Download 2015 08 26 CUPID 2 manuscript CLEAN FINAL

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Calcium Up-Regulation by Percutaneous Administration of Gene Therapy in Cardiac Disease
Phase 2b (CUPID 2): a Randomised, Multinational, Double-Blind, Placebo-controlled Trial
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Barry Greenberg, Javed Butler, G. Michael Felker, Piotr Ponikowski, Adriaan A. Voors, Akshay
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S. Desai, Denise Barnard, MD; Alain Bouchard, Brian Jaski, Alexander R. Lyon, MD, PhD; Janice
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M. Pogoda, Jeffrey J. Rudy, Krisztina M. Zsebo
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Affiliations: UCSD Sulpizio Cardiovascular Center, La Jolla, CA, USA (Prof B Greenberg MD,
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Prof D Barnard MD); Stony Brook University, Stony Brook, NY, USA (Prof J Butler MD); Duke
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University School of Medicine, Durham, NC, USA (Prof G M Felker MD); Wroclaw Medical
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University and Military Hospital, Wroclaw, Poland (Prof P Ponikowski MD); University of
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Groningen, Groningen, Netherlands (Prof A A Voors MD); Cardiovascular Division, Brigham and
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Women’s Hospital, Boston, MA, USA (A S Desai MD); Cardiology, PC, Birmingham, AL, USA (A
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Bouchard MD); San Diego Cardiac Center, Sharp Memorial Hospital, San Diego, CA, USA (B Jaski
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MD); Royal Brompton Hospital and Imperial College London, London, UK (A R Lyon MD);
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Celladon Corporation, San Diego, CA, USA (J M Pogoda PhD, J J Rudy BS); Santa Barbara, CA,
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USA (K M Zsebo PhD)
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Corresponding Author:
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Barry Greenberg, MD
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Distinguished Professor of Medicine
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Director Advanced Heart Failure Treatment Program
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UCSD Sulpizio Cardiovascular Center
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9444 Medical Center Dr., #7411
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La Jolla, CA 92037-7411
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Phone: 858-657-5267
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Email: [email protected]
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Key Words: Gene transfer therapy, heart failure, SERCA2a
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Funding statement: The clinical study, data analyses, and manuscript support were
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funded by Celladon Corporation.
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Summary
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Background Sarco/endoplasmic reticulum Ca2+ ATPase (SERCA2a) activity is deficient
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in the failing heart. Correction of this abnormality by gene transfer may improve
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cardiac function. CUPID 2 investigated the clinical benefits and safety of gene therapy
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through infusion of adeno-associated virus 1 (AAV1)/SERCA2a in heart failure patients
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with reduced ejection fraction.
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Methods CUPID 2 was a phase 2b, multinational, double-blind, placebo-controlled
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study of high-risk ambulatory patients with New York Heart Association class II-IV
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symptoms, ischemic or non-ischemic aetiology, and left ventricular ejection fraction
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≤0·35. The study was conducted at 67 clinical centres and hospitals in the United
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States, Europe, and Israel. Patients were randomised 1:1 via an interactive voice and
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web response system to receive a single intracoronary infusion of 1x1013 DNase-
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resistant particles of AAV1/SERCA2a or placebo. Randomisation was stratified by
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country and by 6 minute walk test distance. Patients were followed for ≥12 months.
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The primary efficacy endpoint was time to recurrent events (hospitalization,
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ambulatory worsening heart failure treatment) analysed using a joint frailty model to
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account for multiple, correlated events within subjects. Primary efficacy endpoint
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analyses and safety analyses were performed on all treated patients. The trial was
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registered with clinicaltrials.gov, number NCT01643330, and is now closed.
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Findings Between July 9, 2012 and February 5, 2014, 1558 patients were screened and
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250 were enrolled; 121 were infused with AAV1/SERCA2a and 122 with placebo.
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Compared with placebo, AAV1/SERCA2a did not improve the primary endpoint (128
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recurrent events versus 104 recurrent events; hazard ratio 0·93; 95% CI 0·53—1·65;
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p=0·81). No safety issues were noted.
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Interpretation CUPID 2 was the largest gene transfer study performed in heart failure
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patients to date. Despite promising results from earlier studies, a single intracoronary
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infusion of AAV1/SERCA2a at the dose tested did not improve the clinical course of
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heart failure patients with reduced ejection fraction.
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Funding Celladon Corporation.
