the current analysis of primary and secondary endpoints, successful pre-specified threshold boundaries were used to define treatment responders. These values, calculated as 6-month minus baseline data, were utilized to ensure that interval changes were outside the range of normal measurement error and had potential clinical significance.

[0171]

[0172] Efficacy results for post-hoc cohorts

[0173] At baseline, there were no significant differences in LVESV, LVEDV, LVEF, or LV infarct volume between treatment groups. However, trends of interest were apparent within the change from baseline data for the 6-month follow-up.

[0174] LV infarct volume:

[0175] At baseline, mean infarct size was similar and very high between placebo and remestemcel-L groups, 40.9 + 13.75 g (mean + SD) and 40.76 + 17.82 g (mean + SD), respectively. Assuming total average myocardial mass in these patients to be approximately 130 g (Stone et al. (2012) JAMA., 307:17, 1817-26), these values represent a very high risk population with approximately 30% infarct size at the time of therapeutic intervention. Since infarct size > 18.5% has been shown prospectively to result in 30% incidence of heart failure related major adverse cardiac events (HF-MACE, defined as heart failure hospitalization or death) within 2 years, this confirms that the AMI patient population evaluated in this post-hoc analysis is at highest risk for subsequent HF-MACE.

[0176] At the end of 6 months, subjects in the remestemcel-L group exhibited a reduction in LV infarct size from baseline value of 40.76 + 17.82 g to 26.6 + 12.94 g (mean + SD). This represents a -14.14 + 13.94 g change. In comparison, placebo subjects showed a nominally smaller reduction in LV infarct size from baseline value of 40.9 + 13.75 g (mean + SD) to 31.59 + 12.70 g. This represents a -7.74 + 10.84 g change. The placebo-corrected difference was -6.40 g (p=0.187).

[0177] These results indicate that relative to placebo, remestemcel-L enhances the natural endogenous healing process of reducing infarct size by 2-fold, from approximately 30% infarct size at baseline to approximately 20% infarct size at 6 months (assuming average LV mass of 130 g).

[0178] LVESV:

[0179] At the end of 6 months, subjects in the remestemcel-L group exhibited a reduction in LVESV from baseline value of 85.0 + 15.89 mL to 73.0 + 24.24 mL (mean + SD). This represents a -12.0 + 16.57 mL change. In comparison, placebo subjects showed an increase in LVESV from baseline value of 90.5 + 23.54 mL (mean + SD) to 92.8 + 35.40 mL. This represents a 2.2 + 28.53 mL change. The placebo-corrected difference was -14.2 mL (p=0.174).

[0180] Summary of LV end-systolic volume at baseline and 6 months post-treatment (LOCF analysis)

[0181]

[0182] Baseline treatment comparisons were performed using ANOVA. Other treatment comparisons used ANCOVA with treatment as a fixed effect and baseline as a covariate

[0183] Source: Table 14.2.17.S.1

[0184] Notably, as seen in the remestemcel-L group, an infarct size change from approximately 30% at baseline to approximately 20% at 6 months (assuming an average LV mass of 130 g) would be expected to reduce LVESV by at least 10 mL over that time period (Wu et al. (2007) Stem Cells, 25:26, 48-59); our results are consistent and confirm the consistency of our dataset.

[0185] LVEDV:

[0186] At the end of 6 months, subjects in the remestemcel-L group exhibited an increase in LVEDV from a baseline value of 142.9 + 24.01 mL (mean + SD) to 154.4 + 37.52 mL. This represents a change of 11.5 + 27.91 mL. In comparison, placebo subjects showed an increase in LVEDV from a baseline value of 151.2 + 35.98 mL (mean + SD) to 167.8 + 41.66 mL. This represents a change of 16.6 + 27.30 mL. The placebo-corrected difference was -5.1 mL (p=0.618).

[0187] LVEF:

[0188] At the end of 6 months, subjects in the remestemcel-L group exhibited an increase in LVEF from a baseline value of 40.6 + 4.23% to 53.1 + 8.71% (mean + SD). This represents a change of 12.5 + 8.88 LVEF units. In comparison, placebo subjects showed a nominally smaller increase in LVEF from a baseline value of 40.3 + 3.47% (mean + SD) to 45.8 + 9.08%. This represents a change of 5.6 + 9.48 LVEF units. The placebo-corrected difference was 6.9 LVEF units (p=0.066) (see Figure 1 and Figure 2 ).

