Use of mesenchymal stem cells in the treatment of juvenile hypoplastic left heart syndrome

Abstract

The present disclosure provides a method of treating hypoplastic left heart syndrome in a patient in need thereof, the method comprising administering a therapeutically effective amount of mesenchymal stem cells. The method may further comprise measuring various biomarkers associated with cardiac health and function following administration of the mesenchymal stem cells to determine both the efficacy of the treatment and whether further administration of mesenchymal stem cells is required to achieve a therapeutic benefit.

Description

[Technical field]

[0001] [CROSS REFERENCE TO RELATED APPLICATIONS] This application claims the benefit of U.S. Provisional Patent Application No. 63 / 203,519, filed July 26, 2021, the contents of which are incorporated herein by reference.

[0002] The present disclosure relates to the use of mesenchymal stem cell compositions in the treatment of Juvenile Hypoplastic Left Heart Syndrome (HLHS). [Background technology]

[0003] Hypoplastic left heart syndrome (HLHS) is a rare cardiac birth defect in which the components of the left ventricle (LV) are variably underdeveloped to such an extent that the LV cannot support the systemic circulation (Ohye, RG, et al., "Comparison of shunt types in the Norwood procedure for single-ventricle lesions", New England Journal of Medicine, (2010) 362(21), 1980-1992). The only reason that HLHS patients survive is because of the presence of a patent ductus arteriosus (PDA) between the neonatal pulmonary artery (PA) and aorta, allowing the right ventricle (right ventricle, RV) to support the systemic circulation. However, the duct closes spontaneously within a few days after birth, and in the absence of a systemic circulation dependent on this duct, HLHS infants cannot survive without early surgical intervention (BARRON et al., "HYPOPLASTIC LEFT HEART SYNDROME", THE LANCET, (2009) 374(9689), 551-564). In addition to an underdeveloped LV, HLHS exhibits a variety of anatomical defects, including a hypoplastic aorta and aortic arch, and mitral atresia or stenosis. Depending on the extent of these abnormalities, HLHS can present with a range of severity.

[0004] In HLHS hearts, deoxygenated blood returns to the right atrium (RA), which is similar to the blood flow seen in a normal heart. However, oxygenated blood that enters the left atrium (LA) from the pulmonary veins does not exit at the LV, but instead enters the RA via a defect in the atrial septum (patent foramen ovale), where it mixes with the deoxygenated blood and causes a cyanotic state. This mixed blood in the RV then proceeds to the PA and splits into two directions. Part of this mixed blood flows into the lungs for oxygenation, which is similar to the blood flow seen in a normal heart. The remaining blood flow passes through the PDA into the aorta, allowing systemic circulation. However, without intervention, the ductus closes, the right side of the heart can no longer support circulation, and the failure of the left heart to support systemic circulation appears, which leads to unavoidable fatal consequences (Barron et al., 2009; Ohye et al., 2010).

[0005] Currently, HLHS is most often diagnosed prenatally using echocardiography to observe the absence of a normal "four-chamber" heart. Although there are chromosomal and genetic abnormalities associated with HLHS, the genetic causes are diverse and heterogeneous (Rychik, J. "Hypoplastic left heart syndrome: from in-utero diagnosis to school age", published in Seminars in Fetal and Neonatal Medicine (2005)).

[0006] Infants with HLHS are born of normal weight and height, but postnatal manifestations of the syndrome and the significant metabolic stress of the required open heart reconstructive surgery result in apparent growth difficulties (Kelleher, Laussen, Teixeira-Pinto, and Duggan, "Growth and correlates of nutritional status among infants with hypoplastic left heart syndrome (HLHS) after stage 1 Norwood procedure," Nutrition, (2006) 22(3), 237-244). Physical growth is measured by age- and sex-adjusted Z-score, which is the number of standard deviations above or below the mean for the general population. A Z-score of 0 corresponds to the 50th percentile, with positive additions to higher percentiles and vice versa. Kelleher et al. reported that at the time of admission for stage II surgery, approximately 60% of children with HLHS were in the fifth or lower weight-for-age percentile (weight-for-age Z score < -1.65), while approximately 40% were in the fifth or lower height-for-age percentile (height-for-age Z score < -1.65). Length of hospital stay, length of ICU stay, and more readmissions were independently correlated with poor physical growth (Kelleher et al., 2006).

[0007] As mentioned above, the variable underdevelopment of LV components is a life-threatening condition in patients with HLHS, which, without surgical intervention, is fatal shortly after birth and accounts for 25%-40% of all neonatal cardiac mortality (Barron et al., 2009).

[0008] The cyanotic state inherent to HLHS, together with an underdeveloped aorta, also leads to coronary insufficiency, which is a major cause of adverse cardiac disease. Furthermore, the single ventricle state of HLHS, even after reconstructive surgery, leads to abnormal loading conditions in the RV as it functions as the only systemic pumping chamber. This can result in adverse remodeling, despite the possibility of cardiac management. Potential manifestations are dilatation (enlargement of the ventricle), myocardial hypertrophy (thickening of the heart wall), and fibrosis (death of cardiac cells replaced by scar tissue), which can ultimately lead to heart failure (Wehman et al., "Mesenchymal stem cells preserve neonatal right ventricular function in a porcine model of pressure overload," Am J Physiol Heart Circ Physiol, (2016) 310(11), H1816-1826.doi:10.1152 / ajpheart.00955.2015). Heart failure can lead to the need for a heart transplant and / or death.

