Recombinant Human C1 Esterase Inhibitor (Conestat Alfa) in the Prevention of Acute Ischemic Cerebral and Renal Events After Transcatheter Aortic Valve Implantation (PAIR-TAVI)

• ClinicalTrials.gov Identifier: NCT05145283
• Recruitment Status: Recruiting
• First Posted: December 6, 2021
• Last Update Posted: February 20, 2024
• Sponsor: University Hospital, Basel, Switzerland
• Collaborators: Swiss National Science Foundation; Pharming Technologies B.V.
• Information provided by (Responsible Party): University Hospital, Basel, Switzerland

Study Description

Brief Summary:

The aim of this trial is to assess the safety and efficacy of conestat alfa (Ruconest®, Pharming Technologies B.V.) on renal and cerebral ischemic events in patients undergoing TAVI for severe symptomatic aortic stenosis (AS) compared to placebo.

Condition or disease	Intervention/treatment	Phase
Acute Ischemic Stroke; Acute Renal Injury	Drug: Conestat alfa (Ruconest®); Drug: NaCl 0.9%)	Phase 2

Detailed Description:

Severe aortic stenosis (AS) is a frequent valvular heart disease in the elderly with a prevalence of 4 to 10% and a mean survival of only 0.5 to 5 years if left untreated. Transcatheter aortic valve implantation (TAVI) has evolved as standard of care for high-, intermediate and potentially even low surgical risk candidates due to a lower perioperative risk compared to surgical aortic valve replacement (SAVR). Despite its relative safety compared to SAVR, embolic events originating from the calcified valve and leading to ischemic stroke and acute renal injury are major complications following TAVI in the acute and subacute period, and are associated with increased morbidity including cognitive decline and mortality. While cerebral embolic protection devices (CEPD) such as the Sentinel® CEPD (Boston Scientific) were designed to reduce the burden of cerebral embolic events, their impact on clinical events has yet to be determined, and other prophylactic options are currently not available. Ischemia/reperfusion injury (IRI) is a key pathophysiological mechanism involved in cerebral and renal embolic events after TAVI resulting in activation of endothelial cells, the contact activation and the complement system and attraction of neutrophils to the site of injury. In this regard, recombinant human C1 esterase inhibitor (rhC1INH, conestat alfa), a potent inhibitor of the complement and the contact system has been shown to reduce the size of cerebral ischemic damage and of renal injury in experimental IRI models, and has successfully been investigated in a pilot study of acute kidney injury following the administration of contrast media. The aim of the current trial is to assess the safety and efficacy of conestat alfa (Ruconest®, Pharming Technologies B.V.) on renal and cerebral ischemic events in patients undergoing TAVI for severe symptomatic AS compared to placebo.

Study Design

• Study Type: Interventional (Clinical Trial)
• Estimated Enrollment: 250 participants
• Allocation: Randomized
• Intervention Model: Parallel Assignment
• Intervention Model Description: Patients will be randomized in two parallel groups to receive either conestat alfa or placebo.
• Masking: Double (Participant, Investigator)
• Primary Purpose: Prevention
• Official Title: Recombinant Human C1 Esterase Inhibitor (Conestat Alfa) in the Prevention of Acute Ischemic Cerebral and Renal Events After Transcatheter Aortic Valve Implantation: a Multi-center, Randomized, Double-blind, Placebo-controlled Investigational Study (PAIR-TAVI).
• Actual Study Start Date: March 16, 2022
• Estimated Primary Completion Date: March 2025
• Estimated Study Completion Date: March 2025

Arms and Interventions

Arm	Intervention/treatment
Active Comparator: Conestat alfa (Ruconest®) intervention group; The intervention group will receive conestat alfa (Ruconest®) as a 10-minute slow intravenous injection (up to 56 ml) once during the TAVI procedure followed by a second administration (up to 28 ml) again three hours later. The first administration will include a dosage of 100 U/kg (maximum 8400 U) conestat alfa. The dosing of the second administration will be 50 U/kg (maximum 4200 U).	Drug: Conestat alfa (Ruconest®); In the current study, participants will receive two intravenous injections of conestat alfa (immediately during the TAVI procedure and again 3h later) at a dose of 100 U/kg (first dose) and of 50 U/kg (subsequent dose), for patients less than 84 kg; two intravenous injections (immediately during the TAVI procedure and again 4h later) of conestat at a dose of 8400 U (4 vials, first dose) and of 4200 U (2 vials, subsequent dose) for patients of 84 kg body weight or greater. The chosen regimen including repeated administration should increase and maintain serum C1INH levels above twice the serum concentration for six to eight hours in the majority of patients. The timeframe of therapeutic concentrations will cover the period of the TAVI procedure itself and the immediate postprocedural period during which reperfusion and additional ischemic events related to global hypoperfusion may occur.
Placebo Comparator: saline injection placebo group; Subjects randomized into the placebo group will receive an intravenous normal saline injection with corresponding volume over 10 minutes during the TAVI procedure and three hours later after the first administration.	Drug: NaCl 0.9%); Normal saline (NaCl 0.9%) will serve as placebo treatment. The respective amount of saline (according to patient weight matching the volume of conestat alfa that would have been used for this patient) will be withdrawn in an opaque syringe for slow IV injection.

