Nabil Dib
Analyst · Maxim Group
Yes, extremely important question, extremely important question. And the way we select those patient, depending on a clinical symptoms, number one. And number two, depending on objective finding, testing that we do. For the clinical symptoms, we have a classification depending on New York heart class, so it will be Class 1, 2, 3 and 4. And 4 is the worst and 1 is the best. And usually, those patients in category 3 and 4, which means on minimal activity, even if they are walking in the room, they might have shortness of breath. Sometimes, if they are sleeping, they wake up with shortness of breath. That's the clinical symptom that's usually. So minimal activity can induce their symptoms. Fatigue, tired, short of breath, those are the complaints. Now we go and we always look ischemic versus non-ischemic is easy to differentiate. If patient have heart attack in the past we call them ischemic, or if they have significant blockages in the blood vessel of their heart, decreasing the blood flow to the heart, those are ischemic. Now we go farther and say, if we cannot fix those artery with a stent, everything usually done for those patients, they already -- if bypass surgery can be done, it should be done, if angioplasty or stent can be done, it should be done. And usually those patient, they have all those already done and they have some of them a pacemaker already in place and they are on optimal medical therapy, which is beta-blockers, ACE inhibitors and so on. But despite the standard of care and that's what's really the importance of this -- of the biologic and cell therapy in this field. So in addition to standard of care, all standard of care there, and they are exhausted and patient continue to suffer, those are the patient -- and angiographically if nothing can be done for them and their heart function reduced less than 30% their function by echocardiography and, well, of course, we'll look at some criteria just to make sure that the procedure is safe, which just means that the aortic valve is okay. We cut across it, there's no clot in the heart, in the ventricle. So is it safe, per se? Those are the patient that surely we would like to -- will be the ideal candidates for this. And from my experience, I did the first stem cell therapy in the United States with the myoblast and it was a Class 3 and 4 population. And we don't want to cross the line to go to a very, very sick patient, who is taking inotrope and his heart is very sick, he might not tolerate the procedure and we can increase the risk. We can have complication that can lead to a problem. So, yes, there is a fine line and very important to recognize a clinically and with objective testing to make sure that we can do the procedures safely and we can -- hopefully, they will help -- also benefit from the cell therapy in the same time. And those are not small number of patient. As you know, in the United States alone, there's 500,000 patients per year die of heart failure and actually, 2/3 of them is ischemic, between 65% to 70%. Those are ischemic because of a coronary artery disease. There's a 5 million admission per year from heart failure. And 2/3 of those, as I said, ischemic. So the market is huge in terms of the market. But for us, for the clinical trial, we have to clearly train our investigators to do that safely. Like what you said, there's a really good fine line between safety and efficacy.