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Bouncing Back At 92

>>Understanding Aortic Valve Stenosis: The aorta is the main artery carrying blood out of the heart. When blood leaves the heart, it flows through the aortic valve into the aorta. In aortic stenosis, the aortic valve becomes stiffened and does not open fully. This decreases blood flow from the heart to the rest of the body. Relatively uncommon, aortic stenosis occurs more often in men than in women.
    People with aortic stenosis may have no symptoms until late in the course of the disease. Symptoms may include:

>> Breathlessness with activity.
>> Chest pain:
     - this may be experienced as crushing, squeezing, pressure or tightness.
     - pain increases with exercise and is relieved by rest.
>> Fainting, weakness or dizziness with activity.
>> Sensation of irregular heartbeat (palpitations).

“I’m not like a 20-year-old, but I like to think of myself as a pretty good 92-year-old,” Amelia Clark says. She’d get no argument there. Clark still lives on her own, in Bedford Hills, drives herself locally to shop, and keeps a fairly active social life. But last summer, all these things became more difficult.

“I wasn’t feeling well,” says Clark, a widow with three children and two grandchildren who retired from the Westchester County district attorney’s office in 1996. “I was always tired and had trouble getting around. I really started to feel my age.” She also had breathing problems so severe that on one occasion she passed out.

About a year earlier, her cardiologist had diagnosed aortic valve stenosis—a stiffening of the valve that controls blood flow from the heart across the aorta, the largest artery in the body. As a result, her heart had difficulty pumping enough blood through the valve. Stenosis is caused by calcium deposits on the valve, which is a common occurrence as a person ages. Since her initial diagnosis, her stenosis had worsened.

Until recently, the only way to replace a faulty valve was through open-heart surgery. At her age, she was too highrisk a candidate for that. Fortunately, though, advances in technology now allow cardiologists and surgeons working together to fix aortic stenosis through a catheter without open-heart surgery, using instead a minimally invasive procedure that replaces the old valve with a new one—a procedure called transcatheter aortic valve replacement, or TA VR.

Clark was referred to cardiothoracic surgeon Gilbert Tang, M.D. She knows the Medical Center well—her daughter, Mickey DeNicola, works in the Pathology Department there. “She’s my health advocate,” Clark says.

“In traditional open-heart surgery, we open the chest, examine the heart, remove the old valve and put in a new valve, sewing it in,” Dr. Tang explains. “We have to stop the heart and put the patient on a heart-lung machine.” The long recovery is simply too taxing for older, frailer patients. “With TAVR we can work on a beating heart and don’t have to open the chest, so recovery is much quicker and easier,” he says.

Clark was “actually on the older side” among TAVR patients, who are generally in their 80s. “But she was adamant about having the procedure,” says the doctor. “She doesn’t want to rely on her daughter for driving and errands.”

Clark confirms this. “I bit the bullet and decided to buy myself some more time, as I put it,” she says, laughing. “I was looking for a better quality of life.”

Her surgery was scheduled for September 2013, but there was one small caveat. Typically, TAVR is started in the femoral artery in the leg, through which the surgeon and cardiologist thread the catheter up to the heart. (This is called transfemoral TAVR ). But her leg arteries were too narrow to accommodate the catheter that delivers the new valve. “Women generally have smaller leg arteries, and some also have some narrowing with age,” Dr. Tang says. The second option was to insert the catheter directly into the chest wall, through the ribs and into the tip of the heart (a procedure called transapical TAVR ). “Using the femoral artery would have been our first choice, but this alternative was still less invasive than open-heart surgery,” the doctor explains.

Under general anesthetic, Dr. Tang slid the pencil-sized catheter into Clark’s beating heart and inserted a new valve right inside the old one. The new valve, made from cow tissue, sits in a metal-alloy frame that presses the old valve out of the way. No stitching is needed. “The old valve anchors it in place and the new valve takes over,” Dr. Tang says. The actual procedure takes about an hour; the time for prep, anesthesia and recovery is roughly three to four hours from start to finish. Clark was in the hospital for about a week, which is typical, he says. (On average, recovery from transfemoral TAVR is a few days quicker.)

Surgery was followed by physical therapy in the hospital and after discharge to help Clark regain strength and independence. “So far, I’m doing very well,” she says. She is on medications to control her blood pressure and heart rhythm. Dr. Tang reports no concerns at her one-month and six-month follow-up visits, and he will see her again in September. “Since the procedure, she seems very happy,” he reports. “She has a better appetite and more energy.”

Clark’s vision is limited by macular degeneration, but she loves to read, so she now enjoys large-print editions. “I know my limitations,” she says. “I pace myself. It’s been about seven months now since the operation, and I feel it’s done me a lot of good. I am grateful there’s a procedure like this that can help us old-timers.” —D.L.

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