Valvular heart disease in older adults

INTRODUCTION — The diagnosis and management of valvular heart disease in older adults has been affected by the dramatic increase in life expectancy that began in the last half of the 20th century. In the United States, for example, the number of persons aged 80 years or older is expected to increase from 6.9 million in 1990 to approximately 25 million by the year 2050 [1]. As a result, degenerative valve disease is likely to become an increasing problem. Furthermore, the prevalence of valvular disease is increasing with age, with more than one in eight people age 75 and older having moderate or severe valve disease [2].

Fortunately, there have been major advances in cardiac surgery, which affect the consideration of surgical treatment in older patients who in the past may not have been surgical candidates. Among patients who survive the surgery and perioperative period, the level of function and quality of life and, in some studies, survival are the same as in a general population of age-matched subjects [3-5]. As a result, the classic view that surgery should be considered only for older patients in excellent general condition is being challenged as higher success rates are obtained in patients with comorbidities. Additionally, development of percutaneous valvular interventions will further increase therapeutic choices for older adults. Indeed, the success of transcatheter aortic valve implantation (TAVI) has spurred active development efforts for mitral and tricuspid valve disease [6,7]. (See "Choice of intervention for severe calcific aortic stenosis".)

Studies have used various age criteria to identify older adults. Although there are no comprehensive population-based data regarding the prevalence of valvular heart disease, several studies have provided important information about the prevalence of significant valvular heart disease, stratified by age (table 1). Aortic stenosis (AS), organic and ischemic (functional) mitral regurgitation, and tricuspid regurgitation are the most common valvular disorders in older adults.

AORTIC STENOSIS — Calcific or degenerative aortic valve disease is a common valvular lesion encountered among older patients [8-10]. In the Helsinki Aging Study, 501 randomly selected males and females aged 75 to 86 underwent imaging and Doppler echocardiography [9,10]. The prevalence of at least moderate AS, defined as an aortic valve area (AVA) ≤1.2 cm² and velocity ratio ≤0.35, was 5 percent; the prevalence of critical AS (AVA ≤0.8 cm², and velocity ratio ≤0.25) increased with age from 1 to 2 percent in persons 75 to 76 years of age up to almost 6 percent in those 86 years of age [10]. Moderate or severe AS was more frequent in females (8.8 versus 3.6 percent in males), but data were not adjusted for body size [9]. (See "Aortic valve area in aortic stenosis in adults".)

Similar prevalence has been reported from referral centers and nursing home populations, with an even higher prevalence in those over 90 years of age [11,12].

The two most common causes of AS severe enough to require surgery are calcification of congenital bicuspid aortic valves and degenerative calcification of tricuspid aortic valves [13,14]. The relative distribution is importantly influenced by age, as illustrated in a study of 932 adults with isolated nonrheumatic AS who underwent operative excision of the valve [14]. Among patients over age 70, approximately 60 percent had a tricuspid valve and 40 percent had a bicuspid valve. In contrast, among patients between the ages of 50 and 70, approximately two-thirds had a bicuspid valve, one-third a tricuspid valve, and rare patients had a unicuspid valve.

AS in older patients may be accompanied by aortic regurgitation. In comparison, isolated aortic regurgitation due to aortic valve disease is uncommon in older adults [15]. (See 'Aortic regurgitation' below.)

Risk factors for degenerative calcific AS — The risk factors associated with the development of calcific AS in older adults are similar to those for atherosclerosis. As an example, the Cardiovascular Health Study evaluated 5201 subjects ≥65 years of age; the incidence of aortic sclerosis and AS was 26 and 2 percent overall and 37 and 2.6 percent among those more than 75 years of age [16]. The major independent clinical risk factors for degenerative aortic valve disease were:

●Age – Each 10-year increase in age was associated with a twofold increased risk.

●Male sex – Twofold excess risk.

●Current cigarette smoking – 35 percent increase in risk.

●A history of hypertension – 20 percent increase in risk.

High serum concentrations of lipoprotein(a) and low density lipoprotein cholesterol were also significant risk factors.

Aortic valve sclerosis — Aortic valve thickening (sclerosis) without stenosis is common in older adults, being found in 26 to 29 percent of individuals ≥65 years of age [16,17]. The prevalence is higher in older subjects: 35 percent between 75 and 84 years of age, and 48 percent of those aged 85 years and above [16]. It is usually detected on echocardiography requested for other indications, although some patients have a midsystolic ejection murmur.

