Aortic Stenosis and PhosphodiEsterase Type 5 iNhibition (ASPEN): A Pilot Study
Phase: PHASE4
Conditions: Aortic Stenosis, LV Remodeling, Hypertrophy
Sponsor: Washington University School of Medicine

Aortic Stenosis and PhosphodiEsterase Type 5 InhibitioN (ASPEN) 
PI: Lindman, Brian R. 
Washington University School of Medicine 
 
November 2012 
1 
 
 
 
 
 
 
 
 
Title: Aortic Stenosis and PhosphodiEsterase Type 5 inhibitioN (ASPEN) 
 
NCT: NCT01275339 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Aortic Stenosis and PhosphodiEsterase Type 5 InhibitioN (ASPEN) 
PI: Lindman, Brian R. 
Washington University School of Medicine 
 
November 2012 
2 
Aortic Stenosis and PhosphodiEsterase Type 5 inhibitioN (ASPEN) 
Study Protocol 
 
Objective:   
To conduct a randomized pilot study to evaluate the tolerability of chronic PDE5 
inhibition (with tadalafil) and its effects on left ventricular (LV) structure and function 
in patients with aortic stenosis (AS). 
 
Clinical / Scientific Problems to be Addressed: 
 
1) Currently, AS is considered a “surgical disease” with no medical therapy available to improve 
any clinical outcomes. 
2) Surgical valve replacement has a number of risks associated with it, including stroke and death.  
Many patients with severe aortic stenosis and symptoms—for whom surgery would be 
indicated—do not undergo surgery for a variety of reasons related to co-morbidities, advanced 
age, or other factors. 
3) LV structural and functional abnormalities are markers of increased risk for adverse outcomes 
in patients with AS. 
4) Animal models of pressure overload have demonstrated a favorable impact of PDE5 inhibition 
on LV structure and function, but this has not been tested in humans with AS. 
5) Patients with AS who have diabetes mellitus (DM) have increased LV hypertrophic 
remodeling, worse LV function, and worse clinical outcomes than non-diabetic patients. 
6) Adjunctive medical therapy has the potential to improve clinical outcomes in patients with AS. 
 
Hypotheses:   
 
1) PDE5 inhibition with tadalafil will have a favorable impact on LV structure by reducing LV 
mass and myocardial fibrosis. 
2) PDE5 inhibition with tadalafil will have a favorable impact on LV function by improving 
measures of LV systolic and diastolic function. 
3) Administration of tadalafil will be well tolerated in patients with AS. 
4) Diabetes will alter the response to PDE5 inhibition in patients with AS. 
 
Potential Impact: 
PDE5 inhibition is a novel strategy to improve clinical outcomes in patients with 
AS using medical therapy.  This study will provide first-in-human data on the 
use of tadalafil in patients with AS, generating important preliminary data for 
designing a larger clinical trial.   
 
Long-Term and Short-Term Goals:   
 
The long-term goal of this research program is to develop novel medical therapies for aortic 
stenosis that will delay the progression of disease leading to symptoms and/or valve replacement by: 1) 
reversing maladaptive hypertrophic remodeling; 2) improving ventricular function; 3) reducing 
pulmonary artery pressure; and/or 4) halting or reversing valve stenosis.  The short-term goal is to 
acquire pilot data on PDE5 inhibition that will enable the PI to design a larger clinical trial to test the 
hypothesis that in patients with aortic stenosis PDE5 inhibition will delay the progression of disease 
and improve clinical outcomes.   
 
Background and Rationale: 
 
Aortic stenosis (AS) is common and, as the population ages, increasing in prevalence.  Although 
some estimates are higher,1,2  AS is present in at least 2% of individuals > 65 years of age.3  Aortic 

Aortic Stenosis and PhosphodiEsterase Type 5 InhibitioN (ASPEN) 
PI: Lindman, Brian R. 
Washington University School of Medicine 
 
November 2012 
3 
sclerosis—thickening and calcification of the valve leaflets without restricted leaflet motion—is the 
precursor to aortic stenosis and is present in ¼ of individuals > 65 years of age.  From these and other 
data, a conservative estimate is that over 1 million people have aortic stenosis in the U.S and over 
10 million people are likely to have its pathologic precursor, aortic sclerosis.  The only effective 
treatment is aortic valve replacement, which has significant morbidity and mortality associated with it.  
Indications for replacement of a severely stenotic valve include symptoms such as chest pain, heart 
failure, or syncope.  At least 1/3 of patients with severe symptomatic AS do not undergo operative 
intervention largely due to advanced age, left ventricular dysfunction, and associated co-morbidities.4,5  
Once symptoms develop, the average life expectancy is < 5 years.  The onset of symptoms can 
markedly change one’s life and functional capacity. 
 
