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Valvular heart diseases
Combined aortic stenosis and regurgitation: double the trouble
  1. Geraldine Ong1,
  2. Philippe Pibarot2
  1. 1 Department of Cardiology, St. Michael’s Hospital, Toronto, Ontario, Canada
  2. 2 Department of Cardiology, Quebec Heart and Lung Institute, Quebec City, Quebec, Canada
  1. Correspondence to Dr Philippe Pibarot, Cardiology, Quebec Heart and Lung Institute, Quebec City, QC G1V 4G5, Canada; philippe.pibarot{at}

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Learning objectives

  • To be aware of the prevalence, pathophysiology and outcomes of mixed aortic valve disease (MAVD), which refers to combined aortic stenosis and aortic regurgitation.

  • To assess the haemodynamic and clinical severity of MAVD using an echocardiographic multiparameter approach and, when necessary, other imaging modalities (dobutamine stress testing, multidetector computed tomography and cardiac magnetic resonance).

  • To identify the triggers and optimal timing for aortic valve intervention in MAVD.


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 few data on the outcome and management of this entity.1–6 Nonetheless, a few recent studies have reported that the prognosis of patients with combined moderate AS and moderate AR is similar or worse than those with isolated severe AS or AR.2 3 The therapeutic management of MAVD is complex and is currently based on the guideline recommendations for the predominant lesion, AS or AR.1 7 The objective of this Education in Heart article is to provide an overview of the prevalence, pathophysiology, outcomes, diagnosis, severity grading and strategies for the therapeutic management of MAVD.

Prevalence, pathophysiology and outcomes of MAVD

Prevalence of MAVD

In a nationwide epidemiology study conducted in Sweden,8 the overall incidence rate of multiple valve disease was 6.4 per 100 000 person-years. This rate increased markedly with age and was higher in men (8.5 per 100 000 person-years) than in women (5.8 per 100 000 person-years).8 MAVD was the most frequent multiple valve disease and 17.9% of patients with AR were diagnosed with concomitant AS.

Pathophysiology of MAVD

The pathophysiology and clinical impact of MAVD are complex and relate to the severity and chronicity of each aortic valve lesion and to the repercussions of these lesions on the remodelling and function of the left ventricle (LV) and other upstream cardiac chambers.5 In patients …

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  • Contributors GO did a review of literature on the topic and prepared the first draft of the initial and revised version. PP made critical revisions and prepared the figures and table.

  • Funding PP received funding from Edwards Lifesciences and Medtronic for echocardiography core laboratory analyses in the field of transcatheter aortic valve replacement with no direct personal compensation.

  • Competing interests PP holds the Canada Research Chair in Valvular Heart Disease and his research programme is funded by the Canadian Institutes of Health Research (grant numbers FDN-143225) (Ottawa, Ontario, Canada). PP received funding from Edwards Lifesciences for echo corelab analyses in the field of transcatheter valve therapy.

  • Provenance and peer review Commissioned; externally peer reviewed.

  • Patient consent for publication Not required.