Technical Description of the Invention Method to induce neovascular formation and tissue regeneration using the Vascular Endothelial Growth Factor (VEGF). More particularly, a method for in vivo localized induction of neovascular formation and tissue regeneration in mammals utilizing VEGF.

Technical Field of the Invention The present invention relates to a gene therapy method for stimulating the revascularization and tissue regeneration.

Background of the Invention Ischemic heart disease is the main cause of morbidity and mortality. The epidemiological and socio-economical impact of coronary heart disease is remarkable.

This disease causes million of deaths all over the world. See Murray, et al., Lancet, 349 : 269-276 (1997). In developed countries, it has been estimated that 5.3 million deaths attributable to cardiovascular disease occurred in 1990, whereas the corresponding figure for the developing countries ranged between 8 to 9 million (showing a relative excess of 70%). See Reddy, et al., Circulation, 97 : 596-601 (1998). In Argentina, ischemic heart disease is the first cause of mortality showing an incidence of around 30%, trend which tends to remain stable since 1980. For the population over 65 years, this rate reaches almost 40%. See Programa Nacional de Estadisticas de Salud, Series 5, Number 38, Ministerio de Salud y Action Social, Republics Argentina (December 1995).

Despite recent advances in prevention and treatment of ischemic heart disease, there are many patients who are still symptomatic and cannot benefit from conventional therapy. Administration of growth factors that promote neovascular formation and growth, such as fibroblast growth factors (FGFs) and VEGF, appear as

a novel and promising alternative for these patients. This mode of treatment is called therapeutic angiogenesis. See Henry, B. M. J., 318 : 1536-1539 (1999).

VEGF is a protein expressed by skeletal muscle cells, smooth muscle cells, ovarian corpus luteum cells, tumor cells, fibroblasts and cardiomyocytes. Unlike other mitogens, VEGF is a secreted growth factor. See Thomas, J. Biol. Chem, 271 : 603-606 (1996); Leung, et al., Science, 246 : 1306-1309 (1989). The human VEGF gene is expressed as different isoforms, secondary to post-transcriptional alternative splicing.

In non-malignant human tissues, four VEGF isoforms are expressed, with different numbers of amino acids (121,165,189,206) and with a molecular weight ranging from 34 to 46 kD. See Tischer, et al., J. Biol. Chem., 266 : 11947-11954 (1991); Ferrara, etal., J : Cell. BiocAçem., 47 : 211-218 (1991).

VEGF specific receptors are VEGFR-1 (flt-1), VEGFR-2 (I (DR/fik-l) and VEGFR-3 (flt-4). See De Vries, et al., Science, 254 : 989-991 (1992) ; Terman, et al., Biochem. Bioplays. Res. Commuyi., 187 : 1579-1586 (1992); Gallant, et al., Geno7nics, 13 : 475-478 (1992). Due to the apparent restricted and confined localization of VEGF receptors to vascular endothelial cells, this growth factor has been described as the most specific mitogen for these cells. It has been proposed that VEGF is not bioactive on non-endothelial cells. See Jakeman, et al., J. Clin. Invest., 89 : 244-253 (1992); Ferrara, et al., Endocr. Rev., 18 : 4-25 (1997); Thomas, et al., supra (1996). However, recent studies have reported mitogenic effects of VEGF on some non-endothelial cell types, such as retinal pigment epithelial cells, pancreatic duct cells and Schwann cells.

See Guerring et al., J Cell. Phisiol., 164 : 385-394 (1995); Oberg-Welsh et al., Mol.

Cell. Endocrinol., 126 : 125-132 (1997); Sundell et al., J. Neurosci., 19 : 5731-5740 (1999). Moreover, VEGF receptors have been found in other cells, such as hematopoietic stem cells, endocardial cells and even cultured rat cardiomyocytes, where VEGF has been shown to activate the mitogen-activated protein kinase cascade. See Asahara et al., Science,275:964-967 (1997); Partanen et al., Circulation, 100 : 583-586 (1999); Takahashi et al., Circ. Res., 84 : 1194-1202 (1999).

Therapeutical administration of VEGF is a significant challenge. VEGF can be administered as a recombinant protein (protein therapy) or by VEGF-encoding gene transfer (gene therapy). See Safi, et al., J : Mol. Cell. Cardiol., 29 : 2311-2325 (1997); Simons, et al., Circulation, 102 : E73-E86 (2000).

Protein therapy has important disadvantages. The extremely short mean-life of angiogenic proteins (e. g. VEGF) conditions therapy to the administration of high or

repeated doses to achieve a noticeable effect. See Simons, et al., supra (2000); Takeshita, et al., Circulation, 90 : II228-234 (1994). Furthermore, intravenous administration of high doses of VEGF protein is known to induce severe or refractory hypotension. See Henry, et al., J. A77l. Coll. Cardiol., 31 : 65A (1998); Horowitz, et al., Arterioscl. Thromb. Vasc. Biol., 17 : 2793-2800 (1997); Lopez, et al., Am. J Phisiol., 273: H1317-1323 (1997). To avoid these disadvantages, gene therapy (e. g. DNA encoding for VEGF) has been proposed. See Mack, et al., J. Thorac. Cardiovasc.

Surg., 115 : 168-177 (1998); Tio, et al., Hum. Gene Ther., 10 : 2953-2960 (1999).

Gene therapy can be compared to a drug slow-delivery system. The gene encoding for the agent of interest is transported into cells in vehicles called vectors (e. g. plasmids, viruses, liposomes). Cell mechanisms specialized in protein synthesis perform the production and localized release of the final product. See Crystal, Science, 270 : 404-410 (1995). In addition, it should be noted that in the case of plasmids the gene product is synthesized for a discrete period of time. This time is usually about two weeks. According to experimental studies, sustained expression during this limited period of time is necessary and sufficient to trigger the angiogenic process.

Based on these advantages, several research groups have studied the therapeutic effects of gene therapy using angiogenic factors in experimental models of heart and limb ischemia. These approaches have yielded promising results. See Magovem, Ann.

Thorac. Surs, 62: 425-434 (1996); Mack, et al., supra (1998); Tio, et al., supra (1999); Walder, et al., J. Cardiovasc. Pharmacol., 27: 91-98 (1996); Takeshita, et al., Lab. Invest., 75 : 487-501 (1996); Mack, et al., Gen. Vasc. Surg, 27: 699-709 (1998); Tsurumi, et al., Circulation, 94 : 3281-3290 (1996). Gene therapy has achieved the expected effects without the shortcomings associated with protein therapy. However, adenoviral gene therapy may induce inflammatory or immune reactions, especially after repeated doses. This type of therapy has been related also to high risk systemic immune response syndrome. These circumstances limit significantly the clinical use of this therapy. See Gilgenkrantz, et al., Hum. Gene Ther., 6 : 1265-1274 (1995); Dewey, et al., Nat. Med., 5 : 1256-1263 (1999); Werston, et al., J. Virol., 72: 9491-9502 (1998); Hollon, Nat. Med., 6 : 6 (2000), Chang, et al., Nat. Med., 5 : 1143-1149 (1999); Byrnes, et al., J Nerosci., 16 : 3045-3055 (1996). According to recent studies, plasmid gene therapy does not have these disadvantages and can be administrated safely in repeated doses. See Simons, et al., supra (2000).