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Introduction
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Despite advances in treatment, morbidity and mortality remain unacceptably high for
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patients with heart failure (HF)1 and new approaches for improving outcomes are
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needed. Identification of derangements in key pathways that regulate cardiac function
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has provided potential novel targets for gene therapy, and evidence that vectors such
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as adeno-associated viruses (AAVs) can deliver genes of interest to cardiomyocytes,
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resulting in sustained transgene expression in the heart, has stimulated interest in
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gene transfer as a strategy for treating HF. The sarco/endoplasmic reticulum Ca2+
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ATPase (SERCA2a) regulates cardiomyocyte contraction and relaxation by transporting
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Ca2+ from the cytosol into the sarcoplasmic reticulum during diastole.2,3 A deficiency
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of SERCA2a is related to HF progression.4,5 Correction of this deficiency has been
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shown to favourably affect calcium flux and improve the function of cardiomyocytes
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derived from failing hearts. Gene transfer of SERCA2a has also been shown to improve
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cardiac performance and survival in experimental models of HF.4,5 Recently, we
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reported that a single intracoronary infusion of recombinant AAV serotype 1 (AAV1)
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delivering the SERCA2a gene to the heart had favourable effects in patients with
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advanced HF in a pilot study.6,7 On the basis of these promising results, the Calcium
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Up-Regulation by Percutaneous Administration of Gene Therapy in Cardiac Disease
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Phase 2b (CUPID 2) study was designed to further assess the effects of AAV1/SERCA2a
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therapy on clinical outcomes in a larger group of patients with moderate to severe HF
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and reduced ejection fraction.8
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METHODS
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Study design
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The CUPID Phase 2b trial (CUPID 2; NCT01643330) was a multinational, double-blind,
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placebo-controlled, randomised study designed to investigate whether gene transfer
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therapy with SERCA2a improved outcomes in patients with HF and reduced ejection
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fraction. The study design has been published.8 The study was conducted at 67 centres
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and hospitals in the United States (US), Europe, and Israel according to the principles
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of the International Conference on Harmonisation Guideline on Good Clinical Practice
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and the principles of the World Medical Association Declaration of Helsinki. All
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relevant Institutional Review Board and Institutional Bio-Safety Committee approvals
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were obtained at each site. Manufacturing information is provided in the Appendix (p
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Participants
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Eligible patients were between 18 and 80 years of age with a diagnosis of stable New
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York Heart Association (NYHA) class II-IV chronic HF due to ischemic or non-ischemic
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cardiomyopathy and left ventricular ejection fraction ≤0·35 on optimal tolerated
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stable medical therapy for at least 30 days prior to randomisation. In response to a
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lower than anticipated pooled event rate during the early period of the trial, a
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protocol amendment designed to increase risk for future HF events was initiated after
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enrolment of 101 patients. This amendment required eligible patients to have
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elevated N-terminal pro–B-type natriuretic peptide (NT-proBNP) (>1,200 pg/mL, or
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>1,600 pg/mL if atrial fibrillation was present) or HF-related hospitalization within 6
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months of enrolment into the study. Patients were required to have <1:2 or equivocal
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anti-AAV1 neutralizing antibody (NAb) titres at screening.
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Exclusion criteria included cardiac surgery, percutaneous coronary intervention,
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valvuloplasty, or intravenous (IV) therapy for HF within 30 days prior to screening. A
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comprehensive list of exclusion criteria has been published. 8 All patients provided
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written informed consent.
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Randomisation and masking
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Following screening, patients were randomised in parallel in a 1:1 ratio to receive
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either 1x1013 DNase resistant particles (DRP) AAV1/SERCA2a or placebo.
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Randomisation was conducted through a fully validated and controlled interactive
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voice and web response system provided by Almac Clinical Technologies.
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Randomisation was stratified by country and the ability to walk between 150 and 425
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meters or outside of these distances on the 6 minute walk test (6MWT). A blinded kit
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was shipped to the investigative site following randomisation. All patients and
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physicians were blinded to treatment assignment, and the company that conducted
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randomisation was not involved with other facets of the trial.
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Procedures
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Drug was administered a single time to each patient. On day 0, before infusion of the
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investigational product, coronary angiography was performed to determine the
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strategy for administering AAV1/SERCA2a and to confirm that at least one coronary
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artery had Thrombolysis in Myocardial Infarction (TIMI) flow grade 3. Infusion of the
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investigational product was tailored to the patient and multiple infusion scenarios
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were possible depending on the extent and distribution of coronary artery stenosis,
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collateralization patterns, and anatomic variations. During the single administration of
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drug, operators were instructed to provide delivery using at most three infusions
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according to the distribution of left ventricular blood flow.8 The overall goal was to
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achieve homogeneous delivery to the myocardium with two-thirds of the dose to the
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anterolateral and one-third to the posterolateral myocardium. It was recognized that
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multiple coronary infusion scenarios were possible based on occlusive disease and
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collateralization patterns and investigators received instruction regarding perfusion
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options at the time their sites were activated. An IV nitroglycerin infusion was started
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10 to 25 minutes prior to infusion of the investigational product to enhance uptake of
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AAV1/SERCA2a in cardiomyocytes by increasing vasodilation of the capillary bed.9
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During the 12-month active observation period, assessments of efficacy, safety, and
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quality of life were undertaken at months 1, 3, 6, 9, and 12. Data collection on
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clinical endpoints continued until the primary analysis data cutoff was reached, which
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was when all patients completed the 12-month active observation period and at least
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186 adjudicated HF-related recurrent events had occurred.
