- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT04732091
Therapeutic Use of Contrast Ultrasound in Acute Coronary Artery Disease (HUBBLE-I)
High Ultrasound Mechanical Index and MicrobuBBLEs to Reduce Acute Myocardial Infarction Burden I
Study Overview
Status
Conditions
Intervention / Treatment
Detailed Description
Initial safety and feasibility human studies demonstrated that intermittent high MI aimed at the myocardial microcirculation could improve capillary blood flow within the risk area and epicardial recanalization rates. In light of this, the investigators published the first prospective randomized human study showing the added value of sonothrombolysis to percutaneous coronary intervention (PCI). Sonothrombolysis improved recanalization rates and reduced infarct size, leading to sustained improvements in systolic function after STEMI. Since both diagnostic ultrasound and intravenous infusions of microbubbles are Class I indication to assess regional and global left ventricular function and risk area in patients with STEMI, the purpose of this study is to 1) demonstrate the clinical effectiveness of sonothrombolysis in multiple centers and in a wide scenario of acute coronary syndromes including pre-hospital care setting; and 2) develop a portable non-imaging ultrasound device prototype, simple-to-handle and capable of generating intermittent ultrasound pulses for sonothrombolysis.
A total of 540 subjects will be included in this study. Subjects will be randomized to either receive DUS guided high MI impulses within and outside the risk area during a continuous infusion of intravenous 3% Definity® or placebo. Comparisons between the two groups will be made on door to dilation times, survival, angiographic recanalization rates at initial angiography and reduction in microvascular obstruction and in infarct size determined by the salvageability index at cardiac magnetic resonance imaging (MRI) post-STEMI and using myocardial perfusion imaging. The effect of high-energy ultrasound therapy and microbubbles on the outcome of sympathetic hyperactivation and autonomic imbalance after MI will be also evaluated. Cardiac remodeling assessed by left atrial and ventricular volumes indexes and myocardial strain imaging will also be measured. Overall survival defined as the time from the start of treatment to death from any cause as well as new MIs events will be assessed.
The study will be divided into 6 subprojects: subproject 1 (n=70 in each group) - safety and efficacy of the therapeutic use of intermittent high-energy ultrasound and microbubbles in the recanalization of acute STEMI treated with primary PCI. Additionally, the investigators will assess the effect of sonothrombolysis on autonomic function, cardiac function and intracellular signaling. All patients will receive conventional PCI approach, including aspirin 325 milligram, clopidogrel 600 milligrams and heparin bolus (5000 units), followed by primary PCI using glycoprotein 2b/3a inhibitors as anti-thrombotic agents using established protocols. Besides angiographic recanalization rates at the time of presentation to the catheterization laboratory, participants will have a fully echocardiography study including myocardial perfusion imaging and strain imaging, serum microRNAS for detecting endothelial cells shear-stress and autonomic control assessment (heart rate and systolic blood pressure variability) at the baseline, 72-96 hours, 30 days and 6 months of follow up. A iodine-123 meta-iodobenzylguanidine (MIBG) cardiac scintigraphy will be carried out at 30 days and 6 months follow up, and exercise echocardiogram at 6 months. Subproject 2 (n=70 in each group) - safety and efficacy of the therapeutic use of intermittent high-energy ultrasound and microbubbles in the recanalization of acute STEMI in patients initially treated in a primary hospital with fibrinolytic therapy within 12 hours. Angiographic recanalization rates at initial angiography and in infarct size determined by the salvageability index at cardiac MRI post-STEMI, and cardiac death and a new MI episode are the main objectives. Participants will receive STEMI/PCI treatment as per current guidelines using standard protocols similar to subproject 1. In addition, both groups will undergo elective PCI after fibrinolytic therapy. Besides angiographic recanalization rates at the time of presentation to the catheterization laboratory, a comprehensive echocardiography study including myocardial perfusion and strain imaging, MRI and exercise echocardiogram will be performed at the time of presentation and during 72-96 hours, 30 days, 3 months and 6 months of follow up. Subproject 3 (n=70 in each group) - safety and efficacy of the therapeutic use of intermittent high-energy ultrasound and microbubbles in the recanalization of acute myocardial infarction without segment elevation or with high-risk unstable angina (NSTEMI). Subjects presenting without persistent ST-segment elevation acute coronary syndromes undergoing early invasive strategy within 24 hours will be randomized to either receive diagnostic ultrasound guided high MI impulses during a continuous infusion of intravenous 3% Definity® or placebo. Participants will receive conventional medical treatment, including aspirin 325 milligram, clopidogrel 600 milligrams and unfractionated heparin weight-adjusted iv. bolus or in