Why do so few older people with aortic stenosis have valve replacement surgery?

Abstract

Background: many older patients with severe aortic stenosis do not have valve replacement surgery. Objective: to determine the proportion of older people with symptomatic aortic stenosis referred for specialist assessment and the reasons for non-referral. Methods: retrospective study of all patients over 75 attending the geriatric department of an English teaching hospital. Confirmation was by reviewing all echocardiographic reports. Results: of 40 patients with symptomatic aortic stenosis, only four had undergone surgery. Seven patients refused operation; five were medically unfit (for reasons other than heart failure) and reasons for not referring could not be found in 13 casenotes. Of the 15 patients referred to a cardiologist, eight were considered suitable for surgery. Conclusion: only one in five patients over 75 with echocardiographically-confirmed aortic stenosis was considered for surgery. Prospective studies are needed to determine why patients and geriatricians do not seek specialist assessment for this treatable condition.

2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease

“…159 -162,216 The decision to proceed with AVR depends on an imprecise analysis that considers the balance between the potential for improved symptoms and survival and the morbidity and mortality of surgery. [217][218][219] …”

Complexity of treatment decisions with older patients: who, when and what to treat?

“…19 Despite this, fairly recent AVR operative rates amongst patients over 75 years in England were as low as 10%, a major obstacle being lack of specialist cardiac referral. 20 In summary, it is important to avoid 'sins of omission' as well as 'sins of commission' . Old patients should be given the opportunity to balance the risks and benefits of therapy.…”

Closed bore XMR (CBXMR) systems for aortic valve replacement: Investigation of rotating‐anode x‐ray tube heat loadability

“…2 Currently, the only clinically acceptable treatment for this disease is open heart surgical replacement of the aortic valve, 3 which provides good clinical outcome for patients. 4 Unfortunately, one-third to two-thirds of patients who need this treatment do not actually receive it due to risks associated with the surgery. 4,5 To increase treatment availability, cardiologists are developing a minimally invasive procedure known as percutaneous aortic valve replacement.…”

“…4 Unfortunately, one-third to two-thirds of patients who need this treatment do not actually receive it due to risks associated with the surgery. 4,5 To increase treatment availability, cardiologists are developing a minimally invasive procedure known as percutaneous aortic valve replacement. 6,7 This technique replaces the aortic valve of the patient using a minimally invasive catheter-based approach, which is less traumatic for patients than open heart surgery, potentially resulting in greater acceptance of the procedure for patients at high risk for surgery.…”