Pathophysiology and management of combined aortic and mitral regurgitation

ArchivesofCardiovascularDisease(2019)112,430—440

Availableonlineat

ScienceDirect

www.sciencedirect.com

REVIEW

Pathophysiology

and

management

of

combined

aortic

and

mitral

regurgitation

Physiopathologie

et

prise

en

charge

des

insuffisances

valvulaires

aortiques

et

mitrales

combinées

Philippe

Unger

,

Patrizio

Lancellotti

,

Mihaela

Amzulescu

,

Aurelia

David-Cojocariu

,

Didier

de

Cannière

a_{DepartmentofCardiology,CHUSaint-Pierre,UniversitéLibredeBruxelles,1000Brussels,}

Belgium

b_{DepartmentofCardiology,HeartValveClinic,GIGACardiovascularSciences,Universityof}

LiègeHospital,CHUSartTilman,4000Liège,Belgium

c_{GruppoVillaMariaCareandResearch,AntheaHospital,70124Bari,Italy}

d_{DepartmentofSurgery,CHUSaint-Pierre,UniversitéLibredeBruxelles,1000Brussels,}

Belgium

Received19March2019;receivedinrevisedform7April2019;accepted15April2019 Availableonline29May2019

KEYWORDS Aorticregurgitation; Mitralregurgitation; Multiplevalve disease;

Heartvalveteam

Summary Thecombinationofaorticandmitralregurgitationisatypicalexampleofa

fre-quentyetunderstudiedmultiplevalvedisease scenario.Theaetiologyisoftenrheumaticor

degenerative; less frequently itcan be induced by drugs or radiation, orcaused by

infec-tive endocarditis or congenital valvular lesions. Aortic regurgitation resulting in secondary

mitralregurgitationisalsonotuncommon. Therearelimiteddatatoguidethemanagement

ofcombinedaorticandmitralregurgitation.Leftventriculardysfunctionisfrequentatinitial

presentation,andevenmoresopostoperatively,suggestingthatsurgicalmanagementshould

notbedelayed,particularlywhensymptomsoccurorwhenthereisevidenceofevensubtle

leftventriculardysfunction.Thedecisiontooperateononeorbothvalvesnotonlydepends

ontheseverityofeachlesion,butalsoonseveralotherfactors,includingage,co-morbidities

andfrailty,theincreasedoperativeriskofdoublevalvesurgery,theincreasedriskoflong-term

Abbreviations: AHA/ACC, American Heart Association/American College of Cardiology; AR, aortic regurgitation; LV, left ventri-cle/ventricular;MR,mitralregurgitation.

∗_{Correspondingauthorat:DepartmentofCardiology,CHUSaint-Pierre,322rueHaute,1000Brussels,Belgium.}

E-mailaddress:punger@ulb.ac.be(P.Unger). https://doi.org/10.1016/j.acvd.2019.04.003

thromboticandbleedingcomplicationswithmultiplemechanicalvalves,theriskofleavingone

valveunoperatedandtheprobabilityofrequiringredosurgery.Theroleofamultidisciplinary

heartvalveteamiscriticalinthissettingtooptimizemanagementandoutcomes.Theroleof

transcatheterapproachesiscurrentlylimited,buttechnologicaladvanceswillprobablysoon

changethemanagementparadigm.

©2019ElsevierMassonSAS.Allrightsreserved.

MOTSCLÉS Insuffisance aortique; Insuffisancemitrale; Cardiopathies valvulaires; Affectionsvalvulaires multiples

Résumé L’associationd’unerégurgitationvalvulaireaortiqueàunerégurgitationmitraleest

unexempletypiqued’affectionplurivalvulaire,fréquenteetcependantpeuétudiée.Les

éti-ologiesrhumatismalesetdégénérativessontlespluscourantes;l’endocarditeinfectieuse,les

atteintesvalvulairesmédicamenteusesetradiques,ainsiquelesvalvulopathiescongénitales

devrontaussiêtre recherchées.L’insuffisance aortiqueavec insuffisancemitrale secondaire

estaussiunesituationfréquente.Lapriseenchargedespatientsdecespatientsn’aétéque

peuétudiée.Ladysfonctionsystoliqueventriculaire,fréquentelorsdudiagnostic,l’estencore

plus enpostopératoire, plaidant pourune priseencharge chirurgicale précoce, etce, dès