[0009] Options for managing HLHS include reconstructive surgery, heart transplantation, and palliative care (also called compassionate care). These options are time-sensitive and parents of children with HLHS experience great stress when making these decisions (Toebbe, Yehle, Kirkpatrick, and Coddington, "Hypoplastic left heart syndrome: parent support for early decision making," Journal of pediatric nursing, (2013) 28(4), 383-392).

[0010] The one-year survival rate for children with HLHS who undergo reconstructive surgery is 20%-60% (Siffel, Riehle-Colarusso, Oster, & Correa, "Survival of Children With Hypoplastic Left Heart Syndrome", Pediatrics, (2015) 136(4), e864-870.doi:10.1542 / peds.2014-1427), and these procedures require several follow-up hospitalizations and additional surgical interventions. Survivors have limited physical abilities, increased risk of cognitive impairment, and other long-term complications (Kon, Ackerson, & Lo, "How pediatricians counsel parents when no best-choice management exists: lessons to be learned from hypoplastic left heart syndrome", Archives of pediatrics&adolescent medicine, (2004) 158(5), 436-441). In those who choose reconstructive surgery, heart transplantation is the final end-of-life option if the postoperative clinical outcome is poor. Nevertheless, the overall 1-year survival rate for patients who have undergone surgery or transplantation is approximately 40% (Kon et al., 2004), a significant and devastating mortality rate, and new therapeutic strategies to improve outcomes are needed.

[0011] Due to technological advances in reconstructive surgery, survival rates after each stage of surgery have improved over the past few decades. However, there is still significant operative mortality, especially in stage I (Norwood) and between stages I and II (Siffel et al., 2015). Morris et al. reported a 26% neonatal mortality rate (up to 28 days after birth) in 463 infants with HLHS from the Texas Birth Defects Registry from 1999 to 2007 (Morris et al., "Prenatal diagnosis, birth location, surgical center, and neonatal mortality in infants with hypoplastic left heart syndrome," Circulation, (2014) 129(3), 285-292). The in-hospital mortality rate after the Norwood procedure has been shown to decline from 40.4% in the 1984-1988 period to 15.7% in the 2009-2014 period (Mascio et al., "Thirty years and 1663 consecutive Norwood procedures: has survival plateaued?", J Thorac Cardiovasc Surg, (2019) 158(1), 220-229). The 1-year survival rate for HLHS is estimated to range from 20% to up to 74% (Ohye et al., 2010; Siffel et al., 2015). A 2018 study showed that the 1-year survival rate is approximately 60% regardless of whether HLHS is diagnosed prenatally or postnatally (Alabdulgader, "Survival analysis: prenatal vs. postnatal diagnosis of HLHS", J Invasive Noninvasive Cardiol, (2018) 1, 8-12). Similarly, Son et al. demonstrated a nearly 60% avoidance of death or transplant one year after the Norwood procedure (Son et al., "Prognostic value of serial echocardiography in hypoplastic left heart syndrome," Circulation:Cardiovascular Imaging, (2018)11(7), e006983).SVR trials have reported 6-year transplant-free survival of 60%. Thus, despite improvements in outcomes, mortality in patients with HLHS remains daunting.

[0012] Neonates, infants, and children combined bear the burden of morbidity and mortality from HLHS. Even with the most advanced standard treatment options, early mortality is significant, reaching 60% by age 15 (Mahle, Spray, Wernovsky, Gaynor, and Clark III, "Survival after reconstructive surgery for hypoplastic left heart syndrome: a 15-year experience from a single institution," Circulation, (2000) 102(suppl_3), Iii-136-Iii-141). Therefore, novel treatment options that improve transplant-free survival and quality of life are desperately needed to improve the current outlook and long-term outcomes of HLHS. Summary of the Invention

[0013] [overview] The following disclosure includes a method of treating HLHS, the method comprising administering to a subject in need of treatment for HLHS a composition of mesenchymal stem cells (MSCs). [Brief description of the drawings]

