Dyspnea in a Patient With Severe AS and Severe MR: Which Valve to Fix

A 70-year-old man presented with 3 months of progressive exertional dyspnea and worsening orthopnea consistent with New York Heart Association Class III symptoms. Past medical history was significant for coronary artery disease (for which he underwent remote coronary artery bypass grafting and percutaneous coronary intervention), hypertension, atrial fibrillation, non-insulin-dependent diabetes mellitus, chronic obstructive pulmonary disease, and peripheral arterial disease. His exam revealed normal vital signs, a grade III/VI crescendo-decrescendo murmur over the right-upper sternal border with diminished S2 and radiation to the left carotid artery, and a III/VI holosystolic murmur over the apex with radiation to the axilla; an S3 was present. A transthoracic echocardiogram showed low-normal left ventricular ejection fraction (LVEF) of 50-55%, basal, inferolateral, and inferior wall hypokinesis with eccentric, posteriorly directed moderate-to-severe (3+) ischemic mitral regurgitation (MR). In addition, he had a calcified aortic valve with restricted opening. By continuity equation, his calculated aortic valve area was 0.8 cm2, with mean aortic gradient of 26 mm Hg, aortic valve peak velocity of 3.1 m/sec, and dimensionless index of 0.18. His left ventricular stroke volume index was reduced at 30 ml/m2. Overall, these findings were consistent with paradoxical low-flow, low-gradient severe aortic stenosis (AS) with preserved LVEF (Videos 1-2). A transesophageal echocardiogram confirmed these findings. A gated chest computed tomography angiography showed a heavily calcified aorta and a measured aortic valve calcium score of 2099 Agatston units. In addition, a left lower-lobe lung mass was found that turned out to be localized adenocarcinoma (T1bN0M0), which has a good prognosis if surgically resected. Because his calculated Society of Thoracic Surgeons Predicted Risk of Mortality score was 8.4% for isolated aortic valve replacement and because of his porcelain aorta, concomitant significant MR, and peripheral arterial disease, the patient was deemed to be of high surgical risk and referred for heart team discussion.

Video 1

Video 2

Given the mixed valvular disease, what would you recommend?

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