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Outcomes
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The primary efficacy endpoint was time to recurrent events, defined as
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hospitalizations due to HF or ambulatory treatment for worsening HF. The secondary
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efficacy endpoint was time to first terminal event, defined as all-cause death, heart
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transplant, or durable mechanical circulatory support device (MCSD) implantation. All
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primary and secondary endpoints were reviewed by a blinded clinical endpoints
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committee (Appendix p 3) and adjudicated according to standardized definitions.
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Adjudication criteria for these events, as well as detailed statistical methods, have
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been previously described.8 Exploratory analyses included the effect of the
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investigational product on change from baseline in NYHA class, exercise ability as
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assessed by the 6MWT, quality of life as assessed by the Kansas City Cardiomyopathy
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Questionnaire (KCCQ), and NT-proBNP.
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Safety was assessed in all patients who received treatment with AAV1/SERCA2a or
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placebo. Safety parameters included incidence and severity of adverse events and
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time to cardiovascular-related death.
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Post-treatment tissue and serum processing
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During follow-up of patients enrolled in the study, participating centres were
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instructed to try to obtain tissue samples from treated patients at the time of cardiac
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transplantation, implantation of a MCSD, or at autopsy. The levels of AAV1/SERCA2a
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were determined using methods previously described.7 In addition, AAV1 NAb testing
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was performed in study patients using serum collected at the 6 month follow-up visit.
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Statistical analysis
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Monte Carlo simulation using background rates and correlations similar to those
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observed in CUPID 1 estimated that 186 recurrent events in 250 patients with a
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median follow-up time of 18 months would provide 80% power at the 0·05 two-sided
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significance level to detect a recurrent event hazard ratio (HR) of 0·55 using a joint
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frailty model.
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The intention-to-treat (ITT) analysis population was defined as all randomised
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subjects.10 A modified ITT (mITT) analysis population was also pre-specified,
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comprising only randomised patients who received study medication.10,11 The primary
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analysis of the primary and secondary endpoints was done at the primary analysis data
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cutoff using the mITT population ; secondary analyses were done using the ITT
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population (all randomised patients) and additional pre-specified populations
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(Appendix p 5). Treatment effects on the primary and secondary endpoints were
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estimated simultaneously by a semi-parametric joint frailty model12 implemented
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using the NLMIXED procedure13 in SAS (SAS Institute, Inc., Cary, NC). This model
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accounts for correlated recurrent events within patients and the correlation between
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recurrent and terminal events (i.e., informative censoring). The reference time point
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was randomisation date for the ITT population and treatment date for the mITT
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population and for the additional pre-specified populations (e.g. excluding patients
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who had major protocol deviations and excluding patients who were positive or
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equivocal for neutralizing antibodies). Primary and secondary endpoints were
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graphically depicted using the mean cumulative function14 and the survival function
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(estimated by the PHREG procedure in SAS), respectively. Sensitivity analyses using
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alternative models for both endpoints were also performed.
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The trial was registered with clinicaltrials.gov, number NCT01643330.
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Role of the funding source
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This trial, including patient management, data collection, and data analysis, was
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funded by Celladon Corporation. Celladon also provided funding for manuscript and
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graphics support. The corresponding author had full access to all data in the study
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and, with the support of the full author group, had final responsibility for the decision
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to submit for publication.
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Results
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From July 9, 2012 through February 5, 2014, 1558 patients at 67 centres in the US,
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Europe, and Israel underwent NAb prescreening for CUPID 2 (Figure 1). Of these
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patients, 921 (59·1%) were NAb positive and 284 (18·2%) were considered ineligible for
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other reasons, leaving 353 (22·7%) with a qualifying NAb titre (<1:2 or equivocal) who
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were eligible for further screening. Of these patients, 103 (29·2%) were excluded for
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reasons summarized in Figure 1, and 250 patients were enrolled into the study and
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randomised. Two of 123 patients allocated to receive AAV1/SERCA2a and five of 127
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patients allocated to placebo did not receive study drug infusion (Figure 1). The
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remaining 121 patients who received AAV1/SERCA2a and 122 patients who received
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placebo constituted the mITT population that was the pre-specified population for the
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primary efficacy analysis. Over the course of the study, 5 patients (3 in mITT)
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withdrew consent and 1 (in mITT) was lost to follow-up.
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The participants were predominantly white and male with two-thirds from the US
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(Table 1). A total of 135/250 (55·6%) patients had coronary artery disease and HF was
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ascribed to an ischemic aetiology in 125/250 (51·4%) patients. Patients had moderate
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to severe HF as evidenced by NYHA Functional Class, ejection fraction, 6MWT
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distance, KCCQ score, and NT-proBNP level. Baseline characteristics were balanced
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between groups.
