What is the management plan for a patient with severe aortic stenosis, severe mitral and tricuspid regurgitation, severe pulmonary hypertension, and signs of heart failure, including left and right atrial dilation and pleural effusion?

Management of Multi-Valvular Disease with Heart Failure

This patient requires urgent surgical intervention with combined aortic valve replacement and concomitant tricuspid valve repair, with strong consideration for mitral valve surgery during the same operation. 1

Immediate Medical Stabilization

Initiate aggressive diuretic therapy to manage volume overload from right-sided heart failure, evidenced by bilateral atrial dilation and pleural effusion. 1

• Loop diuretics are the primary agents for relieving systemic and pulmonary congestion 1
• Add aldosterone antagonists given the likely hepatic congestion from severe tricuspid regurgitation and elevated right atrial pressure 1
• Monitor closely for worsening low-flow syndrome, as diuretics may paradoxically worsen cardiac output in this setting 1

Surgical Strategy and Timing

The presence of severe aortic stenosis requiring intervention creates a Class I indication to address the severe tricuspid regurgitation simultaneously. 1

Aortic Valve Management

• Surgical aortic valve replacement (SAVR) is indicated for symptomatic severe aortic stenosis with heart failure 1
• The severely calcified valve with reduced excursion and concomitant mild-to-moderate aortic regurgitation favors SAVR over TAVR in this multi-valve scenario 1
• TAVR alone would leave the other severe valvular lesions unaddressed 1

Tricuspid Valve Management

Tricuspid valve repair is strongly recommended at the time of left-sided valve surgery. 1

• The severe tricuspid regurgitation with severe pulmonary hypertension and right atrial dilation will not predictably improve after aortic valve replacement alone 1
• Reoperation for isolated tricuspid regurgitation carries 10-25% perioperative mortality, making concomitant repair essential 1
• Tricuspid valve repair adds minimal operative risk and ischemic time compared to the substantial risk of leaving it untreated 1
• Critical caveat: The presence of severe tricuspid regurgitation with severe pulmonary hypertension represents a very poor prognostic sign and is associated with dismal outcomes regardless of treatment strategy 2

Mitral Valve Management

The moderate-to-severe mitral regurgitation requires careful intraoperative assessment and likely concomitant repair. 1, 3

• Degenerative mitral valve disease will not improve after aortic valve replacement 4
• Mitral valve repair is strongly preferred over replacement when feasible 1
• The severely dilated left atrium indicates chronic severe mitral regurgitation that has already caused significant hemodynamic consequences 3
• Symptomatic patients with severe mitral regurgitation and LVEF >30% have a Class I indication for surgery 1

Risk Stratification and Prognosis

This patient faces extremely high operative risk due to the combination of severe tricuspid regurgitation and severe pulmonary hypertension. 2

• In one study, 50% of patients with moderate-to-severe tricuspid regurgitation undergoing valve surgery died within 3 months postoperatively, compared to only 3% without significant tricuspid regurgitation 2
• However, conservative management carries even worse outcomes - patients with severe aortic stenosis and concomitant mitral regurgitation managed conservatively have significantly lower survival than those undergoing valve intervention 2
• The severely dilated atria, pleural effusion, and elevated right atrial pressure indicate advanced heart failure that will progress without intervention 1

Critical Decision Points

Assess for contraindications to surgery:

• Severe right ventricular systolic dysfunction (check tricuspid annular plane systolic excursion - normal is >2.0 cm) 5
• Irreversible pulmonary hypertension (measure pulmonary vascular resistance and transpulmonary gradient) 1
• Life expectancy <1 year from non-cardiac causes 1

If surgical risk is prohibitive:

• Consider staged approach with TAVR first, though this leaves mitral and tricuspid regurgitation unaddressed 1, 4
• Palliative medical management with aggressive diuresis may be appropriate if surgical mortality risk exceeds potential benefit 1
• However, medical therapy alone for severe functional tricuspid regurgitation has limited efficacy 1

Preoperative Optimization

• Invasive hemodynamic assessment with right heart catheterization to measure pulmonary vascular resistance and confirm pulmonary hypertension mechanism 1, 5
• Cardiac MRI or 3D echocardiography for precise assessment of right ventricular function and volumes if 2D echo is suboptimal 1
• Coronary angiography to exclude significant coronary disease requiring concomitant CABG 1

The mildly increased left ventricular wall thickness with normal ejection fraction suggests the ventricle can tolerate multi-valve surgery, but the window for intervention is closing given the advanced right heart failure. 5