Endothelin-1 and Cardiac Allograft Vasculopathy (CAV)

Cardiac Allograft Vasculopathy Clinical Trial

Official title:

Impact of Endothelin-1 on the Development of Cardiac Allograft Vasculopathy in Heart Transplant Recipients: Endothelin Receptor Antagonism and Vasomotor Function

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT05373108
• Other study ID #: 18-001544
• Status: Completed
• Phase: Phase 4
• Start date: May 19, 2022
• Est. completion date: February 14, 2023

Study information

• Verified date: February 2024
• Source: University of California, Los Angeles
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

Many patients with end-stage heart failure, a condition in which the heart fails to pump enough blood to support the body's other organs, are fortunate enough to receive a heart transplant. However, despite taking medicines aimed at blunting the immune system's response to the donor heart, some of them will develop transplant-related disease in the coronary arteries supplying their hearts. Fifty years after the first human-to-human heart transplant, this disorder-cardiac allograft vasculopathy (CAV)-remains a leading cause of long-term death and has been coined the 'Achilles' Heel' of heart transplantation. Indeed, a better understanding of how CAV occurs and improved therapies to prevent and/or slow its development are desperately needed to meaningfully impact patient outcomes.

Endothelin-1 (ET-1) is a key molecular regulator of arterial health, and our prior data suggests that it is associated with accelerated CAV. In this particular study of recent heart transplant recipients, we are asking: Does ET-1 contribute to the coronary artery's capacity to dilate/constrict? To answer this question, during the cardiac catheterization at 1 year post-transplant (standard of care), we will measure blood levels of ET-1 and perform an invasive evaluation of coronary vasomotor function inn a consecutive subset of patients who will have received a 1-week course of the oral endothelin receptor antagonist (macitentan) prior this catheterization, which will allow us to test how much ET-1 contributes to coronary responsiveness.

The findings from this study may provide the necessary foundation to study whether endothelin receptor antagonists are able to effectively reduce the rate of accelerated CAV.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 19
• Est. completion date: February 14, 2023
• Est. primary completion date: February 14, 2023
• Accepts healthy volunteers: No
• Gender: All
• Age group: 18 Years and older

Eligibility

Inclusion Criteria:

• 1) New heart transplant recipients already enrolled into a prospective cohort (parent) study

• 1a) Underwent baseline coronary angiography within the first 4 months of heart transplantation

• 1b) Have yet to complete 1-year coronary angiogram

• 2) =18 years old

• 3) Have a serum creatinine < 2.0 mg/dL (to minimize risk of contrast-induced nephropathy)

• 4) Able to provide informed written consent.

Exclusion Criteria:

• 1) Multi-organ transplant

• 2) Transplant-related complications and comorbidities that preclude the ability to safely perform an invasive coronary evaluation in the cardiac catheterization laboratory

• 3) Pregnant women due to possible fetal harm; all women of childbearing potential must have a negative pregnancy test within 1 week of starting Macitentan, and 30 days after completing the one-week course of Macitentan.

• 4) Patients who are taking potent CYP3A4 inhibitors (e.g. ketoconazole, ritonavir) as these drugs can expose one to higher levels of macitentan

• 5) Cirrhosis or baseline liver function tests (AST/ALT) > 3x the upper limit of normal

Related Conditions & MeSH terms

• Cardiac Allograft Vasculopathy
• Vascular Diseases

Intervention

Drug:
• Macitentan
Macitentan is a nonselective endothelin-receptor antagonist (ERA) that is approved for use in pulmonary arterial hypertension (PAH); the use of Macitentan in post-heart transplant patients is considered investigational.

