Multiple Valve Disease Research Articles

Immediate results of surgery for multiple valve disease

Immediate results of surgery for multiple valve disease

Beyond Aortic Stenosis: Addressing the Challenges of Multivalvular Disease Assessment.

Aortic stenosis (AS) can often coexist with other valvular diseases or be combined with aortic regurgitation (AR), leading to unique pathophysiological conditions. The combination of affected valves can vary widely, resulting in a lack of standardized diagnostic or therapeutic approaches. Echocardiography is crucial in assessing patients with valvular heart disease (VHD), but careful consideration of the hemodynamic interactions between combined valvular defects is necessary. This is important as it may affect the reliability of commonly used echocardiographic parameters, making the diagnosis challenging. Therefore, a multimodality imaging approach, including computed tomography or cardiac magnetic resonance, is often not just beneficial but crucial. It represents the future of diagnostics in this intricate field due to its unprecedented capacity to quantify and comprehend valvular pathology. The absence of definitive data and guidelines for the therapeutic management of AS in the context of multiple valve lesions makes this condition particularly challenging. As a result, an individualized, case-by-case approach is necessary, guided primarily by the recommendations for the predominant valve lesion. This review aims to summarize the pathophysiology of AS in the context of multiple and mixed valve disease, with a focus on the hemodynamic implications, diagnostic challenges, and therapeutic options.

Treatment of multiple valve disease: surgery, structural intervention, or both?

Multiple valve heart disease refers to the simultaneous presence of several valvular anomalies, while mixed valvular heart disease refers to the combination of stenotic lesions or regurgitation affecting the same valve. The pathophysiology of multiple and mixed valvular heart disease depends on the combination of affected valves and the severity of the individual valvular defects. Imaging is essential for diagnosis and assessment of disease severity. The treatment of combined valvular defects currently represents a challenge for both cardiac surgeons and interventional cardiologists since only few data in the literature address the clinical and therapeutic decision-making process related to these complex lesions. These are heterogeneous conditions, which differ from each other in the combination of the valves involved, in the pathogenesis with which they develop, in the severity of the individual lesions, in the associated surgical risk, in the possibility of being repaired, and in the undergoing transcatheter treatments. In addition to the severity of the individual valve defects, the choice of treatment also depends on the ventricular function and the general condition of the patient. This work aims to provide a review of the state of the art regarding the possible management strategies of the most common multiple valve diseases in clinical practice.

Outcome for concomitant mitral regurgitation after surgery for aortic insufficiency.

Moderate/severe aortic regurgitation (AR) with concomitant mitral regurgitation (MR) is a common multiple valve disease for which treatment strategies are controversial. The current study explored long-term outcomes of concomitant MR after AR surgery and the effect of combined mitral valvuloplasty. A total of 506 patients with moderate/severe AR and concomitant MR undergoing aortic valve surgery between January 2013 and December 2021 in our cardiac center were enrolled. Risk factors for early mortality, late mortality and persistent MR were identified by logistic regression and generalized linear mixed model. At least one follow-up record was available for 96.3% patients up to May 2022 and 264 (66.8%) patients had no or trivial MR, 112 (28.4%) had mild MR, 16 (4.1%) had moderate MR and 3 (0.8%) patients had severe MR. Persistent MR was recorded for 92 (23.3%) patients during follow-up. Combined mitral valvuloplasty (odds ratio: 0.23; 95% confidential interval: 0.08-0.64; p = 0.005) and better left ventricular reverse remodeling (odds ratio: 0.99; 95% confidential interval: 0.986-0.996); p < 0.001) were found likely to reduce the possibility of persistent MR during follow-up. Most patients with moderate/severe AR and concomitant MR had a good long-term post-surgical outcome for MR. However, a few had persistent MR during follow-up. Combined mitral valvuloplasty and better left ventricular reverse remodeling reduced the possibility of long-term persistent MR.

Challenges in the management of aortic stenosis, multiple valve disease, culture-negative endocarditis, and cardiac surgery during pregnancy.

Challenges in the management of aortic stenosis, multiple valve disease, culture-negative endocarditis, and cardiac surgery during pregnancy.

