I recently encountered a previously functional and independent 80-year-old woman who slipped and broke her hip. Surgery was required to repair the injury and was her only hope of returning to her premorbid state. She lived alone and was still able to shop, clean, and cook for herself, despite being on several medications for congestive heart failure. She had a long-standing history of aortic stenosis, and reported having been told more than 10 years ago that it was inoperable. An echocardiogram revealed a current aortic valve surface area of 0.4 cm2, placing her in the significant risk category and giving her a 40% risk of developing further complications within the next year. We had no way of knowing at that time if her congestive heart failure was due solely to her significant aortic stenosis or if other cardiac pathology was affecting her cardiac function.
The cardiology consultant doing a preoperative assessment stated that she was a “high-risk candidate for an intermediate-risk surgery.” It was mentioned that her aortic stenosis was deemed inoperable based on her history of it being considered as such, and no further assessment was undertaken. Although the patient initially expressed interest in having everything done to repair her hip, as her hope was that this would enable her to return to her baseline status, she quickly developed a delirium and lost her capacity to make an informed decision. At a family meeting, it was decided that surgery would not be performed and that she would be given “comfort measures” only.
Clearly, the patient’s aortic valve pathology and her congestive heart failure were influencing this decision. I knew that no one had discussed the relatively new method of transcatheter aortic-valve implantation with her or even thought about it as an option to improve her chances of surviving the hip surgery. The label of inoperable had followed her as a final decree for the past 10 years, despite the availability of a new technology that permits aortic valve repair in patients who were previously deemed to be poor candidates for open-heart surgery. Clearly, this new technology is not for everyone and it has its own set of complications to consider, but it must first be identified as an option if there is to be any hope of an altered outcome.
No choice is without risk for the high-risk surgical patient with significant aortic stenosis.