[0014] [Figure 1] Figure 1 shows the change in right ventricular mass for each patient over the course of the clinical trial, with data indexed according to the patient's body surface area (BSA). [Diagram 2] FIG. 1 shows the change in right ventricular ejection fraction for each patient during the clinical trial. [Diagram 3] This figure shows the change in right ventricular end-systolic volume for each patient during the clinical trial. The data was indexed to the patient's BSA. [Figure 4] This figure shows the change in right ventricular end-diastolic volume for each patient during the clinical trial. The data was indexed to the patient's BSA. [Diagram 5] This figure shows the change in stroke volume for each patient during the clinical trial. The data was indexed to the patient's BSA. [Figure 6] FIG. 1 shows the change in height Z-score versus age for each patient over the course of the clinical trial. [Figure 7] FIG. 1 shows the change in weight Z-score versus age for each patient over the course of the clinical trial. [Figure 8] FIG. 1 shows the change in systolic blood pressure for each patient over the course of the clinical trial. [Figure 9] FIG. 1 shows the change in diastolic blood pressure for each patient over the course of the clinical trial. [Figure 10] FIG. 1 shows the change in heart rate for each patient over the course of a clinical trial. [Figure 11] FIG. 1 shows the change in tricuspid regurgitation rate in selected patients over the course of the clinical trial. [Figure 12] FIG. 1 shows the change in net aortic forward flow in tricuspid regurgitation in selected patients over the course of a clinical trial. [Figure 13] FIG. 1 shows the change in tricuspid regurgitation for each patient over the course of the clinical trial. [Figure 14] FIG. 1 shows a comparison of post-treatment survival rates between patients receiving Lomecel-B™ cells for the treatment of HLHS and patients undergoing the clinical trial conducted by Son et al. for the treatment of HLHS. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0015] [Detailed Description] MSCs are multipotent cells that are immune-competent and can migrate to sites of injury and inflammation (Klyushnenkova et al., "Growth and correlates of nutritional status among infants with hypoplastic left heart syndrome (HLHS) after stage 1 Norwood procedure", Nutrition, (2006) 22(3), 237-244; Le Blanc et al., "Mesenchymal stem cells for treatment of steroid-resistant, severe, acute graft-versus-host disease: a phase II study", Lancet, (2008) 371(9624), 1579-1586. doi:10.1016 / S0140-6736(08)60690-X).The exact mechanism of action of MSCs is not yet fully understood, but appears to involve complex cooperation with host cells (Hatzistergos et al., "Bone marrow mesenchymal stem cells stimulate cardiac stem cell proliferation and differentiation", Circ Res, (2010) 107(7), 913-922; A.R.Williams et al., "Enhanced effect of combining human cardiac stem cells and bone marrow mesenchymal stem cells to reduce infarct size and to restore cardiac function after myocardial infarction", Circulation, (2013) 127(2), 213-223, doi:10.1161 / CIRCULATIONAHA.112.131110 2013; A.R.Williams et al., "Intramyocardial stem cell injection in patients with ischemic cardiomyopathy: functional recovery and reverse remodeling", Circ Res, (2011)108(7), 792-796, doi:10.1161 / CIRCRESAHA.111.242610).MSCs have shown potential clinical benefit in cardiovascular disease due to their pro-angiogenic and anti-inflammatory properties (Cao et al., "S-nitrosoglutathione reductase-dependent PPARgamma denitrosylation participates in MSC-derived adipogenesis and osteogenesis", J Clin Invest, (2015) 125(4), 1679-1691, doi:10.1172 / jci73780; Hatzistergos et al.; A.R. Williams and Hare, JM, "Mesenchymal stem cells: biology, pathophysiology, translational findings, and therapeutic implications for cardiac disease", Circ Res, (2011) 109(8), 923-940, doi:10.1161 / CIRCRESAHA.111.243147).

[0016] MSCs secrete many bioactive molecules that stimulate the recruitment, proliferation, and differentiation of endogenous stem cells, inhibit apoptosis and fibrosis, and stimulate angiogenesis. MSCs can also control the host stem cell niche through cell-cell interactions. Thus, MSCs can enhance intrinsic repair and regeneration mechanisms. Preclinical studies have shown that MSCs promote cardiac recovery and regeneration directly through the formation of new tissue and indirectly through paracrine effects (Malliaras, Kreke, and Marban, "The stuttering progress of cell therapy for heart disease," Clin Pharmacol Ther, (2011) 90(4), 532-541, doi:10.1038 / clpt.2011.175; Rosen, Myerburg, Francis, Cole, and Marban, "Translating stem cell research to cardiac disease therapies: pitfalls and prospects for improvement," J Am Coll Cardiol, (2014) 64(9), 922-937, doi:10.1016 / j.jacc.2014.06.1175).

[0017] Therefore, the present inventors have surprisingly found that the use of a composition comprising MSCs can combat the symptoms of HLHS. It has been found that treating a patient suffering from the symptoms of HLHS with a composition comprising MSCs improves the morphology and function of the subject's heart. The above finding is surprising, because there is a general concern among those skilled in the art against using MSCs to treat HLHS, since MSCs are expected to function poorly due to their short residence time in the human body.

[0018] Given the above surprising findings, one objective of the present disclosure is to provide a method of treating or alleviating HLHS, comprising administering a therapeutic amount of MSCs to a subject in need of treatment to alleviate symptoms of HLHS and / or treat progression of HLHS. The efficacy of the treatment methods disclosed herein can be determined by measuring changes in biomarkers related to cardiac health and function. These biomarkers can be changes in the patient's right ventricular mass, right ventricular ejection fraction, right ventricular end systolic volume, right ventricular end diastolic volume, stroke volume, height-for-age Z-score, weight-for-age Z-score, systolic blood pressure, diastolic blood pressure, heart rate, or combinations thereof following administration and / or treatment of MSCs. Thus, the treatment methods disclosed herein can include measuring any of the above biomarkers before and / or after administration of MSCs to the patient. Measuring these biomarkers can determine the efficacy of the treatment and whether further administration of mesenchymal stem cells is required to achieve a therapeutic benefit.

[0019] As used herein, the term "therapeutic effect" includes, but is not limited to, an improvement in the function or health of a patient's heart following administration of MSCs.

[0020] As used herein, the term "patient" includes, but is not limited to, humans and non-human vertebrates, such as wild, domestic, and livestock animals. In some embodiments, the term refers to a human younger than 18 years of age. In some embodiments, a human patient exhibits symptoms of HLHS.

[0021] In some embodiments, the method of treatment includes measuring the change in right ventricular mass of the patient following administration of the MSCs. In exemplary embodiments, following administration of the MSCs, the patient's right ventricular mass increases by 0.1%-10%, 0.5%-10%, 1.0%-10%, 3%-10%, 5%-10%, 7%-10%, greater than 0% to less than 10%, 10%-50%, 20%-50%, 30%-50%, or greater than 50%. In other exemplary embodiments, the change in right ventricular mass of the patient following administration of the MSCs increases to a stable weight where the weight does not decrease by more than 0.1%-10%, 0.1%-5%, or 0.1%-1%.

