Implication of Exercise Training in Patients With Aortic Stenosis　― Reply ―

We thank Dr. Teruhiko Imamura for expressing interest in our study. We have reported on the experience of using exercise training for patients with severe aortic stenosis (AS) in a convalescent rehabilitation ward.¹ Patients who were admitted to the convalescent rehabilitation ward had severe physical disabilities due to the presence of conditions other than AS, including motor disorders, neurological diseases, or disuse syndrome. However, only those patients who were occasionally found to have severe AS were analyzed in our study.

Transcatheter aortic valve implantation (TAVI) and balloon aortic valvuloplasty are the commonly used treatment options for high-risk patients who cannot undergo surgical aortic valve replacement;² however, such patients with severe physical disabilities are ineligible for clinical trials.

We agree that dementia and frailty should be considered as non-cardiovascular risks for TAVI.³ The Revised Hasegawa’s Dementia Scale was used to assess dementia. However, the Clinical Frailty Scale was not used to evaluate frailty because all admitted patients had severe physical disabilities; thus, frailty was presumed. Because patients were admitted to hospital to receive convalescent rehabilitation and not for treatment of severe AS, the applicability of structural treatment for severe AS was beyond the scope of our report.

Comparison with a control group should be considered ethically. Because the patients analyzed were admitted for convalescent rehabilitation, analyzing the observation period without rehabilitation, as recommended by Dr. Imamura as a “pretreatment trend”, should not be allowed. We have acknowledged this limitation in the paper.¹

As mentioned previously, the patients included in this historical cohort study were admitted for convalescent rehabilitation for their physical disabilities. Sequential evaluation of cardiac function as recommended by Dr. Imamura should be considered an additional experimental purpose. Unfortunately, such experimental evaluations of cardiac functions without apparent treatment purposes were not adopted in daily clinical practice at our hospital. Instead, we sequentially used the Functional Independence Measure because it was the target used by our patients and medical staff.

In summary, this is the first report on exercise training for patients with severe AS. We hope that our study serves as a basis for further studies to elucidate the safety and efficacy of exercise training for patients with severe AS.

Sources of Funding

This work was not supported by any grant.

Disclosures

The authors report no conflict of interests in this work.

• Hideki Arai, MD
• Satoru Matsumoto, MD
• Takeshi Morimoto, MD, PhD
• Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya (H.A., T.M.); Department of Rehabilitation, Toyonaka Heisei Hospital, Toyonaka (H.A., S.M.), Japan

References

• 1.   Arai H, Nozoe M, Matsumoto S, Morimoto T. Exercise training for patients with severe aortic stenosis in a convalescent rehabilitation ward: A retrospective cohort study. Circ Rep 2021; 3: 361–367.
• 2.   Perumal J, Lim HQ, Attia ABE, Raziq R, Leavesley DI, Upton Z, et al. Functionality and outcome in older patients with severe aortic stenosis (FOOPAS): An interdisciplinary study concept for a prospective trial. Clin Interv Aging 2018; 13: 185–193.
• 3.   Puri R, Iung B, Cohen DJ, Rodés-Cabau J. TAVI or No TAVI: Identifying patients unlikely to benefit from transcatheter aortic valve implantation. Eur Heart J 2016; 37: 2217–2225.