What is the management of heart failure secondary to severe Aortic Stenosis (AS) and Mitral Stenosis (MS)?

Management of Heart Failure Secondary to Severe AS and MS

For patients with heart failure secondary to severe aortic stenosis (AS) and mitral stenosis (MS), valve intervention is the definitive treatment and should be performed at specialized heart valve centers by experienced operators. 1

Initial Assessment and Medical Management

Medical Therapy for Symptom Control

• Diuretics: For symptom relief when edema or congestion is present 1
• Beta blockers: Preferably beta-1 selective agents to control heart rate and lengthen diastole, improving LV filling 1
• Digoxin: May be considered for heart rate control in patients with atrial fibrillation 1
• Anticoagulation:
  • Vitamin K antagonists (VKAs) recommended for patients with atrial fibrillation 1
  • Consider anticoagulation even in sinus rhythm if TOE shows spontaneous contrast or enlarged LA (M-mode diameter >60 mL/m²) 1

Optimization Before Intervention

• Ensure patients are on optimally tolerated doses of guideline-directed medical therapy before determining severity and intervention needs 1
• Medical therapy alone is inadequate for long-term management of severe stenotic valve disease causing heart failure

Interventional Management

For Severe Mitral Stenosis (MVA ≤1.0 cm²):

1. Percutaneous Mitral Balloon Commissurotomy (PMBC) is first-line for rheumatic MS with favorable anatomy 1

   • Contraindications: More than mild MR, LA thrombus
   • Indications in symptomatic patients:
     • No contraindication to PMBC and high surgical risk
     • Patients with suboptimal anatomy but no unfavorable clinical characteristics

2. Mitral Valve Surgery when:

   • PMBC is unavailable or has failed
   • Concurrent significant MR is present
   • Degenerative MS (calcific) is present (PMBC ineffective)
   • Patient requires cardiac surgery for other reasons

For Severe Aortic Stenosis:

1. Surgical Aortic Valve Replacement (SAVR) for:

   • Low to intermediate surgical risk patients
   • Patients with concomitant CAD requiring CABG
   • Patients with other valvular or aortic disease requiring surgery

2. Transcatheter Aortic Valve Replacement (TAVR) for:

   • High surgical risk patients
   • Patients with frailty or significant comorbidities not captured in risk scores
   • Patients with porcelain aorta or hostile chest 1

Management of Combined AS and MS

• Combined valve disease is complex and may be symptomatic even when each lesion is only moderate 1, 2
• Invasive hemodynamic assessment is often helpful in mixed valve lesions 1
• For patients with both severe AS and rheumatic MS:
  • SAVR + PMBC may be appropriate in selected cases 1
  • SAVR + mitral valve surgery for most cases
• For patients with both severe AS and calcific MS:
  • Combined surgical approach is typically required 1

Special Considerations

Asymptomatic Patients

• Intervention may be appropriate in asymptomatic severe MS when:
  • PASP >50 mmHg at rest
  • Increased risk of systemic embolism (history of embolism, dense spontaneous contrast in LA)
  • Need for major non-cardiac surgery
  • Desire for pregnancy 1

Pregnancy

• Severe MS is associated with high risk during pregnancy
• Even mild MS may be poorly tolerated due to increased heart rate and stroke volume
• PMBC should be considered for severe MS before or during pregnancy

• 50% of women without previous symptoms will develop heart failure during pregnancy 1

Multivalvular Disease

• The combination of MS and MR can lead to marked LA pressure elevations 1
• Patients with both moderate AS and MS frequently have heart failure symptoms (41%) 2
• Independent determinants of HF symptoms in combined AS/MS include:
  • Left ventricular ejection fraction
  • Stroke volume index
  • Atrial fibrillation
  • Right ventricular systolic pressure 2

Follow-up and Monitoring

• For asymptomatic severe MS (MVA ≤1.0 cm²):
  • Follow-up frequency ranges from every 6 months to every 3-5 years depending on guidelines 1
• For symptomatic patients after intervention:
  • Regular echocardiographic assessment to evaluate valve function and hemodynamics
  • Monitor for recurrent symptoms or valve dysfunction

Pitfalls to Avoid

1. Underestimating the dynamic nature of secondary MR - Severity can change with loading conditions and medical therapy 1
2. Failing to distinguish between rheumatic and degenerative MS - Treatment approaches differ significantly 1
3. Overlooking the need for anticoagulation - Especially important in MS due to risk of LA thrombus
4. Delaying intervention in pregnancy - Can lead to maternal and fetal complications 1
5. Missing the hemodynamic impact of combined valve lesions - Even moderate stenosis of both valves can cause significant symptoms 2