l’apparitiondesymptômesoudesignes>mêmediscretsdedysfonctionventriculaire.La

déci-siondetraiterlesdeuxvalvesd’embléeouden’enopérerqu’une dépendranonseulement

delasévéritédechacunedesrégurgitations,maisaussidemultiplesfacteurs,parmilesquels

l’âge,lescomorbiditésetlafragilitédupatient,lerisqueopératoireetdesrisques

hémorrag-iquesetthrombotiquesinhérentsàlachirurgiebivalvulaireetlerisquedelaissertellequ’elle

unevalvedysfonctionnelleetdedevoirl’opérerultérieurement.Uneéquipemultidisciplinaire

spécialiséedanslapriseenchargedesaffectionsvalvulairesseraparticulièrementbénéfique

pourenoptimaliserletraitementetaméliorerlepronosticdupatient.Silaplacedévolueau

traitementpercutanédesaffectionsbivalvulairesrégurgitantesestactuellementlimitée,ilne

faitaucundoutequelesprogrèstechnologiquesmodifierontconsidérablementnotreapproche

thérapeutique.

©2019ElsevierMassonSAS.Tousdroitsr´eserv´es.

Background

The diagnosis ofvalvularheart diseasehas improved con-siderably over recent years, as has its management, but therearestilllimiteddatatoguideclinicaldecisionmaking inpatients withmultiple valvedisease [1—3].Inthis con-text,thecombinationofaorticregurgitation(AR)andmitral regurgitation(MR) is a typical example of a frequent yet understudiedscenario[3].Theaimofthisarticleisto pro-videastate-of-the-artreviewofthepathophysiologyofthis conditionandmanagementstrategies,takingintoaccount itsvariousclinicalpresentations.

Aetiology

and

prevalence

WithareportedprevalenceintheCARDIAstudyof0.5%in subjectsaged21to35years,thecombinationofARandMR isuncommoninyoungadults[4].Amongolderpatientswith amean ageof54 yearsfromtheFraminghamcohort, the prevalence of regurgitation involving twovalves was10% for men and 8% for women, but more than mild MR and morethantraceARwereinfrequent[5].However,Paietal. reportedthat amongpatients with severe AR,up to one-quarteralsohad moderate-to-severeMR [6].Ina Swedish

nationwideregistry includingall hospitals andspecialized outpatient clinics, 10.7% of patients with AR had conco-mitantMR,and 8%of patientswithadiagnosis of MRhad concomitantAR[7].Moreover,22%ofthepatientswith mul-tiplevalvediseasehadacombinationofARandMR,making this the third most frequent form of multiple and mixed valvedisease[7].

In combinedAR and MR, the twoconditions may have a similar aetiology or, less frequently, be the result of twounrelatedprimarydiseaseprocesses.IntheEuroHeart Survey,rheumatic heart disease wasthe leadingcause of multiplevalvedisease (51%of cases)(Fig.1), and degen-erativeaetiologies were responsible for 41% of cases [8]. However,whereastheincidenceofrheumaticheartdisease hasdeclined over thepast few decades, theagingof the population ofindustrialized countries accountsfor a shift towardsdegenerativeaetiologies, without aglobal reduc-tionintheoverallprevalenceofvalvularheartdisease[9]. All other aetiologies, including infective endocardi-tis, drugs, radiation and congenital valvular lesions, are much less frequent. Nonetheless, multiple valve disease is observed in more than 20% of patients with drug- or radiation-inducedheartvalvedisease[10,11].Multiplevalve disease resulting from infective endocarditis carries an increasedriskofheartfailure[12].

432 P.Ungeretal.

Figure1. Combinedrheumaticaorticandmitralregurgitation.AandB.Systolicstillframes.CandD.Diastolicstillframes.

Varying degrees of MR may result from remodelling, shape distortion and impaired function of the left ven-tricle (LV) associated with severe AR, thereby restricting mitral valve motion [13]. Secondary (functional) MR, in whichthevalveisstructurallynormalandtheleaflet coap-tationdefectmainlyresultsfromventricularand/or atrial remodelling,is common in patients withaortic valve dis-ease;however, moststudies included patients withaortic stenosis, and there are limited data focusingon patients withpredominant AR [13,14]. In a series of 779 patients whohad undergone aortic valve replacement, Lim et al. identified155 patients (20%)withmild-to-moderate func-tional MR, but the number of patients with severe MR was not reported [14]. In a series of 816 patients with AR,Beaudoin etal.reporteda5.6%prevalence of moder-ateorseveresecondaryMR[13].Interestingly,theauthors attributedthis lowprevalence to asignificant increase in mitralvalveleafletareacomparedwithcontrols andwith patientswithfunctional MRof other aetiologies[13]. The mechanism of this valvular remodelling was unclear, but itwaspostulated thatthe increasein mitralvalveleaflet

areamightbeacompensatorymechanism,preventingthe developmentof MR by helpingto preservea normal rela-tionship to the area needed for closure in a dilated LV

[13].

Pathophysiology

Both AR and MR increase left ventricular (LV) preload, whereas only AR has a significant effect on afterload,as a result of the impact of the increased total stroke vol-ume ejected on systemic vascular resistance, and of the resulting systolic hypertension [15]. Therefore, severe LV dilatationmayoccurwhenARandMRarepresenttogether. Inaddition,theresultingcombinationofvolumeand pres-sure load further increaseswall thickness[16]. Thus, the resulting LVhypertrophy will usually beeccentric, with a wallthickness-to-cavityratiotypically<0.45,andincreased sphericity[17].Attheonsetofsymptoms,patientsmayhave a reduced LVejection fraction, which can beeven worse thanthatassociatedwithisolatedARorMR[17,18](Fig.2).

Figure2. A.Severemitralregurgitation.B.Severeaorticregurgitation.Leftventricularejectionfractionis35%(notshown).CandD. ShortdP/dt(618ms;C)andmarkedreductioningloballongitudinalstrain(—6.4%;D)areconsistentwithsevereleftventriculardysfunction.

When acuteand severeAR developsin patients with pre-existingMR,themarkedincreaseinLVend-diastolicpressure maybetransmittedbackwards,asprematuremitralvalve closure no longer limits the amount of flow into the left atrium and pulmonary veins(Fig. 3). The combination of ARandMRpredisposestoatrialfibrillationandpulmonary hypertension. As a result of chronic volume and pressure overload,MRisanindependentriskfactorforreduced sur-vivalinpatients withsevere AR,withmortalityincreasing witheachgradeofMRseverity[6].

Diagnosis

The proximal isovelocity surface area (PISA) method and the assessment of vena contractafor quantifying regurgi-tant lesions are lesser load-dependent methods that can beuseful in thissetting. Bycontrast,volumetricmethods of assessing the severity of MR and AR can be chal-lenging, because left-sided assessment of forward flow is invalid. However, the right ventricular outflow tract can

beused as an alternative to assess the net forward flow

[3,19].Thepressurehalf-timecanbeinaccuratein

assess-ing the severity of AR, and the mitral-to-aortic velocity timeintegral ratio is inherently unreliable. Cardiac mag-neticresonanceimagingmaybeusedtoquantifyregurgitant lesions, particularly when the echocardiographic image qualityis inadequate or when echocardiographyvariables arediscordant withclinical assessment [19,20]. However, volumetricmethodscanalsobeinaccurateinthepresence of multiple regurgitant lesions, asthese methods assume that only one valve is affected [21]. Cardiac magnetic resonanceimagingmayaccuratelyquantifychangesin ven-tricularvolumes,massandfunctionand,hence,byassessing the global burden of the valve regurgitations, may con-tributetodeterminingtheoptimaltiming forintervention

[20].

Nostudyhasevaluatedthevalueofglobal longitudinal straininthespecificsettingofmultiplevalvedisease. How-ever,itsrolehasbeenconsistentlyhighlightedinisolatedAR

andMR[22,23]and,consequently,itmightberecommended

434 P.Ungeretal.

Figure3. Acuteaorticregurgitation(AR)asaresultofinfectiveendocarditis.A.Parasternallong-axisviewshowingconcomitantAR(yellow arrows)andmitralregurgitation(MR)(whitearrows)duringend-diastole.B.Thepressurehalf-timeoftheARjetis108ms,consistentwith severeAR.CandD.ColourDopplerandcolourM-modeobtainedinthe140◦planebytransoesophagealechocardiography,confirmingthe occurrenceofdiastolicMR.DiastolicMR resultsfrom increasedleftventriculardiastolicpressure,andreflects prematuremitralvalve closure.LA:leftatrium;LV:leftventricle.

