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Heart Disease (Expert Forum)
Severe Aortic Stenosis in an 80 year old male....
Answered by
Cleveland - OH
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Severe Aortic Stenosis in an 80 year old male....
by johngalt, Jan 14, 2005 12:00AM
My father is 80 years old and has been diagnosed as suffering from severe aortic stenosis. He has had 2 previous bypasses; one in 1977 (3 arteries) and the other in 1993 (5 arteries). He also had angioplasty performed in 1994 (the 1993 surgery was done in Florida, the following year he went back to the surgeon to explain he wasn’t feeling quite right and they decided on the need for the angioplasty). He had a heart attack in 1990 causing some damage to the front part of the heart.
After all of these surgeries, he had continued to lead an active lifestyle, up to and including playing organized baseball until he was 79. He was admitted to the hospital in November 2004 suffering with shortness of breath, swelling in the ankles and new onset of cough (the diagnosed congestive heart failure the result of the stenosis). The echocardiogram showed grade III ventricle with severe aortic stenosis. The valve area was .44 with a gradient of 60. The left ventricular ejection fraction is 25% at rest and 26% post stress. The echocardiogram also showed small amount of leakage in the mitral valve and the biscupid valve although the cardiologist didn’t feel those were big issues.
The medications prescribed have reduced the fluid buildup around the heart and lungs and the swelling in the legs. He has had no chest pain
His current medication regimen is:
q Apo-furosemide - 40 mg. one in the morning.
q Altace or ramipril - 2.5 mg. one a day.
q Novometoprol - 50 mg. one tablet 2 times a day.
q Lanoxin or digoxin - .125 mg. one a day.
q Lipitor - 40 mg. one a day.
He has seen a cardiologist here in Canada and was told surgery to fix the stenosis was not an option (I’m not sure if that is because surgery shouldn’t be done or the result of a socialized system overburdened with long wait times and something less than cutting edge technology).
My questions are:
1. Is another consult in the U.S. (the Cleveland Clinic or Beaumont Hospital in Detroit, since we live in Windsor which is right across the Detroit River) indicated to see if valve surgery is in fact an option?
2. For us, these costs are out of pocket and since this is obviously a 5 or 6 figure operation, my dad will want to know a “ball park” mortality rate so we can assess risk and cost against increased life span.
3. My reading says that generally the valve area will decrease by .1cm². If we do nothing, what kind of life expectancy would he be looking at?
4. Assuming successful valve replacement, what kind of life expectancy would he be looking at? (Obviously, these questions assume no additional problems)
5. Is Minimal Invasive Surgery an option?
6. And the ultimate question, if this was your father, would you be suggesting considering surgery?
7. Do you have any other observations or suggestions?
Thank you very much for your time.
After all of these surgeries, he had continued to lead an active lifestyle, up to and including playing organized baseball until he was 79. He was admitted to the hospital in November 2004 suffering with shortness of breath, swelling in the ankles and new onset of cough (the diagnosed congestive heart failure the result of the stenosis). The echocardiogram showed grade III ventricle with severe aortic stenosis. The valve area was .44 with a gradient of 60. The left ventricular ejection fraction is 25% at rest and 26% post stress. The echocardiogram also showed small amount of leakage in the mitral valve and the biscupid valve although the cardiologist didn’t feel those were big issues.
The medications prescribed have reduced the fluid buildup around the heart and lungs and the swelling in the legs. He has had no chest pain
His current medication regimen is:
q Apo-furosemide - 40 mg. one in the morning.
q Altace or ramipril - 2.5 mg. one a day.
q Novometoprol - 50 mg. one tablet 2 times a day.
q Lanoxin or digoxin - .125 mg. one a day.
q Lipitor - 40 mg. one a day.
He has seen a cardiologist here in Canada and was told surgery to fix the stenosis was not an option (I’m not sure if that is because surgery shouldn’t be done or the result of a socialized system overburdened with long wait times and something less than cutting edge technology).
My questions are:
1. Is another consult in the U.S. (the Cleveland Clinic or Beaumont Hospital in Detroit, since we live in Windsor which is right across the Detroit River) indicated to see if valve surgery is in fact an option?