[0189] Summary of LV ejection fraction at baseline and 6 months post-treatment (LOCF analysis)

[0190]

[0191] Baseline treatment comparisons were made using ANOVA. Other treatment comparisons used ANCOVA with treatment as a fixed effect and baseline as a covariate

[0192] Source: Table 14.2.19.S.1

[0193] Responder analysis

[0194] The difference between the percentage of remestemcel-L and placebo patients who were treatment responders at 6 months post-index AMI was of borderline statistical significance (p = 0.095). Specifically, 60% of remestemcel-L treated patients were treatment responders compared to 27% of placebo patients. This represents a 2.2-fold increase in the responder rate for the remestemcel-L group compared to the placebo group Figure 3 .

[0195] Pooled analysis of "responder" vs. "non-responder" subgroups

[0196] While the responder rate for LVESV reduction was 2.2-fold higher in the remestemcel-L group compared to the placebo group, the average changes in LV remodeling and overall LV systolic function parameters at 6 months were similar for remestemcel-L and placebo responders (reduction in LVESV, no change in LVEDV, and increase in LVEF) compared to remestemcel-L and placebo non-responders (nominal increase in LVESV, large increase in LVEDV, and minimal increase in LVEF).

[0197] In contrast, remestemcel-L treated responder subjects demonstrated a greater reduction in LV infarct volume from baseline to month 6 (-18.8 g) compared to observations for any other subgroup (remestemcel-L non-responders = -7.1 g, placebo responders = -4.8 g, and placebo non-responders = -9.1 g). The mean change in LV infarct volume for the 17 patients included in the last three groups was -7.6 g. This difference in LV infarct volume for remestemcel-L treated responders stands in stark contrast to the data generated from the analysis of LVESV, LVEDV, and LVEF, where the treatment responder data were generally similar for remestemcel-L and placebo subjects.

[0198] Assuming an average left ventricular mass of 130 g in patients with large infarcts after proximal LAD occlusion (Stone et al. (2012) JAMA., 307:17, 1817-26), this represents a change in infarct size from about 30% at baseline to about 17% at 6 months in remestemcel-L responders. This reduction in infarct volume can have a major impact on the rate of HF-MACE events in this group over 2 years (Wu et al. (2007) Stem Cells, 25:26, 48-59).

[0199] Thus, remestemcel-L responders demonstrated:

[0200] 1) A high 2.2-fold achievement rate of the primary efficacy endpoint related to LVESV (p = 0.095);

[0201] 2) A high level of consistency between improvements in LV remodeling, overall LV systolic function, and reduction in LV infarct volume.

[0202] 3) A unique mechanism of improving LVESV and adverse LV remodeling, i.e., reduction in infarct volume.

[0203]

[0204] There were no significant differences in baseline demographics, time from ischemic MI symptom onset to PCI, or occurrence of TIMI perfusion grade 3 flow after PCI for the overall remestemcel-L group (n = 10) versus the placebo group (n = 15). There was a trend for a shorter time from PCI to infusion of the study product and a trend for a shorter time from the first ischemic MI symptom to infusion of the study product for the remestemcel-L group compared to the placebo group.

[0205] In summary, intravenous administration of remestemcel-L 2-7 days after AMI contributed to a reduction in LV infarct size, lessening of adverse LV remodeling, and improvement in overall LV systolic function at 6 months after the index event. It appears that the beneficial effects of remestemcel-L were evident both in the infarct zone (reduction in infarct volume) and in the remote myocardial zone (reduction in LVESV leading to an increase in LVEF) compared to placebo. These findings are expected to ultimately equate to a reduction in the rate of heart failure development in patients after AMI who are at high risk for this condition.

[0206] Example 2

[0207] Correlation between disease severity and therapeutic benefit of MPC on LVESV

[0208] Figures 4 to 9The change in LVESV in subjects assessed 6 months after administration of placebo (control) or MPCs (1.5 x 10 8 The change in LVESV in subjects assessed 6 months after administration of placebo (control) or MPCs (1.5 x 10

[0209]

[0210] These data suggest that the greater the magnitude of baseline left ventricular systolic abnormality in subjects with chronic heart failure due to left ventricular systolic dysfunction, the more beneficial the MPC-related cardioprotective effect observed over the 6-month follow-up period. The data further suggest that the progressive adverse natural history associated with advanced chronic heart failure can be beneficially altered by treatment with MPCs. Without wishing to be bound by theory, the findings support the paracrine cross-talk hypothesis, in which tissue-level biochemical / physiologic derangements create a local environment that promotes the release of beneficial paracrine mediators by MPCs. Thus, the best effect obtained by administration of MPCs in heart failure subjects is observed in subjects at the highest risk of disease progression, i.e., subjects with baseline LVESV > 70 mL.

