Older Patients, Wiser Care

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

Manometer, stethoscope
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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.