1. Key Questions
Can AVR be performed?
Should AVR be performed?

2. Can AVR Be Performed? Identify Obstacles to Success
Technical: Prior Cardiac Surgery (patent LIMA),
Prior XRT, PVD, etc
Organ Morbidity: Renal, Pulmonary, Neuro/Cognitive
Patient Frailty
Institutional: Presence of Multidisciplinary Care Team with Excellent Outcomes
Estimate Risks: STS, NYS, Euroscore, etc
Family/Social Support

3. Should AVR Be Performed?
Is the AS severe?
Is there a clear indication for AVR
(ie symptoms or CHF)?
Are there other causes for symptoms or for CHF?
Will success impact overall functional status and quality of life? If the Answer is Yes, Don’t Wait for Higher Risk!

4. Case 1 95 y/o woman History of hypertension and aortic stenosis
NYHA class IV symptoms
Multiple admissions for heart failure in the past year
Echo with critical AS and decreased LV function
Most recent admission, treated with diuretics and discharged home due to advanced age
Readmitted within one week with CHF and BNP >5000
Renal function: BUN/Cr 24/0.9

5. Case 1: Echocardiogram EF – 25% Severe AS Moderate Pulm HTN ~ 50 mmHg
Peak Velocity m/s
Mean Gradient - 45 mmHg
Valve Area cm2
Moderate Pulm HTN ~ 50 mmHg

6. Case 1: Cardiac Catheterization
RA – 30 mmHg
PA – 70/34/48 mmHg
PCW – 35 mmHg
C.O. – 2.0 L/min, C.I. – 1.2 L/min/m2
Aortic Valve
Peak Gradient – 71 mmHg
Mean Gradient – 45 mmHg
Valve Area – 0.25 cm2
Severe CAD

7. Case 1: High Mortality Risk!
STS Risk Calculator
CABG/AVR – Mortality Risk – 33.8%
AVR Alone – Mortality Risk – 27.9%
Logistic EuroSCORE
CABG/AVR – Mortality Risk – 78.8%

8. Case 1 What Would You Do? BAV TAVI Surgical AVR – surgeons refused
Palliative Care

9. Patient is now 100 years old and still lives independently.
There have been no admissions for CHF in the last 5 years

10. Case 2
80 y/o man with history of CABG 18 years ago presents with progressive dyspnea on exertion
Asymptomatic with negative stress tests until 3 years ago when his walking became limited by spinal stenosis
1 year ago, his wife noted that he was SOB walking short distances indoors

11. Case 2: Additional History
Progressive short-term memory loss
Multiple TIA’s over the past 2 years
CNS Imaging shows multiple old
fronto-parietal infarcts
No significant extra-cranial vascular disease

12. Case 2: Echocardiogram Severe AS Peak velocity 4.3 AVA 0.7 cm2
EF normal

13. Case 2: Cardiac Catheterization
Coronary angiography:
Patent LIMA to LAD
Patent SVG to OM
Occluded SVG to RCA
Severe native 3VD
RA 7 mmHg
PA 32/7 mmHg
PCWP 12 mmHg
PA Sat 68%
Mean AV gradient 40 mmHg
AVA 0.68 cm2

14. Case 2 Risk Calculator What Would You Do? BAV
STS 2.9% mortality, 20% morbidity
Euroscore 26.8% mortality
What Would You Do?
BAV
TAVI – not a PARTNER candidate
Surgical AVR – surgeons refused
Palliative Care

15. Case 2: Balloon Aortic Valvuloplasty
Post BAV:
gradient 8 mmHg
AVA 1.4 cm2

16. Case 2 Wife reported resolution of dyspnea for approximately 2 months
2 months later, repeat Echo showed peak velocity 3.9 mmHg, AVA 0.9 cm2
Underwent successful transfemoral TAVI with 26mm Edwards-Sapien Valve

17. Case 2: Post-op Course
Persistent somnolence, but no new infarct by CNS imaging
Discharged after 5 days
2 years later
Wife reports dyspnea resolved
Severe dementia

18. Mitral Regurgitation in Older Adults
Moderate to severe MR is present in 10% of adults over 75.
Degenerative
Functional
Ischemic
Dilated cardiomyopathy

19. Goals of Treatment Functional MR: Degenerative MR: Improve symptoms
Improve QOL
Decrease hospitalizations for CHF
Degenerative MR:
Eliminate symptoms
Maintain normal survival

20. Degenerative MR Primary disease of the valve leaflets and chordea
Myxomatous
Diffuse calcific degeneration
Regurgitation results from either excess leaflet motion or restriction of leaflets and annular contraction
LV function is initially normal

21. Degenerative (myxomatous) MR
O'Gara, P. et al. J Am Coll Cardiol Img 2008;1:

22. Degenerative MR Surgical Indications
Severe MR prior to consequence (IIa)
Severe MR with consequence
Symptoms (I)
LV Dysfunction (I) (30< EF < 60)
Atrial Fibrillation (IIa)
Pulmonary Hypertension (IIa)
Severe MR with EF < 30 with structural mitral disease and high likelihood of repair (IIa) with NYHA III-IV

23. Degenerative MR Surgical Indications
Severe MR prior to consequence (IIa)
Severe MR with consequence
Symptoms (I)
LV Dysfunction (I) (30< EF < 60)
Atrial Fibrillation (IIa)
Pulmonary Hypertension (IIa)
Severe MR with EF < 30 with structural mitral disease and high likelihood of repair (IIa) with NYHA III-IV