To date, there is no medical therapy for aortic stenosis proven to delay progression of disease, 
symptom onset or progression, or time to valve replacement.  The pathobiology of aortic stenosis is 
characterized by at least three problems: 1) ventricular dysfunction due to hypertrophic remodeling and 
pressure overload; 2) pulmonary hypertension; and 3) progressive valve stenosis.  Although long held 
to be a necessary response to pressure overload, hypertrophic remodeling of the left ventricle may 
not be necessary to “compensate” for pressure overload and maintain ventricular function.6-8  Several 
animal models have shown that ventricular function is maintained despite inhibiting the development 
of ventricular hypertrophy (by various means) in the setting of pressure overload.9-11  Hypertrophic 
remodeling of the ventricle is characterized by fibrosis and myocyte/ventricular hypertrophy that leads 
to contractile dysfunction and increased peri-operative and long-term morbidity and mortality.12-19  
Diabetes adversely affects LV hypertrophic remodeling and LV function in patients with AS.20,21  
Pulmonary hypertension is common in patients with aortic stenosis: among those with severe AS, 
it is present in up to 65% and characterized as severe in 15-20% of patients.22,23  Our own data from 
Washington University demonstrate that in a cohort of 1080 patients undergoing valve replacement for 
severe AS, pulmonary hypertension was present in ~50% (average mean pulmonary artery pressure 
was 24.7 mmHg in the whole cohort and 30.8 mmHg in the sub-group with pulmonary hypertension).  
In a higher risk subset of 29 patients with severe AS referred for a transcatheter aortic valve 
replacement, 66% had pulmonary hypertension (average mean pulmonary artery pressure was 30.2 
mmHg in the whole cohort and 36.5 mmHg in the sub-group with pulmonary hypertension).  The 
presence of pulmonary hypertension is associated with worse heart failure symptoms and increased 
peri-operative mortality.22,24,25  Nonetheless, for patients with severe AS and associated severe 
pulmonary hypertension, surgery provides a mortality benefit while medical therapy has a dismal 
prognosis.24,25  Finally, over the last decade it has become clear that calcification and progressive 
stenosis of the valve is not a passive “degenerative” process; there is an active biology underlying and 
driving these changes with similarities—but also key differences—to atherosclerosis.26  Efforts to 
elucidate these mechanisms and attempts to alter them pharmacologically are in their infancy. 
 
The molecular pathogenesis of AS is only beginning to be understood.  One pathway that has 
emerged is the nitric oxide (NO)—guanosine 3',5'-cyclic monophosphate (cGMP) pathway, which 
affects tissue calcification, cardiac hypertrophy, and pulmonary vasodilation; downregulation of 
this pathway appears to be deleterious.  NO mediates its biologic activity, in part, through generation 
of cGMP, which is selectively hydrolyzed by phosphodiesterase type 5 (PDE5).  Recently it has been 
observed that inhibition of PDE5 (which reduces hydrolysis/breakdown of cGMP) blunts/reverses 
hypertrophic growth of the heart, reduces oxidative stress (which is associated with valve 
calcification), and improves pulmonary vasodilation.  These observations suggest that upregulation of 
NO-cGMP signaling via PDE5 inhibition may prevent disease progression in AS.  Tadalafil is a 
PDE5 inhibitor that has been widely used with a strong safety profile in pulmonary hypertension and 
erectile dysfunction. 
 
There is evidence to suggest that PDE5 inhibition may be helpful in preventing, halting, or 
reversing the hallmarks of AS pathobiology: 

Aortic Stenosis and PhosphodiEsterase Type 5 InhibitioN (ASPEN) 
PI: Lindman, Brian R. 
Washington University School of Medicine 
 
November 2012 
4 
 
1) Hypertrophic ventricular remodeling: In a pressure-overload mouse model, sildenafil (another 
PDE5 inhibitor) altered hypertrophic remodeling of the ventricle.27,28  In this model, the aorta is 
surgically banded to constrict it causing an impediment to flow that increases afterload and mimics the 
physiology of aortic stenosis.  In control animals, PDE5A contributed 35-45% of total cGMP-esterase 
activity; in the pressure-overloaded mice, total cGMP-esterase activity increased 20% over controls 
and the component attributable to PDE5A was 60% of this total.27  Thus, PDE5 is an abundant and 
viable target for inhibition in the myocardium, particularly in the setting of pressure overload.  
When initiated prior to aortic banding (onset of pressure overload), sildenafil blunted the development 
of cardiac hypertrophy and fibrosis.  When initiated after aortic banding—at a point in time when LV 
mass had already increased by 50% (much like patients with severe AS)—sildenafil reversed the 
hypertrophic remodeling process.  Not only did sildenafil favorably alter ventricular structure, but it 
also improved ventricular function compared with control.  Sildenafil had a favorable structural and 
functional impact on the murine ventricle in the setting of pressure overload. 
 
2) Pulmonary hypertension: Based on studies in heart failure patients with secondary pulmonary 
hypertension, there is evidence that sildenafil causes an acute and sustained improvement in pulmonary 
artery pressure and exercise capacity.29-33   
 
3) Valve stenosis: Although there is less data to support a potential effect of sildenafil on the valve 
itself, there is some data to suggest that it may reduce fibrosis and calcification in the valve, processes 
which are central to the progressive stenosis.  Sildenafil has been shown to reduce oxidative stress and 
improve functional coupling of nitric oxide synthase (NOS).34  Oxidative stress and uncoupling of 
NOS have recently been shown to be associated with calcification in human aortic valves.35-37  
 
