Improvement of Cardiovascular Function After Bronchoscopic Lung Volume Reduction Using Endobronchial Valves

Improvement of Cardiovascular Function After Bronchoscopic Lung Volume Reduction Using Endobronchial Valves in Patients With Severe Emphysema: A Randomized Controlled Trial

Sponsors

Lead Sponsor: Daniel Franzen

Source University of Zurich
Brief Summary

There is increasing evidence showing an association between COPD and cardiovascular disease which is independent from smoking. Recently, it has been shown that FMD of the brachial artery, a surrogate marker of endothelial function, is improving after lung volume reduction surgery (LVRS) in patients with severe emphysema. Thus, hyperinflation might be an independent risk factor of atherosclerosis. Bronchoscopic lung volume reduction (BLVR) using endobronchial valves is a minimal-invasive procedure to decrease hyperinflation in patients with severe emphysema. Eventually, successful BLVR with target atelectasis may have the same effect on FMD compared to LVRS, which would underpin the association between hyperinflation and endothelial function. Patients receiving routinely performed BLVR using endobronchial valves due to severe emphysema with hyperinflation are eligible for this study. After obtaining written informed consent, the participating patients will be randomized into an immediate (within 1-2 weeks) BLVR group and a delayed BLVR group (6-8 weeks). Patients in both groups will undergo baseline measurement of primary and secondary endpoints. Immediate BLVR group will be re-assessed 4-6 weeks after successful EBV treatment, whereas the delayed BLVR group will be re-assessed prior EBV treatment. Results of group 1 and 2 will be compared for final analysis.

