31: Valvular Disease

General Principles in Older Adults

Degenerative valve disease is the most common form of valvular heart disease in the United States and as the population ages, clinicians will diagnose and manage more patients with this condition. Advances in surgical techniques have led to a greater number of older patients undergoing surgery for heart valve disease with improved morbidity and mortality risks. The decision to offer surgery to the older patient is complex. The patient’s preference is foremost consideration after detailed discussion of risks, benefits, and goals of care. A multidisciplinary team approach with input from the cardiac surgeon, anesthesiologist, primary care clinician and cardiologist is key to achieving desired outcomes.

Weighing the projected benefit of surgery with the natural course of untreated disease is crucial. The patient’s life-expectancy and quality of life regardless of the valve disease influence the potential benefit derived from surgery. Factors that should be weighed when considering surgery include a diagnosis of dementia, advanced cancer, severe pulmonary disease, significant frailty, symptomatic distress, and reluctance to undergo the procedure. Multivariable prognostic tools designed for older adults have been developed and validated and can provide clinicians more objectivity when estimating life expectancy (see Chapter 3, “Goals of Care & Consideration of Prognosis”).

When deciding whether surgical treatment is indicated in older patients with aortic stenosis (AS), mitral stenosis (MS), mitral regurgitation (MR), or aortic insufficiency (AI), the presence of limiting symptoms referable to the valve disease is the clearest rationale. In asymptomatic patients with severe AI or severe primary MR, the American Heart Association (AHA) and American College of Cardiology (ACC) guidelines recommend operation when the left ventricular (LV) dimension and ejection fraction reach specific parameters. The goal is to prevent further deterioration. Preventive operations such as these are justified in the older patient when the perioperative risks of stroke, acute renal failure, cognitive dysfunction, and other complications that affect quality of life are low relative to the desired benefit. In general, older patients are at increased risk for major complications following valve surgery (both aortic and mitral) including atrial fibrillation (AF), heart failure (HF), prolonged mechanical ventilation, worsened renal function, bleeding, and delirium. As a result, length of stay tends to be longer and convalescence slower.

In-hospital mortality rates associated with valve surgery range from 4% to 8% in all comers. Emergency operations, age >79 years, end-stage renal disease, and ≥2 previous cardiac operations are all strongly predictive of higher risk. Concomitant coronary artery bypass graft (CABG), low body weight, female gender, mitral valve surgery, combined valve surgeries, preoperative arrhythmias, hypertension, diabetes, and LV ejection fraction <30% are other variables predictive of in-hospital mortality following aortic and/or mitral valve surgery.

Aortic Stenosis