Aortic valve sclerosis is clinically important because it can progress to AS and it is a marker for increased cardiovascular risk. Issues related to aortic valve sclerosis are discussed elsewhere. (See "Aortic valve sclerosis and pathogenesis of calcific aortic stenosis".)

Diagnosis of AS in older adults — AS is staged based upon valve anatomy, valve hemodynamics, and hemodynamic (left ventricular) effects [18,19]. This staging system included the syndrome of symptomatic severe low gradient AS. This entity is particularly prevalent in older adults, and presents a diagnostic challenge. (See "Clinical manifestations and diagnosis of aortic stenosis in adults" and "Clinical manifestations and diagnosis of low gradient severe aortic stenosis".)

Outcome of surgery — Isolated aortic valve replacement (AVR) is being performed more frequently in older patients at almost any age, and approximately 60 to 70 percent of all valve surgery performed in older adults are for AS. The indications for surgery are the same as those for younger patients: severe AS with symptoms (angina, dyspnea, or syncope), a left ventricular ejection fraction (LVEF) less than 50 percent, or concurrent coronary artery bypass graft surgery (CABG) [18,19]. (See "Indications for valve replacement for high gradient aortic stenosis in adults".)

However, emerging data suggests that an LVEF of 50 to 60 percent in the context of moderate AS predicts further deterioration of LV systolic function, and should be considered abnormal in patients with more than moderate AS [20].

Older patients with AS tend to have a poorer preoperative status than younger patients. This leads to higher in-hospital mortality in older patients, which ranges from 5 to 18 percent in various studies [3,6,21-26]. Among older adults, age is an important determinant of outcome. In one series, for example, patients ≥80 years of age had higher perioperative mortality than those 65 to 75 years of age (14 versus 4 percent) [3]. At least part of this difference was due to a much higher frequency of New York Heart Association functional class III or IV in the older group (86 versus 36 percent) (table 2). More trials show, in general, lower perioperative mortality (6.4 percent in Partner Cohort A patients) [6].

Another factor related to the poorer outcome is extensive age-related valvular calcification, which is associated with friable tissues. This makes valve surgery particularly difficult in older adults, with a high risk of complications.

Patients undergoing aortic valve replacement generally have increased mortality if concurrent CABG is also performed. Mortality is also increased when aortic valve replacement is combined with procedures other than CABG (eg, mitral valve replacement or valve repair or aneurysm repair) [21]. (see 'Coronary artery disease' below)

Older patients who survive the perioperative period often do well [3,21,25-27]. This was illustrated in a retrospective review that evaluated the outcome after aortic valve replacement in 1100 patients ≥80 years of age [25]. The 30-day cardiac and all-cause mortalities were 4 and 6.6 percent, respectively, while the actuarial survival at one, five, and eight years was 89, 69, and 46 percent, respectively. After the first 30 postoperative days, 70 percent of deaths were due to noncardiac causes (most often malignancy, stroke, or pneumonia).

Older patients have excellent functional recovery and a marked improvement in quality of life, similar to what is observed in younger patients; their level of function and quality of life are the same as a general population of age-matched subjects [3,4]

Choice of aortic valve prosthesis — The choice of prosthesis (bioprosthesis versus mechanical valve) is an important issue in aortic valve disease. The major problems with mechanical valves are thromboembolism and bleeding from chronic anticoagulation [28], while the major problem with bioprosthetic valves is their limited durability due to valve degeneration, although bioprosthetic valve thrombosis is now increasingly recognized [29,30]. (See "Indications for valve replacement for high gradient aortic stenosis in adults".)

Early mortality and actuarial survival in older adults are similar with the two types of valves [25]. However, the longevity of a bioprosthetic valve is inversely related to age [31-33]. In one report, the actuarial estimate of the rate of structural deterioration of bioprosthetic aortic valves at 15 years varied from 63 percent between the ages of 40 and 49 (and perhaps higher under age 40) to 10 percent over age 70 [31]. Similar findings were noted in a Veterans’ Affairs trial in which the rate of bioprosthetic valve failure at 15 years varied from 26 percent under age 65 to 9 percent in patients ≥65 years of age [32]. The lower rate of valve failure in older adults is due at least in part to decreased activity in older patients.

