Conditions: Cardiac Allograft Vasculopathy
Keywords: Heart Transplantation Endothelin-1 Cardiac Allograft Vasculopathy
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 19
Healthy volunteers: no

Brief 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.

Detailed description:

Arms:
arm 1: A consecutive subset of eligible patients based on inclusion/exclusion criteria will receive a 1-week course of Macitentan (10 mg po daily) prior to their routine 1-year coronary angiogram (7th and final dose of Macitentan will occur on the day of the angiogram).

Interventions: intervention 1: Macitentan
Intervention descriptions: intervention 1: 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.

Protocol document:
Prot_SAP_000.pdf: 
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Impact of Endothelin-1 on the Development of Cardiac Allograft Vasculopathy in Heart Transplant 
Recipients: Endothelin Receptor Antagonism and Vasomotor Function   
 
NCT05373108 
 
July 28, 2021 
 
 


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STUDY PROTOCOL 
Sponsor/Institution: UCLA 
Drug Support: Actelion Pharmaceuticals US Inc, a Janssen Pharmaceutical company of Johnson and 
Johnson and represented by Janssen Research and Development, LLC  
Funding Support: American Heart Association 
Principal Investigator: Rushi Parikh, M.D., FACC, FSCAI 
TITLE: Impact of Endothelin-1 on the Development of Cardiac Allograft Vasculopathy in Heart Transplant 
Recipients 
BACKGROUND/SIGNIFICANCE  
Dr. Christiaan Barnard performed the first human-to-human heart transplant in South Africa in 1967.(1) 
Over 50 years later, nearly 5,000 heart transplants are performed annually worldwide, yet the “Achilles’ 
Heel” of long-term survival remains the same—cardiac allograft vasculopathy (CAV).(2,3) CAV is a 
complex immune and inflammatory-mediated fibroproliferative disease of the graft coronary circulation 
defined by concentric intimal and negative remodeling (i.e. vessel shrinkage due to medial 
vasoconstriction and adventitial fibrosis), dual processes that together result in accelerated luminal 
narrowing.(4) Rapidly progressive disease just 1 year after transplantation has been shown to predict 
death and/or graft loss at 5 years.(5,6) Despite advances over the past few decades to prevent CAV 
including the advent of statins, robust immunosuppressive agents to treat acute rejection, and 
aggressive infectious prophylaxis, recent international registry data demonstrate minimal improvement 
in the 5-year incidence and survival due to CAV over this period (32% to 29% and 71% to 76%, 
respectively). Indeed, CAV still accounts for an unacceptably high proportion of long-term graft failure, 
including 1 in 8 late deaths (beyond 1-year post-transplant).(2) These sobering data highlight that the 
clinical care of heart transplant recipients in the contemporary era is greatly limited by a lack of effective 
treatment to prevent and/or slow the progression of CAV. Hence, there is an urgent need to elucidate 
the mechanisms of CAV in order to target new therapies and impact long-term outcomes.  
 
One compelling mechanistic candidate is endothelin-1 (ET-1), a principal molecular mediator of vascular 
integrity with powerful vasoconstrictive, mitogenic, and pro-inflammatory effects throughout the vessel 
wall.(7) Notably, ET-1 also carries immediate therapeutic potential because safe inhibitory drugs—
endothelin receptor antagonists (ERAs)—are  already clinically well-established (approved for the 
treatment of pulmonary arterial hypertension [PAH]) and widely available.(8,9) Furthermore, they do 
not possess and significant drug-drug interactions with the standard post-heart transplant 
pharmacological regimen. 
 
A series of classic studies using rat models of heart transplantation established the plausibility of ET-1 as 
a mechanistic driver of CAV. First, Okada et al. observed strong ET-1 immunoreactivity throughout the 
entire coronary vessel wall post-transplant and found that orally-administered bosentan, a non-selective 
endothelin receptor antagonist, attenuated these changes and significantly reduced intimal growth and 
improved the lumen/vessel ratio.(10) Simonson et al. then conducted similar studies using 
phosphoramidon, an ET-1 converting enzyme inhibitor, and found that it improved allograft survival and 
decreased CAV. Phosphoramidon-treated rats had less smooth muscle cell-derived intimal thickening, 
medial tone, adventitial fibrosis, and macrophage infiltration in the coronary vessels.(11,12) Finally, 
Yamaguchi et al. treated donor hearts with anti-sense oligodeoxynucleotides for ET-1, which markedly 


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reduced ET-1 mRNA and protein expression and significantly reduced intimal hyperplasia.(13) These 
studies collectively provide robust causal evidence for ET-1 in the pathogenesis of CAV and confirm that 
ET-1 exerts effects throughout the vessel wall, contributing to intimal hyperplasia and negative 
remodeling.  
 