Impact of mitral annular calcification on hemodynamic effect in mitral stenosis in multiple valve disease: relevant or not

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Prevalence of mitral annulus calcification (MAC) and degenerative mitral stenosis thus elevated transmitral gradient (TMG) is increased with age and multivalve involvement. The management of degenerative multivalve disease is challenging, as is identification of the presence of multivalve involvement and its hemodynamic impact because of interaction between two or more valve lesions especially in degenerative valve disease. Hemodynamic interaction between significant aortic stenosis and mitral annular calcification is often combined with diastolic disfunction which can result in LA enlargement and abnormal atrioventricular coupling and left atrial and ventricular remodeling. Purpose Study aimed to assess the effect of MAC on mitral valve stenosis in patients with multiple valve disease of degenerative origin. Method We retrospectively analyzed 78 patients with elevated transmitral gradient defined as an elevated TMG &amp;gt;4mmHg, MAC in multivalve involvement, mainly degenerative significant aortic valve stenosis who were treated in our clinic from 2018 to 2021. We excluded patients with prior cardiac surgery, congenital heart disease, hypertrophic obstructive cardiomyopathy and with heart rate &amp;gt;100 bpm at time of study and significant mitral regurgitation. Baseline demographic data were extracted from the electronic medical record and echocardiographic data were analyzed from electronic saved data. Results Study identified a total of 78 patients (average age 71,89 years, 64% females). Of 57 analyzed patients 32% patients had severe MAC and calcification of chordae, and 68% patients had MAC and mild or no significant chordae calcification. Patients with aortic gradients, severe aortic stenosis (AVAi 0,80 cm/m2) were observed more often in patients with severe MAC and significant chordae calcification than in those with nonsevere MAC (p &amp;lt; 0.043).There was no significant difference in mitral annular distension between groups. Baseline mean MV gradients were 6,5+-1.5 mm Hg. Mean MVA (continuity equation) was 1,5+-0.4 cm2, and MVAi 0,8+-0,2 cm/m2, mean LA volume 70 ml/m2, mean E/e 35, mean EF LV 68% and mean GLS -14. Conclusion Result suggest that increasing transmitral gradient if superimposed on severe MAC with only modest mitral stenosis will result in a high mean transmitral gradient. The presence of elevated pressure transmitral gradient in patients with more severe aortic stenosis and more severe MAC combined with chordae calcification may imply hemodynamic effect or stress on mitral valve degeneration in multiple valve involvement. Other imaging modalities and further investigation for better understanding effect of hemodynamic stress in multiple valve disease are needed. These observations need to be evaluated on larger cohorts of patients during a longer period of time.

Predictors of maternal and neonatal complications in women with severe valvular heart disease during pregnancy in Tunisia: a retrospective cohort study

BackgroundSevere valvular heart disease, especially stenosis, is a contraindication for conception according to the World Health Organization. This is still encountered in countries with a high rheumatic fever prevalence. The objective of this study was to determine predictors of maternal cardiac, obstetric and neonatal complications in pregnant women with severe valve disease.MethodsThis is an observational retrospective cohort study of all pregnant women with severe heart valvulopathy who gave birth between 2010 and 2017.ResultsWe included 60 pregnancies in 54 women. Cardiac complications occurred during 37 pregnancies (61%). In multivariate analysis, parity (aOR =2.41, 95% CI[1.12–5.16]), revelation of valvulopathy during pregnancy (aOR = 6.34; 95% CI[1.26–31.77]), severe mitral stenosis (aOR = 6.98, 95% CI[1.14–41.05],) and systolic pulmonary arterial pressure (aOR =1.08, 95% CI[1.01–1.14]) were associated with cardiac complications. Obstetrical complications were noted during 19 pregnancies (31.8%). These complications were associated with nulliparity (aOR = 5.22; 95% CI[1.15–23.6]), multiple valve disease (aOR = 5.26, 95% CI[1.19–23.2]), systolic pulmonary arterial pressure (aOR =1.04, 95% CI[1.002–1.09]), and treatment with vitamin K antagonists (aOR = 8.71, 95% CI[1.98–38.2]). Neonatal complications were noted in 39.3% of newborns (n = 61) and these were associated with occurrence of obstetric complications (aOR = 16.47, 95% CI[3.2–84.3]) and revelation of valvulopathy during pregnancy (aOR = 7.33, 95% CI[1.4–36.1]).ConclusionsRevelation of valvular heart disease during pregnancy is a predictor of not only cardiac but also neonatal complications. Valvular heart disease screening during pre-conceptional counseling is thus crucial.

