86 year old woman with aortic stenosis with valve area of about 0.65 cm2. Ao V2 max of 4.5 m/sec HG. Ao max PG of 77 mm HG. Ao max PG (full) 54.7 mm HG. Ao mean PG 47.0 mm HG. Mild aortic regurgitation. Aortic valve has severe calcification. Recently had symptoms of shortness of breath except when at rest, which is now treated with 3 liters/min supplementary oxygen 24 hours/day to maintain an oxygen saturation level of about 98%. No other symptoms of aortic stenosis have ever developed. Severe mitral valve regurgitation of about two years duration which is presently adequately controlled with 80mg lasix / day, a low sodium (less than 1000 mg salt/ day ) and highly restrictive fluid intake diet (less than 1500 ml/day). At least a moderate level of tricuspid valve regurgitation with a RVSP of at least 70-75mm HG. Pulmonary valve is normal in structure and function. Severe pulmonary hypertension. Severe biatrial enlargement. Severe concentric left ventricular hypertrophy. Hyperdynamic left ventricle systolic function. LVEF more than 70%. Elevated LA pressures. Both the left and right atrium are severely dilated.. Left atrial volume index is 86 ml/m2. Ejection Fraction is more than 55%. Never has had any other heart issues. Never smoked a cigarette or cigar in her life. Angiogram had perfect results. Normal EKG. Blood pressure at rest consistently in the range of about 100/ 55 with a pulse rate at rest of about 75 beats / minute. Low glomerular filtration rate of 30%. This GFR has been consistently between 30% and 35% for the last two years. Slightly elevated blood sugar of 6-7 mmol/liter. Predominately sedentary lifestyle. Appears frail, but weight is well within the normal range for her height. No other chronic health issues. Is very ambivalent about pursuing medical options to replace/repair heart valves. Without surgical/medical intervention, what is the best estimate of how long this 86 year old woman can expect to live?
Life Expectancy for an 86 year old woman with multiple valve issues.
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I did a quick internet search and an average 86 year old woman has a life expectancy of 6.31 years. Probably, her life expectancy, with the heart condition, is something less than that....but who knows, she has already passed the normal life expectancy of around 78-80 by several years. I doubt that a lot of VR surgical experience for that age group exists. My bigger concern would be the quality of life AFTER such a major surgery on a very elderly person. There is a big difference between "quantity of life" and "quality of life". I can understand her ambivalence.
"Life is not measured by the number of breaths we take, but the number of moments that take our breath away"...George Carlin
"Life is not measured by the number of breaths we take, but the number of moments that take our breath away"...George Carlin
Thank you sir. I really appreciate your reply. Personally, I can't see this person (who is my mother) alive in another 6 years without heart valve surgery. Nevertheless, she really has very little else wrong with her at the present time except for her heart valves. Since she has been on supplementary oxygen, I think her quality of life has actually lessened with the realization that she will likely now have to be on supplementary oxygen for the remainder of her life. She has now become very anxious and somewhat pessimistic about her future. Why would her quality of life AFTER such a major surgery be adversely affected?
Jkm7
Well-known member
What does her cardio suggest as her best course? Does he speak 'straight' with both of you?
Have you consulted a surgeon?
Have you consulted a surgeon?
So many variables .....London Health Sciences and Ottawa Heart Institude are doing amazing things in world class reaserch as well as Montreal and Royal Vuc
I live in Alberta, Canada. Her cardiologist is not entirely "straight" with both of us. He is in my opinion now more concerned with his and the local heart institute's reputation then the welfare of my mother. He did send her to consult with two local heart surgeons. The first one 18 months ago was initially all right with doing the surgery. But four months later he backed out saying that her overall condition plus the heavy calcification of one of her heart valves made a surgery prohibitive. Consulted a second heart surgeon here who just asked us what the first heart surgeon said. He then declined without investigating any further. Subsequently, took my mother to McGill University in Montreal and met with Dr. Benoit deVarennes who has an excellent reputation as a heart valve surgeon. He indicated that surgery was feasible and if undertaken he would be able to fix her valves. His primary concern was with her age and frail condition at the time. He estimated using the Parsonnet scoring methodology a 20% risk of her dying or having a serious complication from the surgery. He also thought that her quality of life at the time was still pretty good for a woman of her age. He left open the possibility of surgery if her condition declined to the point that she was been repeatedly hospitalized and using a cost benefit analysis the risk of surgery had now become less than the risk of no surgery. When the cardiologist learned of our consultation with the surgeon in Montreal, he was on the defensive telling us that regardless of what another surgeon told us, if the local surgeons said heart valve surgery was not feasible, then he would back that decision. We are now considering the Cleveland Clinic to look into less invasive alternatives to open heart surgery as well as looking for another cardiologist.