Systemic administration of VEGF has been associated with undesired angiogenesis in peripheral tissues. See Folkman, Nat. Med., 1 : 27-31 (1995); Liotta, et al., Cell, 64 : 327-336 (1991); Lazarous, et al., Circulation, 94 : 1074-1082 (1996); Ferrara, Breast Cancer Res. Treat., 36 : 127-137 (1995); Ferrara, Lab. Invest., 72: 615- 618 (1995); Aiello, et al., N. E7zg J. Med., 331 : 1480-1485 (1994); Adams, et al., Am.

J. Ophthal7nol., 118 : 445-450 (1994); Inoue, et al., Circulation, 98 : 2108-2116 (1998); Simons, et al., supra (2000). The risk of systemic exposure is probably more related to the route of administration than to the nature of therapy (gene or protein) utilized.

In comparison with intravascular delivery, local (e. g. intramyocardial) administration reduces the risk of systemic exposure and undesired peripheral angiogenesis. See Simons, et al., supra (2000).

At the present, it has been demonstrated that VEGF induces angiogenesis in vivo. It has not been reported yet that VEGF induces the formation of blood vessels with smooth muscle layer. See Mack, et al., supra (1998); Tio, et al., supra (1999).

Moreover, it has been postulated that VEGF prevents the neoformation of vascular smooth muscle. See Asahara, et al., Circulation, 91 : 2793-2801 (1995). Smooth muscle plays a significant role in the regulation of vascular function. Its presence at the media layer of blood vessels represents an adaptative advantage since it is involved in the vasomotor tone regulation. Vascular smooth muscle maintains a basal vascular tone and permits self-regulation upon variations on blood flow and pressure.

It has been suggested that the absence of smooth muscle layer is related to vessel collapse. See"Angiogenesis and Cardiovascular Disease", Ware, Ed. (Oxford University Press Inc., New York, USA., 1999), p. 258-261.

Acute myocardial infarction is the consequence of coronary heart disease with the worst short and long-term prognosis. See Bolognese, et al., Am. Heart J, 138 : S79- 83 (1999); Mehta, et al., Herz, 25 : 47-60 (2000); Hessen, et al., Cardiovasc. Clin., 20: 283-318 (1989); Jacoby, et al., J : Am. Coll. Cardiol., 20: 736-744 (1992); Rosenthal, et al., Am. Heart A, 109 : 865-876 (1985). This condition results frequently in a significant loss of myocardial cells, reducing the contractile muscle mass. It is known in the art that cardiomyocytes of human and human-like species preserve their ability to replicate DNA. See Pfizer, et al., Curr. Top. Pathol., 54 : 125-168 (1971).

Recently, it has been informed that some human cardiomyocytes can enter into M (mitotic) phase. However, this phenomenon occurs in a very small proportion of total cardiomyocyte population and under certain pathological conditions. So far, this

phenomenon has only been noted in myocardial infarction and end-stage cardiac failure. See Beltrami et al., N. Eng. J Med., 344 : 1750-1757 (2001); Kajsutra, et al., Proc. Natl. Acad. Sci. USA, 95 : 8801-8805 (1998). There is no conclusive evidence in all these instances that cardiomyocytes divide into daughter cells.

The inability of cardiomyocytes to replicate properly precludes the replacement of myocardial tissue after injury in upper animal species. Under this scenario, myocardial function is diminished because the infarcted area is replaced by fibrotic tissue without contractile capacity. In addition, the remaining cardiomyocytes become hypertrophic and develop polyploid nuclei. See Herget, et al., Cardiovasc.

Res. 36 : 45-51 (1997) ;"Textbook of Medical Physiology", 9th Ed., Guyton et al., Eds.

(W. B. Saunders Co, USA, 1997).

Attempts have been made to restore myocardial cell loss with other cells, such as autologous satellite cells and allogenic myoblasts. The results of these attempts are not conclusive. See Dorfinan, et al., J. Thorac. Cardiovasc. Surg., 116 : 744-751 (1998); Murry, et al., J Clin. Invest., 98 : 2512-2523 (1996); Leor, et aL, Circulation, 94 Suppl. Il : II-332-II-336 (1996); Ren-Ke, et al., Circ. Res., 78 : 283-288 (1996). More recently, it has been suggested that pluripotent stem cells and bone marrow derived angioblasts might restore infarcted myocardial tissue and induce even neovascular formation. However, the efficiency of these methods in upper mammals has not been demonstrated yet. See Orlic, et al., Nature, 410 : 701-705 (2001); Kocher, et al., Nat.

Med., 7: 430-436 (2001). An ideal method should induce cardiomyocyte division originating daughter cells and neovascular formation in myocardial tissue. This procedure would restore tissue loss with autologous myocardial tissue and increase simultaneously myocardial perfusion. A method like this would reduce the morbility and mortality rates associated to left ventricular remodeling, myocardial infarction and ischemic heart disease. See Bolognese, et al., supra (1999).

Likewise, the failure of cardiomyocytes to replicate properly difficult adaptative hyperplasia (i. e. cell number increasing) as a response to other pathological conditions. In these cases, the adaptative response of human and porcine cardiomyocytes is to increase cell volume and nuclear DNA content. Therefore, in certain pathologies (e. g. hypertensive heart disease, dilated cardiomyopathy) cardiomyocytes are also markedly hypertrophic and polyploid. See Pfizer, Curr. Top.

Pathol., 54 : 125-168 (1971); Adler, et al., R Mol. Cell. Cardiol., 18 : 39-53 (1986). In most cases, cell adaptation is insufficient. Besides, the cellular demand for oxygen

and nutrients increases as myocardial hypertrophy progresses. In consequence, the increased demands impair subendocardial perfusion even in the absence of coronary occlusion. Finally, the combination of these factors leads to myocardial function detriment. See"Textbook of Medical Physiology", 9th Ed, supra. An ideal method should induce mitosis on hypertrophic and polyploid cells. This method should result in smaller and better-perfused daugther cells thus reducing the progression of cardiomyopathy towards heart failure.