[0022] In other embodiments, the method of treatment includes measuring the change in the right ventricular ejection fraction of the patient following administration of the MSCs. In exemplary embodiments, following administration of the MSCs, the right ventricular ejection fraction of the patient is reduced by 0.1%-10%, 0.5%-10%, 1.0%-10%, 3%-10%, 1%-5%, 1%-3%, greater than 0% to less than 5%, 10%-50%, 20%-50%, 30%-50%, or greater than 50%. In other exemplary embodiments, the change in the right ventricular ejection fraction of the patient following administration of the MSCs is reduced to a stable level where the right ventricular ejection fraction does not increase by more than 0.1%-10%, 0.1%-5%, or 0.1%-1% after reaching and maintaining an ejection fraction different from the ejection fraction prior to administration of the MSCs to the patient in need of treatment.

[0023] In some embodiments, the method of treatment includes measuring the change in right ventricular end systolic volume of the patient following administration of the MSCs. In exemplary embodiments, following administration of the MSCs, the patient's right ventricular end systolic volume increases by 0.1%-10%, 0.5%-10%, 1.0%-10%, 3%-10%, 5%-10%, 7%-10%, greater than 0% to less than 10%, 10%-50%, 20%-50%, 30%-50%, or greater than 50%. In other exemplary embodiments, the change in the patient's right ventricular end systolic volume following administration of the MSCs increases to a stable volume where the volume does not decrease by more than 0.1%-10%, 0.1%-5%, or 0.1%-1% after reaching and maintaining a volume different from the volume prior to administration of the MSCs to the patient in need of treatment.

[0024] In other embodiments, the method of treatment includes measuring the change in right ventricular end diastolic volume of the patient following administration of the MSCs. In exemplary embodiments, following administration of the MSCs, the patient's right ventricular end diastolic volume increases by 0.1%-10%, 0.5%-10%, 1.0%-10%, 3%-10%, 5%-10%, 7%-10%, greater than 0% to less than 10%, 10%-50%, 20%-50%, 30%-50%, or greater than 50%. In other exemplary embodiments, the change in right ventricular end diastolic volume of the patient following administration of the MSCs increases to a stable volume that does not decrease in weight by more than 0.1%-10%, 0.1%-5%, or 0.1%-1% after reaching and maintaining a volume different from the volume prior to administration of the MSCs to the patient in need of treatment.

[0025] In some embodiments, the method of treatment includes measuring the change in stroke volume of the patient after administration of the MSCs. In exemplary embodiments, after administration of the MSCs, the patient's stroke volume is reduced by 0.1%-10%, 0.5%-10%, 1.0%-10%, 3%-10%, 1%-5%, 1%-3%, greater than 0% to less than 5%, 10%-50%, 20%-50%, 30%-50%, or greater than 50%. In other exemplary embodiments, the change in the patient's stroke volume after administration of the MSCs is reached and maintained at an amount different from the amount before administration of the MSCs to the patient in need of treatment, and then reduced to a stable level where the stroke volume does not increase by more than 0.1%-10%, 0.1%-5%, or 0.1%-1%.

[0026] In some embodiments, the method of treatment includes measuring the change in Z-score of height for age of the patient after administration of the MSCs. In exemplary embodiments, after administration of the MSCs, the Z-score of height for age of the patient increases in the range of 0.1%-10%, 0.5%-10%, 1.0%-10%, 3%-10%, 5%-10%, 7%-10%, more than 0% to less than 10%, 10%-50%, 20%-50%, 30%-50%, or more than 50%. In other exemplary embodiments, the change in Z-score of height for age of the patient after administration of the MSCs increases to a stable level where the Z-score does not decrease by more than 0.1%-10%, 0.1%-5%, or 0.1%-1% after reaching and maintaining a Z-score different from the Z-score before administration of the MSCs to the patient in need of treatment.

[0027] In some embodiments, the method of treatment includes measuring the change in Z-score of the patient's weight for age after administration of the MSCs. In exemplary embodiments, after administration of the MSCs, the Z-score of the patient's weight for age increases in the range of 0.1%-10%, 0.5%-10%, 1.0%-10%, 3%-10%, 5%-10%, 7%-10%, more than 0% to less than 10%, 10%-50%, 20%-50%, 30%-50%, or more than 50%. In other exemplary embodiments, the change in Z-score of the patient's weight for age after administration of the MSCs increases to a stable level where the Z-score does not decrease by more than 0.1%-10%, 0.1%-5%, or 0.1%-1% after reaching and maintaining a Z-score different from the Z-score before administration of the MSCs to the patient in need of treatment.

[0028] In some embodiments, the method of treatment includes measuring the change in the patient's systolic blood pressure after administration of the MSCs. In exemplary embodiments, after administration of the MSCs, the patient's systolic blood pressure increases by 0.1%-10%, 0.5%-10%, 1.0%-10%, 3%-10%, 5%-10%, 7%-10%, greater than 0% to less than 10%, 10%-50%, 20%-50%, 30%-50%, or greater than 50%. In other exemplary embodiments, the change in the patient's systolic blood pressure after administration of the MSCs increases to a stable pressure where the pressure does not decrease by more than 0.1%-10%, 0.1%-5%, or 0.1%-1% after reaching and maintaining a pressure that is different from the pressure before administration of the MSCs to the patient in need of treatment.