These preliminary studies and observations suggest that PDE5 inhibition holds promise as a 
medical therapy for aortic stenosis.  There are currently three FDA-approved PDE5 inhibitors: 
sildenafil (Viagra, Revatio), tadalafil (Cialis, Adcirca), and vardenafil (Levitra).  Both sildenafil and 
tadalafil are approved for the treatment of erectile dysfunction and pulmonary artery hypertension.  
Sildenafil was the first PDE5 inhibitor approved and, consequently, has been the most studied.  With 
respect to their cardiac/hemodynamic effects, invasive hemodynamic studies have shown that the 
PDE5 inhibitors are highly similar in their acute cardiovascular effects.31  Several studies have already 
demonstrated that sildenafil is safe and well tolerated in patients with cardiovascular disease and an 
ACC/AHA Expert Consensus document addresses the use of sildenafil in patients with cardiovascular 
disease.38  Specifically, in patients with primary pulmonary hypertension or heart failure with 
secondary pulmonary hypertension, sildenafil and tadalafil are safe with respect to acute and long-term 
hemodynamics, improve pulmonary artery pressures, do not cause systemic hypotension, and improve 
clinically meaningful outcomes.29-33,39-41  In patients with coronary artery disease, sildenafil has been 
shown to be safe, even having a favorable effect on coronary blood flow and measures of ischemia.42,43  
With respect to its effect on blood pressure, on its own tadalafil produces no significant decrease in 
systemic blood pressure compared to placebo.  Studies in which tadalafil was combined with various 
antihypertensive medications (ACE-inhibitors, angiotensin receptor blockers, calcium channel 
blockers, and ßblockers) showed that tadalafil either had no additional effect on blood pressure 
reduction or a very modest effect, reducing systolic pressure < 8 mm Hg and diastolic pressure < 4 mm 
Hg (data summarized in the package insert).  The ACC/AHA writing group concludes: “consistent 
with the anticipated effects resulting from an increase in cGMP levels in vascular smooth muscle, 
sildenafil possesses vasodilatory properties, which result in mild, generally clinically insignificant 
decreases in blood pressure when taken alone.”38  In patients with left-sided heart failure (like those in 
this study), systemic blood pressure is either unaffected or decreases minimally when measured 
invasively after administration of sildenafil.29,30,32  The available data suggest that administering a 
PDE5 inibitor to patients with aortic stenosis should be safe and well tolerated.  We recently performed 
an invasive hemodynamic study to test the safety and acute hemodynamic effects of a single dose of a 
PDE5 inhibitor (sildenafil) in patients with severe symptomatic AS.  We demonstrated that a single 

Aortic Stenosis and PhosphodiEsterase Type 5 InhibitioN (ASPEN) 
PI: Lindman, Brian R. 
Washington University School of Medicine 
 
November 2012 
5 
dose of a PDE5 inhibitor is safe and well-tolerated in patients with severe AS and is associated with 
acute improvements in pulmonary and systemic hemodynamics resulting in biventricular unloading.44  
These findings support the need for longer-term studies to evaluate the role of PDE5 inhibition as 
adjunctive medical therapy in patients with AS. 
 
Available evidence suggests that PDE5 inhibition is a promising strategy for improving clinical 
outcomes in patients with AS.  PDE5 inhibition may exhibit a favorable effect via altered 
hemodynamics and/or a direct effect on tissue remodeling.  In order to design a larger clinical trial to 
test efficacy, pilot data is needed on short-term tolerability and the effects of PDE5 inhibition on 
hemodynamics, LV structure/function, and relevant clinical metrics (quality of life, 6 minute walk).   
 
Study Design and Intervention Plan:  
 
Eligible Subjects 
! Moderate-severe AS 
   (AVA < 1.5 cm2) 
! No planned surgery 
! EF !  50% 
! LV hypertrophy 
! Diastolic dysfunction 
Baseline Tests 
! Echocardiogram 
! Monitored test 
   dose of drug 
6 / 12 Week Visits 
! Echo (12 wks) 
! 6 minute walk 
! Side effects 
Randomization 
& Additional 
Baseline Tests 
! Assess safety 
   and tolerability 
! Cardiac MRI 
! 6 minute walk 
6 Months 
3 day 
run-in 
6 Month Visit 
! Cardiac MRI 
! Echo 
! 6 min walk 
! Side effects 
DM cohort* 
Non-DM 
cohort* 
n=32 
n=24 
*Each cohort is randomized 1:1 
to tadalafil vs. placebo. 
 
Subjects will be recruited from cardiology and cardiac surgery colleagues at Washington 
University School of Medicine.  The research team will screen the clinics (via Allscripts) and the 
echocardiography lab to identify eligible subjects.  Permission to approach potential subjects will be 
obtained from one of the subject’s treating physicians. 
 
Participants must be willing to attend all scheduled visits, take the study drug as directed and have 
the required tests and procedures done for each visit.  They will be asked to fast for eight hours before 
certain study visits.  Once consent is obtained, baseline testing will be arranged and performed, 
including a fasting blood draw, physical exam (vitals, height, weight, waist circumference), quality of 
life, 6 minute walk, and an echocardiogram.  The Baseline Study Visit will include observation and 
monitoring of a dose of tadalafil (20mg oral).  Heart rate, blood pressure, and O2 saturation will be 
measured for at least 90 minutes after the dose of drug is given (the peak hemodynamic effect of the 
drug has been shown to be 90 minutes).  If, during this 90 minute monitoring period, there is a time 
when 3 successive systolic blood pressures average < 100 mmHg with or without symptoms 
(lightheadedness, syncope, or related symptoms), a subject will not be included in any further aspects 
of the study.  If the systolic blood pressure remains > 100 mmHg, the subject will be given an initial 
prescription for tadalafil (20mg orally once per day for 3 days).  A heart rate / blood pressure (HR/BP) 
monitor will be given to enrolled subjects.  They will be instructed as to how to use it and given 
instructions to keep a daily diary where they will record the time the study drug is taken and the 
time/reading of the HR/BP machine; side effects can also be recorded on the diary.   
 
A Randomization Study Visit will be arranged for ~5-9 days later (allowing for flexibility in 
scheduling).  Prior to this visit, all subjects will have taken tadalafil for 3 days, followed by 2-6 days 
off the drug.  Heart rate, blood pressure, and O2 saturation will be measured; the daily diary will be 
reviewed.  If the drug has been well-tolerated for the 3 day run-in phase, the subject will be 
randomized to tadalafil vs. placebo (1:1 randomization).  Subjects with diabetes will be in the diabetes 
cohort and those without diabetes will be in the non-diabetes cohort.  Reasons to exclude from 
randomization would include: 1) systolic blood pressure < 100 mmHg; 2) not tolerating the medication 
(either due to an intolerable side effect or some other reason); or 3) no longer willing to comply with 
the requirements of the study.  Randomization will be carried out by an investigational pharmacist.  