[0211] The present invention relates to the following embodiments:

[0212] 1. A method for preventing progressive heart failure in a subject with myocardial infarction, the method comprising administering to the subject a population of mesenchymal lineage precursor cells or stem cells and / or progeny thereof and / or soluble factors derived therefrom, wherein the subject has a proximal left anterior descending branch (LAD) lesion.

[0213] 2. The method of embodiment 1, wherein the subject has an LVESV greater than 70 ml.

[0214] 3. The method of embodiment 1 or embodiment 2, wherein the subject has persistent left ventricular dysfunction.

[0215] 4. The method of any one of embodiments 1 to 3, wherein the subject has an LVEF less than about 45%.

[0216] 5. The method of any one of embodiments 1 to 4, wherein the subject has an LVEF less than about 40%.

[0217] 6. The method of any one of embodiments 1 to 5, wherein the mesenchymal lineage precursor cells or stem cells and / or progeny thereof and / or soluble factors derived therefrom are administered about 1-7 days after myocardial infarction.

[0218] 7. The method of any one of embodiments 1 to 5, wherein the mesenchymal lineage precursor cells or stem cells and / or progeny thereof and / or soluble factors derived therefrom are administered about 3-5 days after myocardial infarction.

[0219] 8. The method of any one of embodiments 1 to 7, wherein the subject has creatine kinase-MB and / or troponin and / or myoglobin greater than about 4x normal upper limit.

[0220] 9. The method of any one of embodiments 1 to 8, wherein the subject has infarct size of about 10-25 % left ventricle.

[0221] 10. The method of any one of embodiments 1 to 8, wherein the subject has infarct size greater than about 18.5 % left ventricle.

[0222] 11. The method of any one of embodiments 1 to 10, wherein the LVEF and / or infarct size is measured by cardiovascular magnetic resonance imaging (cMR).

[0223] 12. The method of any one of embodiments 1-11, comprising administering a population of mesenchymal lineage precursor cells or stem cells enriched for STRO-1 + cells and / or progeny thereof and / or soluble factors derived therefrom.

[0224] 13. The method of any one of embodiments 1-12, comprising administering a population of mesenchymal lineage precursor cells or stem cells enriched for STRO-1 亮 cells and / or progeny thereof and / or soluble factors derived therefrom.

[0225] 14. The method of any one of embodiments 1-13, wherein the population of mesenchymal lineage precursor cells or stem cells and / or progeny thereof and / or soluble factors derived therefrom is administered systemically.

[0226] 15. The method of any one of embodiments 1-14, wherein the population of mesenchymal lineage precursor cells or stem cells and / or progeny thereof and / or soluble factors derived therefrom is administered intravenously or intranasally.

[0227] 16. The method of any one of embodiments 1-15, wherein the population of mesenchymal lineage precursor cells or stem cells and / or progeny thereof and / or soluble factors derived therefrom is administered in multiple doses.

[0228] 17. The method of any one of embodiments 1-16, comprising administering 1 x 10 8up to 8 x 10 8 cells.

[0229] 18. The method of any one of embodiments 1-16, comprising administering 1.2 x 10 8 up to 4 x 10 8 cells.

[0230] 19. The method of any one of embodiments 1-18, wherein the population of cells and / or progeny cells are autologous or allogeneic and / or the soluble factors are derived from autologous or allogeneic cells.

[0231] 20. The method of any one of embodiments 1-19, wherein the population of cells and / or progeny thereof have been cultured for expansion prior to administration and / or prior to obtaining the soluble factors.

[0232] 21. The method of any one of embodiments 1-20, wherein the population of mesenchymal lineage precursor cells or stem cells express tissue non-specific alkaline phosphatase (TNAP) and / or the progeny cells and / or soluble factors are derived from mesenchymal lineage precursor cells or stem cells that express TNAP.

[0233] 22. The method of any one of embodiments 1-21, wherein the population of mesenchymal lineage precursor cells or stem cells express angiopoietin-1 (Angl) in an amount of at least 0.1 pg / 10 6 cells and / or the progeny cells and / or soluble factors are derived from mesenchymal lineage precursor cells or stem cells that express Angl in an amount of at least 0.1 pg / 10 6 cells.

[0234] 23. The method of any one of embodiments 1-22, wherein the population of mesenchymal lineage precursor cells or stem cells express vascular endothelial growth factor (VEGF) in an amount of less than about 0.05 pg / 10 6 cells and / or the progeny cells and / or soluble factors are derived from mesenchymal lineage precursor cells or stem cells that express VEGF in an amount of less than about 0.05 pg / 10 6 cells and / or the progeny cells.