Diagrams Fig. 1 illustrates the stress tolerance index for the area under risk. Pre and post-treatment mean values for Group I-T (VEGF) and Group I-P (placebo) are compared. The post-treatment value of Group I-T is higher to the pre-treatment value of the same group. The post-treatment value of Group I-T is higher the post-treatment value of Group I-P. Intra-group paired comparisons show: 1) absence of statistically significant differences between pre and post-treatment indexes for Group I-P and 2) presence of statistically significant differences between pre and post-treatment indexes for Group I-T. The non-paired comparisons between groups show: 1) absence of statistically significant differences between pre-treatment indexes for Group I-T and Group I-P and 2) presence of statistically significant differences between post- treatment indexes for Group I-T and Group I-P.

Fig. 2 illustrates the perfusion improvement index for the area under risk.

Mean values for Group I-T (VEGF) and Group I-P (placebo) are compared. The value for Group I-T is significantly higher than the value for Group I-P.

Fig. 3 shows the length density for the area under risk. Mean values for blood vessels with smooth muscle layer ranging from 8 to 50 urn are illustrated. The value for Group I-T (VEGF) is significantly higher than the value for Group I-P (placebo).

Fig. 4 shows the numerical density for the area under risk. Mean values for blood vessels with smooth muscle layer ranging from 8 to 50 urn are illustrated. The value for Group I-T (VEGF) is significantly higher than the value for Group I-P (placebo).

Fig. 5 shows the length density for the area under risk. Mean values for blood vessels with smooth muscle layer ranging from 8 to 30 am are illustrated. The value for Group I-T (VEGF) is significantly higher than the value for Group I-P (placebo).

Fig. 6 illustrates the effect of ischemia and treatment on cardiomyocyte Ki67- positive nuclei and mitosis. Panel (a) shows Ki67-positive cardiomyocyte nuclei index. No significant differences exist between Group I-T (VEGF) and Group I-P (placebo) individuals. Panel (b) shows Group I-T individuals (VEGF) with a significantly higher cardiomyocyte mitotic index for the area under risk (ischemic area) and the surrounding myocardial tissue (non-ischemic area) as compared with Group I-P individuals. The value for Group I-T (VEGF) is significantly higher than the value for Group I-P (placebo).

Fig. 7 represents the VEGF mRNA transcription curve of the Group II-T individuals. The curve shows a peak by day 10 post-injection of the pUVEK15 plasmid.

Fig. 8 illustrates the metaphase of a cardiomyocyte from a Group I-T individual. Metaphasic cromosomes and mitotic spindle are clearly visible.

Fig. 9 illustrates the telophase of a cardiomyocyte from a Group I-T individual. Sarcomeric striations are clearly visible.

Fig. 10 illustrates the mitotic process of two adjacent cardiomyocytes. The boundary between the cardiomyocytes is distinguishable. The integrity of both cardiomyocytes is clearly observed.

Fig. 11 shows the non-conventional cytokinesis of a cardiomyocyte from a Group I-T individual. Opposite chromosome plates in two adjacent cardiomyocytes are observed. The arrow indicates a possible splitting into daughter cells. Bar=10 um.

Figs. 12 and 13 illustrate blood vessels with smooth muscle layer in myocardial tissue of a Group I-T individual. Vascular smooth muscle was identified with alpha-actin immunohistochemical stain.

Deposit Plasmid pWEK15 was deposited on November 13,2000, under access number DSM 13833 at the DSMZ-Deutsche Sammlung von Mikroorganismen und Zellkulturen, Mascheroder Weg 1B, D-38124 Braunschweig, Federal Republic of Germany.

Description of the Invention One advantage of the present invention is the secure and efficient induction of neovascular formation in hypoperfused and normoperfused tissues. By utilizing the

claimed method, it is possible to stimulate the neoformation, development, proliferation and growth of vessels. The claimed method is effective also for the neoformation, development, proliferation and growth of smooth and striated muscular cells. The method is particularly useful for inducing revascularization in patients with ischemic heart disease. The present invention can also be used in the treatment of patients with peripheral artery disease or severe limb ischemia. The present invention can be utilized as sole therapy of ischemic diseases or associated with conventional revascularization procedures. The claimed method is characterized by the absence of adverse side effects related to the systemic exposure to angiogenic factors in high doses.

Another advantage of the present invention is the regeneration of myocardial tissue (myocardiogenesis). The claimed method induces cardiomyocyte mitosis. In this way, the claimed method replaces infarcted tissue with autologous cardiac muscle. The present invention reverts also the natural development of hypertrophic and dilated cardiomyopathies of any etiology by inducing the mitotic process in polyploid hypertrophic cardiomyocytes and by improving tissue perfusion (i. e. inducing neovascular formation). This circumstance results in higher number of normal daughter cells. These daughter cells have a better perfusion compared to hypertrophic cells. All these advantages indicate that the present invention improves the short, mid and long-term clinical and histophysiological outcomes of heart disease.

Another potential advantage of this invention is its use in transplant medicine.

The claimed invention may be particularly useful in transplanted patients with chronic graft rejection and diffuse coronary disease. The myocardial revascularization induced by the claimed method would restore the impaired perfusion and function in these patients. These patients are frequently not eligible for conventional revascularization methods (CABG, PTCA). The present invention represents an effective alternative revascularization strategy for these patients.

An additional potential advantage of the present invention is its use for increasing perfusion in ischemic tissues of patients with diabetes-related micro and macroangiopathy. The claimed method may revert or reduce chronic complications associated to diabetes such as diabetic neuropathy, vasa-vasorum disease, ischemic heart disease, peripheral artery disease and severe limb ischemia, among others. See Schratzberger, et al., J. Clin. Invest., 107 : 1083-1092 (2001); Rivard, et al.,

Circulation 96 Suppl I : 175 (1997); Rivard, et al., Am. J : Pathol., 154 : 355-363 (1999).

One of the advantages of the claimed method is its higher safety when used along with minimally invasive procedures of percutaneous intramyocardial- transendocardial administration. This administration is achieved by accessing to the left ventricular chamber through a catheter mediated endovascular approach. This type of administration may be assisted by an electromechanical mapping of the left ventricle. In this way the morbility and mortality associated to open-chest surgery is significantly diminished.

The present invention refers to a method for inducing neovascular formation and tissue regeneration characterized by the administration of a nucleotide sequence encoding for the active site of a polypeptide that includes the amino acid sequence of VEGF. In an embodiment of the present invention, a nucleotide sequence encoding for a polypeptide whose amino acid sequence is SEQ ID NO. 1 is administered. In another embodiment of the present invention, the active site of a polypeptide including the amino acid sequence SEQ ID NO. 1 is administered. The nucleotide sequence utilized according to the present invention may be genomic DNA, cDNA and messenger RNA. Preferably, the nucleotide sequence is genomic DNA.