Aortic Stenosis and PhosphodiEsterase Type 5 InhibitioN (ASPEN) 
PI: Lindman, Brian R. 
Washington University School of Medicine 
 
November 2012 
6 
The subject and PI/study coordinator will be blinded to whether the subject has been assigned tadalafil 
or placebo.  An MRI with and without gadolinium will be performed on all randomized subjects prior 
to initiation of the study drug.  Upon randomization, subjects will take 20 mg (once daily) of the study 
drug for 3 days before having the dose increased to 40 mg (once daily).  Instructions will again be 
given to maintain a daily diary of dose timing, HR/BP, and side effects.  If the increase to 40mg daily 
is not tolerated (either due to a side effect or systolic blood pressure < 100mmHg), then the dose will 
be decreased back to 20mg daily. 
 
Follow-up study visits will occur at 6 and 12 weeks and 6 months after randomization.  Testing 
will occur at each of those visits, including blood draws, HR/BP, quality of life, 6 minute walk, 
echocardiogram (12 weeks and 6 months), and MRI (6 months).  The MRIs will be performed in the 
Center for Clinical Imaging Research (CCIR).  Other testing will occur in the Clinical Trials Unit 
(CTU) on the 11th floor of the Center for Advanced Medicine (CAM). 
 
If a subject develops low pressure (systolic blood pressure < 100 mmHg) with or without 
symptoms of lightheadedness, presyncope, or syncope, the study drug will be discontinued for 48 
hours.  The PI will discuss the findings with one of the subject’s treating physicians.  If the subject’s 
treating physician is agreeable, the study drug will be re-initiated 48 hours later (1 dose missed), 
perhaps after an alteration has been made to his/her other cardiac medications (i.e. discontinuation of 
another anti-hypertensive and/or a decrease in the dose of another cardiac medication).   
 
Subjects will be contacted by phone weekly for the first 4 weeks of the study and then monthly 
thereafter to inquire about the HR/BP log, any side effects, or other questions/problems. 
 
Removal of subjects from the study:  If at any time during the study a subject would like to 
discontinue participation, he/she will be removed from the study and no further follow-up testing or 
monitoring will occur.  If a subject needs to discontinue the study drug before completion of the study 
protocol, the PI will determine whether to obtain further testing (MRI, echo, 6 minute walk, blood, 
etc.) at the time the study drug is discontinued; the decision as to whether to obtain further testing will 
largely depend on how long the subject has been taking the study drug.  The PI may withdraw any 
subject whose health or well-being may be threatened by continuation in this study.  The following 
instances require termination of subjects: 1) subjects who have adverse events or intercurrent 
conditions that require discontinuation of study medication; 2) subjects who, in the opinion of the 
investigator, should be discontinued for their well being; 3) subjects who are unable to understand task 
instructions or to perform tests adequately; or 4) subjects who fail to comply with protocol 
requirements. 
 
Clinical Variables: 
Baseline Clinical Data 
  Age 
  Gender 
  BSA 
  BMI 
 Waist circumference 
 Heart rate 
 O2 saturation 
  Systolic BP 
  Diastolic BP 
  Smoking history 
  History of HTN 
 Peripheral Vascular Disease 
  CAD 
o Detailed coronary anatomy if available 
  Prior MI 

Aortic Stenosis and PhosphodiEsterase Type 5 InhibitioN (ASPEN) 
PI: Lindman, Brian R. 
Washington University School of Medicine 
 
November 2012 
7 
  Metabolic Syndrome 
  Diabetes mellitus 
o Microvascular complications 
  GFR 
  NYHA class 
  Syncope 
  Angina 
  Medications 
o ACE-I or ARB 
o ß-blockers 
o Statins 
o CCB 
o Aldosterone antagonist 
o Insulin 
o Oral diabetic meds 
  KCCQ 
 6 minute walk 
 Review for presence and severity of common side effects with PDE5 inhibitors 
Randomization Visit 
 
 Heart rate 
 O2 saturation 
  Systolic BP 
  Diastolic BP 
 Review for presence and severity of common side effects with PDE5 inhibitors 
• Exclusions from being randomized: 
- 
No longer willing to comply with the requirements of the study 
- 
Systolic blood pressure < 100 mmHg 
- 
Not tolerating the medication (either due to side effect or some other 
reason) 
Study Visits 
 
6 Weeks 
12 Weeks 
6 Months 
 Heart rate 
 O2 saturation 
  Systolic BP 
  Diastolic BP 
 KCCQ 
 6 minute walk 
 Review for presence and severity of common side effects with PDE5 inhibitors 
6 Minute Walk 
 Administered by research coordinator at the time of study visits 
Kansas City 
Cardiomyopathy 
Questionnaire (KCCQ) 
 Self-administered, 23-item questionnaire that quantifies physical limitations, 
symptoms, self-efficacy, social interference and quality of life 
Side Effects 
- Headache 
- Flushing 
- Dyspepsia  
- Nasal congestion  
- Runny nose 
- Respiratory tract infection 
- Back pain 
- Extremity pain 
- Nausea  
- Myalgia  
- Sudden decrease or loss of vision in one or both eyes 

Aortic Stenosis and PhosphodiEsterase Type 5 InhibitioN (ASPEN) 
PI: Lindman, Brian R. 
Washington University School of Medicine 
 
November 2012 
8 
- Priapism  
- Lightheadedness 
- Presyncope 
- Syncope 
- Decrease or loss of hearing 
 