Detailed Description

Several studies were able to show an association between COPD and cardiovascular disease which is independent from smoking and other traditional cardiovascular risk factors. Although the mechanisms underlying the association between COPD and cardiovascular disease are not yet completely understood, it seems reasonable to hypothesize that COPD as a cause of hypoxemia, chronic systemic inflammation, and increased oxidative stress may be an important factor in the development and progression of atherosclerosis due to impaired endothelial function. Endothelial function can be assessed by flow-mediated dilatation (FMD) of the brachial artery, which has been shown to provide predictive information concerning the future occurrence of cardiovascular events. Thus, assessment of FMD allows to identify patients at risk of cardiovascular events in the absence of clinically apparent vascular disease. One recent study was able to show that lung volume reduction surgery (LVRS) has a beneficial effect on endothelial function and blood pressure. They concluded that hyperinflation is a risk factor of atherosclerosis independent of cigarette smoking or others. However, hyperinflation cannot solely be treated by LVRS but also by bronchoscopic lung volume reduction (BLVR) using endobronchial valves (EBV), coils, thermal vapour ablation, or lung sealant. The positive effects of EBV on pulmonary function, quality of life and symptoms have been shown in six randomized controlled trials. However, there is no evidence on the effect of BLVR on endothelial function. With this investigator's study, the aim is to contribute to the still limited evidence on the effects of LVR on endothelial function and to confirm the association of atherosclerosis and COPD. In addition, the investigators aim is to validate the data of the study which showed that LVRS had a beneficial effect on endothelial function, by showing similar effects after BLVR. The investigators hypothesizes, that BLVR using endobronchial valves in patients with severe emphysema will improve endothelial function as previously shown in patients after receiving LVRS. Patients who are study-independently planned for BLVR using endobronchial valves will be screened for study inclusion. At this time, all necessary baseline data except FMD, daily physical activity measurement and the ST George Respiratory Questionnaire (SGRQ) are already existing from routine clinical practice. Data collection will need the written informed consent of the patient on the "Patient information FMD after BLVR" after receiving further information by investigators.The investigators will explain to each participant the nature of the study, its purpose, the procedures involved, the expected duration, the potential risks and benefits and any discomfort it may entail. Each participant will be informed that the participation in the study is voluntary and that he or she may withdraw from the study at any time and that withdrawal of consent will not affect his or her subsequent medical assistance and treatment. The participant will be informed that his or her medical records may be examined by authorised individuals other than their treating physician. The formal consent of a participant, using the approved consent form, will be obtained before the participant is submitted to any study intervention. The consent form will be signed and dated by the investigator or his designee at the same time as the participant sign. A copy of the signed informed consent will be given to the study participant. The consent form will be retained as part of the study records. The informed consent process will be documented in the patient file and any discrepancy to the process described in the protocol must be explained. The investigators start the project on the 01.04.2020 and estimate a duration of approximately two years for the recruitment of 40 eligible patients. Referring to data analysis, the investigators plan to finish the project by 31.12.2022. Patients receiving routinely performed BLVR using endobronchial valves due to severe emphysema with hyperinflation are eligible for this study. After obtaining written informed consent, the participating patients will be randomized into an immediate (within 1-2 weeks) BLVR group and a delayed BLVR group (6-8 weeks) using counted and sealed envelopes. Patients in both groups will undergo baseline study specific measurements of primary and secondary endpoints (T0) (see more detailed description under the section 'Arms and Interventions'). The immediate BLVR group will be re-assessed 4-6 weeks after successful EBV treatment, whereas the delayed BLVR group will be re-assessed prior EBV treatment (T1). Results of group 1 and 2 will be compared for final analysis. Routine data measured before and after BLVR will be included into the study as well: Pulmonary function test, 6-Minute-Walking-Test, Laboratory. To investigate the hypothesis, whether BLVR can improve endothelial function assessed by FMD, differences in the outcomes between the group experiencing atelectasis after BLVR and the groups not experiencing atelectasis or not receiving ELVR will be evaluated by unpaired t-tests or by non-parametrical tests as appropriate. The confidence interval (CI) for statistical significance will be defined as 95%. A p value of less than .05 will be considered statistically significant. All statistical analyses will be performed by SPSS Statistics for Windows 25 (IBM, Armonk, NY). Data will be reported as median interquartile range (IQR) or as percentages, as appropriate. The sample size was estimated on the assumption that a clinically relevant mean (SD) difference in FMD between the intervention group and the control group is 2.9% (2.1-3.6% [95% CI]) [8]. To achieve a power of 80%, 38 patients would be required to complete the study. Because of an anticipated dropout rate of two patients, 40 patients will be included. Individual participants will not be identifiable from the results as submitted for publication. Data analysis will only use coded data records. As set out in the Informed Consent, authorized staff of the responsible Ethics Committee may obtain access to all study data under strict adherence to confidentiality rules. Patient baseline data (age, sex, BMI, smoker status, medication list), 6-minute walk test, bronchoscopy reports, lung function data, and radiological findings as well as blood pressure and heart rate measurements, lab results (CRP, BNP) and the result of the transthoracic echocardiography will be drawn from patient record files, coded and stored in hardcopy form. Where copies of the original source document as well as printouts of original electronic source documents are retained, these shall be signed and dated by a member of the investigation site team for validation of the original information. After the measurement of PAL, data will be downloaded from the Fitbit® device and stored as coded data. Data will not be accessible to the device producer and will be deleted from the device once it is transferred. Where copies of the original source document as well as printouts of original electronic source documents are retained, these shall be signed and dated by a member of the investigation site team for validation of the original information. At a later stage, pseudonym data will be analysed using statistic software (e.g. SPSS).The investigators will be responsible for data collection, confidentiality, and data management. Data generation, transmission, archiving, and analysis of health related personal data within this project strictly follow the current Swiss legal requirements for data protection and according to ClinO, Art. 18. Prerequisite is the voluntary approval of the participant given by signing the informed consent prior start of participation of the research project.

