Why We Can't Predict the Final Stage of Heart Valve Problems

Last updated: July 19, 2010
Manometer, stethoscope

Dear Dr. Kernisan:

My dad was just discharged from Rehab after being told there was nothing more they can do for him. One of the valves in the heart is closing up. It was diagnosed a year ago. He's now home under hospice care. How long does it take for a valve to close and what will happen during this process? What will it be like for him?

Sounds like your father has been diagnosed with severe aortic stenosis, a problem in which the valve between the heart and the aorta (the big vessel that brings all the blood out to the body), slowly becomes less and less able to open. Although this can be fixed surgically, an operation may not be an option for those who are very old or otherwise too chronically weak to recover well.

It's impossible to know how quickly your father's valve will decline. Since he's on hospice, his doctors probably expect he's unlikely to live more than six months.

He might very well live longer, however. Take Mrs. D, an elderly woman who was just sent home from our inpatient hospice service -- because she's been doing so well -- after being admitted for bad aortic stenosis six months earlier. She, too, had been told that her aortic stenosis was "terminal" and "end-stage." In the six weeks before she'd been referred to hospice, she'd been hospitalized three times for passing out, and for other complications.

So how could she do so well once in hospice? Well, very bad aortic stenosis usually causes symptoms of congestive heart failure (CHF), since the heart ends up being very strained by the work of pushing blood out through a valve that's getting smaller and smaller. These symptoms include leg swelling, breathlessness, cough, fatigue (especially with exertion), depression, and chest pain. The person may also often have very low blood pressure, which can cause weakness and dizziness, especially when standing. With the heart under such strain, sudden out-of-the-blue cardiac arrests aren't uncommon. (Although the aortic valve can get quite constricted, death generally happens before it closes completely.)

These symptoms sometimes improve, though, if the doctors are able to work out the right combination of diuretics and other medications to improve heart function. In Mrs. D's case, upon admission to hospice we discovered that she had some mild dementia. So she probably hadn't been taking her medicines quite right when she was at home. Once the inpatient hospice nurses started giving her medications every day, she improved.

Still, even with thoughtful attention to medications, many people with severe aortic stenosis eventually find themselves fairly incapacitated by breathlessness and other symptoms of severe CHF. In this case, hospice providers usually try low doses of opiate, and perhaps medications for anxiety. Some people live for weeks or even months in this state. Others may develop pneumonia, or another complication that tips them over the edge.

Unfortunately, it's not possible to forecast just what your father's process will be like. Hopefully his hospice providers will be able to find the right medication combination to keep him comfortable. And perhaps, like Mrs. D, he may even find himself feeling improved and able to more fully enjoy his time left on earth with you.

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10 Comments So Far. Add Your Wisdom.

about 1 month ago

My motherin law is 86 and was diagnosed in jan and has been declining ever since. i enjoy spending time with her and making her as comfortable as possible. she also is on hospice.. some days are better then others..the past few days she been having diarehea and continues to get cold and clammy..thanks for letting me vent..

about 1 year ago

mom is 98, lives alone in her apt. and has severe aortic stenosis. She can't breathe well and was taken to the hospital for oxygen and for falling in the house,she did not break anything. She's back at home. She coughs and still has shortness of breath. She's totally incontinent and cannot sleep because she urinates all night. She refuses help. She's feisty and still in control. I am the only care giver. Help! Do I just wait and watch her decline?

Anonymous said almost 2 years ago

My Mother just passed away 3 weeks ago from Aortic Valve stenosis. She was 91 and had fallen a few months ago in her assisted living. She fractured ribs, ended up with pneumonia twice. The antibiotics they gave her for the pneumonia got rid of her infection, but they caused her kidneys to fail. in the period of 2 months she was in the hospital 5 times, and her heart got weaker and weaker. I had to make the decision to call hospice, and this was gut-wrenching for me as I knew that her lungs were filling with fluid. Even though she didn't want to be prolonged (she had been thru enough), when the time came she asked me what was happening. I still feel I did not do enough, but yet I did everything. I pray for everyone who has to go thru this with their loved one. Its not easy for the patient, or the caregiver.

Anonymous said about 2 years ago

My mother was diagnosed with aortic valvular stenosis approximately three years ago. Sixteen months ago, her heart stopped. We brought her home and she's been there in hospice care ever since. But now she's having night angina and we've been advised to skip the nitro tabs and go right for the roxanol. .... Her physician and nurse "have no idea how she's still with us." ...... Despite the caregivers, oxygen, medications... no one can predict the end. We're not in control. We never were. ... Tell the one's you care about that you love them. Hold their hand. Smile for them. Passing, for some, is not quick, easy or comfortable. And from what I see, it takes a lot of courage.

Anonymous said about 2 years ago

My mother was diagnosed with aortic valve stenosis approximately three years ago. Her heart failed 16 months ago and she's been at home in hospice care. Now, night angina hits about every other night and instead of nitro tabs, she's straight on to roxanol. Pain management. ... No one can predict anything. Despite the caregivers, oxygen, medications... none of us are in control of this life. But I've a feeling her time is near. ... Don't waste time. Tell those who are end-stage anything that you love them. Smile for them. it could be tomorrow. It could be... whenever.

almost 3 years ago

thank you this is exactly the symptoms that my mother is experiencing very helpful

almost 4 years ago

Everything about the article was helpful. Thank you

over 4 years ago

Sorry ... rather than dietetic ... i meant diuretic ...

over 4 years ago

Oh, thank you so much! My Mother was just released from the hospital, today, after saying she was not able to breathe. This is the second time in a week. The doctor had seen her legs swollen and a spot on her lung but did not do anything. This time it turns out she had liquid in her lungs and, of course, the swollen legs were caused by this as well. Again, with a dietetic they were able to stop the swelling. She was diagnosed, first, 12 to 15 years ago with the stenosis .. the latest she was told the mean gradient was 100%. She was sent home with some oxygen. Her mind is extremely sharp so it was she who knew there was the problem and she explained it to them ... she'll be 98 years old this year. We are so concerned about her comfort ... she's dearly loved. These were interesting posts ... again, thank you!

over 4 years ago

Very Informative. Thank You.

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