24. Survival of operative survivors after MR surgery stratified by age at surgery
Figure 1. Survival of operative survivors after MR surgery stratified by age at surgery (≥75 years of age, solid thick line; 65 to 74 years of age, solid medium line; and <65 years of age, solid thin line). For each group, the expected survival curve is indicated with a corresponding dashed line. The numbers at the bottom indicate for each group the ratio of observed to expected survival. A, Survival in all types of MR. B, Survival in patients presenting with degenerative MR.
Detaint D et al. Circulation 2006;114:

25. Trends in operative mortality for MR surgery
Contemporary Results in Age > 80
30 day mortality 5%
3 month mortality 13%
Complications
Stroke: 5% repair, 7% replacement
Prolonged ventilation 50%
Acute renal failure 10%
Nioga L, Euro J CT Surg, 39 (2011)
Figure 2. Trends in operative mortality throughout 4 periods covering the study duration (1980–1983, 1984–1987, 1988–1991, 1992–1995) for patients ≥75 years of age (solid line), between 65 and 74 years of age (dotted line), and <65 years of age (dashed line) operated on for MR. Left, Trends in operative mortality for all causes of MR. Right, Trends in operative mortality for degenerative MR. The probability value applies to the time trends for all age group patients.
In patients over 80
7.7% stroke rate for MVR
Detaint D et al. Circulation 2006;114:
DiGregorio, Annals of Thoracic Surgery, 2004

26. Mitral valve Surgical Outcomes in octoagenarians
Chikwe et al. Eur Heart Journal 2010;32:

27. Functional MR Primary disease of LV: Local-ischemic MR
Global-dilated cardiomyopathy
MR results from restricted valve leaflet motion
LV function is initially depressed

28. Mechanisms of Ischemic Mitral Regurgitation
Papillary muscle traction MR
Increased
tethering
Bulging
Decreased
closing force
Annular dilatation

29. Degree of MR predicts Survival in CHF (Ischemic and Dilated Cardiomyopathy)

30. Functional MR - Current Treatment Options
Medical
RAAS inhibition (ACE inhibition, ARB)
Beta-Blockers
Relieve ischemia
Cardiac resynchronization therapy
Surgical/Transcatheter techniques
- Reduction annuloplasty
Alfieri, Chordal, LV remodeling, LV restraint, posterior leaflet extension, mitral valve replacement
Catheter-based annuloplasty and restraint devices
There are nonsurgical options

31. Surgical Outcomes Ischemic MR – in general
Operative mortality 5-10% overall
~50% five year survival with surgery
Symptomatic benefit in many
Recurrence rate problematic
Effect on mortality unknown
Ischemic MR – paucity of data in elderly
Less than 50% 1 year survival in octogenarians1
Effect on symptoms and quality of life unknown
1Nioga L, Euro J CT Surg, 39 (2011)

32. Decision Not To Operate In Symptomatic Severe MR
49% of patients in the Euro Heart Survey on valvular heart disease with symptomatic severe MR were not operated on.
Mirabel et al. Eur Heart Journal 2007;28:

33. Percutaneous Mitral Valve Repair: Mitral Clip

34. MR High Risk Registry: Mitral Clip
Mean age 76
60% functional MR
Ejection fraction: 54%
STS Score 14%
In hospital mortality = 7.2%
No strokes
CHF hospitalizations reduced by 26%
Whitlow, P. L. et al. J Am Coll Cardiol 2012;59:

35. Older Adult with MR Case
75 y/o man with CAD s/p CABG 14 years ago after inferior MI
Post CABG noted to have progressively decreased LV function, MR, and CHF
3 years ago CRT-D with marked improvement in symptoms
6 months of progressive fatigue, dyspnea on exertion, orthopnea, edema, and ascites despite maximal medical therapy
Rapid loss of independence, yet still working

36. Physical Exam VS: BP 90/60, P 70 Ill appearing elderly man
JVP elevated to angle of the jaw with prominent V wave
Bilateral pleural effusions
PMI in anterior axillary line
Loud systolic murmur at the apex
Pulsatile liver and ascites
Pedal edema to the knees

37. Studies Labs: BUN 60/Cr 1.9 EKG: BiV paced
CXR: enlarged heart and bilateral pleural effusions

38. Cardiac Catheterization
Coronary angiography: Patent LIMA-LAD, Patent SVG OM1-OM2, Occluded SVG-PDA and Occluded RCA
LVEF 35%, Moderate MR
Hemodynamics: RA 12, PA 45/26/32, PCWP 20, CI 2.2, PVR 5
With exercise: PA 60/36, mean PCWP 28, V wave to 45

39. Referred for Surgery Tissue MVR and Tricuspid Valve Repair
1 month later, exercise tolerance had improved and orthopnea and edema had resolved
Lasix dose decreased from 80 mg bid to 80 mg daily
BUN and Cr normalized

40. 3 Year Follow-up
Patient had to cancel his last visit because he was too busy running a retailing business.
Patient works daily.
Patient lives independently.
Symptom free.

41. Conclusions
Valvular disease is an important cause of morbidity and mortality in older adults
Treatment should focus on symptom relief and maintenance of functionality
Improvement in surgical outcomes and emerging percutaneous therapies make treatment available to more high risk patients
Optimizing the timing and selection of the appropriate therapies is evolving

42. AS in older adults Reasons for Treatment Allocation
Wenaweser, P. et al. J Am Coll Cardiol 2011;58: