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Introduction: For S100A1-based heart failure gene therapies, AAV9 and 6 have shown efficacy in pre-clinical large animal studies. As AAV9 has shown concerning signs of toxicity in clinical studies and AAV6 displays poor production yields, there is need for a novel safe and cardiac-specific AAV serotype. Hypothesis: We hypothesized that in a pig model the safety proven and scalably manufacturable AAV5 may be a suitable vector for S100A1-based gene therapy of post-ischemic cardiac dysfunction. Methods: AAV production, 2h balloon-occlusion of the LCX, retrograde cardiac gene delivery, cardiac MRI, late gadolinium enhancement (LGE), global T1 relaxation, qPCR, RNA-Seq, WGCNA, KEGG, Reactome, LAD-ligation mouse model Results: In a comparative study of AAV5-, 6- and 9-luciferase (luc) in healthy farm pigs (n=5 each; 1x10 13 vgc/pig), AAV5 achieved a more homogeneous cardiac apical-basal transduction pattern than AAV6 with a higher luc activity than AAV9. In a clinically relevant endpoint driven study, we demonstrated a significant improvement in EF (+19 ± 5 %) 12 weeks after retrograde AAV5- S100A1 gene delivery compared to AAV5-luc in infarcted pigs (n=4 each; 1x10 13 vgc/pig). Moreover, S100A1 -treated pigs showed significantly less infarct extension (-0.5 ± 0.3 g vs. 5 ± 1.3 g (luc)) measured by cardiac MRI. There were no unfavorable alterations in blood chemistry or ECG. S100A1 expression was predominantly contained to the heart. The WGCNA unveiled a significant correlation between the improved EF and a suppression of inflammatory and immunological pathways (r=-0.96, p < 0.01) and between the absent infarct extension and enhanced activity of cardioprotective signaling (r=-0.82, p < 0.05). With injections of 2х10 11 vgc of AAV5- S100A1 or AAV5-gfp (n=4 each) into the remote myocardium in the mouse model, we confirmed a significant improvement in FS (+43.8 ± 8.8 %, vs. gfp) and suppression of inflammatory gene expression including i.e., IL1b or TNFa by S100A1. Conclusion: We conclude that AAV5 is suitable for S100A1-based gene therapy of post-ischemic cardiac dysfunction and that this vector/target combination can help accelerating the way towards a clinical trial. We also found novel signaling pathways that may be involved in S100A1’s therapeutic actions.

Introduction: A high transduction efficacy and potency of AAV-based cardiac gene therapies is key for the clinical translation in which hereditary and acquired cardiac disorders will be targeted. As such, ultrapure vectors with superior biological and therapeutic capabilities are a must for these therapies. Hypothesis: We hypothesized that our developed affinity chromatography (AC) based purification system will increase AAV recovery and - potency. Methods: AAV vector production, AC based - or iodixanol density gradient (DG) based purification, Q-PCR, WB, EM, LC-MS/MS, P-loop Results: Using the same vector input quantity, the AC-based purification enabled an approximately 13-fold greater vector genome copy (vgc) recovery than the DG-based purification. Mass spectrometry analysis demonstrated ultrapure AAV9 vectors as a result of an AC purification (AAV9 93.24% vs. 6,76% contaminants) whereas corresponding DG preparations resulted in highly contaminated vectors (AAV9 5.49% vs. 94,51% contaminants). Biological potency of AC- and DG-purified AAV9 vectors towards cardiac transduction were determined by systemic injections of 1·10 10 , 1·10 11 or 1·10 12 vgc of AAV9-EGFP in C57BL/6 mice (n=8 each group). AC-purified AAVs achieved a significantly higher cardiac transduction efficacy for every dosage assessed by comparative bulk myocardial DNA, RNA and protein level analysis after 2 weeks. Therapeutic potency was examined for a recently published novel target for chronic heart failure namely the RFXP1-RLN system. To this end, a dosage of 5·10 11 vgcs of either AC- or DG purified AAV9-RXFP1 vectors were systemically injected and the cardiac contractile performance increase was captured after 2 weeks in mice of both groups. Of note, 10 minutes after RLN administration, the rise in LV +dp/dt max. was already significantly greater in the AC- than the DG-vector treated group (AC: 13594+/-1972 vs. DC: 9822+/-801 mmHg/s; n=8 per group, p Conclusion: The data clearly promote AC-based AAV purification as a novel standard for cardiovascular basic and translational research. Higher consistency in results, higher therapeutic effects and superior biological potency can be expected from higher production yields of ultrapure AAVs even at lower vector dosages.