Outcome Measures

Primary Outcome Measures :

1. Total volume of new cerebral ischemic lesions as evaluated by magnetic resonance imaging (MRI) [ Time Frame: on day 4 (+/-1 day) after transfemoral TAVI ]
   Total volume of new cerebral ischemic lesions as evaluated by magnetic resonance imaging (MRI)

Secondary Outcome Measures :

1. Maximum new lesion volume as measured by MRI (i.e. volume of the largest new lesion) [ Time Frame: on day 4 (+/-1 day) after transfemoral TAVI ]
   Maximum new lesion volume as measured by MRI (i.e. volume of the largest new lesion)
2. Number of new cerebral ischemic lesions as measured by MRI [ Time Frame: on day 4 (+/-1 day) after transfemoral TAVI ]
   Number of new cerebral ischemic lesions as measured by MRI
3. Number (incidence) of clinically manifest ischemic stroke [ Time Frame: within 48 hours after TAVI ]
   Number (incidence) of clinically manifest ischemic stroke
4. Change in secondary brain atrophy at 3-months follow-up [ Time Frame: at baseline and at 3-months follow-up ]
   Secondary brain atrophy at 3-months follow-up related to the gradual cellular loss as measured by high resolution 3D T1-weighted MR images (defined as the difference between the brain volumes)
5. Change in secondary infarct growth at 3-months follow-up (defined as the difference between the infarct volumes) [ Time Frame: at day 4 and at 3-months ]
   Change in secondary infarct growth at 3-months follow-up (defined as the difference between the infarct volumes)
6. Total brain damage (defined as the sum of secondary brain atrophy and final infarct volume) [ Time Frame: at 3 months ]
   Total brain damage (defined as the sum of secondary brain atrophy and final infarct volume)
7. Change in National Institutes of Health Stroke Scale Score (NIHSS) [ Time Frame: at baseline and at 3-months follow-up ]
   The NIHSS is composed of 11 items, each of which scores a specific ability between a 0 and 4. For each item, a score of 0 typically indicates normal function in that specific ability, while a higher score is indicative of some level of impairment. The individual scores from each item are summed in order to calculate a patient's total NIHSS score. The maximum possible score is 42, with the minimum score being a 0.
8. Change in modified Rankin scale [ Time Frame: at baseline and at 3-months follow-up ]
   Change in modified Rankin scale; scale runs from 0-6, running from perfect health (0) without symptoms to death (6)
9. Change in trail making test [ Time Frame: at baseline and at 3-months follow-up ]
   Change in trail making test; scoring is based on time taken to complete the test (e.g. 35 seconds yielding a score of 35) with lower scores being better.
10. Change in Montreal Cognitive Assessment test (MOCA) [ Time Frame: at baseline and at 3-months follow-up ]
    Montreal Cognitive Assessment test scores range between 0 and 30. A score of 26 or over is considered to be normal
11. Incidence of acute kidney injury (AKI) defined according to the Kidney Disease: Improving Global Outcomes criteria (any stage) [ Time Frame: within 3 days after TAVI ]
    Incidence of AKI defined according to the Kidney Disease: Improving Global Outcomes criteria (any stage)
12. Peak increase of urinary Neutrophil Gelatinase-Associated Lipocalin (NGAL) [ Time Frame: within 48 hours after TAVI ]
    Peak increase of urinary NGAL (surrogate marker of acute renal injury)
13. Incidence of significant increase in serum cystatin C (>10%) [ Time Frame: within 48 hours after TAVI ]
    Incidence of significant increase in serum cystatin C (>10%)

Other Outcome Measures:

1. Persistent renal impairment after 3 months (defined as increase in serum creatinine of at least 50% from baseline at 3 months) [ Time Frame: at 3-months follow-up ]
   Persistent renal impairment after 3 months (defined as serum creatinine increase of at least 50% from baseline at 3 months)
2. Change in concentration of C1-Esterase-Inhibitor (C1INH) [ Time Frame: during the first 24 hours after TAVI ]
   Change in concentration of C1INH
3. Change in troponin T to assess myocardial injury following TAVI [ Time Frame: within 72 hours after TAVI ]
   Change in troponin T to assess myocardial injury following TAVI
4. Change in urinary biomarkers of renal injury (Kidney Injury Molecule-1 (KIM-1) and osteopontin) [ Time Frame: within 48 hours after TAVI ]
   Change in urinary biomarkers of renal injury (Kidney Injury Molecule-1 (KIM-1) and osteopontin)
5. Change in serum neurofilament light chain (marker of neuroaxonal damage) [ Time Frame: within 3 months after TAVI ]
   Change in serum neurofilament light chain (marker of neuroaxonal damage)
6. Number of adverse events [ Time Frame: within 3 months after TAVI ]
   Number of adverse events
7. Number of serious adverse events [ Time Frame: within 3 months after TAVI ]
   Number of serious adverse events
8. Number of major cardiovascular and renal events (cardiovascular death, non-fatal myocardial infarction, heart failure hospitalization, stroke, dialysis) [ Time Frame: within 3 months after TAVI ]
   Number of major cardiovascular and renal events (cardiovascular death, non-fatal myocardial infarction, heart failure hospitalization, stroke, dialysis)
9. Number of complications of transfemoral TAVI [ Time Frame: within 3 months after TAVI ]
   Number of complications of transfemoral TAVI such as conduction disturbance (including permanent pacemaker implantation) or aortic regurgitation according to the Valve Academic Research Consortium (VARC)-3 criteria, or bleeding according to the Bleeding Academic Research Consortium (BARC)-criteria)

