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Aortic stenosis: current treatment options for a common condition in old age

Published online by Cambridge University Press:  27 March 2012

D Tiwari ,
J Radvan  and
SC Allen
D Tiwari
Affiliation:
The Royal Bournemouth Hospital, Bournemouth University, Poole, UK
J Radvan
Affiliation:
The Royal Bournemouth Hospital, Bournemouth University, Poole, UK
SC Allen*
Affiliation:
Centre for Postgraduate Medical Research and Education, Bournemouth University, Poole, UK
*
Address for correspondence: Professor S.C. Allen, Postpoint A10, The Royal Bournemouth Hospital, Castle Lane East, Bournemouth BH7 7DW, UK. Email: Stephen.allen@rbch.nhs.uk
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Summary

Degenerative-calcific aortic stenosis is mainly a disease of old age. Patients with mild to moderate stenosis without symptoms and those with aortic valve sclerosis do not require mechanical intervention. There is no firm evidence that the rate of progression can be modified by medical therapies, though statins might have some effect. Patients who develop severe stenosis with symptoms have a very poor prognosis if managed medically. Surgical aortic valve replacement greatly improves symptoms and mortality rates and remains the treatment of choice for those fit for major surgery, even above the age of 80 years. For those not suitable for surgery, or who are unwilling to have an operation, outcomes can be significantly improved by trans-catheter aortic valve replacement, which has become an important option for frail elderly patients. Balloon aortic valvuloplasty improves symptoms and short-term survival, but has a less clear impact on mortality beyond 1 year. It is useful as a palliative treatment and as a bridging procedure for patients who are not ready for valve replacement. There is less agreement on the best approach to patients with asymptomatic severe aortic stenosis. Trials indicate that early valve replacement results in outcomes that are comparable to those seen in symptomatic patients, though guidelines advocate delaying surgery until symptoms occur or left ventricular function begins to decline rapidly. All elderly patients with severe aortic stenosis should be considered for a mechanical intervention unless there is a properly considered reason for not doing so, or they are not willing to receive such treatment.

Keywords

aortic stenosisaortic valve replacementelderlyold age
Type
Clinical geriatrics
Information
Reviews in Clinical Gerontology , Volume 22 , Issue 3 , August 2012 , pp. 195 - 203
Copyright
Copyright © Cambridge University Press 2012

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References

1Daloia, A, Antonini-Catterin, F, Baldessin, F, Cas, LD, Faggiano, P, Lorusso, R. Epidemiology and cardiovascular risk factors of aortic stenosis. Cardiovasc Ultrasound 2006; 4: 27–32.Google Scholar
2Passik, CS, Ackermann, DM, Pluth, JR, Edwards, WD. Temporal changes in the causes of aortic stenosis: a surgical pathologic study of 646 cases. Mayo Clinic Proc 1987; 62: 119–29.CrossRefGoogle ScholarPubMed