To date, the published literature in humans has been somewhat inconsistent in establishing a 
mechanistic role for ET-1 in the pathogenesis of CAV. Ravalli et al. initially compared 13 explanted 
allografts with severe CAV to 10 explanted native hearts with normal coronary arteries and observed 
significantly increased ET-1 immunoreactivity throughout the vessel wall in the CAV cohort.(14) Weis et 
al. next studied 33 heart transplant recipients and showed that increased myocardial ET-1 mRNA 
expression was associated with coronary endothelial dysfunction (acetylcholine-induced paradoxical 
vasoconstriction), but that neither ET-1 mRNA expression nor plasma ET-1 were associated with 
maximal intimal thickness (MIT) on 2D planar intravascular ultrasound (IVUS).(15) Ferri et al. 
subsequently demonstrated that interstitial ET-1 expression on endomyocardial biopsy at 3-months 
post-transplant predicted development of angiographic CAV at 2 years in 47 heart transplant 
patients.(16) Larose et al. then studied 18 heart transplant recipients and measured angiographic 
epicardial dilation after intracoronary delivery of 1) BQ-123 (selective ETA receptor antagonist), and 2) 
nitroglycerin (maximal vasodilator). They found that biologically active ET-1 accounted for a significantly 
larger proportion of vasomotor tone among patients with advanced angiographic CAV, thereby 
providing the first mechanistic data in humans supporting a causal link between ET-1 and CAV.(17) More 
recently, Starling et al. measured plasma ET-1 and performed 2D IVUS within 2 months and at 1-year 
post-transplant in 106 heart transplant patients. They observed that changes in ET-1 but not baseline ET-
1 (as a continuous variable) were associated with rapidly progressive CAV (defined as a change in MIT 
≥0.5 mm).(18) Taken together, the findings from these studies generally favor ET-1 as a mediator of 
CAV, but important limitations should be considered. First, the studies were primarily small (<50 heart 
transplant recipients) and cross-sectional in design. Second, they utilized less sensitive techniques—
quantitative coronary angiography (QCA) or 2D IVUS—to evaluate coronary architecture, whereas 
contemporary 3D volumetric IVUS allows for greater accuracy in detecting smaller changes in the vessel 
wall.(19) In addition, the IVUS-based analyses focused solely on intimal thickening and failed to assess 
vessel remodeling, which as described earlier, is an integral component of CAV. Lastly, apart from the 
small study by Larose et al., functional and/or mechanistic exploration was lacking.  
 
I addressed several of these limitations in a recently published retrospective cohort study examining the 
association of ET-1 with early CAV in 90 heart transplant patients at Stanford University from 2002-
2014.(20) The salient findings of this study were 1) elevated baseline ET-1 was the strongest 
independent predictor of rapidly progressive CAV at 1 year as measured by volumetric IVUS [odds 
ratio=4.88 (1.69-14.1), p=0.003] following multivariate adjustment for recipient and donor demographic, 
cardiovascular, and transplant-related risk factors, and 2) higher baseline ET-1 conferred a significantly 
lower risk of late death and/or re-transplantation in multivariate Cox regression analysis [hazard 
ratio=2.94 (1.12-7.72), p=0.02]. These data strongly support the hypothesis that greater ET-1 bioactivity 
accelerates the development of CAV and suggests that ET-1 blockade may have durable prognostic value 
for heart transplant recipients.  
 
These published data serve as the foundation for my ongoing AHA-funded Career Development Award 
entitled “Impact of Endothelin-1 on the Development of Cardiac Allograft Vasculopathy in Heart 
Transplant Recipients,” which aims to leverage contemporary interventional methods to prospectively 
define the role of endothelin-1 (ET-1) in the development of CAV in heart transplant recipients through a 
comprehensive invasive assessment of coronary anatomy, physiology, and vasomotor function. Specific 


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Aim #1 primarily involves the prospective validation of the ability of baseline ET-1 (measured on day of 
initial post-transplant coronary angiogram) to predict accelerated CAV at 1 year after transplant 
(measured using 3D IVUS). Specific Aim #2 primarily involves evaluating the association between 
baseline ET-1 changes in epicardial coronary physiology (measured by fractional flow reserve as well as 
other non-hyperemic pressure ratios) and lipid accumulation (measure by near infrared spectroscopy) at 
1 year. I began enrolling patients in January 2019, and as of December 17th, 2020 we have enrolled 65 
post-heart transplant patients into the study, 30 of whom have undergone their 1-year angiogram and 
thus completed the study.  
 
Specific Aim #3 of the AHA grant involves defining the contribution of ET-1 bioactivity to coronary 
vasomotor tone following heart transplantation. This mechanistic aim of the grant requires short-term 
(1 week) administration of an ERA (Macitentan, which will be provided by Actelion Pharmaceuticals 
US Inc, a Janssen Pharmaceutical company of Johnson and Johnson and represented by Janssen 
Research and Development, LLC) in post-heart transplant patients. I anticipate that the findings of 
this substudy, combined with the data generated from Aims #1 and #2, will provide the necessary 
groundwork to conduct a pilot randomized, placebo-controlled trial to assess whether or not reducing 
ET-1 bioactivity via endothelin receptor antagonism using Macitentan slows the development of CAV 
and improves outcomes in heart transplant recipients. The possible addition of ERAs to the limited CAV 
armamentarium would be a pivotal shift in the clinical practice paradigm of this complex patient 
population. 
 