[0029] In some embodiments, the method of treatment includes measuring the change in the patient's diastolic blood pressure after administration of the MSCs. In exemplary embodiments, after administration of the MSCs, the patient's diastolic blood pressure changes by 0.1%-10%, 0.5%-10%, 1.0%-10%, 3%-10%, 5%-10%, 7%-10%, greater than 0% to less than 10%, 10%-50%, 20%-50%, 30%-50%, or greater than 50%. In other exemplary embodiments, the change in the patient's diastolic blood pressure after administration of the MSCs is reached and maintained at a pressure different from the pressure before administration of the MSCs to the patient in need of treatment, followed by a stable pressure where the pressure does not change by more than 0.1%-10%, 0.1%-5%, or 0.1%-1%.

[0030] In some embodiments, the method of treatment includes measuring the change in the patient's heart rate following administration of the MSCs. In exemplary embodiments, following administration of the MSCs, the patient's heart rate changes by 0.1%-10%, 0.5%-10%, 1.0%-10%, 3%-10%, 5%-10%, 7%-10%, greater than 0% to less than 10%, 10%-50%, 20%-50%, 30%-50%, or greater than 50%. In other exemplary embodiments, the change in the patient's heart rate following administration of the MSCs, once a heart rate different from the heart rate prior to administration of the MSCs to the patient in need of treatment is reached and maintained, changes to a stable heart rate where the heart rate does not change by more than 0.1%-10%, 0.1%-5%, or 0.1%-1%.

[0031] In some embodiments, the method of treatment includes measuring a change in the patient's tricuspid regurgitation following administration of the MSCs. In an exemplary embodiment, the patient's tricuspid regurgitation is improved from a severe condition to a moderate or mild condition.

[0032] In other embodiments, the method of treatment includes measuring a change in the patient's tricuspid regurgitation rate following administration of the MSCs. In exemplary embodiments, following administration of the MSCs, the patient's tricuspid regurgitation rate is reduced by 0.1%-10%, 0.5%-10%, 1.0%-10%, 3%-10%, 5%-10%, 7%-10%, greater than 0% to less than 10%, 10%-50%, 20%-50%, 30%-50%, or greater than 50%. In other exemplary embodiments, the change in the patient's tricuspid regurgitation rate following administration of the MSCs reaches and is maintained at a rate different from the rate prior to administration of the MSCs to the patient in need of treatment, and then decreases to a stable rate where the rate does not decrease by more than 0.1%-10%, 0.1%-5%, or 0.1%-1%.

[0033] In other embodiments, the method of treatment includes measuring a change in the net aortic forward flow of the patient's tricuspid regurgitation following administration of the MSCs. In exemplary embodiments, following administration of the MSCs, the patient's net aortic forward flow of the tricuspid regurgitation increases by 0.1%-10%, 0.5%-10%, 1.0%-10%, 3%-10%, 5%-10%, 7%-10%, greater than 0% to less than 10%, 10%-50%, 20%-50%, 30%-50%, or greater than 50%. In other exemplary embodiments, the change in the net aortic forward flow of the patient's tricuspid regurgitation following administration of the MSCs is achieved and maintained at a net aortic forward flow that is different from the net aortic forward flow prior to administration of the MSCs to the patient in need of treatment, followed by an increase in the net aortic forward flow to a stable net aortic forward flow where the net aortic forward flow does not increase by more than 0.1%-10%, 0.1%-5%, or 0.1%-1%.

[0034] In other embodiments, the method of treatment includes measuring patient survival following administration of the MSCs. In exemplary embodiments, following administration of the MSCs, patient survival is increased by 0.1%-10%, 0.5%-10%, 1.0%-10%, 3%-10%, 5%-10%, 7%-10%, greater than 0% to less than or equal to 10%, 10%-50%, 20%-50%, 30%-50%, or greater than 50%.

[0035] Mesenchymal stem cell compositions used in embodiments of the present invention can include isolated allogeneic human mesenchymal stem cells derived from bone marrow and / or adipose tissue, or LOMECEL-B™ cells (Longeveron formulation of allogeneic human mesenchymal stem cells) as reported in the following U.S. Patent Application Publications: U.S. Patent Application Publication No. 20190038742, U.S. Patent Application Publication No. 20190290698, and U.S. Patent Application Publication No. 20200129558, all of which are incorporated herein by reference.

[0036] As used herein, the term "allogeneic" refers to cells that are of the same animal species but that differ genetically at one or more loci from the animal that will be the "recipient host." It is typically applied to cells that are transplanted from one animal to another, non-identical animal of the same species.

[0037] In an exemplary embodiment, the MSCs are administered in a therapeutically effective amount of about 1×10 6 , 2×10 6 , 5×10 6 , 10×10 6 , 20×10 6 , 30×10 6 , 40×10 6 , 50×10 6 , 60×10 6 , 70×10 6 , 80×10 6 , 90×10 6 , 100×10 6 , 110×10 6 , 120×10 6 , 130×10 6 , 140×10 6 , 150×10 6 , 160×106 , 170×10 6 , 180×10 6 , 190×10 6 , 200×10 6 , 300×10 6 , 400×10 6 , 500×10 6 Or 10 x 10 7 Pieces or 20 x 10 6 ~100×10 6 Any amount of MSCs between 1 and 2 may be administered.

