What is the expected management for a patient with eccentric left ventricular hypertrophy, mild to moderate mitral stenosis, severe mitral and tricuspid regurgitation, aortic valve sclerosis with regurgitation, and elevated pulmonary artery pressures?

Management of Complex Valvular Heart Disease with Pulmonary Hypertension

Surgical intervention is strongly recommended for this patient with multiple severe valvular abnormalities including severe mitral and tricuspid regurgitation, mild-to-moderate mitral stenosis, and pulmonary hypertension. The echocardiogram shows a constellation of findings that indicate advanced valvular heart disease requiring definitive treatment.

Valvular Pathology Assessment

• The patient has eccentric left ventricular hypertrophy with adequate systolic function, indicating compensatory remodeling in response to the valvular disease 1
• Severe mitral regurgitation with mild-to-moderate mitral stenosis (MVA 2.8 cm²) and thickened, calcified leaflets with a Wilkins score of 8 2
• Severe tricuspid regurgitation with structurally normal valve, likely functional due to right heart dilation 2
• Aortic valve sclerosis with moderate (+3) aortic regurgitation 2
• Pulmonary hypertension with pulmonary artery systolic pressure of 50 mmHg 2, 3
• Dilated left atrium, right atrium, and right ventricle, indicating chronic volume overload 2

Management Recommendations

Surgical Intervention

• Combined valve surgery is indicated for this patient with multiple severe valvular lesions and pulmonary hypertension 2
• Mitral valve surgery (repair preferred over replacement when feasible) is recommended for severe mitral regurgitation with associated symptoms, left atrial enlargement, and pulmonary hypertension 2
• Concomitant tricuspid valve repair should be performed for severe tricuspid regurgitation, as isolated aortic or mitral valve surgery may not improve significant tricuspid regurgitation 2
• Assessment of aortic valve during surgery to determine need for intervention on moderate aortic regurgitation 2

Specific Surgical Considerations

• Mitral valve repair is preferred over replacement when technically feasible, particularly for the mitral regurgitation component 2
• If repair is not possible due to significant calcification and thickening (Wilkins score 8), mitral valve replacement may be necessary 2
• Tricuspid valve repair with ring annuloplasty is preferred over replacement for functional tricuspid regurgitation 2
• The presence of severe tricuspid regurgitation significantly increases perioperative risk but should not preclude intervention given the poor prognosis without treatment 4

Risk Assessment

• Pulmonary hypertension (PASP 50 mmHg) increases perioperative risk but is also an indication for intervention to prevent further right ventricular deterioration 5, 3
• The combination of severe mitral and tricuspid regurgitation with pulmonary hypertension identifies a high-risk population 4
• Right ventricular function assessment is crucial as it is a key determinant of perioperative and long-term outcomes 5

Preoperative Optimization

• Optimal management of heart failure with guideline-directed medical therapy should be initiated before surgical intervention 2
• Diuretics to manage volume overload and reduce congestive symptoms 2
• Assessment for atrial fibrillation, which is common in this setting and may require additional management 6
• Comprehensive evaluation of coronary artery disease risk prior to surgery 2

Alternative Approaches

• If surgical risk is prohibitively high, transcatheter options might be considered:
  • Percutaneous mitral valve repair (edge-to-edge repair) may be considered for high surgical risk patients with severe mitral regurgitation 2
  • However, the presence of both stenosis and regurgitation may limit transcatheter options 2

Prognosis and Follow-up

• Without intervention, prognosis is poor with progressive right ventricular dysfunction and heart failure 4
• Successful valve surgery can improve functional status and long-term survival, even in patients with pulmonary hypertension 5
• Regular echocardiographic follow-up is essential after intervention to monitor valve function, ventricular remodeling, and pulmonary pressures 2

Important Caveats

• The presence of severe tricuspid regurgitation significantly increases perioperative mortality (up to 50% in some series with moderate-to-severe TR) 4
• Delaying surgery until development of right ventricular failure significantly worsens outcomes 5
• The decision between mitral valve repair versus replacement should be made by an experienced surgical team based on valve morphology and institutional expertise 2