Annals of Long Term Care

To the Editor:
Dr. Aronow’s¹ recommendation for aortic valve replacement was both informative and directional for patients of elderly age with severe aortic stenosis. I have three very symptomatic patients in their nineties with severe aortic stenosis, with nearly identical clinical presentations as the 80-year-old woman portrayed by Dr. Aronow in his Q&A; all are being treated for congestive heart failure (CHF) with diuretics, angiotensin-converting enzyme (ACE) inhibitor therapy, and beta-blocker therapy. What to do? These patients have no other medical conditions that would contradict aggressive intervention.

Dr. Frank M. Shanley, PA, FACC, FCCP
Diplomate, Internal Medicine and Cardiology
Denville, NJ

Reference
1. Aronow WS. Q & A with the Expert on: Valvular aortic stenosis. Annals of Long-Term Care: Clinical Care and Aging 2007;15(6):29-30.

Response from the author:

Roberts et al¹ reported on nine nonagenarians who had aortic valve replacement (AVR) for severe aortic stenosis at Baylor University Medical Center from 2000 to 2006. The left ventricular ejection fraction was less than 50% in three of the nine patients (33%) (25%, 30%, and 15%). Eight of the nine patients (89%) had concomitant coronary artery bypass grafting at the time of AVR. Of the nine patients, one (11%) died postoperatively, two others (22%) died at 874 days and at 1011 days after AVR, and six (67%) are alive at 738 days, 874 days, 899 days, 1231 days, 1413 days, and 2230 days after AVR.

I know of one nonagenarian who is asymptomatic and working 4 years after AVR for severe aortic stenosis and congestive heart failure. This man also had mitral valve repair and coronary artery bypass grafting at the time of AVR.

These data should be discussed thoroughly with the patients and their families in order that a well-informed decision be made regarding AVR. Of course, an experienced cardiovascular surgeon with excellent results in AVR must perform the AVR if the patient wishes to have this done.

Wilbert S. Aronow, MD, AGSF
Westchester Medical Center/New York Medical College
Valhalla, NY

Reference
1. Roberts WC, Ko JM, Matter GJ. Aortic valve replacement for aortic stenosis in nonagenarians. Am J Cardiol 2006;98:1251-1253.