During a routine checkup in her 80s, my late mother’s doctor picked up a heart murmur. He sent her to a heart specialist who ordered some tests, including an echocardiogram (ultrasound). The diagnosis was aortic stenosis (narrowing of the heart’s aortic valve). I’d never heard of it before, but it’s something that can develop with age and happens in about three percent of people over 75.
Your heart has four valves — aortic, tricuspid, pulmonary and mitral. The aortic valve allows the blood to flow away from the heart. Inside the valve are three leaflets, or cusps, that open and close with every heartbeat.
When we are young, the leaflets are strong and thin — almost see-through. They’re also very pliable, according to Dr. Scott Buchanan, chief of the Division of Cardiovascular Surgery at Maine Medical Center.
“The ideal valve opens completely during systole when the heart contracts and closes completely during diastole, when the heart relaxes,” he explained.
As we get older, our valves can get a bit beaten up and some people will develop aortic stenosis. The condition is not related to how you live your life, it’s the luck of the draw and, in some cases, may have a vague genetic component.
“The reason it happens,” Buchanan said, “is calcium gets deposited in the leaflets themselves, which thickens them and prevents them from opening. Left to its own devices, it’s a fatal problem because it gets to the point where the heart can’t force the leaflets open.”
Developing aortic stenosis is a fairly slow process that can go on for many years. In time, it causes heart failure, which is when the heart muscle becomes weak and unable to pump the blood your body needs to survive.
The main symptoms include shortness of breath; chest pain, pressure or tightness; fainting spells or feeling faint, especially upon exertion such as walking upstairs; and swollen ankles.
Once these symptoms develop, people generally have a 50/50 chance of surviving another year. The only effective treatment is aortic valve replacement.
When my mother was diagnosed, her only treatment option was open heart surgery to replace her faulty aortic valve, but today many people are given another option — a minimally invasive procedure called a transcatheter aortic valve replacement or TAVR.
Simply put, the surgeon makes a tiny incision in the groin and threads a small flexible tube into the femoral artery and up to the aortic valve in the heart, where the new valve is expanded into place. The benefit of TAVR is a much faster recovery. People spend one night in the hospital and go home the next day with a band aid on their leg.
When TAVR was first introduced around 2012, it was reserved for frail elderly people who were considered high risk for complications or death associated with open heart surgery. Over the past 10 years, it has become an option for younger people and those who are considered intermediate or low-risk patients. However, researchers don’t have long-term data on how long the TAVR valve will last as they do on surgically implanted valves. For that reason, there is an age threshold.
“None of us in the business is comfortable with doing a TAVR on a 50- or 60-year-old,” Buchanan said. “Those folks ought to have the traditional approach because it’s a tried and true approach.”
Aortic stenosis usually happens in older people, but younger people are also at risk, particularly if they have something known as a bicuspid valve. As I mentioned, the aortic valve has three leaflets, but when someone has a bicuspid valve it means two of the leaflets are fused together. It’s usually an inherited condition.
Someone with a bicuspid valve is much more likely to show signs of aortic stenosis in their 50s or 60s. As for the rest of the population, as you age, it’s not inevitable that you will develop aortic stenosis, but it’s important to pay attention to any symptoms you might be having.
“If you have chest pain, trouble breathing when you exercise, a sense of dizziness or fainting, get evaluated, don’t ignore it,” Buchanan said. “We have some amazing tools and techniques to fix aortic stenosis and restore a person’s quality of life.”