combination with glycoprotein 2b/3a inhibitors followed by primary PCI using established protocols as per current guidelines. A comprehensive echocardiography study including myocardial perfusion echocardiography and exercise echocardiogram will be carried out at the baseline, 72-96 hours, 30 days- and 6 months of follow up. Subproject 4 (n=30 in each group): safety and efficacy of the therapeutic use of intermittent high-energy ultrasound and microbubbles in reducing microvascular obstruction and myocardial infarction size after primary PCI in patients with anterior wall myocardial infarction. Participants will receive STEMI/PCI approach as per guidelines likewise subprojects 1 and 2. In order to assess microvascular obstruction and no reflow phenomenon, a comprehensive echocardiography study, including myocardial perfusion imaging and myocardial strain will be performed at baseline, 2 months and 6 months of follow up. MRI will be performed at 3 days and 3 months of follow up. Subproject 5: this subproject will be dedicated to the development of an automated hands-free portable prototype emitting ultrasound waves of intermittent high-energy capable of promoting sonothrombolysis. Subproject 6 (n=30 in each group): a pilot study on the therapeutic use of intermittent high-energy ultrasound and microbubbles in the recanalization of acute STEMI in the pre-hospital setting (ambulances). Subjects with acute STEMI will be randomized to either receive diagnostic ultrasound guided high MI impulses during a continuous infusion of intravenous 3% Definity® or placebo while routing from the ambulance to the emergency department. At the admission hospital, all patients will receive conventional PCI approach, including aspirin 325 milligram, clopidogrel 600 milligrams and heparin bolus (5000 units), followed by primary PCI using glycoprotein 2b/3a inhibitors as anti-thrombotic agents using established protocols as per aforementioned subprojects. A complete echocardiography study including myocardial perfusion and strain, and exercise echocardiogram will be carried out at baseline, 72-96 hours, 30 days- and 6 months of follow up.
Study Type
Enrollment (Estimated)
Contacts and Locations
Study Contact
- Name: Wilson Mathias Jr, MD, PhD
- Phone Number: 5511- 984155556
- Email: wmathias@incor.usp.br
Study Contact Backup
- Name: Jeane M Tsutsui, MD, PhD
- Phone Number: 5511-993806992
- Email: jeane.tsutsui@incor.usp.br
Study Locations
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Sao Paulo, Brazil, 05403900
- Recruiting
- Heart Institute of Clinical Hospital of Medical School of University of Sao Paulo
-
Contact:
- Wilson Mathias Jr., Professor
- Phone Number: 5511984155556
- Email: wmathias@me.com
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Contact:
- Luciene F Azevedo, PhD
- Phone Number: 5511999951725
- Email: hubble.eco@gmail.com
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-
-
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Nebraska
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Omaha, Nebraska, United States, 68198
- Active, not recruiting
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Nebraska Medical Center
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Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Sampling Method
Study Population
Description
Inclusion Criteria:
- Age ≥30 years with STEMI with less than 12 hours of chest pain onset.
- Age ≥30 years with STEMI initially treated in a primary setting by fibrinolytic therapy within 12h
- Age ≥30 years with NSTEMI with high-risk unstable angina who will undergo elective PCI
- Eligible for emergent PCI therapy.
- No contraindications or hypersensitivities to ultrasound contrast agents
Exclusion Criteria:
- Known or suspected hypersensitivity to ultrasound contrast agent used for the study.
- Cardiogenic Shock.
- Life expectancy of less than two months or terminally ill.
- Known bleeding diathesis or contraindication to glycoprotein 2b/3a inhibitors, anticoagulants, or aspirin.
- Known large right to left intracardiac shunts or severe pulmonary hypertension.
- Patients who received thrombolytic therapy previously to enrollment.
- Women of childbearing potential.
Study Plan
How is the study designed?
Design Details
- Observational Models: Case-Control
- Time Perspectives: Prospective
Cohorts and Interventions
Group / Cohort |
Intervention / Treatment |
---|---|
Subproject 1 - acute STEMI
Participants with acute STEMI will receive intravenous infusion of microbubbles (3% Definity) with therapeutic ultrasound with 4-20 usec and custom designed high mechanical index (MI) impulses (1.1 to 1.3 MI) designed for the 1.8 MHz S5-1 transducer while waiting for percutaneous coronary intervention.
Treatment will continue after procedure until complete a total of 50 minutes.
|
A custom designed high mechanical index (MI) impulses at 4-20 usec and >1.0 mechanical index designed for the 1.8 MHz S5-1 transducer
|
Subproject 2 - acute STEMI initially treated with fibrinolytic
Participants with acute STEMI initially treated with fibrinolytic therapy within 12 hours will receive intravenous infusion of microbubbles (3% Definity) with therapeutic ultrasound with 4-20 usec and custom designed high mechanical index (MI) impulses (1.1 to 1.3 MI) designed for the 1.8 MHz S5-1 transducer while waiting for percutaneous coronary intervention.