The net effect is that the life expectancy of an octogenarian is shorter than the expected functional life of a bioprosthesis. As a result, a bioprosthetic valve is usually the best choice in older patients [21,25,31,33,34]. In the review cited above of aortic valve replacement in 1100 patients ≥80 years of age, a bioprosthetic valve was implanted in 88 percent [25]. A similar frequency of bioprosthetic valve use (81 percent) was reported in a series of 2447 patients ≥65 years of age who underwent aortic valve replacement between 1992 and 2004 at the Brigham and Women's Hospital in Boston [34].

Over the last years, there was a strong increase in the use of bioprosthetic valves. Indeed, bioprostheses made up 53.3 percent of an estimated 767,375 prosthetic valves implanted in the United States between 1998 and 2011, increasing from 37.7 percent between 1998 and 2001 to 63.6 percent between 2007 and 2011 [35]. For the entire period, bioprostheses were used in 65 percent of patients over the age of 75.  

Small aortic annulus and prosthesis-patient mismatch — Older patients, particularly older females, tend to have a small aortic annulus; this has led to use of a small aortic prosthesis, which may leave a marked residual transprosthetic gradient, ie, a patient-prosthesis mismatch [36-38]. This mismatch may be associated with worse hemodynamics, less functional improvement, and higher in-hospital mortality, particularly in males [37,39,40]. Long-term outcome in patients with patient prosthesis mismatch remain controversial; however, most of the studies have found that early and late mortality and sudden death risk are greater when mismatch is present [39,41-43].

The impact of mismatch may vary among patients. A study found the mismatch has a negative impact in young patients <70 years, but not in older patients; and in patients with decreased LVEF (<50 percent), but not in those with preserved LVEF [44]. Patients with body mass index (BMI) >30 kg/m² with mismatch had similar survival compared with those with a BMI <30 kg/m², suggesting that using body surface area (BSA) to index aortic valve area is not the best way to define mismatch in patients with obesity undergoing AVR. Further studies using an alternative definition of mismatch are needed to evaluate long-term outcome in patients with obesity with AVR.

Some surgeons suggest that a mechanical valve may be preferred in patients with a small aortic annulus. Mechanical valves have smaller transvalvular gradients than bioprostheses and provide better hemodynamics, especially in patients with a small annulus (<21 mm) [21].

The options with a bioprosthetic valve include accepting the higher residual gradient of a bioprosthesis, enlarging the aortic annulus, the use of a stentless bioprosthetic valve, or use of a transcatheter valve. Aortic root enlargement permits the use of a bioprosthesis one or two sizes larger. Although this may prevent a patient-prosthesis mismatch, it adds to the complexity of the procedure [45]. Newer stentless bioprosthetic valves offer a larger orifice area with only a small transvalvular gradient so that enlargement of the annulus is infrequently required [46,47]. However, the durability of these stentless valves remains uncertain since long-term follow-up is not available. The incidence of severe patient-prosthesis mismatch is significantly lower with both balloon-expandable [48] and self-expanding transcatheter valves [49].

Percutaneous balloon valvotomy — Percutaneous balloon valvotomy was initially introduced as an alternative to aortic valve replacement in older patients with AS. Early reports suggested older adults have limited benefit since the aortic valve is usually severely calcified without discernible commissural fusion, making it unsuitable for dilatation, and there has been a high incidence of residual or recurrent stenosis and serious complications, including death, stroke, aortic rupture, and aortic regurgitation [50-52]. (See "Percutaneous balloon aortic valvotomy for native aortic stenosis in adults".)

As a result, balloon aortic valvotomy has traditionally been restricted to very high risk or inoperable patients. However, it can result in immediate improvement in hemodynamics and is palliative in patients with severe AS who are inoperable [53]. Patients who develop restenosis after aortic balloon valvotomy have undergone aortic valve replacement, with good long-term outcome [51,54]. Introduction of transcatheter aortic valve implantation (TAVI) has resulted in an increase in the number of aortic balloon valvuloplasty procedures, mainly due to increased referral of high-risk patients and to the emerging indication of bridge to TAVI [55] (see 'Transcatheter aortic valve implantation' below). Emergency TAVR has been reported in isolated cases, but given the need for complex imaging in terms of route and sizing for TAVI, it has not yet replaced valvotomy.

