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GENERAL PRINCIPLES

Degenerative valvular heart disease (VHD) is expected to grow in prevalence as the population ages. Based on pooled US population studies of adults who underwent echocardiography from 1989 to 1996, the prevalence of VHD is 2.5% and the burden of moderate or severe left-sided VHD increases with age: <1% in those aged 18 to 44 years, 9.9% in those aged >65 years, and 13.2% in those aged >75 years. A more contemporary cross-sectional study of 2500 individuals ≥65 years old enrolled from a primary care population in the United Kingdom and published in 2016 estimates the prevalence of moderate or severe VHD at 11.3%. Mitral regurgitation (MR) and aortic stenosis (AS) are the most common VHDs in older adults.

A standard framework adopted by the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for staging the severity of VHD highlights the progressive nature of VHD:

  1. Stage A: At risk based on structural abnormalities of the valves, myocardium, and vessels

  2. Stage B: Progressive disease based on the hemodynamic effects of the VHD

  3. Stage C: Asymptomatic severe disease

  4. Stage D: Symptomatic severe disease

The emergence of transcatheter techniques, particularly transcatheter aortic valve replacement (TAVR) for treatment of symptomatic severe AS, has transformed the management of VHD in older adults.

The appropriate management of VHD in this population, including the decision to intervene and the choice of intervention, requires complex decision making. The patient’s preference is the foremost consideration after detailed discussion of risks, benefits, and goals of care. Weighing the projected benefit and potential risks of any valve intervention against the natural course of untreated disease is crucial. The patient’s life expectancy and quality of life (QOL) independent of the valve disease influence the potential benefit derived from any intervention (see Chapter 4, “Goals of Care & Consideration of Prognosis”). A multidisciplinary approach with input from members of an integrated heart valve team is key to achieving desired outcomes.

Improving QOL is an important outcome of surgical treatment for VHD, particularly in older patients. A systematic review of 44 studies (predominantly retrospective) measured QOL and functional outcomes in octogenarians following cardiac surgery (coronary artery bypass grafting [CABG] and valve surgery). Although the majority of patients described improvement in symptoms, 8% to 19% experienced deterioration in QOL. In one study, 43% would not recommend surgery at 1 month following surgery, which improved to 14% at 1 year. A tool for predicting postoperative QOL is needed to enhance the informed consent process.

Validated risk stratification models are used to evaluate and counsel patients on the risks and benefits of surgical interventions and transcatheter options. The most commonly used risk calculators are the EuroSCORE and Society of Thoracic Surgeons (STS) score. The 2008 STS score comprises a portfolio of risk models developed and validated using data from patients who underwent cardiac surgery in the United States from 2002 ...

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