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Median follow-up was 17·5 months since the study extended over 30 months in order
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to allow all randomised patients to be followed for at least 12 months. At the time the
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last patient had been followed for 12 months, a total of 232 recurrent and 65 terminal
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events had occurred in the mITT population. Of the 232 recurrent events that
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qualified as primary endpoints, 128 were in the placebo group and 104 were in the
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AAV1/SERCA2a group; most were HF hospitalizations. Treatment with AAV1/SERCA2a
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failed to improve the rate of recurrent events (HR, 0·93; 95% confidence interval [CI]
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0·53 to 1·65; p=0·81; Figure 2A and Table 2). Of the 65 terminal events that qualified
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as secondary endpoints, 29 were in the placebo group and 36 were in the
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AAV1/SERCA2a group; most were deaths (Table 2). AAV1/SERCA2a administration
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failed to improve time to first terminal event (HR, 1·27; 95% CI 0·72 to 2·24; p=0·40;
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Figure 2B). AAV1/SERCA2a treatment also did not improve time to all-cause death
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(Figure 2C).
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No differences between treatment groups were detected in subgroup analyses of the
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primary endpoint (Figure 3). In a pre-specified subgroup analysis of the secondary
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endpoint, there was a significant interaction between treatment and geography
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(Figure 3), with a higher HR in non-US patients compared with US patients. However,
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the number of events in the analysis of non-US patients was small (22 events in 85
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patients), and baseline disease characteristics suggest that non-US AAV1/SERCA2a
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patients may have had more severe illness than non-US placebo patients (Appendix
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Web Table 1). There was no such interaction for the primary endpoint. No other
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significant interactions were detected for pre-specified subgroup analyses, although a
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significant interaction was observed for the non-pre-specified subgroup of patients
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with diabetes. Post-hoc analyses of the primary and secondary endpoints stratified by
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randomisation in the study “pre” or “post” initiation of the protocol amendment
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designed to increase the risk for future HF events showed that there was no
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meaningful difference in treatment effect between these subgroups. For the primary
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endpoint, the HRs were 0·86 (95% CI 0·32 to 2·27) and 1·05 (95% CI 0·53 to 2·08) for
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“pre” and “post” amendment patients, respectively, while for the secondary endpoint
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the HRs were 1·14 (95% CI 0·53 to 2·44) and 1.38 (95% CI 0·59 to 3·25), respectively.
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There were no significant differences between treatment groups for any of the
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exploratory efficacy analyses (change from baseline in NYHA class, exercise ability as
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assessed by the 6MWT, quality of life as assessed by the KCCQ, or levels of NT-proBNP)
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over 12 months of follow-up. No significant treatment group differences were
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observed in the ITT analyses or in analyses conducted in other pre-specified
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populations (Appendix p 5).
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In safety evaluations, there were 262 clinical events in placebo and 190 in
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AAV1/SERCA2a patients (Table 3); most were hospitalizations. There were 20 deaths in
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placebo and 25 deaths in AAV1/SERCA2a patients, 18 and 22 of which were
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adjudicated as being due to cardiovascular causes. Comparisons of treatment-
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emergent serious adverse events occurring in ≥2% of either treatment group identified
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only one significant difference between groups: placebo patients had a higher rate of
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implantable defibrillator insertion than AAV1/SERCA2a patients (6/122 [4·9%] versus
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0/121 [0%]; p=0·03) (Appendix Web Table 2).
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Since the results of CUPID 2 were divergent from those of CUPID 1, which showed a
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beneficial effect of AAV1/SERCA2a on HF outcomes, post-hoc analyses were performed
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to provide potential insights into the differences in the efficacy of AAV1/SERCA2a
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therapy in CUPID 2 compared with CUPID 1. There were no obvious important
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differences in study population characteristics between these trials except for a
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higher use of cardiac resynchronization therapy in CUPID 1 (Appendix Web Table 3),
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which reflected the higher usage of this treatment modality in the exclusively US
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population in CUPID 1 as compared with the international population enrolled in CUPID
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2. A review of manufacturing processes identified a difference in the proportion of
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empty viral capsids (containing only the protein capsid and not the single stranded
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DNA) between CUPID 1 (85%) and CUPID 2 (25%) (Appendix Web Table 4), which may
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have affected transduction efficiency (Appendix p 4 and Web Figure 1).