STUDY OBJECTIVES 
1. To define the contribution of ET-1 bioactivity to coronary vasomotor tone after heart 
transplantation. At 1-year follow-up in a subset of consecutive patients, we will use 3D IVUS to 
measure vasomotor response (% change in lumen volume) to Macitentan and intracoronary 
nitroglycerin (the reference standard for maximum dilatory capacity). Of note, patients will have 
taken a 1-week course of Macitentan 10 mg daily to end on the day of their 1-year angiogram.  
Hypothesis: ET-1 bioactivity accounts for a greater proportion of vasomotor tone (i.e. higher 
macitentan/nitroglycerin luminal volume dilation ratio) in accelerated CAV. 
 
2. To establish short-term safety of Macitentan in post-heart transplant patients. On the day of the 
1-year angiogram, potential drug-related side effects will be recorded and laboratory tests 
including hemoglobin and liver function tests will be collected.  
Hypothesis: Macitentan is safe in heart transplant patients (no substantial increase in rate of 
side effects or laboratory abnormalities compared to historically reported rates).  
 
STUDY DESIGN 
For the remainder of AHA award period (ends 12/1/21), I will continue to recruit new heart transplant 
recipients within the first 4 months of their surgery to participate in this prospective cohort study. For 
those patients already enrolled who have yet to complete their 1-year angiogram (approximately 28 
patients as of 11/1/20) and for new enrollees, a consecutive subset of patients will receive a 1-week 
course of Macitentan and undergo the protocol described below.  
 
The overall study inclusion/exclusion criteria are as follows: 
 
Inclusion Criteria 


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1) Within 4 months post-transplant 
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) 1) Multi-organ transplant (i.e. Heart/Lung) 
2) 2) Transplant-related complications and comorbidities that preclude the ability to safely perform an 
invasive coronary evaluation in the cardiac catheterization laboratory  
3) Contraindicated to undergo coronary angiography and/or IVUS/physiologic assessment (e.g. 
pregnant women due to risk of radiation to fetus). 
 
Additional exclusion criteria for the current Macitentan-based study are: 
1) 1) Patients who are taking potent CYP3A4 inhibitors (e.g. ketoconazole, ritonavir) as these drugs can 
expose one to higher levels of macitentan  
2) 2) Pregnant women due to possible fetal harm; as above, 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,  
3) 3) Cirrhosis or baseline liver function tests (AST/ALT) > 3x the upper limit of normal 
 
There are otherwise no inclusion/exclusion criteria based on gender, race, ethnicity, or language spoken.   
Macitentan Protocol 
As described above, Macitentan is a nonselective ERA that is approved for use in PAH; the use of 
Macitentan in post-heart transplant patients is considered investigational. A consecutive subset of 
eligible patients based on the criteria outlined above will receive a 1-week course of Macitentan 10 mg 
tablets daily prior to their routine 1-year coronary angiogram (7th and final dose of Macitentan will occur 
on the day of their 1-year angiogram). On the day of the angiogram, drug-related side effects, adverse 
reactions, and medication compliance will be recorded. Additionally, laboratory tests including 
hemoglobin, liver function tests, and creatinine will be obtained.  
 
In accordance with the Risk Evaluation and Mitigation Strategy (REMS) program for Macitentan, women 
of childbearing potential (i.e. pre-menopause) will be required to enroll in REMS and 1) have a 
confirmed negative pregnancy test within 1 week of starting Macitentan, and 2) take an additional 
pregnancy test 30 days after completing the 1-week course of Macitentan. The results of these 
pregnancy tests will be recorded in the participant’s case report form.  
 
Per the overall study protocol, a 10-cc blood arterial blood sample will be drawn into an EDTA tube to 
measure plasma ET-1 levels after arterial access is obtained. Next, coronary angiography will be 
performed, after which an initial IVUS run of the left anterior descending coronary artery protocol will 
be done without administering nitroglycerin (Macitentan run). Afterwards, 200 mcg of intracoronary 
nitroglycerin (reference standard for maximum dilatory capacity) will be given and a second IVUS run 
(Nitroglycerin run) will be performed in order to calculate the Macitentan:Nitroglycerin luminal volume 
dilation ratio. Of note, 3D volumetric IVUS analyses will be performed by a blinded, independent IVUS 
core lab at Stanford University. Finally, coronary physiology indices including fractional flow reserve will 
be measured. 
 


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Of note, blood samples will be centrifuged at 4° C within 30 minutes of being drawn and subsequently 
stored in cryovials at -80° C. Remaining blood specimens after ET-1 analysis will remain banked and 
available for future research purposes. 
 
Primary Endpoint 
ET-1 bioactivity as measured by contribution to vasomotor tone via the Macitentan:Nitroglycerin 
luminal volume dilation ratio 
 
Secondary Endpoint 
Frequency of drug-related side effects 
 
STATISTICAL PLAN 
First, I will evaluate the correlation between 1-year ET-1 levels and the Macitentan:Nitrogylcerin luminal 
volume dilation ratio; we hypothesize that higher ET-1 levels will be positively correlated with higher 
Macitentan/Nitroglycerin luminal volume dilation ratios.  
 