Locations

Country	Name	City	State
United States	Ronald Regan UCLA Medical Center	Los Angeles	California

Sponsors (3)

Lead Sponsor	Collaborator
University of California, Los Angeles	American Heart Association, Janssen, LP

Country where clinical trial is conducted

United States, 

References & Publications (20)

Bohm F, Pernow J. The importance of endothelin-1 for vascular dysfunction in cardiovascular disease. Cardiovasc Res. 2007 Oct 1;76(1):8-18. doi: 10.1016/j.cardiores.2007.06.004. Epub 2007 Jun 16. — View Citation

Chih S, Chong AY, Mielniczuk LM, Bhatt DL, Beanlands RS. Allograft Vasculopathy: The Achilles' Heel of Heart Transplantation. J Am Coll Cardiol. 2016 Jul 5;68(1):80-91. doi: 10.1016/j.jacc.2016.04.033. — View Citation

Cooper DK. Christiaan Barnard and his contributions to heart transplantation. J Heart Lung Transplant. 2001 Jun;20(6):599-610. doi: 10.1016/s1053-2498(00)00245-x. — View Citation

Davenport AP, Hyndman KA, Dhaun N, Southan C, Kohan DE, Pollock JS, Pollock DM, Webb DJ, Maguire JJ. Endothelin. Pharmacol Rev. 2016 Apr;68(2):357-418. doi: 10.1124/pr.115.011833. — View Citation

Ferri C, Properzi G, Tomassoni G, Santucci A, Desideri G, Giuliani AE, Starling RC, Ratliff NB, Cook DJ, McCarthy P, Young JB, Yamani MH. Patterns of myocardial endothelin-1 expression and outcome after cardiac transplantation. Circulation. 2002 Apr 16;105(15):1768-71. doi: 10.1161/01.cir.0000015606.69079.27. — View Citation

Kobashigawa JA, Tobis JM, Starling RC, Tuzcu EM, Smith AL, Valantine HA, Yeung AC, Mehra MR, Anzai H, Oeser BT, Abeywickrama KH, Murphy J, Cretin N. Multicenter intravascular ultrasound validation study among heart transplant recipients: outcomes after five years. J Am Coll Cardiol. 2005 May 3;45(9):1532-7. doi: 10.1016/j.jacc.2005.02.035. — View Citation

Larose E, Behrendt D, Kinlay S, Selwyn AP, Ganz P, Fang JC. Endothelin-1 is a key mediator of coronary vasoconstriction in patients with transplant coronary arteriosclerosis. Circ Heart Fail. 2009 Sep;2(5):409-16. doi: 10.1161/CIRCHEARTFAILURE.108.836759. Epub 2009 Jun 15. — View Citation

Lund LH, Edwards LB, Kucheryavaya AY, Benden C, Dipchand AI, Goldfarb S, Levvey BJ, Meiser B, Rossano JW, Yusen RD, Stehlik J. The Registry of the International Society for Heart and Lung Transplantation: Thirty-second Official Adult Heart Transplantation Report--2015; Focus Theme: Early Graft Failure. J Heart Lung Transplant. 2015 Oct;34(10):1244-54. doi: 10.1016/j.healun.2015.08.003. Epub 2015 Aug 28. No abstract available. — View Citation

Mitchell RN, Libby P. Vascular remodeling in transplant vasculopathy. Circ Res. 2007 Apr 13;100(7):967-78. doi: 10.1161/01.RES.0000261982.76892.09. — View Citation

Okada K, Nishida Y, Murakami H, Sugimoto I, Kosaka H, Morita H, Yamashita C, Okada M. Role of endogenous endothelin in the development of graft arteriosclerosis in rat cardiac allografts: antiproliferative effects of bosentan, a nonselective endothelin receptor antagonist. Circulation. 1998 Jun 16;97(23):2346-51. doi: 10.1161/01.cir.97.23.2346. — View Citation

Parikh RV, Khush K, Pargaonkar VS, Luikart H, Grimm D, Yu M, Okada K, Honda Y, Yeung AC, Valantine H, Fearon WF. Association of Endothelin-1 With Accelerated Cardiac Allograft Vasculopathy and Late Mortality Following Heart Transplantation. J Card Fail. 2019 Feb;25(2):97-104. doi: 10.1016/j.cardfail.2018.12.001. Epub 2018 Dec 10. — View Citation