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We assessed the presence of AAV1/SERCA2a in cardiac tissues from patients whose
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condition deteriorated requiring either transplant, or MCSD implantation and patients
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from whom cardiac tissue was obtained at autopsy. A total of 23 heart tissue samples
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were obtained from 7 patients (Appendix Web Table 5). The levels of vector DNA in
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these tissues (approximate median of 43 copies/μg DNA; range <10 to 192) were at the
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lower end of the threshold for dose response curve in pharmacology studies (<500
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copies/μg DNA). Although it is difficult to determine the number of cells that were
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transduced due to the variable ploidy of cardiomyocytes in advanced HF patients,15
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these levels are most consistent with the likelihood that only a very small percentage
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of cardiomyocytes were expressing AAV1-delivered SERCA2a in the myocardium of
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these patients.
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Testing for the presence of AAV1 NAbs showed the expected high rate of
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seroconversion in patients treated with AAV1/SERCA2a, but not in those who were
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treated with placebo (Appendix p 5 and Web Table 6). These NAbs are not expected to
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have influenced the level of SERCA2a expression, as an antibody response occurs days
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to weeks after the cells take up the AAV vector. Testing for the presence of an anti-
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AAV1 specific CD8 T cell response was conducted and found to be mostly negative, so
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a cellular immune response cannot explain the low level of transduced cells and lack
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of efficacy.
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Discussion
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CUPID 2 was the largest study of gene transfer performed in a HF population to date
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and the first to look at clinical events as the primary endpoint. On the basis of strong
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evidence demonstrating that a deficiency in SERCA2a adversely affects cardiac
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function and favourable results with AAV1/SERCA2a gene transfer in both
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experimental models and patients treated in pilot studies,6,7,16-20 CUPID 2 was designed
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to assess whether AAV1/SERCA2a administration improves the clinical course of
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moderate to severe HF patients with reduced ejection fraction who were receiving
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contemporary guideline-recommended therapy. The results showed that
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AAV1/SERCA2a at the dose used did not reduce either recurrent HF events (primary
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efficacy endpoint) or terminal events (secondary efficacy endpoint) in the overall
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study population or in pre-specified subgroups. However, no evidence of worsening of
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the clinical course of study patients emerged during the study.The negative results of
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CUPID 2 raise important questions. Although gene transfer is a promising approach for
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treating human disease, there has been limited success to date with this approach in
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treating patients with cardiovascular disease. Previous experimental studies showed
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that reduced SERCA2a activity was associated with abnormalities in calcium
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homeostasis and cardiomyocyte function and that correction of these abnormalities by
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gene transfer improved cardiac function and survival.2-5,16-19 In a pilot dose-finding
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study of AAV1/SERCA2a (CUPID 1) in patients with HF, administration of 1x1013 DRP
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was associated with stabilization or improvement in several independent measures of
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patient wellbeing and cardiac function. There was also a reduction in the recurrent
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event rate compared with patients who were treated with placebo.6,7, These results
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provided the rationale for and informed the design (including dose) for CUPID 2. The
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reasons for the failure of AAV1/SERCA2a to improve the clinical course of HF patients
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and the differences between the results of CUPID 1 and CUPID 2 are unclear. The
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entry criteria and treatment algorithms were similar between the studies, and
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although CUPID 2 added the requirement for elevated natriuretic peptide levels or a
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recent hospitalization during the course of the study to enrich for recurrent HF events,
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comparison of the profile of the patients included in the studies reveals no striking
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differences. Moreover, post-hoc analyses indicated that the amendment did not
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meaningfully affect the response to treatment for either the primary or secondary
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efficacy endpoints. However, the crude recurrent event rate in placebo patients was
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higher in CUPID 1 compared with CUPID 2 (1·27 per patient/yr vs. 0·7 per patient/yr,
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respectively), and CUPID 1 was a small study, with only 14 patients receiving placebo
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and nine receiving 1x1013 DRP AAV1/SERCA2a. These factors raise the possibility that
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the positive results observed in CUPID 1 were due to chance and/or to greater severity
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of illness in patients randomised to placebo. The negative results of CUPID 2,
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however, do not appear to be related to the high percentage of coronary artery
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disease (56%) in the population enrolled in the study, as there were no differences in
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outcomes by HF aetiology.