Clinical Impact of Rare Aortic Arch Variant

This case report describes the clinical implications of peripheral arterial disease in a patient with a rare variant of the aortic arch branches. The patient was a 68-year old-female with an extensive cardiovascular history including multiple severe peripheral arterial stenoses, systemic and pulmonary hypertension, hyperlipidemia, coronary artery disease, multiple myocardial infarctions, atrial fibrillation, and possible aortic valve disease. The focus of the case report will be how the patient’s anatomical variant played a large role in maintaining cerebral circulation in the presence of significant stenoses of the right vertebral artery, left subclavian artery, and left common carotid artery.

Is Bridging Anticoagulation with Heparin after Valve Replacement Surgery Mandatory? - A Prospective Observational Study in a Centre of Bangladesh

Background: This is a prospective observational single center study to determine whether bridging anticoagulation with heparin along with warfarin is mandatory in a heterogenous group of patients undergoing valve replacement surgery either single or multiple valve (with mechanical or tissue valve) in the post-operative period.&#x0D; Methods: Perioperative data were collected in 41 patients undergoing multiple valve replacement at this center from July/2019 to September/2019 irrespective of age, sex, number and type of valve replaced. No bridging anticoagulation was given in preoperative and postoperative period in these patients. They were prospectively observed for the incidence of any thromboembolic end bleeding events with daily measurement of International Normalized Ratio (INR) till INR reached at therapeutic level for oral anticoagulant warfarin and complications of warfarin therapy.&#x0D; Results: All the patient suffered from chronic Rheumatic heart disease. Single valve disease was in 70.73% and multiple valve disease was in 29.27% cases. Two patients had left atrial thrombus, seven patient (14.63%) had preoperative atrial fibrillation (AF). Postoperative new onset AF was present in 10 (24.39%) cases. No thromboembolism occurred in these patients and warfarin over anticoagulation was found in 1/41 patient.&#x0D; Conclusion: Patients undergoing valve replacement surgery without concomitant postoperative bridging anticoagulation with heparin do not suffer from any thromboembolic and bleeding complications even at lower level of INR. This study also shows that single and multiple valve (both mechanical and tissue valve) have the same in hospital outcome in relation to thromboembolism and bleeding complications.&#x0D; Cardiovasc. j. 2020; 13(1): 27-34

Culture-negative infective endocarditis (CNIE): impact on postoperative mortality.

IntroductionPoor postoperative outcomes have been reported after surgery for infective endocarditis (IE). Whether the absence of positive cultures impacts the prognosis remains a matter of discussion. The aim of this study was to evaluate the impact of negative cultures on the prognosis of surgically treated IE.MethodsThis was a single-center, retrospective study. From January 2000 to June 2019, all patients who underwent valvular surgery for IE were included in the study. The primary endpoint was early postoperative mortality. A covariate balancing propensity score was developed to minimize the differences between the culture-positive IE (CPIE) and culture-negative IE (CNIE) cohorts. Using the estimated propensity scores as weights, an inverse probability treatment weighting (IPTW) model was built to generate a weighted cohort. Then, to adjust for confounding related to CPIE and CNIE, a doubly robust method that combines regression model with IPTW by propensity score was adopted to estimate the causal effect of the exposure on the outcome.ResultsDuring the study period, 327 consecutive patients underwent valvular repair/replacement with the use of cardiopulmonary bypass and cardioplegic cardiac arrest for IE. Their mean age was 61.4 ± 15.4 years, and 246 were males (75.2%). Native valve IE and prosthetic valve IE accounted for 87.5% and 12.5% of cases, respectively. Aortic (182/327, 55.7%) and mitral valves (166/327, 50.8%) were mostly involved; 20.5% of isolated mitral valve diseases were repaired (22/107 patients). The tricuspid valve was involved in 10 patients (3.3%), and the pulmonary valve in 1 patient (<1%). Fifty-nine patients had multiple-valve disease (18.0%). Blood cultures were negative in 136/327 (41.6 %). A higher postoperative mortality was registered in CNIE than in CPIE patients (19% vs 9%, respectively, p = 0.01). The doubly robust analysis after IPTW by propensity score showed CNIE to be associated with early postoperative mortality (odds ratio 2.10; 95% CI, 1.04–4.26, p = 0.04).ConclusionsIn our cohort, CNIE was associated with a higher early postoperative mortality in surgically treated IE patients after dedicated adjustment for confounding. In this perspective, any effort to improve preoperative microbiological diagnosis, thus allowing targeted therapeutic initiatives, might lead to overall better postoperative outcomes in surgically treated IE.