A control group (PCI only) undergoing low MI (<0.2) imaging only with limited (no more than 3) diagnostic high MI impulses to assess regional wall motion and microvascular perfusion before and after PCI; High MI will continue after PCI procedure until complete a total of 50 minutes.
|
A custom designed high mechanical index (MI) impulses at 4-20 usec and >1.0 mechanical index designed for the 1.8 MHz S5-1 transducer
|
Subproject 3 - NSTEMI
Participants with NSTEMI or with high-risk unstable angina will receive intravenous infusion of microbubbles (3% Definity) with therapeutic ultrasound with 4-20 usec and custom designed high mechanical index (MI) impulses (1.1 to 1.3 MI) designed for the 1.8 MHz S5-1 transducer while waiting for percutaneous coronary intervention.
A control group (PCI only) undergoing low MI (<0.2) imaging only with limited (no more than 3) diagnostic high MI impulses to assess regional wall motion and microvascular perfusion before and after PCI.
High MI will continue after PCI procedure until complete a total of 50 minutes.
|
A custom designed high mechanical index (MI) impulses at 4-20 usec and >1.0 mechanical index designed for the 1.8 MHz S5-1 transducer
|
Subproject 4 - No reflow
Participants with acute STEMI will receive intravenous infusion of microbubbles (3% Definity) with therapeutic ultrasound with 4-20 usec and custom designed high mechanical index (MI) impulses (1.1 to 1.3 MI) designed for the 1.8 MHz S5-1 transducer while waiting for percutaneous coronary intervention.
A control group (PCI only) undergoing low MI (<0.2 MI) imaging only with limited (no more than 3) diagnostic high MI impulses to assess regional wall motion and microvascular perfusion before and after PCI.
High MI will continue after PCI procedure until complete a total of 50 minutes.
|
A custom designed high mechanical index (MI) impulses at 4-20 usec and >1.0 mechanical index designed for the 1.8 MHz S5-1 transducer
|
Subproject 6 - Pre-hospital care (ambulance)
Participants with acute STEMI routing from the ambulance to the emergency department will receive intravenous infusion of microbubbles (3% Definity) with therapeutic ultrasound with 4-20 usec and custom designed high mechanical index (MI) impulses (1.1 to 1.3 MI) designed for the 1.8 MHz S5-1 transducer while waiting for percutaneous coronary intervention.
A control group (PCI only) undergoing low MI (<0.2) imaging only with limited (no more than 3) diagnostic high MI impulses to assess regional wall motion and microvascular perfusion before and after PCI.
High MI will continue after PCI procedure until complete a total of 50 minutes.
|
A custom designed high mechanical index (MI) impulses at 4-20 usec and >1.0 mechanical index designed for the 1.8 MHz S5-1 transducer
|
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Angiographic recanalization rate
Time Frame: At initial angiography
|
Percentage of patients with acute STEMI and open artery at initial angiography (TIMI I)
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At initial angiography
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Salvageability index
Time Frame: 72-96 hours and 3 months post infarction
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Percentage of myocardium with viability within the risk area obtained by magnetic resonance imaging
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72-96 hours and 3 months post infarction
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Overall survival
Time Frame: 30 days post infarction
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The time from the start of treatment to death from any cause
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30 days post infarction
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Cardiac remodeling
Time Frame: 72-96 hours, 30 days and at 6 months
|
Left ventricular and left atrial volumes (mL) will be measured using comprehensive two-dimensional echocardiography
|
72-96 hours, 30 days and at 6 months
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Myocardial Mechanics
Time Frame: 72-96 hours, 30 days and at 6 months
|
Percentage of myocardial deformation (%), ie.
left ventricular strain imaging will be assessed to detect subclinical myocardial dysfunction
|
72-96 hours, 30 days and at 6 months
|
Collaborators and Investigators
Collaborators
Investigators
- Principal Investigator: Wilson Mathias Jr, MD, PhD, Heart Institute - University of São Paulo Medical School
- Principal Investigator: Jeane Tsutsui, MD, PhD, Heart Institute - University of São Paulo Medical School
- Principal Investigator: Thomas R Porter, MD, University of Nebraska Medical Center, Omaha, NE
Study record dates
Study Major Dates
Study Start (Actual)
Primary Completion (Estimated)
Study Completion (Estimated)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Actual)
Study Record Updates
Last Update Posted (Estimated)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Additional Relevant MeSH Terms
Other Study ID Numbers
- 2018/06387-8
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
IPD Plan Description
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
product manufactured in and exported from the U.S.
This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.
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