3Iung, B, Baron, G, Butchart, EG, Delahaye, F, Gohlke-Bärwolf, C, Levang, OW, Tornos, P, Vanoverschelde, JL, Vermeer, F, Boersma, E, Ravaud, P, Vahanian, A. A prospective survey of patients with valvular heart disease in Europe: The Euro Heart Survey on Valvular Heart Disease. Eur Heart J 2003; 24: 1231–43.CrossRefGoogle ScholarPubMed
4Lindroos, M, Kupari, M, Heikkila, J, Tilvis, R. Prevalence of aortic valve abnormalities in the elderly: an echocardiographic study of a random population sample. Am J Coll Cardiol 1993; 21: 1220–25.CrossRefGoogle ScholarPubMed
5Bonow, RO, Carabello, BA, Chatterjee, K, de Leon, AC Jr, Faxon, DP, Freed, MD, Gaasch, WH, Lytle, BW, Nishimura, RA, O'Gara, PT, O'Rourke, RA, Otto, CM, Shah, PM, Shanewise, JS, Smith, SC Jr, Jacobs, AK, Adams, CD, Anderson, JL, Antman, EM, Fuster, V, Halperin, JL, Hiratzka, LF, Hunt, SA, Lytle, BW, Nishimura, R, Page, RL, Riegel, B. Guidelines for the management of patients with valvular heart disease. Am J Coll Cardiol 2006; 48: 598–675.CrossRefGoogle ScholarPubMed
6Otto, CM, Lind, BK, Kitzman, DW, Gersh, BJ, Siscovick, DS. Association of aortic valve sclerosis with cardiovascular mortality and morbidity in the elderly. N Engl J Med 1999; 341: 142–47.CrossRefGoogle ScholarPubMed
7Rajamannan, NM, Gersh, B, Bonow, RO. Calcific aortic stenosis: from bench to bedside – emerging clinical and cellular concepts. Heart 2003; 89: 801–5.CrossRefGoogle ScholarPubMed
8Olsson, M, Thyberg, J, Nilsson, J. Presence of oxidised low-density lipoproteins in non-rheumatic stenotic aortic valves. Arterioscler Thromb Vasc Biol 1999; 19: 1218–22.CrossRefGoogle Scholar
9Ghaisas, NK, Foley, JB, O'Briain, DS, Crean, P, Kelleher, D, Walsh, M. Adhesion molecules in non-rheumatic aortic valve disease: endothelial expression, serum levels and effects of valve replacement. J Am Coll Cardiol 2000; 36: 2257–62.Google Scholar
10Galante, A, Pietroiusti, A, Vellini, M, Piccolo, P, Possati, G, De Bonis, M, Grillo, RL, Fontana, C, Favalli, C. C-reactive protein is increased in patients with degenerative aortic valvular stenosis. J Am Coll Cardiol 2001; 38: 1078–82.CrossRefGoogle ScholarPubMed
11O'Brien, KD, Shavelle, DM, Caulfield, MT, McDonald, TO, Olin-Lewis, K, Otto, CM, Probstfield, JL. Association of angiotensin-converting enzyme with low-density lipoprotein in aortic valvular lesions in human plasma. Circulation 2002; 106: 2224–30.CrossRefGoogle ScholarPubMed
12Mohler, ER 3rd, Gannon, F, Reynolds, C, Zimmerman, R, Keane, MG, Kaplan, FS. Bone formation and inflammation in cardiac valves. Circulation 2001; 103: 1522–28.CrossRefGoogle ScholarPubMed
13Antonini-Canterin, F, Popescu, BA, Huang, G, Korcova-Miertusova, R, Rivaben, D, Faggiano, P, Pavan, D, Piazza, R, Bolis, A, Ciavattone, A, Ruggiero, A, Nicolosi, GL. Progression of aortic valve sclerosis and aortic valve disease: what is the role of statin treatment? Ital Heart J 2005; 6: 119–24.Google ScholarPubMed
14Olsen, MH, Wachtell, K, Bella, JN, Liu, JE, Boman, K, Gerdts, E, Papademetriou, V, Nieminen, MS, Rokkedal, J, Dahlöf, B, Devereux, RB. Effect of losartan versus atenolol on aortic valve sclerosis (a LIFE substudy). Am J Cardiol 2004; 94: 1076–80.CrossRefGoogle ScholarPubMed
15Perkovic, V, Hunt, D, Griffin, SV, du Plessis, M, Becker, GJ. Acclerated progression of calcific aortic stenosis in dialysis patients. Nephron Clin Pract 2003; 94: 40–45.CrossRefGoogle Scholar
