Fixing a faulty aortic valve

The one-way valve inside your aorta opens and shuts with every heartbeat, controlling the flow of blood to your body. But with age, the leaflets of this hard-working valve may stiffen and become clogged with calcium deposits, a condition known as aortic stenosis. It affects about one in 20 people by age 65 and becomes more common with advancing age.

Unfortunately, no medications can prevent or treat this problem. The good news: people with serious cases (see "Aortic stenosis symptoms") can get a new valve to replace the damaged one. A nonsurgical approach for placing a new valve has become very popular in recent years, but it doesn't make sense for everyone.

"Historically, surgery was the only option for replacing an aortic valve. But many older people weren't good candidates for this major open-heart surgery because they had too many other medical problems," says Dr. Pinak B. Shah, director of the cardiac catheterization laboratory at Harvard-affiliated Brigham and Women's Hospital. About 20 years ago, doctors first tested a procedure to replace a damaged aortic valve through a catheter threaded through a leg artery up to the heart.

Called transcatheter aortic valve replacement (TAVR), the procedure was first used only in high-risk older people. But since its approval in 2011, the use of TAVR has expanded dramatically, including in people younger than 65 and those at low risk for surgery, says Dr. Shah. Understandably, people prefer TAVR because it doesn't require general anesthesia and has an easier, shorter recovery compared to surgery. But for people in their 60s, the situation is a little more complicated.

Different valves and techniques

There are two types of replacement valves: mechanical valves (made from sturdy metals such as titanium and carbon) and tissue valves (taken from pig or cow hearts). Expert guidelines recommend that people younger than 50 get a mechanical valve because these durable valves — which must be surgically placed — usually last for the rest of the person's life. Because blood clots can form on mechanical valves, however, recipients must take the clot-preventing drug warfarin for the rest of their lives.

With a tissue valve, anti-clotting drugs aren't necessary, and it can be placed through either surgery or TAVR. But the leaflets of a tissue valve don't last forever, says Dr. Shah. "We hope the new valve will last 10 years. And while some last as long as 15 years, others may fail within seven to eight years," he says. That means some people may need a second valve replacement later in life.

Why age matters

Currently, the average life expectancy in the United States is about 78 years, which means the typical person in their 70s or 80s who gets a TAVR is unlikely to need a second valve replacement. But people in their 60s are likely to need another new valve — and a TAVR may not be the best choice the first time around. For one thing, diagnosing and treating coronary artery disease — the most common form of heart disease — may be more challenging in people who've had TAVR. For another, the surgery to replace a failed TAVR valve is more complicated and riskier than regular valve replacement surgery, explains Dr. Shah. If you're going to need at least one traditional valve surgery, you're better off having it in your 60s rather than your 70s, he says. Then, you can get a TAVR the second time around.

If you're facing aortic valve replacement, it's important to be evaluated by a team of experts that includes an interventional cardiologist who does TAVR as well as a cardiac surgeon, says Dr. Shah. They should review your situation carefully to help you select the best option.

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