Next, in order to test the hypothesis that ET-1 bioactivity accounts for a greater proportion of vasomotor 
tone (i.e. higher Macitentan/Nitroglycerin luminal volume dilation ratio) in patients with accelerated 
CAV at 1 year, the Macitentan subset will be divided into 2 groups—those with and without accelerated 
CAV at 1-year post-transplant—and the Macitentan/Nitroglycerin luminal volume dilation ratio will be 
compared between these 2 groups. Accelerated CAV will prospectively be defined as > 75th percentile of 
lumen volume loss measured by 3D IVUS because prior studies using 2D IVUS reported 20-30% rates of 
accelerated disease.(2,15,16) Of note, I will also run a separate sensitivity analysis using the cutoff 
identified in our recently published retrospective analyses. 
 
Power analysis and sample size estimation 
Although Larose et al. used QCA (as opposed to IVUS) to define accelerated CAV and evaluate 
vasomotor response to endothelin receptor antagonism, I used their data to estimate the required 
sample size.(17) Assuming 80% power, a 2-tailed alpha of 0.05, a 25% prevalence rate of accelerated 
CAV, and a 15% drop-out rate, a sample size of approximately 25 patients is needed to detect their 
previously reported standardized effect sizes for the outcomes of interest (Larose and colleagues 
reported an ERA/Nitroglycerin ratio of 12.9% ± 26.3 in patients without advanced CAV versus 53.2% ± 
28.6% in patients with advanced CAV.(12) To date, I have enrolled 65 patients into the parent AHA 
study, 30 of whom have undergone their 1-year angiogram and thus completed the study (i.e. 35 
patients have yet to undergo their 1 year angiogram and eligible to receive Macitentan). I anticipate 
enrolling at least 40 additional patients into the study (end date for enrollment 11/30/21). Thus, 
between these new study participants and the 35 awaiting 1-year angiograms, I will easily be able dose 
Macitentan in > 25 patients, with a goal of 40-50 patients total. However, this assumes that we are  able 
to begin able to dispense Macitentan in the coming months. This expected Macitentan cohort size will 
provide adequate power to test the aforementioned hypothesis. Finally, we will compare the rates of 
drug-related side effects with historically reported rates.  
 
Analytic Strategy 
For continuous variables, we will express normally distributed data as mean±standard deviation and 
non-normally distributed data as median (interquartile range). We will express categorical variables as 
frequency (percentage). Given our relatively small sample size, we will use non-parametric Wilcoxon 
Rank-Sum and Rank-Sign tests to assess for differences between groups of variables, as appropriate. 


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Statistical analyses will be carried out with the SPSS system, version 26 (SPSS Inc., Chicago, IL). A p-value 
<0.05 will be deemed statistically significant.  
 
SAFETY 
Potential Risks 
As outlined in our IRB-approved informed consent form, there are greater than minimal risks associated 
with Macitentan. Although Macitentan is safe and well-tolerated, after 1 week of therapy, there is a 
possibility for side effects including but not limited to headaches, fluid retention and swelling, 
nasopharyngitis, bronchitis, anemia, and elevation of liver function tests. The details of these potential 
risks will be outlined in detail with the potential participants during the informed consent process. In 
addition, laboratory tests including hemoglobin and liver function tests will be checked the day of the 
patient’s 1-year angiogram (i.e. Day 7 of Macitentan). Finally, Macitentan is contraindicated in 
pregnancy. As outlined above, women of childbearing potential will be required to enroll in REMS and 
have a confirmed negative pregnancy test within 1 week of starting Macitentan as well as take an 
additional pregnancy test 30 days after completing Macitentan. 
 
Protection Against Risk 
Importantly, the protocol has been designed to perform vasomotor function testing in response to 
Macitentan at a time point coincident with routine 1-year clinical surveillance at UCLA. The additional 
risk of performing a second IVUS run is negligible. Additional procedures to minimize risk will include: 1) 
conducting the invasive studies outlined above in a cardiac catheterization laboratory that is fully 
equipped with state-of-the-art technology for visualization of catheter and wire placements and 
intracoronary imaging as well as cardiac monitoring and facilities for resuscitation, 2) employing 
procedures for ensuring aseptic and sterile environment, 3) having highly trained personnel conduct the 
procedures, 4) having a formal data and safety monitoring plan (refer to “Data and Safety Monitoring 
Plan” section below), and 5) detailed informed consent.  
 
Potential Benefits of the Proposed Research  
There are no direct/immediate benefits to the study participants. However, data obtained will 
comprehensively define the role of ET-1 in the development of early CAV. These findings will potentially 
lead to a study of whether endothelin receptor antagonists attenuate CAV in heart transplant recipients, 
the results of which could have major clinical implications for all heart transplant recipients. 
 
Data Security 
Clinical and procedural data will be stored in a secure-web-based database (UCLA REDcap). The 
database will be password protected, and only members of the research team will have access to the 
database password. The database will not be coded, but will have study participant ID numbers so that 
when the data is extracted for analysis, the name, MRN, and DOB can be excluded. Blood specimens will 
similarly be labeled using participant ID numbers. The participant ID numbers will only be available to 
the research team. This REDcap set-up is a standard infrastructure for clinical research studies like this 
one and very much minimizes the risk of patient health information being disclosed. 
 