Transcatheter aortic valve implantation — TAVI is an excellent option for older patients with severe symptomatic AS. TAVI is discussed in detail separately. (See "Choice of intervention for severe calcific aortic stenosis".)

AORTIC REGURGITATION — Aortic regurgitation is less common in older adults than AS and mitral regurgitation [10,21,56,57]. The reported prevalences may, due to the method of quantitation, overestimate the severity of regurgitation.

●In the Helsinki Aging Study, aortic regurgitation, mostly mild, was present in 29 percent of patients [10].

●In the Framingham Study, aortic regurgitation that was at least mild was present in 13 percent of subjects [57]. Age was a determinant of risk, as the odds ratio was 2.3 for each 10-year increase of age.

The most common causes for chronic aortic regurgitation in older adults are dilation of the ascending aorta resulting from hypertension or primary aortic disease, calcific aortic sclerosis, and, rarely, a bicuspid aortic valve. Acute aortic regurgitation is most often due to an aortic dissection or endocarditis. (See "Clinical manifestations and diagnosis of chronic aortic regurgitation in adults" and "Acute aortic regurgitation in adults".)

A special category is represented by periprosthetic aortic regurgitation after transcatheter aortic valve implantation (TAVI), presumably due to poor tolerance of volume overload in the face of significant left ventricular diastolic dysfunction in this patient population. Indeed, even mild degrees of periprosthetic aortic regurgitation after TAVI are associated with increased mortality, and outcomes with moderate or more periprosthetic aortic regurgitation are poor [58,59] (see "Transcatheter aortic valve implantation: Complications", section on 'Post-TAVI aortic regurgitation').

While given less attention due to its lower incidence, periprosthetic valve regurgitation after surgically implanted aortic prostheses is equally detrimental. Indeed, in a propensity matched cohort of 86 patients with surgical valve replacement versus 86 with TAVI, peri-valvular regurgitation was associated with similar mortality. Excess mortality attributable to periprosthetic regurgitation was present in patients with low or intermediate Society of Thoracic Surgery (STS) risk scores, but not in those with high risk [60].

Treatment — Aortic valve surgery for pure aortic regurgitation represents approximately 3 to 5 percent of valve surgeries in older adults [26]. Prophylactic surgery is often recommended in asymptomatic adults with chronic severe aortic regurgitation and evidence of left ventricular dysfunction or marked dilation. However, symptoms are the preferred indication in older patients, especially those over age 80. Mild symptoms and not advanced heart failure (HF) should alert the physician to consider surgery if the regurgitation is severe. (See "Natural history and management of chronic aortic regurgitation in adults".)

There are limited data about the outcome of aortic valve surgery for isolated aortic regurgitation in older adults. Although aortic valve replacement is usually the treatment of choice for acute or chronic severe aortic regurgitation, aortic valve repair is sometimes possible in aortic regurgitation due to endocarditis, and valve-sparing operations are a major consideration in patients with aortic dissection. However, if conservative surgery in these patients is not possible or questionable, standard valve replacement should be performed. Increasing age is a risk factor for operative and long-term mortality. (See "Surgery for left-sided native valve infective endocarditis" and "Management of acute type B aortic dissection" and "Natural history and management of chronic aortic regurgitation in adults", section on 'Aortic valve surgery'.)

MITRAL REGURGITATION — Mitral regurgitation is a common valvular abnormality in older adults. In a report from the Framingham Study of 3589 subjects who underwent color Doppler echocardiography, older age was associated with an increased prevalence of valvular regurgitation (odds ratio 1.3 per 10 year increase in age) [57]. Among males and females at least 60 years of age, mitral regurgitation that was at least mild was seen in 19 percent, while significant mitral regurgitation (at least moderate) was found in 4 and 1.9 percent.

Earlier non-population-based studies found a higher prevalence of significant mitral regurgitation, which was especially frequent in patients at least 60 years of age who had mitral annulus calcification (MAC) [61,62]. The higher prevalence may be explained by the combination of referral bias (ie, only patients with MAC), and lack of information about methods of quantification of severity of mitral regurgitation. In one series of 51 patients with an echocardiographic diagnosis of MAC, for example, mild or moderate to severe mitral regurgitation was seen in 22 and 33 percent, respectively [62]. (See "Clinical manifestations and diagnosis of mitral annular calcification".)