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Another possibility is inadequate delivery and uptake of the vector in the hearts of
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patients enrolled in CUPID 2. It is possible that other approaches for introducing
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AAV1/SERCA2a to the heart might have enhanced uptake into cardiomyocytes.21,22
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Intracoronary delivery of AAV1/SERCA2a, however, is simpler and more practical than
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other modes of delivery, and this technique was associated with significant increases
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in SERCA2a gene expression both in a large animal model using the same vector as in
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CUPID 218 and in pilot studies in which HF patients were treated with intracoronary
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delivery of AAV1/SERCA2a.6,7,20 However, in the intervening period between CUPID 1
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and CUPID 2, the work of Mingozzi et al. showed that not only is the quantity of full
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AAV viral capsid particles (containing the single stranded DNA and used for dose
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determination) important for in vivo activity, but also the total viral particle dose,
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including the proportion of empty capsid particles contained in the preparation.23
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Though perhaps counterintuitive, the possibility that a higher proportion of empty
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capsids improves gene transfer is supported by results presented in Appendix p 4 and
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Web Figure 1. These findings differ from results of earlier studies showing improved
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gene delivery with fewer empty capsids,24 likely related to the fact that previous work
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did not address the neutralization that might occur with vascular delivery of AAVs in
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vivo. Thus, empty capsids may serve as “decoy” proteins that block the inhibitory
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activity of antibodies and possibly of other serum-based interfering substances.23 The
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presence of even low titres of NAb (<1:2) or other interfering substances in vivo can
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shift the dose response curve; with a lower percentage of empty capsids in the
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preparation, higher doses are required in order to achieve the same level of gene
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transfer. The difference in the proportion of empty capsids in preparations used in
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CUPID 1 and CUPID 2, with a lower total particle dose infused in this study, may have
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contributed to a reduction in gene transfer efficiency in CUPID 2. Although the low
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level of vector DNA in the limited number of CUPID 2 patients from whom tissue was
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available is consistent with this possibility, these patients may not be representative
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of the overall study population since their condition had deteriorated to the point
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where they required advanced therapies. A fundamental question is whether SERCA2a
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was an appropriate target for therapy. Although deficiencies in SERCA2a activity in the
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failing heart and their correction by gene transfer have been demonstrated in
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experimental models,16-19 it is possible that these findings are not applicable in human
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HF and that, regardless of the level to which SERCA2a activity is raised, the impact
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would be insufficient to alter the trajectory of the disease. It is also possible that
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post-transcriptional or post-translational regulatory factors in patients may have
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negated enhanced transgene expression or enzyme activity in treated patients and
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that the earlier findings in animal studies showing significant improvement using this
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same vector do not translate to humans with HF.
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During the course of the study no signals regarding safety emerged. While it is
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reassuring that the intracoronary delivery of the drug can be safely performed in
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patients with moderate to severe HF due to reduced ejection fraction, concerns about
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the efficiency of AAV1/SERCA2a delivery raise the point that conclusive data on the
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safety of AAV1/SERCA2a will require demonstration of greater uptake and expression
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of the transgene in cardiomyocytes.
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Although we did note a significant interaction between treatment group and
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geography, suggesting that the risk of terminal events might be greater in the
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AAV1/SERCA2a group than in placebo in non-US patients, the number of patients and
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terminal events in this sub-group was small and the non-US AAV1/SERCA2a patients
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appear to have been somewhat sicker at baseline than non-US placebo patients. Thus,
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this finding was likely due to chance, sicker patients being randomized to
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AAV1/SERCA2a, or both. The lack of an increased HR for recurrent events, which
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should have been influenced in the same direction, suggests chance as the most likely
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explanation.
399
While the results of CUPID 2 show that antegrade coronary delivery of 1x1013 DRP of
400
AAV1/SERCA2a does not alter the clinical course of HF patients with reduced ejection
401
fraction, they raise a number of questions that will need to be addressed if future
402
studies in this area are to be successful. For the development of AAV1/SERCA2a,
403
evidence that efficiency might have been compromised by the lower number of empty
404
capsids raises the possibility that the latter was responsible for the negative results of
405
CUPID 2 and it provides the rational for further studies using drug with higher numbers
406
of total capsid proteins, which is best achieved by increasing the dose of
407
AAV1/SERCA2a. In addition, the issues raised by the negative results of CUPID 2 need
408
to be considered in designing trials with other constructs meant to enhance gene
409
expression in the failing heart in the future,25 and they suggest that it will be
410
important to characterize serum effects from the target patient population for their
411
potential impact on the biological potency of drugs used for gene transfer.
412
413
414
18
415
Contributors
416
All authors contributed to the interpretation of the results and writing of the manuscript and
417
all authors approved the decision to submit the manuscript for publication. BG, JB, GMF, PP,
418
AAV, ASD, DB, AB, BJ, and ARL were investigators in this study. JMP was the study statistician.
419
JJR, KMZ, and JMP were involved in study design. BG wrote and prepared the first draft of the
420
manuscript, with input from the other authors.
421
422
Declaration of interests
423
BG, JB, GMF, PP, AV, AD, DB, AB, BEJ, and ARL received financial support from Celladon
424
Corporation, the sponsor of this trial, in the form of grants, personal fees, and other financial
425
support. JMP, JJR, and KMZ were employees of Celladon during the CUPID 2 trial.
426
427
Acknowledgments
428
This trial was funded by Celladon Corporation. Celladon also provided funding for manuscript
429
and graphics support. We would like to thank all of the investigators (Appendix p 3) and
430
patients involved in this study. We wish to thank Roger Hajjar, M.D. (Mt. Sinai, New York, NY),
431
for his guidance on AAV1/SERCA2a development. ARL wishes to acknowledge support from the
432
National Institute for Health Research Cardiovascular Biomedical Research Unit, Royal
433
Brompton Hospital, and the British Heart Foundation. We wish to thank Sharon L. Cross, Ph.D.
