Dr. Raphael Rosenhek,
With an ageing population and an increasing incidence of valvular heart disease, the number of patients presenting with more complex and multivalvular affection is becoming increasingly common. Combined valve disease was traditionally observed in rheumatic disease but is increasingly found in degenerative disease.
In the present session, issues of disease assessment and management were discussed based on two clinical cases. The first case was a patient with aortic stenosis and concomitant mitral regurgitation. The major pitfalls of this case included a reduction of forward stroke volume across the aortic valve due to the regurgitant volume through the mitral valve. With regard to decision-making, in the presence of an indication for aortic valve surgery, the severity of mitral regurgitation, its etiology (functional vs. organic) as well as the increased risk of surgery on a second valve needs to be considered.
The second case consisted of a significantly symptomatic patient with combined stenotic and regurgitant aortic valve disease. Based on a calculated aortic valve area of 1.3 cm2 and a peak aortic jet velocity of 4.3 m/s, aortic stenosis was quantified as moderate and aortic regurgitation as being severe. This case illustrates the fact that advanced symptoms may occur in multiple valve disease, although the contributing part of each single lesion is variable.
Due to a lack of data, current guidelines are not able to provide evidence-based recommendations. In principle, recommendations for each single valve disease should be followed and the interactions between the different lesions have to be considered. Symptoms are an important factor that has to be considered in decision-making process. The decision to intervene on multiple valves should account for the extra surgical risk of combined procedures.
Decision making in patients with multivalvular disease
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