16Freeman, RV, Otto, CM. Spectrum of calcific valve disease: pathogenesis, disease progression and treatment strategies. Circulation 2005; 111: 3316–29.CrossRefGoogle ScholarPubMed
17Faggiano, P, Antonini-Canterin, F, Erlicher, A, Romeo, C, Cervesato, E, Pavan, D, Piazza, R, Huang, G, Nicolosi, GL. Progression of aortic valve sclerosis to aortic stenosis. Am J Cardiol 2003; 91: 99–101.CrossRefGoogle ScholarPubMed
18Faggiano, P, Aurigemma, GP, Rusconi, C, Gaasch, WH. Progression of valvular aortic stenosis in adults: literature review and clinical implications. Am Heart J 1996; 132: 408–11.CrossRefGoogle ScholarPubMed
19Vahanian, A, Baumgartner, H, Bax, J, Butchart, E, Dion, R, Filippatos, G, Flachskampf, F, Hall, R, Iung, B, Kasprzak, J, Nataf, P, Tornos, P, Torracca, L, Wenink, A; Task Force on the Management of Valvular Hearth Disease of the European Society of Cardiology; ESC Committee for Practice Guidelines. Managemant of valvular heart disease. Eur Heart J 2007; 28: 230–68.Google Scholar
20Kume, T, Kawamoto, T, Okura, H, Watanabe, N, Toyota, E, Neishi, Y, Okahashi, N, Yamada, R, Yoshida, K. Rapid progression of mild to moderate aortic stenosis in patients older than 80 years. J Am Soc Echocardiogr 2007; 20: 1243–46.CrossRefGoogle ScholarPubMed
21National Institute for Heath and Clinical Excellence. NICE guideline on antibiotic prophylaxis against infective endocarditis. http://guidance.nice.org.uk/CG64 (accessed 1 June 2010).Google Scholar
22Sareyyupoglu, B, Sundt, TM 3rd, Schaff, HV, Enriquez-Sarano, M, Greason, KL, Suri, RM, Burkhart, HM, Park, SJ, Dearani, JA, Daly, RC, Orszulak, TA. Management of mild aortic stenosis at the time of coronary artery bypass surgery: should the valve be replaced? Ann Thorac Surg 2009; 88: 1224–31.CrossRefGoogle ScholarPubMed
23Zigelman, CZ, Edelstein, PM. Aortic valve stenosis. Anesthesiol Clin 2009; 27: 519–32.CrossRefGoogle ScholarPubMed
24Pai, RG, Kapoor, N, Bansal, RC, Varadarajan, P. Malignant natural history of asymptomatic severe aortic stenosis: benefit of aortic valve replacement. Ann Thorac Surg 2006; 82: 2116–22.CrossRefGoogle ScholarPubMed
25Rahimtoola, SH. Valvular heart disease: a perspective on the asymptomatic patient with severe valvular aortic stenosis. Eur Heart J 2008; 29: 1783–90.CrossRefGoogle ScholarPubMed
26Melby, SJ, Zierer, A, Kaiser, SP, Guthrie, TJ, Keune, JD, Schuessler, RB, Pasque, MK, Lawton, JS, Moazami, N, Moon, MR, Damiano, RJ Jr. Aortic valve replacement in octogenarians: risk factors for early and late mortality. Ann Thorac Surg 2007; 83: 1651–56.CrossRefGoogle ScholarPubMed
27Carnero-Alcazar, M, Reguillo-Lacruz, F, Alwies, A, Villagran-Medinilla, E, Maroto-Castellanos, LS, Rodriguez-Hernandez, JE. Short- and mid-term results for aortic valve replacement in octogenarians. Interact Cardiovasc Thorac Surg 2010; 10: 549–54.CrossRefGoogle Scholar
28Varadarajan, P, Kapoor, N, Bansal, RC, Pai, RG. Survival in elderly patients with severe aortic stenosis is dramatically improved by aortic valve replacement: results of a cohort of 277 patients aged > or = 80 years. Eur J Cardiothorac Surg 2006; 30: 722–27.CrossRefGoogle ScholarPubMed