Blood Collection: 
Baseline 
 Standard 
- CMP (including fasting blood glucose) 
- CBC 
- FLP 
- Hba1c (for diabetics) 
- BNP 
 Research Analyses 
- 3 tubes to plasma and buffy coat aliquots 
- 1 tube for whole blood 
- 1 tube for serum aliquots 
Follow-up Study Visits 
 Standard 
- BNP 
 Research Analyses 
- 2 tubes for plasma aliquots 
- 1 tube for serum aliquots  
 
Echocardiogram Measurements: 
 
• LVESD, LVEDD, septal and posterior wall thickness (res up on ventricle for 
accurate measurement) 
 Ejection fraction (EF) 
 Magnified view of 4Ch and 2Ch for accurate LV volumes 
 AS severity: LVOTd (use same value for all echoes analyzed in study), AVA, 
AVAindex, gradients (mean and peak) 
 Stroke volume and cardiac output: from LVOTVTI, LVOTd, and HR 
 Severity of MR and AR 
 Mitral valve inflow (PW Doppler): load modulation views 
 Tissue Doppler (septal and lateral annulus) 
 Longitudinal strain: 3 apical views 
 LV twist: 3 parasternal short-axis views 
 Pulmonary vein (PW Doppler) 
 RV assessment: 
- 
TAPSE (M-mode of tricuspid annulus)  
- 
Tei (get TV inflow – PW at leaflet tips) 
- 
Tissue Doppler (PW) of the TV annulus 
- 
Speckle tracking view of RV 
 Pulmonary artery pressure estimate:  
- PASP estimate from tricuspid regurgitation (TR) jet (with saline if needed) and 
subcostal view of IVC 
- PADP estimate from the PR jet 
- PA mean from the above and from the RV outflow acceleration time 
- RVOT PW for acceleration time and VTI 
 
MRI Measurements: 
 
• Performed with and without contrast 

Aortic Stenosis and PhosphodiEsterase Type 5 InhibitioN (ASPEN) 
PI: Lindman, Brian R. 
Washington University School of Medicine 
 
November 2012 
9 
• Measurements on chamber dimensions made with Argus software 
 Ejection fraction (EF) 
 LV volumes (LVESV and LVEDV) 
 LV mass 
 Fibrosis: 
- Pre-contrast myocardial T1 times (12 segments individually and global LV) 
- Post-contrast myocardial T1 times (12 segments individually and global LV) 
- Late gadolinium enhancement (both # of segments with LGE and volume/mass 
of LGE) 
 3D multiparametric systolic strain analysis (regional and global strain) 
 
 
Study Visits: 
 
Monitored 
dose of drug 
Blood 
Echo 
6 min walk 
KCCQ 
MRI 
Baseline Visit 
X 
X 
X 
X 
X 
 
Randomization 
Visit 
Vitals and 
side effects 
 
 
 
 
X 
6 Weeks 
Vitals and 
side effects 
X 
 
X 
X 
 
12 Weeks  
Vitals and 
side effects 
X 
X 
X 
X 
 
6 Months 
Vitals and 
side effects 
X 
X 
X 
X 
X 
 
Study Design Summary: 
Patient Population 
 Patients with moderate to severe aortic stenosis with increased LV mass in whom 
valve replacement is not planned. 
Study Design 
 Single center, randomized, double-blind, placebo controlled study 
Study Phase 
 4 
Drug 
 Tadalafil (Adcirca) 20 mg tablets (commercial) 
Sample Size 
 This study will include 56 subjects randomized to placebo or drug 
•  There will be 2 cohorts of patients based on diabetic status 
•  The diabetes cohort will include 32 subjects randomized to placebo or drug 
•. The non-diabetes cohort will include 24 subjects randomized to placebo or drug 
•  To allow for the possibility of drop-out of subjects after consent is signed but before 
randomization occurs (mostly due to the potential for not tolerating the test dose of 
the drug or the run-in phase), we will plan to enroll up to 75 subjects in the study 
Intervention 
 Run-in phase:  
- All subjects receive tadalafil 20mg daily 
 Randomization (1:1 – tadalafil:placebo) within each cohort: 
- Placebo 
- Drug: tadalafil 40mg daily (if tolerated) or resume taking 20mg 
Inclusion Criteria 
1) Moderate to severe aortic stenosis (AVA <1.5 cm2) 
2) LV hypertrophy as evidenced by LV mass index >95 g/m2 for women and >115 
g/m2 for men 
3) Diastolic dysfunction as evidenced by tissue Doppler e’ (average of septal and 
lateral) ≤ 7 cm/s 
4) None or minimal symptoms related to aortic stenosis (NYHA ≤ 2) 
5) The subject and treating physician are not planning on a valve replacement 

Aortic Stenosis and PhosphodiEsterase Type 5 InhibitioN (ASPEN) 
PI: Lindman, Brian R. 
Washington University School of Medicine 
 
November 2012 
10
procedure to occur during the next 6 months. 
6) EF ≥ 50% 
7) Ambulatory 
8) Normal sinus rhythm 
9) 18 years of age and older 
10) Able and willing to comply with all the requirements for the study 
Exclusion Criteria 
1) Need for ongoing nitrate medications 
2) SBP < 110mmHg or MAP < 75mmHg 
3) Moderately severe or severe mitral regurgitation (3 or 4+ MR) 
4) Moderately severe or severe aortic regurgitation (3 or 4+ AR) 
5) Contraindication to MRI or unable to tolerate MRI 
6) Creatinine clearance < 30 mL/min 
7) Cirrhosis 
8) Pulmonary fibrosis 
9) Increased risk of priapism 
10) Retinal or optic nerve problems or unexplained visual disturbance 
11) If a subject requires ongoing use of an alpha antagonist typically used for 
benign prostatic hyperplasia (BPH) (prazosin, terazosin, doxazosin, or 
tamsulosin), SBP < 120 mmHg or MAP < 80 mmHg is excluded 
12) Need for ongoing use of a potent CYP3A inhibitor or inducer (ritonavir, 
ketoconazole, itraconazole, rifampin) 
13) Current or recent ( 30 days) acute coronary syndrome 
14) O2 sat < 90% on room air 
15) Females that are pregnant or believe they may be pregnant 
16) Any condition which the PI determines will place the subject at increased risk 
or is likely to yield unreliable data 
17) Unwilling to provide informed consent 
Endpoints 
Primary Endpoints: 
 
