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Forum Name: Valvular Heart Diseases

Question: Severe aortic stenosis with moderate AR


 SAEM KHAN - Fri Aug 06, 2010 12:14 pm

I am diagnosed with severe aortic stenosis and moderate mitral regurgitation. I am diabetic since last 15 years and am around 68 years of age.I am in India
Surgeons are reluctant to perform surgery for valve change as they are of the view that surgery(open heart) is not the option feasible for me due to my fragile condition.

Can you please advise/guide me how can I get back to health and continue living with my loved ones for some time more......

Regards
 Dr.M.Aroon kamath - Sat Sep 04, 2010 10:10 pm

User avatar Hi,
In patients with severe aortic stenosis being considered for valve replacement surgery, the concomitant presence of intermediate degrees of mitral regurgitation represents an additional risk.

Mitral regurgitation (MR) associated with severe aortic stenosis (AS): can be
- functional, or
- structural.

- patients with a severe degree of MR have a worse prognosis, and are advised to undergo mitral valve surgery even if the MR appears functional.
- However, intermediate degrees of MR with no structural involvement is usually attributed to the pressure overload due to the aortic stenosis and alterations in ventricular anatomy and geometry (functional). Although it is generally believed that MR in these patients will improve or disappear after aortic valve replacement, no clear agreement exists about this.Functional MR is a common finding in patients with AS, with an incidence of > 60%. Its management, therefore, assumes great importance, as simultaneous repair or replacement of MR is associated with greater postoperative morbidity and mortality

Diabetes adversely affects the expected improvement of MR following aortic valve surgery. Role of diabetes mellitus in the lack of improvement of the MR after aortic valve surgery is thought to be due to the following two mechanisms;
- firstly, the indirect association between diabetes mellitus and coronary atherosclerosis, which in both its acute symptomatic form and its silent form adversely affects ventricular remodeling.
- secondly, the role of diabetic cardiomyopathy should be considered. Diabetes mellitus predisposes to the development of heart failure (by myocardial fibrosis or diabetic microangiopathy), even in the absence of significant coronary atherosclerosis, resulting in a less favourable ventricular geometry, thus hindering improvement of the MR after aortic surgery.

Increasing age also adversely affects ventricular remodeling mainly because these patients often have greater ventricular dysfunction, more tricuspid regurgitation and more heart failure.

The increasing numbers of poor surgical candidates in the increasing very elderly population mandate less invasive methods such as Balloon aortic valvuloplasty (BAV) to improve quality of life. A resurgence of this procedure is becoming possible through improved understanding of the disease and refined transcatheter device developments.

The high rate of restenosis and the absence of a significant mortality benefit preclude its use as a definitive treatment option in adults with severe aortic stenosis.

Balloon valvuloplasty can be considered in certain selected indications.
- in patients with severe congestive heart failure or cardiogenic shock,
- as a bridge to valve replacement (palliative measure),
- for patients with other comorbid conditions with a very short predicted life expectancy,
- for those who refuse surgery,
- for those with heart failure who need an urgent major noncardiac surgical procedure, or
- in pregnant women with critical aortic stenosis.

As you have been advised against the "open" surgical option, you may discuss with your cardiologist as to the feasibility and suitability of BAV in your specific case.
Best wishes!

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