According to the present invention, the inducing agent is administered to tissue composed of eukaryotic cells, such as tissue composed of mammalian cells.

Preferably, mammalian cells are of porcine and human origin. More preferably, cells are of human origin.

According to the claimed method, eukaryotic cells are muscle cells.

Preferably, the muscle cells utilized according to the present invention are cardiomyocytes, skeletal striated muscle cells type I and type II, vascular smooth muscle cells and non-vascular smooth muscle cells and myoepithelial cells. More preferably, the muscle cells utilized are cardiomyocytes.

The claimed method is characterized by inducing neovascular formation.

Preferably, the induced neovascular formation is localized in the site of administration of the inducing agent. More preferably, the site of administration is the myocardium.

The claimed method is characterized by inducing localized angiogenesis both in vivo and ex vivo. Preferably, angiogenesis is localized at the administration site of the inducing agent. More preferably, the site of administration is the myocardium. In an embodiment of the present invention, angiogenesis is induced in normoperfused

tissue, either in vivo, in vitro or ex vivo. In another embodiment of the present invention, angiogenesis is induced in ischemic tissue, either ira vivo, in vitro or ex vivo. Preferably, the claimed method induces angiogenesis in hypoperfused myocardial tissue, either in vivo, in vitro and ex vivo. Hypoperfused myocardial tissue may be ischemic, viable, hibernated, stunned, preconditioned, injured, infarcted, non- viable, fibrosed and necrosed. More preferably, the claimed method induces angiogenesis in vivo in hypoperfused myocardial tissue.

The claimed method is also characterized by inducing arteriogenesis in vivo, in vitro and ex vivo. Preferably, arteriogenesis is localized in the site of administration.

More preferably, the site of administration is the myocardium. In an embodiment of the present invention, arteriogenesis is induced in normoperfused tissue in vivo, in vitro and ex vivo. In another embodiment of the present invention, arteriogenesis is induced in ischemic tissue, in vivo, in vitro and ex vivo. Preferably, the claimed method induces arteriogenesis in hypoperfused myocardial tissue in vivo, in vitro and ex vivo. Hypoperfused myocardial tissue may be ischemic, viable, hibernated, stunned, preconditioned, injured, infarcted, non-viable, fibrosed and necrosed. More preferably, the claimed method induces arteriogenesis in hypoperfused myocardial tissue in vivo.

The claimed method is also characterized by inducing vasculogenesis in vivo, in vitro and ex vivo. Preferably, vasculogenesis is in the site of administration. More preferably, the site of administration is the myocardium. In an embodiment of the present invention, vasculogenesis is induced in normoperfused tissue in vivo, in vitro and ex vivo. In another embodiment of the present invention, vasculogenesis is induced in ischemic tissue, in vivo, in vitro and ex vivo. Preferably, the claimed method induces vasculogenesis in hypoperfused myocardial tissue, in vivo, in vitro and ex vivo. Hypoperfused myocardial tissue may be ischemic, viable, hibernated, stunned, preconditioned, injured, non-viable, infarcted, necrosed and fibrosed. More preferably, the claimed method induces vasculogenesis in hypoperfused myocardial tissue in vivo.

The claimed method is also characterized by inducing lymphangiogenesis in vivo, in vitro and ex vivo. Preferably, lymphangiogenesis is localized in the site of administration. More preferably, the site of administration is the myocardium. In an embodiment of the present invention, lymphangiogenesis is induced in normoperfused tissue, in vivo, in vitro and ex vivo. In another embodiment of the present invention,

lymphangiogenesis is induced in ischemic tissue, in vivo, in vitro and ex vivo.

Preferably, the claimed method induces lymphangiogenesis in hypoperfused myocardial tissue, in vivo, in vitro and ex vivo. Hypoperfused myocardial tissue may be ischemic, viable, hibernated, stunned, preconditioned, injured, non-viable, infarcted, necrosed and fibrosed. More preferably, the claimed method induces lymphangiogenesis in hypoperfused myocardial tissue in vivo.

The claimed method is also characterized by inducing mitosis in vivo, in vitro and ex vivo. Preferably, mitosis is induced locally at the site of administration. More preferably, the site of administration is the myocardium. In an embodiment of the present invention, mitosis is induced in normoperfused tissue, in vivo, in vitro and ex vivo. In another embodiment of the present invention, mitosis is induced in ischemic tissue in vivo, in vitro and ex vivo. Preferably, the claimed method induces mitosis in hypoperfused myocardial tissue, in vivo, in vitro and ex vivo. Hyperfused myocardial tissue may be ischemic, viable, hibernated, stunned, preconditioned, injured, non- viable, infarcted, necrosed and fibrosed. More preferably, the claimed method induces mitosis in hypoperfused myocardial tissue in vivo.

The claimed method is also characterized by inducing tissue regeneration ill vivo, in vitro and ex vivo. Preferably, tissue regeneration is induced locally in the site of administration. More preferably, the site of administration is the myocardium. In an embodiment of the present invention, tissue regeneration is induced in normoperfused territories, in vivo, in vitro and ex vivo. In another embodiment of the present invention, tissue regeneration is induced in ischemic territories, in vivo, in vitro and ex vivo. Preferably, the claimed method induces tissue regeneration in hypoperfused myocardial territories, in vivo, in vitro and ex vivo. Hypoperfused myocardial territory may be ischemic, viable, hibernated, stunned, preconditioned, injured, non-viable, infarcted, necrosed and fibrosed. More preferably, the claimed method induces tissue regeneration in hypoperfused myocardial territories in vivo.

In an embodiment of the present invention, the codifying nucleotide sequence is operably linked to a vector. In an embodiment of the claimed method, the vector is a viral vector such as adenovirus, adeno-associated virus, retrovirus and lentivirus. In another embodiment of the present method, the vector is a plasmid vector. More preferably, the plasmid vector is pUVEK15. In another embodiment of the present invention, the nucleotide sequence is transported by a liposome. In an embodiment of the present invention, the inducing agent is contained in a proper pharmaceutical

compound. The pharmaceutical compound containing the inducing agent is administered to the receptor in sufficient doses.

The pharmaceutical compound used according to the present invention may be administered by intravenous, intracoronary, intra-aortic, intrafemoral, intrapopliteal, intrapedialis, intra-posterior tibialis, intracarotideal and ihtraradialis routes. The pharmaceutical compound may be also administered by intrapericardial, intra- amniotic sac, intrapleural, intramyocardial-transepicardial, intramyocardial- transendocardial, intra-peripheral muscle, subcutaneous, intraspinal, and intracardiac (intra-atrial and intraventricular) routes. In addition, the inducing agent may be administered by sublingual, inhalatory, oral, rectal, periadventitial, perivascular, topical epicardial, topical epidermal, transdermal, ophthalmic routes or through the conjunctival, nasopharyngeal, bucopharyngeal, laryngopharyngeal, vaginal, colonic, urethral and vesical mucoses. Preferably, the inducing agent is administered by intramyocardial-transepicardial and intramyocardial-transendocardial injections. More preferably, the inducing agent is administered by intramyocardial-transepicardial injection.

