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Learning Objectives

  • Describe clinical features, diagnostic modalities, and therapeutic options for common valvular diseases in older patients.

  • Identify when patients with valvular disease should be offered surgical intervention.

  • Perform shared decision-making discussion about treatment options after considering each patient’s personal goals and surgical and geriatric risk factors.

Key Clinical Points

  1. Aortic stenosis is very common in older patients, and novel surgical approaches allow older patients a greater number of surgical treatment options.

  2. Transcatheter aortic valve replacement (TAVR)—an alternative to surgical aortic valve replacement (SAVR)—may be considered in older patients.

  3. Aortic insufficiency is managed similarly in younger and older patients (and currently may not be as well-suited for TAVR).

  4. Mitral regurgitation may be structural or functional. Once symptomatic, it is better treated with mitral valve repair than replacement.

  5. The primary treatment option for mitral stenosis is valvuloplasty. Surgical intervention is reserved for severely calcified valves and is associated with high risk.

  6. Anticoagulation and valve degeneration are the two important risks associated with mechanical and biological prostheses, respectively.

  7. A multidisciplinary team approach is advocated to provide patient goal-directed care in managing older patients with valvular heart disease.


As the population ages, valvular heart diseases have become a significant public health problem. The prevalence of moderate or severe valvular heart disease increases with age, from less than 1% in 18- to 44-year-olds to 13% in the population 75 years or older. Without valve replacement, valvular heart disease is associated with decreased survival, functional limitations, and poor quality of life. Due to recent advances in surgical techniques, especially minimally invasive transcatheter valve procedures, older adults who were previously not considered for surgery are treated to improve survival and restore function and quality of life. However, challenges remain as to patient selection for surgical and transcatheter valve procedures, patient goal-directed shared decision-making, and optimization of health status prior to and after the procedure. This chapter summarizes latest evidence on evaluation and management of common valvular heart diseases in older adults, with a focus on the geriatrician’s role in risk assessment and shared decision-making.



Aortic stenosis is the progressive narrowing of the aortic valve resulting in left ventricular (LV) 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, a bicuspid aortic valve, and rheumatic heart disease. In 90% of patients older than 65 years, aortic stenosis is caused by calcific degeneration of a tricuspid aortic valve. Although bicuspid valves are relatively common (~2% of the population), these patients present with ...

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