I hesitated answering your initial question because I sometimes think about what I would do if my current valve needed replacement when I reach my 80s in a very few years. This can be a tough surgery for seniors and post-surgery problems can be difficult to deal with. JKM has the best advice....Talk candidly with her cardio and surgeon concerning the pros and cons for your mom. I am certainly not a medical professional and my response had a lot to do with my personal feelings towards my situation.
http://www.lhsc.on.ca/About_Us/LHSC/Publications/Features/MI_HeartValve.htm#hl=en&qscrl=1&nord=1&rlz=1T4HPIA_enCA331CA331&site=webhp&sa=X&ei=69f_ToL_NeXZ0QG2k9G3Ag&ved=0CBYQBSgA&q=london+health+sciences+minimally+invasive+heart+valves&spell=1&bav=on.2,or.r_gc.r_pw.,cf.osb&fp=f96267a1e716d393&ion=1&biw=1256&bih=783
London Health Sciences Centre (LHSC) is the only centre in southwestern Ontario performing a new method of minimally invasive aortic valve replacement, a procedure which enables surgeons to replace failing heart valves without the patient having to undergo major surgery.
“I am so happy and grateful to have had this procedure at LHSC,” says Klassien Kainz, 76 years old. “I went from not being able to walk across the road, due to my cardiac issues, to now being able to travel, volunteer at my church and live a full and happy life.”
Instead of breaking the patient’s sternum to gain access to the troubled aortic valve and performing open heart surgery, a tiny catheter is inserted into an artery or base of the heart to gain access to the heart and then replace the aortic valve.
The benefits are no broken breast bone, no open-heart operation and a much faster recovery. The transcatheter valve procedure takes about 90 minutes, compared with four to six hours for open-heart surgery.
“This is very exciting non-invasive technology for heart valve replacement,” says Dr. Bob Kiaii, Chief, Division of Cardiac Surgery and Associate Professor, The University of Western Ontario. “The procedure opens doors to high risk patients who would not be served well by current therapies for open-heart surgery.”
Adds Dr. Daniel Bainbridge, Anesthesiologist and Director of Cardiac Anesthesia and Associate Professor, The University of Western Ontario, “This procedure is an excellent example of team work, with each specialty including cardiology, anesthesiology, surgery, nurses and clinical perfusionists, all providing their unique expertise to patient care. The benefit to the patient is an excellent result with minimal pain and rapid recovery after surgery.”
Aortic valves, which regulate blood flow from the heart into the aorta, can fall victim, typically with age and the onset of cardiovascular disease, to stenosis (failure to open) and insufficiency (which leads blood to flow in the wrong direction back into the heart). Aortic stenosis results in a poor quality of life and a high rate of death, approximately 50 per cent, in the first two to three years after diagnosis without surgical intervention.
Approximately one to three per cent of Canadians aged 65-75, two to four per cent aged 75-85, and four per cent older than 85 suffer from severe aortic stenosis.
“The work being undertaken at LHSC is innovative and offers state-of-the-art care for our patients,” says Dr. Patrick Teefy, Cardiologist and Director, Cardiac Catheter Lab and Associate Professor, The University of Western Ontario. “Our entire team is proud to be a part of this important advancement in patient care and clinical research.”
The Cardiac Care team at LHSC has performed this new minimally invasive procedure 13 times. Health Canada approves certain high-risk cases for the procedure, with funding currently being provided through generous donations to London Health Sciences Foundation. The foundation is continuing to raise funds for this procedure, which it says is a good example of donor support helping enhance and advance the current high-standard of health care available to families in the province.
London Health Sciences Centre (LHSC) is the only centre in southwestern Ontario performing a new method of minimally invasive aortic valve replacement, a procedure which enables surgeons to replace failing heart valves without the patient having to undergo major surgery.
“I am so happy and grateful to have had this procedure at LHSC,” says Klassien Kainz, 76 years old. “I went from not being able to walk across the road, due to my cardiac issues, to now being able to travel, volunteer at my church and live a full and happy life.”