In an embodiment of the present invention, the inducing agent is injected perpendicular to the plane of injection area. In another embodiment of the present invention, the inducing agent is injected in parallel to the plane of the area of injection. In another embodiment of the present invention, the inducing agent is injected in an oblique angle in relation to the plane of the injection area. Preferably, the inducing agent is injected at a 45 degree angle in relation to the plane of the injection area. Preferably, injections are homogeneously distributed in the area of injection.

As used herein,"area of injection"is defined as the tissue territory including the hypoperfused area, the transition area and normoperfused area surrounding the transition area."Area of injection"may also be defined as normal tissue.

As used herein,"area under risk"means the myocardial area irrigated by the circumflex coronary artery.

As used herein,"arteriogenesis"is defined as the formation, growth or development of blood vessels with smooth muscle media layer.

As used herein,"induce", as well as the correlated term"induction", refer to the action of generating, promoting, forming, regulating, activating, enhancing or

accelerating a biological phenomenon. An example of induction is the action of VEGF as a vascular proliferation stimulator.

As used herein,"inducing agent"is defined as genomic DNA, cDNA or messenger RNA encoding for the VEGF active site."Inducing agent"also includes any vector containing a nucleotide sequence encoding for VEGF."Inducing agent"is also defined as any polypeptide including the VEGF active site.

As used herein,"Ki67-positive cardiomyocyte nuclei index"refers to a parameter designed to assess the density of cycling (non-quiescent) cells in a tissue sample. This parameter refers to the number of Ki67 positive cells per 106 cardiomyocyte nuclei in an analyzed area.

As used herein,"length density index"refers to a parameter calculated for assessing a tissue vascularization. This parameter was designed to quantify vessels arranged in any variety of orientation. The method for calculating this index is known in the art. See Anversa et al., Am. J. Physiol., 260 : H1552-H1560 (1991); Adair et aL, Am. J Physiol., 266. H1434-H1438 (1994); Anversa et al., Am. J : P/ysiol., 267.

H1062-H1073 (1994).

As used herein,"localized"is defined as a response restricted to the area or tissue of interest.

As used herein,"lymphangiogenesis"is defined as the formation, growth, development or proliferation of lymphatic vessels.

As used herein,"mammal"is defined as a hot blooded vertebrate animal whose progeny feds with milk secreted by its mammal glands. The term"mammal" includes, but is not limited to, rats, mice, rabbits, dogs, cats, goats, sheep, cows, pigs, primates and humans.

As used herein,"mitosis"refers to the complete cell division process.

As used herein,"mitotic index"refers to a parameter designed to assess the density of mitosis in a tissue sample. This parameter refers to the number of mitosis per 106 cardiomyocyte nuclei in an analyzed area.

As used herein,"neovascular formation"is defined as the creation, growth, development or proliferation of blood vessels. Neovascular proliferation includes arteriogenesis, vasculogenesis and lymphangiogenesis.

As used herein,"non-paired comparison"refers to the statistical comparison between two different groups of individuals at the same time.

As used herein,"paired comparison"refers to the statistical comparison of the same group of individuals at different times.

As used herein,"perfusion improvement index"refers to a parameter designed to assess the overall improvement of left ventricular myocardial perfusion. This index is calculated by the arithmetical difference between the post-treatment stress tolerance index and the pre-treatment stress tolerance index.

As used herein,"pharmaceutical compound"refers to a solvent, adjuvant or excipient used to administrate an inducing agent."Pharmaceutical compound" includes any solvent, dispersion media, aqueous, gaseous solutions, antibacterial and antifungal agents, isotonic agents, either absorption delayer or accelerator agents, or similar substances. The use of said substances in the administration of pharmaceutical active compounds is known in the art. Supplementary active ingredients may also be incorporated to the pharmaceutical compound utilized in the present invention.

"Pharmaceutical compounds"include, but are not limited to, inert solid fillings or solvents, sterile aqueous solutions and non-toxic organic solvents. The "pharmaceutical compound"should not react with or reduce in any other manner the efficiency or stability of the inducing agent. Pharmaceutically acceptable carriers include, but are not limited to, water, ethanol, polyethileneglycol, mineral oil, petrolatum, propyleneglycol, lanolin and similar agents."Pharmaceutical compounds" for injection include sterile aqueous solutions (when soluble in water) or dispersions and sterile powders for extemporaneous preparation of sterile dispersions or injectable solutions. In all cases, the formulation should be sterile. The formulation may be fluid to facilitate syringe dispensation. The formulation should also be stable under manufacturing and storage conditions and should be preserved against the contaminant action of microorganisms such as bacteria, viruses and fungi.

As used herein,"post-treatment stress tolerance index"refers to a parameter designed to assess the left ventricular myocardial perfusion in post-treatment conditions. This index is calculated by the arithmetical difference between the post- treatment percentual perfusion value during pharmacological challenge (stress) and the post-treatment percentual perfusion value at rest.

As used herein,"pre-treatment stress tolerance index"refers to a parameter designed to assess the left ventricular myocardial perfusion in pre-treatment conditions. This index is calculated by the arithmetical difference between the pre-

treatment percentual perfusion value during pharmacological challenge (stress) and the pre-treatment percentual perfusion value at rest.

As used herein,"stress tolerance index"is defined as the arithmetical difference between the percentual perfusion value during pharmacological challenge (stress) and the percentual perfusion value at rest. This index is calculated in post- treatment and pre-treatment situations.

As used herein,"sufficient dose"is defined as a quantity of the inducing agent, or of the pharmaceutical compound including the inducing agent, adequate to attain the specified function. In the context of the present invention,"sufficient dose"refers to a quantity of the inducing agent, or of the pharmaceutical compound including the inducing agent, adequate to produce one or more of the following results: 1) the induction of arteriogenesis, vasculogenesis, lymphangiogenesis in eukaryotic cells, 2) the activation of the cell cycle in eukaryotic cells, or 3) the induction or acceleration of the mitotic process in eukaryotic cells.

As used herein,"vasculogenesis"is defined as the formation, growth, development or proliferation of blood vessels derived from undifferentiated or underdifferentiated cells.

As used herein,"VEGF"is defined any vascular endothelial growth factor.

"VEGF"includes, but is not limited to, the VEGF variants A, B, C, D, E and F. See Hamawy, et al., Curr. Open. Ca7 » diol., 14 : 515-522 (1999); Neufeld, et al., Prog.

