Abstract
Aortic stenosis (AS) may present frequently combined with other valvular diseases or mixed with aortic regurgitation, with peculiar physio-pathological and clinical implications. The hemodynamic interactions between AS in mixed or combined valve disease depend on the specific combination of valve lesions and may result in diagnostic pitfalls at echocardiography; other imaging modalities may be helpful. Indeed, diagnosis is challenging because several echocardiographic methods commonly used to assess stenosis or regurgitation have been validated only in patients with the single-valve disease. Moreover, in the developed world, patients with multiple valve diseases tend to be older and more fragile over time; also, when more than one valvular lesion needs to address the surgical risk rises together with the long-term risk of morbidity and mortality associated with multiple valve prostheses, and the likelihood and risk of reoperation. Therefore, when AS presents mixed or combined valve disease, the heart valve team must integrate various parameters into the diagnosis and management strategy, including suitability for single or multiple transcatheter valve procedures. This review aims to summarize the most critical pathophysiological mechanisms underlying AS when associated with mitral regurgitation, mitral stenosis, aortic regurgitation, and tricuspid regurgitation. We will focus on echocardiography, clinical implications, and the most important treatment strategies.
Highlights
Multivalvular disease (MVD), defined as the combination of stenotic or regurgitant lesions of two or more cardiac valves, is increasingly frequent in clinical practice, presenting in 10% of patients undergoing valvular surgery
Degenerative etiology comprises the vast majority of cases; when associated with other valve diseases, rheumatic heart disease should be considered as it is the most common cause of MVD worldwide; typically, rheumatic heart disease affects younger patients [2] and has a faster progression than the degenerative counterpart, involving almost invariably the mitral valve [3]
The clinical impact of combined valve disease depends on hemodynamic interactions between the valve lesions and, on the severity, combination, and chronicity of each valvular defect
Summary
Is Not Alone: Epidemiology, Pathophysiology, Diagnosis and Management in Mixed and Combined. Aortic stenosis (AS) may present frequently combined with other valvular diseases or mixed with aortic regurgitation, with peculiar physio-pathological and clinical implications. Diagnosis is challenging because several echocardiographic methods commonly used to assess stenosis or regurgitation have been validated only in patients with the single-valve disease. In the developed world, patients with multiple valve diseases tend to be older and more fragile over time; when more than one valvular lesion needs to address the surgical risk rises together with the long-term risk of morbidity and mortality associated with multiple valve prostheses, and the likelihood and risk of reoperation. When AS presents mixed or combined valve disease, the heart valve team must integrate various parameters into the diagnosis and management strategy, including suitability for single or multiple transcatheter valve procedures.
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