Instead of breaking the patient’s sternum to gain access to the troubled aortic valve and performing open heart surgery, a tiny catheter is inserted into an artery or base of the heart to gain access to the heart and then replace the aortic valve.
The benefits are no broken breast bone, no open-heart operation and a much faster recovery. The transcatheter valve procedure takes about 90 minutes, compared with four to six hours for open-heart surgery.
“This is very exciting non-invasive technology for heart valve replacement,” says Dr. Bob Kiaii, Chief, Division of Cardiac Surgery and Associate Professor, The University of Western Ontario. “The procedure opens doors to high risk patients who would not be served well by current therapies for open-heart surgery.”
Adds Dr. Daniel Bainbridge, Anesthesiologist and Director of Cardiac Anesthesia and Associate Professor, The University of Western Ontario, “This procedure is an excellent example of team work, with each specialty including cardiology, anesthesiology, surgery, nurses and clinical perfusionists, all providing their unique expertise to patient care. The benefit to the patient is an excellent result with minimal pain and rapid recovery after surgery.”
Aortic valves, which regulate blood flow from the heart into the aorta, can fall victim, typically with age and the onset of cardiovascular disease, to stenosis (failure to open) and insufficiency (which leads blood to flow in the wrong direction back into the heart). Aortic stenosis results in a poor quality of life and a high rate of death, approximately 50 per cent, in the first two to three years after diagnosis without surgical intervention.
Approximately one to three per cent of Canadians aged 65-75, two to four per cent aged 75-85, and four per cent older than 85 suffer from severe aortic stenosis.
“The work being undertaken at LHSC is innovative and offers state-of-the-art care for our patients,” says Dr. Patrick Teefy, Cardiologist and Director, Cardiac Catheter Lab and Associate Professor, The University of Western Ontario. “Our entire team is proud to be a part of this important advancement in patient care and clinical research.”
The Cardiac Care team at LHSC has performed this new minimally invasive procedure 13 times. Health Canada approves certain high-risk cases for the procedure, with funding currently being provided through generous donations to London Health Sciences Foundation. The foundation is continuing to raise funds for this procedure, which it says is a good example of donor support helping enhance and advance the current high-standard of health care available to families in the province.
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The TAVI procedure is fantastic. It is certainly what I would prefer for her. They also do that procedure here in Edmonton for high risk patients in very poor condition. The problem is that if you replace the aortic valve without addressing the mitral valve regurgitation, then she will still suffer from congestive heart failure. There are no other options in Canada to fix a mitral valve without open heart surgery. In the United Sates, they can use a mitral clip which is also a transcatheter procedure. Elizabeth Taylor underwent this procedure for her CHF. It's still pretty experimental with mixed results. The only other option is a robotically assisted less invasive procedure. This is very expensive but likely successful. It still may not necessarily mean she lives longer, which is a major reason for her ambivalence about surgical/medical intervention. However, the quality of her life would hopefully be appreciably better after such procedures.
Jkm7
Well-known member
There are no easy answers here but you know that.
My biggest hesitation is that even for those very much younger and more hearty, OHS often calls for a long recovery. Even those of us in otherwise good health and far fewer years on us can need a full year to reach our optimum recovery. Most of us are in relatively good condition at the six month mark. This needs to be considered IMO in the scheme of a 90 year old woman undergoing such a big surgery.
TAVI and mitral clip would be optimum. (My cardio is not impressed with the clip for whatever that is worth.)
In the end, it really is your mother's decision and only she can have the final say. It's a very tough call and my heart aches for you as it is clear you are so hopeful to get whatever help for her that is available.
Tough, tough choices to make.
Hope others come along to add a perspective.
My biggest hesitation is that even for those very much younger and more hearty, OHS often calls for a long recovery. Even those of us in otherwise good health and far fewer years on us can need a full year to reach our optimum recovery. Most of us are in relatively good condition at the six month mark. This needs to be considered IMO in the scheme of a 90 year old woman undergoing such a big surgery.
TAVI and mitral clip would be optimum. (My cardio is not impressed with the clip for whatever that is worth.)
In the end, it really is your mother's decision and only she can have the final say. It's a very tough call and my heart aches for you as it is clear you are so hopeful to get whatever help for her that is available.
Tough, tough choices to make.