Growth Factor Res., 5 : 89-97 (1994); Olofsson, et al., Proc. Natl. Acad. Sci. USA, 93 : 2576-2581 (1996); Chilov, et al., J. Biol. Chem., 272: 25176-25183 (1997); Olofsson, et al., Curr. Opiat. BiotechnoL, 10 : 528-535 (1999). The VEGF A variant includes, but is not limited to, isoforms VEGF1-121, VEGF1-145, VEGF1-167, VEGF1-165, VEGF1_18 and VEGFI 206. The SEQ ID NO. 1 illustrates an example of isoform VEGFI-l6s. See Tischer, et al., J : Biol. Chezn., 266 : 11947-11954 (1991); Poltorak, et al., J ; Biol. Chem., 272: 7151-7158 (1997). The term"VEGF"also includes the vascular permeability factor or vasculotropin (VPF). See Keck, et al., Science 246 : 1309-1312 (1989) ; Senger, et al., Science, 219: 983-985 (1983). VPF is currently known in the art as VEGF A.

As used herein,"underdifferentiated cells"is defined as cells with a characteristic phenotypic profile but with the capacity of originating cells with a different phenotypic profile."Underdifferentiated cells"include, but are not limited

to, fibroblasts, myoblasts, osteoblasts, endothelial precursor cells, skeletal muscle satellite cells, and neural tissue glyal cells.

The present invention employs a plasmid called pWEK15 of approximately 3086 base pairs (bp). The pUVEK15 plasmid is characterized by including a citomegalovirus (CMV) promoter, a chimeric intron, a DNA fragment containing the vascular endothelial growth factor (VEGF)-codifying sequence and a DNA sequence of approximately 1290 bp, which confers resistance to kanamicyn. The pUVEK15 plasmid is deposited under the access number DSM 13833 at DSMZ-Deutsche Sammlung von Mikroorganismen und Zellkulturen, Federal Republic of Germany.

Having described the invention in general terms, it will be more easily understood by reference to the following examples which are presented as an illustration and are not intended to limit the present invention, save when specifically indicated.

Example 1 Induction oflschemia Eighty Landrace pigs weighing approximately 25 kg (approx. 3 months of age) were submitted to the following protocol: 1) each individual underwent clinical and laboratory assessment of good health; 2) a sterile thoracotomy was performed at the 4th left intercostal space under general anesthesia (induction: thiopental sodium 20 mg/kg; maintenance: 2% enflurane) and the circumflex coronary artery was dissected free from surrounding tissue at its proximal portion; 3) an Ameroid constrictor was placed embracing the origin of the circumflex coronary artery; and 4) the thoracotomy was repaired.

Example 2 Basal Pre-treatment Stlldies Three weeks after the first surgery indicated in the previous example, basal (pre-treatment) studies were performed on the individuals. The studies were conducted under sedation with sufficient doses of intravenous sodium thiopental and under electrocardiographic control. Basal myocardial perfusion studies were performed on each individual. The left ventricular perfusion was quantified by single photon emission computed tomography (SPECT) utilizing an ADAC Vertex Dual

Detector Camera System (ADAC Healthcare Information Systems Inc., USA).

Sestamibi marked with 99mTc was utilized as contrast.

The studies were performed at rest and under pharmacological challenge with progressive doses of intravenous dobutamine. The dobutamine infusion was interrupted when heart rate was at least a 50% above the basal (rest) values.

Individuals fulfilling the inclusion criterium (hipoperfusion in a territory consistent with the circumflex coronary artery bed) were selected. Of the subjects considered, twenty six individuals developed chronic myocardial ischemia and were selected as satisfying the inclusion criterium. <BR> <BR> <BR> <BR> <BR> <BR> <BR> <P> Exaxnple 3<BR> <BR> <BR> <BR> Administation of VEGF Plastnid and Placebo Plasmid The twenty six individuals of the previous example were distributed in two groups: A first group consisting of 16 individuals (Group I) and a second group consisting of 10 individuals (Group II). Group I individuals were utilized to perform histopathological and physiological studies. Group II individuals were utilized to assess the presence and expression of the VEGF plasmid.

Group I individuals were randomized into two subgroups (Group I-T and Group I-P) with the same number of members (4 females and 4 males per subgroup).

The treated group was designated Group I-T. The placebo group was designated Group I-P.

Group II individuals were randomized into two subgroups (Group II-T and Group II-P). Eight individuals were allocated to Group 11-T. Two individuals were allocated to Group II-P. The treated group was designated Group 11-T. The placebo group was designated Group 11-P.

A sterile reopening of the previous thoracotomy was performed each individual of both Group I and Group II (reoperation) under general anesthesia (induction: sodium thiopental 20 mg/kg, maintenance: 2% enflurane).

Each individual from Groups I-T and 11-T received 10 injections of a solution containing pUVEK15 plasmid encoding for vascular endothelial growth factor (1.9 mg of pUVEK15 in 1 mL of saline). Each injection contained 200 1ll of the plasmid solution. Each individual received a total dose of 3.8 mg of the pUVEK. 15 plasmid.

Each individual from Groups I-P and 11-P received 10 injections of a solution containing pUVEK15-VEGF plasmid without the encoding region for the vascular endothelial growth factor (1.9 mg of pUVEK15' in 1 mL of saline). Each injection contained 200 1ll of the plasmid solution. Each individual received a total dose of 3.8 mg of the pWEK15-VEGF plasmid.

Each aliquot was injected intramyocardically, starting from the normoperfused left anterior descending artery territory (2-3 aliquots) and spanning the basal and mid zones of the anterolateral left ventricular wall. The area of injection included the hypoperfused zone, the transition zone and the normoperfused tissue immediately surrounding the transition zone. The injections were administered at a 45 degree angle in relation to the plane of the myocardium area, avoiding intraventricular administration of the solution. The injections were homogeneously distributed in the area of injection. The thoracotomy was repaired in each individual after administration.

Example 4 Post-treatment Studies 1. Histopathological and physiological studies Five weeks after the second surgery (reoperation), post-treatment studies were performed on Group I individuals. The individual were sedated with sufficient doses of intravenous sodium thiopental. The left ventricular perfusion was assessed for each individual following the protocol described in example 2.

The individuals were euthanized using an overdose of thiopental sodium followed by a lethal injection of potassium chloride. The heart, kidneys, liver, lungs, skeletal muscle, eyes and gonads were excised for histopathological assessment, including neoangiogenesis and mitosis determinations. The histopathological studies were performed in myocardial and peripheral tissues according to the following protocols.

