2. Applying Classification of Recommendation and Level of Evidence

3. 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

5. 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

6. 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

13. 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

14. 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)

15. 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