[Valve diseases in the aged: when to operate?]

Valvular lesions, especially aortic stenosis, are not uncommon among the elderly, a sector of the population that is increasing in relative (extreme decrease in birth rates) and absolute terms (reduction of morbidity/mortality due to health and social advances), and their treatment presents a major challenge to the health system. Advanced age constitutes a surgical risk, but this is more likely due to a greater prevalence of comorbid conditions than to an intrinsic effect of old age. Moreover, the morbid effects of age are extremely variable, and an individualized evaluation of the problem is required. The decision to surgically intervene in an elderly patient must take into account of three aspects: a) that the valvular lesion has important hemodynamic consequences; b) that the symptoms are a product of the lesion and not of a concomitant disease, and c) that there is no comorbid condition whose symptoms and prognosis are even worse than the valvular disease itself. The psychological attitude of patients and their family members is also a factor to be considered. In severe aortic stenosis, valve substitution normally has a highly effective palliative effect, although at the cost of a moderately increased surgical risk. In mitral stenosis, preference should be given when possible to valvuloplasty with a balloon catheter. In degenerative mitral regurgitation, reconstructive techniques and prosthetic substitution with chordal preservation have considerably improved surgical outcomes, so that surgery is now indicated earlier to avoid the development of irrecoverable ventricular dysfunction. In mitral regurgitation of ischemic origin, structural damage (rupture of papillary muscle) must be differentiated from functional damage (dysfunction of papillary muscle); in the former, surgery is normally mandatory with a favorable outcome; in the latter the issue is more complex, and the possibility of improving the regurgitation by angioplasty of the culprit vessel must be thoroughly explored. The valvular sequelae of infectious endocarditis, a disease with higher incidence in old age, receive the same treatment at younger ages. Finally, in autochthonous tricuspid regurgitation, which can appear years after successful left side heart surgery, the decision to intervene is more difficult; in most cases it may be an expression of right ventricular dysfunction and a conservative approach would be indicated.