What is the best course of treatment for a patient with moderate to severely reduced left ventricular systolic function, mild mitral stenosis, mild mitral regurgitation, and mild to moderate valvular aortic stenosis?

Management of Multi-Valvular Disease with Reduced Left Ventricular Function

This patient requires comprehensive guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) as the immediate priority, followed by multidisciplinary Heart Team evaluation for potential surgical intervention addressing the aortic stenosis, mitral valve disease, and tricuspid regurgitation simultaneously. 1

Immediate Medical Management

Initiate or optimize GDMT for HFrEF (LVEF 30-35%) immediately, as this addresses the underlying left ventricular dysfunction and provides mortality benefit regardless of valve disease etiology. 1, 2

Heart Failure Pharmacotherapy

• Start sacubitril-valsartan (target dose 97mg/103mg twice daily) as the preferred neurohormonal antagonist, beginning at 49mg/51mg twice daily if not previously on ACE inhibitor/ARB, or 24mg/26mg twice daily if previously on low-dose therapy. 2

• Add beta-blocker (carvedilol, metoprolol succinate, or bisoprolol) titrated to target doses for mortality reduction in HFrEF. 1

• Initiate mineralocorticoid receptor antagonist (spironolactone or eplerenone) given the severely reduced LVEF and evidence of volume overload (dilated IVC with no collapse). 1

• Optimize diuretic therapy aggressively given the elevated right ventricular systolic pressure (49 mmHg), dilated IVC, and likely volume overload contributing to functional mitral and tricuspid regurgitation. 1

Critical Medication Considerations

• Monitor potassium closely when combining sacubitril-valsartan with mineralocorticoid antagonists, as hyperkalemia risk increases substantially. 2

• Avoid NSAIDs as they increase renal impairment risk in patients on renin-angiotensin system inhibitors. 2

• There is no evidence supporting vasodilators (including ACE inhibitors alone) for chronic mitral regurgitation beyond their role in HFrEF management. 1

Surgical Evaluation and Timing

Refer urgently to a multidisciplinary Heart Team including heart failure specialists, cardiac surgeons, and interventional cardiologists for evaluation of combined valve surgery. 1

Indications for Surgical Intervention

Surgery is indicated based on multiple guideline criteria being met simultaneously:

• Aortic stenosis: Mild-to-moderate valvular AS with LVEF <50% warrants consideration for intervention, particularly when combined with other valve disease requiring surgery. 1

• Mitral regurgitation: Surgery is indicated for symptomatic patients with chronic severe MR and LVEF >30%, which this patient meets. 1, 3

• Mitral stenosis: While mild, the presence of pulmonary hypertension (RVSP 49 mmHg) in the context of other valve disease requiring surgery makes concomitant mitral intervention appropriate. 1

• Tricuspid regurgitation: Moderate-to-severe TR with dilated annulus (evidenced by severely dilated IVC) is an indication for tricuspid surgery when performing left-sided valve surgery. 1

Surgical Approach for Combined Valve Disease

Combined valve surgery addressing all significant lesions in a single operation is the preferred approach rather than staged procedures. 1

• Aortic valve replacement (surgical AVR preferred over TAVI given multiple valve involvement and need for concomitant procedures). 1

• Mitral valve repair is strongly preferred over replacement when technically feasible, as repair provides superior outcomes. 1, 4

• Tricuspid annuloplasty should be performed concomitantly using prosthetic ring (superior long-term results compared to suture annuloplasty: 10% vs 20-35% residual TR at 5 years). 1

Timing Considerations

Early surgery (within 2 months of meeting indications) is associated with better outcomes, as even mild symptoms at time of surgery correlate with worse post-operative cardiac function. 1

However, LVEF 30-35% represents a critical threshold:

• Surgery is indicated for LVEF >30% in mitral regurgitation. 1
• If LVEF approaches or falls below 30%, non-cardiac surgery should only be performed if strictly necessary after GDMT optimization. 1
• Operative mortality correlates inversely with LVEF, with LVEF <25% associated with significantly increased surgical risk. 1

Monitoring and Optimization Period

While awaiting surgical evaluation, implement intensive monitoring:

• Serial echocardiography every 3-6 months to assess for further LV deterioration, progression of valve disease, or improvement with GDMT. 3

• Monitor for symptom progression including worsening dyspnea, exercise intolerance, or signs of right heart failure. 1, 3

• Assess for cardiac resynchronization therapy (CRT) candidacy if QRS duration ≥120ms with LBBB morphology, as CRT may improve both LV function and secondary mitral regurgitation. 5

• Optimize volume status as functional mitral and tricuspid regurgitation may improve with aggressive diuresis and GDMT, potentially impacting surgical planning. 1, 5

Critical Pitfalls to Avoid

Do not delay surgical referral assuming GDMT alone will suffice—this patient has structural valve disease requiring mechanical correction, and delaying surgery until further LV deterioration occurs worsens outcomes. 1, 6

Do not underestimate the hemodynamic significance of "mild" stenotic lesions when combined with regurgitant lesions—the interaction between multiple valve lesions creates complex hemodynamics where mild AS may contribute significantly to LV afterload when combined with MR. 1, 7, 8

Do not assume LVEF accurately reflects contractility in mitral regurgitation—the reduced afterload from regurgitation can mask myocardial dysfunction, and "normal" LVEF in severe MR may actually represent early dysfunction. 3, 9

Do not perform isolated mitral or tricuspid surgery without addressing the aortic stenosis, as residual AS will limit hemodynamic improvement and may necessitate reoperation. 1

Do not use NOACs for anticoagulation if mechanical valve prosthesis is implanted—only vitamin K antagonists (warfarin) are indicated. 1

Expected Outcomes

Successful combined valve surgery with GDMT optimization can provide:

• Symptomatic improvement in heart failure symptoms 1
• Potential for LV reverse remodeling if myocardial dysfunction is partially reversible 1, 5
• Reduction in pulmonary hypertension with correction of left-sided lesions 1
• Improved long-term survival compared to medical management alone 1, 6

The presence of moderate-to-severe LV dysfunction (LVEF 30-35%) indicates advanced myocardial damage (Stage 1-2 myocardial damage in AS), emphasizing the urgency of intervention before irreversible dysfunction develops. 1