Management of Severe Valvular Heart Disease Involving Both Mitral and Aortic Valves
When both the mitral and aortic valves are severely diseased, surgery on both valves is the preferred approach when not contraindicated, as this provides the most definitive treatment and best long-term outcomes. 1
Primary Decision Framework
When Both Valves Are Severely Diseased
Proceed with double valve surgery when the patient is an acceptable surgical candidate, as this addresses both lesions definitively and prevents the need for staged procedures 1. The 2017 ESC/EACTS guidelines explicitly state that in patients with severe mitral stenosis combined with severe aortic valve disease, surgery is preferable when not contraindicated 1.
Key considerations for double valve surgery:
- Age and surgical risk must be carefully assessed, as double valve surgery carries higher operative risk than single valve procedures 2
- Left ventricular function is frequently impaired at presentation in combined valve disease, and deteriorates further postoperatively if surgery is delayed 2
- The type of prosthesis matters more with double valve replacement—multiple mechanical valves increase long-term thrombotic and bleeding complications 2
When One Valve Is Severe and the Other Moderate
If mitral stenosis is severe but aortic disease is only moderate, percutaneous mitral commissurotomy (PMC) can be performed to postpone surgical treatment of both valves 1. This strategy is particularly useful in:
- Patients with favorable mitral valve anatomy for PMC 1
- Younger patients where delaying double valve surgery is advantageous 1
- High-risk surgical candidates 1
When Surgery Is Contraindicated
Management becomes extremely difficult and requires comprehensive individualized evaluation by a multidisciplinary Heart Team 1. The guidelines acknowledge this scenario has limited evidence and no clear algorithmic approach 1.
Critical Timing Considerations
Do not delay surgery once symptoms develop or left ventricular dysfunction appears, even if subtle 2. Combined aortic and mitral regurgitation leads to:
- Frequent left ventricular dysfunction at initial presentation 2
- Even more frequent LV dysfunction postoperatively if surgery is delayed 2
- Irreversible ventricular damage if intervention is postponed 3, 4
Prosthesis Selection Strategy
For double valve replacement, the choice between mechanical and bioprosthetic valves requires careful consideration 1:
Age-based recommendations:
- Under 60 years: Mechanical prostheses are reasonable, accepting the burden of lifelong anticoagulation 1
- 60-70 years: Either mechanical or bioprosthetic valves are reasonable 1
- Over 70 years: Bioprosthetic valves are reasonable 1
Anticoagulation requirements with mechanical valves:
- Mechanical aortic valve: INR 2.5 (or INR 3.0 if additional risk factors present) 1
- Mechanical mitral valve: INR 3.0 1
- Add aspirin 75-100 mg daily to warfarin for all mechanical valves 1
Common Pitfalls to Avoid
Never apply single-valve disease management algorithms to combined valve disease—the hemodynamics are fundamentally different and more complex 5, 2. The quantitative assessment of each individual regurgitant lesion becomes critical when both valves are involved 5.
Do not leave a moderately diseased valve unoperated if the patient is already undergoing surgery for the other valve, as this increases the probability of requiring redo surgery 2. Concomitant valve surgery is indicated even for moderate disease when operating on another valve 1.
Avoid delaying surgery waiting for "more definitive indications" in combined valve disease—left ventricular dysfunction develops insidiously and may be irreversible by the time it becomes obvious 2.
Role of Transcatheter Approaches
Transcatheter options remain limited for combined valve disease 2. While TAVI is now approved for aortic stenosis across all risk categories 6, and transcatheter edge-to-edge repair exists for mitral regurgitation 6, there is minimal data on combined transcatheter approaches for double valve disease. Technological advances will likely expand these options in the future 2.
Heart Team Evaluation
All decisions regarding combined valve disease must involve a multidisciplinary Heart Team including interventional cardiologists, cardiothoracic surgeons, imaging specialists, and valve experts 1, 2. This is particularly critical when: