Michael A. Borger, MD, PhD, Division of Cardiovascular Surgery, Toronto General Hospital and Department of Surgery, University of Toronto, Toronto, ON.
Tirone E. David, MD, Division of Cardiovascular Surgery, Toronto General Hospital and Department of Surgery, University of Toronto, Toronto, ON.

Systolic murmurs in older adults require investigation with echocardiography. The most common cause is aortic sclerosis, which does not require therapy, followed by aortic stenosis. Surgery is indicated for aortic stenosis in patients with symptoms (fatigue, shortness of breath, angina and/or syncope) and in asymptomatic patients with left ventricular dysfunction or marked hypertrophy. Older aortic stenosis patients can undergo surgery with minimal increased risk, excellent long-term outcomes, and marked improvements in quality of life. Such patients may be referred directly to cardiac surgeons in order to limit age discrimination that may be present within the medical community.
Key words: aortic stenosis, congestive heart failure, aortic valve replacement, quality of life, outcomes.

Sheldon Singh, BSc

Valvular heart disease is an increasingly common cause of congestive heart failure in the elderly population. Stenosis of the aortic valve is one type of valvular heart disease that can lead to congestive heart failure. Approximately 28,000 aortic valve replacements were performed in the United States in 1994. Sixty-one per cent of these were performed in individuals over age 65. This procedure is the second most common open-heart procedure performed in the elderly after coronary bypass grafting.

In adults, aortic stenosis may be due to previous rheumatic disease or calcification of a congenital bicuspid valve or normal tricuspid aortic valve. Although common worldwide, rheumatic disease is uncommon in North America and Europe. However, because of the increasing aging population, degenerative aortic valve calcification constitutes a substantial health problem.¹

Anatomy
A normal aortic valve is tricuspid. Each leaflet is flexible and composed of three layers covered with endothelium on each side. Degenerative calcific disease is characterized by discrete focal lesions on the aortic side of the leaflet. It is typically an active inflammatory process that bears some resemblance to atherosclerosis; there are protein and lipid infiltration as well as macrophages, foam cells, and the occasional T cell.² The risk factors for aortic valve disease include age, male gender, lipoprotein a, hypertension, smoking, cholesterol and diabetes.