A new perspective on mixed moderate aortic valve disease

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Abstract Background Mixed aortic valve disease (MAVD) is common in patients with aortic valve disease. Some studies suggest that outcomes of mixed moderate aortic stenosis and regurgitation (ASR) are similar to severe aortic stenosis (AS). However, there is limited data on moderate ASR in the Asian population. This study aims to analyze the characteristics and outcomes of MAVD at our center and compare them with isolated moderate AS and severe AS to determine the prognosis of MAVD. Methods This retrospective study collected MAVD patients from a single tertiary center from January 2000 to January 2023 (n=1452). Patients with severe aortic valve stenosis and/or regurgitation, left ventricular ejection fraction (LVEF) ≤40%, other significant valve disease, previous valve surgery, and age <18 years were excluded. Eventually, we identified 55 patients with moderate ASR (mean aortic peak velocity 3.7 ± 0.6 m/s, mean pressure gradient 31.0 ± 11.0 mmHg, aortic valve area 1.3 ± 0.2 cm², AR vena contracta width 0.4 ± 0.1 cm). We compared them with the isolated moderate AS group (n=648) and severe AS group (n=749). We analyzed the outcomes of AVR and mortality across the three groups. In a sub-analysis, AVR rates were compared between the moderate ASR and moderate AS groups. Results Mean age was the lowest in the moderate ASR group (63.7±13.2 years) compared to the moderate AS group (72.2±10.8 years) and severe AS group (72.6±10.5 years, p<0.001). The proportion of males was similar among the three groups. In moderate ASR group, the etiology of valve was identified as 21.8% of bicuspid valve (12/55), 25.5% of rheumatic valve (14/55) and 50.9% of degenerative trileaflet valve (28/55). (Table1) Mean follow-up duration was 4.15 ± 4.02 years. In outcome, the mortality showed similar between the moderate ASR group and moderate AS group, but significant higher in severe AS group in time-varying adjusted cox regression analysis. The cumulative incidence of AVR was higher in the moderate ASR group by the Kaplan-Meier curve (p=0.025, Figure). Freedom from AVR in the moderate ASR group was 71% at 3 years, 61% at 5 years and 54% at 7 years, indicating more slow progression than previous study. Conclusions In this study, mortality rates between the moderate ASR and the moderate AS groups were similar, but the AVR rates were higher in the moderate ASR group. Compared to previous studies, differences in etiology of the valve and ethnicity may affect the slow progression rate of moderate ASR. Further studies with larger cohorts are needed in the future.