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+++++++++++++++++++++++++++++++++++++++++ + +++ +CardiovasCular speCial seCtion ��� +++ +++++++++++++++++++++++++++++++++++++++++ Aortic StenoSiS in the Elderly By Michael S. Firstenberg, MD, FACC, and Eric A. Espinal, MD, FACC C alcification of the aortic valve is a common problem in the elderly. Symptoms such as fatigue, exercise intolerance, shortness of breath, chest pain or syncope often are attributed to ���getting old��� and deconditioning. However, 2% to 5% of patients over the age of 65 have aortic stenosis, and the median survival with medical management is less than two years once symptoms develop.1 Many potentially eligible patients are never referred. As technology evolves, more patients may benefit from surgery that can have a significant impact on quality and quantity of life. Diagnosis. Aortic stenosis often is suspected during a routine physical exam in which an ejection murmur is detected. The diagnosis is confirmed with transthoracic echocardiography. Echocardiography can grade the disease, monitor progression and provide estimated gradients and valve areas that can guide therapy. Cardiac catheterization is typically used for unusual cases where symptoms do not correlate with the echo findings and to define the coronary anatomy prior to surgery. Management. Indications for valve replacement are symptomatic severe stenosis, asymptomatic low-risk patients with critical stenosis or patients with moderate stenosis otherwise undergoing cardiac surgery. 2 Biologic tissue valves are used in the elderly to avoid anti-coagulation. Minimally invasive techniques can be used to minimize 18 | Cleveland/akron/Canton md news the trauma of surgery. Incisional pain is typically minimal as the ribs are softer and more pliable in elderly patients. Many patients are extubated several hours after surgery and sitting in a chair by the next morning. Average post-operative length of stay is seven to 10 days. Because of the dramatic relief of valvular obstruction, patients often feel better within a relatively short period of time. Outcomes. The outcomes after elective aortic valve replacement are clearly superior to medical management. In a review of 145,911 patients undergoing isolated aortic valve surgery, the mean survival was 13 years (ages: 65-69), nine years (ages: 70-79) and six years for those aged 80 and older.3 Operative mortality ranged from 2.5% to 17.2%, and permanent stroke rates ranged from 1.7% to 4.6% ��� both correlated with pre-operative comorbidities. A survival advantage over non-operative management was seen even in very high-risk patients. New Technology. Rapidly evolving technologies are percutaneous aortic valves,4 which are modified tissue valves delivered percutaneously with various access approaches under study. The major advantages are the avoidances of cardiopulmonary bypass and complex surgery. Although outcomes are better in the short-term, there are concerns about the long-term complications and survival benefits of this expensive technology. Procedural-related complications, n mdnews.com n march -april 2013 residual aortic regurgitation and paravalvular leaks challenge this technology. The ideal patient for a percutaneous valve, while still poorly defined, is typically a patient who has been refused conventional surgery (by at least two surgeons) due to poor functional status and severe comorbidities. Conclusions. With the aging population, the incidence of aortic stenosis will increase. Operative valve replacement can offer significant improvement in both quality and quantity of life even in highrisk patients. Patients perceived to be too old, too debilitated or too high-risk should be referred for surgical consultation. Dr. Michael Firstenberg and Dr. Eric Espinal of Summa Physicians Inc.���Cardiothoracic Surgery are board-certified cardiothoracic surgeons and practice at Summa Akron City Hospital. n References 1. Bonow RO, Ca rabello BA , et a l; 2006 Writing Committee Members; American College of Cardiology/American Heart Association Task Force. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. Circulation. 2008;118:e523��� e661. 2. Carabello, BA., and Paulus WJ. ���Aortic stenosis.��� The Lancet (London, England) 373.9667 (2009): 956-966. 3. Brennan, MJ, et al. ���Long-Term Survival After Aortic Valve Replacement Among High-Risk Elderly Patients in the United States Clinical Perspective Insights From the Society of Thoracic Surgeons Adult Cardiac Surgery Database, 1991 to 2007.��� Circulation 126.13 (2012): 1621-1629. 4. Makkar, Raj R., et al. ���Transcatheter aortic-valve replacement for inoperable severe aortic stenosis.��� New England Journal of Medicine 366.18 (2012): 1696-1704.

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