434
for providing manuscript support and Julia Andres for providing graphics support on behalf of
435
Celladon.
436
437
19
438
439
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440
441
442
1
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Jessup M, Greenberg B, Mancini D, et al. Calcium upregulation by percutaneous
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Zsebo K, Yaroshinsky A, Rudy JJ, et al. Long-term effects of AAV1/SERCA2a gene
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8
Greenberg B, Yaroshinsky A, Zsebo KM, et al. Design of a phase 2b trial of
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9
Karakikes I, Hadri L, Rapti K, et al. Concomitant intravenous nitroglycerin with
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21
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Table 1: Characteristics at baseline in the modified intention-to-treat population.
Placebo
AAV1/SERCA2a
All patients
(n = 122)
(n = 121)
(N = 243)
Age (years)
58·4±12·26
60·3±9·77
59·3±11·11
Female sex
24 (19·7%)
21 (17·4%)
45 (18·5%)
White
98 (81·1%)
99 (81·8%)
198 (81·5%)
Black/African American
22 (18·0%)
18 (14·9%)
40 (16·5%)
American Indian/Alaskan Native
0 (0·0%)
1 (0·8%)
1 (0·4%)
Native Hawaiian/Pacific Islander
0 (0·0%)
1 (0·8%)
1(0·4%)
Other
1 (0·8%)
2 (1·7%)
3 (1·2%)
118 (96·7%)
114 (94·2%)
232 (95·5%)
4 (3·3%)
7 (5·8%)
11 (4·5%)
United States
79 (64·8%)
79 (65·3%)
158 (65·0%)
Non-United States*
43 (35·2%)
42 (34·7%)
85 (35·0%)
Coronary artery disease
67 (54·9%)
68 (56·2%)
135 (55·6%)
336·6 (71·29)
319·9 (91·47)
328·2 (82·23)
24·0 (6·26)
23·0 (6·48)
23·5 (6·37)
II
21 (17·2%)
22 (18·2%)
43 (17·7%)
III
100 (82·0%)
96 (79·3%)
196 (80·7%)
IV
1 (0·8%)
3 (2·5%)
4 (1·6%)
KCCQ (overall score)
59·2 (22·7)
58·4 (19·76)
58·8 (21·02)
NT-proBNP (pg/mL)
1504
1754
1679
(849-3031)
(843-3785)
(843-3561)
Characteristic
Race
Ethnicity
Not Hispanic
Hispanic
Country
Six-minute walk test (meters)
Left ventricular ejection fraction (%)
NYHA functional class
22
Placebo
AAV1/SERCA2a
All patients
(n = 122)
(n = 121)
(N = 243)
Ischemic
63 (51·6%)
62 (51·2%)
125 (51·4%)
Idiopathic
50 (41·0%)
48 (39·7%)
98 (40·3%)
Hypertensive
5 (4·1%)
5 (4·1%)
10 (4·1%)
Familial
1 (0·8%)
2 (1·7%)
3 (1·2%)
Peripartum
2 (1·6%)
0 (0·0%)
2 (0·8%)
Other
1 (0·8%)
7 (5·8%)
8 (3·3%)
ACE inhibitor/ARB
110 (90·2%)
111 (91·7%)
221 (90·9%)
Aldosterone antagonist
74 (60·7%)
83 (68·6%)
157 (64·6%)
Beta blocker
117 (95·9%)
117 (96·7%)
234 (96·3%)
Diuretic
109 (89·3%)
111 (91·7%)
220 (90·5%)
Digoxin
48 (39·3%)
45 (37·2%)
93 (38·3%)
OAC/NOAC
81 (66·4%)
76 (62·8%)
157 (64·6%)
Cardiac resynchronization therapy
39 (32·0%)
53 (43·8%)
92 (37·9%)
Implantable cardioverter-defibrillator
89 (73·0%)
98 (81·0%)
187 (77·0%)
Chronic renal insufficiency
37 (30·3%)
36 (30·0%)
73 (30·2%)
Type 2 diabetes
49 (40·2%)
59 (48·8%)
108 (44·4%)
Atrial fibrillation
49 (40·2%)
44 (36·4%)
93 (38·3%)
COPD
18 (14·8%)
15 (12·5%)
33 (13·6%)
Characteristic
Heart failure aetiology
Heart failure regimen
Other medical history
510
511
Data are mean (standard deviation) or n (%) except for NT-proBNP, which is median (IQR).
512
There were no significant differences between the two groups in baseline demographic or
513
disease characteristics.
