Describe clinical features, diagnostic modalities, and therapeutic options for the most common valvular diseases in older patients.
Identify when patients with valvular disease should be offered surgical intervention.
Key Clinical Points
Aortic stenosis is very common in older patients and novel surgical approaches allow more older patients a surgical treatment option.
Transcatheter aortic valve replacement (TAVR)—an alternative to surgical aortic valve replacement—may be considered in older patients.
Aortic insufficiency is managed similarly in younger and older patients.
Mitral regurgitation may be structural or functional. Once symptomatic, it is best treated with mitral valve repair than replacement.
The primary treatment option for mitral stenosis is valvuloplasty. Surgical intervention is reserved for severely calcified valves and is associated with high risk.
Anticoagulation and risk of valve degeneration are the two important risks associated with mechanical and biological prostheses, respectively.
A multidisciplinary team approach is advocated in managing older patients with valvular heart disease.
Aortic stenosis is the progressive narrowing of the aortic valve resulting in outflow obstruction during systole. This is in distinction to aortic valve sclerosis, where the valve leaflets are calcified or thickened, but do not cause a meaningful outflow obstruction.
Aortic stenosis is present in 2% to 9% of older patients and is the leading clinically significant valvular disorder in older adults. Risk factors for developing aortic stenosis include age, bicuspid aortic valve, and rheumatic heart disease. In 90% of patients older than 65 years aortic stenosis is caused by the calcific degeneration of a tricuspid aortic valve. While bicuspid valves are relatively common (~ 2% of the population), patients with bicuspid valves are present with stenosis usually in the fourth to sixth decade of life. Similarly, rheumatic heart disease presents earlier in life and often in association with mitral valve disease.
Although the causes of aortic valve calcification in aging are unclear, the process bears many similarities to atherosclerosis—both diseases are characterized by lipid deposition, inflammation, neoangiogenesis, and calcification. Bicuspid aortic valves are characterized by accelerated calcification and progressive outflow obstruction in the majority of patients. Rheumatic fever results in progressive fusion of the aortic valve leaflets causing both aortic valve stenosis and regurgitation. Aortic stenosis is classified as mild, moderate, or severe based on the valve area, ejection velocity, and the pressure gradient that develops across the valve (Table 78-1).
TABLE 78-1ECHOCARDIOGRAPHIC FINDINGS IN AORTIC STENOSIS ||Download (.pdf) TABLE 78-1 ECHOCARDIOGRAPHIC FINDINGS IN AORTIC STENOSIS
| ||MILD ||MODERATE ||SEVERE |
|Aortic valve area (cm2) ||> 1.5 ||1.0–1.5 ||< 1.0 |
|Velocity (m/s) ||< 3 ||3–4 ||> 4 |
|Mean gradient (mm Hg) ||< 25 ||25–40 ||> 40 |
Aortic valve sclerosis (valve thickening without outflow tract obstruction) ...