Overall Status Recruiting
Start Date June 5, 2020
Completion Date April 30, 2022
Primary Completion Date April 30, 2022
Phase N/A
Study Type Interventional
Primary Outcome
Measure Time Frame
Postinterventional change in endothelial function assessed by flow mediated dilation (FMD) (%) before and after the bronchoscopic lung volume reduction (BLVR). FMD measurement will be done at baseline and once again within 6-8 weeks afterwards.
Secondary Outcome
Measure Time Frame
Physical activity level (PAL) measuring the steps per day, converting that into a distance in kilometers per day Measurement at baseline and once again within 6-8 weeks afterwards.
Blood pressure (mmHg) Measurement at baseline and once again within 6-8 weeks afterwards.
Heart rate (beats per minute) Measurement at baseline and once again within 6-8 weeks afterwards.
Blood oxygen saturation (%) Measurement at baseline and once again within 6-8 weeks afterwards.
St. George Respiratory Questionnaire (SGRQ) Measurement at baseline and once again within 6-8 weeks afterwards.
6-minute walking distance (6-MWD) in meters Done during the routine visit before BLVR, which is before the study phase and it will be repeated during the routine follow-up 4-6 weeks after BLVR
Forced Expiratory Volume in first second (FEV1) in liters Done during the routine visit before BLVR, which is before the study phase and it will be repeated during the routine follow-up 4-6 weeks after BLVR
Residual Volume (RV) in liters Done during the routine visit before BLVR, which is before the study phase and it will be repeated during the routine follow-up 4-6 weeks after BLVR
Residual Volume (RV)/ Total Lung Capacity (TLC) in percentage Done during the routine visit before BLVR, which is before the study phase and it will be repeated during the routine follow-up 4-6 weeks after BLVR
CO-Diffusion Capacity (DLCO) in percentage Done during the routine visit before BLVR, which is before the study phase and it will be repeated during the routine follow-up 4-6 weeks after BLVR
Number of participants with relevant change in C-reactive protein before and after BLVR Done during the routine visit before BLVR, which is before the study phase and it will be repeated during the routine follow-up 4-6 weeks after BLVR
Number of participants with relevant change NT-proBNP before and after BLVR Done during the routine visit before BLVR, which before is the study phase and it will be repeated during the routine follow-up 4-6 weeks after BLVR
Enrollment 40
Condition
Intervention

Intervention Type: Diagnostic Test

Intervention Name: Flow Mediated Dilation (FMD) measurement

Description: FMD measurements will be performed by ultrasound using longitudinal images of the brachial artery using a high-frequency (10.0-MHz) ultrasound scanning probe (VividTM E9 with XDeclearTM; GE Healthcare, Chicago, Illinois, USA) proximal to the antecubital fossa. Two-dimensional images, acquired with electrocardiogram gating, will be obtained at baseline with Doppler ultrasound imaging to assess arterial diameter and flow velocity. Reactive hyperemia will then be induced by inflation of a pneumatic tourniquet around the forearm to at least 200 mm Hg (or > 50mmHg above systolic pressure) for 5 minutes. Post-deflation diameter and flow velocity will be monitored continuously from deflation for 210 seconds. To assess endothelial-independent vasodilation maximal brachial artery diameter will be measured continuously for 3 minutes after a single sublingual dose of nitroglycerin (NTG, 0.4 mg).

Intervention Type: Other

Intervention Name: Blood pressure, pulse and blood oxygen saturation measurement

Description: Blood pressure measurement will be done with a pneumatic tourniquet on the upper arm, after at least 10 minutes rest of the patient. Pulse measurement and oxygen saturation measurement will be done using a finger pulseoximeter, after at least 10 minutes rest of the patient.

Intervention Type: Other

Intervention Name: ST George Respiratory Questionnaire

Description: The is a validated and standardized Questionnaire designed to measure health impairment in COPD patients

Intervention Type: Other

Intervention Name: Physical activity level (PAL) measurement

Description: PAL will be assessed by the number of steps and kilometers per day using a triaxial accelerometer of a multisensory activity monitor (Fitbit Alta HR; Fitbit Inc., San Francisco, CA, USA). The device is worn like a watch on the wrist. The device is worn always, except while showering or swimming.

Intervention Type: Biological

Intervention Name: Withdrawal of a blood sample

Description: 5ml of blood will be withdrawn and preserved after centrifugation at -50 degrees celsius for later analysis at a yet unknown time

Intervention Type: Procedure

Intervention Name: Immediate Bronchoscopic Lung Volume Reduction

Description: Bronchoscopic Lung Volume Reduction by using endobronchial valve placement Within 2 weeks after T0

Arm Group Label: Group 1 (Immediate Group)

Intervention Type: Procedure

Intervention Name: Delayed Bronchoscopic Lung Volume Reduction

Description: Bronchoscopic Lung Volume Reduction by using endobronchial valve placement Within 6-8 weeks after T0 and 3-4 days after T1

Arm Group Label: Group 2 (Delayed Group)

Eligibility

Criteria:

