How Useful Is Aortic Valvulotomy For Aortic Stenosis?

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Question: How Useful Is Aortic Valvulotomy For Aortic Stenosis?

My elderly mother is suffering from aortic stenosis, and is very short of breath. Her cardiologist thinks she is too old and sick for heart surgery, and is suggesting a procedure called aortic valvulotomy. What can you tell me about this procedure?

Answer: Aortic stenosis is a condition in which the aortic valve (the valve that guards the opening between the left ventricle and the aorta) becomes thickened with calcium deposits, and is no longer able to open completely.

Because of this obstruction, the heart muscle has to work extremely hard to pump blood out of the heart, and heart failure often results. The only effective treatment for aortic stenosis is to relieve the obstruction in the valve, typically by surgically replacing the aortic valve. While aortic valve replacement is very effective at treating aortic stenosis, it requires major open heart surgery, and is relatively risky in elderly patients.Aortic valvulotomy is a less invasive approach to treating aortic stenosis. In valvulotomy, a balloon catheter is passed across the aortic valve, and is inflated under high pressure. Inflating the balloon is meant to fracture some of the calcium deposits on the valve, thus allowing the valve to open more completely, and relieving part of the obstruction.

In young patients with congenital forms of aortic stenosis, valvulotomy is often a good option.

Unfortunately, in older people with heavily calcified aortic valves, the results with valvulotomy have not been good. Here is what UpToDate, an electronic reference for doctors and patients, has to say about valvulotomy in elderly people:

"In historical series, serious complications (stroke, aortic regurgitation, myocardial infarction, major access-related complications) occurred in approximately 10 to 20 percent of patients. In-hospital mortality rates were also about 10 to 20 percent.

Restenosis and clinical deterioration occur in most cases within 6 to 12 months, and the long-term outcome resembles the natural history of untreated aortic stenosis."

What this means is two things. First, in the elderly, the rate of serious complications from valvulotomy (especially stroke, heart attack, and aortic regurgitation) is very high. In fact, up to 20% of these patients die before leaving the hospital. This complication rate is higher than is usually reported in elderly patients who have aortic valve replacement.

Second, valvulotomy often simply does not work very well, and the long-term outcome is the same as for patients who receive no treatment at all.

Despite these results, valvulotomy is still sometimes used. For instance, valvulotomy can be employed as a "bridge" to valve replacement surgery. That is, it might be used in an attempt to temporarily improve cardiac function sufficiently to allow open heart surgery to proceed more safely.

However, considering the negative results often seen with valvulotomy in elderly patients, you should be sure to talk to your mother's cardiologist about other options. In addition to surgical valve replacement, these other options might include a different kind of catheter-based treatment for aortic stenosis, called transcatheter aortic valve implantation (TAVI).

Want to learn more? See UpToDate's topic, "Heart Disease" for additional in-depth medical information.

Sources:

Gaasch WH, Brecker SJD, Aldea GS. Percutaneous aortic valvulotomy and transcatheter aortic valve implantation. UpToDate. Accessed: April, 2012.

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