Heart Valve Diseases in Older Adults

Advanced interventional cardiology strategies and transcatheter treatment protocols for heart valve diseases in older adults refer to the process of repairing or replacing calcified, narrowed, or dysfunctional heart valves that develop with advancing age by reaching the heart through catheters inserted via the femoral artery, without the need for open-heart surgery. These non-surgical heart valve treatments, which do not require opening the chest, stopping the heart, or, in most cases, general anesthesia, represent a prominent minimally invasive medical technology for physically frail individuals. In patients with a high surgical risk due to age-related comorbidities, these modern intravascular systems aim to support the heart’s pumping function and improve daily quality of life within a much shorter period.

Why Do Heart Valve Diseases Develop with Advancing Age and What Changes Occur in Our Heart?

Our heart is a tireless organ that contracts an average of one hundred thousand times a day and millions of times each year, pumping oxygen-rich blood to every part of the body throughout life. The structures that ensure blood flows in the correct direction during this pumping process and prevent it from flowing backward are the heart valves. These valves can be compared to one-way doors between the rooms of a house. In the past, infections such as rheumatic fever, especially during childhood, damaged these “doors” and caused disease. Today, however, with increasing life expectancy, a very different picture has emerged. Years of continuous mechanical movement create significant physical stress on these valves.

Over time, calcium minerals naturally present in the blood begin to deposit on these worn valve tissues, just as limescale accumulates inside water pipes. This process is called calcification. A valve covered with calcium gradually loses its flexibility, much like a door with rusted hinges. When the valve cannot open sufficiently, it becomes difficult for blood to move forward, a condition known as stenosis. On the other hand, when the valve cannot close completely, blood leaks backward, which is called regurgitation or insufficiency. In both situations, the heart must work much harder than normal. If left untreated, the heart muscle, constantly working under excessive strain, gradually becomes fatigued and weak. This process usually progresses slowly and silently, but after a certain point, it may significantly limit daily life.

What Are the Symptoms of Aortic Stenosis Commonly Seen in Older Adults?

The left ventricle is the strongest chamber of the heart and is responsible for pumping oxygen-rich blood throughout the body. Blood leaving this chamber passes into the main artery known as the aorta. In older adults, the most common problem is narrowing of the aortic valve at this junction due to calcification. In this condition, known as degenerative aortic stenosis, the left ventricle must generate extremely high pressure to force blood through the narrowed opening. Initially, the heart muscle thickens to adapt to this increased workload. However, the thickened muscle also requires more oxygen, and after a while, it becomes increasingly difficult for the heart to nourish itself.

Once the disease reaches a certain severity, the body begins to send warning signals. These symptoms usually become more noticeable during physical exertion, such as climbing stairs, walking uphill, or carrying heavy objects. Realizing that routine daily activities have become more difficult than before is a sign that the heart can no longer cope with the increased workload. The main signs indicating progression of aortic stenosis include:

• Chest pain
• Shortness of breath
• Fatigue
• Palpitations
• Dizziness
• Fainting episodes

How Is the Aortic Valve Replaced with the TAVI Method in Patients at High Surgical Risk?

In the past, treatment for severe aortic valve narrowing required major surgery involving opening the breastbone, stopping the heart, and connecting the patient to a heart-lung machine. However, such extensive surgery is extremely difficult for elderly individuals or those with kidney failure or reduced lung capacity. At this point, Transcatheter Aortic Valve Implantation (TAVI), introduced into modern medicine, has become an important alternative. TAVI is the process of implanting a new heart valve without the need to open the chest, stop the heart, or, in most cases, place the patient under general anesthesia.

The procedure usually begins with a very small puncture in the femoral artery in the groin. A long, thin catheter carrying a folded biological heart valve at its tip is gently advanced through the blood vessel into the heart. Using advanced imaging systems similar to X-ray guidance, the tip of the catheter is positioned precisely within the diseased calcified valve. The new valve is then expanded either with a balloon or by its own self-expanding mechanism. Once expanded, the new valve pushes the diseased native valve against the vessel wall and immediately begins restoring normal blood flow. Because the breastbone is not opened, recovery is much faster than after conventional surgery, and tissue trauma is kept to a minimum.

Which Conditions Are Suitable for the TAVI Procedure and How Is the Treatment Decision Made?

The decision to perform TAVI is not made by a single physician but by a multidisciplinary team of specialists from various fields. This team, commonly referred to as the “Heart Team,” consists of cardiologists, cardiovascular surgeons, and anesthesiologists. The goal is to carefully analyze the patient’s anatomy, medical history, and overall physical condition to determine the treatment that provides the greatest benefit with the least risk. During this evaluation, internationally recognized surgical risk assessment systems are also taken into consideration.