Inclusion Criteria: - Male or female subject between 40 and 75 years of age - Written informed consent after participant's information signed by patient - Scheduled for BLVR using endobronchial valves at the University Hospital Zurich - Dyspnoea at rest or at minimal physical activity (MRC score ≥2), severe limitation of exercise capacity (6-min walk distance < 500 m). - COPD (GOLD guidelines) with severe obstructive ventilator defect (FEV1 <40% predicted) - Functional aspects of lung emphysema with irreversible hyperinflation, defined as a residual volume to total lung capacity ratio (RV/TLC) of >0.6 - Pulmonary emphysema confirmed by high resolution computer tomography Exclusion Criteria: - Age < 40 years, age > 75 years - COPD exacerbation within the last 6 weeks or > 2 exacerbations per year - Pregnancy - Lacking ability to form an informed consent (including impaired judgement, communication barriers) - Current smokers - Overt active coronary artery disease, left ventricular function impairment - Pulmonary hypertension with a mean pulmonary artery pressure >35 mmHg at rest - Acute bronchopulmonary infection, bronchiectasis on high resolution tomography - Pulmonary cachexia (body mass index <18kg/m2) - Malignant disease with a life expectancy of less than 2 years - Addiction to alcohol/drugs (= inability to withhold intake during 1 week)

Gender: All

Minimum Age: 40 Years

Maximum Age: 75 Years

Healthy Volunteers: No

Overall Official
Last Name Role Affiliation
Daniel Franzen, PD Dr. med. Principal Investigator Universitiy Hospital Zuich, Department of pulmonology
Overall Contact

Last Name: Daniel Franzen, PD Dr. med.

Phone: +41 44 255 97 50

Email: [email protected]

Location
Facility: Status: Contact: Contact Backup: Investigator: University Hospital Zurich, Department of Pulmonology Daniel Franzen, PD Dr. med. +41 44 255 97 50 [email protected] Jasmin Wani, Pract. med. Sub-Investigator
Location Countries

Switzerland

Verification Date

September 2020

Responsible Party

Type: Sponsor-Investigator

Investigator Affiliation: University of Zurich

Investigator Full Name: Daniel Franzen

Investigator Title: Principal Investigator, PD Dr. med. Daniel Franzen

Keywords
Has Expanded Access No
Condition Browse
Number Of Arms 2
Arm Group

Label: Group 1 (Immediate Group)

Type: Experimental

Description: Group 1: Will receive at time T0 the baseline study specific measurements of the primary and secondary endpoints: Flow mediated dilation measurement Blood pressure, pulse, blood oxygenation saturation measurement Fit bit tracker counting steps and distance during 7 days SGRQ (St Georg Respiratory Questionnaire) Withdrawal of a blood sample for preservation for later examinations This group will receive endobronchial valve placement (EVP) within 1-2 weeks after T0. At T1 which will be 4-6 weeks after EVP the measurements done at T0 will be repeated.

Label: Group 2 (Delayed Group)

Type: Other

Description: Group 2: Will receive at time T0 the baseline study specific measurements of the primary and secondary endpoints: Flow mediated dilation measurement Blood pressure, pulse, blood oxygenation saturation Fit bit tracker counting steps and distance during 7 days SGRQ (St Georg Respiratory Questionnaire) Withdrawal of a blood sample for preservation for later examinations This group will receive endobronchial valve placement (EVP) 6-8 weeks after T0. A few days before that the investigators repeat the measurement taken at T0.

Patient Data No
Study Design Info

Allocation: Randomized

Intervention Model: Parallel Assignment

Intervention Model Description: Patients receiving routinely performed bronchoscopic lung volume reduction (BLVR) using endobronchial valves due to severe emphysema with hyperinflation are eligible for this study. After obtaining written informed consent, the participating patients will be randomized into an immediate (within 1-2 weeks) BLVR group and a delayed BLVR group (6-8 weeks) using counted and sealed envelopes. Patients in both groups will undergo baseline study specific measurements of primary and secondary endpoints (T0). The immediate BLVR group will be re-assessed 4-6 weeks after successful endobronchial valve (EBV) treatment, whereas the delayed BLVR group will be re-assessed prior EBV treatment (T1). Results of group 1 and 2 will be compared for final analysis.

Primary Purpose: Prevention

Masking: None (Open Label)

Source: ClinicalTrials.gov