TAVI -Summary

SUMMARY AND RECOMMENDATIONS

• Aortic valve replacement is the mainstay of treatment of symptomatic aortic stenosis (AS). Aortic valve replacement offers substantial improvements in symptoms and life expectancy.

• TAVR has been developed as a treatment for patients with severe symptomatic AS with unacceptably high risk for surgical aortic valve replacement.
• In appropriately screened patients with inoperable severe symptomatic AS, TAVR provides better outcomes compared to medical therapy including percutaneous valvotomy.
• However, TAVR offered no survival benefit compared to standard therapy in patients with an STS score of ≥15 percent because of the high degree of comorbid conditions in these patients.
• In appropriately screened patients with severe symptomatic AS, TAVR and surgical aortic valve replacement are associated with similar rates of one-year survival. However, stroke or TIA and vascular complications are more frequent with TAVR, and major bleeding and atrial fibrillation are more common after surgical valve replacement.
• A multidisciplinary team approach is recommended in approaching high-risk patients with symptomatic AS.

expert consensus document on transcatheter aortic valve replacement
http://www.sciencedirect.com/science/article/pii/S0735109712000022

Comparison of three methods of assessing cardiovascular disability

Class	New York Heart Association functional classification[1]	Canadian Cardiovascular Society functional classification[2]	Specific activity scale[3]
I	Patients with cardiac disease but without resulting limitations of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or anginal pain.	Ordinary physical activity, such as walking and climbing stairs, does not cause angina. Angina with strenuous or rapid prolonged exertion at work or recreation.	Patients can perform to completion any activity requiring ≥7 metabolic equivalents, eg, can carry 24 lb up eight steps; do outdoor work (shovel snow, spade soil); do recreational activities (skiing, basketball, squash, handball, jog/walk 5 mph).
II	Patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain.	Slight limitation of ordinary activity. Walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals, in cold, in wind, or when under emotional stress, or only during the few hours after awakening. Walking more than two blocks on the level and climbing more than one flight of ordinary stairs at a normal pace and in normal conditions.	Patients can perform to completion any activity requiring ≤5 metabolic equivalents, eg, have sexual intercourse without stopping, garden, rake, weed, roller skate, dance fox trot, walk at 4 mph on level ground, but cannot and do not perform to completion activities requiring ≥7 metabolic equivalents.
III	Patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest. Less than ordinary physical activity causes fatigue, palpitation, dyspnea, or anginal pain.	Marked limitation of ordinary physical activity. Walking one to two blocks on the level and climbing one flight in normal conditions.	Patients can perform to completion any activity requiring ≤2 metabolic equivalents, eg, shower without stopping, strip and make bed, clean windows, walk 2.5 mph, bowl, play golf, dress without stopping, but cannot and do not perform to completion any activities requiring >5 metabolic equivalents.
IV	Patient with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of cardiac insufficiency or of the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased.	Inability to carry on any physical activity without discomfort - anginal syndrome may be present at rest.	Patients cannot or do not perform to completion activities requiring >2 metabolic equivalents. Cannot carry out activities listed above (Specific activity scale III).

References:

1. The Criteria Committee of the New York Heart Association. Nomenclature and Criteria for Diagnosis of Diseases of the Heart and Great Vessels, 9th ed, Little, Brown & Co, Boston, 1994. p.253.
2. Lucien C. Grading of angina pectoris. Circulation 1976; 54:5223.
3. Goldman L, Hashimoto B, et al. Comparative reproducibility and validity of systems for assessing cardiovascular functional class: Advantages of a new specific activity scale. Circulation 1981; 64:1227.