Etiology — There are three major causes of significant mitral regurgitation [63]:

●Organic or primary mitral regurgitation due to intrinsic disease of the mitral leaflets or subvalvular apparatus (eg, mitral valve prolapse, flail mitral leaflet, ruptured chordae tendineae, or calcific degeneration).

●Functional or secondary ischemic mitral regurgitation due to reversible ischemia or papillary muscle infarction, with or without rupture, associated with an acute myocardial infarction. (See "Chronic secondary mitral regurgitation: General management and prognosis".)

●Functional or secondary non ischemic mitral regurgitation resulting from papillary muscle apical displacement associated with annular dilatation induced by left ventricular enlargement of any cause.

In older patients, the most common causes of mitral regurgitation that is of sufficient severity to lead to referral for mitral valve surgery are prolapse (ie, myxomatous degeneration) and ischemic heart disease [64-66]. One report, for example, evaluated 614 patients undergoing mitral valve surgery [66]. The 190 patients who were ≥70 years of age were more likely to have degenerative mitral regurgitation (60 versus 39 percent in younger patients) and coronary heart disease (28 percent versus 12 percent).

Outcome of surgery — Chronic mitral regurgitation is the second most common reason for valve surgery in older adults, representing 30 to 35 percent of cases [24,26]. Although surgery may be recommended for young asymptomatic patients with early evidence of left ventricular dysfunction , it is often preferable in patients over age 80 to proceed with surgery only when symptoms are present. (See "Chronic primary mitral regurgitation: Indications for intervention" and "Chronic secondary mitral regurgitation: General management and prognosis".)

Operative mortality is generally higher in patients with functional regurgitation due to ischemic cardiomyopathy (see 'Effect of ischemic mitral regurgitation on mortality' below).Extensive valvular calcification makes both valve repair and replacement more difficult [67].

The outcome after surgery in older patients varies with age and disease severity and is better after mitral valve repair than replacement [64,66,68-71]. In the above series of 614 patients (190 of whom were ≥70 years of age), the operative mortality after mitral valve repair or replacement was similar in the two age groups (3.7 and 3.5 percent), but seven-year survival was lower in the older patients (49 versus 77 percent) [66]. However, freedom from complications-related death at seven years was similar in the two groups (90 and 93 percent) in who underwent surgery while in New York Heart Association (NYHA) class I or II (table 2) with a left ventricular ejection fraction ≥40 percent. This observation suggests that late surgery contributes more than age to the worse outcome in mitral valve surgery in older adults. (see 'Mitral valve repair' below)

The outcomes may not be so favorable in patients ≥80 years of age [21,69,70]. In a report of 86 such patients who underwent isolated mitral valve replacement with a bioprosthetic or mechanical valve, the 30-day mortality was 10.4 percent [69]. Actuarial survival at one, three, and five years was 79, 64, and 41 percent; the values were the same with both types of valves. Two-thirds of the late deaths were due to noncardiac causes. Octogenarians who have combined coronary artery bypass graft surgery (CABG) and mitral valve replacement have an even higher in-hospital mortality (19.6 versus 12.2 percent in younger patients in a report from the National Cardiovascular Network) [70].

Mitral valve repair — Mitral valve repair, if possible, is the surgical treatment of choice for mitral regurgitation. It preserves all of the functional components of the native valve, avoids the use of a prosthesis with its attendant complications, and overall is associated with lower rates of morbidity and mortality than mitral valve replacement. There are conflicting data as to whether the survival benefit compared to valve replacement is or is not seen in patients over age 60 [72,73]. (See "Chronic primary mitral regurgitation: Choice of intervention", section on 'Surgical valve repair versus replacement'.)

Mitral valve repair produces good results in older patients. This was illustrated in a study that evaluated 278 patients ≥70 years of age who underwent mitral valve reconstruction, primarily with an annuloplasty ring [74]. The in-hospital mortality was 6.5 percent with valve repair alone, 13.2 percent when annuloplasty was combined with another reparative procedure, and 17 percent when combined with CABG.

