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10 Valvular Heart Disease in the Elderly

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10 Valvular Heart Disease in the Elderly Chapter 10 / Valvular Heart Disease 231 10 Valvular Heart Disease in the Elderly Milind Y. Desai, MD and Gary Gerstenblith, MD CONTENTS INTRODUCTION DISEASES OF THE AORTIC VALVE DISEASES OF THE MITRAL VALVE CONCLUSION REFERENCES INTRODUCTION Valvular disease continues to be an important cause of morbidity and mortality across the globe with an increasing number of elderly patients affected by “degenerative” valvular diseases on top of a background incidence of unrecognized rheumatic and infective endocarditis (1–3). Although there are no recent population-based data regarding the preva- lence of valvular heart disease in the elderly, several studies have provided relevant information (4,5) (Table 1). Aortic stenosis and ischemic mitral regurgitation are the most common valvular disorders in the elderly. The diagnosis and management of valvular disease in the elderly have been influenced by the dramatic increase in the life expectancy and the number of geriatric patients in the last half of the 20th century. In the United States, for instance, it is estimated that the number of octogenar- ians was around 7.4 million in the early1990s (3% of the population) with a life expectancy of 6.9 years in men and 8.7 years in women. The number exceeded 10 million by the year 2000 and constituted 4.3% of the population (6). As the human life span increases and health care From: Contemporary Cardiology: Cardiovascular Disease in the Elderly Edited by: G. Gerstenblith © Humana Press Inc., Totowa, NJ 231 232 Cardiovascular Disease in the Elderly Table 1 Prevalence of Significant Valvular Heart Disease in the Elderly Valvular abnormality 60–69 years >70 years Aortic stenosis — 5% Aortic regurgitation 3.7% 2.2% Mitral regurgitation 2.3% 5.5% Tricuspid regurgitation 0.9% 3.6% Adapted from refs. 4 and 5. quality improves, more people are reaching an advanced age to present with cardiac disorders that might be treated uneventfully in younger patients. However, in the elderly, there is an important balance between enhanced initial risks and eventual benefits, which are often reduced in the geriatric population. This can lead to difficult medical, as well as ethical and economic decisions. Although there is a substantial variation between chronological and physiological ages, the capacity of elderly patients to withstand a major insult like cardiac surgery is usually reduced because of associated co-morbidities, diminished functional reserve of vital organs, and reduced adaptation capacities (6). It is estimated that the prevalence of co-morbidities in octogenarians with valvular heart dis- ease is as follows: 40%–60% coronary artery disease (CAD), 15%–25% obstructive lung disease, 5%–10% renal insufficiency, 2%–10% periph- eral vascular disease, 20%–50% hypertension, 10%–20% diabetes melli- tus (DM), and 5%–25% cerebrovascular disease (6). In addition, trans- esophageal echocardiography (TEE) has demonstrated that 20% of patients older than 70 years have complex atherosclerosis in the ascending aorta and the transverse arch (7), which significantly increases the risk of embol- ization during cardiac surgical procedures. Finally, impaired cerebral perfusion is another factor that should be considered in the geriatric age group. Potential contributors include non-pulsatile bypass flow, altered cerebral autoregulation, and atherosclerosis, all of which lead to delayed awakening, agitation, and incomplete return of cognitive function, the effects of which can be devastating. It is estimated that 15% to 20% of elderly patients have focal or diffuse neurological deficits after cardiac sur- gery (6). Fortunately, major advances in cardiac surgery have improved the outcomes of surgical treatment in elderly patients who in the past might not have been operative candidates. Also, studies have shown that among surgical survivors, function and quality of life are similar to those in a general population of age-matched subjects (8–10). Hence, the classic thought that valve surgery should be considered only for elderly patients Chapter 10 / Valvular Heart Disease 233 in excellent general health is being challenged as higher success rates are being obtained in elderly patients with non-serious co-morbidities (11). This chapter will provide a detailed outline of the diagnosis and manage- ment of commonly encountered valvular problems in the geriatric age group. DISEASES OF THE AORTIC VALVE Aortic Stenosis ETIOLOGY, RISK FACTORS, AND PATHOPHYSIOLOGY Calcific aortic stenosis is the most common valvular abnormality in the geriatric age group and accounts for 82% of cases in patients over 65 years (12) and 90% of aortic valve replacements in patients over 75 years (13). In the Helsinki