Due to the aging population, aortic stenosis remains the most common valvular heart disease. Aortic stenosis in elderly and senile patients is a problem of both a diagnostic nature and a choice of treatment. Despite new advances in the field of cardiac surgery, primarily the development of methods for transcatheter aortic valve replacement (or implantation) (TAVR), problems associated with concomitant diseases and care for the elderly remain relevant.
Increased life expectancy due to advances in modern medicine entails an increase in the number of diagnosed aortic stenoses. The prevalence of aortic stenosis in patients under 60 years of age is low, but it increases in patients over 80 years of age by approximately 10%. The severity of aortic stenosis also increases with age, and 1 in 8 people over 75 years of age have moderate or severe aortic stenosis.
All of this represents a significant public health problem that is likely to get worse as the population ages.
Contents
Epidemiology of Aortic Valve Alterations
Alterations in the aortic valve represent the most prevalent form of age-related degenerative changes in the heart’s valvular apparatus among the elderly, with over 25% of individuals aged 65 and older exhibiting these changes. While most patients show moderate thickening of the valve leaflets and maintain normal valve function—known as aortic sclerosis—approximately 2-5% of these individuals develop significant aortic stenosis, which impedes the flow of blood from the left ventricle.
Risk Factors and Pathogenesis of Aortic Stenosis
The clinical risk factors for degenerative aortic valve stenosis mirror those for coronary atherosclerosis, including age, male gender, smoking, high levels of low-density lipoproteins and cholesterol, arterial hypertension, and metabolic syndrome. These factors not only precipitate the onset of aortic stenosis but also accelerate its progression, particularly in older patients. The condition is marked by a chronic, progressive fibrous-calcific transformation of the aortic valve leaflets, which can advance to almost complete ossification, significantly obstructing blood flow. This process involves disorganized collagen fibers, chronic inflammatory cells, extracellular bone matrix proteins, and minerals, supporting the notion of a chronic inflammatory origin. Hemodynamic stress further exacerbates endothelial dysfunction, contributing to valve deterioration and progressive calcification that increases leaflet stiffness and narrows the valve opening. Over time, the resultant heightened pressure gradient across the aorta induces left ventricular hypertrophy and eventual heart failure due to sustained pressure overload.
Aortic Stenosis and Comorbidities in the Elderly
In assessing elderly patients with aortic stenosis, clinicians often focus primarily on the valve. However, the presence of other severe comorbidities is critical as they can influence the outcomes of surgical interventions like aortic valve replacement. For example, patients with severe pulmonary conditions, such as pulmonary hypertension or chronic obstructive pulmonary disease, may not experience symptom improvement post-surgery. Postoperative evaluations show that a significant number of patients suffer from impaired pulmonary function, requiring oxygen therapy. Furthermore, conditions like chronic kidney disease, liver disease, and anemia are linked with increased mortality following valve replacement procedures.
Diagnostic Challenges in Elderly Patients with Aortic Stenosis
Diagnosing aortic stenosis in elderly patients necessitates a thorough and detailed collection of medical history. Key symptoms indicating the need for valve replacement include angina, syncope, and heart failure symptoms like orthopnea, edema, and paroxysmal nocturnal dyspnea. These symptoms can be challenging to detect in older adults due to limited mobility or muted symptom expression. Engaging caregivers and relatives is essential, as they might notice subtle changes in the patient’s activity levels, appetite, and overall wellbeing. Exercise tests can help identify asymptomatic individuals by assessing whether aortic stenosis contributes to hemodynamic disturbances. The physical examination is crucial, as it can reveal the severity of aortic stenosis through signs like a pronounced bifurcated systolic murmur. However, factors like arterial stiffness and dorsal kyphosis can obscure these findings. In suspected cases, echocardiography is imperative for confirming the diagnosis and guiding management strategies.
Treatment of Aortic Stenosis in Elderly and Senile Patients
Aortic stenosis is a prevalent cardiovascular disorder among the elderly population, characterized by the narrowing of the aortic valve opening, which restricts blood flow from the heart to the rest of the body. As the global population ages, the management of aortic stenosis in elderly and senile patients has become increasingly important. This condition can lead to significant health complications, including heart failure, reduced physical functioning, and increased mortality. The approach to aortic stenosis treatment in elderly in this demographic must consider the unique physiological and medical challenges posed by older age.
Conclusion
After valve replacement, careful monitoring and control of concomitant diseases is essential. Elderly and senile patients are at higher risk for bleeding, renal failure, arrhythmias, blockade of the cardiac conduction system, and cognitive impairment. Patients with severe aortic stenosis with severe symptoms have a significant decrease in preoperative functional status and severe malnutrition, which leaves patients in the high-risk category in the postoperative period.
Hospitalization is invariably associated with decreased functional status, and postoperative delirium can lead to cognitive decline. Activation and rehabilitation after valve transplantation are important to improve outcomes in elderly and senile patients after AVR. Close monitoring by the treating physician and geriatrician is warranted to evaluate long-term postoperative complications or changes in health status.
