With age, fibrotic thickening and increased opacity occur in the mitral and aortic valves. The aorta becomes stiffer (increasing systolic blood pressure and stress on the mitral valve), and afterload on the left ventricle increases (increasing myocardial oxygen demand and thus the requirement for myocardial blood flow). These age-related effects influence the development of symptoms and complications in elderly patients with valvular heart disease.
In elderly patients, the predominant causes of valvular heart disease are degenerative calcification, myxomatous degeneration, papillary muscle dysfunction, and infective endocarditis; valvular damage from rheumatic and syphilitic diseases is uncommon. Most often, valvular heart disease is suspected when murmurs are detected during the physical examination. Noninvasive imaging techniques help identify the etiology, establish the diagnosis, and assess disease severity.
Medical management is appropriate for many elderly patients; surgery is indicated when symptoms interfere with daily activities or when hemodynamically significant valvular heart disease cannot be controlled medically. Although age per se is not a contraindication to surgery, comorbid disorders and the overall clinical condition may make surgery inappropriate. Generally, for patients > 75 years, the goal of surgery is to improve the quality of life rather than to prolong life.
Antibiotic prophylaxis for infective endocarditis is recommended before dental, gastrointestinal, gynecologic, and genitourinary procedures. (see Table 90-1)