If the patient is considered unlikely to tolerate open-heart surgery successfully, TAVI may be selected as the safer treatment option. Thanks to advances in technology and valve systems, TAVI is now considered a safe treatment not only for very high-risk patients but also for elderly patients with intermediate or even low surgical risk. During the decision-making process, the patient’s anatomical characteristics are evaluated in detail, and an individualized treatment strategy is developed. Situations supporting a TAVI decision include:

• Advanced age
• Previous chest radiotherapy
• Porcelain aorta
• Severe respiratory failure
• Low surgical tolerance

What Should Patients Expect Before and After the TAVI Procedure?

Preparation for TAVI involves an extremely meticulous planning process. Before the intervention, patients undergo multidetector computed tomography scanning. This imaging accurately measures the diameter of the aorta, the extent of calcification, and the width of the blood vessels extending from the groin to the heart. This allows the most appropriate valve size to be selected according to the patient’s anatomy before the procedure. On the day of treatment, the patient is taken to a specially equipped catheterization laboratory. Usually, only the groin area is numbed, and mild sedatives are administered to help the patient relax. As a result, patients do not experience pain during the procedure but often remain aware of their surroundings.

After the procedure is completed, patients are monitored for a period of time. They can usually eat within a few hours and sit up in bed. Short walks are encouraged the following day, and if no complications occur, discharge is generally planned within a few days. After leaving the hospital, several important recommendations should be followed. In particular, regular use of prescribed blood-thinning medications is essential to reduce the risk of clot formation on the newly implanted valve. Recovery is generally comfortable, and patients often report regaining their previous energy levels within a short time.

How Does Mitral Valve Regurgitation Strain the Heart and Affect Quality of Life?

On the left side of the heart lies the mitral valve, which controls the flow of oxygen-rich blood from one chamber to another. This two-leaflet valve should close tightly when the heart contracts to prevent blood from flowing backward. However, with advancing age, prolapse of the valve leaflets or enlargement of the heart may occur. In this situation, the valve no longer closes completely, and blood begins leaking backward instead of moving forward. This condition, known as mitral regurgitation, gradually disrupts the normal functioning of the heart.

The backward leakage of blood accumulates in the left atrium and subsequently increases pressure within the lungs. When fluid builds up in the pulmonary circulation, patients experience difficulty breathing, especially during physical activity or while lying flat. Waking up at night because of shortness of breath and needing to sleep with multiple pillows are among the best-known consequences of this condition. Persistent fatigue, difficulty climbing stairs, and swelling of the legs gradually distance patients from social life and significantly reduce their quality of life.

How Is the Mitral Valve Repaired with the MitraClip Method in Patients at High Surgical Risk?

Surgical repair or replacement of the mitral valve is not always an appropriate option for elderly patients. In such cases, the MitraClip clipping technique offers a promising catheter-based treatment alternative. During this procedure, access to the heart is obtained through the veins in the groin rather than the arteries. After entering the right side of the heart with an extremely thin catheter system, the interatrial septum is crossed to reach the left side and the diseased mitral valve. Throughout the procedure, a specialized ultrasound probe inserted through the esophagus provides the treatment team with a highly detailed three-dimensional view of the valve.

A small clip-like device located at the tip of the catheter grasps the separated valve leaflets. Once the leaflets are positioned correctly, the clip is closed, securing them together in the middle. As a result, the valve assumes a double-orifice configuration resembling the number eight, significantly reducing backward blood leakage through the prolapsing segments. One of the greatest advantages of this method is that the patient’s own valve anatomy is repaired without implanting an artificial frame or replacement valve. Patients generally experience a significant improvement in their exercise capacity after the procedure.

How Is Balloon Treatment (PMBV) Performed for Rheumatic Mitral Valve Stenosis?

Mitral valve problems in older adults do not always involve valve prolapse or looseness; in some cases, the valve leaflets adhere to one another, causing severe narrowing. This condition most commonly develops in individuals with a history of rheumatic fever, where progressive thickening and calcification occur over many years. When the valve cannot open adequately, blood flow from the lungs into the heart is restricted. This can result in severe shortness of breath, elevated pressure within the lungs, and in some cases even coughing up blood.

In patients whose valve structure is not excessively calcified, balloon valvuloplasty, known as Percutaneous Mitral Balloon Valvuloplasty (PMBV), aims to provide highly satisfactory results without the need for surgery. A balloon catheter is advanced through the groin vessels and positioned in the center of the narrowed mitral valve. When the balloon is inflated within seconds using a special fluid, the mechanical force separates the fused valve leaflets. As the valve opening widens, blood flow immediately improves, and patients may notice easier breathing even while still on the procedure table. In appropriately selected patients, this method can provide many years of symptomatic relief.

How Is Edema Caused by Tricuspid Valve Regurgitation Treated with the TriClip Method?

The tricuspid valve, located on the right side of the heart, is one of the main gateways through which deoxygenated blood passes before reaching the lungs. As diseases affecting the left side of the heart progress, intracardiac pressure increases, causing the right side of the heart to enlarge as well. This enlargement separates the three leaflets of the tricuspid valve, resulting in significant blood leakage. Rather than affecting the lungs, tricuspid regurgitation causes congestion in the body’s systemic circulation. Consequently, patients may develop liver enlargement, fluid accumulation within the abdomen, and severe swelling of the ankles.