1) Change in diastolic function as measured by tissue Doppler e’ on echo from 
baseline to 6 months 
2) Change in LV longitudinal peak systolic strain by echo from baseline to 6 
months 
3) Change in LV Mass as measured by MRI from baseline to 6 months 
 
 
Secondary Endpoints: 
 
1) Change in other echocardiographic indices of diastolic function, including E/e’ 
and deceleration time 
2) Change in other echocardiographic indices of systolic function, including stroke 
volume, LV twist, and stress-corrected midwall shortening and whether these 
changes are influenced by diabetes, EF, CAD, and LV hypertrophic remodeling 
3) Safety and tolerability – frequency of the following: hypotension (SBP < 90 
mmHg), symptomatic hypotension (symptoms of presyncope or syncope 
associated with SBP <90), syncope, hospitalization for a cardiac reason, 
myocardial infarction, new onset or worsening heart failure, and new sustained 
arrhythmia requiring intervention) 
4) Change in LV hypertrophic remodeling (relative wall thickness, LV chamber 
dimensions, and wall thickness) 
5) Change in echocardiographic indices of diastolic function (stiffness, 
viscoelasticity, and a load independent index of diastolic filling) using a novel 
methodology (PDF formalism) 
6) Change in myocardial fibrosis (ECV) as assessed by MRI 

Aortic Stenosis and PhosphodiEsterase Type 5 InhibitioN (ASPEN) 
PI: Lindman, Brian R. 
Washington University School of Medicine 
 
November 2012 
11
7) Change in 3D multiparametric strain and ejection fraction by MRI 
8) Change in 6 minute walk 
9) Change in quality of life (KCCQ) 
10) Change in systemic markers of fibrosis and oxidative stress  
11) Change in pulmonary artery pressure 
12) Change in pulmonary vascular resistance 
13) Change in systemic blood pressure 
14) Change in RV function, including TAPSE, S’, and Tei index 
15) Change in AS severity (AVA, mean and peak transvalvular gradients) and 
whether there are sub-groups that progress faster/slower) 
16) Change in BNP 
 
Pre-specified secondary analyses: 
 
1) Evaluate co-variates that may influence the response of the primary endpoints 
to therapy (DM, AS severity, CAD, SBP, SAC, valvuloarterial impedance, 
fibrosis, baseline LV mass, baseline e’, baseline LV systolic strain) 
2) What baseline variables and/or changes over the study period correlate with any 
improvements in KCCQ and/or 6 minute walk. 
3) Evaluate the primary and secondary endpoints in the pre-specified cohorts of 
diabetic and non-diabetic subjects.  Within cohort and between cohort 
differences will be analyzed to evaluate the relationship between diabetes status 
and response to PDE5 inhibition. 
4) Evaluate how biomarkers of collagen turnover, fibrosis, oxidative stress, and 
inflammation change over time with PDE5 inhibition and evaluate whether 
baseline biomarker levels (or change in biomarker levels) can predict (or 
correlate with) the changes in cardiac structure and/or function with PDE5 
inhibition. 
5) Use a novel method (PDF formalism) for assessing the diastolic properties and 
function of the LV (eg. stiffness, viscoelasticity, load independent index of 
filling, etc.); evaluate whether (and which of) these indices change with PDE5 
inhibition and whether these changes are influenced by diabetes, EF, CAD, and 
LV hypertrophic remodeling. 
6) Evaluate whether PDE5 inhibition is associated with change in myocardial 
fibrosis as assessed by extracellular volume (ECV) (by MRI T1 mapping) and 
whether this change is influenced by diabetes, baseline ECV, and baseline 
biomarkers of fibrosis. 
 
Analysis of Peripheral Blood: 
 
• The following signaling pathways relevant to the pathobiology and aortic stenosis will 
be studied: 
- 
Hypertrophic remodeling 
- 
Calcification 
- 
Fibrosis 
- 
Inflammation 
- 
Oxidative stress 
- 
Nitric oxide – cyclic GMP 
 
• The types of analyses to be performed include: 
- 
Quantity of RNA, protein, oxidized lipids, and other systemic markers 
- 
Genetic mutations and polymorphisms 
- 
GWAS 
 
 GWAS Study collaboration:  For the GWAS component of this study, we will 

Aortic Stenosis and PhosphodiEsterase Type 5 InhibitioN (ASPEN) 
PI: Lindman, Brian R. 
Washington University School of Medicine 
 