Eligibility Criteria

• Ages Eligible for Study: 18 Years and older (Adult, Older Adult)
• Sexes Eligible for Study: All
• Accepts Healthy Volunteers: No

Criteria

Inclusion Criteria:

• Informed consent as documented by signature
• Severe AS and scheduled for transfemoral TAVI

Exclusion Criteria:

• Contraindications to the class of drugs under study (C1INH), e.g., known hypersensitivity or allergy to class of drugs or the investigational product
• History of allergy to rabbits (as rhC1INH is derived from the breast milk of transgenic rabbits)
• Women who are pregnant or breast feeding
• Hemodynamic instability requiring emergency TAVI
• Valve-in-valve procedure
• Other access route than transfemoral
• Non-cardiac co-morbidity with expected survival <6 months
• Ischemic or hemorrhagic stroke within 30 days before TAVI
• Dialysis or estimated glomerular filtration rate (eGFR) <20 ml/min/1.73m2
• Contraindication for MRI such as a permanent non-MRI compatible pacemaker or severe claustrophobia
• Liver cirrhosis (any Child-Pugh score)
• Incapacity or inability to provide informed consent
• Participation in another study with investigational drug or medical device within the 30 days preceding and during the present study
• Previous enrolment into the current study
• Any uncontrolled or significant concurrent illness that would put the patient at a greater risk or limit compliance with the study requirements at the discretion of the investigator

Contacts and Locations

Contacts

Contact: Michael Osthoff, Prof. Dr. med.; +41 61 328 54 20; michael.osthoff@usb.ch

Contact: Stephan Moser, Dr. med.; +41 61 265 25 25; stephan.moser@usb.ch

Locations

Switzerland

University Hospital Basel, Division of Internal Medicine; Recruiting

Basel, Switzerland, 4031

Contact: Michael Osthoff, Prof Dr. med. +41 61 328 54 20 michael.osthoff@usb.ch

Contact: Stephan Moser, Dr.med. +41 61 265 25 25 stephan.moser@usb.ch

Principal Investigator: Michael Osthoff, Prof Dr. med.

Stadtspital Triemli Zürich, Division of Cardiology; Recruiting

Zürich, Switzerland, 8063

Contact: Raban Jeger, Prof. Dr. med. +41 44 416 34 11 raban.jeger@stadtspital.ch

Principal Investigator: Raban Jeger, Prof. Dr. med.

Sponsors and Collaborators

University Hospital, Basel, Switzerland

Swiss National Science Foundation

Pharming Technologies B.V.

Investigators

• Principal Investigator: Michael Osthoff, Prof. Dr. med.; University Hospital Basel, Division of Internal Medicine
• Principal Investigator: Raban Jeger, Prof. Dr. med.; Stadtspital Triemli Zürich, Division of Cardiology

More Information

• Responsible Party: University Hospital, Basel, Switzerland
• ClinicalTrials.gov Identifier: NCT05145283
• Other Study ID Numbers: 2021-02025; me19Osthoff
• First Posted: December 6, 2021
• Last Update Posted: February 20, 2024
• Last Verified: February 2024

• Studies a U.S. FDA-regulated Drug Product: No
• Studies a U.S. FDA-regulated Device Product: No

Keywords provided by University Hospital, Basel, Switzerland:

Severe aortic stenosis (AS); Valvular heart disease; Transcatheter aortic valve implantation (TAVI); cerebral embolic events; renal embolic events; Ischemia/reperfusion injury (IRI); recombinant human C1 esterase inhibitor (rhC1INH, conestat alfa); complement system; contact activation system

Additional relevant MeSH terms:

Ischemic Stroke; Acute Kidney Injury; Ischemia; Pathologic Processes; Stroke; Cerebrovascular Disorders; Brain Diseases; Central Nervous System Diseases; Nervous System Diseases; Vascular Diseases; Cardiovascular Diseases; Renal Insufficiency; Kidney Diseases; Urologic Diseases; Female Urogenital Diseases; Female Urogenital Diseases and Pregnancy Complications; Urogenital Diseases; Male Urogenital Diseases; Complement C1 Inhibitor Protein; Complement Inactivating Agents; Immunosuppressive Agents; Immunologic Factors; Physiological Effects of Drugs