23
Sweden (8/7/15), Great Britain (6/8/14), Denmark (5/6/11), Poland (6/5/11), Germany
514
*
515
(5/5/10), Hungary (5/3/82), Israel (5/3/8), Belgium (3/4/7), and the Netherlands (0/1/1) for
516
Placebo, AAV1/SERCA2, and All Patients, respectively .
517
ACE inhibitor=angiotensin-converting enzyme inhibitor. ARB=angiotensin-receptor blocker.
518
COPD=chronic obstructive pulmonary disease. IQR=interquartile range. KCCQ=Kansas City
519
Cardiomyopathy Questionnaire. NT-proBNP=N-terminal pro-B-type natriuretic peptide.
520
NYHA=New York Heart Association. OAC/NOAC=oral anti-coagulant/novel oral anti-coagulant.
521
522
24
523
Table 2: Primary and secondary endpoints at the primary analysis data cutoff in the
524
modified intention-to-treat population
Outcome
Placebo
(N=122)
AAV1/SERCA
Hazard ratio
2a
(CI)
p value
(N=121)
Primary endpoint
Recurrent events
128 (73·9)
104 (62·8)
0·93
0·81
(0·53-1·65)
HF- related
121 (69·8)
96 (57·9)
7 (4·0)
8 (4·8)
29 (16·7)
36 (21·7)
hospitalizations
Ambulatory
treatment for
worsening HF
Secondary endpoint
First terminal event
1·27
(0·72–2·24)
Death
19 (11·0)
24 (14·5)
Heart transplant
2 (1·2)
5 (3·0)
Durable MCSD
8 (4·6)
7 (4·2)
implant
525
526
Data are n (rate per 100 patient-years). CI=confidence interval. HF=heart failure.
527
MCSD=mechanical circulatory support device.
528
0·41
25
529
Table 3. Rates of adjudicated clinical events in the safety population*
Placebo
AAV1/SERCA2a
(N=122)
(N=121)
All clinical events†
262 (147)
190 (111)
All-cause hospitalizations
240 (135)
172 (100)
121 (67·9)
99 (57·7)
Ambulatory treatment for worsening HF
7 (4·0)
8 (4·8)
Non-fatal myocardial infarctions
5 (2·8)
3 (1·7)
Non-fatal strokes
3 (1·7)
5 (2·9)
Heart transplant
4 (2·2)
7 (4·1)
Durable MCSD implant
8 (4·5)
7 (4·1)
20 (11·2)
25 (14·6)
2 (1·1)
3 (1·7)
18 (10·1)
22 (12·8)
Pump failure
11 (6·2)
14 (8·2)
Sudden death
3 (1.7)
7 (4·1)
Presumed sudden death
1 (0·6)
0 (0)
Arrhythmia
2 (1·1)
0 (0)
Fatal stroke
0 (0)
1 (0·6)
1 (0·6)
0 (0)
Outcome
HF- related hospitalizations
Deaths
Non-cardiovascular
Cardiovascular
Non-traumatic subdural hematoma
530
Data are n (rate per 100 patient-years)
531
* The numbers of recurrent and terminal events differ slightly from the numbers in the
532
efficacy analysis shown in Table 2 due to specific definitions used for primary and secondary
533
endpoints. For example, in the primary efficacy analysis, only first terminal events were
534
counted, and recurrent events that occurred after terminal events were not counted.
535
†
536
as a hospitalization.
537
MCSD=mechanical circulatory support device.
538
539
540
541
542
Excluding all heart failure (HF) hospitalizations and any other clinical event already counted
26
543
Figure legends
544
Figure 1. Trial profile
545
546
Fx=failure. HF=heart failure. I/E=inclusion/exclusion. ITT=intention-to-treat. mITT=modified
intention-to-treat. NAb=neutralizing antibodies. URI=upper respiratory infection.
547
548
549
Figure 2. Kaplan-Meier curves for cumulative number of recurrent events per patient at
550
the primary analysis data cutoff (A), the probability of being terminal-event free at the
551
primary analysis data cutoff (B), and the probability of death from any cause (C) in
552
patients assigned to AAV1/SERCA2a (blue) or placebo (yellow) in the modified intention-to-
553
treat population
554
CI=confidence interval.
555
556
557
Figure 3. Subgroup analyses
558
Hazard ratios (HR) for recurrent events (primary endpoint) and first terminal event (secondary
559
endpoint) in the listed subgroups. The size of the square corresponds to the number of
560
patients in each subgroup. Pre-specified analyses consisted of overall patient population,
561
geography, heart failure (HF) aetiology, New York Heart Association (NYHA) class, and years of
562
age. CI=confidence interval. ICD=implantable cardioverter-defibrillator. ITT=intent-to-treat.
563
LVEF=left ventricular ejection fraction. mITT=modified ITT. NT-proBNP=N-terminal pro-B-type
564
natriuretic peptide. US=United States