Understanding aortic stenosis and new treatment options

My mother, who had just turned 90, passed away recently of a condition called aortic stenosis. During a routine checkup about 10 years ago, her doctor picked up a heart murmur. After a series of tests, including an ultrasound, a heart specialist made the diagnosis.

I’d never heard of aortic stenosis before, but learned that it’s yet another thing we can develop with age. It happens in about three percent of people over 75.

Aortic valve

By Valveguru (Own work) [CC BY-SA 3.0 or GFDL], via Wikimedia Commons

Anatomy of the heart

To help explain what it is, I’ll begin with a brief anatomy lesson. There are four valves in the heart — aortic, tricuspid, pulmonary and mitral. Their job is to see that blood flows into your heart from your lungs and then flows out of your heart to the rest of the body. It’s important that it moves in only one direction.

The aortic valve allows the blood to flow out of the heart to the rest of the body. Inside it are three leaflets or cusps, which open and close with every heartbeat. Think of how many beats that would be over 60 to 80 or more years. “When we’re born and when we’re young, they’re thin and pliable,” says Dr. Douglas Sawyer, Chief of Cardiac Services at Maine Medical Center. “But they’re also strong so they can open when the blood flows out and close to prevent blood from flowing back into the heart.”

They get a bit beaten up over time and become calcified. “That calcification can build up with age,” says Dr. Sawyer, “and prevent the leaflets from opening as well. This can eventually narrow the valve. Enough that people develop symptoms because the blood’s not getting out of their heart as well.”

Aortic stenosis is the term for this narrowing. It’s a fairly slow process that goes on for many years, sometimes decades. In time, it causes heart failure. The heart muscle can become weak and unable to pump the blood your body needs to survive.

Symptoms of aortic stenosis

My mother’s stenosis gradually progressed to moderately severe. Until a week or so before she passed away, she had no visible symptoms. Then she developed fatigue and shortness of breath. “When people do develop symptoms,” says Dr. Sawyer, “it’s very predictable that without [treatment] this is likely to take their life. Without symptoms, the narrow valve is generally not a major problem. But when someone does have symptoms due to aortic stenosis the only effective treatment is aortic valve replacement.”

These are the symptoms to watch for:

  • Shortness of breath
  • Fainting. Happens if there isn’t enough blood flowing into your head
  • Angina, chest pressure or chest tightness. Happens when the heart itself isn’t getting enough blood.

Treatment options

Until only a few years ago, the only treatment option for aortic stenosis was open heart surgery to replace the aortic valve. Now, a minimally invasive procedure is available for some patients. It’s called transcatheter aortic valve replacement or TAVR. At MMC, patients must be evaluated by a team of specialists and undergo a series of tests to determine if treatment is necessary and which approach is the best option.

Open heart surgery is generally reserved for people with severe stenosis. In other words, they are at high risk of death or complications. The damaged valve is removed and replaced with either a mechanical valve or one made from a pig or a cow.

TAVR was also reserved for people at high risk — until August (2016), when the U.S. Food and Drug Administration (FDA) gave the ok to use two specific TAVR systems in people with aortic stenosis who are at intermediate risk for death or complications associated with open heart surgery.  Another TAVR system may be approved for use in lower-risk patients in the near future.

As I mentioned, TAVR is a minimally invasive procedure. Simply put, a catheter is threaded up through an artery in the leg into the aortic valve. A balloon is inflated to open up the valve and a new valve is placed inside the damaged valve. Part of the valve is made out of pig or cow tissue and part of it is mechanical.

When the procedure is over, people usually feel better quite rapidly, says Dr. Sawyer. That’s because the heart is no longer under such enormous pressure. With aortic stenosis, the pressure can get well over 200.

“Think about that,” says Dr. Sawyer. “Normal blood pressure is in the 100 to 120 range systolic. Let’s say you need that to live. [With aortic stenosis,] inside the heart muscle pressure is well over 200 in order to drive the blood flow across this tiny narrow opening. So suddenly, you open up that door and the pressure and blood flow can normalize. That’s a huge relief of strain.”

 Age is not the only risk

So far, we’ve only talked about cardiac stenosis related to aging. Some people are at risk at a younger age. Particularly people who were born with two of the three valve leaflets fused. It’s called a bicuspid valve and it’s generally inherited. “People with a bicuspid valve are much more likely to develop aortic stenosis at a younger age,” says Dr. Sawyer. “It’s usually people in their 50s or 60s who are getting bicuspid aortic valves replaced. It’s probably more common than we think.”

Because it’s inheritable, it’s important for people with a bicuspid valve to let other family members know.

As for everyone else: “We’re all at risk for all kinds of stuff as we get older,” points out Dr. Sawyer. “Our bodies wear out and this is one of those things. If someone develops aortic sclerosis at a certain age, the longer he or she lives, the worse it’s going to get. But not everybody develops it. Lots of people have relatively normal aortic valve function and aren’t going to need a valve.”

Diane Atwood and her mother Beverley Swett

My mother’s decision

My mother made it clear that she was not interested in either open heart surgery or the TAVR procedure. I’m grateful we had those difficult conversations and that I was aware of her wishes. When her time came, she received hospice care at Gosnell Memorial Hospice House in Scarborough. My sisters and I were with her 24/7 and at her side when she passed away September 6.

She allowed me to write many stories about her these past few years. She said if it could help someone, she was ok with it.  Hopefully, this will be one of those stories.

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Our Aging in Place blog is written by Diane Atwood, who also writes the blogs Catching Health with Diane Atwood and mylatestart. If you have any topics you’d like us to cover, please let us know in the comments box below. Thank you!

 

 

Categories: Blog and Dealing with Chronic Illness.

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