November 2012 
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collaborate with investigators at the University of Miami (PI: David Seo, MD; IRB 
#20080787; “Genetics of Aortic Valve Disease”).  This is an ongoing project, funded 
by the University of Miami.  We will send blood specimens to them for genotyping.  
These specimens will have unique barcode labels and not have identifying 
information on the tubes.  Additionally we will send some demographic/clinical data 
relevant to the genetic analyses, but without any identifiers.  This collaboration has 
already been IRB approved under HRPO 09-1026 (PI: Lindman). 
Data Analysis 
• Statistical analyses for the primary and secondary endpoints will be conducted with a 
mixed model repeated measures analysis of variance of the relevant parameter at 
baseline and 6 months, testing the interaction between group (tadalafil vs. placebo) 
and time.  This is equivalent to testing whether the baseline to study endpoint change 
in one group is different than the change in the other and uses all available 
information.  A p<0.05 will be considered significant.  The primary analysis of the 
trial will be a pooled analysis, including subjects from both cohorts comparing the 
tadalafil and placebo treated subjects.  Secondarily, within each cohort, endpoints will 
be compared between tadalafil and placebo treated subjects. 
Interim Analyses 
• 2 interim analyses are planned to assess safety and efficacy as well as conditional 
power; the details of these planned interim analyses are spelled out below under the 
Data and Safety Monitoring section 
Power 
Calculations 
• This is a pilot study.  There is no data on effect sizes and variance of change for these 
endpoints in this patient population resulting from PDE5 inhibition.  Even if this 
study generates statistically significant results, follow-up larger studies will be needed 
to more definitively determine efficacy.  The main purposes of this pilot study are to 
assess safety and tolerability and determine effect sizes and variance for several 
important, clinically relevant endpoints that will enable future studies to be 
appropriately planned and powered.  
• Assuming a standard deviation of change in e’ of 2.2 cm/s, the power to detect a 2 
cm/s difference between drug and placebo for a sample size of 56 (28 receiving drug, 
28 receiving placebo) is 91%.  The power calculation is based on evaluating the 
difference in change from baseline to 6 months via a two sample t-test (2-tailed) with 
type I error (alpha) set to 5%.  This is similar to the change observed in comparable 
populations receiving comparable treatments. 
• Assuming a standard deviation for the change in LV mass of 25 grams, a sample size 
of 56 (28 receiving drug, 28 receiving placebo) will be able to detect a difference in 
LV mass change from baseline to 6 months of 23 grams when evaluated with a two 
sample t-test (2-tailed) that is powered at 92% with a type I error (alpha) equal to 5%. 
This is a standardized effect size of 0.92.  Assuming the mean baseline LV mass is 
240 grams, this would reflect a difference of 9.5% in the change in LV mass between 
the 2 groups, which is conservative compared to prior studies on regression of LV 
mass after valve replacement in those with AS. 
• For the diabetes cohort, we will have 80% power to detect a standardized effect size of 
1.04 for change in each of the primary endpoints.  This is comparable (and even 
conservative) to the change observed in e’ and LV longitudinal systolic strain in 
patients with metabolic syndrome treated with an aldosterone antagonist. 
Target Study  
Start Date 
 September 2012 
Target Study 
Completion Date 
 December 2015 
Compensation 
• Total compensation for completion of the entire protocol = $450 
- 
Completion of Baseline Testing: $75 
- 
Completion of Safety and Tolerability Visit: $75 

Aortic Stenosis and PhosphodiEsterase Type 5 InhibitioN (ASPEN) 
PI: Lindman, Brian R. 
Washington University School of Medicine 
 
November 2012 
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- 
Completion of 6 Week Study Visit: $50 
- 
Completion of 12 Week Study Visit: $125 
- 
Completion of 6 Month Study Visit: $125 
 
 
Data and Safety Monitoring Plan: 
 
Individuals involved in data and safety monitoring for this study: 
 
 
 Brian R. Lindman, MD – Principal Investigator 
 
 
 Alan C. Braverman, MD – Professor of Medicine (Cardiology) (independent monitor) 
 
- 
Expertise:  Dr. Braverman is a non-invasive cardiologist who sees patients with a variety of 
cardiac disorders and specializes in caring for patients with a bicuspid aortic valve and 
genetically triggered aortic diseases.  He also has experience participating in clinical trials 
involving drug interventions.  He has a keen understanding of the issues relevant to 
carrying out this study in a manner that protects human subjects. 
 
 
 Lewis Chase, MD – Professor of Medicine (Endocrinology and Metabolism) and Chair, 
Scientific Advisory Committee for the Washington University ICTS (independent monitor) 
 
- 
Expertise: Dr. Chase has extensive experience in leading and supervising clinical and basic 
research.  He will provide a non-cardiologist perspective for the oversight of this study.  As 
chair of the scientific advisory committee of the ICTS, he is well qualified for this task. 
 
 
The principal investigator will take primary responsibility for following enrolled patients for any 
adverse events and will discuss situations in which the patient’s participation in this study may have 
led to an adverse event with Drs. Braverman and Chase.  Drs. Braverman, Chase and the PI will review 
the data on enrolled subjects every 6 months.  If a participant has a serious adverse event the case will 
be reviewed within 7 days to see if any modifications to the protocol need to be made.  This review 
will occur before enrolling another subject to see if any modifications to the protocol need to be made.   
 
Safety:  
 
Adverse Events: 
An adverse event (AE) is any untoward medical occurrence in a subject administered a 
pharmaceutical product, regardless of causality assessment.  An AE can therefore be any unfavorable 
and unintended sign (including an abnormal laboratory finding), symptom or disease temporally 
associated with the use of a study drug, whether or not considered related to the study drug.  
 
An abnormality identified during a medical test (e.g., laboratory parameter, vital sign, ECG data, 
physical exam) should be defined as an AE only if the abnormality meets one of the following criteria: 
- 
Induces clinical signs or symptoms; 
- 
Requires active intervention; 
- 
Requires interruption or discontinuation of study drug; 
- 
The abnormality or investigational value is clinically significant in the opinion of the 
Investigator. 
 