2. For us, these costs are out of pocket and since this is obviously a 5 or 6 figure operation, my dad will want to know a “ball park” mortality rate so we can assess risk and cost against increased life span.
3. My reading says that generally the valve area will decrease by .1cm². If we do nothing, what kind of life expectancy would he be looking at?
4. Assuming successful valve replacement, what kind of life expectancy would he be looking at? (Obviously, these questions assume no additional problems)
5. Is Minimal Invasive Surgery an option?
6. And the ultimate question, if this was your father, would you be suggesting considering surgery?
7. Do you have any other observations or suggestions?
Thank you very much for your time.
Doctor's Answer
by Cleveland Clinic, Jan 14, 2005 12:00AM
, Jan 14, 2005 12:00AM
Your father has several comorbidities that will make will increase the risk of surgery including age, prior surgery and low ejection fraction. That said, none of those alone precludes surgery as an option. I'll answer your questions very generally, as evaluation for surgery, especiall the type you are talking about really requires a careful history and physical as well as close review of all the primary data,
1. Is another consult in the U.S. (the Cleveland Clinic or Beaumont Hospital in Detroit, since we live in Windsor which is right across the Detroit River) indicated to see if valve surgery is in fact an option?
I would say yes indeed. I would recommend being evaluated at a high volume center that does a lot of surgical volume.
2. For us, these costs are out of pocket and since this is obviously a 5 or 6 figure operation, my dad will want to know a “ball park” mortality rate so we can assess risk and cost against increased life span.
Impossible to give without reviewing the data. His prior history age and low EF would probably put surgical mortality above 5%. But his morbidity would also be higher.
3. My reading says that generally the valve area will decrease by .1cm². If we do nothing, what kind of life expectancy would he be looking at?
One heart failure symptoms develop in aortic stenosis, mortality is 50% at one year.
4. Assuming successful valve replacement, what kind of life expectancy would he be looking at? (Obviously, these questions assume no additional problems)
5. Is Minimal Invasive Surgery an option?
6. And the ultimate question, if this was your father, would you be suggesting considering surgery?
7. Do you have any other observations or suggestions?
Although you provided a lot of specifics, its impossible to answer your questions specifically. If he were my father I would sit down prior to any type of visit and discuss if he truly would want to pursue aggressive options to begin with. Then I would seek out the opinion of an experienced cardiologist who specializes in valvular heart disease at a large volume surgical center. I would listen carefully to the options presented with my father and rediscuss those options after the visit and prior to moving forward with any of them. If something bad were to happen with any procedure, I would make sure I would know what yoru fathers expectations and wishes would be in regards to life support and long term care.
This is a difficult time for both you and your father, I wish you the best.
1. Is another consult in the U.S. (the Cleveland Clinic or Beaumont Hospital in Detroit, since we live in Windsor which is right across the Detroit River) indicated to see if valve surgery is in fact an option?
I would say yes indeed. I would recommend being evaluated at a high volume center that does a lot of surgical volume.
2. For us, these costs are out of pocket and since this is obviously a 5 or 6 figure operation, my dad will want to know a “ball park” mortality rate so we can assess risk and cost against increased life span.
Impossible to give without reviewing the data. His prior history age and low EF would probably put surgical mortality above 5%. But his morbidity would also be higher.
3. My reading says that generally the valve area will decrease by .1cm². If we do nothing, what kind of life expectancy would he be looking at?
One heart failure symptoms develop in aortic stenosis, mortality is 50% at one year.
4. Assuming successful valve replacement, what kind of life expectancy would he be looking at? (Obviously, these questions assume no additional problems)
5. Is Minimal Invasive Surgery an option?
6. And the ultimate question, if this was your father, would you be suggesting considering surgery?
7. Do you have any other observations or suggestions?
Although you provided a lot of specifics, its impossible to answer your questions specifically. If he were my father I would sit down prior to any type of visit and discuss if he truly would want to pursue aggressive options to begin with. Then I would seek out the opinion of an experienced cardiologist who specializes in valvular heart disease at a large volume surgical center. I would listen carefully to the options presented with my father and rediscuss those options after the visit and prior to moving forward with any of them. If something bad were to happen with any procedure, I would make sure I would know what yoru fathers expectations and wishes would be in regards to life support and long term care.
This is a difficult time for both you and your father, I wish you the best.