[0235] 24. The method of any one of embodiments 1-23, wherein the population of mesenchymal lineage precursor cells or stem cells express Angl :VEGF in a ratio of at least about 2: 1 and / or the progeny cells and / or soluble factors are derived from mesenchymal lineage precursor cells or stem cells that express Angl :VEGF in a ratio of at least about 2: 1.

[0236] 25. The method of any one of embodiments 1-24, wherein the mesenchymal lineage precursor cells or stem cells and / or progeny cells thereof and / or soluble factors derived therefrom are administered in the form of a composition comprising the mesenchymal lineage precursor cells or stem cells and / or progeny cells thereof and / or soluble factors derived therefrom and a carrier and / or excipient.

[0237] 26. A population of mesenchymal lineage precursor cells or stem cells and / or progeny thereof and / or soluble factors derived therefrom for use in treating or preventing progressive heart failure in a subject with myocardial infarction (MI), wherein the subject has a proximal left anterior descending (LAD) artery lesion.

[0238] 27. Use of a population of mesenchymal lineage precursor cells or stem cells and / or progeny thereof and / or soluble factors derived therefrom in the manufacture of a medicament for treating or preventing progressive heart failure in a subject with myocardial infarction (MI), wherein the subject has a proximal left anterior descending (LAD) artery lesion.

[0239] 28. The population of mesenchymal lineage precursor cells or stem cells according to embodiment 26 or the use according to embodiment 27, wherein the subject has persistent left ventricular dysfunction.

[0240] 29. The population of mesenchymal lineage precursor cells or stem cells according to embodiment 26 or 28 or the use according to embodiment 27 or 28, wherein the subject has an LVESV greater than 70 ml.

[0241] 30. The population of mesenchymal lineage precursor cells or stem cells according to any one of embodiments 26, 28 or 29 or the use according to any one of embodiments 27 to 29, wherein the subject has an LVEF less than about 45%.

[0242] 31. The population of mesenchymal lineage precursor cells or stem cells according to any one of embodiments 26, 28 or 29 or the use according to any one of embodiments 27 to 29, wherein the subject has an LVEF less than about 40%.

[0243] 32. The population of mesenchymal lineage precursor cells or stem cells according to any one of embodiments 26, 28-31 or the use according to any one of embodiments 27-31, wherein the mesenchymal lineage precursor cells or stem cells and / or progeny thereof and / or soluble factors derived therefrom are administered about 1-7 days after myocardial infarction.

[0244] 33. The population of mesenchymal lineage precursor cells or stem cells according to any one of embodiments 26, 28-31 or the use according to any one of embodiments 27-31, wherein the mesenchymal lineage precursor cells or stem cells and / or progeny thereof and / or soluble factors derived therefrom are administered about 4-6 days after myocardial infarction.

[0245] 34. The population of mesenchymal lineage precursor cells or stem cells according to any one of embodiments 26, 28-33 or the use according to any one of embodiments 27-33, wherein the subject has greater than about 4x normal upper limit of creatine kinase-MB and / or troponin and / or myoglobin.

[0246] 35. The population of mesenchymal lineage precursor cells or stem cells according to any one of embodiments 26, 28-34 or the use according to any one of embodiments 27-34, wherein the subject has an infarct size of about 10-25 % left ventricle.

[0247] 36. The population of mesenchymal lineage precursor cells or stem cells according to any one of embodiments 26, 28-34 or the use according to any one of embodiments 27-34, wherein the subject has an infarct size of greater than about 18.5 % left ventricle.

[0248] 37. The population of mesenchymal lineage precursor cells or stem cells according to any one of embodiments 26, 28-36 or the use according to any one of embodiments 27-36, wherein the LVEF and / or infarct size is measured by cardiovascular magnetic resonance imaging (cMR).

Claims

1. Use of a population of mesenchymal lineage precursor cells or stem cells and / or progeny thereof and / or soluble factors derived therefrom in the manufacture of a medicament for treating or preventing progressive heart failure in a subject with reduced ejection fraction myocardial infarction, wherein the subject has a left ventricular end systolic volume (LVESV) greater than 70 ml, has persistent left ventricular dysfunction and has a left ventricular ejection fraction (LVEF) less than 45%, wherein the medicament comprises mesenchymal lineage precursor cells or stem cells and / or progeny thereof and / or soluble factors derived therefrom in an amount effective to: (i) reduce left ventricular infarct size in the subject; and / or (ii) improve left ventricular contractile function in the subject.

