Aortic Stenosis in the Elderly: Understanding the New Therapeutic Options

Abstract

Aortic Stenosis (AS) has become the most frequent valvular heart disease in the western countries with increased prevalence in the elderly. It is associated with very poor prognosis in the absence of surgical treatment and worse quality of life. Patients aged between 80 - 85 years with no major comorbidities and left ventricular ejection fraction between 30% - 50% are still not referred to valve surgery, even if these subjects would likely benefit from surgery in terms of duration and quality of life as compared with the expected outcome of the disease. The decision making process in octogenarian population are not only related to the decision of whether to operate or not, but also to the timing of surgery. The identification of symptoms related to AS is difficult in the elderly and this also delay surgery. Balloon Aortic Valvuloplasty (BAV) and, in the recent years, Transcatheter Aortic Valve Implantation (TAVI) seem to offer an additional chance of valve correction, in patients at high surgical risk or inoperable. For ethical reasons, the first TAVI cases were performed exclusively on patients who had contraindications to surgery because of end stage heart disease and/or severe comorbidities. This accounted for high mid-term mortality rates; however, these findings demonstrated the feasibility of this alternative approach. An overall patient evaluation based on a team approach (involving cardiologists, surgeons and geriatricians) is essential. Results from randomized clinical trials on elderly patients who underwent TAVI are encour-aging and result from one and two years follow-up are now available.