Data and Safety Monitoring Plan 
The proposed research involves greater than minimal risk, though this risk is predominantly 
encountered as part of the subjects’ routine post-transplant clinical care at UCLA (i.e. risks associated 
with performing coronary angiography, IVUS, etc.). The protocol-specific risk that is greater than 
minimal in nature is the potential for an adverse reaction to Macitentan, though this is very unlikely 
given the short duration of therapy (1 week), established safety and tolerability of Macitentan, and lack 


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of drug-drug interactions with standard post-heart transplant pharmacologic regimens. Given these 
greater than minimal risks, I have created the following formal Data and Safety Monitoring Plan: 
1. Safety data will be captured at the time of the 1-year angiogram (Day 7 of Macitentan) and at any 
time point when an adverse event (AE) occurs during the study period (1-week course of 
Macitentan) 
2. As Principal Investigator, I will monitor data and safety internally. I will assess each AE for 
designation as serious AE (SAE) or AE  
3. All study-related AEs will be reported to the UCLA IRB and Janssen per protocol below 
4. Specific safety data collection and reporting will be conducted in accordance with the Janssen 
protocol below (pages 7-13) 
 
REFERENCES 
1.  
Cooper DK. Christiaan Barnard and his contributions to heart transplantation. J Heart Lung 
Transplant Off Publ Int Soc Heart Transplant. 2001 Jun;20(6):599–610.  
2.  
Lund LH, Edwards LB, Kucheryavaya AY, Benden C, Dipchand AI, Goldfarb S, et al. 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 Off Publ Int Soc 
Heart Transplant. 2015 Oct;34(10):1244–54.  
3.  
Chih S, Chong AY, Mielniczuk LM, Bhatt DL, Beanlands RSB. Allograft Vasculopathy: The Achilles’ 
Heel of Heart Transplantation. J Am Coll Cardiol. 2016 Jul 5;68(1):80–91.  
4.  
Mitchell RN, Libby P. Vascular remodeling in transplant vasculopathy. Circ Res. 2007 Apr 
13;100(7):967–78.  
5.  
Kobashigawa JA, Tobis JM, Starling RC, Tuzcu EM, Smith AL, Valantine HA, et al. Multicenter 
intravascular ultrasound validation study among heart transplant recipients: outcomes after five years. J 
Am Coll Cardiol. 2005 May 3;45(9):1532–7.  
6.  
Tuzcu EM, Kapadia SR, Sachar R, Ziada KM, Crowe TD, Feng J, et al. 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.  
7.  
Böhm F, Pernow J. The importance of endothelin-1 for vascular dysfunction in cardiovascular 
disease. Cardiovasc Res. 2007 Oct 1;76(1):8–18.  
8.  
Davenport AP, Hyndman KA, Dhaun N, Southan C, Kohan DE, Pollock JS, et al. Endothelin. 
Pharmacol Rev. 2016 Apr;68(2):357.  
9.  
Sidharta PN, van Giersbergen PLM, 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.  
10.  
Okada K, Nishida Y, Murakami H, Sugimoto I, Kosaka H, Morita H, et al. 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.  
11.  
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.  
12.  
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.  
13.  
Yamaguchi A, Miniati DN, Hirata K ichi, 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 Off 


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Publ Int Soc Heart Transplant. 2002 Apr;21(4):417–24.  
14.  
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.  
15.  
Weis M, Wildhirt SM, Schulze C, Rieder G, Wilbert-Lampen U, Wolf WP, et al. Endothelin in 
coronary endothelial dysfunction early after human heart transplantation. J Heart Lung Transplant Off 
Publ Int Soc Heart Transplant. 1999 Nov;18(11):1071–9.  
16.  
Ferri C, Properzi G, Tomassoni G, Santucci A, Desideri G, Giuliani AE, et al. Patterns of myocardial 
endothelin-1 expression and outcome after cardiac transplantation. Circulation. 2002 Apr 
16;105(15):1768–71.  
17.  
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.  
18.  
Starling RC, Stehlik J, Baran DA, Armstrong B, Stone JR, Ikle D, et al. Multicenter Analysis of 
Immune Biomarkers and Heart Transplant Outcomes: Results of the Clinical Trials in Organ 
Transplantation-05 Study. Am J Transplant Off J Am Soc Transplant Am Soc Transpl Surg. 2016 
Jan;16(1):121–36.  
19.  
Pollack A, Nazif T, Mancini D, Weisz G. Detection and Imaging of Cardiac Allograft Vasculopathy. 
JACC Cardiovasc Imaging. 2013 May;6(5):613–23.  
20.  
Parikh RV, Khush K, Pargaonkar VS, Luikart H, Grimm D, Yu M, et al. Association of Endothelin-1 
With Accelerated Cardiac Allograft Vasculopathy and Late Mortality Following Heart Transplantation. J 
Card Fail. 2019 Feb;25(2):97-104.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
SAFETY EVENT AND PRODUCT QUALITY COMPLAINTS REPORTING 
 
1 
Sponsor/Institution Responsibilities 
1.1 
Health Authority 
As the sponsor/institution of the Study and to the extent required by any applicable laws or regulations 
in each country/territory, UCLA shall be solely responsible for complying, within the required timelines, 


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with any safety reporting obligation towards the competent health authorities, the Ethics Committees 
(EC) or Independent Review Board (IRB) and the participating (co- or sub-) investigators. 
 