An excellent outcome in patients over age 75 was noted in a study of 1344 patients undergoing mitral valve repair at Mayo Clinic between 1980 and 1995 [71,75]. During this interval, perioperative mortality in older adults (total 284 patients >75 years of age) decreased dramatically from 27 percent between 1980 and 1983 to 5 percent between 1992 and 1995. The rate of mitral repair in older patients was similar to younger patients, with an overall increase from 30 to 84 percent during the same interval. Furthermore, five-year survival of older patients after mitral valve surgery was similar to their life expectancy (93 percent of expected), an outcome that was similar to that of younger patients.

Various percutaneous mitral valve repair techniques are currently being evaluated. So far, the largest experience is with the MitraClip [76]; this device approximates the mitral leaflet edges and is commercially available in Europe, Israel, and Australia, but investigational in the United States. While the MitraClip was inferior to surgical correction in terms of overall reduction of mitral regurgitation and need for re-intervention, this is a procedure that could be helpful in inoperable patients, and is approved for clinical use in patients with primary (organic) mitral valve disease. The MitraClip has also been used in patients with secondary (functional) mitral regurgitation, but this indication is not approved yet in the United States. Two recent trials in patients with functional mitral regurgitation (Mitra-FR and COAPT) have reported very different results. There was no advantage of percutaneous intervention over medical therapy in Mitra-FR [77], while there was a significant improvement in both rehospitalization for HF and mortality in COAPT [78]. (See "Chronic primary mitral regurgitation: Choice of intervention", section on 'Transcatheter edge-to-edge repair'.)

MITRAL STENOSIS — Mitral stenosis remains a valvular disease of predominantly young people, and rheumatic fever remains the leading cause of mitral stenosis in all age groups [63]. (See "Pathophysiology and natural history of mitral stenosis".)

Although valvular mitral stenosis is rarely seen in older patients, mitral obstruction may be produced by protuberant mitral annular calcification (MAC). In one series of 100 patients ≥62 years of age with MAC, 6 percent had mitral obstruction [61]. (See "Clinical manifestations and diagnosis of mitral annular calcification".)

Treatment — The preferred surgical treatment for severe mitral stenosis is repair (commissurotomy). Mitral valve replacement is unfortunately often necessary since the valvular morphology in older adults is usually unfavorable (extensive calcification, rigidity, and retraction of all of the valve components), making the valve unamenable to commissurotomy. (See "Surgical and investigational approaches to management of mitral stenosis".)

Percutaneous balloon valvuloplasty is the procedure of choice with a favorable valvular morphology. It has a low risk and performed as well as surgical commissurotomy in randomized trials involving mostly younger patients. However, it is not indicated in patients with mitral obstruction due to mitral annular calcification, and there is a possibility of restenosis and need for valve repair during follow-up. (See "Percutaneous mitral balloon commissurotomy in adults".)

The outcome after percutaneous balloon valvuloplasty can be illustrated by the following findings:

●In a series of 75 patients ≥70 years of age, the procedural mortality was 4 percent, and the initial results in the survivors were good, with an increase in valve area to ≥1.5 cm² in the absence of significant mitral regurgitation being achieved in 66 percent [79]. However, at four years, the actuarial rate of survival free of operation was 59 percent and New York Heart Association (NYHA) class I or II persisted in only 34 percent.

●In a second study of 80 patients more than 70 years of age, valve area increased in all patients from 0.84 to 1.59 cm² [80]. The one- and five-year rates of survival without the need for valve replacement were 51 and 25 percent among the 55 patients who were unsuitable for valve surgery (frailty or associated disease), and 64 and 36 percent in the 25 patients who were considered suitable candidates for valve surgery.

As discussed separately, symptomatic severe calcific mitral stenosis cannot be treated by percutaneous mitral valve balloon valvotomy and mitral valve surgery for this condition is technically difficult and associated with high operative morbidity and mortality. Limited data are available on transcatheter mitral valve implantation for severe calcific mitral stenosis. (See "Management and prognosis of mitral annular calcification", section on 'Mitral valve intervention'.)