Serious Adverse Events: 
A serious adverse event (SAE) is defined as an adverse event, occurring at any dose that meets any 
of the following criteria: 

Aortic Stenosis and PhosphodiEsterase Type 5 InhibitioN (ASPEN) 
PI: Lindman, Brian R. 
Washington University School of Medicine 
 
November 2012 
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- 
Results in death, 
- 
Is life threatening: that is, poses an immediate risk of death as the event occurred, 
- 
Requires inpatient hospitalization or prolongation of existing hospitalization, 
- 
Results in a persistent or significant disability or incapacity, or 
- 
Is a congenital anomaly/birth defect in the offspring of the subject (whether the 
subject is male or female). 
 
The recording of AEs will start after the subject has signed the informed consent form and will end 
at the 6 month follow-up visit.  The PI will monitor each subject closely for AEs and the PI will record 
all observed or volunteered AEs. 
 
 
Among other adverse events, each study participant will have the following information tracked:  
- 
Development of symptomatic hypotension 
- 
Syncope 
- 
Hospitalization for a cardiac reason 
- 
New onset or worsening heart failure 
- 
Sustained arrhythmia requiring intervention 
- 
Myocardial infarction 
 
We will review the occurrence of any of the above on each patient in the study and determine 
whether these events are believed to be due to the patient’s participation in the study or simply a 
known and anticipated clinical event related to the subject’s aortic stenosis and/or other cardiac 
diseases.  All serious adverse events (SAEs) deemed to be related or possibly related to participation in 
the research will be reported to the HRPO within 24 hours,or at the time of continuing review (for all 
other adverse events) using the myIRB Notification System.  
 
Interim Analyses: 
 
• 
Two interim analyses are planned: 
 
1) After 24 total subjects (diabetic and non-diabetic) are enrolled 
2) After 16 diabetic subjects are enrolled 
 
 
At each of these interim analyses, an unblinded analysis will be performed by Ken Schechtman, 
PhD.  The purpose of the interim analysis will be to assess safety and tolerability and conditional 
power.  The study will not be stopped early for efficacy because the main purpose of this study is to 
determine effect sizes and standard deviation of change for several surrogate endpoints and to acquire 
data on safety and tolerability of PDE5 inhibition in this patient population.  The study may be stopped 
early for safety reasons.  The conditional power of the study will be determined based on the actual 
effect sizes (change in the primary endpoints from baseline to 6 months) and variance (standard 
deviation of the change in the primary endpoints from baseline to 6 months) of the enrolled subjects in 
each arm (treatment and placebo).  If based on the effect size and SD of change from the enrolled 
subjects the conditional power is less than originally planned (90% for the pooled analysis and 80% for 
the diabetic cohort), the total sample size and/or the sample size of the diabetic cohort may be 
increased to improve the power to detect a difference in one or more of the primary endpoints.  A 
decision to increase the sample size will consider whether such an increase would be feasible in terms 
of funding and additional time for subject recruitment.  The following are guidelines for the interim 
analysis for the statistician and DSMB.  The unblinded analyses will only be seen by the statistician 
and DSMB. 

Aortic Stenosis and PhosphodiEsterase Type 5 InhibitioN (ASPEN) 
PI: Lindman, Brian R. 
Washington University School of Medicine 
 
November 2012 
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Conditional Power Calculation for the Primary Endpoints – Performed at the Interim Analysis: 
 
• 
The conditional power will be calculated using an unmatched two-tailed t-test comparing treatment 
vs. placebo groups with the actual effect sizes (change in e’, change in longitudinal systolic strain, 
and change in LV mass from baseline to 6 months) and actual variance of those measures for the 
enrolled subjects 
• 
The conditional power will be characterized as favorable, promising, or unfavorable and the 
following actions are suggested for the DSMB.  The primary characterization of the conditional 
power will be based on the primary endpoint demonstrating the greatest power. 
 
 
• 
Favorable: ≥ 90% for pooled analysis, ≥ 80% for diabetic cohort 
 
- 
The study is adequately powered and should continue enrollment to the originally planned 
sample size 
 
 
• 
Promising: 50% ≤ conditional power < 80% (diabetic cohort) or 90% (pooled) 
 
- 
Based on the effect sizes and variance from the enrolled subjects, the conditional power of 
the study is “promising” but somewhat less than originally planned.  The sample size may 
be increased to whichever of the following yields a lower sample size: 
o The sample size will be increased so that the conditional power is increased to what 
was originally planned (80% for the diabetic cohort, 90% for the pooled analysis) 
o The cap for increasing the sample size is 40 for the diabetic cohort and/or 64 for the 
total cohort 
o If the conditional power cannot be increased to 80% by the increase in sample size 
to the pre-specified cap, then an increase in the sample size will likely not be 
recommended 
 
 
• 
Unfavorable: conditional power < 50% 
 
- 
The study will continue enrollment to the originally planned sample size to gather 
important information of effect sizes and variance for several primary and secondary 
endpoints that will be used to plan future studies 
 
Privacy and Data Integrity: 
 
 
Every 6 months, we will review the process by which consents are obtained and stored and how 
data is entered into the database.  We will discuss any known breaches of privacy or data integrity to 
implement procedures that will prevent further occurrences.  
 
Data Monitoring Reports: 
 
 
Every 6 months, the PI will take responsibility for generating a data monitoring report based on the 
above criteria and discussions.  Any recommendations for changes in the protocol or implementation 
of the study (if needed) will be included in this report. 
 
 

Aortic Stenosis and PhosphodiEsterase Type 5 InhibitioN (ASPEN) 
PI: Lindman, Brian R. 
Washington University School of Medicine 
 
November 2012 
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Washington University School of Medicine 
 
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Washington University School of Medicine 
 
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