Because open surgery performed solely for the tricuspid valve is particularly challenging, medicine has sought less invasive treatment options. The TriClip system operates on the same clipping principle as MitraClip but incorporates specially designed clips adapted to the much more complex three-leaflet anatomy of the tricuspid valve. One of the greatest advantages of this system is that it allows the treatment team to grasp each valve leaflet independently. Once the leaflets are brought together and clipped appropriately, backward pressure into the body is reduced. This contributes to decreasing leg swelling, reducing the need for diuretic medications, and improving patients’ daily mobility.

How Can Paravalvular Leaks Around Previously Implanted Artificial Valves Be Closed Without Surgery?

Many elderly patients underwent implantation of mechanical or biological prosthetic heart valves through open-heart surgery years ago. Over time, however, loosening of the sutures, tissue wear, or localized tissue deterioration may develop around the areas where the prosthetic valve is attached to the heart. As a result, small gaps form between the rigid frame of the prosthetic valve and the surrounding heart tissue, allowing blood to leak rapidly through these unwanted openings. This condition is known as a paravalvular leak and can become a significant clinical problem.

The high-pressure passage of blood through these narrow gaps can physically damage red blood cells, resulting in severe anemia. In addition, because blood continuously leaks backward, the heart is forced to work harder. When repeat open-heart surgery carries excessive risk, these leaks may be closed using interventional cardiology techniques. Advanced imaging systems precisely identify the location of the defect. Miniature occluder devices delivered through the blood vessels are positioned within the leak, where they expand like an umbrella and seal the opening. Problems that may result from paravalvular leaks include:

• Destruction of blood cells
• Recurrent anemia
• Need for blood transfusions
• Symptoms of heart failure
• Reduced exercise capacity in daily life

Why Are Frailty and Nutritional Status Important When Making Decisions in Elderly Patients?

Although interventional cardiology offers minimally invasive treatment options, planning therapy for elderly individuals requires focusing not only on the diseased organ but also on the body as a whole. This concept, known medically as geriatric reserve, reflects how well the body can tolerate a stressful intervention. Two of the most important factors considered during this process are frailty and nutritional status. Frailty does not simply mean physical weakness; it also encompasses the individual’s independence in daily life, memory, mental vitality, and ability to perform personal activities.

If a patient is extremely frail, completely bedridden, and severely malnourished, even a technically successful valve repair may fail to produce meaningful improvement in overall quality of life. On the contrary, wound healing after the procedure may be delayed, and physical resilience may decline even further. Therefore, before intervention, the patient’s overall condition, muscle mass, and nutritional reserves are carefully assessed. If necessary, supportive nutritional programs are initiated before the procedure to strengthen the body. Some geriatric assessment factors reviewed by the Heart Team include:

• Ability to perform daily activities independently
• Cognitive and mental status
• Nutritional adequacy
• Muscle mass and strength
• Psychological and social support network

What Should Be Done to Prevent Infective Endocarditis After Heart Valve Procedures?

Whether performed surgically or through catheter-based techniques, individuals who have undergone heart valve replacement or valve repair must pay lifelong attention to one extremely important issue. Any bacteria entering the bloodstream have a tendency to adhere directly to the repaired area or prosthetic material within the heart and multiply there. Infective endocarditis, which refers to inflammation of the heart lining and valves, is a serious disease requiring prolonged intravenous antibiotic treatment and causing profound systemic illness. Such infections are particularly difficult for elderly patients to tolerate.

One of the most common routes through which bacteria enter the bloodstream is the mouth and teeth. Therefore, patients with heart valve disease are expected to pay much greater attention to oral hygiene than the average person. In addition, appropriate preventive measures should always be taken before any dental or surgical procedure associated with bleeding. Recommended measures to reduce the risk of infective endocarditis include:

• Regular and thorough tooth brushing
• Routine dental check-ups
• Preventive antibiotic use before tooth extraction
• Informing physicians before endoscopic procedures
• Seeking immediate medical attention for unexplained persistent fever

Frequently Asked Questions

Prof. Dr. Kadriye Kılıçkesmez

Prof. Dr. Kadriye Orta Kılıçkesmez is one of the leading figures in the field of Turkish cardiology. She was born on January 24, 1974, in Tekirdağ. After completing her undergraduate education at Istanbul University Cerrahpaşa Faculty of Medicine, she chose cardiology as her specialty and received her specialist training at the Cardiology Institute of the same university. In 2015, she was appointed by the university to establish the Şişli Etfal cardiology clinic and Angio laboratory. Becoming a professor in 2017, Kadriye Kılıçkesmez established the cardiology clinic and Angio laboratory of Prof. Dr. Cemil Taşçı Hospital in 2020 and ensured that the clinic became a training clinic.