What is the recommended management for severe aortic stenosis (AS) combined with aortic regurgitation (AR)?

Management of Severe Aortic Stenosis with Concurrent Aortic Regurgitation

In patients with combined severe aortic stenosis (AS) and aortic regurgitation (AR), surgical aortic valve replacement is indicated when symptoms are present or when specific hemodynamic thresholds are met, with treatment decisions guided by which lesion is predominant. 1

Symptomatic Patients

Immediate aortic valve replacement (AVR) is mandatory for any patient with symptoms (heart failure, angina, syncope, dyspnea), regardless of left ventricular ejection fraction. 1, 2, 3

Determining the Dominant Lesion

• When peak transvalvular velocity is ≥4.0 m/s or mean gradient is ≥40 mmHg, the AS component is considered dominant and drives the treatment decision in symptomatic patients 1
• Careful multimodality assessment with transthoracic echocardiography, transesophageal echocardiography, and cardiac MRI is required to identify which valve pathology is predominant 1
• The severity of both lesions must be quantified using standard echocardiographic parameters: for AS (peak velocity, mean gradient, valve area) and for AR (regurgitant volume, effective regurgitant orifice, vena contracta width) 1

Choice of Intervention

• Surgical AVR (mechanical or bioprosthetic) remains the standard treatment for mixed aortic valve disease 1, 2
• TAVR should not be performed in patients with isolated severe AR who are surgical candidates 1, 2
• However, TAVR may be considered in highly selected, inoperable patients at experienced centers when AS is the dominant lesion 1, 4, 5
• Aortic valve repair may be considered at experienced centers when anatomy is favorable and durable results are expected 1, 2

Asymptomatic Patients with Mixed Disease

Indications for Surgery Based on AS Component

When AS is dominant (peak velocity ≥4.0 m/s), surgery is indicated for asymptomatic patients when: 2

• LVEF falls below 50% without another identifiable cause 1, 2
• Peak aortic jet velocity ≥5.0 m/s 2
• Rapid progression (velocity increase >0.3 m/s per year) 2
• Abnormal exercise testing showing symptoms, hypotension, or complex arrhythmias 2
• Marked valve calcification with elevated natriuretic peptides 2

Indications for Surgery Based on AR Component

When AR is dominant or equally severe, surgery is indicated for asymptomatic patients when: 1, 2

• LVEF ≤50% (ESC) or ≤55% (ACC/AHA) without another cause 1, 3
• LV end-systolic dimension >50 mm or indexed >25 mm/m² 1, 2
• LV end-systolic dimension >45 mm (reasonable threshold per ACC/AHA) 1
• LV end-diastolic dimension >65 mm (ACC/AHA) or >60 mm (ESC) 1, 2
• Progressive LV dysfunction documented on at least three serial studies 1

Risk Stratification and Surgical Approach

Surgical Risk Assessment

• Low surgical risk (STS-PROM <3%): SAVR is the standard of care 2
• Intermediate risk (STS-PROM 3-10%): Either SAVR or TAVR may be selected when AS is dominant 2
• High or prohibitive risk: TAVR is preferred when AS is the predominant lesion 2
• EuroSCORE II should be used for comprehensive risk assessment 1

Aortic Root Considerations

• When aortic root diameter is ≥45 mm, replacement of the aortic sinuses and/or ascending aorta is reasonable at the time of AVR 1, 2
• Valve-sparing surgery may be considered in patients with bicuspid aortic valve at comprehensive valve centers 1

Medical Management

Bridging to Surgery

• Medical therapy to reduce LV afterload (ACE inhibitors, ARBs, or dihydropyridine calcium channel blockers) may be used for temporary stabilization but should not delay surgery 1, 3
• Target systolic blood pressure <140 mmHg using vasodilators that do not slow heart rate 3
• Avoid beta-blockers as they prolong diastole and increase regurgitant volume 3

When Surgery is Not Feasible

• Guideline-directed medical therapy with ACE inhibitors, ARBs, and/or sacubitril/valsartan is recommended for patients with prohibitive surgical risk 1, 3
• Balloon aortic valvuloplasty may serve as a bridge to definitive intervention in critically ill patients with dominant AS 6

Concurrent Mitral Valve Disease

When Severe Mitral Regurgitation is Present

• Dual valve surgery is recommended when both AR and MR are severe 1
• Treatment should be guided by the predominant valvular pathology 1
• For primary MR (unlikely to improve after AVR alone): combined aortic and mitral valve surgery in low- or intermediate-risk patients 2
• For secondary MR (may improve after AS correction): treat the aortic lesion first and reassess MR severity after AVR 2, 7

Critical Pitfalls to Avoid

• Do not delay surgery in symptomatic patients for medical optimization—mortality risk increases substantially with watchful waiting 3
• Do not use TAVR for isolated severe AR in surgical candidates, as outcomes are inferior to SAVR 1, 2
• Do not rely on LVEF alone in mixed disease—LV dimensions and serial changes are equally important surgical triggers 1, 2
• Intra-aortic balloon counterpulsation is contraindicated in patients with significant AR 1
• Do not underestimate the AR component when AS appears dominant—post-TAVR AR is more common in mixed disease and impacts outcomes 4

Monitoring Strategy

• Serial echocardiography every 6-12 months for severe mixed disease to detect LV functional decline or progressive dilatation 2, 3
• Cardiac MRI or CT should be employed when echocardiographic windows are suboptimal or to detect subtle progressive LV dysfunction 1, 2
• More frequent monitoring (every 3-6 months) is required when the LV is actively dilating 3