What is the management plan for a patient with mild to moderate regurgitation of the aortic, mitral, tricuspid, and pulmonic valves, with normal left ventricular (LV) function and no evidence of pulmonary hypertension?

Management of Multi-Valvular Regurgitation with Preserved LV Function

This patient requires conservative management with clinical and echocardiographic surveillance every 6-12 months, as none of the valvular lesions meet criteria for intervention and LV function remains normal. 1, 2, 3

Surveillance Strategy

Annual echocardiography is recommended to monitor for:

• Progression of any regurgitant lesion to severe 3
• Development of LV systolic dysfunction (LVEF <55-60%) 1, 2, 3
• LV chamber enlargement (LVESD >50mm or indexed >25mm/m²) 1, 2
• Symptoms attributable to valvular disease 1

Clinical evaluation should occur every 6-12 months to assess for exercise intolerance, dyspnea, paroxysmal nocturnal dyspnea, or orthopnea. 1, 3

Medical Management

Vasodilator therapy is reasonable for the aortic regurgitation component, specifically:

• ACE inhibitors or dihydropyridine calcium channel blockers (amlodipine, nifedipine) to reduce afterload 2, 3
• Avoid beta-blockers, as they prolong diastolic filling time and worsen AR by increasing regurgitant volume 2, 3

For hypertension management (given the mild-moderate LVH), ACE inhibitors or dihydropyridine calcium channel blockers are preferred over beta-blockers. 2, 3

Critical Monitoring Parameters

The combination of multiple regurgitant lesions creates unique hemodynamic challenges that may cause symptoms earlier than isolated valve disease. 1, 2 Specifically monitor for:

• LV remodeling: The mild-moderate LVH suggests chronic pressure/volume overload that requires close observation 1
• Exercise capacity: Consider exercise testing if symptoms are uncertain, as patients with mixed valve disease may develop functional limitations at lower thresholds 1
• Atrial pressures: Multiple regurgitant lesions increase left atrial pressure burden, potentially causing pulmonary symptoms before severe LV dysfunction develops 1

Surgical Intervention Thresholds

Surgery would be indicated if any of the following develop:

• Symptoms attributable to valvular disease despite optimal medical therapy 1, 3
• LVEF decline to <55% (for AR) or <60% (for MR) 1, 2, 3
• LVESD >50mm or indexed LVESD >25mm/m² 1, 2, 3
• Development of severe regurgitation in any valve 1

Common Pitfalls

Do not dismiss mild-moderate symptoms in patients with multiple moderate regurgitant lesions—the combined hemodynamic burden may be greater than each individual lesion suggests. 1, 2 Exercise hemodynamic studies should be considered if symptoms seem disproportionate to resting echocardiographic findings. 1

Avoid aggressive heart rate reduction with beta-blockers, as this worsens AR by prolonging diastolic time and increasing regurgitant volume per beat. 2, 3

The mild-moderate aortic regurgitation requires specific attention to volume status and avoidance of bradycardia, particularly if the patient requires any surgical procedure. 1, 2

Special Considerations for Non-Cardiac Surgery

Elective non-cardiac surgery can be safely performed in this asymptomatic patient with preserved LV function and no pulmonary hypertension. 1 However, perioperative management requires:

• Careful volume status monitoring 1, 2
• Avoidance of bradycardia 1, 2
• Intensive hemodynamic monitoring in the immediate postoperative period 1