Mixed aortic stenosis and regurgitation: a clinical conundrum

Abstract

Mixed aortic stenosis (AS) and aortic regurgitation (AR) is the most frequent concomitant valve disease worldwide and represents a heterogeneous population ranging from mild AS with severe AR to mild AR with severe AS. About 6.8% of patients with at least moderate AS will also have moderate or greater AR, and 17.9% of patients with at least moderate AR will suffer from moderate or greater AS. Interest in mixed AS/AR has increased, with studies demonstrating that patients with moderate mixed AS/AR have similar outcomes to those with isolated severe AS. The diagnosis and quantification of mixed AS/AR severity are predominantly echocardiography-based, but the combined lesions lead to significant limitations in the assessment. Aortic valve peak velocity is the best parameter to evaluate the combined haemodynamic impact of both lesions, with a peak velocity greater than 4.0 m/s suggesting severe mixed AS/AR. Moreover, symptoms, increased left ventricular wall thickness and filling pressures, and abnormal left ventricular global longitudinal strain likely identify high-risk patients who may benefit from closer follow-up. Although guidelines recommend interventions based on the predominant lesion, some patients could potentially benefit from earlier intervention. Once a patient is deemed to require intervention, for patients receiving transcatheter valves, the presence of mixed AS/AR could confer benefit to those at high risk of paravalvular leak. Overall, the current approach of managing patients based on the dominant lesion might be too reductionist and a more holistic approach including biomarkers and multimodality imaging cardiac remodelling and inflammation data might be more appropriate.

Left ventricular reverse remodeling after transcatheter aortic valve replacement for predominant aortic stenosis and mixed aortic valve disease

“…In current guidelines and clinical practice, interventions for such patients are generally based on the predominant lesions 4,5 . Some scholars have suggested that the current approach to managing patients based on their primary lesions may be too crude, because this approach may underestimate the true hemodynamic impact of combined lesions, 6 as the coexistence of pressure and volume overload can lead to unique cardiac pathological changes 7,8 . And the results between the limited previous studies about the severe AS patients with more than moderate AR are contradictory 9,10 .…”

“…And the results between the limited previous studies about the severe AS patients with more than moderate AR are contradictory 9,10 . Therefore, a new perspective is needed to assess the value of TAVR for this cohort of patients 8 . As we all know, the recovery of left ventricular morphology and cardiac function in patients after TAVR is decisive for long‐term prognosis 11 .…”

“…underestimate the true hemodynamic impact of combined lesions, 6 as the coexistence of pressure and volume overload can lead to unique cardiac pathological changes. 7,8 And the results between the limited previous studies about the severe AS patients with more than moderate AR are contradictory. 9,10 Therefore, a new perspective is needed to assess the value of TAVR for this cohort of patients.…”

“…9,10 Therefore, a new perspective is needed to assess the value of TAVR for this cohort of patients. 8 As we all know, the recovery of left ventricular morphology and cardiac function in patients after TAVR is decisive for long-term prognosis. 11 Therefore, this study evaluates left ventricular reverse remodeling (LVRR) in sever AS patients mixed with AR and compared it to patients with isolated severe aortic stenosis (AS).…”

Heartbeat: not all patients with primary mitral regurgitation are the same

“…Another clinical conundrum in management of adults with AS is the problem of combined stenosis and regurgitation of the aortic valve. Nedadur and colleagues8 provide a detailed review of the epidemiology, physiology and clinical outcomes for mixed AS and aortic regurgitation including an overview of the diagnostic approach and summary of current guidelines for timing and choice of intervention.…”