Beyond Aortic Stenosis: Addressing the Challenges of Multivalvular Disease Assessment

Abstract

Aortic stenosis (AS) can often coexist with other valvular diseases or be combined with aortic regurgitation (AR), leading to unique pathophysiological conditions. The combination of affected valves can vary widely, resulting in a lack of standardized diagnostic or therapeutic approaches. Echocardiography is crucial in assessing patients with valvular heart disease (VHD), but careful consideration of the hemodynamic interactions between combined valvular defects is necessary. This is important as it may affect the reliability of commonly used echocardiographic parameters, making the diagnosis challenging. Therefore, a multimodality imaging approach, including computed tomography or cardiac magnetic resonance, is often not just beneficial but crucial. It represents the future of diagnostics in this intricate field due to its unprecedented capacity to quantify and comprehend valvular pathology. The absence of definitive data and guidelines for the therapeutic management of AS in the context of multiple valve lesions makes this condition particularly challenging. As a result, an individualized, case-by-case approach is necessary, guided primarily by the recommendations for the predominant valve lesion. This review aims to summarize the pathophysiology of AS in the context of multiple and mixed valve disease, with a focus on the hemodynamic implications, diagnostic challenges, and therapeutic options.

Keywords: aortic stenosis; echocardiography; mixed valve disease; multimodal imaging; multiple valve disease.

Figure 1

Pathophysiology of Aortic Stenosis by disease stage. In this figure, an illustration of the progression of AS is provided, with particular emphasis on the pathophysiological basis for the occurrence of functional mitral and tricuspid regurgitation.

Figure 2

A case of concomitant severe AS and MS due to severe mitral annular calcification. (A,B). Representative echocardiographic images from parasternal long-axis view and apical 4 chamber. (C,D). Continuous wave Doppler on the AV and MV, showing high gradients. (E–G). CT images of this same patient help identify the distribution of calcium within the LVOT, aortic cusps, and mitral annulus. AS: aortic stenosis; MS: mitral stenosis; AV: aortic valve; MV: mitral valve; CT: computed tomography; LVOT: left ventricular outflow tract.

Figure 3

Proposed algorithm for the management of severe aortic stenosis with concomitant mitral regurgitation. MR—mitral regurgitation; MV: mitral valve; AF: atrial fibrillation; PH: pulmonary hypertension; SAVR: surgical aortic valve replacement; TAVR: transcatheter aortic valve replacement. Adapted from Unger 2016 and Kiriyama 2022 [85,86].

Figure 4

Proposed algorithm for the management of severe aortic stenosis with concomitant tricuspid regurgitation. TR: tricuspid regurgitation; SAVR: surgical aortic valve replacement; TAVR: transcatheter aortic valve replacement; TV: tricuspid valve. Adapted from Vahanian 2022 [50].