2. Use of a population of mesenchymal lineage precursor cells or stem cells and / or progeny thereof and / or soluble factors derived therefrom in the manufacture of a medicament for reducing the risk of a cardiac failure-related major adverse cardiac event (HF-MACE) in a subject with myocardial infarction, wherein the subject has a left ventricular end systolic volume (LVESV) greater than 70 ml, has persistent left ventricular dysfunction and has a left ventricular ejection fraction (LVEF) less than 45%, wherein the medicament comprises mesenchymal lineage precursor cells or stem cells and / or progeny thereof and / or soluble factors derived therefrom in an amount effective to: (i) reduce left ventricular infarct size in the subject; and / or (ii) improve left ventricular contractile function in the subject, thereby reducing the risk of the subject developing a HF-MACE for a period of at least 6 months after administration.

3. The use of claim 1 or 2, wherein the subject has a proximal left anterior descending (LAD) artery lesion.

4. The use of any one of claims 1-3, wherein the subject has an LVEF less than about 40%.

5. The use of any one of claims 1-4, wherein the mesenchymal lineage precursor cells or stem cells and / or progeny thereof and / or soluble factors derived therefrom are administered about 1-7 days after myocardial infarction.

6. The use of any one of claims 1-4, wherein the mesenchymal lineage precursor cells or stem cells and / or progeny thereof and / or soluble factors derived therefrom are administered about 3-5 days after myocardial infarction.

7. The use of any one of claims 1-6, wherein the subject has creatine kinase-MB and / or troponin and / or myoglobin greater than about 4x upper limit of normal.

8. The use of any one of claims 1-7, wherein the subject has an infarct size of about 10-25% of the left ventricle.

9. The use of any one of claims 1-7, wherein the subject has an infarct size of greater than about 18.5% of the left ventricle.

10. The use of any one of claims 1-8, wherein the LVEF and / or infarct size is measured by cardiovascular magnetic resonance imaging (cMR).

11. The use of any one of claims 1-10, wherein the population of mesenchymal lineage precursor cells or stem cells and / or progeny thereof and / or soluble factors derived therefrom are formulated for systemic administration, intravenous administration, intramyocardial administration or intranasal administration.

12. The use of any one of claims 1-11, wherein the population of mesenchymal lineage precursor cells or stem cells and / or progeny thereof and / or soluble factors derived therefrom are provided in a plurality of doses.

13. The use of any one of claims 1-12, wherein the medicament comprises 1 x 10 8 to 8 x 10 8 cells.

14. The use of any one of claims 1-13, wherein the medicament comprises 1.2 x 10 8 to 4 x 10 8 cells.

15. The use of any one of claims 1-13, wherein the medicament comprises 1 x 10 8 to 2 x 10 8 cells.

16. The use of any one of claims 1-13, wherein the medicament comprises 2 x 10 8 cells.

17. The use of any one of claims 1-13, wherein the medicament comprises 1.5 x 10 8 cells.

18. The use of any one of claims 1-17, wherein the medicament is formulated in a dosage form for a single intramyocardial injection.

19. The use of any one of claims 1-18, wherein the population of cells and / or progeny cells are autologous or allogeneic and / or the soluble factors are derived from autologous or allogeneic cells.

20. The use of any one of claims 1-19, wherein the population of cells and / or progeny thereof have been culture expanded.

21. The use of any one of claims 1-20, wherein the soluble factors have been obtained from culture expanded cells.

22. The use of any one of claims 1-21, wherein the mesenchymal lineage precursor cells or stem cells and / or progeny thereof and / or soluble factors derived therefrom are administered in the form of a composition comprising the mesenchymal lineage precursor cells or stem cells and / or progeny thereof and / or soluble factors derived therefrom and a carrier and / or excipient.

23. The use of any one of claims 1-22, wherein the mesenchymal lineage precursor cells or stem cells are mesenchymal stem cells.

24. The use of any one of claims 1-22, wherein the mesenchymal lineage precursor cells or stem cells are mesenchymal precursor cells.

25. The use of any one of claims 1-24, wherein the myocardial infarction is ST-elevation MI (STEMI) or non-ST-elevation myocardial infarction (NSTEMI).

26. A mesenchymal lineage precursor cell or stem cell expressing the marker TNAP+.

27. A mesenchymal lineage precursor cell or stem cell expressing the marker VCAM-1+.

28. A mesenchymal lineage precursor cell or stem cell expressing the marker THY-1+.

29. Use of a mesenchymal lineage precursor cell or stem cell of any one of claims 26-28 for the manufacture of a medicament for treating myocardial infarction in a subject.

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