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Question:
What alternatives are available for my grandmother who has recurrent aortic valve stenosis, and now lung cancer?
My grandmother is 75 yrs old. She had her aortic valve replaced 9 years ago with a pig valve. Last month we were told that the valve is heavily calcified (severe aortic stenosis) and needs to be replaced, and as a result she has congestive heart failure. They say she is too weak to survive surgery and that if she survives, will be on a ventilator for the rest of her life. She also was diagnosed at the same time with lung cancer and is being treated with hormone therapy to put it into remission. We are currently looking into the PARTNER clinical trials for transcatheter aortic valve replacement but it does not look like she will be eligible for that because one of the criteria is that you cannot have previously had your valve replaced and you have to have a life expectancy of over a year, and her cardiologist gave us an estimate survival time of 2 to 12 months. She is currently on oxygen 24 hours a day at a rate of approx. 4 1/2. Can you let me know if there are any alternatives or procedures that can help her?
submitted by Jason from Pennsylvania, on 11/17/09
Answer:
by Texas Heart Institute cardiologist, Christopher M. Frank, MD
As you're probably aware, there are few if any medical therapies that are helpful to patients with severe aortic stenosis, and in general it has to be managed surgically if anything can be done. The first step in a situation like this is to request a second surgical opinion about the risks of a repeat aortic valve surgery, since it's possible that a surgeon and hospital that are very experienced with high risk valve surgeries might feel that the procedure can be accomplished with an acceptable risk. For example, in some cases, we've successfully replaced aortic valves in patients at extremely high risk with the help of temporary mechanical cardiac support from a percutaneously placed ventricular assist device. It's also important to point out that the prognosis for the lung cancer will be extremely important in this decision; no one wants to recommend a high risk cardiac surgery in a patient who has a very poor short-term prognosis because of cancer. If she is truly too high risk for surgical replacement or has a very limited prognosis from a cancer standpoint, another possibility would be aortic balloon valvuloplasty (i.e., without one of the experimental percutaneously placed valves). This procedure is rarely indicated, because it has high procedural risks of stroke or death and because even when successful, its effects only persist for a few months; with that said, there are occasional patients in whom it's reasonable as a palliative procedure. Because it's such a rarely performed procedure, there are only a few places in the United States that have the requisite experience to perform it.
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Updated November 2009