1.2 
General 
The Institution shall notify (Actelion Pharmaceuticals US Inc, a Janssen Pharmaceutical company of 
Johnson and Johnson and represented by Janssen Research and Development, LLC  (Company) 
immediately in case of a suspension of recruitment or premature stop of the concerned clinical study 
because of a safety concern; preferably by means of a telephone contact with the Company 
Representative, alternatively by email within twenty-four (24) hours of the decision.  
Institution shall provide to the Company copies of any and all relevant extraordinary* (not including 
routine initial or follow-up individual case safety report (ICSR submission) correspondences with health 
authorities and ethics committees regarding any and all serious adverse events (irrespective of the 
association with the Janssen Product(s) Under Study). Copies of such correspondence shall be provided 
within 24 hours of such report or correspondence being sent to applicable health authority. 
*See definitions section 4.6 
 
Training: Institution shall be responsible for training the Study personnel (including the Investigator) on 
managing safety information arising from the Study according to agreed procedures and the 
requirements of this Agreement. 
 
Management of Safety Data: The Institution and Investigator will provide safety information arising from 
the Study to the Company on adverse events, special situations including pregnancies and product 
quality complaints as defined within this exhibit. This safety information will be documented by the 
Investigator and reported as described in this exhibit from the time a subject has signed and dated an 
Informed Consent Form (ICF) until 30 days after the last dose of the Janssen Product(s) Under Study. All 
subsequent AEs and SAEs beyond 30 days after the last dose of the Janssen Product(s) under study shall 
be collected/reported if the investigator considers the AE/SAE to be causally related to the use of the 
Janssen Product(s) Under Study.  
 
For the purposes of this Study, the Janssen Product(s) Under Study is (are): macitentan (Opsumit®) 
 
Maintenance of Safety Information:  All safety data arising from the Study shall be maintained in a 
clinical database in a retrievable format. The Institution and Investigator shall provide a summary of all 
non-serious adverse events (NSAES) annually, and both serious and non-serious adverse events will be 
summarized in the final Study report (excluding those from subjects not exposed to a Janssen product). 
The summary shall include a listing of: Patient ID, adverse event term (uncoded), severity, relationship 
to Janssen Product(s) Under Study, and action taken with Janssen Product(s) Under Study. However, in 
certain circumstances more frequent provision of safety data may be necessary, e.g. to fulfill a 
regulatory request, and as such the safety data shall be made available within a reasonable timeframe at 
the Company’s request. 
 
Follow-up: All (serious and non-serious) adverse events reported for a Janssen Product(s)Under Study 
shall be followed up in accordance with good clinical practice (GCP). 
 
1.3 
Reporting of Safety data and Product Quality Complaints (PQCs) to Company 


Parikh IIS 
7.28.21 
11 
 
All adverse events and special situations, whether serious or non-serious, related or not related, 
collected as per protocol design, following exposure to a Janssen Product(s) Under Study are to be 
documented by the investigator and recorded in the CRF and in the subject’s source records. 
Investigators must record in the CRF their evaluation concerning the relationship of the adverse event to 
a Janssen Product(s) Under Study. 
 
The Institution will submit (and procure that the Investigator submits), to the identified Company 
Representative in each Country/Territory the following safety information: 
 
Type of report 
Timelines 
How to report 
Serious Adverse Event  
 
Within 3 business days of 
becoming aware of the event(s) 
By a secure means, as agreed 
by the Parties, on a Serious 
Adverse Event Form. 
Adverse Events of Special 
Interest (AESI) 
Within 3 business days of 
becoming aware of the event(s) 
By a secure means, as agreed 
by the Parties, on a Serious 
Adverse Event Form. 
Reports of drug exposure during 
pregnancy (maternal and 
paternal), with or without SAE. 
Within 3 business days of 
becoming aware of the event(s) 
By a secure means, as agreed 
by the Parties, on a Serious 
Adverse Event Form. 
Reports of Suspected 
transmission of any infectious 
agent via administration of a 
Janssen Product, with or without 
an SAE 
Within 3 business days of 
becoming aware of the event(s) 
By a secure means, as agreed 
by the Parties, on a Serious 
Adverse Event Form. 
Abnormal Pregnancy Outcomes 
(e.g. spontaneous abortion, fetal 
death, stillbirth, congenital 
anomaly, ectopic pregnancy) 
Within 3 business days of 
becoming aware of the event(s) 
By a secure means, as agreed 
by the Parties, on a Serious 
Adverse Event Form. 
Special 
Situation 
(SS), 
if 
associated with an SAE  
Within 3 business days of 
becoming aware of the event(s) 
By a secure means, as agreed 
by the Parties, on a Serious 
Adverse Event Form. 
Special Situation (not associated 
with an SAE) 
Annually and in final study 
report. 
 