Minimally invasive treatment of multiple valve disease: A modified approach through a right lateral minithoracotomy.

Today there is little experience with minimally invasive treatment of multiple valve disease and no standard techniques have been provided yet. We report our early experience with combined aortic and mitral valve surgery with or without tricuspid surgery through a right lateral minithoracotomy (RmT), describing the technical aspects of our approach. From April 2017 to April 2019 thirty patients with mitro-aortic valve disease or with triple valve pathology underwent surgery through a 3 to 4 cm lateral RmT into the third intercostal space. Cardiopulmonary bypass was established through femoral vessels cannulation. Surgery on the mitral valve (MV) was performed first and sutures put into the mitral annulus. Aortic valve replacement (AVR) was performed next. Then, the selected ring or prosthetic valve was implanted in a mitral position throughout previously placed sutures. Finally, if required, tricuspid valve surgery was performed. In combined with AVR, MV replacement was performed in 20 patients (66%), and MV repair in 10 patients (34%). Concomitant tricuspid annuloplasty was performed in five patients (17%). There was no conversion to full sternotomy. Postoperatively, one patient died. Postoperative echocardiography showed no perivalvular leakage in aortic or in the mitral position. No residual mitral regurgitation was observed in patients who underwent MV repair. Minimally invasive surgery of double and triple valve disease is feasible. Our approach through a lateral RmT allows optimal visualization of the aortic, mitral, and tricuspid valves, simplifies the surgical procedure and allows excellent results also in complex MV repair procedures.

Aortic Stenosis with Other Concomitant Valvular Disease: Aortic Regurgitation, Mitral Regurgitation, Mitral Stenosis, or Tricuspid Regurgitation.

Aortic stenosis presenting as part of a multiple valve disease scenario or as mixed valve disease is frequent. These scenarios induce hemodynamic interactions that may result in diagnostic pitfalls. Echocardiography is the cornerstone technique for diagnosis of valve disorders, but other modalities may be useful. In addition to assessment of each individual lesion, the heart valve team must integrate numerous parameters into the management strategy, including global assessment of clinical and hemodynamic effects, operative risk, life expectancy, natural history of untreated valve disease, valve reparability, and/or suitability for single or multiple transcatheter valve procedures.

Combined aortic stenosis and regurgitation: double the trouble

### Learning objectives Mixed aortic valve disease (MAVD) refers to the coexistence of aortic stenosis (AS) and aortic regurgitation (AR). Despite the relatively high prevalence of MAVD, there are very...

Predictors of maternal cardiac complications in pregnant women with severe cardiac valve disease

Maternal mortality in general has decreased in the past decade, but over the same period, cardiac maternal death has not declined. In emerging countries, rheumatic valve disease is the most common cardiac disease in pregnant women. We conducted this study in order to determine predictors of cardiac complication in such pregnant condition. It was a retrospective study including all pregnant women with at least one severe cardiac valve disease and who gave birth in our hospital between 2010 and 2017. Maternal cardiac event was defined as cardiac death, arrhythmia requiring treatment, heart failure, thromboembolic event, endocarditis. We included 60 pregnancies in 54 women during the study period. The mean age was 32.55 ± 5.6 years, the mean gestity was 2.8 ± 1.6 (1–9), the valvular disease was discovered during pregnancy in 45%, a multiple valve disease was diagnosed in 47% of cases. The most frequent severe cardiac valve disease was mitral stenosis (65% of the cases). Cardiac complications occurred in 37 patients (61%). On Univariate analysis, the predictors of such complications was gestity (3.16 ± 1.8 versus 2.21 ± 1.16, P = 0.038), parity (2.45 ± 1.21 varsus 1.69 ± 0.87, P = 0.01), discovery of the valvylar disease during the pregnancy ( P = 0.039), mitral stenosis (86.5% versus 47.8%, P = 0.001), atrial fibrillation (48.6% versus 21.7%, P = 0.37, and systolic pulmonary pressure (57.29 ± 15.8 versus 40.39 ± 9.7, P < 0.001), but on multivariate analysis, the independent factors of cardiac complications was severe mitral stenosis ( P = 0.035, OR = 6.8, 95% CI (1.14–41.05), pulmonary systolic pressure (OR = 1.08, 95% CI (1.015–1.14), parity ( P = 0.023, OR = 2.41, 95% CI (1.12–5.16). Severe Mitral stenosis was the main cause of cardiac complication in pregnant cardiac woman. The percutaneous mitral dilatation could improve the maternal prognosis and should be attempted when anatomic data are in favor.