Aging Study, the prevalence of at least moderate aortic stenosis in patients aged 75 to 86 years was 5% and that of critical aortic stenosis was 6% at 86 years of age (5). Recent studies demonstrate a similarity in risk-factor profile for atherosclerosis and calcific aortic stenosis. The Cardiovascular Health Study demonstrated that the risk factors for the development of calcific aortic stensosis were age, with a twofold increased risk with every decade; male gender, also a twofold increased risk; current smoking, 35% increased risk; hypertension, 20% increased risk; and elevated low-density lipoprotein and lipoprotein (a) levels (14). The pathophysiological hallmark of calcific aortic stenosis is gradually progressive obstruction to left ventricular emptying, leading to an adap- tive hypertrophic response, to generate greater systolic pressure. The mul- tiple pathophysiological sequelae of aortic stenosis are schematically demonstrated in Fig. 1. CLINICAL FEATURES Aortic stenosis is characterized by a long latent period during which patients are asymptomatic and, often, the diagnosis is incidentally made at the time of a routine physical examination. However, advanced aortic stenosis is associated with dyspnea/congestive heart failure (CHF), angina pectoris, and syncope. Dyspnea on exertion can be the result of a com- bination of systolic and diastolic dysfunction with overt heart failure and in the setting of significant left ventricular dysfunction is a late and ter- minal finding. Association of atrial fibrillation (AF) is unusual with iso- lated aortic stenosis, but can occur in association with heart failure, and its occurrence can trigger significant debilitation. Syncope can occur for various reasons: hypotension owing to exercise-induced vasodilatation in the setting of a fixed obstruction, a tachy- or bradyarrhythmia, and/or an abnormal baroreceptor response. Effort-related angina can be the result 234 Cardiovascular Disease in the Elderly Fig. 1. Schematic representation of the various pathophysiological sequelae of aortic stenosis. of concomitant CAD (in about 50% of the cases) and/or to other mech- anisms as demonstrated in Fig. 1. Increased cardiac mass can lead to increased myocardial oxygen demand, reduced coronary flow reserve, reduced coronary perfusion time and pressure, and compression of intra- myocardial arteries (15). Once these symptoms develop, the prognosis is grim without surgical intervention. It is reported that the time from symptom onset to death is 2 years with heart failure, 3 years with syn- cope, and 5 years with angina (16). Another common finding in patients with calcific aortic stenosis is gastrointestinal bleeding, commonly owing to angiodysplasia (Heyde’s syndrome) (17). The risk of bleeding is thought to be caused by an acquired von Willebrand syndrome owing to disruption of von Willebrand multimers during passage through the narrowed valve (18). There is a linear relationship between the severity of the von Wille- brand factor abnormality and the mean aortic gradient (18). Infective endo- carditis is a rare sequelae of calcific aortic stenosis and isolated reports describe systemic embolic events associated with calcific aortic stenosis. However, in a cohort study comparing 515 patients with calcific aortic stenosis, 300 with a calcified nonstenotic aortic valve and 562 controls, there were no significant differences in stroke rates (19). Physical examination is often useful in determining the severity of aortic stenosis and it has been demonstrated that the delay of carotid up- stroke, timing, and intensity of the murmur and absence of the aortic com- Chapter 10 / Valvular Heart Disease 235 ponent of second heart sound correlate with aortic stenosis severity (20). The arterial pulse is characteristically described as parvus et tardus i.e., weak and slow rising, best appreciated in the carotid artery and asso- ciated with a thrill. Age-associated increased central vascular stiffness, however, may result in a normal pressure rise in the setting of significant stenosis. The apical impulse is sustained and usually not displaced until late in the course of the disease when left ventricular dilatation occurs. Upon auscultation, S1 is usually normal, the aortic component of S2 is diminished and at times absent. S2 can be paradoxically split when ste- nosis is severe or ventricular dysfunction develops. An S4 gallop might also be present. A harsh systolic murmur heard best at the base of the heart with radiation to the carotids is characteristic. The murmur peaks early in mild stenosis and moves later with advancing degrees of stenosis. When the murmur radiates to the apex, it might have a musical quality and mimic that of mitral regurgitation (Gallivardin phenomenon). An asso- ciated diastolic aortic regurgitation murmur is common in older
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