The evolution of advanced techniques for the management of symptomatic aortic stenosis in the elderly population: conventional surgical management vs transcatheter valve implantation.
The shifting age demographic of the adult population has affected every area of contemporary medical and surgical practice. Many more people are living well, not just into their 70s but into their 80s and beyond. Their expectations of treatment for every illness have shifted markedly upwards at the same time. Despite the decline in cases of rheumatic fever in Westernised populations in recent times, the ageing population has led to no decline in the prevalence of valvular aortic stenosis. This is now realised to be an active pro-inflammatory disease, rather than a degenerative process. Thus the condition has remained in the mainstream and continues to be responsible for considerable morbidity, hospitalisation and mortality among the elderly and very elderly. Management has always been based on the triage of cases for direct intervention to the valve by surgery. Just as expectations have risen from patients, the techniques, application and monitoring of cardiac surgery have also made huge strides forward to meet this aspiration. More and more, surgeons are routinely asked to consider procedures in frailer, more elderly patients with more severe disease and co-morbidity. Managing the stenosis is rarely the only issue confronting the operating surgeon. Attempts to provide alternatives to open valve replacement surgery on cardiopulmonary bypass have now emerged. These are based around the transcutaneous placement of a valve prosthesis. While these technologies were initially highly selective in their application, they have now reached a stage to be compared with contemporary standards of cardiac surgical practice.
Department of Cardiothoracic Surgery, St George's Healthcare NHS Trust, London, UK. fwilliam@sgul.ac.uk
M
M
Jahangiri
A P
AP
Kappetein
M
M
van Geldorp
A J
AJ
Bogers
D000368:Aged; D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000401:mortality / Q000601:surgery*; D006328:Cardiac Catheterization; D006348:Cardiac Surgical Procedures / Q000639:trends; D019918:Heart Valve Prosthesis Implantation / Q000379:methods* / Q000401:mortality; D006801:Humans; D016896:Treatment Outcome