Advanced and Expensive Cardiovascular Procedures in the Very Elderly–Can We or Should We Limit Access?

With the increasing proportion of elderly patients in the population, physicians are often faced with challenging treatment decisions for the management of coronary artery diseases, valvular heart diseases, advanced heart failure and prevention of sudden cardiac death in the elderly patient population. Comprehensive review of the literature and available evidence is summarized in this chapter to guide such complex clinical decisions. Elderly patients presenting with an acute coronary syndrome (ACS) appear to benefit from percutaneous coronary intervention (PCI) with the use of drug eluting stents (DES). Though current guidelines do not consider age as a prohibitive factor, the risk of major bleeding complications and stroke should be carefully considered. For elderly patients with severe aortic stenosis, trans-catheter aortic valve replacement (TAVR) is superior compared to medical therapy for inoperable patients. TAVR, when performed via the transfemoral approach, remains non inferior and cost effective compared to surgical aortic valve replacement (SAVR). Trans-catheter mitral valve repair (TMVR) using MitraClip appears to be beneficial for inoperable patients with degenerative severe mitral regurgitation but more data are needed. Implantable cardioverter defibrillator (ICD) implantation in the elderly population remains a controversial topic especially for secondary prevention. The current evidence suggests that age should not be the sole withholding factor but the decision for ICD implantation should account for comorbidities and patient preference. On the other hand, cardiac resynchronization therapy (CRT) has definitely a mortality and morbidity benefit in the management of elderly patients with advanced heart failure.