aortic valve rplacement in the elderly

[jery-aroesty]

  My mother is 88 years old and lives in the Ft Lauderdale area. .She was just diagnosed as having aortal valve stenosis and her cardiologist recommended aortic valve replacement given her otherwise good health.I believe that age is a  major predictor of patient survival  .What other factors should we consider before we decide whether to operate and what are the chances of survival and a successful outcome?The cardiologist also says that her quality of life will improve with surgery but not her survival.What else do we need to know to make a rational decision?

[Cleveland Clinic, MD]

_

Dear jerry,

Q:.I believe that age is a major predictor of patient survival .What other factors should we consider before we decide whether to operate and what are the chances of survival and a successful outcome?
A: Other factors are other medical conditions (i.e. diabetes, heart failure, lung problems, etc.), the experience of the hospital and surgeon and the length of surgery needed.

I have included some questions from other patients below (not all will apply to your mother).  Good luck.
Q: Is it possible for him to donate his own blood and what procedure
is used (how much, often, when) and can it be transported by the Red Cross?
A: It may be possible but there are a number of difficulties that would need to be overcome.  The number for the blood bank here is [phone].  I would recommend calling them to discuss your particular situation and what, if anything, can be done to help facilitate your request.  If it is not possible the blood supply is very safe with the risk of acquiring an infection less than 1 in 10,000,

Q: If he waits for a length of time to do the procedure, would another cath have to be done?
A: It depends.  The doctors here will review his outside films.  If there are any questions or concerns a repeat cath may be needed.
Q: How long before he could get on the schedule for the surgery and when do you decide which valve is to be used?
A: Again it depends.  The waiting time for Dr. Cosgrove's elective surgeries is up to 6 months.  For some of the newer surgeons the wait could be as little as a week.  Usually there is a plan as to which type of valve to use before going into surgery but it may change depending on what the surgeons find.
Q: When released from the hospital, would going home (a day's drive) in a car be possible or flying be preferable?
A: A 6-7 hour drive would not be unreasonable with frequent stops (every 2 hours or so) along the way to get out and walk a bit.  Any longer than this he may want to consider flying or taking two days to drive.
Q: Also, would he have to return to Cleveland for follow-up or return to his own doctor?
A: Most people choose to follow-up with their local doctor.

Q: Also, are there accommodations near the hospital for family members?
A: The Cleveland Clinic guest house [phone] and the Omni [phone] are two hotels that are on the Clinic campus.

Q: Can the minimally invasive approach be used in aortic valve surgery?
A:  Yes, the minimally invasive approach can be used in aortic surgery.  It may or may not be an option for you depending on your particular case and surgeon.  
Q: Is there an age limit on using human donor valves?
A: No.  There are no age limits on the use of human tissue valves.
Q: Are there any rejection problems with using a human valve?
A: No.  Rejection problems are only with organ transplants.  Valves are pre-treated in such a manner that there is no immunogens for the body to react to.
Q: Is aortic stenosis considerd mild or moderate based on the mean or peak gradient?
A: It is actually based on the valve area.  The peak and mean gradients are a function of the valve area and are interconnected.
Q: If I maintain a cardiac output or heart rate that is within my areobic range is that ok?
A: Specific recommendation are up to your doctor but in general exercise as tolerated is OK.
Q: Everything i've heard to date has been to "keep whatever plumbing you've got" until you absolutely have to replace it.but if i have to lead a life where i'm always anxious about what i can and can't do,wouldn't it be better to just replace it sooner rather than later?
A: The timing of valve surgery is more of an art than science.  However, if you are starting to experience symptoms due to the stenosis I would say it is time to get the surgery.  
Q: I am concerned about the amount of fatigue I am experiencing. I usually wake up feeling rested and feel pretty good for about four hours, then I seem to really wind down. Is this normal with my condition?
A: Your symptoms of progressive fatigue are common with aortic stenosis (AS) and relate to a reduced cardiac output. With AS, there is a fixed obstruction to blood flow from the left ventricle  to the rest of the body which worsens with time. With this obstruction, fatigue occurs because the heart is unable to pump enough blood to the rest of the body.
Q: My cardiologist said that my left ventricle has begun to dilate (I think internal dimensions of 6.6 up from 5.9 last year?) He also mentioned a shortening fraction of 32% Can you explain these numbers to me please?
A: The normal distance between the walls of the left ventricle is about 5 cm.  When the heart starts to dilate (get larger) these dimensions increase.  The ejection fraction is a measure of the pumping capacity of the heart.  Normal is 50-65%.  Mildly decreased is 40-49%.  Moderately decreased is 25-39% and severly decreased is <20%.
Q: If I take Altace until November, will it reverse the dilation to my left ventricle,
and if so would that be a longer term treatment alternative to surgery?
A: There may be some decrease in the dilation.  This is called remodeling and is somewhat controversial.  It is not a long term solution to heart failure caused by valvular stenosis.
I hope you find this information useful.  Information provided in the heart forum is for general purposes only.  Only your physician can provide specific diagnoses and therapies.  Please feel free to write back with additional questions.
If you would like to make an appointment at the Cleveland Clinic Heart Center, please call 1-800-CCF-CARE or inquire online by using the Heart Center website at www.ccf.org/heartcenter.  The Heart Center website contains a directory of the cardiology staff that can be used to select the physician best suited to address your cardiac problem.