Aortic Stenosis and PhosphodiEsterase iNhibition With Aortic Valve Replacement (ASPEN-AVR): A Pilot Study (ASPEN-AVR)

• ClinicalTrials.gov Identifier: NCT01272388
• Recruitment Status: Terminated
• First Posted: January 7, 2011
• Results First Posted: September 12, 2018
• Last Update Posted: September 12, 2018
• Sponsor: Washington University School of Medicine
• Information provided by (Responsible Party): Brian Lindman, MD, Washington University School of Medicine

Study Description

Brief Summary:

Currently, aortic stenosis (AS) is considered a "surgical disease" with no medical therapy available to improve any clinical outcomes, including symptoms, time to surgery, or long-term survival. Thus far, randomized studies involving statins have not been promising with respect to slowing progressive valve stenosis. Beyond the valve, two common consequences of aortic stenosis are hypertrophic remodeling of the left ventricle (LV) and pulmonary venous hypertension; each of these has been associated with worse heart failure symptoms, increased operative mortality, and worse long-term outcomes. Whether altering LV structural abnormalities, improving LV function, and/or reducing pulmonary artery pressures with medical therapy would improve clinical outcomes in patients with AS has not been tested. Animal models of pressure overload have demonstrated that PDE5 inhibition influences NO-cGMP signaling in the LV and favorably impacts LV structure and function, but this has not been tested in humans with AS. Studies in humans with left-sided heart failure and pulmonary venous hypertension have shown that PDE5 inhibition improves functional capacity and quality of life, but patients with AS were not included in those studies. The investigators hypothesize that PDE5 inhibition with tadalafil will upregulate NO-cGMP signaling, reduce oxidative stress, and have a favorable impact on LV structure and function as well as pulmonary artery pressures and quality of life. In this pilot study, the investigators anticipate that short-term administration of tadalafil to patients with AS will be safe and well-tolerated.

Condition or disease	Intervention/treatment	Phase
Aortic Stenosis	Drug: Tadalafil; Drug: Placebo	Phase 4

Detailed Description:

Patients with severe symptomatic AS who will undergo elective aortic valve replacement will be eligible for this randomized, double-blind, placebo-controlled, pilot study. Prior to randomization, subjects will have testing including: 6 minute walk, quality of life questionnaire, blood draw, and an echocardiogram. If an initial monitored dose of tadalafil is tolerated, participants will be randomized 2:1 to tadalafil vs. placebo. After 4 weeks on drug or placebo, subjects will have the same baseline testing repeated. At the time of aortic valve replacement surgery, the aortic valve and a small piece of LV myocardium will be taken for several analyses.

Study Design

• Study Type: Interventional (Clinical Trial)
• Actual Enrollment: 1 participants
• Allocation: Randomized
• Intervention Model: Parallel Assignment
• Masking: Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
• Primary Purpose: Treatment
• Official Title: Aortic Stenosis and PhosphodiEsterase iNhibition With Aortic Valve Replacement (ASPEN-AVR): A Pilot Study
• Study Start Date: January 2011
• Actual Primary Completion Date: April 2011
• Actual Study Completion Date: April 2012

Arms and Interventions

Arm	Intervention/treatment
Active Comparator: Tadalafil	Drug: Tadalafil; Active drug will be encapsulated to look identical to the placebo pill. Subjects will take a single oral dose of tadalafil once daily from the time of randomization until the surgical date (~4 weeks). Subjects will begin by taking 20 mg (1 pill) daily for 3 days before having the dose increased to 40 mg (2 pills) once daily. If the increase to 40mg daily is not tolerated, then the dose will be decreased back to 20mg daily.; Other Names: Cialis; Adcirca
Placebo Comparator: Placebo	Drug: Placebo; The placebo pill will be encapsulated to look identical to the active drug pill. Subjects will take a single oral dose of placebo once daily from the time of randomization until the surgical date (~4 weeks). Subjects will begin by taking 1 pill daily for 3 days before having the dose increased to 2 pills once daily. If the increase to 2 pills daily is not tolerated, then the dose will be decreased back to 1 pill daily.

Outcome Measures

Primary Outcome Measures :

1. Quality of Life as Assessed by the Kansas City Cardiomyopathy Questionnaire (KCCQ) [ Time Frame: Baseline and 4 weeks ]
   KCCQ overall summary score is reported. Scale is 0-100 (higher value is better).

Secondary Outcome Measures :

1. 6 Minute Walk Distance [ Time Frame: Baseline and 4 weeks ]
   How far the subject walked in 6 minutes.

Eligibility Criteria

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

Criteria

Inclusion Criteria:

• Patients with severe aortic stenosis (AVA < 1.0 cm2)
• Left ventricular hypertrophy
• EF ≥ 45%
• NYHA functional class ≥ 2
• Ambulatory (able to perform a 6 minute walk test)
• Normal sinus rhythm
• 18 years of age and older
• Able and willing to comply with all the requirements for the study

Exclusion Criteria:

• Need for ongoing nitrate medications
• SBP < 110mmHg or MAP < 75mmHg
• Moderately severe or severe mitral regurgitation
• Moderately severe or severe aortic regurgitation
• Creatinine clearance < 30 mL/min
• Increased risk of priapism
• Retinal or optic nerve problems or unexplained visual disturbance
• 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
• Need for ongoing use of a potent CYP3A inhibitor or inducer (ritonavir, ketoconazole, itraconazole, rifampin)
• Cirrhosis
• Pulmonary fibrosis
• Current or recent (≤ 30 days) acute coronary syndrome
• O2 sat < 90% on room air
• Females that are pregnant or believe they may be pregnant
• Any condition which the PI determines will place the subject at increased risk or is likely to yield unreliable data
• Unwilling to provide informed consent

Contacts and Locations

Locations

United States, Missouri

Washington University School of Medicine

Saint Louis, Missouri, United States, 63110

Sponsors and Collaborators

Washington University School of Medicine

Investigators

• Principal Investigator: Brian R. Lindman, MD; Washington University School of Medicine

More Information

• Responsible Party: Brian Lindman, MD, Assistant Professor of Medicine, Washington University School of Medicine
• ClinicalTrials.gov Identifier: NCT01272388
• Other Study ID Numbers: 10-1334a
• First Posted: January 7, 2011
• Results First Posted: September 12, 2018
• Last Update Posted: September 12, 2018
• Last Verified: September 2018

Keywords provided by Brian Lindman, MD, Washington University School of Medicine:

Aortic valve stenosis; Tadalafil; Phosphodiesterase inhibitors; Hypertension, pulmonary; Hypertrophy, left ventricular

Additional relevant MeSH terms:

Aortic Valve Stenosis; Constriction, Pathologic; Pathological Conditions, Anatomical; Aortic Valve Disease; Heart Valve Diseases; Heart Diseases; Cardiovascular Diseases; Ventricular Outflow Obstruction; Tadalafil; Vasodilator Agents; Phosphodiesterase 5 Inhibitors; Phosphodiesterase Inhibitors; Enzyme Inhibitors; Molecular Mechanisms of Pharmacological Action; Urological Agents