Outcomes of moderate mixed aortic valve stenosis and regurgitation

BACKGROUND AND AIMS: There are limited data on mortality in patients with moderate mixed aortic valve disease (MAVD), defined as the combination of moderate aortic stenosis (AS) and moderate aortic regurgitation (AR). Consequently, current guidelines lack specific recommendations for aortic valve replacement (AVR) in this population. This study aims to compare survival between moderate MAVD and isolated severe AS or severe AR, and to evaluate the impact of symptoms or left ventricular ejection fraction (LVEF) < 50%, as current criteria for AVR in severe AS or AR. METHODS: Overall, 1926 patients were included from four centers: 527 with moderate MAVD, 413 with severe AR, and 986 with severe AS. The primary endpoint was all-cause mortality. RESULTS: Over a median follow-up of 7.2 (interquartile range 3.4-11.3) years, 748 patients died. After adjusting for clinical and echocardiographic variables (including New York Heart Association NYHA class, LVEF < 50%, and AVR as time-dependent covariate), moderate MAVD patients showed 10-year survival similar to severe AS but worse than severe AR (62%, 55%, and 79%, respectively; P < .001). Symptomatic moderate MAVD patients showed adjusted mortality comparable to symptomatic severe AS, while asymptomatic moderate MAVD patients had adjusted mortality similar to severe AR (symptomatic and asymptomatic). Moderate MAVD patients with LVEF < 50% had adjusted mortality comparable to severe AS with LVEF < 50%, while those with LVEF ≥ 50% showed mortality similar to severe AR (regardless of left ventricular dysfunction). CONCLUSIONS: In moderate MAVD, the presence of symptoms or LVEF < 50% is associated with increased mortality, comparable to isolated severe AS under similar conditions. Therefore, patients with moderate MAVD should benefit from AVR in the presence of symptoms or left ventricular dysfunction.