Successful Transcatheter Aortic Valve Replacement in a Nonagenarian Patient: A Case Study
Shahab Moossavi, MD, FACC
Concord Hospital Cardiovascular Institute, Concord, New Hampshire
Aortic valvar stenosis is a common diagnosis in cardiology practices across the United States. For symptomatic patients with severe aortic valvar stenosis, 2 treatment options are available and include surgical aortic valve replacement and transcatheter aortic valve replacement. As these patients are more advanced in age, the risk of open procedures with surgery is a consideration in terms of recovery. In our experience, transcatheter aortic valve replacement is less invasive and involves a faster recovery and a shorter length of hospital stay.
Currently, in my practice, I offer my patients with advanced age transcatheter aortic valve replacement with our heart team approach. This approach requires a small area of access to the artery of the wrist and one artery and vein in the groin with minimal sedation. The majority of my patients will be discharged home after 1 night of hospitalization.
In October 2020, an 89-year-old man presented to Concord Hospital (Concord, New Hampshire) with a chief complaint of shortness of breath and acute respiratory distress with dropping oxygen saturation.
His past medical history was significant for chronic lymphocytic leukemia, hypertension, hyperlipidemia, lymphadenopathy, benign prostatic hyperplasia, migraine headaches, and arthritis. The patient was a former smoker who stopped smoking decades prior to presentation.
The course of his hospitalization included consultation by our general cardiology team and an echocardiogram. The echocardiogram revealed preserved left ventricular ejection fraction (LV EF) and severe aortic valve stenosis with a valve area of 0.9 cm2 and a peak transaortic valve velocity of 4.1 m/s.
After the patient’s respiratory status was stabilized with administration of diuretics, he underwent further evaluation with cardiac catheterization. His cardiac catheterization revealed a PA pressure of 35/18 and a wedge pressure of 18 after diuresis. His coronary artery angiography revealed non-flow-limiting coronary artery disease with mild to moderate coronary artery disease, which was not clinically significant.
At this time, our heart team assessed the patient for aortic valve replacement. After he was presented with all treatment options, which included a surgical approach, continuation of medical management, and transcatheter aortic valve replacement, the decision was made to proceed with transcatheter aortic valve replacement.
The patient presented for transcatheter aortic valve replacement on November 24, 2020, less than a month after his index evaluation in the emergency room on October 25, 2020. He underwent transcatheter aortic valve replacement with a 26 mm S3 valve (Figure 1). In light of the patient’s history of peripheral arterial disease, he underwent bilateral balloon angioplasty of the iliac arteries to enable delivery of the S3 valve for his aortic position.
He required 2 nights of hospitalization, and he was discharged home on November 26, 2020, to his prior living facility with significant improvement in his shortness of breath and dyspnea. Post-valve procedure, we placed the patient on ASA 81 mg daily and a course of clopidogrel for 1-6 months in addition to his prior medications.
At his follow-up visit and at the time this article was written, the patient was doing very well from a cardiovascular standpoint with significant improvement in his symptoms.
This type of presentation is commonly seen in patients with aortic valvar stenosis. As the pressure builds in the left ventricle behind the stenotic aortic valve, this extra pressure can cause shortness of breath and dyspnea due to pulmonary edema, which indicates volume retention. In the acute setting, patients respond to Lasix; however, the definite treatment would be aortic valve replacement.
Severe aortic valvar stenosis is a diagnosis of an aging population. We are seeing this condition more frequently in our octogenarian and nonagenarian patients. Generally speaking, these patients will require timely evaluation and awareness of the condition from the time of index presentation with heart failure symptoms. The goal is to proceed with fixing the valve within 4 weeks from the time of index presentation, as long as the patient is clinically stable and deemed a candidate for this procedure.
Close follow-up with the patient, heart team evaluation, and discussion with the patient and the family is critically important to understand the underlying etiology and the treatment options.
Dr. Shahab Moossavi did his internal medicine residency at Wake Forest University Baptist Medical Center in Winston-Salem, North Carolina, and his general and interventional cardiology training at University of Vermont Medical Center, Burlington, Vermont. Dr. Moossavi is board certified in internal medicine, general cardiology, interventional cardiology, and endovascular medicine. He is an interventional cardiologist at Concord Hospital, Concord, New Hampshire. He is trained in and practices interventional cardiology, structural cardiology, and peripheral vascular interventions. With the support of his team, Dr. Moossavi built the transcatheter aortic valve replacement and mitral valve repair program at Concord Hospital. Currently, he practices full-time clinical interventional cardiology at Concord Hospital. He welcomes new patients as well as follow-up on his well-established patients at the Concord Hospital Cardiovascular Institute.
Send correspondence to:
Shahab Moossavi, MD, FACC
Cardiology Section Chief
250 Pleasant St
Concord, NH 03301