[0038] As used herein, a "therapeutically effective amount" refers to an amount of MSCs that promotes improvement of cardiac function. Such improvement is characterized by an increase in right ventricular mass or an increase in end diastolic / end systolic volume. The amount and frequency of administration (e.g., single or multiple administrations) to a patient will vary depending on a variety of factors, including the route of administration, the condition and characteristics of the patient (gender, age, weight, health, size), the severity of symptoms, concurrent treatments, frequency of treatment, and the desired effect.

[0039] In exemplary embodiments, the patient is between 1 and 15 years old, between 3 and 15 years old, between 3 and 10 years old, between 5 and 10 years old, or between 5 and 15 years old. In some embodiments, the patient is under 1 year old.

[0040] In other exemplary embodiments, the treatment methods further comprise measuring changes in a biomarker disclosed herein immediately after administration, one month after administration, two months after administration, six months after administration, nine months after administration, or any time between the start of administration and 12 months after administration.

[0041] In an exemplary embodiment, the MSCs are administered as a single dose. In another embodiment, the MSCs are administered multiple times, e.g., two or more times. In other embodiments, the MSCs are administered at least annually.

[0042] In other exemplary embodiments, administration of the MSCs is repeated such as at least 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, or 18 months after the initial administration of the isolated population of MSCs, or between 2-4, 2-6, 2-8, 2-10, 3-4, 3-6, 3-8, 3-10, 4-6, 4-8, 4-10, 6-8, 6-10, 6-12, or 12-18 months after the initial administration of the MSCs. EXAMPLES

[0043] Example 1 This example is based on a Phase I clinical trial involving the use of mesenchymal stem cells to treat juvenile HLHS. The Phase I trial was an open-label study entitled "Longeveron Mesenchymal Stem Cells (LMSCs) Administered During Stage II Surgery for Hypoplastic Left Heart Syndrome (ELPIS Phase I Trial)". The objective was to evaluate the safety and feasibility of intramyocardial injection of Lomecel-B™ formulations in HLHS patients during stage II reconstructive surgery in 10 consecutive patients who met the enrollment criteria (Kaushal et al., "Study design and rationale for ELPIS: A phase I / IIb randomized pilot study of allogeneic human mesenchymal stem cell injection in patients with hypoplastic left heart syndrome", American heart journal, (2017) 192, 48-56, doi: https: / / doi.org / 10.1016 / j.ahj.2017.06.009).

[0044] The study enrolled 10 HLHS patients requiring stage II surgery. The main exclusion criteria were restrictive or complete atrial septum, presence of significant coronary sinus, patients requiring mechanical circulatory support before surgery, and evidence of arrhythmia requiring antiarrhythmic treatment. After placing patients on cardiopulmonary bypass for stage II surgery, Lomecel-B™ formulation was administered at 2.5×10 ng / mL by intramyocardial injection using a 27-gauge needle once surgery was completed and prior to weaning from cardiopulmonary bypass. 6 Patients were administered 100 cells / kg body weight. Baseline evaluations were performed before stage II reconstructive surgery and follow-up was performed 6 and 12 months after surgery to assess safety and interim clinical outcomes, including cardiac function by MRI.

[0045] During the clinical trial, the following primary endpoints (safety) and secondary endpoints (efficacy) were measured and monitored:

[0046] Primary endpoints included: Incidence of major adverse cardiac events through one year after treatment, including: sustained / symptomatic ventricular tachycardia requiring inotropic intervention; Worsening heart failure; Myocardial infarction; Unplanned cardiovascular surgery for cardiac tamponade; and Death; and First infection in the first month after treatment.

[0047] Secondary endpoints included: Change from baseline in: Right ventricular function; right ventricular end-diastolic volume; right ventricular end-systolic volume; right ventricular end-systolic diameter; Tricuspid regurgitation measured by serial echocardiograms and MRI. Changes in physical growth (weight, height, head circumference); and Assessment of comorbidities, including: cardiovascular disease; The need for transplantation; readmission; cardiovascular mortality; and Mortality from all causes.

[0048] Patient population Table 1 summarizes the demographics and baseline characteristics of the study population. Ten patients who underwent stage II reconstruction were successfully treated with Lomecel-B™ formulation. The cohort included seven men and three women, all of whom were non-Hispanic, seven were Caucasian, and three were African American, with a mean age of 4.89 ± 0.85 months at the time of stage II surgery. All patients had successful stage II surgery with intraoperative injection of Lomecel-B™ formulation. The mean hospital stay was 11.7 ± 9.58 days. All patients had an RV-PA shunt in stage I (Norwood). Other baseline characteristics, including cardiac parameters measured by MRI, are shown in Table 1.

[0049] [Table 1]

[0050] Sphericity for each patient was calculated using the following formula: sphericity = RV length (D) / (RVD SAX A / P).

[0051] Safety findings Intramyocardial injections of the Lomecel-B™ formulation were well tolerated, with no major adverse cardiac events (MACE), infections, or other adverse events considered related to treatment with the study drug reported.

[0052] Efficacy findings Data are presented as mean ± SD. Data were collected from multiple sites. Statistical analysis was performed using GraphPad Prism v9.2. For multiple comparisons, one-way ANOVA with mixed effects model was used with Bonferroni correction. An alpha of <0.05 was considered statistically significant.