Recorded in CRF and reported 
annually and in final study 
report. 
Product Quality Complaints 
Within 3 business days of 
becoming aware of the event(s) 
By a secure means, as agreed 
by the Parties. 
Non-Serious 
Adverse 
Event* 
(*Not meeting other listed 3 
business day reporting criteria 
e.g. AESI or SS) 
Annually and in final study 
report. 
Recorded in CRF and reported 
annually and in final study 
report. 
Follow-up information 
Transmitted within the same 
timeframes as above i.e. if initial 
report was required to be 
submitted within 3 business 
days, follow-up information shall 
Transmitted via same method 
as above i.e. if initial method of 
transmission was on an SAE 
form, follow-up information 


Parikh IIS 
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12 
 
be submitted within the same 
timeframe. 
shall be transmitted in the 
same manner. 
 
The Institution and/or Investigator is responsible for ensuring that these cases are complete and if not, 
are promptly followed-up. A safety report is not considered complete until all clinical details needed to 
interpret the case are received. 
 
Note: In the event the Study is blinded, the Investigator will submit an unblinded SAE or pregnancy 
exposure report to Company. 
 
If the Investigator/agent of the Investigator receives safety information and is aware it involves a non-
study J&J product, it will be reported to Company, indicating it is an incidental spontaneous report 
discovered during the course of the study. 
 
Pregnancy: 
If a subject becomes pregnant during the study, in addition to reporting the pregnancy within 3 business 
days, a determination regarding Janssen Product(s) Under Study discontinuation and subject 
discontinuation must be made by the investigator in alignment with the protocol inclusion/exclusion 
criteria and in consultation with the reference safety information. 
Because the Janssen Product(s) Under Study may have an effect on sperm, pregnancies in partners of 
male subjects exposed to a Janssen Product(s) Under Study will be reported by the Investigator within 3 
business days of their knowledge of the event using the Serious Adverse Event Form.  Depending on 
local legislation this may require prior consent of the partner. 
 
Follow-up information regarding the outcome of the pregnancy and any postnatal sequelae in the infant 
will be required. 
 
1.4 
Sponsor confirmation/review of SAEs 
 
Company Representative or designee will provide the Institution and Investigator with a list of the 
Study’s SAEs (previously received by the Company from the Institution and the Investigator) on a semi-
annual basis. Investigator will confirm to Company that all applicable SAEs related to Janssen Product(s) 
Under Study have been reported to Company.  
 
2 
Company Responsibilities 
Company Representative or designee will provide the Institution and Investigator with the following 
safety information: 
• 
Local Package Insert for the determination of expectedness https://www.opsumit.com/  
• 
ICF risk wording  
• 
any new information, which becomes available during the course of the Study, which may 
affect the overall safety profile of the Janssen Product(s) Under Study. 
 
3 
Company Safety Contact Information 


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Contact details for the Company representative for submission of information required under this 
exhibit. 
 
SAE/Pregnancy Notifications: IIS-BIO-VIRO-GCO@its.jnj.com 
PQC: IIS-BIO-VIRO-GCO@its.jnj.com 
Phone: contact the study assigned Janssen Trial Manager 
Fax: 1-866-451-0371 
 
4 
Definitions 
4.1 
Adverse Event (AE) 
Any untoward medical event in a patient administered a pharmaceutical product which does not 
necessarily have to have a causal relationship with the treatment. An adverse event can be any 
unfavourable and unintended sign (including abnormal finding or lack of expected pharmacological 
action), symptom, or disease temporarily associated with the use of a medicinal (investigational or non-
investigational) product, whether or not related to that (investigational or non-investigational) product. 
This includes any occurrence that is new in onset or aggravated in severity from the baseline condition, 
or abnormal results of any diagnostic procedures, including laboratory test abnormalities.  
 
4.2 
Adverse Event of Special interest 
Adverse events of special interest are events that the Company is actively monitoring as a result of a 
previously identified signal (even if non-serious). Adverse events of special interest of macitentan 
(Opsumit®) will be reported to the Company as defined in the protocol. In case of any amendments to 
the AESI list, Company will notify the Institution/Investigator and the Institution/Investigator will inform 
sites. Institution/Investigator will ensure that these changes are updated in the protocol as soon as 
practical. 
 
4.3 
Serious Adverse Event (SAE) 
Any adverse event occurring that:  
• 
Results in death;  
• 
Is life-threatening;  
• 
Requires in-patient hospitalization or prolongation of existing hospitalization;  
• 
Results in persistent or significant disability/incapacity;  
• 
Is a congenital anomaly/birth defect;  
• 
Any suspected transmission of any infectious agent via administration of a medicinal 
product   
• 
Is considered medically significant* 
 
*Any untoward medical occurrence that is considered medically significant. Medical and scientific 
judgment should be exercised in deciding whether expedited reporting is appropriate in other 
situations, such as important medical events that may not result in death, be life-threatening or require 
hospitalization but may be considered a serious adverse drug experience when, based on appropriate 
medical judgement, that may jeopardize the patient or subject and may require medical or surgical 
intervention to prevent one of the other outcomes listed in the bulleted list above. Examples of such 
medical events include allergic bronchospasm requiring intensive treatment in an emergency room or at 
home, blood dyscrasias or convulsions that do not result in hospitalization, or development of drug 
dependency or drug abuse or malignancy. 
 
