Applying Classification of Recommendation and Level of Evidence

Activity, Exercise Prescription & Cardiac Rehab Recommendations Class I Exercise training (or regular physical activity) is recommended as safe and effective for pts w/ HF who are able to participate to improve functional status Level of Evidence A Class IIa Cardiac rehab can be useful in clinically stable pts w/ HF to improve functional capacity, exercise duration, HRQOL and mortality Level of Evidence B

An Under-diagnosed and Under-treated Disease Studies show at least 40% of SAS patients are not treated with an AVR11-17 Studies show at least 40% of severe aortic stenosis (SAS) patients are not treated with an AVR11-17

What Causes Aortic Stenosis in Adults Less Common More Common Congenital Abnormality Rheumatic Fever Age-Related Calcific Aortic Stenosis Aortic valve stenosis — or aortic stenosis — occurs when the heart's aortic valve narrows. This narrowing prevents the valve from opening fully, which obstructs blood flow from your heart into your aorta and onward to the rest of his / her body.  Usually when aortic valve stenosis becomes severe and symptomatic, per ACC/AHA guidelines, the native valve should be replaced. Left untreated, aortic valve stenosis may lead to sudden death. Images courtesy of John Webb, MD at St. Paul’s Hospital and Renu Virmani, MD at the CVPath Institute

Traditional AS Therapy Medical therapy does not reverse or halt AS progression Balloon Valvuloplasty (BAV) Surgical AV Replacement (SAVR) Surgical approach varies Midline sternotomy Minimally invasive

Characteristics of Traditional Surgical Therapies CardioPulmonary Bypass Pump (CPB) Cross Clamping of Aorta Cerebrovascular Accident (CVA) Bleeding Wound Healing Mobility Fluid Shifts Prolonged Intubation Arrthymia Prolonged Anesthesia Post-operative Permanent Pacemaker (PPM)

In-operable? aka ‘High Risk,’ ‘Prohibitive Risk,’ ‘Extreme Risk’ STS Risk Score > 8% - notes age, sex, BMI, pulmonary disease, coronary disease, renal disease, NYHA STS Mortality Risk > 15% (risk of dying intra-operatively or post-operatively within 30 days) LVEF < 35% Frailty 5 meter gait 6 minute walk Katz Index ADL Independence Edmonton Frail Scale Grip Strength Albumin Level KCCQ-12 Co-morbids Pulmonary HTN Undergoing Cancer Treatment Poorly controlled diabetes Hospitalizations Nutrition Mobility Sniff Test