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Mixed aortic stenosis and regurgitation: a clinical conundrum
  1. Rashmi Nedadur1,
  2. David Belzile2,
  3. Ashley Farrell3,
  4. Wendy Tsang2
  1. 1Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
  2. 2Division of Cardiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
  3. 3Library and Information Services, University Health Network, Toronto, Ontario, Canada
  1. Correspondence to Dr Wendy Tsang, Cardiology, University of Toronto, Toronto, ON M5G 2C4, Canada; wendy.tsang{at}uhn.ca

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.

  • aortic valve insufficiency
  • aortic valve stenosis
  • heart, artificial
  • outcome assessment, health care
  • diagnostic imaging

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Footnotes

  • RN and DB contributed equally.

  • Contributors RN, DB, AF and WT contributed to literature review, drafting, editing and approval of the final manuscript.

  • Funding WT is supported by a Heart and Stroke Foundation of Canada National New Investigator Award.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; externally peer reviewed.

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