Aetiology was predominantly degenerative for aortic stenosis and rheumatic for mitral stenosis. Valve repair was the treatment of choice in about half of the patients with mitral regurgitation, while autografts and mechanical prostheses were equally used in aortic stenosis. The application of mechanical prostheses as compared to bioprostheses in patients operated on for aortic stenosis varied largely by age, as appropriate. Mechanical prostheses were predominantly applied in young patients, whereas in elderly patients a bioprosthesis was the preferred treatment.
Overall the indications for interventions in asymptomatic patients were in agreement with guidelines in the majority of patients (66%-79%), and among the different single native valve disease patients. One-third of patients with severe valve disease and severe symptoms were not operated on. The reasons for not advising intervention were either cardiac, extra-cardiac or both. The multifactorial nature of the decision process in such patients and the absence of precise recommendations in the field of VHD explains the wide variability of advice given and make it difficult to make meaningful comparisons with guidelines.
Aortic stenosis (AS) is the most frequent heart valve disease in Western countries, where its prevalence steadily increases with age. Indications for aortic valve replacement are well defined in guidelines and there is a consensus that intervention should be advised in patients with severe, symptomatic AS. Decision to operate raises specific problems in the elderly, because of the increase in operative mortality and morbidity. In this survey, 216 patients aged 75 or older had severe AS (valve area ≤0.6 cm2/m2 body surface area or mean gradient ≥50 mmHg) and angina or dyspnoea New York Heart Association class III or IV.
A decision not to operate was taken in 72 of these patients (33%). In multivariable analysis, older age and left ventricular dysfunction were themost obvious characteristics of patients who were denied surgery, whereas comorbidity played a less important role. Neurological dysfunction was the only comorbidity significantly related to the decision not to operate.
Conclusion:
Mechanical prostheses were predominantly applied in young patients, whereas in elderly patients a bioprosthesis was the preferred treatment, as appropriate.The indications for interventions in the asymptomatic patient were in agreement with guidelines in the majority of patients.One-third of elderly AS patients with severe symptoms were denied surgery due to cardiac and non cardiac reasons.