For myocardial studies, the pericardium, adherent fat, atria and right ventricular free wall were removed. In each animal, the left circumflex coronary artery was examined at the site of the Ameroid to assess for occlusion. Subsequently, the left ventricle, including the septum, was cut transversally at one third of the distance between the apex and the mitral annulus. Subsequently, a slice of 5 mm in

thickness was cut from the distal end of the upper third, rinsed in Ringer solution and fixed flat for 48 hours in 10% formaldehyde buffered solution. This slice was chosen in order to: 1) limit the analysis to areas clearly perfused by only one vessel (left anterior descending coronary artery, left circumflex coronary artery or right coronary artery), without mixed supply from more than one artery, and 2) match the histology with the perfusion data.

After fixation, the slice was divided into 6 blocks, corresponding, from 1 to 6 to: the posterior half of the septum, the posterior wall, the posterolateral wall, the lateral wall, the anterior wall and the anterior half of the septum. These 6 blocks were embedded in Histowax, and sections of 5 um thickness were mounted on slides previously wetted in a 0.01% polylysine aqueous solution (Sigma Chemical Co., U. S. A.) and dried at 37° C. The sections were stained with hematoxylin-eosin.

Identification of intramyocardial vessels was made under optical microscopy. The endothelium was identified by immunohistochemistry employing the biotin streptavidin technique and a monoconal antibody against von Willebrand factor. The smooth muscle layer was identified by immunohistochemistry to assess arteriogenesis. A monoclonal antibody against alpha-actin (Biogenex Labs. Inc., U. S. A.) was utilized to this purpose.

For quantitative analysis of collateral circulation a digital analysis system was employed (Vidas Kontron, Germany). The analysis focused on arteriole-sized vessels (ranging from 8 to 50 urn of maximum diameter) with smooth muscle layer. The morphometric study was performed on the total slice area. The numerical and length density of collateral vessels were determined. The numerical density was calculated as number of collaterals (n) per square milimeter (n/mm2). The collateral length density (Lc) was calculated with the methodology known in the art for vessels arranged in any variety of orientation. See Anversa et al., Am. J. Physiol., 260 : H1552-H1560 (1991); Adair et al., Am. J ; Physiol., 266 : H1434-H1438 (1994); Anversa et al., Am. J.

Physio, 267 : H1062-H1073 (1994). For n vessels encountered in an area A, Lc, expressed in millimeters per unit volume of myocardium (mm/mm3), is equal to the sum of the ratio R of the long to the short axis of each vessel.

In addition, the length density for intramyocardial vessels ranging from 8 to 30 , um of maximum diameter was also analyzed.

Both indexes (numerical and length density) were averaged for both the ischemic (posterolateral, lateral, and anterolateral walls) and the non-ischemic (septum, anterior and posterior walls) zones.

To evidence cardiomyocytes undergoing cell cycle and mitosis, two double immunohistochemical techniques were used in the tissue sections of the Group I individuals. The following protocols were performed: (a) Tissue sections were incubated with a monoclonal antibody against the Ki67 antigen (Novocastra Labs., U. K.). The Ki67 is a protein expressed exclusively during the cell cycle which identifies nuclei undergoing the Gl, S and G2-M phases and decorates condensed mitotic chromosomes.

The Ki67 expression pattern is not affected by DNA damage or by apoptosis. See Brown et al., Histopathology, 17 : 489-503 (1990); Gerdes et al., R Immunol., 133 : 1710-1715 (1984) ; Ross et al., R Clin. Patrol., 48: M113-117 (1995). Subsequently, the sections were post-treated with a biotinilated anti-mouse immunoglobulin antiserum (Biogenex, USA), followed by peroxidase-labeled avidin and revealed with AEC as clzromogen. Afterwards, the sections were incubated with an anti- sarcomeric a-actin antibody (Dako, USA) to identify striated muscular cells. Subsequently, the sections were post-treated with the biotinilated antiserum followed by alkaline phosphatase-labeled streptavidin (Biogenex, USA) and Fast Red as chromogen.

(b) Tissue sections were incubated with a monoclonal antibody against the Ki67 antigen (Novocastra Labs., U. K.). The sections were post-treated with biotinilated antibodies, and revealed with fluorescein-labeled streptavidin (Vector, USA). Afterwards, the sections were incubated with rhodamine-labeled phalloidin (Sigma, USA), a protein binding F-actin, in order to identify striated muscular cells.

The tissue sections treated with enzyme-labeled avidin were examined with light microscopy with Nomarski optics. The tissue sections stained with fluorescent reactants were examined with confocal microscopy (Zeiss, Federal Republic of Germany).

Cardiomyocyte nuclei (CMN) density (CMN per mm2) was determined by counting the number of CMN in longitudinally oriented cells containing sarcomeric a-actin in a 5 mm2 area of the lateral wall mesocardium. The number of Ki67-positive CMN and the number of cardiomyocyte mitosis were determined in the whole ventricular tissue section area of each individual (total scanned area, TSA). The TSA of the Group I individuals averaged 1345.7289.7 mm2.

The Ki67-positive CMN index was calculated as: [Ki67-positive nuclei/ (TSA x CMN density)] xl06. The mitotic index was calculated as: [mitosis/ (TSA x CMN density)] xl06. Data was expressed as number of Ki67-positive nuclei and number of cardiomyocyte mitosis per 106 CMN. Both indexes were averaged for both the ischemic (posterolateral, lateral, and anterolateral walls) and the non-ischemic (septum, anterior and posterior walls) zones for each individual.

For peripheral studies, the tissues were fixed in 10% formaldehyde buffered solution, sectioned in blocks and included in Histowax paraffin. Tissue slices of 5 , um thickness were obtained from the blocks and stained with hematoxylin-eosin. An histopathological assessment for possible toxic effects in remote tissues was made by optical microscopy.

2. Presence and transcription of VEGFplasniid in myocardial tissue After the second surgery (reoperation) the Group II individuals were euthanized using an overdose of thiopental sodium followed by a lethal injection of potassium chloride, according to the following chronogram: 2 individuals from Group II-T after 3 days of reoperation, 2 individuals from Group II-T and 2 individuals from Group II-P after 10 days of reoperation, 2 individuals of Group 11-T after 16 days of reoperation and 2 individuals from Group II-T after 35 days of reoperation.

Necropsies were performed in each euthanized individual. Myocardial tissue of the area under risk was obtained from each individual.

The molecular assessment was performed to detect the presence of plasmidic DNA and its transcript (mRNA). The presence of plasmidic DNA and mRNA were determined by the polymerase chain reaction (PCR) and the reverse transcriptase- polymerase chain reaction (RT-PCR) techniques, respectively. See Mullis, et al.,

Meth. E7zzymol., 55 : 335-350 (1987); Belyavsky, et al., Nucleic. Acids Res., 17 : 2919 (1989).