Management

Most published results of double valve replacement for combined AR and MR come from studies focusing on youngpatients,predominantlywithrheumaticheartdisease aetiology[17,18,22,24].Whetherolderpatientswith degen-erativevalvedisease,andthus alongerhistoryofvalvular regurgitationanda lowerlifeexpectancy, wouldsimilarly benefitfromextensivesurgeryislargelyspeculative.In gen-eral,thedecisiontooperateononeorbothvalvesdepends on the severity of each lesion, but other factors should also be taken into account. The increased operative risk of double valvesurgery [25,26] and the increased risk of long-termthromboticandbleedingcomplicationswith mul-tiplemechanicalvalves[27]shouldbebalancedagainstthe probabilityof requiring redo surgery and itsinherent risk ifonlyonevalveisreplaced.This decisionmusttherefore takeintoaccountmanyfactors,includingpatientage, co-morbiditiesandfrailty[28].Inaddition,expertiseincardiac imaging,cardiacsurgery,haemodynamicmanagement, geri-atricsandanaesthesia,inthesettingofamultidisciplinary heart valve team, is required to optimize management

[28].

Effects

of

aortic

valve

replacement

on

the

severity

of

MR

LVfunction,mass andvolumesfrequentlyimprove follow-ingaorticvalvereplacementinpatientsundergoingsurgery for severe AR, witha variabletime-courseresponse [29]. Thus,whenconcomitantfunctionalMRismildtomoderate, aortic valvesurgeryfor severe ARis expectedtoimprove MR (Fig. 4). In a study by Lim etal., an improvement in MRseveritywasobservedin88%ofpatients,evenwithout concomitantmitralvalveannuloplasty,andwasparalleled byareductioninLVend-diastolicdimension[14].However, whethercorrectionofthevolumeoverloadbyaorticvalve replacement is sufficient to managesevere secondary MR hasnotyetbeenestablished.

Effects

of

double

valve

surgery

on

LV

volume

and

function

As a result of specific loading conditions, LV function frequentlydecreasesaftermitralvalvereplacementfor iso-latedMR,therebyprecludingmitralvalvesurgeryinpatients withsevereLVdysfunction.Bycontrast,LVfunctionusually

Figure4. Severeaorticregurgitation.A.Usingtransoesophagealechocardiography,thereisalargevenacontracta,consistentwithsevere aorticregurgitation(whitearrow).B.Thereisconcomitantmoderatesecondarymitralregurgitation,asseenbytransthoracic echocardio-graphy(yellow arrow).C.Aortic valvereplacementwasperformed;ontheseventhpostoperativeday,onlytrace mitralregurgitation remained.Ao:ascendingaorta;LV:leftventricle.

improvesafteraorticvalvereplacementforisolatedAR,so thepresenceofevenaseverelydepressedLVejection frac-tion does not exclude aortic valvereplacement. Whether doublevalvesurgeryfor combinedARandMRimprovesor worsens LVperformance isthus an important issue. Essop et al.compared the effects of double valvereplacement forcombinedAR/MRwiththoseofmitralvalvereplacement for isolatedMR. Asimilarreductioninend-diastolic diam-eter was observed, but, 3 months after surgery, a larger

reduction in end-systolic diameter after double valve surgerywasassociatedwithasmallerdeteriorationin ejec-tionfraction[30]. Thisobservation suggeststhatlevelsof ejectionfractionthatprecludesurgeryforisolatedMRmight stillbeacceptablefordoublevalvereplacementforAR/MR

[30]. However, discrepant results were reported by Gen-tles et al. [17]. In a child and young adult population, the development or persistence of postoperative LV dys-function (definedas a Z-score<—2) occurred significantly

436 P.Ungeretal.

Figure5. A.andB.Diastolicandsystolicparasternallong-axisviewsshowingsevereARandmoderate-to-severeMR,respectively.Cand D.Despitebeingpreservedbeforesurgery(C),fractionalshorteningismarkedlydecreasedfollowingdoublevalvereplacement(D).EDD: end-diastolicdiameter;ESD:end-systolicdiameter;FS:fractionalshortening.

more often after double valvesurgery (84.4%) than after isolated aortic valve replacement for AR (35.7%) or iso-latedmitralvalvereplacementforMR(57.1%)[17](Fig.5). The betterresults from Essopetal. were attributedtoa shorterdurationofvolumeloading,therebyemphasizingthe roleof early surgical management [30].Importantly, Sku-dickyetal.observedthat,despiteinitialdeterioration,LV ejectionfractiontendedtonormalize1yearaftersurgery

[24].Moreover,LVejectionfractionandend-systolic diam-eterwereidentifiedasindependentpredictive factorsfor postoperativesystolicperformance[24].Theprobabilityof havinganejectionfraction<50%afterameanfollowupof 40monthsrosesignificantlywhenthepreoperativeejection fractionwas<60%,and/or whenthe LVend-systolic diam-eterwas>40mm[24].Thereiscurrentlynodefinitelower thresholdthatwouldcontraindicateadoublevalve proce-dure,particularlyifARispredominant.

