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* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * Questions Are there “inoperable” patients with aortic stenosis? Can “very high risk” patients for AVR be identified? Questions Are there “inoperable” patients with aortic stenosis? Can “very high risk” patients for AVR be identified? We don’t turn down anyone! Cardiologist- True!! But we never refer at least 1/3 of the patients with AS we see Surgeon’s View of Aortic Stenosis “Inoperable” is in the … Conclusion Surgery was denied in 33% of elderly patients with severe, symptomatic AS. Older age and LV dysfunction were the most striking characteristics of patients who were denied surgery, whereas comorbidity played a less important role. 1993-2003 740 patients with AVA 0.8cm2 287 (38.7%) underwent AVR Annals Thoracic Surgery, 2006 Questions Are there “inoperable” patients with aortic stenosis? Can “very high risk” patients for AVR be identified? Isolated Aortic Valve ReplacementOperative Mortality-STS Database STS Predicted Risk of Mortality with AVR Based on Age Alone %Mortality Age Aortic Valve SurgeryPredictive Risk Algorithms STS EuroSCORE (additive) EuroSCORE (logistic) Ambler (UK) Northern New England New York State Providence Health System Problems with Risk Algorithms All risk algorithms are based on operated patients and don’t factor in “inoperable “ patients Outcomes other than 30 day mortality are not predicted Discharge disposition, Quality of Life not predicted Many risk variables not included Risk Factors Not Included in Risk Algorithms Porcelain Aorta Previous Mediastinal Radiation (Lymphoma) Multiple Previous Sternotomies With Open Grafts Advanced Liver Disease/ Cirrlosis Frailty/ Debility/ Immobility How Do We Evaluate Risk ? Aortic Valve Clinic 2-3 Cardiologists 2-3 Surgeons 2 Research Coordinators Risk of AVR Same age (90) and risk factors Diabetes, atrial fibrillation, hypertension, mild renal insufficiency sts.org Risk of AVR Same age (90) and predicte