Transcatheter Aortic Valve Implantation: How Old Is Too Old?

To the Editor: A centenarian woman with severe calcified aortic valve stenosis had iterative episodes of heart failure. She was still in good condition and preserved mental status. She underwent two successful percutaneous aortic valve balloon valvuloplasties. The first kept her symptom free for nearly 11 months before aortic valve restenosis and the second lasted for 4 months only before the reappearance of paroxysmal nocturnal dyspnea and heart failure. The cardiothoracic surgeons denied her for aortic valve replacement (AVR) because of severe calcification of the aortic arch (Figure 1A) in addition to her advanced age. Cardiac ultrasound showed preserved left ventricular function, high pulmonary artery pressures (systolic pulmonary artery pressure of 65 mmHg), and a third restenosis process of the calcified aortic valve was performed with an aortic orifice calculated at 0.45 cm2/m2. Coronary angiography did not show any significant stenosis that might explain her symptoms. It was decided, after a multidisciplinary discussion with cardiac surgeons, anesthesiologists, and geriatricians, to treat her valvular disease using transcatheter aortic valve implantation (TAVI). Computed tomography did not show significant tortuosity at the level of the thoracoabdominal aorta and iliac arteries. It indicated a right common femoral artery with no relevant calcifications and with a caliber sufficiently large to accept the appropriate catheters (Figure 1B). The aortic ring was measured at 21.5 mm on cardiac ultrasound. The distance between the Valsalva sinuses and the coronary ostia was greater than 11 mm. These findings allowed right transfemoral access to be used. Balloon valvuloplasty using a 20-mm Nucleus balloon preceded valve implantation (Numed, Inc., Cornwall, ON, Canada). The procedure took place through right femoral access using a percutaneous closure device (ProStar XL Percutaneous Vascular Surgical System; Abbott Vascular, Redwood City, CA). The valve used was an EDWARDS SAPIEN-XT 23 Transcatheter Heart Valve (Edwards Lifesciences LLC, Irvine, CA) (Figure 1C,D). Aortic angiography after valve implementation showed no residual aortic insufficiency or coronary impairment (Figure 1E). Control iliac and femoral angiography showed a light arterial dissection at the femoral artery with no retrograde extension and no blood extravasation (Figure 1F). A conservative strategy without stenting to stick the intimal flap was used. The individual was discharged, had an outstanding clinical evolution, and remained symptom free 1 year later with no significant transvalvular gradient. Despite the recent advances in TAVI as a potential treatment option, conventional open heart surgery such as surgical AVR remains the only definite treatment for aortic valve stenosis that improves long-term survival.1 The operative risk of AVR has constantly improved in recent years. Contemporary data have demonstrated that the survival of appropriately selected elderly adults is comparable to that of younger adults.2 Furthermore, roughly one-third of individuals with severe symptomatic aortic valve stenosis do not undergo surgery for AVR owing to advanced age, left ventricular dysfunction, or the presence of multiple coexisting conditions.3, 4 This is probably a consequence of inconsistent survival data in elderly adults, yet continually rising global life expectancy has resulted in a significantly larger older population for whom a less-invasive strategy may be a worthwhile alternative. TAVI has become an elegant and popular technique for the treatment of symptomatic individuals with severe aortic valve stenosis who are not suitable for surgical AVR5 or who are at high risk of surgery6 because of advanced age and associated comorbidities. The advanced “chronological” age of the individual discussed herein was not congruent with her “physiological” age seeing that she had good mental and general status. She had functional limitations owing to her aortic valve stenosis in addition to the multiple episodes of heart failure, so after she had been treated previously using balloon valvuloplasty and showed good early-phase relief of heart failure symptoms, her medical case was discussed in a multidisciplinary staff meeting with cardiologists, cardiac surgeons, anesthesiologists, and geriatricians. The decision was made on the basis of a risk–benefit analysis of an eventual “definitive” intervention that aimed to treat her aortic valve stenosis, and the absence of dyspnea or symptoms during her daily life support the decision. In an era of percutaneous aortic valve implantation, AVR should still be regarded as the criterion standard in the management of aortic valve stenosis, but in very old adults who have been denied surgery by a multidisciplinary staff and depending on “physiological age,” TAVI may be discussed on a case-by-case basis as the sole possible efficacious management. Conflict of Interest: None. Author Contributions: Ziad Dahdouh and Vincent Roule: Preparation and writing the paper. Thérèse Lognoné and Rémi Sabatier: Writing. Massimo Massetti and Gilles Grollier: Revision and approval of the final version. Sponsor's Role: None.

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