TRICUSPID REGURGITATION — Tricuspid regurgitation is a very common valvular issue. Indeed, regurgitation was noted in up to 84 percent of patients in a review of 5223 consecutive echocardiographic studies; moderate or more regurgitation was associated with increased mortality [81]. In the Framingham Heart Study, 74 percent of males and 86 percent of females over 70 years old had tricuspid regurgitation (2 and 6 percent with more than moderate tricuspid regurgitation in males and females, respectively) [57]. While tricuspid regurgitation is very prevalent in older adults, very little is known about its specifics in this population, although age is consistently reported as a risk factor for overall poor outcome and increased surgical risk [81,82]. (See "Etiology, clinical features, and evaluation of tricuspid regurgitation".)

Etiology — Major causes of tricuspid regurgitation are:

●Primary or organic tricuspid regurgitation due to intrinsic disease of the tricuspid leaflets or subvalvular apparatus (eg, tricuspid valve prolapse, flail leaflet/ruptured chordae tendineae, impingement by device lead).

●Secondary or functional tricuspid regurgitation:

•Due to left-sided heart disease and/or pulmonary hypertension. Regurgitation is caused by valvular tethering/tenting due to RV enlargement [83].

•Isolated functional tricuspid regurgitation (without evidence of pulmonary hypertension or organic tricuspid disease) due to annular/right ventricular basal enlargement [83]. This type of tricuspid valve disease is associated with aging and presence of atrial fibrillation.

Treatment — Medical management consists of diuretics as well as management of associated left-sided/pulmonary pathology.

Tricuspid valve surgery is recommended in patients with severe tricuspid regurgitation undergoing left-sided valve surgery [18,19].

The evidence for other indications for tricuspid valve surgery is less well established, as reflected by some differences in recommendations among major society guidelines [18,19]. The indications are discussed in detail separately. (See "Management and prognosis of tricuspid regurgitation", section on 'Indications'.)

Tricuspid valve repair is preferred over replacement; when the latter is considered, large-diameter bioprosthesis is preferred over mechanical valves [19]. Reoperation on the tricuspid valve in cases of persistent tricuspid regurgitation after mitral valve surgery carries a high risk, mostly due to the clinical condition of the patient (see "Management and prognosis of tricuspid regurgitation"). Numerous percutaneous approaches to tricuspid valve repair are being evaluated.

UNDERLYING ATHEROSCLEROSIS — The presence of underlying coronary or aortic atherosclerosis affects the treatment and outcome of older patients in whom surgery is considered for valvular disease [18,19].

Coronary artery disease — Coronary artery disease (CAD) is common in older patients and is often present in those with valvular heart disease. In large series of older patients undergoing surgery for valvular disease, 30 to 50 percent also underwent coronary artery bypass graft surgery (CABG) [5,26,84]. Coronary disease can be a concurrent problem or, in patients with ischemic mitral regurgitation, the cause of the valvular disorder [65]. In both of these settings, CHD is associated with excess short- and long-term mortality; however, the magnitude of effect is different.

Effect of CAD on mortality — Among older patients with concurrent CHD of sufficient severity to require CABG at the time of valve surgery for nonischemic valvular disease, most series have noted increased in-hospital mortality compared to those undergoing valve surgery alone [21,24,84].

In one study of 752 patients, for example, 242 patients (32 percent) had significant coronary disease; 208 of these patients underwent CABG at the time of valve surgery [84]. The presence of CHD was an independent predictor of in-hospital mortality (odds ratio 2.35) and late mortality (hazard ratio 1.57). A similar increase in risk was found in a series of 191 octogenarians [24]. Among those undergoing elective surgery, the perioperative mortality was higher in those undergoing aortic valve replacement plus CABG (17.9 versus 9.6 percent in those undergoing aortic valve replacement alone).

Several other findings have been noted:

●Mortality with combined surgery is higher in patients with left ventricular failure and those requiring urgent surgery [24] as well as in octogenarians compared to younger patients [70]. Not surprisingly, patients without other significant comorbidities do better [26,70].

●Aortic valve surgery plus CABG is associated with a higher in-hospital mortality than CABG alone: 17.9 versus 5.6 percent [24] and 10.1 versus 8.1 percent in octogenarians as well as 7.9 versus 3.0 percent in younger patients [70]. Postoperative morbidity, such as renal failure and stroke, is also increased [70].

In contrast to these observations, other series have found no significant difference in in-hospital mortality among patients undergoing CABG, aortic valve replacement, or both procedures [26,85].