[0053] The BSA of each patient was calculated using the Haycock formula (BSA = 0.024265 h 0.3964 ·w0.5378 , h = patient's height (cm), w = patient's weight (kg).

[0054] The efficacy of the clinical trial was evaluated by determining whether there was a significant change in any of the secondary endpoints after patients were administered Lomecel-B™ cells. These secondary endpoints were measured using echocardiograms and magnetic resonance imaging (MRI). Table 2 contains the secondary endpoint MRI data for all treatment groups (including the Longeveron study mentioned above and the four additional patients), data are indexed to BSA. Table 3 contains the secondary endpoint MRI data for only the Lomecel-B™ formulation treatment group, data are indexed to BSA. Each * indicates p<0.05 compared to baseline. ** indicates p<0.01 compared to baseline. *** indicates p<0.001 compared to baseline.

[0055] [Table 2]

[0056] [Table 3]

[0057] Figure 1 shows the change in right ventricular mass for each patient over the course of the clinical trial. Measurements were taken at the start of the trial, 6 months after treatment, and 12 months after treatment. The data shown in Figure 1 was indexed according to the patient's BSA. Table 4 contains the MRI data used to determine the change in right ventricular mass for each patient after treatment with Lomecel-B™ cells.

[0058] [Table 4]

[0059] Figure 2 shows the change in right ventricular ejection fraction for each patient over the course of the clinical trial. Measurements were taken at the start of the trial, 6 months after administration, and 12 months after administration. Table 5 contains the MRI data used to determine the change in right ventricular ejection fraction for each patient after administration of Lomecel-B™ cells.

[0060] [Table 5]

[0061] Figure 3 shows the change in right ventricular end systolic volume for each patient over the course of the clinical trial. Measurements were taken at the start of the trial, 6 months after administration, and 12 months after administration. The data shown in Figure 3 was based on the patient's BSA. Table 6 contains the MRI data used to determine the change in right ventricular end systolic volume for each patient after administration of Lomecel-B™ cells.

[0062] [Table 6]

[0063] FIG. 4 shows the change in right ventricular end diastolic volume for each patient over the course of the clinical trial. Measurements were taken at the start of the clinical trial, 6 months after administration, and 12 months after administration. The data shown in FIG. 4 is based on the patient's BSA. Table 7 contains the MRI data used to determine the change in right ventricular end diastolic volume for each patient after administration of Lomecel-B™ cells.

[0064] [Table 7] Figure 5 shows the change in stroke volume for each patient over the course of the clinical trial. Measurements were taken at the start of the trial, 6 months after administration, and 12 months after administration. The data shown in Figure 5 was based on the patient's BSA. Table 8 contains the MRI data used to determine the change in stroke volume for each patient after administration of Lomecel-B™ cells.

[0065] [Table 8]

[0066] In addition to examining the changes in right ventricular mass and volume, physical growth was also examined for all patients. Physical growth for each patient was measured by an age- and height / weight-adjusted Z-score, which is one standard deviation above or below the mean for the general population. A Z-score of 0 corresponds to the 50th percentile, with positive additions to higher percentiles and vice versa. FIG. 6 shows the change in height Z-score for each patient's age at the start of the study, after 6 months of treatment, and after 12 months of treatment. FIG. 7 shows the change in weight Z-score for each patient's age at the start of the study, after 6 months of treatment, and after 12 months of treatment. Table 9 contains the data used to determine the change in height Z-score for each patient's age after administration of Lomecel-B™ cells. Table 10 contains the data used to determine the change in weight Z-score for each patient's age after administration of Lomecel-B™ cells.

[0067] [Table 9]

[0068] [Table 10]

[0069] The blood pressure and heart rate of each patient were also monitored during the clinical trial. Both blood pressure and heart rate were measured for each patient at the start of the clinical trial, after 24 weeks of treatment, and after 48 weeks of treatment. FIG. 8 shows the change in systolic blood pressure for each patient after treatment. FIG. 9 shows the change in diastolic blood pressure for each patient after treatment. FIG. 10 shows the change in heart rate for each patient after treatment. Table 11 contains the data used to determine the change in systolic blood pressure for each patient after treatment with Lomecel-B™ cells. Table 12 contains the data used to determine the change in diastolic blood pressure for each patient after treatment with Lomecel-B™ cells. Table 13 contains the data used to determine the change in heart rate for each patient after treatment with Lomecel-B™ cells.

[0070] [Table 11]

[0071] [Table 12]

[0072] [Table 13]

[0073] Tricuspid regurgitation in each patient was also investigated during the clinical trial. FIG. 11 shows the change in tricuspid regurgitation rate for selected patients at the start of the clinical trial, after 6 months of treatment, and after 12 months of treatment. FIG. 12 shows the change in net aortic forward flow of tricuspid regurgitation in selected patients at the start of the clinical trial, after 6 months of treatment, and after 12 months of treatment. FIG. 13 shows the change in tricuspid regurgitation in each patient at the start of the clinical trial, after 6 months of treatment, and after 12 months of treatment. Table 14 contains the data used to determine the change in tricuspid regurgitation rate for each selected patient after treatment with Lomecel-B™ cells. Table 15 contains the data used to determine the change in net aortic forward flow of tricuspid regurgitation in each selected patient after treatment with Lomecel-B™ cells. Table 16 contains the data used to determine the change in tricuspid regurgitation in each patient after treatment with Lomecel-B™ cells.