Pollack A, Nazif T, Mancini D, Weisz G. Detection and imaging of cardiac allograft vasculopathy. JACC Cardiovasc Imaging. 2013 May;6(5):613-23. doi: 10.1016/j.jcmg.2013.03.001. — View Citation

Ravalli S, Szabolcs M, Albala A, Michler RE, Cannon PJ. Increased immunoreactive endothelin-1 in human transplant coronary artery disease. Circulation. 1996 Nov 1;94(9):2096-102. doi: 10.1161/01.cir.94.9.2096. — View Citation

Sidharta PN, van Giersbergen PL, Dingemanse J. Safety, tolerability, pharmacokinetics, and pharmacodynamics of macitentan, an endothelin receptor antagonist, in an ascending multiple-dose study in healthy subjects. J Clin Pharmacol. 2013 Nov;53(11):1131-8. doi: 10.1002/jcph.152. Epub 2013 Sep 4. — View Citation

Simonson MS, Herman WH, Robinson A, Schulak J, Hricik DE. Inhibition of endothelin-converting enzyme attenuates transplant vasculopathy and rejection in rat cardiac allografts. Transplantation. 1999 Jun 27;67(12):1542-7. doi: 10.1097/00007890-199906270-00007. — View Citation

Simonson MS, Robinson AV, Schulak JA, Hricik DE. Inhibition of endothelin-1 improves survival and vasculopathy in rat cardiac transplants treated with cyclosporine. Transplantation. 2002 Apr 15;73(7):1054-9. doi: 10.1097/00007890-200204150-00007. — View Citation

Starling RC, Stehlik J, Baran DA, Armstrong B, Stone JR, Ikle D, Morrison Y, Bridges ND, Putheti P, Strom TB, Bhasin M, Guleria I, Chandraker A, Sayegh M, Daly KP, Briscoe DM, Heeger PS; CTOT-05 consortium. Multicenter Analysis of Immune Biomarkers and Heart Transplant Outcomes: Results of the Clinical Trials in Organ Transplantation-05 Study. Am J Transplant. 2016 Jan;16(1):121-36. doi: 10.1111/ajt.13422. Epub 2015 Aug 10. — View Citation

Tuzcu EM, Kapadia SR, Sachar R, Ziada KM, Crowe TD, Feng J, Magyar WA, Hobbs RE, Starling RC, Young JB, McCarthy P, Nissen SE. Intravascular ultrasound evidence of angiographically silent progression in coronary atherosclerosis predicts long-term morbidity and mortality after cardiac transplantation. J Am Coll Cardiol. 2005 May 3;45(9):1538-42. doi: 10.1016/j.jacc.2004.12.076. — View Citation

Weis M, Wildhirt SM, Schulze C, Rieder G, Wilbert-Lampen U, Wolf WP, Arendt RM, Enders G, Meiser BM, von Scheidt W. Endothelin in coronary endothelial dysfunction early after human heart transplantation. J Heart Lung Transplant. 1999 Nov;18(11):1071-9. doi: 10.1016/s1053-2498(99)00081-9. — View Citation

Yamaguchi A, Miniati DN, Hirata Ki, Hoyt EG, Robbins RC. Ex vivo blockade of endothelin-1 inhibits graft coronary artery disease in a rodent cardiac allograft model. J Heart Lung Transplant. 2002 Apr;21(4):417-24. doi: 10.1016/s1053-2498(01)00397-7. — View Citation

* Note: There are 20 references in all — Click here to view all references

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Macitentan: Nitroglycerin (NTG) Luminal Dilation Ratio as Proportion of Vasomotor Tone Attributable to Endothelin-1 (ET-1)	Macitentan: NTG luminal volume dilation ratio on Intravascular Ultrasound (IVUS). Vasodilation achieved by Macitentan was compared with that after intracoronary nitroglycerin, a maximal dilator of epicardial arteries, to determine the relative contribution of ET-1 to the overall resting vasomotor tone. The contribution of ET-1 to resting vasomotor tone is expressed as the ratio of dilation to Macitentan over the dilation to nitroglycerin.	End of study week 1 (time of 1 year post-transplant coronary angiogram)