Long-term outcomes in patients with combined significant aortic regurgitation and mitral regurgitation

Background Multiple valvular heart disease (MVD) is defined as the presence of stenotic and/or regurgitant lesions occurring in at least two cardiac valves. Among the possible combinations, the combination of significant aortic regurgitation (AR) and mitral regurgitation (MR) is not uncommon. Current guidelines recommend intervention when one of the two lesions progresses to a severe stage in the presence of symptoms, left ventricular (LV) dysfunction, or LV dilation. However, these recommendations are based on evidence from isolated AR or MR, while limited data is available on the outcomes of patients presenting with both lesions. Purpose To evaluate the clinical and echocardiographic characteristics of patients with combined significant AR and MR (≥ moderate AR and ≥ moderate MR) and their outcome in a multicenter setting. Methods A total of 156 patients (age 65 ± 13 years, 72% male) with significant AR and MR were included. Patients were categorized into four groups based on the regurgitation severity: (1) Moderate AR and Moderate MR (n=69); (2) Moderate AR/Severe MR (n=37); (3) Severe AR/Moderate MR (n=30); and (4) Severe AR and Severe MR (n=20)(Figure 1A). Regurgitation severity was determined using a multiparametric approach, in accordance with current ESC/EACVI guidelines. The study endpoint was all-cause mortality, with valve intervention accounted for during follow-up as a time-dependent covariate. Results Over a median follow-up of 6 years (IQR 2-10), 56 (36%) patients died. A total of 90 (58%) patients underwent aortic valve surgery (AVS), 94 (60%) underwent mitral valve surgery (MVS), and 101 (65%) underwent either procedure. Patients with Moderate AR and MR were older and more often female (Table 1). Severe AR was more frequently associated with bicuspid aortic valve, and Severe MR was more often associated with organic etiology. Atrial fibrillation was more prevalent among patients with Severe MR. The presence of Severe AR was associated with greater LV dilation compared to the other groups, while patients with Severe MR showed larger left atrial volume. After adjustment for age, New York Heart Association (NYHA) class, renal function, AR etiology, systolic pulmonary arterial pressure (SPAP) and valve intervention (AVS and/or MVS) as a time-dependent covariate, patients with combined Severe AR and MR showed the worst adjusted 10-year survival (HR 4.16; 95% CI 1.24-13.92; p=0.021) (Figure 1B). This was followed by patients with Severe AR/Moderate MR (HR 3.66; 95% CI 1.50-8.93; p=0.004) and those with Moderate AR/Severe MR (HR 2.50; 95% CI 1.06-5.91; p=0.037). Patients with concomitant Moderate AR and MR showed the best adjusted 10-year survival. Conclusion In patients with combined significant AR and MR, increasing regurgitation severity was associated with poorer survival. Notably, Severe AR was associated with significantly worse outcomes regardless of MR severity.