4.3.1 
Hospitalization 


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For reports of hospitalization, it is the sign, symptom or diagnosis which led to hospitalization that is the 
serious event for which details must be provided. Any event requiring hospitalization or prolongation of 
hospitalization that occurs during a study must be reported as a serious adverse event, except 
hospitalizations for the following: 
• 
Hospitalizations not intended to treat an acute illness or adverse event (e.g., social 
reasons such as pending placement in long-term care facility) 
• 
Surgery or procedure planned before entry into a study. [Note: Hospitalizations that 
were planned before the signing of ICF and where the underlying condition for which the 
hospitalization was planned has not worsened will not be considered serious adverse events. 
Any adverse event that results in a prolongation of the originally planned hospitalization is to be 
reported as a new serious adverse event.] 
 
4.3.2 
Life-threatening Conditions 
As it relates to life-threatening conditions,  
The cause of death of a subject in a study within 30 days of the last dose of Janssen Product(s) Under 
Study, whether or not the event is expected or associated with the study drug, is considered a serious 
adverse event. 
 
Disease progression should not be recorded as an adverse event or serious adverse event term; instead, 
signs and symptoms of clinical sequelae resulting from disease progression/lack of efficacy will be 
reported if they fulfil the serious adverse event definition. 
 
4.4 
Special Situations 
The following special situations must be reported to Company with or without an associated serious 
adverse event (SAE): 
 
• 
Drug exposure during pregnancy (paternal, maternal) 
• 
Suspected transmission of any infectious agent via administration of a Janssen 
Product(s) under study. 
The following special situations must be reported to the Company when associated with a serious 
adverse event (SAE): 
• 
Overdose of Janssen Product(s) under study  
• 
Exposure to Janssen Product(s) under study from breastfeeding 
• 
Suspected abuse/misuse of Janssen product(s) under study 
• 
Inadvertent or accidental exposure to Janssen Product(s) under study 
• 
Any failure of expected pharmacological action (i.e., lack of effect) of Janssen Product(s) 
under study  
• 
Medication error (includes potential, intercepted or actual) involving a Janssen product 
(with or without patient exposure to the Janssen Product(s) under study, e.g., name confusion) 
• 
Unexpected therapeutic or clinical benefit from use of Janssen Product(s) under study 
 
If no SAE is associated with the special situation, the special situation should be recorded in the CRF and 
sent annually to the Company. 
These safety events may not meet the definition of an adverse event; however, the Parties agree that 
for reporting purposes, they are deemed to be adverse events. 
 
4.5 
Product Quality Complaints 


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A PQC may have an impact on the safety and efficacy of a Company product. Timely, accurate, and 
complete reporting and analysis of PQC information from studies are crucial for the protection of 
patients, investigators, and the Company, and are mandated by regulatory agencies worldwide. The 
Company has established procedures in conformity with regulatory requirements worldwide to ensure 
appropriate reporting of PQC information. The Institution agrees that Lot and/or Batch #s shall be 
collected, when available, for all PQC reports, including reports of failure of expected pharmacological 
action (i.e., lack of effect) of a Janssen Medicinal Product. A sample of the suspected product shall be 
maintained for further investigation if requested by the Company. 
 
Any complaint that indicates a potential quality issue during manufacturing, packaging, release testing, 
stability monitoring, dose preparation, storage or distribution of the product or delivery system is 
considered a PQC. Not all PQCs involve a patient.  
 
Examples of PQC include but are not limited to: 
• 
Mislabelling or misbranding   
• 
Information concerning microbial contamination, including a suspected transmission of 
any infectious agent by a product 
• 
Any significant chemical, physical, or other changes that indicate deterioration in the 
distributed product 
• 
Any foreign matter reported to be in the product 
• 
Mixed product, e.g., two drugs are mixed-up in the packaging process 
• 
Incorrect tablet sequence (e.g., oral contraceptive tablets) 
• 
Insecure closure with serious medical consequences, e.g., cytotoxics, child-resistant 
containers, potent drugs 
• 
Suspected counterfeit or tampered product 
• 
Adverse Device Effects including any adverse event resulting from insufficiencies or 
inadequacies in the instructions for use, the deployment, implantation, installation, operation, 
or any malfunction of a medical device or combination product. This also includes any event that 
is a result of a use error or intentional misuse and dosing device malfunctions (e.g. auto-injector 
button not working, needle detaching from syringe, etc.) 
• 
Physical defect (e.g. abnormal product odour, broken or crushed tablets, etc.) 
 
4.6 
“Extraordinary” correspondence 
Correspondence with a regulatory authority or ethics committee regarding a safety issue that may 
impact the safety or benefit-risk balance of the Janssen Product(s) Under Study, and/or may impact 
patients or public health. Examples include: 
• 
Safety issues relating to a quality defect 
• 
Major safety issues identified with changes in the nature, severity or frequency of 
known serious adverse reactions which are medically significant or the detection of new risk 
factors for the development of a known adverse reaction or a new serious adverse reaction. 
• 
Major safety issues identified in the context of ongoing or newly completed post-
marketing studies e.g. an unexpected increased rate of fatal or life-threatening adverse events.