Factors associated with the election of treatment options for mitral regurgitation in elderly inpatients

Objective To review the clinical characteristics and current managementstrategy and to examine the factors to be considered in the selection of treatment options for mitral regurgitation (MR) in elderly inpatients. Methods Elderly patients(≥60years old)who had been diagnosed with moderate to severe MR by transthoracic echocardiography and hospitalized from May 1, 2014 to April 30, 2015were included in this study (N=680). Patients were grouped according to therapy: the surgery group (n=372) and the medication group (n=308). Data at baselineincluding medical history and echocardiography were collected for comparison between the two groups and for analysis of factors associated with treatment choice. Results Of the 680 patients with moderate to severe MR, 45.3% were treated with medication.Compared with the surgery group, patients in the medication group were older, with a lower prevalence of primary MR, a higher prevalence of coronary heart disease and higher Euroscore-Ⅱscores(all P<0.01). Furthermore, the medication group had a lower prevalence of moderate MR(75/308 or 24.4%vs.200/372 or 53.8%, P<0.01), a lower left ventricular ejection fraction (47.8±16.1)%vs.(61.5±9.2)%(P<0.01), and a larger left ventricular end diastolic diameter(59.2±11.4)mmvs.(55.8±8.8)mm(P<0.01). Besides, multivariable analysis revealed that regurgitation grade, left ventricular ejection fraction, multiple valve disease, age, and diabetes were correlated with therapy decisions(OR=62.067, 1.089, 4.791, 0.879 and 0.414, respectively, P<0.01 or P<0.05). Conclusions Old age, impaired left ventricular ejection fraction, low regurgitation grade, diabetes, and absence of multiple valves are the most salientfactors for which surgery should not be selected. Key words: Mitral valve insufficiency; Stroke volume; Risk factors

Characteristics, aetiological spectrum and management of valvular heart disease in a Tunisian cardiovascular centre

Valvular heart diseases occur frequently in Tunisia, but no precise statistics are available. To analyse the characteristics of patients with abnormal valvular structure and function, and to identify the aetiological spectrum, treatment and outcomes of valvular heart disease in a single cardiovascular centre in Tunisia. This retrospective study included patients with abnormal valvular structure and function, who were screened by transthoracic echocardiography at a single cardiology department between January 2010 and December 2013. Data on baseline characteristics, potential aetiology, treatment strategies and discharge outcomes were collected from medical records. There were 959 patients with a significant valvular heart disease (mean age 53±17years; female/male ratio 0.57). Valvular heart disease was native in 77% of patients. Mitral stenosis was the most frequent lesion (44.1%), followed by multiple valve disease (22.3%). Rheumatic origin (66.6%) was the most frequent aetiology, followed by degenerative (17.2%) or ischaemic (8.1%) causes, endocarditis (1.4%) and congenital (0.9%) causes. Native valve disease was severe in 589 patients (61.4%). Percutaneous mitral balloon valvuloplasty was performed in 36.9% of patients with mitral stenosis. Among patients with severe valvular heart disease, surgical treatment was indicated for 446 (75.7%) patients. Only 161 (36.1%) patients were finally operated. Postoperative mortality was 13.6% for all valvular heart diseases. This retrospective study has shown that the main cause of valvular heart disease in Tunisia is rheumatic fever. Mitral stenosis and multiple valve disease are the most frequent valvular heart diseases in Tunisia. Percutaneous mitral balloon valvuloplasty and prosthetic valve replacement are the preferred treatment methods for valvular heart disease.

Surgical Management of Multiple Valve Endocarditis Associated with Dialysis Catheter.

