Outcomes in Moderate Mixed Aortic Valve Disease
What are outcomes for patients with moderate mixed aortic valve disease (moderate aortic stenosis [AS] plus moderate aortic regurgitation [AR]) compared with patients with isolated AS or AR?
Asymptomatic patients were identified with combined moderate AS and moderate AR, and left ventricular ejection fraction ≥50%, followed at Mayo Clinic from 1994 to 2013. Age- and sex-matched control groups were selected with isolated moderate AR (n = 117), isolated moderate AS (n = 117), or severe AS (n = 117). Adverse events were defined as development of New York Heart Association class III-IV symptoms, aortic valve replacement (AVR), or cardiac death.
Follow-up was 9.1 ± 4.2 years. Patients with moderate combined AS and AR (n = 251) were 63 ± 11 years of age, 73% were male, and 38% had a bicuspid valve. Adverse events occurred in 193 (77%), including development of symptoms (69%), AVR (67%), and cardiac death (4%). Predictors of adverse events were older age (hazard ratio [HR], 1.71 per decade; 95% confidence interval [CI], 1.38-1.97; p = 0.001), and relative wall thickness >0.42 (HR, 2.01; 95% CI, 1.86-2.33; p = 0.002). Adverse event rates were similar among patients with combined moderate AS and AR and in the severe AS group (71% vs. 68% at 5 years, p = 0.49), but significantly higher compared to the moderate AS and the moderate AR groups.
Patients with combined moderate AS plus moderate AR had outcomes comparable to those with severe AS, and should be monitored closely for symptoms.
Simple quantification of mixed valve disease can be problematic; for example, the presence of significant AR would be expected to independently increase antegrade flow gradients due to the increased volume crossing the valve, making the characterization of AS severity more problematic. Very few data exist to guide the management of patients with mixed valve disease, and current heart valve guidelines base recommendations on a single dominant valve lesion. However, it seems logical to believe that the hemodynamic and therefore the clinical significance of mixed valve lesions can be greater than the individual components in isolation. Although a majority of patients in this study progressed to severe valve disease prior to intervention, some (11%) developed symptoms despite persistent moderate (mixed) disease, suggesting that adverse events can occur even if neither lesion is hemodynamically severe.
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