“Aortic Stenosis… The Neglected Child” By Dr. Giovanni Ciuffo
By Adam Pick on January 31, 2010
I recently met Dr. Giovanni Ciuffo, a cardiac surgeon at Mount Sinai Hospital in New York City. Although it was our first time chatting, I really enjoyed learning about Dr. Ciuffo’s practice which specializes in minimally-invasive heart valve surgery and, at times, bloodless surgery.
During our conversation, Dr. Ciuffo mentioned an article he just published about aortic valve stenosis and its impact on elderly patients. I found the article, “Aortic Stenosis – The Neglected Child: Novel Techniques To Take Care Of It”, full of educational and interesting information. That said, I thought you might like to review it as well. So, here are select excerpts from Dr. Ciuffo’s latest publication:
Calcific aortic valve stenosis (AS) is quite frequent in our population. A clear increase in prevalence is seen with age: 1-3% in patients aged 65-75 years, 2-4% in those aged 75-85 years, 4% in patients older than 85 years.
It is, without a question, a disease of the elderly with the exception of patients with bicuspid aortic valves who present with severe AS or Aortic Insufficiency (leaky valve) two decades earlier and the rare case of rheumatic valve disease.
Picture Of Calcified Bicuspid Aortic Valve
Most patients are diagnosed because of their symptoms of CHF (shortness of breath and fatigue), angina (chest pain) and syncope (fainting) or because of an obvious and loud systolic murmur heard on the chest with the stethoscope. The current guidelines of the American College of Cardiology are very clear about treatment options on these patients. Severe symptomatic aortic stenosis means that the aortic valve is so calcified and clogged up that it barely opens to allow blood flow from the heart to the rest of the body. It is a uniformly lethal condition.
Unless an effective mechanical relief is offered in the form of aortic valve replacement. There is NO medical treatment for this disease. Without surgery three quarters of these patients will die within three years of symptom onset. The first graph shows very eloquently the striking difference in survival between medical and surgical treatment.
Survivability Rates: Medical versus Surgical (Aortic Valve Replacement)
Further, there is some urgency about taking care of it once symptoms ensue, since several reports have been published of sudden death within three months of onset of symptoms. In spite of these very well-established statistical data, severe aortic valve stenosis continues to be a grossly “neglected child” in our medical community. A good example is the all-too-common case of the little old lady who complains of worsening shortness of breath and ankle swelling.
Her doctor prescribes some Lasix (a diuretic) and she gets better. Two months later she shows up in the emergency room with recurrent CHF that resolves with intravenous Lasix. An Echocardiogram is obtained at this time and it shows severe or moderate-to-severe AS (Aortic Valve Area of 1.1 cm2 or less). This elderly patient and her family are reassured that some more Lasix will do the trick and that, after all, we do not want to rock the boat with a “dangerous” open heart operation.
Few more months go by and the family will call the office to let us know that Grandma has passed away and…well… to thank us for the wonderful care we delivered. There is a widespread and WRONG perception that surgery would not be a good option in an elderly and otherwise functional patient.
If we go back to the mortality rates I discussed, medical therapy is, by far, the most dangerous choice. The life expectancy of AS patients after an aortic valve replacement is the same as any cohort of patients without the diagnosis of AS. At one of my seminars, a local internist asked me if I would change my therapeutic indications in an old lady with several comorbidities (diabetes, hypertension, history of TIA’s). My answer was: “Let’s suppose this hypothetical lady with her comorbidities has mildly symptomatic colon CA (constipation) instead of severe AS….Would you be willing to send her home with a few fleet enemas instead of a referral to a general surgeon to undergo a “dangerous” colon resection? I don’t think so!!!”
Symptomatic severe AS, I might add, does kill you much faster than early colon CA. Let’s now consider our surgical options. A well-meaning relative will ask: “Isn’t Grandma too old and frail to withstand open heart surgery?” My answer is: “No. Grandma is too old and frail to withstand severe aortic valve stenosis. Let me show the statistics on this condition!!!”
The way I perform an aortic valve replacement in my service has dramatically changed the impact of this operation on the overall patient’s experience and on the speed of recovery. Most patients will be able to leave the hospital by their third postoperative day. A few pictures will illustrate this technique better than a thousand words. The surgical incision is about 2” in length and is carried out through the third intercostal space (in-between two ribs).
Minimally Invasive Aortic Valve Replacement Incision
There is no bone cutting involved and this is a great advantage for wound healing in patients with advanced osteoporosis. Furthermore, infection of these mini-thoracotomies is exceedingly rare. The entire operation and all the necessary connections to the heart-lung machine are carried out
through this tiny incision.
As you can see in the picture below, the prosthetic valve is ready to be tied in to replace the calcified valve and it is right at the center of my operative field. I routinely use the same incision for Atrial Septal Defect repairs, Mitral and Tricuspid Valve repairs, excision of atrial myxomas and tumors, Ventricular Septal Defect repairs, septal myectomies in IHSS patients.
Prosthetic Aortic Valve Replacement Device
In female patients many of these operations can be performed through an incision hidden in the skin fold underneath the right breast with excellent cosmetic results.
Our patient recovers in the ICU and is extubated within the next 4-6 hours. On post-operative day #1 the drains are removed and most patients are transferred out of the ICU and start ambulation and physical therapy.
I hope these ideas will help colleagues, patients and concerned families achieve a real contemporary perception of what can be done for aortic stenosis patients of all ages. This low-impact, patient-centered approach to aortic stenosis affords excellent outcomes and restores a normal life expectancy and improved quality of life in the vast majority of treated patients.
If you would like to contact Dr. Giovanni Ciuffo, you can email him directly at firstname.lastname@example.org or call his office directly at (212) 659-6800. Also, you can visit Dr. Ciuffo’s surgeon profile at our new Heart Valve Surgeon Database.
Thanks to Dr. Ciuffo for sharing his research with us!!
Keep on tickin!