29Iivanainen, AM, Lindroos, M, Tilvis, R, Heikkila, J, Kupari, M. Natural history of aortic valve disease of varying severity in the elderly. Am J Cardiol 1996; 78: 97–101.CrossRefGoogle ScholarPubMed
30Kojodjojo, P, Gohil, N, Barker, D, Youssefi, P, Salukhe, TV, Choong, A, Koa-Wing, M, Bayliss, J, Hackett, DR, Khan, MA. Outcomes of elderly patients aged 80 and over with symptomatic, severe aortic stenosis: impact of patient's choice of refusing aortic valve replacement on survival. QJM 2008; 101: 567–73.CrossRefGoogle ScholarPubMed
31Wendt, D, Osswald, BR, Kayser, K, Thielmann, M, Tossios, P, Massoudy, P, Kamler, M, Jakob, H. Society of Thoracic Surgeons Score is superior to EuroSCORE determining mortality in high risk patients undergoing isolated aortic valve replacement. Ann Thoracic Surg 2009; 88: 468–75.CrossRefGoogle ScholarPubMed
32Schenk, S, Fritzche, D, Atoui, R, Koerthe, H, Koerfer, R, Eitz, T. EuroSCORE – predicted mortality and surgical judgement for interventional aortic valve replacement. J Heart Valve Dis 2010; 19: 5–15.Google ScholarPubMed
33Piazza, N, Wenaweser, P, van Gameren, M, Pilgrim, T, Tzikas, A, Otten, A, Nuis, R, Onuma, Y, Cheng, JM, Kappetein, AP, Boersma, E, Juni, P, de Jaegere, P, Windecker, S, Serruys, PW. Relationship between the logistic EuroSCORE and the Society of Thoracic Surgeons Predicted Mortality in patients implanted with the CoreValve ReValving system. Am Heart J 2010; 159: 323–29.CrossRefGoogle Scholar
34Vicchio, M, Della Corte, A, De Santos, LS, Caianiello, G, Scardone, M, Cotrufo, M. Tissue versus mechanical prostheses: quality of life in octogenarians. Ann Thorac Surg 2008; 85: 1290–95.CrossRefGoogle ScholarPubMed
35Maillet, JM, Somme, D, Hennel, E, Lessana, A, Saint-Jean, O, Brodaty, D. Frailty after aortic valve replacement (AVR) in octogenarians. Arch Gerontol Geriatr 2009; 48: 391–96.CrossRefGoogle ScholarPubMed
36National Institute for Health and Clinical Excellence. Interventional procedure guidance 266: Transcatheter aortic valve implantation for aortic stenosis. http://www.nice.org.uk/nicemedia/pdf/IPG266Guidance.pdf (accessed 3 June 2010).Google Scholar
37Bauer, F, Lemercier, M, Zajarias, A, Tron, C, Eltchaninoff, H, Cribier, A. Immediate and long term echocardiographic findings after transcatheter aortic valve implantation for treatment of aortic stenosis: the Cribier-Edwards/Edwards-Sapien valve experience. J Am Soc Echocardiogr 2010; 23: 370–76.CrossRefGoogle ScholarPubMed
38Tamburino, C, Capodanno, D, Mulè, M, Scarabelli, M, Cammalleri, V, Barbanti, M, Calafiore, A, Ussia, G. Procedural success and 30-day clinical outcomes after percutaneous aortic valve replacement using current third-generation self-expanding CoreValve prosthesis. J Invasive Cardiol 2009; 21: 93–98.Google ScholarPubMed
39Webb, JG, Altwegg, L, Boone, RH, Cheung, A, Ye, J, Lichtenstein, S, Lee, M, Masson, JB, Thompson, C, Moss, R, Carere, R, Munt, B, Nietlispach, F, Humphries, K. Transcatheter aortic valve implantation. Impact on clinical and valve-related outcomes. Circulation 2009; 119: 3009–16.CrossRefGoogle ScholarPubMed