Surgery

and

prognosis

In a study dating back to the early 1990s, Niles et al. reportedthatpatientswithdoublevalvereplacementhad

significantlyreducedpostoperativesurvival,andmore fre-quently reportedpersistent postoperative symptoms than patients who underwent surgery for single valve disease

[18].More recently,Pai etal.reportedonaseriesof 191 patients withsevereAR andconcomitant grade3—4+ MR. Among them,65 patientsunderwentaortic valve replace-ment, and had significantly better survival than patients whodidnothaveaorticvalvereplacement[6].Importantly, among these patients, 39 had concomitant mitral valve surgery and 26 had only isolated aortic valve surgery. In thislimitedseries,asurvivalbenefitwasobservedonly in the subgroup that had undergone mitral valve repair (17 patients).Similarbenefitsofmitralvalverepairhavebeen observedinretrospectiveseriesthatincludedpatientswho hadsurgery for both ARandMR [31,32],but studieshave also been published in which no benefit of mitral repair over replacement was shown [33,34]. Prospective data addressingthisissuearecurrentlylacking.Combinedaortic and mitralvalve repair has occasionally been attempted, yielding acceptablelong-term survival rates,but withthe drawbackoflimiteddurability,leadingtoa10-year reoper-ationrateof35%[35].

Figure6. Managementstrategyaccordingtotheseverityofaorticregurgitation(AR)andofmitralregurgitation(MR),accordingtothe AmericanHeartAssociation/AmericanCollegeofCardiologyguidelinesforthemanagementofpatientswithvalvularheartdisease[2]. CABG:coronaryarterybypassgrafting;LOE:levelofevidence;LV:leftventricular;RV:rightventricular.

Management

according

to

lesion

severity

Current literature lacks evidence-based management strategies,asemphasized bytheC levelof evidence sup-porting most recommendations in the current guidelines fromEuropeandtheUSA[1,2].Nomedicaltreatment has provedbeneficialforisolatedorcombinedARandMR. How-ever,asisrecommendedinisolatedAR,highbloodpressure shouldbe corrected usingvasodilators, and diuretics may playanimportantroleinreducingcongestionandsymptoms inpatients withcombinedARandMR forwhomsurgeryis notfeasible.Conventionalheartfailuretreatments, includ-ingangiotensin-convertingenzymeinhibitors,beta-blockers andmineralocorticoidreceptorsantagonists,shouldnotbe used in asymptomatic patients without LV dysfunction to avoid delay in symptom onset and, hence, in referral to surgery,butshouldbeconsideredappropriateinpatientsnot consideredforsurgery,orifsymptomsand/orLVdysfunction persistordevelopaftersurgery.

Inclinical practice,thecombination ofARandMR usu-allypresentsasoneofthefollowingscenarios:(1)thetwo regurgitationsaresevere;(2)ARissevereandMRis mod-erate;or(3)MRissevereandARismoderate.Mildlesions needonlywatchfulwaiting.Amanagementstrategyadapted fromcurrentAmericanHeartAssociation/AmericanCollege of Cardiology (AHA/ACC) guidelinesis presented in Fig. 6

[2].

Scenario

1:

The

two

lesions

are

severe

Inthissetting,bothlesionsshouldbetreated.Mitralvalve repairor replacement inpatientswithchronic severe pri-maryMRundergoingaorticvalvereplacementhasreceived aClassIrecommendation(levelof evidenceB),but hasa ClassIIarecommendation(levelofevidenceC)forsecondary MR. Aortic valvereplacement has a Class I recommenda-tion(levelofevidenceC)forpatientswithsevereARwhile undergoingsurgeryforMR.

