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Questions About A Popular Heart Procedure

Thu, 03/13/2014 - 9:57am
Paula Span

Our great-great-grandparents probably didn’t have to think much about the way the heart’s aortic valve slowly stiffens and narrows over decades, a condition called aortic stenosis. Most of them died before they could experience its distressing symptoms — shortness of breath, chest pain, fatigue, fainting.

Now, an estimated quarter of a million older adults get that diagnosis annually. When the stenosis becomes severe, they have to grapple with their medical options, a decision becoming steadily more complicated.

“There’s no real medical therapy for this” – no drug, that is – “because it’s a mechanical problem,” said Dr. Harlan Krumholz, a professor of medicine at Yale University. For decades, the standard treatment has been aortic valve replacement surgery: opening the chest and stopping the heart to replace the malfunctioning valve.

“That used to be the only treatment that improved symptoms and survival,” said Dr. Dae Hyun Kim, a gerontologist at Beth Israel Deaconess Medical Center in Boston. Once older people develop symptoms, about half die within two years. Surgery drastically reduces that risk.

Still, it is such a big operation that about a third of elderly patients either decide to avoid it or are warned they won’t survive it. Dr. Krumholz, senior author of a recent article in The Journal of the American Medical Association looking at the surgery’s growing use and declining mortality risk, calls it “a technique that’s been around for decades, that’s getting better, but that is traumatic.”

Enter a newcomer, transcatheter aortic valve replacement. T.A.V.R., as it is known, involves a catheter, usually inserted through the groin, that delivers a new valve without a big incision and sometimes without general anesthesia. The Food and Drug Administration approved it in 2011 for patients whose aortic stenosis is considered inoperable, then in 2012 for the larger group of patients deemed “high risk” (an expansion skeptics call “indication creep”).

It sounded like a big step forward. “Here was this new, sexy-sounding procedure that had a huge amount of press,” said Dr. Torrey Simons, a palliative care specialist at Stanford University who has been analyzing the operation’s cost-effectiveness.

If you watch television in New York, you might have seen ads for NewYork-Presbyterian Hospital in which lively older women testified to their happy experiences with T.A.V.R. “No stitches, no pain and in three days, I was home,” an 83-year-old announces. “Unbelievable.”

She was particularly lucky, perhaps. Appearing in the same issue of JAMA with Dr. Krumholz’s article was a review of the first 7,710 procedures reported to a national T.A.V.R. registry. The study reported that the median hospital stay was six days, two of them in intensive care.

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