40Rajani, R, Buxton, W, Haworth, P, Khawaja, MZ, Sohal, M, Brum, RL, Hutchinson, N, de Belder, A, Trivedi, U, Hildick-Smith, D. Prognostic benefit of transcatheter aortic valve implantation compared with medical therapy in patients with inoperable aortic stenosis. Catheter Cardiovasc Interv 2010; 75: 1121–26.CrossRefGoogle ScholarPubMed
41Dewey, TM, Brown, DL, Das, TS, Ryan, WH, Fowler, JE, Hoffman, SD, Prince, SL, Herbert, MA, Culica, D, Mack, MJ. High-risk patients referred for transcatheter aortic valve implantation: management and outcomes. Ann Thorac Surg 2008; 86: 1450–56.CrossRefGoogle Scholar
42Dvir, D, Assali, A, Spargias, K, Kornowski, R. Percutaneous aortic valve implantation in patients with coronary artery disease: review of therapeutic strategies. J Invasive Cardiol 2009; 21: E237–41.Google ScholarPubMed
43NHLBI Balloon Valvuloplasty Registry Participants. Percutaneous balloon aortic valvuloplasty. Acute and 30-day results in 674 patients from the NHLBI Balloon Valvuloplasty Registry. Circulation 1991; 84: 2383–97.CrossRefGoogle Scholar
44Shareghi, S, Rasouli, L, Shavelle, DM, Burstein, S, Mathews, RV. Current results of balloon aortic valvuloplasty in high-risk patients. J Invasive Cardiol 2007; 19: 1–5.Google ScholarPubMed
45Sack, S, Kahlert, P, Khandanpour, S, Naber, C, Philipp, S, Möhlenkamp, S, Sievers, B, Kälsch, H, Erbel, R. Revival of an old method with new techniques: balloon aortic valvuloplasty of calcified aortic stenosis in the elderly. Clin Res Cardiol 2008; 97: 288–97.CrossRefGoogle ScholarPubMed
46Pedersen, WR, Klaassen, PJ, Pedersen, CW, Wilson, JA, Harris, KM, Goldenberg, IF, Poulose, AK, Mooney, MR, Henry, TD, Schwartz, RS. Comparison of outcomes in high-risk patients > 70 years of age with aortic valvuloplasty and percutaneous coronary intervention versus aortic valvuloplasty alone. Am J Cardiol 2008; 101: 1309–14.CrossRefGoogle ScholarPubMed
47Agarwal, A, Kini, AS, Attanti, S, Lee, PC, Ashtiani, R, Steinheimer, AM, Moreno, PR, Sharma, SK. Results of repeated balloon valvuloplasty for treatment of aortic stnosis in patients aged 59 to 104 years. Am J Cardiol 2005; 95: 43–47.CrossRefGoogle Scholar
48Weinschelbaum, E, Stutzbach, P, Oliva, M, Zaidman, J, Torino, A, Gabe, E. Manual debridement of the aortic valve in elderly patients with degenerative aortic stenosis. J Thorac Cardiovasc Surg 1999; 117: 1157–65.CrossRefGoogle ScholarPubMed
49Mendonca, JT, Carvalho, MR, Costa, RK, Barroso, RC, Santos, JE, Tavares Filho, SC. Cirurgia reconstrutiva da valva aortica. Rev Bras Cir Cardiovasc 2003; 18: 364–69.CrossRefGoogle Scholar
50Segalote, RC, Pomerantzeff, PMA, de Almeida Brandao, CM, Stolf, NAG. Aortic valve preservation surgery in elderly patients with aortic stenosis. Rev Bras Cir Cardiovasc 2008; 23: 519–23.CrossRefGoogle ScholarPubMed
51Rosenhek, R, Binder, T, Porenta, G, Lang, I, Christ, G, Schemper, M, Maurer, G, Baumgartner, H. Predictors of outcome in severe, asymptomatic aortic stenosis. N Eng J Med 2000; 343: 611–17.CrossRefGoogle ScholarPubMed
52Brown, ML, Pellikka, PA, Schaff, HV, Scott, CG, Mullany, CJ, Sundt, TM, Dearani, JA, Daly, RC, Orszulak, TA. The benefits of early valve replacement in asymptomatic patients with severe aortic stenosis. J Thorac Cardiovasc Surg 2008; 135: 308–15.CrossRefGoogle ScholarPubMed