Scenario

2:

AR

is

severe

and

MR

is

moderate

SevereARshouldbemanaged accordingtocurrent guide-lines. However, whether moderate MR should be treated concomitantly remains controversial. Indeed, no survival benefit has been demonstrated after the surgical treat-ment of moderate secondary MR in prospective studies. MitralvalverepairinpatientswithmoderatesecondaryMR undergoingcoronaryarterybypasssurgerythereforehasa ClassIIbrecommendation(level ofevidence C)in current AHA/ACCguidelines.Moreover,thelikelihoodofMR improv-ingfollowing aorticvalvereplacementishigh,makingthe need totreat MR in this setting evenmore questionable. Despitethelackofarandomizedcomparisonbetweenvalve replacement andrepair, it is widely accepted that, when feasible,valverepairisthepreferredtreatmentfor moder-ateprimaryMR.Therefore,concomitantmitralvalverepair isconsideredreasonableinpatientswithchronicmoderate primaryMRundergoingcardiacsurgeryforotherindications (ClassIIa,levelofevidenceC).

Scenario

3:

MR

is

severe

and

AR

is

moderate

SevereMRshouldbemanagedaccordingtocurrent guide-lines.Correctingmoderate ARat thetimeof mitralvalve surgeryisconsideredasreasonable intheAHA/ACC guide-lines (Class IIa, level of evidence C), because of the likelihoodofprogressiveworseningofARovertime.

Occasionally, twomoderate lesions mayhave deleteri-ousclinicalrepercussions,includingsymptoms,LVdilatation with or without dysfunction, reduction in net forward flow,increased natriuretic peptide concentrations and/or impairedexercisetolerancewithmaximaloxygen consump-tion(Fig.7). To the bestof our knowledge, nostudy has assessed the impactof combinedmoderate ARand mod-erate MR, and this scenario is not addressed in current guidelines. Nevertheless, such patients should undergo a thorough assessment of the global repercussions of the tworegurgitantlesions. Ifthe results are consistent with

438 P.Ungeretal.

Figure7. AandB.Rheumaticheartdisease,includingmoderatemitralregurgitation(mitraleffectiveregurgitantorifice0.25cm2_;A)

andmoderateaorticregurgitation(venacontracta5mm;B).CandD.Althougheachlesionisseparatelyconsideredmoderate,theleft ventricleismildlydilated(end-diastolicdiameter58mm),consistentwithasignificantglobalimpactofthetworegurgitations.

asignificant globalhaemodynamic impact, valverepair or replacementmightbeconsidered,butthisstrategyrequires carefulexclusionofconfoundingfactors,includingchronic lungdiseaseandprimaryventriculardysfunction.

Themanagementofasymptomaticpatientsinthesetting of combined AR and MR also lacks evidence-based sup-port.Ifthetwolesionsaresevere,the stricterthresholds of MR should be used to indicate surgery, including a LV end-systolic diameter≥40mm and/or a LV ejection

frac-tion<60%[1,24].IfMRorARispredominant,therespective

thresholdsin current guidelines shouldbeused [1,2],but evensubtleevidenceforLVdysfunction,includingreduced globallongitudinalstrain,mightbeconsideredasan incen-tiveforearliersurgery.Asmentionedabove,anassessment of the global repercussion should be strongly considered, including exercise testing to detect pseudoasymptomatic patients.

Role

of

transcatheter

interventions

Percutaneousrepair ofMRhas beenshown tobesafeand efficacious[36]. Although ithas notyet become standard

practice,thereisrecentevidencethattranscatheteraortic valvereplacementmaybefeasibleinpatientsathigh sur-gicalrisk withnativevalveAR[37].However,theuseofa fullytranscatheterapproachforthetwoconditionsremains exceptional.Inarecentliteraturereview,Andoetal. iden-tified37 studiesincluding60patients consideredtobeat high or inoperable surgical risk who had combined tran-scatheteraorticandmitralvalveintervention.Amongthese, fourpatients(7%)hadbothARandMR,threeofwhomhad undergoneatleastonevalve-in-valveprocedure.Onlyone patient had a fully transcatheter approach performed on nativevalves[38,39].

Conclusions

There arelimiteddatatoguide themanagementof com-bined AR and MR. LV dysfunction is frequent at initial presentationandpostoperativeLVdysfunctioniscommon, suggestingthatsurgicalmanagementshouldnotbedelayed, particularlywhensymptomsoccurorwhenthereisevidence of LV dysfunction. As with other combined valve disease

combinations,all decisionsshouldbemadeby a multidis-ciplinaryheartteaminordertooptimizepatientoutcomes. The roleof transcatheterapproaches iscurrently limited, but technologicaladvanceswill probablysoon change the managementparadigm.

Disclosure

of

interest

Theauthorsdeclarethattheyhavenocompetinginterest.

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