[0074] [Table 14]

[0075] [Table 15]

[0076] [Table 16]

[0077] The average survival rate of each patient after treatment was also measured and compared to the survival rate of patients enrolled in previous HLHS clinical trials, specifically the clinical trial conducted by Son et al. (Son et al., "Prognostic value of serial echocardiography in hypoplastic left heart syndrome," Circulation: Cardiovascular Imaging, (2018) 11(7), e006983). Figure 14 illustrates this comparison.

[0078] Study findings Intramyocardial injections of the Lomecel-B™ formulation were well tolerated, with no major adverse cardiac events (MACE), infections, or other adverse events considered related to treatment with the study drug. Efficacy results from the study included improved patient survival and sustained RV function.

[0079] In summary, treatment of HLHS patients with Lomecel-B™ was safe and demonstrated encouraging clinical outcomes, with higher transplant-free survival rates than stage II surgery without Lomecel-B™ (historical controls) and preservation of RV contractile force as measured by GLS. These clinical findings indicate the potential of Lomecel-B™ formulations to treat HLHS and reduce mortality and the need for heart transplantation.

Claims

1. A therapeutic agent for treating juvenile hypoplastic left heart syndrome in a patient, comprising a therapeutically effective amount of allogeneic mesenchymal stem cells.

2. The therapeutically effective amount is 1×10 ６ ~5 x 10 ６ 10. The method of claim 1, wherein the therapeutic agent is administered by intramyocardial injection.

3. The therapeutic agent according to claim 1, for changing the right ventricular mass of the patient after administration of the therapeutically effective amount of allogeneic mesenchymal stem cells.

4. The therapeutic agent described in claim 3, wherein the change in right ventricular weight of the patient after administration of the therapeutically effective amount of allogeneic mesenchymal stem cells is an increase in right ventricular weight of 0.1% to 10%.

5. The therapeutic agent according to claim 1, for changing the right ventricular ejection fraction or tricuspid regurgitation rate of the patient after administration of the therapeutically effective amount of allogeneic mesenchymal stem cells.

6. The therapeutic agent described in claim 5, wherein the change in the patient's right ventricular ejection fraction or tricuspid regurgitation rate after administration of the therapeutically effective amount of allogeneic mesenchymal stem cells is a decrease in the right ventricular ejection fraction or tricuspid regurgitation rate of 0.1% to 10%.

7. The therapeutic agent according to claim 1, for changing the right ventricular end-systolic volume of the patient after administration of the therapeutically effective amount of allogeneic mesenchymal stem cells.

8. The therapeutic agent described in claim 7, wherein the change in right ventricular end-systolic volume of the patient after administration of the therapeutically effective amount of allogeneic mesenchymal stem cells is an increase in right ventricular end-systolic volume of 0.1% to 10%.

9. The therapeutic agent according to claim 1, for changing the right ventricular end-diastolic volume of the patient after administration of the therapeutically effective amount of allogeneic mesenchymal stem cells.

10. The therapeutic agent according to claim 9, wherein the change in right ventricular end-diastolic volume of the patient after administration is an increase in right ventricular end-diastolic volume of 0.1% to 10%.

11. The therapeutic agent according to claim 1, for changing the stroke volume of the patient after administration of the therapeutically effective amount of allogeneic mesenchymal stem cells.

12. The therapeutic agent according to claim 1, for changing the height-for-age Z-score of the patient after administration of the therapeutically effective amount of allogeneic mesenchymal stem cells.

13. The therapeutic agent according to claim 1, for changing the Z-score of weight for age of the patient after administration of the therapeutically effective amount of allogeneic mesenchymal stem cells.

14. The therapeutic agent according to claim 1, for changing the systolic blood pressure of the patient after administration of the therapeutically effective amount of allogeneic mesenchymal stem cells.

15. The therapeutic agent according to claim 1, for changing the diastolic blood pressure of the patient after administration of the therapeutically effective amount of allogeneic mesenchymal stem cells.

16. The therapeutic agent according to claim 1, for changing the heart rate of the patient after administration of the therapeutically effective amount of allogeneic mesenchymal stem cells.

17. The method of claim 1, wherein the therapeutically effective amount of allogeneic mesenchymal stem cells is administered to the patient by intramyocardial injection.

18. The method of claim 1, wherein the therapeutically effective amount of allogeneic mesenchymal stem cells is administered to the patient in a single dose.

19. The therapeutic agent described in claim 1, wherein the patient is under 1 year old.

20. The therapeutic agent according to claim 1 , wherein the allogeneic mesenchymal stem cells are derived from bone marrow and / or adipose tissue.

21. The therapeutic agent of claim 1 for changing the tricuspid regurgitation rate in the patient after administration of the therapeutically effective amount of allogeneic mesenchymal stem cells.

22. The therapeutic agent of claim 1, for reducing tricuspid regurgitation in said patient after administration of said therapeutically effective amount of allogeneic mesenchymal stem cells, thereby increasing net aortic forward flow in said patient.

23. The therapeutic agent according to claim 1, for increasing the survival rate of the patient after administration of the therapeutically effective amount of allogeneic mesenchymal stem cells.

24. The therapeutic agent described in claim 1, wherein the patient is 1 to 15 years old.

25. The therapeutic agent described in claim 1, characterized in that the therapeutically effective amount of allogeneic mesenchymal stem cells is administered to the patient multiple times.

26. A therapeutic agent as described in claim 1 for maintaining RV contractile force measured by global longitudinal strain (GLS).

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