Total RNA was isolated from tissue samples using Trizol reagent (Gibco BRL Life Technologies, USA) and treated with DNAse I (Promega, USA). RNA was quantified by spectrophotometry at A260/280 nm. One u, g of total RNA was reverse transcripted using random hexamers (PerkinElmer, USA). Human VEGF was then amplified from cDNA using Taq polymerase (PerkinElmer, USA) with the oligonucleotide primers 5'CAACATCACCATGCAGATT3'and 5'GCAGGAATTCATCGATTCA3'at cycling conditions of 95°C for 15 sec, 52°C for 30 sec and 65°C for 30 sec, for 35 cycles. Non-competitive amplification of constitutive GAPDH was used to demonstrate the presence of intact mRNA in each total RNA sample. RT-PCR was performed in myocardial tissue of Group 11-T individuals without reverse transcriptase to assess the possible contamination with plasmidic DNA or genomic DNA. The results of this control reaction were negative, excluding the possibility of contamination.

Results 1. Histopathological and plzysiological analysis The perfusion and histopathological studies showed vascular formation and growth in myocardial tissue of treated individuals. The histopathological study also revealed the induction of mitosis in cardiomyocytes, endothelial cells and smooth muscle cells of Group I-T individuals.

The stress tolerance index and perfusion improvement index were determined for each myocardial segment of all Group I individuals in order to assess left ventricular perfusion. Mean values of both indexes were calculated for the area under risk and the surrounding tissue for each individual. Finally, the mean values for each group were calculated.

The analysis of the perfusion in the area under risk revealed that: (a) Group I-P : absence of statistically significant differences between the pre- treatment and post-treatment stress tolerance indexes (intra-group paired

comparison). This result indicates that the perfusion and stress tolerance did not improve in the Group I-P individuals after the placebo treatment.

(b) Group I-T : presence of statistically significant differences between the pre- treatment and post-treatment stress tolerance indexes (intra-group paired comparison). The post-treatment mean value was significantly higher than the pre-treatment mean value. This result indicates that the perfusion and stress tolerance improved significantly in the Group I-T individuals after pUVEK15 treatment.

(c) Pre-treatment stress tolerance indexes: absence of statistically significant differences between the pre-treatment mean values of Group I-T individuals and Group I-P individuals (inter-group non-paired comparison). This result demonstrates that perfusion was homogenous for both subgroups before treatment.

(d) Post-treatment stress tolerance indexes: presence of statistically significant differences between the post-treatment mean values of Group I-T individuals and Group I-P individuals (inter-group non-paired comparison). The post-treatment mean value of Group I-T was significantly higher than the post-treatment mean value of Group I-P. This result indicates that the perfusion and stress tolerance of Group I-T individuals were higher than the Group I-P individuals after treatment with pUVEK15.

(e) Perfusion improvement indexes: presence of statistically significant differences between both subgroups. The mean value for Group I-T individuals was significantly higher than the mean value for Group I-P individuals (inter-group non-paired comparison). This result indicates that the perfusion of the Group I-T individuals improved noticeably in comparison to the perfusion of the Group I-P individuals. Moreover, the perfusion in Group I-P individuals showed a trend to deterioration.

The physiological study demonstrated an overall improvement in the perfusion and stress tolerance of Group I-T individuals when treated with pUVEK15. See Tables 1 and 2; Figs. 1 and 2.

The histopathological study showed statistically significant differences in numerical density, length density and mitotic index between both subgroups (inter- group non-paired comparisons). The Group I-T individuals presented higher mean

values for these indexes when compared to Group I-P individuals. See Tables 3,4,5 and 6 ; Figs. 3,4,5,6,8,9,10,11,12 and 13.

These results confirmed neovascular formation in vivo of myocardial tissue in the individuals treated with pUVEK15. Vascular formation and growth implies an increase in the number of cells taking part of neovessels (endothelial and vascular smooth muscle cells). See Figs. 12 and 13. The administration of the inducing agent enhanced mitosis of vascular cells in the individuals treated. The subgroup of individuals treated with pUVEK15 also showed a proportion of cardiomyocytes in mitotic process more than 5 times higher than the non-treated subgroup. See Figs. 6, 8, 9,10 and 11; Table 6.

Angiogenesis or other adverse side effects were not detected in the peripheral tissues of the individuals treated with pUVEKI5.

2. Presence and Transcription ofthe VEGFPlasmid Molecular studies showed presence of plasmid DNA in injected myocardial tissue of all Group II individuals (PCR technique). Plasmid DNA encoding for VEGF was found in the injected myocardial tissue of the Group II-T individuals. Placebo plasmid DNA was found in the injected myocardial tissue of the Group 11-P individuals.

A positive RT-PCR product for pUVEK15 was detected in the injected myocardial tissue of the Group 11-T individuals at 3 (n=1/2), 10 (n=2/2) and 16 (n=1/2) days post-treatment. See Fig. 7. No RT-PCR product for pWEK15 was detected in inject myocardial tissue at 35 days (n=2) after pUVEK15 injection and in myocardial tissue receiving plasmid devoid of gene (Group 11-P).

A transcription curve (presence of mRNA) showing a peak by day 10 post- injection of pUVEK15 was obtained in the Group 11-T individuals. See Fig. 7.

Presence of mRNA in group II-P was negative.

Table 1 Stress Tolerance Index Pre-treatment Post-treatment (1) (2)

P value Mean # Mean # 1 vs (2 Group I-P-0. 6 2.2-1,2 1,3 0,9 Group I-T-3, 1 2,2 3, 8 1,3 <0, 01 P value 0,42 <0,02 I-T vs I-P Table 2 Perfusion Improvement Index Mean # Group I-P-0, 6 2, 6 Group I-T 6,9 2,6 P value 0, 058 I-T vs I-P Table 3 Numerical Density Index (8-50 µm) Mean Group I-T 1 0.1 Group I-P 0.6 0.1 P Value <0.02 I-T vs I-P Table 4 Length Density Index (8-50 pm) Mean a Group I-T 2.4 0.4 Group I-P 1.3 0.3 P Value <0. 02 I-T vs I-P Table 5 Length Density Index (8-30 jjm) Mean C Group I-T 1 0. 1 Group I-P 0. 6 0. 1 P Value | <0. 02 I-T vs I-P Table 6 Mitotic Index Mean Group I-T 187.1 49.6 Group I-P 35. 4 9. 1 P Value <0. 04 I-T vs I-P The present invention has been described in some detail and exemplified to facilitate its understanding and reproducibility. Certain changes in the form and detail can be made by anyone skilled in the art without departing from the true object and scope of the claims of the present invention. All the publications herein quoted as references to the invention's description