Endocarditis associated with dialysis catheter is a disease that must be suspected in every patient with hemodialysis who develops fever. Multiple valve disease is a severe complication of endocarditis that needs to be managed in a different way. There is very limited data for treatment and every case must be considered individually. We present a patient with this complication and describe the medical treatment and surgical management. We report the case of a 15-year-old patient with acute renal failure that develops trivalvular endocarditis after the hemodialysis catheter was placed, with multiple positive blood culture for Staphylococcus aureus. Transesophageal echocardiography was done and aortic and tricuspid valvular vegetations and mitral insufficiency were reported. Patient was successfully treated by surgery on the three valves, including aortic valve replacement. There is limited data about the appropriate treatment for multiple valvular endocarditis; it is important to consider this complication in the setting of hemodialysis patients that develop endocarditis and, despite the appropriate treatment, have a torpid evolution. In countries where endovenous drug abuse is uncommon, right sided endocarditis is commonly associated with vascular catheters. Aggressive surgical management should be the treatment of choice in these kinds of patients.

Multiple valve disease - assessment, strategy and intervention.

Patients with multiple valve disease are a frequent and heterogeneous entity whose evaluation and management are challenging. The assessment of the severity requires a cautious integrative evaluation. The indications for intervention are based on global assessment of the consequences of the disease, mainly based on symptoms, pulmonary hypertension, and left ventricular dysfunction. The decision to intervene should also take into account the inherent additional risk. Percutaneous intervention in this population is in its infancy but the future development of transcatheter techniques will be of interest in this high-risk cohort and will offer the possibility of tailored and staged procedures.

Concomitant significant mitral regurgitation in patients with aortic valve stenosis undergoing valve replacement: Practical indications

&lt;p&gt;Significant mitral regurgitation (MR) - either of structural or functional origin - is a frequent condition in patients with severe aortic stenosis (AS), candidate to aortic valve replacement (AVR), and raises the problem whether or not to intervene on mitral valve at the same time. Surgical risk related to the double valve intervention is still significantly higher compared to isolated AVR and international guidelines do not always give definite indications in the presence of multiple valve disease. Furthermore, the increasing diffusion of transcatheter aortic valve replacement for patients at high surgical risk has risen the problem of leaving the concomitant MR untreated. This review is an attempt to give a practical guide for the decision-making process about the treatment strategy of patients with concomitant severe AS and significant MR, analyzing the impact of a persistent MR on prognosis after surgical or transcatheter AVR, the main predictors of MR improvement after isolated AVR - according to the current literature – and displaying the emerging approach involving transcatheter treatment of both AS and MR.&lt;/p&gt;&lt;p&gt;&lt;strong&gt; &lt;/strong&gt;&lt;/p&gt;

Incidence of coronary artery disease before valvular surgery in isolated severe aortic stenosis

Background Angina pectoris has been recognized as one of the principal symptoms of aortic valve stenosis (AS), even in patients without significant coronary artery disease (CAD). However, the incidence of angina pectoris and related CAD in such patients is controversial. There is continuing debate as to whether coronary angiography is necessary before aortic valve replacement (AVR) in patients with severe AS. The purpose of this study was to evaluate the incidence and predictors of CAD in patients with severe AS in a Korean population. Methods Data from all consecutive patients with severe AS undergoing AVR at a major tertiary cardiac and vascular center in Korea were entered in a prospective registry beginning in 1995. Clinical and echocardiographic follow-up data were recorded into the database annually. Significant CAD was defined as one or more major coronary arteries having an estimated narrowing of ≥70% and left main coronary arteries having an estimated narrowing of ≥50% on coronary angiography. We excluded patients with multiple valve disease, significant aortic regurgitation, or prior CAD or valve surgery. Results Totally 574 patients with severe AS (mean age, (65.9±9.6) years) were enrolled in this study. Significant CAD was found in 61 patients (10.6%). Factors associated with increased likelihood of CAD were age, hypertension, diabetes mellitus, chronic renal failure, carotid disease, and aorta calcification. In Logistic regression analysis, the independent predictor of the presence of CAD was age (P=0.011). The incidence of CAD increased significantly at 69.2 years of age. Having two risk factors for cardiovascular disease was the most useful cutoff to predict whether a patient was going to have significant CAD. Conclusions There was a low incidence of significant CAD in a population of Korean patients with severe AS. Therefore, coronary angiography before AVR will be considered in patients with multiple risk factors for cardiovascular disease or in patients more than 69 years of age without risk factors for cardiovascular disease.