Management of the elderly patient with aortic stenosis

Aortic stenosis (AS) is now the most frequent heart valve disease in industrialised countries and its prevalence sharply increases with age.1 2 Thus, with the lengthening of life expectancy, the population of old patients with AS is expected to grow in the future.

Aortic valve replacement (AVR) remains the reference treatment for severe symptomatic AS and there are no explicit restrictions for intervention related to age itself according to guidelines.3 4 However, decision making for intervention is often difficult in old patients in whom it may not be obvious whether the benefit of surgery, as compared to spontaneous outcome, outweighs the risk of intervention.

The literature enables results of AVR to be better ascertained in the elderly and compared to the natural history of AS. In addition to their usefulness in improving decision making for surgery, surgical series are the reference for the evaluation of new techniques using transcatheter heart valve prosthesis. As regards current patient management, the difficulty is to translate data from the literature to an analysis of the risk/benefit ratio of different therapeutic possibilities tailored to the individual patient.

SPONTANEOUS OUTCOME

Natural history of aortic stenosis

The natural history of AS has been elucidated by the pioneering work of Ross and Braunwald in the 1960s. The onset of severe symptoms had a major impact since they were associated with a shortening of median survival to 5 years. Median survival was <2 years in the case of left heart failure and <1 year in the case of global heart failure. These findings remain the basis of the recommendation to operate on patients with severe symptomatic AS.3 4 However, the extrapolation of these findings to the elderly with AS may be debatable. In Ross and Braunwald’s study, death occurred at an average age of 63 years.

A contemporary series of elderly patients with …