Hope others come along to add a perspective.
kfay
Well-known member
Have the Dr's you've talked to indicated whether or not they think her pulmonary hypertension will lessen or go away after this surgery? I would think at this point that is as much of a threat to her life as her heart valves. Obviously it is the result of her valve issues, however, I think it is not uncommon for this to not go away after the valves are fixed if it is severe.
I'm sorry you find yourself in this position. IF I could find someone to fix her valves with more minimally invasive procedures, i'd be more likely to pursue it.
Kim
I'm sorry you find yourself in this position. IF I could find someone to fix her valves with more minimally invasive procedures, i'd be more likely to pursue it.
Kim
Your post reminded me of an article I had seen in the New England Journal of Medicine's iPhone app several weeks ago. It involved the daughter of an 86YO woman who accompanies her for a routine physical and asks if her mom should have a colonoscopy (which are NOT recommended for this age). The article addresses involving the elderly in medical decisions and expected lifespan, etc.
Unfortunately, this article is available only for purchase. But perhaps your doctor or your mom's doctors subscribe to the NEJM and can examine the article or provide you a copy. It may be food for thought.
http://www.nejm.org/doi/pdf/10.1056/NEJMp1109990
Unfortunately, this article is available only for purchase. But perhaps your doctor or your mom's doctors subscribe to the NEJM and can examine the article or provide you a copy. It may be food for thought.
http://www.nejm.org/doi/pdf/10.1056/NEJMp1109990
Boston Tiger
Well-known member
I see this as being a key factor, because it raises the question of why she is ambivalent. My mother turned 89 yesterday, and I have a feeling that she would strongly resist having OHS if she were in a similar situation. I think she would have fears that her quality of life would be worse if she had to face a recovery from OHS, and would simply decide to let things play out. The article catwoman cited might provide some insight on how to balance the elderly's desires with their treatment.
Best of luck.
Jkm7
Well-known member
I feel very strongly that IF the patient, no matter the age, has mental capacity capable to make such decisions...... in the end, the patient has the final say.
What a dilemma . . .I agree that if your mom can make the decision, it really should be her decision. Her attitude and optimism will be key in her ability to handle and recover from the surgery.
How is the longevity of you family? Do you have many folks making it their 90's? IF so, then genetics are on her side, too.
I know the recovery can be difficult and the odds of complications (afib, infection, lung issues, etc.) are probably much higher for someone in their 80's. I was only 47 at time of surgery and still developed afib and temporary CHF from the trauma of the valve replacement. Someone 40 years older would have had an even more difficult time handling that little bump, should it arise.
So, I would be more concerned for your mother about the recovery from OHS rather than the actual OHS. You and others have described your mom as "frail" and that is probably not the best place to be facing OHS. She sounds like a prime candidate for the intravenous valve replacement procedure, which would leave her much less vulnerable to infection, etc.
Good luck and keep us posted.
How is the longevity of you family? Do you have many folks making it their 90's? IF so, then genetics are on her side, too.
I know the recovery can be difficult and the odds of complications (afib, infection, lung issues, etc.) are probably much higher for someone in their 80's. I was only 47 at time of surgery and still developed afib and temporary CHF from the trauma of the valve replacement. Someone 40 years older would have had an even more difficult time handling that little bump, should it arise.
So, I would be more concerned for your mother about the recovery from OHS rather than the actual OHS. You and others have described your mom as "frail" and that is probably not the best place to be facing OHS. She sounds like a prime candidate for the intravenous valve replacement procedure, which would leave her much less vulnerable to infection, etc.
Good luck and keep us posted.
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I appreciate everyone's reply to this issue. It seems likely my mother and myself will be going to the Cleveland Clinic to meet with Dr. Marc Gillinov to discuss valve repair/replacement options. I have contacted the Cleveland Clinic and requested an appointment with him as soon as possible.
Excellent idea! Please keep us posted on what you hear.
I've had two surgeons tell me that the issue with Cleveland Clinic is that you get the surgeon "next on the list", and whether it's one of the most experienced or a newbie is basically a crap shoot. Maybe it's different for complex cases or monetary reasons (I'm sure when Dr. Gillinov did Robin Williams' surgery...there was no crap shoot involved). My first surgeon said it was great for him because when he was a resident there he got lots of experience! I had also heard that the surgeon sees you for the surgery and all follow up is done by NPs or residents. I'm dying to know if any of this is true or if the facilities are just fierce competitors.