Among older patients who undergo CABG and mitral valve surgery, most [24,70,74,85], but not all studies [26], have found increased in-hospital mortality compared to CABG and aortic valve replacement. In one review of over 4700 octogenarians, the respective values were 19.6 versus 10.1 percent overall and 18.2 versus 7 percent in those with no other significant comorbidities [70]. The worse outcome with mitral valve surgery is thought to reflect the frequently ischemic nature of mitral regurgitation, with damage occurring to both valve and myocardium [85]. As with aortic valve surgery, in-hospital mortality is higher with combined mitral valve surgery and CABG compared to mitral valve surgery alone (17 versus 6.5 percent in one series) [74].

Effect of ischemic mitral regurgitation on mortality — Among patients with ischemic mitral regurgitation, the operative mortality is generally higher than for other types of mitral regurgitation and the outcome and procedure vary with the severity of regurgitation. (See "Chronic secondary mitral regurgitation: General management and prognosis".)

Aortic atherosclerosis — The aorta is an important source of emboli in patients with unexplained stroke and arterial emboli. Older patients considered for valvular surgery are more likely to have aortic atherosclerosis. In such patients, any manipulation of the aorta during surgery, including aortic cannulation for arterial inflow during cardiopulmonary bypass or aortic cross-clamping, may fragment a plaque, resulting in embolization. (See "Thromboembolism from aortic plaque".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Cardiac valve disease".)

SUMMARY

●Aortic stenosis (AS) and mitral regurgitation are the most common valvular disorders in older adults. (See 'Introduction' above.)

●Risk factors associated with calcific AS in older adults are similar to those for atherosclerosis. (See 'Risk factors for degenerative calcific AS' above.)

●Diagnosis of AS may be more complex in older adults due to the prevalence of “low-gradient severe AS”. In such cases, quantification of aortic valve calcification by computed tomography may prove useful. (See 'Diagnosis of AS in older adults' above.)

●Older patients with AS tend to have poorer preoperative status and higher operative mortality with aortic valve replacement. However, those who survive the perioperative period often do well and have marked improvement in quality of life. (See 'Outcome of surgery' above.)

●When aortic valve replacement is indicated, a bioprosthetic valve is generally preferred to a mechanical valve in older patients in whom life expectancy is shorter than the expected function life of the bioprosthesis. (See 'Choice of aortic valve prosthesis' above.)

●Transcatheter aortic valve replacement is the main choice for patients with severe symptomatic AS who are considered inoperable for surgical aortic valve replacement, and is associated with lower rates of patient prosthesis mismatch. (See "Percutaneous balloon aortic valvotomy for native aortic stenosis in adults".)

●The most common causes for chronic aortic regurgitation in older adults are dilation of the ascending aorta resulting from hypertension or primary aortic disease, calcific aortic sclerosis, and, rarely, a bicuspid aortic valve. Acute aortic regurgitation is most often due to an aortic dissection or endocarditis. (See 'Aortic regurgitation' above.)

●In older adults, the most common causes of significant mitral regurgitation referred for mitral valve surgery are primary mitral valve disease and ischemic heart disease. (See 'Etiology' above.)

●Surgery for severe chronic mitral regurgitation may be recommended for young asymptomatic patients with or without early evidence of left ventricular dysfunction , but in patients over age 80, although early surgery can be discussed, it is often preferred to proceed with surgery when symptoms are present. (See "Chronic primary mitral regurgitation: Indications for intervention".)

●Mitral stenosis is relatively uncommon in older adults. The predominant cause is rheumatic fever. Calcific mitral stenosis due to protuberant annular calcification is occasionally seen. (See 'Mitral stenosis' above.)

●For patients with symptomatic mitral stenosis, percutaneous balloon valvuloplasty is the procedure of choice if valvular morphology is favorable. However, it is not indicated in patients with mitral obstruction due to mitral annular calcification. Transcatheter mitral valve implantation is being investigated for calcific mitral stenosis. (See 'Treatment' above.)  

●Coronary heart disease is common in older patients with valvular disease. When valve surgery is indicated in older patients, coronary angiography is indicated to assess the need for concomitant coronary artery bypass surgery. (See 'Underlying atherosclerosis' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Maurice Enriquez-Sarano, MD, who contributed to earlier versions of this topic review.